The primary aim of this study was to explore the views of homeopaths about their experience and treatment of clients with eating disorders such as anorexia and bulimia. The intention was to reveal the challenges, outcomes and pitfalls of working with individuals with enduring eating disorders and to discover if homeopaths believe homeopathy to be effective in treating the whole person; the symptoms of the eating disorder both mentally and physically.
A constructivist, grounded theory approach was taken and semi-structured interviews were undertaken with homeopaths who have experience in treating people with eating disorders. Data was analyzed using thematic coding.
Findings suggest that it is necessary for homeopaths to distinguish between eating disorders of long standing and short term disorders. Short term disorders have different implications in that they are often easier to deal with. Disorders of long standing have far-reaching implications in practice. In depth knowledge is required of eating disorders in general as well as of the therapeutic relationship in particular. Managing this group of patients is different from other patient groups, and it asks of the homeopath to be very aware of boundaries and professional limitations. Patient choice is perceived as vital for effective treatment. Patients need to be willing to commit to and engage in the process. Furthermore, dealing with maintaining causes and relapses can be challenging. Homeopaths need to have an awareness of the socio/cultural contexts affecting patients with eating disorders and be able to assist in the management of triggers and relapses. Findings also suggest that treatment can have an effect on all levels; mentally, emotionally as well as physically.
Eating disorders are becoming an increasing problem in the western world with up to as many as 1 in 3 girls showing symptoms of some kind of eating disorder (Fløe & Madsen, 2005). According to the Danish Department of health (1999), the death rate for anorexics is 9 times the rate of people the same age and is attributed to complications from starvation or suicide. Anorexia nervosa has the highest mortality rate of any psychiatric illness (Treasure, 2007; Birmingham & Treasure, 2010).
Resent research suggests that although bulimia and other non-specified eating disorders are often viewed as less severe, individuals with bulimia or such non-specified eating disorders have elevated mortality risks similar to the level found in anorexia nervosa (Crow, Peterson, Swanson, Raymond, Specker, Eckert & Mitchell, 2009).
Despite all this, not much in the way of treatment is on offer for this neglected group of patients and it is notable that research on the subject both in conventional and complementary medicine, is conspicuously lacking. When examining the subject carefully it appears that there is great confusion about the whole subject of eating disorders. This is confirmed by patients’ statements that they feel not to be understood (Andersen, 2009; Lassen, 2008; Sørensen, 2004).
There is anecdotal evidence in the homoeopathic literature that increasingly people seek homoeopathic treatment for these disorders (Snowdon 1999; Maslan, Nd). To date, however, apart from one study on the homeopathic treatment of binge eating disorder, there has been a paucity of research in this area. The primary aim of this study was to explore the views of homeopaths about their experience and treatment of clients with eating disorders such as anorexia and bulimia. The intention was to reveal the challenges, outcomes and pitfalls of working with individuals with enduring eating disorders and to discover if the homeopaths find homeopathy effective in treating the whole person; the symptoms of the eating disorder mentally and physically.
Attitude and treatment
According to patients suffering from eating disorders there is a tension between the patients’ own understanding of their disorders, the conventional attitude towards and definition of eating disorders and their ensuing treatments ( Hvid, 1998; Lassen, 2000; Skårderud, 2001; Sørensen 2004). According to Lassen (2008), a psychologist who herself suffered from bulimia for 10 years and who has much experience in treating patients with eating disorders, it is very important which attitude one takes towards an eating disorder. If one looks upon the disorder as being strictly about an erroneous diet or a bad habit then a change of diet is a sensible solution to the problem. But, if it is viewed instead as being an externalisation of existential suffering, then it is necessary to deal with the problem entirely differently. Interestingly, Lassen (ibid.) explains that most people with an eating disorder or a weight problem try to treat themselves and the most prevalent treatment is – the diet. This may be explained by the reinforcement and emphasis which is put on the actual diet in our present time. As one patient with bulimia put it: ” I did not know what to seek help for and the sad thing was I thought the solution to the problem was to become thin” (Sørensen 2004 p. 11).
This is mirrored in the Danish Health Department’s leaflet on eating disorders, which is intended to support people with eating disorders as well as their relatives and to enable people at risk to realize and acknowledge their condition. In the same leaflet, however, they encourage weight regulation as it is healthy. In this way they send out mixed messages and are in fact moving the boarders between health and disease.
At any one time approx. 50 % of women are on a diet in Denmark which is likely to result in an eating disorder (Lassen ibid; Petterson ibid). According to Petterson (1999) this bears witness to the fact that women in certain professions dare not become fat, because if they did perhaps they would not get a job or they would not keep it. The traditional method of treatment of anorexia nervosa in conventional medicine has been one of focussing on the weight gain and in many hospitals the treatment has been based on a system of “punishment and reward” according to the weight loss or gain respectively (Fløe & Madsen 2005).
