Self-harm, such as eating disorders and selfmutilation, represents dissociated compensatory attempts to serve self-regulatory functions. Self-harm develops when the child who has become attached to those who have inflicted pain and suffering maintains that attachment by inflicting pain on himself. Brain imaging studies have found that the communication pattern between parent and child shapes the way the child's attachment system adapts to experiences with the attachment figure, literally hardwiring the child's brain. The good news is that a safe and secure attachment is very good medicine and can rewire the brain. An attachment-based multi-phase approach to treatment is presented.

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Self-starvation, bulimic behavior, and self-mutilation comprise a triad of associated self-harm syndromes that are potentially life threatening, with anorexia nervosa having the highest mortality rate of any psychiatric disorder. They are associated with trauma and are extremely resistant to treatment. These patients present a disturbing lack of anxiety about their own life-threatening behavior, yet are preoccupied with death and anxiety about annihilation. Because dissociation compartmentalizes and separates psychological and somatic aspects of traumatic experience (psychological and somatoform dissociation), it enables these patients to disavow the life-threatening nature of their behavior, which makes the dissociative processes the most destructive factor in this psychopathology. The self-harm symptoms are a presymbolic form of communication that must be decoded and confronted in treatment to make recovery possible. For many patients who starve, purge, or mutilate themselves, the body is speaking of death. They require a treatment that protects their safety, determines their personal construct of death, treats the dissociative pathology and sadomasochism, and builds signal anxiety and other ego functions, especially affect regulation.

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It has not been fully appreciated that psychoanalysis, in its origins, was both a talking and a writing cure. When Freud instructed his patients to say whatever came to mind, using words to verbalize that which was preconscious replaced the hypnotic technique as the "talking cure" and was the beginning of the psychoanalytic method. Freud used writing to an internal other in his self-analysis, and his free association writing has had an enormous influence on psychoanalysis. This author has introduced writing into the treatment of some patients and has found it invaluable with psychosomatic patients, including those who suffer from eating disorders and self-injury, because they tend to use their bodies rather than words to express emotions. Today's "widening scope" evokes a need to develop newer techniques, especially with patients who are unusually resistant to free associating or whose thinking is presymbolic. Caution must be taken that writing eases the resistance to free association and does not serve as a source of resistance itself, and that it serves creative rather than destructive aims. A little-known event in psychoanalytic history is instructive: E. Pickworth Farrow, a former psychoanalytic patient, devised a self-analytic process through writing down his free associations.