PATHOLOGICAL ORGANIZATIONS AND PSYCHIC

RETREATS IN EATING DISORDERS

Yael Adira Kadish

A set of characteristic symptoms allow for the relatively straightforward

diagnosis of eating disorders. Simultaneously and paradoxically, un­
derlying the eating disorders are a wide variety of personality organiza­
tions/disorders, stretching from the neurotic to the borderline and
narcissistic, and even to conditions approaching psychosis. This paper
will argue that the inherent commonalities can be ascribed to patho­
logical organizations of a similar nature and quality, operational across
the spectrum of eating disorders and functioning in a particular, sado­
masochistic way. The typical forms that eating disorders take are based
on the specific ways that food and the body are used, that is, symptom
manifestation. These distinctive symptom manifestations appear to be
related to Steiner’s (1982, 1993) notion of a psychic retreat. Patho­
logical organizations and psychic retreats are latent until called upon
either sporadically or continuously. When activated, these defensive
structures operate like a complex psychic skeleton around which the
unique psychodynamics of each patient become rearranged and there­
by transformed.

Many authors have acknowledged the presence of certain com­

mon features manifested in all eating disorders while simultane­
ously and paradoxically documenting a broad range of under­
lying pathology, stretching across all variation of personality
organization and/or disorder from the neurotic to the borderline
and narcissistic, and even to conditions approaching psychosis
(Shipton, 2004; Sours, 1969; Wilson, 1983). The question of how

I am sincerely grateful to my patients for their permission to use the clinical ma­
terial provided here. I would also like to acknowledge the valuable contributions
of my supervisors, Prof. Gavin Ivey and Dr. Arlene Joffe, as well as the input of
Prof. Gillian Straker to an earlier version of this paper.

Psychoanalytic Review, 99(2), April 2012 © 2012 N.P.A.P.

228 YAEL ADIRA KADISH

this apparent paradox might be conceptualised has not really

been convincingly addressed in the literature. This paper will ar­
gue that many of the commonalities noted despite the differing
personality organizations and/or disorders can be ascribed to
pathological organizations of a similar nature and quality (Stein­
er, 1982,1993) operative across the spectrum of eating disorders
functioning in a particular, sadomasochistic manner.
Notwithstanding the similarity in pathological organization,
the eating disorders can be separated out into characteristic forms
based on the specific way that food and the body are used—that
is, symptom manifestation. It will be argued that these distinctive
symptom manifestations can be directly related to Steiner’s no­
tion of a psychic retreat.
These pathological organizations and psychic retreats lie hid­
den and latent until called upon either sporadically or continu­
ously. When activated they function defensively like a complex
psychic skeleton around which the unique psychodynamics of each
eating-disordered patient become rearranged and thereby trans­
formed.
This paper begins with a consideration of some basic psycho­
analytic understandings of eating disorders from the perspective
of object relations, specifically, Kleinian and post-Kleinian theory,
in order to frame the inherent paradoxes of similarity and differ­
ence. Thereafter John Steiner’s (1982, 1987, 1993) work on path­
ological organizations and psychic retreats is discussed, followed
by a deliberation of the role of transitional and intermediary ob­
jects in the proposed psychic retreats and pathological organiza­
tions of eating disorders. Relevant case material will then be con­
sidered to illustrate the argument.

PSYCHOANALYTIC UNDERSTANDINGS OF EATING DISORDERS

Psychoanalytic literature testifies to certain basic similarities in

the conscious thoughts of eating-disordered patients, such as the
extreme fear of fatness (Wilson, 1983), a preoccupation with
food, and a strict categorization of foods into a moralistic binary
of good and bad (Kearney-Cooke, 1991). On the other hand, au­
thors note the significant diversity in individual personality orga­
PATHOLOGICAL ORGANIZATIONS 229

nization (Shipton, 2004; Sours, 1969; Wilson, 1983). This has un­
deniable implications for the therapeutic work (Johnson, 1991),
but surprisingly makes little difference to the severity of the symp­
toms or medical sequelae: For example, an otherwise neurotic
functioning anorexic would be no less emaciated or physically ill
than an anorexic with severe borderline pathology (Johnson,
1991). Through the lens of the medical model this is unusual; as
a general rule there is a direct correlation between the severity of
the underlying pathology and the rate of morbidity and mortality.
One of the features common to all eating disorders is the na­
ture of the fantasies deriving from the bodily functions of incor­
poration and expulsion originating from the early mother–
infant feeding relationship (Gilhar & Ivey, 2009; Sugarman, 1991).
The nature and quality of this relationship shapes the infant’s in­
ternal world, her1 object relations, and her interactions with the
external world (Wilson, Hogan, & Mintz, 1992; Klein, 1963).
Eating disorders are understood to be the result of serious
disruption to this early relationship. For various reasons and to
different degrees, a mother may have difficulty attuning herself to
her baby, whether because of depression, illness, or character­
ological disorder (Krystal, 1988; Lane, 2002). This compromised
attunement, repeated empathic failure, is experienced by the in­
fant as a series of impingements that disrupt the empathic milieu
that would normally support her gradually evolving awareness of
self; consequently, ego development is impaired (Geist, 1989;
Shipton, 2004). In many such cases it would seem that this sort of
impairment to the inchoate ego includes the development of an
enclave of autistic functioning, as described by Tustin (1978) and
S. Klein (1980); however, a thorough investigation is beyond the
scope of this paper.2
According to Winnicott (1960), such traumatic intrusion dis­
rupts the development of the feeling of going-on-being, or what
­Ogden (1989) has described as the sense of a bounded sensory
floor. In this unstable, traumatic environment, the infant is un­
able to internalize a definite, clear sense of what is inside and
what is outside the self. This in turn impairs the development of
interoceptive awareness—Bruch’s (1973) term—which relates to
the ability to discriminate between somatic and psychic. It is not
230 YAEL ADIRA KADISH

surprising then, that the development of the psychic mechanisms

of introjection and projection are impaired, rendering the infant
susceptible to depletion and fragmentation (Krystal, 1988; Wil­
liams, 1997).
These developmental achievements are essential precursors
for the transition from the sensory to the symbolic (Krueger,
1988). Hence the infant’s developing sense of self is structurally
compromised:
The interweaving of these acute and cumulative developmental
empathic failures (and the resulting structural deficits) becomes
the childhood anlage of eating disorders; the primordial founda­
tion for the adolescent’s later attempt to fill in the structural defi­
cit . . . by symbolically recreating within the symptoms of anorexia
and bulimia both the danger to the self and the efforts at self resto­
ration. (Geist, 1989, p. 17)

