This study included 9 women with a diagnose of AN (5) and ARFID (4). The women’s ages had an average of 38.4 years (ranking between 19 and 52 years of age). 40% of the participants in this group are single and 60% are married. 60% had 1 or more children and 40% of participants were childless. 100% of the participants completed the 12th year, 40% have a degree and 20% of the participants have a master's degree. 40% of the participants are still studying and 60% have a professional activity. Eating Disorders onset happen in childhood/ adolescence for 78% of participants and 22% of the participants had symptoms in adulthood. The interviews were carried out with the minimum time of 48 minutes and the maximum time 1 hour and 20 minutes, with an average interview time of 55 minutes
Table 1 Sociodemographic Information
Items
|
Anorexia Nervosa
|
ARFID
|
N 5
|
100%
|
N 4
|
100%
|
Age Group
18 – 25
26 - 35
46 – 55
|
2
3
|
40%
60%
|
3
1
|
75%
25%
|
Civil Status
Single
Married/Cohabitation
|
2
3
|
40%
60%
|
4
|
100%
|
N of children
0
1 or more
|
2
3
|
40%
60%
|
4
|
100%
|
Educational Level
10 – 12º Grade
College degree
Master degree
|
2
2
1
|
40%
40%
20%
|
2
2
|
50%
50%
|
Occupation
Student
Professionally active
|
2
3
|
40%
60%
|
4
|
100%
|
Symptoms
Childhood
Adolescence
Adulthood
|
3
2
|
60%
40%
|
3
1
|
75%
25%
|
BMI
13/14
15/16
16/17
|
3
2
|
40%
60%
|
2
2
|
50%
50%
|
The study participants, given the early onset of symptoms for most of them, underwent a high number of interventions with psychologists and psychiatrists. Initially, they were referred by family members or family doctors and were monitored in different health responses and various health professionals. Most of the participants had multiple follow-ups with psychologists and psychiatrists. During the process, 75% of the participants were initially referred for support by family members and doctors, however at some point in adulthood they all sought help on their own initiative.
Table 2 The Therapeutic Process
CATEGORIES
|
SUB
CATEGORIES
|
Specific Categories
|
Participants
|
aN 5
|
PIAE 4
|
1. The therapeutic process – client's perception of
Success promoting factors
|
1.1. The Professional Personal and professional qualities
|
1.1.1. Empathetic, interested in listening the client
1.1.2. Guides to solutions without pressure
1.1.3. Provides security/support/care
1.1.4. Provides a safe place/ has time
1.1.5. Doesn't judge, helps understand
1.1.6. Informs about diagnosis/process
1.1.7. Doesn't give up, believes in client recovery
1.1.8 Validates/respects the Clients feelings thoughts
1.1.9. Has experience and knowledge in the field
1.1.10. Teaches coping techniques/strategies
|
100%
20%
80%
60% 100%
20%
20%
80%
80%
80%
|
100%
100%
100%
100%
100%
100%
75%
100%
100%
100%
|
1.2. Client related factors
|
1.2.1. Motivation to change/improve
1.2.2. Trusts in the therapist and process
1.2.3. Cognitive abilities
1.2.4. Faith /spirituality
1.2.5. Self-initiative on the search for help
1.2.6. Desire to stop causing suffering to her family
1.2.7. Improvement of symptomatology
1.2.8. Social/emotional support
|
60%
80%
20%
40%
60%
100%
100%
80%
|
100%
75%
100%
75%
75%
|
Bearing in mind their path and specific vulnerabilities, the participants named a set of factors that they considered as promoters or inhibitors of the therapeutic intervention success, related to the professional and to the client. In Table 2 are shown different categories related to the these factors.
The entire sample of the study participants (100%) identified the professional's interpersonal skills in the psychotherapeutic intervention as fundamental for promoting the success of the intervention. The professional competence to demonstrate empathy, interest and availability in listening to the client, an attitude of acceptance without judgment, validation and recognition of the client's capabilities, feelings and opinions, building a reassuring relationship, were the main aspects referred by the participants.
