Cost of living and the wellbeing of service users

To heat or to eat? These are the worries that many people are facing with the current cost of living crisis, where 89% of adults in the UK report an increase in their bills. The price of necessities like food, gas, and electricity had increased by 13.1% by September 2022, which has led to many reporting having to compensate for this by buying less food, skipping meals, or not heating their home. Maslow's Hierarchy of Needs identifies physiological needs, such as food and shelter, as being the most basic of requirements in a person's life. When even the lowest level of the hierarchy cannot be achieved, how are other needs for a fulfilled life supposed to be properly satisfied?  

Working within Derbyshire Eating Disorder Service, we have already seen the cost-of-living crisis have significant impacts on mental well-being and the process of recovery. When forced to choose between food and other luxuries, this aggravation can strengthen biases around eating, which risks them becoming entrenched in their eating disorder cognitions. A person with anorexia can accomplish their goals by easily justifying cutting out food, whilst someone struggling with bulimia can find themselves with increased levels of food wastage, heightening the shame and guilt maintaining their disorder.  

Decisions surrounding nutrition are intense for those with eating disorders, without the added complexity of money. Regular eating is an essential part of recovery for eating disorder patients to reduce binges or restore weight, with an expectation of service users to prioritise food and therefore treatment over other aspects of their life. Whilst the service is mindful of the impact of this expectation, clinicians are concerned that the cost-of-living crisis will cause further distress to service users. This distress could negatively impact their eating disorder cognitions or cause their mental health to further decline in ways not associated with their eating disorder. 

Clinicians are also concerned that service users may be deemed as 'non-compliant' with treatment for reasons beyond their control. If service users are unable to afford food, they are unable to prioritise regular eating. Furthermore, some of the evidence-based treatments used in eating disorders, for example CBT-ED (cognitive behavioural therapy for eating disorders) or CBT-T (cognitive behavioural therapy for eating disorders – ten sessions), require behavioural experiments such as eating out and social eating. If service users are unable to afford food at home, then there is little chance that they will be able to afford eating at restaurants or social eating. Therefore, these behavioural experiments, an important and beneficial part of treatment, may not be accomplished. Whilst supplementary therapies such as Occupational Therapy and Dietetics are often available to support with budgeting and affordable meal plans, the additional costs being experienced at a basic level are unsustainable for many of our service users. 

Unfortunately, we don't predict many positive outcomes are ahead. With the energy price cap having increased a further 75% in October 2022, our anxieties about the winter period are shared amongst many. 'Uncertainty' seems to be a popular word used to describe the future at the moment, but it feels safe to assume that many of us will have additional financial stresses compared to previous years. We believe it is possible that some of the general population may choose to prioritise other life necessities over food, seeing a possible increase in the prevalence of eating disorders within the UK population. 

Heightened stress often causes individuals to resort to their baseline coping mechanisms, such as restricting intake or binge eating, as a way of regaining control. Together with the positive relationship reported between stress and eating disorder symptom intensity, our service users could be faced with a longer road to recovery filled with added obstacles and increased anxiety. Cold winters and excessive energy bills are likely for our service users who are a low weight, whilst exacerbated food bills are expected for those who binge. These consequences once again increase stress and anxiety, and the cycle continues. It may be hard for clinicians to rationalise these anxieties during treatment, because the reality of struggle is ceaseless at present and limited relief is available. To feel unable to help someone, in a profession so motivated by helping, creates a dissonance that many clinicians will struggle to accept peacefully.  

The wellbeing of service users is naturally of upmost importance to us. Eating difficulties are already challenging for all involved, but with rising living costs, the anticipated mental health deterioration, and the possibility of prolonged waiting lists and caseloads, additional demands on clinicians could prove burdensome. Similar to our service users, clinicians are also experiencing the pressure to make major life changes that can impact on practice. On the one hand, clinicians are considering returning to the office to work, to be in a heated space without having to worry about the cost of heating from home. On the other hand, for those with a long commute and increased fuel costs, some clinicians may prefer to work from home only to then be faced with the cost of keeping warm at home. Either option may not be ideal and has the potential to negatively impact the clinician's wellbeing, which may reduce the effectiveness of therapeutic sessions and thus limit positive changes for the service user.  

For service users facing the same issues with cost of travel, video appointments may be the only choice. Whilst these are being utilised more within the NHS, especially since COVID-19, we all know the issues that can occur: technical difficulties, and lack of confidence in patient safety and confidentiality. Barriers to rapport building in this way may further hinder positive outcomes. Even offering home sessions to overcome these issues may risk burdening the clinician with further travel costs that are already a worry. How can we help our service users when we are faced with the same difficulties? Unfortunately, a moral dilemma may end up beginning for us clinicians – do we choose service user needs or our own? 

As members of the psychological community, we all know the importance of basic necessities in supporting positive mental health and wellbeing, with these issues being relatable to all sectors in some way. Clearly, a conversation needs to be started within Mental Health Services across the UK addressing the above issues and how we can help our service users and colleagues in such a time of need. In an ideal world, for our service users, additional support with food vouchers in a similar way to prescribed medication would be beneficial in maximising the chances of successful and fair treatment for all. Furthermore, we would love to see the government provide a similar, tailored support to the needs of the general public. In the meantime, we worry for our friends, family, colleagues, services users, and ourselves, about how things might progress in the next few months.  

Despite this, we overcome challenges in our daily life and line of work, and it is important we do the same throughout this substantial challenge too. With solidarity, generosity, and compassion, we must come together as a community to support one another and find the light at the end of the tunnel.  

Siân Levell, Shannon Triffitt, and Megan Burkinshaw

Assistant Psychologists at Derbyshire Eating Disorder Service

[email protected], [email protected], [email protected], or [email protected]