It can be somewhat controversial to suggest that untreated recovery from eating disorders is possible. Certainly, people have varied opinions about whether someone can enact the difficult behavioral and attitudinal changes necessary to recover without the help of (at the very least) a therapist and a dietitian. Nonetheless, we still hear stories about individuals who consider themselves recovered without having sought out external sources of professional support.
When I think about untreated (or “spontaneous”) recovery from eating disorders, two studies in particular come to mind. The first study I am thinking about was written by Vandereycken (2012) and explores self-change, providing an overview of community studies of individuals who have not sought treatment for their eating disorders and implications for treatment and recovery. The second, by Woods (2004) is a qualitative study looking at the experiences of 16 women and 2 men who report recovering from AN and BN without having sought treatment. Vandereycken identifies some difficulties associated with trying to study untreated recovery, and Woods’ study highlights some possible mechanisms through which untreated recovery might occur.
Vandereycken grounds his exploration in the idea of “spontaneous recovery,” taken from literature on substance use and addictions. What this means, in short, is that sometimes people “suddenly” (though what suddenly means here might be debateable–often this might come after years of attempts and a great deal of struggle) recover from their disorders without external, formal help. Vandereycken draws on Sobell (2007) to note that this concept has been largely ignored in the eating disorder (and other) literature for a number of reasons:
- The idea that people can spontaneously remit from symptoms can be seen as a “threat” to health care providers, as it may put their role into question
- Those who “spontaneously recover” may not actually come into contact with health care practitioners at all, and so are a more difficult population to study
- It is possible that those who spontaneously recover did not experience the disorder to a degree considered “serious” or “at clinical levels” so they may not be easily compared to those in treatment studies
- Using a disease model means sees disorders as only resolvable via treatment intervention, which closes off the possibility of spontaneous recovery, making it unlikely that it will be studied by those who take this orientation
So, given that spontaneous recovery has not featured heavily in eating disorder research, how can we draw any conclusions about the possibility of recovery without intervention? As the author notes, most of what we know about self-change in eating disorders comes from 3 sources:
- Longitudinal/prevalence studies (e.g., community or population level research)
- Wait-list control/drop out analysis (e.g. following up with those who have not yet received treatment or who drop out of treatment/research studies)
- Active case finding studies (e.g. seeking out those who are suffering but not seeking treatment)
Of course, it can be very difficult to get accurate data about those who don’t seek treatment for a number of reasons, the most basic of which is that if someone is not seeking treatment, they might also be unlikely to want to participate in a research study. Vandereycken presents 10 examples of community studies to see what proportion of individuals achieved “clinical recovery” without treatment.
Clinical Recovery without a Clinic?
Vandereycken defines clinical recovery as “almost complete remission of major eating disorder symptoms” (p. 88). Looking at the 10 studies he outlines, the literature is fuzzy about the possibility of spontaneous recovery, particularly as many individuals sign up for and drop off of treatment wait lists, can be difficult to follow in the long term, and studies use different criteria to define remission and recovery. Some of the findings he highlights are as follows:
- Cases of spontaneous remission from bulimia nervosa have been noted, with women never treated reporting some degree of continuing psychosocial distress (Jager, Klapper & Liedtke, 1994)
- Individuals with binge eating disorder have recovered without treatment, and may be less likely to subsequently seek treatment than individuals attempting to recover from bulimia nervosa without treatment (Fairburn, Cooper, Doll, Norman, & O’Connor, 2000)
- Looking at subclinical eating disorders, spontaneous remission seems more likely; for example, Cotrufo, Monteleone, Castaldo & Maj, 2004 noted that after 4 years, 8 of 12 young women with subclinical eating disorders no longer showed major symptoms
- In a study of Finnish twins, Keski-Rahkonen et al. (2009) revealed many undetected cases of eating disorders and similar remission rates between cases of both AN and BN that were and were not detected
Despite the difficulty of comparing studies, these studies do indicate that at least some people are recovering without the help of medical professionals (and, unfortunately, that this sometimes happens because their disorders have not been noticed by health care professionals). As Vandereycken notes, it can also be hard to get a sense of what did help these individuals to recover, if it wasn’t professional treatment. Few studies explore self-help (outside of self-help as additional support alongside other forms of treatment). Conveniently, the author cites Woods (2004) as one example of a qualitative study looking at how individuals might recover in the absence of formal help.
