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STUDENT LED PROJECT

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VIDEO ON ANOREXIA

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29/05/2014

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This essay aims to show the rationale behind my student project, which is a trigger
video (Ber & Alroy 2001) aimed to promote reflection and discussion about Anorexia
Nervosa (AN). I will be exploring the negative effects that stigma has on the
therapeutic nurse-patient relationship and the advantages of using video as an
educational tool to inform healthcare professionals about AN and thereby, reduce
stigmatizing attitudes. Throughout this essay I will be using the term nurse but it
can be replaced by any other healthcare professional dealing with the patient, such
as physiotherapists, healthcare assistants and dentists.

Anorexia is a complex illness, with no definitive cause but is thought to be a mixture

of biological, psychological, social, spiritual and political factors involved (King &
Turner 2000, Matusek & Knudson 2009, Vitousek et al. 1998). Anorexia Nervosa is
defined as syndrome in which the individual maintains a low weight as a result of a
preoccupation with body image, construed either as a fear of fatness or a pursuit of
thinness (National Collaborating Centre for Mental Health 2004).

Although its prevalence is low at 0.03% of the population, Anorexia Nervosa has the
highest mortality rate of any psychiatric condition (Birmingham et al. 2010). In
addition, due to the ego-syntonic nature of AN, patients often resist treatment which
can be extremely distressing and challenging for healthcare professionals (Crisp
1997, Bell 2003, King & Turner 2000, Bamford & Mountford 2012, Vitousek et al.
1998).

The therapeutic alliance or therapeutic relationship is a phenomenon frequently

highlighted in literature as being the corner-stone of mental health nursing care to

facilitate recovery. This literature also identifies key characteristics the nurse
requires in order to develop the therapeutic relationship which are: trust, nonjudgmental attitudes, acceptance, genuineness and consistency (Peplau 1952,
Ironbar & Hooper 1989, Martin 1987, McQueen 2000, Murray & Huelskoetter 1990).

The need for a therapeutic nurse-patient relationship is paramount to a persons

recovery from AN (Crisp 1980, George 1997, Pereira et al 2006). A positive attitude
of the nurse towards a patient with AN is crucial to allow the therapeutic relationship
to develop (George 1997, Henry et al. 1993). This is highlighted in the views of
patients with AN, given in qualitative studies. The major theme to emerge is the
importance of positive therapeutic relationships developing, especially with their key
nurse (Sly et al. 2014). The therapeutic relationship is commonly regarded as a
bond that develops over time however, the patients initial perceptions of this
relationship can be a significant predictor of weight gain and treatment outcome
(Bourion-Bedes et al. 2012, Sly et al. 2014).

Despite this research, in practice, nurses have reported difficulties in creating these
therapeutic relationships, due to barriers ranging from: a lack of patient collaboration;
patients resistant to treatment; a lack of therapeutic nursing skills or knowledge
about the illness (Deering 1987, Ramjan 2004). The ego-syntonic nature of AN is
thought to be the reason the patient often withdraws from the nurse-patient
relationship (Vitousek et al. 1998). Denial of problems related to AN, which is
inherent in the disorder, is a symptom which can prove challenging to nurses.
However, research has shown that this denial tends to stop when therapeutic
relationships are established (Crisp 1980).

Discussing the complexities of what is required to establish a therapeutic alliance

with a patient with AN is outside the scope of this essay. Instead, the focus will be
on one barrier to therapeutic alliances that is commonly expressed in research - a
lack of nursing education about the complexity of the illness, which leads to
stereotyping, labelling, stigmatising and negative attitudes towards the patients as
nurses struggle to understand the disorder (Garrett 1991, King & Turner 2000,
Ramjan 2000).

Stigma exists when a discrediting attribute or mark that someone has, or is believed
to have, marks them as different and causes them to be denigrated (Goffman 1963,
Hayward & Bright 1997, Major OBrien 2005, Park et. al 2013). There is extensive
literature on the topic of stigma towards mental illness but only a few about eating
disorders (Crisafulli et al. 2008). In a population based survey in the UK, 33%
believed that individuals are solely to blame for their illness and 35% believed that
they could pull themselves together if they wanted to (Crisp 2005). These beliefs
also held by many healthcare professionals, with one study revealing 59.4% of
medical and nursing staff at a general hospital stating that patients with AN were
responsible for their condition (Fleming & Szmukler 1992). Other studies have also
shown that many nurses have the attitude that patients with AN are able to fix
themselves (Ramjan 2004)

AN is frequently associated with low self-esteem and it could be argued that this is
linked to the common comorbidity of AN and depression (Eckert et al. 1982, Huon &
Brown 1984, Rastam 1992, Williams et al. 1990, Williams et al. 1993, Zerbe et al.

