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Intimate partner relationships and recovery from an eating disorder Hughes-Jones, Megan I. 2015

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  Intimate Partner Relationships and Recovery from an Eating Disorder by  Megan I. Hughes-Jones  B.A., The University of British Columbia, 2005 M.A., The University of British Columbia, 2009  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POST DOCTORAL STUDIES (Counselling Psychology)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  March 2015  © Megan I. Hughes-Jones, 2015   ii Abstract It is well established in the empirical, clinical, and theoretical literatures that close relationships influence adult women’s  recovery  from  an  eating  disorder  (ED),  and  research  has consistently identified intimate partners as key figures in this process. Despite this recognition, very little  is  known  about  women’s  lived  experiences  of  their  intimate  partner  relationships  as  a  support during recovery, or the meanings they attribute to this experience. The current qualitative study employed a hermeneutic phenomenological method to address this gap in knowledge. The research question guiding this inquiry was: “what  is  the  meaning  of lived experience of intimate partner  relationships  in  supporting  women’s  recovery  from  an  eating  disorder?” Ten adult women completed qualitative research interviews. Interviews were transcribed verbatim and a thematic analysis was conducted. Five common themes characterizing the women’s  lived  experience of the phenomenon of intimate partner relationships supporting recovery were identified: Sense of Safety, Sense of Mutual Commitment, Communication as Facilitative, Intimacy, and Sense of Identity Beyond the Eating Disorder. Significant findings are discussed within  the  context  of  existing  literature  on  adult  women’s  experiences  of  an  ED  and  recovery.  Implications for theory, practice, and research are addressed, and recommendations for future research are identified.    iii Preface This research was conducted with the approval of The University of British Columbia (UBC) Office of Research Services (ORS), Behavioural Research Ethics Board (BREB), as per certificate of approval number H13-01065. It is the original, unpublished, independent work of the author, Megan I. Hughes-Jones.  iv Table of Contents Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iii Table of Contents ......................................................................................................................... iv List of Tables ............................................................................................................................... vii Chapter 1: Introduction ................................................................................................................1 The Significance of Eating Disorders .......................................................................................1 The Relational Nature of Eating Disorders .............................................................................2 Problem and Rationale: Situating the Study ...........................................................................3 Recovery From an Eating Disorder .........................................................................................4 Further understanding of the role of relationships in recovery ................................................6 Social support...........................................................................................................................7 “Support  provider”  experiences ...............................................................................................8 Couples’  oriented  treatments ...................................................................................................9 Intimate partner relationships ................................................................................................10 Relational-Cultural Theory.....................................................................................................12 Re-statement of the Problem...................................................................................................14 Purpose of the Research ..........................................................................................................15 Practice- and theory- oriented purpose ..................................................................................16 Chapter 2: Literature Review .....................................................................................................18 Eating Disorders and Recovery ..............................................................................................19 Brief overview of the literature ..............................................................................................19 Initial efforts to capture women’s  perspectives  on  recovery .................................................20 The experience and process of recovery: Empirically derived theories ................................27 Social Support ..........................................................................................................................33 Background ............................................................................................................................33 Social support in the area of eating disorders ........................................................................34 Intimate Partner Relationships ..............................................................................................43 Early work: Exploring group differences ..............................................................................45 Relational status and clinical presentation .............................................................................48 Women’s  experiences  in  romantic  relationships ...................................................................49 Partner experiences ................................................................................................................51 Relational-Cultural Theory: Perceived mutuality in partner relationships ............................55 Summary and Re-statement of Rationale for the Current Study .......................................57 Chapter 3: Method .......................................................................................................................59 Ontological and Epistemological Positions ............................................................................59 Critical realism .......................................................................................................................59 Philosophical Hermeneutics and the Hermeneutic Circle ...................................................61 Phenomenology: Historical and Epistemological Developments .........................................62 Hermeneutic Phenomenology .................................................................................................63 Researcher Positionality and Subjectivity: Reflexive Practice ............................................65 Addressing forestructures and pre-understanding: Initial tasks .............................................66 Ongoing reflexive practices ...................................................................................................67  v Statement of Positionality........................................................................................................68 Beliefs and biases ...................................................................................................................70 Assumptions and expectations ...............................................................................................72 Rationale for Study Inclusion Criteria ..................................................................................73 Procedure ..................................................................................................................................76 Participants .............................................................................................................................76 Recruitment ............................................................................................................................78 Data collection .......................................................................................................................79 Data analysis ..........................................................................................................................85 Representation of the Research Findings ..............................................................................90 Evaluating Interpretive Accounts: Establishing Trustworthiness in the Research...........91 General criteria to ensure quality ...........................................................................................91 Evaluation of hermeneutic phenomenology ..........................................................................92 Methods for establishing credibility ......................................................................................93 Ethical Considerations.............................................................................................................97 Ethical procedures ..................................................................................................................99 Risks and benefits ................................................................................................................100 Delimitations ...........................................................................................................................101 Chapter 4: Results......................................................................................................................104 Biosynopses .............................................................................................................................105 Common Themes ...................................................................................................................116 Sense of Safety ........................................................................................................................116 Sense of acceptance and non-judgment ...............................................................................119 Sense of security in the relationship ....................................................................................125 Sense of Mutual Commitment ..............................................................................................129 Shared valuing of the relationship .......................................................................................130 Joining in recovery ...............................................................................................................135 Sense of motivation and accountability ...............................................................................145 Communication as Facilitative .............................................................................................153 Intimacy ..................................................................................................................................162 Shifting relationship to their body .......................................................................................163 Differentiation from other supportive relationships ............................................................170 Sense of Identity Beyond the Eating Disorder ....................................................................174 Summary of Results ...............................................................................................................182 Chapter 5: Discussion ................................................................................................................185 Contextual Considerations ....................................................................................................186 Significant Findings and Theoretical Implications .............................................................187 Relational Climate .................................................................................................................188 Acceptance and validation ...................................................................................................188 Open communication ...........................................................................................................198 Partnership .............................................................................................................................200 From isolation to connection ...............................................................................................201 Mutuality and joining ...........................................................................................................203 Motivational elements ..........................................................................................................208 Relational-Cultural Theory...................................................................................................211     Implications of the Sample ....................................................................................................216  vi     Implications for Practice .......................................................................................................222 Treatment of Eating Disorders .............................................................................................222 Individual counselling ..........................................................................................................223 Couples’ focused approaches ...............................................................................................225 Resources for partners..........................................................................................................230 Implications for Research .....................................................................................................233 Directions for future research ..............................................................................................234 Dissemination plans .............................................................................................................238 Conclusion ..............................................................................................................................239 References ...................................................................................................................................242 Appendix A: DSM-IV Eating Disorder Criteria .....................................................................269 Appendix B: Recruitment Poster .............................................................................................271 Appendix C: Print, Electronic, and Social Media Recruitment Notice ................................273 Appendix D: Telephone Screening Form ................................................................................274 Appendix E: Informed Consent Form .....................................................................................277 Appendix F: Informed Consent Form for Skype Interviews .................................................280 Appendix G: Interview Orienting Statement ..........................................................................283 Appendix H: Interview Questions ............................................................................................284 Appendix I: Resources ...............................................................................................................286 Appendix J: Transcription Services Confidentiality Agreement ..........................................287    vii List of Tables  Table 1 Summary of Participant Demographic Information ............................................... 105 Table 2 Common Themes and Sub-themes ............................................................................ 116  1 Chapter 1: Introduction  The current study employed a hermeneutic phenomenological method to explore the meaning of lived experience of intimate partner relationships in supporting recovery from an Eating Disorder (ED). To this end, the study sought to answer the following research question: “what  is  the  meaning  of lived  experience  of  intimate  partner  relationships  in  supporting  women’s  recovery  from  an  eating  disorder?”  The Significance of Eating Disorders  Eating disorders (ED) are a serious health concern and often result in significant physical, psychological, and emotional consequences (Dall Grave, 2011; Klump, Bulik, Kaye, Treasure, & Tyson, 2009). As  defined  by  the  American  Psychiatric  Association’s  (APA)  Diagnostic  and  Statistical Manual of Mental Disorders (DSM-IV-TR), EDs, including anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS) consist of over-evaluation of the individual’s  shape  and  weight,  and  a  number  of  behaviors  aimed at controlling one’s  shape  and  weight,  including  extreme  restriction  of  dietary  intake,  episodes  of  bingeing  and/or purging, and excessive exercise (see Appendix A for DSM-IV-TR criteria and APA, 2000 for further diagnostic and related information). Eating disorders are significantly more prevalent in women than men, and are estimated to occur in approximately 0.3-1% of the population (van Hoeken, Seidell, Hoek, 2003). That being said, prevalence rates are often considered under-representative, given the secretive nature of EDs and the number of individuals living with ED behaviors who do not seek treatment (i.e., and thus, do not receive a formal diagnosis and are not captured by epidemiological studies) (van Hoeken et al., 2003). Limitations inherent to current classification systems may also affect reported rates (Keel, Brown, Holland, & Bodell, 2012). Unfortunately, it is not uncommon for EDs to run a chronic course, despite professional  2 treatment and supports (Keel & Brown, 2010), and treatment drop-out is common (see Campbell, 2009). Indeed, for many individuals recovery is a long and challenging process, characterized by periods of remission and relapse (Herzog et al., 1999; Liu, 2011).  Given the serious nature of EDs, and the profound impact they have on the lives of women affected by an ED and their loved ones, much scholarly attention has been dedicated to understanding EDs. Researchers across fields and disciplines have explored numerous dimensions of EDs, including, but not limited to, risk factors and causes (see Polivy & Herman, 2002), prevention (see Mintz, Hamilton, Bledman, & Franko, 2008), motivation for change (see Vitousek, Watson, & Wilson, 1998), and treatment approaches (see Wilson, 2005). Taken together, this extensive literature highlights the challenges of change, the often enduring nature of EDs, and the complexity of recovery. It also reveals areas of knowledge and practice warranting further attention and exploration. One such area is adult women’s  relational experiences, namely, their experiences in intimate partner relationships. The Relational Nature of Eating Disorders The empirical and clinical literature demonstrates that EDs are profoundly relational in nature. Research has consistently shown that interpersonal factors can play a significant role in the onset of ED symptoms (e.g., relational stressor, including a loss or ongoing conflict) (e.g., Polivy & Herman, 2002). Interpersonal factors have also been implicated in the perpetuation or maintenance of the ED (e.g., conflicted and/or disempowering relationships) (e.g., Treasure, Sepulveda, Whitaker, Todd, Lopez, & Whitney, 2007a), and in promoting, achieving, and sustaining change (e.g., strong social support, empathic relationships) (e.g., Cockell, Zaitsoff, & Geller, 2004). Importantly, supportive relationships have been identified as integral to successful recovery from an ED, with close others positioned to hinder and/or promote change (Bjork &  3 Ahlstrom,  2008;;  D’Abundo  &  Chally,  2004;;  Hsu,  Crisp,  Callender,  1992;;  Peters  & Fallon, 1994; Pettersen & Rosenvinge, 2002; Rorty, Yager, & Rossotto, 1993; Tozzi, Sullivan, Fear, McKenzie, & Bulik, 2003; Weaver, Wuest, & Ciliska, 2005). Given the challenges of recovery from an ED, it is argued herein that increased understanding of the relational dimensions of recovery is essential to improving outcomes for women struggling with an ED.  Problem and Rationale: Situating the Study Despite empirical (Cockell et al., 2004; Peters & Fallon, 1994; Weaver et al., 2005), clinical (Bulik, Baucom, Kirby, & Pisetsky, 2011; Rieger, Van Buren, Bishop, Tanofsky-Kraff, Welch, & Wilfley, 2010; Tantillo, 2000), and theoretical (Miller & Stiver, 1997) support for the central role of interpersonal relationships throughout the process of recovery from an ED, understanding of women’s  subjective experience of being in a close relationship and/or social support as she engages in the recovery process1 remains seriously limited. Specifically, very little is known about the nature of supportive relationships, exactly how these relationships may facilitate change, or the meaning women construct around these relational experiences as they relate to their recovery efforts. This  is  particularly  true  for  women’s  intimate  partner  relationships (i.e., committed, intimate, romantic relationships2). Although intimate partner relationships have long been identified in the adult ED literature as an important aspect of women’s  experience  (see Arcelus, Yates, Whiteley, 2012; Newton, Boblin, Brown, Ciliska, 2005b), virtually no attention has been paid to the role of these relationships during recovery (Arcelus et al., 2012; Newton et al., 2005b). Indeed, this issue has yet to be explored empirically. This is surprising, and also problematic, given that partners have consistently been identified as                                                  1 Intentionally works to reduce ED symptoms and behaviors and enhance overall health. 2 Research has referred to the partner relationship in a number of ways, including the marital relationship or romantic relationship; in the proposed study, this relationship is referred to as the intimate partner relationship.  4 key  figures  in  women’s  recovery  process and  appear  to  play  a  significant  role  in  some  women’s  attainment of change (Hsu et al., 1992; Pettersen & Rosenvinge, 2002; Rorty et al., 1993; Tozzi et al., 2003).  Recovery From an Eating Disorder  Significant efforts have been made within the field of EDs to understand, conceptualize, and  define  “recovery.” The literature abounds with varying perspectives on, and approaches to, the investigation of this process and experience (Bachner-Melman, Zohar, & Ebstein, 2006; Bardone-Cone et al., 2010a; Herzog et al., 1999; Noordenbos, 2011a, 2011b). In large part, the existing body of work is comprised of quantitative research, reflecting the predominance of a positivist paradigm of science to conceptualize and investigate EDs, both within the field of psychology and across disciplines (e.g., psychiatry). As such, historically, definitions of recovery have focused on physical and behavioral criteria and predictors, broad treatment outcomes (e.g., good, poor), and specified durations free of behavioral symptoms (see Herzog et al.; Noordenbos, 2011a). However, clinicians, scholars, and women self-identifying  as  “recovered,” have emphasized the methodological and theoretical limitations of such an approach (e.g., Garrett, 1997; Noordenbos, 2011b), in which the lived experiences, expertise, personal meanings, and voices of women are inherently obscured or completely absent (Peters & Fallon, 1994). Indeed, contextualized and nuanced knowledge of women’s  experiences of recovering from an ED and the meanings they attribute to their recovery process remain largely inaccessible within a positivist paradigm of inquiry.  The field has reached general agreement however that recovery is not solely an outcome to be achieved, but rather a holistic process involving psychological, social, and relational factors and experiences (Bardone-Cone et al., 2010a; Noordenbos, 2011b; Peters & Fallon, 1994;  5 Weaver et al., 2005). A growing body of qualitative research continues to extend and deepen our understanding of the recovery process by exploring this experience from the perspectives of women themselves (Bjork & Ahlstrom, 2008; Cockell et al., 2004; D’Abundo  &  Chally,  2004;;  Garrett, 1997; Peters & Fallon; Tozzi et al., 2003; Weaver et al.). This research has shown that relationships with close others can have both supportive and/or hindering effects on efforts to initiate (Rorty et al., 1993) and maintain (Federici & Kaplan, 2008; Cockell et al., 2004; Wasson, 2003) change. Close relationships have been cited by women as an essential component of successful change (Bjork & Ahlstrom, 2008; Pettersen & Rosenvinge, 2002) and intimate relationships have been deemed one of the most important factors in their recovery process (Tozzi et al., 2003). While healthy relationships are clearly important, women have also reported that disconnecting from unhealthy relationships is an important step in recovering from the ED (Peters & Fallon; Rorty et al.). To this end, studies have revealed shifts in women’s  relational  functioning that occur over the course of recovery (Peters & Fallon).  Although this  research  clearly  speaks  to  the  relational  nature  of  women’s  healing  process,  it remains significantly limited. Specifically, extant qualitative research in the area of EDs and recovery reflects three general approaches to inquiry: (a) case studies, observations, or reviews; (b) identification and/or quantification of factors deemed relevant to recovery (i.e., reflecting its post-positivist underpinnings); and (c) theoretically grounded studies exploring the meaning and experience of recovery. Consequently, despite being relatively expansive in breadth (e.g., the number of factors identified as being important to recovery), our current knowledge is limited in depth. A variety of relational factors and experiences specific to the intimate relationship have been identified as important criteria for, or aspects of, recovery, including: husband or partner support (Hsu et al., 1992; Pettersen & Rosenvinge, 2002; Rorty et al., 1993); relationship with  6 spouse, partner, or lover (Garrett, 1997; Tozzi et al., 2003); acceptance of, and reliance on relationships, including with one’s  partner  (D’Abundo  &  Chally,  2004);; and negotiating relationships with close others (Bjork & Ahlstrom, 2008). However, few studies have explored women’s  recovery experiences in depth (D’Abundo  &  Chally;;  Garrett; Lamoureux & Bottorf, 2005; Peters & Fallon, 1994; Weaver et al., 2005). In addition, while these latter studies certainly offer substantive, integrated accounts of recovery, given their exploration of recovery in general (e.g., the experience, meaning, process), they do not address in any detail women’s  relational experiences, namely, their experiences of their intimate partner relationships and support during their recovery process. As such, beyond being identified as important, women’s intimate partner relationships and the unique ways in which these relationships may support recovery have not been addressed or explored in the empirical literature.  Further understanding of the role of relationships in recovery. Intimate partner relationships have been implicated in adult women’s  recovery  process  in  various  other  bodies  of  literature and empirical research, each contributing to the overall knowledge base within which the current study is grounded. This includes research focused on social support (Grissett & Norvell, 1992; Jacobson & Robins, 1989; Linville, Brown, Sturm, & McDougal, 2012; Marcos & Cantero, 2009; Rorty, Yager, Buckwalter, & Rossotto, 1999; Tiller, Sloane, Schmidt, Troop, Power, & Treasure, 1997), support provider or  “carer” experiences (Leichner, Harper, & Johnston, 1985; Treasure et al., 2007a, p. 24), couples’  oriented treatments (Bulik, Baucom, & Kirby, 2012; Bulik et al., 2011; Gorin, Le Grange, & Stone, 2003), and romantic relationships (Newton, Boblin, Brown, & Ciliska, 2005a). Each will be briefly addressed below, to further contextualize the current research.  7 Social support. Broadly speaking, research on social support in the area of EDs is limited; that is, it is generally quite dated, is predominantly quantitative, and lacks continuity. For example, this research is comprised almost exclusively of quantitative studies, with small samples and descriptive, cross-sectional designs. It has focused largely on the structural or objective aspects of support, in addition to satisfaction with support, with virtually no attention paid to the nature, quality, characteristics, or experience of support, particularly helpful support. Indeed, in most cases study design precludes understanding of the mutually influential nature of relationships,  examination  of  processes  over  time,  and  any  rich  description  of  women’s  experiences. Insufficient effort has been made to remedy the limitations noted in previous work, or to build on previous findings (e.g., heterogeneity in study measures precludes meaningful comparisons).  Much like the aforementioned recovery literature, the social support literature in the area of EDs lacks explicit focus on the intimate partner relationship. As such, our knowledge of the ways in which this specific relationship may  influence  women’s  recovery is limited to what has been revealed through the small sub-groups of partners included within the context of broader studies. Under these circumstances, any partner-specific findings tend to be further obscured by the over-representation of mothers and fathers (e.g., Marcos & Cantero, 2009). That is, given that several studies have included younger adults and adolescents, with unique developmental and social characteristics and circumstances (e.g., rely on their families for support, are not yet in romantic relationships) (Marcos & Cantero; Rorty et al., 1999), representation of partners has been marginal3.                                                   3 It is acknowledged that many adult women may not be in an intimate relationship and/or may not identify their partners as sources of support, which may also contribute to this lower  8 “Support provider” experiences. A growing number of studies have illustrated the profound impact that being in relationship with, and caring for, someone with an ED can have (Dimitropoulos, Carter, Schachter, & Woodside, 2008; Graap, Bleich, Herbst, Trostmann, Wancata, de Zwaan, 2008; Highet, Thompson, & King, 2005; Huke & Slade, 2006; Leichner et al., 1985; Martin, Padierna, Aguirre, Quintana, Las Hayas, & Munoz, 2011; Perkins, Winn, Murray, Murphy, & Schmidt, 2004; Treasure, Murphy, Szmukler, Todd, Gavan, & Joyce, 2001). This research indicates that “support  providers”4 experience high levels of anxiety, depression, and decreased quality of life, among other areas of impact, and this appears to influence their ability to support  their  loved  one’s  recovery  process (e.g., Leichner et al.; Perkins et al., 2004; Treasure et al., 2007a). For example, preliminary work by Geller and colleagues (2010a) has shown that support provider anxiety is associated with the delivery of directive support attempts (e.g., offering opinions about change, the ED, or recovery efforts; adopting a more demanding stance  in  one’s  interactions  around these issues), whereas research suggests that collaborative support attempts characterized by a concerned and encouraging stance are more helpful (Geller & Brown, 2006; Geller, Zelichowska, Jones, Srikameswaran, Dunn, & Brown, 2010b). Informed by these relational challenges, Treasure and colleagues (2007a) have developed “workshops” (p. 24) aimed at supporting family members, including partners, to provide effective responses and support to their loved one. These skills-based workshops acknowledge the distress experienced by those in relationship with someone struggling with an ED, and aim to decrease the unintended                                                                                                                                                              representation. However, the literature indicates that many women with EDs are in committed relationships (Arcelus et al., 2012; Bulik et al., 2012). 4 Family  members,  partners,  and  friends  are  often  identified  as  “support  providers,”  “care  providers,”  or  “carers”  in  the  scholarly  literature,  reflecting  underlying  assumptions  about  the  nature of these relationships (e.g., tending to negate the bi-directional flow in relationship and identify the woman as a passive recipient of support efforts; disempowering to women). While the implications and limitations of this language are noted, in the interest of describing extant research, similar language has been adopted.  9 consequences of this distress (i.e., the  “interpersonal maintaining factors” associated with the ED; p. 24) by equipping support providers with information/education, strategies, and tools for supporting their loved one’s  recovery  process.  This small but growing area of work offers further information about the immediate relational context within which recovery is situated, and highlights the  tensions  that  can  often  exist  in  attempting  to  support  someone’s  change  process.  Partners are typically included in these studies, however their experiences are seldom the focus. Further, given the paucity of research on intimate partner relationships in the area of EDs, the extent to which these workshops are informed by, or tailored to, this particular relationship (i.e., versus relationships with parents, for example) is limited. In all, very little is known about how partners experience their role and/or relationship during their loved one’s  recovery. The few studies that have examined partner perspectives and experiences suggest that these individuals often experience distress and challenges in attempting to support their partners (Leichner et al.; Huke & Slade).  Couples’  oriented treatments. Along a similar vein to the workshops proposed by Treasure and colleagues (2007a), efforts have been made to involve partners in cognitive behavioral approaches to treatment, including group cognitive behavioral therapy (CBT) for women with binge eating disorder (Gorin et al., 2003). More recently, significant efforts have been made to develop  a  couples’-focused cognitive behavioral therapy for women with AN and their partners (Bulik et al., 2012; Bulik et al., 2011). Bulik and colleagues’ (2011) work is grounded in evidence for the effectiveness of family-based interventions for adolescents with an ED. It draws from various bodies of research on global marital adjustment and distress, communication, sexual functioning, and as previously mentioned, the experiences of support providers. Bulik and colleagues (2011) concur that many women living with an ED do indeed  10 have intimate partner relationships, and assert that these relationships may be a source of support and/or distress, and thus, impact recovery efforts. To this end, they argue that treatments targeting this relationship are indicated, particularly given the limited evidence and efficacy of available treatments for adults with AN (Bulik et al.). Unfortunately, given the limitations to extant research on intimate partner relationships in the area of EDs, in particular the fact that women’s perspectives regarding their relationships and the recovery process have yet to be sufficiently explored in the empirical literature, these treatment approaches may not be optimally informed  by  women’s  experiences and needs. Intimate partner relationships. Existing research on intimate partner relationships in the area of EDs is limited in both breadth and depth, is very dated, and is characterized by significant methodological limitations (see Arcelus et al., 2012; Dimitropoulos, Lackstrom, & Woodside, 2007; Newton et al., 2005b for reviews). This area of inquiry saw some interest in the late eighties and nineties. Initial studies typically focused on problematic areas of functioning; examined associations between ED and related symptoms and marital status; and explored group differences among couples in which one partner was living with an ED, distressed couples, and non-distressed couples, respectively5 (Van Buren & Williamson, 1988; Van den Broucke & Vandereycken, 1988, 1989; Van den Broucke, Vandereycken, & Vertommen, 1995a, 1995b, 1995c; Wiederman & Pryor, 1997). Since these early, descriptive, correlational studies, relatively little empirical work has been done (Arcelus et al., 2012), and no research has focused on the intimate partner relationship in the context of women’s  recovery efforts. Newton and colleagues (2005b) conducted an integrated review of the literature on romantic relationships, reviewing                                                  5 Most  studies  do  not  report  participants’  ethnicity,  cultural  background,  or  sexual  orientation;;  when reported, samples have been comprised of heterosexual women, who are either married or living together. As a whole, this literature is extremely limited in its attention to diversity.   11 studies published between1983 and 20046. These authors identified primarily correlational studies exploring ED symptoms and relationship status, sexual experiences (i.e., attitudes and behaviors)7, communication within the relationship, intimacy, and relationship quality, respectively (Newton et al., 2005b). As might be expected, there was significant heterogeneity with respect  to  women’s  experiences,  however  relationship  dissatisfaction  emerged  as  a  common  theme. In light of the results of their review, including the nature and limitations of the overall body  of  literature  on  women’s  intimate  relationships,  these authors called for increased use of qualitative  methods  to  explore  women’s  lived  experiences  in  relationships (Newton et al.). Indeed,  Newton  and  colleagues’  (2005a,  2006)  work  has  enhanced  our  understanding of women’s  experiences in intimate relationships, through their qualitative explorations of romantic relationships (Newton et al., 2005a) and intimacy (Newton, Boblin, Brown, & Ciliska, 2006) for individuals  with  AN.  