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Antioch University Antioch University AURA - Antioch University Repository and Archive AURA - Antioch University Repository and Archive Antioch University Full-Text Dissertations & Theses Antioch University Dissertations and Theses 2011 Eating Disorder Metaphors: A Qualitative Meta-synthesis of Eating Disorder Metaphors: A Qualitative Meta-synthesis of Women's Experiences Women's Experiences Rachael Brooke Goren-Watts Follow this and additional works at: https://aura.antioch.edu/etds Part of the Clinical Psychology Commons, Mental and Social Health Commons, and the Women's Studies Commons  Eating Disorder Metaphors: A Qualitative Meta-synthesis of Women’’s Experiences by Rachael Brooke Goren-Watts B.A., Brandeis University, 2001 MPH, University of Massachusetts, Amherst, 2007 M.S., Antioch University New England, 2010 DISSERTATION Submitted in partial fulfillment for the degree of Doctor of Psychology in the Department of Clinical Psychology At Antioch University New England, 2011 Keene, New Hampshire  EATING DISORDER METAPHORS ii ���������������������������������� DISSERTATION COMMITTEE PAGE ��������������������������������������������������������� ���������������������������� ���������������������������������������������������� �������������������������� ��� �������������������� �������������������������������������������������� ����������������������������������������� ������������������������������������ ���������������������� �������������������������������� ���������������������������� ����������������� ����������������� ���������������������������������������������� ��������������������� ���������� ����������������������������������������������������������������������������������������  EATING DISORDER METAPHORS iii Acknowledgements This dissertation would not be possible without the support of a number of people. Thank you to Susan Hawes and Barbara Belcher-Timme for agreeing to serve as members on my dissertation committee. Dr. Hawes, I have appreciated your willingness to offer knowledge on qualitative research, and to allow our tangential conversations to occur as they often resulted in my ability to have creative ideas and deeper understandings. Dr. Belcher-Timme, thank you for your honesty, even when it was difficult to hear. Throughout our work in both case conference and dissertation, I have appreciated your compassionate directness, as it models and inspires an authentic way of being in the world and a reminder to be assertive in one’’s beliefs. Dr. Colborn Smith, thank you for stepping in during my adviser’’s sabbatical, having a listening ear when I needed to talk, and maintaining a good enough holding environment for the completion of the memoir. A special thank you to Dr. Martha Straus, my adviser for the duration of my time at Antioch University and the chair of my dissertation committee. Marti, this is a moment where the written word feels too limiting and cliché. Your unconditional love and support kept me going throughout this program. Knowing that you ““got me”” made it feasible to continue plugging along and trust the process. I don’’t feel that I can thank you enough and hope that our relationship can continue beyond the walls of Antioch. To my Antioch community, professors, staff, and students, thank you for being my ““Monday Family”” for the past four years. It has been a source of support and an asset to have you there for the full range of emotional affect that is present in our community. I will miss seeing your friendly faces and hearing about your lives. I want to especially thank my fellow advisees: Jennifer McLean, Maura Cole, and Jamie Carroll for your input and lengthy  EATING DISORDER METAPHORS iv discussions about our dissertations. Although, we all know that what I really want to thank you for is sharing funny You Tube videos, for without humor, life loses its luster. I want to thank my past and present supervisors: Claudia Ciano-Boyce, Eliza McArdle, Steven Klein, Sheri Katz, and Tammy Bringaze. Each of you helped to form my identity as a psychologist and I appreciate your willingness to take a chance on me as a practicum student. Dr. Ciano-Boyce, thank you for the reminders to trust myself as that has been one of the more important lessons of my training. To my parents’’ favorite son, Josh, I want to apologize for not listening to you on the night that my dissertation data disappeared. You were right. Thank you to my parents for your support; you encouraged me to take the risk by attending this program and I am eternally grateful for the experience. Your pride in my abilities to see this through has been a source of strength. To Molly, I know that neither of us knew that my signing onto this doctoral program would mean that you would take the brunt of, well, fill-in-the-blank. Thank you for your patience, appreciation, homemade meals, patience, taking on more than your fair share, researching safe AWD vehicles, patience, putting up with ““processing the process,”” setting the alarm, and have I said patience?! I owe you one and I promise to make more eye contact with you now, rather than my laptop. To my extended family of relatives and friends, thank you for being willing to listen to things that don’’t pertain to you and validating my reality. As a wide-cast net of loving and compassionate individuals, you are all part of my intentional community where we lean on one another for support, reassurance, vitality, laughter, joy and sadness, and the deepest meanings of friendship.  EATING DISORDER METAPHORS v Dedication This dissertation is dedicated to all the women who stayed to choose to fight. May you serve as a reminder that when we believe we cannot fail, anything is possible.  EATING DISORDER METAPHORS vi Table of Contents Acknowledgements........................................................................................................................iii Dedication....................................................................................................................................... v Table of Contents........................................................................................................................... vi Abstract........................................................................................................................................... 