Recovery from Anorexia Nervosa in contemporary Taiwan: A multiple-case qualitative investigation from a cultural-contextual perspective

Abstract

Grounded in a cultural and contextual perspective, the current study examined the lived experiences and the recovery pathways of three Taiwanese women diagnosed with various subtypes of anorexia nervosa, at varying stages of their recovery. Specifically, using a multiple-case qualitative method, this study explored the complex, dynamic interactions of sociocultural factors and forces (i.e., cultural, familial, and societal influences) that impinge upon the three Taiwanese female participants in relation to living with anorexia nervosa in contemporary Taiwan. Data were collected based on in-depth, semi-structured interviews with the participants and relevant written materials and journal entries provided by these participants. The data were first analyzed within each case and then again across all cases. Accordingly, we present the results of the study by illustrating each participant’s story and narrative of struggling with and recovering from anorexia. We then describe three main culturally-related themes that emerged from the cross-case analysis, which pertain specifically to the recovery process of the participants under the East-West ‘biculturalism’ in Taiwan: 1) anorexia as a function of the conflictual bicultural self; 2) recovery as a pathway towards an integrated bicultural self; and 3) the paradoxical roles of Chinese cultural heritage in anorexia and recovery. Findings of the study highlight the role of local cultural factors/forces, including Chinese familism, Confucianism, filial piety, face-saving, gender role prescriptions, biculturalism, Westernization, and self-relation-coordination, in affecting and shaping Taiwanese women’s struggling with anorexia. Implications and recommendations for future research and clinical interventions are discussed.

Keywords

anorexia nervosa (AN)Chinese cultural context multiple case study recovery self-relation coordination Taiwan

Introduction

The rising incidence of anorexia nervosa (AN) in Taiwan has shown it is no longer a “Western culture-bound” syndrome (Lee, 1996; Yeh et al., 2009). Clinically speaking, anorexia nervosa manifests in two major forms, the restricting and the purging subtypes, along with some unspecified or fluid cases (American Psychiatric Association, 2013). In addition to its diverse forms at the symptomological level, multiple studies conducted from Chinese cultural perspectives have revealed multi-faceted, symbolic meanings attached to food refusal among those of Chinese descent. Some of these meanings have been traced to the valorization of slimness and fragility, which is strongly associated with femininity in ancient Chinese history (Leung, Lam, & Chan, 2001); others have identified cultural and historical particularities in the expression of AN in Chinese communities, such as the non-fat phobic type, in which patients’ food restriction appears to be independent of the fear of fatness (Lee, Ho, & Hsu, 1993); still others have attempted to link AN to the recent sociocultural contexts, connecting self-starvation to the developmental issues and crises of the Chinese youth and their families faced with conflictual societal forces in transition (Chan & Ma, 2002; Ma, 2007a).

Although existing literature has suggested multiple symbolic and metaphoric meanings conveyed by AN at the etiological and the phenomenological levels, there is a dearth of research on the lived experiences of Taiwanese individuals who struggle with AN in their home society. This qualitative inquiry aimed to address this gap, by considering the external and the internal cultural forces that impinge on Taiwanese women from an emic (culturally specific) framework. In the current study, we define “Taiwanese/Chinese culture”¹ from the perspective of Han ethnicity, as it is the majority of the Taiwanese population, and from its distinctive Confucian worldview. The Han people in Taiwan are consisted of three ethnic subgroups who migrated from mainland China and settled in Taiwan across different time-point in the Taiwanese history. Specifically, the Hulo and the Hakka people emigrated to Taiwan for economic reasons during the 17th century and the Mainlander group retreated to Taiwan for political reasons after the end of the Chinese civil war in 1949.

Current theoretical and clinical perspectives on anorexia in Chinese societies

In the West, AN is believed to be closely related to the powerful effects of media exposure and the excessive marketing by fashion industries that associate thinness to achievement, autonomy, and happiness (Markey, 2004). In a similar vein, a widely adopted explanation of the increasing prevalence of AN in Chinese societies is the ‘Western acculturation hypothesis’, which links the widespread concern about weight in developing societies to globalized transitions toward increased industrialization, urbanization, mercantilism, and affluence (Lai, 2000). In the process of acculturation, while the outward aspects of a culture or society (e.g., behaviors, life habits, and appearances) may be susceptible to faster changes, the deeply entrenched characteristics (e.g., values and beliefs) may be more resistant to change, creating tensions or conflicts (Berry, 1990).

From this acculturation perspective, the outward aspect of culture change can be linked to Taiwanese women’s identification with the Western ideal of thinness. With the reinforcement of mass media, pop culture, and peer influences, body weight control for Taiwanese women has become socially acceptable, legitimized, and even encouraged (Lee & Lee, 2000; Tseng, Lee, & Lee, 1989). This hypothesis has found support in one longitudinal study (Lee, Ng, Kwok, & Fung, 2010), which revealed an increased incidence of fat-phobia, and body-dissatisfaction, but also reported fewer non-fat phobic AN cases among women in Hong Kong over the past two decades. Further support comes from a cross-regional study (Lee & Lee, 2000), which found a higher prevalence of disordered eating and weight concerns in more urbanized and Westernized regions of Chinese societies.

