Henderson

volume 66 • issue 1

Frames of reference utilized in the rehabilitation of individuals

with eating disorders

•

SARAH HENDERSON

CANADIAN JOURNAL OF

FEBRUARY 1999 • OCCUPATIONAL THERAPY

ABSTRACT

An occupational therapist’s role with

clients diagnosed with eating disorders,

both anorexia nervosa and bulimia ner-

vosa, has been described throughout the

literature. However, the frames of reference

and treatment approaches that occupa-

tional therapists implement have not been

clearly established or validated. This paper

outlines the symptomatology of anorexia

nervosa and bulimia nervosa, and critical-

ly reviews the current literature concerning

the frames of reference and treatment

approaches used by occupational thera-

pists when intervening with this popula-

tion. The literature reviewed indicates that

therapists are using a variety of frames of

reference and treatment approaches. There

appears to be an emphasis on the psy-

choanalytical and cognitive-behavioural

frames of reference, although there is a

lack of empirical evidence in regards to all

frames of reference and treatment

approaches. Reasons for the lack of cur-

rent research with this population, and

possible future areas of research are sug-

gested

RÉSUMÉ

Le rôle de l’ergothérapeute auprès des

clients ayant reçu le diagnostique

d’anorexie mentale et de boulimie mentale

a été décrit dans la littérature. Cependant,

les cadres de référence et les approches

mis en oeuvre par les ergothérapeutes

n’ont pas été clairement établis ou validés.

Cet article expose la symptomatologie de

l’anorexie mentale et de la boulimie men-

tale et fait une analyse critique de la lit-

térature actuelle sur les cadres de

références et les approches utilisés par les

ergothérapeutes qui interviennent auprès

de cette population. La littérature exam-

inée indique que les thérapeutes utilisent

divers cadres de références et approches.

L’accent semble être mis sur les cadres de

référence psychanalytiques et cognitifs-

behavioraux, bien que les preuves

empiriques ne soient pas suffisantes pour

tous les cadres de référence et les traite-

ments. Les auteurs présentent les raisons

pour lesquelles peu de recherches sont

effectuées présentement auprès de cette

population et suggèrent des avenues pos-

sibles pour la recherche.

KEY WORDS

Anorexia nervosa

Bulimia

Frame of reference

Methods, occupational therapy

Sarah Henderson, B.Sc.,

O.T(C), OTR, was a student at

the University of Western

Ontario in London, Ontario at

the time of writing. She is

currently a staff occupational

therapist at the New England

Medical Center,

750 Washington Street,

Boston, Massachusetts 02111

E-mail:

[email protected]

at Canadian Association of Occupational Therapists on April 24, 2016cjo.sagepub.comDownloaded from

Sarah Henderson

LA REVUE CANADIENNE

D’ERGOTHÉRAPIE • FÉVRIER 1999

volume 66 • issue 1

ccupational therapists’ unique contribution toward the

treatment of individuals with eating disorders (ED), is

their combined knowledge of physical, interpersonal and

psychological functioning (Barris, 1986; Giles & Chng, 1984;

Lim & Agnew, 1994). The most effective treatment of ED is

client specific and delivered using a multidisciplinary team

(Beck, 1993; Breden, 1992). The team should include repre-

sentatives from occupational therapy, psychiatry, medicine,

psychology, nursing, nutrition, social work, and recreational, art

and movement therapies (Giles & Allen, 1986; Harries, 1992;

Lim & Agnew, 1994). Individuals with ED encounter problems

in self-care, productivity, and leisure, such as poor nutrition,

excessively high expectations of self, decreased interest in

vocational and social pursuits, poor social skills, excessive

exercise, and lack of meaningful and purposeful activity (Barris,

1986; Beck, 1993). Therefore, the goal of occupational therapy

intervention with this population is to maximize the clients’

function in social, psychological and physical domains, and to

assist them in engaging in meaningful, satisfactory occupations

(Barris, 1986; Giles & Allen, 1986).

The role of occupational therapy among persons with ED,

has only recently been described throughout the literature,

possibly due in part to that fact that prior to the 1970’s, these

clients were placed on general psychiatric wards (Giles & Allen,

1986). The milieu on the general psychiatric wards was not

conducive to developing specialized interventions (Giles &

Allen, 1986). The milieu on the general psychiatric wards was

not conducive to developing specialized interventions (Giles &

Allen, 1986). In the past 20 years, formal eating disorder units

have been established. Due to the lack of occupational thera-

py research investigating the most effective frames of reference

and treatment approaches, it would appear that occupational

therapists are currently basing their multi-modal interventions

on generalizations of others research (Giles & Allen, 1986; Lim

& Agnew, 1994). A suitable frame of reference must be chosen

during occupational therapy programme planning in order to

“...make intervention relevant to the problems and needs iden-

tified in the assessment” (Canadian Association of

Occupational Therapists (CAOT), 1991, p. 37) and to “...provide

guidelines for evaluation and intervention...” (Mosey, 1989, p.

196). The current interventions used by occupational thera-

pists, even if based on others’ research, should continue to be

assessed for their effectiveness within occupational therapy,

either through case studies or other research methods.

In order to acquire an accurate knowledge base from

which to conduct further studies on the application of frames

of reference, and treatment approaches, it is important to crit-

ically review the current research in this area. This descriptive

paper will outline the symptomatology of ED, and define,

explore, and present current research supporting the following

frames of reference, and subsequent treatment techniques,

currently being used by occupational therapists, working with

individuals with ED: psychoanalytical, behavioural, develop-

mental, familial, cognitive-behavioural. Reasons for the lack of

research, and possible areas for future studies will be dis-

cussed.

