Trauma-Informed Approaches to Eating Disorders is clearly a much needed and long overdue book about treatment, written by a diverse group of clinicians and carefully edited to focus on the needs and strengths of clinicians. The complexities and challenges that undergird, surround, and even haunt the nature, diagnosis, treatment, management, and understanding of eating disorders (EDs)-in-relation-to-trauma are so great, even for veteran clinicians, that they can leave practitioners at any level of experience feeling helpless and exhausted. This book, in a way that would be appreciated by practitioners of acceptance and commitment therapy, accepts the reality of those feelings and is committed to improving treatment, understanding, and compassion. The book is designed to foster respect for complexity and link it to humility in the presence of tragedy, tribulations, and suffering, framed all too often by our own shortcomings as healers. EDs are dangerous, ubiquitous, usually chronic in nature, and difficult to treat. Anorexia nervosa (AN) has the highest fatality rate (4%) of any mental illness. Bulimia nervosa reveals a fatality rate of 3.9%. EDs offer an enormous challenge to therapists because of their complexity, which includes severe medical risk, co-occurring anxiety, depression and personality disorders, an addiction component, and body image distortion—all of this within a mediadriven culture of thinness in which starving and purging can for some become lifestyle choices. This complexity is further exacerbated by the presence of painful life experiences or trauma. The book elucidates the connection between trauma and EDs by offering a trauma-informed phase model, as well as chapters describing the ways in which various therapeutic models address each of those phases. It offers an in-depth exposition of a fourphase model of trauma treatment.
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- Go to chapter: Boats and Sharks: A Sensorimotor Psychotherapy Approach to the Treatment of Eating Disorders and Trauma
Boats and Sharks: A Sensorimotor Psychotherapy Approach to the Treatment of Eating Disorders and Trauma
This chapter presents a case study of a sensorimotor psychotherapy (SP) approach to eating disorder (ED) treatment. In contrast to traditional psychotherapeutic approaches, such as cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT), that lean heavily on the impact of thoughts on emotional experiences and somatic patterns, also known as top-down processing, SP also uses bottom-up processing, the effect that one’s somatic organization has on affect and affect regulation, cognitive functioning and specific beliefs about self and other. The very core of SP is four foundational principles that cultivate therapeutic presence and guide both content and quality of interventions: organicity, nonviolence, unity, body/mind/spirit holism. SP understands human experience through the lens of five core organizers: thoughts, emotions, and three somatic organizers. SP explores actions as a cycle with four stages: clarity, effectiveness, satisfaction, and relaxation.
This chapter conceptualizes the preparation phase in three parts for teaching and learning purposes. The preparation phase of the four-phase model is not a one-and-done event. It is visited and revisited often during the therapeutic journey. The first part of preparation is stabilization, sometimes referred to as case management. It is the sine qua non for the remaining parts. The goal here is to make sure that the client is externally safe, as well as internally stable. A second part of the preparation phase is developing skills and resources. Among these are skills that involve changing internal states (self-soothing) and containment of disturbing affect. The third aspect of the preparation phase focuses on short-term successes in which the client gains mastery and confidence in dealing with changeable life circumstances, something of a personal trainer approach.
This chapter focuses on an interpersonal/relational psychodynamic approach to working with eating disorders (EDs), which illuminates the links between symptom and meaning, action and words, isolation and relatedness. The work of any treatment of EDs is an ongoing, complicated mixture of direct intervention with the symptom and exploration of what the intervention means to the patient, including the role the symptom plays in the patient’s intrapsychic and interpersonal world. Understanding this as it unfolds relationally allows the intersubjective experience of both patient and therapist to collide, mingle, and ultimately coexist. Thinking about working with patients with EDs from this vantage point means that the experience of conflict is a therapeutic gain, not obstacle. Multiplicity and the capacity for dissociation are seen as part of the manifestations of what happens with patients with EDs.
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 discusses art therapy: images of recovery. Art therapy is a mental health profession that provides an alternative means of communication and often can be the treatment of choice for clients processing recovery from traumatic events, as well as eating disorders (EDs). Through the art making process, a visual dialogue between the client and the art images is created. The client’s self-talk and internal messages can be documented in an imagistic form. Art therapists are extensively trained to assist the client in creative expression and in facilitation of the client’s self-exploration. Using art therapy with EDs is a unique therapeutic approach that exposes conflicts, problems, thoughts, and behaviors that are not simply about food or a number on the scale. ED patients have extreme fear of being negatively evaluated. The art therapist works toward eliminating those fears by giving the clients creative control over their selfexpression.
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 explores parts or ego states somewhere in the middle of the two that are invested in one or the other form of eating disorder (ED). “Ego state” and “part” are used interchangeably in this chapter. The chapter provides a short neurological explanation of ego states, their purpose, and the difference between dysfunctional and dissociated ego states. It provides an overview of various traditions of parts, which, although not exhaustive, can uncover the common and universal characteristics of ego state work. EDs are very difficult to treat in that they demand attention on so many levels: psychological, emotional, physical, behavioral. The authors believe that it is the reality of dissociation that makes this work all the more difficult, a reality that demands an invitation to all parts of our client to come together and collaborate in the service of healing.
