Sociology and Self-Injury: The State of the Field

Introduction

Self-injury ¹ refers to the intentional, non-suicidal injury of one’s own body. In the past 10 years, there has been a significant sociological contribution to literature on self-injury. Prior to this, explanations of self-injury were provided by psychology and psychiatry. Notwithstanding the usefulness of these offerings, they focused only on the individual, and only individuals in treatment. Such a knowledge base is problematic, as all information on self-injury is skewed towards the minority of those who are under psychiatric care. While there is no reliable demographic data on people who self-injure, one of the few things that is generally accepted is that most people who self-injure do not access inpatient psychiatric treatment. Thus, while there is great value in understanding those who are in treatment, it is essential to understand that they do not represent all people who self-injure, perhaps not even a significant minority. In this essay I review four recent sociological monographs, all of which seek to address this knowledge gap. Each book offers its own substantial contribution, though they are all are premised on some core values:

All four books also cohere around similar themes: emotions; a critique of the individualisation of social issues; and a determined rejection of the psychopathologisation of this behaviour. Each of these books offers new ways of conceptualising self-injury and raises new questions. This essay is organised around the key arguments of these texts and follows with a discussion about the implications it has for the broader body of work. I begin with a brief overview of the literature.

A Very Short History of Self-Injury Literature

Given the sociological study of deviance, it is somewhat surprising that until recently self-injury was a topic that had received little sociological attention. While the practice itself has a long history, it was not until the 1990s that self-injury started to receive attention and most of this was from psychiatrists who, in treating people who were self-injuring, had discovered the absence of clinical guidance. Armando Favazza’s seminal work, Bodies under Siege: Self-Mutilation and Body Modification in Culture and Psychiatry was first published in 1987. Adopting an approach of ‘cultural psychiatry’, Favazza (1996/1987) covered everything from cutting to tattooing and other cultural forms of body modification. It is an important work, though it was correct of Steggals (2015) to make the critique that it covered too many things under the pretence of them being self-injury. It is inaccurate to portend that ear piercing and cutting are alike in intent. While the book was a welcome break away from the pathologisation of self-injury – in that it sought to present a cultural understanding of it – it did offer ways of ‘treating’ the behaviour. Favazza may have understood self-injury with acknowledgement of culture but his text was still a psychiatric offering.

Subsequent literature has addressed self-injury as a symptom of psychiatric disorder culminating in it being added as a disorder in the most recent Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). The addition of this as a diagnosis has divided professionals. Self-injury has historically been linked with Borderline Personality Disorder, childhood sexual abuse and eating disorders (Levenkron, 1998; Strong, 1998). But it has always been understood as a symptom of a broader psychiatric issue. The shift to making the behaviour a disorder itself was seen to further frame it as an individual issue rather than explore what it might represent (which is a problem the current authors seek to remedy).

Portrayed as a largely female behaviour, the typical ‘cutter’ has been painted as an over-achieving, white, middle-class schoolgirl who had issues with control – often because of past sexual abuse (Levenkron, 1998). This representation has permeated widely, though it is difficult to establish either its empirical basis or veracity. Certainly, there are people who fit this profile, but whether they are ‘typical’ is hard to know. Issues with sampling are a perpetual challenge in social research and this area is no exception. Certainly, people who self-injure are more diverse than psychiatric literature has implied, but their broad demographic features remain largely unknown. Some studies have found prevalence to be higher among women (e.g. Adler and Adler, 2011; Daley, 2016), but this is possibly sampling bias. Similarly, there have been links made with child sexual abuse and later self-injury (e.g. Daley, 2016; Levenkron, 1998; Strong, 1998), but this might be that those who have experienced such childhood abuse are more likely to be accessing services where researchers are recruiting. Prevalence of self-injury was once assumed to be highest among youth, but that too is uncertain. The authors in the books I review have moved beyond the clinic to recruit participants and have frequently drawn on digital methods. Though it is likely that most people who self-injure are neither in psychiatrists’ offices nor dedicated online forums, so the demography of this group continues to elude us.

Following from Favazza’s work came journalist Marilee Strong’s book, A Bright Red Scream (1998). Strong drew on the work of Favazza and others, as well as case-studies and interviews with people who self-injure. Strong presented self-injury as more diverse than a schoolgirl’s cry for help, with case-studies from people who were middle-aged and elderly. Strong’s work has been criticised for being too voyeuristic and sensationalist, though it was the first substantial offering from somewhere other than psychiatry. Framed as a ‘language of pain’, Strong (1998) offered an insight into self-injury to a mainstream audience. The tone of the book was at times melodramatic, but at the time of publication the link between emotional anguish and self-injurious behaviours was less commonly understood. Strong drew upon the common medical language of ‘dissociation’ and ‘hardwired trauma’. Her work linked self-injury to past sexual abuse and eating disorders, in turn making a case that self-injury is about reclaiming one’s own body and exerting control over it, an argument that has been supported in more recent work (i.e. Adler and Adler, 2011; Daley, 2016).

