Didier Anzieu’s notion of the skin-ego builds on a long psychoanalytic tradition that began with Freud’s idea that

the ego is first and foremost a body ego, a projection in the psyche of the surface of the body, or, in other words,
the idea that psychic phenomena are always embodied. An interface, a container for the ego, but also its origin:
thus did Anzieu conceptualize the skin’s psychic function. The baby’s fantasy of having a common skin with the
mother is the concrete starting point for a development that, through the prohibition on touching, leads to the
experience of being a separate and individual person. Psychoanalytic work with severe mental disorders makes it
necessary to investigate deficiencies in the skin-ego’s containing function before the patient’s psychic contents
can be explored. In the psychoanalytic situation, the analyst’s words replace tactile contact and thereby contribute
to healing injuries to the skin-ego. The clinical implications of Anzieu’s theoretical model are illustrated by
examples from psychoanalyses of children and adults. The close connection between touch, psychic envelopes,
and thinking opens a wider perspective on the necessity of setting limits to violence, against both nature and
human beings.

Keywords skin-ego, psychic envelopes, borderline conditions, narcissistic personalities, taboo on

touching, thinking ego, limit-setting

My overall purpose in this essay is to give a subjective, personal account of Anzieu’s thinking about the place of
the body in psychoanalysis, how it inspired my clinical understanding, and how it can help us comprehend the
challenges of our time. My starting points are some examples of how the theme of the skin as a primary border is
represented in our culture. After introducing Anzieu’s notion of psychic envelopes and a brief presentation of his
precursors and sources of inspiration, I focus on what is unique in his contribution to psychoanalysis. I continue
with some important clinical consequences of his approach, anchored in a theoretical understanding of the
psychoanalytic setting and the main mechanisms of change, and conclude by referring to Anzieu’s diagnosis of
civilization, today of even greater importance for the future of mankind. Rather than give accounts of entire
treatments, I will use short clinical vignettes to elucidate crucial technical and theoretical points.

Where does the ego come from? How is it based on the biological body? For Anzieu these are not merely
philosophical or speculative questions. In his paradoxical but unequivocal answer, he follows in Freud’s footsteps:
the ego is first and foremost a skin-ego, the projection in the psyche of the surface of the body, namely, the skin
(Anzieu 1986b, p. 63).

“My skin is my unwritten biography” said the anthropologist and paleontologist Nina Jablonski in an interview in
the New York Times (September 1, 2007) in relation to her book Skin: A Natural History(2006). According to
Jablonski, we all carry our history engraved on our skin. Here is the Swedish poet Kristina Lugn in “The Dog
Moment”:

I have always been as blown out.

Of my own body.

I have never fitted into the plot.

In my own life.
 I have always thought that artistic creation is a way for the skinless.

To provide oneself with skin.

[1989, p. 46]

The skin is said to act as “the mirror of the soul.” You can find this formulation in medical compendia on skin
disorders. In Oscar Wilde’s novel, Dorian Gray’s face retains its youthful beauty and innocence, while his portrait
is aging, reflecting his increasing cruelty and cynicism. However, I would like to go further and say that the skin is
the cradle of the soul. According to Anzieu, the skin creates the first differentiation that opens up space for mental
phenomena. In Genesis it is represented by Adam and Eve’s discovery of their nakedness after they have eaten
the forbidden fruit from the tree of knowledge and by their expulsion from the Garden of Eden.

Borders, Psychic Envelopes, and the Skin-Ego

The kernel of Didier Anzieu’s thinking concerns boundaries: the border with the outside world that is made up of
our skin; boundaries that create distinctions between inside and outside, between now and then, but also between
reason and thinking—and insanity and madness. Here is Anzieu from the introductory chapter of The Skin-Ego:

In Freud’s day, and that of the first two generations of his followers, psychoanalysts found themselves dealing with
clear-cut neuroses—hysteria, obsession, phobias or a mixture. Nowadays over half of a psychoanalyst’s practice
typically consists of what are known as borderline cases and/or narcissistic personalities. . . . In actual fact, these
patients suffer a lack of limits—they cannot perceive the frontiers between the psychical and bodily Egos, between
the reality Ego and the ideal Ego, between what depends on the Self and what depends on other people. . . . The
psychoanalytic treatment of borderline states and narcissistic personalities demands both technical adjustments and
a new set of concepts, which would allow better clinical understanding . . . [1985, pp. 7–8].

Freud (1930) saw the repression of our individual desires as a prerequisite for our culture, a prerequisite for which
we pay a high price in the form of inner conflicts, guilt feelings, and neuroses. What Anzieu is suggesting here is
that the patients of Freud and his followers suffered from too many limits, while today’s patients suffer from
an absence of borders or limits.

