Summer 2006, Volume 5, Issue 3
Trauma and Eating Disorders
Trauma and Bulimia Nervosa: A Case Study
With the current issue of The Remuda Review, we continue our series of articles on common co-occurring problems faced by eating disorder patients. Throughout this series, we are considering the assessment, conceptualization, and treatment of self-injurious behavior, anxiety disorders, mood disorders, substance use, trauma, personality disorders, and other co-occurring issues within Remuda’s bio-psycho-social-spiritual model. In each article, we consider how these co-occurring issues relate to eating disorder development, symptoms, and maintenance, and, where relevant, variable manifestations based on age, development, and culture.
The present issue focuses in depth on our fifth topic: trauma and eating disorders. Eating disorder professionals have long recognized a relationship between eating disorders and trauma. Yet treating co-occurring trauma and eating disorders is complicated because, when we treat the trauma, we intensify the negative emotions that lead to eating disorder behaviors; when we treat the eating disorder and encourage patients to stop their eating disorder behaviors, we are asking them to give up a powerful method of emotion regulation on which they have relied, and hence we intensify the trauma experience. Remuda’s Trauma Treatment Model is designed to break through this conundrum and pave a safe course for counselors and patients to follow through the recovery process.
We hope the article and case study in this issue will serve as a short primer on this important topic.
Trauma and Eating Disorders
Marian C. Eberly, RN, MSW, LCSW, DAPA
Remuda Ranch Programs for Eating Disorders
“In this world you will have trouble, but take heart! I have overcome the world.” John 16:33
Eating disorder (ED) professionals have long recognized a relationship between EDs and childhood sexual abuse (CSA). Therapists often find themselves working with ED and CSA simultaneously. We therefore explore the most current research and an established, scientifically-valid, Biblically-based treatment model that addresses this complicated dual diagnosis.
ED professionals agree that CSA occurs at significant rates among ED patients. With quite possibly the largest cohort of ED patients ever evaluated for CSA (N=6033), Remuda has found that 49% of its ED patients report CSA. This is approximately 20% higher than in the general population (Connors & Morse, 1993). Clearly, CSA history should always be assessed when working with ED patients. Conversely, when counseling for CSA, providers should also consider the strong potential for EDs.
Initial research failed to find a clear etiological relationship between CSA and ED (Garner & Garfinkel, 1985; Pope & Hudson, 1992; Vize & Cooper, 1995). But more recent studies have challenged these initial findings. Researchers now agree that a history of CSA does play an important role as a non-specific ED risk factor.
Everill and Waller (1995) found a link between CSA and bulimia nervosa. Wonderlich and colleagues (1997) found that CSA is a risk factor for bulimia more than restricting anorexia nervosa, particularly when psychiatric comor-bidity is present. Others (Lating, O’Reilly, & Anderson, 2002) reported that CSA is a non-specific risk factor not only for EDs but for a range of psychiatric disorders. Wonderlich’s groundbreaking research has clarified that CSA increases binge-eating, purging, restricting, and body dissatisfaction, but that sexual trauma occurring in adulthood in the absence of CSA appears unrelated to ED behaviors (Wonderlich et al., 2000; Wonderlich et al., 2001a; Wonder-lich et al., 2001b). However, CSA plus adult sexual trauma appears to lead to the greatest ED pathology.
The mechanisms by which CSA promotes ED behavior are not entirely clear. Researchers have offered three main explanations. First, CSA increases body shame. EDs may help victims cope with this shame and may modify the body in ways that reduce shame or distress, e.g., reducing breast size. Second, CSA results in a range of psychopathology, increasing the risk of ED. Third, CSA may lead to an impairment in self-regulation, producing pervas-ive psychobiological dysregulation and a spate of impulsive behaviors, including EDs. Each of these causal pathways may work synergistically as well.
Regardless of the exact causal pathways, research strongly suggests that those who have experienced CSA have difficulties regulating their intense negative emotions (Linehan, 1993). The cardinal symptoms of EDs—restricting, bingeing, purging, and excessive exercise—all numb emotions and/or create euphoria to displace negative emotions. In short, EDs are, especially for those with intense pain related to CSA, an emotion regulation method.
Treating co-occurring trauma and ED is complicated because, when we treat the trauma, we intensify the negative emotions that lead to ED behaviors; when we treat the ED and encourage patients to stop their ED behaviors, we are asking them to give up a powerful method of emotion regulation on which they have relied, and hence we intensify the trauma experience. Remuda’s Trauma Treatment Model is designed to break through this conundrum.
