Early intervention treatment for eating disorders in young people

About eating disorders

Eating disorders are serious mental illnesses that involve extreme concern about eating, weight or shape plus disordered eating. They are not a lifestyle choice or “phase”.

Eating disorders have the highest mortality rate of any mental health disorder. One in seven women will experience an eating disorder over their lifetime. Peak onset is in adolescence and young adulthood, but eating disorders can develop before and after this too. They affect boys and girls, men and women, young and old, rich and poor, and people of all cultures.

There are four main categories of eating disorder: anorexia nervosa, bulimia nervosa, binge eating disorder, and “other specified feeding or eating disorder” (OSFED). OSFED is no less serious than the other categories and just means that symptoms don’t exactly match those for anorexia nervosa, bulimia nervosa or binge eating disorder.

Eating disorders aren’t all about food. People with eating disorders often feel a lot of pain, sadness and worry. The eating disorder can be a way to cope.

Eating disorders aren’t just about food

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‘Disordered eating’ can include limiting food intake, binge eating (eating a very large amount of food at once and feeling out of control of eating) and/or purging (making yourself sick or misusing laxatives). People may also exercise a lot, or exercise in rigid ways.

Some of the symptoms associated with eating disorders include:

Thinking about food all the time
Dieting
Missing meals
Eating alone
Counting calories
Worry around meal times
Guilt after eating
Worrying about losing control around food
Comfort eating
Weight loss
Frequent changes in weight
Missed menstrual periods
Vomiting after eating
Signs of damage due to vomiting (like grazed knuckles)
Worries about body shape and weight
Frequent checking of your body shape or weight
Avoiding looking at your body
Comparing your body with others
Eating meals very slowly
Excessive exercise
Frequent trips to the bathroom during or shortly after meals
Stealing food
Regularly asking for reassurance from others about food, body weight or shape
Avoiding lots of foods
Avoiding social situations

Usually at least a few of these symptoms are present in someone with an eating disorder.

“An eating disorder is never the solution to a person’s distress or difficulties. It is always the problem.”

Ulrike Schmidt, Psychiatrist and Professor of Eating Disorders

About early intervention

Early intervention means providing treatment as soon as possible when someone needs it. Research tells us that we should try and reach someone with an eating disorder within the first three years of the illness. People with eating disorders experience changes to their brain, body and behaviour. In early stages these changes are more easily reversed.

After three years, eating disorder symptoms tend to become “hard wired” in the brain. Symptoms can still be changed, but it gets harder to make changes and there may be long-lasting consequences.

There are two key things that stop early intervention for eating disorders: difficulties spotting the illness early, and difficulties getting help. FREED aims to address both sets of difficulties.

Phoebe received treatment through FREED in London. She shares her experiences of her eating disorder, treatment and recovery.

Services using FREED aim to provide rapid, specialised, evidence-based treatment for young people with a recent onset eating disorder (anorexia nervosa, bulimia nervosa, binge eating disorder or another eating disorder). This means that treatment is more likely to be effective and young people are less likely to miss out on study, relationships and other opportunities because of their illness.

FREED was developed for 16 to 25-year-olds with an eating disorder of up to 3 years duration. Eventually, we hope that everyone with an eating disorder will be able to access tailored, specialist treatment quickly. FREED is one step towards this goal.

“FREED has really saved my life. Early intervention is crucial and without this I probably would not be where I am now - I am sustaining a job, have moved out to a new home, and able to love myself. I still have eating issues and anxieties but I have come so far in my wellbeing and quality of life.”

FREED service user

How FREED works

FREED is First Episode Rapid Early Intervention for Eating Disorders. It is a service model and care package for 16 to 25-year-olds who have had an eating disorder for three years or less (anorexia nervosa, bulimia nervosa, binge eating disorder, or another eating disorder).

FREED helps young people to access specialised evidence-based treatment quickly. The goal is for treatment to start within 4 weeks of referral to an eating disorder service.

FREED also attends to the specific needs of young people in the early stages of an eating disorder. It emphasises early, pro-active engagement; early symptom change; family involvement; attention to the effects of eating disorders on the brain; attention to social media use; and attention to transitions (out of school, to university, into work) and ‘emerging adulthood’.

FREED operates as a ‘service within a service’. It complements, rather than replaces, existing eating disorder services and treatments.

“Without FREED I am not sure I would be here today, getting early intervention was such a positive thing to happen to me when I was in a really dark place, and it gave me lots of hope for the future.”

