E. J. KHANTZIAN, M.D. and JOHN E. MACK, M.D.

WE NEED NOT LOOK BEYOND THE PAST TWO DECADES TO FIND ample evidence around us in society and our clinical work of threats to human survival and of self-destructiveness. Despite the fact that ego psychology and object relations theory have become part of the bedrock of psychoanalytic practice and theory, much of our understanding of survival and self-destructiveness continues to be influenced by Freud's early writings. The complex functions relating to self-preservation, self-protection, and survival are relatively neglected in contemporary psychoanalytic literature despite the special urgency of these matters for many of our patients. It is, in fact, surprising in view of the current interest of mental health workers in disadvantaged individuals and families, for whom survival issues including basic protection from real dangers are conspicuous, that so little attention has been given in psychoanalytic theory to the psychology of self-preservation.

The influence of the early psychoanalytic literature is evident in reductionistic formulations which consider such problems as accident proneness, violent or impulsive behavior, weight disturbances,

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substance (drug and alcohol) abuse, and other forms of self-neglect in terms of explicit pleasure-seeking and/or unconscious self-destructive motives. Such formulations fail to consider adequately how these problems are just as often a result of deficiencies or failure in ego functions that serve to warn, guide, and protect individuals from hazardous or dangerous involvements and behavior.

In this presentation we advance a point of view that places greater emphasis on structural and developmental factors to account for certain forms of human self-destructiveness. We describe a complex set of functions that we have designated as "self-care." We believe that failures and impairments in the development of these functions better explain a range of troubled human behaviors. Although denial, conscious and unconscious self-destructiveness, psychological surrender, and other determinants can explain some human self-destructive behavior and impulsivity, we have been equally impressed that the personality structure and character pathology of certain individuals leave them vulnerable and susceptible to various dangers that result in personal injury, ill-health, physical deterioration, and death. We believe such people are often not so much compelled or driven in their behavior as they are impaired or deficient in self-care functions that are otherwise present in the more mature ego. Exploring the components and elements of the functions that comprise self-care not only has heuristic value for a better theoretical understanding of human development and adaptation, but is equally important for understanding and managing destructive behavior in clinical work, particularly in the treatment of impulse and behavior problems.

Self-care as a developed system of functions includes the following elements:

1. A libidinal investment in caring about or valuing oneself—sufficient positive self-esteem to feel oneself to be worth protecting

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2. The capacity to anticipate danger situations and to respond to the cues which anxiety provides

3. The ability to control impulses and renounce pleasures whose consequences are harmful

4. Pleasure in mastering inevitable situations of risk, or in which dangers are appropriately measured

5. Knowledge about the outside world and oneself sufficient for survival in it

6. The ability to be sufficiently self-assertive or aggressive enough to protect oneself

7. Certain skills in object relationships, especially the ability to choose others who, ideally, will enhance one's protection, or at least will not jeopardize one's existence.

In this report "self," as used in "self-care" and "self-preservation," refers to the broader meaning of self pertaining to the entire person. Self-esteem and self-regard also are related to self-care. Unless otherwise specified, however, we are concerned primarily with understanding and explaining the structures and functions that serve the survival of the self or person as a total organism. We also distinguish self-care functions related to protection and survival from self-soothing. Self-soothing activities maintain subjective states of comfort and well-being and will be discussed only briefly.

BACKGROUND

Before he evolved his structural theory of the mind, Freud attempted to encompass what we would now consider fundamental functions of the ego within his theory of instincts. Self-perservation, self-care, self-protection, and the like were originally grouped together by Freud as self-preservative or ego instincts. He referred to these as "instincts which serve the preservation of the individual" as opposed to "those which serve the survival of the species" (1913, p. 182). When Freud elaborated his views on narcissism he regarded the ego instincts as the nonlibidinal aspect of narcissism. Ultimately, Freud rejected this distinction and viewed self-preservation as itself erotic in a narcissistic sense: "the instinct of self-preservation is certainly of an erotic kind, but it must nevertheless have an

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aggressiveness at its disposal if it is to fulfil its purpose" (1933b, p. 209). Thus we see Freud virtually to the end of his life seeking to conceptualize self-preservation within the framework of his instinct theory, even though in 1938 he finally said, "the ego … has the task of self-preservation" (p. 145).

