For counsellors

This was how I felt when first working with a person with an eating disorder.

Time is of essence when working with anorexia or bulimia, as the space is needed, for the client to explore how their eating disorder has developed. There is no secret tool to working with an eating disorder.

Eating Disorders—Such as Anorexia Nervosa, Bulimia Nervosa and over-eating—have many causes, including stress, painful issues and body image. An eating disorder is a serious emotional and physical problem.

While the eating disorder may begin by concentrating on food and weight, they are usually about much more than food.

A person often uses food and the control of food to make up for the feelings and emotions that are too painful to deal with. By concentrating on the food and eating, or not eating, they can avoid these painful issues. Eating disorders can be a way of being in control of their body and life in general.

There can be a reaction to an event or events that go back many years. In some cases body image can be the cause and suffers try to live up to unrealistic images seen in magazines or on television

As counsellor you would need to establish the area of their eating disorder that your client may be in.

More females than males have an eating disorder but males are under similar pressure and can also develop eating disorders.

Eating disorders can be very serious, feelings of fear, anger or embarrassment, for the client can stop them asking for help.

People with eating disorders are often concerned about family members finding out that they have an eating disorder. The sufferers often wish to keep it secret and this will inhibit them from seeking help for themselves. The sufferer may fear they will be criticised or treated unsympathetically. They may have heard of other peoples bad experiences or be afraid of being treated against their will.

You may be the first person that they confide in so holding confidentiality is important. Helping the client to see that they need support is essential.

Support from their GP.

Their GP may be able to help by asking a few questions.

The signs of an eating disorder that their GP will look for may include.

• Low weight for their age,
• Excessive concerns about weight,
• If you are a women, problems with their periods,
• Vomiting that has no other obvious explanation.

The GP may co-ordinate their care with other specialist. The first steps will often be an assessment and possible treatment by a person with special experiences of caring for people with eating disorders.

They may be offered to work with counsellors that specialise in

• Cognitive analytic therapy.
• Cognitive behaviour therapy.
• Interpersonal therapy.
• Focal psychodynamics' therapy.
• Family therapy.

As well as other methods of support.

It is important to understand that eating disorders are not just about food. Eating disorders are a coping mechanism, Using food and the control of food to resolve emotional and painful issues that they cannot deal with in any other way.

Things to look out for with Anorexia

Anorexia nervosa is a potentially life threatening condition which is associated with serious and fatal medical complications. This is due to the effect starvation has on the body. They may experience.

• Hair loss
• Poor concentration
• Sleep disturbance/fatigue
• Irregular/loss of periods
• Thin bones (osteoporosis)
• Low sugar levels
• Swollen feet/ankles
• Numb/cold fingers
• Poor circulation
• Low blood pressure/fainting
• Kidney failure
• Blood cholesterol levels increased
• Muscle damage.

In some cases what starts out as a harmless diet can escalate. The person may feel huge achievements and control. Often they will deny being on a weight loss diet they may wear baggy clothes as this helps to conceal the body. They may become obsessive with making and preparing food for others. The sufferer may linger and take a long time to chew their food and will finish eating after every one else. They may see a distorted image of themselves feeling fatter even while getting thinner.

Their self-esteem and self worth may be low and feel increasingly sensitive.

There is a risk of depression as well as anxiety.

Perfectionism is one of the things a person with an eating disorder will strive to achieve otherwise they perceive themselves as never being good enough. Even when they achieve they still see their failures and will often feel inadequate.

Things to look out for with Bulimia

Bulimia Nervosa is a potentially life threatening condition which is associated with serious/fatal medical complications.

• Hair Loss/dry skin
• Dental decay/blood shot eyes
• Bone marrow fails
• Irregular/loss of periods
• Thin bones (osteoporosis)
• Low sugar levels
• Swollen feet/numb and cold fingers
• Irritability/poor concentration
• Anxiety/depression/fatigue
• Hoarseness/throat bleeding
• Irregular heartbeat/palpitations
• Low blood pressure/fainting
• Chest pain/abdominal pain
• Kidney infection/failure
• Sleep disturbance

The immune system works by defending the body from bacteria, viruses and other infections. Vomiting can cause sore throat as well as dental damage caused by the acid passing through the mouth. The bulimic may eat in desperation, eating quickly and not chewing and digesting the food as well as not enjoying it.

