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 psychother- apy, 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 psycho- dynamic 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

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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 into the developing ego. These early psychoanalytic theories of the devel- – opment of the self from the body were elaborated Written on the body self-harm as by Anzieu’s idea that the ego was constructed as a communication ‘skin ego’ through the baby’s early contact with Self-harm and suicide may be understood to be man- the mother’s skin (Anzieu 1974), and Bick’s ifestations of disorders of the self; as attempts, albeit emphasis on the ‘holding’ function of the skin in pathological, to reinstate the boundary between demarcating a boundary between what is experi- mind and body, and to communicate and resolve enced internally within the body and mind, and childhood trauma. Freud (1914) proposed that what is external (Bick 1968). The early internal acting out was the substitute for remembering trau- physical sensations experienced by the infant are matic childhood experiences and was unconsciously continually modulated by the mother’s affective aimed at reversing that early trauma. The person is state and love for her child in their close physical spared the painful early memory of the trauma and, exchanges, including touch, gaze, smell and via action, masters the early experience, which was

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originally suffered passively. However, if these early BOX 2 Primitive defence mechanisms memories and feelings cannot be symbolised or repre- sented in the mind, they remain unconscious and Acting out Expressing an unconscious wish Projective identification Powerful projec- unprocessed and will continue to be expressed in or fantasy through impulsive action as a way tion of unacceptable aspects of the self to action. This is the essence of what Freud (1920)saw of avoiding experiencing painful affects. someone else, so that the target of the pro- as the repetition compulsion. Idealisation Experiencing others as perfect jection is unconsciously pressurised to Suicide and self-harm may be seen as acts with to avoid anxiety or negative feelings such as behave, think and feel in keeping with what unconscious meanings, communications that convey contempt, envy or anger. has been projected into them. in action repressed thoughts, feelings and fantasies Projection Expelling unacceptable aspects Splitting Division or polarization of self and that cannot be allowed into consciousness or put of the self and attributing them to someone or other into good and bad by focusing select- into words. Previous traumas involving neglect or something else. ively on their positive or negative attributes to abuse of the person’s body in infancy or childhood avoid conflict. cannot be mentalised and remain trapped in the body. Adshead (2016) describes how in self-harm the body becomes the medium of communication in to the person. In Mourning and Melancholia which a form of mapping or writing on it registers (Freud 1917), he describes how mourning is the internal dynamics of relationships with self and impeded if ambivalence and hostility predominate others. towards the lost object, and a state of melancholia ensues. The hated object is incorporated within the The body boundary self, which is then attacked as if it were the object. Self-harm involves a breach of the boundary of the In other words, underlying suicide and acts of self- body – either the skin in cutting, or through inges- destruction are attacks on the self that is uncon- fi tion of medication or poison. The body boundary sciously identi ed with someone whom the person connects the external with the internal, the mind has hated and lost. and the body, and the self and others. The body vio- In children who have been abused, the abuser may fi lation and actual penetration of the skin may be seen be internalised in the psyche as a dangerous gure, as a repetition and unconscious enactment, where yet one with whom there is a deep involvement the opening up of the skin and flow of blood may and from whom it is hard to break free. This is espe- communicate an unconscious wish to excise and cially complicated if the abuser is someone who was expunge what is felt to be bad and to rid the previously trusted and loved, such as a parent. person of unbearable thoughts and feelings (Box 3). Angry and aggressive feelings towards the abuser Crossing the body boundary may represent a tran- are experienced as unacceptable, because the sition: the transition from outside to inside with the object of these destructive feelings is the very ingestion of poisons, from inside to out with the flow person the child is dependent on for support and of blood, from internal mental life to external reality. care. This creates a psychic dilemma where the The idea of transition