Despite the complex and multifactorial nature of AN, current mental health practices and treatments of AN in Taiwan are strongly influenced by Western psychodynamic and family therapy approaches² (Chen, 2010). The psychodynamic approach casts AN as the result of an individual’s failure to develop a sense of self due to unresolved intrapsychic conflicts or early childhood traumas (Ogden, 2011). Food refusal is perceived as a deliberate attempt to avoid and reject maturity and femininity (Bachar, 1998) or as a symbolic means to obtain a sense of control under unbearable parental surveillance (Bruch, 2001). The family therapy model conceptualizes AN symptoms as related to a) enmeshment, overprotection, conflict avoidance, and cross-generational conflict (Minuchin, Rosman, & Baker, 2009); b) rigid family beliefs (Stierlin & Weber, 1989); c) inflexible role prescriptions for the anorectic member (White, 1983); and d) a family culture that discourages individuation of its members (Palazzoli, 1985). Both theories assume the underlying dynamic between the patient’s own selfhood/individuality and her family interactions as the main source of conflict that gives rise to AN. Hence, recovery can be achieved by helping clients gain personal independence and autonomy.³ However, the validity of these Western, individualistic assumptions has been challenged by emerging research on concepts and values of selfhood (Ma, Chow, Lee, & La, 2002) and family (Chan & Ma, 2002) specific to the Chinese culture and context, raising questions about their pertinence to understanding AN in Taiwan.

Contextualizing AN in contemporary Taiwanese society

While several previous studies, grounded in the Western family perspective, have identified ‘dysfunctional’ characteristics in local Taiwanese Anorexic families (Wong, 2004; Lin, 2009; Lin, 2010), they have overlooked potential emic aspects of the AN phenomenon associated with the afflicted individuals and their families to identify any unique cultural factors that may influence or contribute to the onset and the maintenance of self-starvation among Chinese patients (Ma, 2007a).

Chinese familism, filial piety, and gender norms

In Confucian societies, family is the fundamental organizing unit and reference point for all social order and relational structures (Kuo, Hsu, & Lai, 2011). As such, the Chinese view of ‘self’ is best defined by the roles and obligations expected of one in response to the relationships with others and to social contexts, as governed by Confucian ethics – a ‘self in relation’ (Ho, 1995). Traditional Chinese women’s social roles and functions are especially rigid, and require being submissive, subordinate, and subjugated to the male authorities in the household (Hwang, 2001). These culturally endorsed values and norms, centering around Chinese familism, pose challenges to Western theories, particular with respect to the pathologization of interdependence and the prescribed role of the anorexic in a family (Minuchin et al., 2009; Palazzoli, 1985).

Interpersonal harmony and saving/earning face

Taiwanese scholars have observed that conflict avoidance for the sake of maintaining family harmony and accord often holds prime importance for ethnic Chinese in responding to social discord (Kuo et al., 2011). Interpersonal conflicts are often managed through the cultural tenet of ‘self-cultivation’ — a process by which individuals intentionally seek to change themselves with the purpose of enhancing their relationships with important others (Hwang, 2009). A self-cultivated person compromises with others to avoid direct conflict and confrontation when personal interests are incompatible with those of others (Hwang, 2009). Such cultural codes governing social behaviors have been observed to be unevenly applied to women compared to men, possibly due to the Confucian ideology that associates femininity with obedience, demureness, and pliability (Evans, 2002). Relatedly, the concept of ‘face’, which refers to an individual’s awareness of their public image from the perspective of relevant social others, holds paramount importance in the Chinese worldview, shaping social behaviors and relationships. Behavioral acts such as ‘saving/earning face’, which refers to the individuals’ intended endeavors to preserve or enhance the public image of themselves and that of the important others, are commonly used as strategies to resolve interpersonal conflicts as well as to honor and glorify the name of one’s kinship group (Hwang & Han, 2010). Accordingly, what is considered a ‘normative’ or ‘healthy’ pattern of family interactions and communication based on Western theories, such as the use of direct, open confrontation, can contravene the Confucian principles of self-cultivation, conflict avoidance, and harmony preservation (Ma, 2008).

The conflictual bicultural self

Despite the deep-seated influences of Chinese traditionalism, modern-day Taiwan and its people are inevitably shaped by forces from the West – a process that forms a contemporary East-West ‘biculturalism’ in Taiwan (Yang, 2003). Relatedly, the concept of ‘bicultural self’ denotes that both the Chinese ‘self in relation’ and the Western ‘individualistic self’ coexist in varying degrees for individuals living in contemporary Taiwanese society (Lu & Yang, 2006). Consequently, for many Taiwanese, the need to develop self-identity, autonomy, and independence rooted in Western individualism often comes into conflict with traditional values of being relational and respecting social hierarchy as prescribed by the Confucian ideology. This cultural conflict, and the associated stress resulting from having to reconcile and negotiate between two sides of the ‘self’, may be another cause of AN among Chinese patients (Lai, 2000). In fact, studies on anorexic cases in Taiwan, Hong Kong, and Mainland China have found food refusal to be a manifestation of struggles between one’s loyalty to parents or family and personal needs for individuality and self-fulfillment (Chan & Ma, 2002; Ma, 2007c; Wong, 2004).

Self-coordination and self-relation coordination

Recently, Chen (2009) proposed the emic concepts of self-coordination and self-relation coordination as psychological mechanisms to explain the way individuals of Chinese descent attempts to reconcile Confucian social ethics and Western individualistic values in order to achieve a balance or a compromise. Self-coordination refers to a complex and dynamic process of adjustment that requires one to actively and consciously engage in cognitive and behavioral adaptive strategies, in an effort to fulfill one’s social and family roles and obligations, while simultaneously keeping an eye out for, and seeking ways to achieve, one’s own personal goals. At the same time, self-relation coordination compels a Chinese person to resolve interpersonal conflicts by recognizing and emphasizing mutual goals and benefits with the other party involved. The two mechanisms, self-coordination (being self-focused), and self-relation coordination (being other-focused), complement each other in synchrony to assist modern Chinese in restoring psychological homeostasis when encountering interpersonal conflicts. Previous studies (Ma, 2007a, 2007c) have hinted that food restriction might be an indirect, yet powerful tool consciously or unconsciously used by the afflicted youth to assert autonomy and to regain some personal control in the midst of an overwhelming family situation dominated by parental expectations and family obligations. Others (Lai, 2000; Lee, 1995) have argued that AN might act as a nonconfrontational way for Chinese patients to expresses their disagreements or protest against the demand for family loyalty and filial piety without outwardly interrupting harmony and compliance. Hence, it stands to reason that AN might be associated to the strong tendency for Chinese women to engage in self-coordination to avoid conflicts. This relationship, however, has not been empirically explored among Taiwanese cases.

