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Section 10
Eating Disorders and Incest

Question 10 | Test | Table of Contents

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In the last section, we discussed three concepts of dissociative behavior in an anorexic client.  These three concepts of dissociative behavior in an anorexic client included:  bizarre behavior; trances; and manipulative strategies.

In this section, we will examine three concepts related to anorexic clients who are survivors of incest.  These concepts regarding anorexic clients who were victims of incest include:  inability to trust; skewed sexuality; and learned defenses.

One of the societal conceptions of anorexia is the belief that the disorder is inextricably linked to sexual abuse. If a girl has developed anorexia, she must have been abused when she was younger. Obviously, when the anorexic client has survived sexual abuse, this presents certain issues to consider and treat. 

However, in my own experience and in polls taken of anorexic clients, only about 1 in 5, not a majority, have been sexually abused.  This number is not far off from the general population and so the myth that sexual abuse and anorexia go hand-in-hand is false.  However, incest does have a significant effect on the anorexic client making his or her experience a warranted subcategory of the disorder. 

3 Concepts with Survivors of Incest

♦ Concept #1 - Inability to Trust
The first concept of an anorexic client as the survivor of incest is the inability to trust.  Obviously, this refers to the general population, but more specifically, if the client was abused by a parent or guardian, he or she will find it very difficult to trust authoritative figures.  As you are aware, this also poses a roadblock to therapy as the therapist may be construed as another father or parental figure that will ultimately break trust. 

When the incest occurs between siblings, the client may also feel abandoned by his or her parents because they did nothing to prevent the abuse.  This inability to trust will result in the client becoming more and more reliant on themselves.  This can exacerbate the anorexic condition as the initial outset of the disorder for even the general client experiences a manifestation of will power, and any extra independence will prevent a client from looking for a support system which they desperately need.

Katrina, age 21, had been sexually abused by her father from the age of five to thirteen.  Not only did she lose her trust in male figures, but also female ones as well.  Her mother, Katrina believed, had allowed the abuse to take place, even though there was no evidence corroborating this. 

Katrina stated, "I wanted to get back at the world for hurting me.  The day before my sixteenth birthday, I remember my mother looking into the mirror at her stomach.  I smiled, you know, maliciously, and thought to myself, ‘I’ll make her feel like an old, fat hag!’ That’s when I decided to start losing weight!  I didn’t start starving until about two years ago." Katrina had lost any feelings of security and safety around older guardian figures and had also developed a need for vengeance against the crime that had been committed against her. 

Think of your Katrina.  What are his or her opinions towards parental figures?

♦ Concept #2 - Skewed Sexuality
The second concept of an anorexic client, as the survivor of incest, is skewed sexuality.  As an introduction to their disorder, anorexic clients feel the need to fulfill a certain role that society has placed for them.  As mentioned in an earlier section his role can be the role of a perfectionist or, more commonly, of an attractive youth.  This desire to become more physically attractive to the outside world can become even more complicated by incidences of incest.  The anorexic client may not know how to handle his or her own budding sexuality and therefore may be more overt or confused by it. 

Elizabeth, age 19, was five-foot-nine and weighed 95 pounds.  When she first came into the office, she was wearing a very short min-skirt, which she constantly pulled up, and a low cut blouse.  In later sessions, she would reveal that she had been raped by her father, Tom, from the age of seven to twelve.  Elizabeth stated, "I want to be valued by my appearance.  I want to feel interesting and attractive or else I’m not worth shit."

I stated, "Also, I think you may be testing people to see if they will exploit you as your father exploited you.  If they do respond with sexual interest or advances, you're on home ground.  It means you are physically ‘used’, but you’re used to that.  You don’t know whether to be so thin that men won’t want you or to get even with other women by being thinner than they are.  You both want to be exploited, but at the same time trying to prevent it."  Think of your Elizabeth.  How has his or her skewed sexuality resulting from incest affected his or her anorexia?

♦ Concept #3 - Learned Defenses
In addition to the inability to trust and skewed sexuality, the third concept of an anorexic client as the survivor of incest is learned defenses.  While non-incest anorexic clients can develop their own defenses during the onset of the disorder, clients who have been abused in the past have already built up an arsenal of mental and emotional defenses that must be broken down first.  For instance, these defenses may include amnesia, dissociative states, self-harm, and abusive relationships. 

