Creating Inclusive Physical Eating Disorder Spaces

There is no one way to hold space for a client and we all have our own style or are learning our own style of being thoughtful health care workers.

In planning the physical space that you will see clients in there are a few things to consider.

Making an effort to provide a calming, inclusive space signals to our clients that we are aware and willing to support in an individual and intentional way. There may be things that you don't have control over and you may not be able to adapt everything as you may like; but small changes and offerings for clients can aid in signaling that you have the aim of creating a space with the intention of emotional safety.

We can not determine what emotional safety is for individual clients and we can not assume the microaggressions, trauma and experience they bring. We can let them know we are aware that these experiences may be part of their experience and we are considerate of how it may impact them and that we want to adapt to their needs where we can.

Of course it is important to ask each client if there is anything you can do to make them more comfortable, at each session. Here Are some things to consider before your first client even walks in the room.

Clinical Spaces

In coming to a session with a new clinician for the first time a client may be very activated, distressed or overwhelmed with the anticipation of the unknown. With clients emotional safety in mind and possible anticipatory activation we need to consider what we can do in the physical space to aid in calming clients nervous systems.

Clients you see may have experienced harm within the medical system. This may have left them feeling invalidated, failed in their illness or stigmatized. Some may have experienced trauma in previous attempts to seek care for their eating disorder. Just being in a medical space may be triggering for some clients. If sharing a GP office it is worth considering that a clinical room may be unsettling for clients if they have previously experienced medical trauma such as misgendering, weight and body shaming or invalidating support. We may not be able to “un medicalise'' a space but we may be able to add things to the space to help soften it and signal consideration.

We can inform clients before they attend that we work from a medical clinic or a GP room. Your website could include a photo of the room and a short description of what the waiting room and treatment room will look like. This could also be flagged in any automated appointment confirmation or reminder emails.

Some of the offerings below may help to soften a room, assist in grounding the nervous system; for yourself and your client and flag your consideration of people's experience in your wider culture.

Posters and Flags

Having posters and flags in the general area, waiting area and office directly communicates that as an organization and/ or individual practitioner. you acknowledge the experiences of and have considered the possible traumas experiences by marginalized groups.

This may include (Taken from an Australian context):

• Acknowledgement of country plaque / poster

• Social justice inclusion posters including

• First nations

• Transgender

• LGBTQA

• Intersex

• Gender inclusion

• Neuro diversity

Flags may include:

• Aboriginal

• Torres strait islander

• LGBTQIA - Rainbow Flag

• Transgender flag

• Lesbian flag

• Bisexual flag

• Progress pride flag

• Non binary flag

• Intersex flag

• Pan sexual flag

• Asexual flag

Consider including artwork on the walls that include calming colors. You may choose to support independent artists from marginalized groups (prints or framed cards are often inexpensive options).

Furniture set up

Furniture should be set up so that when a client is seated they have a clear view and unobstructed thoroughfare to the door and feel that they can easily leave the room if they become activated or overwhelmed. This is especially important for clients who have a history of trauma.

Seating Options

People in higher weight bodies have generously shared their experience of fear that there will not be seats that can accommodate them in public and private spaces. This may include chairs with arms that are too narrow or chairs that they fear wont hold their weight. Consider this when looking at the seating options in the space you see clients. Is the seating available able to accommodate a range of bodies? Size, shape, weight and accessibility needs?

Positioning ourselves and our bodies in the room with our clients and their bodies is another important consideration. Set the room up so that you can sit facing the client or slightly to the side of the client.

Sitting behind a desk may be disconnected to attunement with the client and may be perceived as a barrier. Consider if you are going to be taking notes while sitting with a client. Will this be with a tablet, laptop or paper? Have you considered what impact this will have in the interaction with the client?

It may be commonplace for some generations to type on a laptop while listening; but not for all!

Consider asking clients at the start of sessions for permission to take notes on your laptop/ table/ notepad. Explain how these notes will be used; i.e. to assist in writing clinical notes for their file.

Consider that the screen of a tablet or notebook may interfere with you being fully present, attuned and engaged in the conversation. If you need to attend to the screen to open a file or open a browser to communicate what you are doing with the client. Being transparent in what you are doing and why with the client will help the client to feel considered, included and at ease.

