Fathers, Daughters, and Anorexia Nervosa

ppc_236

37..47

J. Carol Elliott, PhD, PMHCNS, BC, CNE, RN

PURPOSE.

The study described the nature and

meaning of the fatherdaughter relationship

J. Carol Elliott, PhD, PMHCNS, BC, CNE, RN, is

Assistant Professor, Department of Nursing, Saint
Anselm College, Manchester, NH, USA.

throughout the daughters (N = 11) life from the

perspective of the daughter, who has been in a
2-year recovery from anorexia nervosa (AN).
Particular consideration was given to the
changes over time.
DESIGN AND METHODS.

A narrative analysis

method was used to examine the daughters

stories.
FINDINGS.

Several patterns emerged. This study

is an exploration of the paths and processes that

lead to, through, and into recovery from AN
with regard to the fatherdaughter relationship.
PRACTICE IMPLICATIONS.

The results have

implications for nursing practice, research, and

health policy.
Search terms: Anorexia nervosa, daughters,

fathers, qualitative research

First Received February 15, 2009; Final Revision received May 18,
2009; Accepted for publication July 9, 2009.
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010

Signicance

he National Eating Disorder Association (2006)

reported that about eight million people in the United
States have an eating disorder (ED). For anorexia
nervosa (AN), the estimated prevalence rate for
females is 12% of the general population; the rate is
higher among college-age women, and its incidence is
growing (Hoek, 2006). The health consequences of AN
are associated with impairment in physical health and
interpersonal adjustment. AN has a high relapse and
mortality rate, healthcare utilization, and expense
(Robergeau, Joseph, & Silber, 2006). AN symptoms
impair health and functioning, even in the absence of
full-syndrome AN. Considering that this illness aficts
mainly adolescents, who are generally free of major
health problems, AN is a signicant and disturbing
health issue.
Research about AN has grown considerably, and
researchers concur that its etiology is multidimensional. Studies have identied risk factors, one of
which is family dynamics and relationships (Bulik
et al., 2006). In research of signicant family relationships, mothers are emphasized; fathers are often
overlooked (Maine, 2004). Limited research exists to
demonstrate the impact that fathers have on AN,
although recent developmental research indicates that
fathers have greater inuence than previously thought
on a daughters development (Roggman, 2004).
AN usually begins in females during the move
from childhood to adolescence or from adolescence
to young adulthood (Striegel-Moore & Bulik, 2007).
Because women describe themselves primarily with
reference to relationships (Gilligan, 1982), research is
needed to explore how signicant family relationships
change over time and may contribute to the vulnerability to and development of AN (Rosen, 1996).
37

Fathers, Daughters, and Anorexia Nervosa

Purpose
The purpose of this research was to describe the
nature and meaning of the fatherdaughter relationship, from the perspective of the daughter who has
been in recovery from AN for at least 2 years. The aims
were to: (a) describe the current relationship, (b)
explore their early relationship, (c) investigate any
changes, and (d) examine the meaning underlying the
relationship in relation to AN. The stories in the daughters memories of their fathers from childhood to
adulthood were examined. The outcomes contribute
knowledge about vulnerability to this illness during
developmental transitions.
Literature Review
Kiernan (2006) found in a literature review that
involved fathers positively inuenced their infants
social and cognitive growth, and during preschool,
fathers promoted their childrens acquisition of intellectual, social, and language skills. School-age children
tended to be more successful in their academic, athletic, and social pursuits; have better adjusted personalities; and greater self-esteem when their fathers were
supportive and nurturing (Kiernan, 2006). These inuences continued throughout their childrens lives
(Bronstein, 1988).
In a study by Hosley and Montemayor (1997), teens
felt alienated from their fathers. Yet, the distance facilitated the adolescents separationindividuation processes and promoted independent behaviors (Hosley
& Montemayor, 1997). Daughters wished for a closer
relationship, as the distance they experienced differed
and persisted longer (Bronstein, 1988).
Evidence about fathers of anorexic females is
just beginning to accumulate, although clinicians have
documented problematic relationships for years
(Phares, 1997). In 1980, research suggested that anorexic daughters experienced disturbed paternal relations prior to AN (Crisp, Hsu, Harding, & Hatshorn,
1980), which has been supported by additional
38

research (Fitzgerald & Lane, 2000; Humphrey, 1989;

