European Eating Disorders ReviewEur. Eat. Disorders Rev. 14, 125–135 (2006)

Discursive Constructions of ‘EatingDisorders Nursing’: An Analysisof Nurses’ Accounts of NursingEating Disorder Patients

Victoria Ryan,1 Helen Malson,2* Simon Clarke,3

Gail Anderson3 and Michael Kohn4

1TAFE Counselling, NSW Australia2School of Psychology, University of the West of England, Bristol, UK3Department of Adolescent Medicine, Westmead Hospital, Westmead, NSW,Australia4Department of Adolescent Medicine, New Childrens Hospital and WestmeadHospital, Westmead, NSW, Australia

The contribution of nurses is a significant but notably under-researched aspect of hospital-based eating disorders treatment.This paper reports a qualitative interview-based study in which15 nurses were interviewed about nursing children and adoles-cents diagnosed with eating disorder. A discourse analyticmethodology was employed to analyse the resulting interviewtranscripts and focuses, in particular, on elucidating the variousways in which ‘eating disorders nursing’ was construed inparticipants’ accounts. Three key constructions were revealed inwhich ‘eating disorders nursing’ was discursively constituted (i)as ‘loving’ or empathetic support, (ii) as a surveillance anddisciplining of patients and (iii) as a constant and ever-presentcare. The implications of these constructions are discussed.Copyright # 2006 John Wiley & Sons, Ltd and Eating DisordersAssociation.

Keywords: eating disorders; treatment; nursing; discourse

INTRODUCTION

There is nowawide range of different approaches tothe treatment of eating disorders (Sanders&Gaskill,2000) including dietetic (Mehler & Crews, 2001),pharmacological (Treasure & Schmidt, 2002),behavioural and cognitive-behavioural approaches(Martin, 1985; Dare, Eisler, Russell, Treasure, &Dodge, 2001; Gowers & Bryant-Waugh, 2004),family therapies (Krusky, 2002), individual andgroup psychotherapies (Newton, Robinson, &

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.666

*Correspondence to: Dr. Helen Malson, School of Psycho-logy, University of the West of England, Bristol, FrenchayCampus, Coldharbour Lane, Bristol BS16 1QY, UK. Tel:þ0117 328 2165. Fax: þ0117 328 2904.E-mail: Helen.Malson@uwe.ac.uk

Contract/grant sponsor: Australian Research Council;contract/grant number: LP0234648.Contract/grant sponsor: Westmead Millenium Institute;contract/grant number: 76604.

Hartley, 1993; Gold, 1999; Gowers &Bryant-Waugh,2004), feminist psychotherapies (Orbach, 1993;Fallon, Katzman, & Wooly, 1994) and, increasingly,multi-dimensional approaches (Lacey & Read,1993). Treatment can takeplace in avariety of specia-list and non-specialist contexts including in-patient,out-patient, community-based, internet-based andself-help settings. However, for a significant minor-ity of patients treatmentmay involve hospitalisationand this is not only often lengthy and expensive(Beaumont, 2000; Sanders & Gaskill, 2000; Walleret al., 2003) but may also be of limited efficacy(Ben-Tovim et al., 2001; Lock & Litt, 2003).A considerable body of research has been con-

cerned with evaluating treatment efficacy (Richardset al., 2000); with comparing different approaches(e.g. Dare et al., 2001; Peterson & Mitchell, 1999),different treatment contexts such as in-patient andout-patient care (e.g. Meads, Gold, & Burls, 2001)and with establishing the course of ‘the disorder’(e.g. Ben-Tovim et al., 2001; Herzog et al., 1999;Keel et al., 2000). However, the results of these stu-dies vary considerably and comparison betweenstudies is made problematic because of variationsin the research aims and designs of different studiesand because different criteria and (often non-standardised) measures are employed (Herzog,Keller, & Lavori, 1988; Steinhausen, Rauss-Mason,& Seidel, 1991). Moreover, quantitative comparisonof different forms of intervention may not revealcommon or non-specific factors, such as perceptionsof client-therapist relationship, that maywell have asignificant impact on outcome (see Andersen, 1998;LeGrange&Gelman, 1998; Lindsay, 1997). Compar-ison between studies and between different formsof therapeutic intervention is thus difficult. And,evenwhere outcomes have been found to be favour-able, it often remains unclear which variables werecrucial or significant in producing those outcomes(Grothaus, 1998; Martin, 1985).However, despite these problems in evaluating

treatments, research findings strongly indicate thatcurrently available interventions are often only oflimited success (Button & Warren, 2001; Collings &King, 1994; Eckert et al., 1995; Fichter & Quadflieg,1999; Loewe et al., 2001; Santonastaso, Pantano,Panarotto,& Silvestri, 1991)with estimated recoveryrates ranging between 17 and 77% (see also Ander-son, 1997; Herzog et al., 1999). For example, Loeweet al., (2001), in a 21-year follow up of ‘anorexic’patients, found only 51% had fully recovered whilst21% had partially recovered and 10% continued tomeet all diagnostic criteria (see also Johnson, Cohen,Kotler, Kasen, & Brook, 1992; Santonastaso et al.,

1991; Smith, Feldman, Nasserbakht, & Steiner,1993). A similar picture emerges for bulimia where,for example, a 9-year follow-up study (Reas,Williamson, Martin-Corby, & Zucker, 2000) found33% of ‘bulimic’ patients continued to suffer at leastsomeeatingdisorder symptoms (see also Fairburn&Beglin, 2000). In addition to low recovery rates thereare also considerable problems of chronic relapse(Deter, & Herzog, 1994), of ‘recovered anorexics’maintaining an acceptable weight but developingbulimic symptomatology (Eckert et al., 1995; Eddy-Kamryn et al., 2002), of weight-restored anorexicsand bulimics continuing to experience psychologi-cal and social problems (Button & Warren, 2001;Keel et al., 2000; Nilsson, Gillberg, Gillberg, &Rastam, 1999), and of 5 to 15% of anorexics continu-ing to die from either self-starvation or suicide(Bulik, Sullivan, & Joyce, 1999; Crisp, Callender,Halek, & Hsu, 1992; Emborg, 1999). Moreover, inaddition to these findings of poor outcomes and lim-ited treatment efficacy, research also demonstratestreatment ‘drop out’ rates are high (Eivors, Button,Warner, & Turner, 2003; Mahon, 2000) and that ser-vice users’ satisfaction with eating disorders treat-ment is often low (Newton et al., 1993; Rosenvinge& Klusmeier, 2000; Yager, Landsverk, & Edelstein,1989).Thus, it has been suggested that improved treat-

