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Recovery from bulimia nervosa Truant, Laurie Gail 1991

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RECOVERY FROM BULIMIA NERVOSA By LAURIE GAIL TRUANT B.A., Simon F r a s e r U n i v e r s i t y , 1983  THESIS SUBMITTED IN PARTIAL FULFILLMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE Department o f C o u n s e l l i n g  We accept  STUDIES Psychology  t h i s t h e s i s as conforming  to the required  standard  THE UNIVERSITY OF BRITISH COLUMBIA OCTOBER 1991 ® L a u r i e G a i l Truant, 1991  In  presenting  degree  this  at the  thesis  in  University of  partial  fulfilment  British Columbia,  freely available for reference and study. copying  of  department  this or  thesis by  for scholarly  his  publication of this thesis  or  her  of  The University of British Columbia Vancouver, Canada  DE-6 (2/88)  an  purposes  may  representatives.  It  be is  granted  3, 1991  advanced  by the head  understood  that  for financial gain shall not be allowed without  Counselling  October  for  I further agree that permission for extensive  J  Date  requirements  I agree that the Library shall make it  permission.  Department of  the  Psychology  of  my  copying  or  my written  ii Abstract C u r r e n t r e s e a r c h on formal treatment  approaches t o normal-weight  b u l i m i a p r e s e n t s i n c o n c l u s i v e r e s u l t s on the e f f i c a c y of v a r i o u s treatments  and l i m i t e d e m p i r i c a l knowledge of the c u r a t i v e  mechanisms i n v o l v e d .  In the l i t e r a t u r e on t h e r a p e u t i c change  agent s t u d i e s which i n t e r v i e w s i n d i v i d u a l s who  have recovered  from an e a t i n g d i s o r d e r , only i s o l a t e d a s p e c t s of the  recovery  experience are uncovered so t h a t the meaning and process of r e c o v e r y are l i m i t e d .  T h i s case study a p p l i e d C o l a i z z i ' s  (1978)  e x i s t e n t i a l - p h e n o m e n o l o g i c a l approach t o e l u c i d a t e thematic c a t e g o r i e s u n d e r l y i n g the recovery experience as recounted by a former b u l i m i c i n order t o p r o v i d e a more complete and understanding Initially,  holistic  of the process and nature of r e c o v e r y from b u l i m i a .  f o u r i n d i v i d u a l s who  self-reported feeling  genuinely  r e c o v e r e d from b u l i m i a were prescreened by an independent r a t e r i n o r d e r t o ensure t h a t they had a p r e v i o u s d i a g n o s i s of b u l i m i a nervosa Mental  as d e f i n e d by the D i a g n o s t i c and S t a t i s t i c a l Manual of D i s o r d e r s . T h i r d E d i t i o n Revised  h i s t o r y of a n o r e x i a nervosa,  (1987) and no  previous  t h a t they were f r e e of b u l i m i c  symptoms, and t h a t they e x h i b i t e d no s i g n i f i c a n t i n d i c a t o r s of o t h e r a c t i v e p s y c h o l o g i c a l problems s i n c e having recovered bulimia.  The  four co-researchers described t h e i r  e x p e r i e n c e and each i n t e r v i e w was themes were formulated t r a n s c r i p t and  recovery  transcribed. Categorical  from the r i c h e s t and most comprehensive  i n f o r m a t i o n from another  co-researcher's  t r a n s c r i p t served t o c r o s s - v a l i d a t e the c a t e g o r i e s . remaining  two  from  The  t r a n s c r i p t s were not i n c l u d e d i n the a n a l y s i s  process.  The c o - r e s e a r c h e r v a l i d a t e d the thematic c a t e g o r i e s and  t h e i r d e s c r i p t i o n s and a l s o v e r i f i e d t h a t the c l u s t e r e d c a t e g o r i e s c l e a r l y o u t l i n e d the p a t t e r n or meaning of her recovery experience. R e s u l t s showed t h a t recovery i n v o l v e s a s y n e r g e t i c i n t e r a c t i o n o f c u r a t i v e f a c t o r s both i n s i d e and o u t s i d e of formal therapy.  Once the i n d i v i d u a l acknowledges her e a t i n g problem,  her b u l i m i c behaviours begin t o decrease as she e x p e r i e n c e s  an  i n c r e a s i n g sense of e f f i c a c y and s e l f - r e s p e c t i n areas of her l i f e o t h e r than her body weight and shape.  Her b i n g e i n g and  p u r g i n g g r a d u a l l y d i m i n i s h t o the p o i n t where she no l o n g e r engages i n them.  A s i d e from an o c c a s i o n a l l a p s e , she  now  implements o t h e r a c t i v i t i e s t o d e a l w i t h uncomfortable states.  