Occupational Therapy for Eating Disorders: The Indian Context

An eating disorder is defined by abnormal eating habits, which negatively affect a person's physical and mental health. These mainly include: Anorexia nervosa, Bulimia nervosa, binge eating disorders, Pica, Rumination disorder and Avoidant/restrictive food intake disorder (AFRID).

Aside from our culture and diversity, we Indians are definitely passionate about our food. Food and eating, in the Indian context, is not just a simple ADL, because we place great value on food. It is a multifaceted medium of socialising, showing love, respect and can act as an ice-breaker. If you want to make friends on the first day of school, just share your dabba (lunchbox) with someone and suddenly you are best friends! If your mother wants to apologise to you she won’t say it, but she’ll make you your favourite dish (kheer)! It is almost an alternate form of communication for us.

Therefore, the problems associated with food, eating and body image are also multidimensional:
 

 For many people with eating disorders, extreme behaviours are an unhealthy means of coping - often with a lack of control. In the Indian context, the parenting style is such that there is over-involvement in every aspect of the child’s life. Whether it is the clothes they wear, the careers they choose, the places they go, every decision is made unanimously. Thus the child may feel a lack of control and autonomy over their own lives and try to gain it through other means, often in the form of controlling food intake and eating habits.
 

 In India we are not unfamiliar to the snide comments and taunts that our relatives pass very freely, on our body and at every social occasion. Things like, ”Oh Beta, you’ve put on so much weight in the 10th standard, you should go to the gym”, or “Why don’t you start dieting or eating less?” A child who has an eating disorder in such a socio-cultural context, might actually go unnoticed - and in fact be praised or complimented on losing weight - which might, in turn, reinforce their behaviours. This mental health disorder may therefore not get detected until they fall extremely ill. Thus, in India, cases often don’t get reported as much, because they go unseen most of the time. Additionally, there is a general lack of public awareness about such a disorder even existing!

Indian children are subjected to a lot of academic pressure in school, as well as from their parents. We are expected to participate in a plethora of extra-curricular activities, as well as keep our grades up from a very young age. As we grow older, these expectations shift to learning skills, manners and looking a certain way, to be eligible to get married. Women are subjected to these pressures more often when they reach an age that they are expected to marry. Cultural norms suggest that they should diet, lose weight and cook well, so they can be the 'ideal wife'. All these pressures of being a perfect or 'model' child are a very obvious precursor to eating disorders.

As I mentioned, food is such an intrinsic part of our social experiences. When we go to a relative’s house for Diwali they offer us food; we MUST eat it because, if we don’t, it is a sign of disrespect. Even at home, most Indian mothers think that their child is only completely cared for if he/she eats well. When you don’t eat one dish, your mother might make something you like, just to ensure that you’ve eaten well! Thus, rejecting food is always a conflict between not eating foods that you might think are not good for you and disrespecting an elder. This may cause a lot of internal turmoil, since we are always taught to respect our elders and not refuse food as guests in someone’s home. [1]

The goal of an occupational therapist is to return an individual to their original occupation-based quality of life, with as much independence as possible. Eating disorders impact:

They are also influenced by socio-cultural contexts, such as related to family and peers [2]. Occupational Therapists specialise in analysing complex and multi-faceted performance areas, in order to identify and address occupational performance needs. We focus on that which the client values; we call this an holistic approach.

In India, the team of people treating this disorder usually includes a psychiatrist, psychologist, physician, nutritionist, behaviour/CBT therapist, family therapist and maybe a social worker.
 
 The commonly used assessment scales are:

Occupational therapists are not usually considered as important contributors -
 but we should be!

People with eating disorders have an imbalanced lifestyle. For example, they may not be able to engage in age-appropriate leisure activities, like going to the movies with friends, due his/her disorder. They may not be able to engage in their normal work roles due to constant pre-occupation with food and body image.

Occupational Therapists can improve a person’s volition to change behaviour patterns, through participation in meaningful activities. Through engaging in valued occupations, we tend to make better choices in other performance areas, developing better coping strategies and recognising the link between mental health, physical health, quality of life and wellness.

