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Canadian Journal of Occupational Therapy February 2012 79(1) 15
Michelle L. Elliot
Figured world of eating disorders: Occupations of illness
Key words
Eating disorders
Figured world
Illness
Meaning
Occupation
Mots clés
Maladie
Monde guré
Occupation
Sens
Troubles de l’alimentation
Abstract
Background. The biomedical diagnosis of eating disorders signies a mental
illness with complex physical symptomology. The socio-cultural determinants and
impact of eating disorders on daily occupations are not adequately addressed in
this classication. Purpose. This paper introduces the concept of a gured world
as a framework for how eating disorders exist in daily activity and social discourse.
How occupations become ascribed with meaning generated by an eating disorder
will be proposed through the voice of a composite character in the gured world.
Key Issues. Central elements to contextualizing gured worlds include positional
identity, self-authoring, and semiotic mediation. The generation of meaning in
illness arises from the integration of these elements into this specic gured world.
Implications. The competing agendas of the biomedical model and gured
world permit a new understanding of the challenges associated with recovery. For
occupational therapists, these challenges require the reattribution of meaning of
daily occupations.
Abrégé
Description. Le diagnostic biomédical d’un trouble de l’alimentation est une
maladie mentale accompagnée d’une symptomologie physique complexe.
Toutefois, les déterminants socioculturels et l’impact des troubles de l’alimentation
sur les occupations quotidiennes ne sont pas abordés adéquatement dans cette
classication. But. Cet article utilise le concept du monde guré comme cadre pour
décrire comment les troubles de l’alimentation se manifestent dans les activités
quotidiennes et le discours social. La façon dont on attribue un sens aux occupations
en raison d’un trouble de l’alimentation sera proposée par l’intermédiaire de la voix
d’un personnage composite dans le monde guré. Questions clés. Les éléments
centraux pour contextualiser les mondes gurés sont : l’identité positionnelle,
l’autocréation et la médiation sémiotique. La création de sens face à une maladie
provient de l’intégration de ces éléments dans ce monde guré spécique.
Conséquences. Les programmes concurrentiels du modèle biomédical et du monde
guré favorisent une nouvelle compréhension des dés associés au rétablissement.
Pour les ergothérapeutes, ces dés exigent la réattribution d’un sens aux occupations
quotidiennes.
© CAOT PUBLICATIONS ACE
Michelle L. Elliot, MScOT, OT(C),
Doctoral student, University of
Southern California, Division of
Occupational Science and Occupational
Therapy, 1540 Alcazar Street, CHP – 133,
Los Angeles, CA, 90089-9003.
Telephone: +1-626-807-9374.
Email: mlelliot@usc.edu
Citation: Elliot, M. L. (2012). Figured world
of eating disorders: Occupations of illness.
Canadian Journal of Occupational Therapy,
79, 15-22. doi: 10.2182/cjot.2012.79.1.3
Submitted: April 5, 2011;
Final acceptance: November 10, 2011.
The author received no funding for this
study.
This paper extends the boundaries of the traditional biomedical model of eat-
ing disorders through the introduction of a “gured” or “lived” world frame-
work (Holland, Cain, Lachicotte, & Skinner, 1998; Holland & Skinner, 1997).
e terms “gured” and “lived” world will be used interchangeably throughout
this paper because not only do they imply the lived experience, but also that lived
experience gures in a socio-culturally constructed manner (Holland & Skinner,
1997). In this gured world framework, a basic assumption is that eating disorder/
illness behaviours, thoughts, occupations, and resulting identities are appropriated
and supported in a manner not fully captured by the medical model. e paper
will begin with the introduction of the normative biomedical perspective of eating
disorders, and then this perspective will be contrasted with the co-existing, yet com-
peting, discourse from the gured world of eating disorders. is will be followed
Elliot
16 Revue canadienne d’ergothérapie février 2012 79(1)
by thoughts condemning her weaknesses and failures. Despite
exhaustion, she will put on her shoes and go running into
the night to escape these negative cognitions. She eats noth-
ing but fat-free yogurt and drinks countless cups of coee the
following day as penance for her previous diet transgressions.
