The riddle of self harm

Why do some adolescents self-harm?

…But before trying to answer this, what does the term ‘self-harm’ cover? We assume we know what we are talking about, but when digging a bit deeper the term becomes a puzzle. I refer here to the broad, colloquial term ‘self-harm’, rather than the technical term non-suicidal self-injury that holds a more precise definition.

In the mental health arena, a number of diagnostic categories and terms started out with a narrow focus, a small pool of people falling into them, but have now widened their diagnostic criteria, evolving to encompass a much wider range of phenomena. The autistic spectrum is one example, a condition diagnosed in many more people; or ‘trauma’, once a narrow specialist concept referring to PTSD symptoms, nowadays covering much wider hurts.

Yet it’s strange that self-harm, as a term, has gone in the opposite direction. Instead of the diagnostic inflation we notice in other categories, self-harm has shrunk to include a small set of behaviours, mostly referring to cutting with a sharp object. Sometimes (less often) it can refer to burning oneself, or harming the body in other ways. I still feel the term self-harm in its popularised form mainly refers to cutting.

Usually adolescents are said to self-harm in an effort to ‘manage distress’, self-harm becoming a coping mechanism to deal with overwhelming emotions, but also to regain a sense of control over life and the self. Renowned self-harm researcher Armando Favazza goes as far as to suggest that this behaviour can be ‘understood as a form of self-help, albeit a morbid form of self-help’.

However, this way of seeing self-harm – as a way to cope – doesn’t fit all cases, and is only a recent way of understanding this behaviour.

This narrowing of the common-usage definition cannot be explained by any narrowing of the phenomenon itself which has, in many countries, become prevalent across a larger age range of young people. So I wonder – and have no immediate answers – why this specific concept has become so narrow, in contrast to all these mental health terms that are becoming ever wider.

Understanding self-harm in a wider way

If we open up the term self-harm we realise it falls along gendered lines. Lisa Damour, in her excellent book ‘The emotional life of teenagers’ describes the ways boys tend to express their distress when compared to girls, with self-harm being a clear area of difference. She says:

“boys, in particular, are sometimes socialized to deal with distress through aggression or violence, though this is hardly exclusive to males.”

So, young men in most cases externalise their distress, either through aggression towards other people, objects or themself (e.g. banging their heads). Or they sometimes withdraw into their rooms and shut down. In contrast, research suggests females much more frequently engage in self-harm via cutting (the formal term being non-suicidal self-injury).

Opening it up wider still, would we say that self-neglect, substance abuse or engaging in risky behaviors (such as reckless driving, unsafe sex, or extreme sports) are forms of self-harm? What about emotional self-harm, such as self-criticism, self-sabotage, or harshly berating oneself? And what about eating disorders?

The building of a diagnostic category

In 2017, researchers Chris Millard and Dennis Ougrin wrote a useful short article on the evolution of the term ‘self-harm’ post-1945, coming to represent a psychological / psychiatric diagnostic category when similar behaviours had been classified differently in earlier times. Sarah Chaney’s book ‘Psyche on the skin’ covers similar ground, going in depth in how behaviours we now categorise as ‘self-harm’ were framed, say, 150 years ago.

All this would be of academic interest only,  except there are real-life consequences to these definitional differences. The way we define ‘self-harm’ can unfortunately determine whether certain mental health problems get taken up by services, and if so, how soon. Mental health services may more quickly identify a young person who cuts themself, while a young person who self-harms through constant negative thinking (and acting), withdrawal and self neglect, over-drinking, or risky behaviour runs the risk of being overlooked, especially in over-stretched public health systems.

The symptom itself – whether it’s cutting, isolation or even intense self attacking thoughts – tells us little about what’s going on underneath. Yet symptoms get different treatment, with some assumed to automatically be much more alarming than others, while risk should be defined in more holistic, wider ways.

The question remains: would defining a broader set of actions as forms of self-harm bring more equity when it comes to access to services? Or would the term self-harm then become too wide to remain useful?