Br. J. med. Psychol.
(1969), 42, 207
Printed in Great Britain
The body as transitional object: a psychoanalytic study of
a self-mutilating patient*
BY JOHN S. KAFKAf
Problems of limits-the limits of her body,
the limits of her power, and the limits of her
capacity to feel-were of major importance
in the analysis of a patient whose foremost
symptom consisted of cutting herself and
interfering with wound healing. Winnicott’s
(1953) concepts of transitional objects and
transitional phenomena provide a useful
framework for the formulation of some
aspects of the history of object relationships
of this patient. A point to be developed
concerns the notion that the patient’s own
body can be treated by her as a transitional
object and that this can be related to the
history of self-injury. Some effects on the
development of transference and counter-
transference of this history of object relation-
ships will also be explored.
The image which is most easily evoked in
the listener when reference is made to a
transitional object is the image of the security
blanket belonging to Linus of comic-strip
fame. The patient I will describe illuminated
for me an additional view of the transitional
object. Visualize, if you will, the initial frames
of the films used to teach surgery to medical
students: a piece of carefully cleansed skin,
the location of which is explained in the
accompanying technical commentary, the
skin surrounded by blue non-reflecting drapes,
and the surgeon’sgloved hand making a rapid
scalpel incision. Then there is a pause, which
* Presented at the Annual Meeting of the
American Psychoanalytic Association, 11 May
1968. An abbreviated version of this paper was
also presented at the 13th Annual Symposium at
Chestnut Lodge, Rockville, Maryland, on 13
October 1967.
t 5323ConnecticutAvenueN.W.,Washington,
D.C. 20015, U.S.A.
207
the viewer experiences as longer than it is,
before blood wells up and before the viewer
experiences the emotional shift from what
seems inanimate surgical anatomy to con-
frontation with the wound. How can we
understand the development of a person who
again and again treats her own skin and body
in a somewhat similar fashion? In theorizing
about such matters we must be careful, of
course, to remain aware of the limitation of
words for we are dealing with non-verbal,
largely preverbal, material. Yet even catch-
phrases, such as the transitional object con-
cept, may be useful in introducing a kind of
contagion which is necessary for participation
in the other person’s experience.
SUMMARY OF A CASE
Some aspects of a case which are particularly
pertinent to our topic will be briefly sum-
marized. The patient was a college student
in her late teens when I started working with
her. The psychoanalytic treatment of Mary,
as we will call her, lasted almost five years,
during the first two of which she was hos-
pitalized. Her father is a dry, undemonstrative
engineer, and her mother a talkative woman
with hysterical and hypochondriacal charac-
teristics. The patient has one older brother,
whose superior academic performance she
envied. Her parents had been separated for
several years prior to her hospitalization. The
psychiatrist who had seen Mary on a less
intensive basis for over a year had referred
her for psychoanalysis in a hospital setting
because of symptoms consisting primarily of
cutting herself and interfering with wound
healing. Sometimes she also swallowed pills
indiscriminately, refused to take medication,
and/or cheated on taking medication. Practi-
 JOHN S. KAFKA
cally her whole body surface was narcissistic-
ally considered and treated as an almost
constant object of erotic fascination.
Interference with wound healing had ap-
parently been present since childhood, prob-
ably since the age of six or eight years, but
the symptoms, especially cutting, had in-
creased in frequency since the parents’
separation. She was scarred primarily on
her arms, but her appearance was generally
pasty and her demeanour listless when I
started working with her.
During her first year of life Mary was
gravely ill with a generalized dermatitis,
believed to have been an allergic reaction.
Problems related to touching and skin
sensitivity were thus prominent since infancy.
Furry pets and dolls were always significant
in the household and early contacts with
these furry pets are related to the importance
of texture for Mary. Mother and daughter
competed in taking care of these pets. Father
had for years prior to the separation a relation-
ship with another woman and had totally
neglected his wife sexually. Mother had a
stronglyerotized interest in the household pets
and in her particularly cuddly daughter for
whom the atmosphere also became diffusely
erotized. Mother instructed the patient in how
to spy on father who was always suspected of
infidelity. Father, in turn, was aware of
daughter’s inquisitiveness; daughter had re-
petitive thoughts when she was with him, that
father wanted to push her from bridges, etc.
and she had at least brief thoughts of how
she might retaliate. Erotic feelings towards
father were thus particularly interwoven with
sadomasochistic elements. Mother used a
variety of conversion symptoms to force
some attention from father and others, and
also openly showed her delight when daughter
could get her way in a situation in which this
would not have been expected, such as when
she got a bus driver to stop the bus en route
so she could get a soft drink. Feelings of
omnipotence were encouraged in this and a
variety of other ways, and from the age of
15 on, the patient had a volunteer job in an
animal care and rescue centre where she had
the power of life and death over stray pets
by deciding which ones were to be ‘put to
sleep’ and which ones offered for adoption.
