Psychodynamic Approaches to Suicide and Self-Harm

BJPsych Advances (2018), vol. 24, 37–45 doi: 10.1192/bja.2017.6 Psychodynamic approaches to ARTICLE suicide and self-harm† Jessica Yakeley & William Burbridge-James sociological approaches evolving from Durkheim’s Jessica Yakeley is a consultant SUMMARY work on the role of social control to contemporary psychiatrist in forensic psychotherapy, Director of the Portman Clinic, Rates of suicide and self-harm are rising in many notions of deviance, stigmatisation and self-expres- countries, and it is therapeutically important to and Director of Medical Education at sion (Taylor 2015); cultural approaches examining explore the personal stories and relationships the Tavistock and Portman NHS how suicide and self-harm vary across gender, ethni- Foundation Trust, London. She is also that underlie this behaviour. In this article psycho- city, sexual orientation and other cultural character- Editor of Psychoanalytic analytic and psychodynamic principles and con- Psychotherapy and a Fellow of the cepts in relation to violence towards the self are istics (Cover 2016); and philosophical and ethical British Psychoanalytical Society. introduced and the various unconscious meanings approaches exploring notions of utilitarianism, William Burbridge-James is a of suicide and self-harm are explored within a rela- autonomy and duty to others (Kelly 2011). More consultant psychiatrist in medical tional context and attachment framework. We recent psychopathological models include biological psychotherapy in Southend-on-Sea, Essex, and Chair of the Specialty describe how a psychodynamic approach may approaches studying the neurobiological correlates Advisory Committee of the Faculty of enhance the risk assessment and treatment of of self-injurious behaviour (Blasco-Fontecilla 2016) Medical Psychotherapy at the Royal patients presenting with self-harm and suicidality, and contemporary psychological approaches that College of Psychiatrists, London. particularly examining the role of transference have informed the development of effective thera- Correspondence Dr Jessica and countertransference within the therapeutic Yakeley, Portman Clinic, 8 Fitzjohns peutic interventions. All of these models overlap to relationship. Avenue, London NW3 5NA, UK. some extent, for example many viewing self-harm Email: [email protected] LEARNING OBJECTIVES as an expression of emotional distress. A psychodynamic perspective on self-harm and Copyright and usage • Understand historical and contemporary psy- © The Royal College of Psychiatrists choanalytic theories and concepts regarding suicidal behaviour is one approach that may com- 2018. the aetiology of suicide and self-harm plement others in its focus on affective experience, • Understand the different meanings and expres- unconscious meaning and interpretation within a † In the next issue of Advances, sions of acts of suicide and self-harm relational framework. In this article we will explore Jessica Yakeley will explore psychodynamic approaches to violence. • Understand the use of countertransference in the psychodynamics of self-harm and suicide, focus- the risk assessment and management of self- ing on how an understanding of the possible uncon- harm and suicide attempts scious meanings and functions of these manifestly DECLARATION OF INTEREST destructive acts against the self may assist in their assessment and management. The ideas introduced None. here will be illustrated with brief clinical vignettes, which have been anonymised to preserve confidenti- ality. A glossary of the psychoanalytic terminology The prevention of suicide and self-harm has been used in this article is provided in Box 1. high on the government’s agenda for the past 15 years. Although statistics and demographics are essential in identifying preventive measures or The development of the self high-risk groups for targeted interventions, they By definition, ‘self-harm’ refers to an act aimed at may also overshadow exploration of the myriad the ‘self’. But suicide and self-harm are also destruc- individual stories and relationships that lie behind tive acts against the body. How are the self and body each act of self-harm or suicide. related, and why would a person choose to damage Suicide and self-harm are acts of human behav- or destroy either? iour that take us to the limits of our comprehension. Freud proposed that the mind originally develops Contemporary debates as to whether the causes of from the body (Freud 1923). The ego is initially suicide are located within the individual or society derived from bodily sensations, especially those stem from the early seminal works of Freud (1917) coming from the surface of the body. As the baby and Durkheim (1897) respectively. Since then, becomes more oriented to the external world, pri- many