A pilot study of a virtually delivered dissonance-based eating disorder prevention program for young women with type 1 diabetes: within-subject changes over 6-month follow-up.

INTRODUCTION: In an uncontrolled study, we previously demonstrated the feasibility and preliminary efficacy of our virtual diabetes-specific version (Diabetes Body Project) of the eating disorder (ED) prevention program the Body Project. The aim of the current study was to evaluate further this program for women with type 1 diabetes (T1D) by assessing within-subject changes in outcomes from pretest over 6-month follow-up. METHODS: Young women with T1D aged 16-35 years were invited to participate in Diabetes Body Project groups. A total of 35 participants were allocated to five Diabetes Body Project groups (six meetings over 6 weeks). Primary outcome measures included ED risk factors and symptoms, and secondary outcomes included three T1D-specific constructs previously found to be associated with ED pathology: glycemic control as measured by HbA1c level, diabetes distress, and illness perceptions. RESULTS: Within-subject reductions, with medium-to-large effect sizes, were observed for the primary (ED pathology, body dissatisfaction, thin-ideal internalization, and appearance ideals and pressures) and secondary outcomes (within-condition Cohen's ds ranged from .34 to 1.70). CONCLUSION: The virtual Diabetes Body Project appears to be a promising intervention worthy of more rigorous evaluation. A randomized controlled trial with at least a 1-year follow-up is warranted to determine its efficacy compared to a control condition.

"I am not alone". A qualitative feasibility study of eating disorders prevention groups for young females with type 1 diabetes.

OBJECTIVE: The overall aim of the current study was to qualitatively explore the feasibility of eating disorder prevention groups for people with type 1 diabetes (T1D). METHOD: A generic qualitative focus group design was applied. 17 participants accepted the invitation to attend focus group interviews after completing the intervention. Five focus groups were conducted in total. RESULTS: The qualitative analysis generated one overarching theme, named the benefit of meeting peers with a lived experience of T1D and body image concerns, and four themes: the need for an integrated focus on diabetes, personal relevance, providing sufficient balance between structure and flexibility and enabling a different perspective. CONCLUSION: Results show overall positive feedback regarding the content and structure of the intervention, and underline the importance of targeting preventive efforts to specific risk groups.

Young females with type 1 Diabetes constitute a high-risk group for developing eating problems and eating disorders. Interventions specifically targeted at preventing body image and body dissatisfaction issues in this group are therefore very important. The current study thus aimed to explore participants' experiences with a Diabetes specific version of the targeted prevention program the Body Project, Diabetes Body Project. Participants were invited to attend focus groups interviews after completing the intervention. Results from the study consist of one overarching theme and four themes. Participants highly appreciated the opportunity to meet other young females with type 1 Diabetes, underlining the importance of interventions specifically targeted at this high-risk group. They also emphasized that the script would benefit from a more integrated focus on type 1 Diabetes throughout all six sessions of the intervention.

Burnout among staff on specialized eating disorder units in Norway.

OBJECTIVE: Burnout is commonly associated with low workplace wellbeing. Patients with eating disorders are frequently referred to as a particularly challenging group to treat. It is therefore important to study healthcare providers´ workplace wellbeing in settings which treat eating disorders. The aims of the current study were to (a) measure burnout among healthcare providers working on specialized eating disorder units in Norway, and (b) explore factors predicting burnout. METHODS: 186 participants from 11 specialized eating disorder units in Norway completed an online survey including the Mashlach Burnout Inventory, and eating disorder-specific factors related to burnout, job satisfaction, work environment, emotional dissonance and stress. Multiple regression analysis was used to identify predictors of burnout. RESULTS: Overall, low levels of burnout were found among the participants. Eating disorder-specific factors and emotional dissonance predicted the three central aspects of burnout, namely, emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. CONCLUSIONS: Findings suggest a relatively low level of burnout across age, gender, and professional categories working at specialized eating disorder units, contrary to commonly-held assumptions pertaining to the challenges involved in treating individuals with eating disorders.

