European Eating Disorders Review

Eur. Eat. Disorders Rev. 16, 1–10 (2008)

The Patient’s Account of Relapse

and Recovery in Anorexia Nervosa:
A Qualitative Studyy
Anita Federici 1* and Allan S. Kaplan 2
1
Department of Psychology, York University, Toronto, Canada
2
Loretta Anne Rogers Chair in Eating Disorders, Toronto General Hospital,
Vice Chairman Research and Director of Clinician Scientist Program, Professor
of Psychiatry, University of Toronto, Toronto, Canada

Objective: The purpose of this study was to explore the subjective

accounts of weight-recovered female patients, who met DSMIV
criteria for anorexia nervosa (AN), regarding their views of their
illness following weight restoration.
Method: Qualitative semi-structured interviews were adminis-
tered to 15 participants to ascertain their perspective of the factors
that either contributed to their maintaining a healthy weight, or the
factors involved in their having relapsed over the follow-up period.
Results: Qualitative analyses revealed six core categories: internal
motivation to change, recovery as a work in progress, the perceived
value of the treatment experience, developing supportive relation-
ships, awareness and tolerance of negative emotion and self-
validation.
Discussion: This study provides valuable information about the
way in which AN patients experience their illness and highlight
the factors that help or hinder recovery. These findings may help
enhance relapse prevention programs and potentially enhance our
ability to identify and target those individuals at the greatest risk of
relapsing. Copyright # 2007 John Wiley & Sons, Ltd and Eating
Disorders Association.

Keywords: anorexia nervosa; relapse; recovery; qualitative methodology

INTRODUCTION others continue to struggle, or relapse following a

The process of recovering from anorexia nervosa
(AN) is a complicated and poorly understood
phenomenon. While intensive treatment may be
initially successful in interrupting core symptoms,
long-term outcome of AN is variable. Specifically,
the reasons why some patients fully recover while
* Correspondence to: Anita Federici, Department of Psychol-
ogy, York University, 297 Behavioural Sciences Building, 4700
Keele Street Toronto, Ontario, Canada M3J 1P3.
E-mail: federici@yorku.ca
y
This paper is based on the first author’s Master’s thesis in the
Institute of Medical Science, School of Graduate Studies,
University of Toronto.
period of remission, are unclear. Though longitudi-
nal studies provide some evidence that relapse is
more likely to occur among those who purge,
present with a lower body weight, have a longer
duration of illness, a later age of onset, and
significant comorbidity, the precise role of each
determinant is not clear (Finfgeld, 2002; Herzog,
Schellberg, & Deter, 1997, Pike, 1998; Steinhausen,
2002). In their longitudinal study assessing outcome
in AN, Strober, Freeman, and Morrell (1997) found
significant associations between poor clinical out-
come and aversive family environments, compul-
sive desire to exercise at discharge and difficulties
with socialisation. Carter, Blackmore, Sutandar-

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
additional predictors of relapse in AN, including
history of a suicide attempt, previous intensive
treatment, obsessionality and concern about weight
and shape at discharge. Furthermore, while the
greatest risk of relapse appears to occur during the
first year post-treatment (Herzog et al., 1997), Carter
et al. (2004) found that subjects remained at an
increased risk of relapse up to 17 months post-
intensive treatment, indicating that some patients
will relapse after remaining well for more than
1 year.
Despite increased attention and awareness of both
the severity and chronicity of AN, significant gaps
in our knowledge limit our ability to effectively treat
this disorder. Outcome measures and treatment
responses have largely been defined by quantifiable
physical determinants (e.g. body weight), associ-
ated physical sequelae (e.g. menses), attitudes and
beliefs about weight and shape, and measures of
comorbidity (e.g. personality, temperament). Such
approaches fail to take into account the view of the
patient in her response, or lack thereof, to treatment
and relapse (Garrett, 1997; Peters & Fallon, 1994).
Unravelling the complexities of AN may well be
aided by in-depth, qualitative studies which elicit
the patients’ view of treatment and reasons for
recovery and relapse. To date, only a small number
of studies have methodically examined AN from
this qualitative perspective.
With regard to recovery in AN, qualitative studies
have consistently emphasised the importance of
four key factors: social support, motivation for
change, developing an identity independent from
the eating disorder and factors related to the
therapeutic alliance. Patients report that initiating
and maintaining healthy and diverse, supportive
relationships (Beresin, Gordon, & Herzog, 1989;
Cockell, Zaitsoff, & Geller, 2004; Hsu, Crisp, &
Callender, 1992; Pettersen & Rosenvinge, 2002;
Tozzi, Sullivan, Fear, McKenzie, & Bulik, 2003)
and/or removing oneself from destructive and
negative home environments, has served to facili-
tate adaptive change (Beresin et al., 1989; Hsu et al.,
1992). Willpower, personal strength, the desire for a
better life and psychological readiness have also
been identified as salient factors with regard to
eliciting and maintaining change (Cockell et al.,
2004; Hsu et al., 1992; Keski Rahkonen & Tozzi,
2005; Pettersen & Rosenvinge, 2002). Qualitative
studies have also shown that the ability and desire
to create an identity separate from issues involving
eating, weight and shape have been associated with
recovery. Finally, patients with AN report that the
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
type of treatment and the perceived quality of the
therapeutic alliance play a significant role with
regard to recovery and treatment satisfaction
(Garrett, 1997; Noordenbos, Jacobs, & Hertzberger,
1998; Rosenvinge & Klusmeier, 2000; Tozzi et al.,
2003). Beresin et al. (1989) reported that treatment
compliance was enhanced when patients perceived
therapists as genuine, respectful, consistent and
non-judgmental.
