Responding to Students with
Disordered Eating
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Conservatoire for Dance and Drama
Tavistock House, Tavistock Square
London WC1H 9JJ
www.cdd.ac.uk
020 7387 5101
[email protected]
@conservatoiredd
facebook.com/conservatoiredd
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Contents
Introduction
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Section 1: Information
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1.1 Diagnosis and definition
1.2 Eating disorders and mental health
1.3 Signs to look for
1.4 Body Mass Index (BMI)
1.5 Serious risks associated with disordered eating
1.6 Boundaries
1.7 Performing arts training, ‘perfectionism’ and disordered eating
1.8 Identifying and approaching a student who gives cause for concern
1.9 Deciding how to respond; developing a support plan
1.10 Confidentiality and sharing information
1.11 Using Learning Agreements
1.12 Using internal and external specialist help
1.13 Being asked to stop training for a while or to intermit
1.14 Students who leave
1.15 Working with families
1.16 Supporting other students
1.17 Developing a policy
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Section 2: Management and Prevention
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2.1 Building resilience and self-esteem
2.2 Pastoral care
2.3 Creating boundaries
2.4 Showing by example
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Section 3: Developing or revising school policy
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3.1 Using the checklist
3.2 The checklist
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Introduction
Over the past few years, affiliate staff at all levels of seniority and experience have
expressed concern over what seems to be an increasing number of students
with eating disorders, particularly anorexia nervosa and its associated extreme
weight loss. The following guidance is a response to this concern. We hope
that the information here will provide staff, both new and non-specialist staff as
well as those with responsibility for developing policy and practice, with useful
and relevant information. It is designed as a supplement to the information on
disordered eating in sections 3.5 to 3.7 of the Conservatoire’s Guidelines on
Supporting Students with Mental Health Difficulties (2009).
In summer 2012, Emeritus Professor Julia Buckroyd, research author and
specialist in eating disorders in young performing artists, led two staff
development sessions at the Conservatoire. Many of the insights and practical
suggestions included in these guidelines are a result of her presentation and
the staff discussion that followed. These guidelines were written by Lois Keith,
Equality and Diversity Manager for the Conservatoire for Dance and Drama with
the invaluable support and advice of many affiliate colleagues.1
Section 1 contains information on:
• Diagnosis and definition of eating disorders
• Signs to look for
• The serious risks associated with disordered eating, particularly for
our students who are following courses which place great demands
on their physical and emotional energy
• Body Mass Index (BMI) and ideas about how to respond to students
whose eating patterns, weight loss and mental health give cause for
serious concern
• When it is important to intervene in a student’s training
• Maintaining appropriate boundaries
• Using outside specialist help.
This section also includes case studies based on recent experiences in affiliate
schools. These cases highlight how schools have responded to some of the
challenges that can arise when supporting students with disordered eating.
Section 2 suggests ways of promoting mental health and wellbeing in your
organisation in order to help prevent problems from arising.
Section 3 is a checklist designed to help affiliate schools who are:
• Developing their own policy and practices on responding to and
supporting students whose eating patterns, body weight and mental
health give cause for serious concern and/or
• Reviewing and revising an existing policy.
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The original working group included Georgia Doune (NSCD), Amanda Britton (Rambert), Julia Heeley
(BOVTS) and Simon O’Shea (LCDS). In addition, drafts of the guidelines were read by Elizabeth Nabarro, Counsellor to a number of CDD schools and Louise Ainley (CSB) who offered invaluable advice.
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1. Information
Diagnosis and definition
1.1 Although anorexia and bulimia are the most known diagnostic labels for
Eating Disorders (EDs), most people with disordered eating don’t fit neatly into
a particular medical diagnosis and come under the category of eating disorders
which are ‘not otherwise specified’ (EDNOS). It is quite common for people with
EDs to move between diagnostic labels; Julia Buckroyd’s research shows that
people with EDs often shift from one behaviour to another, for example, 30% of
people with bulimia were previously anorexic.
Not everyone who is troubled by their eating on a daily basis will meet the
threshold for a diagnostic label. Medical definitions can often be an important part
of obtaining specialist treatment, for example, psychiatric treatment or a place in
an eating disorders clinic, but reliance on a specific diagnosis is not particularly
helpful. Where students are preoccupied with their eating in a way that has a
negative effect on their mental wellbeing, training and personal life, it is more
important to find ways to support them and bring them back to good health.