The study of the literature and of biographies of those who have suffered or suffer from anorexia or bulimia shows one of the most striking things to be the matter of choice. On the one hand they describe how they are caught by the disease, but on the other hand how they choose not to do anything about it (Lassen, 2008: Sørensen, 2004) One mother writing about her daughter’s life with anorexia even describes how her daughter “chose death” (Dunbar, 1986).
Common to the persons who have had anorexia or bulimia is the fact that they themselves say that the illness is not about food. The food is just a symptom covering what is going on underneath (Lassen 2008; Sørensen 2004). They also make quite clear that they are not “cured,” they have learned to live with the symptoms of the disease and they get relapses which they use as guidance for situations that they need to be particularly aware of.
Sørensen (2004 p.11) describes bulimia as “the art of eating and throwing up.” “By thinking about food it becomes possible not to think about oneself and one’s feelings which I did not dare accept. By thinking about food I avoided thinking about the problems and solving them.” (Sørensen, 2004 p. 56) and further: “You have to dare feel the pain, the sadness, the happiness, the love, yes everything to do with feelings, because that is what an eating disorder is really all about: FEELINGS.”
According to Sørensen (2004), when one has no self confidence, when one dare not live or believe in the future, a vacuum arises that yearns to be filled with something else like food. To fill that vacuum with food gives a false sense of security which is possible to relate to. A recurring theme through autobiographies from people with bulimia is a common desire to detect and understand the feelings that make the vacuum arise in the first place. Bulimia becomes a sign that something is not quite how it should be.
Often there is a difficulty in accepting the fact that there is a problem. The main point that is emphasized by both patients with anorexia and bulimia is the fact that they are not understood by other people (Andersen 2009; Lassen 2000; Sørensen 2004)
During a visit to the doctor after having fainted from starvation during her anorexia, Sørensen (2004 p. 46) describes the conversation with the doctor: “Then she said something I really hope she has regretted: “Well, take yourself home and get something nice to eat and if you are not better in a week then feel free to call again.” I felt so let down, eventually I had pulled myself together to see the doctor, to elaborate on my innermost feelings and then she tells me to go home and eat!”
But the first criteria for an effect of treatment is the free choice” (Lassen 2008 p.15). Patients with anorexia are usually under 19 when they come, but those who suffer from bulimia or obesity often come of their own free choice, but much later in life.
According to Lassen (2008), it is necessary to look at the whole; all the factors that make a person – not only the diet, but the person who eats the food, the person’s self-conception, and the circumstances that have formed that person’s self-concept, life and eating strategies.
In all the clinical trials the researchers, without exception, call for a greater knowledge-base and a better understanding of eating disorders. The problem that seems to be appearing from the research is the difficulty in combining the physical side of the disorders with the mental aspect of them, and this is probably why it has been so difficult in conventional terms to grasp and treat the diseases.
This again may be one reason why eating disorders have warranted so little interest in terms of conventional research.
As Konrad (2007) pointed out “it may be possible to re-feed the anorexic person or teach them to eat, or reinforce their control and maintain their level of food balance, but so far nobody has been able to make the anorectic person feel good about herself.”
“As eating disorders include both psychological and physiological components, appropriate management of these disorders requires input from a number of disciplines working together in a coordinated manner, following an integrated programme” (Loria et al 2009, p. 558). Fennig and Hadas (2010), point out that too much emphasis is still put on the eating behaviour itself and since the risk of suicide is so great due to depression, they stress the need to detect and treat the depression, as the depression seems to amplify illness severity. However, even in the trial by Loria et al (2009), in which they acknowledge the necessity of directing the treatment of eating disorders at different levels, the greatest emphasis is put on the nutrition programme in which the focus is on “achieving healthier habits and modifying eating behaviour” (ibid. p. 558).
Of the few trials on anorexia, two randomised controlled trials (RCTs) that incorporate the use of family therapy seem to come up with the best results.
Correlations showed that adolescents who gained more weight in the early sessions (69%) were more likely to agree with the therapist on the goals of the therapy (p<0.02) and stay with it (ibid, 2006). It is, however, a small trial with 40 patients in the study, but subsequent studies on the same topic have yielded similar results (Zanadin et al 2007). The overall outcomes of both studies are good. In the other study on family therapy 75% of patients reported no anorectic symptoms at all after 5 years; only 8% have relapses and there are no deaths (Eisler et al 2007).
However, according to Guarda (2007): “Evidence-based data on treatment interventions for anorexia nervosa are scarce and methodological problems afflict the few published, controlled trials.”