Objectives

The current study examined the recovery pathway of three adult Taiwanese women who had struggled with AN by using a qualitative multiple-case study method (Stake, 2005; Yin, 2014). While previous AN studies with Chinese populations have focused mainly on therapists’ perspectives (Lee, 1995; Ma, 2011), we focused on the lived and subjective recovery experiences of participants with AN. Building on the tenets of cross-cultural psychology (Berry, 1989) and Chinese indigenous psychology (Yang & Ye, 2005), we aimed to explore and identify the overarching cultural and societal forces that impinged upon the participants and their families as they responded to AN. Our key research questions were: (1) What are the critical pathways and processes associated with Taiwanese women’s recovery from AN within the specific cultural contexts of today’s Taiwanese society?; and (2) What socio-psychological, cultural, and familial factors interact to shape the recovery experiences and processes for these women, and how do they do this?

Methods

The present study examined three Taiwanese women’s recovery from AN by generating detailed case descriptions and case-based themes (Yin, 2014). We chose a multiple case study design because this approach: a) is grounded in social constructivist philosophy (Gergen, 2010; Stake, 2005) that gives credence to multiple realities and subjective meanings constructed by individuals within specific sociocultural contexts; b) allows researchers to examine the ‘phenomenological world’ of the participants; and c) helps researchers identify both emic and etic (culturally universal) aspects of the AN experiences across multiple participants through cross-case comparisons and contrasts (Stake, 2013).

Reflection on researchers’ subjectivities and assumptions

As researchers, we converge on the perspective that the development of, and the recovery from, AN are a function and product of the individual’s interaction with their broader sociocultural systems. We consider the first-hand experiences of the participants to be a rich and reliable source of information and knowledge to help us better understand the person-environment interaction. Finally, as individuals of Taiwanese descent who are native speakers of Mandarin/Taiwanese, we regard our shared cultural heritage and linguistic sensitivity as a valuable asset to effectively interpret the study’s findings. We believe that our ‘cultural insider’s’ perspective affords us a nuanced appreciation of the participants’ perceptions, contexts, and realities. On the other hand, we believe that our diversity³ provides us with sufficiently varied viewpoints to allow for a rich interpretation of the findings of the study.

Data collection and analysis

Data collection involved a two-part interview procedure with each participant (one formal semi-structured, in-depth interview, and another follow-up interview a year later) conducted by the first author in Mandarin Chinese. All the interview sessions were audio recorded and subsequently transcribed verbatim. The interview questions were designed to explore the participants’ recovery processes and to further gauge the interaction between participants’ own cultural characteristics, backgrounds, and values and their individual recovery experiences with AN. Furthermore, we used additional sources of data based on relevant written and/or visual documentations belonging to the participants (i.e., photos, paintings, and journals, etc.)

A combined inductive (data-driven) and deductive (theory-driven) thematic analysis approach was employed to identify themes across all three cases (Braun & Clarke, 2006, 2012). An added effort was made to analyze, comprehend, and link the emerging themes to aspects of Chinese culture. We first introduce each single case by describing their idiosyncratic characteristics. Then, we highlight and discuss salient themes that emerged from cross-case comparison and contrast, as recommended by Stake (2005). Prior to writing up this article, we also submitted our findings and interpretation to all participants for their feedbacks as member checks.

Participant recruitment

The study received research ethics approval from the Tri-Service General Hospital in Taipei (File #1-103-05-147). Recruitment advertisements that included the participation criteria⁴ were placed in several university counseling centers in Northern Taiwan and on the website of a prominent eating disorder internet support group. At the end of the recruitment process, three ethnically Han women, alias ‘Chi’, ‘Ya’, and ‘Ti’ agreed to participate. In term of their diagnoses, Chi, Ya, and Ti represented three different subtypes of AN, i.e., the purging, the restricting, and the non-specified subtypes, respectively. Written informed consent was obtained from all participants.

Results

Case 1: Chi’s story

Born in the 1980s in a middle-class, nuclear family of Mainland parentage, Chi was the oldest child, with an identical twin sister and one other younger sister. Chi and her sisters were all overachievers because their parents, who both held a teaching position, had great expectations about their academic achievement. Although there appears to be no open sibling rivalries, Chi reported having experienced tremendous pressures when people made comparison between hers and her twin sister’s physical appearances, personalities, achievements, etc. During middle school, Chi began a chronic diet after receiving comments from peers on her and her twin sister’s body shape, such as “you must be the older one because you are larger than your twin sister”. From that moment on, she held her twin sister’s weight as a reference point for evaluating her weight control.

Chi described her father as a ‘typical Chinese father’ who was emotionally restrained, serious, and distant, whereas her mother was domineering, overbearing, and highly emotional. Interaction and communication between her parents, and between her parents and the children, were minimal. Growing up a “submissive girl”, Chi became used to suppressing her thoughts and feelings for the sake of appeasing others and of fulfilling others’ expectations. In term of meals and food, Chi’s mother insisted on strict “vegetarianism” with the entire family’s diets, forbidding her girls from eating out on the pretext that food available outside was unhealthy and insanitary. Chi perceived this “eating-in-vegetarianism”-only family rule as an implicit means employed by her mother to exert control over the life of her entire family.