Eating disorders and mental health
1.2 People with EDs frequently have associated psychological problems such as
depression and anxiety and may show other signs of visible self harm. Disordered
eating in its most serious and long term form is a mental health condition and
students presenting with clear signs of a recognised eating disorder are entitled
to support and reasonable adjustments to their training. When planning a
programme of support for these students, it is worth thinking about the kind of
reasonable adjustments your school might offer other disabled students.
A student with a long term mental health condition is also eligible to apply for the
Disabled Students’ Allowance. For more information on this, contact:
[email protected]
Signs to look for
1.3 There are a number of warning signs that might indicate a potential eating
disorder. Some are more obvious than others and include:
• Significant weight loss. This is the most obvious sign of anorexia.
Other connected signs can include: hollow cheeks, dull, lifeless hair,
constant tiredness, feeling cold, frequent headaches or increased
body hair.
• Students with bulimia and those who are caught in a cycle of binge
eating and purging/vomiting can maintain a ‘healthy’ BMI but may
have one or more of the following signs: bad breath, discoloured teeth
and puffy ‘chipmunk’ cheeks. In both cases, there may also be signs
of physical self harm; cutting themselves and associated scarring.
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• Changes in behaviour. In addition to weight loss, students with
disordered eating can also display changes in energy levels and
behaviour. A once outgoing student might attempt to hide in the
crowd or move to the edges of the studio or workshop to draw less
attention to themselves. There may be other signs of unhappiness and
a sense of isolation.
• Secrecy is a frequent component of disordered eating and anorexic
students may try to hide their appearance with baggy clothing.
Disordered eating behaviour works for the individual and is hard to
give up so when these students are approached, their first reaction is
often denial, shock and outrage.
• Excessive exercise. Physical activity can be an important part of
Conservatoire training, but excessive (and sometimes obsessive)
levels of exercise beyond the requirements of the course can be an
indicator.
Case Study 1
Y was a European student in her first year of full time training. She was
small with a very slight build but as a dance student this is obviously fairly
common. Y was highly motivated and focused. She approached every area
of her training with an almost obsessive desire to ‘get it right’. Similarly her
written work was obsessively neat, and despite speaking English as a second
language her work was of a very high standard.
Towards the end of the first term, staff noticed a sudden and dramatic
change in her appearance: she seemed to have lost a considerable amount of
weight. For experienced dance teaching staff this seemed to have happened
very quickly, and all expressed surprise that they had not noticed it earlier.
Because of the rapid loss in muscle mass this student was very quickly in
danger when training in the dance studio. It was decided that counselling
would be offered, but that the student should not dance until her weight had
risen to an acceptable level determined by the School’s experts. The other
reason for withdrawing Y from classes was to minimise the impact of this
shocking weight loss from other students. Disordered eating is notoriously
‘contagious’, and amongst a group of young impressionable first year
students it was felt that the School should be clear that extreme thinness is
neither desirable or acceptable.
Unfortunately in spite of counselling over a number of months, Y was not able
to maintain the weight gain necessary to enable her to have the strength to
train. She deferred. A year later she re-auditioned but was still not deemed
strong enough for the training.
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Body Mass Index (BMI)
1.4 BMI is a formula which relates body weight to height and is one of the
measures that can be used to monitor a student who shows signs of rapid or
extreme weight loss. However, many experts now argue that an eating disorder
cannot be diagnosed by BMI alone and other factors such as general mental
health and wellbeing, menstruation patterns (for female students) and the
student’s attitude to weight and food must also be taken into consideration.
For most people, a BMI of between 19 and 25 is considered healthy and whilst
it is important not to think of this as the only factor to monitor, there are low BMI
figures which should give cause for concern. There is a general consensus in
affiliate schools (particularly in dance schools) that a BMI below 17.5 in female
students and below 18.5 in male students indicates that we need to keep a
careful eye on them. Where weight falls below this, particularly where there are
other worrying indicators, students will normally be asked to stop training for
a while whilst they receive the specialist help and support they need. This will
usually include advice from a nutritionist and counselling support.1
Serious risks associated with disordered eating
1.5 Conservatoire training places high demands on students’ physical and
emotional energy and there are medical and ethical issues in allowing students to
continue training where a very low BMI is likely to mean future problems with their
health, strength and, for female students, their fertility.
Anorexia has the highest mortality rates of any mental health disorder and
the chronic restriction of calories to maintain excessive thinness is extremely
harmful to health in both the short and long term. Some of these risks include:
disrupted menstrual patterns which can further contribute to fertility problems and
osteoporosis in later life; cardiac arrhythmia and risks of heart attack; reduced
bone health and risks of stress fractures; suppressed immune system leading
to risk of infection; hair thinning and loss and skin problems. Loss of minerals
such as sodium, potassium and calcium that maintain the balance of body fluids
can be potentially dangerous consequences of serious eating disorders. Other
complications include anaemia, gastrointestinal problems such as constipation
and kidney problems.
