All the little pointers: a poetic representation of a female elite athlete’s experience of living with and seeking treatment for an eating disorder

ABSTRACT

Eating disorders are highly prevalent in elite athletes but the lived experience of these has not been investigated extensively. In this article, we draw on life story data generated from four hours of interviews with a young (20 years plus), Swedish, elite, female athlete in an individual sport, named Lisa (a pseudonym) to explore her experiences of living with, seeking treatment, and attempting to recover from a diagnosed eating disorder. This exploration is accomplished by the use of poetic representations. Having made the methodological case for their use we then present the poems for consideration by the reader. The three poems are entitled All the little pointers, The voice inside my head, and Turning it around. Following this, we offer some reflections on how each poem might act as a pedagogical resource to assist those involved with elite athletes to better understand the nature of eating disorders, how the sporting environment can play a role in initiating and sustaining them, and how athletes might be supported and guided on the road to recovery.

KEYWORDS:

• Life story
• psychiatric disorder
• poetic representation
• pedagogical resource
• qualitative research

Eating disorders are mental illnesses that can have serious consequences for those living with them in terms of their physical and emotional health and general well-being (American Psychiatric Association, 2013). People with eating disorders are known to deny the severity of their symptoms and generally have a higher mortality rate compared to the general population, with anorexia nervosa six times higher, and bulimia nervosa and atypical eating disorders twice as high (American Psychiatric Association, 2013, 2016; Smith et al., 2018). With regard to athletes, the consequences of living with an eating disorder can include compulsive eating and/or restrictive eating as well as compulsive exercising that can result in chronic energy and nutrient restriction, dehydration and an increased risk of illness and injury as well as other mental health problems such as depression, anxiety and suicidal ideation (Wells et al., 2020). Accordingly, Bennett (2021) emphasised the need to understand the uniqueness of the athlete population in relation to the treatment of eating disorders.

According to Papathomas (2016), disordered eating can be considered an umbrella term that describes a range of problematic eating attitudes and behaviours. These range from unhealthy dieting to clinical conditions such as anorexia nervosa and bulimia nervosa. He pointed out that although numerous idiosyncratic variants of disordered eating exist, “most are underpinned by a negative body image, an overwhelming fear of weight gain and an obsessive preoccupation with food” (p. 176). Significantly, Papathomas noted that for some athletes, “pressures to lose weight for performance gains, particularly in sports where weight and/or aesthetics are considered central to success, can lead to a variety of unhealthy eating practices” (p. 176).

With regard to the prevalence of eating disorders in elite sport, Schaal et al. (2011) found that 4.9% of French elite athletes had been diagnosed with at least one eating disorder within the last 6 months (females 6.5%; males 4.0%). Likewise, Bratland-Sanda and Sundgot-Borgen (2013) also found disordered eating in as many as 6–45% of female athletes and 0–19% of male athletes which meant athletes had a higher prevalence of disordered eating compared to the general population. A prior or present eating disorder diagnosis (evaluated by a licensed caregiver) was also the second most common psychiatric disorder self-reported by elite athletes in Sweden, with only depressive disorders being more common (Åkesdotter et al., 2020). Furthermore, among elite athletes seeking psychiatric treatment in Sweden that fulfilled the diagnostic criteria for at least one psychiatric diagnosis as defined by the World Health Organization (2009), 37% of female athletes were diagnosed with at least one eating disorder (Åkesdotter et al., 2022). In view of this situation Sundgot-Borgen et al. (2013, p. 1012) recommended that medical teams “must know when to raise the alarm and how to advise athletes who are affected by extreme dieting or clinical EDs [eating disorders].” Likewise, Wells et al. (2020) pointed out the need for all those involved in sport to be vigilant and aware of the symptoms of eating disorders and poor body image in athletes.

Historically, research into eating disorders in elite sport have been dominated by a bio-medical perspective that has relied predominantly on quantitative, cross-sectional survey designs that investigate the prevalence of self-reported symptoms of disorders (Joy et al., 2016; Wells et al., 2020; Papathomas & Lavallee, 2012a). For example, in their recent review of research into mental health and female athletes, Perry et al. (2021) found that 83.3% of the included studies were quantitative using a cross-sectional design. Against this backdrop, they called for greater methodological diversity that would include a narrative perspective. This call echoed that of Papathomas and Lavallee (2012a) and Pereira-Vargas et al. (2024) who argued that whilst quantitative forms of inquiry play an important role in researching eating disorders in elite sport, they provide a narrow base for understanding the complexities of this phenomenon which would be enhanced by the use of narrative approaches.

A narrative approach to understanding eating disorders in elite sport has been taken up by a number of scholars. For example, Papathomas and Lavallee (2006, 2010, 2012b, 2014) and Papathomas et al. (2015), extensively explored the experiences of athletes with eating disorders. They highlighted the influence of peer – and performance pressures along with the ideal of the “slim” body in the development of disordered eating in elite sport as well as the ways in which athletes used dismissive narratives to downplay the severity of their illnesses. Another example is provided by Busanich et al. (2014) who used a narrative approach to compare the experiences of a male and female distance runner both of whom had eating disorders. They found that the performance narrative governed the identities of these runners and that disordered eating emerged when these identities were threatened by, for example, poor performance and/or injuries. A narrative approach was also used by de Bruin and Oudejans (2018) to examine how body image contributed to the development of eating disorders in female athletes. Their findings suggested that these athletes recognised the impact of their sporting environment on their disordered eating behaviours in, for example, the form of negative body evaluation and comparison with other athletes. Finally, McGannon and McMahon (2019) used a narrative approach to focus on the turning points in published autobiographies of female elite athletes suffering from eating disorders. Here the struggle to recover from disordered eating within elite sport was highlighted along with the ways in which various meanings attributed to the body are influenced by the narrative resources available in any given sport.

