Supporting younger people with an eating disorder to access support earlier: one year on at the FREED service at GMMH

One year on from the launch of FREED, in honour of Eating Disorders Awareness Week 2022, staff at Greater Manchester Mental Health NHS Foundation Trust (GMMH) reflect on the service, how it has developed, and ambitions for the future.

What is FREED?

FREED is the First Episode Rapid Early Intervention for eating disorders. It is a flexible, evidence-based treatment approach with a focus on early intervention.

It is accessible for young people aged 18-25 who are struggling with an eating disorder, including anorexia nervosa, bulimia nervosa, and binge eating disorder.

The FREED model was designed to reduce barriers and improve access to treatment, and provides a truly equitable and specific early intervention eating disorder treatment pathway for all young people and families within the service. Young people are offered rapid access to specialised treatment focusing on their eating disorder, with the aim to offer assessments within 2 weeks of referral and start therapy within 4 weeks.

Treatment is evidence based and tailored to the needs and challenges that young people face during these years of their life, as well as in the early stages of an eating disorder.

Why it was set up

The FREED service was developed and evaluated by the South London and Maudsley NHS Trust Foundation’s Eating Disorders Unit and King’s College London.

FREED demonstrates that if someone has been unwell with an eating disorder for a shorter period of time, treatment seems to work better. Changes to their brain, body and behaviour that occur as part of an eating disorder are more easily reversed in the first three years and we think this is most true during adolescence and early adulthood.

A two-year follow-up study on FREED, showed that individuals who were treated for anorexia nervosa via FREED had better clinical outcomes including a reduced need for day/inpatient care, compared to patients that were treated via standard care pathways.

When FREED was compared with service as usual, FREED reduced the amount of time an eating disorder was left untreated, FREED patients waited less time for assessment and treatment and had better treatment outcomes. Most made a full recovery from their eating disorder within one year.

Progress at GMMH

FREED first launched in Manchester and Salford in March 2021, as part of a phased introduction of the FREED pathway across Greater Manchester. FREED was then rolled out to Heywood, Middleton and Rochdale (HMR) in October 2021; and a further four areas in Greater Manchester will adopt the pathway in 2022/23.

At GMMH, we launched FREED during the COVID-19 pandemic, at a time of increased referrals nationally amongst eating disorder services. Across GMMH’s eating disorders services, we had to quickly adapt the way we delivered psychological interventions, to ensure safe and quality care and treatment could continue. This included utilising digital tools in line with national guidance, such as making phone calls, and conducting individual and group psychological therapy via Microsoft Teams. We have also continued to safely see some service users face-to face where there has been clinical need or where it has been requested.

We are also really pleased to now be offering first line psychological interventions for eating disorders (MANTRA and CBT-T) in a group format, with the benefit of individuals being able to access evidence based treatments more quickly, and also to reduce the isolation that often comes with an eating disorder, particularly during the pandemic.

So far, 73 people have received therapy on the FREED pathway with a further 7 people ready to start. Whilst still in its infancy, outcomes so far are promising.

At the end of September 2021, those who had completed therapy on the FREED pathway, demonstrated an overall reduction in eating disorder symptoms and behaviours, and in both anxiety and depression.  We continue to record and evaluate outcomes, to help and inform the FREED model going forward.

Ambitions for the future

GMMH have been fortunate to recently receive a grant from the Academic Health Science Networks (AHSM) who are involved with FREED nationally and actively support health innovation. The grant money secured has allowed us to start an exciting project across our eating disorder services looking at under-represented groups, specifically young people of colour (YPoC), and access to FREED.

The aim of the project is to ensure that FREED is accessible to all young people, including those from racialised communities (communities experiencing racial inequality) who often face multiple barriers to accessing mental health services due to ongoing systemic inequalities.

The project will involve conducting outreach work with specific community groups in Greater Manchester, to help us gain an understanding of how we can encourage and support young people of colour with an early onset of an eating disorder to access FREED. The focus on early intervention will work towards removing disparities in perceived diagnosis and need for treatment; and the promotion of the early intervention pathway, with the proactive community outreach, is hoped to assist those from a PoC background to feel more confident to come forward for help.

Anonymous case study (please note that certain personal characteristics have been changed to ensure that the information shared is non identifiable)

A 19-year-old, female university student from Korea was referred to GMMH under the FREED service pathway last year. She was deemed FREED appropriate, and was offered an initial assessment within 2 weeks of her referral.

The service user requested an interpreter, which was organised promptly within our service, with an interpreter being present throughout all of our interactions with her. The sessions were also extended to 1.5 hours each week to allow space for interpreting.