This paper seeks to identify the nature and functioning of

the particular structural manifestations inherent in eating disor­
ders. I argue that the interaction between the apparently danger-
ous and self-restorative aspects are integral to the particular manner
of operation of sadomasochism in the pathological organizations
in eating disorders. A review of Steiner’s theory follows to provide
a backdrop for the argument.

INTRODUCTION TO PATHOLOGICAL ORGANIZATIONS

AND PSYCHIC RETREATS
John Steiner (1982, 1987, 1993) developed his theory of psychic
retreats and pathological organizations in an attempt to under­
stand the dynamics of patients who are not merely resistant in the
usual way but who are, for all intents and purposes, unreachable
to the analyst for shorter or more extended periods in treatment.
Such patients seem also to display intrapsychic structure of a high­
ly organized and often sadomasochistic nature. Such powerful re­
sistance had been first described by Freud (1909, 1910, 1914),
who noted in the case of “The Ratman” (1909) a patient who felt
compelled to commit a crime under the influence of internal
“agents provocateurs” (p. 261). Abraham (1919, 1924) contributed
to these ideas in his study of narcissistic resistance, as did Reich
PATHOLOGICAL ORGANIZATIONS 231

(1933) in adding his notion of “character armor,” while Riviere

(1936) presented her significant paper addressing negative thera­
peutic reaction. Klein (1958) made the important distinction that
unconscious destructive parts of the self were not part of the su­
perego but were split off, remaining separate from both ego and
superego. Thereafter, Joseph contributed two influential papers,
“The Patient Who Is Difficult to Reach” (1975) as well as “Addic­
tion to Near Death” (1982), while Rosenfeld (1971) presented an
incorporative theory to try to explain these sorts of resistances,
which he termed “destructive narcissism,” and introduced the
term “narcissistic organizations.” His conceptualization was a sig­
nificant precursor to Steiner’s pathological organizations.
Steiner’s (1993) theory attempted an even broader reach
than Rosenfeld’s, as reflected by his use of “pathological” rather
than “narcissistic” to describe the organizations that he believed
could occur in a wide range of patients, including certain types of
neurotic patients as well as those who are narcissistic, borderline,
and perverse, and even psychotic patients who are accessible to
psychoanalytic treatment (Steiner, 1993). In fact, Steiner asserted
that all individuals may, under conditions of extreme anxiety,
withdraw to a psychic retreat; a psychodiagnostic distinction can
be made regarding the duration of said retreat (the shorter, the
healthier) and the extent of the pathology inherent in the organi­
zation (Steiner, 1993).
According to Steiner’s theory, the patient who has withdrawn
from meaningful contact into a psychic retreat in analysis may re­
late in a number of ways. She may present with an aloof superior­
ity, with a shallow, “as if” sort of cooperation, or with a dishonest
manner of engagement. In response to these particular sorts of
contact, the analyst may feel frustrated, shut out, and/or pres­
sured to behave in a superficial, corrupt, colluding, or perverse
manner (Steiner, 1982). Steiner proposes that these particular
sorts of defensive maneuvers are undertaken behind the protec­
tive armory of a rigid pathological defensive organization of the
personality, which functions as a safe haven that can be retreated
to at any time in order to avoid the menace of seemingly unbear­
able anxieties.
Steiner co-opted Meltzer’s (1968) and Rosenfeld’s (1971) no­
232 YAEL ADIRA KADISH

tion of the internal “mafia” or “gang” that offers protection to the

vulnerable part of the self so long as there is complete deference
shown to the ruthless, terrorizing “regime.” In certain cases there
are strong sadomasochistic components; this becomes evident in
a transference–countertransference wherein the patient derives
sadistic pleasure from, for instance, opposing the analyst’s wish to
be helpful, as well as masochistic pleasure in remaining “sick”
rather than improving.

PSYCHIC RETREATS

The psychic retreat, which becomes available only under the aus­
pices of a pathological organization, is conceptualized structurally
(Steiner, 1993, pp. 11, 39) as a latent and expedient third posi­
tion, located between Klein’s (1946, 1952) two other develop­
mental positions. In times of overwhelming anxiety of a paranoid-
schizoid or depressive nature, the pathological organization is
activated and the psychic retreat becomes available as a refuge.
Psychic retreats take different forms; they can be undertaken dur­
ing anxiety-provoking periods in therapy, but are also accessible
outside of analysis in everyday life when an individual is faced with
the threat of unbearable anxiety.
It seems possible, then, that the sorts of psychic retreats par­
ticular to eating disorders might be a flight into certain states of
bodily experience that comprise the specific form of the retreat.
In other words, eating-disorder symptomatology—binging, purg­
ing, and/or the changes in psychic state brought upon by severe
food restriction—all bring about this third position, the escape
into a psychic retreat as a defense against overwhelming anxiety.
This would explain why the underlying psychic structure of the
individual can be neurotic, narcissistic, borderline, or mildly psy­
chotic, but that under conditions where anxiety seems overwhelm­
ing the latent psychic skeleton of the pathological organization is
activated, making escape into a psychic retreat possible. I have
used the term psychic skeleton because the pathological organiza­
tion is a complex, powerful default defensive structure, deployed
when the individual feels psychologically overwhelmed. The indi­
vidual’s typical psychodynamics are then partially restructured
PATHOLOGICAL ORGANIZATIONS 233

and absorbed into this new structure that has arisen to take over
psychic functioning. The reign of the new state might be short-
lived or continuous. The more severe the eating disorder, the
more prolonged the psychic retreat. In fact, in chronic cases of
anorexia the psychic retreat becomes status quo unless it is dis­
turbed by treatment or some profoundly disruptive event.

