Rationale
The International Classification of Diseases 2011 (ICD-11) groups feeding and eating disorders together, using the criteria of a person exhibiting abnormal eating behaviours (ICD-11, 2022). However, eating disorders differ from feeding disorders, due to their association with the individual aiming to change their weight and shape (ICD-11, 2022). Eating disorders can therefore be broken down into: Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Avoidant-Restrictive Food Intake Disorder or Other Specified Feeding or Eating Disorder (ICD-11, 2022).
In 2019, the National Institute for Healthcare Excellence (NICE) estimated the prevalence of eating disorders in the United Kingdom (UK) to be as high as 700,000, with 90% of cases presenting in females (NICE, 2019). However, throughout the Covid-19 pandemic the UK saw rising levels of people seeking support for various eating disorders, with Beat experiencing an 81% increase in demand for their eating disorder support services, following 2020’s first national lockdown in March (Priory Group, 2022). While relying on charities and hospital groups, such as Priory Group, may suggest a superficial nature to statistics due to their potential bias, the secretive nature of eating disorders, alongside the often seen resistance in people being treated with eating disorders (Nicholls & Viner, 2005) may make gathering data on the topic particularly difficult, therefore limiting the availability of more reliable sources.
The impact of eating disorders can be long term and severe, with medical consequences ranging from amenorrhea (with subsequent fertility problems), cardiovascular abnormalities, problematic renal functions and musculoskeletal impairment (NICE, 2019). Further to this, Office for National Statistics data identified 66 people who died from having an eating disorder between 2017 and 2019 (Office for National Statistics, 2020). However, eating disorders also have severe psychological impacts often leading to anxiety, low mood and suicidal ideation, with NICE suggesting that 20% of people with an eating disorder die from suicide rather than the medical complications of the disorder itself (NICE, 2019). Therefore, overall mortality, while unclear, may be much higher than initial statistics suggest.
The National Health Service (NHS) website indicates that treatment for people with eating disorders is often individual therapy or group therapy, which will be coordinated by a specialist group (NHS, 2021). NICE guidelines further expand on this, suggesting that support for eating disorders should focus on psychoeducation, physical observation monitoring and specific therapies such as Cognitive Behavioural Therapy – Eating Disorders (CBT-ED) (NICE, 2020).
The increasing prevalence of eating disorders, alongside the potentially fatal consequences, suggests that further support is needed for managing this disorder. Further literature as well was the NICE guidelines, suggest that a multidisciplinary team is not only common, but recommended for the treatment of those with eating disorders (NICE, 2020). However, the impact of the individuals within this team, namely Occupational Therapists, is unclear, despite the fact that anecdotal information suggests Occupational Therapy is vital to eating disorder recovery (Mescher, 2022). Furthermore, academic research indicates that Occupational Therapists are uniquely skilled in supporting individuals with eating disorders, due to their ability to analyse the impact of a variety of factors on a person’s performance of occupations (Devery et al., 2018; O’Reilly & Johnson, 2016).
In order to analyse the broad topic area of Occupational Therapy and eating disorders further, a literature review was conducted to identify key themes and gaps for further research through a database search. Key themes identified amongst the literature were: what can occupational therapists bring to eating disorders, multidisciplinary teams, white/western culture, motivation and role blurring. The literature searching and the identified themes helped to indicate that while research regarding eating disorders is abundant, research exploring the direct impact of Occupational Therapy is limited.
A range of research methodologies were considered when constructing this research proposal, including a case-control trial and a focus group. However, when considering the ethical dilemmas of research that includes participants who have experienced mental health problems, a smaller study design was chosen in order for the wellbeing of participants to be more easily monitored and therefore supported. Therefore, this research proposes a qualitative study focusing on a small sample size – in order to be able to ethically support the individuals – of semi-structured interviews, to gain a deep understanding of the impact Occupational Therapy can have on individuals with eating disorders. By using an interpretivist methodology, and small sample size, the study can therefore aim to establish a rich understanding of individual experiences (Maltby et al., 2014).
Literature review
This study began with a comprehensive database search, which aimed to identify gaps in the literature within the broad topic area of ‘Occupational Therapy and Eating Disorders’. 30 databases were initially identified as relevant to ‘Allied Health and Social Care’. From this, each database summary was read and a final number of 13 databases were identified as relevant to the topic area. Following this, search terms were identified as: Occupational thera* AND eating disorder* AND outcome*. And finally, inclusion and exclusion criteria were identified, see table 1.
