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Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
Rules of Engagement: Qualitative Experiences of Therapeutic Alliance When Receiving In-Patient Treatment for Anorexia Nervosa ab
bc
bd
Richard Sly , John F. Morgan , Victoria A. Mountford , Francesca b
b
b
Sawer , Charlotte Evans & J. Hubert Lacey a
School of Nursing Sciences, University of East Anglia, Norwich Research Park, UK b
Eating Disorders Research Team, Department of Personal, Social, Health and Economic Education, St. George’s, University of London, London, UK c
Yorkshire Centre for Eating Disorders, Leeds, UK
d
Institute of Psychiatry, King’s College London, London, UK Published online: 06 Jan 2014.
To cite this article: Richard Sly, John F. Morgan, Victoria A. Mountford, Francesca Sawer, Charlotte Evans & J. Hubert Lacey (2014) Rules of Engagement: Qualitative Experiences of Therapeutic Alliance When Receiving In-Patient Treatment for Anorexia Nervosa, Eating Disorders: The Journal of Treatment & Prevention, 22:3, 233-243, DOI: 10.1080/10640266.2013.867742 To link to this article: http://dx.doi.org/10.1080/10640266.2013.867742
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This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Eating Disorders, 22:233–243, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2013.867742
Rules of Engagement: Qualitative Experiences of Therapeutic Alliance When Receiving In-Patient Treatment for Anorexia Nervosa
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RICHARD SLY School of Nursing Sciences, University of East Anglia, Norwich Research Park; and Eating Disorders Research Team, Department of Personal, Social, Health and Economic Education, St. George’s, University of London, London, UK
JOHN F. MORGAN Eating Disorders Research Team, Department of Personal, Social, Health and Economic Education, St. George’s, University of London, London; and Yorkshire Centre for Eating Disorders, Leeds, UK
VICTORIA A. MOUNTFORD Eating Disorders Research Team, Department of Personal, Social, Health and Economic Education, St. George’s, University of London; and Institute of Psychiatry, King’s College London, London, UK
FRANCESCA SAWER, CHARLOTTE EVANS, and J. HUBERT LACEY Eating Disorders Research Team, Department of Personal, Social, Health and Economic Education, St. George’s, University of London, London, UK
Recent research has emphasised the importance of therapeutic alliance to treatment outcomes for anorexia nervosa. This study aimed to examine the experiences of service users in developing therapeutic alliance whilst in treatment for their eating disorders. This qualitative study, using purposive sampling, recruited a sample of service users receiving treatment at a national eating disorders service. In-depth interviews were audiotaped and transcribed, with transcriptions being subject to interpretative phenomenological analysis. Participants were eight adult women receiving tertiary level eating disorder treatment in a specialist setting. The text analysis produced four dominant categories: alliance as a key experience; being active, not passive; taboo talking; and first impressions count. The development of therapeutic alliance is a Address correspondence to Richard Sly, School of Nursing Sciences, University of East Anglia, Norwich Research Park NR4 7TJ, UK. E-mail: [email protected] 233
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core component of treatment. This study identifies important areas that contribute to the successful cultivation of positive therapeutic alliance.
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INTRODUCTION There is a widely held consensus that anorexia nervosa (AN) is one of the most difficult psychiatric disorders to treat (Vitousek, Watson, & Wilson, 1998). The experience of treatment for AN often can be overwhelming for the service user, and weight gain in particular can often feel intolerable (Touyz, Thornton, Rieger, George, & Beumont, 2003). AN is ego-syntonic in nature, and as a result, attempts to change eating disordered behaviour can often be extremely distressing and challenging (Bamford & Mountford, 2012). This can lead to an entrenched battle between service users, who often experience high levels of ambivalence (Tierney, 2008), and the therapy team who are challenging the eating disordered behaviour (Geller & Drab, 1999). It is perhaps because of the intense challenges patients and clinicians face that dropping out of treatment is such a pervasive feature of AN treatment programmes (Sly, 2009). Drop-out rates as high as 50–58% have been cited for both out-patient and in-patient samples receiving specialist treatment for their eating disorder (Button, Marshall, Shinkwin, Black, & Palmer, 1997; Sly, Morgan, Mountford, & Lacey, 2013). Therapeutic alliance may have an important role in the explanation of treatment outcome (Elvins & Green, 2008), and there is emerging research in the field of eating disorders, an area in which building therapeutic alliance is—clinically, at least—considered a key aspect of treatment (Brown, Mountford, & Waller, in press; Tierney, 2008). Pereira, Lock, and Oggins (2006) found that therapeutic alliance was related to early weight gain in treatment, and later treatment outcome. This study was carried out with adolescents with AN who were taking part in a family therapy treatment. A recent study examining treatment outcomes in adult in-patient services also found therapeutic alliance to be a key predictor of treatment outcome (Sly et al., 2013). This study examined the early perceptions of therapeutic alliance between service users and their allocated nurse. Fosberg et al., (2013) examined therapeutic alliance between adolescents and clinicians in both family-based treatment and adolescent-focused therapy, and found that it was predictive of partial remission, although not so of full remission. Qualitative examination of therapeutic alliance in treatment for AN emphasised the difficulties that both service users and clinicians have in forging a workable, productive therapeutic relationship (Ramjan, 2004). Ryan, Malson, Clarke, Anderson, and Kohn (2006) identified the multi-dimensional nature of providing nursing care for anorectic service users in a specialist eating disorder ward. The role of the nurse was described as being as diverse
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as providing loving and empathic support whilst also performing “surveillance” on service users. This dichotomy of roles is likely to have some kind of effect on the quality and development of a working therapeutic alliance in such a setting. These studies concentrated primarily on the role of therapeutic alliance from a nursing perspective, and there has been little work to date about how therapeutic alliance is experienced by service users receiving treatment for AN. The objectives of this study are to examine the service user experience of therapeutic alliance, to assess its perceived importance, and to explore what elements help contribute to building a stronger alliance with clinical staff.
