T h e L i v e d Experience of Anorexia Nervosa:

A Phenomenological Study

by

L o r r a i n e Marie King-Murphy

Thesis submitted to t h e

School of Graduate Studies

in partial fulfilment of the

requirements f o r the degree of

Master of Nursing

School of Nursing

Mernor ia l University of Newfoundland

St . John' s , Newfoundland

J u l y 14, 1997

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Dedicated to

My mom who, s t a r t i n g o u t on t h i s j o u r n e y with m e , i n s p i r e d m e

a n d stayed w i t h m e , s p i r i t u a l l y , th rough to its end.

H e r faith i n m e gave m e t h e s t r e n g t h t o c o n t i n u e .

M y two beautiful c h i l d r e n , Tonya and Ger ry , who

through t h e i r u n s e l f i s h love, a l l o w e d me to p u r s u e my goals.

Without their s u p p o r t , my dream w o u l d never have become a

r e a l i t y .

iii

ABSTRACT

Anorexia nervosa has the h i g h e s t ntortality rate of a l 1

emotional i l lnesses and daims the lives of 5 to 10 percent of

its' victims. Despite the plethora of quantitative research on

eating disorders, the prevalence of anorexia nervosa continues to

rise, and the trajectory of the disorder rernains dismal.

In t h i s study, a phenomenological mode of inquiry was used

to explore the l ived experience of anorexia nervosa. Data

analysis was in line with van Manenrs Hermeneutic Phenomenology.

Six fernales, nineteen years cf age and older, participated in two

audiotaped unstructüred interviews. Participants were encouraged

to speak freely and openly about their overall experience of

living with anorexia nervosa.

Through data analysis of the transcripts (interviews) eight

themes emerqed: the weakoned sel f , 2 s t r q g l e f û r c s n t r u ~ ,

controlled by the illness, concealing the self, consumed by the

illness, readiness to change, letting-go while holding-on, and

breaking the cycle. The web of interrelationships between these

themes allowed the essence of the lived experience of anorexia

nervosa to be captured as a persistent struggle to find

i v

meaning i n l i f e . S t u d y participants d e s c r i b e d t h e d e v e l o p m e n t of

a c o n n e c t e d n e s s w i t h a n o t h e r as p r o v i d i n g a s e n s e of mean ing and

purpose t o their lives, a n d a l t e r i n g t h e destructive c o u r s e of

the illness. T h e f i n d i n g s also e m p h a s i z e d the i m p e t u o u s nature

of therapy (i. e., e x e r t i n g power a n d c o n t r o l over c l i e n t s ) i n t h e

i l l n e s s t r a j e c t o r y . The onus is c e r t a i n l y on health care

p r o v i d e r s t o r e e v a l u a t e current approaches t o care a n d develop a

u n i f i e d treatment mode1 f o r anorexia nervosa t h a t w i l l be more

effective i n facilitating r e c o v e r y from t h i s i l l n e s s .

Many t h a n k s to m y t h e s i s s u p e r v i s o r , D r . C h r i s t i n e Way, who

worked diligently with me throughout the e n t i r e process, as both

a guide and mentor . S i n c e r e t h a n k s , a s well, t o my thes is

committee, especially Kather ine Hustins, whose guidance and

i n s i g h t were i n v a l u a b l e .

To my f a m i l y , e s p e c i a l l y J e a n - thanks f o r believing i n a n d

e n c o u r a g i n g m e . Your support meant more than you could know.

T o my f r i e n d s , e s p e c i a l l y Susan and S h e i l a g h , who have

always been there for me, in more ways than one : t h r o u g h you, 1

have t r u l y learned the meaning of friendship and learned to

U d i t v e in m y s e l f .

T o t h e s t a f f of t he V a l l e y Reg iona l Hospital, K e n t v i l l e ,

Nova S c o t i a , especially D r . Joelle Caplan, 1 o f f e r rny deepest

gratitude. Your unfailing k i n d n e s s and s u p p o r t enabled m e t o

comple te t h i s work.

vi

Last, but by no means least, to a l 1 the participants in this

study without whose willingness and CO-operation none of t h i s

would be possible: I would l i k e to express rny admiration for

your strength and courage. Your growth has been reflected in the

a b i l i t y to reach through your own pain, to help others suffering

£ r o m a n o r e x i a nervosa. A deeply felt t h a n k you.

TABLE OF CONTENTS

Abstract

Acknowledgrnents

Chapter

1 INTRODUCTION

Background and Rationale Problem Statement Research Question

LITERATURE REVIEW

Anorexia Nervosa as a Disorder Historical Profile Diagnostic Criteria

Subtypes Behavioral Strategiss Gender and Cultural Influences

Risk Factors Predisposing Factors Precipitating Factors

Anorexia Nervosa and Associated Conditions Treatment Modalities and Prognosis Summary

A ~ o r e x i â Xsrvûsâ â s an Iiiness: Quaiita~ive Insights Eating Disorders and Health Promotion Strategies Discussion

METHODOLOGY AND METHODS

Methodology Hermeneutic Phenomenology

Met hods Participants Procedure Ethical Considerations Data Analysis Reliability and Validity

P a g e

ii3

v

4 FINDINGS

Introduction to Participants Thematic Analysls

Weakened Self Struggling for Control Controlled by the Illness Concealing the Self Feeling Consumed Letting-Go While Holding-On Readiness for Change Breaking the Cycle

Interrelationships Among Themes The Essence

5 DISCUSSION

Lived Experience of Anorexia Nervosa Weakened Self and Struggling for Control Controlling, Concealing and Consuming Readiness, Letting-Go/Holding-On and Breaking The Essence

Revisiting the Meaning of Health Care

6 NURSING IMPLICATIONS, LIMITATIONS AND SUMMARY

Implications Nursing Education Nursing Practice

Unified rnodels for health promotion N u r s i n g Fesearch

Limitations Surnmary

RE FERENCES

APPENDIX A APPENDIX B APPENDIX C APPENDIX D APPENCIX E APPENDIX F

Introduction

Anorexia nervosa is an emotional illness characterized

by an intense fear of fatness, dissatisfaction with body

image, and the relentless conviction that controlling body

weight Fs a prerequisite for happiness (Garner, 1986) . In

the past decade the incidence and prevalence of anorexia

nervosa escalated at alarming rates, especially arnong young

women (Canadian Mental Health Association [CMHA] , 1989;

Rosenfield, 1988; Wilfley & Grilo, 1994) . It is estimated

that i in 100 Canadian teenagers develop serious forms of

the illness and 5 in L O O develop milder forms (CMHA, 1.989) .

Further projections suggest that from 200,000 to 300,000

Canadian women between 12 and 40 years of age will develop

anorexia nervosa at sorne point in their lives (CMHA, 1989) .

As the incidence and prevalence cf anorexia nervosû

rise, it is becoming apparent that gender and social status

will not be granted immunity from this illness (Leichner,

Arnett, Rallo, Srikameswaran, & Vulcano, 1986; Paxton, 1993;

Ratinasuriya, Eisler, Szmukler, & Russell, 1991) . Only four

decades ago anorexia nervosa was considered a rare disorder

believed to be confined to middle and upper class fernales.

Recent findings indicate that it has increased significantly

i n males ( L e i c h n e r e t a l . , 1986) , w i t h estirnates a r o u n d

i9 p e r c e n t (Hoek, 1 9 9 1 ) , a n d across al1 s o c i o e c o n o m i c

s p e c t r u m s (CMHA, 1989; G a r n e r , 1993; W i i l i a r n s ù n , 1 9 9 0 ) .

What is rnost a l a r m i n g i s t h e g r o w i n g t r e n d t o w a r d s

ear l ier age of i l l n e s s o n s e t , w i t h s i g n s of t h e i l l n e s s

p r e s e n t i n twelve year o l d s (CMHA, 1 9 8 9 ) . Arnong a d o l e s c e n t

g i r l s , t h e r e a p p e a r s t o b e g r e a t e r p r e o c c u p a t i o n w i t h

a c c e p t a b l e b o d y w e i g h t (Feldman, Hodgson, C o r b i n , & Q u i n n

1 9 8 6 ) . U n f o r t u n a t e l y , s t a t i s t i cs o n the i n c i d e n c e a n d

p r e v a l e n c e of a n o r e x i a n e r v o s a a re mere estimates, b e c a u s e

s e c r e c y , a d o m i n a n t d e f i n i n g illness symptom, p r e c l u d e s

a c c u r a c y .

T h e t r a j e c t o r y a n d p r o g n o s i s of a n o r e x i a n e r v o s a are

dismal. High m o r b i d i t y rates are a s s o c i a t e d w i t h s u c h

p s y c h o l o g i c a l i l l n e s s e s as d e p r e s s i o n a n d a f f e c t i v e

d i s o r d e r s (Damkberg, 1 9 9 1 ) , a n d p h y s i o l o g i c a l d i s o r d e r s ,

i n c l u d i n g c a r d i o v a s c u l a r disease, o s t e o p o r o s i s a n d

e l e c t r o l y t e i n b a l a n c e ( S h a r p & Freeman, 1 9 9 3 ) . A n o r e x i a

nervosa a l s o h a s t h e h i g h e s t m o r t a l i t y rate of al1 m e n t a l

i l l n e s s e s ( S t r a u s s , 1 9 9 5 ) , w i t h 5 t o 2 0 p e r c e n t o f p a t i e n t s

who d o n o t r e s p o n d t o t h e r a p y d y i n g ( G a r f i n k e l & Goldbloom,

1 9 8 8 ) . I t nas been a r g u e d that greater e f f o r t s m u s t be

d i r e c t e d t o w a r d s e a r l y detection and t r e a t r n e n t , i f w e are t o

make significant inroads toward improving the health and

well being of this population (Crisp, 1988; G a r f i n k e l ,

Kennedy, & Kaplan, 1995; Shisslak, Crago, & Neal, 1990;

Wilf ley

develop

nervosa

& Grilo, 1994) . The purpose of this study was to

a greater understanding of the meaning of anorexia

for individuals living with this illness.

Backqround and Rationale

The proliferation of research over the past f e w decades

has implicated genetic, metabolic, developmental, familial,

sociocultural and behavioral factors in the development of

eating disorders (Wilf l e y & Grilo, 1994) . The cornplex

interaction of multiple factors constituting the causal base

for a n o r e x i a nervosa has generated multidimensional

treatment regimes. Despite considerable advances, the

illness remains h i g h l y resistant to s u c c e s s f u l treatment,

especially when it evolves i n t o a c h r o n i c illness (Jenson,

1994 ; Kennedy & Garfinkel, 1992; Shisslak et al., 1990) .

T h e problerns posed by anorexia nervosa are apparent

from the changing demographics of eating disorders, their

increasing incidence and prevalence, and the seemingly

ineffectiveness of various treatment modalities under the

biomedical mode1 of care. From a review of the literature,

i t seems t h a t c o n s i d e r a b l e d i f f i c u l t y e x i s t s i n c l e a r l y

d i f f e r e n t i a t i n g a n o r e x i a n e r v o s a f rom o t h e r e a t i n g

d i s o r d e r s , a n d deciding w h e t h e r c o r n o r b i d i t y conditions

(e.g., d e p r e s s i o n , o b s e s s i v e - c o m p u l s i v e d i s o r d e r ,

p e r s o n a l i t y d i s o r d e r s ) c o n t r i b u t e t o t h e o n s e t o f t h e

i l l n e s s o r are a c o n s e q u e n c e o f i t (CMHA, 1 9 8 9 ; G a r f i n k e l e t

a l , , 1 9 9 5 ; Kennedy & G a r f i n k e l , 1992; M u s c a r i , 1987) .

The c o n c e p t u a l and c l i n i c a l a m b i g u i t y s u r r o u n d i n g t h e

i l l n e s s has p r o d u c e d a multitude o f risk f a c t o r s ,

p r e d i s p o s i n g syrnptoms, co rnorb id i t ies , and t r e a t m e n t

r n o d a l i t i e s . I t has been a r g u e d t h a t r e s e a r c h f i n d i n g s are

l i m i t e d d u e t o c o n c e p t u a l a n d r n e t h o d o l o g i c a l p r o b l e m s

i n h e r e n t i n s t u d y designs ( R o s e n f i e l d , 1988; W i l f l e y &

G r i l o , 1 9 9 4 ) . M o s t r e s e a r c h i n q u i r i e s have focused o n

d e v e l o p i n g re l iable and v a l i d d i a g n o s t i c t o o l s a n d e f f e c t i v e

t r e a t r n e n t modalities as opposed t o p r e v e n t i o n and h e a l t h

p r o m o t i o n s t r a t e g i e s .

Based on t h e a s s u m p t i o n t h a t p r o g n o s i s may improve w i t h

e a r l y d i a g n o s i s and t r e a t m e n t , p r e v e n t i o n and h e a l t h

p r o m o t i o n s t r a t e g i e s have i n c r e a s i n g l y becorne the f o c u s of

r e c e n t r e s e a r c h ( C h i l d r e s s , Brewer ton , Hodges, & J a r r e 1 1

1993; C r i s p , 1988; Kennedy & G a r f i n k e l , 1 9 9 2 ) . However,

c o n f l i c t i n g f i n d i n g s e x i s t c o n c e r n i n g t h e t i n e l i n e s s ,

5

a p p r o p r i a t e n e s s a n d e f f e c t i v e n e s s o f p r e v e n t i o n s t ra tegies

( C r i s p , 1988; P a x t o n , 1 9 9 3 ; S h i s s l a k e t a l . , 1 9 9 0 ; W i l s o n ,

1 9 9 3 ) . The d e v e l o p m e n t o f a knowledge base g r o u n d e d i n

i n d i v i d u a l s ' e x p e r i e n c e s w i t h a n o r e x i a n e r v o s a i s e s s e n t i a l

f o r t h e p r o v i s i o n o f q u a l i t y care b y h e a l t h care p r o v i d e r s .

P t o b l e m Statement

The p o s i t i o n t a k e n by this r e s e a r c h e r is t h a t b e c a u s e

the early w a r n i n g s i g n s o f anorexia nervosa are n o t readi ly

d i s c e r n i b l e t o o t h e r s , e v e n t o " e x p e r t eyes " , t h e o n l y r ea l

a c c e s s i s t h r o u g h some form of phenorneno log ica l i n q u i r y .

That is , a greater u n d e r s t a n d i n g of i l l n e s s mean ings c a n

o n l y be g l e a n e d from a n i n - d e p t h , t h e r n a t i c a n a l y s i s o f

n a r r a t i v e descriptions of t h o s e l i v i n g w i t h a n o r e x i a

n e r v o s a . Instead o f searching f o r u n i v e r s a l i t y i n r e f i n i n g

d i a g n o s t i c t o o l s a n d i rnproving therapies, Ne should f i r s t

focus Our e f f o r t s on g r a s p i n g a n a p p r e c i a t i o n f o r t h e

i n t r i n s i c , p e r s o n a 1 side t o t h e e x p e r i e n c e . N u r s i n g may

well be p r e p a r e d t o meet t h e p h y s i o l o g i c a l s e q u e l a e of t h i s

illness. However, t h e e f f i c a c y o f t r e a t m e n t r n o d a l i t i e s

(pr irnary, s e c o n d a r y , a n d t e r t i a r y ) w i l l r e m a i n limited u n t i l

t h e meaning o f the lived e x p e r i e n c e o f a n o r e x i a nervosa i s

c a p t u r e d .

Research Question

T h i s study was designed to address the following

research q u e s t i o n : What is the meaning of t h e lived

exper ience of anorex ia nervosa?

CHAPTER 2

Literature Review

The plethora of literature on anorexia nervosa can be

attributed to the contributions from various disciplines

(e. g., psychiatry, psychology, nursing, and social work) .

With few exceptions (e-g., Hilde Bruch's work), limited

attention has been given to qualitative inquiry. Most

studies which used a quantitative approach were guided by

the medical mode1 of care. The vast majority of these

studies focused on the identification of factors related to

diagnosis and treatment, with lesser emphasis on health

promotion and disease prevention.

This literature review provides an overview of

relevant theoretical insights, research and clinical

findings which capture current understandings of anorexia

nervosa. The first section discusses anorexia nervosa as a

disorder. Special attention is given to the historical

development, current diagnostic criteria, predisposing and

precipitating risk factors, associated conditions, as well

as treatment modalities and prognosis. The second section

discusses qualitative research findings on anorexia nervosa.

The third section deals with eating disorders and health

promotion strategies.

Anorexia Nervosa as a Disorder

In the past diagnostic thinking about anorexia nervosa

was considerably rnyopic with heavy reliance on single factor

causal theories to explain this multidimensional disorder

(Bruch, 1973; Garner, 1993) . A glance at the historical

development as an antecedent, which narrowed the focus of

health care delivery to clients with anorexia nervosa, will

clarify clinical and academic difficulties experienced in

preceding decades.

Historical P r o f i l e

Anorexia nervosa is not new to society. Accounts of

self-induced weight loss can be traced back to the Middle

Ages. One of the earliest writings addressing the signs of

eating d i so rde rs :vas by Richard Morton in 1489 (Garfinkel,

Garner & Goldbloom, 1987; Maceyko & Nagelberg, 1985; Wilfley

& Grilo, 1994) - In 1868, the term anorexia, which means

"loss of eating or nervous loss of appetite", was first

coined by William Gull, in England. Psychological factors

were labeled as precursors i~ the development of anorexia

nervosa, but disagreement existed about the nature of these

factors.

By 1 9 1 4 , a f t e r Simmons d i s c o v e r e d à e s t r u c t i v e

rn ic roscop ic l e s i o n s i n t h e post-mortem p i t u i t a r y g l a n d of

some c a c h e x i a p a t i e n t s , t h e t e r m Simmons Disease w a s

u n c r i t i c a l l y a p p l i e d t o a l 1 p a t i e n t s w i t h extreme w e i g h t

loss. A n o r e x i a ne rvosa was l a b e l e d a p h y s i c a l d i s o r d e r , and

t r e a t e d as h y p o p i t u i t a r y c a c h e x i a .

I n 1930, Berkman d e f i n e d a n o r e x i a nervosa as a

p h y s i o l o g i c a l d i s o r d e r , s e c o n d a r y t o p s y c h i c d i s t u r b a n c e .

T h e p s y c h i a t r i c community now c a t e g o r i z e d t h i s disorder as

compuls ion n e u r o s i s , hysteria o r p s y c h o s i s . I n t h e 19401s,

Waller, Kaufman, a n d Deutsh i n t r o d u c e d the p s y c h o a n a l y t i c

era. W i t h symptoms based on s p e c i f i c and u n c o n s c i o u s

f a n t a s i e s c e n t e r i n g around o r a l i rnpregna t ion , t h e t r e a t m e n t

of c h o i c e was a c c o r d i n g l y , p s y c h o a n a l y s i s (cited i n

Coovadia , 1 9 9 5 ) -

By the 1 9 6 0 1 s , it became a p p a r e n t t h a t t h i s treâtnent

m o d a l i t y was i n e f f e c t i v e . The modern era of p s y c h o l o g i c a l

t h i n k i n g evo lved a n d c o n t i n u e s today ( T u r n e r , 1 9 9 0 ) . Major

c o n t r i b u t i o n s t o c u r r e n t u n d e r s t a n d i n g s of e a t i n g d i s o r d e r s

have been made b y Hilde Bruch, Uni ted S t a t e s ; R u s s e l l a n d

C r i s p , U n i t e d Kingdom; and G a r f i n k e l a n d Ga rne r , C a n a d a

(Coovadia , 1995) .

Diaqnostic Criteria

G a r f i n k e l , Kennedy, & K a p l a n ' s (1995) r e c l a s s i f i c a t i o n

o f t he D i a g n o s t i c S t a t i s t i c a l M a n u a l - I I I ( D S M - I I I ) t o t h e

D i a g n o s t i c S t a t i s t i c a l Manual-IV (DSM-IV) w i l l h o p e f u l l y

i d e n t i f y t h o s e i n d i v i d u a l s with e a t i n g d i s o r d e r s who escaped

e a r l y d e t e c t i o n i n t h e p a s t . The DSM-IV o u t l i n e s t h e

c l a s s i f i c a t i o n s a n d d i a g n o s t i c c r i ter ia f o r a l1 e m o t i o n a l

disorders ( A n e r i c a n P s y c h i a t r i c A s s o c i a t i o n , 1 9 9 4 ) . One

i m p o r t a n t cr i ter ia fo r a n o r e x i a n e r v o s a i s the r e f u s a l t o

m a i n t a i n body w e i g h t w i t h i n t h e m i n i m a l a c c e p t a b l e norms for

age and h e i g h t ( L e . , m a i n t e n a n c e of b o d y w e i g h t b e l o w 85

p e r c e n t o f t h a t e x p e c t e d ) . A s e c o n d c r i te r ia is t h e

p r e s e n c e of a n i n t e n s e fear o f g a i n i n g w e i g h t o r becoming

f a t e v e n when o n e i s u n d e r w e i g h t . A n o t h e r c r i t e r i a i s a

d i s t u r b a n c e i n body image ( i . , f e e l i n g f a t e v e n when

e m a c i a t e d ) . Finally, t h e âbsence of three c o n s e c u t i v e

m e n s t r u a l c y c l e s i n females is c o n s i d e r e d t o be a

s i g n i f i c a n t symptom i n d i c a t i n g t h e p r e s e n c e o f a n o r e x i a

n e r v o s a (Amer i can Psychiatric A s s o c i a t i o n , 1 9 9 4 ) .

Subtypes. There are t h r e e s u b t y p e s o f a n o r e x i a

n e r v o s a . The r e s t r i c t o r s u b t y p e is a l abe l reserved f o r

t h o s e who fast f r o m food but do n o t e n g a g e i n p u r g i n g

b e h a v i o u r s . I n c o n t r a s t , n o n - r e s t r i c t o r s a l t e r n a t e b e t w e e n

periods of fasting, and binge-eating or purging behaviours.

A third label is reserved for those who have an unspecified

eating disorder with anorectic features ( L e . , meet most but

not al1 the diagnostic criteria for anorexia nervosa)

(American Psychiatrie Association, 1 9 9 4 ) .

Behavioral stratecries. A number of behavioural

strategies are associated with anorexia nervosa to e n s u r e

weight loss and/or prevent weight gain. Some of these

strategies include, but are not limited to, the following:

1) extreme restriction of food intake; 2) hiding and toying

with or disposing of food; 3) compulsive use of laxatives,

appetite suppressants, and/or diuretics well beyond

recornmended dosages; 4) intensive and excessive exercise

regimens; a ~ d 5) self -induced vomit ing (purging) (Haller,

1992) .

Gender and cultural influences. Although the

forementioned diagnostic criteria are used to diagnose both

males and fernales, some gender differences are apparent in

how the disorder is manifested (Eating Disorders Association

[EDA], 1988) . Men, more so than women, are more

achievement-oriented, show more sexual anxiety, appear

excessively athletic, and over-value physical fitness, body

appearance and muscle strength (EDA, 1988).

12

I n a d e s c r i p t i v e c o r r e l a t i o n a l s t u d y , O l i v a r d i a , Pope,

Mangweth, and Hudson ( 1 9 9 5 ) i n v e ç t i g a t e d select f a c t o r s

a s s o c i a t e d with e a t i n g d i s o r d e r s . Males d i a g n o s e d w i t h a n

e a t i n g disorder (n = 2 5 ) were compared w i t h a g roup of women -

w i t h b u l i m i a (g = 3 3 ) and males w i t h Osgood -Sc l a t t e r d i s e a ç e

(n = 2 6 ) . A l 1 s u b j e c t s w e r e a d m i n i s t e r e d t h e D i a g n o s t i c

Su rv ey f o r E a t i n g Disorders - Rev i sed , t h e S t r u c t u r e d

C l i n i c a l Interview fo r DSM I I I - R , E a t i n g A t t i t u d e s T e s t

( E A T ) , E a t i n g D i s o r d e r I n v e n t o r y (EDI), and a n i n t e r v i e w

s c h e d u l e on demographic , body image, e x e r c i s e and d i e t i n g

b e h a v i o u r s , c h i l d h o o d e x p e r i e n c e s , a n d family

c h a r a c t e r i s t i c s . T h e r e s u l t s indicated t h a t men w i t h eating

d i s o r d e r s had s i g n i f i c a n t l y higher EAT and EDI s c o r e s , a n d

a d v e r s e c h i l d h o o d e x p e r i e n c e s ( s e x u a l abuse , p o o r e r

r e l a t i o n s h i p s w i t h f a t h e r s ) t h a n men i n t h e compar i son

g roup . Al though men w i t h e a t i n g d i s o r d e r s i d e n t i f i e d no re

major mood d i s o r d e r s , problems w i t h s u b s t a n c e abuse , a n x i e t y

d i s o r d e r s , and d i s s a t i s f a c t i o n w i t h body image t h a n t h e i r

male c o u n t e r p a r t s , t h e y d i d n o t d i f f e r s i g n i f i c a n t l y f r om

women w i t h b u l i m i a . I n contrast t o p r e v i o u s s t u d y f i n d i n g s ,

t h e r e were no s i g n i f i c a n t d i f f e r e n c e s o b s e r v e d between t h e

two male groups on rates o f homosexual b e h a v i o r o r gender

i d e n t i t y d i s t u r b a n c e s .

13

Studies have also documented cultural influences on the

emergence of eating disorders (Lee, Ho, & Hsu, 1993;

Sohlberg & Norring, 1995). While the drive for thinness is

a cardinal sign of anorexia nervosa in Western society, it

is not a notable manifestation of anorexia nervosa in other

cultures. Lee et al. (1993) conducted a retrospective chart

audit of patients (N - = 70) with a clinical diagnosis of

anorexia nervosa who had been followed prospectively for two

years. The findings indicated that food refusal due to fat

phobia (41.4%) were less predominant than non-fat phobia

(58.6%) (gastric bloating, lack of appetite, fear of food) .

Non-fat phobic patients had a lower than ideal body mass

index (BMI), whereas, fat phobic patients had a higher than

average BMI, and exhibited m o r e f requent binge-eating,

vomiting, and physical exercise behaviours. The au tho r s

concluded t h a t significant cross-cultcral differences exist

in the manifestation of anorexia (Lee et al ., 1993) . Lee

(1996) criticized the diagnostic criteria for anorexia

nervosa as being too insensitive for detecting cultural

differences.

Risk Factors

Two types of risk factors play a key role in the

deveiopment of eating disorders: predisposing and

precipitating. Major risk factors associated with eating

disorders identified frorn the literature include: (a)

demographic characteristics, (b) personality traits, (c)

f amily communication patterns, (d) f arnily history of eating

disorders and substance abuse, and (e) a history of dieting

and biological components (Le., genetic vulnerabilities,

comorbidity with m o o d disorder, appetite control problems,

metabolic alterations) ( C r i s p , 1988; Muscari, 1987; Snisslak

et al., 1990) . However, the presence of any one of these

factors (precipitating and/or predisposing) is not

sufficient for the development of anorexia nervosa. In a

recent study of women (N - = 35) w h o had recovered £rom an

eating disorder, Russell, Trierweiler, and E l d e r (1996)

found that subjects gave variable weightings to specified

risk factors and identified diverse and cornplex reasons for

illness onset.

Predisposing factors. Demographic characteristics,

personality factors, family traits and dynamics in

combination with the sociocultural forces have been

implicated in the development of anorexia nervosa (Garfinkel

et al., 1987; Paxton, 1993; Shisslak et al., 1990; Wiifley &

Grilo, 1 9 9 4 ) . Wi th regard to demographic characteristics,

15

f e m a l e s t w e l v e t o eighteen years o f age i n m i d d l e t o h igher

socioeconomic groups i n W e s t e r n s o c i e t i e s a r e c o n s i d e r e d t o

be a t greater r i s k f o r d e v e l o p i n g e a t i n g disorders Chan

t h e i r male c o u n t e r p a r t s ( F i s h e r , S c h n e i d e r , P e g l e r , &

N a p o l i t a n o , 1 9 9 1 ; G a r f i n k e l e t a l . , 1987; Hawkins,

McDermoth, S e e l e y , & Hawkins, 1992) . Whi taker , Davies, S h a f f er, Johnson, Abrarns , Walsh, a n d

Kalikow ( 1 9 8 9 ) d e s i g n e d a c r o s s - s e c t i o n a l s t u d y t o

i n v e s t i g a t e t h e e a t i n g a t t i t u d e s a n d b e h a v i o u r s of h i g h

s c h o o l s t u d e n t s ( N - = 5108) i n g r a d e s 9 t h r o u g h 1 2 . Da ta

w e r e c o l l e c t e d w i t h t h e E a t i n g Symptoms I n v e n t o r y ( E S I ) ,

E a t i n g A t t i t u d e s T e s t (EAT), as w e l l as a d e m o g r a p h i c a n d

m e d i c a l h i s t o r y q u e s t i o n n a i r e . S t u d y f i n d i n g s s u g g e s t e d

that a l t h o u g h fernale ES1 and EAT scores d o u b l e d t h o s e of

t h e i r ma le p e e r s , s t u d e n t s of both sexes w i t h h i g h e r body

mass i n d e x e s were more l i k e l y to score higher on the EAT and

E S I , e n g a g e i n b i n g e eating, a n d experience b i n g e distress.

Also , fernales tended t o r e l y more on m u l t i p l e me thods of

s e r i o u s weight c o n t r o l (72 p e r c e n t v e r s u s 31 p e r c e n t w e r e

d i e t e r s , r e s p e c t i v e l y ) and h a v e a higher i n c i d e n c e of

f a s t i n g t h a n males; whereas , males r e p o r t e d more r e c u r r e n t

b i n g e - e a t i n g t h a n females.

L e i c h n e r , A r n e t t , R a l l o , S r ikameswaren , a n d Vulcano

16

(1986) used the E a t i n g A t t i t u d e s T e s t t o survey s t u d e n t s (N -

= 4659) aged 1 2 t o 20 y e a r s i n p u b l i c s c h o o l s and o n e

u n i v e r s i t y s e t t i n g . T h e r e s u l t s i d e n t i f i e d £ive p e r c e n t o f

males and twenty- two p e r c e n t o f f e m a l e s w i t h p o t e n t i a l

e a t i n g a t t i t u d e p r o b l e m s . Study findings also d e n o n s t r a t e d

a h i g h e r p r e v a l e n c e of p r o b l e m a t i c eating a t t i t u d e s i n

f e r n a l e s , 1 9 t o 20 years of age, w i t h a h i g h b o d y mass i n d e x ,

a n d l i v i n g i n urban settings when compared w i t h males.

