Creating an Opportunity to Reflect: Ear Acupuncture in Anorexia Nervosa - Inpatients' Experiences.

ABSTRACT The aim of this study was to elucidate the meaning of receiving acupuncture as a complement in the treatment of anorexia nervosa at a specialist unit. Nine inpatients were interviewed, one to three times. The sixteen interviews were analysed with a phenomenological hermeneutic method. The main theme found was “Creating a pause, a framework for rest and reflection.” The participants described acupuncture to be an attractive part of the treatment, offering a pause in a very stressful situation. The relaxing effect was palpable. They described unusual calmness and a meditative state allowing them to think clearly and to reflect, and also positive physical sensations like getting warm. Anxiety decreased and gaining weight became easier to endure. Participants appreciated acupuncture as an optional treatment that they could influence. The given frame for reflection allowed processing emotions, releasing control and seeing themselves as capable to relax. Where symptoms are intense and pharmacological treatments have modest effect, like in anorexia nervosa, adjunctive therapies that help manage symptoms deserve greater attention.


Introduction
Anorexia nervosa (AN) is a serious eating disturbance, coexisting with suffering and low quality of life (NICE, 2004). Ear acupuncture is used as a complement in psychiatric care (Carter & Olshan-Perlmutter, 2015;Stuyt & Voyles, 2016). There is a lack of knowledge about how patients with AN experience ear acupuncture.

Anorexia nervosa (AN)
The characteristics of AN-a strong wish to lose weight, fear of gaining weight and a lack of concern about the emaciation of the own body-lead to starvation followed by severe medical complications, such as kidney, liver and heart failure, oestrogen deficiency and osteoporosis (NICE, 2004). Persons with AN often have emotional instability and inadequate social relations (Pemberton & Fox, 2013), and tend to have perfectionism as a key characteristic in their personalities (NICE, 2004). AN has a high co-morbidity with general psychiatric symptoms, such as depression, suicidality, and cognitive dysfunctions, and the highest mortality rate among mental illnesses (Papadopoulos, Ekbom, Brandt, & Ekselius, 2009). Anxiety, especially around mealtimes, is a central symptom that increases with weight restoration (Long, Wallis, Leung, & Meyer, 2012;Pemberton & Fox, 2013).
AN is difficult to treat, and there are few evidence-based treatments. Evidence for what kind of psychological treatment is release of beta-endorphins, ACTH, serotonin, noradrenaline and oxytocin is affected, leading to a sense of well-being, and regulation of emotions, memory processing and autonomic functions (Fang et al., 2009). In a review on acupuncture in anxiety, all articles reported positive findings, and especially ear acupuncture was found to be as effective as drug therapy (Pilkington, Kirkwood, Rampes, Cummings, & Richardson, 2007).
There is a variety of acupuncture styles. NADA (National Acupuncture Detoxification Association) is a standardized ear acupuncture protocol where five needles are inserted in specified points in each ear, originally developed to treat withdrawal symptoms (Stuyt & Voyles, 2016). NADA is used in more than 50 countries and has been implemented in several psychiatric clinics, as an adjunct in treatment of inpatients and outpatients with insomnia, anxiety, stress, addiction and depression (Landgren, 2008). Qualitative studies on patients' experiences of acupuncture in psychiatric diseases are sparse but indicate positive experiences of calm, well-being, increased energy, improved sleep and better concentration. Patients also described reduced craving and irritability and reduced need of medication on demand (Bergdahl, Berman, & Haglund, 2014). Only few articles describe the effect of acupuncture used as an adjunct therapy in the treatment of AN, but report that body acupuncture and acupressure improved the quality of life and decreased anxiety, stress and perfectionism (Fogarty, Harris, Zaslawski, McAinch, & Stojanovska, 2010;Smith et al., 2014). Interviewing patients with AN about their experience of ear acupuncture will deepen the understanding of what acupuncture possibly can add to AN treatment.

Aim
The aim was to elucidate the essential meaning of patients' lived experiences of receiving acupuncture as a complement to usual care in AN.

