It may be helpful to begin by acknowledging how different members of the family feel about Christmas including their fears, concerns and hopes. For a person with an eating disorder, there may be raised anxiety about the abundance of rich food during Christmas, the Christmas meal itself and the need to eat together with relatives or large groups. It is important also for parents to try to acknowledge and share their feelings around Christmas. Parents may feel under pressure to create a ‘perfect’ day or feel very emotional about how the eating disorder is likely to impact upon the whole family’s Christmas experience. Social media and the pressure it creates for both parents and teenagers to be seen to have a ‘perfect’ Christmas can be harmful.
During these discussions, these steps may be useful:
Try to emphasise Christmas as a season of your own traditions and for the people you care about to get together. Try to set the context of the Christmas meal and food being a smaller part of this whole. What traditions does your child enjoy (short walks with the family, games, choosing a Christmas tree, watching a film together)? These traditions can be particularly important for a young person who is struggling with the food aspect of Christmas, but still may be able to find joy and comfort in activities and rituals from previous Christmas experiences. This may help the child to feel loved and secure despite the eating disorder.
Your child and your family may be in a very challenging place with the eating disorder and feel great anxiety about Christmas. If this is the case, it may also be helpful for everyone to try to consider Christmas as one of 365 days in the year and to focus on keeping it in perspective: not to perceive it as a reflection of your family well-being nor to compare it to previous Christmases before the eating disorder
A significant aspect of Christmas is the emphasis upon getting together with relatives and friends. From the perspective of a young person with an eating disorder, this may be very challenging. If they have not seen relatives for several months or longer, they may feel anxious simply about seeing them and particularly about comments they may make (however well meaning). An individual with an eating disorder is likely to feel particularly anxious about eating with people who they do not share meals with on a regular basis.
These concerns and issues can become a source of conflict: the young person with an eating disorder may have strong views on what they feel they can and cannot cope with while other family members may feel your Christmas should not be dominated by the eating disorder. These steps may be useful:
Perhaps invite only close relatives or friends to your Christmas meal, which is likely to be a major pressure point. Who does your child feel most comfortable with, particularly when eating?
Consider getting together with wider family and relatives in a way whereby food (particularly sitting down for a meal) is not the primary focus, for example, going for a short family walk together, or a more informal ‘drop-in’
Talk to your relatives in advance about what may help and what may not be helpful. Explain that any comments about appearance, even “you look well” could be misinterpreted by a person with an eating disorder (to suggest weight gain/fatness) and it is best to avoid any comments about appearance. It is also best to avoid any comments about anyone else’s appearance and certainly to avoid discussion about New Year diets. Comments about how much food is being eaten are also unhelpful (“I’m stuffed”/ “aren’t you doing well”)
If relatives feel worried they will ‘say the wrong thing’, reassure them that people with eating disorders usually welcome talk during mealtimes as distraction. General talk about all subjects not related to food/body imagine/eating disorders are helpful. Straightforward statements like “I’ve been really looking forward to seeing you” are a positive way of starting conversation. Relatives may need to be aware that the young person may be less chatty than they have been on previous occasions.
THE CHRISTMAS MEAL
It is very helpful to discuss and agree portions and strategies in advance. At Newbridge House, we have a Christmas meal early in December. This helps young people prepare and we also share portion sizes (weights and photographs) with the families we work with. It is worth considering, for example, how will you organise your Christmas meal, what might help?
It may be useful to have an agreement such as: parent will plate up the meat and potatoes for the young person and perhaps do the same for others. This way, the young person has an agreed portion of protein and carbohydrate, has a choice of vegetables and is not ‘singled out’ as having their meal in a different way to others
Think about how you plate up, considering your child’s personal triggers for anxiety and how to balance addressing those and the way your Christmas meal is served overall
It may be helpful for the young person to sit next to a designated supporter who they trust and knows them well. Some people find it useful to copy their supporter’s portions, which is helpful if people are serving themselves
It is often helpful to have an activity planned for after the Christmas meal as a distraction, such as a board game or watching a film
“I think it is really important to prepare and make a plan for Christmas with your loved one, then to be prepared for your plan to go off course. Try to be flexible and be aware of your own expectations; it is probably better to lower them a little. If your teenager needs some time out in their own room it may be better to allow that than to have a big fight. My daughter is in recovery from anorexia and certainly has issues with food still, but she loves Christmas. She loves the traditions and as she moves into her early twenties, she really values the time together with family and that certainly outweighs the food anxieties, even though they are still there.”
