Abstract
Contemporary Western psychiatry treats self-harm and suicidality as discrete pathological phenomena requiring clinical intervention—yet this framework is neither universal nor ancient, but a historically contingent construction with potentially iatrogenic consequences. This synthesis traces how behaviours now classified as "self-harm" and "suicide" have been understood across cultures and centuries, revealing that current medicalised framings emerged from specific Enlightenment, Christian, and professionalisation processes rather than natural scientific discovery. Drawing on Foucauldian genealogical methods, cross-cultural evidence, and recent meta-analytic findings on risk assessment and post-discharge outcomes, the evidence suggests that some contemporary interventions—particularly involuntary hospitalisation, risk assessment protocols, and certain institutional responses—may paradoxically increase harm for vulnerable populations, while alternative frameworks grounded in community, dialogue, and cultural continuity show promise. The analysis calls for epistemic humility about current categories, attention to potential harms of intervention, and serious engagement with alternatives.
Keywords: suicide, self-harm, social construction, Foucault, risk assessment, cultural continuity, Open Dialogue, critical suicidology
The medicalisation of suicide and self-harm represents one of the most significant yet least examined transformations in how Western societies understand and respond to human suffering. Contemporary psychiatric practice proceeds from largely unexamined assumptions: that suicidal behaviour reflects individual pathology, that clinical risk assessment can identify those at elevated risk, and that institutional intervention—including involuntary hospitalisation—protects vulnerable individuals. Yet a growing body of evidence challenges each of these assumptions, while historical and anthropological scholarship reveals the profound contingency of categories now treated as natural kinds.
This review synthesises genealogical, anthropological, and epidemiological evidence to critically examine contemporary approaches to self-harm and suicide. Following Foucault's (1965, 1977, 1978) analytical methods, it traces the historical conditions that enabled current "regimes of truth" while examining cross-cultural variation that destabilises universalist claims. It then evaluates empirical evidence on the effectiveness—and potential iatrogenic effects—of standard interventions, before considering alternative frameworks that reconceptualise the locus of intervention from individual pathology to social and cultural conditions.
The transformation of suicide from philosophically defensible act to mortal sin represents one of the most dramatic conceptual shifts in Western thought. Stoic philosophers explicitly advocated suicide under specified conditions: Seneca recognised three acceptable grounds—sacrifice for country or friends, escape from chronic illness rendering virtuous life impossible, and preservation of personal freedom (Griffin, 1986). His own ordered death under Nero became paradigmatic of philosophical composure. Plato's Phaedo presents Socrates expressing guarded acceptance of the Pythagorean position that the soul occupies a "guard-post" placed by the gods, while his Laws nonetheless permits suicide when one's mind is "morally corrupted beyond salvation" or when compelled by extreme unavoidable misfortune (Cholbi, 2011).
Augustine's City of God fundamentally reframed self-killing as violation of the Sixth Commandment, arguing that suicide constitutes a worse sin than any it might avoid—it cannot function as shortcut to heaven (Minois, 1999). Thomas Aquinas systematised this position through three arguments: suicide violates natural self-love, injures the community ("every man is part of the community"), and sins against God's sovereignty over life and death (Aquinas, 1265-1274/1948). The criminalisation that followed was severe. English common law developed the concept of felo de se—felon of himself—with penalties including property forfeiture to the Crown, corpse desecration through ritual staking, and burial at crossroads without clergy (MacDonald & Murphy, 1990). This legal status persisted in England until the Suicide Act 1961.
The Enlightenment initiated secularisation but not immediate medicalisation. David Hume's posthumously published "Of Suicide" (1777/1995) systematically dismantled Aquinas's framework, arguing that if natural laws permit death through sickness, conscious choice does not violate divine providence any more than other human actions. Hume's essay, as Cholbi (2011) notes, "sets up the starting point for contemporary debate"—the question of whether life conditions could present morally acceptable reasons for autonomous death.
Esquirol's (1838) psychiatric reframing declared suicide "an effect of disease," anticipating the transition from sin and crime to product of psychological forces beyond individual control. As Marsh (2010) demonstrates in his Foucauldian analysis, this period marked the emergence of suicide as "first and foremost a matter of psychiatric concern," with deaths increasingly "understood as private, individual events largely divorced from social, cultural and political contexts" (p. 3).
