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Why is she Wearing her Underwear?

Working in residential, I did not have much experience with treating eating disorders. Most people with eating disorders go to a special eating disorder clinic or a residential that focuses specifically on the eating disorder itself. Sure, I had some patients in residential who would binge and purge on occasion, but we would not accept patients with anorexia nervosa because we were not medically equipped to handle such.

So when I started working inpatient, I was surprised to see so many anorexic patients and had to quickly learn how to give them the best care possible.

If you know someone who has an eating disorder or have one yourself, then you get it. It’s hard. I had to learn the right ways to communicate with these patients that would allow them to feel appreciated and understood. And I thought I had patience before, but lord have mercy, these patients taught me the true meaning of having patience.

To put it in simplest terms, there were times when I would only have two patients during my shifts: one with anorexia and the other a very mild case that didn’t need much of my attention throughout the day. This was because the patient with anorexia truly needed me most the shift. Next week, I will share another story about one of my patients who truly taught me so much about eating disorders and the way I provide care for these patients. This week, I am going to tell you about the first anorexic patient I had the privilege of caring for and some of the struggles I faced with her while providing her care.

We will call her Ally.

She was just twelve years old when she was admitted to the unit for anorexia. She was already on the unit my first week working inpatient. She was so quiet and kept to herself. She was adorable and kind and calm. For being just twelve years old, she was so insightful about her illness and knew how to take it a day at a time. Some days were harder than others of course, but she never gave up and always pushed herself to eat.

She was very skinny when I started to take care of her, but in reality she had gain almost seven pounds since being on the unit. Her skin color looked great, her hair wasn’t falling out, the dark circles around her eyes were fading. When I started taking care of her, I was impressed and seemed to think that she was doing just fine. Why was she still on the inpatient unit?

However, once I had the privilege of being her nurse for four days in a row, I understood the severity of her illness and I also learned that of all my patients, those with eating disorders can be some of the most manipulative. (I mean this in the nicest way possible!)

I’m sure by now, if you’ve been keeping up with my blog, you know that I am one who always gives the patients the benefit of the doubt. I am never accusatory. I never call a patient out on a lie unless it is deemed necessary. The issue here was, well, I didn’t know she was lying. She did great saying what she needed to say when she needed to say it. I learned very quickly that I had to stand my ground while still being her biggest advocate and let me tell you, that was hard.

Let me break down what a day on inpatient looks like for someone with an eating disorder.

1. Daily weights. First thing in the morning they get weighed. They aren’t allowed to see the number on the scale which can become a challenge when you have a patient who is determined to see the number. We have them get on the scale backwards. We cover up the number with a piece of paper and over that, block the view with our hands. Sometimes, they still manage to turn around at the right time and move your hand enough for them to see the dreaded number on the scale. When that happens, their day usually starts out rocky. So being consistent in not letting them see it is crucial.

2. Supervised, planned meals. The treatment team develops a plan for meals including how many calories are needed for each meal. Once that is done, the cafeteria and dietitian develop the meals. The patient has no say in what foods are chosen. When I first started working inpatient, I hated this. But over time it did make sense. You would sit in a private room with the patient with a timer set for 30 minutes. The patient had that much time to eat their meal and whatever wasn’t finished by the end of the 30 minutes had to be finished by drinking an ensure drink with the remaining amount of calories. While they eat, you had to watch their every move. Were they hiding food on purpose? Did they drop it so they didn’t have to eat it? After they finished eating, they weren’t allowed in their room or bathroom for an hour after meals to prevent purging. Some patients were not allowed in their bathroom or bedroom alone at all and had to be watched while using the bathroom. That was the worst part.

3. This was repeated for three meals a day and three snacks a day. The whole day is based on eating.

To me, it seemed like a nightmare. Imagine being on an inpatient unit struggling with an eating disorder and yet being forced to spend your entire day focusing on food!

On day two of being with Ally, I noticed some sneaky behavior and I wondered what the best way was to address it. We were sitting in one of the private rooms during lunch and I noticed she kept wiping her mouth consistently with a napkin every time she took a drink of her milk. I then noticed that she was spitting small amounts of the milk into the napkin.

