What does eating disorder recovery really look like? When you say the word “recovery,” differences of opinion loom large. The lack of definitional clarity around the concept of recovery came up many times at ICED, and continues to surface in discussions among researchers, clinicians, and individuals with eating disorders themselves. We’ve looked at recovery on the blog before (for example, Gina looked at how patients define recovery here; Tetyana surveyed readers about their perspectives on whether or not they thought of themselves as being in recovery and wrote about it here; I wrote about men’s experiences after recovery here). It’s something of a hot topic in the research literature, too.
My Master’s thesis focused primarily on recovery, with one “take home message” being that there can be a disconnect between what recovery means in treatment settings, in popular understanding, and among individuals who have experienced eating disorders. Of course, my study was qualitative and from a critical feminist standpoint, so it is still unclear how well my findings map onto the larger dynamics of recovery. Still, understanding and seeking to define “recovery” continues to fascinate me (good thing I’m doing my PhD on the subject!).
If there is one thing that researchers and clinicians seem to agree on, it is that there is no consensus definition for the concept. And if there is no consensus definition, how can we really compare between studies investigating recovery? With the lack of definitional clarity and the multiple perspectives on recovery that circulate in research, clinical, and “real world” settings, I thought it might be interesting to write a series of posts focusing on how recovery has been conceptualized in the literature. If nothing else, these points of view will highlight how difficult it can be to tie down the construct of “recovery from eating disorders” when the disorders themselves are so complex and require complex solutions.
RECOVERY FROM ANOREXIA NERVOSA USING THE RECOVERY MODEL
To kick off this series, I will report on a very recent article by Dawson, Rhodes, and Touyz (2014) exploring “the recovery model” in the context of anorexia nervosa. What is the recovery model, you might ask? Well, I’m glad you asked.
As Dawson and colleagues explain, the recovery model is based in a movement designed by mental health client (consumer) advocates that can be traced back to the 1930s. Now a part of many mental health programs and services, it is rooted in a sense of frustration with the pessimistic outlook offered to individuals with mental illness prior to this time. You can find out more about the model here and here. It is more than just a perspective on recovery; grounded as it is in consumer advocacy movements, it can also be considered a social movement.
As Dawson et al. note, Anthony (1993; open access) defined recovery as follows:
A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness. (Anthony, 1993, p. 527, cited in Dawson et al. (2014) p. 3)
Perhaps one of the more surprising elements of this approach to recovery is that it is not necessarily dependent on “going back to where one was before,” in terms of symptoms. Instead, an emphasis is placed on:
- Personal responsibility & control
- Symptom management
- Overcoming stigma
(From Schrank & Slade, 2007)
This approach highlights facets of recovery beyond remission of symptoms. Patients are also placed in the role of experts over their experiences and are encouraged to seek advice and guidance from others who have experienced similar issues.
Dawson and colleagues sought to determine whether this orientation toward recovery could be helpful in approaches to treatment for anorexia nervosa.
THE PERSPECTIVES OF PATIENTS WITH ANOREXIA NERVOSA
The authors looked to qualitative literature to explore patient perspectives on recovery, reporting on some of the major studies inviting participants to comment on factors they felt contributed to recovery.
None of these findings are particularly surprising; they certainly make intuitive sense. As Dawson and colleagues note, these findings also fit quite cleanly within a recovery model. Again, this makes sense: the recovery model is a very patient-centered approach, and the primarily qualitative literature adding patient voices to the picture indicates that individuals with AN are more likely to recover:
- If they perceive treatment to be effective;
- If they have positive support and experiences in their lives;
- If they feel empowered, and if they think recovery is possible; and
- If they work actively to achieve it
In some ways, the above look like a bit of a “picture perfect” trajectory toward illness; the skeptic in me thinks that it would be rare for all of the above to fall into place at the same time, facilitating an “easy” recovery. Nonetheless, it is possible that explicitly stating these factors might lead to a greater focus on going beyond the individual in work toward recovery, which is something I can definitely get behind. Speaking of treatment and support, how well do the current offerings map onto a recovery model?