Table 1: Inclusion and Exclusion Criteria
| Inclusion Criteria | Exclusion Criteria |
| Involvement of an occupational therapist or occupation focussed therapyClient/participants have an eating disorder | Remove duplicatesRemove articles not written in English Remove content older than 2013 (the year in which Binge Eating Disorder was added to DSM-5 classification and was therefore recognised globally as an eating disorder.) |
Initial data base searching identified 6,450 sources (see table A1 and A2 in appendices). These were then screened by title, then by abstract and finally by full text resulting in the final 7 articles which this study has analysed (see figure A1 in appendices). These articles were thematically analysed to identify the key themes: what can Occupational Therapist’s bring to eating disorders, multidisciplinary team, white/western culture, motivation and role blurring.
Why is Occupational Therapy suited to supporting eating disorders?
O’Reilly & Johnson (2016) explore in depth how Occupational Therapy is not only able to support those with eating disorders, but how valuable Occupational Therapy can be in this area. O’Reilly & Johnson identify that eating disorders are complex and can impact on every aspect of wellbeing, therefore affecting a person’s ability to engage in occupations. Despite the complexities of the disorder, O’Reilly & Johnson argue that due to Occupational Therapist’s ability to observe behaviours and consider various impacts on occupations, therapists can help to break down barriers to engagement; and because activities associated with food are a constant within our lives, it is vital for people with eating disorders to still be able to engage in these activities, such as food shopping or socialising (O’Reilly & Johnson, 2016). Whilst O’Reilly & Johnson is a book based on anecdotal experiences of working in eating disorders and therefore may be considered bias towards promoting Occupational Therapy, further research has supported the concept of Occupational Therapy being vital in the treatment of eating disorders. Coelho et al (2020) ran a voluntary study within a specialised day treatment unit for children and young people with eating disorders, where patients were asked to engage in individual therapy sessions with an Occupational Therapist and/or psychologist to identify occupation focussed goals. Using the Canadian Model of Occupational Performance (COPM), these goals were measured for satisfaction levels before and after treatment. Coelho et al found that through self-identification of goals, alongside support from a therapist to reach these goals, levels of satisfaction as well as mBMI increased. Coelho et al argue that imposed goals dimmish motivation, whereas the person-centred creation of goals that Occupational Therapists can support, increase motivation and therefore improve the chances and rate of recovery. This was evident within the study with two thirds of the youths discharged from the programme evidencing significant improvement in occupational performance (Coelho et al., 2020).
Whist Coelho et al’s research shows a good evidence base and identifies clear aims within the study and clear outcomes, some criticisms may lie in the difficulty in making this study generalisable to the population. As this was a voluntary programme, it may be suggested that the participants already had motivation for change, which is often uncommon in people who are particularly unwell with eating disorders (Nicholls & Viner, 2005). Furthermore, as there was no comparison group within the study, the differences in improvement are difficult to evidence and quantify. Finally, while an Occupational Therapist was present within the study, and this study was occupation focussed, the study itself identified that a psychologist could take on the support role for the participants. Therefore, this may bring into question if an Occupational Therapist specially is needed.
What is the lived experience of Occupational Therapists in eating disorder settings?
The identified theme that Occupational Therapists may be experiencing role blurring within eating disorders is prevalent within the literature. As already stated, Coelho et al’s study identified that an Occupational Therapist and/or a psychologist could support patients. While this is speculative analysis of one article, anecdotal experience has also been identified. Devery et al (2018) conducted a mixed methods study using questionnaires and interviews to gain the perspectives of Occupational Therapists working in eating disorders, with a specific focus on workplace burn out. Key conclusions from the study identified that Occupational Therapists who possessed a stronger sense of professional identity, experienced higher levels of exhaustion. Interviews indicated that this was because Occupational Therapists felt that their role was being blurred due to pressure to complete non-occupation focussed interventions such as CBT-ED (Devery et al., 2018).
However, Devery et al’s (2018) research was a small sample, largely due to the specialised area that eating disorders are resulting in a small workforce. Furthermore, it may be questioned what the participants reasons were for choosing to participate and whether they had any bias or residual effects of stress and burn out that may have affected their views on their service specifically. For instance, Devery et al did acknowledge that similar trends have been found across all mental health services, therefore the reliability and transferability may be questioned. However, further studies into the treatment of eating disorders have shown similar trends of the experience of role blurring identified by Devery et al’s participants.
