What happens when you realise a client has an eating disorder, but you're not an eating disorder specialist?

As therapists, we're taught not to work beyond our competence. But specialist eating disorder services are stretched, waiting lists can be long and sometimes there isn't anywhere else for a client to go.

So does referring on always have to be the answer?

In this episode of the Good Enough Counsellors podcast, I'm joined by counsellor, trainer and researcher Kel O'Neill to talk about why eating disorders aren't only an issue for specialist therapists.

Kel explains why eating disorders can be easy to miss, particularly when they aren't the reason someone originally comes to therapy. We talk about the influence of diet culture and weight loss medications, and why someone's weight doesn't necessarily tell us how unwell they are.

We also explore the difficult question of competence. How do you know whether you have enough knowledge to help? What role do supervision, training and multidisciplinary working play? And how can therapists think about risk without becoming so frightened of getting something wrong that they feel unable to help at all?

Kel also talks very movingly about her own lived experience and why a counsellor being willing to work with her made such an important difference to her life.

We discuss:

• why all therapists need some awareness of eating disorders
• how eating disorders can be hidden behind other presenting issues
• shame and the stereotypes that can prevent people seeking help
• diet culture, body image and weight loss medications
• why you can't judge the seriousness of an eating disorder by someone's size
• competence and knowing when you need additional support
• multidisciplinary working in private practice
• managing risk and the fear of getting things wrong
• how training and specialist supervision can help
• what therapists can offer even when they're not eating disorder specialists
• VOXED and the importance of learning from lived experience

About Kel O'Neill

Kel O'Neill is a counsellor, trainer and researcher specialising in eating disorders. Alongside her private practice, she provides training and supervision for therapists and is the founder of VOXED, Voices of Experience in Eating Disorders, which brings together lived experience, clinical practice and different perspectives on eating disorder work.

Find out more about Kel via her website HERE and connect with her on Instagram HERE

Private Practice: Who Do You Most Want to Help?

One of the things therapists often worry about is feeling they need to know everything about every possible client presentation.

Becoming clearer about the people you most want to help gives you the opportunity to develop your confidence and expertise in the areas that particularly interest you.

On Saturday 26 September, I'm running a live Onlinevents workshop, Private Practice: Who Do You Most Want to Help?

We'll be exploring how to identify your niche and become clearer about the work you most want to do.

The workshop is pay what you can, and you can book directly through Onlinevents HERE

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You can also find me here:

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My website: josephinehughes.com

Keywords: eating disorders, eating disorders counselling, eating disorder therapy, therapists and eating disorders, counsellors and eating disorders, working with eating disorders, eating disorder competence, therapist competence, eating disorder risk, eating disorder awareness, eating disorder training, private practice counselling, diet culture, body image, weight loss medications, GLP-1, therapist supervision, Good Enough Counsellors, Kel O'Neill

The information contained in Good Enough Counsellors is provided for information purposes only. The contents of this podcast are not intended to amount to advice and you should not rely on any of the contents of this podcast. Professional advice should be obtained before taking or refraining from taking any action as a result of the contents of this podcast.

Josephine Hughes disclaims all liability and responsibility arising from any reliance placed on any of the contents of this podcast.

Kel O'Neill: 00:00:00

And in reality, the situation most people are going to be presented with is perhaps they realise the client has an eating disorder, be that in the duration of therapy or be that from the outset, and they seek to refer that person to specialist services. And that person is not eligible for specialist services. You've already recognised to some degree.

Maybe I'm not competent to do this work, maybe this requires a specialist. This person is saying, please help me because I'm going to be left for two years. Otherwise, how do you feel about not helping?

Josephine Hughes: 00:00:35

Welcome to Good Enough Counsellors, the podcast for growing a private practice without the pressure to be perfect. I'm Josephine Hughes, counsellor and creator of Therapy Growth Group, helping you get the clients you want and create the practice of your dreams.

Today I'm joined by Kel o', Neill, a counsellor, trainer and researcher who specialises in eating disorders as well as running a busy private practice.

Kel teaches therapists across the uk, contributes to research and is passionate about helping us better understand eating disorders and the realities of working with them in practice.

I'm really looking forward to our conversation because although eating disorders are often seen as specialist work, many of us are going to encounter clients where food and eating form part of the picture. Kel, welcome to Good Enough Counsellors.

Kel O'Neill: 00:01:42

Thank you for having me.

Josephine Hughes: 00:01:44

So let's just start by saying that many people will hear the word eating disorder and think that's specialist work and it's not for them. Yet many of us will encounter clients, won't we, where eating is part of the picture. I've certainly had that happen in my practice.

So why do you think this is an important conversation for therapists, for all therapists, not just specialists?

Kel O'Neill: 00:02:07

The reality that we've presently got with specialist eating disorder services is that they absolutely cannot see even really a small percentage of folks who are affected by eating disorders. So we know that in the uk. So if we go back in time a little bit, maybe if we start there.

When I first started working in eating disorders, we were saying 1.25 million people in the UK were affected by eating disorders.

Josephine Hughes: 00:02:36

That's a huge amount.

Kel O'Neill: 00:02:38

Well, it is, but it's. It's now known to be significantly more than that.

So the latest data suggests that it's something closer to around 1 in 14 people who are suffering and 1 in 8 people who may be symptomatic of an eating disorder.

So have, like, some symptoms but maybe not fully meet a diagnostic criteria, as per a medical model, which actually would make it something more like 10 million people in the UK.

So it, it makes it as common as depression, anxiety, any and many of the other issues that we would typically be encouraged to learn about and support in our practices. And yet it continues to be this.

What I've been referring to, what I've been referring to as having is this like referral reflex where we just hear eating disorders and we go, okay, I refer that.

But with NHS services only being able to see a small proportion of those folks, due to the magnitude of the amount of people affected, they have nowhere to go. So of course they're going to.

As we learn more about therapy and counseling and people become more educated on mental health, those folks are going to come forward seeking support. And right now there simply isn't even remotely close to enough specialists to work with people.