Parente, 1998; Weir, 1994). Bugola (1995), Sours (1980),
and Ward, Ramsay, Turnbull, Benedettini, and Treasure (2000) found a strong but stressful attachment
between the fathers and daughters. Humphrey (1989)
concluded that the father undermines the daughters
attempt to individuate.
AN fathers were found to be narcissistic perfectionists, emotionally constricted, and depressed (Fassino
et al., 2002). Daughters perceived their fathers as more
admired and inuential than their mothers (Gurevitch,
1993). The fathers valued achievement, ambition, selfcontrol, appearance, and thinness; and the daughters
values were quite different. The fathers were highly
judgmental of others characteristics, including those of
their daughters (Dixon, Gill, & Adair, 2003). The daughters, aware of their fathers dissatisfaction, needed their
approval and feared their rejection (Connor, 1993;
Gutzwiller, Oliver, & Katz, 2003). Fathers believed they
exhibited signicantly more empathy, congruence, and
regard toward their daughters than the daughters perceived (Weir, 1994); yet, research indicates that the
daughters perceptions of the familys functioning and
interactions were most accurate (Connor, 1993; Waller,
Calam, & Slade, 1988).
Method and Design
Narrative analysis (NA) utilizes stories to interpret
the storytellers understanding of their experiences
and actions (Elliott, 2005). Symbolic interactionism is
its guiding framework (Charon, 1998). NAs analytic
techniques differ depending on the researchers discipline and questions (Riessman, 2002). For this study,
Lieblich, Tuval-Mashiach, and Zilbers (1998) holisticform model served as a guideline for analysis.
Magilvy, Congdon, and Craig (1992) described the
effectiveness of photographs to generate data and to
illustrate patterns. Photo-interviewing is an especially
useful tool to discover a participants perceptions of
family relationships. Concentrating on the photographs removes the focus from the participant, making
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010

the interaction less stressful and more natural (Gerace,

1989).
For this study, a convenience sample of 11 women,
ages 1860, was obtained through newspaper advertisements in the northeastern United States. The majority were Caucasian, college graduates. The average age
of AN onset was 17 years. Each chose family photographs to begin the interview. A few discussed their
relationships with men who were not their biological
fathers, but who acted as their fathers throughout their
lives. Protection of human subjects was assured by the
academic institutional review boards procedural
approval.
The data consisted of audiotaped, unstructured
interviews. Probes were used for clarication and/or
detailed explanation. Notations of observations and
insights were made. The interviews were transcribed
verbatim and were veried for accuracy. While listening to the tape, notations about the womens speech
patterns were added to aid interpretation (Gee, 1991).
The fatherdaughter relationship stories from each
participant were extracted from the transcript, placed
on separate pages, and arranged chronologically. The
remaining data were explored for supportive and contextual information (Riessman, 1993). The stories were
examined for what happened and for the storys
meaning (Cortazzi, 1993), and then coding began. The
course, turning points, and rough spots of each participants stories were scrutinized. With each new
interview, the stories and codes were compared
and contrasted. The codes were combined into more
abstract categories. The patterns that emerged
described the participants collective experiences of
their fatherdaughter relationships with regard to AN.
The issues of rigor and validity of the ndings were
addressed by discussing my analytic plans with an NA
expert for validation (R. Josselson, personal communication, October 18, 2004). I consulted with other qualitative researchers to prevent bias and to assess the
conrmability, dependability, and credibility of the
analysis (Lincoln & Guba, 1985). I have kept my analytic notes and memos for auditability of my research.
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010