– Parent of young person who was treated for anorexia at Newbridge House
If you are struggling to cope with Christmas and want to talk to someone, we recommend you call the Beat helpline. This is run by trained specialists and Beat is the national charity dedicated to supporting people with eating disorders and all those affected by them. Their helpline is open on Christmas Day. The Helpline number is 0808 801 0677 or 0808 801 0711 for the Youthline. On Christmas Day, the lines are open from 6pm to 10pm and on all other days, including Boxing Day, they are open 3pm to 10pm.
Newbridge specialists gave a very well received presentation on Working with families at a national eating disorders conference.
Organised by the charity Beat, the two-day conference was entitled Eating disorders: support for the frontline and considered the complex challenges faced by affected individuals, their families and the professionals treating them.
Newbridge House was represented by Deputy Clinical Manager Natalie Maley and Gill Williams, Parent Practitioner, who described the Programme for Parents, a practical course we provide in addition to family therapy, family liaison and Parent and Carers’ Group.
“The Programme for Parents is very practical: it is about the parental experience of having a child with an eating disorder, about how to manage meal times and food shopping, guidance on how to communicate with your child.
“It is something which we developed at Newbridge six years ago and have continuously refined what we offer to meet the needs of parents and carers.”
Natalie and Gill described the programme to the Beat conference, explaining the key themes: introduction to eating disorders and experiences as a parent, parenting a young person with an eating disorder, motivational interviewing, coaching and practical tips and parenting a well sibling.
The programme considers parents’ perspective on the eating disorder: how a blame-based perspective is backward looking and negative, whereas a responsibility-based perspective supports a positive sense of taking control in the ‘here and now’.
It also highlights the risk of “splitting”: when the eating disorder has a destructive impact upon the relationship between parents (or between the parents and their child’s eating disorder service) and how a split allows the eating disorder to continue.
The programme also reflects on parenting a child with an eating disorder: how people can lose confidence in their ability to parent and relationships are harmed. Parents are encouraged to find some emotional and psychological distance from the eating disorder.
Natalie Maley commented: “We were really pleased to be involved with this conference which was all about the tough, complex issues families face and how to support parents and carers in practical, effective ways.
“We are really proud of the range of family support we provide at Newbridge, reflected in Gill’s post as Parent Practitioner, a role dedicated wholly to linking with families and ensuring they are continuously supported.”
A Focus on feeding was the theme of a comprehensive and thoughtful Masterclass delivered by Dr Rachel Bryant-Waugh of Great Ormond Street Hospital.
This was the tenth Masterclass of the series and brought a well-received focus on ARFID (Avoidant/Restrictive Food Intake Disorder) as a distinct diagnostic term.
Dr Bryant-Waugh, who is Joint Head of the Feeding and Eating Disorders Service at GOSH, began by describing how ARFID developed from the “muddle” of presentations which did not fit standard eating disorder diagnostic criteria.
“There can be many similarities with anorexia: restrictive eating, low weight, sudden weight loss and an emotional component,” explained Dr Bryant-Waugh. “But critically, in ARFID, the disorder is not driven by weight and shape issues.”
Dr Bryant-Waugh described the three elements which drive the feeding or eating disturbance in ARFID as: low interest, sensory difficulties, fear/trauma.
ARFID can be seen in very young children, but it is not a child and adolescent disorder; it can occur at any age and affected individuals can also be within a normal or high weight range, emphasised Dr Bryant-Waugh.
It is essential that patients with ARFID are accurately diagnosed and appropriately treated.
“You can make things worse if you treat an ARFID patient as if they have anorexia,” explained Dr Bryant-Waugh.
