Contributions of Winnicott’s Psychoanalytic Theory to the Study of Self-injury: A Scoping Review

Contribuições da Teoria Psicanalítica Winnicottiana ao Estudo da Autolesão: Revisão de Escopo

Contribuciones de la Teoría Psicoanalítica Winnicottiana al estudio de las Autolesiones: Scoping Review

Abstract:

This study aimed to map the scientific evidence and contributions of Winnicott’s Psychoanalytic Theory to the study of self-injury (also known as self-harm). Familial, social, political and historical environments are deeply entangled with individual distress, and Winnicott’s psychoanalytic theory offers relevant contributions to rethinking self-injury as this contextualized issue. The authors conducted a scoping review in the BVS, Scopus, PsycInfo, and Web of Science databases, selecting 36 studies. The thematic analysis resulted in three categories: the role of skin in the constitution of the self, self-harm as survival/reaction to environmental invasions, and implications of Winnicottian perspective for the care of non-suicidal self-injury. This study questioned dualistic and conventional notions of self-harm as a disorder, addiction, or coping strategy, alternatively presenting deeper and more subtle ways of thinking about its meanings. Finally, it is suggested that caring for people who self-harm should focus more on exploring these meanings than on seeking abstinence.

Keywords:
self-harm; psychoanalysis; Winnicott; literature review

Resumo:

O ambiente familiar, sociopolítico e histórico está profundamente relacionado às manifestações individuais de sofrimento e a teoria psicanalítica de Winnicott oferece contribuições para repensar a autolesão de forma contextualizada. Este estudo teve como objetivo mapear as evidências científicas e contribuições da teoria winnicottiana para o estudo da autolesão. Foi realizada uma revisão de escopo nas bases BVS, Scopus, PsycInfo e Web of Science, selecionando 36 estudos. Emergiram três temas finais: “O lugar da pele na constituição de si mesmo”; “A autolesão como sobrevivência/reação a invasões ambientais”; e “Implicações da perspectiva winnicottiana para o cuidado à autolesão”. Este estudo questionou noções dualistas e convencionais de autolesão enquanto transtorno, vício ou estratégia de enfrentamento, apresentando, alternativamente, modos mais profundos e sutis de pensar sobre os seus significados. Sugere-se, enfim, que o cuidado à pessoa que se autolesiona seja mais sobre a exploração destes sentidos do que sobre buscar abstinência.

Palavras-chave:
autolesão; psicanálise; Winnicott; revisão de literatura

Resumen:

Este estudio objetivó mapear las evidencias científicas y las contribuciones de la teoría winnicottiana al estudio de la autolesión. El entorno familiar, social, político e histórico está profundamente relacionado con las manifestaciones individuales del sufrimiento, y la teoría psicoanalítica de Winnicott ofrece aportes para pensar la autolesión de forma contextualizada. El análisis temático resultó en tres categorías: el lugar de la piel en la constitución del yo, la autolesión como supervivencia/reacción a invasiones ambientales y las implicaciones de la perspectiva winnicottiana para el cuidado de la autolesión. Este estudio cuestionó nociones dualistas y convencionales de la autolesión como trastorno, adicción o estrategia de afrontamiento, presentando, en cambio, formas más profundas y sutiles de pensar sobre sus significados. Se sugiere, por último, que el cuidado de la persona que se autolesiona debería centrarse más en explorar estos significados que en buscar la abstinencia.

Palabras clave:
autolesión; psicoanálisis; Winnicott; revisión de literatura

Non-suicidal self-injury (NSSI) has been widely discussed in the media, on digital platforms, in literature, and in public policies. Its relevance is so great that it has become a legal issue with the establishment of the National Policy for the Prevention of Self-harm and Suicide in Brazil through Law No. 13,819, of April 26, 2019. This policy defines the prevention of self-injury as a permanent strategy of the public authorities by law, regulating the obligations of the State in addressing it. Recognizing the multiplicity of definitions of NSSI, in this article we will follow the definition of the International Society for the Study of Self-Injury (ISSS), which defines it as deliberate injury to one’s own body without the intention of death, and which is not socially accepted (therefore excluding piercings and tattoos) (Kiekens et al., 2023).

