Abstract
Binge eating disorder is a significant issue that affects a large number of individuals, most of whom are women. This disorder can be a chronic problem and is associated with negative consequences that may reduce the quality of life for the individuals who struggle with it. However, little is known about the recovery process from this disorder.
The purpose of this study was to create a theoretical model for understanding what is involved in the process of adapting behavioural changes in order to impact recovery from binge eating disorder. A snippet of a brief therapy session with an individual who suffered from a binge eating disorder was analyzed utilizing the grounded theory method. The basic social process uncovered was Self-Awakening, a process whereby the individual resolves the issue of disconnection to self. A three-phase model of help-seeking behaviour emerged: Self-Reflection, Assessing Present Life Situation and Planning for Recovery.
Introduction
Binge eating disorder (BED) is a recently acknowledged eating problem (American Psychological Association, 1994). Due to its relatively new status as a diagnostic category, the research on recovery from BED is limited. For instance, the research on recovery has not yet focused on people’s subjective experiences of the recovery process from this particular disorder. In addition, the research has not addressed the strategies used for recovery or the factors that have stimulated or aided recovery.
Both psychological, as well as physiological effects have been linked to BED. For instance, the presence of BED has been found to be highly associated with distress (Spitzer et al., 1992). Those who binge eat report feeling guilt, depression, self-condemnation, disgust (Amow, Kenardy, & Agras, 1992; Leon, CarrolL Chernyk, & Finn, 1985; Loro & Orleans, 1981), feeling fat or overweight, feeling angry towards themselves and stressed (Lingswiler, Crowther, & Stephens, 1989).
Physiological consequences of binge eating include abdominal pain, headaches, dizziness, and fatigue (Leon et al.;, Lingswiler et al.;, Loro & Orleans). BED is also linked with obesity, which is itself associated with a number of medical conditions (Romano & Quinn, 1995; Striegel-Moore, 1995).
An understanding of the process of recovery from BED is important for several reasons. BED affects a large number of individuals (Spitzer et al., 1992; Spitzer et al., 1993), most of whom are women (Smith, Marcus, & Eldredge, 1994; Spitzer et al., 1992). This disorder is associated with many negative consequences that may reduce the quality of life for the individuals who struggle with it (see Nature of the Problem). As well, BED has been thought to be a chronic problem for many individuals (Spitzer et al., 1993).
This, however, can be corrected, and research has shown that it is possible for people to make successful changes without professional help. Schachter (1982) found that 60% of people in two community studies made changes on their own by quitting smoking or losing weight. It has also been found that situational changes such as losing one’s job, changing schools, moving to a new location, or the death of a parent serve as powerful triggers for change (Bakker, 1975).
Virginia Satir’s model of change is thoroughly outlined by Gross (1994) and involves six stages. The first stage is labelled “status quo.” At this stage, there is little thought by the individual that things should be different. Life remains predictable and is maintained by self-reinforcing repetition. In the second stage, “the foreign element,” the status quo is disrupted by the entry of something external to the system.
The foreign element may be a new experience, a loss, social pressure or support from significant others, situational events involving shifts in social roles, maturational or developmental events, and physical or emotional pain from an accident or illness. “The tension between the impulse to remain the same on the one hand and the impulse to change on the other is heightened by the foreign element to set up chaos—the third stage…” (p. 99).
Stage three, chaos, is a stage of flux and involves the eruption of the tension to both resist and move toward a change. What was previously known and predictably becomes disarranged? In this stage, the person may experience fear about the loss of security, anger over an imposed change, or sadness over the loss of an imagined future. Next comes implementation, stage four. Feelings that once seemed intolerable become tolerable, assertion replaces submissiveness, healthier lifestyle choices are made, and risks are now taken. Stage five relapses, an arbitrary stage that could occur at any point between the third and sixth stages.
Relapse is considered a return to the status quo. Finally, stage six is the development of a new status quo. During this stage, the problems of integrating the new into the old system of actions, thoughts, and feelings have been solved, and the strange or new has become familiar. At this stage, support from others is essential (Gross, 1994).
The next theory of change, the transtheoretical model, has five stages (Prochaska & Norcross, 1999). The stages represent the various constellations of intentions and behaviours that individuals pass through as they move from having a problem to doing something about it. The first stage is pre-contemplation, when the individual has no intention to change their behaviour in the foreseeable future. Contemplation, the second stage, occurs when the person is aware that he or she has a problem and is seriously thinking about overcoming it but has not made a commitment to take any action. The third stage is preparation.
The person at this stage is intending to take action immediately and starts to show some small behavioural changes. The fourth stage is the action stage. The individual is modifying their behaviour, experiences, and/or environment in order to overcome their problems. Maintenance is the fifth and final stage. It is the stage at which the person is working to prevent any relapses and consolidate the progress made during the action stage.
This grounded theory research aimed at determining the core categories which emerged when a young lady spoke about her intent to rid herself of maladaptive eating behaviours and adopt a more healthy conceptualization of her weight utilizing the concepts of both the Satir and the transtheoretical models of change (See App. 1).
