Treatments for Eating Disorders: The Patients' Views

Eating disorders (EDs) have generated increasing concern in the last decades, both in the mental health field and in the general public. They are amongst the most frequent chronic health problems in adolescents, and the mortality rate of Anorexia Nervosa (AN) is one of the highest of all psychiatric illnesses. Clinical experience has demonstrated that EDs tend to be highly resistant to different modalities of treatment, and outcomes tend to be relatively poor, especially for those who do not receive early specialized interventions (Treasure et al, 2005). One study showed that of a sample of patients with AN who received inpatient treatment, less than 30% showed a good outcome and almost 60% had a poor outcome (Salbach-Andrae et al, 2009). Moreover, adherence is often poor, resulting in patients abandoning treatment; it is not infrequent for them to enter into treatment programs numerous times, both inpatient and outpatient, only to abandon them again. This not only worsens their prognosis but also implies a significant loss of resources for Health Services.


Introduction
Eating disorders (EDs) have generated increasing concern in the last decades, both in the mental health field and in the general public. They are amongst the most frequent chronic health problems in adolescents, and the mortality rate of Anorexia Nervosa (AN) is one of the highest of all psychiatric illnesses. Clinical experience has demonstrated that EDs tend to be highly resistant to different modalities of treatment, and outcomes tend to be relatively poor, especially for those who do not receive early specialized interventions (Treasure et al, 2005). One study showed that of a sample of patients with AN who received inpatient treatment, less than 30% showed a good outcome and almost 60% had a poor outcome (Salbach-Andrae et al, 2009). Moreover, adherence is often poor, resulting in patients abandoning treatment; it is not infrequent for them to enter into treatment programs numerous times, both inpatient and outpatient, only to abandon them again. This not only worsens their prognosis but also implies a significant loss of resources for Health Services.
In this context, the fact that relatively little is known about patients' subjective opinions about the treatments they receive becomes highly relevant: what aspects do they value the most? Which are the elements they value least and could contribute to them abandoning treatment? Which health services do they feel can best respond to their needs? Although EDs have been studied from different perspectives, this particular area has been neglected within ED research (Bell, 2003;Vanderlinden et al, 2007).
Another important aspect to consider is the frustration the treatment team experiences when patients abandon treatment despite the severity of their illness and the efforts that have been made to motivate them to adhere. However, previous research suggests that there are significant differences between aspects of treatment valued by providers and patients (de la Rie et al, 2008), and learning about the sufferer's perspective could contribute to developing interventions which may be more effective.

Theme
Valued Aspects Non-Valued Aspects

Types of Interventions
Individual psychotherapy Cognitive-behavioural techniques, help with expression and regulation of emotions.

Support
From care providers Constant support. Lack of support during the night in the in-patient ward. Lack of communication between care providers and family members who constitute patients' stable support network.
From family members Feeling supported and accompanied during the therapeutic process.
Lack of support from family members.

Patient-Centered Care
Motivation, being able to participate in treatment plans.
Lack of an individualized approach to care, not being given all the information concerning treatments. Participants also described certain negative aspects of care providers which they perceived as obstacles to their therapeutic process. On a personal level, they described feeling a lack of dedication and commitment from some professionals, and feeling distanced from them which made it more difficult to establish trusting relationships: "…one of the things I feel… is the distance from the psychiatrist" (Interview 7).
Participants also referred to receiving negative messages from some members of staff and how this stood in the way of their recovery: On a professional level, one cause for concern for participants was the lack of coordination and communication amongst the different professionals treating them, which meant they often had to tell the same things twice and which ultimately led them to lose their trust in the treatment team: Another thing which participants felt hindered their recoveries was that at times one of the professionals treating them had to leave and was replaced with someone new. This once again brought up trust issues for the patients, making them feel vulnerable, as if they were starting over or going backwards in their therapeutic process: Finally, in terms of professional characteristics of care providers, participants identified that one central aspect which was missing from their treatments was for it to be undertaken by professionals who are specialized in EDs: "And the lack of nutritionist, which I think is fundamental. I think there should be a nutritionist here, who was in charge, lets say, of the area of eating disorders" (Interview 4).

Types of interventions
A second theme which emerged from the participants' responses involved the types of interventions they received during the therapeutic process, among which individual psychotherapy was highly valued. Patients' described certain cognitive-behavioural techniques which they felt had helped them in their recovery, including having to fulfill certain tasks between sessions and working through a book with the help of their therapists: Another intervention which participants described as having a negative impact on their recovery was absolute bed rest, which was perceived as a very restrictive measure: "…one knows that what they are saying is really for your own good, but sometimes they like, one tends to think they exaggerate greatly, and it's like they take away your freedom, for example I was here the first days in absolute bed rest.

