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Self mutilation
Journal of Adolescence x982, 5, x - I 3
Self mutilation WENDY J. B. RAINE* In this paper, the various theoretical avenues which have been explored in an attempt to understand the difficulties of self-mutilating patients, have led to the conclusion that the primary p r o b l e m is in the area of very early symbiotic object relationships, where skin assumes great significance, and where, in these patients, an unclear differentiation between mother and self has come about. Cutting the skin enhances the differentiation, and so can be seen as serving an adaptive function for the patient, although in terms of a therapeutic relationship, it is a major form of acting-out.
INTRODUCTION Aggression turned against the self can.take many forms. The young infant's scratching of his face, the older child's head-banging, nail-biting, hairpulling, major and minor accidents of all "kinds, deliberate self-injury and mutilation, suicide, psychosomatic illnesses, various forms of sadomasochistie behaviour, the inhibition of potential achievement, self-denigration, self-condemnation and guilt feelings, all contain the common element of aggression turned against the self. This paper deals with one specific form of aggression to the self--repeated acts of damage to the skin, by cutting, occasionally accompanied by burning, with no clear suicidal intent. Various aspects of this phenomenon are explored. A typical case
Rose, aged x5, was the elder of two girls, who first came to psychiatric attention after repeatedly running away from home with a school friend. The described change in her behaviour, from being an ideal, well-behaved daughter, to being difficult and rude, was put down to the influence of her * Consultant Child Psychiatrist, Department of Child and Family Psychiatry, Royal Hospital for Sick Children, Glasgow. ox4o-x97zI8z/oloooz + x3 $oz.oo/o
9 x98z The Association for the Psychiatric Study of Adolescents
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friend but the behaviour continued after the friend was taken into care, following a sexual incident with an elderly man during one of her running episodes. Rose witnessed this. Her behaviour became quickly worse, until she became openly aggressive towards her mother and her school teacher, threatening the latter with a broken bottle on one occasion. She periodically refused to attend school, and when there, would talk wildly about being fostered, hating her mother, and at other times would seem remote and supercilious towards her class-mates. During her admission to the Adolescent Unit in Glasgow, she began to scratch her wrists, tentatively at first but more deliberately and more frequently later. At first she said she wanted to kill herself, but soon this idea was dropped and she cut obviously to relieve tension, usually in the evening, or following an altercation with a staff member; and on one occasion she severely cut her arms and her face when her parents went off on holiday without her. Rose's mother was an identical twin, the passive member of the twinship, and an eternal dogsbody. She left home with her twin at the age of x4, to get away from their alcoholic and aggressive father. She spent the next t~velve years working with her sister and moving about the country, before they both became engaged within weeks of each other. Her ~vin's marriage failed because of her husband's aggression, and her own was also a failure because of her husband's alcohol difficulties and sexual infidelity. Although they stayed together, because Rose's mother was quite unable to put a stop to this relationship, she was openly derisory of her husband and set up an idealized and symbiotic relationship with Rose. This came to an abrupt end with Rose's adolescence and the onset of behavioural difficulties. Rose was a tall, thin girl with straight shiny fair hair, who held herself in a stilted and rigid manner, and who had difficulty in making good eyecontact. She seemed abrupt in relationships, but also seemed to welcome contact. She was boyish in appearance although she wore skirts and chose pastel colours, and kept herself aseptically clean. She demonstrated a very vivid fantasy life, talking with pleasure about what she saw as her ideal parents and an ideal home--endless food, a warm cosy nest, never-ending tolerance, gentle control, and no demands. Alternatively she would talk with excitement about knives, broken bottles, prison, robbing, and would sit on the edge of a chair biting her nails. She hated menstruation, hated boys and "all that stuff". At times in the ward she would threaten hunger strike, and certainly never over-ate. On a couple of occasions she took small overdoses of aspirin. On about three occasions, she went missing, and was found curled up and asleep, buried in a pile of dirty linen in a small linen cupboard. Another time she squeezed through a trap door in the ceiling, and lay in the space between the ceiling of one room and the floor of the room up above, for several hours, until she was found.
SELF M U T I L A T I O N
Other studies
There have been quite a few studies now of this phenomenon of delicate self-cutting (Offer and Barglow, i96o; Graft and Mallin, x967; Grunebaum and Klerman, x967; MeKerracher et al., x968; Rosenthal et al., x972; Novotny, x972; Bach-y-Rita, i974; Fabian et al., I973; Gardner and Gardner, i975), as it has been dubbed by Ping Nie Pao, in his contribution to a detailed study of the patients, carried out at Chestnut Lodge in the States (Pao, I969; Kafka, i969; Burnham, i969; Podvoll, x969). From them all, there appear certain common themes. The patient is usually a teenager or a young adult, and is very often female. They are often described as talented, intelligent, attractive, and these positive aspects can put into stark contrast the awful spectacle of the badly cut and bleeding patient. Wrists and arms are commonly used sites. Cuts may be many and fine or deep and destructive. Cigarette burns are common accompaniments. T h e act is often painless, and becomes painful later. T h e face is only occasionally attacked, the genitals even less frequently, in women especially. In men genital mutilation seems to comprise a slightly different syndrome. The patients may have many other symptoms of emotional disorder. Recurrent depression, abnormal eating patterns of bulimia and anorexia, promiscuity, tom-boy behaviour, or sexual inhibition (certainly profound confusion over sexual identity) addiction to drugs or abuse of alcohol are all listed. Of two controlled studies done (Rosenthal et al., i972; Gardner and Gardner, x975) , the cutting group has, however, been found to be very similar to a control group of patients in all symptoms except psychosexual disorders and eating disorders, which are both significantly more common in the cutting group. Many of the cases described in the literature are American, and attract a diagnosis of schizophrenia. However, it seems clear that these patients often have the capacity to cope and conduct their lives fairly competently on the surface, and show distinct and occasionally very swift changes into confused, tense, and sometimes very withdrawn states around the cutting episodes. However, it seems generally fair to say that all eases have severe difficulties in their interpersonal relationships. Common to most of the studies, and certainly confirmed by the experience of the adolescent ward in Glasgow, is the finding that these patients have severely disrupted and often deprived backgrounds. In Rosenthal's New York Study (i97z), of 24 cutting and 24 control patients, they found a high correlation between self-mutilating patients and early experiences of physical trauma and surgery, especially before the age of five years. In one ease study, there was prolonged and severe eczema during infancy, which had been treated with bandaging and
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severely restricted physical bodily contact. In this study, none of the patients began to cut themselves before the menarche, but there was a marked difference between the control and cutting group with how they felt about menstruation. The majority of controls were happy or relieved a t the menarche, whereas the cutters were unhappy, frightened, and often had irregular menses or amenorrhea.
