Introduction

Chapter 1: Defining Eating Disorders

Chapter 2: Soical Precipitants

Chapter 3: Psychological Precipitants

CHAPTER SEVEN TREATMENT

The treatment of eating disorder patients is multifaceted and complex.  Each patient must be viewed as an individual, with her own combination of precipitating factors based on information obtained from the assessment interview and adjunctive diagnostic tests, if used.  An eating disorder is a psychological disturbance, yet one that causes extensive physiological problems.  Both must be treated.  And if the physical problems are debilitating, they must be the primary focus before psychotherapy can be effective.

A decade or two ago, many inpatient programs were developed to specifically treat eating disorders.  However, very few still remain, primarily due to the lack of reimbursement by insurance companies.  For this reason, it is important to manage the treatment program as much as possible on an outpatient basis.  Inpatient treatment now would mean admission to a general psychiatric unit, or possibly a medical unit if treatment involved re-feeding by nasogastric tube or IV.

A cognitive-behavioral approach to therapy appears to produce the best results (Garfinkel and Kennedy, 1992).  While the patient is beginning to understand the reasons for her behavior, she must also be changing the behavior, replacing it with more appropriate and effective methods.  Many studies support this approach with documented improvements.  The literature on cognitive-behavioral treatment up to 1985 estimates that 40% of patients were no longer bingeing by the end of treatment, 30% had a reduction in symptoms of at least 50% and the remaining 30% showed little improvement (Garfinkel and Kennedy, 1992).

Studies of the benefits of interpersonal therapy indicate similar success rates.  Many therapists chose a combination of cognitive-behavioral and interpersonal psychotherapy approaches.  Group therapy is also seen as beneficial for treating bulimic patients (Garfinkel and Kennedy, 1992: Herzog, 1992).  And family therapy would be important for the patient who lives with her family of origin.

Group therapy may not be as helpful for the anorexic patient as the bulimic patient.  The competitive and perfectionistic qualities of anorexic patients often lead them to compete for thinness or severity of symptoms in a group environment.  The bulimic patient, however, often feels relieved to see that other people have the same problem, and thus the group provides a more positive support mechanism.

The various elements of a cognitive-behavioral treatment approach are outlined below.

COGNITIVE-BEHAVIORAL TREATMENT

Goal Weight
Insurance company tables for normal weight should be avoided in this process.  They do not take into consideration realistic variations in individual body types, based on genetics, activity level and overall health and well-being.  As stated earlier, thinness is a national obsession, and in establishing a goal weight for a patient, the patient must be assisted to steer away from this cultural pressure.  Rather than establishing an exact weight, it is recommended to assist the patient to find the weight at which she is comfortable and which does not require chronic dieting to maintain.  According to set point theory, patients will probably initially gain more weight than they will actually keep, before their weight settles at a level where the body is comfortable and operating at optimum health.

This idea terrifies most eating disorder patients, who will often say that they would rather die than to gain weight.  It is important to inform the bulimic patient, who is frequently sabotaging her efforts to lose weight by her binge-purge behavior, that upon resumption of normal eating she may even settle at a lower weight because of the metabolic paradoxes mentioned earlier in this study.  This is a very difficult concept for patients to accept.  Any success stories or examples from a patient population would be helpful to establish trust in this idea.

The patient should be discouraged from weighing herself at home.  Patients with an eating disorder will often weigh themselves several times a day, and adjust their eating and exercise accordingly.  If it is a necessary part of the treatment plan to monitor weight, or if the patient insists that she continue to weigh herself, it is best handled by the therapist, on a once a week basis (Garner et al, 1985).  Patients may even be encouraged to give their scale to the therapist.  This way any anxieties that arise over weight gain can be dealt with in the therapy session.