It is important to note, however, that in these studies the authors have adopted the position of story analyst as described by Smith (2016) and Smith and Sparkes (2009). Here, the stories told by elite athletes about their eating disorders are subjected to, for example, a systematic thematic analysis and/or a structural analysis. In this process, rather than letting stories do the work of analysis and theorising, the researcher steps back from the story generated and employs analytical procedures, strategies, and techniques to abstractly scrutinise, explain, and think about its key features. They also theorise from a disciplinary perspective to develop theoretical abstractions.

For story analysts, the “findings” of this process are generally presented using the conventions of the realist tale as described by Sparkes (2002) and King (2016). This kind of tale, they argued, when skilfully constructed can connect theory to data in a way that creates spaces for peoples voices to be heard in a coherent context, with specific points in mind that provides compelling, detailed, and complex depictions of the psychological and social world. This kind of tale, however, is not the only one available to sport psychology researchers to represent their findings about the experiences of elite athletes and eating disorders. As McMahon (2016), Sparkes (2002), and Sparkes and Smith (2014) have illustrated, a range of alternative tales for representing the findings of narrative studies and other forms of qualitative inquiry are now available under the umbrella term of “creative analytical practice” (Richardson, 2000). These include the following: confessional tales, autoethnography, poetic representations, ethnodrama/theatre, ethnographic nonfiction and creative fiction, and musical performances.

A poetic representation, as described by Sparkes and Smith (2014), is where researchers transform their data into a poem-like composition, often using the exact words of the participants arranged to create a meaningful representation of the participant’s lived experience. The process involves word reduction with a view to communicating the findings of a study in an economic and condensed form that encapsulates the essence of events and experiences whilst at the same time illuminating the wholeness and interconnectedness of thoughts. In this reduction, as Leavy (2015, p. 64) explained, poetry is extremely attentive to space, which includes breaths and pauses, in order to create or paint a “feeling picture” that can act as a vehicle for “evoking a snippet of human experience that is artistically expressed as in a heightened state.”

To date, relatively few scholars have used poetic representations in sport psychology. Early examples of this approach in action explored the following. The career motivations of elite female golfers (Sparkes & Douglas, 2007), the sport and exercise experiences of men with severe mental health difficulties (Carless & Douglas, 2009), women’s experiences as recruited athletes within the US intercollegiate sports system (Chawansky, 2011), and same sex attraction and desire for young males in sport and physical education settings (Carless, 2012). More recently, poetic representations have been used to explore the characteristics of a successful coach as defined by parasport athletes (Culver & Werthner, 2018), the experiences of South Asian adults with asthma who engage in sport and/or exercise (Yusuf, 2019), and elite sport coaches and their sense of vulnerability (Hägglund et al., 2024). Such work reveals that poetic representations can be a practical and powerful method for analysing social and psychological worlds. Accordingly, they have the potential to play an important part in exploring the lived experiences of physical and mental wellbeing in the athlete population.

For Sparkes and Smith (2014) poetic representations have the potential to create evocative and open-ended connections to the data for the researcher and the audience (reader or listener) in ways that can touch both the cognitive and the sensory to recreate moments of experience. Such moments, show another person how it is to feel something, with an economy of words. As part of this process, given that people respond differently to poetry than prose, poetic representations can provide the researcher and the audience with a different lens through which to view the same scenery, and thereby understand data, and themselves, in different and more complex ways. Finally, poetic representations are better able to maintain the anonymity of the participants than the standard realist tale that relies on “thick description” and contextual detail. This is an important benefit when the lives of well-known elite athletes are explored, and the findings are presented for public consumption.

Based on the rationale for, and advantages of poetic representations described above, in what follows we use this form of creative analytical practice to explore the experiences of an elite Swedish athlete named Lisa (pseudonym) who, having lived with an eating disorder for a number of years, decided to seek and receive psychiatric treatment during her sporting career. To our knowledge, this is the first time a poetic representation is used in relation to this topic within sport psychology.

Methodology

Lisa was involved in a larger study in which the key questions revolved around how Swedish elite athletes living with diagnosed psychiatric disorders gave meaning to and experienced their disorders over time (Åkesdotter et al., 2024). The inclusion criteria for this study were that the athlete was currently active in a Swedish national team, or had been so within the last two years, were over 18 years of age and diagnosed with at least one psychiatric disorder according to the International Classification of Diseases (ICD-10) (World Health Organisation, 2009), and had previously sought and accessed professional support and treatment for their disorder.

Following ethical approval from a Regional Ethical Review Board, five athletes meeting these inclusion criteria were recruited with the assistance of medical professionals from the treatment records of an open psychiatric clinic at a major city in Sweden. In what follows, we focus on the lived experience of one of these athletes named Lisa (a pseudonym). As Lisa is competing at the highest level (e.g., national team) and is part of a small, potentially identifiable group of participants in one country, in order to protect her anonymity, only limited demographic details are made available. Lisa is in her early 20s, engaged in an individual sport and had received treatment for a long-term eating disorder that she believed started when she was around 10 years of age.

