The two preliminary research questions are intended to set the context for the main research question. They will be addressed using quantitative measures.
1. How do young people with AN perceive their stage of, and readiness for, change? 2. How do they perceive the eating disorder unit, in terms of ward atmosphere,
satisfaction with, and overall helpfulness of, the unit?
Main Research Question
This research question will be addressed using a qualitative approach.
How do young people with AN experience their treatment on in-patient, specialist eating disorder units?
CHAPTER 2 ~ M ETHOD
OVERVIEW
Semi-structured interviews were conducted with 19 adolescents receiving in-patient treatment for anorexia nervosa. Interpretative Phenomenological Analysis (IPA) was used to analyse the data. This chapter has five main sections. The first will describe the setting in which the research took place, the second, ethical considerations, the third, participants, the fourth, measures used and the fifth, analysis of the qualitative data.
TH E SETTING
As the patient turn over on adolescent eating disorder units is small and each eating disorder unit has on average 10 beds, there were two units from which participants were recruited. Both units were regional NHS units, but both took out of area referrals. To ensure confidentiality they shall be referred to as Unit 1 and Unit 2. Further, in accordance with the conditions upon which permission for this study was given, no comparisons between the units will be drawn.
Adolescent eating disorder units in general are more like therapeutic communities than hospitals, with the unit generally becoming the patient’s home for a minimum of three months, but more often about six months. Typically they have around ten beds each and
Chapter Two ~ Method
are self-contained. Adolescents eligible for admission to in-patient eating disorder units are usually aged between twelve and eighteen, have lost a large amount of weight and are seriously emaciated, often showing the physical complications of starvation, although admission criteria vary between units. AN is the most common reason for admission, but patients with severe bulimia and pervasive refusal are also sometimes admitted. Although weight restoration is a major treatment goal, individual and family therapy is viewed as an essential component, in order to help the adolescent and their family understand why the anorexia developed and to think about relapse prevention.
The basic components of the treatment offered by the two units were similar, but the units had a different ethos thus emphasising different treatment components. Both units have a school and so patients attend school, with breaks for meals / snacks and which can be interrupted for therapy. On both of the units daily exercise was included and patients had individual cognitive therapy weekly, and family therapy at least fortnightly. Unit 2 offered art therapy which was optional, and Unit 1 included compulsory motivation enhancement therapy. One difference in the treatment regimes of the two units was in the slightly different meal regimes: for example on Unit 1, patients ate three meals a day. On Unit 2, patients ate three meals and three snacks each day. In addition Unit 1 used naso gastric feeding as a means of re-feeding patients less often than did Unit 2.
Information about the ethos of the two units was gathered from discussions with the respective consultant psychiatrists and nursing teams, and the ethos differed more significantly than did the treatment regimes. Unit Us ethos was collaborative and patients
were involved in decisions about their treatment, for example as to by how many calories their diet plan increased each week. Despite the collaboration between staff and patients, no debate was permitted about whether patients completed meals, and naturally the ultimate treatment decisions lay with the medical and nursing team. From admission, patients were involved in a strong programme of rehabilitation, which included liaison with their schools, frequent contact with their friends and regular family meals. The maximum length of stay allowed was 6 months, and if this meant that re-admission would be required at a later date, then discharge nonetheless occurred. The rationale for this was to try to prevent patients from viewing and choosing the unit as their home, and thereby becoming ‘stuck’, avoiding discharge (consciously or otherwise) for long time periods.
The culture of Unit 2 was a less collaborative and less lenient one than Unit 1 and patients were less autonomous. Rehabilitation began at a later stage on Unit 2, as patients were not allowed to go home, even for one day until they had reached a certain weight for height. There was no maximum length of stay on Unit 2, and, indeed, many patients had been there for around 9 months.
ETH ICA L CONSIDERATIONS
Ethical approval for this study was granted by two local ethics committees (see Appendix
Chapter Two ~ Method
Minimising the potential distress of participants was of paramount importance in designing this study. In terms of recruitment, the preferences and protocols of each unit was followed, so as to cause the least amount of confusion and disruption to the young people. In addition, parents were not contacted until after consent had been gained from the patients themselves. This was so that there could be a discussion with participants about their parents having to give consent, and any problems with this raised, and also in an attempt to remove potential pressure from parents for their child to participate and
‘help others with anorexia’.
It was decided that individual interviews with participants instead of focus group discussions would both maximise the opportunity for participants to speak freely about their experiences and minimise the possibility for them to feel pressured into talking by other patients. It was also hoped that this would help participants to feel that what was discussed was wholly confidential.