There was a wide-ranging discussion about how patients can be referred to eating disorders services as the first ‘port of call’, although their pathways are often designed for patients with anorexia.
In terms of treating ARFID, Dr Bryant-Waugh cautioned that as a relatively new part of the diagnostic lexicon, there is very little evidence base. She described the treatment tool kit required and the core principles of explore, understand, accept, challenge, change.
“The end-point is unlikely to be eating a full Sunday Roast, but it is often having a ‘good enough’ diet and a reduction in social impairment.”
In the afternoon session, Dr Bryant-Waugh shared her work with an adult eating disorders service where she observed a third of service users were also mothers responsible for feeding children.
“They were very low in confidence about their role as a mother; there was a lot of anxiety about doing the right thing and particularly concerns about passing an eating disorder on to their child/children. Equally however, there was very high motivation to be a good mother.”
Dr Bryant-Waugh described common issues and behaviours arising through the three pregnancy trimesters and the need for a realistic approach to questions like breast-feeding, when a mother has an eating disorder. Targeted support for these mothers is very beneficial; they are unlikely to access regular parenting groups due to shame about their eating disorder.
The final session considered the risk of intergenerational transmission of eating difficulties.
“For children to learn how to eat, parental modelling is vital. It is important for children to see their parents eating a range of foods, including new foods,” said Dr Bryant-Waugh.
There was discussion about how a parent’s eating disorder can affect feeding decisions and how preparing food and supervising children at mealtimes can impact upon the parent’s eating.
“It is complex; it is not one but many different interactions, one after another. My own reading is that the one thing that may dispose to future eating disorders in children is high levels of parental anxiety and conflict at mealtimes.”
Professor Hubert Lacey, Medical Director of Newbridge House concluded the Masterclass by thanking Dr Bryant-Waugh for leading an excellent day.
“You have explained, with great depth and clarity, not only the pathogenesis of ARFID but also the different aspects required in treatment. Your work on intergenerational transmission risk was illuminating and very well received.
“It was evident throughout the day how many participants came and spoke to you to seek guidance about issues they are seeing in their services ‘at the coalface’. This is what Masterclasses are all about: a really high quality educative experience and a genuine opportunity to share experiences and draw on specialist advice and support.”
Newbridge House’s tenth Masterclass will focus on feeding and intergenerational disorders, led by a leading Great Ormond Street Hospital clinical psychologist.
Dr Rachel Bryant-Waugh’s Masterclass will address two main topics: Avoidant/Restrictive Food Intake Disorder (ARFID) and challenges to child feeding behaviours in the context of maternal eating disorders. The full day educational event will take place on Tuesday, November 28th at Fairlawns Hotel, Aldridge, West Midlands.
This will be the tenth Newbridge House Masterclass in a series which has featured speakers from Australia, Canada, Norway, Sweden and the UK. The principle is offering free, high quality education with internationally renowned experts. Participants are eating disorders professionals working in many different types of service across the country, facilitating many opportunities for shared learning and reflection.
Dr Bryant-Waugh is a clinical psychologist based at Great Ormond Street Hospital for Children (GOSH) in London, where she is Joint Head of the Feeding and Eating Disorders Service and Honorary Senior Lecturer at the Institute of Child Health, University College London.
Rachel has acted as National Clinical Advisor for the Children and Young People’s Evidence Based Treatment Pathway for Eating Disorders and has served on DSM-5 and ICD-11 Work Groups. She has won national and international awards for her work in the field of feeding and eating disorders in recognition of her contribution to this field. She has published widely and trains and lectures in many countries.
Her Masterclass will cover: What is ARFID (Avoidant/Restrictive Food Intake Disorder) and where did it come from? ARFID and evidence based practice: where do we stand at present? Mothers with eating disorders and early feeding and concluding with strategies to reduce risk of intergenerational transmission of eating difficulties.
