"Approximately 30% of individuals with an eating disorder have a history of childhood sexual abuse. When the body has been the source of the trauma, one invariably struggles to find comfort in their own skin, and some will reject and hate the body and themselves as a result of the trauma."
Dr. Anita Federici is a Clinical Psychologist and the Owner of the Centre for Psychology and Emotion Regulation, a private practice specializing in the assessment and treatment of eating disorders, personality disorders, and trauma. She is a registered member of the College of Psychologists of Ontario and the elected Co-Chair for the Suicide and DBT Special Interest Group for the Academy for Eating Disorders. Anita has an established reputation for her work as a therapist, clinical trainer, researcher, program director, and consultant. She has provided clinical training and program development for numerous hospitals and organizations in North America. In 2019, she was awarded Business Woman of the Year by the Meridian Women of Excellence Committee. Dr. Federici is a recognized authority on eating disorder treatment and dialectical behaviour therapy (DBT). Her work has been presented at international conferences and published in peer-reviewed journals and invited book chapters.
SWY: Can you tell us a little bit about yourself and the way you came into this work?
AF: I am a clinical psychologist practicing in Midland, Ontario. I have been working in the field of eating disorders, personality disorders, and trauma for the past twenty years. I didn’t know I was going to go into psychology at first. I went to university later in my life and just enjoyed learning. My undergraduate degree was in health sciences, as was my master’s degree at U of T. I was accepted into a medical sciences program tied to the eating disorders unit at Toronto General Hospital and I really connected with that work. Eating disorders are very misunderstood and complex and our treatments still have a long way to go in terms of effectiveness and recovery rates. When I began working at CAMH during my PhD, I worked with the DBT team in the Borderline Personality Disorders Clinic and really loved it. As I explain below, DBT is designed for those with multiple problem behaviours and has been superior to any other treatment modality I have been trained in over the years.
SWY: One of the types of therapy you specialize in is DBT - Can you tell us more about this kind of therapy and how it works?
AF: DBT is a really incredible treatment model. It was originally designed for those suffering from chronic suicidal and self-harming behaviours and because it was so successful, the treatment evolved as a way of helping anyone struggling with emotion regulation difficulties. In DBT, the overarching theory is that problematic behaviours (e.g., self-harm, eating disorders, substance use) are caused by problems with the way a person regulates or manages emotion.
When people participate in standard DBT, they work with a highly trained team of clinicians for one year, where they receive weekly DBT individual therapy, attend weekly DBT skills training groups, have access to telephone skills coaching, and where the team meets weekly to maintain adherence to the treatment model. We work with individuals and families to teach key skills in four areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. There is also evidence that for some individuals, shorter doses of DBT may be effective.
SWY: What are the benefits of DBT for helping one overcome and heal from childhood abuse and trauma?
AF: Childhood abuse deeply impacts the way a person views themselves and the world, damages one’s sense of safety and trust, impairs emotion regulation, and can result in PTSD, suicidal and self-injurious behaviours, substance use, and other disorders as the person struggles to survive and cope. Due to its comprehensive nature, DBT is ideally suited for those struggling in these ways.
Some of the benefits of participating in DBT are:
Learning how to get out of crisis/survival mode
Eliminating suicidal and self-harming behaviour
Learning how to regulate intense emotions
Developing skills that help people set healthy limits, get out of toxic relationships, and build healthy connections with others
Developing skills to reduce black-and-white thinking patterns
Building skills to help the mind stay in the present moment (instead of worrying about the future or getting stuck in the past)
Gaining self-empowerment through non-judgmental and self-compassion skills
SWY: Often times, survivors of abuse have difficulty regulating their emotions - Can you explain what emotional regulation is and how it can change one’s psychological wellbeing?
AF: The ability to regulate emotion means that a person can identify what they are feeling, can validate their emotions (e.g., they don’t judge, criticize, or shut down), has skills that allow them to moderate intense feelings (so they don’t become destructive), and can be effective in communicating what they need and feel. Many people with child abuse histories struggle in these areas. It is also extremely difficult to feel safe or grounded if emotions are not stable.
There is growing research that shows differences in the brains of those with posttraumatic stress disorder (PTSD). Those with PTSD show more activation in the part of the brain that controls our emotions. In fact, imaging studies have shown that the amygdala, the part of the brain related to fight-flight-freeze responses, is significantly larger in those with PTSD. This means that a person is much more likely to respond emotionally to triggering situations. Those struggling with emotion dysregulation also tend to either be under controlled (e.g., impulsive, self-destructive, angry outbursts) or overcontrolled (e.g., feeling very little emotion, socially isolated, not open to new experiences). Depending on how a person presents, we have different evidence-based treatments to help a person find ways to regulate emotion and build a life that is more stable and comforting.
