Knowledge Share

Understanding bulimic dissociation to create new pathways for change

Rebecca Heselmeyer & Eric W. Cowan December 1, 2012

Given the extensive research on eating disorders, motivated clients and a gold standard treatment — cognitive behavior therapy — it is perplexing that recidivism rates remain so high for bulimia. It behooves us as counselors to investigate possible hindrances to effective treatment and adjust our approach accordingly for those clients with bulimia who have not achieved long-term resolution. It is notable that, despite the substantial evidence linking dissociation and bulimia, many counselors remain unaware of this connection. Further, the nature of the relationship has not been sufficiently explored. In this article, we apply principles from self-psychology to bulimic dissociation and use this new understanding to inform clinical practice.

When I (Rebecca) first met Sonya, she sat across from me tearfully expressing the shame she felt about her binging and purging and the feeling of defeat she experienced from failed efforts: to stop thinking about food, to stop scrutinizing her body, to stop mindlessly gorging on food and then rushing to vomit. Sonya presented as many clients with bulimia do — she expressed a desire to change and a willingness to try whatever therapeutic assignments I may assign to her. Rather than engage with her in familiar and expected territory by focusing on food (nutrition, food journals and so on), I turned my attention to a different part of Sonya’s experience, inviting into our conversation the part of her identity that up until then had likely been unacknowledged and invalidated repeatedly. We have labeled this the dissociated bulimia identity (DBI). To explain our reasoning for yet another coined term with a nifty initialism, let’s shift gears and look at the underlining theory.

Self-psychology and the vertical split

Heinz Kohut proposed that children need specific interactions and feedback from caregivers to formulate cohesive, integrated selves. An important part of this process involves mirroring, in which caregivers demonstrate accurate, empathic affective attunement with the child. For example, a child may cry out upon seeing shadows in a dark bedroom at night. An attuned care provider might respond by giving language to what the child is experiencing (“You are afraid”) and comforting the child. Through such interactions, the child not only learns language for his or her affective state, but also learns that he or she can be afraid and still be loved. Gradually, with additional interactions in which the caregiver reflects the child’s fear in a nurturing manner, this affective state becomes identified and integrated into the child’s sense of self.

Assuming the care provider responds to the multitude of emotional experiences with validating, reflective attunement, the self then develops into a cohesive being where all affective states — love, joy, fear, grief, discouragement, excitement, loneliness and so on — have an identified and accepted place. The child has been welcomed into the world of shared meanings and connections and has formed a cohesive sense of self composed of, to use Harry Stack Sullivan’s language, “reflected appraisals.” Further, the process that enables identification and integration also teaches the child about self-care; the nurturing and soothing interactions with the caregiver over time become internalized so that the child develops the ability to self-soothe and manage emotional experiences without relying on the caregiver’s presence.

Now imagine the same child in the frightening, dark bedroom, crying out at the lurking shadows. In this house, the caregiver responds with taunts, calling the child a scaredy-cat and snapping at her to go back to sleep “or else.” Continued interactions of this nature also identify the affective state while invalidating the experience of it. The child is taught that fear is not allowed and is shamed for experiencing it. There is no comforting hug or lullaby to internalize; there is only the message of rejection. There is a disconnect between the child and others, which results in a parallel disconnect from internal thoughts and feelings. Dependence on the caregiver is crucial for survival, so anything that might threaten this relationship is sacrificed. Consequently, affective states met with invalidation become disavowed and denied integration into the “socially acceptable self.” But where do these affective states go?

Kohut proposed that lack of adequate and empathic mirroring results in a “vertical split” — a metaphor for the partition between self-experiences integrated into the “normal” self and disavowed affects and frustrated developmental needs. Repression can be understood as a horizontal split, with unconscious desires tucked away deep in the psyche and blocked from the rest of the aware mind and body. The vertical split, on the other hand, designates a chasm between selves: the integrated affects and being states that were met with empathic mirroring and those that were sacrificed in an attempt to maintain the essential relationship with primary caregivers.

