Self-Harm, Eating Disorders and Emotion Dysregulation

By Leslie Karwoski Anderson, Phd

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One of the most heartbreaking elements of eating disorders is the idea of someone seeming to disregard their well-being and intentionally causing harm to themselves. Eating disorder behaviors (eg., food restriction, binging, purging, over-exercise) are undoubtedly damaging, and many individuals with eating disorders inflict further harm on themselves by cutting, scratching, burning, etc. This article will provide a brief overview of the association between eating disorders and self-harm, with a focus on the role of emotion dysregulation and effective treatment.

Definition

Self-harm, also known as non-suicidal self-injury (NSSI), was included in the DSM-V for the first time, as a condition for further study in the appendix (APA, 2013). In the DSM, NSSI is defined as intentional self-inflicted damage to the surface of the body with the expectation that the injury will not lead to death. As aptly described by Armando Favazza, “a person who truly attempts suicide seeks to end all feelings whereas a person who self-mutilates seeks to feel better” (Favazza, 1998, p. 262). Usually, the purpose is to reduce a negative emotional state or resolve an interpersonal problem. Patients generally report a sense of urgency and/or preoccupation preceding the behavior, and a short-lived sense of relief afterwards.

The co-occurrence of self-harm and ED

Self-harm and eating disorders commonly co-occur. A recent review found that SIB (self-injurious behavior) occurs in 25-55% of eating disorder patients. Among patients with SIB, 54-61% meet criteria for an eating disorder (Svirko & Hawton, 2007). Both self-harm and eating disorder behaviors typically begin in adolescence or early adulthood, and occur mostly in females (Suyemoto, 1998). Some studies have shown an increase in the prevalence of both self-injurious behavior and eating disorders in recent decades.

Function of the behaviors

Both self-harm and eating disorder behaviors can be thought of as ways to escape, avoid or otherwise regulate aversive emotional states (Buckholdt et al., 2015). Patients with self-harm and eating disorder behaviors often describe experiencing strong negative emotions, or emotional lability that feels out of control. They also tend to judge themselves harshly for having feelings, or are afraid of their emotions, which leads them to feel desperate to find relief.  If you ask a patient why they self-harm and use eating disorder behaviors, typically they will tell you that it is because those behaviors numb their emotions, distract them from their emotions, or give them a brief sense of calm or relief. A couple of years ago, I polled a group of adolescents in our clinic with self-harm and eating disorders on what they believe drives these behaviors and here are some of their answers:

• It’s hard for me to explain but I do behaviors to numb out emotion and to feel better about myself.
• I used the behavior to relieve my feelings.
• To numb emotions, to deal with unwanted feelings.
• I did it because it made me feel mentally and emotionally good.
• Because it suppressed all of the emotions I didn’t want to deal with. It’s an escape. It was a way to torture and sabotage myself because I hated myself so much.
• I used it because it’s an escape from feeling my emotions that I get tired of feeling.

As paradoxical as it may seem, self-harm and eating disorder behaviors are extremely effective in regulating emotion (in the moment), and that effectiveness makes it hard to stop. Of course, the relief tends to be short-lived, and soon followed up by guilt, shame, or other negative consequences, and the self-harm doesn’t solve the original problem that caused the emotion dysregulation. Thus, the person is likely left with as much or more negative emotion, and the cycle of behaviors continues.

So why stop self-harming?

I have had many patients argue with me about self-harm behaviors, reassuring me that they are not suicidal and this is just their way of making themselves feel better. Marsha Linehan addressed this issue in her seminal 1993 book introducing dialectical behavior therapy (DBT). She listed four main reasons for self-harm to be a primary focus of therapy, and I have used these reasons countless times when explaining to a patient who doesn’t want to stop self-harming why I am unwilling to ignore their behaviors.

1) Self-harm is one of the best predictors of eventual suicide. Studies have shown that risk of suicide increases 50-100 times within the first 12 months after an episode of self-harm, compared to the general population risk (Cooper et al., 2005). Additionally, the majority of people who die by suicide have a history of self-injury (Appleby, et al., 1999). Frequency of self-harm is more strongly related to suicidal behavior than depression, anxiety, borderline personality disorder, or impulsivity (Klonsky, May & Glenn, 2013).

2) Self-harm behavior damages the body, sometimes permanently. Cutting and burning often cause scars that last forever. There is also the possibility that self-harm may unintentionally result in death.