Tile episode The examination of circumstances surrounding the cutting episodes can be very illuminating. Various in-patient studies (McKerracher et al., i968; Rosenthal et al., 1972 ) have shown that the majority of cuts occur on Saturday and Sunday or at times of holidays. One study, where the hospital practice was for doctors to attend an out-patient clinic on Wednesday afternoons, showed a peak then. Rose's worst episode was when her parents were leaving on holiday without her, although she herself had chosen to stay behind. Seen under the microscope, it has been possible in some instances, to relate episodes of cutting to minor incidents of abandonment, perceived as major by the patient, certainly at some level but, until looked for, perhaps missed completely by the staff; for example, a nurse day-dreaming while "specialing" a patient, or a nurse turning to speak to another patient. Another feature of one study (Rosenthal et al., i972 ) was the finding that 60 per cent of cutting episodes took place at the time of the patient's menses, half of these being during the last two days of bleeding, and so not easily attributed to premenstrual tension. The cut is nearly always made with a razor blade or glass, often stolen and hidden and cherished. I t is interesting, however, that there was no increase in cutting episodes on a ward which allowed free use of razor blades.
Tile skhz The skin is a major organ of communication in all species. It uses a language of visual, olfactory, and tactile signals, clearly seen amongst animals, but the cosmetic industry and the importance of grooming, indicate its continuing importance in humans. Adornment of the skin serves a major function in the identification of groups--for instance punk rockers, and, amongst adolescents, skin tattooing. There is profound disgust at the appearance of diseased skin, which has been explained in evolutionary terms on the basis of a need to avoid the catastrophe of contagious skin disease in our remote past. Professionals in a burn's unit know this feeling. Then there is the very common problem of acne at adolescence, and its
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sometimes devastating effect upon the self-image of adolescents. From the Bible, Job seemed able to withstand all the trials that Satan sent him, until he was smitten with running sores, and his friends were initially unablc to recognize him. Skin is the most easily conceptualized, the simplest body boundary, serving as intermediary between outside and inside, the container of the body's contents, and a definitive factor in body image. Taking the last of these first, we can see that in the early stages of the development of identity, when the ego is primarily a body ego, the larger part of body image is made up of bodily sensatiofi with its source in skin contact. At this early stage the relationship to the outside world and to the mother is mediated largely through the skin, and gradually through this contact, and adding to it, motility, proprioception, vision and hearing, a wider body image is set up. In this sphere, Leboyer's theory of child birth is of interest (Leboyer, I975). Generally, he postulates that labour wards provide an excessively overstimulating environment into which to be born, over-stimulating to the point of pain, in terms of light, sound, and touch. He designs an atmosphere and a technique to provide the baby with as gentle and gradual a change from intra-auterine to extra-auterine life as possible, encompassing the lighting of the labour room, the sound produced, the posture of the baby, the timing of cutting the cord. He is very eloquent about it--"Touch is the first language. It is skin speaking to skin, and from this sense organ, all others derive. These in turn are like windows in the wall of skin that contains us and holds us separate from the world. The new-born baby's skin has an intelligence and sensitivity that we cannot conceive of". Leboyer suggests that if this transition is not done gradually and gently, that because of the overwhelming sensation input, the baby withdraws, shuts its eyes, screams. As an aside, it is intriguing that certain areas of s"ldn, certain zones, become the focus for libidinal satisfactions, and one wonders whether this is necessarily so or whether a certain amount of the intensity of libido focused in these areas, particularly the oral, is partly directed there by the withdrawal of the libidinal cathexis from the whole body surface. However, it is probably 9that these patients have not had adequately satisfying experiences with the mother in this early stage, either through oral or general skin contact. One mother, badly scarred from previous cutting episodes, brought her new baby to see me and I was struck by the lack of physical contact she had with her baby, who was closely wrapped up in shawl, hat and mittens throughout an hour long interview, despite a hot room. In the early stages of development, skin and oral contact with the mother, give the child pleasure, enabling it to relax into sleep, with its temporary
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dissolution of the body image, the loss of ego boundaries, and the feeling of merging with the mother, the situation often perceived by disturbed adults as tantamount to death. Lewin's (195o) oral triad of wishes, "the wish to eat, the wish to be eaten, and the wish to die or to sleep", may well form the basis of these girls' anxieties. Phyllis Greenaere (1958) in her paper The Sense of Identity, makes a distinction between external and internal factors in the building up of an identity: the internal being to do with oral incorporation and internalization, and the external with sight and touch of the mother, her face, and later same sex genitals. The face and genital areas are the most highly cathected. Freud (1923) has something to say about the body image in this context too. In The Ego and the ld he says "A person's own body and above all its surface is a place from which external and internal perceptions may spring. The ego is first and foremost a body ego--not merely a surface entity, but the projection of a surface. The ego is ultimately derived from bodily sensations, chiefly the surface of the body. It is a mental projection of the body". From this stage, and dependent upon the mother and her manipulation, caring, and stimulation of the body of her child, through its various stages of development, and upon her adapting her behaviour with each stage to create optimum frustration, comes a healthy adult identity.
The wound In the anthropological field, skin cutting is a common ingredient of initiation ceremonials. In some Aboriginal tribes, sub-incision of the penis-opening the penile urethra along the ventral aspect from the urethral orifice a variable distance proximally--is practised. The purpose of inflicting these wounds on pubertal boys is interesting--Bettelheim (z962) suggests that the wound so inflicted symbolized the male initiate's identification with his mother by making him bleed and by representing the female vagina, and this is done to help him deal with his envy of females and to accept his masculine role. Symbolic identification with the mother may also aid him in the loss of his mother, associated with passing over from childhood to adulthood. In some Aboriginal tribes "sorry cuts" are meted out by tribal elders as punishment for misdeeds. Erikson (195 o) in Childhood and Society, describes a dance performed by the Sioux Indians where the men make deep cuts in the skin of their chests, Erikson interpreting this as atonement for the infantile wish to bite the mother's breast. In self-mutilating patients, the same significance may be attached to the wound. Many of these patients have, as shown, quite ambivalent and confused ideas of their sexual identity and certainly, some explanation has to
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be given to account for the very high preponderance of female cutters, and the peak around menstruation. The site of the wound, and the feelings and sight of the blood, seem to be important to these individuals, and crop up in each description of an incident. It may be that what is of importance is the turning of a passive wound, castration, and menstruation, its reminder, into an active one controlled by the patient. Helene Deutsch (I944), exploring the subject of genital trauma and menstruation, discusses various attempts solving the menstrual conflict. The most obvious way is to eliminate bleeding, as in amenorrhea. She lists among other means, "vicarious menstruation" which invokes displacement, transferring the bleeding to some other part of the body. For some patients, who describe themselves as empty and void, the sight of their own flesh inside the skin, may be important. And then later, for some, the actual scar itself assumes importance and this can also have a variety of mechanisms--it may act like a tattoo, identifying like with like, becoming part of the self-image of the patient. The scar also signifies permanency over time and this may be its important aspect. It may serve an exhibitionistic wish, visible castration as opposed to the invisible. One adolescent boy was referred for psychiatric help from a surgical ward because of his open and persistent displaying of his amputation site to every new visitor in the ward. Then there is the question of sexual feelings in the skin. A build-up of tension in patients with this phenomenon, culminating in cutting, seems to serve some kind of orgasmic function, and allied with this, punishment. In one patient, this was an openly expressed and very frightening conscious feeling, experienced by a girl who had had an incestuous relationship with an older brother.
