It cuts both ways: an analysis of the psychological discourse on self-injury from a linguistic point of view.

It Cuts Both Ways: An Analysis of the Psychological Discourse on Self-Injury from a Linguistic Point of View Vered Bar-On This article proposes an analysis of the phenomenon of self-injury through the prism of current linguistic theories. The author uses the clinical distinctions made by Roman Jakobson between metonymic and metaphoric aphasia to suggest that the psychological community and those who harm themselves are participating in separate “language games.” While the clinical “language game” is characterized by the dominance of metaphor and a conception stressing the hierarchy between metaphor and metonymy, the “language game” of self-mutilators is dominated by metonymy. The author explores the clinical implications of understanding the language game of those who injure themselves as metonymic.

Semiotics is the theory of signs The theory of signs is the theory of scars The theory of scars is a set of wounds That haven’t healed. A wound that has healed Has the appearance of transparency Who can speak the language of transparency Who can write on glass even if his father is A glazier to say nothing of a semiotician —Raquel Chalfi, “Semiotics Is”

Self-injury is a form of human behavior that is both fascinating and worrying. On the one hand, it arouses one’s intuitive feeling that such behavior “is not natural,” a deviation from the evoluThis article is part of the work for my Ph.D. at Bar Ilan University, Israel. I wish to thank Prof. Avi Sagi, Dr. Aner Govrin, Dr. Dror Yinon, Dr. Dorit Lemberger, and Dr. Yael Babad for their valuable contributions and constant support. Psychoanalytic Review, 101(5), October 2014

© 2014 N.P.A.P.

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tionary principles of protecting life and the integrity of the body. On the other hand, it occupies an honored and normative place in human culture, be it in religious culture (such as its symbolic ritualistic prominence in Christianity and Shi’ism), and in general Western culture (as exemplified by the practice of tattooing and piercing). This intermingling of alienation and affinity, the normative and the abnormal, make it a fascinating and intriguing phenomenon. There is general agreement in the clinical discourse that the encounter with cutters is among the most difficult for the therapist. Since the phenomenon was first noted in scientific discourse it has aroused troubled responses from therapists. It began with astonishment in the face of the unknown, the incomprehensible, leaving the therapist uneasy and baffled, as expressed, for example, by Andrews in 1872: “Truly a mystery which no one could solve” (p. 19). Many negative responses and emotions were evoked by this kind of behavior. For example, Menninger (1938), in his famous book Man Against Himself, opens the chapter dealing with the phenomenon of self-harm with a warning to the reader: “We physicians, familiar from our daily experiences with these unlovely sights, often forgot that for most persons the barriers imposed by these taboos are quite high. . . . It is certainly not reading for children” (p. 203). Among the first to express this from the point of view of the clinical staff were Offer and Barglow (1960): “The initial response of hospital personnel was fragmented and diffuse, with widespread confusion, guilt, heated arguments and breakdowns in communication, resulting in an untherapeutic environment” (p. 194). Similar statements are repeated in many articles. Frances (1987) accurately noted that “the typical clinician, myself included, treating a patient who self-mutilates, is often left feeling a combination of helpless, horrified, guilty, furious, betrayed, disgusted and sad” (p. 316). During my years treating cutters in psychiatric hospitals and private clinics I have had to deal with the matter of the special difficulty that arises in an encounter between the therapist and the cutter. Besides general statements such as the preceding quotations, which express the enormous difficulty in an encounter with

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the cutter, there are very few examples in the literature that emphasize the therapist’s experience encountering the actual cut itself (Kafka, 1969; Motz, 2009). I would like to stress this aspect of the therapeutic encounter amid the more general difficulties referred to in the literature by a description of my personal encounter with “L” and her cuts: L tells me that she cut herself again. “Do you want to see?” she asks. A good question I think to myself. . . . I am not sure. The last time that L showed me a deep cut she had made I was surprised by the strength of my reaction. I was agitated, shocked. The cut seemed to me to be deep and painful in a way that was hard for me to bear. I equivocate a little and ask L about her wish to show me the cuts. She says that she wants to break away from all the technical talk about cutting. I think to myself that shocking me is crucial to her. I take a moment and look: She lifts her skirt a bit and I see the injured thigh, with dozens of cuts in rows, cuts crossing over cuts, covering the injured area like a kind of spider’s web. The thigh is very red, like raw meat. I look at the wounded thigh; I am shocked, I feel numb and without sensation. A kind of iron curtain descends between us with a loud bang and I am aware of how unusual this feeling is for me. While looking with a frozen countenance at her thigh I remember the reaction of her father to her suicide attempt: He told me that he does not believe it, that she attempted suicide; however, he did not tell her that he does not believe it. I remember how he reacted when I first told him that his daughter cuts herself: “Really? So what?” I feel that the numbness and lack of sensation that comes over me is pleasant and protective and, for all that, also frightening. I decide to reveal my lack of feeling to L, to see if she is familiar with it. L listens to what I am saying; she looks tense and alert. She nods her head vigorously, and then, embarrassed, she says she wants to tell me a secret. Horror scenarios pop into my mind. L tells me with great embarrassment that she takes pictures of herself with her mobile phone while she is cutting herself and asks me if I want to see them. Of course I want to—this is a window of opportunity, to see the cut in real time, and not to see only the

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scars of the closed wound. For me the pictures are harder to look at than I had anticipated. She commemorates the cut in many pictures: immediately after making the cut, waiting for the blood to gush out, pictures of the blood flowing. This time the cut happens to be very deep. She photographs her bed and the floor covered with pools of blood. I see a slaughterhouse and my blood pressure begins to drop. I feel giddy with a mixture of shock and deep repugnance along with L’s profound emotion, and a feeling of risk and a thrill at the forbidden intimacy that we share. I return to the treatment of L later in order to discuss its difficulties and failures as well as its sudden termination. A variety of explanations have been put forward over the years regarding the difficulties in an encounter between the therapist and the cutter. Pao (1969, p. 202) claimed that the difficulty in the treatment of cutters arises from the waiver of the object, which leaves the therapist abandoned and castrated. Podvoll (1969) agrees with this interpretation of the dynamics behind the difficulties in the therapeutic relationship, seeing it as an attempt by the cutter to waive the need of an object; Podvoll asserts that instead of another, the cutter selects her1 own body as a chosen love object. Feigenbaum (2010) links this to the problem self-harmers have with regulating their emotions, due to invalidating environments, the most extreme expression of which is childhood abuse. Thus the difficulty that occurs in the therapeutic encounter reflects the testing of boundaries, the internalized experience of rejection, and the impulsivity that are the results of early abuse. Motz (2010) goes a step further and claims that these difficulties in the therapeutic interaction are not merely a reconstruction but an expression of hope, revealing an attempt to find a helpful response to distress, similar to the hopeful aspect in antisocial tendencies described by Winnicott (1956). Another frame of reference for these difficulties is in the conceptualization of addiction. Thus, for example, Glick (2010) claims that “similarly to other addictive patterns, self injury stems from a psychological difficulty but becomes the center of difficulty and destruction in and of itself: a two edged sword which enables dealing with unbearable psychic pain but at the same time