Anthropological evidence demonstrates that what the West calls "suicide" encompasses radically different phenomena cross-culturally, challenging claims of universal pathology. In Japan, seppuku was not merely acceptable but honourable, demonstrating courage, self-control, and resolve (Pinguet, 1993). Kitanaka's (2012) ethnography Depression in Japan documents how suicide was "once normalized by many Japanese as an act of free will" through the concept of kakugo no jisatsu ("suicide of resolve"). The contemporary emergence of karō jisatsu ("overwork suicide") represents a contested medicalisation where families and workers use pathological framing strategically to highlight the "dire cost of work stress" rather than individual deficiency (Kitanaka, 2012, p. 183).
Durkheim's (1897/1951) foundational sociological typology identified altruistic suicide—arising from excessive social integration rather than insufficient—as fundamentally different from Western egoistic patterns. This recognition that the same behaviour can emerge from opposite social conditions undermines purely psychological explanations. Counts (1990) established that "anthropology seeks to explain suicide as being a culturally constructed act performed in the context of a system of meaning" that "communicates the rules of suicide for those who would kill themselves and a code of understanding for survivors" (p. 1). Micronesian youth suicide involves revenge predicated on understanding communal consequences; Melanesian women commit suicide expecting predictable relative responses enabling vicarious revenge (Counts, 1990).
World Health Organization data reveals dramatic rate variations that correlate with social structures rather than individual pathology (WHO, 2014). South Asia is the only region where female suicide mortality exceeds male; indigenous populations in Canada and Australia show rates dramatically elevated above non-indigenous communities (Kirmayer et al., 2007). Kirmayer (1994) identifies that "the sex difference in suicide mortality is a culture-bound phenomenon, meaning that cultural expectations about gender and suicide strongly determine both its existence and magnitude" (p. 5). Kleinman (1988) warned that the majority of DSM categories are "culture-bound to North America and Western Europe" yet the "culture-bound syndrome" label applies only to "exotic" conditions—what he termed "category fallacy."
The separation of "self-harm" from suicide attempts occurred largely within living memory. Menninger's (1938) Man Against Himself introduced "focal suicide"—self-mutilation as partial suicide to avert total suicide—but interpreted this through Freud's death instinct. The concept that self-injury was distinct from suicidal intent was one "no one was willing to deal with in depth" until Pattison and Kahan's (1983) "Deliberate Self-Harm Syndrome" in the American Journal of Psychiatry. Their proposal for DSM inclusion analysed 56 case reports identifying onset in late adolescence, multiple recurrent low-lethality episodes, and behaviour extending over years.
Favazza's (1987) Bodies Under Siege became foundational, distinguishing culturally sanctioned body modification from pathological self-injury. His classification separated major self-mutilation (castration, eye enucleation—usually associated with psychosis), stereotypic patterns (rhythmic behaviours in autism or developmental disability), and superficial/moderate forms including cutting and burning. The critical analytical move was distinguishing practices embedded in communal rituals—scarification among the Dinka, Nuer, and Mursi; flagellation in Catholic and Shia traditions; Lakota Sun Dance piercing—from Western pathological categories.
Why did cutting become pathological when scarification existed for millennia? The distinction rests on five factors: cultural practices are communally sanctioned and performed publicly rather than secretly; they serve group membership and identity rather than individual emotion regulation; they are socially valued rather than stigmatised; they reflect choice within cultural frameworks rather than compulsion from distress; and they mark transitions acknowledged by the community (Favazza, 1987; Turner, 1980). Turner's (1980) concept of "social skin" positions the body as canvas for cultural construction, while Van Gennep's (1909/1960) "rites of passage" framework situates bodily transformation within social orderliness.
The DSM's treatment evolved from embedding self-harm solely within Borderline Personality Disorder (American Psychiatric Association, 1980) to proposing Non-Suicidal Self-Injury (NSSI) as a condition for further study in DSM-5 (American Psychiatric Association, 2013). The diagnostic criteria require five or more days of intentional self-harm in the past year without suicidal intent—a threshold some argue is too low. Test-retest reliability proved unacceptable in clinical trials (Zetterqvist, 2015). Critically, approximately 80% of adolescents meeting NSSI criteria do not meet BPD criteria (In-Albon et al., 2013), supporting independence of the categories, yet recent scholarship proposes reclassifying NSSI from standalone disorder to clinical specifier (Hooley et al., 2025).
Marsh's (2010) Foucauldian analysis in Suicide: Foucault, History and Truth traces how suicide came to be understood as "first and foremost a matter of psychiatric concern," with deaths "understood as private, individual events largely divorced from social, cultural and political contexts" (p. 3). Foucault's (1978) concept of biopower—technology exercised over biological life involving both disciplinary control of individual bodies and biopolitical surveillance of populations—creates a paradox for suicide governance: how can power that defines itself by "fostering life" address self-inflicted death? In the era of biopower, death has become "a scandal and a catastrophe" (Marsh, 2010, p. 47).