Anne will return to the oce prepared for the day’s agenda
and to continue the cycle of her dual realities. When asked if
she is happy with her life, Anne characteristically just smiles.
She speaks to her position and the opportunities it aords her.
en with the grace and charm of one in the communication
business, she seamlessly changes the subject.
Competing Discourse
Within the eating disorder–gured world proposed in this
paper, there is a competing discourse. e more familiar rep-
resentation of the medical perspective of eating disorders as
illness will be introduced rst, followed by the gured world
perspective of eating disorders as a normative aspect of life.
Medical Perspective
e American Psychiatric Association’s (APA) Diagnostic and
Statistical Manual of Mental Disorders (2010) denes eating
disorders within the categories of anorexia nervosa, bulimia
nervosa, binge eating disorder, and other specied feeding or
eating disorders. is paper will include references to anorexia
nervosa and bulimia nervosa (herein referred to as anorexia
and bulimia), though all of the classications exist within the
proposed gured world. Hallmark features of anorexia are sig-
nicantly low body weight, a fear of subsequent weight gain,
and endorsement of means to maintain a restrictive intake of
food (APA, 2010). Bulimia is characterized by regular patterns
of binge-eating behaviours followed by compensatory mea-
sures to eliminate the food (purge), without the corresponding
low body weight (Treasure, Claudino, & Zucker, 2010).
Eating disorders result from the complex interplay of
physiological, psychological, and sociological forces produc-
ing cognitive distortions and conicted interpersonal relation-
ships (Cockell, Geller, & Linden, 2003). ey are also strongly
correlated with the creation of a disordered lifestyle (Lock,
2000). e multiplicity of variables aecting and being inu-
enced by the illness and the high rate of relapse complicate the
ability to denitively conclude rates of “successful recovery”
(Wilson, 2005). Living with an eating disorder as opposed to
recovering from it thus becomes a reality.
Many people with eating disorders struggle to fully cope
with daily activities, whether they be grocery shopping, orga-
nizing time, or managing the demands of work or school (Lock,
2000). e chronicity of the illness (Holliday, Wall, Treasure,
& Weinman, 2005; Steinhausen, 2002), particularly anorexia,
infuses the daily occupations through the meanings ascribed
to the activities structuring the day, and it becomes the lens
through which the world is seen. Essentially, the meaning
associated with engagement in everyday occupations becomes
enveloped within eating disorder behaviours and cognitions.
e construction of this meaning is an essential element in the
propagation of the gured world of eating disorders.
by a discussion of the way in which daily occupations become
subsumed into the eating disorder through three theoretical
concepts of gured worlds: positional identities, self-author-
ing, and semiotic mediation. Implications for occupational
therapy practice using the conceptualization of illness-derived
meaning in occupation will be acknowledged. e character
of Anne, a representative member of this gured world, is
introduced as the voice of the paper. She is an amalgamation
of the many stories and personally constructed narratives that
exist and were witnessed by the author in an eating disorder
treatment setting. Using this composite voice aords Anne the
cumulative attributes to fully illustrate the theoretical-gured
world concepts being introduced without adding the complex-
ity of concurrent background stories. Bruner (1990) claimed
that the signicance of the narrative matters not in whether it
is real or imagined. ough the individual character of Anne
may not be real, her narrative is real because of the multiple
truths and voices it represents.
Looks Can Be Deceiving
Anne is a tall, slim woman with a thoughtfully cultivated sense
of style. She works in a downtown oce as a manager of a per-
sonal relations company, servicing many corporate contracts.
She is single; her small circle of friends joke that she is married
to her work as she rarely dates, though privately, she yearns for
companionship. Long days at the oce mixed with aer-hour
work functions prevent her from establishing her new house
with the warmth and decorative appeal that makes a house a
home. Anne’s strong and dedicated work ethic, drawn from
the desire to achieve the success she and her parents always
envisioned, has contributed to her securing this managerial
position. Anne’s life, from an outsider’s perspective, appears
successful. is has come at a cost, for she has sacriced per-
sonal relationships and opportunities, developing a lifestyle
not conducive to wellness or balance.