"Listening, really wanting to know how I feel, not judging me or saying that what I feel or think is ridiculous or doesn't make sense, respecting my suffering and what's important to me." P3
“She wanted to understand me, get to know me, it was very different from others, she wanted to understand my relationship with food, I liked it a lot.” P8
“It was very important, she never judged me, was always very sweet, feeling that I'm not being judged, I am not being a burden, that helped a lot. The feeling that she won't give up on me… “P2
“I felt very anxious, but she seemed very relaxed, she smiled like the others didn’t, she was really available, so I let myself go…” P4
The majority of the participants also considered very important the technician's attitude/ competence in teaching the client appropriate techniques/strategies to deal with her situation; In having time to be with the client in a safe therapeutic space; in explaining the diagnosis, negotiate and adjust the intervention to the client's specific needs and characteristics.
“The doctors who helped wanted to understand, they helped me deal with the situation and didn’t judge me, helped me calm me down, gain weight naturally, they gave me time. They didn’t rush me” P1
“It is important to explain things and not make people feel that their fears are stupid, they make us think that, in their facial expressions and in their words” P4
“She was trying to use my reality, what I was learning in college, to explain and address the topic. My biggest fear was getting fat and the fact that she didn't tell me that that was the goal helped me or I had run away.” P2
“She gave me strategies to use when it got worse, it was very important “P8
“It's important to have a diagnosis, it's important to have a name, to know what to call things, to explain, because people don't know and blame themselves for being sick, they think they chose the situation. "P2
“I felt so bad and guilty about being anxious, if they had explained to me what it was, what was happening, I wouldn’t have thought that it was something I was doing wrong and that it was my fault” P4
“The first doctor who saw me didn’t have much knowledge, but she could have referred me to someone who could help me” P24
“I was always so nervous the days before the appointments, so afraid of not gaining weight that I would lose weight, just the idea that they were going to weigh me down made me so nervous. Until a doctor listened to me and stopped weighing me, it made all the difference, I'm not so nervous anymore and I managed to gain weight” P1
The success promoting aspects of the therapeutic intervention related to the client had some differences between the AN and the ARFID group.
In the AN group 100% of the participants considered the most relevant factors the desire not to cause more suffering to their family members and the perception of improvements in their symptoms after the therapeutic intervention.
“When I saw my mother and dad so bad, I realized I couldn't do that to them. They were really worried and the situation caused them a lot of suffering. "P3
"I don't do anything for myself, I do it for my mother, for my sister, for my boyfriend, I know it's important for them that I look good, I don´t want to cause them suffering"
"I realized that I was causing a lot of damage to my family, my children, I was going too far, so I decided to look for help." P30
100% of the ARFID participants highlighted the client's motivation and wish to change and improve, as well as being of her own initiative the request for help the most relevant success promoting factors of the therapeutic intervention
“What kept me going was holding on to my truth, if others don't understand it's not my fault, holding on to myself, my wanting to improve and trying to get them to help me.” P4
“Whenever I left there, I felt better, so I wanted to keep going…” P24
The availability of social/emotional support, the trust in the professional and in the therapeutic process and people's faith and spirituality were also considered relevant for the majority of participants of both groups.
