By Maeve Lewis BA (Hons) (Psych), Dip. Psychotherapy, H.Dip.Ed.. MIAHIP
The term “eating disorder” covers a wide variety of behaviours ranging on a continuum from the self-starvation of anorexia nervosa through the binge eating and purging of bulimia, to the consistent extreme overeating of obesity. Eating disorders imply a pattern of eating which is outside that which is socially acceptable and which, in extreme situations, can lead to ill-health or even death. Nutritional needs and hunger are replaced by an intense, obsessive relationship with food as the primary motivator of what, and how much to eat.
Incidence of Abusive Relationships with food
When I reviewed the clinical histories of the female clients I have worked with who have been sexually abused in childhood, I realised that, almost without exception, abuse of food is an issue. There is a wide literature available on the extreme forms of eating disorders – anorexia, bulimia and obesity – and there is strong evidence to suggest a history of childhood sexual abuse in significant numbers of women who develop these disorders (¹). Very little has been written about the array of eating behaviours along the continuum which are not in themselves life threatening, but which overshadow the lives of those caught up in abusive relationships with food: excessive continuous dieting, comfort eating, overeating, “chocaholism”, mild bulimia etc. Yet, for clients who have been sexually abused, it is in this arena that the vast majority conduct their battles with food, and these are the issues which tend to recur again and again in the therapeutic setting. Therefore, it is my intention in this article to concentrate on the unhealthy, but not necessarily life threatening, relationships which women who have been sexually abused tend to develop with food and eating, and the challenges this presents for the therapist.
Influence of Other Traumas on Eating Behaviour
It is difficult for two reasons to isolate sexual abuse in itself as a predictor of eating disorders. Firstly, I think it is fair to say that most women in the Western world have an uncomfortable relationship with their bodies and very few are satisfied with their natural body shape (²). Women diet and exercise themselves in a futile effort to reach what is, for most of us, an impossible target weight or size. Women who have been sexually abused are subject to the same societal influences as everybody else. Secondly, sexual abuse always takes place within a context, and the experience of sexual abuse is highly individualised. It is generally accepted that long-term sexual abuse within the family is among the most destructive forms of sexual abuse. The factors which allow intrafamilial sexual abuse to take place, to remain secret often even among family members, or to be tolerated by other adults in the family, suggest an environment where the needs of the child are subsumed to the needs of the sexual abuser. Quite apart from the experience of sexual abuse, children growing up in such an environment have great difficulty in developing a strong healthy sense of self. In addition, other traumatic experiences in childhood, such as emotional abuse or neglect, unresolved bereavement, abandonment by primary caretakers, perinatal trauma and poverty, can enhance the impact of sexual abuse. Where food and eating is an issue, the influence of other traumas can often be seen in the complex patterns of eating behaviours which emerge, and it becomes impossible to identify sexual abuse specifically as a causative factor.
Most women who have been sexually abused in childhood, present with a distorted relationship to food. This tends to mirror the dynamic, which operates in a relationship where a child is being sexually abused, and the ways in which this dynamic affect the developing intrapsychic world of the person (³). It is as if the effects of sexual abuse as experienced by the client can be expressed symbolically through the patterns of eating. There are a number of themes which tend to recur among people who have been abused which manifest in the abuse of food.
The Physical Nature of Sexual Abuse
Sexual abuse by its nature is very physical. The abuse is perpetrated through the body, and the resultant trauma becomes embodied. It is very common for people who have been sexually abused to develop patterns of eating which are either an attempt to use physical means to assuage and control the emotional and psychological distress associated with the abuse, or to use food in such a way that the physical discomfort arising from the abuse of food mirrors the emotional and psychological distress. In the first situation, the client may present with a pattern of over or under eating where food or hunger is used to repress uncomfortable feelings, in much the same way as alcohol or recreational drugs can be used (4). In the second situation, the client may develop a pattern of eating which causes actual physical pain. This is especially obvious in clients who binge eat to the point where they develop severe abdominal cramps. It is as if the physical pain expresses the inexpressible internal pain. Client who have developed this coping strategy may also have a tendency to self-mutilate. The choice to over or under eat does not seem to be as important as the function it serves.