Scales and Intervention Tools

Walk into your space and try to put yourself in the shoes of your client. How do you feel in space? What can you see? So common items in health practitioner officers we may be used to and not notice. Something such as a scale. For so many reasons the sight of the scale in the room may be jarring for a client. Their head may be flooded with thoughts that are so distracting that they cant be present and engaged.

“Are they intending to weigh me ?

When ?

Why ?

What if it's different from the other scales ?

Will they tell me the number ?

What will I feel if I do ?

What will they think of the number ?”

Weight and the process of weighing is triggering and complex for all of our clients. If the scales can be stored out of sight, consider doing this. If they can't be moved, can they be covered or can you acknowledge them in the room and discuss it with the client.

“ There are scales permanently in this room as I share it with other practitioners and am unable to move them. I won't be using them as part of our assessment today and if at some point there is a reason to weigh you I will discuss this in detail with you and we will come up with a way to do this they feel most comfortable for you.”

If we go back to the exercise of thinking like a client, what else is in the room to consider?

Health promotion posters that may be triggering? Measuring tapes?

How could you move these things or discuss them with the client overtly?

Calming the nervous system

We are unable to decide what creates emotional safety and helps others to feel calm; but we can be aware of providing the ingredients in the hope that each client can access what they need.

Lights can be deliberately soft, with warm globes and extra lamps used to create a softer light in the rooms without windows.

If you have the opportunity to control the colors in the room you can consider which colors will help to create a calming and inviting atmosphere. This may include warm shades, greens, blues, violets, pinks, tans, soft whites and warm grays. You may not be able to paint the walls but you can consider this in the soft furnishings, artwork and decor of the room.

You can consider offering a range of tactile experiences for the clients that may be calming. This may include soft furnishings such as pillow, blankets, and/ or weighted lap pads,

Diffuses could be used with the aim of olfactory calming of the nervous system. Always check with clients to make sure it isn't too overwhelming for them and ensure it can be easily removed. Some people are very sensitive to fragrance.

Plants, real or not, are known to be calming and can be added to a space. Consider if you are able to offer water or tea for clients. Warm cups can give anxious hands something to do; as do fidgets.

It may be worth considering a range of fidgets and other activities that clients can use while they are in the session. These are helpful for all, not just for people who identify as neurodivergent. Activities such as coloring in and puzzles may be something that can be a focus for people who are overwhelmed - aiding in them feeling more able to talk about what may be difficult topics.

Arriving in the room and starting the session

Orientate a client to the space if they are new. Let them know where the bathroom is. Offer them a range of seating options. Offer them a drink. You may detect that someone is activated before the session commences; this may be anticipatory anxiety or the process of finding a new office may be stressful. Check in with the client and allow them to speak about getting there, getting a park etc. The process of coming to a new space and the logistics can be very activating and clients may need a little time to debrief and settle.

If you notice the client is activated you may offer them a moment to ground and arrive in the space. This may be a few minutes to catch their breath and settle. If it is a new client and you are unsure how they will respond to this invitation you can always model some grounding. This may be something like.

“ Oh, it has been such a busy day, I like to take a pause and a few deep breaths at the start of a session so I can be fully present and calm with you.

*take a few deep breaths*

That's better - shall we get started?”

Reflection

After reading this article what are some of the things that you have reflected on you could do differently?

Are there things in your work space that clients have commented on, appreciating them?

Dr Christie Bennett and Josephine Money ©2023 

Creating Inclusive Virtual Eating Disorder Spaces

There are many things to consider when bringing a client into a shared physical space; how does this cross over to the virtual space?

COVID forced health care to go virtual rapidly and I am sure that many practitioners have learnt from their own and colleagues experiences on how to best support clients in this mode. Clients may choose telehealth for a range of reasons; Telehealth may provide a safer way for them to connect that feels less distressing; it may be convenient or face to face may not be accessible for them.

For virtual sessions we can not signal our consideration of clients possible experiences in the same way that we can in a face to face session. Room colors, fidgets and flags are not going to be helpful. We can ensure that we are signaling our consideration of their unique experience with the client on our website and other public domains, in communication pre and post sessions.

