One of the most common definitions of eating disorder recovery I have seen comes from a 2010 study by Bardone-Cone et al. Before I begin exploring this study I thought I might direct readers to some more resources on recovery: Carrie Arnold over at ED Bites wrote a few posts about recovery on her blog, and the first in the series can be found here. In this post, Carrie looks at the 3 dimensions of recovery that surface in Bardone-Cone’s article, so I thought I might also explore a study Bardone-Cone et al. published in the same year, which specifically touches on self-concept in eating disorder recovery, for variety’s sake.
ASPECTS OF EATING DISORDER RECOVERY
One of the most appealing things about Bardone-Cone and colleagues’ definition of recovery is that it looks at more than just the physical aspects of recovery. The researchers conceptualize recovery instead as comprised of 3 main areas:
Of these elements, Bardone-Cone et al. argue that the psychological elements of recovery are the most often absent from definitions and understandings of recovery. Psychological elements, they suggest, include continued:
- Body image disturbance
- Weight and shape preoccupation
- Negative affect
- Drive for thinness
They suggest that these factors may predict relapse; so, if they are not measured, it can be hard to tell if an individual is recovered or perhaps vulnerable to relapse. Similarly to what Carrie writes in her post, I think it might be interesting to go beyond the factors mentioned above when we talk “psychological recovery” and look at mood, anxiety, perfectionism, depression, suicidality etc. to really get a strong picture of psychological recovery. Other studies have looked at eating disorders in conjunction with these disorders and aspects of psychological functioning, but these don’t tend to feature strongly in examinations of recovery in particular (of course, correct me if I’m wrong, but I haven’t seen much of this!).
When they say “physical recovery,” Bardone-Cone et al. mean that someone:
- Does not meet eating disorder diagnostic criteria
- Has not binged, purged, or fasted over a period of 3 months or longer
- Has a BMI of 18.5 or higher
- Has similar scores (1 standard deviation at most from norms) to individuals without eating disorders (matched for age) on the Eating Disorder Examination Questionnaire
They also note that someone could be considered “partially recovered” if they meet the first 3 criteria but not the EDE-Q criterion.
Here is where the qualitative researcher in me wants to ask: is it possible that someone’s score on a standardized questionnaire may be at odds with their subjective experience? You can see how a more quantitative definition of recovery, which uses scores on measures specifically designed to measure things like symptom frequency might be at odds with the recovery model introduced in my last post, where subjective experience was centrally important.
Though Bardone-Cone et al. offer a relatively holistic interpretation of recovery, their definition is also quite conservative; that is, someone would not be considered recovered if they had any remaining symptoms, regardless of the purpose these symptoms serve for them. Taking a more harm-reduction orientation for recovery would not be possible using this definition of recovery; of course, taking a more harm-reduction orientation for recovery still seems like a controversial thing to say (especially when we think about younger people, or those with short course disorders). Then again, those who take a more harm-reduction orientation may not desire a label of recovered, so I might be making a moot point here. Still, some things to think about
APPLYING THE MODEL
In order to explore the usefulness of their model, Bardone-Cone et al. looked at how “fully recovered” (20 participants) individuals differed from individuals identified as “partially recovered,” (15 participants) with an active eating disorder (53 participants), and healthy controls (67 participants).
All participants completed a structured clinical interview that included the three domains identified above to determine eating disorder/recovery status and psychosocial functioning.
The authors measured psychosocial functioning using questions from Herzog et al.’s (1993) LIFE EAT II scale that explored work, school and relationships. They also looked at whether participants were currently experiencing a mood disorder (e.g. depressive disorders), an anxiety disorder, and/or a substance use disorder. They found that:
- Healthy controls, fully recovered and partially recovered groups reported better psychosocial functioning
- Healthy controls had better father and friendship relationships than those with active eating disorders
- There was a slight difference (with healthy controls faring better) in terms of romantic relationships
Interestingly, some participants in each of the fully/partially recovered and active eating disorder groups reported that remnants of their eating disorder still impacted their psychosocial functioning in some way. Though the percentage of participants in the fully recovered group who noted this kind of interference was small (only 2 of the 20 participants in this group), I still find this an interesting and perhaps oddly reassuring finding- very often, at least in popular media, recovery tends to be represented as though life is only sunshine and rainbows.
While I hesitate to critique this ideal, what it could potentially serve to do is alienate those who still experience moments of struggle. Here I’m thinking of representations I’ve seen circulate online that juxtapose thoughts and feelings defined as eating disordered with those defined as recovered. Because recovery may look different for everyone, it could be detrimental to see a list like this and feel that your recovery is somehow “not good enough” because you don’t do or think certain things.
Importantly, however, both those in the fully recovered group and the partially recovered group in this study were much less likely to feel that their eating disorder impacted their lives, which is still a very optimistic finding.
