No More Cuts: The Curious Fate of Self-Mutilation in Its Development

In this article, we present descriptions of four young women with relatively severe personality disorders. All four were in psychodynamic psychotherapy and all had the symptom of self-cutting. During their treatment, it became evident that their self-cutting had undergone a transformation and a new symptom had appeared in its place. In three, self-cutting was substituted by behaviors that we might call “cutting equivalents” and, in the fourth, by an enhanced self-reflective attitude and by journal-writing. We suggest that symptom-replacement for self-cutting may be common in its developmental course or in its course as it becomes influenced by psychotherapy, and that the replacement is sometimes, perhaps often, salutary. Approaching severe personality disorders psychodynamically has its pros and cons (1-3). On the one hand, it provides a deeper and more specific understanding of the patient, one in which his or her symptoms are seen as intricately bound with constitutional givens, early childhood experiences, and unconscious fantasies. On the other hand, if symptoms are end-products of a ‘trauma-fantasy-wish-defense’ sequence, any effort aimed simply at symptom-reduction is conceptually suspect and has practical risk. Psychodynamic models of etiology compel the prediction that removing a manifest disturbance might be undesirable, if the underlying issues responsible for it remain unresolved. This consideration acquires greater significance in cases of severe personality disorders (e.g., borderline, schizoid, antisocial, paranoid), which in some instances appear nearly intractable. The best outcome could be that a new, less toxic symptom replaces the older, more toxic one. Of course, if the former takes sublimatory or even “pseudo-sublimatory” form (1), the outcome can be regarded as not bad after all.