A systematic review and meta-synthesis of the effects and experience of mentoring in eating disorders and disordered eating

Eating Behaviors 21 (2016) 66–75

Contents lists available at ScienceDirect

Eating Behaviors

A systematic review and meta-synthesis of the effects and experience of mentoring in eating disorders and disordered eating Sarah Fogarty a,⁎, Lucie Ramjan b,c, Phillipa Hay d a

University of Western Sydney, Australia School of Nursing and Midwifery, University of Western Sydney, Australia Centre for Applied Nursing Research (CANR), Ingham Institute of Applied Medical Research, Australia d School of Medicine, University of Western Sydney, Australia b c

a r t i c l e

i n f o

Article history: Received 28 May 2015 Received in revised form 11 November 2015 Accepted 16 December 2015 Available online 23 December 2015 Keywords: Mentoring Eating disorders Disordered eating

a b s t r a c t In this review, we aimed to explore the benefits, effects and experiences of mentoring on those with an eating disorder or disordered eating. After a systematic search of the literature, four papers were included in the review. A qualitative analysis of the papers identified three key themes. The themes were (1) diverse benefits (mentees), (2) finding comfort in belonging (mentees), and (3) affirmation of the transformation they have made (mentors). The experience of mentoring was shown to have value for both mentors and mentees. Mentorship should be further utilized in the areas of eating disorders and disordered eating, as it shows promising reciprocal benefits for both mentor and mentee © 2015 Elsevier Ltd. All rights reserved.

Contents 1. 2.

3.

4. 5.

Background . . . . . . . . . . . . . . . . . . . . . . . . Materials and methods . . . . . . . . . . . . . . . . . . . 2.1. Types of participants . . . . . . . . . . . . . . . . . 2.2. Types of intervention(s)/phenomena of interest . . . . 2.2.1. Inclusion criteria . . . . . . . . . . . . . . 2.2.2. Types of outcomes . . . . . . . . . . . . . . 2.2.3. Exclusion criteria . . . . . . . . . . . . . . 2.2.4. Types of studies . . . . . . . . . . . . . . . 2.3. Search strategy . . . . . . . . . . . . . . . . . . . 2.4. Assessment of methodological quality and data extraction 2.5. Data synthesis . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Description of studies . . . . . . . . . . . . . . . . 3.2. Mentees' experiences . . . . . . . . . . . . . . . . 3.3. Mentees' benefits . . . . . . . . . . . . . . . . . . 3.4. Mentors' experiences . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . .

Conflicts of interest

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Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

⁎ Corresponding author at: PO Box 2002, Homebush West, NSW 2140, Australia. E-mail addresses: [email protected] (S. Fogarty), [email protected] (L. Ramjan), [email protected] (P. Hay).

http://dx.doi.org/10.1016/j.eatbeh.2015.12.004 1471-0153/© 2015 Elsevier Ltd. All rights reserved.

S. Fogarty et al. / Eating Behaviors 21 (2016) 66–75

1. Background Eating disorders according to the DSM-5 include Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), PICA, Rumination Disorder, Avoidant/Restrictive Food Intake Disorder (ARFID) or Other Specified or Unspecified Feeding or Eating Disorder (OSFED or UFED) (American Psychiatric Association, 2013). OSFED/UFED replaces the Eating Disorder Not Otherwise Specified (EDNOS) category. In the developed world the lifetime prevalence of eating disorders is 1.01% (Hudson, Hiripi, Pope, & Kessler, 2007; Qian et al., 2013) and this appears to be increasing (Mitchison, Hay, Slewa-Younan, & Mond, 2012; Qian et al., 2013). Eating disorders are the second leading cause of disability in females aged 10–24 years in Australia (Hall, Patton, & Degenhardt, 2011). Mortality rates, mainly due to suicide, are twice as high for those with Bulimia Nervosa (BN) and close to six times higher for those with Anorexia Nervosa (AN), when compared to expected population mortality rates (Arcelus, Mitchell, Wales, & Nielsen, 2011). Eating disorders pose a high risk for premature death due to natural and unnatural causes (Harris & Barraclough, 1998). The socio-economic cost of eating disorders is also of concern and includes suffering for individuals and their families and outcomes such as death (including suicide), marriage breakups, stress, social isolation, relocation, heart attacks from stress and loss of careers (Treasure, Claudino, & Zucker, 2010). Disordered eating is the most common indicator of the development of an eating disorder. Disordered eating can have a destructive impact upon a person's life and has been associated with reduced ability to cope with stressful situations (Ball & Lee, 2002; Ginty, Phillips, Higgs, Heaney, & Carroll, 2012; Thome & Espelage, 2004) and an increased risk of self-harm (Ginty et al., 2012; Wright, Bewick, Barkham, House, & Hill, 2009). A multidimensional treatment approach is most commonly adopted for the treatment of eating disorders and disordered eating. Multidimensional treatment addresses physical, psychological, psychosocial and family needs of the individual, and involves a multi-disciplinary team including psychiatrists, psychologists, primary care physicians, social workers, nurses and dieticians. Effective treatment involving multi-disciplinary team and a stepped care approach has been identified as important to recovery (Hay et al., 2014; Treasure et al., 2010). Stepped care is about having the right service in the right place, at the right time delivered by the right person, so that effective but less resource intensive treatment is trialed first, prior to a decision to ‘step up’ or ‘step down’ services (Unützer, Schoenbaum, Druss, & Katon, 2006). However a stepped care approach can be difficult due to a lack of treatment options for eating disorders across community care settings, difficulty in accessing treatment outside of psychological treatment and a lack of providers who know how to treat eating disorders (Perez, Kroon Van Diest, & Cutts, 2014). There is also a particular need for treatment options for those who have transitioned from inpatient settings back into the community or are not yet in need of inpatient eating disorder care. A stepped care approach is not a single therapeutic approach; it can take multiple forms such as psychological, self-help, computerized treatments and/or mentoring and above all, it may potentially meet the needs of those transitioning from acute care to the community and vice versa. ‘Hope is a powerful thing’ (King, 1982). It is powerful because according to the Hope Theory, hope involves agency and pathways which is the goal-directed energy, determination and planning to obtain the desired outcome (Snyder, 2002). Hasson-Ohayon, Kravetz, Meir, and Rozencwaig (2009), Hawro et al. (2014) and Yadav (2010) have shown hope to be linked positively to quality of life (Hasson-Ohayon et al., 2009; Hawro et al., 2014; Yadav, 2010) and lack of hope has been identified as a major obstacle for ‘recovery’ from chronic anorexia nervosa (Dawson, Rhodes, & Touyz, 2014). People with an eating disorder have stressed the importance of hope for treatment and recovery (Dawson, Rhodes, & Touyz, 2014; Hay & Cho, 2013; Lindgren, Enmark, Bohman, & Lundström, 2015; Wright & Hacking, 2012). There