With respect to most studies on eating disorders, there seem to be a few design problems. Generally, there seems to be a lack of consensus in the field (Guarda 2007; Southgate, Tchanturia & Treasure, 2009), both in regard to definitions of psychological and physiological criteria for recovery, symptom remission, problems about other forms of treatment, co-morbidity, target weight and prognosis which makes it very difficult to compare the different studies.
The quality of evidence therefore is generally weak and the trials are difficult to reproduce.
Furthermore, studies suggest that people with eating disorders do not turn up for help with the treatment of an eating disorder, but rather for symptoms secondary to the eating disorder (Hay, 2007).
One clinical study that stands out is the study on binge eating disorder and homeopathy carried out by (Jacobs, 2001). In this study there is an emphasis on the physical as well as the mental and emotional plane. According to Jacobs (ibid. p. 22):
“Homoeopathy may help on several planes simultaneously. The simillimum aims to address the low self-esteem, fears and obsessions and restore the appetite to normal, while healing any physical and psychological consequences of such a disorder.”
The homoeopathic perspective
Usually, homeopaths look at the underlying reason for the individual to become ill in the first place, whatever that might be, and a homeopathic approach to treatment would invariably involve a holistic assessment of the patient.
Looking at one of the few single cases of anorexia nervosa available in homoeopathic literature by Montani (1999), it becomes apparent that when the patient started feeling better, she started gaining weight, the menses returned, her anxiety disappeared and the other physical symptoms disappeared, and not least, her diet became stable. A single case cannot qualify as scientific evidence (Thompson 2004) even if the results are mirrored in other similar cases, for example in a case study reported by Crump (1995). However, when successful treatment by homeopaths are reported in a number of cases (Fixen 2006), (Lefevre 2005), it might suggest that further investigation is warranted into this as a potentially effective healing modality.
The patients themselves seem to regard the disorders as an externalisation of existential suffering, whereas the help they get seems to spring from a treatment based on the first attitude, in this way reinforcing the vicious circle of the disorders and resulting in a tension between the patients’ understanding of themselves and the ensuing treatment.
Theoretical framework and epistemology
“The exact nature of the definition of research is influenced by the researcher’s theoretical framework” (Mertens, 2005 p. 2 cited in Mackenzie & Knipe, 2006) with theory being used to establish relationships between or among constructs that describe or explain a phenomenon, by going beyond the local event and trying to connect it with similar events.
The researcher is influenced by the Danish philosopher Søren Kierkegaard (1813-1855), one of the founders of the hermeneutic tradition, and by John Dewey (1859-1952) one of the founders of pragmatism.
Pragmatists have the philosophical stance that knowledge should not be taken as an objective reflection of reality, but as a useful tool which shows its applicability in practice.
The researcher holds the belief that you learn from experience and what is true is what works, but she also strongly believes that all individuals have a freedom to choose. As Kierkegaard (1980 p. 29) puts it: “That, which combines the different elements in the human synthesis, is the quality of the human being to relate to oneself and to have an understanding of oneself as a freely acting individual.” Kirkegaard (ibid.) also stresses, however, that “The self is composed of infinity and finiteness. But the synthesis is a relationship, and it is a relationship which, though it is derived, relates itself to itself, which means freedom. The self is freedom. But freedom is the dialectical element in terms of possibility and necessity.” This is where, in my opinion, this existential hermeneutic belief system ties in well with the symbolic interactionists in that although the person makes his own choices, he is very much a product of the necessities and possibilities in his own life, culture and society.
Symbolic interactionism has its roots in pragmatism and is governed by a humanist perspective. Flick, Kardoff & Steinke (2004 p. 81) suggest that the term “symbolic” in the phrase symbolic interaction refers to the underlying linguistic foundations of human group life, just as the word interaction refers to the fact that people do not act toward one another, but interact with each other. By using the term interaction, symbolic interactionists commit themselves to the study of the developmental course of action that occurs when two or more persons (or agents) with agency (reflexivity) join their individual lives of action together into joint actions.”
To the researcher it is important to look at the society and times in which eating disorders become an increasing problem, through the lens of cultural criticism which was so characteristic for Dewey, and to keep asking questions. This includes scrutinizing the strong influence of the mass media whose “basic task is to make the second hand world we live in appear to be natural and invisible” (Flick et al 2004 p.83).
It is interesting that symbolic interactionism reflects the duality in the “interpretive, subjective study of human experience. On the other hand, they sought to build an objective science that would conform to criteria borrowed from the natural sciences” (Ibid. p. 84). This is exactly what homoeopaths are up against and in actual fact what people with eating disorders are struggling with as well. They do not fit into the world view of the natural sciences, as they cannot combine the mental aspect of the disorder with the physical side of it. This leaves the individual stranded in her own existential searching in the midst of all the striving for objectivity.