consumes the person by continually tightening its grip” (p. 163). According to Glick, conceptualizing self-injury as addiction allows for another layer in the therapeutic dialogue through an acknowledgment of the component of lack of control and the absence of alternative skills. Recognition of this allows for a more empathic approach by the therapist to self-injury, instead of automatically classifying it as a manipulative act or an act that has the characteristics of “borderline” behavior. In this paper I propose another possible way of looking at and understanding the difficulties in the therapeutic interaction with the cutter. I do this by using linguistic analytical tools. The twentieth century introduced sweeping changes in thinking in philosophy, mathematics, and logic. The “Linguistic Turn,” as these changes have been called, put language at the center of philosophical thinking. In its wake, language began to be perceived as the starting point of human activity in all its forms. The philosophical debate came to understand that the meanings of actions taken are not obvious but rather are defined by the way in which they are described in language. In other words, the inquiry can begin only from the moment when we encounter language. What occurred previously is not open to investigation. In the spirit of the “Linguistic Turn” I attempt to analyze the way in which the cutters and therapists discuss self-injury, describe it, and make claims with regard to it, out of an understanding that language—talking about it and giving it a name—determines a reality. Using metaphor and metonymy as analytical tools, as suggested by the linguist Roman Jakobson, I suggest that there is a divide between the metonymic language game of the cutters and the metaphoric language game of the therapists, and I consider the difficulties in terms of this distinction. Before turning to a linguistic analysis I briefly review the phenomenon of self-harm. I will discuss self-injury in the psychological discourse, in which it is defined as a psychopathology. In my view the phenomenon of self-injury is more widespread than what we encounter in our clinics. Moreover, it is defined in various places in Western culture in a way that occasionally contradicts the definition of the phenomenon in the psychological discourse, which is only one possible discourse.2

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THE SELF-INJURY: THE PSYCHOLOGICAL DISCOURSE

The psychological discourse in relation to self-injury focuses on the type defined by Favazza and Rosenthal (1990) as repetitive selfmutilation. The definition that is consistent with many works of research in the field is that self-injury “is direct and socially unacceptable, it is repetitive and results in minor or moderate harm. Is not suicidal in intent; and is not related to general cognitive impairment”(Suyemoto, 1998, p. 532). In the psychological discourse self-injury appears under a range of names such as self-abuse, self-inflicted violence, selfwounding, self-injury, self-mutilation, NSSI (non-suicidal self-injury), and DSH (deliberate self-harm). It tends to begin in adolescence or early adulthood and continue for years (Nock, 2009; Suyemoto & MacDonald, 1995). The most widespread method of self-injury is skin cutting (e.g., Muehlenkamp & Gutierrez, 2004; Nock, 2009; Ross & Heath, 2002). Many studies repeat the claim that there has been a dramatic rise in the incidence of this phenomenon (Jacobson & Gould, 2007; Nock, 2009; Ross & Heath, 2002; Whitlock, Eckenrode, & Silverman, 2006). However, this claim still needs to be confirmed. There are wide discrepancies in the research in respect to the frequency of the phenomenon. Reports of the incidence of self-injury within the population as a whole vary from between 1 percent and 5 percent (Brieire & Gil, 1998; Jacobson & Gould, 2007; Rodham, Hawton, & Evans, 2004) and between 2.2 percent and 6 percent (Gibson & Crenshaw, 2010), to as much as 35 percent (Gratz, 2001). Among nonhospitalized adults there are findings of 1 percent to 4 percent (Jacobson & Gould, 2007). Among students there are reports of an incidence of 17 percent (Whitlock et al., 2006), while other studies claim an incidence of between 13 percent and 35 percent (Gibson & Crenshaw, 2010). Among nonhospitalized adolescents there are findings of 13 percent to 23 percent (Jacobson & Gould, 2007), as well as other findings that suggest a range of 4 percent to 38 percent (Gratz, Conrad, & Roemer, 2002; Heath, Toste, Nedecheva, & Charlebois, 2008; Klonsky, Oltmanns, & Turk heimer, 2003). Among populations who are under psychiatric care the incidence has been found to move in a range of between


13 percent and 65 percent (Adshead, 2010); among hospitalized adolescents the range reported is between 40 percent and 60 percent (Darche, 1990). Despite sporadic claims regarding the similar prevalence among men and women (Klonsky, 2007; Nock, 2009), most of the recent studies show that self-injury is a “feminine” phenomenon without reference to ethnic origins3 or socioeconomic level (Hilt, Nock, Lloyd-Richardson, & Prinstein, 2008). Family characteristics that were found to have a high correlation with self-injury were divorce of parents in childhood, dysfunctional parenting, and physical or sexual abuse. I would like to draw attention to a description that is common to cutters, who testify that prior to the act of cutting they experience an extreme buildup of tension, anxiety, anger, or fear. The execution of the act of cutting leads to an immediate feeling of relief, calm, or satisfaction. There are many and various forms of self-injury: cutting, burning, scratching, reopening of wounds, and the like. The most frequent of these behaviors is skin cutting (Nock, 2009), mostly with the aid of a razor, a penknife, and, sometimes, fingernails. The cuts we are talking about go as far as to produce bleeding. It is not an impulsive act, but rather, for the most part, preplanned, executed in secrecy while the person is alone, and its outcome hidden beneath clothing. Such injuries are most often inflicted on the inner arm and thigh. Isolation from others almost always precedes the act of self-harm. The acts generally take place in solitary without the knowledge of others (Doctors, 1981), though sometimes, as shown by Rosen, Walsh, and Barent (1989) and Fenning, Carlson, and Gabrielle (1995) in their articles, self-injury in fact starts and is maintained among couples and groups. As mentioned earlier, self -injury is considered to be one of the most problematic and difficult forms of behavior for therapists to contain. Therapists report difficulty and a lack of understanding when treating self-injuring patients, as well as such feelings as anger, rejection, frustration, and a lack of ability to conduct a satisfactory discussion with the patient about the self-injury (Barglow, Chandler, Molitor, & Offer, 1992; Favazza, 1996; Zila & Kiselica, 2001). At the same time, patients who injure themselves de-

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scribe how an inappropriate attitude to their injury on the part of the therapist leads them to represent their injury as an attempted suicide in order to get a more empathic and fitting response from the therapist. I suggest viewing these difficulties from a different perspective, and I offer an alternative explanation from a linguistic point of view. ROMAN JAKOBSON ON METAPHOR AND METONYMY IN LANGUAGE AND IN LIFE

Roman Jakobson (1896-1982), a Russian linguist of Jewish descent, was one of the most influential intellectuals of the twentieth century. One of his most important contributions was the development and nurturing of interdisciplinary research. Jakobson’s linguistic method was based on a structural analysis of language. Jakobson’s method strives to achieve a constant review of the mutual relations between the various parts at all levels of the linguistic system, ranging from the relations between the smallest units, phonemes, to the relations between the various words in a sentence, up to and including the relation of language as a discipline to other disciplines. The method is comparative, interdisciplinary, rich, and open. It places emphasis on the asking of questions and the examination of differences no less than on providing answers and searching for the common denominator. In the article “Two Aspects of Language and Two Types of Aphasic Disturbances,” Jakobson (1956) examined, as part of his structuralist method and his affection for binary analysis, the famous and ancient pairing of metaphor and metonymy, which are two forms of semantic change (trope). A metaphor borrows, transfers, or uses a word or phrase not in its usual meaning but for the sake of being more picturesque. Jakobson, basing himself on Aristotle, defined a metaphor as the transference from one domain to another on the basis of similarity, or, in modern terms, the transference from one referred-to field to another. In a metaphor a relation is formed between the signifier in one semantic field and the signified from another semantic field. One word or phrase is compared to another, but without explicitly using the compared word.


