There’s a high percentage of people with eating disorders who have a trauma history. In the initial assessment for an eating disorder, a clinician should assess for trauma. If there is a history of trauma, those symptoms and memories, whether they meet the criteria for PTSD or not, need to be part of the treatment planning. It informs how healing happens in someone’s soul. Experiences of trauma may be at the root of maladaptive beliefs, behaviors, what’s going to trigger them, and what’s going to soothe them.

Any co-occurring problem with an eating disorder has to be considered thoughtfully. If somebody has anxiety, depression, OCD, or PTSD, you have to consider how and when to address it in the healing process. Otherwise, a coexisting disorder may interfere in recovery or actually end up fueling the illness.

For many people with eating disorders, trauma has contributed to the development of the illness. Dissociation, a central symptom of a trauma response, is the mind’s attempt to separate from traumatic events and memories by disconnecting from the body. For someone with a history of trauma and an eating disorder, the body may be experienced as a holder of the trauma instead of as a part of a whole, integrated self. The creates a situation where the eating disorder can more easily make a split between the mind and body. For example, someone with an eating disorder and trauma history may not see the incongruence of achieving academic goals, being a good friend, and having an active spiritual life while at the same time exercising compulsively, binge eating, purging, or starving themselves. These negative projections onto the body may be an attempt to separate from or numb the pain of traumatic body memories.  

Identifying dissociative episodes as they are happening and gaining some awareness of them are important recovery steps. Because trauma disrupts a sense of safety, an important step in the therapeutic work focuses on accessing a sense of safety in the present moment through the use of grounding strategies, self-talk, or reaching out to another person.

In my practice, I treat the eating disorder first when possible, because food helps our whole system—brain, body, emotions, and hormones—regulate. If a client is binging and purging, overexercising, or depriving themselves of food, they’re going to be mentally and emotionally dysregulated. People with eating disorders may seem very concerned about food and health externally, but in reality they internally discount the importance of nutrition as integral to their wellness. Therapists work hard to break through this key component of denial that is part of the eating disorder lens. Focusing on regulating food first allows the client to better tolerate dealing with the trauma.

There are different theories and treatments that work well for trauma itself. Dialectical behavior therapy is one of them: It’s a specialized, skills-based form of therapy that focuses on helping people experience life as worth living and is most well known for being effective with chronic suicidality. DBT skills center on tolerating distress, regulating and managing difficult or intense emotions, and improving the interpersonal skills needed for positive relationships. Each of these skills builds trust back in the body, mind, and relationships—all of which are compromised by trauma as well as eating disorders. As someone develops greater ease with these practiced skills, they feel more competent overall. Thus, they are less likely to attempt to use eating disorder behaviors to numb memories or disconnect from the body.

Another therapy for trauma is cognitive processing therapy. The Veterans Association uses this as one of the treatments for PTSD. CPT is based on confronting the just-world belief. Watch most movies for children and you’ll see the just-world belief play out: Good people may struggle, but in the end, good things always happen to the good people because the world is viewed as just. We teach kids this myth because we want them to have a hopeful sense of the world. If you raise children with this idea that the world is always fair for people who are good, and then they experience a trauma, they have two choices. Either they can decide they’re not good because something bad happened to them—because bad things happen only to bad people—or they can decide the world actually isn’t fair or safe and that people cannot be trusted. Both all-or-nothing perspectives are problematic. In CPT, we confront the complexity of human experience rather than accepting the just-world belief as rigidly true.

Adjusting the just-world belief doesn’t mean teaching clients that the world is all bad or all good. It doesn’t mean no one is trustworthy, nor does it mean everyone is. It doesn’t mean the world is always safe or always unsafe. It doesn’t mean you have no control or you need complete control. CPT therapists encourage clients to identify the all-or-nothing beliefs about safety, trust, control, intimacy, and self-esteem that they’ve developed to try to cope with a traumatic event or series of events. These rigid thoughts are inadvertently keeping them stuck in the trauma. So we work to develop a new set of beliefs—rooted in a more accurate, compassionate human experience—which includes the fact that sometimes bad things happen to good people.

For someone with an eating disorder, healing from trauma means it becomes possible to no longer retreat into eating disorder behaviors for pseudo protection, pseudo control, or self-punishment. The goal of this therapy is to reestablish trust in self and others, to exert positive control over goals, to employ reasonable safety practices, to engage in self-care, and to enjoy close relationships. Without challenging cognitive stuck points, there are meaningful risks: missing out on the joy that comes from all the good you can give, missing out on all the connections and intimacy that come from the love you can receive, and missing the adventure of living.

Body image issues are a central part of any eating disorder. If there’s been trauma, making the body very small, big, or sick may be an unconscious way to defend against another experience of trauma.

The negative body image component of the eating disorder may be a mechanism for keeping yourself out of the sexual world as an act of safety. Starvation suppresses hormones, slows or stops development, and diminishes sex drive. Binge eating and purging also dysregulate hormones; because there is also the internalized and conscious and unconscious belief that somebody may not be as attractive as a partner, or as likely of a victim, if they’re in a larger or underweight body, binging or starving can feel like an act of safety.

