Copyrighted Material. For use only by pinc2011. Reproduction prohibited.

Usage subject to PEP terms & conditions (see terms.pep-web.org).

PROD #: 003

Psychoanalytic Psychology Copyright 2003 by the Educational Publishing Foundation

2003, Vol. 20, No. 1, 103–116 0736-9735/03/$12.00 DOI: 10.1037/0736-9735.20.1.103

THE SUBJUGATION OF THE BODY IN

EATING DISORDERS
A Particularly Female Solution
Susan H. Sands, PhD
Psychoanalytic Institute of Northern California

Object relations theorists have explained the ruthless control of the body seen in
eating disorders as an attempt to dominate the bad maternal object. It is more
useful clinically to view it as an attempt to subjugate one’s needy self experi-
ence. The patient’s vehement denial of need makes it much more difficult to
develop a self-object transference. The split between needing and not needing in
the patient’s subjectivity is reciprocally related to a specific split in the thera-
pist’s subjectivity between worry and neglect. Many more women than men
develop eating disorders because women are more likely to use their bodies to
contain their disavowed, intolerable need states, whereas men are more likely to
experience the Other in this way.

It is by now generally accepted that eating disorders serve essential self-regulatory func-
tions (Gehrie, 1990; Geist, 1985; Goodsitt, 1985; Kohut, 1977; Sands, 1991). The disor-
dered relationship to food has been viewed, essentially, as filling in for a missing bond
with a self-regulating Other. We have not, however, adequately explained why individuals
who use eating disorders to regulate themselves and their environment ruthlessly control
and attack their bodies in the process. In this article, I explore why it is that the particular
self- and mutually regulatory (Lachmann & Beebe, 1996) processes seen in eating dis-
orders necessarily involve the violent subjugation of the body—and how these subjugation
processes are generated intersubjectively and intrapsychically inside and outside of the
analytic relationship. In so doing, I revisit another question I first considered over a decade
ago (Sands, 1989)—the question of why women are so much more likely than men to
develop eating disorders. My discussion will revolve around the different strategies that
women and men employ to manage the psychic pain that develops when basic needs go
unmet in a chronically unempathic environment.

Susan H. Sands, PhD, faculty, Psychoanalytic Institute of Northern California.

An earlier version of this article was presented at the 23rd Annual International Conference on
the Psychology of the Self, Chicago, November 12, 2000.
Correspondence concerning this article should be addressed to Susan H. Sands, PhD, 1664
Solano Avenue, Berkeley, California 94707. E-mail: susansands@earthlink.net

103
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

104 SANDS

The Subjugation of the Body

Object relations theorists, both American and European (e.g., Birksted-Breen, 1989;
Boris, 1994; Chasseguet-Smirgel, 1995; Fischer, 1989; Palazzoli, 1981; Sugarman &
Kurash, 1982), have explicitly addressed the violent domination of the body seen in cases
of eating disorder. They have emphasized these patients’ equation of the body and the bad,
maternal object; their consequent fear of their own bodies; and their desperate attempts to
separate their bodies from those of their mothers. Chasseguet-Smirgel (1995) has de-
scribed how the frightened girl can experience her bodily changes at puberty as if her
mother’s body were being imposed on her from the outside. She concluded that “the aim
of anorexia is to triumph over the body-as-mother” (Chasseguet-Smirgel, 1995, p. 459).
According to Palazzoli (1981), the anorexic is more afraid of her own body than she is of
food; the body has become “a threatening force that must be held in check” (p. 86).
Chasseguet-Smirgel (1995) noted that individuals with eating disorders often engage in
other body-attacking activities as well, like skin picking or violent masturbation. Sepa-
ration from the maternal object, therefore, has been viewed as the motivation behind the
tyrannizing of the body by object relations writers as well as those from other orientations
(e.g., Bruch, 1973).
While I agree that separation problems are salient, I think it is more useful clinically
to conceptualize the subjugation of the body as an attempt to dominate one’s needy self
experience rather than the maternal object. The eating disordered individual is seeking to
obliterate her whole early experience of need for and dependence on a chronically unat-
tuned and unresponsive Other, as need has too often brought with it painful feelings of
shame, helplessness, and rage. In the language of Lachmann and Beebe (1996), chronic
interactional misregulation has led to solitary, drastic self-regulation.
It is true of course—as object relations and drive theorists have taken pains to point
out—that these patients find certain bodily experiences of need, like hunger or sexual
feelings, particularly disorganizing and that they specifically target these bodily experi-
ences for obliteration. But I think it is misleading—a red herring—to assume therefore that
the bodily impulses are at bottom the fearsome forces. These patients fear all experiences
of relational need, not just bodily ones (Sands, 1991, 2000), because their yearnings have
not received the kind of attuned responsiveness that would allow their symbolization and
integration into the central personality (Kohut, 1971, 1977; Stolorow, Brandchaft, &
Atwood, 1987). The body’s desires, because of their urgency and inescapability, are but
particularly vivid and dramatic concretizations of overwhelming, early need. These pa-
tients are as afraid of their desires for soothing, admiration, love, or any other emotional
nourishment as they are of their appetites for food or sex. They fear any affective,
relational experiences that make them feel out-of-control, messy, or “too much,” because
they do not have the ability to metabolize intense affect. That is why most individuals with
eating disorders are alexithymic to a greater or lesser degree and why their ability to make
emotional contact through language is disturbed (Rizzuto, 1988). They have put into body
what cannot be put into mind.1
The concretization (Stolorow et al., 1987) of neediness in the body serves several
important self-regulatory functions. First, if the experience of needy dependency is dis-

1
Although it is of course true that individuals with eating disorder symptomatology represent
a wide range of psychodiagnostic configurations, it is my clinical experience that the psychic
constellation that I am describing here, organized around the vehement denial of need through the
subjugation of the body, cuts across diagnostic categories.
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

