Eating Disorders

Guilt, Food, and Control- Three Women's Experience with

Eating Disorders

by

CIBeverleyJ.Antle,B.S.W.

A thesissubmittedin partial fulfillment ofthe requirementsforthedegreeof

Master of Social Work

St.John's

Schoolof SocialWork MemorialUniversityof Newfoundland

February, 1990

Newfoundland

1.1

Theauthorhasgranted an ltrevocab'enon- .>«:luslvelicenoe_theNalionalUbnlly ofCanadatoreprodooe,ban. distriluteorseI copiesofhlsIher thesis byanymeans andIn any formorformat,makingttis thesisavaIable

to Interested~: •

The author retainsownefShipoftheoopyrighl in his/her thesis.Neitherililt! thesisllOf subs tantial extracts fromIt maybeprinted or otherwise reproducedwithouth1s1herper- mission.

l'8UtetKaaooord~unalicenceIrr8vocabIeet non exclusiVepermettMt ..IaBlbGoth6Que nationaleduCanadadereproduk'e.prAter. dlslrlbuef00 _ des- . .desa tMse dequelque manl«o atSOlISquelquetonne quecosoil pourmettrs deselCemp&airesde cene theseA.tadisJX)Sltiondespersonnes lnt<!ressees.

l'ElUteuroonseNetaproprietedu dn::Mt d'auteur quiprotegesa these.NiIatMse nldeseldJ'ajls substantielsdeceue-cr ne doivent Atrs ImprimAs ou autrementreprodults sans son autorisation.

I5BM 0-315-65307-B

ABSTRACT

Eating disordershave emerged overthelast decade as a serioushealth and socialproblem.Thechallenge in understandingthe developmentalprocesses for eatingdisordersis in movingpast the strangeand fascinating behaviour.The literature pointsto three constellationsof factors as significant in the emergence of eating disorders.Theseare: socio-culturalnorms andexpectations, family composition and relationships,and personal characteristics.

Thisstudyexploresthreewomen' s experiences with theemergenceand treatment ofan eatingdisorder.Thestudyexamines. through themedium of in-depthpersonalhistories,thelifeand treatmentexperiences of womenwho had been diagnosed ashaving anorexianervosa.bulimiaaervosa, or both.

The data analysisattemptsto bring together the collective wisdomof the existingliteratureand theinformation providedbythewomenin thisstudy.

Therewas agreat dealofconsistencybetweenthe participant'sstorieswith respectto theirobsessionsandritualsrelated to body shape,weight,and controlof eating.Theanalysisrevealedthattheeating disorderissymbolic of moredeep-seatedemotionalproblems.Familyexperiences and socio-cultural pressurestowardsthinnesswerealso seenas significantfactors.

Theseissues arefurther analyzed to developan understandingof theroleof socialworkin thetreatmentofeatingdisorders.Considerationis giventothe directionsindicated forthe development of earlyintervention strategies.

\

ACKNOWL EDGEMENT S

Iwouldliketo thankmy fundingsource,the Schoolof GraduateStudies,for awarding a fellowshipwhichhelpedme to studyon a full time basis.

I wouldliketothank Dr.Ross Kleinfor his time.encouragement,and critical analysis;as well as hisbeliefinmyability10 completethis thesisin the time frameIhad set.I wouldalso liketo thank ProfessorMarjory Campbell for her critiqueof the sectionon famitytherapy theory.

I wouldlike to acknowledgetheencouragementofferedbyDr.Hawkinsand Dr.Kimberleyto pursue graduatestudies.

Finally,1 wouldlike to thankTom, and our familiesand friends,whoalways knew whenIneededmoralsupport.

LIST OF TABLES

SocioculturalFactors... ...97

n Familyfactors... . ... .... .. . ...99

m

TABLE OF CONTENTS

ABSTRACT •••• •••••••••• •• • • • • • •• • •• ••1

ACKNOWLEDGEMENTS • . . . .. .•. .•. .•. . . .n LIST OF TABLES • • • •••• • • • • ••••• •••• • •••UI INTRODUCTION•••••• • •• •••••• ••••• ••• ••1 PROBLEMSTATEMENT • • • •••• • • •• ••••••• • ••2 RESEARCHQUESTION•• • ••• •••••••••••• •• •.7 LITERATURE REVIEW • • • • ••••• •• •••••••• ••9 Socio-CulturalNormsand Expectations.•••••••..•.•••9 FamilyComposition and Relationships ••••• •.•.• •.•• 22 FamilyModels: An Illustration . ... • •.... .•• • . ••26 Summary ••• • • •••••••••••••• • ••• ••• •32 RESEARCH MEI11000WGY •• •••• • ••••••••• • 34 OperationalizationofConceptsandVariables • •.••.• •• •.34 DataCollection .•. .. ..•.•.••• • •••.•• .••42 Population .•.•. .• • • . . •.•.•••• •.• •.••43 Data Analysis . .•.. .... ..• •. •. .• •. ••46 EthicalIssues.•• .•. . . .•.•••.••.••• •.•• 47 Pre-Test ••.•••. ... •..••.•••••. •••••50 DATA COLLECTION ••••• ••••••••• • •••••• • 51 Anne-"Foodhasalways bcen aweapon"••..••••.•••• •54 Ca1nie--"Foodistheenemy" ...•.•••••• •••.•• 6S Dianne-"Foodislikeanaddiction" •••• • .••• • •.•. • •79

DATAANALYSIS ••••• • • • • • • • • • ••• • • • • • ••114 A.ComparativeDiscussionofEachWoman'sStory and the Variables Identifiedin the Literature •• .•.••••. • • ••••••.94 B.A Reconsiderationof the Dataand the Knowledge and ConceptsDrawn from theLiterature• .••• •.•••• •• .•• ••.•• •109 C.Examinationof theIssues for SocialWorkPractice• .••••116 CONCWSIONS ANDRECOMMENDATIONS •••• ••••• 120 Implications.•• ••••. ..• ••.•.••••.. ••. 122 Recommendations •.•• • . .••. ••• ••• •.••.. 124 Limitations •. . .. . ••. • .••• •. • ••.••• •. 126 APPENDIXA ••• ••••• •••••••• ••• •••••• 127 APPENDIXB •••••••••• • ••• • •••• ••• •• • 134 BmLIOGRAPIIY ••••• • ••••••••••• •• ••• •136

"Andso the younganorexicwascaughtin a cruel trap.She refusedtoeat in order10preserveher personalidentity,but in order to preserveher life she had toeat,andthis sheexperiencedasanactof self betrayal...

HildeBruch (ascitedin Selevini-PaIauoli,l974,p. 65)

INTROOUCTION

Eatingis essential to tife.Eatingis alsoaritualthathas meaningbeyond meetingaphysicalneed and is associatedwithcomfort,caringandsocializing.

Feeding is infactthe first form of contactbetween aparentand a child,andis viewedas integraltothe developmentoftheir emotional bonds.

Disorderedeating,suchas anorexianervosaandbulimianervosa,has emerged over the pastdecadeas both a serioushealthand social problem.Female adolescentsappeartobemost vulnerableto developingeating disorders. At a time when manynaturalbodychangesare occurring,adolescentswitheating disordersbecometotallyfocused on body size.They appearto connect self-worthto aregimented and often destructivecontrol of eating. Giventhe manychanges that are seenas normalduringadolescence,the ritualsofeating disorderscan be easilymissedor overlooked by familiesand professionals.

Participation inthe treatmentof eatingdisorderspresents a uniquechallengeto the socialwork profession.The debilitating, seeminglyself-imposed,and potentiallylifethreateningnatureof anorexiaand bulimia,often leave the socialworkerfeelingtremendouslyinadequate. Howeverthe profession's strengthliesin workingwith individualsin the contextof theirfamily and community.If anorexia and bulimiaareviewedasrepresenting an inadequate copingmechanism inthe contextof a dysfunctional family,then socialwork intervention shouldbe seen as integralto treatment. Giventhis, an increased understandingofeatingdisordersfroma socialwork perspective is necessary toprovidemore meaningfulintervention.

Thisstudyisconcernedwithexaminingthefactorsthat are associatedwith the development of eatingdisorders.Itisqualitativein natureand will explore the lifeexperiencesand perceptionsof womenwith an eating disorder.This enrichedunderstanding of theclient's perceptionsof the developmentalprocess foranorexiaandbulimia,willenablesocial workers to be better equippedto detecttheseconditionsandintervene moreeffectively.

The issues tobeaddressed are:

The specificindividual,family,andsoclc-cultural factors associated with thedevelopmentof anorexiaand bulimia,

The activities, behaviours andfamilyconditionsthatareassociatedthe development ofanorexiaandbulimia.

The individual's perceptions of thedevelopmentandtreatmentof hereating disorder.