METHODS Qualitative Interviews Semi-structured in-depth interviews were employed, covering themes elicited from the literature review and refined in a focus group of eating disorder specialists. The following interview topics were covered: background, past treatment history, experiences of care provided by key nurses, impressions of therapeutic alliance, and experiences of therapeutic alliance. Interviews lasted approximately 50 minutes, recorded using a digital audio recorder, and subsequently transcribed in their entirety, available for external scrutiny within the bounds of confidentiality. Interviews covered the key topics as summarised above, but were also flexibly responsive to the participants’ narratives. The principle research question was the experience of developing therapeutic alliance whilst in treatment for AN.
Participants and Sampling Methods Eight service users (aged 18–34, mean 25) who were at the time receiving hospitalised treatment for AN participated in semi-structured individual interviews. A total of 12 service users had been approached to take part in the interviews, but 4 potential participants declined to take part, citing lack of time or desire to take part in the study. Sampling was purposive, and data saturation prior to cessation of data collection was not sought: when using an interpretive phenomenological analysis (IPA) framework, data saturation is often not possible or indeed desirable (Hale, Treharne & Kitas, 2008). Instead, this small sample would provide rich data based upon their own personal lived experiences—the primary goal of employing IPA as a framework. All participants were female and Caucasian, reflecting the demographics of service users at the eating disorders centre at the time of data collection. The interviews were conducted by R.S. under supervision of J.F.M., V.A.M., and J.H.L. The study was reviewed and approved by the relevant ethical review bodies.
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Analysis R.S., C.E., and F.S. independently read the review transcripts and highlighted themes as primary topics of relation to the research question. They independently re-read transcripts and codified primary topics throughout, and amalgamated data on the themes. Definitions of themes were subsequently agreed upon. R.S., C.E., and F.S. coded half of the transcripts according to those definitions, and then recoded all subsequent transcripts. Definitions were refined on discussion throughout this process. R.S. re-read a random sample of transcripts to assess the construct validity of theme definitions. Categories of inter-related themes were developed independently by R.S., C.E., and F.S., with flow charts being employed to associate themes and categories. Horizontal analyses were used to group clusters of text thematically, and the repetition of analyses ensured bias was minimised, and no major themes were overlooked. As themes emerged, evidence that was potentially contradictory was sought and explored, and analysis was modified to take this into account.
RESULTS Four key categories emerged from the analysis, which will be separately discussed in subsequent sections: alliance as a key experience; active, not passive; taboo talking; and first impressions count.
Alliance as a Key Experience The development of a positive, working relationship with one’s key nurse was identified as a central aspect of treatment by almost all participants. Good or bad, the relationship with key nurses was often described as a reflection of the treatment experience as a whole: I think when I look back at past admissions, I can see that my relationship in key work was like, not like it is now. For me now, we are working so well together and I feel that in treatment elsewhere too, I feel more ready to tackle what I need to.
Participants also spoke of how their relationship with their key nurse was central to their perceived capacity to tackle the problems that arose during treatment: For me, I’d look forward to our [weekly] sessions, they generally came around like when my motivation was struggling, or like when I needed support, and I knew I could keep going because soon we’d have key work and talk it through.
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Difficulties and challenges often appear during the course of treatment for AN, and all participants noted that without a good relationship with their key nurse, these challenges could feel insurmountable:
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It’s hard, you know? It’s like, getting nearer and nearer to target [weight] you’re feeling worse and worse about yourself. There’s a lot to keep you going—family, goals, and all, but they’re not there all the time you know? But she [key nurse] is, pretty much, I always know she’s there for me at those times.
Indeed, having a poor relationship with their key nurse seemed to elucidate feelings of isolation and loneliness within service users who were experiencing negative emotions during treatment: We had no understanding, no relationship, so you know, I was on my own with it all, all the time, no one to really take things to, and in the end, I just thought “that’s it” I need to get out and go home you know?
Active, Not Passive The importance of an equal relationship—or a perceived equal relationship—between key nurses and participants was consistently reported. Participants identified the importance of being made to feel like they were actively involved in treatment, rather than a passive recipient of it: I think that being part of treatment, like, having a say about what I wanted to focus on first, and then working together on a plan based on our discussions, made me want to work harder with her.
Participants noted that particularly in the early stages of treatment they were in effect, passive recipients of treatment, but identified the importance of being treated as if they were actively involved whilst in key work sessions: At the start [of treatment] we can’t choose anything for ourselves, like meals, snacks, you know? Going out. But [nurses name] has always involved me, made me feel involved, even if I couldn’t do anything about it, and that helped, really helped for later on you know?
Approximately three quarters of participants talked about past experiences of key nurses with whom they had a relationship which was felt to be unbalanced. Some thought it was in terms of the key nurse being too domineering, [Nurses name], last admission, told me what to do, told me in no, in a way that gave me no choice, what I was going to do or needed to do.
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All I did from then was resist, fight her, even if she made sense, her way, her manner of talking to me just made me dig my heels in.
