When the Body Is the Target: Self-Harm, Pain, and Traumatic Attachments (Book Review)

Author:  Farber, Sharon Klayman
Publisher: Jason Aronson
Reviewed By: Thurer, Shari, Vol. XXVI, 4 (Fall 2006), pp. 74-75

Paradox is the stock in trade of psychoanalytic psychotherapists. It’s the stuff they analyze, that which distinguishes them from other sorts of therapists who tend to take things more at face value. Without patients’ self-contradictory feelings and behavior, without an unconscious that sneakily belies conscious thought, there would be no psychoanalytic theory, no underlying dynamics, nothing to explore and decipher—fewer intellectual thrills for psychoanalytic therapists who tend to delight in untangling paradoxical impulses, especially when the disentanglement proves to be therapeutic.

But, paradoxically, many of us shy away from working with patients whose pathology is the most paradoxical of all: those raging, desperate individuals who, instead of seeking to ameliorate their pain, seemingly amplify it. These patients repeatedly engage in extreme self-harm such as compulsive cutting, scratching, scarring, piercing, tattooing, erotic vomiting and starvation. Their predicament may pique psychoanalytic curiosity, but their gruesome behavior is so eerily disturbing that it often feels too overwhelming to many solo practitioners, especially ones unconnected to a clinic. Besides, many of these patients are character-disordered, unreflective, and in crisis. They are given to destructive repetitions and often have a hard time attaching to the therapist. In other words, they are most often viewed as poor candidates for insight-oriented treatment. And they frequently are unable to pay for treatment. So serious self-mutilation, self-induced vomiting, and violent laxative abuse are not the usual grist for the psychoanalytic mill. Thorough, nuanced, long-term case studies of extreme self-harm are relatively sparse.

Sharon Farber is one of the increasingly rare psychoanalytically trained clinicians who have chosen to treat this challenging cohort and investigate the dark meaning of their pathology. Her excellent book, When the Body Is the Target is the result of her inquiry. It is an encyclopedic review of the literature and a report from the clinical trenches of often-successful treatment as well as a summary of her data-based research. Farber attempts to connect the dots from the origin of the masochistic impulse to its manifestation in bodily self-harm, arguing that this freakish behavior seems to be a repetition of violence that individuals had suffered (or witnessed passively), that is now performed by the victims themselves on themselves and has become an irresistible habit. These folks, she persuasively asserts, are speaking via their body. Their self-harm may actually serve to regulate their intolerable emotions and allow them to survive. It is a continuation and exaggeration of impulses that are available to us all.

By making sense out of seemingly senseless behaviors, by rendering these patients’ actions human and understandable, Farber promotes empathy, a necessary component of treatment. In contrast to many psychoanalytic practitioners, she argues (and demonstrates!) how psychoanalytic psychotherapy (informed by attachment theory), may be clinically useful, even in the face of stormy transference/counter-transference feelings.

Farber’s promiscuous intellect is evident as she locates images of self-harm all over present day culture. From the glamorization of S&M, to the ubiquity of wraithlike models, to make-up named “Blood” and “Fetish,” we are subject to subtle persuasion to do appalling things to our bodies. Culture provides a convenient and trendy template for the psychosomatic expression of victims’ paradoxical attachment to abuse. It can easily disguise the repetition compulsion, the ironic urge that some victims experience to repeat the pain they had endured, making self-harm like severe anorexia or piercing sometimes appear to be nothing more than ordinary vanity.

Farber discovers aspects of self-harm in many contexts, thereby taking it out of the exclusive realm of the bizarre. She explores its surprising connection to the elemental experiences of religious purification. She finds self-harm behavior in other species, like tropical birds in captivity that pluck out their feathers. She points out that nail biting, symbolic of more extreme self-mutilation, might be viewed as an evolutionary remnant of ancestral grooming behavior. She goes on to point out that, anthropologically speaking, male ritual nose bleeding in New Guinea may be viewed as self-harm. So may the Kellogg brothers’ nineteenth century sanatoriums, where colonic purging, exercise machines and rigid diets were the rule. It is everywhere in literature, she adds, such as Margaret Atwood’s Cat’s Eye and Franz Kafka’s The Hunger Artist. Clearly self-harm is not limited psychiatric patients.