Metonymy, on the other hand, is metaphor’s “less famous” sister. Mostly it is not treated as an independent concept, but rather it is left enfolded within the definition of a metaphor on the understanding that there is a hierarchical relation between them: “Metonymies stay at home on domestic detail, while metaphors go out to discover and conquer the world” (Matus, 1989, p. 311). Metonymy is a trope of the contiguity of one entity with another in space and/or time. This trope is derived from the association of the verbal vehicle’s referent with an entity close to that referent in space/time. Consider, for example, the question “May I borrow Leonard Cohen from you for the weekend?” It is not my intention to borrow the singer himself for the weekend, but rather the compact disc of his songs. In the sentence, “Leonard Cohen” is a metonymy in which the name stands in for the named person’s product, which is the CD. A metonymy appears when different terms in the sentence replace one another, and it can also appear as a synecdoche. A synecdoche is a subtype of metonymy that is also based on a process of replacement, except that in this exchange the part replaces the whole. For example, in the sentence “There are a lot of good heads at the University,” a body part stands for person and for the intellectual attributes conventionally associated with the body part. The age-old debate between metaphor and metonymy is problematic because researchers disagree about the definition and importance of metaphor and metonymy as well as how necessary they are to the structure of understanding and language recognition. There are researchers who rank the value of metonymy above that of metaphor, and there are those who see in the metaphor a form of expression that preceded metonymy and exists, in fact, in all the various forms of representation, not just linguistic. Some contrast these two types of trope, while others merge and combine them. For Jakobson, it is important to sharpen the distinction between the two concepts and present them as two poles apart, and not as two terms in a fixed hierarchy.4 In his treatment of the metaphor he emphasizes the similarity that exists in a metaphor between signified and signifier, compared to the contiguity that characterizes the metonymy. Another important contribution made

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by Jakobson is the identification of the various cognitive capacities that are the basis of all semantic changes. The cognitive capacity that produces a metaphor is the ability to form a word-for-word selection and substitution: the selection of one option out of many, but with a limited number of analogous but different options from another semantic field, and the substitution of the chosen option for the original word. For example, “thy belly is like an heap of wheat set about with lilies” (Song of Solomon, 7:2) is the way in which the poet chooses to describe his beloved’s belly, by selecting one concept from many possible concepts to describe the fully extended, soft, and sweet smelling belly, and using it in place of the prosaic option—one that would in no way promote the poetic and emotional state in which the speaker finds himself. The cognitive capacity that is responsible for creating metonymy is the faculty for combination and contexture, that is to say, a combination for the purpose of continuity and the capacity to infer from a context. Combination and insertion into context are, according to Jakobson, two facets of the same action. Jakobson’s binary distinction between these two figures of speech, metaphor and metonymy, is very fundamental. It is valid at all levels of language, at both the intra- and interpersonal levels, and makes possible the understanding of human thinking and behavior as expressed in literature, painting, dreams, ritual magic, and the like: “The dichotomy discussed here appears to be of primal significance and consequence for all verbal behavior and for human behavior in general” (Jakobson, 1956, p. 131). This is also so in the field of psychology. Jakobson illustrates an interesting clinical application to the dichotomy under discussion. As part of his structuralist interdisciplinary method, Jakobson investigates the ways in which the fields of linguistics and research into aphasia can at the same time make a contribution one to the other and also be mutually beneficial. He believes that research into the breakdown of language could give the philologist new insights into the relation between a language’s general rules and the process by which they are acquired. His involvement in the work of doctors at Karolinska hospital in Stockholm, led him to think about the link between different


kinds of aphasia and two different poles of language functions: combination and selection. He suggests a new classification for aphasic disorders depending on whether the main impairment stems from the capacity for selection and substitution (the metaphoric capacity) or for combination and contextualizing (the metonymic ability). Jakobson argues that those suffering from aphasia are divided into two opposite and complementary types: those who suffer from similarity disorder,5 an impairment in their capacity for selection and substitution, and the sufferers from contiguity disorder,6 an impairment of their capacity to combine and contextualize. I want to respond to Jakobson’s invitation and analyze the psychological discourse on self-injury by means of the suggested analytical tool: the distinction between metaphor and metonymy.7 I attempt to apply this tool to the metapsychology of self-injury as well as to the psychological discourse in practice by analyzing the language used by the injurers in describing their self-injury. To Jakobson’s definitions I attach (following Aristotle) metaphor and metonymy and place the emphasis on the qualifications pointed to by Jakobson in relation to each one of the tropes. Above all, in furtherance of Jakobson’s suggestion, I seek to view them as a dichotomous rather than a hierarchical pairing. TOWARD AN ANALYSIS OF THE PSYCHOLOGICAL DISCOURSE ON SELF-INJURY USING JAKOBSON’S APPROACH

I begin with an analysis of the various accepted theoretical explanations of the phenomenon in the psychological discourse and progress to an analysis of the self-harmers’ language as it is expressed in that discourse. In my view, the classification offered by Suyemoto (1998) arranges the various conventional theoretical explanations in a helpful way. She suggests six functional models of self-injury. 1. The sexual model (originating in the drive models) 2. The antisuicide model (originating in the drive models) 3. The affect-regulation model (most strongly rooted in ego and self psychology)

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4. The boundaries model (originating in object relations) 5. The environmental model (originating in behavior and systems theory) 6. The dissociation model (most strongly rooted in ego and self psychology) Metaphoric Models The sexual and antisuicidal drive models which I examine are rooted in psychoanalytic theory and, at least chronologically, they are the foundation of the psychological discourse on self-injury. They include an attempt to understand self-injury as an expression or a repression of the life, death, and sexual drives. 1. The Sexual Model. The link between sexuality and self-injury is based on the frequency with which self-injury starts at puberty, and almost never before it. It is furthermore based on the high correlation between sexual abuse and self-injury and on the high correlation between self-injury and the sexual dysfunction (Briere & Gil, 1998; Dulit, Fyer, Leon, Brodsky, & Frances, 1994; Fliege, Lee, Grimm, & Klapp, 2009; Gibson & Crenshaw, 2010). According to the sexual model, based on Menninger (1938), self-injury is linked to sexuality both in a positive as well as in a negative sense. It serves as a way of obtaining sexual excitement, while at the same time it punishes the young woman for her sexual drives (Menninger, 1938). There is a hypothesis (Novotny, 1972) suggesting that young women who injure themselves experienced conflict and difficulties at the very earliest stages of their psychosexual development, leading to problems in their sexual development that are given expression in cutting, which is equated with “self-penetration.” According to this hypothesis self-injury is selfpenetration, which in a symbolic way represents the desire for, and fear of, incest with the father, while at the same there is a subconscious wish to destroy the sexual organs for being at the root of these urges. Thus the conflict is transferred from the sexual organs to cutting, and the bleeding becomes controllable— turning the passive experience into an active one: “What do I celebrate when I cut? I love the passing of time, the interval between the incision and the arrival of the blood. I wait.