The abused anorexic client will sink deeper into these layers of mental defenses and ideas, which will make "compensation" for his or her original damage unacceptable.  Just as anorexia has completely usurped the client’s identity, so too does the memory of incest parasitically live off of the client and reconfirms his or her lack of self-worth.

♦ Technique:  Displacing Guilt
Tonya, age 18, had been abused by her older brother Shane from the ages of five to thirteen.  Since then, Tonya has moved from one abusive relationship to another.  When she felt she could no longer find abusive boys to harass her, she began to abuse herself in the form of her anorexia. 

She stated, "It was all my fault!  When we were younger, Shane had a temper and he would have mood swings. When he was angry, he would tie me down and beat me!  He’s eight years older than me, so you can imagine how much his beatings hurt.  When he was in a good mood, we would do ‘sex play.’  Sometimes I was aroused by it and I soon got used to the guilty feelings afterwards!  I didn’t tell my parents because whenever he was in a good mood, my parents were happy too." 

Because Tonya believed it was her duty to keep her brother in a good mood, she felt an extreme amount of guilt and responsibility for allowing the abuse to take place.  To help Tonya relieve her own sense of guilt, I suggested she try the exercise "Displacing the Guilt."  In this exercise, I asked Tonya to write a letter to herself and to her brother.  I asked that she concentrate on lifting the blame from herself, as she was just a young child, to her brother, who was older and understood right from wrong. 

Tonya’s Displacing Guilt letter included the following passage to her brother:
That night, you… who were nearly thirteen made me, a five year old, do something that only adults should do!  You knew it was wrong when you told me not to tell Mom and Dad.  You knew it was wrong when you did it again and again.  Did you feel as guilty as I did or did you have no conscience at all, even abusing a helpless little girl?

Although she did not have to send the letter to her brother, I also found that this letter allowed Tonya, a people-pleasing perfectionist, to express the anger that she had bottled up inside.  Think of your Tonya.  Could he or she benefit from Displacing Guilt?

In this section, we discussed three concepts related to anorexic clients who are survivors of incest.  These concepts of anorexic clients who were victims of incest included:  inability to trust; skewed sexuality; and learned defenses.

In the next section, we will examine three manifestations of anger in anorexic clients.  These three manifestations of anger in anorexic clients include:  repression; acting-out; and defense mechanism.
Reviewed 2023

Peer-Reviewed Journal Article References:
Christian, C., Perko, V. L., Vanzhula, I. A., Tregarthen, J. P., Forbush, K. T., & Levinson, C. A. (2020). Eating disorder core symptoms and symptom pathways across developmental stages: A network analysis. Journal of Abnormal Psychology, 129(2), 177–190.

Criscuolo, M., Marchetto, C., Chianello, I., Cereser, L., Castiglioni, M. C., Salvo, P., Vicari, S., & Zanna, V. (2020). Family functioning, coparenting, and parents’ ability to manage conflict in adolescent anorexia nervosa subtypes. Families, Systems, & Health, 38(2), 151–161.

Duffy, M. E., Calzo, J. P., Lopez, E., Silverstein, S., Joiner, T. E., & Gordon, A. R. (2021). Measurement and construct validity of the Eating Disorder Examination Questionnaire Short Form in a transgender and gender diverse community sample. Psychological Assessment, 33(5), 459–463.

Farber, S. K., Jackson, C. C., Tabin, J. K., & Bachar, E. (2007). Death and annihilation anxieties in anorexia nervosa, bulimia, and self-mutilation. Psychoanalytic Psychology, 24(2), 289–305.

Lejonclou, A., Nilsson, D., & Holmqvist, R. (2014). Variants of potentially traumatizing life events in eating disorder patients. Psychological Trauma: Theory, Research, Practice, and Policy, 6(6), 661–667. 

Mallinckrodt, B., McCreary, B. A., & Robertson, A. K. (1995). Co-occurrence of eating disorders and incest: The role of attachment, family environment, and social competencies. Journal of Counseling Psychology, 42(2), 178–186.

QUESTION 10
What are three concepts related to anorexic clients who are survivors of incest? To select and enter your answer go to Test.

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