By: Natalie Fruchter, Ph.D.
Treating Eating Disorders Through a Trauma-Informed Lens
Every June, PTSD Awareness Month serves as a reminder to deepen our understanding of trauma and its profound impact on mental health. Because eating and trauma related disorders are highly comorbid, it is no wonder that the phrase trauma-informed care is increasingly sought out by patients seeking comprehensive treatment for eating disorders. However, what this actually looks like in practice is quite different than what most people expect.
It is often quite difficult to disentangle the onset of eating disorders from traumatic experiences, as trauma is often a large part of the clinical picture for patients struggling with weight and shape concerns. Research consistently shows high rates of trauma exposure among individuals with anorexia nervosa, bulimia nervosa, binge eating disorder, ARFID, and OSFED. Trauma may include childhood abuse or neglect, bullying, medical trauma, sexual assault, attachment disruptions, community violence, chronic invalidation, systemic oppression, or other experiences that overwhelm a person’s ability to cope.
Even so, trauma-informed treatment does not simply mean “talking about trauma.” In fact, particularly in higher levels of eating disorder care, immediate trauma processing is often not the first clinical priority.
As a clinician certified in both Cognitive Behavioral Therapy for Eating Disorders (CBT-E) and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), I have seen firsthand how nuanced this balance can be. Many patients enter treatment carrying profound trauma alongside severe eating disorder symptoms. However, the acute medical and psychological risks of the eating disorder often required stabilization before deeper trauma work could safely begin.
This distinction matters. Trauma-informed care should not feel forced, expedited, or prioritized over life-threatening conditions, such as the medical complications of eating disorders. Instead, this work is most effective when patients and clinicians are aligned regarding therapeutic goals, and an understanding of how trauma can cause challenging physical and psychological symptoms, often related to eating. Additionally, trauma-informed care not only includes the therapeutic relationship between patient and clinician, but also the bonds between family members and friends, and how these dynamics can assist in creating supportive environments for recovery.
How Do Trauma and Eating Disorders Intersect?
Individuals who have experienced trauma have chronically aroused nervous systems, might feel heightened emotions to the point of numbness or dissociation, can be overly self-critical, and often disconnected from homeostatic cues, especially those related to hunger, fullness, and fatigue. In response to this dysregulation, eating disorders can function as almost adaptive coping strategies, giving individuals a sense of control over the overwhelming chaos in their mind.
This might look like restriction of intake to maintain order, binge eating to provide temporary comfort, purging to bring relief, or excessive exercise to create a false sense of safety. Even something seemingly benign such as developing food rituals can serve as another attempt to manage the unpredictability that comes in the wake of experiencing trauma.
While this framework might help to better explain the connection between eating disorders and trauma, it does not by any stretch excuse these harmful behaviors. Still, by shifting the clinical narrative to take into account what each individual experiences, we are able to better understand how disordered eating behaviors might be serving as survival mechanisms for those who are deeply struggling. This perspective is foundational to trauma-informed care.
What Does Trauma-Informed Care Actually Mean?
Trauma-informed care can be applied to multiple therapy modalities, as it guides the framework through which treatment is delivered to patients. Practitioners utilizing trauma-informed care must first recognize that trauma impacts patients’ relationships with safety, trust, control, emotions, their bodies, and relationships. In order to avoid re-traumatization when supporting patients recovering from eating disorders, the following core principles are important to keep in mind.
Safety: Both physical and emotional safety are essential components of trauma-informed care, and in the context of eating disorder treatment, might include supporting each patient’s emotional regulation during meals or group therapy sessions, and recognizing when certain body-based interventions might feel vulnerable or triggering. Individuals with trauma histories might have a harder time with the already insurmountable challenges of eating disorder treatment, including but not limited to, supervised and timed meals, frequent weight checks, or physical examinations by providers, as these can evoke feelings of helplessness, scrutiny, and a loss of autonomy. Therefore, it is important to utilize a trauma-informed approach that openly acknowledges this reality, rather than dismissing it outright.