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is evidence that those with an eating disorder find it beneficial (to varying degrees) to hear about others who have had an eating disorder, who are now ‘healthy’ as this provides hope and increases motivation (Dawson, Rhodes, Mullan, et al., 2014; Dawson, Rhodes, & Touyz, 2014; Lindgren et al., 2015). Mentoring is a term used to “describe a relationship between a less experienced individual (the mentee), and a more experienced individual known as a mentor (Collins Dictionary of the English Language, 1979). Mentoring in eating disorders has been used primarily as a prevention initiative that assists with increasing self-esteem and improving body image (Lippi, 2000; McCarroll, 2012; McVey et al., 2010; Perez et al., 2014). Mentoring has been used successfully in healthcare for conditions such as alcoholism and overeating, professionally in teaching and vocationally (Perez et al., 2014) however there has been limited use of mentors in recovery from eating disorders and disordered eating. The aim of this systematic review is to undertake a critical review of studies in order to better understand the benefits, effects and experiences of mentoring on those with an eating disorder or disordered eating. More specifically, the objectives are to identify: the benefits of mentoring on those with eating disorders or disordered eating and the meaningfulness/experience of mentoring on those with eating disorders or disordered eating. 2. Materials and methods The authors have followed the structured process of PRISMA in this systematic review (Moher, Liberati, Tetzlaff, & Altman, 2009). 2.1. Types of participants This review considered studies that included participants with eating disorders or disordered eating. Disordered eating is defined as: “…troublesome eating behaviors, such as purgative practices, binging, food restriction, and other inadequate methods to lose or control weight, which occur less frequently or are less severe than those required to meet the full criteria for the diagnosis of an ED” (Pereira & Alvarenga, 2007, p. 142). 2.2. Types of intervention(s)/phenomena of interest 2.2.1. Inclusion criteria This review considered studies and literature that investigated the use of mentoring for those with an eating disorder or disordered eating. 2.2.2. Types of outcomes This review considered studies or literature that reports the experience and/or benefit of mentoring for those with an eating disorder or disordered eating. 2.2.3. Exclusion criteria This review did not review publications or literature using mentoring for the prevention of eating disorders or disordered eating. Textual papers selected for retrieval were assessed by the first two authors independently for authenticity prior to inclusion in the review. Research published prior to 1980 and in languages other than English was also excluded from this review. 2.2.4. Types of studies The review considered descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion as well as studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. This review considered mixed methods, experimental and/or epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, prospective and

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retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion. Due to the limited number of research studies, other text such as opinion papers and reports were considered. The textual component of the review considered expert opinion, discussion papers, position papers and other text. 2.3. Search strategy As research can be difficult to find (Thomas & Harden, 2008) both electronic searches of databases and searching ‘gray’ literature were used. Publications/literature were identified with a systematic online search of CINAHL Plus with Full Text (EBSCOhost, EBSCO), Scopus (Pubmed), Dissertation and Theses, Google Scholar and Google up to the date of 22nd September 2014, using the keywords (“mentoring” and “eating disorders”) or “disordered eating” as well as “mentoring” AND “anorexia” and “mentoring” AND “bulimia” The Scopus search used ‘All Fields’ and retrieved 185 results and a further three results were retrieved from Dissertation and Theses and a manual search of the reference sections of the identified studies (see Fig. 1). The aim was to obtain sufficient articles to reach ‘conceptual saturation’. The search strategy aimed to find both published and unpublished studies. 2.4. Assessment of methodological quality and data extraction Identification of the studies and literature was undertaken by the first author. Publications and literature selected for retrieval were assessed by the first and second author for methodological validity prior to inclusion

in the review. Due to uncertainty as to whether media releases/newspaper articles were advertisements for particular programs, and thus the reported benefits may be questionable; these were excluded from the review. All remaining articles were assessed using a modified standardized critical appraisal instrument called Critical Appraisal Skills Program (CASP) (Critical Appraisal Skills Program (CASP) Qualitative Research Checklist 31.5.13). The CASP is a qualitative assessment tool that provides an indication of the trustworthiness and relevance of findings (Critical Appraisal Skills Program (CASP) Qualitative Research Checklist 31.5.13). The CASP was modified to provide a score. For each of the ten questions a score of 0 = little or none, 1 = moderate, needs further detail and 2 = fairly full description was allocated, with a possible maximum score of 20. Any disagreements that arose between the reviewers were resolved through discussion, or with a third author. Data extracted included specific details about the interventions, populations, study methods, outcomes of significance and specific objectives.

2.5. Data synthesis In synthesizing the evidence from relevant included literature we followed the method described in Shaw (2012), i.e. both authors read and re-read the papers separately, then together constructed a table of themes as reported in the primary paper (first-order constructs), then together translated studies by compiling second order constructs and a comparison of concepts from studies into one another, and then presented findings as a series of themes supported by quotes from the original paper(s). These categories are then subjected to a thematic

Fig. 1. Flow chart of study selection.

Author (Year)

Country setting & type of mentoring provided

Participants N, age, ED features or EC features

Study question/objective Objective of program

Study design/methodology and transparency Program type

Rigor of analysis and reporting

Lippi (2000)

New Jersey, USA. One-on-one support mentoring. “South Jersey Eating Disorder Task Force”, a network of professionals promoting eating disorder awareness at the community level, conceived the support mentoring idea and developed mentoring dyads from present and former clients.

