Sarah Chaney’s Psyche on the Skin is lucidly written, engagingly illustrated and refreshingly critical. It treads a fine line of critique, avoiding an unnecessarily confrontational approach (with mental health services), whilst making sure to point out the limitations of some psychiatric approaches to self-harm. Chaney’s critique is historical, as the title suggests. She argues with abundant justification that ‘Medical diagnoses – especially but not only in psychiatry – shift across time and culture …To assume that today’s ideas are “true” in a way that yesterday’s were not is to suggest that modern science is omniscient’ (p. 12).

The reflective stance chimes with Chaney’s decision to place herself and her experiences inside the narrative that she weaves. These experiences function largely as bookends, but important ones. The book opens with an arresting description of one interaction with a particularly unsympathetic – indeed downright unprofessional – general practitioner who refused referral to a charity service for scar-covering make-up (pp. 7–8). I am tempted to call this approach refreshing and honest, but I do not believe that self-harm is something that one needs to disclose in order to be ‘honest’ about it. There is nothing ‘dishonest’ about keeping such information private. The place of personal reflection in medical humanities scholarship (and academic scholarship more generally) has become a topic of concern in recent years. Chaney negotiates this with much skill, and her experiences truly enrich and help to situate her narrative.

Chaney tracks ideas of self-harm across diverse periods and cultures, with the predominant focus on the Victorian period – the subject of her PhD – where the analysis is detailed and comprehensive. However, I was not entirely convinced by the logic of the sweeping first chapter, ‘From Ancient Castration to Medicinal Bloodletting’. Chaney admits that these things were not all called self-harm (or even all thought to be harmful), but she uses these examples ‘to question the notion that self-harm can be thought of as a constant, universal human behaviour with a particular set of meanings’ (p. 12). I agree with that wholeheartedly, and with the logic that these things might be used as contrasts.

Her aim is to expose those who might cherry-pick examples from history to buttress an idea of an eternally valid self-harm. She defends this strategy robustly (especially pp. 48–50), although a number of questions remain. For example, why is a medieval flagellation in a book on self-harm? I understand that it is included because it isn’t self-harm, but this does strike me as a rather odd reason to include it. I feel that including things that are not self-harm muddies the water. Chaney uses this approach to argue that she does not ‘take modern definitions as a given from which earlier models depart’ (p. 17). However, she does seem to focus overwhelmingly on actions that break the skin. She uses the term, ‘self harm’ among others, ‘primarily to refer to self-inflicted acts resulting in tissue damage of some kind, although sometimes the way definitions are shaped in a particular era means that I touch on other behaviours, in particular overdosing and food refusal’ (p. 17). It hardly needs to be said – and I am sure that Chaney would agree – that breaking the skin is not necessarily harmful (in surgery or tattooing, for example), but it does leave me wondering why skin-breaking practices are afforded such prominence. Self-harm does not necessarily have much to do with the skin; this volume’s title sets the agenda on this point, but doesn’t explicitly justify it as much as I would have liked.

I found the best parts of the book (outside the detailed Victorian heartlands) to be on the rise of modern ‘trigger warnings’ in relation to self-harm epidemics in psychiatric institutions, and a fantastic chapter on ‘motiveless malingerers’ in the early twentieth century. The narrative is sharp, engaged and accessible, without ever being patronising. The archival work, from Bethlem, the Royal London, Queen’s Square and more, are examples of first-rate exegesis that avoids the bogged-down traps of ‘interesting archives’, keeping the vignettes short, punchy and relevant. On top of this, differences and similarities between periods and with the present are sensitively drawn and expertly deployed. As she deftly puts it regarding the supposedly hysterical ‘motiveless malingerers’, ‘We tend to assume today that a psychological approach must be “progressive”, simply because it aligns more neatly with modern understandings of self-harm’ (p. 141). Chaney meticulously avoids this assumption throughout.

One of the most interesting parts of this book is rather buried in the conclusion, where Chaney’s personal experiences resurface. She states:

It would be a mistake to reduce this work of history to a cathartic, therapeutic working-out of its author’s psychology. It is so much more than that – a broad, detailed, accessible, sensitive and critical work of history. But its sensitivity and its critical engine are just as much driven by the author’s commitments as by the detailed archival work. These strands are united in a fantastic history where the personal really is political, cultural and historical.