Similar to how trauma often leads to shame, many people with eating disorders have body shame. When someone’s body remembers trauma and an eating disorder also commands, “This body is not good enough,” accepting their imperfect human body as a part of the self to love and care for can take a significant amount of time.

With trauma, not having control is one of the major themes to overcome in the recovery process. One of the ways eating disorders seem to work is by providing a false sense of safety. Eating disorders offer pseudo control. The pseudo control goes like this: If I eat only x, y, and z today, then I’ve had a good day. If I exercise, I am good and safe. The central lie of an eating disorder is that controlling food leads to a safe, good, satisfying life. It doesn’t matter what happens in my relationships; it doesn’t matter if I’m learning or loving or enjoying music—controlling what I eat is all that is required to avoid a bad day.

That control can create a pseudo secure, predictable sense of safety, and it is very hard to break those patterns if the world doesn’t seem safe because of a traumatic experience. Part of the treatment for a person with an eating disorder, especially if they also have PTSD, is about creating a greater sense of safety in the world; it’s about being able to control life in a positive way.

It’s why treatment often starts with a strict meal plan—the plan can substitute for that sense of control a client might have been getting from their eating disorder behaviors. You try to transfer to the maladaptive attempt to control to positive control. As recovery progresses, meal plans become less rigid and eating becomes more responsive to hunger, fullness, social settings, and pleasure. There is room for spontaneity.

There is a fairly strong association between binge eating disorder and a history of trauma. Binge eating is a complete loss of control with food. However, if you look a little deeper, the loss of control around food may actually be a strategy to control strong emotions.

Unfortunately, we don’t educate people about how to accept and manage negative emotions. In America, we have a very strong bias toward positive emotions. Not that there’s anything wrong with feeling happy, excited, joyful, etc.—but by telling people the only acceptable emotions are positive ones, you force negative emotions underground.

For some, binge eating disorder is a way to exert control over those negative emotions, which, you may imagine, can be intense for someone who has experienced trauma. After binge eating, there is shame about eating a large amount of food rather than identifying negative emotions, what led to them, how to cope, or who can be leaned on for support. This shame can lead to avoiding people. The distress from the loss of control with food may serve as distractors from negative emotions—and problems developing trusting relationships—both of which may have arisen out of the trauma.

Oftentimes with binge eating disorder, there is still the dieting mind-set. Even if someone isn’t dieting, they think they should weigh less and should look a way they don’t. So people with binge eating disorder often try to tightly control their food—and the binge is a rebound after an effort at deprivation and control. Even if it never manifests as a literal diet, it’s the mind-set that I shouldn’t have eaten that; I shouldn’t have done this; I shouldn’t ever have sugar; I shouldn’t have carbsI shouldn’t have dated that person. I shouldn’t have gone there that day. I shouldn’t have trusted anyone. These internalized guilt-based diet myths and victim-blaming messages are pervasive.

There’s a psychiatrist, Bruce Perry, who works with young children who have been in homes or situations where there’s trauma or violence. His work is extremely helpful for professionals and families at the moment when someone experiences a trigger. Dr. Perry talks about three different stages of anchoring someone back into the present and helping them in the aftermath of a trigger, and they’re referred to as the three R’s: regulate, relate, and reason.

REGULATE: Often when someone’s upset, we just want to jump in and try to reason with them. Our instinct is to want to get them to be more rational. But after a traumatic trigger, our brain can’t get to that level of thinking, because our brain is too aroused, too dysregulated. You first have to help someone regulate. That could be going for a walk with them, hugging them, letting them scream or cry, wrapping them in a big or weighted blanket, or listening to music with them. People can take their hand and put it on their own chest to just feel the weight of their own hand and feel grounded to themselves. You could have someone sit on the floor and feel the steadiness of the ground under them. The goal is to reduce the brain’s arousal by returning to the present moment.

RELATE: Once they start to become regulated, they calm down. Maybe they’ve cried for a while or they’ve yelled or they’ve been upset, and you see the settling start to happen and you can connect. Let them know you’re there. You might hold their hand and look in their eyes. You might want to look at something with them. If they say they don’t want to talk about it, you can say, “What do you want to talk about?” It’s about relating with whatever they want to relate about.

REASON: Once someone’s calmed down and they feel connected to you, they feel safe. They know they’re okay, and they know they’re back in the present. They have support. That’s when you are able to reason with them: “What’s a good decision to make? Let’s look at the options here. I know you want to go binge and purge right now, but let’s think about that. How do you feel after you binge and purge usually?” Or if they say, “I’m going to take laxatives,” it’s your opportunity to respond and say, “Okay, how do you feel after you do that and what would you feel like if you didn’t do that? What are the other options? What are the alternatives?” You’re able to reason with them.

In that exact moment when someone is emotionally aroused, especially from traumatic triggers or memories, you can’t go straight to reason. That’s where parents make mistakes with children and adolescents: They want to turn to problem-solving too quickly. Dr. Perry’s three R’s—regulating, relating, and reasoning—work in a lot of different situations, not just trauma and eating disorders. And they can really work well as an intervention when anyone is extremely negatively aroused or upset.