Pépin & King (2013) and Hibbs et al (2015) both conducted studies regarding the burden of being a carer of a person with an eating disorder. Both studies provided education-based skills training in order to learn to cope with caring for their loved one and both mentioned that Occupational Therapists can deliver the support. However, both articles discuss therapeutic involvement generally and involved other members of a multidisciplinary team. Whilst multidisciplinary teams are recommended for the treatment of eating disorders (NICE, 2020), these articles mention the use of an Occupational Therapist without specific occupation focussed treatment such as Motivational Interviewing and psychoeducation. This suggests a similar theme found by Devery et al, that Occupational Therapists may be experiencing role blurring, whereby an Occupational Therapist or another therapist could conduct the same work, therefore potentially diluting the skills that Occupational Therapy specifically can bring to eating disorder treatment.
Finally, this gap in treatment is further identified by Lynch et al (2013) who suggests that changing problem behaviours in eating disorders would be more successful if the patient acknowledges that those behaviours are preventing them from achieving their goals; but that there are limited recommendations for treating adults with eating disorders. Furthermore, Hay (2020) provides an overview into the treatment of eating disorders, but focuses on psychological treatments, which they state can be conducted by an Occupational Therapist, and pharmaceutical treatments. Given the identified skills that Occupational Therapists could bring to eating disorders, as identified by O’Reilly & Johnson (2016), and the evidence that details how occupation focussed work can increase recovery levels (Coelho et al., 2020), Occupational Therapy may be the treatment needed to fill the gap identified by Lynch et al (2013) to further develop treatment.
With limited research into the direct impact of occupation focussed work with eating disorders, Occupational Therapy within eating disorders may be difficult to justify. Furthermore, the research that is available is predominantly from a white/western culture with all of the identified studies being from America, the UK or Australia, therefore the impact that Occupational Therapy has on eating disorders in other cultures is as yet unclear. However, given the researchers cultural background it would be impractical to conduct the foreign research that is needed within this study. Therefore, this research will focus on what the direct impact is of Occupational Therapy on eating disorders within the UK.
Research methods
When initially deciding upon the method in which to conduct a study into the impact of Occupational Therapy on eating disorders, a quantitative approach was first examined. For this topic area a case-control trial could be considered. With this method the researcher could examine a sample of clinical cases one half in which has had the input of an Occupational Therapist and the other half which has not had the input of an Occupational Therapist. By using this method, the researcher could identify the differences between the two samples to establish a conclusion regarding the relationship being examined (the presence of an Occupational Therapist) and the outcome for the patient, by utilising content analysis (Walliman, 2018). The benefit of this methodology is that it produces quantitative data which may be considered more scientific and may therefore have an impact on how influential the findings are (Maltby et al., 2014). Furthermore, as the study requires no physical participants, because the information comes from clinical notes, the time and cost of the study is lessened (Maltby et al., 2014) and ethically there is less chance of harm to a participant as they are not having to relive an experience. However, the results of the study should be anonymised to further protect the participant information used (Wiles, 2012). Whilst this method has merit, what should be considered is whether this method would uncover the direct impact of Occupational Therapy. As seen in previous literature, Occupational Therapists can be involved in a multidisciplinary team, but this does not mean that the care was occupation focussed and therefore just examining notes may not give a clear indication of the impact one professional has had amongst a team.
Following the review of a quantitative method, a qualitative method was considered in order to gain a deeper understanding of the impact of Occupational Therapy. For this, a focus group was considered whereby a sample population of adults, who had recovered from eating disorders, would come together with the researcher to answer questions about their experience of Occupational Therapy as part of their treatment. Focus groups can provide a more natural setting for discussion, as the research is done more conversationally (Maltby et al., 2014). Furthermore, time and money can be saved by doing the interviews as a group rather than individually (Maltby et al., 2014). Moreover, focus group research can allow the researcher to observe non-verbal communication, as well as what is said as part of the group, which may help add understanding and depth to the results (Ross, 2012). However, while focus groups can and have been used within healthcare research, it is a research method originally created for marketing purposes (Maltby et al., 2014). Therefore, when relating this to a topic where participants may be vulnerable or may feel the embarrassment or shame common in eating disorders (Troop et al., 2008), participants may feel uncomfortable talking as part of a group, therefore limiting the data that could be collected.
