“Oh, no, that won’t work,” my friend said. “I have a meeting with my therapist then.” We were trying to make a lunch date. She is a friend, but not a particularly intimate one. She said the word "therapist" as simply as she might’ve said "dentist". I’ve had many conversations like this. They're light and frank. At least, in the circle of my young city-based friends, a therapist is nothing to be ashamed of.
We don’t talk about the scars. The thin white marks that appear in the summer when sleeves are shorter. I have several friends with such scars. They are people who care for pets, hold down jobs and move gently through the world. They don’t refer to the marks and nor do I.
Once, someone I loved cut their fingers and touched my face with the blood-warm tips. They loved me back and in the heat of mania could find no other way to say it. We were both young. I didn’t know what to do. I felt there was no one I could tell. Malaise or grief might be socially acceptable, blood was not. And so, I walked home, with blood crusting on my cheeks. I barely remember what we said to each other or how exactly the cut was made. But the silence of that walk remains with me. I stood alone in the pale light of a bathroom and slowly sponged off the dark flakes.
Almost a decade later, I still think about how the most frightening thing was not warm, red liquid, but the silence afterwards. We are both OK now, but I wonder how much easier it might’ve been if we’d felt less alone. Everything in the media seemed to say it was gothy. It was in some way self-indulgent. Worst of all, self-harm was attention-seeking.
The person I loved didn’t want to be judged. And I didn’t want to be judged for loving them. We didn’t know how to ask for help.
Almost a decade later, and self-harm doesn’t seem much easier to talk about. When I mentioned to a friend that I was going to write this article, he seemed worried. Was self-harm really something I wanted to be associated with? But I wanted to find out where this stigma comes from and how we might change it.
In a crowded London coffee shop, I looked around for Dr Sarah Chaney. It was the morning and the small space was filled with caffeine-seeking bodies. Chaney is a historian specialising in self-mutilation and psychiatry. Her book on the history of self-harm is called Psyche On The Skin. I knew her research interests, but I had no idea what she looked like.
Eventually, a woman with wavy hair and a wide smile caught my eye. “Are you Rowan?”
At first, it felt a little awkward to be asking this stranger about something so unhappy and intimate. I couldn’t help but think of the suited men one table over. Were they listening? What must they make of us? But soon I was absorbed by what I was learning. She explained that, for much of history, blood-letting was an accepted medical practice. It was only in the 19th century that medical literature began to describe self-injury as a problem.
In 1870, a British medical journal ran a series of articles on what they called “motiveless malingerers”. These motiveless malingerers were women, often middle-class women, who injured themselves without any apparent reason. Usually, these women created artificial skin lesions or burned themselves with household substances. Psychoanalysts described it as motiveless-malingering, because they assumed that a man or a working-class woman injuring himself or herself would be shirking work. The psychoanalysts couldn’t see a motive for these middle-class women. This was true even when the women provided the explanation. Chaney described a study in which a patient, “said that she struggled to get by in the world, she’d been denied job opportunities that would have happened if she was a man". Her psychoanalyst considered such a reason to be ridiculous and further proof that the woman was making up her miseries.
By the early 20th century, hysterical self-injury was treated as attention-seeking. Psychoanalysts felt it proved “that women, all women, are naturally more deceptive than men”. The profile of the deceptive, self-harming woman seeped into studies in the 1960s and 1970s. At this time, studies on self-harm focused on “delicate self-cutting”, which was, again, associated with women. This image of the attention-seeking woman seeped into popular culture.
Those who self-harm aren’t the only ones accused of doing something upsetting for attention. It’s a charge that has been thrown at feminists for decades
This prejudice from over 100 years ago had wormed its way into my life. It was what kept me from trying to find help for one of the people I loved most. We were sure everyone would think it reflected poorly on our characters. And this concern is common.
It’s not a topic most people feel comfortable talking about, so I reached out using the veil of the internet. I asked if anyone wanted to talk about their experience with self-harm. I was struck by the fact that, far from seeking attention, most responders wanted their names held back. W, a British novelist living in New Zealand, wrote, “I would keep my self-harm absolutely private, with a deep shame and covering myself in layers of clothing or jewellery that covered up any marks.” W was so careful that even her partner was unaware of the harm for a while. “Any mistaken idea that I was seeking attention was terrifying to me.” W didn’t want attention. Instead, she longed for understanding and acceptance.
A Korean-American woman in her twenties, Z, complained that “I feel like the misrepresentation made it really difficult to speak out about it…The media paints it as a teenage girl thing where people just slash their wrists and wear heavy eye make-up. In reality, a lot of us cut elsewhere to hide it and, rather than attention-seeking, it’s something that brings you deep shame.”
Those who wrote gave many reasons. L, a Chinese-British woman, wrote that, for a time, self-harm was the only way she could cope with the stress of having two autistic children. A man, whose struggle with self-harm is ongoing, explained that it began when he was 15. “I was really depressed and it feels good to focus the hurt into something physical and concentrated instead of just a diffuse pain throughout my whole mind.”
I have received few correspondences so frank and personal as those I exchanged for this article. I was so grateful that these individuals had given me their stories. But my responses felt weak. All I could say was, “I’m so sorry you’re going through that.” Or, “It’s wonderful that you’re find thing things easier now.” They weren’t the responses I’d need if I was in pain. So, I went out looking for hope and better answers.
Ian Noonan is head of the department of mental-health nursing at King’s College London. He facilitates a group for young people dealing with self-harm, is running a research project studying adults who have succeeded in stopping self-harming and has worked in A&E assessing cases of self-harm.
