Meal Supervision and Support in an Eating Disorders Inpatient Program

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1 Meal Supervision and Support in an Eating Disorders Inpatient Program Rachel Barbara Eating Disorders Consultant Victorian Centre of Excellence in Eating Disorders Introduction Normalizing eating behaviour is a priority of treatment. Habit and conditioning are strong reinforces of eating-disordered behavioural patterns. Patients experience compelling drives to restrict their food repertoire or engage in eating rituals such as dicing food eating excessively slow or fast, hiding food, inappropriate mixing of food, and so on. Eating is a social activity for healthy individuals; however, those with an eating disorder often avoid social eating or food preparation. Teaching normal food preparation and social eating skills is, therefore, a critical focus of the program. pg308 Patients with eating disorders, who are underweight, have impaired control and choice resulting in great difficulty for the individual in changing their behaviour. The disordered behaviours, the effects of starvation and/or the binge-purge cycle perpetuate preoccupation with food and weight and dissatisfaction associated with body image. These factors not only perpetuate the impaired control and choice but will often exacerbate it. Successful treatment is usually intensive and requires the removal of stimuli that triggers the habitual eating response. This may include conditioned emotional responses to high calorie foods. Inpatient treatment that focuses on behavioural techniques to normalise eating behaviour have been demonstrated as effective The often incongruent goals between the patient and the treatment team pose particular challenges: - Progress in outpatient treatment can be difficult - The ambivalence the patient normally feels toward change means that the patient and clinician cannot develop a mutual goal of recovery and hence have a shared commitment towards the treatment. - The patient often enters the treatment process with little motivation to overcome the eating disorder but rather enters treatment with the goal of changing or controlling the physical, emotional and cognitive consequences. The fear of weight gain overrides the belief in the need to overcome the disorder. The experience of many clinicians involved in the care of these patients, is not of fighting the illness but of fighting with the person. Sir William Gull who provided one of the earliest clinical descriptions of anorexia, described this conundrum as a sparring match she was most loquacious and obstinate, anxious do overdo herself both mentally and physically (Gull, 1874) Although severely underweight patients with anorexia nervosa may recognise a need to gain weight, they fear that if they relinquish control over their intake, they will gain too much weight. Similarly, bulimic patients may be motivated to stop bingeing and vomiting but are opposed to

2 consuming binge foods in normal portions successful treatment requires consumption of a regular balanced and varied diet including risk foods, despite body dissatisfaction or desire to lose weight. Calorie restriction dieting, even for overweight patients with bulimia, is best delayed at least six months beyond remission of symptoms. (Guarda & Heinberg, pg 298) The patient maintaining her attempts to lose weight continue to trap her in the restraint-binge-purge cycle. The Cognitive Shift The cognitive shift required for successful recovery is so significant, for many if feels impossible. The patient needs to move from perceiving dieting as the answer to their problems to acknowledging that the behaviour is the primary cause of their poor health and poor functioning. In contrast, exploring hypothetical causes of the eating disorder or dieting behaviour in psychotherapy, although helpful in resolving underlying difficulties and providing a meaningful narrative to patients in the long term, is not equivalent to, and often not likely to bring about, any significant behavioural change. Once established, disordered eating maintains itself and becomes a way of life. To recover, patients need to acknowledge their behaviour, recognise its rewarding nature, and relinquish control over it. Given the polarity involved between the patient versus the team s goals, role induction and the building of a therapeutic alliance are of paramount importance for the newly admitted patient. (Guarda and Heinberg, pg 298) The Ward Milieu The environmental context of the inpatient setting often means that there needs to be an emphasis on Group therapy to avoid common complications often associated with individual therapy in a short stay inpatient program: refusal to talk in groups, becoming overly attached to the individual therapist leading to termination issues, and staff splitting. Motivation The level of motivation and stage of change is rarely considered in the decision making relating to whether to admit a patient to an inpatient program or not, hence it is not considered at the commencement of meal support. clinical observation indicates that motivation for recovery improves with successful treatment and behavioural change. Common Components of Treatment that may assist in Meal Support/Supervision 1. A uniformly applied behavioural protocol 2. Frequent multi-disciplinary team rounds 3. Nutritional rehabilitation, including weight restoration if underweight, and normalization of eating behaviour 4. Family involvement, mandatory in the case of adolescent patients 5. A minimum of three hours of group therapy daily 6. Relapse prevention and maintenance of healthy behaviours A Uniformly applied behaviour protocol All patients entering an inpatient program are placed on a uniformly applied behavioural protocol. There may be differences in the protocol depending on the goals of treatment for the patient for eg. Weight gain protocol as opposed to maintenance

