The development of the self

By definition, ‘self-harm’ refers to an act aimed at the ‘self’. But suicide and self-harm are also destructive acts against the body. How are the self and body related, and why would a person choose to damage or destroy either?

Freud proposed that the mind originally develops from the body (Freud Reference Freud and Strachey1923). The ego is initially derived from bodily sensations, especially those coming from the surface of the body. As the baby becomes more oriented to the external world, primarily represented by the mother, its ego develops via a gradual process of identification with the goodness of the mother in her provision of care and sustenance, which alleviates painful bodily feelings such as cold or hunger. Winnicott (Reference Winnicott1965) and Bion (Reference Bion1970) emphasised the role of the mother's emotional relationship to the infant's body, enabling the infant to contain anxiety or physically painful states via the mother's physical and emotional presence, which is then internalised into the developing ego.

These early psychoanalytic theories of the development of the self from the body were elaborated by Anzieu's idea that the ego was constructed as a ‘skin ego’ through the baby's early contact with the mother's skin (Anzieu Reference Anzieu, Lebovici and Widlocher1974), and Bick's emphasis on the ‘holding’ function of the skin in demarcating a boundary between what is experienced internally within the body and mind, and what is external (Bick Reference Bick1968). The early internal physical sensations experienced by the infant are continually modulated by the mother's affective state and love for her child in their close physical exchanges, including touch, gaze, smell and vocalisations, which are gradually integrated to form the developing body image; thus, the earliest sense of self is embedded and mediated through bodily sensations. These psychoanalytic formulations have been substantiated by more recent studies that show the importance of early handling and touch for brain growth, stress and immune function, attachment, the regulation of physiological systems, and the development of cognitive and affective awareness of the body (Lemma Reference Lemma2010).

Attachment theory develops these psychoanalytic ideas further, in proposing that the development of the self occurs through the internalisation of different types of attachment relationship with significant early caregivers, usually the mother, to form ‘internal working models’ or representations of relationships with these caregivers (Bowlby Reference Bowlby1969). A secure sense of self develops in the presence of a loving and understanding primary caregiver who is able to mirror the infant's emotional states, to help the infant make sense of and differentiate its internal and external environment, identify and tolerate affects, regulate impulses, develop the capacity for symbolisation and reflection, and gradually develop a stable sense of integrity.

However, when there is a lack of attunement and sensitive mirroring between mother and infant, or when the child's early experiences are frankly traumatic if parental figures are abusive, depriving or absent, the child internalises pathological attachment relationships and an impaired capacity to represent and regulate feelings. Here, the healthy development of the sense of self has been impeded and is poorly differentiated from internal representations of significant others. In psychoanalytic terms, the child's ego remains fragile and relies on primitive defence mechanisms (Box 2) such as projection, projective identification and splitting to avoid painful feelings. Anxiety-provoking experiences of the infant's body cannot be represented in the mind, but are instead enacted and communicated via the body. Good and bad, self and other, inner and outer reality become confused.

Written on the body – self-harm as communication

Self-harm and suicide may be understood to be manifestations of disorders of the self; as attempts, albeit pathological, to reinstate the boundary between mind and body, and to communicate and resolve childhood trauma. Freud (Reference Freud and Strachey1914) proposed that acting out was the substitute for remembering traumatic childhood experiences and was unconsciously aimed at reversing that early trauma. The person is spared the painful early memory of the trauma and, via action, masters the early experience, which was originally suffered passively. However, if these early memories and feelings cannot be symbolised or represented in the mind, they remain unconscious and unprocessed and will continue to be expressed in action. This is the essence of what Freud (Reference Freud and Strachey1920) saw as the repetition compulsion.

Suicide and self-harm may be seen as acts with unconscious meanings, communications that convey in action repressed thoughts, feelings and fantasies that cannot be allowed into consciousness or put into words. Previous traumas involving neglect or abuse of the person's body in infancy or childhood cannot be mentalised and remain trapped in the body. Adshead (Reference Adshead, Weldon and Van Velsen2016) describes how in self-harm the body becomes the medium of communication in which a form of mapping or writing on it registers the internal dynamics of relationships with self and others.

The body boundary

Self-harm involves a breach of the boundary of the body – either the skin in cutting, or through ingestion of medication or poison. The body boundary connects the external with the internal, the mind and the body, and the self and others. The body violation and actual penetration of the skin may be seen as a repetition and unconscious enactment, where the opening up of the skin and flow of blood may communicate an unconscious wish to excise and expunge what is felt to be bad and to rid the person of unbearable thoughts and feelings (Box 3).