This  research  has  highlighted  the  fluidity  of  women’s  experiences  in  intimate relationships, namely, the processes of emotional and physical connection and disconnection that occur over time, and the factors associated with such experiences (Newton et al., 2005a). While their work has not specifically addressed experiences of support, it extends extant  research,  contributes  foundational  knowledge  about  women’s  experiences  in  their                                                   6 The authors aimed to focus exclusively on studies with women with AN, but were inevitably inclusive of all diagnoses, given diagnostic migration and the limitations of diagnostic classification; the authors did not review studies focused explicitly on women with BN or EDNOS, however. 7 Research has examined sexuality and sexual functioning in the area of EDs (e.g., Pinheiro et al.,  2010).  While  numerous  theoretical  perspectives  on  this  aspect  of  women’s  experience characterize the ED literature, there has been less empirical research, and extant studies reflect a medical model of conceptualization and inquiry. Generally speaking, this research has focused on  women’s  “dysfunction”  and  the  various  factors  contributing to difficulties with sexual intimacy.  Given  the  current  study’s  focus  on  the  experience  of  partner  support  during  recovery,  a  full review of the literature on sexuality is beyond the scope of this project, and the interested reader is therefore directed  to  Newton  and  colleagues’  (2005b)  and  Pinheiro  and  colleagues’  (2010) work for a more comprehensive review of this area.  12 committed relationships, and reinforces the importance of further, focused inquiry into intimate partner support.  Relational-Cultural Theory Generally speaking, across the aforementioned bodies of ED-related research there is a marked absence of theoretical coherence; that is, studies have not drawn upon, or been grounded in, theoretical frameworks. Relational-Cultural Theory is  an  overarching  theory  of  women’s  development that  situates  women’s  psychological  growth  and  wellbeing  within  the  context  of  close relationships (Miller & Stiver, 1997). As such, RCT offers a framework within which the research on interpersonal relationships and EDs may be considered, and provides theoretical support  for  the  importance  of  women’s  relationships  to  their  experience  of  an  ED  and  recovery.  RCT posits that psychological distress, including EDs, stems from relational disconnections (Miller & Stiver, 1997; West, 2005). Broadly speaking, these disconnections consist of empathic failures, may be fleeting or enduring, and result in various negative intra- and interpersonal consequences for the recipients (Jordan, Kaplan, Miller, Stiver, & Surrey, 1991). RCT  speaks  to  the  ways  in  which  one’s  contexts, culture(s), and dominant and/or minority identity(ies) influence experiences of connection and disconnection, highlighting the complex constellation of factors and experiences that influence relational development, and thus, psychological wellbeing (Comstock, Hammer, Strentzsch, Cannon, Parsons, & Salazar, 2008). RCT proposes that psychological health, including recovery from an ED, is fostered within the context of mutually empathic and empowering relationships (Jordan, 1991; Miller & Stiver; Tantillo, 2000). To this end, growth (i.e., positive change) is thought to occur through connection with others,  which  is  inherently  influenced  by  one’s  culture(s).   13 Despite strong theoretical appeal and frequent clinical application (Duffey & Somody, 2011; Tantillo, 2000),  very  little  empirical  research  has  examined  RCT’s  central  tenets (Jordan, 2011), particularly in the area of EDs. For example, central to RCT is the notion that growth occurs in the context of mutual relationships, which are thought to foster motivation (Jordan, 1991) and empowerment (Miller & Stiver). However, this core theoretical tenet has yet to be empirically examined.  According to RCT, relationships characterized by high levels of perceived mutuality are thought to be growth promoting (Jordan, 1991; Miller & Stiver, 1997) and thus, related to women’s  recovery  from  an ED (Tantillo, 2000; Tantillo & Sanftner, 2003). Perceived mutuality is the extent to which a woman feels that her relationship with another is characterized by a bi-directional flow of thoughts and feelings, and empathic understanding (Genero, Miller, Surrey, & Baldwin, 1992; Jordan). To date, a small body of research has explored the construct of perceived mutuality (PM) in close relationships (e.g., mothers, fathers, partners, friends) with women struggling with body image concerns (Sanftner, Ryan, & Pierce, 2009), disordered eating (Wechsler, Riggs, Stabb, & Marshall, 2006), and EDs (Jones, 2011; Sanftner et al., 2006; Sanftner, Tantillo, & Seidlitz, 2004; Tantillo & Sanftner, 2003). Research has demonstrated that women living with an ED report lower PM in their relationships with their partner than women without a clinical diagnosis (i.e., control group) (Sanftner et al., 2004). Research has also revealed a relationship between PM and ED symptoms (Sanftner et al., 2006; Sanftner et al., 2004). Specifically, studies have shown that lower PM in the partner relationship is associated with greater body dissatisfaction (Sanftner et al., 2006), and that lower PM in parental relationships may be associated with greater symptomatology (Tantillo & Sanftner). That said, given  that  few  studies  have  explored  this  aspect  of  women’s  relational  experiences, the extent to  14 which  RCT’s  tenets,  constructs,  and  processes  fit  for  women  recovering  from an ED remains uncertain, particularly within the context of intimate partner relationships. As such, while RCT offers a promising lens or  perspective  on  women’s  recovery,  emphasizing  the  relational  contexts  within which change may occur, further research is needed. Re-statement of the Problem  Considered together, the aforementioned bodies of literature depict the relevance of women’s  relational  experiences  during  recovery  from  an  ED  and  highlight  the  limitations  of  our  knowledge to date. There exists converging evidence from the recovery, social support, support provider, treatment, romantic relationship, and RCT literatures illustrating relationships as being integral  to  women’s  ED  and  recovery  process. However, this work reveals a number of limitations, including the frequent exclusion  of  women’s  lived  experience, meanings, and voices and virtually no focus on the intimate partner relationship during recovery. To date, very little is known about the nature of  women’s  intimate  partner  experiences,  specific ways in which women perceive these relational experiences as being associated with recovery, or the meaning women attribute to these relational experiences within the context of their  recovery  efforts.  The  paucity  of  research  on  adult  women’s  intimate  partner relationships and recovery reveals a disconcerting gap in knowledge, given that partner support has been identified as central to recovery for many women (Tozzi et al., 2003). Moreover, associations between ED symptoms, motivation for change, and marriage (Bussolotti, Fernandez-Aranda, Solano, Jimenez-Murcia, Turon, & Vallejo, 2002) have been documented. Research has also described the challenges often experienced within these relationships (Leichner et al., 1985; Van den Broucke et al., 1995a, 1995b, 1995c), partner distress in response to the ED (Leichner et al.; Huke  &  Slade,  2006;;  Perkins  et  al.,  2004),  and  women’s  experience  of  dissatisfaction  in  their   15 intimate relationships (Newton et al., 2005b; Woodside, Lackstrom, & Shekter-Wolfson, 2000), depicting a complex relational picture requiring further empirical exploration. Indeed, further research certainly seems warranted given that new treatment approaches are being developed on what is arguably a limited body of research (Bulik et al., 2011). Greater attention  to  women’s  experiences in their intimate partner relationship during recovery is highly warranted – supported clinically, empirically, and theoretically – and is therefore the focus of the current study.   Purpose of the Research The current study employed a hermeneutic phenomenological method to increase understanding of the meaning of lived experience of intimate partner relationships in supporting recovery from an ED for adult women. The research question guiding the inquiry was: “what  is the meaning of lived  experience  of  intimate  partner  relationships  in  supporting  women’s  recovery  from  an  eating  disorder?”  Phenomenology seeks to explore and understand experiential, pre-reflective human experience. It moves from a theoretical perspective and abstractions to experiences as lived in everyday life (van Manen, 1997b). Phenomenology is therefore uniquely suited to this particular area of inquiry, given its limited nature,  the  absence  of  women’s  subjective  experiences  and  voices in the literature, and the imperative of accessing detailed descriptions from women themselves. A hermeneutic phenomenological inquiry, specifically, aims to deepen our knowledge, elucidate the contexts within which experiences are embedded, and importantly, access and identify the meanings associated with such experiences. To this end, rich descriptions of  women’s experiences were generated to both supplement and extend the existing literature.  Furthermore, this methodology  reflects  the  study’s  roots  in  Counselling Psychology (CNPS), and thus, its efforts to privilege individual experiences and voices that have often been  16 overlooked and are missing within the traditional, positivist approaches to inquiry and knowledge generation (Morrow, 2007), as seen in the field of EDs. Indeed, the approach is congruent with CNPS philosophy in its attendance to the depth, complexity, and situated nature of human experience (Morrow).   Practice- and theory- oriented purpose. Findings from this research contribute to both clinical and academic domains, and possess both practice- and theory- oriented purpose and significance (Haverkamp & Young, 2007). This research aimed “to inform practice by providing rich, elaborated descriptions of specific processes or concerns within a specific context”  (Haverkamp & Young, p. 274). It sought to generate knowledge appropriate for translation to clinical practice with women and their partners, and thus, contribute to advances in treatment and couples-focused approaches in the area of EDs (see Bulik et al., 2011). Specifically, this research sought to ameliorate and advance existing efforts to involve partners in the recovery process, treatment, and professional supports. Research of this nature is of paramount importance if treatments are to be informed by  women’s  experiences, especially within this unique relationship; moreover, it serves to ensure that treatments fit with women’s needs, and thus, are effective in promoting healing, outcomes, and the overall recovery process. Indeed, given that previous efforts to involve spouses in group based CBT treatment have failed to demonstrate significant benefits over individual CBT (Gorin et al., 2003), greater understanding of what women find supportive of their change efforts, and how and why, is sorely needed. In addition, this research sought to  “elaborate  elements  of  a  theory  in  new  domains...and  expand  researchers’  understanding  of  specific  constructs”  (p.  273).  Indeed,  by  virtue  of  exploring  women’s  relational  experiences  with  a  hermeneutic  phenomenological approach (i.e., and broadly articulated research question), the study provides empirical findings relevant to the  17 application of RCT and associated concepts (e.g., connection, disconnection, mutuality, growth) in the area of EDs.  Overall, increased understanding  of  women’s  lived  experiences  and the meanings they ascribe to their intimate partner relationships in supporting recovery expands current knowledge in the field, informs future research, and offers insights into the ways we may enhance our clinical practice with women engaged in the process of recovery, and their partners, to better account for relational experiences and optimize recovery supports and outcomes.                  18 Chapter 2: Literature Review In the following chapter I review and critique literature pertaining to the relational experiences of women engaged in recovery from an ED, with particular focus on the ways in which various bodies of research have explored women’s  intimate  partner  relationships.  In this review I aim to elucidate important gaps in our knowledge, situate the proposed study within the existing literature, and reinforce the unique contribution this particular study will make in understanding women’s  experiences and meanings of their intimate partner relationships in supporting their recovery from an ED.  I begin with a review of extant research on recovery, with attention to qualitative studies that  have  examined  the  process  of  recovery  from  the  women’s  perspective.  This research emphasizes the centrality of interpersonal and social support experiences to change efforts and recovery. However,  given  studies’  broad  focus  on  recovery  in  general, the depth to which specific relational experiences, and the intimate relationship in particular, are explored remains seriously limited. I then turn to other bodies of research that have explored interpersonal relationships in the area of EDs, such as the literatures on social support and intimate partner relationships. In reviewing this scholarship, it became increasingly evident that research in these areas is limited in scope, that is, it is predominantly quantitative, cross-sectional, and focused on discrete elements  of  women’s  experiences.  These studies have afforded a general picture  of  women’s  social experiences and identified a number of relational difficulties of clinical relevance. Importantly, they have implicated the intimate  partner  relationship  in  a  woman’s wellbeing and eating difficulties. However, they have done very little to advance our understanding of women’s  experiences in this relationship or the ways in which these experiences may influence recovery.  19 It is therefore argued that, as a whole, the existing literature creates a solid foundation and rationale for more focused inquiry, as it affirms the centrality of relational experiences and highlights the need for further exploration of women’s  lived  experiences in their intimate partner relationships, as they engage in the process of recovery. Eating Disorders and Recovery  Brief overview of the literature. Positivist approaches to inquiry have identified indices, predictors, and temporal patterns of remission, recovery, and relapse, respectively (e.g., Berkman, Lohr, & Bulik, 2007; Lowe, Zipfel, Buchholz, Dupont, Reas, & Herzog, 2001; Keel, Dorer, Franko, Jackson, & Herzog, 2005; Kordy et al., 2002; Ro, Martinsen, Hoffart, Sexton, & Rosenvinge, 2005; Von Holle et al., 2008), and steps have been taken to integrate cognitive and psychosocial factors into recovery focused research, conceptualizations, and definitions (Bachner-Melman et al., 2006; Bardone-Cone et al., 2010a). Findings from this research have been quite mixed, with respect to predictors of successful change (Herzog et al., 1999) and criteria for remission and recovery (Kordy et al., 2002), for example. Different approaches to measurement; definitions of recovery, remission, and relapse; and time of follow-up have all complicated the picture, and despite significant empirical efforts, the field lacks consensus around these issues (Noordenbos, 2011a).  A growing body of qualitative literature has been exploring recovery from women’s  perspectives, extending and deepening the existing body of quantitative research (Bjork & Ahlstrom,  2008;;  D’Abundo  &  Chally,  2004;;  Federici  &  Kaplan,  2008;;  Garrett,  1997;;  Matusek & Knudson, 2009; Noordenbos, 2011b; Peters & Fallon, 1994; Tozzi et al., 2003; Weaver et al., 2005). Qualitative methodologies have afforded a more textured, nuanced, and rich account of the process of recovery; this body of literature illustrates dimensions, experiences, and processes  20 deemed important by the women themselves. As previously noted, approaches to inquiry in this area have consisted of case studies or reviews, the identification of factors associated with successful recovery, and theoretically grounded studies exploring the meaning and experience of recovery. Considered together, these studies demonstrate the extent  to  which  women’s  experiences are embedded within social and relational contexts (Peters & Fallon, 1994; Weaver et al., 2005), and speak to the central role of social support and interpersonal relationships to achieving (e.g., Tozzi et al.) and maintaining change (e.g., Cockell et al., 2004).  Initial efforts to capture women’s  perspectives on recovery. Root (1990) conducted one of the first investigations of recovery based on women’s  subjective experiences and perspectives. In this small study of female university students (N = 21)8, Root explored perceptions of recovery, history of relapse, and perceived stability of recovery (p. 398). Particularly noteworthy was  the  study’s exploration of women’s perceived stability of recovery, an issue that has received virtually no further empirical attention.  To  examine  women’s  perspectives  on  recovery,  Root drew three general conceptualizations from the literature, and explored (a) the extent to which women endorsed these definitions, and (b) factors associated with the  women’s  respective  perspectives. To this end, women were asked to select the definition/conceptualization of recovery that best described their experience: (a) “I  am  recovered;;  I  no  longer  struggle  with  food, weight, and/or body-image;;” (b) “I  am  recovered,  but  I still struggle with food, weight, and/or body-image;;”  or  (c) “I  will never be completely over my eating disorder; I will always struggle with an eating disorder” (p. 399). Despite self-identifying  as  “recovered,” the majority of women chose the second                                                  8 Root focused on women with a diagnosis of BN, however, 57% of the sample had a history of AN, highlighting the frequency of diagnostic migration and the limitations of classification for empirical purposes.   21 definition (71.4%), acknowledging an ongoing challenge with ED related issues. The meaning or definition of recovery adopted by the women appeared to be related to their confidence in being able to maintain changes; confidence was related to the duration of their recovery to date (i.e., longer duration free of ED led to greater endorsement of the first definition) and overall level of psychological distress. Psychosocial issues were frequently cited as risk factors for relapse; indeed, 81% of the women had  relapsed  after  having  thought  she  was  “over”  the  ED  (i.e.,  relapse was defined as engaging in > 1 episode of bingeing and purging) (p. 399). Women reported relapses lasting from one episode to multiple episodes for periods of months, with the longest being 4 years (M = 5.4 months), highlighting the enduring vulnerability many women experience throughout their recovery journey. Given the well established role of social support and interpersonal relationships in maintaining changes and reducing risk of relapse (Cockell et al., 2004; Federici & Kaplan, 2008; Keel et al., 2005; Wasson, 2003), these findings suggest that greater understanding of the ways in which close others may  enhance  women’s  self-efficacy around recovery may have important long-term implications for women, their partners, and treatment approaches.  Case studies and reviews reflect additional efforts to explore women’s  experience  of  recovery (Hsu et al., 1992; Woodside, Kohn, & Kerr, 1998). Hsu and colleagues (1992) reviewed six cases in an attempt to discern factors related to recovery from AN. While a range of key experiences were identified (i.e., treatment, willpower, fear, disconnection from unhealthy family relationships, faith), for half the women, their relationship with their husband proved to be the most significant or one of the most significant factors in recovery. There were a number of methodological limitations to the study, noted by the authors (e.g., assessment of recovery, recruitment, data collection), however, findings contributed to the developing picture of  22 women’s  subjective  perspective  of  the  factors  associated  with  change.  Woodside, Kohn, and Kerr (1998) adopted a similar approach to inquiry as Hsu et al., and reviewed the cases of four previous patients; two of the women cited romantic partners as influential in their recovery.  Rorty and colleagues (1993) investigated factors associated with recovery in a group of adult women with a history of BN9 (N = 40), who self-identified as being recovered for a year or more. These authors inquired about (a) what stimulated recovery; (b) what professional and nonprofessional treatments were utilized, and levels of treatment satisfaction; (c) how life experiences and important others may have  “helped  or  hindered”  recovery (p. 249); and (d) what aspects of BN were hardest to change and what would participants still like to change.  A number of women indicated that close others played a role in the initiation of recovery. For example, having  someone  close  to  them  “take  a  strong  stand,”  experiencing  an  increase  in  self-esteem due to a new romantic relationship, and starting or ending a romantic relationship (p. 253) were all deemed facilitative experiences. Over half the participants reported that support from family, partners, and friends was very helpful. In fact, supports from these close others were rated  the  most  helpful  “non-treatment related life experiences”  associated  with  recovery.  Conversely, the least helpful  experience  was  a  “lack  of  understanding  or  insensitivity  from  partner,  friends,  or  family,”  endorsed  by  33%  of  the  participants.  Second only to friends, partners were deemed the least harmful, in terms of hindering effects one might have on recovery. That said,  16%  of  the  group  identified  their  partners  as  “actively  harmful”  to  their  recovery  process,  and 13% felt that they received insufficient emotional support from their partner (Rorty et al., 1993).                                                  9 31% of participants had previously been diagnosed with AN.   23 The women were also asked about the ways in which close others supported their recovery, with respect to emotional and practical support. Out of all support providers (i.e., mothers, fathers, siblings, partners, and friends), partners were deemed the most emotionally supportive; that is, 55% of the sample indicated that their partners provided emotional support, as compared to mothers (10%), fathers (10%), siblings (33%), and friends (45%). Partners appeared to provide much less practical support however (8%), compared to mothers (33%) and fathers (26%), but more than siblings (3%) and friends (0%) (Rorty et al., 1993).  Unfortunately these authors  did  not  offer  any  descriptive  information  about  participants’  relationships; they noted that 87.5% of participants had never been married, but did not state how many women were in a relationship, nor did they report length of relationship or other relevant descriptive information (e.g., co-habitation) for those in a relationship (Rorty et al., 1993). This seriously limits interpretation of the results as presented (i.e., percentages of individuals who endorsed categories). In addition, it is unclear whether the categories of emotional and practical support, respectively, were generated by the authors or if they emerged as themes. As such, while the results of this study both affirm and supplement the aforementioned findings regarding the role of partners (e.g., frequently cited as a source of support during recovery, for many are the primary source of emotional support),  the  study’s  methodological  limitations  are  substantial and leave a number of gaps in our knowledge.  More recently, other methods of examining  women’s  perspectives  have been employed. For example, Keski-Rahkonen and Tozzi (2005) reviewed material posted online by women contributing to an online support group; they found that relationships were cited as helpful to recovery. Although profoundly limited in terms of method and detail, this descriptive study is noteworthy in that it demonstrates an alternate, and inclusive, means of accessing women’s   24 views about recovery. In other efforts, Noordenbos and Seubring (2006) generated a list of criteria for recovery, based on existing literature, and asked both women (n = 41) and therapists (n = 57) the extent to which they thought each factor was relevant to recovery. Findings from this study offered further support for the conceptualization of recovery as a holistic process involving physical, behavioral, somatic, psychological, emotional, and social dimensions. Interestingly, when  the  women’s ratings were compared to therapist ratings, the women rated all but one of the five social criteria as being of more important to recovery than did the therapists (Noordenbos & Seubring, 2006). This discrepancy re-iterates the need  for  women’s  voices  in  the  literature,  the  extent  to  which  social  dimensions  are  important  to  women’s  view  of  wellbeing, and the relevance of empirical attention in this area.  Indeed, a number of other studies have focused on the identification and evaluation of factors that women deem relevant to recovery (Bjork & Ahlstrom, 2008; Noordenbos & Seubring, 2006; Noordenbos, 2011b; Pettersen & Rosenvinge, 2002; Tozzi et al., 2003). Using a phenomenography method, Bjork and Ahlstrom (2008) explored women’s  perceptions  of  what  it  means to be recovered. Adult (> 18, M = 27) women (N = 14) self-identifying as being recovered or  “markedly  improved”  following treatment (p. 929) were invited to participate in this study. Ten of the women were in a relationship (i.e., married, living with partner, in relationship). Based on their findings from research interviews, the authors generated four categories, comprised of fourteen statements total, to describe recovery according to the participants. Participants emphasized the development of a more relaxed relationship with food, eating, and one’s  body;;  greater  self-acceptance and esteem; and social re-connections. Women described a process  of  “[moving]  toward  social  relations…instead  of  withdrawing”  (p.  938), and engaging in more authentic ways with others. They spoke about cultivating a social life, including increasing  25 one’s  capacity  for  mutuality  in  relationships,  hopes  for  parenthood,  and  developing  the  courage  to be vulnerable and close in relationship. The women identified ability to listen to others, engage in open dialogue, and consider both others’ and their own perspectives, as significant. With recovery, greater value was placed on both being authentic in relationships and the relationships themselves. Women also noted the importance of recognizing when distance in relationship was needed (Bjork & Ahlstrom). Overall, this study affirms that women view interpersonal functioning as relevant to recovery; in particular, these women identified their capacity to engage meaningfully with others as an indicator of wellbeing and healing.  In a larger study, Pettersen and Rosenvinge (2002) sought to understand 48 adult women’s  (i.e., > 18 years of age, M = 27.6) perspectives on recovery, including (a) factors associated with or contributing to recovery, and (b) how women define recovery. Women with an ED (i.e., AN, BN, EDNOS) of duration of three years or more years (M = 11.1 years duration) were invited to participate. Data were collected via interviews and questionnaires. Of note, the authors stated that the interviews were transcribed and analyzed based on approaches documented in the literature; no further methodological details were offered, limiting interpretation of findings. Findings generated an overarching theme,  “the  desire  for  a  better  life,” along with three sub-themes,  “effects  of  professional  treatments,”  “effects  of  nonprofessional  care,”  and  “effects  of  positive  life  events  and  important  persons”  to depict factors contributing to recovery (p. 65). This latter dimension was particularly relevant to the current study. Consistent with other research, partners, parents, and close friends were identified as supports; specifically, these close others were deemed to be sources of emotional and practical support, trust, and acceptance. Positive life events, such as having a partner, were also deemed important to recovery [just over  26 half the women in the study had a partner (52%)]. According to these women, close others were often the first to know about the ED and to encourage treatment. Interestingly, their support was viewed as integral  to  the  women’s  self-esteem (Pettersen & Rosenvinge, 2002), suggesting a mechanism through which support may influence change efforts. In another study aimed at identifying factors  associated  with  women’s  recovery  process,  Tozzi and colleagues (2003) asked women for their perspective on both the causes of their ED, and the factors promoting recovery. Although participants were women with a lifetime diagnosis of AN, 58% of the sample had a history of BN or subthreshold BN, suggesting findings may be generalizable among women with various eating difficulties. With respect to recovery status, the majority of  participants  were  “recovered” as  per  the  study’s  definition  (n = 62; no longer meeting diagnostic criteria for an ED), however some women were still living with the ED (n = 7). In this study, a supportive relationship or partner was the most frequently cited factor related to recovery [27.45% of participants cited this factor, and just less than half the sample (46.4%) were married; no other relationship information was offered]. In fact, participants indicated  this  relationship  was  “the  driving  force  that  assisted  them  in  recovery”  (p.  151). The authors gave the following examples to represent the ways in which partners were mentioned by participants:  “met  husband;;”  “good,  healthy  relationship  with  husband,  unconditional  love  and  acceptance;;”  “supportive  husband  – treated  [me]  normally  all  the  way  through  it;;”  “being  valued  by husband”  (p.  148).  The authors’ conclusion that interpersonal factors play a central role in recovery seems warranted, as findings certainly resonate with extant knowledge in this area. In particular, the finding that partners are highly influential supplements the aforementioned findings to this effect, documented in case reports and reviews (Hsu et al., 1992; Woodside et al., 1998). However, given  the  study’s  method (e.g., very focused interview questions aimed  27 specifically at the identification of factors), findings  lack  substantive  information  about  women’s  intimate partner relationships (e.g., nature and perceptions of support), and thus, while extending of the breadth of our knowledge in this area, do little to deepen it. Indeed, considered as a whole, all of the aforementioned studies offer evidence that women view close others as important to their attainment of recovery, but do little to elucidate or deepen our understanding of these relational experiences or how they effect change.  The experience and process of recovery: Empirically derived theories. Although limited in number, several authors have pursued comprehensive investigations of the recovery process (D’Abundo  &  Chally,  2004;;  Garrett,  1997;;  Lamoureux & Bottorf, 2005; Peters & Fallon, 1994; Weaver et al., 2005). This  research  extends  our  understanding  of  “what”  constitutes  and  occurs  during  recovery,  and  expands  and  elaborates  descriptions  of  “how”  healing  occurs.  These qualitative studies have conceptualized recovery from an ED in a number of ways, including recovery as  a  process  of  “becoming  the  real  me”  (p. 183; Lamoureux  &  Bottorf),  a  “personal  awakening”  (Peters  &  Fallon), a  “circle  of  acceptance”  (D’Abundo  &  Chally), “transformation”  (Garrett), and “self-development from perilous self-soothing to informed self-care” (Weaver et al.). They describe renewed relationships with self, embedded within and co-occurring with re/connections with others. Women’s  relational  experiences  are woven throughout these recovery stories with close others consistently playing an important  role  in  the  women’s journeys.  Peters and Fallon (1994) were among the first who sought to explore and understand the complexities and processes of change and recovery,  based  on  women’s  lived  experiences. Situating their work within the existing literature at the time, the authors argued that a general reliance  on  outcome  studies  had  “left  no  place  for  recovered  women  to  instruct  us  about  the   28 process  of  change,  nor…allowed  for  the  discovery  of  curative  factors  beyond  the  experimenters’  assumptions”  (p.  339). Indeed, their grounded theory research, informed by feminist theory and based  on  Peters’  unpublished dissertation study, was one the earliest comprehensive accounts of women’s  experience  of  recovery,  and  highlighted  a  number  of dimensions and processes that had yet to be discussed and examined in the empirical literature. Women in the study (N = 30) had a previous clinical diagnosis of BN, and self-identified as being in the process of recovery or having recovered. While 17 women were asymptomatic, 13 were still experiencing ED symptoms; eleven of these latter women indicated that they had attained partial recovery. Average duration without ED symptoms was just over one year. Mean age of participants was 29 (19-46) and age of onset ranged from 10 to 28 years of age.  This study was foundational in highlighting women’s  perspectives  on the contexts within which recovery occurs, and the processes and relational dimensions involved. Peters (1990, cited in Peters & Fallon, 1994) identified three continua along which the women moved during their recovery process: (1) denial to reality, (2) alienation to connection, and (3) passivity to personal power (p. 341). While psychosocial factors and changes certainly  permeated  the  women’s  accounts, the relational nature of recovery was best captured by the notion  of  “alienation  to  connection” (p. 345). This continuum  described  women’s  process  of  re-connecting to parts of self  and  others,  including  increasing  openness  around  the  ED  and  one’s  struggle, growing capacity to both recognize and express needs and boundaries in relationships, and addressing sexual and emotional intimacy and romantic relationships. Bulimia was viewed  as  a  “disorder  of  denial,  disconnection,  and  disempowerment,”  and  recovery  as  a  “personal  awakening  to  secrets,  alienation,  and  powerlessness” (p. 353), during which, women’s relationships with self, others, and culture shifted towards connection. Many of the changes described in the study were  29 relational, and thus, contrast the change process depicted in much of the clinical and outcome literature, where the focus lies on symptom reduction and behavioral change (e.g., Herzog et al., 1999; Kordy et al., 2002). These women’s  experiences, and the conceptualization of recovery generated, reinforce the need for further, focused exploration of the relational dimensions of change. In particular, the identification of intimacy as a relevant aspect of the  women’s  recovery experiences supports further exploration of the intimate partner relationships of women in recovery. In addition, given the study’s focus on women with a lifetime diagnosis of BN, findings may not resonate to the same degree for women who have struggled with other eating difficulties and patterns, and thus, more inclusive research on  women’s  recovery  may add to the transferability of these findings.  Weaver, Wuest, and Ciliska (2005) conducted perhaps the most rigorous study of recovery, focused on the experiences of women who have recovered from AN. Similar to Peters and Fallon (1994), Weaver and colleagues conducted a grounded theory study informed by feminist theory,  with  the  aims  of  situating  women’s  subjective experience of recovery within the context of family, community, and society. Citing the limitations to extant research on recovery, they call  for  greater  attention  to  women’s  voices,  experiences,  and  meanings. Noting that research has tended to focus on “isolated  elements…[constricting]  the  phenomenon  of  recovering  into  discrete  variables” (p. 189), they pay particular attention to the social contexts and processes involved in recovery.  In their study, recovery is described as a process of “self-development,”  in  which  individuals move from “perilous self-soothing”  with  the  ED, to “informed self-care” in recovery (p. 188). Women shift from a place of not knowing self, identity, or place in society, and as they begin to find themselves, are better able to engage more authentically with both self and others;  30 shifts from disengagement to engagement with others occurs. Importantly, Weaver and colleagues assert that this process of reconnection is largely contingent upon the availability and quality of supports.  “Letting  others  in”  is another phase of the recovery journey, and is associated with the women’s  recognition that  “they  need  help  from  others  to  recover  further” (p. 198). The women in this study observed that relational support had the potential to decrease isolation, validate their identity as individuals beyond the ED, and help distract from ED related thoughts. Both affiliative support and instrumental support were identified by the participants as being helpful to their recovery. Affiliative support consisted  of  “feeling  heard,  validated,  and ‘of  concern’ and ‘of  interest’ to others,” whereas instrumental support  consisted  of  “financial,  child  care, clothing, and transportation resources” (p. 198-199). In keeping  with  women’s  navigation  and negotiation of close relationships throughout recovery, some women identified their need to re-structure relationships to meet their needs. Consistent with the literature, lack of support was thought  to  hinder  one’s  recovery  process. Although the authors situate recovery within social/relational contexts, little is said about how close others facilitate or hinder change, or the extent to which this occurs, leaving questions about these relational processes unanswered. For example, how might partners be involved in women’s  processes  of  “self-differentiation,” “self-awareness,” and/or  “self-regulation” (p. 192), key tasks of recovery. Indeed, noting that self-development was “adversely affected when [the women’s]  environments lacked social or therapeutic support,”  the  authors  suggest “that the type and degree of support offered by family, friends, and health professionals be further investigated,” offering support for the current study.   