SUBJUGATION OF THE BODY IN EATING DISORDERS 105

placed to the body, it becomes not-me, and the patient’s conscious experience of self can
remain strong, admirable, and invulnerable. The patient can maintain that she emotionally
needs nothing from anyone else. She remains locked in an omnipotent, closed system,
proudly invested in her own self-sufficiency rather than in other people.
Second, concretizing neediness in the body makes it more possible to actually manage
and tyrannize such needs. Because the body can be coerced, starved, and cleaned out in
a way that purely affective experience cannot, eating disorders provide a concrete, doable
solution to the experience of intolerable, overwhelming affect and need. The efficacious-
ness of the strategy is particularly obvious in bulimia. When the bulimic individual finds
herself completely overwhelmed by unmanageable affect, she can create an analogous
experience in her body by stuffing herself to the bursting point, then quickly getting rid
of the excess through purging. Hence, both the problem—“my body is too full”—and the
“solution”—empty it—become reassuringly obvious.
Third—the bottom line, of course—is that the eating disordered individual’s subju-
gation of her body serves a relational, mutually regulating function by protecting the bond
with her needed Other. When she as a child first began to look to her body to soothe
herself all by herself, she was trying to regulate the caregiving relationship by “dissocia-
tively cleansing” herself of any needs or affects which might disrupt or burden her
caregivers (Sands, 1994, 2000). Because she could not offer her overwhelming distress to
the Other in the hopes of finding comfort, she had to put her distress into her body, where
she could contain it (somewhat) through a process of internal subjugation that I will
describe shortly. The upshot was that the caregivers were “excused” from being asked to
meet her needs and failing, and the child was protected from her shame, disappointment,
and rage at their failure to respond. The child was saying, in essence, “since I don’t have
needs and desires, you are not failing to meet them.” In this way, the caregivers were
shored up and could remain idealizable enough.
The particular kind of self-regulatory process I am calling “bodily subjugation” op-
erates by means of a vertical split in the personality. Counterposed against the needy
domain of self experience is the more omnipotent sector whose aim it is to dominate, or
even kill off, all that is experienced as small, weak, needy, and dependent. This vertically
split-off, grandiose, omnipotent domain of the personality (A. Goldberg, 1999; Kohut,
1971, 1977), which I have discussed previously in relation to bulimia (Sands, 1991),
develops in compliance with the caretakers’ wishes for a “needless,” admirable child by
defending against the depression and annihilation anxiety which accompany unmet de-
velopmental longings. It takes “need” out of relationship in order to preserve relationship.
And there are other benefits as well. The omnipotent sector invites and is gratified by the
admiration of the Other for its “strength” and precocity. And its brutal regimentation of
eating or frenetic activity “plunders” the body for sensory arousal or stimulation, coun-
teracting inner feelings of deadness by providing experiences of pseudovitality and pseu-
dointegration (P. Goldberg, 1995). Thus, this subjugation strategy, despite its violence to
the needy self state, actually feels to the patient like the safest, most self-protective route.
The internal subjugator is experienced as the internal protector. In the words of General
Westmoreland, it “bombs the village in order to save it.”
The omnipotent, subjugating part can also be seductive and “tricky,” qualities which
I think are most evocatively described by the neo-Kleinian concept of pathological orga-
nization. The more dependent part of the personality is kept in thrall to and imprisoned by
the more tyrannical part, which takes a mocking view of human relationships and prom-
ises protection as well as easy solutions to all of life’s problems (e.g, Meltzer, 1973).
Meltzer (1973) describes how the tyrannical part can be “tricky,” confusing what is good
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

106 SANDS

and bad, strong and weak. A good example of such confusion is the anorexic’s conviction
that the emaciated body is beautiful and strong. The subjugating sector, like any addictive
aspect of the personality, can seduce or shame the individual into “bad” behavior with all
kinds of twisted or semidelusional rationalizations—in the case of the anorexic, for
example, encouraging self-starvation with such thoughts as “I’m fat” or “I really don’t
need food to survive.” The crucial point is that while the subjugating domain of the
personality uses cruel methods, its ultimate aim is life-sustaining and protective in that it
seeks to protect the individual from the shame, terror, helplessness, and aloneness which
result when one is forced to depend on an unreliable Other.
The situation, however, is more complicated. The needy sector—like any oppressed
population—cannot simply comply, and rises out of repression time and again and rebels
against the Tyrant by means of the disordered eating activities. It insists on getting “fed”
or, more fundamentally, on getting “hers” through bingeing in the case of the bulimic or
through Epicurean obsession in the case of the anorexic. The relationship to food is often
described as a love affair—furtive, passionate, and dangerous. Food is fantasied as a
trustworthy and reliable archaic Other over whom she has omnipotent control. The eating
(or not eating) rituals provide fleeting selfobject experiences and hold the place of the
self-regulating Other in her psyche (Gehrie, 1990; Geist, 1985; Goodsitt, 1985; Kohut,
1977; Sands, 1989, 1991)—even though at the same time food can be viewed with
tremendous suspicion and fear and, once inside the body, as persecutory. Food is, of
course, a particularly compelling selfobject substitute, as it is developmentally a first
bridge between self and other—the first medium for the transmission of soothing and
comfort. Indeed, the way the patient relates to food eerily reflects the ways she has been
forced to relate to the frustrating others in her life—longed for, deprived of, greedily
gobbled up, restricted, idealized, or rejected—but not able to be taken in in the calming,
incremental way which builds internal structure and capacities.
Thus, as I have argued previously (Sands, 1991), an eating disorder is always para-
doxical; it attacks and subjugates basic needs at the same time that it offers an avenue for
attending to them. It works in two ways simultaneously: first, it bolsters grandiose self-
sufficiency through Herculean control of the body, thereby defending against the depres-
sion accompanying thwarted narcissistic needs; second, it expresses and in some ways
gratifies these needs through the attempted selfobject relationship to food.