suggests that self-harm may child simultaneously perceives and confuses the be a communication of difficulties faced at points good object with the bad behaviour. The ensuing 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 BOX 3 Clinical vignette: violation of the body significant others. In clinical practice, suicidal patients are at increased risk at points of transition Clara, a 23-year-old woman, presented to mental health services with a chronic history of cutting her legs, abdomen between care-providers, for example following dis- and genitals. Inquiry into the motivations of her self-harm charge from an emergency department or psychi- revealed that cutting her skin provided an outlet for feelings atric in-patient unit to care in the community of revulsion about her body. Clara associated this with (Crawford 2004)(Box 4). being sexually intruded upon in childhood and adolescence by her mother, who insisted on cleaning and ‘washing out’ Aggression towards self and others Clara’s vagina until she was 15. She felt that her body had been irreversibly damaged and that her insides were a Suicide and self-harm are activities that can be disgusting mess. This internal ‘mess’ could affect any part understood in relational terms, in which, as of her body: she feared that the dentist would discover described above, early adverse experiences result revolting decay in her mouth, or that her acne would spread in internal representations of the self and others rampantly all over her skin and repel everyone. Piercing her that have not been fully differentiated. Freud pro- skin and seeing blood oozing from her wounds offered posed that suicide resulted from internalised anger temporary relief by ‘washing out’ toxic parts of her body. that had been originally directed at someone close

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the person’s life. These include what he calls the BOX 4 Clinical vignette: idealisation, merger and separation ‘revenge fantasy’, the ‘assassination fantasy’ and the ‘merging fantasy’. In the revenge fantasy, the Anne was in her late 30s when she was seen therapist would find that she had burnt her- aim is to make others suffer for how they have mal- for individual psychotherapy for severe self while he was away. It seemed as if she treated the person. In the assassination fantasy, depression. She had taken a serious overdose did not have a good enough internal object which is more common in those with psychosis, the following the end of a brief relationship that that she could turn to, and she had to protect body is experienced as a source of madness, which had promised hope. She self-harmed by her wished-for idealised absent mother– must be killed off so that the self survives: the burning the skin on her arms, which left deep therapist and turn her hatred on herself for her person is therefore acting in self-defence. In the scarring. Anne had been adopted as a baby by early loss. As the ending of her therapy drew merging fantasy, which Hale believes underpins all a kind and committed couple and she did not close, Anne became fraught with anxieties other fantasies, the suicidal wish is to merge with know about her biological family. about whether she would survive or kill her- an omnipotent mother to attain a state of timeless self, and she withdrew from therapy and During the course of therapy her therapist bliss and to escape the intolerable pain of living. became an idealised parent figure. He felt a isolated herself at home. It was only with the Maltsberger & Buie (1980) contextualise this regres- deep empathy for her, but felt drawn into this close involvement of her psychiatric team that sive suicidal quest in what they describe as the myths idealised position, which he needed the help she was able to return to therapy and start to of supervision to process. It was as if there process some of her feelings about ending of religious beliefs, the collective expression of com- was no room for her therapist to be anything and become more aware of her hostility to her monly shared fantasies in which the wish for – other than a perfect ‘other’ in Anne’s mind therapist now recognised as a complex merger accompanies the fantasy of death as a – and in her therapy. Breaks in the therapy object, neither all good or all bad for passage into the new world of infinite peace. became difficult for Anne to bear and the abandoning her. Therapy was ended safely. Gardner (2001) 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 unbearable confusion, rage and horror are interna- often described an ambivalence about separation lised as parts of the bad self, allowing the child to from their mothers. She proposes that their self- hold onto a fantasy of the loved and needed object harm is based on an unconscious fantasy of being as good. This may result in the child believing that stuck with an overwhelming, malevolent and avar- they are to blame for what took place, so that icious maternal figure. She