Professionals working in eating disorders services are welcome to apply for a place, but Masterclasses are heavily over-subscribed and places are allocated to allow for a wide range of services to attend. For more information, please contact Amanda Deakin, Masterclass administrator on 0121 580 8362 or email Mandy.Deakin@newbridge-health.org.uk
Newbridge’s clinical manager is leading a session at a prestigious conference bringing together eating disorders professionals working throughout Europe and beyond.
Rachel Matthews is speaking at a debate considering consent in eating disorders treatment, together with Túry Ferenc from Budapest, Hungary.
The meeting is the European Council on Eating Disorders (ECED) conference, which is taking place in Vilnius, Lithuania on September 7th to 9th.
The ECED was established in 1986 by Professor Hubert Lacey to bring together people working in eating disorders across Europe to share dialogue, research and discussion. The ECED today has more than 750 members.
Professor Lacey, who is medical director of Newbridge House, said: “This is a very prestigious international meeting with leading speakers from across Europe. Newbridge is proud to be part of it; we all gain from sharing our experience and hearing the perspectives and models used elsewhere.”
Taking place in Lithuania, it will be the first meeting of the ECED in a country which was once part of the Soviet region and it is an opportunity for eastern and western Europeans to reflect on service and cultural differences in eating disorders treatment.
Newbridge House has been praised as an “outstanding example” in a comprehensive review which shows our service is one of just ten in the country to achieve the top rating.
The Care Quality Commission (CQC) report states Newbridge House is one of just ten services out of a total of 275 inspected who were awarded an outstanding rating.
Among services like Newbridge, called inpatient child and adolescent units, Newbridge was one of three (out of 54) to achieve the outstanding rating.
The review, which analyses the findings of inspections of all English mental health services between 2014 and 2017, demonstrates how few achieve the highest rating.
Among 54 NHS trusts providing mental health services, just six per cent were judged to be outstanding. The figure was even lower for the 221 independent mental health services (of all types) like Newbridge who are commissioned by the NHS: only three per cent achieved an outstanding rating.
The work and strengths of Newbridge House are highlighted in the report, entitled State of care in mental health services, 2014 to 2017, together with two other flagship mental health trusts.
Professor Hubert Lacey, Medical Director of Newbridge House, comments: “We were absolutely delighted to receive our outstanding rating last year. This review demonstrates the scale of that achievement: it provides, for the first time, a complete picture of all mental health services, enabling us to benchmark ourselves.
“It shows how few services reach the very demanding standards required to receive the highest rating: only Newbridge and two other child and adolescent children’s services have done so. We are among the three per cent of all independent mental health services to achieve this.
“Every single member of our highly skilled and committed staff should feel very proud of their part in this impressive achievement.”
The CQC report states that the vast majority of people working in mental health services are caring. The other key ingredient required for outstanding care, the report suggests, is outstanding leadership.
It states: “When we analysed a number of inspection reports, we found six key themes that contributed to a rating of good or outstanding for well-led: leadership, a clear vision and set of values, a culture of learning and improvement, good governance, quality assurance, and engagement and involvement.”
The CQC review features Newbridge House as an outstanding example, including extracts from the summary finding of the 2016 inspection:
“Patients and parents were overwhelmingly positive about the care and treatment provided by Newbridge House. Patients felt safe there and knew how to complain if they were unhappy. They understood their care and treatment plans, and had been involved in developing them.
The company invested in, and was responsive to the needs of, its staff. As a result, staff morale was good. Staff provided high-quality treatment and care. Different professionals worked well together to assess and plan for the needs of patients. Staff used specialist tools to assess the severity of the patients’ eating disorder. To aid their recovery, patients had access to a wide range of specialist psychology and occupational therapy led therapies.”
Newbridge experts speak at eating disorders awareness conference
Specialists from Newbridge spoke at a conference established to raise awareness of eating disorders.
Newbridge House Clinical Manager, Rachel Matthews and Senior Dietitian, Samantha Grigg, chaired a session titled: Are healthy eating messages in the media putting young people at risk of eating disorders?
The conference, which took place at the University of Birmingham on June 9th, was for professionals (including those working outside of mental health services) who want to build their understanding of eating disorders.
Topics covered included the signs and symptoms of eating disorders, surviving mealtimes, Autistic Spectrum Disorder and eating disorders and multi-family therapy.