Self-harm has been studied in multiple contexts over the last decade. Despite the intense effort to categorize it, understand it, and present definitive criteria and answers, what we find is great variation and volatility in the way self-harm is understood. For example, there is no consensus on the nomenclature to be used; terms such as self-mutilation, self-inflicted injury, self-inflicted violence, and cutting are frequently used. There is also inconsistency regarding its conceptualization. Self-harm was once considered a symptom of psychopathologies such as psychotic disorders (Tostes et al., 2018) and borderline personality disorder (BPD) in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association [APA], 1994). The same manual, in its fifth edition, presented it as a disorder in itself, with its own symptoms and diagnostic criteria (American Psychiatric Association [APA], 2014). Furthermore, the debate about its relationship with suicide reflects the complexity of the subject, since, while some studies point to it as a risk factor for suicide, others suggest that NSS may represent a coping mechanism that reaffirms life (Simopoulou & Chandler, 2020).

This multiplicity of perspectives raises central questions: is self-harm an attempt at survival? A coping mechanism? A form of communication? An addiction? Or even a way of belonging to groups? Each approach answers these questions in different ways, reflecting the richness and contradiction that permeate the topic. This scenario suggests that many questions remain unanswered and that new perspectives can broaden understanding NSSI.

Based on this panorama, this study proposes a scoping review with the objective of integrating the vast field of literature on NSSI in light of Winnicottian psychoanalytic theory. We chose this approach because of the unique contributions it offers to the understanding of complex phenomena related to emotional development and the individual-environment relationship. In addition, no articles were found which seek to understand how this theory has been used to advance knowledge and practice related to self-harm, representing a significant gap in the literature.

D. W. Winnicott (1896–1971), pediatrician, child psychiatrist and psychoanalyst, dedicated his work to the theory of emotional maturation, emphasizing the importance of the environment in development of the self (Winnicott, 1984a). His pioneering work in expanding psychoanalysis beyond individual psychic processes allows for a perspective which values ​​both subjectivity and the relational contexts that involve self-harm. Thus, we believe that the Winnicottian perspective, with its focus on the environment and emotional maturation, can offer an enriching lens for understanding and treating NSSI. This study aimed to map the scientific evidence and contributions of Winnicott’s theory to the study of self-harm.

Method

We conducted a Scoping Review according to the guidelines of the Joanna Briggs Institute (JBI) to develop this study (Peters et al., 2020). We implemented the Population, Concept, and Context (PCC) strategy to construct the research question, in which: Population (P) - all age groups; Concept (C) - non-suicidal self-injury; Context (C) – Winnicott’s psychoanalytic theory. Thus, the following guiding question was established based on these definitions: How has non-suicidal self-injury been understood from Winnicott’s psychoanalytic theory?

We searched for studies in February 2021 in the BVS, Scopus, PsycInfo, and Web of Science databases and libraries. It was necessary to adapt the descriptors and free terms used according to the specificities of each database, as shown in Table 1.

Table 1
Databases, descriptors and free terms used

Base	Descriptors	Free terms
BVS	Comportamento Autodestrutivo/Self-Injurious Behavior/Conducta Autodestructiva	Autolesão/Automutilação/Self-Injury/Automutilación e Winnicott
Scopus	Self-Injurious Behavior/Self-Mutilation	Winnicott
PsycInfo	Self-Injurious Behavior/Self-Inflicted Wounds/Self-Mutilation and Object Relations/Winnicott	-
Web of Science	Self-Injurious Behavior	Self Mutilation/Non-Suicidal Self-Injury/NSSI/Cutting and Winnicott

The Boolean terms AND and OR were used in conjunction with the descriptors to compose the formulas in the databases. The references listed in the studies found were also searched, aiming to identify additional documents for potential inclusion in this review.

The inclusion criteria for the selected studies were: studies of any approach and type that addressed non-suicidal self-harm/injury from the perspective of Winnicottian psychoanalysis; be in English, Spanish and Portuguese; with no limitation on the year of publication, as recommended by the JBI; published or made available until February 2021. Moreover, books, dissertations and theses were excluded, as well as other studies that did not answer the research question.

A total of 279 studies were found in the search database; however, 1 study was added to these after searching the references, and 4 studies included by the authors because they answered the review question. After eliminating duplicates, the titles and abstracts were read by two reviewers, as well as full reading and double-blind data extraction.