Another grounded theory study exploring the experience of recovery was conducted by D’Abundo  and  Chally  (2004). Participants were women who felt that they had made progress in  31 their recovery efforts, and, similar to  other  studies,  these  authors  relied  on  women’s  self-reported ED and recovery status. Results led to a model of ED development and recovery identified by the  authors  as  the  “eating  disorder  curve” (p. 1098). Within this model, recovery was depicted as a  “circle  of acceptance” (p. 1098), reflecting  women’s  acceptance  of  the  ED,  and  their  spirituality and relationships, all of which are thought to cultivate feelings of self-worth. Findings shed light on women’s  perspectives  on  the  development of the ED, namely, increasing severity of symptoms, their peak (i.e., most severe), and a turning  point.  “Turning  points”  (p.  1099) included specific events or people that prompted change for the women (D’Abundo  &  Chally, 2004). With respect to the relationships that helped initiate and support recovery, most women cited deep long-term relationships, including significant others or family members; in fact, according to study participants, relationships with close others were more common and influential than relationships with professional supports. While this may be due in part to the group of participants (i.e., self-reported ED, lower clinical severity and thus, less treatment contact), it affirms the central role that close others play throughout the process. Relationships were considered sources of unconditional love, support, trust, inspiration, and hope (p. 1101), with mothers, partners, and fathers being cited most often. The  “ED  curve” ultimately reflects a reduction in ED symptoms, during which time women re-connected with others, re-building social relationships (D’Abundo  &  Chally). While relationships permeated the women’s  recovery  process, enhancing self-worth and supporting change, little is said about partner relationships, and there is little elaboration regarding the role relationships play or the nature of support provided/received.  Yet another grounded theory study of recovery from AN was conducted by Lamoureux and Bottorf (2005). Women in this study had a previous clinical diagnosis of AN, and at the time  32 of the research, self-identified as being recovered (N = 9). In this particular study, trust in relationship was identified as a key factor throughout recovery. Trust created safety in relationships and support systems, which was deemed central to initiating and achieving change. According to the women in this study,  “simply  having  trustworthy  individuals  around…wasn’t  sufficient  to  begin  [the]  process.” Rather,  it  was  “individuals who offered the women unconditional and unwavering support”  that “assisted them in learning to trust and build courage to  move  cautiously  from  relying  on  anorexia  to  relying  on  trustworthy  individuals”  (p.  176). Having this consistent support from family and friends fostered a sense of emotional safety, which in turn, allowed the women to move forward with the daunting task of change. Indeed, feeling  safe  within  support  systems  enhanced  women’s  capacity  to  be  vulnerable  and  seen,  decreasing their reliance on the AN. Some women noted that having close others (i.e., another perspective, another voice), as a counter to the AN voice, helped them sustain change; this co-occurred  with  increasing  confidence  in  one’s  own  values,  thoughts,  and  needs,  and  the  ability to privilege these over external voices. An ongoing sense of unconditional acceptance from others, in which there were no expectations about how one should be, also helped increase self-acceptance and confidence. Setting boundaries and creating distance in some relationships proved important, and “reclaiming  personal  power”  proved  fundamental  to  the  healing  process  (p. 178). These findings re-iterate a general theme contained in this body of research, namely, women’s  ongoing  process  of  navigating  and  negotiating  intra- and interpersonal relationships, and the critical role of close others in cultivating the safety necessary for this process.   Overall, this body of research has strengthened conceptualizations of recovery as a long, ongoing, and challenging process, comprised of both intra- and inter-personal tasks. While close others are consistently cited as supports, there is seldom mention or elaboration of the specific  33 role that intimate partners may play or  women’s  experience  of  the support they receive from others. Research has yet to focus on this particular dimension  of  women’s  recovery journey.  Social Support Background. Social support has an extensive history in the social sciences (e.g., House, Umberson, & Landis, 1988; Sarason & Sarason, 2009; Umberson, Crosnoe, & Reczek, 2010) and has long been associated with mental health outcomes (e.g., Corrigan & Phelan, 2004; Kessler, Price, & Wortman, 1984; Thoits, 1995). Social support and close relationships seem to play a particularly important role in the lives and wellbeing of women (e.g., Belle, 1987; Miller & Stiver, 1997; Taylor, Klein, Lewis, Gruenewald, Gurung, & Updegraff, 2000). For example, during times of stress women have been shown to seek connection (Taylor et al., 2000) and access more social support, from more diverse sources, than men (Belle).  Broadly speaking, research on social support has explored objective and subjective components (e.g., network size and density, satisfaction with support), including structures and processes (e.g., type and frequency of contact with social ties, nature of support; see House et al., 1988). Support has also been conceptualized and investigated within the context of relational or dyadic coping (e.g., Kayser, Watson, & Andrade, 2007). This distinct yet related body of research offers information about support processes unique to intimate partner relationships (e.g., partners’  relationship  to  the  problem,  patterns  of  engagement  or  avoidance,  independent  or  dyadic coping), particularly when coping with some form of physical or mental health concern (e.g., Kayser et al., 2007). The social support literature has shown that intimate relationships play an  important  role  in  adults’  health  behavior  (Umberson et al., 2010), are a strong overall indicator of social support, and are associated with higher levels of perceived support (i.e., married individuals report higher perceived support) (Thoits, 1995). Research has also suggested  34 however, that those closely related to the individual requiring support may not provide optimal support given that they too are impacted by the stressor (Thoits), and that genders and spouses may differ in the types of support desired and deemed helpful (Kayser et al., 2007; see Thoits for review). Studies on social support have relied predominantly on quantitative designs (e.g., non-experimental, longitudinal, cross-sectional, and retrospective) (House et al., 1988), and despite ample attention, the complexities inherent to this area of inquiry have resulted in mixed findings, numerous unanswered questions, and gaps in our knowledge (e.g., mechanisms through which social support may influence wellbeing, moderating and mediating factors, nature of support over time, personal meanings) (Sarason & Sarason, 2009; Thoits, 1995). However, a consistent finding has emerged, in that perception of social support has been reliably associated with mental health related outcomes. In particular, perceived emotional support has been linked to lower psychological distress and identified as a buffer in the face of negative events and chronic strains (Thoits, p. 70). This reinforces the importance of subjective measures and accounts of experience. Indeed, qualitative work, although significantly more limited, has been highlighted for its unique contributions to our knowledge base, including the ability to address the meanings individuals endow their social support experiences (Thoits).  Social support in the area of eating disorders. As previously stated, interpersonal relationships are often implicated in the onset, maintenance, and reduction of ED behaviors, and research suggests that close others can either hinder or promote recovery efforts and successful change. Specifically, research with recovered individuals has shown that strong social support can both initiate (Linville et al., 2012) and maintain change (Cockell et al., 2004). In particular, research has found that social support seeking at one-month post-treatment predicts outcome at  35 six months post-treatment. However, individuals seek less social support following treatment (i.e., compared to during treatment) (Binford, Mussell, Crosby, Peterson, Crow, & Mitchell, 2005). Seeking social support has been related to outcome at up to 2.5 years follow-up (Bloks, Van Furth, Callewaert, & Hoek, 2004). Relatedly, difficulties within social relationships/social stressors have been identified as predictors of relapse for women with BN and EDNOS (Grilo et al., 2012). Research with a non-clinical sample has also suggested that low social support coupled with negative life events leads to increased bulimic symptoms (Bodell, Smith, Holm-Denoma, Gordon, & Joiner, 2011). Taken together, these findings illustrate the profound impact social interaction and supports may have on ED recovery efforts. It is also important to note that the literature suggests that many women with an ED experience difficulty with their relationships (see Arcelus, Haslam, Farrow, & Meyer, 2013 for review). Some studies indicate that women with an ED are dissatisfied with the social support they receive (Grissett & Norvell, 1992; Rorty et al., 1999; Tiller et al., 1997), and seek less support and have smaller social networks than women without an ED (Tiller et al.). Conversely, some studies deny the presence of poor social support (Jacobson & Robins, 1989), claiming that many women are generally quite satisfied with their social support, are able to identify several support providers, and are able to obtain various forms of support (Marcos & Cantero, 2009). Research suggests a number of intra- and interpersonal factors that may be related to satisfaction with perceived social support, including overall psychological distress and interpersonal functioning (Geller et al., 2010b), and social support more generally, including anxiety, substance use, family self-concept, and importantly, having an intimate partner (Marcos & Cantero). Very little is known however, about what constitutes helpful support, what factors might facilitate the delivery of helpful support attempts (i.e., support that is perceived as helpful  36 and beneficial to the individual), and how this support may facilitate change. Overall, research on social support in the area of EDs remains extremely limited, in both breadth and depth, and knowledge of partner support in particular, is scarce.  Furthermore, existing research in this area is quite dated and suffers from a number of conceptual and methodological issues. For example, virtually all studies are grounded within a positivist paradigm of inquiry; have generally focused on discrete elements of this multifaceted construct, such as network size or degree of satisfaction with support; employed different definitions and measures precluding meaningful comparison of results; and relied on small sample size (Grissett & Norvell, 1992; Jacobson & Robins, 1989; Tiller et al.,1997). Findings have been quite mixed, doing very little to advance our understanding of social support experiences, particularly those that may promote successful recovery, and we lack a cohesive picture  of  women’s  experiences.  Early studies of social support in the area of EDs are rooted in (a) findings that women with BN report a number of interpersonal and social difficulties (e.g., Herzog, Keller, Lavori, & Ott, 1987), and (b) the growing body of theoretical and empirical literature on social support and health outcomes established during the 1980s (see Grissett & Norvell, 1992). Jacobson and Robins (1989) published one of the first studies in this area. They examined social dependency and social support, and characteristics thereof, in adult women (i.e., > 18) with BN (n = 23) as compared to women with no ED (n = 38). To measure social support, participants indicated the extent to which specific support behaviors were offered by others, over the past four weeks. They responded to another questionnaire assessing their thoughts and feelings in close relationship, as a measure of social dependency. Results revealed that women with BN reported higher social dependency, however, there were no differences between the two groups on  37 amount of social support received. Noting surprise that there were no differences in social support, given the often tumultuous relationships of women with BN, the authors attributed the result, in part, to the measure of social support (Jacobson & Robins). That is, items referenced a number of relationships, which may have obscured the identification of any specific relational problem; it focused on positive behaviors (i.e., negative interactions have been shown to be particularly salient in relation to ED symptoms; Grissett & Norvell, 1992; Sanftner et al., 2004); and, the measure aimed for an objective index, and did not assess perceived adequacy, quality, or satisfaction. Indeed, findings say little about women’s  experience  of  the  support. In another small study, Grissett and Norvell (1992) examined perceived support, quality of relationships, social skills, and psychological distress in a group of women with BN (n = 21) as compared to women with no diagnosis (n = 21). Women completed measures of perceived social support from family and friends, quality of relationships (i.e., depth, conflict, and support), social interactions (i.e., positive and negative; perceived impact and personal attributions), and social competence (i.e., discomfort in social situations) to assess their relational functioning. Contrary to previous findings by Jacobson and Robins (1989), results revealed that women with BN reported less support from family and friends; women in this study also reported less social competence and, after controlling for overall psychological distress, more negative interactions and conflict than women with no ED. Bulimic symptoms were correlated with the number of negative interactions, perceived impact of such interactions, and conflict, respectively (Grissett & Norvell), offering further support for the notion that negative interactions are of particular relevance in this group. A unique strength of this study was its inclusion of an objective measure of social competence. Participants were asked to role-play an interpersonal scenario with a trained confederate (blind to group status), and were then rated by observers (also blind to group  38 status) on various social competencies. Results of this analysis corroborated the self-report findings, revealing that observers deemed women with BN to be less interpersonally effective overall (Grissett & Norvell). Of note, neither of these two aforementioned studies were conducted with clinical populations or reported the types of relationships targeted in measures. Tiller and colleagues (1997) conducted the first study of social support with a clinical sample, including both women with a diagnosis of AN (n = 44) and BN (n = 81), respectively. This study was also the first to assess perceived adequacy, quality, and amount of support together. Relationships with mothers, fathers, siblings, partners, and friends were included. Just under half the women with AN (44%), and over half the women with BN (66%) had a partner; no further descriptive information was offered about these relationships.  Results revealed that women with an ED reported less emotional and practical support than women without an ED (n = 86; students10). With respect to support from specific providers, both women with AN and BN reported less support from friends, and women with BN, in particular, also perceived significantly less support from partners, parents, and siblings as compared to the control group. Women with an ED also reported lower levels of ideal support than the control group; moreover, women with AN had lower levels of ideal support from a partner than both other groups. The discrepancy score between actual and ideal support scores was used as an index of satisfaction. Women with BN were significantly more dissatisfied with support than the control group, and with respect to support from parents, were more dissatisfied than both groups. The authors note that such findings refute the notion of a global, negative perception of support (Tiller et al., 1997); moreover, support needs may differ by relationship.                                                  10 The authors note that using students as a control group may have let to greater differences given that students may be more socially connected, and thus, report higher levels of support than other sub-groups.  39 Results regarding satisfaction must also be considered in light of general expectations about support, as ideal scores influenced differences in satisfaction between ED groups. Finally, duration of illness was not correlated with social support. Overall, the social support experiences of women with AN and BN appeared similar, with a few exceptions specific to various support providers.  Extending this small body of research, Rorty, Yager, Buckwalter, and Rossotto (1999) examined relations among social support, social adjustment, and recovery status in adult women (M = 24.5 years) with BN (n = 39), women in remission11 (n = 40; remission for > 1 year, criteria for remission not defined), and women with no history of ED or disordered eating (n = 40). The authors collapsed husband, partner, and friends into one category (i.e., friends), which they compared with family on network size and type of support (i.e., thing, help, emotional support, and advice giving, respectively). With respect to the nature of support, the non-ED group reported more emotional support available from family than both BN groups; there were no group differences on the three other support dimensions. The women in remission and non-ED groups each had more friends available to provide support than the women with a current diagnosis, and these former groups did not differ from each other. With respect to satisfaction, there were differences between friends and family. That is, the non-ED group reported higher levels of satisfaction with emotional support from family than both BN groups, who did not differ from each other. There were no differences among the three groups however, with respect to satisfaction with emotional support from friends, or advice giving from either friends or family (Rorty et al.). Finally, the women in remission were equal to the non-ED group on several                                                  11 Given the heterogeneity in recovery criteria seen across the research, this group, for whom the average time in remission was 43 months, is arguably comparable  to  ‘recovered’  groups  in  other  studies.   40 indices of social adjustment (i.e., social and leisure functioning), with both groups higher than the women with a current diagnosis; there were no group differences on work functioning however. The authors concluded that women with BN had greater social impairment than women with no history of ED, with women in remission generally falling in the middle; they suggest this reflects both improvement and residual problems, for women with a history of BN (Rorty et al., 1999). Notably, the primary area of difficulty for women with current or lifetime BN was emotional support, and both these groups were largely dissatisfied with their social support from family members, suggesting ongoing challenges with these relationships. Unfortunately, little information was offered about these target relationships, and information specific to partner support  was  lost  in  the  collapsed/inclusive  category  of  “friend  support.”  In general, findings  from  Rorty  and  colleagues’ (1999) study were consistent with those of Grissett and Norvell (1992) and Tiller and colleagues (1997), regarding both network size and degree of satisfaction with support. Results  differed  from  Jacobson  and  Robins’  (1989)  however,  who reported that women with an ED were not dissatisfied with support. Rorty and colleagues (1999) suggest this discrepancy may reflect differences in measurement; for example, Jacobson and Robins did not separate family and friends, and they focused on support received or enacted (i.e., objective versus subjective measure) (Rorty et al., 1999). Overall, findings from Rorty et al.’s study supplement previous work, affirming difficulty with family relationships and perceived support, and increase our understanding of the ways in which these various components of social functioning may compare for women who are currently struggling with an ED versus those who have reached a point of remission or recovery.  Following these initial studies, virtually no research was conducted on social support until more recently (e.g., Brown & Geller, 2006; Geller et al., 2010a, 2010b; Linville et al., 2012;  41 Marcos & Cantero, 2009), with some empirical attention being paid to overall social and interpersonal functioning, adjustment, and/or problems (see Arcelus et al., 2013 for review). Marcos & Cantero (2009) recently explored social support in a larger group of women (N = 98). Including women with a diagnosis of AN (n = 60), BN (n = 27), and EDNOS (n = 11) afforded another look at differences between these groups and further information about the experiences of women with AN, given that much research in this area has tended to focus on women with BN. This study employed questionnaires to examine multiple domains of support, including support provider type, number of support providers, satisfaction with support, type of support received (i.e., emotional, informative, practical), amount of support received, and intrapersonal factors associated with support (Marcos & Cantero). Unlike previous studies that assessed social support in general, this study focused on support in relation to a specific issue, in this case, the ED.  A number of results from this cross-sectional study are noteworthy. Consistent with other research  (e.g.,  D’Abundo  &  Chally,  2004), mothers were the most frequently cited support figure, with partners second. Partners were included in the support networks of just over half the sample; of the women with partners, 73.1% cited their partner as a support, whereas 27% did not. The authors note the younger age of the sample (M = 20.8, SD = 5.61) as a possible reason for the lower number of women who did not include a partner in their network. Regarding satisfaction with support, over half of those in a relationship were very satisfied with support from partners. Interestingly, women in an intimate relationship had more support providers overall than the women who did not have a partner, and they received more support in terms of listening, finance, offers of help, and support from friends. The authors noted some differences in terms of type of support, between women living with their partner and those that did not.  42 Specifically, women who were not living with their partner received more practical support, and support overall, than both women living with their partners, and women without a partner. The authors  also  found  that  women’s  family  self-concept was related to multiple dimensions of support. That is, the extent to which women had a secure sense of belonging and support with their family was positively correlated with the number of support providers cited, their satisfaction with support, and informative, emotional, and practical supports.  The most frequently endorsed support attempts were listening, encouraging, advising, and informing, respectively, and women with AN received more informing and accompanying actions than women with BN. With respect to differences by diagnosis, results revealed that women with AN had slightly more support providers than women with BN; there were no differences between these groups on satisfaction with support, however. These findings are somewhat dissimilar to Tiller and colleagues (1997) study, in which there were (a) no differences in number of support providers by diagnosis, and (b) differences in the extent to which women with AN or BN were satisfied with their supports. Overall, in this study, satisfaction with support was high. As previously discussed, measurement differences may account for some of the variability in findings across this body of research.   In efforts to  increase  understanding  of  women’s  social  support  experiences, a small body of research has begun to investigate factors associated with support satisfaction (Geller, Jones, Zelichowska, Dunn, Srikameswaran, & Lockhart, 2010a; Geller et al., 2010b). Preliminary research  has  found  that  the  individual’s  level  of  distress  and  interpersonal  style,  respectively,  influence her or his satisfaction ratings. In addition, results suggest that individuals living with an ED find collaborative support attempts, characterized by encouraging and concerned interactions, to be optimal. Conversely, directive support attempts characterized by unsolicited  43 opinions have been shown to be less helpful, and associated with lower satisfaction (Geller et al., 2010b). Despite seeming intuitive, the literature suggests that delivery of collaborative support attempts, despite recognizing their utility, is often challenging (Brown & Geller, 2006), and is likely tied to support providers’ level of distress (Geller et al., 2010a; Perkins et al., 2004; Treasure et al., 2007a). Taken together, studies on social support reveal a number of mixed findings. Some research suggests that women with an ED experience a range of difficulties, including limited social networks, less than optimal support from others, and negative interactions (Arcelus et al., 2013). Other research concludes that women have adequate support and are generally satisfied with the support received (Marcos & Cantero, 2009). Research method, that is, a general reliance on a positivist paradigm and cross-sectional design, has certainly influenced the current state of knowledge in this area. To this end, the literature supports the use of qualitative methods to not only contextualize  women’s  experiences, but to increase understanding of the meanings they construct around support and its relation to their change efforts. Further, most research to date has focused on social deficits (Arcelus et al.), with less empirical attention to the aspects of social and interpersonal relationships that promote wellbeing and change. The question remains, what  are  women’s  experiences  of  support,  namely,  with  their  intimate  partners,  and  how  do  these  support experiences actually influence their recovery efforts? Intimate Partner Relationships Similar  to  research  on  social  support,  the  literature  on  women’s  intimate  partner  relationships reflects a surge of attention in the late 80s and 90s (e.g., Van den Broucke & Vandereycken, 1988), with very little subsequent work until quite recently (see Arcelus et al., 2012; Newton et al., 2005b). Overall, existing  research  on  women’s  intimate partner  44 relationships in the area of EDs is limited in both breadth and depth. The literature is quite dated, is predominantly descriptive in nature, is focused on heterosexual women who are married (i.e., versus women in long-term, committed relationships), suffers from small sample sizes and lack of attention to diversity (e.g., racial and ethnic identities, cultural background of participants, sexual orientation), and frequently attends to the negative or problematic aspects of functioning. Further,  reliance  on  positivist  paradigms  of  inquiry  has  minimized  the  extent  to  which  women’s  voices, perspectives, and meanings have been included.  Initial research in this area sought to substantiate theoretical and professional assumptions and/or speculation about the role of marriage in the onset and maintenance of EDs (see Van den Broucke & Vandereycken, 1989),  negating  exploration  of  women’s  subjective  experiences and meanings, and the ways in which their relationships may offer support or impetus for change (i.e., as documented in the recovery related literature; e.g., Hsu et al., 1992; Tozzi et al., 2003). Specifically, building upon clinical observation and case reviews, early studies in this area investigated differences between married and non-married women with an ED on various clinical variables (see Van den Broucke & Vandereycken, 1988). Subsequent studies continued this line of inquiry (Kiriike, Nagata, Matsunaga, Tobitani, & Nishiura, 1996; Wiederman & Pryor, 1997), and explored differences in conflict resolution (Van Buren & Williamson, 1988; Van den Broucke, Vandereycken, & Vertommen, 1995a), relationship satisfaction (Van Buren & Williamson), husband’s  distress  (Van  den Broucke, Vandereycken, & Vertommen, 1994), marital intimacy (Van den Broucke, Vandereycken, & Vertommen, 1995b), and marital communication (Van den Broucke, Vandereycken, & Vertommen, 1995c), respectively, among couples in which one partner had an ED, maritally distressed couples, and non-distressed couples. All studies were quantitative, cross-sectional, descriptive, and very  45 small; moreover, many of these studies appear to have employed the same group of participants (e.g., Van den Broucke et al., 1995a, 1995b, 1995c).  More recently, research in this area has examined changes in the marital relationship over the course of treatment (Woodside et al., 2000), the impact of marital status (Bussolotti et al., 2002) and co-habitation on ED symptomatology (von Soest & Wichstrom, 2008), and experiences in romantic relationships (Newton et al., 2005a) and of intimacy (Newton et al., 2006), respectively, for women with AN.   Early work: Exploring group differences. In efforts to empirically examine the clinical and theoretical claims regarding the role of the marital relationship in EDs permeating the literature at the time (e.g., more married women presenting for treatment, poor outcomes for this group, marriage as a maintaining factor; see Van den Broucke & Vandereycken, 1988) Van den Broucke and colleagues conducted a series of studies. In their research, they compared couples in which one partner had an ED, couples identified as maritally distressed (i.e., seeking marriage counselling, high scores on a measure of marital distress), and non-distressed couples (i.e., recruited from the community, low scores on measures of psychiatric symptoms and marital distress), on a number of clinical and relational domains, including conflict resolution, communication skills and style, relationship quality and satisfaction, intimacy,  and  husband’s distress (Van den Broucke et al., 1994; Van den Broucke et al., 1995a, 1995b, 1995c). Of note, these researchers found no differences among the women by diagnosis, and thus, all diagnostic subgroups were included in one group, in each respective study. Furthermore, these authors did not typically report  participants’  heterosexual orientation, nor did they report cultural background.   46 Regarding relationship satisfaction, findings were somewhat mixed. In the first of these studies, Van Buren and Williamson (1988) found that women with an ED were less satisfied with their relationship than married women in a control group comprised of couples not seeking any professional treatment. Subsequently, Van den Broucke and Vandereycken (1989) found differences  with  respect  to  satisfaction  with  sexual  and  social  aspects  of  one’s  relationship,  but  no group differences on global satisfaction. More recently, one study demonstrated that women’s  satisfaction with their marriage increases over the course of hospital day treatment (Woodside et al., 2000). In this latter study, women (n = 22) reported lower satisfaction, as assessed by a measure of marital intimacy, at both pre- and post-treatment (i.e., 8 -14 weeks duration), as compared to their partners (n = 22) (Woodside et al.). In contrast to their partners however, the women experienced an increase in satisfaction or perception of marital intimacy, as ED symptoms decreased. A  closer  look  at  women’s  perceptions of their relationship offers support for the notion that women and their partners may find specific aspects of their relationship more or less adequate; that is, both partners indicated they were significantly less satisfied with the affection, their sense of identity, and their sexuality, within the relationship. Considered together, results from these few studies suggest that although there is certainly heterogeneity  in  women’s  experiences, for many, there appears to be a general dissatisfaction in  one’s  marital  relationship;;  this  seems  particularly  true  for  certain  aspects  of  one’s  relationship,  suggesting  that  specific domains of relational functioning may be fueling dissatisfaction. Relatedly, differences in measurement likely contributed to these results.  Similar discrepancies in terms of findings have emerged  with  respect  to  husband’s  distress.  Specifically,  initial  efforts  to  explore  husbands’  perspectives  on  their  marriage  suggested that husbands experienced more distress than men in a normative sample (Van den  47 Broucke & Vandereycken, 1989), however, further research suggested otherwise, revealing no differences from men in non-distressed marriages (Van den Broucke et al., 1994). These latter results are surprising given that clinical (Leichner et al., 1985) and empirical literature (Huke & Slade, 2006; Perkins et al., 2004) indicates that partners experience significant distress in response  to  their  loved  one’s ED. That being said, this latter research is qualitative, and to date, these earlier studies remain the only controlled comparisons of partner experiences (i.e., partner experiences are discussed further below).  With respect to communication and conflict resolution in the marital relationship, a number of patterns emerged across these early studies. In a self-report, questionnaire study, Van Buren and Williamson (1988) found that women with BN (n = 12) tended to use less problem solving skills, and engage in greater avoidance or withdrawal from conflict, than women in their control group (n = 15). In two more comprehensive studies involving both self-report questionnaires and direct observation, Van den Broucke and colleagues (1995a, 1995b) found that couples in which one partner had an ED (n = 21) displayed less positive behavior than non-distressed couples (n = 21), but less negative behavior than distressed couples (n = 21), during conflict resolution (Van den Broucke et al., 1995a). Results from a second study on communication processes, focused on basic communication skills (i.e., speaking and listening), non-verbal communication, and equality and reciprocity in dialogue, supplement the aforementioned findings (Van den Broucke et al., 1995b). Results from this second study affirmed greater negative verbal and non-verbal communication than non-distressed couples, and less negative communication than the distressed couples. Considering their findings together, the authors suggested a pattern of communication whereby  these  couples  “neutralize  conflicts,” that is,  as  one  partner’s  communication becomes increasingly negative, the other attempts to  48 moderate; however, in the absence of more positive behavior (i.e., relative to non-distressed couples), overall communication is hypothesized to lack the same effectiveness as seen with non-distressed couples (Van den Broucke et al., 1995a, 1995b).   Relational status and clinical presentation. Research has also examined differences between married and single women with an ED, with respect to a number of clinical and psychosocial domains (Kiriike et al., 1996; Wiederman & Pryor, 1997). Notably, these studies do not  report  participants’  sexual  orientation.  Kiriike and colleagues (1996) in Japan found no differences in ED symptomatology between married (n = 40) and unmarried women (n = 22). Wiederman and Pryor (1997) replicated these results in a much larger study (N = 314). Specifically, these authors found that after controlling for age, there were no differences in symptomatology between the women who were married and those who had never been married. Bussolotti and colleagues (2002) conducted a similar, yet more comprehensive study, and obtained different results. This group distinguished among (a) women living with a stable partner (n = 41; minimum of 6 months), (b) women in a stable relationship but not co-habiting (n = 129), and (c) women with no partner (n = 162). Results revealed that women living with their partner were more symptomatic; these women were also older however, suggesting longer duration of illness. Women with a partner were also more motivated to recover than women without a partner. Relatedly, women with a diagnosis of BN were more motivated for change than those with a diagnosis of AN (Bussolotti et al., 2002). von Soest and Wichstrom (2008) conducted the first longitudinal study examining associations between ED symptoms and relationship status, namely, co-habitation. Findings from this study depict a different picture than Bussolotti et al., as co-habitation with a partner was shown to reduce certain bulimic behaviors. Specifically, co- 49 habitation led to a reduction of bingeing and purging behavior, leading the authors to assert some support for the role of social control (von Soest & Wichstrom, 2008).  