She  f e e l s s t r o n g e r i n knowing who  emotional  she i s , she c h e r i s h e s  h e r s e l f as she i s , and she i s eager t o a f f i r m her p e r s o n a l growth by s h a r i n g her experience w i t h r e c o v e r i n g b u l i m i c s . t o a more comprehensive t h e o r e t i c a l understanding  In a d d i t i o n  of recovery,  t h i s study p r o v i d e d a deepened a p p r e c i a t i o n of the complexity of the r e c o v e r y p r o c e s s . m u l t i f a c e t e d and  I t a l s o underscored  i n d i v i d u a l i z e d treatment  a d j u s t e d throughout  the need f o r a approach which i s  the recovery process as the a d a p t i v e  f u n c t i o n s o r meanings of c l i e n t s ' e a t i n g behaviours  change.  iv Table of  Contents  Abstract  i i  T a b l e of Contents  iv  Acknowledgement  vi  Chapter I: I n t r o d u c t i o n Overview D e f i n i t i o n of Terms S i g n i f i c a n c e of the Study Treatment Outcome S t u d i e s T h e r a p e u t i c Change Agent S t u d i e s Assumptions L i m i t a t i o n s of the Study  1 1 2 4 5 8 12 12  Chapter I I : L i t e r a t u r e Review Treatment Outcome S t u d i e s Psychodynamic Therapy S t u d i e s Systemic Family Therapy S t u d i e s C o g n i t i v e - B e h a v i o u r a l Therapy S t u d i e s T h e r a p e u t i c Change Agent S t u d i e s Summary My P r e s u p p o s i t i o n s  14 14 15 18 24 29 39 40  Chapter I I I : Methodology Design Co-researcher S e l e c t i o n Procedure Analysis  45 45 47 53 56  . . . . .  Chapter IV: Results Interviews From T r a n s c r i p t i o n t o Formulation of Themes The V a l i d a t i o n Interview C l u s t e r s of Themes and S i g n i f i c a n t P r o t o c o l Statements Condensed O u t l i n e of C l u s t e r e d Themes Exhaustive D e s c r i p t i o n of the Recovery Experience . .  59 59 65 66 67 68 69  Chapter V: Discussion Summary of R e s u l t s L i m i t a t i o n s of the Study E v a l u a t i n g the F i t n e s s of T h e o r e t i c a l Approaches . . Implications for Counselling Recommendations f o r Future Research Summary and Conclusions  105 105 105 107 114 116 118  References  120  V  Table of Contents (continued) Appendices A. D i a g n o s t i c C r i t e r i a f o r B u l i m i a Nervosa . . . . B. D i a g n o s t i c C r i t e r i a f o r Anorexia Nervosa . . . . C. P r e - s c r e e n i n g Interview Summary Sheet D. Contact L e t t e r f o r C o u n s e l l o r / T h e r a p i s t . . . . E. Contact L e t t e r t o V o l u n t e e r F. Advertisement f o r S u b j e c t s G. Consent Form H. L.S.'s P r o t o c o l J. P.Y.'s P r o t o c o l K. Co-researcher's V a l i d a t i o n L e t t e r  125 126 12 7 128 12 9 13 0 131 132 190 247  vi Acknowledgement In Man's Search N i e t z s c h e ' s words: almost  f o r Meaning. F r a n k l (1963) quotes "He who has a why t o l i v e f o r can bear  any how" (p. 121, 164).  with  This t h e s i s i s dedicated t o the  women i n therapy who l o n g i n g l y asked me how they would r e c o v e r from b u l i m i a nervosa.  T h e i r q u e s t i o n p r o v i d e d t h e i n i t i a l and  c o n t i n u i n g i n s p i r a t i o n f o r me t o pursue and complete t h i s research  study.  I would l i k e t o thank my committee members—Dr.  Ishu  Ishiyama, Dr. L a r r y Cochran, and Dr. E l l i o t G o l d n e r — f o r guidance  and v a l i d a t i o n throughout  a l s o g r a t e f u l t o Beth and Sarah  their  the research process.  I am  f o r t h e i r c a r e f u l and thorough  work i n t h e e d i t i n g and t y p i n g o f t h e manuscript.  The constant  u n d e r g i r d i n g o f l o v e and support from my f a m i l y i s a l s o deeply appreciated. Finally,  I would l i k e t o acknowledge t h e c o o p e r a t i o n ,  courage, and hard work o f t h e c o - r e s e a r c h e r s who shared  their  r e c o v e r y s t o r i e s and wisdom i n a n a l y z i n g t h e experience o f r e c o v e r y from b u l i m i a .  I am g r e a t l y indebted t o these women f o r  t h e i r commitment and openness which was f o u n d a t i o n a l t o t h e completion  of this project.  1 Chapter I Introduction Overview Bulimia  i n normal-weight women without h i s t o r i e s o f  a s s o c i a t e d weight d i s o r d e r s f i r s t appeared i n t h e r e s e a r c h l i t e r a t u r e i n 1978 (Oesterheld, McKenna, & Gould, 1987). 