Kierkegaard (1980) describes fear, depression, and despair as being constituting elements in the human being, as a means to reach greater self- knowledge. This is where the naturalistic view differs from the existentialistic and homeopathic viewpoints. In the allopathic treatment of such symptoms they would be eliminated and from an existentialistic viewpoint that would be tantamount to denying the person the possibility of solving their own problems and thereby reaching a state of increased self-knowledge. This of course goes along with the homeopathic theory of repression and suppression, instead of treating the person so that she achieves a greater awareness. Kierkegaard suggests that when having symptoms of for example fear, the person is being given a choice and he must choose; i.e. he can choose to develop a greater understanding – or he can choose not to, by suppressing his symptoms with medicine. By making the latter choice he has chosen to live a figurative life, in that he has chosen not to give his life a purpose. This theory is reflected in (Hahnemann 1988 § 9). The existential belief system is also mirrored in Kent (1987 p.79): “If man is in the highest order and is rational, he wills to keep himself in continuous order, that his thoughts may continue rational; but he is so placed in freedom that he can also destroy his rationality.”
This study is acknowledged to be rooted in a constructivist paradigm assuming a pragmatic ontology. Constructivist approaches to research intend to understand the situation under study from the participants’ perspective, suggesting that “reality is socially constructed” (Mertens, 2005 p.12). The constructivist researcher tends to rely upon the “participants’ views of the situation being studied” (Creswell, 2003 p.8), and acknowledges the impact on the research of their own background and experiences. Constructivists do not generally begin with a theory (as with postpositivists), rather they “generate or inductively develop a theory or pattern of meanings” (Creswell, 2003 p.9) throughout the research process. Qualitative methodologies are the most obvious ways of eliciting this data.
The methodology chosen was grounded theory as it seemed appropriate to the research aims and objectives and it was coherent with the researcher’s own theoretical perspectives providing the context for the research process, namely symbolic interactionism and hermaneutism as explained above. There was no initial hypothesis to be tested. In grounded theory conclusions are generated from the research and the researcher can therefore remain open to all possibilities.
It is important to note that when assuming a constructivist approach in grounded theory, the researcher not only looks at how the research participants view their situations, but also theorizes on the interpretation of the participants. Therefore, the researcher acknowledges that the resulting theory is an interpretation which is in fact dependent on the researcher’s view (Charmaz, 2006). “Grounded theorists may borrow an insight from Silverman’s (2004) observation of conversational analysis. He contends that only after establishing how people construct meanings and actions can the analyst pursue why they act as they do” (Charmaz, 2006 p.130). She goes on to explain that the “logical extension of the constructivist approach means learning how, when, and to what extent the studied experience is embedded in larger and often, hidden positions, networks, situations, and relationships. Subsequently differences and distinctions between people become visible as well as the hierarchies of power, communication, and opportunity that maintain and perpetuate differences and distinctions. A constructivist approach means being alert to conditions under which such differences and distinctions arise and are maintained.”
Here, an analogy can be drawn to homeopathy in which it is considered of great importance to detect the maintaining cause in an individual case. In my view we have to go beyond that and detect and understand the “collective maintaining causes,” Dehn (2005), which may have an immense influence on certain groups of patients as may be the case in patients with eating disorders.
Outline of the study design
The most common methods to extract knowledge in grounded theory are one-to-one interviews or focus groups with data collection and analysis occuring concurrently. This concurrent process involves using early analytical thought generated from initial analysis. As the researcher lives in Denmark and the interviewees live in England, the most appropriate method in this study was one-to-one interviews over the phone as the distance made it impractical to establish focus groups or carry out face-to-face interviews. Therefore it was decided that one-to-one semistructured interviews would be the most effective way to elicit a comprehensive understanding of the individual homeopath’s experience of treating persons with eating disorders. “What we observe is the limit of our observation, what we memorise forms the limit of our understanding” (Miles, 1992 p.68).
Homeopaths are used to conducting interviews and analyzing the data gathered. In fact this process with semistructured interviews mirrors the homeopathic consultation (Gray, 2008). There is no doubt, however, that an interview conducted face to face would have been more appropritate as important information especially body language was missed over the phone. It was more difficult to use non-verbal techniques;the use of interpersonal space, pacing of speech and length of silence in the conversation, variations in volume, pitch and quality of voice on the phone which is othervise used in a face-to-face interview. On the other hand, the fact that the interviewees were all qualified homeopaths and had experience from 6-25 years of treating patients, and the fact that they had implicit knowledge of both homeopathy and the subject in question made it easier to interview them over the phone, than it might have been to interview somebody without similar experience of conducting interviews in their own consultation.