The notion of borderline was created as a collective label descriptive of patients not reached by classical
psychoanalytic technique—that is, patients “on the border of analyzability” (Stern 1938; Knight 1953, 1954). The
German-born Swedish psychoanalyst and Norwegian citizen Stefi Pedersen (1978)preferred to speak of “border-
people” or “guests of reality,” who resemble refugees without actually being refugees. She wrote that they were
strangers in their own country, in their immediate surroundings, and were strangers to themselves. Difficulties with
borders and limits were, according to her, the essence of their difficulties. Borderline literally means a dividing
boundary. To act as a borderline, an asymmetric membrane with two layers, one turned outward and the other
inward, but also to be the origin of the ego, is, according to Anzieu, the psychic function of the skin. The boundary
that is problematic in cases of severe mental disorders is, in his view, the “psychical skin.” The notion of the skin-
ego was introduced by Anzieu1 in 1974. This is how he describes its origins in A Skin for Thought, a book of
interviews:
 [I was a cosseted child] in the most physical sense of the term. I was not allowed to risk myself in the outside air
without being smothered under several layers of clothing: sweater, overcoat, beret, and scarf. The envelopes of care,
concern, and warmth with which my parents surrounded me, one upon another, did not part from me even when I left
home. I carried their load with me on my back. My vitality was hidden at the heart of an onion, under several
coverings. . . . I was fifty when I became fully aware of it. I then came up with the notion of psychic envelopes, and I
published—this was in 1974— my first article on the Skin Ego. This time what became thinkable for me was not what
I had lacked but what I had had too much of [Anzieu 1986b, pp. 3–4].

For the next twenty-five years, Anzieu devoted himself to researching the psychological significance of the skin
and psychic envelopes—“wrappings” for our feelings, thoughts, and memories. In the same way as the skin, this
sack of epidermis and dermis, is the body’s protective envelope, Anzieu sees the skin-ego as a psychic envelope
that contains, delimits, and protects, but also structures, the psyche.

Before we try to further understand Anzieu’s notion, I would like to refer to the “private theories” of preschool
children about the human body. I take examples from the book Old Aunties Don’t Lay Eggs(Levengood and
Lindell 2001). The following are comments made by five- and six-year-olds:

“A body is what’s around the people” [Celine, p. 49].

“The skeleton is wrapped in sausage skin. In this way, the guts stay inside the four walls of the body” [Thomas, p. 50].

“You can compare the skeleton with an umbrella. The skin protects us from the rain” [Ingrid, p. 57].

“If we did not have our skin, the soul would loosen and jump out” [Julie, p. 57].

“The skin is a kind of sleeping bag. Inside it you can feel warm and safe” [Ola, p. 59].

What children intuitively understand here is the skin’s function as a border. The skin, the surface of the body,
enables us to distinguish between stimulation from the outside and stimulation from within. Similarly, the children
imagine that the soul—the self or the ego—is what is inside the sack of skin. Inspired by Freud, Anzieu now turns
this relationship inside-out and thinks of the skin-ego as the envelope of our psyche. One of the most important
functions of the skin-ego is to distinguish what belongs to the self and what does not, to differentiate between
one’s own wishes, thoughts, and affects and those of other people, to demarcate the inner reality from the reality
of the biological body and the outer world. The skin is this interface—the sheet that makes up the ego, says
Anzieu, with reference to computing terms (1986b, p. 63).

Ola, five years old, said: “The skin is a kind of sleeping bag. Inside it you can feel warm and safe.” But what
happens when you cannot feel warm and safe inside the skin’s sleeping bag? As part of research on young adults
in psychotherapy (Philips et al. 2007; Werbart et al. 2017, 2018), we have studied their expectations. Here is a
quote from another research report:

One way the young people want to change in their therapy can be summarized as the wish for increased or
decreased permeability to one’s inner world. This seems to be pictured by them as a kind of more or less compact
boundary between the outer world and the person’s inner world. Thus, change means that the person wants to make
this boundary “thicker” or “thinner.” Someone wants to become less vulnerable and take things that happen in life less
 personally. Following the border metaphor, this person wants to be less permeable. Someone else wants to learn to
feel more and to express more feelings, that is, to increase permeability. Accordingly, one of the reasons for seeking
therapy may be to change the permeability. There also seems to be a tendency to gender difference in this regard.
More young women seem to strive to decrease permeability and more young men want to increase it [Bengtsson
2004, p. 13].

Clinical Examples

Vignette 1

A young Syrian woman in psychoanalysis complains that her skin is constantly cracking and is of “second-rate
quality.” She states that she has grown up in extremely indigent circumstances and suffered from hunger, extreme
cold, and lack of attention, human warmth, and care. According to her “private theory,” she was an unwanted child
who was born unfit for life and should have been “set out in the desert [to die].” As an adult, she is not worthy of
anything better than “second-rate quality” clothes, but under this “sack” of outerwear she is secretly wearing chic
and expensive underwear. After a few years of analysis, she describes how her skin has become thicker and the
chapping has disappeared. Moreover, she tells me she has acquired her “mother tongue,” Urmian, a language I
have no command of, but which I encouraged her to use when she could not find the right Swedish word.

Vignette 2

A middle-aged man has sought analysis to free himself from his lifelong “armor.” In the second year he suddenly
has an anguishing experience of flowing down the edge of the couch onto the floor. There is nothing that keeps
him together anymore; he is like soft Plasticine or a piece of dough, like the watch in Salvador Dali’s painting, or
the mangled carcasses in Francis Bacon’s paintings. It’s horrendous, he says, how can I ask him to say
everything that pops up in his head? After this experience, the dough and the armor become a recurring theme in
the analysis, the shapeless liquid pulp inside and the hard-but-brittle shell around it. Before we approach the end
of the analysis, he describes his experience of the dough being fully yeast-raised and baked; the bread has quite
a crisp crust that preserves the freshness of the soft inside.

