Table 1.

Mental health-specific clinical practice standards

1. Co-ordination of services

1.1. Communication within the multidisciplinary care team

i. Understand the significance and importance of a multidisciplinary team in treatment, and know the role of each member

ii. Know how to set up a multidisciplinary team consistent with the treatment model being delivered

iii. Participate in implementing treatment recommendations consistent with own professional background and work collaboratively with other team members both within and external to own practice

iv. Understand the impact eating disorder pathology can have on the functioning of the multidisciplinary team (e.g.) The therapeutic process can be greatly impeded by incidents of splitting

v. Ensure processes and systems are set up for effective communication between all parties, such as sharing case notes, letters, case conferencing, to ensure consistent, collaborative care

1.2. Communication with patients

i. Explain the limits of confidentiality and establish treatment non-negotiables

ii. Outline an individual case formulation and explain how treatment goals relate to this formulation

1.3. Communication with family and significant others

i. Understand the role of families and carers in assessment, engagement, treatment and recovery support for children, young people and adults

ii. Work collaboratively, and in an age appropriate way, with patients to allow their family to share information with the treatment team

iii. If divisions around key issues and concerns arise within the family, ensure these are discussed openly, whilst providing understanding and support to the patient, and resolving these in favour of reducing the impact of the eating disorder

2. Establishing a positive therapeutic alliance

i. Recognise the central role the therapeutic alliance plays in therapy and the importance of the therapeutic alliance in the variability of patient outcome

ii. Work to develop a relationship where the patient feels heard and respected.

iii. Outline the tasks of therapy consistent with the therapist’s model of working. (e.g.) outlining the core principles of a cognitive behavioural therapy.

iv. Obtain a collaborative and informed agreement about the tasks and goals of therapy. (e.g.) highlighting the role of dietary restriction in anorexia and binge eating and working collaboratively with the patient to obtain an understanding that reversing dietary restriction is an active goal of therapy

v. Understand that there is a complex bidirectional interplay between therapeutic alliance, readiness for change, self-efficacy and early behaviour change.

vi. Wherever possible early behaviour change should be the initial aim of therapy as it has shown to be correlated to better therapeutic alliance and better outcomes

3. Professional responsibility

i. Understand the need for a developmentally sensitive family and person-centred approach to setting up and implementing treatment

ii. Understand the impact of culture, mental health stigma, weight bias and stigma that can prevent people from accessing support

iii. Consistently reflect on and judge knowledge and experience limitations so that safe care is consistently provided

iv. Understand the importance of clinical supervision as required by own professional body to enable effective reflective practice, as well as to support treatment planning and therapy model implementation

v. Understand that clinical supervision on eating disorder cases should be undertaken with a clinician experienced in eating disorders and that regular eating disorder focused clinical supervision is an essential professional requirement. In addition, clinical supervision supports clinicians to know the limits of their expertise and when to seek advice or refer on

vi. Understand the importance of continuing professional development as required by their professional body with the aim to develop the knowledge, skills and attitudes required to provide and manage mental health care for people experiencing an eating disorder

4. Knowledge of levels of care

i. Understand the services that are available at different care levels locally and match the treatment context to symptom severity

ii. Understand how the treatment context will impact the implementation of an evidence-based model

iii. Recognise the indicators for referral to a higher level of care (e.g. as an inpatient or day patient) and the aim of each care level. Factors like patient age and illness severity and duration as well as available access to higher levels of care will impact on decision making

iv. Understand when and how involuntary treatment is implemented for the person with an eating disorder as a matter of urgency and duty of care

v. Determine when to refer on for further assessments to address physical, psychiatric or nutritional needs

5. Mental health assessment

i. Know how to assess eating disorder symptoms, being aware that symptoms may be minimised by the person with an eating disorder • Bingeing, purging and compensatory behaviour ▪ Type of compensatory behaviour (e.g. laxative use, excessive exercise, diet pills, steroid use) ▪ Frequency ▪ Amount ▪ Types of food ▪ Triggers to binge • Height, weight and rate of any weight changes • Core cognitive features ▪ Over evaluation of weight and shape ▪ Eating-related cognitions (e.g. guilt, control) ▪ Body dissatisfaction ▪ Body checking ▪ Fear of fatness and weight gain ▪ Perfectionism • Food intake • Eating behaviours ▪ Past and current, and motivation to change these ▪ Food rituals ▪ Avoided foods and food sensitivities ▪ Fluid intake • Medical consequences of disordered eating behaviours • Psychosexual and interpersonal functioning • Treatment history • Comorbidity (medical and psychological) and be aware of the impact of nutritional status on mood and anxiety • Mental state assessment • Mental health risk factors (e.g. suicidality) • Family of origin and support system • Trauma history • Psychometric assessment – such as the Eating Disorder Examination-Questionnaire (EDE-Q) or the ED-15. The ED-15 and the 12-item EDE-Q are suitable for a session by session assessment of progress, which is also shown to enhance the effectiveness of treatment.

