Eating disorders– altering communication to increase engagement and promote recovery
In a mental health context, prevention can mean aiding recovery and managing a condition to prevent serious complications or hospital admissions. Eating disorders in particular arise from a variety of physical, emotional, and social issues, all of which must be addressed for effective prevention and treatment. In this blog, specialist eating disorders dietitian Sharleen Woods describes how she used communication skills to help a young person with anorexia nervosa recover and achieve a healthier relationship with food (and thus a healthier weight for her), meaning she did not need to be readmitted to a specialist inpatient unit.
Within dietetic sessions, Maria struggled to engage in two-way conversation and refused to discuss ‘the future’, weight or her oral intake therefore considerable time was spent focusing on why she felt unable to move forward - ‘sticking with the stuckness’ - via motivational interviewing techniques. This resulted in a mutual agreement that conversation would shift away from ‘the future’ and weight (with the view that weight and physical health continued to be monitored) and that sessions would explore nutrition in the context of achieving a balanced relationship with food. Maria’s participation in sessions increased as we focussed on who Maria was and her relationship with nutrition and health. However, this shift was overshadowed by a deterioration in physical health which required a paediatric admission (Figure 1 below).
- Transition from CAMHS/SEDU to Wigan-Bolton CYP CEDS.
- Older sister transferred to Paediatric ward & NG passed.
- Older sister admitted to SEDU & subsequently sectioned. Dietetic provision commenced for Maria.
- MDT review at Wigan CAMHS – Agreement with dietitian not to discuss weight and ‘the future’.
- Admission to Paediatric Ward.
- Discharge from Paediatric Ward.
- Family therapy appointment
- Worked collaboratively with Maria as gained >1kg in 1 week and agreed to reduce meal plan.
- Agreed with Maria that prolonged periods of standing would be addressed in order to incorporate social activity such as P.E. classes into weekly routine.
- Agreed that could attend P.E. lessons (x1/week).
- Maria reports menstruation has commenced
Maria initially struggled with the refeeding plan on the ward; displaying compensatory behaviours and becoming highly distressed. The CYP-CEDS team worked collaboratively with Maria and her parents to “be radical” seizing the crisis as an opportunity to do something different – “It is the difference that makes a difference” (Bateson, G. 1972), which is a tenet of systemic thinking. Dietetic sessions were reframed to focus on re-nourishment at a physical health level with the view to shift Maria’s thinking towards short term goals.
Maria expressed a strong desire not to be readmitted to SEDU and it was via this motivational driver that a posture of positive risk taking was facilitated; agreeing for family to provide occasional meals and snacks on the ward (which was usually against ward policy). Maria began to comply with her meal plan resulting in physical health improvement and discharge five weeks after admission.
Back in community, dietetic sessions steered away from the narrow narrative of weight and instead focused on metabolism of nutrients in ‘tutorial’ format, in response to Maria’s love of science and education. Consequently, these have served to support Maria’s conversations with others about food and nutrition leading to a willingness to explore and try new foods.
Where are we now?
Figure 1 highlights Maria’s weight trajectory for the six months following her transfer to the CYP-CEDS. Since then, Maria and her parents report a significant reduction in AN symptoms. Maria is menstruating regularly, engaging in leisurely physical activity and openly discussing various aspects of her journey and her relationships in joint dietetic and family therapy sessions. By prioritising the voice of the young person, a strong therapeutic relationship was established between Maria and her dietitian; disrupting the process of the illness and facilitating an environment for change and recovery.
Maria reports that shifting the discourse from weight to nourishment was an important factor in improving her relationship with food. This is an important consideration within the realm of eating disorder dietetics where weight is usually not only used as an informative tool in sessions but as one of the primary outcomes in recovery.Back