As with the homeopathic interview, the questions had to be non-directive and open-ended, so participants were able to describe their own experiences as fully as possible, but at all times during the interviews as well as in the whole process, there was the risk of bias on the part of the reseacher. This is why it is so important for the researcher to be reflexive; that is being aware of one’s preconceived ideas and assumptions.
3 women and 3 men were interviewed (n=6), between December 2009 and February 2010.
4 homeopaths lived and practiced in England, 1 in Ireland and 1 in Denmark, but they all qualified in England at colleges approved by the Society of Homeopaths.
2 homeopaths relied solely on homeopathy
2 homeopaths had close collaborations with psychotherapists
1 homeopath was also a counsellor and a nutritionist
1 homeopath had taken further education in Cognitive Behavioural Therapy related specifically to treating patients with eating disorders
Overview of categories
As a result of the data gathered it became apparent that there was a primary theme going through certain characteristics of the patients with an eating disorder, the process itself and the manner of treatment. In order to understand the greater picture, the challenges and pitfalls of treating patients with eating disorders, therefore, categories were generated specifically related to these characteristics. Categories were collapsed that related only to individual patients without relevance to the greater context.
The 7 main categories that were generated from the data were:
· Longstanding process
· Manner of treatment
· Therapeutic relationship
· Patient commitment and engagement
· Maintaining cause
· Successful outcome
The themes that ran through the findings were “cooperation,” “engaging in the process,” “taboo,” “trust,” “control,” choice/want of choice,” “case management,” “causation,” “fundamental core,” “combination of qualities,” “dependency,” “boundaries,” “relapse” and they were all embraced in one of the main categories or they became a subcategory in their own right.
This category embraced two polarities; the fact that treating patients with longstanding eating disorders was very challenging for the homeopath and in depth knowledge of both eating disorders in general and the therapeutic relationship in particular were needed, in order to achieve a successful outcome for these patients. However, the polarity showed that patients with subclinical eating disorders or eating disorders that had just been diagnosed, were reasonably easy to treat and homeopathy worked very well even in cases where patients were not ready yet to acknowledge the fact that there was a problem.
First of all it became clear that most patients who suffer from serious eating disorders, have done so for a long time and it is something that takes a long time for the patients to work through.
“Patients suffer from a Longstanding chronic condition” (5) and “The skill is enabling the patient to understand the work that has been undertaken and they need to embrace it for a long time.” (4) “to make them realize that it has gone on for a long time and often has roots back to childhood and to make them realize that it will be a long process as in my experience it is not going to be a quick fix” (6) “The challenge is when the condition has lasted for a long time with lots of pathology as a result.” (3) “The challenge is establishing the therapeutic relationship and getting the patient to commit and understand it is a long process.” (4) The polarity was shown clearly by homeopath number 2 who had only treated children who had not had the disorders very long and they were reasonably easily resolved.
And 2 of the homeopaths who had a lot of experience in treating patients with eating disorders stressed that in some cases it was very easy to find the correct remedy and the patient just got better.
Manner of treatment
Homeopaths : 1,2,3,4,5,6
This category embraced most diversities in the question of how to treat persons with eating disorders. 4 homeopaths relied only on homeopathy 1 homeopath was a counsellor as well as a homeopath and 1 homeopath had extra training in cognitive behavioural therapy. 2 homeopaths were able to discuss their cases with a psychotherapist. They all agreed that a straight forward classical method was most appropriate. The greatest variance was in regard to nutritional advice. The category of “focus on nutritional advice” encompasses a polarity in that 3 homeopaths decidedly disagreed with nutritional advice, whereas 3 homeopaths offered nutritional advice as part of the treatment.
All the homeopaths in the study when asked said that they used a classical approach in homeopathy and they prescribed constitutionally. It was, however, in this category of “manner of treatment” that most differences emerged with regard to the treatment of patients with eating disorders. So although basically agreeing on the homeopathic content of the treatment, one homeopath described it as follows:
“So that to me, it is doing what is appropriate. It is not to be so close to one school of thought that you let it blind you to the alternatives.” (3)
The discrepancies arose around what else the treatment should consist of when working with patients with eating disorders.
The one most outstanding difference was whether or not to offer advice on nutrition.
3 homeopaths offered advice: Homeopaths 2,4,6 whereas homeopaths 1,3, 5 did not.
