# Admission and goodbye letters from adolescents with anorexia nervosa in a day hospital

Sarah Pinto, Lisa Minier, France Hirot, Pauline Drecq, Nathalie Godart, Caroline Huas

► To cite this version:

Sarah Pinto, Lisa Minier, France Hirot, Pauline Drecq, Nathalie Godart, et al. Admission and goodbye letters from adolescents with anorexia nervosa in a day hospital. BMC Psychiatry, 2025, 25 (1), 10.1186/s12888-025-06647-0. hal-05059144

HAL Id: hal-05059144

https://hal.science/hal-05059144v1

Submitted on 15 May 2025

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
RESEARCH

Open Access

<figure><img src="image_2.png" /></figure>

Check for
updates

# Admission and goodbye letters from adolescents with anorexia nervosa in a day hospital

Sarah Pinto<fnref n="1" />,<fnref n="2" />*, Lisa Minier<fnref n="3" />, France Hirot<fnref n="1" />,<fnref n="2" />,<fnref n="4" />, Pauline Drecq<fnref n="3" />, Nathalie Godart<fnref n="1" />,<fnref n="2" />,<fnref n="4" />† and Caroline Huas<fnref n="1" />,<fnref n="2" />,<fnref n="5" />†

**Abstract**

**Background** Care providers working with adolescents with anorexia nervosa (AN) encounter difficulties inherent in the illness (denial, ambivalence) and those related to the fact that it is most often the parents who bring adolescents to care units. Our aim was to study attitudes towards care among adolescents with AN treated in a specialised day hospital using an analysis of letters written before and after treatment.

**Methods** Adolescents (12–20 years old) treated for AN in a specialised day hospital, providing multidisciplinary care while enabling a return to schooling inside the facility were included. We analysed 50 admission letters and 23 goodbye letters using general inductive analysis. A mirror analysis was conducted.

**Results** In the admission letters, symptoms, calls for help, and reports on the adolescents' care trajectories were central themes. Among the categories noted in both the admission and the goodbye letters, some were similar, some mirrored others and a few differed.

**Conclusions** This study highlights how ambivalence and motivations towards care, recovery and illness all interact. It also shows the evolution of the adolescents' positions via their narratives on their experience of care, the constraints involved and its benefits for them. The results are discussed in a care perspective.

**Keywords** Anorexia nervosa, Day hospital, Adolescents, Motivational interview

**Background**

Anorexia nervosa (AN) is a severe psychiatric disorder, which requires specialized care [1, 2]. Three quarters of AN cases start before the age of 22, with an onset peak at 15.5 years [3]. Care provision for AN encounter many challenges, including patient ambivalence or denial: *why would I want to get better when I do not feel ill?* [4–6]. Ambivalence towards seeking care is considerable among adolescents with AN [7]. It is often the parents who bring their child to a care facility, and it is also they who initiate the request [8].

Depending on the gravity of the symptoms, AN can be treated on different levels of care. According to the French Health Authorities, multi-disciplinary care and

<footnote>†Nathalie Godart and Caroline Huas are equal contributors to this work and designated as co-last authors.</footnote>

<footnote>*Correspondence:</footnote>

<footnote>Sarah Pinto
sarah.pinto@fsef.net</footnote>

<footnote n="1">¹Fondation Santé des Etudiants de France (FSEF), Service Hospitalo-
Universitaire de Santé Mentale de l'Adolescent et du Jeune Adulte (SHU-
SMAJA), Paris, France</footnote>

<footnote n="2">²Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif 94807, France</footnote>

<footnote n="3">³Unité de Médecine de l'Adolescent, Hôpital Ambroise Paré (AP-HP),
Boulogne, France</footnote>

<footnote n="4">⁴UFR Des Sciences de la Santé Simone Veil, Versailles, France</footnote>

<footnote n="5">⁵Department of Family Medicine, Faculty of Health Sciences Simone Veil, University Versailles-Saint- Quentin-en-Yvelines (UVSQ), Montigny le Bretonneux 78180, France</footnote>
hospitalisation near the patient's home are recommended "to facilitate care continuity at discharge, to involve the family, and to maintain the patients' social and occupational links in their usual environment"(p.28) [9]. Day hospital serves to take over from full-time hospitalisation, or to organise outpatient follow-up. For minors, requests for care are often encouraged by parents and healthcare professionals. The issue here is not only to what extent adolescents agree to care, it is also how they adjust to it. In particular, care provision for adolescents requires consideration of concerns linked to the age group, such as socialising with their peers and schooling. These concerns can be exacerbated by AN. It is thus essential to motivate and involve the adolescents. This is central to the work carried out during care in our unit, complementing somatic, nutritional, psychiatric and psychological care. With this objective in mind, teams in our Foundation, when receiving adolescents, ask them to write a motivation letter to be included in their admission application file, a process shared by other units specialised in care provision for eating disorders [10, 11]. The reason for this letter is that their commitment to care is determined by their being involved, concerned and active in the recovery process [11, 12]. A goodbye letter has been added to our day hospital programme as proposed by Giombini et al., bringing the adolescents to look back over their experience of care [13].

To our knowledge, two studies have used letters, written either during care or in a research setting, to gain a better understanding of patient perceptions of their disorder and their relationship with AN [14, 15]. The patients, whether adults or adolescents, wrote about their disorder and their relationship with it, sometimes considering AN as a friend, sometimes as a foe [14]. We did not find any studies including both admission and goodbye letters. One study was conducted on admission letters submitted before treatment to identify the motivations of adults with AN [11].