In addition to these physical complications, people with anorexia are likely to
be experiencing other mental health difficulties such as depression, anxiety and
obsessive-compulsive disorders. Being clear about when it is best to stop training
and helping students find the right support and treatment are all important in
restoring them to good health.
1
See for example: http://www.prixdelausanne.org/v4/index.php/health.html - Prix de Lausanne’s
Health Policy by Dr Carlo Bagutti
http://www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/module1/text/module1print.pdf Using BMI-for-age for growth charts by Dr William Dietz
www.uksport.gov.uk/publications/eating-disorders-in-sport - A guideline framework for practitioners
working with performance athletes.
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Case Study 2
Teachers expressed concern about G as she had lost a significant amount
of weight in a short period of time, coming back after a holiday looking pale,
tired and very withdrawn.
G was referred to the college counsellor and after initial denial was able to see
that there might be an issue. G was stopped from dancing as her BMI was
16.2, her periods had stopped and she had some very ingrained behaviour
around limiting her food intake.
A support plan was put in place. This included liaison with her GP, a weekly
therapeutic session and referral to a specialist dietician. This enabled her to
look at the reasons why her behaviour had become so extreme whilst also
encouraging her to reconsider her eating patterns.
Once her BMI and general wellbeing had returned to a healthy level, G was
offered a phased return to her classes and ongoing weekly support for
the rest of the school year. This support reduced as her recovery became
stronger and in her final year she checked in for support only once or twice a
term.
Boundaries
1.6 Staff in performing arts schools know their students well and it is natural to
want to help those who are troubled in some way. However, few staff are experts
in mental health issues and it is essential to recognise that there are limits to what
an individual can do.
It is important for staff not to offer help that is beyond their role and be clear
about boundaries. There is a difference between being generally supportive and
offering specific, specialised support. Everyone has something to offer, but it is
vital that staff are aware of what they can realistically do and do not try to take
on anything beyond the boundaries of their knowledge or area of responsibility.
A clear, widely understood plan or policy which clarifies where staff should seek
advice and/or refer students on if they have concerns, can avoid these pitfalls.
Students should also be aware of who they can talk to within their school. They
may wish to confide in a particular member of staff about their concerns and the
staff member will of course listen sympathetically. But it is important to encourage
the student to talk to the counsellor or other member of staff with expertise in this
area.
There are boundaries to the support that any school can provide in managing
students with seriously disordered eating and it is vital that schools form good
links with specialist psychiatric services and refer students on as quickly as
possible.
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Performing arts training, ‘perfectionism’ and disordered
eating
1.7 There is evidence to show that EDs are endemic in the ‘thin professions’
(i.e. some aspects of the performing arts, models, athletes etc.). There are
considerable pressures within the training environment, particularly in dance
training, where the high levels of perfectionism, competition and focus on body
shape can increase the risks of disordered eating.
Applicants to our schools demonstrate a high commitment to their chosen art
form and are often perfectionists. Whilst this might be necessary to achieve
the standards required, it can also demonstrate a quality that is often a part of
being anorexic. Eating disorders are a coping mechanism, a means of emotional
management and a defence against other anxieties. Julia Buckroyd’s research
suggests that some students with a predisposition to disordered eating are
attracted to dance (and perhaps other arts disciplines) and don’t just develop
disordered eating because of the pressures and demands of the training.
We are hard wired to eat so refusing to eat takes some effort. Food produces
changes to the brain that make you feel good. Not eating or starving will produce
a similar chemical in the brain to overeating.
Case Study 3
S was in her second year of full time dance training when teaching staff
began to notice that her weight was dropping. It was obvious that she was
getting weaker in class, and both her endurance and strength were noticeably
deteriorating. She was extremely hard working (bordering on obsessive/
perfectionist) and it had been noticed on several occasions that she was
arriving very early in the morning to add an aerobic training regime to her
usual warm up: this included skipping, additional Pilates and circuit training.
S’s name came up during a routine staff meeting, where students’ concerns
are always addressed. Through discussion it was decided who might be the
best member of staff to approach the student, and to try and gently tease out
the situation. Evidently a good choice was made, as in a series of meetings,
a good rapport developed between the student and the member of staff
chosen. A gradual build-up of trust and mutual respect allowed the student to
begin to discuss the issue more openly, and another member of the support
team was brought in to help the student on a practical level (advice on a
suitable exercise regime and further nutritional guidance.)