12 individuals in total aged 18–65 years. All 12 participants were female with an eating disorder (AN, BN, EDNOS). 6 were in the early stages of recovery (mentees) and 6 were in the later stages of recovery (mentors).

Aim: To investigate the mentoring relationship as a support system for women recovering from eating disorders. Research questions:

Study design: Descriptive and evaluative program using a case-study approach. Methodology: Used criterion based sampling and reputational case-selection. Final interview was conducted by the researcher using a phenomenal approach. Program type: Pairs were matched through homogeneity of diagnosis, personality traits, developmental age and stage and personal interests. Program ran for 6 weeks and mentors met once a week. Data Collection: Multiple methods of data collection; journaling and exit interview and researcher recorded observations. Interview were audiotaped then transcribed. Data analysis: Grounded theory or constant comparative approach. Verification of findings was done using checking of data for disconfirmations, monthly debriefing of the researcher and maintain an audit trail.

CASP score = 18/20 Nothing about those who chose not to take place in the study. Limited data on the critical examination undertaken or the researchers role in the analysis.

Study design: Quasi-experimental design (no control group) — pilot study.

CASP score = 17/20 The publication mentions the need for

McCarroll Michigan, USA. (2012) Group mentoring program.

Total Mentees: 31 adolescent girls in 7th and

1) What were the elements or themes that emerged within the context of the mentoring relationship? 2) How did the mentoring relationship impacts the recovery process? 3) How did the mentoring relationship effects both the mentor and the mentee? What were the commonalities and/or differences in their experiences? 4) How did personal sharing in the mentoring relationship effects the recovery process? 5) How did both the mentor and the mentee describe their overall experiences, as a result of the mentoring relationship? Was this a learning experience for them? If so, in what way? Aim: Examine the effects of being involved in a

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(continued on next page)

S. Fogarty et al. / Eating Behaviors 21 (2016) 66–75

Table 1 Characteristics of included papers/literature.

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Table 1 (continued) Author (Year)

Bailey et al. (2008)

Participants N, age, ED features or EC features

Study question/objective Objective of program

It's Great to be a Girl! is a group mentoring program that employs a feminist empowerment model to assist adolescent girls in coping with the developmental challenges they face during an often tumultuous period in their lives.

8th grades registered in the It's great to be a girl program at a local middle school in Ypsilanti, aged between 12 and 14. Mentors: 36 university women enrolled in the Conversations with Girls course at Eastern Michigan University aged between 18 and 58 years. Mentoring occurs once a week for eight weeks.

mentoring program on both the mentors and mentees on the following domains; disordered eating, psychological distress, objectified body consciousness, self-esteem and feminist identity.

Study design/methodology and transparency Program type

Methodology: Used convenience sampling. Program type: Participants participated in the It's Great to be a Girl! mentoring program for 8 weeks. Group discussion format, once a week for 8–10 weeks, addressing issues such as friendship, teasing and harassment, body image and dream building. Each session is 2 h involving 2 mentors (Femtors) and 3–7 adolescent girls. Femtors met with each other to discuss experiences during the mentorship program. Data collection: Pre- and post-mentoring program. Data analysis: Analysis done by MANOVA. Mostly in the USA. Total 141 individuals. Aim: Cross sectional, retrospective study with the Support mentoring 34 female mentors average 34 years of use of online self-report questionnaires. age. Included 4 mental health Natural control group — waitlist for 1) Examine benefits of a mentor model for professionals with no ED history and 30 mentoring services provided the control individuals recovering from an eating recovered individuals (average 8 years sample (labeled unmatched mentees). disorder recovered). 2) Use common, empirically validated, 56% had experiences of AN, 38% BN, 15% self-report questionnaires BED and 38% EDNOS. 3) Provide perspective of the mentor and Total 107 mentees, average age 31, the needs of the sample predominately women. 4) Quantify topics that mentors and 58 mentees were matched with a mentees regularly discussed, support mentor and 49 mentees were needs for mentees and impact of unmatched. mentoring on mentors. UK program (Girls in Motion TM) run at Mentors: 25 college women. Mentees: Aim: Evaluate whether the positive Matched pairing based on common interest. Elon University. 25 local girls aged 10–11 years. changes in measures of social physique Program ran for 8 weeks meeting once a Support mentoring focusing on body image. anxiety (SPAS-C) and EDI-DT and EDI-BD week for 75 min to exercise and discuss are maintained at one-year follow-up. topics (i.e. exercise for health, body shapes and sizes, media influences on body image, and nutrition). Mentors contacted their mentees at least once a week via phone or email.

Rigor of analysis and reporting

evidence on the effect of mentoring on adolescents with subclinical eating disorders however having a subclinical eating disorder was not listed as an inclusion to participating in the study. Disordered eating was the central phenomenon investigated in the study however the mentoring program was not specifically designed to address subclinical eating disorders. Not clear how the McKnight Risk Factory Survey was used to determine composite eating disorder measures or binging, purging or emotional eating. CASP score = 18/20 Some recall bias as do not know how long the duration of the retrospective sampling. No descriptions of how open-ended questions were analyzed.

CASP score = 13/20 Ethical issues not addressed, recruitment process unclear, study methodology unclear, statistical analysis method unclear. Unsure who matched, collected data and undertook analysis and if they were blinded to the study.

S. Fogarty et al. / Eating Behaviors 21 (2016) 66–75

Perez et al. (2014)

Country setting & type of mentoring provided

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Table 2a Themes related to the benefits and the meaningfulness/experience of mentoring for the mentees as reported in the primary papers. Benefits from mentoring — Mentees Publication Theses and journal publications Lippi (2000) McCarroll (2012)

Perez et al. (2014)

Posters/Oral presentations Bailey et al. (2008)

Themes/Results Recovery process continued to be fostered, with an increased self-awareness and more in-depth understanding of recovery as a process. Significantly lower score on the composite eating disorder measures post-intervention. Post-intervention levels of binging, purging and emotional eating (both eating more and eating less to cope with emotions) and dieting behaviors dropped significantly below the normative levels for the population. No significant changes for self-objectification, psychological distress or self-esteem. Feminist identity significantly higher post-intervention. Significantly higher levels of QoL in education/vocation, family and close relationships, future outlook, psychological, emotional, values and beliefs, and physical domains than unmatched mentees. No differences between groups for motivation, energy and confidence towards recovery. Greater frequency of communication with a mentor was positively associated with higher levels of quality of life in the education/vocation, family and close relationships, future outlook, psychological, emotional, values and beliefs and physical domains. Anxiety — no benefit 1-year post program follow-up. EDI-DT and EDI-BD — no benefit 1-year post program follow-up.