1 Chapter 1......................................................................................................................................... 2 Chapter 2: Literature Review.......................................................................................................... 4 Scope of the Problem of Eating Disorders.................................................................................. 4 Eating Disorder Duration, Recovery, and Relapse..................................................................... 6 Gender and Eating Disorders...................................................................................................... 8 Race, Ethnicity, Sexual Orientation, Age, and Eating Disorders ............................................... 9 Critique of Literature ................................................................................................................ 10 Chapter 3: Metaphors and Social Constructionist Thought.......................................................... 15 Social Constructionist Theory................................................................................................... 17 Application of Metaphor........................................................................................................... 18 Chapter 4: Theoretical Conceptualizations of Eating Disorders................................................... 23 Psychological Models............................................................................................................... 23 Addictions Model/Twelve-Step................................................................................................ 28 Trauma and Comorbidity.......................................................................................................... 29 Biomedical Models................................................................................................................... 32 Socio-Cultural/Feminist Models............................................................................................... 33 Chapter 5: Method ........................................................................................................................ 38 Hermeneutics ............................................................................................................................ 38 Qualitative Meta-synthesis........................................................................................................ 40 Procedures................................................................................................................................. 42 Chapter 6: Findings....................................................................................................................... 50 Context for the Eating Disorder: Perceived Precipitants of the Eating Disorder ..................... 50 The Experience of the Eating Disorder..................................................................................... 55 Reasons for Seeking Treatment and/or Starting Recovery....................................................... 84  EATING DISORDER METAPHORS vii Experience of Initial Stages of Recovery/Treatment................................................................ 88 Experience in Recovery.......................................................................................................... 113 Experiences of Being Recovered............................................................................................ 132 Chapter 7: Discussion and Conclusion ....................................................................................... 140 Meaning of ED Metaphors...................................................................................................... 140 Understanding Women’’s Metaphors with Theoretical Paradigms ......................................... 145 Implications for Treatment ..................................................................................................... 147 Implications for Future Research............................................................................................ 149 Concluding Thoughts.............................................................................................................. 152 References................................................................................................................................... 153 Appendix A: Appraisal Report Guide......................................................................................... 169 Appendix B: Comparative Appraisal of Qualitative Studies...................................................... 170 Appendix C: Comparative Appraisal by Content....................................................................... 174 Appendix D: Breakdown of Publication by Date ....................................................................... 177 Appendix E: Breakdown of Author Affiliations......................................................................... 178 Appendix F: Breakdown by Publisher Type............................................................................... 179 Appendix G: Geographic Location of Study .............................................................................. 180 Appendix H: Orientation Towards Target Phenomenon ............................................................ 181 Appendix I: Breakdown of Orientation Toward Inquiry............................................................ 182 Appendix J: Data Collection Methods........................................................................................ 183 Appendix K: Demographics of Samples in Studies.................................................................... 184 Appendix L: Breakdown of classifications of the findings ........................................................ 187 Appendix M: Taxonomy of Findings Pertaining to Eating Disorder Experiences..................... 188 Appendix N: Conceptual Synthesis ............................................................................................ 194 Appendix O: Reciprocal Translation Codes and Frequency....................................................... 218 Appendix P: Eating Disorder Metaphors.................................................................................... 