THE CASE OF THE BULIMIC MAFIA AND THE TOOLS OF THEIR TRADE

Abstract

Following a discussion of some psychoanalytic approaches to bulimia nervosa (and in particular its multi‐impulsive sub‐type), the place of pathological organizations of the personality within such pathologies and aspects of their NHS treatment, the paper focuses on the omnipotent management of separation difficulties in such eating‐disordered women. The role of shame and the ego‐ideal is discussed, as are their by‐products: secrecy and a preoccupation with the gaze and iconic figures, as seen in the general body‐ego pathology and over‐valuation of thinness in these patients. Illustrating these ideas with material drawn from the early stages of a woman seen in twice‐weekly NHS psychotherapy, the author discusses the literal and metaphorical roles of a box or case and its manic contents, which the patient employed to support her retreat. These secreted items (the box and its magazines, razors, laxatives and paracetamol tablets) constituted the concrete tools of the trade of her Mafia‐like pathological organization. The need to give appropriate clinical attention to such details is stressed and aspects of technique are discussed, especially the importance of creating and sustaining an appropriate therapeutic ‘play‐space’.

Acknowledgements

I would like to thank Marilyn Lawrence, Gianna Williams and all those on the D9 course at the Tavistock Clinic for their help in formulating my ideas, as well as Janet Sayers for her containing supervision and Roger Willoughby for his sensitive and careful editing.

Notes

Venlafaxine has been noted to be related to appetite change in some users, an increased appetite and weight gain being an ‘uncommon’ side‐effect, nausea being far more common. In patients with an eating disorder such issues need careful clinical consideration. Another possible though ‘rare’ side‐effect of Venlafaxine is skin rashes, something which may have contributed to Miss A's appearance as described in this paper.