Social support has been noted as key in helping individuals with any number of health issues to cope with illness and even thrive in adverse situations (Sarason, Sarason & Pierce, 1990). Individuals with eating disorders may be encouraged, as an adjunct to treatment or even in the absence of formal treatment, to seek out social support to help with the day-to-day management of their disorder (Holt & Espelage, 2002). However, not everyone with an eating disorder seeks out social support; in fact, some may actively avoid seeking support during trying times. To find out more, Akey, Rintamaki & Kane (2012) examined social support seeking among men and women with eating disorders.
The authors interviewed 34 men and women, aged 18-53 (mean age 25) diagnosed with eating disorders and used grounded theory methodology (Glaser & Strauss, 1967) to analyze their data. As explained in a prior post, grounded theory is a qualitative methodology that uses participants’ accounts to develop practical theories that apply to particular situations or phenomena.
Analysis was framed in a popular health behaviour theory, Health Belief Model (HBM; Rosenstock, 1966, revised by Janz & Becker, 1984). According to HBM, people enact health behaviours (in this case, seeking social support) based on 5 key factors:
- Perceived susceptibility to a health threat
- Perceived severity of a health threat
- Perceived benefits of engaging in protective behaviours
- Perceived self-efficacy of using protective behaviours
- Perceived barriers to enacting protective behaviours
In this study, the “health threat” is the eating disorder and related complications, and the protective behaviour is seeking social support. This theory has been widely used in health promotion contexts, however, this was one of the first times I have seen it linked to social support, which intrigued me. On the one hand, I am encouraged by social support being seen as a health protective behaviour; on the other, I am always hesitant to try to make things fit into neat little health model boxes. Nevertheless, I was intrigued enough to learn more.
WHAT DID THEY FIND?
Authors report that in their sample, individuals’ perceived susceptibility was linked to whether they were in denial of the eating disorder and/or it’s severity, as one might predict. This means that when individuals are actively denying their eating disorder, they might be less inclined to seek social support, as it would not seem necessary.
If an individual with an eating disorder sees their eating disorder as “less severe,” for example in comparison to others’ disorders, they were unlikely to enlist social support. The comparison aspect struck me as the most interesting element of this finding; it would seem that participants evaluated severity based on comparison with real or imagined others with eating disorders:
For instance, Derek explained, ‘‘It’s nothing too serious to me. I’m not like, ‘oh my god, I might have a heart attack tomorrow.’’’ Similarly, Joanne remarked, ‘‘I know I have the problem, but I don’t see it as severe.’’ sometimes this minimal sense of severity was a result of comparing one’s self to others. Joanne continued by explaining, ‘‘You always see someone else’s problems way worse than yours.’’
Participants discussed reservations about the support they might receive in terms of its quality and effectiveness. Notably, some of these reservations stemmed from past encounters with ineffective support, for example if a family member had been in denial about the disorder or refused to acknowledge it:
Ryma, who explained, ‘‘in the past (my family) were in denial, they didn’t believe I had a problem.’’ For some, this concern stemmed from the fact that their symptoms did not present with exaggerated weight loss or diminutive body mass. […] Simon presented with an additional concern that being a man would further impair people’s ability to recognize his eating disorder. […] Friends and family likely lacked the requisite knowledge to provide meaningful and effective support, leaving them unable to know what to do or say to be of assistance.
In situations where others might be willing to offer support, some participants were hesitant to seek their support for fear of obtaining unhelpful or even detrimental help, concerns that surfaced even when participants discussed the possibility of seeking professional help. Again, past experiences with negative “support” coloured participants’ views about the effectiveness of support, should they seek it.
Mary explained how previous clinicians with whom she worked did not address the psychological component to her eating disorder, instead offering her medications, which fell short of her expectations and left her disheartened about clinical interventions.
Barriers to support revealed in this study included a lack of access to sources of support both formal and informal. Stigma also inhibited support seeking, as participants feared significant others in their lives coming to see them in a different (negative) light if they revealed their illness and asked for help. Fears of being dismissed also surfaced, and similarly to the results for “perceived barriers” were largely based on past experiences:
For instance, Azita described her sister’s antagonism towards her for having an eating disorder, as well as how she publicly denounced those struggling with the disease: “She has made it really hard, because she will openly say that she doesn’t think it should be covered by insurance and doesn’t think it’s a problem.She says that it is just a matter of will power and I should just get over it.”
Finally, participants often refrained from seeking support as they didn’t want their loved ones to feel distressed. The authors describe this as putting others’ needs above their own.
Finally, participants expressed that they often felt unable to ask for what they need and were fearful of losing control over information related to their eating disorder. This inability to articulate what kind of help is desired, coupled with the fear of stigma or loss of control, led participants to isolate themselves instead of seeking support.
Still other participants chose to self-isolate and remove themselves from their social circles, which also impaired their ability to seek support. Ann provided a clear illustration of this strategy […]: I stopped myself from going to activities. I talk myself into the fact that I don’t deserve to be with people. I seclude myself a lot of times and I isolate myself. They say that isn’t good, but I think that in the case of my nephews and my niece, I’m isolating myself from them because I don’t wanna be a negative impact on them.
Examining eating disorder management outside of the clinical environment holds important implications, as not everyone with an eating disorder seeks or obtains medical care. As the authors suggest, social support likely plays an important role in coping with an eating disorder.
However, I found myself asking what this study revealed that we don’t already know about eating disorders. HBM is often used because it is relatively intuitive; it makes sense that its various dimensions would play into an individual’s decision-making process surrounding health behaviours. Sometimes I felt as though the participants’ responses were being fit to this model in a less-than-organic way, however, which had me questioning the “groundedness” of the conclusions.
To me, the most interesting thing about these findings is the way in which prior interactions with potential support-providers (e.g. a significant other or a parent) affects future decisions to seek support. This underscores the importance of providing families, friends, health care professionals and society in general with better information about eating disorders.
I think the onus lies less with the people seeking support (i.e. those with eating disorders) and more with the givers of support; of course one would be hesitant to reach out for support, no matter how much they might want to, if they are faced with dismissal or unhelpful responses.
The importance of making attempts to decrease stigma and shame around eating disorders emerges once again as a key factor in enabling individuals with eating disorders to feel more comfortable seeking formal and informal sources of support. Of course, this is easier said than done, but that’s another story entirely…
Akey, J.E., Rintamaki, L.S., & Kane, T.L. (2013). Health Belief Model deterrents of social support seeking among people coping with eating disorders. Journal of Affective Disorders, 145 (2), 246-52 PMID: 22840616