ment models are urgently required (Ben-Tovim,2003). There is therefore a clear need for furtherresearch to facilitate this development. And, whilstoutcome studies assessing and comparing the effi-cacy of the various treatment approaches continueto be vital, there is also,wewould argue, a particularneed for additional research which engages with abroader range of methodologies and theoreticalperspectives to address a wider variety of aspectsof treatment including, for example, investigationof patients’ and health care workers’ experiences oftreatment (see Burns, 2004; Eivors et al., 2003;Gremillion, 2003; Malson, Finn, Treasure, Clarke,&Anderson, 2004; Ramjan, 2004) andof non-specificfactors in treatment (see Le Grange & Gelman, 1998;McIntosh, Jordan, Luty, McKenzie, & Joyce, 2004)which may not be revealed in quantitative research.

Nursing and Treatment for Eating Disorders

Amongst the various aspects of treatment deservingof further research, the contributionmade by nursesin treating eating disorder patients stands out, notleast because of the considerable time, relative toother health care professionals, that nurses spendwith patients (King & Turner 2000; Kenny 1991;

126 V. Ryan et al.

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 125–135 (2006)

McNamara, 1982; Ramjan 2004). Nursing care maythus constitute a highly significant aspect of treat-ment and of patients’ treatment experiences (seeGarrett, 1991; Lindsay, 1997). Yet, there is a notablelack of empirical research investigating nurses’ per-spectives on or experiences of nursing eating disor-dered patients (Garrett, 1991; King & Turner, 2000;Newell, 2004; Ramjan, 2004). What research doesexist suggests that, for a number of reasons, nursesmay find caring for eating disordered patients tobe particularly challenging (Garrett, 1991; Grothaus,1998; Kenny, 1991; King & Turner, 2000; Lindsay,1997; Ramjan, 2004). For example, research indicatesthat eating disordered patients experience bodyimage distortion, overestimate their body size(WHO, 1992), and may cherish or feel ambivalentabout their ‘eating disordered’ status (Malson,1998; Orbach, 1993). Hence, some patientsmaywantneither diagnosis nor treatment (Treasure &Schmidt, 2001). Thus, those diagnosed as eating dis-ordered have been described as uncooperative, dif-ficult to treat and challenging to nurse (Garrett, 1991;Grothaus, 1998; Kenny, 1991; King & Turner, 2000).Openor covert resistancemay lead to feelings of fail-ure, frustration, exhaustion and emotional turmoilamongst nursing staff (King & Turner, 2000;Grothaus, 1998; Ramjan, 2004). And, where resis-tance to treatment is covert, additional challengesmay arise where patients are viewed as untrust-worthy (Garrett, 1991; King & Turner, 2000) so thatpotentially therapeutic relations between nursingstaff andpatientsmaybedifficult todevelop (Marks,2000; see also Newell, 2004; Ramjan, 2004). More-over, nurses may struggle in seeking to understandthe complexities of this ‘disorder’ and may experi-ence additional difficulties in implementing a ‘con-trolling’ treatment programme while working withpatients who are themselves understood as control-ling (Ramjan, 2004).In short, nursing may constitute a major aspect of

treatment, particularly for hospitalised eating disor-dered patients, and eating disorders nursing (EDnursing) may be experienced as a particularly chal-lenging area of nursing (Garrett, 1991; King &Turner, 2000; Ramjan 2004). Yet there is a scarcityof research into ED nursing (Garrett, 1991; King &Turner, 2000; Newell, 2004; Ramjan 2004) and thusa clear need for further research here. This articleaims, therefore, to contribute to current understand-ingsofEDnursingbydeployingan interview-based,discourse analytic methodology to explore thewaysin which ‘ED nursing’ was constituted in nurses’accounts of nursing eating disorder patients. Indoing so the article seeks to elucidate some of the

complexities and challenges involved innursing eat-ing disordered patients.

METHOD

Participants

15 participants were recruited from three wardsspecialising in (but not exclusively dedicated to)treating eating disorder patients in two large metro-politan hospitals in Australia. The three wardswhere the participants worked included two chil-dren’s wards and one adolescent ward, withpatients aged from 8–11 years, 12–14 years and14–18 years, respectively. Approximately 85% ofpatients hospitalised for an eatingdisorder hadbeendiagnosed with anorexia nervosa, the remaining15% being diagnosed with either bulimia nervosaor EDNOS. The treatment approach across all threewards areas is ‘traditional’ and multi-disciplinary,combining a behavioural programme with indivi-dual and group therapy, family therapy and—because of the medically compromised conditionof patients at the time of hospital admission—amedically-driven approach, sometimes involvingnasogastric feeding.The 15 nurses, who chose to participate in the

study all nursed eating disorder patients on one ofthese wards. They included 13 women and twomen who were registered nurses, enrolled nurses,nurse unit managers (NUMS), clinical nurse educa-tors and clinical nurse consultants. However, toensure anonymity no further participant details aregiven here and neither participants’ roles nor levelsof seniority nor the wards in which they work areidentified in the following analysis.

Procedure

Participation was invited from all nurses who cur-rently cared for eating disordered patients in oneormore of the threewards. Participationwas soughtby contacting theNUMs of eachward. The aims andnature of the project were explained and permissionsought to invite nurses’ participation. Copies of the‘Participant Information’ sheet were left with theNUMsand thefirst author,who conducted the inter-views, arranged times when she would be availableto conduct interviews so that staff interested in par-ticipating could approach her privately to arrangean interview. In addition to the written ‘ParticipantInformation’ the interviewer also gave a verbaldescription of the study to prospective participants,

Discursive Constructions of ‘Eating Disorders Nursing’ 127

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 125–135 (2006)

explaining again that participation was voluntaryand would be treated confidentially.Each participant then took part in a one-to-one

semi-structured interview lasting approximatelyone hour. Participants were asked to discuss theirviews on and (past and present) experiences ofnursing; of what they considered should andshould not be entailed in nursing eating disorderpatients; how they considered that nursing in thisfield may be similar to and different from otherareas of nursing; their understandings of ‘eatingdisorders’ and of eating disorder patients; andtheir views on and experiences of their immediateworking context of a multi-disciplinary eating dis-orders treatment team. Whilst each interview fol-lowed the interview schedule, participants werealso encouraged to discuss any additional issuesthey considered to be relevant. Each interviewwas audiotape-recorded and transcribed verbatimand the resulting transcripts were then analysedusing a discourse analytic methodology.