The relevance and applicability of the above-
mentioned qualitative findings for AN patients in
the months immediately following completion of
intensive treatment are not clear. Previous studies
have typically interviewed patients several years
(ranging from 6 months to 12 years) following
various forms and durations of treatment. Given
that inpatient and day hospital programs are among
the primary treatment interventions for individuals
with AN, and in light of the greater potential for
relapse immediately following treatment com-
pletion, understanding the factors that facilitate or
prevent change are paramount. To date, only one
study has qualitatively explored relapse in individ-
uals with AN following intensive treatment. Cockell
et al. (2004) interviewed 32 female patients, the
majority of whom met diagnostic criteria for AN, 6
months following completion of a residential
treatment program. Participants identified a sense
of loss (e.g. lack of structure), feeling disconnected
from others, engaging in self-defeating beliefs (e.g.
unrealistic expectations about recovery, desire for
control) and difficulties dealing with the stress of
‘real life’ (e.g. returning to work, daily hassles,
coping with the ‘diet culture’) as primary factors
that hindered recovery. Replication and extension
of these data among AN patients in the months
following intensive treatment may have important
implications for relapse prevention programs.
The aim of the current study was to investigate the
patients’ view of relapse and recovery utilising a
qualitative, phenomenological approach (Holloway
& Wheeler, 2002; Morse & Field, 1995; Van Manen,
1997). Specifically, we sought to identify how
patients conceptualise and understand their ability
or desire to maintain change in the first year
following intensive treatment. In keeping with a
phenomenological approach (Creswell, 1998;
McLeod, 2001), every effort was made to ‘bracket’
preconceived ideas and assumptions about the
processes of recovery and relapse in AN. While both
authors view recovery as a complex process that
involves multiple factors (e.g. nutritional rehabilita-
tion, motivation, emotion regulation), the suspen-
sion of a priori hypotheses allowed the investigators
Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
Relapse and Recovery in AN
to explore concepts as they were presented by the
participants without imposing biases or presuppo-
sition onto the analysis.
MATERIALS AND METHODS
Procedure
Patients with AN who had successfully completed
intensive treatment (BMI
20 kg/m2 at discharge)
at the Toronto General Hospital (TGH) were invited
to participate in the study. Briefly, participants had
completed inpatient or intensive outpatient treat-
ment. Treatment primarily focused on nutritional
rehabilitation and utilised group-based cognitive
and behavioural interventions to target related
psychosocial issues (e.g. interpersonal relation-
ships, assertiveness, self-esteem, body image, sexu-
ality). Following intensive treatment, all partici-
pants participated in a manualised and controlled
relapse prevention protocol that consisted of weekly
outpatient CBT for up to 1 year.
All participants were female, 18 years of age or
older, and met diagnostic criteria for AN at
admission to treatment as determined by a clinical
psychologist. A total of 31 women were contacted
approximately 1 year following discharge from
treatment to assess their willingness and eligibility
to participate in the current study. In order to
establish two clinically homogeneous groups, one
clearly relapsed and one clearly recovered, partici-
pants with a BMI  17.5 kg/m2 were considered
weight-relapsed and participants with a BMI

19 kg/m2 were considered weight-recovered. Parti-
cipants whose BMI was between 17.5 and 19 kg/m2
were not eligible for this study because recovery
status is more difficult to determine among patients
with such body weights. Six patients did not meet
the BMI criteria (BMI < 19 and >17.5 kg/m2). Two
had a BMI greater than 19 kg/m2 but were actively
binging and vomiting. A total of 23 patients met the
inclusion criteria. Five did not return our calls
following the initial screening, two stated that they
were no longer interested in participating in a
research study and one patient declined to partici-
pate, as she was not willing to travel to the hospital
for the interviews. A final sample of 15 participants
took part in the current study.
All participants signed informed consent prior to
their participation in the study, which received
ethics approval from the TGH’s Research Ethics
Committee. In order to establish the clinical state of
each participant at the time of the interviews, the
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
3
Structured Clinical Interview for DSM Disorders
(SCID; First, Spitzer, Gibbon, & Williams, 1996) and
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-
itative interviews, developed by the authors: the
first explored the participants’ perspective of the
factors that contributed to their having maintained a
healthy weight (BMI
19), having no bulimic
symptoms (binging, vomiting) and normal eating
behaviours (n ¼ 7). The second interview assessed
the participants’ view of the factors that contributed
to their having lost weight and relapsed
(BMI  17.5) following intensive treatment (n ¼ 8).
