Adolescent inpatient treatment for anorexia nervosa: A qualitative study exploring young adults' retrospective views of treatment and discharge

Abstract

Objective: To explore young adults' views regarding: the inpatient treatment they received for anorexia nervosa during their adolescences; their experiences of discharge; and the impact their admission had on issues of control and low self-esteem. Method: Semi-structured interviews were conducted with seven young adults treated in general adolescent psychiatric units. Data were analysed using Interpretative Phenomenological Analysis. Results: Four super-ordinate themes emerged from participants' accounts: (1) Removal from normality versus connecting with the outside world; (2) Treated as another anorexic versus a unique individual in distress; (3) Control and collaboration; (4) The importance of peer relationships. Discussion: Findings unique to this study concerned a sense of feeling removed and disconnected from 'normality'; a feeling that one's developmental needs were not always addressed; and the importance placed on supportive relationships with fellow patients. It was also found that authoritarian approaches may compound patients' feelings of ineffectiveness, worthlessness and isolation.

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European Eating Disorders Review
Eur. Eat. Disorders Rev. 14, 377–387 (2006)
Adolescent Inpatient Treatment for
Anorexia Nervosa: A Qualitative
Study Exploring Young Adults’
Retrospective Views of Treatment
and Discharge
Abaigh Offord1*, Hannah Turner2and Myra Cooper1
1Oxford Doctoral Course in Clinical Psychology, University of Oxford, UK
2Community Clinical Sciences, School of Medicine, University
of Southampton, UK
Objective:
inpatient treatment they received for anorexia nervosa during
their adolescences; their experiences of discharge; and the impact
their admission had on issues of control and low self-esteem.
Method:Semi-structured interviews were conducted with seven
young adults treated in general adolescent psychiatric units. Data
were analysed using Interpretative Phenomenological Analysis.
Results:Four super-ordinate themes emerged from participants’
accounts: (1) Removal from normality versus connecting with
the outside world; (2) Treated as another anorexic versus a unique
individual in distress; (3) Control and collaboration; (4) The
importance of peer relationships.
Discussion:Findings unique to this study concerned a sense of
feeling removed and disconnected from ‘normality’; a feeling that
one’s developmental needs were not always addressed; and the
importance placed on supportive relationships with fellow
patients. It was also found that authoritarian approaches may
compound patients’ feelings of ineffectiveness, worthlessness and
isolation. Copyright # 2006 John Wiley & Sons, Ltd and Eating
Disorders Association.
To explore young adults’ views regarding: the
Keywords: inpatient; adolescent; anorexia nervosa; qualitative research
INTRODUCTION
Anorexia Nervosa (AN) is a serious condition with
mortality rates estimated to exceed all other adoles-
cent psychiatric disorders, including depression
(Herzog, Rathner, & Vandereycken, 1992). The risk
of mortality coupled with parental and professional
concern means that for some adolescents, their
treatment will involve a period of inpatient care
(Gowers, Weetman, Shore, Hossain, & Elvins,
2000). However, whilst hospitalisation is generally
effective in achieving substantial weight gain,
research indicates high rates of relapse and re-
admission following discharge (Treasure, Todd, &
Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association.
Published online 11 July 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.687
*Correspondence to: Dr Abaigh Offord, Clinical Psycholo-
gist, Family and Young Person’s Consultation and Therapy
Service, Shelley Clinic, 22 Tower Road, Boscombe, Bourne-
mouth, BH1 4LB, UK. Tel: 01202 646300. Fax: 01202 397060.
E-mail: abaigeal.offord@dorsethc-tr.swest.nhs.uk

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Szmukler,1995;Vandereycken,2003),andithasalso
been suggested that this type of intervention may
compoundsomeoftheintrinsicfeaturesofAN,such
as low self-esteem and a sense of personal ineffec-
tiveness (Gowers et al., 2000).