1980,  In  b u l i m i a was acknowledged as a d i a g n o s t i c e n t i t y (American  P s y c h i a t r i c A s s o c i a t i o n , 1980) , and i n 1987 t h e d i a g n o s t i c c r i t e r i a were r e v i s e d (American P s y c h i a t r i c A s s o c i a t i o n , 1987). Although S t r i e g e l - M o o r e ,  S i l b e r s t e i n , and Rodin  (1986)  observed t h a t t h e onset o f b u l i m i a can occur w e l l a f t e r t h e young adult years,  t h e d i s o r d e r u s u a l l y begins i n l a t e adolescence o r  e a r l y twenties. unavailable  While good e p i d e m i o l o g i c a l data  ( E a t i n g D i s o r d e r Task Force,  1989), s t a t i s t i c s  on t h e prevalence  i s as y e t  1989; Tonkin & Wigmore,  o f b u l i m i a as d e f i n e d by t h e  c r i t e r i a o f t h e D i a g n o s t i c and S t a t i s t i c a l Manual o f Mental D i s o r d e r s . T h i r d E d i t i o n Revised 1.3%  (DSM-III R. 1987) range from  t o 5.0% o f c o l l e g e women (Drewnowski, Yee, & Krahn, 1988).  Since o n l y 10% o f b u l i m i c s are male (Drewnowski e t a l . ) , I w i l l use t h e feminine bulimia.  pronoun she when r e f e r r i n g t o i n d i v i d u a l s with  Given t h a t t h e t r u e i n c i d e n c e o f b u l i m i a i s d i f f i c u l t  t o assess because o f t h e shame and secrecy a s s o c i a t e d with i t (Newman & Halvorson, 1983) and s i n c e many normal-weight women not diagnosed as b u l i m i c r e p o r t s u f f e r i n g from t h e symptoms o f t h e disorder  (Johnson & Connors, 1987), t h e extent  o f b u l i m i a may be  f a r g r e a t e r than t h a t r e v e a l e d by c u r r e n t s t a t i s t i c s Wigmore).  (Tonkin &  2 In any p a s t two  event, the i n c r e a s e d p r e v a l e n c e of b u l i m i a  decades w i t h i t s d e l e t e r i o u s p s y c h o l o g i c a l  p h y s i o l o g i c a l h e a l t h e f f e c t s as w e l l as the associated mortality spurred  research  significant  (Herzog, Hamburg, & Brotman, 1987)  therapeutic  change agents.  understanding of how  recovery  Tonkin and Wigmore (1989) "we  occurs i s l a c k i n g . are s t i l l  understanding of e a t i n g d i s o r d e r s and 11  recovery  a holistic  According  s t r u g g l i n g with  how  to  our  b e s t t o h e l p those  who  (p. 147) .  the purpose of t h i s study i s t o i n v e s t i g a t e the  meaning of the recovery recovered  has  However, the  s t u d i e s t o date are i n c o n c l u s i v e or a n a l y t i c a l , and  Therefore,  and  i n t o e t i o l o g i c a l f a c t o r s , treatment,  i n t e r v e n t i o n s , and  s u f f e r from them  i n the  experience from the p e r s p e c t i v e  of  b u l i m i c s by e x p l o r i n g the nature and p r o c e s s of from b u l i m i a .  Hopefully,  understanding of recovery  a more comprehensive  w i l l r e s u l t so t h a t t h e o r e t i c a l  approaches can be c r i t i q u e d , i n d i v i d u a l s w i t h b u l i m i a can primed f o r therapy, and  treatment e f f e c t i v e n e s s can be  by p r o v i d i n g an optimal  therapeutic  be  enhanced  environment.  D e f i n i t i o n of Terms According  t o the DSM-III R  f o r b u l i m i a nervosa are:  (1987), the d i a g n o s t i c  (a) at l e a s t two  criteria  weekly binge e a t i n g  episodes f o r a minimum of 3 months; (b) a f e e l i n g of l a c k of c o n t r o l d u r i n g the binges; use  (c) r e g u l a r l y engaging i n  vomiting,  of l a x a t i v e s or d i u r e t i c s , s t r i c t d i e t i n g or f a s t i n g , or  vigorous  e x e r c i s e ; and  (d) preoccupation  weight.  In c o n t r a s t t o the D i a g n o s t i c  w i t h body shape and  and  S t a t i s t i c a l Manual of  3 Mental D i s o r d e r s , T h i r d E d i t i o n (DSM-III. 1980), the DSM-III R c r i t e r i a are f i r m e r i n t h a t a minimum frequency of binge e a t i n g episodes i s s t a t e d and  the requirement of depressed mood and  s e l f - d e p r e c a t i n g thoughts f o l l o w i n g e a t i n g binges i s e l i m i n a t e d as i t i s regarded as a common a s s o c i a t e d S i n c e a l l of the DSM-III R  feature.  (1987) c r i t e r i a must be met  d i a g n o s i s of b u l i m i a nervosa, an i n d i v i d u a l i s by recovered  from b u l i m i a i f she does not meet any  criteria.  definition  one  of  the  W i t h i n the l i t e r a t u r e , t h e r e i s no t h e o r e t i c a l  d e f i n i t i o n o f recovery using behavioural purging,  for a  from b u l i m i a .  