“Why are you spitting out your milk?” I asked her.

“I’m not. I’m just making sure I don’t have a milk mustache,” she laughed. I smiled back but I wasn’t laughing. I may be new to treating eating disorders, but I wasn’t stupid.

“Can I have another napkin?” She asked when she realized hers was now covered in milk.

“I can’t give you another napkin. I’m sorry,” I told her. Once the patient started eating, she was not allowed to be left alone. I could not leave to get her another napkin and honestly, she didn’t need it now that I realized what she was trying to do.

That became a trend that day; her trying to get me to leave the room.

“Can you reheat my food?” “Can I have a cup of water?” “I dropped my spoon. Can I have a new one?”

She eventually realized that I was quickly catching on and she finally stopped asking me.

One day after snack, she stood up and a piece of cracker fell out of her gown.

“I don’t know how that got in there!” she tried to quickly explain.

Seriously, though. How did that happen? I had been watching her the entire time and yet she still managed to try to sneak food in her gown.

During treatment team that morning, I had to tell the doctor about what had been happening with this patient. And honestly, I didn’t want to.

There were very few doctors I’ve ever worked with that I butted heads with and he was one of them. Not because he wasn’t a good doctor, because he was really smart. However, he was smart in the sense of details, not in bedside manner. And you cannot work in mental health if you do not have good bedside manner! Some of his conversations with patients would make me cringe because there was no sympathy, no patience, no happiness. It was always a judgmental, rude conversation with a lack of thought behind his words. Did he know what he was talking about? Yes. Did he know how to appropriately articulate it? Absolutely not.

“What do you mean she’s hiding food?” He asked me when I told him. “She can wear her purple gown and that’s it. No underwear. No bra. Then there is no where for her to try to hide it,” he said matter-of-factly.

“You want her to sit in a chair in only a purple gown? I’m not making her take off her underwear. Her bra, fine,” I told him. I was instantly annoyed.

He didn’t respond as he walked away, which was fine with me. I mean, seriously. I get it. But I am not making her walk around the unit in a thin purple gown to sit on a chair with no underwear.

“The doctor really wants you to take off everything except your purple gown for meals now,” I told her. She started to cry.

“That really makes me feel so uncomfortable. I don’t want to be naked on the unit!” She continued to cry and I didn’t blame her one bit. It’d be different if she was trying to hide a lot of food every meal, but it was a one time thing and I was much more aware of what was going on. At that point it was a concern of whether we were keeping her safe and healthy versus violating her rights.

After she calmed down, she did agree to take off her bra. I didn’t say a word about the underwear and didn’t plan to.

However, I should have known, the doctor wouldn’t have it. During the following meal, she was eating great. She was almost finished with her meal. She was smiling. She was in a much better mood and to see her smiling during a meal was huge progress. That ended quickly when the doctor walked into the room.

“Why is she wearing her underwear?” He said as soon as he walked into the room. No hello. No how are you. No good job eating. Just straight to bringing up the underwear.

She quickly put her head down and started to cry.

“She can’t be trusted,” he said as he walked out of the room and shut the door behind him. I was furious.

I encouraged her to finish her meal and she did so with only a few second left on the timer.

Once she was finished, I went back to the doctor and told him I did not appreciate the way he handled the situation and after a long conversation, he finally agreed to let her keep her underwear on.

When I told her about it, she was so happy and she did great eating the rest of her meals for the day.

“Thank you for listening to me and being on my side,” she said.

“You’re welcome. I want you to get better. I don’t want this to be a set back for you.”

She smiled.

The moral of sharing the story is this: never stop advocating for your patients. Never stop advocating for what you know is right.

While inpatient is a place for safety and stabilization, it is crucial to ensure your patients still have a sense of control. Especially preteens and teens! That’s what they crave! Control! Being on an inpatient unit takes that away from them and finding anyway possible to make them feel a sense of control is vital to their progress.

Also, please, don’t be afraid to stand up for their needs. No matter how hard it is, because I know how hard it can be to stand up to a provider. But ultimately it is the patient who suffers if you don’t do what you know is right.

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