1993). Self-stigma is when a person cognitively and emotionally accepts the

negative stereotypes assigned to them about mental illness. This causes them to
denigrate themselves due to belief that they are of less value than others because of
their diagnosis (Bilton et. al 1996, Rusch 2005). Due to the common link between
low self-esteem and AN, it is crucial that nurses are aware of self-stigma when
treating patients.

I believe there is a great need for nurses, who treat individuals with AN, to receive
some educational input regarding the disorder, which is regularly mentioned in the
literature (Fleming & Szmukler 1992, Garrett 1991, George 1996, King & Turner
2000). This education should target the common misconceptions of AN, that reduce
the quality of care given, primarily that people are to blame for their illness and can
pull themselves together if they want to (Crisp et. al 2000, Ramjan 2004). Evidence
shows that interpersonal contact with stigmatized individuals correlates to more
positive attitudes towards that group, from others (Corrigan et. al 2001, Couture &
Penn 2003, Link & Cullen 1986, Penn & Nowlin-Drummond 2001, Pettigrew & Tropp
2006).

In the case of nurses, this results in a significant increase in the likelihood of

the development of therapeutic relationships.

Before deciding on the educational tool to use, the barriers to nursing education
need to be thought through. The most obvious one is the lack of protected time
nurses have to explore evidence-based research. There is sometimes a lack of
willingness on the nurses part, but if they are willing, opportunities to participate in
courses on mental illness or have direct contact with patients who conduct live
teaching sessions are not always available (Penn et al. 2003). Tools to reduce

psychiatric stigma are limited those that are available are often unable to be
accessed by a large number of individuals, in a cost-effective manner (Penn et al.
2003).

Watching a five minute video, allows nurses to schedule time for the intervention as
they know how long the video will take. Also, a video generally requires far less time
than reading evidence-based literature on the topic (Dave & Tandon 2011). In
addition, if the video were to be posted online, this allows healthcare professionals
quick and easy access to it, which is increasingly cost-effective.

Video can be used to foster appropriate attitudes and combat subtle prejudices
(Raingruber 2003). It allows individuals to deal openly with their beliefs and
attitudes, even if they may be stigmatizing, allowing them to critically evaluate and
reflect on them. In addition, videos allow teachers to provide feedback without the
potential of embarrassment. There is a risk, if the patient is present, that they may
be offended if nurses dealing openly with stigmatizing attitudes (Ber & Alroy 2001).

Healthcare educators, in recent times, have started using films and videos as a
curricular tool, as it is important to find new and creative ways to stimulate, motivate
and increase learning for student nurses (Alexander 2005, Higgins & Lantz 1997).
This has been labelled cinemeducation (Alexander et. al 1994) and provides a
useful counterweight to traditional didactic ways of teaching. Nursing education
should not solely be a fact-loading process but also facilitate critical thinking and
reasoning (Facione et. al 1994). Film and video are entertaining ways of learning,
are known to engage attention and are enjoyed by users (Alexander 2005, Dave &

Tandon 2011).

Videos have the ability to portray behavioural and mental health themes with both
the aspect of realism and an emotional punch (Alexander 2005). They become a
window for practitioners to peer into, to see how afflicted individuals experience
illness in their day-to-day life (Silenzio et al. 2005). After watching them, videos can
easily trigger discussion and reflection and teachers can provide feedback in a
supportive, non-judgmental environment (Alexander 2005, Ber & Alroy 2001, Kalra
2012, Kalra 2013, Leelapattana et al. 2007).

Education should seek to examine the learners beliefs and integrate new, more
refined ideas into their belief system, thereby facilitating the learning process (Kolb
1984). Kolbs learning cycle (1984) highlights the importance of experience followed
by reflection, in order to promote alterations in thinking and behaviour. This is where
deep learning occurs. This is exemplified in cinemeducation which allows persons
to become emotionally involved in an experience, whilst at the same time, maintain a
distance because of the medium. This helps to foster objectivity in the reflection
process (Higgins & Dermer 2001, Kalra 2012, Leelapattana et al. 2007). In addition,
with videos often offering realistic yet sensitive portrayal of characters, the potential
to generate empathy and tap into the viewers emotional intelligence increases
(Kalra 2013, Pave & Tandon 2011).
Chan et al. (2009) found that educating teenagers in Hong Kong about
Schizophrenia with a lecture about stigma coupled with a video showing life
experiences of four individuals recovery from schizophrenia, significantly reduced
stigmatising attitudes. Clement et al. (2011) found a similar result in the UK with

student nurses watching a DVD of mental health service users and their carers
talking about their experiences, being as effective in reducing stigma as the live
speaking sessions. This reinforces the fact that video can be just as useful as live
interpersonal contact with stigmatized individuals. Ber & Alroy (2001) utilise the term
trigger videos to describe brief 3-10 minute clips that are used to provide reflection,
stimulate discussion and help medical students confront their feelings about aspects
of care in the doctor-patient relationship.