criteria:  Recovery i s o p e r a t i o n a l i z e d  abstinence  from b i n g e i n g  or s e l f - r e p o r t of l a p s e s with no p e r c e i v e d  c o n t r o l over e a t i n g behaviour f o r at l e a s t one  and  l o s s of  year  (Brownell,  M a r l a t t , L i c h t e n s t e i n , & Wilson, 1986;  Connors, Johnson, &  Stuckey, 1984;  1989;  Cooper, Cooper, & H i l l ,  Johnson & Connors,  1987) . However, as the course of b u l i m i a " i s c h r o n i c i n t e r m i t t e n t over a p e r i o d of many y e a r s " 68), the process  of recovery  and  (DSM-III R,  i n v o l v e s episodes of  1987,  p.  remission—  wherein the frequency of b u l i m i c behaviours i s r e d u c e d — a s w e l l as p e r i o d s of r e l a p s e .  D e f i n i t i o n s of r e l a p s e i n c l u d e "a r e t u r n  t o pretreatment base r a t e " (Mines & M e r r i l l , bingeing  and purging  1987,  p.  a t l e a s t e i g h t times a month as  approximates the DSM-III R  (1987) frequency c r i t e r i o n  564), this (Pyle,  M i t c h e l l , E c k e r t , Hatsukami, Pomeroy, & Zimmerman, 1990), or a "perceived  l o s s of c o n t r o l " over e a t i n g behaviours (Brownell  al.,  p. 766).  1986,  W i t h i n the context  of t h i s study,  relapse  et  4  occurs when t h e i n d i v i d u a l experiences a l o s s o f c o n t r o l over her eating  behaviours.  As t h e r e a r e few s t u d i e s which examine t h e r e c o v e r y experience from the recovered b u l i m i c s p e r s p e c t i v e , s t u d i e s which i n t e r v i e w r e c o v e r e d a n o r e x i c s a r e addressed  i n order t o provide a  broader b a s i s f o r understanding the r e c o v e r y p r o c e s s . the c r i t e r i a  Therefore,  f o r a n o r e x i a nervosa a c c o r d i n g t o t h e DSM-III R  (1987) a r e : (a) maintenance o f body weight 15% below t h a t expected;  (b) i n t e n s e f e a r o f g a i n i n g weight even though  underweight; weight,  (c) d i s t u r b a n c e i n the way i n which one's body  s i z e , o r shape i s experienced; and (d) absence o f a t  l e a s t t h r e e c o n s e c u t i v e menstrual otherwise expected t o occur.  c y c l e s i n females when  Correspondingly, i f an i n d i v i d u a l  does not meet any one o f these c r i t e r i a ,  she i s by d e f i n i t i o n  r e c o v e r e d from a n o r e x i a . S i g n i f i c a n c e o f the Study A review o f the treatment  outcome s t u d i e s p e r t a i n i n g t o  normal-weight b u l i m i a showed i n c o n c l u s i v e r e s u l t s on the e f f i c a c y of v a r i o u s treatment  approaches and l i m i t e d e m p i r i c a l knowledge  of t h e c u r a t i v e mechanisms o f formal t h e r a p e u t i c i n t e r v e n t i o n s . Furthermore,  i n the l i t e r a t u r e on t h e r a p e u t i c change agents which  i n t e r v i e w e d i n d i v i d u a l s who had recovered from an e a t i n g d i s o r d e r , o n l y i s o l a t e d aspects o f t h e r e c o v e r y experience a r e p r e s e n t e d such t h a t knowledge o f the meaning o f t h e experience and t h e p r o c e s s o f recovery i s l i m i t e d .  C u r r e n t l y , no r e s e a r c h  s t u d i e s e x i s t which p r o v i d e a h o l i s t i c understanding recovery process.  T h e r e f o r e , t h i s study proposes  o f the  t o uncover the  5 thematic c a t e g o r i e s u n d e r l y i n g the experience of r e c o v e r y i n o r d e r t o p r o v i d e a more complete understanding  of r e c o v e r y .  S i n c e the e t i o l o g y and maintenance o f b u l i m i a i s m u l t i d i m e n s i o n a l and  involves s p e c i f i c b i o l o g i c a l , psychological,  f a m i l y , and s o c i o c u l t u r a l f a c t o r s 1985;  S t e i g e r , 1989;  (Schwartz,  Striegel-Moore et a l . ,  B a r r e t t , & Saba, 1986), the p a t t e r n of  p r e c i p i t a t i n g and p e r p e t u a t i n g f a c t o r s i s unique f o r each individual. and  Thus, based on c l i n i c a l o b s e r v a t i o n s , a m u l t i f a c e t e d  i n d i v i d u a l i z e d treatment  approach i s paramount i n which  v a r i o u s p s y c h o t h e r a p e u t i c treatments  are i n t e g r a t e d i n o r d e r t o  address both the b u l i m i c symptoms and the m u l t i p l e m a i n t a i n i n g factors  (Herzog e t a l . , 1987;  Manley, 1989;  Steiger).  