Have I cut deep enough to bring up the blood? Or is this a virgin’s cut? I must wait. I am used to such waiting. The cut in my body did not bleed until I was twelve; so I know all about waiting for a cut to bleed. Up it flows, up and out, spilling over my skin—Pure. No effluence of eggs. No dead babies here. No smelly stains . . . this blood is pure.” (Bollas, 1993, p. 139)

If we seek to apply Jakobson’s dichotomous categories to the sexual drive model, we will see that the sexual model suggests a metaphoric explanation for cutting. The cut symbolizes the female sexual organ, preserving with it a similarity, and even acts as a substitution. The substitution of the sexual organ by cutting has added value: The metaphoric use of cutting gives a feeling of control over what had been experienced as a loss of control over the changing and developing “traitorous” body, all the more so among girls who were victims of sexual abuse. For them the cutting that symbolizes the sexual organ is experienced as putting it under their exclusive control. 2. The Antisuicide Model. The antisuicide model focuses on the act of self-injury as an active coping mechanism that serves as a way of avoiding suicide (Firestone & Seiden, 1990; Himber, 1994; Menninger, 1938). According to this model, antisuicidal self-injury is an attempt to avoid total and irreversible destruction by localized, specific, and reversible destruction. In this model self-injury amounts to a “micro suicide”: It shares the self destructive behavior with the suicidal act, turning the aggression inward and providing the illusion of control over death. The difference between it and suicide is that the central dynamic at the basis of self-injury is the sacrifice of a part in order to preserve the whole. Thus, according to the antisuicide model, self-injury represents a victory for the life instinct over the death instinct or, in Menninger’s (1935) words, “In any circumstance, however, while apparently a form of attenuated suicide, self-mutilation is actually a compromise formation to avert total annihilation, that is to say, suicide. In this sense it represents a victory, sometimes a Pyrrhic victory, of the life instinct over the death instinct” (p. 466, emphasis added). This model also suggests a metaphoric explanation in which the cutting plays a symbolic role defined by a process of selection and substitution. The cut as a metaphor, according to this model,

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goes through yet another process of abstraction over the sexual model. The act of cutting symbolizes suicide, and the cut itself also symbolizes the basic drives that are at work in the psychic world—the tension between the life instinct and the death instinct. The acts of cutting and the cut are clearly similar to the act of suicide and the death instinct and are therefore selected as metaphors. However, the substitution differs from the signified metaphor due to the reversibility and superficiality of the injury (linked to the life instinct). If so, the cutting simultaneously symbolizes the death instinct as well as symbolizing the act of coping with that instinct and temporarily overcoming it. The cutting becomes a metaphor of compromise between the central drives in Freud’s theory—a compromise between the life instinct and the death instinct. 3. The Affect-Regulation Model. A third model that deals with the phenomenon is the affect-regulation model. According to this model, self-injury stems from the need to express or control anger, fear, or pain that cannot be expressed verbally or in any other way. This model suggests that self-injury responds to the need to feel real physical pain as opposed to a purely emotional pain. It would appear that young women who injure themselves are in need of physical evidence of their emotional injury in order to sense that their emotions are real and justified or controllable. The applicability of this model can be based on a narrative that is often repeated in the therapeutic field. It is an account of a general, unfocused feeling of malaise: The cutting is done “for no reason” or “perhaps I’m just faking it.” On the other hand, the cutting confirms their feeling that the situation is indeed serious. Moreover, the self-injury helps to regulate the feeling that arises, by turning a passive pain into an active pain that can be controlled (Allen, 1995; Franklin et al., 2010; Gibson & Crenshaw, 2010; Nock, 2009). If so, it can be seen that the affect-regulation model also proposes an explanation by way of metaphor. The cutting makes the substitution of an unbearable mental pain by a physical pain, the substitution of an unfocused mental pain by a focused razor sharp pain, and the substitution of a mental pain that fills an inner void by a superficial external pain on the surface of the skin.


Moreover, the affect-regulation model explains the phenomenon as, using Jakobson’s term, a “similarity disorder” in which a connection can be found between girls who injure themselves and their difficulty in giving verbal expression to feelings (Rosen, Walsh, & Rode, 1990; Zlotnick, Donaldson, Spirito, & Pearlstein, 1997). According to these approaches, the problem young women who cut themselves have in expressing feelings verbally is linked to a failure in their ability to trust the therapist and to their inability to grasp symbols as a way of getting beyond the feelings of omnipotence and helplessness. Thus, the affect-regulation model claims that self-injury stems from damage to these girls’ metaphoric capacity, and it does this by means of a metaphoric interpretation of the phenomenon itself. 4. The Boundaries Model: Between the Metaphoric and Metonymic. The fourth model for explaining the phenomenon of self-injury is the boundaries model. The origins of the boundaries model are in the theory of object relations, which suggests that girls who injure themselves have not completed the early developmental task of separation and individuation from the mother due to a weak or insufficiently secure primary attachment to the parent. According to the boundaries model, self-injury is an attempt to consistently redefine one’s self-boundaries in relation to the other so as to distinguish between the self and others, and thus to defend oneself against merging and engulfment. The assumption, according to this model, is that the boundary between the cutter and the other person is diffuse (Nock, 2009; Suyemoto, 1998). “Do you know why I cut myself today, even though I promised you that I wouldn’t do it without first talking to you? Because I suddenly panicked. Real panic. Perhaps I’m a doll? I had to cut myself to see that I had something that a doll doesn’t . . . that I have blood. Yesterday, when I was with you, I so much wanted you to touch me. But I’m afraid. Afraid that if you touch me once , I’ll want it again, and if you touch me again, I’ll want it always. And you won’t be able to always touch me. Sooner or later you’ll go away. Even though you have told me a thousand times, my fear is renewed every day that you won’t be able to stand the pressure I put on you. That one day you’ll be fed up and you will cut off the connection between us.” (Trieste, 2002)