Notwithstanding Freud's final admonition that self-preservation was a task for the ego, subsequent psychoanalytic investigators have continued to stress instinctual factors to account for much of human behavior that is dangerous to the self. Works by Menninger (1938) and Tabachnick (1976) are representative examples that illustrate this continuing trend. Menninger believed that Freud's hypothesis of a death instinct could best account for the varied and manifold forms of human self-destructiveness, such as asceticism, martyrdom, invalidism, alcohol addiction, antisocial behavior, and psychosis. He considered such problems as forms of "chronic suicide" and accounted for these tendencies by human aggression turned on the self. Tabachnick came to similar though not identical conclusions in his studies of automobile accidents. He distinguished two types of victims in his study, one group (20%) in which the victims were depressed, and another group (80%) in which the victims were action-oriented but not depressed. Although he identified different features and dynamics in these two groups, he concluded that a "death trend" was common to both groups as a result of tremendous rage and aggression turned on the self. Citing the work of Dunbar (1943) and Alexander (1949) who believe that action-oriented characters are involved in multiple accidents, Tabachnick suggests that a "death or self-punitive trend" might be involved in action orientation. However, Tabachnick concedes that the accident can be an unintended result of conflict in action-oriented characters. In our opinion, such formulations fail to consider sufficiently how the active pursuit of danger, bravado, fatalism, and action substitute for less well-developed, sustaining, stabilizing, and self-preservative functions. These compensatory character traits flourish in lieu of more stable self-care (ego) functions and processes that most often protect human beings from their own self-destructive inclinations.

The functions that are responsible for self-preservation,

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standing in opposition to self-destruction, have been ascribed to the life or ego instincts, and more generally to the ego. Although an adaptational, ego-psychological view subsumes self-perservation in human existence, there is little in the psychoanalytic literature that specifically identifies or explains the functions and mechanisms that are involved in assuring human survival and self-care.

In concluding remarks in his classic work on the ego and adaptation, Hartmann (1939) observes that although "emphasis on the ego apparatuses may delineate more precisely our conception of the 'self-preservative' drives … we have so far treated [them] like a stepchild" (p. 107). His ideas about the role of the ego apparatus, the part it plays in general adaptation, and its specific role in survival remain central to our understanding of the capacity for self-care and self-protection. In a subsequent paper, Hartmann (1948) allows that both sexual and aggressive drives contribute to the development of psychic function and ultimately serve purposes of self-preservation. He also states that the reality, pleasure, and Nirvana principles and the repetition compulsion can under certain circumstances subserve self-protective functions. He concludes, "it is the functions of the ego, developed by learning and by maturation—the ego's aspect of regulating the relations with the environment and its organizing capacity in finding solutions, fitting the environmental situation and the psychic systems at the same time—which become of primary importance for self-preservation in man" (p. 84). It is surprising how little psychoanalysis has expanded upon or advanced Hartmann's thinking in delineating more specifically the component structures and functions that serve survival.

A review of the literature on self-preservation reveals that a number of psychoanalysts are aware of how little we know about its development and the importance of gaining a better understanding of this much neglected area of human adaptation. Glover (1933) appreciated how children early in their development both depended on external objects for self-preservation and also could experience real threat to their survival as a result of external dangers, injury, and aggression. Loewenstein (1940) stated bluntly, "the self-preservative instincts have

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hitherto been greatly neglected" (p. 388). He felt that the so-called self-perservative instincts were not instincts at all (especially not connected with the death instinct), but that they must be seen in relation to the whole development of the ego. In commenting on Loewenstein's work, Zetzel (1949) underscores the importance of the survival instincts and the role of anxiety in relation to real external dangers. Rochlin (1965) indicates that "instincts of self-preservation" are present earlier than has been supposed and that small children manifest early concerns about death and self-preservation. Mahler (1968) observes, "the function of, and the equipment for, self-preservation is atrophied" in the human species (p. 9). Most modern-day psychoanalysts would agree with this observation, but little systematic attention has been given to how the "function of, and equipment for, self-preservation" develops and operates to protect the self from danger and harm. Recent theoretical and clinical work focusing on child development, narcissistic disturbances, affects, impulsivity, and substance abuse has helped, nevertheless, to illuminate how the capacity for self-preservation or self-care develops.

Winnicott (1953), (1960) and Mahler (1968) have stressed the importance of the quality and quantity of nurturance and care in the earliest phases of the mother-infant relationship. The ways in which this maternal care is administered has important implications for the development of self-care. The works of Winnicott and Mahler share an emphasis on optimal nurturance that avoids extremes of deprivation and indulgence and enhances the capacities of the ego to tolerate delay, frustration, and distress. As a result of this process the parent's nurturing and protective functions are incorporated into the child's ego capacities in the service of maintaining adequate self-esteem, ego defense mechanisms, and adaptation to reality. By implication the "good enough mothering" and care obtained from the environment during preoedipal development contributes significantly to the individual's eventual capacity to take care of himself or herself.

