Part one: Trauma-informed approaches to treating eating disorders via telehealth

Presented by:

  • Emma Riebl, Primary Therapist at Within Health
  • Jacquie Rangel, Primary Therapist at Within Health
  • Caitlin Kelly, Primary Therapist at Within Health

Virtual eating disorder treatment has made it possible for countless people to receive the high-quality care they need to recover and heal. Unfortunately, not everyone has the option of going away to in-person treatment, either because of responsibilities like caregiving and work or geographical or transportation barriers. 

Telehealth expands treatment access and allows people to receive treatment in their homes or wherever they’re comfortable. Many individuals find it more powerful and healing to receive care in their home environment because they can work through triggers that are present and find long-term healing that way. 

However, telehealth can also be risky, especially for those with a history of trauma or those in an active trauma situation at home. Patients need to feel safe in their homes and in themselves to benefit from eating disorder treatment.

Benefits of trauma treatment via telehealth

Trauma-informed care, both in-person and virtually, is vital to ensuring patient safety. Clinicians using a trauma-informed approach assume a patient with an eating disorder is more likely to have experienced trauma than not. As such, treatment providers create a safe, respectful, and compassionate environment that minimizes the risk of retraumatizing or triggering patients while helping them heal.1

Some benefits of trauma treatment via telehealth include:2

  • Accessibility: Clients who may otherwise not have access to care can receive treatment for their eating disorder.
  • Flexibility: To an extent, clients can remain at work, in school, and/or with their families while receiving care.
  • Unique opportunities at home: Recovering in the home environment creates unique opportunities like exposure work, encountering triggers in real life, and using coping strategies in real-time.

Risks of trauma treatment via telehealth

Although virtual trauma treatment has many benefits, it also comes with some risks, such as:2

  • Risks to confidentiality: Because treatment occurs in the home, confidentiality can be broken if family members or other household members overhear therapy sessions.
  • Acuity of safety concerns: Various dangers, such as suicidality, non-suicidal self-injury, dissociation, and severe eating disorder symptoms, can worsen during telehealth and may necessitate in-person care, at least until they are safe and stabilized.
  • Unsafe environment: Virtual trauma work may be contraindicated in clients who are currently experiencing abuse, domestic violence, or harmful family dynamics because if a client is in an environment where trauma is being perpetuated, then that won’t be a healing space for them.

Pros and cons of telehealth

Not every client is a good fit for virtual eating disorder care, especially regarding trauma work. Like any other treatment setting, there are pros and cons to telehealth.


  • Accessibility
  • Flexibility
  • Increased patient comfort at home
  • More time to spend with family and loved ones


  • Loss of human connection from in-person to virtual
  • Therapeutic mindset (entering and exiting treatment sessions)
  • Potential for technology issues

How to create safety in the telehealth space

People with eating disorders and a history of trauma need to feel safe within the virtual treatment space, their therapeutic relationship, their homes, and their bodies. 

Screening and assessment

One of the first things clinicians do when working with an eating disorder patient via telehealth is screen and assess for acuity of safety concerns, such as suicidality, homicidal ideation, non-suicidal self-injury, substance use, medical conditions and stability, dissociation, mental status, and activities of daily living.

It’s essential to assess for these things regardless of the setting, but they are particularly important for treating someone via telehealth. For example, if a clinician determines that someone has safety concerns, they may refer them to in-person care, such as in a hospital or inpatient setting.

Secure technology

An essential part of creating a safe virtual space is using secure technology, such as an encrypted and HIPAA-compliant telehealth and communication platform. Ideally, the client should have access to a secure internet network with a high-speed connection. Unfortunately, not every client has private WiFi access. Still, clinicians should troubleshoot and problem-solve with them, whether that looks like using a hotspot, finding low-cost internet plans, or finding WiFi grants for low-income people.

Informed consent in telehealth

Informed consent is a paramount part of entering the therapeutic relationship. This involves talking to clients about the benefits and risks of telehealth, the potential risks of confidentiality, communication between settings, and clinician and client responsibilities. Essentially, informed consent contributes to a safe space by educating and empowering the client.

Clinicians also want consistency in how they show up to calls, how they dress and present, and the video call etiquette they follow.

Physical environment 

Creating a private and safe therapeutic space is essential to the therapeutic relationship, client safety, and the healing process. A few things that can help create a safe physical environment include:

  • Therapeutic space: The space should be private, quiet, and free of distractions, and headphones should be used if needed.
  • Clinician awareness: Treatment providers should be aware of who is in the client’s physical vicinity, how this may impact the client, and confidentiality.
  • Client use of therapeutic tools: Clinicians should encourage clients to use comfort items to create a sense of grounding and physical safety. Pets are a common example because of their familiarity, comfort, and love.