The Experience of Trauma
In her groundbreaking work, Trauma and Recovery (1992), Judith Herman defined the traumatic experience: “It is an affliction of the powerless; a victim is rendered powerless by force, meaning and connection are destroyed, it is a threat to life or bodily integrity, differentiated from ordinary suffering”.
Herman is attempting to describe the indescribable. Traumatic experiences take people to a place of intense fear, affecting a part of the mind that is only accessed in extreme situations. Bessel van der Kolk and colleagues (1996) further describe trauma:
Despite the human capacity to survive and adapt, traumatic experiences can alter people’s psychological, biological, and social equilibrium to such a degree that the memory of one particular event comes to taint all other experiences, spoiling appreciation of the present. This tyranny of the past interferes with the ability to pay attention to both new and familiar situations. When people come to concentrate selectively on reminders of their past, life tends to become colorless, and contemporary experience ceases to be a teacher.
In short, the traumatic experience can become the lens through which all other life experiences are filtered.
Yet trauma survivors who have expressed their suffering in art or literature have also demonstrated the healing power of telling their story. Their testimonies yield evidence of the mind‘s ability to adapt with strength and creativity to horrific life events. Our role as counselors is to help CSA survivors to do just that, without ED behaviors.
The Therapist’s New Role
Diane Langberg, in Counseling Survivors of Sexual Abuse (1997), discusses counseling with CSA survivors who find it difficult to talk about their trauma:
The paradox, of course, is that in order to heal at all, from such violence, one must learn to speak the unspeakable… What is too terrifying to hold for long moments, in the mind must be remembered and reflected upon. That which is utterly impossible to put into words, must finally be spoken about again and again. Not only must the indescribable be described, but that which so powerfully isolates one human being from others must be uttered within the context of relationship if healing is ever to occur.
The therapist needs to embrace a holy regard for the intolerable suffering of the afflicted and realize that it is a high calling to enter into a healing relationship with those who have the courage to reach out beyond this pain. Langberg reminds us of the words of Elie Wiesel, a Holocaust survivor who was able to articulate in writing his encounter with trauma. He says that one who was not there can never begin to understand it, and one who was there can never communicate it. Wiesel tells us that we cannot speak for, or instead of, the survivor. We are encouraged then to take the role of witness. “To be a witness is to know by personal presence and perception what has occurred” (Langberg, 1997). In treating CSA, the therapist has a new role, then—witness to the redeeming work of God in the lives of those who ask for his healing and our help.
Remuda’s Trauma Treatment Model
So what does CSA treatment look like when blended with a complicated ED diagnosis? In June 2003, I facilitated a task force to develop a treatment model for the dual diagnosis of trauma and EDs. Although trauma recovery is God’s redemptive work and there is no exact formula to follow, there is a need for practical guidance and the simultaneous use of sound Biblical principles to ensure safe and effective clinical practice.
The treatment model is predicated on a commitment to the safety of patients, safe practice by clinicians, the highest ethical codes of conduct, scientifically-valid research, and the truth of God’s Word. The goals in developing the model were multi-factorial: to synthesize the plethora of research on trauma, to apply a Biblically-based and cognitive-behavioral theor-etical approach to the treatment of trauma with co-occurring EDs, and finally to determine how best to equip patients to cope more effectively by imparting new skills.
Remuda’s Trauma Treatment Model is not intended to completely resolve all effects of trauma, since this is often an extended process; but rather to teach patients skills that assist them, at a minimum, in preventing further exacerbation of their ED and, optimally, in achieving recovery from their ED while they take significant steps to work through trauma issues. So often, ED patients use trauma as an explanation for their continued need to rely on ED behaviors. Remuda’s Trauma Treatment Model aims to rapidly impart sufficient skills so that patient trauma issues are no longer so intense that ED recovery work is repeatedly frustrated and derailed. The model allows patients to manage their trauma issues satisfactorily so that they can make substantive progress on their ED. Once in recovery from their ED, they can return as needed to more in-depth trauma work without significant risk of ED relapse.
Remuda’s Trauma Treatment Model has three phases.
Phase I: Preparation
“You are one of God’s living stones, being built up in Christ as a spiritual house.” 1 Peter 2:5
Phase I involves three building blocks that lay the foundation for a stable recovery process: safety, education, and an awareness of living in God’s truth.