Collaboration and Choice: Because trauma often involves a loss of power or control, collaborative treatment is especially important, even when standard eating disorder care might not be. While clinicians need to prioritize nutritional rehabilitation on inpatient units, trauma-informed care means preserving a patient’s dignity and agency whenever possible. Even small changes like explaining the rationale behind certain interventions, involving patients in treatment planning discussions, and encouraging questions can make a big impact.
Empowerment: Traumatic experiences can leave individuals feeling powerless, ashamed, and even disconnected from their sense of self. Therefore, trauma-informed care emphasizes a person’s strengths, recognizing their resilience in the face of adversity, as well as their survival strategies, insight, and capacity for recovery. This is especially important in the context of eating disorder treatment, where pathology and symptom naming often overtakes the clinical discussions, and can feel disheartening to say the least.
Trustworthiness and Transparency: Since patients with trauma histories are often sensitive to unpredictability and interpersonal challenges, consistency is key. Providers should strive to communicate clearly, follow up frequently, and openly repair ruptures with their patients. In this way, the trust can be rebuilt over time, and recovery can follow a more linear trajectory.
Why is Trauma Work Not Always Immediate in Eating Disorder Treatment?
One might assume that trauma-informed care means that treatment will always initially focus on processing traumatic memories; however, this is very rarely the case, especially in the context of psychopathology as debilitating as eating disorders. When patients first enter treatment for eating disorders, they are usually not neurologically, emotionally, or medically stable enough for intensive trauma processing. At higher levels of care, patients can present with severe malnutrition, cognitive impairment, medical instability, high emotional dysregulation, and even suicidality.
During my clinical training year on an inpatient eating disorder unit, I often found it challenging to help patients remain engaged in working towards recovery given their desire to focus on their trauma histories that they believed brought them here. It quickly became apparent, however, that in these situations, the immediate priority is often stabilization and interruption of life-threatening eating disorder behaviors. From a CBT-E perspective, this makes clinical sense. CBT-E conceptualizes eating disorder symptoms as self-perpetuating cycles maintained by rigid rules, overvaluation of shape and weight, mood intolerance, and behavioral reinforcement. Nutritional rehabilitation and behavioral stabilization help restore cognitive flexibility, emotional regulation, and the capacity to engage meaningfully in deeper therapeutic work.
Additionally, TF-CBT emphasizes the importance of stabilization before trauma processing, namely through psychoeducation, emotional regulation, relaxation strategies, coping skills, and safety-building. This is because without sufficient preparation, processing one’s trauma history can be quite overwhelming, and in the context of eating disorder treatment, even intensify life-threatening symptoms. While trauma history is a key component of a patient’s clinical picture, treatment must be organized first around what the nervous system can safely tolerate.
In practice, this might look like helping patients identify connections between trauma histories and eating disorder behaviors, reviewing grounding and emotion regulation strategies, and monitoring triggers and dissociation tendencies. In order to validate a patient’s trauma history and the significant impact on their current wellbeing, clinicians might often need to defer intensive trauma narrative work until their patients are more stable. Although this might seem counterintuitive, this approach is not only imperative to foster safety and trust, but is often the safest and most effective option.
Moving Toward Integrated Healing
This article only scratches the surface of the complicated relationship between eating disorders and trauma, yet the message is clear: in order to safely unpack an individual’s trauma history, they must first be physically and psychologically stable with regard to their eating disorder. And still, patients deserve treatment environments that recognize the complexity of their past experiences, and prioritize long-term healing.
Trauma-informed care for eating disorders might look different for everyone, but the goal is creating a safe environment for recovery to take place. For clinicians, this might look like striking the perfect balance between the necessary structure of a treatment facility and the compassion driving their initial pursuit of this line of work. For caregivers, it means an understanding that recovery is often nonlinear, and that their role is to create a nonjudgemental and predictable home environment wherein overwhelming emotions and physical sensations are accepted. For patients, the biggest challenge might lie in following a slower pace towards allowing their narratives to unfold safely.
During PTSD awareness month, we are reminded that the effects of trauma can be devastating and longlasting, forever shaping relationships, nervous systems, and how we view ourselves. Eating disorders can emerge as a result of trauma histories, often as attempts to survive unbearable emotional pain. Trauma-informed care for eating disorders recognizes the etiology of these conditions while holding onto hope for recovery.