3) Self-harm is antithetical to the process of therapy. Patients are in therapy to learn to be happier, to better their lives, to learn to love themselves and have healthy relationships. It is hard to imagine these goals can be accomplished while actively causing physical damage to one’s body. “Actions based on the intent to harm oneself are simply incompatible with every other goal of any therapy. The effectiveness of all voluntary psychotherapy is based, at least to some extent, on developing an intent to help rather than harm oneself. Thus, treatment of self-harm goes to the heart of the therapeutic task” (Linehan, 1993, p. 127).

4) We cannot, as therapists, credibly communicate caring for a patient without reacting to their self-harm and insisting that it must stop. In that sense, devoting therapeutic time and energy towards cessation of self-harm can be considered strong communications of compassion and care.

Treatment of Self-harm

Treatment of self-harm and ED is notoriously difficult. Many of us have an impulse to judge self-harm; it’s hard to understand and we want them to “just stop”. Therapists must approach the topic non-judgmentally and join with their patients to determine the function(s) of the behavior.

There are several reasons that self-harm can be difficult to tackle successfully. Just as with eating disorder behaviors, there is an inherent ego-syntonicity and ambivalence toward stopping the self-harm. My patients frequently let me know that although learning new skills might help regulate emotions, these skills often don’t work as well – and as quickly – as self-harm. Self-harm also tends to be glorified in some social media and peer groups. Whether they learned about the behavior from others or not, self-harm often gets a reaction out of others, even if that is not the intent behind the behavior. Most of us have an instinct to comfort, reassure, and try to help someone who is expressing the urge to self-harm, and this support can be a powerful reinforcer, inadvertently increasing the chances of the behavior recurring. Self-harm behaviors can also satisfy an internal need to rebel against someone or something, or to prove a point, even if no one knows about the self-harm.

Treatment should be focused on teaching the patient how to regulate his or her emotions in more skillful ways. The patient must learn to be aware of and accept emotions as a normal and non-threatening part of life, and not avoid meaningful life activities out of fear of negative emotions. S/he must also learn to not necessarily act on emotions, especially on impulsive, self-destructive behaviors. Lastly, the patient must learn skills and strategies for reducing the intensity and duration of unwanted emotions (Gratz & Roemer, 2004).

Skills for coping with emotion are taught in many therapy modalities and DBT is a well-researched treatment with a heavy focus on skills acquisition (Kliem, Kröger, & Kosfelder, 2010). The therapist’s stance of refusing to settle for a life that includes self-harm, combined with learning new skills for emotion regulation, can be a powerful and effective approach to recovery.

About the author -
Dr. Leslie Karwoski Anderson is a clinical assistant professor and training director at UCSD Eating Disorders Center. She has a Ph.D. in clinical psychology from the University of Kansas, and completed her clinical internship at Duke University Medical Center. Before coming to UCSD, she held a clinical faculty appointment at the University of Washington, was a supervisor in Marsha Linehan’s DBT training clinic, and was a staff psychologist at the DBT Center of Seattle. She currently oversees the training and clinical supervision of the UCSD EDC staff, and conducts individual, family and group therapy for anorexia, bulimia, binge eating disorder and EDNOS. Her research interests are in treatment development, evaluation, and outcomes, especially with regards to adaptations of DBT and FBT, and she has published several papers in this area. She frequently gives talks and workshops on DBT, eating disorders, suicidality, and related topics in the community and at national conferences. She is currently serving as the co-chair of the Academy of Eating Disorders DBT Special Interest Group.

References -Appelby, L., Cooper, J., Amos, T., & Faragher, B. (1999). Psychological autopsy study of suicides by people aged under 35. British Journal of Psychiatry, 175, 168-174.

Buckholdt, K.E., Parra, G.R., Anestis, M.D., Lavender, J.M., Jobe-Shields, L.E., Tull, M.T., & Gratz, K.L. (2015). Emotion Regulation Difficulties and Maladaptive Behaviors: Examination of deliberate self-harm, disordered eating, and substance misuse in two samples. Cognitive Therapy and Research, 39, 140-152.

Cooper, J., Kapur, N., Webb, R., Lawlor, M., Guthrie, E., & Mackway-Jones, K. (2005). Suicide after deliberate self-harm: A 4-year cohort study. American Journal of Psychiatry, 162, 297-303.