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The concept of “skin ego,” coined by the French psychoanalyst Didier Anzieu (1989), can be a huge contribution to the understanding of the phenomenon. Through this concept. Anzieu developed a systematic and broad analogy between the skin and the ego’s functions. The “skin ego” is a concept that forms a bridge between the body and the psyche, between a person’s experience of himself or herself as subject and as object. According to Anzieu, the ego and the skin have both a metaphoric and metonymic relationship The metaphoric is a relation of similarity in which the ego and the skin are substitutes or replacements, whereas the metonymic is a relation in which there is continuity between the broad concept of the ego and the narrower concept of “the skin”: “The idea of the Skin Ego is, admittedly, a metaphor of very broad scope—more precisely, it seems to me to be a product of that metaphoro-metonymic vacillation” (Anzieu, 1989, p. 6). Inappropriate touching at a very early age can create a lasting experience of being uncomfortable in one’s skin, which can lead to more profound significant damage to the structural components forming the psyche. The cutting is an attack on this formation; it is an attack on the interface, the seam between the internal and external world. The cut is a contact with the body that is intended to sharpen the feeling of boundary. The incision is an attack on the wholeness and continuousness of the body, its inclusiveness and retentiveness, on the umbilical link, the need for the “other,” whomever that may be. Thus, the boundaries model suggests a metaphoric–metonymic description of self- injury. The cutting of the skin and the outpouring of blood symbolize the defuse boundary between the young woman and the world, between the young woman and her internalized objects, as well as the perforated parental container that failed to give her a feeling of inclusion and calm at the beginning of her life. On the one hand, the level of abstraction that here defines the similarity between the phenomena and enables the metaphoric substitution to be made is especially high, and stems from the theory of object relations, a metatheory in psychology. The analytical interpretation of the action of cutting in this theory is a metaphoric interpretation that is linked to a sys-


tematic metaphoric displacement of physical events by the object relations symbolized by them. On the other hand, the cutting of the skin is not only a metaphor for injured mental functions. The injured skin itself is continuously linked to the infant skin that was not satisfied by physical contact. Furthermore, I find value in Sela’s (2011) conclusion on the lack of congruence between Anzieu’s epistemologically revolutionary theory and his conservative therapy in practice, which remains metaphoric. Toward Metonymic Theories of the Phenomenon of Self-Injury The three first models that I have reviewed—the sexual odel, the antisuicidal model, and the affect-regulation model— m provide us with metaphoric explanations of self-injury, while the fourth, the boundaries model, wavers between a metaphoric and a metonymic explanation. Before presenting the two remaining explanations, I wish to return to a broad description of girls who cut themselves. Before cutting they feel an extreme accumulation of pressure, anxiety, anger, or fear. The act itself leads to an immediate feeling of relief, calm, or satisfaction: “Before I cut myself I had what I called a crazy headache, and after I had let blood my headache went away, and I thought that the cutting of my wrist, and letting the blood flow had cured it.” (Emerson, 1913, p. 44) “It’s like a relief. I do it every couple of weeks just to get a relief . . . from pressure that builds up inside . . . [I] just, just feel that there’s a pressure building up inside of you that you have to do something about. That you feel like you’re going to explode if you don’t. And cutting is a way to release that.” (Himber, 1994, p. 623)

These descriptions are metonymic, where the buildup, linkage, and contextualization produce continuity: pressure–cutting– relief. Moreover, the girls’ own comments, quoted earlier in this paper, reinforce the metaphoric explanations, which also have metonymic characteristics.

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“Do you know why I cut myself today, even though I promised you that I wouldn’t do it without first talking to you? Because I suddenly panicked. Real panic. Perhaps I’m a doll? I had to cut myself to see that I had something that a doll doesn’t . . . that I have blood.” (Trieste, 2002)

By cutting, the patient negates a metaphoric perception of her identity. She wants to discover that she is not a doll. The act of cutting is validated by the metonymic contiguity of blood testifying to her being a “person of flesh and blood.” The blood is metonymic evidence of actual existence. It does not symbolize abstract mental images that have a substantive similarity to blood (that would be a metaphor.) The blood remains blood and nothing more than that. The account given by Bollas’s (1993) patient (quoted in the section on “The Sexual Model”), in which she describes the wait between the cutting and the arrival of the blood, and which arouses a metaphoric association in the therapist connecting the cutting to the sexual organ, is also metonymic. It must be noted that the description given by the cutter does not contain the metaphoric interpretation of the act of cutting. On the contrary, she distinguishes between it and the menstrual bleeding from her sexual organ. In fact, it is the menstrual bleeding that she interprets metaphorically as being composed of “dead babies,” whereas the blood from the cut gives a pure response to the pressure that accumulated prior to the action. For someone listening on the sidelines it is of course difficult to ignore the analogy, arising from this description, between the sexual organ and the cut, although this view is disconfirmed if we accept what the patient says at face value—that the time during which she is waiting for the blood is, for her, a time of celebration. She does not choose to replace a sexual experience with the sexual organ by cutting. Rather, she in fact draws a parallel between the experience she accumulated during her years as a virgin and the expectation of blood in what appears as a metonymic sequence: cutting–eager expectation–blood. The incongruity between the metonymic description of selfinjury given by the girls and the metaphoric tendency that dominates the various dynamic theories can also be seen in the meta-


phoric way in which Emerson (1913) explains the metonymic description given by his patient of her self-injury: “Before I cut myself I had what I called a crazy headache, and after I had let blood my headache went away. . . . It was about three weeks afterwards that I decided I must cut myself again” (p. 44). Emerson explains her behavior in the following metaphoric way: “The menses had always been irregular, and after the patient began cutting herself, she said she cut herself every four weeks. This correspondence to the catamenia period is obvious” (p. 51). I find this distinction between the metonymic feature of the descriptions given by the injurers and the psychological metaphoric interpretation interesting and thought provoking. One possible explanation may be found in the claim made by the affect-regulation model that the metonymic traits of the girls’ description reflect an impairment of their metaphoric abilities, an explanation that is not in the spirit of Jakobson and which assumes a hierarchy between the metaphoric and the metonymic abilities. Such a hierarchy between metaphor and metonymy is fundamental to my understanding of the psychological discourse and is linked to a Western cultural outlook in which the more complete the symbolism, the more the act is developed, and the more acceptable and healthier it becomes (Milia, 2000). Another way of understanding the gap between the metonymic dominance of the injurer and the metaphoric psychological explanation is linked to the great importance attached to the metaphoric in the psychoanalytical tradition. The psychoanalytic discourse is conducted around metaphors and sometime employs them. The psychological analysis mimics the language of the patient in the metaphoric field, decodes his or her deeper underlying psychology by using fundamental metaphors, and treats the patient by reorganizing his or her self-awareness by using these same metaphors. Having said that, according to Govrin (2011) most psychoanalysts relate to psychoanalytical notions as having real substance and not merely as metaphors inserted into the language during the psychoanalytical discourse. Therefore metaphoric thinking is out, and the use of metaphor acquires a kind of quasi-scientific status in psychoanalytical language games and is occasionally adopted as a quasi-factual description of psychic real-

