Posted: June 9th, 2015

case study concerning service use, challenging presentation and intervention deployed

Jade (a pseudonym), 17 years old, was referred to the unit of my recent placement, by a local eating disorders service. They had received a referral from her GP who surmised that she may have anorexia nervosa (AN). Two practitioners from the service conducted an assessment with Jade and they were sufficiently concerned at the risk of serious physical complications as a result of substantial weight loss to warrant admission. Jade agreed to an informal admission to the unit.

AN includes features such as a refusal to maintain healthy body weight, as standardised by the Body Mass Index (BMI), and a persistent and disproportionate fear of weight gain (Cromby et al, 2013). AN is deemed as multifactorial in its nature, part of which is concerned with the psychological well-being of the individual, and in many instances familial and social elements are evident in the development of the condition (Turner and Baldock, 2011).

Case history: Jade was accompanied to the unit by her mother. It was noticeable from the outset that there was uneasiness between Jade and her mother, evidenced in part by Jade’s choice to sit with distance between them. The original referral from the GP had expressed concern about conflicts within the family. The literature on the subject of family influence in people with eating disorders is broad in its nature, and includes issues such as consistently high levels of adverse childhood experiences, early separation and child abuse in many cases (Jacobi et al, 2004). Eisler et al (2009) suggest a note of caution where assigning causality to the family is concerned as the evidence for dysfunction or specified behavioural patterns is inconsistent across families.

Jade was invited to share her thoughts about the development of her issue with eating, and she suggested that the family had begun talking about it in the last few weeks. This contrasted with her mother’s suggestion that they had been concerned about Jade’s ‘preoccupation with dieting’ for the last 18 months. This discussion in some way illustrated how individuals with AN often dissociate themselves from their eating disorder as ‘a problem’, and something that others are unnecessarily concerned about, from the perspective of the person with AN (Aherne and Bell, 2010). This theme continued throughout the discussion, with expressions of distress from Jade’s mother, and indifference from Jade herself.

What was apparent during this interview was that Jade’s eye contact was fleeting at best, and she sat during the process with her feet up on the seat and her knees tucked up to her chin; to the observer a regressive posture, i.e. childlike. Regressive behaviour in people with eating disorders is not uncommon, and according to Farnham (2011) may, besides offering some notion of the young persons’ mind set in the challenging climate of a mental health assessment, also potentially, point to the origins of their condition, in terms of seeking sanctuary through the need to avoid the responsibilities and expectations that arrive with maturity.

During discussion, it emerged that Jade had experienced some difficulty around 18 months earlier concerning an ex-boyfriend. Jade confided that her virginity was ‘still intact’ and this was ‘under threat’ during that time, and led to her breaking off the relationship. She said that she had heard some ‘horror stories’ about first sexual encounters and this had made her very anxious about the prospect of sex. A study by Bullard (2007) involving a group of women aged between 18 and 23 years, indicated that a common reason for the early development of food refusal was the delay or interruption of sexual maturity. Reasons for this could include the experience of childhood sexual abuse, family dysfunction or psychosexual disturbances resulting from distorted beliefs about sex (as perhaps in Jade’s case), or distressing sexual experiences (Walters & Hamilton, 2003; Mughal & Price 2007).

……………………………….Case history goes on to identify potential causative indicators and other important issues such as protective factors in Jade’s case, and profiling her family/social network. You could use a genogram or socio-gram to develop a picture of the family/social network. Jade’s perspective is sought in order to better understand the lived experience.

A major challenge faced by Jade and the team was the issue of feeding against Jade’s will. Having been a ‘picky eater’ as identified by her mother, Jade had long had a difficult relationship with food. When a person experiences an eating disorder, it frequently brings sufferer and parent, often the mother, back into a relationship concentrating on food and feeding but in a far more fraught and painful manner (Bowyer 2009). This role is taken on by staff members once the individual is admitted to a mental health or eating disorder unit, and, as offered as a note of caution by Turnbull (2011), a process of transference may occur, whereby the association with eating and parental control may extend to the nurse, regardless of her or his good intentions. Efforts at collaboration, a key principle of recovery, are directly compromised in a situation such as this.