Like all the athletes in the larger study Lisa was involved in recorded life story interviews as described by Atkinson (2007). Here, they were invited to reflect on their experiences of living with a psychiatric disorder at different points in their careers. A biographical mapping method, in the form of a timeline, was also used to connect key points in the athlete’s life stories in a temporal order (Schubring et al., 2019). Author 1, who has clinical training in psychotherapy and the treatment of eating disorders under supervision, conducted the interviews, and given the sensitive nature of the topic, confidential psychological support was made available to the athletes should they require it post-interview. Adopting the position of story analyst as described above, all interview transcripts in the larger study were subjected by Author 1 to a thematic and structural narrative analysis as recommended by Riessman (2008) to examine not only what was said in the stories told (i.e., content) but also how it was told (i.e., structure). The findings were the presented in the form of a realist tale as described earlier (Åkesdotter et al., 2024).

With regard to how the life stories were told by the elite athletes, and Lisa in the larger study, it is important to note that all were structured and framed by the performance narrative. This type of narrative, according to Douglas and Carless (2014), is characterised by a single-minded dedication to sport performance to the exclusion of all other areas of life and self. Athletes with eating disorders often adhere to this narrative to become successful in sport. For example, Busanich et al. (2014) found that the performance narrative shaped the stories told by two distance runners who both struggled with disordered eating by creating a dichotomy between a body that is “disciplined” and successful (i.e., slim) in elite sport as opposed to an ill-disciplined body (i.e., not slim) that is associated with failure. In a study by Papathomas and Lavallee (2014), the same narrative structure with its emphasis on performance and an idealised thin body, was also seen to shape the experiences of a female athlete with a history of disordered eating. The performance narrative in elite sport can therefore provide a justification for athletes with disordered eating to rationalise and maintain pathological behaviours. As such, this narrative type can act as a dangerous companion to athletes with disordered eating or any psychiatric disorder, because it creates and sustains a particular kind of unwelcome “trouble” in their lives that influences their behaviours (Åkesdotter et al., 2024; Frank, 2012; Sparkes & Stewart, 2019).

Against this backdrop described above, and for the reasons given below, a decision was taken to focus specifically on the life story of Lisa and to represent her experiences as an elite athlete with an eating disorder in poetic form. According to Sparkes (2002), “the data generated in qualitative research do not self-evidently lend themselves to the construction of poetic forms” (p. 126). It is important to note, therefore, that it was whilst listening to the interviews, reading the transcripts, and conducting the thematic and structural narrative analysis, that Author 1 noted the ways in which Lisa, in particular, used rich metaphors and evocative language in a rhythmic way to describe her experiences of living with her eating disorder over time. These features, as with the work of Sparkes and Douglas (2007), suggested that the data from her interviews were more amenable and open to an alternative representational style than the interviews generated by the four other athletes in the study. The decision was made, therefore, to construct a poetic representation of Lisa’s experiences that necessarily built upon, and was informed by, the findings of the thematic and structural analysis previously conducted by Author 1 in her role as story analyst. With these findings providing a solid foundation, Author 1 then shifted her position with regard to the data generated in her interviews with Lisa from that of story analyst to that of storyteller as described by Smith (2016) and Smith and Sparkes (2009). Here, the analysis is the poetic representation itself that invites readers to feel Lisa’s experiences which they are free to interpret and evaluate from their own unique vantage points.

Constructing the poetic representation

The 4 hours of interview with Lisa that were conducted in Swedish resulted in 80 pages of double-spaced transcript, amounting to 25,824 words, that provided the data for the 879-word poetic representations that follow. The use of such data leads to what Janesick (2016) and Lahman and Richard (2014) described as research, interpretive or transcription poetry. In constructing these types of poems Richardson (2003) explained how, following social research protocol after 5 hours of interview that produced 35 pages of text, she used only her participant’s words, tone, and diction, but relied upon poetic devices such as repetition, off – rhyme, sounds, meter, and pauses to convey her participant’s narrative. The speech style and the words in the poem, therefore, along with her sense-making process, was that of the participant, but the poetic representation, including the ordering of the material were Richardson’s. Such practices also informed the work of Sparkes and Douglas (2007) as they transformed 35 pages of interview data into four poetic representations using only the words of their participant to give a sense of the narrative flow of her speech and to convey some of the meanings she attached to specific events in her golfing career.

As with Richardson (2003), Sparkes and Douglas (2007), Culver and Werthner (2018) and Yusuf (2019), in what follows only Lisa’s words and phrases are used in the three poetic representations we offer of her experiences of living with an eating disorder. These were constructed by Author 1 following multiple readings of the interview transcripts in which, as suggested by Leavy (2015), she marked evocative or emotionally strong words, the repetition of key phrases and narrative turning points in Lisa’s story. For example, with regard to repetitions, Lisa often referred to the pressures exerted on athletes within her sport to be thin and so her words about how these pressures were exerted are included in the poem called All the little pointers. Likewise, Lisa spoke several times in interview about the voice inside her that she associated with her eating disorder and so this phrase features in the poem called The voice inside my head. As part of this process Author 1 also reflected on the rhythms of Lisa’s speech and the temporal order of events in her life so that these could be condensed into a poetic form that fairly portrayed her sense-making and experiences of living with an eating disorder over time.