Crossing the body boundary may represent a transition: the transition from outside to inside with the ingestion of poisons, from inside to out with the flow of blood, from internal mental life to external reality. The idea of transition suggests that self-harm may be a communication of difficulties faced at points of transition in life and the challenges these pose. These difficulties may be the echo of earlier points of transition in childhood and adolescence related to attachments and ruptures in relationships with significant others. In clinical practice, suicidal patients are at increased risk at points of transition between care-providers, for example following discharge from an emergency department or psychiatric in-patient unit to care in the community (Crawford Reference Crawford2004) (Box 4).

Aggression towards self and others

Suicide and self-harm are activities that can be understood in relational terms, in which, as described above, early adverse experiences result in internal representations of the self and others that have not been fully differentiated. Freud proposed that suicide resulted from internalised anger that had been originally directed at someone close to the person. In Mourning and Melancholia (Freud Reference Freud and Strachey1917), he describes how mourning is impeded if ambivalence and hostility predominate towards the lost object, and a state of melancholia ensues. The hated object is incorporated within the self, which is then attacked as if it were the object. In other words, underlying suicide and acts of self-destruction are attacks on the self that is unconsciously identified with someone whom the person has hated and lost.

In children who have been abused, the abuser may be internalised in the psyche as a dangerous figure, yet one with whom there is a deep involvement and from whom it is hard to break free. This is especially complicated if the abuser is someone who was previously trusted and loved, such as a parent. Angry and aggressive feelings towards the abuser are experienced as unacceptable, because the object of these destructive feelings is the very person the child is dependent on for support and care. This creates a psychic dilemma where the child simultaneously perceives and confuses the good object with the bad behaviour. The ensuing unbearable confusion, rage and horror are internalised as parts of the bad self, allowing the child to hold onto a fantasy of the loved and needed object as good. This may result in the child believing that they are to blame for what took place, so that harming their own body may be seen as punishment for any gratification that may have been experienced and to assuage an unconscious sense of guilt.

Self-harm may also be a way of reversing the helplessness and powerlessness experienced in the face of abuse. The child may manage these feelings via passive resistance and dissociation, which, as psychological defences, provide a sense of personal control and power in a situation where these are not possible. However, these coping mechanisms may then become incorporated into the self, becoming a way of being and relating in which the child feels different and distant from others and wary of future relationships. Self-harm may represent the desire to regain control over the abuser; however, the abuser is now part of the self and becomes confused with the victim self, so that the self-destructive act represents an unconscious attack on both perpetrator and victim.

Unconscious fantasies

Hale describes various fantasies that are expressed by suicidal people (Hale Reference Hale, Briggs, Lemma and Crouch2008). Over a period of 25 years he interviewed more than 500 individuals who had been admitted following a suicide attempt. These suicidal fantasies, which vary in their level of conscious awareness, elaborate the relationship between the self, the body and significant others in the person's life. These include what he calls the ‘revenge fantasy’, the ‘assassination fantasy’ and the ‘merging fantasy’. In the revenge fantasy, the aim is to make others suffer for how they have maltreated the person. In the assassination fantasy, which is more common in those with psychosis, the body is experienced as a source of madness, which must be killed off so that the self survives: the person is therefore acting in self-defence. In the merging fantasy, which Hale believes underpins all other fantasies, the suicidal wish is to merge with an omnipotent mother to attain a state of timeless bliss and to escape the intolerable pain of living. Maltsberger & Buie (Reference Maltsberger and Buie1980) contextualise this regressive suicidal quest in what they describe as the myths of religious beliefs, the collective expression of commonly shared fantasies in which the wish for merger accompanies the fantasy of death as a passage into the new world of infinite peace.

Gardner (Reference Gardner2001) also emphasises the fantasy of an omnipotent mother, but one that is experienced as persecutory. In her work with young women who were cutting, Gardner noted how these individuals often described an ambivalence about separation from their mothers. She proposes that their self-harm is based on an unconscious fantasy of being stuck with an overwhelming, malevolent and avaricious maternal figure. She observed in these women's relationship with their mothers an ‘intrapsychic struggle characterised by a quality of enslavement and a longing to cut the ties that so tightly bound this relationship’ (Gardner Reference Gardner2001: p. 12). She suggests that this psychic conflict stems from the development of early object relationships where the self is captivated and held in thrall by a particular aspect of the mother that threatens complete incorporation. This forms a tyrannical inner object configuration which overwhelms the child and from which there is ambivalence about separation, leading to a desperate oscillation between going towards and away from the malevolent figure. She also observed that the young women appeared to be enthralled in a state of mind that she termed ‘encaptive’. This involves a sense of being captivated and intensely involved with the object in an omnipotent pact, and a wish to get away from the object's possession, manifest as withdrawal and aggression turned on the self (Box 5).