The data from the studies were extracted using an instrument structured by the researchers in accordance with JBI guidelines, which included: study title, journal, year of publication, authors, country of origin, language, methodological design, type of publication, objective, context, population, and results related to the research question. This last item was analyzed through reflective thematic analysis (Braun & Clarke, 2021).

As part of the data familiarization and initial coding phases, the first and second authors read the results multiple times, identifying possible initial codes and patterns in response to our specific research question. Disagreements were resolved by the last author. We then began to group these codes into a series of intermediate codes through an interactive and reflective process. Three final themes were then generated, guided by the Winnicottian psychoanalytic perspective (Winnicott, 1984a).

Results

The study search and selection process for this review is presented in Figure 1, as recommended by the JBI, according to the checklist adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al., 2009).

Figure 1
Search strategy for scoping review, adapted from PRISMA

Of the 36 selected studies, 75% (n = 27) were in English, and the others were in Portuguese (n = 9; 25%). The countries of origin of the studies were: the United States (n = 11; 30.5%), Brazil (n = 8; 22%), England (n = 5; 13.8%), Italy (n = 3; 8.3%), Israel (n = 2; 5.5%), Canada (n = 1; 2.7%), France (n = 1; 2.7%), Poland (n = 1; 2.7%) and Sweden (n = 1; 2.7%), in addition to three multicenter studies - one conducted in the United States and Argentina; one in the United States, Israel and New Zealand; and another in Brazil and Spain. Publication dates ranged from 1969 to 2021.

Regarding the type of studies, 32 (88.8%) were primary studies, and 29 of these used qualitative methodology, two used quantitative approaches, and one used quantitative-qualitative approaches. Furthermore, two (5.5%) were literature reviews and two (5.5%) were theoretical studies. Regarding the population to which the studies referred, the majority discussed NSSI in adolescents and young women (n = 20 - 55.5%), followed by NSSI in adult women (n = 9 - 25%). In addition, two other studies dealt with adolescents and young people of both genders (5.5%), and five did not specify the population.

The results and reflections on NSSI from the perspective of Winnicottian psychoanalytic theory were grouped into three final themes, as described below.

Final theme 1 - The role of skin in the constitution of the self

From the analysis of the 36 studies found, it became clear that one of the main contributions of Winnicottian psychoanalysis to understanding self-harm is its interpretation of the role that the skin occupies in the health and disease processes and in the constitution of the self. By using Winnicott’s understanding to interpret self-harm, these authors located it in an interrelationship theory between the somatic and the psyche, allowing the emergence of new interpretations and findings.

We believe it is important in this theme to briefly review some of Winnicottian concepts regarding body and skin. According to this thinker, physical touch and bodily sensations assume an important place in the maturation process even before birth, when the baby is enveloped by the amniotic membrane, reinforced by the uterine wall. The tactile sensations of containment and contour on the skin begin to be imprinted even at this moment of mother-baby unity (Winnicott, 1984a).

There is no clear division at birth between the internal and the external, or between the self and the non-self for the baby. It is only through sufficiently good care that the baby can begin the differentiation process, the process of recognizing what is internal and external, what is baby and caregiver, what is baby and environment (Winnicott, 1984a). It is at this moment that the importance of the skin begins to be understood. It is through holding, handling, feeding, bathing, rocking, and changing that the baby survives and can become a baby (Winnicott, 1984a). Psychological care is mainly expressed through physiological care. The baby receives love through touch, support, and skin care rituals. Feeling touch when being held by a caregiver demonstrates the body’s limits; it is through touch that the baby can feel its contours, feel where the baby ends and the external world begins (Winnicott, 1984a). Two of his most famous concepts, holding and handling, come from this notion of holding in the arms, of skin-to-skin contact which allows the baby to integrate into a unit, feeling gathered, surrounded and supported (Winnicott, 1984a).

Holding generally refers to the physical and emotional support of the baby, including care in the broad sense, such as the creation of a trusting and welcoming environment, while handling refers to the physical handling of the baby, meaning how they are physically carried, touched and cared for. Both are essential to the baby’s health experience and consequently to the adult they will become. The skin is at the origin of the maturation process and the constitution of the self, and is indispensable for integrating the body and mind. It is through it that it is possible to feel the first caring moments, it is what separates the internal from the external, and it is the covering that protects (Winnicott, 1984a).