SWY: In one of your blog pots, you say that invalidation (abuse, neglect, being ignored) increases emotional dysregulation and worsens mental health - Can you explain more on this topic?
AF: Invalidation communicates that a person (or their emotions, thoughts, or behaviours) doesn’t make sense, doesn’t belong, isn’t loved, or doesn’t matter. We have all experienced invalidation. When you are trying to tell somebody an important piece of information and they are distracted, we are invalidated as the message (intended or not) is that “I am not important enough for you to listen to”. When you are working really hard to complete a task and someone laughs at you or asks what’s wrong with you for taking so long, we experience invalidation.
The science behind invalidation is really interesting. Research studies have shown that we become more upset and dysregulated when we experience invalidation: our heart rates increase, blood pressure rises, and we feel more emotional. The opposite physiological effect happens when we VALIDATE ourselves or others: we feel calmer, heart rates drop, blood pressure stabilizes. In this way, invalidation is perceived by the brain as a threat and the body responds accordingly.
When a person has problems regulating emotion, it can be difficult for others to understand what is going on so invalidation happens frequently. People might say “stop being so dramatic” when one is upset not realizing that regulating emotion does not come easily to that person. Invalidation itself occurs on a continuum of severity. On one end, someone may miss what you need or may misunderstand you. On the other end, people are abused. Sexual, physical, and emotional abuse are the most severe types of invalidation. Chronic invalidation causes people to feel emotionally dysregulated, to doubt themselves, to stop trusting their instincts, and to look to others for cues on how to act.
SWY: Some of your research focuses on the intersection between childhood trauma and the development of eating disorders. Can you give more information as to why this correlation exists?
AF: Approximately 30% of individuals with an eating disorder have a history of childhood sexual abuse (CSA). While we can’t conclude that CSA causes an eating disorder (ED) (because there are many people with childhood trauma histories that do not go on to develop an ED), research does show greater vulnerability to develop bulimic symptoms in those with histories of CSA.
Childhood abuse fractures one’s developing sense of safety, self-worth, identity, and impacts how one experiences their body. Individuals with an ED often report feeling that they want to disappear, or lose weight in an effort to not be noticed or attractive to others. Some report that their ED symptoms help them (maladaptively) cope with intense and negative emotions; this is also supported by research that shows that ED behaviours lead to short term positive feelings, a sense of relief, and a way to numb or distract from painful feelings. When the body has been the source of the trauma, one invariably struggles to find comfort in their own skin, and some will reject and hate the body and themselves as a result of the trauma.
"Childhood abuse fractures one’s developing sense of safety, self-worth, identity, and impacts how one experiences their body."
SWY: From your knowledge and experience, what do you think we need to do as a society to raise awareness about childhood abuse and trauma and the stigma that comes along with being a survivor?
AF: We need to find better ways to improve access to evidence-base treatment for those struggling. Currently, most individuals cannot afford the treatment that would save or change their lives. Hospitals are not designed to provide the longer-term interventions needed as they focus mainly on crisis and behavioural stabilization. Treatments like DBT and cognitive processing therapy (CPT – one of the leading treatments for PTSD), are offered in private clinics but the cost is prohibitive.
We also know that secrets keep people sick. One cannot heal if one is unable to talk about what happened. The difficulty is that stigma and misinformation about childhood trauma stop people from speaking up and asking for help and this is even more of an issue for men and those that experience oppression and marginalization.
Psychoeducation is important. Teaching kids what is appropriate vs inappropriate with respect to their bodies is essential; the earlier kids develop language around their bodies and safety, the more likely they are to speak up if someone tries to hurt them. I also believe that more needs to be done to help educate and support doctors, police officers, teachers, and other professionals. I still hear so many stories of people who seek help from the police or another professional only to be shamed or told they are “making it up”. If we can’t talk to the very people who are meant to protect us in our society, then we are in trouble.
We want to thank Dr. Anita Federici for sharing with us the research behind the correlation between the development of eating disorders in individuals who have experienced childhood abuse. If you want to learn more about Dr. Federici's practices and research findings make sure to check out her website and Instagram.
Starts With Youth would like to thank #RisingYotuh, TakingITGlobal, Canada Service Corps and the Government of Canada for their generosity and support. With their help, we will continue working to address intergenerational trauma and childhood abuse, creating a positive change in our community.