Eating disorders: missing the wood for the trees.
During my training, one of my placements was in the sixth form of a local high school. When I met with the deputy head, who led the pastoral team at the school, to discuss the arrangements and likely topics of discussion with her students, she said: “you’ll be seeing a fair amount of eating disorder stuff in your work here”. She wasn’t wrong.
At one point, clients talking about eating disorders made up over 80% of my placement practice and so much of my emotional energy. Their experiences; their stories; their feelings; their openness had a huge impact on me and helped influence my decision to try to further build my knowledge and expertise in eating disorder work once in private practice, especially for those aged 11-25.
This year - the final year of my masters studies - I am focusing my dissertation on the experience of clients who have recovered, or are in recovery, from an eating disorder to try to understand what were the key things about therapy they had that helped them. As well as hoping to publish my findings, I want my research to help me continue to improve my understanding and my practice to help more and more clients.
I am fascinated by this work and the clients I have the privilege of working alongside.
The placement built on my experience of three people - three friends - I knew who had an eating disorder(s) and seeing how they talked about it and how they experienced it and at times it took over them. My private practice work since qualifying has only deepened my passion for this field. Alongside the wide variety of clients and client work I do, eating disorder work makes up a significant chunk of my practice. Although, as with all clients, everyone’s experience is unique, I see two huge trends with clients who talk with me about their eating disorder(s).
Firstly, the right help is very rarely available to them. The NHS help is either at the very end of a very long waiting list - a list, incidentally, that disappears completely if the clients falls in the latter stages of CAMHS and misses out on that service and isn’t in the right queue for adult services. Or, when the NHS help is given it is too short-lived and too focused on weight (being under-weight appearing to be the single most important measure - not just to receiving treatment but in determining the point of discharge from the service). Of course, medically-vulnerable or medically-unsafe weight levels require specialist input - but I hear time and time again from clients that they are refused treatment on the NHS because they don’t hit an “unsafe” or “under” weight level - and their treatment is stopped the minute their reach what their clinicians consider to be a safe weight even though they are desperate for the support to continue. They require help and can’t get it because of a number not because of their need.
This whole area is of course hugely complex. Client’s own emotional position means they are not always ready to receive the help when it is available - but that argues for more time and support, not less. The services themselves are, like all NHS services, massively overwhelmed and under-resourced, forcing those involved to make crude decisions about need and risk. Saving lives with the limited resources available takes priority over offering the right support to everyone based on their need. This is understandable in the circumstances but simply highlights the appalling position the United Kingdom is in. It is a national disgrace that in the sixth richest country in the world, people with eating disorders are being denied treatment - critical treatment that could help them recover and live a full and happy life - because of money.
The second big trend that I see is that eating disorders, in my experience, are too often treated as the problem and not a symptom of a problem. Here again, I say that every client is unique and their experiences and situation are individual to them, but my experience to date shows me that treatments and services focus on the eating disorder behaviours rather than the root cause; the underlining trauma; the mental health condition(s) and context which has led the client to lean on their eating disorder(s) as a coping mechanism(s).
To do the work to get under the skin of what is really going on and why clients are in the place they are, takes time and a patient and measured approach. This luxury of time is not available to many on the NHS. The time it takes to help someone explore the underlining stuff that is going on, whether that be anxiety, childhood trauma or any other experiences that have left an emotional mark, is rarely quick and easy but pain-staking and full of ups and downs. It takes time. It needs to give clients the space to go at their own pace. It needs to put them - not targets and limits of six, ten or twelve sessions - first.
The oft-quoted evil or social media and societal pressures on body image and body-shaming take up so much of the public debate around eating disorders and yet, in my experience of client work, they form a smaller part of the overall story than the impact of lived experiences that are difficult to cope with. It is from these difficult feelings that eating disorders can often grow and thrive. These can be - and at times are - body-image related, but can also be other things.
I see clients every week who tell me how their NHS or employer-funded therapy (usually CBT) was too short-lived and too focused on behaviours (including in relation to eating disorders) and not enough on the deeper feelings and experiences which have led them to behave in upsetting or harmful ways. They will often say to me, I know what I am doing isn’t helping me in the long run but I don’t know why I do it or how to stop. I want to understand it. I want to get to bottom of it.
Therefore, asking them to attend an eating disorder clinic and immediately and regularly weigh them isn’t going to cut it, neither is saying you will be sorted with a meal plan and six sessions of CBT. I caricature the position to make a point - but not by much.
As I’ve written before - and make no apology for repeating again here - working with eating disorder clients for me is about helping them to explore (if they want to and I find that most of my clients do) how and why they got here - not what’s wrong with them, but what happened to them. I hear over and over again that when my clients had the chance to get help or get considered for help (on the waiting list for assessment to see if they get on the 12 months + waiting list for treatment) they were always asked about the numbers on the scales and the behaviours more than the feelings which led to the eating disorder.
By following this approach, we are not seeing the wood for the trees. We are not helping enough. We are letting too many people down.
We need to work with the full story of a client’s life; we need to truly see them, hear them and work with them. Not focus on the eating disorder but on the client themselves. We can start with the language. They are not anorexic or bulimic, for example. They are people with a condition. A condition they can recover from. A condition that is a temporary response to something else. They are not defined by it. They are not it. They are so much more than it.
We can see that, if we look hard enough and take the time.