By Helen Hewitt @helen_mhns
Helen is a third-year mental health nursing student at Middlesex University, currently in the process of completing her extended essay which focuses on the challenge of maintaining therapeutic relationships while delivering care within eating disorder settings.
It is concerning to see someone that we care for showing signs of an eating disorder. While this may include changes in physical appearance, eating disorders (EDs) are not always visible from the outside. We might notice, for example, that someone with anorexia starts distancing themselves from communal activities involving food; they may seem withdrawn or preoccupied, perhaps denying themselves comfort of any kind. Someone with bulimia or binge-eating disorder might eat compulsively (usually alone), afterwards feeling shame and self-loathing which can lead to purging or self-harm.
With an estimated 1.25 million people affected in the UK, according to leading charity BEAT, it is becoming increasingly likely that every one of us will encounter someone with an ED in our personal or professional lives. But while we might be aware someone is struggling, it can be harder to know how to help.
Despite the prevalence and severity of eating disorders, their treatment is currently a specialism scarcely covered either in nursing or medical training. This is an issue which is putting lives at risk. Additionally, stereotypes and stigma often associated with EDs can form barriers to the person seeking help, despite mounting evidence to show that early intervention is key to improving outcomes.
We all have a part to play in addressing these concerns, especially as nurses are in a prime position to detect early signs of an ED and offer support before it becomes harder to treat.
Although early intervention for young people has been marked as a priority in NHS England’s Five Year Forward View for Mental Health, recent reports show that people are waiting too long before getting the help that they need. There has been a sharp rise in hospital admissions for eating disorders, a statistic that carries a personal resonance and sadness for me. The number of people I’ve encountered that have lost their lives to this illness has increased in recent years: the causes as diverse as the individuals themselves. These losses have made me more determined to pursue a path working in this field, as well as raising awareness where I can.
As a student nurse, I chose to study therapeutic relationships between nurses and patients in ED units for my final year literature review. This has unveiled some findings which I think may have relevance to nurses in all care settings. Although there are no magic words or formulae, simply signalling emotional availability and showing an openness to understanding can go a long way.
Findings from several studies based in UK eating disorder units show that, for patients, the most difficult experiences of treatment appear to be linked with negative attitudes from staff, such as feeling misunderstood or unsupported. Patients stress the importance of having skilled and empathic staff that can help them process and challenge their ED, supporting them in strengthening their own identity and gradually letting go of the disorder.
Staff who are able to keep patients safe and who don’t shy away from addressing ED symptoms are also valued. Although people may fear being forced to give up safety behaviours (such as purging, restricting intake, taking laxatives or waterloading to disguise weight), they often want – and need – someone to recognise these urges and offer support. Although setting boundaries can present challenges in therapeutic relationships, nurses who help patients find alternative ways of coping with difficult emotions, providing a rationale for change and interventions, have an important role to play.
While most people with EDs are treated as outpatients, some require hospital treatment and it appears that an increasing proportion of these are admitted under section. Restrictive interventions such as NG feeding (sometimes under restraint) may become necessary to ensure physical safety when the patient is unable to accept nutrition orally. For nurses, this can be a challenging part of working in this field, with staff reporting feelings of anxiety and distress after having to undertake these roles.
It can also be difficult when patients relapse or require readmission: a common cyclical pattern according to a recent report into the impact of EDs. This is something that may evoke feelings of frustration or inadequacy in us as clinicians. We may also feel rejected if our offers of help are refused. However the reasons this happens can be varied, such as ambivalence about recovery, fears around change or of losing control. It can also be due to the common perception among people with EDs that they are somehow undeserving of care or support.
As nurses, this is something we can challenge by showing that we want to help, unconditionally, even if we may not always get it right.
Developing an empathic understanding of the emotional world of EDs, and seeking opportunities for reflective practice, might help to process our own responses to these issues as well as help us offer more effective support. Working with an ethos of honesty, acceptance, and above all being fully present and committed to walking alongside the person in their struggle, can lay the foundation for a trusting and collaborative relationship which promotes the possibility for change.
While not overlooking the profound impact EDs can have, it is important to sustain a sense of optimism for those we work with. People can, and do, recover fully from eating disorders, even after decades of illness, and even those who do not can still make significant progress in their quality of life. As clinicians, we have every reason to be hopeful.