Chi recalled that she often forced herself to eat more food than she would have wanted to eat otherwise, urged on by her parents to do so, in order to avoid arguments with them and to maintain harmony. The cumulative stresses, resulting from Chi’s repeated avoidance of, conformity with, and deference to the family rules surrounding food and eating gradually evolved into a binging-purging cycle. Her eating disorder was compounded by an enormous anxiety over her career indecision during her college senior year, where her weight drastically dropped to its lowest point of 35kg (BMI 13.7). While the secretive binge eating behavior made her deeply shameful and self-loathing, Chi vividly recalled that the act of purging provided her with a profound degree of relief, control, and independence, having to live with a domineering mother imposing rigid dieting rules.

In term of her pathway to recovery from AN, Chi identified three significant relationships crucial to this process. One was with her male therapist, whom Chi described as a level-headed and reliable father-figure. The therapist provided her with timely support and guidance as she journeyed through her delayed adulthood and maturity. Interestingly, adhering to an individualistic stance, Chi’s therapist continued to support Chi in her attempts to individuate herself from her family and encouraged her to take more personal responsibility for her own life. The therapy process pointed Chi toward an alternative path to achieve personal growth and development despite her family culture and upbringing. During therapy, Chi’s strong desire to be acknowledged by her therapist motivated her to commit to her recovery and self-healing. Chi also identified her twin sister, who was nonjudgmental and never interfered with her struggles with food, and who had voluntarily provided financial support for her psychotherapy, as a crucial person in her healing. Finally, Chi pointed to her relationship with her father as the most significant and impactful factor in ending her AN. Chi stated unequivocally that it was her father’s sudden death when she was 34 that led to her resolve to return to normalcy after her prolonged AN. His death made Chi consider the changing priorities in her life, with respect to important relationships and the social roles she played in family and the larger social world. Chi’s profound affection and reverence for her father is apparent in this following statement:

“For people at my age, weight shouldn’t be an important issue…Now that my family is growing old, I need to seize the moment to connect with them…to not to replicate the regret I now have with my father’s death…”⁵⁽¹⁾

Looking back at her struggles with her past criticism about her body and disordered eating, Chi went on to challenge the stereotypical portrayal of eating disorders by the Taiwanese mass media as an act of vanity on the part of woman. She asserted:

“….I do feel that eating disorders in Taiwan tends to be portrayed as nothing but a girl’s obsession with her appearance. This is really misleading and oversimplifying the issue. It’s absolutely more complicated than this.”⁽²⁾

Chi’s narrative points to her journey of recovery as a long and tumultuous struggle, involving personal growth and maturation. Chi did so by having to tactfully negotiate and coordinate her relationships with her important others. However, Chi recounted that she resorted to two separate, though sometimes conflicting value systems in defining and evaluating her ‘maturity’. One involved her interdependence and her ability to fulfill family duty (“I should get more involved with my parents’ business, care more about how they feel and what they want”). The other involved her independence and self-reliance (“I should focus more on my own things, have my own voices out”). These two-pronged strategies used by Chi offer a good example of a ‘bicultural’ self that actively involves ‘self-relation-coordination’ across different social and personal contexts (Chen, 2009). Chi’s symptoms of AN only began to diminish when she finally found a way to accept and negotiate the conflicting prescriptions of the preservation relational harmony and of fulfilling her own individuality. She stated:

“As I started seeing myself as independent from my mom, I became more comfortable and no longer felt inferior to her….My binging and purging frequency reduced because it is no longer an option for me to force myself to eat, simply to conform.”⁽³⁾

Case 2: Ya’s story

Ya, 28 years old, was the firstborn of three daughters in a working-class Hulo⁶ family. Her parents, who received very little formal education, had to work long hours in low-wage jobs with limited incomes. Growing in a household with constant financial strain, Ya’s parents consistently implored the children to study hard and to achieve academic success, so they could get to move up the socioeconomic ladder. Consequently, Ya became the first and only child in her extended family to be admitted to the most prestigious university in Taiwan – a superlative accomplishment that earned her a special status in the household.

Ya’s dieting habit, however, began during her freshman year at the university, as she was becoming increasingly overwhelmed by the new environment, people, and responsibilities. Her feelings of anxiety and inadequacy quickly surfaced in one incident, when the young man who was the object of her romantic interest chose another young woman, who was slimmer than she was. Devastated by this experience, Ya’s weight drastically dropped to only 40 kg (for a height of 162 cm) by the end of that first semester. Additionally, Ya observed that the excessive family pressure and expectations that she felt during that time were preventing her from exploring and developing an adult identity for herself. Ya described:

“College was the time for departure, but separation is difficult in my family and anorexia was the way I chose. I couldn’t change the external environment and other people…”

In her narrative, Ya clearly linked the onset of her anorexia to the overbearing familial and social pressures surrounding her being the eldest daughter in a traditional Taiwanese family. Ya described her family pattern as tightly organized around the Chinese ‘son-preference principle’, a male-dominant belief in Confucian culture according to which sons are more valuable and more entitled to social privileges and family resources than daughters. The fact that Ya’s parents had no son created a difficult, negative social dynamic for her parents, resulting in their enduring sense of losing face within their extended family – a phenomenon often observed in traditional Chinese contexts. Consequently, Ya felt the full brunt of her parents’ disappointment as she had to fill the gap and shoulder the added responsibilities and demands that came with the absence of a male child. Her mother often displaced her dissatisfaction and distress onto Ya, by making disapproving comments about her performance on house chores and body size. As she recounted:

“I became quite ‘parentified', undertaking a lot of tasks. I always put others’ needs or the interest of my family as priorities. I didn’t allow myself to gain weight, just like I didn’t allow myself to have needs…”⁽⁴⁾

Ya’s pathway to recovery began when she decided to seek professional help from a therapist at the university counseling center where she attended graduate school. Her therapist, whom she described as a warm, supportive, and savvy mother figure, guided her in exploring her relationships with her parents and family, and subsequently helped her rebuild confidence in her body and life. In therapy, Ya gradually came to recognize that AN was an easy but deceptive approach that she employed to respond to the uncontrollable things in her life; it also served as an unhealthy means for her to release the pain she felt as a result of the tension, conflicts, and oppression in her family. In her journals, Ya reflected:

“…anorexia rendered some immediate rewards to keep me from getting drowned in my lack of confidence, feeling of deprivation… However, no matter how hard I try, my family life won’t be perfect…”⁽⁵⁾

Following completion of graduate school, Ya made an unprecedented decision to move out of her family’s home, which marked the beginning of her individuation. This move gave Ya a sense of distance from her family, physically and psychologically, allowing her to move away from the key source of stress and anxiety in her life. This transition was accompanied by support from her therapist, who extended the therapy sessions for an additional six months, as well as from her first boyfriend, who provided both physical and emotional support for Ya. Her boyfriend helped Ya reestablish a good relationship with food, her body, and herself by accepting her whole person, attending to her needs, and demonstrating a nonjudgmental attitude toward her body size and her choice of food.

Remarkably, during our initial interview, while she described herself as “in recovery”, Ya expressed a strong endorsement of individualistic values, including her need for individuation and equalitarianism, and considered separation from her family as an essential protective factor in her recovery from AN. Ya asserted:

“…my family changed after I left…of course my parents were unhappy…in the first place. But they eventually got used to it. We started to interact in a more equal way.”

In our follow-up interview a year later, Ya described herself as “almost fully recovered”. Interestingly, by that time, Ya had moved back in with her family. She reported that her relationship with her parents had improved significantly since then, and that the quality of their relationship was more mutual and reciprocal. Speaking in a relaxed tone, Ya noted:

“…now I’m living a life by taking things easy and letting them taking care of me.… They’re pretty happy about that and I feel no guilt at all.”⁽⁶⁾

Reflecting on a sociocultural context, Ya pointed to cultural and generational differences over beauty standards and challenged the current ideal of thinness, expressing a preference for the full-bodied type that was once popular with her parents’ generation, back when Taiwanese was less affected by Western commercialism. She stated:

“In our culture, being chubby should mean pretty and lucky. My first memory of the really thin women were Western models and movie stars…My mom always said they are ugly”⁽⁷⁾

It appears that Ya’s trajectory of recovery was further consolidated by her growing clarity about the ways in which her perception of beauty was profoundly shaped and influenced by a mixture of traditional Taiwanese and Western, commercial forces widespread in modern Taiwanese society. Ya identified that this stirring insight had prompted her to become more aware of, and to take a more conscious stance against, disparaging comments and messages about the female body from contemporary Taiwanese popular media and pop culture. Consequently, Ya grew in her ability to accept and appreciate her body as she began to write and practice body-affirmation in her journals, to engage in positive self-talk in her conversations with her female colleagues, and to become physically active by participating in yoga and hiking.

Case 3: Ti’s story

Ti, 27 years old, is the firstborn child (with a younger brother) of a traditional Hakka⁷ household, which consisted of three generations, including her paternal grandmother. Ti was raised in a devout Christian family, her father being a church pastor. In contrast to Chi and Ya, Ti described her family as loving, caring, joyful, and close-knitted. However, growing up as a pastor’s daughter, Ti experienced tremendous pressure arising from her own self-imposed expectation to act ‘perfectly’ in every single role she assumed (i.e., being a daughter, a sister, a pastor’s kid, a model student in class, etc.). In retrospect, Ti recognized that she had always strived to live up to her parents’ unspoken, implicit expectations, as a result of observing their own relentless pursuit of self-discipline and self-cultivation. Ti internalized those parental values, and her pursuit of thinness originated from a need for self-enhancement. In middle school, Ti observed that ‘thin girls’ were more admired and popular, leaving her with a sense of inferiority with regard to thinner women. Reinforced further by mass media and peer culture around thinness, Ti went on a strict diet, which led to a severe weight drop from 45 kg to 35 kg within less than two months. Ti poignantly recalled:

“Growing up in a family like that, I had always wanted to be a perfect kid, one who would allow my parents to hold their heads up high. I applied my perfectionist mindset to dieting as soon as I realized it was something I could strive for.”⁽⁸⁾

As with many Taiwanese families, mealtime was held to be sacred, reflecting the Chinese belief that eating together works toward preserving harmony, cohesion, and unity in the family. Being fully present at the dining table therefore represents one’s loyalty and respect towards the family. Ti recalled that her paternal grandmother was the matriarch of her family, and was in charge of meal preparation. Symbolically, the grandmother’s cooking and food serving signified her devotion to, and affection for, her children. The entire family was, in turn, expected to reciprocate their grandmother’s gesture by observing filial piety and obeying her rules about food and meals.

