11 Dec 2020
Dietitians play an essential role within specialist mental health inpatient units for patients with eating disorders. The dietitian is a key team member within a unit’s eating disorder programme, overseeing nutritional assessment, re-feeding, meal planning, nasogastric feeding, mealtime support and liaising with the patient and family to support the inpatient admission and transition back into the community.
One of the most important components of the dietitian’s job on such units is to build up a therapeutic relationship with the patients and work collaboratively with patients and their families. Patients with anorexia nervosa have been some of the most difficult and yet immensely rewarding to work with during my career. The nature of their illness can make them irrational, distressed and argumentative, particularly around increasing meal plans to promote weight regain.
An eating disorders dietitian can walk a fine line between being seen by the patient on the one hand as playing the role of wicked stepmother and on the other hand being a therapist and clinician who the patient learns to trust and value. As the patient does learn to trust us, the whole recovery process can become a lot smoother.
Enter stage left our newest recruit!
There is a growing body of evidence about the potential benefits that pets bring to physical and mental health e.g. reducing stress and anxiety (1, 2 - see references below). This article describes how the evolving role of the dietitian in eating disorders may be augmented by using the therapeutic benefits arising from interaction between people and animals.
Within the NHS, Animal Assisted Activity (AAA) involves animals visiting people (or vice versa). It has broadly based therapeutic aims and can be repeated with different people, unlike a therapy programme that is tailored to a particular person or medical condition. AAA provides opportunities for social, motivational, educational, recreational or therapeutic benefits to enhance quality of life and, in my experience, a sense of patient wellbeing which arises from being involved in a normal, everyday activity such as a dog walk.
My Welsh springer spaniel, Brecon, has been coming since he was a puppy to the adult eating disorders unit I work at, where he is able to interact with our patients. Our patients often come in at a BMI of 12 or 13 and stay with us for several months to enable them to reach a healthy weight of BMI 19-20. During that time, they have an opportunity to get to know Brecon.
On weigh day, patients are typically particularly anxious. This is due not only to being weighed but also having the weekly ward round during which patients make requests for the upcoming week such as time off the unit. Our unit is CBT led. One of the aims we work towards with patients is towards “getting a life”. Therefore, we decided it was time for Brecon to up his game and introduced a weekly dog walk on weigh day and use him as a therapeutic support dog.
Having decided to introduce a dog walk, one of our first actions was to involve the patients in drafting guidelines for this new activity – a case of poacher turned gamekeeper! The guidelines include patients obtaining prior agreement from the multidisciplinary team to attend the walk, being a BMI of >14, and being committed to keeping at the same pace as the dog (a big ask!). At the end of the walk, patients give dog treats. Our patients often struggle to handle food so this is also seen as part of the walk expectations. We assess the risk each week and expect the patients to take responsibility for keeping themselves safe.
We have had patients on the ward who are sectioned under the Mental Health Act. Some have been known to try and escape by climbing over the garden fence. For patients like this, we hope attending the dog walk will act as part of a stepped approach in giving responsibility back. Others attend who are struggling to manage their exercise levels, as well as those suffering from low self-esteem or social withdrawal.
After a period of 12 months now, we are beginning to see positive outcomes. Some former patients have since got their own dogs/puppies and even signed on to do Borrow My Doggy, which connects dog owners with people who would like to take care of a dog for a period of time.
In a way, Brecon assists me in helping to achieve clinical goals together with the patients. It is not just the patients who benefit, however. Interestingly, members of the staff team also promote the advantages of having a dog on the unit. For example, as one occupational therapy technical instructor said: “It just brightens up our mood. It is like a stop button and makes me forget about my stresses.”
In summary, what started out as something of a ‘nice idea’ has turned out to be demonstrably more beneficial on the unit than we imagined at the outset. Patients and staff are able to interact with the dog, and some choose to pat and stroke, and even hug him. Brecon works as a great ice breaker and lifts the spirits of patients on ward visits, and offers hope for what life may be like once patients leave the unit. It’s not the purpose of this article to assess whether or not an occasional dog visit to the unit may affect our blood pressure and stress levels, but it is my feeling that it does! I am grateful to the senior management team for enabling Brecon to make his visits. I am sure that our patients and the team will echo this.
Requirements of a therepeutic support dog
Have a certificate of animal suitability from a recognised organisation such as Pets as Therapy (PAT) or equivalent specialist organisation or veterinarian.
Evidence of up-to-date vaccinations and appropriate veterinary care
Not fed a raw food diet currently or in the preceding six months (to minimise the risk of salmonella transmission).
A signed animal registration form completed by the owner of the animal visitor and kept in a file related to animal associated activities in the service.
Yearly risk assessment
“It is a real leveller between staff and patients.”
“We are doing something normal and at a normal pace.”
“You can go on the dog walk however you are feeling, engage however much you want. It is therapeutic just by being outside, with other people and not about how many calories you are burning.”
“We talk about stuff, not about treatment and just chat about anything, which I think is really nice.”
“Activity is something I’ve struggled with. On the dog walk we walk together at a slower pace than I’m used to, but it’s more fun – we chat, we’re out in the fresh air, we’re off the unit and sometimes we go into the park opposite. Walking Brecon is something we all look forward to on Mondays.”
“It offers a change of scenery, fresh air, nature sounds and a feeling of adventure (choice of route). It offers me a sense of freedom getting outside from the ward and the clinical setting but also feels proactive as it’s still part of the treatment programme.”
“Being with a member of staff takes the pressure off me having to worry about time keeping, helping me to relax and enjoy the group experience (this is actually my only time outside where I do feel relaxed).”
“Due to feeling calm and relieved for being outside, my mood increases, my head space opens up and I notice I want to talk to others and socialise more. When walking outside I find talking feels easier and more natural to communicate compared to being stationary on the ward and overthinking/having anxiety about the social aspect of things and thoughts about food and body.”
“The dog walk offers a chance for patients to do a social activity together where they don’t have to think about mental health and can be completely distracted from even being an inpatient at all and get a short sense of normality. I have been finding this motivating in my recovery because it helps me look towards the future and be mindful of how enjoyable and important the small things in life are... Also because I eventually want to get a dog and be fit/healthy enough to take my dog out on regular walks. I love being able to see and stroke Brecon as he’s very friendly and it’s amazing to be around an animal when I miss mine at home so much. It is also an exciting bonus to give him a treat at the end of each walk.”
“Time with a group of people off the unit in a relaxed way – not going for a walk, going for a dog walk. Dogs are not going to judge you or reject you.”
1 Hiroharu Kamioka, Shinpei Okada, Kiichiro Tsutani, Hyuntae Park, Hiroyasu Okuizumi, Shuichi Handa, Takuya Oshio, Sang-Jun Park, Jun Kitayuguchi, Takafumi Abe, Takuya Honda, Yoshiteru Mutoh. (2014) Effectiveness of Animal-Assisted Therapy: A Systematic Review of Randomized Controlled Trials. Apr; 22(2):371-90. Complement Ther Med
2 Bert F, Gualano MR, Camussi E, Pieve G, Voglino G, Siliquini R. (2016) Animal assisted intervention: A systematic review of benefits and risks. Oct;8(5):695-706 Eur J Integr Med
Dietitian , Cotswold House