Findings: Patterns and Themes Within the Patterns

Childhood: Life in the Fast Lane
I had to grow up fast. You have to think like an
adult and thats kind of scary. In childhood, the participants perceived the need to grow up quickly. They
indicated that they were given or assumed parental
attitudes and/or responsibilities. Growing up quickly
was an anxiety-producing and confusing situation for
these women.
Uncertainty. The fatherdaughter relationship was
marked by uncertainty. The participants were
unsettled by their fathers behaviors, as their fathers
were intermittently unavailable, emotionally and
physically. When I was growing up, I dont think I
realized that he was sometimes a good dad and sometimes a bad dad. There was no in-between. So, it was
really hard. Because of this, the participants spoke of
not knowing that their fathers loved them and sought
proof of their fathers love. Sporadic paternal absence,
combined with parental marital conict, magnied
the uncertainty for the participants. I was afraid I
wouldnt have a family. They reason that, without
them, their parents would be happier.
Fear of Abandonment. Fear of abandonment featured prominently in the participants narratives. I
was afraid I wouldnt have a family. This dread lingered and triggered additional fears of other unknown
troubles that might have been lurking. The uncertainty
of their fathers availability, their parents marital
discord, and chaotic home environments were anxietyproducing situations.
Transitions: Like Father, Like Daughter
The participants described their temperamental
similarity to their fathers. We think alike, have a lot in
common, and understand each other. The majority of
the participants discussed their earlier closeness and
admiration of their fathers. They idealized their fathers,
and consequently, emulated their fathers behaviors.
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Fathers, Daughters, and Anorexia Nervosa

Now You See Him, Now You Dont. All of the

participants fathers gradually became less accessible
during their adolescence. I didnt really deal with the
abandonment when my dad left. The majority of the
fathers left early in their daughters teen years, about
the beginning of the participants puberty, and eventually disappeared from their lives. The reasons for the
departures were varied. The fathers absences were not
necessarily related to the participants pubertal development. At least, the participants did not openly
discuss that.
Now You See Her, Now You Dont. The participants talked of coping ineffectively with the changes of
puberty, not only within their own bodies, but also in
their relationships with their fathers and their environments during adolescence. I dont think he really got
it, the girl thing. Although turning away from family
toward peers is normal adolescent behavior and necessary for individuation, most of the participants used
words that suggested distancing, and/or disappearing
as their method of coping. I pulled away at that
point.
AN: A Catalyst
But this [AN] changed everything. Most participants weights dropped to a critical level, and all of the
participants required hospitalization. A catalyst usually
accelerates the rate of a reaction and produces change.
In some instances, the catalytic reaction is dramatic to
observe; while for others, the reaction is slow, steady,
and barely observable, and other chemicals, when
mixed, experience nothing at all. AN was a way for the
participants to alter the painful loss of their fathers and
prompted a change in the fatherdaughter relationship.
If the catalyst of AN was effective in promoting change
in the fatherdaughter relationship, ANs power
diminished. If the catalyst failed to instigate any reactions and the relationship did not change, the daughter
continued to struggle with AN. The participants did
not experience the same reaction to the catalyst; therefore, they did not experience the same change.
40

She Changed. The participants were the persons

who changed most frequently in the fatherdaughter
relationships as a result of AN. With therapy, they
changed their expectations of their fathers and were
able to see them more realistically than before the
illness. These participants realized that their fathers
could not or would not be their ideal of a father. I
became independent.
He Changed. Only one participants father in this
study changed in response to AN. Her father became
involved in her care upon discharge from the hospital.
At the time, he was dealing not only with his daughters illness, but also the terminal illness of his mother.
Constance stated, Then, my dad opened up. It
changed him completely.
They Changed. Both the fathers and the daughters
changed in reaction to AN, and therefore, the father
daughter relationship changed. I think a really telling
vignette that really illustrates how we changed was
when he was over at my apartment after I had decorated. The participants modied their expectations
about their fathers and were able to accept them as
they were, not as they wished them to be. The fathers
changed as well and became more available emotionally to their daughters.
Nothing Changed. Another pattern that emerged,
albeit small, was that the catalyst of AN was not always
successful in bringing about a change in either the
fathers or the daughters. As a result, nothing changed
in the relationship. The participants that did not experience change as a result of the catalyst continued to
suffer from the illness. I didnt make the most of them
(2 months of inpatient treatment) because Im not
maintaining (weight). With all the treatment, the therapist or doctors, they would always ask me, What
about the death of your father?
Current Relationship: Catalytic Reaction
Most of the stories were success stories, as the
majority of the participants were in recovery from AN.
The endings of their stories were not the same. Most
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010