This is why the aim of this research was to study attitudes towards care and their evolution among adolescents with AN between admission and discharge in a day hospital, investigating their expectations and feedback on their experience; the idea was to identify the mechanisms, or possibly the levers, that could potentially be useful in this care setting. This research is supported by the assumption that adolescents are experts on their own care experience.

## Methods

This research took place in a unit specialized in the treatment of AN for young people aged 12 to 20 years, which opened in October 2019. The day hospital is an alternative to hospitalisation, either as a relay for outpatient care or after stabilisation of acute situations in inpatient care.

It is the first unit in France to offer intensive multidisciplinary day care (five days a week) specialising in eating disorders while enabling a return to schooling inside the facility [12].

Admission letters were included in the admission request form filled in by the families and the adolescents. The instruction was to include "a letter from the adolescent explaining their expectations towards the day hospital". Goodbye letters were included at the end of the discharge evaluation without communication with the healthcare providers, so as to enable them to express themselves freely. The instruction was: "Your time at the day hospital is coming to an end. We would like to have some feedback on your experience with us in a goodbye letter". These letters were asked only from adolescents whose discharge corresponded to the end of treatment and a reorientation to outpatient care. Letters were both developed for healthcare purposes, not for research. Instructions have been added as a supplementary file.

The inclusion criteria were as follows: admission letters were to be from adolescents who had been diagnosed with AN, and admitted to the unit from October 2019 to April 2021. The exclusion criterion was a diagnosis of bulimia nervosa. The letters were retrieved from the adolescents' files and made anonymous.

A total of 52 adolescents were admitted: 50 wrote letters at admission, and 2 did not. Of these, 23/50 also wrote letters at discharge. We collected 73 letters in all. Each goodbye letter had a corresponding admission letter. Among the 27/50 adolescents without goodbye letters, 14 were discharged for transfer to an inpatient unit, 7 dropped out of the treatment programme, 5 were missing (including 2 due to a rapid discharge during the Covid-19 pandemic), and 1 refused.

The adolescents were aged from 12 to 19 years, 15,7 years on average (±2,0). Among them, 48 were girls and 2 were boys. All of them had a diagnosis of AN, 37 presented a restricting type and 13 a binge-eating/purging type [1]. The length of stay was 5,7 months on average with a minimum of 1 week and a maximum of 17 months. Half of the adolescents had been hospitalised at least twice before being admitted to the day hospital. The BMI at admission was 16,6 kg/m² on average (±2,5). Comorbidity was more the rule than the exception, most of the adolescents had comorbid depressive and or anxiety disorder, obsessive compulsive disorder or autism spectrum disorder.

This research obtained approval from the Paris-Saclay University Research Ethics Committee and reference methodology MR-004, Commission Nationale de l'Informatique et des Libertés (CNIL), after having informed the adolescents and their parents at admission.

A general inductive approach was used to analyse the letters in order to capture the core meaning of textual
data [16]. One of the purposes of the general inductive approach is “to develop a framework of the underlying structure of experiences or processes that are evident in the raw data.” (p.237) [16]. Thus, the general inductive approach is a well-recognised qualitative method to establish categories making sense of the content of the letters [16]. As required by qualitative research, the researchers kept a diary to monitor their impressions and biases and support reflexivity [17]. In order to ensure the thoroughness and reliability of the analysis, a double coding was performed. SP and LM (psychologist in the unit) analysed letters. The first coder created an inductive coding scheme based on 10 letters randomly chosen among the 50. This grid was used by the second coder and then modified if necessary by consensus. The same process was applied to the goodbye letters, with 5 letters chosen to create the first coding scheme. The categories were challenged by CH who wasn’t involved in the unit to limit subjectivity. After discussion, the final coding scheme was established. Some categories may seem broader than the extracts reported from the letters, as they result from a process of grouping smaller categories. No new elements emerged after the 38th admission letter (data saturation). Data saturation was not reached for the goodbye letters. A mirror analysis was conducted. It consisted in confronting the categories from the two types of letter in order to highlight the evolution in attitudes towards the illness and the treatment.

Extracts from the letters were made anonymous and have been translated for the purpose of this article endeavouring to capture the underlying meaning.

## Results

The coding schemes included 15 categories for admission letters and 14 for goodbye letters (see Table 1). The codes for the goodbye and admission letters were grouped into three categories: common codes, mirror codes and different codes. The “common” codes were those present in both letters. The “mirror” codes were directly or indirectly linked. The “different” codes appeared either in the admission or in the goodbye letters but not in both (see Table 1).

## Description of the letters

The 50 admission letters were about 18 lines long, with a minimum of 2 lines and a maximum of 98 lines, i.e. 3 and a half pages. About half the letters were written using the admission request form, and the other half on a standard sheet of paper. Most adolescents presented the context of their request, stating their name, their age and their last hospitalisation, if applicable.

The 23 goodbye letters were about 17 lines long, with a minimum of 6 lines and a maximum of 42 lines. All the letters were written on the page following the

self-administered discharge questionnaire, except for one, which was written on a separate standard sheet of paper. The adolescents reminded about their day-hospital stay and were free to talk about whatever they wanted.