observed in these harming their own body may be seen as punishment women’s relationship with their mothers an ‘intrap- for any gratification that may have been experienced sychic struggle characterised by a quality of enslave- and to assuage an unconscious sense of guilt. ment and a longing to cut the ties that so tightly Self-harm may also be a way of reversing the help- bound this relationship’ (Gardner 2001: p. 12). lessness and powerlessness experienced in the face of She suggests that this psychic conflict stems from abuse. The child may manage these feelings via the development of early object relationships where passive resistance and dissociation, which, as psy- the self is captivated and held in thrall by a particu- chological defences, provide a sense of personal lar aspect of the mother that threatens complete control and power in a situation where these are incorporation. This forms a tyrannical inner object not possible. However, these coping mechanisms configuration which overwhelms the child and may then become incorporated into the self, becom- from which there is ambivalence about separation, ing a way of being and relating in which the child leading to a desperate oscillation between going feels different and distant from others and wary of towards and away from the malevolent figure. She future relationships. Self-harm may represent the also observed that the young women appeared to desire to regain control over the abuser; however, be enthralled in a state of mind that she termed the abuser is now part of the self and becomes con- ‘encaptive’. This involves a sense of being captivated fused with the victim self, so that the self-destructive and intensely involved with the object in an omnipo- act represents an unconscious attack on both perpet- tent pact, and a wish to get away from the object’s rator and victim. possession, manifest as withdrawal and aggression turned on the self (Box 5). Unconscious fantasies Hale describes various fantasies that are expressed Pathways to suicide by suicidal people (Hale 2008). Over a period of 25 Although for many individuals who self-harm there years he interviewed more than 500 individuals is no conscious intention to kill themselves, for who had been admitted following a suicide attempt. others the boundary between the acts of self-harm These suicidal fantasies, which vary in their level of and suicide are not so clear cut. In her paper conscious awareness, elaborate the relationship Addiction to Near Death, Joseph (1982) highlights between the self, the body and significant others in how compulsive and addictive the urge to self-

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BOX 5 Clinical vignette: confusion of self/other BOX 6 Clinical vignette: addiction to near- boundaries death

Clara (described in Box 3) experienced her relationship with William had been referred to drug and alcohol services for her mother as a confusion of boundaries and lack of dif- alcohol dependence and addiction to benzodiazepines, and ferentiation. As an adult, Clara moved to another country to was receiving treatment in a relapse prevention group. escape her mother and speak a language different from her Although expressing a wish to remain abstinent, William ‘mother tongue’, but she felt compelled to telephone her continued to procure diazepam over the internet; he took every day. She remembered making an active decision in this in such large doses that the other group members adolescence to hate her mother, but began to experience became very worried for his safety. William denied actively suicidal feelings and started to self-harm by cutting. We wanting to kill himself, but said he was addicted to the may conceptualise her mother’s sexually intrusive behav- feeling of being ‘on the edge’–on the border of con- iour as interfering with Clara’s ability to separate her own sciousness and unconsciousness, hovering between life body from her mother’s body, so that she was unable to and death. Group sessions became dominated by William’s internalise a stable body image that could adequately excited accounts of drug-induced euphoria, leaving the defend her against separation anxiety. Confronted with her other group members not knowing whether they would see developing sexual body at puberty, Clara’s previously him alive at their next meeting. Here we can see that all unconscious hatred of her mother’s body became con- feelings of despair and helplessness were projected into scious, but Clara remained unconsciously unable to distin- the other group members, while William remained guish between her own sexual body and that of her omnipotent and in control of the group. Only when he was mother’s, the hatred became directed at herself, and was told that he could not remain in the group if he did not enacted in self-harm. address his drug addiction did he admit to seriously plan- ning to kill himself because of the hopelessness of his life, and accepted intervention from the crisis team.

