This module is designed to help eating disorders professionals understand:
- The life transitions taking place for many young people at the same time as transferring ED services
- Pressures and practical considerations related to these changes
This module is also available as downloadable PDF.
This module is part of the Eating Disorders Transitions Learning Series.
Module 1: Setting the Scene - Definitions and Context
Module 2: Supporting Transitions Between Services
Module 3: Digging Deeper - Preparing For and Talking About Transitions
Module 4: Involving Parents and Carers
Module 5: University Transitions and Emerging into the Wider World
Types of Transitions
Many young people experience some kind of transition around the age of 18.
Can you take a moment to think about some of the routes that people of this age may take and the pressures these might involve?
These are some of the transitions our clients might go through:
Moving to University
This may be the first time young people have to take greater control over their day-to-day timetable.
Starting a new job
Sudden changes in support system (i.e., moving away from family and friends)
Taking a gap year
Increased sense of isolation
Moving abroad
Increased study/work responsibilities and changes in social norms
Travelling abroad
Needing to access new services and change GP (this might require higher levels of motivation and insight from the young person)
It is important to note that some of these transitions may be transient (e.g., university students returning home over the holidays).
This means that the young person and their families will have to navigate fluctuations in independence.
Why is it Important to Talk about Transitions?
These transitions can be exciting but can also have a destabilising effect, even for young people who do not experience mental health difficulties.
It is therefore important for services to highlight potential difficulties associated with the move towards independence and support the young person to create tailored plans on managing independent living and when or who to seek help from.
"I thought recovery was going well, but I’d done absolutely no preparation… for mentally coping with the changes of moving to university. I think it was partly because of that that I became so much more unwell once I reached university.”
- Young Person
Support with Processes and Protocols
What can Services Think about Before Planning a Transition?
What can Services Do?
Services should establish joint working practices with other institutions where possible. These can include local GPs, university mental health/wellbeing/sports services and local charities.
Some outreach ideas for service providers include:
- Attending fresher’s week
- Asking for a physical space at universities for drop-ins
- Handing out information leaflets
- Talking to sports teams/gyms
- Arranging talks at local colleges or sixth forms
Provide information to patients on services available before they move to university or in a different area and make sure you have up-to-date information on their new GP to be able to communicate effectively with them.
“I didn't know for sure where I'd be going to university, which was very soon after I turned 18 … that meant I didn't know which eating disorder service I'd go to cause it's linked to the city and I didn't want to stay with CAMHS and see yet another person from CAMHS.”
- Young Person
Before you and the young person start planning a transition it might be helpful to think about whether now is the right time for them to be facing this.
In particular, you might find some of the below documents helpful in having discussions with the patient about this and making the best treatment plan for them:
- Medical Emergencies in Eating Disorders (MEED) guidelines might help you assess the young person’s physical health risks in order to determine whether changing services and moving away might be too risky and, if the young person still wishes to go, what support will they need and how can it be set up?
- These guidelines are also helpful when someone is planning to move abroad or go travelling. Are they fit to do so? Do they have insurance? What support will be available to them?
- Fitness to study guidelines might help you assess whether a patient might be able to attend university or whether they need to postpone their start date. This guideline might also help increase motivation in our patients by giving them a goal to work towards!
- If possible, ‘home’ services should continue working with the young person even when they start university unless high levels of risk prevent this
- Royal College of Psychiatry guidance recommends that the ‘home’ mental health makes ‘every effort’ to support young people to identify and access appropriate service(s) before they start university
Differences in referral protocol, provisioning, and commissioning between trusts can make it difficult to navigate accessing appropriate services when moving geographically; however, attempts should be made to avoid gaps in care:
- Waiting list placement should be honoured where possible
- ‘Home’ services may be able to continue to provide care remotely during term time or vice versa
- It is important to remember that young people can register with 2 GPs when attending uni (home and university), allowing for ongoing physical monitoring
Supporting Independent Living
Relapse Prevention
As soon as you become aware of a possible transition, help the young person work towards a relapse prevention plan.
First, help them think about the difference between a lapse and a relapse.
Lapse
A lapse represents a temporary slip or return to a previous behaviour that one is trying to control or quit.
Relapse
A relapse is when someone in recovery returns to disordered eating or weight control behaviours.
- What would be the difference between the two for them?
- Who do they need to contact in each situation?
Other factors that might be helpful to consider include:
- Possible stressful / high-risk times. What may be helpful for them to focus on at those times?
- What are their early warning signs and how can they manage these?
- Help them make a list of local support options available to them
- Remind them to register with a local GP as soon as possible. If helpful, provide support to help the young person register temporarily so they can continue to be registered with their home GP. When writing a discharge letter, you might find it helpful to send a copy to both GPs.
Dietetic Advice
Whether young people are under or over eating, you can help them think about eating as being on a spectrum (some people are at the over-controlled end and some the under-controlled end) – the advice is meant to help them move towards the middle of the spectrum.
Help them plan a personal template for eating:
- Start by focusing on the early days and settling in period. Getting a routine going from day one as it is really difficult to establish one later on, especially if living with others
- All in the planning, boring but less stressful than arriving and not being confident about it. They can be more adventurous once settled in!
- Signposting: Plenty of advice online and from student cookbooks, such as batch cooking for the freezer and buying food in bulk between a few students etc.
- If the young person will be in catered halls, help them think about what they will get as part of the package. What happens if they miss one of the meals? Do they have a contingency plan?
- Help them think about shopping and cooking; practice cooking and shopping at home before leaving
Download the FREED dietetics handout here with further information and tips for patients who might be struggling with chaotic eating/binge eating.
