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2. INDIVIDUAL THERAPEUTIC SERVICES
Eating Disorders Queensland (EDQ) provides quality therapeutic services to individuals through several different funding streams – Queensland Health funded services, Medicare counselling services and NDIS funded packages.
Therapy is available to individuals across Queensland aged 16 years and over and can be provided either face-to-face or via telehealth. Clients do not require a medical diagnosis of an eating disorder to access the services at EDQ. Therapeutic support allows people to explore their underlying issues with skilled practitioners in a safe, therapeutic and confidential environment.
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9. Safety is always a priority: the therapeutic relationship.
Workers must consistently facilitate a safe therapeutic environment. Given that many clients who have experienced an eating disorder have a history of childhood trauma, safety is of paramount importance. One of the most effective ways of establishing safety in the sessions is through developing a strong therapeutic alliance. There should be clear communication and transparency in the therapeutic relationship where the counsellor is authentic, empathic, compassionate, flexible and kind. This is one way that we ensure that we can facilitate safe exploration for the client.
In Judith Herman’s stages of recovery, the first stage is safety, especially the relational safety found in the therapeutic relationship.
The first task of recovery is to establish the survivor’s safety. This task takes precedence over all others, for no other therapeutic work can possibly succeed if safety has not been adequately secured. No other therapeutic work should even be attempted until a reasonable degree of safety has been achieved . 16
10. Safety is always a priority: risk assessment and safety planning.
A key part of ensuring safety for the client is to undertake thorough risk assessment and safety planning with the client. This is an ongoing process that continues for the duration of the therapy in recognition that the level of risk may change throughout the course of therapy 17 . It is also important to ensure that confidentiality issues and issues of consent are covered in the initial session, and throughout therapy as needed.
11. Safety is always a priority: physical health implications.
Eating disorders have serious physical health implications, so it is essential that all clients have an open and active relationship with their general practitioner (GP) 18 . Therapists are not medically trained and do not have the authority to monitor physical symptoms. Workers should refer to the client’s GP if they have concerns about the physical health of a client. This should only be undertaken in consultation with the client, unless there are mitigating factors that may reduce the safety of the client. in the initial session, and throughout therapy as needed.
12. The lived experience of the client is always valued.
This is a core principle of feminist practice – that the therapeutic relationship is based on the notion that the client is the expert over their lives regardless of their experiences and backgrounds 19 .
Sessions should be tailored to fit with the knowledge and experience of the client. This means that a flexible approach is essential. If the worker approaches each session in a directive way that does not allow client agency and empowerment, the session will most likely meet the needs of the worker, but not the client.
This is a crucial issue given that over 75% of people who identify as having an eating disorder do not seek help 20 . It appears there are many reasons for this including the shame and stigma that come from having an eating disorder 21 . By valuing and affirming the client’s lived experience we can encourage and support them towards recovery.
We value the lived experiences of those who have had eating disorders by incorporating these diverse voices in all levels of the organisation.
13. Therapy is person centred and client led.
Person centred approaches put the needs of the person at the core of all decision making about treatment and support. 22
One of the core practice principles of working with people with eating disorders is to ensure that the services provided are person and family centred 23 . Individual treatment plans are developed within a person-centred, family and culturally sensitive and recovery-oriented framework 24 .
We need to see the whole person and work with the entirety of the client, not just their eating disorder. We believe that eating disorders are the solution to a greater problem in the client’s life, so we need to actively work to know the client as a person and to understand the life experiences that have brought them to this point.
We meet clients where they are now, at this point in their lives. We build on their protective factors and strengths and work towards building a healthy sense of self. It is always the client who sets the direction and the goals for the sessions in a respectful collaboration with the practitioner.
A diagnosis should not be required for access to services. This is in line with the national standards developed by the NEDC 2012 to remove ‘diagnostic criteria as a point of access to services.’ 25
14. Therapy is trauma informed.
A trauma informed approach to work with clients with eating disorders recognises that experiences of trauma, especially in childhood, may underlie an eating disorder. Trauma in childhood may involve a range of experiences including abuse and neglect, traumatic and insecure attachment to primary care givers, serious illness or death of family members, motor vehicle accidents, peer bullying and abuse, invasive medical procedures and many other events 26 .
All workers in this sector should be informed about the nature of trauma and its responses and organisations should adhere to trauma informed practice guidelines.
The Blue Knot Foundation has developed Practice Guidelines for Clinical Treatment of Complex Trauma 27 . These internationally recognised guidelines provide extensive information and resources for workers in this and related fields.
