By Sylvia Foley, AJN senior editor
Bar the View by HereStanding, via Flickr
For adolescents with severe anorexia, experts have long relied on treatment in specialized pediatric acute care settings, using programs that are based on behavior modification principles and that promote stability through refeeding.
But what is it like to be a young inpatient in such a program? And how does the behavior modification approach affect the nurse–patient relationship? To learn more, nurse researcher Lucie Michelle Ramjan and colleague Betty I. Gill conducted a study in an Australian acute care facility. Their findings are reported in this month’s CE: Original Research feature, “An Inpatient Program for Adolescents with Anorexia Experienced as a Metaphoric Prison.”
The research. Ramjan, the study’s principal investigator, conducted in-depth, face-to-face interviews with 10 adolescent patients being treated for anorexia and 10 pediatric nurses. The interviews were audiotaped; the tapes were then transcribed verbatim, read and reread, and subjected to thematic analysis. As another writer has noted elsewhere, in qualitative research, metaphors often “illuminate the meanings of experiences.” In this study, the researchers found that both nurses and patients “consistently used the metaphor of prison life to articulate their experiences.”
That striking metaphor offered Ramjan and Gill a framework for interpreting the data, and three major themes emerged, as follows:
- entering the system
- “doing time” within the system
- on parole or release
Various subthemes were also identified, and Ramjan and Gill have provided numerous examples from the interviews.
The implications. In discussing the findings, they write,
The challenge of forming positive therapeutic relationships is magnified for nurses working with adolescents being treated for anorexia in an inpatient behavior modification program. In such programs, the ward may function as a metaphoric prison, with patients seeing themselves as inmates and nurses as prison wardens . . . The inherent conflict between administering treatment based on behavior modification, on the one hand, and developing therapeutic relationships, on the other, may pose the greatest challenge for nurses.
Ramjan and Gill also address the nursing implications of their findings, before noting in conclusion, “The challenge before us is to reform the culture of inpatient behavioral anorexia treatment programs without losing their benefits.” They suggest several policy changes that might do just that. The full article is free online.
Have you worked with patients being treated for anorexia through an inpatient behavior modification program? How does your experience compare with what Ramjan and Gill describe? Please let us know.
My question is “what are the outcomes of this therapy?” Are 50% of patients “cured”? 75%? 5%?
I have a family member who was hospitalized for two weeks for titration off of several benzos , prescribed by a primary care provider ,in a chem dep unit. Her experience was exactly what these researchers have noted.
Is the only way to treat very ill patients, whose diagnosis is a mental illness, through harsh, regimented treatment protocols? I am not convinced.
I appreciate the above comment. Severe eating disorders can be lethal, and the patients are a challenging population. Many treatments implemented on patients are difficult for nurses to tolerate providing, particularly in ICU and Emergency settings.
This being said, as a PICU nurse, one shift I floated to the Peds unit, which was very busy. Only “specially trained” nurses were assigned the IP eating disorder patients, but because it was so busy, I was asked to simply sit and watch a boy eat his dinner. Not yet in junior high, a plate of tofu and broccoli sat before him, and his disinterest in it was clear. I was instructed not to talk to him; he was to focus on eating. Even though it’s not a healthy choice, I kept thinking how freakish it was to expect a boy that age to eat broccoli and tofu, instead of a burger and fries. I was told about another patient, an adolescent girl, who was weighed daily naked, because she had been caught attaching stones to her hospital gown to fake weight gain. The whole experience was very depressing, and I never volunteered to go back.
It’s a harsh reality but a life-changing alternative to living with an evil illness or starving to death. IP is simply necessary for severe cases when the patient’s weight is critical – it cannot be restored without transferring control of food and activity to professionals. More importantly, intensive therapy is absolutely necessary to ensure learning how to nourish oneself and function socially, after the complete destruction of security and probably anxiety and depression. It’s a rehabilitation. It’s not pretty, but it doesn’t have to be. As real as cancer or any other disease, hospital stay and treatment makes sense.