Meaningfulness/Experience from mentoring — Mentees Publication

Themes

Theses and journal publications Lippi (2000)* Role modeling: Mentors role modeling normalizing recovery, recovered self-image, healthy eating and providing suggestions and examples and sharing ideas about what worked for them. Sharing: Eating disorder thoughts, secrets, personal stories, relationships, feelings, personality traits. Sharing views on recovery in a supportive environment. Journaling as part of the mentoring process allowed feelings to become ‘visible’ and out of one's head. Self-acceptance: Not being judged, being understood by someone else. Someone who as walked in ‘their’ shoes. Not feeling so weird or strange. Validation of own recovery. Finding their own strength, personal growth and improved self-esteem. Self-discovery: Personal growth from the experience of mentoring/being mentored. Courage in being involved in program. Letting go of eating disorder and finding a new identity. Strength to see positives in life. Self-realizations: Finding one's self, finding a purpose, raised awareness of issues around their own eating disorder that needed addressing. Becoming more self-aware. Program: Less rigid than treatment and something fun. Difficult to work with someone thinner or someone overweight. Ability for program to be not too structured. Issues around food when meeting up. Reciprocity, friendship and equality in the relationship. Looking forward to meetings and the talks (talking about their own issues and not worrying about other people's issues). Impartiality. Feel connected by experiences. Drawing from mentors' experiences and benefitting (reciprocity). Skills and resources: Making healthy connections are crucial to the recovery process. Relearning social skills in a safe environment. Being ready and wanting to recover. Feeling connected. Positive relationship; transitioning towards recovery. Mentors providing hope for recovery. Perez et al. (2014)* Significantly less missed treatment appointments for those receiving mentoring. Sharing: Someone to talk to about how to manage or reduce eating disorder thoughts and behaviors. Supported: Someone to help manage recovery — motivation, commitment to recovery, relapses, how to choose recovery, setting and working towards goals, and dealing with triggers. McCarroll (2012)* Relationships: Importance of building a beneficial relationship. *Themes are not from a qualitative analysis rather extracted by authors from the publications.

analysis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. 3. Results 3.1. Description of studies Thirteen publications were initially identified, all thirteen were read and of these four were included and nine were excluded. The nine excluded were: a repeat article, five press releases (Government of Western Australia; ISIS The Eating Disorder Centre., 2014; Lee, 2003; National Eating Disorders Association, 2011; Royal Melbourne Hospital, 2008), a conference poster (Fredenberg, 2010), a conference paper (De Ayala & Perry, 2005) and a television reality program based on women battling eating disorders (Starving Secrets Episodes 1–6, 2011–2012). Of those included one was a qualitative study, two were quantitative studies and one poster presentation. The four papers included in the review are described in Table 1. Two of the papers included eating disorders (Lippi, 2000; Perez et al., 2014) one strongly indicated sub-clinical eating disorders (McCarroll, 2012) and one was unknown but likely to be eating disorder related (Bailey, Tapler, French, & Bailey, 2008). McCarroll's

(2012) program was designed to cater for adolescents with subclinical eating disorders however they did not report the number of participants with sub-clinical eating disorders, they did report that the adolescents had a significantly higher than normative scores for over concern with weight and weight control behaviors. Bailey et al. (2008) was a poster presentation that provided a limited description of the sample including type of eating issue, however, a validated eating disorder inventory was used in their study indicating a likelihood of either an eating disorder or disordered eating. Mentees varied from 12 to 107 in each paper and were predominately women. Themes related to mentoring benefits and experiences in the 4 articles are summarized in Tables 2a and 2b. The themes resulting from translation across studies are summarized in Table 3.

3.2. Mentees' experiences The main theme that emerged for the mentees was the experience of finding a sense of comfort in belonging. This involved three subthemes, one of which included sharing with someone who had walked in their shoes. Participants reported on the impact of

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Table 2b Themes related to the benefits and the meaningfulness/experience of mentoring for the mentors as reported in the primary papers. Benefits from mentoring — Mentors Publication

Themes/Results

Theses and journal publications Lippi (2000) Validation of own recovery. Reinforcing own coping skills. An increased self-awareness and more in-depth understanding of recovery as a process (‘a refresher’). Improving own social skills. Drawing from mentees' experiences and benefitting (reciprocity). My ED (life experience) has had some purpose — a positive connection to another woman. Feeling of satisfaction, something to offer another, elevating self-esteem. McCarroll (2012) Feminist identity significantly higher post-intervention. No changes in any of the outcomes measures for the mentors. Meaningfulness/Experience from mentoring — Mentors Publication

Themes

Theses and journal publications Lippi (2000) Self-realizations: Raised awareness of issues around their own eating disorder that needed addressing. Self-discovery: Personal growth from the experience of mentoring/being mentored. Reminding them how far they have come in their own recovery. Self-acceptance: Not feeling so weird or strange. Skills and resources: Being understood by someone else. Feel connected by experiences — ‘walked in their shoes’. Becoming more self-aware (like looking in a mirror). Positive relationship; transitioning and watching someone embrace a new self. Sharing: A level of intimacy in the relationship. Wanting to help others. Able to understand and have experienced an eating disorder and what the mentee is going through. Program: Journaling as part of the mentoring allowed identification and expression of feelings in a safe place. Looking forward to meetings. Helping others, making a positive difference. Sharing views on recovery in a supportive environment. Perez et al. (2014) Strengthening the skills they learned while in recovery. Solidifying the steps required towards recovery. Reminding them how far they have come in their own recovery/the unhealthy place they were with their eating disorder.

engaging with someone who has ‘walked in their shoes’ as a source of inspiration: “It's like someone has walked on the same path that I have been on” (Lippi, 2000, p. 142). “My mentor gave me that extra 5%. Just listening to her speak and knowing she have been at the same place” (Lippi, 2000, p. 205).

knowing look on someone's face who share's this pain is unspeakable” (Lippi, 2000, p. 118). “It's just an incredible perspective to have someone else relate to the same things I feel, unprompted and truthful” (Lippi, 2000, p. 240). Mentees found support from “staying motivated and committed to doing the hard work of recovery” (Perez et al., 2014, p. 8).