Josephine Hughes: 00:03:59

Yeah, I can imagine. Yeah. So can we just sort of like, just a bit, a little bit of definition by what we mean about eating disorders?

Because I think a lot of us sort of think of maybe something like anorexia, for example, but when you're talking about them, what sort of things do you include in your definition?

Kel O'Neill: 00:04:15

Yeah, so I, I think I probably would apply a pretty broad stroke.

The definition that I tend to use when I'm teaching around eating disorders, which maybe is a bit of a mouthful, is that eating disorders are complex mental health problem characterized by marked distress expressed in relation to body image, weight, shape, size and. Or food. And almost always these behaviors go on to have an impact on the person's physical health as well. So I was to break that down a little bit.

What I'm essentially saying is that when there's distress in relation to body image, weight, shape, size or food, in my mind that's an eating disorder, kind of irrespective of terminology. Like anorexia or bulimia.

Josephine Hughes: 00:04:59

Yeah, yeah. So how would you sort of define that distress? Because I think a lot of us have difficulties, say, with our body image.

But where does it sort of like almost tip over, do you think, into like extreme distress?

Kel O'Neill: 00:05:13

Yeah, that's a good question. I think it's. There's definitely not a definitive line that we can say, you know, at this point you've crossed it.

But if you imagine, you know, I, and I try to be quite open about the fact that A, I have lived experience and I'm fully recovered, but B, that does not mean I have 100% positive body image because that is just an unrealistic expectation in this society that we live in.

So as a recovered person, I get up in the morning and maybe once in a While I think something about my body, I think, oh, those jeans have got too tight or that doesn't look right, or maybe something about how I'm feeling that day doesn't quite feel 100%, but I'm gonna get dressed, I'm gonna go in the kitchen and have my breakfast and feed my dogs and get on with my day. It's not going to be a constant conversation in the back of my head of that as an issue that I carry with me through everything that I do in the day.

Whereas somebody with an eating disorder will carry that with them. So they may get up in the morning and feel that negative thing about them.

And it may then go on to inform many of the decisions they make for the rest of.

They might be decisions about food, they might be decisions about eating disordered related behaviors like purging or over exercising, they might be related to hiding your body, it might be related to relationships.

And so if you are walking around just getting on with your daily life and those thoughts are invading kind of what would be your normal, otherwise happy, average life, then I think we've probably crossed the line.

Josephine Hughes: 00:06:50

Yeah, that's. I think that's a really interesting and helpful way of seeing it actually, because.

Because it can really sort of impact people, can't it, that it becomes something that people are thinking about constantly.

I notice when people talk about, and we'll probably move on to talk about this a bit more, when they talk about weight loss drugs that they say it stops a lot of that sort of food noise. Is that the sort of thing you're, you're talking about that sort of food noise type thing?

Kel O'Neill: 00:07:14

Yeah, to some degree, I would say that's become quite a popular media term, hasn't it, in the sort of last 612 months, perhaps in relation to some of that drive for food or internal monologue related to food or body image.

So yes, in some ways I think probably in relation to the weight loss medication that GLP wants, the conversation is a little bit more complicated because in a society where we're, many people are driven by thinness and we're encouraged to be thinner, many people diet.

And when we diet, especially if it's significant or beyond what our body thinks is healthy or appropriate for us, we're going to think about food more.

Even if, I don't know, maybe prior to coming onto this call with me today, maybe you've had a really busy morning, you haven't had time to think about your lunch yet. By halfway through the time that we're doing this Recording, you're going to be thinking about food.

That might be considered food noise, but that doesn't mean that that's unhealthy because actually it's your body just saying, hey, go, go, go, go get your lunch if you haven't done so already.

Josephine Hughes: 00:08:22

Yeah.

Kel O'Neill: 00:08:22

So I have some reservations about kind of GLP1s being used as a way to like commute food noise because if you're engaging in heavy dieting and your body therefore is distressed and asking for food, it's saying, feed me, I need energy. Then that quote unquote, food noise is not a problem.

It's a normal biological given versus somebody who's kind of stuck in those cognitions of self worth and their values and their identity being very much wrapped up in that as well. I think that line's even more blurry.

I think there's, it's going to be a very difficult one for the, the fields to untangle over the coming years, I think.

Josephine Hughes: 00:09:04

Yeah, I'm thinking there's almost a sort of correlation where we say, you know, it's unrealistic for, to expect people never to feel anxious, for example, never to feel worried because there will be things sometimes that come up that are worrying. So, you know, it's not about squashing those feelings away. It's about acknowledging that life sometimes can bring fear.

And fear is a good thing, isn't it? Because fear makes you run away. So likewise hunger and that sort of food noise, if you want to call it that, makes you eat. Which is healthy.

Kel O'Neill: 00:09:33

Exactly, yeah.

Josephine Hughes: 00:09:34

Yeah. So how are dieting culture and weight loss medications influencing what you're seeing, do you think?

Kel O'Neill: 00:09:42

Try not to get too wrapped up in the social media thing, but it's, it's scary how much is everywhere at the moment, right, that, that we have celebrities vanishing literally before our eyes, including folks who historically have been very body positive and been very. For living in their natural weighted bodies rather than kind of going along with the weight loss side of things.

And something I'm definitely noticing in my practice is that perhaps as a consequence of this, folks seem to be losing sight on what actually a healthy body looks like because we're being given so much visual input of thinness that it just, it sort of becomes. Seems like it's normal once you've seen it a lot, which is kind of proving to be a challenge.

And I also think that it's becoming harder and harder to differentiate the good advice from the bad advice on social media in relation to health and nutrition. And many, in my opinion, at Least many people who are taking GLP1s or be they prescribed via doctor or not.

Many of those folks would actually meet criteria for an eating disorder and would benefit from psychological support whereas being treated as something kind of purely physical. Right. I think we've shouted about this enough over the years that we can't separate the brain and the body from one another.