Through the analysis of narcissistic transferences, Kohut (1971) reconstructed how failures in parental (particularly maternal)

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care leave certain individuals ill-equipped to maintain and regulate their self-regard and self-esteem because of impairments in ego-ideal formation. He stressed failure in maternal empathy and traumatic disappointments in idealized parental figures as central determinants in narcissistic disturbances. Among the consequences of such disturbances are: (1) the external living out of a search for omnipotent, idealized objects that are admired or admiring for achieving a sense of well-being; and (2) the failure to transform through minute internalizations in the preoedipal developmental period various functions of the parents that ultimately contribute to the ego apparatus of the individual. Kohut only touches on the implications for self-preservation of such internalization processes, indicating that the analyst might have to "alert the patient's ego … in the interest of self-preservation" to certain impending dangers (p. 158). His emphasis, however, on the deficits in self-esteem and on failures of internalization in the formation of psychic structure is quite germane to our concept of how the capacity for self-preservation and self-care is acquired from parental figures, particularly from those aspects of parental care that have provided protection and vigilance as the developing and growing child explores his or her environment.

The works of Tolpin (1971) and Sandler and Sandler (1978) are germane to the concept of self-care in that they consider the part early object relations play in the development of psychic structure. They provide a basis for considering what constitute the precursors and components of the capacity for self-care. Tolpin focuses on the part that transmuting internalizations play as a means through which the infant may develop protective, caring, and anxiety-signaling functions. Sandler and Sandler stress how wish-fulfilling relationships with early objects become the basis for incorporating a sense of well-being and safety.

These reports converge to indicate that the various functions required for self-protection and self-care have their origin in the child-caretaker relationship as well as in maturational processes of both drives and ego. For this reason they are best studied from a developmental perspective.

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DEVELOPMENTAL PERSPECTIVE

Freud (1916–17) clearly appreciated children's initial ignorance of danger and the parents' role in helping them to acquire a capacity to avoid harm:

Anna Freud's (1965) description of the developmental line from irresponsibility to responsibility in body management comes close to some of the processes that concern us in relation to self-care. She reminds us that the satisfaction of essential physical needs, such as feeding and elimination, are only gradually taken on by the child. According to Anna Freud, the slow assumption of responsibility for self-protection occurs in consecutive phases that involve (1) a shift in the expression of aggression away from the body (e.g., biting and scratching) toward the external world; (2) an increasing orientation in the external world whereby cause and effect and the control of dangerous wishes are understood; these ego functions together with the narcissistic cathexis of the body "protect the child against such external dangers as water, fire, heights." But, she then observed, "there are many instances of children where—owing to a deficiency in any one of these ego functions—this advance is retarded so that they remain unusually vulnerable and exposed if not protected by the adult world" (p. 77); (3) the child's voluntary endorsement of rules of hygiene and physical requirements—normally the latest acquisition.

Once established, superego functions naturally play a part throughout one's life in protecting the self. In striving to do

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"the right thing," "following the rules," and consistently obeying internalized parental admonitions and prohibitions, one is less likely to encounter danger or harm. Too severe or rigid superego representations seem at times paradoxically to inspire dangerous risk-taking, as if the child were trying to escape the hold of a restrictive conscience by seemingly heedless activity. However, self-protection or preservation which relies too heavily upon superego strictures is personally costly and likely to limit severely a variety of ego functions and satisfactions. The superego aspect of self-care needs to be distinguished from the complex combination of adaptive and self-caring ego activities which are the primary focus of this paper.

The capacity for self-care relates to the broader question of how infants and small children develop the capacity for self-regulation in general. Greenspan (1981) has identified three levels, or stages of learning, in the formation of psychic structures which subserve self-regulation. In the first stage learning is largely somatic or imitative, dependent on the global fulfillment of body needs by the caretaker. In the second or contingent stage, beginning at 6 to 8 months, affective exchanges with the object become more organized; although imitative modes may still predominate, internalization through identification with elements of the interaction with the parent occurs. In the third phase, beginning at 14 to 18 months, representational learning and more complex affect management and self-regulatory behavior takes place.