Normal Eating
It is imperative to help the patient establish a pattern of normal eating.  Many patients who have been dieting since puberty have no idea what this is.  Ellyn Satter (1987) describes normal eating as follows:
Normal eating is being able to eat when you are hungry and continue eating until you are satisfied.  It is being able to choose food you like and eat it and truly get enough of it – not just stop eating because you think you should.  Normal eating is being able to use some moderate constraint in your food selection to get the right food, but not being so restrictive that you miss out on pleasurable foods.  Normal eating is giving yourself permission to eat sometimes because you are happy, sad or bored, or just because it feels good.  Normal eating is three meals a day, most of the time, but it can also be choosing to munch along.  It is leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful when they are fresh.  Normal eating is overeating at times:  feeling stuffed and uncomfortable.  It is also under-eating at times and wishing you had more.  Normal eating is trusting your body to make up for your mistakes in eating.  Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.

In short, normal eating is flexible.  It varies in response to your emotions, your schedule, your hunger and your proximity to food.

The key to normal eating is flexibility (Satter, 1987).  An important part of therapy is to help the patient to become more in touch with her internal signals.  Eating disorder patients have lost the ability to assess hunger and satiety.  If the patient begins to listen to her body’s messages regarding when and what and how much it wants to eat, food will be eaten in normal and varying amounts, not gross amounts as the eating disorder patient would suspect.  Because this individual has denied herself for so long, she is terrified of responding to her body’s cravings because that could mean losing total control and eating monstrous amounts of food.  She needs to learn, and come to believe through her experience, that she can trust her own body to know when to stop and it is satisfied.  And the more she responds to her body’s needs, the more easily it becomes satisfied with smaller amounts of food. 

All foods are permissible.  There is no such thing as a bad food.  The patient does not necessarily need to sit down to a meal including the proper amounts of the four food groups.  She need only eat what she feels like, when she feels like it.  Amazingly, the cravings and bingeing will cease when she gives herself this permission.  Food ceases to be the focus of her day, as it was when she was depriving herself.

Exercise
Exercise is an important part of treatment, but will need to be redefined.  The anorexic who is accustomed to overly vigorous compulsive exercise will need to be discouraged from continuing this pace during treatment, since it will be important for her to gain weight.  However, a minimal amount of body movement is beneficial.  Exercise allows the new weight to be more evenly distributed, thus preventing the patient from panicking over her changed body.  Minimal exercise such as stretching and walking are good initially.  When the patient shows a good pattern of weight gain, a somewhat more vigorous exercise in permissible.   This should be something enjoyable, not a cardio workout or maximum fat burning as in aerobics.  A redefinition of physical exercise and sports for pleasure should be emphasized.  Likewise, bulimic patients should be encouraged to become more in touch with their body through some type of movement and physical exercise for the sake of pleasure.

Pleasurable physical activity is beneficial for reducing stress, allowing oneself free time, improving strength and self-esteem, socializing and overall good health.  It needs to be reframed in this manner and away from the compulsive weight loss, fat burning focus which has become so popular.

Abstinence Verses Non-abstinence
There are different schools of thought on this subject.  Most professionals agree that the patient must be made aware that to continue the dieting, bingeing and purging behavior are incongruous with recovery.  They should be encouraged to abstain.  However, relapses will occur and when they do the therapist must help the patient to deal with her feelings of guilt, shame and failure so that she can continue in treatment and not completely give way to her food behavior again.  It is always good to remember the all-or-none thinking of these patients and not to reinforce this through a too rigid requirement to abstain.  The therapist can help the patient to learn that life for most people includes this kind of up and down from day to day, and that it can be survived and is okay.  Reinforce the idea that normal eating sometimes means eating more than you really need and that’s okay.  Each day is a new beginning and not a failure.

Insisting on abstinence as a prerequisite for treatment would prevent most eating disorder patients from ever getting the help they need.  And it would be applying the same type of rigidity towards their eating behavior that they already employ.

