Little attention has been paid to the eating experience of anorectic females during the course of their illness. In order to enrich this understanding, two adult anorexics were selected and their emails were collected and analyzed. Analysis of these emails reveals the patients' experiences with and feelings about eating, which can provide an in-depth understanding of their circumstances and family dynamics. The paper ends with a discussion of the results, limitations, and implications of using emails as the data source of a qualitative study, and how they can reveal the informants' inner landscapes.
Key Words: Anorexia nervosa, eating, email, qualitative research & Hong Kong
The use of emails as qualitative data sources has both its advantages (including speediness, easy access to a wide spectrum of samples, unobtrusiveness, and being user-friendly) and disadvantages, for instance, the potential for biased selection of a population, and inability to observe non-verbal behaviors of both researchers and the researched subjects (Selwyn & Robson, 1998). In nursing research, the use of emails for concept synthesis was examined with three types of participants: the elderly living in a retirement facility, people with AIDS, and cancer patients undergoing active treatment (Bunting, Russell, & Gregory, 1998). However, not a study can be identified in Hong Kong, which has used emails as a research tool in qualitative studies of anorexia nervosa (AN).
Two local studies (Ma, Chow, Lai, & Lee, 2002; Chan & Ma, 2002) have shown that anorexia nervosa is culturally specific to the patients' familial contexts. For example, self-starvation of an anorectic daughter can be viewed as disciplining the body and punishing the family (Chan & Ma, 2002). However, there is no interpretative analysis of the anorexics' eating experience based on the data collected by emails.
The data collected for this study were obtained from the research project "Evaluation of Structural Family Therapy for Chinese Anorexia Nervosa Patients in Hong Kong" (Ma, Lai, & Lee, 1999). This project is staffed by a research team comprising members of the Department of Social Work and the Department of Psychiatry of The Chinese University of Hong Kong. The principal researcher and co-author of this paper (JLCM) was the main therapist to the families who participated in the project. A reflexive team, consisting of postgraduate students who are learning family therapy, observed the therapy sessions behind a one-way mirror and provided feedback on these sessions. The first author of this paper (ZCYC) is one of the reflexive team members.
ZCYC is a registered nurse, a Ph.D. student and a research assistant of the above project. She has to carry out several tasks: conducting the pre-and-post family therapy interviews; observing the family therapy sessions from behind the one-way mirror; offering psychological support and health education; and replying the anorectic patients' emails. After six months of writing and replying these patients' emails, two anorectic females were selected in exploring their subjective experiences of eating.
When ZCYC began corresponding with the patients by emails, she had no intention of conducting the present study as a means to understand their anorexic eating. In fact, the idea for study was formulated only after the prolonged engagement with both informants and after reading through the content of the emails.
Two common themes emerged from the emails: the informants' anorexic eating is unique to each and, in both cases, is related to their family dynamics. This is a qualitative approach that intends to explore the deeper meanings of the anorexic eating from the informants' perspective. From the researcher's perspective, email as a research tool offers several advantages in the present inquiry: to minimize the research effect that would inevitably arise from the face-to-face interview; to offer the informants an ownership in expressing their views towards any topics in an unstructured format; to serve as a communication channel between the informants and the researchers, and last but not the least to achieve a therapeutic purpose.
This paper comprises four parts: 1. the literature review of local studies on anorexic eating, 2. research method, 3. results, and 4. conclusion.
Local studies of anorexia nervosa can be roughly grouped into three types: diagnosis- and symptoms-oriented (e.g., Lee, 1993), exploration of the perception of the general public toward AN (e.g., Lee, 1997), and verification of the psychometric measures of eating disorders (e.g., Lee, Lee, Leung, & Yu, 1997).
Davis and Katzman (1997) used a closed-ended questionnaire to examine body weight satisfaction, self-esteem, depression and compensatory behaviors of dieters among Chinese students in Hong Kong, and then compared the findings with Chinese students in the United States. While appreciating the inter-relationship among the different variables under study, this study failed to explore the actual meanings of the compensatory behaviors of dieting from the participants' perspective. The instrument employed was developed in the West and its content validity in a Chinese context was doubtful.
Lee, Lee, and Leung (1998) evaluated the cross-cultural validity of the Chinese version of the Eating Disorder Inventory (EDI) in a clinical sample of patients with eating disorders. This study aimed to validate the EDI, rather than to tap into the actual eating experience of the patients.
Lee, Lee, Ngai, Lee, and Wing (2001) explored the rationales for food refusal among Chinese patients with AN (N = 48) using self-reporting questionnaires. This study examined the rationales of food refusal with a quantitative approach with the pre-assumption of certain answers. Its research design has rendered it impossible to explore the meaning of food refusal in a Chinese context.