The final research method that was chosen was a qualitative method in order to gain the depth in understanding that may not be provided by a quantitative study (Maltby et al., 2014). Semi-structured interviews were therefore chosen with the intention of creating a small scale but in-depth study. By using semi-structured interviews, the researcher can spend time one-to-one with the participant, with a guide to support the participant in sharing their experience, but with the flexibility to expand on a point if they feel able to (Ross, 2012). Furthermore, by being one-to-one the researcher can identify distressing topics more easily than in a group and can therefore safeguard the participant more effectively. While the sample would be smaller due to time limitation of conducting interviews, the results would be richer and could provide more theoretical basis for further research (Maltby et al., 2014). In order to ensure the participant is able to give informed consent the sample will consist of adults who have recovered from an eating disorder – this is because of the cognitive affects that can occur due to eating disorders (NICE, 2020). Furthermore, because of the secretive nature of eating disorders (Nicholls & Viner, 2005), alongside the shame often experienced (Troop et al., 2008) convenience sampling will be used as a contingency for the risk that there are few people who want to participate. Convenience sampling will therefore be conducted by advertising the study in local eating disorder services to access the population of ‘expert by experience’ volunteers and practitioners. This population will be focused on, rather than advertising the study more generally, as they may be more likely to be willing to discuss their experience as this is part of their day-to-day role.
With this chosen method, the data collection is required to be done in a way that will not inhibit the conversational tone of the interview, as this may risk the participant feeling less comfortable with the researcher. Therefore, the interviews will be voice recorded and transcribed post-interview. Qualitative data analysis may be considered an interactive process whereby the collection and analysis of data should impact the research throughout in order to guide the research (Maltby et al., 2014). Therefore, once one interview is done the data will be analysed and coded for themes, which will then inform the researcher of which topic areas to focus on for the next interview. Whilst this can be more time consuming, following this iterative approach means the research and data becomes more focussed with each stage, rather than remaining broad (Maltby et al., 2014). Furthermore, a thematic analysis of the data, supported by quotes from the interviews, can allow for clear identification of common experiences (Maltby et al., 2014).
Ethical principles
Ethics are vital within research, not only to protect the participants but to protect the research and researcher (Maltby et al., 2014; Stanley et al., 1996). Key in any research is the aspect of informed consent (Wiles, 2012). Informed consent must mean that the participants not only agree to take part in the study, but that they also understand what the study entails, such as audio recording, and what risks there are in taking part (Stanley et al., 1996). The ethical challenges of ensuring that informed consent is given, surrounds how and when to provide information regarding the research. Wiles (2012) explores this when considering the dilemma of how much information to provide to ensure it is informative, without it being overwhelming or difficult for the participant to understand. Wiles (2012) further identifies the challenges in ensuring that the participates are competent in understanding the information, so as to provide informed consent. When considering this, this research will only allow participants who are over the age of 18, as there can be ethical dilemmas of gaining informed consent from children (Wiles, 2012), and who have recovered from their eating disorder. As previously mentioned, this is due to the cognitive impairment that can occur in people who have eating disorders (NICE, 2020). Furthermore, all participants will be provided with information regarding the study in the form of a leaflet, with the intention that this would be easier to engage with, which will include the main focus of the study as well as information regarding where to access support. In addition, all participants will be informed that they can stop the interviews at any time, and their data can be withdrawn from the study up to 2 weeks after the interview, to allow the participant time to reflect on their experience and make an informed decision if they are willing for their interview to feature in the study (Wiles, 2012). In order to give informed consent, the participants must also understand the risks of participating (Stanley et al., 1996) which, in this circumstance may be re-traumatisation. However, in order to negate this risk, the researcher will only interview participants who are recovered and information on mental health support will be given at the beginning of the study. Furthermore, as the interviews are one-to-one, the researcher can more easily identify any signs of distress within the participant and provide support if needed (Maltby et al., 2014).
A further ethical principal to consider is anonymising the data and confidentiality. By anonymising the data, the participant is protected from unwanted attention or contact that may come from the dissemination of the research (Stanley et al., 1996). Furthermore, as this study is researching the impact of specific professionals, the participants may not want to be named in case their previous clinical team read the study. Therefore, by keeping the data anonymous the participant is protected from harm and may feel more open to discussing their experiences (Maltby et al., 2014). However, while the data can be anonymised, confidentiality can only be assured as long as the participant is not disclosing information that may put themselves or others at risk (Wiles, 2012). In order to ensure the participant understands this, the researcher will discuss the differences between anonymity and confidentiality with the participant and should a disclosure occur that needs to be escalated due to safety concerns, the researcher will discuss this with the participant first.