And one of the things I often say to clients is diet culture is making a rich middle aged white man somewhere in the middle of America a billionaire. So let's not give him any more of our money.

Josephine Hughes: 00:11:27

Yeah, yeah, yeah, I do agree with you.

I think especially being an older woman as well, you know, and I've put on weight since the menopause that, you know, you look around and you start thinking, you know, I'm the outlier now.

And it's really difficult to sort of resist that pull and seeing people who are much thinner and thinking, you know, I'm much bigger than everybody else and just sort of thinking this is normal actually. But no, it's sort of difficult to resist the sort of siren call of sort of thinking, oh, I could be thinner if I did something like this.

And yeah, I find it a real challenge actually to, you know, hold myself, to accept myself for who I am, really. So. And I'm sure that's shared by very many other people as well.

Kel O'Neill: 00:12:14

I mean, we're constantly told who we are needs to change, physically who we are needs to change. Sometimes it's deeper than that, but often, especially as women, it's something, something physical.

Josephine Hughes: 00:12:27

Yeah, yeah. So I was wondering actually, because I think eating disorders can show up not necessarily when people first cross the door, can't they?

How might they show up without it being the presenting issue? What would you say therapists need to be aware of?

Kel O'Neill: 00:12:43

Maybe there's an assumption that the majority of people, perhaps even all people with eating disorders that were coming to therapy would A, know they have an eating disorder and B, feel comfortable disclosing that out of the gate.

And I think the reality is that actually lots of people don't realize that they have an eating disorder if it's, if it's not at the very worst end of the spectrum.

Josephine Hughes: 00:13:05

Yeah.

Kel O'Neill: 00:13:06

And especially if they've been living through it kind of throughout their life.

Course, you know, so I'm, I'm 40 now, so if I imagine if I've been experiencing something since I was say, 15, be very normal to me at this point and requires you to play down. So I definitely see a lot of that kind of reality with with people I meet in various contexts of my work. In fact, it's not uncommon.

So bear in mind most of the training that I deliver is to counsellors and therapists. It's not uncommon. Almost every time I deliver a session for somebody in the room to go, oh, hang on, wait, I think I've got an eating disorder.

And that's in a room full of therapists.

Josephine Hughes: 00:13:39

Yeah.

Kel O'Neill: 00:13:40

So if we've got a little bit more knowledge on mental health, you would think we would be ahead of that game a little bit in noticing the challenges. But sometimes it's just, especially with the diet culture conversation, it's so normalized.

Josephine Hughes: 00:13:52

It is, isn't it? You don't even realize that you're part of it because you're just so in it. I think.

Kel O'Neill: 00:13:59

Yeah. And I think in some ways the, perhaps this is because of dieting culture and the GLP1s and that type of thing.

The perception of where the line has been, the line that you asked about as we began speaking has maybe moved and people think unless I'm doing all of these things that it's not an eating disorder.

But if we go back to my definition and we take into account that we've known for a long time that early intervention is their best course of action in eating disorders, that the earlier somebody gets help, the better chance of full recovery and shorter duration of illness as well.

So, yeah, lots of people are going to arrive and maybe if we ask questions about food and body image and relationship with self in that way it might become apparent and we might find ourselves asking questions. I know I haven't always only worked with clients with eating disorders. I do only see clients with eating disorders in my private practice now.

But that wasn't always the case and sometimes would give people my business cards and you know, to write an appointment on the back of, or whatever and they would say, oh, you're, you're an eating disorder specialist. Can I talk to you about this? Maybe I've already had 10 sessions with them and they haven't even disclosed it to me.

Yeah, well, so maybe also sometimes people just come focusing on, you know, okay, maybe I've been sent by work to talk about work related stress. That's the topic.

Josephine Hughes: 00:15:20

But it's there in the background and I imagine there's quite a lot of shame around it as well. Shame about body image maybe or even shame about, I don't know. I don't know if people have feel shame about going on diets.

It's so sort of common, isn't It. But is there a role, do you think, people holding things back because they feel ashamed to admit it?

Kel O'Neill: 00:15:41

Yeah, absolutely. I think. I think in terms of dieting, I think it's. It's so common, isn't it?

You can't sit in a cafe without hearing somebody on the table next to you talking about it.

Josephine Hughes: 00:15:50

Yeah.

Kel O'Neill: 00:15:50

I often wonder, is it appropriate for me to start handing out my business cards in these places? Haven't quite taken to it yet. But once it becomes more of an issue, the shame, I think, tends to become part of hiding it.

Hiding it is part of maintaining the disorder. And hiding it is also very much related to shame across all types of eating disorders, I would say, and especially if you don't meet the stereotype.

So the stereotype for forever in a day in eating disorder work has been the eating disorders affect skinny, white, affluent girls, so teenage girls, effectively, which we absolutely know is not the case. It affects people right across the lifespan of all different types of backgrounds. For some reason, this stereotype continues to prevail.

So I think there's maybe more shame for men with eating disorders or adult women, particularly older adult women with eating disorders or people who come from particular cultural or religious backgrounds, where it would be particularly shamed by perhaps their elders. And I think the less you fit that stereotype, the more difficult it is to come forward.

I think that's the case with different types of eating disorders as well.

So most people with eating disorders aren't thin and yet the majority of people that even come to me for therapy are thin because I think it's easier to come forward if you fit the stereotype.

Josephine Hughes: 00:17:14

Yeah. And I suppose it's that recognition, like you were saying, of actually realising that you have actually got an eating disorder.

Because I suppose there's a sort of like a threshold that people maybe feel that they need to meet. So, you know, either they can't stop dieting or that they, you know, they really have bad bulimia or something.

It took me a while to realize, actually, when I was younger, basically I just really ended up hurting myself over exercising. And that was all related.

And I was in this incredibly unhealthy community with a major dieting organization where we'd vie to be the most active and ended up hurting myself, which is a good. Was a good lesson, I think, you know, But I look back now and I think, blimey, that was so unhealthy.