Each interview began with an exploratory ques-
tion which invited participants to describe which
factors, if any, they felt contributed to their (a)
having maintained a healthy weight or (b) having
lost weight and relapsing following intensive
treatment. Participants were encouraged to speak
openly about their perceptions and beliefs and were
prompted occasionally by the interviewer to
elucidate, develop and expand on their ideas. Once
participants had ample time to discuss their
thoughts, the interviewer proceeded to explore
additional content areas as follows: eating specific
factors (exploration of various factors related to the
adoption or avoidance of weight control measures;
i.e. caloric restriction, participation in exercise,
vomiting, taking diet pills, etc.), environmental
factors (family difficulties, extra-familial relation-
ship difficulties, peer influences, cultural and
media, etc.), individual factors (personality traits,
presence and regulation of negative affect, self-
esteem), genetic factors and family history. In
addition, interviews explored the patients’ view
of their treatment experience and how this may
have contributed to their having lost or maintained
a healthy weight.
Data Analysis
In-depth interviews were tape recorded and
transcribed verbatim into textual data. Qualitative
research software, NVIVO version 2.0, was used to
aid in data organisation and analysis. Transcripts
were read in detail and a brief, interpretive
summary was written capturing potential themes
and overall impression. Emergent ideas and
thoughts were documented and this initial sum-
mary was discussed and explored with the thesis
supervisor and thesis committee members. The
language used by and the emotional presentation of
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-
out the developing analysis. Significant statements
pertaining to the phenomenon of interest were
extracted and categories were developed. Names of
codes were created using the participants’ words.
Similar codes were grouped together to form
clusters of themes which were compared and
contrasted with one another in order to verify
common elements. Any discrepancies among and/
or between various clusters were re-analysed. The
developing analysis was rated by independent
reviewers in order to ensure credibility and validity.
In addition, debriefing sessions with the supervisor
and thesis committee were scheduled at regular
intervals to add credibility to the study and well as
to ensure the integrity, rigor and dependability of
the findings. This allowed for an external check of
the research process whereby methodology,
interpretations and ideas were challenged, dis-
cussed or reassessed. Finally, the results were
integrated into an exhaustive description in order
to clearly illustrate the participant’s perspective of
relapse and recovery.
RESULTS
Interviews were conducted on an average of
14 months (SD ¼ 4.5) following discharge from
intensive treatment. Each interview lasted approxi-
mately 2 hours. Analyses revealed no significant
differences between eligible patients who agreed to
participate (n ¼ 15) and those who did not (n ¼ 8) in
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),
treatment setting (87% inpatient), prior number
of eating disorder hospitalisations (median ¼ 2,
range ¼ 0–12) or lowest past weight (BMI; M ¼
15.77, SD ¼ .43 kg/m2). There was a trend (x2 ¼ 3.63,
p ¼ .089) for a greater percentage of those who
refused the study to be of the binge-purge subtype
of AN (75%) compared to those who participated
(33%).
At the time of the interviews, the mean BMI for the
15 individuals who participated in the study was
21.1 (SD ¼ 1.7 kg/m2) for those in the weigh-
t-recovered group and 16.5 (SD ¼ 1.1 kg/m2) for
those in the weight-relapsed group. The two groups
did not differ with regard to age (M ¼ 26 years,
SD ¼ 6.5), admission BMI (M ¼ 15.9, SD ¼ 1.94 kg/
m2), lowest past weight (BMI; M ¼ 15.9, SD ¼
.50 kg/m2) or number of prior eating disorder
hospitalisations (median ¼ 2.3, range 0–12). Although
a greater percentage of participants in the weigh-
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
t-recovered group were more likely to meet criteria
for the restricting subtype of AN (85.7%) compared
to those in the weight-relapsed group (50%), a
Mann–Whitney U-test failed to show significance:
U ¼ 18.0; p ¼ .282. In terms of duration of treatment,
women in the weight-recovered group spent signi-
ficantly less time in treatment (M ¼ 78.6 days,
SD ¼ 20.8) than those in the weight-relapsed group
(M ¼ 116.8 days, SD ¼ 28.7; U ¼ 6.00, p ¼ .008). There
were no significant differences between the two
groups in terms of treatment setting; in total, nine
participants had been admitted to the inpatient unit
and six had been day hospital patients. A two
(weight-recovered vs. weight-relapsed) by two
(presence or absence of a DSM IV Axis I disorder)
contingency table was used to test differences
between the two groups with respect to current
or lifetime presence of an Axis I Disorder as
measured by the SCID. Weight-relapsed partici-
pants were significantly more likely to meet criteria
for a lifetime or current diagnosis of OCD (x2 ¼ 8.04,
p ¼ .009).
Qualitative Results
Qualitative analyses yielded six core categories that
described the primary factors participants believed
contributed to their having lost or maintained their
weight following intensive treatment. Each category
is described in detail below:
Category I: internal motivation for change
Recovered Participant:
I think that my own drive to get better and my
commitment to myself had been incredibly import-
ant. I’m not doing it for anyone else because, as much
as your parents and your friends care for you, it’s not
their problem. This is up to me. I have to do this.
