Experience tells me that, if I open this article with the words ‘eating disorder’, a substantial proportion of those reading will simply skip to the next page, perhaps looking for something that sounds more relevant to them or their practice. However, hopefully I will have caught your attention before that happens. I believe that this is an important topic; it is an issue with which many counsellors are working, whether or not they intend to, and irrespective of the fact that clients with a diagnosed eating disorder are generally meant to be referred to specialist services.1
The term ‘eating disorder’ is an umbrella title, used to indicate any of a number of complex mental health issues.1 Most notably, these are anorexia nervosa, bulimia nervosa and binge eating disorder, along with ‘otherwise specified feeding and eating disorder’ (which may also be termed ‘eating disorder not otherwise specified’). Sub-clinical types of related difficulties are typically referred to as ‘disordered eating’.
To those of you who are new to this topic, I believe the minutiae of the diagnostic labels are not relevant to understanding the overall conversation here. So, simply put, eating disorders are those conditions in which food, weight, body shape or size becomes a way of coping with distress. Eating disorders are illnesses of both mind and body, and this is perhaps why they are acknowledged as having the highest mortality rate of any mental health illness.2
A recent update to the relevant National Institute for Health and Care Excellence (NICE) guidelines1 states that those affected by eating disorders should have equal access to treatment, with trained and skilled workers, at the earliest opportunity. However, despite this – and perhaps due to huge increases in the diagnosis of eating disorders3 – specialist services often have long waiting times4 or strict referral criteria.5 This can result in individuals being referred to less suitable services, such as IAPT, or having to access therapy privately. Since research suggests that 6.4 per cent of the population display signs of an eating disorder6 (this works out at over four million people in the UK), we can only assume that this issue is going to continue.
If you have yourself received an ‘inappropriate’ referral of a client with an eating disorder, you will have perhaps experienced some of the reasoning behind why this could be a problem. Counsellors often tell me that they have no training in this area, while clients report an assumption that all counsellors know at least a little. The fact is that the stereotypes surrounding eating disorders run deep in our society and often this is the only ‘knowledge’ that counsellors have to rely on. Therefore, I cannot blame you if you are not aware that 25 per cent of those displaying signs of an eating disorder are men,6 or if you do not understand what re-feeding syndrome7 is, or that the leading cause of death among those with bulimia nervosa is cardiac and respiratory arrest.8
The stereotypes surrounding eating disorders often also lead us to believe that the risk associated with them is death as a result of starvation and emaciation. In reality, people die of eating disorders at any weight, as was tragically highlighted recently when a bright 16 year old died from bulimia nervosa – without prior notice – when her heart simply stopped.9 In 2014, I also lost a friend to anorexia nervosa. She was ‘in recovery’ and at a healthy weight. She died by suicide, another common cause of death among this group. These are just two examples among many. There is no sliding scale of urgency when it comes to eating disorders, because the risk is rarely visible; it far transcends the weight or appearance of the clients.
Current research suggests that only around half of those who develop an eating disorder achieve a full recovery,10 and even then the individual might be left with long-term medical issues, such as osteoporosis11 and gastro-oesophageal reflux disease.12 So, even for those individuals who do survive, and indeed recover, their experience may have a lifelong impact.
Furthermore, the stereotypes around eating disorders paint a particular picture of who develops these conditions and why. While it is true that, in many cases, the onset of an eating disorder happens in adolescence,13 there is also evidence of onset throughout the lifespan, including in later life.14 There is not necessarily a ‘typical’ person presenting with an eating disorder, and this is something certainly reflected in my own practice, where I see a wide demographic of clients each day.
Glossy women’s magazines and general popular media would have us believe that eating disorders are caused by social media and size zero models – that they are perhaps an ‘illness of vanity’. However, the reality is far more complex than this. In fact, I have yet to meet a client who professes either of these factors to be the primary or sole cause of their difficulties. Rather, these influences tend to be more of a maintaining factor, serving to normalise distorted attitudes towards weight, body shape and food. Instead, the aetiology is far more multifaceted, with genetics15,16 and the lived experience both playing interrelated roles. The ‘reasons’ that contribute are as individual and varied as the clients.
Irrespective of the cause, eating disorders ravage people’s lives; physically, psychologically and socially. Clients often describe their disorder as if it were another person – the disorder moves in and takes control. Typically, clients feel powerless and hopeless – feelings often also mirrored in the therapist. They also report feeling misunderstood, so much so that research has identified that the stigma surrounding these disorders can be just as damaging as the illness itself.17
At its core, an eating disorder is simply a coping mechanism, much like drinking too much, or self-injury. A person with anorexia nervosa might be starving themselves in an attempt to starve away their pain, or a person with binge eating disorder might be attempting to fill an emotional void with food. However, beyond the basics of being a coping mechanism, eating disorders can be exceptionally complex, both generally, and within each individual.
Professionals from across the disciplines of genetics, neuroscience, psychiatry and preventative education are all working to better understand, treat and prevent these disorders. They are uncovering interesting findings that might shape the future of care and treatment in this sector. But what about those affected right now? What can we do, right now, when we receive a referral – perhaps in a time-limited setting, and when the client doesn’t meet eating disorder referral pathway criteria?
From all my years of experience in the eating disorder field, I think the essential points have to be that we do not dismiss the person’s struggles, we do not trivialise them, we do not add to the shame they feel, and we do not overlook the level of risk. This is not supposed to sound condescending, and actually I think it is much easier said than done.