Participants reported that the absence of the aforementioned positive characteristics makes it difficult for the client to become involved and promotes the abandonment of the therapeutic process. In Table 3 are shown the specific categories related to these factors
Table 3 Successful and Inhibiting Factors
CATEGORIES
|
SUBCATEGORIES
|
Specific Categories
|
Participants
|
aN 5
|
ARFID 4
|
2. success
Obstacles/inhibiting factors
|
2.1. Professional Personal and professional characteristics
|
2.1.1. No Experience /training/knowledge
2.1.2. No time or Interest in listen to the client
2.1.3. Does not negotiate objectives tasks
2.1.4. Apply rigid protocols
2.1.5. Use of Inadequate strategies
2.1.6. Passive, cold, distant attitude
2.1.7. Does not inform Diagnosis /T
2.1.8. Medication, doesn’t explore alternatives
2.1.9. Devalues / doesn’t validate the client’s feelings
2.1.10. Doesn’t teach strategies to deal with the situation
2.1.11. Wrong diagnosis
|
60%
60%
60%
40%
60%
80%
40%
|
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
|
2.2. Client related factors and main difficulties experienced
|
2.2.1. Accept the need for help / get started
2.2.2. Adverse life events
2.2.3. Multiple interventions/negative/imposed
2.2.4. Comorbidity with other PM
2.2.5. Inadequate Procedures
2.2.6. Fear of failure/disappoint others
2.2.7. Resist constant urge to give up
2.2.8. AN Advantages (Control/attention/praise)
2.2.9. Extreme tiredness/internal and external struggle
2.2.10. No hope of recovery/ in the therapist
|
80%
40%
40%
40%
60%
80%
60%
60%
|
100%
100%
100%
100%
|
As success inhibit factors of the therapeutic intervention related to the professional, 100% of the ARFID participants and between 60% to 80% of the AN participants referred the lack of interpersonal skills (empathy, interest and availability to listen to the client, a non-judgment attitude) as particularly important. Not validating the clients’ feelings, opinions and thoughts, not involving the client on her own therapeutic process by not informing, negotiating and/or adapting the intervention to the person's particular characteristics and needs was also felt as relevant to inhibit the success of the therapeutic process.
"I've been to several psychiatrists before and the experiences were not very good, it was just medication, the consultations were horrible" P2
“I went to several psychologists, psychiatrists, they didn't help much, or gave me medication or said I had to eat and that was the last thing I wanted to hear. They didn't care too much about what I felt. I even had one who told me that when I got married it would pass.” P3
“I went to a psychiatry, she didn't explore why I couldn't eat, she thought it was for image reasons. And she didn't even try to listen, she didn't really want to know. I didn't go back there…” P4
“I went to a doctor, I don't know if she was a specialist, we talked and she told me to have positive thoughts, I stopped going...” P24
"I had some good doctors, but there were doctors who don't care, don't strive to help." P1.
“I went to a doctor because I had a lot of fears, and he rubbed things in my face. I said I wasn't comfortable with that approach, but he didn't want to know, I didn't go there anymore...” P4
The factors identified as most relevant for inhibiting the positive results of the therapeutic process referring to the clients in the AN group, were the difficulty in accepting/recognizing that they were sick and needed help and the perceived advantages of maintaining AN.
“I know I'm sick, but I don't think I'm sick” P2
“When I started to lose weight, people started praising me, saying how beautiful I was, the guys start taking an interest in me, I liked feeling that way, I didn't want to lose it” P3
“There were things I couldn't handle, I couldn´t do things the way I wanted to, I felt trapped between perfectionism and lack of control, I was the only thing I could control. "P30
"At the beginning I didn't have a negative body image, it was rebellion, my way of protesting, but when I got thin, I started to like seeing myself thinner, I was able to wear other things." P30
In the ARFID group, 100% of the participants mention, the occurrence of several adverse life events; the multiple previous negative interventions experiences; the comorbidity with other MD and their perception of the procedures applied by the therapist as inadequate, as significant obstacles to the success of the therapeutic intervention related to the client.
“The lack of understanding, of answers, everything was unknown, no one understood or helped me, people thinking that I wanted to be like this, if I was asking for help it was because I didn't want to be like that. "P4.
“Some situations were very difficult, I was hospitalized because I wasn´t well, and the staff and some nurses made critical comments, because they thought I didn't want to get fat (do you think you're that fat?) and things like that. I knew I was thin and that wasn't what I wanted, it caused me a lot of suffering and I just wanted to give up on everything. “P1.