And it's at the time, you know, you sort of get that sense of, I suppose, being in control and, you know, you feel good about yourself, all that sort of stuff. Listening to Kel, you might be thinking, how do I know what I'm competent to work with?

One of the things I often see therapists worrying about is that they need to know everything about all sorts of different presentations.

In reality, building a sustainable private practice often comes with being clearer about the people who you most want to help and developing confidence and expertise in that particular area. And that's exactly what we're going to be exploring in my online events workshop, which is called Private Practice. Who do you most want to help?

That's coming up on Saturday 26th September. You book directly with online events. It's a pay what you can fee, so it's, you know, it's up to you how much you actually pay and can afford.

And I will pop the link into the show notes. And now back to Kel. So going back to sort of like thinking about the competence side of things.

So therapists usually told you mustn't work beyond your competence, but also a specialist service are difficult for clients to access. So I think both therapists and clients are left in a sort of difficult position.

So how do we know whether or not we're competent enough to work with someone?

Kel O'Neill: 00:19:36

I wish there was a nice, simple answer to this one, and I hope that one day there is. I'm actually starting my PhD later this year and to some degree we'll be looking at aspects of that in what I hope to do next.

But I think the question of competence sounds like a definitive line, right? It sounds like, okay, I've done this CPD in it, I've got this qualification or I've got this experience, so now I can do that thing.

And in reality, the situation most people are going to be presented with is perhaps they realize a client has an eating disorder, be that in the duration of therapy or be that from the outset, and they seek to refer that person to specialist services. And that person is not eligible for specialist services or is placed on a very long waiting list.

So there are areas of the country where for adults with eating disorders, the waiting list is two years long.

And all of a sudden I think we're left with not just am I competent to do this work, but you've already recognized to some degree, maybe I'm not competent to do this work, maybe this requires a specialist.

And also this person is saying, hey, please help me because I'm going to be left for two years otherwise, or I'm never going to access help because I'm not eligible for the service for some reason, which is often weight related. And how do we, how do we feel about not helping in that instance? What is, what is the competence about?

Is the competence about our capacity to, quote, unquote, treat an eating disorder? Is the competence about our capacity to hold a safe space where they can work through some things?

And I think sometimes we're, we're looking at the wrong point for the competence we're looking at, do I know all things and everything about eating disorders enough to treat an eating disorder? Because that's the language that's used in relation to eating disorders.

Josephine Hughes: 00:21:33

Yeah.

Kel O'Neill: 00:21:34

Rather than maybe something much more person centered about it. You know, can I, can I offer this person a space where I can work with inside what in my instance, BACP ethical framework suggests?

And how do I go find some extra support to enable me to do that if needed, such as specialist supervision or more training? But I think the profession needs to ask itself a bigger question in relation to this.

Like, okay, well, do we need to know where that line is between can we work safely and can we not work safely? And how do we place that line somewhere?

How do we ensure therapists have enough knowledge that we can work with some of those people, at least that can't go to specialist services? How do we increase our base level of capacity?

Josephine Hughes: 00:22:27

Are there any sort of, you know, like list of competencies or anything out there? No. No.

Kel O'Neill: 00:22:32

So there are guidelines around medical management of eating disorders and so on, which would be particular appropriate for kind of like doctors and psychiatrists and in hospital based settings, and those are used in community based settings as well. But as far as counseling and therapy goes.

No, I think for as long as at least I've been around, it's been this referral, reflex response, specialist services. I've been having some conversations with some people about if that might be something that can be considered in the future.

But these things take a long time as well, especially in eating disorders where our research and knowledge tends to be years behind anything else.

So if, if you were to say to me tomorrow, okay, let's make a competency framework, it would still require quite a lot of legwork in researching really what that could even look like.

Josephine Hughes: 00:23:23

Oh, wow.

Yeah, yeah, there's not, there's not, there's sort of nothing definitive out there that helps you say whether or not something falls within your competency.

Kel O'Neill: 00:23:34

Yeah, no, it would very much be the kind of medical guidance which certainly how I handle that in my practice is that my clients see the GP or a psychiatrist or both or Sometimes an eating disorder service in addition to me, because I'm not a medical professional. But then that leaves us without any sort of framework to measure our competency.

Josephine Hughes: 00:23:56

Yeah, it's interesting, isn't it?

Because what's coming up for me is certainly sort of reading on some of the forums that if you're working with someone who's got an eating disorder, it needs to be a sort of team based approach. And that can be quite difficult if you're in private practice, can't it? I don't know. If you. Do you.

If you have a client, would you be talking to other sort of people who are treating them or do you keep it all very much private?

Kel O'Neill: 00:24:20

It would definitely depend. So you're absolutely correct. The guidelines are multidisciplinary team. And of course that's because it's. It requires multidisciplinary input.

We're affecting mental health, affecting our physical health. And in that way it needs multiple professionals to be involved. So I require my clients to see their gp.

That's a conversation I have out of the gate before we make any contract to work together. And I usually, in most instances, write to the GP to let them know that I exist. In some instances that's kind of as.

As much as is required to know that the GP is on the page and doing the thing. But there are also many instances where I, despite being in private practice, may be communicating with or in relation to.

So sometimes the client is the facilitator of the communication and sometimes it's more actively a team around the client. There might be a gp, a psychiatrist, a nutritionist or a dietitian, an occupational therapist, a support worker, a coach.

There could be any number of professionals really involved and more if there's kind of physical consequences as well. So, yeah, I think it definitely requires a little bit more administratively in that respect, which I'm sure probably puts some people off.

Josephine Hughes: 00:25:39

I suppose it's sort of like if you're almost starting from cold, it must be probably knowing who to go to and who to speak to must be quite hard. I don't know if you had. Did you have connections already when you first started working in private practice with this?

Kel O'Neill: 00:25:53

To some degree, yes.

So when I came into private practice, which I guess is about 13 years ago now, I'd already been involved in eating disorder work for quite a number of years. Probably eight years, maybe at that time.