Support
Patients' responses generated a third theme which had to do with the importance of feeling supported throughout the road to recovery. Receiving constant support from their care providers, feeling accompanied and contained by them was highly valued:

"Look, what I most highlight is, is like, the time, and the, I don't know if the interest, but…they take good care of you, at least the Doctor [names her psychologist]…the whole thing has actually felt quite nice. They have been like really fraternal… the nutritionist also, I mean I've felt like… I don't know if love, but… like, like they support you a lot" (Interview 3).
On the other hand, participants mentioned the lack of support they felt during the night in the in-patient ward as a negative aspect of their treatment:

Patient-centered care
The fourth theme that emerged from the participants' interviews involved the desire for patient-centered care. Patients identified that in order to truly be at the centre of their own treatment they needed to be motivated, to feel that it was possible to get better, and to take responsibility for their recovery, and they valued receiving this motivation from their care providers: "…if a patient with an eating disorder arrives to treatment like very unmotivated, I mean, that you can tell that [she has] zero interest in that, start motivating her little by little to a recovery… with positive messages, that she, that what she has is not, she's not a sick person, rather she has a sickness that can be healed and that is not forever. Or, if it will be there… during her life… that she can control it, that she will be able to get to a point where she will be able to control it, and live her life, because this really, takes away your life" (Interview 2).
Participants described that once they were able to recognize their illness and become motivated to recover, they were able to leave the role of the "victim" and take a more active stance in their treatment, which they felt had positive repercussions for their recovery: Feeling like they were able to participate in their treatment plans was also valued by participants: "… afterwards the doctor changed my medication, he told me that these were effective for the problem I have… but that I wasn't going to gain as much weight as with the ones he gave me at the beginning. Because I told him that I wasn't going to go any more because I was already gaining weight, I didn't want to continue any more, so he made a whole change [in the treatment]" (Interview 10).
On the other hand, not being given all the information concerning their treatments was perceived as negative by participants, making them less willing to cooperate: "… the paramedic comes and gives me another pill, which I though was like strange, I didn't want to take it. Because first they have to ask me about things, or explain why they are giving me a pill" (Interview 1).

"[They should] explain a little bit the reasons for the restrictions" (Interview 3).
Finally, patients expressed that an individualized approach to care, which focuses on the specific needs of each person, was missing from their treatments: "Me as, as a person, as ME, I would like to receive help for anorexia… I think that…that the patient has to be studied more and see which medication [is] effective that will really be good for the, the person, because we don't all have the same body, we don't all have the same mind" (Interview 9).
"We the patients are not all the same" (Focus group).
"They put us all in the same bag" (Interview 3). www.intechopen.com