At assessment, she presented with eating difficulties consistent with a diagnosis of bulimia nervosa. She described a cycle of restricting her food throughout the day and binge eating in the evening followed by self-induced vomiting. She explained that she weighed herself multiple times a day and engaged in shape checking behaviours such as measuring her waist with a tape measure and scrutinising her body in the mirror in conjunction with avoiding her body at times and wearing baggy clothes. She also described feeling lonely and isolated as her family were based in Korea and she was studying an undergraduate degree at one of the Universities in Manchester during the pandemic.

Although she presented with eating difficulties as the primary concern, there were a number of wider mental health difficulties including a history of low mood and self-harm. She also talked about the stigma of having a mental health difficulty in her home country and how she felt a significant amount of shame accessing support for her eating difficulties.

She was offered 10 sessions of brief cognitive behavioural therapy (CBT-T) for her eating difficulties, and this commenced two weeks after her FREED assessment. At the beginning of therapy, we worked on establishing a regular eating pattern and weighing herself once a week (only) at our weighing clinic which appeared to reduce her pre-occupation with food and weight. We also worked on understanding her emotional triggers behind her binge eating – looking at how difficult it was for her living in a completely different culture, miles away from home, during the pandemic.

We also talked about her cultural background and the stigma around having a mental health problem, empathising with how difficult this must be for her as well as trying to normalise that as humans we all endure suffering at some point in our lives and it is ok to seek help. Finally, we identified some body image concerns and set behavioural experiments to challenge the way in which she saw herself. Tailoring CBT-T to meet this client’s individual needs, including using some of the FREED resources, such as information on emerging adulthood, led to a positive outcome.

By the end of therapy, we are delighted to say she was no longer binge eating and had established a regular eating pattern. She also reported that she understood her eating difficulties much more and was able to use different techniques to contend with difficult emotions and emotional triggers that had previously led to binge eating. She described feeling happy about the progress that she had made in a short time frame and felt encouraged to continue her newly formed techniques and behaviours.

GMMH FREED champions – why FREED is important to us

“Many people experience eating disorders for years before they seek help, with many people fearing that they aren’t ‘sick enough’ to access support. For me, what’s important about FREED is that it challenges this idea, it encourages people to identify the signs sooner and seek help sooner, thus increasing the chances of a sustained recovery and reducing the impact on young people’s lives. This enables young people to gain the quality of life they deserve, free from the effects of an eating disorder. FREED supports and demonstrates that recovery is possible. “ 

Siobhan Connor, Psychological Therapist & Manchester FREED Champion

“The FREED pathway allows young people who have recently developed an eating disorder to access evidence based psychological support to help them make a quick recovery. We tailor the therapy to meet their unique individual needs, recognising that being a young person in this current climate is not easy. It is often a time of transition, and it can be incredibly difficult for young people to navigate their way through a period of significant change let alone deal with emerging eating difficulties. We are incredibly passionate about FREED, and I would encourage any young person (18-25 years old) who has developed problems with their eating (within the past 3 years) to go to their GP as a first step. The GP can then make a referral to our service. We know that early intervention is key to making a full recovery from an eating disorder!”

Dr Eleanor Reed, Counselling Psychologist & Manchester FREED Champion

“One of the greatest things about FREED is that young individuals have not only experienced reductions in eating disorder symptoms, but throughout treatment they have focused on life beyond their eating disorder, have built a support network and become their own therapist!”

Dr Angelina Baslari, Counselling Psychologist & HMR FREED Champion

​​​​​​​​​​​​​​“Recovery can be possible no matter how long someone has had an eating disorder. But we know the quicker people are able to access treatment and support, the sooner they can get back to their lives. FREED gives those working in eating disorders the best chance at supporting young people to get help early, minimise disruption and get on with their lives. FREED is helping us win the race against eating disorders. It inspires hope and it is real joy to be part of that process.”

Dr Zoe Tsivos, Senior Clinical Psychologist & Salford FREED Champion

What support is out there for anyone struggling with an eating disorder and/or how they can be referred to FREED

GMMH’s Eating Disorder Services offer support and treatment to anyone experiencing an eating disorder. Whatever their age, gender, culture, background, and however long an eating disorder has been present, we encourage people to seek help. Recovery is always possible.

To access GMMH’s Eating Disorder Services, including FREED, please see your GP and seek a referral. If you are working with a mental health or care professional already, please discuss a referral with them and they can also refer on your behalf. For more information about how to access the service, please contact the relevant team below:

Manchester residents: Manchester Eating disorder Service – 01612710621.

Heywood, Middleton & Rochdale, Oldham, Tameside & Glossop, Bury and Wigan Residents: Salford Eating Disorder Service – 0161 271 0508

For anyone struggling with an eating disorder the following websites also provide useful information, resources and details for how you can access help and support:

–  BEAT           https://www.beateatingdisorders.org.uk/

–  For more information on FREED please see  https://freedfromed.co.uk/

– GMMH website https://www.gmmh.nhs.uk/eating-disorder-service

Don’t delay, seek help.

FREED, it’s time to win the race against eating disorders.