Given the preliminary and thus limited nature of this body of research, many questions remain about the exact role that  women’s  intimate  partner  relationships  may  play  in  the  course  of  their ED and recovery. For example, in what ways might this relationship motivate recovery, and how do the women themselves view their relationship as influencing their symptoms? Women’s  experiences  in  romantic  relationships.  Newton and colleagues have advanced our  understanding  of  women’s  experiences  in  intimate  partner  relationships, conducting the first qualitative studies in this area (Newton et al., 2005a, 2006). Their phenomenological research on romantic relationships speaks to processes of connection and disconnection in romantic relationships (Newton et al., 2005a), and depicts experiences of intimacy for women living with AN (Newton et al., 2006). These authors found that relational engagement with partners occurs within the context of trusting and comforting relationships, as women feel understood and supported, and that this experience is facilitated by open dialogue. Conversely, relational disengagement or distancing occurred as women felt afraid of judgment and rejection, and as secrecy  and  one’s  focus  on  the  ED pervaded (Newton et al., 2005a). These  authors’ research has also revealed the importance of emotional and physical closeness, and companionship to women’s  experience  of  intimacy  (Newton  et  al.,  2006).  For  the  participants  in  Newton  et  al.’s  studies, emotional closeness was characterized by feelings of trust and acceptance, feeling “known,”  and  “partner  congruence”  (e.g.,  sense  that  partner is also contributing to the emotional closeness of the relationship) (p. 46). These qualities enabled the women to share their experiences with their partner, which was key to their experience of emotional closeness and engagement in the relationship (Newton et al., 2005a, 2006).  Newton  and  colleagues’  also  found   50 that for women with families, mutual investment and shared goals around parenting contributed to closeness in the relationship. Given the focus on women diagnosed with AN however, a gap remains with respect to the experiences of women whose ED symptoms do not meet this particular classification, including women with bulimic symptoms. Given the higher prevalence of BN and EDNOS in adult populations (APA, 2000), research including women with these particular difficulties is necessary. This seems warranted given the findings that women with BN, specifically, have less overall support (Marcos & Cantero, 2006) and greater dissatisfaction with social support (Tiller et al., 1997) than women diagnosed  with  AN.  Furthermore,  although  Newton  and  colleagues’  (2005a, 2006) work contributes significantly to the dearth of research in this area and advances understanding  of  women’s  subjective  experience  in  intimate  relationships, both of these publications stem from the same study and group of participants. Several other issues related to these studies warrant attention. For example, two of the eleven participants had not been in an intimate relationship, and thus, spoke to this experience, and ‘expectations’ about the phenomenon of intimacy (i.e., problematic in light of the phenomenological method employed). Furthermore, for those women in previous or current relationships, the duration of relationships was highly varied, ranging from weeks to several months; four women were in longer-term relationships (i.e., M = 3.5 years; ED preceded relationship in 50% of the women) (Newton et al., 2006). As such, only four women were in long-term, committed relationships during the course of their ED and recovery. The authors did not address the ways in which this heterogeneity may have influenced their findings. Finally, in a significant omission, the authors did not state the sexual orientation of their participants, leaving it unclear whether the group was comprised of  51 heterosexual women or whether there were any participants of sexual minority orientation, and/or same sex relationships. Partner experiences. Research exploring the experiences of family, partners, and friends, often referred to inclusively  as  “support  providers”  or  “carers,”  offers  additional  perspective  on  the immediate relational contexts of women living with an ED (Highet et al., 2005; Huke & Slade, 2006; Leichner et al., 1985; Martin et al., 2011; Perkins et al., 2004; Raenker et al., 2013). The literature suggests that, in light of the serious medical and emotional sequelae of the ED, support providers often experience significant concern and distress (Perkins et al., 2004), which may unintentionally impact their ability to offer optimal support (Geller et al., 2010a; Treasure et al., 2007a).   Several studies have explored the effects of caring for a loved one with a serious ED. This work has explored the impact of being in this role (Dimitropolous et al., 2008; Martin et al., 2011), the experiences (Highet et al., 2005; Perkins et al., 2004; Raenker et al., 2013) and needs (Graap et al., 2008; Winn et al., 2004) of support providers, and established professional interventions to aid both family and women with the recovery process (Treasure et al., 2007a). In their study of care provider experiences of supporting someone with an ED, Perkins and colleagues (2004) highlighted the pervasive and consistent impact that this role, the ED, and the relationship can have. For example, participants reported a range of emotional and physical responses  to  the  ED  and  their  loved  one’s  struggle,  including  self-blame, frustration, anger, worry, overwhelm, fear, and guilt (p. 261). Some found it very difficult to cope with their loved one’s  illness  and  reported  the  toll it took on their own physical health. Indeed, Graap and colleagues’  (2008)  findings  were consistent with Perkins et al.; Graap et al. reported that care providers experienced high levels of anxiety and depression, exhaustion, and in some cases,  52 physical health  concerns,  given  the  stress  imposed  by  their  loved  one’s  ED.  Unfortunately, this body of research has focused on family, with little explicit focus on committed, romantic relationships (i.e., spouses and partners). Raenker  and  colleagues’  (2013)  sample was sufficiently large to compare partner (n=28), mother (n=144), and father (n=80) experiences, although the highly disproportionate number of parents remains consistent with other research (Dimitropolous et al., 2008; Martin et al., 2011; Perkins et al., 2004). They found that partners did not differ from parents on a measure of the overall impact of the ED, and partners and mothers experience similar levels of distress and time  spent  “caregiving”  (e.g.,  engaged  in  tasks  related  to  organizational, practical, food, and medical care, respectively; and emotional support; p. 351). This  is  comparable  to  other  research  reporting  similarities  between  partners’  and  mothers’  experience of the impact of the ED and being in a supporting role (Martin et al.). However, results from this study showed that partners receive less support than parents, and rated this support less favorably, and are thus thought to be more isolated and in need of supports (Raenker et al.).  Findings from the above body of research supplement the paucity of research on partner experiences, specifically (Huke & Slade, 2006; Leichner et al., 1985; Van den Broucke et al., 1994). Leichner  and  colleagues’  (1985) descriptive study of partner experiences in a support group indicates that partners often struggle with feelings of frustration, and uncertainty about how to best support their partner (Leichner et al.). Huke and Slade (2006) conducted a qualitative study focused on partner experiences, and found similar results to the body of research on “carer”  experiences  outlined  above, echoing the sense of powerlessness that partners may feel in response to the ED. Specifically, Huke and Slade (2006) employed an interpretive phenomenological analysis to understand the experience of living with an individual with BN  53 (N=8). They reported the following main themes characterizing partners’ experiences:  “living  with  the  secrecy  and  deception,”  “struggling  to  understand  and  find  reasons,”  “discovering  your  powerlessness,”  “‘it’s  like  growing  to  live  with  it,’” and  “experiencing  strains  and  strengths  in  relationship”  (p.  439).  They reported that despite wanting to provide support, partners often struggled to do so. Importantly, these authors noted partners’  perception  of  strengths in their relationships, highlighting the potential role partners can play in supporting their loved one, and expanding the largely negative picture of these relationships to acknowledge the presence of inherent resources (Huke & Slade, 2006). Finally, Van den Broucke and colleagues (1994) compared  the  distress  levels  of  husbands’  of  women  living  with  an  ED (n=21), husbands in non-distressed couples (i.e., absence of psychological and marital distress; n=21), and husbands in maritally distressed couples (i.e., couples seeking therapy; n=21). Results revealed no differences in the levels of psychological distress reported by husbands of women living with an ED and husbands in non-distressed couples; both groups reported less distress than husbands in the maritally distressed group, which appeared  to  be  accounted  for  by  this  latter  group’s  interpersonal style, as opposed to their symptoms of psychological distress per se (i.e., measurement issue; Van den Broucke et al., 1994). These results reflect a different picture than the majority of the literature on partner experiences, which has been qualitative in nature, and must be seriously considered given that this study represents the only controlled investigation of partner distress.  As a whole, the literature has shown that as a result of reported distress, and despite having good intentions, family members, partners, and close friends often struggle to support their loved one in making desired changes (Graap et al., 2008; Huke & Slade, 2006; Leichner et al., 1985; Treasure et al., 2007a; Winn et al., 2004). Care providers report the highly challenging  54 task of determining what to say, how to say it, and when to say it, in terms of offering support and feedback (Perkins et al., 2004), and interpersonal communication has been highlighted as an area of significant difficulty (Graap et al.). For example, research has shown that high expressed emotion, namely, interactions characterized by expressions of negative emotion and criticism, may in fact perpetuate the ED behaviors and thus, hinder change (see Treasure et al.). Given the sensitive nature of the issues involved, and the functional benefits and egosyntonic nature of many EDs (Vitousek et al., 1998), navigating the recovery process for both the individual herself and her family, friends, and partner can be extremely challenging. Coupled with the aforementioned reports that support providers, including partners, commonly experience negative emotions and have strained communication with their loved one (Graap et al.; Leichner et al.; Huke & Slade, 2006; Perkins et al.; Van den Broucke et al., 1995a, 1995b), this finding suggests a tenuous and powerful relational climate capable of significantly impacting ED recovery. A small program of research has begun to investigate the characteristics and support styles of family members, partners, and friends, with the aim of identifying factors related to helpful social support (Brown & Geller, 2006; Geller et al., 2010b). Preliminary findings have shown that, despite recognizing that collaborative support attempts are optimal, that support providers frequently use directive approaches (i.e., are less collaborative than they hoped to be) (Brown & Geller, 2006). There is also some evidence to suggest that this discrepancy between what is believed to be supportive versus what is actually enacted may be related to distress; that is, multiple regression analyses revealed that high discrepancy between beliefs about support and support behaviors was associated with anxiety (Geller et al., 2010b). This work has also begun to explore potential differences among mothers, fathers, and partners, with respect to their  55 experiences supporting their loved one. Results of an initial analysis revealed that these support providers did not differ in the types of support offered to their loved ones (Geller et al., 2010a).  Relational-Cultural Theory: Perceived mutuality in partner relationships. As previously discussed,  RCT  has  been  proposed  as  a  framework  for  understanding  women’s  experience  of,  and recovery from, an ED (e.g., Sanftner et al., 2004; Tantillo & Sanftner, 2003). As a theory of women’s  psychological  development  and  wellbeing,  RCT  locates  psychological  distress  within  the context of close interpersonal relationships (Miller & Stiver, 1997). To this end, RCT views acute and/or  enduring  disconnections  and  connections  in  one’s  close  relationships  as  etiological  and recovery related factors, respectively, in the course of disordered eating and EDs (Tantillo & Sanftner, 2010; Tantillo, 2000). Although published research in this area has been very limited, conducted predominantly by one group of researchers (Sanftner et al., 2006; Sanftner et al., 2004; Tantillo & Sanftner, 2003), studies have revealed preliminary support for RCT’s  fundamental tenets. Research to date has explored associations between perceived mutuality in close relationships (e.g., mother, father, partner, friend) and a range of ED and related outcomes. For the most part, studies have been cross-sectional, employing correlational designs, and only one study has examined PM in romantic relationships for women with an ED (Sanftner et al., 2004). There is one additional study with college women however, that included assessment of PM in romantic relationships (Wechsler et al., 2006). In their pilot investigation of perceived mutuality in the area of EDs, Sanftner, Tantillo, and Seidlitz (2004) found that adult women with an ED (n = 35) had lower PM in relationships with both partners and friends, compared to women without a psychological diagnosis (n = 39). Twenty-one women in the ED group had partners, and thus, completed the Mutual Psychological Development Questionnaire (MPDQ; Genero et al., 1992) for this relationship; women without  56 partners completed the measure for a close friendship. The authors also found a significant difference between the groups for the negatively valenced items of the MPDQ, that is, items describing negative relational qualities, feelings, and/or characteristics of less mutual interactions.  This  led  the  authors  to  speculate  that  “lack  of  connection”  (p.  95),  that  is,  relationships and interactions with less mutual empathy and feelings of empowerment may be particularly salient for women with an ED. Notably, 69% of the women in the ED group had a concurrent diagnosis of depression, and after controlling for depression, a significant difference between the two groups on the negatively valenced items remained. This finding is congruent with  RCT’s  position  that  disconnection  in  relationship  is  associated  with  psychological  distress,  and lends some support to this notion within the area of EDs, specifically. Results also revealed that PM with friends was a stronger predictor of ED symptoms than PM with partners. The authors acknowledged the surprising nature of this finding, given the literature suggesting the challenges often encountered in the romantic relationship, but were limited in their ability to explain this finding, as they had little further data about the sample and their overall relational functioning and experiences. Further research exploring the role of partners and respective relationships has been recommended (Sanftner et al.), including the use of other methodologies capable  of  accessing  other  dimensions  of,  or  perspectives  on,  women’s  relational  experiences  (Sanftner et al., 2006).  Three studies with non-clinical, student populations have followed, each with a larger sample size (N = 397, Sanftner et al., 2006; N = 102, Sanftner et al., 2009; N = 149, Wechsler, et al., 2006) and thus, greater inclusion of partner relationships. Both studies by Sanftner and colleagues  (2006,  2009)  reported  an  inverse  relationship  between  perceived  mutuality  in  one’s  relationship with a romantic partner and body image concerns. In the first of these studies, low  57 perceived  mutuality  with  one’s  partner (n = 238) was related to a number of ED related issues, including body dissatisfaction, feelings of ineffectiveness, impulse regulation, and social insecurity (Sanftner et al., 2006). In  the  second  study,  low  perceived  mutuality  with  one’s  partner  was also related to body dissatisfaction (Sanftner et al., 2009). Wechsler, Riggs, Stabb, and Marshall  (2006)  examined  relations  among  perceived  mutuality  with  one’s  partner,  self-silencing, and eating disorder related symptoms (n = 105). As one might expect, low PM was associated with self-silencing, interpersonal distrust, and interoceptive awareness, however, contrary to previous findings, PM was not significantly related to body dissatisfaction (Wechsler et  al.,  2006).  Wechsler  and  colleague’s  inclusion  of  “self-silencing”  as  a  relational  construct  to  be  explored  within  the  context  of  women’s  intimate  partner  relationships  extends  previous  work  in  this  area  in  theoretically  meaningful  ways.  “Silencing  the  self,”  that  is,  denying  one’s  thoughts, feelings, and experiences within the context of a close relationship, and thus, relying on external information and others for self-regulation,  has  been  implicated  in  RCT’s  general  conception  of  psychological  distress  and  heath.  Specifically,  the  “central  relational  paradox”  espoused by RCT, posits that women disconnect from their sense of self in order to maintain connection in close relationships (Miller & Stiver, 1997, p. 81). Theoretically, recovery is associated with reconnection to self and others, a process that has been articulated in the recovery related research (e.g., Peters & Fallon, 1994; Weaver et al., 2005).  Summary and Re-statement of Rationale for the Current Study  Research  on  women’s recovery process, social support, intimate partner relationships, and RCT all implicate close others, including partners, in recovery from an ED. In fact, it is documented across these bodies of research that many adult women identify their partners as key supports. As one moves beyond the qualitative research on recovery however, into the literatures  58 on social support and intimate relationships, numerous gaps in knowledge become evident. While  elements  of  women’s social context and interpersonal functioning have been examined within a positivist paradigm, contextualized perspectives and approaches privileging women’s  lived experience and meanings are largely absent. Consequently, the nature and depth of our knowledge regarding support experiences remains limited. Based on the literature reviewed herein, it is argued that further, focused inquiry into women’s  experiences  of, and meanings around, intimate partner relationships and support during recovery is a critical next step in developing both academic and clinical knowledge  relevant  to  women’s  healing  and  wellbeing.                  59 Chapter 3: Method  The current study employed a hermeneutic phenomenological method to explore adult women’s  experience  of their intimate partner relationships in supporting recovery from an eating disorder and the meanings they ascribe to this experience. The research question guiding inquiry was: “what  is  the  meaning  of lived experience of intimate partner relationships in supporting  women’s  recovery  from  an  eating  disorder?” A hermeneutic phenomenological method of inquiry is well suited to answering this research question and obtaining a rich, deep understanding  of  women’s  lived experiences, and the meaning they ascribe to such experiences. Hermeneutic phenomenology is also indicated when investigating an understudied phenomenon, such as women’s  experiences of their intimate partner relationships during recovery. Further, hermeneutic phenomenology contextualizes  women’s  experiences and privileges the daily, taken-for-granted experiences often overlooked in both clinical and academic literature, affording new perspectives and knowledge regarding the phenomenon of interest.  Ontological and Epistemological Positions  The current research adopted a critical realist ontological perspective (Denzin & Lincoln, 2005; Finlay, 2009; Martin & Sugarman, 2001; Sims-Schouten, Riley, & Willig, 2007) and a hermeneutic epistemological position (Martin & Sugarman, 1999; Packer & Addison, 1989b). In adopting these positions for the research, I aimed to integrate the embodied, phenomenological experiences of the participants (i.e., pre-reflexive experiencing), while acknowledging the multiple influential contexts within which these women are embedded (e.g., social, cultural). I view these as intersecting dimensions of knowledge construction, as detailed below.  Critical realism. Denzin  and  Lincoln  (2005)  have  described  “critical  realism”  as  a  “transcendental  realism  that  rejects  methodological  individualism  and  universal  claims  to  truth,”   60 (p. 13) that views knowledge as socially constructed. In their comprehensive review, Danermark and colleagues (2002) explain that “critical  realism”  holds  that  there  “exists  both  an  external  world independently of human consciousness, and at the same time a dimension which includes our  socially  determined  knowledge  about  reality”  (p.  5-6). The  term  “critical”  within  the  current  study  follows  from  Danermark’s  definition. This stance reflects a middle ground, a balance between essentialist and anti-essentialist, and realist and relativist positions, respectively. Martin and Sugarman (2000) argue that a critical realist ontological perspective affords recognition and integration of facets of both positivism and postmodernism, as they inform paradigms of inquiry in psychology (Martin & Sugarman, 2000). Finlay (2009), in her review of phenomenological methods, echoes this stance. She highlights the paradigmatic challenges and decisions faced by phenomenological researchers, and  argues  that  phenomenologists  must  “go  beyond  the  lines  drawn by both modernism and postmodernism embracing both and neither”  (p.  17).  The  study’s  ontological  and  epistemological  positions are grounded predominantly in the work of Martin and Sugarman (1999, 2000, 2001) and Packer and Addison (1989a, 1989b), whose work draws fundamentally from the philosophy of Heidegger and Gadamer. Martin and Sugarman privilege the pre-reflexive, existential phenomenological human experience as a means of knowing, while necessarily locating that individual experience within broader sociocultural and historical contexts. As noted, Martin and  Sugarman’s  work  is  rooted  largely  in  Gadamer’s  philosophical  hermeneutics  (see  Annells,  1996;;  Gadamer,  2004),  and  draws  on  Packer  and  Addison’s  application  of  hermeneutic  philosophy  within  the  discipline  of  psychology  (Packer & Addison, 1989b).     61 Philosophical Hermeneutics and the Hermeneutic Circle  Philosophical hermeneutics, the practice or process of interpretation, can be traced to the works of Martin Heidegger and Hans-Georg Gadamer (see Annells, 1996; Lopez & Willis, 2004; Langdridge, 2007). Gadamer’s  philosophical  hermeneutics  emphasizes  the  relationship  between  interpretation and understanding, the embedded nature of understanding within historical and sociocultural contexts, and the concept of the hermeneutic circle (Annells, 1996; Langdridge, 2007; Packer & Addison, 1989b). Gadamer held that knowledge and meaning are co-constructed, as individuals engage in dialogue, with language privileged as fundamental to understanding  (Annells).  Through  dialogue,  a  “fusion  of  horizons”  occurs,  in  which  one’s  “prejudices”  (i.e.,  considered  by  Gadamer  to  be  one’s  pre-judgement or fore-understanding; Annells,  p.  707)  meet  the  other’s  perspective  (e.g., research participant) or horizon, resulting in a broadening of understanding (Annells). Central to the philosophy of both Heidegger and Gadamer  is  the  “hermeneutic  circle,”  which  can  be  thought  to  symbolize  the  “dynamic  movement  between  the  parts  and  the  whole...within  the  seeking  of  understanding”  (Annells,  p.  707). Relatedly,  notions  of  the  “life  world”  and  “being  in  the  world”  are  key  tenets  (Lopez  &  Willis,  2004,  p.  729),  and  speak  to  the  inextricable  relation  between  one’s  personal  horizon,  entrance to the hermeneutic circle, and meaning making process (Annells; Lopez & Willis; Packer & Addison).  Packer and Addison (1989a, 1989b) extend these ideas to the discipline of psychology and related methods of inquiry. As previously noted, hermeneutic psychology and methods of inquiry are concerned with the way in which the researcher enters the hermeneutic circle (Packer & Addison, 1989a). The researcher must approach a phenomenon of interest, of inquiry, with a “concerned  engagement”  (see Martin & Sugarman, 2001, p. 202). She will bring forth all of her  62 preliminary understandings, beliefs, assumptions, knowledge; all of which constitute her “horizon  of  meaning.”  As  she  enters  the  hermeneutic  circle,  to  seek  what  is  yet  unknown  (i.e., from her current place of knowing), she sets out on a forward arc of projection, to establish a new point of view (Packer & Addison, 1989b). As she meets another horizon of experience and meaning, a fusion of horizons occurs (i.e., intersubjectivity) (Lopez & Willis, 2004; Martin & Sugarman) and meaning is constructed. Meaning construction is circular and reciprocal. It reflects an ongoing dialectic of parts and whole (i.e., obtaining new parts and assessing these against the whole, moving between what is known and what is yet unknown; Martin & Sugarman; Packer & Addison, 1989a, 1989b). It is in the backward arc that evaluation occurs; the researcher  considers  the  meaning  in  relation  to  her  ‘whole,’  her  knowledge  and  pre-understanding (Packer & Addison, 1989b). Hence, the interpretive/hermeneutic epistemological position informing the current study holds that meaning emerges within a relational, intersubjective context, co-constructed through language as the researcher and participants engage in research conversations (Packer & Addison 1989a). Phenomenology: Historical and Epistemological Developments  As a method of psychological inquiry, phenomenology has a strong and extensive philosophical foundation. Rooted in the work of Edmund Husserl, phenomenology has been elaborated and extended by philosophers who would both converge with and diverge from Husserl’s original views (Langdridge, 2007). Consequently, phenomenology as an approach to inquiry has evolved in significant ways, with respect to epistemological and ontological assumptions and associated methodological implications.  Husserl’s  phenomenological  method  aims  to  identify  and  describe the essential structures of a phenomenon (Langdridge, 2007). Husserl  believed  that  one  could  “bracket”  experience  and   63 knowledge,  and  thus  “set  aside  [one’s]  natural  attitude”  in  order  to  perceive  the  phenomenon  as  it  appears (Langdridge, p. 17). Husserl’s descriptive or transcendental phenomenology has a long and well-established history within the field of psychology and remains widely used today (Creswell, 1998; Creswell, Hanson, Plano Clark, & Morales, 2007), whether authors have stated this explicitly or not (i.e., frequent omissions exist in the literature, regarding  studies’  epistemological and ontological assumptions; see Wertz, 2005). It has been argued that descriptive phenomenology, and in many cases its post-positivist epistemology, remains  “too close to describing meaning as expressed by the participants and [fails] to take this further through interpretation”  (Langdridge,  2007,  p.  158).  Indeed, from a hermeneutic epistemological perspective, descriptive or empirical phenomenology may also be critiqued on epistemological grounds, for failing to account for what is conceived to be the inherent interpretive process of meaning construction. Hence the philosophical and epistemological shifts that ultimately expanded,  and  departed  from,  Husserl’s  original approach (e.g., the work of Heidegger, Merleau-Ponty, and Ricoeur, respectively). Such shifts are evidenced perhaps most saliently in the work of Heidegger, who was interested in understanding the meaning of being in the world and interpreting lived experience.  As  previously  stated,  Gadamer’s  philosophy  aligned  closely  with  Heidegger’s,  with  each  forming  the  foundation  for  hermeneutic  phenomenology  (Annells,  1996). Hermeneutic Phenomenology Comparing descriptive and hermeneutic phenomenology, Lopez and Willis (2004) emphasize  the  hermeneutic  goal  of  extending  beyond  “mere  descriptions  of  core  concepts  and  essences to look for meanings embedded in common life practices”  (p.  728).  This reflects the core epistemological and methodological distinction between the two approaches to phenomenology. In  hermeneutic  phenomenology,  the  researcher  aims  to  “grasp  the  essential   64 meaning”  of  the  phenomenon,  that  is,  to  determine  and  depict  “the  structure  of  meaning  of  the  lived  experience…to  effect  a  more  direct  contact with  the  experience  as  lived”  (van  Manen,  1997b, p. 77-78).  As previously discussed, hermeneutic phenomenology stems largely from the phenomenological philosophy of Heidegger and Gadamer (Annells, 1996; Langdridge, 2007), and is therefore located within an interpretive/constructivist paradigm of science (Annells; Haverkamp & Young, 2007; Ponterotto, 2005). Accordingly, knowledge is considered to be co-constructed between the researcher and participant, each situated within her own broader historical, sociocultural, and political contexts. Within this framework of understanding, meaning is thought to emerge in dialogue or conversation between individuals, who each bring forth their own individual fore-knowledge (Haverkamp & Young; Langdridge; Packer & Addison, 1989a). That  is,  “the  interpretive,  meaning-giving researcher and the phenomenon as described by the meaning-making participant [co-constitute] one another”  within the hermeneutic process (Hein & Austin, 2001, p. 14). As such, it is recognized that my interpretive frame is an inextricable part of the construction of meaning in this study.   There have been claims that hermeneutic phenomenology is becoming increasingly prevalent as a method of inquiry within psychology (Hein & Austin, 2001; Langdridge, 2007; Smith, 2004). van Manen (1997a, 1997b, 2006) is often cited as a central figure in the development of hermeneutic phenomenological methods [e.g., Earle (2010); Hein & Austin; Langdridge], and his approach guides the current study. van Manen (1997b) proposes the following six steps for conducting a hermeneutic phenomenological inquiry:  (1) turning to a phenomenon which seriously interests us and commits us to the world, (2) investigating experience as we live it rather than as we conceptualize it, (3)  65 reflecting on the essential themes which characterize the phenomenon, (4) describing the phenomenon through the art of writing and rewriting, (5) maintaining a strong and oriented pedagogical relation to the phenomenon, and (6) balancing the research context by considering parts and whole. (p. 30-31) Employing a hermeneutic phenomenological method, I aimed to  “identify  and  provide  an  understanding of the variety of constructions that exist  about  a  phenomenon” (Annells, 1996, p. 708), that is, women’s  experience of intimate partner relationships in supporting recovery from an ED. Prior to further description of the method, consistent with a hermeneutic perspective, I situate myself as the primary researcher. Researcher Positionality and Subjectivity: Reflexive Practice  Researcher subjectivity, or positionality, is an integral component of conducting qualitative research (Finlay, 2002; Haverkamp, 2005; Langdridge, 2007; LeVasseur, 2003; Morrow, 2005; Tracy, 2010), particularly, hermeneutic/interpretive research (Geanellos, 1998a, 1998b). My statement of positionality is articulated below, and subjectivity was thoroughly explored and addressed as I conducted the study, through use of reflexive questions, journaling (i.e., personal and research journals), and conversations with colleagues and supervisors.  Within the context of a hermeneutic phenomenological study, the aims of initial reflexive practice are twofold: (a) to elucidate the  researcher’s/my natural attitude (i.e., lack of curiosity) (LeVasseur, 2003), and (b) to increase awareness and insight around the ways in which the researcher’s/my subjectivity and positionality may influence the co-construction of meaning (Lopez & Willis, 2004). To be clear, these efforts are to be distinguished from those employed in descriptive  phenomenology,  where  the  aim  is  to  “bracket”  one’s  views  (e.g.,  Champlin, 2009) in order to preclude influence on analysis. Rather, the aim of these tasks, from a hermeneutic  66 approach, was to bring my knowledge, biases, beliefs, assumptions, and expectations into consciousness, reflect on them, and consider the ways in which they would influence both my interviewing and interpretation of the texts (Geanellos, 1998b). To this end, identifying and reflecting on pre-understandings and forestructures constitute the initial phase of interpretation within  the  context  of  a  hermeneutic  method.  Citing  Gadamer’s  work,  Geanellos  (1998b)  states  that pre-understandings  may  have  a  facilitative  or  hindering  influence  on  the  researcher’s  interpretive practices.  However,  by  identifying  and  examining  one’s  pre-understandings, the researcher  optimizes  their  facilitative  potential.  That  is,  by  considering  “their  origin,  adequacy  and legitimacy in relation to: (i) the phenomenon under investigation; and (ii) textual interpretation”  (p.  243)  she  increases  the  likelihood  that  the  phenomenon  will  reveal  itself  (i.e.,  she maintains an openness to it). Conversely, in the absence of diligent examination of pre-understandings,  the  researcher  is  at  risk  of  finding  or  ‘seeing’  what  she  already  expects  or  assumes she will find, in relation to the phenomenon; this may manifest as leading participants during  interviews  or  identifying  statements  and  themes  that  confirm  one’s  beliefs  during  data  analysis (Geanellos, 1998b). As such, the primary aim of this initial and ongoing reflexive practice is to prevent “premature  interpretive  closure”  (Geanellos,  1998a,  p.  157) through all phases of the research, and maintain an open and curious stance, affording the phenomenon the opportunity to reveal itself.   Addressing forestructures and pre-understanding: Initial tasks. In keeping with the imperatives of conducting a hermeneutic phenomenological study (see Geanellos, 1998b), I engaged in a number of practices in an attempt to bring forth and address my pre-understandings and forestructures (Geanellos, 1998a, 1998b). As per the recommendations made by Geanellos, I completed the following tasks: (a) rendered my understandings of the phenomenon explicit by  67 developing a conceptualization of intimate partner relationships in supporting recovery from an ED, (b) identified forestructures of intimate partner relationships in supporting recovery from an ED, and (c) formulated my pre-understandings of intimate partner relationships in supporting recovery from an ED (Geanellos, 1998b, p. 238). As part of this reflexive practice, I also explored and answered the questions outlined by Langdridge (2007) (e.g., why am I carrying out this study, what do I hope to achieve, how do I feel about the work, how might the findings impact on the participants; p. 59). This process helped me stay open to the research question and data, and thus, contributed to the trustworthiness of my interpretive process and findings. Findings from these reflexive exercises are summarized below, in my statement of positionality.  Ongoing reflexive practices. Given the complexities of negotiating reflexivity, particularly within an interpretive/constructivist paradigm, multiple perspectives or variants of reflexive practice were incorporated throughout the  research.  In  particular,  Finlay’s  (2002)  conceptualization  of  reflexivity  as  “introspection”  (i.e.,  examining  one’s  personal  experiences  and meanings; p.  213)  and  “intersubjective  reflection”  (i.e.,  “explore  the  mutual  meanings  emerging  within  the  research  relationship;;”  p. 215) served as general guides. Adopting these approaches maintained epistemological and methodological coherence with the hermeneutic phenomenological method, and grounded the  reflexive  practices  in  the  study’s  purpose, aims, and focus (Finlay, 2002). I also incorporated Haverkamp’s  (2005)  recommendation  to  explore  “professional  reflexivity”  (i.e.,  “whether  or  not,  and  how,  our  research  practice  and  relationships  with participants incorporate the relevant aspects of  our  professional  selves;;”  p. 152). For example, given my professional role as counsellor, I was mindful of the ways in which clinical tendencies could arise during research interviews, and sought to maintain the bounds of my role  68 as the researcher. These reflexive practices occurred independently (e.g., journals, writing) and in conversations with colleagues and supervisors. Taken together, engagement in ongoing reflexive practices [e.g., introspection, intersubjective reflection (Finlay, 2002); professional reflexivity (Haverkamp, 2005); journaling; conversations with colleagues and supervisors] helped me remain curious and open to the women’s  experiences  and  phenomenon.  