While Farber synthesizes many theories of the causation of self-harm, she prioritizes attachment theory, which, she argues, offers the richest potential for integration of concepts from other disciplines, including evolutionary biology, ethnology, psychoanalysis, cognitive psychology, chaos science, and nonlinear dynamics. This theory emphasizes the importance of a good early parent-child relationship for an ability to form future healthy attachments. In the absence of good parenting, and especially when children suffer trauma or abuse, they may use self-harm as a form of self-medication to regulate moods, relationships, and self-esteem. The reenactment of earlier trauma may be an attempt at mastery. The localized pain may feel far more tolerable than their diffuse emotional suffering. In instances when the abuser proceeded slowly and over a period of time, the child victim may have had an unfortunate opportunity for sexual excitement to build slowly and gradually, as it does in adult foreplay, and to be experienced as loving and sensual... hence, the later confusion of pain with pleasure. Perhaps the self-induced pain simultaneously gratifies a need to punish the victim for the taboo pleasure. Also, according to Farber, many victims reacted to their abuse by developing an ability to dissociate which enabled them to engage in “doublethink,” and thereby ironically become, as they mature, their own predators.

Farber discusses symptom substitution, why self-harm behavior seems to be more common in women and why it is contagious, a fact I observed personally when I taught at a university. Her data based study suggests a strong association between binge and purge behavior and self-mutilating. I cannot hope to do justice here to many complicated byways of Farber’s thinking regarding her rich clinical material. Her many poignant case vignettes will grab even the nonprofessional reader, as will the pointed examples of self-harm drawn from memoirs, novels and film that are interwoven throughout the narrative and buttress her points. The descriptions of her own therapeutic work convey warmth and talent as a clinician, an ability to sit and listen empathically to horrific life stories, as well as an enviable capacity for enduring personal insults and rage directed at her by her patients.

The latter part of Farber’s book discusses her method of psychoanalytic treatment, which she derived in part from Gertrude and Rubin Blanck, as well as Hans Loewald. The work of treatment, in her view, is to provide an environment, in which a safe and secure attachment relationship can grow, and to hold and contain the patient while decoding their bodily enactments. Like the Blancks and Loewald, Farber embraces a model that does not see either conflict or deficit as an all-or-nothing proposition, but is based on the concept that building ego functions increases the structuralization of the ego, which can ultimately make self-harming patients more capable of sustaining the demands on their fragile egos of a more intensive psychotherapy. This is accomplished by building in patients a capacity to reflect upon their experience, to enable them perform a symbolic leap from body to mind to speech. Meaning is constructed out of chaos; words become the means for expressing and regulating affect. Farber suggests that the therapist and patient play with words, ideas, fantasies and meaning in a safe transitional space.

The appendix, The Study and Transitional Space, describes Farber’s research, elaborating on her idea that the study itself should be a transitional space. By this she means that the data collection instrument used should ideally be experienced by the subject as an invitation to engage in an authentic dialogue (in the sense of Martin Buber’s “I-Thou” relationship).

Though attachment theory goes far to explain how self-harming behavior might develop in people who grew up in neglectful or abusive homes, I wonder how it might be useful for explaining eating disorders and cutting among individuals who have grown up in average acceptable environments. Farber’s analysis begs the question of whether these self-destructive inclinations and practices may occur among folks who had happier childhoods. She also skirts the issue, posed by queer theorists, who argue that all behavior, even self-harm, is okay. But a completely permissive attitude toward all alternative practices is a slippery slope. I recently read gay activist/journalist Michael Bronski’s (2002) detailed account of his erotic encounters with consenting adults that entailed the use of razors, Exacto blades and scalpels. He described these “blood sports” as tenderhearted. Does this high functioning individual need treatment? Would Farber think so? If not, where would she draw the line?

When the Body Is the Target is impressively comprehensive and jargon-free. Apart from its contents, its up-to-date bibliography alone makes it a must-read for graduate students. But the book is a worthy addition to even a seasoned clinician’s library. By unraveling some of the paradoxes of self-harm, by demonstrating a successful method for dealing with individuals who engage in this behavior, she has enlarged the scope of psychoanalytic treatment and provided hope for an underserved group. She earns our gratitude for doing so. My only criticisms, and these are minor, would be a lack of concision and an inappropriate book jacket. The cover is taken from a painting by Edouard Manet of a beautiful woman serenely gazing at something beyond the viewer. I suggest that one of the paintings of raw meat dripping with blood by French expressionist artist Chaim Soutine might more accurately reflect the psyche of the suffering individuals Farber has sought to understand and treat.

Shari Thurer

References

Bronski, M. (2002) Dr. Fell, In Fairfield, S. et al. Bringing in the Plague: Toward a Postmodern Psychoanalysis, edited by (New York, Other Press, 2002).

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