Why Women?

If the foregoing is true, then we must ask, Why is it that women are so much more likely
than men to develop eating disorders? Men are certainly not immune to the psychic pain
that goes hand in hand with unmet narcissistic need. The problem of neediness is arguably
even more desperate for men, who must also contend with the societal strictures against
male vulnerability and dependency. So what do we make of the 1 to 10 male–female ratio
for diagnosable eating disorders?
Societal explanations have been emphasized in the eating disorders literature and
popular press—particularly our society’s impossible standard of slimness for women.
Eating disorders have also been seen both as exaggerations of and rebellions against the
female role (e.g., Wooley, 1991). As mentioned above, object relations views have em-
phasized the onslaught of bodily changes at puberty and the girl’s need to separate her
body from that of her mother (e.g., Chasseguet-Smirgel, 1995; Palazzoli, 1981). I have
previously suggested (Sands, 1989) three reasons why women may be more likely to
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

SUBJUGATION OF THE BODY IN EATING DISORDERS 107

develop eating disorders than men: first, the distorted, overstimulating mirroring of the
little girl’s body in our society and consequent choice of the body pathway to express
concerns relating to exhibitionism and shame; second, the lack of idealizable female role
models to provide regulating functions and consequent use of eating disorders to aid in
self-regulation; and third, the tendency for girls to be used by their mothers as narcissistic
extensions more often than boys and consequent use of eating disorders to define and
delimit the developing self as separate from the maternal object.
I would now like to explore another possible explanation of why so many more
women than men turn to eating disorders—an explanation which grows directly out of the
above discussion of the body’s role in managing unmet need. Both men and women who
have not been adequately nurtured share the lifelong challenge of managing intolerable
affect, but their strategies are quite different. I suggest that while men are more likely to
experience the Other as embodying their disavowed, intolerable need states, women are
more likely to experience their own bodies in this way. In the language of Bion, one could
say that while men are more likely to use the Other to attempt to contain their dependency
needs, women are more likely to use their own bodies for containment. I think this is why
many more men than women use sexual perversions to manage the intolerable affect states
associated with their thwarted narcissistic needs, whereas women are more likely to
develop eating disorders, cutting, or other body-harming behaviors.2 I must emphasize, of
course, that these gender distinctions are not hard and fast and that at times both men and
women may use either strategy. Jessica Benjamin (1998) wrote of the process by which
the boy gets rid of intolerable feelings of helpless passivity:

Originally the mother’s containing function actually ought to protect the child from helpless
overstimulation. . . . But if the boy is barred from incorporating that function through iden-
tification, of if he is too flooded to develop ownership of desire, what does he do? He must
develop a defensive activity. Unable to be his own container, he must instead defensively use
the activity of discharge into the object who contains. (p. 56)

Benjamin described the process by which the boy “splits” the oedipal mother, pre-
serving the more agentic, desiring aspects in his own consciousness and projecting the
helpless dependency onto a feminine object. The “normative” result of this process is the
widespread cultural denigration of women. But if there is significant early environmental
failure, the boy (then man) may also need to develop some strategy, like a sexual per-
version or addiction, to deny his neediness and, at the same time, to regulate his over-
whelming affect states. He “operates” on the Other in such a way as to objectify and
omnipotently control it in order to deny his dependency on the Other and, in so doing, to
temporarily vitalize and solidify his experience of self.
Benjamin does not in her discussion detail what the unresponded-to little girl does
with her helpless dependency, but she has suggested (Jessica Benjamin, personal com-
munication, 1999) that the little girl may as part of her identification with the containing
function of the mother use herself as her own container. In my view, she specifically
attempts to use her own body as a container by concretizing in the body her unmet,
developmental yearnings, where she can more easily subjugate those yearnings through
disordered eating as discussed above. (The above holds true as well for those who practice
delicate self-cutting—a surprisingly common symptomatic response to severe childhood

2
Eating disorders have been viewed as female perversions (Chasseguet-Smirgel, 1995; A.
Goldberg, 1999).
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

108 SANDS

trauma among women but hardly ever among men.) At the same time, of course, the little
girl comes to fear her own body, because in fact it functions more as receptacle than
container, and she can never successfully metabolize or even subjugate the unprocessed
affect that it carries. I should add that it seems intuitively plausible to me that the female
reproductive potential—namely, the abilities to contain another body in one’s own and to
feed another with one’s own body—must contribute to women’s use of their own bodies
to contain dependency needs.
When we look to the internal fantasies of men and women—the world to which we
therapists have privileged access—we do find the differences I am describing, although of
course the differences are highly confusing and complex. In women, we see many more
anxieties and obsessions about food intake—specifically the fear of being unable to
regulate that intake. In the inner world of men we see more anxieties and fantasies
involving domination of the Other via sex or aggression or both—particularly when the
Other is perceived as someone one urgently needs, like a sexual partner or person in
authority. Here we see how the reality of the sexed body influences the mind’s preferred
defenses (Elise, 2000); the man “penetrates” the Other and deposits his neediness there,
while the woman “receives” her neediness in her own body cavity where she can, alter-
nately, fearfully experience or fearfully tyrannize her “hunger.” Stoller (1975) has called
perversion an erotic form of hatred. I believe that eating disorders are an autoerotic form
of hatred. In both cases the hatred is of the needy self.
One could certainly point to many “male pattern” behaviors which are examples of
men subjugating their bodies, like excessive exercise or substance abuse or not taking care
of their health (Courtenay, 2000). But very few men subjugate their bodies through their
actual eating behaviors. Why? I think that, in subjugating their bodies, men and women
are addressing different anxieties about body image. Recent research in men’s health
(McCreary, 2000) suggests that men’s bodily anxieties center around being too small; they
have what is termed a “drive for muscularity.” Women are worried about being too heavy
and have a “drive for thinness.” So while both men and women are anxious about
dependency, I would argue that they are concerned with what I might call different
“edges” of dependency. Men more often fear the passive–helpless edge of dependency:
being too “little.” Women are more likely to fear the greedy–desiring edge of dependency:
being too “big.” Indeed, as many psychoanalytic feminists currently argue, men are more
comfortable than women experiencing all forms of appetite and desire (e.g., Benjamin,
1998; Elise, 2000)—hunger included. Men are certainly more at home with hearty appetite
than are women. The comic strip “Cathy” reminds us daily that a morbid obsession with
food is one way in which women can express desire and even greed at the same time that
they feel compelled to hate and attack their bodies for subjecting them to such indignities.