Design
This was an inductive qualitative study where patients in a psychiatric ward for eating disturbances were interviewed. Based on the assumption that people give meaning to their life worlds when they tell their story, narrative interviews were used. The transcribed text was analysed with phenomenological hermeneutic method, inspired by Ricour and described by Lindseth and Norberg (2004), used not only to describe how things appear to a specific person, but also to understand and interpret a person's lived experience involving a specific phenomenon.

Setting
This study was carried out in a locked inpatient specialist high-intensity eating disorder unit with 10 beds situated in a psychiatric hospital in Sweden, serving an area consisting of 1, 3 million inhabitants. Most patients are admitted voluntarily, but some are there under the Compulsory Psychiatric Act. Patients spend approximately 3-6 months at the ward, in single or double rooms. Following the Swedish national guidelines for eating disorder care (Fagerström, 2015), the main goal during the acute phase is weight restoration, incorporating meal Weeks in hospital at the first interview, median (range)  (.-) Weeks in hospital at the second interview, median (range)  (-) Weeks in hospital at the third interview, median (range)  supervision. Initially, some patients are too malnourished to do anything but eat and bed rest under supervision. After meals, patients, often with high anxiety levels, rest together in the day room in order to prevent provoked vomiting and exercise. The treatment further consists of nutritional complements, motivational talks with nurses, psychiatric nurse assistants, psychologists, and doctors, focusing both on eating behaviour and attitudes to weight and shape. Physiotherapy, cooking, relaxation exercises in group and medication are other components in the treatment program. The freedom to move outside the ward is heavily restricted. Since January 2015, all inpatients are offered NADA-acupuncture twice a week by nurses and nurse assistants on the regular ward schedule, plus on demand if trained staff is available. Acupuncture is offered after meals, sitting in the day room, or individually in the patients' rooms, with dimmed light and the possibility to lie down. When the needles are inserted, the patients rest for 40 minutes before the needles are removed.

Participants
A consecutive series of patients admitted to the ward and receiving acupuncture between August 2015 and January 2016 were given oral and written information about the study by a nurse. Nine patients agreed to participate and signed informed consent. After a first interview, the participants were asked for a second and third interview after six and 12 weeks, and all agreed. Six participants were interviewed after six weeks and one also after 12 weeks, rendering in total 16 individual interviews. Some background data such as age, length of stay and body mass index (BMI) is missing, as it was delivered by the participants during interviews, spontaneously or after a probing question ( Table 1). Notes of vocal tone and general demeanour were taken. The participants had been suffering from AN for a long time. Some had been treated in general psychiatry, feeling they did not belong there. One patient had been admitted to the ward for the first time, the others had been admitted once or twice before. They had been outpatients and day patients, received different kinds of counseling, and changed medications several times without finding a cure. They struggled with eating normal sized meals to gain weight, and with ambivalent emotions when their BMI increased. Beside psychiatric symptoms, the participants had muscular tension, pain, and headaches. One was involuntarily committed and at least one was under threat of being so.

Data collection
Narrative interviews, 5-35 minutes long (median 28), were conducted by the last author (KL) in a private, quiet room at the ward. The interviewer clarified that she was independent from the unit. The length of the interview depended on the patient's fatigue. Interviews were recorded with permission of the participant and started with a broad open question; "Would you please tell me about your experience of acupuncture?" followed by probing questions when the participant became silent. The interviewer strived for minimal interruptions and to reach richness and depth in narratives to get a deeper understanding of the participants' experiences.

Data analysis
The interviews were transcribed verbatim in total 34,500 words, and analyzed by a phenomenological hermeneutic method described by Lindseth & Norberg (2004). First, the transcripts were read several times to grasp the meaning as a whole. As authors, we let the text touch us, and a naïve understanding was formulated, guiding the further analysis. A structured analysis followed, first separately and then comparatively. To identify patterns of meaning, the text was divided into meaning units expressing thoughts and emotions, condensed and coded. The codes were organized in subthemes based on similarities, and clustered into themes, which were compared with the naïve understanding for validation. The themes were discussed until agreement of the most probable interpretations was achieved among the authors. We interpreted the text without concluding or judging if it was right or wrong, thereby gaining understanding of the patients' life world. During this process, we moved between understanding and explanation in a hermeneutic circle between naïve interpretation and structural analysis towards a comprehensive understanding. In the final comprehensive understanding, a main theme was formulated, and in a critical in-depth interpretation, the result was validated with the naïve understanding and existing literature.