Healthcare providers' wellbeing at work is important for their health and their satisfaction and performance at work well as quality of patient care. Patients with eating disorders are frequently referred to as a particularly challenging group to treat, and may therefore affect healthcare providers' working with this patient group sense of wellbeing. The current study thus aimed to measure levels of burnout and its relationship with associated aspects, e.g. work environment, job satisfaction, emotional dissonance and eating disorder specific factors among healthcare providers working specifically with this patient group. The outcome of the study showed relatively low levels of burnout among participating healthcare providers. Factors associated with eating disorders strongly predicted burnout.

Feasibility of a virtually delivered eating disorder prevention program for young females with type 1 diabetes.

OBJECTIVE: This study aimed to develop a virtual diabetes-specific version of the eating disorder (ED) prevention program the Body Project, and to assess feasibility and preliminary efficacy of this program for young females with type 1 diabetes. METHOD: Young females with type 1 diabetes aged 16-35 years were invited to participate in the study. A total of 35 participants were allocated to five Diabetes Body Project groups (six meetings over 6 weeks) and completed pretest assessments; 26 participants completed all sessions and posttest assessments (<7 days after last meeting). Primary measures included ED risk factors and symptoms, and secondary outcomes included diabetes-specific constructs previously found to be associated with ED psychopathology (e.g., diabetes distress and illness perceptions). RESULTS: The ease of recruitment, timely conduct of five groups, moderate drop-out rate and appreciation of the intervention by participants indicated that the Diabetes Body Project is feasible. Meaningful reductions occurred on the primary outcomes (i.e., ED psychopathology, body dissatisfaction, and thin ideal internalization) and on internalization of appearance ideals and appearance pressures at posttest (Cohen's d ranging from .63 to .83, which are medium to large effects). Small to medium effect sizes were found for diabetes illness perceptions and distress (.41 and .48, respectively). DISCUSSION: The virtual Diabetes Body Project is a promising and much-needed intervention, worthy of more rigorous evaluation. A randomized controlled trial is warranted to determine its effectiveness compared with a control condition.

Family members' reflections upon a family-based inpatient treatment program for adolescent anorexia nervosa: a thematic analysis.

BACKGROUND: Family-based outpatient treatment is usually recommended as the treatment of choice when a child develops anorexia nervosa. However, some young persons will inevitably require higher levels of care. Qualitative research on family perspectives may help inform strategies to adapt family-based practices into intensified treatment settings. Our overarching aim was to investigate family members' perspectives following a family-based inpatient treatment program for adolescent anorexia nervosa and to discuss clinical implications for treatment providers. METHODS: A subsample of eight families taking part in a naturalistic outcome study at a specialized eating disorder unit participated in the study (8 patients, 14 parents, and 10 siblings). The thematic analyses were inductive, predominantly descriptive, and guided by a multi-perspective framework. RESULTS: Five main themes were identified: 1: Expectations and evaluation of needs. Entering treatment from different vantage points, 2: Interactions with peers during the admission as highly beneficial or problematic, 3: Perspectives on staff expertise and the eating disorder unit's structure, 4: Influencing within family relationships in different ways, and 5: Being admitted is at best only half the job: reflections on leaving the eating disorder unit. CONCLUSIONS: Our study offers insight into how former inpatients and their family members experienced an inpatient treatment program designed to align treatment with the central elements of an outpatient family-based treatment approach for adolescent anorexia nervosa. Overall, the findings support emerging research underlining the necessity of strengthening the family-based treatment approach within intensified treatment settings. Moreover, the results emphasized the need for more knowledge on how to optimize inpatient treatment as well as the importance of providing smooth transitions between care settings.

Family-based inpatient treatment for adolescent anorexia nervosa: a thematic analysis of former patients' post-treatment reflections.