But a lot of it has been built over the years from just reaching out to people and going, hey, can we have a conversation and see if we're on the same page. I want to have a list of dietitians. I can feel confident saying to clients, here's. Here's some options to look at.

I've been cautious not to have a dietitian that I work with and a psychiatrist that I work with, so that clients kind of got some autonomy of choice over that. But also, like you say, you don't want to be going into it blind every single time.

Josephine Hughes: 00:26:36

Yeah. So it's sort of like just building, building up over time. And presumably as well, you get referrals from, from them.

But, you know, to you, if they have a client who, who wants some private therapy as well.

Kel O'Neill: 00:26:47

Yeah, yeah. The vast majority of.

The vast majority of my referrals now actually come from other therapists who have maybe reached that point where they're like, okay, this is beyond my competency.

Josephine Hughes: 00:26:57

Yeah.

Kel O'Neill: 00:26:58

However soon or far into a journey that might be.

But also some of the eating disorder services, when they kind of get to the end of the provision that they're allowed to offer, some of those eating disorder services will refer to me. So I think hopefully that's indication that I've got a good reputation.

But also some of it's having to work at making yourself visible as a professional.

Josephine Hughes: 00:27:20

Yeah, yeah. Just sort of like you say, reaching out to people and getting to know them. Yeah.

So do you think people can sort of grow their competence through training and supervision?

Kel O'Neill: 00:27:38

I think the answer is that it has to be yes.

Josephine Hughes: 00:27:39

Yeah.

Kel O'Neill: 00:27:40

I don't, I don't think everybody necessarily emotionally has the capacity to do the work. That's not necessarily a moment in time decision. That might be to do with the level of anything going on in your life at any one moment in time.

You know, if I was to look over the last 10 years of my practice, there's been times where I've increased and reduced how many clients I see based on my capacity to hold space for the complexity that I work with.

And they do tend to be more complex presentations than, let's say we were just kind of offering general counselling or bereavement or anxiety, those types of things. And so I think it. It can require a bit more of us.

And lots of people that come to me for supervision come with this sense of fear of the work, which in many ways I don't want people to stop feeling. I think if you stop being afraid, then you stop being as diligent as you need to be in the work. And yes, I carry that fear.

And, you know, I've seen hundreds and Hundreds of clients at this point. I'm able to not carry that into my personal life.

So I do say to people, you know, if you're gonna go away and you're gonna be lying in bed staring at the ceiling, thinking about this at 3 o' clock in the morning, you can't do that to yourself. That's beyond your capacity right now, for whatever reason. But in terms of knowledge, I actually think that.

I think counsellors and therapists have wonderful skills that people with eating disorders need. That is actually not part of treatment, as usual. It's not. You wouldn't usually see a counselor in the NHS in an eating disorder service setting.

And predominantly what we need other than that kind of support from maybe specialist supervision is to understand eating disorders enough that we don't kind of keep hitting the brick walls that kind of present as part of the disorder. I guess that maybe that's where the complexity lives.

Josephine Hughes: 00:29:36

Yeah. I'm just really interested to hear you say that. It's, you know, you have to have the capacity for it.

Because what it's saying is that actually this is, you know, sort of quite scary. Deeper work, perhaps, than perhaps. Perhaps because maybe called general counselling.

What is it about working in eating disorders that makes it sort of more complex and scary?

Kel O'Neill: 00:30:03

I think the main thing that people coming for supervision would say would be the risk. And the risk is ultimately the risk is death. Right. From the physical consequences of the eating disorder.

And also the prevalence of suicide amongst folks with eating disorders is very high as well. So both types of risk are presenting. But it's usually the physical risk that people are scared of.

It's not necessarily the suicide risk that therapists are scared of. Probably quite. Quite used to holding that in other contexts.

Josephine Hughes: 00:30:32

Yeah. But it's the fact that someone might die from an eating disorder. Yeah.

Kel O'Neill: 00:30:38

And maybe feeling responsible for that for some degree. I think that goes back to that, like, treatment language. And we're told that it's eating disorder treatment. And I'm not.

I'm like, I'm not treating eating disorders. I'm an eating disorder counselor.

Josephine Hughes: 00:30:50

Yeah.

Kel O'Neill: 00:30:51

Of course, that doesn't absolve me of all responsibility, but also it's also not all on us. And that's part of that multidisciplinary working as well, is that we're sharing the responsibility.

Josephine Hughes: 00:31:01

Yeah.

I really like that distinction, actually, because that must help you to hold it more lightly than feeling that terrible burden of responsibility for people. Yeah.

Kel O'Neill: 00:31:12

I guess the thing that helps. Helps me.

Guess the thing that helps me carry it is thinking if, if and when something awful happens, I often say to people, if you're going to work predominantly or solely in eating disorders, you are going to lose clients. Statistically speaking, about 20% of people with anorexia, for example, will die as a consequence of their eating disorder.

So if you're going to work with hundreds of clients, you're going to. The statistics would have it born that you're going to lose somebody at some point.

And I think there's an acceptance process that you have to go through with that in order not to stop carrying the fear, but in order to not be stopped by the fear.

But I think the thing that keeps me going despite the potential for immense amounts of worry in the work, is knowing that for me, when I was unwell, if a counselor didn't take that risk, somebody did. If a counselor hadn't taken that risk for me, I would be dead. And I don't question that for a minute. And I've said that to her many times before.

Maybe she doesn't like that. I kind of say that I would.

Josephine Hughes: 00:32:22

Be dead if you helped me.

Kel O'Neill: 00:32:23

You saved my life. But that is the reality of that downward slope of the eating disorder. And if there's no other support available. So somebody has to be brave enough.

And I'm not saying I can help every client I work with, but it's.

Josephine Hughes: 00:32:39

A very strong motivation.

Kel O'Neill: 00:32:41

Will try.

Josephine Hughes: 00:32:41

Yeah, yeah, yeah. Amazing. Yeah.