Given that the interviews with Lisa were conducted in Swedish but the poems were constructed in English, Author 1 wanted to know if they “worked” in this language to portray Lisa’s experiences. Accordingly, she made the poems available to Author 2 who spoke Swedish and English and Author 3 whose first language was English. Both agreed that the poems took them into Lisa’s experiences in an authentic manner. Author 1 also made the poems available for comment to two former elite athletes, one fluent in both English and Swedish and the other one a native English speaker. Both expressed the view that the poems felt “real” and moved them in strong and direct ways by portraying aspects of psychological suffering within elite sport that in their experiences were rarely discussed or acknowledged. One of them also stated that the poems gave him another view on elite sport as a whole by stepping outside the glorified descriptions often presented in the media.

Importantly, Lisa was given the opportunity to read and reflect on the poems prior to commenting on them in a meeting with Author 1. At this meeting Lisa said that she recognised herself in the poems and that “this was how it was.” Lisa also expressed that it was helpful for her to read the poems at that point in time as her own relationship with, and distance from, her prior eating disorder had continued to grow and, therefore, the poems reminded her about the good work she had done so far to get to where she is today. Lisa felt this process was very helpful but also emotionally charged, as she had started to forget how much she had suffered during those years when she was in the grip of the disorder. She also felt that the poems represented her experiences accurately, fairly, and truthfully. Accordingly, Lisa was happy for them to be made available in the public domain as part of this article, especially if her experiences were useful in helping to raise the awareness of other athletes, coaches and support staff regarding the impact of eating disorders in the lives of elite athletes.

Returning our interpretations of Lisa’s experiences to her in the form of poetic representations and then inviting her to comment upon them can be seen as a form of “member reflection” as opposed to the more problematic notion of “member checking” or “respondent validation” as described by McGannon et al. (2021), Sparkes (2024), Smith and McGannon (2018), and Sparkes and Smith (2014). For them, member reflections are not about verifying results, finding correspondence with the “truth”, or getting at the independent reality of another as is often the case when member checking is utilised by some qualitative researchers. In contrast, member reflection invites the participant to offer their comments on the accuracy, fairness, rigour, and credibility of the researcher’s interpretations about their experiences. In addition, however, member reflections, as part of an ethical practice involving reflexive dialogue, also provide an opportunity for the participant and researcher to work together in a collaborative manner to generate additional data and new insights into a phenomenon of shared interest. As Smith and McGannon (2018, p. 108) pointed out, whereas member checks as a method are often used to sort out, or resolve, contradictory or different claims to knowledge, the notion of member reflection more productively reframes this issue “as a practical opportunity to acknowledge and/or explore with participants the existence of contradictions and differences in knowing.” Such a process, they argued, can lead to a meticulous, robust, and intellectually enriched understanding of the research and how it might be further developed in the future.

Results

All the little pointers

Always little pointers

You should think about your weight

My two best friends in sport

Much bigger than me

It was made clear it did not look good

Talk on the sidelines

Look how big she is.

In the national team

Lectures on exercise and diet

A couple of times a year, nothing strange about them

But for the overambitious

They become tools

Realising how training

Could change the body

A lot of chat about weight and looks

Almost fun to talk about together

God! I am so fat, look at my thighs!

Like our disorders were doing the talking

We wanted to say it was hard living with pressures to be thin

But nobody dared

So we laughed

In sport, like a little society

Cheering each other along

If you are not alone, it does not feel so strange

Almost a little pride

At least among us athletes

A group dynamic

Just working like that

The real consequences

I kept hidden deep inside

For me it was not real, what it did to me

The result of this facade

Pushing it away

Just aiming forward

Caught in a spin

The voice inside my head

This voice inside your head

Not really yourself

A sick mind talking, telling you to do it more and more

Of course, the illness wants to make it worse

Making me sicker

Making everything so hard

Splitting me in half

I don’t want this

But the voice inside me does. It says,

You have to, you have to do this more

Motivating everything with … 

You will get thin

You will look better

More people will want to be with you

It’s not like everything has been bad

I could be in the grip of that voice

But still win a championship medal, be very happy for a while

It’s not like I got depressed

The suffering was more below the surface

It was when I started to fight back

Things got really hard in treatment

I can never tell when it sneaks up on me

It is so subconscious

Looking in the mirror a bit longer, less pasta on my plate

I am no victim of some illness

Not as sick as others say I am

Just being stupid

Letting it control my life

And then it goes on like that

Getting worse and worse

Training hard, constantly thinking about food

Eating small or uneven amounts

Getting sicker

Blaming myself

Until I crash

The voice

Always in the back of my head

Not sick enough to deserve treatment, a good patient is sicker than me

The psychologist doesn’t really think I deserve to be here

At the same time

Denying

Thinking I am not sick at all

I would fuss and lie about things

Very tiresome

Competing, every time I went back to the psychologist

I wanted to portray something better

That I had improved

Sometimes I had

Sometimes I exaggerated or denied

Turning it around

Treatment was awful

Until I got better

Sometimes, I just wanted to go back to the way it was before

Not being aware and just living

Easier than to constantly be reminded

Not to do what the voice tells you

Having this thing I could not control

Starting treatment again and again over time

Not making progress

Thinking I had to get worse, to be able to pick myself up

Only puking 2–3 times a week?