According to the American Psychiatric Association’s (APA)

iagnostic and Statistical Manual

, fourth edition (

DSM-IV

)

(1994), ED consist of two specific diagnoses, Anorexia Nervosa

(AN) and Bulimia Nervosa. AN is an illness which combines

social, biological, and psychological factors, whereby the

symptoms of the mental illness are exhibited through bodily

behaviours (Giles & Chng, 1984; McColl, Friedland, & Kerr,

1986). According to

DSM-IV

(1994), there are four criteria to AN,

which are as follows:

1. “...refusal to maintain a minimally normal body weight”

for one’s height and age (p. 539)

2. extreme fear of becoming fat

3. distorted body image, self-evaluation dependent upon

body image, or denial of the grave nature of being under-

weight

4. lack of menstruation in post-menarcheal females, for three

consecutive cycles.

Weight loss occurs because of excessive exercise, a self-

limiting diet, or purging, which occurs in 30%-50% of individ-

uals with AN (

DSM-IV

, 1994; Martin, 1989). Purging consists of

ridding oneself of ingested food, through behaviours such as

“...self-induced vomiting, use of laxatives or diuretics, strict

dieting or fasting...” (Beck, 1993, p. 584).

The personality characteristics of individuals with ED

include low self-esteem, decreased insight regarding their ill-

ness, and perfectionistic or obsessive-compulsive tendencies

(Beck, 1993; DSM-IV, 1994; Giles & Chng, 1984). Bruch (1973)

postulates that individuals with AN seek control and indepen-

dence, but end up misguiding this desire into an obsessive

control over one’s own weight. In addition to these symptoms,

there are a set of physical aspects which include: constipation,

pain in the abdomen, intolerance to cold temperatures, exces-

sive energy, or feelings of lethargy. The prevalence of this dis-

order, in industrialized societies, is between 0.5%-1.0%, fol-

lowing chronic or episodic courses, with over 90% of the indi-

viduals being female (DSM-IV, 1994). ED occurs predominantly

in societies which are industrialized, and whose media con-

tains multiple messages of thinness equalling attractiveness

(DSM-IV, 1994).

Bulimia Nervosa (BN) was first identified as a separate

syndrome by DSM III, in 1980 (Martin, 1989). The five criteria

to BN are as follows:

1. episodes of recurrent binge-eating

2. behaviours to compensate for binge-eating, such as vom-

iting, diuretics, overabundance of exercise, abuse of laxa-

tives, and enemas or fasting

3. the above criteria occurring, on average, twice weekly, for

a three month period

4. self-evaluation heavily dependent upon body’s shape and

weight

at Canadian Association of Occupational Therapists on April 24, 2016cjo.sagepub.comDownloaded from

CANADIAN JOURNAL OF

FEBRUARY 1999 • OCCUPATIONAL THERAPY

volume 66 • issue 1

Sarah Henderson

5. all of the above not occurring solely during episodes of

AN (DSM-IV, 1994).

Individuals with BN may have difficulty communicating

their feelings, and may deal with their psychological stress by

bingeing (Martin, 1989, 1991). Often these individuals are lone-

ly, narcissistic, intelligent, attractive, tend to have low self-

esteem, and are ashamed of their behaviours (DSM-IV, 1994;

Martin, 1989, 1991). Along with these personality characteris-

tics, there are a constellation of physical features associated

with BN which include destruction of dental enamel, and occa-

sional menstrual irregularity. For the majority of individuals,

weight is within normal limits for their age and height (DSM-

IV, 1994). Prevalence of BN in the general population is 1%-3%,

with over 90% of individuals being women (DSM-IV, 1994). Age

of onset is usually late adolescence or early adulthood, with

the course being episodic or chronic (DSM-IV, 1994).

As with AN, BN is most often recognized in industrialized

countries. Other similarities between individuals with AN and

BN may include: perfectionistic qualities; engagement solely in

tasks where one feels a sense of control over the outcome;

and feelings of deprivation, rejection, anxiety, and anger

(Bailey, 1986; Beck, 1993). Speculations of the cause of both

illnesses have pointed to inherent personality characteristics of

the individual, such as low self-esteem, and being easily per-

suaded by societal pressures (Harries, 1992). Other possible

explanations of the cause of ED include conflicting media mes-

sages, and a belief held by western society that an individual

must be thin in order to be attractive (Breden, 1992; Harries,

1992). In contrast to AN, individuals with BN tend to be older,

approximately 16-40 years of age, and may engage in other

impulsive behaviours such as stealing and promiscuity (Martin,

1989, 1991).

Individuals with ED encounter many difficulties in func-

tional performance such as limited communication skills, inad-

equate time management skills, and a lack of assertiveness

skills (Beck, 1993; Bridgett, 1993; DSM-IV, 1994). In order to

develop these skills and promote functional behaviour, occu-

pational therapists utilize therapeutic activities (CAOT, 1991). To

engage a client in “relevant, meaningful, and purposeful activ-

ity” (p.51), occupational therapists must choose an appropriate

frame of reference (Rockwell, 1990). A frame of reference is a

“link between theory and practice” serving as a guide that

“delineates the types of interactions considered to eliminate or

minimize dysfunction” (Mosey, 1986, p. 5). Accordingly, inter-

vention will be defined as “…the process of interceding to

affect functional change…by the use of purposeful activity”

(CAOT, 1991, p. 51). Furthermore, approaches will be defined as

those interventions which are congruent with the principles of

the chosen frame reference (CAOT, 1991).

Rockwell (1990), found that most eating disorder units

treated clients with AN and BN with the same intervention, and

thus, throughout this paper, frames of references and treat-

ment approaches used for AN and BN will discussed in unison.

Regardless of the similarities in functional treatment of AN and

BN, there continues to be a debate concerning the frames of

references occupational therapists are using to guide their

interventions. Generally, there appears to be a consensus that

a number of frames of reference should be used in treatment,

although there continues to be a debate concerning which

combination should be used (Giles & Allen, 1986; Harries,

1992; Martin, 1989). Harries (1992) states that a combination

of psychoanalytical, medical and behavioural frames of refer-

ence are necessary in the treatment of individuals with ED,

whereas Giles and Allen (1986), stated that in addition to the

above mentioned frames of reference, treatment planning

should include cognitive-behavioural and familial perspectives.

