Do I Need to be Fully Weight Restored from my Eating Disorder to start trauma therapy?
This is a question that comes up frequently in eating disorder treatment, and the honest answer is: it depends.
As an eating disorder therapist who works from a relational and anti-oppression lens, I believe in holding space for the complexity of each person’s healing journey. There’s no one-size-fits-all answer to the question of whether someone must be fully weight restored before beginning trauma work. Instead, it’s important to consider the individual’s physical, cognitive, emotional, and relational readiness — not just their number on a scale.
The Traditional View
Historically, many treatment models have operated from a more linear framework: First weight restore, then process trauma. This approach is often grounded in legitimate concerns about cognitive functioning, emotional capacity, and the risks of trauma work when the body is still in a malnourished state (trauma therapy tends to be more destabilizing than stabilizing- in the beginning).
There is research to support that malnutrition and starvation can impair concentration, emotional regulation, and memory consolidation (Kaye et al., 2013; Walsh, 2013). From this lens, it can make sense to prioritize re-nourishment before diving into trauma work that requires presence, stability, and emotional bandwidth.
But Here’s the Thing…
Trauma doesn't always wait until someone is "ready" — and the impacts of trauma often underlie or intersect with the eating disorder itself. For many clients, the eating disorder functions as a way to cope with unprocessed trauma. To ask them to suspend trauma work until they meet a certain weight threshold can feel dismissive of the significance of the trauma and impossible. As a therapist I have heard some iteration of this question amongst survivors: “You want me to give up my coping skill (eating disorder) without helping me heal from what is hurting me first?!” And quite frankly, I understand how unrealistic this feels to many clients I work with.
A growing number of clinicians and researchers are acknowledging that trauma and eating disorders are deeply intertwined, and treatment approaches must be flexible. In fact, some studies have found that some trauma interventions support eating disorder recovery, even before full weight restoration (Trottier & MacDonald, 2017; Brewerton, 2019).
What the Research Tells Us About Trauma and Eating Disorder Treatment
Trottier & MacDonald (2017) conducted a comprehensive review of the literature and highlighted several key findings:
Trauma is a highly prevalent risk factor in the development and maintenance of eating disorders. Rates of childhood abuse, emotional neglect, and bullying are notably higher among individuals with eating disorders compared to the general population.
Trauma-related symptoms such as dissociation, emotion dysregulation, and hypervigilance often mirror or reinforce eating disorder symptoms. For instance, restriction or binge-purge behaviors may serve to numb overwhelming feelings or regain a sense of control.
Critically, the review emphasized that trauma-informed approaches should be integrated earlier in eating disorder treatment, rather than being postponed until full recovery is achieved.
They called for a paradigm shift — moving away from the traditional "treat the ED first, trauma later" model, and instead adopting more integrated, flexible care that addresses both.
Brewerton (2019) added to this conversation by exploring the link between Post-Traumatic Stress Disorder (PTSD)and eating disorders, arguing that trauma symptoms often go undiagnosed or under-treated in ED populations — particularly in outpatient settings or with clients who do not present with “classic” trauma narratives.
Brewerton identified that trauma exposure can exacerbate eating disorder severity, prolong recovery, and increase relapse risk when left unaddressed.
Importantly, he argued that trauma-informed treatment — including resourcing, somatic interventions, and gradual exposure techniques — can be safely introduced even before full weight restoration, provided that clients are adequately supported and stabilized.
His work particularly emphasized comorbidity with complex trauma, noting that many clients with EDs may meet criteria for Complex PTSD or experience trauma that isn’t captured by conventional diagnostic frameworks (e.g., systemic oppression, medical trauma, fatphobia).
Both researchers underscore the importance of clinical attunement and individualized pacing — suggesting that for many clients, early trauma-informed work can actually facilitate eating disorder recovery, rather than hinder it.