Favazza, A.R. (1998). The Coming of Age of Self-Mutilation. The Journal of Nervous and Mental Disease, 186, 259-268.

Kliem, S., Kröger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling. Journal of Consulting and Clinical Psychology, 78, 936-951.

Klonsky, E.D., May, A.M., & Glenn, C.R. (2013). The relationship between nonsuicidal self-injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122, 231-237.

Linehan, M.M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

Suyemoto, K.L. (1998). The functions of self-mutilation. Clinical Psychology Review, 18, 531-554.

Svirko, E., & Hawton, K. (2007). Self-injurious behavior and eating disorders: The extent and nature of the association. Suicide and Life-Threatening Behaviour, 37, 409-421.

Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B., & Goodyear, I. (2011). Clinical and psychosocial predictors of suicide attempts and non-suicidal injury in the adolescent depression antidepressants and psychotherapy trial. American Journal of Psychiatry, 168, 495-501.

TUTU THIN INTERVIEW

Author Dawn Smith-Theodore, MA, MFT, CEDS, joined us to discuss her book, Tutu Thin: A Guide to Dancing Without an Eating Disorder. What follows are our questions in italics, and Dawn’s thoughtful responses.

You note a familiar eating disorder experience when you state, “Life had always been one goal after the other, with little appreciation for anything but the achievement. Yet these achievements were never enough, much like the numbers on the scale.” Please tell us more about this insight.

As the number dropped on the scale in the beginning of my journey through anorexia, I would tell myself that if I just lost 5 pounds that I would be happy. The eating disorder in my head had begun the deception that I believed.  Five pounds turned to another five and eventually, I had lost over 25 pounds.  No matter what I lost, it was never enough for my eating disorder.  I could never be thin enough.

Very similarly, I have always been a very driven and determined person who would work hard to accomplish goals.  When I would achieve one goal, I did not allow myself any time to enjoy the accomplishment until I was on to the next goal.  This inability to appreciate the present left me pushing forward to what I felt I needed to do in order to be successful.  With each accomplishment, I was pushed to another goal.  The feeling was the same… “It is never enough”

I am still a very determined person, as I have realized this is part of my temperament.  The difference is that I enjoy the process of achieving the goals that I set for myself and I have learned to appreciate my accomplishments.

You developed Tutu Thin: A Guide to Dancing Without an Eating Disorder specifically for dancers who have or suspect they have an Eating Disorder, their parents and their guardians. What is the prevalence of Eating Disorders in the dance community?

Dancers are 20 times more likely to develop an eating disorder than the general population. In the white middle class population, on the average, 1 in 100 will develop an eating disorder.  In the ballet world, 1 in 5 dancers will develop an eating disorder. 

What are your recommendations for dancers and their families regarding nutrition?

As a dancer, you need proper nutrition to fuel your body to perform at its best. It is important to learn from a young age to eat balanced meals for the rest of your life as opposed to going on a crash diet for a certain role or audition. You are an athlete and your body is your instrument. Hence, you need to keep it functioning well. This can be difficult as dance studios are often filled with obsessive talk about weight and new diets. It is important that you have a solid sense of what you need to eat as a dancer and not engage in unhealthy dieting behavior. Being educated about nutrition and what you need to eat in order to maintain your weight as a dancer will help eliminate the chances of developing an eating disorder. 

As a dancer, it is so important that you have food with you during the day. Plan your day the night before and include all your meals and snacks. Be sure that you leave enough time to eat your food and always take snacks and meals with you. If you are rehearsing or in class, you may run late so always be prepared. Remember that food is the fuel for your body to be able to dance and perform. Dancers who are prepared each day with meals and snacks will be able to be flexible. Avoid going more than 2–3 hours without a meal or snack. You do not have to be perfect with your food, but consistency is very important. Remember to listen to your body—hunger and fullness are built in regulators, we just have to learn to listen. 

Dancers and perfectionism – Can you please explain how this combination may be a slippery slope?

Dance breeds perfectionism. Perfectionism is the trait or temperament of a person who is striving for high-performance standards—flawlessness with a strong drive and motivation to achieve their goals. Temperament is the way an individual thinks, behaves and reacts in their environment. People can be influenced by their environment as well as by their genetics.  Perfectionists will have self-discipline, and an obsession with the end result. They are conscientious and have a great work ethic. 

