Federici 2007
Federici 2007
Federici 2007
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
Published online 26 July 2007 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.813
2 A. Federici and A. S. Kaplan
Pinnock, and Woodside (2004) identified several type of treatment and the perceived quality of the
additional predictors of relapse in AN, including therapeutic alliance play a significant role with
history of a suicide attempt, previous intensive regard to recovery and treatment satisfaction
treatment, obsessionality and concern about weight (Garrett, 1997; Noordenbos, Jacobs, & Hertzberger,
and shape at discharge. Furthermore, while the 1998; Rosenvinge & Klusmeier, 2000; Tozzi et al.,
greatest risk of relapse appears to occur during the 2003). Beresin et al. (1989) reported that treatment
first year post-treatment (Herzog et al., 1997), Carter compliance was enhanced when patients perceived
et al. (2004) found that subjects remained at an therapists as genuine, respectful, consistent and
increased risk of relapse up to 17 months post- non-judgmental.
intensive treatment, indicating that some patients The relevance and applicability of the above-
will relapse after remaining well for more than mentioned qualitative findings for AN patients in
1 year. the months immediately following completion of
Despite increased attention and awareness of both intensive treatment are not clear. Previous studies
the severity and chronicity of AN, significant gaps have typically interviewed patients several years
in our knowledge limit our ability to effectively treat (ranging from 6 months to 12 years) following
this disorder. Outcome measures and treatment various forms and durations of treatment. Given
responses have largely been defined by quantifiable that inpatient and day hospital programs are among
physical determinants (e.g. body weight), associ- the primary treatment interventions for individuals
ated physical sequelae (e.g. menses), attitudes and with AN, and in light of the greater potential for
beliefs about weight and shape, and measures of relapse immediately following treatment com-
comorbidity (e.g. personality, temperament). Such pletion, understanding the factors that facilitate or
approaches fail to take into account the view of the prevent change are paramount. To date, only one
patient in her response, or lack thereof, to treatment study has qualitatively explored relapse in individ-
and relapse (Garrett, 1997; Peters & Fallon, 1994). uals with AN following intensive treatment. Cockell
Unravelling the complexities of AN may well be et al. (2004) interviewed 32 female patients, the
aided by in-depth, qualitative studies which elicit majority of whom met diagnostic criteria for AN, 6
the patients’ view of treatment and reasons for months following completion of a residential
recovery and relapse. To date, only a small number treatment program. Participants identified a sense
of studies have methodically examined AN from of loss (e.g. lack of structure), feeling disconnected
this qualitative perspective. from others, engaging in self-defeating beliefs (e.g.
With regard to recovery in AN, qualitative studies unrealistic expectations about recovery, desire for
have consistently emphasised the importance of control) and difficulties dealing with the stress of
four key factors: social support, motivation for ‘real life’ (e.g. returning to work, daily hassles,
change, developing an identity independent from coping with the ‘diet culture’) as primary factors
the eating disorder and factors related to the that hindered recovery. Replication and extension
therapeutic alliance. Patients report that initiating of these data among AN patients in the months
and maintaining healthy and diverse, supportive following intensive treatment may have important
relationships (Beresin, Gordon, & Herzog, 1989; implications for relapse prevention programs.