Early phases of the psychoanalytic work
were often characterized by a sullen, silent
attitude on her part, to which I found myself
responding in a similar way. After two months
of analysis the problem of the limits of her
powers was highlighted dramatically : she
developed a fulminating case of virus pneu-
monia which required transfer to a general
hospital. She went rapidly downhill and,
despite heroic measures, the internist and
consultant expressed the opinion that she
was a terminal case and would not survive the
next 48 hours. When fully conscious in the
oxygen tent, she still insisted that she only
wanted to drink a particular kind of fruit
juice, not readily available, and refused the
more common juices which were offered. At
this point 1 told her that she was not expected
to survive, and that she might as well drink
the available juice if she still wanted to taste
any juice at all. A marked behavioural change
occurred at that time. She looked frightened,
talked about her fear of death and drank the
juice which was offered. This seemed to mark
a clear turning-point and left me with the
feeling that my ability to be blunt with her
had saved her life. After her recovery from
pneumonia, the theme of my power over her
life and death became a prominent one in
analysis. Cutting of her arms and legs con-
tinued until I experienced fully my inability
to save her life. She then seemed to experience
more power over her own life, and self-
mutilation stopped. It was the unfolding of
the transference which gave us most of the
history of her development described in the
previous section. My experiencing an unusual
degree of erotic and sadistic fantasies found
its place in the analysis as representing some
repressed aspects of father’s, but predomi-
nantly of mother’s, relationship with the
patient. To be singled out for further descrip-
tion and theoretical consideration will be
one of the many examples in the analysis,
 The body as transitional obiect
when echoing her own experience of her
body, I experienced her as not quite living
matter. The more routine psychoanalytic
work, some of which you may infer on the
basis of the history given, will not be described
here. There was much working through of
material relating to complexities of inter-
personal relationships as she moved out of
the hospital, became a private patient, found
work, had plastic surgery to remove at least
some of her many scars, and started to have
increasingly frequent and meaningful dates.
The intensive and complex work with the
patient’s family and the difficult and subtle
administrative and nursing management of
this patient can also not be described in the
present context.*
DISCUSSION
The problem of limits is illuminated by
Winnicott’s formulation :
It is generally acknowledged that a statement of
human nature is inadequate when given in terms
of interpersonal relationships. There is another
way of describing persons. . .that suggests that
of every individual who has reached to the stage
of being a unit with a limiting membrane and an
outside and an inside [my italics] it can be said
that there is an inner reality to that individual, an
inner world which can be rich or poor or can
be at peace or in a state of war.
My claim is that if there is a need for this
double statement there is a need for a triple one:
there is the third part of the life of a human
being, a part that we cannot ignore, an inter-
mediate area of experiencing, to which inner
reality and external life both contribute. It is an
area which is not challenged [my italics], because
no claim is made on its behalf except as it exists
as a resting place for the individual engaged in
the perpetual human task of keeping inner and
outer reality separate yet interrelated (Winnicott,
1953, p. 230).
Winnicott’s ‘Study of the First Not Me
Possession’, as he subtitled his paper (1953),
* Burnham (1966) has described how this
patient decorated almost every inch of her room
with furry or other textured objects, pictures of
animals, etc.
209
is pertinent to the discussion of a patient
who considered her body in precisely these
terms. This patient, who early in life had
spiked braces placed on her teeth in an
unsuccessful attempt to keep her from
thumb-sucking and thus producing bad
teeth alignment, was fascinated, for instance,
by the theme of autocannibalism. She had
vivid fantasies about starving arctic explorers
eating parts of their own bodies to survive
and at times she actually ate small (and
sometimes not so small) pieces of the flesh
and skin of her own fingers.
Because of her apparently life-threatening
early allergic dermatitis, her entire body had
been swaddled and bandaged during practi-
cally the whole of her first year. Tt may be
recalled in this connexion that Winnicott
(1953, p. 232) suggests ‘that the pattern of
transitional phenomena begins to show at
about 4-68-12 months’. Particular care was
given to the problem of Mary irritating her
own skin with her own hands. The parents
recall the problems related to picking up and
touching the baby and managed to convey
a picture of what is likely to have been
contact hunger and acute pain with contact.
