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Defining What if Means to Be "Recovered"

By Anna M. Bardone-Cone, PhD & Christine R. Maldonado, MA
Reprinted from Eating Disorders Today
Spring 2008 Volume 6, Number 3
©2008 Gürze Books

It is not surprising that some individuals with eating disorders feel hopeless and defeated during the therapeutic process of treatment. They are often presented with grim outcome statistics and an uncertain prognosis. Some of the most common questions asked of health professionals are: “Will I get better? How will I know I’ve recovered?”

Professionals are hard-pressed to give clear answers and with good reason. Within the field, there is debate and no consensus on how to define recovery. Is it enough to restore to an appropriate weight and begin menstruating again (i.e., physical recovery), but still be having eating disordered thoughts (i.e., psychological recovery)? Other improvements may be behavioral (e.g., cessation of restriction, excessive exercise, bingeing, and purging), and social (e.g., ability to create and maintain meaningful relationships and be successful in school or work).

To understand these different aspects, our research lab at the University of Missouri embarked on an in-depth study by interviewing over 90 girls and women who had had an eating disorder at one point in their lives, and who had been seen at a primary care facility in Missouri for their eating disorder concerns. Participants self-reported on their current stage of recovery; those who identified themselves as “recovered” described why they felt that way, with most of them reporting at least 4 years of recovery. The remaining portion of this article will shed light on what the women who considered themselves recovered (and who no longer met eating disorder criteria) had to say about how they see themselves in recovery. Their voices, while distinct, revolve around common themes that we have grouped as physical, psychological, behavioral, and social.

Physical Recovery
Physical recovery is usually assessed via weight restoration and the return of menses. However, what passes as adequate weight for one individual (e.g., in terms of BMI or percentile of ideal weight) may not be sufficient for everyone else. Perhaps in physical recovery, in particular, more individualized definitions are needed. Interestingly, no women volunteered weight gain or menses as a way they knew they were healthy, although, per measured weight and height, all had achieved a BMI of at least 18.5. While BMI was assessed in this study as a contributing indicator of eating disorder status, there are clear limitations in relying on BMI to measure health. One woman did refer to being “able to listen to [my] body’s signals,” suggesting that one aspect of physical recovery focused on being in tune with one’s body.

Psychological Recovery
Themes of decreased obsessions related to weight and food were often present in this stage. The women spoke of decreased mental energy going toward the eating disorder:

• “Not battling it every day”
• “Other things preoccupy my mind, not food”
• “Not obsessed with calories/food grams”
• “No obsessive thoughts about food/excessive exercise”
• “Doesn’t consume my time or thoughts”

In some exceptional cases, women endorsed a clean split with eating disordered thinking: “I never even contemplate bingeing/purging,” and “I no longer have a fear of food or the need to control it.” In other cases, the women acknowledged some eating disordered thoughts but appeared confident in their abilities to respond positively: “I can stop myself from thinking and doing things when I know that they’re not the best for me.”

There were expressions of comfort with eating and an absence of guilt: “I don’t feel bad about what I eat. I am satisfied with how I eat,” and “I eat anything without feeling guilty.” In addition, there was a separation between food and a stress response in comments such as, “I don’t overeat because of stress,” suggesting the use of other coping mechanisms. Indeed, one woman explicitly stated that she knew she was recovered since she does not “have to use food as a coping mechanism.” There were also degrees here—for example, one woman reported being able to eat all foods “with little or no guilt” most of the time, rather than always feeling guilt-free.

Although not as frequently referenced, some women reported that holding positive attitudes toward their bodies was an indication they were healthy. Their statements included “being satisfied with [myself] and the way God made [me],” and being “content with my body.”

Behavioral Recovery
While behavioral change has generally been a well-accepted and utilized index of recovery, it is inspiring to hear what these women volunteered. Regarding eating, they said:

• “No restricting meals”
• “No bingeing/purging”
• “Giving up counting calories”
• “I am able to eat all kinds of food without reservations or regret”
• “I can eat whatever I want to…”
• “Eat normal meals daily”
• “Eat out”
• “Eat anything without having urges”
• “I used to pick food apart, but now I eat like normal”

Some felt that no longer needing a rigid eating structure or meal plan was an index of recovery. This notion is perhaps best captured by the woman who said, “I eat what I want, when I want.” Others acknowledged that behavioral change was more a matter of degree, citing “not as restrictive,” rather than absolute change. Women also pointed to differences in exercise: “[I am] not trying to burn off every calorie I eat… [I] exercise normally.”

Social Recovery
This stage has arguably received the least attention from the research and medical community. Most often eating disorders develop in adolescence and young adulthood, causing disruptions in social growth and expected developmental milestones. For example, the individual’s unhealthy behaviors often co-occur with social withdrawal, impeding more mature and intimate relationships. The following are some comments made by recovered women regarding these aspects.

One woman mentioned “being able to eat in front of people,” which in many cultures is central to developing and maintaining relationships. Without this ability, individuals with eating disorders miss out on opportunities to “do lunch” with family and friends and, undoubtedly, foster relationships. Another woman pointed out the ability to now “take advice of those close [to me].” Acknowledging loved ones’ concerns and considering their advice may reflect repaired relationships, including renewed trust. Lastly, one woman volunteered, “focusing on ‘life’ and [my] personality.” For this woman, and no doubt for others, recovery means regaining a sense of self and life experience that is not wrapped up in an eating disorder.

Concluding Remarks
Based on these voices and what is known among researchers and clinicians, recovery is both about what is absent (e.g., no binge eating, no obsessions) and what is present (e.g., ability to eat whatever one wants, happiness with life). For some, current life is experienced as if there never was an eating disorder; for others, there may be reminders or “scars,” such as occasional restriction or urges, but now with new coping skills. To paraphrase Dr. James Lock: “Recovery may be when life replaces the eating disorder.” One young woman poignantly reflected this during the interview. While she answered questions, she relayed that the eating disorder felt far away. She could recall details and remembered the pain, but it was like a distant dream and very separate from her current life.

As researchers continue to grapple with defining recovery, both in general terms and with an eye toward individualization, the goal is to apply the information so as to give everyone the best chance at the fullest life possible.

Anna M. Bardone-Cone, PhD, is an assistant professor in the Department of Psychological Sciences at the University of Missouri. Christine R. Maldonado, MA, is a clinical psychology doctoral student in the Department of Psychological Sciences at the University of Missouri.

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