Cockell, Zaitsoff, & Geller, 2004; Hsu, Crisp, & The aim of the current study was to investigate the
Callender, 1992; Pettersen & Rosenvinge, 2002; patients’ view of relapse and recovery utilising a
Tozzi, Sullivan, Fear, McKenzie, & Bulik, 2003) qualitative, phenomenological approach (Holloway
and/or removing oneself from destructive and & Wheeler, 2002; Morse & Field, 1995; Van Manen,
negative home environments, has served to facili- 1997). Specifically, we sought to identify how
tate adaptive change (Beresin et al., 1989; Hsu et al., patients conceptualise and understand their ability
1992). Willpower, personal strength, the desire for a or desire to maintain change in the first year
better life and psychological readiness have also following intensive treatment. In keeping with a
been identified as salient factors with regard to phenomenological approach (Creswell, 1998;
eliciting and maintaining change (Cockell et al., McLeod, 2001), every effort was made to ‘bracket’
2004; Hsu et al., 1992; Keski Rahkonen & Tozzi, preconceived ideas and assumptions about the
2005; Pettersen & Rosenvinge, 2002). Qualitative processes of recovery and relapse in AN. While both
studies have also shown that the ability and desire authors view recovery as a complex process that
to create an identity separate from issues involving involves multiple factors (e.g. nutritional rehabilita-
eating, weight and shape have been associated with tion, motivation, emotion regulation), the suspen-
recovery. Finally, patients with AN report that the sion of a priori hypotheses allowed the investigators
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
Relapse and Recovery in AN 3
to explore concepts as they were presented by the Structured Clinical Interview for DSM Disorders
participants without imposing biases or presuppo- (SCID; First, Spitzer, Gibbon, & Williams, 1996) and
sition onto the analysis. the Eating Disorder Examination (EDE; Fariburn
and Cooper, 1993) were administered. All inter-
views were conducted by the first author. Sub-
sequently, participants received one of two qual-
MATERIALS AND METHODS itative interviews, developed by the authors: the
first explored the participants’ perspective of the
Procedure
factors that contributed to their having maintained a
Patients with AN who had successfully completed healthy weight (BMI 19), having no bulimic
intensive treatment (BMI 20 kg/m2 at discharge) symptoms (binging, vomiting) and normal eating
at the Toronto General Hospital (TGH) were invited behaviours (n ¼ 7). The second interview assessed
to participate in the study. Briefly, participants had the participants’ view of the factors that contributed
completed inpatient or intensive outpatient treat- to their having lost weight and relapsed
ment. Treatment primarily focused on nutritional (BMI 17.5) following intensive treatment (n ¼ 8).
rehabilitation and utilised group-based cognitive Each interview began with an exploratory ques-
and behavioural interventions to target related tion which invited participants to describe which
psychosocial issues (e.g. interpersonal relation- factors, if any, they felt contributed to their (a)
ships, assertiveness, self-esteem, body image, sexu- having maintained a healthy weight or (b) having
ality). Following intensive treatment, all partici- lost weight and relapsing following intensive
pants participated in a manualised and controlled treatment. Participants were encouraged to speak
relapse prevention protocol that consisted of weekly openly about their perceptions and beliefs and were
outpatient CBT for up to 1 year. prompted occasionally by the interviewer to
All participants were female, 18 years of age or elucidate, develop and expand on their ideas. Once
older, and met diagnostic criteria for AN at participants had ample time to discuss their
admission to treatment as determined by a clinical thoughts, the interviewer proceeded to explore
psychologist. A total of 31 women were contacted additional content areas as follows: eating specific
approximately 1 year following discharge from factors (exploration of various factors related to the
treatment to assess their willingness and eligibility adoption or avoidance of weight control measures;
to participate in the current study. In order to i.e. caloric restriction, participation in exercise,
establish two clinically homogeneous groups, one vomiting, taking diet pills, etc.), environmental
clearly relapsed and one clearly recovered, partici- factors (family difficulties, extra-familial relation-
pants with a BMI 17.5 kg/m2 were considered ship difficulties, peer influences, cultural and
weight-relapsed and participants with a BMI media, etc.), individual factors (personality traits,
19 kg/m2 were considered weight-recovered. Parti- presence and regulation of negative affect, self-
cipants whose BMI was between 17.5 and 19 kg/m2 esteem), genetic factors and family history. In
were not eligible for this study because recovery addition, interviews explored the patients’ view
status is more difficult to determine among patients of their treatment experience and how this may
with such body weights. Six patients did not meet have contributed to their having lost or maintained
the BMI criteria (BMI < 19 and >17.5 kg/m2). Two a healthy weight.