Analysis

The term ‘discourse analysis’ covers a range oflanguage-oriented qualitative methodologies con-cerned with analysing talk, text and other signifyingpractices (Burman & Parker, 1993; Potter & Wether-ell, 1987; Potter, 2003). Within this methodologicalframework discourses are viewed not as transpar-ently reflective of reality but, rather, as social prac-tices in which particular ‘versions of reality’ (Potter& Wetherell, 1987)—objects, events, identities, expe-riences and so forth—are actively constructed inparticular context-specific ways (Burman & Parker,1993; Foucault, 1972; Potter, 2003). From this perspec-tive, then, discourses do not transmit already-existingmeaning but involve ‘the more active labourof making things mean’ (Hall, 1982: 64). Hence, theaccounts analysed below are viewed as actively con-stituting (rather than transparently reflecting) EDnursing in particular ways. And, in thus constituting‘reality’ in one way rather than another, these acco-unts thereby ‘induce effects of truth’ (Foucault, 1980:193); producing, maintaining or challenging particu-lar ‘truths’, norms and practices in ED nursing.The procedural steps involves in discourse analy-

sis have been described in detail elsewhere (see e.g.Burman & Parker, 1993; Potter, 2003; Potter &Wetherell, 1987). Briefly, however, discourse analy-sis can be described as involving two stages, the firstof which involves repeatedly reading and re-read-ing the transcripts in order to identify prominentfeatures—topics, themes and issues—in the tran-

scripts. From these initial readings and through aprocess of consultation within the research team aseries of coding categories were then decided upon:for example ‘the ideal ED nurse,’ ‘nurses whoshould not care for eating disorder patients,’ ‘eatingdisorders as illness,’ ‘eating disorders as chosen,’‘battlegrounds’ and ‘issues of control.’ The inter-view data were then systematically coded usingthese categories and compiled into a compendiumof coded interview extracts using the qualitativedata management programme, N-Vivo-3. Workingwith the coded interview material we then pro-ceeded to a more detailed analysis. This involvedan attention to the specificities of the ways in whichparticipants talked about their experiences of andperspectives on nursing eating disorder patientsand to the variations as well commonalities in theseconstructions of ED nursing.

RESULTS

As noted above, the interviews covered a variety ofissues relating to ED nursing (including, for example,participants’ understandingsof ‘eatingdisorders’ andtheir experiences of working within a multi-diciplin-ary team), a comprehensive discussion of which isbeyond the scope of a single article (see, however,Ryan (2004) &Malson (2004) for further details). Thisarticle focuses specifically, therefore, on the ways inwhich participants talked about nursing patientsdiagnosed as eating disordered.As would be expected from a discourse analytic

perspective (Potter & Wetherell, 1987; Burman &Parker, 1993), in talking about ED nursing partici-pants articulated a multiplicity of different con-structions of ‘ED nurses’ and ‘ED nursing.’ Forexample, ‘the ED nurse’ was variously portrayedas a mother-figure, a disciplinarian, an under-resourced health care worker, an equal member ofa multi-disciplinary team and a subordinatedmem-ber, a professional health care worker, a ‘handmai-den’ to the medical profession, and a pivotalperson in delivering care (Ryan, 2004). However,in analysing participants’ accounts we have, asnoted above, focused specifically on participants’accounts about their nursing of patients ratherthan, for example, their experiences of working inmulti-disciplinary teams.Andwithin these accountsthree particularly prominent constructions of EDnursing were revealed whereby ‘ED nursing’ wasdiscursively constituted, firstly, as ‘loving’ or empa-thetic support, secondly, as a surveillance and disci-plining of patients and, thirdly, as a constant and

128 V. Ryan et al.

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 125–135 (2006)

ever-present care. It is these three particularlyprominent constructions which are reported below.

ED Nursing as ‘Loving’ or Empathetic Support

One of the most frequently articulated ways inwhich ED nursing was discursively constituted byparticipants was as a practice of ‘loving’ care andempathetic support for patients. As the followingextracts illustrate, EDnursingwas construed in verypositively valued terms of praising, ‘loving’ andsupporting patients and developing warm relation-ships with them.

Casey: You can become quite attached to some ofthese kids . . . Some of them have got the mostwonderful personalities and a lot of them arelovely kids.Sally: We can offer them support. . . . give themsort of love.Susan: [We give patients] positive feedbackthrough giving them time and giving them lovewhen their behaviours are appropriate. . . . Inhelping them to feel good about themselves, find-ing things for them to do that give them a sense ofachievement.

In these accounts EDnursing involves ‘becom[ing]quite attached to some of these kids,’ appreciatingthat ‘a lot of them are lovely kids,’ ‘offer[ing] themsupport,’ ‘helping them to feel good about them-selves’ and ‘giving them love.’ It is a constructionof ED nursing which was often construed as ‘mater-nal care’ andwhichwas frequently associatedwith aparticular construction of the ED nurse as ‘amother’or mother-figure (see also Gremillion, 2003; Ryan,2004). For example:

Phillipa: I’ve been called a lot of things, like prob-ably the mother of the ward is the one that I likethe best, because I try to be kind all of the time.. . . I counsel them with a lot of love.

Thus, Phillipa associates counselling patients‘with a lot of love’ with being called ‘the mother ofthe ward.’ However, in addition to the genderingof nursing entailed in this construction of ED nur-sing as ‘maternal care’ (see Gremillion, 2003; Ryan,2004), what may be of particular significance here,is the importance that is given in this discursive con-text to developing warm and supportive relation-ships with patients. These accounts can, we wouldargue, be read as illustrating a construction of ED

nursing as a form of non-specific supportive carewhich, as recent research confirms,maybe consider-ably more successful than other interventionsfor those diagnosed as eating disordered (McIntoshet al., 2004).

