ED Transitions Module 4: University Transitions and Emerging into the Wider World

This module is part of the Eating Disorders Transitions Learning Series.

In a hurry? Use the buttons below to navigate through the content of this module.

Many young people experience some kind of transition around the age of 18.

Can you take a moment to think about some of the routes that people of this age may take and the pressures these might involve?

These are some of the transitions our clients might go through:

It is important to note that some of these transitions may be transient (e.g., university students returning home over the holidays).

This means that the young person and their families will have to navigate fluctuations in independence.

Why is it Important to Talk about Transitions?

These transitions can be exciting but can also have a destabilising effect, even for young people who do not experience mental health difficulties.

It is therefore important for services to highlight potential difficulties associated with the move towards independence and support the young person to create tailored plans on managing independent living and when or who to seek help from.

Support with Processes and Protocols

What can Services Think about Before Planning a Transition?

What can Services Do?

Services should establish joint working practices with other institutions where possible. These can include local GPs, university mental health/wellbeing/sports services and local charities.

Some outreach ideas for service providers include:

• Attending fresher’s week
• Asking for a physical space at universities for drop-ins
• Handing out information leaflets
• Talking to sports teams/gyms
• Arranging talks at local colleges or sixth forms

Provide information to patients on services available before they move to university or in a different area and make sure you have up-to-date information on their new GP to be able to communicate effectively with them.

Before you and the patient start planning a transition it might be helpful to think about whether now is the right time for them to be facing this.

In particular, you might find some of the below documents helpful in having discussions with the patient about this and making the best treatment plan for them:

• Medical Emergencies in Eating Disorders (MEED) guidelines might help you assess the patient’s physical health risks in order to determine whether changing services and moving away might be too risky and, if the patients still wishes to go, what support will they need and how can it be set up?
• These guidelines are also helpful when someone is planning to move abroad or go travelling. Are they fit to do so? Do they have insurance? What support will be available to them?
• Fitness to study guidelines might help you assess whether a patient might be able to attend university or whether they need to postpone their start date. This guideline might also help increase motivation in our patients by giving them a goal to work towards!
• If possible, ‘home’ services should continue working with the YP even when they start university unless high levels of risk prevent this
• Royal College of Psychiatry guidance recommends that the ‘home’ mental health makes ‘every effort’ to support patients to identify and access appropriate service(s) before they start university

Differences in referral protocol, provisioning, and commissioning between trusts can make it difficult to navigate accessing appropriate services when moving geographically; however, attempts should be made to avoid gaps in care:

• Waiting list placement should be honoured where possible
• ‘Home’ services may be able to continue to provide care remotely during term time or vice versa
• It is important to remember that young people can register with 2 GPs when attending uni (home and university), allowing for ongoing physical monitoring

Supporting Independent Living

Relapse Prevention

As soon as you become aware of a possible transition, help the young person work towards a relapse prevention plan.

First, help them think about the difference between a lapse and a relapse.

• What would be the difference between the two for them?
• Who do they need to contact in each situation?

Other factors that might be helpful to consider include:

• Possible stressful / high-risk times. What may be helpful for them to focus on at those times?
• What are their early warning signs and how can they manage these?
• Help them make a list of local support options available to them
• Remind them to register with a local GP as soon as possible. If helpful, provide support to help the young person register temporarily so they can continue to be registered with their home GP.  When writing a discharge letter, you might find it helpful to send a copy to both GPs.

Dietetic Advice

Whether patients are under or over eating, you can help them think about eating as being on a spectrum (some people are at the over-controlled end and some the under-controlled end) – the advice is meant to help them move towards the middle of the spectrum.

Help them plan a personal template for eating:

• Start by focusing on the early days and settling in period. Getting a routine going from day one as it is really difficult to establish one later on, especially if living with others
• All in the planning, boring but less stressful than arriving and not being confident about it. They can be more adventurous once settled in!
• Signposting: Plenty of advice online and from student cookbooks, such as batch cooking for the freezer and buying food in bulk between a few students etc.
• If the young person will be in catered halls, help them think about what they will get as part of the package. What happens if they miss one of the meals? Do they have a contingency plan?
• Help them think about shopping and cooking; practice cooking and shopping at home before leaving

Download the FREED dietetics handout here with further information and tips for patients who might be struggling with chaotic eating/binge eating.