Martin (1989) maintained that intervention from the behav-

ioural, and familial frames of references may specifically help

individuals with BN. In addition, it is interesting to note that

when using the Model of Human Occupation (MOHO) as a

frame of reference, which will be expanded upon later in this

paper, a number of treatment approaches drawn from many

frames of reference can be utilized (Barris, 1986).

There have been two studies conducted to determine the

frames of reference and treatment approaches currently being

used by occupational therapists in the treatment of individu-

als with ED. Rockwell (1990) sent out 204 questionnaires to

occupational therapists working with individuals who have ED.

This descriptive research design consisted of a 15 item ques-

tionnaire. The participants were asked to choose the answer

that matched most closely with their beliefs, from a set of pre-

determined responses. Three of these items sought informa-

tion concerning the frames of reference and treatment

approaches being used at their facilities. One question

addressed the participant’s beliefs in relation to the etiology of

ED. The other 11 items pertained to the facility itself. The return

rate was 32%, all by mail, although only 21% of the question-

naires could be used for data analysis. A follow up letter,

mailed out a few weeks after the initial questionnaire, may

have helped to increase the response rate. The data collected

was at the ordinal level, and weighted rank orders were cal-

culated.

Results indicated that participants felt the cause of ED are

as follows, in descending order: psychological issues, dysfunc-

tional family structure, cognitive distortion, faulty develop-

ment, social pressure, learned behaviour and physiological dis-

turbance (Rockwell, 1990). Rockwell did not specify whether

the occupational therapists were using only one frame of ref-

erence, or a number of them in combination. The most fre-

quently used frames of references are, in descending order:

psychoanalytical, cognitive, familial, developmental, medical,

behavioural (Rockwell, 1990). There was a 89% match between

theoretical etiologies and choice of frames of reference, indi-

cating that the occupational therapists theories of disability

matched their choice of intervention. Treatment activities and

approaches most frequently used are projective media, menu

at Canadian Association of Occupational Therapists on April 24, 2016cjo.sagepub.comDownloaded from

Sarah Henderson

LA REVUE CANADIENNE

D’ERGOTHÉRAPIE • FÉVRIER 1999

volume 66 • issue 1

planning, crafts, stress management training, relaxation thera-

py and assertiveness training (Rockwell, 1990). Other activities

that are employed include: movement therapy, clothes shop-

ping, behavioural strategies, education, vocational training,

weight/exercise training, dining out, and nutrition classes

(Rockwell, 1990).

A second study was conducted by Lim and Agnew (1994),

to determine the current frames of reference and treatment

approaches used by occupational therapists. Their descriptive

study was based on Rockwell’s (1990) research. Lim and

Agnew distributed 80 questionnaires to all occupational thera-

pists working in the Eastern States of Australia. Lim and Agnew

developed a questionnaire using open and close ended ques-

tions seeking information concerning the facility in which the

occupational therapists were working, and the current frames

of references being utilized. Lim and Agnew’s study had a

return rate of 26.3%, a low response rate similar to Rockwell.

The majority of participants replied by mail, and the other par-

ticipants were interviewed by a person unidentified in the

study. This difference in data collection may have influenced

the results, because the individuals who were interviewed had

the opportunity to clarify questions they may have had (Lim &

Agnew, 1994). Results indicate that the occupational therapists

felt the etiology of ED is as follows: psychological issues, cog-

nitive distortions, dysfunctional families, social pressure,

learned behaviour, faulty behaviour, and physiological distur-

bances (Lim & Agnew, 1994). The most frequently used frames

of reference include: cognitive-behavioural, Kielhofner’s occu-

pational dysfunction (MOHO), psychoanalytical, family therapy,

behavioural, medical, and developmental (Lim & Agnew, 1994).

The overwhelming majority of participants, 95.2%, stated that

they used a combination of frames of reference. Common treat-

ment approaches used were “cookery groups, assertiveness

training, group discussions and communication skills groups”

(Lim & Agnew, 1994, p. 312). Lim and Agnew discussed the dis-

crepancy between participants theory of disability concerning

ED, and their choice of frame of reference. These authors state

that it is due to a lack of “commitment to beliefs” on behalf of

the participants (Lim & Agnew, 1994, p. 313). This discrepancy

could be the result of confusion on part of the participants,

concerning the definition of a frame of reference, since Lim and

Agnew did not include clear terminology in their study. There

was, however, a thorough discussion of possible areas for

future research, and other occupational therapy issues sur-

rounding treatment with individuals with ED.

Rockwell (1990), and Lim and Agnew (1994) conducted

descriptive research, in the form of questionnaires. Similarities

between Lim and Agnew and Rockwell’s studies include com-

parable beliefs concerning the causes of ED, and very low

response rates, a factor which limits their abilities to draw sta-

tistically significant conclusions (DePoy & Gitlin, 1994). A major

difference among these studies is that Lim and Agnew did not

include a definition of a frame of reference, while Rockwell pro-

vided her own interpretation. This variation may have con-

tributed to some of the differences found in the results, such

as utilization of different frames of reference, and therefore

treatment approaches and activities. In addition, because both

groups of participants were practising in different areas of the

world, critical differences in their environments may have influ-

enced their choice of etiologies, frames of reference and treat-

ment approaches. These limitations make it more difficult to

generalize the results to similar populations. Another drawback

to both studies was that there were a limited number of ques-

tions about the most commonly used frames of reference and

treatment approaches. The majority of questions on the ques-

tionnaire concerned the facility in which the participants were

working. It seems as if the authors were searching for a pro-

file of an ED unit, rather than discovering which frames of ref-

erence and treatment approaches were currently being utilized.

Rockwell’s (1990) and Lim and Agnew’s (1994) explorato-

ry research, although having several methodological limita-

tions, suggested the most commonly used frames of reference

were as follows: psychoanalytical, behavioural, developmental,

familial, cognitive-behavioural, and Kielhofner’s occupational

behaviour. These frames of reference, their treatment

approaches, and supportive research, will now be defined and

further explored.