When asked to describe the factors that con-
tributed to their ability to maintain a healthy weight,
participants in the recovered group articulated a
powerful desire to change, to let go of symptoms
and to move beyond the illness. Participants spoke
of being tired of their symptoms, of a desire to be
healthy and of their recognition that the illness
conflicted with valued personal beliefs and
life goals. Participants stated that the decision to
recover had been a self-initiated and self-directed
process; rather than completing treatment for the
sake of others, women in the weight-recovered
group stated that they pursued recovery for
themselves.
Eur. Eat. Disorders Rev. 16, 1–10 (2008)
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Relapse and Recovery in AN
Relapsed Participant:
By the second week I knew it was a bunch of—and
I’d be sick the second I walked out of there, but I just
had to show everyone that I could make it through
the 12 weeks. I knew it wasn’t going to work! I was
like . . . I’ll humour them and put on the weight, but
I know . . . it won’t take me long to take it off again.
Participants who had relapsed stated that they
had been more ambivalent about their recovery and
their capacity to maintain change throughout, and
following intensive treatment. They reported that
the benefits of using symptoms as a coping strategy
continued to outweigh the costs. Many participants
reported that they had entered and completed
treatment in order to satisfy significant others. As a
result, participants reported that they were ‘not
ready’ for treatment or that they had only been
‘willing to go so far’ in terms of symptom reduction.
Category II: recovery as a ‘work in progress’
Recovered Participant:
. . . it’s not like, get out of the hospital weight
restored - you’re better! It totally was hard work,
being on top of it, staying with the meal plan, keep
taking risks, being open and honest about things
that are becoming scary again - because things do
become scary again!
Participants in the weight-recovered group
emphasised that recovery was an on-going process
that required sustained vigilance and persistence.
Even in one year post-treatment, participants did
not view themselves as ‘recovered’, rather they
considered themselves to be in the ‘process of
recovery’. Reaching weight-restoration in a treat-
ment program was merely the first of a succession of
steps. Many noted that their expectations about
recovery had been fairly realistic and that they had
anticipated and planned for the obstacles and
challenges that presented themselves post-
treatment.
Relapsed Participant:
. . . it was very hard to hang onto my weight. If there
was an opportunity to either eat safer or to cut out
one or two exchanges, I wouldn’t hesitate . . .
Participants who subsequently relapsed reported
that their experience of treatment and recovery
had been considerably different from their initial
expectations. Some reported feeling overconfident
about their recovery and assumed that the difficult
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
5
work was behind them. As a result, many stated
that they had been less strict about utilising
behavioural and self-care strategies in the months
following treatment. Unlike those in the recovered
group, participants who relapsed stated that they
had not anticipated the challenges and struggles
that presented themselves following intensive
treatment. Despite this, several weight-relapsed
participants did not see themselves as ‘relapsed’
and argued that the investigator-imposed categor-
ies of relapse and recovery did not fully capture
their experience of their clinical state. Much like
those who had maintained their weight, weigh-
t-relapsed participants considered themselves to be
‘in the process of recovery’.
Category III: perceived value of the treatment
experience
Recovered Participant:
I was with fellow women that suffered with the
same thing so that allowed me to be open about
issues . . . and because people were speaking about
them, I was able to speak about them.
Women in the weight-recovered group reported
that they were considerably more satisfied with
their treatment experience compared to those who
relapsed. With regard to the intensive portion of
therapy, weight-recovered participants stated that
they felt safe, supported and validated by both staff
and fellow group members and that the specific
interventions (e.g. psychoeducation the structured
meal plan, weekly weigh-ins) had been essential
components of their recovery. Similarly, with
respect to the relapse prevention phase of treatment,
participants who maintained their weight felt that
follow-up care had helped ease the transition out of
intensive treatment and had been a crucial aspect of
their ability to maintain change.
Relapsed Participant:
I feel like I didn’t deal with any of the issues that
were there to begin with. The bereavement, the
self-esteem issues . . . I hadn’t dealt with why I had
this eating disorder. How can I fix something when
I don’t even know what the cause of it is?
In contrast, those who relapsed reported feeling
dissatisfied with their treatment experience. Specifi-
cally, participants stated that the behavioural goals
of treatment (e.g. weight restoration) overshadowed
the identification and processing of core psycho-
logical and emotional issues. As a result, and
regardless of having gained weight, participants
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
after treatment’. Many stated that they felt particu-
larly vulnerable and unskilled at managing ongoing
emotional and interpersonal stressors in the months
following treatment. Likewise, participants repor-
ted that follow-up care had been too inflexible and
behavioural in orientation. They felt that too
little attention had been given to issues involving
relationships, current stressors and negative emo-
tions. As a result of not meeting their needs, many
stated that they subsequently discontinued therapy.
Participants emphasised that either treatment nee-
ded to be longer or follow-up care more intensive to
account for the difficulty they encountered trying to
maintain change.
Category IV: developing supportive relationships
Recovered Participant:
My family was very supportive at the beginning of
my recovery, and I think that was the most
important part . . . for them to take the illness
seriously . . . their understanding [and] willing[-
ness] to accept that I wasn’t deliberately doing this
to make myself sick.
Participants reported that maintaining change
following intensive treatment was strongly related
to the availability, support and non-judgemental
stance of family members and friends in the months
following treatment. Participants emphasised the
importance of feeling understood, accepted and of
being taken seriously by the people in their lives.