Hacking's (1995, 1999) "looping effects" concept illuminates how diagnostic categories reshape the behaviours they describe. His framework distinguishes interactive kinds (human classifications where awareness changes behaviour) from indifferent kinds (natural classifications unaffected by awareness). The psychiatric system involves classification criteria, people being classified, institutions, knowledge dissemination, and experts—components that interact dynamically. "We think of these kinds of people as definite classes defined by definite properties," Hacking (1999) writes, "but they are moving targets because our investigations interact with them and change them" (p. 108).
The professionalisation of suicide prevention institutionalised particular framings. Edwin Shneidman founded the American Association of Suicidology in 1968, coined "suicidology," developed the psychological autopsy method, and introduced concepts including "psychache" (intense psychological pain) and "postvention" (Shneidman, 1993). The Critical Suicidology movement, consolidated in White, Marsh, Kral, and Morris's (2016) volume, argues mainstream suicidology has "become too focused on the biomedical paradigm: a model that pathologizes distress and obscures the social, political, and historical contexts that contribute to human suffering" (p. 1).
The most troubling evidence concerns risk assessment accuracy. Franklin and colleagues' (2017) landmark meta-analysis of 50 years of research examining 3,428 risk factor effect sizes found prediction was "only slightly better than chance for all outcomes" (p. 187). No broad category or subcategory accurately predicted far above chance levels. Predictive ability has not improved across five decades. The authors conclude that "a suicide expert who conducted an in-depth assessment of risk factors would predict a patient's future suicidal thoughts and behaviors with the same degree of accuracy as someone with no knowledge of the patient who predicted based on a coin flip" (Franklin et al., 2017, p. 215).
Large and colleagues (2016) demonstrated the base rate problem: even with an odds ratio of 10.9 for high-risk categorisation, predictive value fell below 2% due to suicide's low base rate. Approximately 3% of "high-risk" patients completed suicide within one year—but approximately 60% of suicides occurred among those categorised as "low risk." NICE guidelines (2022) now explicitly state: "do not use risk assessment tools and scales to predict future suicide or repetition of self-harm" and "do not use risk assessment tools and scales to determine who should and should not be offered treatment."
Risk assessment may function primarily as governance technology rather than clinical tool. The "prevention paradox" (Rose, 1981) shows that "the greatest burden of disease or death is caused by those at low to moderate risk due to their larger numbers"—most people who die by suicide were categorised as low risk. Research in institutional contexts notes that "although attempts to standardize the outcomes of risk assessment exist, professional judgments in specific client scenarios remain highly divergent... ultimately organizational dynamics and resource availability determine disposition" (Broadhurst et al., 2010, p. 1054).
The evidence on hospitalisation outcomes is deeply concerning. Chung and colleagues' (2017) meta-analysis of 100 studies and over 17,000 suicides found post-discharge suicide rates approximately 100 times the global suicide rate during the first three months after discharge; patients admitted with suicidal thoughts or behaviours showed rates nearly 200 times the global rate. Even years after discharge, rates remain approximately 30 times higher than typical global figures. A subsequent meta-analysis found that one-week post-discharge rates reached approximately 3000 per 100,000 person-years—about 300 times the global rate (Large et al., 2019).
Franklin and colleagues (2017) found that prior psychiatric hospitalisation was the strongest statistical risk factor for later suicide across 50 years of research. A paradoxical finding emerged in some studies: patients who received more post-discharge psychiatric care were significantly more likely to die by suicide than those receiving less care (Hjorthøj et al., 2014). This does not establish causation—sicker patients receive more treatment—but challenges assumptions that more intensive intervention necessarily produces better outcomes.
Involuntary admission produces measurable harms. The EUNOMIA study across 10 European countries (n=2,030) found forced medication associated with patients being significantly less likely to justify their admission at three-month follow-up (Kalisova et al., 2014). All coercive measures were associated with longer hospital stays. Experience of involuntary admission can be "traumatic, frightening, stigmatising," leading to "long-term avoidance of mental health support" and increased risk for further coercion during subsequent admissions (Katsakou & Priebe, 2007, p. 237).
PTSD incidence after seclusion and restraint ranges from 25% to 47% according to systematic review (Cusack et al., 2018). SAMHSA (2011) notes that "restraints and seclusion can be harmful and is often re-traumatizing for an individual who has suffered trauma." Programs that reduced or eliminated seclusion and restraint showed reduced injuries, reduced staff turnover, higher staff satisfaction, reduced lengths of stay, and cost savings (Huckshorn, 2006). Constant observation has been criticised for "the absence of demonstrable effectiveness"—due to ethical constraints, no randomised controlled studies have been conducted (Bowers & Park, 2001).