harm may become. This may be due, in part, to the physical release of endorphins following cutting of developed. This state of mind is usually triggered the skin, but cutting may also hold a significant psy- by an interpersonal event that the person experi- chological function for the person. Joseph concep- ences as a rejection or betrayal, and may last for tualises this psychoanalytically as the pull of the hours or days. However, at some stage there is a individual by the death instinct into a private place final trigger that precipitates the person into a confu- of violence, a no man’s land between life and death sional state in which feelings and thoughts become where the person is unreachable by others on the fragmented. The trigger will vary according to the side of the living. Joseph’s ideas are pertinent to individual and circumstances, but in Hale’s experi- the current era of the internet, where someone with ence usually involves a perceived rejection. The suicidal thoughts can hide with like-minded indivi- trigger may be as apparently innocuous as a verbal duals in a secret arena in which their fantasies may insult, a look or a turning away of the other person, be rehearsed in virtual reality. but the suicidal person experiences it as a psychic Hale (2008) describes a suicidal fantasy that he assault. This pushes the person into a mental calls ‘dicing with death’, in which the person state in which the distinction between fantasy and gambles their life according to fate, assigning reality becomes blurred and more mature ego responsibility for life to others. Joseph elaborated defence mechanisms fail, allowing into consciousness further the intrapsychic and interpersonal function unacceptable ideas and feelings that must be expelled of this fantasy in emphasising how the destructive immediately by primitive physical defences. The part of the mind triumphs over the more healthy body boundary is now crossed and the suicidal part. The person remains trapped in an excited but fantasy is translated into physical action. Once this very dangerous state of omnipotence and destruc- crucial border between mind and body is breached, tiveness, in which any feelings of vulnerability and it becomes easier to discharge intrapsychic tension hopelessness are projected into the therapist. When via a physical pathway, which may be one explan- this manic defence breaks down, excitement is ation for the fact that the most important actuarial replaced with desperation, virtual reality becomes risk factor for future suicide is previous suicide concrete reality, and suicidal thoughts are put into attempts. action (Box 6). In his work with suicidal patients, Hale describes what he observed as a common pathway to suicide in Self-harm as a sign of hope which the person enters into a ‘pre-suicidal state’ In contrast to the devastating aftermath of com- (Ringel 1976) where the suicidal fantasies become pleted suicides, Motz (2009) suggests that self- more conscious and plans for the suicidal act are harm is fundamentally an attempt to stay alive

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through its communicative aspects and powerful self-destructive ideation and behaviour can be function for the person, and must be clearly distin- accessed. Managing the patient’s acute risk is, of guished from a suicidal attempt. She draws on course, the primary task; but following self-harm Winnicott’s(1956) notion of the anti-social ten- the patient’s psychological defences are weaker dency as a sign of hope, in that the act of aggression and the patient may be more conscious of the under- or delinquency, apparently destructive and hope- lying triggers, beliefs and emotions that preceded the less, reflects the person’s hope that an environment act. This is therefore an important time for the clin- exists that can recognise and meet their needs. She ician to assess the patient’s mental state – not only to cites Straker (2006), who studied transcripts from ascertain on-going risk, but to gain understanding of people who self-harmed that were often more elo- more unconscious motivations before these are lost quent than expected if self-harm is solely viewed as from sight as the patient becomes more defended. an inability to verbalise. Straker proposes that self- The clinician’s countertransference is a tool through harm is more than just a form of communication, which the patient’s internal world may be accessed but is an act of self-creation and self-identification. (Box 7). Countertransference refers to the therapist’s She describes cutting as ‘signing with a scar’,in thoughts, feelings and responses to the patient, which self-mutilation is not inferior to words, but which reflect the patient’s unconscious mental may be a more meaningful language for the person states. Countertransference may be understood as an who is discovering herself. unconscious communicative process in which the Linking to cultural and theological theories of self- patient uses primitive defence mechanisms, such as harm, Motz (2009) talks of the ‘flesh-made word’, projection and projective identification, to rid where self-harm is a transformational act