MEAL SUPPORT, Part 1

Distorted beliefs about food and abnormal eating habits are a part of daily life for those living with an eating disorder. These thoughts and behaviors can prolong or prevent eating, which interferes with the client’s nutritional status. As a consequence, clinicians are constantly challenged to develop and implement treatment plans that restore their clients’ physical health, improve their nutritional status, and foster a healthier relationship with food. Meal support is a vital treatment component to accomplish these goals.

What Is Meal Support?

Meal support can be offered to groups of patients or individual clients in every possible treatment setting, from private practice, inpatient and ambulatory care programs to community-based treatment. But, no matter what the setting or the number of clients involved, meal support is about health care providers sitting down to a meal with clients and giving them emotional support.

Emotional support can be defined as giving clients encouragement and reassurance and helping them cope with their anxiety and fears about eating. Support staff can help encourage clients by highlighting their eating successes and give reassurance by emphasizing the physical and psychological benefits of renourishment. Health care workers can help clients lower their anxiety level by listening to them express their fears, distracting them with “healthy” conversation, and promoting relaxation techniques during the meal.

Benefits of Meal Support

While providing meal support to this patient population can potentially reduce the need for longer hospitalizations and more aggressive and invasive refeeding methods (e.g., enteral tube feeding), the sole intent of meal support is not monitoring the client’s food intake. Instead, meal support gives clients an opportunity to challenge rules and rituals that are dictated by their eating disorder. In the safe, structured environment of staff-supported meals, clients can begin to “normalize” eating habits that attract unwanted attention when carried out in public. At the same time, clients can incorporate “forbidden foods” into their meals and gradually learn to feel safe with foods they wouldn’t normally permit themselves to eat.

Meal support can also help clients dispel feelings of shame and isolation that are often associated with eating. By engaging in conversation with the staff about non-eating disorders topics (e.g., topics not related to food, weight/shape, exercise), clients can re-learn the social aspects of eating.

For staff members, meal support is an opportunity to develop rapport with clients and to observe their eating behaviors. These observations can supplement the client’s medical and psychosocial assessments and highlight psychological and nutritional treatment issues that need to be addressed in individual and/or group therapy sessions.

Emotional support from staff immediately following a meal can help those clients who have urges to binge-eat, purge, and/or over-exercise after eating. Clients can interrupt the binge-eating/purge cycle by learning to exchange the familiar, but self-destructive eating disordered behaviors for more effective and healthier ways of coping. After meals, staff can organize activities such as journal writing, watching videos, or doings arts and crafts for clients. With time, post-meal support can teach clients to distract and delay acting on their urges to purge or exercise.

Some Drawbacks of Meal Support

Clients may report feeling watched or self-conscious when eating with their health care providers. However, they may also feel more supported and less supervised when staff has a meal with them. Clients may also feel that their independence with eating is compromised during meal support; that is, they are eating to please the staff and not themselves.

When meal support is conducted with groups of clients, clients may feel compelled to compare their food intake and manner of eating with others. Meal support may be a frustrating experience when clients at different stages of nutritional recovery eat together. For clients further along in recovery, negative emotions can be triggered by the behaviors of those who have a very eating disordered mindset.

A drawback for the staff could be the amount of time available to offer meal support. Health care staff may already feel stretched trying to fit all their responsibilities into their workday. Treatment teams that have a limited number of staff members may have to go straight from therapy sessions into meal support, and thus don’t have a “time-out” from clients.

Establishing a Meal Support Component

Offering an effective meal support component to clients requires a commitment from staff, who need to devote time and energy to ensure meal support is conducted in a consistent manner. The responsibilities inherent in providing meal support may at first seem daunting to the staff. But, with well-developed guidelines and appropriate staff training, health care providers from all professional disciplines can offer an effective meal support service to clients.

Staff training. Education and training sessions allow staff to come together to discuss the process of supporting clients, their attitudes and beliefs about meal support, and issues of practice such as personal dietary practices and maintaining therapeutic boundaries.

Prior to implementing a meal support service, staff members need to determine the nutritional intake and behavior expectations for their clients. For example, are clients expected to eat 100% of their meals? Can clients eat diet or low-fat food items at meals? Developing meal support guidelines helps communicate these expectations to clients and outline how staff will provide support. Staff members need to decide how they will find the “fine balance” between providing clients with emotional support and ensuring that the program guidelines are followed.

Guidelines. Guidelines provide clients with a sense of safety and structure during meal support because they understand what is and what is not acceptable in terms of food intake and behavior. Health care providers may consider developing guidelines related to nutritional intake, such as the amount of food to be eaten at a meal, the replacement of uneaten food, and appropriate portion sizes. Other essential guidelines concern mealtime conversation, eating disordered behaviors at the table (e.g., excessive use of condiments or spices, or unusual mixing of foods), the time duration of the meal, clients leaving the table before the end of the meal, and post-meal support.

It is important that staff members are clear about the rationale behind each guideline. Before beginning treatment, staff can review the meal support guidelines with clients, explain the rationale, and clarify the responsibilities of the support staff. This knowledge may help clients make more of a commitment to meal support. Depending on the treatment program’s philosophy, staff may wish to discuss their own dietary practices with clients at this time.

Because meal support can be an opportunity for staff to model healthy eating for clients, staff may need to assess the appropriateness of their own dietary practices. Education and training sessions allow health care providers to make decisions about the eating and behavior expectations for support staff. Relevant questions that staff should consider are: What personal dietary practices are acceptable when eating with clients? Should staff members openly discuss their dietary practices and beliefs with clients? Are support staff expected to eat a complete meal? If staff members have too many dietary limitations, are they appropriate candidates for providing meal support? By answering these questions, health care providers can develop their philosophical stance regarding staff dietary practices at meal support.

Setting boundaries. Staff members may also consider developing a philosophical stance on professional boundaries. The social atmosphere of meal support can increase the likelihood of clients asking personal questions. Before becoming involved in conducting meal support, staff members need to define their therapeutic boundaries, including the information they do and do not feel comfortable disclosing to clients. As well, staff members need to consider how they will handle the meal support scenario of clients testing their professional boundaries.

The responsibilities inherent in providing meal support may seem daunting to health care workers. But, with well-developed guidelines and appropriate staff training, health care providers from all professional disciplines can offer an effective meal support service to clients.

(Note: Click Here to read Part 2 outlining meal support guidelines developed by St. Paul’s Hospital Eating Disorders Program.)

— Linda M. Watts, MA, RD