## Seeking help, determination, and experience of care: from admission letters to goodbye letters

In the admission letters, the adolescents first of all introduced themselves, recounting their healthcare trajectories with the different hospitalisations they had been through (“I was first hospitalised in April 2019 at [name of hospital]” [F,16]). Most of them expressed a request for help linked to their symptoms, and/or their impact on their daily lives, or to their experience of distress that had become unbearable (“Today, I’m asking for your help, to help me escape from this illness, which has become hell for me and people close to me.” [F,17]). Seeking help was associated with the will to recover, often associated with great distress.

Determination, which was present in more than half of the letters, was depicted as the corner-stone to recovery, the key to change. The adolescents who had been previously hospitalised stated the importance of determination in the process of adhering to treatment.

The adolescents’ requests for help and their determination in their admission letters could also be observed in their goodbye letters, alongside their perception of the support they had received from the healthcare team. This support could also be felt as a constraint, sometimes considerable. In the goodbye letters, it was common to observe that these adolescents recollected their first day at the day hospital and stated how difficult it had been for them to accept treatment. Other adolescents reported experiencing moments of emptiness and boredom during treatment. However, most of them expressed their gratefulness towards the caregivers for their support (“Thank you for having accepted my tears and my bouts of anger, for having understood and appeased them.” [F,18]), despite the times when the constraint was felt.

This hindsight on their care trajectory seemed to be linked to their clinical evolution and the support of the healthcare team throughout their treatment. Their positions at discharge were more nuanced than those expressed in the admission letters. In the goodbye letters, they were thus able to give an account of their progress, whether clinical, academic or familial, and project themselves into the future (“It is a new departure, now is the time to turn the page and have new adventures.” [F,15]).

## Hovering between factors of stress and motivational levers: school, family and a desire to belong

In the admission letters, the adolescents also wrote about their motivations, about how they perceived the care that
<table><caption>**Table 1** Mirror coding for admission and goodbye letters (the categories for the goodbye letters are only shown if they differ from the admission categories)</caption><thead><tr><th colspan="2">Admission letters</th><th colspan="2">Goodbye letters</th></tr></thead><tbody><tr><td rowspan="5">Common codes</td><td>Categories</td><td>Verbatim</td><td>Categories</td><td>Verbatim</td></tr><tr><td>Academic</td><td>During my stay, I would like to resume my school lessons more seriously as year 11 is very important to me [F,15]</td><td>I can start this school year tomorrow confidently. [F,18]</td><td></td></tr><tr><td>Affects</td><td>I am really desperate. [F,15]<br>I'm happy to be among you once again [discharged from full-time hospitalisation] [F,14]</td><td>After several days, I was relieved [F,15]<br>I was very anxious. [F,19]</td><td></td></tr><tr><td>Family</td><td>What's more, the fact of not being cut off from my family means that I can focus on getting better and not on the thought of seeing them again. [F,15]</td><td>Now I can make the most of being with my family [F,15]</td><td></td></tr><tr><td>Recovery</td><td>Succeeding in getting rid of this voice which is harmful to me and which I can hear. Getting rid of this desire not to get better, even if it scares me. Also afraid of getting better. [F,14]</td><td>Thanks to you, I am no longer in hell, nor is my family. [F,15]</td><td></td></tr><tr><td rowspan="7">Mirror codes</td><td>Self-knowledge</td><td>What I expect from a stay at the day hospital is a supportive environment that will enable me to reconnect with myself help me to understand and know myself better [F,17]</td><td>Self-awareness</td><td>As months go by, with the mediations and appointments, I have learnt to know myself, and to understand better how I function. [F,19]</td></tr><tr><td>Help</td><td>Today, I'm asking for your help, to help me escape from this illness, which has become hell for me and people close to me. [F,17]</td><td>Support from the care team</td><td>For once in my life, I have not run away from the issue as I usually do, but I have "put my finger where it hurts", with the support of a whole team. [F,16]</td></tr><tr><td>Peer affiliation</td><td>I am convinced that this clinic will not cut me off from my social world, because I will be able to open up to young people who are experiencing situations similar to mine. [F,15]</td><td>Positive relationships</td><td>Even so, I have had some very good times, especially with girls and boys who have also helped me to share and laugh again... [F,15]</td></tr><tr><td>Fear of relapse</td><td>Unfortunately, I had a relapse after my first hospitalisation and I would like to avoid a second relapse at all costs. [F,16]</td><td>Perspective</td><td>My path towards a cure has not yet completely ended, but I am sure that it will come to an end. [F,13]</td></tr><tr><td>Evolution</td><td>My state is getting worse and worse. [F,14]</td><td>Change</td><td>I have been feeling a bit better since I got here. [F,16]</td></tr><tr><td>Determination</td><td>The 29th of July 2019 is the day I decided that I was going to stop enduring the dictatorship of this illness. [F,15]</td><td>Constraint</td><td>I was not the only one to remind you that being here pisses me off. [F,16]</td></tr><tr><td>Distress</td><td>I am afraid of my own vulnerability. I am afraid of what I could do to myself [F,14]</td><td>Gratitude</td><td>Thank you for having accepted my tears and my bouts of anger, for having understood and appeased them. [F,18]</td></tr><tr><td rowspan="4">Different codes</td><td>Care</td><td>I was first hospitalised in April 2019 at [name of hospital] [F,16]</td><td>Future</td><td>It is a new departure, now is the time to turn the page and have new adventures. [F,15]</td></tr><tr><td>Consequence</td><td>Since I was 13, I have been regularly bothered by my anxiety nervosa, which has incessantly disturbed the course of my existence and the projects that I have had. [M,18]</td><td></td><td></td></tr><tr><td>AN Symptoms</td><td>At that time, I used to eat lettuce and half a cucumber a day. I regularly had binging episodes. [F,18]</td><td></td><td></td></tr><tr><td>Sport</td><td>My parents have started to forbid the practice of my passion: athletics [F,14]</td><td></td><td></td></tr><tr><td></td><td></td><td>Opinion</td><td>The days are much more structured, and are therefore not wasted. [F,18]</td></tr><tr><td></td><td></td><td>Boredom</td><td>I got very bored during the mediation sessions. [F,12]</td></tr></tbody></table>