Fortunately in this case there was a happy ending: the student achieved very
well. Much later she confessed that a potentially serious problem had been
caught in the nick of time, and thanked the staff for their sensitive handling of
the situation.
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Identifying and approaching a student who gives cause for
concern
1.8 A confident and experienced staff team will usually be aware of students
who show signs of an eating disorder. This is often through personal observation
of the typical warning signs (see 1.3 above). Other students may tell you that
they are concerned about a friend or have noticed changes to a fellow student’s
behaviour, weight and eating patterns. Students sometimes self disclose either
by talking to a trusted staff member or through the health declaration or the
disclosure statement on the application form. Concerned family members might
sometimes contact the school.
If you notice that a student has lost a lot of weight or if there are other worrying
signs, it is important to approach the student with calm, genuine concern.
Secrecy and denial are often components of disordered eating and students often
refuse to admit that there is a problem. In these cases, a kind but firm insistence
that they make an appointment to see the relevant person in your school, their
personal tutor, the head of student support or the school counsellor for example,
is much better than leaving this unsaid.
Deciding how to respond; developing a support plan
1.9 Schools will usually have in place a team of staff whose job it is to meet and
discuss the best way to respond to students whose eating and/or weight loss
gives cause for concern. This might be a Student Support Team or (particularly
in small schools) a weekly staff meeting. Preliminary discussions will involve
observation, planning how to discuss the situation with the student and deciding
who should take direct responsibility for developing the support plan and
monitoring the student’s weight and progress.
No matter what the situation, the aim of these early discussions is to try to gain a
better understanding of the individual’s circumstances in order to determine the
most appropriate way to provide assistance. The goal is to stabilise the situation
as soon as possible in order to prevent further weight loss and in the longer term,
to support the student in turning from a pattern of self harm to someone with a
healthier diet, body condition and sense of wellbeing.
There are limits to the amount and types of support schools are able to offer
and it is important to be realistic about this to both the student and other staff
members.
In developing an appropriate support plan, a number of other decisions need to
be made. These include decisions about:
• Which staff member (or members) should have primary responsibility
for monitoring the student’s progress and return to good health
• How you plan to monitor the student’s weight, BMI and general health
and wellbeing
• Whether your school has the resources to offer the support that is
needed
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• Who has responsibility for liaising with external specialist support and
keeping records.
Where an agreement has been made either to stop a student from taking part in
classes or to attend only part of the training until there are clear signs of recovery,
a decision also has to made about what concessions can be made in regard to
attendance and assessment. Your concessions policy for students with EDs (and
other students who are experiencing what we hope will be temporary difficulties)
needs to be easily available to staff and students.
Case Study 4
P was struggling with mental health problems including anxiety and
depression. He had a difficult relationship with his family. The school had
arranged counselling but his relationship with the counsellor had broken
down. During a meeting with a member of the school’s support staff, P
disclosed that he was controlling his weight by the frequent use of laxatives
and disclosed that he was bulimic and caught in a cycle of ‘binging and
purging’. The school wrote to him articulating their concerns, particularly in
regard to continuing his dance training and encouraging him to see his GP. At
the first consultation, the doctor told P that the GP practice was able to offer
specialist support to people with disordered eating but as P’s BMI was ‘too
high’, he was not eligible for this treatment.
The school’s Support Team agreed that P would continue to be supported
and agreed on the staff member who would lead this. After three or four
sessions where they discussed a number of issues, P was encouraged to
return to the doctor and re-start communication with his family. P gave his
permission for some of the information disclosed in these discussions to be
shared with the member of visiting staff who had responsibility for monitoring
students’ BMI, stamina and general health and wellbeing.
P continued to misuse laxatives but in consultation with the GP, began a
course of anti-depressants. This helped to stabilise his mental health but after
a few months he decided not to continue with the medication. His family life
remained turbulent and he was unable to handle both the stress of family life
and the stress of his studies. With advice and support, P decided to intermit.
During this period, he stayed with other relatives and with their support, he
began to resolve some of the problematic family issues. P’s mental health
became more stable and his self esteem improved. This gave him the
confidence to return to school at the start of the new academic year where he
is now in the process of successfully completing his final year.