Moore (1990) d e f i n e d a n o r e x i a n e r v o s a as a disorder

t h a t u s u a l l y f i r s t a p p e a r s d u r i n g a d o l e s c e n c e b u t may

surface i n rniddle age. C h i l d r e n as young a s n i n e years o f

a g e have b e e n shown t o d e m o n s t r a t e a desire t o l o s e w e i g h t ,

b e l i e v i n g t h a t t h e i r p e e r s p e r c e i v e them t o b e fat. When

e x p r e s s i o n s o f discontent w i t h f e e l i n g o v e r w e i g h t a re

combined with b e h a v i o r s that l e a d t o thinness a t a n e a r l y

a g e , t h e r e exists a s t r o n g predisposition Eor developing an

e a t i n g d i s o r d e r (Maloney, McGuire, D a n i e l s , & S p e c k e r , 1989;

S a s s o n , Lewin, & Roth, 1 9 9 5 ) -

A l a t e r age of o n s e t has been associated w i t h c h e m i c a l

d e p e n d e n c y o r p s y c h i a t r i c i l l n e s s (Hsu, I W O ) , a n d t h e

c h a n g i n g ro le of women i n s o c i e t y ( G r e m i l l i o n , 1 9 9 2 ) .

C e r t a i n p e r s o n a l i t y t r a i t s h a v e a l s o b e e n i m p l i c a t e d i n t h e

d e v e l o p m e n t of a n o r e x i a n e r v o s a : low s e l f - e s t e e m , with o r

17

w i t h o u t d e p r e s s i o n ( S i l v e r s t o n e , 1 9 9 0 ) ; a t e n d e n c y t o w a r d s

o b e s i t y ( P o n t o , 1 9 9 5 ) ; d i s t o r t e d body image; f e e l i n g s of

l o s s of c o n t r o l ; t h e p r e s e n c e of a s t r o n g need t o give t o

o t h e r s ; f e e l i n g g u i l t o r shame when t r y i n g t o p l e a s e

o n e s e l f ; p e r c e i v e d g e n e r a l i n e f f e c t i v e n e s s ; a n d a dr ive t o

achieve p e r f e c t i o n (Muscar i , 1 9 8 8 ; S h i s s l a k e t al., 1 9 9 0 ) -

A c c o r d i n g t o Minuchin , Rosrnan, and B a k e r ' s ( 1978 ) work

o n f a m i l y f u n c t i o n i n g , t r a n s a c t i o n a l p a t t e r n s p l a y a k e y

r o l e i n t h e development of a s e n s e of autonomy and p e r s o n a l

i d e n t i t y . When f a m i l y i n t e r a c t i o n p a t t e r n s are

c h a r a c t e r i z e d as enmeshed o r d i s e n g a g e d , t h e c h i l d r s s e n s e

of c o n t r o l o v e r p s y c h o l o g i c a l a n d b o d i l y f u n c t i o n i n g may be

compromised, and , t h e r e f o r e , p l a c e h im/her a t greater r i s k

f o r d e v e l o p i n g p s y c h o s o m a t i c i l l n e s s (Minuchin e t a l . ,

1 9 7 8 ) . Johnson and F l a s h (1985) also identify f a m i l y

i n t e r a c t i o n patterns t h a t place hiçh ernphasis o n

o v e r p r o t e c t i v e n e s s and less on self e x p r e s s i o n , as

s i q n i f i c a n t r i s k f a c t o r s i n t h e deve lopment o f e a t i n g

d i s o r d e r s . Anorexies, f o r e x a m p l e , o f t e n have a h i s t o r y o f

f a m i l y r e l a t i o n s h i p s which impede autonornous growth (Bruch,

1973; M u s c a r i , 1988 ; R o s e n f i e l d , 1 9 8 8 ) . I n some i n s t a n c e s ,

t h e s e f a m i l i e s may v e r y well p r e s e n t t h e image of b e i n g t h e

" p e r f e c t farni ly".

Additional family risk factors include: fernale

dominated or only/last child families; emphasis placed on

achievement and physical appearance as opposed to emotions

or feelings (Canadian Mental Health Association [CMHA] ,

1989); families with a psychiatric history of eating

disorders, and/or affective disorders (Johnson, 1995;

Muscari, 1988); and, fatherrs behavior towards daughters at

puberty (e-g., rejection or teasing may translate into shame

and self-disgust about oner s body) (Sanford & Donovan,

1984). Rorty, Yager, and Rossotto (1994) also suggested

that a history of physical, sexual or psychological abuse

increases an individualrs susceptibility to eating

disorders - Sociocultural influences are also believed to play a

significant so le in the developrnent of eating disorders.

Garner and Garfinkel (1980) designed a cross-sectional study

to compare the eating attitudes and behaviours of

professional dance (n =183) and rnodeling (n = 56) students - -

with women of the same age and social class diagnosed with

anorexia nervosa ( n = 68), attending university (2 = 59), or -

music school (n - = 35). The Eating Attitudes Test (EAT) and

Hopkins Syrnptorn Checklist were used during data collection-

Women in the dance and mode1 groups had significantly higher

19

EAT scores than either the music or university students. In

addition, a significant positive correlation b e t w e e n eating

attitudes and psychological symptoms were found i n the

anoretic and dance groups b u t not the university group. The

authors concluded t h a t c u l t u r a l emphasis on thinness

combined with other predisposing factors "are forcing a

certain number of vulnerable adolescents below a threshold

which triggers anorexia nervosa" ( p - 655).

Powerful messages are being sent to young people by

media images that promote thinness ( e . g . , television

advertisements, diet ads, fashion magazines) , movie stars

that equate thinness with power and success, and societyfs

overall preoccupation with thinness and weight l o s s . You

can never be "too thin" or "too p o w e r f u l " is t h e message

that the media has successfully instilled in the rninds of

Western society (Smead, 1985) .

In a descriptive correlational study, Tiggemann and

Pickering (1996) investigated the relationship between type

of television programs viewed, body dissatisfaction, and the

"drive for thinness" in ninety-four high school girls (rnean

age = 15.5). Subjects were asked to complete the Drive For

Thinness subscale of the Eating Disorder Inventory, and

record television prograrns watched d u r i n g the previous week.

20

The results d e m o n s t r a t e d a s t r o n g c o r r e l a t i o n between body

d i s s a t i s f a c t i o n and video c o n t e n t (e. g., f i t n e s s ) and

television programs ( e - g . , s p o r t s , s o a p s ) , and t h e d r i v e f o r

t h i n n e s s and m u s i c v i d e o s .

Gender s o c i a l i z a t i o n d i f f e r e n c e s is a n o t h e r component

o f s o c i o c u l t u r a l i n f l u e n c e s which have been i m p l i c a t e d i n

t h e development of a n o r e x i a nervosa , p a r t i c u l a r l y i n

females. Boys grow up l e a r n i n g that i n d i v i d u a l

accompl ishments w i l l p o s i t i v e l y affect how o t h e r s respond t o

them. Conve r se ly , girls a r e o f t e n v a l u e d f o r t h e i r l o o k s -

the s o u r c e of most p o s i t i v e feedback ( J a s p e r , 1 9 9 0 ) . Gender

s o c i a l i z a t i o n "teaches u s how t o act and behave s e p a r a t e l y

as women and men, a n d a b o u t t h e d i f f e r e n t r o l e s t h a t w e a r e

e x p e c t e d o r r e q u i r e d t o play" (Friedman, 1995 , p . 3 4 ) .

Precipitating factors, Reynolds ( 1 9 9 5 ) n o t e d t h a t

"there is substantial e v i d e n c e that d i e t i n g is a major risk

f a c t o r i n t h e deve lopmen t o f an eating d i s o r d e r " (p . 1257) .

The d i e t i n g cycle is prompted by perceived plurnpness,

n e g a t i v e comments from s i g n i f i c a n t o t h e r s abou t one ' s weight

and p o s s i b l y d e p r e s s i o n (Garner , 1993; Hsu, 1990; Loader,

1980; Orbach, 1982; Roth , 1992; Wi l l i amson , 1 9 9 0 ) . D i e t i n g

and body image c o n c e r n s a s p r e c u r s o r s i n t h e development o f

a n o r e x i a n e r v o s a have been documented i n numerous r e s e a r c h

studies (de C a s t r o & G o l d s t e i n , 1995;

1987; Pax ton , 1993; Pon to , 1 9 9 5 ) .

M e l l i n , 1 9 9 2 ;

21

M u s c a r i ,

H i l l , O l i v e r , a n d R o g e r s (1992) surveyed d i e t a r y

r e s t r a i n t s , s e l f - e s t e e m , body s a t i s f a c t i o n a n d body f i g u r e

i n a sample o f young g i r l s aged n i n e ( n = 8 4 ) a n d f o u r t e e n -

(fi = 8 6 ) from t h e same s c h o o l . S tudy f i n d i n g s i d e n t i f i e d

d i e t i n g restrictive p r a c t i c e s i n a s i g n i f i c a n t number of

n i n e year o l d s . I n a d d i t i o n , a p p r o x i m a t e l y 4 0 p e r c e n t o f

t h o s e who dieted i n b o t h age g r o u p s w e r e n o t o v e r w e i g h t .

M o t i v a t i o n f a c t o r s s t i m u l a t i n g d i e t a r y a c t i o n s had l i t t l e t o

d o w i t h a c t u a l body w e i g h t , and seemed t o be r e l a t e d t o

p e r c e p t i o n o f body s h a p e (Hill e t a l . , 1 9 9 2 ) . S i m i l a r

f i n d i n g s on d i e t i n g and w e i g h t h h a p e c o n c e r n s i n e l e m e n t a r y

school c h i l d r e n were r e p o r t e d by de Castro a n d G o l d s t e i n

( 1 9 9 5 ) , a n d M e l l i n ( 1 9 9 2 ) .

F i s h e r , S c h n e i d e r , P e q l e r , a n d Napol i tano (1991)

i n v e s t i g a t e d t h e r e l a t i o n s h i p s among e a t i n g a t t i t u d e s a n d

b e h a v i o u r s , s e l f - e s t e e r n , a n x i e t y , and h e a l t h - r i s k b e h a v i o u r s

i n a s a m p l e (N - = 2 6 8 ) o f s t u d e n t s (mean age = 1 6 . 2 ) . S t u d e n t s from g r a d e s 9 t h r o u g h 12 were a d m i n i s t e r e d the

l a t i n g A t t i t u d e s Test, R o s e n b e r g S e l f - E s t e e m Scale, Ç t a t e

Trait A n x i e t y I n v e n t o r y f o r C h i l d r e n , and a q u e s t i o n n a i r e on

select h e a l t h - r i s k b e h a v i o u r s . The f i n d i n g s r e v e a l e d a

22

moderately, p o s i t i v e c o r r e l a t i o n be tween eating a t t i t u d e s

and self-esteem, anxiety, a n d w e i g h t a t t i t u d e s . F u r t h e r ,

most of t h e h e a l t h - r i s k b e h a v i o u r s (smoking, substance u s e ,

sexual a c t i v i t y ) depicted a low b u t s i g n i f i c a n t , p o s i t i v e

r e l a t i o n s h i p with eating a t t i t u d e s a n d self-esteem.

P a r t i c i p a t i o n i n c o r n p e t i t i v e s p o r t s and careers

emphasizing t h i n n e s s (e .g., model ing) a r e additional f a c t o r s

i d e n t i f i e d as precursors t o t h e development of a n o r e x i a

n e r v o s a (War ren , S t a n t o n , & B l e s s i n g , 1990) . B a l l e t d a n c e r s

are c o n s i d e r e d t o be a h i g h r i s k g r o u p because o f t h e

a t t e n t i o n g i v e n t o m a i n t a i n i n g a slim phys ique ( l e Grange,

T i b b s , & Noakes , 1 9 9 3 ; Szmukler , E i s l e r , Gillies, & Hayward,

1985).

A d o l e s c e n t s , s t r u g g l i n g t o f i n d t h e i r own i d e n t i t y , are

f a c e d w i t h t h e a d d i t i o n a l p r e s s u r e o f c o n f o r m i n g t o

a c c e p t a b l e peer n o m s . P e r s o n s t e a s e d o r r i d i c u l e d by t h e i r

p e e r s are a t g r e a t e r r i s k of d e v e l o p i n g poor s e l f - i m a g e

(Cash, W i n s t e a d , & Janda, 1 9 8 6 ) . The combined e f f e c t of low

self-esteem a n d the n e e d t o be a c c e p t e d b y p e e r s , e s p e c i a l l y

i n grades 5 t o 7 , is b e l i e v e d t o be t h e d r i v i n g force b e h i n d

t h e d e v e l o p m e n t of e a t i n g disorders (Thompson, C o o v e r t ,

R i c h a r d s , J o h n s o n , & C a t t e r i n , 1 9 9 5 ) .

A d d i t i o n a l f a c t o r s c o n s i d e r e d r e s p o n s i b l e f o r

increasing womenfs susceptibility for anorexia nervosa

include irregular eating habits, such as binging or

emotional eating (Crisp, 1988) , and major life changes

and/or stressors ( e . g . , parental separation or divorce,

puberty, leaving home, or commencing post-secondary

education) . However, Garner (1 993) cautions that

ineffective and inadequate coping skills underlie many of

these precipitants .

Anorexia Nenrosa and Associated Conditions

The complexity in the treatment and diagnosis of

anorexia nervosa is further confounded in the presence of:

a) alcohol and substance abuse, and b) premorbid and

comorbid emotional disorders. Severa l authors estimated

that up to 25 percent of clients with eating disorders have

associated alcohol and drug abuse problems ( G o h i b l o o m et

al., 1992; Lesieur & Blume, 1993; Peveler & Fairburn, 1990;

Watts & Ellis, 1992). Clinical manifestation common to

p e r s o n s with eating disorders and substance abusers include:

(a) loss of control, (b) preoccupation with the abused

substance ( e - g . , food or alcohol) (c) seeking relief from

inner emotional pain, (d) secrecy about behavior, (e) denial

of the problem, (f) persistent abuse of the substance (e-g.,

food o r a lcohol) d e s p i t e adverse hea l th e f f e c t s , and ( g )

non-cornpliance with t reatment regimens (Haller , 1992;

Hamburg, Herzog, Brotman, & S t a s i o r , 1 9 8 9 ; Hsu, 1990; Watts

& E l l i s , 1 9 9 2 ) .

Anorexia nervosa may be e i t h e r t h e primary diagnosis

w i t h a comorbidity of an a f f e c t i v e d i sorder , o r t he

secondary diagnosis i n t h e presence of o ther p s y c h i a t r i c

d isorders such as depression, schizophrenia o r persona l i ty

disorders (Mann, Wakelinq, Wood, Dobbs, & Szmukler, 1 9 8 3 ) .

I n secondary o r a t y p i c a l cases , persons who present w i t h

c l i n i c a l manifestat ions r e f l e c t i n g t h e diagnost ic c r i t e r i a

for anorexia nervosa, without body image d i s t o r t i o n ,

generally respond w e l l t o t reatment once the primary

diagnosis i s t r e a t e d (Coovadia, 1995) . T h e coexistence of

these forementioned a s soc ia t ed diagnoses a r e va r i ab le s w h i c h

o f t e n cloud cliniciansr diagnostic judgments a n d alter t h e

course of treatrnent f o r anorexia nervosa.

Treatment Modalities and Proqnosis

Anorexia nervosa is laden with a m u l t i t u d e of cornplex

and i n t r i c a t e f a c t o r s which must be considered i n order t o

e n h a n c e t he e f f i cacy of treatrnent modal i t ies . The treatment

of ea t ing d isorders varies considerably depending upon a

particular clinician's theoretical preference. The

intricacies and pathogenesis of eating disorders and the

generalization of counselling-therapy strategies often

becorne secondary to the clinicianrs practice mode1 (Bruch,

1973; Roth, 1992). Even with recent advances in the

treatment of eating disorders, the importance of the

interplay of biological, psychological, familial and

sociocultural variables in its development and continuance

has not received adequate attention. Researchers have yet

to achieve a consensus, or develop a unified theory, on

eating disorders (Garner, 1993; Gwirtsman, 1993; Haller,

1992; Irwin, 1993).

Treatment modalities, whether in-patient or out-patient

based, consist of one or more of the following:

psychoanalytical (Goldbloom & Kennedy 1988); cognitive-

behaviourol ( G a r ~ e r , 1 9 8 8 ) ; experiential-expressive (Hornyak

& Baker, 1989); psychopharmacological (Goldbloom & Kennedy,

1988); psychoeducational (Garner, 1988); or group,

individual, and f a r n i l y therapy (Meades, 1993; Strauss,

1995). The decision to treat on an in-patient or out-

patient basis, which includes day programs, is determined by

the physical and mental status of the client. For example,

it is common practice that when a person presents a danger

26

to h e r s e l f / h i m s e l f i n t e r m s o f weight l o s s o f more t h a n 25

p e r c e n t o f body w e i g h t ( L e . , a c c o r d i n g t o the D S M - I V ) , is

n o n - r e s p o n s i v e t o out-patient t r e a t m e n t , o r d e m o n s t r a t e s

s e v e r e e m o t i o n a l distress ( L e . , su ic ida1 f e e l i n g s a n d

i d e a t i o n ) , t h e c l i n i c i a n p r e f e r s i n - p a t i e n t treatment

(Hamburg, Herzog , Brotman, & S t a s i o r , 1 9 8 9 ) .

The p r o g n o s i s f o r a n o r e x i a n e r v o s a i s dismal ( G a r f i n k e l

& Goldbloom, 1988 ; H a l l e r , 1 9 9 2 ) . One i n t e n cases w i l l

result i n dea th from s t a r v a t i o n , cardiac arrest o r s u i c i d e .

P o o r e r r e c o v e r y rates are a s s o c i a t e d with g r e a t e r w e i g h t

l o s s , o l d e r age o f i l l n e s s o n s e t and l o n g e r illness d u r a t i o n

(EDA, 1 9 8 8 ) . S u c c e s s rates a re much h i g h e r f o l l o w i n g e a r l y

d i a g n o s i s and treatment ( P a t t e r s o n , 1 9 9 5 ) .

Summaxy

Research on anorexia n e r v o s a as a disorder under the

m e d i c a l mode1 of care h a s r e s u l t e d i n t h e ( a ) d e v e l o p m e n t of

d i a g n o s t i c c r i t e r i a and i n s t r u m e n t s ( i . e . , E a t i n g D i s o r d e r

I n v e n t o r y by G a r n e r , O l m s t e d , & P o l i v y , l984), (b )

i d e n t i f i c a t i o n of r i s k f a c t o r s a s s o c i a t e d w i t h t h e o n s e t of

a n o r e x i a nervosa, a n d (c) a c c e p t a n c e o f a n o r e x i a n e r v o s a a s

a d i s o r d e r . Al though t h e g r o w i n g r e s e a r c h base o n a n o r e x i a

nervosa has i n c r e a s e d h e a l t h care p r o v i d e r s r awareness o f

27

the complexities involved in the diagnosis and treatrnent of

this multidimensional disorder, limited efforts have been

expended on identifying an anoretic's perception of living

with the illness. Until a deeper understanding of the

meaning of health and illness in this population is

captured, Anorexics will remain in a constant struggle to

restore the self that was damaged long before illness onset.

Anorexia N e r v o s a as an Illness: Qualitative Insiahts

To date, qualitative research insights into the rneaning

of anorexia nervosa for persons living with this illness is

limited. A f e w studies were found in the literature that

stressed the importance of understanding illness meanings in

order to successfully treat anorexia nervosa.

Hilda Bruch's contributions from her life-long work

with Anorexics are docurnented in her writings (e.g., The

Golden Cage, The Enigma of Anorexia Nervoça, 1977;

Conversations with Anorexics, 1988). Bruch has been

foremost in proposing that deficiencies in ego development

during the f i r s t few years of life result from faulty

interactions with the mother. The child is often paralyzed

with a sense of ineffectiveness, which is central to the

psychopathology of the disorder. Because the self is

e x p e r i e n c e d o n l y i n r e s p o n s e t o the demands of o t h e r s ,

p e r s o n a l p l e a s u r e s are minirnized. Based o n c l i n i c a l

i n t e r p r e t a t i o n s of a n o r e x i a n e r v o ç a , Bruch a r g u e d t h a t

t h e r a p e u t i c success would remain e l u s i v e u n l e s s autonomy,

ove r - con fo rmi ty , s e l f - e s t e e m , a n d i l l n e s s meanings are given

a t t e n t i o n i n t r e a t m e n t m o d a l i t i e s ,

S a n t o p i n t o (1988) used a phenomeno log i ca l approach t o

study t h e meaning o f the " r e l e n t l e s s d r i v e f o r thinness" f o r

two Anorexies. Three c o n c e p t s e v o l v e d £rom t h e thematic

a n a l y s i s : 1) withdrawing-engag ing - e n t e r i n g i n t o r e l a t i o n s

w i t h others and the w o r l d w h i l e s e e k i n g p r o t e c t i o n t h r o u g h

concealment ; 2 ) p e r s i s t e n t struggle - c o n f l i c t between t h e

drive t o p u r s u e t h e d e s i r e d b o d y - s t a t e o f thinness w h i l e

f e e l i n g bitter a n d d o u b t f u l a b o u t d o i n g i t; and 3 ) imaged

s e l f - one o f t h i n n e s s t h a t somehow remains e l u s i v e .

Santopinto' s ( 1 9 8 8 ) study f indings conf l i c t ed w i t h tnose

from o t h e r phenomenolog ica l s t u d i e s (Binswanger , 1958 , and

Boss, 1963, c i ted i n S a n t o p i n t o , 1988) which d e p i c t e d t h e

l i v e d e x p e r i e n c e of t h e a n o r e t i c as one of d e s p a i r and

h e l p l e s s n e s s grounded i n t h e p a s t w i t h o u t a clear s e n s e o f

t h e future. S a n t o p i n t o (1988) a r g u e d t h a t the a n o r e t i c ' s

imaged self is longed for, n o t f e a r e d o r d r e a d e d : "Ever

aware of t h e was, one moves t oward t h e w i l l - b e r choos ing

opportunities that expand horizons of meaning" (p. 3 3 ) .

This author stressed the importance of focusing on both

particular and universal aspects of therapeutic

interactions.

Turner ( 1 9 9 0 ) , in a theoretical perspective on the

phenomenology of anorexia nervosa, depicted loss of appetite

or refusal to eat as an act intended to defy societal

expectations and break communication ties between the person

and society. Creating a parallel between loss of appetite

and loss of speech, Turner stressed that success with

therapeutic interventions is highly dependent on identifying

"the conditions u n d e r which an anoretic patient can be given

a voice" (p. 1 6 5 ) . This author argued that given the

evolution of anorexia nervosa £ r o m a complex interaction of

diverse processes (i . e., cultural, social, familial anci

z m t u r a t i o n a l ) , sixcessfül diagnosis and treatment requires a

multidisciplinary perspective that is capable of grasping

the variant conceptual levels of the illness.

Moreno, Fuhriman, and Hileman (1995) designed a

qualitative study to explore factors contributing to

positive outcornes in group therapy. Content analysis of the

data revealed that group members identified emotional

connectedness as the most salient variable in therapy. Van

den Broucke, Vandereycken, and Vertomrnen (1995) also used a

triangulated approach to identify anorexies' relationship

patterns. Although data from the quantitative measures

failed to detect significant differences between control ând

study g r o u p s , the self-reporting methods did reveal

relatively low levels of openness a n d high levels of

intimacy p r o b l e m s in the study group.

In summary, many researchers a n d clinicians recognize

the complexity a n d multidimensional nature of anorexia

n e r v o s a . The problems posed by failure to achieve true

emotional connections with others ernerged as a recurrent

theme in theoretical and clinical perspectives on the

experience of living with anorexia nervosa. However, more

qualitative studies are n e e d e d to capture the 'essence" of

living with this illness to facilitate health promot ion

e f f m b T p p p p p p p p - - - - - - - - - - - - - - - - - - - - - -

Eating Disorders and H e a l t h Promotion Strategies -- - - - - - -- - - -

Social, cultural, p o l i t i c a l and economic forces have

had a significant impact on the s l o w evolution of h e a l t h

p r o m o t i o n and illness prevention programs. The

rnultidimensional nature and c o m p l e x i t y of ea t i ng disorders

have led numerous a u t h o r s to conclude that such programs are

sorely needed if we are to combat escalating prevalence

rates (Crisp, 1988; Paxton, 1993; Piran, 1995; Rosen, 1989).

Currently, researchers are increasing their efforts in

developing health promotion and prevention programs for pre-

adolescents. However, following an exhaustive review of the

literature no studies were identified that focused

specifically on health promotion programs for individuals

diagnosed with anorexia nervosa or other eating disorders.

Despite the apparent political readiness for addressing

primary prevention in health, limited attention is given to

the efficacy of health promotion programs for eating

disorders (Crisp, 1988) . Shisslak et al. (1990) and Rosen

(1989) used quasi-experimental designs to evaluate the

effectiveness of health promotion and illness prevention

programs with high school students. Both studies

dernonstrated a treatment effect for knowiedge but not eating

behaviors or attitudes. These authors concluded that study

findings were limited by using quasi-experimental designs,

and recomrnended time series designs for future research in

this area.

Paxton (1993) designed a time series design (1 month,

and 12 months) to deliver a health promotion and illness

prevention program to grade nine high school students. The

c o n t e n t and d e s i g n of the research was Sased on t h e

recommendat ions of previous a u t h o r s (Crisp, 1988; S h i s s l a k

et al., 1 9 9 0 ) . S t u d y f i n d i n g s failed t o detect a t r e a t m e n t

effect f o r e a t i n g b e h a v i o r s a n d a t t i t u d e s . Paxton s u g g e s t e d

t h a t t h e e f f i c a c y of h e a l t h p r o m o t i o n and illness p r e v e n t i o n

programs might be enhanced b y t a r g e t i n g younger s t a d e n t s .

Murphy and Dale (1995) c o n d u c t e d a p i l o t s t u d y i n a

r u r a l h i g h s c h o o l t o i d e n t i f y e a t i n g d i s o r d e r c o n c e r n s and

the n e e d for h e a l t h p romot ion p rograms . P r e t e s t f i n d i n g s on

t h e s u s c e p t i b i l i t y o f students f o r d e v e l o p i n g e a t i n g

d i s o r d e r s were comparab le t o n a t i o n a l s t a t i s t i cs . Younger

s t u à e n t s ( g r a d e s s e v e n and eight) r e p o r t e d less symptorns

t h a n g r a d e n i n e s t u d e n t s { f o u r t e e n and fifteen years o l d s ) ,

b u t o l d e r students had g r e a t e r knowledge about eating

d i s o r d e r s . A health promotion program w a s d e v e l o p e d i n

response t o s t u d y f i n d i n g s . A l t h o u g h changes i n e a t i n g

h a b i t s a n d attitudes were n o t assessed, post-test s c o r e s

demonstrated a n o v e r a l l i n c r e a s e i n knowledge levels for al1

g r a d e s (three weeks f o l l o w i n g the s t r u c t u r e d s e s s i o n ) . T h e

a u t h o r s c o n c l u d e d t h a t h e a l t h p r o m o t i o n p rograms s h o u l d

ta rget junior h i g h s c h o o l s t u d e n t s , and t i m e series d e s i g n s

used t o m o n i t o r b e h a v i o r a l a n d a t t i t u d i n a l change (Murphy &

Dale, 1 9 9 5 ) .

Moreno and Thelan (1993) used a quasi-experimental

design to address the efficacy of a health promotion and

illness prevention program developed for grades 6 and 7

students. The experimental group demonstrated increased

knowledge, and had healthier attitudes and intentions about

dieting and weight. Piran ( 1 9 9 5 ) , in a time series study of

an elite cornpetitive ballet school (high risk population),

reported comparable findings. Sirnilar findings were also

reported by Neumark-Sztainer, Butler, and Palti (1995) from

a quasi-experimental design with high school students (N =

341). However, these authors âcknowledged that significant

behavioral changes were noted only in students who did not

have an eating disorder.

Porter, Morrell, and Moriarty (1986) showed a

significant change in eating attitudes and behaviors in

stude~ts aged n i n e ta sixteen, according to tne Eatinq

Disorder Inventory (EDI) . Teaching strategies (e. g., art,

dance, music and film to "inoculate" against the drive for

thinness) were identified as prerequisites for altering

eating behaviors and attitudes in this population. However,

generalizability of the findings is limited because

participants were at lew risk for developing eating

disorders.

34

In surnmary, the discrepancies evident in the f indings

from health promotion intervention studies highlight the

complexities associated with providing treatment t o clients

w i t h anorexia nervosa. The effectiveness of health

promotion interventions can best be assessed by relying on

frameworks t h a t capture the multidimensional aspects of this

illness. In addition, appropria te study designs must be

used to track the efficacy of interventions over time.

Crisp (1988) noted t h a t prevention i s a form of intervention

directed towards altering t h e natural history for the

b e t t e r . Pr i rnary prevention means intervening before

problems with eating disorders surface. Study f i n d i n g s

suggest that greater success is achieved with early

detection and intervention. Education started at the

elernentary school level will provide a sound knowledge

to facilitate the formation of healthy attitudes and

behâviors (Paxton, 1993)

Discussion

base

From the literature review, it is evident that there is

a dearth of research which focuses on the experience of

l i v i n g with anorexia nervosa. The paucity of research in

this area was also noted by o thers (e . g . , S a n t o p i n t o , 1988) .

In contrast,

studies that

35

there is an abundance of quantitative research

focus primarily on epidemiological, diagnostic

and treatment variables. As well, many of these studies

have been plagued by methodological and conceptual problems.

Rosenfield (1988) stressed the importance and urgent need

for more quasi-experimental and longitudinal designs, as

well as "rigorous qualitative research to investigate a

hurnan response about which very little is known" ( p - 51) ,

Considering the unknown origin of anorexia nervosa, the

absence of a unified theory, lack of culturally sensitive

diagnostic tools, a typ ica l presentations of the illness and

the presence of confounding comorbid conditions, it cornes as

no surprise that the diagnosis and treatment of anorexia

nervosa continues to rnystify clinicians. The positive

direction provided by recent insights into preventive

approaches and a greater uillingness to use health promotion

strategies is acknowledged and supported by a number of

authors (Crisp, 1988; Muscari, 1987; Paxton, 1993).

The diagnosis and treatment of anorexia nervosa, in the

past, has been dominated by the biomedical mode1 of care.

The term "disorder" is accepted without question by

clinicians despite knowing that the pathogenesis of anorexia

nervosa extends far beyond the scope of its biophysical

sequelae. Most clinicians recognize the interplay of

multiple factors in the onset and t r a j e c t o r y of anorexia

nervosa. Without a u n i f i e d multidimensionaS mode1 to guide

treatrnent, significant intradisciplinary and

interdisciplinary d i f f e r e n c e s regarding appropriate

modalities will continue to exist. The prognosis for these

clients will remain dismal until precedence is given to

t h e i r needs.

Gremillion (1 992) argued that dominant treatrnent

modalities of the past failed b e c a u s e consideration was not

given to al1 relevant variables (e.g., social,

p h y s i o l o g i c a l , familial, cultural). T h i s author also noted

that the discipline of psychiatry has been largely

unsuccessful in treating a n o r e x i a nervosa b e c a u s e i t poses a

challenge to "psychiatrie epistemology as well as-thes-ocial p p p p p p p p p p p p p - - - - - - - - - - - - - -

-

milieu in which both illness and explanation are embedded by

reproducing certain core cultural values and meanings of the

illness" ( p . 5 8 ) . I n view of t h e fundamental concerns and

limitations of current research and the need to enhance the

efficacy of h e a l t h care for anorexics, an investigation into

the lived experience of the i l l n e s s is a plausible effort

that will facilitate early detection and treatrnent.

