Not only in America

Despite the continued rise in the number of people suffering
from eating disorders in the UK and the US, the ways these two
countries treat disorders such as anorexia and bulimia are often
poles apart.

In general, the UK has little or no provision for specialist
training of GPs, psychiatrists, social workers and other
professionals working with eating disorders. There is a shortage of
specialist assessment and treatment for this client group. NHS
in-patient beds are limited and the waiting list is growing. And,
even after people have been discharged, there are few community
support facilities – resulting in frequent relapse.

Few local authorities in the UK deploy social workers to treat
eating disorders, mainly because of resource constraints. By
contrast, social workers in the US are often seen as vital to
therapeutic work with this client group. The specialised role of
social workers in the US offers something that UK social workers,
local authorities and health services could consider worth

The eating disorder unit of a “for profit” private hospital in the
Chicago suburbs provides evaluations and therapy to help people
stabilise. Action includes a meal plan for weight gain if the
client is anorexic; if they are bulimic, the emphasis is on
stopping or decreasing bingeing and purging behaviour.

Starting from the minimum intervention, the hierarchy of provision

  • Outpatient support twice weekly.
  • Intensive outpatient from 1pm to 6.30pm each day including
  • Part hospitalisation and intensive outpatient visits from 10am
    to 6.30pm on weekdays. Lunch, dinner and afternoon snack are
  • In-patient provision for three to five days for those who are
    suicidal or likely to self-injure or are “medically compromised”.
    (Medically compromised criteria include abnormal electrocardiogram,
    electrolytes imbalance or less than 75 per cent of their ideal body
  • Residential care for up to several months.

Gina Di Pasquale, a case manager in the unit, is committed to a
therapeutic relationship with service users. She says: “There are
other programmes that use a rapid refeeding model. I consider this
to be unethical. I use theories of cognitive behaviour therapy and
a psychodynamic model, the principles of empowerment combined with
a feminist and societal approach. It is the re-introduction of
normal feelings that forms the basis for therapy provided through
the hospital’s programmes.”

The case management is comparable with UK disciplines but a major
difference is the therapeutic practice used as part of the
programme. A typical day comprises:

  • 45 minutes’ individual therapy with some of the five clients on
    her caseload.
  • Family therapy session.
  • Supporting clients with meal sessions.
  • Negotiating additional programme time with insurance
  • Group therapy sessions.

Most service users are white, middle to upper class. A typical
profile for the family of an individual with anorexia consists of
an over-involved mother and an emotionally distant or workaholic
father. Similarly, the UK Royal College of Psychiatrists indicates
that people with anorexia are more likely to come from professional
and managerial families than from working class backgrounds.

According to Di Pasquale: “People who suffer anorexia are extremely
fearful of food and likely to be perfectionists. Those with
anorexia and bulimia may come from chaotic backgrounds. Sexual
abuse is a common underlying cause.”

The part health professionals play in the team is vital. Di
Pasquale says the two professions co-operate effectively. “Health
professionals appreciate the role of social workers. Medication is
not the only solution to the person’s condition.”

The psychiatrist is the lead person in charge of each case. In the
US a shift in the roles of psychiatrists and social workers in the
US has evolved, with psychiatrists transferring much of their
therapeutic work to social workers, while concentrating on the
biochemical medicine regime. It is debatable whether this is purely
due to the expense of a psychiatrist’s time, compared with a social
worker’s, but this would be an interesting possibility for future
development in the UK. For UK social workers this could provide a
missing opportunity to develop a therapeutic role within their
professional practice.

The UShealth system is funded largely by private insurance.
Everyone on Di Pasquale’s programme is covered by insurance,
although self-funders would also be welcome.

Insurance companies, on receiving assessments, sanction between
three and five days’ support from the unit, but social workers must
seek further approval for any additional time. Social workers have
to make a strong case for additional services. Insurance companies
have a financial incentive to ensure people receive the most
efficient intervention possible. They have the authority to stop
funding the support at any time. The social worker’s role is to try
to achieve the most effective plan on behalf of their client,
negotiating the best resources to meet their needs.

By law the insurance reviewers must be licensed professionals –
such as counsellors, social workers or registered nurses. Yet,
although they are trained in mental health, some do not fully
understand the nature of eating disorders. It is also problematic
that they have not met the patient and the review is carried out by

One difficulty of this process is that insurance companies try to
achieve an outcome for their client which, as well as being
effective, is also the most efficient and least costly
intervention. This could necessitate the social worker having to
play down initial progress made by the client to have any hope of
accessing additional support.

People with no insurance may be funded through the federal
government’s Medicare system if they are senior citizens or have a
disability. People on low incomes can apply for Medicaid. A doctor
will carry out an assessment against eligibility criteria for the
Department of Health and Human Services.

Di Pasquale also undertakes work for a group practice of private
social worker associates. This arrangement can augment the
short-term supports funded by insurance companies and achieve
long-term solutions for individuals. Private social workers are
accorded high status in the US.

Eating disorders and the role of social workers present some
interesting points: There is a link between the possible underlying
causes of anorexic and bulimic disorders and areas of social work
expertise such as dealing with sexual abuse.

Resource issues are the same on both sides of the Atlantic, with
social workers spending significant time negotiating for additional
resources. There is a clear therapeutic role for social workers in
these disorders – a role that merits development in the UK.

Eating disorders

Eating disorders are believed to represent a coping mechanism,
through which the individual numbs any feelings, with the
unconscious aim of gaining control over their situation while
avoiding having to deal with trauma. 

In the UK the Eating Disorders Association states that (at any
one time) 165,000 people (three in every 1,000) are struggling with
eating disorders. In the US the estimate is higher – between five
and 10 million people (50 to 100 in every 1,000) coping with the
condition. In the US, one in five women at college is thought to
suffer from an eating disorder.  

In the UK, the Royal College of Psychiatrists states that women
are 10 times more likely to suffer from an eating disorder than men
(the proportion is the same for the US). One out of 150 15-year-old
girls is also likely to suffer from an eating disorder. 

There is a cultural ambiguity in both the UK and US, positively
reinforcing thin body shapes and giving the message “You can never
be too thin”, but perversely looking down on women who end up with
an eating disorder.   

Gerry Graham is an independent consultant working in the
field of social care and Supporting People .

Background information

The Eating Disorders Association, 0870 770 3256 or

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