CLINICAL PERSPECTIVES ON EATING DISORDERS AND ABUSE
CLINICAL PERSPECTIVES ON EATING DISORDERS AND ABUSE
With any form of trauma, it is probably most effective to consider emotional
abuse as a factor that influences the presentation of the EDs, rather
than as the immediate or longer-term cause of the EDs. In other words, it is
important to view emotional abuse as a moderator of other factors that predispose
an individual toward the development of an ED (e.g., genetics and
temperament, social experiences, personality factors), rather than being a
sufficient factor to cause the eating problem in itself.
When there is a history of emotional abuse, our clinical experience
suggests that there is likely to be an increased severity of specific eating
symptoms (particularly vomiting) as well as greater comorbidity (e.g., a
greater level of impulsivity, obsessive-compulsive features) that reflect the
impact of the emotional experience. The following examples reflect two different
forms of emotional abuse and two variations in ED symptoms:
Lizzie had a history of being emotionally abused by both parents,
although their patterns of managing her emotions differed substantially.
When she was a child and an adult, her father ignored her increasingly
distressed state, while her mother continually told her that her behavior
in childhood was just like that of her grandmother, who had to be “put
320 G. Waller et al.
away.” When Lizzie was an adult, her mother told her that she had
turned out just like her grandmother, and that she was beyond hope.
When she was a teenager, Lizzie began to use alcohol and then self-cutting
to cope with her emotions “silently,” and only developed bulimic
eating patterns when she moved out and could control her own diet.
Anna grew up in a home where neatness and order were encouraged,
and active displays of emotion were discouraged. She began to develop
obsessive ruminations about making errors that would lead her parents
to criticize her and this developed into compulsive checking to try to
avoid such an eventuality. Her compulsivity began to extend to body
checking, calorie counting, and restrictive eating, in case her family
were to comment on her physical changes around puberty.
Developing and testing the clinical relationship between emotional
abuse and eating disorder severity/comorbidity requires much work to support
or refute it. In order to escape from simply collecting disparate findings,
effective examination first requires a clear conceptual framework.
What is apparent from our experience is that these patients have marked
difficulties in tolerating distressing emotions, along with the associated pattern
of conditional assumptions and core beliefs. We find that Linehan’s
(1993) construct of the “invalidating environment” is extremely useful, both
in terms of modeling the general impact of emotional abuse and in terms of
understanding individual experiences among our patients.
THE CORE ELEMENT OF EMOTIONAL ABUSE:
We see emotional invalidation as the core element of how emotional abuse
affects the individual. When emotional invalidation occurs, the emotional
experience of the individual is ignored or responded to incongruently.
Thus, the individual perceives his/her experiences and distress as being
minimized or treated with indifference. One of the starkest examples of
emotional invalidation can be observed with childhood sexual abuse, when
the child is often told that they are enjoying something they are not, or that
they should not feel scared or hurt when they do. However, such invalidation
can occur just as strongly in the context of emotional and physical
abuse, and even in the absence of overt, identifiable abuse.
The concept of the “invalidating environment” was proposed in the
Dialectical Behavior Therapy model (DBT; Linehan, 1993), which was
originally developed for individuals with borderline personality disorder.
Emotional Abuse in Eating Disorders 321
Linehan (1993) defines the invalidating environment as one in which communication
is responded to negatively or ignored. An emphasis is placed on
being happy and “getting on with things” regardless of the situation. Displays
of negative affect and individuality are discouraged. Three types of
invalidating environments have been defined:
• The chaotic environment, in which parents are often physically or emotionally
unavailable, due to factors such as substance misuse, mental
health difficulties, or financial reasons. The parents often respond with
anger to the child’s need or requests for emotional support.
• The perfect environment, in which the parent becomes distressed or angry if
the child displays affect (e.g., fear, upset, or anger) that suggests that there are
any problems. As a consequence, suppressing emotions is seen as desirable.
• The typical environment, in which control over emotions, achievement,
and success is deemed essential, and the central theme is “behaving like a
Such environments are not exclusive, and often co-occur.
In contrast, the child may experience times or situations in which their
experiences are validated. It is hypothesised that the experience of a validating
relationship (or positive attachment/bonding) may act as a protective
factor when there are other invalidating people in the child’s environment.
Therefore, in our experience, the ED patients who we see tend to come
from backgrounds where there has been emotional invalidation from both
major caregivers, whether or not the style of invalidation is the same (e.g.,
Jilly) or different (e.g., Lizzie) across those caregivers.
The construct of emotional invalidation has been the subject of increasing
interest over recent years, as clinicians and researchers alike have
sought to understand the processes and impact of childhood abuse (e.g.,
Kinzl, Traweger, Guenther, & Biebl, 1994; Krause, Mendelson, & Lynch,
2003; Mountford, Corstorphine, Tomlinson, & Waller, 2007). It is not yet
clear how the different styles of invalidation have their impact, although it is
hypothesized that there is an interaction of factors including the child’s early
environment and her/his temperament.
Early and later experiences of invalidating environments can have a
number of related manifestations, including difficulties in tolerating distress,
emotional inhibition, and secondary alexithymia. The common theme is that
the individual has difficulty in identifying and labelling emotional states on
the basis of internal experiences alone (e.g., thoughts and physiological
states). As a result of the caregiver’s incongruent responses, the individual
learns not to trust their reaction to events and instead has to search the
environment for cues (e.g., parental facial expression) as to the appropriate
response. Because the individual does not learn to tolerate negative emotional
states (and hence does not have the opportunity to identify adaptive
322 G. Waller et al.
responses to those states), he/she may learn to dissociate from emotions,
display extreme behavior to trigger a reaction from the parental figure, or
exhibit avoidant patterns of coping with overwhelming or difficult affects.