(Sharon Klayman Farber, PhD, and Jason Aronson, Northvale, NJ; 2000; 580 pp; $60.00)

Here is a deep, richly textured book by a psychoanalyst-psychotherapist-clinical social worker who loves to write, written primarily for clinicians who love to read. In a fluent, literary style, Farber engages in a thick brew of theory and clinical narrative.

Her own clinical background includes experience as a drug counselor, working with patients damaged in cults, conducting psychotherapy with children and adults, and engaging in specialized work with eating disorders patients. Through this, she came to study the relationship between eating disorders symptoms, self-mutilation, other forms of self-harm involving drug and alcohol abuse, compulsive sex, shoplifting, compulsive shopping, compulsive risk-taking and related phenomena. Data from her own formal study of 99 patients with bulimia nervosa, 75 of whom were severe self-mutilators and 24 of whom self-mutilated mildly or not at all, provide systematic findings. Material from her clinical practice provides detailed, nuanced vignettes.

To understand these phenomena, Farber calls upon a wide array of perspectives. These include sources from many schools of thought, including biological psychiatry, psychobiology, neuropsychology, ethology (the scientific study of animal behavior), evolutionary psychology, ethnology (the anthropologic study of cultural origins and factors influencing cultural change), anthropology, and culture. So broad a spectrum of images, allusions and points of reference are called upon that you sometimes feel that you’re taking a survey course in the humanities focusing on self-harm in the arts, literature, and through the ages.

Farber’s primary focus on adaptation and attachment theory is informed by all these sources. Her core premise is that self-harm can be understood as a “creative unconscious solution to formidable problems of living,” i.e., adaptive solutions, the best adaptation of which the patient is capable at the time. The chapters on attachment are scholarly and bring the reader up to date, beyond Bowlby and Mahler, to include illuminating perspectives afforded by the developmental-biologically based work of Myron Hofer, the systematic interactive observational research of Mary Ainsworth, new developments in self-psychology, and the increasingly influential synthetic writings of Allan Shore, among others. Her good chapters on traumatic attachment and “addiction” to these attachments link to rich conceptualizations of the self as prey and predator, primitive sadomasochism, and destructive narcissism. She deals with issues of symbolic use of the body, and sadomasochism and its relation to body image, gender and perversion. She sees self-harming behaviors as attempts to deal with “hunger disease,” an “addiction to wanting” what these individuals cannot have, through which these individuals are driven to possess and consume people or things in an addictive manner. They never feel full or satisfied because their fundamental desires for closeness and warmth, never sufficiently experienced as children, now form holes that cannot be filled.

The clinical implications of these views are spelled out: therapists have to do a lot of attachment repair to help these individuals experience and develop supportive attachments. Farber’s chapters on diagnosis and assessment of self-harming patients are intelligent, thorough, and go beyond the DSM to areas of destructive narcissism, masochism. Beyond individual therapy, family and group approaches are discussed. The wrap-up chapter, “From Self-Harm to Self-Reflection,” portrays some of the detailed therapeutic processes occurring in the patient, and between the patient and therapist, in the course of treatment.

There’s a lot to read here-580 pages—in relatively small type. All in all, this is a book that psychodynamically oriented therapists will enjoy and value. The clinical insights offered will push the thinking of experienced clinicians. However, the extent to which these treatment approaches, alone or in combination with other psychosocial and biological intervention, lead to sustained improvements in large numbers of patients dealing with these very difficult to treat problems remains to be demonstrated.

— J.Y.