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Ironically, as a trauma specialist, I'd probably seen many clients who were using food to self-soothe, hurt their bodies, reclaim power and control, or covertly communicate painful experiences—I just hadn't realized it. Over time, as I became more open to acknowledging and treating eating disorders, I began to notice several recurring themes. These clients often fought with friends and family members about their "weird eating," their habit of running to the bathroom immediately after meals, their obsessive concern about their weight. However, I became aware of an even greater internal struggle between the parts of them that stubbornly clung to and even took pride in their ability to exercise "self-control" around eating and the parts that felt self-repulsion, shame, guilt, and self-hatred. They were at war with themselves, and the battleground was their own bodies.

Working with Cathy

These days, after nearly 20 years of working with eating-disordered clients, I've incorporated ideas about the emotional significance of the disorder into my work with clients who struggle with their relationship with food. Consider 35-year-old Cathy, a striking brunette who was a divorced mother of a 10-year-old boy and 12-year-old girl and a successful business executive, who came to see me for help with managing the discord with her children, her work colleagues, and her personal relationships. Now I incorporate questions about bingeing, purging, and starving into my initial assessment with clients, whatever their presenting difficulty. Thus, in the first session, Cathy wound up telling me about her secret struggles.

"Sometimes, I feel kind of superior to other people, because I can go a whole day without eating," Cathy admitted. "And if I do eat, I'm glad I know how to get rid of it, so I can feel better. But afterward, if I'm really honest about it, I feel worse. I feel crazy, and I hate myself for having this albatross around my neck. I feel like I have to 'do' my eating disorder, but I hate myself for having to do it."

This inner sense of polarization and conflict seemed to leave Cathy—like so many of my eating disordered clients—with a fragmented sense of self.

Reflecting back to her what she'd told me, I said, "It sounds like there's a part of you that takes pride in starving—feeling powerful and in control. And at the same time, I'm hearing that another part or parts of you struggle with it, hate it, maybe even feel hijacked by it?"

"Hijacked is a really good word!" she said, nodding her head in vigorous agreement.

Encouraged, I continued, "What's it like for you to have such competing agendas inside?"

Cathy's eyes immediately welled up with tears. "It makes me really sad and angry. No wonder I'm exhausted and feel so stuck."

If she wasn't wholly integrated and connected to herself, how could she successfully connect to me or anyone else? It wasn't surprising that all her interpersonal relationships were so conflicted. She was isolating herself from other people because of chronic guilt and shame and the amount of time taken up with bingeing and purging. At home, she felt disconnected from her kids, who spent their free time pursuing their own interests and friendships. She'd "given up" on the dating scene and made excuses for not participating in work-related social outings. Despite her impressive professional and academic accomplishments (typical of many eating-disordered clients), she found it hard to form emotional intimacy or genuine connection with others. Indeed, such clients tend to keep people at arm's length, making therapeutic alliances difficult to build and sustain.

Taking the focus off food and exploring the historical context of her behavior with Cathy, I asked about family rituals, expressions of parental affection, dynamics during family dinnertime, vacations, and holidays. Emotionally neglected as a child, she felt her parents minimized and dismissed her feelings and needs, labeling her "overly sensitive" and "a burden." Crying was "unacceptable," as was talking at the dinner table or not finishing everything on her plate. Cathy had no memories of being physically comforted and couldn't remember her parents ever saying "I love you." According to her, her parents' greatest emotional priority was "making sure their Scotch bottles were never empty." Her only meaningful attachment was with her grandfather, who breached that trust by molesting her when she was 9.

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