ED Nursing as Discipline and Surveillance

The second construction which emerged promi-nently in our analysis of participants’ accounts wasone in which ED nursing was construed in terms ofdiscipline, surveillance and an authoritative con-tainment of patients. For example:

Jenny: You have to be firm with them. Make surethat ah, they keep within the perimeters of theprogram.Casey: Then we get the others that fall down assoon as they go home. . . .And then that’s veryfrustrating when you’ve put so much effortin . . . and you’ve just, you’ve just spent [sighs]youknow, allweekwatching everymouthful theyput in their mouth, watch that they don’t exercise.

As previous research on nursing eating disorderpatients suggests, ED nursing often involves modi-fying patients’ behaviours through surveillanceand discipline (Garrett, 1991; Gremillion, 2003;Ramjan, 2004). An aspect of ED nursing that isclearly articulated in the above accounts where itentails ‘watching every mouthful,’ ‘watch[ing] thatthey don’t exercise’ and keeping patients ‘withinthe perimeters of the program’ by ‘be[ing] firmwith them’. It is a construction of ED nursingwhich,unlike the construction of ED nursing outlinedabove, was frequently portrayed as difficult or pro-blematic. In Casey’s account above, for example, itcan be ‘very frustrating’ and in the two extractsbelow it is again problematised.

Ramise: They shouldn’t um, be too strict onthem, . . .nurses that have been here for a while,they yell at them.Charlie: So it’s actually sort of keeping them co-ordinated and keeping them within the confinesor the boundaries of the program. . . .we’re notthe authority, prison guards but we’re there; theyknow that we’re there, um, you know.

Thus, Ramise criticised some nurses for being ‘toostrict’ thereby indicating the possibility of a ‘toostrict’ interpretation (and enactment) of being ‘firm’.In Charlie’s account he spontaneously differentiates

Discursive Constructions of ‘Eating Disorders Nursing’ 129

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 125–135 (2006)

ED nurses in this context from ‘the authority, prisonguards’, thus suggesting that this problematicallyquasi-penal interpretation may be all-too-readilyavailable. He seems to view it as a potential or latentaccusation requiring immediate countering. Indeed,in her analysis of interviewswith EDnurses, Ramjan(2004: 500–501) observed a similarly quasi-penaltheme and argued that nurses were ‘unconsciouslyacting like jailers’ who ‘administered punishmentfor not eating’ and viewed patients ‘as ‘bad patients’(Goffman, 1961) or even criminals’. Moreover, con-trolling or disciplining aspects of treatment, sheargued, ‘led to rebellion in patients’ and to stress innurses due to their ‘ongoing struggle for control’(ibid: 498), an issue which was similarly apparentin our participants’ accounts. For example:

Sally:And [patients are] challenging. They’re verycunning, andmanipulative . . .You just have to letthem knowwho’s the boss but sometimes if thereare so many of them it’s a battle.

In Sally’s account when ED nursing involves ‘let[ting] them know who’s the boss’ then it may alsoinvolve ‘a battle’ betweennurses andpatients.Disci-pline and authoritative containment of patients‘within the perimeters of the program’ is thus asso-ciatedwith thepossibility of nurse-patient conflict aswell as with potentially negative portrayals ofnurses and patients themselves.In the construction, outlined earlier, of EDnursing

as empathetic support ED nursing was construedin clearly positively valued terms and entailedpositively construed nurse-patient relationships. Incontrast, accounts of ED nursing as involving a dis-ciplining of patients illustrate very different andoften problematised or negative constructions ofED nurses, nursing and nurse-patient relationships,thus suggesting that this aspect of ED nursing maybe experienced by participants as particularly pro-blematic.

ED Nursing as Constant and Ever-present Care

The third prominent construction of EDnursing thatwas articulated by participants emphasised a con-tinual presence and constancy of nursing care. Forexample:

Delphi: [It’s] important to have constant um, Ithink in looking after some of these eating disor-der patients is that they have a constant care of,a constant carer. . . . I find that my role is very

valued in that way. . . .As a constant, as a some-body who’s just not coming and going [in] theirlives.Susan: The nurses . . . they’re giving the 24 hourcare, they’re the pivotal people and I would see[that] patients come into hospital because the restof the team aren’t managing them on an out-patient level, so they actually come into hospitalbecause they need to be nursed.

Thus, in both Delphi’s and Susan’s accounts EDnursing is constituted as around-the-clock ‘constantcare’ and it is because nurses are ‘constant carer[s]’that they are ‘very valued’ and indeed ‘the pivotalpeople’ in delivering effective in-patient care. Inthe interview extract below this constancy of nur-sing care is again apparent. It functions to again sig-nal the particular value of nursing care and todifferentiate ED nursing from the more occasionalor intermittent care deliveredbyhealth careworkersin other disciplines. And, in providing an account of‘24-hours a day’ nursing, Charlie also thereby elabo-rates a construction of ED nursing in which its ther-apeutic value is infused throughout all nursingtasks.

Charlie: The nursing team are here 24 hours a dayand they see everything and they’re handing overto each other, you know, three times a day so theyknowwhat’s goingon. . . .nursing is such a caring,well still caring in sort of a sense of handson, . . . you need to actually have that input /Int:Hmm/ into the patients and you’re a differentinput as well, like you’re not the psychologist,which comes down twice a week to talk abouthow they’re feeling today . . . you’re the nursethat’s making the bedwith them or hassling themabout something you know, and all of a suddenyou can turn conversations around or pick thingsup which are totally different. So its definitelylooking after eating disorders is definitely handson um, . . . and the treatment is in with everythingyou do.

In this account being on theward ‘24-hours a day’,distinguishes nursing interventions from thoseof, for example, psychologists who might ‘comedown twice a week’. And it is this constant pre-sence (and implicitly its consequent consistency)that signals the particular (and implicitly greater)therapeutic value of ED nursing because (unlikehealth care workers in other disciplines) nursestherefore ‘see everything’ and are ‘caring in sort of

130 V. Ryan et al.

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 125–135 (2006)

a sense of hands on’. It is in these extensive nurse-patient interactions and the seemingly mundaneday-to-day activities such as ‘making the bed withthem or hassling them about something’ that nursescan ‘pick things up’ (which others may miss) andengage in meaningful therapeutic interactions withpatients in which ‘all of a sudden you can turn con-versations around’ and thus affect change. Thus, aswith the construction of ED nursing as empatheticsupport outlined above, ED nursing is constitutedhere as a very positive and distinctly non-specificintervention. The therapeutic value of ED nursingas it is articulated here is found in its constancy ofcare and is ‘in with everything you do’.

