Ambivalence and Eating Disorders: Inpatient Treatment, Belonging, and Identity

When Tetyana Tweeted and “Tumblr-ed” (is there a better name for putting something on Tumblr?) a quote from a qualitative research article about ambivalence and eating disorders, I knew I would want to write a blog post about it. Of course, life happened, and so this post is coming a little later than I had intended. Nonetheless, I am happy to be sharing a post about a fresh article by Karin Eli (2014) about eating disorders and ambivalence in the inpatient hospital setting. The article itself is published through PLOS One and so is also open access, in case you are interested in reading the original.

THE STUDY

This article is about one aspect of a larger longitudinal study Eli conducted in Israel between 2005 and 2011. The broader study explores the “sensory experiences” (embodied feelings, sensations, and perceptions) of individuals with eating disorders and how these relate to identity. This paper considers one part of participants’ broader stories of having eating disorders; specifically, how individuals with eating disorders experienced inpatient hospitalization.

Eli conducted interviews with 13 participants. Of these participants:

• All had been hospitalized in an adult inpatient ED unit in Israel
• 4 participants were interviewed only at the first point in time
• 9 were interviewed at 2 points in time 5 years apart
• 2 of these participants who were interviewed twice were hospitalized again between the 2 time points
• 6 were recruited using an informal network of referrals (e.g. other participants told them about the study)
• 4 were recruited from an outpatient clinic for EDs
• 2 were recruited from an online pro-recovery forum
• 1 was recruited from an ED advocacy organization

In terms of demographics, participants were:

• 12 women, 1 man
• Aged 18-38 when first interviewed
• 12 diagnosed with AN or EDNOS AN-type
• 1 diagnosed with BN

Interviews focused on the course of the eating disorder and how participants experienced their eating disorder in their bodies (e.g. the sensory experience of having an eating disorder) and how they made meaning during their eating disorder and in recovery. Eli conducted modified interpretive phenomenological analysis (IPA) on the interview data.

Broadly, IPA is a qualitative methodology that researchers use to explore how participants experience a specific phenomenon (in this case, an eating disorder). One of the key aspects of IPA is an attempt to centralize what experiences or phenomena mean to participants, rather than what they might mean to someone else. Eli refers to her approach to IPA as “modified” as while IPA researchers normally explore themes within cases, she clustered themes across the participants’ stories. [Caveat: of course IPA is much more complex than this brief summary, and nor is IPA my approach to qualitative research, so please check out these resources if you are interested in learning more: Hefferon & Gil-Rodriguez, 2011; Smith & Osborn, 2007; Biggerstaff & Thompson, 2008)]

Eli analyzed her transcripts looking for participants’ experiences of treatment, both positive and negative. In doing so, she found that participants’ accounts often reflected a feeling of ambivalence toward the treatment experience: that is, participants talked about how inpatient treatment had been not wholly positive or wholly negative, but both and in-between. With this in mind, the author turned to the data and explored the experience of ambivalence within the inpatient treatment unit.

THE MAIN RESULTS

Three main themes emerged from the data:

1. Recognition and legitimacy
2. Dynamics of the inpatient community
3. Boundaries

Each of these themes had 2 subthemes (described below using Eli’s theme names). Participants actively negotiated their individual and social positions within the hospital unit and beyond, and accounts were rife with complexity and ambivalence. The findings are particularly intriguing as the same environment was interpreted and experienced differently not only between participants but also by the same participant at different moments in time.

Recognition and Legitimacy

The Eating Disordered Self

Eli describes how participants came to experience their eating disorder as “legitimate” when diagnosed and when they subsequently entered inpatient treatment. While this affirmation of the “eating disordered self” could help someone feel validated, participants were not always comfortable being lumped into a group of individuals with eating disorders.

In some ways, inpatient treatment was affirming, particularly if participants had felt “not sick enough” to warrant treatment. The clinician’s authority was respected, perhaps particularly as participants’ accounts reflected a sense of eating disorder identities as fluid and requiring work to uphold. For example, one participant said:

Just like you, you know, worked really hard, [and] with blood, sweat, and tears got those two degrees of yours, [then] I’m not worthy of this title, I didn’t spend enough on it… not enough blood, not enough tears, not enough suffering. (Vered)

The Patient as an Individual

Though participants did feel that clinicians’ diagnoses and inpatient treatment affirmed their eating disorders, they sometimes felt frustrated with the way in which their diagnoses came to be regarded as the most important part of their identity in interactions with healthcare providers. This was especially true when participants had experiences or emotions not related to their eating disorders that were brushed off as part-and-parcel of what clinicians understood to be “the eating disorder.” One participant said:

When I was at [the ward] and I had a [GI condition] and it was really painful, and they told me, no, it’s psychological because they raised your [calorie intake]…. They didn’t believe me until they found me, fainted…. That’s what annoys me, that they don’t trust you. (Danielle)

Dynamics within the Inpatient Community

Seeing the Self in Others

Some participants felt a strong sense of community in the inpatient unit, for example noting that they made friends who could understand what they were going through. Eli describes how participants felt “a sense of connection with the patient community that extended beyond speech and toward embodied practice- a shared way of being-in-the-world” (p. 5). Extending this beyond other work looking at the development of community in eating disorder treatment, the author reflects that participants sometimes experienced shifts in how they saw themselves as a result of interacting with like others.