Respect for the participants must also be observed (National Institues of Health, 2016). This can be shown by ensuring the researcher does not impose their own opinion in response to a participant, as well as ensuring the participant is informed of new information and are informed of the final study (National Institues of Health, 2016). Furthermore, allowing participants to review the transcripts of their interviews can both show respect to the participant and ensure that the transcription is reliable and representative to the participants opinions (National Institues of Health, 2016).
Researcher bias must also be considered as an ethical principal to be navigated (Maltby et al., 2014). Bias can influence everyday lives both consciously and subconsciously. For instance, if the researcher has a background in working in eating disorders, then they may already have their own conclusions on what their results may show. This is turn may affect the overall results. Therefore, in order to ensure the research is ethical and free of bias, the research can be reviewed. Initially, this will be through an ethics committee who will overview the entirety of the research to ensure that it is ethical to conduct (Maltby et al., 2014). Then throughout the research, the data can be checked by having two people code the transcripts. This is then compared and discussed to identify any differences in coding. This ensures that the researcher is not bias in coding the results therefore making the overall results more valid and ethical (Maltby et al., 2014).
Finally, dissemination of the research must be considered (Wiles, 2012). Dissemination is vital to the ethical principles of research, firstly because it would be unethical to ask participants to relive poetically traumatising periods of their life for the research to then not be used (Wiles, 2012). Furthermore, when the aims of the research are to gain a better understanding of Occupational Therapy and eating disorders, in order to improve the treatment currently available, it may be considered unethical to not disseminate the research when it may be able to impact current practice.
Second to consider is how the research is disseminated. Wiles (2012) explores how publishing online can pose problems in confidentiality, as guarantees over safe storage of data may be more difficult to gain. Furthermore, as dissemination via the internet is global, the work is liable to being copied and reproduced out of context (Wiles, 2012), therefore there may be an ethical risk to sharing research in this way if it is at risk of being misused. Therefore, dissemination should be conducted in a manner in which it can be peer reviewed and safely stored and shared.
Conclusion
To conclude, a database search of 6,450 articles identified 7 sources for critical analysis, within a literature review, which identified a gap in the literature of the broad topic ‘eating disorders and Occupational Therapy’, of the direct impact that Occupational Therapy has on eating disorder patients. The literature identified that Occupational Therapists appear to be experiencing role blurring, whereby they are providing treatments not occupation focussed that other member of multidisciplinary teams could conduct, such as CBT-ED (Devery et al., 2018). Therefore, this research aims to explore the direct impact of Occupational Therapy on eating disorders to discover if occupation focussed therapy is as valuable to eating disorder treatment as has been discussed (O’Reilly & Johnson, 2016). To do this, the researcher considered a range of methodologies including a quantitative study, such as a case-control trial (Maltby et al., 2014), or a qualitative study, such as a focus group (Ross, 2012). However, the finial research design proposes a qualitative study of semi-structured interviews, utilising convenience sampling, in order to gain a depth of understanding in the area (Ross, 2012). The key limitation of this study is the difficulty in making small scale studies transferable to the wider population (Maltby et al, 2014). However, due to ethical dilemmas of ensuring that participants are not retraumatised, a smaller scale study allows the researcher to better understand each participant and therefore more successfully safeguard them.
References
Accurso, E., Sim, L., Muhlheim, L. & Lebow, J. (2020) Parents know best: Caregiver perspectives on eating disorder recovery. International Journal of Eating Disorders, 53(8), pp. 1252-1260.
American Journal of Occupational Therapy (2020) Occupational Therapy Practice Framework: Domain and Process—Fourth Edition. American Journal of Occupational Therapy, 74(87), pp. 1-87.
Anderson, K. et al. (2021) From research to practice: a model for clinical implementation of evidence-based outpatient interventions for eating disorders. Journal of Eating Disorders, 9(1), pp. 1-7.
Bailey, M. (2014) Occupational therapy for patients with eating disorders . In: D. Gibson, ed. The Evaluation and Treatment of Eating Disorders. New York: Routledge.
Bannigan, K., Bryant, W. & Fieldhouse, J. (2014) Creek’s Occupational Therapy and Mental Health. 5th ed. Oxford: Churchill Livingstone.
Brownell, K. & Walsh, T. (2017) Eating Disorders and Obesity, Third Edition: A comprehensive handbook. 3rd ed. New York: The Guilford Press.