ETIOLOGY OF A PATHOLOGICAL ORGANIZATION

Steiner proposed a pathological organization to be the end result

of various defensive maneuvers resorted to by the individual after
the failure of normal splitting processes has occurred. He cites
Klein’s (1952) formulation that the individual, under the weight
of severe anxiety, has defensive recourse first to normal splitting
processes, which implies the splitting of the object with its result­
ing splitting of the self/ego (Klein, 1957; Rosenfeld, 1950).
Healthy splitting entails a good object in a relationship with the
good part of the self/ego kept separate from a bad object in rela­
tion to the bad part of the self/ego. In a situation where this sort
of splitting fails to bring about equilibrium, the individual may
then turn to the good object and good parts of the self to combat
the bad object and bad parts of the self. If this defensive strategy
also proves insufficient, a violent and archaic form of projective
identification occurs, which entails the expulsion of the self and
the object now fragmented in bits (Bion, 1957).
A pathological organization, different in form in each indi­
vidual, may then develop to “collect the pieces” and reconstitute
the personality; however, it is a contaminated conglomeration in
that good and bad bits of the self projected into objects have be­
come inextricably mixed up together. The new structure, com­
prised therefore of impure “building blocks,” is an attempt to re­
store the former good/bad split within, but this task is impossible;
instead a complex, “Frankensteinian” structure emerges—the
pathological organization.
This hybridized personality structure—pathological organi­
zation—presents itself as good and protective, offering the weak li­
bidinal self/ego a place of safety against attack; however, this is
­illusory. Due to its above-mentioned origins, the pathological or­
234 YAEL ADIRA KADISH

ganization is constituted by mixed-up bits, and nothing is as it

seems. The organization appears to seduce and mislead the weak
libidinal ego; however, there is always some degree of collusion
(Steiner, 1993). Tyranny and sadism are allowed to dominate the
weak, dependent libidinal self/ego that both knows and does not
know the nature of the unholy bargain that has been struck, which
thus by definition is a perverse engagement. Unwavering compli­
ance is demanded and obtained because safety against over­
whelming anxiety is offered in return; hence a rigid, often ideal­
ized, sadomasochistic structure becomes entrenched (Steiner,
1982, 1993).
If the omnipotent protection of the organization is relied
upon excessively, healthy growth is arrested. This is because psy­
chological development relies upon the flexible use of projective
identification as an object relational tool. Since pathological orga­
nizations are comprised of multiple split-off, disowned parts of
the self in complex formation, no one element can be separated
out and identified as being part of the self, mourned (which
would allow the withdrawal of projections) and then internalized,
as is necessary for depressive functioning. Thus in cases where
these organizations are entrenched there can be no healthy flexi­
bility of projective identifications, and development is frozen
(Steiner, 1993).
This stagnant situation can often be found with eating-disor­
dered patients. There appears to be a particular sort of patho­
logical organization where the sadistic “mafia boss,” as conduit
for projections of harsh, punitive ideology regarding “fatness”
and greed, is engaged in a relationship with a masochistic part con­
taining loathed, disavowed parts of the self. At first glance this
situation seems most apparent in anorexia, where sadomasoch­
ism manifests in the symptom and in the transference–counter­
transference (Bach, 1997; Lane, 2002; Risen, 1982). It is not only
the building blocks of the organization that must be compre­
hended, but also the particular way in which they are placed and
held together. This is vital because the analyst might well be­
come an element in the organization, enacting either or both
the oppressive and malevolent part or the passive and compliant
component.
PATHOLOGICAL ORGANIZATIONS 235

The discussion now turns to the central role of intermediate

and transitional objects in the pathological organizations and psy­
chic retreats of eating disorders.

AN INTRODUCTION TO TRANSITIONAL
AND INTERMEDIATE OBJECTS

As the infant moves through each developmental phase, the deep

pleasures of the phase-specific zone and object are left behind.
The child associates the loss of pleasure with object loss: the wan­
ing of the dominance of the organ and its product (Kestenberg,
1968). Each zone and its associated product are then psychically
condensed, becoming an intermediate object. An intermediate
object is different from Winnicott’s (1953) notion of a transition­
al object in that the former originates from the body, whereas the
latter does not (Kestenberg, 1968; Kestenberg & Weinstein,
1988). An example of an intermediate object would be milk from
the breast or bottle, vomit, feces, and urine. Intermediate objects
are able to change shape and merge or separate from the indi­
vidual’s body; they transform and decay quickly, unlike true tran­
sitional objects.
Intermediate objects may thus be considered to be a special
type of forerunner to transitional objects, an additional stage in
the progression from the use of the body and its products to the
use of, for instance, a piece of a blanket or rag doll (Kestenberg,
1968; Kestenberg & Weinstein, 1988). This additional stage oc­
curs at a juncture where the infant has neither a secure inner rep­
resentation of the mother nor of her own body. Thus intermedi­
ate objects typically function as a bridge to the mother (Kestenberg,
1968). They are precursors to transitional objects because by na­
ture they cannot last, but decompose and are destructible. The
“robustness” of a transitional object, on the other hand, means it
is the first object experienced psychically as having some sort of
sustained existence in the space between “me” and “not me.” This
endurability allows for the internalization of a sustainable third
area, whereas intermediate objects, originally a joint possession of
mother and infant, diminish in “value” when they are detached
from the body (Farrell, 1995).
236 YAEL ADIRA KADISH