222  EATING DISORDER METAPHORS 1 Abstract Eating disorders have reached epidemic levels in the United States and cause immense pain and suffering. Given the high fatality and relapse rates of eating disorders, as well as the numerous medical complications associated with them, it is useful to know more about how individuals view their eating disorder, and the meaning making during the recovery process in order to better understand the experience. Narrative theory, and specifically the metaphors women use to story their experience, enrich our understanding of eating disorders within a social constructionist lens. This qualitative meta-synthesis utilizes hermeneutics and identifies and describes the metaphors that women use to talk about their eating problems. Findings demonstrate that the woman’’s relationship to her eating disorder, as revealed by her language and metaphor, shifts during the recovery process. This shift was reflected in the metaphors as they progressed from a positive metaphor while they were struggling, to a negative association during initial stages of recovery, to a more complex and nuanced expression throughout recovery, and finally to gratitude metaphors when identifying as recovered. This research adds more qualitative descriptive information to the sparse facts that are provided by diagnosis alone. The metaphors and metaphorical nature of eating disorders are discussed within the theoretical paradigms to assist in conceptualization, clinical application, future research, and public policy implications.  EATING DISORDER METAPHORS 2 Eating Disorder Metaphors: A Qualitative Meta-synthesis of Women’’s Experiences Chapter 1 Eating disorders (EDs) are complex, potentially physically harming and/or fatal psychological disorders that cause significant distress to the individual, as well as friends, family, and loved ones. Unfortunately, relapse rates are high, treatment is expensive, and recovery can be a long process. Much of the previous research and literature examines recovery and healing from a diagnostic lens. Previous quantitative research has been focused primarily on treatment models and/or diagnosis. Within the qualitative studies, researchers pay attention to the themes of eating disorder etiology and recovery process; however, to date, the metaphorical language used by women has not been explored qualitatively across diagnostic categories. Metaphors are useful in understanding how individuals make meaning of their experiences. Given the high prevalence and morbidity of EDs and eating problems, coupled with the high relapse rates and recovery duration, understanding meaning-making during the recovery process, by attending more closely to women’’s own experience and voice, might help to improve long-term treatment effectiveness. In this dissertation, I explore the metaphors of women’’s experiences with EDs and recovery based on a hermeneutic meta-synthesis of qualitative research. I explore how women talked about their EDs and whether these metaphors reflected theoretical conceptualizations. This dissertation is divided into seven chapters and provides a literature review on EDs and recovery, includes the existing metaphors in the theoretical and research literature, describes the utilized methodology, illustrates the findings of the meta-synthesis, and discusses the limitations and implications of this research. In the next chapter, Literature Review, I provide an overview of the quantitative and qualitative research on EDs, elaborate upon the reasons for this research, and include preexisting knowledge regarding the etiology and recovery process of EDs  EATING DISORDER METAPHORS 3 in the context of metaphorical understanding and language paradigms that I gleaned from the research. I then situate metaphor within the context of social constructionist thought and narrative theory in the third chapter, to frame the subsequent sections that describe the metaphors in the theoretical and quantitative research. Next, I explore application of these concepts by reviewing current treatment modalities for EDs and accompanying metaphors utilized in the fourth chapter, Theoretical Conceptualizations of Eating Disorders. In the fifth chapter, Method, I explain the hermeneutic method, qualitative meta-synthesis, and the procedures employed. The sixth chapter illustrates the findings, through figures, narrative, and metaphors. The Discussion and Conclusion, the seventh chapter, provides a more in-depth exploration and integration of the metaphors with the theoretical research, to provide a deeper theoretical understanding and basis for addressing and treating individuals with EDs using the specific metaphors they offer. Strength, limitations and implications of this research are also discussed.  EATING DISORDER METAPHORS 4 Chapter 2: Literature Review This section provides an overview of quantitative and qualitative research on EDs, including the scope of the problem, prevalence, duration, recovery, and relapse rates. This section also explores how gender, race, ethnicity, sexual orientation, and age affect etiology of EDs. Included is a critique of the literature that identifies limitations and gaps that my research sought to fill. I also explain the utility of the current meta-synthesis and potential implications for treatment. Scope of the Problem of Eating Disorders EDs have reached epidemic levels in the United States, affecting almost 10 million individuals, 90% of whom are women (Anorexia Nervosa and Associated Disorders, 2008). EDs (Anorexia Nervosa [AN], Bulimia Nervosa [BN], Binge-Eating Disorder [BED], and Eating Disorder Not Otherwise Specified [EDNOS]) are complex; they involve serious disturbances in eating behaviors, including restriction of food intake, purging behaviors, such as vomiting, laxative use, or exercise, and bingeing behaviors, as well as feelings of distress or extreme concern over body shape, size, and weight (Department of Health and Human Services, 2007; DSM-IV-TR, American Psychiatric Association, 2000). Physical and psychological complications. Numerous physical and psychological repercussions and complications of EDs include: malnutrition, dehydration, ruptured stomach, heart, liver, and kidney damage, tooth/gum erosion, esophagus tears, osteoporosis and reduction in bone density, muscle