Based on these concepts, Lanfrance (2009) and Sloate (2008) emphasize that loving physical contact is essential for developing a living and integrated self, and the ability to feel pleasure through physical experience. Similarly, Le Breton (2018) says that the skin acts as an emotionally invested envelope of our being and envelops the body, delimiting the self. Because it is also our entry point into the world, it is a place of living memory: it serves as a border between the interior and the exterior, the self and the other, the bodily self and the psychological self, being alive and porous at the same time.

According to the studies of Boćwińska-Kiluk (2020), Cossidente and Sarti (1984), Lanfrance (2009), Le Breton (2018) and Sloate (2008), the skin is concretely and symbolically involved in the support, integration, definition, protection and separation processes. Among other facets, the literature interprets skin lesions as attempts to repair one or more of these processes, which were made impossible or interrupted during maturation. Such interpretations will be further explored in the descriptions of the following themes.

Final theme 2 - Self-injury as survival/reaction to environmental invasions

Some of the studies included in this review used Winnicottian thinking to reframe self-harm, understanding it as an attempt to repair processes that were interrupted, invaded, or made unfeasible by the environment (Boćwińska-Kiluk, 2020; Migliorini & Freitas, 2018; Riter, 2018; Santos, 2016). This theme brings together data and interpretations brought by these authors regarding the unconscious functions of self-harm observed in the trajectories of their participants and patients.

Based on a case study, Riter (2018) interprets self-harm as a mechanism for protecting the ego. According to the author, physical pain allows a perception of the body as a shell and limit, functioning as a way of protecting the self from unthinkable agonies. Therefore, self-destruction would emerge as a barrier to prevent the destruction of the true self, a defensive strategy which prevents psychological disintegration (Le Breton, 2018). In a similar sense, Yates (2004) argues that self-harm would be a poorly adapted self-preservation strategy, in which the individual prefers to inflict trauma on themselves rather than relive external traumas.

Guinjoan et al. (2001) and Santos (2016) present another possible ‘unconscious’ role of self-harm, saying that this act could represent an attempt to feel alive and to be recognized by the other, in an unconscious function of existing. Santos (2016) explains that Winnicottian theory understands that existence is only possible through recognizing and reflecting the other’s gaze, and that the narratives of people who self-harm are usually marked by the absence of the other, which highlights the unconscious function of seeking the gaze and recognition. Similarly, Gargiulo and Margherita (2019) interpret NSSI as a ‘sacrificial offering’ to another who notices.

Farber (2008), Gallop (2002) and Medina (2011) expand the analysis on the absence of the other frequently reported by people who self-harm, pointing out that this absence usually results in a lack of support and effective mechanisms of emotional regulation. These studies suggest that self-harm can play an unconscious regulatory role, being interpreted as an attempt at self-regulation, self-medication or even pain relief (Farber, 2008; Gallop, 2002). Costa, Gabriel, et al. (2021a) and Riter (2018) add that the need to resort to self-harm to regulate oneself emotionally arises, above all, in contexts where there has been no development of internal capacities to support and calm oneself. This may occur due to the absence of an environment which allows safe expression of pain or that fails to recognize and support the individual’s suffering. Still related to the search for the other, Yakeley and Burbridge-James (2018) use Winnicott’s concept of delinquency to say that self-harm could similarly be a sign of claim and hope that the environment can respond and meet the subject’s needs.

According to Boćwińska-Kiluk (2020), another unconscious function of self-harm would be to ensure/demarcate separation and contour. Based on clinical observations, this author argues that self-harm would be the production of a ‘second skin’ in an attempt to: protect the cohesion of the self, delimiting contours; renounce and expel unacceptable aspects of oneself; increase the self’s adherence to caregivers who provide holding; and separate oneself from the object (Boćwińska-Kiluk, 2020). Tillman (1999) also points to the ambiguous functions of cuts, which can represent both an affirmation of the self/non-self boundaries, as well as an attempt to erase such boundaries, allowing the internal to externalize itself and the other to enter in the desire for union with the environment or with the parental figure. It then becomes evident from these studies that self-harm can be deeply related to processes of separation and individualization.