Or indeed, too passive:
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I was able, or my anorexia was able, I don’t know, but able to dominate them, just run the programme and [nurses name] was really nice and friendly and all, but couldn’t control it, me. I liked it at the time but it didn’t really work well did it?
“Good” therapeutic relationships were when neither patient nor key nurse dominated the other, but rather accepted and respected one another, and worked together in sharing the rigours of treatment. This included participants being able to tell the key nurse what they would like out of the key work sessions, and likewise being told by the key nurse what was expected of them: Give and take, absolutely. It felt like an even, like we were even in things. I told them what I found useful in challenging [eating disordered behaviours], I told them what I didn’t find useful, and they’d do the same—like what they expected of me and that, it was good.
Taboo Talking During the course of hospitalised treatment for AN, service users are generally expected to cease eating disordered behaviours. Participants identified using behaviours secretively, and not feeling that they could admit this to their key nurse as a key hurdle to recovery, and as decelerating the development of alliance: Once there’s a secret there, like between us, and it’s not admitted, I just continued and things just spiralled. It all becomes fake so quickly.
However, there was a strong trend identifying how key nurses who willingly sought to talk of these “treatment taboos” were more likely to be nurses that formed strong and effective therapeutic alliances: In key work, she’d start off, every session like, by asking what behaviours I was struggling with, the triggers and that. It made it easier to talk about my difficulties, and be honest when things went out of control.
Within this category was a dominant theme regarding the need for “straight talking” from the key nurse. Participants identified increased feelings of safety in a key nurse who was prepared to be firm in their conversations and interventions:
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At first I was like scared, because they were like telling me stuff I didn’t want to hear, but now, there’s a kind of safety in it, in knowing that no matter what, I can’t get away with stuff I would have in the past.
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This straight talking was only felt helpful if given in a supportive way, whilst maintaining a level of equality as previously discussed. Firm messages, when given outside the context of an equal relationship were seldom found to be helpful or useful: I think being spoken to honestly, firmly at times, is what I need. Just be straight and fair and I respond to that. With [nurses name], in my other treatment, she was always like “you have to do this or don’t do that or whatever,” but we never really discussed it you know? Explained why not. It just felt so unsupportive, although they were maybe trying, for me it wasn’t good, didn’t work at all.
First Impressions Count Participants identified that therapeutic alliance was mediated by the first impressions they had of their key nurse. Even how key nurses were dressed on initial meetings was deemed important: Nurses now, on the ward like, they look really smart, I don’t know, they used not to, they used to be much more casual you know? I just thought, it makes you feel more able to open up to them if they look like approachable, friendly, not if they look like staff, waiters and waitresses you know?
The first session spent between key nurse and participant also was identified as being important to setting the tone for the rest of treatment: I think you just know if you’re going to get along you know? Almost straightaways. You can tell if, how they’re going to be and it lets you either open up and talk or hang on and see.
But not everyone agreed with this: No, I think I’ve had like nurses before who I thought were just going to be bad you know, like straight away. But we couldn’t change and I think over time we got to a stage where she was like the one I’d always go to for time, for support and that.
What was almost universally agreed upon however, was the importance of how the first session was conducted. In participants’ views, a “good” session at the start of treatment was characterised by how little talking the key nurse did during that session:
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They let me tell them about me mostly, they took the time to understand my past and that, and what I found difficult before in treatment. They, looking back now, didn’t say a lot, but just asked questions, like I was important to them you know?
Conversely, “bad” initial sessions involved the key nurse taking an overly authoritarian stance:
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All they did, thinking now, is just talk at me. Told me what I couldn’t do, gave me rules, told me stuff like that, and I’m thinking like, hello, I’m here don’t you care? I’m not just another patient to give rules to, I need your help you know?
This first session paved the way for the development—or not—of good therapeutic alliance. Many participants spoke of a kind of momentum that built up in treatment, and traced this momentum back to the early stages of treatment with their key nurse: Looking at where I am now, you know, I look back to those times and wonder how I got here! It was just so hard you know to keep going, but I think she played such a strong part, really stable, and we just kept going, a bit at a time until, well, here.