Johnson, Connors, & Tobin,  However, the treatment  1987;  outcome  l i t e r a t u r e abounds w i t h s t u d i e s comparing the e f f e c t i v e n e s s of one m o d a l i t y w i t h another w i t h l i t t l e  c o n s i d e r a t i o n of the  perpetuating factors involved. Treatment Outcome S t u d i e s Upon reviewing the treatment  outcome s t u d i e s , a l l  p s y c h o l o g i c a l approaches—psychodynamic, f a m i l y systems, c o g n i t i v e - b e h a v i o u r a l , c o g n i t i v e , or b e h a v i o u r a l — s e e m  to  a m e l i o r a t e the b e h a v i o u r a l symptoms of b i n g e i n g and p u r g i n g  with  no one m o d a l i t y showing c l e a r s u p e r i o r i t y  (Cox & Merkel,  1989;  Johnson & Connors, 1987;  & P i r k e , 1987;  Yager,  1988).  Laessle, Zoettl,  Furthermore, a c c o r d i n g t o Hudson and Pope (1986) and  Johnson and Connors (1987), c o n c e r n i n g which treatment bulimia:  little  consensus has been  reached  i s most s u i t a b l e f o r which subtype of  b u l i m i a complicated by substance  abuse, o b s e s s i v e -  6 compulsive behaviour, d e p r e s s i o n , or sexual abuse (Lacey, Ordman & Kirschenbaum, In Herzog,  1983;  1985).  the c o n t r o l l e d psychodynamic treatment study by Norman, and Chauncy (1986), s t a t i s t i c a l l y  significant  improvements on measures of d i s o r d e r e d e a t i n g behaviours were found a t a one-year  follow-up.  Concerning f a m i l y therapy outcome  s t u d i e s , an u n c o n t r o l l e d study conducted by Schwartz  et a l .  (1985) which employed s t r u c t u r a l f a m i l y therapy and symptomfocussed d i r e c t i v e s found t h a t a t the end of treatment 66% of the s u b j e c t s had reduced the frequency of t h e i r b u l i m i c episodes from a mean of 19.3  per week t o one or fewer per month.  The  controlled cognitive-behavioural studies also report statistically  s i g n i f i c a n t r e d u c t i o n s i n binge/purge  80% a b s t i n e n c e a t post-treatment  (Lacey, 1983),  i n the frequency of v o m i t i n g a t the three-month of the p a r t i c i p a n t s  behaviours:  a 60% r e d u c t i o n follow-up f o r 77%  ( K i r k l e y , Schneider, Agras, & Bachman, 1985) ,  a 50% or g r e a t e r r e d u c t i o n i n the frequency of b i n g e i n g and p u r g i n g a t post-treatment f o r 55% of the i n d i v i d u a l s al.,  1984),  and 20% a b s t i n e n c e and 55% who  (Connors et  had reduced  behaviours t o one day per week (Ordman & Kirschenbaum,  bulimic 1985).  F i n a l l y , the outcome r e s u l t s from s t u d i e s which compare the e f f i c a c y of d i f f e r e n t treatment m o d a l i t i e s are a l s o For  inconclusive.  i n s t a n c e , i n the study by F a i r b u r n , K i r k , O'Connor, and  Cooper (198 6)  which compared a c o g n i t i v e - b e h a v i o u r a l  w i t h s h o r t - t e r m psychotherapy,  approach  the r e s u l t s i n d i c a t e d t h a t both  groups made s u b s t a n t i a l improvements on measures of  binge/purge  behaviour which were maintained over a twelve-month follow-up  7 period.  S i m i l a r l y , the study by Freeman, S i n c l a i r , T u r n b e l l ,  Annandale (1985) found t h a t a l l t h r e e  treatments—individual  psychodynamic, i n d i v i d u a l b e h a v i o u r a l ,  no treatment c o n t r o l  g r o u p — e f f e c t i v e l y reduced b i n g e i n g  and  O v e r a l l , e f f e c t i v e e v a l u a t i o n and treatment approaches i s precluded r e s p e c t t o age selection and  and  purging. comparison of d i f f e r e n t  by s u b j e c t d i v e r s i t y w i t h  of onset, d u r a t i o n of i l l n e s s , method of  (Ordman & Kirschenbaum, 1985;  subject  Johnson & Connors, 1987),  presence of a c t i v e p s y c h o l o g i c a l problems (Lacey, 1983).  Another f a c t o r which impedes between-study comparisons i s the l a c k of u n i f o r m i t y  i n methodology r e l a t e d t o usage of a c o n t r o l  group as w e l l as treatment d u r a t i o n , of s e s s i o n s per week (Cox  s e s s i o n l e n g t h , and  & Merkel, 1989).  V a r i a b i l i t y between  the s t u d i e s i n r e p o r t i n g post-treatment r e s u l t s a l s o evaluation:  sometimes n e g l e c t e d reduction  the  don't respond t o treatment i s  (Cooper e t a l . , 1989), some s t u d i e s  report  i n the a c t u a l number of b u l i m i c episodes w h i l e  r e p o r t percentage r e d u c t i o n s , short  jeopardizes  the l e v e l of s i g n i f i c a n c e of r e s u l t s and  percentage of s u b j e c t s who  number  and  follow-up  (Herzog, K e l l e r , & L a v o r i , 1988;  others  length i s diverse  and  Johnson & Connors, 1987).  