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Stories of self-harm and the impossibility of care

In 1987 renowned psychiatrist Armando Favazza, in his field-defining book on self-injury Bodies Under Siege, declared (with remarkable confidence) that “no one loves self-mutilators” (244). In fairness to Favazza, he makes the statement in order to elicit sympathy for the so-called ‘self-mutilators’, but nonetheless, I found the statement troubling, or perhaps just straightforwardly upsetting. In part, of course, I found it upsetting because it seems like such a horrifying generalisation, which I know is entirely untrue. But it was also upsetting because of how much it often does feel true, and moreover how often it seems to be proved true.

And indeed this contention, that people who self-harm are not loved – or in my phrasing ‘cared for’ – is at the heart of my recent doctoral research into fictional depictions of self-harm. Having read and watched a wide range of books, TV shows, and films which included self-harm, and having discussed them with people who had experience of self-harm, a concern that we all shared was how often fictional characters who self-harmed were portrayed as hard to care for.

We talked about how they were presented as difficult to understand, as incomprehensible – for instance, like Glenn Close’s character in Fatal Attraction. We talked about how they were framed as melodramatic, as over-the-top or even glamorous, and therefore inauthentic, like Effy in Skins. We talked about how often self-harming characters felt embarrassing or pathetic, and therefore hard to sympathise with, like Violet in American Horror Story. We talked about how often recovery was the way that stories about self-harm ended, from Girl Interrupted to Young Adult novels like Melody Carlson’s Blade Silver. This conclusion seemed to be the only way for self-harming characters to succeed, to gain approval – they deserved care, so long as they stopped self-harming. Over and over characters who continued to self-harm put themselves ‘beyond care’ by engaging in a practice which narratives took to be self-evidently ‘wrong’, and which thus positioned the characters themselves as mistaken and incorrect. And over and over again, for the people I talked to, this spilled over from fiction into life, where these stories caused mis-perceptions of self-harm and encouraged carelessness or even cruelty.

This wasn’t what I had anticipated the over-arching argument of my PhD would be – but perhaps I should have predicted it. Because as I’ve talked about elsewhere, there’s no doubt that the care provided for people who self-harm is often inadequate, or even harmful. And while Favazza’s statement might seem simply old-fashioned or out-of-date, in fact such attitudes undoubtedly persist. It was saddening (if unsurprising) that a recent report by Alison Faulkner and Rachel Rowan Olive, evaluating the wonderful charity Self-Injury Support, found that the most significant theme among people who self-harm was “difficult, sometimes punitive experiences in A&E and with mental health services” in which they were often judged as “deliberately manipulative, attention-seeking, or time-wasting.”

We might find such continued attitudes shocking – but can we really be surprised by them? And in particular, can we really frame them as the ‘exception’, as the preserve of just a few bad apples? I would suggest not. It’s worth bearing in mind the association between self-harm and the much-contested diagnostic label ‘Borderline Personality Disorder’ (BPD). When self-harm was initially included in the so-called ‘Psychiatrist’s Bible’, the Diagnostic and Statistic Manual (DSM), it was listed as a diagnostic criteria for BPD. And while the two are now listed separately, and many (perhaps the majority of) people who self-harm do not receive such a diagnosis, there undeniably remains a link between the two. And this link, to me, came into particular focus reading a recent advert for a Royal College of Psychiatrists (RCP) event on Personality Disorders which states without evidence that “PD patients […] cause considerable distress to both themselves and those around them.”

And this statement is, I think, instructive. Because it makes (shockingly) clear the fact that the unthinking response to people in great distress is to see them as “causing” that distress – both in themselves and in those around them. By being distressed, upset, self-harming, or simply ‘mad’ we cease to be people experiencing difficulty and become the source of that difficulty. In many ways (as Faulkner and Rowan Olive also note), we seem to have made precisely no progress since the 1980s when Favazza wrote. Indeed he cited Frances, who declares that “of all disturbing patient behaviours, self-mutilation is the most difficult to understand and treat” such that the clinician is left feeling “helpless, horrified, guilty, furious, betrayed, disgusted, and sad” (Favazza, 244) – the RCP might as well have quoted this on their advert. Both now and then self-harm stops being something we do to ourselves – it becomes something we have done to those around us.

In such a context, it is hardly surprising that Faulkner and Rowan Olive report poor experiences with mental health services. The difficulties of such attitudes go beyond the need, so frequently at the centre of mental health campaigns, for ‘awareness.’ To me, it seems even beyond the tendency to focus on ending ‘stigma’ – ‘stigma’ is too general, too mild a word for what is happening here. This is rejection, it is a casting out, it is the designation of ‘un-care-able’.  In a sleight of hand so swift as to be both bewildering and dazzling, the more a person who self-harms needs care, the more they prove themselves to be both undeserving of it and unfit for it. Here pain is not evidence of need, and thus a prompt for care – instead, it is the signal for abandonment.

In their “unreserved apology” for the Personality Disorder event and its advertising material, the RCP claims that it “represents the opposite to the College’s values.” But when such an advert successfully passes through the steps to publication without a single person raising concerns, when poor care for self-harm remains prevalent, as Faulkner and Rowan Olive demonstrate, how can clinical bodies claim such “values”? How can they deny that the “values” of clinicians remain those that lead to cruel and punitive care? And how can they suggest that simply “working collaboratively” with those with lived experience will resolve these failures? It is here that a return to the question of fiction and culture might be important – because looking at the stories that we tell about self-harm we can see the breadth, the depth, the longevity of the views which might lead to self-harm’s un-care-ability. And if we recognise that the people who are supposed to provide care for those who self-harm will have been steeped in this culture, in these stories, we might begin to understand both the scope of the problem, and the place we might start addressing it. It is only by knowing the building blocks that make self-harm un-care-able that we might be able to tear down this way of working, of knowing, of responding. This requires widespread education and change – not simply a hollow re-iteration of ‘values’ which are not in evidence. I do not believe that it’s impossible to care for people who self-harm, not in the slightest. But to make that care the norm, rather than the exception, we have to start with the spaces, stories, and systems of un-care-abilty, and we have to see changing them as our most urgent priority.