In the course of the analysis she described
how, when she slowly and deliberately cut
herself (for instance, with a razor-blade or
with a broken light-bulb smuggled under her
bed-covers while gazing lovingly at her
‘favourite nurse’ who was ‘specialing’ her)
she would not feel it, but ‘I always stopped
as soon as I did feel it’ and she managed to
convey the exquisite border experience of
sharply ‘becoming alive’ at that moment.
This sharp sensation was then followed by
the flow of the blood which she succeeded
in describing as being like a voluptuous bath,
a sensation of pleasant warmth which, as it
spread over the hills and valleys of her body,
moulded its contour and sculpted its form.
Blood was described by the patient as a
transitional object. In a sense, as long as one
has blood, one carried within oneself this
potential security blanket capable of giving
warmth and comforting envelopment. Dream
210 JOHN S.
and fantasy material suggested that internal
blood was probably linked to the internalized
mother, and the patient felt superior to others
or omnipotent because she could use her
knowledge to make external this comforting
mother-blanket. Winnicott (1953, p. 232)
does say that mother herself can be the
transitional object (‘ . . .Sometimes there is
no transitional object except the mother
herself ’), but he does not specifically make the
point being stressed here that part of the
body-here the blood, representing the
internalized mother-can be a transitional
object.
Through a major portion of the analysis
she expressed concern and/or threats that
the pleasurable sensation associated with
cutting would make it impossible for her to
resist the temptation to scar particularly her
face and trunk. But the relationship of what
is often described as body taboo to her
particular kind of body taboo cannot be
developed here. At times she felt not only
superior to others, but seemed genuinely
puzzled how others could go through life
without even occasionally indulging in the
forbidden fruit of a blood bath, available so
readily through a ‘zip’ in the skin. She made
jokes about having ‘zippers’ in the skin and
reported many dreams relating to shedding
of skin, burnt tar papers forming peeling
blisters, etc. She also reported that, in con-
nexion with frequent snowball fights in her
childhood spent in a northern city, she often
had vivid fantasies that an invisible layer
around her stopped snowballs at some
distance from her body. Her weight, incident-
ally, had fluctuated greatly during much
of her life. She was fascinated by a magazine
article describing an avant garde artist who
painted the skin of his models and then
instructed them to transfer the pigment to
canvas by throwing their bodies or rolling
themselves against the canvas. She, herself,
had for years prior to this already used
worms to crawl through spilled ink on to
white paper and thus make designs, the
fascination in both instances being in the
KAFKA
use of the living body as a tool, an object
transitional between living and dead matter.
Worms, incidentally, were particularly fasci-
nating to her in connexion with their clearly
segmented structure, their excretory and
sexual organs in each segment, and their
ability to grow parts after they have been
severed.* Perhaps it would make sense in this
connexion to talk of something transitional
between the part and the whole object.
In the countertransference I experienced
this patient frequently as a not quite living,
not quite animate object; in other words, as
a transitional one.
In retrospect one of the factors which
permitted me to be so blunt, or perhaps so
sharp, with this patient when she was ap-
parently dying of pneumonia, was my not
quite experiencing her as a living person in
the first place. The degree to which we ascribe
to another the quality of being alive (assuming
that I consider myself to be alive) depends
on our ability to be empathic and/or to
identify with the other person. Mary, with
her pasty appearance, and her ability to slice
into her own skin without any change in facial
expression, treated herself, apparently, as a
not quite living object, or at least considered
parts of her body as something other than
her own living tissue. My experience in the
face of her self-mutilations was not always
‘don’t do that. . .don’t hurt yourself. . . I
won’t let you hurt yourself’. My experience
was perhaps more in line with what Winnicott
(1949) has called ‘hate in the counter-
transference’ or at least my subjective feelings
could have been verbalized in some such
fashion as ‘go ahead, slice yourself to ribbons;
let’s find out if you’re alive or not’.
Elsewhere (Kafka, 1964) I have expressed
the idea that a mother, in order to permit
her infant to take a first step, must have the
delusion that the infant will not fall, a pre-
differentiation delusion of unity. Work with
this patient was one of the factors which have
now led me to believe that another parental
* Parenthetically,one may ask if the segment
of a worm is a whole or a part object.
 The body as transitional object
delusion, if you will, is necessary to permit
individuation of the offspring. The delusion
that the offspring is not alive. Let me explain.
Physicians cannot adequately treat members
of their own families because they are not
‘objective’ enough; because, let me rephrase
this, they cannot treat members of their own
families sufficiently as non-living objects. At
crucial times every parent must treat his own
offspring a little bit as a doctor does, however.