participants personally resolved the issues they perceived as problematic in their fatherdaughter relationships. The outcomes may not have been the most
desirable for the participants, but they came to an
acceptance. One of the things that I had to come to
terms with was knowing who he was, is, and what hes
capable of, and not wishing or craving for something
that hes not capable of giving or Our relationship
couldnt be any better.
Discussion
Childhood: Life in the Fast Lane
The participants stated that they grew up quickly,
which meant thinking and acting like an adult while
still a child. This pattern has not been documented in
previous AN studies. Developmental studies have
shown that when fathers were unavailable to their children, the children perceived the need to mature more
rapidly than their chronological and developmental
levels would indicate (Schwartz, 2003). In a study
by Ross and Hill (2002), parental inconsistency was
common in alcoholic families. Children of alcoholics
had difculty gaining knowledge of and becoming
skilled at the combination of roles necessary to mold
healthy personalities (Burnett, Jones, Bliwise, & Ross,
2006). Instead, the children frequently developed and
held on to the roles that promoted survival and security (Burnett et al., 2006). Researchers have shown that
women with AN typically desire to maintain their prepubescent images when family members, especially
fathers, experience difculty accepting their maturation (Phares, 1999). This resistance may be related to
parental inconsistency as found in children of alcoholics. This possibility has not been explored.
It is hoped children will complete each psychosocial
stage successfully. If unsuccessful, children are likely to
develop self-perceptions of inadequacy or incompetence that may continue into adulthood (Erickson,
1963). Research has shown that a fathers presence and
interaction with his children promoted feelings of
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010

safety, security, and competency in his children

(Kiernan, 2006). These children were able to accomplish the necessary developmental skills, and these
positive effects continued into adulthood (Lamb,
2004). The participants perceived a deciency and an
inconsistency in their fathers presence and interaction
during childhood. I concluded that without the fathers
fortifying presence and interaction, the participants
may have encountered difculty in navigating future
transitions because they had not mastered the previous
developmental stages.
Yahav and Sharlin (2000) found that childrens anxieties about the quality of their parents marriages lead
to the childrens perceptions of being responsible for
maintaining the marriages of their parents. From this
and my participants stories, I concluded that the
participants felt the responsibility to preserve their
parents marriages and their families in order to allay
their fears of abandonment. My conclusion is consistent with previous ndings that ED daughters were
more fearful of losing attachment gures (Ward et al.,
2000) than non-ED daughters.
Uncertainty. The daughters discussed their fathers
intermittent availability, unreliability, and marital dissatisfaction as contributors to their feelings of uncertainty. Of greatest importance was the uncertainty
of knowing and experiencing their fathers love.
Researchers have concluded that the emotional deprivation in AN women was related consistently to paternal uncaring and un-nurturing behaviors, together
with perceived paternal rejection (Humphrey, 1989;
Parente, 1998). This studys ndings support the previous studies.
Developmental research ndings suggested that
unpredictability of relationships was the most frequent factor that resulted in a childs need for control
(Ross & Hill, 2002). Research has shown repeatedly
that women with AN desired control (Butler &
Montgomery, 2005). My ndings suggested that the
participants control need was precipitated by the
uncertainty in their childhood relationships with their
fathers.
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Fathers, Daughters, and Anorexia Nervosa

