In 2006 the BBC made a documentary called ‘I’m a child anorexic’ (appendix 1) it focuses on “Rhodes Farm” – a treatment clinic in north London that specialises in children suffering from anorexia nervosa from girls as young as 12 years old. The programme follows the girls’ highs and lows at the clinic – the initial tantrums as they struggle to eat the foods they fear most, their interactions with staff, the friendships they make, their family dealings and then the tears of sadness when they finally have to leave.
The documentary focuses primarily on the struggle of 2 young girls in particular, 12-year-old Natasha and 13-year-old Naomi. I have chosen this clip because as well as educating about anorexia in young girls, it does a brilliant job of illustrating different types of relationships the girls have with the people surrounding them during this difficult time. It portrays variances in communication between them and their families, carers and peers. It also reveals how the young girls are feeling during their time at the clinic and demonstrates examples of how they are made to feel isolated and different.
Wherever you are and however you may be nobody likes to feel isolated and alone; being part of a community has a positive impact on your life. A sense of loneliness leads to feelings of sadness and anxiety, which consequently can complicate health problems. In health care settings in particular it is important that individuals feel a sense of belonging among other things. For this reason if progress is to be made by the girls at Rhodes Farm then is important that their care follows the ‘relationship-centred’ framework.
This framework has been developed so that all participants (staff included) experience a sense of: security, belonging, continuity, purpose, achievement and significance (Nolan et al. 2006). Whilst this framework was designed with a focus on older people, the six senses have wider applicability to other clinical areas to. The concept is that if all these senses are met, then the care you are giving and receiving is at its highest possible level. Throughout the clip there are arious scenes that demonstrate how happy the girls are to have one another.
It is extremely important, in their fragile states that they are not going through this journey alone and the fact that there are other girls of similar ages going through the same thing means that the girls can all relate to one another. This is important because it makes them conscious that they are not the only ones that are suffering with this illness. By establishing these close friendships the girls are achieving a sense of belonging within the clinic.
Having others that are going through the same as them also gives them the security to know they are not alone, which helps to ease sadness and pain. It is through communication that we build these friendships. Effective mutual communication is of paramount importance. Research shows that in order to make a difference to children’s lives healthcare practitioners must be able to relate to the children, support them in making decisions, listen to them, and involve them. “Good communication between healthcare professionals and patients is essential” (Nice 2012).
There are numerous scenes in the clip where Dr Dee Dawson founder of Rhodes Farm (referred to as Dr D throughout) is seen talking directly to the girls, both individually and in group situations; and in my opinion she does not always demonstrate good communication or meet all the senses from the framework I have mentioned earlier. It can be very difficult to judge what a child understands or knows (NHS), and this is apparent when Dr D is talking to Naomi about her personal progress at the clinic.
Dr D presumes that Naomi is aware about the calorific content of water, and by repeating her question and raising the tone and volume of her voice she appears to patronise Naomi quite significantly. This represents a distinct lack of empathy on Dr D’s part. Additionally what that caught my attention in this scene was how the majority of what Dr D has to say focuses on the negative aspects of Naomi’s journey; such as failing all her weekends away and how they feel she is keen to stay on, instead of picking up on the more positive aspects such as the meals she has eaten and the weight she may have gained.
You also see in this scene that because of the emotional and cognitive impacts that the illness has on Naomi, alongside the pressure from Dr D, she really struggles to verbalise her feelings. This is validated when Naomi breaks down in tears. One of the key qualities central to therapeutic communication is the ability to truly ‘attend’ to the other person. This has been referred to as giving ‘free attention (Egan 1990). Heron (1975) described this as, “a subtle and intense activity of being present for the client. “Talking is the main ingredient in medical care and it is the fundamental instrument by which the doctor-patient relationship is crafted and by which therapeutic goals are achieved” (Rotter and Hall 1992). In the clip, there is a scene that shows Naomi being made to drink water, as punishment for her behaviour. What is interesting about this scene is the difference in communication and in the relationship between the carer and Naomi compared with that of Dr D. The carer uses a more healing style when talking to her, using more positive phrases such as, “you can do it,” and generally being more encouraging.
She points out to Naomi what has already achieved in order to support her with what she has remaining. Carers are taught the basic principles of motivational interviewing (Miller and Rollnick, 1991). When people are hostile or hesitant to change the principles of this approach should be used. This approach can be summarised in the phrase ‘less is more’. Less serves as an acronym for the fundamental principles of this approach: listen, empathy not sympathy and sharing, af? rmation and support. Whitaker et al. 2005) Chitty and Black (2007, p. 218) explain that communication is the exchange of information, thoughts and ideas through verbal and non-verbal communication at the same time. They explain that verbal communication consists of entirely speech whereas non-verbal communication consists of gestures, postures, facial expressions, tone and level of volume. Children in particular once they have grown out of infancy, are acute observers of body language and the mood of others.