A generalised treatment plan can cause patients to lose their identity and identify with a diagnosis. Occupational therapists can help individuals engage in health-promoting, meaningful occupations, that help them regain their sense of self.
 

Therapeutic activities

The fostering of different forms of self-expression does have a place in the treatment of anorexia nervosa. In India, I have observed that dance, music and art are a huge part of self-expression. Parents encourage their children to learn multiple classical dance forms, like Kathak, Bharatanatyam or even freestyle and contemporary. Indian classical music, playing instruments or painting and drawing are also encouraged from a young age. These can be used to guide therapeutic intervention based on the child’s interest, helping to express areas such as 'how I see myself' or 'what I feel like after a meal.' These occupations can be used as a coping strategy when someone feels overwhelmed with anxiety or fear.

Image: Jenna Simons expresses her struggle with eating disorder through her sketches.

Functional or occupation-based activities

Clothes shopping: In the Indian scenario, activities such as going clothes shopping can be very stressful for a teenager who goes shopping with her mother, even at the age of 17 or 18. Her mother may pick out the 'appropriate' clothes for her although she might want to dress in unisex t-shirts. Someone going shopping for the first time, after being in treatment for a while, may require support to be able to experience their new body without having anxiety.
 

Across different states and cultures, dressing styles and norms vary. However, the need for self-expression and confidence in what you wear remains the same! Like choosing to wear jeans after wearing kurta’s for your whole life, it can feel so empowering and help clients find their individuality.

Food management: If you are a teenager, you are not responsible for cooking your own meals, however you can decide your likes and dislikes with the therapist and your parents. Behaviour contracting is a good way to get the individual to take responsibility of managing food. This can include going grocery shopping with parents, or deciding which sabji’s you will eat in your lunchbox everyday. Additionally, identifying fixed daily consumption levels can support behaviour change. All these can be suggested by the therapist and made into a written contract, in return for something the child may demand (such as going to a party). A lot of adults who live alone may not be independent in cooking meals and may rely on take-out or instant noodles, or may just skip meals and survive on a liquid diet. These can be unhealthy eating habits, which can be changed by encouraging a meal plan, going grocery shopping and helping skill development in meal preparation. [3]

Time management: If you are an Indian child you probably have activities scheduled all day, from school/college, to tuitions and extra-curricular classes. It can be difficult, but the therapist must encourage the child to set their own timetable, scheduling leisure activities and time to relax, meditate or just watch some TV. (Sunday’s are not the only days meant for relaxing; you can incorporate it into your daily schedule!)

Education and awareness about eating disorders among families and the wider public is crucial, especially due to increased 'Westernisation of trends' in the urban Indian cities.
 

Parents whose children refuse to eat or show compulsive rituals - such as hiding, throwing food or lying - may find their behaviours disrespectful, rather than seeing them as a warning sign.

It is important to make parents aware that these behaviours are due to distorted thinking patterns and the rules that a person with eating disorders makes for themselves. Indian parents can almost immediately resort to shouting and punishing, without trying to have a conversation about the problem. They may also make casual jokes about the child’s weight, which may negatively impact their mental health. Occupational therapists can also educate parents, supporting them to change their style of communication and be be mindful of the comments that they make around weight and eating habits.

Image: Illustrator and photographer Rajshree Saraf throws light on Anorexia. This widespread eating disorder is often a result of social conditioning and flawed ideas of beauty. She portrays the everyday struggles of an anorexic being.

Family Based Approach: Interviewing and observing family dynamics and inter-personal relationships in a group session or during meal times is essential, in order to understand the context of eating patterns. Meal times in India usually see certain cultural patterns or norms followed: children live with not only grandparents but also aunts, uncles and cousins. The whole family is expected to eat together, or elders/men of the house may eat before the others. Conversations around the dinner table may also be dominated by the elders, as well as dictation of what to eat or how much to eat. The environment created during meal times is very important for individuals with eating disorders. Negative experiences, like being forced to eat, or shouted at for ritualistic behaviours like breaking food, dragging out meals or hiding food, may actually increase the behaviours.
 

Therapists should examine these aspects and try to make mealtimes a positive experience in the family home. For example, allowing the child to choose what they would like to eat and not forcing them to eat certain fixed quantities.