Pathways to suicide

Although for many individuals who self-harm there is no conscious intention to kill themselves, for others the boundary between the acts of self-harm and suicide are not so clear cut. In her paper Addiction to Near Death, Joseph (Reference Joseph1982) highlights how compulsive and addictive the urge to self-harm may become. This may be due, in part, to the physical release of endorphins following cutting of the skin, but cutting may also hold a significant psychological function for the person. Joseph conceptualises this psychoanalytically as the pull of the individual by the death instinct into a private place of violence, a no man's land between life and death where the person is unreachable by others on the side of the living. Joseph's ideas are pertinent to the current era of the internet, where someone with suicidal thoughts can hide with like-minded individuals in a secret arena in which their fantasies may be rehearsed in virtual reality.

Hale (Reference Hale, Briggs, Lemma and Crouch2008) describes a suicidal fantasy that he calls ‘dicing with death’, in which the person gambles their life according to fate, assigning responsibility for life to others. Joseph elaborated further the intrapsychic and interpersonal function of this fantasy in emphasising how the destructive part of the mind triumphs over the more healthy part. The person remains trapped in an excited but very dangerous state of omnipotence and destructiveness, in which any feelings of vulnerability and hopelessness are projected into the therapist. When this manic defence breaks down, excitement is replaced with desperation, virtual reality becomes concrete reality, and suicidal thoughts are put into action (Box 6).

In his work with suicidal patients, Hale describes what he observed as a common pathway to suicide in which the person enters into a ‘pre-suicidal state’ (Ringel Reference Ringel1976) where the suicidal fantasies become more conscious and plans for the suicidal act are developed. This state of mind is usually triggered by an interpersonal event that the person experiences as a rejection or betrayal, and may last for hours or days. However, at some stage there is a final trigger that precipitates the person into a confusional state in which feelings and thoughts become fragmented. The trigger will vary according to the individual and circumstances, but in Hale's experience usually involves a perceived rejection. The trigger may be as apparently innocuous as a verbal insult, a look or a turning away of the other person, but the suicidal person experiences it as a psychic assault. This pushes the person into a mental state in which the distinction between fantasy and reality becomes blurred and more mature ego defence mechanisms fail, allowing into consciousness unacceptable ideas and feelings that must be expelled immediately by primitive physical defences. The body boundary is now crossed and the suicidal fantasy is translated into physical action. Once this crucial border between mind and body is breached, it becomes easier to discharge intrapsychic tension via a physical pathway, which may be one explanation for the fact that the most important actuarial risk factor for future suicide is previous suicide attempts.

Self-harm as a sign of hope

In contrast to the devastating aftermath of completed suicides, Motz (Reference Motz and Motz2009) suggests that self-harm is fundamentally an attempt to stay alive through its communicative aspects and powerful function for the person, and must be clearly distinguished from a suicidal attempt. She draws on Winnicott's (Reference Winnicott1956) notion of the anti-social tendency as a sign of hope, in that the act of aggression or delinquency, apparently destructive and hopeless, reflects the person's hope that an environment exists that can recognise and meet their needs. She cites Straker (Reference Straker2006), who studied transcripts from people who self-harmed that were often more eloquent than expected if self-harm is solely viewed as an inability to verbalise. Straker proposes that self-harm is more than just a form of communication, but is an act of self-creation and self-identification. She describes cutting as ‘signing with a scar’, in which self-mutilation is not inferior to words, but may be a more meaningful language for the person who is discovering herself.

Linking to cultural and theological theories of self-harm, Motz (Reference Motz and Motz2009) talks of the ‘flesh-made word’, where self-harm is a transformational act anchored in cultural and religious practices that signify the presence of other unseen aspects of the self which are made explicit through scarring. This is linked to the work of Favazza (Reference Favazza1996), who, through his study of the cultural significance of scarification, proposes that the scars resulting from self-mutilation have symbolic meaning relating to notions of rebirth, continuity of life and stability of relationships. Favazza describes self-harm as the deliberate destruction of one's body tissue without conscious suicidal intent. Self-injury is understood as a morbid form of self-help, temporarily alleviating distressing symptoms, and attempting to heal, to attain some measure of spirituality and to establish a sense of personal order.

The role of countertransference in the assessment and management of self-harm and suicide attempts

Many patients who self-harm or have suicidal thoughts are treated with a lack of empathy, and even hostility, by healthcare professionals. Patients may feel that more importance is paid to their physical health, rather than their mental state (Cole-King Reference Cole-King, Parker and Williams2013). Self-harm is often viewed as deliberately ‘attention-seeking’, which is seen as a negative behaviour that should be discouraged. However, people who self-harm may indeed be seeking attention, but their attention-seeking is a plea for compassion and understanding of the unconscious communications in which action has taken the place of words.