Conclusion
The objective of this study was to explore the views of Chilean patients who have received treatment for an ED about these treatments, in order to identify the aspects that patients value and feel have helped them in their recovery as well as the aspects they feel have hindered their recovery. The participants' responses centered around four main themes, which included positive and negative aspects of care.
The first theme involved personal and professional characteristics of care providers. On a personal level, participants valued care providers who were empathetic, understanding, concerned, and who they felt they could build a trusting relationship with, stating that this contributed to them liking their treatments and motivated them to "want to keep coming". On the other hand, care providers who were perceived as distanced from the patient, difficult to trust or uncommitted were evaluated negatively. These results are in line with previous findings which suggest that the quality of the therapeutic relationship is an important element of ED patients' satisfaction with their treatments (Bell, 2003;de la Rie et al, 2006;Escobar-Koch et al, 2010). Participants also described professional aspects of their care providers which they felt were negative and hindered the development of the therapeutic alliance: the little time available to them with their psychiatrists, the cancellation of appointments and the fact that professionals were at times replaced with others (due to the Salvador Hospital being a teaching facility), which patients expressed made it difficult to trust their treatment providers and made them feel as if they were "going backwards" in their recovery. This supports the notion that a positive therapeutic alliance may contribute to improving treatment adherence and outcomes (Federici & Kaplan, 2008;Gallop et al, 1994) and suggests that effort should be made to provide patients with a stable treatment team which emphasizes the development of the therapeutic relationship.
Regarding professional characteristics of care providers valued by participants, they described wanting to receive treatment from specialists in EDs. Previous studies suggest that ED literacy amongst clinicians who are not specialized in the treatment of these disorders is relatively poor. One study found that primary care physicians lacked knowledge about diagnostic symptoms, physical complications and epidemiology of EDs (Currin et al, 2009). Another study showed that health professionals with an interest in EDs but not specialized in this field did not have more knowledge about the risks and maintaining factors of these disorders than a group of patients or a sample of college students (Schmidt et al, 1995). This supports participants' views that treatment for EDs should be provided by specialists in order to ensure the best care possible.
The fact that it is difficult to access specialized treatment within the public health system was also pointed out by participants. Chile has a public health system which serves over 70% of the population, including the poorest people in the country (MINSAL, 2006). However, few specialized ED treatment centres exist within the public system, and patients are often treated in general psychiatric facilities. Accessing specialized private care is very costly and therefore impossible for many patients. A similar situation was described by a British study in which almost 40% of participants ended up paying for private care due to the lack of specialized treatment centres within the (public) National Health Service (Newton et al, 1993), and a recent study suggested that this lack of availability of public ED Services in the UK still exists (Escobar-Koch et al, 2010). These findings emphasize the importance of developing specialist ED services that are available to all patients and ensuring that financial constraints are not an obstacle to receiving adequate care.
Receiving treatment from a multidisciplinary team was also identified as a positive aspect of care by the participants of this study. Previous research has indicated that due to the complexity of these disorders treatment provision by a team of professionals, including psychiatrists, psychologists, experts in nutrition and social workers, is warranted, and periodical team meetings must be held to discuss each patient and agree on a treatment plan (Miranda-Sánchez, 2010). However, amongst the negative aspects of care, patients mentioned the poor coordination that sometimes existed between their treatment providers, including instances in which one health professional did not know who the other clinicians treating the patient were. This highlights the importance of not only having a group of different professionals available to provide treatment but also ensuring that they are organized and truly collaborate as a team.
The second theme which emerged from participants' responses referred to types of interventions received, and, in accordance with previous findings, individual psychotherapy was highly valued (Bell, 2003;Escobar-Koch et al, 2010;Rosenvinge & Klusmeier, 2000). Patients in this study highlighted the benefits of cognitive-behavioral techniques, in line with a recent study in which patients with bulimia nervosa and eating disorder not otherwise specified responded well to cognitive-behavioral treatments (Fairburn et al, 2009). Moreover, participants described how therapy had enabled them to understand the connection between their difficulties in expressing and regulating their emotions and their ED behaviours, and they valued help in learning "to listen to what was going on inside", in recognizing and dealing with their emotions. This supports the notion that Emotion-Focused Therapy, which promotes the processing and expression of emotional experience, may be beneficial for the treatment of EDs (Dolhanty & Greenberg, 2009).
Pharmacological interventions were less valued than therapy by participants in this study. This supports previous findings that medication alone does not seem to be an effective treatment for EDs, due at least in part to the fact that many patients suffering from these disorders are reluctant to accept such treatment (Halmi et al, 2005). Therapeutic interventions focusing exclusively on weight gain were also evaluated negatively, in line with previous research which has identified the importance of not limiting ED treatments to issues of food and weight (Bell, 2003).
A third theme generated by participants in this study stressed the importance of feeling supported by their treatment providers during the recovery process. It has been shown that strategies focusing on support are predictors of ED patients' satisfaction with their treatments (Clinton, 2001;Clinton et al, 2004), and it is therefore essential for ED services to provide constant support to their patients. Feeling supported by their families was also valued by participants, and they expressed concern about what they felt was insufficient communication between their care providers and their support network. Similarly, a study evaluating anorexia nervosa patients' treatment perceptions found that many of the participants felt that their parents had not received sufficient help to support their daughters (Halvorsen & Heyerdahl, 2007). These findings suggest that ED treatment teams should have regular sessions with their patients' families in order to provide information and guidance about how to best support them during the therapeutic process.
The final theme which stemmed from the participants' views involved their wish for patient-centered care. In accordance with previous findings, patients identified the need for an individualized approach to treatment (Boughtwood & Halse, 2010;Escobar-Koch et al, 2010;Schaffner & Buchanan, 2008). The importance of feeling motivated and taking responsibility for their recovery was also highlighted, and participants described how becoming motivated enabled them to take on an active role in their treatment which had a positive impact on their recovery. ED patients tend to be very ambivalent about treatment and often enter into it reluctantly, and this is associated with bad treatment adherence and high drop out rates (Feld et al, 2001). In this context, finding ways to increase ED patients' motivation becomes essential. Motivational interviewing, which stemmed from the idea that motivation is not a personality trait but rather arises from an interpersonal process (Miller & Rollnick, 1991), offers a such a possibility. Its goal is to improve patients' intrinsic motivation to change by helping them explore and resolve their ambivalence, emphasizing personal choice and responsibility, and it has been suggested that it could be successfully applied with ED patients (Treasure & Ward, 1997, Treasure & Schmidt, 2001.
In summary, this study explored the views of Chilean ED patients about their treatments, identifying aspects that are valued by them as well as elements which they consider to have had a negative impact on their recovery. Themes generated from their responses echoed several findings from previous research, such as the importance of the therapeutic relationship, the need for treatment to be provided by specialized multidisciplinary teams, the lack of availability of specialized treatment facilities, the preference for individual psychotherapy and treatments that don't focus exclusively on issues of food and weight, the importance of receiving support from treatment providers and family members during the process of recovery and the wish for patient-centered, individualized care. The central role of patient motivation during the therapeutic process was also highlighted. The main limitation of this study was its small sample size. The main strength was that it is, to our knowledge, the first study evaluating the views of ED patients in a South American country. Eating disorders are common, frequently severe, and often devastating pathologies. Biological, psychological, and social factors are usually involved in these disorders in both the aetiopathogeny and the course of disease. The interaction among these factors might better explain the problem of the development of each particular eating disorder, its specific expression, and the course and outcome. This book includes different studies about the core concepts of eating disorders, from general topics to some different modalities of treatment. Epidemiology, the key variables in the development of eating disorders, the role of some psychosocial factors, as well as the role of some biological influences, some clinical and therapeutic issues from both psychosocial and biological points of view, and the nutritional evaluation and nutritional treatment, are clearly presented by the authors of the corresponding chapters. Professionals such as psychologists, nurses, doctors, and nutritionists, among others, may be interested in this book.