Caldwell, A., Skidmore, E., Bendixen, R. & Terhorst, L. (2020) Examining child mealtime behavior as parents are coached to implement the Mealtime PREP intervention in the home: Findings from a pilot study. British Journal of Occupational Therapy , 83(10), pp. 631-637.
Coelho, J. et al. (2020) Perceived occupational performance in youth with eating disorders: Treatment-related changes. Canadian Journal of Occupational Therapy, 87(5), pp. 423-430.
Devery, H., Scanlan, J. & Ross, R. (2018) Factors associated with professional identity, job satisfaction and burnout for occupational therapists working in eating disorders: A mixed methods study. Australian Journal of Occupational Therapy, 65(6), pp. 523-533.
Hart, S. et al. (2013) Effectiveness of a day program for patients with eating disorders. Journal of Eating Disorders, 1(1), p. 1.
Hay, P. (2020) Current approach to eating disorders: a clinical update. Internal Medicine Journal , 50(1), pp. 24-29.
Hibbs, R., Rhind, C., Leppanen, J. & Treasure, J. (2015) Interventions for caregivers of someone with an eating disorder: A meta‐analysis. International Journal of Eating Disorders, 48(4), pp. 349-361.
Hurst, K. et al. (2020) ANZAED practice and training standards for mental health professionals providing eating disorder treatment. Journal of Eating Disorders, 8(1), pp. 1-10.
ICD-11 (2022) ICD-11 for Mortality and Morbidity Statistics.
Available at: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1412387537
(Accessed 10 March 2022).
Josman, N. (2018) Development of the Do-Eat Tool and Performance Outcome Evaluation With Children With Neurodevelopmental Disorders. Salt Lake City, American Journal of Occupational Therapy.
Kelly, A. & Tadca, G. (2016) Within‐persons predictors of change during eating disorders treatment: An examination of self‐compassion, self‐criticism, shame, and eating disorder symptoms. International Journal of Eating Disorders, 49(7), pp. 716-722.
Lynch, T. et al. (2013) Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an inpatient program. BMC Psychiatry, 13(293), pp. 1-17.
Maltby, J., Williams, G., McGarry, J. & Day, L. (2014) Research methods for Nursing and healthcare. 1st ed. London; New York: Routledge.
Mescher, M. (2022) Treating Eating Disorders: An Occupational Therapy Approach.
Available at: https://www.nationaleatingdisorders.org/blog/treating-eating-disorders-occupational-therapy-approach
(Accessed 10 March 2022).
National Institues of Health (2016) Guiding Principles for Ethical Research.
Available at: https://www.nih.gov/health-information/nih-clinical-research-trials-you/guiding-principles-ethical-research
(Accessed 10 March 2022).
NHS (2021) Overview – Eating Disorders.
Available at: https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/eating-disorders/overview/
(Accessed 10 March 2022).
NICE (2019) Eating Disorders: How commin is it?.
Available at: https://cks.nice.org.uk/topics/eating-disorders/background-information/prevalence/
(Accessed 10 March 2022).
NICE (2019) Eating Disorders: What at the complication.
Available at: https://cks.nice.org.uk/topics/eating-disorders/background-information/complications/
(Accessed 10 March 2022).
NICE (2020) Eating disorders: recognition and treatment.
Available at: https://www.nice.org.uk/guidance/ng69/chapter/Recommendations#treating-anorexia-nervosa
(Accessed 10 March 2022).
Nicholls, D. & Viner, R. (2005) ABC of Adolescents: Eating disorders and weight problems. The British Medical Journal, 330(7497), pp. 950-953.
Office for National Statistics (2020) Deaths from eating disorders and other mental illnesses.
Available at: https://www.ons.gov.uk/aboutus/transparencyandgovernance/freedomofinformationfoi/deathsfromeatingdisordersandothermentalillnesses
(Accessed 10 March 2022).
O’Reilly, C. & Johnson, L. (2016) Working with people with eating disorders. In: J. Clewes & R. Kirkwood, eds. Diverse Roles for Occupational Therapists. 1st ed. Cumbria: M & K Update Limited, pp. 251-277.
Palavras, M. et al. (2018) Comparing cognitive behavioural therapy for eating disorders integrated with behavioural weight loss therapy to cognitive behavioural therapy-enhanced alone in overweight or obese people with bulimia nervosa or binge eating disorder: study protocol for a randomised control trial. BioMed Central, 16(578), pp. 1-10.