Specifically, the adoption of a non-dieting approach
by significant others and spending time with people
who were less focused on body weight and shape,
were perceived to be significant factors that contri-
buted to the recovery process. Moreover, partici-
pants highlighted that recovery involved actively
‘letting people in’, asking for help and developing
trust in others. For many, choosing to move towards
rather than away from people was a crucial part of
recovery.
Relapsed Participant:
I think I have trouble accepting help or accepting
that I might need help. I feel that it’s a weakness to
need help, like . . . I can do this on my own . . . just
leave me alone.
I just felt very isolated and alienated from my
family . . . they just didn’t know how to accept what
I was going through . . ..
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
In contrast, those who relapsed reported that they
did not have adequate social support and noted that
they typically felt judged and misunderstood by the
people in their lives. Marked by a pervasive sense of
loneliness, isolation and alienation, participants
expressed frustration and disappointment that their
families and friends did not understand the
difficulties they were experiencing. Many partici-
pants reported that their recovery was hindered
by the continual emphasis on body weight and
dieting within the family or social environment. In
addition, participants stated that they had con-
siderable difficulty accepting help from others. For
many, asking for help was perceived as a sign of
weakness and failure.
Category V: awareness and tolerance of negative
emotion
Recovered Participant:
I am able to tolerate negative emotions and that has
had a very positive influence [on] stay(ing)
well . . . on my getting recovered and maintaining
it. So, the negative emotions . . . [I’m] totally able to
feel them and not get overwhelmed by them and not
have them translate into negative beha-
viours . . . that’s fundamentally important!
Participants in the recovery group felt that
learning to identify and tolerate negative emotions
was central to their recovery process. Although
learning to sense and manage emotions began in the
hospital, the continual effort to work with emotions
in the months following treatment was considered
to be a significant contributing factor. Such work
helped participants feel less overwhelmed and
threatened when negative feelings surfaced. Com-
municating with parents, sharing feelings with
partners and talking with friends about their
emotions increased their self-esteem and enabled
them to develop a greater sense of control over
negative affect. Participants stated that they gradu-
ally began to express their feelings in healthier,
more adaptive ways.
Relapsed Participant:
I was feeling frustrated with having to feel
everything so I started drinking three days a week,
where it wasn’t just a little bit of drinking, it was
like . . . carry me home drinking . . . using the
alcohol to numb myself out. I needed something
else to take away the pain, to take away everything
that was inside that I wasn’t ready to let out.
Eur. Eat. Disorders Rev. 16, 1–10 (2008)
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Relapse and Recovery in AN
Those who relapsed reported that maintaining
positive changes following weight restoration was
complicated by considerable difficulty tolerating
negative affect. Many stated that they had accom-
plished little during treatment in terms of identify-
ing and learning to tolerate unpleasant feelings. In
the months following discharge, weight-relapsed
participants stated that they struggled to cope with
intense feelings of depression, anxiety and lone-
liness. Furthermore, participants stated that the
discrepancy between their weight-restored bodies,
which appeared ‘normal’, and their minds, which
continued to be consumed by ‘anorexic thoughts’,
was one of the most difficult issues they faced
following treatment. Specifically, they reported that
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
feelings, some participants reported that they found
other, self-destructive ways of coping (e.g. self-
harm, substance abuse).
Category VI: self-validation
Recovered Participant:
. . . it’s two sides of the same coin. Self-discipline is
part of the reason I was able to be anorexic.
Unfortunately you have to be extremely disciplined
to starve for months and years, right? The flipside
is the discipline is helping me stay with the eating,
not missing one single meal!
Participants who maintained their weight
reported that cultivating and maintaining a sense
of personal worth and value was highly related to
the maintenance of change following intensive
treatment. Participants described themselves as less
self-critical, more assertive, more accepting of their
bodies and more likely to take credit for personal
successes and accomplishments. Maintaining
recovery was strongly related to focusing on
positive aspects of the self and challenging
unhealthy thoughts about appearance and body
weight. Furthermore, many reported that person-
ality traits once thought to have played an essential
role in the development of their disorder were now
used to facilitate healthy change (e.g. patience,
stamina, determination, perfectionism).
Relapsed Participant:
I think ultimately I got sick because of this
incredible unhappiness and dissatisfaction with
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
7
myself that I haven’t resolved, and until that totally
resolves, eating is going to be an issue.
In contrast, participants who relapsed reported
that their recovery was hindered by severe self-
criticism, intense fears of failure, a pervasive sense
of worthless and a feeling of hopeless for the future.
They stated that they had considerable difficulty
asserting their needs, acknowledging personal
accomplishments and noted that they remained
heavily invested in the opinions, views and desires
of others. Finally, participants reported that
ongoing body weight and shape concerns played
a significant role in their inability to maintain their
recovery.
