An interpretive phenomenological study of the therapeutic relationship between women admitted to eating disorder services and their care workers.

Abstract

Aim: To explore the lived experience of the relationship between women with anorexia and their care workers in the context of a specialist eating disorder unit.

Background

The establishment of a positive therapeutic relationship (TR) has been widely acknowledged internationally as an intrinsic part of therapy and caring services; which is healing and restorative in its own right. A TR is crucial when working with patients who are difficult to engage and have high 'drop-out' rates such as those within eating disorder services who are considered to be ‘high risk’, ‘difficult’, ‘defiant’, ‘reluctant to engage in treatment’ and ‘frustrating’ (Fairburn and Harrison, 2003; Pereira et al, 2006). To date there has not been any qualitative exploration of the therapeutic relationship involving women and their care workers.

Method/ Methodology

This interpretive phenomenological study focuses on women with anorexia and their care workers in both day care and in-patient specialist eating disorder services in the UK. Van Manen's methodological and analytical approach was adopted for this study. Twelve women with anorexia and thirteen of their care workers (nurses, doctors, dieticians and therapists) participated in the study which was conducted in two phases. Phase one was conducted with care workers and women with anorexia in a day care service (between October - November 2009). Phase two was conducted with care workers and women with anorexia within an inpatient care unit (between May – June, 2011). Semi-structured interviews were conducted with all participants to explore their experience of the therapeutic relationship. Phase one data were thematically analysed, following which the full data set (phases one and two) was analysed as a whole, using MAXQDA as a tool for the organisation of the emerging themes. The initial themes were subsequently re-organised into themes and sub-themes through the lens of Merleau-Ponty's existential themes and Heidegger’s concept of ‘authenticity’.

Findings

The findings illustrate that the experience of the therapeutic relationship for women with anorexia and their workers cannot be viewed without fully acknowledging the impact of the anorexia, the anorexic identity, the context (the therapeutic landscape) in which this exists and the effect of time. Hence Merleau Ponty's existential lens provided a very suitable framework for the findings.
Corporeality, the bodily experience, is integral to the lifeworld of both women and workers and reflects the primary goal of eating disorder services. Its associated sub-themes of 'identity', 'externalisation' and 'recovery measured in kilos' highlight how anorexia is integrated within the women’s perception of their identity , as well as the care workers focus on weight restoration. ‘Spatiality’ reflects the significance of ‘space’ in the creation and experience of a TR; the sub-themes of 'lived space', 'the therapeutic landscape' and 'rules and regulations’ consider the contextual basis of care. The theme relationality focusses on the person-to-person encounters and included the sub-themes 'conflicting perspectives' and 'maternalism'. Finally, the time spent together was considered to be fundamental to the connection made between the women and the workers and so, within temporality, 'the gift of time' and 'availability' emerged as sub themes within the data. The fifth theme, 'authenticity' is pivotal to both the therapeutic relationship and also phenomenology and reflects Heidegger’s perception that authenticity is 'being one's self', for which honesty and truthfulness are essential components. Hence this last theme includes the sub-themes of 'the power and uniqueness of the individual', 'empathy for the worker' and 'trust'.
Both the women and the care workers valued the relationship but the externalisation of the disorder created difficulties in the authenticity of the relationship. A temporary, maternalistic, nurturing approach was highly valued and recognised as only transitory.

Contribution to knowledge of the subject

This study offers new knowledge and understanding about the experience of the relationship that occurs between women with anorexia and their care workers. Overall, the findings suggest that a whilst a relationship that has therapeutic effects existed between the women with anorexia and their care workers, some fundamental features of the therapeutic relationship that have been previously accepted as pre-requisites in other contexts (e.g. mutuality and reciprocity) were not identified as crucial to the instrumental nature of the relationship. Care workers should re-consider the assumptions of mutuality for this client group and thus construct their relationship differently. A meaningful connection can be made between the care workers and the women which is based upon a 'tear and repair' model, but it is only therapeutic if the patient perceives it to be therapeutic for them. A fractured relationship is inevitable when the woman's sense of self is split, that is, divided into the authentic ('real') self and the anorexic self. Hence, in order to gain an authentic connection, it is suggested that the care worker focus on the 'real' woman in order to establish a relationship with the part of the person that has the capacity for an authentic relationship. Thus, a two-fold intervention takes place; the relationship is potentiated and the woman's battle remains between her and her anorexia, rather than with her care workers.