Why should I go to a psychologist for that?

I can take care of this myself

Just need to sharpen up

Often, I could not feel it

The impact of being sick

Denial was so strong, I rarely connected the dots

I would feel so tired

Judging my body extremely hard

But I did not see a connection

Rarely reflecting on what I was doing

The psychologist says that, You will like yourself better

Feel more comfortable in your body

That did not motivate me at all, could not see how that could ever change

I was already so hard on myself

But to talk about my career

That worked

Because there is nothing I care more about than that

Treatment, not making progress

Neglecting advice

Psychologist says, I must inform the national team

Almost a threat

This is not just about me

It affects everyone around me

My goals, my career, my whole life

Now I know how it works

Would not make the wrong choices so easily

Instead of following that voice, I push myself in the opposite direction

Every time I eat a piece of bread

I do something my illness would never allow

And every-time

I do it anyway

Before, the illness was like a magnet

But now I turned it around

I don’t think I will easily get sick again, but must be careful

The voice is extremely good at camouflage

Becoming a part of me

I still have my road to travel

To make it silent

I don’t pick up on things as easily anymore

Because I used to think about it all the time

If someone said something about weight, it felt like they were talking about me

There may not be less talk on the sidelines

I just experience it less

All the little pointers

They kind of pass me by

Discussion

In this article, based on the life story of one elite athlete called “Lisa” we have used poetic representations to explore her experiences of developing, living with, seeking treatment and recovering for an eating disorder. Stepping back from the poetic representation itself, we now consider what coaches, entourage members, medical teams and sport psychologists might learn from each poem and how this form of representation can be used as a pedagogical resource to better understand and support elite athletes struggling with eating disorders. As part of this “stepping back” we offer below some reflections on what we have learned from our reading of the three poems provided above. We have chosen this strategy in the interests of transparency. This is because we feel it is important to acknowledge that as researchers, who have immersed themselves in the data, we actively make interpretations based on the various perspectives and theoretical leanings we bring to the study of Lisa’s life story. To suggest otherwise would be both disingenuous and dishonest. This said, it is important to recognise that we are not offering our current interpretations as the only ones possible for ourselves and other readers. Our own interpretations may change as our thinking about eating disorders and elite athletes develop over time. Other readers of the poetic representations will also bring their own particular frameworks of meaning and theoretical backgrounds to the process of interpreting Lisa’s experiences. As such multiple interpretations are not only to be expected but are invited as part of developing a critical dialogue from a diverse range of perspectives about mental health issues and elite athletes.

All the little pointers

The first poem, All the little pointers, described how talk about weight and shape in Lisa’s sport, from both athletes, coaches and the sidelines, created a group dynamic governed by harsh and negative body evaluations among the athletes that plant the seeds of an eating disorder in some athletes. In Lisa’s story it was made clear that in her sport, “You should think about your weight”, and she describe that negative body evaluations were frequently present in her talk with other athletes, “God! I am so fat, look at my thighs!” de Bruin and Oudejans (2018) have previously found that these negative body-image-evaluations can contribute to the development of disordered eating. Likewise, a systematic review by Scott et al. (2019) on team member influence found that their behaviours play an important role in this development by being both protective (e.g., being supportive, promoting healthy eating) or a risk factor for eating disorders (e.g., critical comments on body, shape and form).

Disordered eating behaviours can be contagious, and athletes often compare and influence each other, for example regarding different diets, the level of body fitness and training routines (Freedman et al., 2021; Scott et al., 2019). It is therefore important to address negative body evaluations amongst athletes in elite sport. In hindsight, Lisa noted that she was not the only one in her sport with disordered eating and reflected that it was “like our disorders were doing the talking” and this talk revolved around losing weight and a pressure to be thin. Accordingly, Lisa stated: “I think we wanted to say that it was hard, but nobody dared, so we laughed.” Downplaying the severity of their disordered eating and hiding its very existence, is a common behaviour of people with eating disorders (American Psychiatric Association, 2016; Gaudiani 2018). Previous research has also found that athletes tend to “put on a mask” and hide the real suffering of their psychiatric disorders in elite sport by remaining silent due to fear of stigmatisation (Åkesdotter et al., 2024). Noteworthy, in this poem we also see how standard “lectures on exercise and diet” can be reworked by some athletes at risk to change their bodies and lose weight instead of optimising their health and performance.

Another aspect of living with an eating disorder, rarely openly discussed by athletes, was Lisa’s description of a sense of pride in controlling her eating and training that was reinforced by other athletes: “If you are not alone [having disordered eating], it does not feel so strange – Almost a little pride – At least among us athletes – A group dynamic – Just working like that.” For Goss and Allan (2009) both shame and a sense of pride can play an important role in the development of disordered eating. They pointed out that pride was an affect associated with social success and feeling approved of or admired by others which often involved “a social comparison and competitive element, of feeling that one is outperforming others or winning in some kind of competition” (p. 310).

With regard to anorexia nervosa, Skårderud (2007) found the interplay between shame and pride (in fulfilling the strict behaviour regime dictated by the disorder) to be a risk factor in maintaining this disorder. More recently, a study with male athletes by Freedman et al. (2021) found that a sense of pride was associated with disordered eating, as it adhered to the masculine dominant cultural norms in elite sport of “doing what it takes.” This is exemplified by an athlete in their study who remembered thinking that he would sometimes declare to his teammates that he had an eating disorder with a sense of pride as this indicated he was more committed than them because he was willing to suffer this disorder to achieve his dreams. As this athlete stated, “it was almost a like a badge of honor” (p. 8).

