To raise awareness of eating disorders, and the role that child psychotherapists can have in supporting young people and their families, we have spoken to some of our members who work in specialist eating disorder services to hear more about their work.
A day in the life of the Lead Child and Adolescent Psychotherapist at the Adolescent Eating Disorder Service in the Royal Free Hospital London.
Elizabeth Anscombe tells us about her work in an Eating Disorder Service as a Child Psychotherapist. She is the Lead Child and Adolescent Psychotherapist at the Adolescent Eating Disorder Service in the Royal Free Hospital London.
Over the last 10 years Elizabeth has seen the team grow and develop. The team now receives between 150-200 referrals a year and covers 5 London boroughs with over 400 patients. Elizabeth is part of a multidisciplinary team, which includes Psychiatrists, Psychologists, Specialist Nurses, Family Therapists and Dieticians.
A core part of Elizabeth’s day is seeing individual patients for child psychotherapy. As a service, they offer 30 sessions of psychotherapy, but don’t tend to offer psychotherapy until a young person is weight restored and has completed the specialist Family Therapy (FT-AN), unless there are extenuating circumstances, such as parental or sibling illness or bereavement. This is because when a young person is starved, his/her brain is also starved and is unable to maximise the use of psychotherapy. Elizabeth additionally offers joint assessments to new patients with one of the psychologists with a young person and their parent to think about whether CBT or psychotherapy is the appropriate form of individual therapy.
As well as seeing individual patients, Elizabeth is involved with the meetings of the multidisciplinary team. They are all trained in Family Therapy for Anorexia-NICE guidelines 2017-as this is the first line treatment for children and adolescents with Anorexia Nervosa. The first part of the treatment is often the hardest for the young person, and there are frequently lots of conversations about how much a young person is struggling with high levels of distress. There are also other meetings that Elizabeth may have to attend as the Lead Child Psychotherapist – for example; the intensive eating disorders service meets to think about a smaller number of patients with very complex presentations. They are often young people with significant concerns about physical health, as well as emotional and psychological health.
As a Lead Child Psychotherapist Elizabeth also offers supervision to other members of staff to further support their work.
We spoke with Elizabeth yesterday. Here she offers further reflections on the role:
What can a child psychotherapist add to an MDT eating disorders team?
As a child and adolescent psychotherapist we are trying to understand the complex emotional and inner world of the young person. Using a psychoanalytic approach and observational skills, a psychotherapist will look beneath the surface of problematic emotions, behaviours and or relationships. This is especially so with eating disorders, I particularly like this quote, where Dr Kenneth Nunn a neuro psychiatrist has said, “it is an illness of communication between the world inside and the world outside: patients become, locked in and locked out.” Young people with eating disorders can find it very liberating to be able to make connections to their inner world and deepest thoughts and how it impacts their behaviours and relationships.
I also supervise the intensive nursing group who are with are very unwell patients sometimes up to 8 to 10 hours a day. The psychoanalytic thinking is really valued in terms of understanding the patients, their parents and also their reactions to the patients.
Which young person has benefited most from child psychotherapy in your experience?
In our team there is a two tier assessment before receiving child psychotherapy to assess young people to see whether psychotherapy or CBT may be more helpful. A young person is then offered a three sessions child psychotherapy assessment, in which the young person has a conversation with the psychotherapist about entering into psychotherapy. The patients who are ready to make sense of their illness and how anorexia may serve as an identity to cling to in the face of the storm of adolescence, are the patients who benefit the most.
Which books have you found most helpful and why?
In terms of psychotherapy with eating disorders patients, I have really valued Gianna Williams, “Internal landscapes and foreign bodies.“ Marilyn Lawrence’s book called the “Anorexic Mind” and Jeanne Magana’s book, “The silent child.”
We have heard about the clinical roles that child psychotherapists can have within eating disorders teams. However, child psychotherpists also contribute to eating disorder services in other ways too.
Cathy Troupp, a Child and Adolescent psychotherapist who was in the national specialist eating disorder team at Great Ormond Street, was one of the four leaders of the National Training for Community Eating Disorders. This training was designed and delivered to around 1000 eating disorders specialists in nearly 80 teams in 2017-18. It aimed to improve skills in all professionals in the multi-disciplinary staff group, share knowledge and practice and, best of all, develop a unified team approach to the management of eating disorders in children, and their families.
As well as the Family Based Therapy for Anorexia that Elizabeth Anscombe mentioned above, Cathy Troupp has also been involved in the provision of a new therapy for Anorexia called Adolescent Focused Therapy (AFT). AFT is a meaning-focused therapy, where the young person and therapist together explore the connections between the eating disordered behaviour and emotions. AFT takes a developmental approach to adolescence, exploring family and peer relationships, self-esteem, depression and anxiety, and addresses factors that may be maintaining the eating disorder. Cathy Troupp will be convening a group of therapists to further establish and support this work.