• They may then experience feelings of self-loathing and disgust.
• They may rid themselves of the food by inducing vomiting or taking laxatives.
• They may feel euphoric after doing this but feelings of depression may occur.

Often the person with bulimia will purchase the food separately and hide the evidence from others.

Possible Fears and concerns from a client

• In Anorexia the person has a fear of getting fat/gaining weight gain/being fat/being unhealthy.
• They will feel fat even when they are thin.
• Bingeing / not being able to stop eating the food.
• Liking food and then feeling guilty.
• Other people seeing you eat and feeling disgusted.
• Feeling more self-conscious.
• Will exercise a lot.
• Going back to the way they were, food connected to feelings/memories/need for other behaviour.
• Will eat very little or nothing at all.

Some of health issues that may arise are.

Diabetes

If they are diabetic they should have regular health checks as they are at high risk of problems with their eyes and other serious complications.

Pregnancy.

If pregnant and have an eating disorder they should be carefully monitored throughout their pregnancy and after they give birth.

Osteoporosis.

Osteoporosis and other bone disorders should be advised by health care professionals as physical activities might lead to a fall

Dental problems.

If they are vomiting on a regular basis they can seriously damage their teeth and gums.

They should………..

• Avoid brushing their teeth after vomiting.
• Rinse with a non-acid mouthwash after vomiting.
• Avoid acidic such as fruits, fruit juices, carbonated drinks, pickled products, yoghurt, and some alcoholic drinks.
• Visit their dentist regularly.

Laxatives.

If they are taking excessive amounts of laxatives they should be advised to reduce the use of them. They should be advised that using laxatives does not mean that they will decrease the number of calories that their body absorbs.

Recognising that they can become physically unwell with anorexia nervosa, particularly if their weight is low and they are losing weight rapidly.

Heart Disease.

People with Anorexia can be more at risk of certain kinds of heart disease they may need an ECG to test that the heart is working as it should. This is important if they are taking medication.

In a small amount of people bulimia nervosa can lead to physical problems, such as dehydration and changes in the chemical balance in their bodies and this could result in heart and other physical problems. If they are vomiting often, or taking large amounts of laxatives, they should see their GP to test their fluid levels and chemical balance.

Anorexia Nervosa

Anorexia can start at any time. The main age on onset is 15 years, but can start at any point between 6 and 72. Anorexia is principally a psychological disorder. Its fear is of fatness and a pursuit of being thin. There may be a distortion of body image which the person may perceive themselves to be fat when they are thin. It can start by just being on a diet that escalates.

The person may feel a sense of success as well as achievement and control. They will often deny they are on a weight loss diet where as someone on a diet will admit to being on a diet and often want to talk about their lapses as well as triumphs.

The anorexic may become phobic about eating socially and may hoard food in order to eat alone and unnoticed. They may be plagued by feelings of low self worth as well as low self-esteem. Many people with anorexia become highly active. They try to be busy and on the move and often find it difficult to switch off. The may walk and exercise for long periods and indulge in calorie burning activities. After eating they may exercise to rid them selves of the calories they have consumed. If they cannot exercise and do not have any privacy they may become anxious and agitated. This can be extremely tormenting for the individual. If they are free to exercise they will do so for a long as time and strength will allow. They may cook and create recipes for others as this will lead away attention from their own concerns.

There is the risk as anorexia takes its grip that physical activities may dominate their day.

By restricting their food intake many people maintain their body weight well below the healthy range. By measuring their height and weight it is possible to work out their body mass index (BMI) and to know just how far below this range they are.

People with very low body weight may feel weak and find it a struggle to cope with simple day to day activities.

When it comes to studying their course work they may find it very tiring as well as draining.