The Transference–Countertransference Matrix

A central problem in treatment should by now be apparent. The eating disordered indi-
vidual’s vehement denial of need for the Other makes it much more difficult for her to
form a developmental or selfobject transference—that is, a transference in which the
therapist is experienced as the longed-for Other. Because the patient’s unmet, early needs
are concretized in her body, where they are relentlessly attacked, and because they are
detoured into and experienced primarily through the eating process, they are not as
available to be mobilized in the analytic relationship. There is a notable initial absence of
selfobject transference (Sands, 1991). The “transference” is to the food or eating activity
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

SUBJUGATION OF THE BODY IN EATING DISORDERS 109

rather than to the therapist, which is why so many eating disordered patients are so often
described anecdotally by their therapists as less “accessible” than other patients and why
these patients’ true needs can remain sequestered indefinitely if the therapist does not
know what to look for and how to respond when the walled-off needs first appear.
What this means is that there is another step in the treatment of patients with eating
disorders (Sands, 1991, 2000). The patient must first understand her selfobject transfer-
ence to the food or eating process; then, only secondarily can she “shift” it onto the
therapist, where it can become intersubjectively elaborated. A similar process has been
described by Ulman and Paul (1989) in regard to substance abuse. The patient must come
to understand how her deepest relational longings have been split off into a separate self
state (Sands, 1991), quite distinct from her usual self experience, and how these longings
are experienced and temporarily gratified, as well as subjugated, primarily through her
eating disordered symptomatology. Although the patient may have been aware prior to
treatment that her disordered eating was often preceded by some sort of negative affect,
like anxiety, depression, or anger, she can now begin to let herself know more about the
heretofore disavowed state preceding the negative affect. In my experience, this is very
often the state of “wanting” or needing something from someone. The patient must be
encouraged to somehow bring this disavowed state itself into the consulting room where
the therapist can empathize directly with all of its highly paradoxical needs and functions.
We must be extremely careful to recognize the self-affirming as well as the self-
destructive intentions of the eating disordered self state and to communicate a kind of
reverence for this secret, sacred part (Sands, 1991). Because the patient’s deepest needs
are sequestered in her body, the therapist must remember the body. If we forget the
patient’s body, we forget the child in the patient. This does not mean, of course, that we
should focus in a mechanical, behavioral way on the patient’s disordered eating behaviors,
on meal plans, or the like, but rather on the subjective meaning of the bodily subjugation
process. Our respectful understanding of all the intricate workings of the eating disordered
system allows the patient to begin to transfer her early longings from the eating activity
to the therapist—to develop a genuine selfobject transference. Once the patient can ex-
perience, explore, and understand these needs in relation to another human being rather
than to the food or eating rituals, she can begin to make her “appetites” her own.
A typical countertransference response to the eating disordered patient’s insistent
denial of need through bodily subjugation is to feel quite useless and to wonder “what am
I doing here?” The patient has brought her own rigid, tried-and-true method of dealing
with need—that is, attacking her body for it—and she makes it clear that we are to be mere
bystanders to this subjugation process. We can feel that we cannot compete with the
patient’s powerful, internal system and can feel quite defeated. At the same time, however,
her need—particularly the anorexic’s—is loud and clear in the room. Her emaciated body
horrifies us. Her body cries out to be fed, even as she declares that she needs nothing. This
“pull–push” dynamic, well illustrated by Fischer (1989), provides the thorniest transfer-
ence–countertransference challenge in the initial stages of working with anorexic and
other eating disordered patients. Fischer (1989) characterized the patient’s communication
thus: “I feel so helpless, inadequate and alone—you must help me to function—but if you
do I will feel hurt and enraged—your help will make me feel more helpless and over-
whelmed—you must help me” (p. 45). In my experience, the patient’s paralyzing, double-
binding message is delivered in many forms: “I need you/I don’t need you”; “Help
me/Don’t help me”; “Admire me for my strength/See my fragility’; “Cure me/Stay away
from my symptoms”; “My life is in your hands/You have no power over me.”
Moreover, the patient’s split-off need, which is concretized in the body and attacked,
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

110 SANDS

can be experienced as emanating from the therapist and resisted (Boris, 1994). It becomes
the analyst who wants the patient to eat, to stop harming her body, not the patient.
According to Boris (1994),

[Anorexics] believe that (in Beckett’s words) the quantum of wantum is not negotiable: that
they have only to instill all the wanting that threatens to happen into their analysts and they
will feel blessedly free of want and frustration, and filled instead with serenity (p. 171). . . .
it is the other who wants, not she. She relies on this, desperately. It can get to the point where
she will die for it. (p. 174)

