EMOTIONAL ABUSE

Young’s (1994) terms, the negative core belief that tends to be elevated
among patients with any reported history of childhood emotional
abuse tends to be “mistrust/abuse.” Particularly early experiences of emotional
abuse are also associated with high levels of “abandonment” beliefs
(Ganis, 2003). Therefore, these two beliefs need to be considered as clinical
targets when assessing any patient who reports a history of emotional
abuse. Methods of working with such core beliefs are detailed elsewhere
(Waller, Kennerly, & Ohanian, 2007; Young, 1994).
While the aim of the previous stage of treatment was to address beliefs
about emotions, the aim of this stage is to address the beliefs that drive the
emotions. The focus here is to reduce the emotion-driven behaviors. The
principle underlying such work is to achieve a shift in the way that abusive
experiences are understood. In brief, at a cognitive level, this requires a shift
from seeing the core beliefs as unconditional (and hence beyond change,
because they simply “are true”) to viewing them as available for evaluation.
Modifying core beliefs is based on helping the individual to test out the
accuracy of explanations for their beliefs against the background schema of
processes that tend to maintain those beliefs. Given that ED patients share
the depressive individual’s attributional style for negative events (e.g.,
Morrison, Waller, & Lawson, 2006), the patient who has experienced early
and lifelong emotional abuse is likely to attribute these abusive experiences
in the ways outlined above—internally (“My parents told me that they hated
me because I am unlovable”), globally (“Everyone treated me like dirt”),
and stably (“I will never be liked”). Through cognitive restructuring and
behavioral experiments (Waller, Kennerly, & Ohanian, 2007), the aim is to
help the individual to identify evidence that his/her experiences can be
attributed to others, such as the abuser (i.e., external attribution of the negative
event), that they apply to a limited element of his/her life (i.e., local
attribution), and that they applied in the past but not now (i.e., unstable attribution).
For example:
Emotional Abuse in Eating Disorders 329
Considering the evidence in favor of her abandonment belief, Lizzie
began by concluding that her parents had been right to treat her that
way, as she had clearly been emotionally out of control as a child and
still was. Lizzie was asked to imagine whether she would treat her own
child in that way when he/she came to her for emotional support. In
historical review, Lizzie was also asked to consider whether her parents’
treatment of her followed her emotional outbursts (as she assumed), or
whether her outbursts followed their treatment of her legitimate emotions.
These techniques led her to reappraise her beliefs, reaching the
conclusion that her feelings and actions were valid ones when she was a
child, and that the problem lay in her parents’ inability to handle emotions
of any sort (external attribution). She also concluded that while her
parents might not have been able to help her with her emotions, there
were other relatives and friends who did validate her feelings (local attribution),
and that this supply of supportive people had grown since she
moved out of the home (unstable attribution).
Imagery rescripting (e.g., Ohanian, 2002; Smucker, Dancu, Foa, &
Niederee, 1995) can result in powerful and rapid attributional shifts. However,
this is a powerful tool and both clinician and patient need to be thoroughly
prepared before using it.
ADDRESSING THE EATING PATHOLOGY
Once the protective strategies have been reduced, it becomes possible to
work effectively with the ED cognitions and behaviors (either in parallel
with or after the core belief work). While this work will often be cognitivebehavioral
in orientation (e.g., National Institute for Clinical Excellence,
2004; Waller et al., 2007), other structured approaches to the EDs can
be equally effective in this context (e.g., Murphy, Russell, & Waller,
2005)
CONCLUSIONS
We have outlined how emotional abuse can result in the individual
developing two levels of cognition (i.e., conditional beliefs about the
acceptability of emotional expression and experience; negative core
beliefs about the self), which are associated with difficulties in emotional
functioning. Those difficulties result in the use of protective chaoticdissociative
or detached-alexithymic coping strategies, which predispose
the individual to using unhealthy eating behaviors. Consequently, treatment
for ED patients who report a history of emotional abuse needs to
focus on addressing these cognitions, as well as the central eating pathology,
itself.

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