No-suicide contracts—once standard practice—now represent contraindicated interventions. There is "not a shred of empirical evidence" for their effectiveness, and evidence suggests they "do not decrease liability and may do the opposite, including increasing risk for suicidal behavior" (Rudd et al., 2006, p. 242).
Peer contagion in adolescent inpatient settings is documented. Taiminen and colleagues (1998) found deliberate self-harm incidents were statistically clustered in a closed adolescent psychiatric unit (p<0.05) and could spread to previously self-harm-naive adolescents. Research on adolescent psychiatric units identifies iatrogenic factors including socialisation of unsafe behaviours and harmful effects of witnessing coercive practices (Bryson et al., 2017).
Cassidy and colleagues' (2014) research on autism and suicide reveals profound gaps. In a clinical cohort study of 374 adults diagnosed with Asperger's syndrome, 66% reported lifetime suicidal ideation—more than nine times higher than the general UK population—and 35% reported suicide plans or attempts. Critically, more adults reported suicidal ideation (66%) than depression (31%), indicating a different pathway to suicidality than in the general population. Yet no evidence-based suicide prevention interventions have been developed specifically for autistic people (Cassidy et al., 2018).
Autistic individuals encounter "stigma, miscommunication and a lack of understanding within healthcare systems" (Camm-Crosbie et al., 2019, p. 1). Camouflaging autistic traits is associated with suicidal thoughts (Cassidy et al., 2020). Standard interventions designed for neurotypical populations may cause harm through sensory overload, communication mismatches, and failure to recognise autistic presentations.
The distinction between ego-dystonic and ego-syntonic suicidal ideation has clinical significance often overlooked in standardised assessment. Suicidal obsessions in OCD are intrusive, unwanted thoughts causing significant distress—individuals fear acting on them—whereas suicidal ideation typically aligns with feelings or desires (Wetterneck et al., 2020). In OCD, suicidal thoughts are symptoms to be treated as obsessions through Exposure and Response Prevention; mistaking them for genuine suicidal intent can lead to inappropriate hospitalisation and counterproductive safety planning that "feeds into and worsens OCD" (Abramowitz & Jacoby, 2014, p. 192).
Prevalence data reveals that 94% of people experience unwanted intrusive thoughts according to Radomsky and colleagues' (2014) international study across six continents. The "high place phenomenon"—sudden urge to jump from heights—affects over 50% of non-suicidal individuals (Hames et al., 2012). The content of intrusions is indistinguishable between clinical and non-clinical populations; the difference lies in interpretation and response. Thought-Action Fusion—believing that thinking about something makes it more likely to occur—may maintain suicidal distress by increasing cognitive preoccupation, while thought suppression attempts paradoxically increase intrusion frequency (Rassin et al., 2001).
The concern that asking about suicide "plants" ideas has been definitively refuted. Gould and colleagues' (2005) randomised trial with 2,342 high school students found no difference in distress or suicidal ideation between those receiving suicide questions and controls; high-risk individuals with depression and suicide history who received assessment reported lower distress and ideation than high-risk controls. DeCou and Schumann's (2018) meta-analysis of 13 studies (5,562 participants) found no significant iatrogenic effects from assessing suicidality. However, questioning style matters—the mechanism for benefit may involve interpersonal connectedness during assessment (Dazzi et al., 2014).
Open Dialogue, developed in Western Lapland, Finland, offers a radically different approach. Core principles include immediate response within 24 hours, social network involvement, flexibility and mobility (meeting in homes), psychological continuity with the same team throughout, tolerance of uncertainty, and dialogism where all voices are heard (Seikkula & Olson, 2003). Five-year follow-up studies show 83% of first-episode psychosis patients returned to work or studies, 77% had no residual psychotic symptoms, and only 33% used neuroleptic medications versus 100% in comparison groups (Seikkula et al., 2006). The approach treats crisis as interpersonal phenomenon requiring immediate social network response rather than individual pathology requiring institutional containment.
It must be noted that the evidence base, while promising, has limitations: the original Finnish studies involved small samples (n=42) in a demographically homogeneous region. The ongoing ODDESSI randomised controlled trial in the UK will provide more robust evidence (Freeman et al., 2019).
The Trieste model, originating with Franco Basaglia's transformation of Italian mental health services culminating in Law 180 (1978), abolished psychiatric hospitals entirely. Trieste reduced from 1,200 psychiatric beds to only 6 general hospital beds and 30 community centre overnight beds (Mezzina, 2014). After implementing Intensive Home Treatment in 2017, compulsory admissions dropped 78.8% within one year (Mezzina et al., 2019). Guiding principles include "freedom is therapeutic," social recovery through human connection, and "relentless negotiation" rather than coercion.
