Since deinstitutionalization in the 1970s, the role of occupational therapists working with people with eating disorders (ED) has changed. Traditionally occupational therapy intervention related to an ED has been in inpatient settings; however, the current health climate has led to more community based treatments, meaning clinicians have to adapt their practice. Occupational therapists have the skills and creativity, and a unique perspective of occupation to support recovery from ED. Through the use of meaningful occupation, client centredness, community collaboration and pushing the boundaries of what activities are 'realistic', occupational therapists can promote hope, meaning and purpose in life. This article reviews the current literature with the following questions in mind: What is the impact of an eating disorder on occupational performance, and therefore on recovery; What is the role of occupational therapy in an eating disorders service?
Impact of eating disorders on occupation
Approximately 1.7% of New Zealanders are diagnosed with an eating disorder at any one time. These include anorexia nervosa (an illness of self starvation, with extreme fear of fatness, worthlessness and powerlessness); bulimia nervosa (involving binging and purging behaviours) and eating disorders not otherwise specified. Occupational performance issues in ED are global, affecting all areas of life from preparing meals, shopping, carrying out the demands of work or study, and managing difficult emotions when socialising with friends and family (Gardiner & Brown, 2010; Karpowicz, Skerseter, & Nevonen, 2009; Reiss & Johnson-Sabine, 1995). Self care routines can be disrupted by an inability to look after personal needs due to negative thoughts or body image problems, for example inability to look at or touch one's own body leading to difficulty with getting dressed (Goldberg, 1997).
Low body weight affects the person's ability to think clearly. Poor attention, concentration and memory are common side effects of starvation (Breden, 1992) and make engagement in occupations such as work or study difficult. Starvation increases obsessional thinking, thus increasing anxiety with a subsequent focus on weight, resulting in a spiral of weight loss and decreased functioning (Lawson, Waller, & Lockwood, 2007). Costa (2009) described the frightening experience of supermarket shopping, agonizing over what to buy for lunch, obsessional checking of food labels and extreme rigidity in routines; making simple tasks take hours instead of minutes. The flow-on effect of time use is detrimental to sustaining other activities. If one spends too long
in the supermarket it means less time in the day for work, friends, and other meaningful activities creating occupational imbalance similar to people with other chronic mental illnesses (Costa, 2009; Eklund, 2009; Sutton, 2008). Some clients will over-exercise every day leaving no room in their life for anything else (Lawson, et al., 2007).
A distorted perception of body image also impacts on time use and the desire to socialise. Clients with ED often find they do not know what activities they enjoy and so they have difficulty having fun (Gardiner & Brown, 2010). Many authors have commented on the poor social skills of clients with ED, especially in food-related situations (Gardiner & Brown, 2010; Giles & Allen, 1986; Kloczko & Ikiugu, 2006). Family meals can become times of extreme conflict and distress (Reiss & Johnson-Sabine, 1995) thus, difficulty engaging in social roles and occupations is prevalent for this population of mental health clients. Family members can also hold specific expectations for the client about the roles they should fulfill, which sometimes upholds the illness; for example, when the parental relationship is deteriorating and the ED acts as a buffer (Henderson, 1999).
Furthermore, parents or siblings reactions, which may initially have been functional and even necessary (such as prompting the young person to eat), have the potential to become maladaptive over time (created dependency). …