Theseissues willbefurther analyzedtodevelopan understandingof theroleof social work in the treatmentofeating disorders. Consideration willbegivento thedirectionsindicatedfor the developmentof .:arly interventionstrategies.

Problem Statement

This study exploreseatingdisorders andthe factorsassociatedwith their development.Anorexianervcsa and bulimia nervosawiltbeof primary interest.They representtwoofthefourdiagnosticcategoriesofeating disorderspresented in theDiagnosticandStatisticalManual/orMenial Disorders(DSMIII - R).Theother twocategories are picaand rumination.

Picaispersistenteatingofnonnulritivesubstancesandis^$CCtIprimarilyin childhood.Ruminationispersistentchewingandisseen primarilyininfancy. (Goldman,1988).

TheDSMm⁴Ristherocognized standard forpsychiatricdiagnosisinNorth America. Acco rd ing IDGoldman(198 8)theDSMm~Rdiagnosticcriteriafor anorexianervosaare:

I.Refusaltomaintainbody weightwithresultingweightlossbetow IS% of normalfor ageandheight.

2.Anintensefear of gaining weightand becoming fat.

3.Adisturbanceintheperceptionofbodysizeandshape.

4.Infemales,missio~alleast threeconsecutivemenstrualcycles,for which thereisnoother organiccause.

Thediagnosticcriteriaforbulimianervosaare:

I.Recurrentepisodes ofbinge eating,which isdescribedaJrapid consumption of foodinadiscreteperiodoftime.

2.A minimumaverageof two bingeepisodesa week, for atleastthree months.

3.Afeelingof beingoutofcontrol whenovereatingduringabingingepisode.

4.Regularly engagingineitherself-inducedvomiting,use of laxativesor diuretics, strictdieting,fasting or vigorousexercisetoloseweight.

5.Persistentoverconcernwithbodyweight and shape.(Goldman,1988)

Elementsof anorexia and bulimia nervosaseem closelyrelateddespitethe separatediagnosticcategories;for examplebothdemonstrate:anoverconc:em withbodysbe,foodandweight.FurthermorestudieshaveshownthatthereiJ ortenoverlapbetweenthetwo disorders.Themostcommonpresentationisthe development of bulimianervosafo1lo".vingan establishedanorexicperiod.

Caspeo,Eckert, Halmi,Goldberg,and Davis(1980) (as citedinOarke,Parr and Castelli. 1988)revealedthat 415oftheanorexicsthey studied became bulimic.However the conversehasnot beenfound.Itisrareforanorexiato besecondary10bulimianervosa.

This suggeststhat there maybe commonissuesinthe developmentalprocesses foranorexia and bulimia nervosa.This is mostevidentinthesocio-cultural andfamilyissues,whichare particularlysignificanttoasocialwork perspective. Inthis studytheissuesrelatedtothedevelopmentofboth anore xiaandbulimia nervosawillbeexamined. Thischoicebowev-r,isnot intended to diminishtheworkofrecentauthorswho haveest.1blishedbulimia nervosaasauniqueclinicalentity.(Rootetat.,1986;Pope!tHudson,1984)

Sincetheexplorationoftheseissues mayconceivablybedirectedtowards enhancing earlyinterventionortowardsenhancingprevention,itisimportantto establisha focus ofstudy.Theliteraturerevieweddoesnotrd dressthe efficacyof eitherdirection.Theliterature primarilyfocuses XIdlscussicnof incidencerates for eating disorders, clinical symptoms andtreatments,and the impressionsof clinicians(Bruch,1978: Emmett,1985: Lachenmeyer&.

Mti~i-Brander,1988;Liebman,Sargent&Silver,1983;Root,Falonand Freiderich,1986).

Whileoneis drawntothepreventiondirection,afocusOQearly intervention maybemore~fulconsideringNewfoondlandanditsneeds.ibisconctusaon is basedon a recognition that thereis littlegenttalawarenessofeating disordersinNewfoundland.Inaddition, thereis00recognizedtreatment centrewithintheProvince.Treatmentintervention appearstobefragmented andisprimarily offeredbyprofessionalswhohavedevdopcdaspecialin~

ineatingdisorders.TheprtsefllievelofservicedevelopmentinNe\li1foundland suggestsaneedfor theenhancementof strategiesforearlyinterventionrather thanprevention.

Anorexiaandbulimianervosaare viewedasmulti-determinedconditions.

Threefactors are seenasmostsignificant inthedevelopmentofanorexiaand bulimianervosa. Theseare:(a) socio-culturalnorms,(b)familycomposition andrelationships, and(c)personalcharacteristics(Bruch,1978;EmmeU,198S;

Gamer,Garfmkel,Schwaru&Thompson,1980;Kincy, 1984; Kog&

Vancle~ben,1985; Lachcnmcyer&Muni-Brander,IS88;LiebllWletal, 1983;Minuchin&Baker, 1978;Rootetal,1986;Selevini·PaIano1i,1974).

Sincethisstudyisintendedto enhancetheunderstandingoreatingl:!isorders from a socialworkperspective,whichas previouslyidentified focusesonthe individual and family inthe centeatof acommunity,theassociation of each of thesethreefactorswillbeexamined.

A finalconsiderationis the relevanceofthiskindofstudy.The life threatening anddebilitatingnature of eatingdisorders.formsa convincing motivationforfurtherinvestigation. Howevercriticismhasbeenraisedthat anorexiaandbulimia nervosa onlyaffecta proportionatelysmall numberof

peopleand that researchefforts maybebetterdirectedtowardstreatmentof, forexample,obesity(Brone andFisher,1988).

Two factors that servetodispel thiscriticismare:

1.There hasbeenadramaticincreaseof theoverallincidenceof eating disorders in thepast decade. WhilenoCanadianstatistics havebeen reportedin the literaturereviewed,Jones and coworkers(1980)reportedon asurveyin Monroe County,NewYork, which founda400% increasein the numberofnewcasesof anorexianervosain femaleswhencomparing the period1970-1976 with 1960-1969(ascited inGoldman, 1988).

Furthermore,recentsurveysof non-clinicalcollegeand high school populations indicateamorewidespreadincidenceofsub-clinical disordered eating.lachenmeyerandMuni-Brader(1988)reportincidencerates of 59-79% in females and3049%inmales.Thisis significantlyhigher than previous reports fromclinicalpopulationswhich indicate a4.4-15% rate for both malesand females (Lachenmeyer and Muni-Brader,1988).

2. Afurther examination ofthesurveysreportedbyLachenmeyer and Muni-Brader(1988) revealthat the proportion of males withsub-clinical disorderedeatingis significantlyhigherthan previously thought. In addition,thelower socio-econcmlcgroups in theirsurveydemonstrated incidencerates comparablewiththose fromahighersocio-economicgroup.

The onlysignificantdifference between thesegroupswas that those of higher socio-economicstatuswere more likely toreportuseof dietpills and

diuretics,whilethosefrom thelowergroupweremorelikelytoreport bingeeating.

There isnoway torelate suchincreasestotheCanadianor Newfoundland experienceasthere are no pP valencestatistics presentlyavaila.:;le(National EatingDisorderInformation Centre [NEDICl,1988).However.these statistics supportthe subjective reportsinthe literatureoftheincreasing prevalence ofanorexiaand bulimianervosa(Broneet al,1988;

Laschenmeyeretal,1988).

Research Question

Thisstudyaddressestwo questions.What are the socio-cultural, familial,and personal factors associatedwiththeemergenceof anorexianervosaandbulimia nervosa? Howmightan increased understandingof thesefactorsfromthe client'sperspective contributeto thedevelopment of earlyintervention strategiesforsocial workers?

These questionsformthe direction for research.The studyisqualitativein natureandexplores,throughthe medium of personal histories, the lifeand treatmentexperiencesofyoung women whohavebeentreated foranorexia nervosa, bulimia nervosa,orboth.Theexplorationof these factorsisintended toenhanceandenrichourunderstanding of theperceptionsof theeating disorderedperson.

Datagatheredfrom a reviewof the literatureis analyzedand comparedwith thecollectiveperceptionsof the eatingdisorderedindividuals.This data is then further examinedtodevelopdirectionsforsocialworkintervention.

LITERATUREREVIEW

Anorexiaand bulim'anervosa are seenas multi-detenninedconditions. When the factorsassociatedwith anorexia and bulimianervosa are examined,the literatureconsistently highlightsthreedirections.Theseare:(a) soclo-culturat nonnsandexpectations,(b)familycomposition andrelationships,and(c) personalcharacteristicsoftheindividualswhodevelopeating disorders.Each ofthesedirectionswillbe discussed separatelyinthetextthatfollows.