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.
Hypnosis relates to when a person’s behavior shows he or she is in a trance like frame of mind, dissociated from his or her usual conscious awareness. Hypnosis challenges the polarization between the different aims of behavioral and analytical therapy. The reports of many of the patient shows the real source of their distress, and sometimes seem to make the problem worse. This has been eloquently expressed by a young doctor, a survivor of childhood anorexia. “When you live with anorexia, you fight your own thoughts and fears, your own self, every second of every minute of the day. Recognizing this spontaneous hypnosis or trance state as a clinical sign involves a different level of listening skills, a modified approach to history taking and to all the advice given. The focus of therapy is turned from the past to the future from regression to progression.
Energy psychology comprises a body of knowledge and a family of therapeutic modalities that are concerned with the interface between mind and body, mediated by working with the body’s subtle energy system. Although the mechanism is uncertain, research indicates that such methods do work, bringing about emotional, cognitive, and physiological changes rather faster than would be expected with purely talk-based psychotherapies. Another important component used by some practitioners is “energy testing” sometimes known as “muscle testing”, although it is not the muscles tested, but small variations in muscle tone are considered to provide information about both psychological and energetic states. This chapter discusses two case studies where, energy testing revealed significant internal objections to resolving their eating disorders (EDs). It concludes that energy psychology modalities form useful additional components of psychotherapeutic approach to EDs, helping to alleviate the intensity of emotional distress and facilitate the flow of energy and information.
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.
This chapter provides an overview of recovery and beyond: dealing with triggers and setbacks. Recovery means holding tight to foundational ways of living that were learned in treatment and generalized into daily life during the healing process. Recovery can be inconsistent and unpredictable at times, demanding strength and courage to continuously redefine ne one’s self-story and live from one’s authentic self. Negative life events, whether they are large or small traumas, can act as powerful triggers, leading to the return of the eating disorders (ED). Stressful life events and daily life stressors can easily disturb unprocessed traumatic material, activating memory networks and causing pain and suffering, along with adding new traumatic material to the brain and body system. In the end, the therapist supports and celebrates the unique image of recovery that is self-defied, value-based, inclusive of fractures and imperfections, and created by the client.
- Go to chapter: Discovering the Power of Movement: Dance/Movement Therapy in the Treatment of Eating Disorders and Trauma
Discovering the Power of Movement: Dance/Movement Therapy in the Treatment of Eating Disorders and Trauma
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.
- Go to chapter: The Many Faces of Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), Other Specified Feeding or Eating Disorder (OSFED), Bulimarexia, and Orthorexia
The Many Faces of Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), Other Specified Feeding or Eating Disorder (OSFED), Bulimarexia, and Orthorexia
Feeding and eating disorders (EDs) are severe mental illnesses. This chapter gives a concise overview regarding EDs, their diagnostic configuration, and comorbidity with other mental illnesses. Moreover, the focus included vulnerability and psychological aspects of EDs, with particular attention given to the impact of dysfunctional attachment dynamics and relational trauma on the onset of each type of ED. The chapter covers EDs such as anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding or eating disorder (OSFED). Types of EDs also included those that are not present in Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), but are frequently found in clinical practice. Such disorders (e.g., bulimarexia or orthorexia) are symptomatological manifestations that require further investigation to clarify risk factors related to their onset and to shed light on their mechanism of action.
Eye movement desensitization and reprocessing (EMDR) is an integrative, client-centered psychotherapy developed by Francine Shapiro, PhD, in 1987. EMDR engages the natural information processing systems in the brain to process disturbing life experiences that are, according to Shapiro, the bases of pathological behaviors. The Adaptive Information Processing (AIP) model was developed by Francine Shapiro to explain the effects of EMDR therapy; guide case conceptualization, treatment planning, and interventions; and predict treatment outcomes. The AIP model assumes that both pathology and health are the development of early life experiences that are stored in neurobiological memory networks. Early life experiences, therefore, are the building blocks of perception, attitudes, and behaviors. Neurobiologically speaking, our life experiences get translated into physically stored memories on which we rely to guide us in life choices and interpretations.
This chapter provides a brief description on eating disorders and the case for emotions. Throughout this chapter, the author have used the terms “emotion” and “feeling” interchangeably, although neurologically they can be understood as different stages of the emotional experience. Much of this chapter is how the author teach clients emotional courage and competence, but it has also helped many clinicians in their own journeys. Change is what we most often fear, even if it means shaking off toxic residue and stepping into the unknown of a different and healthier identity. So-called “good” feelings often end up scaring us as much as the “bad” ones, because they, too, invite change. Feeling requires courage. The emotion knocking on your door is letting you know that you have reason to be excited or fearful and that your aliveness is calling you to a larger version of yourself.