DISCUSSION Past research into the role of therapeutic alliance when treating eating disorders have provided evidence which states it is both crucial (Sly et al., 2013), and difficult (Ramjan, 2004) to successfully achieve. The current study has elucidated several factors that from service user perspectives, are important in the development of positive alliance. The first theme to emerge—alliance as a key experience—supports the quantitative literature (e.g., Pereira et al, 2007; Sly et al, 2013) that identifies alliance as being a key aspect of treatment for AN. A “good” relationship seemed to signify treatment progressing in a positive manner, and a “poor” relationship reflected a lack of positive treatment progression. Clinical settings would be well advised to pay increased attention to supporting staff to develop the skills and frameworks needed to maximise the development of therapeutic alliance. The majority of participants stated that they felt they could tell if they were going to have a good relationship with their key nurse from very early on in treatment. This also fits with previous quantitative findings, in which response to the initial key work session proved to be predictive of treatment outcome (Sly et al., 2013). Many participants mentioned the importance
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of staff appearance in their initial impressions and subsequent decisions to engage with them. Staff who were dressed “too smart” were, in the eyes of the participants, less immediately approachable than those who were dressed more casually. In the treatment setting in which this study took place, staff do not wear uniforms, but immediately prior to the study, there was a policy shift to ensure staff were dressed in smart clothes in clinical areas. According to participants, this only served to highlight a “them and us” dynamic, creating a rather corporate, instead of therapeutic, atmosphere. First impressions extend to the initial meeting between key nurses and service users. Participants reported that a session in which they were allowed to take a leading role were more likely to leave them with positive impressions on the relationship they would forge with their key nurse. Allowing service users to, for example, talk of their past experiences and future expectations for treatment seemed to enforce in participants’ minds that they would be treated as individuals, and be at the centre of their care. In contrast, key nurses whose initial session is more rule-orientated and directive give the impression of treatment being more uniform, and elicits a negative response in service users. These factors are important considerations when delivering an initial session, which past research has indicated is key to future treatment progress (Sly et al., 2013). Nursing staff may benefit from increased support when planning initial sessions with service users, and given the importance of these sessions, may also benefit from structures being put in place to allow them to focus on these sessions. For example, nurses could be allocated some protected time prior to their meetings with service users, in which they could fully focus on preparing for the session. Following on from the initial session, participants reported that their response to treatment gathered its own momentum, for good or ill. This momentum seems to be dependent, according to participant reports, on being engaged in treatment in an active way, rather than just passively receiving treatment. There is a case to be made that how engaged service users become largely depends on their own motivation to engage, which is often low (Vitousek et al., 1998). However, in the data for the current study, a strong recurring theme was how important it was for key nurses to actively engage the participants in the treatment process. This was true even in aspects of treatment that service users had little say in, and participants reported that an approach that was collaborative allowed them to truly engage in what was expected from them. They spoke of the need for nurses to not be too domineering, and at the same time, to not allow service users to dominate them: a fine line to tread, without a doubt. In clinical practice, regular bi-directional appraisals between service users and key nurses would be advisable, during which both parties could reflect on the engagement process, and talk openly about what aspects of their relationship were working or not working particularly well.
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The final theme from the data bears a resemblance to the previous theme, in which key nurses are walking the line between giving too much and too little. The ability to “taboo talk,” addressing issues of treatment that service users initially may be unwilling to discuss, requires a straighttalking attitude on behalf of the nurse involved. Participants reported feeling a sense of relief at being able to talk about, for example the use of eating disordered behaviours whilst in treatment. Nurses that did not present as being open or accepting about such a topic would typically not be given the truth by the service user, and increased levels of deceit and deception would quickly follow, eroding the therapeutic process. The ability to portray a level of acceptance and openness to such treatment taboos were felt to be a key aspect of a “good” key nurse in the eyes of participants. However, that straight-talking attitude appears to be a difficult balancing act, with participants reporting that over-stepping the mark and doing it in a way that does not feel constructive is likely to result in a deceleration of the therapeutic process. This is another example of how difficult it can be at times for nurses and service users to get the balance right in their relationship, a finding which supports those of previous work in this field (Ramjan, 2004). Although this is a small study, the narrative accounts of participants support and extend the findings from both qualitative and quantitative studies into this area. The experiences described by this sample make it clear that the development of therapeutic alliance is a key component of treatment, and is a process fraught with difficulty. The role of the key nurse on an eating disorders unit requires many fine lines to be trod, and based on the testimony of the participants in this study, they run the risk of alienating service users if these lines are over or under stepped. It is also possible, due to the treatment-resistant nature of eating disorders, that “any excuse” to derail the therapeutic process will at times be sought by some service users. The role of the key nurse on an eating disorders unit is complex, with many potential pitfalls. There should be an increased emphasis placed on support for this role, such as the provision of protected time before sessions, and regular, high quality training and supervision sessions. The relationship between service user and key nurse should be routinely assessed by all parties, and additional support and intervention offered to help buffer against any difficulties. Although a difficult task, the current study supports past work, identifying this relationship as a key aspect of successful treatment for those with eating disorders.
REFERENCES Bamford, B., & Mountford, V. A. (2012). Cognitive behavioural therapy for individuals with longstanding anorexia nervosa: Adaptations, clinician survival and system issues. European Eating Disorders Review, 20, 49–59.
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Brown, A., Mountford, V. A., & Waller, G. (in press). Early behaviour change and therapeutic alliance in CBT for anorexia nervosa. Behaviour Research and Therapy. Button, E. J., Marshall, P., Shinkwin, R., Black, S. H., & Palmer, R. L. (1997). One hundred referrals to an eating disorders service: Progress and service consumption over a 2–4 yr period. European Eating Disorders Review, 5, 47–63. Elvins, R., & Green, J. (2008). The conceptualization and measurement of therapeutic alliance: An empirical review. Clinical Psychology Review, 28, 1167–1187. doi:10.1016/j.cpr.2008.04.002 Fosberg, S., Lotempio, E., Bryson, S., Fitzpatrick, K., Le Grange, D., & Lock, J. (2013). Therapeutic alliance in two treatments for adolescent anorexia nervosa. The International Journal of Eating Disorder, 46, 34–38. Geller, J., & Drab, D. L. (1999). The readiness and motivation interview: A symptomspecific measure of readiness for change in the eating disorders. European Eating Disorders Review, 7, 259–278. Hale, E. D., Treharne, G. J., & Kitas, G. D. (2008). Qualitative methodologies II: A brief guide to applying interpretative phenomenological analysis in musculoskeletal care. Musculoskeletal Care, 6, 86–96. Pereira, T., Lock, J., & Oggins, J. (2006). Role of therapeutic alliance in family therapy for adolescent anorexia nervosa. The International Journal of Eating Disorders, 39, 677–684. doi:10.1002/eat.20303 Ramjan, L. M. (2004). Nurses and the “therapeutic relationship”: Caring for adolescents with anorexia nervosa. Journal of Advanced Nursing, 45, 495–503. Ryan, V., Malson, H., Clarke, S., Anderson, G., & Kohn, M. (2006). Discursive constructions of “eating disorders nursing”: An analysis of nurses’ accounts of nursing eating disorder patients. European Eating Disorders Review, 14, 125–135. Sly, R. (2009). What’s in a name? Classifying “the dropout” from treatment for anorexia nervosa. European Eating Disorders Review, 17, 405–407. Sly, R., Morgan, J., Mountford, V., & Lacey, J. (2013). Premature termination of treatment for anorexia nervosa: The roles of therapeutic alliance, motivation, and behaviour change. Eating Behaviours, 14, 119–123. Tierney, S. (2008). The individual within a condition: A qualitative study of young people’s reflections on being treated for anorexia nervosa. Journal of the American Psychiatric Nurses Association, 13, 368–375. Touyz, S., Thornton, C., Rieger, E., George, L., & Beumont, P. (2003). The incorporation of the stage of change model in the day hospital treatment of patients with anorexia nervosa. European Child & Adolescent Psychiatry, 12(Suppl. 1), I65–71. doi:10.1007/s00787-003-1109-5 Vitousek, K., Watson, S., & Wilson, G. T. (1998). Enhancing motivation for change in treatment-resistant eating disorders. Clinical Psychology Review, 18, 391–420.
Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
Rules of Engagement: Qualitative Experiences of Therapeutic Alliance When Receiving In-Patient Treatment for Anorexia Nervosa ab
bc
bd
Richard Sly , John F. Morgan , Victoria A. Mountford , Francesca b
b
b
Sawer , Charlotte Evans & J. Hubert Lacey a
School of Nursing Sciences, University of East Anglia, Norwich Research Park, UK b
Eating Disorders Research Team, Department of Personal, Social, Health and Economic Education, St. George’s, University of London, London, UK c
Yorkshire Centre for Eating Disorders, Leeds, UK
d
Institute of Psychiatry, King’s College London, London, UK Published online: 06 Jan 2014.
To cite this article: Richard Sly, John F. Morgan, Victoria A. Mountford, Francesca Sawer, Charlotte Evans & J. Hubert Lacey (2014) Rules of Engagement: Qualitative Experiences of Therapeutic Alliance When Receiving In-Patient Treatment for Anorexia Nervosa, Eating Disorders: The Journal of Treatment & Prevention, 22:3, 233-243, DOI: 10.1080/10640266.2013.867742 To link to this article: http://dx.doi.org/10.1080/10640266.2013.867742
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
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This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Eating Disorders, 22:233–243, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2013.867742
Rules of Engagement: Qualitative Experiences of Therapeutic Alliance When Receiving In-Patient Treatment for Anorexia Nervosa
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RICHARD SLY School of Nursing Sciences, University of East Anglia, Norwich Research Park; and Eating Disorders Research Team, Department of Personal, Social, Health and Economic Education, St. George’s, University of London, London, UK
JOHN F. MORGAN Eating Disorders Research Team, Department of Personal, Social, Health and Economic Education, St. George’s, University of London, London; and Yorkshire Centre for Eating Disorders, Leeds, UK
VICTORIA A. MOUNTFORD Eating Disorders Research Team, Department of Personal, Social, Health and Economic Education, St. George’s, University of London; and Institute of Psychiatry, King’s College London, London, UK
FRANCESCA SAWER, CHARLOTTE EVANS, and J. HUBERT LACEY Eating Disorders Research Team, Department of Personal, Social, Health and Economic Education, St. George’s, University of London, London, UK
Recent research has emphasised the importance of therapeutic alliance to treatment outcomes for anorexia nervosa. This study aimed to examine the experiences of service users in developing therapeutic alliance whilst in treatment for their eating disorders. This qualitative study, using purposive sampling, recruited a sample of service users receiving treatment at a national eating disorders service. In-depth interviews were audiotaped and transcribed, with transcriptions being subject to interpretative phenomenological analysis. Participants were eight adult women receiving tertiary level eating disorder treatment in a specialist setting. The text analysis produced four dominant categories: alliance as a key experience; being active, not passive; taboo talking; and first impressions count. The development of therapeutic alliance is a Address correspondence to Richard Sly, School of Nursing Sciences, University of East Anglia, Norwich Research Park NR4 7TJ, UK. E-mail: [email protected] 233
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core component of treatment. This study identifies important areas that contribute to the successful cultivation of positive therapeutic alliance.