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Confidentiality and sharing information
1.10 As explained in paragraph 1.2 above, disordered eating in its most
serious and long term form is a mental health condition and students presenting
with clear signs of a recognised eating disorder are covered by the Equality
Act (previously the Disability Discrimination Act) and are entitled to the same
support and reasonable adjustments as other disabled students. One of these
entitlements is rights relating to passing on information. Information about mental
health is considered ‘sensitive information’ and we need to:
• Ask students’ permission to pass on information in order to make it
possible for reasonable adjustments to be put into place
• Inform the students of any procedures or decisions that are in place
• Guarantee that sensitive and other personal information is kept
confidential.
Unless the student has specifically requested that this information be made
available, teaching staff are not typically informed of the details of the decisions
that are in place to support a student with disordered eating or given personal
information about any events that might have triggered the situation. Staff, fellow
students and others involved are often curious about the health or wellbeing of
an affected student and an appropriate response is that the Principal, Student
Support Team or other senior staff member/s are aware of the situation and that
the student is receiving the support s/he needs.
Using Learning Agreements
1.11 Given the importance of respect for confidentiality as explained in
paragraph 1.10 above, it might seem contradictory to recommend the use of
a Learning Agreement or Personal Learning Plan to support these students.
However, used with care, such an agreement can be a helpful part of developing
and monitoring a planned programme of support for a student during the period
when they are still studying and may be following only a part of their training. It
can also be a useful tool in making a formal agreement with students who are
taking time out from the course whilst they return to good health. A Learning
Agreement can, for example:
• Include information about the student’s condition in a way that
respects confidentiality
• Clarify who has access to this information
• Explain the support plan and any reasonable adjustments staff are
required to make to their teaching
• List the agreements made so that the student both understands
and agrees to the plan, for example, that they agree to attend
regular meetings to monitor their BMI and general health, follow the
concessions arrangements during this period, see the counsellor and/
or seek external professional support.
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Using internal and external specialist help
1.12 There are a number of key specialist services that are crucial to a student’s
return to a healthy weight and general wellbeing. Staff and students should know
who they are and where appropriate, how to contact them. They include:
• The school counsellor or psychologist. This is usually the first port
of call. Good practice is for the school to employ a professional
counsellor who can see students on site or near to the school and to
whom they can self refer
• A professionally trained nutritionist who can offer advice on good
nutrition and healthy eating both one to one and in group sessions,
ideally on many occasions and not just once at the beginning of the
course
• Other relevant professionals such as a physiotherapist, osteopath and
Pilates teacher
• The student’s GP: with the student’s permission, the school might
contact their GP with written information on the reasons for concern,
steps taken so far and the potential risks to the student without
specialist treatment
• Specialist eating disorder clinics either local to the school or near to
the student’s family home.
Being asked to stop training for a while or intermit
1.13 In some circumstances a student with a serious eating disorder may be
advised to interrupt their studies until they are well enough to continue training
and where their BMI has returned to an acceptable level. This decision will only
be made where there are reasons for concern for their own health and safety and
for the safety of others, particularly in the practical and performing arts elements
of their training.
Wherever possible, decisions about stopping training will be taken with the
student’s consent and there will normally be a formal or semi-formal agreement
about conditions for returning to school. Such an agreement will usually include
the need to seek appropriate professional help and return to a healthy BMI.
In most cases a condition of return will also include written evidence from a
professional such as a psychiatrist or the student’s GP which confirms that the
student has received treatment and is well enough to return to rigorous, full time
training.
Where a student’s absence is longer than can be accommodated within the
school’s current attendance and concession policies, a decision has to be made
about whether the student will need to restart the year.
All decisions of this kind should be recorded in writing and a copy of any letters
sent or received needs to be retained in school.
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Students who leave
1.14 There are some situations where students neither seek help nor respond to
the support on offer and for complex reasons are unable to overcome their eating
disorder and other mental health difficulties. This is always regrettable and where
a decision is made that it is not appropriate for students to continue their training
(either by the student, the school or both), it can be helpful to offer counselling
to help them to understand that they have made the choice to train with us and
with this choice comes the necessity to eat. Students are autonomous and have
a responsibility for their actions and decisions. Leaving training might well be the
right choice for them at this stage in their lives.
Case Study 5
L, an overseas student in her final year on an acting degree was in rehearsal,
working with a visiting director. The director had noticed that L was losing
weight but assumed that school staff were aware of this and felt that her
job was not to intervene but to allow L to continue acting and performing
as this is what L most wanted to do. However, when L attended her first
costume fitting, staff were shocked at her extreme weight loss. The costume
department notified the senior management team who decided that it would
be dangerous to allow L to continue training and performing.