CHAPTER 3

Methodology And Methods

Methodology means " p u r s u i t of knowledge" a n d i n

research r e f e r s t o t h e mode o f i n q u i r y u s e d by t h e

i n v e s t i g a t o r . A s a method i n t h e human s c i e n c e s ,

phenomenology focuses o n g r a s p i n g a n d t h e n r e n d e r i n g the

l o g i c of t h e l i v e d e x p e r i e n c e without d i s t o r t i n g i t . The

goal of phenomenology i s t o p r o v i d e a " d e s c r i p t i o n of t h e

e x p e r i e n t i a l mean ings w e l i v e as w e l i v e them" (van Manen,

1 9 9 4 , p. 11).

Methodology

P h e n o m e n o l o g i c a l research is c o n c e r n e d w i t h t h e

concepts o f ( a ) r a t i o n a l i t y , (b) i n t e n t i o n a l i t y , ( c )

c o n s c i o u s n e s s , (d) o r i g i n a l a w a r e n e s s , a n d (e) essences (van

Manen, 1 9 9 0 ) . R a t i o n a l i t y i n human s c i e n c e o p e z a t e s o n the

a s s u m p t i o n t h a t e x p e r i e n c e is i n t e l l i g i b l e a n d r n e a n i n g f u l t o

t h o s e who l i v e i t . The powers of thinking, i n s i g h t , and

d i a l o g u e a l l o w o n e t o u n d e r s t a n d t h e w o r l d frorn t h e

p e r s p e c t i v e o f those who l i v e i t . R a t i o n a l i t y i s a n

e x p r e s s i o n of faith t h a t w e c m make t h i n g s u n d e r s t a n d a b l e

t o e a c h o t h e r ( v a n Manen, 1 9 9 0 ) .

Bermeneutic Phenomenology

This s t u d y u s e d van Manen's ( 1 9 9 4 ) he rmeneu t i c

phenomenology method t o capture t h e l i v e d e x p e r i e n c e s of

women w i t h a d i a g n o s i s of a n o r e x i a ne rvosa . The following

s t e p s w e r e t a k e n by t h e r e s e a r c h e r i n t h i s s t u d y : a ) t u r n i n g

t o t h e phenomenon of i n t e r e s t ; b) i n v e s t i g a t i n g the

e x p e r i e n c e a s it is l i v e d , n o t as i t is c o n c e p t u a l i z e d ; c )

r e f l e c t i n g on t h e themes which c h a r a c t e r i z e t h e phenomenon;

d) d e s c r i b i n g t h e phenomenon t h r o u g h t h e a r t o f w r i t i n g and

r e w r i t i n g ; e) m a i n t a i n i n g a s t r o n g and o r i en t ed r e l a t i o n t o

t h e phenomenon; and f) b a l a n c i n g t h e research c o n t e x t b y

c o n s i d e r i n g p a r t and whole.

Turninq to the phenomenon. Phenomenology i n q u i r y i s

d r i v e n by a c o r n i t r n e n t of t u r n i n g t o an o b i d i n g c o n c e r n .

T h i s comrnitment of n e v e r wave r ing frorn t h i n k i n g a sinqle

t hough t is the p r a c t i c e o f " t h o u g h t f u l n e s s " . T h i s a p p r o a c h

t o t h e phenomenon allows t h e r e s e a r c h e r t o c o n c e n t r a t e o n

t h e whole as opposed t o its p a r t s . T h e r e s e a r c h q u e s t i o n

g u i d e s t h e i n q u i r y and t h e e x p l i c a t i o n o f o n e ' s a s s u m p t i o n s

and p r e - u n d e r s t a n d i n g s of t h e phenomenon which, i n t u r n ,

d i r e c t the r e s e a r c h e r ' s o r i e n t a t i o n t o t h e phenomenon o f

i n t e r e s t (van Manen, 1 9 9 4 ) .

39

Investigatinq the experience. T h i s s t ep refers t o t he

impor t ance of being strongly o r i e n t e d t o t h e n a t u r e o f t h e

q u e s t i o n . T h e " taken for gran t ed f f and "the given" are h e l d

i n abeyance i n o r d e r t o e n t e r the world o f t h e p e r s o n under

study ( L e . , t h e a n o r e c t i c ) . T h e r e s e a r c h e r i n v e s t i g a t e d

t h e l i v e d wor ld o f anorexia nervosa t h rough : (1) t h e r a p e u t i c

s k i l l s a c q u i r e d from c l i n i c a l e x p e r i e n c e s i n mental h e a l t h

" t o truly h e a r " the messages being conveyed b y study

p a r t i c i p a n t s ; ( 2 ) e x p e r i e n t i a l d e s c r i p t i o n s c a p t u r i n g t h e

" l i v e d worlds" of eight women wi th a d i a g n o s i s of anorexia

n e r v o s a ( L e . , two i n a p i l o t s t udy , and s i x i n t h e current

study); (3) r e f l e c t i v e accounts of t h e human e x p e r i e n c e of

a n o r e x i a n e r v o s a from diar ies and j o u r n a l s (ci ted i n Banks,

1992; Turner , 1 9 9 0 ) , books such as "The Golden C a g e " and

"Conve r sa t i ons w i t h Anorex i c s " (Bruch, 1 9 7 7 , 1988 ) a n d "When

Food is Love" (Roth, 1991), and a poem, ' If R i v e r s Could Run

Backwards" (unknown a n o r e t i c a u t h o r ) ; ( 4 ) t h e r e s e a r c h e r ' s

j o u r n a l w r i t i n g s d u r i n g data c o l l e c t i o n and a n a l y s i s which

p r o v i d e d deep ref l e c t i o n a n d i n s i g h t i n t o t h e phsnomenon;

and ( 5 ) a r e v i e w of o t h e r phenomenological s t u d i e s (e .g.,

Hepworth, 1 9 9 4 ; Moreno, Fuhriman & Hileman, 1995;

Santopinto, 1988; S t a p l e s & Schwartz, 1990 ; Sutton-Edmands,

1986; Van den Broucke, Vandereycken, & Vertommen, 1 9 9 5 ) t o

create greater insight into how Iived experiences may be

interpreted.

Phenomenological reflectinq. Phenomenological

reflecting r e f e r s to trying t o grasp the essential meaning

of that which has been articulated. The analysis was

directed towards "recovering a theme or themes that are

embodied and dramatized in the evolving meanings and imagery

of the work" (van Manen, 1994, p. 7 8 ) . By using the line-

by-line approach as described by van Manen (1994), the

researcher reviewed and studied the lived-experience

descriptions while searching for comon themes.

Composing linguistic transformation of each transcript

systematically facilitated the development of interpretive

narratives that explicated the meaning of the text while

remaining true to the essence of t h e lived experiences.

Following repeated revisions of interpretive sumrnaries, the

information was compiled into categorical propertics

according to the common themes and then labeled. This

process helped the researcher identify gaps in the data

which were subsequently c l a r i f i ed and augmented i n a second

interview with participants. Insightful conversations with

members of the thesis cornmittee concerning the themes, was

also beneficial in gaining a deeper understanding of the

text. Reflecting on these themes in alliance with the

forementioned pathways of investigating the text, the

researcher was able to isolate tne incidental £rom essential

themes whicn articulated the meaning of the lived

experience.

Describinq the phenomenon. The main function of the - -

phenomenological description is to provide 'a reliable guide

to the listenerrs own actual or potential experience of the

phenomenon" (Speigelberg, 1965, p. 673) . As s u c h , it

"describes the original of which the description is only an

example" (van Manen, 1994, p. 182). A powerful

phenomenological description allows one to "see" that which

was not seen before in terms of depth of meaning of the

lived experience.

The description of the phenomenon of anorexia nervosa

was articulated through the art of writing and rewriting of

the text. Writing allowed distancing from immediate

involvement with the things in the world and allowed one to

externalize what was, in sorne sense, internai. Writing

united the researcher more closely with the lived world of

the anoretic.

Stronq/oriented relation to the phenomenon. While

assurning a strong orientation to the phenomenon, the

42

researcher became e n g r o s s e d w i t h t h e o r i g i n a l q u e s t i o n i n

order t o g a i n access t o l i v e d e x p e r i e n c e s a n d t o ask t h e

subject "what i s it l i k e ? " ( v a n Manen, 1 9 9 4 ) . Even with a

s t r o n g o r i e n t a t i o n t o t h e phenornenon, d e s c r i p t i o n i s j u s t

o n e i n t e r p r e t a t i o n , and does n o t n e g a t e t h e p o s s i b i l i t y o f

a n o t h e r cornplementary , r i c h e r , o r d e e p e r d e s c r i p t i o n .

Balancinq. Phenomenolog ica l t h e m e s may be

c o n c e p t u a l i z e d a s t h e e x p e r i e n t i a l s t r u c t u r e s which make up

an e x p e r i e n c e . Themes are t h e parts which f i t t o g e t h e r t o

make u p t h e w h o l e . Each theme i s i n t e r c o n n e c t e d and

d e p e n d a n t on t h e o t h e r . The r e s e a r c h e r c o n s t a n t l y measured

t h e overall d e s i g n of t h e t e x t a g a i n s t t h e s i g n i f i c a n c e t h a t

t h e p a r t s m u s t p l a y i n t h e whole s t r u c t u r e . I n t h e a r t of

w r i t i n g a n d r e w r i t i n g t h e t e x t , one c a n l o s e a s e n s e of

d i r e c t i o n a n d f a i l t o c a p t u r e t h e e s s e n c e (whole) . It was,

t h e r e f o r e , n e c e s s a r y t o paüse and step back, look a t cne

t o t a l o r "the g i v e n " , and try t o i d e n t i f y how e a c h p a r t

c o n t r i b u t e d t o t h e whole .

Methods

van M a n e n f s ( 1 9 9 4 ) p h e n o m e n o l o g i c a l a p p r o a c h w a s u s e d

t o g u i d e t h e i n q u i r y i n t o and t h e a n a l y s i s of womenrs

e x p e r i e n c e s i n l i v i n g with a n o r e x i a n e r v o s a . With t h i s form

of inquiry, the researcher is viewed as a scholar of human

science research and the phenomenological method as

"scholarship" (p .29) . This section will present a detailed

overview of the methods used in this study.

Participants

The population of interest was women who met the

diagnostic criteria for anorexia nervosa, or relevant

subtypes of this eating disorder. Study participants met

the following inclusion criteria: (a) female, (b) out-

patients, (c) English-speaking, (d) nineteen years of age

and older, (e) living within 100 km radius of St. John's,

Newfoundland or Kentville, Nova Scotia, (f) physically and

emotionally stable i e . , clinical competency was assessed

by attending psychiatrist in Newfoundland, and clinician in

Nova Scotia), and ( g ) participating in health promotion

activities, such as group or individual counselling.

A phenomenological inquiry lends itself to fewer

participants, as interviews yield vast amounts of narrative

data for analysis (Dukes , 1984) . Although small sample

sizes are normally adequate, subjects were enrolled into the

study until no new descriptions and/or themes emerged from

the data. Six participants were recruited for this study.

Procedure

P o t e n t i a l p a r t i c i p a n t s were selected t h r o u g h

c o n s u l t a t i o n w i t h p r o f e s s i o n a l s ( i n t e r m e d i a r i e s ) work ing

w i t h t h e H e a l t h Care C o r p o r a t i o n of St. J o h n ' s ,

Newfoundland, a n d V a l l e y R e g i o n a l Kea1 t h , Nova Scotia .

P o t e n t i a l p a r t i c i p a n t s who m e t t h e i n c l u s i o n c r i t e r i a w e r e

c o n t a c t e d b y t h e i n t e r m e d i a r i e s to: ( a ) i n f o r m them of the

s t u d y , (b) d e t e r m i n e t h e i r i n t e r e s t i n p a r t i c i p a t i n g , a n d

(c) o b t a i n p e r m i s s i o n for t h e i n v e s t i g a t o r t o c o n t a c t them.

Three o f t h e n i n e c o n t a c t e d r e f u s e d t o p a r t i c i p a t e b e c a u s e

of c o n c e r n s t h a t t a l k i n g a b o u t t h e p a s t would cause a n

i l l n e s s relapse.

A l 1 s t u d y p a r t i c i p a n t s chose t o b e i n t e r v i e w e d i n t h e

r e s e a r c h e r ' s o f f i c e . I n t e r v i e w s were s c h e d u l e d a f t e r c l i n i c

h o u r s t o maximize cornfort a n d e n s u r e c o n f i d e n t i a l i t y . A

detailed overview of t h e s t u d y w a s p r e s e n t e d , a n d informed,

w i t n e s s e d c o n s e n t w a s o b t a i n e d p r i o r t o the first interview

(see Appendix A ) .

The f i r s t i n t e r v i e w of e a c h p a r t i c i p a n t was a u d i o t a p e d

a n d l a s t e d a p p r o x i m a t e l y n i n e t y m i n u t e s . P a r t i c i p a n t s were

asked t o d e s c r i b e t h e i r e x p e r i e n c e s w i t h a n o r e x i a nervosa,

a n d open-ended q u e s t i o n s used t o prompt o r c l a r i f y

s t a t e m e n t s (see Appendix B) . With phenomenology, t h e

researcherfs question guides the mode of inquiry and the

sub j ect ' s commentary, in turn, guides t h e reflective

questions posed by the researcher (van Manen, 1994).

During the second interview, two to three weeks

following the first, each participant was asked t o confirm

an interpretive summary derived £rom the text of the first

interview. Insigbtful questions were asked t o clarify

identified gaps in the text. One participant also agreed to

review the thematic classification generated by the

researcher, adding further richness and support to the

emerging themes. The phenomenological writing of the text

was edited based on feedback from this participant, and a

third interview arranged for further understanding and

confirmation of the thematic analysis.

E t h i c a l Considerations

Permission to conduct this study was granted by the

Human Investigation C o r n m i t t e e (HIC), Mernorial University of

Newfoundland (see Appendix C ) , and the Research Comrnittee at

Valley Regional Hospital, Western Regional Health Board,

Nova Scotia (see Appendix D) - L e t t e r s of suppor t for the

study were also received £rom psychiatrists (see Appendix E)

and administrative personnel (see Appendix F) at t h e Health

Care C o r p o r a t i o n o f S t . J o h n ' s .

F o r e thical r e a s o n s , the H I C a t Mernorial University,

r e q u i r e d that t h e a t t e n d i n g p s y c h i a t r i s t address t h e

competency l e v e l of p o t e n t i a l p a r t i c i p a n t s p r i o r to

i n t e r r n e d i a t o r c o n t a c t , S t u d y p a r t i c i p a n t s f r o m Nova S c o t i a

were evaluated for c l i n i c a l compe tency by t h e a t t e n d i n g

c l i n i c i a n . P r o v i s i o n s w e r e also made f o r a n F n d e p e n d e n t

c l i n i c a l compe tency a s s e s s r n e n t of Newfoundland s u b j e c t s

a c c o r d i n g t o s p e c i f i e d cr i teria ( see Appendix E ) .

During t h e i n i t i a l t e l e p h o n e c o n t a c t , t h e r e s e a r c h e r

o u t l i n e d p o s s i b l e r i s k s a n d b e n e f i t s , t h e p u r p o s e of the

s t u d y , and t h e v o l u n t a r y n a t u r e of p a r t i c i p a t i o n . Upon

r e c e i v i n g verbal a g r e e m e n t , a n ifiterview t i m e and s e t t i n g

w a s a r r a n g e d .

At t h e i n i t i a l i n t e r v i e w , i s s u e s of c o n c e r n were

c l a r i f i e d ; 2nd w r i t t e n , in formed c o n s e n t o b t a i n e d f o r

p a r t i c i p a t i o n and a u d i o t a p i n g i n the p r e s e n c e of t h e

r e s e a r c h e r and a w i t n e s s . P a r t i c i p a n t s w e r e i n f o r m e d t h a t

t h e y c o u l d w i t h d r a w from t h e s t u d y a t a n y t i m e a n d r e f u s e t o

a n s w e r any q u e s t i o n s posed b y t h e r e s e a r c h e r ; and t h a t t h e i r

t r a n s c r i p t s w o u l d be read by t h e t h e s i s s u p e r v i s o r a n d one

c o m m i t t e e mernber. To a s s u r e p a r t i c i p a n t s o f t h e

c o n f i d e n t i a l i t y o f d i s c l o s e d i n f o r m a t i o n , a l 1 were i n f o r m e d

t h a t : (a ) c o d e s as o p p o s e d t o names would be u s e d t o

i d e n t i f y t r a n s c r i p t s and c o r r e s p o n d i n g a u d i o t a p e s ; (b)

direct q u o t e s would be u s e d t o s u p p o r t t h e e m e r g i n g themes

b u t t h e u s e of i n t e r v i e w numbers a n d o m i s s i o n o f i d e n t i f y i n g

m a r k e r s (e-g., p h y s i c i a n s , h e a l t h care f a c i l i t i e s o r

t h e r a p i s t s ) would e n s u r e con£ i d e n t i a l i t y ; (c) a u d i o t a p e s

would be erased f o l l o w i n g a r e v i e w of t r a n s c r i p t s f o r

âccuracy; a n d (d) i n t e r v i e w t r a n s c r i p t s a n d consent forms

would be k e p t i n a l o c k e d filing c a b i n e t a c c e s s i b l e o n l y t a

t h e r e s e a r c h e r and t h e s i s s u p e r v i s o r .

A l though p a r t i c i p a n t s were r e a s s u r e d t h a t there were no

e x p e c t e d risks, i t w a s stressed that c e r t a i n i n t e r v i e w

q u e s t i o n s c o u l d p o t e n t i a l l y e l i c i t u n c o m f o r t a b l e mernories.

P a r t i c u l a r a t t e n t i o n w a s given t o p a r t i c i p a n t s ' v e r b a l and

non-verbal r e s p o n s e s d u r i n g t h e i n t e r v i e w s , and r e m i n d e r s

were i n t e r j e c t e d t o address o n l y those issues tney were

c o r n f o r t a b l e d i s c l o s i n g . A l 1 q u e s t i o n s asked b y t h e

r e s e a r c h e r were r e c e i v e d b y t h e p a r t i c i p a n t s as non-

t h r e a t e n i n g , a n d a l 1 commented on how c o r n f o r t a b l e t h e y f e l t

i n r e v e a l i n g t h e i r lived w o r l d s t o t h e researcher.

A s w e l l , t h e r e s e a r c h e r has e i g h t e e n y e a r s o f c l i n i c a l

e x p e r i e n c e i n t h e area of m e n t a l h e a l t h , h a s c o m p l e t e d a

p r a c t i c u m i n c o u n s e l l i n g a t Mernorial U n i v e r s i t y ' s

C o u n s e l l i n g C e n t r e , a n d i s p r e s e n t l y a m e n t a l h e a l t h

c l i n i c i a n i n t h e p r o v i n c e o f Nova S c o t i a . Based o n t h i s

background , i t w a s a n t i c i p a t e d t h a t r i s k s t o p a r t i c i p a n t s

would b e m i n i m a l , I f t h e r e s e a r c h e r d e t e c t e d r n a l a d a p t i v e

c o p i n g , t h e i n t e r v i e w was t o be t e r r n i n a t e d . I n a d d i t i o n ,

t h e e m o t i o n a l s t a t u s o f each p a r t i c i p a n t w a s assessed before

t e r m i n a t i n g the interview. A l l were e n c o u r a g e d t o c o n t a c t

t h e r e s e a r c h e r i f a n y c o n c e r n s o r q u e s t i o n s s u r f a c e d .

D a t a Analvsis - -

Imrned ia te ly f o l l o w i n g each m e e t i n g , t h e researcher

t r a n s c r i b e d v e r b a t i m t h e a u d i o t a p e d i n t e r v i e w w h i l e

c a r e f u l l y n o t i n g n o n v e r b a l i n f o r m a t i o n recalled. Each

t r a n s c r i p t w a s r e a d a n d r e r e a d t o grasp what w a s "being

said". T h i s a p p r o a c h al lowed t h e r e s e a r c h e r t o d w e l l with

t h e data, ând â c q u i r e a d e e p e r mean ing a b o u t the lived w o r l d

o f anorexia n e r v o s a .

The r e s e a r c h e r made al1 p o s s i b l e e f f o r t s t o bracket any

t h o u g h t s , f e e l i n g s , p r e c o n c e p t i o n s , a n d b e l i e f s a b o u t t h e

phenomenon u n d e r s t u d y . The u s e o f a " d e t a i l e d a p p r o a c h " ,

as o u t l i n e d b y van Manen (l994), d u r i n g t h e m a t i c a n a l y s i s

f a c i l i t a t e d i d e n t i f i c a t i o n of wha t w a s b e i n g r e v e a l e d a b o u t

t h e phenomenon. Through r e a d i n g a n d r e r e a d i n g of each

s e n t e n c e i n t h e t e x t , t h e r e s e a r c h e r e x p l i c a t e d t h e themes

and m e a n i n g s . T h e o r e t i c a l s a r n p l i n g was used t o o b t a i n

r e p r e s e n t a t i v e sl ices of d a t a t o s u p p o r t t h e c o n c e p t u a l

themes e m e r g i n g f r o m the data.

The t h e m a t i c coding of e a c h t e x t w a s a l s o c o n d u c t e d by

t h e t h e s i s s u p e r v i s o r . F o l l o w i n g a n a l y s i s o f t h e f i r s t f o u r

i n t e r v i e w s , a m e e t i n g w a s h e l d be tween the researcher a n d

t h e s i s supervisor t o d i s c u s s the i d e n t i f i e d e m e r g i n g themes .

T h i s m e e t i n g e n d e d w i t h a c o n s e n s u s on t h e t h e m a t i c a n a l y s i s

p r o c e s s and t h e e m e r g e n t themes. A s t h e themes w e r e

c l a r i f i e d t h r o u g h t h e p r o c e s s of w r i t i n g a n d r e w r i t i n g , t h e

researcher w a s a b l e t o g r a s p a b e t t e r u n d e r s t a n d i n g of the

t e x t . E v e n t u a l l y , t h e d e s c r i p t i v e commenta r i e s r e f l e c t e d a n

h e r m e n e u t i c a l i n t e r p r e t a t i o n of the text which p r o v i d e d a

m e a n i n g f u l c o n t e x t f o r t h e thematic s t a t e n e n t s .

T o w a r d s t h e e n d of t h e datâ c o l l e c t i o n period, t h e text

of two p a r t i c i p a n t s w a s a l s o c o d e d by a committee mernber.

Another m e e t i n g w a s h e l d t o d i s c u s s t h e e m e r g e n t thernes and

d i a l o g u e w i t h the phenornenon. This d i s c u s s i o n w a s f o l l o w e d

by a p e r i o d of d e e p e r r e f l e c t i o n , and r e w r i t i n g of t h e t e x t

t o c a p t u r e t h e e s s e n c e o f t h e lived e x p e r i e n c e of a n o r e x i a

n e r v o s a .

R e l i a b i l i t y and Validity

It is difficult to achieve the same degree of

reliability and validity with qualitative research as in

quantitative research. Although reliâbility in

phenomenology is more readily attained than with other

qualitative modes of enquiry, van Manen (1994) indicates

that the only generalizability allowed in phenomenology is

"never generalize" (p. 22) .

Qualitative enquiry is evaluated in terms of

credibility, fittingness, auditability, and confirmability

(Krefting, 1991) . Credibility was established by having

participants review the surnmary of their interview. Study

participants read their interpretive summary, written to

ref lect the ernerging themes, and readily identif i2d the

descriptions as their own.

Credibility and auditability (consistency) is

reinforced through member checks (Hof fart, 1991) . Two

researchers experienced in qualitative analysis (i.e.,

thesis advisor and cornmittee member) read the transcripts

and conducted a thematic analysis of the text. Discussions

confirmed and refined the themes, and helped clarify the

meanings emerging from the text.

Fittingness (applicability) of the findings is ensured

by recruiting participants who are good in for rnan ts ( L e . ,

clearly articulate the "lived experience" of a n o r e x i a

nervosa). Study participants were good historians who

provided rich data t o facilitate insight into major themes.

Confirmability (neutrality) is ach ieved through

credibility, auditability, fittingness and bracketing. The

researcher used bracketing t o promote objectivity and limit

potential bias by recording thoughts and feelings during

data analysis. Credibility, auditability and fittingness

were enhanced by having p a r t i c i p a n t s confirm their

sumrnaries, through member checks, and by having a r t i c u l a t e

and open informants.

What i s i t

f o r c e s act upon

These q u e s t i o n s

CHAPTER 4

Findings

like t o l i v e with a n o r e x i a n e r v o s a ? What

a n d n u r t u r e t h e growth of t h i s i l l n e s s ?

are e x p l o r e d f rom the p e r s p e c t i v e of s i x

women who have l i v e d w i t h a n o r e x i a ne rvosa .

T h i s c h a p t e r is d i v i d e d i n t o f o u r s e c t i o n s . The f irst

s e c t i o n p r e s e n t s a b r i e f o v e r v i e w o f s t u d y participants.

T h e second s e c t i o n describes the themes t h a t emerged f rom

t h e phenomenolog ica l a n a l y s i s of t h e t e x t . The t h i r d

o u t l i n e s t h e i n t e r r e l a t i o n s h i p s arnong t h e themes. T h e f i n a l

s e c t i o n c a p t u r e s t h e essence of t h e l i ved experience of

a n o r e x i a ne rvosa .

Introduction to Participants

The women who agreed t o p a r t i c i p a t e i n t h i s s t u d y had

been l i v i n g wi th a n o r e x i a n e r v o s a f o r a p e r i o d of six t o

e i g h t e e n years. The t i m e i n t e r v a l v a r i e d from time o f onse t

o f t h e e a t i n g d i s o r d e r t o a c t u a l d i a g n o s i s and t r e a t m e n t .

The d u r a t i o n of the d i s o r d e r , as w e l l as t h e a g e o f o n s e t

and t i m i n g o f d i a g n o s i s , w e r e k e y v a r i a b l e s a s s o c i a t e d w i t h

p r o g n o s i s .

Recovery i s d e f i n e d a s r n a i n t a i n i n g a s t a b l e weight and

not actively engaged in restrictive behaviours (e.g.,

excessive dieting and exercise, medications); whereas,

prognosis refers to the probable course of the disorder and

the prospect of recovery (Bruch, 1988; Reiff, 1990) . Based

on this criteria for illness stability, al1 were considered

to be at different points in the recovery process with

prognosis potential varying £rom good to poor.

One participant, a single woman pursuing postsecondary

studies, had a family history of both eating and obsessive

compulsive disorders. Initially diagnosed with the non-

restrictor form of anorexia nervosa in early adolescence,

she was subsequently reclassified as the illness progressed

to restrictor subtype. From her own reports, she had been

living with this illness for approximately ten years.

Although never hospitalized, she had extensive involvement

with health care professionafs over tne years. She is

currently considered to be in the recovery phase. Her

prognosis is rated fair to good.

A second participant is married with no children, and

is currently working in the health care field. From her

reports, the illness started in early adolescence. Although

she has lived with anorexia nervosa for seventeen years, she

was not clinically diagnosed u n t i l three years ago. This

woman a l s o h a s t h e c l i n i c a l diagnosis o f o b s e s s i v e

compu l s ive d i s o r d e r . She has been actively i n v o l v e d i n

i n d i v i d u a l and group t h e r a p y a n d h o s p i t a l i z e d on two

o c c a s i o n s . She is c u r r e n t l y c o n s i d e r e d t o be i n r e c o v e r y ,

a n d her p r o g n o s i s is f a i r .

A third participant, a s i n g l e woman work ing as a

r e c e p t i o n i s t , s t i l l l i v e s a t home w i t h her mother . There is

a f a m i l i a l h i s t o r y o f a l c o h o l i s m . Based on h e r r e p o r t s ,

e a t i n g disorder problems did n o t s u r f a c e u n t i l h e r e a r l y

t w e n t i e s . She h a s been l i v i n g w i t h a n o r e x i a n e r v o s a f o r

e i g h t t o t e n years b u t w a s n o t d i a g n o s e d u n t i l e i g h t e e n

months ago. H o s p i t a l i z e d a t t h e tirne of d i a g n o s i s , s h e has

been r e c e i v i n g o u t - p a t i e n t t h e r a p y s i n c e d i s c h a r g e . A t t h i s

stage of h e r i l l n e s s s h e i s n o t c o n s i d e r e d t o be i n

r e c o v e r y . H e r p r o g n o s i s is f a i r t o poo r .

T h e f o u r t h p u r t i c i p a n t , a s i n g l e woman p u r s u i n g

p o s t s e c o n d a r y s t u d i e s , i s s t i l l l i v i n g at home w i t h h e r

p a r e n t s . T h e r e is a f a m i l i a l h i s t o r y o f e a t i n g d i s o r d e r s .

From h e r r e p o r t s , t h e i l l n e s s s t a r t e d i n e a r l y t o m i d -

a d o l e s c e n c e . Diagnosed w i t h a n o r e x i a nervosa s i x y e a r s ago ,

s h e h a s r e c e i v e d v a r i o u s f o r m s of treatment b u t has a v o i d e d

h o s p i t a l i z a t i o n t o d a t e . Her p r o g n o s i s i s f a i r t o good, a n d

she i s currently "on t h e r o a d t o r ecove ry" .

55

A fifth participant is married with two children and Fs

a clerical worker in the public service sector. This woman

was diagnosed with clinical depression in late adolescence

and hospitalized for treatment at this time. Although she

reports having lived with anorexia nervosa for about

eighteen years, she was not clinically diagnosed until two

years ago. H e r exposure to health care professionals and

formal treatment for an eating disorder problem has been

quite lirnited. She is considered to be in the recovery

phase of her illness, with a good prognosis.

The sixth participant, a divorced woman with no

children, works in the food service industry. First

diagnosed in early adolescence, she has been living with

anorexia nervosa for seventeen years. Since the onset of

her illness she has received extensive therapy. This woman

h a s expe r i enced several relapses snd continues to oscillate

between periods of recovery and acute illness episodes

requiring hospitalization. Her prognosis, to date, is poor.

This section presents a detailed discussion on the

themes i d e n t i f i e d from the thematic analysis of the

interview transcripts of six women living with anorexia

nervosa. Although presented separately to highlight

different aspects of the lived experience, the themes are

interrelated and interdependent with each flowing i n t o and

overlapping with the other. The eight thernes identified

were: weakened self, a struggle for control, controlled by

the illness, concealing the self, feeling consurned,

readiness to change, letting-go while holding-on and

breaking the cycle .

Weakened Self

The image

ref lected upon

of the weakened self unfolded as participants

the onset and trajectory of their illness.

Websterf s (1988) dictionary defines weaken as "to lose or

cause to lose strengtn or vigor". Synonyms for weaken

include debilitate, undermine, cripple, and disable .

üsed in thê current context, this suggests that study

participants never really acquired an adequate sense of

self.