Finally, in this same sense, Cossidente and Sarti (1984) and Migliorini & Freitas (2018) suggest that self-harm can emerge from problems related to the transition between the internal and the external, the individual and the other, and can be an attempt to use one’s own skin as a transitional object between subjective and objective reality. These authors use the Winnicottian concept of transitional object to understand NSSI. In a simplified way, transitional objects would be objects which assist in the transition between the internal world and the external world, or in Winnicott’s language (2005), the subjectively conceived world and the objectively perceived world. They are at the same time the self and the non-self, and exist in the intermediate area between the internal and the external, acting in the separation and differentiation processes.

It is then observed that self-harm, skin, blade and blood assume functions which resemble those of a transitional object: they are in the intermediate area, between the inside and the outside, they represent the self and the non-self, they assist in the separation and individuation process, in the conquest of the symbolic, in feeling supported and in object relations (Kafka, 1969). However, two studies (Farber, 1997; Gilzean, 2011) argue that self-harm fails as a transitional object because it does not lead towards maturation, functioning instead as a fetish object (Le Breton, 2018), in a kind of parody of the transitional object (Gilzean, 2011).

Final theme 3 - Implications of Winnicottian perspective for the care of NSSI

A total of 17 studies found in this review directly addressed issues related to the conduct of the therapist or caregiver in caring for people with a history of self-harm based on the Winnicottian perspective (Birch et al., 2011; Carlsson, 2018; Costa, Gabriel, et al., 2018; Costa, Gonçalves, et al., 2021a; Farber, 1997, 2008; Farber et al., 2007; Feldman, 1988; Frankel, 2001; Gilzean, 2011; Guinjoan et al., 2001; Nicholson, 2010; Santos, 2016; Talmon & Ginzburg, 2021; Tillman, 1999; Yakeley & Burbridge-James, 2018; Zila & Kiselica, 2001). The data were gathered in this theme, which makes it clear that in addition to the theoretical reflections addressed in the first two themes, it is necessary to deepen practical discussions about action in the context of care. In turn, we describe the contributions of each of these articles to practice below.

Birch et al. (2011) and Santos (2016) start from the understanding that self-harm would be a response to a rupture in the process of continuity of being, to argue that some of the main qualities of care for self-harm are continence and continuity. Farber (1997) follows the same direction when he says that the therapist must work towards restoring the rupture, creating a good enough, and above all safe environment, which allows the person to trust the environment, possibly for the first time. Other studies explain that patients who have been marked by absence organize themselves in the presence of the other; therefore, the therapist must remain present for a long period, enabling the feeling of continuity of being (Birch et al., 2011; Nicholson, 2010; Santos, 2016).

According to Farber (1997), finding a safe haven in the therapist is a great achievement, which will serve as a basis for other processes. Talmon and Ginzburg (2021) and Zila and Kiselica (2001) corroborate this idea by stating that the patient does not feel the need to protect themselves so intensely in a safe environment, allowing the false self to give way to the true self. The results indicate that therapy can promote integration of the self and development of new object relations through the care and trust of the therapeutic environment.

Other studies address the role and position of the therapist when caring for people who self-harm. Gilzean (2011) argues that the therapist’s stance resembles that of a good enough caregiver (mother). Yakeley and Burbridge-James (2018) follow this line, stating that, just as a mother digests the world for her baby, the therapist must receive and contain intolerable thoughts, feelings and conflicts for the patient, communicating them in an accessible way. In this same sense, we emphasize that the Winnicottian perspective understands that one of the healthy and expected movements in the clinic is for the patient to regress to previous stages of their maturation, relying on the support provided by the therapist (just as a mother for her baby), so that maturation is possible (Winnicott, 1984b).

Farber et al. (2007) also state that it is possible and sometimes desirable for the therapist to assume a closer and more protective stance at the beginning until the patient develops a minimum sense of preservation and care. Similarly, Farber (2008) recommends that professionals have an open and genuine approach to self-harm, recognizing that it may have had important survival functions, and that other ways of dealing with and revealing pain can be found over time.

This theme also provides examples of practical and creative interventions, highlighting the value of allowing therapeutic experiences that go beyond the verbal. Brazilian researchers report the use of therapeutic consultations with dialogic mediators such as drawings and games as a valuable approach in caring for adolescents who self-harm, as they allow expression beyond the verbal (Costa, Gabriel, et al., 2018; Costa, Gonçalves, et al., 2021a). In this sense, Gilzean (2011) demonstrates that creative writing in groups enables care to be provided beyond psychotherapy, in spaces which involve communication and the sharing of experiences facilitated by professionals from different areas. In both cases, paper, pen and ink can be used to communicate instead of using blades, lesions and skin.

