9 learnings from working inside an NHS adult eating disorder service
I write and podcast about the psychology of eating disorders. I have personally recovered from bulimia and have worked as a therapist for 20 years. I hope to inspire, educate and improve understanding about eating disorders through my writing and audio. Names used are fictional and stories shared are a combined insight of many client experiences. I believe that full recovery is possible for everyone.
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I worked as a therapist in an NHS adult eating disorder service on and off between house moves, babies and life between 2004 and 2023.
Working in the NHS had never been my strategic career plan.
At 23 years old, I knew that I wanted to work in eating disorders, but the chaos of my early twenties meant that I was running on ideas and dreams, rather than having any concrete plan.
Initially, my decision to train as a therapist came from my own wounded healer abandonment issues and wanting to save others.
This wounded place was a helpful starting point and initiation for change. It gave me purpose and hope as I floundered in the choppy waters of life, but feeling reassured by the distant lighthouse shining its beacon out to sea.
I began my therapist training aged 25, with vigorous youthful enthusiasm and joy.
4 years later and working in Student Support at my local university, I fell upon a job advert for an eating disorder therapist.
It was a new service coming to my city and embedded deeply in a psychological approach to treatment.
I decided to apply, even though officially, I was an unsuitable candidate for the role.
Ideally, they wanted a clinical psychologist or someone with NHS training qualifications.
I had my personal experience. I had volunteered on eating disorder helplines.
I had written letters (it was the year 2000!) to people struggling with eating disorders, whilst volunteering for BEAT on their self-help network.
I was by then, a qualified counsellor.
I had heaps of determination and passion for the field. But I wasn’t a psychologist by training.
Miraculously, I was offered the job and the incredible mentors who interviewed me back in 2004, continue to be in my life today.
And it opened me up to a whole wealth of experience and learning for the next 19 years.
Here are 9 things I learned: -
1. High quality psychological support is everything
We were a very small team back in the early days. One clinical psychologist, one psychiatrist and 2 therapists.
The emphasis was on high quality psychological intervention and support.
Our resources were limited but considered and intentional.
People were referred to us and received a detailed and comprehensive assessment.
Assessments were motivational, warm and deeply thorough.
Cases were discussed as a team and clients received personal therapy letters following their initial contact.
I learned the power of thorough assessment and truly making clients feel seen.
Much care and attention were considered for each person’s journey.
Sadly, we were very under-resourced so only a small number of very worthy people made it through the door.
Many equally worthy people were turned away.
It was frustrating to serve only a tiny segment of the county need. But we were deeply invested in the clients that we worked with.
2. The pros and cons of inpatient treatment
In most eating disorder services, inpatient treatment is the last resort.
When other less intensive treatments have not been adequate.
Ideally, someone should be assessed early-on in their eating disorder journey and then offered therapy, dietetic support and risk management as an outpatient.
This enables someone to continue with life purpose, structure and relationships.
To stay in touch with friends and the fabric of day-to-day life that brings belonging and meaning.
But sometimes an inpatient stay is the only viable outcome for a client.
Many people reach this stage due to late diagnosis and misunderstandings about eating disorders.
When someone is too unwell physically and entrenched in the coping of the eating disorder, they need the intensity and help that only inpatient can offer.
The inpatient stay offers 24-hour monitoring and rigorous support around eating and routines. Patients receive therapy, dietetic support and occupational health intervention. This can be transformative and life-changing, as skills are relearned.
The downsides of inpatient are also worth noting. The removal of people from the ‘normality’ of day-to-day life can result in them becoming institutionalised and the ed identity becoming entrenched.
Anyone who has experienced a lack of emotional or physical care in early life, will find the inpatient ward offering cosy, wrapped-up-in-cotton-wool type bliss as responsibilities are removed and you are taken care of.
Not to say that an inpatient stay is blissful by any means. It is hugely challenging on many levels.
Patients can feel simultaneously drawn to the care whilst also feeing over controlled and smothered.
People also learn unhelpful habits within a hospital setting which they may never have explored before. For example: seeing fellow patients pacing for hours on end can encourage development of these behaviours.
3. Deaths will happen
When I worked in the Service, we did experience patient deaths from anorexia.
Thankfully, this is still a rare occurrence.