When a dancer stands at the barre with the other dancers, everyone is striving for perfection. Perfection is what is perceived on stage, but there is a journey to get there. It is important for the dancer to master technique. To work in class each day is a part of the journey. Setting realistic goals is important so that the dancer does not put too much pressure on his/herself. The goal of focusing on the process as opposed to the end goal is essential for a dancer to understand. It is not an easy concept to grasp. 

The goal to be the best dancer in the class or in the company is an example of how perfectionism is like chasing the rainbow. The high standards set by a dancer will motivate that person to continue to push beyond their capabilities to achieve the highest arabesque, the most turns or the lead in a ballet or show. There is always a carrot that is dangling ahead of the dancer, even after achieving success. Sometimes this drive to achieve perfection can become detrimental to their work as a dancer, and eventually lead to an eating disorder. 

Why do you feel it is important to have “balance” in a dancer’s life?

When a dancer does not have balance or perspective, he/she may begin to be obsessive. This obsessional state can manifest itself in the pursuit of being the perfect dancer, having the perfect body or pursuing the ideal role in the next show. It is through the lack of balance in life—which includes nutrition, sleep, and relationships—that a dancer can find him/herself on a negative path. 

If an individual is only focused on becoming a dancer, and finds most of his/her time spent in the studio, there is not a lot of time for relationships. This is when an unhealthy relationship with oneself can possibly begin to develop, and it becomes an escape from the pressure and stress to succeed. There is a lack of balance and no outlet for emotions. The development of an eating disorder serves as a method to numb out and mask the disappointment that can come with working hard and not getting the recognition. 

Dance incorporates mind, body and spirit in the art form. Learning to find all of these within the self and managing internal struggles with external pressures can present quite a challenge to find balance in the life of a dancer. It is the journey we are all on as dancers. It is never about the end result being the perfect job or gig, but about the journey we embark upon to find each job. 

On that journey, we also need to develop the balance within oneself to sustain the ability to tolerate rejection as well as accomplishments.  

If you find that balance as a dancer, you will believe in yourself and know that you are proud of what you accomplish. It will also allow you to have belief in your talents, which will lessen the stress, insecurities, and pressure you feel to succeed. It will become about the journey to be on pointe!

Can you please share some suggestions for dancers on how they can respond to critical comments about their body size and shape?

It is so important to feel good about who you are as a person and a dancer.  Remember that your body is what allows you to dance.  Musicians take care of the instruments they play and dancers need to care for their bodies.  

Dancers come in all shapes and sizes.  Look for positive things about yourself and your body.  Treat it well so it will allow you to continue to dance.  

What would you like parents of dancers to know regarding how they can help guide their children to maintain physical and mental health?

Emphasize the importance of who your child is as a person rather than the size of their body. It is important that your dancer has good self-esteem and is confident in whom they are. This confidence will get a child far in his/her life as a dancer or in any career your child may choose. If a child is happy living life and doing what he/she loves, food will not have the power in their life. If your young dancer understands this and feels good about the person they are, then your child on the right track. 

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About the author:

Dawn Theodore, MA, MFT, CEDS,  is a leader in the treatment of eating disorders, adding to her therapy practice the insights of a dance professional and teacher, studio owner, and dancer who has personally recovered from anorexia nervosa. She is currently the Director of Day Treatment Services for Monte Nido and Affiliates. She also has a private therapy practice in Calabasas and Brentwood, California. 

She appeared on Health Zone with Amy Hendel and Recovery Talk Network as a therapist with a specialty in the eating disorder field. She has also been a guest teacher at Pepperdine University and California State University Dominguez Hills. She appeared on several episodes of the Lifetime Network documentary about the treatment of eating disorders, “Starving Secrets.” 

Dawn owned and operated her dance studio in Calabasas for twenty-five years. Before opening her studio, Dawn lived in New York City where she taught and performed for the legendary Henry LeTang. Dawn has been featured in many productions, commercials and TV shows.     

She has written the chapter “Fitness or Fanatic” (with Carolyn Costin) in her rewrite of the 1997 The Dieting Daughter, released in 2013. Dawn has also written for The Recovery Journal on the relationship between eating disorders and crystal methamphetamines. 

Eating Disorders among Orthodox Jewish Women: same or different?