“I think it gave me hope to get to the next point…it gave me courage to do that. Just listening to my mentor and knowing there is a light at the end of the tunnel” (Lippi, 2000, p. 254).

Many participants described the importance of feeling ‘normal’ and being able to express their feelings without judgment when involved in the mentoring relationship as represented in the following quotes:

“What I really benefited from was knowing that she had an eating disorder, and she was sick, and now she is sitting across from me, and she has a husband, a son, a job, and that's what I loved hearing about” (Lippi, 2000, p. 205).

“It was kind of like I could tell my mentor different things and she wasn't going to think I was nuts….” (Lippi, 2000, p. 140).

It was also important for the mentees to feel understood and supported and that only someone who has been where they have been can truly understand their predicament: “I felt the mentee's fear, I understood her lack of assertiveness with other and her need to please others. I was also able to understand her symptoms, such as the runners high I got from starvation…The

“Talking to my mentor makes me realize that I am not strange or extreme” (Lippi, 2000, p. 142). 3.3. Mentees' benefits The review found that the benefits for mentees were diverse. Qualitative benefits included the fostering of the recovery process with greater self-awareness and a deeper understanding of the process of

Table 3 Translation of themes related to mentoring across the 4 primary studies. Relates to:

Themes

Sub-themes

Mentees—benefits

Diverse benefits

a) b) a) b) c) a) b) c)

Mentees—experiences Finding comfort in belonging

Mentors—experiences

Affirmation of the transformation they have made

Paper origin

The importance of building a relationship McCarroll (2012), Perez et al. (2014), Bailey et al. (2008) Benefits (or lack of) were across many domains Sharing with someone who has walked in their shoes Lippi (2000), McCarroll (2012), Perez et al. (2014) Being understood and supported Normalization Keeps me in check Lippi (2000), McCarroll (2012), Perez et al. (2014) Validation of own recovery Reinforces current skills and enhances those learnt in recovery

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recovery. Quantitative benefits included lower post-intervention levels of binging, purging, emotional eating and dieting behaviors and an increase in feminist identity, quality of life in the domains of education/vocation, family and close relationships, future outlook, psychological, emotional, values and beliefs, and physical domains. Areas where there was no change included motivation, energy and confidence towards recovery and psychological distress, objectified body consciousness and self-esteem. While initial positive changes were found in social physique anxiety, drive for thinness and body dissatisfaction, these changes were not maintained at a one-year follow-up. The validated questionnaires that were utilized to assess changes were also diverse and included the Eating Disorder Inventory, Social Physique Anxiety (SPAS-C), Eating Disorder Quality of Life Scale, Rosenberg Self-Esteem Scale and Quality of Life measures. The studies also indicated the importance of building a relationship and how this had the potential to affect the mentoring relationship. Greater frequency of communication with a mentor was positively associated with higher levels of quality of life in the education/vocation, family and close relationships, future outlook, psychological, emotional, values and beliefs and physical domains (Perez et al., 2014). The mentoring relationship could affect the benefits of mentoring positively and negatively as illustrated in the below quotes: “It is so amazing to have a friend who identifies with me (and I with her) on physical, emotional and spiritual aspects of eating disorders and recovery” (Lippi, 2000, p. 180). “My mentor would talk about things that were going on in her personal life, which weren't the healthiest things…I was thinking how is she going to give me advice” (Lippi, 2000, p. 196). “While a few mentors were working closely with the girls, many of the mentors were observed to be more interested in interacting with each other (McCarroll, 2012, p. 101).

3.4. Mentors' experiences The theme that emerged for the mentors was affirmation of the transformation they have undergone in their own lives. Participants described that mentoring kept them ‘in check’ as in the following quotes: Mentors were “positively impacted by strengthening the skills they learned while in recovery, solidifying the steps required towards recovery” (Perez et al., 2014, p. 8). “I thought that the mentoring relationship was a refresher. The foodstuff is gone for me. The personal stuff is the hardest work for me now. It's an ongoing process…” (Lippi, 2000, p.153). “It was funny that I could hear myself telling her: this is how it is and this is what you should do. At the same time I'm like god, I'm not doing any of this. I brought out my book from the hospital, and showed her and at the same time it helped me” (Lippi, 2000, p. 170). Mentors found that mentoring validated their own recovery and how well they were now doing and how differently they were now thinking: “I was able to validate my own recovery. Especially, when we discussed the food part of it. I'm not counting calories anymore! This is huge!” (Lippi, 2000, p. 162). “I don't feel trapped and that's a good way to feel” (Lippi, 2000, p. 162).

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“Don't you think about your food (mentee to mentor)? How much fat is in it? How many calories are in it? I say no, I think about food when I'm hungry and eat what I like. It's a miracle to me too” (Lippi, 2000, p. 207). Mentors found the experience of mentoring “reminding them of how far they've come in their own recovery and the unhealthy place they were with their eating disorder” (Perez et al., 2014, p. 8). Mentors found that mentoring reinforced current skills and enhanced those learnt in recovery: “I was reinforcing coping skills that I use. Of course, as I am talking about them, I'm reminding myself of them” (Lippi, 2000, p. 162). “For me, it gave me the opportunity to practice a healthy relationship that I didn't have ties with already” (Lippi, 2000, p. 168). “In attempting to clarify some issues with her mentee, she believed that she might see herself more clearly” (Lippi, 2000, p. 239).