There was evidence of this as Jade resisted and reminded the attending staff member that ‘she isn’t a child’. Such a situation places the nurse in a position of dilemma whereby the autonomy of the service user is compromised by the duty of care to preserve health and life, i.e. an act of beneficence. As suggested by Treasure et al (2011), it is easy to perpetuate negative outcomes in attempting to promote recovery in a person with AN, e.g. coercive re-feeding may further augment food avoidance behaviour, and anxiety expressed by the professional may be mirrored by the service user; this is particularly problematic where the eating disorder represents a coping mechanism.

Whilst Jade found the eating ritual difficult to bear, she responded well to therapeutic approaches which attended to her anxieties/emotional disturbances, especially where food was not part of the discussion. The desire to decide on what is best for oneself and to orchestrate one’s own recovery is, according to Colton and Pistrang (2008), key to sustained coping. By some contrast, a study by Westwood and Kendall (2012) suggests, at least in some cases, that on reflection, many young people reported resentment at first, but appreciation of the firm management of their treatment and condition later on.

Where control may present as a problem in the individual’s case, the professional is left with a dichotomy to address. In the case of Jade, openness about the need to re-feed, whilst difficult at the outset, was met with some degree of understanding later on when she developed a different mind-set about her condition.

………………………alternatively, the author could continue by addressing other treatment issues such as family work, and a particular challenge could be that of engaging Jade and her family without appearing to take sides and reinforcing views about where blame may be located in the relationship (supported by relevant literature)

Recovery in Action: Challenges for Practice

Extended assignment guidelines

Written assignment.

Students are asked to outline a case example concerning a service user they have worked with, involving a challenging presentation; offering a case history and a critical appraisal of the intervention(s) deployed. The student will reflect also on recovery issues in relation to their chosen case example.

The aim of this assignment is for you to demonstrate your understanding of recovery in practice and some of the challenges faced when applying interventions. Every case has its own challenges, therefore when writing up your assignment, you can choose to focus on any service user, regardless of their mental health issue, i.e. you do not need to be limited to the mental health presentations covered in this module.

Use the sample essay to guide you on assignment style and the types of critical discussions you may cover in relation to implementing recovery focused care. In addition, use the guide below to assist you to structure your assignment.

*Please note that relevant literature needs to be applied throughout your assignment.

1. Introduction – (approx. 50 words)

This is a statement of intent – i.e. what it is you will be doing in the assignment.

1. Main Body – (up to 2700 words)

Case study critical discussion

• Introduce the service user, with some brief demographic information e.g. age, gender, ethnicity, (please ensure that confidentiality is maintained and a statement should be written to confirm that confidentiality has been maintained. Do not mention the service user’s real name or the name of the clinical service they are under, or the names of places).

Include the setting, (the type of service where they are in receipt of care), any cultural considerations, co-existing conditions, (physical health, substance misuse for example), pre-existing conditions, any communication issues, spiritual and religious issues, socioeconomic status – (finance, housing etc.), psychosocial (employed/unemployed? social network?), legal – (Mental Health Act? medication?)

• Presenting issues. What are the needs? Precipitating factors – current causes/triggers; what are the factors leading up to presentation?   Service user’s views on current presentation.

         Intervention

• Critically reflect upon the implementation of intervention(s). What is being implemented and why? How was it facilitated? Challenges in relation to recovery, for example were there any issues related to collaboration and patient centred care, (both recovery themes)? Were there any other challenges in promoting or engaging the recovery approach? Give examples and ensure that all points asserted are supported by relevant literature, (which should be no more than 10 years old, unless it is considered classic text).

• Many care contexts may provide fertile ground for discussion concerning challenges to recovery, e.g. CPA processes; C.T.O.’s; changing roles (e.g. the nurse as AMHP); continuing observation; physical restraint; enforced treatment; assertive outreach. Whatever the care context you will find literature to support your discussion

1. Conclusion (approx. 250 words)

What is it you have learned by reflecting on this case study in relation to recovery challenges in practice? What impact will this reflection have on your development as a mental health nurse?

REFERENCES

A minimum of 10-15 references should be included in your work (aim higher where possible). Sources can be articles from journals, books, reliable internet sources for example and all should be listed in the Harvard style of referencing. Avoid over-use of a particular source; e.g. not too many internet examples. Make use of the very good electronic resource facility offered by the library; you can potentially access numerous helpful journal articles related to your case study.

Kindly send a draft before the final submission.