Palmer, R. (2014) Helping People with Eating Disorders : A Clinical Guide to Assessment and Treatment. 2nd ed. Oxford: John Wiley & Sons.
Pépin, G. & King, R. (2013) Collaborative Care Skills Training workshops: helping carers cope with eating disorders from the UK to Australia. Social Psychiatry & Psychiatric Epidemiology, 48(5), pp. 805-812.
Priory Group (2022) Changing behaviours and eating habits of those who may be struggling with an eating disorder.
Available at: https://www.priorygroup.com/blog/looking-out-for-loved-ones-who-may-develop-eating-disorders-in-lockdown
(Accessed 31 January 2022).
Reel, J. (2013) Eating Disorders: an Encyclopedia of Causes, Treatment, and Prevention. 1st ed. California: ABC-CLIO, LLC.
Ross, T. (2012) A survivual guide to health research methods. 1st ed. Maidenhead: Open University Press.
Selby, C. (2018) The Psychology of Eating Disorders. 1st ed. New York: Springer Publishing Company.
Smith, K., Tchanturia, K., Dandil, Y. & Baillie, C. (2019) Well-Being Workshops in Eating Disorder Wards and Their Perceived Benefits to Patients and the Multi-Disciplinary Team: A Pilot Study. Brain Sciences, 9(10), pp. 1-11.
Stanley, B., Sieber, J. & Melton, G. (1996) Research ethics : a psychological approach. 1st ed. Lincoln: University of Nebraska Press.
Troop, N., Allan, S., Serpell, L. & Treasure, J. (2008) Shame in women with a history of eating disorders. European Eating Disorders Review, 16(6), pp. 480-488.
Walliman, N. (2018) Research Methods: The basics. 2nd ed. Oxon; New York: Routledge.
Wiles, R. (2012) What are qualitative research ethics?. 1st ed. London; New York: Bloomsbury.
Williams, A. (2019) Eating disorders sourcebook. 5th ed. Detroit, MI: Omnigraphics.
Wright, K. (2019) Pocket Guide for the Assessment and Treatment of Eating Disorders. Journal of Mental Health, 28(5), pp. 1-2.
Appendices
30 databases were identified through the ‘Allied Health & Social Care’ filter. From this each database description was analysed and the relevant databases were then opened to begin searching. 13 databases were searched in total, the results for which can be seen below:
Table A1: Database results
| Database | Sources Identified when inclusion/exclusion criteria added | Duplicates | Sources for analysis |
| AMED | 4 | 0 | 2 |
| CINAHL Complete | 11 | 3 | 1 |
| Conference Proceedings Citation Index | 24 | 5 | 2 |
| Ebook Central (formally EBL) | 5184 | 0 | 8 |
| Embase | 70 | 8 | 0 |
| NICE | 561 | 0 | 0 |
| OAIster | 2 | 2 | 0 |
| PsycINFO (via EBSCO) | 13 | 9 | 0 |
| PubMed Central | 429 | 3 | 3 |
| Social Care Online | 1 | 0 | 0 |
| Social Sciences Citation Index | 25 | 0 | 1 |
| TRIP Database | 6 | 0 | 0 |
| Google Scholar | 130 | 9 | 8 |
| Total: 13 | 6,450 | 38 | 25 |
Following the initial screening of databases and sources by title, the remaining 25 sources were then screened by abstract to assess the relevance when considering the inclusion and exclusion criteria. Following this, the sources that are deemed most relevant were then read and analysed in full.