loss and weakness, high blood pressure, high cholesterol levels, heart disease, diabetes, reproductive complications, gallbladder disease, depression, low self-esteem, anxiety, obsessive-compulsive behavior, shame and guilt, impaired family and social relationships, mood swings, and perfectionism (ANAD, 2008; Finfgeld, 2002; Holtkamp, Muller,  EATING DISORDER METAPHORS 5 Heussen, Remschmidt, & Herpertz-Dahlmann, 2005; National Eating Disorder Association, 2005). Approximately six to 10 percent of severe cases with AN result in death, with AN having the highest premature fatality rate of any mental illness (American Psychiatric Association, 2000; ANAD, 2008). Incidence and prevalence rates. Even the studies with the most complete case-finding methods yield an underestimate of the true incidence of EDs (Hoek & van Hoeken, 2003). Exact epidemiological information regarding how many individuals struggle with EDs varies depending on definition, utilized tests, and which population is represented (Lelwica, 1999). Keshi-Rahkonen et al. (2007) found that half of the cases of AN had not been detected in the health care system and similarly, Hoek and van Hoeken concluded that only one-third of people with AN receive mental health care. Estimates for American females range from .5% to 3.77% with symptoms that meet full criteria for AN (Keshi-Rahkonen et al., 2007; Lelwica, 1999; NEDA, 2005). Between 1.1 and 4.2 % of females in late adolescence and early adulthood meet full criteria for BN and BED affects 5% of women (Lelwica, 1999; NEDA, 2005). Yet, these estimates appear to grossly under report the actual incidence and prevalence of EDs. Other studies based on similar criteria showed up to 20% of college aged women suffering from AN and/or BN (Lelwica, 1999). Lelwica explained that with less rigid criteria, percentages of those affected increase significantly; almost 40% of college women demonstrate ““anorexic-like”” behavior and 20% report bingeing and purging. Further, one half of teenage girls and nearly one third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives (Neumark-Sztainer, 2005). Cultural influences are indisputable as the incidence of EDs has more than doubled since the 1960s and continues to increase in younger age groups with girls as young as seven years of  EATING DISORDER METAPHORS 6 age dieting and worrying about their weight (Eating Disorders Coalition for Research, Policy, & Action, 2009). Indeed, most girls in the United States struggle with body dissatisfaction and EDs are symbolic (if not metaphors) of the complicated relationships that girls have with their bodies, social supports, and the culture (Straus, 2007). In this research, I considered the therapeutic importance of studying EDs that meet diagnostic criteria, as well as subclinical EDs (disordered eating). Given my social constructionist frame, a clinician doesn’’t have to diagnose an ED to make it so, thus, allowing for a broader understanding of the depth of personal experience. Eating Disorder Duration, Recovery, and Relapse Duration of disorder. Even with over two decades of research and a pressing need for effective interventions, we still have a limited understanding of ED recovery, especially with regard to long-term outcomes (Keshi-Rahkonen & Tozzi, 2005). The duration of an ED can be a long struggle, with 60% of individuals reporting their EDs lasting six years or more (Pope et al., 2006). It is estimated that 50% of individuals do not recover sooner than six years after their first treatment from AN and average recovery time for individuals with AN who also engage in purging behaviors can be as long as 11 or more years (Finfeld, 2002). Keshi-Rahkonen et al. (2007) found the 5-year clinical recovery rate of AN was 66.8%. Similarly, in Fichter, Quadflieg, and Hedlund’’s (2006) 12-year long-term course study of AN, mortality was high and symptomatic recovery long and drawn-out with 47% still classified with an ED at 12-year follow-up. Recovery rates. Recovery from an ED can be a challenge, but many individuals do reach partial or full recovery (Cockell, Zaitsoff, & Geller, 2004). At least 50-75% of individuals with EDs will fully recover with integrated treatment (nutritional counseling, psychotherapy,  EATING DISORDER METAPHORS 7 physiological monitoring, and psychopharmacology), living a life free of food and weight obsession, maintaining healthy interpersonal relationships, having a positive relationship with food and their bodies, and not engaging in disordered eating behaviors (Strober, Freeman, & Morrell, 1997). Unfortunately, fewer than a third of individuals with EDs will receive treatment (Anorexia Nervosa and Related Eating Disorders, 2004). Without treatment, EDs have a high mortality rate, made even more so because of suicide; it is estimated that one out of every ten individuals with an ED will die (ANRED, 2004; Finfgeld, 2002). Treatment has been proven to reduce mortality to 3% (ANRED, 2004). Recovery and treatment. Presently, there is no universally accepted standard treatment for AN, BN, BED, or EDNOS. Treatment tends to be related to the ways in which the practitioner views the etiology and theoretical conceptualization of the ED. However, the current most accepted ““ideal”” treatment model includes an integrated approach with a treatment team, incorporating the skills of numerous practitioners, including: dietician or nutritionist, mental health professionals (psychologist, therapist, and/or psychiatrist), endocrinologist, general practitioner, gynecologist, dentist, and non-Western treatments such as massage therapist, yoga instructor, and acupuncturist (Department of Health and Human Services, 2007). Integrated treatment for EDs is costly and typically extends over several years. Unfortunately, insurance and the range of options of treatment are exceedingly inadequate, especially in non-urban areas. The average direct medical costs for treating ED patients in the United States is between five to six billion dollars per year (NEDA, 2005). It is becoming increasingly apparent that treatment and research efforts for EDs are too limited and insufficient. Given the high psychological, physical, and financial cost of these disorders to society, and the individuals that suffer from them, it is imperative that more efficacious treatments are developed.