Adler and Adler’s (2011) book, The Tender Cut drew on 135 qualitative interviews with people aged between 16 and their mid-50s who were mostly Caucasian and overwhelmingly female (85%). Additionally, they collected between 30,000 and 40,000 internet messages and emails making this almost certainly the largest collection of qualitative material ever gathered on the subject. With this material, they offer a rich, descriptive account of self-injury that shifts away from the medical paradigm. Adler and Adler (2011) make familiar connections with child abuse, emotional pain and control of one’s body. They contend that women’s relationship with their own bodies is fraught after experiences of rape. In turn, self-injury provides women with a way to hurt, heal and control their own bodies. Chandler, in Self-Injury, Medicine and Society, has rightly pointed out that this book falls short in its analysis and theoretical offering. It is overly descriptive and thin in its use of theoretical framing, nonetheless its insights are useful.

In the decade since Adler and Adler’s work, there has been an explosion of sociological accounts of self-injury, to which my attention now turns. Chandler’s latest offering is the most critical of the four texts. She applies the traditions of critical sociology and offers a deeply reflective, traditionally sociological, monograph. Positioning herself within her own work offered depth and insight not found elsewhere. McDermott and Roen’s Queer Youth, Suicide and Self-Harm focuses on lesbian, gay, bisexual, transgender, queer or questioning and intersex (LGBTQI) young people and in turn, their work has some important, direct applications for those working with this population. Drawing on data from three empirical studies conducted over a decade, they provide a painful illustration of how class position shapes queer youth’s mental health. In Making Sense of Self-Harm, Steggals offers an abstracted, cultural framing of self-injury and Brossard’s Why Do We Hurt Ourselves? draws on a French sample to answer the deceptively complex question of what motivates people to harm themselves?.

Why Do People Self-Injure?

At the core of most research about self-injury is the question, ‘Why do people do it?’ Steggals invites us to reimagine self-injury as a ‘violent, non-verbal speech act’ (p. 9) that has been framed as an individualist behaviour because of the socio-political environment in which it has manifested. Using both document analysis and data from 30 interviews, he draws on Bordo’s axis of continuity in offering a tripartite theorisation, unpacking the ontological, aetiological and pathological factors which he claims form the foundation from which self-injury manifests. There is an over-use of theory in this text, which at times sees the focus of the tripartite model get lost among a sea of other social theorists and the qualitative material not used to its fullest. At its core, Steggals’ work makes a case to consider self-injury beyond the everyday, individualist understanding of it and to think about the neo-liberal issues it might represent.

McDermott and Roen offer an application of this. They suggest that when we look at self-injury as an individual issue, it is easy to find other diagnosable ‘illnesses’ and emotional distress is pathologised. But when we give attention to the socio-political factors of the emotional distress, we can see self-injury as a physical response to emotions associated with hate, subjugation and oppression. Quite powerfully, McDermott and Roen explain that these emotions, when coming from experiences of homo/bi/transphobia, can manifest as shame and terror. In turn, young people, often grappling with their own personal struggles with sexual identity, are weighted with immense feelings of shame, fear and terror. This goes some way to explaining the astonishingly high rates of suicide and self-injury among LGBTQI young people they report. In understanding this process, we move from seeing self-injury as a symptom of individual psychopathology, to the consequence of individual suffering and social persecution.

Utilising data from self-injury specific net forums as well as traineeships in two youth mental health facilities in France, Brossard seeks to understand how people are led to self-injury, wanting to ‘analyse the specific configurations surrounding, if not producing, the very acts of self-harming’ (p. viii). Brossard was the only one of the authors that looked at the function of the self-injury. His interest in how self-injury is practised differed from looking at what motivates it, or what it represents. This approach tasks us with considering what people are doing and feeling when they self-injure.

A core argument Brossard makes in explaining self-injury is that parental expectations burden young people. This relational explanation is critical in understanding drivers for self-injury, which is central to McDermott and Roen’s explanation. Brossard’s presentation of the relational influence was at times lacking complexity and the simplicity of its explanation left me questioning why such expectations burdened some to the point of self-injury and not others. There is no doubt that his participants felt immense pressure from their parents, but why they had manifested this into self-injury was unexplained. For instance, when Brossard’s participant, Vanessa, explained that she did not want to go home after being discharged from a mental health facility, Brossard challenges the mental health system rather than questioning what might be happening at home that makes it so undesirable for his participant. There was an odd juxtaposition of accepting as objective fact the explanations of some (i.e. Vanessa); while challenging the motivations of others (the mental health system and young people’s parents – neither of whom were participants in the study).