DISCUSSION
In the current study, phenomenological method-
ology was used to discover how individuals with
AN understand the process of recovery and relapse
in the year following intensive treatment. This study
emphasises the importance of psychological change
in the recovery of AN. Though all participants
responded behaviourally to treatment, in that each
was discharged from hospital after reaching their
target BMI of 20, the two groups differed in the
degree to which they were able to maintain their
recovery following treatment. The emergence of six
core categories illustrates that recovery was an
on-going process that required internal motivation,
belief in the capacity to change, the ability to
develop trust and the expression of emotion. In
contrast, relapse was characterised by uncertainty,
reluctance to change, difficulty asking for help,
intense negative emotion and a pervasive sense of
worthlessness. These findings have important
implications for relapse prevention and psychoe-
ducation programs, as described below:
1. Motivation and recovery expectancies: These
data expand our understanding of the role of
motivation in the processes of both relapse and
recovery, and support the more recent emphasis
on motivational interventions (i.e. motivational
enhancement therapy) in the treatment of AN
(Feld, Woodside, Kaplan, Olmsted, & Carter,
2001; Tantillo, Nappa Bitter, & Adams, 2001;
Treasure & Ward, 1997; Vitousek & Watson,
1998). They are also consistent with the work
of Hsu et al. (1992) and Pettersen and Rosenvinge
(2002) who found that ‘being ready’ and feeling
‘motivated to change’ were salient factors in the
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
found that, while motivation to change was cen-
tral during the initial stages of recovery, it was
also a key factor in later stages of recovery.
Participants who relapsed were more ambivalent
about change prior to, during, and after treat-
ment, whereas those who sustained a healthy
body weight reported greater motivation to
change during and subsequent to intensive treat-
ment. These data also highlight the significance
of recovery as an autonomous, self-motivated
choice that was consistent with the long-term
goals and values of the individual. In addition,
and consistent with the work of Cockell et al.
(2004) and Constantino, Arnow, Blasey, and
Agras (2005), expectancies regarding the recov-
ery process appeared to play an important role in
participants’ ability and desire to maintain
change post-discharge. For example, compared
to those who relapsed, participants who main-
tained their recovery stated that they had realistic
expectations about continuing to work on symp-
toms in the months following treatment. Internal
motivation, treatment expectancies and goal
identification may be important issues to empha-
sise and measure in pre-treatment interventions
as well as in relapse prevention programs.
Specifically, the inclusion of motivational strat-
egies prior to, during, and after treatment may
serve to enhance therapeutic response and
clinical outcome.
2. Emotion regulation: This study also highlights
the importance of emotional processing and
affect regulation in the process of recovery from
AN. Based on these data, the ability to access,
integrate and express emotions was central to the
maintenance of positive change following inten-
sive treatment. Therapeutic approaches that
place a greater emphasis on emotion regulation
and exploration of internal affective states (e.g.
Dialectical Behaviour Therapy (DBT); Emotion-
Focused Therapy) may have important implica-
tions for the treatment of AN. Recent findings
demonstrating positive outcomes using time-
limited group-based and individual applications
of DBT lend further support to the value of
focusing specially on enhancing emotion regula-
tion skills in the treatment of eating disorders
(Safer, Telch, & Agras, 2001; Telch, Agras, &
Linehan, 2001).
3. Social support: Consistent with earlier studies
(Beresin et al., 1989; Hsu et al., 1992; Pettersen
& Rosenvinge, 2002; Tozzi et al., 2003), the pre-
sence of supportive and non-judgemental
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
relationships emerged as a significant factor that
contributed to the maintenance of change follow-
ing treatment. In addition to the presence or
absence of supportive relationships, those who
maintained their recovery were differentiated
from those who relapsed by three factors. First,
social support was mediated by the ability and
willingness to request and accept help. Many
participants who relapsed stated that asking
for additional help was weak, awkward or sha-
meful. Second, the adoption of a non-dieting
approach by family and friends was reported
to have been a key factor that either facilitated
or hindered recovery. Finally, the involvement in
non-eating disorder-related community and
extracurricular activities appeared to support
the recovery process perhaps by fostering the
growth of a new identity within the context of
a supportive, nurturing environment. These data
suggest that post-treatment planning and relapse
prevention programs may facilitate treatment
outcome by focusing specifically on enhancing
problem-solving and interpersonal effectiveness
skills. Increasing patient awareness about the
importance of social support and the obstacles
involved in seeking help and encouraging
patients to pursue non-eating disorder hobbies
or activities would be beneficial. Additionally,
addressing the complexity of these issues in
psychoeducation formats for family and friends
would also be beneficial.
4. Treatment and relapse prevention: The pub-
lished literature suggests that the quality of
therapeutic alliance plays an important role in
recovery and treatment satisfaction (Constan-
tino, Castonguay, & Schut, 2002; Horvath & Bedi,
2002; Loeb et al., 2005). In the current study, the
degree to which participants felt a sense of safety,
support and acceptance, by their therapists and
fellow group members was reported to have
either helped or hindered recovery. These data
suggest that monitoring and placing a greater
emphasis on the development of the therapeutic
alliance over the course of intensive treatment
and throughout the relapse prevention phase
may improve treatment outcome for a greater
number of patients.
Additionally, these data suggest that intensive
programs may be sufficient interventions for
weight restoration; however, for a subgroup of
patients, they do not foster lasting psychological
change. Given the emphasis on readiness and
internal motivation for change, matching
patients to treatment type and intensity and/or
Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
Relapse and Recovery in AN
utilising stepped-care approaches may be
particularly important for patients with AN.
