Evaluation of Current Research and Suggestions for Future Research

The small sample size was a considerable weakness of this study. There may have been a number of reasons for the difficulties with recruitment, but several of the subthemes may help to explain these difficulties. For example, all participants spoke about their experiences of being rejected or not being taken seriously by others, such as professionals. Many also spoke about feeling ashamed about their eating problems and perhaps felt vulnerable in terms of discussing it with me. Previous research has suggested that individuals experiencing difficulties relate to eating disorders likely to try and hide their issues (Judit et al., 2005;

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Hoek, 1991), which may have impacted on the recruitment. Overall, there seemed to be a reluctance to self-refer for the study amongst the population that the study was aiming to recruit. Interestingly, many women who made contact were currently bulimic and/or had seen a CBT therapist only once or twice to address their eating difficulties. Although they could not be included in the study, the level of interest from individuals, who had not benefited from therapy could indicate that those with unhelpful therapy experiences may be more willing to share their experiences or possibly the number of individuals in this category exceeds those who met the inclusion criteria.

The recruitment of participants heavily relied on a third party to share information about the study, distribute leaflets and encourage individuals to consider taking part. Although the NHS services were inherently positive about the project and supporting me with the recruitment, I observed clinicians’ reluctance to discuss the study with their clients as they had already deemed the clients unsuitable for the study. In many cases this was alleviated by me actively clarifying the research criteria with them, although judging the impact of this is difficult. To me, this process indicated that there was an element of wanting to protect the vulnerable. I am unsure whether it was the clients, who were perceived to require additional gate-keeping or whether the service and the clinicians also felt rather exposed. Statistics show that bulimia is associated with high relapse rates and thus, many clients have to return to services multiple times. It may be that treating such a client group is inherently stressful and also perhaps frustrating. Perhaps maintaining a level of control over the clients by not passing on the information, the clinicians showed their biases towards infantilising the clients by expecting them to make unwise judgements about their ability to take part.

The study also had some considerable strengths. For example, the participants had received treatment in different geographical areas at different points of time. As the study was not connected to any specific organisation, participants may have been able to be more honest in their accounts. This may have contributed to the participants evaluating both strengths and weaknesses of their therapies and therapists during their interviews, and discussing the challenges in relation to accessing and ending treatment. Overall, the study provided novel insights into the area and provided further evidence concerning individuals’ therapy experiences. It also gave a platform to the individuals to discuss and think about an experience that perhaps is often associated with shame and other difficult emotions. It is hoped that this acted as a step towards de-stigmatising eating difficulties. Some potential and actual participants expressed a similar hope as their reason for wanting to take part in the study.

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The findings highlighted various areas of interest that have not previously been investigated in much detail. For example, deviations from the CBT treatment manuals for bulimia may be helpful, as certain types and levels of divergences could have a positive impact on the therapy relationship and the outcome. Also, the role of social support alongside therapy has not been considered in other research examining ED treatments. In relation to the impact of therapists’ physical characteristics on therapy relationships, Fairburn (2008) noted that currently there is very little research concerning this interesting aspect of therapy relationships. Finally, the relationship between CBT or other psychotherapies and identity concerns in eating issues would appear to be an interesting, but also an important area for future research, as it could help to shed more light on the wider reaching impacts of therapy. Also, this type of research would help to evaluate whether therapy interventions focusing on identity concerns would indeed promote positive outcomes to our clients.

Qualitative research studies could discover further information about how clients with eating difficulties engage in therapy. GT would potentially be a useful approach for future studies to be able to build theory frameworks on clients’ experiences. The findings could be utilised to evaluate the current match between the availability and necessity of different interventions for this client group to guide policy making and the development of ED service provision.

Studies employing the Foucauldian discourse analysis (FDA) could examine how clinicians and medical professionals, such as GPs may speak about working clients with eating difficulties. The current study indicated that perceived power dynamics in the relationships between the participants and professionals had an impact on the therapy process both directly and indirectly. Many also spoke about resistance to certain elements of treatment. FDA could be utilised to investigate how language is used to resist those perceived to be in power. Negotiating interventions with the therapist and struggling to their assert own concerns when seeking help or attending therapy were interesting narratives that emerged in the current study. Focusing on the power dynamics between the client and the professionals may provide new insights into the barriers to treatment engagement.

Future qualitative research findings could add to the knowledge base and potentially act as a platform for developing quantitative methods to investigate these areas in larger populations and different groups. Current quantitative methods, such as questionnaires often utilise concepts and terminology that are relevant to CBT, whereas developing measures based on the clients’ reports may gather different type of data. Also, no research to date has considered the timings of drop-out in ED treatments. The current research study highlighted certain stages of CBT-E that clients may find especially distressing. As the attrition rates are

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currently high, investigating the timings of and reasons for drop-out could provide valuable information about the stages that could be considered as high risk.

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