Depersonalization In almost all the papers surveying these patients, the same words are used in the description of events leading up to and surrounding the cutting episodes. The subjective experience of the patient is of becoming tense, restless, or confused, and then numb, unreal, empty, blank, floating helpless, switched off. They return to full consciousness following the act either as a result of pain, the sight of the blood, or wound, or the feeling of the warm blood dripping from the wound. Following this they feel better, the confusion is gone; they feel real again, normal, in touch. It seems fairly safe to say that under the stress of quite intense feelings, a period of depersonalization comes about, and that during this the cutting takes place, and the
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depersonalization episode is terminated by the cutting, exactly as in pinching oneself to make sure one is not dreaming. Whether the intense feelings express phallic castration anxiety or an earlier separation--abandonment--dependency anxiety, or both, or more, the final common pathway seems to be an episode of depersonalization. Seen from this angle, cutting the skin serves a defensive function--a reintegrative one. Indirectly, by increasing the skin cathexis, the bodily ego boundaries are reinforced and mental ego boundaries are affected in the same way. Depersonalization, according to Nunberg (1955), is always a response to a loss, especially "the sudden loss of love or a love object". The perception of loss of the love object or the lowering of libido quantities is accompanied by the feeling that the reality of the perceptions and sensations of the ego has been lost. Destructive instincts are released and patients complain painfully. Schilder (195o) characterizes depersonalization as the situation occurring when the individual does not place libido either in the outside world or in his own body. He feels sadomasochism is a most important component of this. Oberndorf (195o) likens it with the playing dead defence used by animals in great danger. Blank (i954), describing this state in a young female patient, talks of it as "an emergency defense against threatened eruption of massive complexes of feelings of depression, rage, and anxiety". Jacobson's paper (1959) on depersonalization in a group of political female prisoners in Nazi Germany is interesting in its understanding of how and when depersonalization was used as an emergency defense, and how later the group evolved other defenses in managing themselves. Without stretching the point too far, there may be some similar!ty to be gained from comparing these prisoners with hospitalized patients, and there may be some lessons to be learnt in the treatment of hospital patients from what these normal people came up with by trial and error. A lot of patients only begin to cut after they have been hospitalized. Self mutilation often happens after imprisonment, and must have some connection with the behaviour of caged animals, and the incidence of head-banging in deprived children and of self mutilation in sensory deprivation. Jacobson's prison group's initial reaction to imprisonment was intense confusion, general stupification, and feelings of unreality regarding themsevles and their environment. They were subject to sudden severe regression to infantile positions. Gradually, they came out of this and learned to adapt, apart from brief periods of depersonalization in response to stress, for example, following interrogation. The prisoners would wake feeling their
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limbs or face did not belong to them and would anxiously touch the estranged parts. Clearly, although depersonalization can be seen itself as a defense, it is experienced as frightening, and these prisoners tried to use touching to end it. Jacobson saw this depersonalization as the result of loss, the threat of the overwhelming loss of identity brought about by the sudden change from their familiar things, values and people. The loss was of those things external, concrete, and abstract, which help us to maintain an identity, and so the prisoners were prone to depersonalization. Their guards disregarded their past identities and positions, they were treated as criminals, and this threatened to undermine everything on which their images of themselves were founded. Jacobson found that all the defensive struggles of these prisoners were against losing their old identity and against assuming a new criminal one. Initially this was brought about by massive depersonalization, but later more organized defenses were brought into play. She postulated initial ego weakening by the detachment from familiar surroundings, and an imbalance between ego and id caused by eruption from the id of tremendous hostility evoked by the traumatic experiences and that together, these caused a failure of repression. This was, early on, dealt with by splitting, depersonalization, and interestingly, parts of the body to lose sensation were the mouth, hands and arms. Later on, more organized defences, to aid the ego in repression, included the political prisoners organizing themselves into a separate group from ordinary prisoners, with emphasis on their difference from the criminal group. They rejected intimacy with the criminals, introduced a firm ethical code, encouraged reading and bodily cleanliness, neatness, and curbed oral greed by sharing their food meticulously, and adopting a coolly polite relationship with their guards. There may be seeds in this of ways to help ego-weak cutting patients, but I can also see that there are mechanisms here which must function in the establishment of a cutting identity as opposed to a healthy and normal one. A pre-requisite to depersonalization as stated by Jacobson, seems to lead to further understanding of the early conflicts and difficulties of girls who cut. She stated that depersonalization requires the evolution in childhood of narcissistic object relationships-----of relationships between self and object where there is no clear distinction between self and other, where the boundaries are unclear, and where inside and outside, 'me and not me, is also unclear. The importance of skin and mouth in the successful negotiation of this phase is obvious.
Aggression The self aggressive component of the act of cutting can have many aspects--it can be aggression against the self where the self represents the
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object. It can serve as a punishment for an act or thought. There may be unclear subject-object discrimination, causing self aggression. The use of self aggression may serve as reproach to a neglectful object, it may be based on identification with an aggressive object, compliance with a hostile object, or a masochistic sexual suffering. These acts of self cutting must represent some very basic primitive methods of dealing with aggression, and profound incapacity to express it effectively and externally. For the ability to express aggression outwardly and confidently to develop, it seems necessary that, early on, the mother should have the capacity to receive the baby's projected aggression and to neutralize it. An absent mother or a mother incapable of receiving and holding these projections, leaves the infant to deal with them in other ways, and an incomplete separation between infant and mother comes about, with the mother experienced not as an omnipotent and safe focus for projection of unwanted aggression from the baby, but as a helpless victim of the baby's anger and violence. Then, because of the failure of differentiation between subject and object, the subject, the infant's ego, overwhelmed by aggression, becomes fused with this victim object. Shelly Orgel (1974) calls this state of affairs fusion with the victim, which he differentiates from the healthier state of affairs, identification with the aggressor. This seems to be reminiscent of Winnicott's (1949) hate in the counter transference. Solnit (1966) too has spoken of this "appropriate counter-aggression by adults towards children in some cases of severe object loss, in order to establish healthy identification with the aggressor". He feels that certain elements of object constancy can be better achieved in relationships characterised by aggressive interactions than by libidinal ones.