Anzieu on the Skin-Ego

Anzieu’s fundamental thesis is that the psyche is built on the soma in interaction with the environment. The
biological anchorage is not only to the brain but first and foremost to the skin. The whole organism—but especially
its surface—is included in thinking. The skin is the body’s largest organ and provides a protective barrier to the
environment. The skin is also the largest sensory organ, which accounts for a significant part of our contact with
the world and is of great importance in our social and sexual relationships. The skin receives and preserves
sensory impressions, but it is also a shield against the outside world. It is a uniting sack, an envelope for our inner
self, and it connects the physical and the psychic. In everyday language, we use a variety of metaphorical
expressions that indicate the psychological significance of the skin: to be thin- or thick-skinned, to save our skin,
to get under someone’s skin, to jump out of our skin, to have skin in the game, to be comfortable in our own skin,
to make one’s skin crawl, to be no skin off one’s nose, to save one’s skin, to skin someone alive. How the ego
depends on the skin is aptly summarized by Anzieu:
 In fact, tactile experience has the peculiarity in comparison with all other sensory experiences of being at once
endogenous and exogenous, active and passive. I touch my nose with my finger: my finger gives me the active
sensation of touching something, and my nose gives me the passive sensation of being touched by something. This
double sensation, passive and active, is peculiar for the skin. Tactile sensation procures the basic distinction between
‘inside’ and ‘outside’, and it is the only one that can provide it; the other senses can only do it by reference to tactile
sensation. . . . The skin is so fundamental, its functioning is taken so much for granted, that no one notices its
existence until the moment it fails. . . . It takes a whole effort to appreciate that this surface is there [1986b, pp. 63–
64].

Accordingly, the sense of touch is the basic reference point for all other senses and the intersensorial function of
the skin-ego connects sensations of various sorts (Anzieu 1985, p. 112).

Anzieu’s Precursors and Sources of Inspiration

Every new theory or concept arises from interaction with previous knowledge, as a further development or in
opposition to some aspects of earlier theories or concepts. Anzieu’s notion of the skin-ego builds on a long
psychoanalytic tradition that began with Freud’s idea that the ego is principally a body ego, or in other words, that
psychic phenomena are always embodied. In Freud’s The Ego and the Id we find the famous cryptic phrase “The
ego is first and foremost a bodily ego; it is not merely a surface entity, but is itself the projection of a surface.” In
the English translation of 1927 this sentence is followed by a footnote that, according to James Strachey, was
authorized by Freud:

I.e. the ego is ultimately derived from bodily sensations, chiefly from those springing from the surface of the body. It
may thus be regarded as a mental projection of the surface of the body, besides . . . representing the superficies of
the mental apparatus [1923, p. 26 n. 1].

These spatial relations play a central role for Anzieu. He also gets inspiration from Freud’s ideas of stimulus and
contact barriers, formulated in the 1895Project for a Scientific Psychology. Just as bodily trauma entails puncture
of the skin’s protective shield, so mental trauma means penetration of the skin-ego by an overdose of excitation.

The Hungarian psychoanalyst Imre Hermann (1935), taking note of the early separation of the human child from
its mother, developed a theory of two complementary drives: clinging and going-in-search. Young mammals cling
to the mother’s fur to experience physical and psychic safety. The absence of fur on the human body promotes
the exchange of primary meanings between mother and child via touch. Following Hermann’s line of thinking,
Anzieu regards borderline and narcissistic conditions as the result of repeated, contradictory fluctuations between
excessive clinging and unpredictable detachment.

Further sources of inspiration for Anzieu were Bowlby’s attachment theory (a further development of Hermann’s
ideas) and Winnicott’s notion of the “good-enough” mother and the holding environment. Bion’s theory of the
containing function, the container, and the contained (1962) inspired Anzieu to distinguish between psychic
envelopes and psychic content.

Also important in this context was Esther Bick’s now classic paper, “The experience of the Skin in Early Object-
Relations” (1968), which Anzieu discovered only after publishing his first article on the skin-ego (1974). Bick
 makes a distinction between two forms of “second skin.” In the “sack of apples” state, the patient is touchy, in
need of constant attention and praise, while in the “hippopotamus” state, the patient is aggressive, tyrannical, and
relentless in following his own path. Likewise, Rosenfeld (1964, 1987) distinguished between two categories of
narcissistic personality, “thin-skinned” and “thick-skinned.” This distinction has been elaborated by many authors.
For example, Britton (2003, 2004) has described distinct difficulties analysts encounter in work with the two types
of patient. “Thin-skinned” borderline patients overwhelm the analyst with demands for love, impulsive acting out,
and threats of suicide. They try to take over the consulting room and make the analyst feel overinvolved in their
world. Owing to experiences of repeated rejection and chaotic parenting, such patients attempt to eradicate the
analyst’s otherness, demand total understanding, and thereby get “under the analyst’s skin.” By contrast, “thick-
skinned” schizoid and narcissistic patients are aloof and “hived off.” They create an empty space in the consulting
room and make the analyst feel excluded from their world. Owing to fears of being traumatically invaded by the
psychic content of another person, they withdraw into their own skin, which becomes like a shell, and they make
the analyst insignificant. The list of other psychoanalytic contributions to the psychic function of the skin and the
role of boundariedness could be long; an extensive account of how Anzieu’s ideas intersect with or differ from
other contemporary psychoanalytic ideas about the psychic function of the skin can be found in The Skin-
Ego (Anzieu 1985).

