Supporting neurodivergent people with eating disorders in therapy

There has been a significant rise among individuals who are neurodivergent and who also have an eating disorder (ED) (Adams et al, 2022). It may be that certain terms and descriptors are not acceptable to some and I find myself struggling with inadequate words to describe often nuanced experiences, which are specific to each person. Perhaps, professionals are better informed about these differences, yet I feel that we have a long way to go to properly support this population.

Specialist professionals who work in ED services, communicate about their sense of inadequacy to deliver the optimum care for these people, due to their perceived lack of knowledge and training about neurodiversity. Similarly, practitioners working in neurodiversity services don’t feel confident in supporting individuals with an ED.

What do neurodivergent people with eating disorders need from therapy?

There is clearly a need for services which are properly able to assess and offer therapy for people who are neurodivergent and have a diagnosed eating disorder. Therapy needs, therefore, to adapt its approaches to include neurodivergent people who are undiagnosed and/or who experience disordered eating. It would be very much part of therapy to openly discuss the client’s needs and adapt the therapy accordingly until we get it right for you. Additionally, therapy needs to support neurodivergent people with EDs, alongside their carers and families, if considered appropriate and helpful.

Research shows that around 37% of individuals with EDs, often also have autistic traits. People don’t have to have a diagnosis of autism to benefit from some of the therapy adaptations; there are many traits that overlap between EDs and autism spectrum conditions (ASC), such as all-or-nothing thinking.

Furthermore, people on the autistic spectrum with eating disorders are likely to have had negative experiences in the way that they have been misunderstood, judged, bullied and treated badly in other ways.

As a therapist, I take responsibility for adapting my interventions in therapy to include a quiet, uninterrupted environment, where people can enter the consulting room knowing what to expect and feeling safe and secure to share what their individual needs are - and perhaps in the course of the collaborative discussion, discovering some new ones that can be thought about in therapy as adaptations to facilitate the smooth running of the therapy process for these individuals. 

For example, it is essential that sensitised language is used, helping people to feel respected, acknowledged, understood and heard. I have been given feedback clarifying that making art materials available has been super helpful, enabling people who may find it hard to speak, can draw out what they want to communicate and express themselves more effectively through art. I always have art materials available for this reason. Individuals may also want to listen to music to help settle into the session, which I encourage my clients to utilise. 

What is the importance of autism assessments for individuals with ED’s?

Therapy services can helpfully offer autism assessments in relation to therapeutic interventions for EDs and offer psychoeducation on why a person’s autism might still not have been diagnosed as an adult. Therapists can additionally helpfully explore each individual’s sensory profiles and figure out with the person how the therapist can best support the individual. Therapists are hopefully adapting interventions and creating psychoeducation materials to support people’s needs, including adaptations to the physical environment.

NICE guidance (2019) recommends observation and interview-based assessments for autism and I therefore employ ADOS-2 to explore whether someone being treated in therapy for an eating disorder, also experiences sensory difficulties and social challenges that may be related to autism. It can be helpful in therapy to discuss and distinguish between difficulties arising as a result of ASC and those caused by the eating disorder. Knowing that a person has autistic traits means that therapy can be individualised to accommodate this, which may include:

• Taking into account sensory sensitivities when setting up a room for therapy.
• Offering time-outs during a session to manage sensory arousal.
• Ensuring that therapy sessions suit a person’s learning style in terms of pace and content.

From research and conversations with autistic people with an ED, alongside their families, carers and friends, there can be benefits to receiving an ASC diagnosis. For example, it may:

• Help to explain why the person has struggled to recover from their eating disorder.
• Allow someone to access specialist support and benefits.
• Enable access to peer support groups, such as those run by the National Autistic Society. 

It would be progressive to work together to create open, trusted dialogues in therapy, to ensure that the environment is what is needed to grow and develop. People who are neurodivergent and with eating disorders have likely experienced too many negative experiences in healthcare and education.

We need to find ways to improve this, By sensitising our use of verbal and non-verbal communication, we can be curious and reflective regarding the different ways that therapy can be adapted to best meet the needs of those who are neurodivergent and with eating disorders. It is much hoped that neurodivergent people with eating difficulties feel encouraged and welcome to seek therapy which they feel will be tailored to their individual needs, towards gaining an improved quality of life.