Within the narratives conveying the experience of

living with anorexia nervosa, frequent reference was made to

early childhood experiences that undermined development of

adequate feelings of self-worth and self-esteem. Self

concept is how we see ourselves - the value that we place on

a l l o f the p a r t s t h a t make up and s h i p e o u r p e r s o n h o o d .

Self-esteem is the f e e l i n g component of self concept and is

a s t a t e m e n t a b o u t how much a person likes t h e s e l f . I f h igh

va lue is placed o n beauty and t h i n n e s s , t h e n f e e l i n g s about

the self will be i n f l u e n c e d by t h e degree t o which an idea l

image is a c h i e v e d ,

P a r t i c i p a n t s used words like " a l w a y s shy", "low self-

esteem" or "never l i k e d m y s e l f " t o describe earliest

mernories about t h e m s e l v e s . One woman s ta ted:

I always h a d a body image problem . . . . Like, I r v e a l w a y s t h o u g h t I was t o o fat. Always. Not pretty enough. Too f a t . Always. E v e r s i n c e 1 can remember.

She recalled a c r y i n g e p i s o d e a t h e r s e v e n t h b i r t h d a y p a r t y

w h i c h was p r o m p t e d by wanting t o l o o k l i k e her c l o s e friend:

"Why c a n r t I be pretty l i k e that? Why c a n r t 1 b e skinny

l i k e she I s ? " Xow does a cniia of s e v e n d e v e l o p low self-

esteem and be r e d u c e d t o tears b e c a u s e s h e d o e s n o t f e e l

p r e t t y enough?

Maslow's h i e r a r c h y d e p i c t s a l i n e a r p r o g r e s s i o n t h r o u g h

t h e l o w e r basic n e e d s (Le., f o o d a n d shelter, s a f e t y a n d

s e c u r i t y , l o v e and b e l o n g i n g ) t o h i g h e r l e v e l needs (Le.,

s e l f - e s t e e m , s e l f - a c t u a l i z a t i o n ) . F o r p e r s o n s l i v i n g w i t h

a n o r e x i a n e r v o s a , a t t a i n m e n t o f l o w e r l e v e l needs becomes a

p e r s i s t e n t s t r u g g l e . A c h i l d ' s cry a t a n early age, a s

described above , reflects a n innate r e s p o n s e t o i n a d e q u a t e

f u l f i l r n e n t o f b a s i c n e e d s ( L e . lack o f food , s h e l t e r ,

s a f e t y , security, l o v e o r warmth) . T h e i m p o r t a n t q u e s t i o n

i s which o f t h e s e n e e d s w e r e n o t m e t during h e r c h i l d h o o d

and, e q u a l l y important, how d i d she l e a r n t o equate the

basic n e e d s o f s u r v i v a l w i t h beauty and t h i n n e s s ?

When c h i l d r e n are deprived of love and a f f e c t i o n , the

turmoil and p h y s i c a l / e m o t i o n a l pain l e a v e s them weakened -

t h e c o r e o f t h e i r p e r s o n h o o d a l t e r ed b y t h e severed bond.

When f o r c e d to separate £rom h e r p a r e n t s a t an e a r l y age

b e c a u s e of p h y s i c a l a n d e m o t i o n a l a b u s e £rom h e r mothe r ,

w h i l e a n o t h e r s i b l i n g was a l l o w e d t o s t a y at home, one woman

e x p e r i e n c e d f e e l i n g s sf r e j e c t i o n :

But she d i d n r t keep me! . . And 1 remember t h a t [brcîther] w a s a i iowea c o be cfiere [home] and 1 wasnr t . They wanted h im b u t t n e y dia n o t w a n t m e . . . . I ' v e got a lump i n my t h r o a t now- I t r s hard. I t ' s h a r d .

The p a s s a g e o f t i m e has not a m e l i o r a t e d h e r grief. Because

p o s i t i v e comrnents r e c e i v e d f rom others were p r i m a r i l y

e x p r e s s e d i n t e r m s of how a t t r a c t i v e she l o o k e d , s h e began

t o d e f i n e h e r s e l f - w o r t h i n terrns of ex t e rna l a p p e a r a n c e s .

I a l w a y s f e l t like I had t o be p r e t t y . What would 1 do i f 1 wasnr t? They wouldnr t love m e . They wouldnr t have a n y t h i n g good t o Say about m e . Because t h e y never

s a id a n y t h i n g else other t h a n t h a t .

A s a c h i l d s h e l e a r n e d t o d e v a l u e her s e l f - w o r t h a n d moved

i n t o the o u t s i d e w o r l d without adequate s k i l l s to form

m e a n i n g f u l r e l a t i o n s w i t h o t h e r s .

To t r u s t i s t o have f a i t h i n , t o b e l i e v e i n , t o c o n f i d e

i n , o r t o commit t o someone t h e r e s p o n s i b i l i t y of care.

W i t h o u t a s t r o n g f o u n d a t i o n f o r t r u s t , a person's a b i l i t y t o

t r u s t t h e r n s e l v e s and d e v e l o p c l o s e and m e a n i n g f u l

r e l a t i o n s h i p s , which always c o n t a i n an e l e m e n t o f risk, i s

s e v e r e l y hampered . One woman s p o k e a b o u t n o t f e e l i n g bonded

o r c o n n e c t e d t o a n o t h e r :

1 never felt c o n n e c t e d t o anyone, I have always b e e n moving a r o u n d a t work b u t I never c o n n e c t . . . . The o n l y o n e 1 d id c o n n e c t t o was a two year o l d child (pause) . She h a d c a n c e r ( l onger pause, n o eye contac t , no change in voice tone). And she died.

T h e h p o c t ûf mit feeling connectes was conveyed t h r o u g h t h e

l a c k o f e m o t i o n a l e x p r e s s i o n i n her words , v o i c e t o n e , a n d

body e x p r e s s i o n s . H e r e m o t i o n a l g r o w t h w a s somehow damaged,

l eav ing her s e a r c h i n g f o r a s e n s e of who s h e was and mean ing

i n life.

A synonym f o r c o n n e c t i o n i s a t t a c h m e n t . A t t achment i s

d e r i v e d f rom t h e Middle E n g l i s h " a t t a c h e n " a n d t h e o l d

French " a t t a c h e r / e s t a c h i e r W which means t o f a s t e n .

Attachent p r o j e c t s t h e image o f someth ing , a l t h o u g h n o t

t a n g i b l e , t h a t i s very s t r o n g and power fu l , a l l o w i n g o n e t o

becorne whole .

I n t e r a c t i o n patterns w i t h i n f a m i l i e s impeded autonornous

g rowth and h e a l t h y separation o f these women from f a m i l y

m e m b e r s . Some talked abou t family dynamics as c o n t r o l l i n g

( i . e., " d i c t a t e d " , "ve ry r e l i g i o u s f r , " r e g i m e n t a l l y r u l e d " ) . One woman d e s c r i b e d p a r e n t a l c o n t r o l t h u s : " W e were not

a l l o w e d t o go o u t a f t e r s choo l ; w e had t o come right home."

The lack of connec t ednes s and r e s t r i c t i o n s on i n t e r a c t i o n s

w i t h i n and o u t s i d e t h e f a m i l y u n i t e rec ted barriers t o

healthy s e p a r a t i o n and, u l t i m a t e l y , t h e a t t a i n m e n t o f

autonomous e x i s t e n c e ,

For t h o s e who talked about family r e l a t i o n s h i p s as

be ing 'really, r e a l l y c l o s e " , t h e r e w a s a d e f i n i t e s e n s e o f

overconnectedness . Webster (1988) de£ ined close as t h e

degree o f commonali ty among a s s o c i a t e d elements whereby

there i s n o d e v i a t i o n from t h e o r i g i n a l . A s d e s c r i b e d b y

c e r t a i n p a r t i c i p a n t s , f a m i l y r e l a t i o n s h i p s appeared t o

reflect "complete enmeshrnent". T h e growth of t h e s e l f a n d

i n d i v i d u a l i t y a r e l o s t when one becomes a m e r e shadow o r

r e f l e c t i o n o f t h e o t h e r .

When n o t a l l o w e d t o assume r e s p o n s i b i l i t y f o r

i n d e p e n d e n t t h i n k i n g o r autonomous a c t i o n s , t h e person moves

i n t o t h e o u t s i d e w o r l d full of fea r and u n c e r t a i n t y . The

v o i c e s of two women e c h o e d t h i s :

1 hate f a m i l y r e u n i o n s . 1 h a t e i t when a l 1 my farnily is home. Being sick has k e p t m e home. So 1 envy them [family members] !

1 want t o leave home b u t 1 a m s o scared. S c a r e d t h a t i t [anorexia] w i l l corne back [tearful].

A s these women talked about close r e l a t i o n s h i p s w i t h

s i g n i f i c a n t o t h e r s , the e m o t i o n a l p a i n of n o t b e i n g able t o

s e v e r farnily t i e s and move on w i t h t h e i r lives was appzrent.

Today, Goth women are l i v i n g a t home a n d s t i l l d e p e n d e n t

upon t h e i r families for t h e basic necessities o f l i f e -

s a f e t y and s e c u r i t y . The i n t e n s e f a m i l y c l o s e n e s s a p p e a r s

to have l e f t these w o m e n i n "a body w i t h o u t a voice".

Women who were s o c i a l i z e d w i t h i n e i t h e r close o r

dist=,rit families leârced not to t a i k about tneir f e e l i n g s ,

t h o u g h t s o r e m o t i o n s . There were n o g u i d e p o s t s o r m a r k e r s

to h e l p with the m a s t e r y of s o c i a l l y a c c e p t a b l e means of

e x p r e s s i o n .

1 d o n ' t know how t o t a l k on that l e v e l (about feelings, fears, thoughts or o p i n i o n s ] .

Growing u p w e w e r e a close f a m i l y b u t w e n e v e r t a l k e d about Our f e e l i n g s ! . . 1 always kept t h i n g s t o m y s e l f . 1 w a s a l w a y s s c a r e d of h u r t i n g someone e lse! O r , they would Say i t w a s no big deal.

F e e l i n g i n a d e q u a t e and w o r t h l e s s i n s o c i a l i n t e r a c t i o n s w i t h

p e e r s , these women were p r e o c c u p i e d w i t h h i d i n g and

p r o t e c t i n g t h e r n s e l v e s £rom o t h e r s . T o avoid h u r t , o r t o

receive c o n f i r m a t i o n of f e e l i n g s of i n a d e q u a c y , s o c i a l

a c t i v i t i e s were restricted o r o n l y superficial r e l a t i o n s

formed ( L e . , n o t h a v e " t i g h t f r i e n d s " ) . One wornan made t h e

f o l l o w i n g comment a b o u t he r a d o l e s c e n t years:

A l 1 t h e a t t e n t i o n w a s on h e r - 1 w a s n o t h i n g . 1 w a s - l i k e - n o t t h e r e ! . . . 1 w a s so s m a l l . Like 1 felt l i k e 1 was s o s m a l l .

I t w a s a l m o s t as i f she was s a y i n g that o t n e r s would n o t

like t h e "real" her (Le., I d o n o t l i k e m e , s o how c a n

o t h e r s l i k e m e ? ) . T h e r e was a n o b v i o u s lack of t r u s t i n

h e r s e l f ( L e . , n o t f e e l i n g safe o r secure w i t h t h e self).

T h i s i n a b i l i t y t o c o n n e c t w a s e c h o e d by o t h e r s i n comments

about f r i e n d s h i p s : '1 c o u l d n o t c o r r e s p o n d w i t h them."

I n some ways, t h e s e wonen e x h i b i t e d c h i l d - l i k e f e a t u r e s

( L e . , i n s e c u r i t i e s a n d f e a r s e s p e c i a l l y when faced w i t h

e m o t i o n a l stress) as t h e y t a l k e d a b o u t f e e l i n g " l i k e a

child". A p o i g n a n t exarnple o f t h i s w a s one womanrs

d e s c r i p t i o n of a d i s p u t e w i t h h e r husband:

When I g o t home, h e w a s s h a k i n g a f i n g e r at me and 1 j u s t snapped! 1 s n a p p e d ! 1 d o n ' t know! 1 t h i n k 1 o n l y weighed 8 0 p o u n d s . 1 snapped! 1 f e l t like he r e a c h e d into my little c h e s t a n d t o r e my little h e a r t o u t a n d t h r e w i t on t h e f l o o r . I c o u l d see

m y little heart g o i n g a c r o s s t h e f l o o r . 1 d i d n o t t a l k t o nirn. 1 had nothing t o do with h i m . I called Morn t o corne and get me. She said t o hang i n , i t w a s t h e h o l i d a y s . W e l l , 1 was s h o t !

C h i l d - l i k e judgments were a l s o e v i d e n t f rom p a r t i c i p a n t s '

c a t e g o r i z a t i o n s of behaviours within the f a m i l y , s o c i e t y o r

t h e m s e l v e s a s being either good o r bad, r i g h t o r wrong.

T h i s kind of m o r a l r e a s o n i n g o r dichotomous thinking is

c h a r a c t e r i s t i c o f c h i l d r e n .

Emot iona l r e a c t i o n s t o t h e p i v o t a l r o l e p l ayed by

f a m i l y i n t e r a c t i o n patterns i n i l l n e s s development were

manifested in d i v e r s e ways (i .e., ange r , d e n i a l o r without

f e e l i n g ) . One p a r t i c i p a n t conveyed a n g e r t h rough v o i c e t o n e

and body p o s t u r e as she spoke of her b a t t l e "to get even"

with her p a r e n t s : '1 r e b e l l e d , I got p r e g n a n t and I w a s

g l a d t o get back a t t h e m " . I n c o n t r a s t , a n o t h e r became

t o a r f ~ l 2nd Uezied thât her mother's eariier p r e o c c u p a t i o n

w i t h body i m a g e c o u l d be a c o n t r i b u t i n g f a c t o r in t h e

development of h e r e a t i n g disorder: 'Tt w a s n o t my m o t h e r ' s

f a u l t . + . c o n s c i o u s l y , 1 d o n ' t r e m e m b e r h e r b e i n g

p r e o c c u p i e d a b o u t her weight." Another p a r t i c i p a n t a p p e a r e d

t o be working on f o r g i v e n e s s and tried t o rationalize what

had happened b y p l a c i n g events i n a rneaningful c o n t e x t :

"Alcohol ism was h i s c o n t r o l and a n o r e x i a is rny c o n t r o l " .

64

When a t r u e bond o f a f f e c t i o n and f r i e n d s h i p is f o r g e d

w i t h a n o t h e r , g rowth and d e v e l o p m e n t i s n u r t u r e d - like the

seed p l a n t e d i n r i c h s o i 1 and exposed t o warmth a n d

s u n s h i n e , A s t h e s e women told t h e i r s t o r i e s a b o u t l i v i n g

with anorexia nervosa, each d e s c r i b e d a weakened s e n s e o f

t h e self which b e g a n in e a r l y childhood. W i t h o u t a s t r o n g

base for growth and deve lopment , t h e y wandered a i m l e s s l y

w h i l e engaging i n a p e r s i s t e n t struggle with daily l i v i n g .

Strugqlinq for Control

T h e i n t e n s e fears about n o t b e i n g able t o c o n t r o l

t h i n g s e . , external c o n t r o l s too p o w e r f u l for the self t o

feel " i n - c h a r g e " ) were echoed by al1 t h e participants.

Webster ' s (1988) d i c t i o n a r y d e f i n e s c o n t r o l as ' h o l d i n g

steady o r i n check; t o regulate". C o n t r o l i s a l e a r n e d

b e h a v i o u r a l response. A two year old c h i l d e x h i b i t i n g

temper t a n t r u m s l e a r n s , w i t h appropr ia te d i s c i p l i n e , that

such o u t of c o n t r o l b e h a v i o u r s are n o t acceptable. A s a

c h i l d moves t h r o u g h t h e various stages of g r o w t h and

development, s (he) becomes more i n tune with how t h e self

i n t e r a c t s w i t h the e n v i r o n m e n t and learns how t o c o n t r o l

self-gratification impulses.

At a very young age, these women had fears about n o t

b e i n g able t o c o n t r o l t h i n g s i n t h e i r l i v e s . Some talked

a b o u t p a r e n t a l c o n t r o l , t ac t ics c o n c e r n i n g d i e t , and e a t i n g

habits. One p a r t i c i p a n t t a l k e d a b o u t feeling fat a n d used

the word "rnortified" t o describe h e r r e a c t i o n t o b e i n g

f o r c e d b y h e r rnother t o j o i n a n e s t a b l i s h e d w e i g h t r e d u c t i o n

p rogram. A s she t a l k e d a b o u t having t o associate w i t h

a d u l t s (Le,, "1 w a s t h e y o u n g e s t ; 1 did n o t want t o b e

t h e r e . " ) , h e r fears a b o u t h a v i n g no c o n t r o l o v e r h e r l i f e

w a s e v i d e n t . L a t e r , s h e a c q u i r e d a l i k i n g f o r t h e program

a n d w a s d r i v e n b y i t s secondary g a i n s :

1 was l o s i n g w e i g h t and t h a t w a s good . . . a l 1 t h e c o m p l i m e n t s and e v e r y t h i n g t h a t g o e s w i t h it . . . 1 t h i n k t h a t was t h e f i r s t t i m e t h a t 1 did a n d 1 w a s s u c c e s s f u l a t d o i n g i t .

H e r s e l f - c o n c e p t w a s b o o s t e d b e c a u s e t h i s s t r u c t u r e gave h e r

t h e c o n f i d e n c e t o i n c o r p o r a t e d i e t i n g behaviours into her

daily routine. She naà l e a r n e c i a means of c o n t r o l , which

a l l o w e d h e r t o f e e l good a b o u t h e r s e l f . However, when h e r

m o t h e r observed a n adequate w e i g h t l o s s , she o n c e again

resumed c o n t r o l of h e r d a u g h t e r f s w e i g h t and f o r c e d her t o

withdraw f rom t h e dieting program.

A s e c o n d p a r t i c i p a n t t a l k e d a b o u t e a r l y mernories o f her

m o t h e r f s r e a c t i o n s and b e h a v i o u r s t o w a r d s h e r e a t i n g h a b i t s :

I n e v e r d i d e a t much. My mom would g e t a f t e r m e t o e a t b r e a k f a s t . I n e v e r l i k e d e a t i n g b e f o r e

t h a t . My m o t h e r l i t e r a l l y s a t o n m e t o make m e eat. G o i n g t o school s h e would pack a l u n c h and 1 would n o t eat i t . [long pause] 1 n e v e r [ p a u s e ] . Like i f t h e r e w a s a n o t h e r way t o l i v e , e a t i n g would n o t be i n my life. 1 always s a i d t h a t .

I r o n i c a l l y , o n e woman was f o r c e d n o t t o e a t and a n o t h e r

forced t o ea t ; b o t h l e a r n e d t o reject f o o d i n t h e i r s t r u g g l e

f o r c o n t r o l .

F a m i l y i n t e r a c t i o n patterns a l s o e l i c i t ed a n e g a t i v e

impact o n eating b e h a v i o u r s . One woman p l a c e d h e r p r o b l e m s

w i t h c o n t r o l a n d t h e u s e of r e s t r i c t i v e b e h a v i o u r s t o manage

stress w i t h i n t h e f a m i l y c o n t e x t .

I n Grade six, l i k e 1 remernber i t as if it w a s y e s t e r d a y . My m o t h e r and f a t h e r w e r e going t h r o u g h a d i v o r c e / s e p a r a t i o n . T h e r e are s e v e n i n m y f a m i l y . . . . I t affected u s a l 1 d i f f e r e n t l y . I t a f f e c t e d me by n o t eating. I t was s t r e s s f u l a n d t h e only way 1 c o u l d deal w i t h stress was n o t e a t i n g . . - . Then i n h i g h s c h o o l the exams came a n d t h e o n l y way t o deal w i t h t h e stress o f exams was n o t eating. 1 was scared t o gain w e i g h t ! 1 felt i n c o n t r o l [pause] . 1 f e l t it w a s h e l p i n g m e d e a l w i t h t h e stress, 1 f e l t better when 1 d i d n o t e a t . T h i s m o n s t e r i s a l 1 a b o u t c o n t r o l .

F o l l o w i n g a s t r e s s f u l p e r i o d i n h e r life, she l e a r n e d t h a t

d o i n g w i t h o u t f o o d e a s e d h e r a n x i e t y a n d l e f t her w i t h a

g r e a t e r s e n s e o f control.

O t h e r s ' c o r r n e n t s a b o u t body image p r o v o k e d intense

a n x i e t y and heightened f e e l i n g s of w o r t h l e s s n e s s . Because

of l o w self-esteem, some w e r e u n a b l e t o accept c o n s t r u c t i v e

criticisrn o r place it i n a n a p p r o p r i a t e c o n t e x t s : 'Some

g o o d legs t o walk o n . Meaning t h e y w e r e q u i t e s o l i d a n d

c h u n k y legs!" One p a r t i c i p a n t ' s worst f e a r w a s t h a t n o

m a t t e r what she did, i t would never be good enough.

They told m e t o l o s e w e i g h t . So I was r e a l l y u p s e t . 1 w a s l i k e r e a l l y u p s e t . So, 1 s tar ted d o i n g the e x e r c i s i n g a n d a l 1 t h a t s t u f f again. 1 used t o e x e r c i s e p r o b a b l y two t o t h r e e hours a d a y . . . . I r d just e x e r c i s e a n h o u r m o r e . 1 k e p t a d d i n g on h o u r s t h a t 1 w o u l d n ' t n o r m a l l y e x e r c i s e .

S e l f - e s t e e m a n d s e l f - w o r t h w e r e equated w i t h b e i n g thin; t h e

b e g i n n i n g p r e o c c u p a t i o n w i t h body image. H e i g h t e n e d

f e e l i n g s of f a t n e s s were eased o n l y b y a s t r ic t exercise and

r e s t r i c t i v e d i e t a r y regime.

F o r a n o t h e r p a r t i c i p a n t , f e e l i n g s of w o r t h l e s s n e s s a n d

fears o f r e j e c t i o n were Li f t ed a f t e r a weight l o s s d u r i n g a n

h o s p i t a l i z a t i o n f o r d e p r e s s i o n . P o s i t i v e f e e l i n g s about

h e r s e l f vere a l s s reinforced when someone took a n i n t e r e s t

i n h e r . She p e r c e i v e d h e r t h i n n e s s as t h e r e a s o n f o r t h e

a t t r a c t i o n : "The f i r s t t i m e I e v e r felt good about rnyself".

W i t h o u t a s t r o n g i n n e r core, t h e s e women were forced t o

r e l y o n i n f o r m a t i o n f rom o t h e r s t o judge t h e i r self w o r t h

and i d e n t i t y . T h i s i n n e r struggle f o r c o n t r o l and

a c c e p t a n c e led t hem on a life l o n g j o u r n e y o f t r y i n g t o

please o t h e r s :

I do too much f o r e v e r y o n e . I b a s i c a l l y do not know how t o l o o k a f t e r myself. I f 1 d o n ' t do it, 1 f e e l guilty a b o u t i t . So, I push i t to t h e ex t reme l i m i t when 1 c a n f t do anything f o r m y s e l f . I a m c o n s t a n t l y , go ing : that l i t t l e e n e r g i z e d bunny on TV, t h a t r s m e . 1 keep going and going. And on n o t h i n g . 1 basically p u t a l 1 my energy i n t o making him l i v e . 1 d i d n r t r e a l i z e I was s l o w l y k i l l i n g mysel f t o l e t h i m l i v e .

1 always d i d t h i n g s t o please o t h e r s . 1 f e e l g u i l t y when I do t h i n g s f o r rnyself .

F e e l i n g s o f inadequacy and low s e l f - w o r t h p r o p e l l e d t h e m t o

seek c o n f i r m a t i o n o f t h e i r v a l u e frorn t h e p l e a s u r e s r e c e i v e d

frorn d o i n g t h i n g s f o r others.

Without a sense o f self ( L e . , " c o n t r o l l e d a l 1 my

l i fe") and s t r u g g l i n g t o be a c c e p t e d (i-e., '1 was n o t wor th

i t") , these women l e a r n e d frorn p a r e n t s , and to a lesser

e x t e n t s o c i e t y , that t h i n n e s s meant goodnes s . Perfection

and a c c e p t a n c e could be a t t a i n e d th rough thinness.

Neil, grûwing u p . . . p e o p i e would S a y t h a t 1 w a s - you know - pretty or wha teve r . . . b u t 1 d id n o t b e l i e v e i t . [short l a u g h ] . . . . Never did, never will . . . and , I always had t h i s t h i n g a b o u t my body - t h a t it had to be a size f i v e . I t j u s t - i f i t w a s n f t - c a u s e where I ' m kind of ta11 - s i z e f i v e would be t h e size 1 wanted t o be, no m a t t e r w h a t r i g h t ? 1 d i d n ' t care what 1 had t o do.

I t w a s kinda brought t o rny attention by my p a r e n t s t h a t 1 was a b i t h e a v i e r t h a n 1 s h o u l d b e . 1 remember g o i n g shopp ing w i t h my f a t h e r . . . . And 1 ended up w i t h a l a rge r s i z e . . . when 1 came home my mother was r e a l l y u p s e t . . . . And you know they had t o go back!

All of t h e s e women s u b s e q u e n t l y came to o p e r a t e under t h e

d e l u s i o n t h a t body image w a s t h e most s u c c e s s f u l e x p r e s s i o n

of s e l f - w o r t h and t h e o n l y w a y t o receive a t t e n t i o n , p r a i s e

or a c c e p t a n c e .

R e s t r i c t i v e b e h a v i o u r p r a c t i c e s w e r e learned through

f r i e n d s , f ami ly , and the media.

1 heard about it [restrictive behav iours] at work.

Weight was a lways a b i g t h i n g i n my family.

T h e rest of my botkers and sisters wexe ve ry heavy. 1 was always s c a r e d t o pu t on a n ounce of w e i g h t

Then 1 guess with t e l e v i s i o n , newspapers, and magazines . . . t h i s be thin paraphernalia and a l 1 that s t u f f .

A r m e d w i t h the e s s e n t i a l knowledge on the "how-tos" of

r e s t r i c t i v e p r a c t i c e s , these women now had t h e means to

e x p r e s s i o n ând control.

Self a p p r a i s a l was r a t e d i n t e r m s of feedback received

from o t h e r s following the u s e of restrictive behaviours

(i .e., d i e t i n g and e x e r c i s e ) t o promote a n ideal body image.

P o s i t i v e feedback o f t e n provided a needed boost f o r low

se l f -es teern f ee l i ngs : "They al1 t o l d m e 1 looked good. 1

f e l t great!" These women had l e a r n e d from outside t h e s e l f

that dieting and r e s t r i c t i v e behav iours did bring happiness

a n d some c o n t r o l i n t o t h e i r l i v e s : "1 h a d c o n t r o l . I t w a s

t h e o n l y way 1 cou ld c o n t r o l . "

P e r i o d s of o s c i l l a t i n g between weight g a i n and l o s s

dictated how o n e f e l t a b o u t t h e se l f . Weight g a i n w a s

accompanied b y a bad mood:

1 h a t e d t h e way I l o o k e d . 1 h a t e d it. 1 - l i k e - 1 d i d not want - 1 j u s t d id n o t want t o l o o k a t m y s e l f . [ A n d with weiqht loss] 1 f e l t great.

S e l f - w o r t h c o u l d be m e a s u r e d o n t h e ba th room scales: '1

would weigh m y s e l f a l 1 t h e tirne."

P a r t i c i p a n t s i d e n t i f i e d s p e c i f i c b e h a v i o u r s a n d

c o g n i t i v e m e a s u r e s t h a t a l l o w e d them t o feel i n c o n t r o l

(Le., "1 u s e d d i e t pills, laxatives a n d d i u r e t i c s " ; "1

c o u l d n o t p u r g e s o 1 had t o s t o p e a t i n g " ) . Having n e v e r

f e l t a good s e n s e of c o n t r o l o v r r t h e i r l i v e s , when c o n t r o l

was d e m o n s t r a t e d t h r o u g h exercise a n d d ie t they f e l t

s t r o n g e r 2nd more secüre i n dea l ing with s t r e s s f u i l i f e

e v e n t s .

I t w a s l i k e always s o m e t h i n g g o i n g on . s o m e t h i n g i n t h e f a m i l y - stress! I t w a s a l w a y s stress t h a t b r o u g h t i t o n . I r d get up i n the rnorning a n d see t h a t I gained w e i g h t . And oh, . . . the scales I w a s a l w a y s o n them. W e had t o t h r o w them o u t of t h e house . 1 go t o w a r d s d i e t p i l l s , l a x a t i v e s , o r w a l k s o m e t i m e s . I t was n o t h i n g f o r me t o w a l k t e n t o f i f t e e n m i l e s a d a y . 1 felt g r e a t t h e n . I r d t h i n k 1 had i t al1 o f f a n d t h e n I ' d f e e l great!

T h e i n t e n s i t y a r o u n d d i e t a n d e x e r c i s e r e s t r i c t i o n s was

o f t e n accornpanied by a s t rong d r i v e t o a c h i e v e h i g h grades

i n s c h o o l o r exce l i n careers. F o r some, d e v e l o p i n g a

c o r n p e t i t i v e s p i r i t a n d a n i n t e n s e p r e o c c u p a t i o n with being

s t r o n g w i l l e d g e n e r a t e d i n - c o n t r o l f e e l i n g s .

S i n c e s t r e n g t h a n d c o n t r o l w e r e t h o u g h t t o be gained

from d e n y i n g t h e body f o o d , t h e s e wornen measured a n o t h e r ' s

weakness a g a i n s t s imi l a r s t a n d a r d s ( L e . , eating food). For

example, some p a r t i c i p a n t s r e p e a t e d l y e n t i c e d o t h e r s w i t h

t h e i r c u l i n a r y s k i l l s a n d w a t c h e d them eat, o r chose c a r e e r s

t h a t i n v o l v e d a n a l y s i n g o r p r e p a r i n g f o o d s ; however , none

chose t o be c o n n o i s s e u r s o f food.

Can you i m a g i n e 1 took p a s t r y c o o k i n g w i t h a n e a t i n g d i s o r d e r . 1 l o v e d b a k i n g a n d c o o k i n g for my sisters and b r o t h e r s . I l o v e d see ing o t h e r p e o p l e eat! . . . But to sit a n d e a t it, is a whole d i f f e r e n t b a l 1 game! . . . When 1 a m t e n s e 1 c a n ' t ea t ! . . . 1 c a n ' t even l o o k a t it.

A m t h e r ~àrticipant t a l ked about c o o k i n g meals f o r h e r

f a m i l y ( a l 1 o b e s e ) a n d achieving c o n t r o l by j u s t s i t t i n g a t

t h e t a b l e p i c k i n g h e r f o o d .

1 w a s s i t t i n g down w i t h them and 1 was e a t i n g some. It w a s hard! I t w a s hard! I t t o o k a l o t ! 1 found , if 1 a m cooking f o r someone else, 1 will s i t down a n d p i c k . Bu t when 1 a m a l o n e , i t i s n o t w o r t h c o o k i n g f o r o n e p e r s o n . I t ' s n o t w o r t h i t .