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INTRODUCTION There is a widely held consensus that anorexia nervosa (AN) is one of the most difficult psychiatric disorders to treat (Vitousek, Watson, & Wilson, 1998). The experience of treatment for AN often can be overwhelming for the service user, and weight gain in particular can often feel intolerable (Touyz, Thornton, Rieger, George, & Beumont, 2003). AN is ego-syntonic in nature, and as a result, attempts to change eating disordered behaviour can often be extremely distressing and challenging (Bamford & Mountford, 2012). This can lead to an entrenched battle between service users, who often experience high levels of ambivalence (Tierney, 2008), and the therapy team who are challenging the eating disordered behaviour (Geller & Drab, 1999). It is perhaps because of the intense challenges patients and clinicians face that dropping out of treatment is such a pervasive feature of AN treatment programmes (Sly, 2009). Drop-out rates as high as 50–58% have been cited for both out-patient and in-patient samples receiving specialist treatment for their eating disorder (Button, Marshall, Shinkwin, Black, & Palmer, 1997; Sly, Morgan, Mountford, & Lacey, 2013). Therapeutic alliance may have an important role in the explanation of treatment outcome (Elvins & Green, 2008), and there is emerging research in the field of eating disorders, an area in which building therapeutic alliance is—clinically, at least—considered a key aspect of treatment (Brown, Mountford, & Waller, in press; Tierney, 2008). Pereira, Lock, and Oggins (2006) found that therapeutic alliance was related to early weight gain in treatment, and later treatment outcome. This study was carried out with adolescents with AN who were taking part in a family therapy treatment. A recent study examining treatment outcomes in adult in-patient services also found therapeutic alliance to be a key predictor of treatment outcome (Sly et al., 2013). This study examined the early perceptions of therapeutic alliance between service users and their allocated nurse. Fosberg et al., (2013) examined therapeutic alliance between adolescents and clinicians in both family-based treatment and adolescent-focused therapy, and found that it was predictive of partial remission, although not so of full remission. Qualitative examination of therapeutic alliance in treatment for AN emphasised the difficulties that both service users and clinicians have in forging a workable, productive therapeutic relationship (Ramjan, 2004). Ryan, Malson, Clarke, Anderson, and Kohn (2006) identified the multi-dimensional nature of providing nursing care for anorectic service users in a specialist eating disorder ward. The role of the nurse was described as being as diverse
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as providing loving and empathic support whilst also performing “surveillance” on service users. This dichotomy of roles is likely to have some kind of effect on the quality and development of a working therapeutic alliance in such a setting. These studies concentrated primarily on the role of therapeutic alliance from a nursing perspective, and there has been little work to date about how therapeutic alliance is experienced by service users receiving treatment for AN. The objectives of this study are to examine the service user experience of therapeutic alliance, to assess its perceived importance, and to explore what elements help contribute to building a stronger alliance with clinical staff.
METHODS Qualitative Interviews Semi-structured in-depth interviews were employed, covering themes elicited from the literature review and refined in a focus group of eating disorder specialists. The following interview topics were covered: background, past treatment history, experiences of care provided by key nurses, impressions of therapeutic alliance, and experiences of therapeutic alliance. Interviews lasted approximately 50 minutes, recorded using a digital audio recorder, and subsequently transcribed in their entirety, available for external scrutiny within the bounds of confidentiality. Interviews covered the key topics as summarised above, but were also flexibly responsive to the participants’ narratives. The principle research question was the experience of developing therapeutic alliance whilst in treatment for AN.
Participants and Sampling Methods Eight service users (aged 18–34, mean 25) who were at the time receiving hospitalised treatment for AN participated in semi-structured individual interviews. A total of 12 service users had been approached to take part in the interviews, but 4 potential participants declined to take part, citing lack of time or desire to take part in the study. Sampling was purposive, and data saturation prior to cessation of data collection was not sought: when using an interpretive phenomenological analysis (IPA) framework, data saturation is often not possible or indeed desirable (Hale, Treharne & Kitas, 2008). Instead, this small sample would provide rich data based upon their own personal lived experiences—the primary goal of employing IPA as a framework. All participants were female and Caucasian, reflecting the demographics of service users at the eating disorders centre at the time of data collection. The interviews were conducted by R.S. under supervision of J.F.M., V.A.M., and J.H.L. The study was reviewed and approved by the relevant ethical review bodies.
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Analysis R.S., C.E., and F.S. independently read the review transcripts and highlighted themes as primary topics of relation to the research question. They independently re-read transcripts and codified primary topics throughout, and amalgamated data on the themes. Definitions of themes were subsequently agreed upon. R.S., C.E., and F.S. coded half of the transcripts according to those definitions, and then recoded all subsequent transcripts. Definitions were refined on discussion throughout this process. R.S. re-read a random sample of transcripts to assess the construct validity of theme definitions. Categories of inter-related themes were developed independently by R.S., C.E., and F.S., with flow charts being employed to associate themes and categories. Horizontal analyses were used to group clusters of text thematically, and the repetition of analyses ensured bias was minimised, and no major themes were overlooked. As themes emerged, evidence that was potentially contradictory was sought and explored, and analysis was modified to take this into account.
RESULTS Four key categories emerged from the analysis, which will be separately discussed in subsequent sections: alliance as a key experience; active, not passive; taboo talking; and first impressions count.
Alliance as a Key Experience The development of a positive, working relationship with one’s key nurse was identified as a central aspect of treatment by almost all participants. Good or bad, the relationship with key nurses was often described as a reflection of the treatment experience as a whole: I think when I look back at past admissions, I can see that my relationship in key work was like, not like it is now. For me now, we are working so well together and I feel that in treatment elsewhere too, I feel more ready to tackle what I need to.
Participants also spoke of how their relationship with their key nurse was central to their perceived capacity to tackle the problems that arose during treatment: For me, I’d look forward to our [weekly] sessions, they generally came around like when my motivation was struggling, or like when I needed support, and I knew I could keep going because soon we’d have key work and talk it through.
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Difficulties and challenges often appear during the course of treatment for AN, and all participants noted that without a good relationship with their key nurse, these challenges could feel insurmountable:
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It’s hard, you know? It’s like, getting nearer and nearer to target [weight] you’re feeling worse and worse about yourself. There’s a lot to keep you going—family, goals, and all, but they’re not there all the time you know? But she [key nurse] is, pretty much, I always know she’s there for me at those times.