4. Discussion The present research is to our knowledge the first systematic review on the benefits and experiences of mentoring for those with eating disorders or disordered eating. We found four studies, and notwithstanding the limitations of the small number of studies, some themes emerged. The themes were generally related to an understanding of the experiences and value of mentoring for both mentors and mentees. The themes identified were (1) diverse benefits (mentees) (2) finding comfort in belonging (mentees), and (3) affirmation of the transformation they have made (mentors). Belonging is not a new concept, with Abraham Maslow identifying that belonging is an essential human need that is required before a sense of worth can be established (Maslow, 1970). A newer definition of ‘belongingness’ can also be applied in this context: “... a deeply personal and contextually mediated experience that evolves in response to the degree to which an individual feels (a) secure, accepted, included, valued and respected by a defined group, (b) connected with or integral to the group and (c) that their professional and/or personal values are in harmony with those of the group” (Levett-Jones & Lathlean, 2008, p. 104). Dawson, Rhodes, & Touyz, (2014), Federici & Kaplan, (2008), Fogarty et al. (2013) and Warin (2009) have identified belonging and being understood as important in eating disorder treatment (Dawson, Rhodes, & Touyz, 2014; Federici & Kaplan, 2008; Fogarty et al., 2013; Warin, 2009). Belonging is a key element of eating disorders, both in the journey into and out of an eating disorder and motivation for not seeking treatment (Warin, 2009). Feelings of not belonging or feeling disconnected from society are hypothesized as influential factors in developing an eating disorder (Warin, 2009). The eating disorder satisfies an intense and unmet need for belonging and thus it is difficult to be motivated to ‘recover’ (Warin, 2009). The feeling of being misunderstood was associated with low motivation to change, which in turn has been associated with poorer outcomes (Dawson, Rhodes, & Touyz, 2014). Not feeling understood has been identified as one of the key factors in being unready/unable to change in chronic Anorexia Nervosa and conversely improvements in being understood was a key phase in the ‘tipping point’ of change where there is a more internal locus of control and an increase in motivation to ‘recover’ (Dawson, Rhodes, & Touyz, 2014). Feeling understood and accepted has also been associated with ‘recovery’ (Dawson, Rhodes, & Touyz, 2014; Federici & Kaplan, 2008). Mentoring may play a key role in the provision of a service that provides the experience and sense of belonging and being understood, during the many different stages of an eating disorder.

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The demonstration of skills and behaviors, through healthy role modeling from mentors, to the mentees may form part of the active pursuit of recovery phase of recovery (Dawson, Rhodes, & Touyz, 2014). During this phase of recovery new skills were used to pursue recovery although “skill development and habit formation were extremely difficult and challenging” (Dawson, Rhodes, & Touyz, 2014). Repetition and practice are required to replace old habits and patterns of behavior (Dawson, Rhodes, & Touyz, 2014). New behaviors and skills may need to be learnt or re-learnt during the pursuit to recovery from an eating disorder and the use of role modeling may provide knowledge, skills and values of healthy, ‘normal’ behaviors and characteristics (Cruess, Cruess, & Steinert, 2008). Acting as role model to another (i.e. mentee) can potentially strengthen and reinforce the current coping skills and skills learnt during recovery for the mentor. An important part of maintaining recovery from an eating disorder includes maintaining the changes developed during recovery and focusing on the positive aspects of the self (Dawson, Rhodes, & Touyz, 2014; Federici & Kaplan, 2008; Lindgren et al., 2015). Fostering and sustaining a sense of personal worth and value are also related to the maintenance of change (Federici & Kaplan, 2008). Engaging in activities that provide a sense of personal worth and validate the skills and characteristics of recovery may strengthen recovery and act as a deterrent to relapse. Mentoring affirms the changes the mentors have made on their journey to recovery and enhances the mentors' skills in managing a life without an eating disorder. Providing support for someone with an eating disorder is crucial and can help facilitate recovery for those with an eating disorder (Lindgren et al., 2015). Important and supportive relationships specifically with someone who has had an eating disorder have been identified as influential in the recovery process (Hay & Cho, 2013; Lindgren et al., 2015). The provision of mentoring support may help the mentor feel valued, increase self-worth through positive and self-affirming experiences and new relationships, all of which may reinforce recovery (Hay & Cho, 2013). The benefits from the validated questionnaires used in these studies showed mixed results (Bailey et al., 2008; McCarroll, 2012; Perez et al., 2014). The effect of mentoring on eating behaviors was diverse with some reporting positive benefits (Bailey et al., 2008; McCarroll, 2012) however there was no effect of mentoring when eating was measured as part of eating disorder quality of life (Perez et al., 2014) and the changes found in the Bailey study were not sustained at a one-year follow-up (Bailey et al., 2008). The relationship of the mentors and mentees is vital in the success of mentoring and thus the outcomes of the mentoring program (Shelmerdine & Louw, 2008; Straus, Johnson, Marquez, & Feldman, 2013). A successful mentoring relationship is characterized by “reciprocity, mutual respect, clear expectations, personal connection, and shared values” (Straus et al., 2013, p. 86) and includes the capacity to establish personal connections which transgress the program's ultimate goals (Shelmerdine & Louw, 2008). Whereas a failed mentoring relationship is characterized by “poor communication, lack of commitment, personality differences, perceived (or real) competition, conflicts of interest, and the mentor's lack of experience” (Straus et al., 2013, p. 86). The studies in this review used a number of methods to match, including matching through researcher matching determined by homogeneity of diagnosis, personality traits, developmental age and stage and personal interests (Lippi, 2000), mentee preferences (based on information provided by mentors including their personal recovery history, why they want to mentor and what they have to offer) (Perez et al., 2014) and no matching as the program was a group mentoring program (McCarroll, 2012). The majority of the programs were one-on-one mentoring except for the group mentoring program and all programs had weekly contact. The diverse benefits from being involved in a mentoring program may reflect both the content of the program (the structured aspects/goals of the program) and also the quality of the mentoring relationship.