Having an eating disorder can isolate you from a variety of experiences, such as attending family gatherings, managing a healthy relationship with physical activity and participating in mealtimes. A balanced lifestyle involves paying attention to all performance areas of occupation.
 

Self care: Includes engaging in self-nurturing behaviours, such as a balanced exercise routine, mindful eating and a healthy diet (decided by nutritionist) and adequate sleep.
 

Work and productivity: An eating disorder can interfere and completely disrupt your life. If the disorder is causing absenteeism from work, an occupational therapists can help clients through time management and motivational interviewing, in order to improve volition. Coping strategies, such as goal setting and planning, can encourage a change in behaviours. Additionally, developing routines and habits can also help the individual get back on track and engage in work/educational roles. [4]
 

Leisure: For a lot of people with eating disorders, this can be confused with exercising. Together with the therapist, a client can explore various opportunities in the community for engaging in recreational activities. At the community level in India, sports (e.g. squash, badminton, tennis, swimming, yoga) and other activities (e.g. a dance class, book club, playing an instrument) are available almost everywhere. Additionally, the therapist can encourage social participation in the community, by going to picnics, movies and restaurants with friends or family. [5]
 

These not only act as a distraction but also allow the person to engage in enjoyable activities, instead of exercising vigorously.

Behaviour strategies
 Although mainly the domain of a behaviour therapist, occupational therapists can reinforce these strategies in daily living at home. Examples of communication strategies to use with anorexic/bulimic patients include: "Don't eat or drink other than in the company of others and "Decide what is to be eaten before beginning to eat." In addition, engaging in behaviour that conflicts with binging may also be useful, such as meditating at the time binging is most likely to occur.

 For adults who live alone, it might be suggested that they live with a friend or talk to someone at work, in order to help them monitor their behaviour.

 Stress Management

Through trial and error, it is important for each individual to find out what works best for them. Some ideas:

 Group therapy is such an integral part of treatment. Unfortunately there are only a handful of centres in India that provide in-patient or group therapy. Some are present in Goa, Bangalore, Pune and Mumbai, but awareness of the existence of such group services is very limited among the population. [6]
 

Social groups

Social outings with other patients, to the mall, movie theatre or restaurants, gradually encourages the person to eat in a public place, whilst also providing support. These can be later translated to eating with family and friends.

 Communication groups (support groups, like Over-eaters Anonymous)

These type of groups involve talking about feelings, progress made and practical solutions. Talking about societal norms regarding 'thin idealisation' and how people negatively perceive their bodies can also be helpful. I find that there are very few support groups in India, most of which people are unaware of!

 Psychodrama and role play groups

These are important for examining complex inter-personal relationships, especially in families where individuals might feel suppressed or lacking control over important decisions in their lives. Role play involves playing out scenarios and practicing assertiveness; this can be helpful in managing socio-cultural differences in eating.

To have a better understanding of eating disorders, I would suggest you watch To the bone (on Netflix). It is an informative movie, that shows an inpatient treatment program which has been adapted for clients of many age groups. Also check out I am Maris, a Netflix documentary that highlights the same issue.

I find the role of Occupational Therapy to be essential in treatment of eating disorders. This is an attempt to increase awareness of what we do and how we can help! Treating teams should definitely consider including an Occupational Therapist as a team member, for an holistic treatment approach.

[1] https://theswaddle.com/cultural-risk-factors-of-eating-disorders-in-india/

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657488/

(Eating disorders: Prevalence in the student population of Mysore, South India)

[3] https://ajot.aota.org/article.aspx?articleid=1885234

Anorexia Nervosa and Bulimia: An Activity-Oriented Approach by Gordon Muir Giles

[4] https://www.nationaleatingdisorders.org/blog/treating-eating-disorders-occupational-therapy-approach

[5] https://covalentcareers.com/resources/occupational-therapy-eating-disorders-bridging-gap/
 [6] https://www.eatingdisorderhope.com/treatment-for-eating-disorders/international/india

[7] Willard 8th Edition

[8] Occupational therapy in Psychiatry and mental health, Crouch and Alers, 5th Edition

Additional references: