As I worked with my client in therapy, we reviewed once again how her efforts to deal with her sexual abuse eventually led to her eating disorder. The connection, although not logical to some, had emotional reason and logic to her. She needed to own her body, control it, and manipulate it to feel safe. Yet she needed to disown it as well, hate it, and distance herself from it, from the pain and the memories of the abuse that it held. The result was anorexia with episodes of purging. Without eating disorder treatment, her recovery from the sexual abuse or the eating disorder would not be possible. From time to time in therapy we needed to review her progress and issues that began the eating disorder in order for her to deal with the primary causes instead of just the distraction of the addiction to thinness. I have found that with cases such as these, with patients who have a history of both diagnoses, treatment is necessary, in spite of their belief that they can do it on their own.

Empirical Data

When my clients who are victims of child abuse begin their recovery process, they cope with their trauma in various ways. Researchers have found that the more excessive, lengthy, or frequently the patient was sexually abused, the more problematic and pathological the survival responses are probable to become. Other factors such as the level of trust between the victim and abuser as well as the developmental stages of the patient also affect how the abuse will be experienced (http://nccanch.acf.hhs.gov; Chalk, Gibbons, & Scarupa, 2002). Research also suggests that children who suffered sexual abuse as a child self-harm more often than their non-abused counterparts. When researchers (Gibson, 2005; Gratz; Van der Kolk, Perry, &Herman, 1991; Simeon & Hollander, 2001; Zlotnick, Mattia, & Zimmerman, 1999; Zlotnick, Shea, Pearlstein, Simpson, Costello, & Begin, 1996) studied participants who engaged in self-harm, which was described as the “deliberate, direct destruction of body tissue that results in tissue damage,” they found that self-harmers had a greater likelihood of experiencing insecure attachments, childhood sexual and physical abuse, and neglect from caregivers. These researchers found that this population are especially vulnerable to eating disorders, personality disorders (borderline, antisocial), post traumatic stress disorder, and substance abuse to name just a few. (Simeon & Hollander, 2001; Zlotnick et al., 1999;Zlotnick, et al., 1996). The Department of Health and Human Services approximated that over 896,000 children were abused in 2002, ten percent of these victims were sexually abused. Comparing this to the statistics that estimate fifty percent of all eating disorder clients have been sexually abused, it is safe to say that those working with this population should explore the childhood sexual history of their client. After the abuse has taken place, one of the most important priorities for the victim is self-soothing and the search for understanding of the abuse. This dulls their suffering but can lead to self-punishment or personalization of the caretakers’ abuse. Many of my clients will reenact the abuse through sexual acting out, sexual cut-off or cutting their sexual body parts. As a therapist working with this population, it is important to help my clients realize that these behavioral reactions (cutting, burning, purging, starving, carving, etc.) are a reflection of their deep sense of hurt and betrayal rather than their inability to recover or trust others again. In the end, you ask them to confront their biggest fears; learn to trust themselves and others, and to identify an identity beyond self harm and victimization. As a clinician, I realized that these more serious disorders are developed in order for the victim to express emotional pain as if to answer the unanswerable question of, “Why would he or she treat me this way?” Many clinicians have been helpful by reframing their questions and helping clients separate out their abusive self-talk with reality.

As seen in previous qualitative literature, (Claude-Pierre, 1997), the eating disorder client has a strong “negative mind” which incessantly creates derogatory scripts of self-devaluation; creating a daily battle of depression, perfectionistism, and temptations to self-harm. As a clinician working with eating disorder clients, specifically those who suffered sexual abuse, the negative mind repeats its chilling message of self-hatred, worthlessness, shame, and being permanently damaged. Often time the clients will ask themselves, “How could this happen to me? I was so young!” The conclusion that they draw from the abuse is often times that there was something innately evil, broken, or wrong with them in order for them to deserve the abuse that they endured. As Piaget discovered, the brain cannot reason abstractly during childhood; it cannot tell the child that the perpetrator is the one that did evil to the child; instead they personalize the abuse and take responsibility for it. Hating their body, the vessel of the abuse, they dissociate and separate their sexual experiences from their reality; therefore they live with one foot in the past, identifying with the abuse and objectifying their body as the perpetrator did in the abusive experience.

Interventions

Because sexual abuse is so shaming, it becomes very difficult to speak about in therapy. Retelling the experiences over and over is usually not effective in helping the victim overcome its devastating consequences; however, having the client revisit it in order to establish a context and circumstances surrounding the abuse, is critical to the healing process. A few interventions that I find provoking and especially helpful in therapy offer the client a chance to talk about the abuse without feeling judged or shamed. When a victim is asked about their abuse, they usually begin by telling facts without feeling, as if they were reciting a movie or a time line, it becomes the telling of events without emotions. I allow them to tell their story in this way in order for me to understand the context of the abuse. During this part of the therapy process the client is usually dissociating or trying to retell the experience without having to relive it. After I understand the basic events of the trauma, I will then push them to connect the events with emotions. This may take time and you will want to make sure that your therapeutic relationship is strong and has trust.

Due to the fact that trauma is stored in the limbic system of the brain, it is not easily processed through talk therapy. Talk therapy accesses the prefrontal cortex, not the limbic system. In order to get to the trauma, I want to take the client to the area of the brain where the trauma is stored. The limbic system also is the part of the brain where people access their sensory capabilities, such as smelling, tasting, touch, sounds and sight. Therefore, asking the client to access memories using these sensory memories will have a greater impact for the client. Perhaps it is because we store trauma in the limbic system that coping with the devastation through an eating disorder seems so natural for these clients. Using the physical pain of starvation or purging, helps them to equal the emotional pain inside.

Asking the client to close her eyes, I have her envision the child or the adolescent inside of her that was traumatized. The age the client refers back to is strictly up to them and there is no right or wrong answer. I have the client walk into the room with their younger self, not during the abuse, but at a time when he or she felt that their younger self was hurting. I have the client notice what body positions the younger self is in, who is in the room with the younger child (normally they are all alone), paying close attention to how that child was feeling. I have the client observe the child before approaching her. I ask her to go talk to the younger child, approach them the way that they need to be approached, then to whisper something in the younger child’s ear. They are then to touch the child in an appropriate way; giving them a hug or leading them by the hand. I have the present self and the younger child go somewhere safe together. I have the client tell the younger child that they will be back to visit them whenever the younger child needs help; they only have to ask. This intervention can be repeated several times, with several variations, taking the younger child to a place where they can “spiritually” clean themselves, maybe having the younger child play in a waterfall that has cleansing powers to wash away all of the bad or “icky” feelings that the younger child is holding onto. Having the client journal their experiences in session is helpful for them so that they remember what the feelings of safety were like in the session. If I have a client that is too anxious to approach this experience, I will sometimes use BelleRuth Naparstak’s Health Journeys: A Guided Meditation for Healing Trauma (PTSD).This allows the client to physically relax and to gently explore some of their feelings about the sexual abuse, finding ways in which the trauma can give them “treasures” instead of giving them only torturous effects.

Other activities in therapy that might help the brain access and deal with trauma are to bring in an old pair of clothes and have the client write out memories, emotions, thoughts, and feelings on paper, then stuffing them into the clothes. When the client is ready, they can use the empty chair technique and confront and interact with the “dummy” in a way that will feel powerful to them. Getting emotions out helps the client, especially the eating disorder client, separate the trauma from their own bodies, and separate it from the eating disorder.

Additional ways of connecting the sexual abuse to the eating disorder are to have the client collect two boxes, putting in each box a symptom or problematic behavior related to the eating disorder or to their trauma symptoms. I will do education of the results of trauma so that the clients know what the symptoms are. Then, we keep a lid on the box and only open it when the client wants to talk about it or when they are manifesting a symptom. This allows the client to see how they are not their symptom or their emotion, keeping the symptoms apart and boxed up helps them to keep themselves differentiated from the trauma. This same concept can be used with clients at home when they are having flashbacks; they are to write down the flashbacks, seal them in a box and keep them closed until they can process them with someone.

Probably one of the most important needs of someone who is suffering from an eating disorder and sexual abuse is to get the pain out, in a very physical way. I have included some drawings done by a client which identifies the suffering she has felt as a result of the sexual abuse. Notice in the drawing how she expresses the pain through representations of her body. Allowing herself to get her feelings out and to make a physical representation of how the abuse physically racks her body allows herself to grieve or get angry while decreasing the need to self-harm or enter into her eating disorder cycle. This process also allows her to see what responsibility she is holding for the abuse which in turn allows us to discuss this in therapy. Activating the limbic system by throwing ice, making a graffiti wall with sidewalk chalk, or getting a massage, stimulates the senses, helping her to feel as if she can connect to the trauma and release some of the pain.