The admission letters are presented in relation to the content of the goodbye letters.

was to come and what this care could mean for them. School, family and a desire to belong to a peer group were seen as factors of stress, and were therefore prominent in the letters. The adolescents explained how these factors interacted with the illness, increasing their overall level of anxiety, which in turn increased the symptoms of

AN. Whether these AN symptoms became perceptible to the family or whether they were uncontrollable for the adolescents, their aggravation inevitably led to medical attention. In certain cases, the severity of the symptoms required immediate and urgent care.
<figure><img src="image_3.png" /><figcaption>**Fig. 1** Categories by number of hospitalisations</figcaption></figure>

School, family and a desire to belong to a group of peers could also be seen as motivational levers. Wishing to know themselves better, keeping up a sports activity and fear of relapse also continued to be significant factors, encouraging them to ask for help and in the long term to seek recovery. Keeping up a sports activity was the only item in the adolescents' desires outside their illness and school.

A central place was given to schooling. Indeed, it constituted a decisive reason for requesting admission to the day hospital, and it was frequently the only reason for accepting care ("During my stay, I would like to resume my school lessons more seriously as year 11 is very important to me" [F,15]). This preoccupation was less prominent in the goodbye letters. A decrease in preoccupations about school could be linked to the fact that the adolescents had resumed schooling within the facility.

Concerning family, in the admission letters, the adolescents wrote about how the illness had changed their relationships, creating conflicts, guilt or worry for these adolescents and their parents, often aggravated by previous hospitalisations, particularly during times of separation ("What's more, the fact of not being cut off from my family means that I can focus on getting better and not on the thought of seeing them again." [F,15]). In the goodbye letters, they explained how recovery had enabled them to return to the relationships they had before the onset of the illness.

Concerning the desire to belong, certain adolescents wrote that they hoped to meet other young people with a similar experience to theirs, while some of them wanted to return to a seemingly normal adolescent life, which was often linked to a return to school. Most young people did not feel included in their current peer group, they

wrote about how the illness prevented them from keeping up and maintaining relationships with adolescents of their age. They mentioned their isolation and loneliness ("I am convinced that this clinic will not cut me off from my social world, because I will be able to open up to young people who are experiencing situations similar to mine." [F,15]). In their goodbye letters, the adolescents spoke about having formed real and significant relationships, and positive links with other adolescents and with the healthcare team ("Even so, I have had some very good times, especially with girls and boys who have also helped me to share and laugh again..." [F,15]). Concerning relationships with their peers, they had experienced the creation of links with adolescents with the same diagnosis, and they thus felt understood. Building solid relationships was as important as feeling accepted by a group.

## Motivations and previous hospitalisations

Among the admission letters, 4 of them clearly included the adolescents' wish not to be treated. It can be noted that some of these adolescents had already been hospitalised in the past.

The types of motivation mentioned in the admission letters varied according to the number of these young people's past hospitalisation experiences. Two groups emerged: the first group was made up of 25 adolescents who had either never been hospitalised, or only once (see Fig. 1). The second group was made up of 25 adolescents who had been hospitalised from two to four times. We observed that the level of determination, the level of distress, and the clinical evolution— most often a deterioration in the patient's state— were more often mentioned by the adolescents in the first group. The categories relating to the family, to their healthcare trajectory, to fear of
relapse, to school, to their desire to belong in their peer group and to symptoms, were more often mentioned by the adolescents in the second group. In this group, issues around separation from the family linked to hospitalisations, and their desire to return to school were at the centre of their preoccupations.

## Motivations and AN sub-types

The motivations also seemed to vary according to the AN sub-type: the restricting type or the binge-eating/purging type. We therefore conducted an analysis according to AN sub-type. The first group consisted of 37 female adolescents diagnosed with the restricting type. They mentioned school, sport and fear of relapse as important levers. They wrote a lot more about their healthcare trajectory and sometimes about the impact of undernourishment on their lives. They more often expressed major distress. The second group was composed of 13 adolescents with the binge-eating/purging type. For them, the desire to know and understand themselves better was a particularly important aspect. Most adolescents in this group wrote about their symptoms, describing most often binge-eating episodes and their comorbidities (depression, anxiety and self-harm).

## Self-knowledge, relationship with recovery and vigilance towards symptoms

Self-awareness was a major issue in the goodbye letters, which echoed the motivation to accept treatment and to know and understand oneself found in the admission letters ("What I expect from a stay at the day hospital is a supportive environment that will enable me to reconnect with myself help me to understand and know myself better" [F,17]). We could hypothesise that once the treatment is underway, and the path to recovery initiated, the adolescents were once more able to retrieve their identity, free from the illness, and to learn to know themselves again ("As months go by, with the mediations and appointments, I have learnt to know myself, and to understand better how I function." [F,19]). From being adolescents with anorexia nervosa, they became just adolescents.