Supporters of the psychoanalytical frame of reference

state that the causes of ED are “manifestations of underlying

psychological problems and self doubts” (Lim & Agnew, 1994,

p. 310; Rockwell, 1990). A more classical view is put forth by

Martin (1985a), who asserts that ED are due to unresolved sex-

ual and hostile conflicts, and that these individuals lack ego

strength, which limits their ability to interact with the environ-

ment. These individuals have distorted thoughts in regards to

their eating habits (Martin, 1985a). Giles and Chng (1984) state

that the psychoanalytical frame of reference views ED as “oral

ambivalence”, and that the self-induced restricted diet is a

fearful reaction to prevent “magical impregnation” (p. 139). In

theory, occupational therapy treatment using a psychoanalyti-

cal frame of reference allows the individuals to describe and

communicate feelings, and engage in success experiences to

improve self-esteem through the use of creative activity

(Breden, 1992).

Interventions using the psychoanalytical framework

includes approaches and activities such as projective art, psy-

chodrama, beauty and make-up lessons, dressmaking, relax-

ation, social skills training, menu planning, cooking, dining at

restaurants, and creative movement groups, that allow for self-

expression (Bailey, 1986; Giles & Allen, 1986; Giles & Chng,

1985; Martin, 1991). Projective art focuses upon testing new

skills, developing insight and self-awareness, improving com-

munication, and to “...utilize insights gained” (Martin, 1985b,

p. 459). One of the advantages of using projective art as a

at Canadian Association of Occupational Therapists on April 24, 2016cjo.sagepub.comDownloaded from

CANADIAN JOURNAL OF

FEBRUARY 1999 • OCCUPATIONAL THERAPY

volume 66 • issue 1

Sarah Henderson

treatment technique is its ability to be easily graded, and used

as a third party activity in facilitating discussions (Bailey, 1986;

Martin, 1991).

There are few empirical studies validating the use of the

psychoanalytical frame of reference in guiding treatment. Giles

and Allen (1986), Giles and Chng (1984), and Lim and Agnew

(1994) declare that the use of psychotherapy alone has not

been proven to be effective, and that this framework will not

help the individual to deal with the functional problems he/she

will encounter. Harries (1992) expressed the view that a “com-

bination of medical, behavioural, and [psychoanalytical]

approaches is necessary in order to both restore weight and

to provide effective psychotherapy...” (p. 334). She provides

three case studies of individuals with AN, from the Maudsley

ED Unit at the Maudsley Hospital, in London, England, as evi-

dence (Harries, 1992). The reported case studies use a psy-

choanalytical frame of reference to promote an understanding

of ED through the use of self-expression, and through

enhancement of functional skills of daily living (Harries, 1992).

The main modality through which these goals are accom-

plished is projective art. Harries states she conducted a survey

of London eating disorder units, and discovered that the treat-

ment goals and activities utilized at her unit were “widely

acknowledged” (p. 335). Harries did not include a reference or

any empirical evidence to support the effectiveness of this

approach. All three case studies used projective art to deter-

mine problem areas and explore feelings related to their ill-

nesses. Outcome measures of these case studies included sta-

bilization of weight, re-engagement in productive roles, and

changes on drawings completed by the clients. One of the case

studies reflected long term success, whereas, the other two

reflected short term improvements, based on subjective inter-

pretations of art completed while in the hospital.

Two case studies were reported by Bailey (1986), at the

Sheppard and Enoch Pratt Hospital in Baltimore, Maryland.

They used activity-based treatment, working mainly from the

psychoanalytical frame of reference in conjunction with the

familial frame of reference. The occupational therapists used

mainly treatment modalities from the psychodynamic frame of

reference, consisting of art therapy and dance therapy.

Problems were identified, addressed, and monitored through

art and dance therapy. Similarly to Harries’ article (1992), the

outcome measures used were subjective. Bailey reported suc-

cessful functional outcomes with both individuals, however, it

is difficult to attribute this success to the psychoanalytical

framework alone, because the participants were receiving co-

intervention from the cognitive-behavioural frame of reference.

There appears to be a lack of empirical evidence con-

cerning the effectiveness of the psychoanalytic frame of refer-

ence. The results of the documented case studies, can not be

generalized due to their non experimental, exploratory nature

(DePoy & Gitlin, 1994). However, case studies do provide

descriptive information on a single individual. Outcome mea-

sures included re-engagement in previous or new roles, art,

and more conventional outcomes, such as weight gain. The

case study was strengthened by including objective and sub-

jective outcome measures. Further research is required in order

to validate the use of the psychoanalytical frame of reference.

The behavioural frame of reference views ED as a set of

maladaptive learned behaviours that result in anxiety when

eating or gaining weight (Martin, 1985a; Rockwell, 1990). This

framework only deals with observable behaviours, and there-

fore, dysfunctional thoughts are not addressed or changed

through therapy (Giles, 1985). Occupational therapists working

from this frame of reference, shape appropriate behaviour

through positive and negative reinforcements and modelling,

to promote weight gain (Giles & Chng, 1984; Martin, 1985a;

Rockwell, 1990).

Behaviour therapy became a pillar in many eating disor-

der units (McGee & McGee, 1986), however, Giles (1985) has

questioned the ability of behavioural reinforcers to generalize

to real life situations outside the hospitals. There is little

research concerning the effectiveness of occupational therapy

treatment using the behavioural frame of reference. Eating dis-

order programmes are described by Bridgett (1993), and by

McColl et al. (1986). Bridgett (1993), described a programme at

Newington Children’s Hospital that uses behavioural and func-

tional frames of reference. The interventions described consist

of regaining or acquiring self awareness, using activities that

focus on body image, time management and stress manage-

ment skills. It appears that this setting used a cognitive-behav-

ioural frame of reference, rather than a pure behavioural

approach as Bridgett states, and therefore, will be described in

greater detail under that heading.