L was offered counselling but her weight did not improve. After consultation
and discussion, it was agreed that L would return to her family in her home
country, regain a healthy weight and then restart the final year of her training
in the following September. There were three conditions for her return to
training: that she would seek professional help during the year that she was
out of school, return to a healthy weight and not engage in paid modelling or
acting work (which L had done in previous vacations).
In the summer of the following academic year, the school contacted L to
discuss her return to school but it was clear that she had not followed any of
the conditions and her weight was still too low for her to continue training. In
telephone counselling, L agreed that the best choice for her at this stage in
her life was to stay with her family in her home country. The school supported
her decision and encouraged her to seek professional help to deal with her
eating and very low weight.
The school reviewed its practice on the pastoral support offered to students in
their final year of training. All students are now offered regular meetings with
their year tutor. Directors and other visiting staff are also given information
on how to contact staff if they have any concerns about students’ health and
wellbeing.
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Working with families
1.15 When a student who is over 18 has been identified as having a serious
eating disorder which requires specialist support, the approach will be to offer
reasonable and appropriate support to the student without direct involvement
of their parents or guardians. Some students are caught in a cycle of low self
esteem and a desire for self control and don’t welcome support either from
the school or from their family, but where a student gives their agreement that
information about their condition and/or treatment can be shared, the involvement
and co-operation of the student’s family can be very helpful. This is particularly
important where the agreed plan is for the student to withdraw from training until
their condition has improved and/or they have returned to a healthy weight.
Where students are 18 or over, they are legally adults and have the right to make
their own decisions, including behaving in ways that other people might consider
inappropriate or foolish as long as this behaviour does not have a negative effect
on others. Where students are under 18, the duty of care is different and it is
important to make clear to students and their families how we plan to balance the
responsibility of duty of care with the student’s personal autonomy. For example,
in cases of serious concern over the students’ health and wellbeing, the school
will usually try to work with the student’s family or guardians to help the student
to return to good health. How this will work needs to be clearly explained to both
student and family and decisions need to be recorded.
Supporting other students
1.16 It is often other students who are most involved in the daily lives of those
who are experiencing different forms of disordered eating. Fellow students and
housemates may be the first to notice changes in a friend or peer’s weight,
appearance or mood. These could include the overuse of laxatives, purging and
vomiting, refusing to eat or share meals, too much talking about being overweight
(‘fat talk’), dramatic weight loss (or gain), clear signs of stress and anxiety.
Fellow students need to know who they can go to within the school and feel
confident that their concerns will be taken seriously. In these early conversations
with flatmates, friends and fellow students, staff need to try to establish the
severity of the situation and give students the reassurance that they will be dealt
with appropriately.
Once a school ‘knows’ that there is cause for concern, it needs to find ways to
approach the student without breaking confidentiality. Appropriate strategies can
include:
• Keeping a close eye on the student causing concern, i.e. looking for
the key signs (see section 1.3 above)
• Gathering information based on personal observation and concerns
expressed by other staff members
• Approaching the student to say why you are concerned.
The goal is to get the student to come to you to seek support.
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There are some extreme circumstances where the behaviour of a student
with eating disorders (and there are likely to be other presenting mental health
difficulties) can disrupt the whole house. Teaching other students what to
expect so they aren’t afraid of the behaviour of their friend or fellow student can
help them to offer some support whilst at the same time protecting their own
wellbeing, independence and training.
Developing a policy
1.17 Each affiliate will have its own methods of identifying students who show
signs of disordered eating and understand that it is important to be able to
respond to individual circumstances in a flexible and sensitive way.
However, it is also essential for schools to have a clear statement which is widely
known and understood by staff, students, governors and other stakeholders. A
written policy, however informal its style and presentation, will help to explain
the approach and procedures that are in place to support students whose
eating patterns, weight and mental health give cause for concern. It can help to
encourage a consistent approach to making decisions that are often difficult and
sensitive.
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2. Management and Prevention
Below are some suggestions on ways to promote a positive environment within
our schools, one that will help to create a climate of healthy eating and reduce the
risk factors that contribute to eating problems and other associated mental health
difficulties.
Building resilience and self esteem
2.1 Students should be encouraged to identify their strengths and acknowledge
their achievements. Rather than an over-reliance on validation from staff, students
should be encouraged to develop a realistic self-assessment of how well they are
doing. In addition:
• We should try to develop a situation where students are happy to
approach staff to discuss these issues and/or ask for help
• Students can be over-controlled in performing arts training, and it is
important to develop a positive, responsive climate where students
have room to talk about how the training makes them feel
• Staff and students interact with respect
• The system of evaluation and assessment should be transparent.