TREATMENT MODELS AND THE RECOVERY MODEL
The authors point out that treatment models for AN fit most comfortably with the recovery model in the factors that underlie the various types of treatment, such as the therapeutic relationship, the aims and goals of treatment, and the treatment philosophy.
Evidently, each approach to treatment places emphasis on different pathways to change. Dawson and colleagues offer a few examples of approaches whose philosophies and strategies tend to be more patient-driven and thus more closely aligned with a recovery model (links provide more information, if you’re interested):
- Motivational Interviewing
- Specialist Supportive Clinical Management
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- Family-Based Treatment (authors provide Lock et al., 2001 reference)
- Narrative Therapy
In these approaches, therapists tend to place patients (or parents/families) in the expert role, focusing instead on individual or familial impetus and capacity for change. Narrative therapy in particular strikes a chord with the consumer-survivor movement that spurred the development of the recovery model, as narrative therapists have worked with clients to construct “anti-anorexia” and “anti-bulimia” stories that overtly encourage patient resistance (for more on narrative therapy, see this post).
Peer-driven models like multiple family therapy are also noted to be more cleanly aligned with a recovery model, as it tends to bring families together in a mutually supportive environment to facilitate change.
WHY USE THE RECOVERY MODEL IN TREATMENT?
The authors point out that though aspects of the recovery model can be found in many approaches to treatment, it is not consistently or systematically integrated into all approaches to treatment. They go on to offer examples of models of care for severe and enduring anorexia (SE-AN; Touyz et al., 2013 and Williams et al., 2010), which take a slightly different approach to treatment: namely, the focus of treatment shifts from symptom reduction to quality of life improvement. (Tetyana has blogged about approached to treat SE-AN here, mentioning the Williams et al., 2010 study.)
The description of these two programs reminded me of some conversations I have had with Tetyana and others about the possibility of taking a more harm-reduction based approach to enduring eating disorders, rather than continuing to focus on using approaches that (often subtly) equate recovery with being “symptom free.” Going back to the definition of the recovery model, which stipulates that recovery is not simply the absence of symptoms, I can see how these approaches, which shift the focus toward ways to support individuals in achieving their desired quality of life, regardless of their symptoms.
The authors call for further research into the adaptation of the recovery model into treatment, suggesting that this approach may:
- Inform practice by grounding treatment in a “philosophical framework and professional language”
- Offer innovative solutions to long-standing issues in eating disorder treatment protocols (such as redefining treatment goals, engaging with individuals rather than their labels, providing a continuum of care, and expanding focus beyond symptoms)
- Help to bring the patient voice to bear on clinical practice
Given that we continue to search for definitional clarity around the idea of recovery, I think the first point the authors make is particularly timely. If we continue to disagree about and make haphazard use of the word “recovery,” how can we know if we are meeting the needs of the individuals we are talking about as “recovered” (or “not recovered”)?
The last point also makes me very happy: it makes a lot of sense, in my opinion, to honour the voices of the individuals with lived experience when defining recovery and trying to assist in its achievement. If those individuals disagree with the definition you are putting forward, the goals you are setting in getting there, and the ultimate outcome, what is the point?
Of course, I don’t think that the recovery model is the be-all-end-all in defining and supporting recovery, and nor do the authors. They point out that researchers have historically found that individuals with AN may have less desire to change than individuals with other mental illnesses. I’d love to debate this point just a little, but this post is getting a bit epically long, so will leave it at I’m unconvinced about this one as a blanket statement.
Importantly, they note that despite the recovery model’s focus on patient empowerment, the approach recognizes that people may not always make the decision that is best for them, nor do proponents advocate poor mental health care. Further, adopting a recovery model is not incompatible with “evidence-based practice”; in fact, the authors argue that combining a philosophical recovery-model approach with a medical model may be “the best way forward” for eating disorder treatment.
With its focus on patient empowerment and seeing recovery beyond symptom remission, I think the recovery model at least has the potential to open up a discussion around whose voice (or whose voices) are most important in defining and understanding recovery. Of course, it is not the only approach to conceptualizing recovery (more on that in the next post!).
Dawson, L., Rhodes, P., & Touyz, S. (2014). The recovery model and anorexia nervosa. The Australian and New Zealand Journal of Psychiatry. PMID: 24927735