PSIP Meets an Active Eating Disorder: A Calculated Risk in the Field of Trust
A Case Study Beyond Standard Contraindications in Psychedelic Somatic Therapy
I typically consider an untreated eating disorder a contraindication for PSIP1. As with substance use, it’s important to first establish alternative strategies for regulation—methods to calm, soothe, and manage the underlying discomfort that the maladaptive behavior is attempting to address. Without these new pathways in place, the intensity of PSIP can increase system pressure and risk exacerbating the eating disorder, as the client is being asked to stay in contact with the very material their system has long relied on the behavior to avoid.
Despite this general contraindication, I want to share a case involving a client who entered treatment with an active eating disorder—binging and purging at least once a week for the past 20+ years. We had already completed the intake and preparatory work, but the client only disclosed the eating disorder right before our first medicine session. Had it come up during the intake, I likely would have referred them out for specialized support. But since we were already in motion, I chose to continue—I had a sense that if their system could experience more relational solution2, the eating disorder might begin to loosen its grip organically. This isn’t a belief I hold as an absolute, but something in me trusted that direction, and I decided to follow it.
I’m not going to walk through a play-by-play of how the eating disorder faded. Instead, I’ll be focusing on specific moments that hold the most clinical value. To keep this case study grounded in reality, I want to name the amount of time, energy, and commitment that was poured into this process. The client engaged in monthly intensives (e.g., 2-hour medicine-assisted sessions on Monday, Tuesday, and Wednesday), and we occasionally exchanged audio messages to bring in more relationship in the immediate aftermath of a binge/purge cycle.
Their partner’s consistent support as my client unraveled, and the risks my client took in naming when they had just purged, were also significant parts of the process. Not to mention the months of destabilization and stuckness they endured while balancing relationships, a business, and a family. The grip of the eating disorder fluctuated, but showed a steady downward trend over the course of 10 to 12 months. At this point, after continued PSIP work, it has been about six months since they’ve reached for that mechanism. It’s also worth noting that the client made the decision to taper off antidepressants before we began our work together. Seen alongside the eating disorder, it speaks to how hard they were trying to find ways to manage what had long felt unmanageable.
In my experience, two core dynamics often make interrupting a pattern like this challenging.
First, if there isn’t an alternative pathway (e.g. secure attachment, community) to meet the underlying need the behavior is fulfilling—binging and purging, in this case—any interruption is unlikely to hold through the natural fluctuations of life.
From what I could feel in this case, the binging and purging—while clearly harmful—seemed to be the most viable strategy the client’s system had for managing what felt unmanageable. I wasn’t working to treat the eating disorder directly, and I would not have continued had their symptoms worsened during the process.
Instead, we focused on cultivating relational solution—creating many moments of secure attachment and inviting that experience to expand beyond the SI container3. That movement felt like an adaptive shift: not away from the behavior, but bringing relationship into the shame-filled behavior and toward a growing capacity to regulate through relationship, rather than purging in isolation. We were slowly widening a constricted hallway—the narrow path where needs and emotions had to be purged, because they weren’t allowed in relationship within their family of origin.
As this new pathway became more trustworthy and real, my client found themselves in a pocket of intense discomfort between sessions. They were purging far less frequently, and when they did, the relief that once followed was noticeably absent—the behavior was losing its hold and function. This felt like an organic shift, a byproduct of a different solution gradually finding its way into their system and life. I remember a check-in during this phase where we reflected on how purging was no longer working like it used to—and how isolating the behavior remained. Although there was connection before and briefly after purging episodes, the actual moments of binging and purging happened in isolation. Those parts of their experience never had a chance to enter relationship. For them, purging was an attempt to clear the system and be “okay enough” to re-enter connection—but the very needs and feelings being pushed away never got to be held in relationship. It was a painful dilemma: wanting connection so deeply that they were willing to harm their body—and yet, the very behavior meant to protect that need often kept true relationship just out of reach.
Second, deeply proceduralized maladaptive behaviors often serve to manage or soothe the charge of an emotional memory(s) that’s been activated. When that underlying charge remains potent and unresolved, building or sustaining new adaptive behaviors can feel limited—or even impossible.