THIRD AREA OF EXPERIENCING VERSUS THIRD POSITION

Winnicott’s (1960) notion of a third area of experiencing must be

differentiated from Steiner’s (1993) notion of a “third position,”
which is a psychic retreat from overwhelming anxiety originating
from the first, paranoid-schizoid, or second, depressive, develop­
mental positions. In eating disorders, psychic retreats (the third
position) are used as an escape from anxiety that cannot be con­
tained within the self due to the individual’s inability to access a
third area of experiencing or transitional space. These develop­
mental disturbances preclude the use of symbols or the tolerance
of ambiguity or paradox and prohibit secure internalization of
soothing and tension-regulating structures (Bach, 1997; Bruch,
1978; Geist, 1989). This renders distress incomprehensible and
hence inexpressible within an object relationship (Bach, 2002;
Kearney-Cooke, 1991).
The reason for these serious object relational difficulties is
believed to lie in the earliest mother–infant interactions (Birk­
sted-Breen, 1989; Bruch, 1978; Lane, 2002). Some theorists sug­
gest a narcissistic mother (Lane, 2002; Sours, 1974) who at­
tempts to use her infant’s body inappropriately to rid herself of
unwanted feelings by way of projections into the infant. The ba­
by’s body then becomes a transitional object for the mother in
her attempt to reach a third area/transitional space of experi­
encing (Farrell, 1995; Winnicott, 1960). This is a highly toxic
situation for the infant and is experienced as an impingement
or series of impingements (Williams, 1997). The child is left
with intrapsychic deficits. Rather than being able to contain and
process their emotional experiences, eating-disordered patients
use food, bodily products, and altered psychic states in a per­
verted way in order to escape from terrifying indigestible experi­
ence.
Jordá-Fahrer et al. (2001) describe the cases of two patients,
an anorexic and a bulimic, attributing their progress to their utili­
zation of transitional objects during treatment. This was possible
after some therapeutic work had been done; prior to this they had
starved and used food concretely. The patients improved consid­
erably after they were able to use transitional objects associated
with their therapists to soothe themselves in between sessions. Ul­
PATHOLOGICAL ORGANIZATIONS 237

timately it is anticipated that patients become able to access an

internal transitional space through their internalization of the
soothing, containing qualities of the therapist and the therapeu­
tic relationship.
Before this can be accomplished, however, eating-disordered
patients use food and bodily products as if they are the object in
the way of a symbolic equation, as discussed by Segal (1957), in
which the separateness of the object is denied. Food used instead
of an object relationship functions to deny and substitute for said
object rather than representing it. In other words, it enables the
patient’s feelings of omnipotence and self-reliance, allowing her
to disavow the needs of her libidinal self for an object to meet the
need. Hence, a psychic retreat is resorted to, rather than a third
area/transitional space, as the latter involves a true awareness of
separation between self and object (A. Joffe, 2010, personal com­
munication).
Material from three eating-disordered patients will now be
discussed. Although transference–countertransference manifesta­
tions are acknowledged to be crucial for the apprehension of
these states, this is not the focus of the paper. Instead, the clinical
material has been selected in order to highlight the internal dy­
namics in each case. The following clinical vignette provides an
illustration of the workings of a pathological organization in an
anorexic patient.

SESSION MATERIAL FROM A RESTRICTING ANOREXIC PATIENT

“Jenna,” a recovering adolescent anorexic patient in once-weekly

therapy, gave an eloquent description of her struggle against op­
posing currents within herself, which I regard as being compo­
nent parts of her sadomasochistic pathological organization.
j: I think there is a part of me that enjoys torturing myself; I can’t
explain it. It’s like when I was little, if I hurt my dog I would bash
my head against the wall so I could feel the pain that he was feel­
ing, that I had made him feel. And with the anorexia, if I really
want a particular food and I am dying for it, another part of me
enjoys saying “No, you can’t have it!” It likes watching me not have
it. It’s so weird, it’s as though I like to see myself suffer.
238 YAEL ADIRA KADISH

therapist: You feel like there is a part of you that wants things
and another part that enjoys seeing you not get what you want.
j: Yes, just like that, like I get some kind of happiness from that.
It’s so abnormal; are other people this abnormal? I always look at
people and wonder what goes on behind closed doors. Everyone
else looks so perfect, so normal, but maybe not . . .
therapist: Maybe you are wondering if I think you are a bit crazy
when you tell me about these thoughts and feelings.
j: Sometimes I do think that, you know, I wonder if there is some­
thing really wrong with me that things never seem to go right
whatever I try. Maybe I don’t trust myself, maybe that’s why I’m
scared to give up the anorexia completely. It gives me something
I can do right, I can lose weight when I eat less. I can rely on that.
therapist: I can see why it’s so hard to give it up then, because it
makes you feel certain about something when other things feel
out of control.
j: Yes, and I think that’s why I’m feeling confused about my eating
again. Part of me wants to eat less, like last night I thought I must
have two crisp-breads and tea instead of the cup of Milo and two
biscuits that I am supposed to have, so I would be eating less.
Then another part of me feels like I don’t want to go through all
that again, being in the hospital and everything, and I know I
looked terrible then, I can see that when I look at pictures now. I
don’t want to look like that again. I mean, a normal person would
know what to do. It’s like a moral dilemma but what’s so hard is
that there isn’t a right or wrong answer, neither side is completely
good or bad; they both offer different things. Like if I listen to the
anorexic part that makes me want to eat less, then I feel like I am
in control and I will never get fat again, but on the other hand I
wish I wasn’t so rigid about food. I eat the same things all the time
because I’m so scared to try new foods, like I would love to have
an ice cream but I’m too scared. When I left the hospital I thought
I would be free from all this because in the hospital it’s really good
the way they are all behind you and you just have to concentrate
on eating properly so you can go home. You just rest on your bed
and you don’t have to worry about your schoolwork or anything.
PATHOLOGICAL ORGANIZATIONS 239