Method
During this study, a transcript of a brief therapeutic session with a young woman who suffered from a binge eating disorder was studied. The transcript was obtained from ______________________. Grounded theory methodology was used to analyze the transcript. Using grounded theory, comparisons were made between the interview and the literature in order to arrive at a new conceptualization of the dynamics of the experiences the participant delineated.
Glaser & Strauss (1967) delineated a process where there was a continual interplay between analysis and data collection. Essentially the researcher moves back and forth between collecting data and data analysis. The data are also compared and contrasted again and again to provide a check on their trustworthiness (Hutchinson, 1986). The theory that emerges from this process is grounded in the data rather than in the expectations of the researcher (Glaser & Strauss, 1967).
The procedures for the grounded theory method outlined by Strauss and Corbin (1990) were followed for this study. Strauss & Corbin (1990) delineated three different types of coding during the data analysis of the grounded theory method: open coding, axial coding, and selective coding (Strauss & Corbin, 1990). For the purposes of this study, open coding and selective coding were utilized. The first step of the analysis was coding data and writing memos about the concepts that recur in the data (Corbin, 1986). Open coding is the naming and categorizing of the phenomena through close examination of the data (Strauss & Corbin, 1990). Questions such as “What do I see going on here?” “What are people doing?” “What is happening?” were asked during this stage (Charmaz, 1983).
To start the analysis process, the data were broken down into concepts, which are the basic units of analysis (Strauss & Corbin, 1990). The researcher identified concepts that were cut from the transcript. These concepts were then grouped into substantive codes, which reflected the substance of what the participant had said (Glaser & Strauss, 1967). The substantive codes were organized with labelled envelopes. For example, any comment that participants made about starting to eat food that they had previously considered forbidden was given the substantive code name “incorporating forbidden food” and put into the same envelope. Substantive codes based only on the data aids in the prevention of the researcher from imposing preconceived impressions on the data (Hutchinson, 1986).
After the initial open coding, selective coding was conducted. Selective coding is the process of selecting the core category, systematically relating it to other categories, validating those relationships, and filling in categories that need further refinement and development (Strauss & Corbin, 1990). At this stage, the primary task is the integration of the categories to form a theory.
After a determination of the core category, the integration process was undertaken. The integration process of the categories at the selective coding stage was then conducted. There were five steps involved in the integration process, which were not meant to be followed in a linear fashion, but rather used when needed. These steps included: explicating the storyline; relating subsidiary categories around the core category by means of the paradigm; relating categories at the dimensional level; validating those relationships against the data; and filling in the categories that needed further refinement and/or development (Strauss & Corbin, 1990).
Analysis
After the interview snippet was analyzed using the grounded theory methodology discussed, the core category of Self-Awakening emerged. Self-Awakening describes a fundamental aspect of recovery from BED. Self-Awakening unfolded throughout recovery and entailed the participant learning more about herself, opening herself up to new experiences, and becoming more present, aware, and involved in her life. The experience of “awakening” or “opening up” is also found in other literature on recovery. The concept of Self-Awakening is compared to different types of literature to provide support for its use as the core category in this study. The types of literature include personal accounts of recovery from compulsive overeating found in self-help literature and literature on recovery from trauma and mental illness.
Self-help author Geneen Roth has written many books about compulsive overeating. In Roth’s (1993) book Feeding the Hungary Heart, personal accounts are given by women who have experience with compulsive overeating. Women’s stories found in this book capture the concept of Self-awakening (Roth, 1993). For example, Laura Fraser writes, “But I’ve stopped letting myself be controlled by the external—whether food or outward perceptions of appearance—and I’ve learned to listen to my inner self and to like that self. I’ve freed myself forever.” (p. 171).
Florinda Colvin also shares her experience, ‘The process of recovering from food and alcohol abuse has been a transition, a bridge that has taken me across to another side where my eyes are open, my senses alert.” (p. 194). The theoretical model developed through this body of research is one which begins with delineates that in order for an individual to establish a healthy relationship with food, it is prudent for that individual to engage in the process of Self-Awakening and a strong determination to change maladaptive behaviour.
During the course of the therapy, the session participant described a method she utilized when attempting to stop smoking. In so doing, she first became aware of the problematic behaviour and its impact on her life and then was determined to stop. Her decision to stop was coincidental with the arrival of a new year. The therapist was able to assist the client in her quest to end her binge eating behaviour by utilizing her willpower and the ability to stay on task (App.1).
Virginia Satir’s model and the transtheoretical model lend support to the model of recovery developed in this study. Virginia Satir’s six-stage model of change (Gross, 1994) contains concepts about recovery similar to the ones discovered in this study. In Satir’s model, there is the “status quo” stage wherein there is little thought about change. At the beginning of the interview, the young lady saw adopting healthy eating habits as somewhat of an impossibility (App.1).