Group and socialfactors Two aspects are worthy of mention. Firstly, the cutting has a contagious quality when it occurs in a hospital ward or some form of group living. Several papers have mentioned this---often the spates of cutting are triggered off by a "real cutter" and the imitators are said to cut less severely, o~" to scratch only, or to be subnormal in intelligence, or psychotic, or in some other way impaired and easily led. However, two authors, both working in adolescent groups (Offer and Barglow, i96o), described epidemics of cutting, lastingseveral days and recurring in bouts which were handled successfully only by manipulation of the group of teenagers involved, by discharge, and admission of new group leaders. Secondly, it is an undisputed fact that the emotional impact of a cutting episode on others is enormous, bringing up intense feelings of fear, helplessness, disgust in those around, the families, friends and caretakers involved.
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The defences used to cope with these feelings must be looked at, with regard to the treatment relationships set up with these girls. Since I have said cutting episodes are often triggered off in the setting of a perceived abandonment in a relationship, the embarkation on a psychotherapeutic relationship brings with it the risk of cutting in the context of the relationship. At first the patient sees the cutting as an unrelated act, a closed act, an act which brings symptom relief and involves no-one else, The helplessness and anger engendered in others is partly brought about by this, and then is often not expressed for fear of precipitating another episode; so the act is in danger of remaining closed, with other people's feelings not impinging or having to be acknowledged. One aim of a psychotherapeutic relationship is to enter this dosed circle to help the patient see the triggers, the interpersonal factors that bring the cutting episode about within the relationship and then to offer oneself as an object for projection, instead of the self-self cycle. These patients often have a propensity for becoming "special patients" with the danger of splitting the staff, which Burnham (i966), Main (i957) and Podvol (I969) have all written about. They are seen by one faction as poor, helpless, but attractive and talented, worthwhile patients whom only this faction can help, and by others as psychopaths, manipulators etc. As in all these cases, and particularly so in cutting patients, where feelings run very high, splits amongst the staff must be healed, for the patient to be helped. Family pathology often reflects the splitting. In wards, the splitting is often between night and day staff and may also involve other patients.
Treatment
A few specific points need to be made about the treatment of these patients. Management of the actual cutting episode is not very successful. Short of sedating the patient to the point of unconsciousness, there seems little to be gained from drug treatment, since none seem to be able to reduce the tension which precipitates the act, and many of these patients become readily addicted. Individual nursing of a patient may be helpful under certain circumstances, but the stress to the nurse and to others involved has to be taken into account. Gardner and Gardner (I975) look at the cycle of increase in tension, cutting episode, release of tension, as being almost an obsessional-compulsive pattern, and suggest a behavioural approach to treatment. However, they have found it difficult to imagine an alternative form of tension-relief, since cutting seems such a successful method.
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Graft and Malin (i967) , who understand the basic problem of these girls as being fundamentally one of verbal communication and that the cutting is a non-verbal communication, suggest that non-verbal treatment has a major part to play in the early stages of the treatment relationship and attempt to help their patients by including "non-sexual" touching at times of crisis. The opposite view is, of course, adhered to by some who feel that these patients have such highly eroticized skin that touch by the therapist can never be therapeutic, only over-stimulating. The management of group episodes and other uncontrollable cutting episodes may require transfer of a patient from the setting in which it occurs to a standard hospital ward, where relationships are likely to be less intense, and the cycle may thereby be broken. This is often successful in the shortterm, but may do nothing to help with the basic relationship problem and may only repeat previous rejections. All in all, a long-term psychotherapeutic relationship seems to be the only hope of really helping these patients through to a more mature level of functioning, and opportunities for this are the exception rather than the rule. REFERENCES
Bach-Y-Rita, G. (1974). Habitual violence and Self-mutilation. ~tmerlcanJournalof Psychiatry x3I, xoI8-IOZO. Bettelhelm, B. (1962). The Symbolic lVound. New York: Collier. Blank, H. R. (1954). Depression, hypomania, depersonalization. Psychoanalytic Quarterly 23, 20-37. Burnham (1966). The special problem patient: victim or agent of splitting. Psychiatry 29, lO5-122. Burnham, R. C. (1969). Symposium on self-mutilation--discussion. British Journal of ~redical Psychology 42, 223-229. Deutsch, H. (I944). Psychology of lVomen, Vol. 1. New York: Grune and Stratton. Erikson, E. (I95O). Childhood and Society. New York: Norton. Fabian, J. J., Maloney, M. P. and Ward, M. P. (I973). Self-destructive and suicidal behaviour in neuropsychiatric inpatient facility. American Journal of Psychiatry 13o, 1383-1385. Freud, S. (1923). The Ego and The Id. Standard Edition 19. Gardner and Gardner (1975). Self-mutilation, obsessionality and narcissism. British Journal of Psychiatry I27, I27-I32. Graft, H. and Mallin, R. (1967). The syndrome of the wrist-cutter. AmerlcanJournal of Psychiatry IZ4, 36-42. Greenacre, P. (I958). Early physical determinants in development of the sense of identity. Journal of American Psychoanalytic Mssociation 6, 612-627. Grunebaum, H. and Klerman, G. (1967). Wrist-slashing. tlmerican Journal of Psychiatry 124, 527-534Jacobson, E. (1959). Depersonalization. Journal of the American Psychoanalytic Association 7, 581-61o. Kafka, J. (1969). The body as transitional object. British Journal of 3Iedical Psychology 42, 2o7-213.
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Leboyer (I975). Birth u'ithout Violence. Fontana. Lewin, B. 095o). The Psychoanalysis of Elation. New York: Norton. McKerracher, D. W., Loughnane, T. and Watson, R.A. 0968). Self-mutilation in female psychopaths. British ffournal of Psychiatry xx4, 829-832. Main, T. F. 0957). The ailment. British ffournal of l]ledieal Psychology 30, I29-I45. Novotny, P. (x97z). Self-cutting. Bulletin of the l~lenhlger Clinic 36, 5o5-514. Nunberg, H. (x955). Principles of Psychoanalysis. New York: International University Press. Oberndorf, C. P. (I95o). The role of anxiety in depersonalization. International Journal of Psychoanalysis 3x, I-5. Offer, D. and Barglow, P. (I96o). Adolescent and young adult self-mutilation incidents in General Psychiatric Hospital. Archives of General Psychiatry 3, 1oz-x Iz. Pao, P. N. (t969). Syndrome of delicate self-cutting. British Journal of l~ledical Psychology 4z, x95-zo7. Podvoll (x969). Self-mutilation within a hospital setting. British Journal of l~ledical Psychology 4z, zI3-zz3. Rosenthal, R., Rinzler, C., Wallsh, R. and Klausner, E. (x97z). Wrist-cutting syndrome: the meaning of a gesture. American Journal of Psychiatry xz8, I363-I368. Schilder, P. 0950). linage and Appearance of Human Body. New York: International University Press. Solnit, A. J. (x966). Some adaptive functions of aggressive behaviour. In Psychoanalysis : A General Psychology, R. M. Lowenstein et al. (Eds). New York: International University Press. ~Vinnicott, D. W. (I949). Hate in the counter transference. International Journal of Psychoanalysis 3 ~, 69-74.