Indeed, having a poor relationship with their key nurse seemed to elucidate feelings of isolation and loneliness within service users who were experiencing negative emotions during treatment: We had no understanding, no relationship, so you know, I was on my own with it all, all the time, no one to really take things to, and in the end, I just thought “that’s it” I need to get out and go home you know?
Active, Not Passive The importance of an equal relationship—or a perceived equal relationship—between key nurses and participants was consistently reported. Participants identified the importance of being made to feel like they were actively involved in treatment, rather than a passive recipient of it: I think that being part of treatment, like, having a say about what I wanted to focus on first, and then working together on a plan based on our discussions, made me want to work harder with her.
Participants noted that particularly in the early stages of treatment they were in effect, passive recipients of treatment, but identified the importance of being treated as if they were actively involved whilst in key work sessions: At the start [of treatment] we can’t choose anything for ourselves, like meals, snacks, you know? Going out. But [nurses name] has always involved me, made me feel involved, even if I couldn’t do anything about it, and that helped, really helped for later on you know?
Approximately three quarters of participants talked about past experiences of key nurses with whom they had a relationship which was felt to be unbalanced. Some thought it was in terms of the key nurse being too domineering, [Nurses name], last admission, told me what to do, told me in no, in a way that gave me no choice, what I was going to do or needed to do.
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All I did from then was resist, fight her, even if she made sense, her way, her manner of talking to me just made me dig my heels in.
Or indeed, too passive:
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I was able, or my anorexia was able, I don’t know, but able to dominate them, just run the programme and [nurses name] was really nice and friendly and all, but couldn’t control it, me. I liked it at the time but it didn’t really work well did it?
“Good” therapeutic relationships were when neither patient nor key nurse dominated the other, but rather accepted and respected one another, and worked together in sharing the rigours of treatment. This included participants being able to tell the key nurse what they would like out of the key work sessions, and likewise being told by the key nurse what was expected of them: Give and take, absolutely. It felt like an even, like we were even in things. I told them what I found useful in challenging [eating disordered behaviours], I told them what I didn’t find useful, and they’d do the same—like what they expected of me and that, it was good.
Taboo Talking During the course of hospitalised treatment for AN, service users are generally expected to cease eating disordered behaviours. Participants identified using behaviours secretively, and not feeling that they could admit this to their key nurse as a key hurdle to recovery, and as decelerating the development of alliance: Once there’s a secret there, like between us, and it’s not admitted, I just continued and things just spiralled. It all becomes fake so quickly.
However, there was a strong trend identifying how key nurses who willingly sought to talk of these “treatment taboos” were more likely to be nurses that formed strong and effective therapeutic alliances: In key work, she’d start off, every session like, by asking what behaviours I was struggling with, the triggers and that. It made it easier to talk about my difficulties, and be honest when things went out of control.
Within this category was a dominant theme regarding the need for “straight talking” from the key nurse. Participants identified increased feelings of safety in a key nurse who was prepared to be firm in their conversations and interventions:
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At first I was like scared, because they were like telling me stuff I didn’t want to hear, but now, there’s a kind of safety in it, in knowing that no matter what, I can’t get away with stuff I would have in the past.
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This straight talking was only felt helpful if given in a supportive way, whilst maintaining a level of equality as previously discussed. Firm messages, when given outside the context of an equal relationship were seldom found to be helpful or useful: I think being spoken to honestly, firmly at times, is what I need. Just be straight and fair and I respond to that. With [nurses name], in my other treatment, she was always like “you have to do this or don’t do that or whatever,” but we never really discussed it you know? Explained why not. It just felt so unsupportive, although they were maybe trying, for me it wasn’t good, didn’t work at all.
First Impressions Count Participants identified that therapeutic alliance was mediated by the first impressions they had of their key nurse. Even how key nurses were dressed on initial meetings was deemed important: Nurses now, on the ward like, they look really smart, I don’t know, they used not to, they used to be much more casual you know? I just thought, it makes you feel more able to open up to them if they look like approachable, friendly, not if they look like staff, waiters and waitresses you know?
The first session spent between key nurse and participant also was identified as being important to setting the tone for the rest of treatment: I think you just know if you’re going to get along you know? Almost straightaways. You can tell if, how they’re going to be and it lets you either open up and talk or hang on and see.
But not everyone agreed with this: No, I think I’ve had like nurses before who I thought were just going to be bad you know, like straight away. But we couldn’t change and I think over time we got to a stage where she was like the one I’d always go to for time, for support and that.
What was almost universally agreed upon however, was the importance of how the first session was conducted. In participants’ views, a “good” session at the start of treatment was characterised by how little talking the key nurse did during that session:
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They let me tell them about me mostly, they took the time to understand my past and that, and what I found difficult before in treatment. They, looking back now, didn’t say a lot, but just asked questions, like I was important to them you know?
Conversely, “bad” initial sessions involved the key nurse taking an overly authoritarian stance:
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All they did, thinking now, is just talk at me. Told me what I couldn’t do, gave me rules, told me stuff like that, and I’m thinking like, hello, I’m here don’t you care? I’m not just another patient to give rules to, I need your help you know?
This first session paved the way for the development—or not—of good therapeutic alliance. Many participants spoke of a kind of momentum that built up in treatment, and traced this momentum back to the early stages of treatment with their key nurse: Looking at where I am now, you know, I look back to those times and wonder how I got here! It was just so hard you know to keep going, but I think she played such a strong part, really stable, and we just kept going, a bit at a time until, well, here.
