Working with Eating Disorders: A Guide for Professionals

Beyond the Stereotype

With the rising prevalence of eating disorders, every mental health professional will eventually sit across from a client who opens up about their struggles with food and body image. This brave disclosure might happen during an initial intake, or it might come months or years into an established therapeutic relationship. Because eating disorders are often hidden in shame and secrecy, sharing takes tremendous courage.

Given this reality, mental health providers must challenge their assumptions about how eating disorders present in clients. While society's hyperfocus on thin bodies as the sole presentation of eating disorders has fueled misconceptions, we, as practitioners, are responsible for examining our biases and preventing them from compromising the quality of care we provide. 

Research shows that only 6% of people with eating disorders are medically diagnosed as "underweight" (Flament et al., 2015). Eating disorders occur among individuals across the entire weight spectrum, and dangerous health consequences do as well. Eating disorders can affect all populations, including men, BIPOC communities, LGBTQ+ individuals, older adults, and athletes, and yet they're often overlooked in these populations because they don't fit the stereotypical image of an eating disorder. Body size is not an indicator of health, and assumptions based on appearance can prevent accurate diagnosis and delay life-saving treatment. I encourage every provider to maintain clinical curiosity regardless of their client's appearance or demographics in order to screen for this dangerous mental health condition.  

Your Four-Step Response

When a client discloses an eating disorder or disordered eating behaviors, here are some first steps to follow: 

1. Validate their courage in sharing something so difficult and personal. It likely took a lot of courage and trust in your relationship for them to share this with you, and it should not be taken lightly. 

2. Assess the frequency, duration, and severity of food and body behaviors to gather an accurate picture of the problem. I often ask, “How much time do you spend each day thinking about food or your body?”. I would also encourage you to ask about any medical concerns, suicidality, and support systems (whether or not they are aware of this issue). If you do not feel equipped to assess these areas, referring out for an assessment with an eating disorder specialist is always a great option. 

3. Consult with and/or refer out to specialized care—including ED therapists, dietitians, medical providers, and psychiatrists. Given the medical risk of these behaviors, eating disorder providers are trained to thoroughly assess and determine the appropriate level of care needed for clients struggling with eating disorders. 

4. Hold boundaries about your scope of practice and what role you can play. Eating disorders have the highest mortality rate of any mental health condition. Medical complications include cardiac abnormalities, electrolyte imbalances, organ failure, bone density loss, and death. Because of these life-threatening risks, eating disorders must be treated as the primary condition. 

This means that the ED providers have the expertise to set the treatment framework, and other providers can best support clients’ safety by following the ED-specialized therapist’s recommendations.

This means:

• Recognizing how the medical severity of eating disorders requires a specialized approach

• Being open to a different treatment plan than you may be used to 

• Collaborating with the ED team and following their recommendations, even when they differ from your typical approach

• Holding boundaries with the client as an aligned front around treatment recommendations, which may sometimes involve ending care with a client who isn’t medically safe to remain in outpatient care and unwilling to step up to a more appropriate level of treatment 

• Deferring to the ED specialists’ judgment on readiness for additional therapeutic work (e.g., trauma work, EMDR, movement, etc.) 

• Communicating regularly with the rest of the client’s team

This isn't about hierarchy- it's a medical necessity, just as you would defer to an oncologist's protocol for cancer treatment. 

 

How You Can Help

1. Educate yourself about ED presentations and complications

2. Build a referral network of ED specialists (that’s us at Bloom!) 

3. Update intake forms with screening questions about relationship to food, body, health, and exercise 

4. Examine your own biases about weight, food, and bodies

5. Set clear policies about your scope of practice

6. Coordinate care with the other providers in your client’s treatment team

Check out the resources on this page to start learning!

The Bottom Line

Eating disorders require specialized, coordinated treatment. Honor your client's trust in your relationship by ensuring they receive comprehensive care—even when that means stepping into a supporting role or holding boundaries with your clients in new ways. Every mental health provider will encounter eating disorders in their practice, and it is our responsibility to respond with informed, ethical care that prioritizes client wellbeing.

RESOURCES

Flament, M. F., Henderson, K., Buchholz, A., Obeid, N., Nguyen, H. N. T., Birmingham, M., & Goldfield, G. S. (2015). Weight status and DSM-5 diagnoses of eating disorders in adolescents from the community. Journal of the American Academy of Child & Adolescent Psychiatry, 54(5), 403–411. https://doi.org/10.1016/j.jaac.2015.01.020