Safety and Confidentiality

In the virtual space we can not rely as much on the non verbal cues and signs between us and the client and need to be more direct in setting up safety for ourselves and the client in the room.

Ensure that the platform you are using to connect online is secure to ensure client privacy and confidentiality. Ensure this is communicated in writing or verbally to the client.

Check the location of the client each session. With the variety of presentations of clients we see we can not know all risks for the client. It is important to know where the client is connecting to the session from; home, work, in their car at the local supermarket. Hopefully you will not need to know this information; but in the case of an emergency this information is imperative. This can always be asked in a less formal way if it feel more comfortable:

“ You are in a room I haven't seen before; where are you joining me from today?”

Ask if there is anyone else in the room or the location with the client.Ask the client if they feel they are in a space where their confidentiality is protected and they can speak freely.

“ Is there anyone else there with you today ? Do you feel comfortable to speak freely and not be overheard?”

Let the client know any measure that you have taken to protect their privacy. This may be using headphones,being alone in the room, and having the door closed.

“You may notice the door is open behind me today and I dont have my headphones; I wanted to reassure you that I am home alone today and no one will be coming home during our session time. “

Requesting the address that client is at for a virtual session could also be built in to you practice policy and communicated to clients on the website, in confirmation and reminder email and in new client form.

“ As you know our practice policy is that I need to have the address of where you are each session, could you please add it to the chat or let me know so I can add it to the notes. Thanks.”

Starting the session

It can be easy to miss the small talk and checking in that is often present at the start of the session and can be easy to dive into the session. When meeting someone face to face we often greet them in a waiting area, make small talk as we walk to the room together and get settled in the room. This process may seem insignificant but it can create a powerful transition time for you and the client to ‘arrive’ mentally and emotionally ready for the session.

When connecting online we may need to make a deliberate effort to engage in this same transition process to move into the session. This may include orientation to both your locations as described above, checking in on confidentiality, some small talk about weather or a small antidote.

Over time you will develop your own style and range of tools for this. An option may be acknowledging that there is a need to arrive for the session.

“ It sounds like you have had a busy morning at work and I can see you in one of the meeting rooms at work. I have gone from session to session this morning. Would you like to take a moment with me to take 3-4 deep breaths together so we can both feel more grounded and ready to start the session?”

This can be a lovely role moedling an opportunity to educate clients about helpful grounding tools and the power of transitions between different parts of our days.

During the session

The connection with a client in a virtual room can be just as powerful as face to face; Especially with clients we know well. While we are developing rapport with clients there may be times that we assume a reaction from them implies something. We need to be sure to check in with the client if what we are thinking is correct or not ( this is valid for face to face sessions).

“I noticed that as we started talking about this you have sat back in your chair and are looking down. I am wondering how you are feeling if this discussion is difficult or bringing something up for you?”

As always it is important to check in with the client how they are feeling in a session and the impact that information we have offered has landed. This may need to be a more direct question during virtual sessions where we are unable to see their whole selves and have access to nonverbal cues in the same way as a face to face session.

“We have been talking for a while now and I just wanted to pause and check in on you? How are you feeling? Are there any feelings coming up in your body or thoughts?”

Some people find it harder to concentrate in virtual sessions; let me know if you would like to take a pause or if there is anything that might help you?”

Be aware of your own concentration and attunement in the session. For some online sessions feel easy and for others they won’t.

Are you taking notes on the computer during the session? Have you asked consent from the client to do this? Are you able to fully be connected and listen to the client or is it distracting you and the client?

Through trial, error and discussion with colleagues you will find what works best for you.

It may be a weighted lap pad, or a fidget. IT may be sitting at a desk or a comfy chair. Experiment to find the way you can be more regulated and attended while holding virtual space for a client.

Reflection

Are there things that you think you could do differently when doing telehealth?

Have you had the experience of being the client in a telehealth session ?

How was it different to face to face?

What did you notice? How did you feel?

Is there anything that could have been done differently to make you feel more comfortable?

How could you apply this to your own practice?

Dr Christie Bennett and Josephine Money ©2023