The immediate aftermath of a suicide attempt or act of serious self-harm may be a window in which the underlying fantasies that fuel the person's self-destructive ideation and behaviour can be accessed. Managing the patient's acute risk is, of course, the primary task; but following self-harm the patient's psychological defences are weaker and the patient may be more conscious of the underlying triggers, beliefs and emotions that preceded the act. This is therefore an important time for the clinician to assess the patient's mental state – not only to ascertain on-going risk, but to gain understanding of more unconscious motivations before these are lost from sight as the patient becomes more defended.

The clinician's countertransference is a tool through which the patient's internal world may be accessed (Box 7). Countertransference refers to the therapist's thoughts, feelings and responses to the patient, which reflect the patient's unconscious mental states. Countertransference may be understood as an unconscious communicative process in which the patient uses primitive defence mechanisms, such as projection and projective identification, to rid themselves of affects and object relationships that they cannot recognise as internal to themselves, by projecting and attributing them to others. Countertransference is seen as a source of useful information about the patient, in that the therapist's response to the patient may reflect how other people respond to the patient, thus providing information about the patient's internal object relationships.

Containment versus acting out

For people who self-harm or are suicidal, the clinician may become the unwitting recipient of the patient's unwanted feelings. Feelings of aggression, hatred, hopelessness, desolation, anguish and despair are expelled through self-violence or projected into those around them. These are paradoxically often the people who are trying to help them, as any care is experienced as untrustworthy and dangerous and must therefore be killed off. The dilemma facing the healthcare professional is to accept the self-harm while enabling the patient to gradually recognise and own their aggression towards themselves and others. This means that the clinician must receive and contain thoughts, feelings and conflicts that the patient cannot tolerate, understand their unconscious meaning and communicate this back to the patient in a form that the patient can bear, enabling the patient to gradually comprehend and verbalise emotions, experiences and memories that were felt to be unbearable. The therapist is unconsciously asked to perform the dual role of retaining hope while surviving the patient's hostility and aggression. This is often not easy as the professional's own unconscious conflicts – of faith and faithlessness, of love and hatred, of loneliness and longing – may become entangled with those projected by the patient, which may result in confusion and re-enactments. Here, the professional who has been invested with the patient's unwanted aspects may unconsciously identify with what has been projected into them and be unconsciously pressurised by the patient to act out in unhelpful and sometimes destructive ways, thus mirroring the patient's self-destructiveness (Box 8). The importance of clinical supervision and other facilitative spaces for clinicians and other professionals involved in the care of people who self-harm or are suicidal to reflect on their responses, acknowledge and process negative feelings, and understand their meanings must not be underestimated.

Psychodynamic psychotherapy for self-harming and suicidal patients

Although there is some evidence showing the efficacy of psychological interventions in reducing the repetition of self-harm episodes compared with routine care, the evidence base is hampered by uncertainty and heterogeneity with respect to the population studied, treatment length, therapeutic modality and setting, which lower the quality of the evidence (National Collaborating Centre for Mental Health 2012). A recent Cochrane review of psychosocial interventions for self-harm in adults (Hawton Reference Hawton, Witt and Taylor Salisbury2016) showed that psychological interventions based on cognitive–behavioural therapy (CBT) can result in fewer individuals repeating self-harm, although the quality of this evidence ranged from moderate to low. The review also found that dialectical behaviour therapy for people with multiple episodes of self-harm or probable personality disorder may lead to a reduction in the frequency of self-harm, but this finding was based on low-quality evidence. Other therapeutic approaches were mostly evaluated in single trials of moderate to very low quality and therefore the evidence relating to these interventions was inconclusive.

However, there is a growing body of empirical evidence from high-quality outcome studies to show that psychodynamic psychotherapy is as effective as psychological interventions such as CBT in the treatment of a range of mental disorders (Shedler Reference Shedler2010; Driessen Reference Driessen, Van and Don2013; Yakeley Reference Yakeley2014). This includes recent evidence of the effectiveness of psychodynamic psychotherapy in patients with treatment-resistant depression, a population in which the rate of suicide attempts and completed suicides is significant (Fonagy Reference Fonagy, Rost and Carlyle2015).

Psychodynamic psychotherapy is just one of several psychodynamically informed therapeutic interventions potentially available to psychiatrists to assist in the overall treatment of suicidal and self-harming patients, and we are not advocating that all such patients should be referred for specialist psychotherapy. However, a psychodynamic understanding of the patient's unconscious mental processes and motivations may guide clinical encounters and interpersonal exchanges between patient and clinician, and contribute to the development of effectual multimodal and multidisciplinary approaches to the complexities and challenges that psychiatrists face in their work with patients at risk of self-harm and suicide.