Of course, the anorexic’s life-threatening situation puts actual pressure on the therapist
to behave in such a way as to give substance to the patient’s fears by hospitalizing her, and
so on. Boris advises therapists to not want anything from their patients in order to not play
into their projections. What Boris does not say explicitly, however, is that the patient,
at the same time that she is ridding herself of her need, is also staying connected to her
need through her food obsessions and by “experiencing-it-through-the-other” (Sands,
1997, p. 691, 1998).
As Arnold Goldberg’s group has amply illustrated (A. Goldberg, 1999), a vertical split
in the patient is always accompanied by a similar split in the therapist. As will be shown
in the case illustration which follows, it is my experience that a very particular split in the
therapist’s subjectivity is likely to arise in reciprocal relationship to the split between
needing and not needing in the eating disordered patient. This split is characterized by an
oscillation between worry and neglect. The therapist alternately becomes overconcerned
and overactive, then oblivious and neglectful, in response to the patient’s ominous physi-
cal condition. Stated differently, each part of the patient develops its own transference to
us (Sands, 1994) who, in turn, develops our own separate countertransference responses
to each part. If we can contain the warring, oscillating states of worry and neglect in
ourselves, we can better understand and “hold” the extremities of the patient’s experience.
In particular, it is our ability to address both sides of the patient’s split between needing
and not needing in the same interpretation that allows the patient to hold both parts in
mind simultaneously. The patient’s long-disavowed need states can then slowly make
their way into the consulting room and into relationship.
Once the patient is actually experiencing her needs vis-à-vis the therapist and a
developmental transference is in place, therapeutic action can occur in a number of ways.
Very briefly, we will see a transmuting internalization process (Kohut, 1971), in which the
therapist’s regulating functions and the analytic dyad’s mutually regulating functions are
internalized by the patient. Second, there occurs a “desomaticizing” (Brickman, 1992)
process in which the affective communications emanating from the patient’s body or soma
are “translated” and symbolized by the therapist’s attuned responses into distinct affects
and thoughts. Finally, we will observe an integration process in which the therapist’s
ability to contain and “hold” the patient’s different contradictory parts simultaneously—
and to make interpretations that bridge (A. Goldberg, 1999) across the different parts—
allows the patient to bring them together in her conscious awareness.

Case Illustration

The above issues are well illustrated in the case of Bonnie, a 22-year-old woman who led
off treatment with a frightening example of bodily subjugation. She came into the first
session complaining of severe muscle weakness which she attributed to her extreme
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

SUBJUGATION OF THE BODY IN EATING DISORDERS 111

laxative abuse (up to 65 pills a day) and violent, Ipecac-induced vomiting. She said, “the
only place I can be is in the bathroom,” and she lived in a constant state of wrenching
abdominal pain caused by her laxative abuse. I immediately referred her to the internist
specializing in eating disorders with whom I customarily work, but Bonnie could not bring
herself to call him. She was afraid to see him, she said, because he “would tell me I was
overweight” and “would make me stop using the laxatives.” She expressed dismay about
her rapidly weakening state yet at the same time seemed strangely unconcerned. I felt
extremely worried yet, because of her apparent lack of fear, found myself questioning how
worried I should be.
Within a few weeks of beginning treatment, Bonnie was so weak that she was having
trouble climbing the steps to my office. At this point, I forcefully demanded that she
call the internist, and she finally went to see him. In his report to me, the internist
expressed concern and puzzlement about the muscle weakness but offered no diagnosis
beyond anorexia. I relaxed a bit. Meanwhile, over the next week or so, Bonnie continued
to appear more and more physically debilitated, even as she continued to make seemingly
productive use of her sessions. Her body said “help”; her words said “don’t help.” She
rarely brought up her physical weakness unless I did, although it was powerfully there
between us.
I was dimly aware that an insidious dynamic was already starting to develop between
us. Bonnie’s “help/don’t help” communications were helping to stimulate in me two very
different states: one an anxious need to control her, make her see the doctor and make her
stop the laxatives and Ipecac, the other a state in which I would “forget” about and neglect
her ominous physical condition as we continued to enthusiastically discuss her emotional
issues on a grown-up, symbolic level. Sometimes I was aware of having to muster my
resolve to “get past” her stoicism in order to express my concern about her weakened state
and terrible abuse of her body.
Two weeks later, when her weakness had become so severe that she was having
trouble speaking, I told her frankly how frightened I was and demanded to speak to her
father (who had seen her recently but, incredibly, had failed to react to the severity of her
condition), and she acquiesced. Her father immediately drove her to the internist, who
finally diagnosed her as having a rare and severe case of Ipecac-induced myositis. In the
sessions that followed, I had the growing sense of being more, to use Winnicott’s term,
useable to her. She ceased taking the Ipecac, and her muscle strength increased slowly and
steadily over the course of the next several months. She clearly had needed me to “hold”
her body’s needs and anxieties and, at least in this initial phase of treatment, to demand
that her body be taken care of.
Bonnie’s history was one of profound neglect. As she told it, her life began its
downward turn when she was 4 years old, when her father left the family after her mother
became involved with another man. The other man moved in and established an alcoholic,
abusive regime in the household that continues to this day. Her mother and younger
brother got the brunt of the verbal humiliations and beatings, and Bonnie became the
precociously mature caretaker of her brother and the only one who would stand up to her
stepfather. Her mother was addicted to prescription drugs as well as alcohol and put the
needs of her abusive husband before anyone else’s. Bonnie recalls how, at age 6 years, left
with a babysitter, she made phone calls all over town trying to find her mother to make
sure she was all right. Bonnie’s self-esteem revolved around her ability to “mother” her
brother and, more generally, to be what she called the “only adult in the household,” and,
indeed, she received a great deal of admiration from many people for her unusual maturity
and competence. Predictably, Bonnie’s eating disorder intensified dramatically when she
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