The conference was organised by Forward Thinking Birmingham (FTB) in partnership with the national eating disorders charity, Beat. There are speakers from the University of Birmingham counselling service, local eating disorders services including Newbridge, FTB and Beat.
Rachel Matthews said: “We are really pleased to be involved in and to support this excellent conference which brings together many partners working with people affected by eating disorders.”
“There is a really relevant and engaging programme which supports not only people working in mental health services but the many professionals, such as teachers and school nurses who can play a vital role in identifying individuals who may be at risk of an eating disorder and helping them to find appropriate support.”
Samantha Grigg added: “We chose the topic of healthy eating messages because this is something that is frequently raised by the young people we work with and their families. Although there is clearly the need for information about healthy eating, the content of messages and how they are interpreted by young people is highly variable and can be a concern.”
An innovative new approach to improving self-esteem developed at Newbridge will be presented at a national conference.
Assistant Psychologist Hannah Biney will describe the Newbridge self-esteem programme and initial results which show consistent improvements for all patients.
Her presentation will be to the Children and Young People Eating Disorders Research Consortium on May 12 at Great Ormond Street Hospital, London.
Low self-esteem is a common precipitating factor in the development of eating disorders and a feature which needs effective work during treatment.
“This means supporting young people to value themselves in other ways than in terms of their weight and shape,” explains Professor Hubert Lacey, Medical Director of Newbridge House.
“Self-esteem is a central part of each patient’s individual therapy programme, according to their particular needs, but the team at Newbridge proposed an additional intervention focused wholly upon self-esteem.”
The psychology team, led by Dr Matt Hutt devised a six-week programme using CBT (cognitive behavioural therapy) techniques to improve self-esteem. This programme is based on the key components of Melanie Fennel’s low self-esteem model.
Although the use of CBT for self-esteem is established in adult services, the Newbridge programme, adapting the same principles for children and adolescents, is understood to be the first of its kind.
An assessment was used to measure participant’s self-esteem before the Newbridge programme commenced and after it was completed.
“We found there was a significant, consistent improvement in self-esteem for everyone who took part in the programme,” commented Hannah Biney.
The self-esteem programme is at the audit stage and is currently offered on a small group basis (four participants per group).
Two groups have now completed the programme, with one group being younger and the other older (overall age range 12 to 17) A third group is currently undertaking the programme at Newbridge.
“The results are very promising, although we are mindful that this is a small sample,” says Hannah. “They provide an initial audit, which is a first step, with further work to evaluate this approach ongoing.”
The issue of exercise can cause a lot of worry and uncertainty when an individual is recovering from an eating disorder. Over-exercising is often a feature of anorexia, carried out compulsively as a tool in weight loss and maintenance of the disorder.
Eating disorder inpatient units provide an environment where exercise is very precisely managed. Zero exercise will be allowed at low weight and further into treatment when exercise is slowly introduced, it will be gentle and carefully managed activity. At Newbridge, young people join Leisure Group, which enables them to do yoga, moving on to badminton and finally swimming (undertaken in conjunction with body image work).
However, once a young person leaves the inpatient unit and returns home, it isn’t possible to control exercise in the same way. So how should reintroduction to exercise be managed?
“This is something parents are very concerned about as they prepare for discharge,” explains Gill Williams, Newbridge nurse who runs the Programme for Parents. “We advise it is much better for young people to take up organised activities and team sports, because these are structured activities within specific time frames and there are social benefits in being part of a team or group.” The structure nature of team practices and organised activities make it more feasible to plan and agree additional snacks to compensate for energy used and to ensure exercise is contained within clear limits.
“We would be much more concerned about a young person in recovery going running alone,” explains Gill. “There is the risk of runs getting longer and more frequent and no benefits of socialising with others.” If a young person prefers going to the gym to team sports, see if you can join them at the gym so their exercise is not a lone activity without time limits.