Althoughtheimportanceofdrawinguponservice
user feedback to inform service development has
been highlighted by a number of authors (Buston,
2002; Street & Svanberg, 2003) to date only a small
number of studies have been conducted exploring
young people’s experiences and views of inpatient
treatment for AN. In relation to treatment compo-
nents, it has been found that adolescent inpatients
valued individual psychotherapy and exercise most
highly and family therapy least highly (Cockett,
1992). In an earlier study of adolescent inpatients,
Brinch and colleagues reported low levels of
treatment acceptably (Brinch, Isager, & Tolstrup,
1988). Participants reported feeling pressured and
‘watched’, and the restricting aspects of treatment
oftenledtofeelingsofangerandambivalence.Using
a discovery-orientated phenomenological appro-
ach, Colton and Pistrang explored adolescents’
experiences of specialist inpatient treatment for
AN, and related this to their ‘stage of change’
(Colton & Pistrang, 2004). As well as identifying
the following key themes: ‘What is the illness that I
have?’; ‘Do I want to get well?’; ‘Being with others:
supportversusdistress’;‘Beinganindividualversus
just another anorectic’ and ‘Collaborating in treat-
ment versus being treated’, the authors also found
thatthosewhofeltmorereadytochangealsotended
to find the treatment programme more helpful.
Whilst the studies conducted so far provide
invaluableinformationregardingthepatientexperi-
ence, they have focused on patients’ experiences of
specialist eating disorder inpatient services. How-
ever, given regional variation in service provision,
particularly in the UK, a significant proportion of
adolescents continueto betreated ingeneraladoles-
cent inpatient units (Gowers & Bryant-Waugh,
2004). Studies have also focused on the patient’s
experience during admission and whilst this pro-
vides useful information regarding the ‘here and
now’, it is possible that the passage of time could
yield important new information regarding the
impactofadmissiononissuesthatareoftenintrinsic
to AN (e.g. control and self-esteem), as well as facil-
itate our understanding of the process of discharge
and transition to outpatient services.
Thisstudyaimedtoaddtothecurrentliteratureby
asking a group on young adults their views on the
treatmenttheyhadreceivedforANwhilstadmitted
to a general adolescent psychiatric unit. The study
also aimed to elicit participants’ views regarding
the impact their admission had on issues such as
control and self-esteem, and their views regarding
theprocessofdischargeandsubsequentadjustment
to life back in the community.
METHOD
Setting
Participants were recruited either via past inpatient
records from general adolescent units or via face-to-
facecontactwithcliniciansinadultoutpatienteating
disorder services.
Participants
Fifty potential participants were invited to partici-
pateinthestudyandsevenchose toopt-in.Allwere
female, white, of British nationality and ranged in
age from 16 to 23 years. One participant was
recruited via adult eating disorder services and the
remaining six were recruited via past records at two
general adolescent inpatient units. All had received
treatment for AN in a general adolescent inpatient
setting, and all had been discharged from inpatient
care 2–5 years prior to the study.
Ethics
Ethical approval for the study was granted by a
Multi-Centre Ethics Committee.
Interview Measure
A semi-structured interview schedule that included
open questions and prompts was developed for the
study. This was used flexibly in order to allow each
participant to determine the direction of the inter-
view. Broad topic areas were identified from a
review of the existing literature and from the
authors’ clinical experience. Topics included: views
on the helpful and unhelpful aspects of treatment;
perceived balance in addressing physical and psy-
chological/emotional needs; the experience of the
hospital environment; the degree of control experi-
enced when in hospital; views on being around
other patients both with and without an eating dis-
order;viewsregardingtheimpactadmissionhadon
one’s sense of self; relationships with family and
friends outside the hospital (whilst an inpatient
and following discharge); views on the discharge
experience (perceived readiness, preparation, fol-
low-up and support); and managing and adjusting
totheoutsideworldfollowingdischarge.Interviews
378
A. Offord et al.
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Eur. Eat. Disorders Rev. 14, 377–387 (2006)

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lasted between 60 and 90 minutes, and were con-
ducted either at the participants’ home or at a local
clinic. All interviews were tape-recorded and tran-
scribed verbatim. Confidentiality was assured and
identifying information was removed from the
transcripts.