For example, I was able to notice when I had made a link between something a participant had shared,  and  my  “pre-understandings” (e.g., knowledge from previous clinical experiences). Journaling afforded me increased awareness of my reactions and  responses  to  the  research  interviews,  both  with  respect  to  the  participants’  stories  (e.g.,  noting surprise, feeling affirmed at the importance of the research, observing the different ways in  which  participants’  articulated  their  experiences and how this influenced my facilitation of the interviews), and the process itself (e.g., negotiating my role as researcher, namely, balancing the creation of an open space with the use of specific follow-up questions to achieve the aims of the interview and method, and ensuring the elicitation of concrete examples of lived experience). I also observed that through the process of journaling, I raised questions about the data; for example, I found myself asking, “what  does  this  mean?”  in  relation  to  the  experiences  described  and the phenomenon under investigation. Such questions further supported my efforts to remain open to, and curious about, the phenomenon; avoid premature foreclosure on interpretations (Geanellos, 1998a); and  identify  the  relation  between  my  “pre-understandings”  and  the  co-construction of meanings with research participants.  Statement of Positionality I am a 32 year-old, presently able-bodied, married, heterosexual Caucasian woman of European heritage. I was born and raised in Western Canada. I am English speaking, highly  69 educated, and of middle-class socio-economic status. In light of my location within numerous intersecting, dominant cultures, I acknowledge that I live with significant privileges, and that these privileges influence and shape my experiences and relationships with others.  My personal and professional history has resulted in significant experience with, and knowledge of, EDs. For the past nine years I have worked in the area of EDs, as both a research assistant and counsellor in an adult outpatient ED program. My work as a research assistant at a provincial tertiary ED program increased my knowledge of the ED literature, treatment programs and approaches, and models of service delivery, and the multitude of empirical, theoretical, and clinical perspectives and trends present within the field. My research interests and pursuits have focused on the relational dimensions of change, including factors associated with readiness and motivation for change, social support, mutuality in relationships, and interpersonal difficulties. As previously stated, I have also acquired significant practice knowledge in my position as a counsellor in an ED program, where I engage in both individual and group therapy with clients. My work with adult women and men struggling with an ED has reinforced the extent to which I view EDs as being situated within relational contexts. Clients frequently share about their intimate partner relationships, or, their thoughts and feelings about intimate partner relationships in general, if they are not in a relationship. They describe ways in which their partners are supportive and/or hindering of their recovery. Notably, many clients who have achieved desired change have reported their partners to be a significant support; indeed, I feel as though clients often experience their partners, to varying degrees, in supportive ways. My personal and professional histories have resulted in significant knowledge about EDs, recovery,  and  support,  rendering  me  an  ‘insider’  in  many  ways  to  the  phenomenon  under  investigation. That being said, I have minimal clinical experience working with couples.  70 Nonetheless, I recognize that diversity and plurality of meaning always exists, despite shared or common experiences. Importantly, from a hermeneutic perspective, given that my lived experiences shape my pre-understandings and forestructures of intimate partner relationships in supporting recovery from an ED,  and  constitute  my  “horizon”  and  entry  point  into  the  hermeneutic circle, they are articulated in further detail below.  Beliefs and biases. I believe that sociocultural norms, messages, and expectations have a profound  impact  on  women’s  lived  experiences  and  the  development  of  EDs.  I  situate  the  development, maintenance, and recovery from EDs within this broad context. I adopt a bio-psycho-social etiological perspective, and acknowledge the multiple and converging pathways leading to the development and maintenance of an ED. I believe that ED symptoms and behaviors serve a function, and while the particular function may vary among women, the ED is typically a means of coping with something that is otherwise less- or un- manageable for the individual. To this end, I believe that the ED is often a very powerful and effective means of coping, however, offers short-term relief at the cost of long-term wellbeing, outcomes, and goals. Importantly, the ED is further reinforced by the broader sociocultural context, with its dominant, pervasive messages, as previously stated.  I believe that recovery from an ED is a process occurring over time, most often long periods of time, and that the duration of the recovery process varies among women. For the majority of women, the recovery process includes periods of remission and/or relapse (i.e., variability in symptom presence and frequency, and re-emergence of symptoms after periods of abstinence). My research, clinical, and personal experience all suggest that the meaning of, and criteria for, recovery also varies. For instance, some individuals feel that they have achieved a “full”  recovery,  and  define  this  in  various  ways,  whereas  others  consider  themselves to be  71 symptom  free,  yet  always  “in  recovery.” That being said, I believe that to have attained recovery from an ED a woman must no longer be engaging in ED behaviors (e.g., extreme restriction, objective bingeing, purging, excessive exercise). She may however continue to experience body dissatisfaction and/or other thoughts about controlling her shape and/or weight, but she does not act on these thoughts, as seen with active EDs. I believe that recovery involves both intra- and interpersonal shifts, including a heightened awareness of the underlying causes of the ED and efforts  to  address  these  (e.g.,  meet  one’s  needs  in  more  healthful  ways,  process  unresolved  issues). Relatedly, recovery may involve increased ability to identify and challenge sociocultural messages that perpetuate EDs. However, given the pervasive yet subtle nature of many messages and norms, the extent to which women are critically aware will vary, and may be influenced by the tasks and/or treatments they pursue during their recovery journey. While I believe that a woman is ultimately responsible for immediate behavioral change during recovery, I recognize that her experience is situated within and influenced by relational, social, cultural factors and contexts, and that these systemic issues also require attention and change.  I believe that, for women in an intimate partner relationship during recovery from an ED, this relationship constitutes an immediate context within which recovery may occur. This relationship plays a central role in recovery, and may both promote and hinder recovery efforts (e.g., at different times/in different ways throughout the process). In order for a relationship to be supportive, I believe it must be safe, validating, understanding, and empathic. Importantly, partners must be able to communicate this understanding, validation, and empathy, and with their partner, cultivate and maintain trust and honesty. The relationship must afford space for experimentation with new behaviors and ways of being (e.g., emotional expression, communication about both positive and difficult experiences, autonomy and closeness), without  72 imposing great pressure for change. I believe that recovery requires hope, attention to the process and efforts (i.e., rather than sole focus on outcomes), and validation and celebration of small and incremental changes. These qualities must therefore be present within a supportive relationship. I also believe that recovery involves a delicate balance between acceptance and change, and that both the women and their partners must learn to navigate all experiences with patience and compassion.  Given  my  belief  that  the  ED  has  profound  consequences  for  close  others’  in  the  woman’s  life, I believe that most partners supporting a woman through recovery must be able to tolerate anxiety and distress, and manage their own needs, in order best support their partner through the challenges of the ED and recovery. This is consistent with my view that relationships are bi-directional or mutually influential, in that, the experiences and actions of each partner influence the  other,  and  it  is  therefore  difficult  to  consider  “support”  in  isolation  of  the  relationship  itself.   Assumptions and expectations. In addition to the aforementioned beliefs and biases, which inherently influenced my  expectations  about  the  women’s  experiences  and  the  phenomenon under investigation, I identified several other assumptions and expectations. In conducting this research, I expected that the participants would identify their relationships as safe, and that they would have disclosed the ED to their partners. I anticipated that partners would be described as having experienced varying degrees of distress, mixed emotions, understanding  of  the  ED  and  the  woman’s  experience,  and  challenges  in the relationship. I imagined that the women would describe mixed feelings about this, including guilt, shame, and frustration. I anticipated that partners who were experienced as significant in the woman’s  attainment of recovery would have been open and willing to learn about the ED, including  73 strategies to support her. I also expected that the women would describe instances of both practical and emotional support.  As  per  my  inclination  towards  RCT  as  a  theoretical  frame  for  understanding  women’s  psychological wellbeing and growth, I anticipated the women would describe processes and periods of connection and disconnection in their intimate relationship. I also imagined that the supportive qualities and aspects of the intimate partner relationship would reflect both similarities and differences from those of other relationships, such as relationships with parents, siblings, extended family, friends, and/or professional supports. For example, I anticipated that sexuality, sexual intimacy, and body image would likely be addressed as the women shared about their intimate relationship during recovery. I also anticipated that the women would discuss their values and hopes for the future, including interpersonal and family related hopes (e.g., sustaining a strong relationship, not hurting their partner, starting a family), and their unique role in recovery. Rationale for Study Inclusion Criteria Given that variability exists with the field of EDs regarding a number of the constructs included in the current research, definitions for  the  study’s  key constructs are outlined and rationale for inclusion criteria therefore provided. These inclusion criteria draw from extant empirical  and  theoretical  literature  (e.g.,  RCT),  and  women’s  subjective  perspectives12.   “Eating  disorder.” The study adhered to the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV-TR; American Psychiatric Association (APA), 2000; see Appendix A] classifications for EDs, and included women with a history of clinically diagnosable AN, BN,                                                  12 Potential participants were asked whether they perceive themselves as having recovered from an eating disorder. This subjective perspective was considered in conjunction with the objective criteria to determine eligibility to participate in the research.  74 and/or EDNOS. History of ED symptoms meeting criteria for a clinical diagnosis was required given the study’s  aim of understanding the relational experiences of women who recovered from a serious ED (see Halse & Honey, 2005). Diagnostic information was obtained via potential participants’  self-report, during the telephone screening process (see Appendix D)13.   “Intimate  partner  relationship.” In the current study, an intimate partner relationship referred to a romantic relationship with a person of the same or different gender or sex, lasting a minimum duration of six months. Partners may have been cohabiting, common-law, or married during the  woman’s  recovery  process.  However,  in  order  to  remain  inclusive  of  individuals’  choices and extend the scope of extant  research’s  exploration  of  intimate  partner  relationships  (e.g., beyond those who are married), participants were not required to fit these additional criteria. Women must have been in this intimate relationship during their recovery process, as they worked to decrease ED behaviors, and experienced this relationship as significant in their attainment of recovery. Of note, women may no longer be in this same intimate relationship at the time of the study.  “Recovery.”  As previously discussed, significant empirical efforts have been made to conceptualize and define recovery from an ED (e.g., Bardone-Cone et al., 2010a), however, there remains a lack of consensus in the field. Positivist paradigms have typically considered it an endpoint to be achieved, measured primarily by behavioral and/or physical indices of change (e.g., symptoms, body mass index, menstruation) (e.g., Bachner-Melman et al., 2006; Herzog et al.,  1999;;  Kordy  et  al.,  2002).  Research  exploring  women’s  subjective  experiences  of  recovery                                                   13 Diagnostic  assessment  relied  on  potential  participants’  retrospective  self-report of symptom severity, frequency, and duration. Formal diagnosis may have been assigned for some (e.g., those who entered treatment) but not all women interested in participating in the study.  75 consistently  conceptualizes  recovery  as  a  process  and  espouses  a  multitude  of  ‘subjective  definitions’  of  recovery  (Noordenbos,  2011b).   The current study drew from this body of empirical work and employed both objective criteria and  women’s  perspectives to determine recovery status. To this end, the following criteria needed to be met in order to  satisfy  the  study’s  conceptualization  of  having  “recovered”  from an ED: (a) the woman did not currently meet DSM-IV-TR criteria for an ED (APA, 2000; Noordenbos, 2011a); (b) the woman had not met DSM-IV-TR criteria for an ED in the past year; (c) the woman had not engaged in any ED behavior (i.e., extreme restriction, objective bingeing, methods of purging and/or inappropriate compensation; APA, 2000) in the past year14 (see Bardone-Cone et al., 2010a; Herzog et al., 1999; Kordy et al., 2002); and (d) the woman identified herself  as  having  “recovered”  from  her  ED,  in  that  she  is  no  longer  engaging  in  ED  behaviors and the ED no longer consumes, compromises, or impairs her sense of self, her life, and her daily functioning (Bjork & Ahlstrom, 2008; Noordenbos, 2011b15; Root, 1990).  This conceptualization of  “recovery”  drew from empirical research, used conservative estimates for symptom free periods to safeguard participants’ wellbeing, and acknowledged that recovery is an ongoing process. With respect to this latter point, in keeping with the lived                                                  14 If a woman had engaged in minimal/residual ED behavior(s) in the past year, however, self-identifies as having recovered, I inquired in detail about the behavior(s) to determine whether the woman met this criterion. I used clinical judgment, coupled with empirical research, to make this decision. When necessary, I consulted with my supervisor to clarify and consider the implications of involvement or declining involvement. 15 Noordenbos’  (2011b) review of the literature generated the following list of client-identified criteria for recovery: normalized eating and drinking behavior, physical activity, and exercise; flexible, relaxed attitude towards food; accepting, positive body evaluation; achievement of medical and physical stability; psychological health, including sense of self and esteem that are not tied to the ED identity; ability to effectively manage and express emotions; overall decrease in tension and anxiety, marked by increased relaxation; social and interpersonal engagement; greater sexual intimacy and enjoyment; an absence of psychiatric co-morbidity related to ED (p. 444).  76 experiences of recovery that have been documented in the literature to date, it was acknowledged that recovery takes time and some women may still experience thoughts and feelings related to their eating, shape, weight, and history of ED, while simultaneously self-identifying as being “recovered”  (Bjork  &  Ahlstrom, 2008; Liu, 2011; Pettersen & Rosenvinge, 2002; Root, 1990). Importantly, the required duration of time elapsed since engaging in any ED behaviors aimed to maintain the safety and wellbeing of participants by ensuring they had reached a certain level of health prior to engaging in the research process16. To the extent possible, this served to minimize risk to participants that may exist when discussing experiences of the ED, and optimized the likelihood of capturing the phenomenon of interest (i.e., intimate partner relationships in supporting recovery from an ED).   “Process of  recovery.” Within the context of the current study, to have been in the process of recovery means that participants identified as having been engaged in efforts to reduce ED symptoms (e.g., working to reduce cognitions, behaviors, and ameliorate wellbeing, and/or involved with professional support/treatment program) while in an intimate relationship lasting a minimum of six months. Procedure Participants. Adult women (i.e.,  > 19)17 with a history of a clinically diagnosable ED (i.e., DSM-IV-TR; APA, 2000) who met the following inclusion criteria were invited to                                                  16 See Kordy et al. (2002) and Herzog et al. (1999) for findings from longitudinal studies on remission, recovery, and relapse, and periods of heightened vulnerability for relapse, which informed the current criteria. See Halse & Honey (2005) for discussion of ethical considerations when conducting research with women with a current or previous ED diagnosis. 17 Most ED research has focused on adolescents and young adult women, with a growing body of work examining EDs in mid-life (e.g., Brandsma, 2007; Cumella & Kally, 2008). Less is known about EDs in mid-life however, and to date, little is known about EDs in later adulthood (i.e., > 65; prevalence, symptom presentation, course, outcomes) (Beck, Casper, & Anderson, 1996; Cosford  &  Arnold,  1992).  The  current  study  aimed  to  be  inclusive  of  all  adult  women’s   77 participate in the current study: (a) were in an intimate relationship of six months or more while engaged in recovery from their ED; (b) were in this intimate relationship no more than 5-10 years ago18; (c) identify this intimate relationship as being significant in their attainment of recovery (i.e., supporting recovery); (d) meet study requirements for having recovered from an ED (i.e., do not currently meet DSM-IV-TR criteria; have not met DSM-IV-TR criteria in the past year; have not engaged in ED behaviors, namely, extreme restriction, objective bingeing, methods of purging and/or inappropriate compensation, in the past year); (e) self-identify as being  “recovered.” In addition, given the methodological imperatives of a phenomenological study, the participants needed to be willing and able to both reflect on their experiences and articulate them in English, in conversation with the researcher (Polkinghorne, 2005).  The literature presents several views on the number of participants to be included in phenomenological studies. Creswell (1998) suggests that a phenomenological inquiry include no more than ten participants; review of published phenomenological studies seems consistent with this guideline [e.g., (N = 6; Palmer & Daniluk, 2007); (N = 8; Spivack & Willig, 2010)]. Wertz (2005) acknowledges that the number of participants must be considered in relation to the research purpose and question, and states that one may not know the final number of participants at  the  outset  of  the  research.  Benner  (1994)  suggests  researchers  anticipate  the  “size  of  the  text”  (p. 107) and recruit accordingly (i.e., if participants are interviewed twice, then fewer participants may be recruited). In general, the researcher is encouraged to adopt a flexible stance with respect to recruitment and data collection, with the aim of obtaining sufficient, rich data to                                                                                                                                                              experiences, particularly those that have not been voiced in the extant ED literature. As such, there is no maximum age for participation. However, given available data on prevalence of EDs in later adulthood (Beck et al.; Casper & Anderson) it was anticipated that most women would be in early adulthood or mid-life. 18 This time frame was recommended in order to ensure that women were able to recall the phenomenon under investigation.  78 capture and illustrate the phenomenon of interest in detail and depth (Morrow, 2007). To this end, it has been suggested that data collection continue to the point of theoretical saturation (Morrow).  Recognizing  that  ‘true’  redundancy  is  unattainable within an interpretive/constructivist paradigm,  Morrow  explains  that  “themes  are  theoretically  saturated  when they account for all of the data that have been gathered and illustrate the complexity of the phenomenon  of  interest”  (p.  217),  thereby  suggesting  some  degree  of  redundancy  for  the  purposes of the research.   In keeping with the aforementioned recommendations, including the depth and length of the research interviews and the notion of theoretical saturation (i.e., no new themes emerging), ten women were recruited to participate in the study. Sufficient interview data was collected to ensure I was able to co-construct and comprehensively describe the essence of the phenomenon of interest, the experience of intimate partner relationships supporting recovery from an ED, and to reach theoretical saturation of the data.   Recruitment. I employed purposive sampling in order to elicit rich, informative accounts from women who were willing and able to reflect on and articulate their experience of the phenomenon, intimate partner relationship in supporting recovery from an ED (Langdridge, 2007; Polkinghorne, 2005). Langdridge (2007) states that recruitment in a hermeneutic phenomenological study is “likely  to  be  purposive and homogeneous,” in that the researcher seeks to include individuals who have shared the experience under investigation and  “do  not  vary  significantly across demographic characteristics,” in order to “develop  detailed  descriptions”  and  “make  claims  about  these  people  and  their  particular  shared  experience”  (p.  58).  Adult women were widely recruited using recruitment posters and print and online notices, including the use of social media pages (i.e., Facebook; British Columbia Eating Disorder Centre for Excellence;  79 British Columbia Association of Clinical Counsellors online newsletter; Looking Glass Foundation website), in efforts to reach women who had recovered from an ED and found their intimate partner relationship to be a support during this process (see Appendices B and C).  During the initial telephone contact (see Appendix D) I informed women of the purpose of the study and welcomed any and all questions (e.g., regarding the research, participation, my experience and interest in the area of study). I followed a detailed screening form to ensure that potential participants met the study inclusion requirements. If women met the inclusion criteria and offered verbal consent to participate in the research, we scheduled a research interview for a mutually agreed upon date, time, and location. I did my best to ensure that participants fully understood the nature of the interview process (e.g., duration, topic discussed, disclosure of sensitive personal information) so they were able to make an informed decision about an appropriate location. Interviews took place in quiet, private areas, including both library and church study spaces, a building amenity room, private office space, and via Skype19. Written informed consent was obtained at the start of the interview, and this process is discussed in detail below (see Appendices E and F).   Data collection. Consistent with a hermeneutic phenomenological method, research data consisted of women’s  personal  accounts  of  experiencing  the  phenomenon, that is, an intimate partner relationship in supporting recovery from an ED. Data was collected using in-depth, audio-recorded interviews. As the co-investigator and primary researcher responsible for execution of the study, I conducted the research interviews. Seven interviews were conducted in person at various locations within the community. Three interviews were conducted using Skype                                                  19 Various issues were considered when supporting the women to identify a comfortable place for the interview, including means of transportation,  privacy,  and  proximity  to  the  participant’s  home.   80 technology (Deakin & Wakefield, 2013; Hanna, 2012). In light of connectivity issues, one of the Skype interviews lost its video option and thus, turned into a phone interview (i.e., using the Skype technology) (Holt, 2010). Although in-person interviews have long been considered optimal in qualitative research, there is growing support for the use and benefits of technology as a means of data collection (see Deakin & Wakefield; Hanna; Holt). Specifically, the use of Skype as a medium has received support given that it preserves the synchronous, face-to-face aspects of the in-person interview, and also, allows individuals at a geographical distance or with limitations to their availability, to participate in the research (Deakin & Wakefield). In the current study, the three participants for whom Skype was used were all living in regions that precluded travel for an in-person interview. In addition, it afforded convenience for one participant with a young child at home. There were no other notable distinctions between participants who engaged in a Skype interview and participants who engaged in an in-person interview. Further implications of using Skype, with and without the video function, are discussed throughout this section on the data collection process. Oral depiction or narration of experience  enabled  the  women  to  “stay  close  to  [the] experience  as  it  is  immediately  lived”  (van  Manen,  1990,  p.  67). Polkinghorne (2005) encourages the obtainment  of  detailed,  inclusive,  “intense,  full,  and  saturated  descriptions  of  the  experience under investigation”  (p.  139).  Morrow (2005) recommends that researchers possessing significant knowledge of the subject area (i.e., familiarity with the phenomenon being explored; insider) seek clarification around, and move  deeply  into,  the  participants’  subjective  meanings and embodied experience (see Langdridge, 2007). I kept these recommendations in mind as I engaged in the interviews, specifically, as I used follow-up questions to deepen my understanding and elicit concrete examples.   81 It has also been argued that researchers with a counselling psychology background and clinical skills may establish rapport and elicit participant stories and experiences with greater ease, reducing the time necessary to attain depth during interviews (Haverkamp, 2005), and thus, the need for multiple interviews with participants. In light of my counselling psychology training and being sensitive to the total time required for participation in the study, I conducted one interview with each participant. I proposed the possibility of conducting a second data collection interview to participants at the outset of the study, during the screening interview and prior to obtaining consent, in the event this was felt to be necessary or beneficial (i.e., by myself or a participant), however, this did not occur. A primary aim in the interviews was to create a safe relationship  that  supported  the  women’s  articulation  of  their  experience  and  the  obtainment  of  a  deep, rich description of the phenomenon and the meanings women attribute to their experience. To this end, I adopted a collaborative stance (i.e., as described below, in the overview of the interview orienting statement) and employed basic counselling skills (e.g., active listening, non-verbal and verbal prompts).  For the Skype interviews with video, I made a concerted effort to communicate both verbally and non-verbally as clearly and audibly as possible, to optimize the extent to which this information was conveyed through the video function, and to aid in the establishment of rapport. To the best of my knowledge, and in the absence of feedback from participants stating otherwise, I believe that the Skype interviews with video were effective means of obtaining interview data, and retained the benefits of in-person interviews. For the Skype interview with no video function, I relied more heavily on verbal prompts and communication. I acknowledged the challenges imposed by not having face-to-face contact (i.e., loss of non-verbal communication), and  its  impact  on  the  ‘flow’  or  bi-directional nature of our dialogue (Holt, 2010); the participant  82 expressed understanding of the implications and we agreed to address issues openly as we proceeded through the interview. A collaborative stance was therefore employed, as the participant and I negotiated our dialogue. For example, to facilitate the interview in the absence of visual cues, I inquired more frequently about whether she had more to say on a topic, and as previously noted, used verbal prompts to encourage her to continue. In doing so, I informed the participant of my intentions in communicating in this manner. Notably, Holt has identified the benefits of using the telephone as a means of interview data collection, one of which being the need  for  “full  articulation”  on the part of both researcher and participant, and  thus,  a  “much  richer  text”  (p.  116). Importantly, literature suggests that participants evaluate this means of interviewing positively (Holt), and I did not receive any feedback suggesting otherwise. Before starting each research interview, I invited and addressed any additional questions or concerns about the research that may have arisen since the initial telephone contact. We then reviewed and signed the informed consent form (see Appendices E and F). Review of the form included discussion of the study’s purpose, procedures, confidentiality and limits thereof, potential risks and benefits, and contact information. After ensuring the participant understood the implications of involvement in the research, she was asked to sign the form. Each participant was given a copy of the informed consent form for her records. For participants who were interviewed via Skype, the informed consent form was emailed to them prior to the date of research interview, such that we could review together. The participant then provided verbal consent and signed the informed consent form, which was then sent to me at her earliest convenience following completion of the interview. At this time, I asked all participants to generate a pseudonym for use throughout the duration of the study and the dissemination of findings. Lastly, I let the participants know that I had additional support resources available to  83 them, should they feel the need/want to follow-up after the interview, and I gave them each a list of these resources (see Appendix I). These resources were emailed to participants completing the interview via Skype. Notably, no participant contacted me following the data collection interview to check-in or request additional support, and thus, to the best of my knowledge no participants required or followed-up with the resources provided.  Once the informed consent form was signed and the participant indicated she was ready to begin the interview, I turned on the audio recorder and informed the participant of the same. I stated the date and pseudonym of the participant, and began the research interview with an orienting statement (see Appendix G) followed by the primary research question (see Appendix H). I reminded participants that they were welcome to share as much and/or as little as they wished regarding their experience and that we could pause, take a break, or stop the interview at any time, at their discretion. I invited participants to direct the flow and pace of the conversation, but let them know that I may respond with additional questions, seek clarification, or re-direct our focus, in the interest of the research purpose (e.g., to ensure I understood, encourage more detail to enhance and deepen the description and/or elaboration of meaning, and/or keep us well oriented to the research question) (see Appendices G and H). To this end, the research interviews were largely  unstructured,  allowing  space  for  the  women’s  experience  and  meanings  to  emerge (Benner, 1994), with some structure imposed as the interview progressed, to ensure detailed information about the phenomenon was collected (Langdridge, 2007). As noted above, a series of interview questions was used during the interviews, and introduced as a means of re-focusing the participant on the phenomenon, encouraging detailed description of the phenomenon, eliciting concrete examples of the phenomenon, exploring meanings attributed to the phenomenon, and in general, deepening exploration and depiction of the lived experience (see  84 Appendix H). I also used probes and clarification when necessary, to ensure I understood the narratives and the meanings the participants were expressing (Benner, 1994). In addition, as per van Manen’s (1997b) suggestions for the hermeneutic phenomenological researcher, I kept the following principles in mind as I facilitated the interview: (a) stay close to experience as lived; (b) focus on concrete experiences (i.e., re-direct when the interviewee begins to make generalizations about the experience or becomes very reflective or theoretical); (c) ask the interviewee to think of a specific instance, situation, person, or event; and (d) explore instances of the experience to the fullest. van Manen urges the researcher to stay oriented to her primary research question, and I remained mindful of this, and relied on the research question as an anchor throughout the interview process.  Consistent with the collaborative spirit of the research process, determining when to end the interview was a joint decision, and occurred when  the  “conversation gradually diminishe[d] into  a  series  of  more  and  more  pauses,  and  finally  to  silence,”  suggesting  that  “something  has  been  fulfilled”  (van  Manen,  1997b, p. 99) and we had attained a comprehensive description of the experience and meanings, as per both the participant and myself. Interviews ranged in length from one hour and fifteen minutes to two hours and thirteen minutes; mean duration of the interviews was one hour and thirty-seven minutes.   A final component of the data set was my research memos. Memos consisted of observations obtained during the interview (e.g., if/when a participant became tearful) and reflections from both during and after the interview, regarding its content and/or process. Memos were not transcribed in full and analyzed, but rather, used as an aid to my interpretive process. To this end, memos were reviewed alongside each transcribed interview to ensure that all relevant information about the interview was contained in the transcript. In addition, as I  85 proceeded with the analysis, as described further below, I referenced the memos from each individual interview to ensure I was considering and/or including observations, thoughts, or questions about meaning from the interviews, in the interpretive process, as relevant (e.g., some comments were redundant with what participants had said, or were reminders for me of areas to follow-up on in the interview).  All data was stored in a locked  filing  cabinet  in  the  primary  researcher’s  (M. Hughes-Jones) residence. Data will be kept secure for the duration of the study and destroyed after five years as per UBC policy. Data analysis. As previously described, examination of pre-understandings and forestructures constitutes the first stage of interpretation and analysis in hermeneutic phenomenology (Geanellos, 1998a, 1998b). I continued to engage in reflexive practices over the course of data collection and analysis, with the aim of preventing “premature  interpretive closure”  (Geanellos, 1998a, p. 157); that is, to ensure I was not leading the participants during interviews and/or identifying aspects of the transcripts that merely confirm what I may expect to find.  All interviews were audio-recorded and transcribed verbatim by a hired, professional transcriptionist, who signed a transcription services confidentiality agreement (see Appendix J). All participants were informed of the transcription process during the informed consent process and associated discussion regarding confidentiality. The transcription process is considered to be a step in the interpretive process, during which the researcher immerses herself in the data and begins to formulate initial interpretations about the data (Lapadat & Lindsay, 1999). It could therefore be argued that hiring a professional transcriptionist to complete this step compromised my ability to be fully immersed in the data and continue formulating impressions at this stage. In  86 order to address these implications, upon receiving the completed transcripts, I made additional efforts to immerse myself in the data. Specifically, I re-read each individual transcript while listening to the audio-recording and reviewing my memos, to ensure that the transcript was a verbatim,  detailed,  and  accurate  reflection  of  the  participant’s  account,  and  included all the information I obtained about  the  women’s experience. To this end, I added or emphasized pauses,  silences,  and/or  breaks;;  participants’  expressed  emotion  (e.g.,  tears,  smile,  laughter);;  and/or nuances in speech (e.g., pace, tone), based on my experience of conducting the interviews and in consult with my memos from the interview. This latter step also ensured consistency across all transcripts with respect to how the audio was translated into the written text (e.g., noting and differentiating between silences, breaks, and pauses) (Lapadat & Lindsay). I also formatted the transcripts to include wide margins for notes, comments, and initial analytic reflections (Langdridge, 2007).  