Socio·Cult uralNorms andExpect atio ns

Authorsexamining theculturalnormsin reference 10eatingdisordersfocus mainlyon the socialization of women.The twomostconsistentthemesthat emerge are: (a) exaggeratedemphasis011women'sbodyshape and weight,with a particularpromotionof thinness.and(b)socialization of womenlobepassive and to deferto anextemal locusof control (Chemin.1981; Garner,Garfinkel

&Irvine, 1986;Hirschmann&zaphiropolous,1985;Orbach, 1986;Rootet ai,1986;Selvini-Palazzoli ,1974,Sours, 1980).

Garnerand hiscolleagues (1980)maintainthereare culturalpressures for womentobethinnerandto diet. To demonstratethistheychosetoreview the changesin weightovera 20 year span for Miss America contestantsand Playboycenterfolds;twogroupsthey felt symbolicallyrepresented!beideal woman.Their reviewof womenin Playboycenterfoldsshowed a steady decreaseover timein bustand hipsize with a concurrenttrendtowardsgreater height. The idealizedbodyshapefor womenchanged tobeleaner andmore evenly proportioned.

Gamerand hiscolleagues(1980) reviewofthe MissAmericaPageantrevealed thatthepageant wInnerswere more likelytoweighsignirlcantlylessthan other contestants.Furthermore,theaverageweightof all ofthecontestants over the12 yearspandroppedby11% •The lowestweightwas seeninthe lastyearsurveyed (1978) andwas12%lowerthantheactuarialaverageweight for women atthat time.Since the diagnostic criteria foranorexiaisIS%below the averageweight,thisrepresentation of the symbolicallyideal womanisvery closetobeinganorexic.

Associated withthisphenomenon is theculturalemphasisondieting, particularly amongwomen.Areview of six women' s magazinesrevealed that atotalof 467articlesondietinghadbeenpublishedbetween1959and1979.

The average number of articleshadincreasedbyover 56%inthesecond decadeofthisreview (Gameret ai,1980).This escalationinthe promotionof dietingis furtherhighlightedby the workofChemin (1981). Sheexamineda number of books publishedondieting. ShefoundIhat jusl lhree titles had collectively soldoverfivehundred andeighty million (580,000,000) copies.

Rootandher colleagues(1986)also foundthatsomeofthediets published advocatepurgingbehaviour,which isassociatedwith bulimianervosa.They report on TheBeverlyHillsDict(Mazel,1981ascitedin Root etal,1986) which isbasedon theauthor's strugglewithweight control throughtheuseof diuretics,dietpillsand starvation.

Morerecentlythis focus ondietinghas shifted toincludeaconcurrent promotionoffitness.Particularemphasisis giventotheimportanceof fitness

in a healthy lifestyle. Ironically.studies haveshown that mild to moderately overweight womenhave nohighermortalityrates than those who are thinner.

Infact,women in the highestand lowest 20%of weightdisttihution were reportedto havegreatermortalityrates~~"'lierand Garfinkel,1985).

These factors becomeparticularly significant whenviewedin the contextofthe literature on eating disorders.Dietingisconsistently citedasbeingassociated with the developmentof both anorexiaand bulimianervosa. (Garneret al, 1986: Hirschmanandlaphiropolous,1985;Rootet al, 1986:Sours, 1980)In addition, vigorous over-exerciseis oneof thediagnostic criteria for both anorexia and bulimianervosa.Furthermore,Hawkins,Raymond,Fremoun, Witllams,&Clement(1984) havefounda positive correlationbetweendietary restraint and the binge eatingthat is associatedwith bulimianervosa.

Paradoxically,thispromotion of thinness is contrary toa paralleltrendfor the average NorthAmericanwoman tobeheavierbecauseof improvednutrition.

The stresscreated bythis disparity betweenculturalideals for thewoman's .bodyandactual norms,isfelt tofurther contribute to thedevelopmentof

extreme responses inorder to attainthinness (Gameret al,1980).

The second cultural factoridentifiedisthe socialization ofwomen 10be passive and todefer to an externallocus ofcontrol. Thisfactorbecomesan important consideration asthedevelopmentofeating disordershasalsobeen associated with anattempt toimpose control overlifeevents (Orbach,1986;

SeIivini-Paiazzoli,1974:Selevini-Palazzoli&Viaro,1988;Rootet al,1986; Sours, 1980).

Rootand her colleagues(1986)indicate that socialization encourageswomento believethatpowerrests intheirbeautyandkindness.TheySlatethat this socializationbeginsearlyand is evidencedinfairy tales suchasCinderellaand SnowloWlife,andis later perpetuatedinadult romance novelsandsoapoperas.

Thequalities that are promotedasfeminineare: nurturing,self-sacrificing, delicate,small,and helpless.

Orbach(1986)reinforcestheassertionsof Rootand her colleagues(1986).She see that eatingdisorders(her work focusedon anorexia)mustbe understoodin a sociallhistorica1 context,Shestatesthat throughoutWesternhistorya woman'sbodyhas beenbothan object andsymbol of beauty.A beautiful womanconfersan additionalstatustoher malepartner.Orbach further asserts that a woman'ssenseof identityhascometo be deeplyenmeshedwithher view of herselfasanattractiveperson,andof herbodyas an objectwith which to negotiatein the world. Womenhavethuscome to define themselvesin terms of theirbody shapeand its influence onothers,

Contrary to the traditionalroleof womentoachieve self satisfaction by living throughand forothers,thereisanincreasing trendfor womento pursue non-traditional careers and lifestyles.Womenwho havebeen socializedto maintaintraditionalqualities,nowmost competein a maledominatedcareer world that demandsincreasedindependence, assertivenessand achievement. The autonomyrequiredto competein these non-traditional careers is

incongruent withthesociali:zationof womenand culturaldefinitionsof femininity(Orbach,1986;Wells.1977, as citedinRootet al, 1986).

Theparadoxof theseconflictingmessagesisembodiedin a recentmagazine articleentitledBreastFrellZ'j(1988. December). Thearticle reportedthat an estimated average of$168-$374 million is spent annuallyon breast augmentationintheUnited States. North.Americanwomenweremorelikely toproceedwiththissurgerydespite significant health risks,whencompared withSwedishwoman. The article presented that thechoice of breast augmentationwas in fact a reflectionofwomen'spersonaland financial freedom.

Onemustquesti on though,how large breastshave cometobeconnected to self satisfaction.Itappears that the culturalprescriptionsfor the femaleshape remainintricately intertwinedwiththeissueof de ferring controltoothers.In thisexampleof breastaugmentation Dr. MarciaHuchlnson (1988, December) maintains that women are in factM. . .substituting masteryoveronepartof theirbodiesformastery overtheirselfimagesand theirIives"(p.89)Thisis analogoustothesearch for controlbythe eatingdisorderedperson.

Theliteraturepays very little attentiontothe impact ofcultural normson men.

Rootand hercolleagues(1986)proposethat menare socializeddifferentlythan women in that a man'sself-worthis more connectedwith occupationand financial status. Theymaintain thatbody sizeandweight willhave fewer implications for achievementinthese areas.

Despitethis assertion wehaveseenthattheemergenceof eating disordersin menis increasing.Recentsurveysoftheeatingpatternsof collegestudents showedthat the incidenceof sub-clinical disorderedeatingemceg menhas increased.Statisticsfor men rangedbetween30-49%andwhile this isstill lowerlhanthe rates forwomen inthe samesurvey group, thenumbers representasignificantportionofthemale population (Lachenmeyerand Munl-Brader,1988).

Of furthersignificance isrecent researchby TumbulJ,Freeman,Barryand Annadale(1987), whichshowed that presentstandardizedquestionnairesmay notbeeffectivein identifying maleswitheatingdisorders.Theyfoundthatof thefivemenbeingtreated for moderate-severebulimia nervosa,none would havebeen identifiedby presentrecognized scales(EAT,EDI -Gamer&

Garfinkel,1983: BITE-Henderson&Freeman,1987). Theyproposethat these questionnaireswere developedbasedon femalepopulation and thus do not reflect thespecialexpressionofeating disordersin males.

At presenttheassociation betweensocio-eulturalnorm sand men,inthe developmentof eating disordershas not beenestablished.Itisrecognized thoughthat asthe roles of womenchange10non-traditi onal fields, aconcurrent changemayalso occuramongmales.Thesechangesmay affectthe impactof socio-culturalnorms ondevelopmentofeatingdisordersin men.

Personal Characteristics

Despitethe uniquediagnostic categoriesforanorexia andbulimianervosa,the literature reportscertain personal characteristics which appear tobecommonto

bothdisorders. The personalcharacteristicsreported herewillreflectthe qualitiesmostfrequentlyreportedin theliterature, and are broaderin scope thanthe DSM- m ·R criteria (Bryant·Waugh,Knibbs,Fossen, Kaminski&

Ll'sk,1988;Goldman, 1988; Hirshman&2aphiropolous,1985; Minuchin&

Baker,1918;Root etal,1986;Selevini-Palazaoll, 1914; Sours, 1980).