Normally, it is the compulsive approach to exercise which may still need to be considered and after discharge. “Think about the motivation an individual has for exercising,” explains Sue Taylor, HCA, who also works on the Programme for Parents. “Your daughter or son might say – ‘It makes me feel better’. This is exactly the role of sports and exercise for many, many people. But if the individual feels bad and guilty and bad if they don’t exercise, that is an indication they still have a problematic relationship with exercise.”
All sports and activities are not the same in terms of risk for individuals in recovery from an eating disorder. Endurance sports such as long distance running and triathlons present a raised risk because of the very high levels of energy and dedication they demand (and how this can be expressed in a person predisposed to eating disorders). Aesthetic sports such as dancing and ice skating are higher risk for young people in recovery because of their potential to maintain body image anxiety.
But it is widely agreed that even though exercise presents challenges for the recovering anorexic, it isn’t possible or advisable for individuals to permanently avoid exercise. “Often, sport and exercise is a big part of young people’s lives before they became ill,” explains Sue. “Sport and exercise became a tool of anorexia while they were ill, but in recovery, young people are often very keen to enjoy exercising again.”
If the route back into exercise is a positive one, such as someone taking up a team sport and finding a function for exercise which is primarily about enjoyment, socialising and belonging, this can be supportive of recovery,” says Gill. “We know how important motivation is in the process of recovery; building up a full life which they don’t want to lose by becoming ill again. Safe, balanced exercise as part of a team or an enjoyable regular activity can serve as important motivation to maintain recovery.”
Canadian Professor Josie Geller led a highly engaging and interactive Masterclass evaluating what makes treatment and clinicians most effective.
This was the ninth in the Newbridge House Masterclass series, bringing together eating disorders professionals from across the UK for training with internationally renowned specialists.
“I have known Josie for more than 20 years and have always been impressed by the work she does,” said Professor Hubert Lacey, introducing the Masterclass. “It is so relevant to all we do; to the issues we see and the challenges we face.”
Professor Geller began by considering patients’ motivation and readiness for change. She described how when starting work in the eating disorders field, she was struck by the high number of patients who were not motivated or ready for action orientated treatment.
“The evidence shows clearly that motivation is the best predictor of outcome,” explained Professor Geller. “That means one individual may have a lower BMI and high levels of distress, but if their motivation is higher, treatment is more likely to succeed than for someone with a higher BMI but lower motivation.”
Professor Geller described the treatment pathways British Columbia Clinical Guidelines which she designed. Patients are triaged into appropriate care and treatment defined by their readiness for change.
There followed consideration of motivational interviewing and collaborative versus directive styles. Professor Geller cited studies which showed eating disorders professionals stated an intention to work in a motivational, collaborative way, but in practice, frequently employed a directive stance (controlling, defensive, dominating).
“For the last ten years, this has been my purpose in life – to ask: what gets in the way? We want to work collaboratively but find it hard to stay on task.”
There followed widespread discussion about the challenges which eating disorders professionals face and how they affect stance and communication. “We need to know ourselves as clinicians: how do we react? To know – this is me at my worst and what is most supportive of me being at my best?”
Professor Geller considered the common ingredients in three widely established eating disorders treatments: cognitive behavioral therapy (CBT-E), dialectical behavior therapy (DBT) and family based treatment (FBT). Each approach was assessed in terms of three dimensions: patient engagement, skills and safety.
“My take home message is that our evidence based therapies have more in common than there is significant difference and what I’ve been looking at is not what we do but how we are doing it. In other words, can the spirit in which we deliver treatment improve outcomes?”
The basic principles of a collaborative stance were described as: no assumptions or judgements, an aspiration to help with what matters to the patient, maximising choice for the patient and always showing care and concern (even in particularly challenging scenarios).
There were also sessions considering the importance of self-compassion for both patients and clinicians and on setting treatment non-negotiables, generating broad discussion of scope and feasibility.
“Treatment non-negotiables have to be meaningful; you need to be able to look your patient in the eye and explain the rationale,” explained Professor Geller. “No matter how stringent the non-negotiables are, the patient must still have choices. We are maximising patient autonomy while also agreeing a shared, non-negotiable framework for treatment.”