Acknowledgment of the potential benefits of having the interviews transcribed is also warranted. Having the audio-recordings transcribed afforded me perspective from the data, allowing me to return to the interviews with  ‘fresh  eyes,’  and prompting me to reflect upon the participants’  experiences  in  new  ways, as I re-reviewed the data and incorporated additional information. To this end, I feel that having the interviews transcribed aided my interpretive process. In addition, by incorporating this step into my research procedure, I became more reflexive about the transcription process itself, and the implications of transcription to the interpretive process; this reflexivity around transcription has been encouraged and identified as an important research step in and of itself (Lapadat & Lindsay, 1999).  Consistent with the ongoing interpretive process of hermeneutic phenomenology, I continued  to  formulate  impressions  about  the  women’s  individual  experiences during the initial  87 review of the transcripts (i.e., as is highlighted by van Manen and hermeneutic philosophy, this process of interpretation began within the context of the data collection interview itself as the woman and I engaged in dialogue around her experience). I captured these initial impressions of the  women’s  experience  of  their  intimate  partner  relationship  supporting  recovery  by generating and writing down statements that depicted possible meaning structures.  While descriptive phenomenology typically adheres to methods of analysis proposed by Giorgi, Colaizzi, or Moustakas (see Creswell et al., 2007; Sanders, 2003; Willig, 2008), hermeneutic inquiry in psychology (see Parker & Addison, 1989b) and hermeneutic phenomenologists specifically (van Manen, 1997a, 1997b, 2011) encourage a more flexible conceptualization of, and approach to, analysis (Hein & Austin, 2001; Langdridge, 2007). I therefore retained this  “openness”  during  the  data  analysis  phase  of  the  research,  while using van Manen’s  (1997b) approach to guide the process. As previously stated, van Manen (1997b) proposes the following six steps for conducting a hermeneutic phenomenological inquiry:  (1) turning to a phenomenon which seriously interests us and commits us to the world, (2) investigating experience as we live it rather than as we conceptualize it, (3) reflecting on the essential themes which characterize the phenomenon, (4) describing the phenomenon through the art of writing and rewriting, (5) maintaining a strong and oriented pedagogical20 relation to the phenomenon, and (6) balancing the research context by considering parts and whole. (p. 30-31)                                                  20 Langdridge (2007) suggests that a researcher in the field of psychology substitute the word “psychological”  for  “pedagogical,”  to  reflect  her  or  his  particular  orientation  to  the  phenomenon (p. 123). I followed this recommendation.  88 van Manen (1997b) refers to themes as meaning units or structures of meaning21, stating that  “reflecting  on  lived  experience  then  becomes  reflectively  analyzing  the  structural  or  thematic  aspects  of  the  experience”  (p.  78). He outlines three approaches to thematic analysis: (1) wholistic, (2) selective or highlighting, and (3) detailed or line-by-line, and recommends a combination of two of these approaches to ensure a comprehensive analysis. I engaged in the first two approaches to data analysis.  As per the wholistic approach, as I first read the text (i.e., individual transcript) as a whole, I asked myself  “what  sententious  phrase  may  capture  the  fundamental  meaning  or  main  significance  of  the  text  as  a  whole?”  (van Manen, 1997b, p. 93). I then crafted a statement that captured this overall meaning of the experience for the participant. This statement was revised with subsequent review of the transcript, as my understanding and interpretation of her experience was further developed, deepened, and refined. As per the selective approach, I then re-read each interview text and asked myself  “what  statement(s)  or  phrase(s)  seem  particularly  essential  or  revealing  about  the  phenomenon  or  experience  being  described?”  (van Manen, p. 93). I then highlighted these statements in the transcript and constructed a statement for each that articulated its meaning. This process generated a number of meaning structures for each individual  participant’s  experience. van Manen offers these additional questions  to  guide  one’s  reading of the texts:  “what  is  going  on  here?”  “what  is  this  an  example  of?”  “what  is  the                                                   21 van  Manen’s  (1997b)  conceptualization  of  “themes”  includes  the  following:  (1)  Theme  is  the  experience of focus, of meaning, of point; (2) Theme formulation is at best a simplification; (3) Themes are not objects one encounters at certain points or moments in a text; (4) Theme is the form of capturing the phenomenon ones tries to understand; (5) Theme is the needfulness or desire to make sense; (6) Theme is the sense we are able to make of something; (7) Theme is the openness to something; (8) Theme is the process of insightful invention, discovery, disclosure; (9) Theme is the means to get at the notion; (10) Theme gives shape to the shapeless; (11) Theme describes the content of the notion; (12) Theme is always a reduction of a notion (p. 87-88).  89 essence…of  [the  phenomenon]  and  how  can  I  capture  this” (p. 86), and I therefore kept these in mind throughout the analytic process.  I completed the above analytic process for each individual transcript. Throughout this process I began to generate interpretations of the data set as a whole. I captured these interpretations by writing down statements that depicted possible meaning structures, common to all the women. As such, I had begun the process of considering individual “parts”  in  relation  to  the  “whole.”  I  continued  to review my initial findings from the individual level analyses (i.e., each respective transcript), considered them in relation to the entire data set (i.e., all transcripts), and attempted to identify themes common to the experiences of all the participants. I therefore sought what was universal, from the particular (Langdridge, 2007), to distinguish essential versus incidental themes structuring the phenomenon (van Manen, 1997b). To this end, I engaged in  a  process  of  “free  imaginative  variation,”  asking  myself  “is  [the  experience  of  intimate partner relationships in supporting recovery from an ED] still the same if we imaginatively change or delete this theme from [said]  phenomenon?”  and  “does  the  phenomenon  without  this  theme  lose  its  fundamental  meaning?”  (van Manen, p. 107). This “across”  participant analysis generated the essential meaning structures of the phenomenon, which constitute the results reported in the next chapter.  Importantly, the generation, development, deepening, and refinement of these essential themes occurred through an iterative process of writing, re-writing, referencing individual transcripts, and returning to the data set as a whole (i.e., ongoing movement between the parts and the whole). With my initial essential themes in mind, I returned to each individual transcript. I re-reviewed both the transcript itself and the meaning structures generated from the individual level analysis to ensure that  the  essential  themes  were  indeed  captured  in  each  woman’s   90 experience. This resulted in further development and refinement of the essential themes (e.g., some themes were collapsed into others, some themes became sub-themes, some themes were deemed incidental); this refinement also occurred through the process of writing and re-writing the themes (van Manen, 1997b). In addition, the analytic process included several meetings with my research committee members, during which we discussed the process of analysis and findings to date, including whether themes were essential or incidental, whether the ways in which themes were conceptualized and articulated reflected and captured experience as lived, and the extent to which themes were distinct. A number of the aforementioned questions posed of the data during analysis were once again explored in these meetings. Overall, the data analysis process involved deep immersion in the data (i.e., reading and re-reading the transcripts, moving between the individual transcripts and the data set as a whole, selecting illustrative quotes), phenomenological reflection around meanings (i.e., generating and writing22 statements that capture meaning structures), and writing and re-writing with the aim of bringing these meanings to life in a rich and evocative text (van Manen, 1997b, 2006).  Representation of the Research Findings The results of this hermeneutic phenomenological study consist of a comprehensive written description of the essential meaning structures (i.e., the essential themes) of women’s experience of their intimate partner relationships in supporting recovery from an ED generated from  the  “across”  participant  analysis  (Langdridge, 2007; van Manen, 1997b; Wertz, 2005). The lived experiences and voices of the women are highlighted throughout the final text with rich, illustrative quotes. Additionally,  in  order  to  contextualize  the  study’s  findings, I present a brief biographical description of each participant in the Results chapter.                                                   22 van Manen (1997b) considers writing to be an inherent aspect of research method; specifically, he  views  writing  as  the  path  to  “seeing”  themes  (p.  79).  91 Congruent  with  the  study’s  interpretive/constructivist paradigmatic frame, it is also acknowledged that the essential themes generated reflect one possible interpretation of the data/text, and other investigators and/or readers may make different interpretations and/or generate different findings (Hein & Austin, 2001). Likewise, findings reflect the experiences of the study participants and may not necessarily reflect the experiences of all women who experienced their intimate partner relationship as significant to their recovery from an ED. Such contextual considerations for interpretation of the findings are presented in the Discussion chapter. Evaluating Interpretive Accounts: Establishing Trustworthiness in the Research  Given  the  underlying  positivist  assumptions  of  “validity”  (i.e., correspondence theories of truth; see Packer & Addison, 1989a) and thus, the incommensurable nature of this concept with a hermeneutic phenomenological mode of inquiry, the current study adopts various methods of “evaluation,”  through  which  the  trustworthiness of the research may be considered (Packer & Addison, 1989a). To this end, I employed relevant criteria put forth for qualitative inquiries in general (Morrow, 2005; Tracy, 2010; Yardley, 2000), hermeneutic psychological inquiry (Packer & Addison, 1989a), and hermeneutic phenomenology (Langdridge, 2007; van Manen, 1997b) respectively, to ensure the rigor and credibility of my work.   General criteria to ensure quality. Morrow  (2005)  identifies  social  “validity”  (i.e.,  social  relevance), subjectivity and reflexivity, adequacy of data, and adequacy of interpretation as overarching criteria for trustworthiness, irrespective of philosophy of science (i.e., to be addressed in a manner that is consistent with my epistemological stance, herein constructivist/interpretive). Similarly, Yardley (2000) outlines the following principles as general guides to evaluating qualitative research: sensitivity to context, commitment and rigor,  92 transparency and coherence, and impact and importance. Given the paramount importance of establishing  the  “quality”  of  qualitative  research  (Tracy,  2010),  I  have  attempted  to  fulfill the aforementioned broad criteria throughout my research process (e.g., level of detail in conducting and reporting the research, reflexive practices, epistemological coherence).  Evaluation of hermeneutic phenomenology. Morrow (2005) suggests evaluation criteria specific to an interpretive/constructivist paradigm, including fairness, authenticities, and meaning (p. 251) (see also Denzin & Lincoln, 2005; Guba & Lincoln, 2005). Indeed, particularly important to a hermeneutic phenomenological study are issues of representation, attainment of deep understanding, and articulation of the co-constructive process of meaning-making (Morrow). Packer and Addison (1989a) emphasize that although evaluation itself is not interpretation  free,  four  processes  can  aid  one’s  efforts  in  assessing  the  trustworthiness  of  an  interpretive account. Specifically, they suggest one consider coherence, external evidence, consensus, and practical implications,  as  they  relate  to  the  researcher’s epistemological position23. Langdridge (2007) outlines four criteria for evaluating a phenomenological study: analytical rigor, producing a persuasive account, collaborative working (i.e., with colleagues), and participant feedback (i.e., as indicated by epistemological position), revealing his subtle bias towards  ensuring  the  credibility  of  one’s  work  within  the  academic  community.  van Manen (1997a, 1997b, 2006) emphasizes the quality of the written text as a key component in establishing the value of a hermeneutic phenomenological study, specifically.  He  asserts  that  “the  researcher as author is challenged to construct a phenomenological text that possesses                                                  23 Some  of  these  ‘terms’  (i.e.,  language)  appear  to  be  epistemologically incongruent with the study, but Packer and Addison (1989a) emphasize the ways in which the researcher might understand and approach each criteria area, consistent with hermeneutic epistemology.   93 concreteness, evocativeness, intensity, tone,  and  epiphany”  (1997a, p. 368). According to him, the final text must be “oriented, strong, rich, and deep”  (1997b, p. 151). Indeed, he privileges resonance, the final text’s  ability  to  evoke  feeling  and  connect  with  one’s  senses,  as  the  ultimate  goal.   I consider the various aforementioned criteria for evaluating the trustworthiness of a hermeneutic phenomenological study to be largely subsumed under the notions of rigor and credibility. Indeed, both Morrow (2005) and Tracy (2010) echo the idea that any claims of transferability included in the final report are largely contingent upon well-established rigor and credibility. As such, I describe below the specific steps taken to ensure the credibility of my research.  Methods for establishing credibility. Credibility was achieved through rigorous attendance to, and communication of, each stage of the research process (Morrow, 2005; Tracy, 2010). To this end, I have provided a detailed description of the methodology, including procedures (e.g., recruitment, participants, data collection, and analysis) and researcher reflexivity; this level of detail ensures transparency and epistemological coherence throughout the research process. During the data collection phase, my supervisor Dr. Haverkamp listened to the audio-recording and read the transcript for my first interview to ensure that I adopted an open stance and conversational style conducive to attaining a rich, concrete, detailed description of the phenomenon, and maintained an appropriate researcher-participant relationship (i.e., versus a counselling relationship). My research committee was consulted throughout the data analysis and writing processes to ensure I presented clear and persuasive descriptions of the meaning structures of the phenomenon (Langdridge, 2007; Yardley, 2000). With respect to representation of the findings, I situate the participants within their respective personal contexts (i.e., synopsis  94 of biographical information) and present thick, detailed, descriptive accounts of their experiences, augmented by illustrative quotes (van Manen, 1997a, 1997b).  Another central means for establishing credibility was member checks (Morrow, 2005; Tracy, 2010). Member checks are follow-up interviews with participants to increase the likelihood that the final report achieves resonance (Tracy). My initial interpretations (i.e., common themes) and respective biographical synopses were brought back (i.e., emailed) to each participant following completion of all data collection interviews and the initial thematic analysis. The aim of the member checks was to optimize trustworthiness and resonance of my interpretation  of  the  women’s experience and meanings of their intimate partner relationship supporting recovery from the ED. They were also used to confirm demographic information included in the biographical synopses. Each member check interview was scheduled for a mutually agreeable time and participants were given a choice of conducting the interview in person or over the telephone. All interviews occurred over the phone, and some participants provided feedback around the findings via email. The member check interviews ranged in duration from 15 to 60 minutes (M = 35 minutes).  As previously noted, findings were presented to participants tentatively,  as  “initial”  results, in attempts to ensure participants felt safe to disagree or amend in an honest and meaningful way. In this sense, my adherence to a collaborative researcher-participant relationship aimed to moderate researcher authority and power, and privilege the participants’  voices. I asked each participant whether the common themes resonated with her personal experience and meanings, that is, if this is  “what  the  experience  is  really  like”  (van  Manen,  1997b, p. 99) and if the themes captured the experience of having an intimate partner relationship support recovery from an ED. Participants were also asked questions such as “was  95 there anything in the findings that surprised you,”  “  was  there  anything you expected to see more or less of,” or “do  you  feel like anything is missing.” The purpose of these questions was to support and invite the women to provide their thoughts. It was acknowledged with each participant that some aspects of the experience, as depicted by the themes, may resonate more than others, given that the interpretation reflected the common and essential aspects of the experience,  rather  than  the  nuances  of  each  participants’  individual  experience.  During the member-check interviews, all of the participants affirmed that the common themes reflected their personal experience, and depicted the phenomenon of having an intimate partner relationship support recovery from an ED. They shared they  “felt  heard;;”  that  the  findings, and  hearing  other  women’s  voices,  were  “so  beautiful;;”  that  they  “couldn’t  believe  some  of  the  similarities”  in  experiences  among  themselves and  others;;  that  results  were  “spot  on”  and they were  “totally  shocked”  at  how  much  the  findings  resonated and reflected their experience. Some commented that reading the results was yet another reminder of how impactful their intimate relationship had been. Many women noted that they were uncertain as to whether certain illustrative quotes were their voice or not, given the similarity in experiences and extent to which they related. A few of the women acknowledged that certain themes resonated more than others, or that some themes felt most resonant or reflective of their experience. These responses were validated and normalized. Notably, throughout the member-check interviews I maintained awareness of, and grounded in, literature exploring the management of interpretive discrepancies (Borland, 1991),  to  ensure  that  all  of  the  women’s  reactions  and  responses  were  discussed and managed with the utmost ethical sensitivity. Despite finding that the results resonated with her experience, one participant observed that the overall description of the phenomenon  appeared  “very  positive,” and commented that her  96 relationship also had its challenges. We discussed this reaction to the results (see Borland, 1991). Specifically, I validated her perception, contextualized the findings in relation to the research question and purpose (i.e., focus on supportive experiences), identified the ways in which I had tried to capture the depth, dimensions, and variability in the relationships, and suggested ways I might translate some of her feedback into the findings (i.e., state more frequently or explicitly the difficulties that accompanied the support). The participant expressed understanding and agreement around all of the above. As such, I re-visited the results, identified aspects of the women’s  experience  that  may  have  included  some  reference  to  challenges  in  the  relationship,  and, as appropriate, incorporated specific statements to enhance and deepen my description through the depiction of the co-occurring support and challenges. Similarly, despite affirming that the findings fit for her, and described the phenomenon of interest, one participant queried the extent to which the theme “Mutual  Commitment” was reflective of her experience. Again, her impressions were validated, normalized, and discussed (see Borland, 1991). Specifically, we explored her thoughts and feelings about the theme, including aspects that she related to and aspects that she felt less certain about (e.g., she shared that, at times, she  questioned  her  partner’s  commitment  to  her), and discussed the nature of the interpretive process. I offered specific examples from her narrative that had informed my understanding of her experience, and this theme specifically, to illustrate my meaning making process around her experience. Over the course of our discussion, the participant acknowledged the ways in which this theme reflected her experience, and re-affirmed once again that the finding fit, albeit, somewhat less than others (e.g., for this woman “Intimacy” was a particularly salient component).  97 Finally, another participant commented that there were also instances when she felt “triggered”  by  her  partner’s  struggle  to  understand  the  ED  and  related behavior. In order to capture this variability in experience, and in light of its congruence with the feedback described above regarding relational challenges, a statement was added to the sub-theme “Sense  of  Security” in an attempt to contrast the supportive experiences (i.e.,  partner’s  ability  to  tolerate  distress and confusion around the ED), with an instance that felt less supportive, and thus, further elucidate the complexities of  the  women’s  relational experiences.    Overall, high standards of fairness and equity in representation  of  the  women’s  experiences were goals (Morrow,  2005).  However,  Finlay’s  (2002)  assertion  that  “preoccupations  with  collaboration  and  egalitarianism  can  result  in  claims  which  disguise  the  inequalities actually  present”  (p. 226) reminded me that, as I negotiated and represented the women’s  voices  and  my  own,  ultimate  responsibility  and  authority  around  representation  rested  in my hands and required tremendous ethical sensitivity (see Borland, 1991; Haverkamp, 2005).  Finally, each participant’s  biosynopsis  was  sent to her for review (i.e., for accuracy, amount and level of detail, and comfort with the information presented). Biosynopses were then edited if necessary, and have been approved by each participant.  Ethical Considerations  Given that conducting qualitative research involves multiple, complex ethical dimensions, particularly when research is being undertaken with vulnerable populations (Jones & Pye, 2012), the research process was informed by the writing of various scholars (e.g., Haverkamp, 2005; Tracy, 2010) and the Canadian Psychological Association (CPA) code of ethics (CPA, 2000) to ensure sound ethical decision making at every stage of the research process.   98  Tracy (2010) highlights four broad domains of ethical practice: procedural ethics, situational ethics, relational ethics, and exiting ethics. In brief, procedural ethics are concerned with institutional requirements, situational ethics are concerned with the specific context within which the research is being conducted, relational ethics are  concerned  with  the  researcher’s  relationship with participants and invoke an ethic of care, and finally, exiting ethics are concerned with the manner in which the researcher manages and communicates the findings (see Tracy, 2010 for detailed description). Haverkamp (2005) asserts that while procedural ethics and codes offer moderate guidance around ethical decision-making, the ambiguity often arising over the course of qualitative research, particularly within an interpretive/constructivist paradigm, requires an acute ethical awareness and sensitivity. This awareness includes knowledge of alternate, or supplemental, frameworks (e.g., virtue ethics, feminist ethics of care) to extend the reach afforded by principle ethics. Haverkamp  identifies  three  “cornerstones”  to  aid  researchers  with ethical dilemmas: the examination of foundational ethical principles, conscious application of an attitude of care, and consideration of virtuous character (p. 150). She emphasizes relational ethics as particularly salient when conducting applied research, and urges researchers to exert great caution and care with researcher-participant relationships. Within the context of said researcher-participant relationships, and the associated concerns of power, voice, and representation, Haverkamp (2005) emphasizes the imperative of attending to the inherent power imbalance  in  the  relationship.  She  suggests  that  the  researcher  adopt  a  “fiduciary  role  in  reference to...research participants...in which one party with greater power or influence accepts responsibility  to  act  in  the  other’s  interest”  (p.  151).   As I navigated my roles and responsibilities as the primary researcher conducting the study, I was cognizant of the boundaries between research and counselling when engaged in  99 long, in-depth interviews with participants on the sensitive topic of intimate partners facilitating recovery from an ED (e.g., dual roles) (Haverkamp; Jones, Pye, & Palandra, 2014; Kvale & Brinkman, 2009). I employed basic counselling skills to create a safe research relationship for participants and journaled to maintain professional reflexivity. As previously articulated, I adopted a collaborative stance at each stage of the research process to minimize the power differential, while sustaining fiduciary responsibility. For example, participants were consistently invited to ask questions and/or check-in around the progress of the research, and were provided with a formal update during the analysis phase of the research, prior to circulation of the common themes and member check interviews. In addition, participants were all invited to provide feedback and suggestions regarding the dissemination plan for the research (i.e., see Discussion chapter for further details).  Ethical procedures. A behavioral ethics application was submitted to the behavioral research ethics review board at UBC. Given my dual role as a clinician and researcher in the area of EDs I was aware that potential participants may be previous clients or individuals with whom I have had some form of clinical contact24. Likewise, there is always the possibility that a participant may seek professional support in the future and thus, the potential for future contact. I addressed these possibilities during the telephone screen and informed consent process, respectively. One woman with whom I had a previous clinical relationship expressed interest in participating in the study. During our telephone screen interview I explained that our previous relationship precludes her participation in the study and she expressed understanding around this decision. Issues of confidentiality were discussed at length during the informed consent process,                                                  24 I was previously a research assistant at the local tertiary care eating disorders program. In this position I met with many treatment seeking women for research assessments, which included a clinical interview focused on their ED symptoms and their readiness and motivation for change. Women with whom I had previous research contact were eligible for participation.  100 including use of a professional transcriptionist, management of disclosures regarding third-parties during interviews (e.g., individuals with whom participants are/were in a relationship), limits  regarding  participant  and  others’  safety, representation of findings (e.g., use of pseudonyms, use of direct quotations in documents), use of Skype technology to conduct the interview (i.e., for three participants), and communication and dissemination of findings (e.g., presentations and publications within academic and clinical contexts) (Haverkamp, 2005). Participants were also informed of the overall time commitment required for participation in the research study, including the initial interview, possible follow-up interview, and member check interview. Informed consent adhered to all institutional policies, and was considered an ongoing process, negotiated with the research participants and monitored closely as the research progressed (Haverkamp; Thompson & Russo, 2012). Risks and benefits. Potential risks and benefits of participating in the research were outlined in detail, to the extent possible in qualitative research (Halse & Honey, 2005), and discussed with participants during the initial informed consent process (Haverkamp, 2005) (see Appendix E). Although there were no clear anticipated risks associated with participating in the study, I acknowledged that the research focuses on a sensitive issue and vulnerabilities may present themselves as the women discussed their history of an ED and process of recovery (e.g., identification of issues that triggered ED behaviors, struggles associated with recovery) within the context of an in-depth interview. As such, it was acknowledged that women may experience some uncomfortable feelings during and/or after the interviews (e.g., shame around ED, sadness around losses incurred during ED, frustration around less helpful relational experiences). The women were invited to contact me at any time for debriefing and/or to discuss additional professional support if needed (e.g., referral to counsellor). Information regarding community  101 supports and resources was provided to all participants (see Appendix I) before the initial data collection interview began. As previously stated, no women contacted me about support needs, referrals, or resources following the interview. Some scholars have suggested however that participating in qualitative research can be rewarding for participants (e.g., van Manen, 1997b). van Manen indicates that participants may feel  “hope,  increased  awareness,  moral  stimulation,  insight,  a  sense  of  liberation,  a  certain  thoughtfulness”  and in some instances, experience changes in their life (p. 162). For example, it was acknowledged that the women may be reminded of the supports they received during their recovery. Indeed, the study participants consistently expressed a strong sense of gratitude for their partners and a desire for their appreciation to be known to their partners. These sentiments were re-iterated by many participants after reading the results, as they were reminded of the powerful experiences they shared with their partner. It has also been suggested that women who have recovered from an ED engage in some form of activism around the issue or a cause that is important to them (see Liu, 2011). As anticipated, several participants expressed value in contributing to knowledge regarding what they believed to be the important role of partners in recovery from an ED, and as previously noted, many of these sentiments were re-iterated upon reviewing the study findings, hence, the outcome of their contribution.  Delimitations  Several delimitations are now addressed, namely, the  study’s  conceptualization of key constructs, and delineation of inclusion and exclusion criteria. Given that participants were required to have had a previous ED diagnosis the study referenced a medical view of EDs and inevitably precluded the involvement of women who subjectively identified as having had difficulty with disordered eating and/or shape and weight concerns without meeting a clinical  102 threshold, or those who reject these labels altogether (Garrett, 1997; Halse & Honey, 2005). Similarly, with respect to the duration criteria set around recovery process and status, although both objective and subjective criteria were employed, inclusion of the empirically based criteria may have precluded the involvement of some women who self-identify  as  “recovered,”  yet,  did  not meet the outlined objective criteria. This also excluded women currently working to reduce ED symptoms, who did not yet meet the criteria. The duration criteria for length of intimate relationship also excluded women in intimate relationships of shorter durations.  During recruitment I relied on retrospective self-report accounts from potential participants to determine whether they have a history of ED symptoms meeting criteria for an ED diagnosis. Likewise, self-report was used to determine if potential participants met criteria for recovery status. Additionally, the participants were English speaking, and this requirement precluded the involvement of women who may have met inclusion criteria but were not English speaking. Given that the study focused specifically on the supportive and facilitative aspects of the women’s  recovery  and  relational  experiences,  participants must have experienced their intimate partner relationship as significant to their attainment of recovery from an ED. As such, the study excluded women who did not identify their relationship as having been particularly supportive of their recovery (e.g., women with more challenging or conflicted relational experiences, women who were in an intimate relationship but identify with other predominant sources and supports of recovery). To  this  end,  it  must  be  acknowledged  that  current  findings  illustrate  adult  women’s  experiences of having an intimate partner relationship support their recovery from an ED and do not necessarily represent the full range of recovery related experiences (e.g., supports and challenges) or fully depict the complexities of the intimate partner relationship during recovery  103 (e.g., less supportive elements, experiences that may have hindered recovery efforts). Relatedly, despite efforts to recruit widely, all participants identified as heterosexual, in heterosexual relationships. Given that the dominant Western cultural context of these women and their male partners is highly gendered, privileging heterosexual orientation and emphasizing traditional sex roles, it was deemed theoretically and methodologically sound to pursue investigation of the phenomenon of interest with this group, despite absence of same sex couples and greater diversity. The implications of this sample are discussed further in the Discussion chapter.                  104 Chapter 4: Results The research question guiding this hermeneutic phenomenological inquiry was: “what  is  the meaning of lived experience of  intimate  partner  relationships  in  supporting  women’s  recovery  from  an  eating  disorder?” This chapter begins with biographical synopses of the study participants, to contextualize the lived experience of intimate partner relationships supporting recovery from an ED described by the women (see Table 1).  These  “biosynopses”  are  followed by presentation of the essential meaning structures, or common themes, constituting the women’s  lived  experiences (see Table 2). These common themes are presented as follows: Sense of Safety, Sense of Mutual Commitment, Communication as Facilitative, Intimacy, and Sense of Identity Beyond the ED. Three of the common themes also consisted of sub-themes, specifically, Sense of Safety included the sub-themes Sense of Acceptance and Non-judgment and Sense of Security in the Relationship. The theme Sense of Mutual Commitment included the sub-themes Shared Valuing of the Relationship, Joining in Recovery, and Sense of Motivation and Accountability. Lastly, the theme Intimacy included the sub-themes Shifting Relationship to Their Body and Differentiation From Other Supportive Relationships. While the common themes are not presented in any particular order, Sense of Safety was a foundational and pervasive aspect of  the  women’s  experience, consistently woven throughout the other themes, and is therefore presented first. The lived experiences and voices of the women are highlighted throughout the text with rich, illustrative quotes.      105 Biosynopses Table 1 Summary of Participant Demographic Information Pseudonym Age Racial/ Ethnic Identity Duration of ED Treatment Time in Recovery Duration of Relationship Status of Relationship Chelsea 22 Caucasian 6 years Outpatient Residential 1 year 1 year Ended Lauren 27 Caucasian 10 years Outpatient Residential 2 years 4 years Married Paula 36 Caucasian 7 years Outpatient 10 years 11 years Married Elizabeth 27 Caucasian 10 years Outpatient 2 years 2 years Ended Sundari 39 Caucasian 8 years Outpatient Residential 10 years 12 years Ended Ruth 26 Caucasian 8 years Outpatient 6 years 8 years Married Brooke 24 Caucasian 10 years Outpatient 1 year 3 years Ended Mary 32 Caucasian 15 years Outpatient Residential 1 year 15 years Married Sally 24 East Indian 2 years Outpatient 4 years 2 years Ended Abby 32 Caucasian 9 years Outpatient 5 years 7 years Common-law Note. Mean age = 29. Mean duration of ED = 8.5 years. Mean duration of recovery = 4.2 years. Mean duration of relationship = 6.5 years. All participants and their partners identified as heterosexual. Seven of the 10 women lived with their partners. For women whose relationship had ended, three identified as having recovered during the course of the relationship and two identified  as  having  recovered  after  the  relationship’s  end.  