In a d d i t i o n t o these i n c o n c l u s i v e f i n d i n g s on the e f f i c a c y of v a r i o u s treatment m o d a l i t i e s , e m p i r i c a l knowledge of c u r a t i v e f a c t o r s of formal In the f a m i l y and  therapeutic  the  interventions i s limited.  psychodynamic therapy s t u d i e s , knowledge of  e f f e c t i v e n e s s of s p e c i f i c t h e r a p e u t i c  interventions i s  precluded  because a wide v a r i e t y of i n t e r v e n t i o n s were implemented treatment  (Norman et a l . , 1986;  Schwartz, 1982;  the  during  Schwartz et a l . ,  8 1985).  S i m i l a r l y , with the c o n t r o l l e d  s t u d i e s , i t i s impossible  cognitive-behavioural  t o determine t h e s p e c i f i c  of t h e treatment packages which are r e s p o n s i b l e behavioural  interventions  f o r reducing  symptoms (Cooper e t a l . , 1989; F a i r b u r n e t a l . , 1986;  Johnson & Connors, 1987; K i r k l e y e t a l . , 1985). Nonetheless, assumptions about f a c t o r s which recovery  are inherent  facilitate  i n the v a r i o u s treatment approaches.  For  example, from a psychodynamic approach, the b u l i m i c symptoms w i l l d i m i n i s h as u n d e r l y i n g and  self-esteem  i n t r a p s y c h i c c o n f l i c t s are worked through  increases.  Systemic f a m i l y therapy proposes t h a t  w h i l e e f f e c t i v e f a m i l y r e s t r u c t u r i n g i s necessary f o r recovery, s p e c i f i c i n t e r v e n t i o n s aimed a t the b u l i m i c behaviours may a l s o be necessary. recovery  F i n a l l y , cognitive-behavioural  by implementing b e h a v i o u r a l  therapy  techniques t o r e e s t a b l i s h  c o n t r o l over e a t i n g behaviours as w e l l as u s i n g i n t e r v e n t i o n s t o modify the u n d e r l y i n g values  facilitates  cognitive  d i s t u r b e d t h i n k i n g and  about body shape and weight.  Therapeutic  Chancre Agent  Studies  With r e s p e c t t o q u a l i t a t i v e s t u d i e s which examine t h e f a c t o r s both i n s i d e and o u t s i d e o f formal facilitative  o f recovery,  therapy which are  the body o f knowledge i s minimal and  a n a l y t i c a l such t h a t only a l i m i t e d understanding o f the meaning of change events and the process o f recovery  exists.  Information  on t h e c u r a t i v e f a c t o r s which " i n f l u e n c e t h e f i n a l r e s u l t as a f u n c t i o n o f the t h e r a p i s t ' s a c t i o n s , the other group members, and the p a t i e n t h e r s e l f " (Vandereycken, Vanderlinden, & Van Werde, 1986,  p. 61) has been gathered by i n t e r v i e w i n g r e c o v e r i n g o r  9 r e c o v e r e d b u l i m i c s and recovered a n o r e x i c s about c r i t i c a l  change  events i n r e c o v e r y . Hobbs, B i r t c h n e l l , Harte, and Lacey a s p e c t s of group psychotherapy  (1989) found t h a t the  which b u l i m i c c l i e n t s c o n s i d e r e d  t h e r a p e u t i c a l l y important d i f f e r e d from those c i t e d by therapists.  their  While c l i e n t s r e p o r t e d i n s t i l l a t i o n of hope,  v i c a r i o u s l e a r n i n g , and u n i v e r s a l i t y as most important, t h e r a p i s t s r a t e d s e l f - d i s c l o s u r e and acceptance as more important.  However, o n l y a l i m i t e d understanding of the  t h e r a p e u t i c e f f e c t s i n a group environment  i s gained as the  meaning of the f a c t o r s and t h e i r impact on i n d i v i d u a l s i s sketchy. Stanton, Rebert, and Zinn (1986) i n t e r v i e w e d 15 who  individuals  had recovered from b u l i m i a i n the absence of therapy and  had  been a b s t i n e n t from b i n g e i n g and purging f o r an average of 7 months.  F a c t o r s which i n i t i a t e d change i n c l u d e d a d e s i r e t o  improve s e l f - e s t e e m and r e c o g n i t i o n of the i l l - h e a l t h e f f e c t s of bulimic behaviours.  S o c i a l support, b e h a v i o u r a l s t r a t e g i e s ,  p o s i t i v e s e l f - t a l k were r e p o r t e d t o f a c i l i t a t e change.  