FREED service user

The FREED service was developed and tested by the South London and Maudsley NHS Foundation Trust’s Eating Disorders Unit and King’s College London. The initial trial took place across 2014-2015. Compared to treatment-as-usual, FREED reduced the amount of time an eating disorder was left untreated and improved treatment outcomes.

Key benefits included:

32% reduction in the waiting time from referral to assessment
41% reduction in the waiting time from assessment to treatment
35% reduction in the need for day-patient or inpatient treatment
59% of FREED patients with anorexia nervosa reached the healthy weight range by 12 months (vs. 17% of treatment-as-usual patients)
70% of FREED patients had eating disorder symptom scores below clinical cut-points by 12 months

Introducing FREED did not result in non-FREED patients waiting longer for treatment.

FREED confirmed that treating people as early as possible leads to better results for eating disorder treatment.

In 2016, FREED was introduced to three new eating disorder services in the UK. In 2018, FREED was introduced to eight new services. By 2020, we hope that at least 20 services will be using FREED. Work is also being done to establish FREED in Australia. Services that use FREED form part of the FREED Network. FREED is also being used in South Australia under the term EmergED.

We have an online training package and implementation toolkit for services interested in adopting FREED. This covers the why, what and how of delivering FREED and working effectively with young people and their families. There is currently no charge for this material but we ask that you register to access this part of the site.

We also have guides for healthcare professionals to use and guides and tools you can share with patients and carers. You don’t need to register to use these.

The FREED team

Ulrike Schmidt

Professor of Eating Disorders, Consultant Psychiatrist and FREED Executive Director (Kings College London)

Karina Allen

FREED Consultant Clinical Psychologist

Jessica Griffiths

Eating Disorders Therapist & FREED National Co-lead (Maudsley)

Giulia Di Clemente

Senior Counselling Psychologist and FREED National Co-lead (Maudsley)

Danielle Glennon

Clinical Lead/Principal Psychotherapist (Maudsley)

Lucy Hyam

PhD Student (Maudsley)

Regan Mills

Research Assistant (Maudsley)

Muhammad Ahmed

Assistant Psychologist (Maudsley)

Jessica Wilkins

PhD Student (Maudsley)

Louise Melhuish

Clinical Psychologist and FREED Champion (Hampshire)

Amie Buckley

Psychological Therapist and FREED Champion (Black Country)

Louise Willis-Richards

FREED Champion and Occupational Therapist (Cornwall)

Katherine Webley

Nurse Therapist / Non-medical Prescriber and FREED Champion (Derbyshire)

Beth Wilks

FREED Champion & Occupational Therapist (West Essex)

Charlotte Terry

Eating Disorder Family Practitioner and FREED Champion (Hull)

Laura Mumford

Eating Disorders Therapist and FREED Champion (Leicestershire)

Ellie-May Watkins

Assistant Psychologist (Leicestershire)

Charlotte Long

Senior Eating Disorders Practitioner & FREED Co-ordinator (Lincolnshire)

Hannah Gordon

FREED Champion / Clinical Psychologist (Liverpool)

Mike Lewis

FREED Champion / Specialist Nurse (Liverpool)

Siobhan Connor

Psychological Therapist and FREED Champion (Manchester)

Zoe Tsivos

Clinical Psychologist/FREED Champion (Greater Manchester/Salford)

Catherine White

Senior Specialist Nurse & FREED Champion (Kent & Medway)

Lucy Owen

Counsellor & FREED Champion (SET CAMHS, Essex)

Sinead Smithson

FREED Champion and Specialist Mental Health Nurse (Nottinghamshire)

Kirsty Manning

Counselling Psychologist / FREED Champion (South-West London & St George's)

Claire Killengray

Mental Health Practitioner / FREED Champion (Surrey & Borders)

David Tate

Senior Eating Disorders practitioner & FREED Champion (Tees, Esk & Wear Valleys) / Project Lead FREED, AHSN NENC (Cumbria, Northumberland, Tyne and Wear)

Rashmeet Gupta

CBT Therapist and FREED Champion (West London)

Charlotte Dacey

FREED Champion/Clinical Psychologist (Liverpool and Sefton)

Vicky Tinker

Clinical Psychologist (Liverpool and Shefton) & FREED Champion (Liverpool and Sefton)

Radost Ruseva

CBT Therapist & FREED Lead (Stockport)

Victoria Frater

FREED Champion (Northumberland)

Stephanie Wild

Senior Nurse Practitioner (Knowsley and St Helens)