Kel O'Neill: 00:32:44

And accept that actually when it goes wrong, I'll have to do things to look after me.

Josephine Hughes: 00:32:50

I think that's. That's a really sort of touching on a really interesting point because I think we often avoid stuff because we're scared of the outcome.

Kel O'Neill: 00:32:58

Yeah.

Josephine Hughes: 00:32:59

And what you're telling me is that you try and be courageous, you try and act in spite of perhaps an outcome that you wouldn't want and recognize that. Yeah. The statistics say it's going to happen at some point. So how do I deal with it when it happens?

Kel O'Neill: 00:33:17

Yeah.

Josephine Hughes: 00:33:18

Is the thought of it almost worse? I don't know. I don't know if that sounds a bit of a silly question, really. Sometimes we're so scared about something and we hold ourselves back.

Yet when it happens. I mean, it's pretty awful, obviously.

Kel O'Neill: 00:33:31

Yeah.

Josephine Hughes: 00:33:32

But it's almost like the thinking about it worse than when you actually go through it. I don't know.

Kel O'Neill: 00:33:37

Yeah. I think. I think it really depends. Having been able to supervise kind of people with different temperaments doing the work and see.

And seeing it happen, I think sometimes I notice that some of us are kind of scared of legal action or scared of, like, professional repercussions. More than. More than holding the individual and the risk that the individual holds, we kind of worry that we're gonna somehow get in trouble.

Josephine Hughes: 00:34:02

Yeah.

Kel O'Neill: 00:34:03

And those questions about, like, what is ethical and what is beyond my competency and am I going to go to prison? I think is a question I've heard a couple times.

Josephine Hughes: 00:34:11

Oh, gosh. Yeah. That's very scary thought. Yeah.

Kel O'Neill: 00:34:13

Yeah. I don't. I don't think you. You can prepare yourself for the reality of the experience. Experience when it happens. I've been very fortunate.

It's only happened once in. In my entire working life so far.

Josephine Hughes: 00:34:30

And.

Kel O'Neill: 00:34:33

I think if you've got that support system in place, that you've got a good supervisor and the people in your personal life know what type of work that you do and maybe you go get some personal therapy in those instances. For me, I guess I made the same piece with it as I. As I make with taking the risk that.

That, at least in the instance I'm referring to with myself, nobody else was willing to help that person and we were both very actively consenting to trying to make a difference. And unfortunately, the outcome isn't always what you would hope it would be.

But equally, I have worked with and met in other contexts, therapists and other professionals working in eating disorders who have had a client or a patient pass away as they're eating from their eating disorder or from suicide, and they've not felt able to continue to do the work. So I guess that's. That's a real reality for some people as well.

Josephine Hughes: 00:35:30

But I think the thing is, is if you're working sort of like in the nhs, you're surrounded by other colleagues, aren't you, who perhaps can reassure you. Whereas when you're working in private practice, it can actually be a really lonely experience.

I should think, especially facing something like that can be really, really difficult.

Kel O'Neill: 00:35:47

Yeah, yeah, I think it's. I think you keeping notes that work for you is really important in those instances, so you can reflect on the decision process that you went through.

And I think the going into supervision, like all cards on the table, is really important so that, A, if you need support, that becomes apparent, but also B, you're not holding the bits because you're worried or ashamed or anxious about, did I make a mistake? You need to kind of have a good relationship with your supervisor. So, yeah. Can air it all.

Josephine Hughes: 00:36:22

Yeah. So it's the same sort of what ifs or if onlys, but if you've brought everything to supervision and had the chance to talk it through.

Kel O'Neill: 00:36:29

Yeah.

Josephine Hughes: 00:36:29

It gives you sort of like more of a sense of. Yeah, I did do the best that I could. Yeah. It's just shocking though, isn't it? I think that's. That's part of it.

Just a real shock when we lose a client like that. Yeah, yeah, yeah.

Gosh, I still didn't expect to go there, but it's an interesting thing because I think that's probably, like you say that that's that fear. Either of you know what's going to happen? Are people going to take me to court or, you know, what's. What's going to happen to my client?

And I think that sense of responsibility that many of us carry for our client outcomes, it really does. It really can hold us back. So it's very interesting to hear.

Kel O'Neill: 00:37:09

Yeah.

Josephine Hughes: 00:37:09

Sort of your, your perspective on it. Yeah. So are there questions that we should always ask, do you think, when we. When we're working with somebody, you know, to assess risk or.

Kel O'Neill: 00:37:20

Mm. So I think having a realistic picture of risk as a counselor or a therapist in eating disorders is pretty unrealistic. You know, we.

We do not have X ray vision. I cannot check blood tests and I think there's been.

So my master's research looked at how therapists risk assessment decisions changed based on the presenting weight of the client. And what it showed me was that actually it does.

So people's perception is still very much in relation to eating disorders, driven by this idea that if the person is thinner, they're sicker, which is absolutely not the reality.

Which is exactly why I require all of my clients, irrespective of how they might physically seem, to have that kind of check up with the GP as a minimum basis.

And I guess part of that risk management bit for us, that fear bit that we were talking about, is knowing that actually I. I'm here supporting the mental health aspect of this. I'm here in a counseling role and there is some bits here I can't do anything about.

I think I'm quite lucky that I've been in the eating disorder field long time at this point and I maybe am a bit more primed to notice some of the signs that might indicate a medical concern. And I've got kind of some accidental medical knowledge from running osteopathic clinics and a first aid business in another lifetime.

But you don't need those things to do the work, I don't think. I think the reality is accepting, you know, I can't do this on my own. I'm not a medical professional.

And also, we know that oftentimes folks with eating disorders, largely out of shame or concern that we're going to make them change their behaviors, they might hide bits of what they're experiencing from us. You know, I can.

Sometimes I find out that somebody's engaging in a really risky eating disorder behavior months into working with them, which, if I had not done that GP bit at the beginning, I might now all of a sudden be thinking, oh, no one scrambling around to do that. So I kind of start with the basis that risk is probably high, and I think that's the safest way so far I figured out how to handle it.

