Eating Disorders have been and continue to be a continuing problem worldwide. Every individual has issues with disordered eating of some kind, be it control, eating unhealthily, occasional restriction or bingeing, etc. However, some people take this extreme to another level with constant binges and purges and skipping meals at a time. According to the Eating Disorders Coalition, eating disorders are the third most common chronic illness among adolescent females (2016). Being under the age of eighteen, these adolescent women are enrolled in school. Because the average high schooler spends 35 hours per week in school, staff should provide a safe space for students rather than perpetuating stressors. Rather than removing students with eating disorders for residential treatment elsewhere, schools should offer various education, supports, groups and programs for their students rather than being a large source of students’ stress and requiring them to leave their lives to live in residential treatment.
- Defining Eating Disorders
American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders recognizes four specific eating disorders (2013). These are Anorexia Nervosa, Bulimia Nervosa, Binge-eating Disorder, and Eating Disorder-Not Otherwise Specified (ED-NOS). Anorexia is the obsessive act of restricting food intake, bulimia is the obsessive act of cycling through bingeing and purging food, Binge Eating Disorder is the act of binge eating that is out of control and ED-NOS is a diagnosis given when a person exhibits frequent behavior across multiple different eating disorders (American Psychiatric Association, 2013).
The National Association of Anorexia Nervosa and Associated Disorders states that every 62 minutes, at least one person dies as a direct result of an eating disorder; thus, eating disorders have the highest mortality rate of any mental illness (2017). One in five anorexia-related deaths is by suicide (2017). Clearly, this issue is pervasive and life-threatening. Because it afflicts 30 million people in the U.S. (2017), schools need to step up and treat this as the life-threatening illness that it is, not a weird habit of insecure youth that will go away.
A. School Systems’ Current Attitude Toward Eating Disorders
Students spend the bulk of their week in school, and rather than it being a supportive and nurturing environment, it often is the source of many huge stressors for students with eating disorders. Harper and Hardman in their article “Eating Disorders, School, and Academic Achievement” state, “Academic performance and school activities are almost completely curtailed in the advanced stages of an eating disorder and will lead to a massive disruption in a student’s educational advancement” (2017). They go on to say that a student’s life and studies are put on hold in their advanced stages of an eating disorder because of multiple hospital stays, the gravity of one’s depression and being sent to residential treatment (2017). Even for students who do not require hospitalization, participating in school is challenging because of social stressors, inability to pay attention and lack of interest all characteristic of mental and emotional disorders. School is academically and socially competitive, so it makes sense that students who are really struggling want to mentally check out. However, academic leadership will simply see slipping grades rather than the complex issues happening in each aspect of the student’s life, thus pushing the student even harder in school. It is a downward, self-perpetuating cycle.
B. Why Change is Necessary
Students with eating disorders deserve teachers, counselors, coaches and administrators who care about their mental, physical and emotional health rather than solely their academic performance. There are a multitude of potentially triggering elements in a school day: a large cafeteria, gym class and athletic clubs, social pressure and academic competitiveness. Adolescence is a formative stage in a person’s life, and if schools can gently nudge their students toward emotional health, these students will be all the better and healthier for it. Only one in three people with eating disorders seek treatment (Eating Disorders Coalition, 2016), so if schools can educate students about eating disorders, allow for school supports and foster after-school treatment, then more people would be served before hospitalization becomes necessary and without needing to go to residential treatment somewhere else.
Residential treatments are often necessary and great at what they do, but the problem is that it takes people away from their real world and does not always help them adjust to going back into their lives and existing environments. Bill Camp in a blog post for First Step Addiction Recovery Programs talked about how unrealistic life in residential treatment is (2014). Not only is it a major issue that insurance does not cover inpatient treatment, but the structure and seclusion of this treatment, while beneficial in doing intensive therapies, is unrealistic in the long run and makes transitioning home a jolting experience (2014). There need to be more options for teenagers than being in a hospital or going away for a month.
II. Review of Treatment Plans in Place for eating Disorders
Many evidence-based treatments for eating disorders exist outside of hospitalization. These include residential treatments, outpatient treatment, individual therapy, group therapy and both Eating Disorders Anonymous and Overeaters Anonymous (American Psychiatric Association, 2013). Residential treatments are great in that they allow for intensive therapy and a break from life’s stressors to really do one’s work (Camp, 2014). This is less realistic for someone in high school. Treatment of the eating disorder has to include every aspect of the student’s life.
Melissa Groman, LCSW discusses the impact of whole-person focused treatment in her book Better is Not So Far Away (2015). She says, “A life well lived means more than just a lessening of symptoms; it means a true shift in how you think and how you relate to and tend to your own thoughts and feelings”. The goal is the students’ quality of life, not academic scores and decreasing eating disorder behavior.
One evidence-based practice that is effective for young people with eating disorders is Dialectic Behavior Therapy (DBT), which C. C. Ross, MD, MPH discusses in her book Healing Mind, Body, and Spirit (2007). The mind and body connection is crucial in overcoming eating disordered behavior, and DBT focuses on that as well as mindfulness and emotion regulation. She says, “By changing mental activity, one can also change central nervous system activity” (2007, p. 116). This breaks the perceived urge to engage in behavior and changes one’s perception of meal time. She suggests putting this into practice by mindfully serving one’s one plate, sitting silently in gratitude before eating it and paying attention to each bite and chew (2007, p. 117).