McColl et al. (1986) described an eating disorder unit at

Toronto General Hospital, which used a behavioural system

consisting of different levels of privileges. Progression through

the levels is dependent upon weight gain. The authors report-

ed that initially, clients attempt to gain as many privileges as

possible throughout treatment. Interestingly, McColl et al.,

noted that when these women had attained the highest level

of privileges, and were engaging in various activities, they did

not report a sense of satisfaction. This could be due to an

internal characteristic of individuals with ED. No other descrip-

tion of occupational therapy intervention was included by

McColl et al. It would have been helpful to incorporate a case

study, which detailed specific intervention using the behav-

ioural frame of reference.

There appears to be a lack of empirical evidence, to sup-

port the use of the behavioural frame of reference. There was

one description of an Eating Disorder Unit that uses a behav-

ioural framework (McColl et al., 1986). The role of the occupa-

tional therapist was to design activity-based, client-specific

programmes. The treatment approaches or activities, were not

further described or validated (McColl et al., 1986).

at Canadian Association of Occupational Therapists on April 24, 2016cjo.sagepub.comDownloaded from

Sarah Henderson

LA REVUE CANADIENNE

D’ERGOTHÉRAPIE • FÉVRIER 1999

volume 66 • issue 1

engage in dysfunctional behaviours such as bingeing and

restricting their diets (Giles, 1985; Giles & Chng, 1984; Martin,

1991).

Giles (1985), and Giles and Allen (1986), argue that this

framework is the best fit with occupational therapy due to its

focus on functional problem-solving, which helps the client to

identify and practice alternative behaviours to problem situa-

tions. Giles and Chng (1984), and Giles advocate “an activity-

oriented approach to cognitive restructuring” (p. 139), and

Martin (1991) advocates a contractual-coping approach, in

order to assist the client in attaining a more accurate body

image, enhanced self-confidence and change in dysfunctional

eating behaviours. In the contractual-coping approach, the

contract, developed by the client and the therapist, lays out

specific goals determined by the client. The contract forces

clients to take responsibility for their behaviours. The activity-

oriented approach, utilizing the contract, allows the therapist

to choose activities which are relevant to the areas the client

would like to change (Giles, 1985; Giles & Chng, 1984).

Treatment approaches from the cognitive-behavioural

frame of reference have a similar purpose of attempting to

change behaviour by influencing cognition. Identified treat-

ment approaches, and activities include the following: food

diaries; journaling; stress management techniques; assertive-

ness training; crafts; social skills training; relaxation training;

education concerning, and engagement in, physical exercise;

body image therapy; coping skills training during meal prepa-

ration, clothes shopping, eating a meal; money management;

use of video equipment; and education concerning ED (Bailey,

1986; Beck, 1993; Giles & Allen, 1986; Giles & Chng, 1984;

Martin, 1991).

Recent research suggests that treatment of choice for ED

is a combination of behavioural and cognitive techniques

(Fairburn, Jones, Peveler, Hope, & O’Connor, 1993; Freeman,

1995; Garner et al., 1993). Research has been conducted to

evaluate the effectiveness of cognitive-behavioural therapy

with clients with bulimia nervosa (Agras, et al., 1992; Fairburn

et al., 1993; Garner et al., 1993). These studies have indicated

that cognitive-behavioural treatment is effective in decreasing

psychiatric symptoms, and improving psychological variables,

such as self-esteem (Agras et al, 1992; Fairburn et al., 1993;

Garner et al., 1993). These interventions were employed by

psychiatrists, clinical psychologists and medical doctors. In

addition, these studies investigated the effects of cognitive-

behavioural therapy with individuals who are diagnosed with

bulimia nervosa exclusively. It would be more applicable if

occupational therapists could conduct research to investigate

the effectiveness of these cognitive behavioural interventions

using functional outcome measures such as performance in

self-care, productivity and leisure.

One descriptive study of occupational therapy interven-

tions has been conducted by Bridgett (1993), who described

Subscribers of the developmental frame of reference

believe that ED are caused by a lack of consistent and regular

responses to the needs of the individual during childhood (Lim

& Agnew, 1994; Rockwell, 1990). Rockwell asserts that this

developmental problems results in an inability of the child to

differentiate between interpersonal and biological feelings

(Rockwell, 1990). Treatment using this frame of reference pro-

vides an atmosphere for interaction and exploration with the

environment to enhance a sense of effectiveness (McColl et al.,

1986). This frame of reference appears to be well defined in

the literature, but there was no published research of occupa-

tional therapy intervention using this framework available to

the author at the time of this review.

Supporters of the familial frame of reference emphasize

the environment, and view dysfunctional families as the cause

of ED (Rockwell, 1990). Families of individuals with ED are

reported to emphasize thinness, attractiveness, appearance,

and equate these characteristics with self-discipline, self-con-

trol, and self-worth (Giles & Allen, 1986; Rockwell, 1990).

Treatment is aimed at resolving underlying familial issues and

problems, such as over protectiveness, and failure to reach sat-

isfactory resolutions to conflict (Giles, 1985; Lim & Agnew,

1994; Rockwell, 1990). A pilot study conducted by Le Grange,

Eisler, Dare, and Russell (1992) indicated that conjoint family

therapy and family counseling appear to “…be effective in

bringing about significant symptomatic relief” (p. 355) such as

weight gain, and improvements in psychological factors.

However, the individuals facilitating family therapy in this study

were psychologists, psychiatrists and social workers. Although

this frame of reference is used often by occupational thera-

pists, as documented by Rockwell (1990), there is no research

or descriptions of the types of occupational therapy interven-

tions based on this frame of reference.