For them, self-awareness greatly justified their stay at the day hospital. The fact that they had learned to know themselves and understand certain dimensions in their functioning seemed to reassure them on the time they had spent in care and on how this could help them continue to progress in the future.

Generally speaking, few terms relating to sadness, fear, surprise, anger, joy or disgust were found. In the admission letters, emotions were rather linked to the care trajectories and to the evolution of the illness. In the goodbye letters, emotions seemed to be linked to clinical improvement and relationships.

In the admission letters, the perception of the stage of evolution of the illness was variable. Certain young people experienced the different symptoms very intensely, whereas others did not recognise the existence of the disorder, and some considered themselves to be cured. Indeed, out of the 50 letters, 18 did not mention an eating disorder or anorexia nervosa, even if some of them described their symptoms. However, in their letters we found a structure and a distribution of categories that were similar to those for the letters written by adolescents who did name their eating disorder. Among these letters, 5 did not mention any aspect linked to the clinical symptoms of anorexia nervosa, but they mentioned comorbidities (depression, anxiety, self-harm). In the goodbye letters, the young people's position on their overall clinical evolution was more unanimous and nuanced. They all shared the feeling that they had gone a long way, but they remained prudent about the variations of an illness for which they had learned to identify the different symptoms ("My path towards a cure has not yet completely ended, but I am sure that it will come to an end." [F,13]). This vigilance then replaced their fear of relapse. Knowledge of themselves and their own functioning was also part of the recovery process, described as generated and/or reinforced via their experiences at the day hospital. Where recovery had been seen as a linear and immediate phenomenon, it had become an ongoing, fluctuating process.

## Discussion

The aim of this research was to study attitudes towards care among adolescents with AN at admission to, and at discharge from, day hospitalisation, and their evolution. We investigated their expectations and the feedback on their experience.

## Ambivalence in the acceptance of care and cure - evolution of the discourse

The young people's discourse was pervaded by ambivalence [4, 7]. Indeed, in the admission letters, each of the factors increasing the level of stress was also presented as a motivation or a resource. Indicators of ambivalence appeared on different levels of interpretation (themes or wordings). Ambivalence was noted mainly in the following categories: Peer affiliation, Academic, Family, which appeared as fundamental aspects. The adolescents explained how these aspects had an impact on, and were impacted by, the illness. For each of these fundamental aspects, the letters showed ambivalence, expressed in either negative or positive mode. For example, the young people sometimes described the schooling provided in the unit as the only motivation, and at the same time, expressed the anxiety it generated for them. Some of them had experienced a return to school and had
concluded that it had been too demanding physically and psychologically for them. Ambivalence has also been found in numerous other studies. In a study by Gorse et al. on admission letters from adults with AN, ambivalence had two dimensions: “inner struggle and fear of recovery” (p.4) [11]. We found these two dimensions in these adolescents’ letters. Ambivalence noted in the admission letters was also mentioned by the adolescents in their goodbye letters. They expressed what they had felt at the time of their admission request.

In the admission letters, this ambivalence was also visible in the discourse on the care trajectory and recovery ("Succeeding in getting rid of this voice which is harmful to me and which I can hear. Getting rid of this desire not to get better, even if it scares me. Also being afraid of getting better." [F,14]).

Seeking help, motivation for change and ambivalence are key aspects in the treatment of AN [18, 19]. The adolescents' determination to get better was very prominent in the letters studied. Several other studies have found this dimension when exploring AN adults' and adolescents' positions with regard to their illness. These studies associated the determination to get better with the young people's desire to regain control of the situation [14, 15]. Determination and resolve to get better have also been described as a variable in care trajectories [20].

In the goodbye letters, we noted that wishing to get better and feeling ready to change were distinct from agreeing to be treated for the eating disorder. Despite their determination to get better mentioned in their admission letters, the adolescents experienced treatment as a constraint. Their determination to change did not prevent them from finding it difficult ("I would be lying if I told you that I only had good times. On the contrary, it was very difficult for me to accept all these changes at the start, all these new things." [F,18]). As has also been described among adults, adolescents may want to get better but without being ready to change their behaviours [20]. This discrepancy between feeling ready to change and the actual process of change has also been widely described in the theorisation of the different stages of change by Prochaska & DiClemente, mainly on addictive behaviours and on AN [21, 22]. Furthermore, people with AN have been found to present certain deficits in cognitive flexibility, which contributes to making their adaptation to change harder [23].

Further to this, we noted the absence of any mention of eating disorder or AN in more than a third of the admission letters. We found it surprising to write a motivation letter in a context of specialised care for eating disorders without naming the illness. This could be because the subject of the request is obvious, in view of the specificity of the day hospital, or it could result from a degree of denial of the disorder by the adolescents. The

non-recognition of AN has been frequently described as a major challenge for the treatment of this complex disorder, which reinforces ambivalence [4, 5, 24]. The literature indeed provides numerous recommendations on the management of ambivalence in the treatment of AN with a focus on motivation, particularly in the setting of motivational interviews [6, 18, 22].