Development of Distorted Body Image
Children who are sexually abused tend to internalise the abuse, and take upon themselves the responsibility for provoking the abuse. As a result, sexually abused clients will usually describe very low levels of self-esteem. This is often projected onto the client’s physical appearance, and they feel ugly and unattractive. It is common for sexually abused clients to have a very distorted body image, usually experiencing themselves as being much bigger than they actually are. Dissatisfaction with external appearance, and the battle to conform to stereotyped notions of beauty through modifying food intake, can become the metaphor for a hopeless internal struggle towards self-acceptance. Setting unrealistic goals of weight reduction sets up a cycle of dieting and bingeing which serves further to undermine self esteem and to perpetuate self-loathing. The discipline involved in perpetual dieting, and the rituals associated with purging, can also be seen as a form of self-punishment, denying oneself the nurturance and the pleasure that can come from good food.
Children who have been sexually abused have experienced profound helplessness and powerlessness. In adulthood, this can manifest as a victim consciousness, where the person sees themselves as being helpless to effect change in their circumstances, and seems frozen in a position of childlike dependence, unable to move towards a more adult autonomy. The relationship which sexual abuse survivors develop with food, can serve to reinforce the sense of powerlessness, where food and eating patterns are perceived to be outside the person’s control, or are believed to control the person. It also assists in maintaining a victim consciousness by removing responsibility from the client for her life decisions by postponing living: “When I’m a size 10, then I’ll be happy/attractive etc.”
Food, Shame and Guilt
In sexual abuse, particularly where the perpetrator is a family member, a relationship develops where normal boundaries are violated and breached. As children learn how to relate through their experience in early relationships, the adult survivor is usually struggling with issues of boundaries and control. This is often reflected in the relationship the survivor develops with food: the severe control of dieting and, in extreme cases, anorexia, or the apparent lack of control in the binge eater or obese person. The secrecy and lies involved in an abusive relationship are also mirrored in the food relationship – eating secretly and covertly, covering up amounts eaten or not eaten, and the shame and guilt which ensues.
Sexuality and Eating Disorders
It is perhaps in the area of sexuality that the link between sexual abuse and eating disorders is most clearly seen. It is almost impossible for a person who has been sexually abused to develop a comfortable relationship with their own sexuality. While most people who have been sexually abused go on to have sexual relationships, it is an aspect of relationship that is fraught with difficulty. In particular, fear of intimacy and revulsion towards bodily functions, prevent the person engaging freely and openly in sexual activities. In addition, many people who have been abused are very cut off from their bodies. They may experience themselves as being disembodied, existing from the neck up, and therefore out of touch with bodily sensations. They may also feel ugly and unattractive, as discussed above. Since sexual expression is inextricably linked with the body, it is very common for clients to use food to control or change their natural body shape, as an avoidance of sex. This emerges in two forms. At one extreme, clients will control their body to the point that they have not developed their bodies. This will be noticed particularly in women in their thirties and older who have retained an adolescent shape, where they do not “fit” with their bodies, where the body appears almost stunted. At the other extreme, clients will eat excessively to the point that their bodies are bloated with weight, so that their shape is lost inside an armouring of fat (6). Given the social ideal of sexual attractiveness currently prevailing, and the obsession with thinness, the layers of fat not only effectively protect the woman from involvement in sexual activity, but also reinforce her self-image of ugliness.
Exploring the Client’s Relationship with Food
Women who have been sexually abused, and who seek therapeutic intervention will rarely present at the first session with food issues, unless their disorder has evolved into anorexia or serious bulimia. This is partly because of the shame that is attached to lack of control around food, and partly because, for many clients, an unhealthy relationship with food has become such an intrinsic part of their lives that they are not consciously aware of it being a problem. In general, with issues of food abuse, the approach I take is to avoid becoming entangled in the mechanics of the patterns, but rather to explore the client’s relationship with food as a metaphor for their relationship with self and others. Where anorexia, bulimia or severe obesity are involved, I will insist on a medical check-up to evaluate the level of physiological damage that has been sustained. With anorexia, I will contract a minimum weight which the person must sustain, and explain that should they go below that weight, they will no longer be sufficiently well to engage in psychotherapy.
Healing within the Relationship
The person who has been sexually abused, has been traumatised in the context of a relationship, and I believe that healing must also take place within a relationship. The food relationship may be the most intense relationship in the client’s life at that point, and the type of pattern that the client has evolved with food will generally be a good indicator of the transference issues which are going to surface in the therapeutic relationship. A key issue will be intimacy, and the client’s difficulty in being vulnerable and trusting within the relationship with the therapist. Victim consciousness is likely to emerge in relation to the client’s life in general, but also as regards the relationship with food. The therapist will find that the client is projecting the same power and responsibility onto the therapist as she has done with food. However, even when the pattern of eating seems to be out of control, and the client perceives herself as helpless, the underlying dynamic will be one of the client trying to control her world through eating or not eating, and the impact this has on her body.