Thereportedcharacteristicsassociated withbothanorexiaand bulimianervosa fallinto fourbroad categories: (a) personaldemographies,(b) personal history,(c)eating habits,and (d) distortions ofbodyperception. Eachof these categorieswillbediscussedin greaterdetail in the text that follows.

Personal Demographics

Therearetwofactors related to personaldemographics:sexandage.While datafromnon-clinicalpopulationsshowthat thenumber of malesare at risk of developingeating disorders is increasing significantlymorefemalesare diagnosedwilheating disordersthan males (Goldman,1988;Lachenmeyer&

Muni-Brander,1988; Rootet ai,1986).

Adolescentsappear tobeat greatest risk,allhough the averageageof onset differsfor anorexiaandbulimia. Anorexia is morelikelyto develop in early adolescence,whilebulimiais morecommon in thelate teens,earlytwenties agegroup.

Personal History

The (actorsrelatedto personalhistoryare: highachievement,depression.and sexualvictimization.

A hislOry of expresseddesire (orhigh achievement, and a concernaboutthe attitudeof otherstowardspel-.ulachievement, havebeenassociatedwith eatingdisorders. Goldman(1988)reports Ihattheseindividualsdemonstrate perfectionlsuc tendencies. good academic achievement. andactive involvement in esua-curriculer activities.

Somehave postulatedthatthis desireforhigh achievement is more an expressionof concern abouttheview of others.particularlyparents.than actual desirefor achievement. This is reinforcedby Bruch(1978) who maintains that theadolescent'spleasing "superperfectlon"is in facta mask that servesto hide aninner misery. These positionsmaybeindirectly supportedby theresearch of Szumukler,Berkowitz,Eisler,Leff&Dare (1987) on expressedemotionin families of anorexicdaughters.Their observations revea led that thenumberof criticalcommentsbytheparentswerehighertowards the anorexicdaughter thanina controlgroup.Furthermorethesecriticalcommentswere more evidentwhen thedaughterwas present,thanwhenthe parentswereinterviewed alone.

A historyof depressionis often associatedwith bothanorexiaand bulimia nervcsa. Popeand Hudson(1984)have reportedon a double-blindcontrolled clinicaltrialofimipramine, an anti-depressantdrug,in the treatmentorbulimia nervosa. Their results revealthatthe drugwas successfulin reducingthe binge

eatingepisodes by 70%.Itisfelt thatthe anti-depressant qualitiesofthedrug werethemostsignificant factors,as there wasa concurrent50%improvement in depressivesymptomsduringthe clinicaltrial.

Chronictensionhasbeenrelatedtodepression,and hasbeen demonstratedto behigherin bulimicwomenwhen comparedto controlgroups.(Butterfield&

leClair, 1988).Depressionandchronic tensionhavealsobeen also relatedto thedesirefor highachievement. Cattenachand Rodin(1988) foundthat the bulimicwomenthey interviewed had setimpossiblyhighstandards for themselves.Thewomen reportedfeeling tenseand depressedwhentheydid notachievetheseunrealistic goals.

Sexualvictimization hasmore recentlybeenassociatedwith eatingdisorders. Rootandher colleagues (1986)report that73%of the bulimicstheytreated had sufferedat least onevictimizationexperience,ofteninchildhood. This informationisfurthersupportedby theworkofOppenheimer,Howells, Palmer, andChaloner(1985) inwhichover66%ofeatingdisorderedpatients theystudied reportedan adverse sexualexperience. Approximately80%

reportedthat theseevents occurredinchildhood.

EatingHabits

Therearesixfactorsrelatedtoeatinghabits. Theseare:dieting, obsession withfood,ritualizationoffoodpreparation, binging,purging.andfear of overeating.

Ahistory ofdieting has been associatedwith the onsetofbothanorexiaand bulimianervose.Itisfelt that adolescentsare particularlyvulnerable giventhe normal sensitivityabout personalappearancethatis associated with this developmentalphase.The positivereinforcementreceivedfor weightloss is felt to furthercontributeto the progressiveobsessionwithdietingactivities (Garneret aI, 1986; Hirschmanand zaphlropolcus,1985:Rootet aI,1986;

Sours.1980).

Individualswitheatingdisorderswill often be obsessedwithfood eventhough they severelyrestrict its intake. This may be evidencedin a passionate interest in buying foodand preparing meals,and then refusingto eat.

Anorexicsare reportedto becomevery ritualisticboth inthe preparation and consumptionof the smallportionsof food they do eat. This may be evidenced in the meticulousarrangementoffood on the plate,or inthe compulsive attention to the order in which food must be consumed.During adolescence these obsessionswithfood and the rituals of eating can be dismissedby parents as teenage fads.

For bulimics,eating habits also involveepisodesofbinging.Clinical diagnosrlcdescriptions of binging whichrefer to eating large amountsoffood in a shortperiodof time.do not impart an appreciationof theseverity of this problem.Drs. Goldbloomand Garfinkel (1988, September)ofthe Toronto General Hospital have providedthis frame of reference. Theystale that ina bingingepisode a personmay consumeup to 6000calories in one hour.This is equivalentto the caloric intake of one person forthree days.

Purgingbehaviouris associatedwithboth bulimiaandsevereanorexia,andcan have very seriousphysiological side effects.Purgingnot onlyinvolves self-induced vomiting,but can extendto excessiveuse of laxativesand diuretics,as wellascompulsive over-exercise.Anexampledrawn from personalclinicalexperienceinvolves a younganorexicwhowas takingupto36 laxativesa day.Hermedicaltreatment foranorexia waspromptedby an admissionfor severedehydration.Shehad beensecretly abusinglaxativesfor severalmonthsandwasreluctant to revealthis onadmission for dehydration.

Anorexicsandbulimics also experienceafearof eatingtoo much.Bulimics particularlyfeelout-of-control and fear binging.Itisfelt thatthis fear maybe related to aninability torecognize the physiologicalcuesofhunger,leavingthe person feelingunable torely oninternalcontrols (Rootet 31,1986, Selevini -Palazozli, 1974).

Almost all ofthe behaviours described in this section havebeenreportedin associationwithstarvation(Goldman1988,NEore,1988). Gamerand Garfinkel (l985)alsoreported onthe Minnesotaprojectcarriedout by Keys, Brozek, Henschel, Mikelsen,&Taylor,(1950). Theystudiedtheeffectsof inducedstarvationon36normalweightandhealthymales. Theirstudy revealedthatwhentheircaloric intake wasreducedbyhalf,the men experiencedobsession withfood,foodpreparationrituals,hinging despitethe diet,and increasedexperiencesofhunger. In additon,the menreported disturbancesinemotional,cognitive, andsocial functioning.

Distortions of Body Perception

There are three factorsassociated with distortions ofbodyperception. These are:(a) lack of recognition of the physical manifestations of hunger.(b) distortion of perception of body image,and (c)misperception of the influence of body shape on interpersonalrelationships.

Eating disorders are oftenconnected with an apparent inabilitytorecognize the physiological manifestations of hunger. Selevini-Palazwli (1974) maintains this inabilitytorecognize hunger stemsfrom an early reinforcementtoignore the body's cues. She states that the childisthen not abletorely on his/her own body sensations without feeling out of control.

She presents the following schema tic of thisprocess:

need

I

signal emittedbythe child

I

non satisfaction of that need

I

naming of another needbythe parent impoaitlonI

I

confused conceptualizationbythe child of body stimuli

This conceptualizationis further supported by the work of Hirschman and laphiropolous (1985).They state that parents should only feed their children based on their childrens' reports of hunger andsatiation. They see this "feed on demand" schedule as thebaseline for raising childrenwhowillnot have food or weight problem.

Individuals with eatingdisordersalso have an exaggerated concern withbody size and weight.This maybeevidencedinstrong over-reactionstocomments aboutbodysizeor diet,and/orinastrongdenialof any weightlossproblem whenconfrontedwith such a concern.In anorexia.thisis also associated with a grossmisperception of bodyshape andweight, often with specificemphasis on the sizeoftheir hipsand thighs.

Althoughnot directlyidentifiedin the literaturereviewed,relatedtothis phenomenonisa mlspercepttcnof the influenceofbodyshapeon inter-personal relationshipsor career achievements.Bodyshapeappearsto be perceivedas the over-ridingfactorin allaspects of life.Thiscommentfroman anorexic youngwoman,drawnfromclinicalexperience, servesasan example; ..Ifmy thighswereonlytwoand a half(21/2)inchessmallermy bosswouldnot have becomeupsetwithme today."If onerefers backtothediscussionof cultural influences,it mightbe arguedthatthis phenomenon isan extremeexpressionof thesocialization ofwomen 10believe that powerrestsin their beauty.