Carlsson (2018) presents a study on the benefits of equine therapy for adolescents who self-harm. Based on interviews with the adolescents, the authors observed that a relationship with horses brought them closer to experiences characteristic of transitional objects by offering an experience in the intermediate area; a silent space, free from judgments, demands and expectations. Equine therapy facilitated expression of genuine gestures, allowing the adolescents to have opportunities to play and be creative, favoring the connection with more authentic aspects of the self (Carlsson, 2018).

Still aiming to provide guidelines for practice, Feldman’s study (1988) argues that excessive restrictions even in hospitalization cases are not useful because they rarely inhibit self-harm and harm the therapeutic bond. Excessive control over the patient is also contraindicated because it makes the patient the total responsibility of the team (Feldman, 1988). We would also like to add that there are ethical and dignity implications involved in restrictive treatments, which tend to be paternalistic, decontextualized and asylum-like.

The literature also sheds light on countertransference in the relationship with the patient who self-harms. The authors recognize that supporting people who self-harm can be difficult and evoke strong emotions (Nicholson, 2010); cause anxiety and worry (Tillman, 1999) and a search for control (Feldman, 1988). According to Tillman (1999), the countertransference intensity is due (among other reasons) to conflicts of differentiation and separation, and there may be an attempt to erase the skin contour in order to emerge physically and psychologically with the therapist.

It is necessary to recognize and work on countertransference so that the therapist can “continue to be” in the therapeutic space and thus allow the patient to experience continuity of care and being (Feldman, 1988). Some suggestions found in these studies for dealing with emotional reactions and the therapist/patient fusion are to: seek frequent and continuous opportunities to express anxieties and reflections with supervisors and colleagues (Farber et al., 2007); negotiate breaking confidentiality with the patient when it is necessary to involve other people in the care (family, friends, other professionals) (Frankel, 2001); and involve co-therapists to dissolve the transference (Gilzean, 2011).

Discussion

The results of this review point to self-injury as a response to environmental invasions which interrupted psychological maturation. It appears through the relationship with the body and attacks on the skin as an attempt to communicate and repair processes that were interrupted or made impossible.

From the studies analyzed in this review, it can be seen that one of the main contributions of Winnicott’s thinking to the discussion on self-harm is a reflection on the relationships between the skin and the self, as well as between the body and psychological maturation. Winnicott (1984a, 1984b) highlighted that one of the fundamental psychological needs of human beings is to be physically held, which generates a sensation of having skin, living in it, and constituting a self through it. The skin functions as the surface which demarcates the boundaries between the self and the other, the near and the distant, the internal and the external. In this sense, it becomes a resource for creating meaning, constituting the self, and sustaining oneself in situations where this was not possible in any other way (Winnicott, 1984b). The skin appears in self-injury as the layer that is cut, injured, and marked, but that also survives, perhaps providing a refuge from the need to feel alive.

However, Winnicott was not the only or the last to explore the role of bodily sensations in maturation. Authors such as Merleau-Ponty (1969) also approached the body as a central element in developing the sense of being. Based on the contributions of these theorists, Simopoulou and Chandler (2020) state that studying the relationship between the subject and their skin allows us to overcome the binary of hurting-caring often present in explanations of self-harm, and opens space for richer, more complex, and refined understandings.

Similarly, Winnicott proposed very complex, welcoming and depathologizing conceptions of health throughout his work. He was concerned with separating the idea of ​​health from the idea of ​​normality, explaining that illness is not indicative of abnormality in facing unfavorable environmental conditions. In his words, “sometimes it may be more normal for a child to be sick than to be well” (Winnicott, 1984b, p. 58). For him, health is not an eternal achievement, but rather a dynamic process of integrations and disintegrations, with successive gains and losses. In his view, creative vitality and feeling alive and real are more important than achieving normality, and the focus should be on exploring what makes life meaningful more than curing patients. His thinking contributes to the complexity of the relationship between health and illness, suggesting that madness and life, illness and life, death and life, and (in the case of this review) self-harm and life could coexist.

