Bodies Under Siege: Self-mutilation, Nonsuicidal Self-injury, and Body Modification in Culture and Psychiatry, 3^rd edition

As busy clinicians, we often read only the abstracts of published studies, or enroll in workshops that summarize current knowledge on a topic, or scan literature for clinical pearls. If your practice contains a young woman who cuts herself each week, a child who suffers from mental retardation and head-banging, or a patient who has attempted self-castration or other often irreversible acts of self-maiming, this book will not help you design a management plan before the next clinic visit. By skipping directly to Part III—“Insight and Treatment”—you might become a more compassionate clinician or understand some broad trends in the treatment of non-suicidal self-injury, but you will not find what to try next. By starting at the beginning of this book, you may feel under siege yourself as Armando Favazza presents page upon page of descriptions of mutilation, past and present, with little context. While the sheer volume of anecdotes gives the façade of completeness, he manages simultaneously to give only superficial coverage to some major examples and traditions of self-injury while including many irrelevant ones.

Favazza himself agrees with one reviewer of an earlier edition that the book is a “classic” (page xi). Since the publication of the first edition in 1987, Bodies Under Siege has legitimized the scholarly study of self-mutilation while putting modern self-mutilating behaviours seen in psychiatric practice into a cultural and historical context. Many of the topics mentioned—initiation rites, torture, masochism—have been studied from various angles within academia, but few books describe both decapitation during France’s 18th-century Reign of Terror and also the biology of self-injury in 21^st-century hospitals. Bringing together these disparate strands is an accomplishment. However, while a classic by definition has enduring features, it is often surpassed in its day-to-day usefulness: the union of history, anthropology, sociology, psychology, and medicine that was novel 25 years ago, now leaves the reader wishing the connections were tighter and the explanations more plentiful, despite Favazza’s protest that his book “is more than a catalog of horrors. It goes beyond mere description to search for meaning” (page xv).

This third edition is divided into three parts. The first examines beliefs about mutilation in different cultures and religions over time; the second could be the “catalog of horrors” to which the author was referring but distancing himself from in his preface, as it lists clinical cases under anatomical headings—e.g. “The Genitals”; the third deals with assessment and treatments and attempts to provide the promised “meaning” of mutilation.

The first two parts suffer most as the reader is presented with stories and examples with too little context, the “meaning” to all this evidence coming too late on page 197. An example of the superficial nature of the treatment are the pages on Christian mortification of the body, for Christian “self-mutilation” from the 2nd to the 20th centuries was far more than Favazza concedes (page 33–39), the concept of penance and its integral physical component in the Middle Ages demanding better analysis. The ancient, medieval, and modern concept of fasting is ignored altogether. It is true, his point is to compile examples from different centuries and cultures rather than give an exhaustive treatment of any single example. And case catalogs have a long and illustrious history in psychiatry and have provided great insights into the classification, natural history, and phenomenology of disorders. However, if more than a catalog is the objective, more explanation is necessary.

The subtitle to Bodies under Siege includes the terms “self-mutilation” and “nonsuicidal self-injury,” and since Favazza has authored articles on self-injurious behaviours in college students (Favazza, 2006), we were expecting to gain a better understanding of the growing proportion of adolescents we see in our clinical work with nonsuicidal self-harm behaviours. To our dismay, the majority of the book is about the not-so-common and extreme forms of mutilation of the body. For example, we started Chapter 3, entitled “Self-injury and Eating Disorders,” hoping for a better understanding of this association, but were disappointed to find yet another anthropological-psychodynamic narrative mostly about religion and cannibalism.

Favazza’s extensive observations and compilations do provide the foundation for his useful classification of self-injurious behaviours later in the book. This is divided into “Culturally Sanctioned Body Modification” with the subheadings of “Rituals” and “Practices,” and “Pathological Self-Injury” with the subheadings of “Major,” “Stereotypic,” “Compulsive,” and “Impulsive (episodic and repetitive)”. Dividing the culturally-sanctioned from the pathological is, after all, a major role of the psychiatrist, whether when teasing out delusions or separating major depression from normal grief. Also, the author provides information on non-medication treatments of self-injury including CBT (cognitive behaviour therapy), DBT (dialectic behaviour therapy), and S.A.F.E. (Self Abuse Finally Ends), this last a programme that gets Favazza’s applause as it is billed as “no-nonsense, highly practical, tough but caring, and efficacious but non-academic” (page 264), while DBT, which has demonstrated efficacy, is portrayed as the concrete child of a superficial and lesser god.

The reader closes Bodies Under Siege in agreement with its author that he has “presented an overwhelming array of cultural and clinical information on deliberate self-harm” (page 195). Whether he has fulfilled his second mandate, that of “pulling the material together and making sense of it all,” is in question. This book does not help understand or plan treatment for adolescents presenting to psychiatrists with nonsuicidal self-injurious behaviours, regardless of the presence of comorbid diagnoses. However, it would be of interest to students of ethnology and anthropology and the study of self-mutilation through the ages.

The topic is, to many, mysterious and macabre, and many readers may leave with more questions than answers, thus prompting close scrutiny of Favazza’s extensive and current bibliography. If a book ultimately forces this attitude upon a reader, perhaps it is a classic.