Since her later years of high school, when she felt like
an outsider who belonged everywhere and nowhere, Anne
has struggled. She did not seem to meet the criteria for any
one socially constructed peer group, and consequently she felt
powerless to change her perceived lot in high school life. In
response to the disconnection she felt equally from her class-
mates and her own self-worth, Anne sought means to assert
control. Cultivating her own pursuit of perfection, Anne
excelled academically. She took up running almost as a disci-
pline and became a strict vegetarian, believing it was a means
to live more ethically. She counted calories and weighed her-
self daily. Her parents assumed it was a phase, something that
most girls grew out of. Anne never did, for she still engages in
these behaviours today, many years later. Anne has an eating
disorder.
She takes pride in her ability to exercise self-control at the
functions she attends, where food and drink are readily avail-
able. Recently, however, Anne has begun keeping chocolates
in her desk drawer, which she consumes prior to these events
or in response to particularly stressful encounters. e oce
bathroom is a single room, which aords her the privacy to
vomit in secret aer eating from this illicit cache of food. Going
home to a dark and empty house, Anne is oen immobilized
Elliot
Canadian Journal of Occupational Therapy February 2012 79(1) 17
ates a gured world from these other conceived realities are the
symbolism, meanings, interpretations, and identity generation
that emerge from the interaction of members with the associ-
ated occupations, objects, spaces, and fellow members. Cain
(1991) and Holland et al. (1998) provide a detailed account
of Alcoholics Anonymous to exemplify the symbolic dimen-
sion of the gured world construct. e process of attributing
meaning to occupations occurring in the eating disorder–g-
ured world will be introduced in the next section.
“Doing” in the Figured World
Christiansen and Townsend (2010) broadly dened occupa-
tion as the daily and active pursuits from which signicance,
meaning, and purpose are attributed to life. In other words,
meaning is created through the participation and process of
engagement rather than being inherent in the activity itself
(Bruner, 1990; Singlehurst, Corrs, Griths, & Beaulieu, 2007).
is connection between meaning and occupation can be
translated to eating disorder behaviours as understood in the
proposed gured world.
Concluding their studies on the meaning of self-star-
vation, Nordbo, Espeset, Gulliksen, and Skarderud (2006)
determined that the symptomatic behaviours of eating disor-
der illness develop personal meaning and signicance for the
individual with the illness. ese behaviours include restrict-
ing, binging, or purging. Using Christiansen and Townsend’s
(2010) denition of occupation, these diagnostically sig-
nicant behaviours could be dened as occupation; they are
meaningful, purposeful, and structure the daily routines in
the eating disorder–gured world. To make such a statement
challenges the implicit assumption in the denition that mean-
ing in occupation is health promoting and life arming. Kan-
tartzis and Molineux (2011) argue the need for understanding
and situating occupation within “alternate constructions of
daily life” (p. 62), thus further challenging the traditional con-
ceptualization of occupation.
is paper introduces the idea of illness-directed mean-
ing and illness occupation, using gured world as an exem-
plar of the “alternate life construction,” by translating Jackson’s
(1998) concept of complementarity poles to occupation. Jack-
son suggested that the broad understanding of a term can
remain consistent across a continuum of representations. For
example, the healthy, engaged experience of an occupation
exists at one pole, contrasted with the other pole, whereby the
same occupation exists in the gured world and is reinforced
with illness-focused meaning. Alternatively, occupations
emergent within the eating disorder experience itself, includ-
ing binging, purging, or restricting, also exist along the contin-
uum. eir positioning in proximity to the poles is dependent
upon which competing discourse is most dominant, as will be
discussed shortly.