112 SANDS

left home to go to college in another state, and, thanks to it as well as in spite of it, she
managed to keep her guilt sufficiently at bay to maintain the physical separation from her
family. When she began treatment, she still experienced terrible survivor guilt in relation
to her brother and remained her mother’s loyal supporter and confidant.
Bonnie’s ruthless domination of her body began early in life. “I’ve hated my body
since I was 6,” she told me during the first session. “I’ve been dieting since I was 9.
Thinking about my weight has dominated my life since I was 13.” As treatment unfolded,
she became aware of how she was using her eating disorder to create an alternative self
state to dissociate unbearable feelings of rage and shame as well as to define herself as
distinct from her mother and father. She told me, “When I take Ipecac, there’s a feeling
that builds, then I’m a different person. There’s no stopping it. I feel excited, spaced out,
so focused . . . It’s mine . . . and it makes me feel separate from them.” She could see how
she used the attacks on her body both, paradoxically, to deplete and punish herself and to
feel real, strong, and alive. In regard to the laxatives, she said “it’s this secret part, a part
I have to hide because I’m ashamed. . . . Laxatives are about the pain. When I imagine not
taking them, I imagine things being too soft, not real enough.”
Bonnie’s early, unconscious recruitment of an eating disorder allowed her to create a
sense of precocious self-sufficiency and competence and to regulate and protect her
relationships with her emotionally immature caretakers. Not needing food was equated
with not needing anything from anyone. Because her biological father always seemed
“put-upon” if she wanted anything, she made a decision when she was very young to “just
not ask.” And there was fierce pride in her refusal. “I decided that if I got really skinny,
I’d show my Dad I didn’t need anything, that I was totally strong.” She summed it up this
way: “I’m good when I’m not eating. I’m bad when I’m eating.” We see here the ominous
mixing-up of what actually makes the body strong or weak, healthy or unhealthy.
Bonnie’s lifelong mission to rid herself of all bodily need was striking in its omnipo-
tence. She told me, “It’s like I don’t need food, like I can defy the laws of nature. Only
other people need food, and I’m taking from them if I eat.” Since adolescence, Bonnie had
harbored a poignant fantasy of “being grown-up,” which strikingly captured her starkly
ascetic relationship to her needs and her body. In her words, “I’m living alone in a white
apartment. Everything is white—walls, carpet, everything. Everything is clean, in order.
I’m exercising every morning early. I’m in control.” We discussed together how Bonnie
had made her body into “the white apartment” by using laxatives and Ipecac to ruthlessly
scour out her insides in order to empty herself of all human desire.
Little by little, over the first year of treatment, Bonnie’s emotional longings began to
appear. She began to be able to put into words what she had previously only been able to
put into her body. She let herself depend on me more as she depended on her eating
disorder less. She acknowledged, following my vacation, that she had “missed coming to
therapy.” She reported “saving things up” to bring to me. At the same time, she began to
feel rage at her father’s abandoning her to remarry, and along with the rage came feelings
of being entitled to get more from him: “I was first,” she declared one day, “I should come
first in getting things.” She spoke, pointedly but still carefully, to her mother about the
horrors of her childhood and allowed her mother to apologize to her. During one session,
she wondered “what would I be doing if I weren’t spending so much time thinking about
how terrible my body is?” When I asked her what she thought she would be doing, she
replied immediately, “wanting things,” then went on to talk excitedly about several jobs
she was interested in pursuing.
Over the course of the next 4 months Bonnie allowed herself to gain 10 pounds and
keep the weight on. We began tracking a back-and-forth movement from needing things
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

SUBJUGATION OF THE BODY IN EATING DISORDERS 113

to needing nothing (and thinking it was I who needed her to need things), then back to
needing again. For example, following a session in which she talked about how much she
loved to be with her boyfriend, she came in feeling anxiously guilty about abandoning her
brother and announced plans to move back to her family home to take care of him. She
revealed that she was attacking herself emotionally and physically in every possible way,
including taking more laxatives and eating less and resolutely shutting me out. When I
interpreted this as “backlash” for letting herself “have more” of her boyfriend and of me
in the previous session, she was able to return to herself and resume her exploration of her
own independent future.
I also continued tracking (usually with hindsight) that back-and-forth movement in
myself between “forgetting” and “remembering” the abuse being secretly perpetrated
against her body outside the office. We would be doing a good, consistent piece of work,
and then I would suddenly “wake up” and remember her body. We would find out later
that during those times that I was “buying” her stoicism and averting my gaze from her
bodily pain, she had reverted to using the Ipecac again or was even more ruthlessly
scouring her body with laxatives. My own oscillations between neglect and worry were,
in retrospect, a few times shockingly long, for periods of weeks or even months. One time,
after “waking up,” I spoke to her about my failure to remember her body, and I added that
I thought I could now better understand what it was like for her to have two, such separate,
states of mind. We discussed how my “neglect” replayed her family’s neglect of her and
led her into having to be strong on her own—and deeper and deeper into dangerous
waters.
The terror on the other side of the eating disorder was revealed in a particularly
stunning moment. Bonnie told me, “Last week in the hotel, getting out of the shower, I
caught myself in the mirror by surprise. I suddenly saw myself as ‘nonfat.’ I felt total
panic. I thought, ‘Where do I go?’ ” In this telling moment, she found herself “naked” with
herself, stripped of her organizing obsession, with nothing to subjugate her true needs and
longings, with nothing to contain all her unmanageable affect. She suddenly felt terribly
alone with all of it—without her internal subjugator “bodyguard” to help her. It was a
terrifying moment. But after we had spent some time understanding this together, she was
able to relax again into herself and refind her own developmental momentum. And so it
continued to go between us, back and forth, needing to needless, needless to needing, as
she inched ahead.