“I will just help them to understand what good nutrition is, and when they are in a better place they will embrace that more”.(4)
“So trying to help somebody stabilize their weight and trying to encourage them to eat more nutrient rich food, is something I would do as well which is outside homeopathy.” (6) “I think I learned a lot from doing this. I think I probably would follow a broadly similar approach. I certainly think I was right in choosing not to focus on weight and weight gain and diet.”(3)
The other difference was in relation to cognitive behavioural therapy. One homeopath found it very effective in her practise: “I want to have a sense of engaging from the outset. So first case will be pretty much that I can then see what type of eating disorder they have, how long standing, who have been involved in it, what are the structures that they set in place to help them, what are the resources that they have to help them in the process of healing. That will be my first case taking with them. And then I will also give them a lifestyle questionnaire which is different to the one I would give to my other clients which is a general questionnaire. This one will be specifically focused on their eating disorder. It is different. And then in actually taking their case subsequently it varies, sometimes it will be a straight forward homeopathic consultation where I will be looking for sensation, looking for the remedy, but once I have found the remedy that is working or seems to be working I may introduce some activity between sessions like recording their food in a diary or their binge episodes, or their laxative abuse episodes, so I have the record of what is actually happening. So I would introduce that, and I also see it as a way of sorting it out in a CBT model as homework of engaging the client in their process. I trust that when I give them a remedy the remedy will be working. But the client can endeavour to engage in the process of healing and gaining extra information.”(6)
Whereas another homeopath found cognitive behavioural therapy too simplistic when dealing with a highly complex situation:
“I think that although she had been seeing the person in the NHS, she refers to as her counsellor for a long time, I do not think there had been any significant improvement as a result of that relationship. Because it was on too cognitive a level. We are talking about cognitive behavioural therapy. Her approach was quite cognitive in the sense that; look your weight is going down. We can see your weight is going down. You know what you need to do to make your weight go up. You can deal with this without having, well the idea is that if you understand it you should be able to do something about it, but it is not as simple as that because you are dealing with someone who has complex obsessions about food. Maybe I am not really being very fair to cognitive behavioural therapy here, perhaps it has some other approach, of which I am not aware. But I felt instinctively that a simplistic approach to these problems is not really going to help. What you needed to do was follow a method which would enable you to unravel a highly complex situation with a lot of highly developed physical as well as psychological pathology.” (3)
The category of “therapeutic relationship” embraced the subcategories of “trust”, “withholding information”, “support” and then the subcategory of the homeopaths’ own “boundaries”. Interestingly, within the subcategories “withholding information” and “support” were polarities in that within subcategory “withholding information” homeopaths numbers 2 and 4 did not find that the persons with eating disorders held anything back or found it difficult to talk about certain things, whereas this was volunteered by the other homeopaths. Within the subcategory “support” the polarity of dependency became apparent as homeopaths 1 and 3 stressed the fact that it was necessary to be aware of a dependency when this category of patients needed more time and support.
The primary objective was to determine whether homeopathy had an effect on all levels of the person with an eating disorder. All the homeopaths agreed that homeopathy worked on all levels of the person, but it also showed that it was necessary to address the causation and reach the central disturbance hence the subcategories: “Aetiology” and “Fundamental core.”
Five homeopaths agreed upon the fact that homeopathy worked on all levels.
One homeopath said: ” Homeopathy works equally well on all levels.” (2) and “Homeopathy is effective on the level that needs treating.” (2) “There is no difference in the actions of homeopathy on the different levels than with other patient groups.” (1)
“The physical, the mental and the emotional go hand in hand.” (5) “So I think that the remedies make a huge difference both in helping their physical health and addressing their physical issues that are happening, but also their mental health, reducing their obsessional qualities and reducing the volume of their perfectionism, that they can be driven by.” (6)
There was one difference in opinion, however:
“Because using counselling you bring the matter into the room and into the awareness of the patient and then the remedy starts to help them moving forward. Without the remedy you just kind of keep going over and over it again and it is a very laborious process. I would not want to even try to approach it without homeopathic treatment, because I find that the remedy provides the momentum for the patient… it does not particularly provide the awareness, that is what I am trying to say.”(4)
“Homeopathy makes people with eating disorders feel better, but it does not raise their consciousness.” (4)
There was a consensus among most of the homeopaths that in order to help the whole person with the eating disorder on all levels it was necessary to unravel the whole and get to the central disturbance. It was necessary to be able to perceive the causation or aetiology and this could be a great challenge. Depending on the pathology and the length of time the condition had persisted this could also be a long process and very time consuming.
Although it seemed that each of the homeopaths tackled this challenge in different ways and with different tools they agreed that within this process they would: “focus on the reason the patient has the disorder and not the disorder itself. If you just take a homeopathic case based upon the fact that they have got an eating disorder, I find rarely that homeopathy will help.” (4) But “with the raised consciousness and the right remedy it will start to help.” (4)
Patient commitment and engagement
As indicated by one homeopath the patients with eating disorders often exhibit a strong determination not to get better. They demonstrate strong control. The homeopaths concurred that in order to help this patient group, it was necessary to make them acknowledge the fact that in order to help them they needed to engage in the process to make a choice to commit. Hence the subcategory “Choice/ want of choice” which also encompasses control.