Prevention of Bingeing and Purging

It has been found that patients tend to binge eat often as a result of depression, anxiety or stress.  However, this has been found an unlikely response in non-dieting individuals.  The patient’s craving for certain foods and the resultant binge are a natural outcome of her feeling deprived through rigorous dieting. And because eating disorder patients have not learned how to handle stress in more positive, outcomes-oriented ways, filling themselves up with “forbidden” foods is a temporary comforting measure.

Therefore, two important areas of focus in the pre-binge state are: 1) to help the patient give up dieting and establish a normal eating pattern, and 2) to help her to learn to deal with stress in a more positive manner, which will be discussed under psychotherapy.

The patient will, at first, require much assistance in establishing a normal pattern of eating.  Allowing the patient too much freedom initially is dangerous as it will increase her stress and confusion and the patient is likely to relapse.  Certain methods can be employed to help the patient begin to understand what normal eating is, and this can then be reviewed in each session with the therapist.  In a hospital setting, re-establishment of normal eating can happen rather quickly because of the daily, and sometimes meal-by-meal, therapy the patient receives.  On an outpatient basis the progress will be slower, but the outcome still achievable.

Meal planning – Meal planning involves building some structure into the patient’s pattern of eating.  This will involve quantity and quality of food, as well as appropriate spacing of meals throughout the day.  The therapist can help the patient establish a normal diet.  This may seem as rigid as the anorexic’s starvation routine, however this kind of structure is necessary initially for these patients who have gotten completely out of touch with their body’s signals, and will not know how to develop a normal diet.  The goal is that eventually this becomes a process that the patient regulates based on her own body’s needs and signals.

The amount of calories prescribed will depend upon the patient’s weight, metabolic conditions and the patient’s tolerance for change.  The important thing is that it be consistent.  The number of calories can be adjusted weekly to promote a gain of approximately one to two pounds per week (Garner et al).  The therapist may want to use instead of calorie counting, the basic four food groups as a guide, or even the size of the meal so that she begins to develop a sense of what a normal meal looks like.  The important thing is that the patient feels satisfied and not hungry.  The urge to binge is far less compelling if an adequate amount of all kinds of food can legitimately be consumed on a daily basis.  And to reiterate an earlier point, the patients who are used to starving, bingeing and purging will be surprised to find that they gain little or no weight as a result of normal eating.

The patient should be encouraged to incorporate small amounts of her “forbidden” foods into her daily diet, and that this does not indicate a “blown diet” or out on control behavior.  By making these foods a part of her normal diet, the stigma of good or bad foods is dropped, and likewise the emotional attachment to them.  Individuals who feel they can have cookies any time they want will rarely binge on the entire bag.  Connars and Johnson state that “the best defense against binge eating is to eat”.

Meal planning also involves putting thought into a meal and preparing and eating it with care, rather than rushing in the door from work and quickly grabbing something to binge on.  A suggestion is to prepare a meal with different courses, set the table beautifully, even if the patient lives alone, light candles, put on music and focus on the meal so that it can be fully enjoyed, rather than distracting with T.V..  Turn meals into a process rather than a quick fix.

Meal spacing is an important concept to teach the patient.  Most anorexic and bulimic patients tend to starve themselves all day in hopes of successfully making it through the day without eating.  The result is that by evening their hunger is all-consuming during the most unstructured time of the day.  It is easy for eating to become out of control under these conditions.  The patient should be encouraged to eat three to four times per day (Garner et al).  In the beginning this may seem rigid to the patient, but eventually she will learn when she is hungry and needs to eat, and self-regulation will let the individual know when and what to eat.

Naturally the patient will be overwhelmed by this initially.  She will fear gaining an inordinate amount of weight.  However, once again, refer to the body’s amazing metabolic adjustments.  Consuming more calories spread evenly throughout the day actually results in a higher metabolism.  Garner et al state that “more calories are burned by frequent stoking of the furnace with fuel”.