15. Therapy is trauma informed: Explore the role the eating disorder plays in the client’s life.
We know that eating disorders serve a purpose for the client and it may help the recovery process for the client to be clear about why their eating disorder developed. For many clients this will relate to experiences of trauma in their childhood and the eating behaviour will have provided a coping strategy to help them deal with a greater trauma they were experiencing.
We all hope to develop healthy coping skills to assist us to cope with difficulties in life, but children have very few options for this if they are not guided by an emotionally attuned caregiver. Children will do whatever is required to survive and adapt. The benefits of working from a trauma informed approach has a strong evidence base in the research 28 .
16. Therapy is trauma informed: Externalise the eating disorder part.
At times it can appear that there are ‘two selves’ and a split exists between the self and the eating issue. This is often experienced as a ‘battle’ - a critical, illogical and irrational entity that battled against and controlled their rational, true self 29 .
Related to a trauma informed approach, clients with eating disorders often find it helpful to externalise the ‘eating disorder part’ of them. Clients learn from the ‘eating disorder self’ and this helps to develop and strengthen the ‘healthy self’ so that this part might contribute more to the recovery journey.
The use of externalising questions comes from narrative therapy 30 and is also informed by parts work which is a well-established strategy for working with trauma survivors and others who have mental health concerns. This work relates to inner child work 31 ,
Internal Family Systems Therapy 32 , Schema Therapy 33 and models of Structural Dissociation 34 . It can be helpful to differentiate between the different parts of us and to see and understand our inner critic and our inner nurturer.
This can be very useful way of working as we ensure that we’re working with the eating disorder part rather than demonising this part of the client. Some therapists use a process of dialoguing to achieve this 35 .
17. Therapy is recovery oriented.
Recovery from an eating disorder is possible and should be the goal of all service provision 36 . A recovery approach is aimed at restoring the human rights and full community inclusion of people with mental health issues 37 . Recovery-oriented approaches are typically seen as an alternative to the medical model approach which is frequently considered pathologising and deficit based 38 . It is crucial that the client determines what recovery looks like for them.
Central to all recovery paradigms are hope, selfdetermination, self-management, empowerment and advocacy. Also key is a person’s right to full inclusion and to a meaningful life of their own choosing, free of stigma and discrimination. 39
There are many definitions of the components of recovery from an eating disorder 40 . Bjork and Ahlstrom 41 suggest there are five important factors:
• having self-acceptance • accepting one’s body • having a relaxed attitude to food • having a functioning social life • being in contact with and having courage to express emotions.
Costin & Grabb 42 outline 10 phases of recovery from an eating disorder that incorporate the stages of change outlined in motivational interviewing approaches 43 . This is valuable information for workers in this sector to understand the process of change for clients and how we can assist in facilitating their recovery. Included in this are helpful understandings about the nature of resistance and ambivalence in the change process.
Resistance and ambivalence to change are features of work with clients with eating disorders, especially anorexia nervosa. It is unfortunate that these characteristics have also been interpreted as constituting difficult-to-treat clients 44 . An alternate view is both possible and more therapeutically valuable as we consider the stages of change and the difficulties for many clients in moving from pre-contemplative and contemplative stages of change to achieving sustainable change.
It is critically important to recognise that eating disorders do not develop for no reason and that they serve important adaptive functions, often related to experiences of trauma in a person’s life. This includes the mitigation of profound distress 45 .
18. The process of therapy is valued.
The process of therapeutic work must be valued as much as the outcome. This is a key principle of feminism. The way we go about doing our work is as important, if not more important, than the outcome that is achieved. It is suggested that an outcome achieved through a harmful or disrespectful process, must be questioned.
This is an integrity issue and, in direct practice with clients, it is important that actions are consistent with values. Therefore, all the strategies employed must be consistent with the overall aims and values of the organisation.
19. Explore the use of creative and expressive therapies in sessions.
Expressive and creative therapies provide a very positive contribution to the strategies available to therapists for work with clients with eating disorders. For people who develop eating disorders, the ability to access and put feelings into words is blunted and poorly developed 46 .
Creative arts therapies, which include art therapy, music therapy, drama therapy and dance / movement therapy, each share an appreciation of the non-verbal aspects of communication and understand the use of imagery,
symbolism, and metaphor as a link to psychological / emotional states. They acknowledge the need to work safely in the presence of a secure therapeutic relationship, guided with interventions that are based on the therapeutic aims of the specific individual as well as the client population 47 .