Sifneos et al. (1977) hypothesize that psychosomatic disorders are related to developmental failures in self-regulation. It is possible that the inability of such patients to recognize and verbalize their feelings grows out of failures of self-regulation in the somatic or preverbal period. Along these lines, Krystal and Raskin (1970) and Krystal (1977) have identified developmental disturbances and traumatic regressed states in substance abusers, concentration camp survivors, and sufferers from psychosomatic illness that we believe are related to self-care disturbances. Such individuals are unable to identify or verbalize their feelings and use them as guiding signals. Similarly, they also suffer because of impairments in self-comfort, self-soothing, and ultimately self-care. Because of difficulties in

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including these basic life-maintaining and affective functions in their self-representation, they turn outside themselves for care and self-governance.

The complex functions of self-care and self-protection which we are considering take shape largely during the period of representational learning. Precursors of these functions begin to develop during the somatic and contingent stages. It is possible that older children and adults, who have a good capacity for self-soothing or self-nurturing but poor ability for self-protection, may have identified strongly with nurturant qualities of caretakers during the somatic and contingent periods, while failing later to internalize the more complex representations out of which caretaking and self-protection are structured.

Mahler's (1968) observation of toddlers are consistent with those of Anna Freud and highlight the early appearance of such vulnerability in certain children. Using the case of Jay, Mahler explores how the mother's failures in attending and remaining vigilant as the toddler physically separates from her and explores his environment result in the child's becoming oblivious to dangerous situations. Mahler describes Jay's inability to exercise restraint of his impulses and a recurrent tendency to invite danger as a result of disorientation in space, lags in reality testing, and a tendency to overlook obstacles in his path. Mahler traces some of the origins of Jay's incautious behavior to his mother who maintains a troublesome and bizarre distance and fails to protect Jay's body as he carelessly moves about. Jay obviously was precocious in his locomotor development and was therefore in even greater need of a mother functioning as an auxiliary ego to anticipate and protect him from harm.

One of us (E.J.K.) had the unfortunate opportunity to witness a case in which a similar combination of a child's advanced motor skills and aggressive exploratory behavior and the parents' lack of vigilance led to the child's death. Bill, an 18-month-old, very active, likable, black child, was the son of a patient participating in a methadone maintenance program. He frequently attended his father's group therapy sessions because the baby's mother worked at a full-time position as a secretary. The parents were an attractive couple who cared deeply about

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each other, but the father's long-standing addiction to opiates left him discouraged and brooding and his wife depleted.

During the father's group sessions Bill would actively bolt around the large conference room in which the meetings were held. He was noted to pick up anything on the floor that appeared "mouthable," whether edible or otherwise, and put it in his mouth. He frequently stumbled, banging various parts of his body, usually his head. He seemed to sustain his bumps and bruises with impunity, cried rarely, and often appeared to be amused by the looks of shock and startle of the adults in the room. Unfortunately, his father usually was not one of those who was alarmed by and concerned about Bill's behavior and injuries.

Around 10 o'clock one morning Bill was discovered to be cyanotic and apneic in his crib. He was rushed to the hospital and placed on artificial life-support systems. He succumbed 10 days later. Subsequent to his admission the staff reconstructed that the child had gone to the refrigerator the previous evening and had drunk a mixture of fruit juice and methadone belonging to his father. Because of the gradual onset of action, Bill had played normally for a while and had then been put to bed by his mother. Unfortunately, neither parent realized that the child had ingested what for him was a lethal dose of narcotics.

In view of the many real dangers in the environment, it is a wonder that children do not more often suffer serious injury and death. That most children escape serious harm suggests how well most parents take care of them, as a result of which they may rather early acquire a capacity to anticipate and avoid danger. The works of Stechler and Kaplan (1980) and Virginia Demos (personal communication to John E. Mack) suggest that, beginning in infancy, a subtle balance exists between the parents' permission for the child to take initiative, to risk and explore, and the parents' protective function, which keeps the risks within reasonable bounds or creates for the child a self-protective representation.

Using video tapes, Demos has documented a range of responses of mothers to the exploratory initiatives of their children. Some mothers allow a rich exploration of the environment up to the point of danger and then set appropriate limits

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in a finely tuned pattern of interactions. Others show little interest in the child's undertaking and interact only minimally with the child. Gradually, through reciprocal interactions between the small child and his caretakers in the context of explorations of the outside world, the child acquires mental representations of danger, the capacity to anticipate harm, and the ability to renounce unduly risky sorts of gratification.