anchored themselves of affects and object relationships that in cultural and religious practices that signify the they cannot recognise as internal to themselves, presence of other unseen aspects of the self which by projecting and attributing them to others. are made explicit through scarring. This is linked Countertransference is seen as a source of useful to the work of Favazza (1996), who, through his information about the patient, in that the therapist’s study of the cultural significance of scarification, response to the patient may reflect how other proposes that the scars resulting from self-mutila- people respond to the patient, thus providing informa- tion have symbolic meaning relating to notions of tion about the patient’s internal object relationships. rebirth, continuity of life and stability of relation- ships. Favazza describes self-harm as the deliberate Containment versus acting out destruction of one’s body tissue without conscious suicidal intent. Self-injury is understood as a For people who self-harm or are suicidal, the clin- morbid form of self-help, temporarily alleviating dis- ician may become the unwitting recipient of the tressing symptoms, and attempting to heal, to attain patient’s unwanted feelings. Feelings of aggres- some measure of spirituality and to establish a sense sion, hatred, hopelessness, desolation, anguish of personal order. and despair are expelled through self-violence or projected into those around them. These are para- doxically often the people who are trying to help The role of countertransference in the assessment and management of self-harm and suicide attempts BOX 7 Countertransference Many patients who self-harm or have suicidal thoughts are treated with a lack of empathy, and • Countertransference refers to the thoughts, feelings and even hostility, by healthcare professionals. emotional reactions that the therapist/clinician has Patients may feel that more importance is paid to towards the patient their physical health, rather than their mental • It is an unconscious process that the therapist may not state (Cole-King 2013). Self-harm is often viewed be fully aware of as deliberately ‘attention-seeking’, which is seen as • It arises from the projections of the patient’s unwanted a negative behaviour that should be discouraged. thoughts and feelings, as well as unresolved conflicts, However, people who self-harm may indeed be into the therapist seeking attention, but their attention-seeking is a • It provides information about the patient’s expectations plea for compassion and understanding of the of relationships unconscious communications in which action has • Awareness of, and reflection on, countertransference taken the place of words. allows the clinician to act more thoughtfully towards The immediate aftermath of a suicide attempt or the patient, rather than making unthinking and some- act of serious self-harm may be a window in which times unhelpful responses the underlying fantasies that fuel the person’s

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them, as any care is experienced as untrustworthy and dangerous and must therefore be killed off. BOX 8 Clinical vignette: an enactment of countertransference The dilemma facing the healthcare professional Dr S, a core trainee in psychiatry, while on discussion of this patient in the Balint group is to accept the self-harm while enabling the call at night, was asked by the nursing staff to for core trainees run by a consultant medical patient to gradually recognise and own their see a patient on the ward who had a diag- psychotherapist, Dr S realised that the patient aggression towards themselves and others. This nosis of emotionally unstable personality was unconsciously splitting the staff looking means that the clinician must receive and disorder and a history of severe self-cutting, after her. Dr S’s negative countertransferen- contain thoughts, feelings and conflicts that the and who was expressing suicidal ideation. tial feelings reflected the patient’s destruc- patient cannot tolerate, understand their uncon- However, when Dr S interviewed the patient tive feelings, which the patient disowned and scious meaning and communicate this back to she denied feeling suicidal and said that the projected into Dr S. the patient in a form that the patient can bear, nurses were always interfering and exagger- The patient was also experiencing as enabling the patient to gradually comprehend ating things. The nurses insisted that half an intolerable any hopeful feelings reflecting and verbalise emotions, experiences and memories hour earlier the patient had expressed a wish progress and this was projected into the that were felt to be unbearable. The therapist is to die, and said they were concerned as they nursing staff, whose care she denigrated. felt she had been making progress. Dr S found unconsciously asked to perform the dual role of Unable at the time to reflect on her affective herself, by contrast, feeling annoyed and retaining hope while surviving the patient’s hostil- state, Dr S had instead acted out by chastis- resentful and wondered why a patient with a ‘ ’ ity and aggression. This is