Josephine Hughes: 00:39:36

Yeah.

So with something like that, where someone has hidden something, is it sort of like you might ask them a whole series of questions and they just say no, but in actual fact they're doing it. Or do you not tend to question people at the start or.

Kel O'Neill: 00:39:49

It depends. So sometimes I might kind of like use a formal assessment process and sometimes. Sometimes I might use no assessment process whatsoever.

Kind of depends on how the client presents at the outset. But sometimes it might be that they feel really ashamed about a specific behavior and they don't feel comfortable to talk about it.

So let's say, for example, if somebody has a diagnosis of anorexia and they are predominantly restricting, that does not mean that they're not engaging in any other eating disorder behaviours. It just means that the restriction and the lack of nutrition is the predominant symptom. They may also be, for example, making themselves sick.

And there tends to be more shame associated with making yourself sick because it kind of sounds a bit gross.

And sometimes even folks will think, okay, well, if my doctor or my psychiatrist knew I was making myself sick, they wouldn't say that that was anorexia, which is not necessarily true. And there's almost like some odd kind of elitism sometimes in that presentation that people think there was more shame attached with that.

So I want that type of diagnosis.

Josephine Hughes: 00:40:59

Yeah, yeah. Because like you say, making yourself sick might be considered a bit icky. So, you know, you don't necessarily confess to it. Yeah.

Kel O'Neill: 00:41:09

I think probably the thing I tend to find out most often as a later thing, something that doesn't come out in the beginning, even if I sometimes ask about the question, is laxative misuse.

Josephine Hughes: 00:41:19

Really? Yeah.

Kel O'Neill: 00:41:20

And I guess maybe we don't like talking about toileting habits very much.

Josephine Hughes: 00:41:25

Notice there's too much, you know, shame around it. I should think so. Yeah. The other thing I just wanted to come Back to.

Because I don't know enough about eating disorders to know the answer, which is that it's not necessarily thin people who are very ill, it can be big. Is it big people can be ill as well. Is that like nutrition again? What, what did you mean by that?

Kel O'Neill: 00:41:44

Yeah, so people at any point on the kind of weight spectrum can be at increased risk as a consequence of their eating disorder behaviors, like physically at risk. So particularly like self induced vomiting.

We know that can be especially dangerous behavior because when you're making yourself sick, your body becomes depleted of things like potassium and magnesium which your body needs to function, which are really bad for for example, cardiac health. So you know, problems sounds scary. Heart problem sounds scary.

Already about 80% of folks with eating disorders may have cardiac symptoms issues at some point, again, irrespective of weight.

So I think the perception probably would be underweight people would be at the most risk, high weight people would be at the next risk, and then average people would be last on the list. Actually, we know more risky times tend to be periods of change.

So for example, if you've just gone through a refeeding process and gained some weight and then your eating disorder behaviors change, your body is trying desperately to cope with all this change happening, far more likely to throw up a medical problem there. So yeah, it doesn't just, it really doesn't make a difference.

I've worked with clients with very short term eating disorders in perfectly average weight kind of body presentations and they've had serious medical consequences.

And I've also worked with people in very underweight bodies who maybe we would assume had very high risk, whose bodies have done miraculous with coping with what has happened to them. So I think a lot of it is just kind of our individual genetic robustness.

Josephine Hughes: 00:43:26

Yeah, it can just depend on sort of what it's on people, different bodies. So is there something that should, should never be ignored, do you think? Is the things that come up where you just think, oh, this really needs.

Kel O'Neill: 00:43:37

More help or in terms of kind of the physical side of things, the risk side of things, anything.

Josephine Hughes: 00:43:44

I think, you know, it's just what should people look out for?

Kel O'Neill: 00:43:48

I guess if you find yourself working with somebody with an eating disorder and their behaviors are continuing to get worse.

Yeah, that would be a red flag for not necessarily, doesn't necessarily mean you're doing anything wrong, but it might just mean that what they need isn't what you're offering. And I often have that conversation with clients.

I'm very much kind of humanistic, existentially Based as a therapist, which is not kind of standard eating disorder treatment, which would be cbt. But different people need different things.

So if we're offering something and it's continuing decline over months of time, I'm not going to hang out there too long with a client before we look at kind of some other options. What are the modalities or methods might there be here that might be.

That might at least stop the physical aspect of the eating disorder getting worse? We know a big time for risk is when change happens.

So if there's been a lot of change and then the client starts pulling back, that's usually the red flag. I like viscerally feel the most.

Like if a client has been going through a refeeding process or has had a big change in their life and I know that that's related to what triggers eating disorder behaviors for them and then all of a sudden they're canceling sess. That's the one that tends to make me panic.

Josephine Hughes: 00:45:03

Yeah, yeah. What do you do in that sort of situation? Do you get back in touch with them or. I don't know what you do.

Kel O'Neill: 00:45:10

I guess the answer to that one is that depends as well. I guess to everything. I'm very explicit in my contracting with clients.

I have a reasonably extensive written contract that I send to clients in advance, which actually sets out what I would do in that type of scenario in terms of frequency of contact and at what point I might contact an ex of kin, for example. And a couple of times I have been very worried and then the client's just been like, I'm really sorry I broke my phone or something like that.

All of a sudden they get back in touch and you're like, okay, I'm just going to scrape myself back off the ceiling. And sometimes clients don't come back and you never get to know why. And.

And sometimes maybe there has been something that's changed and maybe they've ended up in hospital, for example.

Josephine Hughes: 00:46:00

Yeah. Yeah. You just don't know sometimes. Yeah. So it's so interesting to hear and to speak to you. I know you're just scraping the surface with us here.

So tell us a little bit about voxed.

Kel O'Neill: 00:46:16

Sure. So voxed Voices of Experience in Eating disorders is. Is one of my thought babies. I think we're referring to it as. So it's at the moment it is.