Occupations associated with daily living, such as cook-
ing, working, shopping, exercising, and grooming, can become
enveloped within the eating disorder (Lock, 2000). In the
gured world, everyday occupations that previously held a
neutral aliation aord space for eating disorder inuences
to emerge. Consequently, the meaning ascribed to such occu-
Figured World
Anne’s doctor is concerned for he believes, and has shared with
her, that she endorses symptoms of a subtype of anorexia and
encourages her to seek therapeutic support. Anne does not
perceive herself as having an eating disorder, though. To her it
is simply a way of life rather than an illness, granted a life that
possesses many layers of restriction. e rigid eating patterns,
cognitive distortions, and perfectionist determination con-
tribute not to a symptomatically diagnosed problem, but to a
self-identied way of participating in her life. e perspectives
of illness (biomedical) and identity (gured world) co-exist,
although through a competing discourse.
As social and cultural constructions, gured worlds are
conceived to exist through the practices and interactions of
collective groups of people, in variable environments, and with
a range of symbolically derived artifacts (Holland et al., 1998).
A gured world is conceptualized as an “as if ” realm in which
the social interaction or engagement in daily events creates
symbolic, imagined, and culturally determined signicance
(Holland et al., 1998). e “as if ” potential of a gured world
indicates that, while people are participating in their everyday
lives, they may be doing so concurrently engaged in a world
with a specic interpretive dimension. In the gured world of
eating disorders, members live as if the diagnostic symptomol-
ogy were merely one part of their daily existence and, thus, not
entirely outside the realm of “normalcy.” ere is an important
mediational element to the development of gured worlds and,
thus, this interpretive lens by which life is perceived is real-
ized through the interaction of objects, rituals, traditions, and
occupational and interpersonal roles of members (Holland &
Skinner, 1997). Entrance into or exit from a gured world for
an individual may be determined by his or her socially con-
structed position and personally generated narrative, both of
which contribute to the formation of personal identity within
this world. e fundamental elements of social position and
personal identity will be more fully discussed in later sections.
e classroom serves as a representative example of a g-
ured world that many people have experienced. In general, a
classroom is conceived as a space in which knowledge dissemi-
nation and reception occurs. As a gured world, the classroom
is a structured environment where cultural norms and rules
are generated, contributing to the formation of student and
teacher identities. e artifacts signifying a classroom include
blackboards, desks, and books. ese objects are neutral out-
side the classroom; however, in this gured world they assume
the symbolic meaning of tools for learning, which is under-
stood by all members. e social construction of the class-
room ensures that members of this gured world, teachers and
students, actively participate in the creation and maintenance
of social norms, etiquette, and hierarchy. Occupations inher-
ent in the classroom, such as teaching, studying, and playing
become associated with the meaning the classroom-gured
world aords.
e boundaries of a gured world are not conned to
concrete, physical space as implied in the classroom example.
Figured worlds are not necessarily represented in every occu-
pational context or associated with dierent roles that people
play in the course of their daily lives. Rather, what dierenti-
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18 Revue canadienne d’ergothérapie février 2012 79(1)
a diagnosis and collection of occupations is seen by those with
eating disorders as more socially acceptable, requiring greater
commitment, control and strength than bulimia (Brooks,
LeCouteur, & Hepworth, 1998). e occupations Anne dem-
onstrates as symptomatic of anorexia include overexercising
and restrictive eating. She does occasionally binge eat and
purge; however, she has concealed that aspect of her identity,
fearing it would cast a negative light on her perceived compe-
tency in the workplace. Such occupations would also lower her
esteemed position within the anorexia domain of this gured
world (Brooks et al., 1998; Broussard, 2006; Rich, 2006). In
maintaining this social position, there is a signicant amount
of occupational engagement and time consumed: exercising,
counting calories, comparing herself to others, deception, and
planning how and when she might exercise or eat (Patching &
Lawlor, 2009). Eating disorder–specic occupations thus exist
within the complementarity poles, though their positions are
dependent upon their hierarchical nature.
A caveat to this representation of eating disorder occupa-
tions, specically those regarding exercise and weight manage-
ment, is that outside the gured world these are normalized.
Advertising and media representations (Bishop, 2001), as well
as health literature (Healthy People, 2010), support engage-
ment in healthy eating and exercise for optimal well-being.