A patient comes to mind, for instance, who
was paralysed in his parental function in the
face of his child’s slightest injury. There are
some moments, borderline situations, in
which not only the treatment, but also the
raising of children, demands a dealing with,
sometimes even infliction of, pain, which,
however brief the moment may be, we can
only do if we consider the tissue as not quite
as alive and responsive as our own.
On the descriptive level we are on rather
firm ground in applying the transitional
object concept to the situation. This patient
certainly did treat parts of the surface of her
body as though she were not dealing with
quite living skin and there is much evidence
to support the notion that she was much
preoccupied with the, for her, very much
unfinished business of establishing her body
scheme.*
In applying the transitional object concept
to the genetic aspects of the situation, to the
developmental roots in the history of the
patient, we are on somewhat less firm ground.
We can offer a speculation at worst and a
hypothesis or a theory at best. Genetically,the
* In this context the distinction between
Schilder’s (1950) body image and Federn’s (1952)
notion of a bodily ego feeling may be pertinent.
This distinction refers to the fine but important
one of the knowledge of how one’s body functions
as a tool, as an instrument, on the one hand, and
the feeling of emotional intimacy with one’s
body, its being part of the ‘me’ feeling, on the
other hand. It is perhaps in this border area
between body image and bodily ego feeling that
the transitional object concept makes the most
sense.
I4
21 1
intensity of the early contact hunger, and the
pain when there was contact, is conceptualized
as a traumatic fixation point, an area of still
strikingly unfinished business when analysis
began, an area in which the ‘perpetual human
task of keeping inner and outer reality
separate yet interrelated’ (Winnicott, 1953)
was particularly difficult. The possibility that
a rather dramatic connexion probably exists
in this case between the early skin disease and
the later symptom may offer a lead. Although
less dramatically, early traumatic fixation
points, relating particularly to the formation
of the membrane of the body scheme, may
play a part in the developmental history of
other patients with the cutting syndrome.
In a wider framework which is being elabo-
rated elsewhere(Kafka, 1966a), I have come to
think of benevolent parental communication
of tolerance of ambiguity-the ambiguity,
for instance, of pain through, but hunger for,
contact-as related to the offspring’s individu-
ation without alienation. The dynamic semi-
permeable membrane, which helps to define
the individual, yet permits two-way passage
from and to the social environment, is
gradually formed by sequences of parental
communications or meta-communications
appropriate to the age of the offspring
(Kafka, 1966a) to the effect that ambiguities
and contradictions are tolerable. If in this
paper Winnicott’s concept of the transitional
object and the transitional phenomenon is
being expanded or extended, the major
justification for this extension derives from
his emphasis on a ‘neutral area of experience
which will not be challenged’ (Winnicott,
1953, p. 239). This lack of challenge, I would
say the tolerance of ambiguity, permits the
gradual formation of a membrane which is
ego syntonic to the extent to which it was
not prematurely and externally imposed but
individually established through much active
exploratory crossing and recrossing of the
culturally poorly or ambiguously defined
border territory. In discussing the genesis of
certain fugue states I have elsewhere (Kafka,
1966b) spoken of ‘the importance for normal
Med. Psych. 42
212 JOHN S. KAFKA
development of a stage of acceptance of
ambiguous sensory experience’, a territory
which the parents consider a no-man’s-land.
‘The question is not to be formulated,’ says
Winnicott (1953, p. 240).
But let us return for a moment to the
membrane which particularly concerns us
here, the cutter’s skin. While sadism and
masochism are generally considered two sides
of the same coin, it remains a fact that one
or the other side of the coin often dominates
a particular clinical picture. The study of
how one’s own body can be a ‘not-me’ object
may illuminate the general question of the
sadistic or masochistic preference. In a sense
the cutter’s choice is a transitional one
between the sadistic and masochistic object,
his own not-me skin. It is his skin-which,
however, he experiences as not his own. In
analysis the ebb and flow of sadomasochistic
transference and countertransference may be
conceptualized as a factor contributing to the
re-formation of a more integrated, more
bodily-ego-syntonic membrane, and thus
contribute to the eventual elimination of the
symptom.
ACKNOWLEDGEMENTS
I would like to acknowledge pertinent stimu-
lating discussions with many colleagues. I would
like particularly to express my appreciation to
Dr Harold Searles, with whom I had the oppor-
tunity to discuss my developing ideas during
several years, although the responsibility for the
formulations offered is, of course, mine.

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