And I felt positive and free for a while afterwards, but now I’m
stressed again: over Jamie, if he likes me, school is hard, and I’m
worried about the school dance. I just want to go into a chemi­
cally induced coma (laughs nervously). Okay, I know that sounds
bad . . . I want to hibernate, just to go away somewhere and hiber­
nate, not eat, not exercise, and not have to worry about anything,
just sleep.
therapist: So maybe it feels like the anorexia offers you a way to
escape to somewhere safe where you won’t have to face all this
stress; it seems to offer something like a cocoon for you.
j: Yes, then I wouldn’t have to worry about all this stuff, I could
just go away. But I know that won’t be good, I don’t want to re­
lapse. This is so hard . . .
In this excerpt Jenna discusses the way that anorexia might
allow her to escape from the anxiety induced by the challenges
she must again face, now that she is back in the world and out of the
hospital. Some of these anxieties seem to be depressive because
they demand that she grapple with issues regarding genitality, ma­
ture object relations. She is preoccupied with thoughts about
whether the boy she likes, likes her back. She worries about how
she will manage her schoolwork and if she will cope socially at the
school dance. These are normal adolescent concerns; however,
the anorexic girl often develops her illness because she cannot
manage these very issues. It is a time where true separation and
individuation is called for, and this elicits powerful depressive
anxiety and the revival of earlier fixation points. This is often a
stumbling block for vulnerable individuals. Obsessive thoughts
and rituals function as conscious defenses against physical appe­
tite/greed and unconscious fears about separation and whole ob­
ject relationships.
For patients like Jenna, anorexia seems to offer something of
a solution in the face of apparently overwhelming anxiety brought
about by puberty (Bruch, 1978; Lane, 2002; Shipton, 2004). In
the vignette this can be seen in the way that the mafia boss/inter­
nal object of her pathological organization is experienced as a
voice or a part of her that demands compliance via starvation in
return for “protection” from anxiety. Self-imposed starvation and
240 YAEL ADIRA KADISH

the altered perceptual states it produces, such as dizziness, light-

headedness, or feeling “high” (Jordá-Fahrer et al., 2001) offer an
omnipotent escape. The psychic retreat allows her respite from
overwhelming anxiety regarding object relations and her terrible
struggle to cope as a separate being (Birksted-Breen, 1989; Gen­
tile, 2006). Jenna refers to this altered mental state as a “chemi­
cally induced coma” or “hibernation.” This state is only accessible
through total compliance, saintlike abstinence, which bolsters
omnipotent feelings and as such comprises the psychic retreat
characteristic of anorexia. Lawrence’s (2001) notion of the “white-
out” state of mind of the anorexic—where the oedipal3 couple do
not exist and the world is felt to be pure and clean—describes
something of the nature of the underlying fantasy that accompa­
nies the altered anorexic mental state. Thus her pathological or­
ganization and accompanying psychic retreat operates like a psy­
chic skeleton functioning as if superimposed over habitual
intrapsychic mechanisms. The activation of this default structure
allows entrée into a state of manic omnipotence where the reali­
ties of her life can be denied.
In other types of eating disorder, where starvation is not a
feature of the illness or is only one aspect, the role of food and
bodily products is central; I now present such a case.

CASE MATERIAL FROM A BINGE-EATING PATIENT

“Cassie,” the youngest of four siblings and the “runt of the litter,”
was controlled by an internal object that was dominating, critical,
and contemptuous and that resembled her father, who was par­
ticularly disdainful of greedy girls, that is, those who ate fattening
foods, and of loose women. All evidence of physical appetite, both
in relation to food and sex, had to be disavowed. Cassie also had a
weak and passive part of herself that seemed derived from a par­
tial identification with her mother, who was portrayed as passive,
dependent, and depressive, with a preoccupation with body weight.
Cassie’s binge-eating symptom began when she was an ado­
lescent; at this time her disgust at her developing body was exacer­
bated by her father’s disapproving comments. She felt furious
with him but was unable to articulate this to anyone. In her family,
father was the only one who had been permitted to express anger,
PATHOLOGICAL ORGANIZATIONS 241

and as a result Cassie had found it almost impossible to confront

unacceptable situations or express angry feelings. Instead, she
withdrew from such situations and then binged. She would eat
low-calorie foods with her family at the dinner table but then
would binge secretly in her bedroom late at night. This behavior
continued into adulthood, when she would eat normal meals in
front of her weight-conscious husband, but then on most nights
would carefully plan a secret late-night binge. Cassie was able to
become aware that her binge eating was in part an angry rebellion
against, particularly, her father’s conditional approval, now pro­
jected onto her husband. In fact, her father had not commented
on her weight for many years, so essentially it seemed to be a re­
volt against the father of her youth, whom I suspected personified
the internal dominating critical object in her pathological organi­
zation (Steiner, 1982).
Cassie’s defensive structure seemed comprised of this domi­
nating critical part in close relation to a weak and passive part,
and this coupling seemed to function sadomasochistically in the
way that Steiner (1982, 1993) described in his formulation of cer­
tain types of pathological organization. During the course of the
therapy I came to understand that there was at least one other
prominent aspect in Cassie’s defensive organization: an angry, de­
fiant third part of her that attempted to challenge the sadomas­
ochistic pairing. However, it was extremely difficult for Cassie to
allow herself any appearance of anger, so it seemed that this an­
gry, defiant third part most readily found expression in her binge
eating, which operated as a psychic retreat from stressful under­
currents in her life.
Cassie’s binges functioned as a “safe” way to experience inex­
pressible, angry feelings, but they operated in another important
way as well. Cassie’s interest in sex was minimal to nonexistent;
she communicated this to me with something akin to pious pride.
Apropos, it seemed as though her libido had been prematurely
“derailed,’ or fixated on an oral and anal trajectory, and that gen­
ital functioning in general was underdeveloped. In Kleinian
terms, much of her functioning was paranoid-schizoid; feelings of
envy and greed as well as angry anal attacks were counterbalanced
by the terror of persecutory retaliation from a vengeful object.
For the most part, periods of depressive whole object relations
242 YAEL ADIRA KADISH