Anzieu’s Unique Contribution

Anzieu (1985) claims that up to now psychoanalysis has focused on exploring what is contained, that is, psychic
content: wishes, feelings, thoughts, and fantasies that give the analyst an insight into unconscious conflicts and
make neurotic symptoms understandable. More difficult and increasingly common cases, such as narcissistic
personalities and borderline conditions, some psychoses, self-injuring behavior and somatizing, require, according
to Anzieu, an exploration of deficiencies in the psychic containing function. Freud’s description of the barriers
between the conscious, the preconscious, and the unconscious must be complemented by the spatial structures
of the skin-ego and psychic envelopes. The primordial contact between mother and baby cannot be described
simply as a breast-mouth relation, but must take into account the skin-to-skin contact between two bodies. In
Freud’s model, functions and structures of the psyche develop through Anlehnung, literally by leaning on the
organic functions of the living body. In Anzieu’s reading,

identification is the transposition into the psychic domain of the incorporation of the food, and in the first instance of
the milk given by the mother’s breast or feeding bottle. Moral control over thoughts forms on the basis of sphincter
control over the faeces. . . . Certain character traits make one and the same mark upon the body and the spirit. . . .
In The Ego and the IdFreud [1923] wrote in an elliptical way that the superego derives from acoustic roots: this means
that the orders, injunctions, and threats that the child has heard uttered are at the origin of the superego—in short,
parental voices. . . . The superego derives from an acoustic origin: it forms with the acquisition of speech [Anzieu
1986b, pp. 62–63].

Following Freud, Anzieu maintains that the body is the bedrock of the mind (1986b, p. 61): every psychic activity
is anaclitically dependent on a biological function (1985, p. 44). The protective function of the skin-ego as a shield
against stimulation leans on the function of the surface layer of the epidermis. The function of a containing and
unifying sac for affects, experiences, and conflicts is set in train primarily by the mother’s bodily responses with
gestures and voice to the baby’s sensations and emotions. The origin of memory is the skin function of storing the
tactile sensory traces. In Anzieu’s formulation, “The Skin-ego is the original parchment that acts as a palimpsest,
preserving the crossed-out, scratched-through, over-written drafts of an ‘original’ pre-verbal writing made of traces
on the skin” (1985, p. 114).

Now we arrive at the “kernel” of Anzieu’s model: the psychic envelope consists of two layers, different in structure
and function. The external, harder layer at the periphery is turned toward the outside world and forms a screen
that receives and filters excitation. The internal layer of the membrane, thinner and more sensitive, receives,
deciphers, and registers signs—this is the surface of communication and meaning. This connects with Freud’s
description of the ego as having two layers, like the “Mystic Writing-Pad” (1925). One writes on the upper
transparent sheet and the traces are visible, but also removable from the lower sheet of waxed paper. However, it
is easy to discover that a permanent trace of what was written is retained on the lower sheet. In a similar way, the
skin-ego is asymmetrical: there is no protective shield facing inward and acting as a shelter from stimulation from
within. The underlying surface of meaning has a function of registering signifying traces and plays a decisive role
in how we handle what comes from within. That is where the memory traces are engraved, and it is the basis for
the construction of the apparatus for thinking thoughts—containing, representing, symbolizing, and
conceptualizing them (Anzieu 1985, pp. 93, 226, 260–261).

Borderline conditions are, according to Anzieu, a paradigmatic disturbance in the interface of the psychic
envelope. In these states, the entire structure of the skin-ego is damaged: “Its two faces form one, but this single
face is twisted in the manner of the strip described by the mathematician Moebius . . . : this is what causes them
difficulty in distinguishing between what comes from the inside and what comes from the outside” (1985, p. 136).
Affects and feelings migrate from the center toward the periphery, resulting in the same Moebius-strip structure:

just as the outside becomes an inside and then an outside again, over and over, so the poorly-contained content
becomes a container that contains poorly. Finally, the central place of the Self, deserted by those primary affects that
were too violent—distress, terror, hatred—becomes an empty space and the anxiety of this central inner emptiness is
what such patients complain most about, unless they have managed to fill it with the imaginary presence of an object
or an ideal person (a cause, a master, an impossible passion, an ideology, etc.) [1985, pp. 136–137].

In a similar way, in autistic phenomena the external layer of stimulus barrier is overinvested and the inner layer of
meaning, the inscription surface, is underdeveloped (Anzieu 1993), resulting in a “crustacean ego” (Anzieu 1985,
p. 286), a phenomenon previously described by Bick (1968) as a second muscular skin, by Tustin (1972) as
“autistic encapsulation,” and by Meltzer et al. (1975) as “adhesive identification.”