Realising the Danger of Power
The therapist can find herself getting drawn into subtle (or not so subtle) power games. If the current pattern of eating has been allowed to become a major issue in therapy, the therapist may find herself involved in a struggle to enforce healthy eating patterns which the client will sabotage. Decisions around food must be presented as a matter of choice which only the client has the power to exercise. It is helpful to explore fully the ways in which the eating patterns have served the client, the investment she has in maintaining these patterns and her fears regarding life possibilities if the relationship with food were to be let go. It will usually be found that the client is terrified of moving on to a life where she is free to make life choices but also has to be responsible for them. The familiarity of the constricted world of pain and struggle may seem safer than the possibility of living to the full. Exploring the patterns of food abuse, and the needs which the client is attempting (but failing) to meet through eating, allows those needs to be acknowledged as valid, but more appropriate ways of meeting them can be developed. As one client who developed anorexia in adolescence remarked: “I wanted my family to notice how unhappy I was without me having to tell them.”
Freeing the Intrapsychic Pain
Food abuse, in whatever form, will, at its core, be an attempt to numb the appalling intrapsychic pain of sexual abuse and to block the traumatic experience. One of the tasks of therapy is to facilitate the person to move towards the repressed pain, to allow themselves to experience it and, ultimately, to free themselves from it. This is usually terrifying for the client, and as she moves towards experiencing the emotional pain, the food relationship may intensify in a desperate attempt to ward off what seems to be unbearable and overwhelming. The therapist needs to be very open and non-judgemental, to be able to hold the client psychologically, but also to be able gently to challenge. As the sexually abused person has been traumatised through their body, most of the trauma will be held in the body. Bodywork can be very helpful at this time, in helping the person to embody herself and become aware of her body and its sensations, in facilitating emotional catharsis, and, ultimately, in developing a new relationship with her body.
Focussing on the Body Image
Once a client becomes more in touch with her body, it becomes possible to begin to work with body image, which I see as a projection of internal self-image. Challenging distorted cognitive perceptions, using imagery, art work and suggesting regular massage, can all facilitate this process. I view the focus on body image as a parallel process which must be accompanied by a shift in the underlying perception with self. Encouraging the client to begin to care for her body in a non-punitive, loving way opens the way towards self acceptance at a deeper level. Helping the client to see the patterns of eating she has developed as a survival mechanism, can facilitate shifting the shame she has experienced both at the time of the abuse as a result of her eating patterns. In other words, the food relationship can come to be seen as a tactic that allowed the client to survive sexual abuse and its aftermath. While at one time it had value, it is now no longer necessary.
Moving towards Self Acceptance
Working with people who have been sexually abused in childhood is usually a long, slow process. The patterns of eating and the intense relationship with food will wax and wane during this time. Ultimately, my aim with a client is to reach a point where she understands the way in which her relationship with food enabled her to block off the traumatic experience to support her in facing her pain so that she no longer needs to engage in old patterns of defence and to be with her as she moves towards a place of self-acceptance. Unlike other substances that a client may abuse, it is not possible to abstain from food. Therefore, it is unrealistic to assume that food and eating will never be an issue again for the client in times of stress, she may find herself slipping back into old ways of coping with emotional stress However, since she has acknowledged and experienced the trauma of the sexual abuse and moved from a victim stance she will be aware that she now has alternative ways at her disposal of responding to life.
Maeve Lewis is Director of New Day Counselling Centre
1. Richard C., Hall M et al (1989) “Sexual Abuse in Patients with Anorexia Nervosa and Bulimia “ Psychosomatics, Vol I, No. 1 73-79.
2. Wolf N, (1990) The Beauty Myth, Vintage.
3. Cole P & Putman F (1992) “Effect of incest on self and social functioning: A developmental perspective.” Journal of Consulting and Clinical Psychology 60, 174-184
4. McFarland B & Baker-Baumann T. (1988) Feeding the Hungry heart, Hazelden
5. Alexander P, (1992) “Application of attachment theory to the study of sexual abuse” Journal of Consulting and Clinical Psychology 60, 185-195.
6. Orbach, S. (I984) Fat is a Feminist Issue, Hamlyn.