Chapter 8 Bulimia as Metaphor: Twinship and Play in the Treatment of the Difficult Patient

Over the past several decades psychoanalysis has increasingly recognized the significance of the capacity for play as a central dimension of successful child development. Winnicott (1971) was perhaps the first to assert that the eventual real work of analysis was the liberation of a capacity to play. The implications of observationally based infant research further deepened the understanding of play as a primary intersubjective template for the subsequent capacity for self-cohesion (Lichtenberg 1983; Stern, 1985; Beebe and Lachmann, 1988). Most recently, Meares (1993) has made a systematic effort to expand the scope of self psychological theory and practice in regard to the treatment of severely character-disordered individuals by charting the vicissitudes of their incapacity for effective symbolic play.

My purpose here will be to elaborate upon some innovative technical implications of play in regard to patients manifesting severe forms of psychopathology. In particular, I will present material from the treatment of an extreme case of bulimia. According to Meares, early developmental failure to develop a fluid capacity for symbolic play implies manifold pathologic consequences for the self throughout development, often resulting in the crystallization of a borderline state or severe narcissistic disorder in adulthood. Incapacity for play may result in a breakdown in the self's sense of introspective consciousness and cohesive flow; it can adversely affect “hedonic tone,” which is the heart