Table A2: Article analysis
| Source | Database | Relevant following abstract review | Critical analysis of source |
| (Coelho et al., 2020) | AMED | Yes | Impairments to occupations were analysed and goals were set in line with clients wishes in order to increase motivation. mBMI increased throughout treatment. However, this was a specialised day unit utilising a voluntary programme. Therefore, it may be difficult for this to be transferred to public use. Furthermore, with the programme being voluntary it may be argued that the client was already motivated and therefore more likely to succeed within the programme. Finally, this is a white/western perspective and may not be useful for other cultural demographics. |
| (Devery et al., 2018) | AMED | Yes | A mixed methods study identifying the challenges of being an OT and working in eating disorders in Australia. Provided detailed insight into the sector from an OT perspective. However, the author cannot be sure that their sample size is representative as it is unclear how many OT’s work in this area. Furthermore, it may be questioned if people are more likely to share negative experiences over positive as they feel they need to ‘speak up’. |
| (Caldwell et al., 2020) | CINAHL Complete | No | Not focussed on eating disorders but on general feeding instead |
| (Hurst et al., 2020) | Conference Proceedings Citation Index | No | Not focussed on occupation/occupational therapy |
| (Accurso et al., 2020) | Conference Proceedings Citation Index | No | Not focussed on occupation/occupational therapy |
| (Bannigan et al., 2014) | Ebook Central | No | Only very brief section on occupational therapy and eating disorders |
| (Williams, 2019) | Ebook Central | No | Not focussed on occupation/occupational therapy |
| (Wright, 2019) | Ebook Central | No | Not focussed on occupation/occupational therapy |
| (Brownell & Walsh, 2017) | Ebook Central | No | Not focussed on occupation/occupational therapy |
| (Palmer, 2014) | Ebook Central | No | Not focussed on occupation/occupational therapy |
| (Selby, 2018) | Ebook Central | No | Not focussed on occupation/occupational therapy |
| (Reel, 2013) | Ebook Central | No | Not focussed on occupation/occupational therapy |
| (O’Reilly & Johnson, 2016) | Ebook Central | Yes | A book section exploring how OT’s can support people with eating disorders including assessment and intervention suggestions. Informed well with sources as well as anecdotal information. However, also written from a white/western perspective and it may be questioned if this source accurately depicts what OT’s actually do within eating disorders or rather what they might be able to do. |
| (Hart et al., 2013) | PubMed Central | No | Focusses on work from multidisciplinary team not specific to occupational therapy |
| (Smith et al., 2019) | PubMed Central | No | Focusses on work from multidisciplinary team not specific to occupational therapy |
| (Anderson et al., 2021) | PubMed Central | No | Focusses on work from multidisciplinary team not specific to occupational therapy |
| (Josman, 2018) | Social Sciences Index | No | Focus on neurodevelopmental disorders rather than eating disorders |
| (Hibbs et al., 2015) | Google Scholar | Yes | A meta-analysis examining the support given to caregivers of people with eating disorders. Studies taken from Japan, UK, USA and Australia, however there was a heavy weighting towards the western perspective with 8 of the 13 articles being from one team in the UK. Identified that support given to caregivers is largely education based. While OT’s can follow an educative approach, this may also be followed by may other professions. Therefore, it may be questioned if this shows how OT’s can be interchangeable in eating disorder services currently. |
| (Palavras et al., 2018) | Google Scholar | No | Deducted from final list of articles during last sage of screening. While the study does outline how an OT supported a team of people in Brazil to help change eating disordered behaviours, this is only a pilot study and the results cannot be accessed. Therefore, the ‘outcome’ (which was part of the inclusion/exclusion criteria) cannot be determined. |
| (Kelly & Tadca, 2016) | Google Scholar | No | Deducted from final list of articles during last sage of screening. While the study did utilise an OT, the focus was on how the previous literature had not focussed on ‘within-person’ predictors of change and was therefore not occupationally focussed enough to be useful to this study. |
| (Lynch et al., 2013) | Google Scholar | Yes | A UK study into RO-DBT which identified how it can be useful to focus on changing behaviours that are inhibiting the client doing what they wish to achieve in order to increase motivation and support recovery. While only 1 OT was used the principles of this study, which lay in the use of skills building session, had a level of occupation focussed ideology. However, ethically it must be considered if it is safe to focus solely on client goals when eating disorders can impair a persons cognition. |
| (American Journal of Occupational Therapy, 2020) | Google Scholar | No | Provides an overview of occupational therapy but not specific to eating disorders |
| (Hay, 2020) | Google Scholar | Yes | This source was an overview of eating disorder treatment in Australia. The source largely depects how psychology and pharmacuticals are being used to support people with eating disorders. However, the source does also state that OT’s can be used. Interestingly though, the source identifies that OT’s can support interventions such as CBT-E rather than interventions that are occupation focussed. |
| (Pépin & King, 2013) | Google Scholar | Yes | A pilot study that analysed the effects of caregivers attending a training workshop which was run by an OT and a clinical psychologist. The results showed a decrease in care giver burden and psychological distress. However, as with other articles the intervention was not necessarily occupation focussed such as motivational interviewing. |
| (Bailey, 2014) | Google Scholar | No | Source was a chapter in a book published in 2014, however the chapter was written prior to my date cut off |
Figure 1: Database search results flow chart