Ethical considerations
The Regional Ethical Review Board approved the study (Dnr 2014/698). As the interviewed patients were vulnerable, great consideration was taken not to burden them further and to make sure that they had understood that they could discontinue at any moment.

Naïve understanding
Our naïve understanding of the phenomenon of receiving acupuncture when being an inpatient with AN, was that acupuncture offered a soothing pause in a stressful period of life when they suffered from inner turmoil. From the first readings of the text, we understood that the participants were willing to try anything that could help to reduce anxiety and cope with weight gain and the sense of being locked up. Acupuncture was found attractive and very relaxing, both emotionally and physically, helping them to think more clearly. The anxiety, especially around meals, became easier to endure.
The main theme Creating a pause, a framework for rest and reflection emerged in the analysis along with two themes; Searching for a handle to hold on to and Acupuncture as a pause button, and five sub-themes. The themes are shown in Table 2 and described in the text below, including quotes marked with Table . Main theme, themes and subthemes formulated from the analysis.

Creating a pause, a framework for rest and reflection
Searching for a handle to hold on to Acupuncture as a pause button Holding on to the handle Relaxing and resting makes a difference Regaining control Acupuncture having a palpable effect Thinking clearer a letter and a number, indicating participant and first, second or third interview.

Searching for a handle to hold on to
Recovery was perceived as a slow process, and they were eagerly "looking for something to hold on to that'll hold" (C:2), and to find something that could help them through the recovery process. Acupuncture was described as help in the recovery process, a lifeline to hold on to in a cold sea.
I was terrified of dying. It felt like I had been very close to death. And I wasn't able to cope with anything by myself. (B:1) Alongside gained weight, they experienced increased suffering and anxiety, leading to ambivalence between motivation and relapse, and they were now intensively struggling with their demons. They had kept "the trolls shut into the closets" (C:2) by controlling food and body weight, now the trolls had been let out and needed to be dealt with. The women were ready to grasp any help that could relieve their symptoms and had hope of finding their way out of suffering and managing an everyday life with work or studies. They wanted to be able to think clearly and soundly, and were willing to try anything to do it. Even the ones initially sceptical to acupuncture, or afraid of pain, were now willing to try it to get help.
The first time I tried/acupuncture/, I was desperate enough, because I didn't really believe in it. It was more like I'll give it a try, I'm here all days and nights anyway so I'll give it a try. (A:2) When the women felt the effect of the acupuncture, they gained a trust toward the treatment and hope toward recovery and wanted to continue, holding on to the handle they had found.

Holding on to this handle
The women voiced the importance of receiving acupuncture often enough to help and described a sense of comfort in knowing that acupuncture was offered at least twice a week.
The women were aware of a hard time awaiting them outside the ward, and several wanted the opportunity to receive acupuncture post discharge. Acupuncture was seen as a lifeline against stress and relapse prevention.
Those having suffered horrible things could have gone to drop in at the local health center to get/acupuncture/half an hour and feel, yes like a small weight lifted from their shoulders. (E:2)

Regaining control
The participants valued that acupuncture treatment was optional in the otherwise very regulated environment. The opportunity to guide the treatment themselves was also appreciated, as in leaving the needles in for a shorter time or getting fewer needles. The ability to regulate the pain at insertion through breathing was also valued; taking a deep breath decreased the pain. For those who perceived the pain as helpfully diverting anxiety, it was a possibility to keep their breath when the needle was inserted. Acupuncture was perceived as something one could control in a treatment where most control was taken away from the patient.
And it being optional. Yes, it's important to be able to decide something for yourself and yes, to have a choice. And then I'm able to decline if it feels like that some day. I find that great! (D:1, involuntary admitted)

Acupuncture as a pause button
The women were wound up and exhausted, looking for means to cope with everyday life. Being surrounded by severely ill people, sometimes in shared rooms, with constant noise from commercial radio and TV in the eating room and the day room increased the need of calm and quiet, and the women appreciated acupuncture while learning to rest instead of pushing through without reflection. Acupuncture was found to give a pause, a rest from anxiety during the strenuous challenging recovery when anxiety rose as the BMI increased.

