Do Therapists Need Specialist Training to Work With Eating Disorders?

Eating disorders can feel like specialist work.

As therapists, we’re taught to work within our competence, so if a client has an eating disorder it might seem obvious that we should refer them to someone who has specialist training.

But what if there’s no one available to take the referral?

And what if we’re already working with someone with an eating disorder but it only becomes apparent once the relationship has developed?

I spoke to counsellor, trainer and researcher Kel O’Neill for the Good Enough Counsellors podcast about what therapists need to know about eating disorders.

Our conversation made me question whether we need to think differently about competence. Not because therapists should work beyond their competence, but because eating disorders may be far more relevant to general counselling practice than many of us realise.

You can listen to the full conversation here:

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Why All Therapists Need Some Understanding of Eating Disorders

One of the things Kel would like every therapist to understand is that at some point we’re likely to find ourselves working with someone with an eating disorder.

Eating disorders are common. The latest figures suggest around one in 14 people may be suffering from an eating disorder, with as many as one in eight experiencing some symptoms.

Kel says there’s often what she calls a “referral reflex” around eating disorders. We hear that someone has an eating disorder and immediately think they need specialist help.

Of course, sometimes they do. The difficulty is that specialist services simply don’t have the capacity to help everyone who needs them.

So what happens to the person who can’t access a specialist service?

That’s where the question becomes more complicated than simply asking whether eating disorders fall within our competence.

How Eating Disorders Can Show Up in Therapy

One of my questions for Kel was what we actually mean by an eating disorder. Does it mean anorexia or bulimia?

Kel uses a much broader definition. She thinks about eating disorders in terms of significant distress around body image, weight, shape, size or food, particularly when that distress begins to have an impact on someone’s everyday life.

For someone with an eating disorder, their thoughts about their body can begin to influence decisions throughout the day. They might affect what they eat, whether they exercise, what they wear, their relationships or how they feel about themselves.

And many people coming for counselling won’t know they have an eating disorder or mention it during assessment.

They may have lived with certain behaviours for so long that they simply seem normal.

Eating Disorders Don’t Have a Particular Body Type

Another important part of our conversation was the stereotype of what someone with an eating disorder looks like.

For many years, eating disorders have been associated with thin, white teenage girls.

In reality, they can affect people of different genders, ages, weights and backgrounds.

If someone doesn’t fit that stereotype, they may be less likely to recognise they need support.

And therapists can be influenced by this stereotype too. Kel has completed research that showed therapists’ assessment of risk changed according to the presenting weight of the client.

But people in larger or average-sized bodies also experience serious physical consequences from eating disorder behaviours.

Do You Need to Be an Eating Disorder Specialist to Help?

There isn’t currently a straightforward competency framework for counsellors working with eating disorders.

Kel pointed out that we can sometimes think about competence as though it’s a qualification we acquire. We complete a particular piece of CPD and can then say we’re competent to do the work.

However, in real life, you may have been working with a client for ten sessions before discovering they have an eating disorder. You might encourage them to access specialist help only to discover they don’t meet the criteria, or face a very long waiting list.

Where does that leave them?

Kel suggests reframing the question.

Instead of asking, “Do I know enough to treat this eating disorder?”, perhaps the question is whether we can offer this person a safe therapeutic space, recognise the limits of our role and get the additional support we need.

That might include further training or specialist supervision.

It doesn’t mean every therapist should work with every client with an eating disorder. But neither does it necessarily mean that the moment an eating disorder appears, the therapeutic relationship has to end.

Understanding Risk & Working Safely With Eating Disorders

Risk is one of the reasons therapists can feel frightened about working with eating disorders because there can be serious physical consequences. 

And remember, it’s not possible to assess someone’s level of physical risk simply by looking at them.

Multidisciplinary working is therefore important and Kel described how she achieves this in her practice. 

For example, she requires her clients to see their GP and, depending on their needs, other professionals might also be involved in their care. She’s also built a professional network of connections such as dietitians and psychiatrists.

Competence doesn’t mean doing everything on your own. Sometimes it’s about making sure other professionals are involved.

Kel also talked about noticing when a client’s eating disorder behaviours continue to worsen. This may mean that what we’re offering isn’t what that particular client needs at that point.

Capacity and Supervision

While training and supervision can increase competence, it’s also important to consider individual capacity to hold the work.

Eating disorder work involves uncertainty and risk. And while a degree of fear can keep therapists diligent, lying awake worrying about clients may indicate reduced capacity.  Capacity can also fluctuate according to personal circumstances.

Therefore, being honest in supervision, including the things we worry we may have gone wrong, is important. Good record keeping also helps us reflect on the decisions we’ve made.

Competence isn’t necessarily about certainty. It’s also about knowing what to do when feeling unsure.

How Therapists Can Learn More About Eating Disorders

After talking to Kel, I realised there’s a strong argument that we all need some awareness of eating disorders.

We need enough knowledge to notice when food, body image or eating behaviours might be part of what’s happening for a client. We need to understand that eating disorders don’t have a particular look. And we need to know when to seek supervision, further training or support from other professionals.

Kel’s suggestion for therapists who want to learn more is simply to start learning.

She founded VoxEd, Voices of Experience in Eating Disorders, partly because much of the existing eating disorder education can be expensive and heavily situated within a medical model. This online events conference brings together people with lived experience and professionals working with eating disorders from a range of different perspectives.

So, Do Therapists Need Specialist Training to Work With Eating Disorders?

I don’t think the answer is that every therapist needs to become a specialist.

But perhaps the question isn’t simply whether we’re qualified to “treat an eating disorder”.

If people with eating disorders are already coming into our counselling rooms, we need enough knowledge to recognise what we might be seeing. We need to understand the limits of our competence, use supervision well and know when medical or more specialist support is needed.

You can hear my full conversation with Kel O’Neill on the Good Enough Counsellors podcast, where we talk about eating disorders, diet culture and weight-loss medications, competence, risk, supervision and what therapists can do to become better prepared for the clients they may already be meeting.

Frequently Asked Questions About Working With Eating Disorders