Anothe r p a r t i c i p a n t repeatedly e m p h a s i z e d t h a t s h e w a s n o t

bulimic b e c a u s e s h e w a s s t r o n g enough n o t t o e a t . Another

72

i n d i c a t e d t h a t she was j e a l o u s o f people who w e i g h e d e i g h t y

pounds and w a n t e d t o be l i k e thern because, 'They got t h e

will power n o t t o eat."

The l i v e d w o r l d of t h e s e women reflected images of o n e

who i s u n a b l e t o identify i n n e r s t r e n g t h a n d regulate the

s t r e s s o r s that accompany d a i l y l i v i n g . Without a w e l l

d e v e l o p e d s e n s e of self, a l 1 were l e f t t o rely o n feedback

frorn others t o judge t h e i r self-worth. A s t h e y s t r u g g l e d t o

l i v e a rnean ingfu l life, t h e y l e a r n e d t h a t r e s t r i c t i v e

b e h a v i o u r s e n h a n c e d t h e i r sense of c o n t r o l over s t r e s s f u l

events and b o o s t e d their self-esteem.

Controlled bv the Illness

When d i e t i n g becomes an o b s e s s i o n , e v e r y t h i n g else

revolves around i t . Obsession from the L a t i n word p p p p p p p p p p p p p - - - - - - - - - - - - - -

- - - -

"obsidere" means t o besiege o r t o have a n unreasonable

compuls ion , idea or e m o t i o n causing p r e o c c u p a t i o n . A l 1

t h e s e women had l e a r n e d t o engage i n r e s t r i c t i v e behaviours

t o measure s e l f - w o r t h a n d g a i n c o n t r o l : "The thinnest 1

c o u l d be was the best that 1 c o u l d be." A s they became

obsessed with restrictive behav iou r s , t h e y w i t h d r e w f rom a

world where they f e l t no c o n t r o l .

A s p a r t i c i p a n t s became more and more ~bsessed with

t h e i r we igh t , d i e t i n g c o n t i n u e d t o be rnon i to red e "1

weighed m y s e l f al1 the time, 1 0 t o 15 times a day.") a n d

e x e r c i s e h o u r s i n c r e a s e d t o b u f f e r c a l o r i c i n t a k e . All o f

these women t a l k e d a b o u t studying c a l o r i e books a n d using a

c y c l e of i n t e n s e e x e r c i s i n g (e .g. , '1 e x e r c i s e d like

c r a z y . f f ) t o r id t h e self o f the c a l o r i c i n t a k e . T o eat w a s

a s i g n of f a i l u r e a n d a w e a k n e s s t h a t was v i s i b l e t o o t h e r s :

"Then when 1 see wha t Ir rn e a t i n g , 1 f e e l s o bad, l i k e 1 a m a

f a i l u r e . " A s s t r e s s o r s i n c r e a s e d o u t - o f - c o n t r o l f e e l i n g

s ta tes , some i n c o r p o r a t e d a d d i t i o n a l r e s t r i c t i v e measures

(e. g . , d i e t p i l l s , l a x a t i v s s , p u r g i n g , and d i u r e t i c s ) t o

r e g a i n c o n t r o l a n d p u r s u e t h e i r q u e s t f o r a n ideal body

image: " I n high s c h o o l 1 tried die ts , d i e t p i l l s , l a x a t i v e s ,

e x e r c i s e . I a m s t i l l f a n a t i c a b o u t e x e r c i s i n g . . . 1 h a v e

t r ied it all. 1 have d o n e it!" O t h e r s s o u g h t c o n t r o l b y

developing a relationship with somêone r e f l e c t i n g their

idea l body image (i. e . , " t a l l " , " t h i n f f , " a b s o l u t e l y

g o r g e o u s " ) . However, t h i s type o f r e l a t i o n s h i p c r u s h e d

t h e i r self-esteem a n d created f u r t h e r i n n e r t u r m o i l .

C y c l e s o f s e v e r e food r e s t r i c t i o n s , e x c e s s i v e

e x e r c i s i n g and o v e r - t h e - c o u n t e r remedies followed by binge-

e a t i n g , purging o r s t a r v a t i o n exposed t h e body a n d t h e mind

t o p o t e n t i a l l e t h a l i n s u l t s . A s o n e p a r t i c i p a n t n o t e d :

Binges , where I had t o eat sornething . . . would las t f o r t h a t moment, then 1 would be depressed. . . . Then I would have t o starve myself again.

T h i s intensified ou t -o f - con t ro l f e e l i n g s a n d pushed her

a n x i e t y t o t h e p o i n t where t n e o n l y e f f e c t i v e relief came

from engag ing i n r e s t r i c t i v e behov iour s : "1 told myself 1

w a s s t r o n g and 1 had t o do i t . 1 had t o be s t r o n g enough t o

s t o p t o do i t [eating]!"

When r e l a p s e s were expe r i enced w i t h r e s t r i c t i v e

a c t i v i t i e s , t h i s conf i r rned t h e i r image of thernselves as

weak. P e r i o d s of being unable t o m a i n t a i n high l e v e l

d i e t i n g e . , " l o s t c o n t r o l of it") were l a b e l l e d as

" f a l l i n g - o f f " o r "b inge e a t i n g " and evoked i n t e n s e d i s l i k e

f o r t h e body (i .e., "1 looked h o r r i b l e . " ) . Some o f t h e

women d e s c r i b e d t h e p h y s i c a l p a i n c o n s e q u e n t i a l t o t h e i r

body's reaction ( L e . , " seve re abdominal cramping",

"dizziness", "unable t o s t a n d " ) t o n i g h doses of l a x a t i v e s ,

d i u r e t i c s o r diet p i l l s , a s wel l as e x e r c i s e and d i e t i n g .

Y e t , the d r i v e t o engage i n r e s t r i c t i v e behaviours t o boos t

f e e l i n g s o f being i n c o n t r o l took p recedence over t h e i r

p h y s i c a l health ( i . e . , "1 d i d no t care."; "1 had to do

Two o f the women talked about t h e p re sence of medica l

problems and t h e e f f e c t s on t h e body and m i n d :

1 had a l o t of medical symptoms b e f o r e - b u t i t was when my p e r i o d s s tarted t o g o - like 1 was t i r e d - always having h e a d a c h e s - f a i n t i n g . I had t o be moved [ a r e a of work] .

1 w a s d i z z y , 1 was p a s s i n g o u t , 1 c o u l d n o t s t a n d up for long p e r i o d s of time, which 1 had t o do i n s c h o o l , It w a s . [ l o n g s i g h ] 1 was t i red. I t had c o n t r o l o v e r m e . 1 f e l t like that 1 j u s t had t o d o it.

The rneasures c h o s e n to facilitate feeling " i n c o n t r o l "

e v e n t u a l l y p r o g r e s s e d t o "take control" as c o g n i t i v e o r

t h o u g h t processes a l s o became affected:

1 c o u l d n o t e v e n t a l k c l e a r l y . . . 1 w a s n o t allowed t o answer t h e p h o n e s any l o n g e r b e c a u s e the cus to rne r s cou ld n o t understand what 1 was s a y i n g .

Even when such extreme p o i n t s w e r e reached, there w a s a

s t r o n g d e n i a l t h a t there was a problem. However, due t o t h e

presence of e x t e r n a l s i g n s of something b e i n g wrong, i t

became e x c e e à i n g l y more d i f f i c u l t t o c o n c e a l t h e illne- p p p p p p p p p p p p - - - - - - - - - - - - -

As these women became nore a n d more c o n t r o l l e d b y the

i l l n e s s , f e a r s a b o u t n o t b e i n g good enough f o r s o c i a l

i n t e r a c t i o n s e n h a n c e d f e e l i n g s o f w o r t h l e s s n e s s : '1 n e v e r

f e l t as good as them." The e n d r e s u l t was enhanced a n x i e t y

f e e l i n g s which d r o v e them d e e p e r i n t o t h e r e l e n t l e s s pursuit

of thinness and t h e s t r u g g l e for g r e a t e r c o n t r o l . However,

each rneasure i n s t i t u t e d led them f u r t h e r away from t h e real

wor ld and a step c l o s e r t o t h e u n r e a l i t y of r e s t r i c t i v e

behaviours .

One p a r t i c i p a n t ta lked a b o u t her e x p e r i e n c e a t

m o d e l l i n g school a n d the d e c i s i o n s s h e w a s forced t o make i n

order t o reduce a n x i e t y .

1 d i d n ' t want t o t a l k a b o u t it [weight] , because 1 was a f r a i d t h e y would ask - , . . 1 w a s too b i g t o be t h e r e . . . . N o t p r e t t y enough t o be t h e r e . . . . So 1 q u i t . . . . 1 f e l t better a f t e r t h a t .

Al1 o f t h e women e c h o e d s i m i l a r remarks a b o u t t h e i r

i n a b i l i t y t o c o p e w i t h the demands o f w e i g h t r e s t r i c t i v e

measures: "The only t h i n g 1 c o u l d d o w a s t o s t o p eating.

I t was t h e o n l y way 1 c o u l d c o n t r o l t h i n g s . "

For these wornen, t h e e x p e r i e n c e of living w i t h anorexia

n e r v o s a w a s d e s c r i b e d a s a s t r u g g l e for c o n t r o l w h i l e

s i m u l t a n e o u s l y being c o n t r o l l e d b y t h e illness. The

contizüoiis s t rüggle for s e i f - c o n t r o l escalated when

i n c r e a s e d f e e l i n g s o f i n a d e q u a c y a n d h e i g h t e n e d a n x i e t y

s t a t e s were relieved b y a d d i t i o n a l r e s t r i c t i v e b e h a v i o u r s .

A s c o n t r o l o v e r s e l f - i m p o s e d r e s t r i c t i o n s waned, t h e

s t r u g g l e t o c o n c e a l the i l l n e s s became more d i f f i c u l t .

Concealina the Self

Concealment is d e r i v e d £rom the Middle E n g l i s h term

"concelen", the O l d F r e n c h " c o n c e l e r " , a n d t h e L a t i n

' c o n c e l a r e " , w h i c h means i n t e n s i v e m e a s u r e s t o hide. T h e

s t r o n g p r e o c c u p a t i o n w i t h c o n c e a l i n g restrictive b e h a v i o u r s

w a s a s s o c i a t e d w i t h : ( a ) f e a r s of r e j e c t i o n - t h e m a j o r

d r i v i n g f o r c e b e h i n d p r o j e c t i n g an image o f s t r e n g t h o r

normalcy ; and (b) h o l d i n g o n t o u n r e a l i t y t o p r o t e c t t h e

self a g a i n s t r e a l i t y .

F e a r s a b o u t be ing rejected by o t h e r s i f t h e y became

aware o f t h e d e s p e r a t e m e a s u r e s u s e d t o a c h i e v e c o n t r o l i s

c a p t u r e d i n t h e f o l l o w i n g s t a t e m e n t :

It would be h u m i l i a t i n g for a n y o n e t o know t h a t w a s how I w a s t r y i n g t o c o n t r o l my w e i g h t . I n e v e r would h a v e t o l d a s o u l .

T h e i m p o r t a n c e of a p p e a r i n g normal and b e i n g accepted by

o t h e r s n e c e s s i t a t e d s e c r e c y c o n c e r n i n g r e s t r i c t i v e

b e h a v i o u r s . B r e a k i n g t h e c o n c e a l m e n t would be c o m p a r a b l e t o

aàmitting Fnner weakness and d i f f a r e n t n e s s .

T h e dr ive t o c o n c e a l w a s a l m o s t as i n t e n s e as t h e

o b s e s s i o n w i t h r e s t r i c t i ve b e h a v i o u r s . One p a r t i c i p a n t

became t e a r f u l as s h e t a l k e d about why h e r p a r e n t s c o u l d n o t

know a b o u t h e r e a t i n g d i s o r d e r :

My parents did n o t see ne, they d i d n o t know what 1 looked l i k e . [ p a u s e ] 1 did n o t w a n t them t o worry about m e .

I n t h e e a r l y s t a g e s of the i l l n e s s , c o n c e a l m e n t was

p o s s i b l e as fârnily a n d f r i e n d s p e r c e i v e d d i e t a r y a n d

e x e r c i s e h a b i t s t o be n o r m a l b e h a v i o u r s . For some, t h e l a c k

o f r o u t i n e a r o u n d meals eased t h e b u r d e n of c o n c e a l i n g

a b e r r a n t b e h a v i o u r s :

1 n e v e r a t e d i n n e r . . . . 1 j u s t p r e t e n d e d 1 had d i n n e r . I r d make t h e p l a t e l o o k d i r t y and s o m e t i m e s l i k e I ' d j u s t t h r o w it o u t . I'd j u s t t e l l h i m 1 a t e a t work .

T h e s e e x p e r i e n c e s p r o v i d e d p o s i t i v e r e i n f o r c e m e n t a n d

i n c r e a s e d f e e l i n g s of c o n t r o l . As r e s t r i c t i o n s became more

p e r v a s i v e a n d w e i g h t l o s s i n c r e a s e d , t h e s t r u g g l e t o keep

t h e secret became m o r e d i f f i c u l t : '1 w a n t e d hirn t o see m e

e a t i n g . 1 n e e d e d h im t o t h i n k 1 w a s e a t i n g . "

A grea t deal of t i m e a n d e n e r g y w e n t i n t o d e v i s i n g

p l a n s t o c o n v i n c e o t h e r s t h a t t h e y w e r e "normal" .

S i t u a t i o n s had t o be c o g n i t i v e l y a p p r a i s e d a h e a d of t i m e for

t h e i ~ ~ ~ ~ ~ U ü c i ~ ~ - c z e s s for tonceaiing r e s c r i c c i v e b e h a v i o u r s

( L e . , l o c a t i o n o f b a t h r o o m i n t e r m s o f a u d i b i l i t y r e g a r d i n g

p u r g i n g ; e a t i n g w i t h f r i e n d s p r i o r t o class b u t p o s s i b l y

d r a w i n g n e g a t i v e a t t e n t i o n t o the s e l f by h a v i n g t o l e a v e to

purge). O t h e r s described food games t o c o n c e a l r e s t r i c t i o n s

( L e . , "pushing t h e f o o d a round" ; "throw it o u t i f 1 c o u l d

. . . when n o o n e w a s l o o k i n g " ; "get u p f r o m t h e t a b l e . . .

a n d d i s t r a c t " ) .

Denial that a problem existed helped these women

project an image of normalcy. For one woman, denying

allegations about restrictive b e h a v i o u r s made by her friends

allowed her to continue the struggle for control and

acceptance. Although hospitalized several tirnes for

depression, antenatal problems and deliveries, none of t h e

health care workers considered an eating disorder problern.

Her farnily doctor, whom she visited regularly for check-ups,

and her family also failed to n o t i c e the extreme weight loss

or address the issue. Because s h e was successful a t hiding

restrictive behaviours and her weakened self, she believed

that she was strong and in control.

The intensity of the obsession with restrictive

behaviours l e f t some with no time t o dwell on real world

i s s u e s .

One day he was there, the next day he w a ç gone; I was devastated.

My parents are so happy, now . . . . When 1 found out about tneir separation I was n o t going to go home! I just lost it!

Seeking to e s c a p e a world which constantly reminded them of

persona1 weakness, they entered a world dominated by control

through preoccupation with thinness.

Even at the point of extreme emaciation, t h e s e wornen

s a w themselves as f a t . This altered body image is conveyed

i n t h e f o l l o w i n g p a s s a g e :

1 c o u l d n o t figure o u t who t h i s p e r s o n [on the picture] w a s . Even when my sisters said: Look a t it . . . 1 said who is t h i s ? 1 d o n ' t remember anyone b e i n g t h e r e . They s a i d : It's you! [ p a u s e ] I looked h o r r i b l e , 1 looked t e r r i b l e a n d 1 d i d n ' t r e c o g n i z e m y s e l f !

Despite u s i n g d r a s t i c rneasures t o g a i n c o n t r o l t h r o u g h

w e i g h t l o s s a n d concea lmen t of t h e s e b e h a v i o u r s £rom o t h e r s ,

s e l f - e s t e e m plummeted.

A s s t r e s s o r s i n c r e a s e d a n d h i g h e r d o s e s o f r e s t r i c t i v e

b e h a v i o u r s were r e q u i r e d t o a l l e v i a t e t h e p a i n , t h e r e w a s a

c o n s t a n t preoccupation with t h i n n e s s : 'It [ f o o d ] was a l w a y s

on my mind." For a l1 t h e s e women, h i d i n g t h e secret a l l o w e d

them t o remain i n c o n t r o l a n d e s c a p e r e j e c t i o n by o t h e r s .

S u c c e s s f u l concea lmen t a l s o h e l p e d them deny that a problem

existeà, e v e n i n tne p r e s e n c e o f medical p rob l ems .

U l t i m a t e l y , the d u a l o b s e s s i o n s (Le., restrictive

behaviours and c o n c e a l m e n t ) became t o o p o w e r f u l , weakening

p e r s p e c t i v e of r e a l i t y and heightening their f e e l i n g s o f

l i v i n g a rnean ing less e x i s t e n c e .

Feeling Consumed

Feelings of " b e i n g consurnedu by t h e i l l n e s s w e r e

expressed e i t h e r i m p l i c i t l y o r explicitly by al1 of these

women. To consume is derived f rom the L a t i n word

'consumere" which means t o take c o r n p l e t e l y o r to take up

i n t e n s e l y . The synonyms f o r consume (e .g . , d e v o u r ,

d iss ipate , demolish, d e s t r o y , waste), when applied t o a

person with anorexia n e r v o s a , conjures up a n i m a g e of

sorneone b e i n g e a t e n up and l e f t w i t h a s e n s e o f

" n o t h i n g n e s s " .

A s t h e person progresses from f e e l i n g i n c o n t r o l t o

be ing c o n t r o l l e d and t h e n consumed, the illness i s

objectified or s e e n as separate £rom the se l f ( L e . , "You

are consumed by i t . "; "It consumes you. " ) . One wornan gave a

v iv id d e s c r i p t i o n of m o v i n g £rom a period of f e e l i n g g o o d

about h e r s e l f and life i n g e n e r a l ( L e . , f irst three years

of marriage) t o b e i n g c o n t r o l l e d b y h e r h u s b a n d a n d t h e n

consumed by anorexia nervosa. When faced with m a r i t a l

s t r e s s o r s , s h e f o u n d it difficult t o cope w i t h t h e m a g n i t u d e

o f e x t e r n a l c o n t r o l s .

1 f e l t l i k e h i s p u p p y dog on a l e a s h and every t i m e h e would t u g m e back when 1 would be out too far . . . . 1 w a s n o t s u p p o s e d t o be sick. I was supposed to t a k e c a r e of hirn . . . . 1 d i d n ' t r e a l i z e 1 w a s slowly killing rnyself to let h im live . . . . He took my f r eedom . . . Then h e a l m o s t t o o k m y l i f e . 1 went two y e a r s w i t h o u t e a t i n g . 1 lived o f f c h o c o l a t e bars, tea, coffee, a n d water . That is t h e o n l y way 1 could h a v e control. 1 did not c a r e any more.

Each t i m e s h e e x p e r i e n c e d a relapse it becarne more d i f f i c u l t

t o f i n d a s a f e place b e c a u s e t h e s t r u g g l e became harder:

"It 's a b a t t l e a n d 1 a m l o s i n g . " The i l l n e s s eventually

p r o g r e s s e d t o a p o i n t where s h e f e l t consumed by o u t - o f -

c o n t r o l f e e l i n g States:

L i v i n g w i t h a n o r e x i a i s l i k e h a v i n g a m o n s t e r i n s i d e o f you. It consumes you. You c a n r t escape it . L i k e it has c o m p l e t e c o n t r o l of y o u r whole l i f e . It w a n t s you t o d o one t h i n g a n d y o u r body wants you t o do s o m e t h i n g else. T h i s m o n s t e r takes o v e r . I t r s v e r y h a r d ! It h a s al1 t h e c o n t r o l ; you h a v e none .

T h e d e p t h s o f her s t r u g g l e t o g a i n c o n t r o l t h r o u g h

r e s t r i c t i v e m e a s u r e s escalated t o the p o i n t o f z e r o

t o l e r a n c e f o r f o o d : "Like t h e s i g h t , t h e s m e l l o f f o o d made

m e v o m i t . 1 c o u l d n o t go t o t h e g r o c e r y store."

O t h e r women s p o k e a b o u t t h e p a r a d o x i c a l n a t u r e o f

a n o r e x i a n e r v o s a . What a t f i r s t seem~d t o b e a means t o

zckieve m ~ t r c l , k t c r becâne a c a t a i y s t for e n n a n c i n g fears

a n d i n s e c u r i t i e s . The fa l se s e n s e o f s e c u r i t y b r o u g h t b y

s e l f - c o n t r o l t h r o u g h restrictive b e h a v i o u r s r a p i d l y

d i s s i p a t e d a n d w a s r e p l a c e d b y f e e l i n g consumed b y

r e s t r i c t i o n s . F o r some, it becarne e x t r e m e l y d i f f i c u l t a t

t i m e s t o s e p a r a t e t h e r e a l f rom t h e u n r e a l i e dreams

a b o u t e a t i n g o r b l o w i n g a diet evoked p a n i c a t t a c k s ) .

1 wished 1 c o u l d ea t b e c a u s e a l 1 day 1 t h o u g h t a b o u t f o o d a n d I r d even drearn a b o u t f o o d a n d e a t i n g i t . And

I f d wake up and t h i n k that 1 had ate - and being a l 1 anxious because 1 thought 1 had e a t e n a n d blown my d i e t . But t h e n realized 1 d i d n r t , you know, so it was, it was a l w a y s there.

Another woman talked about being consumed by t h e

illness as she struggled to gain control of her life.

U l t i m a t e l y , restrictive behaviours escalated to the point of

total preoccupation w i t h food: '1 just decided 1 was not

eating." H e r belief that d e n y i n g the body food would b r i n g

control is also evident as she talked about the painful

experiences of raising her children:

Anorexia nervosa consumed me [pause, eyes cas t to f l o o r and voice low]. 1 missed out on a lot of rny c h i l d r e n ' s younger years. 1 could n o t cope. 1 had t o be strong. I had to stop eating [eye contact and tone increased].

When consumed by t h e illness, there was a t o t a l

preoccupation with restrictions. S t i l l , during a pregnancy,

to ensure the safety of her unborn child, s h e was able to

eat a whole lot b u t I did eat." In the early stages of

i l l n e s s i t seems t h a t s h e could still exercise some control

over restrictions. This sense of control could not be

recaptured, however, when she described f e e l i n g consurned by

t h e illness: "1 could n o t even care for my children." Her

perceived inadequacies as a p e r s o n forced h e r t o relinquish

child-care responsibilities to h e r parents.

It appears t h a t feeling consumed by anorexia nervosa

destroys or dissipates the core or the essence of

personhood - self-identity. Many of these women reached the

point where restrictive behaviours were no l o n g e r effective

i n controlling anxiety and feelings of worthlessness. -What

remained upon awakening each day were the pains of the past

and the constant inner s t r u g g l e with finding meaning in

life.

Letting-Go While Holdinq-On

Once the illness had progressed to the point where

became difficult to hide restrictive behaviours, the

concealment was broken. The skeletal prominence as well as

the food games were visible to others. Yet, al1

participants continued to deny having eating disorder

problems. When confronted about weight loss and restrictive

behaviours, they resisted the allegations and accused others

of not really understanding their situation: "1'11 never

speak to you again if you donrt stop."

Emotional reactions were c l a s s i f i e d as "shocked" or

"angry", words common to grief reactions to a loss. Shock

is derived £rom the French word "choquer" which means to

strike (with f e a r ) , or a violent collision or impact. One

p a r t i c i p a n t d e s c r i b e d t h e i n t e n s i t y of he r f e a r s f o l l o w i n g a

break i n c o n c e a l m e n t a n d s u b s e q u e n t weight gain: 'It was

l i k e 1 was hit with a Mack Ton t r u c k . "

F i n d i n g i t d i f f i c u l t t o "let-go" of t h e only e f f e c t i v e

means o f c o n t r o l t h e y had , a l 1 p a r t i c i p a n t s refused t o

a c c e p t the f a c t t h a t t h e y n e e d e d p r o f e s s i o n a l he lp . To do

s o would be a r e a f f i r m a t i o n of their p e r c e i v e d w e a k n e s s .

D e s p i t e using d e s c r i p t o r s s u c h as s h o c k t o d e s c r i b e

r e a c t i o n s t o o t h e r s ' c o n f r o n t a t i o n s about restrictive

behaviours, altered body images and thought p r o c e s s e s forced

them t o "hold-onf ' .

I n a l 1 i n s t a n c e s , t h e breaking of t h e c o n c e a l m e n t

i n t e n s i f i e d t h e d r i v e t o g a i n c o n t r o l , When p s y c h o l o g i c a l

o r p h y s i c a l c o n t r o l s were i n s t i t u t e d by others t o c u r b

a b e r r a n t behaviours, some o f t h e s e women became o b s e s s e d

with overcoming t h e b a r r i e r s a n d r e g a i n i n g c o n t r o i t h r o u g h

r e s t r i c t i v e d i e t i n g .

1 f e l t 1 w a s even more i n s e c u r e a f t e r t h a t , . . maybe, cause s h e t o l d m e that p e o p l e were watching m e . So my s e l f - e s t e e m s h o t e v e n l o w e r . It was c r a z y . And t h e n 1 went nowhere! . . . 1 g o t more s i c k . - . My e a t i n g h a b i t s . , . 1 d o n ' t know. They g o t worse.

Other wornen t a l k e d a b o u t t h e i n n e r t u r m o i l and p a i n

experienced £rom being forced t o e a t :

1 cried and cried al1 over my meals.

1 felt like they were ganging up on me. Bringing me places 1 did not want to go, Forcing me to eat, forcing me- That was really, really bad. They could not understand [pause],

Being forced to eat was taking away the control; the only

means of dealing with lifefs stressors. Most external

controls had a negative impact and only served to intensify

anxiety and inner turmoil. A few reached the point of not

caring who was aware of the restrictive behaviours: "No, 1

just did not care!"; "1 did not want he lp . "

Hewever, with the concealment broken, these women were

l e f t without the "in-control" feelings provided by

restrictive behaviours. In a sense, they were stripped of a

constant and trustworthy means to achieve happiness,

leaving them completely defenceless in a foreign world. The

f c c x x â s s t i Z l on regaining con~roi ( L e . , enhanced

preoccupation with restrictive thoughts, devising ways to

evade barriers, and ultimately achieving even greater

highs) . With the developing awareness that restrictive

behaviours were causing a great deal of pain for family

rnembers, many became anxious and felt guilty. Enhanced

conflict between self and others' needs/concerns diminished

f e e l i n g s o f i n n e r c o n t r o l b e c a u s e t h e t i m i n g and type o f

r e s t r i c t i v e b e h a v i o u r s w e r e limited t o t h o s e easiest t o

h i d e : " I ' d eat when 1 was a t home b e c a u s e 1 knew when 1 went

back t o s c h o o l I r d s t o p e a t i n g . "

The lived w o r l d of a n o r e x i a n e r v o s a o f t e n l e f t t h e s e

women f e e l i n g o u t - o f - c o n t r o l . Unaware of how t o s t o p t h e

i n n e r p a i n a n d t u r m o i l , t h e y again relied o n o t h e r s t o

d i c t a t e a c o u r s e o f ac t ion . One woman's fear o f s e l f - h a r m

l ed h e r t o a c c e p t t h e p s y c h i a t r i s t t s referral t o a

p s y c h o l o g i s t . However, t r e a t m e n t was i n i t i a t e d w h i l e

o p e r a t i n g under t h e d e l u s i o n that this m i g h t help h e r " s tay

t h i n f o r e v e r " - H e r r e f u s a l t o a c c e p t t h e d i a g n o s i s of

anorexia nervosa a l s o p r e v e n t e d h e r f rom i n i t i a l l y seeing

p o s s i b l e b e n e f i t s from being a d m i t t e d t o a psychiatrie u n i t .

However, as h e r anxiety i n t e n s i f i e d she realized t h a t

s u p p o r t w a s needed to control suicidai thoughts a n d s e v e r e

r e s t r i c t i o n s .

T h e p e r c e i v e d i n s i g h t f u l n e s s o f o t h e r s , o r f e e l i n g

c o n n e c t e d t o a n o t h e r who u n d e r s t o o d , p r o v i d e d the g l i m r n e r o f

l i g h t that s l o w l y began t o p i e r c e the "veil of d a r k n e s s "

t h a t t h r e a t e n e d t o e n g u l f them. T h e s e women described t h e

i m p a c t that c o n n e c t i n g t o a n o t h e r p e r s o n had on t h e i r l i v e d

world (Le., j o g g i n g and s h a r i n g feelings, o r b e i n g a r o l e

mode1 b y seeking h e l p ) as c r i t i c a l e v e n t s which a l l o w e d

g r e a t e r a c c e p t a n c e of t h e s e l f . S u p p o r t i v e b e h a v i o u r s by

s i g n i f i c a n t o t h e r s w e r e p e r c e i v e d p o s i t i v e l y a n d p r o v i d e d

them w i t h t h e i n c e n t i v e t o deal w i t h t h e i r i l l n e s s .

Denial w a s s t i l l p r e s e n t b e c a u s e of t h e d i f f i c u l t y

a c c e p t i n g that others could have access t o t h e i r p e r c e i v e d

i d e n t i t y - a weak p e r s o n . T h e p r o c e s s of letting-go while

hold ing-on t o t h e r e s t r i c t i v e behaviours which domina ted t h e

l i v e d wor ld w a s c l ouded by f e a r s a n d i n s e c u r i t i e s .

U l t i m a t e l y , c o n n e c t i n g t o a n o t h e r p e r s o n p r o v i d e d a bond of

trust and a v i s i o n o f s t r e n g t h and s e c u r i t y .

Readiness for Chanqe p. .- -

What f a c i l i t a t e s change i n a p e r s o n with a n o r e x i a

ne rvosa? T h e wornen i n t h i s s t u d y t a l k e d about t h e

importance of challenging r e s t r i c t i v e b e h a v i o u r s a n d

a c c e p t i n g h e l p from o t h e r s . They a l s o emphas ized that

r e a d i n e s s t o change had t o corne f rom within t h e s e l f .

C r i t i c a l t o f e e l i n g ready t o change was t h e i n c r e a s e d

a b i l i t y to form a "bond o f t r u s t " w i t h a n o t h e r .

P a r t i c i p a n t s t a l k e d about the r e a d i n e s s t o change

p e r i o d i n t e r m s of a t u r n i n g p o i n t i n t h e i r l i v e s . While

some f e l t s e t f r e e from p r o t e c t i v e shel ls ( L e . , wanting t o

be less dependent o n a n o t h e r and d e v e l o p i n g more confidence

and a s s e r t i v e n e s s ) , others becarne more s e l e c t i v e over

f r i e n d s . S t i l l o t h e r s s tarted t h i n k i n g about what they

r e a l l y wanted i n l i f e e h a v i n g c h i l d r e n meant moving to

r e d u c e d e s t r u c t i v e effects on the r e p r o d u c t i v e s y s t e m ; o r ,

having a career required comple t ing a university degree) .