Pastoral care
2.2 Our schools are small and our students are well known to staff. We take
pride in providing good pastoral support and in providing regular opportunities for
students to talk to staff and ask their advice. Other ways to ensure good pastoral
care include:
• An effective year tutor system
• Providing access to professional help. This might include employing
a counsellor, student welfare or student support officer. Ideally this
person will be a ‘known face’ around the building, so that it is easy for
students to self-refer.
• Encouraging peer support so that students can help each other to eat
well and take care of themselves
• Repeatedly emphasising the need for good nutrition and self-care (not
just once in the first year)
• Where students are developing disordered eating, encouraging them
to self-disclose to a member of staff they trust and then having clear
procedures for developing an individual programme of support.
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Creating boundaries
2.3 It is important to have clear policies about lines of responsibility within an
organisation. In particular there needs to be a clear, shared understanding of
the difference between offering students general support and concern for their
wellbeing, and specific, specialist support.
• There should be a shared understanding of school practice with
regard to whether students who are severely underweight or ill should
be allowed to continue training
• Staff should be encouraged to talk appropriately to students and
avoid ‘fat talk’, including talk on what the student will not be able to
do (or companies they won’t be able to work for) if they are too ‘heavy’.
Showing by example
2.4 It is helpful if members of staff act as models of appropriate self-care and
good nutrition, for example in relation to smoking, eating, resting and taking care
of themselves in periods of illness. This can include:
• Ensuring that students have time for eating during the day
• Providing students with high quality food at good prices
• Using successful members of the profession to encourage good
habits of self-care.
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3. Checklist: developing or revising school policy
Using the checklist
3.1 This checklist is presented as statements followed by a list of questions.
These questions are designed to help schools who wish to either:
• Develop their school’s policy on responding to students with
disordered eating or;
• Discuss and review an existing policy.
The checklist
1. POLICY ON DISORDERED EATING
It is important for schools to have a clear, written statement which is widely known and
understood by staff, students and Governors.
Yes/No
Do you have a written policy statement which explains your current practice
and procedure?
Are there mechanisms for sharing this information with staff, students and
other stakeholders?
Does this include visiting staff?
Is there a procedure for reviewing and where appropriate, amending your
current policy?
Have your staff had training on responding to students with disordered
eating?
Are you confident that they understand and share the school’s policy and
practice?
2. SPOTTING THE SIGNS
Schools need procedures for identifying where there is cause for a concern over a
student’s weight, eating and general mental health, and where students know who to
approach to discuss difficulties.
Have staff and students been given information and training about the
warning signs that might indicate a potential eating disorder?
Is there a regular forum for staff to discuss their concerns about a student
who exhibits signs of disordered eating, for example at a weekly support or
other regular staff meeting?
Do students know who they can approach when they want to discuss these
issues or have concerns about a friend or fellow student?
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3. DEVELOPING A PROGRAMME OF SUPPORT
Schools should have in place a team of staff who meet to discuss the best way to
respond to students whose eating and weight gives cause for concern.
Is there a designated member of staff who takes the lead on developing
a programme of support for students? This programme might include
measuring and monitoring a student’s weight and general health (see point
6 below for more details) and liaising with specialist, professional staff.
If there is more than one member of staff responsible for supporting
students with disordered eating, how do you ensure expertise and
consistency of approach?
4. STAFF BOUNDARIES
It is important for staff not to offer help that is beyond their role and to be clear about
their boundaries. There is a difference between being generally supportive and offering
specific, specialised support.
Are staff clear about their boundaries and do they understand the difference
between offering general support for students who are experiencing
difficulties and specific, specialist support?
Do staff know who to go to to discuss concerns over students who give
cause for concern and how students are referred on to specialist help?
5. CONFIDENTIALITY
Information about students with disordered eating and other related mental health
issues is ‘sensitive and personal’ information. Sharing this information needs to be
done appropriately, with respect for confidentiality and with the student’s agreement.
Are all staff aware of the need for confidentiality of information and respect
this?
Is there a procedure for writing a Learning Agreement or plan and/
or sharing appropriate information whilst respecting confidentiality of
information?
Do you have a way of storing information, (for example letters to specialist
services, records of conversations, information about a student’s weight)
which ensures confidentiality?
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6. MONITORING BMI
BMI is a formula which relates body weight to height and enables people to determine
whether they are at a weight which is healthy for them. BMI is used as one of the
measures to monitor a student who shows signs of rapid or extreme weight loss.