Our systematic review on the experience of mentoring for those with an eating disorder or disordered eating has been shown to have value to both mentors and mentees. Mentoring has a place in a stepped care approach to eating disorders however there is limited access to mentors and mentoring programs for those suffering from an eating disorder or disordered eating (Perez et al., 2014). Communities, eating disorder foundations/institutes, health care organizations and governments will all need to play a part to ensure that mentoring can be both accessible and available to eating disorder sufferers and those with disordered eating. Continuation of research into the benefits and effects of mentoring and the establishment of quality mentoring relationships are recommended. Limitations were the small number of studies in our review however these studies provided rich data for a review. A strength was the use of two reviewers during data extraction. 5. Conclusion This review provides insight into the effects and experience of mentoring in eating disorders and disordered eating. From this review the mentoring partnership has potential benefits for both mentors and mentees and should not be underestimated, but rather further harnessed and explored in future studies. For the mentee, the relationship enhances a sense of comfort in belonging and support. The mentor provides inspiration and positive encouragement, by understanding the mentees' journey. The interactions and relationship with mentees affirms and reminds the mentors of the transformation of ‘self’ they have undergone to achieve their own recovery and solidifies the skills developed in their own recovery. Mentorship should be further utilized in the areas of eating disorders and disordered eating, as it shows promising reciprocal benefits for both mentor and mentee. Conflicts of interest The authors declare that there is no conflict of interest. Acknowledgments This review is part of a study funded by the Ian Potter Foundation (20140706).

References American Psychiatric Association (2013). The diagnostic and statistical manual of mental disorders. Feeding and Eating Disoders (5th ed.) (Retrieved 6th September, 2013, from http://www.dsm5.org/Documents/EatingDisordersFactSheet.pdf). Arcelus, J., Mitchell, A.J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724–731. Bailey, E.K., Tapler, A.S., French, A., & Bailey, S.P. (2008). Changes in body image one year post participation in a mentoring prgam for 10 and 11 year old girls. Paper presented at the Exercise, Sport and Body Image. Ball, K., & Lee, C. (2002). Psychological stress, coping, and symptoms of disordered eating in a community sample of young Australian women. International Journal of Eating Disorders, 31(1), 71–81. http://dx.doi.org/10.1002/eat.1113. Collins Dictionary of the English Language (1979). In G. A. E. Wilkes (Ed.), Collins dictionary of the English language. Sydney: Collins. Critical Appraisal Skills Program (CASP) Qualitative research checklist 31.5.13. Retrieved 22nd September, 2014, from http://www.casp-uk.net. Cruess, S.R., Cruess, R.L., & Steinert, Y. (2008). Role modelling—Making the most of a powerful teaching strategy, Vol. 336, . Dawson, L., Rhodes, P., & Touyz, S. (2014b). “Doing the impossible”: The process of recovery from chronic anorexia nervosa. Qualitative Health Research, 24(4), 494–505. http://dx.doi.org/10.1177/1049732314524029. Dawson, L., Rhodes, P., Mullan, B., Miskovic, J., & Touyz, S. (2014a). Recovery stories — Helpful or unhelpful? A randomised controlled trial. Journal of Eating Disorders, 2(Suppl. 1), 050. http://dx.doi.org/10.1186/2050-2974-2-S1-O50. De Ayala, R.J., & Perry, C.M. (2005). The effects of a mentoring program on eating behavior, physical activity, and self-efficacy in overweight upper-elementary students. Paper presented at the AAHPERD National Convention and Exposition (http://aahperd. confex.com/aahperd/2005/finalprogram/paper_7104.htm). Federici, A., & Kaplan, A.S. (2008). The patient's account of relapse and recovery in anorexia nervosa: A qualitative study. European Eating Disorders Review, 16(1), 1–10. http://dx.doi.org/10.1002/erv.813. Fogarty, S., Smih, C., Touyz, S., Madden, S., Buckett, G., & Hay, P. (2013). Patients with anorexia nervosa receiving acupuncture or acupressure; their view of the therapeutic encounter. Complementary Therapies in Medicine. http://dx.doi.org/10.1016/j.ctim. 2013.08.015.

S. Fogarty et al. / Eating Behaviors 21 (2016) 66–75 Fredenberg, L. (2010). The body balance disordered eating and mentoring program. Journal of the American Dietetic Association, A-43(Suppl. 2). Ginty, A.T., Phillips, A.C., Higgs, S., Heaney, J.L.J., & Carroll, D. (2012). Disordered eating behaviour is associated with blunted cortisol and cardiovascular reactions to acute psychological stress. Psychoneuroendocrinology, 37, 715–724. Government of Western Australia. WA—First program brings hope to young participants. Retrieved 22 Sept, 2014, from http://health.wa.gov.au/snapshots/eating_disorders.cfm. Hall, M.R., Patton, V.T., & Degenhardt, L. (2011). What are the major drivers of prevalent disability burden in young Australians. The Medical Journal of Australia, 194(5), 232–235. Harris, E.C., & Barraclough, B. (1998). Excess mortality of mental disorder. The British Journal of Psychiatry, 173(1), 11–53. http://dx.doi.org/10.1192/bjp.173.1.11. Hasson-Ohayon, I., Kravetz, S., Meir, T., & Rozencwaig, S. (2009). Insight into severe mental illness, hope, and quality of life of persons with schizophrenia and schizoaffective disorders. Psychiatry Research, 167(3), 231–238. http://dx.doi.org/10.1016/j.psychres. 2008.04.019. Hawro, T., Maurer, M., Hawro, M., Kaszuba, A., Cierpiałkowska, L., Królikowska, M., & Zalewska, A. (2014). In psoriasis, levels of hope and quality of life are linked. Archives of Dermatological Research, 306(7), 661–666. http://dx.doi.org/10.1007/ s00403-014-1455-9. Hay, P.J., & Cho, K. (2013). A qualitative exploration of influences on the process of recovery from personal written accounts of people with anorexia nervosa. Women & Health, 53(7), 730–740. http://dx.doi.org/10.1080/03630242.2013.821694. Hay, P., Chinn, D., Forbes, D., Madden, S., Newton, R., Sugenor, L., ... Ward, W. (2014). Royal Austalian and New Zealand college of psychaitrists clinical practice guidelines for the treatment of eating disorders. Australian and New Zealand Journal of Psychiatry, 48(11), 977–1008. Hudson, J., Hiripi, E., Pope, H., & Kessler, R. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3), 348–358. ISIS The Eating Disorder Centre (2014, 19 April 2015). Isis writes for Australian and New Zeland academy for eating disorders. Retrieved 19th April 2015, 2015, from http:// www.isis.org.au/isis-writes-article-for-australian-and-new-zealand-academy-foreating-disorders King, S. (1982). Rita Hayworth and the Shawshank Redemption Different Seasons. Viking Press. Lee, J. (2003, Jul 10). No longer dying to be thin: New pilot program pairs people struggling to overcome eating disorders with mentors. Daily Bulletin, 12. Levett-Jones, T., & Lathlean, J. (2008, Mar). Belongingness: A prerequisite for nursing students' clinical learning. Nurse Education in Practice, 8(2), 103–111 (18). Lindgren, B. -M., Enmark, A., Bohman, A., & Lundström, M. (2015). A qualitative study of young women's experiences of recovery from Bulimia Nervosa. Journal of Advanced Nursing, 71(4), 860–869. http://dx.doi.org/10.1111/jan.12554. Lippi, D.E. (2000). The impact of the mentoring relationship upon women in the process of recovering from eating disorders. (Doctor of Philosophy) Temple University, Bell & Howell Information and Learning Company (UMI Microform 9969913). Maslow, A. (1970). Motivation and personality (2nd ed.). New York: Harper & Row. McCarroll, M. (2012). A pilot study on the effects of mentoring on disordered eating behaviour. (Doctor of Philosophy) Eastern Michigan University (Paper 388). McVey, G., Kirsh, G., Maker, D., Walker, K., Mullane, J., Laliberte, M., ... Banks, L. (2010, Jun). Promoting positive body image among university students: A collaborative pilot study. Body Image, 7(3), 200–204. http://dx.doi.org/10.1016/j.bodyim.2010.02.005. Mitchison, D., Hay, P., Slewa-Younan, S., & Mond, J. (2012). Time trends in population prevalence of eating disorder behaviors and their relationship to quality of life. PLoS One, 7(11), 1–7.