Bulimia/Binge Eating

People with Bulimia nervosa can feel they have a desperate need to control and restrict their intake of food. With bulimia sometimes they are caught in a cycle of eating large quantities of food they may end up purging then vomiting, taking laxatives and diuretics. Or excessive exercising and fasting in order to prevent weight gain. This behaviour can effect daily life, and lead to difficulties in relationships and social situations. They can experience mood swings, and feel anxious. It may also be a way of dealing with distressing feelings. Many people are surprised to learn that in fact vomiting after eating is not a good method of getting rid of food. When the stomach suddenly contracts to vomit, around 50% of its contents is pushed further down into the intestine where it will be digested and absorbed. Only half of the food is expelled. We lose one of the most important minerals with repeated vomiting" Potassium" vital for a healthy heart. Low body weight may lead to slowing of the heart rate and Should the client say they are fainting or collapsing they should seek medical advice from their GP.

The sufferer may exist in a state of starvation for a length of time; the rigid diet broken by binge eating in which everything available is eaten rapidly. The food is eaten without being enjoyed and may not have been chewed and digested properly.

This is called a bulimic episode, and is followed with feelings of self loathing and disgust, which prompts the person to quickly get rid of the food. They may do this by self-induced vomiting or by taking large amounts of laxatives, in order to get rid of the food before the calories have been absorbed.

Between 40 – 50 % of people with anorexia experience bulimic episodes and is characterised by feelings of guilt, self-disgust and failure. It is also self-abusive, in that the person regards the post-binge purging as a form of self-punishment. In contrast to the control and perfectionism of anorexia, a bulimic tends to be associated with impulse. The feelings of self-disgust experienced by the person with bulimia may reach the extreme of self-harm, such as body cutting or burning and may prompt suicide attempts.

Self Harm

People self harm in different ways some cut their arms or legs, other bang or bruise their bodies. Some people take tablets but not enough to take an overdose, but enough so they can blot things out for a while. Others use self-harm to cope over long periods of time. they may self harm when the things get to tough and it is a way for them to relieve the pressure. People self-harm because they are in pain and are trying to show that something is wrong and that they need to be taken seriously. All sorts of people self-harm. Even people in high powered jobs. There is a lot of secrecy about self –harm. But many people cope in this way for a while. Many people stop self harming when they are ready. They sort out their problems and find other ways for them to deal with their feelings. things like starving, overeating, smoking drinking are all types of self-harming.

Student experiences

These are just a few of students shared experiences.

"I had been afraid to ask for help, I hadn't wanted it, I had wanted to be thin, I had wanted to go away and find a place to die. I had never had any help or treatment I did not know what it was. I was afraid to fail and let the family down so I plodded on suffocating my illness. Nobody got me out, nobody could, not until I was ready. I did not know there were options, people on the outside of my world seemed only to want to make me fat at that stage in my life that was all this was about fat-thin, success-failure, life-death. I spent four lonely years wrapped up in my eating disorder. I did not even realise that I was lonely, well maybe I did but my faith-full friend was by my side, my Anorexia then my love hate relationship bulimia and self harm began. I worked like a Trojan but could not achieve what I should. I was one out of two people in the whole year that got a third class degree. I really failed."

"I went to uni and things fell apart quickly and I came home. I felt so bad and like I had let every one down. I was offered support quickly through a referral from my doctor. It took me a while to begin to see how my eating disorder had taken the opportunity to rule my life. I then applied to refer my course to a nearer one where things would be more familiar."

"It was really hard work trying to study and make changes in my life style but I was not going to be beaten. Some days I did manage well, but I kept going and the old patterns I knew so well did not run riot in my body"

"I was living in a shared house. I found that I could not eat with the people so I found some accommodation near others but on my own and this helped me to work with my support team to get well. It was hard being on my own but it meant I knew I could do what I wanted when I wanted to. "

"I tried to shut my parents out even when in hospital, but to be honest created to much stress, therefore I guess the moral is not to be scared to ask for help and make some safe bases you can ring. "

How to help the client.

There are ways in which counsellors can offer practical help to the client by identifying a possible root cause.

• It may be helpful for the client to listen to a relaxation tape.
• Keep a diary of their day, they may like to share this with you. This could be to ask them to keep a diary of their meals for the day. Alternatively it may be a diary about their thoughts and feelings such as when preparing food and eating.
• Encourage the client to identify their needs and where they are with their eating disorder. This may give an insight to how it started.
• They may feel their lives are out of control. Encourage them to identify where they think they lost control which may be a time when they experienced a particular event such as being bullied at school.