ii. Understand the common medical co-occurring diagnoses that are typical for people with an eating disorder and assess the short- and long-term physical impacts of an eating disorder, including the need for urgent assessment and intervention if there is a risk of medical instability

iii. Understand the common psychiatric co-occurring diagnoses that are typical for people with an eating disorder; including risk of suicide and self-harm

iv. Assess the range of impacts an eating disorder has across the domains of life; ascertain illness progression and its impact on psychological, social and quality of life factors

v. Identify and support the recognition of strengths and resources for the person with an eating disorder

vi. Know how to engage key parents, carers or significant others

vii. Understand the use of and implementation of age-appropriate validated eating disorder assessment tools and psychometric tests

6. Mental health diagnosis

i. Ability to identify the diagnostic criteria for eating disorders, and apply appropriately including distinguishing from differential diagnoses

ii. Understand the risk factors that contribute to the development of eating disorder, including awareness of populations at high risk for developing at eating disorder

iii. Understand the signs of an eating disorder at different stages of progression and have an awareness of the way in which the seriousness of eating disorder symptoms can be minimised when clinicians are poorly informed

iv. Identify when a person requires urgent medical assessment or psychiatric assessment and when they should be referred to a hospital emergency department

v. Develop a case formulation including preliminary hypotheses about predisposing, precipitating and maintaining factors, as well as noting the individual’s strengths and protective factors

7. Mental health intervention

7.1 Knowledge of evidence-based treatment

i. Understand, describe and have a working knowledge of the current evidence base for eating disorder treatments and how they are implemented for each diagnosis  • Weighing of the patient at each appointment and sharing that information with the client wherever possible  • Reviewing eating and disordered behaviours  • Establishing regular eating  • Identifying antecedent variables (triggers) to eating disorder behaviour  • Working with families or significant others to support the patient towards recovery, in a developmentally appropriate way. For children or adolescents this will include eating disorder-focussed family therapy.  • Provision of alternative coping strategies to replace the eating disorder. This is likely to involve seeking support and strategies to manage affect and relational triggers  • On an ongoing basis, addressing issues of motivation, body image and quality of life

ii. Provide support to a person with an eating disorder and their family and significant other (where possible) while awaiting specialist care or evidence-based treatment to commence

iii. Have awareness of components of effective medical management and ensure that regular medical reviews are occurring

iv. Understand how the symptoms of an eating disorder can impact engagement and adherence to treatment; it is important to have clear treatment goals and outcomes to mitigate against poor progress

v. Put risk management plans in place for self-harm and suicidal ideation

vi. Have a knowledge of developmentally appropriate basic nutritional and healthy eating principles

vii. Advise the person and family or significant other (where possible) about basic immediate steps and their benefits such as regular eating, supervision and support, the need for weight gain

viii. Understand the complex relationships between motivation and behavioural change for people with eating disorders and that ambivalence is common in eating disorder presentations, despite a strong underlying need to feel better

ix. Understand the need for speciality training and supervision to learn and implement a treatment model competently and with fidelity

8. Managing risk

i. Identify and manage suicidality at all levels of eating disorder care. Risk factors for suicide can include:  • previous suicide attempts  • deliberate self-harm  • substance abuse  • comorbid depression  • additional mental illness  • social isolation  • lack of fear of death  • access to medication and others means of harm  • increased family conflict  • thinking that they are a burden  • impulsive traits  • experiences of trauma (including but not limited to post-traumatic stress disorder) severity of eating disorder  • recent rapid weight loss

ii. Identify protective factors

iii. Manage co-occurring mental health diagnoses across the course of treatment

9. Monitoring and evaluation

i. Measure treatment adherence and outcomes using methods that are standardised or of an accepted standard in the field such as monitoring weight, binge-purge frequency, or eating disorder psychopathology with psychometric measures

ii. Provide a follow-up schedule that matches the severity of the eating disorder and the treatment model being implemented