3 and normalization protocol. The protocol will often involve nursing observation to block eating disorder behaviour. What is Meal Support and Supervision? Support: assisting the patient cope with difficult emotions, triggers and mood states associated with eating and motivate and support the patient in the achievement of their goals Supervision: monitoring, challenging and observing eating behaviours to assist the patient achieve compliance with the protocol. Assisting Patients progress through a hierarchy of structured tasks aimed at normalizing food intake, broadening food repertoire, and developing increasing mastery of normal eating behaviour. In the case of underweight patients, weight restoration to a BMI of 21, age-adjusted for individuals under 25 years of age is a third goal. Bulimic patients, whether normal or overweight, are prescribed a weight maintenance, 2,000 calorie diet. Patients are weighed daily but do not see their weights unless they are on weight maintenance and close to discharge. Similarly, they are not informed of their target weight until they have maintained in this range for at least a week, Is this too controlling and paternalistic? This approach can help in preventing excessive focus on weight gain and behavioural reactions to such information on a daily basis (e.g. arguing, attempting to negotiate lower weight. Once patients achieve independent maintenance of their weight, many report that they are thankful that choice was initially taken away from them and are able to recognize how their eating disorder controlled their autonomy, preventing them from making rational behavioural choices. Mealtime Guidelines To undertake effective meal support and supervision, it is recommended that you develop a set of uniform guidelines around eating and mealtimes, for eg. - All foods are served in normal meal combinations and amounts - Clear policy relating to food dislikes eg. No dislikes permitted or a limitation/boundary placed on dislikes. Some programs allow the patient to nominate 2 3 dislikes at the commencement of the program and these remain fixed through the length of treatment. No flexibility exists. - Patients are expected to complete their meal within a set time frame i.e. 45 minutes or 30 minutes. - Vegetarianism is observed only if the family can corroborate that this pattern of eating preceded onset of dieting or fear of fatness symptoms by three years (pg306) - Meal Support and Supervision is more often undertaken in a group setting, with patients eating together and nursing staff monitoring meals. - There needs to be an expected outcome, should patients not be able to complete the meal within the limitations of the protocol. For some programs there is an intervention in response to non-compliance, this may be the insertion of Naso-gastric Tube feeding or bolis feeding, modifications to meal plan to achieve target weight restoration. For other programs the group process is used, or more senior, recovery-motivated patients are encouraged to supportively confront non-compliance or disordered behaviours, where the group therapist will use other members of the group to act as role models.

4 Generating such peer pressure is extremely effective in getting patients to eat their meals. - Some programs like Banksia House where patients are expected to feed themselves and the use of NG feeding is not part of the protocol, the use of peers and group processes can assist the patient to achieve 100% compliance with the behaviour protocol within a short time of entering the program. Refer to existing guidelines used at your program Non-Food Related Behaviour Protocol - Between the hours of 8am and 10pm (eg only) patients are restricted to the day area in view of the nursing station, unless the program structure requires participation in groups or meals. - This allows the program to assist contain other problematic behaviours associated with the disorder, ie. to help block urges to exercise or purge. (pg306-7) - Bathroom use is supervised by nursing staff with regularly scheduled bathroom breaks every two hours. Nurses check the toilet before flushing. - Outside of the 8am 10pm time period, patients are allowed to move freely around the unit, spend time in their rooms, and use the bathroom unsupervised. - Once the patient is able to comply with the protocol, has stabilized medically, and gaining more than 1 kg per week, the behaviour protocol can be reviewed and consideration of less supervised meals is appropriate. - As normal eating behaviour is progressively achieved, relapse prevention is the emphasized and the treatment shifts to assisting the patient develop methods to cope with: 1. Dysphoric mood states and trigger situations 2. Independence over food selection 3. Return to the environment in which the patient was active in his or her eating disorder Exercise - Weight Gain protocol: calories are gradually reduced once at target weight, and exercise is introduced. Weight training rather than aerobic exercise is encouraged for patients with osteopenia or osteoporosis - Patients with Bulimia are permitted to exercise two to three hours a week. - All medically stable patients are encouraged to participate in a daily 30 minute walk with other patients and staff. Daily Meal Planning and Nutritional Rehabilitation - As the person nears recovery, they are expected to have enough control over their eating to be able to participate in daily meal planning and preparation groups. - This part of the program, can assist the patient to practice skills necessary for relapse prevention and eventual success in maintaining behaviour change - Meal groups are run by nursing and allied health staff and may include: menu planning, grocery shopping, cooking and social eating activities. Other Group Programs and Program Features that Can support and facilitate recovery and improve the success of meal support therapy

5 Structuring the program around meal times with group programs and therapy can assist the person through distraction and relaxation before and after meal times. Suggested Group Programs that can assist in the behaviour change, compliment meal support and ultimately aid the recovery process: - Behavioural Recovery Group - Meal Planning and Preparation - Body Image Group - Self esteem and skills training group - Family Issues Group - Psychoeducation Group - Nutrition Group - Discharge Planning and relapse prevention - Stretch and relaxation and yoga groups References: Angela S Guarda and Leslie J Heinberg, Chapter 15, Inpatient and Partial Hospital Approaches to the Treatment of Eating Disorders, From Eating Disorders pp BC Children s Hospital, Eating Disorders Program, Meal Support Therapy for Health Professionals, Vancouver BC Video and Supporting material

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