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I asked, "Can you access the most self-loving part of you, to help the 9-year-old part to see that differently?"

Cathy started to cry and said, "Mom made me feel like I didn't deserve anything because she wouldn't give me any attention. But that was about her—not me. And the abuse wasn't my fault. I had no choice. He threatened to hurt me. I tried to tell my mother, but she didn't believe me. She didn't care. I had no choice." Then, holding her arms around herself and leaning toward the chair with the 9-year-old, she whispered, "We had no choice. We had no choice."

It was a breakthrough for Cathy to realize that starving was a reenactment of parental neglect, and purging was fueled by the self-blame related to memories of her grandfather's sexual abuse. For many clients, the behavior has a deeper meaning, often connecting to unresolved pain or trauma. Clients who binge may be creating a "protective shield" of fat, making themselves physically larger in the world because they feel inherently vulnerable or unsafe. For some clients, gaining weight is a creative way of avoiding sexual intimacy, thus warding off flashbacks to earlier abuse and preventing feelings of revictimization in the bedroom. Other clients binge to punish their bodies for "participating" in sexual trauma. Still others may be reenacting the physical pain of sexual trauma through the violent act of bingeing. Inviting an open curiosity about purging sometimes reveals the client's need to "cleanse" a body that feels "dirty" or "damaged." This was true in Cathy's case. Since purging is often viewed by clients as "gross" or "embarrassing," the act might be communicating a deep sense of shame, saying through the behavior, "I'm bad."

Once Cathy connected her current behavior to her past trauma, I asked her to think about how she'd feel toward her daughter if she'd been violated and betrayed at 9 years old. "If my daughter had been hurt like that, I'd hold her, tell her it wasn't her fault, and do everything I could to comfort her," she said. We incorporated this into a role-play, so she could express those words of comfort and nurturance out loud.

"It's powerful to hear my own voice say this," she said, "I wish my mother had said this to me when I was a child."

Taking it one step further, I asked, "Would you blame your daughter or tell her to hurt her own body as a result of being abused?"

Cathy looked at me as if I were crazy, and then she understood. "Never," she said. "That's the last thing I'd do."

During this work, she identified a scared 5-year-old part. Younger parts often give us important information about attachment patterns. In Cathy's case, her parents' chronic neglect didn't allow her to sustain healthy, trusting, and consistent attachment, which meant she never learned appropriate self-soothing strategies and was forced to resort to unhealthy ones. Giving clients alternative ways to self-soothe that don't evoke guilt, shame, or revictimization is a key part of the work, and should be introduced early in treatment. Of course, it's easier for them to behaviorally integrate self-care once some amount of self-compassion has developed. I always assess for medication to alleviate anxiety and depression, while introducing methods of self-care designed to rekindle respect for the body. Aromatherapy, listening to soothing music, gently massaging the hands with scented lotion, wrapping the body in a soft comforter and rocking, reading positive affirmations may all seem obvious self-soothing strategies to most of us, but are often quite foreign to clients who've spent years waging war with their bodies.

Since so many eating-disordered clients are bereft of healthy attachments, I work with members of the extended family and significant others to rebuild and strengthen safe interactions and intimate communication. Working with family members to enhance empathy and compassion, teaching them about the cycle of self-destructive behaviors, and encouraging them to move away from a pathologizing and hopeless mindset can be crucial to the success of treatment. When particular family members are unsafe, it's necessary to find a surrogate social-support system for attachment. In Cathy's case, her parents' drinking worsened as she got older, and I trusted her instincts when she said it would be 'useless and very unsafe' to bring them into therapy. Getting her connected to Al-Anon became a powerful way for her to find a loving group of people who fully embraced and accepted her. In addition, she chose to reconnect with her religious faith, and found great comfort and support within that community.

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