The nature of eating disorders is a complex issue lacking clarity in academic and clinical understanding. Although the medical model predominates in diagnosis (Papathomas & Lavelle, 2012) other models of self and subjectivity may contribute usefully to the understanding and treatment of eating disorders (White, 2011).  There may indeed be a metaphoric link between indigestible social discourses (Papathomas & Lavelle, 2013) and eating disorders. The research project, Eaten Stories Untold (ESU) is based on the idea of ‘un-telling’ stories that have become introjected; enfolded from the ‘outside’ of the body to the ‘inside’ of subjective experience.  The project involves an inquiry into the use of imagery and metaphor in writings by people with experiences of disorded eating. The work is analysed through the social theory paradigm of narrative theory. Imagery and metaphor were chosen as a focus for analysis of all the various possible devices of language as they provide tangible forms of expression about what can otherwise be a slippery concept to capture in written form. The evocative function of imagery and metaphor has the potential to hold condensed meaning for the individual writer. This project sought to listen carefully to the ways that introjected stories may be ‘untold’ for the benefit of those experiencing disorded eating. This report brief report provides an overview of the process of eaten Stories Untold, and the outcomes from the project.

The biomedical model has contributed valuable insights into a structuralist perspective of diagnostics (Lavelle and Papathomas, 2012; Fairburn, 1995; Stickney, 1999; Kotowicz, 2011; Lock & LeGrange, 2005; Wade, Slater et al, 2013; Knox & Cooper, 2010).  The biomedical model argues that eating disorders, being those experiences which align to diagnostic criteria and not beyond, are essentially biochemical imbalances coupled with complex psychological pathology, given long-term suffering prognosis and high levels of comorbidity (NEDC, 2014; TBF, 2014). When viewed through the biomedical lens a picture of a significant, painful and long term illness is painted.

Whilst this approach has opened up important areas for discussion, it does do so through a framework which positions a passive ‘consumer’ in the face of an expert panel of diagnosticians. Through the assumptions that authoritative knowledge comes from the objective scrutiny of the expert, this approach disables contribution to the field from lived experience of conditions under enquiry (Wheeler, 2005).

Valuing of lived experience is a position adopted in ESU to value the knowledge and insight historically overlooked, in view of contributing texture and accessibility to a situation that is very much still stigmatised and misunderstood in Australian society (Howard-Taylor, 2008). These gaps in the biomedical framework invite a qualitative and post-structuralist eye to complement discovery thus far established and layer upon this a dimension of understanding of the disordered eating experience yet uncharted within the biomedical framework.

As established in the above review of research from the biomedical framework, a qualitative approach can offer richness to the landscape that quantitative research has predominantly inhabited on this subject (Punch, 2014; Trafimow, 2013; Duffy, 2008;Trafimow, 2013) McLeod and Smith, 2011; Smith, 2009;  Bryman, 2008 ).

Unlike other forms of qualitative research, narrative theory is not only concerned with methods but also with broader ontological issues. As mentioned by Tamboukou (2015) and also reflected on by Besley (2002), the political and the social is a false dichotomy. It is not just the social stories which illuminate (Monk, G. & Gerhart, D. R., 2003; Murray, M., 1997; Punch, K. F., 2014) ‘but also the political and the way they are inextricably interrelated’ (Besley, 2002, pp. 20).

Narrative research is about making sense of the world, connecting events over time though stories, not just examining a series of symptoms. These factors are essential pillars to narrative research on disordered eating, which from a narrative framework are fundamentally interwoven in the very fabric of the experience.

A narrative research approach holds that people see the world not event by event but through under woven meaning in a forming a narrative for their life (Murray, 1997). There is a key point of difference here from biomedical contributions in a positivist versus post positivist stance.

The biomedical positivist approach searches for universal laws in psychology. Whereas Monk (2003) identifies the narrative therapist as a socio-political activist, acknowledging influences of Foucault (Barty, 1988) in his thinking. The concept of discourse, as articulated by Foucault (Barty, 1988), refers to a patterned set of meanings and social practices established through a multitude of conversations. Foucault states that “the manifest discourse, therefore, is really no more than the repressive presence of what it does not say; and this ‘not-said’ is a hollow that undermines from within all that is said” (Foucault, 1974). Internalised effects of repression of the un-said has been a very influential concept in the design of ESU. The very use of the word ‘untold’ in the research title attempts to capture the telling-out of stories consumed (relating to the word Eaten in the research title) from outside oneself, a way of viewing self from the outside can begin to be unravelled. What must be considered is the importance of language and meaning in influencing and structuring our experiences and life-trajectories in the developing process of self-formation (Weingarten,1998; Thornhill, et al, 2004; France, et al., 2013).