Subscribers of the cognitive-behavioural frame of refer-

ence believe that dysfunctional values and beliefs, and mis-

construed perceptions of reality, in regards to weight and the

shape of the individual’s body, are the cause of ED (Giles &

Allen, 1986; Lim & Agnew, 1994). Treatment from this frame of

reference is aimed at examining, challenging, and modifying,

the validity of the individual’s beliefs (Rockwell, 1990). The

client is taught to monitor “automatic thoughts” (Giles, 1985,

p. 512) to correct “distorted conceptualizations” (Giles & Allen,

1986, p. 56), take responsibility for their behaviours, and to

identify the influence of cognition on their behaviours. Giles

and Chng (1984), and Giles and Allen (1986), have argued that

frames of reference and treatment approaches focusing solely

on either the cognitive or behavioural aspect of an individual

will result in ineffective treatment because they fail to recog-

nize the link between behaviour and cognition. Successful

treatment from the cognitive-behavioural frame of reference

depends upon the client’s motivation, and proposes that as

client’s awareness into their illness rises, they will cease to

at Canadian Association of Occupational Therapists on April 24, 2016cjo.sagepub.comDownloaded from

CANADIAN JOURNAL OF

FEBRUARY 1999 • OCCUPATIONAL THERAPY

volume 66 • issue 1

Sarah Henderson

an eating disorder programme at Newington Children’s

Hospital, which she classifies as using the behavioural, and

functional frames of reference. She stated that this eating dis-

order programme uses treatment techniques to address dis-

torted body image, assist in increasing awareness, time man-

agement, and stress management skills. Bridgett reported

that, throughout intervention, clients gain self-awareness and

become able to identify and learn new ways to meet their

physical, cognitive, and emotional needs. She does not

include a case study in her description.

There have been three case studies using the cognitive-

behavioural frame of reference. Meyers (1989) described a case

study using naturalistic inquiry. Data collection consisted of

interviews and observation of the participant in her natural

environments. The participant was a women who reported her

occupational therapy experience while in hospital. The partici-

pant felt that the occupational therapist was confrontative,

challenged her thoughts and taught her alternative coping

strategies for stressful situations outside of the hospital.

Through the use of crafts, clothes shopping, process groups,

and body image therapy, the participant felt as if she was

exploring her strengths and weaknesses and gradually “was

able to feel more congruent” (Meyers, 1989, p. 40). The results

of the case study, from the participant’s perception, were suc-

cessful. Limitations of this type of research, such as the inabil-

ity to generalize to other clients with similar diagnosis, were

acknowledged by Meyers.

Two case studies were reported by Breden (1992) at the

Sheppard Pratt Hospital, that used the cognitive-behavioural

frame of reference, in conjunction with the psychoanalytical

frame of reference. The first case study described the partici-

pants history, her assessment and treatment while in hospital.

The second case study did not describe the participants his-

tory. It provided information regarding the intervention the par-

ticipant received, and the outcome of her case. Both case stud-

ies used treatment approaches from the psychoanalytical

frame of reference, with the purpose of expressing emotions.

However, the majority of treatment techniques were from the

cognitive-behavioural frame of reference: stress management

skills, meal preparation, task skills, and assertiveness commu-

nication, with the purpose of addressing cognitive distortions

to influence behaviours.

Results of the case studies were conflicting. The first par-

ticipant, after intervention at this eating disorder unit, contin-

ued to believe that her behaviour cycle of bingeing and purg-

ing was the most effective way to alleviate stress. The only

positive outcome identified was that the participant engaged

in new leisure roles. Results of the second participant case

study were not as clear. Breden (1992) stated that the partici-

pant appeared to make gains while in therapy, but that she

continues to be seen as an outpatient. Both case studies used

functional and subjective outcome measures, such as clinical

observation (Breden, 1992). These measures are useful, but it

would have been helpful to include an objective measure of

improvement. The author did not account for the differences in

the outcomes of the case studies.

Meyers (1989) and Breden (1992) both reported case

studies consistent with the cognitive-behavioural frame of ref-

erence. Breden stated that she used both the cognitive-behav-

ioural frame of reference and the psychodynamic frame of ref-

erence. As with previous authors, this combination makes it

difficult to assess which frame of reference and treatment tech-

nique contributed to her successful outcome. In regards to

choosing a frame of reference, Breden claims that in “occupa-

tional therapy, the frame of reference used depends on the par-

ticular functional activity being performed” (p. 54). It may help

clarify her approach, if she were to allow her chosen frame of

reference to guide her treatment approaches, and thus her

activities, rather than allowing her activities to guide her frame

of reference.

Both case studies are limited in their ability to generalize

to other populations. However, they do provide valuable and

descriptive information in regards to the treatment of individ-

uals with ED, particularly Meyers’ (1989) case study. It not only

provides in-depth information concerning the intervention

used, but allows the reader to understand a client’s perception

of the occupational therapy intervention. Further quasi-experi-

mental, and experimental type research should be done to

determine the effectiveness of this approach, because it

appears that it is commonly used (Lim & Agnew, 1994).

The final frame of reference which will be reviewed, the

Model of Human Occupation (MOHO), by Kielhofner (1995), is

commonly used in treatment settings (Lim & Agnew, 1994).

Barris (1986) advocates using the MOHO for “...exploring the

nature of occupational dysfunction that accompanies eating

disorders..” (p. 28). Similarly Kerr (1990) advocates the use of

the MOHO and a variety of related assessments (as cited in

Beck, 1993). Barris provided an overview of the use of the

MOHO with a client with an ED, and described an individual’s

volition, habituation, performance, and the environment. Barris

described possible treatment techniques that form this frame-

work, which include: use of play to increase comfort in social

settings; expansion of an individual’s peer network; use of a

journal to help increase awareness of rationale for engaging in

tasks; and use of time management to help decrease the need

for control.

Barris, Dickie, and Baron (1988) published a quasi-exper-

imental study, with the purpose of attempting to “provide

empirical validation” of the use of the MOHO with psychiatric

clients (p. 6). Barris et al. collected information on 152 partici-

pants, three groups of psychiatric clients, and one group with-

out any known psychiatric illness. Tests of significance were

not completed on these groups to statistically document any

differences among them. Groups one, two, and three, consist-

at Canadian Association of Occupational Therapists on April 24, 2016cjo.sagepub.comDownloaded from

Sarah Henderson

LA REVUE CANADIENNE

D’ERGOTHÉRAPIE • FÉVRIER 1999

volume 66 • issue 1

ed of individuals with chronic conditions, ED, and adolescents

hospitalized for psychiatric disorders, respectively. Group four

consisted of participants with no known illnesses. Groups one,

two, and three, were gathered from one of six hospitals.