According to Anzieu, the skin-ego can be threatened from outside by physical pain and from within by psychic
pain. Psychic traumas produce holes in the skin-ego. Pain forces its way through the network of contact barriers,
causes topographical disturbance, and threatens to destroy the skin-ego, erasing the gap between its inner and
outer surfaces. It takes up all the space available and annihilates differences: better to die than to go on suffering
(Anzieu 1985, pp. 225–226). One way of attempting to restore the skin’s containing function if it is not sufficiently
developed or is collapsed after a trauma can be to inflict a real envelope of suffering on oneself: “I suffer therefore
I am” (p. 227). To inflict physical pain on oneself via the skin—for example, by cutting oneself—can for some
individuals be a way of experiencing oneself as real and restricting the unbearable pain to a fixed place.
 Paradoxically, self-mutilation can reinforce a sense of the skin’s holding the person together. Self-harm can be an
attempt to manage deficits in the skin-ego’s different functions and all the forms of anxiety attaching thereto, such
as those about not holding together as a person, fragmentation of the body, or bursting into pieces under the
influence of excessive feelings. Another way to defend against fragmentation is to build up a narcissistic envelope
of invulnerability.

Anzieu (1986a) maintains that the outer space itself has mental properties. Observations of infants confirm that
there is a primary confusion between the significant other and the place this person occupies in the physical
space. When this person disappears from the view of the baby, she takes with her the piece of space she
occupies, and this is associated with great horror. Such fantasies can be observed when working with patients
with schizophrenia: the physical cohesion of the self is threatened and the outer space is fragmented.

Anzieu’s conclusion regarding clinical practice is that an exploration of ideas of spatial relations between one’s
own body and other bodies might reveal deficiencies in the functioning of the skin-ego. The following is his most
important contribution to theoretical and technical developments in psychoanalysis: Therapeutic work with ideas of
space and psychic containers must precede work with wishes, feelings, thoughts, and fantasies. We must first
restore and strengthen the skin-ego before we can explore unconscious contents. During separations from the
analyst, such as breaks or termination, the topographical structure of the patient’s psychic apparatus can be
broken. According to Anzieu, such ruptures are always experienced as a rupture of the skin-ego. Therapeutic
work with deficiencies in the functions of the skin-ego can lead to transitional states of disintegration. In order to
function in a containing manner, therefore, the psychoanalytic situation must have clear and fixed boundaries.

The following clinical example illustrates the creation of a containing function. A thirteen-year-old boy comes to his
first consultation assisted by two caregivers from a treatment home. He has become impossible to discipline, has
been banned from several schools, and has been given a diagnosis of ADHD. The first thing he does in my office
is to catch sight of a phone book (which of course stands for communication, “connecting people”) and begin
systematically tearing out page after page. I crawl on the floor, collecting pieces of paper, put them in a glass jar,
and say to him: “This is something important that you are trying to tell me, something that you can’t tell me in any
other way. It’s valuable information that you are giving me. I’ll keep these pieces in a glass jar until I see you
tomorrow and we can look at them together.” This becomes the beginning of a three-year analysis. A few months
later he makes a drawing, and explains: “I’m a BOMB.” For a long time, his favorite occupation in the analysis is to
draw increasingly sophisticated “tags,” graffiti artists’ signatures. Toward the end of his analysis, he gives me a
“tag” with the subtitle “THE FUTURE I$ HERE.”

The Ontology of the Skin-Ego and the Taboo on Touching

So where is the skin-ego to be found? Anzieu (1985) answers that it is real in the order of fantasy: “it appears in
phantasies, dreams, everyday speech, body language, and thought disorders; and it provides the imaginary space
in which phantasies, dreams, thought, and all psychopathological formations are set up” (p. 4). His perspective is
that of developmental psychology: “By Skin-ego I am referring to a mental image used by the child’s Ego during its
early stages of development to represent itself as an Ego containing psychical contents, based on its experience
of the surface of the body” (p. 42). He explains:
 The infans begins to perceive its skin as a surface when it experiences contact between its body and that of its
mother, in the framework of a secure relationship of attachment to her. Through these experiences it comes to
develop not only a notion of a boundary between the inside and the outside but also the confidence it will need to
control its orifices . . . [p. 42].

The baby’s original fantasy in relating to the mother is of having a common skin with her. Here is Anzieu once
again:

In imagination each of them develops in different parts of a single skin, which allows them immediate exchange and
contact. The prohibition upon touching detaches the baby and his mother from this over-close contact. This is the
moment when the mother picks up the baby less often, when she holds him less closely to her, stops suckling him, or
gives him more solid food on a spoon, that is, with her hand. The psychic function of the hand, a function of taking or
grasping objects, words, and thoughts, supersedes the containing function vested in the surface of the body [1986b,
pp. 72–73].

This coincides in time with the acquisition of speech and walking, and it represents one of the conditions for acquiring
speech. If in fact the growing child persists in taking his mother’s or an adult’s hand and leading them up to an object
he needs or wants so that that hand can give it to him, then there is no reason to make an effort to ask for it with
words. . . . As soon as the child is walking, he is forbidden to touch dangerous objects or to touch in a way that gives
hurt or destroys [p. 72].

