Inpatient Treatment for Anorexia Nervosa

When patients receiving inpatient care for AN are labeled as treatment-resistant, it may be possible that they have not had treatment suited to their unique needs. This was one conclusion from a recent study by Dr. Rebekah Rankin and colleagues at Western Sydney University School of Medicine, Sydney, Australia (J Eat Disord. 2023. 11:95). The researchers examined the lived experiences of inpatients through a systematic review of 11 studies involving 159 participants (156 females, 3 males) 12 to 45 years of age.

Four major themes emerged from their research: (1) patients felt there was no such thing as individualized treatment; (2) patients described the often-restrictive setting of inpatient treatment as “living in a bubble,” (3) patients described the impact of meeting others with AN and the downside of comparisons, and (4) patients wanted to be viewed by clinical staff as more than ‘just another anorexic.’

Theme 1: Lack of individualized treatment

When an individual first enters an impatient treatment facility, the emphasis is naturally on weight loss and its associated health complications. Because of this, the emphasis is naturally on addressing the physiologic symptoms of the eating disorder. In 7 studies, the participants were disappointed with this nearly exclusive emphasis on physiologic rehabilitation at the cost of psychological wellbeing. Individual values and identity, and treatment goals were important to most patients, particularly soon after admission. In a study by Colton and Pistrang, for example, participants felt that the main goal of their inpatient treatment was to “fatten them up” and restore weight instead of working with psychological recovery and wellbeing (Eur Eat Disord Rev. 2004. 12:307). In other studies patients engaged in acts of resistance to preserve their identity.

Theme 2: ‘Living in a bubble’

According to patients, the highly regimented schedules and the inpatient treatment setting acted to separate them from normal external experiences. Most participants had a sense of ambivalence about the inpatient setting. On the one hand it made them feel “stuck” and unable to get out, but on the other it gave them a “safe space” and a “safety bubble” that protected them from the outside world and acted as safe haven. The restrictive setting also removed chances to use unhealthful behaviors associated with their eating disorder.

Theme 3: Living with others and with a ‘similar demon’

Inpatients being treated for AN live in a similar environment. According to the authors, for many patients this is often the first time they have met or interacted with other people with an eating disorder. This often helps normalize and validate their experience, helps them learn new coping skills, and gives hope for recovery. One downside is that the eating disorder can also be triggered by the close proximity of other patients, and an inpatient can watch others’ progress, appearance, and everyday practices. Patients at different stages of recovery can also stir the distress associated with comparisons with other patients.

Theme 4: ‘I am not just another anorexic’

Study participants stressed the importance for healthcare professionals and treatment teams to see them as individuals, not as just another case of AN. They mentioned that too many staff members were too busy, with not enough time to listen or to care about what they did, just as long as they complied with treatment. Their feelings about not being understood by clinical staff members seemed to encourage a climate of resistance. In contrast, when they felt seen and acknowledged as individuals, inpatients were more likely to participate in recovery-oriented behavior and to seek help more readily and easily.

During inpatient treatment, patients often live away from home for several weeks or months. They typically go through several transitions of treatment: reconciling with the AN diagnosis and understanding that they needed medical intervention; adjusting to treatment and the treatment environment, and reflecting on and integrating the experience. Most patients had positive and negative feelings about their experiences. Readiness for change was another important element. Some had to select whether they were willing to let go of the eating disorder to collaborate in treatment. Ironically, in the group of those wanting to get better and to let go of their eating disorder, some temporarily acted as perfect obedient patients yielding to the clinical team. The authors noted that participants’ values, treatment goals, and connections to their identity outside the eating disorder diagnosis also appeared to have an impact on how participants viewed their diagnosis and treatment.

Whether a patient engaged in inpatient treatment was not just a matter of a patient agreeing to stop using a set of unhealthful behaviors but the consideration of identity, values, and purpose outside the eating disorder, Thus, factors separate from treatment, such as life events, personal values, self-reflection, life goals, and a personal understanding of AN as a disorder are likely to influence individual motivation for change (Aust Psychol. 2023. 58:1; Int J Eat Disord. 2013. 46:482).

An important role for clinical staff members

Clinical staff members were critically important in the formation of patients’ experiences. When patients were seen as individuals and more than just another case of AN, they were more likely to use recovery-oriented behaviors. The ability of staff members to “hold hope” for an individual patient’s recovery seems to help strengthen patient motivation and a connection to sense of self or identity as someone other than a person with an eating disorder.

The authors suggest that adopting person-centered and recovery-oriented treatment approaches that stress patient safety and autonomy will be more successful when it is balanced with both the physiologic and psychological needs of the individual.