CONCLUSIONS

Nursing, as noted above, constitutes a major aspectof treatment for those diagnosed as eating disor-dered (Grothaus, 1998; Garrett, 1991), especially forthose who are hospitalised (King & Turner, 2000;Ramjan, 2004). Yet it remains significantly under-researched (Garrett, 1991; King & Turner, 2000;Ramjan, 2004; Newell, 2004). This article has sought,therefore, to contribute to current understandings ofnursing in this field through a qualitative analysis ofnurses’ accounts of their experiences of andperspec-tives on ED nursing.Whilst much of the research into treatment aims

to assess the efficacy of particular interventionsand/or identify other factors affecting outcome,this research does not lead to any recommendationof, for example, a particular intervention as moreefficacious than another. Neither can our findingsbe generalised without caution. As noted above,the participants in this study were recruitedfrom three wards in two large metropolitan hospi-tals in Australia, all with very similar treatmentapproaches. It is quite possible that nurses workingin other hospitals or other countries may have pro-vided different accounts of ED nursing to thosegiven by our participants. Moreover, as numerousdiscourse analysts (e.g. Burman& Parker, 1993; Pot-ter, 2003; Willig, 2001) have argued, interviewtranscripts (and other texts) are always open tomul-tiple interpretations. The above analysis is thus pro-visional rather than definitive in that both theaccounts themselves and our analysis of them arecontext-specific (see Burman and Parker, 1993; Fou-cault, 1977; Potter, 2003) andmaybeparticular to the21st Century urban Australian milieu in which bothparticipants and researchers were located. How-ever, the fact that, like other discourse analysts, we

have included verbatim quotes to illustrate our ana-lysis renders the plausibility (or otherwise) of thatanalysis transparent to the readerwhilst the fact thatthere are commonalities (as well as variations)across contemporaryWestern societies in, for exam-ple, health care services, nursing and treatment forthose diagnosed as eating disordered suggests thatour findings may be applicable in similar contextsoutside of the hospitals in which the research wasconducted and indeed, as discussed below, ourfind-ings converge in a number of ways with those ofprevious studies. Moreover, there are, we wouldargue, clear implications of our analysis both forthe practices of ED nursing and for understandingand supporting the contribution nursing can makein the treatment of children and adolescents diag-nosed as eating disordered.As others have already argued, trust and commit-

ment (Morse, 1991), empathy, support, consistencyand a non-judgemental attitude (Anderson, 2003;Dexter & Walsh, 1995; Halek, 1997; Murray &Huelskoetter, 1991; Ramjan, 2004) are essential indeveloping therapeutic relationships with patientsdiagnosed with eating disorders. And, as recentresearch confirms, non-specific supportive therapymay be considerably more successful than otherinterventions (McIntosh et al., 2004). The discursiveconstruction articulated by our participants of EDnursing as ‘loving’ care and empathetic supportclearly converges with these characteristics thathave been identitified in successful therapeutic rela-tionships and can, we would argue, be read as con-stituting a form of non-specific supportive therapy.Our analysis thus indicates a key way in which nur-sing may be central to successful treatment andhighlights the importance of providing sufficientresourcing and training to facilitate the develop-ment and maintenance of positive therapeutic rela-tionships with these complex patients.As noted above, this construction of ED nursing

was frequently associated in participants’ accountswith a construction of the ED nurse as a mother ormother-figure. Gremillion (2003) has similarlyobserved that ‘mothering’ appears as a key meta-phor in health care workers’ accounts of workingin an American Eating Disorders clinic. This con-struction of the ED nurse as ‘a mother’ and of EDnursing as ‘maternal care’ can of course be under-stood as a consequence of the age-groups of thepatients in question. Hence, it is entirely possiblethat constructions of nursing asmaternal or parentalcare would occur in other contexts where childrenor adolescents are nursed. However, whether ornot it is specific to nursing children or adolescents

Discursive Constructions of ‘Eating Disorders Nursing’ 131

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 125–135 (2006)

diagnosed as eating disordered, it is clearly a keyway in which our participants (and those in Gremil-lion’s research) construed their nursing of thispatient group. And, in emphasising the develop-ment of warm and supportive relationships withpatients, it thereby illustrates the significance of nur-sing in providing non-specific supportive therapy.The second key construction of ED nursing evi-

denced in participants’ accounts represented EDnursing as a surveillance and disciplining ofpatients. In contrastwith the construction of EDnur-sing as empathetic support, in these accountsnurses, patients and nurse-patient relationshipswere frequently construed negatively: a findingwhich converges with those of Ramjan (2004),Gremillion (2003), Garrett (1991) and others (seeKing & Turner, 2000; Marks, 2000; Newell, 2004)who similarly found that enforcing the regulationsof treatment programmes was often portrayed asproblematic. As noted above, ED nurses’ ‘loving’and supportive care often figured in participants’accounts as ‘maternal care’ and this second, disci-plinary aspect of ED nursing might also be viewedas an aspect of a parental-type care that is ‘firm butfair.’ Yet, whilst ‘authoritative’ parenting (seeNSPCC, 1989) and firm control (see Baumrind,1973) are normative aspects of parenting and disci-plinary practices appear widespread in ED nursing(Anderson, 1997;Garrett, 1991;Marks, 2000), the dif-ficulties involved in ‘keeping [patients] within theconfines or the boundaries of the program’, particu-larly when some patients may want neither diagno-sis nor treatment (Treasure&Schmidt, 2001), shouldnot be underestimated or left unexamined. As Ram-jan (2004: 500) found in her analysis of interviewswith ED nurses, ‘the struggle for control’ entailedfor nurses in disciplining patients constituted asource of considerable stress and a ‘major obstacleto developing therapeutic relationships’ withpatients. Whilst ‘loving’ care and discipline mightboth be viewed as integral to parenting and to a par-ental-type nursing care, theymight also, asRamjan’sand our participants’ accounts suggest, be read (andexperienced) as conflictual. Our analysis thusemphasises, firstly, the necessity of regularlyreviewing the ways in which issues of disciplineare managed so that positive therapeutic relation-ships are not undermined and, secondly, of provid-ing adequate support, supervision and specialisttraining for nurses engaged in the complex task ofnegotiating these potentially conflictual aspects ofED nursing.The final construction of ED nursing evidenced