This study investigated former patients' experiences with family-based inpatient treatment. Interviews of thirty-seven patients diagnosed with anorexia nervosa during the admissions were conducted to examine their post-treatment perspectives. The accounts were analyzed by utilizing an inductive thematic analytic approach. The analysis yielded 4 main themes, constituted by in all 8 subthemes. The main themes were; 1) Enabling new ways of understanding and relating, 2) Enhancing or maintaining negative power dynamics, 3) Vulnerable transitions, and 4) Sibling relationships and different ways of involvement. With its "insider focus," this study contributes to knowledge on how family-based inpatient treatment is perceived from a user perspective. The current study has value for both advancing the development of family-based inpatient treatment, and by adding patient perspectives to the ongoing effort of providing family-based approaches at higher levels of care.

Job satisfaction at specialized eating disorder units in Norway.

OBJECTIVE: Patients with an eating disorder are frequently referred to as a particularly challenging group to treat. As a consequence, it is important to understand how working with eating disorders affects workplace well-being. Job satisfaction is a key indicator of workplace welfare. The aims of the current study were to (a) measure overall job satisfaction among healthcare providers working at specialized eating disorder units in Norway, and (b) to investigate possible differences in job satisfaction between professional groups and between staff working fixed versus rotating shifts. METHOD: This cross-sectional study is part of a larger study investigating work-related well-being at specialized eating disorder units in Norway. The total sample was composed of 186 participants from 11 specialized eating disorder units. RESULTS: Overall, high job satisfaction was found across all professional groups. There were significant differences between daytime and shift workers on several dimensions of job satisfaction. Medical doctors and clinical psychologists scored significantly higher than nursing staff on several aspects of job satisfaction. DISCUSSION: This study suggests high job satisfaction across all professional groups among healthcare providers working at specialized eating disorder units, contrary to commonly-held beliefs that working with eating disorders is very demanding.

External support and personal agency - young persons' reports on recovery after family-based inpatient treatment for anorexia nervosa: a qualitative descriptive study.

BACKGROUND: Recommended treatment for adolescent anorexia nervosa (AN) is usually family-based and an overarching treatment aim is to empower the parents to manage the difficult meals and aid their child toward recovery. While family-based treatment prioritize collaborating with the parents, understanding the young persons' views on recovery is also important. Understanding the young person's views and ideas is relevant as this may facilitate the therapeutic alliance and thus aid the therapeutic process. The purpose of the present study was to investigate the reflections of young persons with a lived experience of anorexia nervosa, and what factors they consider important for the recovery process. All participants had been provided with a family-based inpatient treatment program, a program inspired by the core features of outpatient family-based treatment. METHODS: Participants (n = 37) presented with an extensive treatment history, including outpatient and inpatient treatment for AN. Interview transcripts were analyzed by applying a predominantly inductive thematic approach to generate themes across participants. RESULTS: The qualitative analysis generated a thematic structure entailing three levels. The superordinate theme, "Recovery is a long and winding journey: recognizing the need for support and highlighting the need for action", captured three main themes, "Realizing you have a problem", "Being involved in important relationships", and "Giving treatment a real chance". CONCLUSIONS: Our results demonstrated that although young persons with a lived experience of anorexia nervosa recognized the importance of support from others, they placed a distinctive emphasis on self-responsibility and determination. We recommend clinicians working within the recommended family-based treatment frameworks be curious about young patient's subjective perspectives of the recovery process, as connecting with their views can potentially strengthen therapeutic relationships and facilitate change. PLAIN ENGLISH SUMMARY: Recommended treatment for adolescent anorexia nervosa is usually family-based. These recommendations are supported by decades of research. In family-based treatment the overarching aim is to empower the young person's parents to manage and take charge of the difficult situation caused by the eating disorder. As recommended family-based treatments usually prioritize collaborating with the parents, it is important to be curious on the adolescents own views of what is regarded as important for the recovery process. The present study offers insights into factors considered important to the recovery process by young persons with lived experience of AN. Although voicing the importance of enlisting support from families, friends, and loved ones, the young participants distinctly emphasized their own responsibility, motivation and self-determination as critical factors for recovery. Inspired by our findings, we recommend that clinicians address the young patient's own preferred ideas for recovery during treatment.