How this message is interpreted is where the dierence lies:
in one lived world, these are strongly encouraged methods to
be and stay healthy; in this gured world, they become edicts
and endorsements for furthering the eating disorder. Such a
distinction reects the same occupations as existing in the
complementarity poles of meaning interpretation.
Anne also takes pride in her inuential managerial posi-
tion. Her morning routine entails a meticulous grooming
regime, consistent with the self-care occupations of people
with eating disorders (Gardiner & Brown, 2010). Anne tries
on multiple outts before selecting the one which she believes
makes her look the least fat. She believes that how she looks is
a reection of how she does her job, and so feels tremendous
pressure to appear as though she is worthy of her executive
position. Anne’s ability to succeed in this managerial role has
required her to battle the defeating thoughts which dominate
her inner world. oughts of being incompetent, useless, stu-
pid, and fat are a daily reminder of the cognitive distortions
associated with the illness (Cockell et al., 2003). In her pro-
fessional circle, Anne assumes an occupational position of
authority; in the gured world, this high social status is gar-
nered by the eating disorder, leaving Anne in an emotionally
subservient position (Patching & Lawlor, 2009; Weaver, Wuest,
& Ciliska, 2005). e tension imbued in the disparate social
positions contributes to the creation of Anne’s sense of herself
in the gured world. Her personal narrative is also the prod-
uct of the interrelational negotiation occurring in the social
environments.
Self-authoring
Self-authoring is the process of creating one’s own personal
identity through the appropriation of relevant social discourse
(Holland et al., 1998). By navigating through multiple and
pations goes beyond the scope of productivity, self-care, or
leisure (Kantartzis & Molineux, 2011). ey exist at one end
of the complementarity pole, where the meanings of certain
occupations become associated with the negative and punitive
elements of the eating disorder. In this gured world, cook-
ing may become an occupation in which foods are carefully
weighed, fats are excluded, or recipes are modied. e sin-
gle occupation of cooking invokes a multiplicity of meaning,
much of which is guided by eating disorder cognitions. Further
examples of occupations from Anne’s life, specically shop-
ping and running, will be discussed in subsequent sections.
e derivation of illness-infused meaning from occupa-
tions is a dierent way to understand occupational engage-
ment generally and the occupational challenges of people with
eating disorders more specically. Hasselkus (2002) referred
to occupation as “the vehicle by which life is experienced” (p.
69), a representation from which the meaning associated with
illness experiences can overpower those occupations of daily
living. is meaning becomes the frame of reference from
which occupations are undertaken in the creation of an eating
disorder identity in the gured world. In summary, members
in the gured world of eating disorders actively participate in
both diagnostically identied illness behaviours, herein under-
stood as occupations, and the previously neutral occupations
aligned with illness-derived meaning. Figured worlds exist
through active occupational engagement, but such worlds are
also structured on the pertinent social themes of positional
identities, self-authoring, and semiotic mediation (Holland et
al., 1998). Each of these components will be discussed through
the lens of the eating disorder signicance in Anne’s daily
occupations.
Positional Identity
Identity creation and maintenance in gured worlds is mul-
tifaceted. One aspect is the personal narrative, internally
generated and socially constructed, inherent in the daily
engagement of activity. Another is more nuanced, emerging
from the interrelational domain of social position. Holland et
al. (1998) dened these as positional identities, in which the
expression of self is bounded by the hierarchical and categori-
cal nature of social relations. Positional identities are oen an
implicitly formed outcome of participation in daily activities.
ey emerge as representations of power and privilege, contin-
ually reproduced within the social and cultural construction
of the gured world (Holland et al., 1998). Returning to the
earlier example of the classroom, positional identities develop
from the hierarchy of teacher and student. Neither student nor
teacher may be given explicit instructions as to what role each
plays or the manner in which they play it, and, yet, in class-
rooms this positional identity is regularly reproduced. Reect-
ing on Anne’s life experience in this eating disorder world, she
participates in social environments that contribute to the cre-
ation of a relational sense of self from diering social positions.