During her adolescence, Ti gradually came to realize the ways in which the high moral standards of her family and her upbringing had contributed to her perfectionistic attitude and mindset. Meanwhile, Ti began to notice flaws in her mother’s relationship and interactions with her grandmother. Upon observing these shortcomings, she felt justified in challenging the authority of adults in the household and the inflexible ‘family ritual’ around food and meals. Following this, meal intake became a flash-point for Ti as she grew into a teenager. Her food restriction represented a silent means of protesting higher authority without overtly disagreeing with the familial status quo. Ti illustrated:

“I wanted to have some freedom from my parents but I didn’t want to go against them. Their control/protection was benign, good for me, but it’s seamless and suffocating. I just need some space to make my own choice. Anorexia was part of my identity because eating and weight are the only things I have control over.”⁽⁹⁾

Ti’s recovery process entailed finding meaning, establishing her identity, and repairing her relationships with her parents. With the approval of her parents, Ti began her path to recovery with support in the form of Christian-based counseling from a pastor – a relatively ‘Western’ idea. Specifically, Ti underscored the critical importance of having received sufficient space from her parents, which allowed her to explore her own self-identity, to reset her relationship with her family, and to reexamine her personal faith in Christianity through the counseling process. The combination of family support and professional help provided sufficient impetus for Ti to arrive at her eventual self-acceptance, both in terms of her own body image and her identity. The following quote illustrates aptly Ti’s newfound freedom and insight.

“It was the first time I got to learn about myself and my Christian belief as a person instead of simply being as a pastor’s daughter…”⁽¹⁰⁾

Subsequently, Ti’s awakened sense of loyalty towards her family and her desire to restore honor to her parents had given her the momentum she needed to face up to her AN.

“…my anorexia was a face-losing thing…I felt like becoming too much a burden… I was eager to become normal again…so that I could save face for my parents”⁽¹¹⁾

Externally, Ti’s sense of confidence with her body image and identity was further

reinforced by her cross-cultural experiences. Throughout her high school and college years, Ti participated in an international exchange program via a Christian ministry. Later, Ti moved to the US for her graduate studies. Ti highlighted that these cross-cultural exposures and experiences living abroad had enabled and empowered her to challenge the stereotyped images of beauty portrayed and perpetuated by Western media. Ti observed:

“After I came to the US, I realized that people here do not look like those in the movies…”⁽¹²⁾

Discussion

Comparative analysis of these cases of AN revealed three culture-related themes that pertain specifically to the recovery process of the participants under the unique dynamic of East-West ‘biculturalism’ in Taiwan. In the following section, we discuss these themes and interpret them through the conceptual perspectives of cross-cultural psychology and Chinese indigenous psychology.

Theme 1: Anorexia as an expression of the conflictual bicultural self

The current study reveals a unique characteristic of AN in contemporary Taiwan – namely, that the causes of food restriction and dieting for Taiwanese women were rooted not only in the pursuit of a socially desirable body shape, but also in the cultural tug-of-war between the demands of Chinese traditionalism and the pressure of Western modernism – a process closely aligned with the conflicts associated with being a ‘bicultural’ individual (Lu & Yang, 2006). Moreover, speaking from a developmental-contextual perspective (i.e., Walsh, Galassi, Murphy, & Park-Tayloret, 2002), all three participants experienced the onset of AN during their late adolescence or early adulthood – a critical developmental phase in which the individual’s primary task is to explore and establish a sense of self-identity (Lai, 2000). During this maturation process, they were caught between the long-standing Confucian principles of interdependence, familism, and patriarchal hierarchy on the one hand (Yang & Ye, 2005), and the ever-expanding and ubiquitous Western ideals of individualism, independence, egalitarianism, and gender equality on the other (Cheung & Chan, 2002; Hwang, 2001).

It seems that their experiences with AN were, in one way or another, rooted in or related to their familial and social interpersonal conflicts. Food restriction and body weight control were used by these Taiwanese women as an indirect means to exert their personal agency and as a silent response to fend off family and sociocultural pressures (Ma & Lai, 2005): for example, Chi’s need to be released from her mother’s control over her diet and from Confucian values that were dictating her behaviors; Ya’s and Ti’s use of restricted food intake to counter deeply-engrained family beliefs, expectations, and codes of conduct. In other words, dieting/slimming functioned as a covert and subtle outlet for these young women to release their psychological pain and distress in a rapidly changing culture and society with many generational and familial conflicts. These behaviors are often misconstrued as signs of health, fitness, beauty, and self-mastery, as perpetuated by the Western mainstream standards and popularized by mass media, pop culture, and peer influences (Lai, 2000; Ma, 2007a).

At the conceptual level, the experience with AN among Taiwanese/Chinese populations could well be understood as an attempt to ‘self-coordinate’; that is, to regulate the self in relation to others. This study provides evidence for this claim, in that our participants used food restriction and weight control as means to restore a sense of balance in response to their external and internal conflicts, without resorting to open and direct confrontation, which would betray Confucian ethical values of family loyalty, filial piety, and the preservation of harmony. Paradoxically, this distinctive dynamic can frequently backfire and lead to more intrafamilial conflicts and parental interference as a result, as demonstrated by our participants. These above findings and observations find support in a number of other recent empirical studies, which have linked AN in non-Western countries and populations to cultural clashes (Chan & Ma, 2002; Cheng, 2014; Ma, Chow, Lee, & Lai, 2002) and to acculturative stress (Demarque et al., 2015; Lai, 2000; Kawamura, 2011), respectively, due to the rapidly increasing Westernization in those countries and regions.

Theme 2: Recovery as a pathway towards an integrated bicultural self

The current study further revealed an intriguing association between the Taiwanese participants’ degree of integration of their ‘bicultural self’ (i.e., the co-existing of Eastern-Western cultural ideologies) and their levels of recovery. In particular, the participants’ ability to effectively navigate the intersection of Chinese/Taiwanese cultural expectations and Western ideas and values, and that of their relational, interdependent self and their person-centered independent self (Chen, 2009), has been found to play a critical role in shaping their response to, and battle with, AN.