Satir’s second stage, “die foreign element,” describes the entry of something external to the individual’s system, such as a new experience, a loss, social pressure or support from significant others (Gross, 1994). This stage is also comparable to what occurs in Phase I of the present theory. The categories of Life changes/transitions and Disapproval from others particularly capture the concept of “the foreign element.” The women experienced moving, a loss, the ending of relationships, the beginning of school or a new job, or a birthday. They were also faced with negative comments about their weight and the amount they were eating. These experiences were the contexts in which the motivation to make the transition to the second phase of recovery occurred.
An intermediary stage within the theoretical model developed in the course of this study is one that involves assessing one’s situation and initially resisting change. During this process, the client attempts to arrive at a reason why change could not occur. In an attempt to counteract this, the therapist asks the client if she always falls short of what she is determined to do. This engages the client, and she begins to delineate an experience wherein she was able to delineate an instance when she was able to successfully eliminate maladaptive behaviour. This served to reassure the client that she was indeed able to make life-altering changes.
In so doing, it effectively eliminated her resistance (App.1). The resistance stage of this theoretical model mirrors the chaos stage of Satir’s model. In the chaos stage, Satir captures the eruption of the tension to both resist and move toward a change (Gross, 1994).
The final stage of this grounded theory model is one in which we see an emergence of an attitude to attempt to adapt to healthier life choices (App.1). In this model, there is only a change in attitude, but in the fourth stage of Satir’s, the individual does more than contemplate changes. The individual begins to impact those changes, become more assertive, and take risks (Gross, 1994). Although Virginia Satir’s model of change and the model of the present study do not occur in the same number of phases, they both contain comparable ideas about what occurs in recovery.
Like Virginia Satir’s model of change, the transtheoretical model of change also has many similarities with this study’s model of recovery. As discussed earlier, the transtheoretical model has five stages (Prochaska & Norcross, 1999). The precontemplation stage closely mirrors the Self-awareness phase of this study as well as the “status quo” phase of Satir’s model. They are similar in the sense that the participant in this study had not yet realized the scope and ramifications of an eating disorder. Nevertheless, there is a difference between the two models’ first stages. The difference is that the participant in this study was attempting to recover in Phase I by seeking help and by focusing on weight loss. These recovery strategies, particularly focusing on weight loss through diet and exercise, is commonly found among people with BED (Spitzer et al., 1993).
However, these strategies were aimed at addressing the effects of binge eating, including the distress in the women’s lives, rather than tackling the problem of binge eating itself. Perhaps attempts to recover at this phase may not be found with people struggling with problems other than binge eating. People with BED could be attempting to recover early on in their struggle with binge eating because weight gain and being overweight is not socially acceptable in North American culture but are often a symptom of binge eating. Future research is needed to clarify this point.
Within the transtheoretical model of change, there are five stages. The other stages being contemplation, preparation, healing/restoring and maintenance. The grounded theory developed in this study does exemplify some of the elements demonstrated in the stages of the transtheoretical model in that we do see some level of contemplation, and there is a definite preparation for healing and a plan for maintenance.
Discussion
Researchers have only recently begun to take an interest in the area of recovery from BED. The specific aims of the study included: generating a theoretical framework for understanding the process of recovery, identifying and describing the factors that stimulated and aided in the process of recovery, and identifying and describing the strategies that helped along the process of recovery.
In analyzing the data from this interview, one clear theme emerged—Self-awareness. The grounded theory described in this study mirrored many of the elements shown in both the Satir and transtheoretical models of change. We see the study subject first realizing her role in her disorder and then going through a phase of denial only to emerge realizing the necessity to engage in a healthy relationship with food and depart from the maladaptive behaviour.
A number of strengths and limitations emerged in this study of recovery from BED. One inherent strength is the fact that the study examined recovery from BED from the perspective of the participants. The theory of recovery was developed using the information relayed through the dialogue the participant engaged in with the therapist. Gaining insight from an individual who is actually experiencing the disorder goes far beyond simple theory. Another strength of this grounded theory is that it fits the criteria of a useful theory outlined by Glaser and Strauss (1967). It “fits” the situation being researched, has “grab,” and “works” when put to use. The theory “fits” because the generated categories are indicated by and applicable to the data.
Although many measures were employed to ensure the trustworthiness of this study, caution must be taken when considering the results of this study. The transferability of this study was compromised to some degree because it utilized one individual as a test subject and a host of theoretical and practical research. Another limitation of this study is the fact that the study subject may have portrayed some inaccurate information either intentionally or unintentionally.
The grounded theory analysis of BED is one that points to various ways that counselling can be improved when working with women who have BED. As well, issues that counselling psychologists need to be aware of and address in therapy when working with this population emerged. The counselling implications discussed are supported by literature in the area of eating problems. Counsellor awareness is definitely one of the implications of the study in that the literature, as well as the data analysis, indicates that there are a few issues for counsellors to take into account when working with clients who have BED. One of these issues involves prior addictive behaviour and whether those were overcome or not. If the client has successfully overcome a prior addiction, a similar method can be utilized to overcome BED.
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