Case Discussion

Bonnie’s treatment has elements in common with those of many other eating disordered
patients I have seen. The patient’s history was one of severe emotional deprivation, which
forced her into an early, solitary self-regulatory regimen of food restriction and rigid
bodily control. Her eating disorder allowed her to create a proud and precocious sense of
self-sufficiency and strength. Not needing food was equated with not needing anything
from anyone, and, therefore, not having to endure the shame of exposing the soft under-
belly of her need to neglect, attack, or rebuff. Making her body the repository of early,
intolerable need states allowed her to experience them as “not me” and made it possible
for her to attack and ruthlessly control them. In addition, it also protected the bond with
her caregivers by “cleansing” herself of any needs that might overburden or threaten them.
The patient presented initially with an unusual and dramatic example of bodily sub-
jugation. She was in a severely weakened state, which could not be adequately explained
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

114 SANDS

by her laxative abuse and vomiting and about which she seemed oddly unconcerned. Her
frightening physical condition coupled with her stoic, self-sufficient stance made me
alternately frantic with worry and puzzled about how worried I should be. This initial
crisis was resolved when active intervention on my part led to medical diagnosis and
gradual recovery. The stage, however, had been set for a particular transference–
countertransference enactment.
The drastic self-regulation offered by my patient’s well-established system of bodily
subjugation was so “effective” that her conscious experience of desire had virtually
disappeared. Thus, it was initially impossible for her to develop a developmental or
selfobject transference—that is, a transference of early need. Her emotional longings were
either directed toward the disordered eating process or experienced as emanating from me.
Her eating disorder, like all eating disorders, functioned paradoxically both as an avenue
for attending to and gratifying basic needs and as a means of rigidly controlling and
punishing herself for them.
As she settled more into treatment, the patient’s long-banished, developmental long-
ings (and rage at her deprivations) began to appear. The patient began to be able to bring
her archaic need states into the room and to experience them more in relation to me. In
more technical terms, her “transference” began to shift from the disordered eating process
onto me, and with this shift came the beginnings of a “desomatization” process. The
patient began to be able to put into words what she had once put into her body.
I continued to track a back-and-forth movement between the patient’s states of need-
ing and not needing me and to link these to transference fears and disappointments. With
mounting dismay, I also watched my own states shift precipitously between “forgetting”
about the patient’s ominous physical condition and “remembering” with horror the harm
the patient was inflicting on her body. At times I had to forcefully remind myself to
remember her bodily subjugation. I came to realize that these distinct and separate states
of “worry” and “neglect” were reciprocally related to the patient’s oscillating states of
needing or not needing me. When I was in the “worry” stance, I felt an anxious need to
control her and force her to take care of her body or to take care of it for her. In the
“neglect” position, I would “forget” about her dire physical state and join with her in what
I saw as solid psychoanalytic work, while the patient’s bodily tyranny would continue to
operate silently outside of the office. This perplexing and dangerous transference/
countertransference enactment arises, in my experience, most blatantly with those eating
disordered patients whose bodily abuse is severe.
The patient was bringing her childhood into my office, testing to see if I really wanted
her to be my good, no-trouble-at-all child whom I did not have to worry about. I was
encouraged to ally with her grandiose self-sufficiency and pseudomaturity just as her
parents had done. In forgetting about her body, I was forgetting about her child self. She
was taking care of me by not overwhelming and depleting me with her repulsive needs
but, instead, feeding me delicious psychoanalytic insights. My “neglect”—the disavowed
part of myself—was helping to perpetuate the disavowal of the needy part of herself. My
disavowal was enabling hers, hers mine, in an endlessly repeating cycle.
My attempts to acknowledge the glaringly separate and contradictory parts of myself
to myself and to my patient helped me better understand, from the inside out, the recip-
rocal split in my patient’s subjectivity. Living-through my own states of worry and neglect
helped me “hold” the patient’s oscillating states of needing and not needing and allowed
us to stay in contact with her emerging needs as she refound her developmental thrust. As
I struggled to mend the worry/neglect division in myself (A. Goldberg, 1999), I found a
more secure platform from which to generate interpretations that addressed both the needy
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

SUBJUGATION OF THE BODY IN EATING DISORDERS 115

and not needy parts of the patient. She could be strong and needy. She could long for my
admiration and help. She could think about both sides at the same time. She could
experience both parts in relationship to one object—myself (Bromberg, 1994). As the
patient became more able to hold both parts in mind simultaneously, she could begin the
difficult process of integrating her long-disavowed “appetites” into her ongoing, lived
experience.