FamilVCom position andRelati onships

The familyis a powerfulforce inthetransmissionof socio-culturalnorms.

Throughthisfunctionitcanbeexpectedtohavea significantinfluenceon the developmentof eatingdisorders.Theliteraturealso referstotherelationships withinfamiliesas connected10 theemergenceof an eatingdisorder.Thetwo mostsignificant issuesarefamilycomposition, andfamily relationships (Goldstein,1984;Kog&Vandereycken, 1985;Liebmanelal,1983;Minuchin

&Baker,1978; Selevini-Palazzoli,1974 ;Rootet al,1986).

Factorsrelatedtofamilycomposition are:(a)socio-economic stalUS,(b) incidenceof weightproblems in immediate familymembers,and (c)incidence of physicalillness,depression andalcoholabusein immediatefamilymembers. Factorsrelatedto familyrelationshipsare:(a) enmeshment,(b) overprotectiveness,(c)rigidity,(d)triangulation,and (e) chronictension.

FamJ1yComposit io n

Socio-economic status hasbeen correlated withthe presenceof an eating disorder.KayandVandereycken (1985)in theirreviewofthe research literature reportedthat upper class familieshave beenconsistently over-representedineating disordertreatmentpopulations.Thisassociation mustbeviewed in lightofrecentresearchthathas shownthat lower socio-economic groupsare increasinglyrepresentedin non-clinicalpopulations (Lachenmeyer and Munl-Brader,1988).

Koyand Vandereycken(1985) also revealedan associationbetweenthe presenceof an eatingdisorder and incidenceof weightcontrol andeating problems in immediatefamily members. Obesityhasbeen mosthighly associated with parentsofbulimics, ascomparedwithanorexics. Strober, Morrell, Burroughs,Salkin andJacobs (1985) in a controlledstudy of anorexic familiesreportedthatthe incidence of eatingdisordersin first and second degreerelativeswassignificantly higher thananon-eatingdisordered psychiatricpopulation.Strober also reported onthe work of Gershonand his colleagues,(1983)who showedthat eatingdisorders were 6 times higherin firstdegree relativesof anorexics, thanin acontrolgroup.

Kay and Vandereycken(1985) further reportedan associationbetweenme presenceof physical illness, depressionor alcoholabuse in immediatefamily membersand eatingdisorders. This Is supportedby the work of Rootand her colleagues(1986). They presenta familymodelin whichsubstanceabuseand depressionare apartof the familydynamicsconnectedto the developmentof eating disorders. Root's proposalwillbe discussed in greater detail in the followingsection on familyrelationships.

Family Relationships

Minuchinand Baker (1978) have studiedextensivelythe patternsof interaction in families where the child has a psychosomatic illness,includinganorexia.

Minuchinand his colleaguesin treatingthese families refer to the familyas a system. The conceptsof familyinteractionused for this study are derived from a systemticconceptualization and thereforeof the family, the basic tenantsof the structural familytherapy model will be presentedas a backgroundto the discussionof the pertinentfamilyinteractionpatterns (Hoffman1981;

Minuchin&Baker, 1978;&Minuchin&Fishman 1981 Root etal, 1986).

These are:

1.The family is an open system, which is constantlychangingduetointernal and external forces.

2.There is a structureor set of regulatorycodes which affectsthe patternsof interaction both insideand outsidethe family. These codes are generated

from values, religion ,laws,philosoph y,and political ideology, and combinetocreate the unique personalityof thefamily.

3.TIlefamily system isdynamic.Individu al familymemberswill attemptto maintain homeostasisor stabilitywithi n the familysystem.Theseshifts will havebothadaptiveandmaladaptive conseq uences for the family.

4. The familymaintainsa hiera rchalstru cture, with the parental and spousal sub-system ina gove rningposition over thechild and sibling sub-system s.

Family theoristsmaintain thatthedifferentiation producedby the normal parent/childhierarch ical structureisnecessarytothehealthy functioning of the familysystem,

5,The familywillmovethrough a seriesof developmentalstageswhichwill resul t in the family members havingto createnewskillstomatchthe grow th ofitsmembers .

The famil yrelationshipvariablesmost associated with eatingdisord ersare:

enmeshment , overprctective nese, rigidity,triangulati on ,and chronic tension.

These variableswillfirst bediscussedinterms of family therapy theory.The postulatedconnec tionof thesefacto rstothedevelopm entofeating disorders willthen be illustrated usingRoot's (1986)threeconceptualmodels of eating disordered familiesas aframe ofreference ,

Enmeshment isunderstoo d inthecontex t of familycohesion. Cohesionis definedasthe emotional bonds that existbetween familymembersand the degreeto whichan individual experiencespersonal autonomy.In enmeshed

familiesthere are very close emotionalbondsbetween familymembers. Of most significancein eatingdisordersaretheemotionalbondsthatcross generationalboundaries and lead to littledifferentiationof needsandemotions betweenparentandchild.Enmeshment oftendisruptsthe normalhierarchical structureof the family.

Overproteettreness is reflectedinthe parents'overemphasisonthefamilyto theexclusionofthose outsidethefamily.Itis relatedtoenmeshmentin that personal boundaries betweenfamilymembersarepoorly defined. Membersof thefamily tend to definethemselvesin referencetotheneedsofotherfamily members.There is a resultingpoorpersonaldifferentiationandautonomy, whichleadsthe individualtoonly feetcompleteinthefamilycontext. Family loyaltywillmore likelysupersedeindividual needs.

Rigidityrefersto aninflexibility in thefamily system.This maybeexpressed instringent rulesfor conflictresolution andforindividualbehaviour,orin an equallystrict unwillingnessto recognizethe needfor conflictresolution andlor role expectations.Either constructreflects an inabilityof the familysystemto adapt tothe changing needs of itsmembers.

Triangulationrefers to a process wherebyathirdpersonisdrawn in to help reducetheconflict betweentwo people.Whiletriangulation maybenormal andhealthy,itcan becomedestructive when family members developarigid pattern of triangular interaction.Tr.;mgulatlon forthepurposesofthis study refers toacoalitionor covertalliancewhichcrosses generational lines. Often neitherthepatents nor the childis consciouslyawareofthisprocess,however

thechildexperiencesanxiety and concernfor the maritalrelationship and alternating feelingsof powerand helplessness. Closelyallied withthe conceptsofenmeshment,overprctect lvenessand triangulationisthronIc tension.Thisisasubjective experience and referstothe presenceofconstant worryor anxiety.Thesefeelingsarefelt tobea reflectionofan overallsense of powerlessness, which is embodied inthe family's inabilitytoresolveconflict ortoallowdevelopmentofpersonalautonomy.

Family Models:AnlJIustratlon

Rootand her colleagues (1986)haveproposed threeconceptualmodelsof familieswith eating disorders.They are:(a)the perfectfamily,(b)the overprotective family,and(c)the chaotic family.Models(a)and(b)are associated withboth anorexia and bulimianervosa. Model(c) ismosthighly associatedwithbulimianervosa.Thesemodelswin bepresentedin the text that follows.Emphasiswill beplacedon furtherexplicatingthe family interactionvariables justdescribed,aswellashighlightingthe postulated functionof the eatingdisorder within thefamily.Each familymodelwillbe describedusingthecategories of boundaries,identity,emotional expression, end powerlessness.

The PerfectFamilyItA Job WorthDoingIs WorthDoing Well"

Theperfectfamilypresentsin aclinicalsituationaseager,attentiveand seeking the "perfecttherapy".Cliniciansreportasense ofunrealityaboutfamily

members,describingthem as"plastic", "robots", "ever-smiling"(Rootet 01,1986).

Boundaries:Whilethe external representationofthefamilyrelationships appearsharmonious,the boundariesbetween familymembersare rigidlyset.

Emphasisis givento the"right" wayto behave. EnmeshmentexistsamongaU familymembers,but is mostevidentinthemotherand the eatingdisordered.

child.Itisfeltthat the enmeshmentrepresents the parents'desiretoprotect theirchild frommistakes and to ensurethe child makesthe"right..decisions.

Jd'-nJiry:The identity ofthe familyissetby the perceptionsof others. rather thanpersonalvaluesand feelings.Emphasisison theexternalandthe search for therightway. Thisrigiditycreateschronictensionandlackofstability.

EmOlloflOlExpression:Familymembersarereinforcedtoalwaysseek the positivein problem situations.Familyloyaltydemandsthat painandconflict besuppressedordealtwithin waysthatareprescribedby rigidfamily rules.