Record keeping – Keeping a written diary of meals is a good way for the patient to visibly see what a normal diet might consist of, as well as to record the situations and emotions that surround her eating.  These tools allow the patient to write what might have provoked a negative eating behavior, or even how she feels about eating a normal meal.  Is it frightening, rewarding, shameful or liberating?  How did the patient feel before, during and after a meal?  This provides a good forum for discussion at weekly sessions with the therapist.  This provides the fuel for the psychotherapy sessions which will help the patient to begin to understand her behavior and make necessary changes.

Interruption at the pre-binge stage – A result of the self-monitoring mentioned above is that the patient will begin to identify the situations which increase her pressure to binge.  Certain strategies can be employed to help break the cycle at this point.  They are distraction, delay and parroting, or affirmations.

Bingeing and purging are impulsive behaviors.  If the patient can at first distract herself from the situation for a few moments, she has a chance of over-riding the impulse and learning new ways to cope with stress.  This distraction must be pleasurable and may need only last a few moments to be effective.  Going for a walk, phoning a friend or putting on loud music and dancing around the room are possible suggestions.

Delay is another helpful method to break the cycle.  The patient can tell herself she can only binge after she reads three pages of a novel, hits the tennis ball against the garage door for fifteen minutes or some other measured activity.  The patient may find that delaying the impulse gets rid of it altogether.  Both distractions and delays should be planned beforehand with the therapist, and even written down so that the patient can easily refer to them when the impulse strikes.  The impulse to binge can be so strong that patients are unable to think about anything else at the time.

Parroting phrases, or affirmations, should also be written down and recited by the patient to herself on a daily basis and especially when the impulse to binge or purge arises.   Examples of affirmations are “I can eat any food I like, any time I like and not gain weight”, “I am a valuable person and I treat my body well”.  The therapist will need to help the patient develop phrases that are meaningful to her, as she will be at loss to create such positive statements about her body or food.

Identifying Mood States
After the patient has kept her food diary for awhile and practiced delaying the impulse to binge and purge, she will begin to be able to identify her emotions more easily.  Previously, the food-related behavior would defuse the emotions before they could even be examined, and the emotions would be turned into feelings about her eating behavior or her body instead.  The eating behavior prevented the patient from dealing with any real issues. Now the patient has an opportunity to identify her emotional states, to recognize what her true needs are and to find ways to satisfy them or work through them in a healthy way.  Is she lonely, angry, hurt, anxious?  About what, whom?  What can she do to actually change the situation, or to effectively relieve the feelings?  Call a friend, punch a pillow, take a bubble bath, go for a long walk?  This will be a painfully demanding task for these patients who have successfully avoided dealing with uncomfortable emotional states through food related behavior.
There are certain recurring emotional themes that make patients particularly vulnerable to bingeing:
Anger – This is an emotion that bulimic patients have particular difficulty with.  They are extremely fearful of losing control and also fearful of the consequences of expressing this emotion.  Such responses as disapproval, rejection or retaliation from others are terrifying.  Thus the patient stuffs the feelings with food, and ends up feeling angry at herself for her bingeing, thus diffusing her real emotions.  These patients have learned to be self-abdicating, and thus require assistance to change their behavior to one of acceptance for their angry feelings, recognizing these feelings as a signal that something is wrong and learning to assertively deal with the problem.  The self-esteem gained from this helps a great deal in the prevention of bingeing behavior.

Perfectionism/Pressure to accomplish – Many eating disorder patients have difficulty with alone time because of a constant nagging need to accomplish things.  Left alone with their own thoughts they will come up with a thousand projects that need to be done.  This pressure is so great that bingeing is often the only escape they have from a perceived “duty”, and in that it provides relief.  The therapist can help the patient by giving her permission to be lazy, perhaps to take 30 minutes per day where she does absolutely nothing useful or redeeming in any way – watch a silly T.V. show, take a nap, lie in the sun, anything that is not an accomplishment and gives the patient a break from responsibility.