## Day hospitalisation: non-constraining treatment provision experienced as a constraint

Because of ambivalence and the severity of symptoms, treatment can be imposed, often against young people's will. The experience of constraint was particularly marked in our sample, given that most of them were minors. Treatment was under parents' legal authority and supported by the healthcare teams. Although the adolescent's opinion is sought on admission, most are minors and are therefore admitted at the request of their parents, which partly explains the resistance to admission [25]. Legally, adolescents cannot choose to terminate treatment on their own. In the goodbye letters, some adolescents remembered how difficult it had been to actually step inside the unit for the first time. Some remembered writing in their admission letter that they did not want to go there ("I 'm not the only one to remind you that being here pisses me off." [F,16]). They nevertheless sometimes added that it had been beneficial for their progress. In a study by Tsiandoulas et al., patients treated for AN in paediatrics for acute somatic episodes, recognised and understood this constraint in the aftermath [26]. In the present case, the acceptation of care was related to the severity of their condition. The more severe was their condition, the more difficult they found it. As their condition improved, it became easier for them to accept treatment. At the end of their treatment, the patients expressed their recognition and gratitude, as found in most goodbye letters ("Thank you for having accepted my tears and my bouts of anger, for having understood them." [F,18]). As shown in the existing literature, the perception of coercion is partly linked to the awareness of the need or not to be hospitalised [27]. It has been shown that although the feeling of constraint remains stable after 2 weeks of care, the feeling of need for hospitalisation does change [28]. This may explain the evolution in the adolescents' statements in their goodbye letters.

Treatments and healthcare teams were seen as constraints; however, relationships with the care team were mostly viewed in a perspective of assistance, support and understanding, perceived and felt by the adolescents. As Tan et al. described, despite the fact that care was often imposed by the parents, and that some young people clearly expressed their wish not to come, most of them ultimately found it worthwhile and were grateful for the help they had received. The trusting relationship
that adolescents built with the team or more specifically
with some members of the team was decisive, and helped
them accept the feeling of constraint [29].

For healthcare providers, it is frequent to perceive the
difficulties that young people have in enduring constraint
during care. It is sometimes difficult and trying for the
teams [30], but this work has shown how essential it can
be. Mitrofan et al. observed the importance of continu-
ity and constancy among health professionals in young
people's care trajectories [31].

The treatment of adolescents in psychiatry raises ethi-
cal issues, particularly in the treatment of anorexia ner-
vosa [27, 32]. It is considered that ‘Coercive pressure is
justified only by the likelihood that treatment will be
beneficial.’ (p.112) [28]. In the case of day hospitalisation,
parental constraint is justified by the effectiveness of the
care, both in clinical terms and in terms of social integra-
tion. This has been widely demonstrated and justifies a
position of firm recommendation by the parents, which
helps to initiate care and build a therapeutic alliance [33].
Furthermore, day hospitalisation is well received by ado-
lescents [34]. In the unit, adolescents attend every day
with no major resistance.

Envisaging adolescent life outside a care setting: the
importance of schooling in the acceptance of care in a day
hospital with a treatment + schooling programme

Schooling is a major concern for adolescents, and it was
often the central motivation in the admission letters for
the day hospital, with its schooling facility. In our study,
for some adolescents with a quite long treatment trajec-
tory, schooling had been interrupted for several months
or years. In this case, the schooling facility often moti-
vated the adolescents to agree to be admitted to our day
hospital. Paradoxically, when schooling had resumed,
academic issues, while mentioned in both admission
and goodbye letters, were less often mentioned in the
goodbye letters. We could hypothesise that returning to
school within the care unit could have eased concerns
on this subject. Patients were then able to invest in other
areas such as relationships or projects.

In the admission letters, the young people mentioned
their current concerns and what they had seen as having
been changed by their illness, particularly the impact on
their life project. Nordbø et al. showed that feeling cor-
nered, with no project or perspective, was an important
factor with a negative impact on the motivation to get
better [5]. In the goodbye letters, our adolescents had a
more marked tendency to project themselves into the
future and talk about future projects.

Through the letters, we could also observe that clini-
cal progress enabled projections towards the future, with
implications, projects, and especially desires beyond the
illness. Indeed, discharge is an important milestone in the

course of the illness, as recounted in the goodbye letters.
It seemed that looking back over their progress and tak-
ing a step back from their treatment at the day hospital
enabled the adolescents to think about what was next for
them, beyond AN. Most of the goodbye letters followed
this pattern.

The treatment + schooling programme offers two lines
of approach to care provision, each an asset for the other:
schooling and the associated healthcare [10, 12]. School-
ing is one of the main motivations for our admission
requests. It is therefore a way to enable young people
to commit themselves to intensive care, which is not in
itself a motivation for them. For young people who have
been in care for several years, this programme provides
a bridge towards a return to normal schooling, and for
those initiating treatment it can help to avoid drop-out
from school.

At admission, some adolescents testified to difficul-
ties in coping with the illness when returning to their
normal environment ("*after each of my hospitalisations,
the return to normal was quite abrupt for me...*" [F,16]).
They described how the unit had met their need for a
transition in their trajectory, especially once they were
discharged from full-time hospitalization. Therapeutic
teamwork within the treatment + schooling programme
enables each adolescent's care trajectory to be person-
alised, combining treatment and their studies. In the
unit, when the end-of-care objectives have been met, the
adolescent gradually stops attending school inside the
clinic and returns to their own school while continuing
to receive part of their care in the day hospital for a few
weeks. After this transition period, the treatment is con-
cluded and the adolescent is referred to outpatient care.

Generally speaking, the introduction of schooling in
hospital could make hospitalisation more acceptable for
adolescents, and facilitate the transition from hospital to
daily life.

Strengths and limitations

To our knowledge, this is the first study to analyse both
admission and goodbye letters written by adolescents
being treated for AN in a day hospital, and to put them
into some kind of perspective. One of the main strengths
of this study was the size of the sample, with 73 letters
subjected to a qualitative analysis.