Patients must be able to keep themselves consistently safe through changing moods and their emotional reactions to the memories they would rather forget. Among ED women, 50% self-injure in some way (Eberly, 2006). Most utilize their ED behaviors to self-soothe or regulate difficult emotions. This underscores the need for safety plans before therapy begins.
Safety starts with building a therapeutic relationship and establishing trust and positive rapport between patient and therapist. Safety also requires education and practice that enable patients to acquire adaptive coping skills. Patients learn to tolerate distress by attaining skills such as distraction, self-soothing, deep breathing, and relaxation. These replacement skills are best taught and practiced in Phase I while there are no crises or perceived dangers and prior to challenging discussions about patients’ CSA. It is helpful to utilize a skills card listing the various skills. Patients can reference this card when feelings of fear, agitation, or distress occur, reminding themselves of the tools they can use to maintain their safety and prevent reliance on ED behaviors.
In this preparation stage, patients also consider their choices as adults. Educational discussions about responsible living and choice-making are significant at this juncture. People can make irrational behavioral choices based on emotions. Defining what it means to live responsibly throughout treatment can be helpful. Patients may or may not be aware of their own personal slippery slope and how they are most likely to act out when stressed. Discussing these issues honestly and early provides a safety net for patients: they have an explicit plan to use the skills they are learning when the time comes to use them.
Nurturing hope in someone experiencing hopelessness is the work of the Holy Spirit, but often the Spirit’s conduit is an earthly servant. Exploring together the loving nature of God, the patient’s identity in Christ, and the provision of his grace is necessary education to help rebuild crushed spirits. It is difficult to work with the hopeless, because there must simultaneously be respect for the loss and suffering and a tenacious desire not to leave anyone in that barren, lonely, desolate place. Walking out of the grave with someone is not easy. It requires great patience and trust in the Lord, who is, after all, the redeemer of the days the locust has eaten (Joel 2:25).
These spiritual explorations open the door for patients to learn how to live in God’s truth. Adversity and suffering can lead to a place of spiritual healing and hope, and into the safe arms of a loving God. But we obviously cannot assume that CSA survivors feel God’s presence or have an understanding of his love. Trauma “has the potential to draw one to God or away from God… but often to confuse one about God” (Langberg, 1997). A common question worthy of exploration is, “Where was God?”. This familiar refrain is one of the most important questions that trauma survivors ask and is intensely important to explore with them. CSA survivors may have lost hope and trust in God, because they had believed that God would never allow them to suffer in this horrific way. For many survivors, this damage produces powerful despair: people can feel desperate because they experience their faith as shattered. Re-establishing hope is the key ingredient to begin resolving this grief and loss in a personally meaningful way.
Phase II: Transformation
“You can be transformed by the renewing of your mind.” Romans 12:2
Within the context established in Phase I, the process of transformation can begin, since patients now have the tools to speak about their trauma without relying on ED behaviors to cope with the emotions that arise.
Bessel van der Kolk and colleagues (1996) described trauma as coloring all present situations, infectiously invading one’s worldview, such that “contemporary experience ceases to be a teacher”. The constructivist narrative approach challenges this dimension of trauma and successfully battles it to the ground (Miechenbaum & Fitzpatrick, 1993). This cognitive therapy approach works for patients who can address trauma issues without severe emotional decompensation.
Narrative psychology studies the stories we tell and the meaning we assign to them: how we as a result construct our worldview. People construct narratives that tell others about them. Threatening and traumatic experiences can invalidate the most fundamental beliefs one holds. Narratives once held no longer make sense in light of the trauma, the new reality. Typically, new narratives are therefore created, often negative and false, to help make sense of the trauma.
Here’s a basic example. A woman is raped by a man. As a result, she determines that all men are to be feared, untrustworthy, hostile, and dangerous. Because God did not protect her, she concludes that He does not exist. The woman is not merely over-generalizing to the entire male population; the traumatic act has shattered her worldview and fundamental belief in God. “The basic tacit rules or implicit beliefs that guide a person’s life can be challenged or nullified by stressful events” (Meichenbaum, 1995).
Recovery from such trauma is contingent upon rebuilding the victim’s world. The constructivist narrative would support rebuilding by assimilating the victimization experience in an adaptive manner (Meichenbaum, 1995). The goal is to help patients tell their story and in the process reconstruct it. Patients are helped to find new meaning, salvaging something redemptive from the trauma. This enables patients to have a new sense of mastery, control, competence, and self-acceptance. It allows them to question and pry open the door of faith once again, and even to trust God.