Self-nurturance – Because of the above mentioned pressure towards responsibility, eating disorder patients often feel empty and drained.  Food may be the only means by which they feel nurtured.  Taken in an impulsive way, they later feel guilty about it because they have so much difficulty actually giving to themselves.  These patients have learned that it is selfish to indulge in their own needs.  The therapist can help the patient to find ways to indulge herself, in small ways at first so that she can become comfortable with this practice.  Such things as buying herself flowers, getting a manicure and eventually even working up to something as indulgent as a massage are all ways the patient can begin to give to herself so that food is not her only source of nurturance.

Problem solving – The perfectionistic and obsessive qualities of eating disorder patients can make the activity of problem solving so overwhelming that the patient becomes immobilized in her procrastination and indecisiveness.  Her all-or-none thinking leads her to believe that unless she makes the “right” decision, catastrophe will follow.  Hence, a binge, to avoid this most difficult of tasks.  The therapist can help the patient learn basic problem-solving skills, such as making a list of pros and cons, identifying what the patient wants versus what she perceives others want and to understand that most decisions are not irrevocable, but can be revisited if the outcome is not satisfactory.  And, there are no “mistakes’ in making a decision based on information at the time.  Life is static, not stagnant, situations change and so can the decisions which affect them.

Absence of social support – Many eating disorder patients will state they feel lonely; however, it is often self-created.  So conscious of the opinions of others, they will not divulge true feelings to others and will avoid people when they feel depressed or hurt, the times when friends are needed most.

Once again they turn to food as their sole support.  Again, the patient must be reminded that feelings are okay, nobody is perfect, everyone has problems and that’s what true friends are for, to be there no matter what.  The patient can be encouraged to risk this kind of disclosure on an emotional state or situation that is not a particularly sensitive matter.  She can assess the response of the person she shared with to see if they might be able to tolerate more important issues at another time.  She will be able to see that she did not crumble from the experience, and she will also begin to know which friends can be taken into confidence, and which friends are purely social.

Breaking the Postbinge Cycle
It is the patient’s compulsive all-or-none thinking that will keep her trapped in the vicious binge-purge cycle.  Recovery from an eating disorder is not a linear event, i.e. once the patient starts therapy she will never binge again.  There will be many relapses, many stops and starts and gradually there will be many more symptom-free days than days of bingeing and purging.

When the patient does relapse and experiences a binge, she can still at this point avoid the addictive cycle.  Unfortunately, the kind of thinking she has about this experience can send her spiraling further and further along in the behavior.  Common reactions to a relapse are, “I’ve blown it, I might as well keep bingeing all day”, or “Now I’m not going to eat for another three days”, or “I’ll vomit and take twenty laxatives and run five miles”, or any other combination of self-defeating behaviors.  Hopelessness and shame are common emotions that can be debilitating.

Instead of falling victim to this entrapping cycle, the patient should continue the next meal exactly as planned.  Once again, this is the greatest insurance against a future binge.  It breaks the cycle.  The patient will soon discover that disaster has not befallen her because she binged, and eventually her ability to self-regulate will eliminate the need to binge.

As with preventing the binge, similar techniques can be employed in the postbinge state to prevent purging.  Distraction, delaying the purge by 45 minutes and talking to a supportive friend can often diffuse the need to purge.

When a relapse occurs the therapist can help the patient to learn from the experience by identifying the precipitant and discuss ways that it might better have been dealt with.  The patient is also to be given credit for her binge-free period, and help her to note progress during this time when she will see nothing but hopelessness and despair.

Setting Behavioral Goals
Patients will need help in establishing goals that are meaningful, but at the same time not so unrealistic as to insure failure.  In characteristic perfectionism a patient might say her goal is to abstain from bingeing for one week.  In the initial phase of treatment this is a difficult task and a blow to the patient’s self-esteem if not met.  Perhaps a goal such as eating one normal meal per day is a reasonable first step, one that has a good chance of providing success and thus increasing the patient’s sense of self-mastery.  The therapist must help the patient to acknowledge any small success, as the patient will minimize these, not seeing them as enough progress made.  The patient’s all-or-none thinking can sabotage her goals if she is not supported and encouraged along the way through each small achievement.

