Self-Mutilation, Substance Abuse, and the Psychoanalytic Approach: Four Cases

Some borderline patients and some psychotic patients have a history of substance abuse and self-mutilation. Many experts, including a portion of psychoanalytic practitioners, view these patients as especially in need of “ego-supportive” interventions, directive and prescriptive measures, and behavioral and interactive procedures. The author feels that while these parameters to psychoanalytic technique are at times unavoidable, the psychoanalytic method is still the treatment of choice. This stance is based on the idea that self-destructive behaviors are the sum outcome of numerous unconscious phantasies. Several cases are offered to illustrate the use of psychoanalytic psychotherapy as the vehicle for reconstitution in these more primitive patients. These case examples include several derailments and failures of “proper technique” that seem to be inevitable in the work and valuable to analyze with the patient.