Relaxing and resting make a difference
Women who earlier had had difficulties in allowing themselves to rest were surprised how they during acupuncture could lay with closed eyes in stillness. Feeling rejuvenated and relaxed was a very pleasant sensation. Acupuncture offered a breathing space; the women could get away for a while and let go of disturbing thoughts. It was described as a well-wanted pause button in life.
It feels like relaxing, you soften, your body becomes warm and then you kind of float away. Sometimes I've fallen asleep and sometimes I don't know if I've been sleeping or not. I can hear but I can't say I've been awake. (A:1) In this meditative state, the women described winding down, letting go of anxiety and stress for 40 minutes. During the break given by acupuncture treatment, they could let go of control, and they described this sense of calmness a goal to return to.
It's actually almost better than the medications!/Acupuncture/makes me calmer. I don't feel any effect from the medications. With needles I can even fall asleep! … I get so calm I can't do anything else simultaneously! (D:2) Even when very wound up, the women described a sensation of "high", a pleasant trance-like state where they silently floated away from anxiety into another world.
I'm not used to drugs at all, but it might be similar to being a bit high. Or it might just be endorphins … We turn quiet, and then we just lie down somewhere between sleeping and being awake … It was easier for me to achieve this kind of trance alone, and it felt better to disappear for a while by myself. But on the other hand, it felt like a trance the first time as well, and at that time there were three of us leaning towards each other in the same couch! (E:1) Anxiety and discomfort peaked and became physical during the mandatory post-meal rest with the sensation of having a full stomach. At home they had been used to work out compulsively or clean the whole kitchen after meals to burn off calories and to lessen the anxiety. When receiving acupuncture, they could disappear for a while, and actually relax after a meal. Acupuncture became an aid to withstand eating. I have received/acupuncture/after meals some times as well, and then it really has good effect. Things calm down, I calm down. The anxiety before meals and the discomfort in my body, the disgusting sensation of fullness (voice shivering) disappears. (F:1) The relaxing effect lasted for some hours, sometimes even during the day after. After acupuncture, winding down and falling asleep were easier. The same relief from stress and anxiety was described at the second interview. Just knowing that acupuncture was available had in itself a calming effect. Even the least enthusiastic participants described a relief of the anxiety peak. I can't say it's been negative. Maybe even toward the positive. … When receiving it post meals I'm surprised at how much I've been able to relax … I'm on a quite high stress level, inner stress, that makes me constantly ON. I think it helped me some. (C:2) Barely allowed to leave the building, participants had to endure a long time at the ward while working on becoming well. During acupuncture, forty minutes was perceived to pass quickly.
So/acupuncture/is good enough. It gives something in this very stressful situation, a bit of breathing space. That is what it does. (I:1) The women described that acupuncture provided a beneficial framework for rest, offering the calmness and clarity of mind necessary to become well. The importance of having this break in a stressful environment was emphasised, and knowing that it was repeatable over and over again was comforting. Acupuncture was perceived as practise in being still, to stop and reflect. The sense of peace and well-being after acupuncture was compared to the feeling after physical exercise. Reflection made it possible to reach and let go of emotions, gave strength to thwart the disease and hope for change. Acupuncture gave the quiet space necessary to endure when all they had wanted to was to escape.
For me it's been very good to have a framework, and to rest within that framework given by me knowing that now, while sitting with these needles, I can't get up and walk around. It would have wasted this thing that can give me something good! (I:1) Acupuncture was seen as a different way of practising mindfulness. The women experienced that with acupuncture, relaxation came automatically, without them actively having to focus on following exercises and without anyone else being involved. This was appreciated as other relaxation exercises required concentration the women did not always have.
It´s really to NOT escape, something that can come in handy even later when I don't have the acupuncture … And besides, the acupuncture becomes an opportunity to sit down and be with oneself. (B:1)