Therefore, for clients with bulimia, validated affective states become integrated into the normal, socially acceptable self, while invalidated affective states are sequestered on the other side of the split, forming the unacknowledged, rogue DBI. Acknowledging this part of the self-experience has been deemed threatening and forbidden. Perhaps more important, the child never learns to effectively acknowledge, self-soothe and manage this part of self-experience. Needless to say, mere ignoring cannot relieve the emotional demands of loneliness, lust, anger, guilt, despair and other feelings. When the DBI demands attention, the now-adult client may address it in the one way she or he knows how — with food.

Media teach us time and again that food is a source of comfort, pleasure and love. The absurdity of media campaigns goes so far as to sexualize food. Jean Kilbourne, in her “Killing Us Softly” lectures, observes the potency of a variety of media messages, including ones that offer food as a substitute for relationships. Food is also culturally anchored in our experiences: family gatherings, celebrations and times of mourning. Our bodies respond physically and physiologically to eating. In the most basic sense, food literally fills a void within us. Binging provides momentary relief and escape, and the process at work is twofold.

Dissociative symptoms are present throughout the binge-purge cycle, with peaks occurring during the binge and immediately after the binge. Dissociation is commonly thought of as an escape from painful psychological experiences. Dissociative symptoms are on a continuum ranging from minor alterations in perceptual functioning to significant disruptions, such as a dissociative fugue. The dissociation associated with bulimia is primarily categorized as mild to moderate. Clients may feel out of control or have a detached experience of watching themselves binge.

Let’s explore the dual process at play, using Sonya as an example.

Dissociation, revisited

Sonya would often report the quick onset of the urge to binge. As she began, her feelings of disconnectedness and lack of control grew, enabling her to eat beyond capacity by blunting both the physical and emotional discomfort she would otherwise experience. Psychologically, the dissociative symptoms she experienced also provided temporary relief from the triggering affective state. At the same time, the dissociative experience allowed Sonya to “jump” the vertical split and access the very region housing the unmet need that was triggering the binge — in her case, a deep sense of helplessness. This dis-integrated part of her self-experience that was reproached during her development has shown up in her adult life, but she lacks the ability to effectively identify, manage and attend to it.

The binge-purge behavior brings with it dissociative processes that temporarily provide Sonya with both an escape from pain and access to the region where she can acknowledge and soothe that otherwise denied self-aspect. The function of dissociation is to “escape” to a very specific and important place: her DBI. In other words, while Sonya is desperately (and ineffectively) seeking physical comforts, her psychological self is likewise seeking to self-soothe the neglected and needy DBI. She is momentarily allowed access to this outlawed part of the self and can attend to the very real need for nurturing and validation.

With the conclusion of the binge also comes the conclusion of dissociative symptoms. Sonya becomes more aware of her physical self — and simultaneously is returning to her socially acceptable, normal psychological self — and is swept by feelings of shame and guilt. Physically she feels great discomfort and embarrassment at the quantity of food she has consumed, while psychologically she has trespassed to visit and comfort the forbidden DBI. She has broken the rules — physically by food consumption and psychologically by traversing the vertical split. Guilt reigns supreme, and she purges to expunge herself of the harm done.

Through this lens, the functionality of the binge-purge behavior and dissociation can be seen as the client’s best effort to attend to a disorganized self-experience. For many clients, including Sonya, bulimia is a clinical presentation that, at its core, is a disorder of self rather than being fundamentally rooted in body image concerns. The clients’ repeated attempts at self-care through the use of food fail because the core unmet developmental needs are never brought out of exile and given their rightful place in the integrated “normal” self. Symptom-focused counseling that serves largely as behavior management — food journals, nutritionists, love-my-body activities — prove ineffective for these clients because there is no room for the underlying disorder of self to emerge in the therapeutic dialogue. For this to happen, there needs to be a shift in the counseling mindset and conversation.

Clinical applications

If I had partnered solely with Sonya’s desire to extinguish her bulimic behaviors, I would also have partnered solely with her “socially acceptable” self  — that part of her that genuinely does want to stop binging and purging. Concurrently, I would have communicated to her that her DBI was not welcome.

The DBI relies on the function of her behaviors for much-needed psychological care, so there is likely a very substantial part of Sonya that wants to binge and purge and has no intention of giving this up. Focusing the counseling conversation on ways to extinguish and change behavior, without also addressing the purpose of the behavior and offering an alternate way of accomplishing the function, invalidates the part of the client’s experience that appreciates and needs the behavior. If approached in this manner, the client’s DBI is likely to “go into hiding” for fear that successful counseling will result in its extinction (rather than integration). In effect, this guarantees an unsuccessful long-term counseling outcome.