Contrastingly, Chandler delves deeper and accepts nothing at face value, not even her own initial interpretations. Drawing on two sets of qualitative interviews undertaken seven years apart, she puts aside the question of why people self-injure and turns her attention to how we understand self-injury. Her focus is the concept of authenticity: how and in what circumstances is self-injury understood as authentic (emotional pain) or inauthentic (i.e. ‘attention seeking’). What pain is authentic? What explanations of self-injury are authentic? Chandler questions the narratives of her participants, reflecting on how their own explanations might have been influenced by the medicalised presentations of it. The process of this is difficult to balance ethically: do participants provide personal narratives with the knowledge that it might not be accepted at face value? Positioned explicitly within her own work, disclosing her own self-injury and in turn, her beliefs and views about it, Chandler gracefully weaves critique of her own construction of the issue throughout her analysis of others’ explanations of it. In doing this, we see that there is no simple or single explanation for self-injury but that understanding it is as much about realising the limits of understanding human behaviour.

Expressing Emotions in Everyday Life

The most dominant explanation for the function of self-injury is the narrative of control and release. The catch cry, ‘It made me feel alive’, permeates many accounts of why people engaged with a behaviour that can be seen by others as painful and disturbing. Underneath the sense of ‘aliveness’ is usually a story of wanting or needing to control one’s own body and emotions. Along with this is an explanation of needing to ‘release’ pent up emotions. As Steggals incisively highlights, these explanations are based on an acceptance of the popular psychology pretence that emotions can physically accumulate within the body, leading to an ‘overflow’. What is touted as both problem and solution is usually talk therapy: the inability to talk about emotions is why the person is distressed, the solution to the distress? To talk!

Emotions are, obviously, central to this explanation. As Steggals pointed out, in the West any psychic pain is framed as solvable via the ‘expressive imperative’ (p. 15). Brossard inadvertently illuminates to us that self-injury is just that: a form of expression, albeit a violent, non-verbal one. We could see this as a limitation of the individual: they cannot ‘open up’, they cannot express their emotions though Steggals suggests that this might be a limitation of language: by self-injuring, people are trying to express the inexpressible. While we should not accept that the resolution to complicated emotions is to accept self-injury as a form of expression, when we think about it this way we shift away from individual pathology and start to think about what is creating emotions so powerful that: (a) they cannot be expressed in language; (b) they need to be expressed in self-violence.

Chandler discusses the dilemma of people disclosing their self-injury. Within this discussion we see the complexity of her analysis: to be authentic in who we are, we should not hide. But to divulge self-injury is often perceived as ‘attention seeking’. But how then are people offered an opportunity to use alternative forms of expression? Jay, one of Chandler’s participants, embodies this when she discusses that she hides her self-injury not because she wants to, but because she is aware of how the public display of self-injury is perceived, and that the negative public response essentially invalidates the very emotions that drove the injury in the first instance. This creates a paradox for those wishing to express themselves: judgement for not discussing their feelings before self-injury; then judgement for displaying their self-injury in a way that might begin a discussion about it.

It is imperative that we focus on these emotions as beyond the theory are some very distressed individuals. McDermott and Roen explained that LGBTQI young people report histories of suicidality at more than twice the rates of their cisgender, heterosexual counterparts yet are less likely to ask for help and report feeling that they should cope alone. Brossard’s insight that ‘many people who self-harm feel abandoned in a world that does not make much sense to them, and which in turn, seems unable to make much sense of them’ (p. 126) seems particularly poignant here.

Emotional Pain of Social Problems

McDermott and Roen raised the issue of class and use it as an analytic tool. Understanding that experiences of minority sexual/gender identification might lead some to self-injure and not others, these authors looked at what other issues were at play. They made a compelling case that personal experiences of homo/bi/transphobia are shaped by a young person’s class position. The more class status that someone has, the more ability one had to avoid difficulty with their queer identity. For instance, working-class young people were unable to escape homes or neighbourhoods where they experienced homo/bi/transphobia as they did not have the resources or opportunity to relocate. Contrastingly, middle-class young people used university as a way of escape, choosing to move away for study, and in turn, making a conscious decision to be open about their gender/sexual identity. This analysis is very helpful as it begins to explain why some may be more likely to self-injure than others. Using class as an analytic tool might also help to weave out the nuance in Brossard’s data, to unpack why parental pressure might have been so enveloping for some, while many others have similar pressure with no self-injurious desire.

Conclusion

In reading these texts the recurrent question was, ‘But why are people in such emotional anguish?’ A pathological, at-risk model of understanding self-injury is not helpful. Acknowledging that structural, socio-political issues are core to understanding why some people self-injure reframes the motivation of self-injury away from the individual and onto society. When the problem of self-injury is framed as a problem of society, ‘solutions’ or interventions that might help people would in turn be shaped around social and community responses rather than pathologising individuals.