Self-mutilation is frequently a symptom within the borderline spectrum of psychopathology. This chapter discusses work with a patient who cut herself periodically, focusing in particular on her preconscious fantasies of grandiose destructiveness and the role of aggression in the treatment relationship. This patient was neither a daily cutter, nor did she require major suturing; nevertheless, her cutting horrified her family and frightened the patient as well, because she saw it as both “crazy” and yet as an action necessary to prevent her from killing herself. Her therapy took place in a small, open, residential treatment centre in which a patient’s freedom to live daily life as fully as possible carries with it the responsibility to manage oneself and to use the collective resources of those around to assist with this. The work was relatively short-term, lasting about three months. The treatment produced for the patient genuinely surprising insights leading to a shifting understanding of the locus of her difficulties.