Triangulationbecomes a safe wayto diffusetension.

Powerlessness:The powerin perfectfamilies is often unevenlydistributed, with thefatherholding mostof therealpower.Thereisalsoa rigid prescriptionfor decision-making whichlimits thedevelopmentof personal autonomy,particularlyfor the femalechildren. Althoughmatechildrenmay experience a"false"autonomycreatedby therigidrole expectationsfor men.

Functions of the Eating Disorder:The Perfect Family

1MPerfectRebellion:The illnessprovidesa legitimateway to breakthefamily rules.This is particularly true for bulimicswho oftencarryout bingingand purgingbehaviourin private.

Boundaries:The eating disorderbecomesa way(;fcreatingdistancefromother familymembersand of creatingpersonalspace.

Emotional expression: Anger, pain,guilt, and frustrationare all emotionsnot permitted in the perfect family.Theeatingdisorderprovidesa focusand outlet forlheseemotions.

Au/onomy: The eating disorderprovidesa mechanismfor completepersonal controland delineationof personalidentity.Itfundamenlally reflectsthe underlying powerstrugglewithinthe family.

The Overprotective Family"All For One and One For All"

The overprotective familypresentsina clinical situationas surprisedby the problem.The parentsexpress howmuchthisdiscoveryhas hurt them.The personwith theeating disorderis represented,and indeedappears, much youngerthan her age.

Boundaries:There is very little senseof separation betweenfamilymembers.

Enmeshmentis observedprimarilybetweenthe motherand the eating disordered child,but mayalso includethe father.It is felt that the enmeshment represents the parentsattemptto livetheirlivesthroughthe child.

ItknJlty:The familymessage is that individualsdeterminetheiridentityin referencetoothersinthe family.This leavesmembers withconfusion about how theywillexist outsidethe contextofthefamily.

Emolionalexpression:Negative emotions aresuppressedin anefforttoensure thatother familymemberswillnotbe hurt.Outbursts of angerorsadnessare respondedtowithexpressionsof painandconfusion byfamilymembers.

Powerlessness:Autonomyis discouraged,particularlyinthe youngestchild.

Thischildis atgreatestrisk of developingan eatingdisorder.Parentsmay smother thechild with attentionand affection whichinterfereswiththe child's naturalprogression to adulthoodandseparation.Triangulationof the child in maritalconflictbecomes extremelyeasyand thefamilymayindeedpresent clinicallyasa"three waymatrimony"(Selevini-Paiazolli,as citedinRootet 01,(980).

Functionsofthe EatingDisorder: TheOverprotectiveFamily

Boundaries:Theeating disorderbecomesa safewayto createa personalspace withinthefamily. Thisseparationis perhapsmore greatlymarkedinthe activitiesofabulimic,which can be kepthiddenfromthefamily foramuch longer time thantheanorexic.

Emotional Expression:As inthe perfectfamily,theeatingdisorderprovidesa channel forunexpressedemotion,particularly anger, giventhe familytaboo abouthurtingethers.

MairuenanaoflheMarilal Relationship: The eatingdisorderbecomesanissue that consistentlyjoinsthe parentsand thusthe eating disorder appearstoform an importantfunctionin maintainingthe marriage.

DelaysHavingTo LeaveHome:Eatingdisorders oftenemergeinadolescence whenthe childis strugglingwithseparation fromthefamily.The eating disorderservesto delay this separation processandthusdelaysthe perceived hurt forthe parentsthat is associated with the childleaving the family.

71IeChaotic Family"The Onl yOne YouCan ReallyRel yOn Is Yourself"

Rootand her colleagues(1980)maintainthat the chaoticfamilyrepresentation is mosthighlyassociatedwithbulimianervosaand most resembles the conceptualizationof addictivefamilies.Theyreportthat unlikethe rigidityand closenessseenin the perfectand overprotectivefamities, the chaoticfamilyis markedby seriousdisorganizationand distance. Substanceabuseand victimizationexperiences are oftenmorecommonin these families.

Boundaries:The boundarypatternswill changefrequentlywithalternating high expectations ornone at all. Contact betweenparentandchild, and husbandandwife is oftendistant.

Identity: Thereis littlesenseof"family",dueto the familydisorganizationand distance.Oftentheeatingdisorderedchild becomesthe pseudo-parent and/or pseudo-spouse.Thereis a resultingconfusionaboutidentityand autonomyas these roles fluxuateaccording10parentalneeds.

EmotionalEx,rJression:Anger is the pervasive emotioninthe familyandis unpredictableand often explosive.Love is conditionalandinconsistent Sadnessisoftennot distinguished fromdepression.

Powerlessness:All familymembersfeel a senseof powerlessnessandlack of control. The father mayexert dominancethroughphysicalor verbal abuse.

Trlanau1atlonoften occurswiththe motherenmeshlngwiththe daughterin order to cope with the husband' sabuse.This childwillexperiencealternating feelingsof powerfulnessandhelplessnessasherrole is switchedwithinthe family.

Functions of theEating Disorder:The Chaotic Family

Boundaries:Emotion aldistanceand personalspace arecreated by theeating disorder.The bathroombecomesa haven and a placefor privacy.

Affection andNUfurance:Theeatingdisorderprovidesa senseof comfortand predictability,as thoughthe eatingdisorderbecomesa distinctforce tobe countedon.

EmotionalExpression:Emotional expressionwithin the familyis often explosive.The eatingdisorderbecomes a safe way10 expressanger and outrage.Italso serves to maskandnumbfeelingsof sadnessand less.

selfAbuse:The eatingdisorderalsoservesto carry onthe cycle of abuse experiencedin the family.

RelinquishingResponsibility:Theeatingdisorder provides amechanismto escapethe parentalandspousalfunctions imposedby the family.

Predictability/Autonomy:The fluxuating role expectations are verystressful.

Theeatingdisorderprovides a structure thatdoesnot existwithinthefamily system.Italsopromotesasenseof control andmastery.

The familyrelationship variablesofenmeshment,overprotecuveness,ridgity, triangulationandchronic tension appearineachof thesefamilymodels.Yet the configurationof these variables arcqualitativelydifferentforeachfamity model. Root andher colleagues(1986)maintainthatthesedifferenceshave implications for treatmentstrategies. these differenceswill thereforebe recognizedin the analysisof the datafor thisstudy.

Summary

Anorexiaand bulimianervosa are multi-determinedconditions. The literature pointstothreeconstellationsoffactors as significantintheemergenceof eating disorders.Theseare:socio-culturalnormsand expectations, family compositionandrelationships,andpersonal characteristics.Inthis preliminary review,a greatdealofconsistencyexistsbetween thepresenceof thesefactors and theemergence ofbothanorexiaand bulimia nervosa,eventhough each disorderis aunique clinicaldiagnosis.

One can seethat variables related to eachofthese..onstellation of factors appearinterconnected.Forexample the personalcharacteristicsof depression, sexualvictimizationand focuson bodysize appeartoalsorelateto

socio-culturalissues.While desire for high achievement and responseto hungercanalsobe relatedtoparentingstyles. Yet thecomplexity of these emergingconnectionsdoesnotallow usto seethepathfromone to theother. In reflectingon thesefactorsit may be beneficial to viewthemassimilar to Bronfenbrenner' ..(1979)representationof thehierarchyof humanexperience as.. a set of nestedstructures,like a setof Russian dolls"

(Bronfenbrenner,1979 ascitedin Emmet,1985).Howeverit seemsthatthe familystructure ispivotal in impacting ontheexpression ofbothsocio-cultural andpersonalfactors.

RESEARCHMETHODOLOGY Introduc tion

This is an exploratorystudyoftheassociationof three levelsofhuman experiencewith the emergenceofaneating disorder.Itwillexaminethe socio-cultural,familial,andpersonalfactorsassociated with the development of anorexia nervosa andlorbulimia nervosa.These factorsare thenanalyzedin thecontextofthe client'sperceptions oftheireatingdisorder.

The study isqualitative innatureandexplores, throughthemediumof in-depth personalhistories,thelifeandtreatment experiences of womenwhohave been diagnosedas havinganorexianervosa,bulimianervose,or both.Thisstudy is intendedto enrichthe social workprofession'sunderstandingof clients' perceptions of their eating disorderanditstreatment.Considerationis given10 thedirectionsindicated for the development of socialworkstrategies for early intervention.

OperationallzatlonOfConcepts And Variables

The variablesto be studiedareclusteredunder the categories of:

(a)soclo-culruretnorms,(b)family composition andrelationships,and (c) personalcharacteristics.Eachofthese conceptswillbe operationalizedas variablesfor datacollectionand analysis.