Two inadequacies of these studies were found: the researchers' gender insensitivity and an absence of the AN patients' voices. Besides, guided by a positivist paradigm, these studies had employed a mechanical research design that failed to examine self-starvation in an in-depth manner within a Chinese cultural context.
In the view of the above, there is a knowledge gap in understanding the anorexics' subjective eating experiences. This study can be regarded as the first academic pursuit to fill in the knowledge gap.
In order to understand the informants' unique subjective experience, this study had employed a qualitative inquiry with case studies as its research design. Audet and d'Amboise (2001) stated that improving our understanding of a deeply embedded phenomenon could be accomplished by a qualitative approach. Zucker (2001) suggested the patient's perspective is significant in a case study design. The present study integrated these two views. The data were collected from the emails, which were written by the two adult female anorexics. They sent emails to ZCYC in order to seek both psychological support and advice on issues related to their health, and to express their feelings in a non-intrusive and more relaxed manner.
The first informant, Nancy (a pseudonym), aged 25, an accountant trainee who had met the diagnostic criteria of DSM-IV (American Psychiatric Association, 1994), was selected from the data set of our family therapy research. At a height of 158cm, she weighed 28 kg when she was first referred to family therapy on 21 April 2001. The details of her body weight are presented in Table 1. Nancy's family members include her mother, aged 55, a housewife; her father, aged 56, a businessman; and a younger sister, aged 18, a Form 6 student. This family has received a total of nine sessions of family therapy at the time of preparing this manuscript and is continuing with the treatment (all family sessions were provided by JLCM).
The second informant, Ann (a pseudonym), aged 21, a third-year university student who had met the diagnostic criteria of DSM-IV (American Psychiatric Association, 1994), was also selected from the data set of our family therapy research. At a height of 160cm, she weighed 34kg when she was first referred to family therapy in September 2000. The details of changes in her body weight throughout the treatment are presented in Table 1. Rose's family members include her mother, aged 54, a housewife; her father, aged 57, a departmental supervisor; an elder sister, aged 25, a nurse; and a younger brother, aged 19, a second-year university student. This family received ten sessions of family therapy with one session of marital therapy for her parents. The family treatment was terminated upon the patient's recovery.
|Date||Body Weight||Date||Body Weight|
|April 28, 2001||28 kg||Sept 3, 2000||34 kg|
|May 6, 2001||29 kg||Sept 10, 2000||34.5 kg|
|May 12, 2001||29.5 kg||Sept 18, 2000||35.7 kg|
|May 20, 2001||30 kg||Oct 29, 2000||37.3 kg|
|June 2, 2001||30 kg||Nov 26, 2000||39 kg|
|June 16, 2001||30.5 kg||Dec 10, 2000||39.5 kg|
|July 13, 2001||32.5 kg||Jan 7, 2001||39.5 kg|
|July 28, 2001||32.5 kg||Feb 4, 2001||40.5 kg|
|August 14, 2001||33.5 kg||April 15, 2001||40 kg|
|July 5, 2001||45 kg|
At the beginning of the email relationship, we had no intention of collecting and analyzing the emails for research purposes. Rather, it was for the purposes of communication only. After several months of exchanging emails, their anorexic eating experience began to emerge, and this information was missing from the local literature. Both informants' written consent had been obtained in the first family session for participating in Ma et al.'s (1999) project, but as the informants had not been informed that their emails would be used for the present study at the start of the project, the purposes of the present study was further explained to both informants; their verbal consent was sought before extracting and presenting their emails.
Twenty-four emails were collected from the informants: eighteen from Nancy and six from Ann. The emails varied in length, ranging from half a page to two pages, with a font size of 10-12 on A4 paper. The emails from Nancy were sent between May and August 2001; emails from Ann were sent between April and July 2001.
Murphy, Dingwall, Greatbatch, Parker, and Waston (1998) have suggested that in offering an alternative plausible explanation for the data under study, the researchers should be aware of the fact that the potential bias or the particular stance they held would affect the interpretation of the result. Sensitivity to the informants' context and the researcher's reflexivity during the research process are the key factors for ensuring the quality of the study (Seale, 1999).
In order to ensure authenticity and the trustworthiness of this study, a client-driven approach to data collection was employed. These emails were edited as little as possible to present the subjective experiences of the informants vividly, with their own choices of word, mood and writing style. The selections presented below were chosen by ZCYC. They were then given to the informants to read in an attempt to prevent any misinterpretation. More importantly, the informants had final authority over whether to disclose the data, based on whether they felt there was any potential for harm in so doing. Here, then, are the emails.