It is becoming an annual conference. So we ran. I ran all the way back in the pandemic, if we can even remember that far back at this point in time.

I ran a Small event online during Eating Disorders Awareness week, which is usually the last week of Feb. And I just popped out a message on my waiting list. I was like, not my waiting list, my mailing list.

And I was like, hey, if people want to come and hang out during Eating Disorders Awareness Week and talk to me about what you think is important in eating disorders stuff, then I'll be here. Here's my zoom link. And that was what we did.

And what it turned into was that lots of the people there had lived experience or were clinicians with lived experience or people who were working in eating disorders and they were kind of sharing with me their pain points, if you like, about eating disorder field. And one of the things that came up was that actually eating disorder conferences and eating disorder education are a exceptionally expensive.

So the main eating disorder conferences are sort of circa 500 pounds a day, which is not accessible for most therapists in private practice. And then you add to that like travel and accommodation and all the rest of it. And they're also very situated within a medical model.

So there's lots of lingo and medical bits that just wouldn't really speak to us as a profession.

And then a specific bugbear, which was that although conferences have started to make space for folks with lived experience, there's usually a spot, like a singular spot in the duration of the conference for the person with lived experience, almost like they've been popped on a pedestal to perform for 20 minutes, which is all very icky and uncomfortable.

And so what people were asking for was a financially accessible, linguistically accessible, like not situated with a medical model, lived experience centered conference for us, the folks that are out here on the front line doing the work, who maybe aren't specialists in many instances, but are interested in the topic. And one day I was chatting to John at online events, who I've done many events with over the years, and he was, was like, why don't we do it?

And I was like, okay, let's do it. And we kind of imagined.

So it was this last February was the first one, February 26th, we kind of imagined we were going to have maybe half a dozen speakers and put on a day. That was the plan. And then we opened it up for submissions and started to see the interest.

And what we ended up with there was four streams, 34 speakers. Oh blimey, I guess that's 20 something hours of CPD from the day. So it's low cost, it's centered around lived experience in all its forms.

So that might mean actual personal lived Experience or lived experience of doing this work as well. And we're not afraid of having conversations that maybe are a bit difficult. So they typically.

he controversy. I'm there. So: 2020

Josephine Hughes: 00:49:31

Intrigued, go on. Yeah,: 2026

Kel O'Neill: 00:49:34

2026 Went really well. We had about three attendees. The feedback was great and people were like, oh, we're doing it again.

th of Feb, in: 2027

I actually, before we hopped on the call today, was starting to trawl through the speaker submissions. And I'm kind of hoping it continues to grow in other ways as well.

I think there's really a need for a community in this space where, like you say, particularly people that are in not healthcare settings are in private practice or smaller settings, kind of need for there to start to be kind of a system to support the care that there's currently a gap for.

And I think what I even learned from the conference was that actually there is other people out here doing what I'm doing just quietly in their own corners, and they're all learning things by those experiences that we need to hear so that we can hopefully start to move forward as a profession in supporting folks with eating disorders. So.

Josephine Hughes: 00:50:39

Fantastic. Yes.

Kel O'Neill: 00:50:41

That's kind of where it came from and what it is.

Josephine Hughes: 00:50:45

Yeah, it sounds like the community side might be something that grows and grows through that, as usual.

I mean, I looked when you were speaking at the clock to think, oh, blimey, we've been talking for nearly an hour already and it really doesn't feel like it's been absolutely fascinating. So I'm going to just help us to sort of close. So what's one thing you wish every therapist understood about eating disorders?

Kel O'Neill: 00:51:09

I wish that every therapist understood that they will find themselves working with clients with eating disorders. And so they need a base level of knowledge about the work.

Josephine Hughes: 00:51:24

Brilliant. And what's a sensible first step for someone who's like me perhaps thinking, yeah, okay, what more can I do?

What would be a sort of sensible first step, do you think, to start, you know, learning more about it?

Kel O'Neill: 00:51:37

Maybe. Maybe come and join us for the conference or watch the recording from the conference for last year.

I might have previously said, come and join one of my workshops, which is still an absolutely valid thing to come and do.

However, the great thing about the conference is there's a whole plethora of people talking about eating disorders from different perspectives and with different angles, which I think makes that. I don't want to say balanced, because of course there's going to be kind of thematically topics, but it's coming from multiple people's perspectives.

So it's kind of not my bias, if you like.

Josephine Hughes: 00:52:08

Yeah. It's just sort of like a richer experience, maybe with different perspectives. Yeah.

So what's the message you'd most like therapist to leave with today?

Kel O'Neill: 00:52:19

I guess I would like therapists to leave thinking rather than with a message thinking. That's interesting. I would like to learn more.

Josephine Hughes: 00:52:29

Yeah, brilliant. And if people want to look you up, Kayl, what's your website address?

Kel O'Neill: 00:52:34

So, my main counselling website is counsellingandtraining.co.uk I am also just refreshing my own personal website, so if you look for it today, you won't find it, but it's coming. So my other website is kelloaneal.co.uk, which is where you would find kind of links for the conference and things. And I'm also on social media.

Josephine Hughes: 00:52:52

What's your social media?

Kel O'Neill: 00:52:54

Just Kelo, Neil. As simple. Simple as that.

Josephine Hughes: 00:52:57

Well, thank you so much for coming along.

It's been so interesting and hopefully people will feel a bit more maybe, you know, prepared to try and do some learning and maybe not worry quite so much about, oh, I've got to make a referral, obviously, with, with supervision. So thank you so much for Kel for coming along. I really appreciate it.

Kel O'Neill: 00:53:16

Thanks for having me.

Josephine Hughes: 00:53:17

Thank you. Thanks for listening. Do come and join my Facebook community. Good enough counsellors.

And for more information about how I can help you develop your private practice, please Visit my website, JosephineHughes.com if you found this episode helpful, I'd love it if you could share it with a fellow therapist or leave a review on your podcast app. And in closing, I'd love to remind you that every single step you make gets you closer to your dream. I really believe you can do it.