One of the main limitations of this study was the desir-
ability bias [35]. Certain letters had a very conventional
format, resorting to the classic codes of letter writ-
ing, with a very artificial type of discourse. The adoles-
cents were not informed about the impact of the letter
on the decision for inclusion in the program. Concern-
ing the goodbye letters, it is important to note that they
were only from adolescents who had reached the end of
their care trajectory. This excluded adolescents who had
discharged themselves against medical advice and those who had been transferred to full-time hospitalisation. Our data is specific to our population and highlights the interest of the treatment + schooling programme in day hospital. Only the young people's admission requests were studied. The parents' requests remain to be studied, especially as acceptation of, and investment in, care rest partly on them. With interviews, it would also be valuable to be able to explore the adolescents' experiences of their treatment and the different areas of care implemented in order to identify what they felt was beneficial or lacking, particularly at some distance from the end of treatment.

## Conclusions

Adolescents with AN are often in denial of the disorder, which interferes with their motivation to seek care. An admission request letter could therefore be an interesting tool to mobilise them, and to work with during care.

The goodbye letters were characterised by an omnipresent gratitude towards the team, expressing how they had supported the adolescents throughout their stay. Self-awareness of their own behaviour enabled the adolescents to learn to be aware of their own emotions and to detect evolutions in their symptoms. Patients who have a good experience of care are perhaps more likely to seek help again, if they need it. It seems to us that this is an important focus for day hospitals.

For a population deeply preoccupied with schooling, where generating the motivation to get better is difficult, the care/schooling model in a day hospital specialised in eating disorder is a valuable resort. In this sample, many of the adolescents had previously required several hospitalizations. Day hospital care provides an opportunity to work alongside the families, in the adolescents' own environments, focusing on their current concerns related to AN, comorbidities and age. In addition to promoting or supporting progress towards recovery, this system enables adolescents to reconnect with the reality of other young people in a secure environment.

It would be interesting to explore the young people's feedback on the treatment, at a distance from it.

## Abbreviations

AN Anorexia nervosa

## Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12888-025-06647-0.

Supplementary Material 1

## Author contributions

SP gathered data, analysed data, wrote the first draft and finalized the manuscript. LM analysed data. FH participated to the building of discussion and to the writing of the manuscript. PD designed the study and supervised

analysis. CH and NG designed the study, supervised analysis and writing and approved final manuscript. All authors approved final manuscript.

## Funding

SP benefits from a CIFRE funding for her PhD thesis.

## Data availability

Data are in the medical files, in a paper version. It could be consulted on site, under certain conditions.

## Declarations

### Ethics approval and consent to participate

This research obtained ethics approval from the Comité d'Ethique pour la Recherche of Paris-Saclay University. The use of the data was possible in the terms of the reference methodology MR-004, Commission Nationale de l'Informatique et des Libertés (CNIL), after having informed the adolescents and their parents, when under 18, at admission in accordance with the Declaration of Helsinki. According to French regulations, the data used in this research were data from the medical files collected during the treatment process, which classifies this research as a non-interventional study. It does not require consent but the information of adolescents and, if minor, of their parents. In absence of opposition, the data was used. Après avoir informé le jeune ainsi que ses parents si minuers, les données des jeunes qui ne se sont pas opposés à l'utilisation de leurs données ont été incluses dans la rechre.

### Consent for publication

Not applicable.

### Competing interests

NG and SP are working in the specialised ED unit. LM and PD used to work in the unit until the end of 2021.

Received: 26 June 2024 / Accepted: 21 February 2025

Published online: 11 March 2025

## References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. American Psychiatric Association. 2013. https://psychiatryonline.org/doi/book/10.1176/appi.book.9780890425596

2. Schmidt U, Wade TD, Treasure J. The Maudsley model of anorexia nervosa treatment for adults (MANTRA): development, key features, and preliminary evidence. J Cogn Psychother. 2014;28(1):48-71.

3. Solmi M, Radua J, Olivola M, Croce E, Soardo L, Salazar De Pablo G, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry Janv. 2022;27(1):281-95.

4. Espíndola CR, Blay SL. Anorexia Nervosa's meaning to patients: A qualitative synthesis. Psychopathology. 2009;42(2):69-80.

5. Nordbø RHS, Espeset EMS, Gulliksen KS, Skårderud F, Geller J, Holte A. Reluctance to recover in anorexia nervosa. Euro Eat Disorders Rev. 2012;20(1):60-7.

6. Vitousek K, Watson S, Wilson GT. Enhancing motivation for change in treatment-resistant eating disorders. Clin Psychol Rev. 1998;18(4):391-420.

7. Williams S, Reid M. Understanding the experience of ambivalence in anorexia nervosa: the maintainer's perspective. Psychol Health. 2010;25(5):551-67.

8. Williams EP, Russell-Mayhew S, Moules NJ, Dimitropoulos G. My whole world fell apart: parents discovering their child has anorexia nervosa. Qual Health Res. 2020;30(12):1821-32.

9. Haute Autorité de Santé. Anorexie mentale: prise en charge. https://www.hasante.fr/jcms/c_985715/fr/anorexie-mentale-prise-en-charge 2010.

10. Hirot F, Huas C, Durand D, Godart N. The evaluation of therapeutic residential care for adolescents and young adults in France: A systematic review. Front Psychiatry. 2021;12:609365.