Self mutilation WENDY J. B. RAINE* In this paper, the various theoretical avenues which have been explored in an attempt to understand the difficulties of self-mutilating patients, have led to the conclusion that the primary p r o b l e m is in the area of very early symbiotic object relationships, where skin assumes great significance, and where, in these patients, an unclear differentiation between mother and self has come about. Cutting the skin enhances the differentiation, and so can be seen as serving an adaptive function for the patient, although in terms of a therapeutic relationship, it is a major form of acting-out.
INTRODUCTION Aggression turned against the self can.take many forms. The young infant's scratching of his face, the older child's head-banging, nail-biting, hairpulling, major and minor accidents of all "kinds, deliberate self-injury and mutilation, suicide, psychosomatic illnesses, various forms of sadomasochistie behaviour, the inhibition of potential achievement, self-denigration, self-condemnation and guilt feelings, all contain the common element of aggression turned against the self. This paper deals with one specific form of aggression to the self--repeated acts of damage to the skin, by cutting, occasionally accompanied by burning, with no clear suicidal intent. Various aspects of this phenomenon are explored. A typical case
Rose, aged x5, was the elder of two girls, who first came to psychiatric attention after repeatedly running away from home with a school friend. The described change in her behaviour, from being an ideal, well-behaved daughter, to being difficult and rude, was put down to the influence of her * Consultant Child Psychiatrist, Department of Child and Family Psychiatry, Royal Hospital for Sick Children, Glasgow. ox4o-x97zI8z/oloooz + x3 $oz.oo/o
9 x98z The Association for the Psychiatric Study of Adolescents
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friend but the behaviour continued after the friend was taken into care, following a sexual incident with an elderly man during one of her running episodes. Rose witnessed this. Her behaviour became quickly worse, until she became openly aggressive towards her mother and her school teacher, threatening the latter with a broken bottle on one occasion. She periodically refused to attend school, and when there, would talk wildly about being fostered, hating her mother, and at other times would seem remote and supercilious towards her class-mates. During her admission to the Adolescent Unit in Glasgow, she began to scratch her wrists, tentatively at first but more deliberately and more frequently later. At first she said she wanted to kill herself, but soon this idea was dropped and she cut obviously to relieve tension, usually in the evening, or following an altercation with a staff member; and on one occasion she severely cut her arms and her face when her parents went off on holiday without her. Rose's mother was an identical twin, the passive member of the twinship, and an eternal dogsbody. She left home with her twin at the age of x4, to get away from their alcoholic and aggressive father. She spent the next t~velve years working with her sister and moving about the country, before they both became engaged within weeks of each other. Her ~vin's marriage failed because of her husband's aggression, and her own was also a failure because of her husband's alcohol difficulties and sexual infidelity. Although they stayed together, because Rose's mother was quite unable to put a stop to this relationship, she was openly derisory of her husband and set up an idealized and symbiotic relationship with Rose. This came to an abrupt end with Rose's adolescence and the onset of behavioural difficulties. Rose was a tall, thin girl with straight shiny fair hair, who held herself in a stilted and rigid manner, and who had difficulty in making good eyecontact. She seemed abrupt in relationships, but also seemed to welcome contact. She was boyish in appearance although she wore skirts and chose pastel colours, and kept herself aseptically clean. She demonstrated a very vivid fantasy life, talking with pleasure about what she saw as her ideal parents and an ideal home--endless food, a warm cosy nest, never-ending tolerance, gentle control, and no demands. Alternatively she would talk with excitement about knives, broken bottles, prison, robbing, and would sit on the edge of a chair biting her nails. She hated menstruation, hated boys and "all that stuff". At times in the ward she would threaten hunger strike, and certainly never over-ate. On a couple of occasions she took small overdoses of aspirin. On about three occasions, she went missing, and was found curled up and asleep, buried in a pile of dirty linen in a small linen cupboard. Another time she squeezed through a trap door in the ceiling, and lay in the space between the ceiling of one room and the floor of the room up above, for several hours, until she was found.
SELF M U T I L A T I O N
Other studies
There have been quite a few studies now of this phenomenon of delicate self-cutting (Offer and Barglow, i96o; Graft and Mallin, x967; Grunebaum and Klerman, x967; MeKerracher et al., x968; Rosenthal et al., x972; Novotny, x972; Bach-y-Rita, i974; Fabian et al., I973; Gardner and Gardner, i975), as it has been dubbed by Ping Nie Pao, in his contribution to a detailed study of the patients, carried out at Chestnut Lodge in the States (Pao, I969; Kafka, i969; Burnham, i969; Podvoll, x969). From them all, there appear certain common themes. The patient is usually a teenager or a young adult, and is very often female. They are often described as talented, intelligent, attractive, and these positive aspects can put into stark contrast the awful spectacle of the badly cut and bleeding patient. Wrists and arms are commonly used sites. Cuts may be many and fine or deep and destructive. Cigarette burns are common accompaniments. T h e act is often painless, and becomes painful later. T h e face is only occasionally attacked, the genitals even less frequently, in women especially. In men genital mutilation seems to comprise a slightly different syndrome. The patients may have many other symptoms of emotional disorder. Recurrent depression, abnormal eating patterns of bulimia and anorexia, promiscuity, tom-boy behaviour, or sexual inhibition (certainly profound confusion over sexual identity) addiction to drugs or abuse of alcohol are all listed. Of two controlled studies done (Rosenthal et al., i972; Gardner and Gardner, x975) , the cutting group has, however, been found to be very similar to a control group of patients in all symptoms except psychosexual disorders and eating disorders, which are both significantly more common in the cutting group. Many of the cases described in the literature are American, and attract a diagnosis of schizophrenia. However, it seems clear that these patients often have the capacity to cope and conduct their lives fairly competently on the surface, and show distinct and occasionally very swift changes into confused, tense, and sometimes very withdrawn states around the cutting episodes. However, it seems generally fair to say that all eases have severe difficulties in their interpersonal relationships. Common to most of the studies, and certainly confirmed by the experience of the adolescent ward in Glasgow, is the finding that these patients have severely disrupted and often deprived backgrounds. In Rosenthal's New York Study (i97z), of 24 cutting and 24 control patients, they found a high correlation between self-mutilating patients and early experiences of physical trauma and surgery, especially before the age of five years. In one ease study, there was prolonged and severe eczema during infancy, which had been treated with bandaging and
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severely restricted physical bodily contact. In this study, none of the patients began to cut themselves before the menarche, but there was a marked difference between the control and cutting group with how they felt about menstruation. The majority of controls were happy or relieved a t the menarche, whereas the cutters were unhappy, frightened, and often had irregular menses or amenorrhea.