Persons in group four, which consisted of both adults and ado-

lescents, were gathered from occupational therapy assistant

students, occupational therapy students, acquaintances of the

investigators, and children of colleagues. Groups one, two, and

three excluded individuals who were unable to read and write.

The intervention consisted of six instruments. Four of them

were paper and pencil tasks, and others were administered by

interview by a different therapist at each setting. The instru-

ments were: Life Attitude Profile, Internal-External Scale, Role

Checklist, Prevocational Evaluation of Rehabilitation Potential,

Family Environment Scale, and Role Performance Scale (Barris

et al., 1988). Standardization of the intervention was attempt-

ed, by providing a videotaped protocol of instrument adminis-

tration, but this instruction cannot eliminate all variations of

administration of the instruments. The clients with ED per-

formed consistently higher on evaluations of skill, in compari-

son to the two other groups of psychiatric clients (Barris et al.,

1988). This group had an external sense of self-control and

“lacked a sense of purpose and meaning in life” (Barris et al.,

1988, p. 12). The participants productive roles were not

impaired, although the authors did not provide any explana-

tions for these results.

This quasi-experimental study was a good attempt at

establishing the applicability of the MOHO. However, there was

several limitations that rendered the results weak, and difficult

from which to draw conclusions. These limitations were

acknowledged by Barris et al. (1988). Firstly, the normal and

psychiatric groups were of unequal numbers. Secondly, data

collection for all of the instruments was non-standardized, due

to the variety of therapists completing the instruments. Thirdly,

there were missing client data for some instruments, making

the results more difficult to analyze. Finally, the participants

were all gathered from different hospitals, in different geo-

graphical areas (Barris et al., 1988).

The numerous methodological errors rendered the results

more problematic to generalize to similar psychiatric popula-

tions. However, quasi-experimental research, although not hav-

ing the strictest controls, attempts to provide empirical evi-

dence that is stronger than case studies or other non experi-

mental designs (DePoy & Gitlin, 1994). This study, investigat-

ing MOHO, is the only quasi-experimental research on any of

the frames of reference previously discussed, and is a basis

from which to conduct further research on the use of MOHO as

a frame of reference.

As seen by the review of current literature, there is a lack

of empirical evidence validating the effectiveness of the frames

of reference and treatment approaches currently being used by

occupational therapists working with clients with eating disor-

ders. There are numerous reasons for this weakness in

research. First, occupational therapy intervention with this pop-

ulation has recently become more specialized. Prior to special-

ized eating disorder units, these clients were on general psy-

chiatric wards and therefore did not receive treatment geared

directly towards their multiple problems. Secondly, throughout

the descriptions of Eating Disorder Units, there did not appear

to be a shared understanding of a frame of reference. Authors

either did not state their framework, or seemed to mislabel it

at times (Bridgett, 1993; Meyers, 1989). Ideally, the profession

should use common definitions. This may be too difficult, and

therefore as an alternative, authors could state their definition

of a frame of reference, in their study. Thirdly, Giles and Allen

(1986) propose that the occupational therapy services are

underutilized due to lack of promotion on behalf of occupa-

tional therapists themselves, and other professions lack of

knowledge of our services (Giles & Allen, 1986; Lim & Agnew,

1994). Fourthly, Mosey (1989) asserts that the lack of occupa-

tional therapy research is due to limited time and individuals

performing research. Lastly, due to the present economic cli-

mate, there are less funds available to conduct research in the

clinical setting.

Although there are many reasons for the lack of research

concerning the treatment of individuals with ED, occupational

therapists should attempt to produce the strictest research

possible. Research is especially urgent in this day and age,

with health care dollars being routed to services that can prove

their effectiveness. Individuals conducting research could start

using quasi-experimental, and experimental type designs

which allow the investigator to state causal relationships, and

make greater generalizations to other populations (DePoy &

Gitlin, 1994). This research should use a combination of objec-

tive and subjective outcome measures, which will detect evi-

dence of success.

Research should focus primarily on the legitimacy of the

frames of reference and treatment techniques so that the occu-

pational therapy profession can be ensured of the “…delivery

of effective services” (Mosey, 1989, p. 199). Another important

topic that could be investigated is the phenomenon that

clients with ED rarely have difficulties in their productive roles

(Barris et al, 1988; Giles & Allen, 1986; Giles & Chng, 1984). If

occupational therapists were to determine what resources and

skills individuals with ED possess which enable them to

engage successfully in a productive role, some of these same

resources and skills could be optimized in other areas of occu-

pational performance. A second phenomenon that reoccurred

in the literature, is that clients with ED do not experience a

sense of effectiveness or satisfaction with the tasks in which

they successfully engage (McColl et al., 1986). It would be

interesting to ascertain whether occupational therapists are not

assisting these individuals to engage in meaningful tasks, or if

this pervasive sense of dissatisfaction is a symptom of the ill-

at Canadian Association of Occupational Therapists on April 24, 2016cjo.sagepub.comDownloaded from

Freeman, C. (1995). Cognitive therapy. In G. Szmukler, C. Dare, & J.

Treasure (Eds.),

Handbook of eating disorders: Theory, treatment

and research

(pp. 309-331). West Sussex, England: John Wiley.

Garner, D. M., Rockert, W., Davis, R., Garner, M. V., Olmsted, M. P., &

Eagle, M. (1993). Comparison of cognitive-behavioural and sup-

portive-expressive therapy for bulimia nervosa.

American Journal

of Psychiatry, 150

(1), 37-46.

Giles, M. G. (1985). Anorexia nervosa and bulimia: An activity-oriented

approach.

The American Journal of Occupational Therapy, 39,

510-517.

Giles, M. G., & Allen, M. A. (1986). Occupational therapy in the reha-

bilitation of the patient with anorexia nervosa.

Occupational

Therapy in Mental Health, 6,

47-66.