By Caryn Gorden, Psy. D.

Eating disorders among Orthodox Jewish females are a major and continuous cause for concern.  Despite inconclusive data on whether the rate of eating disorders among Orthodox Jewish women and teens is higher than its incidence in the general and larger Jewish population there is concurrence that until recently these eating disorders remained under-reported and often unaddressed. Currently there is increasing awareness and greater numbers of women seeking treatment. 

Eating disorders among observant Jewish women and teens are both the same as and different than they are in the larger Jewish or general population. They occur for many of the same complex reasons and present with the same signature features.  

Cultural Difference

What distinguish eating disorders in the Orthodox Jewish population are unique cultural and religious elements. These aspects may intersect with other existing vulnerabilities and increase a woman’s risk of developing an eating disorder. These factors include: the mixed and contradictory obligations embedded in the religion, the importance of food, the significance of family, the shidduch (matchmaking) phenomenon and the traumas of the Holocaust.  

Mixed messages and incompatible expectations

Nothing intrinsic to Orthodox Judaism causes an eating disorder. However, the underlying mixed messages and incompatible demands to observe a traditional, spiritual way of life while functioning in a modern, secular world may serve as fertile ground for putting some females at risk. This may be truer now because the recent shift of orthodoxy to the right demands an increased, effortful negotiation of the gulf between this traditional culture (with its circumscribed gender roles) and a contemporary  existence (where gender and sexuality are significantly more fluid).

For example, Jews are taught to celebrate and take pleasure in their bodies, yet the many restrictions regulating this enjoyment send another message. There are laws dictating the modest clothing women are permitted to wear, married women must cover their hair when in public and women are allowed only limited contact with men, including when they can be physically intimate with their husbands. 

The observant female’s attempt to reconcile the contradictory expectations can at the very least generate conflict but more worrisome, can catalyze her asceticism, body shame and sexual discomfort which often underlie an eating disorder.

Perfectionism and Desperation

Jews highly value education, and professional and economic achievement, which can lead to greater contact with the secular culture. However Orthodoxy privileges a good shidduch (match), marrying young and having many children, skillful domesticity and physical appeal while in modest dress–values and expectations that may be felt as paradoxical and impossible to fulfill.

My patient, Elana, struggles with this dilemma. A thirty year old, high powered attorney and mother of 4, she relentlessly strives to meet the demands of her law firm, while also attending to every detail of her children’s lives, preparing large meals for Sabbath company and staying thin and physically desirable. Elana suffers from perfectionism and a belief that she must always be in control. This manifests in her relationship to food—initially Elana restricted herself to eating only “healthy food” but eventually developed full-blown anorexia punctuated by weekly “Sabbath binges.”

Susan, an academically successful seventeen year old, responded to the impossibility of fulfilling both traditional and modern gender roles by silencing herself and protesting against these irreconcilable pressures.  Her anorexia and the related loss of menstruation and fertility were a communication of her failed attempt to live in these incongruous worlds as well as a desperate solution to her problem: In this state, she could not be expected to pursue pre-med at an ivy-league university, while also marrying young and quickly having a large family and home to manage.

Food as a prime medium for acting out

Food plays a prominent and preoccupying role in Orthodox Jewish life because of its link to religious practices and the demands of preparing for and feeding large families. Like other essential elements of Judaism food is layered with contradictions. It is a source of joy, embedded in many familial and communal traditions and rituals such as the Sabbath and holiday meals.  Yet there are many rules surrounding preparing and eating food such as Kashrut (keeping kosher), blessings before and after meals and fast days. Food’s distinct role in the Orthodox Jewish population makes it a prime vehicle for playing out unspoken conflicts and confusion. The religious regulations regarding food that demand strict observance can serve as the scaffolding for the rigidity, control and deprivation that characterize restrictive anorectic eating.

The challenges of separating and staying connected to family

The importance of family is a central and abiding principle. Maintaining the legacy and ties to previous generations is so essential, that observant Jews consider parental disrespect a sin against God. Yet marrying and creating a large family is similarly fundamental to Judaism. The universal challenge to stay connected to one’s original family yet separate so that one can develop a self-identity and create one’s own family may be a source of intensified conflict. This is particularly evident in enmeshed mother-daughter relationships, which are often a hotbed for the development of an eating disorder. 

