The PANY Bulletin

Psychoanalytic Association of New York
Volume 39, Number 3 Fall 2001

Book Review:

When the Body is the Target: Self-Harm, Pain and Traumatic Attachments
by Sharon Klayman Farber

Jason Aronson, 2000, 580 pp.
Reviewer: Leon S. Anisfeld, D.S.W.

In this well-written, well-researched, and thorough volume, Sharon Klayman Farber integrates a number of sources which explain those addictions characterized by dependence on substances and/or behaviors that are not, in and of themselves, addictive by nature (that is, physiologically or chemically), as compared with those substances, such as heroin, that have concerned us for decades. Possession of the familiar addictive substances has usually been made illegal, as are the activities generally engaged in in order to procure the substances. The activities, in addition to the risk and legal penalties involved, also entail self-degrading aspects, such as prostitution and theft in order to support the drug habit.

Another group of substances (such as food) or behaviors (such as tattooing, self-mutilation, binging and purging), not typically used to satisfy the physiological craving of an addicted user, are the subject of the volume under review.† Addiction to these substances or behaviors often requires the participant to avoid or overuse/misuse substances. Examples would be anorexia and bulimia. Or the behavior would be considered self-punishing or self-destructive, as is the case with hair-pulling, bodily mutilation (cuffing, piercing, etc.), tattooing, subjection to self- or other-imposed physical pain or "punishment" such as whipping.

There is generally no legal consequence for denying oneself food or cutting oneself because there is no illegal substance use or behavior that is visible in such a way as to attract legal notice. There is no conventional "victim" or "perpetrator", no crime. Yet we cannot call these "victimless crimes" either.† They are "crimes" that the individual solicits and would probably not want others to know about. This last point introduces the fact that these behaviors, though compulsive, are secretive and hidden, lest the "addict" or "abuser" suffer the shame that often accompanies the substance or activity misuse.

Because the symptoms of the various addictions discussed by Dr. Farber involve self-harm and shame, they are often analyzable in terms of the mechanisms of splitting of the ego and superego-administered self-punishment. There is also the mechanism described by Waelder in his 1936 paper on multiple function, which may be invoked to make the various behaviors more comprehensible as compromises among the psychic agencies, the repetition compulsion, and the external world.

Farber's book is written in a style and with the use of language that feels authentic with regard to her subject matter. There is a genuinely manic affective tone in those paragraphs that describe the loneliness, desperation, and helplessness/hopelessness of people who tie themselves in inescapable knots. Similarly, she dramatically evokes the horror of a culture that subscribes to the emaciated "beauty" of the anorectic, or the suffocating smell of vomit interspersing courses of bulimically ingested food without taste. This portion of the book, focusing on the illnesses that fall within the rubric of eating disorders, is thorough and at the same time quite educational. Farber demonstrates the complexities of helping these food abusers to return to a reality in which they can live.

The book is written from both a theoretical/philosophical perspective and from a clinical vantage point that is primarily psychoanalytic. Farber includes valuable sections that analyze clinical material from the viewpoint of culture, filling in those gaps left by a purely psychoanalytic orientation with a discussion of the ways in which the role of early trauma is explained by attachment theory. Attachment theory appeals to Farber because of its appreciation of how traumatic early separation from the primary caretaker accounts for later self-harm and self-inflicted pain. Her vignettes provide helpful demonstrations of how detailed knowledge of the patient's separation-individuation experiences can be clinically used to help individuals in overcoming the damage emanating from that genetic period, particularly the rapprochement sub-phase.

Farber's book, drawing heavily on attachment theory in understanding the origins of the kinds of addictive pathology described above, provides an engaging opportunity to rethink the continuing dialectic between† Freudian drive theory and Bowlby's belief in the centrality of attachment issues in human development and psychopathology. Her exhaustive and scholarly review of all relevant theoretical viewpoints sheds light on a previously under-studied group of clinical problems and invites the clinician to think about patients from a very broad and informed conceptual framework.