As Freedman et al. (2021, p. 8) noted, wearing this badge of honour involved a “commitment to an ongoing training routine of extreme behaviours as reinforcers in the sport environment that normalised maladaptive eating and exercise behaviours and sustained their disorder.” For such athletes, compensatory behaviours were used to regulate shape and weight, but these behaviours were also seen as a positive sign of their strong athletic commitment. This positive signalling of commitment can be found also within Lisa’s training group when she spoke about “cheering each other along” because “if you are not alone, it does not feel so strange” and so there is a sense of “almost a little pride.” Importantly, as seen later in Lisa’s story, this sense of pride and joy is short-term and is soon followed by an “extremely hard” self-criticism and judgement of her body. This interplay between self-criticism along with pride and positive feelings when adhering to the strict demands of the disorder has been described by Goss and Gilbert (2014) as a shame-pride cycle that reinforces and maintains eating disorders.

In elite sport, many behaviours found in distorted eating are not only normalised, but also encouraged and reinforced by, for example, extensive weight regulation strategies and excessive (potentially compulsive) exercising (Freedman et al., 2021; Monell et al., 2018). Eating disorders may therefore hide within the expected norm of what constitutes a highly motivated athlete (Thompson & Sherman, 1999). To increase eating disorder literacy, All the little pointers, provides an important window to view one athlete’s experience and reflect upon how being in an environment governed by harsh and negative body evaluations may eventually shape maladaptive eating behaviours. From a pedagogical perspective, this poem exemplifies the need for sport organisations, coaches, and medical teams to counteract the negative impact of social norms associated with the toxic culture of thinness which is a key driver in the onset of eating disorders in both athletes and the general population (Arthur-Cameselle & Quatromoni, 2014a; Arthur-Cameselle et al., 2017). In this regard, All the little pointers may help readers to sense the dangers for elite athletes of operating in an environment in which messages about bodily appearance and weight are communicated informally by the athletes themselves and those they interact with on a daily basis (e.g., coaches and other support staff).

The voice inside my head

The second poem, The voice inside my head, focused on Lisa’s experiences of being in the grip of an eating disorder and the impact it had on her both mentally and physically. It provides insights into how an eating disorder can just “sneak up” on those affected and almost become a part of themselves via small, often subconscious, and frequent behaviours such as “looking in the mirror a bit longer” or putting “less pasta on my plate.”

Lisa describes the difficulties of understanding the consequences of her disorder while she was still living with it, “For me it was not real, what it did to me – The result of this facade – Pushing it away – Just aiming forward – Caught in a spin.” In hindsight, Lisa also acknowledges that she downplayed the severity of her problems by questioning her need for treatment “-Only puking 2–3 times a week? Why should I go to a psychologist for that? I can take care of this myself.” Previous research has found that these kinds of dismissive narratives are common in athletes with eating disorders, and that they, just like Lisa, often downplay the severity and consequences of their behaviours (de Bruin, 2017; Plateau et al., 2017). As described by Lisa, “I often could not feel it – The impact of being sick – Denial was so strong – I rarely connected the dots.” The same pattern is well known in clinical eating disorders outside of sport.

In her book, Sick Enough, Gaudiani (2018) uses a “house on fire” metaphor to describe the tendency of those affected by eating disorders to dismiss their symptoms and maintain a storyline that they are “just fine.” Here, Gaudiani asks us to imagine a young woman standing outside her burning house, and the fire department rushes up. The firefighter jumps out and says to her “We are here to put out your fire.” But she says, “What fire?” The firefighter looks concerned and says, “Well, your fire. I smell the smoke. I feel the heat. I see the flames.” The young women then smiles and says, “Oh, no. If my house was on fire, it would be so hot that my sidewalk would be bubbling. And because my sidewalk is not bubbling, I could not possibly have a house fire” (p. 18).

Another dismissive narrative, noted by Gaudiani (2018) that is commonly used by eating disorder patients is the narrative of “not sick enough.” Here, as a function of their illness, patients don’t think that they are worthy or in need of professional care, treatment and support. Plateau et al. (2017) found this to be a key challenge and hindrance for elite female athletes in seeking treatment for their disordered eating. Both the narratives, “just fine” and “not sick enough”, are present in the The voice inside my head when Lisa stated that she was, “Not sick enough to deserve treatment, a good patient is sicker than me – The psychologist doesn’t really think I deserve to be here – At the same time – Denying – Thinking I am not sick at all.”

Significantly, Lisa speaks about her disorder as “a voice” when she says, “This voice inside your head – Not really yourself – A sick mind talking, telling you to do it more and more – Of course the illness, wants to make it worse.” The “eating disorder voice” has been described by Gaudiani, (2018, p. 7) as the “judgmental, unkind, relentless, comparison making, rule creating, never satisfied thoughts” that often occupy the mind of those suffering from eating disorders. Mantilla and Birgegard (2017, p. S552), stated that it is common for patients with these disorders to, just like Lisa, “spontaneously talk about their disorder in terms of a symbolic other (e.g., a demon, a voice, or a guardian).” Indeed, according to Pugh and Waller (2017), for patients with anorexia those who experience a stronger voice generally take longer to recover, are known to use more severe compensatory behaviours, and have a higher level of negative eating attitudes.