In asserting a qualitative framework as the most appropriate for the ESU subject area, and within that a narrative framework and discourse analysis best fitting as an analysis approach for the data, this section will review what has currently been researched on disordered eating experiences within a narrative perspective.
Papathomas and Lavelle (2012) looked at how alliance to dominant social storying of an eating disorder indicated more recovery structured narratives. The article also highlights that eating disorder literature can benefit from innovative methodologies and new ways of conceptualising.

Papathomas and Lavallee (2013) in another article show wider eating disorder literature has been criticised for an unduly narrow medicalised approach that fixates on symptoms and marginalises understanding of experiential features. Convenience and perhaps compliance can be found from a ‘ready-made’ explanation that can be internalised, or from ESU’s perspective, metaphorically eaten (Papathomas & Lavellee, 2012). Value is attributed to the narrative approach, noting that narrative inquiry is typically underpinned by a relativist ontology and an interpretivist epistemology. Papathomas and Lavelle (2013) show that illness is given a purpose in recovery narratives.

White (2002) discusses power issues in narrative research on disordered eating, including how the social oppression of women is an external social factor which can be introjected and enfolded by women vulnerable to these discourses. White (2007) discusses how an older form of power such as traditional sovereign power structure has transitioned into modern power structures shown in the of women and of feminine power. These ideas have been amply covered by feminist thinkers, beyond the narrative framework (Irigary, 1977; Felman, 1977; Johnston, 1997; Noble & Day, 2015).

Madigan (2011) discusses social discourses of comparison, perfectionism and guilt contributing to the manifestation of disordered eating from a narrative perspective. Papathomas and Lavelle (2013) also observe a dominant cultural storyline in which only success and achievement leads to self-worth. The relational dynamic of an individual with disordered eating is crucial in validating the true experience of disordered eating. The shame and guilt Madigan refers to (2011) are the very fuel for intensifying disordered eating. Shame and guilt are spoken of by those with lived experience prolifically (Costin, 2012; Howard-Talor 2008), yet not touched upon in the literature from a bio-medical paradigm.

Murray (Brett, 1996) identifies properties to deepen understanding of narratives as a way of constructing reality and bringing sense to something obscure and unusual. There is relevance in exploring alternative story fragments and options for meaning making as Willig (2009) also describes. Indeed ‘a narrator is trying to organise the disorganised’ (Willig, 2009, pp. 4).

Lock (2014) with Conti (2013) considers the interpretive reception of the problem. For example in contemporary western society there is an interpretation of a set of behaviours as a psychiatric illness which in medieval times might have been seen as evidence of sainthood through self-starvation, an ability to move beyond the bodily realm.

From a narrative research perspective there is emergence of interest in the stories of disordered eating as valuable contributions in themselves Madigan, S. (2011). Perspectives on narrative approaches offer value in a constructivist narrative approach, albeit fundamental in a shift of thinking in this area.

Quantitative research can often offer more tangible outcomes but tends to view subject matter from a perspective that is not coherent with a narrative post-structuralist paradigm Mcleod, J., 2011; Mcleod, J., 2013; Gardner, F. & Coombs, S.J., 2010). Qualitative research risks making conclusions that overly simply results, but is also more open to finding meaning in unexpected places and allows a way of working within research that is aligned with the ESU thesis concept ethically.

However looking into the terrain of metaphor and imagery in disordered eating experiences there is a gap in research completed to date. Despite comprehensive searches on major academic journal databases, there was little within a narrative framework touching on ideas of metaphor and imagery in disordered eating (Ed. Dulwich Centre., 2004;  Epstom, D. & White, M., 1992;  Freedman, J. & Combs, G., 1996).

Metaphor and imagery are important concepts as languaging such a complex and internal experience as a disordered eating experience can be too slippery to be meaningful, especially when reduced to thematic research outcomes. If lived experience is to be truly valued, a scope of languaging of the experience could benefit from representational concepts which might capture the complex and perhaps disorganised content of the lived experience. Narrative research into disordered eating to date has focused on story structure and social enfoldment, both of which have been trailblazing initiatives (Bruner, J., 1990; Smith, J. (ed), 2007). However there is an aspect of story missing without metaphor and imagery analysis.

