Psychodynamic approaches to suicide and self-harm

Abstract

SUMMARYRates of suicide and self-harm are rising in many countries, and it is therapeutically important to explore the personal stories and relationships that underlie this behaviour. In this article psychoanalytic and psychodynamic principles and concepts in relation to violence towards the self are introduced and the various unconscious meanings of suicide and self-harm are explored within a relational context and attachment framework. We describe how a psychodynamic approach may enhance the risk assessment and treatment of patients presenting with self-harm and suicidality, particularly examining the role of transference and countertransference within the therapeutic relationship. LEARNING OBJECTIVES• Understand historical and contemporary psychoanalytic theories and concepts regarding the aetiology of suicide and self-harm • Understand the different meanings and expressions of acts of suicide and self-harm • Understand the use of countertransference in the risk assessment and management of selfharm and suicide attempts DECLARATION OF INTERESTNone.The prevention of suicide and self-harm has been high on the government's agenda for the past 15 years. Although statistics and demographics are essential in identifying preventive measures or high-risk groups for targeted interventions, they may also overshadow exploration of the myriad individual stories and relationships that lie behind each act of self-harm or suicide. Suicide and self-harm are acts of human behaviour that take us to the limits of our comprehension. Contemporary debates as to whether the causes of suicide are located within the individual or society stem from the early seminal works of Freud (1917) and Durkheim (1897) respectively. Since then, many theoretical frameworks have emerged that offer different conceptualisations and understandings of the causes, associated factors and effects of self-harm and suicidal behaviour. These include sociological approaches evolving from Durkheim's work on the role of social control to contemporary notions of deviance, stigmatisation and self-expression (Taylor 2015); cultural approaches examining how suicide and self-harm vary across gender, ethnicity, sexual orientation and other cultural characteristics (Cover 2016); and philosophical and ethical approaches exploring notions of utilitarianism, autonomy and duty to others (Kelly 2011). More recent psychopathological models include biological approaches studying the neurobiological correlates of self-injurious behaviour (Blasco-Fontecilla 2016) and contemporary psychological approaches that have informed the development of effective therapeutic interventions. All of these models overlap to some extent, for example many viewing self-harm as an expression of emotional distress.A psychodynamic perspective on self-harm and suicidal behaviour is one approach that may complement others in its focus on affective experience, unconscious meaning and interpretation within a relational framework. In this article we will explore the psychodynamics of self-harm and suici...

The Punished Self, the Unknown Self, and the Harmed Self – Toward a More Nuanced Understanding of Self-Harm Among Adolescent Girls

“…Several studies emphasize how earlier trauma, sexual or physical abuse and neglect in early years are risk factors for self-harm in adolescence (Hawton et al, 2012 ; Nock, 2014 ; Miller et al, 2019 ). The motoric action of self-harm may be a possible link between the private and public domain – an attempt to express and communicate unconscious or non-verbal private content through bodily actions to oneself or others (Lemma, 2010 ; Yakeley and Burbridge-James, 2018 ). The scars can even be a sign and identification of inner problems, showing a narrative of their history, a dialogue without words between themselves and their wounds (Gardner, 2001 ).…”

“…In several clinical case studies, authors have emphasized how self-harm may be understood as a way to handle and cope with trauma (Gardner, 2001 ; Turp, 2003 ; Yakeley and Burbridge-James, 2018 ). Further, these authors underline how self-harm may have several functions – to regulate affects, to handle memories related to trauma, and to communicate mental content that cannot be expressed with words.…”

How Do Young People Understand Their Own Self-Harm? A Meta-synthesis of Adolescents’ Subjective Experience of Self-Harm

“…Based on systematic studies of multiple or single cases and treatment processes, several authors (Friedman, Glasser, Laufer, Laufer, & Mohl, 1972;Kafka, 1969;Pao, 1969;Podvoll, 1969) underlined the intersubjective and interpersonal developmental context in the understanding of the function of self-harm, and, still, accentuated self-harm as related to intrapersonal mental contents like unconscious feelings and unsatisfied needs. These studies have influenced psychodynamic intra-and interpersonal perspectives on the function of selfharm (Yakeley & Burbridge-James, 2018). I will focus on presenting how self-harm may be understood as related to psychological separation processes, establishing self-boundaries, nonverbal communication, and deficits in the capacity to mentalize.…”

The interpersonal processes of non‐suicidal self‐injury: A systematic review and meta‐synthesis

“…NSSI may also emerge as a form of peer affiliation or bonding (Klonsky, Glenn, Styer, Olino, & Washburn, 2015; Young, Sproeber, Groschwitx, Preiss, & Plener, 2014). Interpersonal processes are seen as significant in the psychodynamic literature on self‐injury, often drawing on observations from case studies (Yakeley & Burbridge‐James, 2018). Within this field, it has been suggested that self‐injury may serve to re‐affirm psychological boundaries between self and other or provides a way of turning hostile feelings towards others back on the self, where such feelings appear unacceptable or inexpressible.…”