Winnicott also argues that the maturation processes can be resumed when environmental conditions adapted to the needs of the subject are offered with support and holding. In this context, holding is fundamental for transforming states of illness, facilitating reestablishment of balance and the continuity of emotional maturation. This reinforces what was highlighted by multiple articles in this review: care for the person who self-harms is possible and necessary, and it is essential that it be provided with support by genuinely concerned people, groups and societies who create conditions of belonging and safety (Winnicott, 1984a).

Decades ago, Babiker and Arnold (1997) and Hewitt (1997) explored the attempt at self-care present in acts of self-harm, mainly emphasizing the role of wound care. Expanding on this idea, Simopoulou and Chandler (2020) analyzed the discourses of people who self-harmed and identified that self-harm sustained the sense of self, functioning as an attempt at healing and creating meanings through the relationship with one’s own body. Self-harm would be a significant experience that provides, or tries to provide, the feeling of being alive. Such a coping strategy alternatively presents deeper and more subtle ways of thinking about its meanings. Finally, it is suggested that care for the person who self-harms should be more about exploring these meanings than about seeking “abstinence” (Simopoulou & Chandler, 2020).

Nevertheless, it is necessary to highlight an important gap in the literature found. Most of the studies analyzed by this review were conducted with female participants, and although the studies provide excellent in-depth analysis of intrapsychological and relational issues, they rarely discuss gender issues which may be involved in self-injury. This points to a gap in the literature regarding the interface between self-injury, Winnicott and gender.

In fact, international literature demonstrates that the recurrence of self-injury is higher among women (Mergl et al., 2015). In a study conducted in Australia with women in psychological distress, Fullagar and O’Brien (2016) analyzed the gender components involved in suicidal behaviors, and how gender roles shape how women experience their sense of identity, relationships and subjectivities. The researchers argue that the psychological distress of women/girls is closely related to the expectations, inequalities and violence to which women are exposed in a patriarchal society. In turn, to talk about self-injury as a problem which involves gender is to recognize how gender, identity and power norms shape such experiences, and to abstain from this discussion is, in a way, to reproduce the violence and silencing of patriarchy (Fullagar & O’Brien, 2016).

Finally, there are limitations to this study, with the main one being the non-inclusion of books, theses and dissertations, as well as the restriction to studies published only in English, Portuguese and Spanish. Despite these limitations, based on this scoping review of studies centered on Winnicott’s psychoanalytic theory, we understand that self-injury is a complex phenomenon, to which the search for absolute truths and definitions has little to contribute. We argue that the best way to conceive of self-injury is by opening space for its contradictions and ambiguities, and expanding the perspective from the “subject” to the “subject in the environment”.

The studies analyzed herein point to self-harm as more than a response to trauma, but also as a search for reparation. We understand that it is possible to have wisdom, value and a search for maturity amidst experiences permeated by pain. We leave space open for future studies which look at the interface between self-harm and gender, and that position people who self-harm as protagonists, survivors and experts in their own stories of searching for life.

This study contributes to the literature by offering an in-depth and unique analysis of self-harm from the perspective of Winnicott’s psychoanalytic theory, highlighting the complex relationships between skin, self and psychic maturation. In practice, this approach offers new paths for the care of people who self-injure, discussing possibilities of transference and countertransference, repositioning the therapist in the relationship, and demonstrating multiple possibilities for the use of transitional objects. Furthermore, by addressing the interface between self-injury, gender and social norms, this work points to the need for an inclusive clinical practice that is sensitive to the structural issues which permeate psychological suffering.

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• How to cite this article:
  Costa, L. C. R., Gonçalves, M., Jandoso, B., Moura, H. G. L., Trez, L., & Carlos, D. M. (2025). Contributions of Winnicott’s psychoanalytic theory to the study of self-harm: Scoping review. Paidéia (Riberão Preto), 35, e3516. https://doi.org/10.1590/1982-4327e3516
• Article derived from the master’s dissertation of the first author under the supervision of the sixth and co-supervision of the second, defended in 2022, in the Postgraduate Program in Nursing at Universidade Federal de São Carlos. Support: Fundação de Amparo à Pesquisa do Estado de São Paulo - FAPESP (Process No. 19/27564-8).

Edited by

• Associate editor:
  Wanderlei Abadio de Oliveira

Publication Dates

• Publication in this collection
  29 Aug 2025
• Date of issue
  2025

History

• Received
  13 Aug 2024
• Accepted
  02 Jan 2025
• Reviewed
  02 Dec 2024