Patients reconsider the trauma-influenced implications and conclusions they have drawn about themselves and the world. They can learn to cope more effectively as they explore these issues, developing meaningful and acceptable interpretations of stressful life events, such as “my family drew closer to each other than ever before, and certainly closer to God”. Tim Hansel (1985), mountaineer turned author, constructed this narrative after a fall from a mountain which shattered his body:
But one of the ways that our faith expresses itself is by our ability to be still, to be present and not to panic or lose perspective. God still does his greatest work in the most difficult of circumstances. The spirit is more powerful than the will, more powerful than pain, more powerful than our weakness and our doubt. We can experience the living God here and now, and our most difficult circumstances will be the very opportunity for our faith to grow.
This is also a time for patients to resolve losses and learn to grieve. This may entail naming losses, perpetrators, identifying negligence for what it was, and accepting what is in the present tense. Grief and loss work is an in-depth, individualized process. Patients may become impatient because it can take a long time and is frankly excruciatingly painful for them. Grief is dreaded by many, leading some to minimize and short-circuit it. Therapists must be vigilant about this potential minimization.
Other issues addressed in this phase are voice, relationships, and power (Langberg, 1997). Each must be explored one layer at a time in response to trauma. Finally, it is pivotal to move toward forgiveness in altering the narratives one has constructed about oneself, the world, and God. Patients are helped to understand the price paid for holding onto resentment. Many good resources exist for assisting patients with forgiveness, such as John Ensor’s Experiencing God’s Forgiveness: The Journey from Guilt to Gladness or John MacArthur’s Forgiveness: The Art of Giving and Receiving. Ultimately, this phase of treatment allows persons to walk through the sorrow and suffering to the other side, finding peace.
Phase III: Integration
“You can be confident that God will complete the good work He has begun in you.” Philippians 1:6
The final phase is called integration because it provides opportunities to integrate the skills and truths one has discovered in the previous phases of trauma recovery and apply these to the everyday challenges of ED recovery. When tensions and fears escalate, the skills of the earlier phases are brought to bear on the situation. Patients can now focus squarely on ED recovery, including such areas such as body image and establishing a continuing care plan.
Patients often continue to grapple in Phase III with questions of personal safety, such as learning not to take out their frustrations and anger on themselves physically or emotionally through the ED. Choosing to trust in themselves and others in decision making on such issues as nutrition, medication, medical concerns, and aftercare plans can continue to be a challenge, but is an ongoing part of learning to make responsible life choices while recovering from an ED.
Many patients find group work to be beneficial at this point. Various groups provide oppor-tunities for exploration and expression in ways that individual therapy cannot. Art therapy is one such modality which can foster new insights. Trauma recovery groups provide support, build community, reinforce skills, and prepare patients for life’s daily challenges by offering a safe place to practice the skills learned in Phase I and reinforce the voice, relationship skills, and personal power explored with the therapist in Phase II.
Ultimately the goal of Phase III is simple: for patients to use the skills they mastered in the earlier phases to manage their trauma issues, so that trauma no longer derails or impedes ED treatment. Patients can now engage in full-scale ED treatment and achieve substantial ED recovery. Since EDs can be life threatening and are always medically compromising, it is essential to treat the ED right away. Once the ED is stabilized during Phase III, patients can later resume trauma work as needed without significant risk of ED relapse.
Trauma recovery work, combined with ED recovery, can be challenging and complicated. We harness the knowledge available to us and ask the Lord for his blessing as we go about this restorative work. And most of all, we harness our faith. As Langberg (1997) reminds us so frankly, “recovery from trauma never happens in a straight line”.
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Eberly, M.C. (2006). Understanding self-injurious behavior in eating disorders. The Remuda Review: The Christian Journal of Eating Disorders, 4, 26-30.
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Trauma and Bulimia Nervosa: A Case Study
Kerry Hulsey, MS, LPC
Department of Clinical Services
Remuda Ranch Programs for Eating Disorders
Trauma and eating disorders are often treated simultaneously, as with Jennifer. Jennifer was a college student, admitted to Remuda Ranch with a history of bulimia nervosa and major depression. She admitted at 134 lbs., 96% of her ideal body weight. Jennifer also exhibited self-injurious behavior (SIB). SIB began only weeks prior to admission and typically involved scratching her arms with her fingernails when intrusive thoughts about her past came to mind.
Given her recent SIB, Jennifer was proactively placed on high-risk precaution status at admission. This alerted her treatment team to keep her within their eyesight for 72 hours following admission. Jennifer’s therapist met with her during this time to teach her basic grounding skills and help her develop a safety plan that she could rely on should she experience urges toward SIB.