had a BMI greater than 19 kg/m2 but were actively
binging and vomiting. A total of 23 patients met the
Data Analysis
inclusion criteria. Five did not return our calls
following the initial screening, two stated that they In-depth interviews were tape recorded and
were no longer interested in participating in a transcribed verbatim into textual data. Qualitative
research study and one patient declined to partici- research software, NVIVO version 2.0, was used to
pate, as she was not willing to travel to the hospital aid in data organisation and analysis. Transcripts
for the interviews. A final sample of 15 participants were read in detail and a brief, interpretive
took part in the current study. summary was written capturing potential themes
All participants signed informed consent prior to and overall impression. Emergent ideas and
their participation in the study, which received thoughts were documented and this initial sum-
ethics approval from the TGH’s Research Ethics mary was discussed and explored with the thesis
Committee. In order to establish the clinical state of supervisor and thesis committee members. The
each participant at the time of the interviews, the language used by and the emotional presentation of
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
4 A. Federici and A. S. Kaplan
each participant were carefully considered through- t-recovered group were more likely to meet criteria
out the developing analysis. Significant statements for the restricting subtype of AN (85.7%) compared
pertaining to the phenomenon of interest were to those in the weight-relapsed group (50%), a
extracted and categories were developed. Names of Mann–Whitney U-test failed to show significance:
codes were created using the participants’ words. U ¼ 18.0; p ¼ .282. In terms of duration of treatment,
Similar codes were grouped together to form women in the weight-recovered group spent signi-
clusters of themes which were compared and ficantly less time in treatment (M ¼ 78.6 days,
contrasted with one another in order to verify SD ¼ 20.8) than those in the weight-relapsed group
common elements. Any discrepancies among and/ (M ¼ 116.8 days, SD ¼ 28.7; U ¼ 6.00, p ¼ .008). There
or between various clusters were re-analysed. The were no significant differences between the two
developing analysis was rated by independent groups in terms of treatment setting; in total, nine
reviewers in order to ensure credibility and validity. participants had been admitted to the inpatient unit
In addition, debriefing sessions with the supervisor and six had been day hospital patients. A two
and thesis committee were scheduled at regular (weight-recovered vs. weight-relapsed) by two
intervals to add credibility to the study and well as (presence or absence of a DSM IV Axis I disorder)
to ensure the integrity, rigor and dependability of contingency table was used to test differences
the findings. This allowed for an external check of between the two groups with respect to current
the research process whereby methodology, or lifetime presence of an Axis I Disorder as
interpretations and ideas were challenged, dis- measured by the SCID. Weight-relapsed partici-
cussed or reassessed. Finally, the results were pants were significantly more likely to meet criteria
integrated into an exhaustive description in order for a lifetime or current diagnosis of OCD (x2 ¼ 8.04,
to clearly illustrate the participant’s perspective of p ¼ .009).
relapse and recovery.
Qualitative Results
RESULTS Qualitative analyses yielded six core categories that
described the primary factors participants believed
Interviews were conducted on an average of contributed to their having lost or maintained their
14 months (SD ¼ 4.5) following discharge from weight following intensive treatment. Each category
intensive treatment. Each interview lasted approxi- is described in detail below:
mately 2 hours. Analyses revealed no significant
differences between eligible patients who agreed to
Category I: internal motivation for change
participate (n ¼ 15) and those who did not (n ¼ 8) in
Recovered Participant:
terms of admission BMI (M ¼ 15.8, SD ¼ 2.0 kg/m2),
duration of treatment (M ¼ 101.30 days, SD ¼ 28.9), I think that my own drive to get better and my
treatment setting (87% inpatient), prior number commitment to myself had been incredibly import-
of eating disorder hospitalisations (median ¼ 2, ant. I’m not doing it for anyone else because, as much
range ¼ 0–12) or lowest past weight (BMI; M ¼ as your parents and your friends care for you, it’s not
15.77, SD ¼ .43 kg/m2). There was a trend (x2 ¼ 3.63,
their problem. This is up to me. I have to do this.
p ¼ .089) for a greater percentage of those who
refused the study to be of the binge-purge subtype When asked to describe the factors that con-
of AN (75%) compared to those who participated tributed to their ability to maintain a healthy weight,
(33%). participants in the recovered group articulated a
At the time of the interviews, the mean BMI for the powerful desire to change, to let go of symptoms
15 individuals who participated in the study was and to move beyond the illness. Participants spoke
21.1 (SD ¼ 1.7 kg/m2) for those in the weigh- of being tired of their symptoms, of a desire to be
t-recovered group and 16.5 (SD ¼ 1.1 kg/m2) for healthy and of their recognition that the illness
those in the weight-relapsed group. The two groups conflicted with valued personal beliefs and
did not differ with regard to age (M ¼ 26 years, life goals. Participants stated that the decision to
SD ¼ 6.5), admission BMI (M ¼ 15.9, SD ¼ 1.94 kg/ recover had been a self-initiated and self-directed
m2), lowest past weight (BMI; M ¼ 15.9, SD ¼ process; rather than completing treatment for the
.50 kg/m2) or number of prior eating disorder sake of others, women in the weight-recovered
hospitalisations (median ¼ 2.3, range 0–12). Although group stated that they pursued recovery for
a greater percentage of participants in the weigh- themselves.