Acupuncture having a palpable effect
During acupuncture, participants experienced a distinct physical sensation of muscular relaxation, and sometimes a tingling sensation in the body. Somatic symptoms could disappear, expressed by one women as " … and I definitely don't take as many painkillers" (A:2). Their arms and legs felt looser and softer, and breathing became easier. The physical sensations were seen as proof that acupuncture produced real effects. A distinct sensation of warmth was described as a comforting reminder of normality.
The blood circulation gets much better … It's not make belief! I get all warm, not just my ears, but my hands and feet! Oh, this very sense of warmth! I've always been very cold, all the way up here (pointing at shoulders). It was unpleasant … My nails were blue! When I've had/acupuncture/the whole day is saved. (A:1)

Thinking clearer
Thoughts spun in their heads, and there was a need to disconnect from worry and sick thoughts. According to the women, a relief of their inner turmoil followed the relaxation. Their usual restlessness changed into a state of peace and tranquility where they could reflect or just let go, sit down and just be with themselves. They closed their eyes and "the thoughts stopped playing their games" (E:3). Their heads became empty in a pleasant way.
… and there are no sick thoughts during that period …, half an hour to forty minutes. It doesn't take long before it really kicks in, maybe ten minutes. There can be lots of sick thoughts straight after the meal, but then they just disappear. It's weird! … It's a security to know that that little break exists, absolutely! … That something exists to relieve my emotions too. (E:3) The women experienced clearer thinking when the pause came, allowing them to process their thoughts. Obsessive thoughts about eating and exercising were reduced, and resting became easier to accept. The women described how their usual thoughts like "eating is ugly, eating is wrong" (I:1) declined with acupuncture.
I felt such terror for gaining weight … While being calm, one thinks more logically, that being normal of weight actually is a part of recovery … That might have made me allow myself to gain weight, something I didn't do before. It feels like somehow I accept things and can handle them. (A:2)

Comprehensive understanding and reflection
The essential meaning that emerged from the narratives was that acupuncture became a framework that offered a pause in a very stressful and restrictive therapeutic environment. Severely ill for a long time, the participants were well aware that there is no quick fix for AN. During the long inpatient stay, acupuncture gave a breathing space from the stressful thoughts tormenting them and helped them to practice the skill of resting and finding peace within themselves. Acupuncture made time fly and brought a special sensation of psychological and physical relaxation, like a weight was lifted from their shoulders for a while. Even when the symptoms would decrease only for some hours, the situation became easier to endure.
A majority of the codes landed under the subtheme "Relaxing and resting. " This was unsurprising as earlier studies have shown that acupuncture reduces anxiety and stress (Arvidsdotter et al., 2013;Bergdahl et al., 2014;Errington-Evans, 2012). In a review (Pilkington et al., 2007) especially ear acupuncture was found to be effective and having the same anxiolytic effect as medication, supporting our results. For the participants in our study, it was consoling to know that there was a safe and repeatable treatment that could offer this frame for relaxation and the same sensation of well-being, over and over again.
Resting is a central component of the treatment of AN. Beside starvation, excessive work out is a strategy to cope with angst (Kolnes, 2016). Our participants, used to being in constant movement to maximise burning of calories, compared the sense of well-being after acupuncture to that after working out and were thereby shown a way to exchange over-exercise with acupuncture.
The participants described acupuncture as an exercise in just being, taking care of oneself, in receiving without the need of giving. In a disease so tightly connected with control (Pemberton & Fox, 2013;Smith et al., 2016), relaxing and letting go may be a big step forward (Carter & Olshan-Perlmutter, 2015). During acupuncture, their private sphere was affected, they let themselves be touched, literally leaning toward each other when they were treated in a couch. The muscular relaxation promoted "good" sensations of calm, tiredness and peace, but also gave awareness of otherwise present tension and pain. They became aware of their bodies signaling need to rest.
In the present study acupuncture was perceived as an aid for handling and withstanding anxiety and the challenging transition towards a normal body weight. Beside the obvious benefit of saving calories, the pause gave room for the creative silence where it was possible to reflect, and to gradually process emotions in a relaxed state. When stressed and wound up, thinking clear is difficult. Becoming calm and relaxed clears your mind, nurturing reflection. When patients understand AN as part of their own identity, recovery brings a loss of identity (Espindola & Blay, 2009). At home the participants in our study had at times been able to ignore the AN and perceive themselves as more than their eating disorder diagnosis, e.g. also as healthy persons, mothers, partners, students. At the ward there was full focus on their severe illness, and they became painfully aware of it 24:7. During the pause they got a possibility to rest, finding their healthy selves and letting go of the anorectic identity. During acupuncture one is left in peace and there is no expectation of talking. This empowered the patients to think clearly for themselves without the influence of someone else.