One point raised by 3 homeopaths was the fact that the greatest challenge, but also what would be part of a successful outcome, was that the person with the eating disorder needed to actively engage in the process. The patient needed to be committed to the treatment. This was important as this patient group sometimes is determined not to get better. Cooperation was a main factor in a mutual and respectful therapeutic relationship.
“Not a placebo effect as they are so determined not to get better when they first come to see you. Certainty that nothing can help them.” (5) “The commitment works both ways. Building an honest relationship.” (5) “The challenge is establishing the therapeutic relationship and getting the patient to commit and understand it is a long process” (4) Another point raised was the fact that the patients are not always given a choice of a suitable treatment, when they have acknowledged that they have a problem. Homeopaths who actively worked with eating disorders experienced that: “Homeopathy has some potential other therapies do not have. (5)
One of the greater challenges in dealing with patients with eating disorders was seen to be the maintaining causes and relapses they were prone to. This was why “maintaining cause” was chosen as a major category with the subcategory “relapse”. People with eating disorders were shown to be prone to maintaining causes, and relapses. The homeopaths were very conscious of those factors and some incorporated this perception in the way they engaged in the actual treatment, to try to avoid relapse, or teach the patient how to deal with situations that could trigger binges etc. The media, familial contexts, allopathic treatment, anorexia itself and starvation were seen as maintaining causes as well as the socio-cultural context:
“An obesogenic culture that also promotes thinness. Socio-cultural context so their experience in which people are on diets are constantly talking about their weight, their own values and self worth in terms of how they look, how much they weigh, so that I experience as the significant maintaining cause, the culture we are in, and to have resilience and an increased sense of self-worth within that context can be very challenging for some people.” (6) “Less of a tendency to relapse on homeopathy as the remedy has made it possible to move on in a way other therapy cannot.” (4) “I just keep coming back to the fact that it helps so much more and helps avoiding relapse if they understand as much of their own situation as possible at the same time. Then the physical, mental and emotional go hand in hand.” (5)
Successful outcome, challenges and pitfalls
In order to achieve a successful outcome for patients with eating disorders several different aspects were pointed out. Firstly, it was seen to be important to establish an honest and authentic relationship. “The combination of the therapeutic relationship, the rapport and the homeopathic remedy were mentioned to be ingredients of a successful outcome.” (4) Secondly, the commitment from the patient was necessary. It was necessary to get through to the patient and make her understand that the success of the treatment was due partly to her own engagement in the process. “Necessary to get through to the patient. In order for the homeopath to succeed in treating the patient, the patient has to commit to the treatment.”(5)
Thirdly, it became clear that patients with eating disorders often needed much more time and support in order to stick with the treatment. “To achieve a successful outcome you need to be there.”(2) Another challenge was seen to be the fact “that they do not want to talk about the eating disorder or cravings and aversions tampered with from dietary rules or the media.” (1)
Parents’ and carers’ anxiety was seen to be a challenge and the difficulty keeping it in place so that it did not interfere with treatment. Furthermore, it could be a challenge “to understand the causation” (2), and “if the patient is unable to access their central disturbance then it is less successful.” (4) or “when the condition had lasted for a long time with lots of pathology as a result” (3). “Whilst there may be an aversion to some of their compensatory behaviours there is also a lot of investment in them, so yes they are asking to be released from something they are very attached to. That is a challenge.” (6)
The more personal challenges for the homeopaths were keeping their own boundaries, knowing when to hold back, how much to say at any one time and not create dependency. Obstacles to the treatment could be the parents’ anxiety or interference with the treatment. Another pitfall might be if the relapse was so serious that hospitalization was needed and some kind of intervention like force feeding. “Awareness of risk of hospitalization.” (3)
According to one homeopath it would be “a human let down if the homeopath would have to say that the patient had to go to hospital.” (5) Furthermore, it was seen as a “pitfall if the patients do not understand the fact that treating an eating disorder is a long process and therefore may take a long time.” (5)
Limitations of the study
The intention of this study was to recruit 10 homeopaths. This would still comprise a small sample, but unfortunately the method in the ideal world was not realized in the real world, which made the sample even smaller, comprised only of 6 homeopaths. This study does not claim to be representative of the sample or the results. It is an exploratory study of homeopaths’ experience with the treatment of a much neglected group of patients not previously addressed by research in homeopathy. The difficulties of access and the lack of previous research to build on are therefore major justifications for using a qualitative method in this study (Flick, 2007a).