Social Life and Eating/Drinking
Help the young person think about how they will manage drugs and alcohol. It may also be useful to work through how they will approach new friendships, including setting boundaries or working through potentially sensitive conversations.
Make a plan to support the young person with eating out and eating with other people:
- How can they keep to the meal plan when living on their own/at university/abroad?
- Do they need support with food shopping?
Top tips:
- Suggest the young person practices meal preparation when at home so they become familiar with the process and also get used to managing portion sizes.
- Include how they can manage difficult situations and topics (e.g., if someone they know starts talking about wanting to diet).
- The service or carers may be able to provide structured support to the service user and work through several stages of preparation for social eating or individual planning. For example, this could include initially working through tasks together, then setting goals for the service user doing some elements independently, and finally transferring responsibility to the service user when they feel confident.
- Occupational therapists and peer support workers may be able to offer additional support in these areas.
Structuring Time
Help the young person think about how they will structure their time and support them in thinking about how they will balance work/studying, having a social life, self-care and leisure. For example, how will they manage exercise when at university or living independently?
Top tip:
- Some young people might find using a planner really helpful.
Click the buttons below for some examples of what some young people suggested around structuring time:
Productivity
- Managing workloads at university (i.e., coursework/reading)
- Managing money
- Paying bills/keeping on top of finances
- Managing a job if you have one
- Chores
- Managing shared spaces/making it fair
- Registering at the GP
- Having a list of important contacts
Leisure
- Hobbies (i.e., reading/crafts/baking)
- Joining societies at university or taking part in after-work activities with colleagues
- Getting fresh air/going for a walk
- Exploring a new city
Social
- Going for drinks/meals
- Having communal meals
- Movie nights with friends
- Going for a walk with friends
- Managing going out drinking/socialising
- Putting self ‘out there’ to make friends/meet others
Self-care
- Diary/journaling
- Sleep hygiene - making sure you are getting enough sleep
- Keeping in touch with family/partners/friends
- Hobbies
- Referring to treatment resources
- Contacting services if needed
- Following meal plan
- Showering/washing hair
- Taking care of appearance in a way that is meaningful to you
- Taking any prescribed medication
Exercise
When thinking about transitions and in particular moving to university, it is important to address excessive exercise and how to manage this.
When preparing the young person to transition it might be helpful to think about exercise and how they are currently using it. If they are excessively exercising, it might be helpful to support them in recognising when this is happening and what they can do to avoid this (particularly if joining gyms or clubs).
If helpful, help the young person create a personalised plan around exercise (how much each week) and, if planning to decrease it, create a plan on how they can do this in the upcoming weeks (e.g., keeping a diary and planning behavioural experiments).
You might find it helpful to use the diagram below to have a conversation about excessive exercise and think about ways of reducing this.
Disclosing Eating Difficulties
Start having conversations with the young person on whether it would be helpful for them to disclose their eating difficulties. Help them list the pros and cons of disclosing and of not disclosing.
- Who do they want to share this with?
- Do they want to let the university/workplace know?
- What support do they need and how will they communicate this?
- Help the young person decide how much information to share.
Equality and Diversity
Family dynamics and cultural/gender identity mean that the process of transition and emerging adulthood may be very different between individuals. It’s important to be open and curious about these differences, when talking about the transition process and in more general discussions as well.
Examples of individual circumstances and adaptations during a transition include:
- Taking account of cultural differences around meal content, timings and social relevance when meal planning.
- Navigating independence if the young person starts university/employment while still living at home and having a prominent child/care-receiver role.
- Being curious about open questions around gender, and about cultural differences in family units and body image/standards.
Resources
FREED equality and diversity module
Template for thinking about adaptation to FREED care
Other Areas to Consider When Planning Transitions
Providing a space to think about the practicalities of independent living is important.
Problem-solving, providing practical resources, and practicing skills can provide young people with a realistic view of independence and increase a young person's confidence in their ability to cope.
Key practical areas to consider:
- Basic budgeting
- Cooking tasks and tips
- Shared food storage space
- Study/work time management/lack of structure
- Maintaining contact with current support system
- Building new social support
- Drugs and alcohol
- Sexual health/safety
- Where to go for support/how to tell uni/new GP
Resources:
FREED Preparing for University Guide
Supporting Independent Living: What to Take
Living Outside of England and Wales
Travelling abroad for work, study or leisure can present its own unique challenges for young people.
New Foods, Cooking and Eating Practices
Different cultures can have varying attitudes and approaches to food.
Lack of Access to Cooking Facilities when Traveling
Certain appliances (e.g., hobs and ovens) can be hard to come by while on the move.
Different Healthcare System
Healthcare systems can vary widely in different countries.
Language Barriers
Communication issues can arise from misunderstandings.
Increased Isolation
Travelling can often make people feel homesick or lonely.
Clinicians should encourage young people to consider their medical risks when deciding if moving abroad or travelling for a prolonged period is right for them.
Like any transition, specific, proactive planning on how to manage the experience itself as well as when/where to seek help is key.
There are several helpful resources on this topic you can refer to:
Support For Carers
For many young people, going off to university is a rite of passage.
Moving out of the family home is often a natural part of this transition.
While some may leave permanently, many young adults will return regularly, whether for weekends, term holidays or after graduating. However, for university students with eating disorders, this milestone presents a host of unique challenges. These challenges are not limited to the students themselves, as their families and caregivers may also face additional worries and concerns.
Download the Support for Carers Guide to learn more.
This module is part of the Eating Disorders Transitions Learning Series.
Module 1: Setting the Scene - Definitions and Context
Module 2: Supporting Transitions Between Services
Module 3: Digging Deeper - Preparing For and Talking About Transitions
Module 4: Involving Parents and Carers
Module 5: University Transitions and Emerging into the Wider World
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