270 Treating Eating Disorders
of 1–2 kg per week is usually the aim, which results in an average admission
period of between 12 and 14 weeks.
The process of weight restoration is achieved by utilizing many of the
strategies described by the behavioral components of CBT. For example,
meals are taken at a table with other patients and with the nurses. This
provides the patient with support from their peers and enables the nurses
to provide reinforcement in the form of verbal encouragement and praise.
It also provides a forum for the patient to relearn the pleasures of social
eating and to model the normal eating behavior of the nurses. Communal
eating also enables patients who are further down the recovery path to
support the newer patients, which can facilitate self-esteem in the healthier
patients and provide additional peer reinforcement for the less well indi-
viduals. It also enables the nurses to observe and comment upon abnormal
eating behaviors such as rumination, cutting up food into tiny pieces, and
counting food, and provides a forum for these problems to be discussed.
Patients are also weighed regularly. Some clinics tell the patient their weight,
which aims to build trust and active collaboration. Other clinics keep the
patients’ weight from a patient to minimize a preoccupation with weight
and reduce any anxiety caused by weight gain. There is no evidence for
the relative effectiveness of these two practices for anorexic patients (see
chapter 9 for a discussion of weighing in general).
The structure of the eating regimen also helps towards restructuring the
patient’s cognitions. On admission to the ward, the nurses will take com-
plete responsibility for the patient’s choice of food and the amount eaten.
Negotiations about food will be kept to a minimum, and nurses will take
control of a patient’s eating behavior. Many patients are determined not
to eat but are being told to eat by their bodies. Handing over responsibility
for eating to the nurses enables the patient to eat without feeling the panic
of losing control. They can therefore continue in their belief that they are
solving their problems and keeping control of their lives by not eating, while
at the same time consuming food. Gradually, control over food intake is
handed back to the patient once the patient begins to see that eating
and any accompanying weight gain do not bring with them the anticipated
catastrophic consequences. Accordingly, changes in the patients’ behavior
precede changes in their cognitions.
For a small minority of patients, behavioral strategies are not sufficient
to motivate the patient to eat, which has triggered a debate concerning the
right of the patient to refuse treatment and the use of forced refeeding.
For example, some units resort to intravenous feeding or tube feeding, while