Erotized Transference and Self-Mutilation

In psychoanalytic work, the optimal progression of treatment includes securing a working therapeutic alliance, the ability to use interpretation, and the development and working through of a transference neurosis. In some patients this progression may be wildly askew. In this paper, I present the work with two patients with psychotic liabilities who developed erotized transferences to their outpatient psychotherapists followed by the onset of a new symptom—severe self-mutilation by cutting. In the context of such a transference, both patients were unable to maintain a reliable working alliance. Their ego strength was severely compromised, with the event of deep cutting taking each referring outpatient therapist by surprise. The intensity of the preoccupation with, and pursuit of, the therapist outside of the boundaries of a therapeutic relationship disrupted these treatments and led to repeated psychiatric hospitalizations and a state of chronic crisis management.

In both of these cases, the self-mutilating behavior first occurred in the context of an erotized psychotic transference. This new symptom suggests not only difficulty with affect regulation and cognition, but also relational difficulty within an erotized dyadic treatment. As with most symptoms, the underlying dynamic structure was multifaceted. In each case, perverse dynamics, sadomasochistic trends, difficulty with affect regulation, and severe self/other boundary disturbance was present. In this paper I focus on the symptom of self-mutilation as an attempt to manage an overwhelming psychotically erotized transference.