Put strategies into place to attempt to address the problem.

• Writing their feelings down.
• Recording meal plans.
• Phoning a friend.
• Listening to music.
• Offering where they may get help additional help and support.

As a counsellor we may find we have our own issues with food this can be difficult when we are trying to help someone else with an eating disorder. Work with your own transference and draw on your counselling experiences. Look deeper for the issues that are hidden behind the food. Often it is not about the food they eat but more about feelings that they have buried. Try not to get drawn into the dynamics of the food by getting diverted from the person to the food. There is an underlying emotion why we hide behind food. This is a form of being in denial. It is important to remain optimistic and stress that people do overcome their eating disorder and recover. Hopefully with help and support from GP, therapists, family and friends the sufferer can come through the experience and become stronger than before.

Living with and recovering from an eating disorder is like sailing round the world single handed on a boat too big for one, you need help that will stick with you and let you try to steer your own course.

There may be some stormy seas to sail through, some people will die, some will get blown off course, some will lose their way and many can make it through with the help belief, support and hope

Low self-esteem

Low self esteem can contribute to how a person feels with an eating disorder. When our self-esteem is low they we can have thinking errors and may not relate to others so well and may distort our view of how we should be. This creates a situation where they cannot see their achievements and feel what they do achieve is not good enough. They may think that they are worthless and have a distorted body image of themselves believing they are disgusting and fat. This can lead to abnormal eating patterns. Helping the client to explore where the low self-esteem began may help the counsellor. This may lead into how and when the eating disorder developed.

Scenario of a carer’s aspect of eating disorder.

A young carer helps and supports someone in their family or where they live who is unwell. They may feel different to other people and may not able to talk about issues that may be concerning them.

Carers need help and support too. They have a need to off-load and share their experience with others is necessary. Have up to date information where they may get support.

Caring for someone with an eating disorder can be demanding as well as stressful. They may have to face numerous challenges and have to deal with difficult situations in their role as a carer. They may not be getting much time and attention at home. They may feel guilty for not having an eating disorder. They may wish they had someone to talk to about how it is for them. Encourage them to speak to their tutor, doctor or counsellor if they are anxious or worried.

Caring is a tough relentless job. It takes enormous strength and dedication to be a carer and even more to create your own life.

Organisations offering support for Carers.

• G Ps.
• National Carers line 0345 537369
• SANE line 0345 678000
• National Eating Disorder Association
• SWEDA helpline 01458 448611

The Counsellor in supervision.

Supervision may help the counsellor to assist the client to look deeper. By sharing my experiences in supervision enabled me to focus the client in a different direction and explore alternative avenues. Role-playing your client helps to understand what is going on for them.

One client did not know how their eating disorder had started. The client could not eat out in front of others. After many sessions in counselling what materialised was as a small child they were separated from others when given food to eat and put on their own.

Once the client had an understanding of how it began we were able to work on healing the underlying factors. After a year the client was able to eat out in public places.

Key points for the counsellor to look out for.

• Look at the client's self-esteem.
• Look at the client’s personal history.
• Look at how they see their body image.
• Identify their needs and where they can get support.

Bibliography:

"Helping people with eating disorders."
A Clinical Guide to Assessment and Treatment
By Bob Palmer
ISBN 047198647

"Overcoming Anorexia Nervosa"
A self help Guide using CBT
By Christopher Freeman
ISBN 1854879693
"Bulimia Nervosa and Binge Eating "

"A Self help guide using CBT"
By Peter J Cooper
ISBN 1854871714

"Eating Disorders -A parents Guide"
From the Great Ormond Street Hospital E.D. Clinic.
By Rachel Bryant-Waugh and Brian Lask
ISBN 0140263713
(A parental guide but very useful for professionals.)

Further Information

SWEDA Helpline (For support and help)
Tel: 01458 448600

Somerset & Wessex Eating Disorder Association
(SWEDA)
Tel: 01458 448611

SWEDA Website:
http://www.sweduk.org

SWEDA 18-25 Project with universities and colleges
18-25 Project booklets

There are numerous booklets aimed at providing practical ideas for supporting students available from the project.