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...