In light of the above research, I decided to direct and create my own trigger video
for healthcare professionals, in order to stimulate reflection and change stigmatizing
attitudes regarding AN. Firstly, I created a script and storyboard, integrating the
research about stigma and AN with the personal experiences of a friend who has the
illness. A voiceover of my friend provided her point of view and was juxtaposed with
a voiceover from myself to provide information. I deliberately endeavoured to utilise
the open question What do you see when you look at me? as a repetitive phrase
throughout the video, to stimulate reflection of those watching it. (See appendices
for a more detailed storyboard).

Crisafulli et al. (2008) created a questionnaire to be given after an educational input

regarding AN. This evaluates different facets of participants attitudes towards
individuals with AN including their views as to the cause of it. In addition Penn et al.
(1994) created a characteristics scale to elicit the views of students about
characteristics they associate with schizophrenia. Using these two papers as
inspiration, I created two shorter questionnaires, one that could be given before the
video and one after to evaluate its effect on stigmatizing attitudes (See appendices

for a sample of questionnaires I created).

In conclusion, AN is a complex illness which can often lead to stigmatizing attitudes

from the public and healthcare professionals. These attitudes can have a
detrimental effect on a persons recovery due to them creating barriers to the
formation of therapeutic relationships. This video highlights the experience of one
girls, Frances, struggle with AN, however, I believe that showing the commonalities
and differences between several peoples struggles would be more effective. This is
because people may perceive Frances experience as unique and not applicable to
others with Anorexia, so therefore an exception to the stereotype. In addition, I
believe this video could not only be utilised by healthcare professionals, but also by
family members of those with AN, the general public and students both in school and
on healthcare-related courses.

References

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Storyboard

Correction:
The title Anorexia
should be corrected to
Anorexia Nervosa, with
the term Anorexia
simply meaning loss of
appetite not the
diagnosed mental
illness.

Black balloons in the

background symbolising
the constant influence
individuals have due to
their illness (Anorexia
Nervosa) is a theme
throughout the video.

Regular body checking

is a common behaviour
for individuals with
Anorexia Nervosa
(Hasse et al. 2011, Suda
et al. 2013).

Masking the illness in front of friends and family

Feeling alone, with no

one to turn to for help,
all she can do is cry as
she doesnt know what
to do.

Many patients describe a

constant battle between
Anorexia as a friend and
an enemy (Colton &
APistrang,
jump cut
to Serpell et
2004,
Frances
now outdoors
al.1999).
in a field. This part of
the video, filmed
outdoors, aims to be
more surreal and
symbolic of the internal
thoughts and battle in
an individuals mind
with Anorexia.

One balloon is still left;

highlighting that
recovery is a lifelong
process for most
people with Anorexia
Nervosa. Recovery
does not mean the
problem is gone,
recovery requires
maintenance, follow
ups and regular
monitoring.

I believe this added

another dimension to
this video. The video
Trying to run away
reveals the actress in
from the problem or
the video has
ignoring it.
Letting go
of Anorexia
experienced
Anorexia
Nervosa first hand.
Ties well with the
repeated question:
What do you see
when you look at me?

A finale quote, aiming

to stimulate further
reflection alongside
the video

References
Colton A. & Pitstrang N. (2004) Adolescents Experiences of Inpatient Treatment for
Anorexia Nervosa. European Eating Disorders Review 12(5), 307316.

Haase A.M., Mountford V. & Waller G. (2002) Associations between body checking
and disordered eating behaviours in nonclinical women. International Journal of
Eating Disorders 44(5), 465468.

Haase A.M., Mountford V. & Waller G. (2002) Associations between body checking
and disordered eating behaviours in nonclinical women. International Journal of
Eating Disorders 44(5), 465468.

Serpell L., Treasure J., Teasdale J., & Sullivan V. (1999) Anorexia nervosa: friend or
foe? a qualitative analysis of the themes expressed in letters written by anorexia
nervosa patients. International Journal of Eating Disorders 25(1), 177186.

Suda M., Brooks S.J., Giampietro V., Friederich H.C., Uher R., Brammer M.J.,
Williams S.C.R., Campbell I.C. & Treasure J. (2013) Functional neuroanatomy of
body checking in people with anorexia nervosa. International Journal of Eating
Disorders 46(7), 653662.

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