The eating disorder often communicates the struggle of merger and separation and concretizes the wish for a boundary and demand for control. Jewish educators note that for many teens who spend a gap year abroad studying in Israel the transition and abrupt separation from family for the first time may be mediated by the eating disorder.

The Shidduch may generate body image dissatisfaction

The importance of making a good shidduch shapes the lives of many young women, and creates an indelible timeline. The trend is to date briefly prior to an engagement, quickly marry and then begin having many children. The common underexposure to the opposite sex can, however, create fear and an avoidance of physical intimacy. A resulting eating disorder can function then as a solution to overcoming the conflict regarding physical desire.  

The shidduch process has morphed for some into a shopping expedition with a list of necessary “attributes” and the “shidduch resume” has become a common occurrence. My patient Sarah was therefore nonplussed when Jonathan’s mother asked the matchmaker, what size dress Sarah wore and even “What size does Sarah’s mother wear?” suggesting that anything larger than a size 4 might lower Sarah’s chances to marry her son. The pressure to make a good shidduch, and overvaluing a thin bride can objectify young women and foster body dissatisfaction, that may further the development of an eating disorder.

History of Persecution and Holocaust Trauma

Though sparse research exists exploring the correlation between Holocaust exposure and disordered eating in the Jewish population, particularly among the children and grandchildren of survivors (Zohar, Giladi & Givati, 2007), there are many anecdotal examples and clinical case studies that buttress the link between these two variables (Grubrich-Simitis, 1984; Rabinor, 2002).  

The unfathomable emotional and physical horrors visited on the survivors resulted in their dissociation of experience, where traumatic memories remain incomprehensible — unsymbolized, unspoken and disconnected. The survivor’s inability to develop a coherent narrative, served as fertile ground for intergenerational transmission, and for their offspring’s reenactment, of this trauma history. The transmission may have occurred both through the attachment relationship and parenting as a result of the adaptive strains that accompanied the parents’ survivorship (Kestenberg, 1982,; Bar-On et al., 1998,; Scharf & Mayseless, 2011) as well as through the children’s unconscious identification with the previous generation and their (known or unknown, spoken or unspoken) history (Auerhan & Laub, 1984,; Faimberg, 2005).  Similarly the long-term biochemical shifts resulting from trauma are thought to have been transmitted intergenerationally even at the prenatal stage or during infancy and early childhood when maternal behavior influences a child’s hormonal and metabolic processes (Yehuda & Bierer, 2009).

The unmourned persecutory and Holocaust traumas of previous generations rendered many from subsequent generations affectively dysregulated, psychically concrete, somatically encoded, relationally enmeshed, and unwittingly identified alternately with the helpless victim and/or unmerciful aggressor. These same psychodynamics and vulnerabilities are often identified as facilitating or underlying patterns of disordered eating.  

Affective Dysregulation

A child’s affect tolerance is developed through exposure to the internalization of the parent’s regulatory capacity. The traumatized and affectively dysregulated parent’s inability to organize and contain their child’s affective experience often results in the child’s failure to modulate and express strong affect “[o]ne generation’s trauma leads to the next generation’s lack of affect tolerance” (Wilson, 1985). 

The psychoanalytic literature, which clearly establishes a link between empathic failures and eating disorders (Bromberg 2001; Sands 2003; Ferguson 2011), views the dysregulation of affect as the crucible for the development of disordered eating.  The absence of a self-regulating experience of human relatedness and its potential for reparation results in the individual’s necessary reliance on her own physiological and affective states. The outcome of this protracted self-reliance is the dissociation of psyche from soma, thought to be at the heart of eating problems (Bromberg, 2001; Farber et al., 2007). Where there is inability to self-regulate affect, the eating disorder functions as a self-regulatory Other, as a failed attempt to ward off or control anxiety and as an anesthetic, relieving the patient from her intense and overwhelming feelings. For example, compulsive overeating becomes a way for patients to “stuff down their feeling” while maintaining the imperative for verbal silence (Rashkin, 1999).

Starvation 

Of the entire bodily trauma that Holocaust victims endured, the most ubiquitous was severe starvation. Subsequently, many survivors were preoccupied with food and eating. Their offspring may then unconsciously identify with their ancestors’ previous emaciated condition and enact the same physical and psychic state by starving themselves or by secret binge eating. Additionally, the survivor guilt experienced by those victims who lost family members yet survived may be lived out by the next generation(s) who silently tell this story through their ravaged bodies (Farber et al. 2007; Jackson & Davidson, 1986). Their anorexia, which comprises a “deadened” state, is a compromise formation for the feelings of guilt over being alive. 