References
Benjamin, J. (1998). Shadow of the other. New York: Routledge.
Birksted-Breen, D. (1989). Working with an anorexic patient. International Journal of Psycho-
Analysis, 70, 29–40.
Boris, H. (1994). Sleights of mind: One and multiples of one. New York: Jason Aronson.
Brickman, B. (1992). The desomaticizing selfobject transference: A case report. In A. Goldberg
(Ed.), Progress in self psychology (Vol. 8, pp. 93–108). Hillsdale, NJ: Analytic Press.
Bromberg, P. (1994). “Speak! That I may see you”: Some reflections on dissociation, reality, and
psychoanalytic listening. Psychoanalytic Dialogues, 4, 517–547.
Bruch, H. (1973). Eating disorders: Obesity, anorexia nervosa and the person within. New York:
Basic Books.
Chasseguet-Smirgel, J. (1995). Auto-sadism, eating disorders and femininity: Reflections based on
case studies of adult women who experienced eating disorders as adolescents. In M. Hanley
(Ed.), Essential papers on masochism (pp. 453–470). New York: New York University Press.
Courtenay, W. (2000). Constructions of masculinity and their influence on men’s well-being: A
theory of gender and health. Social Science and Medicine, 50, 1385–1401.
Elise, D. (2000). Women and desire. Reasons women may not want to want. Studies in Gender and
Sexuality, 1, 125–145.
Fischer, N. ( 1989). Anorexia nervosa and unresolved rapprochement conflicts: A case study.
International Journal of Psycho-Analysis, 70, 41–54.
Gehrie, M. (1990). Eating disorders and adaptation in crisis: An hypothesis. Review of Psychiatry,
9, 369–383.
Geist, R. (1985). Therapeutic dilemmas in the treatment of anorexia nervosa: A self-psychological
perspective. Contemporary Psychotherapy Review, 2,115–142.
Goldberg, A. (1999). Being of two minds: The vertical split in psychoanalysis and psychotherapy.
Hillsdale, NJ: Analytic Press.
Goldberg, P. (1995). “Successful” dissociation, pseudovitality and inauthentic use of the senses.
Psychoanalytic Dialogues, 5, 493–509
Goodsitt, A. (1985). Self psychology and the treatment of anorexia nervosa. In D. Garner & P.
Garfinkel (Ed.), Handbook of psychotherapy for anorexia nervosa and bulimia (pp. 55–82). New
York: Guilford Press.
Kohut, H. (1971). The analysis of the self. New York: International Universities Press.
Kohut, H. (1977). The restoration of the self. New York: International Universities Press.
Lachmann, F., & Beebe, B. (1996). The contribution of self- and mutual regulation to therapeutic
action: A case illustration. In A. Goldberg (Ed.), Progress in self psychology (Vol. 12, pp.
123–140). New York: Analytic Press.
McCreary, D. (2000). An exploration of the drive for muscularity in adolescent boys and girls.
Journal of American College Health, 48, 297–304.
Meltzer, D. (1973). Sexual states of mind. Strathtay, Perthshire, Scotland: Clunie Press.
Palazzoli, M. S. (1981). Self-starvation: From individual to family therapy in the treatment of
anorexia nervosa. New York: Jason Aronson.
Rizzuto, A. (1988). Transference, language, and affect in the treatment of bulimarexia. International
Journal of Psycho-Analysis, 69, 369–387.
Copyrighted Material. For use only by pinc2011. Reproduction prohibited. Usage subject to PEP terms & conditions (see terms.pep-web.org).

116 SANDS

Sands, S. (1989). Female development and eating disorders: A self psychological perspective. In A.
Goldberg (Ed.), Progress in self psychology (Vol. 5, pp. 75–104). New York: Analytic Press.
Sands, S. (1991). Bulimia, dissociation and empathy: A self-psychological view. In C. Johnson
(Ed.), Psychodynamic treatment of anorexia nervosa and bulimia (pp. 34–50). New York:
Guilford Press.
Sands, S. (1994). What is dissociated? Dissociation, 7, 145–152.
Sands, S. (1997). Protein or foreign body? Reply to commentaries. Psychoanalytic Dialogues, 7,
691–705.
Sands, S. (1998). Reply to Stolorow, Atwood and Orange. Psychoanalytic Dialogues, 8, 727–730.
Sands, S. (2000). Self psychology therapy. In K. Miller & J. Mizes (Eds.), Comparative treatments
of eating disorders (pp. 182–205). New York: Springer Publishing Company.
Stoller, R. (1975). Perversion: The erotic form of hatred. New York: Pantheon Books.
Stolorow, R., Brandchaft, B., & Atwood, G. (1987). Psychoanalytic treatment: An intersubjective
approach. Hillsdale, NJ: Analytic Press.
Sugarman, A., & Kurash, C. (1982). The body as a transitional object in bulimia. International
Journal of Eating Disorders, 1, 57–67.
Ulman, R., & Paul, H. (1989). A self-psychological theory and approach to treating substance abuse
disorders: The “intersubjective absorption” hypothesis. In A. Goldberg (Ed.), Progress in self
psychology (Vol. 5, pp. 121–142). Hillsdale, NJ: Analytic Press.
Wooley, S. (1991). Uses of countertransference in the treatment of eating disorders: A gender
perspective. In C. Johnson (Ed.), Psychodynamic treatment of anorexia and bulimia (pp. 34–50).
New York: Guilford Press.
PEP-Web Copyright

Copyright. The PEP-Web Archive is protected by United States copyright laws and international treaty provisions.
1. All copyright (electronic and other) of the text, images, and photographs of the publications appearing on PEP-Web is retained by
the original publishers of the Journals, Books, and Videos. Saving the exceptions noted below, no portion of any of the text, images,
photographs, or videos may be reproduced or stored in any form without prior permission of the Copyright owners.
2. Authorized Uses. Authorized Users may make all use of the Licensed Materials as is consistent with the Fair Use Provisions of
United States and international law. Nothing in this Agreement is intended to limit in any way whatsoever any Authorized User’s
rights under the Fair Use provisions of United States or international law to use the Licensed Materials.
3. During the term of any subscription the Licensed Materials may be used for purposes of research, education or other
non-commercial use as follows:
a. Digitally Copy. Authorized Users may download and digitally copy a reasonable portion of the Licensed Materials for their own use
only.
b. Print Copy. Authorized Users may print (one copy per user) reasonable potions of the Licensed Materials for their own use only.

Copyright Warranty. Licensor warrants that it has the right to license the rights granted under this Agreement to use Licensed
Materials, that it has obtained any and all necessary permissions from third parties to license the Licensed Materials, and that use of
the Licensed Materials by Authorized Users in accordance with the terms of this Agreement shall not infringe the copyright of any third
party. The Licensor shall indemnify and hold Licensee and Authorized Users harmless for any losses, claims, damages, awards,
penalties, or injuries incurred, including reasonable attorney's fees, which arise from any claim by any third party of an alleged
infringement of copyright or any other property right arising out of the use of the Licensed Materials by the Licensee or any Authorized
User in accordance with the terms of this Agreement. This indemnity shall survive the termination of this agreement. NO LIMITATION
OF LIABILITY SET FORTH ELSEWHERE IN THIS AGREEMENT IS APPLICABLE TO THIS INDEMNIFICATION.

Commercial reproduction. No purchaser or user shall use any portion of the contents of PEP-Web in any form of commercial
exploitation, including, but not limited to, commercial print or broadcast media, and no purchaser or user shall reproduce it as its own
any material contained herein.