It is a sad and inevitable part of the eating disorder service journey, when working with people who are sometimes exceedingly unwell and chronically underweight.
Most commonly, deaths from anorexia (from my experience in our Service) were due to secondary physical illnesses people encountered. It would be very unusual for someone to die on an eating disorder specialist ward.
When so severely unwell, the body has no immunity and limited defence to fight illness.
There is much blame and misunderstanding about treating eating disorders.
Yes, professionals can do better and should be informed and proactive in their care.
Yes, we should be better resourced with people getting the help that they need early on.
When things go wrong, the blame and fall out can be huge on individual professionals, when really this is a broader reflection of a failing system.
This creates a lot of fear and health professionals are reluctant to work in eating disorders due to this.
4. The power of a group therapy.
I ran bulimia and binge eating groups for a few years in the Service.
Pre-Covid, this was face-to-face support. The pandemic brought a move to online working and Zoom, which was a blessing and bonus for group engagement.
‘Did not attend’ numbers fell dramatically with people trapped within their houses in lockdown and group attendance was sky high.
People would join groups with much apprehension and trepidation.
This is an understandable fear, as there is much shame around eating disorders.
People particularly feel embarrassed to talk about their binge eating and purging with others.
But the groups were potent and powerful for shame reduction and facilitating connection.
As the weeks of the group progressed, members would slowly bond and individuals would be incredibly supportive of one another.
They would often continue to meet once the group ended.
When you have struggled in shame and loneliness, these connections are invaluable.
5. Too much admin
There was far too much administration when working in the NHS.
Every little thing needed to be documented, and I understand the importance of this.
But it was a lot.
We typed our client therapy letters. They were valuable but several pages long. These were psychological letters that required thought and care.
At one point, we had enough admin team support to dictate our letters – something that I developed skills at, after initial resistance.
I do not miss the admin.
6. The dynamics that play out in teams
Eating disorders often come with perfectionism and over-control.
Interestingly, this also played out in our team dynamics.
I recognise that we were all individuals susceptible to this interplay.
Several of us had been on our own journeys with food.
Personally, as a younger less confident version of myself, this team dynamic felt comfortable and familiar to me. I was receptive and familiar with set ways of doing things.
Thankfully, this changed as I grew personally in life and work confidence. And I took more responsibility for sharing my viewpoint and staying grounded in my counselling therapy background.
7. The value of supportive colleagues
I really appreciate the care and attention that was taken when recruiting people to our Team.
We were psychologically invested in ourselves and each other. We were. in the most part, self-aware.
This allowed a safe environment of deep sharing and connection between team members, not only to get support in sharing client cases but in holding one another through all kinds of life events.
I remain in touch with members of my Team to this day and am hugely grateful for these relationships.
8. Motivational approaches
Clients with eating disorders are deeply ambivalent about change, as an eating disorder is a coping strategy, consciously or unconsciously.
As a therapist, this can feel frustrating at times, as the person in front of you has understandable ambivalence about engaging in therapy and making changes.
Working motivationally is key to supporting and empowering clients.
As a therapist, it’s vital to not getting drawn into pushing or persuading or rescuing but encouraging the client to find their own voice.
This is particularly relevant in adult eating disorder services. In child and adolescent services, a more directive approach is often needed.
9. Times are changing
The eating disorder service has grown exponentially in size since those early days.
This has been a positive shift and an injection of much needed funding to services.
They now offer FREED – (early intervention support).
Outpatient services have also expanded beyond the psychological and can support clients with eating, often to avoid a hospital stay.
Back in the day, support was black and white with either intensive inpatient or weekly psychology with not much in-between. Many people do need more intermediary support.
The growth has meant a dilution of the psychology and a greater focus on risk management.
This has been impactful for clients but also staff members who are carrying a great deal of load with less outlet and support for them.
Risk management is essential to keep clients safe and to monitor their health variables.
But an over focus on this can reinforce the ed identity with emphasis on the physical, food and weight, rather than treating the core pain.
As a therapist, I do firmly believe that eating disorders are not really about food, but about feelings. Psychology is a vital part of the process.
Do you relate?
Have you had experience of treatment within an NHS eating disorder service?
Have there been particularly positive or negative experiences you have had?
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