W i t h o u t a s e n s e of r e a d i n e s s t o accept h e l p , efforts by

significant o t h e r s (e .g., farnily, f r i e n d s , o r h e a l t h care

worke r s ) w e r e p e r c e i v e d as e i t h e r t h r e a t s t o c o n t r o l o r

feeding the drive to regain control: 'It go t w o r s e after

t h a t [breaking the concealment] "; "1 did n o t wan t their h e l p

- 1 did not care."

Some women e x p e r i e n c e d c r i t i c a l e v e n t s that prov ided a

b r e e d i n g ground for c h a n g e . The positive effects d e r i v e d

from b e c o m i n g pregnant were d e s c r i b e d by one p a r t i c i p a n t p p p p p p p p p p p p - - - - - - - - - - - - - - - - -

If 1 had not h a v e g o t t e n p r e g n a n t [ l o n g pause - s i lence] . . - 1 would not be h e r e t o d a y . 1 thank God f o r t h a t .

T h e s e n s e of life w i t h i n gave t h i s woman a purpose f o r

living - a mother-to-be. T h e focus changed f r o m a

p r e o c c u p a t i o n w i t h food t o c a r i n g for the needs o f a n u n b o r n

child.

For a second woman, c o n n e c t i n g with a n o t h e r was

p r e c e d e d by t h e j o l t £rom a CAT s c a n r e p o r t t h a t r e v e a l e d

she had e x t e n s i v e o s t e o p o r o s i s . T h e concrete, tangible

p i c t u r e of her damaged b o n e s "opened h e r e y e s " t o t h e

r e a l i t y of t h e d e s t r u c t i v e e f f e c t s of h e r r e s t r i c t i v e

behaviours. S u b s e q u e n t l y , s h e m e t s o m e o n e who b r o u g h t a

glimrner o f hope i n t o her l i f e : '1 c o n n e c t e d w i t h her" ; "She

h e l p e d m e f i n d myself ."

When s u c c e s s f u l i n forming a m e a n i n g f u l a t t a c h m e n t w i t h

a n o t h e r p e r s o n , t h e s e women f e l t t r u l y c o n n e c t e d f o r tne

f i r s t t i m e i n t h e i r l i v e s : "1 f e l t l i k e a pe r son" ; '1

r e a l i z e d t h a t 1 w a s a p e r s o n " ; "1 c o n n e c t e d w i t h her"; "She

h e l p e d m e find m y s e l f . " T h e b e g i n n i n g steps, i n t h e

t r a n s i t i o n £ r o m f e e l i n g e m o t i o n a l l y empty t o f e e l i n g

c o n n e c t e d , w e r e d e s c r i b e d i n terms of a dawning o r

r e c o g n i t i o n of o n e ' s s e l f - w o r t h .

1 am a sornebody. A i l my l i f e 1 w a s made t o feel like a nobociy. 1 w a s moulded by m y p a r e n t s ' l i t t l e world . . . With m y f i r s t h u s b a n d i t was t h e same.

F e e l i n g c o r n f o r t a b l e w i t h the caring b e h a v i o u r s d i s p l a y e d b y

a n o t h e r p e r s o n w a s c r i t i c a l i n helping them "connec t " . This

power beh ind human c o n n e c t e d n e s s is d e s c r i b e d b y S a r t r e

( 1 9 5 6 ) a s : "1 see m y s e l f because someone else sees m e . I

e x p e r i e n c e m y s e l f as a n o b j e c t f o r t h e o t h e r " (c i ted i n van

One p a r t i c i p a n t spoke a b o u t t h e i m p o r t a n c e of

u n c o n d i t i o n a l a c c e p t a n c e by others.

Whereas w i t h t h e l a d i e s . . . t h e y are l e t t i n g m e be m e . I a m a b l e t o s a y I like myse l f a b i t b e t t e r b e c a u s e t h e s e ladies are h e l p i n g m e f i n d m e . I do n o t f e e l i n t i m i d a t e d by them . . . . I a m r e a l l y , r e a l l y c o m f o r t a b l e w i t h them a n d I f e e l I c a n be m e .

Another t a l k e d a b o u t h e r r e l a t i o n s h i p w i t h someone who

e v e n t u a l l y became her husband. D e s p i t e f e e l i n g l i k e s h e

wanted t o h i d e o r b e " i n v i s i b l e " when i n i t i a l l y s o c i a l i z i n g

w i t h h i s f r i e n d s , a s a t r u s t i n g bond was formed w i t h h i m s h e

became more s e c u r e i n s o c i a l i n t e r a c t i o n s .

I have t o g i v e him a l l t h e credit . . . . H e talked t o m e and t o l d m e t h a t I c o u l d d o i t . . - . I s t a r t e d t o m e e t a l o t of h i s f r i e n d s and s t a r t e d t o t a l k t o them. I w a s t h i n k i n g , "Gee I can do t h i s ." I r e a l l y s u r p r i s e d m y s e l f .

The s t r e n g t h +ad impcrtance of forming a bond of t r u s t w i t h

a s i g n i f i c a n t o t h e r i s c a p t u r e d i n t h e f o l l o w i n g pa s sage :

One p e r s o n and he i s e x t r e m e l y good t o me. H e u n d e r s t a n d s . H e doe sn r t f o r c e m e . 1 c a n t e l l him a n y t h i n g . H e i s my b e s t , b e s t f r i e n d . H e i s a gem !

What w a s most r e v e a l i n g a b o u t h e r d e s c r i p t i o n o f this

r e l a t i o n s h i p was t h e obv ious e x p r e s s i o n o f e x c i t e m e n t ,

s u r p r i s e and joy when she t a l k e d a b o u t s h a r i n g meals w i t h

him: 'I pick, b u t I enjoy i t ! I e n j o y it!" D e s p i t e feeling

92

r e l a x e d a n d d e r i v i n g p l e a s u r e from e a t i n g w i t h someone s h e

h a d l e a r n e d t o t r u s t , s h e c o n t i n u e d t o experience a n x i e t y

when e a t i n g w i t h o t h e r s : " B u t w i t h a n y o n e else 1 a m always

stressed. You can almost feel an anxiety attack coming on!"

As care and trust u n f o l d e d i n m e a n i n g f u l r e l a t i o n s h i p s ,

some a c q u i r e d t h e s t r e n g t h , w i l l i n g n e s s and p u r p o s e t o

c h a l l e n g e d e s t r u c t i v e b e h a v i o u r s .

1 j u s t woke one d a y a n d said 1 a m g o i n g t o do t h i s t o d a y [ e a t ] .

1 j u s t d e c i d e d t h a t he must b e r i g h t . E v e r y t h i n g he h a s t o l d m e s o far is right, so 1 decided t o t r y e a t i n g .

The c r i t i c a l e v e n t , t r u s t i n g o t h e r s enough t o g a i n a c c e s s t o

the self , p r o v i d e d t h e i m p e t u s t o i n i t i a t e rneasures which

d i s b u r s e d t h e h o l d i n g p o w e r s o f anorexia n e r v o s a .

When e v e n t s o r r e l a t i o n s h i p s s u r f a c e d t h a t c r e a t e d t h e

potential fo r change, thoy di6 mt ü 1 x â p t r s n s i a t e i n t o

c o n c e r t e d a c t i o n s t h a t l ed t h e p e r s o n t o p e r m a n e n t l y modify

r e s t r i c t i v e b e h a v i o u r s . A l though a p r e q n a n c y p r o v i d e d two

o f t h e s e women w i t h a r e p r i e v e frorn the i n t e n s i t y of

r e s t r i c t i v e p r a c t i c e s , it was not powerful e n o u g h t o

overcome u n c e r t a i n t i e s and fears a b o u t t h e m s e l v e s . Anorexia

n e r v o s a s a t patiently waiting f o r a v u l n e r a b l e moment

( s t r e s s o r s ) when it c o u l d l a u n c h a n o t h e r a t t a c k . F o r one

woman, the a d d e d s t r e s s o r s o f being a new mom c o u p l e d w i t h

m a r i t a l d i s c o r d r e a f f i r m e d h e r weakness and p r o v i d e d t h e

r e k i n d l i n g fuel t o resume r e s t r i c t i v e b e h a v i o u r s .

T h e b r e a k i n g of the bond of t r u s t a l s o d e c r e a s e d t h e

desire t o change. Each time t h e bond with another was

b r o k e n , these women resorted t o res t r ic t ive behaviours t o

h e l p t h e m cope.

It happen s o fast! T h e o n l y way t o cope w a s t o s t o p e a t i n g . 1 shut off £rom food a g a i n .

L i k e m y best f r i e n d , my b o s s , rny roommate [the same person] . L i k e my e a t i n g d i s o r d e r i s so bad that s h e would h a v e t o r u n o v e r t o t h e bar a n d tell them e v e r y t h i n g !

When c o n f r o n t e d with c r i t i c a l e v e n t s which renewed f e a r s of

trusting o t h e r s , p e r s o n a l i d e n t i t i e s were o n c e again lost t o

t h e powers o f t h e i l l n e s s .

F o r a l 1 of t h e s e women, r e a d i n e s s t o c h a n g e w a s

preceded b ÿ à c r i t i c a l e v e n t (a c o n n e c t e d n e s s w i t h t h e se l f )

which gave them a p u r p o s e o r meaning t o fight the battle of

a n o r e x i a n e r v o s a . B y for rn ing a meaningful bond with

a n o t h e r , p a r t i c i p a n t s l e a r n e d t o trust t h e i r a b i l i t i e s t o

overcome t h e i l l n e s s and remove r e s t r i c t i v e c o n t r o l s .

Readiness t o c h a n g e a l s o h e l d the p e r s o n in therapy and

weakened t h e s t r e n g t h of t h e bond forged w i t h t h e disorder .

Success i n t h e r a p y required the d e v e l o p m e n t of grea ter se l f -

94

awarenes s a n d f a i t h i n t h e i r s e l f - w o r t h , and the c o n t i n u e d

p r e s e n c e o f a t r u s t i n g r e l a t i o n s h i p w i t h a n o t h e r .

Breaking the Cycle

The women i n this study v e r y c l e a r l y a r t i c u l a t e d t h e i r

s t r u g g l e w i t h b r e a k i n g t h e c y c l e . Conf ron t ed with h a v i n g t o

s h e d the p r o t e c t i v e b a r r i e r s h i d i n g the weakened se l f , and

a c c e p t i n g t h e risk of embark ing on a journey i n search of

t h e e l u s i v e idea l se l f , t h e y w e r e besieged w i t h f e a r s and

u n c e r t a i n t i e s t h a t t h r e a t e n e d t o e n g u l f them. W i t h o u t a

c lear p i c t u r e of what r e c o v e r y would mean, they sought

r e f u g e i n a p l a c e where t h e y had more c o n t r o l (i -e., t h e

r e s t r i c t i v e b e h a v i o u r s o f a n o r e x i a n e r v o s a ) : '1 f i g h t every

d a y w i t h it . . . . it is someth ing t h a t 1 p r o b a b l y w i l l

have t o struggie w i t h for the rest of my l i f e . "

The word b r e a k means " t o make i n e f f e c t i v e as a b i n d i n g

force" o r ' to d i s r u p t t h e o r d e r " o f someth ing ( W e b s t e r ,

1988) . When applied t o the c y c l e of r e s t r i c t i v e b e h a v i o u r s

domina t i ng t h e l i v e d world o f t h e anorexie, it refers t o a

change o r i n t e r r u p t i o n t h a t is temporary o r l e n g t h y

depending o n t h e p e r c e i v e d s u p p o r t i v e a n d c a r i n g p r e s e n c e o f

o t h e r s . Al1 t h e s e women v o i c e d two i n t e g r a l f o r c e s which

helped b r e a k t h e c y c l e and maintain a cornmitment t o

r ecove ry : a ) having someone who u n d e r s t o o d what i t w a s like

t o l i v e w i t h a n o r e x i a ne rvosa and, b ) t h e presence of a

t r u s t i n g environmont free from external controls.

A l 1 had l e a r n e d n o t t o t r u s t t h e self o r o t h e r s , a n d t o

r e l y on restrictive b e h a v i o u r s t o give them a s e n s e of

c o n t r o l o v e r i n t e r a c t i o n s w i t h t h e o u t s i d e wor ld . One woman

spoke a b o u t t h e contrasting effects o f d i f f e r e n t i n t e r a c t i v e

app roaches on h e r a b i l i t y t o deal w i t h a n x i e t y d u r i n g a n d

a f t e r t h e r a p y :

1 go t o see h e r [psychologist] p r o b a b l y o n c e e v e r y two weeks . . . f o r about t w o years . . . She, l i k e , makes m e feel really good when I go i n , and s h e d o e s sornething t h a t nobody else has done w i t h m e . S h e d o e s r e l a x a t i o n t e c h n i q u e s and stuff. So, l i k e , a l o t o f tirnes 1% r e a l l y anx ious a n d f r u s t r a t e d when 1 go i n but s h e f l l c a l m m e down. And none of thern, l i k e t h e o t h e r people t h a t I ' v e s e e n had never t r ied that with m e before. L i k e , I w o u l d go i n and feel a n x i o u s , and p.--- -- ---t Lu.,kL,y vu^ I x 0 ~ 1 d stiii f e e i a n x i o u s and pissed off .

T h i s woman's i n s e c u r i t i e s and fears w e r e alleviated by a

t h e r a p i s t who h e l p e d h e r relax b e f o r e d e a l i n g w i t h i l l n e s s

issues, and i n t e n s i f i e d by one who t r e a t e d h e r as a

"textbook casef*.

Other women viewed h e a l t h rare workers a s having

i n a d e q u a t e knowledge a b o u t eating d i s o r d e r s - One woman

h i g h l i g h t e d t h e differences between effective and

i n e f f e c t i v e a p p r o a c h e s i n t e r m s o f t h e r a p i s t s r s k i l l s and

p r a c t i c a l knowledge .

T h e f i r s t l a d y 1 saw, s h e d i d n o t have any e x p e r i e n c e . . . . T h a t idea of m e a s u r i n g t h i n g s , recording the f o o d , you s h o u l d never d o that w i t h p e o p l e who have an e a t i n g disorder . . . . That w a s a B-A-D t h i n g t o do , cause 1 w a s t o o sick a n d 1 r e a l l y did not want h e l p . T h e other lady . . . . a s o f t , s p o k e n person . - . a d i e t i c i a n i n t o c o u n s e l l i n g . , . knew a l o t a b o u t e a t i n g d i s o r d e r s . So w e worked o n b o t h t h i n g s . How 1 felt and what 1 could do t o h e l p m y s e l f . W e always set l i t t l e goals.

When c o n f r o n t e d with i n e f f e c t i v e i n t e r a c t i o n s d u r i n g

t h e r a p y , al1 p a r t i c i p a n t s e x p e r i e n c e d i n c r e a s e d i n n e r

t u r m o i l a n d sought ways t o e s c a p e t h e s i t u a t i o n : " Y o u are

making m e w o r s e . T h e r e w a s no way 1 would go back; 1 ran

o u t of h i s office"; "1 did n o t make a n o t h e r a p p o i n t m e n t .

[ p a u s e ] 1 j u s t d id n o t feel c o m f o r t a b l e . "

Break ing t h e c y c l e required developing a w i l l t o l e t -

gc. O e f e r r x e xâs ûftrn made t o c n a n g e s tna t a l tered t h e

c o u r s e o f t h e i r l i v e s , a n d if o n l y t e m p o r a r i l y , t h e i l l n e s s .

"Feeling connec t ed" required finding someone who w a s n o t

o n l y k n o w l e d g e a b l e a b o u t and u n d e r s t o o d anorexia nervosa,

b u t a l s o t r a i n e d t o do c o u n s e l l i n g .

She i s j u s t l i k e a mediator, a go-between . . she h a r d l y s a y s a n y t h i n g . Like, she j u s t s i t s t h e r e a n d i f 1 need t i m e t o s t o p a n d r e g r o u p , s h e r l l . . . stop for a few m i n u t e s - j u s t r e l a x , you know.

When f u r n i s h e d with a n o n - t h r e a t e n i n g and non- judgmenta l

e n v i r o n m e n t t o e x p r e s s fears and c o n c e r n s , these women felt

safe a n d secure t o l e t - g o of t h e p a s t and e x p l o r e f u t u r e

possibilities.

Therapists who failed t o communica te o n a p e r s o n a 1 a n d

a f f e c t i v e l e v e l , who conveyed p i t y or used t h r e a t s , were

perceived as unwilling or u n a b l e t o u n d e r s t a n d what it w a s

like t o l i v e w i t h t h e i l l n e s s ,

It's like he [therapist] d i d n f t u n d e r s t a n d . . . he knew what it w a s a b o u t from r e a d i n g a book. H e d i d n ' t know what it was about - l i v i n g t h r o u g h it. And 1 would be t a l k i n g t o him and h e wou ld make m e feel stupid.

It w a s h i s [therapist] o v e r a l l a p p r o a c h . I r e a l l y d o n ' t know what he was trying t o do. H e w a s t r y i n g t o get m e on m e d i c a t i o n . I f m n o t t h a t k i n d o f p e r s o n . 1 w a s depressed . . , . 1 sa id NO! ! B u t he kept p u s h i n g , and pushing . . . . Like he k e p t o n s a y i n g t h a t i f 1 d i d n o t d o t h i s that he would p u t m e i n t h e h o s p i t a l . T h r e a t e n i n g me, t k rea t zn i r i g me, i i k e rnat . . . . Then, t h e r e w a s one day, t h e r e xss a fruit-fly, one of t h o s e that you can h a r d l y see, g o i n g a r o u n d rny head. 1 was b r u s h i n g it away and h e a s sumed t h a t I w a s i n s a n e ! Like he d i d not know what 1 was doing . . . . 1 dreaded g o i n g to see him, h o n e s t l y .

Such communication a p p r o a c h e s reaffirmed and e c h o e d t h o u g h t s

about t h e self as b e i n g weak - a n o t h e r knock a g a i n s t self-

esteem. T h i s o n l y i n c r e a s e d t h e s e n s e of distrust i n

o n e s e l f a n d o t h e r s : "1 felt l i k e 1: was a number. 1 was a

nurnber! S h e was not c o m p a s s i o n a t e . She w a s c o l d . " Those

women who s t a y e d i n therapy d e s c r i b e d a n a t m o s p h e r e o f

u n c o n d i t i o n a l a c c e p t a n c e a n d p o s i t i v e regard: "She listened

t o m e " ; "She d id n o t j u d g e me"; "She w a s i n t e r e s t e d i n m e . "

Lack o f c o n n e c t e d n e s s and f e e l i n g s o f b e i n g c o n t r o l l e d

w e r e e v i d e n t £rom words t h a t r e f l e c t e d c o u n t e r p r o d u c t i v e

a p p r o a c h e s t o t h e r a p y ( L e . , " t h r e a t s " , 'scare tactics",

"blame", " p i t y " , o r "shame"). Some of t h e s e women f e l t t h a t

t h e i r b a s i c rights, t o be t reated w i t h r e s p e c t and d i g n i t y ,

w e r e v i o l a t e d by s o m e r n e m b e r s of t h e h e a l t h care t e a m .

Examples o f t h e s e negative e x p e r i e n c e s i n c l u d e d :

H e b l amed my mom. 1 hated him . - . . 1 d i d not want h i s help b u t h e w a s j u s t a w f u l .

H e s a id t o m o m t a k e h e r home a n d feed her. S i t on her i f you have t o ! H e t o l d m e t h a t t h e r e w a s no n e e d o f m e doing t h i s f o o l i s h n e s s . From t h a t d a y o n , 1 did n o t t r u s t anybody. H e w a s a d o c t o r ! I r m l i k e OK, if this is y o u r a t t i t u d e !

O t h e r s t z l k e c ! about r e c e i v i n q mixea m e s s a g e s from h e a l t h

care p r o v i d e r s d u r i n g h o s p i t a l i z a t i o n s :

[some] t o l d me 1 n e e d e d t o i n c r e a s e my w e i g h t and [ o t h e r s ] t o l u m e t o m a i n t a i n my w e i g h t a t t h e c u r r e n t level. I c o u l d n o t do that, 1 w a s not eating, 1 c o u l d n o t m a i n t a i n t h i s weight.

O t h e r s felt t h a t their n e e d s were s e c o n d a r y t o t h e hospital

staff's routine: " T a l k when t h e y were ready"; " N o o n e e v e r

t a l k e d on t h e weekends . "

Many women e x p r e s s e d d i s s a t i s f a c t i o n w i t h h e a l t h care

w o r k e r s who f a i l e d t o a d d r e s s t h e i r anxieties a n d needs or

used c o n t r o l l i n g t ac t ics . One woman described how h e r pain

and anxiety e s c a l a t e d f o l l o w i n g a negative e x p e r i e n c e w i t h a

therapist :

You have t o get weighed. You have t o ! 1 knew f w a s going t o t h i n k 1 w a s o v e r w e i g h t . 1 knew if she t h o u g h t 1 w a s u n d e r w e i g h t , then s h e would t r y and get m e t o ea t a n d eat a n d ea t ! N o way, not f o r c i n g m e t o eat. CAN'T DO IT! * . . . She p u t m e on t h e scales backwards and t h a t ' s how she weighs m e backwards. S h e weighed m e , marked i t down and did n o t t e l l m e . Then t h a t week I w a s a t rny f r i e n d ' s house a n d s h e had scales . 1 weighed rnyself . . . . 1 w a s s o u p s e t . 1 t h o u g h t 1 weighed a l i t t i e less a n d 1 did n o t .

O t h e r s spoke a b o u t b e i n g f o r c e d t o r e c o r d t h e i r d i e t a r y

intake b y c o u n t i n g c a l o r i e s .

S h e t h o u g h t t h a t was h e l p i n g m e t o show m e how many c a l o r i e s could be i n m e . B u t it w a s showing m e how t h i s MONSTER c o u l d take t h i s and run with i t . T h i s m o n s t e r had a f i e l d d a y w i t h i t . C o u n t i n g c a l o r i e s a n d t h e s c a l e s . p p p p p p p p p p p p p - - - - - - - - - - - - - - -

Use of weighing ~ c a l e s or a c o u n t i n g calorie system as signs

of r e c o v e r y o n l y s e r v e d t o r e i n f o r c e perceptions t h a t self-

esteem w a s m e a s u r e d i n terms of weight.

The v o i c e s of t h e s e women e c h o e d the i m p o r t a n c e of

getting to know and a c c e p t i n g t h e self. Some made a

c o n s c i o u s d e c i s i o n t o throw o u t t h e b a t h r o o m scales,

r e m i n d e r s about t h e o ld , weak self. Others l e a r n e d , th rough

t h e r a p y , that wellness w a s measured i n t e r m s o f o n e ' s

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a b i l i t y t o i n t e r a c t w i t h others wi thou t having t o rely on

r e s t r i c t i v e behav iou r s .

The e x p e r i e n c e o f becoming e m o t i o n a l l y connected w i t h a

person (a therapist a n d / o r another) "opened their eyes" and

i n t r o d u c e d them t o a new form of communication: '1 never

communicated on that level befo re" ; '1 d i d n o t know w h a t i t

meant." Once t hey were able t o see thernselves a n d o t h e r s i n

a new light i e f t r u s t i n g self and o t h e r s ) , they found t h e

s t r e n g t h t o f i g h t t h e battle of f r e e i n g t h e imprisoned self

from the powers of a n o r e x i a nervosa.

Interrelationships Among Themes

Phenornenologlcal themes are d e f i n e d a s e x p e r i e n t i a l

structures which f i t together whole; they a r e t h e

threads around which phenomenological descgiiptionç a r e - wouen p p p p p p p p p p p p p - - - - - - - - -

(var. Manen, 1 9 9 0 ) . T h i s s e c t i o n atcempts t o c a p t u r e t h e

interrelationships among t h e themes ( t h e weakened s e l f , a

struggle f o r c o n t r o l , controlled b y t h e i l l n e s s , c o n c e a l i n g

t h e s e l f , feeling consurned, readiness to change, letting-go

w h i l e holding-on, a n d Sreaking t h e cycle) t h a t d e s c r i b e t h e

experience o f l i v i n g with a n o r e x i a nervosa .

F i l l e d with mernories of p h y s i c a l / p s y c h o l o g i c a l

r e j e c t i o n s ( p e r c e i v e d o r r ea l ) from family and pee r s , the

p r e - a n o r e x i c ch i ld p e r c e i v e d t h e unknown as a p e r s i s t e n t

t h r e a t t o s a f e t y a n d s e c u r i t y . F e e l i n g deprived of a

rnean ingfu l e x i s t e n c e a n d the a b i l i t y t o t r u s t o t h e r s , t h e s e

women were l e f t w i t h o u t a 'voice" t o cornrnunicate t h e i r

t h o u g h t s , f e e l i n g s , a n d c o n c e r n s . The media, s o c i e t y ,

p a r e n t a l a t t i t u d e s and S e h a v i o u r s a b o u t t h i n n e s s and f o o d

c a p t i v a t e d them. C o n v i n c e d t h a t s t r e n g t h and c o n t r o l w e r e

e q u a t e d with d e n y i n g t h e body food, t h e y s t r u g g l e d t o a t t a i n

a p o s i t i v e self-image by c o n t r o l l i n g r e s t r i c t i v e b e h a v i o u r s .

Because r e s t r i c t i o n s h e l p e d reduce e m o t i o n a l p a i n , t h e y

were d e l u d e d i n t o t h i n k i n g t h a t t h i n n e s s would increase

t h e i r c h a n c e s of b e i n g accepted b y o t h e r s .

F e e l i n g s of w o r t h l e s s n e s s and i n a d e q u a c y l e f t t h e m

u n p r e p a r e d t o meet t h e c h a n g e s and c h a l l e n g e s o f a d o l e s c e n c e

a n d young a d u l t h o o d . These wornen w e r e eager t o l a t ch on t o

s o m e t h i n g o r someone to relleve their inner anguish and

f e e l i n g s o f e m p t i n e s s as t h e y s t r u g g l e d f o r i n n e r c o n t r o l .

Dieting and e x e r c i s i n g became the c o n s t a n t s - t h e t h i n g s

that were c o n t r o l l a b l e . T h e i r o b s e s s i o n w i t h , a n d r e j e c t i o n

o f , f o o d p r o v i d e d a n e f f e c t i v e c o n t r o l s t r a t e g y t h a t

f a c i l i t a t e d c o n c e a l m e n t of t h e i r weakened s e l v e s a n d e s c a p e

from r e a l i t y .

D e s p i t e t h e v i g o u r app l i ed t o r e s t r i c t i o n s , there was

102

a n i n c r e a s e i n o u t - o f - c o n t r o l f e e l i n g s ta tes a n d i n n e r pain

i n r e s p o n s e t o new stressors, e n h a n c e d f e e l i n g s of

w o r t h l e s s n e s s a n d weakness , a n d , u l t i m a t e l y , a r e d u c e d

a b i l i t y t o c o p e . When r e s t r i c t i v e d i e t a r y and e x e r c i s e

m e a s u r e s f a i l ed , as w e l l as m e d i c a t i o n s , sorne resorted t o

more d ra s t i c s o l u t i o n s by r e f u s i n g t o eat. A s r e s t r i c t i v e

b e h a v i o u r s began t o d o m i n a t e t h e l i v e d w o r l d , t h e i l l n e s s

moved t o t a k e c o n t r o l .

The c o n c e p t of c o n t r o l is a p a r a d o x . T h e weakened

self , who tasted a n d l o v e d the false s e n s e o f s e c u r i t y

d e r i v e d f r o m r e s t r i c t i o n s , c o n t i n u e d t o rely on these sarne

b e h a v i o u r s t o avoid s o c i a l contact. Denying o r c o n c e a l i n g

t h e i l l n e s s from o n e s e l f and o t h e r s f u l f i l l e d t h e n e e d t o be

a c c e p t e d and a p p e a r normal. Unable t o a r t i c u l a t e f e e l i n g s

o r reduce fears o f r e j e c t i o n , t h e need t o c o n c e a l e s c a l a t e d .

Although temporary relief could s t i l i b e achieved by

i n t e n s i f y i n g r e s t r i c t i v e b e h a v i o u r s , t h e d o s e - r e s p o n s e c u r v e

was c h a n g i n g t o p a r a l l e l t h e g r o w t h of a n x i e t i e s a n d

i n s e c u r i t i e s . A s t h e se l f became p r o g r e s s i v e l y weaker ,

t h o u g h t p r o c e s s e s a l s o were d i s t o r t e d b e c a u s e of the e x t r e m e

d e n i a l of n u t r i e n t s t o t h e b o d y . P a r a d o x i c a l l y , as a n o r e x i a

n e r v o s a g a i n e d c o n t r o l , t h e s e women becarne more consurned by

t h e i l l n e s s w h i l e d e s p e r a t e l y s t r u g g l i n g f o r c o n t r o l a n d

concea lmen t of r e s t r i c t i v e behaviours.

Breaking t h e c o n c e a l m e n t increased t h e s t r u g g l e for

c o n t r o l and, u l t i m a t e l y , p r o v i d e d t h e c a t a l y s t , f o r some, t o

b r e a k the c y c l e . A s medical p r o b l e m s s u r f a c e d and t h e

a b i l i t y t o a p p e a r n o r m a l waned, loss of c o n c e a l m e n t

t h r e a t e n e d t h e i r c o n t r o l - safety ând s e c u r i t y . P r e s s u r e d

b y concerned o t h e r s t o r e d u c e r e s t r i c t i v e b e h a v i o u r s , t h e s e

women p a n i c k e d b e c a u s e t h e y w e r e b e i n g a s k e d t o r e l i n q u i s h

t h e o n l y c o n t r o l t h a t t h e y knew. S t i l l f e e l i n g d e p r i v e d of

l o v e and trust and u n a b l e t o remember a t i m e when they had

been content w i t h t h e i r l i v e s o r t h e m s e l v e s , they became

extremely f e a r f u l of t h e f u t u r e .

With t h e c o n c e a l m e n t b roken a n d t h e i r i n a d e q u a c i e s

exposed t o others, they w e r e c o n f r o n t e d w i t h t w o p r o s p e c t s -

s t a r t b e l i e v i n g i n themselves and accept the n e e d t o change;

o r i n t e n s i f y r e s t r i c t i v e behaviours and wi tndraw further

f rom t h o s e who c o u l d n o t u n d e r s t a n d thern. A l 1 of t h e s e

women e x p e r i e n c e d a r e a d i n e s s t o c h a n g e w h i l e s t i l l

struggling w i t h f e e l i n g consumed and c o n t r o l l e d b y the

i l l n e s s . F u r t h e r r e j e c t i o n s a n d f e e l i n g c o n t r o l l e d by

others could, w i t h o u t w a r n i n g , t i p t h e b a l a n c e and s e n d

them f u r t h e r a n d f u r t h e r i n t o t h e m s e l v e s and t h e d e p t h s of

d e s p a i r . Their s t r u g g l e t o merge t h e f e e l i n g and t h i n k i n g

1 O4

parts of themselves into a meaningful whole was diminished

when they connected with someone (e-g., therapist) who

accepted and believed in them. As well, the constant

presence of a loving, caring significant other was needed to

prevent the mind from turning upon itself and once again

generating a lethal force that propelled the person along a

path of self-destruction.

