Occupational therapy’s role in the exploration of meaning in anorexia

Anorexia holds the highest mortality rate of any mental health illness, associated with poor treatment response and high relapse rates (Van Hoeken and Hoek, 2020). Given the associated physical health risks, the goal of treatment is to resolve malnutrition, often meaning care and focus for anorexia is foregrounded in the body (Eli and Lavis, 2021). Although addressing physical effects is lifesaving and imperative, qualitative accounts of treatment consider that the prioritisation of food and weight eclipses other psychosocial needs of the individual (Conti et al., 2021; Rance et al., 2017). As a result, treatment interventions can overlook other meanings held by individuals (Conti, 2018), and clinicians can infer meanings around anorexia, such as body image concerns and a drive for thinness (Eli and Lavis, 2021). There have been calls for a consideration into what anorexia does for the individual, as opposed to only what it does to an individual’s body (Lavis, 2018). Such discussions can provide insight into the lived experience of anorexia and the complex functions maintaining its presence.

Meaning is not unique to occupational therapy or occupational science; it has been examined across fields of sociology, literature, psychology and philosophy, and debated throughout human history. A core belief within occupational therapy is the premise that occupations are vessels for life meaning, contributing to a sense of identity, sustaining wellness and acting as a transformative force in the face of illness, trauma and life transitions. Consideration of who defines meaning; the dimensions of meaning; the link between occupation, meaning and health; and how meaning is constructed and enhanced has remained unclear, contributing to a lack of unanimity around meaning within the profession (Ikiugu et al., 2015). There have been calls to broaden our understanding beyond simple categorisation of occupation to research meaning and the complexity of individual’s occupational engagement (Hammell, 2017; Twinley, 2017). Pentland’s recent editorial in the British Journal of Occupational Therapy urged members of the profession to engage with complexity, and the wider context of how occupation is given meaning to (Pentland, 2021). As a highly complex illness, anorexia requires an equally complex conceptualisation.

Eating disorders are considered egosyntonic, referring to how individuals value and hold positive meanings towards their illness, viewing it as part of who they are. Appearing to be a friend, offering safety and protection, a form of self-care and a way of living through the distresses of everyday life (Lavis, 2018). Serpell et al.’s (1999) grounded theory study was among the first to explore the psychological meanings anorexia holds, whereby anorexia acted as guardian, helped to avoid emotions, gave a sense of control and communicated distress. Since then, several researchers have explored the meaning of anorexia, revealing the strong sense of identity that anorexia offers, for which abandoning would mean losing oneself (Gagnon-Girouard et al., 2019; Marzola et al., 2016). A plethora of research has now built clinical consensus on the maintaining factors of anorexia, which are incorporated into models and interventions such as the Maudsley Model of Anorexia Nervosa Treatment for Adults (Treasure et al., 2020).

Despite this, others suggest that a combination of clinical, practical and theoretical reasons means ‘meaning focused’ therapies [have] faded from the field’ (Troupp, 2019: p. 19), superseded by attention towards physical restoration. In an illness where ambivalence to recovery is well documented, and trust is fragmented between patients and healthcare providers, exploring meaning offers space to communicate to individuals, a sense of being heard and understood (Sorlie et al., 2020). Exploration of meaning has been recommended to help understanding of individuals’ inner worlds, and the subjective meanings they hold (Espíndola and Blay, 2009).

Individuals with anorexia and their occupational engagement can be assumed to be pivoted around shape and weight concerns; however, research from the social sciences reveal there are overlooked meanings in the experiences of eating disorders. Including how food practices are connected to themes of morality (Cheney et al., 2018), a way of managing trauma (Lavis, 2018), related to ideas around asceticism and wider cultural meanings around food and eating (Churruca et al., 2017; Moola and Norman, 2017).

Occupational therapy’s traditional goal within eating disorders has been to improve function in occupational engagement. However, dating back to 1986, McColl and colleagues noted how engagement in activities for individuals on an inpatient eating disorder ward was limited, concluding ‘doing is not enough’ (McColl et al., 1986, p. 143). They concluded future research should explore whether occupational therapists are engaging individuals in meaningful tasks which address underlying meanings. More recently, Dark and Carter (2019) found although occupational engagement and doings increased during recovery from an eating disorder, it was the changed meanings of occupations that participants noted an even greater transformation.

The observation that people’s experiences of occupations are not always fully, or sometimes ever, addressed led to Twinley’s (Twinley, 2021) theoretical concept, the dark side of occupation. A pertinent concept concerning eating disorders, as the occupations of the illness, although highly destructive, are purposeful and ‘reinforced with illness-focused meaning’ (Elliot, 2012, p. 17). The dark side of occupation offers an alternative here, appreciating the complexity of occupation, which is contextual, avoiding categorisation of experience, and turning to a more authentic occupational therapy practice.

Recovering from an eating disorder against a cultural backdrop characterised by dietary restraint and weight management, exacerbated by government and public health narratives, can contain conflicting and contradictory constructions of food and eating. Everyday taken-for-granted occupations such as exercise and healthy eating are considered ‘normal’ practices and commended within Western contexts. As such, these occupations are never questioned or challenged. In practice, therefore, the meaning and motivation of occupation can be hidden by individuals themselves or overlooked by professionals due to personally held beliefs and assumptions about what constitutes ‘healthy/unhealthy’ occupation.

What does this mean for occupational therapists? Firstly, it is important for occupational therapists to avoid generalised assumptions concerning both medicalised and taken-for-granted Western assumptions of meaning. This will enable a greater understanding of the meaning individuals hold towards their illness, encouraging holistic practice, and supporting understanding of what sustains the illness (Marzola et al., 2016).

Secondly, there needs to be a willingness to enter an individual’s world and to consider hidden meanings held towards occupations. If occupational therapists fail to understand the meanings beyond visible engagement they could, at best, develop wrong assumptions but, at worst, leave individuals with a meaning vacuum once the meaning of the illness is taken away. An exclusive focus on weight and food in treatment approaches may deprive individuals of meaningful ways of being in the world, without the presence of more functional ones (Stockford et al., 2018). Paradoxically, treatment can lead individuals to engage even further in health-compromising activities as a means of asserting their autonomy and sense of self, causing them to retreat into the safety and meaning of their illness (Holmes et al., 2021). In conclusion, further exploration of occupational meaning in relation to eating disorders could lay the groundwork for more meaningful conversations and support ‘ways of filling the void left by the eating disorder’ (Cowan and Sørlie, 2021: p. 118).