When the Body is the Target: Self-Harm, Pain, and Traumatic Attachments.

Abstract

Farber, Sharon Klayman. When the Body is the Target: Self-Harm, Pain, and Traumatic Attachments. Northvale, NJ: Jason Aronson, 2000. xxxiii + 580 pp. $60.00. This is the first book written by Sharon Farber, Ph.D., whose postgraduate work was done at the Institute for the Study of Psychotherapy. She has published little in professional journals but has presented at a few clinical and research conferences. Through her training, she began to question how the mind and body work together unconsciously to inflict harm on the body. Her book is the result of her studies and clinical work with eating-disordered patients who engage in self-mutilating behaviors. She writes, "I came to think that nail biting and other habitual behaviors were low versions of human impulses that were articulated far more powerfully by the severe eating disordered and self-mutilating behavior of the subjects in my study" (p. xix). The author has written a compelling and massive review of self-harm behaviors within a psychological and cultural framework. She integrates attachment theory with psychoanalytic, family systems, and cognitive-behavioral notions of self-harm, and through this process she articulates the meanings of self-mutilation in our patients' lives and the importance of understanding these meanings before we are able to help patients make changes. The book's four main parts review the cultural, historical, religious, mythological, and anthropological literature. In part I, "The Borderland of Self-Harm," Farber broadens the current concept of self-harm to include moral masochism, unconscious self-sabotage, disordered eating, as well as self-mutilation. The reader needs to ask if broadening the definitions of self-harm weakens or strengthens the concept of self-inflicted, nonsuicidal injuries. In my opinion, the inclusion of less direct methods of self-harm dilutes the true nature of the act which is defined as "... the direct deliberate destruction or alteration of one's own body tissue without conscious suicidal intent" (Favazza, 1996, p. 225). Farber's broad definition begs the question: Are the dynamics of indirect self-harm identical to those of direct self-harm? Expanding the definition of self-harm to be inclusive rather than a distinct entity leads to a lack of clarity. This practice has been abandoned by mainstream psychiatry in lieu of the practicality of the DSM in understanding and treating clinical symptoms. Part II, "Neglect, Violence, and Traumatic Attachments," links violence, abuse and neglect to self-mutilation and masochistic behaviors. Cutting, eating disorders, and other self-injurious behaviors are a sign that something has gone wrong in the development of self-regulatory functioning and the separation-individuation process. She calls into play Darwin's theory of natural selection, mythology, religion, and contemporary cultural thought about self-mutilation. She opines that humans were once prey for larger animals and then became predators to ensure survival. She then lyrically parallels this with people who harm themselves as initially being prey to the abuser and then becoming a predator to themselves through cutting and self-injurious behaviors to survive their psychic pain and torment. Part III, "The Body Speaks," explores the symbolization of self-harm and self-mutilation as a gestural articulation of trauma, with each methodically crafted scar reflecting a person's painful history. Cutting may represent an inability of persons to articulate their inner pain and to self-regulate their emotions so as not to be overwhelmed by them. Thus, feeling outer bodily pain is preferable to feeling horrendous inner psychic pain. Cutting, as with binging and purging, may become a way to control one's body as it had been controlled in the past. Farber reviews the gender differences in early versus a late adolescent onset of self-harm, aging, sadomasochism, and perversions. Patients' stories about their cutting, binging, purging, and other self-harmful, self-mutilating behaviors leads the reader to obtain a clearer understanding of the importance self-injurious behaviors play in maintaining emotional homeostasis and control. Part IV, "Clinical Implications," focuses on the utility of attachment theory, family systems, and psychoanalysis in helping patients gain the ability to self-reflect and heal themselves. Farber strongly supports psychotherapy as being "a safe attachment that has the potential to alter and even repair the attachments to pain and suffering encoded in the brain in those who harm themselves" (p. 353). The therapist's attitude and demeanor are critical to help patients get through this process. Working in isolation without support and consultation can set in motion a process in which the therapist becomes angry, detached, and blaming of the patient who then becomes traumatized all over again. "The overall task of treatment is twofold: first, to help the patient move from living primarily in the immediacy of bodily experience to living within a reflective self in a representational world; and second, for the attachment relationship in the treatment to serve as a bridge to new and different relationships in the real world" (p. 361). Because the therapist-patient relationship is the cornerstone of therapy, issues of transference and counter-transference need to be understood by therapists before they take on the challenge of these complicated, at times provocative, patients. Therapists must possess the ego strength necessary to maintain the secure, safe environment that patients need to express their anger and aggression. The appendix, "The Study and Transitional Space," is a description of the study Farber did that helped her understand the behaviors and treatment of patients who self-injure. She discusses the idea of a transitional space as "an intermediate area of experience between the researcher and the subjects" and the role this space plays in the treatment of patients who cut themselves. The appendix is thought provoking and helpful to the clinician as the author describes how her subjects felt about the very personal questions used to understand their behavior. In these times of biological revelations, we psychiatrists sometimes undervalue the importance of psychological and cultural insights for understanding behavior. Faber's book is a lengthy and always interesting read, but most psychiatrists, I suspect, will not devote the time and energy necessary to read it. More's the pity because it definitely is worthwhile and informative, albeit expensive. Cheryl Hemme, M.D. Assistant Professor of Psychiatry; Director Residency Training Program; University Missouri, Columbia