Nancy sent the following email to ZCYC seeking advice about her eating behaviour (email dated in May 2001):
Thank you for your email. Now I am more relieved about my late-night binge. But I still have some doubts, hope you can help me clear them up:
- Is it OK that I eat that much at the end of each day rather than distributing it equally throughout the day? (though the former way seems better, as I can tell myself "hey, girl, after all, you are eating less than your sister! after all!");
- I am eating junk food - ice cream, loads of biscuits, bread, those Garden chocolate roll cakes, chocolate fingers, chocolate McVita's, buttery cookies... it seems that this is not as healthy as gaining weight by eating meat, milk, or carbohydrates;
- Is it unhealthy to eat just before bed?
- Could it become difficult to stop? After all, this is not a normal eating habit.
- Am I controlled by food then, just in another way -- keeping the quota to the end of the day, albeit I am eating more than before?
Nancy was struggling with refeeding at home after the third family therapy session. She was confused and curious about her eating habits. ZCYC offered her psychological support and normalized her perceived eating problems, explaining that her body was being honest with her after a long period of self-starvation. Her body was telling her that she is in great need of food in order to fight the battle against anorexia.
Nancy expressed her fat phobia (email dated in May 2001):
Now that I am eating more than my sister, I am really scared, very scared indeed. Not only because I am eating far more than my sister AND having fat deposited in undesirable parts of my body and getting a totally worse figure than she has - that fat which I had tried so hard for 3 years to get rid of - but it may also become another problem even BEFORE I get rid of the AN problem. I really don't want to have another problem. Any advice?
Nancy described her worries of developing a binge-eating type of anorexia nervosa (email dated in June 2001):
I have a big worry: I eat normally during the day (as much as my sister is eating, though maybe less a bowl of rice in total) but I eat two scoops of ice cream at the end of the day followed by a large package of cookies (you know, those buttery blue-labelled type), and then 2 pieces of honey bread from Garden's bakery. I am really scared that I am becoming a binge eater, or worse still, developing anorexia-bulimia, like many AN sufferers do.
I am not exaggerating the situation - I really eat this much. Last week, I could only stuff myself with 2 scoops of Haagen Daz after dinner, but these days it's getting worse - now that I can add bread and buttery cookies (a whole packet - not those mini-size ones, mind you). What should I do? I know that I should gain weight but I should be getting the extra pounds by more normal means like meat or milk - and I am really worried that once this binge and indulgence becomes a habit, it's very difficult to get rid of, just like AN, and this is really not what a normal person would do.
When this email was written, she had received the fourth family session and she had gained 2 kg since the first session. From the above vignettes, it is clear that Nancy still experienced some reservations about refeeding. For example, she considered the nutritional components between the so-called junk food and the balanced diet that were very important for her weight restoration. What ZCYC did was to ensure that she should not stick on the dichotomy of nutritious food versus "junk food"; rather, getting enough calories and following her food preferences should be the motives for resuming health.
Nancy explained that she was always comparing her eating patterns with her younger sister (email dated in June 2001):
Mom, Dad and Sister would be having bread and bagels for breakfast. I couldn't help counting how few calories my sister would be having. She hates bread and she would definitely have only very very little soy milk. How could this be enough??? She was having much less calories and fat than I was -- since I'd have finished a whole carton of Resource by noon- with 250 calories and 6g of fat. How desperate I am to hope my sister is taking in more calories and fat than I am. I know I shouldn't compare with her because I have to gain weight and I have to be healthy, but I just can't help it - this is the very thing that keeps me from eating freely and enjoyably. Whenever I eat, I either calculate how many calories she's taking or I let her finish first so I can count how much she's eaten compared with me. How ridiculous and yet real this is. I shouldn't be letting this bother me, I should just control myself. I just can't. I am soooo weak! I really have to call ZCYC- I have nowhere to turn to.
Nancy sent the above email after she had received the sixth family session and weighed 30.5kg. The content of the email made it clear that she required some ongoing support apart from the family treatment. The support included reassurance and diet advice. Most significantly, the informant reported her family dynamics when away from the family treatment setting. This patient-reported information offered a holistic view of her symptoms within her family context and offered more comprehensive information for the next family session.
Nancy discussed her relationship with her younger sister (from the same email as above):
BTW, my sister is treating me with a very bad attitude, mainly because she thinks that I always intrude on her eating territory, but this also makes her feel that it gives her 'license' to criticize me on other aspects too.