often not easy as the ing the nurses and cutting off the patient, primary diagnosis of personality disorder had mirroring the patient’s ‘cutting out’ of professional’s own unconscious conflicts – of been admitted as an in-patient. She told the intolerable states of mind that she could only faith and faithlessness, of love and hatred, of lone- nurses they were wasting her time, and communicate by cutting her body. liness and longing – may become entangled with abruptly interrupted the patient’s discourse, those projected by the patient, which may result saying that she was clearly fine. During in confusion and re-enactments. Here, the profes- sional 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 the frequency of self-harm, but this finding was out in unhelpful and sometimes destructive based on low-quality evidence. Other therapeutic ways, thus mirroring the patient’s self-destructive- approaches were mostly evaluated in single trials ness (Box 8). The importance of clinical supervi- of moderate to very low quality and therefore the sion and other facilitative spaces for clinicians evidence relating to these interventions was and other professionals involved in the care of inconclusive. people who self-harm or are suicidal to reflect However, there is a growing body of empirical evi- on their responses, acknowledge and process dence from high-quality outcome studies to show negative feelings, and understand their meanings that psychodynamic psychotherapy is as effective must not be underestimated. as psychological interventions such as CBT in the treatment of a range of mental disorders (Shedler 2010; Driessen 2013; Yakeley 2014). This includes Psychodynamic psychotherapy for self- recent evidence of the effectiveness of psycho- harming and suicidal patients dynamic psychotherapy in patients with treatment- Although there is some evidence showing the effi- resistant depression, a population in which the rate cacy of psychological interventions in reducing the of suicide attempts and completed suicides is signifi- repetition of self-harm episodes compared with cant (Fonagy 2015). routine care, the evidence base is hampered by Psychodynamic psychotherapy is just one of uncertainty and heterogeneity with respect to the several psychodynamically informed therapeutic population studied, treatment length, therapeutic interventions potentially available to psychiatrists to modality and setting, which lower the quality of assist in the overall treatment of suicidal and self- the evidence (National Collaborating Centre for harming patients, and we are not advocating that Mental Health 2012). A recent Cochrane review of all such patients should be referred for specialist psy- psychosocial interventions for self-harm in adults chotherapy. However, a psychodynamic understand- (Hawton 2016) showed that psychological interven- ing of the patient’s unconscious mental processes and tions based on cognitive–behavioural therapy motivations may guide clinical encounters and inter- (CBT) can result in fewer individuals repeating personal exchanges between patient and clinician, self-harm, although the quality of this evidence and contribute to the development of effectual multi- ranged from moderate to low. The review also modal and multidisciplinary approaches to the com- found that dialectical behaviour therapy for plexities and challenges that psychiatrists face in people with multiple episodes of self-harm or prob- their work with patients at risk of self-harm and able personality disorder may lead to a reduction in suicide.

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MCQs 2 Acting out: 4 Unconscious fantasies: Select the single best option for each question stem a may be a manifestation of the repetition a differ between self-harm and suicide compulsion b may only be understood in psychotherapy 1 In the development of the self: b represents symbolic thinking c are always based on lived experience a Freud proposed that the body image develops c may be a substitute for forgetting d may be linked to difficulties in separation from from the ego d embodies processed traumatic experiences primary caregivers b early psychoanalytic theories have not been e is a mature defence mechanism. e when triggered, always translate into physical substantiated by recent neurobiological studies action. c the ‘skin ego’ demarcates the ego from the id 3 Self-harm: d one effect of traumatic experiences may be lack a in psychodynamic terms equates with a suicidal 5 Countertransference: of differentiation between internal representa- act a is a negative phenomenon tions of self and others b is always an unconscious communication for help b is the opposite of transference e self-harm may represent the bodily enactment of c is often a manipulative behaviour c is always caused by the patient’s projections symbolised experiences. d always involves projective identification d only relates to the relationship between patient e always involves a relationship, whether con- and clinician sciously or unconsciously. e may provide understanding of the patient’s internal object relationships.

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