The survivors’ history also often included experiences of desperate hiding, of having to either escape or retreat. The symptoms of anorexia can simulate this physical withdrawal. The hiding is enacted through the disappearance and invisibility the anorectic feels as she is shrinking, as well as the way she may conceal her body in baggy clothing. The bulimic or compulsive overeater may similarly obscure her shame and greediness by eating in secrecy and shrouding her unacceptable feelings in the layers of protective fat.

Identification with the Aggressor

Like their earlier ancestors, offspring of survivors often alternately act out the paradox of survivorship (special for surviving yet degraded for being victimized, (Auerhan & Laub, 1984), as well as the oscillating and contradictory self-states of victim and aggressor. The anorectic offspring may play out this history by condensing both sides of this dyadic interaction. Through starvation (or bulimia) the offspring operates self-destructively, being both aggressor and victim to herself, and though she remains alive (survives) despite the starvation, in her profound loss and mourning she is lifeless and dead in life. 

In identifying with the aggressor, the offspring may enact not only the sadism of her ancestors’ persecutors, but also introject their ethnic hatred and anti-Semitism. This is illustrated by the offspring’s (often unconscious) self-hatred of her Jewishness, which among other genetically predisposed traits is stereotypically represented through her “zaftig” Jewish body, which she wishes to control and alter into a thin non-Jewish profile. Moreover, by striving for and achieving perfection, she unconsciously hopes to avoid criticism and anti-Semitism.

Particular issues related to treatment, recovery and prevention

Similar to the disorder, the treatment and recovery process with eating disordered Orthodox Jewish females is both the same and different than it is for the general population. A therapeutic relationship that privileges the patient’s experience of being seen and known (often absent from the young woman’s psychic development) is an essential ingredient to recovery for anyone with an eating disorder (Gorden & Kofman, 2015). Additionally, although important in any treatment regardless of the issue, sensitivity, privacy and trust are particularly critical factors in the treatment of the orthodox eating disordered female. For my patient Rachel they are especially important due to her close (at times intrusive) family ties and the stigma she believes could impact her shidduch potential if her disorder was known.

Accordingly, Rachel initially wanted a therapist outside of the Orthodox community so as to safeguard her privacy. However, she also required someone culturally sensitive, who possessed a solid understanding of the role Orthodox Judaism occupies in her life or at least a therapist with a keen curiosity, respect, and willingness to collaborate with her rabbi or another psychologically minded religious figure. My being culturally informed was subsequently essential in clarifying whether some issue Rachel presented was an expression of a religious imperative or a reflection of the restriction and rigidity of the disorder. Appreciation of the role Judaism played in Rachel’s life likewise allowed me to use and rely on religious values and rituals regarding self-care of the body that were ultimately helpful in furthering Rebecca’s treatment and recovery.

As Jewish Orthodoxy continues to shift to the right, modern technology and globalization is infiltrating and impacting every aspect of daily life. This consequent collision of traditional and modern culture presents young women with irreconcilable demands. Mixed messages regarding body image and gender role expectations have increased women’s conflicts and the desperation of their solutions.

In thinking about prevention, it is important to consider eating disorders in the context of cultural/religious factors, while continuing to look at unique biological and psychological issues. As cultural shifts are clearly beyond our control, it is essential to focus effort on ways to broaden and redefine individual female identity and role expectation. Loosening the shackles of traditional gender roles can contribute to the development of Jewish orthodox women’s positive self-esteem, realistic and healthy body image, and a sense of empowerment. By doing so, we can provide observant Jewish women with greater freedom to access their desire, and make choices about how they want to live.

About the author:Caryn Gorden, Psy. D., is a faculty member and supervisor at the Stephen Mitchell Center for Relational Studies and a visiting faculty member at the Eating Disorder Compulsions & Addictions Service of the William Alanson White Institute. She teaches, lectures and writes about eating disorders in the Orthodox Jewish population and the intergenerational transmission of trauma.

References:

Altmann, E. (2009. June). Food, body image and eating disorders in the Jewish community. Paper presented at Renfrew Center Foundation Conference. 

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