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ity. At the same time, metonymies are considered to be an external screen that hides the (metaphoric) psychic facts. Metonymic Models The two models that remain, as opposed to those preceding them, point in the direction of metonymy. 5. The Environmental Model. The environmental model originates from behavioral and systemic theories. It focuses on the interaction between the cutter and her environment, and assumes that the self-injury serves both the cutter and the social system (family, hospital, youth groups, and the like). According to this model, self-harming behavior may be acquired in two main ways: 1. As detailed in environmental models, the injurer creates a relationship of conditioning between the pain and the care. She regards the cutting as an attempt at self-care (Suyemoto, 1998). 2. Through the reinforcement described in the behavior model, the self-cutting is accompanied by a feeling of relief. This feeling constitutes immediate internal reinforcement. A different reinforcement system relates to the environmental support received from family, colleagues, or therapists. Such reinforcement stems from the large amount of attention paid to the patients by their therapists as well as from the patients’ control over others (Allen, 1995; Nock, 2009; Suyemoto, 1998). The systemic model relates to the social fabric as a whole. In relation to the social context as the sum total of all the contexts in which the self-harmer functions, self-injury may be a way for the self-harmer to maintain the status quo by diverting attention toward the self-injurious behavior. She becomes an “identified patient” who is being treated, the center of attention, rather than that attention being focused on other systemic problems that are, at times, more fundamental. The environmental model gives a metonymic explanation for self-injury: In light of the two elements that Jakobson identified with metonymy—“combination” and “contextualization”— self-injury is explained on the basis of the context in which it is


carried out and on an internal logic that guides it. The motivation for self-injury stems from the creation of continuity and proximity between pain and care, between the act and the reinforcement it receives. The perception of the self-harmer as “the identified patient” can be perceived as a synecdoche in the environmental context. The broad problems in the social system are transferred to one organ, which represents the whole. Within the framework of this explanation, the cut is not given a metaphoric interpretation, but rather a role against the background of its being combined with other environmental conditions and the context in which the girl functions. 6. The Dissociation Model. The dissociation model focuses on preserving a self-concept or an identity. Bromberg (1998) suggests seeing the dissociative process as the main mechanism for regulating and protecting the psyche. He perceives dissociative processes as relevant both for pathologies (dissociative disorders) and a healthy psyche. In traumatic or extremely invalidating environments, dissociative processes are essential for maintaining the continuity of the self, but these processes take a significant toll on the psyche. Since emotional arousals and intrapsychic conflicts are experienced as dangerous for maintaining the continuity of the self, a person finds himself or herself cut off from whole-self situations. This situation necessitates constant readiness for the mobilization of dissociative mechanisms that will maintain the disengagement among the parts of the self, thus causing the loss of ability to feel secure. Moreover, interpersonal situations are automatically linked with the need for dissociation, due to the danger of invalidation by the other person. Like the affect-regulation model, the dissociation model assumes that self-injury facilitates emotional regulation, but focuses on the dissociative experience and the way in which the self-injury affects and is affected by it. The self-injury was found to aid patients in coming out of the dissociative experience (Allen, 1995; Fliege et al., 2009; Gibson &Crenshaw, 2010; Klonsky & Glenn, 2008; Nock, 2009). As most of the girls do not feel pain during the cutting, the assumption is that the stunning redness of the blood brings the dissociation to an end (Simpson, 1975, 1980). When the self-harmer sees blood, it “reminds” her that she is

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alive and reduces the dissociative disruption (Paris, 2005). In addition, the scars that remain following the self-injury may arouse in the cutter a sense of existential continuity, a feeling of connection between dissociative episodes, or a sense of preserving past events or feelings that cannot be integrated into the concept of self. Therefore we can say that, according to the dissociation model, self-injury is an attempt to protect the metonymic psychological capabilities of combination and contextualization, which are damaged during the dissociative process—a plea to create continuity within the dissociation, which is characterized by lapses in continuity, interruptions, and disengagements. The dissociation model suggests that the cutter’s main realm of coping is the metonymic one, in which she is required to cope daily with difficulties in maintaining continuity, as well as with destructive combinations that exist within her and preserve themselves. My therapeutic experience shows that, for the most part, the self-cutting method is very calculated. The array of cuts forms a kind of map on which one route leads to another. The new cut is perceived in terms of its metonymic continuity and its significance is based on its relationship with the previous cuts. It Cuts Both Ways

From the preceding analysis it is clear that while the clinical language game relating to self- harm is mainly characterized by metaphoric dominance, the language game of the cutters is dominated by metonymy. The metaphoric dominance of the psychological “language game” entails the perception of a hierarchical relationship between metaphor and metonymy, and an understanding of the self-harmers’ metonymic dominance not as something that exists in and of itself, but rather as something that reflects a deficiency in their metaphoric ability. In this sense, the perception of the self-injurers’ metonymic dominance as a deficiency, as a lack, and not as the ability to cope, is apt to cause one to miss the mark. In the footsteps of Jakobson (1956), I think it is correct to adopt the part in his approach that negates the hierarchy between the meta-


phor and metonymy and to look at the set of rules that guides every such possibility as expressing abilities, aptitudes, and even various needs and different coping mechanisms. Following this I want to emphasize each of the two claims separately. First is the claim that the cutters’ language game is metonymic. In light of the things that have come out of the preceding analysis, I propose that the self-injurers’ way of coping with difficulties lies, first of all, along the metonymic axis: They come from there, they struggle there, and they seek first aid there. The disability lies along the metonymic axis, in particular the difficulty in maintaining the experience of the existential continuity that includes disengagements, interruptions, and disruptions or the creation of rigid, pathological and destructive combinations. This claim supports assertions such as those of Miller and Bashkin (1974) that self-harm arises from an ahistorical view of a life experience. The creation of a cut is a visible, concrete, and dramatic reminder preserved in the flesh of something that the cutter is unable to otherwise accommodate in the fabric of her personality. Understanding the self-injurer’s metonymic “continuity-based” function in relation to the injury experienced along a continuum, which characterizes many self-harmers, reconceptualizes the self-injury not as destructive behavior but as a way of coping and an attempt at self-care and self-healing, and highlights the adaptive and lifeaffirming aspects within it. To return to my previously mentioned encounter with L: The opportunity to respond to her invitation to come closer and look at the bleeding cut enabled me to be physically connected to an experience that was disconnected and fragmented. The unmediated view of the wound created a continuity between us as well as making possible a continuity within her fragmented internal experience. It let me participate in her fragmented experience as a partner in the experience of dissociative detachment as well as to experience the flood of emotional experiences rather than remaining aloof. On the practical level, therefore, the therapist who meets with the self-injurer should suspend his or her metaphoric “language game” and, in lieu of that, recognize a different, metonym-