Data Analysis
Given that this study aimed to explore young peo-
ple’s views in detail, interview transcripts were
codedandanalysedthematicallyinaccordancewith
the principles of Interpretative Phenomenological
Analysis(IPA)(Smith&Osborn,2003).IPAwascho-
sen because it is phenomenological; it is concerned
with individuals’ personal perceptions or accounts
of an event (Smith, Jarman, & Osborn, 1999) and
aims to gain a better understanding of what it is like
to live a particular moment from an ‘insider’ per-
spective(Willig,2001).Eachtranscriptwasanalysed
individually. Key-word or emerging theme titles
were noted and themes were then clustered to pro-
duce a table of super-ordinate and subordinate
themes along with sample quotes. Themes from all
seven tables were then clustered and integrated to
generate a list of ‘master themes’ which attempted
to capture the quality of the participants’ shared
experiences. This whole process was carried out in
an iterative manner with the researcher frequently
referring back to the original transcripts to ensure
that themes were grounded in the data. A number
of procedures were also conducted in order to pro-
mote optimum rigor or ‘trustworthiness’; the pri-
mary researcher shared random pages of interview
transcripts with fellow qualitative researchers and
compared analyses; an audit-trial of the analysis
process(fromtheoriginalcodingtothefinalcluster-
ing of themes) was conducted; and ‘member check-
ing’ was carried out with three of the participants, a
process that involves sharing with participants the
tableofthemesconstructed fromtheir specificinter-
view to check understanding (Elliot, Fischer, &
Rennie, 1999). The primary researcher also kept a
research diary throughout this process in order to
track the development of ideas and maintain a
‘reflexive stance’ (Silverman, 2000).
RESULTS
Four super-ordinate themes emerged from partici-
pants’ accounts of their experiences of treatment
and discharge. These themes, along with their sub-
ordinate themes (indicated using italic sub-head-
ings) will now be discussed in turn. All names
have been changed to protect anonymity.
Theme 1. Removal From Normality vs
Connecting With the Outside World
For the majority of participants their experience of
being an inpatient carried with it a pervasive sense
of being removed from the outside world and the
normality of adolescent life; their development
being temporarily suspended. This appeared to
affect participants’ sense of self and their emotional
well-being, and posed a challenge to subsequent re-
adjustment to the ‘real world’ following discharge.
Suspension of Real-Life
‘...you know being in hospital, you’ve got nothing.
Like my life had finished...it was just like a void,
because everything to do with my life before
stopped...’(Sophie;1admissionlasting9months)
For Sophie this included a cessation of her friend-
ships and her participation in any meaningful activ-
ities, to the extent that many areas of her life ground
to a halt. Many participants felt that they were
actively discouraged from engaging in real-world
activities such as their hobbies and school-work—
even those not linked to exercise or their eating dis-
order. Several participants were also acutely aware
of life moving on for peers, whilst theirs remained
stagnant. For Sarah this appeared to block her
progress:
‘...butIwasveryawarethattheyweregettingonwith
their lives, erm, they were doing their ‘‘A’’ levels, they
were gonna be going off to university at the end of the
year, and that was really hard for me cos I had fears of
everybody going...and I’d never catch up... ...it
meant that I sort of stayed stuck because I didn’t have
muchincentivetosortofmove-on.Ithought,well‘‘this
is it now’’ (Sarah; 1 admission lasting 6 months).
Several people felt that encouraging some form of
‘normal’activityoutsidetheunitwouldhavehelped
theirtransitionfollowingdischargeandservedasan
incentive to get well. Similarly, after discharge the
key to successful re-adjustment and recovery for
many involved having real-life incentives such as a
college course,new friendsor a job,which provided
a focus away from eating difficulties and a motiva-
tion to stay well.
Normality Around Mealtimes
In relation to mealtimes, there was a general view
that practices such as ‘having to lick one’s plate
Patients’ Experiences of Treatment and Discharge
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Eur. Eat. Disorders Rev. 14, 377–387 (2006)

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clean’, i.e. eat up everything served, created an
‘abnormal atmosphere’ that was generally per-
ceivedasunhelpful.Incontrast,severalparticipants
found that creating a ‘normal atmosphere’ during
mealtimes, with staff and patients eating together
was very helpful:
‘We all ate together like all the lads and everyone ate,
and that was really good cos you’d get the lads ‘just
get on with it!’ (chuckles) and it was like, sometimes
it was kind of like really helped to see normal people
eat’ (Chloe; 2 admissions, total length 13 months).