The acquisition of the capacity for self-care is promoted by intricate, often subtle, reciprocal communications between a child and his parents. For example, at the age of 22 months, Chris appeared to all who encountered him as a rather reckless, wild boy. He would carom from one piece of furniture and one person to another, sometimes glancing up at his mother with devilish glee before heading off on a new, cyclonelike path. Taking a certain delight in the child's rambunctious, explorative nature, the mother would tolerate a great deal of such activity, but as tensions would mount, she would after awhile "just blow." When he reached the limits of her tolerance, or was in any danger of hurting himself or destroying property, she would make clear in unequivocal terms that "that was it." He was to stop and to go no further. In fact, Chris developed an interest in rock climbing and went on expeditions in which a group would scale precipitous cliffs. His father, a circumspect and thoughtful man, worried about these ventures. He did not stop Chris, but he insisted that there be adequate adult supervision, that Chris learn everything he could about mountain climbing, and that he use proper equipment at all times.

Chris's parents did not simply put a stop to his behavior or demand that he control his impulses. Each parent in her or his way took pleasure in the child's motor skills, his explorations of the world around him, and his mastery of new challenges. They clearly valued him and his efforts at self-development. But, recognizing the danger involved, they set clear limits, thereby conveying the message: we love you and deeply respect that you wish to express yourself and your aliveness and to learn about the world. But we want to protect you, and we do not want you to be hurt or to damage anything else. So we will limit the risks that you will be allowed to take. We wish to get across to you that we love and value you enough to protect you, that you are a being worth protecting.

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There is clear evidence that Chris incorporated these messages, which became part of his self representation and ego functioning. He learned to master, first as a 2-year-old, and later in childhood and adolescence, the challenges he undertook. Chris was a boy who from early on liked to "do it my way." The thrust toward mastery, from which he derived satisfaction and considerable self-esteem enhancement, characterized Chris's functioning. Although he clearly was overcoming fears in relation to danger, his activities were not primarily defensive in their function.

We can see in Chris's case, and that of many children like him, that the function of self-care is intimately related to the development of self-esteem. The capacity for self-care grows in the context of a loving parent's communication that he or she values the child and therefore considers the child worth taking care of. The child incorporates this message and comes to value himself enough to protect himself from injury. A complex of functions—expressing pleasure in motor exploration, anticipating danger, setting limits upon oneself when danger is discerned, postponing or modifying the activity to make it safer and more secure—all these depend on valuing oneself enough to invest in self-caring. Small children and adolescents who, in contrast to Chris, take excessive risks and engage in dangerous rebellious behavior show an absence of self-care functioning. Such behavior may be indicative of pseudomastery. Exaggerated risk-taking is accompanied by denial of fear, which is not mastered. In such instances the self as subject undervalues the self as object and permits undue risks to be taken. True mastery is associated, as in Chris's case, with relatively little self-destructive risk.

A distinction should also be made between self-care, in the sense of taking care of, looking after, or protecting oneself, and self-comforting or nurturing. Many individuals are quite capable of soothing themselves, being "good" to themselves with food, alcohol, music, or even hypochondriacal behavior. Such individuals may readily stay home from work with minor illnesses or make frequent trips to the doctor. But self-comforting activity of this sort may not be associated with a genuine

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capacity to look after oneself realistically or to guard against excessive risks and dangers.

Yet, even if a reasonably good capacity for self-care has been acquired, it is, like other ego capacities and functions, subject to erosion and regression, as the following case demonstrates. Walter was a 12-year-old black boy, who, by his own admission, was ordinarily conscientious and always tried to do what his parents wished. He had been admitted to the hospital after accidently burning his legs while starting a power lawnmower. He described in some detail how he usually would carefully wipe off any residual gasoline and then pull the starter rope to the motor. On this occasion he somehow had neglected to do this. When he started the motor, it suddenly burst into flames. During his hospitalization the psychiatric liaison service was asked to see him because of his excitability and exaggerated sensitivity to pain. The two psychiatrists who saw him learned that there were two small children at home, a sister, aged 2, and a baby brother, a few months old. With a mixture of pride and irritation, Walter described how his parents looked to him as a big brother for assistance in taking care of his younger siblings. He also indicated that he had had his own room until he had been displaced from it by his baby brother. In the course of the evaluation Walter revealed that his usual attentiveness and caution with the mower had not been present because of anger, irritation, and preoccupation with his changed status in the family.