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ic language game. In the metonymic language game there is a great deal of importance to continuity, linkage, and contextualization, and, consequently considerable importance in paying attention to the immediate present, the here and now, the body and the concrete wound—looking at it in relation to the previous wounds, looking at the bleeding body not a metaphor. The metonymic conceptualization of the self-harmers’ language is influenced by a setting that places the emphasis on the creation of continuity by holding regular, frequent sessions and ensuring the therapist’s availability even beyond the regular session framework. Besides creating the proper setting for the needs along the metonymic axis, another important aspect stemming from conceptualization of the self-harmers’ language as metonymic is the possibility of creating a “metonymic discourse” in the clinic. In this context, I would like to mention the important contribution made by Yarom (2010) in suggesting “the topographic–relational interpretation” as a development and complement to Anzieu’s (1989) “deficient” methodology. Yarom suggests a dialogic interpretation, in which the patient and therapist are invited to make a place in the discourse for the physical presence of both of them in the treatment room. The contribution of this dialogic interpretation to the self-harmers’ metonymic needs lies in the incorporation of the physical aspect of the therapist–patient duo, as well as in the reciprocity of the therapeutic discourse, both of which make it possible to start “stitching up” the physical and psychological wounds in order to reach an emotional experience that is less wide open and discontinuous. Second, I examine the way the clinical language game relates to selfmutilation as metaphor. From the various analyses of the psychological theories regarding self-harm, it is clear that the metaphoric is dominant. It could be asked: What relationship is there between the metatheory of self-harm and the way therapists in fact speak and think in the treatment room when meeting their patients, the cutters? Let me illustrate with an example from my private experience treating L. I meet with L after my return from vacation, and she tells me that she did not cut herself while I was gone. Yesterday she cut


herself. . . . I ask her about it. She tells me that it was after a late night telephone call with her homeroom teacher, with whom she corresponds in the small hours of the night, whom she loves as a soulmate and hates for her relationship with her best friend. . . . All adults are liars and self-interested exploiters. . . . She suspects that this teacher had been raped. . . . I feel how very difficult it is for us now to sit down together, how difficult it must be for her to have confidence in me again, after the vacation, how many crises of confidence we have already gone through together. I think about the suspiciousness, the mistrust, L’s enormous need to know about others without revealing anything about herself, of the romantic trios and relationships with no boundaries. A question begins to bother me: Perhaps L had been sexually abused? At the beginning of the treatment she rejected this possibility. I am amazed at how this question gains power, how it forces itself upon me and will not let go. The power of the feeling frightens me and I decide to ask L about it. She remains silent for a long while. I imagine her indecision about whether or not to tell me. When she starts to speak after a long silence she says that she wants to quit, to stop treatment. She shares her frustration with my being stuck on certain things, mainly around the subject of interpersonal relations and sexual abuse and my not understanding that there are other things . . . the things L says cut me to the quick. All my attempts to change her mind fail and she stops coming. The termination of the treatment in which we both had invested so much left me hurting, with many unanswered questions. Was this a powerful reaction to a prolonged separation that was due to my going on vacation? Was she seeking to protect herself from a relationship that was blooming and growing stronger? Perhaps I was on target but somehow insensitive concerning a painful point? I could add a list of other explanations that passed through my mind which may serve to capture something of L’s experience. Following the analysis offered here, I propose that one aspect of the difficulty in the treatment of cutters is related to the encounter with the open wound as a fact, not as a metaphor. At the beginning of this paper I described my unbearable experience in

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face of L’s cuts. I found looking at her cuts to be an unusually difficult thing to do, with my emotions ranging from excitement and being flooded with feelings that were hard to contain, to a shutting down, a kind of “systems failure.” I suggest that what had happened subsequently, in the last encounter, and it seems not only then, was that I was distancing myself from the cut. I averted my eyes from the gaping wound. In order to remain aloof I turned to metaphoric devices that helped distance me from the unendurable: L says “cut” and I think “parents,” L repeats “cut” and I think “trauma.” In view of this I suggest that aside from the familiar metaphoric tendency of general psychological theories,8 the case of self-injury is an intensely private act where the open wound offends social taboos and is thus especially challenging to the therapist, who may have unaccustomed difficulty in finding the correct distance and therefore may resort more than is usual to a heightened use of metaphor in order to maintain his or her distance. One possible explanation that occurs to me is that the cultural challenge presented by the open wound may be related to the distinction suggested by the anthropologist Mary Douglas concerning purity and impurity. Douglas (1966) points to our tendency to sort phenomena in as pure a fashion as possible, where undefined intermediate states are experienced as unbearable. What cannot be classified, whether as being inside or outside, solid or liquid (such as viscous material), is seen as a disturbance threatens order. The open cut can be used as another example of an extreme disruption of order, one which is so difficult for the culture to accept that it produces within us powerful reactions on every level of consciousness in a situation where we therapists are prone to keep our emotional distance. In face of these cultural conditions, I suggest that the direct encounter with the cut is a way of bypassing the metaphoric way of thinking. As I see it, the therapist must remain close to his or her experience, even if it includes being shocked by the cut, or asking the patient to re-create in words the act of cutting or to describe the actual wound, thus bypassing the metaphoric language, or at least not letting metaphor govern his or her response. Three years after L suddenly terminated treatment she con-


tacted me and asked for an appointment. She told me about various other therapists that she had consulted since then. She mentioned that she hardly ever cuts now and that she has enrolled in a university to study psychology. She said that she came back to me for treatment because she wanted to tell me that I was wrong: She did not suffer from sexual abuse. She said that she left because I was stuck in a rut, preoccupied with her parents and with sexual abuse. Why did she come back? Because she was on the street passing by my clinic and she missed me. . . . L stayed with me for treatment for another significant length of time. As I see it, it was important to her to return and to repair my mistake, which was the mistake of keeping my distance from her through the overuse of metaphors. I believe that her return says something about the beneficial possibilities in the metonymic closeness between us as well as the development of her metonymic ability to preserve a higher degree of internal continuity, where experiences over a period of time coalesce into a rich internal experience that is not invalidated even by a disappointing incident. CONCLUSION

This paper has attempted to throw light on the self-injury phenomenon from a less well-known perspective by using methodology borrowed from linguistic philosophy. It is an analysis of the psychological discourse regarding self-injury using analytic tools proposed by the linguist Roman Jakobson (1956), who makes a distinction between metaphor and metonymy as a dichotomous pair, where metaphor is based on similarity between the topics, on the cognitive ability to select and to substitute, while metonymy is based on contiguity between the topics and the faculty for combination and contexture. The analysis proposes that while the therapeutic language game regarding self-injury is clearly dominated by metaphor, the language game of the self-injurers themselves is actually dominated by metonymy. The paper then examines the preponderance of metaphor in the therapeutic discourse and the dominance of metonymy in the language of the self- injurers as separate entities,

