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Book Review - When the Body is the Target Self-Harm, Pain, and Traumatic Attachments

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

Sharon Klayman Farber

Reviewed by Lorna Goldberg, M.S.W., L.C.S.W.

Many years ago, before vacation periods, I would invariably get into an accident of some sort. I had acquired an attitude about myself as someone who was just clumsy and accident-prone. After I had begun therapy, I had a minor car accident before a long-awaited summer vacation. When I entered my therapy session, I offhandedly told my therapist about the accident, but proudly dismissed it, declaring, “I’m not going to let this ruin my vacation.” My therapist was not so ready to brush this off. He encouraged me to explore all the feelings that I had felt before and after the accident. This continuing process of looking at the underlying thoughts and emotions that are expressed in the self-harming action of accident-proneness has allowed me to begin to live a more accident-free and emotionally free life.

Dr. Sharon Farber captures this concept and so much more in her beautifully written book, When the Body Is the Target. From a conceptual point of view, in revealing the “mystery” of self-harm, she points out how self-harm is used to maintain the outward sign that something is wrong on the inside. Farber notes that some of us might self-harm in relatively minor ways, in behaviors (such as nail biting) that are low-key versions of the impulses that are more strongly expressed by severe eating disorders or self-mutilating behaviors. We are informed that self-harm is about individuals who cannot live peacefully in their own skin. When the Body is the Target focuses on those who experience their emotions not in their minds, but in and through the immediacy of their bodies. In the authoritarian world of the cult, self-reflection and “negative” feelings are discouraged and demeaned through the leader’s manipulations and doctrine, and interfered with through numerous thought-stopping techniques. The result of these limitations might be that the body becomes a central expressive source for the discharge and regulation of feeling, particularly pain and anger the cult member experiences. According to Farber, for those individuals who severely harm themselves, the predominant mode of self-experience is sadomasochistic pain and suffering. That is, physical violence is the language of those who lack the ability to use metaphor or symbols to express emotions or unspeakable pain; they use their bodies to speak for them. These ideas, all clearly presented, are fundamental to Farber’s understanding of self-harm and are useful for those of us who work with individuals who have learned that they must submit to the needs of others rather than allow the direct expression of their own needs.

The concepts in this book, while complex and psychoanalytically based, are written with clarity and without psychoanalytic jargon. For example, Farber emphasizes that self-harming behavior can be seen as a psychological symptom that is caused by more than one factor, serving multiple and paradoxical functions in the psyche in the individual’s attempt to feel better or gain relief. She shows the reader how this behavior, which is quite risky and potentially dangerous, allows those who are deadened by depression or dissociation to “come alive,” or, by contrast, how such behavior offers relief to those who experience the anxiety of constant hypervigilance. In this way, Farber views self-harm as playing an adaptive role and self-regulatory function in the life of the trauma survivor, by terminating a painful state of dissociation or hyperarousal.

In exploring self-harm’s connection to trauma as a causative factor, Farber explains how childhood shock traumas of physical and sexual abuse, medically related traumas, or the strain trauma of neglect are experienced as direct assaults to the body. If no one was present to protect and soothe the child at a time of overwhelming pain, the child might begin to repeat this hurtful experience through self-injurious body behavior in an attempt to regulate mood or states of hyperarousal. This scenario contrasts with the background of the protected child who develops the expectation of comfort from others and eventually repeats this positive experience by soothing herself and taking care of her body.[1] Although Farber touches on many psychoanalytic theories, she emphasizes attachment research and its connection to trauma. She particularly cites the work of Peter Fonagy and his associates to establish the relationship between a secure early relationship and the ability to be self-reflective and to know the minds of others.

The findings of Farber’s research study, presented in this book, suggest that it is the severity of the trauma suffered in childhood and adolescence, particularly the cumulative trauma of violent sexual and physical abuse maintained in a climate without secure attachments, that is a key factor in the development and maintenance of dissociation, self-injurious habits, and eating-disordered habits in childhood. The severity of the trauma also is significant in the development in childhood of a general sense of body alienation, which can contribute to the development of eating-disordered behavior, self-mutilating behavior, and other forms of self-harm later in adolescence and or adulthood.

However, Farber indicates that self-harm might not be solely the result of trauma experienced early in life. Self-harm can result from the ordeal of being under the influence of a powerful, manipulative, sadomasochistic leader who co-opts one’s ability to think critically and have ownership over one’s own body. Self-harming behavior in these instances is seen as the outcome of cult programming and cult-learned practices and rituals that create dissociative behaviors to enhance the leader’s influence and doctrine in which dietary restrictions or various forms of abuse are either encouraged or seen as acceptable. Those of us who examine the world of cults have seen how dietary restrictions or physical or sexual abuse often is redefined as necessary to increase the members’ level of purity. The acceptance of this destructive behavior is supplemented by the contagion and peer pressure of the group. In my work with former cult members, I also find that self-harm may be the result of an attempt to play out, through the body, a cult-induced message not consciously acknowledged by the former cult member.

