For my six week clinical practice placement in an adolescent mental health unit I chose to focus my project on a 15-year-old anorexia nervosa patient. This disorder largely affects young women and is an extremely challenging problem to treat. I felt that working with an anorexia nervosa patient in this controlled environment, under the guidance and supervision of a mentor, would be a particularly good application of action learning because “action learning… can rapidly develop critical skills.”[1] In particular I wanted to develop interpersonal skills necessary to communicate well with patients and colleagues, and learn to relate to any issues raised by my patient being a teenager. As I learn better from hands-on training than through just reading and discussion I felt this would a valuable use of my clinical placement.
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Anorexia nervosa patients often have low self-esteem and “a desire for achieving perfection in all the things they do”[2] – this was something I had to be aware of during the placement because it raises the problems with goal setting. With anorexia it is difficult to agree on goals with a patient because the main goal, from a health perspective, is weight gain, which they want to avoid.[3] The other issue is that the patient is 15-years-old. This fits the common case that many patients “seek therapy at the insistence of parents… [so] the patient arrives at for the consultation poised to resist, anticipating the same pressures for change.”[4] These factors combine to make treatment extremely difficult: first, the patient is resistant to change; second, the patient specifically wants to avoid weight gain, which is the main goal; third, if you can get the patient to agree on a goal they might feel anxiety because of their perfectionism, leading to more controlling behaviour – i.e. trying to lose weight.
My mentor was especially helpful in highlighting some of these points to me with regards to the patient, and helping me think about ways we could deal with them clinically. In my last placement I did a training course in cognitive behavioural therapy (CBT) and my mentor and I felt this could be useful. There is extensive clinical evidence supporting the use of CBT in treating anorexia nervosa[5] and “once the disorder is initiated, it is the cognitive self-reinforcement that becomes the key factor in regulating it.”[6] We agreed that since cognitive behaviour is key to the illness it has potential to break the negative thought cycle.
I used clinical guidelines to understand more about the possible benefits of CBT for anorexia nervosa. One item of interest is that: “The CB approach has two particularly valuable sources of flexibility and creativity applicable to the issue of engagement. These are structured assessment and models of resistance… structured assessment can be very helpful in developing an in-depth understanding surrounding resistance to services.”[7]
With the guidance of my mentor and other clinic staff I worked on my assessment skills with the aim of engaging this particular patient. Unfortunately, in the course of my six week placement the patient proved very difficult to engage with, perhaps because “change involves a patient giving up a cherished and valued state.”[8] If this had been in an unsupported setting I would have found this very discouraging and probably would have doubted my methods. However, through using the learning side of the process I found that “motivation and engagement are commonly poor or ambivalent in patients with eating disorders, particularly anorexia nervosa”[9] and that “patients with anorexia nervosa react to stress both in childhood and adulthood with a helpless style of coping and a tendency to use avoidance strategies.”[10] These findings showed that I was dealing with a widespread problem, not something specific to my patient.
This insight, and the supportive atmosphere from the other clinical staff, helped me keep my focus on the patient, and not think of the challenges as personal failings. In the space of six weeks I didn’t have time to work through these issues with this particular patient, but the action learning process gave me the confidence that I would be able to address them in future. It also put in perspective that the patient continued to lose weight. That is obviously not the outcome desired but knowing that: “70 percent of the [eating disordered] subjects for CBT remained symptomatic”[11] assured me that this is also a common problem.
During the placement my mentor and I discussed these problems and talked about different methods that might be useful to overcome them. One area I decided it was important for me to focus on is relational skills with patients. With anorexia nervosa, especially, “the interpersonal process… needs to take this ambivalence or indeed resistance into account. The skills of motivational interviewing are invaluable.”[12] We also talked about the possibility of using other types of therapy along with CBT. Most of the clinical data supports CBT as effective, but there have been some studies that show family therapy can be beneficial[13], which we thought might be a useful avenue to explore since the patient is 15. However, my mentor cautioned me that family difficulties often lie at the root of eating disorders and suggested I check some literature. I found out that “women with anorexia nervosa typically describe both their parents negatively… and women with eating disorders described their parents as typically unsupportive of their independence.”[14] This would suggest treating family therapy with caution. It could be that patients come from genuinely unhappy families, or it could also be that anorexia nervosa patients resent their parents’ perceived intrusion of trying to make them eat as an attack on their independence. I’m glad my mentor raised this issue, because it made me realise that before using additional therapies you need to consider patient history and resistance, and you also need to understand the reasons they might not want to do a particular therapy, to allow you to make the best decision about treatment options.