In a study that compared the perceptions of elite coaches regarding athletes suffering with either symptoms of depression or disordered eating, McArdle et al. (2018) found the coaches believed athletes were more responsible for the latter and even suspected them of using their eating disorder as an attention-seeking strategy. Such notions of responsibility are also evident when Lisa stated that she was “Just being stupid, letting it control my life” which suggested she was making an active choice and just needs to “sharpen up.” Set against this, The voice inside my head challenges the myth of rational “choice” by helping readers to understand that those suffering from eating disorders are not willingly manipulating their symptoms and situation. Rather, the “voice of their disorders” is driving their behaviours by its relentless and persistent demands along with its promises of rewards that are never forthcoming. Accordingly, as Bulik (2014) pointed out, “eating disorders are not choices, but seriously biologically influenced illnesses.”

Turning it around

The third poem, Turning it around, provides an example of the challenging road towards recovery for those suffering from eating disorders as echoed in the following comment by Lisa: “Treatment was awful – Until I got better – Sometimes, I just wanted to go back to the way it was before – Not being aware and just living – Easier than to constantly be reminded.” In relation to treatment and recovery, Gaudiani (2018, p. 32), noted that an eating disorder will “passionately defend itself”, and that the “voice” of the disorders can become very cruel, especially when the person affected tries to challenge the voice and break its control over them. This can help explain why treatment for these disorders that challenge this voice can be met by resistance. As Lisa stated, “It was when I started to fight back. Things got really hard.”

Having synthesised the findings of twelve qualitative research studies that focused on the process of recovery from eating disorders, Eaton (2020) used a swimming metaphor to summarise the trajectory of the experiences of those involved. First, the eating disorder was compared to a lifejacket that those affected were very reluctant to abandon as it provided a sense of security, control and identity. At this stage, just as for Lisa in Turning it around, the patients struggle to see the impact of their illness. Eventually various consequences start to become apparent which include the feeling of drowning because the lifejacket is no longer working. For Lisa, this stage came when she realized that her eating disorder threatened her future career as an athlete. For her, like other athletes, becoming aware of such negative consequences associated with their eating disorder formed a common turning point that initiated help seeking on the road to recovery (Arthur-Cameselle et al., 2017). This desire to get back and continue with their sporting career, as Arthur-Cameselle and Quatromoni (2014a, 2014b) pointed out is a common factor that assists athletes to persevere in their journey towards recovery. Accordingly, with regard to the importance of her athletic career as a motivator for her recovery, Lisa stated that “there is nothing I care more about than that.”

Regarding her process of recovery, Lisa spoke of “starting treatment again and again over time, not making progress, thinking I had to get worse, to be able to pick myself up.” Importantly, as Arthur-Cameselle and Quatromoni (2014a) have pointed out, recovery from an eating disorder is contingent on many factors, is often provisional, and relapses are common. In part, this is because on the road to recovery, new coping skills along with cognitive and behavioural changes need to be acquired in order to break free from the demands of eating disordered voice (Arthur-Cameselle & Quatromoni, 2014b; Fairburn et al., 2003). That she was developing such skills are evident in the following statement by Lisa: “Instead of following that voice, I push myself in the opposite direction – Every time I eat a piece of bread – I do something my illness would never allow – And every-time – I do it anyway.” By acting in this manner, as Eaton (2020) noted with regard to the final phases of recovery, the athlete is able to increase the distance between themselves and the voice of their disorder which generates a new found sense of freedom and agency. As Lisa pointed out,

“I don’t pick up on things as easily anymore – Because I used to think about it all the time – If someone said something about weight, it felt like they were talking about me – It may not be less talk on the sidelines – I just experience it less.”

Strengths and limitations

Having offered some reflections on what might be learned from the poetic representation of Lisa’s experiences, it is important to note that each athlete that develops an eating disorder has their own unique trajectory that involves a combination of risk factors (de Bruin & Oudejans, 2018), not all of which are evident in Lisa’s life story. For example, other known risk factors are perfectionism (Fairburn et al., 2003) and genetic influences (Bulik et al., 2006).

Given our aspirations for how the poetic representations of Lisa’s lived experiences as an elite athlete with an eating disorder might be used as a pedagogical resource, it behoves us to consider a number of issues that might be deemed problematic by some. The first of these is the “problem” of generalising from a sample where n = 1. Clearly, qualitative research does lack generalisability when it is viewed only from the perspective of statistical-probabilistic generalisability. As Smith (2018) and Sparkes and Smith (2014) pointed out, however, whilst this kind of generalisability is relevant to quantitative research it is not a relevant or meaningful goal for qualitative research which is based on a different logic, set of assumptions, and purposes. Accordingly, they offer alternative notions of generalisability that are consistent with the non-random and purposeful sampling procedures used in qualitative research, such as naturalistic generalisation, transferability, recognisability, generativity, analytical generalisability and intersectional generalisability. Of these, generativity, defined by Barone and Eisner (2012, pp. 151–152) as “the ways in which a work enables one to see or act upon phenomenon even though it represents a kind of case study with an n of only one,” is of particular relevance to our use of poetic representations.