Fear of Abandonment. Abandonment and fears of

abandonment were frequent narrative topics for the
participants. Research using attachment theory as a
framework for EDs has begun only recently (Dallos,
2004; Ward et al., 2000). Most literature on attachment
and childhood development has focused on maternal
bonding but has given credence to other early primary
contacts, as well, of which the fatherdaughter relationship is one that has developmental implications.
Failure to achieve autonomy for women with AN
has been documented (Lamoureux & Bottorff, 2005).
Humphrey (1989) concluded that the inconsistent
father thwarts the daughters attempts to individuate.
My ndings suggested that daughters with AN perceive an inconsistent and insecure attachment to their
fathers. If daughters are not securely attached to their
fathers, detachment is ultimately impossible, individuation is difcult, and psychosomatic symptoms are
likely (Bowlby, 1969).
Women with AN had difculty with the developmental tasks of separation and individuation (StriegelMoore & Franko, 2006). Researchers have focused on
daughters failures to complete these growth steps from
their mothers. A few AN researchers extended the task
from the parents as a unit, and found that individuals
who experienced inconsistent parenting had insecure
attachments (Latzer, Hochdorf, Bachar, & Canetti,
2002). Chassler (1997) showed that inconsistent parenting led children to compensatory, proximity-seeking
behaviors. Without secure attachments to their fathers,
the participants in my study may have adopted the
proximity-seeking behaviors that may have contributed
to the difculty in the separationindividuation process
found in AN women.
Transitions: Like Father, Like Daughter
My participants experienced the onset of AN symptoms during the transitional periods from childhood
to adolescence, or from adolescence to adulthood.
Research strongly suggests that these are vulnerable
periods for ED onset (Keel, Leon, Fulkerson, Ingram, &
42

Price, 2001). The inuence of a fathers personality on

his daughters growth has been examined in the developmental literature, and has recently been extended to
ED women. The fathers personality was signicantly
and positively related to an increased severity of symptoms in AN patients (Wallin & Hansson, 1999). My
ndings suggested that the participants were inuenced by their fathers dispositions. The effect did not
necessarily increase AN symptom severity, but it did
inuence how the participants viewed and coped with
the world.
The majority of participants discussed the similarity
of their personalities to their fathers. Neither the
AN nor developmental literature suggests a father/
daughter resemblance of characteristics, but my
nding is consistent with Banduras (1977) social learning theory. One of the theorys assumptions is that
individuals are more likely to model behavior if the
demonstrator has admired status. Adolescents perceived their fathers as more powerful, admired, and
inuential in their relationships than their mothers
(Rosen & Baptiste, 2002). The participants stated that
their fathers used denial, avoidance, and/or withdrawal as their preferred coping techniques when confronted with a problematic situation. I concluded that
because the participants admired their fathers, they
emulated their fathers coping behaviors.
Now You See Him, Now You Dont. According to
psychoanalytic theory, by simply reaching puberty,
most women experience the painful loss of their
fathers love and feel abandoned (Secunda, 1992). Adolescent girls needed and sought more approval from
their parents than did boys; daughters, more than sons,
felt a need to gain their fathers approval (Sharpe,
1994). Approval that was withheld or perceived as
inadequate sabotaged the girls condence and independence, and increased the likelihood of externalizing and internalizing symptoms throughout their lives
(Sharpe, 1994). This study supports other ndings that
reported an association between AN and perceived
paternal rejection, and the fathers lack of care and
nurturing in regard to their daughters (Parente, 1998).
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010

Fathers of teens spent less time with their children,

were less involved, and were perceived by the adolescents as distant, in a study by Flouri and Buchanan
(2003), but the teens did not consider their fathers as
absent from their lives. It was the adolescents condence in their fathers availability that was of greater
importance to the adolescents and to their development than the fathers actual involvement (Scott, Booth,
King, & Johnson, 2007). In the current study, the participants perceived their fathers as absent during their
adolescence, and this may have been detrimental to
their development.
Now You See Her, Now You Dont. AN women,
without a secure sense of attachment, tended to transition into and out of adolescence without needed
developmental skills and feelings of worth, competency, and efcacy (Striegel-Moore & Franko, 2006).
Westbrook (2004) found that AN women experienced
injurious psychological events in their lives that
resulted in developmental stagnation. My participants
had anxious attachments to their fathers in childhood,
and their insecurity was compounded by the fathers
absences in adolescence. Fathers can be signicant
sources of help and comfort to their children during
difcult developmental transitions (Holmbeck, 1996).
Without a rm developmental foundation, secure
paternal attachment, and their fathers help during
adolescence, the separationindividuation process
was very difcult for the participants in the current
study.
My ndings are consistent with Lazaruss (1993)
meta-theory of stress, emotion, context, and coping
processes in which individuals will try various types
of coping methods when encountering stressful
circumstances, depending on the personal signicance. If the individuals appraisal determines that
the situation is unalterable, then emotion-focused
coping, such as denial and distancing, will be used.
Denial and distancing, as in the participants narratives, are enticing coping mechanisms because, as
Lazarus states, these stress responses permit an individual to evaluate the situation as benign, thus reducPerspectives in Psychiatric Care Vol. 46, No. 1, January 2010