Giles, G. M., & Chng, C. L. (1984). Occupational therapy in the treat-

ment of anorexia nervosa: A contractual-coping approach.

British

Journal of Occupational Therapy, 47,

138-141.

Harries, P. (1992). Facilitating change in anorexia nervosa: The role of

occupational therapy.

British Journal of Occupational Therapy, 55,

334-339.

Keilhofner, G. (1995).

A model of human occupation: Theory and appli-

cation.

Baltimore, MD: Williams & Wilkins.

Le Grange, D., Eisler, I., Dare, C., & Russell, G.F. (1992). Evaluation of

family treatments in adolescent anorexia nervosa: A pilot study.

International Journal of Eating Disorders,12,

347-357.

Lim, P. Y., & Agnew, P. (1994). Occupational therapy with eating disor-

ders: A study on treatment approaches.

British Journal of

Occupational Therapy, 57,

309-314.

Martin, J. E. (1985a). Anorexia nervosa: A review of the theoretical per-

spectives and treatment approaches.

British Journal of

Occupational Therapy, 48,

236-240.

Martin, J. E. (1985b). Occupational therapy in anorexia nervosa.

Journal

of Psychiatric Research, 19,

459-463.

Martin, J. E. (1989). Bulimia: A literature review.

British Journal of

Occupational Therapy, 52,

138-142.

Martin, J. E. (1991). Occupational therapy in bulimia.

British Journal of

Occupational Therapy, 54,

48-52.

McColl, M. A., Friedland, J., & Kerr, A. (1986). When doing is not

enough: The relationship between activity and effectiveness in

anorexia nervosa.

Occupational Therapy in Mental Health, 6,

137-

150.

McGee, K. T., & McGee, J. P. (1986). Behavioural treatment of eating dis-

orders.

Occupational Therapy in Mental Health, 6,

15-25.

Meyers, S. K. (1989). Occupational therapy treatment of an adult with

an eating disorder: One woman’s experience.

Occupational

Therapy in Mental Health, 9,

33-47.

Mosey, A. C. (1986).

Psychosocial components of occupational therapy.

New York: Raven Press.

Mosey, A. C. (1989). The proper focus of scientific inquiry in occupa-

tional therapy: Frames of reference.

Occupational Therapy Journal

of Research, 9,

195-199.

Rockwell, L. E. (1990). Frames of reference and modalities used by

occupational therapists in the treatment of patients with eating

disorders.

Occupational Therapy in Mental Health, 10,

47-59.

is held by the Canadian Association of Occupational Therapists. Permission must be

obtained in writing from CAOT to photocopy, reprint,reproduce (in print or electronic

format) any material published in CJOT.There is a per page,per table or figure charge

for commercial use.When referencing this article, please us APA style,citing both the

date retrieved from our web site and the URL.For more information,please contact:

[email protected].

CANADIAN JOURNAL OF

FEBRUARY 1999 • OCCUPATIONAL THERAPY

volume 66 • issue 1

Sarah Henderson

ness. These topics could be researched to discover how occu-

pational therapy could be tailored more specifically to this

population.

In conclusion, this paper has established that occupa-

tional therapy interventions with clients with ED are felt to be

valuable by many clinicians, although there is a lack of

research validating this claim (Giles, 1985; Rockwell, 1990).

Giles (1985) states that occupational therapy “is vital in link-

ing the practical, emotional, and cognitive aspects of the treat-

ment of an anorexic or bulimic individual” (p. 517). Despite the

lack of research in this field, occupational therapists should

not be impeded from researching and implementing the high-

est quality of care with clients with eating disorders.

Acknowledgements

The author wishes to acknowledge Kristine Bartmanovich and

Heather Emerson for their patience and guidance throughout

the development of this paper.

References

Agras, W. S., Rossiter, E. M., Arnow, B., Schneider, J. A., Telch, C. F.,

Raeburn, S. D., Bruce, B., Perl, M. & Koran, L. M. (1992).

Pharmacologic and cognitive-behavioural treatment for bulimia

nervosa: A controlled comparison.

American Journal of

Psychiatry, 149,

82-87.

American Psychiatric Association. (1994).

Diagnostic and statistical

manual of mental disorders

(4th ed.). Washington, DC: Author.

Bailey, M. K. (1986). Occupational therapy for patients with eating dis-

orders.

Occupational Therapy in Mental Health, 6,

89-116.

Barris, R. (1986). Occupational dysfunction and eating disorders:

Theory and approach to treatment.

Occupational Therapy in

Mental Health, 6,

27-45.

Barris, R., Dickie, V., & Baron, K. B. (1988). A comparison of psychiatric

patients and normal subjects based on the model of human

occupation.

Occupational Journal of Research, 8

(1), 3-23.

Beck, N. L. (1993). Eating disorders: Anorexia nervosa and bulimia ner-

vosa. In H. L. Hopkins, & H. D. Smith (Eds.),

Willard and

Spackman’s Occupational Therapy

(8th ed., pp. 584-588).

Philadelphia: Lippincott.

Breden, A. K. (1992). Occupational therapy and the treatment of eat-

ing disorders.

Occupational Therapy in Health Care, 8,

(2/3), 49-

68.

Bridgett, B. (1993). Occupational therapy evaluation for patients with

eating disorders.

Occupational Therapy in Mental Health, 12,

79-

89.

Bruch, H. (1973).

Eating disorders: Obesity, anorexia nervosa, and the

person within.

New York: Basic Books.

Canadian Association of Occupational Therapists. (1991).

Occupational

therapy guidelines for client-centred practice.

Toronto, ON: CAOT

Publications ACE.

DePoy, E., & Gitlin, L. N. (1994).

Introduction to research: Multiple

strategies for health and human services.

St. Louis, MO: Mosby.

Fairburn, C. G., Jones, R., Peveler, R. C., Hope, R. A., & O’Connor, M.

(1993). Psychotherapy and bulimia nervosa.

Archives of General

Psychiatry, 50,

419-428.

at Canadian Association of Occupational Therapists on April 24, 2016cjo.sagepub.comDownloaded from