Another intervention I have used with an extremely emotional client was using a cognitive approach to help them become less emotionally fused. For example, using the obsessive/compulsive addictive cycle (Berrett, 1996) can identify core negative emotions or negative issues that may stem out of the abuse and create anxious and distorted thoughts; these thoughts later become externalized or expressed in dysfunctional behaviors. Identifying and recreating their cycle helps them to connect how the messages from the sexual abuse affect the relationship and the self harm they enact on their body. Going through their cycles you can help them find interventions that will help them to combat problematic thoughts, feelings, and behaviors. Using Burns (1980) CBT skills and interventions, help your client identify their distorted thoughts and re-frame them, tracking daily cognitive distortions. For clients who are intellectual, using interventions that provoke emotion can help your client get in touch with the sexual abuse and the underlying reasons for their eating disorders.

Lastly, family therapy has been documented to be one of the most effective ways in helping eating disorders recover. Families can be the most helpful by allowing the victim to express their feelings without shame, judgment, or by demanding details. Family members are often time exhausted from fighting the foodgames and the other symptoms of the eating disorder and do not want to be told that they are somehow to blame for these behaviors. Clients, who are usually others-oriented, are tired of minimizing their pain and suffering in silence. Using family systems theories and approaches such as Bowenian or Structural therapies, clinicians can train families to identify familial ideas, patterns, and values around perfectionism, anger, hurt, victimization, sexual values, and honesty. Family roles, rules, and unsettled business are usually always a part of helping family members come to terms with how they are involved in the client’s struggle for survival and recovery from abuse. Teaching families how to achieve differentiation, healthier boundaries, and clear roles gives the eating disorder client permission to take care of herself, instead of taking care of the family. Interventions such as increasing anxiety, forcing physical closeness by using family psychodramas, or talking for the family members are ways that I have encouraged and prompted second order change to occur in family settings.

Summary

As sexual abuse becomes more of a frequent problem other diagnoses such as eating disorders, self-harming, and personality disorders will manifest to show the intensity and the degree of the abuse and subsequent pain. Clinicians will have to be wellversed in addressing a multiplicity of issues and their symptoms in order to help families and individuals resolve and recover from the effects of sexual abuse and eating disorders. A variety of intellectual and emotional interventions will need to be used to cover all your bases. In-patient treatment might be necessary to medically or emotionally stabilize the client. Sometimes, these clients will take months or even years to recover, depending on their specific case; knowing how hard to push your client and when to ease off is a delicate balance that will be essential for the healing process to occur. Remember to recruit the family in order to create second order change. It is hard if not impossible for these victims to go back to an unstable or uneducated family and to keep their recovery process going. Be creative, and don’t be afraid to make up some interventions that you feel will reach your client’s inner child. Model a professional, but caring and warm relationship so that they can trust again.

Written by: Melissa K. Taylor, MS, LMFT

References:
Berrett, Michael E. (1996), An Obsessive/ Compulsive/ Addictive Cycle Burns, David B., (1980). Feeling Good: The new mood therapy. New York, NY: Avon Books.

Chalk, R., Gibbons, A, & Scarupa, H. J. (2002). The multiple dimensions of child abuse and neglect. New insights into an old problem. Washington, DC: Child Trends.

Claude-Pierre, P. (1997). The secret language of eating disorders. Vintage Books, New York, NY.

Gibson, L. E. (2005). Self Harm. Department of Veterans Affairs; A National Center for PTSD.

www.ncptsd.va.gov/facts/problems/fs_self_harm.html. Gratz, K.L., Conrad, S.D., & Roemer, L. (2002). Risk factors for deliberate self-harm among college students. American Journal of Orthopsychiatry, 72, 128 - 140.

National Clearinghouse on Child Abuse and Neglect Information: National adoption information clearinghouse (2005). Long-term consequences of child abuse and neglect. Washington, DC. http://nccanch.acf.hhs.gov

Simeon, D., & Hollander, E. (Eds.). (2001). Self injurious behaviors: Assessment and treatment. Washington, DC: American Psychiatric Press.

U.S. Department of Health and Human Services, National Clearinghouse on Child Abuse and Neglect Information. (2004).Child Maltreatment 2002: Summary of key findings. Washington, DC, Government Printing Office.

Van der Kolk, B.A., Perry, J.C., & Herman, J.L. (1991). Childhood origins of self-destructive behavior. American Journal of Psychiatry, 148, 1665 - 1671.

Zlotnick, C., Mattia, J.I., & Zimmerman, M. (1999). Clinical correlates of self-mutilation in a sample of general psychiatric patients. The Journal of Nervous and Mental Disease, 187, 296 - 301.

Zlotnick, C., Shea, M.T., Pearlstein, T., Simpson, E., Costello, E., & Begin, A. (1996). The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation. Comprehensive Psychiatry, 37, 12 - 16.