ing the psychological stress. The participants in my

study realized that they were incapable of altering
their fathers absences, assessed the situation as
benign, and used denial and distancing to cope with
the loss.
AN: The Catalyst
AN serves a need for the woman and her family
(Minuchin, Rossman, & Baker, 1978). The functional
nature of this disorder makes treatment difcult, and
not all AN women perceive the need for change (Birmingham, Su, Hlynsky, Goldner, & Gao, 2005). A vast
amount of literature is available to clinicians on AN
treatment. However, the diversity of styles actually
limits their utility (Irwin & Charles, 2006).
In contrast, the literature about AN recovery is
limited. The term recovery has often not been operationalized or it is dened differently across studies (Couturier & Lock, 2006). In several outcome studies,
participants were dened as recovered after 8
symptom-free weeks. As relapse often occurs after
treatment, meaningful evaluations of recovery can only
be obtained on long-term follow-up (Richard, Bauer, &
Kordy, 2005).
The medical denition of recovery, restoration of
menses and weight, is the most dominant and quantiable. Researchers have agreed that the etiology is
multimodal, but recovery is measured by the physical
aspects only. Clients views of their recovery and the
recovery process are rarely reported in literature
(Weaver, Wuest, & Ciliska, 2005).
She Changed, He Changed, They Changed. According to family systems theory, when one person in
the family changes, the other family members also
experience change (Minuchin et al., 1978). The change
was not the same for each of the participants. Most,
through therapy, were able to adapt to the loss of their
fathers in adolescence. Two goals of therapy are to
create sufcient mental safety to allow the individual
to feel the stress and to reframe and interpret it from
anew (Schein, 2004).
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Fathers, Daughters, and Anorexia Nervosa

Some of the participants spoke of abandoning their

hopes of having a satisfactory and nurturing relationship with their fathers, as they realized that their
fathers were unable to fulll their expectations. When
stressors change, coping methods change. Researchers
have found that healthier and more adaptive coping
methods encourage healing in women with AN (Bloks,
Spinhoven, Clallewaert, Willemse-Koning, & Turksma,
2001). For the participants, their changes promoted
their healing.
As with family systems theory, Sharkey-Orgnero
(1999) found that as the daughters with AN changed,
the parents opened up to change. She concluded that
the fathers who changed were jarred out of their own
unthinking responses and became more thoughtful in
relationship to their daughters. My ndings support
Sharkey-Orgneros results, as well as the literature
about family systems theory.
Nothing Changed. Change and reintegration may
not always be possible (Schein, 2004). The inability to
grow from past experiences results in life stagnation
(Richardson, 2002). Most participants were able to
change; others were unable to grow from their adversity. As found by Schein (2004), if women who were
struggling with AN were unable to reinterpret and
change perceptions, thoughts, attitudes, and feelings,
they continued to use denial and distancing. The participants who did not change continued to struggle
with AN.
Current Relationship: Catalytic Reaction
Most of the participants were able to attain the
autonomy, separation, and individuation from their
families that have often been difcult for women with
AN (Lock & le Grange, 2007). The participants developed a sufcient self-denition that they did not need
to rely on the acceptance and approval of their fathers.
Through therapy, these participants were able to form
healthier relationships.
Some participants needed to remove themselves
from their family systems to remain healthy. Research44