Rigidity over portion sizes and diet plans was
often seen as helpful during the admission, but
unhelpful when trying to eat more normally follow-
ing discharge. Many participants also described
their experiences of being observedafter mealtimes,
commenting that staff who were able to balance a
relaxed approach with more professional support
when needed were the most helpful:
‘the younger staff used to be really good like sort of..I
don’tknowtalkaboutwhattheydidlastnight,andjust
hearing a bit of normal life...that really helped’
(Chloe).
Suspension in Development
For many, being in hospital meant their own social
and emotional development was restricted or even
arrested. Anna expressed anger for how her inpati-
ent experience had failed to encourage the develop-
ment of age-appropriate skills but had instead
fostered dependence, which had long-term implica-
tions for her:
‘IknewthatIcouldn’tcopeasanadult.CosI’dbeenlike
hidden-awayfromsocietysowasstillonlya14yearold
really, in my head...still now.. I’ll phone up my mum
forthestupidestreasonandshe’llsay... ‘‘Annayou’re
22 I think you can do that yourself’’ and I’ll just be like
‘‘ah no I can’t do that’’’ (Anna; 2 admissions, total
length 18 months).
Compounding a Sense of Isolation
Chloe described how unit practices which encour-
aged isolation, such as bed-rest, actually mirrored
certain aspects of her anorexia:
‘I think you’re isolated enough with the illness I think
without, I just think isolation really with eating disor-
ders is not good. Cos you isolate yourself from your
friends when you’re getting ill anyway’ (Chloe).
Aspects of unit programmes that failed to foster
connections with friends and relatives were seen to
compound one’s sense of loneliness and isolation.
These practices included inflexible visiting hours,
lack of visiting space and the withdrawal of contact
as part of behavioural reinforcement schedules. For
Anna this isolation from her family also affected her
sense of self and belonging:
‘I had quite a low self-esteem...and I felt, I didn’t,
that’s it, I didn’t feel like I belonged anywhere. Because
hospital’s hospital and I’d go home at weekends, but
becauseIwasonlywithmyfamilyatweekendsIdidn’t
really feel like I belonged in the family either’ (Anna).
Contrasts in Structure and Support
Participants frequently commented on the extreme
difference between the high level of structure and
support found in the unit and that found in the
world outside. This often led to strong attachments
to unit life and painful emotions on discharge. Post-
discharge, adjusting to the absence of a structured
routine, and the need to make independent deci-
sions also proved difficult. In light of these transi-
tionalchallenges,participants
discharge planning and the continuation of a rela-
tively high level of support post-discharge helpful.
Abrupt transitions were often experienced as scary
and rejecting whilst those planned in a gradual
and collaborative manner were more positively
experienced:
foundcareful
‘everything, was slowly introduced, so we decided that
in x amount of weeks I was going to leave
wassortof...slowlydone,insteadofsaying,thisweek-
end you’re going home, next weekend you’re going to
school, week after you’re gonna leave, it was done
slowly’ (Katie; 2 admissions, total length 15
months).
and...it
Family and individual work that acknowledged
andpreparedforthepotentialchallengesassociated
with discharge was also viewed as useful, and sev-
eral reported that it would have also been helpful
to have received ongoing psychological/ emotional
support from the practitioner they saw whilst an
inpatient. However others preferred support pro-
vided by local services; discharge marking a ‘fresh
start’. It was also important that the level of support
reflected the individual’s stage of recovery. For
example, Katie viewed the support she received
initially as too superficial and infrequent, comment-
ing that this may have contributed to her relapse.
When nearing complete recovery, having someone
at a distance, although sometimes viewed as irritat-
ing, was regarded as necessary and helpful.
380
A. Offord et al.
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Eur. Eat. Disorders Rev. 14, 377–387 (2006)

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Theme 2: Treated as Another Anorexic vs a
Unique Individual in Distress
There were several aspects of care that led partici-
pants to feel they were viewed simply as another
anorexic, rather than being seen as an individual in
their own right. These encompass the following
three subordinate themes:
Staff Assumptions About Eating Disorders
Many participants described finding it unhelpful
whenstaffconveyedassumptionsabouthowyoung
people with AN behave or think. This gave a strong
message that one was perceived as an anorexic
entity rather than a unique individual.