One source of pride for Anne is her ability to demonstrate
restraint when eating in public. She also runs regularly and
thus receives the admiration of her colleagues. Within the g-
ured world, Anne assumes an inuential position. Anorexia as
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Canadian Journal of Occupational Therapy February 2012 79(1) 19
ing alongside identity-generating elements. ey are also the
occupations that give shape to her days and which the general
public believes are healthy. Take for example her occupation
of running. In the gured world, Anne runs to purge calories,
to distance herself from the onslaught of negative thoughts, to
relieve her building anxiety, and because the loudest voice she
hears is the one telling her that she “must” (Dignon, Beards-
more, Spain, & Kuan, 2006). It helps her feel special, taking
satisfaction in her ability to do what others cannot (Weaver et
al., 2005), which is to push her body past the point of exhaus-
tion. Outside this gured world, running is a socially accept-
able leisure pursuit oering multiple meanings depending on
personal connection to this occupation (Primeau, 1996). In
both lived worlds, the occupation of running and occupational
identity as a runner appears similar. Yet in self-authoring, the
conventional social discourse (healthy activity) and Anne’s
internal dialogue (punishment and escape) possess diametri-
cally opposed meanings in how she navigates and participates
in this single occupation.
Semiotic Mediation
e previous two constructs pertain to the creation of identity
in gured worlds through social positioning and self-author-
ing. e nal construct discusses the creation of symbolic
meaning for an otherwise neutral object or behaviour, the use
of which is then to aect a dierent subjective experience. is
is referred to as semiotic mediation (Holland et al., 1998). e
acquisition of such symbolic artifacts is through active and
collective engagement in the socially constructed lived world
(Holland et al., 1998). Time and sustained use of these power-
ful objects create symbolic meaning and invite the construction
of a new relationship between self and object. e symbolic
associations to previously neutral artifacts (Rich, 2006) are
strongly present in the gured world of eating disorders.
e weigh scale is generally used to provide basic infor-
mation about a person’s body weight. at same scale in Anne’s
world is the instrument against which her self-worth is mea-
sured. It guides her choice of food and clothing as well as her
occupational decisions for the day—will she join a friend for
lunch or cancel in order to restrict; will she buy that new scarf
she has been eyeing or avoid spending money because she
does not deserve anything new? e scale becomes a symbol
for how eating disorder–driven Anne’s day will be.
Clothing size is also a mediating device incorporated into
the occupation of shopping. It aords a shopper the knowledge
of whether an item is likely to t based on the historical asso-
ciation with that particular item. In the gured world, clothing
size serves a similar role as the scale, though it too has a histor-
ical element. Anne will not buy any item of clothing if it is not
the size she believes is the “right” one for her. When her own
clothing of that same size no longer ts, this symbolizes either
success (too loose) or failure (too tight) in her eating disor-
der occupations, and she must respond accordingly. Ironically,
Anne likes shopping. She enjoys the aesthetic experiences, the
colors, textures, and opportunity for creatively matching items.
She also enjoys the feeling of being able to slip into the smallest
sizes; a reality she recognizes is not aorded to everyone.
competing voices of perspective, the self is internalized and
expressed with personally signicant characterizations (Asaba,
2005). Holland et al. (1998) conceived that we make meaning
of ourselves through the process of self authoring. is occurs
through the dialogic orchestration of distinct “voices” present
in the social world in concert with our own inner voice. In a
gured world, the creation of personal identity is inuenced
not only by active engagement in ordinary occupations and
social positioning, but also by the interpretation of compet-
ing labels, categories, or inferences made through the gured
world’s collective social discourse. In this paper, that compet-
ing discourse exists between the biomedical perspective of
illness and the normative perspective inherent in the gured
world.