While there is some interest and work into narrative approaches of disordered eating, much of this has taken place through verbal accounts rather than written contributions, and there is a gap within creative and free-form writing contributions rather than more autobiographical accounts. What much narrative research has focused in on when researching disordered eating is the coherency and structure of the storying from research participants. There is some interest in metaphor and imagery but this has not been researched within a structured narrative paradigm.

It seems the area of imagery and metaphor in a narrative analysis of disordered eating experiences could begin to offer a complement to some of the research unfolding in this area.

ESU emerged from my interest in how those experiencing disordered eating tell their stories. The aim of ESU is to inquire into the narrative expressions of those experiencing disordered eating in order to enhance understanding of the experience, and make practice recommendations based on these findings. I have specialised in the field of eating disorders for a number of years as the clinical manager of the leading national eating disorder organisation, The Butterfly Foundation (Butterfly), and have a private practice specialising in eating disorders. I was in a privileged position to be able to bridge gaps that have been apparent in the field, and had large scale resources with which to conduct this research opportunity.

From my professional experience specialising in the field of eating disorders I noticed that clients utilise imagery and metaphor commonly in spoken language, as the complexity of the experience is not adequately captured in linear language. My hypothesis was that this would transpose in writing as participants reflected on their lived experience. I wanted to explore in more detail the nature of the imagery, metaphors and main themes used.

According to narrative theory, dominant social discourses may be retold unwittingly by individuals (Freedman & Combs, 1996). If these stories are ‘thin’ (in narrative terms meaning underdeveloped self-concepts [White, 2007]) they limit the richness of alternate stories in that individual’s life. They also limit the experience of re-authoring , which is to bring more awareness, ‘thickness’ and depth to a story about self to allow for more autonomy and meaning in ones’ life (White, 2011).

Dominant social discourse is a relevant narrative term which refers to socially bred concepts which may be supressing for an individual (Foucault, 1974).  Dominant plot is another narrative term that will be used in the analysis and refers to the dominant thinking style and self-concept in ones’ life (Conti, 2015).

The aims of ESU were to approach transcripts with a qualitative epistemology, to let the voices of the authors be heard and explored. The structures around the investigation supported a special focus on language and specifically the use of metaphor and imagery to articulate the unspoken element of a disordered eating experience. Metaphorical self-concept and personal inquiry was not represented in the academic literature. ESU’s vision was to put words from lived experience to the unacknowledged components of an eating disorder.

Qualitative research aligns with narrative theory’s philosophical underpinning (White, 2007) which is the foundation of ESU. Qualitative research is a paradigm that has the capacity to hold complexity socially and ontologically (McLeod, 2007).

McLeod’s (2013) note that empowerment is a research goal of qualitative approaches is congruent with the narrative theory’s framework (Boeije, H. , 2010).

The data from ESU was reviewed through the methodological framework of discourse analysis. I chose a narrative theory approach to discourse analysis because of its understanding of subjects as products of a storied world (Conti, 2013).  Narrative theory derives from literary theory (White, 2011) which matched my interest in exploring how participants used language. Discourse analysis also focuses on the specific use of language and complements Foucault’s theories on discourses as the influential ‘un-said’ which can be dissected through language analysis (Foucault, 1974).

With language as the lens of analysis I conducted a word frequency analysis, as well as examining dominant themes in the written contributions. Word frequency revealed the most common terms used by participants in relating their experiences; and this approach could allow for grouping similar terms so that an interpretation and meaning from the data could be drawn. In addition, I grouped written material into themes. The emerging themes suggested common plot forms in the experience of disordered eating. These plots encoded  political, social and personal implications, which will be further detailed in the data analysis section of this report.

Influential researchers such as Carl Rogers, Aaron Beck, Les Greenberg, among others, have used research to elaborate and promote their vision of how therapy should be practised (Mcleod, 2013). ESU is also informed by this intent. Professionally I identify a clear need for greater awareness of disordered eating within the mental health profession. ESU provides some understanding of how disordered eaters may be trying to re-narrate their experiences, and I hope to use some of the findings for advocacy to propel change within the profession.

Data was analysed through the frame of discourse analysis. I grouped emerging themes from the writing and identified 11 categories of consistently used language, imagery and metaphors such as ‘perfectionism’ and ‘ambivalence.’