- Go to chapter: Second Helpings: AEDP (Accelerated Experiential Dynamic Psychotherapy) in the Treatment of Trauma and Eating Disorders
Second Helpings: AEDP (Accelerated Experiential Dynamic Psychotherapy) in the Treatment of Trauma and Eating Disorders
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.
- Go to chapter: Trauma-Informed Approaches to Body Image Disturbance: A Historical Review for a Holistic Future
The chapter analyzes the gestaltists view, psychoanalytic view, feminist and sociocultural views, and tries to come to some understanding of where one might be going in promoting change from body image disturbance (BID) to positive experience. The gestaltists sought to recognize the incredible power of the mind to organize information, so that one can effortlessly make sense of all we take in via one’s senses. The psychoanalytic view greatly helped our understanding of BID in various forms of psychopathology. However, the denial of the traumatizing effect of sexual abuse, it also greatly limited the potential for care. For many disorders, treatment models followed the historical sequence from psychoanalysis to behavioral to cognitive behavioral. The treatment of BID in eating disorder drew in one more viewpoint in1970s, that of the feminist view. Finally, the cognitivists sought to explore the internal processing that links cultural influence and learning history to psychopathology.
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.
Neurofeedback therapy is a modality that can help a stuck brain get unstuck and learn new and better ways to fi re and function. This chapter describes what neurofeedback therapy is, how it works, and how it can be a valuable part of treatment for eating disorders (EDs). Neurofeedback therapy, also called EEG biofeedback or neurotherapy, makes use of the brain’s capacity for change to reshape brain networks. Neurofeedback uses EEG information to provide feedback to the trainee. Neurofeedback is a powerful training tool that can be used within a comprehensive treatment plan to assist clients to begin to have more control over how their brain fires. Neurofeedback therapy shifts arousal in the brain, which helps clients to alter the state they experience and to create a new narrative about themselves and the world around them.
- Go to chapter: Recognizing the Territory: The Interaction of Trauma, Attachment Injury, and Dissociation in Treating Eating Disorders
Recognizing the Territory: The Interaction of Trauma, Attachment Injury, and Dissociation in Treating Eating Disorders
This chapter briefly discusses the interaction of trauma, attachment injury, and dissociation in treating eating disorders (EDs). What is it that causes some people to develop an ED, and others to manage eating behaviors in a relatively normal manner? The answer is anything but simple. EDs are a biopsychosocial illness. They are the result of a complex interplay of factors including genes, temperament, social interactions, early attachment, culture, and of course life experiences. These variables come together and affect each other in a perfect storm fashion and may result in ED psychopathology. The cycle of being flooded with early, unprocessed trauma upon remittance of ED symptoms, followed by relapse, reduces the foundation of treatment to shifting sand. Unless the trauma and the ED are treated simultaneously, treatment becomes futile at best: fraught with multiple relapses, behavioral substitutions, feelings of hopelessness, and premature termination.
Trauma is unrelenting and pervasive; it bleeds into the present moments of daily life, often stealing joy, muting a person’s ability to fully connect and accomplish tasks of daily living. Starting with an overview of the internal family systems (IFS) model, this chapter discusses how IFS conceptualizes eating disorders (EDs) and approaches trauma treatment. IFS differs from other approaches to trauma treatment in several ways that we elaborate, especially eschewing the idea that stabilization and explicit skills training are necessary prerequisites for processing traumatic memories. Instead, IFS asserts that clients can learn to interact with the different parts of themselves without getting overwhelmed or needing the therapist to actively manage the process. The chapter uses case vignettes to illustrate how IFS achieves the goals of phase-oriented trauma treatment to heal EDs in a nonlinear, relational way.
This chapter offers ways to be an effective therapist for clients who suffer from both an eating disorder and trauma (ED&T). It describes the importance of therapeutic presence and how to facilitate safety and healing through the therapeutic relationship. The information provided is equally applicable to all phases of treatment. Therapy for ED&T clients involves providing safety, education, insight, and a corrective emotional experience, thereby allowing the client to rectify faulty thought, emotional, and behavioral patterns. Therapists need to use their training and the therapeutic relationship for this to happen. The author’s experience treating ED&T clients corroborates the need for therapy training programs to increase their focus on training therapists how to achieve therapeutic presence, establish a positive alliance, and use the relationship to put the client’s symptoms out of a job.
Overwhelming evidence exists that traumatic experiences leave traces in our minds and bodies. Traumatic experiences such as sexual, physical, and emotional abuse have a negative impact on our capacities to relate to and trust other people, but also on the neurobiological functioning of our brain and thus our mind. They also affect our immune systems. Hence, traumatic experiences make dealing with emotions, both positive and negative, quite challenging. In this chapter, a “state-of-the-art” review reveals the presence of a wide variety of traumatic experiences and their consequences in anorexia nervosa, bulimia nervosa, and binge eating disorder patients. Almost all studies investigated the association of retrospectively reported childhood abuse with current ED symptoms using cross-sectional designs. A special focus is on the presence of dissociation in ED patients, as it is one of the main characteristics in EDs with severe trauma.