Psychotherapy
An important task for the anorexic in psychotherapy is to discover a sense of self, a true identity separate from that which is dictated by her parents.  Clinical staff should avoid “interpretations” of the patient’s feelings, which reinforce her sense of inadequacy and dependence.  Psychoanalytic interpretation mimics her home environment, where family members speak for other family members, interpreting and invalidating one another’s thoughts and feelings.

In psychotherapy the patient should be allowed to uncover her abilities and resources for thinking, feeling and acting.  She must learn that she does not need to be perfect and always pleasing others, but that she can take control of her own life and begin to do what she wants.

Involving the patient as much as possible in her treatment is a way of letting her feel she has some control.  She can identify her goals for treatment and monitor her progress.

Since particular incidents can send a bulimic patient right into a binge, the therapist must assist her in identifying her “red flag” issues, and developing more positive problem-solving strategies.  These red flags can be people or situations which make her feel rejected, defeated or incompetent.

Like anorexics, the bulimic patient must learn to better communicate her needs and to stop accommodating others.  She must learn to be assertive and to appropriately express anger.  She must be confronted each time she interprets what she thinks others are thinking of her.  Since bulimics tend to focus on past failures or future tragedies, it is imperative to help them focus on the present, the reality at hand and how to deal with it.

The bulimic needs to learn it is all right not to be perfect.  In goal-setting she should avoid setting herself up for failure with goals such as “I’ll never binge again”.  Something like “I will try today to ask for help if I need it”, or “I will do my best today to talk in group”, are more likely to provide her with success.  She must learn to reward herself for any small success, rather than berate herself for not meeting goals.  Goals should reflect a commitment to trying, not to perfection.

The bulimic woman needs to redefine the feminine role from one of total abdication to others, particularly men, to one of strength, independence and capability.  In a group setting the therapist can promote a strong sense of “sisterhood” among the members, thus increasing self-esteem as women.

Since the bulimic tends to use binge-purge behavior as a way to avoid anxiety and pain, the therapist can help her learn to use painful thoughts and feelings as a catalyst for growth and change.

Pharmacotherapy
Controlled trials of antidepressants have found a significant reduction in the frequency of behaviors associated with bulimia (Garfinkel and Kennedy, 1992).  Interestingly, these medications have appeared to be as effective in treating bulimic patients who are non-depressed as well as those who are depressed.  For this reason, it is proposed that the mechanism of action may not be antidepressant, but instead may affect the neurotransmitters, such as serotonin and norepinephrine, involved in the regulation of eating (Garfinkel and Kennedy).

In the treatment of anorexia nervosa, antidepressants, antipsychotics and antianxiety medications may be used.  The benefits of these pharmacological agents are not as well documented as for bulimia (Garfinkel and Kennedy).

When Hospitalization is Necessary
In many cases anorexics and bulimics can be treated as outpatients.  However, if the illness becomes debilitating, either emotionally or physically, the person must be hospitalized.  The following are criteria for inpatient treatment:

• Significant weight loss
• Metabolic abnormalities, especially hypokalemic alkalosis from bulimic complications
• Lowered mood; thoughts or intents of suicide
• Non-responsiveness to outpatient treatment
• Demoralized, nonfunctioning family (for the patient living with family of origin)
• Lack of outpatient facilities (Brownell, 1986)

Before psychotherapeutic methods can be employed, it is first necessary to bring the patient’s weight up to where normal psychological functioning can take place.  In severe cachectic conditions, the body is in a toxic state which maintains an abnormal mental status.

The critical weight level is related to the height and body build of the patient and is generally felt to be around 90 to 95 pounds (Bruch, 1978).  In extreme cachexia, bed rest may be required, along with intravenous fluid therapy, nasogastric tube feedings or hyperalimentation therapy.  Solid food should be offered at the same time in order to retrain the patient to eat.