Tile episode The examination of circumstances surrounding the cutting episodes can be very illuminating. Various in-patient studies (McKerracher et al., i968; Rosenthal et al., 1972 ) have shown that the majority of cuts occur on Saturday and Sunday or at times of holidays. One study, where the hospital practice was for doctors to attend an out-patient clinic on Wednesday afternoons, showed a peak then. Rose's worst episode was when her parents were leaving on holiday without her, although she herself had chosen to stay behind. Seen under the microscope, it has been possible in some instances, to relate episodes of cutting to minor incidents of abandonment, perceived as major by the patient, certainly at some level but, until looked for, perhaps missed completely by the staff; for example, a nurse day-dreaming while "specialing" a patient, or a nurse turning to speak to another patient. Another feature of one study (Rosenthal et al., i972 ) was the finding that 60 per cent of cutting episodes took place at the time of the patient's menses, half of these being during the last two days of bleeding, and so not easily attributed to premenstrual tension. The cut is nearly always made with a razor blade or glass, often stolen and hidden and cherished. I t is interesting, however, that there was no increase in cutting episodes on a ward which allowed free use of razor blades.
Tile skhz The skin is a major organ of communication in all species. It uses a language of visual, olfactory, and tactile signals, clearly seen amongst animals, but the cosmetic industry and the importance of grooming, indicate its continuing importance in humans. Adornment of the skin serves a major function in the identification of groups--for instance punk rockers, and, amongst adolescents, skin tattooing. There is profound disgust at the appearance of diseased skin, which has been explained in evolutionary terms on the basis of a need to avoid the catastrophe of contagious skin disease in our remote past. Professionals in a burn's unit know this feeling. Then there is the very common problem of acne at adolescence, and its
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S
sometimes devastating effect upon the self-image of adolescents. From the Bible, Job seemed able to withstand all the trials that Satan sent him, until he was smitten with running sores, and his friends were initially unablc to recognize him. Skin is the most easily conceptualized, the simplest body boundary, serving as intermediary between outside and inside, the container of the body's contents, and a definitive factor in body image. Taking the last of these first, we can see that in the early stages of the development of identity, when the ego is primarily a body ego, the larger part of body image is made up of bodily sensatiofi with its source in skin contact. At this early stage the relationship to the outside world and to the mother is mediated largely through the skin, and gradually through this contact, and adding to it, motility, proprioception, vision and hearing, a wider body image is set up. In this sphere, Leboyer's theory of child birth is of interest (Leboyer, I975). Generally, he postulates that labour wards provide an excessively overstimulating environment into which to be born, over-stimulating to the point of pain, in terms of light, sound, and touch. He designs an atmosphere and a technique to provide the baby with as gentle and gradual a change from intra-auterine to extra-auterine life as possible, encompassing the lighting of the labour room, the sound produced, the posture of the baby, the timing of cutting the cord. He is very eloquent about it--"Touch is the first language. It is skin speaking to skin, and from this sense organ, all others derive. These in turn are like windows in the wall of skin that contains us and holds us separate from the world. The new-born baby's skin has an intelligence and sensitivity that we cannot conceive of". Leboyer suggests that if this transition is not done gradually and gently, that because of the overwhelming sensation input, the baby withdraws, shuts its eyes, screams. As an aside, it is intriguing that certain areas of s"ldn, certain zones, become the focus for libidinal satisfactions, and one wonders whether this is necessarily so or whether a certain amount of the intensity of libido focused in these areas, particularly the oral, is partly directed there by the withdrawal of the libidinal cathexis from the whole body surface. However, it is probably 9that these patients have not had adequately satisfying experiences with the mother in this early stage, either through oral or general skin contact. One mother, badly scarred from previous cutting episodes, brought her new baby to see me and I was struck by the lack of physical contact she had with her baby, who was closely wrapped up in shawl, hat and mittens throughout an hour long interview, despite a hot room. In the early stages of development, skin and oral contact with the mother, give the child pleasure, enabling it to relax into sleep, with its temporary
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dissolution of the body image, the loss of ego boundaries, and the feeling of merging with the mother, the situation often perceived by disturbed adults as tantamount to death. Lewin's (195o) oral triad of wishes, "the wish to eat, the wish to be eaten, and the wish to die or to sleep", may well form the basis of these girls' anxieties. Phyllis Greenaere (1958) in her paper The Sense of Identity, makes a distinction between external and internal factors in the building up of an identity: the internal being to do with oral incorporation and internalization, and the external with sight and touch of the mother, her face, and later same sex genitals. The face and genital areas are the most highly cathected. Freud (1923) has something to say about the body image in this context too. In The Ego and the ld he says "A person's own body and above all its surface is a place from which external and internal perceptions may spring. The ego is first and foremost a body ego--not merely a surface entity, but the projection of a surface. The ego is ultimately derived from bodily sensations, chiefly the surface of the body. It is a mental projection of the body". From this stage, and dependent upon the mother and her manipulation, caring, and stimulation of the body of her child, through its various stages of development, and upon her adapting her behaviour with each stage to create optimum frustration, comes a healthy adult identity.
The wound In the anthropological field, skin cutting is a common ingredient of initiation ceremonials. In some Aboriginal tribes, sub-incision of the penis-opening the penile urethra along the ventral aspect from the urethral orifice a variable distance proximally--is practised. The purpose of inflicting these wounds on pubertal boys is interesting--Bettelheim (z962) suggests that the wound so inflicted symbolized the male initiate's identification with his mother by making him bleed and by representing the female vagina, and this is done to help him deal with his envy of females and to accept his masculine role. Symbolic identification with the mother may also aid him in the loss of his mother, associated with passing over from childhood to adulthood. In some Aboriginal tribes "sorry cuts" are meted out by tribal elders as punishment for misdeeds. Erikson (195 o) in Childhood and Society, describes a dance performed by the Sioux Indians where the men make deep cuts in the skin of their chests, Erikson interpreting this as atonement for the infantile wish to bite the mother's breast. In self-mutilating patients, the same significance may be attached to the wound. Many of these patients have, as shown, quite ambivalent and confused ideas of their sexual identity and certainly, some explanation has to
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be given to account for the very high preponderance of female cutters, and the peak around menstruation. The site of the wound, and the feelings and sight of the blood, seem to be important to these individuals, and crop up in each description of an incident. It may be that what is of importance is the turning of a passive wound, castration, and menstruation, its reminder, into an active one controlled by the patient. Helene Deutsch (I944), exploring the subject of genital trauma and menstruation, discusses various attempts solving the menstrual conflict. The most obvious way is to eliminate bleeding, as in amenorrhea. She lists among other means, "vicarious menstruation" which invokes displacement, transferring the bleeding to some other part of the body. For some patients, who describe themselves as empty and void, the sight of their own flesh inside the skin, may be important. And then later, for some, the actual scar itself assumes importance and this can also have a variety of mechanisms--it may act like a tattoo, identifying like with like, becoming part of the self-image of the patient. The scar also signifies permanency over time and this may be its important aspect. It may serve an exhibitionistic wish, visible castration as opposed to the invisible. One adolescent boy was referred for psychiatric help from a surgical ward because of his open and persistent displaying of his amputation site to every new visitor in the ward. Then there is the question of sexual feelings in the skin. A build-up of tension in patients with this phenomenon, culminating in cutting, seems to serve some kind of orgasmic function, and allied with this, punishment. In one patient, this was an openly expressed and very frightening conscious feeling, experienced by a girl who had had an incestuous relationship with an older brother.