By taking a macro view I was able to reduce the 11 categories into 6 main categories of the most commonly used concepts. I measured the frequency of usage of each of the stimulus words to gauge their importance to the participants.  I found that there were three themes most commonly referred to directly in language, and more indirectly in concepts (such as not mentioning the actual term like ‘self–worth,’ yet discussing ones’ own value in similar terms).

I chose to look at themes expressed in participants’ written material to examine, from within the framework of narrative theory, social scripts that may be absorbed by subjects (Boeiji, 2010). Taking this key premise of narrative theory, I identified those themes most related to social discourses and most relevant in participants writing. I identified ‘legacy’, ‘relationship’ and ‘agency’ as the most prominent themes. Of the stimulus words on offer I grouped these into three categories of conceptual notions; visceral/ physical, relational/social, abstract/ conceptual.

The theme of legacy captured a sense of the writer telling other women how to fare better, encouraging them not to subscribe to social ideals about the female body and making commentary on how women are placed socially. The theme of agency captured a sense of self-efficacy, trust in self and the world, or a lacking thereof.  The theme of relationship included relating to self, to others, and to disordered eating.

I was interested to note the frequent use of the word ‘paradox’ which was not offered as a stimulus word, but was used ten separate times by five writers, as well as the related word ‘catch 22’ used twice by another two different writers.  ‘Trust’ was used frequently. Also ‘suffocation, chocking and weight’ were used multiple times. These words have been reassessed in further analysis, factoring in the numerical usage of language terms as tropes (figurative uses of language).

The use of words such as ‘paradox’, ‘catch 22’ and ‘trust’ added another dimension to the initial report on stimulus word usage. I searched further for more synonyms for the stimulus words which altered initial findings. The use of words such as suffocation, choking and weight (as a conceptual noun, weight used with physical reference was calculated separately) were abundant. When I looked at language usage in terms of tropes rather than frequency I noted that the word ‘weight’ was used as a synonym and also very much a metaphor, which holds its own irony in the context of writing about disordered eating. ‘Weight’ was used 145 times, the word ‘fat’ 42 times, ‘huge’, and ’bones’ were also used with significant frequency. Relational concepts showed ‘friend’ used 67 times, often in relation to the eating disorder, ‘hope’ 73 and ‘trust’ 42 times.

Of all the data, 8.4% of text related to the theme of ‘agency’. This is twice as much as text related to the themes of ‘relationship’ (4.2%) and almost four times as much as text related to the theme of ‘legacy’ (2.4%).

Looking at usage of key stimulus words with synonyms as themes Abstract/ Conceptual  came to 5.2%, Visceral/ Physical  was at 3.1 % and Social/ Relational was 3%.

The most commonly used words were (in order of frequency): me, eat, want, weight, life, man, body, enough. Another noteworthy finding was that the terms man/men/and synonyms were used 2.6 times more than the terms women/ girl and synonyms. This was surprising given that all the project participants are women.

Notably the term ‘girl’ was used a third more than the term ‘woman’, often in reference to themselves by writers who are all adults.  The term ‘boy’, by contrast, was only used three times in total.  Perhaps this refers to the un-said elements of women’s experience of their social positioning relative to men, and social expectations of the genders.

The sense of agency has clearly presented as the main theme in the written material, with abstract and conceptual terms the strongest word types used. Participants have expressed in their writing that their disordered eating experience is linked to philosophical conflicts. This data would suggest the experience of disordered eating is predominantly a philosophical and social issue. Self-concept, sense of agency and self-trust, means of feeling safe in the world and how to make sense of the world, culture and society were important preoccupations in participants’ written material.  A meta-story emerges from the collective writings that offers the narrative of a sensitive, capable, strong and intuitive subject trying to find a congruent position in a world which only offers ‘shapes that don’t fit’. A sense of knowing truths but being ‘unable to speak’ them echoed in the writing. There was an apparent sense of knowing one’s capacity and potential, but being unable to ‘launch’ this. Through this approach the disordered eating could be understood as one the means of expressing this existential ‘paradox’, rather than being an issue in and of itself, as a bio-medical framework would suppose.

In an effort to triangulate the preliminary findings I decided to share them with participants to elicit their feedback on my analysis. I applied for ethics approval to alter my methodology to include this process and once granted I asked participants  to reflect on a summary of the analysis. 25% of the participant cohort responded. Some respondents reflected on their stance on several components of the research, while others focused on the areas most relevant to them. In relation to themes 16% of respondents said aspects of the relationship theme resonated with their experience, 33% affirmed the theme of legacy and 50% the theme of agency. This feedback is consistent with the initial findings. It is important to also consider that the 25% who responded might have responded because of a form of experience which led them more towards receiving the data in a particular way. For example, those who resonated more with ideas of legacy might have felt more inspired to participate in triangulation of feedback for their desire to catalyse change.

