Melanie Phelps, a counselling psychologist and associate fellow of the BPS, shares with us some insights into the Therapy practices for Eating Disorders. Taken from her own experience in practice.
An Eating Disorder can be defined as a mental health problem masquerading as a food and / or dietary problem. Instead of pleasurable or neutral thoughts and feelings around food, meals and eating, the person with an Eating Disorder suffers negative emotions (such as guilt, shame, fear, anger, frustration, stress and worry) around food, mealtimes, body size, image, shape and their weight. Mealtimes become the enemy and food dominates their life.
Eating disorders (ED’s) are most common in the 12-30 female age group, although they can of course affect those of any gender or age. Around 2% of the working population are affected (according to B-eat the ED charity) and particularly those in what we might term high risk industries: fashion, catering, arts, sports and the caring professions.
For those with ED’s, any pleasant or neutral feeling about food are replaced with feelings of shame, fear, guilt, anger, frustration, stress and worry. They can appear moody, over-sensitive, secretive, impulsive or over-controlled and are likely to be people pleasers, procrastinators and perfectionists with low esteem and low assertion. This means they often struggle in their relationships with others (including therapists!) and can be socially isolated. The cousins of eating disorders are Addictions, OCD, Anxiety, Depression and Borderline Personality Disorder, and co-morbidity is common.
So, what makes counselling for Eating Disorders different to counselling for anything else? Eating Disorders therapists tend to use an integrated approach which incorporates different counselling and psychotherapeutic models including CBT and coaching.
It’s helpful to alternate between coaching and counselling or psychotherapeutic interventions (a flip- flop approach) as the psychotherapy can become intense and evoke more of the feelings which trigger ED behaviours. The coaching is important for the effective practical day to day management of the ED and can help the client start to feel as if they are regaining control. It also functions to shift the responsibility of “getting better” back to the client.
Coaching approaches include commitment to regular attendance. Eating Disorder clients are very emotional decision makers. Therefore, it helps to pre-empt their feelings about attending. Namely, they may or may not feel like attending but they still need to commit to regular attendance. They also need to commit to being weighed. Although contentious, this forms part of the therapy as it enables the emotions around the number on a scale to be addressed in the therapy room as well as being some measure of body mass index and therefore, safety. It also aims to take the (often) obsessive need to weigh out of the client’s everyday life and into the therapy.
Weighing behaviour is a part of the ED which is perpetuating the problem, rather than part of the clients “normal” everyday home life. The client is also asked to commit to breakfast, lunch and dinner (3 square meals a day). Portion size can be negotiated (and reviewed regularly) and “meals” can be snacks or nourishing drinks, but regular eating of regular food forms part of the rehabilitation for those with eating disorders. Alongside this there is usually a commitment to undertake a food and mood diary to include thoughts, feelings and behaviours before, during and after eating (including levels of hunger as those with ED usually bypass and over-ride their hunger and satisfaction mechanisms and need help to reassess their natural appetite triggers). The food /mood diary is valuable information and can form a significant part of the in-session discussions.
Another coaching style intervention is the use of Psycho-education or appropriate information sharing. This element could include information about the approach, what “weight” is (ie. not all “fat” and more than just a magic number to be attained), how metabolism works and how restrictive, purging and overeating behaviours can affect the metabolism to the extent that it may not fully recover. Information about exercise and nutrition can be included, and forms of exercise are negotiated. Some clients exercise to burn calories, or punish themselves and others don’t exercise and beat themselves up about not doing so. The aim is to reframe exercise as a way of relieving stress or relaxing, as a form of self-care and keeping healthy.
Skills training can often be discussed and incorporated into sessions. Communication skills such as assertion, decision making, regulating emotions, appetite training, relaxation & meditation skills training, and relapse prevention would all come under this heading.
It is important to realise that there is no one cause of eating disorders and no one cure. With each client, we look at how they have got to where they are at. This could take the form of a discussion, a more formal formulation or a spider diagram. There is space to process feelings, life events, and traumas, and we often use “empty chair” or the ED letters technique (such as writing a goodbye letter to the ED, and future oriented letters where the client imagines they are writing back from a time in the future where the ED has got worse or better, including how they are feeling and what life might be like). These can provide rich material for in-session work.
Other techniques include challenging unhelpful thoughts & beliefs (such as: “I am too fat, I have failed, I deserve to be punished, if I eat an extra rice cracker I will gain a kilo…”) and working on some more helpful self-statements and affirmations instead (such as: “I am working towards recovery and taking back control, I deserve to look after myself, it feels as if I am fatter after eating the extra rice cracker but feelings are not facts, I am working on this ED thing… I am a woman /man on a plan!”).
Sometimes it can be helpful to draw out a self Esteem circle (pie-chart) for clients who place huge emphasis on their looks and body image for their esteem and add in extra slices (options) for attaining self -esteem in other ways (such as volunteering, meaningful work or activities such as learning something new, building relationships, giving something back, working on chosen projects, doing something creative and so on).
It is also necessary to work with co-morbidity as the ED is tangled up with depression, anxiety, OCD and /or other addictions which means it can be a long haul. As with other addictions, relapse is always an area which should be addressed, normalised and explored as and when it happens. It is important to reframe relapses as valuable learning events. Weekly then fortnightly sessions can be gradually weaned off and often a monthly ongoing supportive session is recommended for a few months, with the caveat that the door is always open and sessions can be moved forward if necessary or pushed back.
Collaborating with the client about their choices and control over the spacing of their sessions enables their continued engagement.
Eating disorders can be unpacked and explored; behaviours, thoughts feelings and beliefs around food can be challenged and within a mutually trusting and consistent collaborative alliance people start to turn the corner and recognise that their ED doesn’t have to define or control them any longer. Here are some links to organisations who offer further information, training and all important support for carers of those with ED’s, who often benefit from their own sessions too. There is also a simple 5 question simple screening questionnaire for ED’s.
Eating Disorders Association (www.b-eat.co.uk)
National Centre for Eating Disorders (www.eatingdisorders.org)
Over eaters anonymous (www.oa.org)
SCOFF questionnaire: a quick screening for ED’s:
1. Do you ever make yourself Sick because you feel uncomfortably full?
2. Do you worry you have lost Control over how much you eat?
3. Have you recently lost more than One stone over a 3m period?
4. Do you believe yourself to be Fat when others say you are too thin?
5. Would you say that Food dominates your life?
Melanie Phelps is a counselling psychologist, associate fellow of the BPS and practitioner for the National Centre for Eating Disorders, clinical supervisor, tutor / lecturer / conference speaker and has held a sessional role as the Eating Disorders specialist at Surrey University.
She has appeared on radio and Sky TV in programmes about Eating Disorders. She runs a private practice on the Surrey Hants and Berks borders and also undertakes psychological assessments for legal cases.
For more information on Melanie's work or to get in touch, email here