Exploring Untreated Recovery
Woods used grounded theory to explore the experiences of 18 individuals who had recovered without formal treatment. Of these:
- 2 were men
- 16 were women
- Participants ranged in age from 18-21
- 8 women and 1 man had experienced purging-type BN
- 6 women and 1 man had experienced restricting-type AN
- 2 women had experienced binge-purge type AN
- Average duration of illness was nearly 2 years (range 6 months-4 years)
Participants filled out an open-ended questionnaire about their experience of having an eating disorder, whether there was a “turning point” toward recovery, whether they had experienced any kind of treatment, and what they found helpful in maintaining recovery. Of the participants, only two had experienced any kind of interaction with healthcare providers around their disorders, both of which were with a primary care physician.
Exploring the “turning point” in recovery, participants tended to report that empathy and support from a loved one had been key to their movement toward a place of wellbeing. Some also noted that the physical ramifications of their disorders got to a point where they realized the seriousness of their disorder, sparking in them the desire to move away from their symptoms. Recovery was not an easy upswing from this point, however. Among difficulties on the way to recovery, participants noted continued disordered thoughts, trouble finding an identity without their disorder, and troublesome physical discomfort (e.g. feeling “too full” after a meal).
Perhaps interestingly, given my strongly feminist orientation in my research, I found that Woods’ exploration of this study’s results hinges a bit too strongly on the sociocultural factors that lead to the development of eating disorders. The findings relating to the importance of social support and empathy in support of recovery are important and I think useful for guiding supportive alternative measures for individuals who don’t feel that their needs are being met in traditional treatment settings.
However, we know that not everyone who experiences pressure around thinness and perfection develops an eating disorder. While the kinds of measures Woods advocates in her article (e.g. supportive and empathetic interactions with loved ones) are almost self-evidently a good idea, providing this is not a guaranteed buffer against the development of an eating disorder or a guarantee that recovery attempts will be successful. When we talk about families and eating disorders, I cannot overstate the importance of avoiding blame: too often, findings such as these result in families (particularly mothers, historically) being implicated in the development of disorders. It is important to cautiously interpret and share results like these to avoid this kind of blaming.
It is also important to consider that not everyone has access to the kind of highly supportive family and friend network that would facilitate untreated recovery. Equally, untreated recovery is not a categorically good idea for all. Often, medical intervention is necessary to restore health; the complexity of the physical, emotional and affective components of eating disorders complicates the idea of recovering with no intervention at all.
As Vandereycken notes, too, “spontaneous recovery” does not mean that recovery does not involve a lot of work. Perhaps the kinds of environments Woods advocates for can help to make the process a bit more smooth, but recovery is still not something that happens at the snap of one’s fingers of even with the decision to get better.
What Does the Existence of Untreated/Spontaneous Recovery Do for Our Understanding of Recovery?
In my opinion, these studies further emphasize the variability in recovery and the pathways for getting there. Vandereycken in particular highlights the tensions around the idea of self-change: on the one hand, this offers some degree of hope that people can get better even if they do not seek or receive treatment; on the other, this knowledge can instil a sense of false hope and/or lead to the mistaken assumption that this approach works for everyone (which has implications for service delivery and insurance models).
Both studies take seriously the voices of individuals themselves in defining recovery. Though Vandereycken does define recovery in a rather medicalized way, the article itself highlights the importance of attending to people’s active roles in their recovery processes. Woods, too, notes the agency of her participants, who together with supportive loved ones attained wellbeing. Misnomer aside, the idea of “spontaneous recovery” offers up a lot of food for thought about ways in which we can work toward valuing different pathways to a place and sense of wellbeing amongst individuals facing various social contexts as they move toward “recovery.”
Woods, S. (2004). Untreated recovery from eating disorders. Adolescence, 39 (154), 361-71 PMID: 15563044
Vandereycken, W. (2012). Self-change in eating disorders: is “spontaneous recovery” possible? Eating Disorders, 20 (2), 87-98 PMID: 22364341