During the placement there was a good mix of clinical work and theory. I found my relationship with my mentor was the most important element during my time working with the patient, as they modelled good patient care and helped me reflect on my own work. They emphasised to me that “reflection is important within formal professional courses… and for demonstrating work-based learning,”[15] which is something I probably wouldn’t have really thought about without their guidance. One of the possible weaknesses of action learning, according to some practitioners, is that: “where real work and learning are explicitly associated, the excitement, significance and immediacy of the action element can often submerge the learning element.”[16] I can see how that could happen in a busy clinical setting – for example an A&E department – but I felt that within the setting of the mental health clinic there was adequate time for learning and there was a chance to access books, clinical guidelines and advice from the staff.
As a result of what I learned during my project my development goal is to practice my therapeutic communication skills and make an effort to get feedback on them. This placement made me see how important interpersonal skills are, as well as the different challenges. In working with my patient I felt lack of engagement was one of the biggest difficulties, and led to an unsuccessful outcome in the short term. Developing strong therapeutic communication skills is a way to overcome resistance to treatment. Using the listening skills of therapeutic communication will also help understand the patient’s needs and challenges related to treatment – such as possible family issues in anorexia nervosa.
It was somewhat discouraging to not see a better result with this patient, but the placement taught me that: “in Action Learning the emphasis is on the courageous struggle to act and understand; not on short cuts and quick fixes”[17] and I think that knowledge will enhance my confidence as I approach the challenges of improving my communication skills and taking forward what I learned.
Bibliography
Bennett-Levy, J., Butler, G., et al., Oxford Guide to Behavioural Experiments in Cognitive Therapy, Oxford University Press, 2004
Bulman, C. and Shutz, S., Reflective Practice in Nursing: The Growth of the Professional Practitioner, Blackwell Publishing, 2004
Cassidy, J. and Shaver, P., Handbook of Attachment: Theory, Research, and Clinical Applications, Guilford Press, 2002
Costin, C., The Eating Disorder Sourcebook: A Comprehensive Guide to the Causes, Treatments, and Prevention of Eating Disorders, McGraw-Hill Professional, 2006
Garner, D. and Garfinkel, P., Handbook of Treatment for Eating Disorders, Guilford Press, 1997
Grant, A., Mulhern, R., et al., Cognitive Behavioural Therapy in Mental Health Care, SAGE, 2004
Marquardt, M. and Callahan, M., Action Learning, American Society for Training and Development, 1997
Newell, R. and Gournay, K., Mental Health Nursing: An Evidence-based Approach, Elsevier Health Sciences, 2000
Norman, I. and Ryrie, I., The Art and Science of Mental Health Nursing: A Textbook of Principles and Practice, McGraw-Hill International, 2004
Pedler, M., Action Learning in Practice, Gower Publishing, Ltd., 1997
Footnotes
[1] Marquardt, M. and Callahan, M., Action Learning, American Society for Training and Development, 1997, p. 13
[2] Bennett-Levy, J., Butler, G., et al., Oxford Guide to Behavioural Experiments in Cognitive Therapy, Oxford University Press, 2004, p. 267
[4] Garner, D. and Garfinkel, P., Handbook of Treatment for Eating Disorders, Guilford Press, 1997, p. 99
[5] Garner, D. and Garfinkel, P., Handbook of Treatment for Eating Disorders, p. 95
[7] Grant, A., Mulhern, R., et al., Cognitive Behavioural Therapy in Mental Health Care, SAGE, 2004, p. 149
[8] Newell, R. and Gournay, K., Mental Health Nursing: An Evidence-based Approach, Elsevier Health Sciences, 2000, p. 253
[9] Bennett-Levy, J., Butler, G., et al., Oxford Guide to Behavioural Experiments in Cognitive Therapy, p. 282
[10] Newell, R. and Gournay, K., Mental Health Nursing: An Evidence-based Approach, p. 247
[11] Costin, C., The Eating Disorder Sourcebook: A Comprehensive Guide to the Causes, Treatments, and Prevention of Eating Disorders, McGraw-Hill Professional, 2006, p. 118
[12] Norman, I. and Ryrie, I., The Art and Science of Mental Health Nursing: A Textbook of Principles and Practice, McGraw-Hill International, 2004, p. 463
[14] Cassidy, J. and Shaver, P., Handbook of Attachment: Theory, Research, and Clinical Applications, Guilford Press, 2002, p. 508
[15] Bulman, C. and Shutz, S., Reflective Practice in Nursing: The Growth of the Professional Practitioner, Blackwell Publishing, 2004, p. 30
[16] Pedler, M., Action Learning in Practice, Gower Publishing, Ltd., 1997, p. 229
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