Chelsea Chelsea is a 22-year old heterosexual, presently able-bodied, Caucasian woman. Her religion was an important aspect of her recovery and healing, and she continues to see her faith  106 as an important aspect of her life. At the time of her relationship she was studying Arts, but taking some time off of her studies, and working part time. She is currently engaged in full-time studies in efforts to complete her Bachelor’s  degree. Chelsea struggled with symptoms consistent with Bulimia Nervosa (BN) for approximately six years, starting at age 14. She also experienced difficulties with alcohol abuse and self-injury, which impacted both her recovery from the ED and her intimate partner relationship. Chelsea identifies as having been recovered for approximately one year. Over the course of her ED and recovery journey Chelsea pursued various forms of treatment, including outpatient counselling and sessions with a Psychiatrist; specialized outpatient ED treatment, including sessions with a counsellor, dietitian, and physician; and residential treatment. She also accessed support through an online support group. Chelsea and her partner met during late adolescence and early adulthood, respectively, and were together for approximately one year. Her partner, also Caucasian, held a certificate, and worked, in the area of trades. They did not live together during their relationship, and Chelsea was living at home with her parents. Although Chelsea had pursued outpatient treatment prior to meeting her partner, she was also involved in counselling and sessions with a Psychiatrist during their relationship. Her partner did not attend treatment with her. Chelsea and her partner are no longer in a relationship, and Chelsea is currently single. Notably, Chelsea found that the ending of this intimate relationship was an incredibly significant turning point in her recovery. She shared that the loss of this relationship was extremely motivating of change and fueled her pursuit of further intensive treatment, specifically, enrolment in a three month residential treatment program, and led to her full recovery.    107 Lauren Lauren is a 27-year old heterosexual, presently able-bodied, Caucasian woman. During the period of her recovery with her partner, she was completing a college diploma in the area of social services and now works with children, and also, in the area of aesthetics. Lauren struggled with symptoms consistent with Anorexia Nervosa (AN) for approximately one year, starting around age 13, and subsequently, symptoms of Bulimia Nervosa (BN), for approximately nine years. Lauren identifies as having been recovered for approximately two years. Over the course of her ED and recovery journey she pursued outpatient treatment with a specialized ED program, including sessions with a Psychologist and dietitian, respectively, medical monitoring with a physician, and both individual and group therapy. She also completed a residential program, and returned to the outpatient program for further support upon completion of the intensive, three month long residential  program.  While  the  majority  of  Lauren’s  ED  treatment  occurred  prior  to  her relationship, she continued to see a counsellor during the early stages of her time with her partner.  While  Lauren’s  partner  was  not  involved  in  her  treatment,  he  remained  actively involved in her recovery efforts and translation of skills and strategies from treatment into their every day lives.  Lauren’s  partner  is  also  Caucasian,  and holds a certificate, and works, in the area of trades. Lauren and her partner met in their mid-twenties. They met through mutual friends, and have been together for approximately four years. Lauren shared initial apprehension about entering an intimate relationship, however, indicated that over time and through the establishment of a friendship with her partner, she opened up to the romantic relationship. They moved in together shortly after initiating an intimate relationship, are now married, and since the time of our initial interview have welcomed their first child into the world.    108 Paula Paula is a 36-year old heterosexual, presently able-bodied, Caucasian woman. She shared that she has a learning disability, which affected her self-esteem and experience with education growing up. During her recovery, and the associated period of time in her relationship, she was pursuing studies in the social sciences.  She  now  holds  a  Master’s degree and works in the area of social services/healthcare. Paula found both Eastern philosophy and Aboriginal healing practices to be significant to her recovery from the ED and healing process. In particular, she felt that Aboriginal healing practices were important to her intimate partner relationship, and continue to be central in their lives and relationship. Paula struggled with symptoms consistent with Anorexia Nervosa (AN), including purging, for approximately seven years. She shared that symptoms emerged in her late adolescence, and worsened around age 19. She first connected with treatment around age 21, at which point she consistently attended medical monitoring appointments with her physician, and participated in some adjunct therapy as part of her treatment and recovery journey. She identifies as having been recovered for approximately 10 years. Paula and her partner met when they were in their mid-twenties. They moved in together after dating for a year, and following a year and a half of living together, separated for six months before re-uniting. Paula shared that her partner struggled with alcohol and substance use, and that this affected their relationship. Paula and her partner have now been together for over 11 years,  and  are  married  with  a  child.  Paula’s  partner  is  36  years  of  age,  Aboriginal, and college educated. At the time of her recovery, he was working in the trade industry, however, now works with youth. During their relationship Paula continued to see her physician and pursue arts-based therapy. While her partner was not involved in her professional ED treatment, as previously noted they engaged in Aboriginal healing practices together and he was therefore present for this  109 part of her healing process. While her partner was less actively involved in supporting her to make ED related changes, she believes their creation of a life and involvement in pursuits together was particularly significant to her recovery journey and healing. Notably, Paula shared that the birth of their child was a final milestone in her recovery process, as she gained a growing acceptance of her body after pregnancy and birth.  Elizabeth Elizabeth is a 27-year old heterosexual, presently able-bodied, Caucasian woman. At the time of her relationship she was enrolled in full-time studies, working towards an undergraduate degree at university. She now holds a Master’s degree and works in the area of social services/healthcare. Elizabeth struggled with symptoms consistent with Anorexia Nervosa (AN) and Bulimia Nervosa (BN) for approximately ten years, starting at age 15. She shared about her family environment growing up, namely, perceived pressures to be thin and restrict the nature and amount of food eaten, and the ways in which she feels this influenced the development of her ED and her relationship to her body. Over the course of her ED and recovery journey Elizabeth pursued outpatient counselling with a Psychologist and medical monitoring with a physician. She identified as being in recovery for approximately two years. Elizabeth and her partner met in late adolescence, and were both attending university, where they were living in residence.  Elizabeth’s  partner,  also  Caucasian,  was  studying at the time of their relationship, and has now completed a graduate degree. They were together for approximately two years. They did not live together during this time, however they lived in the same residence on campus, and during breaks from school  spent  time  at  each  other’s  respective  home  towns.  During  the  relationship Elizabeth pursued outpatient counselling, however, her partner did not attend this treatment with her. Elizabeth noted that while she feels her partner would have been open to  110 attending treatment with her, she preferred to pursue this independently. Elizabeth shared that her partner had increased knowledge about EDs due to his lived experience with supporting a family member with an ED. She acknowledged that, at times, this appeared to increase his overall sense of anxiety around her ED, but also aided him in providing support to her. Elizabeth and her partner are no longer in a relationship. At the time of our interview she was single, but has since entered a new intimate relationship.  Sundari Sundari is a 39-year old heterosexual, presently able-bodied, Caucasian woman. During her recovery, and the associated period of time in her relationship,  she  held  a  Bachelor’s degree and was working in the area of social services/healthcare. She now holds a Doctor of Philosophy degree and continues to work in the area of social services/healthcare. Sundari struggled with symptoms consistent with Bulimia Nervosa (BN), including fasting and over-exercise for approximately eight years. While she experienced some ED symptoms as an adolescent, symptoms worsened during her twenties. She identifies as having been recovered for approximately ten years. Over the course of her ED and recovery journey she pursued various forms of outpatient treatment, including therapy with a Psychologist, therapy with a Social Worker, medication monitoring with a Psychiatrist, sessions with a Dietitian, and group therapy. Sundari and her partner initially met during their late adolescence, prior to the onset of her ED, and many years prior to entering an intimate relationship with each other in their late twenties. They had a romantic relationship when they were younger, and although they separated they stayed in touch over the years; they ultimately re-united and married. Her partner, age 40 and also Caucasian, works in the area of trades. In the early stages of their intimate relationship Sundari pursued intensive ED treatment. Shortly after completing this treatment, Sundari and her  111 partner married and moved in together. Her outpatient treatment continued throughout their relationship, and she considered it to be a significant resource in her recovery. To this end, she felt that many of her support needs were met by virtue of professional treatment, and also, that engagement in treatment increased her sense of what she needed and what would be helpful in terms of her intimate relationship supporting her recovery. Sundari and her partner were together for  approximately  12  years,  during  which  time  they  had  a  child.  Sundari’s recovery occurred within the first several years of their relationship. They have since separated and divorced, and Sundari is currently single. Sundari reflected that the aspects of their relationship and relational qualities of her partner that proved instrumental to supporting her in her recovery, were also related, in some ways, to the eventual ending of the relationship. She noted that as she attained recovery and left the ED behind, her needs and desires shifted, and acknowledged that this may have played a small role in changes, and separation, in the relationship over time.  Ruth Ruth is a 26-year old heterosexual, presently able-bodied, Caucasian woman of Christian faith. During her recovery, and the associated period of time in her relationship, she was completing  a  Bachelor’s degree at university.  She  now  holds  a  Master’s degree and works in the area of social services/healthcare. She struggled with symptoms consistent with Anorexia Nervosa (AN) and Bulimia Nervosa (BN) for approximately eight years, starting around age 12. She shared that her symptoms worsened over time, and were most serious in her mid- to late-adolescence (i.e., age 15-19). She identifies as having been recovered for approximately six years. Over the course of her ED and recovery journey she pursued specialized outpatient treatment, which included both individual and group therapy, and follow-up with a Psychiatrist; she also accessed online resources and supports. Ruth and her partner met in late adolescence  112 and early adulthood, respectively, and have been together for approximately eight years. They dated for four years, and were then married; they began living together following marriage. They do  not  have  any  children.  Ruth’s  partner,  also  Caucasian  and  of  Christian  faith,  was  also completing  a  Bachelor’s degree and working part time during her recovery. He now has several occupations and pursues work in education. Ruth shared that her partner was a strong motivator for her to seek professional treatment, and she had not been involved in any specialized ED treatment prior to the relationship. She began ED treatment approximately four to six months into their relationship. While her partner did not attend any treatment with her, he accompanied her to appointments, and she felt he was very interested and involved in this aspect of her recovery process. Brooke Brooke is a 24-year old heterosexual, presently able-bodied, Caucasian woman. During her recovery, and the associated period of time in her relationship, she was completing a Bachelor’s degree at university and working part time.  She  now  holds  a  Bachelor’s  degree and currently works in marketing. Brooke struggled with symptoms consistent with Bulimia Nervosa (BN) for approximately 10 years. She began to experience ED symptoms in early adolescence, around age 13, however, her symptoms worsened in her late adolescence (i.e., between the ages of 15-20). She identifies as having been recovered for approximately one year. Over the course of her ED and recovery she pursued various forms of outpatient treatment, including counselling, sessions with a Psychiatrist, sessions with a Psychologist, and follow-up with a physician. She was involved in this treatment during her relationship, and her partner attended several counselling sessions with her. She acknowledged that the most intense and significant period of her recovery was while she was in her intimate relationship with her partner. Brooke and her  113 partner met through work when they were in their early twenties. They were together for approximately three years, during which time they lived together for a period of time. Her partner, also Caucasian, held a vocational degree and worked in a trade. Brooke and her partner ended their relationship approximately six months ago, and she is currently single. She noted that aspects of their relationship that had proved essential to her recovery, also contributed to the ending of the relationship. That is, over time, as her needs and hopes changed, she felt that the relationship was no longer optimally  conducive  to  her  and  her  partner’s  growth.   Mary Mary is a 32-year old heterosexual, presently able-bodied, Caucasian woman, of Christian faith. During her recovery, and the associated period of time in her relationship, she was pursing an undergraduate degree. She now holds a university degree in a health care field and a post-graduate college certificate, and works in healthcare. Mary struggled with symptoms consistent with Bulimia Nervosa (BN) for approximately 15 years, starting at age 16. She identifies as being recovered for approximately one year. Over the course of her ED and recovery journey she pursued various forms of treatment, including outpatient counselling and residential treatment. She was involved in this treatment at various points during her undergraduate studies, and completed residential treatment during the course of her relationship with  her  partner.  Mary’s  partner  was  involved  in  her  ED  treatment,  in  that  he  accessed  resources  for family members and attended some counselling sessions with her. Mary and her partner met in late adolescence and early adulthood, respectively. They have been together for approximately 15 years. They first moved in together when Mary was 19, however, lived apart for periods of time, while Mary pursued school  and  her  partner  served  in  the  Military.  Mary’s  partner,  also  Caucasian, now holds a college degree in the area of public services, and is currently pursuing  114 further studies. Mary and her partner married when Mary was 26, and they now have two young children. According to Mary, her family and children played a significant role in her attainment of recovery. Sally Sally is a 24-year old heterosexual, presently able-bodied, East Indian woman. Her Eastern religion was an important aspect of her recovery. During the time of her recovery and relationship, Sally was engaged in full-time studies at university. She  now  holds  a  Bachelor’s degree and is currently pursuing graduate studies in a professional field. Sally struggled with symptoms consistent with Anorexia Nervosa (AN) and EDNOS for approximately two years. While she began to experience ED symptoms in her late adolescence, symptoms worsened in her early twenties. She identifies as having been in recovery for approximately four years. Over the course of her ED and recovery journey she pursued outpatient counselling with various practitioners, and group therapy through her university. She was involved in this treatment during her relationship with her partner, however, felt that she had already begun her recovery process  upon  meeting  him.  Sally’s  partner  attended  some  counselling  sessions  with  her,  and  was  actively involved in her recovery, namely, supporting her to practice and employ alternate coping  skills.  Sally  shared  that  her  partner’s  interest  in  her experience with the ED, and engagement in her recovery process, contrasted her experience with her family and was particularly important to her experience of support. Sally and her partner met in their early twenties and were together for approximately two years. Her partner, also East Indian, held a Bachelor’s  degree and was pursuing a graduate diploma at the time of their relationship. Sally shared that they practiced different religions, although both of Eastern origin, and she felt that this was very helpful to her recovery, as it offered her another way of thinking about her  115 wellbeing and healing. Sally and her partner did not live together during their relationship, and Sally lived at home with her family. While Sally and her partner are no longer in an intimate relationship, they maintain a friendship.   Abby Abby is a 32-year old heterosexual, presently able-bodied, Caucasian woman. During the time of her recovery and relationship she was pursing her undergraduate degree. She now holds a Bachelor’s  degree and is currently pursuing graduate studies in the social sciences. Abby struggled with symptoms consistent with Anorexia Nervosa (AN) and Bulimia Nervosa (BN) for approximately nine years, starting at age 17. She identifies as being recovered for approximately five years. Over the course of her ED and recovery journey she pursued various forms of treatment, including outpatient counselling, sessions with a dietitian, family therapy, and medical monitoring with her physician. Abby and her partner met their mid twenties and early thirties, respectively, and have been together for approximately seven years. They identify as common law partners and were living together during her recovery. Her partner is Caucasian, holds a Bachelor’s  degree, and works in the area of trades. Abby was involved in extensive ED treatment prior to entering her intimate relationship, however, her outpatient counselling and sessions with a dietitian continued during her relationship, and she identifies this work as being particularly significant to her attainment of recovery due to her greater level of readiness and motivation for change at that time in her life. Although her partner did not attend treatment with her, he supported her decision to relocate for a period of time in order to pursue this treatment. Abby shared that her relationship was a significant motivator for pursuing further treatment and working towards recovery.    116 Common Themes The thematic analysis generated five common themes, which are now presented as follows: Sense of Safety, Sense of Mutual Commitment, Communication as Facilitative, Intimacy, and Sense of Identity Beyond the Eating Disorder (see Table 2). Table 2 Common Themes and Sub-themes Common Themes Sub-themes Sense of Safety Sense of Acceptance and Non-judgment  Sense of Security in the Relationship Sense of Mutual Commitment Shared Valuing of the Relationship  Joining in Recovery  Sense of Motivation and Accountability Communication as Facilitative  Intimacy Shifting Relationship to Their Body  Differentiation From Other Supportive Relationships Sense of Identity Beyond the Eating Disorder   Sense of Safety All of the women in the study described a deep sense of emotional, psychological, and relational safety in their relationship with their partner. This sense of safety permeated their experiences and was viewed as being fundamental to their recovery process. While safety manifested itself in a variety of different ways for the respective women, it was consistently  117 associated with a sense of acceptance for who they are, a sense of non-judgment on behalf of their partners, and a sense of security in the relationship.  The  perceived  sense  of  feeling  safe  was  a  foundation  for  the  participants’  change  efforts,  and remained integral to their engagement in the recovery process over time. The women consistently associated a sense of safety with their ability to manage and overcome feelings of anxiety  and  fear  associated  with  both  the  ED  and  the  “letting  go”  of  the  ED.  That  is,  a  sense  of  safety within their relationship was described as an essential component of approaching and exploring their ED behaviors and the role and function of the ED in their lives. Thus, for these women, a sense of safety enhanced their capacity to change their relationship to the ED. One woman  described  experiencing  the  security  of  a  “safety  net,”  having  someone  there  to  “catch  you,”  and  the  comfort  this  afforded  as  she  worked  towards  recovery.  She  shared  the  following  about her experience: …it  was  like a big warm blanket that you need when you just wanna, you just need some time to be nice to yourself and just to kind of step away from always feeling not worthy or not good enough or not pretty  enough  or  not  skinny  enough…it’s  not  that  it  fixed  it,  it  just kind of made it feel not as bad, and then when it didn’t  feel  as  bad  or  as  strong  then you can kind of you know, start fighting. For the women in this study, that sense of comfort within their relationship provided some respite from the internal dialogue and negative self-perceptions maintaining the ED, and contributed  to  the  sense  of  safety  and  “space”  required  for  the  work  of  recovery: …the comfort was paramount in my recovery just because I had felt so uncomfortable with myself in the way  that  I  couldn’t  just,  I  couldn’t  give myself the permission to get better  because  I  didn’t  think  I  deserved  it. And when I felt that anxiety of who I was, was  118 kind of alleviated, even temporarily, it kind of gave me some room to give me permission to really start working on recovering. It appeared that, for these women, a sense of safety was inherently related to their capacity to be vulnerable in the relationship and with recovery; that is, an ability to be vulnerable appeared to be a key precursor to experimenting with new ways of being, relating, and behaving. One  woman’s  words  captured  this  experience,  as  she  shared  that  safety  afforded “the  space  for  [the ED] to be there in our relationship, to sort of explore and come to know, rather than it always being something I was hiding and ashamed of.” Indeed,  the  women’s  capacity  to  be  vulnerable within the safety of their relationships afforded them opportunities to take risks in their recovery, including being able to speak openly with their partner about a range of recovery related experiences, being able to identify and process distressing emotions, and/or being able to challenge themselves around eating. One woman shared how her partner “helped  [her] with the bravery component of healing”  because  he  was  there  by  her  side;;  she  felt  she  “had somebody”  with her in her life. She shared the many ways in which this partnership encouraged her to open up to life, its possibilities and its gifts, versus remaining within what had in many ways been experienced as the safe, yet restrictive confines of her ED. This illustrates how, for many women in the study, the relationship came to provide the safety that was once ensured by the ED. The women described the ways in which, over time, this sense of safety and the development of new capacities it afforded reduced their reliance on their ED and de-stabilized the functions it was serving. They described the establishment of new ways of coping, and emphasized safety as a key aspect in their growing capacity to manage any discomfort and challenges associated with the recovery process.   119 Sense of acceptance and non-judgment. Integral  to  the  women’s  sense  of  safety  in  their  intimate relationship was their experience of acceptance and non-judgment on behalf of their partners. All of the women shared a profound sense of being accepted by their partners, and closely tied to this sense of acceptance was a sense of non-judgment. The women described feeling accepted by their partners for all aspects of their being, the wanted and unwanted aspects of self. They felt completely  seen  by  their  partners,  “the good, the bad and the ugly, in so many different  ways,”  and  felt  no  judgment.  One  woman’s  words  illustrate  the  power  of  being  in  this  relational climate, in terms of her recovery process: I really needed to be in a non-judgemental space, and for me to go through my process what was really fundamental was that non-judgemental kind of non-conditional loving space…I  think  really  what  was  essential,  at  the  core,  was  being  in  an  environment  where  I was accepted, there was no judgement and I felt loved...and that alone, feeling loved, feeling acceptance, feeling non-judgement,  feeling  I’m  okay  as  I  am,  feeling  care  and  the  responsiveness,  all  of  that  helped  me,  you  know,  even  though  it’s  not  like  directly  helping  me in a specific way,  it  helped  me  to  be  able  to  take  that  journey  and  to  go  through  it…I  could go through it and I could complete it. It was like a safe container, it was like the safe womb space. Many  women  described  feeling  as  though  they  were  “enough”  in  their  relationships, in contrast to the image and sense of self as insufficient, or of not meeting their own expectations or the perceived expectations of others. Reflecting the experience of many other women in the study, one participant shared the constant sense of pressure she lived with, and the release from expectations that her intimate relationship afforded her:  120 You’re  just  carrying  so  many  different  things  on  your  shoulders,  so  being able to just feel like  you’re  enough  is  huge  because  you  never,  you  never  feel  like you’re  enough  or  you’re  doing  enough  or you’re  going  to  amount  to  enough.  And so to be in a relationship where they value just who you are right now and really  make  that  known…he’s  very  good about validating just who I am right now and validating me for me, not me because of my work or because of how much I did in a day or  whatever,  [that’s]  huge. The  women  shared  a  sense  of  relief  as  they  described  experiencing  some  “space”  and  distance  within their intimate relationship from distressing thoughts and feelings associated with, and fueling, the ED. In the words of one participant:  He  was  a  giant  place  for  me  to  be  able  to  just  like  step  away  from  all  the  pressures  I’d  put  on myself and all the pressures that, you know, that breathing room, he just provided that in so many ways for me. The words of another participant re-iterate the value the women placed on these relational qualities  and  the  climate  they  created.  In  particular,  this  participant’s  words  highlight  the  sense  of  peace the acceptance and non-judgment afforded these women:  …the possibility that I could just be and continue, like, just be [myself]…the way that I was, and  didn’t  have  to  keep  striving  towards  something was like this incredibly sort of calming…like  you  can  relax…that was sort of how that felt. Indeed, the women were unanimous in that they felt  able  to  just  “be” with their partners, without needing to change themself or be different, and that this was powerfully healing. These words were echoed by yet another participant who shared the sentiment that being with her partner can be “so  calm…it’s  a  really  peaceful  place  when  I’m  with  him,”  which  for  her,  contrasted  with  the  constant sense that she needed to be or do something different, something more.   121 Of particular importance to the participants’  experience  of  acceptance  and  non-judgment was  their  partners’  demonstration  of  openness  around  the  women’s  experience  of,  and  struggle  with, the ED. Several participants described how liberating this was, as illustrated here by one woman: I feel like I was really trapped in a lot of ways, and so it was a kind of freeing for me to be known by someone and to be accepted in that way…with a lot of people I had felt like they  like  me  because  they  don’t  know  this  about  me, or  I’m  okay  with  this  person  because  they  don’t  know  this  about  me, and for this person to know this about me and still like want to love me and be close to me and to be my significant other, it really influenced how I looked at myself. These sentiments were echoed by another woman, who shared: I was always terrified that once he found out, and once he knew just how crazy I was, he’d  run  away  – and I would not judge him for doing so. But to – when they stick it out and they talk to you, you realize, maybe  I’m  not  as  crazy  as  I  think  I  am. Indeed, the majority of the women spoke emphatically about the positive impact of experiencing acceptance and non-judgment with respect to their ED, despite the fact that their partners did not fully comprehend the reasons for their ED and/or symptoms. Partner acceptance and non-judgment in spite of not understanding, relating to, or agreeing with the ED resonated profoundly with the women and served to deepen and strengthen the value and validity of their overall sense of acceptance. As captured by the words of one participant: Seeing that he was willing to still support  me  and  be  by  my  side  while  he  still  didn’t  understand it, was something that meant a lot me. So  even  though  he  didn’t  get  why  I  was  doing it to myself, he still wanted to understand or be there, and I remember him saying  122 like, ‘I  won’t get  why  you’re  doing  this,  I  don’t  think  I  will  ever  get  why  you’re  doing  this, but I still wanna be with  you.’   The  women  believed  that  their  partner’s  ability  to  sit  with, or manage, their own confusion, uncertainty, and/or frustration around the ED, while simultaneously providing support, was deeply  affirming  of  their  partners’  commitment  to  them  and  their  recovery. To this end, the women expressed awareness around the challenges their partners may have experienced in their efforts to provide support. Relatedly, several women described feeling compassion from their partners. They shared an  appreciation  for  their  partner’s  extension  of  kindness  in  response  to  their  experience  with  the  ED, despite their partner’s  struggle  to  understand  or  relate  to  the  ED.  Reflecting  the  experience  of  many  women  in  the  study,  one  participant  described  the  ways  in  which  her  partner’s  acceptance, non-judgment, and openness reduced her sense of isolation in her ED:  I felt like no one understood me, even professionals at the time. I had had bad experiences and I had felt like there was no hope for me. So  when  he  told  me  that  he  didn’t  judge  me  for  it  and  that  he  didn’t  understand  but  that  he  would  try  to,  it  made  me  believe  again that maybe  someone  would…even  though  he  didn’t  understand,  he  had  a  desire  to, and that comforted me. Similarly,  another  participant  viewed  her  partner’s  compassion  as  a  reflection  of  his  ability  to  connect to her deeper struggles and suffering as she fought to overcome the ED:  …that  flavour  definitely  carried  through  for  most  the  time,  just  this  kind  of  unconditional  acceptance  and  compassion,  even  though  he  couldn’t  understand  everything,  that  was  okay…he  couldn’t  understand  everything  but  he  could  still be compassionate about it and support  me  without  needing  to  understand…there  was  a  love,  there  was  a  gentleness   123 towards  me  and  even  though  he  couldn’t  understand  the  details  of  what  this  is  or  why  I  needed what I needed, there was still a love and an acceptance and a deeper understanding…he  understood  on  a  different  level.  Even  though  on  one  level  he  didn’t  get the whole eating disorder thing, but he understood the deeper struggle. Acceptance, non-judgment, and compassion appeared to be powerful antidotes to the feelings  of  shame  characterizing  the  women’s  experience  of  their  ED.  Being  both  fully  witnessed  and accepted, in and of itself, appeared to be healing for these women, as it served to challenge some of the negative beliefs underlying the ED and compromising their wellbeing. One woman captured  the  healing  power  of  her  partner’s  acceptance,  and  how  the  gradual  internalization  of  her  partner’s  messages  changed  her  relationship  to  herself  and  her  ED: …in my eyes I was flawed, maybe in his I was too, but it  was  like  it  didn’t  matter  because  he still  loved  me,  and  that  wasn’t  important…it was that much more of a powerful message to get, that one of compassion and acceptance and love and worth and all the rest, because I was so wrapped up in this struggle of  thinking  I  was  fat.  So,  yeah…the confidence began to grow and the self-worth and the self-compassion and um, the shame and the self-hatred and all those sorts of things began to sort of like, shrink a little bit. For many women shame was associated with avoidance, with remaining hidden – be it from aspects of themselves and/or their ED. The women noted the consequences of avoidance, namely,  a  sense  of  ‘stuckness’  in  their  ED  and  immobility  in  their  efforts  to  change  and  recover.  They described a consequent struggle to attend to, and address the ED, and feeling entangled with the mechanisms maintaining their ED, including feelings of low self worth or efficacy, and/or feelings of fear and self-doubt. Reflecting the experience of the other participants, this woman described the relief associated with feeling fully seen and accepted by her partner:  124 …being  able  to  expose  yourself  so  much  to  someone  kind  of  lets  you  know  that  you  don’t  really have anything else to be afraid of. Because I think a lot of fear has to do with showing another person your darkest places, and having that already on the table you don’t  have  to  really  be  afraid  of  that  anymore,  ‘cause  it  just  is  what  it  is…they know your best parts and darkest parts, and what’s  going  on  in  your  life, and some things you might be  ashamed  to  expose  so…having someone that you can feel comfortable enough to tell all those things to or share all those things with, I mean that in itself kind of eliminates the fear. For  these  women,  their  partner’s  acceptance,  non-judgment, and compassion, and the sense of safety they instilled, appeared to create the conditions essential to recovery. Another participant illustrated the relationship between acceptance and space for healing: …as  far  as  what  I  needed,  especially  in  that first year of my recovery, was I just really needed a container or a womb space where I could completely you know, be held or be accepted  for  who  I  was…he  was  just  like  a  beautiful  holding  space  that  sort  of  allowed  my journey without you know, getting involved, or demanding that I be a different way, or expressing his discontent with me. And I think that was probably pretty huge because I think that was at a time in my life where I guess I just really needed to be completely accepted for who I was, so I could just internalize that myself. Another  example  of  these  facilitative  conditions  was  captured  by  the  women’s  experience  of  disclosing their ED to their partners. Many participants shared their felt sense of acceptance and support in response to their disclosure. In the words of one woman: …a very supportive, understanding, compassionate [response], a lot of that sort of lifted and it was like ah, relief. And it was still there, and it was still heavy, and it was still  125 painful, but it was like okay, there it is, wow you know, I said it. And then it gave space to talk  about  it  and  I  think  that…the shame continued to kind of strip away or be broken up…which allowed for me to be able to bring more attention to it, because you know, without that shame being there I was able to actually think about it.  Relatedly,  most  participants  shared  that  their  partner’s  acceptance  and  non-judgment contributed to their ability to make behavioral changes around the ED, including changes to their eating, as depicted by this woman:  …so  instead  of  feeling  guilty  or  bad  or  ashamed  that  I  have  to  eat  food  in  this  way,  for  now,  for  me  to  be  okay,  it  was  completely  accepting  that  this  is  how  it  is  now,  and  I’m  going to respect and honour that. And I had control to do that, like no one was going to tell me otherwise or make fun of me or make me feel ashamed. Overall, in contrast to the encompassing nature of the ED, and associated feelings of shame  and  immobility,  the  women’s  experience  of  acceptance  and  non-judgment in their intimate relationship appeared to foster a sense of separation from ED related thoughts and feelings. This distancing afforded participants opportunities for change; specifically, the women consistently shared that within the safety of their relationship, they felt more capable of approaching their ED and underlying issues and needs, which they viewed as paramount to recovery.  