While in this case the boy's immaturity in combination with specific conflicts and stresses led to what one hopes was a temporary lapse in self-protection, there are other cases in which the capacity for self-care develops unevenly. A 28-year-old single, professional woman in analysis functioned in a highly capable fashion, handling the stressful, at times physically threatening, requirements of her job with unusual intelligence and skill. Working in a field close to that of her highly competent father, she could "look after" herself most effectively. Since age 4 she had suffered from moderately severe attacks of asthma, which continued in her adult life. Her view of her capacity to handle the illness was unrealistic, and as a result she sometimes used poor judgment. On several occasions during the analysis she

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had permitted asthma attacks, for which there was a clearly effective medical regimen, to reach the point where breathing was severely compromised and her life threatened. The asthma had been heralded in childhood by a severe attack which brought the patient to the point of coma before its nature was discovered in the hospital. The asthma became the arena in which an anxious struggle occurred between the patient and her mother. Constantly fearful for her daughter's safety, the mother held her in an intimate bond, anxiously protecting her and conveying the message that true autonomy was threatening to the mother's survival. The patient failed to develop independent skills in self-care in relation to her health, relying on others to rescue her when asthmatic attacks reached crisis proportions. Sometimes she wistfully communicated to her analyst her longing for a "self-management company." The patient's parents also had failed to protect her as a small child from the violent assaults of her troubled older brother. As a consequence she was drawn to the religiously observing Roman Catholic family next door, who, in their elaborate system of rituals directed by an all-powerful God, seemed to have a way of providing protection from harm for small children.

Specific fantasies, growing out of disturbances in narcissistic development, may interfere with self-protection and self-care. Most important of these are wish-laden, grandiose ideas of protection that interfere with the capacity to guard oneself from danger. There may be the idea, for example, that no harm can befall one, that no matter what risks are taken, a powerful being will look after, protect, or come to the rescue. Often this fantasy is acted out dangerously in trying to rescue others. In these instances the "rescuee" represents the endangered self of the rescuer. The vulnerability and absence of self-care become manifest in the consequences which befall the rescuer, often at the hands of the rescuee, in the course of misguided though "well-meaning" rescue operations.

The study of children who are accident prone, injure themselves, and become involved in dangerous activities offers an opportunity to understand some of the predispositions and vulnerabilities which result in impairments in self-care. Such vulnerabilities in children also allow for comparisons with children,

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such as Chris, who are not so inclined and enable us to consider what forces compel accidents and self-injury. But even more important, they provide an opportunity to consider the psychological structures and functions that ordinarily stand in opposition to or protect against danger and harm. Several reports (Frankl, 1963), (1965); (Lewis et al., 1966); (Malone et al., 1967) provide vivid examples and vignettes of children and adolescents who suffer injuries and accidents. Although these reports shed light on important determinants that compel the dangerous activities and behavior of certain individuals, they consider only in passing, if at all, the factors that more usually protect against injury and accidents. As in the case of the adult literature on accident proneness, these reports tend to place undue emphasis on drive theory and aggressive instincts, to the exclusion of other considerations (e.g., structural and maturational deficiencies), in accounting for self-injuries and destructive behavior.

Reviewing problems of self-preservation and accident proneness from a developmental perspective, Frankl (1963) presents many compelling accounts of accidents and injuries sustained by normal and disturbed children and adolescents. She seems to appreciate that among healthy children the caring and protective functions of the parents (or substitutes) are gradually taken over by the child in the course of normal development. The failure to take over these functions leaves the children more susceptible to harm and is the result of deprivation of object love and a lack of cathexis of the child's body. However, in her subsequent discussion and formulations, she repeatedly attributes accidents in childhood and adolescence to conflicts relating to impulsivity, superego representations, and (unfused or defused) aggressive instincts turned on the self. Her observations are graphic and clear, but suggest alternative mechanisms and interpretations. She presents, for example, the case of Eric, who was 14 years old when he put his eye out with a dart by pulling on a string that he had attached to the dart as a means of retrieving it (p. 477f.). Frankl interprets this unfortunate accident as the result of the boy's turning aggressive feelings against himself. She supports this interpretation with Eric's own admission that the self-injury was a form of attack on the

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parents aimed at disappointing and hurting them and making the prospects of success in school less likely. Most striking in Eric's case and Frankl's other cases is the absence of elements of caution, worry, anticipation, or other self-protective measures.

In a study exploring the determining factors involved in accidental ingestion of poisons by children, Lewis et al. (1966) carefully evaluated developmental factors and family influences in 14 children (7 boys and 7 girls ranging in age from 14 to 43 months). These children were compared with a control group, for whom it was assumed that the availability of poison and the child's ability to explore the environment were the same. The most important factors in the accidental ingestion were developmental characteristics (e.g., motor skills, exploratory and imitative behavior, degree of negativism) in the child and the quality of the mother-child relationship at the time of the accident. The latter in particular involved the way the mother organized the family environment, which in this study appeared to have been seriously disrupted within a year before the poisoning event in the majority of the cases. Two factors loomed large as disorganizing influences on the families of the children: (1) a recent birth or death of a sibling; and (2) a loss of adult support for the mother. In this study, spatial or physical elements in the environment invited an accidental ingestion by children who displayed high exploratory activity, superior motor skills, but poor impulse control. These factors combined with a "maternal depletion" that was present in all the cases in which the ingestions occurred. The depletion state consisted of a relative exhaustion of the mother's psychic or emotional resources as a result of inadequate support or a sudden decrease in assistance from other adults upon whom she depended, most usually the husband or the mother's mother.