Noonan is softly spoken. He’s the sort of man you can imagine wanting to talk to if you were in pain. As soon as I sat down in his office, he offered me a cup of tea. Noonan explained that, increasingly, studies showing instances of self-harm are evenly split between men and women. Self-harm can be cutting. But it can, as in the case of one of Noonan’s patients, be a young boy asking his friend to jump on his arm and break it. Often even medical professionals can fail to recognise instances of self-harm if the person hurting themselves doesn’t fit a recognised stereotype.
Noonan described a couple he encountered in A&E. A young woman had been out drinking all day with her boyfriend. They argued. The woman smashed a bottle of Bacardi Breezer and cut herself. An ambulance was called and she was referred to Noonan for his mental-health expertise. She explained that she’d cut herself because she was drunk and in a rage. She smashed the bottle, initially thinking she might cut her boyfriend. She’d realised she couldn't do that. But the angry energy had to go somewhere and so she cut herself. At the end of their session, she asked Noonan if he was going to see her boyfriend. Noonan was surprised and asked why. The woman explained that after the ambulance had been called, her boyfriend wanted to travel with her, but had been stopped. He punched through the ambulance window and cut his hand badly. He had to see plastic surgeons. But no one referred him to Noonan, because the A&E view was that that was just how drunk men behaved. “But functionally,” Noonan said, “I don’t see how they’re different. They’re both expressing anger, in a way that involved breaking glass and injuring themselves.” It was only because the young woman told Noonan that the young man received therapeutic attention.
Self-harm is, as he says, a coping mechanism. Deciding to give up a coping mechanism can be stressful or upsetting in itself. This can lead to an increased desire to self-harm
We may not recognise self-harm in “the boy with the broken arm, the boy with the re-infected wound, the man who punched a window… if you go to the pub and drink 13 pints over the course of the evening, you fall off the bus, hurt yourself and spend the night in A&E covered in your own vomit – you’re a lad.” Yet, this behaviour can serve the same function as something like cutting, which we more easily recognise.
The stereotype of self-harm as a teenage-girl issue doesn’t work very well for women, either. In Noonan’s words, “As soon as you label it as part of a different group, that labelling prevents you seeing what the person’s asking for.” This can mean that women, like Z, find it harder to seek help.
I asked what he thought of the idea of self-harm as attention-seeking. He paused before saying, “I’ve never understood this idea of attention seeking as being in and of itself a bad thing. My thought is always, 'What is it that you want me to attend to?'” None of the patients he’d dealt with in his work framed self-harm as a way to get attention. However, it could, on occasion, draw attention that was sorely needed.
Even well-intentioned professionals can enter a sour relationship with the patient – I’m trying to heal you. You’re trying to hurt yourself. In fact, the professional should be addressing the issue that has led the patient to self-harm.
One patient self-harmed to escape a violent partner. She locked herself in the bathroom to escape him. She knew he didn’t want her to die. So, she opened the medicine cabinet and overdosed. He stopped trying to hurt her and called an ambulance. At least in the hospital she was safe for a moment. “Thank God that she sought that attention. It saved her life,” Noonan said. Although it took her a while to be able to articulate the abuse, Noonan said she wasn’t hiding anything. It was just that it wasn’t something she was able to express at first. In her case, the threat was coming from the outside – her partner. Even when the threat is internal, depression or stress, Noonan emphasises that the best way to understand self-harm is to look at the problem the patient is using self-harm to address.
There are many strategies for approaching that greater psychological pain, more than can be covered here. But Noonan is working with a choice-based treatment. The idea of stopping can set patients up to fail. Self-harm is, as he says, a coping mechanism. Deciding to give up a coping mechanism can be stressful or upsetting in itself. This can lead to an increased desire to self-harm. Noonan tries to move self-harm lower down the list of coping mechanisms. He suggests that the sufferer consider another coping mechanism first. For example: talking to a friend, smashing a watermelon, punching a cushion or yelling.
He tries to discover what the self-harm helps with. If the answer is a negative emotion, stress, for example, Noonan asks patients what for them is the opposite of that emotion. For one patient the opposite of stress might be calm. For another it might be hope. Noonan would then ask, when was the last time you felt hopeful? They might respond – painting or working with clay or exercising. He’d then encourage them to try engaging in that activity before resorting to self-harm.
In all his strategies, Noonan emphasises the importance of acknowledging that people self-harm for a reason. There is some deeper problem that needs help, attention and understanding. This receptive approach is one I think we can all consider. When we discover that a family member or friend or acquaintance self-harms, our first response can be to choose to listen.
The day I went to see Noonan, the light was low and clear. It was a winter brightness that has been with me for so many years. Red double-deckers tooled by on the street below. It was a day like so many others. In his office, there were no futuristic brain scanners or mind-reading devices. Yet, our conversation felt fresh and radical. His approach was so kind and so pragmatic. As I thought about the events of all those years ago, I wished I’d had someone like Noonan in my life. Stepping out in to the sun, I felt comforted to know that people like him are working on changing the way we talk about self-harm.
Those who self-harm aren’t the only ones accused of doing something upsetting for attention. It’s a charge that has been thrown at feminists for decades. Women who were trying to get attention – not for themselves, but for a major societal problem. Whether in the context of mental health or social justice, to say a person is doing it for attention is a way to dismiss the underlying issue. Often those being denied a hearing are those who need it most.
Attention comes from the verb attend, which originates from the Latin tendĕre – to stretch. To attend is therefore to stretch your mind towards something. When we ask for attention, we are asking to be stretched towards. It doesn’t seem an unreasonable thing to want. Can we try a little harder to stretch towards each other?
Let’s start offering our attention. It may make all the difference.