Is there a shared plan for making decisions about how your school
manages BMI and body weight where a student is known to be at high risk
or has disclosed a problem with disordered eating?
Do you have a BMI figure below which a student is not allowed to continue
training? If so, are staff clear about this policy?
Do you have a designated member of staff (either visiting or permanent
staff) who can undertake a programme of measuring and monitoring a
student’s BMI and general health and wellbeing? If so, does this person
have specialist knowledge of this area?
Is this a person directly involved with the student’s training or assessment?
7. COUNSELLING AND OTHER SPECIALIST HELP
Schools should employ a counsellor who is able to see students without too much
delay and students should be able to self refer. Schools need to develop relationships
with other specialist services such as a nutritionist, osteopath and external specialist
psychiatric services including local eating disorders clinics.
Do you offer in-house or locally available specialist counselling support? If
so, is it easy for students to self-refer? Is it free?
Do you employ a specialist nutritionist or dietician who visits the school on
a regular basis? Can students self-refer to the nutritionist?
Are there other visiting specialists (or members of your permanent staff)
who can work with students with eating disorders/low weight and offer
advice on the dangers of continuing training until a healthy BMI is restored?
Are you confident that your school has good links with external, specialist
psychiatrist services such as your local eating disorders clinic?
Is there a designated staff member with this expertise who takes
responsibility for writing referral letters and making contact with external
specialists?
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8. GOOD NUTRITION
What kind of information are students given about good nutrition, and the
importance of eating well in a training that places high demands on their
emotional and physical energy?
Do you employ a professional nutritionist on a regular basis, i.e. not just
once at the beginning of their training? Do they offer group sessions
for students interested in learning more about the particular nutritional
demands for performing arts students (not just for dancers)?
Are students able to get one-to-one support from a nutritionist?
9. SUPPORTING OTHER STUDENTS
A student who exhibits symptoms of disordered eating is also likely to create concern
for their friends, flatmates and fellow students and it is necessary to ensure that
support is in place.
What steps have been taken to create a climate where students feel
confident about coming to discuss concerns that they have with friends,
flatmates and peers?
Are you confident that students know who to go to and would not doubt
that their concerns would be treated as confidential?
10. SHARING INFORMATION WITH FAMILY AND OTHER STUDENTS
Is there an agreed policy/practice on disclosing information to a student’s
family where there is cause for concern?
Are there different procedures for students who are under 18 years old?
Is there an agreed way of sharing information with other students in a way
that reassures friends, flatmates and fellow students whilst respecting
confidential information?
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11. WHEN A STUDENT INTERMITS OR LEAVES
How do you maintain contact with students who are asked to intermit?
How are students informed of what they will need to do before they can
return to training? e.g. by formal letter or ‘contract’, informal agreement etc.
Are students asked to provide evidence (for example a letter from a
psychologist or other specialist) to show that they are well enough to return
to training?
Do you offer counselling to students where a decision has been made for
them to leave?
12. MANAGING AND PREVENTING DISORDERED EATING
Are there procedures to promote a climate of healthy eating and reduce
the factors that contribute to eating disorders and other associated mental
health difficulties, for example, do you:
•
Help students to identify their strengths and acknowledge
achievements and provide students with transparent systems of
evaluation?
•
Create a positive climate where students are happy to self disclose to a
member of staff they trust?
•
Provide students with regular access to a counsellor, nutritionist and
other specialist staff?
•
Organise staff development on this topic?
•
Have clear boundaries about staff responsibility?
•
Encourage staff to act as models of appropriate self-care and good
nutrition, for example in relation to smoking, eating, resting and taking
care of themselves in periods of illness?
(Endnotes)
1 References to Professor Julia Buckroyd in these guidelines refer to the staff
training she delivered at the Conservatoire for Dance and Drama in July 2012.
See also her books: Understanding Your Eating; How to Eat and Not Worry About
It, 2012 and The Student Dancer, Aspects of the Teaching and Learning of Dance,
2000.
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Conservatoire for Dance and Drama
www.cdd.ac.uk
Bristol Old Vic Theatre School
www.oldvic.ac.uk
Central School of Ballet
www.centralschoolofballet.co.uk
Circus Space
www.circusspace.co.uk
London Academy of Music and Dramatic Art
www.lamda.org.uk
London Contemporary Dance School
www.lcds.ac.uk
Northern School of Contemporary Dance
www.nscd.ac.uk
Rambert School of Ballet and Contemporary Dance
www.rambertschool.org.uk
Royal Academy of Dramatic Art
www.rada.ac.uk
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