Future studies evaluating the development and
application of individually-tailored treatments
would also be a valuable contribution to the
existing literature. While cognitive-behavioural
interventions are particularly beneficial interven-
tions for patients with eating disorders, utilis-
ation of alternative treatment modalities may be
especially salient in the relapse prevention phase.
For example, in addition to focusing on weight
restoration, focusing explicitly on helping
patients develop comprehensive skills for nego-
tiating life stressors, interpersonal problems or
coping with emotion dysregulation may further
enhance treatment outcome.
5. Measuring and defining change: Although
additional research studies with larger sample
sizes are needed, these results have important
implications for the way in which we currently
classify and measure treatment success and long-
term outcome. Given that most participants,
regardless of their clinical state at the time of
the interviews, considered themselves to be ‘in
recovery’ highlights the complex and subjective
nature of change and progress. The inclusion of
more broadly based outcome measures and
criteria that include behavioural as well as qual-
itative psychological measures (i.e. patients’ per-
ception of their illness and recovery) has the
potential to provide rich data with regard to
treatment response.
Study Limitations
While the use of qualitative methodology is a
considerable strength of this study, it may also be a
limitation in that findings were based on the
personal stories and information participants selec-
tively chose to disclose. While every effort was
made to build rapport between participant and
researcher, some participants may not have felt
comfortable revealing all the details of their
experiences. The study is further limited by its
retrospective design in that participants may not
have been able to clearly recall past events or
feelings. In addition, their recollection of the factors
that contributed to their having maintained or lost
weight may have been influenced by their current
state of illness (e.g. whether a participant was
weight-relapsed or weight-recovered at the time of
interview). Generalisability is limited by the small
sample size and the fact that participants were
self-selected based on their experience with the
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
9
phenomena of interest. Additionally, the women
who participated in this study were all Caucasian,
middle to upper class and well educated, which
may further limit generalisability. Finally, partici-
pants did not read the transcripts or receive a
summary of the results, which would have
enhanced the validity of the findings.
CONCLUSION
This study contributes valuable information about
how patients with AN understand the processes of
relapse and recovery. This study demonstrates that
AN patients have various and unique treatment
needs and that some patients may require different
or additional treatment post-weight restoration in
order to facilitate long-term psychological change.
Furthermore, this research highlights the import-
ance of using in-depth, qualitative approaches to
facilitate a richer understanding of the constructs
involved in the process of recovery that may be
more difficult to access with traditional quantitative
methods. Clearly, there is a great deal to be learned
from patients about their illness. Further qualitative
research in this area could contribute to the
enhancement of relapse-prevention programs and
facilitate the development of more individually
tailored and effective treatments.
ACKNOWLEDGEMENTS
The authors wish to thank the patients who shared
with us their personal views. We also appreciate the
support and collaboration of Dr Marion Olmsted,
Dr Jacqueline Carter, Dr Blake Woodside, Dr Gary
Rodin and Dr Mary Jane Esplen, who served on the
first author’s Thesis Committee. In addition, the
authors would like to acknowledge Dr Pavla
Resnick who contributed to the conceptualisation
of the methodology.
REFERENCES
Beresin, E. V., Gordon, C., & Herzog, D. B. (1989). The
process of recovering from anorexia nervosa. Journal of
the American Academy of Psychoanalysis, 17, 103–130.
Carter, J. C., Blackmore, E., Sutandar-Pinnock, K., &
Woodside, D. B. (2004). Relapse in anorexia nervosa:
A survival analysis. Psychological Medicine, 34, 1–9.
Cockell, S. J., Zaitsoff, S. L., & Geller, J. (2004). Maintaining
change following eating disorder treatment. Pro-
fessional Psychology: Research and Practice, 35, 527–534.
Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv
10
Constantino, M. J., Arnow, B. A., Blasey, C., & Agras, W. S.
(2005). The association between patient characteristics
and the therapeutic alliance in cognitive-behavioural
and interpersonal therapy for bulimia nervosa. Journal
of Consulting and Clinical Psychology, 73, 203–211.
Constantino, M. J., Castonguay, L. G., & Schut, A. J. (2002).
The working alliance: A flagship for the scientist-
practitioner model in psychotherapy. In G. S. Tryon
(Ed.), Counselling based on process research: Applying
what we know (pp. 81–131). Boston: Allyn & Bacon.
Creswell, J. W. (1998). Qualitative enquiry and research
design: Choosing among five traditions. Thousand Oaks,
CA: Sage Publications, Inc.
Feld, R., Woodside, D. B., Kaplan, A. S., Olmsted, M. P., &
Carter, J.C. (2001). Pre-treatment motivational enhan-
cement therapy for eating disorders: A pilot study.
International Journal of Eating Disorders, 29, 393–400.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W.
(1996). Structured clinical interview for DSM-IV axis I
disorders—patient version (SCID-I/P, version 2.0).
New York State Psychiatric Institute, New York.
Fariburn, C. G., & Cooper, Z. (1993). The eating disorder
examination (12th ed.). In C. G. Fairburn, & G. T.