Christiansen (1999) asserted that “one of the most
compelling needs that every human being has is to be able
to express his or her unique identity in a manner that gives
meaning to life” (p. 548). In this gured world, identity is in
part expressed through occupations associated with the eating
disorder, giving rise to meaningful association between behav-
iours, thoughts, and self (Garrett, 1997; Holliday et al., 2005;
Nordbo et al., 2006). When identity is formulated by the illness
experience, without recognition of the distinction between “I
have an illness” and “I am my illness,” meaning may be con-
structed in those occupations that rearm illness identity
(Hannam, 1997).
e traditional medical representation of mental illness
disassociates people from their illness insofar as it claims that
the disease is aecting a person rather than becoming the per-
son (Holland et al., 1998). Eating disorders are a psychiatric
illness and, thus, according to the biomedical opinion voiced
in Holland et al. (1998), separate from the construction of self-
identity. Due to the presence of dialogically opposed views,
the eating disorder literature, imbued with the voices of people
living in the gured world alongside Anne, would disagree.
Matusek and Knudsen (2009) wrote about the “master narra-
tive,” the culturally dominant perspective of the appropriate
ways to experience and behave in the world. Shohet (2007)
referred to this master narrative as originating from the medi-
cal etiological discourse of illness. ere is, however, an alter-
nate master narrative emergent in the illness experience that
also guides and directs behaviour. In the gured world, the
diagnostic label of anorexia may be viewed as a label of power
rather than illness (Garrett, 1996). Yet, in the representation
of eating disorders by popular media, those living with the ill-
ness are referred to as “victims” (Bishop, 2001), perpetuating
the stigmatizing nature of eating disorders under the mental
illness banner (Garrett, 1996). ese oppositional viewpoints
represent the competing voices within the gured world; the
voice of the illness, which is both highly regarded and reec-
tive of its seriousness (Rich, 2006), and the cultural discourse,
which problematizes the illness (Saukko, 2000).
Anne navigates the dual realities both within and outside
the gured world, where contradictory messages impede her
own ability to assert the voice of which she is most innately
connected. If you were to ask Anne which voice that was, the
response would likely be dependent upon the day. Her daily
occupations are infused with eating disorder–derived mean-
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20 Revue canadienne d’ergothérapie février 2012 79(1)
Semiotic mediation is not conned simply to tangible
artifacts in the gured world. e bathroom at Anne’s place
of work retains eating disorder meaning, for this is where she
secretly engages in purging. Consequently it is a daily reminder
of her inability to control herself around food. Anne’s home
also possesses a duality. Her career success has independently
aorded her the opportunity to purchase a beautiful house, yet
the house’s lack of communal warmth embodies her loneliness..
Discussion
is paper has introduced gured worlds as the perspective
from which eating disorders co-exist as both identity generat-
ing and symptomatic of illness. Elements of the gured world
pertaining to identity construction, social discourse, and sym-
bolic meaning have been discussed to support this assertion.
Engagement in illness occupations, cognitive distortions, and
ascription of eating disorder meaning to daily occupations is
reected as the norm in this world. How might an individual
begin to recongure this gured world should meaning no
longer assert its dominant inuence through the eating dis-
order? e following metaphorical reference provides insight
into the challenges recovery entails.
In the lm e Shawshank Redemption, one of the central
characters describes life in prison in such a way as to facili-
tate understanding of gured world. e character Red speaks
about the obstacles facing a newly released Brooks, an older
man who had spent the previous 50 years incarcerated. In jail,
Brooks was an important man, an esteemed and educated
man. He knew how the prison, and his life in it, was socially
and institutionally structured. Beyond the security and pro-
tection aorded by those prison walls though, Brooks was a
“nobody.” He did not possess the basic skills from which to
navigate the fast-paced, oen confusing outside world. His
occupational repertoire and knowledge were ineectual in cre-
ating a sense of freedom; thus, Brooks longed to return to his
familiar connement.
While eating disorders are not prisons in the literal sense,
they can imprison individuals in a gured world. ere are par-
allel realities between Brooks’ world and Anne’s world, includ-
ing the transformation of meaning over time. For Brooks, the
prison walls initially signied incarceration and punishment,
though over time they became the familiar walls of security.
Anne’s proverbial walls of security provided by the eating dis-
order have also been shaped through routine, trust, and time.