11. Gorse P, Nordon C, Rouillon F, Pham-Scottez A, Revah-Levy A. Subjective motives for requesting In-Patient treatment in female with anorexia nervosa: A qualitative study. Paterson K, éditeur. PLoS ONE. 2013;8(10):e77757.

12. Minier L, Bréan C, Godart N, Équipe De L. Unité De Jour Michel-Ange. Dans les coulisses de l'Unité de jour Michel-Ange: repenser la prise en charge des adolescents souffrant de troubles des conduites alimentaires. Enfances Psy. N° 2021;90(2):124-34.
13. Giombini L, Nesbitt S, Waples L, Finazzi E, Easter A, Tchanturia K. Young People's experience of individual cognitive remediation therapy (CRT) in an inpatient eating disorder service: a qualitative study. Eat Weight Disord. 2018;23(4):499-505.

14. Serpell L, Treasure J, Teasdale J, Sullivan V. Anorexia nervosa: friend or foe? Int J Eat Disord. 1999;25(2):177-86.

15. Freedman G, Leichner P, Manley R, Sandhu PS, Wang TC. Understanding anorexia nervosa through analysis of thematic content of letters in an adolescent sample. Eur Eat Disorders Rev Sept. 2006;14(5):301-7.

16. Thomas DR. A general inductive approach for analyzing qualitative evaluation data. Am J Evaluation Juin. 2006;27(2):237-46.

17. Symon G. Qualitative research diaries. Qualitative methods and analysis in organizational research: A practical guide. Thousand Oaks, CA: Sage Publications Ltd; 1998:94-117.

18. Kelly AC, Waring SV. A feasibility study of a 2-week self-compassionate letter-writing intervention for nontreatment seeking individuals with typical and atypical anorexia nervosa. Int J Eat Disord Août. 2018;51(8):1005-9.

19. Price-Evans K, Treasure J. The use of motivational interviewing in anorexia nervosa: motivational interviewing and anorexia nervosa. Child Adolesc Mental Health Mai. 2011;16(2):65-70.

20. Nordbø RHS, Gulliksen KS, Espeset EMS, Skårderud F, Geller J, Holte A. Expanding the concept of motivation to change: the content of patients' wish to recover from anorexia nervosa. Int J Eat Disord Nov. 2008;41(7):635-42.

21. Prochaska JO, DiClemente CC, Norcross JC. Search of how people change: applications to addictive behaviors. Am Psychol. 1992;47(9):1102-14.

22. Treasure J, Ward A. A practical guide to the use of motivational interviewing in anorexia nervosa. Eur Eat Disorders Rev Juin. 1997;5(2):102-14.

23. Miles S, Gnatt I, Phillipou A, Nedeljkovic M. Cognitive flexibility in acute anorexia nervosa and after recovery: A systematic review. Clin Psychol Rev Nov. 2020;81:101905.

24. Halmi KA, Agras WS, Crow S, Mitchell J, Wilson GT, Bryson SW, et al. Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Arch Gen Psychiatry 1 Juill. 2005;62(7):776.

25. Hubert T, Pioggiosi P, Huas C, Wallier J, Maria AS, Apfel A, et al. Drop-out from adolescent and young adult inpatient treatment for anorexia nervosa. Psychiatry Res. 2013;209(3):632-7.

26. Tsiandoulas K, McSheffrey G, Fleming L, Rawal V, Fadel MP, Katzman DK, et al. Ethical tensions in the treatment of youth with severe anorexia nervosa. Lancet Child Adolesc Health Janv. 2023;7(1):69-76.

27. Schreyer CC, Coughlin JW, Makhzoumi SH, Redgrave GW, Hansen JL, Guarda AS. Perceived coercion in inpatients with anorexia nervosa: associations with illness severity and hospital course. International Journal of Eating Disorders; 2016.

28. Guarda AS, Pinto AM, Coughlin JW, Hussain S, Psych MRC, Haug NA et al. Perceived coercion and change in perceived need for admission in patients hospitalized for eating disorders. Am J Psychiatry. 2007.

29. Tan JOA, Stewart A, Fitzpatrick R, Hope T. Attitudes of patients with anorexia nervosa to compulsory treatment and coercion. Int J Law Psychiatry Janv. 2010;33(1):13-9.

30. Wu W, Chen S. Nurses' perceptions on and experiences in conflict situations when caring for adolescents with anorexia nervosa: A qualitative study. Int J Mental Health Nurs Oct. 2021;30(S1):1386-94.

31. Mitrofan O, Petkova H, Janssens A, Kelly J, Edwards E, Nicholls D, et al. Care experiences of young people with eating disorders and their parents: qualitative study. BJPsych Open Janv. 2019;5(1):e6.

32. Tan JOA, Fegert JM. Capacity and competence in child and adolescent psychiatry. Health Care Anal. 2004;12(4):285-94.

33. Baudinet J, Simic M. Adolescent eating disorder day programme treatment models and outcomes: A systematic scoping review. Front Psychiatry. 2021;12:652604.

34. Gledhill LJ, Maclnnes D, Chan SC, Drewery C, Watson C, Baudinet J. What is day hospital treatment for anorexia nervosa really like? A reflexive thematic analysis of feedback from young people. J Eat Disord. 2023;11(1):223.

35. Miotto P, De Coppi M, Frezza M, Rossi M, Preti A. Social desirability and eating disorders. A community study of an Italian school-aged sample: social desirability and eating disorders. Acta Psychiatrica Scand Mai. 2002;105(5):372-7.

**Publisher's note**

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.