How to support patients therapeutically during a meal

This module will take a closer look at how to support patients during a meal; this is the second and third B’s of meal support – Be Confident and Be Kind. The videos in this module will show examples of meal support in different settings to demonstrate how you can put this into practice.

• Understand what eating disorder behaviours are, how these may present before/during/after meals, and how to appropriately address this.
• Learn how to engage the patient with appropriate distraction techniques during a meal.
• Gain confidence with holding boundaries to support the patient to consume all of the prescribed nutrition.
• Learn how to manage escalations and understand where your responsibility falls with meal support.

When patients are particularly unwell, they may demonstrate ‘eating disorder’ behaviours around mealtimes. These may look like self-imposed dietary rules (a form of dietary restraint) in an attempt to control food intake. Remember, these behaviours are driven by the psychopathology of the disorder (including starvation) rather than being rational behaviours, it is important to separate the patient from the disorder. Eating disorder behaviours can be key maintaining factors of an eating disorder which means that by continuing to do them, the patient remains stuck in a cycle. By interrupting the disordered eating behaviours, patients can then reduce their need for  excessive control around food. It is only by challenging these behaviours that the cycle can be broken, and full recovery can take place.

Before meals:

• Delaying going to the dining room or getting up from the table at the start of the meal.
• Avoiding variety – always making the same ‘safer’ choices. Or spending excessive time worrying about choices and checking food labels/calories.
• Contesting portion sizes, finding it difficult to serve or be served a “normal” portion.

During meals:

• Cutting, tearing or breaking up food (e.g., bread, or biscuits), pushing food around the plate, mashing food, smearing food, hiding/dropping food onto floor, eating small mouthfuls, chewing excessively.
• Spoiling food by adding extra salt, burning toast, drinking/eating food too hot/cold.
• Dietary rules, e.g., eating food in a certain order, separating milk from cereal.
• Asking to change meal plan at the table or during the meal. Not completing the meal plan.
• Appearing detached at mealtimes, not talking, or making conversation. OR food orientated talk at the table, making inappropriate comments.
• Very anxious about eating a certain food, walking out of the dining room. OR becoming rude/aggressive in the dining room.
• Competitive with others, for example trying to finish after others or copying behaviour from other patients.
• Delaying the start of the meal by any means or using talking to distract staff and delay meals.

After Meals:

• Compensatory behaviours after eating: purging, exercising, self-harming, overuse of laxatives.
• Following set rules or rituals, for example, brushing teeth after eating, or washing hands.
• Body checking behaviours. For example, taking photos before and after meals for comparison, excessive mirror exposure scrutinising a specific part of the body, using fingers to measure wrist circumference.

The videos in this module will highlight some examples of patients displaying some of these eating disorder behaviours, observe how the staff respond in these circumstances. The patients in these videos are played by actors and are not real patients, the staff are real eating disorder clinicians.

• Prompting patient to not break the muffin apart.
• Distraction techniques:
  • Talking about weekend activities, family.
  • Observing environment, artwork on walls.
• Ensuring patient completes all nutrition.
• ‘Thank you for your hard work, I appreciate that must’ve been difficult’. Validating patient’s emotions.

When helping someone with their meals, it’s important to think about whether praising them is helpful. Praise can make some people feel supported and validated, but for others, it might be upsetting and worsen their eating disorder. The best approach is to understand the person you’re helping. You could even ask them directly what kind of support they prefer, ensuring you choose the best way to assist them.

The video in this section is an example of meal support in an acute hospital, taking a closer look at some more common eating disorder behaviours. When patients with an eating disorder are admitted to an acute hospital, meal support is still important to ensure that patients are completing the meal plan.

• Staff noticing that the patient has dropped/hidden some food whilst they were not looking.
• Staff holding boundaries around the amount of water that the patient should have.
• Validation that the meal is difficult for the patient.

Meal support will not always go to plan, this is okay and often part of people’s recovery process. The next video shows an example of meal support that didn’t go to plan and what to do.

There are two possible endings to this scenario, watch and observe the difference between the two. The final outcome of how much nutrition the patient consumes may be out of your control.

• An example of a patient highly distressed during the meal.
• Patient appears irritable and raises their voice, although it is the eating disorder driving this behaviour.
• Clinician remains calm and does not give up on the patient.
• De-escalation takes place outside of the dining room, clinician uses grounding techniques to calm the patient down.

If you’ve done meal support, you’ve done the task, regardless of whether the patient has completed the nutrition. It’s crucial to learn as you expose yourself to more meal support that there will be limitations to how much support you can offer. It’s important that you don’t develop an over-inflated sense of responsibility of your role in getting people to complete their meals. Ultimately, the patient themselves is an expert in their own eating disorder and can become their own therapist.