Clinicians’ perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings

Abstract

Background Admissions to intensive treatment (i.e., inpatient [IP] and/or day patient [DP]) for individuals with severe anorexia nervosa (AN) are common. Growing literature indicates potential risks and benefits of each intensive treatment approach; however, existing research has focused on patient and carer perspectives of these treatments. Also, there is scant empirical evidence available for guiding the parameters of intensive treatments for AN. We therefore explored clinicians’ perspectives and experience of supporting adults with severe AN in intensive settings. Methods We conducted twenty one semi-structured interviews with clinicians who deliver intensive treatments (i.e., IP and/or DP) for individuals with severe AN across four specialist Eating Disorder Services in the United Kingdom between May 2020 and June 2021. We asked clinicians about their views and experiences of supporting individuals with severe AN in intensive treatment settings and the challenges and opportunities associated with IP and DP treatment. Data were analysed using reflexive thematic analysis supported by NVivo software. Results Five broad and interrelated themes were identified: (1) Intensive Support; (2) The Severity of Patients’ Illnesses; (3) Hope and Recovery; (4) Which Treatment When; (5) Limited Resources; and (6) Carer Burden. We identified various similarities between the two intensive treatment approaches, including the value of intensive and multidisciplinary support and carer involvement, and the challenge of managing complex and unique needs in resource-limited intensive settings. We also found differences in the relationship of treatment to patients’ home environments, the necessity of patient motivation, and the management of risk. Conclusions Both intensive treatment settings are valued by clinicians; however, there are unique challenges and opportunities for supporting individuals with severe AN within each. Our findings suggest DP treatment may be used as an alternative to IP treatment for individuals with severe AN. However, clear questions remain over which intensive treatment setting is best suited to which patient when and should be the focus of future research.

Clinicians’ perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings during the COVID-19 pandemic

“…The pandemic hampered DP and IP services’ abilities to carry out these activities and limited patients’ opportunities to develop and practice transferring skills. Some clinicians suggested DPs’ permanency in their home environments better facilitated the transfer of (albeit limited) skills, consistent with research suggesting DP, compared to IP, treatment may have greater applicability and allow for a better transfer of skills from treatment to one’s life [ 11 , 24 ]. Despite success in transitioning aspects of intensive support to virtual delivery, patients may prefer in-person equivalents [ 21 , 22 ].…”

“…Across both settings, concerns arose over patients’ limited opportunities to foster social connections. In IP settings, patients were isolated from friends/family and (socially/physically) distanced from clinicians, factors that may intensify social isolation, reduce patient engagement and autonomy in recovery, and thereby exacerbate IP institutionalisation [ 11 , 28 ]. This finding echoes research into adolescents’ and their carers experiences of IP treatment during the pandemic; COVID-19 restrictions meant contact between patients and families, and families and clinicians, was perceived as limited and more emotionally burdensome [ 29 ].…”

“…This shift appeared most notable in DP settings and corroborates research into Italian clinicians’ perspectives—virtual support may afford greater opportunity to foster patients’ autonomous motivation and more collaborative treatment [ 8 ], which have been associated with a greater reduction in ED behaviours [ 31 ]. DP, compared to IP, treatment appears to better facilitate responsibility in recovery [ 11 , 32 ], thus, virtual support may further increase this opportunity. Nonetheless, whilst this shift appeared helpful for some, it was unhelpful for others.…”

The Efficacy of Health Realization/Innate Health Psycho-education For Individuals With Eating Disorders: Pilot Study

“…Clinicians have agreed that sustaining hope for recovery is an important aspect of treatment (Webb et al, 2022). Most participants in this study described increased feelings of hope following the group which appears to be an important prognostic factor in the outcome of eating disorders with hopelessness hampering both motivations to change and engagement with treatment (Siegfried & Bartlett, 2015).…”

Competing for perfection: A scoping review evaluating relationships between competitiveness and eating disorders or disordered eating behaviours

“…Although the ED literature features ample discussion on social comparison, there is less discussion on competitiveness and EDs, as well as why people with EDs might compete to ‘outperform’ others with respect to severity of ED symptoms, such as weight or body mass index. Additionally, some authors conflate social comparison with competitiveness (Egan, 2013; Webb et al., 2022), but they are distinct concepts: the process of social comparison is necessary in order to compete, but competition is not an inevitable consequence of social comparison. In Festinger's (1954) seminal article, competitiveness is differentiated from social comparison in that competition includes a ‘unidirectional push upward’ to protect one's perceived dominance over others (p. 138).…”