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
Relapse and Recovery in AN 5
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
6 A. Federici and A. S. Kaplan
stated that they had not been well prepared for ‘life In contrast, those who relapsed reported that they
after treatment’. Many stated that they felt particu- did not have adequate social support and noted that
larly vulnerable and unskilled at managing ongoing they typically felt judged and misunderstood by the
emotional and interpersonal stressors in the months people in their lives. Marked by a pervasive sense of
following treatment. Likewise, participants repor- loneliness, isolation and alienation, participants
ted that follow-up care had been too inflexible and expressed frustration and disappointment that their
behavioural in orientation. They felt that too families and friends did not understand the
little attention had been given to issues involving difficulties they were experiencing. Many partici-
relationships, current stressors and negative emo- pants reported that their recovery was hindered
tions. As a result of not meeting their needs, many by the continual emphasis on body weight and
stated that they subsequently discontinued therapy. dieting within the family or social environment. In
Participants emphasised that either treatment nee- addition, participants stated that they had con-
ded to be longer or follow-up care more intensive to siderable difficulty accepting help from others. For
account for the difficulty they encountered trying to many, asking for help was perceived as a sign of
maintain change. weakness and failure.
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
Relapse and Recovery in AN 7
Those who relapsed reported that maintaining myself that I haven’t resolved, and until that totally
positive changes following weight restoration was resolves, eating is going to be an issue.
complicated by considerable difficulty tolerating
negative affect. Many stated that they had accom- In contrast, participants who relapsed reported
plished little during treatment in terms of identify- that their recovery was hindered by severe self-
ing and learning to tolerate unpleasant feelings. In criticism, intense fears of failure, a pervasive sense
the months following discharge, weight-relapsed of worthless and a feeling of hopeless for the future.
participants stated that they struggled to cope with They stated that they had considerable difficulty
intense feelings of depression, anxiety and lone- asserting their needs, acknowledging personal
liness. Furthermore, participants stated that the accomplishments and noted that they remained
discrepancy between their weight-restored bodies, heavily invested in the opinions, views and desires
which appeared ‘normal’, and their minds, which of others. Finally, participants reported that
continued to be consumed by ‘anorexic thoughts’, ongoing body weight and shape concerns played
was one of the most difficult issues they faced a significant role in their inability to maintain their
following treatment. Specifically, they reported that recovery.
it was increasingly difficult to relate to family and
friends who expected them to be free of their
disorder due an otherwise ‘healthy’ outward
appearance. In order to cope with their intense DISCUSSION
feelings, some participants reported that they found
In the current study, phenomenological method-
other, self-destructive ways of coping (e.g. self-
ology was used to discover how individuals with
harm, substance abuse).
AN understand the process of recovery and relapse
in the year following intensive treatment. This study
emphasises the importance of psychological change
Category VI: self-validation
in the recovery of AN. Though all participants
Recovered Participant:
responded behaviourally to treatment, in that each
. . . it’s two sides of the same coin. Self-discipline is was discharged from hospital after reaching their
target BMI of 20, the two groups differed in the
part of the reason I was able to be anorexic.
degree to which they were able to maintain their
Unfortunately you have to be extremely disciplined
recovery following treatment. The emergence of six
to starve for months and years, right? The flipside core categories illustrates that recovery was an
is the discipline is helping me stay with the eating, on-going process that required internal motivation,
not missing one single meal! belief in the capacity to change, the ability to
develop trust and the expression of emotion. In
Participants who maintained their weight
contrast, relapse was characterised by uncertainty,
reported that cultivating and maintaining a sense
reluctance to change, difficulty asking for help,
of personal worth and value was highly related to
intense negative emotion and a pervasive sense of
the maintenance of change following intensive
worthlessness. These findings have important
treatment. Participants described themselves as less
implications for relapse prevention and psychoe-
self-critical, more assertive, more accepting of their
ducation programs, as described below:
bodies and more likely to take credit for personal
successes and accomplishments. Maintaining 1. Motivation and recovery expectancies: These
recovery was strongly related to focusing on data expand our understanding of the role of
positive aspects of the self and challenging motivation in the processes of both relapse and
unhealthy thoughts about appearance and body recovery, and support the more recent emphasis
weight. Furthermore, many reported that person- on motivational interventions (i.e. motivational
ality traits once thought to have played an essential enhancement therapy) in the treatment of AN
role in the development of their disorder were now (Feld, Woodside, Kaplan, Olmsted, & Carter,