‘they were like ‘right, you’ve all got an eating disorder,
so we’re gonna think you’re the same person’ so they
kind of treated us all the same’ (Beth; 1 admission
lasting 5 months).
These assumptions were often experienced as
being over-simplistic, undermining, patronising
and accusational. For example, Chloe spoke about
an assumption that anorexics are always irrational:
‘youarerationalsometimes,anditdidannoymesome-
times that it was ‘it’s the anorexia talking’ and it’s like
‘‘no it is me!’’ (chuckles) you know and ‘‘give me a
chance!’’’(Chloe).
These assumptions often led to the development
and indiscriminate implementation of rules desi-
gnedto address specific
behaviours.
eating disordered
Standardised Programmes
All units appeared to have set treatment programs
forpatientswithAN,andthesewereoftenperceived
as inflexible and punishing, especially when they
were based on strict behavioural approaches. Parti-
cipants commented that staff often failed to offer an
adequate rationale for certain practices, leaving
patientsfeeling upset, confused andfrustrated. Sev-
eral participants felt that the least helpful aspect of
their treatment was the absence of truly individua-
lised care. Most felt that programmes did not allow
for individual differences, and thus patients were
often left feeling punished for the behaviour of
others within their diagnostic group:
‘...but they have this set programme and like for
instance, I have never had a problem with being sick,
or anything like that, and the idea that I couldn’t go
tothelooincaseI’dbesickwasjustlikebizarrebecause
it didn’t apply to me. And they all knew that it didn’t
applytome,buttheysaid‘‘wellwe’vegottodothiscos
it’s the rule’’ (Anna).
Physical Recovery Prioritised Over
Psychological Recovery
Many participants described the use of a staged
approach, with the primary focus being on weight
gain and the prevention of weight loss behaviours;
psychological support being withheld until one’s
target weight was achieved. This often led to a per-
ception that staff simply wanted to ‘fatten them up’;
their emotional and psychological needs not being
viewed as important. The withholding of group
therapy and of individual psychological input was
viewed by many as illogical and punishing:
‘You didn’t see a therapist or anyone cos I wasn’t, they
said you weren’t cognitively well enough, but that’s
just crap because you need someone’s support...and
youfeel likethe anorexiapunishesyou more. Theanor-
exia is punishment, then you feel like you’re getting
punished by the hospital as well’ (Chloe).
Several participants acknowledged that any psy-
chological input needed to match their cognitive
ability, particularly in terms of their ability to con-
centrate and reflect on deeper issues. However they
also maintained that some form of emotional sup-
port is necessary for any sustainable weight gain.
A failure to address psychological issues could lead
to a perception that hospitalisation merely com-
pounded one’s illness. For Chloe, enforced weight-
gainwithoutcorrespondingpsychologicalgainsim-
ply compounded her sense of a lack of control:
‘cos I left there just feeling, I felt so out of control
because the weight had not gone on how I wanted it
to go on, and I didn’t really want it to go on anyway,
but if I had to, it didn’t really go on properly it went
on really quickly and wooarrggh! And just feel really,
you just feel even more sort of, scared really’ (Chloe).
Aspectsof inpatient treatmentwhich wereseen as
most helpful were those which conveyed that
patients were being viewed as unique individuals in
distress. The following
describe how this can be achieved:
3 subordinate themes
Recognising the ED as a Symptom
Many participants stressed how their eating disor-
der was just a symptom of more fundamental pro-
blems. Services were viewed as valuable when
they recognised this and supported individuals to
uncover and address the underlying issues. Chloe
describedanincidentwhenshewasinacutedistress
and wasbeing restrained. However this was experi-
enced in a supportive manner, which valued her as
an individual who was battling against her anor-
exia—here, perceived as an external symptom:
Patients’ Experiences of Treatment and Discharge
381
Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association.
Eur. Eat. Disorders Rev. 14, 377–387 (2006)