theoretical frameworks have emerged that marily represented by the mother, its ego develops offer different conceptualisations and understand- via a gradual process of identification with the good- ings of the causes, associated factors and effects of ness of the mother in her provision of care and sus- self-harm and suicidal behaviour. These include tenance, which alleviates painful bodily feelings 37 Downloaded from https://www.cambridge.org/core. 01 Oct 2021 at 09:11:20, subject to the Cambridge Core terms of use. Yakeley & William vocalisations, which are gradually integrated to BOX 1 Psychoanalytic terminology form the developing body image; thus, the earliest sense of self is embedded and mediated through Death instinct The innate destructive force underlying bodily sensations. These psychoanalytic formula- human aggression, proposed by Freud (1920), that operates tions have been substantiated by more recent insidiously in opposition to the ‘life instinct’. studies that show the importance of early handling Ego In Freud’s structural model of the mind (Freud 1923), and touch for brain growth, stress and immune func- the ego mediates between the conflicting demands of the tion, attachment, the regulation of physiological id, superego and reality. The ego is the executive organ of the psyche, controlling motility, perception and contact systems, and the development of cognitive and affect- with reality, and, via the defence mechanisms located in its ive awareness of the body (Lemma 2010). unconscious part, the ego modulates the drives coming Attachment theory develops these psychoanalytic from the id. ideas further, in proposing that the development Identification A normal developmental process in which of the self occurs through the internalisation of dif- the qualities of another person are internalised and grad- ferent types of attachment relationship with signifi- ually become part of the self, as opposed to the more cant early caregivers, usually the mother, to form primitive process of ‘introjection’, where internal repre- ‘internal working models’ or representations of rela- sentations still feel like ‘other’. tionships with these caregivers (Bowlby 1969). A Mentalisation The capacity to reflect and think about secure sense of self develops in the presence of a one’s mental states, including thoughts, beliefs, desires loving and understanding primary caregiver who is and affects, and to be able to distinguish one’s own mental able to mirror the infant’s emotional states, to help states from those of others. the infant make sense of and differentiate its internal Object A significant person in the individual’s environ- and external environment, identify and tolerate ment, the first object usually being the mother. affects, regulate impulses, develop the capacity for Object relation(ships) The individual’s mode of relating symbolisation and reflection, and gradually develop to the world. Object relations theory, developed by psy- astablesenseofintegrity. choanalytic theorists such as Klein and Winnicott, proposes However, when there is a lack of attunement and that the child’s experience, perceptions and fantasies about sensitive mirroring between mother and infant, or their relationships with significant caregivers become when the child’s early experiences are frankly trau- incorporated in the mind at an early stage of development matic if parental figures are abusive, depriving or to become prototypical mental constructs that influence absent, the child internalises pathological attach- their mode of relating to others in adulthood. ment relationships and an impaired capacity to Repetition compulsion A manifestation of the death represent and regulate feelings. Here, the healthy instinct whereby a person’s unconscious tendency in adult development of the sense of self has been impeded life is to repeat behaviour associated with past traumatic and is poorly differentiated from internal representa- experiences, in an attempt to resolve feelings of helpless- fi ness and conflict (Freud 1920). tions of signi cant others. In psychoanalytic terms, the child’s ego remains fragile and relies on primitive defence mechanisms (Box 2) such as projection, pro- jective identification and splitting to avoid painful such as cold or hunger. Winnicott (1965) and Bion feelings. Anxiety-provoking experiences of the (1970) emphasised the role of the mother’s emotional infant’s body cannot be represented in the mind, relationship to the infant’s body, enabling the infant but are instead enacted and communicated via the to contain anxiety or physically painful states via body. Good and bad, self and other, inner and the mother’s physical and emotional presence, outer reality become confused. which is then internalised

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