There were several singular event traumas that emerged during their process, many dimensions of them anchored in the neck and throat. One involved a medical trauma from infancy, where they had been intubated—a memory that surfaced with significant intensity, along with tightness and choking patterns that seemed to hold back emotional distress. But the more prominent memory, which brought both insight and a dramatic softening around the eating disorder, was the sexual assault they experienced in adolescence. As this surfaced, there was a surge of sensation and activation around the neck and throat, followed by the memory of their sleep becoming chronically disrupted in the aftermath of the assault. They recalled waking in the middle of the night and going to the fridge to self-soothe—patterns that began around the time of the assault.
The most significant shift that led to this mechanism coming to rest occurred after one of their intensives surrounding the sexual assault. As their system started to mobilize in the SI container, their arm began to tremble and slowly lift toward their mouth and throat. The movement had the quality of primary consciousness4—emergent, unfiltered, and driven from within—although in hindsight, an aspect of it was a learned response built out over the years to manage the unresolvable. We followed the impulse, allowing their hand to lead. As it reached their chin, it continued to make its way inside their mouth and triggered dry heaving and eventually some vomiting. We stayed with the process and continued the session. The following day, before beginning the medicine work, we paused to reflect. They had just revealed a behavior that had long lived in secrecy and shame—and now it had emerged directly in the therapeutic space. Although I see this behavior as a management strategy, I think there was something incredibly therapeutic to bring this shame-filled strategy into our relationship in real-time.
As we began the next session, their system returned to a similar place. There was significant charge again, along with the same tremulous movement of the arm toward their neck and mouth. I invited them to stay with their body and gently soften the throat to soften the choking sounds that accompanied the charge and overwhelm. As the movement intensified and their hand inched toward their mouth, I placed my hand near their chin to block their fingers from entering their mouth or throat, preventing purging/vomiting. This intervention stirred more activation and pain—sensations that had previously been interrupted by purging—and ultimately led to a completion. Something long caught in the loop of the eating disorder seemed to move through.
From that session forward, the automated impulse to move toward binging and purging closed out. What was most striking was how naturally this shift emerged. They weren’t straining to resist the behavior—the impulse was simply absent. Even more telling, this new orientation has been stress-tested several times since. Despite experiencing significant pockets of destabilization afterward, the impulse has not returned.
This case underscores that healing from deeply ingrained behaviors is neither linear nor simple. While the eating disorder gradually loosened its hold, it required sustained relational engagement, ongoing somatic processing, and a great deal of energy and commitment. The shifts emerged not through force or quick fixes, but by creating new relational solutions—pathways that could hold the intense charge behind the behavior and offer a way toward resolution, allowing the maladaptive strategy to finally pause.
I want to emphasize that this case is a unique situation and not a recommendation to bypass established eating disorder treatment before engaging in intense work like PSIP. Proper care and specialized support remain essential, and this client’s journey reflects a rare constellation of factors, preparation, and timing.
It’s also important to challenge the common perception that a single psychedelic session can “cure” complex trauma or entrenched patterns overnight. For many, including this client, the process of healing unfolds over months and years, with continued relational support from the therapist and other supportive relationships.
This case has deepened my curiosity about a recurring clinical question: when is it more therapeutic to build new, healthier patterns — strengthening a client’s adaptive capacities — and when is it better to focus on the root, offering a relational solution that potentially loosens maladaptive behaviors? I think of similar situations with clients who struggle to shift their nervous system to a genuine state of regulation, via resourcing. How much time should we spend nudging and building that capacity, versus looking for the underlying relational friction, attachment need, or perceived threat that makes resourcing impossible with/without persistency and nudging? In the messy middle — when both approaches are possible but neither is obvious — how do we choose?
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1 PSIP: Psychedelic Somatic Interactional Psychotherapy
2 Relational Solution: The necessary condition for the nervous system to engage the healing response. When relational, it is often the good object: a mental representation of a reliable, nurturing caregiver internalized during early development, which provides a template for emotional security and healthy relational functioning.
3 SI Container (Selective Inhibition): Inhibiting voluntary secondary management strategies to increase access to our primitive and primal healing response.
4 Primary Consciousness (Robin Carhart-Harris): A fundamental, immediate mode of awareness involving raw sensory and emotional experiences, without reflective thought or conceptual processing.