So why is it such a challenging area to investigate? Perhaps this is reflected in the disorders themselves. Eating disorders are surrounded by taboos, controversies and a general aversion to being involved. As discussed in the text below, it may be that patients do not seek homeopathic treatment for these disorders, in which case there are not enough homeopaths with the required expertise, which actually then reflects an entirely different limitation of the study, as it is also impossible to answer that question. Another reason may be that homeopaths are not familiar with scientific trials, so they may decide not to take part.
Certain aspects of the findings were limited, as in order to get the answers, it would actually be necessary to ask the patients with the eating disorders themselves. It was, however, necessary first of all to form a general view of the area in order to know what to do next.
The findings in the study seem to indicate certain consistencies that clearly warrant further research in the area.
On the basis of the findings, there are certain consistencies that are clear, although the findings are based on a small sample. It is important to note although describing application to practice; “These hypotheses are probability statements, not facts that are verified. Grounded theory is not verificational” (Glaser, 1992 P. 29).
The findings show that it is necessary for homeopaths to distinguish between eating disorders of long standing and those of short term. Those of short term have different implications in that they are often easier to deal with or homeopathy may even be preventive. Those disorders of long standing have far-reaching implications in practice in that an in-depth knowledge of eating disorders in general is necessary as well as of the therapeutic relationship in particular. Managing this group of patients is different from other patient groups and it asks of the homeopath to be very aware of her own boundaries and limitations. The first criterion for effective treatment is the patient choice, and in order to achieve a successful outcome with these patients, the patients need to be willing to commit to the treatment and engage in the process.
Furthermore, dealing with maintaining causes and relapses can be challenging and homeopaths need to have an awareness of the socio/cultural contexts affecting patients with eating disorders, and be able to assist in the management of triggers and relapses.
Conclusion and recommendations
The main aim of this study was to explore the views of homeopaths about their experience and treatment of patients with eating disorders such as anorexia and bulimia. The intention was to reveal the challenges, outcomes and pitfalls when working with patients with an eating disorder.
The primary objective was to determine whether homeopaths found homeopathy effective in treating the whole person; mentally, emotionally as well as physically. Despite the limitations of the study such as access, only 6 homeopaths participated in the study, and lack of previous research, the findings seem to indicate certain consistencies that clearly warrant further research. The researcher believes she has met the aims and objectives, but in order to be validated the study would need to be repeated with a larger sample and perhaps in other countries.
The literature review reveals tensions and contrasts regarding the subject of eating disorders that are highlighted and substantiated by the findings in this study. It is evident that the treatment of eating disorders is influenced by the attitude taken towards the disorders.
The patients themselves seem to regard the disorders as an externalisation of existential suffering, whereas the help they get in conventional terms seems to spring from a treatment based on the attitude that the disorders have to do with erroneous diets and bad habits, in this way reinforcing the vicious circle of the disorders and resulting in a tension between the patients’ understanding of themselves and the ensuing treatment. In this context the literature review also disclosed a possible manipulation of information which may influence patient choice.
The findings suggest that homeopaths distinguish between eating disorders of long standing and short term, that is to say subclinical eating disorders. The latter group includes patients who had just been diagnosed, or patients who had not yet realized they had a problem. Eating disorders of short term duration are often easier to treat and resolved fairly easily. In some cases homeopathy may even be preventive. Long standing disorders have far-reaching implications in practice. In-depth knowledge of eating disorders in general is necessary as well as knowledge of the therapeutic relationship in particular.
The first criterion for effective treatment seems to be the patient choice and the skill is to make the patient realize that in order to achieve a successful outcome, she needs to be willing to commit to the treatment and engage in the process.
Managing this group of patients is different from other patient groups. Often they need more time and support. Therefore it asks of the homeopath to be very aware of her own boundaries and limitations. This put emphasis on the significance of the therapeutic relationship.
In-depth knowledge of the socio/cultural contexts affecting patients with eating disorders appears to be important in order to be able to detect maintaining causes and assist in the management of triggers and relapses.
Moreover, the findings show that homeopathy has an effect on all levels; mentally, emotionally as well as physically, which means that homeopathy has no difficulty in combining the physical side of the disorder with the mental aspect of it, and therefore offers a more complete form of therapy than any other type of treatment. The findings indicate, that by concentrating on the underlying reasons the eating disorder appeared in the first place, addressing the central disturbance and aetiology, homeopaths in actual fact connect with the patients, building an honest mutual therapeutic relationship so that the patients stick with the treatment.
As well as recommending further research in the area of eating disorders, it is hoped that this study provides new information that will stimulate the development of further education in homeopathy, especially in relation to the therapeutic relationship.
Dissemination of information to the general public is recommended in relation to the homeopathic process in eating disorders, including what to expect and how best to deal with difficult situations, triggers and relapses.