Jennifer’s psychosocial assessment revealed an extensive childhood history of sexual abuse. Jennifer had been repeatedly molested by an older cousin from early childhood into her teenage years. She was also date-raped at a party just prior to treatment. She was open with her therapist about these experiences, but did not want to discuss them with her family. She was quite obviously ashamed and embarrassed about her sexual abuse history.
As Jennifer entered Phase I of Remuda’s Trauma Treatment Model, she struggled. She was increasingly uncomfortable addressing her feelings of shame, grief, and loss, and experienced heightened anxiety from discon-tinuing her binge/purge cycle. She therefore required multiple one-to-one coaching sessions to help her learn the cognitive-behavioral skills needed to cope safely with her difficult emotions. Once she had practiced these skills sufficiently, she began using them daily. They replaced the eating disorder behaviors and SIB that she had previously believed were the only ways to alleviate the anxiety caused by her traumatic memories. This was a turning point. She was no longer resorting to bulimia and SIB to manage her moods.
Jennifer was now able to begin Phase II work. During Phase II, she routinely relied on distress tolerance skills to deal with difficult feelings. It was common to see her journaling or drawing after a distressing therapy session: she was using appropriate forms of distraction. She also frequently applied a favorite hand lotion during free time as a form of self-soothing. She had previously felt that she did not deserve to use this nice lotion.
During Phase II, if appropriate, patients are encouraged to salvage something redemptive from their trauma experiences. As Jennifer’s scheduled week of intensive family therapy approached, she asked for assistance planning how to discuss her sexual abuse with her baby sister. She decided to do so at the beginning of Family Week. The carefully planned discussion with her sister went well. Jennifer was shocked to learn that her sister had also been molested by the same cousin. This revelation gave Jennifer a deepened feeling that she wasn’t alone in her pain, that her experiences and struggles were truly not her fault but were normal and valid reactions to what she had endured. Jennifer also learned that using her voice to speak the truth could bring validation and healing rather than shame and pain.
The sisters’ mutual validation and newfound alliance gave them both the courage to tell their parents about the abuse. During Family Week, Jennifer unveiled the secret that she and her family had been avoiding nearly her entire life. She spoke the truth in love, and in response her family embraced an emotional openness and vulnerability with one another that Jennifer had longed for but never imagined possible. In particular, Jennifer was able to talk to her father for the first time about their father-daughter relationship.
As Family Week ended, the family members continued to voice that a profound healing had begun to take root. Of her own accord, Jennifer realized that something redemptive had been drawn from her abuse. Her conviction in this deepened in subsequent weeks. She believed that without the need to talk openly about the horrible experiences she had endured, her family would never have learned to communi-cate soul to soul.
Following her intensive Family Week, Jennifer continued to work on grieving a childhood lost to sexual abuse and its aftermath. Through trauma recovery group she recognized that years of molestation had left her vulnerable to the date-rape that occurred in her freshman year of college. As a result, she no longer blamed herself or God for her perpetrator’s willful actions. Anger at God receded and her relationship with God began to thaw.
Jennifer had now accomplished some preliminary, but powerful, reconstruction of her trauma story, finding new meaning and peace about the experience. She was ready for Phase III of her trauma work, shifting focus to deal primarily with the aspects of her eating disorder that had not yet been addressed. During Phase III, Jennifer successfully remained at her target weight and free of eating disorder behaviors and SIB. Although she began Phase III work at Remuda, she needed to continue it following discharge.
In her discharge plan, she arranged to continue addressing her abuse history and related issues with an outpatient treatment team with whom she made initial outpatient appointments even before leaving Remuda. She also found an outpatient trauma recovery and eating disorder support group. Jennifer expressed a desire to receive ongoing support in her efforts to fully embrace the concepts of grace and forgiveness that had helped in her trauma recovery. She began the process of locating a church that could promote this spiritual growth.
At discharge, she recommitted to remain free of self-harm and developed an updated Safety Plan with her treatment team to rely on during the transitional days ahead. She had significant body image work remaining, but life-threatening ED behaviors were in remission. She had successfully completed Remuda’s Trauma Treatment Model and had built a foundation for continued recovery in the months ahead from both her trauma and her eating disorder. She left Remuda with much hope for her future, believing that she had crossed a threshold toward healthy living and would continue journeying in that direction for many years to come.
Next Issue: Emotional Eating