There were also differences between the groups in terms of other disorders, with the active eating disorder group showing the highest rates of concurrent diagnoses (7 times more likely than healthy control and fully recovered groups) and the partially recovered group also showing a higher rate than healthy control and fully recovered groups (3 times more likely). Encouragingly, healthy controls and fully recovered groups looked very similar in this domain.
SELF-CONCEPT AND RECOVERY
As mentioned above, it is possible that even the more holistic definition of recovery that Bardone-Cone et al. advance still misses out other areas of psychosocial functioning. Expanding on their work, Bardone-Cone et al. also looked specifically at self-concept in recovery, suggesting that a positive self-concept might help to maintain recovery. This study helps to support the other I’ve included in this post that give evidence for the need for a well-rounded definition of recovery.
“Self-concept” refers, generally, to how and what one knows about themself; this includes things like self-esteem, self-directedness, and self-efficacy (feeling able to enact behaviors and strategies, for example). Self-concept is made up of a set of interrelated but distinct parts. That is, just because one element of self-concept is low does not necessarily mean all parts will be (i.e. someone might have low self-esteem but still be quite self-directed), but they are often linked.
Bardone-Cone et al. cite evidence for the relationship between eating disorders and self-concept:
- Self-acceptance and self-worth have been linked to recovery in qualitative studies (e.g. Federici & Kaplan, 2008; Patching & Lawler, 2009; Vanderlinden, Buis, Pieters & Probst, 2007)
- Negative self-schemas (understanding of one’s self in the world that shapes how a person reacts to events, etc.) have been linked to disordered eating (Stein & Corte, 2007)
- Self-criticism and worthlessness may precede relapse (Federici & Kaplan, 2008); so might low self-esteem (Fairburn, Peveler, Jones, Hope & Doll, 1993)
In this study, Bardone-Cone and colleagues measured self-esteem, self-directedness, and the imposter phenomenon to determine whether there were differences between fully and partially recovered individuals and those with an active eating disorder. They used the same method as in the study above (i.e. dividing participants into four groups, assessing using a structured clinical interview); it seems that this is the same set of participants (the numbers for the groups are the same as above- 67 healthy controls, 53 active eating disorder, 20 fully recovered and 15 partially recovered).
THE MAIN RESULTS
There were no significant differences between healthy control and fully recovered groups for:
- Overall self-esteem
- Imposter phenomenon
There were no significant differences between active eating disorder and partially recovered groups for the same variables.
Differences emerged between fully and partially recovered groups as expected, with the fully recovered group showing:
- Higher self-esteem
- Higher self-directedness
- Lower imposter phenomenon
When they broke self-esteem down into component parts, the researchers found that those in the fully recovered group were especially likely to show more self-esteem related to appearance than those in the partially recovered group, but not in other areas of self-esteem (such as sociability, relationships, and sense of humour, for example). Another interesting difference the authors note was that partially recovered individuals tended to have higher intimate relationship self-esteem than those in the active eating disorder group.
So, what does it all mean? For one, I’m pleased to see researchers paying attention to the many things that can support or detract from recovery. I especially liked seeing the study on self-concept; as many treatment models make an effort to enhance patients’ sense of self-esteem and self-efficacy, it makes a lot of sense to explore what role these actually have in recovery.
One thing I would like to see more of is an exploration of how factors outside of the individual impact recovery. While it is important to measure things that are internal to an individual (like self-esteem, negative affect, etc.), we do not exist in a vacuum. Even when measures are quite sophisticated and acknowledge that external forces can have an impact on internal psychological factors, I still feel that there is room for attending to how others’ interpretations of recovery can impact feelings of recoveredness. Even measures that explicitly address sociocultural context (i.e. looking at thin ideal internalization) may miss culturally-specific aspects of recovery that vary from individual to individual and that contribute to the many shades and appearances of recovery.
Overall, however, I really appreciate Bardone-Cone and colleagues’ ongoing efforts to unpack the monolith that is eating disorder recovery, and can certainly see how this model might help us move toward a consensus definition for recovery, especially in research contexts.
Bardone-Cone AM, Harney MB, Maldonado CR, Lawson MA, Robinson DP, Smith R, & Tosh A (2010). Defining recovery from an eating disorder: Conceptualization, validation, and examination of psychosocial functioning and psychiatric comorbidity. Behaviour Research and Therapy, 48 (3), 194-202 PMID: 19945094
Bardone-Cone, AM, Schaefer, LM, Maldonado, CR, Fitzsimmons, EE, Harney, MB, Lawson, MA, Robinson, DP, Tosh, A, & Smith, R (2010). Aspects of Self-Concept and Eating Disorder Recovery: What Does the Sense of Self Look Like When an Individual Recovers from an Eating Disorder? Journal of Social and Clinical Psychology, 29 (7), 821-846. DOI: 10.1521/jscp.2010.29.7.821