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Responding to Students with Disordered Eating

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Conservatoire for Dance and DramaTavistock House, Tavistock SquareLondon WC1H 9JJ

www.cdd.ac.uk020 7387 5101info@cdd.ac.uk @conservatoireddfacebook.com/conservatoiredd

Contents

Introduction

Section 1: Information

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

Section 2: Management and Prevention

2.1 Building resilience and self-esteem 2.2 Pastoral care 2.3 Creating boundaries 2.4 Showing by example

Section 3: Developing or revising school policy

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.

1 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, Coun-sellor 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: lois.keith@cdd.ac.uk

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 Dramawww.cdd.ac.uk

Bristol Old Vic Theatre Schoolwww.oldvic.ac.uk

Central School of Balletwww.centralschoolofballet.co.uk

Circus Spacewww.circusspace.co.uk

London Academy of Music and Dramatic Artwww.lamda.org.uk

London Contemporary Dance Schoolwww.lcds.ac.uk

Northern School of Contemporary Dancewww.nscd.ac.uk

Rambert School of Ballet and Contemporary Dancewww.rambertschool.org.uk

Royal Academy of Dramatic Artwww.rada.ac.uk