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Section 22
Treating Self-Mutilating Borderline Clients

Question 22 | Test | Table of Contents

Several preexisting conditions seem to place patients at risk for self-mutilation. A number of chaotic life events, such as physical traumas, and radically inconsistent environments may ultimately lead to overwhelming experiences of a malevolent and chaotic world. Boundary transgressions, lack of stable semiotic structures, and exposure to unbearable emotional experiences overwhelm the individual's capacity to integrate emotional experience and interfere with the establishment of a stable self-organization. Complications arising during puberty may have an adverse impact on the predisposed adolescent's capacity to differentiate from the mother (Chasseguet-Smirgel, 1995; Cross, 1993). Struggles over the psychic ownership of body and self may help to explain the sudden emergence of self-mutilation and eating disorders in adolescence--during puberty--when the young girl's body develops a likeness to her mother's. The formation and subsequent arrest in the development of defenses, and the internalization of precariously differentiated self- and other representations, further complicate the capacity to assume ownership of the body.

Noxious life events and their subsequent pathological adaptations make these patients vulnerable to ego fragmentation and psychotic regression. These vulnerabilities may lead patients to be extremely sensitive to any challenge to their self-integrity, and may lead to a defensive insistence on controlling their environment. Thus any challenge to their sense of control over themselves and the environment may upset their fragile narcissistic equilibrium, leading to rage and unmodulated aggression. Once in the midst of such rageful spoiling, patients may engage a series of primitive defenses such as idealization, splitting, and devaluation in order to ward off fragmentation. When these defenses fail, these patients may self-mutilate in a desperate effort to rid themselves of noxious affects, and unconsciously to assert control over their fused sense of body, the other, and the outer world. By cutting the outer boundary of the body, they may in fact create a concrete marker of their differentiation from the environment.

Such a tentative formulation precludes any definitive statement on treatment; nevertheless some technical recommendations may provoke further thought and inquiry into this treatment-resistant population. Integrating research findings from this study and Plakun's (1994) principles for the psychodynamic treatment of self-destructive borderline patients at serious risk for suicide has proven quite useful. While Plakun focuses primarily on the problem of suicide attempts that seriously threaten the continuity of the treatment alliance, we have successfully applied several principles to the treatment of self-mutilating patients.

At the outset of treatment, we recommend that the therapist set a frame about how crises will be managed, including the exploration of self-destructive acts as part of the interpretive process. These efforts to come to a mutually agreed-upon protocol for handling crises and an agreed-upon interpretive task will help to highlight the differentiated role and task for patient and therapist. We have found that this recommendation helps patients use the clearly articulated frame to temporarily reinforce their limited capacities for self-other differentiation and often eliminates the power struggle over interpreting the self-destructive acts.

A second recommendation, to metabolize countertransference reactions prior to responding to the suicidal or self-destructive behavior, is particularly appropriate when one considers the self-mutilating patient's disturbed object relations, vulnerability to narcissistic injury, and preponderance of primary process aggression. The capacity to acknowledge and tolerate countertransference hate is requisite for treating psychotic and borderline conditions, and has been particularly fruitful in our experience. This is not to suggest that therapists silence their reactions, but rather to modulate their responsiveness carefully to match the task of the treatment. The risks inherent in therapists' unmetabolized self-disclosures of guilt or rage are greatest because they may lead the patient to conclude that the therapist is out of control and dangerous. Equally disastrous is the patient's interpretation of the therapist's unbridled reaction as a challenge to the patient's autonomy.

Defense analysis and an exploration of the patient's experience of self-mutilation before interpreting the latent aggression may be particularly important because the patient's capacity for recognizing somatic sensations as emanating from within his or her own body as a signal of rage is often lacking. The timing and empathic delivery of interpretations of self-destructive acts seem particularly relevant, given our findings of self-mutilating patients' unmodulated primary process aggression on the Rorschach. Such unmodulated internal states need to be interpreted and opened for the fullest range of experience so that patients integrate these experiences of anger through secondary process channels of fantasy, reconstruction, and protest.

Once therapist and patient have explored the ramifications of the recent suicidal/self-destructive act as aggressive, Plakun (1994) recommends that both parties search for the perceived narcissistic injury that precipitated the self-destructive behavior. There are several interpenetrating reasons for this intervention, including the opportunity for the therapist to acknowledge accurately perceived failures (Cooperman, 1989). The crucial element, from our vantage point, is the exploration of the transference and the likely disillusionment and injury that occurred in the preceding sessions. By placing a premium on exploring the unconscious and conscious meanings of the self-destructive act, the therapist is holding to the therapeutic task and, in so doing, is reaffirming the requirements of the therapeutic frame to seek meaning. Following these principles will in no way eliminate the risk of provocative acting out and self-destruction. Rather, we hope these recommendations and the measured use of consultation and hospitalization will aid in the effective treatment of these patients.
- Fowler, J. Christopher, Mark Hilsenroth, and Eric Nolan; Exploring the inner world of self-mutilating borderline patients: A Rorschach investigation; Bulletin of the Menninger Clinic; Summer 2000; Vol. 64 Issue 3.

Self-Mutilation and Pharmacotherapy

- Smith, B. D. (2005). Self-Mutilation and Pharmacotherapy. Psychiatry. p. 28-37.

Personal Reflection Exercise #8
The preceding section contained information about treating self-mutilating Borderline clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
A Rare and Complex Case
of Non-suicidal Self-Mutilation
in a Patient With Schizophrenia

- Khanna, A., & Agustines, D. (2023). A Rare and Complex Case of Non-suicidal Self-Mutilation in a Patient With Schizophrenia. Cureus, 15(1), e33269.

Peer-Reviewed Journal Article References:
Boylan, K., Chahal, J., Courtney, D. B., Sharp, C., & Bennett, K. (2019). An evaluation of clinical practice guidelines for self-harm in adolescents: The role of borderline personality pathology. Personality Disorders: Theory, Research, and Treatment, 10(6), 500–510.

Hepp, J., Lane, S. P., Wycoff, A. M., Carpenter, R. W., & Trull, T. J. (2018). Interpersonal stressors and negative affect in individuals with borderline personality disorder and community adults in daily life: A replication and extension. Journal of Abnormal Psychology, 127(2), 183–189.

Hope, N. H., & Chapman, A. L. (2019). Difficulties regulating emotions mediates the associations of parental psychological control and emotion invalidation with borderline personality features. Personality Disorders: Theory, Research, and Treatment, 10(3), 267–274.

Lyons-Ruth, K., Riley, C., Patrick, M. P. H., & Hobson, R. P. (2019). Disinhibited attachment behavior among infants of mothers with borderline personality disorder, depression, and no diagnosis. Personality Disorders: Theory, Research, and Treatment, 10(2), 163–172.

Sansone, R. A., Sellbom, M., & Songer, D. A. (2018). Borderline personality disorder and mental health care utilization: The role of self-harm. Personality Disorders: Theory, Research, and Treatment, 9(2), 188–191.

QUESTION 22
What two recommendations does Fowler make regarding addressing a BPD client’s self-mutilating behavior? To select and enter your answer go to Test.

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