Clinical reflections on self-attack

Abstract

This paper reflects on the clinical phenomena of mental and physical self-attack as encountered in everyday psychotherapeutic practice in the NHS. The author considers two distinct but closely related internal dynamics which he terms ‘melancholic’ and ‘antilibidinal’. In both, there is a sadomasochistic structure which serves a number of defensive purposes for the individual. The origins and functioning of these structures are explored in the clinical material. These defensive systems are often perversely rewarding for the patient and highly resistant to change. The author discusses some of the major obstacles to working therapeutically in this area, and emphasizes the role of the transference and countertransference in helping the therapist to understand who is doing what to whom within the therapeutic relationship and within the patient. Although the paper deals with theoretical issues the emphasis throughout is on clinical understanding and effectiveness within a (mainly) once-weekly analytic setting.

Keywords:

• melancholic
• antilibidinal
• separation
• self-attack
• narcissism
• sadomasochism

Acknowledgements

Firstly I want to thank my patients for permission to use their material and for their honest and illuminating comments about what they read. I would also like to thank NHS colleagues, past and present, for reading various drafts of this paper over the years and for all their encouragement and help: Annika Gilljam, Lesley Cann and – more recently – Walter Gibson, Susie Godsil, Jane Morris and James Johnston. Finally, I am grateful for the small research grant I received at the very outset from the Tavistock Institute of Medical Psychology. The paper has taken me so long to complete that they must surely have abandoned hope of ever seeing a finished product. If anyone is still there – thank you, and here it is.

Notes

 1. Freud (1917, pp. 249–250) follows Abraham in seeing this as a libidinal regression to the earliest oral-incorporative stage of ‘devouring’ the object.

 2. The libidinal ego corresponds here to Winnicott's (1960/1965) ‘true self’, the central ego being the ‘false self’.

 3. In fact this ‘critical agency’ (later called superego) is itself formed through identification with introjected parental objects, as Freud elaborates in ‘The Ego and the Id’ (1923, pp. 28–39; cf. Abraham, 1924/1927, pp. 461–462).

 4. The sense of being possessed and controlled by objects concretely lodged inside one's body is well described, from a Kleinian perspective, by Caper (1999, pp. 95–100).

 5. To clarify: ‘B’ represents the name the patient used for her subjective self-state, distinct from ‘X’ and ‘Y’. I therefore refer to the patient as ‘B’ from the perspective of her own internal world, and as ‘Ms B’ (‘B’ + ‘X’ + ‘Y’) from my own perspective.

 6. Ms B was treated in an outpatient Borderline Personality Disorder service, so that individual analytic therapy was one element of a team treatment approach.

 7. The patient was seen once weekly for several years, then twice weekly for one year, then once weekly again for a further period. For the past few years it has proved very effective to continue with monthly sessions maintaining an interpretive focus.

 8. For the developmental impact of an absent (or ineffectual) father, and/or failure to internalize the father and his link with the mother, see especially Burgner (1985), Britton (1989), Glasser (1992), Campbell (1995/1999), Fonagy and Target (1995/1999) and Birksted-Breen (1996).

 9. I think the prospect of ending therapy, though not yet discussed, was ever present for her.

10. From another perspective I think my fatherly intervention, though initially welcomed as helpful, was soon experienced as a threatening oedipal intrusion into her love-death affair with mother earth.

11. This kind of trans-generational projective identification is vividly described by Fraiberg, Adelson, and Shapiro (1975) in their classic paper ‘Ghosts in the nursery’.

12. One patient, raised by a violent mother, told me how she had ‘pushed and pushed’ her boyfriend to be violent with her. ‘I know this sounds funny,’ she said, ‘but when he was hitting me I felt loved.’

13. Sexual intrusion is always accompanied by a psychological ejaculation into the victim. In the two worst cases of parent/child incest I have ever seen, the abuse evidently started after the abuser had suffered a significant object loss which was then, in effect, pushed into the victim.

14. MacCarthy (1988) and Milton (1994) describe these situations particularly well, with detailed clinical illustrations.