Layers of Meaning in Self-Cutting

Raine (1982) concludes her survey of the literature on the treatment of self-cutting in this way; “…a long term therapeutic relationship seems to be the only way to really help these patients … and opportunities for this are the exception rather than the rule”. Is it only the notorious lack of service provision that is responsible for this, or is there a therapeutic relationship at best uncertain and all too often perhaps perverted into a form of torture for both patient and therapist?

The “delicate self-cutting syndrome”, as Pao described it, produces patients who express a need and a wish for treatment; they may, however, be quite unable to use help. In the clinical material presented by Pao, he stresses the patients' inability to “get together with the therapist” and their lack of an “observing ego” available for treatment. The recurrence of cutting can provoke strong feelings in the therapist. Kafka reports the arousal of sadistic impulses toward the patient, and more recently Gabbard (1986) provides a vivid description of the anxiety and rage provoked by the patient's continued cutting.

Such reactions in the therapist imply a certain type of transference at work in the treatment of these patients. Podvoll describes the underlying dynamic of the self-cutting patient as “the flight…from symbiotic wishes towards a primitive love object to a reliance on the autoerotic use of one's own body”. It would follow that such a symbiotic urge and the defensive substitution of autoerotic stimulation would be re-enacted or at least attempted in the treatment relationship. Thus, from a different point of view, the developing transference does not consist of relations to an object so much as apparently, the vehicle for “self object” projections. Moberly (1986) uses Kohut's concept of self-object to show how, when there is insufficient self structure, some patients use the therapist to function as a substitute for psychic structure. Just as the cutting patient's bod