Trauma-informed care in Australian inpatient eating disorder guidelines: a systematic review and thematic analysis

Abstract Background There are high rates of trauma among those with eating disorders, which affects both eating disorder severity and treatment outcomes. Inpatient treatment also has the potential to be a source of initial trauma (treatment-related trauma) or to re-traumatise patients with a history of trauma, with greater risk of traumatisation or re-traumatisation when treatment is coercive or restrictive. Trauma-informed care has been prioritised within Australian mental health policy over the last decade. However, its incorporation into inpatient eating disorder treatment guidelines has not been systematically examined. Methods A systematic review of Australian adult inpatient eating disorder guidelines was conducted, which involved searches of published guidelines in PubMed, PsycINFO and Embase as well as grey literature searches and direct contact with state and local health services. Eligible guidelines were analysed using qualitative thematic analysis, and the themes were informed by established trauma-informed care principles. Both deductive and inductive coding approaches were used. Results Twenty-four guidelines met inclusion criteria and were included in the analysis. While a minority of guidelines explicitly referenced trauma-informed care or acknowledged high rates of trauma among eating disorder populations, most of them did not operationalise how trauma histories should inform treatment planning. Trauma-informed care was commonly conceptualised as a style of delivering restrictive interventions more sensitively, rather than as a framework for minimising or critically examining coercive practices. Initial thematic analysis used predetermined trauma-informed care principles of safety, trustworthiness, choice, collaboration and empowerment. Additional themes of recognising trauma and trauma-informed care; respect for inclusion and diversity; and balancing coercive care with trauma-informed care emerged during analysis. Conclusion Australian inpatient eating disorder guidelines demonstrate limited and inconsistent integration of trauma-informed care principles. Without clearer guidance on proportionality, including patient perspectives, trauma-informed care risks remaining primarily a style of delivering coercive interventions, rather than a framework that shapes clinical decision-making in inpatient settings.