Autonomy
Patients with AN have reported a sense of lack of privacy and intrusiveness in the context of inpatient care and demand personalisation of treatments (Segal, 2003). A sense of autonomy is associated with remission (Espindola & Blay, 2013). In our study, where locked doors even for voluntary patients, and heavy restrictions gave a feeling of being treated like a child, patients found a possibility to influence treatment and mood. The possibility of choosing or abstaining from acupuncture, having acupuncture on demand and adjusting the number of needles was perceived as valuable in the otherwise rigorously detailed schedule. For example one woman in the present study used active form, saying: "take acupuncture", not "get acupuncture. " Involuntary commitment raises special ethical, legal and clinical issues for all involved. As acupuncture is always an optional part of the treatment, it may increase the perception of autonomy, not the least in the context of active resistance and for those involuntarily committed.

Side effects
Like in earlier studies (Bergdahl et al., 2014;Fogarty et al., 2010Fogarty et al., , 2013, only few and minor side effects were reported. It is interesting that the only side effect was described as simultaneously negative and positive: the tiny pain of inserting the needle was also perceived as diversion from psychological pain.

Trustworthiness
Acupuncture is a complex intervention, including both specific and non-specific factors. Qualitative studies are valuable to illuminate experiences that get lost in quantitative trials (Lindseth & Norberg, 2004), not the least where quantitative data is limited. In qualitative research the aim is not to find a result that can be repeated, but rather to better understand the participants' life world. We have illuminated and interpreted experiences described by the participants, and thereby uncovered possible meanings of lived experience of having AN and being treated with acupuncture. Through the narratives, we could participate in the interviewed women's life worlds and share their experiences. However, it is a challenge to get rich narratives from persons with a very low BMI, as starvation renders cognitive impairment. However, the repeated interviews and the follow-up questions provided us with data, rich in depth as well as in breadth. To further establish credibility, the narratives were analysed systematically and rigorously, first separately and then comparatively, and the emerging themes were discussed between the authors until we reached agreement. To achieve confirmability, both authors read the transcribed interviews separately before starting the analysis, and reached a naive understanding of the text. To achieve dependability, the research process is clearly described. To further confirm the result, quotes from the interviews were used to verify the findings, and in the third step of the analysis, the findings were validated with the existing literature (Lindseth & Norberg, 2004). There is always more than one way of understanding a text. We consider the final result to be the most credible interpretation of the text.
In a qualitative study, the authors' pre-understanding is part of the interpretative process and a guiding tool. SH is a registered nurse at an eating disorder clinic, trained in ear acupuncture. KL is a nurse specialized in psychiatry and in acupuncture, with an extensive experience of teaching NADA-acupuncture but without nursing experience in eating disorders. Throughout the process, the authors' pre-understandings were discussed, critically reflected upon and bracketed in order to broaden our awareness of the risk of a biased interpretation. Our different preunderstandings enriched our discussions about possible interpretations, leading to a strong consensus concerning themes.
All participants in the present study were inpatients at the same ward, had AN, were female and got standardized NADA acupuncture, implying that the results cannot be generalized to other settings, diagnoses, genders or types of acupuncture. It is however plausible that our results might be transferable to other psychiatric settings where anxiety and stress are prevalent, in persons of any gender.
Persons with anorexia often have suppressed feelings and a strong need for predictability (Pemberton & Fox, 2013). Being perfectionists, a part of the disorder, they are rarely enthusiastic and often critical toward their treatment (NICE, 2004). Their ambivalence to treatment must be taken into consideration when patient satisfaction is interpreted. With this backdrop it is even more interesting that the participants in this study were so positive about acupuncture.