Many different approaches that can be used to great benefit, but art therapy has a particularly strong history in work with clients with eating disorders. In verbal therapy sessions, clients often experience difficulty in finding the words to express confusion and pain. Art therapy, by contrast, is an effective means for clients to tell their personal story, safely and indirectly 48 .
20. Power and control are central issues for anyone experiencing an eating disorder and must be addressed in therapy.
One of the features of the therapeutic relationship in this form of therapy is that the power imbalances are broken down by having a non-clinical approach. We meet the client as another human being rather than as an eating disorder. Feminist approaches to therapy are collaborations, partnerships between the client and the therapist, rather than relationships based just on client need and therapist expertise.
21. It is the worker’s responsibility to ensure appropriate boundaries are in place in all client work.
Ensuring appropriate boundaries in the therapeutic relationship is the responsibility of the worker. All workers in this sector should hold professional qualifications and be registered with their professional association. Workers should adhere to the boundaries prescribed by their profession and their codes of ethical practice 49 .
This also highlights the importance of workers engaging in regular professional clinical supervision with an external professional who is experienced in eating disorders work 50 . Each organisation has a responsibility to provide workers with high levels of supervision and support in recognition of the complexity of this work.
22. Language is important.
Pathologising language is inherent in the medical model’s approach to eating disorders. The impact of this on clients can be significant. From a feminist perspective eating disorders are not seen as ‘disorders’ but rather as ‘issues’ that result from meanings made of experiences, many of which are the product of our social system.
We are always attempting to challenge the shame and stigma attached to eating disorders, so we must use language that is accessible to clients and that encourages a more compassionate perspective. At times it is important to adapt our language to the client’s preference, but if the client is using disrespectful and negative language to describe themselves and their eating disorder, it is important to discuss this and provide a safe challenge to their use of language.
23. Fast-track services for early onset intervention.
Ensuring early onset for intervention, especially with young people, indicates a shorter duration for all eating disorders 51 . With early detection and intervention prospects of recovery from eating disorders are high 52 . This requires services to fast-track young people who are at the early stages of their eating disorder.
This is the case for a range of mental health issues where it is clear that if treatment commences at the earliest possible time, interventions are more effective and recovery time is shorter 53 .
24. Psychoeducation is a valuable addition to therapeutic interventions.
Clients need to have an accurate understanding of the nature of eating disorders and the underlying causes that may be relevant to them. This may mean providing information to clients in sessions and / or encouraging them to access a range of psychoeducational groups that provide information about eating disorders and recovery.
25. Appropriate use of self-disclosure is a useful strategy when it is purposeful.
Self-disclosure from workers can be a useful strategy in counselling if the worker is clear about the purpose and intention of their sharing. Self-disclosure reduces the inherent power imbalances between counsellor and client and normalises many of the client’s experiences in a safe relational way.
26. Advocate for multidisciplinary treatment.
The value of a multidisciplinary treatment team is clear 54 . Ideally the client will have a range of supports accessible to them including medical, nutritional, exercise physiology, and counselling. At a minimum, clients who are seeking counselling for their eating disorder should always have a general practitioner overseeing and actively monitoring their physical health condition. As workers, we must ensure we have consent from our clients before engaging with the treatment team.
27. Plan for transitions.
The average time for people to recover from their eating disorder once they have sought professional help is between one and six years 55 . Most therapists are unable to provide an unlimited number of appointments for clients, especially if the client requires low- or no-cost sessions. It is therefore important to be transparent about the time limited nature of these sessions and to explore options for future support if needed.
If the organisation can offer a range of services, the client may move between these different programs to continue their recovery. Clients should be made aware of the range of services and programs available to them. This is an important aspect of the transition for clients as organisations ensure that programs are provided to suit the client’s recovery journey and stage of change.
28. Acknowledge weight stigma and societal impacts to eating disorders.
A key part of a bio-psycho-social approach to eating disorders is to acknowledge the impacts that our social system has on our clients’ eating disorder. How the clients’ experiences sit within a broader picture of society is a useful addition to the therapeutic process.
In particular, the negative impacts of weight stigma / fat phobia on both physical and mental health have been well documented 56 . Experiences of weight stigma have very strong correlations to restriction, purging, and binge eating 57 . There is also evidence that disordered eating behaviours including severe dietary restriction are often misdiagnosed, unrecognised, or otherwise overlooked when the client has a higher body weight 58 .