The patient should be watched closely for turning off the electronic infusion device.  At this stage she is extremely angry about being “force-fed” and frightened about gaining weight.  These patients are very manipulative and will do almost anything to sabotage their nutritional therapy.

This practice of giving back nutrition to the patient is a sensitive one.  If her life is endangered due to her physical status, care givers must proceed with nutritional therapy, despite her protests.  However, it must be done in such a way that her overall therapy program is not jeopardized due to control issues.  It is important to deal with this type of nutritional therapy with empathy and warmth.  It is also imperative not to succumb to the patient’s pleas to stop, nor to become angry and dictatorial.  It should be remembered that this patient is extremely sick, both mentally and physically.  The efforts to feed her are saving her life and must be carried out in a calm, caring and non-judgmental manner.  An appropriate way for the care giver to deal with the patient’s feelings at this time would be to simply validate them by repeating back to her what she is saying.  Saying something like “It sounds like you’re really angry with me”, or “I know you’re afraid of gaining weight”, is more effective than getting into a verbal struggle.  Her attitude may improve once she has been given the proper nutrients.

Different institutions and physicians will have their own parameters for when a patient can discontinue this type of re-feeding with bed rest, and begin minimal ambulation on the unit.  From minimal ambulation, such as getting up to the bathroom or walking in her room, she may progress to stretching and walking exercises.  Not until she has progressed significantly in her treatment program, with an acceptable weight gain, will she be allowed to engage in any vigorous exercise.  A moderate exercise program is helpful in distributing the new weight evenly over her body.  It is important that the weight gain not be so dramatic that the patient panic and return to her former habits.

Nursing Implications in Clinical Treatment
The nurse plays an important role in the successful hospitalization of eating disorder patients.  It is imperative to foster a trusting relationship and establish honest communication.  With this kind of relationship the nurse can recognize and acknowledge any slight distortions or misinterpretations in the patient’s thinking.  Good listening skills and responding with sensitive validation will give the patient something she has been deprived of throughout her development.  These patients should always be approached with empathy and warmth.

Since patients with eating disorders are manipulative and tend to split staff, it is important for the staff to be cohesive with each other and consistent in the way they interact with the patient.  These patients invariably incite anger and frustration among the nursing staff.  In order for nurses to effectively care for these difficult patients, there must be a staff support meeting where nurses can express their feelings and receive support from their peers.

Nurses are responsible for monitoring behavior, weight, vital signs, physical activity and nutritional rehabilitation.  The nurse may need to assist the patient with choosing a menu as anorexic patients can spend hours doing this and still end up with nothing.  It may be necessary for a nurse to be with a patient while she eats and for a period of time afterwards, to insure against starvation or binge-purge behavior.

A nurse can help her patient discover new interests, particularly those she can become involved in during hospitalization.  The nurse can help her explore ways she can treat herself well and have her make it a goal to do so once a day.  This can be an activity such as taking a long hot bubble bath, buying flowers for herself or spending time reading her favorite magazine.  The idea is to do something for herself which has nothing to do with anyone else’s expectations or needs.

Patients should set up goals for the entire hospitalization, as well as daily goals.  The nurse can assist the patient in identifying these goals and in prioritizing them, so that she only takes on what can reasonably be accomplished in a day.  This will prevent the inevitable feeling of failure when she has taken on too much and cannot accomplish it all.

A nurse may confront a patient with her unhealthy eating behavior if it is noticed.  You cannot force a patient to stop bingeing or purging, however you can bring it to her attention by “naming” the behavior when you see it.  Continual confrontation and honesty from the staff is imperative for the patient to stop denying the existence of the problem and to make the decision to change.

Nurses must always remember, it is the patient who is responsible for her behavior.  A power struggle will only result in both parties losing.  Through honest, empathic communication, nursing staff can help these patients to help themselves.

Next: OUTCOME OF TREATMENT