Depersonalization In almost all the papers surveying these patients, the same words are used in the description of events leading up to and surrounding the cutting episodes. The subjective experience of the patient is of becoming tense, restless, or confused, and then numb, unreal, empty, blank, floating helpless, switched off. They return to full consciousness following the act either as a result of pain, the sight of the blood, or wound, or the feeling of the warm blood dripping from the wound. Following this they feel better, the confusion is gone; they feel real again, normal, in touch. It seems fairly safe to say that under the stress of quite intense feelings, a period of depersonalization comes about, and that during this the cutting takes place, and the
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depersonalization episode is terminated by the cutting, exactly as in pinching oneself to make sure one is not dreaming. Whether the intense feelings express phallic castration anxiety or an earlier separation--abandonment--dependency anxiety, or both, or more, the final common pathway seems to be an episode of depersonalization. Seen from this angle, cutting the skin serves a defensive function--a reintegrative one. Indirectly, by increasing the skin cathexis, the bodily ego boundaries are reinforced and mental ego boundaries are affected in the same way. Depersonalization, according to Nunberg (1955), is always a response to a loss, especially "the sudden loss of love or a love object". The perception of loss of the love object or the lowering of libido quantities is accompanied by the feeling that the reality of the perceptions and sensations of the ego has been lost. Destructive instincts are released and patients complain painfully. Schilder (195o) characterizes depersonalization as the situation occurring when the individual does not place libido either in the outside world or in his own body. He feels sadomasochism is a most important component of this. Oberndorf (195o) likens it with the playing dead defence used by animals in great danger. Blank (i954), describing this state in a young female patient, talks of it as "an emergency defense against threatened eruption of massive complexes of feelings of depression, rage, and anxiety". Jacobson's paper (1959) on depersonalization in a group of political female prisoners in Nazi Germany is interesting in its understanding of how and when depersonalization was used as an emergency defense, and how later the group evolved other defenses in managing themselves. Without stretching the point too far, there may be some similar!ty to be gained from comparing these prisoners with hospitalized patients, and there may be some lessons to be learnt in the treatment of hospital patients from what these normal people came up with by trial and error. A lot of patients only begin to cut after they have been hospitalized. Self mutilation often happens after imprisonment, and must have some connection with the behaviour of caged animals, and the incidence of head-banging in deprived children and of self mutilation in sensory deprivation. Jacobson's prison group's initial reaction to imprisonment was intense confusion, general stupification, and feelings of unreality regarding themsevles and their environment. They were subject to sudden severe regression to infantile positions. Gradually, they came out of this and learned to adapt, apart from brief periods of depersonalization in response to stress, for example, following interrogation. The prisoners would wake feeling their
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9
limbs or face did not belong to them and would anxiously touch the estranged parts. Clearly, although depersonalization can be seen itself as a defense, it is experienced as frightening, and these prisoners tried to use touching to end it. Jacobson saw this depersonalization as the result of loss, the threat of the overwhelming loss of identity brought about by the sudden change from their familiar things, values and people. The loss was of those things external, concrete, and abstract, which help us to maintain an identity, and so the prisoners were prone to depersonalization. Their guards disregarded their past identities and positions, they were treated as criminals, and this threatened to undermine everything on which their images of themselves were founded. Jacobson found that all the defensive struggles of these prisoners were against losing their old identity and against assuming a new criminal one. Initially this was brought about by massive depersonalization, but later more organized defenses were brought into play. She postulated initial ego weakening by the detachment from familiar surroundings, and an imbalance between ego and id caused by eruption from the id of tremendous hostility evoked by the traumatic experiences and that together, these caused a failure of repression. This was, early on, dealt with by splitting, depersonalization, and interestingly, parts of the body to lose sensation were the mouth, hands and arms. Later on, more organized defences, to aid the ego in repression, included the political prisoners organizing themselves into a separate group from ordinary prisoners, with emphasis on their difference from the criminal group. They rejected intimacy with the criminals, introduced a firm ethical code, encouraged reading and bodily cleanliness, neatness, and curbed oral greed by sharing their food meticulously, and adopting a coolly polite relationship with their guards. There may be seeds in this of ways to help ego-weak cutting patients, but I can also see that there are mechanisms here which must function in the establishment of a cutting identity as opposed to a healthy and normal one. A pre-requisite to depersonalization as stated by Jacobson, seems to lead to further understanding of the early conflicts and difficulties of girls who cut. She stated that depersonalization requires the evolution in childhood of narcissistic object relationships-----of relationships between self and object where there is no clear distinction between self and other, where the boundaries are unclear, and where inside and outside, 'me and not me, is also unclear. The importance of skin and mouth in the successful negotiation of this phase is obvious.
Aggression The self aggressive component of the act of cutting can have many aspects--it can be aggression against the self where the self represents the
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object. It can serve as a punishment for an act or thought. There may be unclear subject-object discrimination, causing self aggression. The use of self aggression may serve as reproach to a neglectful object, it may be based on identification with an aggressive object, compliance with a hostile object, or a masochistic sexual suffering. These acts of self cutting must represent some very basic primitive methods of dealing with aggression, and profound incapacity to express it effectively and externally. For the ability to express aggression outwardly and confidently to develop, it seems necessary that, early on, the mother should have the capacity to receive the baby's projected aggression and to neutralize it. An absent mother or a mother incapable of receiving and holding these projections, leaves the infant to deal with them in other ways, and an incomplete separation between infant and mother comes about, with the mother experienced not as an omnipotent and safe focus for projection of unwanted aggression from the baby, but as a helpless victim of the baby's anger and violence. Then, because of the failure of differentiation between subject and object, the subject, the infant's ego, overwhelmed by aggression, becomes fused with this victim object. Shelly Orgel (1974) calls this state of affairs fusion with the victim, which he differentiates from the healthier state of affairs, identification with the aggressor. This seems to be reminiscent of Winnicott's (1949) hate in the counter transference. Solnit (1966) too has spoken of this "appropriate counter-aggression by adults towards children in some cases of severe object loss, in order to establish healthy identification with the aggressor". He feels that certain elements of object constancy can be better achieved in relationships characterised by aggressive interactions than by libidinal ones.