Minding the adolescent in family-based inpatient treatment for anorexia nervosa: a qualitative study of former inpatients' views on treatment collaboration and staff behaviors.

BACKGROUND: For some young persons diagnosed with anorexia nervosa, treatment will inevitably involve phases where hospitalization is required. Inspired by the encouraging evidence-base for outpatient family-based treatment for adolescent anorexia nervosa, clinicians and program developers have started to incorporate outpatient family-based treatment principles into higher levels of care. During family-based inpatient treatment, collaborative efforts are largely directed toward the parents of the adolescent. Consequently, the therapeutic focus on the young person is more of an indirect one. With this study we aimed to understand how young persons with lived experience from a family-based inpatient treatment setting, where the adolescents were admitted together with their parents, viewed therapeutic aspects related to staff-patient collaboration and staff-related behaviors. METHODS: Thirty-seven semi-structured interviews of former adolescent inpatients were conducted. Participants' post-treatment reflections were inductively analyzed by applying a thematic analytic framework. RESULTS: Based upon user perspectives from a treatment setting highly influenced by a family therapeutic approach, findings revealed that former inpatients prefer tailored treatment and a collaborative approach. Eight subthemes constituting two main themes emerged: 1) There are no ready-made solutions. Staff should facilitate collaboration by tailoring treatment toward the young person's perspectives, and 2) Emphasizing skills that matter. Staff should display a non-judgmental stance, educate patients, stimulate motivation, enable activities and prevent iatrogenic effects during the stay. CONCLUSIONS: This study adds valuable user perspectives to the ongoing work with adapting family-based frameworks into higher levels of care. Clinicians could benefit from viewing their practice from the standpoint of the young person's post-treatment reflections. From their unique perspectives as having lived experience and hence, "insider knowledge" with a specific treatment situation, clinicians are reminded of the importance of being mindful on the young persons' views.

General and Eating Disorder Specific Flexibility: Development and Validation of the Eating Disorder Flexibility Index (EDFLIX) Questionnaire.

Findings from studies investigating cognitive flexibility in eating disorders (EDs) are inconsistent, and although neuropsychological tests are commonly used to measure these skills, they may not be particularly effective in predicting everyday functioning. Also, extant studies have largely focused on flexibility in anorexia nervosa (AN), with assessments targeting general rather than specific flexibility, and cognitive, rather than behavioral flexibility. Knowledge regarding ED specific flexibility and flexibility in bulimia nervosa (BN) and binge eating disorder (BED) is still scarce. The aim of this study was to develop and validate a novel measure assessing general and ED specific flexibility in a diagnostically diverse sample, and in healthy controls (HCs). A sample of 207 adult individuals with EDs (55% AN, 29% BN, 16% BED) and 288 HCs responded to an online, 51-item, pilot questionnaire on ED specific and general flexibility. In addition, participants completed the shift subscale from the Behavior Rating Inventory of Executive Function Adult version (BRIEF-A), and the Eating Disorder Diagnostic Scale (EDDS). A principal component analysis (PCA) in the clinical sample yielded a 36-item, three-factor solution capturing general flexibility, flexibility related to food and exercise, and flexibility concerning body shape and weight. Results showed that the measure had good to excellent internal consistency, and good convergent validity. A confirmatory factor analysis (CFA) using data from HCs revealed good fit indexes, supporting the original factor solution. A receiver operating characteristics analysis (ROC) demonstrated excellent accuracy in distinguishing scores from those with and without EDs. A cutoff score of 136 yielded the most balanced sensitivity and specificity. Significant differences in general and ED specific flexibility were found between individuals with and without EDs. Overall, HCs achieved the highest flexibility scores, followed by those with BED, BN, and AN. In sum this novel measure, the Eating Disorder Flexibility Index (EDFLIX) questionnaire, was found to be reliable and valid in the assessment of cognitive and behavioral flexibility, with results offering support for the conceptual distinction between general and ED related flexibility. The study also provides strong evidence for the discriminant validity of the EDFLIX with results revealing significant differences in flexibility in people with and without EDs. In addition, significant differences in flexibility also emerged when comparing diagnostic groups, indicating the utility of the assessment instrument for classification purposes.