Physical and social environments both constrain and support
the propagation of gured worlds. Disconnection does exist
between gured worlds and other lived worlds; thus, the way in
which a person exits the gured world becomes a complicated
process. e personal narrative literature on recovery from an
eating disorder cites a transformative process whereby a new
self is authored (Weaver et al., 2005) and created in the tempo-
rally disjunctive space between past and future selves (Shohet,
2007). Exiting the gured world necessitates the cessation of
eating disorder occupations and transitioning previously held
illness-ascribed meaning toward wellness in daily occupations.
If Anne were to exit the gured world, however, she would
likely not require a vastly dierent occupational prole. She
would need to connect with her current occupations in a new
way, creating a dierent understanding of what those activi-
ties personally represent (Broussard, 2005; Garrett, 1997). In
so doing, she would begin the process of positioning herself
outside the gured world of eating disorders and authoring a
new sense of self as part of the recovery journey.
Implications for Occupational Therapy
To enable the reconguring of the relationship between occu-
pation and meaning, occupational therapists need to extend
this awareness to the assimilation of meaning and illness in
occupation. Traditionally occupational therapy has worked
within the sphere of the medical model, which in the gured
world operates in direct opposition to the life experience of
eating disorder illness. Anne’s transition from this gured
world, should she ever be motivated to seek recovery and
begin to live life in a dierent way, would require the therapeu-
tic partnership to begin the process of: exploration of meaning
construction; environmental, temporal, and social reorganiza-
tion; lifestyle balance; and occupational analysis.
Anne’s ability to begin taking action toward changing
how she engages in her daily occupations is predicated on
her existing motivation, availability of personal supports and
resources, capacity to challenge distorted thoughts, and trust
in the therapeutic relationship. Acknowledging the tension
between leaving the familiarity of the gured world and the
potentially harmful realities of untreated illness requires a sen-
sitive approach. e bridge between the gured world and the
medical/treatment world is heavily traveled with bidirectional
member movement between recovery and relapse. Occupa-
tion is a means by which meaning, identity, and position are
assumed in both worlds; thus, occupational therapists play a
valuable role in navigating the ow of trac across this meta-
phorical bridge.
Conclusion
is paper introduces the gured world, a unique perspective
from which one can conceptualize the occupational experi-
ences of a person with an eating disorder. It is well documented
that meaning and identity are generated through, and trans-
formed by, engagement in occupation. In the gured world,
behaviours symptomatic of eating disorders are occupations,
and previously neutral daily occupations and artifacts become
subsumed into the illness experience. ey all contribute to
the construction of the occupational identity by which a per-
son meaningfully participates in his or her world.
e theoretical frameworks presented here provide a dif-
ferent lens from which to understand the occupational real-
ity of individuals with eating disorders. ey bring a deeper
dimension to understanding the complementarity poles of
meaning in occupation, replete with both illness and wellness
meaning. e gured world also highlights the signicant chal-
lenge that recovery poses, requiring the transformation of the
meaning and foundation on which life has been constructed.
For a therapist working with Anne, understanding her as a
member of a gured world creates a perspective on how illness
has become the meaningful construction for her occupational
Elliot
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experiences. Transitioning out of this gured world requires a
reconstruction of this meaning leading to future possibilities
for self-identication.
Key Messages
• A gured world is an “as if ” realm in which social
interaction in daily activities creates symbolic, imag-
ined, and culturally determined signicance. is
alternate representation of eating disorders reects the
dynamic aspects of identity construction in illness.
• Meaningiscreatedintheoccupations,thoughts,and
behaviours of an eating disorder illness existing in a
gured world.
• e concept of occupation can be understood as
having complementarity poles; the health-arming
potential of occupation existing opposite the illness-
derived meaning in occupation.
Acknowledgments
e author wishes to thank former clients and colleagues.
Sincere thanks are also extended to reviewers of earlier dras
of this work, particularly Mary Lawlor, ScD; Carol Ewashen,
PhD; and Jeanne Jackson, PhD, for their dedicated time and
thoughtful suggestions. is article was written in partial ful-
llment of the author’s requirements for a doctoral degree in
occupational science at the University of Southern California,
Los Angeles, California.
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