Among the three participants, Ti reported the least Confucian-Western value conflicts, as compared to Chi and Ya. This was because of Ti’s unique cross-cultural upbringing, owing primarily to her parents’ willingness to incorporate Western, Christian values and practices into their parenting and family relationships. For example, in receiving pastoral counseling, Ti was able to attain a growing sense of personal identity that was independent of her familial obligations and of other social role expectations about her. Concurrently, Ti’s recovery pathway from AN was also further sustained by her identification with, and commitment towards, her Taiwanese cultural heritage and identity (i.e., the upholding of filial piety and family honor). In this respect, Ti’s eventual full recovery from AN coincided aptly with her achieving a sense of integrative bicultural self-identity. Similarly, Ya’s eventual recovery was made possible only by achieving an integrated ‘bicultural’ self, which occurred when Ya was able to reconnect with her family and also to attend to her personal needs, interests, and autonomy. A similar pattern of self-identity and self-relation integration was also observed in Chi’s narrative. Chi’s struggle with maturity was reflected in a split in her identity, between her Chinese relational self and her Western individualistic self. Subsequently, Chi’s healing from AN began only after she was able to communicate her own voice to those around her and to develop a sense of self confidence in maintaining social ties with her important others.

In contrast to Western theories that typically view ‘complete individuation’ as the benchmark for personal maturity and as the criterion of recovery from AN (Minuchin et al., 2009; Palazzoli, 1985), our Taiwanese participants’ narratives suggest that the trajectory of their recovery embodies a complex and dynamic process of negotiation and navigation between and among various sociocultural systems and forces. From an interpersonal/relational perspective, recovery from anorexia for these Taiwanese women involved tactful strategies of conflict resolution to address and meet their needs, goals, and expectations and those of their important others. Such an approach resembles Chen’s (2009) notion of ‘self-relation coordination’. In short, the recovery experiences of the three Taiwanese women in the current study exemplify an effortful search, on the part of these individuals, for a culturally balanced and integrated personal identity. This act, by extension, reveals an alternative pathway toward the psychosocial maturation of individuals who live in a rapidly changing bicultural Taiwanese society.

Theme 3: Dynamic and paradoxical roles of Chinese cultural heritage in anorexia and recovery

Confucian norms and values, including filial piety and face-saving, were observed to shape the Taiwanese participants’ experiences with AN in a dynamic, yet paradoxical way. These indigenous cultural elements are pervasive and deep-seated in many spheres of Taiwanese individuals’ personal, family, and social lives, even in the face of rapid societal changes and upheaval. As a result, it is evident that the onset of AN for all three women was partly triggered by the tensions and the emotional burdens resulting from their paradoxical desire to be a filial and loyal daughter to earn face for their parents and, at the same time, to break away from the shackles of these cultural constraints. However, the findings of the present study also highlight the facilitative, constructive roles of such Chinese cultural practices in motivating these Taiwanese women to engage in change and recovery. For instance, all three women described various degrees of support and care they received from their respective families at different points of their recovery process, through direct, indirect, material, physical, and/or emotional forms of assistance. Their motivation for eventual healing was partially inspired and driven by the profound connection, reverence, and commitment they had towards their families. Such findings are empirically supported by several previous studies on family treatments with families of Chinese anorexics (e.g., Chan & Ma, 2002; Ma, 2005). Our current study, however, adds to previous research by identifying the additional importance of the role of face-saving and face-earning in motivating Taiwanese women with AN to embark on a path to recovery.

By extension, the findings of this study point to an alternative interpretation, according to which Confucian cultural norms and values can be transformed, from imposed constraints into resources upon which individuals can draw to overcome their AN. This finding suggests the vital importance of having a successfully integrated, bicultural self, which enabled the participants to achieve such a transformation. By successfully and adaptively coordinating indigenous cultural values and newly acquired Western values, Chinese practices that involve family relations, filial piety, and face-saving priorities can actually be mobilized and translated into a potent drive to engage these women in change and to sustain them through their long recovery journey. However, this happened only after they were able to negotiate the conflicting imperatives of being filial and of meeting their own emotional and developmental needs – that is, engaging in a form of filial piety that was flexible and compatible with their circumstances. Furthermore, their intention to restore integrity and honor for themselves and their parents and families (i.e., to save or earn face) by overcoming their AN, in turn, contributed to their eventual recovery. These examples illustrate the unique features of the cultural dynamic of AN recovery for Taiwanese women.

In short, the above findings suggest that to fully and concisely understand and study the healing pathway among Taiwanese/Chinese populations with AN, it is imperative for researchers and practitioners alike to incorporate critical indigenous aspects of Chinese cultural principles and worldviews, such as filial piety, face-saving/earning, self-relation coordination, biculturalism, etc., in the conceptualization, assessment, and analysis of AN in these cultures and contexts.

Conclusion

Although many of the intrapsychic conflicts and psychosomatic symptoms associated with AN in the clinical literature were clearly evident and reported by our three participants, Chi, Ya, and Ti, the present study poses challenges to the cross-cultural validity and appropriateness of conceptualizing Taiwanese family relationships and dynamics from the vantage point of Western assumptions, without adequately accounting for relevant sociocultural factors and contexts (i.e. filial piety, gender roles, Confucianism, familism, biculturalism, etc.).