DISCUSSION Past research into the role of therapeutic alliance when treating eating disorders have provided evidence which states it is both crucial (Sly et al., 2013), and difficult (Ramjan, 2004) to successfully achieve. The current study has elucidated several factors that from service user perspectives, are important in the development of positive alliance. The first theme to emerge—alliance as a key experience—supports the quantitative literature (e.g., Pereira et al, 2007; Sly et al, 2013) that identifies alliance as being a key aspect of treatment for AN. A “good” relationship seemed to signify treatment progressing in a positive manner, and a “poor” relationship reflected a lack of positive treatment progression. Clinical settings would be well advised to pay increased attention to supporting staff to develop the skills and frameworks needed to maximise the development of therapeutic alliance. The majority of participants stated that they felt they could tell if they were going to have a good relationship with their key nurse from very early on in treatment. This also fits with previous quantitative findings, in which response to the initial key work session proved to be predictive of treatment outcome (Sly et al., 2013). Many participants mentioned the importance
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of staff appearance in their initial impressions and subsequent decisions to engage with them. Staff who were dressed “too smart” were, in the eyes of the participants, less immediately approachable than those who were dressed more casually. In the treatment setting in which this study took place, staff do not wear uniforms, but immediately prior to the study, there was a policy shift to ensure staff were dressed in smart clothes in clinical areas. According to participants, this only served to highlight a “them and us” dynamic, creating a rather corporate, instead of therapeutic, atmosphere. First impressions extend to the initial meeting between key nurses and service users. Participants reported that a session in which they were allowed to take a leading role were more likely to leave them with positive impressions on the relationship they would forge with their key nurse. Allowing service users to, for example, talk of their past experiences and future expectations for treatment seemed to enforce in participants’ minds that they would be treated as individuals, and be at the centre of their care. In contrast, key nurses whose initial session is more rule-orientated and directive give the impression of treatment being more uniform, and elicits a negative response in service users. These factors are important considerations when delivering an initial session, which past research has indicated is key to future treatment progress (Sly et al., 2013). Nursing staff may benefit from increased support when planning initial sessions with service users, and given the importance of these sessions, may also benefit from structures being put in place to allow them to focus on these sessions. For example, nurses could be allocated some protected time prior to their meetings with service users, in which they could fully focus on preparing for the session. Following on from the initial session, participants reported that their response to treatment gathered its own momentum, for good or ill. This momentum seems to be dependent, according to participant reports, on being engaged in treatment in an active way, rather than just passively receiving treatment. There is a case to be made that how engaged service users become largely depends on their own motivation to engage, which is often low (Vitousek et al., 1998). However, in the data for the current study, a strong recurring theme was how important it was for key nurses to actively engage the participants in the treatment process. This was true even in aspects of treatment that service users had little say in, and participants reported that an approach that was collaborative allowed them to truly engage in what was expected from them. They spoke of the need for nurses to not be too domineering, and at the same time, to not allow service users to dominate them: a fine line to tread, without a doubt. In clinical practice, regular bi-directional appraisals between service users and key nurses would be advisable, during which both parties could reflect on the engagement process, and talk openly about what aspects of their relationship were working or not working particularly well.
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The final theme from the data bears a resemblance to the previous theme, in which key nurses are walking the line between giving too much and too little. The ability to “taboo talk,” addressing issues of treatment that service users initially may be unwilling to discuss, requires a straighttalking attitude on behalf of the nurse involved. Participants reported feeling a sense of relief at being able to talk about, for example the use of eating disordered behaviours whilst in treatment. Nurses that did not present as being open or accepting about such a topic would typically not be given the truth by the service user, and increased levels of deceit and deception would quickly follow, eroding the therapeutic process. The ability to portray a level of acceptance and openness to such treatment taboos were felt to be a key aspect of a “good” key nurse in the eyes of participants. However, that straight-talking attitude appears to be a difficult balancing act, with participants reporting that over-stepping the mark and doing it in a way that does not feel constructive is likely to result in a deceleration of the therapeutic process. This is another example of how difficult it can be at times for nurses and service users to get the balance right in their relationship, a finding which supports those of previous work in this field (Ramjan, 2004). Although this is a small study, the narrative accounts of participants support and extend the findings from both qualitative and quantitative studies into this area. The experiences described by this sample make it clear that the development of therapeutic alliance is a key component of treatment, and is a process fraught with difficulty. The role of the key nurse on an eating disorders unit requires many fine lines to be trod, and based on the testimony of the participants in this study, they run the risk of alienating service users if these lines are over or under stepped. It is also possible, due to the treatment-resistant nature of eating disorders, that “any excuse” to derail the therapeutic process will at times be sought by some service users. The role of the key nurse on an eating disorders unit is complex, with many potential pitfalls. There should be an increased emphasis placed on support for this role, such as the provision of protected time before sessions, and regular, high quality training and supervision sessions. The relationship between service user and key nurse should be routinely assessed by all parties, and additional support and intervention offered to help buffer against any difficulties. Although a difficult task, the current study supports past work, identifying this relationship as a key aspect of successful treatment for those with eating disorders.
REFERENCES Bamford, B., & Mountford, V. A. (2012). Cognitive behavioural therapy for individuals with longstanding anorexia nervosa: Adaptations, clinician survival and system issues. European Eating Disorders Review, 20, 49–59.
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