You see the frustration in seeing an amazing, lovely girl, where there’s nothing, nothing bad to say about her, and she’s just ruining her life over nonsense…. And you suddenly get what other people who talk to you are going through. (Emily)

Dangerous Others

On the other hand, some participants felt triggered and/or learned new eating disorder related behaviours in the inpatient setting. Participants sometimes experienced feelings of jealousy when comparing themselves to incoming patients and/or expanded their repertoire of symptoms. This was not necessarily about asking other patients what they did, Eli explains, but more a side-effect of being in close community with others with eating disorders.

Boundaries

Sheltering Boundaries

Inpatient settings are evidently relatively rigid environments with set schedules and plans. Some participants found this “regimented living” to be comfortable:

There is something really good about the fact that there’s an organized diet, that there’s some sort of certainty…. Things are very clear. And it spares you this engagement, a certain part of the engagement that used to exist at an obsessive level. (Alon)

At the same time, the “greenhouse” bubble, as participants referred to the inpatient setting, was acknowledged to be a carefully constructed place set apart from the “real world.”

Oppressive Boundaries

Although the created environment of the inpatient ward could be comforting, some experienced it as overly constraining. This was especially true, Eli notes, for participants who were older and/or had many responsibilities outside of the ward:

Even though I feel that I progress a lot and such, I’m really sick of this.… It’s very very difficult for me, this distance from [my daughter], from my home…. Being here, eating this diet, I have no strength anymore, I’m tired already. (Vered)

Eli describes the inpatient unit as “liminal,” or in-between. It is “a space of constant transitions” (p. 7) like other parts of a hospital. This liminality is linked to the experience of an eating disorder itself; the state of “being eating disordered” is, as noted above, often experienced as dynamic and changing. So, it seems appropriate to look at this experience in terms of ambivalence. Too often, the word “ambivalent” in the eating disorder context gets taken as a “bad sign,” or an indicator of not caring. Eli’s article challenges this association, suggesting instead that ambivalence is perhaps more an indicator of how patients negotiate the experience of living in this in-between-ness.

IMPLICATIONS

Overall, I think that this article offers us lots of food for thought when considering the lived, embodied experience of eating disorders. I really wish that it had been available while I was working on my Masters thesis, because many points resonate quite well with my participants’ experiences. This article opens up room for discussion about that which is neither wholly positive nor wholly negative about eating disorder treatment.

The point about “dangerous others” reminded me of discussions I’ve had in the comments section on previous posts about inpatient settings and how this environment is not always a healthy place for individuals with eating disorders. In the context of the article’s focus on ambivalence, Eli does a good job at exploring how this is more complex than simply saying that inpatient communities are always negative or always positive. While inpatient communities and strategies for treatment might be experienced as traumatic, there are also elements of safety or refuge in the inpatient community, for some. This isn’t necessarily good or bad; it reflects in part the “built environment” of a hospital.

Eli’s discussion of the “liminality” of the inpatient eating disorder community does justice to the complexity of this experience. I feel like a broken record when I say that we need to continue to contend with the complexity of eating disorders and recovery, but I think that this article highlights just that. The complexity of the author’s exploration of the lived experience of eating disorders is encouraging.

I’ve found that in feminist literature, inpatient settings tend to be described as replicating the rigidity of eating disorders themselves; while this may certainly be true, and while I agree in many ways with this analysis, Eli’s article helps to complicate this idea, centralizing on how participants also noted feeling that this environment provided a “space away” for contemplation and recovery. What I am missing, however, is a deeper exploration of the transition back into the “real world.” What are the implications of the constructed and regimented environment as participants move back into their social worlds? Are we just setting up new rules that people need to abide by “in recovery”?

I would love to see more work in this vein exploring life “after” the inpatient experience, or around the experiences of those who do not seek treatment. How might their experiences differ? Are there other spaces of community and yet “dangerous” belongings that individuals with eating disorders experience outside of the inpatient unit? I think (and hope) that this study opens the door for more research looking into ambivalence and avoiding the polarization of eating disorder experiences as “negative” or “positive.” It is just so much more complex than that.

References

Eli, K. (2014). Between difference and belonging: configuring self and others in inpatient treatment for eating disorders. PloS ONE, 9 (9) PMID: 25210886