In-Depth Work with Patients Who Self-Harm: Doing the Impossible?

This paper attempts to answer the following urgent question: is it possible to bring about psychic change without lengthy, intensive treatment? In the world of Cognitive Behavioural Therapy, CAT and the like, this is of critical concern for psychoanalytic practitioners. In this paper I try to show that psychoanalysis provides conceptual frameworks sufficiently robust to answer the question in the affirmative. Such a view suggests that practitioners have to continue to find ways of ‘translating’ psychoanalytic concepts into patient-specific behavioural and cognitive constructs in order to avert the danger of psychoanalysis being positioned within the NHS as something marginal or even irrelevant. The work described here shows how psychoanalytic thinking plays a central role in the treatment of highly disturbed patients. The clinical material aims to demonstrate how vital it is to understand the primitive projections and the inevitable countertransferences that emerge. It is through the practitioner's capacity to contain these powerful, anxiety-provoking dynamics that the daunting prospect of psychic work becomes possible for the terrified patient.