This chapter deals with structural dissociation in the treatment of trauma and eating disorders. Dissociation is the inability to stay present when intolerable feelings and mental contents are activated. It is a way of making the overwhelming less overwhelming. A dissociative process is an unconscious attempt to sequester the intolerable away into the recesses of the mind, never to be contacted again. The chapter uses structural dissociation theory of the personality. Structural dissociation theory distinguishes two action systems that govern human behavior. The first action system is daily life and second action system is defense. The theory defines three levels of dissociation, primary dissociation, secondary dissociation, tertiary dissociation. Treating dissociation is a phase-oriented approach. The first phase is stabilization and preparation for trauma reprocessing. This is where the dissociation is treated. The second phase is reprocessing the painful memories. The third phase is full consolidation and integration.

Eating disorders (EDs) may be among the most self-destructive and persistent behaviors that emerge in the aftermath of trauma. Researchers are becoming curious about the role of the body, and, in particular, the nervous system, as it relates to ED symptoms and the management of dysregulated affect states. This chapter highlights the psychobiological processes that somatic experiencing (SE) is built upon with regard to working with trauma, with specific considerations for its application when working with the ED population. A natural starting point for understanding the intersection between trauma and EDs involves a brief overview of the effects of trauma on the nervous system. SE treatment goals are accomplished not only by listening to the client’s narrative but also by closely watching the body’s expression of the nervous system to slow the process down and explore the various elements of an experience.

This chapter explores the neurological link between trauma and eating disorders (EDs) by describing one of humans’ basic functions: response to stressors. Adverse life events interact with the genome and developmental processes, leading to biological changes that predispose one to a broad range of psychiatric problems, including EDs. The mechanisms involved include abnormalities in the stress response, changes in appetite, altered reward sensitivity, and increased sensitivity to rejection. Specific genes increase one’s susceptibility to stressful experiences, and stressful experiences have the ability to alter one’s genes (i.e., epigenetics). Epigenetics refers to the way in which environmental exposures have the capacity to influence the genome in a way that affects later gene expression. Findings from epigenetic research and neural-based interventions offer evidence against the long-standing understanding of genes and neurocircuitry as “rigid” structures.

This chapter discusses what happens in the aftermath of trauma, abuse, and disordered eating. This aftermath includes connection to illness as identity and disconnection from sense of self, spiritual identity, higher power, and significant others. Furthermore, there is disconnection from spirituality, passion, purpose, meaning in life, internalized principles, dreams, and deepest desires. We have also provided a few of the many interventions that we have found valuable in reducing suffering and helping clients to reclaim their identity. It focuses our attention on the processes of assessment and therapeutic intervention, and, by so doing, directly addresses the building and nurturing of self. The chapter attempts to describe the journey from ED and trauma identity to knowing, strengthening, valuing, honoring, and sharing self. It is through this that an individual is able to withdraw trust and faith in illness as a way of dealing with life.

This chapter provides a brief description on trauma-focused cognitive behavior therapy (CBT) and eating disorders (EDs). CBT has proven to be the most well-supported approach for EDs in the empirical research. It is considered the first-line “treatment of choice” for individuals diagnosed with bulimia nervosa and recommended for the treatment of anorexia nervosa (AN), atypical EDs, and binge eating disorders (BED). Furthermore, multiple studies have demonstrated the efficacy of using CBT for post-traumatic stress disorder and trauma symptoms. CBT for EDs is approximately 20 sessions for treating bulimia nervosa or BED, whereas treatment for anorexia nervosa can require a much longer treatment, typically lasting 1 to 2 years. Addressing trauma work will add to the number of sessions. CBT for EDs and for trauma can be done concurrently or sequenially. Deciding on the format can be done on the basis of clinical presentation and in collaboration with the client.

Dance and movement therapist and psychologist Ann Krantz believes that “the symptoms of eating disorders (EDs) serve to disconnect affect from the body, particularly as sexuality, trauma, and cultural influences contribute to conflicts in the woman’s [individual’s] developmental struggle toward self-identity”. Individuals suffering from both trauma and EDs have difficulty making their “house” a “home”. They often run away from “home” in an attempt to feel safer, centering their lives on using emotionally driven behaviors as a way of attempting to alleviate the often horrific anxiety they might otherwise experience. Dance and movement therapists weave together nonverbal dialogues that transform everyday movements into expressive communication. The cognitive markers can be used by therapists and patients alike to decode, track, and understand the experiences that fit into the bigger picture of their lives.

Accelerated experiential dynamic psychotherapy (AEDP) is an attachment-oriented, emotion-focused model of psychotherapy and trauma treatment. This chapter details the course of AEDP treatment for clients with active eating disorders (EDs). It uses vignettes and a transcript from a live therapy session to highlight salient concepts and illustrate AEDP interventions in action. AEDP is fundamentally an experiential model. AEDP uses two versions of the triangle of experience to conceptualize the process and the piece of work. The first represents what AEDP calls the client’s self-at-best, or the resilient self. The second represents what AEDP calls the client’s self-at-worst, or compromised self. At the beginning of treatment, AEDP interventions are focused on building safety and regulating anxiety so that core affect can surface. Metaprocessing is an essential element of any AEDP treatment process. It undoes our clients’ aloneness with dysregulating new experiences and helps them to metabolize them instead.

This chapter presents a guide for assessing comorbid eating disorders (EDs) and trauma in a way that shapes and directs treatment. It draws together a combination of assessment tools and principles from the fields of EDs, trauma, and generic mental health, as there is limited literature available on this specific area of assessment. The chapter summarizes various aspects of assessment into distinct sets of guidelines, to help steer the clinician and client through a vast maze of information toward a meaningful formulation and treatment plan. It provides a road map to facilitate comprehensive assessments that lead to the construction of insightful formulations and the delivery of engaging treatment plans. The authors believe that trauma-informed ED assessment guides safe and effective treatment, shining a beacon of light on the road toward transformation and healing.

Eating disorders (EDs) are common chronic illnesses that most clinicians, regardless of specialty, will encounter at some point, and trauma is universal in those who have EDs. Trauma from physical and/or psychological injuries overwhelms the mind and body’s capacity to adapt, and can set off or perpetuate an already present ED. The nutritional support of an individual who struggles with an ED and is a trauma survivor can be one of the most challenging tasks a dietitian encounters. One of the most accurate ways to assess the nutritional status of the body is to do two types of tests: metabolic testing and body composition analysis. Physicians, dietitians, and nutritionists who treat EDs will be treating trauma. Physicians, specifically, have a critical role in diagnosing and treating EDs. Medical caregivers need to let the patients know that they will stay the course and support them for as long as it takes.