What’s more, waiting for full weight restoration — particularly when defined by rigid BMI targets — may not always be relative or appropriate, especially for those in larger bodies who will never be considered “underweight” but still very much struggle with an eating disorder. So that begs the question- how are we defining under nourishment if we can’t rely on a single biometric marker? Here are factors to consider that have helped me decide when someone is ‘ready enough’ for trauma work in ED recovery.
Factors to Consider Before Starting Trauma Therapy
Rather than using weight restoration as a blanket requirement, it may be more helpful to assess readiness for trauma processing using a range of biopsychosocial factors, including:
Physical stability: Is the client medically stable enough to tolerate emotional processing? How have they handled emotional experiences so far in our work together? Does their dietician and/or medical provider have insight into physical stability that is beyond my scope (i.e. lab work, vitals, medical complications)?
Cognitive capacity: Are they able to concentrate, reflect, and engage in insight-oriented work enough that therapy is generally effective around topics that don’t involve trauma?
Nutritional sufficiency: Are they meeting non-negotiables (a bare minimum meal plan set by RD) to fuel their brain and body, even if they’re not “fully weight restored”?
Coping strategies: Do they have distress tolerance or other safe coping skills in place?
Support systems: Are there safe relationships or therapeutic supports to help hold what arises between sessions? Is their living environment supportive?
Consent and autonomy: Does the client want to engage in trauma work? Are they feeling pressured? Do they know the risks/benefits to a variety of trauma therapy approaches?
I highly recommend not only person reflection on these questions, but also group/peer consultation to make sure you are following ethical decision making guidelines and addressing any biases around competency and disability.
A Harm Reduction Approach
For some, doing trauma work while still in active eating disorder recovery can be destabilizing. For others, addressing trauma sooner can actually reduce eating disorder symptoms by targeting the root causes of distress. While it may temporarily make recovery harder, in the long run, it can be a way to reduce long term harm of leaving the trauma unaddressed.
There’s also a middle ground: focusing on resourcing, psychoeducation, and attachment work that lay the foundation for deeper trauma processing later. This can include somatic coping skills, inner child work, safe place guided imagery, or narrative therapy — all of which can gently support healing without diving headfirst into trauma reprocessing like EMDR or prolonged exposure.
The Bottom Line
The decision to begin trauma therapy before full weight restoration should be made collaboratively, based on the client’s needs, goals, and capacities — not arbitrary timelines or treatment hierarchies.
Healing is not linear. Trauma work and eating disorder recovery don’t always happen in separate silos. For many clients, it’s the integration of trauma therapy and eating disorder therapy that ultimately supports long-term recovery.
If you’re looking to begin therapy for trauma, eating disorders or both, we are here to help you. Reach out today to schedule a free 15 minute phone consultation to see if we are the right fit!
Citations:
Brewerton, T. D. (2019). Posttraumatic stress disorder and disordered eating: The significance of trauma in eating disorder care. Psychiatric Times.
Kaye, W. H., Wierenga, C. E., Bailer, U. F., Simmons, A. N., & Bischoff-Grethe, A. (2013). Nothing tastes as good as skinny feels: The neurobiology of anorexia nervosa. Trends in Neurosciences, 36(2), 110–120.
Trottier, K., & MacDonald, D. E. (2017). Update on psychological trauma, other severe adverse experiences and eating disorders: A review of the literature. Journal of Eating Disorders, 5(1), 1-23.
Walsh, B. T. (2013). The enigmatic persistence of anorexia nervosa. American Journal of Psychiatry, 170(5), 477-484.
At Eating Disorder OCD Therapy, we offer compassionate, relational, and individualized care, rooted in the belief that healing is not one-size-fits-all. Honoring client autonomy, collaboration, and anti-oppressive, neurodivergent-affirming practices, we walk alongside you as the expert in your own life. We provide therapy for Eating Disorders, OCD, Body Image, Trauma, Maternal Mental Health, and offer Ketamine Assisted Psychotherapy (KAP), Group Therapy (globally), Recovery Coaching (globally), and Clinical Consultation and Supervision for clinicians. We are currently accepting new clients for in-person therapy in San Diego and virtual services in California, Washington, Utah, and Florida.