Instead, I invited Sonya to tell me about the part of her that wants to binge and purge. This is a potentially shame-laden and socially ostracized part of Sonya’s being, so it is important for me to seek it out and welcome it rather than assume it will enter the therapeutic dialogue without active and sometimes repeated invitation. Counselors need to provide an experience in which all parts of the client’s experience — both the desire to cease behavior and the desire to maintain it — are welcomed and validated. We encourage counselors to address the DBI directly (“Tell me about the part of you that needs to keep doing this”) or by using third-person language (“Tell me about her — the part of you that defies your attempts to control her”). In addition, use language that demonstrates an appreciation for the adaptive function of bulimia that is, in a sense, trying to help.

Occasionally, it may serve as a powerful paradoxical intervention for the counselor to urge the client not to give up the binge-purge behavior too quickly. Clearly, this intervention is not appropriate when working with clients who have significant health risks. But for clients in relative physical good health, and especially for those who have had extensive counseling, an intervention of this sort likely will be unexpected and get beyond psychological resistance by “siding” with the DBI against the socially conforming self. You can observe to clients how cruel they are to their bulimic selves when they use disparaging language (“I’m such a fatso loser when I binge”).

Once it is established in the therapeutic dialogue that all parts of the client’s experience are welcomed and validated, new pathways for healing can emerge because the client, with the counselor’s support, can begin to acknowledge and express the frustrated developmental needs that are the driving force behind the bulimic behavior. An important part of this approach is keeping the therapeutic conversation focused on the client’s inner world of needs, feelings and thoughts, particularly those that are outside the client’s normal experience, so the client can expand self-reflective awareness.

Once clients gain insight into the role their bulimia has served in managing emotions and needs, a powerful experiential process unfolds as the counselor provides the empathic mirroring response that was previously withheld during the client’s childhood development. Counseling provides the repeated, accurate, empathic attunement that the client’s caregivers failed to supply. Just as over time the child internalizes the caregiver’s ability to soothe and comfort, the client’s new awareness of emotional triggers, coupled with the empathic, attuned response from the counselor, allows the client an opportunity to begin addressing and meeting her or his needs in a new, direct way. The ongoing process of welcoming the formerly forbidden self-experiences into the counseling relationship gradually breaks through the wall of the vertical split, allowing a merging of selves into a now fully integrated self. As this happens, the need for bulimic behaviors diminishes and, without a purpose, the behaviors eventually cease.

Similar to the experiences of other clients, the turning point for Sonya came when she felt at liberty to speak about the part of her that could not imagine life without binging and purging. Gradually, Sonya’s sense of inner connectedness and connection with others grew, and she became skillful at recognizing her emotional needs and attending to them in healthy ways. Her binging and purging has subsequently tapered.

We hope you will find this conceptualization and the suggested techniques enriching to your counseling practice.

“Knowledge Share” articles are based on sessions presented at American Counseling Association Conferences.

Rebecca Heselmeyer is a staff counselor in residence at the James Madison University (JMU) Counseling and Student Development Center, adjunct instructor for the JMU Counseling Programs and a member of the Rockingham Memorial Hospital Psychiatric Emergency Team. Contact her at

Eric W. Cowan is a professor in the Department of Counseling and Graduate Psychology at JMU and the author of Ariadne’s Thread: Case Studies in the Therapeutic Relationship. Contact him at


  1. Trp

    Thank you.
    This is one of the best things I have read on bulimia. As a long time sufferer of the disease this rang true and helped me in a weak moment where I wanted to binge and purge…but reading this made me reconsider and for that I am very grateful. I wish I had a therapist who had such a nuanced approach.
    Thank you again,
    From Australia

  2. Becca

    This is fascinating. I have been recovered for a few years now but am having massive problems overcoming some issues, specifically to do with feeling pressured (emtional as opposed to work related). I hugely agree with the part about encourging not to just try and give up cold turkey, I started getting better the day I was told it was ok to f***k up every once in a while, which in and of itself took away some pressure I suppose. I avoid reading about it usually as I find it incredibly hard, but this has made me look at it a bit differently, thank you!