used to facilitate healthy change (e.g. patience, 2001; Tantillo, Nappa Bitter, & Adams, 2001;
stamina, determination, perfectionism). Treasure & Ward, 1997; Vitousek & Watson,
Relapsed Participant: 1998). They are also consistent with the work
of Hsu et al. (1992) and Pettersen and Rosenvinge
I think ultimately I got sick because of this (2002) who found that ‘being ready’ and feeling
incredible unhappiness and dissatisfaction with ‘motivated to change’ were salient factors in the
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
8 A. Federici and A. S. Kaplan
recovery process. Importantly, the current study relationships emerged as a significant factor that
found that, while motivation to change was cen- contributed to the maintenance of change follow-
tral during the initial stages of recovery, it was ing treatment. In addition to the presence or
also a key factor in later stages of recovery. absence of supportive relationships, those who
Participants who relapsed were more ambivalent maintained their recovery were differentiated
about change prior to, during, and after treat- from those who relapsed by three factors. First,
ment, whereas those who sustained a healthy social support was mediated by the ability and
body weight reported greater motivation to willingness to request and accept help. Many
change during and subsequent to intensive treat- participants who relapsed stated that asking
ment. These data also highlight the significance for additional help was weak, awkward or sha-
of recovery as an autonomous, self-motivated meful. Second, the adoption of a non-dieting
choice that was consistent with the long-term approach by family and friends was reported
goals and values of the individual. In addition, to have been a key factor that either facilitated
and consistent with the work of Cockell et al. or hindered recovery. Finally, the involvement in
(2004) and Constantino, Arnow, Blasey, and non-eating disorder-related community and
Agras (2005), expectancies regarding the recov- extracurricular activities appeared to support
ery process appeared to play an important role in the recovery process perhaps by fostering the
participants’ ability and desire to maintain growth of a new identity within the context of
change post-discharge. For example, compared a supportive, nurturing environment. These data
to those who relapsed, participants who main- suggest that post-treatment planning and relapse
tained their recovery stated that they had realistic prevention programs may facilitate treatment
expectations about continuing to work on symp- outcome by focusing specifically on enhancing
toms in the months following treatment. Internal problem-solving and interpersonal effectiveness
motivation, treatment expectancies and goal skills. Increasing patient awareness about the
identification may be important issues to empha- importance of social support and the obstacles
sise and measure in pre-treatment interventions involved in seeking help and encouraging
as well as in relapse prevention programs. patients to pursue non-eating disorder hobbies
Specifically, the inclusion of motivational strat- or activities would be beneficial. Additionally,
egies prior to, during, and after treatment may addressing the complexity of these issues in
serve to enhance therapeutic response and psychoeducation formats for family and friends
clinical outcome. would also be beneficial.
2. Emotion regulation: This study also highlights 4. Treatment and relapse prevention: The pub-
the importance of emotional processing and lished literature suggests that the quality of
affect regulation in the process of recovery from therapeutic alliance plays an important role in
AN. Based on these data, the ability to access, recovery and treatment satisfaction (Constan-
integrate and express emotions was central to the tino, Castonguay, & Schut, 2002; Horvath & Bedi,
maintenance of positive change following inten- 2002; Loeb et al., 2005). In the current study, the
sive treatment. Therapeutic approaches that degree to which participants felt a sense of safety,
place a greater emphasis on emotion regulation support and acceptance, by their therapists and
and exploration of internal affective states (e.g. fellow group members was reported to have
Dialectical Behaviour Therapy (DBT); Emotion- either helped or hindered recovery. These data
Focused Therapy) may have important implica- suggest that monitoring and placing a greater
tions for the treatment of AN. Recent findings emphasis on the development of the therapeutic
demonstrating positive outcomes using time- alliance over the course of intensive treatment
limited group-based and individual applications and throughout the relapse prevention phase
of DBT lend further support to the value of may improve treatment outcome for a greater
focusing specially on enhancing emotion regula- number of patients.
tion skills in the treatment of eating disorders Additionally, these data suggest that intensive
(Safer, Telch, & Agras, 2001; Telch, Agras, & programs may be sufficient interventions for
Linehan, 2001). weight restoration; however, for a subgroup of
3. Social support: Consistent with earlier studies patients, they do not foster lasting psychological
(Beresin et al., 1989; Hsu et al., 1992; Pettersen change. Given the emphasis on readiness and
& Rosenvinge, 2002; Tozzi et al., 2003), the pre- internal motivation for change, matching
sence of supportive and non-judgemental patients to treatment type and intensity and/or
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
Relapse and Recovery in AN 9
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
10 A. Federici and A. S. Kaplan
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