According to Anzieu, the notion of the incest taboo must be supplemented by the taboo on touching. The
prohibition on touching is a precondition for transition from the skin-ego to the thinking ego2 (1985, pp. 164–165).
It makes us give up the primacy of the pleasure of the skin so that concrete tactile experiences can be
transformed into inner representations and ideas. Violations of the taboo on touching are a consequence of
psychopathology and lead to further pathology.

Clinical Implications

The distinction between the containing function of the skin and the hand’s function of grasping objects, words, and
thoughts has, according to Anzieu, important clinical implications. The analyst’s and the patient’s words
symbolize, replace, and re-create tactile contact. Thus, the “talking cure” can contribute to healing deficiencies
and injuries to the skin-ego. In psychoanalysis, the symbolic reality of the exchange is more effective than its
physical reality, and this is protected by the psychoanalytic boundaries (1985, p. 169).

Psychoanalysis can take place when physical separation between the analyst’s body and the patient’s body is
maintained [1986b, p. 73].

Experience shows me that it is sufficient to resort to symbolic touching: one can touch with the voice. In ordinary
language we say ‘make contact with someone’ or ‘be in good contact with a person’. . . . What strikes me as
specifically analytic is finding, by relying on various sense organs and various sensory fields, verbal equivalents for
the primitive exchanges that introduce the infant to the world of signifiers—exchanges that then need to be
abandoned in order for the being to develop [1986b, pp. 78–79].

In the final paragraph of the first edition of The Skin-Ego he comments:

 Spoken words—and even more, written words—have the power of a skin. . . . At first it was a personal intuition and it
took some time for me to transform it into an idea. When I wrote this book it was also to defend my Skin-ego by
writing [1985, p. 291].

Healing damage to the skin-ego requires modification of classical psychoanalytic technique (Anzieu 1985, pp. 12–
13). Regarding the psychoanalytic prohibition on touch, Anzieu is steadfast: psychoanalysis is a “talking cure” par
excellence. In some phases of treatment, the couch needs to be abandoned in favor of a face-to-face position.
Physical care can be replaced by, for example, a “bath of words” (1985, pp. 183–186). An important clinical
implication of Anzieu’s thinking is that we need to consider the two surfaces of the skin-ego: the outer layer that
receives and filters stimuli, and the inner layer that receives, deciphers, and records meanings. Work with the
containing function must run in parallel with work with what could be called symbolization or mentalization.

If we can draw the skin, as well as other forms of psychic envelope, into the psychoanalytic dialogue, we get a
powerful instrument for influencing the ego. Following Anzieu’s line of thought, we could say that the main
mechanism of change in psychoanalysis consists of restructuring the skin-ego, and above all, of rebuilding the
inner envelope of meaning. When loving and sexual cathexes are weak and the temptation toward self-destruction
predominates, a one-sided interpretation of wishes, fears, and fantasies leads to a risk of attacks on the patient’s
body, on the capacity for thinking, and on the patient’s life (Anzieu 1986b, pp. 56–57). However, in my experience,
people who cut themselves can feel understood if an analyst focuses on how they are feeling more than they can
contain within their body, or that they are afraid their skin will crack from too much strong excitation.

Clinical Vignette 3

The following example illustrates the shift of focus from the contained to the container. A young woman who
sought help for her panic attacks also had anorexia and impulses to cut herself. In sessions, she fantasizes wildly
about different subjects connected to her own and others’ aggressiveness and sexuality. She believes that her
mother begrudges her artistic achievements, envies her for being a head taller than she, and can’t bear her
boyfriends. She avoids meeting her mother lest she harm her mentally or physically. Dad she can meet, but only if
she keeps this a secret from Mom. She does, however, think that Dad looks in a special way at her breasts under
the semitransparent top, and at her buttocks and thighs. When she talks about this, a blush spreads over her skin,
which starts to itch; she gets a rash. She recalls having had severe eczema as a child. She believes that her
mother’s breast milk was “diluted” or “poisoned.” Perhaps, I tell her, she conceives of my words as diluted or
poisoned milk. Suddenly, she experiences leaving her body and falling to pieces. When the session is over, it is
difficult for her to stand up; it is as if she cannot pull herself together. In the following sessions, she fantasizes that
all her problems may be due to her possibly having been the victim of incest. She has frightening dreams that take
place in a cellar. What has just happened?

This woman was absorbed in an intensive exploration of psychic contents in her fantasies. But the fantasies were
located on the surface, not concealed by other material. My intervention intensified her paranoid-schizoid anxiety,
and she was increasingly disintegrating. In my countertransference I felt like a perpetrator, breast-feeding her with
poisoned milk and at the same time trying to look under her clothes. Acknowledging my transgression helped me
see how fragile her boundaries were.
 Finally, I tell her that it is as if everything she fantasized about came oozing out through pores in her skin and
caused a flare-up—as if what we are talking about was too much to contain within a little girl’s body. This
becomes a theme in her analysis: in various situations she experiences an excitation that is too much for her,
more than she can hold within herself. For example, she remembers how exciting it was when her father threw her
up in the air and then caught her. It was a funny feeling—a “too muchness”—more than she had room for, as she
had to pee all of a sudden. More memories followed from childhood, as well as from current life, including her
experiences in sessions with me. In short, she and I are now consistently working with an exploration of her
fantasies about psychic envelopes. When she reports a dream, I do not pay attention to her unconscious wishes.
Instead we investigate open or closed windows and doors; we sort out what is inside and what is outside rooms
and buildings. We begin to collaborate in regulation of excitement in sessions, being attentive to moments of “too
muchness” in our exchanges. She is not “leaking” anymore, and her disintegrated states are much more rare. Her
agoraphobia is declining, and panic attacks in crowded subways or department stores have altogether
disappeared. Having put on weight, she says she has developed subcutaneous fat so she does not feel freezing
any longer; she has a more feminine appearance that she struggles to integrate with her inner image of being a
“skinny stick.”