According to Barone and Eisner (2012, p. 152), “the arts typically project an image that reshapes our conception of some aspect of the world or that sheds light on aspects of the world we had not seen before.” For them, good arts-based research generalises in such a fashion because it has “legs” that allow us to go someplace. Such work, therefore, “possesses the capacity to invite you into an experience that reminds you of people and places that bear familial resemblances to the settings, events, and characters within the work” (p. 152). Accordingly, by inviting the reader into the lived experiences of Lisa in relation to her eating disorder via poetic representations, we seek generalisability in the form of generativity. Here, as with naturalistic generalisations and transferability as described by Smith (2018) and Sparkes and Smith (2014), the onus is placed on the reader to reflect upon and make vicarious connections between Lisa’s experiences and their own depending on how they are positioned in relation to her.

Given that our use of poetic representations to illuminate aspects of Lisa’s experiences of living with an eating disorder puts the onus on the reader to make vicarious connections, then questions might be raised about the quality of the poems offered if this goal is to be achieved. After all, we as authors are social scientists with no academic background in literature. In view of this, Piirto (2002), a literary writer and a qualitative researcher, asked the following question: Should we accept inferior poems as qualitative research? In answer to her own question Piirto offered up the case of a poem she wrote using data from a research project. Having presented this poem to a special interest group at a major academic conference, she told the audience that when judged by her personal and literary standards it was an inferior poem. The audience, however, informed her that the poem had merit too, that it worked at a number of levels ranging from the emotional to the pedagogical, and was therefore effective for the purposes of qualitative research. In short, the poem was good enough, it worked, for the job it was intended to do at that time for that particular audience.

For Lahman et al. (2019) and Sparkes (2020) the notion of researchers producing poem-like, not-quite poetry or poemish representations to convey experiences to an audience provides a safe space for growth and “good enough” creations depending on the desired goals. One does not therefore need to be a “proper” published poet to produce poemish representations that are good enough and work. Of course, this is not to say that such representations cannot be improved and made better by working collaboratively with a recognised poet who can support and guide the researcher through the process of crafting poetry of various kinds to suit a range of purposes. This, however, as in our case, is not always possible.

That All the little pointers, The voice inside my head, and Turning it around are good enough and work for their intended purposes is evident in the reactions of people who have read them. In relation to this, the two elite athletes that read the poems felt that they gained a deeper understanding and empathy for the process of living with and seeking treatment for an eating disorder by reading the poems. Likewise, having been invited to provide feedback on a previous draft of this article, a clinician specialising in eating disorders, stated that that the three poems could provide a useful resource for the families and friends of those living with an eating disorder as well as clinicians who often experience frustration regarding the slow or apparent lack of progress of such patients. Significantly, given the accessibility of the poetic representations of Lisa’s experiences to a wide range of audiences, this clinician stated that in her future lectures with coaches and trainers about eating disorders, she would include the poems “to illustrate the lived experience and to enhance empathy and acceptance in my audience.”

The comments above by the athletes and specialist in eating disorders suggest that, while they might read All the little pointers, The voice inside my head, and Turning it around from different positions, these poetic representations are good enough for our purposes and that they work in a number of ways. First, they are able, with an economy of words, and by eliciting a different response than would be generated by a standard prose account, to create evocative and open-ended connections between the reader and the data that allows for an empathetic understanding of what it means to live with an eating disorder as an elite athlete. Second, regardless of their level of expertise in and awareness of the area of eating disorders, the poetic representations provide the reader with an alternative lens through which to engage with and understand this phenomenon in more nuanced ways.

Closing comment

Just how an eating disorder comes into the life of an elite athlete, how they live with it on a daily basis, and how they recover from such a disorder is a complex phenomenon. In view of this, diverse methodological approaches are required to assist sport psychologists and others to better understand this phenomenon and to develop relevant strategies to assist elite athletes on the long and challenging road to recovery. In this article, we have suggested that a narrative approach in which researchers adopt the position of story analyst and present their findings in the form of a realist tale has a part to play in this methodologically diverse quest for understanding. Beyond the use of such tales, we have further suggested that poetic representations can be a practical and powerful method for analysing the social and psychological worlds of elite athletes living with an eating disorder. Accordingly, we articulated both how and why we produced a poetic representation of one elite athlete, named Lisa, and her experiences of living with an eating disorder. Having presented three poems, we then considered how each one worked to take the reader into the lived realities of Lisa’s disordered eating experiences and what we might learn from the different insights generated by them.

We hope that our use of a poetic representation in this article has revealed the usefulness of this form of creative analytic practice in action and how such representations can provide an important pedagogical resource by inviting readers into the experience of an eating disorder and allowing them to develop different ways of knowing about this phenomenon in relation to their own personal positioning towards it. As such, we suggest that poetic representations have a part to play in increasing eating disorder literacy and awareness among elite athletes, and those who work with them on a regular basis, so that all those involved can recognise the symptoms of such a disorder and be better prepared to provide the support and care that each individual athlete both requires and deserves.

Acknowledgements

We would like to extend our thanks to Lisa for her generosity in sharing her experiences with us, the two anonymous reviewers for their insightful comments on earlier drafts of this article, and Emma Forsén for reading and commenting on the poems.

Disclosure statement

Author 2 had a part-time employment as a psychotherapist at the clinic used for recruitment but was not in any way involved in Lisa’s treatment. There are no other competing interests to declare.