Social Life and Eating/Drinking

Help the young person think about how they will manage drugs and alcohol. It may also be useful to work through how they will approach new friendships, including setting boundaries or working through potentially sensitive conversations.

Make a plan to support the young person with eating out and eating with other people:

• How can they keep to the meal plan when living on their own/at university/abroad?
• Do they need support with food shopping?

Top tips:

• Suggest the young person practices meal preparation when at home so they become familiar with the process and also get used to managing portion sizes
• Include how they can manage difficult situations and topics (e.g., if someone they know starts talking about wanting to diet)
• The service or carers may be able to provide structured support to the service user and work through several stages of preparation for social eating or individual planning. For example, this could include initially working through tasks together, then setting goals for the service user doing some elements independently, and finally transferring responsibility to the service user when they feel confident.
• Occupational therapists and peer support workers may be able to offer additional support in these areas.

Structuring Time

Help the young person think about how they will structure their time and support them in thinking about how they will balance work/studying, having a social life, self-care and leisure. For example, how will they manage exercise when at university or living independently?

Top tip:

• some young people might find using a planner really helpful

Click the buttons below for some examples of what some service users suggested around structuring time:

Exercise

When thinking about transitions and in particular moving to University, it is important to address excessive exercise and how to manage this.

When preparing the young person to transition it might be helpful to think about exercise and how they are currently using it. If they are excessively exercising, it might be helpful to support them in recognizing when this is happening and what they can do to avoid this (particularly if joining gyms or clubs).

If helpful, help the young person create a personalised plan around exercise (how much each week) and, if planning to decrease it, create a plan on how they can do this in the upcoming weeks (e.g., keeping a diary and planning behavioural experiments).

You might find it helpful to use the diagram below to have a conversation about excessive exercise and think about ways of reducing this.

Disclosing Eating Difficulties

Start having conversations with the young person on whether it would be helpful for them to disclose their eating difficulties. Help them list the pros and cons of disclosing and of not disclosing.

• Who do they want to share this with?
• Do they want to let the university/workplace know?
• What support do they need and how will they communicate this?
• Help the young person decide how much information to share

Equality and Diversity

Family dynamics and cultural/gender identity mean that the process of transition and emerging adulthood may be very different between individuals. It’s important to be open and curious about these differences, when talking about the transition process and in more general discussions as well.

Examples of individual circumstances and adaptations during a transition include:

• Taking account of cultural differences around meal content, timings and social relevance when meal planning
• Navigating independence if the young person starts university/employment while still living at home and having a prominent child/care-receiver role
• Being curious about open questions around gender, and about cultural differences in family units and body image/standards

Resources

• FREED equality and diversity module
• Template for thinking about adaptation to FREED care

Other Areas to Consider When Planning Transitions

Providing a space to think about the practicalities of independent living is important.

Problem-solving, providing practical resources, and practicing skills can provide patients with a realistic view of independence and increase a young person's confidence in their ability to cope.

Key practical areas to consider:

• Basic budgeting
• Cooking tasks and tips
• Shared food storage space
• Study/work time management/lack of structure
• Maintaining contact with current support system
• Building new social support
• Drugs and alcohol
• Sexual health/safety
• Where to go for support/how to tell uni/new GP

Resources:

• FREED Preparing for University Guide
• Supporting Independent Living: What to Take
• Supporting Independent Living: Budgeting
• Supporting Independent Living: Sexual Health

Living Outside of England and Wales

Travelling abroad for work, study or leisure can present its own unique challenges for young people.

Clinicians should encourage patients to consider their medical risks when deciding if moving abroad or travelling for a prolonged period is right for them.

Like any transition, specific, proactive planning on how to manage the experience itself as well as when/where to seek help is key.

There are several helpful resources on this topic you can refer to:

• BEAT and Student Minds travelling abroad experience pieces
• NHS and .gov pages on living in foreign countries
• EHIC, and planning healthcare abroad
• FREED ‘Thinking of going on holiday’

Support For Carers

While some may leave permanently, many young adults will return regularly, whether for weekends, term holidays or after graduating. However, for university students with eating disorders, this milestone presents a host of unique challenges. These challenges are not limited to the students themselves, as their families and caregivers may also face additional worries and concerns.

Download the Support for Carers Guide to learn more.