A Special K retreat: Dynamics which threatened the psychotherapy of an eating‐disordered patient

Abstract

When considering dynamics which threaten the therapies of patients with eating disorders the first aspect that occurs to me is how much the notion of ‘threat’ is a feature of the life of a person with an eating disorder. Working as a psychotherapist on an in‐patient unit for severely ill eating‐disordered patients, I am continually reminded how the patients in our unit live with the constant threat of serious physical damage, if not death (although this last is on the whole not felt to be a threat by the patient). At the same time, they are mostly subjected to ferocious internal threats of what will be done to them if they attempt to give up and therefore betray the eating disorder. Patients with eating disorders can be threatening, intimidating and controlling to the people around them; they will vigorously fight anyone who attempts to threaten the perceived safety of their internal system. In addition, they can feel threatened with punishment by the team on the unit, who they feel can increase their food intake or decrease their freedoms at a whim in a controlling and retaliatory manner.

Keywords:

• Anorexia
• bulimia
• threat
• retreat
• omnipotence
• dependency
• transference

Notes

1. Lara is not my patient's real name. All names and identifying characteristics have been changed in order to protect confidentiality.

2. See Steiner (1993, pp. 8–11), ‘The place of safety is provided by the group who offer protection from both persecution and guilt as long as the patient does not threaten the domination of the gang … The organization “contains” the anxiety by offering itself as a protector, and it does so in a perverse way very different from that seen in the case of normal containment, such as that described by Bion, to take place between a normal mother and her baby … The patient can withdraw to a retreat at a borderline position where he is under the protection of a pathological organization from either of the two basic positions’.

3. Rosenfeld (1971) described his understanding of the destructive narcissistic organization in his paper. He wrote:

it is as if one were dealing with a powerful gang dominated by a leader, who controls all the members of the gang to see that they support one another in making the criminal destructive work more effective and powerful. … the narcissistic organisation not only increases the strength of the destructive narcissism, but it has a defensive purpose to keep itself in power and so maintain the status quo. The main aim seems to be to prevent the weakening of the organization and to control the members of the gang so that they will not desert the destructive organization and join the positive parts of the self or betray the secrets of the gang to the police, the protecting superego, standing for the helpful analyst, who might be able to save the patient (1971, p. 249).

4. In his paper, Sohn (1985) described his thoughts on this type of internal organization in terms of an ‘identificate’. He wrote:

To me it appears that in the narcissistic organiszation, an identification by projective identification has taken place; the process of identification starts the narcissistic organization: that is to say, by becoming the object, which is then felt to be within the possession of the self. It is this that produces the feeling which we call omnipotence … It is, however, done destructively and can never be used constructively – the destruction being to the state of the ego, and to the object which is consequently devalued. This accounts for the hollowness of such a process, which so differentiates it from normal identification.

To differentiate it from normal identification, Sohn preferred to use the term ‘identificate’. He wrote:

Something takes place, dictated by envy, followed by omnipotent denial, in which a part of the ego becomes as if concretely differentiated, yet plastic in its manoeuvrings, in which the new roles and functions of this part of the ego assure omnipotent control, by virtue of the enhancement of the omnipotence over the ego‐remnants produced by the split that has taken place within it. By ‘concrete’, I mean that the identificate believes itself to be the whole ego … It is this, so called concretized, split part, which does all the ‘becoming’ and ‘being’ that I wish to apply to the term identificate. It is not simply that the identificate becomes God, Napoleon et al. which it can do … It is deprived of any enrichment and concern, it is hidden and covert, and mimics a variety of apparently positive situations (Sohn, 1985, pp. 271–292).

5. See Rey (1994, pp. 47–75).