I feel really disrespected and I don't know how to mend this situation. Can we EVER get back to our loving relationship like before? How can I regain my dignity and be respected and be her role model so she would think that I am a superb sister, not one that she can treat like rubbish??
Nancy expressed the ineffective relationship with her younger sister. It was also Nancy's desire to get back into the role of elder sister. Thus, eating was not only Nancy's individual concern, but it had become a source of sibling rivalry.
Nancy expressed her association between AN and her relationships with her sister and mother as a love-hate relationship (email dated in July 2001):
You are right. On reflection, I have a deep love-hate feeling towards my mom and sister:I love my mom because she has sacrificed a lot for me;I dislike her because she focused her attention on my younger sister after she was born;I love my sister because she is my sister;I dislike my sister because she competes for Mom's attention, and she doesn't respect me as a sister or even as a stranger.
After reading the above email, ZCYC wrote the poem Jealousy (Chan, 2001) to express the researcher's feelings about the relationship between Nancy and her sister:
What kind of jealousy is the most toxic?
Probably, jealousy between sisters is the most toxic
Sisters have blood-ties but also have the desire to compete with each other
Jealousy emerges due to both similarities and differences having the same parents and living in the same family having different abilities and working in different worlds
The conflicting idea - love and hate ignite jealousy
Jealousy ruins relationships but cannot be prevented
Nancy sought to express the reasons for her resistance to recovery as follows (email dated in July 2001):
I guess my prolonged recovery is due to:
- I keep comparing myself with my sister, because there is nothing that sets me apart from her, nothing that I can regard as being better than her, nothing that my parents have ever said that I am better than her; instead, I know there are many things that I should learn from my younger sister, like a happy personality and cute face. But somehow I may think that being thinner is the only visible thing that distinguishes me from her. I guess this self-invalidation is subconsciously affecting me;
- I don't know what I am good at, that's why I have to use my skinny figure and weight as the visible thing to convince myself that I AM DIFFERENT, though this is stupid;
- I ACKNOWLEDGE the stupid comparison with my sister, but I can't BELIEVE that there are things that I am better at.
Nancy seemed to know clearly the reasons for her prolonged recovery from anorexia nervosa. In this case, the patient had a sense of self-awareness about her anorexia nervosa and an understanding of how her eating problem had affected her family relationships.
Nancy showed her powerlessness toward her AN and asked for the support (email dated in July 2001):
These things have been unsolved and I just don't know how to solve them. Please help me find my value, my strengths and my hope to drive me to go on. I know what keeps you at your best is your goals, your passion and most important of all, your love for yourself. How can I learn???
Nancy liked to compare the progress of her recovery with other anorexics (email dated in August 2001):
Recovered AN all learned a lot from their experience, but it seems that I haven't learned anything in this 3-month medical leave. Am I so useless?
The above email was the eighteenth one she sent. She had received the ninth family session and weighed 33.5kg, which amounted to a weight gain of 5.5kg in 18 months, during the course of family treatment.
Ann explained that her eating has a special meaning in her circumstances (email dated in May 2001):
I really ate lots of food at that time. But every time I ate I needed someone to accompany me. I liked to shop in supermarkets to search for food to eat. My most favourite foods are ice cream, chocolate and cookies - all sweet foods I like to eat. At that time, my habit was like this: after I finished a meal, I'd ask my mum or dad to accompany me to the supermarket to buy other snacks to eat. But I didn't want to eat by myself; it feels lonely if I just eat by myself. My mum will eat a little if I ask her to, but if she's so full that she can't eat anymore, my temper would start again and I would need others to eat with me. My dad is the only one that can accompany me to eat more.
This was the first email Ann sent to ZCYC. She had completed a course of ten sessions of family treatment offered by JLCM. However, continued monitoring for any signs of relapse was provided through telephone follow-up and emailing. Ann weighed 45kg in July 2001; she weighed only 34 kg when she first sought help from our family practice center.
The fact that Ann's father was eating with and buying food for her showed how much he cared, and facilitated her recovery (email dated in June 2001):
It's really a surprise: in my mind have an image of him always caring about my brother and not caring about me much, but he still eats with me even if he's already very full - I found that actually my dad also loves me a lot, although he loves my brother most and my sister second, he also loves me. In my childhood that was really easy to see: he always bought my brother what he liked, always helped him do his chores like tidying his room, and many other actions that allowed even strangers to see that he liked my brother most. Now that we are all adults, the situation continues but it is not so serious. He'll also sometimes buy me the food I like to eat, and that makes me feel like my position among the three of us is more balanced.
