The Case of the Bulimic Mafia and the Tools of their Trade

Following a discussion of some psychoanalytic approaches to bulimia nervosa (and in particular its multi-impulsive subtype), 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’.