Safety planning

It’s important to have telehealth-specific safety planning in place, which may include:

  • Confirming a client’s physical location/address at the start of every session
  • Having a list of designated emergency contacts for the client
  • Having the phone numbers for local police and fire departments readily available
  • Knowing local crisis resources (domestic violence shelter, hospital, urgent care, mobile crisis services, etc.)

Psychodrama in telehealth

Psychodrama is an experiential, action-based psychotherapy that employs guided dramatic action to examine problems or issues. It’s often used as a form of trauma treatment. This type of group therapy facilitates insight, personal growth, and integration of cognition, affect, and behavior, allowing participants to learn and practice new roles and behaviors.3

This type of therapy merges someone’s thoughts with their feelings and their somatic and behavioral presentation in such a way that participants can practice new behaviors, have healing conversations, and try out new roles they might be uncomfortable with otherwise.

Core concepts and goals of psychodrama

Core concepts and goals of psychodrama include:

  • Access spontaneity and creativity: Clients can leave their comfort zones and combat rigidity.
  • Guided role-play: Clients can talk with someone real or a part of themself.
  • Concrete action: Clients can practice setting boundaries instead of talking about boundaries.
  • Role flexibility: The more roles clients can step into, the better their role flexibility and psychological health.
  • Gain insight: Psychodrama groups can provide clients breakthroughs and insights into their behaviors, relationships, feelings, and more.

Psychodrama group structure

Structure is fundamental in psychodrama groups to ensure patient safety and meet their goals. The structure tends to follow these three phases:

  • Warm-up: Every warm-up can be very different, but the purpose is to get the group warmed up to each other and to issues they want to discuss in the group that way. Part of the warm-up involves the director choosing what the action will be that day and who will do the work.
  • Action: One or more participants do work around a therapeutic problem in their lives, doing role play and role reversal or whatever the issue calls for.
  • Sharing: After the action, participants and the director share their experiences, debrief, and process their feelings and experience.

Psychodrama and trauma treatment

When treating patients with a history of trauma, psychodrama can be a great way to facilitate healing. 

Some benefits of psychodrama and trauma treatment include the following:3,4,5

  • The experiential element can help patients avoid intellectualizing their issues.
  • The spontaneity and creativity patients access can lead to psychological resiliency.
  • They can practice new behaviors, which is incredibly important for trauma and eating disorder recovery.
  • Clients can improve role flexibility and step out of the victim role.
  • Clients have the opportunity for corrective experiences, in which they do or say something they wish they could have in the moment or set a boundary they wish they’d gotten to set.

It’s important to note that psychodrama therapy doesn’t re-enact trauma, as that can be extremely retraumatizing for the patient. 

Some risks for psychodrama therapy and trauma treatment may include:6

  • Spontaneity and creativity can lead to client discomfort
  • Potential for retraumatization
  • Potential exposure to triggers

Although there will always be risks, there are a few ways to mitigate these risks, including: 

  • Warm up slowly: Build internal and external safety and make incremental progress.
  • Emphasize resourcing: External resources, such as a grounding physical object, can lead to inner safety.
  • Create containment: Build a strong contract before the psychodrama, so the participants know what is going to happen, the protagonist knows what to expect, they know that they’ll have the director’s support, and then after the action phase, they need to de-role and create separation by shaking off the energy and saying “I am not ____.” 
  • Emphasize sharing: Encourage clients to share their feelings using “I” language to share their feelings.
  • Consider having a group leader: Having a group leader in addition to the director can provide clients with another resource for one-on-one support if needed.

At the end of the day, patient safety is of the utmost importance, especially in the telehealth space, where there is less oversight and professional monitoring. And if, at any point, a patient feels unsafe, triggered, or is experiencing a mental health crisis, they can always transition into an in-person care setting to receive a higher level of care.


  1. Buffalo Center for Social Research. (n.d.). What is Trauma-Informed Care? Retrieved November 8, 2022.
  2. Brothwood, P. L., Baudinet, J., Stewart, C. S. et al. (2021). Moving online: young people and parents’ experiences of adolescent eating disorder day programme treatment during the COVID-19 pandemic. Journal of Eating Disorders, 9, 62. 
  3. Orkibi, H., & Feniger-Schaal, R. (2019). Integrative systematic review of psychodrama psychotherapy research: Trends and methodological implications. PloS one, 14(2), e0212575. 
  4. Giacomucci, S. and Stone, A. (2019). Being in two places at once: renegotiating traumatic experience through surplus reality of psychodrama. Social Work with Groups, 42(3), 184-196. 
  5. Kellermann, P. F., & Hudgins, K. (2000). Psychodrama with trauma survivors: Acting out your pain. Jessica Kingsley Publishers. 
  6. Pramann, R. (2016). Benefits, Limitations, and Potential Harm in Psychodrama (Training). CCCU Training in Psychodrama, Sociometry, and Group Psychotherapy.