The Essence --

Through formal, unstructured interviews, participants

reflected upon and described their lived experiences with

anorexia nervosa. Interpretive analysis of the transcripts

and confirmation of individual, specific insights with each

participant facilitated the grasping of the whole which

subsumed a l 1 other parts. The essence of the lived world of

persons with anorexia nervosa is s e e n as a persistent

struggle to find meaning in life.

Separately, each of the themes that capture the lived

experience of anorexia nervosa provide insight into a world

that few corne to know or understand. This separation is

artificial and distracts one from grasping the importance

and totality of the whole. When woven t oge the r to form a

phenomenological description of the lived experience of

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anorexia nervosa, the themes portray an irnage that leaves

one silently wondering about an experience with living that

is at once elusive to grasp but powerful in rendering its

message.

For these women, obsession with food or excessive

exercise was an expression of control in a world where they

felt no control. U n a b l e to feel good about themselves o r i n

control of their lives, restrictive behaviours and the

"relentless pursuit of thinness" gave thern a purpose for

living: 'It was the f i r s t time that I felt good about

myself." Besides feeling in control, it brought temporary

relief f r o m stressors while successfully concealing

perceived i n n e r weakness .

Feeling deprived of a reason for living, and not

trusting their abilities to interact socially, they avoided

situations wkich required opening thernselves to others.

Withdrawing while relating impeded meaningful bonding with

others - being with others while alone with themselves.

Consumed with p r o j e c t i n g an ideal image to the o u t s i d e

world, a great deai of time and energy was devoted to trying

to please others while concealing the "true" weakened self:

"1 do everything else f o r others but this [anorexia nervosa]

is for me. "

1 O6

T h e restrictive b e h a v i o u r s , wh ich w e r e l e a r n e d from and

rewarded b y o t h e r s , a l l o w e d t h e p e r s o n t o f e e l a s e n s e o f

t h e self, t o r e d u c e t h e i n n e r p a i n , a n d t o e s c a p e f rom t h e

w o r l d w h i c h d ic ta ted and r e i n f o r c e d t h e i r f e e l i n g s o f

w o r t h l e s s n e s s . A s t h e i l l n e s s moved t o assume c o n t r o l ,

r e s t r i c t i v e b e n a v i o u r s were found t o be less e f f e c t i v e i n

d e a l i n g w i t h e r n o t i o n a l p a i n a n d t h e stress of i n t e r a c t i n g

w i t h o t h e r s i n t h e i r w o r l d . Moving f u r t h e r a n d f u r t h e r away

frorn t h i s i d ea l image o f t h e m s e l v e s , t h e y became more

d e s p o n d e n t a n d consumed w i t h e m p t i n e s s . Whi le s t r u g g l i n g t o

g i v e mean ing t o t h e i r l i v e s t h r o u g h t h e p u r s u i t o f t h i n n e s s ,

t h e y e x p e r i e n c e d greater p a i n a n d a n g e r when c o n f r o n t e d w i t h

r e j e c t i o n s a n d o t h e r s ' a t t e r n p t s a t c o n t r o l . Once a g a i n ,

they r e c e i v e d c o n f i r m a t i o n t h a t they were n o t good enough

a n d n e e d e d t o t r y h a r d e r t o be t r u l y a c c e p t e d by o t h e r s .

F e e l i n g alone a n d r n i s u n d e r s t o o d , a l 1 p e r s p e c t i v e w a s

l o s t on how t o e n g a g e i n m e a n i n g f u l r e l a t i o n s w i t h o t h e r s .

Moving t o l e t - g o o f r e s t r i c t i v e b e h a v i o u r s , w h i l e h o l d i n g -

o n , left some w i t h o u t t h e n i 1 1 t o l i v e .

1 know t h a t I f m a l w a y s going t o s t r u g g l e w i t h i t . But l i k e 1 know t h a t 1'11 get t h r o u g h Ft . . . . L i k e , o n e t i m e 1 d i d n r t e v e n care i f i t d id . Bu t now, 1 d o n f t want i t t o k i l l m e .

Like, i t ' s hard for m e to Say it, but 1 d o n r t know if 1 would h a v e - p r o b a b l y would 've h u r t rnyse l f o r

something. Because 1 w a s kind o f feeling like t h a t . Like , 1 d o n f t know i f i t f s a c t u a l l y f e e l i n g suicidai, but close enough t o it t h a t 1 p r o b a b l y would've tried, b u t n o t i n t e n d i n g t o e n d my l i f e .

And I had h i s i n s u l i n and needle. 1 w a s going t o [ p a u s e ] But b e f o r e t h a t I had ca l led m y mom a n d a s k e d h e r t o corne a n d get m e . . . . I f she c o u l d n ' t h e l p , t h e o n l y way to stop this was [ l o n g pause]. 1 was bad. 1 w a n t e d t h e h u r t t o STOP . . . . I t was not w o r t h it anymore. L i f e is n o t w o r t h i t .

C o n v e r s e l y , t h o s e who were able t o connect w i t h a s p e c i a l

someone i n t h e i r p e r s o n a 1 l i v e s as w e l l a s w i t h a "special"

t h e r a p i s t were able t o begin t h e task o f b r e a k i n g t h e

h o l d i n g powers o f a n o r e x i a nervosa. These c o n n e c t i o n s w e r e

s e e n as t h e g l immer of hope, t h e l i g h t a t t h e end of t h e

t u n n e l , t h a t p r o m i s e d t o h e l p them b r i n g n e v rneaning i n t o

t h e i r l i v e s .

A n a àid you g e t wha t

you w a n t e d £rom t h i s life, even so?

1 d id .

And what d i d you w a n t ?

To c a l 1 rnyself b e l o v e d , t o feel m y s e l f

b e l o v e d o n t h e e a r t h .

(Raymond C a r v e r , c i t e d i n "When Food w a s Love", Roth, 1 9 9 1 )

CHAPTER 5

Discussion

Anorexia nervosa is a daily struggle to deal with

deep emotional pain and inner turmoil consequential to

interactional effects of sociocultural, environmental,

the

the

familial, and personal factors upon the self. This chapter

discusses study findings in relation to the current body of

knowledge on anorexia nervosa. Cornrnentary is also provided

on new insights gleaned from the data and what meaning this

has for health care delivery.

Lived Eamerience of Anorexia Nesvosa - - - - - . -

While this study's findings provide new insights into

the experience of living with anorexia nervosa, certain

components of the themes augment clinical and research

findings presented in the literature. The piece of the

analysis which provides the greatest support for current

perspectives is reflected in the essence of the lived

experience for study participants - the persistent struggle

to find meaning in life. In the t e x t that follows, themes

that depict the strongest interrelationships are discussed

together .

Weakened S e l f and Struggling for Control

As described by the women in this study, the image of

the weakened self emerged f rom the interactive ef fects of

individual, family, and societal factors. A number of

authors speak to the importance of these predisposing

factors in increasing a personfs susceptibility for anorexia

nervosa (Garfinkel, Garner, & Goldbloom, 1987; Garner, 1993;

Paxton, 1993; Shisslak, Crago, & Neal, 1990; Wilfley &

Grilo, 1 9 9 4 ) . However, the presence of any one or even a

combination of these factors, with or w i t h o u t precipitating

factors, will not necessarily lead to anorexia nervosa

(Russell, TrierweiIer, & Elder, 1996) .

The weakened self theme portrays the image of a person

who has not been successful in developing a true a f f i n i t y

w i t h the self o r finding mean ing in life. For many of these

wornen, anorexia nervosa surfaced and evolved in response to

psychological and emotional problems. Garner (1993)

indicated that eating disorders are most l i k e l y to develop

when l o w self esteem and negative body images are

accompanied by inadequate coping s k i l l s .

Within the confines of a family environment t h a t was

overprotective or controlling, the women in this study

failed to experience autonomous growth and doubted their

110

a b i l i t i e s t o share t h e m s e l v e s w i t h others. T h e i m p o r t a n t

i n f l u e n c e o f f a m i l y i n t e r a c t i o n p a t t e r n s i n d i m i n i s h i n g

anorexies' f e e l i n g s o f s e l f - w o r t h and s u p p r e s s i n g c o n f i d e n c e

about assurning i n d e p e n d e n c e i s s u p p o r t e d by Bruch (1977 ) ,

G a r f i n k e l and Golàbloorn (l988), and Turne r ( 1 9 9 0 ) , Bruch

( 1 9 7 7 ) h i g h l i g h t e d t h e key r o l e p l ayed b y c o n t r o l l i n g

p a r e n t s i n s u p p r e s s i n g autonomous g r o w t h , a n d g e n e r a t i n g

f e e l i n g s o f low s e l f - w o r t h a n d fears o f b e i n g r n i s u n d e r s t o o d .

T u r n e r (1990) e m p h a s i z e d h o w family communica t ion p a t t e r n s

c a n h a v e t h e a n o r e t i c a n x i o u s a b o u t t h e self , w i t h o u t a

c o m p l e t e sense o f i n d i v i d u a l i t y , and i n s e c u r e a b o u t

comrnunicat ing w i t h o t h e r s .

G a r f i n k e l and Goldbloom ( 1 9 8 8 ) e x p a n d e d the s p h e r e s of

i n f l u e n c e b e y o n d t h e f a r n i l y t o i n c l u d e t e a c h e r s , p e e r s , and

o t h e r s o c i e t a l f o r c e s (e.g., c u l t u r a l , media) . T h i s

perspect ive is in line with Erickson's ( 1 9 5 0 ) t h e o r y on

p e r s o n a l i t y d e v e l o p m e n t which emphasized t h e i m p o r t a n t

i n f l u e n c e o f d i f f e r e n t s o c i a l w o r l d s o n t h e p e r s o n (ci ted i n

B o o t z i n & A c o c e l l a , 1 9 8 8 ) . A c c o r d i n g t o E r i c k s o n r s t h e o r y ,

successful r e s o l u t i o n of c o n f l i c t s c o n f r o n t i n g t h e p e r s o n a t

d i f f e r e n t d e v e l o p m e n t a l stages ( L e - , trust v e r s u s m i s t r u s t

a n d autonomy v e r s u s shame a n d d o u b t ) is c r i t i c a l t o ego

i d e n t i t y f o r m a t i o n (c i ted i n B o o t z i n & A c o c e l l a , 1 9 8 8 ) .

S t u d y p a r t i c i p a n t s a p p e a r e d t o have n o t mastered t h e

c o r e d e v e l o p m e n t a l t a s k o f l e a r n i n g t o trust o r feel

c o r n f o r t a b l e with au tonomous e x i s t e n c e , a n d e n t e r e d t h e

o u t s i d e w o r l d m i s t r u s t f u l a b o u t s h a r i n g their t r u e selves

w i t h o t h e r s (e. g . , f r i e n d s , p e e r s , CO-workers ) .

I n s e c u r i t i e s and f e a r s of r e j e c t i o n became manifested as

" a f r a i d t o l o v e " o r " a f r a i d t o t r u s t " . Other a u t h o r s h a v e

l i n k e d f e a r s of l o s i n g p e r s o n a 1 c o n t r o l t o u n d e r l y i n g

f e e l i n g s o f h e l p l e s s n e s s a n d a s e n s e o f p e r s o n a 1 m i s t r u s t

(Bruch, 1973, 1977; G a r f i n k e l & Goldbloom, 1988; M u s c a r i ,

1 9 8 7 ; S a n t o p i n t o , 1988; S e l v i v i - P a l a z z o l i , 1974; T u r n e r ,

1990; Vari d e n Broucke , V a n d e r e y c k e n , & Vertommen, 1 9 9 5 ) .

T h e f u n d a m e n t a l p s y c h o p a t h o l o g y o f a n o r e x i a n e r v o s a

f r e q u e n t l y relates t o a n i n t e n s e d r i v e t o m a i n t a i n a s e n s e

o f s e l f - w o r t h t h r o u g h w e i g h t c o n t r o l . U l t i m a t e l y , f o r t h e

women i n t h i s s t u d y , self-esteem becamé h i g h l y bound t o

e x t e r n a l s t a n d a r d s (e. g . , b e a u t y , t h i n n e s s , s t r e n g t h ) i n

t h e i r s t r u g g l e t o f e e l g o o d a b o u t t h e m s e l v e s a n d g a i n

a c c e p t a n c e from o t h e r s . I n sorne i n s t a n c e s t h e s t r u g g l e f o r

c o n t r o l s t a r t e d w i t h a d i e t t h a t g o t o u t of c o n t r o l : "It

s t a r t e d o u t slowly as a d i e t . The way you a re s u p p o s e d t o

d i e t . " O t h e r a u t h o r s h a v e a l s o s u g g e s t e d t h a t t h e p u r s u i t

o f t h i n n e s s may beg in w i t h t h e i n n o c e n c e o f d i e t i n g t o

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improve oner s body image ( G a r n e r , 1993 ; Hsu, 1 9 9 0 ; Muscari,

1988; W i l l i a m s o n , 1990).

G a r f i n k e l a n d Goldbloom (1988) n o t e d t h a t when

e a g e r n e s s t o c o n f o r m t o e x t e r n a l s t a n d a r d s i s fueled by

d i c h o t o m o u s t h i n k i n g s t y l e , particular c u l t u r a l looks o r

images can be c a r r i e d t o a p a t h o l o g i c a l e x t r e r n e , Bruch

(1977) asserted t h a t t h e p e r s o n who chooses t o engage i n

d i e t a r y p r a c t i c e s is, i n t h i s i n s t a n c e , driven by a n x i e t y t o

p r o v e that s(he) has t h e a b i l i t y t o do it and t o d e r i v e some

benef its f rom d o i n g it (i .e., reduce anxiety, and f e e l good

a b o u t o n e s e l f a n d s u p e r i o r t o o t h e r s ) . The paradox is t h a t

t h e a n o r e t i c h a s learned t o feel good a b o u t t h e self while

b e i n g u n h e a l t h y .

Contzolling, Concealing and Consuming

T n e weakened se l f , s t r u g g l i n g f o r c o n t r o l t h r o u g h

restr ict ive b e h a v i o u r s , e v e n t u a l l y becarne controlled b y the

i l l n e s s . When these women e x p e r i e n c e d i n c r e a s e s i n o u t - o f -

c o n t r o l f e e l i n g s t a t e s , t h e i r o b s e s s i o n with r e s t r i c t i v e

b e h a v i o u r s intensified ( e . g . , laxatives, d i u r e t i c s ,

s t a r v a t i o n , and i n c r e a s e d e x e r c i s e h o u r s ) t o rid t h e body of

p e r c e i v e d excesses a n d regain c o n t r o l . S t i l l in denial t h a t

a n i l l n e s s existed, t h e y f o u g h t d e s p e r a t e l y t o c o n c e a l

restrictive measures but in so doing became consumed by

them. The popular concept of "the relentless p u r s u i t of

thinness" described by numerous authors embraces these three

themes (Bruch, 1977; Garfinkel & Garner, 1987; Garner, 1993;

Halmi, 1994; Santopinto, 1988; Staples & Schwartz, 1990;

Turner, 1 9 9 0 ) .

Unab le to achieve a true emotional connectedness with

another human being, to nurture the development of the self,

these women forged a bond with restrictive behaviours to

boost their s e n s e of self-worth. As the b ~ n d with the

illness solidified, it further eroded the weakened self,

enhanced fears and uncertainties about forming meaningful

relations with others, and left them devoid of a meaningful

existence. Santopintors (1988) concept of persistent

struggle describes the anorexic as struggling to achieve an

i dea l image (the not yet) whiie iosing the self (the now) to

the controlling illness. A second concept, withdrawinq-

engaging, views the anorexic as attempting to form relations

with others while hiding the true self.

As the mind and body became depleted of needed

nutrients, these women experienced physical problems and

altered thought processes (i-e., delusional regarding food

and body image). Overwhelmed with feelings of worthlessness

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and l i r n i t e d c o n t r o l a n d s e c u r i t y , t h e y f o u n d it i n c r e a s i n g l y

d i f f i c u l t t o d i s t i n g u i s h t h e rea l f rom t h e u n r e a l a n d ,

u l t i m a t e l y , l i ved i n f e a r o f l o s i n g t h e i r s e l v e s t o t h e

i l l n e s s . G a r n e r ( 1 9 9 3 ) noted that as i l l n e s s s e v e r i t y i s

enhanced by food d e p r i v a t i o n , c o g n i t i v e f u n c t i o n i n g and

t h o u g h t p r o c e s s e s become d e l u s i o n a l ( i . e . , d i s t o r t e d body

image) -

Readiness, Lettinq-go/Holdinq-on and Breaking

With regard t o t h e theme r e a d i n e s s t o c h a n g e , t h e women

i n t h i s s t u d y i n d i c a t e d t h a t u n l e s s t h e y f e l t r e a d y t o

change and were w i l l i n g t o s e e k h e l p , a l 1 e f f o r t s £rom

o t h e r s would be f u t i l e a n d even p u s h them f u r t h e r i n t o

restrictive b e h a v i o u r s . When it dawned o n them that o t h e r s

knew a b o u t t h e i r secret, t h e y o f t e n reacted angrily t o

â c c u s a t i o n s and becarne aaamant i n t h e i r refusal t o s e e k

he lp . S u p p o r t for t h e s e f i n d i n g s i s also f o u n d i n the

l i t e r a t u r e (Brcch, 1 9 7 7 ; MacDonald, 1 4 9 5 ; P a r k i n , 1 9 9 5 ;

S t a p l e s & S c h w a r t z , 1990 ; S t r a u s s , 1 9 9 5 ; Sut ton-Edmands ,

1 9 8 6 ) . Bruch (1 977) stressed the i m p o r t a n c e of a s s e s s i n g

t h e a n o r e x i c f s r e a d i n e s s t o c h a n g e b e f o r e p r o c e e d i n g w i t h

t h e r a p y b e c a u s e of t h e s t r o n g resistance p o t e n t i a l f r o m

fears o f d i s t r u s t and t h e n e e d t o blame o t h e r s .

115

T h e theme of l e t t i n g - g o w h i l e h o l d i n g - o n was d e s c r i b e d

by s t u d y p a r t i c i p a n t s a s recognizing the need for

p r o f e s s i o n a l h e l p w h i l e s t i l l be ing r e l u c t a n t t o a c t u a l l y do

so because of f e a r s and u n c e r t a i n t i e s a b o u t a f u t u r e w i t h o u t

r e s t r i c t i o n s . U l t i m a t e l y , t h e f o r g i n g o f a t r u s t i n g bond

w i t h a n o t h e r f a c i l i t a t e d t h e i r a c c e p t a n c e of t r e a t m e n t , and

t h e s u p p o r t and p u r p o s e for b r e a k i n g the c y c l e a n d s t a y i n g

o n t h e r o a d t o r e c o v e r y . The women i n t h e c u r r e n t s t u d y who

s t a y e d w i t h t r e a t m e n t perceived t h e t h e r a p i s t as a c a r i n g ,

c o m p a s s i o n a t e person who u n d e r s t o o d and a c c e p t e d them as a

p e r s o n . It a p p e a r s that a window o f o p p o r t u n i t y exists for

c l i n i c i a n s , e a r l y i n t r e a t m e n t , t o r e a c h o u t i n a c a r i n g

manner and connect w i t h these clients. It is also a p p a r e n t

t h a t t h e concep t of c o n n e c t e d n e s s i s c r i t i c a l t o t h e h e â l i n g

process. These f i n d i n g s are s u p p o r t e d b y Moreno, Fuhriman

2nd Hileman ( 1 9 9 5 ) who found that persons w i t 3 e a t i n g

d i s o r d e r s rated the e m o t i o n a l e x p e r i e n c e of c o n n e c t i n g w i t h

ô n o t h e r p e r s o n as t h e most s i g n i f i c a n t a n d m e a n i n g f u l a s p e c t

o f therapy.

W i t h i n t h e r a p e u t i c r e l a t i o n s h i p s , t h e s e women w e r e able

t o learn t o t r u s t t h e s e l f , by t r u s t i n g in o t h e r s who

empathized w i t h them and t r u l y heard t h e i r s t o r i e s , f e a r s ,

c o n c e r n s , a n d struggles. When r e l a t i o n s h i p s w i t h t h e r a p i s t s

116

were s e e n a s t r u e e q u a l i t a r i a n p a r t n e r s h i p s , t h e y were able

t o c o n f r o n t fears about b e i n g rejected and become more

c o m f o r t a b l e w i t h s h a r i n g t h e i r selves w i t h o t h e r s . The u s e

of t h e pronoun "we" t o d e s c r i b e i n t e r a c t i o n s w i t h t h e r a p i s t s

suggested that t h e s e women f e l t some c o n t r o l over t h e

h e a l i n g p r o c e s s . The impor t ance of e s t a b l i s h i n g h e a r t f e l t

c o n n e c t i o n s a n d collaborative work ing r e l a t i o n s w i t h

a n o r e x i c s during t h e r a p y is s u p p o r t e d by Yager ( 1 9 9 2 ) .

Wanlass ( 1 9 9 6 ) a l s o stressed t h e i m p o r t a n c e of e s t a b l i s h i n g

a s e n s e o f c o n n e c t e d n e s s among a n o r e x i c s participating i n

group therapy b e c a u s e of t h e i r p rob l ems w i t h s e l f - d i s c l o s u r e

a n d i n t e r p e r s o n a l d i s t r u s t .

T h e Essence

T h e Iived w o r l d of anorexia n e r v o s a , a s d e s c r i b e d by

the xomen i n t h i s s t u d y , was a s t r u g g l e t o find meaning i n

l i f e . T h e i r stories reflected f e e l i n g s o f r e j e c t i o n and

f a i l e d attempts t o truly c o n n e c t w i t h o t h e r s . Moore ( 1 9 9 7 )

stated t h a t : "Meaning is c e n t r a l t o life i n that it a l l o w s

humans t o make s e n s e o f t h e i r e x i s t e n c e i n t h e face of

a d v e r s i t y and chaos, or d u r i n g t i m e s of r e l a t i v e calm" ( p .

3 4 ) . T h e l i v e d w o r l d o f a n o r e x i a n e r v o s a , as d e s c r i b e d by

study participants, echoes empty, meaningless existence.

T h e p a i n from despair c o u l d be seen i n t h e i r f a c e s as they

described p e r i o d s o f not caring anymore and "want ing t h e

p a i n t o s t o p " . Fitzpatrick (1983) stated that: "Those who

have n o meaning do n o t continue to live" (p. 295). Frankl

(1984) d e s c r i b e d p e r s o n s domina ted by meaningless f e e l i n g s

a s having "enough t o live by but nothing t o l i v e for ; they

have t h e rneans b u t no meaning" (p . 1 6 5 ) . It i s clear f r o m t h i s study 's f i n d i n g s t h a t e f f o r t s

d i r e c t e d a t m o d i f y i n g l i f e s t y l e s , w i t h o u t a d d r e s s i n g t h e

unde r ly ing f o r c e s that p r o p e l t h e p e r s o n towards a n o r e x i a

nervosa, will n o t be e f f e c t i v e i n r e d u c i n g t h e s e v e r i t y o f

the i l l n e s s o r f a c i l i t a t i n g b r e a k i n g t h e c y c l e - When t h e s e

women came i n t o c o n t a c t wi th t h e h e a l t h care system, t h e

lack of c a r i n g and compassion f rom n u r s e s and o t h e r h e a l t h

c x e w o r k ê r s sêrved t o r e i n f o r c e f e e l i n g s of h e l p l e s s n e s s

and lack of p e r s o n a l control. These f i n d i n g s were s u p p o r t e d

b y Moore ( 1 9 9 7 ) who suggested n u r s e s need t o see t h e world

from t h e p e r s p e c t i v e of their c l i e n t s . Frankl (1984)

asserted t h a t when p e o p l e d i s c o v e r meaning, t h e y a r e

empowered t o r ise above t h e forces t h a t a t t e m p t t o c o n t r o l

t h e i r l i v e s . T h e most i m p o r t a n t t a s k facing t h e t h e r a p i s t

i s t o work on "broadening t h e visual f i e l d of t h e p a t i e n t so

that the whole spectrum of potential rneaning becomes

conscious and visible to him" (Frankl, 1984, p. 133) .

Revisiting the Meaninq of Health C a r e

Although the multidimensional components of anorexia

nervosa have been accepted by most clinicians and

researchers, reaching consensus on a unified treatment mode1

remains elusive (Conrad, Sloan, & Jedwabny, 1992; Halmi,

1994; Meades, 1993; Parkin, 1995). Study participants

viewed the approach to health care as lacking continuity and

often being iatrogenic (Le., negatively affecting the

trajectory of their illness) . Family physiclans, often the

gate-keepers, are overburdened and have limited expertise in

diagnosing eating disorders or providing a clear sense of

direction for clients and their families.

Becvar and Becvar ( 1 5 9 3 ) note that socialization of

children is the process by which one learns appropriate

behaviours and ways of thinking. Informa1 socialization

occurs within the family unit, while forma1 socialization

takes place within the school structure. In this study, al1

participants reaffirm the fact that anorexia nervosa 3 s a

complex, multidimensional disorder and that familial and

broader societal issues play a role in the o n s e t and

t r a j e c t o r y of t h e i l l n e s s . T h e s c h o o l env i ronment ,

t h e r e f o r e , i s a n ideal forum f o r p r o m o t i n g h e a l t h y l i v i n g .

T e a c h e r s ' and p a r e n t s ' attitudes on eating, d i e t i n g a n d

g e n d e r d i f f e r e n c e s a f f e c t and mould t h e c h i l d ' s v a l u e s ,

rnorals a n d p r i n c i p l e s .

S t u d y p a r t i c i p a n t s a l s o e m p h a s i z e d t h e n e e d t o

r e o r g â n i z e the c u r r e n t h e a l t h care d e l i v e r y sys tern i n o r d e r

t o meet t h e needs of p e r s o n s w i t h a n o r e x i a n e r v o s a a n d

c u r t a i l t h e s e l f - d e s t r u c t i v e effects of t h e i l l n e s s . H e a l t h

care workers must l o o k beyond t r a d i t i o n a l r o l e s t o address

broader f a m i l i a l a n d s o c i o c u l t u r a l i s s u e s , and be w i l l i n g t o

r e l i n q u i s h c o n t r o l a n d i n v o l v e c l i e n t s as a c t i v e a g e n t s i n

t h e i r own care. A l 1 o f t h e s e wornen i d e n t i f i e d a p p r o a c h e s

r e f l e c t i n g power s t r u g g l e s , s u c h as l a b e l l i n g a n d b l a m i n g ,

t o be c o u n t e r p r o d u c t i v e t o h e a l t h p r o m o t i o n . G r e m i l l i o n

( 1 9 9 2 ) â s s e r t e d t h a t t h e i d e o i o g y o f medicine r e a f f i r m s

power r e l a t i o n s h i p s by l a b e l l i n g , o r g a n i z i n g , a n d

c o n s t r u c t i n g " a n o r e x i a n e r v o s a a s a r e i f i e d and bounded

c o n d i t i o n t h a t is rernoved f rom c u l t u r a l i d e o l o g i e s a n d

p r o c e s s e s , as an i l l n e s s e n t i t y which c a n be g r a s p e d a n d

f ixed" ( p . 5 9 ) . T h i s s t u d y l e n d s s u p p o r t t o G r e m i l l i o n r s

work.

T h i s s t u d y r s f i n d i n g s a l s o s u p p o r t t h e i m p o r t a n c e o f

120

d i r e c t i n g health promotion and illness prevention e f f o r t s at

a l 1 age groups. The c u r r e n t emphasis on devising health

promotion programs for school-based populations (Childress,

B r e w e r t o n , Hodges, & Jar re l l , 1993; P a x t o n , 1993; Shisslak,

Crago, & N e a l , 1990) may well prove to be to be too narrow a

focus to curb the e s c a l a t i n g rates being observed across a l 1

age g r o u p s .

CHAPTER 6

Nursing Implications, Limitations and Summary

This studyfs findings have implications for n u r s i n g

education, practice and research, as well as for the total

health care delivery systern. In view of the present

economic realities, increased emphasis is being placed on

delivering cost-effective programs. While consumers have

been asked to assume greater responsibility for their health

status, they can also take a proactive role in articulating

their concerns about how governments are choosing to

allocate health care dollars.

Mental health care services have been considered the

poor cousin in health care, Consistently fewer dollars have

been allocated to mental health care than any other service

(Dellasega, 1991). As the prevalence of anorexia nervosa

anà otner eating disorders continue to rise, governments and

health care professionals have an ethical obligation to

explore alternative methods of providing cost-effective and

quality mental health services to address the specific needs

of this population.

This s t u d y ' s f i n d i n g s h i g h l i g h t e d t h e v a l u e t h a t

p a r t i c i p a n t s p l a c e d o n t h e c a r i n g , u n d e r s t a n d i n g and

c o m p a s s i o n a t e r o l e of health care p r o v i d e r s . T h e p r e s e n c e

o f s u c h a p e r s o n h e l p e d t h e m l e a r n t o t r u s t t h e m s e l v e s a n d

others. W i t h i n t h e c o n f i n e s o f a t r u s t i n g r e l a t i o n s h i p ,

these women f e l t s e c u r e enough t o challenge old c o p i n g

s t y l e s ( e - g . , res t r ic t ive b e h a v i o u r s ) a n d i n c o r p o r a t e new,

h e a l t h y b e h a v i o u r s i n t o t h e i r l i f e s t y l e s . U n f o r t u n a t e l y ,

none o f t h e p a r t i c i p a n t s i d e n t i f i e d n u r s e s as these special

p e r s o n s who h e l p e d t h e m d u r i n g t h e h e a l i n g p r o c e s s .

Where w a s n u r s i n g ? Anderson ( 1 9 9 5 ) described n u r s i n g

as a n " i n v i s i b l e " p r o f e s s i o n . She c h a l l e n g e s n u r s e s t o

work c o l l a b o r a t i v e l y i n d e l i n e a t i n g z role f o r n u r s i n g i n

health care r e f o r m a n d delivery . F u r t h e r , she recommends

that nurses form a u n i t e d v o i c e t h a t e c h o e s Our p r o f e s s i o n a l

o b l i g a t i o n t o p r o v i d e q u a l i t y c a r e t o c l i e n t s . O t h e r

nursing a u t h o r s a l so s u p p o r t t h i s p e r s p e c t i v e (McKay, 1993 ;

Stuart, 1 9 9 3 ) .

Nursinq Education

N u r s i n g e d u c a t o r s have the r e s p o n s i b i l i t y t o z d u c a t e

t h e i r s t u d e n t s a b o u t t h e meaning and i m p o r t a n c e o f

m a i n t a i n i n g a c a r i n g a t t i t u d e w h i l e p e r f o r m i n g d i v e r s e

r o l e s . S t u d e n t s m u s t d e v e l o p good l i s t e n i n g s k i l l s a n d

therapeutic ways of connecting w i t h t h e i r c l i e n t s .