We live in a society where poor body image and dieting behaviours are common place. Weight loss is typically something that is complimented and desired, and therapists have been shown to have less empathy for clients with eating disorders.18 Unfortunately, it therefore makes sense that clients often report feeling that their struggles are underestimated.
The very nature of eating disorders means that we all have related biases, and recognising these is an important factor in working with this client group more effectively. We have to take a step back, not only from our own ‘stuff’, but also from the societal norms that risk impacting how we respond to clients with these diagnoses. For example, you may have your own perception of what constitutes ‘healthy eating’, a ‘healthy’ body weight or a ‘healthy’ relationship with food, but how would you make sense of this in relation to your clients, and their experience of eating disorders and eating disorder recovery? Is what you know fact, or is it opinion?
For the above reasons (our biases, and the medical risks), along with the complex nature of eating disorders, I believe it is especially important that counsellors attend CPD or establish a solid foundation of knowledge on the topic. I understand that we cannot be experts in everything our clients bring to therapy, and nor do I think we should be. However, when we work with clients with eating disorders, we are working with life and death scenarios and, accordingly, we must know enough so that we can work safely.
Perhaps you have received a referral of a client who has depression. Upon some initial questioning, it transpires that your client makes themselves vomit when they are feeling negatively towards themselves. Their goals for therapy might be to improve their mood and self-esteem sufficiently, so that they no longer want to use this unhealthy coping mechanism. The client may easily find themselves referred into an IAPT service or to a practice counsellor. The person who placed the referral or conducted the initial assessment may not be fully educated about eating disorders, or the client may not have disclosed the intentional vomiting. Perhaps there is no eating disorder service in your locality, or they were not considered an appropriate eating disorder service referral because they were not displaying ‘severe enough’ symptoms. I have heard about all of these versions of events happening. However, this client is likely to have an eating disorder – they have ‘eating disorder not otherwise specified’, of a purging subtype. People with this condition do die.
It is entirely possible that you can help this client. In fact, perhaps, you already have helped someone with a very similar presentation. However, are you aware of the medical risks associated with self-induced vomiting? Additionally, what do you want or need to do about that? Some readers will come from more medical backgrounds, and may very well be aware of the risks. Other readers are perhaps wondering what this has to do with working as a talking therapist with this client – a completely valid thought! In brief, forced vomiting may have only minor impacts upon the individual’s physical health, such as tooth decay and indigestion. However, in some cases this behaviour could result in more dangerous side effects, such as electrolyte imbalances and even oesophageal ruptures, both of which are potentially life threatening. As a talking therapist, this knowledge might seem irrelevant to our role – after all, knowing the risks associated with any given behaviour does not necessarily give us power to do anything about it. We are not medical professionals in the traditional sense. However, you may very well be the only person with any awareness of the potential risk facing this hypothetical client.
Many counsellors would consider it ethical to breach confidentiality if the client was actively suicidal. There is no similar pre-set response available to those working with eating disorders in non-eating disorder specialist services. There is no clear line in the sand that indicates a need to encourage or take action to safeguard a client. However, as we have already outlined, the risk of death from an eating disorder is statistically higher than the risk of suicide among those with depression.
When the above is acknowledged, I believe there is a clear need for counsellors to have at least some basic education in this field – education that might allow you to establish where you stand ethically with regard to working with clients with eating disorders, supporting them to access additional medical care, and also potentially breaching confidentiality to save someone’s life.
I am not suggesting that we become so paranoid about medical risk that we become frightened to work with this client group, or that we lose the therapeutic process to medical management. Rather, I am suggesting that we are better equipped to respond to such clients in the safest way possible, with the knowledge available to us and the skills that we have. I have seen talking therapy make a massive difference in the lives of this client group.
Personally, I consider that holding awareness of someone being at high risk, and choosing not to take any action is negligent. I therefore contract with clients with eating disorders to seek medical monitoring. I state clearly that I am not a medical professional, I bring to the client’s attention the inherent risks of their behaviour, and I express my genuine concern for their physical safety. Perhaps this is a little outside of the typical therapeutic norm, but it has become my way of attempting to ensure that I am working as safely as possible.
Similarly, I feel a duty – knowing that counsellors often frequently are not educated in the risks of eating disorders, and how to handle them – to take action by bringing this topic to the awareness of as many practitioners as possible. I can only hope that, upon reading this, at least some will take notice, and take action. Perhaps, by doing so, you will save someone’s life.
Kel O’Neill is a registered MBACP (Accred) counsellor and supervisor with a specialist interest in eating disorders. She combines her professional practice with teaching and writing, and is currently researching therapists’ responses to working with clients with eating disorders. You can follow Kel’s award-nominated blog at: www.mentalhealthbites.com
Counselling for depression: efficient, effective and evidence based
Open article: Rinda Haake reports on the use of counselling for depression in the NHS. Healthcare Counselling and Psychotherapy Journal, October 2017
Dynamic interpersonal therapy: working with perceptions of the self and other
Free article: Deborah Abrahams outlines the contribution of short-term psychodynamic work to IAPT services. Healthcare Counselling and Psychotherapy Journal, July 2017
Couple therapy: the IAPT service for couples working with relational factors in a diagnosis of depression
Free article: Kate Thompson explores the lack of couple therapy on offer within IAPT and argues its expansion. Healthcare Counselling and Psychotherapy Journal, April 2017
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