ers have noted that women with AN who have poorer

outcomes continued to experience disturbed family
relations (Lock & le Grange, 2007). Tozzi, Sullivan,
Fear, McKenzie, and Bulik (2003) found that AN
women who did not have supportive fatherdaughter
relationships and did not relinquish their relational
hopes continued to suffer from AN. My ndings are
consistent with those of Tozzi et al. (2003).
Limitations
The participants and my assumptions, as well as
our relationship, inuenced the type, scope, and depth
of data collected and data interpretation. I must
acknowledge the limitations of vocabulary, the inuence of societal norms on a narratives growth and
development, and the storys psychological context.
The reexive nature of NA is limited by the participants memories, abilities, and willingness to share the
information and the researchers interpretation of their
stories. NA with its small sample size precludes generalizability from the ndings. Although ages varied,
the samples homogeneity also presented constraints.
An unstructured interview allowed the participants to
decide on the shared information, which may have
limited the data.
Implications for Nursing Practice
The fathers inuence on the growth and development of his children has received little attention in the
nursing literature. Fathers are participating more in
child rearing (Phares, Fields, & Kamboukos, 2009), and
as nurses intervene with fathers and their children, an
understanding of the role of the father in the development of AN is essential. Prior to this study, a researchbased description of the fatherdaughter relationship
in AN was missing from the literature. My ndings
suggest the importance of assessing the father
daughter relationship when an AN diagnosis is a possibility. This studys results also provide insights for
nurses about the signicance of family members on
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010

persons with AN and will promote a family-centered

approach to care.
Nurses practice in hospitals, schools, homes, and
communities with adults, children, and aggregates;
therefore, nurses encounter AN in girls and young
women in its many forms and stages. Nurses initiate
primary, secondary, and tertiary interventions, and are
in a position to be involved in the prevention, education, diagnosis, and treatment of AN. This research
offers nursing insights by providing an understanding
of the AN experience and the signicant father
daughter relationship.
Early stages of treatment would benet from an
assessment of the fatherdaughter relationship.
Assessment of and interventions about the daughters
and fathers willingness to change are important, as
change in the fatherdaughter relationship in my
study was the key recovery factor. Interventions
about the development of alternative coping mechanisms may ameliorate the length and severity of
symptoms. Fathers may be unaware of their importance to their daughters and lack the knowledge of
effective fathering. Educational interventions would
be benecial.
Nursing research needs to extend the understanding of womens experiences with AN. Psychological
stress and stressful life events can initiate AN, but
the nature of these stressors are poorly understood
(Cooper, 2005). Additional research, using an attachment theory framework, is needed to explore a
possible link of insecure attachments, paternal role
inconsistency, and AN symptoms. My ndings suggest
childhood similarities in role tenacity of women with
AN and children from alcoholic homes. Studies are
needed that examine these groups. More qualitative
studies need to examine the processes throughout the
AN encounter.
Nurses, as patient advocates, should become active
in health policy development. All of my participants
needed professional help, but their health insurance
did not always cover the costs. Insurance companies
are reluctant to pay for the prolonged AN treatment
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010

(Josephson & Combrinck-Graham, 2006). Mandatory

insurance coverage is needed. Most public schools are
eliminating services, including nursing hours, because
of the economy. Policies to increase the availability of
school nurses could be a cost-effective method to ultimately decrease healthcare costs and the mortality
rates of AN.
This studys purpose was to describe the nature and
meaning of the fatherdaughter relationship from the
daughters perspective. I examined their stories about
the relationships with their fathers throughout their
life spans with consideration of the changes over time.
Several patterns emerged from the participants narratives. This study is an exploration of the paths and
processes that lead to, through, and into recovery from
AN. The participants demonstrated that they were
willing to discuss their families and AN experiences
with healthcare providers in the hope that, in sharing
their stories, other women will not have to follow in
their footsteps.
Author contact: celliott@anselm.edu, with a copy to the
Editor: gpearson@uchc.edu.
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