Table 4 Participants Change Perception
Categories
|
Subcategories
|
Specific Categories
|
Participants
|
aN 5
|
ARFID 4
|
3. Reflection on the main changes process
|
3.1. Positive outcome
after therapeutic intervention
|
3.1.1. Increased positive internal speech
3.1.2. Improved ability to ask for help
3.1.3. Self-care strategies and symptom relief
3.1.4. Confidence dealing with people/situations
3.1.5. Learning to use adaptive strategies
3.1.6. Healthy self-acceptance/self-esteem
3.1.7. Adjusted reality perceptions and Beliefs
3.1.8. Less stress/ impact of others judgments
|
60%
100%
60%
60%
60%
60%
60%
60%
|
50%
100%
100%
50%
50%
75%
75%
75%
|
3.2. Absence of positive results after therapeutic intervention
|
3.2.1. Increased symptomatology
3.2.2. Reinforcement of unhealthy coping strategies
3.2.3. Increased resistance to intervention
3.2.4. Skepticism regarding positive results
3.2.5. Dropout of the therapeutic process
|
60%
60%
60%
60%
100%
|
100%
100%
100%
100%
100%
|
3.3. Changes related with MD
|
3.3.1. More compassionate/understanding/attentive
3.3.2. Less judgmental
3.3.3. Desire to help others
|
100%
100%
80%
|
100%
75%
50%
|
With regard to patient’s reflection on their change process (Table 4), 100% of the group study participants reported the perception of positive results subsequently to the therapeutic intervention, after meeting a professional with whom they identified. 100% of the participants stated improvements regarding the ability to ask for help.
“I know I can ask her for help, it's someone I can call” P2
100% of the ARFID participants and 60% of the AN participants mentioned progress related to the use of self-care strategies and symptoms relieve.
“I know how to be careful now and take care of myself and not go back to the same thing” P30
More than 50% of all the participants reported improvements referring the use of positive internal speech, feeling more confidence when dealing with people and/or situations and in learning how to use adaptive coping strategies.
“I am more stable, now I know how to deal with the problems.” P1
“The way I deal with anxiety has changed a lot, before I was completely blocked, now I try to understand what is triggering those thoughts in my head because I know that’s where it comes from” P4
The development of a healthier self-acceptance/self-esteem and a more adjusted perception of the reality and personnel beliefs where also referred as positive results by 60% to 75% of the participants. The same percentage of participants mentioned feeling a decreased on the stress/ impact caused by the judgments of others
"I started to feel calmer, less anxious." P3
"I learned to understand how my brain works, there are no right or wrong thoughts, only thoughts." P2
“It had an impact, it had a positive impact on me feeling more comfortable with others, working on shyness, not caring about what others think and that changed, I feel more comfortable with people saying what I think, that helped me a lot. “P24
A negative experience with multiple therapeutic interventions felt as inadequate by the participants reinforced the maintenance and worsening of unhealthy behaviors and disorder symptoms in 100% of the ARFID participants and 60% of the AN participants. It also increased the intervention resistance and skepticism in positive results in 60% of the AN participants and in 100% of the ARFID group. At some point all the study participants dropout of their therapeutic process.
“They weighed me down in every consultation, which made me feel worse. I knew I would be weighed and just the idea of that number, I would stop eating, used laxatives, vomited and all I could remember... that number had to be low. I was getting worse. It wasn't until I found a psychiatrist who listened to me, noticed what was happening and stopped doing that (I'll always be grateful to her for that). Only then I started to get better.” P2
"It was good for people to have more training, to know how to deal with others so as not to do harm" P4
“It would be good not to generalize, because by doing so they are hurting more than helping” P1
Between 75% and 100% of the participants reported being more compassionate and understanding with issues related to mental health. The participants considered that there was a decrease in their negative critical judgment in relation to people with MD after therapy. A desire to help others grapple with mental health challenges was expressed by 80% of the AN participants and 50% of the ARFID participants.
"We have to learn from what happens, but since I have to go through this, let it be to help someone, to listen to someone, to give affection, attention." P2
“I think it made me more tolerant towards others, I was always very demanding, perfectionist, strict, then I realized that we all have our weaknesses, that sometimes an appearance of security hides many facets and weaknesses.” P30
“It made me try to understand more about others, how they are and how they feel. As I felt firsthand what it's like to be criticized and judged for situations that people don't understand, I think well before I speak and try to put myself in the other's shoes.” P1