Clinical Vignette 4

Self-mutilation can also function as a substitute for engraving memory traces, as in the following example. A
young woman has previously dropped out of treatment with a “containing” and passive therapist, attempted
suicide, and then tried CBT treatment. She has no story to tell me, no memories. Everything is engraved on her
skin, which is covered with scars that she hides under several layers of baggy clothes. She can date every scar
and remember the immediate circumstances of each one. There are traces of razors, needles, knives and
cigarettes that she makes use of when an unspeakable, uncanny horror takes possession of her. She wants to
make the process short, such as having a forty-eight-hour therapy in one go, but she thinks she would not survive
it. All feelings are dangerous, they easily become “too much” and merge into a lump of anxiety. Together, we find
a way to jointly regulate what we are talking about in sessions, so that it will not be too much and too hot for her
and for us. The work with differentiation between what is inside and what is outside her, between imagination and
reality, thought and action, love and hatred, but also finer shades of different emotions, slowly yields results. She
starts to remember how in puberty she suffered from inner chaos and a fear of losing her tomboy’s body. A new
danger lurks, when things are running too smoothly, when the analysis and the analyst become too important to
her, and her impulses to cut herself are stronger again. I could have interpreted her destructiveness. Instead, I am
thinking of her allowing herself to be touched by my words and feeling like new skin is growing layer on layer – it is
as though she needs to carve memories of our work on her skin. When I say something about this to her, she
reveals that she has planned to make a small tattoo on her back to remember her analysis. She begins to lose
weight and thinks she no longer needs such a thick layer of fat in order to protect herself. The function of her skin
as a parchment with scars as traces of signs and memories is gradually replaced by an inner, psychic surface for
traces of narratives, stories and symbols. Before it is time to end, she is convinced that her entire skin will
remember what she acquired in the analysis and that she no longer needs to write it on her skin as a tattoo.

An Example from Supervision

 A young woman came to a therapeutic community after repeatedly attacking and injuring her two children. Now
she is allowed to visit them only when chaperoned by another adult. She herself feels miserable, worthless, and
vulnerable. She says that she is skinless and without protection, but tries to live in the world anyway. She states
that her body parts do not hang together, her trunk is too big and her limbs too small. She often talks about her
breasts, belly and abdomen, and wants to live without them. Repeatedly, she buys nice new clothes only to throw
them away a few days later because they do not match her image of her body. Her therapist carefully tries to
approach her fear of her own wishes, fantasies, and impulses. After visiting her children, they talk again about her
aggressive fantasies and fear of hurting the children. But such a focus brings no relief. In fact, the night after the
therapy session, she again attacks her body, cutting herself in her stomach and genitals. Following supervision,
the therapist makes a shift. He then involves his patient as an active participant in controlling what they are talking
about in sessions so that the emotional atmosphere is not too much and too hot. The painstaking work of
differentiation between inside and outside, imagination and reality, thought and action, and different feelings goes
on. Over time, the patient feels she has begun to have some skin on her knees. Not on her whole body, but on her
knees. “It’s the most important place,” she explains, “to have ‘knee protection’, like in ice hockey. There’s head
protection, shoulder protection, elbow protection, knee protection.” The therapist understands that this is a
beginning of being able to protect herself against dangers coming from the outside and from the inside. He hopes
that together they will obtain more ice hockey equipment; that the skin on her knees will begin to grow in other
places. The therapeutic contact continues after discharge from the therapeutic community. At follow-up a few
years later, the woman says that she has arranged an internship at a botanical garden. She goes to a chiropractor
for her spinal aches and, on his advice, even to massage and swimming. She cares for her skin and the skin
keeps her together.

To conclude: Patients often recount early traumatic damage to their psychic envelopes through a kind of
psychodrama, staging their fantasies about containers in the therapy room and in their life. In my experience, this
is often a fruitful perspective that can indeed be applied to various forms of therapeutic work with the pathology of
the skin-ego. I can only agree with Glen Gabbard (1996), who stated that successful psychoanalysis results in the
ability to live “in one’s own skin.”

