Made Simple:
EMDR for Eating Disorders

In one sentence: Eating disorders are a common trauma coping mechanism and can be effectively treated with EMDR—if the right questions are being asked.

In one paragraph: While eating disorders may emerge as helpful coping mechanisms in response to trauma, they are ultimately maladaptive. Integrating questions about Eating Disorders (EDs) into EMDR assessment can help paint a clearer picture of the relationship between trauma and the ED. By incorporating EDs into the other EMDR phases, we can heal EDs alongside the underlying trauma.

Every person can identify with disordered eating at one time in their life or another. We’ve all turned to food to soothe emotions; why else would comedy movies and television shows ubiquitously reference turning to ice cream, chocolate, or chips following an emotional breakup?

In the beginning, disordered eating can be a very helpful coping strategy, bringing immediate relief to uncomfortable feelings. However those coping strategies can become maladaptive when one’s relationship with food takes on a life of its own.

Over the long run, eating disorders wreak havoc on our lives. Individuals using the Eating Disorder (ED) to help control feelings of being out of control may soon find they have lost control completely.

Eating Disorders and the Trauma Connection

Many clinicians and researchers have noted the connection between trauma and the development of EDs. Racine & Wildes (2015) observed that in ED populations there are often high levels of self-reported childhood sexual, physical, and emotional abuse. Trottier et al (2017) surveyed therapists working directly with ED individuals who reported that they see results when treating their ED patients for trauma symptoms.

In our experience, eating disorders are coping mechanisms which emerge to help an individual deal with not only feelings of shame and fear resulting from earlier life experiences, but also with experiences of being out of control, overwhelmed, unlovable, or not good enough.

Barring a brain anomaly, we were not born being confused about hunger and fullness. We were not born with strong negative beliefs about our bodies. We were not born obsessing about calories, our size, shape or attractiveness. We learned to focus on appearance, calories, exercise, restricting or numbing, etc., as coping mechanisms which ultimately confused our bodies’ signals.

While treating patients with EMDR, if we can understand how EDs developed as coping mechanisms, we can better help individuals deal with the underlying traumas they need help coping with.

Treating EDs in Eight Phases and Three Prongs (Past, Present, Future)

When embarking on a new EMDR journey with a client who also has an ED, it’s important to integrate ED-specific questioning into the EMDR protocol.

Phase 1

In addition to gathering history from your client about traumatic events, be sure to collect information about the development of disordered eating behavior.

We find it helpful to ask some or all the following questions to generate a portrait of the ED:

• How long have you had an issue with food/restricting/exercising/binging or purging?

• When was the first time you remember engaging in ED behaviors?

• How old were you when this first occurred?

• How did the idea come to you to restrict/binge/purge/exercise?

• What else was going on in your life when this first happened?

• Has there ever been a time when you stopped for a while?

• Have you ever been able to “interrupt” the ED? For example, could you get yourself to eat when you were actively restricting? Stop a binge? Not purge following a binge? If so, what was that like for you?

• What thoughts do you have about yourself when you are actively restricting/binging/purging?

• Does anyone know about the ED? If so, how did they find out? What was that like for you?

• What do you think or believe people or family members think about you or about your ED?

• How is restricting/binging/purging/exercising helping you? How do you see it as harmful to you? What does it make you believe about yourself?

Asking the right questions tactfully and allowing clients to explore coping mechanisms without judgment can help you uncover cases where clients might not proactively disclose their ED to you initially.

Phase 2

While we cannot possibly address all the complexities and considerations for the scaffolding that may need to be in place prior to entering the processing phases of EMDR, we can offer a list of possible preparation exercises that we have found helpful when working with patients who have EDs or disordered eating:

• Further dissociation evaluation (based on DES, MID, your own intuition)

• Calm/Safe place exercise (Shapiro, 2019)

• Light stream exercise (Shapiro, 2019)

• Guided imagery exercises

• Psychoeducation as needed to understand neurobiological responses to trauma, feelings identification, somatic awareness exercises.

• Earth, Air, Water, and Fire exercise (Shapiro, E., 2012)

• Resource Development Installation (RDI) (Korn & Leeds, 2002)

Please also consider what your specific population may need based on your personal experience, trainings you attended, and clients you have treated.

In phase two, we often trust our intuition as to whether we need further understanding of the level of dissociation the individual may be using to cope with their internalized shame.

Phases III-VIII (assessment through closure)

When assessing the negative belief systems that characterize traumatic experiences, we find commonalities among patients who are comorbid with EDs. The following are the most common negative cognitions for clients with eating disorders:

• Responsibility
  • I am not good enough
  • I am unlovable
  • I am worthless
  • There is something wrong with me/my body
  • I am ugly/disgusting
  • I am a disappointment
• Safety/Vulnerability
  • I cannot trust myself (my appetite, body image, level of exhaustion)
  • It's not ok to feel my feelings/emotions
• Control/Choice
  • I am powerless
  • I am weak
  • I am a failure
  • I am inadequate

In working with EDs and disordered eating, it’s important to remember these are not “one and done” processing sessions. Our clients often have multiple targets that hold negative cognitions and are interfering with everyday life, and many experiences that support the structure of their negative self-referencing belief system.

When identifying targets and entering the reprocessing phases, apply the standard three-pronged protocol to as many recent events of binge and/or purge episodes as the client can tolerate.

The goals here are to clean out the past situations and circumstances that laid the foundation for the ED episodes, and review the current life situations that are triggering maladaptive thoughts, ideas, and behaviors.

Finally, turn your attention to the future, using the future template to imagine future situations with adaptive reactions to triggering situations.

Special Considerations

While we need to be cautious about working with clients who have compromised health conditions, only a very small percentage of eating disordered patients are in this category. Those clients with active Anorexia Nervosa who are hospitalized and medically fragile are not appropriate for EMDR phases 3-7. With medical stability, however, they are fully capable of benefiting from much of the phase 2 work we would normally do with clients. And they are typically being taught Dialectical Behavior Therapy (DBT) skills, affect tolerance, and state change exercises while gaining medical stability.

We also need to consider that some clients might not proactively disclose their ED to you initially. Asking the right questions tactfully and allowing your clients to explore coping mechanisms without judgment can help you uncover such cases.

Conclusion

Being an EMDR therapist means we are trauma-informed therapists. This perspective gives EMDR therapists the unique opportunity to treat more than what meets the eye.

Being aware of the potential for disordered eating symptoms in individuals with trauma histories allows EMDR therapists to treat more than the underlying trauma: we can give people their lives back.

When the focus of someone's day is on more than dealing with body image, shame, societal ideals of body sizes and shapes, and preoccupation with what is happening inside, we offer people the freedom to live their lives as whole, loving, relational humans.

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