Implications for nursing practice
We have shed light on how inpatients with severe AN experience acupuncture, providing support that acupuncture is perceived as helpful, in concert with earlier results (Fogarty et al., 2010(Fogarty et al., , 2013. When we understand patients´experiences, we get a new perspective, and can change and improve care. Patients in the present study appreciated that acupuncture was integrated into usual care. Transition to outpatient care can be challenging (Bezance & Holliday, 2013), and our participants wanted acupuncture following discharge, seeing acupuncture as a handle to hold on to through the recovery process.
Recovery from AN is a very complex process; there will be frustration, rebellion, refusal and relapse. Patients are often in denial of the severity of their disease and reluctant to treatment. There are no interventions with a curing effect and no evidence for anxiolytic medical treatment effective on malnourished patients (NICE, 2004). As the risk of side effects is higher in persons with AN, medications should be prescribed with caution (NICE, 2004). A psychiatric assessment cannot be done, and psychological treatment is of limited value, before the acute starvation is abolished. While striving for a safe weight, treatment may focus on improving the patient´s subjective sense of well-being (NICE, 2004). Where symptoms are intense, as for inpatients with AN (Long et al., 2012), and pharmacological treatment has modest effect, adjunctive therapies like acupuncture could be welcomed to help patients reduce symptoms in a safe way.
Accepting treatment requires questioning of values and dealing with defense mechanisms and fear of change (Espindola & Blay, 2009). Hope is a key to recovery in this process. Nurses could address the patients' underlying emotional regulation difficulties and optimize the therapeutic environment by creating a space for rest and reflection, thereby helping to manage symptoms and attain coping skills. Giving acupuncture is hands on and a caring way to offer a pause during the long rehabilitation period, increasing quality of life. In our study, acupuncture showed promising possibilities to improve anxiety. The palpable effect of acupuncture was perceived to help coping and enduring, making it an attractive treatment and instilling hope for recovery.
Motivating the ambivalent patient and engaging her in a treatment plan is a precondition for a successful AN treatment. An essential element of the care should be professionals taking time to build an empathic, supportive and collaborative relationship with patients (Bezance & Holliday, 2013;NICE, 2004;Pemberton & Fox, 2013). Treatment satisfaction is influenced by the experience of support by the staff (Long et al., 2012). A well-tolerated, person-centered treatment like acupuncture, that patients in the present study perceived as helpful and attractive, can be a tool for creating an alliance and strengthening a therapeutic patient-nurse relationship.
Acupuncture provided a possibility to step aside, talk to staff and then to be left in peace and silence. Being non-verbal, acupuncture offered a silent pause in a treatment that otherwise relies on talking. Therapeutic talks are challenging and with trust issues involved, the possibility of receiving non-verbal care without having to open up can be comforting. It was compared to mindfulness, but with relaxation and calmness coming without having to strive for it. Body acupuncture, delivered by an external acupuncturist, has shown potential as an adjunct therapy in the treatment of eating disorders (Fogarty et al., 2010). In the present study, ear acupuncture was administered by ordinary staff, making it more accessible and a part of usual care. This was possible as a standardized type of ear acupuncture was chosen, easy to learn. Compared to the common but more complicated body acupuncture, ear acupuncture presents an interesting treatment modality.

Conclusion
This study adds to the current literature by shedding light on how patients with AN experience ear acupuncture. Ear acupuncture was perceived to help AN patients rest, thereby providing an opportunity for reflection. Anxiety decreased, which was seen as valuable during the long recovery period. The positive results are promising and motivate a quantitative study evaluating the effect of ear acupuncture in psychiatric care.

Declaration of interest
KL teaches ear acupuncture. The authors report no other conflict of interest.

Funding
This work was supported by Lindhagastiftelsen.