Twelve Step recovery groups are inclusive to eating disorders, but considering the demographic of adolescents and implementing healthy and nurturing practices in schools, the most realistic and effective implementations in terms of treatment would be Dialectic Behavioral Therapy while also encouraging after-school outpatient programs.
A. What Schools should implement and change
Before schools can properly and practically introduce Dialectic Behavioral Therapy, other elements of the system need to change. Harper and Hardman in their article “Eating Disorders, School, and Academic Achievement” urge teachers and school staff to see the reality that eating disorders are not just about the behaviors and weight insecurity but also mental and emotional pain (2017). If the staff only addresses the behavior and not a person’s underlying issues, then nothing will change. Staff knowledge and education is important, and that can happen by requiring summer reading about eating disorders to teachers and having professional seminars. A publication in Australia led by the National Eating Disorders Collaboration encourages their schools to take a whole-school approach and talk about eating disorders across the whole school, not just with those who have a diagnosis (2016). A whole-school approach involves training staff, including a school policy statement that promotes body positivity, encouraging non-competitive athletics outside of school teams, offering balanced foods and multiple options in the lunch space and being cognizant and responsive to bullying (2016, p. 13).
Discussion and having groups for people to attend is an important part of a whole-school approach to treating eating disorders. As Groman discussed, DBT is a powerful treatment, and school counselors can and should be licensed to lead DBT groups with students. An aspect of DBT that G. L. Jantz highlights in his book Hope, Help, and Healing for Eating Disorders is learning the ability of limited focus and shifting focus (2010). DBT teaches people to concentrate their attention on one given task or activity as well as recognizing a trigger without reacting to it (2010). This is an evidence-based approach, especially in its historical effectiveness for teenagers (2010). On top of Groman’s proposed activities to improve the meal experience, Jantz encourages people to soften their inner dialogue and shift their focus to self-forgiveness and understanding rather than judgment (2010, p. 193). This would be a highly effective message for young women, and school counselors and school social workers should be able to lead and facilitate groups that teach and encourage such DBT practices.
A group from BMC Psychiatry studied a population of schools in Germany to test the efficacy of a universal prevention program, which is a whole-school approach to awareness, discussions and treatment of eating disorders (2017). This study found that participating schools led more seminars and awareness programs and allowed outreach to students. They later showed a decrease in anxiety for the average student with an eating disorder diagnosis. The eating disordered behaviors did not see as large of a decrease as expected, but many students reported that the increase in knowledge and having available supports made their school a better environment (2017). Educating people and talking about eating disorders is important, but as this study shows, it does not always affect behavior. There needs to be both discussion as well as regulating students’ stressors and offering safe groups they can attend as needed. Treatment and education need to be present together because they cannot work without each other.
III. Implications for Social Workers in Schools and/or with Teenage Clients
For a school to implement a whole-school approach as well as DBT groups, school social workers will step into many different roles (National Eating Disorders Collaboration, 2016). First, it will be the job of the social worker to present to school administrators the research that supports the need for schools to have this whole-school approach. It will then be the job of the social worker to educate or to find another professional to educate the staff on eating disorders, what they look like, what the underlying psychological and emotional issues are and how best to respond. Then, school social workers will likely be the ones to lead the DBT groups (2016). Ideally, if any of the students in school are going to a social worker or therapist for outside therapy, it would be in that individual’s best interest for these professionals to communicate and track progress together. The universality of treatment in school, home and therapy is ideal for safety and consistency in the student.
- Summary and Conclusion
In closing, it is in a student’s best interest for quality of life if the whole school approaches eating disorders as a mental and emotional disorder that can be treated. Rather than the student’s best options to be living in residential treatment, suffering through the day then having outpatient treatment or suffering in silence, schools need to give their students a safe place to struggle and recover. Schools should incorporate education and awareness while also providing accommodations that relieve stressors while also providing groups and counseling sessions for their students. This approaches the whole person rather than just focusing on the behaviors. Eating disorders are complex and manifest physically, emotionally and mentally, thus schools must see, respond to and nurture each of those aspects in their students. Schools that implement this approach could not only see an increase in those applying recovery into their lives, but this may also serve as a preventative measure for future students.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Eating Disorders Coalition. (2016). Facts About Eating Disorders: What the Research Shows.
Camp, B. (2014). Five pros and cons of inpatient vs. outpatient treatment centers. First Step Addiction Recovery Programs.
Groman, A. (2015). Better is not so far away: Decide to recover from bingeing, starving, or cutting. New York, NY: McGraw Hill Publishing.
Gumz, A.; Weigel, A.; Daubmann, A.; Wegscheider, K.; Romer, G. & Lowe, B. (2017). Efficacy of a prevention program for eating disorders in schools: a cluster-randomized controlled trial. BMC Psychiatry.
Harper, T. O. & Hardman, R. K. (2017). Eating disorders, school, and academic achievement: A formula for failure. Center for Change.
Jantz, G. L. (2010). Hope, help, and healing for eating disorders: A whole-person approach to treatment of anorexia, bulimia, and disordered eating. Colorado Springs, CO:WaterBrook Press
National Eating Disorders Collaboration. (2016). Eating disorders in schools: Prevention, early identification and response (2nd ed.). Australia: Australian Government Department of Health.
Ross, C. C. (2007). Healing body, mind, and spirit: An integrative medicine approach to the treatment of eating disorders. Denver, CO: Outskirts Press.