prominently in our participants’ accounts pre-

sented ED nursing as constant and ever-presentcare and accorded a positive therapeutic value ofnursing in the ‘24-hours a day’ presence of nurseson the ward and in the time spent with patients. Inthese accounts the nursing team is always thereand an individual nurse is a ‘constant carer . . . asomebody who’s just not coming and going [inpatients’] lives’ but is with patients on a daily basisfor extensive periods of time, conversing withthem,‘making the bed with them or hassling themabout something’. In talking about ED nursing as‘24-hour care’ participants thus articulated multi-ple ways in which time devoted to being withpatients may be of considerable therapeutic value.It enables not only a constancy but a consistency incare (because ED nurses are ‘constant carer[s]’ and‘they’re handing over to each other . . . three times aday so they know what’s going on’). Because ofregular and lengthy nurse-patient interactions,ED nurses thus ‘see everything’ and ‘know what’sgoing on’. They can ‘pick things up’ which healthcare workers in other disciplines that are less‘hands on’ might miss. In this construction of EDnursing the therapeutic value of nursing is there-fore ‘inwith everything you do’ and can, wewouldargue, be read as a pre-condition of the other twoprominent discursive constructions of ED nursingboth as empathetic, supportive care and as a disci-plining of patients. That is, both surveillance anddiscipline and the provision of empathetic suppor-tive care are facilitated by the (ideally) extensivetime nurses spend with patients, enabling themto develop amore thorough knowledge andunder-standing of and positive therapeutic relationshipswith patients in which ‘you can turn the conversa-tion round’ and thus affect change. Our analysisthus indicates again both the clinical importanceof resourcing nursing in such a way that nursesare facilitated in their roles as ‘constant carers’and of valuing nurses’ knowledge of and interac-tions with patients as a potentially key factor indelivering successful treatment.

ACKNOWLEDGEMENTS

The research reported in this paper was funded bygrants from the Australian Research Council(LP0234648) and the Westmead Millenium Institute(76604).Our thanks also to the participantswho tookpart in interviews and talked candidly about theirexperiences of and perspective on nursing eatingdisorder patients.

132 V. Ryan et al.

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 125–135 (2006)

REFERENCES

Andersen, A. E. (1998). Sequencing treatment decisions:Cooperation or conflict between therapist and patient.In G. Szmukler, C. Dare, & J. Treasure (Eds.),Handbookof eating disorders: Theory, treatment and research.Chichester: Wiley.

Anderson, G. (1997). Anorexia nervosa: Complex illness,complex adolescent nursing. Lamp, 54, 6–7.

Anderson, G. (2003). Through the eyes of young peopleand nurses: Nursing adolescents hospitalized withanorexia nervosa. Poster presented at ‘The Art AndScience Of Advancing Adolescent Development: The2nd Australian And New Zealand Adolescent HealthConference’ (October 22nd–24th 2003, WestmeadHospital, Sydney, Australia).

Baumrind, D. (1973). The development of instrumentalcompetence through socialisation. In A. E. Pick (Ed.),Minnesota symposium on child development. Minneapo-lis: University of Minnesota Press.

Ben-Tovim, D., Walker, K., Gilchrist, P., Freeman,R., Kalucy, R., & Esterman, A. (2001). Outcome studyin patients with eating disorders: A five year study.Lancet, 357(9264), 1254–1257.

Ben-Tovim, D. (2003). Eating disorders: Outcomes, pre-vention and treatment of eating disorders. CurrentOpinion in Psychiatry, 16(1), 65–69.

Beumont, P. (2000). Anorexia nervosa as a mental andphysical illness: The medical perspective. In D.Gaskill, & F. Sanders (Eds.), The Encultured body: Policyimplications for healthy body image and disorderedeating behaviour. Brisbane, Queensland: University ofTechnology.

Bulik, C., Sullivan, P., & Joyce, P. (1999). Temperament,character and suicide attempts in anorexia nervosa,bulimia nervosa and major depression. Acta Psychia-trica Scandinavica, 100(1), 27–32.

Burman, E., & Parker, I. (Eds.). (1993). Discourse analyticresearch: Repertoires and readings of texts in action.London: Routledge.

Burns, M. (2004). Constructing bulimia: Implications forsubjectivity and practice, Unpublished PhD Thesis,University of Auckland.

Button, E., & Warren, R. (2001). Living with anorexianervosa: The experience of a cohort of suffers fromanorexia nervosa 7.5 years after initial presentation toa specialized eating disorders service. European EatingDisorders Review, 9(2), 74–96.

Collings, S., & King, M. (1994). Ten-year follow-up of50 patients with bulimia nervosa. British Journalof Psychiatry, 164, 80–87.

Crisp, A., Callender, I., Halek, C., & Hsu, L. (1992). Long-term mortality in anorexia nervosa. British Journal ofPsychiatry, 161, 104–107.

Dare, C., Eisler, I., Russell, G., Treasure, J., & Dodge, L.(2001). Psychological therapies for adults with anor-exia nervosa: Randomised controlled trial of out-patient treatments. British Journal of Psychiatry, 178,216–221.

Deter, H., & Herzog, W. (1994). Anorexia nervosa inlong-term perspective. Psychosomatic Medicine, 56, 20–27.

Dexter, G., & Walsh, M. (1995). Psychiatric nursing skills:A patient-centred approach. London: Chapman andHall.

Eckert, E., Halmi, K., Marchi, P., Grove, W., et al. (1995).Ten-year follow-up of anorexia nervosa: Clinicalcourse and outcome. Psychological Medicine, 25(1),143–156.

Eddy-Kamryn, T., Keel, P., Dorer, D., Delinsky, S.,Franko, D., & Herzog, D. (2002). Longitudinal com-parison of anorexia nervosa types. International Journalof Eating Disorders, 31(2), 191–201.