and  As with  the study by Hobbs e t a l . (1989), the meaning and impact of these factors i s limited. H a l l and Conn's 1983  survey  ( c i t e d i n H a l l & Cohn,  r e v e a l e d t h a t of the 30 i n d i v i d u a l s who  1986)  r e p o r t e d t h a t they were  cured of b u l i m i a or a d u a l d i a g n o s i s of both a n o r e x i a and b u l i m i a , p r o f e s s i o n a l therapy was  r a t e d by 80% as h e l p f u l ,  f r i e n d s and f a m i l y were r a t e d by 54%, r a t e d by 47%.  and s p i r i t u a l p u r s u i t s were  In a d d i t i o n t o the f a c t t h a t the scope of p o s s i b l e  10 facilitative  f a c t o r s was l i m i t e d t o the t h e r a p i s t s ' p e r s p e c t i v e s ,  o n l y l i m i t e d i n s i g h t was gained i n t o the meaning and impact of these events f o r the i n d i v i d u a l s . Kirk treatment  (1986) a d m i n i s t e r e d a q u e s t i o n n a i r e o f 74 p o t e n t i a l o r r e c o v e r y methods t o 123 recovered b u l i m i c s .  items r a t e d as most h e l p f u l t o more than 50% o f the  The 9  respondents  were:  " l e a r n i n g why I turned t o o r away from food when bored,  tired,  angry"  (73.3%), " f i n d i n g a sense o f my t r u e s e l f  l o n g e r s t a n d i n g o u t s i d e o b s e r v i n g my own b e h a v i o u r s ) "  (no (69.8%),  " l e a r n i n g t o c a l l on my i n n e r r e s o u r c e s - d e t e r m i n a t i o n , patience" thoughts  (64.9%) (p. 65), " l e a r n i n g t o c o n t r o l and f e e l i n g s "  over-concerned  courage,  self-defeating  (69.2%), " l e a r n i n g not t o be  w i t h o t h e r peoples' o p i n i o n s and r e a c t i o n s "  (69.0%), " l e a r n i n g c o n s t r u c t i v e ways t o d e a l w i t h anger" "letting  go of my should statements"  range o f s o c i a l a c t i v i t i e s "  (65.5%), and "widening  (63.8%) (p. 69).  most h e l p f u l items was a food i s s u e :  (65.7%), my  Only one of the  "learning t o eat a healthy  b r e a k f a s t , lunch, and d i n n e r " was h e l p f u l t o 66.9% o f the respondents"  (p. 71).  A d d i t i o n a l i n f o r m a t i o n on f a c i l i t a t i v e gained from open-ended q u e s t i o n s .  f a c t o r s was  also  T r u s t i n g and l o v i n g  r e l a t i o n s h i p s w i t h s u p p o r t i v e b o y f r i e n d s , spouses,  f a m i l y members  or God helped i n d i v i d u a l s r e a l i z e t h a t they "had good q u a l i t i e s of  [ t h e i r ] own and t h a t [they] d i d n ' t have t o earn l o v e ,  f r i e n d s h i p and a t t e n t i o n " partial  (Kirk, 1986, p. 130).  meanings of some o f the f a c i l i t a t i v e  Thus, w h i l e  events were  11 e l u c i d a t e d , no c l e a r p a t t e r n o f the recovery process  was  presented. Beresin  (1985) presented  the meaning and impact o f some o f  the c u r a t i v e f a c t o r s r e p o r t e d by recovered a p a r t i a l p a t t e r n o f recovery.  a n o r e x i c s and sketched  For i n s t a n c e , a v a l i d a t i n g  r e l a t i o n s h i p w i t h one's t h e r a p i s t helped  individuals to identify  and t r u s t t h e i r f e e l i n g s and i n i t i a t e d r i s k t a k i n g with individuals.  A l s o , w h i l e body image was t h e most  other  difficult  aspect t o change, becoming a mother f o s t e r e d an i n c r e a s e d sense of s e l f - w o r t h , and i n t i m a t e sexual r e l a t i o n s h i p s f a c i l i t a t e d the a b i l i t y t o a p p r e c i a t e one's body r a t h e r than b e i n g ashamed o f i t . Maine (1985) i n t e r v i e w e d 25 recovered the treatment and recovery processes, and  anorexics to illumine  and t o uncover the meaning  impact o f events which i n d i v i d u a l s c o n s i d e r e d  recovery.  F a c t o r s which f a c i l i t a t e d recovery  f a c i l i t a t i v e of  included  personal  r e s p o n s i b i l i t y f o r getting better, a p o s i t i v e therapeutic r e l a t i o n s h i p e i t h e r w i t h i n formal therapy  or within informal  r e l a t i o n s h i p s , acceptance o f the d y s f u n c t i o n w i t h i n t h e i r f a m i l y as w e l l as t h e c o n f l i c t i n g messages from t h e s o c i o c u l t u r a l system, and s e l f - a c c e p t a n c e . i s also discussed.  The meaning o f each o f t h e f a c t o r s  For example, i n e x p e r i e n c i n g a v a l i d a t i n g  t h e r a p e u t i c r e l a t i o n s h i p with o p p o r t u n i t i e s f o r intimacy and interdependence, i n d i v i d u a l s developed the c o n f i d e n c e t o e s t a b l i s h new r e l a t i o n s h i p s which r e q u i r e d n u t r i t i o n and strength. In summary, the treatment outcome l i t e r a t u r e  offers  assumptions about the c u r a t i v e f a c t o r s i n v o l v e d i n recovery and  12 the s t u d i e s i n t e r v i e w i n g recovered a n o r e x i c s have begun t o i l l u m i n e a p a t t e r n of r e c o v e r y .  