Wilson (Eds.), Binge eating: Nature, assessment and treat-
ment. New York: Guilford Press.
Finfgeld, D. L. (2002). Anorexia nervosa: Analysis of long-
term outcomes and clinical implications. Archives of
Psychiatric Nursing, 16, 176–186.
Garrett, C. (1997). Recovery from anorexia nervosa: A
sociological perspective. International Journal of Eating
Disorders, 21, 261–272.
Herzog, W., Schellberg, D., & Deter, H. (1997). First
recovery in anorexia nervosa patients in the long-term
course: A discrete-time survival analysis. Journal of
Counselling and Clinical Psychology, 65, 169–177.
Holloway, I., & Wheeler, S. (2002). Phenomenology. In I.
Holloway, & S. Wheeler (Eds.), Qualitative research in
nursing (2nd ed., pp. 170–187). Oxford, UK: Blackwell
Publishing.
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C.
Norcross (Ed.), Psychotherapy relationships that work:
Therapists contributions and responsiveness to patients
(pp. 37–69). New York: Oxford University Press.
Hsu, L. K., Crisp, A. H., & Callender, J. S. (1992). Recovery
in anorexia nervosa: The patient’s perspective. Inter-
national Journal o f Eating Disorders, 11, 341–350.
Keski Rahkonen, A., & Tozzi, F. (2005). The process of
recovery in eating disorder sufferers’ own words: An
internet-based study. International Journal of Eating
Disorders, 37, S80–S86.
Loeb, K. L., Wilson, G. T., Labouvie, E., Pratt, E. M.,
Hayaki, J., Walsh, B. T., et al. (2005). Therapeutic
alliance and treatment adherence in two interventions
for bulimia nervosa: A study of process and outcome.
Journal of Consulting and Clinical Psychology, 73,
1097–1107.
McLeod, J. (2001). The phenomenological approach. In J.
McLeod (Ed.), Qualitative research in counselling and
Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association.
A. Federici and A. S. Kaplan
psychotherapy (pp. 35–53). Thousand Oaks, California:
Sage Publications.
Morse, J. M., & Field, P. A. (1995). Qualitative approaches.
In J. M. Morse, & P. A. Field (Eds.), Qualitative research
methods for health professionals (2nd ed., pp. 151– 170).
Thousand Oaks, CA: Sage Publications.
Noordenbos, G., Jacobs, M. E., & Hertzberger, E. (1998).
Chronic eating disorders: The patients’ view of their
treatment history. Eating Disorders, 6, 217–223.
Pike, K. M. (1998). Long-term course of anorexia nervosa:
Response, relapse, remission and recovery. Clinical
Psychology Review, 18, 447–475.
Peters, L., & Fallon, P. (1994). The journey of recovery:
Dimensions of change. In P. Fallon, M. A. Katzman,
& S. C. Wooley (Eds.), Feminist perspectives on
eating disorders (pp. 339–354). New York, NY: The
Guilford Press.
Pettersen, G., & Rosenvinge, J. H. (2002). Improvement
and recovery from eating disorders: A patient
perspective. Eating Disorders, 10, 61–71.
Rosenvinge, J. H., & Klusmeier, A. K. (2000). Treatment for
eating disorders from a patient satisfaction perspect-
ive: A Norwegian replication of a British study. Euro-
pean Eating Disorders Review, 8, 293–300.
Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical
behaviour therapy for bulimia nervosa. American Jour-
nal of Psychiatry, 158, 632–634.
Steinhausen, H. (2002). The outcome of anorexia nervosa
in the 20th century. American Journal of Psychiatry, 159,
1284–1293.
Strober, M., Freeman, R., & Morrell, W. (1997). The long-
term course of severe anorexia nervosa in adolescents:
Survival analysis of recovery, relapse, and outcome
predictors over 10–15 years in a prospective study.
International Journal of Eating Disorders, 22, 339–
360.
Tantillo, M., Nappa Bitter, C., & Adams, B. (2001). Enhan-
cing readiness for eating disorder treatment: A rela-
tional/motivational group model for change. Eating
Disorders: The Journal of Treatment and Prevention, 9,
203–216.
Telch, C. F., Agras, W. S., & Linehan, M. M. (2001).
Dialectical behaviour therapy for binge eating dis-
order. Journal of Consulting and Clinical Psychology,
69, 1061–1065.
Treasure, J., & Ward, A. (1997). A practical guide to the use
of motivational interviewing in anorexia nervosa.
European Eating Disorders Review, 5, 102–144.
Tozzi, F., Sullivan, P. F., Fear, J. L., McKenzie, J., & Bulik,
C. M. (2003). Causes and recovery in anorexia nervosa:
The patient’s perspective. International Journal of Eating
Disorders, 33, 143–154.
Van Manen, M. (1997). Researching lived experience: A
human science for an action sensitive pedagogy
(2nd ed.). Ontario, Canada: Althouse Press.
Vitousek, K., & Watson, S. (1998). Enhancing motivation
for change in treatment resistant eating disorders.
Clinical Psychology Review, 18, 391–420.
Eur. Eat. Disorders Rev. 16, 1–10 (2008)
DOI: 10.1002/erv