Lewis et al.'s (1966) observations and conclusion underscore the importance of the mother's caring and protective functions in preventing dangerous behavior in children. Their work has implications for understanding how lapses in the early mother-child relationship and maturational lapses contribute to later vulnerabilities in self-care. The authors suggest that most children do not ingest poison because in the usual closeness of the mother-child relationship the child senses and anticipates the

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mother's disapproval of a dangerous act and responds to her guidance to avoid danger. In contrast, when the mother suffers from depletion states as a result of loss or stress, she is less attuned to the child and the positive bond of care and mutual attachment is disrupted. The child is then guided more by the wish to satisfy his own explorative curiosity and/or negativistic pleasure rather than the pleasure of pleasing mother. The authors stress that the timing for the establishment of such functions as motor skills, impulse delay, anticipation, and reality sense, all of which require some degree of inner guidance, varies from child to child. We would add that the establishment of these and related functions early in life is crucial for assuring ego capacities for self-preservation and self-care later on.

Studies of children from extremely disrupted environments, such as urban slums or poorly run orphanages, provide dramatic evidence of how experiences from such backgrounds can seriously warp, distort, and impair survival skills at an early age. Using a nursery school as a socializing and therapeutic setting, Malone et al. (1967) observed the disabilities of a group of children who came from disorganized lower-class families in an urban slum of Boston. In particular, their findings about the children's motor activities and appearance vividly demonstrate what we have referred to as impairments and deficits in self-care. The children "seemed to lack any self-protective measures, being careless with the use of their bodies and seemingly not trying to prevent injuries … [and] accidents and injuries were usually not accompanied by expressions of appropriate affect" (p. 57). A general lack of body care, heedlessness, and absence of caution were evident as they "carelessly careened around the room stumbling and bumping into things, tipping over chairs or toys and falling off the climber, slide or wings" (p. 140). The authors stress that such behavior was even more significant in view of these children's otherwise good to advanced motor skills (p. 140f.). Malone et al. poignantly describe how the teachers actively had to intercede and substitute their own protectiveness and caution to avoid injury. But through repeated intervention, instruction, and growing attachment to the teachers, the children seemed to exercise growing caution and to learn to request assistance. Strikingly, the authors also

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observed reversion and regression to incautious behavior as a consequence of parental separation, harsh punishments, or parental criticism.

Frankl (1963) describes similar findings in children from residential nurseries who had suffered discontinuities in early mothering and subsequent relative deprivation of object love and unsatisfactory care. She indicates that there was a much higher incidence of accidents in children who received unsatisfactory residential care. She contrasts these with children raised in nurseries where they felt greatly valued and appreciated by the staff and where accidents were unheard of or could not be recollected. Frankl invokes the mechanism of aggression turned on the self to explain the injuries sustained by the children who suffered discontinuities in object love and care.

Those who try to explain the behavior of children from extreme environments often fail to distinguish between self-neglect and self-hatred. In fact, Anna Freud (1965) makes this distinction when she differentiates maturational defects from "turning aggression on the self" (p. 76), the latter being a defense mechanism adopted by the ego in conflict situations. Although aggression may play a part in self-destructiveness and accidents in children, we believe that there is more involved than aggression turned on the self or a self-punishment motive. It is likely that aggression in these cases brings about ego disorganization, which in turn causes the individual to become less able to exercise the judgment, control, synthesis, reality testing, and related functions that otherwise assure adequate self-care and protection.

We conclude this section by presenting an example of normal children at play in whom elements of self-care were evident at a relatively early age. The play situation provided a glimpse of one child's appropriate fearfulness and inhibition of impulsive action in the face of what surely constitutes a most common challenge to self-protective aims. Three children aged 6, 9, and 10 were happily running around in a backyard. The two older children decided to climb a tree in which there was a makeshift platform-treehouse about 12 feet high. They appeared to do this with skill and ease. A noticeable change in the lighthearted tone of the play could be observed at the point when the older

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boys began to challenge the younger boy on the ground below to join them. As the boys' challenges escalated to taunts and teasing, the younger boy at first became unhappy and tense, then more obviously fearful, and began to cry. Despite the two boys' continued derision, the younger boy refused to join them. Notwithstanding the obvious intense pressure of his playmates and his own shame about his inability to keep up with them, he seemed to respond more to his own fear and apparent awareness that he did not possess his playmates' strength, coordination, and skill to climb the tree.