This was the third email Ann sent: she expressed her positive experience with her father. She now believed that her father actually loved her very much and reported that she had a better relationship with her younger brother and elder sister.
Ann described her extraordinary eating behavior in the following vignettes (email dated in July 2001):
One horrible eating habit I must mention here is that I liked to eat drinking powder during the time I was very thin. I liked to eat the drinking powders; I liked to eat plain cooking sugar, and sometimes I liked to eat the decayed food, which was thrown out by my family in the rubbish bin. I would take them out and eat them there beside the rubbish bin. This behavior is really horrible. When I think of this, I'm glad that I can eat like a normal human being now.
Ann recalled some of the extraordinary eating behaviors she exhibited when she still suffered from anorexia nervosa. By revisiting past and present eating behaviors, she gained insights into changing her anorexic eating.
What have these emails revealed to us? Nancy's emails showed that she was experiencing uncertainty when she asked for advice about her eating patterns. She also sought the psychological support, as she felt so powerless. ZCYC seemed to be one of her major sources for sharing her inner world. The most striking observation from Nancy's email was when she mentioned the conflicting idea of the love-hate relationships in her life. Orbach (1986) has argued for the importance to explore the mother-daughter relationship during therapy as the love and hatred relationship between the mother and the daughter and its unconscious meaning may be transferred to food. Nancy disclosed her love-hate relationships with her sister and mother in the email because the first author had sent an email prior to hers in which she asked Nancy, "How do you feel the love-hate relationship? Does it have any association with your anorexic eating?" The first author avoided being directive and suggestive; instead, a sense of openness and an attitude of not knowing were maintained. Unpredictably, Nancy expressed her love-hate relationships with her sister and mother.
Three themes about her anorexic eating had been identified from Ann's writing. First, she could eat more when her parents had meals with her. Second, she felt happy when her father brought her food and showed his concern for her. Finally, she had developed an extraordinary eating behaviour that was beyond our imagination, that is, eating decayed food near the rubbish bin.
In both cases, there is a shared theme: anorexic eating is related to family dynamics. Nancy was comparing her eating pattern with her younger sister while Ann was looking for her parents' support during her course of recovery, especially the strong emotional tie she developed with her father. The results of this study have indicated that family dynamics have an association with the anorexics' eating behaviour.
In reading the results of this study, one should take into account the limitations of this study, namely the researcher's bias and the incomplete representation of both informants' eating habits. First, these results, to a certain extent, reflected the researcher's own perceptions of anorexic eating. Selection and presentation of the results was inevitably subjected to the researcher's own preference. Second, for ethical considerations we have to struggle and finally decided not to include those presenting materials that were too sensitive and might cause psychological harm to both informants if they were published. In addition to that, both informants' eating experiences were presented and interpreted by their written texts only. To further increase the trustworthiness of the results, it is recommended that in future study the researcher should conduct a participant observation by having at least a meal together with the informant. This strategy can deepen and enrich the understanding of the informants' eating patterns. Despite the limitations of this study, emails have shown to be a non-intrusive data collection method for future qualitative studies.
Several implications can be drawn from this study. First, communicating via email between the informants and the researcher for several months allows mutual friendship, rapport and trust to build up. The informants may be more willing to express their unspoken experiences through emails. Second, the researcher can show his/her concerns and sincerity to the informants by replying to their emails at greater length. Third, the researcher should provide telephone counseling or follow-up, offer support and advice, and more importantly, share his/her own personal issues with them. Research interviews have been shown to have therapeutic impacts on the clients which were different from that provided by therapy (Gale, 1992). This has also been applicable to this study; emails from the informants can supplement work done in family therapy by illuminating their eating habits and their family dynamics in the natural family context rather than in artificial interview settings.
To conclude, emails can be recommended as a data source for a qualitative inquiry because a sense of reciprocity is promoted and any power inequality between the researcher and the researched subjects can be avoided.
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This work is supported in part by a grant (CUHK: 4090/99H) from the Hong Kong Research Grant Council. The deepest respect and appreciation are extended to the families who were brave enough to seek help from our practice team and were kind enough to participate in the study. Finally, we are grateful to Professor Kelly Lai and Professor Sing Lee of the Department of Psychiatry of The Chinese University of Hong Kong, who referred the patients with anorexia nervosa to us for family therapy.
Chan, Z. C. Y., & Ma, J. L. C. (2002, December). Anorexic eating: Two case studies in Hong Kong. The Qualitative Report, 7(4). Retrieved [Insert date here], from http://www.nova.edu/ssss/QR/QR7-4/chan.html
Zenobia C. Y. Chan and Joyce L. C. Ma
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