  3. Samantha

    I found this very insightful. I ALWAYS thought (having suffered from acute Anorexia Nervosa from ages 13-14 and Bulimia mixed with EDNOS from 15-present day 21yrs of age!) That ALL the inpatient and outpatient programs I went into had the body image,body love etc activities and I would think to myself… Why is it that I get virtually nothing long lasting or life changing from ANY of these approaches?!? I guess I sort of always knew that my Bulimia was about VIOLENT, uncontrolled & unmanageable emotions from my teen years especially (teen angst mixed with school plus family issues) but this brought me back even further to childhood where I recall the anxiety in third grade, my “abnormal” behavior as a child, what I was abs what I was told to be. I always wanted to protray and be someone else. I LEARNED to dislike who I was (and still am-just v older) naturally throughout the years. I wish I would’ve gotten help sooner. Thank you for this article!! Xo from the States U.S

  4. Jessa Patterson

    Thank you for this detailed and well crafted article about bulimia. I have experienced the problem for a long time now. I can not state that my treatment isn’t effective, but I am not totally yet well. However, I am seeing some large positive changes. I still believe I’ll have the ability to be fully cured.

  5. Willow

    I have suffered with Bulimia for 35 years.
    Last night I made the connection with being disassociated.
    I googled dissociated bulimia and found your page.
    This may have saved my life.
    It all makes sense now.
    Thank you so much.
    I will continue to learn about this and use this angle to get better.
    I have tried everything over the years, it always comes back.
    I have opened up to a friend about my problem, but I don’t think he could ever grasp what a dark place it is, to be caught up in the throws of this disorder.
    Thank You so much.

  6. Eileen

    May I suggest that anyone who has made the connection between chronic bulimia, and what Rebecca Heselmeyer & Eric W. Cowan dubbed DBI, Google Richard Schwartz IFS (Internal Family Systems) and learn about PARTS. Ironically, much of his development of this work originated with bulimics.

    I am in my 70s, and have been bulimic since the 1970s, despite a decade of ongoing therapy preceding it. Bulimia was my “self-discovered perfect solution to keep excess weight off” while at my relatively thin stage of a lifetime of emotional eating.

    Despite well-meaning, caring therapists, the concept of Complex PTSD (CPTSD) and IFS had not filtered down to the general world of therapy practitioners until this past decade. No one’s fault, but how I wish what I’d intuitively known had been recognized and the modalities of treatment: IFS PARTS work, somatic (body work), and compassion and mindfulness had existed back then. I’ve been fortunate in many ways, and functioned well enough in the outside world–albeit with lapse–because there have always been strong, creative, strong parts that abuse never destroyed. Parts we all have. And I am positive that you, who found this article, have done the same or better.

    I hope that my lived insights and research might help direct others who struggle with bulimia (and any eating disorder) find the help you seek, asI have finally been able to do. Those who have been chronic, cyclical, relapsing bulimics–because it “works on so many levels–all the deep described here. –for almost two decades I was actually at a perfect healthy weight, or slightly above it. For many decades, bulimia allowed me to “have my cake and eat it too”–literally. Life time weight issue was resolved. Of course, back in those years, it was not only bulimia but intentional self-addiction to Valium, cigarettes, and coffee that allowed me to function very well in the outside world in a competitive creative profession. But I lacked the integrated core to sustain me when life got tough., I suffered my mother’s unbridle emotional abuse (undiagnosed mentally ill mother) until her death into her 90s when I was in my late 60s. And that was with 40 years of therapy as it was them taught and practiced. No doubt they helped to keep me alive–at times barely– through their care and modeling.

    So, know that there is so much help out there for you, if you take the initiative to finding it. And so much available, especially on Youtube and in books written by experts in the trauma field. Check out Bessel van der Kolk, Gabor Mate, Janina Fisher, Tara Brach, and of course, Richard Schwartz(IFS) which will lead you along the way. Since you came to this site, I have no doubt that you are on the journey. Good luck and best wishes to all of us. :) And, for those of us who have been dealing for decades, it is true that it is never too late. Oh, it really isn’t our fault! Find out why that is true (for all trauma defenses needed to survive.) It has never been about food!! But somewhere deep inside, you already know that.:)


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