Many people with eating disorders experienced serious abuse and neglect while growing up. When people with eating disorders and serious trauma-based disorders, including dissociative identity disorder, post-traumatic stress disorder (PTSD, sometimes misrepresented as post stress traumatic disorder) and borderline personality disorder, come to a hospital or residential treatment center, they may have problems with anorexia, bulimia, over-eating, or a combination of all three. They may avoid certain foods that remind them of past trauma, and they may be triggered or experience flashbacks because of smells, textures, or other qualities of food. Mealtimes may have been traumatic in and of themselves in childhood, with fighting, anger, verbal abuse, or intoxication characterizing many meals. There may have been highly unhealthy family rules, beliefs and behaviors concerning food and body image.
People who come for eating disorder treatment rarely have only eating disorders. Often, in the present or the past, there have been many other self-destructive and addictive behaviors. Usually, trauma-based disorders including depression, anxiety disorders, dissociative identity disorder, post-traumatic stress disorder (PTSD, post stress traumatic disorder), borderline personality disorder and other mental health problems are also present. Inpatient treatment may not focus on the eating disorder if more pressing problems require attention. For instance, active suicidal ideation or a current abusive relationship may be higher priorities in the inpatient setting.
No matter how much trauma there was in childhood, or in adulthood, and no matter how many other mental health problems and addictions accompany the eating disorder, the eating disorder always serves the same basic function. Like all addictions and self-destructive behaviors, eating disorders are avoidance strategies. They help focus attention off of problems, conflicts, life situations and intolerable feelings, and they provide an illusion of power and control.
While Rome burns, everything seems OK because today’s food intake was under seven hundred calories.
To a considerable extent, treatment is not really driven by diagnosis. We take the diagnosis into account, but most of the goals and tasks of therapy are not determined by diagnosis. If a person has an alcohol problem, we will certainly recommend an AA program, and alcohol will be a topic of conversation. If a person is clinically depressed, an antidepressant will almost always be prescribed. But most of the work of recovery is the same, no matter the combination of addictions and trauma-based diagnoses, which may include dissociative identity disorder, post-traumatic stress disorder (PTSD, post stress traumatic disorder) and borderline personality disorder and other trauma-based disorders.
Why is this so? The answer is quite simple. Treatment is not about the avoidance strategy. It is about what is being avoided. One person may use alcohol to avoid grief and loneliness. Another may act out sexually, while a third person gambles and a fourth is a rage-aholic. Although these people have different diagnoses, they share the same underlying problem. This logic applies to eating disorders as well.
Of course, if a person’s weight is so low, or her electrolytes so out of balance, that life is threatened, therapy has to wait until the medical danger has passed. We are not equipped to handle such situations at Del Amo because they require intensive medical care and monitoring. But if a person is medically stable, then the work of recovery can begin, or start again.
It would make no sense to never mention food in the treatment of an eating disorder. Similarly body weight is always a topic of conversation. The goal, however, is to move the focus off of food and body image onto the underlying problems. These are not “psychiatric” problems as such – rather, they are common human, life problems. I am talking about sadness, loss, grief, emptiness, lack of direction, unhappy or abusive relationships, and psychological trauma, contributing to trauma-based disorders, including dissociative identity disorder, post-traumatic stress disorder (PTSD, post stress traumatic disorder) and borderline personality disorder. All of these are part of the human condition. People who come for treatment have experienced much more trauma, loss and grief than the average person, but they are not in a separate category from everyone else as a result. They have common human problems to an uncommon degree.
It is the coping strategy that is the psychiatric disorder. In therapy, the goal is to understand the function of the unhealthy behaviors, then to build more flexible, healthy coping strategies. This is done through a mix of educational, cognitive and experiential strategies. The purpose of the experiential treatment is two-fold: desensitization and skill building. In a structured, one-step-at-a-time manner, one learns to tolerate the intolerable, and learns new skills for dealing with feelings and conflict. When these tasks have been accomplished, the need for the old, unhealthy behaviors associated with dissociative identity disorder, post-traumatic stress disorder (PTSD, post stress traumatic disorder), borderline personality disorder and other trauma-based disorders melts away.
There is one other principle that is relevant for eating disorders: “just say no to drugs.” We classify all unhealthy, addictive avoidance strategies as “drugs.” In order to get better, you have to make a serious commitment to recovery. This means a serious commitment to tolerating feelings and conflicts which are intense and painful. It is long, hard work but it can be done.
As therapists we ignore eating disorders and we also focus on them. We do this to the same degree that we simultaneously ignore and focus on all other symptoms, coping strategies and addictions. If you focus too much on the defense, you miss the real problem. If you focus too much on the underlying problem, you never learn how to substitute more healthy defenses. It is all a matter of balance. There is no simple formula that applies to everyone because everyone is different. But the general principles are the same, as are the basic tasks and goals.
I hope this clarifies the approach to eating disorders within when the person has also experienced severe psychological trauma, inclusive of trauma-based disorders such as dissociative identity disorder, post-traumatic stress disorder (PTSD, post stress traumatic disorder), borderline personality disorder.
Ross, C.A. (2006). Overestimates of the genetic contribution to eating disorders. Ethical Human Psychology and Psychiatry, 8, 123-131.
Ross, C.A. (2009). Psychodynamics of eating disorder behavior in sexual abuse survivors. American Journal of Psychotherapy, 63, 211-226.
Ross, C.A., & Halpern, N. (2009). Trauma Model Therapy: A Treatment Approach for Trauma, Dissociation and Complex Comorbidity. Richardson, TX: Manitou Communications.