Sense of security in the relationship. Contributing further to the sense of safety described  by  the  women  was  their  sense  of  “security”  in  their  relationship.  Security  was  established in various ways, and included the belief that their relationship with their partner was not contingent upon their recovery from the ED; importantly, this was true for all women in the study, including those for whom their intimate relationship had since ended. Security was  126 manifest through a sense of reliability or consistency in the presence of their partner, including their  partner’s  availability,  and  the  experience  of  unconditional  regard  and  support  from their partner. To this end, many women voiced trust that their partner would be there for them, no matter  what.  One  woman  described  this  as  a  deep  sense  of  connection  and  “grounding,”  and  spoke  of  the  ways  in  which  the  “security”  of  this  “attachment”  allowed her to experiment with making changes: …if you have one anchor person, one person that you can go to and you know, their behaviours may not be great and there may be challenges to them, but you know that their intentions towards you are good. And, and if  you  have  that,  then  you’ve  got  the  attachment where you can start to go… This  experience  reflects  the  women’s  shared  sense  that  their  partners  provided  a  starting  place,  “home  base,”  or  “secure  base”  for  growth and engagement in recovery. It also acknowledges the women’s  identification  of  challenges and complexities in their relationships, and in doing so, illustrates the perceived value the women attached to their partner’s  commitment  and  support.  For  participants  in  the  current  study,  the  relationship’s supportive qualities were experienced as being prominent and strong enough to overcome the relational and recovery-related difficulties encountered along the way. Similar sentiments were captured in the words of another participant, which highlight the ways in which trust pervaded these relationships, and contributed to the sense of security: …knowing  they’re  gonna  be  there,  like depending on someone, that you’re  not  gonna  have to keep checking behind you and making sure  that  they’re  gonna  be there supporting you all the time. You  can  just  trust  that  they’re  there  and  then you can kind of just go and dive into whatever you’ve  been  scared  to…that  they’re  gonna  still  be  there  and  pick  it  up   127 and  we’ll  try again…that’s  what  let me kind of give myself that room to go there with my recovery. The  women’s  sense  that  their  relationship  with  their  partner  was  not  contingent  upon  recovery from the ED appeared to contribute markedly to their feelings of safety and security in their relationships. Indeed, for these women, the sense of security relieved them of a sense of “pressure”  or  expectation  to  change,  and  the  anxiety  associated  with  perceiving  such  pressures.  One  woman  recognized,  that  “as significant as [the ED] was in [her] life, it was never something that he was willing to part with [her] over.”  As  previously  noted,  this sentiment was reflected in all  of  the  participants’  experiences,  including  the  women  whose  relationships  eventually  ended, and the two women who attained recovery after their relationships had ended. Relatedly, several women observed that their partners were not afraid of, or overwhelmed by, the ED, which was viewed  by  the  women  as  contributing  to  their  partner’s  stability,  consistency,  and  availability.   Participants’  belief  that  their  partners could ultimately tolerate and withstand the women’s  experiences and struggles with  the  ED  further  promoted  the  women’s  sense  of  security.  In describing her experiences of this over time, one woman spoke of the trust and faith she had in her partner, in light  of  his  consistency  and  availability.  She  shared  that  she  “knew  that  he  wasn’t  gonna go anywhere, and [she] knew that  he  wasn’t  scared  or  overwhelmed  by  [the  ED].” Like many of the participants, particularly those in longer-term relationships, she reflected that the presence of these relational qualities, and the security they endowed, enabled her to risk experiencing the vulnerability necessary for recovery. Some participants noted however, their partner’s  “frustration”  around the ED behaviors and difficulties of achieving change; these women’s experiences highlight what appeared to be variability  in  partners’  responses  to  the  ED, and their ability to cope with and navigate the ED. It was noted by one participant that when her  128 partner struggled to understand her ED related behavior and voiced distress around it, she felt triggered (i.e., leading to thoughts, feelings, and behaviors that she was ultimately trying to change). Another woman commented that she viewed her  partner’s  distress  with compassion, and acknowledged it to be an understandable aspect of being witness to the ED and recovery process; she explained that by adopting this view of  her  partner’s  experiences,  she  was  able  to  manage her own reactions and remind herself that he was grounded in a place of concern. The  women’s  experience  of  their  partners  as  reliable,  consistent,  and  available,  across  their recovery related needs and experiences, also contributed to a sense of unconditional support. This sense of unconditional support reinforced the participants’  sense  of  safety  and  security in the relationship, and increased their trust in their partner and the strength of their relationship. One woman was emotionally moved as she reflected on this aspect of her experience: …if I needed to ask for more help, he would just be there, and if I was struggling, he would be there, and he was just so  steady.  Like  that’s  the  one,  he’s  always  steady, not always, he has a lot of ups and downs of his own, but  he’s  there  for  me  in  a  way  that  I  don’t  think  I’ve  ever experienced someone being available to me, I never had that growing  up…I  think  I  tried  to  push  him  away  so  many  times  and  he’s  just  always  there and  I’m  like,  oh  my  God,  to  have  that, it shifted everything.  This  woman’s  experience  beautifully  captures  the  value  participants’  placed  upon  partners’  consistency,  and  the  security  it  instilled.  She  recognized  and  appreciated  her  partner’s  own  experiences and challenges, and the presence of struggles and disconnects in their relationship over time, and thus, felt deeply touched that in spite of this, he remained open and available as a grounding place and support to her. To this end, it appeared that for the majority of these  129 participants, steadiness and consistency were established over time, as the couples navigated the “ups  and  downs”  of  both  partners, and the relationship itself. Reflecting the experience of many women in the study, one participant described the importance of the security she experienced in her intimate relationship, with particular focus on the continuity it afforded throughout her recovery process, in relation to other supports: …it  was  the  primary  grounding…like  it  was  my  home  space,  was  with  him,  or  where  we  were, and it was like the primary grounding, solid support. Where I would go out you know,  to  see  a  psychiatrist  or  I’d  go  out  to  the  group  therapy  or  I’d  go  out  to  my  counsellor and process different pieces but he, and the home there with him, was like the, was the one constant. Um, yeah very constant, very steady and just al- always there during that time whereas you know, these other supports for little pieces, but this was just very grounding, it was very steady, it was this solid foundation of support. Participants’  sense  of  security  in  their  relationship  was  intimately  related  to  their sense of trust  in  their  partner’s  capacity  to  support  them  unconditionally,  including  their  partner’s  acceptance, non-judgment, compassion, availability, and consistency. Trust was in turn essential to  the  women’s  overall  sense  of  safety,  and  thus,  their ability to be vulnerable and open in their relationships and throughout their recovery.  Sense of Mutual Commitment All of the women described a sense of shared commitment and investment, between them and their partner, to each other and the relationship and to recovery from the ED. The women described a shared valuing of the relationship, and an associated sense of unity around efforts to foster the relationship. The women also described a joining in recovery from the ED, a sense that both they and their  partners  were  invested  in  the  process.  To  this  end,  the  participants’  described   130 the experience of partnership – in both relationship and recovery. The women all described the sense of motivation this mutuality instilled, and emphasized the sense of accountability that took root within this shared investment in the relationship and recovery process.  Shared valuing of the relationship. The women experienced a strong, mutual valuing of their intimate relationship. They experienced both themselves and their partners as being invested in each other, and in making the relationship prosper. As they described their commitment to the relationship, the women spoke of compromise and working together, being “open  minded”  and  “flexible,”  “being  on  the  same  page,”  and  needing  to  “shift  perspectives”  at  times. To this end, the relationship was often experienced as a partnership, characterized by efforts to attend to, and respect, each  partner’s  needs.  Several women acknowledged the ways in which the ED interfered with, or rendered more challenging, their efforts to be optimally present and available in the relationship, yet re-iterated their desire and efforts to do so. One woman commented,  “your  partner  is  there  and  living  it  with  you,  and  if  it’s  going  to  work  then  there’s  got  to  be  some  kind  of  give  and  take  a  little  bit.”  She  acknowledged,  “I  need  to  be  able  to  accept  what  he’s  gonna  say,  and  understand that  he’s  living  with  me, and  it’s  not  always  easy  for  him, but also, he needs to be mindful that [recovery is] not straight  up  hill,  it’s  definitely  a  rollercoaster.”  Echoing  the  words  of  other  participants,  the  following  woman  voiced  her  deep  gratitude for her partner and the shared valuing of their relationship she experienced. In particular, she captures the sense of commitment experienced by the women in this study: It’s  like  I  have  the  root  of  this  relationship  that  provides  more  happiness  than  anything  could, and anything has, and that’s  what matters. And I feel like we, I keep coming back to that with him, because  that’s  the  focus.  It’s  just  constantly  making  sure  that [we’re]  doing everything we can to  make  sure  that  we’re  contributing  to  that…and  that  it’s  not   131 just  about  me  and  what  I’m  doing, and how I can get worked up with my own stuff, but that  we’re  really responsible to each other. The  following  participant’s  words  further  capture  this  aspect  of  the  women’s  experience,  with  particular attention to the intentionality of the women in addressing relational issues with their partners: …it’s  been really amazing to be able to work through problems from a place of knowing that  we’re  really  in  it  together.  That  we’re  not  separate and we’re  not  isolated and that we just  come  together  because  it  works  or  something,  it’s  like,  no  this  is  us  really  moving  together, and these feelings come up, and  why  are  they  coming  up,  because  it’s  two  of  us,  not just one. Similarly,  in  speaking  about  her  and  her  partner’s  shared  commitment  to  their  relationship,  another woman emphasized her perception that her partner was consistently willing to work on issues that emerged within the context of the intimate relationship. As such, her experience of her partner as being invested in overcoming challenges strengthened her trust in his support. She shared a strong belief in his dedication to making their relationship as strong as it could be, which increased her confidence that they could sustain challenges and grow together: I  think  it  wasn’t  even  as  much  advocating  just  for  recovery  but  it  was  advocating  for  us… he was there for the long haul…he was willing to work on things, he was willing to be there through things…we were willing to put the effort and you know, he showed me that he was okay with going to counselling sessions with me. Like  if  things  aren’t  working,  he’s  willing  to  seek  help, and so that meant that he was willing to work on this marriage...and make it not about him and not about me, but  it’s  about  us  and  working on things together.  132 Relatedly, several of the women shared their experiences of a bi-directional flow of support in the relationship, which further contributed to a sense of partnership and mutual investment  in  both  their  own  and  their  partner’s  wellbeing.  One  woman  shared  that  her  experience of mutual commitment to the relationship reinforced her efforts to reciprocate in her relationship, demonstrate care for her partner, and share her appreciation for his support. For the following  woman,  the  presence  and  recognition  of  her  partner’s  life  experiences  served  to  de-centralize the ED as the primary focus within the relationship, and uphold their relationship – its functioning and quality – as a priority: …he  didn’t  stop  going  through his own stuff either and he was open about when things, when he was struggling with stuff, and that  was  helpful  too  ‘cause  then  it  wasn’t all about me  and  it  wasn’t  all  about  my  recovery  and  my  process. It was still both of us in the relationship with one another…  The above sentiments were echoed by another participant, who felt strongly committed to contributing to the partnership that she and her husband had created, by endeavouring to provide support  to  her  husband  when  needed.  She  shared,  “we’re  here  for  each  other, and it makes me try harder on the days when  he’s  having  difficult  days.  I really have to turn around in my head and say, ‘okay he was  here  for  me,  I’m  going  to  be  here  for  that  man.’”  Relatedly,  the  following  participant reflected on the ways in which being in a committed relationship shifted her focus from herself, towards the partnership. For this woman, her valuing of her intimate relationship led to growing awareness of how the ED interfered with her sense of connection in the relationship. She shared how upsetting it was for her to realize the negative relational consequences of the ED, and how much this reinforced her valuing of her partner and their relationship.  133 …it got me out of just focusing on myself. ‘Cause  that  was  definitely  a  default  for  me,  just always going back to, ‘what’s  wrong  with  me,  what’s  wrong  with  my  life,  what’s  wrong with the way I’m  functioning, and what’s  wrong  with  how  I’m  approaching  things’ and it was more about how can we be with one another, and the eating disorder was just totally causing us to be apart from one another. The  women  described  the  ways  in  which  their  perception  of  their  partner’s commitment engendered a sense of hope about the future, and strengthened belief in the possibility of recovery. One woman explained that her relationship opened her eyes to the potential inherent in both her relationship and her life, and observed her growing willingness to approach and engage with that potential, versus remaining in the depths of the ED: We both really felt right off the bat that we wanted to be together for a really long time and so, knowing that just made it more, I guess for him and for me, being that invested in the  relationship…we were both so invested in each other…I think it kind of ties into what I was talking about, about not being able to think that I was ever gonna get out of [the ED] and so to now have something else in my life that could be wonderful, could be healthy, could be really positive, and allowing myself to move towards that. For this woman, the value of being in a fulfilling relationship began to outweigh the value associated with the ED. Similarly, in speaking to her cultivation of a relationship with her partner, one woman reflected upon the ways in which being in an intimate relationship contrasted her experience in the ED. Specifically, she reflected that her rigid adherence to the ED restricted her lived experience,  and  juxtaposed  this  “stoic”  and  “puritanical”  way  of  living  with  the energy and freedom of pursuing love and connection through her relationship:  134 …to  make  a  choice  to  move  towards  is  not  an  avoiding  behaviour,  right,  like  if  you’re  moving  towards,  you’re not avoiding, and that, I think, is quintessentially opposite as well…there’s  such a  compulsion  towards  vitality…love  is  vital  and if  you’re  moving  towards  that,  then  you’re moving towards a purpose again, that is far more important than any compulsion to be unwell.   To this end, the relationship appeared to afford a sense of purpose and meaning, greater than the ED. Indeed, several women highlighted the importance and meaning of building a life with their partner, and the ways in which this pursuit outweighed the ED in its significance. Of note however, the extent to which a shared commitment to, and vision for, the relationship characterized  and  permeated  the  women’s  experience  varied  somewhat  among  the  women,  between those who were still currently with their partner, and those whose relationship had ended. Specifically, while all the women experienced a shared valuing of their relationship, a focus on the future and an orientation towards long term hopes and visions for the relationship tended to be more apparent for women who remained with their partners over the long term. To this end, many of the women in longer term relationships and those still with their partner spoke of shared hopes, goals, and visions for their relationship and their life with their partner. This included, but was not limited to, a prioritizing of family, a desire for and commitment to children, and attaining an optimal quality of life. Notably, participants spoke about the ways in which plans for the future promoted more immediate efforts and changes with respect to their recovery from the ED. As one woman reflected: …you also start to think about things in the future, like you think down the road and you’re  like,  eventually  if  I  want  to  have  kids,  then  I  can’t  be  doing  this  to  my body and  135 then  that  becomes  not  about  me,  that’s  about  a  baby  and  it’s  also  about  them,  because  they are the other person… Similarly,  another  participant  shared  the  belief  that  her  and  her  partner’s  commitment  to  having  a  healthy family fuelled her recovery efforts, and helped her move beyond a particularly difficult time in her life and ED by providing a sense of purpose in her recovery. She explained that in truly  reflecting  upon  the  question,  “what,  really,  do  I  want?”  she  realized,  and  became  committed to, something more significant than the ED: …I want another baby, and I mean he was supportive, and  that’s  what  our  goal  is,  that’s  what we want, so you know, he was supportive in that, so I guess in a sense that was supporting my recovery. Like many participants  in  the  study,  this  woman  felt  that  her  and  her  partner’s  shared  hopes  for  their future united them around common values, provided a sense of direction in recovery, and ultimately facilitated change efforts.  Joining in recovery. In addition to a shared commitment to the relationship itself, all of the women experienced a mutual investment in the recovery process. To this end, they described a  partnership,  or  joining,  in  recovery.  They  spoke  of  a  unity,  of  “we,”  “us,”  and  a  “team”  in  the  recovery journey, and the ways in which this promoted change. Reflecting the experience of all the  women  in  the  study,  one  woman  commented,  “you’re just in it with somebody, and  that’s  extremely helpful.” Another participant described the supportive nature of this unity, including the sense of encouragement it afforded her: …it  felt  more  hopeful  and  it  felt  more  supported, because all of a sudden it  wasn’t  just  me, you know, it was like, ‘oh we’re  in  this  together,’  and ‘I’m  gonna stand beside you  136 and  I’m  gonna still love you when you fall and when you get back up, and when you do well  and  when  you  do  poorly,’  and all that sort of stuff.   Another  participant’s  words  further  illustrate  this  aspect  of  the  women’s  experience,  as  she  described what it was like for her to have her partner by her side through the various stages of the ED and recovery: …it  challenged  me  just  to break out of the pattern that I was in and to kind of trust that if I did that there would be you know, a better opportunity or a better way of living or of accepting  myself…and  on  days  where  I would slip up or days where I felt like maybe without  him  would’ve,  I  don’t  know  if you want to call it relapse or, but relapse for much longer or, just been in a really bad place for a longer time, I had someone to help me… As articulated above, of particular importance to the women was the sense that their partner would be by their side through both the successes and challenges of recovery. The women consistently acknowledged the efforts, work, and difficulties of recovering from their ED, and voiced appreciation for the presence of their partner. One woman was particularly moved as she spoke of what this commitment meant to her: I really think it was a testament to how much he wanted you know, the relationship and wanted me and so, willing to go through like not only being in a relationship with someone with an eating disorder but willing to go through the  recovery  process…I  think  they’re  both  very  hard…just  living  with  someone with an eating disorder is difficult but willing to go through that you know, the disappointments and the exciting parts of feeling better about myself or gaining weight or you know, being able to exercise again and not be triggered, things like that. Willing to go through that with me, believing that in the end I  would  be  able  to  make  it  even  though  I  didn’t think at the time I would be.  137 The  above  sentiments  are  echoed  by  another  participant,  who  experienced  her  partner’s  presence  and commitment throughout all aspects of her recovery, as paramount to her experience of the relationship as a support: …he’s  always  gonna  be  by  my  side,  he’s  supportive,  he’s  there  for  the  long  haul,  he’s  there  through  shit,  he’s  there  through  the  good  times,  he’s  just,  he’s  there. And I mean I guess  that’s,  I mean  that’s  really  all  you can ask for, I mean that’s  exactly  the  example  of an intimate relationship supporting recovery, just, he’s  been  there. For these women, a sense of partnership in recovery was particularly important in reducing feelings of isolation associated with their experience of the ED. The participants all shared  the  sentiments  voiced  by  this  woman,  that  “eating disorders are so isolating, and distancing,”  and  involve  “secrecy,”  yet  with  the  relationship  “it’s  not,  I’m  not  alone.” Another participant’s  words  further  illustrate  the  women’s  feelings  that  an  experience  of  partnership  in  recovery decreased this sense of disconnection: I  wasn’t  going  at  it  alone…[it’s]  such a lonely kind of disorder that you put yourself in, there’s  no  social  aspect  to  it…it’s  such  a  internal  struggle  but  then  to  have  someone  that’s  now  kind  of  in  on  it  in  some  ways… This woman speaks further about her experience of having her partner voice his investment in her recovery, and his desire to join with her in the journey, and observed the impact this had: I had never really  considered  recovery  before…it  just  felt  like  [the  ED] was always gonna be with me and this was gonna be like my life for the rest of my life and so for someone to say,  you  know,  ‘you  could  be  getting better, I want you to get better, this is how you can get better with me, I want to do this with you, I  want  to  help  you  in  this  way’…it  138 pushed me to start going to different groups, it pushed me to talk about what I was talking about at therapy or different things like that. Another woman shared that “you  do  take,  I  think,  more  risks  when  you  have  someone  who’s  supporting you and who believes in you, when  you  don’t  really  believe  in  yourself,  then  it  gets a little bit easier every  time.”  To  this  end,  another  woman  commented,  “I  think  it’s  a  combination  between  [partners]  providing  that  strength  and  kind  of  teaching  you  that  you  are  strong.”  Indeed,  many women expressed growing awareness and appreciation of their capacities, and found their experience of their partners joining with them in recovery to be affirming and reinforcing of their efforts  to  make  changes.  For  example,  one  woman  commented  that  “to see that pride in someone that you care about so much, and that cares about you, and to see them be really excited for you and really cheering you on”  when  changes  have  been  made,  was  significant.   For the women in this study the experience of joining in recovery manifested in a variety of different ways. In addition, the extent to which partners were directly involved  in  the  women’s  recovery  efforts  appeared  to  vary  among  the  women,  and  appeared  related  to  the  women’s  needs  and  preferences  for  support.  To  this  end,  the  women’s  partner’s  orientation  to,  or  stance  towards,  the  women’s  recovery  efforts,  and  the  women’s  perception  of  their  partner’s  efforts  to  support  them,  appeared  to  be  particularly  important  to  the  women’s  overall  experience  of  support. For example,  in  speaking  to  her  partner’s  orientation  towards  her  recovery  efforts  and  needs,  one  woman commented: …  he  didn’t  have  any  ideas  about  what  was  right  or  wrong in terms of it, he  wasn’t  criticizing  me  for  what  I  was  eating,  what  I  wasn’t  eating,  my  exercising… As illustrated above, the women shared the belief that they were themselves largely empowered to guide their recovery process. This involved however, an experience of working with their  139 partner to determine the nature of support – to this end, they often spoke of a sense of collaboration  with  their  partners.  The  following  participant’s  words  capture the experience of several women, who experienced less direct involvement and feedback around the day-to-day steps and tasks of making changes to ED behaviors, yet felt profoundly supported and united with their partners in their journey: …he never tried to direct me or say ‘what  about  trying  this,’  it  was  always  up  to  me  to  kind of find a way. He was more there to be like, kind of like I said, he was a cheerleader for  whatever  decision  it  was…if it seemed like it was a behaviour that was maybe gonna put me in a bit of a box again he would kind of, he would maybe point to that, but generally he really advocated for what I felt I needed to do and what strategies I needed to  use… Another woman shared that her partner never “gave  [her] the key to recovery, he never told [her] ‘you need to take these steps, you need to do this, don’t  do  that,’”  and  she  believed  he  wasn't  equipped to provide specific strategies. However, like many women in the study, she felt that his presence and availability were key in establishing a sense of unity.  The women in this study also shared that their partners validated and encouraged their efforts  to  make  changes,  and  in  many  cases,  “gently  challenge[d]”  them  to  attempt  alternate  behaviors or ways of coping, and to reflect on their experience. To this end, the women often spoke  of  their  partner’s  stance  in providing support,  sharing  that  their  partner  would  “check-in,”  share  an  observation,  or  appear  “curious”  about  the  women’s  experiences.  The following participant captured this latter  dimension  of  the  women’s  experience,  as  she  described  the  ways  in which the ED and related issues were often broached in her relationship:  140 …he  would  check-in, he would ask me about [it], you know, see how I was doing and I felt like there was an openness to talk about it, and I think it caused me to be pushed out of my comfort  zone… These  aspects  of  partner’s  joining  in  recovery  are  further  illustrated  by  the  following  participant’s  experience:   …he would help me monitor my emotions in some ways, so if I  was  really  upset  he’d  ask  me  what  would  I  be  doing  that  night  to  make  sure  that  I  wouldn’t  want  to  binge  and  purge  or things like that, so yeah monitoring, I think, my affect  in  some  ways…just being really in tune with how I was doing and being aware that often that would relate to my eating habits or to my disorder, and so really understanding that relation and then being able to help me with that.  Indeed, many women shared the perception that their partner became aware of factors related to the ED (e.g., vulnerabilities, patterns), and used this knowledge of the women and their experiences to inform the kind of support they might offer, and also, as illustrated above, when they  might  “check-in”  with  the  women.  The  words  of  another  participant  capture  this aspect of the  women’s  experience: …he  really  learned  what  my  all-or-nothing thinking was, or he really learned what my triggers were, or he really learned my weaknesses or how I would react to certain things, and so he would be able to predict sometimes how I would respond to things and help me in  those  ways… The women in the study emphasized their experience of emotional support within the context of their intimate relationship, however, many also described more tangible, behavioural, and practical support, and shared ways in which these kinds of support facilitated their recovery  141 efforts. One woman, whose partner was more actively involved in her recovery efforts, described her experience of her partner joining with her to promote changes to her eating, and voiced how meaningful this partnership in recovery was: …he became an amazing support because he was probably the first person that I was ever that honest with right off the bat. And  so  when  we’d  go  out  for  dinner,  we  would  either  go late [or] eat something beforehand. He would check-in and see how I was doing. We would check-in periodically throughout the night. It was extremely helpful because it’s  different than a friend. It’s  different  than  your  parents  ‘cause  they’re  not  going  to be there in those  situations…it was always okay just to check-in, to set goals so if we got, if I got through  that  night  and  it  was  okay,  we  could  leave  at  any  time,  we’d  go  snowboarding  together the next day and do something fun. Like,  not  that  I  wasn’t  allowed  to  do  that if I didn’t  get  through  the  night  but  there  was  just  incentive  to  do  things…and I found that to be extremely helpful, but also  there  was  no  judgement  if  I  didn’t  get  through. Another  participant  found  her  partner’s  presence  to  be  particularly  helpful,  as a distraction, as she worked to manage urges to engage in ED behaviors. She described how instrumental and supportive  this  felt:  “[him]  just being there with me during that time, like I needed someone to just, you know, like kind of talk me through it or sit with me through it until the feelings passed, and he did,”  and  “that’s  a  huge  way  that  he  was  there  for  me.”  Several  other  women  also  described their  partner’s  efforts  to  suggest  or  participate  in  alternate  ways  of  coping.  One  woman  found  her  husband’s support around their home, and teaming up for grocery shopping to be particularly  helpful.  Relatedly,  many  women  appreciated  their  partner’s  flexibility  around  what  kinds of foods would be available in the home, and many found that eating meals and/or engaging in post-meal distractions with their partner were supportive. One participant shared that  142 this joining around meals, including preparation, was particularly helpful in re-defining her relationship to food, meals, and eating; she shared that she and her partner, together, were able to find ways to make the process and time together enjoyable, which helped her construct new meanings around food related practices. Indeed, most women described the ways in which their intimate relationship helped them to normalize their relationship with food. For example, some women identified partner modeling of a more flexible relationship with food, and partner validation of their efforts to eat in healthful ways, as contributing factors; others spoke of giving themselves  “permission”  to  eat  within  the  safety  of  their  relationship.  Ultimately,  participants  all  described the ways in which they began to challenge existing beliefs around eating and food, and experiment with new eating practices, within the context of their intimate relationship.  Several women also indicated that their partners encouraged them to pursue, accompanied them to, and/or participated in aspects of their treatment. For these women, their partner’s  involvement  in  treatment  was  perceived  as  a  reflection  of  their  partner’s  care,  concern,  and willingness to be an active partner in the recovery process. They also found it to be validating of their experience. For the women whose partners were not directly involved in their professional treatment, several noted that their partner expressed interest in their treatment experiences, and shared the belief that their partner would have been open to engaging in treatment, had this been desired. As illustrated here, one woman spoke to the significance of her partner’s  involvement  in  her  intensive  treatment: …it  was  nice  because it was acknowledging what I was doing. You know, it’s  all  fine  and  dandy for me to go off for a month and you know, for him to see me occasionally, but to actually acknowledge what I was doing and to come and to try and be a part of it and try and you know, be part of my team.  143 Relatedly, a common and particularly salient example of partners joining in recovery was the  women’s  experience  of  their  partner’s  efforts  to  seek  and  obtain  information and resources on EDs.  The  women  frequently  expressed  sentiments  such  as,  “he really wanted to learn how he could be a part of helping me get through this,”  “he actually went and sought out information,”  and  he  was  “very open to wanting to learn more about it.”  The women shared  that  their  partner’s  efforts in this regard created a deep sense of being valued and loved. Many women commented that these efforts enhanced their sense of trust and security in the relationship, as they reinforced their  partner’s  commitment  to  them,  their  relationship,  and  their  recovery.  This  woman’s  words reflect the experience of most participants in the study, of feeling very moved by, and grateful for,  their  partner’s  attempts  to  seek  information  and  provide  support: …to have no resources or no idea of what to say or what to do, and to immediately be reaching  out  to  anyone  he  can  think  that’s  gonna  help  him be able to help me was just like, I mean I was so, so lucky to have someone that, during that time in my life, ‘cause  he didn’t  have  to  do  that…to  really  make  those  proactive  steps  was  huge. And that really reaffirmed that it was something he truly cared about and that I could be open with him about, because he really was concerned, wanted to be there to help me move forward. Importantly,  the  women  consistently  noted  that  it  was  their  partner’s  efforts to support them that were most significant in contributing to their experience of their intimate relationship as a support throughout recovery. As previously illustrated, while participants experienced a number of tangible supports and variable degrees of active involvement from their partner, they voiced that  their  partner’s  efforts  to  support  them  were  instrumental  to  their  perception  of  support,  as  compared to the specific strategies partners employed or the outcome of their partner’s  efforts.  This  is  illustrated  here  by  one  participant  who  acknowledged  that  although  she  didn’t  always   144 experience  her  partner’s  support  attempts  as  helpful  in  the  moment,  the  fact  that  he  was  trying to support her was ultimately facilitative: …he was trying to think of ways that he could help, so sometimes it  wouldn’t even really feel like it was helping me feel better, but it was [helping], because I knew that he was doing it, [and] that made me feel  better…so  not feeling like he had to get it a hundred percent, but just that he was trying to, and that he wanted to, made me feel like I was worth that effort or worth trying… That being said, several women shared the belief that their partners’  efforts to educate themselves did indeed result in perceived  improvements  in  partners’  ability  to  provide  informed,  responsive,  and  effective  support.  For  example,  this  woman  found  that  her  partner’s  active  involvement in her treatment translated to their relationship in important ways: …he  went  to  a  family  group  and  I’m  sure  he  probably  felt  pretty  weird going but he went, so even from the beginning he kind of had a better understanding of what was going on, so he was better able to support me…he knows not to say  things  like  that  because  he’s  actually taken the time to go and find out about these kind of things, and through like my treatment and things like that, he came t