E d u c a t o r s s h o u l d g i v e e q u a l weight t o i n t e r p e r s o n a l as well

as t e c h n i c a l c o m p e t e n c i e s i n f a c i l i t a t i n g t h e h e a l i n g

p r o c e s s . N u r s i n g e d u c a t o r s a r e c h a l l e n g e d t o d e v e l o p a n d

implernent a c u r r i c u l u m t o prepare s t u d e n t s t o meet t h e n e e d s

of d i v e r s e p o p u l a t i o n s i n a c h a n g i n g h e a l t h care system.

Dyer, H a m m i l l , Regan-Kubinsk i , Yur ick , and K o b e r t

(1997) present a new paradigm f o r d e l i v e r i n g c o s t e f f e c t i v e ,

c o m p r e h e n s i v e mental health care- These a u t h o r s d i s c u s s t h e

P s y c h i a t r i c - P r i m a r y Care N u r s e P r a c t i t i o n e r program a t t h e

U n i v e r s i t y o f P i t t s b u r g h which is designed t o e q u i p n u r s e s

w i t h t h e knowledge, s k i l l s a n d c o m p e t e n c i e s t o d e l i v e r

pr i rnary , s e c o n d a r y and t e r t i a r y m e n t a l h e a l t h care t o

p o p u l a t i o n s . This rnodel could be adapted t o m e e t t h e

e d u c a t i o n a l needs o f m e n t a l h e a l t h care n u r s e s which would

e n h a n c e t h e q u a l i t y o f care d e l i v e r y f o r t h e eating disorder

p o p u l a t i o n -

Nursing Practice

Numerous a u t h o r s have addressed t h e r o l e o f n u r s i n g

( p r i m a r y , s e c o n d a r y and t e r t i a r y ) i n t h e p r o v i s i o n and

124

management of h e a l t h care for c l i e n t s w i t h a n o r e x i a n e r v o s a

(Brown, 1991; Brown-Sanders , 1987; C a h i l l , 1994 ; Childress,

Brewerton, D e e r i n g , 1987; Conrad, Sloan, Jedwabny, 1 9 9 2 ;

Deer ing , N i z i o l e k , 1988; D i c k s t e i n , 1985; H a l r n i , 1994;

I r w i n , 1993; Lilly, Meades, 1993; Simmons, 1990 ; S o r d e l l i ,

F o s s a t i , D e v o t i , & L a V i o l a , 1 9 9 6 ) . D e s p i t e t h e i n c r e a s e d

emphas i s on e x p a n d i n g n u r s i n g r o l e s t o d i v e r s e s e t t i n g s ,

mos t p r a c t i c i n g n u r s e s i n m e n t a l h e a l t h are p r i m a r i l y

restricted t o i n - p a t i e n t u n i t s which are governed by t h e

medical mode1 of care.

Based on t h e l i t e r a t u r e a n d t h i s s t u d y ' s f i n d i n g s ,

there are specific r o l e s a n d s k i 1 l s wh ich d i n i c i a n s must

r n a s t e r i f they are t o be a c t i v e forces i n p r o m o t i n g t h e

h e a l t h s t a t u s of c l i e n t s w i t h a n o r e x i a n e r v o s a - F i r s t ,

n u r s e s mus t become aware of their a t t i t u d e s a n d beliefs

zibout t h i n n e s s , d i e t i n g , and eating b e n a v i o u r s . Second,

t h e y m u s t a c q u i r e the n e c e s s a r y knowledge a n d s k i l l s t o

p e r f o r m e f f e c t i v e c o u n s e l l i n g and d i a g n o s t i c a s s e s s r n e n t

( G a r n e r , 1993; Haller, 1992; Hsu, 1990; W i l l i a m s o n , 1 9 9 0 ) .

T h i r d , and most i m p o r t a n t l y , t h e y m u s t t a k e the t i m e t o

"get-to-know" t h e p o r s o n w i t h a n o r e x i a n e r v o s a .

S t u d y p a r t i c i p a n t s viewed h e a l t h care p r o f e s s i o n a l s a s

having l imi ted knowledge a b o u t a n o r e x i a nervosa a n d

inadequate counselling s k i l l s . Ethically and morally,

clients have the right to adequate health care services; and

professionals are ethically obligated to be cornpetent.

Nursing is very farniliar with the importance of gathering

data for an assessment - the first step in the nursing

process. The assessment must be individualized and directed

towards generating information about the problem, and the

person with the problem, in order to plan client-focused

care ( D i c k s t e i n , 1985) . Accurate and comprehensive

assessment of the illness and the usefulness of

interventions requires that clinîcians becorne thoroüghly

familiar with the core features of anorexia nervosa

(Garfinkel & Garner, 1982; Garner, 1993) . Ongoing

assessments and re-evaluations of client needs must occur

throughout the course of treatment, and c l i n i c i a n s rnust be

forever cognizant of the important sole tnat connectedness

plays (e . g . , sensitivity, compassion, interest and respect)

especially with anorexies, in promoting health status.

Santopinto (1988) indicated that nurses must foster a

sense of interconnectedness with al1 clients by "being

present" to the particular and u n i v e r s a l aspects of t h e

relentless d r i v e for thinness. I n the current study, al1

participants t a lked about the significant impact that

126

c o n n e c t i n g w i t h the self a n d o t h e r s h a d o n t h e outcome of

their i l l n e s s . These women e m p h a s i z e d that when a caring

a p p r o a c h w a s n o t p r e s e n t d u r i n g t h e r a p y , t h i s h a d a n e g a t i v e

i m p a c t on t h e i r h e a l t h s t a t u s .

S t u d y f i n d i n g s sugqest t h a t nurses n e e d t o r e v i s i t t h e

mean ing of n u r s i n g care. J e a n Watson (1989), i n k r t heory

of human care, asserted t h a t n u r s i n g has lost i t s a b i l î t y t o

care b e c a u s e of i t s o v e r i n d u l g e n c e w i t h t e c h n o l o g y . Study

p a r t i c i p a n t s d id n o t p e r c e i v e n u r s e s as c o m p a s s i o n a t e and

c a r i n g a s t h e y w e r e p e r c e i v e d t o be too b u s y with r o u t i n e .

Moore (1997) States: "When n u r s e s c a n m e e t p e o p l e i n t h e i r

e x p e r i e n c e o f pain and are w i l l i n g t o walk w i t h t h e m through

t h a t p a i n , i t opens t h e p o s s i b i l i t y for t h e t r a n s f o r m a t i v e

n a t u r e of caring t o b e g i n t o work a n d f o r a process of

c o n n e c t i o n " (p . 35) . These women t a l k e d a b o u t feeling

cornfortable i n an environment which p r o v i d e u u n c o n d i t i o n a l

a c c e p t a n c e , and s a f e t y a n d s e c u r i t y - n u r s i n g was not

m e n t i o n e d i n t h i s c o n t e x t .

Unified models f o r health promotion. P a r t i c i p a n t s i n

the current s t u d y a r t i c u l a t e d t h a t dieting a n d exercise

b e h a v i o u r s s tarted a t t h e o n s e t of a d o l e s c e n c e . Concerned

t h a t t h e i r body image f e l l s h o r t of the idea l , a n d

d e s p e r a t e l y w a n t i n g t o c o n n e c t and g a i n acceptance f r o m

peers, they embarked on a serious dieting and exercise

program. A l 1 participants talked about the importance of

building self-esteem at a very e a r l y age, and accepting

persona1 differences as uniqueness, rather than

imperfections.

Because of the declining age of onset of eating

disorders and the increasing prevalence in school-age

populations, community healtn nurses need to become more

proactive in planning and implementing health promotion

strategies that will help offset the escalating rates in

this population (Rosenfield, 1988) . Nursing must take a

leadership role in developing school based health promotion

and illness prevention programs. Critical to the efficacy

of these programs are collaborative efforts with other

disciplines, constant availability throughout the

i m p l e r n e n t a t i o n phase for consultâtion and counseiling, and

willingness to assume a pivotal role in program evaluation.

Gresko & Karlsen (1994) described the Norwegian program

for primary, secondary and tertiary prevention of eating

disorders. A comprehensive, collaborative approach,

involving al1 government departments, health care

professionals, educators and clients, was designed to combat

the rising incidence and prevalence of eating disorders in

128

t a r g e t e d p o p u l a t i o n s (e .go, s c h o o l s , a t h l e t i c s , etc) . T h i s

model p r o v i d e s a glirnrner o f hope f o r d e v e l o p i n g a u n i f i e d

h e a l t h p r o m o t i o n model t o address p r i m a r y , s e c o n d a r y and

tertiary l e v e l s of h e a l t h care d e l i v e r y f o r c l i e n t s w i t h

a n o r e x i a n e r v o s a and t h e i r f a m i l i e s . A s imi l a r p r e v e n t i o n

mode1 i n Canada i s t h e HUGS program (Ornichinski & H a r r i s o n ,

1 9 9 5 ) . T h i s p rogram f o c u s e s on h e a l t h y l i v i n g i n s c h o o l age

p o p u l a t i o n s . The goal is t o modify t h e p a t t e r n of t h i n k i n g

and b e h a v i o u r s cornrnonly l a b e l e d as t h e "diet m e n t a l i t y f ' .

T h i s r e s e a r c h e r e n v i s i o n s a c o m p r e h e n s i v e , s c h o o l

b a s e d , health p r o m o t i o n model f o r a n o r e x i a n e r v o s a which

reaches across al1 age, g e n d e r , and s o c i o c u l t u r a l b a r r i e r s .

A c o m p r e h e n s i v e program, therefore, s h o u l d i n c l u d e t h e

education o f c h i l d r e n , as w e l l as t h e i r f a m i l i e s and

t e a c h e r s . The program s h o u l d be d e v e l o p e d i n t h r e e p h a s e s ,

with each p h a s e b u i l d i n g on Knowiedge a t t a i n e d f r o m the

p r e v i o u s o n e . T h e c o n t e n t s h o u l d be age s p e c i f i c , a d d r e s s

a l 1 t h e f o r e m e n t i o n e d a s p e c t s o f h e a l t h y l i v i n g , a n d

emphasize s e l f - e s t e e m b u i l d i n g a n d p e r s o n a l r e s p o n s i b i l i t y

for m a i n t a i n i n g health.

F o r o p t i m a l effect, t h e p rogram s h o u l d be s u p p l e m e n t e d

w i t h l e a r n i n g a c t i v i t i e s , and e d u c a t i o n a l strategies ( i . e . ,

drama, m u s i c , f i l m , art, p o e t r y , etc. ) w h i c h s t i m u l a t e t h e

129

learning process (Porter, Morrell, & Moriarty, 1986) . The

potential health problerns - including health risks related

to dieting and the development of eating disorders (Le.,

anorexia nervosa) - need to be gently and persuasively

presented, but powerful in rendering its message. Such a

Learning plan would capture the interest and imagination of

young people, thereby enhancinq and entrenching awareness of

attitudes, beliefs and behaviours which constitute a healthy

lifestyle.

Nursinq Research

Based on this s t u d y r s findings, a number of suggestions

can be made for future research in the area of anorexia

nervosa. F i r s t , additional qualitative investigations into

the lived experience of anorexia nervosa, using participants

from vârious cultural ana socio-economic groups, are needea

to determine if others manifest comparable lived

experiences. Second, greater qualitative research efforts

are needed to further our understanding of the role thzt

society's emphasis on thinness actually plays in the onset

of eating disorders.

Third, qualitative inquiry is needed to investigate if

there is, in fact, a window of opportunity for timely

delivery of preventive health care services for perçons

susceptible to developing eating disorders. If such a

window does exist, it could prove to be crucial in altering

the high attrition rates of anorexia nervosa clients. Most

irnportantly, additional qualitative and quantitative

research is necessary to provide useful data to help design

appropriate and health promotion comprehensive programs.

Finally, research is required to identify the most

effective role for clinicians in facilitating positive

health outcomes for tnis target population. The concept of

emotional connectedness surfaced as an important force in

instigating and keeping study participants in therapy and on

the road to recovery. This concept certainly warrants

further research efforts .

Limitations

Recent research indicates that persons from al1

socioeconomic classes may be affected by anorexia nervosa

(Nasser, 1994; Leichner et al., 1986) . In this study,

participants were interviewed at various stages of the

illness. The effect of demographic data, especially in

terrns of martial status and viable births, on the outcome of

the trajectory of the illness requires future investigation.

13 1

Only women meet ing t h e DSM-IV c l a s s i f i c a t i o n f o r a n o r e x i a

nervosa a n d a s s o c i a t e d sub types w e r e recruited f o r t h i s

s t u d y . However, t h e m a j o r i t y of study p a r t i c i p a n t s were

diagnosed w i t h anorexia nervosa. Further r e s e a r c h e f f o r t s

a r e needed t o i n v e s t i g a t e t h e meaning of t h i s illness i n a

more r e p r e s e n t a t i v e group .

I n phenomenological r e s e a r c h , t h e n o t i o n of c r e d i b i l i t y

of the f i n d i n g s i s enhanced by t h e s e l e c t i o n of

participants. P a r t i c i p a n t s m u s t be able t o c l e a r l y

a r t i c u l a t e their l i v e d e x p e r i e n c e s i n o r d e r t o p r o v i d e r i c h

data. Consequent ly , s t u d y p a r t i c i p a n t s tend t o be t h e most

a r t i c u l a t e , a c c e s s i b l e , o r h i g h - s t a t u s members of t h e i r

group - a problem w h i c h Sandelowski ( 1 9 8 6 ) refers t o as

"elite bias" ( p . 32) . Because s t u d y p a r t i c i p a n t s w e r e

f a i r l y wel l -educa ted and i n v o l v e d i n c o u n s e l l i n g , t h e y were

p o s s i b l y zore i n t r o s p e c t i v e and s e l f - a n a l y t i c a l than women

with a s i m i l a r diagnosis but who have less e d u c a t i o n or n o t

a c t i v e l y involved i n group o r i n d i v i d u a l c o u n s e l l i n g .

Q u a l i t a t i v e r e s e a r c h findings s h o u l d never be

g e n e r a l i z e d . Al1 p a r t i c i p a n t s i n t h i s study were Caucas i an ,

and held careers i n fields which would i n d i c a t e possession

of pos t - secondary degrees o r diplornas. I t i s p o s s i b l e t h a t

women i n o t h e r cultures and £ r o m o t h e r socio-economic

classes would express the lived experience o f anorexia

nervosa i n a d i f f e r e n t voice.

sunaaary

This phenomenological study on the lived experience of

a n o r e x i a nervosa used van Manen's (1994) method of analysis

to explore the question: What is the rneaning of the l i v e d

experience of anorexia nervosa? From t h e data collected in

two unstructured interviews w i t h each of the six

participants, eight themes were identified as: the weakened

self, a struggle for control, controlled by the illness,

concealing the true self, feeling consumed, readiness to

change, letting-go while holding-on, and breaking the cycle.

From the themes, the essence of the lived world of persons

with anorexia nervosa i s seen as a persistent struggle t o

f i n d meaning i n iife.

The findings were discussed in light of the current

body of knowledge on anorexia nervosa and provided new

meanings for health care delivery for c l i e n t s and their

families. Implications for nursing education, research, and

practice were presented as w e 1 1 a s the limitations r,f the

study.

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be thin: A survey of anoretic and bulimic syrnptoms in a

non-referred adolescent population. Psychological

Medicine, 19, 143-163.

Wilfley, D. E., & Grilo C. M. (1994) . Eating disorders: A

women's health problem in p r i m a r y care. Nurse

Practitioner Forum, 5 (1) , 34-45 . Williamson, D. (1990). Assessment of e a t i n g disorders. New

York: Pergamon Press, Inc. - p p p p p p p p p p p p p p p p - - - - - - - - - - - - - -

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Wilson, G. T. (1993). 3elation of dietïng and v o i u n t a r y

weight loss to psychological functioning and b i n g e

eating. Annals of I n t e r n a 1 Medicine, 1 1 9 (7), 727-730.

Yager, J. (1992) . Patients with chronic, recalcitrant

eating disorders. In J. Yager, H. E. Gwirtsman, & C.

K. Edelstein (Eds.), Special problems in managing

eating disorders (pp. 205-231) . Washington, DC:

American Psychiatric Press.

APPENDIX A

Consent Form

School of Nussing Memorial University of Newf oundland, St. John's, Newfoundland, A1V 3V6

Consent to Participate in Nursing Research

T i t l e : The L i v e d Experience of Anorexia Nervosa: A Phenomenological Study

Investigator: Lorraine Murphy Telephone: 334-2042

You have been asked to participate in a research study. Participation in this study is entirely voluntary. You rnay decide not to participate or may withdraw from the study at any time without affecting your normal treatrnent.

Confidentiality of information concerning participants will be maintained by the investigator. The investigator will be available during the study at a l 1 times should you have any problems or questions about the study.

Purpose of the Study: The purpose of this study is to explore and describe the lived experience of Anorexia Nervosa. By gaining an understanding of the things that are important to help you deal with this illness, the quality of care to other Anorexies may be improved.

Description of Procedures: pYmsrcp bsïng a s k e a to- - - - - -

p p p p p - - - - - -

participate in two interviews which will be conducted at a time and place that is convenient for you. Interviews will be audiotaped (with your permission), During the first interview you will be asked to reflect upon your experiences with anorexia nervosa and share any thoughts and feelings that you recall about it. In addition you will be asked to indicate what you find rnost helpful and least helpful about the medical/nursing care that you have received. During the second interview you will be asked to read a written summary of major themes identified from the text of your first interview, confirm whether it accurately reflects your experiences with anorexia and medical/nursing care, and provide any information that you consider important for c l a r i f y i n g your experiences.

Duration of Participation: Each i n t e r v i e w w i l l l a s t a p p r o x i m a t e l y 60 t o 90 m i n u t e s . B o t h i n t e r v i e w s s h o u l d be cornple ted w i t h i n f o u r rnonths.

Foreseeable Risks, Discomforts, or Inconveniences: There are no e x p e c t e d r i s k s f r o m p a r t i c i p a t i n g i n t h i s s t u d y . It is p o s s i b l e that c e r t a i n i n t e r v i e w q u e s t i o n s rnay e l i c i t u n c o m f o r t a b l e m e m o r i e s . I f you f i n d t h a t any q u e s t i o n s make you f e e l u n c o m f o r t a b l e a b o u t d i s c l o s i n g a n y d i s t u r b i n g o r p a i n f u l memories a s s o c i a t e d w i t h t h i s e x p e r i e n c e , you rnay r e f u s e t o a n s w e r t h e m . You rnay t e r m i n a t e t h e i n t e r v i e w a t any t i m e , a s w e l l as y o u r p a r t i c i p a t i o n i n t h i s s t u d y . T h e r e s e a r c h e r rnay also t e r m i n a t e t h e i n t e r v i e w a n d refer you back t o y o u r p s y c h i a t r i s t i f s h e d e t e r m i n e s t h a t you c o u l d b e n e f i t f rom a d d i t i o n a l c o u n s e l l i n g s e r v i c e s .

Al1 i n f o r m a t i o n that you p r o v i d e w i l l be k e p t s t r i c t l y c o n f i d e n t i a l , s e c u r e d i n a l o c k e d f i l e , and accessible o n l y t o t h e p r i n c i p l e i n v e s t i g a t o r and t h e s i s s u p e r v i s o r . Your name w i l l n o t appear o n t h e a u d i o t a p e o r w r i t t e n copy.

Benef i ts of Paxticipation: You w i l l h a v e an o p p o r t u n i t y to e x p r e s s y o u r f e e l i n g s a n d d i s c u s s y o u r e x p e r i e n c e w i t h a n i n t e r e s t e d l i s t e n e r . A l though you rnay n o t b e n e f i t d i r e c t l y from t h i s s t u d y , y o u r p a r t i c i p a t i o n rnay p r o v i d e n u r s e s and o t h e r h e a l t h care p r o f e s s i o n a l s w i t h h e l p f u l knowledge t o improve t h e q u a l i t y of care f o r p e r s o n s w i t h a n o r e x i a nervosa.

Other Information: F i n d i n g s of t h i s s t u d y w i l l be made a v a i l a b l e t o you a n d h e a l t h c a r e p r o f e s s i o n a l s upon r e q u e s t . Study f i n d i n g s w i l l be p u b l i s h e d b u t you w i l l n o t be i d e n t i f i e d . If you h a v e a n y c o n c e r n s a b o u t t h e s t u d y a f t e r r e f l e c t i n g upon the i n t e r v i e w c o n v e r s a t i o n , the i n v e s t i g a t o r w i l l be a v a i l a b l e a t a l 1 t i m e s t o address a n y q u e s t i o n s o r c o n c e r n s t h a t you may h a v e a b o u t y o u r c o n t i n u e d p a r t i c i p a t i o n .

Your signature on this form indicates tha t you have understood to your satisfaction the information regarding your participation in the research project and agree to participate as a subject. In no w a y does this waive your legal rights nor release the investigator, sponsors, or involved institutions f r o m their legal and professional responsibilities .

1 r the undersigned, agree to my participation in the research study described.

Any questions have been answered and 1 understand what is involved in the study. 1 reolize that participation is voluntary and there is no guarantee that 1 w i l l benefit from my involvement. 1 acknowledge t h a t a copy of t h i s form has b e e n given to m e .

(Signature of Participant) (Date)

( S i g n a t u r e of Witness) (Date)

1 r the undersigned, agree to be audiotaped during each interview.

( S i g n a t u r e of Witness) (Date)

To the best of my ability, 1 have fully explained to the subject the nature of this research study. 1 have invited questions and provided answers. I believe that the subject f u l l y understands the implications and voluntary nature of the study.

(Signature of Investiqator) (Date)

APPENDIX B

Interview Schedule

Interview Schedule

I n t r o d u c t o r y commentary:

1 a m interested i n your e x p e r i e n c e w i t h Anorexia Nervosa. 1 would l i k e f o r you t o t a k e some time t o r e f l ec t upon y o u r e x p e r i e n c e and t e l l m e i n your own words what i t is l i k e t o l i v e w i t h Anorex ia Nervosa. You rnay share a n y thoughts and feelings a b o u t your illness and /o r t h e quality o f m e d i c a l / n u r s i n g care that you have r e c e i v e d . F o e 1 free t o t a l k about wha teve r cornes t o your mind. A t tintes, 1 may a s k a f e w q u e s t i o n s , j u s t t o help you describe you r e x p e r i e n c e t o the best of your a b i l i t y .

Examples of P r o b e s / Q u e s t i o n s t o F a c i l i t a t e t h e I n t e r v i e w

1. T e l l me about y o u r average day, l i v i n g with a n o r e x i a nervosa .

2 . When d id you f i r s t r e a l i z e t h a t you may have a n o r e x i a ne rvosa?

3 - R e f l e c t i n g back can you remernber a n y t h i n g , i n p a r t i c u l a r , that would t r i g g e r the onset of your illness?

4 . What aspects of your treatrnent do you f i n d most h e l p f u l / l e a s t h e l p f u l ?

5 . Can you rernember âny p a r t i c u i a r tning and/or p e r s o n that led you t o s e e k help?

6 . How do you cope w i t h Anorex ia? What h e l p s ? What does not help?

7 . How do you see people who try t o h e l p you? (e.g., f a m i l y , f r i e n d s )

8 . Are there any other t h o u g h t s o r cornrnents that you would like t o share w i t h me abou t your experience w i t h a n o r e x i a nervosa?

APPENDIX C

Approval from Human Investigation Cornittee

University of Newfoundland

Human Investigation Cornmittee Rescarch and Graduate Studics Faculty of Medicine The Hcalth Sciences Centre

Ms. bflaiL1e M q h y CIO DT. Christine Way School of Nursiag

Dear Ms. Murphy:

This wi l l acknowledge receipt of your correspondence dated Thxernber 17,1996, wherein you cl- issues and provide a revised consent form for the research application entitled 'The Uved Experience of A n o d a Nervosa: A Phenomenologld Studp.

At a meeting held on January 16, 1997, the Human Investigation Committee granted full approval of this research study.

We take this opprtunity to wish you every success with your research study.

cc Dr. KM.W. Keough, Vice-President, Research Dr. Eric Parsons, Vice-President, Medical SeMces, HCC

St. John's. NF. Canada A1 B 3V6 Tel.: (709) 737-6974 Fax: (7091 737-5033

Universiv of Newfoundland

Office of Rtsearch and Graduatc Studics (Medicine) FacuIty of Medicine The Hcalth Sciences Centre

1997 O 1 17

TO: Ms. hrraine Mwphy

FRO1M= Dr. Vema M. Skanes, Assistant Dean Research & Graduate Studies (Medicine)

S m : &plication to the H m In . U-ee - #96.138 vesb

The Human Investigation Cornmittee of the Fadty of Medicine has reviewed your proposal for the study entitled @#The Lived Experienee of Anorexîa Nenosa: A Phenomenologicril Study'.

Fuli approval has been granted for one year, £rom point of view of ethicr as d e h e d in the terms of reference of this Faculty Cornmittee.

For a hospital-based study, it is your responsibilitv to seek aecessan w~roval h* (hg th Care Cornration of St. John S.

Notwithstanding the approvai of the HIC, the primary responsibility for the ethical condua of the investigation remains with you.

Vema M. ~kanea ~ h . 0 . Assisîant Dean

cc Dr. K.M.W. Keough, Vice-President, Research Dr. Eric Parsons, Vice-President, Medical Services, HCC

Sc. John's. NF, Canada .UB 3V6 -Tel.: 1709) 737-6762 -Fax: (7091 737-5033 memail: rgs @ morgan. ucs.rnun.ca

APPENDTX D

Approval from Research Cornmittee

February 26, 1997

Ms. Lorra ine Murphy Community Mental Aeal th Nurse Kings County clinic Valley M e n t a l Health Services

Dear Ms. Murphy,

On behalf of t h e Research Committee, Valley Menta l Hea i th services, I w a n t to i n f o r m you that the research proposal The Livsd Experience of Anorexia Nervosa: A ~henornenolosical Studv has been approved as submitted w i t h the revisions requested.

Pleass accept Our best The cornmittee asks t h a t you once completed fo r Our reco update the Committee every of the project.

Yours t r u l y ,

w i s h e s submit

rds. As six mont

.'] - Peter Kief L) C h a i r n-,, r i i e 5 ~ ~ 3 ; . ~ ~ ~ L ~ ~ t ~ ~ ~ Valley M e n t a l Health exv vices Western ~egionaï Aealth Board

in t h e work on your project . a f i n a l report of the project well, we would ask t h a t you hs on the progress and sta tus

APPENDZX E

Approval f rom P s y c h i a t r i s t s

St- Clare's Mercy Hospital LeMarchant Road

164 h

SL John's. Newfoundland ( Canada A l C 508 Phone (709) 778-3 1 1 f Fax (709) 7384080

Sept. 17, 1996

To Whom It May Concem:

Re: Lorraine Muiphy Box 87, Mobile AOA 3A0

This is to certi@ that Lorraine Murphy has my support for the proposed study, the lived experience of Anorexia Nervosa; A Phenomenological Approach.

Once you have received ethical approval fkom HIC at Mernorial University of Newfoundland, 1 will facilitate the identification of suitable clients meeting the inclusion criteria for physical and mental competency.

Yours sincereiy,

Dr. %@Pd D.A. Ma aug in,F.RCP.C.

OWNED AND OPERATED BY THE CONGREGATION OF THE SISTERS OF MERCY

Corporation of St. John's

May 23, 1996

Ms. Lorraine Murphy, BN, RN P.O. B o x 87 Mobile, NF AOA 3A0

Dear Lorraine:

Your proposed study IlThe Lived Experience of Anorexia Nervosa: A ~henomenological Studytq was discussed at the departmental meeting of the Psychiatry Department of the Health Sciences Centre on May 22 , 1996. 1 am pleased to advise you that you have the support of the entire department including my colleagues, Drs. Nurse, Doucet, OtLoughlin and myself, for your proposed study. Once you have received ethical approval from the Human Investigations Cornmit tee of Mernorial University and The General Hospital , w e w i l l facilitate i d e n t i f i c a t i o n of sui table clients meeting the inclusion criteria for physical and mental cornpetence.

Yours s cerely,

r"\ / .

D . V . ~xkg, Site ~ h i e f Health - - - - - - - -

General Hospital Hcalth Scienccs Centre, 300 Pnncc Philip Drive. Sr. John's, Scn-hundbnd, Canada h l B 3V6 Tel. i7091737-6300 F u (709)737-6400

May, 1996

Dr . T. CantweU Medical Director, Waterford Hospital S t. John's, Newfoundland

P.O. Box 87 Mobile, NF AOA 3A0

D e a r Lorraine:

You have my support for the proposed study, "The Lived Experience of Anorexia Nervosa: A f henomenological Study." Upon receiving ethical approval from the Human Investigations Cornmittee, Mernorial University, if the need arises, 1 agree t o serve as an independent consultant to evaluate the competency level of possible participants for your study.

W i t h regards to participation in a research s tudy of this nature, 1 would evaluate competency in the folîowing manner: 1) degree of insight that these women have into their illness, Le., aware of illness, and accepts the need to participate in treatment programs; 2) understands t h e purpose of the s tudy and expectations/responsibiLities regarding their participation; and, 3) aware of the voluntary nature of their participation a n d the right to withdraw from the study at a n y time.

APPENDIX F

Approval f r o m Prograrn Managers and D i v i s i o n Directors

Corporation of St. John's 1997 02 06

TO: Dr. C. Way

FROM: Eric R Parsons, MD,CCFP,

SUBJECT: Research Proposal

Your research proposal HIC # 96.138 - The Lived Experience of Anorexia Nervosa: a Phenomenological Approachn has been considered by the Research Proposd Approval Cornmittee (RPAC) of the Hedth Care Corporation of St. John's at their most recent meeting.

The cornmittee has approved your proposal to be conducteci at the General , Waterforci & St. Clare's Sites within the Health Care Corporation of St. John's. This approval is contingent on the appropriate funding being provided and continued throughout the project and on the provision of regular progress reports at least amuaily to the RPAC Cornmittee.

ERIC R. PARSONS, MD,CCFP, Vice-President, Medicai Services

EREVsh C.C. Linda Purchase, Research Centre

General Hospital Hcdth Sciences Centre, 300 Prince Philip Drive, St. John's, Nc\\-foundland, Canada AIB 3LT6 Tcl. (709)737-6300 Fa.. (709)737-6400

8

September 15, 1996

Coiieen Simms Program Director, Mental Health Heaith Care Corporation S t. JO hn's, NewfoundIand

P.O. Box 87 Mobile, NF AOA 3A0

This is to certify that you have my support for the proposed study, "The Lived Experience of Anorexia Nervosa: A Phenomenological Study." Once you have received ethical approval fkom the Human Investigations Committee, Memonal University, 1 will facilitate identification of suitable clients meeting the inclusion criteria for physical and mental wmpetency.

i i r i r ~ v ~ L V ~ \ L U M I I W I Y

TEST TARGET (QA-3)

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