Group and socialfactors Two aspects are worthy of mention. Firstly, the cutting has a contagious quality when it occurs in a hospital ward or some form of group living. Several papers have mentioned this---often the spates of cutting are triggered off by a "real cutter" and the imitators are said to cut less severely, o~" to scratch only, or to be subnormal in intelligence, or psychotic, or in some other way impaired and easily led. However, two authors, both working in adolescent groups (Offer and Barglow, i96o), described epidemics of cutting, lastingseveral days and recurring in bouts which were handled successfully only by manipulation of the group of teenagers involved, by discharge, and admission of new group leaders. Secondly, it is an undisputed fact that the emotional impact of a cutting episode on others is enormous, bringing up intense feelings of fear, helplessness, disgust in those around, the families, friends and caretakers involved.
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The defences used to cope with these feelings must be looked at, with regard to the treatment relationships set up with these girls. Since I have said cutting episodes are often triggered off in the setting of a perceived abandonment in a relationship, the embarkation on a psychotherapeutic relationship brings with it the risk of cutting in the context of the relationship. At first the patient sees the cutting as an unrelated act, a closed act, an act which brings symptom relief and involves no-one else, The helplessness and anger engendered in others is partly brought about by this, and then is often not expressed for fear of precipitating another episode; so the act is in danger of remaining closed, with other people's feelings not impinging or having to be acknowledged. One aim of a psychotherapeutic relationship is to enter this dosed circle to help the patient see the triggers, the interpersonal factors that bring the cutting episode about within the relationship and then to offer oneself as an object for projection, instead of the self-self cycle. These patients often have a propensity for becoming "special patients" with the danger of splitting the staff, which Burnham (i966), Main (i957) and Podvol (I969) have all written about. They are seen by one faction as poor, helpless, but attractive and talented, worthwhile patients whom only this faction can help, and by others as psychopaths, manipulators etc. As in all these cases, and particularly so in cutting patients, where feelings run very high, splits amongst the staff must be healed, for the patient to be helped. Family pathology often reflects the splitting. In wards, the splitting is often between night and day staff and may also involve other patients.
Treatment
A few specific points need to be made about the treatment of these patients. Management of the actual cutting episode is not very successful. Short of sedating the patient to the point of unconsciousness, there seems little to be gained from drug treatment, since none seem to be able to reduce the tension which precipitates the act, and many of these patients become readily addicted. Individual nursing of a patient may be helpful under certain circumstances, but the stress to the nurse and to others involved has to be taken into account. Gardner and Gardner (I975) look at the cycle of increase in tension, cutting episode, release of tension, as being almost an obsessional-compulsive pattern, and suggest a behavioural approach to treatment. However, they have found it difficult to imagine an alternative form of tension-relief, since cutting seems such a successful method.
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Graft and Malin (i967) , who understand the basic problem of these girls as being fundamentally one of verbal communication and that the cutting is a non-verbal communication, suggest that non-verbal treatment has a major part to play in the early stages of the treatment relationship and attempt to help their patients by including "non-sexual" touching at times of crisis. The opposite view is, of course, adhered to by some who feel that these patients have such highly eroticized skin that touch by the therapist can never be therapeutic, only over-stimulating. The management of group episodes and other uncontrollable cutting episodes may require transfer of a patient from the setting in which it occurs to a standard hospital ward, where relationships are likely to be less intense, and the cycle may thereby be broken. This is often successful in the shortterm, but may do nothing to help with the basic relationship problem and may only repeat previous rejections. All in all, a long-term psychotherapeutic relationship seems to be the only hope of really helping these patients through to a more mature level of functioning, and opportunities for this are the exception rather than the rule. REFERENCES
Bach-Y-Rita, G. (1974). Habitual violence and Self-mutilation. ~tmerlcanJournalof Psychiatry x3I, xoI8-IOZO. Bettelhelm, B. (1962). The Symbolic lVound. New York: Collier. Blank, H. R. (1954). Depression, hypomania, depersonalization. Psychoanalytic Quarterly 23, 20-37. Burnham (1966). The special problem patient: victim or agent of splitting. Psychiatry 29, lO5-122. Burnham, R. C. (1969). Symposium on self-mutilation--discussion. British Journal of ~redical Psychology 42, 223-229. Deutsch, H. (I944). Psychology of lVomen, Vol. 1. New York: Grune and Stratton. Erikson, E. (I95O). Childhood and Society. New York: Norton. Fabian, J. J., Maloney, M. P. and Ward, M. P. (I973). Self-destructive and suicidal behaviour in neuropsychiatric inpatient facility. American Journal of Psychiatry 13o, 1383-1385. Freud, S. (1923). The Ego and The Id. Standard Edition 19. Gardner and Gardner (1975). Self-mutilation, obsessionality and narcissism. British Journal of Psychiatry I27, I27-I32. Graft, H. and Mallin, R. (1967). The syndrome of the wrist-cutter. AmerlcanJournal of Psychiatry IZ4, 36-42. Greenacre, P. (I958). Early physical determinants in development of the sense of identity. Journal of American Psychoanalytic Mssociation 6, 612-627. Grunebaum, H. and Klerman, G. (1967). Wrist-slashing. tlmerican Journal of Psychiatry 124, 527-534Jacobson, E. (1959). Depersonalization. Journal of the American Psychoanalytic Association 7, 581-61o. Kafka, J. (1969). The body as transitional object. British Journal of 3Iedical Psychology 42, 2o7-213.
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Leboyer (I975). Birth u'ithout Violence. Fontana. Lewin, B. 095o). The Psychoanalysis of Elation. New York: Norton. McKerracher, D. W., Loughnane, T. and Watson, R.A. 0968). Self-mutilation in female psychopaths. British ffournal of Psychiatry xx4, 829-832. Main, T. F. 0957). The ailment. British ffournal of l]ledieal Psychology 30, I29-I45. Novotny, P. (x97z). Self-cutting. Bulletin of the l~lenhlger Clinic 36, 5o5-514. Nunberg, H. (x955). Principles of Psychoanalysis. New York: International University Press. Oberndorf, C. P. (I95o). The role of anxiety in depersonalization. International Journal of Psychoanalysis 3x, I-5. Offer, D. and Barglow, P. (I96o). Adolescent and young adult self-mutilation incidents in General Psychiatric Hospital. Archives of General Psychiatry 3, 1oz-x Iz. Pao, P. N. (t969). Syndrome of delicate self-cutting. British Journal of l~ledical Psychology 4z, x95-zo7. Podvoll (x969). Self-mutilation within a hospital setting. British Journal of l~ledical Psychology 4z, zI3-zz3. Rosenthal, R., Rinzler, C., Wallsh, R. and Klausner, E. (x97z). Wrist-cutting syndrome: the meaning of a gesture. American Journal of Psychiatry xz8, I363-I368. Schilder, P. 0950). linage and Appearance of Human Body. New York: International University Press. Solnit, A. J. (x966). Some adaptive functions of aggressive behaviour. In Psychoanalysis : A General Psychology, R. M. Lowenstein et al. (Eds). New York: International University Press. ~Vinnicott, D. W. (I949). Hate in the counter transference. International Journal of Psychoanalysis 3 ~, 69-74.