Our observations of this realistically fearful boy, as well as the cases we cited where such fear was absent, indicate that the functions for self-care and self-protection begin to develop early in life and may operate (or be deficient) in young children. The capacity for self-care is complex and involves multiple affective and cognitive processes, component functions, mechanisms of defense, ego functions such as signal anxiety, reality testing, judgment, control, delay, and synthesis, as well as relatively stable superego functions. Cognitively, self-care involves a capacity to perceive, realistically assess, integrate, and attend to relevant cues in the environment. Affects are used as a guide for appropriate action, or as signals to institute defense mechanisms or avoid potentially harmful or dangerous situations. Gradually, in the context of experienced parental protectiveness, the child assumes the process of self-protection and care and incorporates those family and societal rules which help to insure his safety. When present, these functions operate automatically or deliberately to guide us away from danger or, once in trouble, to guide us out of difficulty. It is the collective action and interaction of these cognitive and affective processes that we refer to as the ego function or capacity for self-care.

Self-care functions become internalized through the ministrations of the caring and protection of parents. In the earliest phases of development self-care begins with incorporative processes in which the nurturing role of the mother contributes to a rudimentary sense of harmony and security (Meissner, 1979). In subsequent periods internalization of the caring and protective qualities of the parents occurs as the child, under their watchful eyes, encounters and explores the environment. If the

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parents' attendance to and care of the child are good, the developing child acquires a capacity to care for himself or herself and to protect against and anticipate harm and danger.

CONCLUSIONS

We have reviewed a number of reports that document and interpret a range of human problems involving self-injury and harm, including impulsivity and accidents in children. Most of these accounts lay heavy emphasis on drive theory and a motivational psychology that places aggressive drives at the heart of most forms of human self-destructiveness. In this presentation we have considered the functions which ordinarily stand in opposition to these destructive trends and how normal self-care and self-protection develop.

As with most human functions and reactions, problems of survival and self-destructiveness are multiply determined. Much of human destructiveness, including the self-directed form, may of course be compelled, defensive, or specifically motivated. In seeking to identify and understand impairments in survival skills and self-care, we have stressed a developmental perspective focused upon how early nurturing attitudes and the caring and protective functions of parents, particularly the mother, are internalized and transformed into positive attitudes of self-regard and adequate structures and functions assuring self-care and self-protection.

We have shown that self-care capacities are closely associated with positive self-esteem, for the developing child must internalize the conviction that he is a being of value, that he is worth protecting, before he can care for himself. We have noted the dysjunction which sometimes occurs between self-soothing or self-nurturing and the full capacity for self-protection or self-care, suggesting that the former function may grow out of earlier more somatically based experience, while the latter depends on more highly structured representational learning.

This report can only be considered preliminary in attempting to explain the complex relationships between self-regard, self-care, and human self-destructiveness. Although self-care functions are fundamental for survival, they build upon an

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earlier sense of well-being and harmony within the self. It is most likely from such early subjective states that we derive a sense of optimism and "aliveness." When this rudimentary sense is lacking or violated, despair and feelings of "deadness" may later result (Kohut and Wolf, 1978); (Friedman, 1980).

In the developmental model we have presented, self-preservation is contingent upon the establishment of particular structures and ego functions. Furthermore, self-destructiveness results as much from lapses and failures in self-care and protective functions as it is specifically motivated, overdetermined, or driven. Further reports and explorations in this area must ultimately consider self-care functions in dynamic interaction with other operative factors. We have only touched, for example, upon how basic attitudes about the self, starting with beginning self-awareness and self-experiences, are crucial for making one feel that the self, and ultimately existence, is worth preserving. We need to understand further how early failures in the development of a cohesive sense of self and the resultant search for self-comfort and self-worth become so overriding, that matters of self-care and survival often remain tragically subordinate, secondary, and underdeveloped. We also need to consider how anger, rage, depression, aggression, or other affect states erode or interfere with established self-care functions. We need to explore especially how conditions of depletion, anergia, and inertia associated with intense affective states may cause a lapse or regression in self-care. Further study is needed, for example, of the extent to which self-care functions become relatively immutable and autonomous once established or, in contrast, may under particular circumstances that burden or threaten the ego become temporarily or permanently lost.

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