Eivors, A., Button, E., Warner, S., & Turner, K. (2003).Understanding the experience of drop-out fromtreattment for anorexia. European Eating DisordersReview, 11, 90–107.

Emborg, C. (1999). Mortality and causes of death in eatingdisorders in Denmark 1970–1993: A case registerstudy. International Journal of Eating Disorders, 25(3),243–251.

Fairburn, C., & Beglin, S. (2000). Studies of the epidemiol-ogy of bulimia nervosa. American Journal of Psychiatry,147(4), 401–408.

Fallon, P., Katzman, M., & Wooly, S. (Eds.). (1994).Feminist perspectives on eating disorders. New York:Guilford Press.

Fichter, M., & Quadflieg, N. (1999). Six year course andoutcome of anorexia nervosa. International Journal ofEating Disorders, 26(4), 359–385.

Foucault, M. (1972). The archaeology of knowledge.New York: Pantheon Books.

Foucault, M. (1977). Discipline and punish: The birth of theprison. Hammondsworth: Penguin.

Foucault, M. (1980). Power/knowledge: Selected interviewsand other writings 1972–1977, C. Gordon (Ed.). London:Harvester Wheatsheaf.

Garrett, C. (1991). Bread and Butter stuff: Nursing peoplewith anorexia nervosa (Report for CHER, University ofWestern Sydney). Sydney: University of WesternSydney.

Goffman, E. (1961). Asylums: Essays on the social situationsof mental patients and other inmates. Harmondsworth:Penguin.

Gold, B. (1999). An ethnic disorder: The challenge thateating disorders patients offer group analysts. GroupAnalysis, 32, 7–20.

Gowers, S., & Bryant-Waugh, R. (2004). Management ofchild and adolescent eating disorders: The currentevidence base and future directions. Journal of ChildPsychology and Psychiatry, 45(1), 63–83.

Gremillion, H. (1992). Psychiatry as social ordering:Anorexia nervosa, a paradigm. Social Science Medical,35(1), 57–71.

Gremillion, H. (2003). Feeding anorexia: Gender andpower at a treatment center. Durham: Duke UniversityPress.

Grothaus, K. (1998). Eating disorders and adolescents.Journal of Child and Adolescent Psychiatry, 11(4), 146–151.

Halek, C. (1997). Eating disorders: The role of the nurse,Nursing Times, 93, 63–66.

Hall, S. (1982). The rediscovery of ‘ideology’: Returning tothe repressed in media studies. In M. Gurevitch, T.

Discursive Constructions of ‘Eating Disorders Nursing’ 133

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 125–135 (2006)

Bennet, J. Curran, & J. Woollacott (Eds.), Culture,society and the media. London: Methuen.

Herzog, D., Keller, M., & Lavori, P. (1988). Outcomes inanorexia nervosa and bulimia nervosa. Journal ofNervous and Mental Disease, 176(3), 131–143.

Herzog, D., Dorer, D., Keel, P., Selwyn, S., Ekeblad, E.,Flores, A., Greenwood, D., Burwell, R., & Keller, M.(1999). Recovery and relapse in anorexia and bulimianervosa: A 7.5 year follow-up study. Journal of theAmerican Academy of child and Adolescent Psychiatry,38(7), 829–837.

Johnson, J., Cohen, P., Kotler, L., Kasen, S., & Brook,J. (2002). Psychiatric disorders associated with risk forthe development of eating disorders during adoles-cence and early childhood. Journal of Consulting andClinical Psychology, 70(5), 1119–1128.

Keel, P., Mitchell, J., Miller, K., Davis, T., Traci, L., &Crow-Scott., J. ( 2000). Social adjustment over 10 yearsfollowing diagnosis with bulimia nervosa. Interna-tional Journal of Eating Disorders, 27(1), 21–28.

Kenny, T. (1991). Anorexia nervosa: A nursing challengethat can bring results. Professional Nurse, 6(1), 666–669.

King, S., & Turner, S. (2000). Caring for adolescentfemales with anorexia nervosa: Registered nurses’perspective. Journal of Advanced Nursing, 32(1),139–147.

Krusky, M. (2002). Women and thinness: The watch onthe eve of the feast, therapy with families experiencingtroubled eating. Journal of Systemic Therapies, 21(1),58–76.

Lacey, J., & Read, T. (1993). Multi-impulsive bulimia: Aninpatient eclectic treatment programme. EuropeanEating Disorders Review, 1(1), 22–31.

Le Grange, D., & Gelman, T. (1998). Patients’ perspectivesof treatment in eating disorders: A preliminary study.South African Journal of Psychology, 28(3), 182–186.

Lindsay, G. (1997). The psychological characteristics ofpatients suffering from anorexia nervosa and thenurse’s role in creating a therapeutic relationship.Journal of Advanced Nursing, 26(5), 899–908.

Lock, J., & Litt, I. (2003). What predicts maintenance ofweight for adolescents medically hospitalized foranorexia nervosa? Eating Disorder, 11, 1–7.

Loewe, B., Zipfel, S., Buchholz, C., Dupont, Y., Reas, D., &Herzog, W. (2001). Long term outcome of anorexianervosa in a prospective 21 years follow-up study.Psychological Medicine, 31(5), 881–890.

Mahon, J. (2000). Dropping out from psychologicaltreatment for eating disorders: What are the issues?European Eating Disorders Review, 8, 198–216.

Malson, H. (1998). The thin woman: Feminism, post-structuralism and the social psychology of anorexia nervosa.London: Routledge.

Malson, H., Finn, D. M., Treasure, J., Clarke, S., &Anderson, G. (2004). Constructing ‘The Eating Dis-ordered Patient’: A Discourse Analysis of Accounts ofTreatment Experiences. Journal of Community andApplied Social Psychology, 14(6), 473–489.

Malson, H. (2004). A critical psychological investigation ofnurses’ experiences, understandings and perceptions ofnursing eating disordered patients. Final Report sub-

mitted to the Australian Research Council. Project No.LP0234648.

Marks, P. (2000). In-patient care from a nursing perspec-tive. In D. Gaskill, & F. Sanders (Eds.), The enculturedbody: Policy implications for healthy body image anddisordered eating behaviours. Brisbane: QueenslandUniversity of Technology.