Soclo-culturalNorms

Twoconceptsare usedto study the influenceof socio-culturalnorms:

I.Exaggeraled emphasisonwomens'bodysizeandpromotion o/lhlftMss:

'Thisconcept is represented bystatements expressing:IIdesirefor thinness, indications thatbodysizeandshape are viewedas important to life satisfaction,andindications that dissatisfactionwithbodysizeappears relatedto comparison witha perceivedidealshape.An examplemight be..

I don't seehowitis possibleto like myselfwhen mylegs are so fat.",..I don't knowwhymy boyfriendputsup withme.evenOprahWinfreylooks gorgeous nowthatshe lostallthatweight."

2. Sociaiiwioncfwomen tobe passiveandtodefertoaneuemattocusof comrot..This conceptisrepresentedby statements which:attribute responsibility for life eventstoothers,expressdecision-makingprimarilyin referenceto theviewsof others, and expressdeferencetotheopinionsof others.An examplemightbe "Well my motheralways saidthat I wasn' t going to makeit in school,and I guess myteachers just don't want me to passeither"."My motherhas alwayssaid thatIwasgoingtohave a weight problem,therejust doesn'tseemto be anythingthatIcan do now."

Famil y Variables

Familyvariablesare categorized undertwoheadings:familycompositionand familyrelationships.

FamUv Composition

There are threevariables relatedto familycomposition.Theseare:

I.Socio-economicstarus:Thisis definedas theparticipant'sperceptionofher family'ssocial class, usingthe subjectivecategoriesof lowerclass,working class,middle class, upper-middleclass or upper classfamilies.

2.Incidenceof weight problemsinimmediarej amily members:Thisis defined interms of the participant'sperceptionof a weight problem as evidencedin family membersexpressedunhappinessabout body sire,or the participant's knowledgeof theiractualattemptstoloseweight.Theterm"immediate familymembers"will refer to parentsand siblings.

3. Incidence of physicalillness.depressionoralcoholabusein immediare familymembers:Thisisdefined in terms of the participant's knowledgeof medical treatmentfor anyofthese problems.Itwill alsoinclude the participant'sown perceptionof depressionor alcoholabuse inimmediate family members.The term"immediatefamily members"willrefer to parents and siblings.

Familv Relations hips

There arefivevariablesthat concern familyrelationships. Theseare:

1.Enmeshment be/Weenparentand child withan eatingdisorder:

Enmeshmentreferstoan extremelycloseset ofemotionalbonds between family members,to the degreethatthereisa lackof personalautonomy experiencedinthefamilysystem. Enmeshmentis rel1ected in: reports of lack ofpersonalprivacy,a perceptionof theparent(s)as a siblingmore than parent, adifficultyin separatingpersona!life goals fromparental desires for those goals. Someexamplesmight be:" Weneverclosedthe

doorsinour house,noteventothe bathroom",..Momtellsmeall abouther problems withDad",.. I don' tknowwhatIwanttobe,butmomalways saysIreallyhavea specialtalentfor cosmetologyandshe wasalwaysgood withapplyingmake-up."

2.Overproteaiveness of parentstowards thefamily system:

Overprctectlvenessis reflcctedin theparents'overemphasison thefamily totheexclusionof thoseoutsidethe family.Familyloyaltyis expectedto

"tpersede the needsof individual familymembers.Personalboundaries betweenfamily membersare poorlydefined, oftenwithno clear rules regardingage appropriate behaviour.

Indicatorsof overprotecrlvenessare: expressionof concernforthe family image,referencesto beingtold to protectthe family image,concernabout hurtingotherfamilymembers,anda sense of not fittingin withthose outsidethe family.Someexamplesmightbe, " Myparents neverfought, but sometimesIjust getcrazy and start yellingforno reason.Momthen startscryingandI endup feelingevenworse.",..Iwentto tlteschool guidancecounselloronce, and Dadjust blewupwhen she calledhomefora parentinterview.Hesaid I disgraced the family."

3.Triangulationof theeatingdisorderedchild in parental/maritalco'lflict:

Triangulationrefersto a coalitionor covert alliancewhichcrosses generationallines.Often neitherthe parents northechildis consciously

awareof thisprocess,howeverthechild experiencesanxietyandconcern forthemaritalrelationshipandalternatingfeelings of powerand helplessness.

Triangulationisconsideredpresentby:referencestosenseofLeingcaught betweenbothparentswhentheyfight(orfought),afeeling of alwaysbeing on oneparent'ssideand or,a feeling ofresponsibilityforkeeping parents together.Some examplemightbe"Idon't knowwhybut everytimemy parentshad afightIwouldfind myself in the middle,usuallyagreeingwith mom.Funny, you know halfofthe timeIdidn'tevenreally agree with her.","SometimesIwonderhow myparents willsurviveifI leavehome."

4,Rigidity within111efamilysystem, particularly aroundconflictresolulionand role expectations:Rigidity is expressed in an inflexibility aboutways conflict canberesolved,andinan inflexibilityabouthoweachperson

"should" act.Itmayalsobeseenin notbeingwillingtorecognizetheneed for conflictresolutionor role expectations.

Reflectionsof rigidityinclude:referencestothe familyemphasison "the rightway"to do things, a feeling thatonehad to actin a certainway.or a sensethat theindividualwasonly viewed oneway within the family.Some examples might be.. Dad hastheanswerforeverything,justonce I would liketodosomething without him tellingmetheright way.", "Momthinks I'm justa klutz, shewon't letmein the kitchenbecauseshesays I'll ruin dinner.But I hateber meals,they're sofattening."

S.Chronic tens ion:Chronictension refers10theconstantpresence ofanxiety.

Thesefeelingsare attributedtoan overallsenseof powerlessnessinthe family.Itis a subjectiveexperience and willbe operationalizedon thebasis oftheparticipant'sperceptionof:"beingonedge".having to·walkon egg shells·,or experiencinga nagging worry.

Personal Characteristics

There arefour categoriesofvariablesthat reflectpersonalcharacteristics. They are: personal demographics, personalhistory, eating habits,anddistortionsof bodyperception.

PersonalOfImographlcs

Thereare twovariablesrelatedto personaldemographics.Theseare:

1.Sex:whichis definedas male or female 2. Age:which i!'ldefined bydateof birth.

PersonalHislory

Threeelements of personalhistoryarerelevanttothis study:

t.History of high achievement:whichis basedon self-reportof driveorfelt pressureforhigh achievement,as wellas indocumentation of self-reported academic and careeraccomplishments.

2.Historyofdepression:whichis definedon thebasisof self-reportof medical treatmentor perceptionof havinga problemwithdepression.

3. His/ory01sexual vic/imiwion:whichisbasedonself-reportofhaving experiencedsexual contactwhichwascoercedor unwanted.

Ealing Habits

Eatinghabitsare importantto a studyof eatingdisordersas they areboththe focalpointof theobsessionandthe externalsignalof the problem.Thereare six variablesrelatedto eatinghabitsbeingexplored:

1.Ithistoryoldieling:whichis definedby selfreportof pastor present efforts to controlor Joseweight.Participantsareasked to describetheir experiences withdietingand weightcontrol,andto indicatethelength of timethey havebeen concernedwith losingweight.

2.A.historyof purgingactivities:whichis definedby self-reportof presentor pastinvolvc.nemin anyof theseactivities:self-inducedvomiting;over-use of laxatives,diureticsor enemas;vigorousover-exercise;or fasting.

3. A his/Dry of binging:Whichis definedby self report of: eatinghuge amountsof food ina short periodof time,eatingrapidly,eating until physicallysick,feelingout of controlwheneating, and feeling miserable anddepressed after binging.

4. Anobsessionwi/hjood:Whichis definedby theself-reportof thoughts that are predominantlypreoccupied with someaspectoffood or eating.These thoughtsmayfocus on food purchaseandpreparation of favouritemeats,

strategiestoavoidfoodor overeating,cootracting withoneselfaboutthe foodstobeeatenthatday.OftentOeobsessionisSCCtlasinterfering with abilitytoconcentrateondailyactivities.

5.RitumizJUiono//oodprrparationandconsumption:Whichisdefinedby self-reportof;rigid patterns aboutthesequenceandtypeoffood preparation;strict rulesabouthowthefoodappears ontheplateandthe orderinwhichitisconsumed;andobsessions withfads aboutfood consumption.OnesuchfadaboutfoodconsumptionIsbelievingthateating anorangeslicefirstwillensurethat caloriesareburned morequickly.

6.Afear ofovereating:Which is byselfreportof:feeling extremeanxiety about not beingable10stop eatingand preoccupation withstrategies for foodavoidanceorconsumption.

