The Lived Experience of Anorexia Nervosa: A Phenomenological Study by Lorraine Marie King-Murphy Thesis submitted to the School of Graduate Studies in partial fulfilment of the requirements for the degree of Master of Nursing School of Nursing Mernorial University of Newfoundland St . John' s, Newfoundland July 14, 1997
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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
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,
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
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
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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 -
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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
105
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
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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
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)
APPLIED IMAGE. lnc 5 1653 East Main Street - -. - - Rochester. NY 14609 USA -- -- - - Phone: 71 W82-0300 -- -- - - Fax: il 6/28â-5989