"Do you see what I mean?" staff collaboration in eating disorder units during mealtimes.

BACKGROUND: Eating disorders are psychiatric illnesses with potentially life-threatening consequences. Inpatient treatment is typically required for the most severely ill patients, who are often emaciated or significantly malnourished. A core therapeutic objective is to normalize eating patterns and facilitate weight gain. These goals guide the efforts of milieu therapeutic staff working with this patient group, who support renourishment through the positive manipulation of a structured environment, as well via relational aspects. However, there is a lack of empirical research exploring inpatient staff members' perspectives concerning various aspects of this work. This article explore staff's teamwork during mealtimes on inpatient eating disorder units. Specifically, we investigated the collaborative strategies employed to support core therapeutic goals of meal completion and normalized eating behavior, while concurrently maintaining a supportive, friendly atmosphere during mealtimes. METHODS: This was a exploratory qualitative study. Data was collected through 20 semi-structured in-depth interviews with staff members working on a specialized eating disorder unit. The interviews were performed after the conduction of meal time support. Cultural historical activity theory was used as the key theoretical tool for analysis. RESULTS: The analysis revealed three main themes: 1) strategic seating arrangements mediates division of labor, 2) the use of verbal and nonverbal communication as collaborative tools, and 3) the importance of experience as a collaborative resource. CONCLUSIONS: The present study found that mealtime collaborative strategies on inpatient EDUs were mainly of non-verbal nature, with level of experience as an important premise for staff collaboration. Greater awareness about how collegial collaboration is practiced may help staff members to learn routines and regulate scripts for mealtime practices.

To bend or not to bend? Rule adherence among staff at an eating disorder unit.

On inpatient eating disorder units, resolving under-nutrition and reestablishing normal eating behavior are key treatment aims. Consequently, the provision of support at mealtimes is a core work task for patients with severe eating disorders. The purpose of this study was to explore staff deliberations and actions, as observed during staff-patient interactions at mealtimes on an inpatient eating disorder unit (EDU). We specifically aimed to characterize how and why staff members intervene during staff-patient interactions in which a refeeding script is activated. This exploratory qualitative study combined non-participant observation and in-depth interviews. Content analysis was used to categorize and abstract the data material. Through the described analysis, we identified two main types of patterns which were categorized as rule adherence and rule bending, describing how staff chose how to intervene in situations where refeeding scripts were activated. The current findings may contribute to enhanced insight and awareness regarding staff behavior and deliberations when providing meal support, and thus help staff members to better understand how meal time support is practiced on inpatient EDUs.

"Time's up" - staff's management of mealtimes on inpatient eating disorder units.

BACKGROUND: Refeeding and normalizing eating behaviour are main treatment aims for individuals admitted to inpatient eating disorder units. Consequently, mealtime activities are specific, everyday activities, serving a clear therapeutic purpose, despite numerous challenges for both staff and patients. Few studies have specifically addressed staff involvement, interactions, and management activities to structure mealtimes. In this study, we investigated the structure of mealtime activities on inpatient eating disorder units, and identified associated staff behaviour. METHODS: Descriptive and exploratory qualitative study using video observations to investigate the structure of mealtimes and staff management of mealtime activities. Forty main meals were video recorded and the observational data were analysed using interaction analysis. RESULTS: An initial analysis during data screening identified three main parts of the meal: 'pre-eating', 'eating', and 'meal completion'. For each part, a regular pattern of activities occurred which were associated with staff behaviour. CONCLUSIONS: Increased awareness amongst staff regarding how they manage the meal and act through a clear internal structure can help staff members to further explore their behaviours and collaboration during mealtimes, and also contribute to improved interaction with patients during the various phases of the meal.