Distortions of BodyPerception

Cognitivedistortions, particularlyas theyrelatetobodyshapeareasignificant aspectofeatingdisorders.Thereare threevariablesrelatedtotheconceptof distortionofbodyperception:

I.Alad.: o/rtcognition a/thephysical manijtsllJJlons ofhungtr:Thisis definedby the participant'sperceptionofawarenessofthebody's sensationsandsignalsfor hunger. Forexample,..1 neverfecihungryor full.Ijustfeel scared whenI'meating.","Mystomachisn'thungry,butmy

mouthis." Forboth bulimicsandanorexics, theinability toproperly recognizeandrespond tothe physicalmanifestations of hungercontributed tothe overallanxietyabout eating.

2. A distortion of body image:This refersto the person'sinabilityto accuratelycompare orrepresenther bodysize orshape,basedonthe interviewer'sview of an incongruencebetweenthe persons'sactualphysical size and her verbal descriptionof hersize.

3.Amapercepttonof theInfluence of bodyshape ontmerpersonal relationships:This is evidencedin expressionsthat reflect that the interviewee perceivesthat body size is seenas a primarysourceof problemsin interpersonalinteractions.Forexample, .. If onlymy thighs were 2Vlinches smallerI would have no problemsgetting alongwith my

Data Collection

tanossa and Wolf (1985)maintainthatsincethe1960' s the professional interestin theorybuild ing has led to anincreasein qusetitetive familyresearch.

Their reviewof the Journal of Marriageand the Familybetween the years 1965-1983reveals an overwhelmingemphasison quantitativeresearch.Out of atotal of 775 articles, 69%were exclusivelyquantitative.This number increasesto 84% when articles that wereprimarilytheoretical are removed fromthe sample(l8%).Ofthe remaining13%, only 9% could be considered exclusivelyqualitative.

Mostof thepublishedliteratureon eatingdisordersis quantltanve.Itisalso presented primarily fro mtheclinician'sexperience(see:Bruch,1978; Emmett,1985;Garner, Garfinkel,Schwartz&Thompson.1980;Kog&

Vandereychen,1985; Lachenmeyer&Muni-Brander,1988;Liebmanet all 1983;Minuchin&.Baker, 1978;Rootetal,1986;Selevini-Palazzoti,1914). Cherin (1981)and Orbach (1986) are unique in theirconcern with the woman's perspective andeatingdisorders.HoweverKinoy(1984) is oneof theonly authors of systematicresearchfromthe client'sperspective in the literature reviewed oneatingdisorders.

Aqualitativemethod was chosenfor thisstudy in responsetothis imbalancein the methodologyofpublishedresearch.Itwasrecognizedthataqualitative approach wouldcomplement andenhancetheexistingliteraturereviewedon eatingdisorders.Itwasalsofelt that studyingtheclient'ssubjective reality, while inherently biased, offersaunique opportunityfor socialworkerstogain insight intothe client'sviewofhersituation. Thisinformationisfundamental tothesocialworkprofess ion'spremise of starting"wheretheclient is"and providesarich basefor meaningfulintervention.

Population

Threewomen were selec ted10participate inthisresearch.Itwasdecidedto study an exclusively femalepopulationasmostoftheliteraturereviewedhas beendeveloped aroundtheexperiencesofwomen. II was furtherrecognized thatmenneed10bestudi edasa uniquepopulation.

Theparticipantsforthestudy are drawnfrom a clinicalpopulation.A senior clinicianwasrequestedto makethe selectionof potentialparticipantsonthe basisof the followingcriteria:(a) theindividual is femaleand 20 yean or older,(b)hasbeen diagnosedashavinganorexia,bulimiaor both,and (c)has completedtheacutephase of treatment.Completion of theacute phase of treatmentwill meanthatwhile the personmightbestill undergoingtherapy, her weight andcognitive/em otional functioninghasstabilized.

Thisselection process was chosento ensurethat theresearch did not interfere withtreatment, andtoalsoreducethe possibilityof negativerisks of the research for the participant.This processalso ensuresaccessto follow-up therapyshouldthis benecessary.

Potentialparticipants werecontactedfirstthroughtheir clinician,either by letteror telephone. Eachclinician wasgiven a letterto introducepotential participantstothe study.(See AppendixA)Theclinicianwas then responsible forreferringany interested individuals.The researcherencouragedclinicians to havetheirclientsmakethe firstcontactwith theresearcher,sothatthe participanthadoptimalcontrolover thedecisiontoparticipate.

Datacollectionthenproceededinthree phases:

1.Abriefinitialmeetingwasheld toreview thepurpose andthe format of the research.Thisallowed the participantan opportunityto actuallyseethe researcher and10re-consider her decision10participate.Atthistime

written consentwaspresentedandobtained.Theethicalissuesaround consentwerediscussed inalater section.(See AppendixAfor theconsent form)

2.Theprimaryinterviewsessionof threetofour hours thentook place,inthe interviewing roomsat theSchoolof Social Work at MemorialUniversityof Newfoundland.Thesessio n wasaudio-videotaperecorded.The researcher followeda non-structuredinterviewformat,allowing theparticipantto presentherstory withoutthe researcherbiasingthe information through structuredquestions.Lofland andLofland (1984)recommendpreparinga verygeneralinterviewguide that willfacilitatediscussionduri ng the interviews. The guidealso provides a mechanismfor taking quicknotes of an aspectof thesessionthaiseems particularlysignificant(SeeAppendix B)If the participant so wishedshemayhavehadacopy oftheaudio-video tapeforreview beforethefinalsession.This wasintended 10provide participants witha senseofpersonalautonomywithrespect 10 the research process,byhavinganopportunity10provide feedbackon thecontentof their interview.

3.Afinal shortersessionwasheld to ensuretheparticipant hasprovidedall theinformation shewished and to clarifyany materialon theaudio-video tape.This also providedthe researcherwith anopportunityfor clarification of anyinformationfromthe previous interview.Emphasiswasbegiven to terminating sensitively.If atthistimethe researcher'sclinicaljudgement indicatedthat theparticipanthadunresolved clinicalissues,thiswasraised andsuggestions for counselling referrals made.

DataAnalysis

In aqualitative study,dataanalysispresentsone ofthe mostsignificant challengestothe whole researchprocess.(Lofland&Lofland 1984.Plummer 1983) Data analysisoccurred on twolevels,data collation and dataanalysis:

1.Data collation:Eachparticipant'svideo-tapewas reviewedindetailby the researcher. Thisinvolved viewing the tapes,completingdetailednoteson thecontentof the interviews andwhennecessary.partialtranscription of the audio-videotapematerial.Emphasis wasplaced on recording and understandingeachwoman'slife storyindependent of the other<J.The researchercompleted this processpersonally asa way of enhancingthe understanding ofthe informationshared,andstimulatingthe analytic process.

2.Data analysiswasconducted on threelevels:

a}a comparisonofthe responses of each of the participantsto establish commonalitiesanddifferences

b) an assessmentofthe collectiveresponsesusingthe socio-cultural, familial,andpersonal factorsconstructedfrom the literaturereview as pointsof comparison.Root and her colleagues(1986) conceptual models ofthe familywasused tosituate family-relatedinformation.

Theseconceptswereintendedtofacilitatethe analytic process and will form a pointof referenceandaflexiblestructure foranalysisand comparison.CareW;lStaken to ensurethatthis processdidnot invalidate the attempttorecordtheparticipants'subjective reality;and

(c)consideration of the implications of these resultsfor socialwork practice.

Ethical Issues

Thisstudy iscarriedout under the guidelinesoftheHumanSubjects Committeeof the Schoolof GraduateStudies,and with a commitmentto maintaining high ethicalstandards. The relevant ethicalissuesforresearch are:

(I)the relative risks andbenefitsof thestudy,(2)ensuringconfidentiality, and (3)obtainingvoluntaryandinformed consent.Each are discussedbelow:

1.Relativerisksand ben crtts sLaRossa, BennettandGelles(1981)have discussedissues relatedto therisks mostoftenassociated with qualitative research.Of primaryrelevance tothisstudyares(a)thedifficultyin predictingrisksinqualitativeresearch,(b)participantsmay disclose more informationthantheyhad originallyintended.Eachoftheseissueswill be discussedingreaterdetail in thetextthat follows:

a)The difficultyInanticipati ngrisks. This issuehas beenaddressedIn thisstudyby requesting cliniciansto assistinthepopulation selection process.Theselectionby clinician's notonlyensuresthat participant's are felttobe emotionallystable,but italsoensuresa therapeuticbackup. b) Part icipantsriskdisclosing merepcrsonallnfonnationthan originallyintended. This risk demandsa high degreeof professional skill onthepart ofthe researcherinmaintainingtheappropriate distance and neutrality, whilestill maintaininganatmosphereconduciveto discussion of lifeevents. LaRossaand his colleagues (1981)suggest that