In the scene where Dr D is standing at the front of the room talking to the girls as a group I noticed that body language is evident from her and the girls. I also noted that she shows very little empathy or support towards them. In this scene the girls are sat at a lower level, they therefore need to look up to her as if she is more important than them. In doing this she is distancing herself from the girls. In their fragile conditions they already see her as the authoritative figure, and this positioning clarifies that further.
You can see in the girl’s facial expressions that they lack interest in what she has to say; their faces appear jaded. There is little eye contact made between the doctor and the girls as the majority of them have their heads down; some have their faces in their hands, other are picking their nails. These are common signs of disinterest and anxiety. The language that Dr D uses here is derogatory and I imagine makes the girls feel even more alienated. She emphasises this by categorising them, using phrases such as, “you people” and referring to non-anorexic people as “normal people”.
It is highlighted in studies how important it is to transfer warm, af? rming and respectful methods of communication however as seen in this clip Dr D seems neither warm nor affirming. I do not feel that she is seen to be being respectful of their low self-esteem and I do not see any example of her making an effort to be heartfelt or affectionate. To be able to identify and accommodate to the particular conversational practices of different social groups, you must have what Hymes calls ‘communicative competence’ (Hymes, 1972. This is a term used to describe a speaker’s potential for communicating effectively. Proficiency must be shown across a wide range of social, interpersonal and cultural contexts. This skill is a prerequisite for Dr D when communicating with these young girls and I would have thought that as the doctor who set up the clinic and therefore presumably has a keen interest in young people with this illness, that she would practice this theory in order to engage with the girls more and make them feel more at home and comfortable.
Studies show that an adult’s values and attitudes effect children close to them quite substantially, therefore it is vitally important that adults develop the insights; self-awareness and skills that are needed to guide the child, especially within a setting such as Rhodes Farm. From the day they are born children start to develop a sense of who they are. One of the main factors that contribute to their identities is relationships; this can be with family members, other adults and children, friends and other figures such as members of their community.
As well as being a standard of ethical practice, finding out what children and young people are feeling, hoping, thinking, and fearing in regards to their treatment, as well as decision making which affects them directly is now a statuary requirement. (Department of Health 2002) Family are important in any environment where young children are involved as they create a balance between change and stability. In early 1960s when Bowlby and Robertson established that there were negative consequences to he well-being of a child that is hospitalised and recognition of the family as a unit increased (cited by Alsop-Shields and Mohay 2001).
The concept of family-centred care (FCC) has become much more frequently used to describe a practice that identifies the family as the fundamental source of support. It also considers the deliberate involvement of the family essential to promote the health of all family members (Franck and Callery 2004, Shields et al. 2006). The classic view of parent – adolescent relationships is one of conflict, Anderson and Clarke (1982) opposed this view.
In the scene where Natasha is about to go out for a meal with her father for the first time since being at the clinic, she is talking to the camera about how hard it is has been for her to spend time without seeing her family. In a situation where Natasha was not sick or separated from her family for a long amount of time, her feelings and reactions on this subject may not be the same. When the parents arrive at Rhodes Farm to see the girls, the girls run out to hug them. Research suggests that children of a young age rely on the support of their families.
Through hugging the girls the parents show them love, affection and support. To feel secure, attention to the essential physiological and psychological needs need to be met and part of this can be done through hugging. In the clip when Natasha is alone with her father, I noticed that one of first thing that Natasha’s father tells her is how great she is looking. Giving children messages of love, approval, encouragement and above all respect, allows them to develop a positive sense of who they are.
Sick children in particular need to feel this; it can be one of the factors that contribute towards a faster recovery. These messages give them the confidence to voice their own feelings, views and opinions and aid them in making their own choices when appropriate. In Natasha’s case this support her father is showing her could have a direct influence on the way she perceives herself and therefore speed up her recovery. As Faulkner (1998) stated: “To be able to communicate effectively with others is at the heart of all patient care. ”
All the relationships seen in this clip have an immediate and vast impact on the girls. Dr D demonstrates how not relating to the girls makes it hard for her to gain their attention and presumably respect. When she talks to them as a group they have little interest in what she has to say, when she has one of the girls on her own the girl struggles to verbalise her feelings, resulting in tears. The relationships between the girls are what keep them motivated and happy. Without these friendships I imagine that the girls would feel so much more isolated and less inspired to get better.
The carer’s positive attitude and encouraging words are also key factors in making the girls feel safe giving them a sense of achievement and making them feel secure in these particular surrounding, The relationships between the father and daughter also gives the girl a sense of security as well as continuity. He is supporting her and showing love, which will give her the confidence she needs to get well. Within any type of relationship, especially within a care setting, it is imperative that the senses of belonging and security are met. Once these have been met, a trust is in place that makes communication much easier.