Anzieu’s Coda for Our Time

The close connection between touch and words, between psychic envelopes and thinking, opens a wider
perspective. In the introductory chapter of The Skin-Ego Anzieu takes a leap from clinical practice and applies his
thinking about our need for boundaries to the situation in the world at the turn of the millennium. In two long and
emotionally charged sentences, he emphasizes the need to set limits to the current violence against nature and
against human beings:

If I were to sum up the situation of the West—perhaps of whole humanity—at the end of the twentieth century, I would
emphasise the need to set limits: limits to demographic expansion, to the arms race, to nuclear explosions, to the
speeding-up of history, to economic growth, to insatiable consumption, to the widening gap between the rich nations
and the third world, the huge scale of scientific projects and economic enterprises, the invasion of the private sphere
by the media of mass communication, the incessant pressure to break records, at the cost of over-training and
doping, the compulsion to go faster, further, more expensively, at the price of congestion, nervous tension,
cardiovascular diseases and general discontent. We need to set limits on the violence against nature as well as
against human beings—air pollution, ground pollution, water pollution, the squandering of energy resources in the
 name of producing everything we are technically capable of, down to mechanical, architectural or biological
monstrosities; limits on the breaking of moral laws and social rules, on the assertion of individual desires, on the
threat of technological advances to the integrity of our bodies and the freedom of our minds, to natural human
reproduction and the survival of the species [p. 7].

He goes on:

Small wonder that a civilization which fosters outsize ambitions, panders to the demand of the couple, the family and
social institutions to take charge of the individual, passively encourages the collapse of all boundaries in the artificial
ecstasy of chemical or other drugs, exposes the child, who is more and more often an only child, to the traumatic
focus of the unconsciouses of both parents in a household that is more and more restricted in size and in solidity;
small wonder, then, that such a culture favours immaturity and provokes a proliferation of borderline psychical
disturbances. . . . Thus, in my view, we face a task of greatest psychological and social urgency: to rebuild limits,
restore frontiers and create for ourselves recognisable and habitable territories. These limits and frontiers must both
institute differences and enable exchanges between the newly defined regions—regions of the psyche, of knowledge,
of society and humanity [p. 8].

When Freud wrote Civilization and Its Discontents (1930) his main thesis was that civilization, in order to preserve
social cohesion, restricts individuals’ sexual and aggressive impulses, and therefore inevitably comes into conflict
with individual desires. Conflicts between individuals and society in external reality correspond in the inner,
psychic reality of each person to conflicts between instinctual impulses and demands of the superego. What
makes us discontented are, according to Freud, unconscious guilt feelings resulting from these unconscious
conflicts. Anzieu’s civilization diagnosis, by contrast, references the boundless state causing today’s patients to
suffer from a lack of limits. His plea must not be misinterpreted as an expression of longing for clear-cut borders or
unambiguous dogmas. Instead it is a powerful appeal for respect for differences and for the need for mutual
exchanges in this era of globalization accompanied by the resurrected ghosts of nationalism and fundamentalism.
Freud’s criticism of civilization has undoubtedly influenced and changed our culture. Can psychoanalysis today
contribute to the dual task of restoring boundaries and promoting exchanges across borders? Current longing for
“stony” borders and unwavering norms, the allure of nationalism and fundamentalism, runs parallel to and is a
reaction to the culture of boundlessness (see Moss 2016; Werbart 2014). We are all living in a transitional period,
witnessing a development where the boundaries between the private and the public sphere, between truth, fiction,
“alternative facts,” and lies are repeatedly blurred, with unforeseeable consequences for the survival of our planet.

Professor of Clinical Psychology, Department of Psychology, Stockholm University; Training and Supervising
Analyst, Swedish Psychoanalytical Society.

An earlier version of this paper was presented at the 31st Annual Conference of the European Psychoanalytical
Federation in Warsaw, Poland, March 24, 2018.

1
Didier Anzieu (1923–1999) was a French psychoanalyst, member of the Association Psychanalytique de France
and professor at the University Paris X Nanterre. He won international renown with his book about the origins of
psychoanalysis as reflected in Freud’s self-analysis. That book, his doctoral thesis in 1959, was published in
extended editions in 1975 and 1988. His most original contribution is the theory of the psychological significance
 of the skin, extensively presented in Le Moi-peau (1985). Anzieu’s theory remains an important contribution to the
ongoing debate on the role of biology in understanding human psychological and social life. In addition to studies
of the history of psychoanalysis and of the skin-ego, he has been interested in group processes, creativity, and
theory of thinking. Anzieu is a psychoanalytic thinker who contends against any form of orthodoxy and does not
hesitate to move in areas beyond the traditional domain of psychoanalysis.

2
What does Anzieu mean by the dualities of the prohibition? The taboo relates to both the sexual and the
aggressive drives. It has a double face, one turned outward and one turned toward inner reality. The outer
prohibition separates the area of the familiar and safe from the unfamiliar and dangerous: don’t put your hand in
the fire, don’t touch knives or the rubbish. The intrapsychic taboo helps to create a border or interface between the
ego and the id and to develop a differentiation of the psychic apparatus. The prohibition is created in two phases:
the first against full-body contact—the fusion or confusion of bodies—and the second, more selective, against
touching with the hand. Consequently, we have to distinguish between prohibition against bodily attachment or
clinging and against mastery by the hand. Further, the prohibition is bilateral and applies to the person issuing it
and to the person it is addressed to—it must be respected both by the parents and by the child [Anzieu 1985, pp.
159–163].

ORCID iD

Andrzej Werbart https://orcid.org/0000-0003-0859-1012

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