Martin, J. (1985). Anorexia nervosa: A review of thetheoretical and treatment approaches. British Journal ofOccupational Therapy, 48(8), 236–240.

McIntosh, V., Jordan, J., Luty, S., McKenzie, J., & Joyce, P.(2004). Non-specific supportive clinical managementfor anorexia nervosa. Paper presented atNourishing theMind: Second Annual Australian and New ZealandAcademy for Eating Disorders Conference, RoyalWomen’s Hospital, Melbourne, 27th–28th August,2004.

McNamara, R. J. (1982). The challenge of treating eatingdisorders: The role of the nurse at the bedside table.Canadian Nurse, 78, 35–40.

Meads, C., Gold, L., & Burls, A. (2001). How effectiveis outpatient care compared to inpatient care foethe treatment of anorexia nervosa? A systematicreview. European Eating Disorders Review, 9(4),229–241.

Mehler, P., & Crews, C. (2001). Refeeding the patient withanorexia nervosa. Eating Disorders, 9, 167–171.

Morse, J. M. (1991). Negotiating commitment andinvolvement in the nurse-patient relationship. Journalof Advnced Nursing, 16, 455–468.

Moorey, J. (1991). Living with anorexia and bulimia.Manchester: Manchester University press.

Murray, B. M., & Huelskoetter, M. M. W. (1991).Psychiatric/mental health nursing (3rd ed.). San Mateo,CA: Appleton and Lange.

Newell, C. (2004). Viewpoint: Nursing and eatingdisorders. European Eating Disorders Review, 12, 1–3.

Newton, T., Robinson, P., & Hartley, P. (1993). Treatmentfor eating disorders in the United Kingdom. Part 11,Experiences of treatment: A survey of members of theeating disorders association. European Eating DisordersReview, 1(1), 1–21.

Nilsson, E. W., Gillberg, C., Gillberg, I. C., & Rastam, M.(1999). Ten-year follow-up of adolescent-onset anor-exia nervosa: Personality disorders. Journal of theAmerican Academy of Child and Adolescent Psychiatry,38(11), 1389–95.

NSPCC (1989). Putting children first: An NSPCC guide.London: NSPCC.

Orbach, S. (1993). Hunger strike. London: Penguin.Peterson, C., & Mitchell, J. (1999). Psychosocial and

pharmacological treatment of eating disorders: Areview of research finding. Journal Clinical Psychology,55(6), 685–697.

Phoenix, A., Woollett, A., & Lloyd, E. (Eds.). (1991).Motherhood: Meanings, practices and ideologies. London:Sage.

Potter, J., & Wetherell, M. (1987). Discourse and socialpsychology. London: Sage.

Potter, J. (2003). Discourse analysis and discursivepsychology. In P. M. Camic, J. E. Rhodes, & L. Yardley(Eds.), Qualitative research in psychology: Expanding

134 V. Ryan et al.

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 125–135 (2006)

perspectives in methodology and design. Washington:APA.

Ramjan, L. (2004). Nurses and the ‘therapeutic relation-ship’: Caring for adolescents with anorexia nervosa.Journal of Advanced Nursing, 45(5), 495–503.

Reas, D., Williamson, D., Martin-Corby, K., & Zucker, N.(2000). Duration of illness predicts outcome foebulimia nervosa: A long-term follow-up study.International Journal of Eating Disorders, 27(4), 428–434.

Richards, P., Baldwin, B., Frost, H., Clark-Sly, J., Berrett,M., & Hardman, R. (2000). What Works for treatingeating disorders? Conclusions of 28 outcome reviews.Eating Disorders, 8, 189–206.

Rosenvinge, J. H., & Klusmeier, A. K. (2000). Treatmentfor eating disorders from a patient satisfactionperspective: A Norwegian replication of a Britishstudy. European Eating Disorders Review, 8, 293–300.

Ryan, V. (2004). A critical psychological investigation ofnurses’ experiences, understandings and perspectives ofnursing eating disorder patients. Unpublished MA(Hons) thesis, University of Western Sydney.

Sanders, F., & Gaskill, D. (2000). Body image andeating disorders: Implications for policy. In D. Gaskill,& F. Sanders (Eds.), The Encultured Body: Policyimplications for healthy body image and disordered eatingbehaviours. Brisbane: Queensland University of Tech-nology.

Santonastaso, P., Pantano, M., Panarotto, L., & Silvestri,A. (1991). A follow-up study on anorexia nervosa:

Clinical features and diagnostic outcome. EuropeanPsychiatry, 6(4), 177–185.

Smith, C., Feldman, S., Nasserbakht, A., & Steiner, H.(1993). Psychological characteristics and DSM-III-Rdiagnoses at 6-year follow-up of adolescent anorexianervosa. Journal of the American Academy of Child andAdolescent Psychiatry, 32(6), 1237–1245.

Steinhausen, H. C., Rauss-Mason, C., & Seidel, R. (1991).Follow up studies of anorexia nervosa. PsychologicalMedicine, 21(2), 447–454.

Treasure, J., & Schmidt, U. (2001). Ready willing and ableto change. European Eating Disorders Review, 9, 4–18.

Treasure, J. & Schmidt, U. (2002). Anorexia nervosa.Clinical Evidence, 7, 824–833.

Waller, D., Mugan, M., Morshed, T., Setnick, J.,Cummings, M., & Hynan., L. (2003). Three yearfollow-up study of children and adolescents withanorexia nervosa initially treated in a continuum ofcare programme. Eating Disorders, 11, 63–72.

Willig, C. (2001). Introducing qualitative research in psychol-ogy: Adventures in theory and method. Milton Keynes:Open University Press.

World Health Organisation. (1992). ICD-10: Classificationof mental and behavioural disorders. Geneva: WHO.

Yager, J., Landsverk, J., & Edelstein, C. (1989). Helpseeking and satisfaction with care in 641 women witheating disorders: Patterns of utilization, attributedchange, and perceived efficacy of treatment. Journal ofNervous and Mental Disease, 177(10), 632–637.

Discursive Constructions of ‘Eating Disorders Nursing’ 135

Copyright # 2006 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 14, 125–135 (2006)