Today I have the distinct pleasure of writing about one of my favourite articles about eating disorder recovery by Malson et al. (2011) exploring how inpatients talk about eating disorder recovery. I have personally found this article to be very helpful in understanding some of the difficulties of understanding and achieving recovery in our social context.
As Malson and colleagues explain (and as we’ve established), eating disorder recovery is elusive. Often, poor prognosis is described in relation to individual factors, including:
- Treatment resistance
- Ambivalence about change
- Ambivalence about the possibility of change
Problematically, seeing these as the primary reasons for which patients do not recover can make individuals with eating disorders themselves feel as though they are to blame for their “inability to recover,” which help approximately no one. How do patients internalize these kinds of framings, and what impact does it have on how possible they feel recovery is?
Malson et al. used discourse analysis to explore patients’ perspectives, looking at how these participants felt about themselves currently and imagined their future “in recovery.”
THE STUDY METHOD
To clarify, critical discourse analysis is a methodology that social scientists use to look for how power surfaces in interactions. By looking closely at how people talk, we can uncover sometimes-subtle expressions of power and power imbalances that inform how we think about people and concepts. In a (very reductive) nutshell, one of the main foci of the approach is the idea that language is not neutral, and the way that we talk (including the common expressions we use) can have power for how we understand ourselves and others. To do critical discourse analysis, researchers generally focus on similarities and differences in sections of talk and then situate these within social context.
In this case, the authors analyzed interviews with 39 individuals (age range 14-45, 38 women and 1 man, 31 hospitalized at the time of the study) diagnosed with AN or BN who had experienced hospitalization for their eating disorder. Though interviews were quite comprehensive, the results the authors present in this article hinge on two questions in particular (quoted verbatim below, from page 27 of the article):
- Would you describe yourself as being on the road to recovery or not?
- From your point of view what would it mean to be recovered?
The results can help us to understand how participants talked about recovery, what it is, and how it applies to their current and possible future selves.
THE MAIN RESULTS
Eating Disorder as Normal vs. Eating Disorder as Problematic
Participants related to their eating disorder in complex ways, often seeing the eating disorder as a “waste of time” or as getting in the way of fully living their lives. For example, one participant said:
Belinda: They [others] just say, they’ve had it for a while [inaud.] and then they say don’t let it, you know, take your life ’cos you see so much go by and you miss out on so much. And I just, I don’t want to like waste my life away. /Int: mm/ I just don’t want to see all good experiences go down the drain.
Seeing the eating disorder as a problem and seeing recovery as something to strive for, however, did not mean that participants saw if as something that could be easily achieved, or even something that they could fully imagine. In their present circumstances, participants sometimes described recovery as “scary,” “bleak,” unimaginable, or uncertain. For example:
Becky: Take it day to day, cos if I think too far ahead then it’s just too scary. It’s just too (.) bleak at the moment, so (.) that’s all I can do. And if I think of myself now and being better then I just can’t see myself ever being that, so (.) like I say (.) it just makes me think: oh God and where do I go from here.
Recovery as “unimaginable” is tied up in the role that the eating disorder played in many participants’ lives, and, as Malson and colleagues describe, into the social context we live in. There is a well-acknowledged split between the kinds of strategies imposed in treatment for eating disorders and the preoccupation with body image in contemporary Western culture. More than that, however, individuals with eating disorders might find that their sense of self is tied up their eating disorder.
The authors suggest that when individuals with eating disorders are described as, and come to internalize, the identity of “the anorexic” or “the bulimic,” it becomes even harder to imagine a life without the eating disorder.
Some participants combatted the conflation of their self and their eating disorder by externalizing their eating disorder. I wrote about externalization in more detail in this post about narrative therapy, so I won’t go into depth here, but the authors describe how some participants found externalization helpful in making the state of “eating disordered” seem less permanent.
Externalization does not necessarily mean calling the eating disorder “Ed” or giving it total agency, but surfaced in these participants’ accounts as an ability to see how the eating disorder was not the whole self, and being able to see the negative impacts of the disorder on the self:
Rachael: Like just me getting over it would be so good because you just have, it’s just one of those things that takes so much of your time and so much out of you /Int: mm/ And it has made me more tired and a more irritable person so, sort of, relations with your friends as well ’cos they’ve been damaged by it as well.
Recovery was, predictably, more than just no longer meeting diagnostic criteria for an eating disorder. Participants in this study saw recovery as:
- Escaping concerns about food, weight & shape
- Being happy in their lives
- Having better relationships with important others
- “Living their lives”
Generally, recovery was multidimensional (like it was for Bardone-Cone et al.), comprised of emotional, psychological and social domains above and beyond “physical” recovery.
I think one of the most important things about this study is how it highlights a few of the problematics of disorder-first language. Reducing people to their diagnosis is a powerful way of shutting down the other elements of a person that exist before, during, and “after” the eating disorder. How is someone to imagine recovery when one is reduced to their eating disorder? Getting rid of the eating disorder would essentially mean getting rid of one’s whole sense of self.
Another important element of this study is its emphasis on the fact that just because participants saw their current circumstances as imperfect and described their quality of life as bleak did not mean that participants could somehow “snap out of it.” This is an important consideration; “wanting” recovery does not mean it is easily imagined or easily achieved. This might seem obvious, but I think it bears repeating.
This study is fairly easy to reconcile with the recovery model presented in part 1 of this series; when they were able to imagine recovery, patients clearly saw their version of recovery as going deeper than symptom remission. Looking at this study together with Bardone-Cone et al.’s studies reinforces the importance of taking a holistic approach to recovery.
More than that, it demonstrates how patients themselves understand recovery and the possibility of achieving it. Understanding this might help us to better support individuals who desire recovery but cannot imagine what it might look like or how to get there. For starters, we can stop using language like “the anorexic” and “the bulimic,” wrapping people up into neat diagnostic category bows and allowing for the possibility of multiple parts of selves.
So, readers: how do you feel about the link between disorder-first language and recovery? Do you think that externalization can help in opening up the possibility of recovery?
Malson, H., Bailey, L., Clarke, S., Treasure, J., Anderson, G., & Kohn, M. (2011). Un/imaginable future selves: a discourse analysis of in-patients’ talk about recovery from an ‘eating disorder’. European Eating Disorders Review, 19 (1), 25-36 PMID: 21182163