In contrast to mainstream Western, individualism-oriented theories and treatment approaches, this study attempted to provide a richer, fuller, and more nuanced analysis and comprehension of the phenomenon of AN in Taiwan, exploring the importance of the often ‘invisible’ sociocultural forces that can profoundly shape one’s lived experience with AN at the immediate, microscale inter- and intra-personal level (Hong & Ham, 2001; Kam & Lee, 1998). We suggest that future AN research with other diverse and international populations should systematically examine relevant cultural and contextual factors. Similarly, in terms of clinical practice and intervention, therapy and treatment with women with AN should be broadened to examine influences that originate from the macroscale systems to which a patient belongs (e.g., cultural, generational, or societal domains), while attending to their psychosocial developmental history at the individual/personal levels (e.g., concerns about fat, intrapsychic conflicts, developmental needs, interpersonal relationship, and family dynamics) (Kempa & Thomas, 2000; Ma, 2005). For example, judiciously addressing cultural issues – such as Chinese traditionalism (i.e. familism, filial piety, harmony, face-saving), Western acculturation, or the cultural clashes and conflicts patients of non-Western heritage may face – will likely benefit the therapy process and increase the cultural and clinical responsiveness of interventions (Lee et al., 1993; Lee, 1995; Ma, 2007b; Ma & Lai, 2006).

The results of this study should, however, be treated with caution in view of the following limitations. First of all, the study employed a multiple-case study method with only three Taiwanese women participants. Second, all three participants in the present study were ethnically Han individuals, and all were highly educated and articulate. The extent to which their experiences represent Taiwanese AN patients broadly speaking is unclear. Our results therefore should be treated as tentative. Clearly, further studies with larger, more diverse samples are needed. The field of AN research would greatly benefit from more systematic cultural and cross-cultural studies of non-Western European populations. This kind of research can enable the field to identify unique cultural issues, themes, and patterns associated with AN in diverse populations, elaborate from contextually grounded conceptual frameworks, and test the generality of mainstream theories of AN.

Supplemental Material

sj-pdf-1-tps-10.1177_1363461520920327 - Supplemental material for Recovery from Anorexia Nervosa in Contemporary Taiwan: A Multiple-Case Qualitative Investigation from a Cultural-Contextual Perspective

Supplemental material, sj-pdf-1-tps-10.1177_1363461520920327 for Recovery from Anorexia Nervosa in Contemporary Taiwan: A Multiple-Case Qualitative Investigation from a Cultural-Contextual Perspective by Yunung Lee, Ben C. H. Kuo, Ping-Hwa Chen and Nien-Hwa Lai in Transcultural Psychiatry

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Yunung Lee is a registered counseling psychologist in Taiwan. She works mainly at the community psychiatry clinics and counseling centers with people from all walks of life. Her specialties include cross-culture adaptation, cross-generation conflicts and reconciliation, weight and eating-related issues, and identity issues. Prior to her study on counseling psychology, she obtained a B.A. in Foreign Language and Literature from National Taiwan University. She then obtained her M.Ed. in counseling psychology from the National Taiwan Normal University, in Taiwan, and the University of Missouri, US. Her research focuses on the intersection of multiculturalism and social diversity, Chinese culture, social justice, gender, class, political violence, and eating and body-related issues. She adopts a humanistic and interdisciplinary approach in researching and practicing. Her Master’s thesis on anorexia and cultural transitions in contemporary Taiwanese society won the Taiwanese National Thesis/Dissertation Award in Counseling and Guidance in 2017. [Email: yunungl@gmail.com]

Ben C. H. Kuo is a Professor in Adult Clinical Psychology at the University of Windsor, Canada, and a registered psychologist in Ontario, Canada. His research focuses on the intersection between culture and psychology, particularly on the areas of multicultural counseling and training and cross-cultural psychology. Dr. Kuo regularly teaches and supervises clinical psychology graduate students in multicultural psychotherapy courses and also supervises practicum with diverse clients, including refugees. Dr. Kuo has lectured, taught, and provided training internationally. Dr. Kuo was the recipient of the Outstanding Research Award: Established Researcher/Scholar Category and of the Faculty of Arts, Humanities, and Social Science’s Dr. Kathleen E. McCrone Teaching Award in 2017 and most recently the Mary Lou Dietz Equity Leadership Award in 2019 at the University of Windsor. [Email: benkuo@uwindsor.ca]

Ping-Hwa Chen is a former professor in Educational Psychology and Counseling at the National Taiwan Normal University (NTNU). She holds a Ph.D. in counseling psychology from the University of Illinois Champaign - Urbana. Her previous positions and services include faculty member in Counseling Psychology at the NTNU, director of the NTNU Student Counseling Center, and chairman of the Taiwanese Association of Guidance and Counseling. Currently, she works at the Ling Leung Pastor and Missionary Theological Seminary, Taiwan, as an adjunct professor teaching pastoral counseling. She also practices counseling and psychotherapy at the Cosmic Light Holistic Care Organization in Taipei. Her research interests focus on multicultural counseling, spirituality, and counseling.

Nien-Hwa Lai is a Professor in Psychology and Counseling at the National Taipei University of Education and a registered counseling psychologist in Taiwan. Her specialties include psychodrama, art therapy, group therapy, crisis intervention, trauma work, and family and couple therapy. Her research interests focus on developing culturally-appropriate intervention modalities with diverse and minority clients. She is currently chair of the Department of Psychology and Counseling at the NTUE, the head supervisor/professional consultant at the Katerpillar Art Psychotherapy Center and the Angel Heart Foundation, Taiwan. Dr. Lai provided training internationally in China, Macau, Malaysia, and Japan as a visiting scholar. She was a recipient of the Senior Fulbright Research Grants in 2013-2014 and the David Kipper Scholar Award from the American Society of Group Psychotherapy and Psychodrama in 2017.

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