Reflecting on the words most commonly used through the writing ‘weight’ was the one word which each respondent agreed was closely relevant to their experience: ‘Weight is the word that relates…’ Another participant reflected ‘Weight would be the strongest … significance and power’; other participants reflected on the connection between weight and men in their experience: ‘men are less stigmatised with regards to value and relation to appearance than women’, and ‘… driven by my weight…it is because I want to be in a relationship with a man… a walking contradiction… because my weight dictates… (even) desire to be with a man’. Within this last statement another paradox is presented. However there were also respondents for whom the term ‘man’ was not relevant ‘Eat and weight relate strongly…Men/man not at all.’

Reflecting on the findings as a whole, participant responses highlighted the very varied experiences that disordered eating encompasses. Generally the preliminary findings in ESU were echoed in respondent’s reflections. ‘Overall these words are accurate in representing my experience’, ‘Agency is about trust’ ‘weight has a sense of power and place and for me direct correlation to sense of worth. ‘Eat’ less so because to me little about my anorexia is to do with eating. And man not at all although woman very much so.’ ‘I fear gaining weight because I don’t trust that men will find me appealing when I’m heaver.’ ‘…weight and food become …central to the person’s life in sickness and recovery. Although they are not always causal factors…”

The findings from ESU suggest valuable future research might be found in the use of a sociological framework for discerning meaning relating to disordered eating. The themes that came from the research were not predicted in current literature on the topic, which suggests that the findings at a quantitive and bio-medical level are at odds with the lived experience expressed through a narrative theory approach to quantitative research.

A narrative frame, or a framework that extends beyond the biological to take in social and related factors, may better capture some of the experiences of disordered eating. The findings indicate that social and philosophical concepts are important for those experiencing disorded eating. Yet these ideas are not addressed significantly in the literature on the subject, nor by standard treatment options, nor in training on disorded eating for clinicians across a variety of disciplines. The literature review highlighted a lack of research into disordered eating outside of the medical paradigm. This leaves a significant gap in research which research such as ESU may begin to fill.

There were also elements of data that did not fit the analysis and need further exploration. There were participants who stated they didn’t feel social issues were relevant for them, that body image hadn’t been a factor for them, and they had not experienced social pressures as a limiting factor in their lives. They indicated that their gender, and the treatment and representation of women culturally did not feel relevant to their experience. For them their experience of disorded eating related to something else that was not identified.

But as the data analysis has demonstrated, ‘agency’ was the main theme across the participants’ contributions, with the strong use of conceptual rather than visceral or relational language.

ESU’s findings highlight how disordered eating relates to social narratives. A recommendation based on this research is that analysis of the social impacts on disordered eating be addressed in research and application to treatment. This should include an appreciation that the experience is not necessarily centred on food, and perhaps not even body image for some, and that these may be secondary symptoms of an experience which at its core is best understood as social in the context of one’s personal meaning making. Although when disordered eating first manifests in an individual, they might require treatment anchored in a medical paradigm, it is important that the experience is understood in a broader frame by any member of the treatment team, and by social support networks. As discussed by Nobel and Day (2015) much clinical training is immersed in discourses that the trainee may leave unexamined, leading at times to a retelling of the very stories most destructive to clients.

The word ‘paradox’ was chosen by many participants to capture their lived experience of disordered eating. This begs the question, if therapy practitioners were better informed of the complexity of the disorded eating experience, and its relationship to social narratives of identity were understood, would this situation still look like a paradox? If practitioners generally subscribe to the same discourses which usurp the agency of those experiencing disorded eating, can they truly offer effective therapy?

Without a thickening of the narrative around disordered eating, the risk is that a two-dimensional response is given to a three-dimensional issue. For example, although the medical aspects of treatment such as regulating food intake are relevant, the more complex aspects of the disordered eating experience risk being overlooked in the process. This merely practical level of care is limits recovery.  Without addressing the relevance of broader social issues that may have invited one into disordered eating and maintained their stay in these behaviours, understanding and treatment will remain crisis-based, rather than providing prevention and opportunity for personal transformation. The findings of ESU would strongly support further work to address this gap in academic, clinical and social applications.

*full report available on request

**full reference list available on request