were ephemeral. Hence, her binges operated orally insofar as un­

mitigated greed was rapturously liberated and anally in that her
rage and defiance were given some sort of expression, albeit in
fantasy. The libidinal investment in her binges was evident in the
way she described them, almost like an illicit love affair in the se­
cretive planning and associated anticipation of some sort of per­
fect bliss or “escape” to what she described as her “food island.”4
This oral–anal libidinal trajectory meant that her participation in
her sex life was at the level of bland compliance, absent of desire.
This was another way in which her binge “worked.” It seemed to
be a tacit reaction to the psychic conflict between her father’s in­
struction to be ladylike and her anxiety-provoking physical desires.
Her binges “resolved” this conflict by displacing genital desires
onto oral ones, where appetite could be more safely indulged in
the realm of the food island/psychic retreat.
However, the dominance of sadism in her pathological orga­
nization meant that “positive” and “adaptive” aspects of the psy­
chic retreat were short-lived. Part way into her binge, the food
ceased functioning as a self-soothing intermediate object/psychic
retreat and was transformed into horror at her greed and destruc­
tiveness. She seemed to awaken to the perverse way she had used
the food, as if it were a loved object that could be devoured to her
heart’s content. Suddenly, like Adam and Eve, nakedness ex­
posed, she felt she had been cast out of paradise, the mirage of
the retreat exposed. Her attempt to escape from the demands of
the external world via the psychic retreat/binge was short-lived.
Immediately post binge, her anxiety would reach a crescendo as
the reality of her frenzied eating sunk in. This made her especial­
ly vulnerable to the renewed pull of the pathological organization.
“It” severely chastised her for her wanton greed, but then offered
her protection against her resulting anxiety of becoming fat and
disgusting. This impure mix of soothing and destructiveness can
be apprehended in a careful analysis of the stages of the binge.

Stages of the Binge

Entry into the psychic retreat appeared to begin from the
planning stage, stretching over the hours before and then into
PATHOLOGICAL ORGANIZATIONS 243

the first period of the actual eating. The prolonged anticipation

seemed to be a sensuous and idealized fantasy distracting her
from anxiety. When she described this period, my reverie was of a
little girl anticipating her birthday party, where she would be
made to feel special, surrounded by pretty cupcakes and confec­
tionary. I came to understand that this state of omnipotent fantasy
functioned as a defense against overwhelming mental states.
However, the magical promise of the safe, self-contained
“Eden” was short-lived. Once the actual eating commenced, the
omnipotence broke down. A growing sense of anxiety meant that
her voluptuous experience with the food quickly transformed it
into decaying waste, in the way of an intermediate object. In her
growing distress she would begin to shovel food down frenetically
until she felt stuffed and ill. She feared she would be “caught” in
this disgraceful act and be punished, although she could not say
how or by whom, just that she knew she would feel very guilty and
ashamed.
Cassie told me that after her binge, wracked with guilt and
self-loathing, she would feel painfully full and nauseous. The ago­
nizing aftermath was the way she punished herself for her greedy,
rebellious transgression. Harsh and critical feelings of the “now
look what you have done” variety appeared as crushing admoni­
tions from her “critical father” part in relation to her “passive
mother” part; she would be overtaken by hopeless despair. Before
the therapy she had not been able to consider her behavior in a
thoughtful way. Instead there was a desperate need to renew her
compliance with the strict rules laid down by the harsh, critical
part of the pathological organization in return for protection
against these unbearable feelings that she was sordid and destruc­
tive. She would recommit herself to total acquiescence—eating
the bare minimum of “permissible” foods—and the disavowal of
“bad” thoughts. Predictably, when her feelings of deprivation and
anger became overwhelming once again, the cycle would repeat
itself.
In therapy, the processing of her binges and their underlying
meaning and function led over time to a drastic decrease in binge-
eating behavior. This meant that during stressful times she was
able to develop ways to work through and express her anger in­
244 YAEL ADIRA KADISH

stead of automatically escaping via psychic retreat. She was also

able to confront her disgust about sexuality and understand her
unconscious linking of greed and sexual desire. She was eventu­
ally able to renounce concrete intermediate objects in return for
greater reliance on object relationships.