Chandler and Lalonde's (1998) cultural continuity framework demonstrates that suicide rates vary dramatically across First Nations communities in British Columbia—some with rates 800 times the national average, others with virtually zero suicides. Six markers of cultural continuity predict suicide rates: self-government, land claims engagement, control over education, control over police and fire services, cultural facilities, and health services control. Youth suicide links to inability to maintain coherent sense of self across time; community-level cultural continuity acts as "hedge against suicide" (Chandler & Lalonde, 1998, p. 191). The implication challenges individualised clinical intervention in favour of collective cultural restoration.
The Hearing Voices Movement offers a parallel model. Beginning in the late 1980s through collaboration between Dutch psychiatrist Marius Romme and voice-hearer Patsy Hage, the movement established that voice-hearing is a natural human experience (2-6% of the general population hears voices), diverse explanations should be accepted and valued, and acceptance proves more helpful than suppression (Romme & Escher, 1993). Approximately 70% of voice hearers report onset after severe trauma or emotional events. Non-patients differ from patients in self-efficacy and anxiety, not voice characteristics (Romme et al., 2009). The framework suggests suicidal thoughts might similarly be understood as meaningful responses to circumstances amenable to narrative exploration rather than purely pathological symptoms requiring elimination.
The paracetamol overdose threshold question illuminates how self-harm statistics are partially constructed through clinical guidelines. The same underlying population behaviour produces dramatically different statistics depending on treatment thresholds, definition breadth, uncertainty management protocols, administrative coding, and admission policies—which show four-fold variation between hospitals (Bateman et al., 2014).
The UK's 2012 MHRA changes—triggered by a single death leading to coroner's concern—lowered the treatment threshold from 200 mg/L to 100 mg/L for all patients, ceased risk factor assessment, and mandated treatment for all staggered or uncertain overdoses. Hospital presentations increased 8.9%, admissions increased 7.1%, and NAC treatment increased 13.2% (Bateman et al., 2014). The estimated cost per life saved reached £17.4 million—estimated to save less than one life every two years. The guideline change captured many "therapeutic excess" cases (accidental over-medication for pain), shifting them into "overdose" statistics alongside intentional self-harm.
This has profound implications for interpreting epidemiology. Apparent "epidemics" can emerge from definitional expansion rather than behavioural change. Guideline revisions driven by single-case medico-legal concerns create real increases in recorded presentations without proportionate mortality benefit.
The genealogical evidence suggests several conclusions. First, current Western categories of "self-harm" and "suicide" represent historically specific constructions rather than natural kinds—they emerged from particular religious, legal, medical, and professional processes and vary dramatically across cultures. Second, the evidence base for core interventions is weaker than commonly assumed: risk assessment performs little better than chance (Franklin et al., 2017), hospitalisation shows paradoxical associations with harm (Chung et al., 2017; Large et al., 2019), coercion damages therapeutic relationships and produces trauma (Cusack et al., 2018), and some populations (autistic individuals, adolescents) face specific iatrogenic risks. Third, alternative frameworks emphasising community, dialogue, cultural continuity, and non-coercion show promising outcomes where implemented (Chandler & Lalonde, 1998; Mezzina et al., 2019; Seikkula et al., 2006).
This analysis does not suggest abandoning clinical response to genuine crisis, but rather calls for epistemic humility about what current categories capture, attention to potential harms of intervention, and serious engagement with alternatives. The Adverse Childhood Experiences research demonstrates that almost two-thirds of adult suicide attempts are attributable to ACEs (Dube et al., 2001)—suggesting upstream prevention through safe, stable, nurturing environments may accomplish more than downstream risk assessment. Structural interventions addressing housing, employment, social connection, and community belonging address the conditions Durkheim (1897/1951) identified as generating anomic and egoistic suicide.
The critical suicidology movement argues for understanding suicidal distress as "a question of social justice rather than individual pathology" (White et al., 2016, p. 2). White (2017) defines the movement as "rethinking what it means to study suicide and enact practices of suicide prevention in more diverse and creative, less psychocentric and less depoliticized, ways" (p. 473). The evidence supports this reorientation. When 60% of suicides occur among those categorised as "low risk" (Large et al., 2016), when post-discharge rates reach 100 times baseline (Chung et al., 2017), when cultural continuity predicts community suicide rates better than clinical variables (Chandler & Lalonde, 1998)—the imperative shifts from perfecting individual prediction and containment toward transforming the social conditions that produce despair.
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