by Dr. Emily Wacker, LCMFT

I have been specializing in working with individuals affected by eating disorders for several years. It wasn’t until recently that I stumbled upon a therapy approach that made me rethink everything I thought I knew about healing. I often explain to clients that eating disorder treatment is like an iceberg. The tip of the iceberg includes the things that we can see, restriction, bingeing, weight loss, you name it. These are the things that are more commonly treated through behavioral strategies for symptom reduction. There is absolutely nothing wrong with behavioral strategies. In fact, given that eating disorders are a life threatening condition, it is imperative to intervene quickly in reducing these destructive behaviors.

However, I tell clients that if we only focus on the behaviors, the “tip of the iceberg,” we miss the mechanisms that maintain these behaviors. For example, it is not uncommon that clients will reduce their binge-purge behaviors and then before long they will notice that their drinking is out of control.

Without even realizing it they have replaced their self-destructive coping mechanism with something else.

This is actually an incredibly resourceful strategy. Until clients can understand why these self-destructive coping mechanisms developed in the first place, they will continue to bounce from symptom to symptom, and sit on the top of the iceberg.

Therefore, in this metaphor, the bottom of the iceberg involves the factors that maintain eating disorders. This could be anything from childhood trauma, relationships struggles, issues of self-esteem and many more. Consider how the bottom of the iceberg is usually larger and almost impossible to see.

With this concept in mind, I started to become really curious about the wounds that maintain eating disorders, and how many clients are not even aware of these wounds.

Due to their resourcefulness, clients have become experts in pushing these wounds away. If we pay attention, I think we can learn a lot about what an eating disorder might be trying to tell us.

So remember that model of therapy I mentioned at the beginning? Here’s where it comes in to play. Several months ago I felt like I was hitting a road block in my work. I could help clients to feel safe in the therapy room, we could work on healthy coping strategies to reduce destructive behaviors, but something was missing. We were still sitting on top of the iceberg.

Then I stumbled upon the work of Pia Mellody who developed methods to heal relational trauma. Relational trauma, from Mellody’s perspective, involves experiences with caregivers that are “less than nurturing.” These could be overt in the way of physical and sexual abuse, but it could also involve more subtle experiences. This covert kind of trauma could be anything from neglecting to provide your child space to form her own opinion, or a parent who is unable to provide appropriate nurturance when a child comes to them in tears. One way to think about it is that every human on the planet has likely experienced relational trauma, we all had experiences with our caregivers that were less than nurturing. The frequency, extent, and impact of these “less than nurturing” experiences on a given individual is what separates someone who may be able to come out on the other side relatively unscathed, from those who show up in my office.

According to Mellody, when someone has experienced relational trauma they go on to develop difficulties around any or all of the “core issues,” which include boundaries, self-esteem, dependency, and owning and expressing their own reality. Remember that iceberg metaphor? Well, these core issues are what make up the bottom of the iceberg. In order for someone to believe they are more than their jean size, they have to go back to the younger version of themselves that internalized the belief that their worth was conditional. For example, this might involve working with an adult client as she starts to name the various ways that she felt nurtured and loved by her parents, and identifying that the majority of these methods were through external validation. Getting good grades, having a lot of friends, losing weight, these were the things that caught parents’ attention. So low and behold, over time she developed a belief that she had to DO things in order to be loved, that she wasn’t worthy just as she was, just because she was born.

I want to be very clear here that the goal of this model is not to blame caregivers. The focus is on impact not intent, it’s about naming these less than nurturing experiences in order to then heal the trauma. After naming the relational trauma they’ve experienced, most of my clients are able to put it in context, “it makes sense that my Mom never hugged me, given that her father was so emotionally unavailable.” And through this process, they not only resonate with a younger version of their parents, but they invite in space for forgiveness and healing.

If you are at all skeptical about these ideas, let me be the first to tell you that I used to hear the words “inner child” and roll my eyes. However, being able to witness clients as they name and reclaim what was not provided to them in childhood is an incredible experience that is hard to put into words. It has been transformative, both in the way that I conceptualize healing and in my understanding of the capacity for human resiliency.

Case example: I had been working with Anna for several months. She had a history of an eating disorder in adolescence resulting in a three month hospitalization. She was now in her early thirties, progressing in her career, newly married, with almost a decade of eating disorder recovery under her belt. She came to my office and was tearful as she recalled weighing herself for the first time in months and then collapsing on the floor in tears after seeing the number. She was frustrated that her weight still held such a stake in her life, even after all these years.

I had Anna envision the first time she stepped on the scale in her teenage years. We walked through it slowly and she identified the circumstances in her life at the time. There had been a significant death in the family, but everyone around her appeared to be emotionally closed off and going on as if everything was normal. I asked Anna to envision what she really needed when she stepped on that scale almost two decades ago. Tears streamed down her face and Anna stated, “I wanted someone to give me a hug. To ask me how I was feeling. To tell me things were going to be ok.” Physical nurturance, acknowledgement of emotions, and reassurance. These are things that we all need, they are the very crux of what make us human. And when Anna’s caregivers were unable to provide these to her she found ways to get these needs met on her own. Through re-parenting strategies we worked to help Anna provide the emotional nurturing to her younger self from the stance of her now functional adult. It was painful, it took time, but it was powerful, and it worked.

Thanks, friends!

-Dr. Emily Wacker, LCMFT

Mellody, P., Miller, A. W., & Miller, J. K. (2011). Facing codependence: What it is, where it comes from, how it sabotages our lives. Harper Collins.

Kendra O'Hora( PhD, LCMFT )

Dr. K started Wellness & Co. with the desire to provide top-notch therapy to our local community. Now, Wellness & Co., has therapists, coaches, tutors, and professional organizers – all to provide wrap-around, boutique style care to our clients. Dr. K specializes in couples therapy, healing from infidelity, and supporting individuals through relational transitions.