INTERVIEW MATERIAL FROM A BULIMIC PATIENT

I will now contrast the cases of Jenna and Cassie to the analysis of
material derived from a journal excerpt5 from a bulimic research
subject, “Sarah.” The narrative was obtained as part of a research
interview process and therefore is a different order of material
from the other two. I decided to use Sarah instead of one of my
bulimic patients because the material appears to allow relatively
direct access to a bulimic individual’s experience of her patho­
logical organization. The extract is from a journal she kept during
a period when she studied overseas. It was during this time that
she became bulimic. This is not uncommon; going away to a uni­
versity is a well-documented catalyst for eating disorders (Gordon,
1990). It should be noted that when Sarah referred to “voices,”
these are different from the voices reported by psychotic patients.
Sarah recognized the voices as being internal to her. In her case
they seem to manifest not unlike the “agents provocateurs” in the
case of the “Ratman” (Freud, 1909). She wrote:
I should have guessed that the peace would not last, as I’d got to
my block of flats and began to walk up the stairs, familiar feelings
tugged at my feet. I tried hard to hang on to the joy, but it melted
as quickly as the snowflakes clinging to my face. An overwhelming
loneliness washed over me as I opened the door and walked into
my flat. The silence was broken and the voices started again. “This
is something you should only experience with Jonathan, how can
you be so selfish as to enjoy this on your own, you shouldn’t even
be here, you are just self centred, egotistical . . .”

Sarah experienced feelings of guilt about having chosen to

separate from her object, in this case her husband, to pursue her
own agenda, that of studying overseas. It seems that her decision
had evoked anxiety about the dangers of separation. Her joy at
being able to walk in the snow to her own flat in a new city quickly
PATHOLOGICAL ORGANIZATIONS 245

turned to loneliness, as if she had been abandoned rather than

having chosen to leave her home. This is then associated with the
fantasy of the angry retaliation of an object scorned, embodied by
her sudden awareness of the critical, cruel voices of her pathologi­
cal organization.
I tried not to listen it was such a magical, unique experience; I
didn’t want to let go of the peace and the beauty. As I took off my
wet coat and gloves I realized that I was shivering. I longed for the
taste of something warm and sweet in my mouth—hot milk and
sugar. I hugged a smile to myself as I thought of my dad pouring
out tall glasses of hot milk and ceremoniously stirring two spoons
of sugar in each. The memory warmed me as the milk had warmed
our bodies. . . . I held the milk up to my lips, enjoying the sensa­
tion of the rising steam on my face. A sense of longing washed over
me and was followed by a feeling of shame.

Here, Sarah seems to try to satisfy her need for emotional

nurturing with the milk that she associates with her father’s care,
in a concrete attempt at self-soothing. A sense of shame follows
one of longing for the closeness with her father. This may well be
understood through the lens of oedipal and/or even preoedipal
strivings denied; however, as she was not my patient I was unable
to explore this. Nevertheless, what follows is an experience some­
what similar to Cassie’s in that her attempt to use food as an inter­
mediate object to escape her painful feelings is short-lived. Feel­
ings of shame, guilt, and anxiety precede self-punitive compensatory
measures.
The voices seized the opportunity . . . “You greedy pig, how can
you have a glass of milk when you’ve had a full supper and a slice
of cake?” Earlier that evening at the bible study we’d been offered
cake with our coffee, I think someone was celebrating a birthday. I
had tried desperately to think of an excuse not to have any but I
knew that I was being carefully watched by the study leaders who
were rather concerned about my diminishing appetite. After an
intense inner struggle I’d accepted a small piece and eaten half of
it. My fears were justified as the voices began to attack me with this
latest evidence of my gluttony, my sloth. “No wonder you are so fat
you are just a glutton how could you, you can’t even say no to one
piece of cake and you could have left some of your supper as well.
If you’d have taken the plates to the kitchen no one would have
noticed, you will just have to exercise more tomorrow or you can
246 YAEL ADIRA KADISH

get rid of it now.” I tried to stop the thoughts, it was just a small
piece of cake and I ate less than everyone else at supper I will get
up early and do exercise, I will go for a long walk in the snow to­
morrow. Please I don’t want to be sick I promised Jonathan I
wouldn’t and what if I can’t. The last few times I tried it was so hard
and my throat ended up bleeding and sore for days, it’s not worth
it. I feel so tired and drained afterwards.

Here the extent of the sadism of her pathological organiza­

tion is evident. It is as if a terrified her is being persecuted by a
monstrous tyrant. There is bargaining to and fro; the pathological
organization offers her chance to “get rid” of the food. She seems
invested in her status as victim as a way of avoiding responsibility
for her decision to purge. Possibly here is the collusion Steiner
speaks of, between the weak libidinal ego/self and the pathologi­
cal organization in return for the omnipotence it brings. In Sar­
ah’s case the omnipotence comes from a perverse engagement
that allows her to purge without taking responsibility for the deci­
sion. Here I think Klein’s (1958) notion of a split-off destructive
part of the self, not belonging to either ego or superego, is evi­
dent. Until the split-off destructiveness can be acknowledged, in­
tegration of the self is impossible.
I looked out at the falling snow again and again and cried. Was
there no escape? I could phone someone and talk it through but
who? The sense of shame and disgust at what I was contemplating
prevented me from reaching out as the panic feelings rose I know
that I would have to do it, if it wasn’t now it would be later. There
would be no rest from the voices until they were appeased, until I
carried out due penance for my lack of control.

Sarah feels unable to use her relationships to mediate her

painful feelings. She engages masochistically with the sadism of
the voices of her pathological organization. She calls her purging
“due penance,” a biblical allusion. This is significant because she
is a religious person. She appears to experience the voices as if
emanating from a wrathful God demanding sacrifice. At the same
time there is a denial of the knowledge that she will actually be
incredibly relived not to gain weight from her lapse of control.
I suddenly remembered a box of chocolates that I’d been given for
a Christmas gift; although it was March they were still in the cup­
PATHOLOGICAL ORGANIZATIONS 247

board sealed in the cellophane for my protection. I had known

that opening the box would be fatal. I had hidden them away and
tried to forget their existence but now they taunted and taunted
from their hiding place. The struggle continued to rage inside me
for a long time while I stared into the silently falling snow. Slowly
and mechanically I walked over to the cupboard and took out the
chocolates. I chose one that I liked and then closed the box and
put them away—just one, just a little treat.