75

Moher, D., Liberati, A., Tetzlaff, J., & Altman, D.G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement, Vol. 339, . National Eating Disorders Association (2011, March 01). National eating disorders association launches innovative mentoring program ‘NEDA Navigators’. Retrieved 22 Sept, 2014, from https://www.nationaleatingdisorders.org/press-room/press-releases/ 2011-press-releases/national-eating-disorders-association-launches-innovativementoring-program-neda-navigators Pereira, R.F., & Alvarenga, M. (2007). Disordered eating: Identifying, treating, preventing, and differentiating it from eating disorders. Diabetes Spectrum, 20(3), 141–148. http://dx.doi.org/10.2337/diaspect.20.3.141. Perez, M., Kroon Van Diest, A., & Cutts, S. (2014). Preliminaray examination of a mentorbased program for eating disorders. Journal of Eating Disorders, 2(24). Qian, J., Hu, Q., Wan, Y., Li, T., Wu, M., Ren, Z., & Yu, D. (2013). Prevalence of eating disorders in the general population: A systematic review. Shanghai Arch Psychiatry, 25(4), 212–223. http://dx.doi.org/10.3969/j.issn.1002-0829.2013.04.003. Royal Melbourne Hospital (2008). Peers help patients with eating disorder. Retrieved 22 Sept, 2014, from http://www.health.vic.gov.au/archive/ archive2010/humanservicesnews/mar08/eating.htm Shaw, R. (2012). Identifying and synthesising qualitative literature. John Wiley and Sons. Shelmerdine, S., & Louw, J. (2008, Aug). Characteristics of mentoring relationships. Journal of Child & Adolescent Mental Health, 20(1), 21–32. http://dx.doi.org/10.2989/JCAMH. 2008.20.1.5.490. Snyder, C.R. (2002). Target article: Hope theory: Rainbows in the mind. Psychological Inquiry, 13(4), 249–275. http://dx.doi.org/10.1207/S15327965PLI1304_01. Starving Secrets Episodes 1–6. (2011–2012) [Televison]. In G. Entertainment (Producer), Starving Secrets. USA: Lifestyle Television. Straus, S.E., Johnson, M.O., Marquez, C., & Feldman, M.D. (2013, January). Characteristics of successful and failed mentoring relationships: A qualitative study across two academic health centers. Academic Medicine, 88(1), 82–89. http://dx.doi.org/10.1097/ ACM.0b013e31827647a0. Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology, 8(45). http://dx. doi.org/10.1186/1471-2288-845. Thome, J., & Espelage, D.L. (2004). Relations among exercise, coping, disordered eating, and psychological health among college students. Eating Behaviors, 5(4), 337–351. http://dx.doi.org/10.1016/j.eatbeh.2004.04.002. Treasure, J., Claudino, A., & Zucker, N. (2010). Eating disorders. Lancet, 375(9714), 583–593. Unützer, J., Schoenbaum, M., Druss, B.G., & Katon, W.J. (2006). Transforming mental health care at the interface with general medicine: Report for the presidents commission. Psychiatric Services, 57(1), 37–47. http://dx.doi.org/10.1176/appi.ps.57.1.37. Warin, M. (2009). The complexities of being anorexic abject relations: everyday worlds of anorexia. Studies in Medical Anthropology. (pp. 70–98)Rutgers University Press, 70–98. Wright, K.M., & Hacking, S. (2012). An angel on my shoulder: A study of relationships between women with anorexia and healthcare professionals. Journal of Psychiatric and Mental Health Nusing, 19, 107–115. Wright, F., Bewick, B.M., Barkham, M., House, A.O., & Hill, A.J. (2009). Co-occurrence of self-reported disordered eating and self-harm in UK university students. British Journal of Clinical Psychology, 48(4), 397–410. http://dx.doi.org/10.1348/ 014466509X410343. Yadav, S. (2010). Perceived social support, hope, and quality of life of persons living with HIV/AIDS: A case study from Nepal. Quality of Life Research, 19(2), 157–166. http://dx. doi.org/10.1007/s11136-009-9574-z.