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and not as two sides of the same coin, as is usual in psychological methodology. Two important insights emerged during the analysis using these tools: one is specifically related to the phenomenon of selfinjury, and the other is of a more general nature. The first insight is that the scene of the confrontation and the inner stress of the self-injurers themselves is first of all within the metonymical axis; it is where they are struggling and it is from there that they first request help. The disability lies on the metonymic axis, whether it is a problem in maintaining an existential continuum, which includes disconnection, cutting off, and disruptions, or in the creation of rigid, pathological, and destructive combinations. Understanding the metonymic function of self-injury as sequential conceptualizes self-injury not as a destructive behavior but as a way of coping and as an attempt at self-healing and selftreatment, with the emphasis on its adaptive and purposeful aspects. The sequential nature of the metonymic function in a therapeutic setting brings into sharp focus the importance of paying attention in the immediate here and now to the body and to the actual wound in relation to previous wounds. The dominance of metonymy also emphasizes the importance of creating continuity by regular, frequent sessions with the therapist and calls for the availability of the therapist over and beyond regular appointments. It also encourages the creation of a “metonymic discourse” in the clinic by putting emphasis on the reciprocal nature of the therapeutic discourse and acknowledging the physical presence of both the therapist and the patient. Second, the dominance of the metaphoric in psychological theories of self-injury is clearly evident both in the general bias of psychological theories as well as in specific applications to the phenomenon of self-injury. The general train of thought theorizes a hierarchical relationship between metaphor and metonymy, which is not in the spirit of Jakobson. Such an assumption is based on the Western cultural view whereby when symbolism is more complete, the act is assumed to be more developed, acceptable, and healthier. Following this line of thinking, the psychoanalytic discourse is conducted around metaphors and sometimes by metaphors.


Many analysts refer to psychoanalytic concepts as real entities and not as mere metaphors, which are ingrained in their vocabulary and in the psychoanalytic discourse. Thus metaphoric thinking and the use of metaphors bestows a quasi-scientific status on the psychoanalytic language game, which is frequently adopted as if it were a factual description of psychic reality. This paper argues that the dominance of metaphor in the psychological theories in regard to self-injury reflects a special aspect of this phenomenon. Self-injury is a private act where the open wound assaults cultural taboos and presents a unique challenge for the therapist. On a cultural level it is very difficult to deal empathetically with the open wound. It evokes a powerful response on all levels of consciousness, and the therapist confronted with this situation is prone to overuse metaphors as one way of keeping his or her distance, a kind of defense mechanism. This paper proposes a linguistic analytical tool for distinguishing between metaphor and metonymy in order to throw light on other difficult aspects in the clinical encounter between the cutter and the therapist. By pairing metaphor and metonymy as a dichotomy and not as a hierarchy, the therapist is asked to examine the various mutual relationships and challenges to each of them without reducing one to the status of just a part of the other, or repairing one by using the other. Beyond that, the metonymic conceptualization of the self-harmer’s realm of coping invites therapists to reexamine our perception of the supremacy of metaphor underlying the psychological “language game,” to see the creativity and imagination concealed in it in addition to its other advantages, but also the dangers embedded in it, such as the possibility of distancing ourselves from the present, from the here and now, and, heaven forbid, from the patient herself.

NOTES

1. The feminine pronoun is used in this paper to refer to cutters because most of the recent studies show that self-injury is a “feminine” phenomenon. 2. In the psychological discourse I am including contemporary research (e.g., Brent, 2011; Feigenbaum, 2010; Nock, 2010; Wilkinson, Kelvin, Roberts, Dubicka, & Goodyear, 2011), case studies (e.g., Motz, 2010); description by selfinjurers of the injury and the treatment they underwent (e.g., Leathman,

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2006; Motz et al., 2009), and instruction manuals for injurers and therapists (e.g., Briggs, Lemma, & Crouch, 2008; Ougrin, Zundel, & Ng, 2009). The link between these different forms of writing is complex. Despite the differences of opinion between them, I am allowing myself to link them out of my understanding that they are all participants in the same language game: They all share a great esteem for science and the empirical method, whose origin is in the psychoanalytic school of thought. So too, they all share a reliance on essentialist metatheories in relation to human nature and its drives, and in research and the description of incidents, they examine and support the metatheory. 3. Passe (2011) discovered in his research that among students self-injury is more widespread among white students than Asian American and African American students. 4. Netzer (2011) argues that Jakobson’s denial of the supremacy of the metaphor over the metonym parallels the denial of the primacy of the West’s conceptual–symbolic–scientific language over the mythological–supernatural– presymbolic language of tribal cultures by Lévi-Strauss (1966), Jakobson’s friend and colleague, who claims that we should “make no mistake: We are not talking about two stages or two levels in the development of knowledge in which both ways are valid at one and the same time” (p. 26). 5. The similarity disorder is also termed by Jakobson “the escape from sameness to contiguity” (1956, p. 175). The disability in these patients is within the purview of selection. The context, so far as these patients are concerned, is the essential and decisive factor. In talking, such patients are merely responding. They are able to complete a sentence where the beginning of the sentence is a given, but they would be hard put to begin a conversation—to the extent that many are unable to do so at all. The context is what makes it possible for these patients to talk. The commencement is the main difficulty for them because that is what creates the context and requires selection capacities. An extreme expression of the impediment would be a difficulty in specifying the name of a given object. Because of an inability to produce the comparative predicate, they will specify the function of the object or its characteristics instead of naming it. Jakobson illustrates the “escape from identity to reliance” in describing a patient who was asked for the word “window” and instead said “glass” (1956, p. 175). 6. The contiguity disorder is a type of aphasic illness in which the links in a sentence unravel. The first to be affected are words with pure grammatical functions such as conjunctions, prepositions, and so forth. The sentences uttered will be in a range from an amalgam of unconnected words to one-word sentences. At the point at which the context unravels, the action of selection among these patients continues. Jakobson points to the metaphorlike attribute of the speech of such patients, as opposed to the metonymic character of the speech of those who suffer from similarity disorder. 7. In the past two important members of the psychoanalytic community responded to Jakobson’s invitation. Jacques Lacan (1977), in his analysis of subject formation, and his pupil Laplanche (1976), in The Derivation of the Psychoanalytical Entities. Their fascinating analyses differ greatly from the way in which I propose to use the analytical tool, be it in their choice of defining the “tropes” or in their preservation of the hierarchy between the metaphor and the metonym.


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The Psychoanalytic Review Vol. 101, No. 5, October 201

"Cuts both ways": collagenases, lipocyte activation and polyunsaturated lecithin.

Maternal choice: will it work both ways?

Sparse canonical correlation analysis from a predictive point of view.

Discourse bootstrapping: preschoolers use linguistic discourse to learn new words.

From the nurses view point.

An accurate point of view?

[Vaccinations from the pulmonologist's point of view].

Discussion from the neurosurgical point of view.

ERAS: Can It Be Revamped? One Point of View.

Exhaled breath condensate--from an analytical point of view.

Race and History: Comments from an Epistemological Point of View.

[EPH-gestosis from an immunobiological point of view (proceedings)].

[Substance abuse and pregnancy from an obstetric point of view].

The Problem of Life from a Girl's Point of View.

Genetic screens: CRISPR screening from both ways.

Remarks on cerebral infarct from another point of view.

An integrative relational point of view.

The dangers of NSAIDs: look both ways.

Understanding the oriented-attachment growth of nanocrystals from an energy point of view: a review.

Sex selection from Islamic point of view.

Looking both ways.

Epidemiology of twin births from a climatic point of view.

Scrapie-a point of view.

Scrapie: a point of view.