Interestingly, Sarah narrates her experience as if she is ab­

sent of any desire for the chocolates. Her yearning for them is not
mentioned, but they are seen to “taunt” her. She has kept them
unopened for three months, and now her pathological organiza­
tion offers her the opportunity to eat them because she already
knows she is going to purge. Hence there is once again evidence
suggesting a perverse engagement, collusion with the sadistic ele­
ment. The perverse engagement entails her surrender to the
“punishment” of the vomiting in return for being able to eat the
forbidden chocolate without admitting that she has made the de­
cision to give herself “a little treat.” However, once done, the in­
ternal sadism is exacerbated.
It was a long time since I had allowed myself chocolate, it tasted so
good. But the voices were having none of that: “Chocolate!” “That
is what fat people gorge themselves on, you have no self control,
how could you open a whole box now what are you going to do
with the rest?” “I suppose you intend to ration yourself to one a
day, that’s a joke.” “If you eat them quickly and vomit them all up
they won’t affect your weight.” The rest of the chocolates disap­
peared fast. I continued to watch the gently falling snow but it no
longer looked white and pure. The whole world had been con­
taminated by my evil greed. I suffered and suffered to try to fill the
gap in me that was never satisfied. Then I went and vomited until
my heaving only yielded blood, I could no longer even swallow sa­
liva through my swollen throat.

In this final part the internal sadism provokes masochistic

shame and terror at her greed; the greed is experienced as being
able to destroy her whole world. However, there is also the ac­
knowledgment of an insatiable void inside herself, which is a
hopeful portent, a moment of insight.
In fact Sarah had already recovered from bulimia at the time
of the interview. She attributed this to therapy, both individual
248 YAEL ADIRA KADISH

and group, as well as the “therapeutic way” she used her diary.
Gentile (2006) described a similar case in her analysis of the dia­
ries of Hannah, a bulimic woman. The diaries were kept from
early adolescence. Gentile tracked the way that Hannah used her
diaries to create an externalized space, a third area of experienc­
ing. Gradually through her writing, Hannah was able to develop
the capacity to discriminate between self and object and to sym­
bolize her traumatic experiences. This, together with therapy, led
to psychological recovery.

DISCUSSION

In all three cases there is evidence to suggest the operation of sa­

domasochistic pathological organizations. Overwhelming anxiety
instigates the activation of the latent psychic skeleton. In the three
cases psychic vulnerability, that is, an impaired ability for object
relations and an inability to access a third area of experiencing,
appear to necessitate engagement with the organization. In all
three cases too, profound feelings of shame and guilt about greed
underpinned the sadomasochistic organization.
Regarding the use of psychic retreats in the three cases, there
were notable differences. Jenna used the omnipotence afforded
by her starving state as a psychic retreat from anxiety, whereas
Cassie and Sarah used food and/or vomit as intermediate objects,
concrete props in their psychic retreats. Typical of restricting an­
orexics, Jenna did not use food, but the avoidance thereof, as an
intermediate object.
If one considers the nature of the anxieties that caused the
activation of the pathological organization leading to the eating
disorder, there was also some variation. Jenna’s anorexia began as
a result of anxiety of a paranoid-schizoid and depressive nature at
the time of puberty. She used her anorexia as a way of not having
to attempt the challenges of genitality, but rather to retreat to a
“chemically induced” “hibernation” state. Cassie’s psychic retreat
began in the period of anticipation of the binge. When she did
finally allow herself to partake, her omnipotence faded and over­
whelming anxiety returned. As a result of this she renewed her
reliance on her pathological organization in the aftermath of the
PATHOLOGICAL ORGANIZATIONS 249

binge. Cassie’s anxiety was paranoid-schizoid and depressive in na­

ture, felt in relation to her object relations and sexuality. Sarah, on
the other hand, appeared to use her ritualized bouts of “out of
control” eating and vomiting as psychic retreats from her anxiety
about separation and individuation as well as guilt about her greed.

CONCLUSION

In this paper I have argued that many of the commonalities found

in eating disorders can be ascribed to particular sorts of sadomas­
ochistic pathological organizations (Steiner, 1982, 1993) opera­
tive across the spectrum of eating disorders and functioning in a
particular manner. Case material from three women—a recover­
ing anorexic, a binge eater, and a bulimic—were used to demon­
strate the specific ways that food and the body are used concretely
for psychic retreat from overwhelming anxiety. It was proposed
that both the similar pathological organizations but different psy­
chic retreats function as a “psychic skeleton” around which the
unique psychodynamics of each eating-disordered patient become
arranged. In eating disorders, food and bodily products seem to
operate as intermediate objects, concretely in the place of an ob­
ject. In this way the separateness of the object is denied. Food
used instead of an object relationship seems function to deny and
substitute for said object, rather than representing it This enables
the patient’s feelings of omnipotence and self-reliance, allowing
her to disavow the needs of her libidinal self for an object to meet
the need. Hence a psychic retreat is resorted to, rather than a
third area/transitional space, as the latter involves a true aware­
ness of separation between self and object.

NOTES
1. The feminine pronoun will be used throughout the paper because the case
material derives from female patients, which is reflective of the predomi­
nance of eating disorders in the female population.
2. See Kadish (2011).
3. Oedipal concerns are highlighted in eating disorders, and each case present­
ed in this paper includes oedipal issues; however, a thorough exploration is
beyond the scope of this paper.
4. Shipton (2004) describes a similar dynamic in her patient “Amy.”
250 YAEL ADIRA KADISH

5. This journal excerpt formed part of the data for a research project titled On
the Relationship between Anxiety and Binge in Bulimia Nervosa: A Qualitative Study,
undertaken at the University of the Witwatersrand, by Yael Kadish, 2000.

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