Farber explains that, just as addictive alcoholism is a progressive disease, the behavior of chronic bulimics and self-mutilators follows a progressive course from preoccupation to ritual preparation (which helps to induce a dissociated mental state) to compulsivity (need to perform the behavior) to shame and despair. She considers that this behavior might reveal a psychological addiction to trauma, a compulsion to repeatedly and unconsciously reenact and express, through bodily self-harm, severe trauma suffered in childhood. Having been the passive victim of traumatic abuse in childhood, the individual will be compelled to repeat the trauma, sadistically inflicting violence on others or masochistically inflicting violence upon the self. Anger that is physically directed at the self is central to the life of the individual who has been abused and violated, leading to repetitive reenactments upon the body that have the potential to become dangerously out of control. Although Farber touches on this, I might more centrally suggest that these early abusive experiences (particularly, but not only, by those who suffered from sexual abuse) also have a libidinal component, and libido is interwoven with aggression in these acts.

I found the section of the book on clinical implications to be as illuminating and extensive as the previous sections on theory. Not only does Farber give the reader principles for working with this population, she also highlights these principles with vignettes from her own and other therapists’ clinical work. First and foremost, after a comprehensive understanding of the inherent power of these symptoms, Farber assures the reader that attachment to self-harm can be both emotionally and biochemically altered through the development of a secure attachment. The attachment relationship can serve as a bridge to the idea of the possibility of different relationships in the real world. These early relationships were quite destructively exciting and aggressive, and sexual feelings become mixed together in potentially destructive ways. Farber explains that the aim of therapy can be to transform harmful bodily enactments by building in patients a capacity to reflect upon their experience and make a symbolic leap from the body to the mind. Treatment addresses this pathological split between mind and body. In promoting this, Farber again emphasizes the necessity for the therapist to recognize the meaning of this behavior and the understanding that patients do what they do, no matter how hurtful, to feel better.

To begin to change this course of action, the therapist needs to moderate each patient’s harsh judgments about the self. For example, the patient might feel disgust at feeling turned on by the self-harming behavior. The tendency to have harsh attitudes toward these regressive episodes will need to be challenged, and it is an important step for the patient to develop empathy toward herself. If the therapist can explore all of this in a nonjudgmental fashion and begin to look at the connection to the past, the patient’s harsh attitude might be modified. Helping the patient link present behavior with repressed or dissociated feelings can not only aid in awareness of the full meaning of the behavior, but also increase awareness of feelings and the ability to put emotions into words rather than express them through enactments. Furthermore, Farber points out that the therapist’s attitude of strength, vitality, and humor is needed in order to tolerate the patient’s aggression (and seductiveness), and to resist either rescuing the patient (who might demand to be rescued), or getting pulled into retaliating during dramatic enactments that might occur. If the therapist can recognize and reflect on what has occurred, enactments that generate from the patient’s intense sadomasochistic relationship style developed in the past can be a positive and useful force that involves a corrective experience for the patient. In the process of recognizing and reflecting, the therapist must be able to contain powerful affects, listening to her own inner states and taking responsibility for her own feelings. Farber does an excellent job illustrating, with her own case material, how the therapist might handle all of these highly charged situations. She also suggests the need for taking on a body “caring” role in focusing on how the patient abuses or neglects the body. This focus can become a corrective experience for the patient while it also might lessen body alienation. Farber returns to concentrating on the adaptive role of the behavior. She suggests that the therapist might question, “What does the self-harm do for you? How does it help you?”

Themes of victimization and narcissistic entitlement, as well as boundary violations, might be played out by the patient with the therapist in treatment sessions. I particularly feel that Farber’s discussion on a patient’s sense of specialness and entitlement is quite helpful for therapists. For example, she wisely suggests that patients might need to look at how getting others to do what she wants might not always be to her advantage.

Farber encourages the therapist to use supervision or peer-group support, as well as to work collaboratively with other professionals, such as medical doctors, for the therapist’s benefit as well as the patient’s. In addition to a psychodynamic focus, it is important for the patient to be armed with a variety of coping mechanisms—i.e., cognitive-behavioral strategies for tolerating impulses to self-harm and to better manage the dysphonic affect associated with the impulse. Having these skills will lead to a patient’s feeling more in control of her impulses.

Farber has given those of us who work in the cult field a scholarly and clinically informative work about our patients who suffer and affect us in powerful ways. Many of our patients who are former cult members enter treatment and don’t initially reveal self-harming behaviors, either because of discomfort and shame or because these behaviors are habitual and dissociated. However, in time, patients often begin to share their secrets with us. Farber’s book not only contributes directly to our understanding of self-harm, but also indirectly increases our understanding and management of potentially harmful symptoms that patients might defend against through action and that might elicit strong emotions in ourselves.

Cultic Studies Review, Vol. 7, No. 3, 2008, Page

[1] Because it is commonly understood that men generally tend to be the perpetrators of violence on others, while women tend to be the perpetrators of self-inflicted violence and the targets of others’ violence, I will refer to these individuals as females.