But, t o date, none of the  s t u d i e s o f normal-weight b u l i m i a have p r o v i d e d a h o l i s t i c s y n t h e s i s of p a t t e r n s of meaning of r e c o v e r y .  Therefore,  this  study proposes t o i n v e s t i g a t e the phenomenon of r e c o v e r y from b u l i m i a by a s k i n g f o u r women t o d e s c r i b e t h e i r experience recovery.  of  Thematic c a t e g o r i e s u n d e r l y i n g the unique r e c o v e r y  experiences w i l l be e l u c i d a t e d and d e s c r i b e d i n o r d e r t o render a more complete p a t t e r n and understanding  of r e c o v e r i n g from  bulimia. Assumptions The assumptions u n d e r l y i n g t h i s study a r e : 1. The  i n d i v i d u a l who  has recovered from an e a t i n g d i s o r d e r  i s the expert on the meaning and e f f e c t of the v a r i a b l e s which were c r i t i c a l  i n her recovery  (Maine, 1985).  2. The c u r a t i v e f a c t o r s are not l i m i t e d t o those i n s i d e of formal therapy  (Maine, 1985).  3. The t h e r a p i s t and c l i e n t o f t e n emphasize d i f f e r e n t c r i t i c a l change experiences  i n t h e i r assessments of  treatment  (Hobbs e t a l . , 1989). 4. The  i n i t i a l change events are d i f f e r e n t from those t h a t  m a i n t a i n recovery  (Brownell e t a l . , 1986).  L i m i t a t i o n s of the Study S e l f - s e l e c t e d i n d i v i d u a l s may  be d i f f e r e n t from the  larger  p o p u l a t i o n i n terms of w i l l i n g n e s s t o share p e r s o n a l i n f o r m a t i o n w i t h o t h e r s as w e l l as being p s y c h o l o g i c a l l y minded and expressive.  verbally  T h e r e f o r e , sample b i a s c o u l d be an important  factor  13 t o c o n s i d e r when a p p l y i n g t h e r e s u l t s t o t h e r e c o v e r y f o r women w i t h normal-weight b u l i m i a (Borg & G a l l , Furthermore,  experience  1983).  t h e p a t t e r n o f recovery from b u l i m i a may be  d i f f e r e n t f o r males o r i n d i v i d u a l s w i t h o b e s i t y .  Thus, the  r e s u l t s o f t h i s study which d e s c r i b e t h e p a t t e r n o f r e c o v e r y f o r the one c o - r e s e a r c h e r may be a p p l i c a b l e t o some o t h e r women with normal-weight b u l i m i a .  14 Chapter I I L i t e r a t u r e Review What c o n s t i t u t e s recovery facilitative  of recovery  t h i s eating disorder? these q u e s t i o n s . s t u d i e s and  and what i s the process  T h i s chapter  explores  of recovery  from  issues r e l a t e d to  l i t e r a t u r e i s reviewed on treatment outcome  assumptions concerning  recovery  d i s o r d e r s , my  presuppositions  clinical  The  from b u l i m i a  i n the v a r i o u s approaches are a l s o d i s c u s s e d .  based upon the l i t e r a t u r e and my  recovery  What f a c t o r s are  s t u d i e s which examine t h e r a p e u t i c change agents.  l i m i t a t i o n s and inherent  The  from b u l i m i a ?  experience  Finally,  i n eating  about the nature and process  of  from b u l i m i a are s t a t e d so t h a t they can be s e t a s i d e  d u r i n g the r e s e a r c h  process.  Treatment Outcome S t u d i e s The  scope of t h i s p a r t of the l i t e r a t u r e review i s l i m i t e d  to c l i n i c a l  s t u d i e s on t r e a t i n g normal-weight b u l i m i c s , and  excludes s t u d i e s of b u l i m i c s with a s s o c i a t e d anorexia obesity.  nervosa or  Furthermore, t h i s review i s c o n f i n e d t o non-drug  treatment i n t e r v e n t i o n s which t h e r a p i s t s or c o u n s e l l o r s implement w i t h i n a c l i n i c a l  setting.  i n c l u d e the many pharmacological the u t i l i t y of t r i c y c l i c  Therefore,  included.  i t does not  antidepressant  drug therapy i n the manifest  depressive  However, the outcome s t u d i e s p e r t a i n i n g t o  psychodynamic and group and  can  s t u d i e s , most of which i n d i c a t e  treatment of normal-weight b u l i m i c s who symptoms.  thus  f a m i l y t h e r a p i e s as w e l l as the c o n t r o l l e d  i n d i v i d u a l c o g n i t i v e - b e h a v i o u r a l treatments have been According  to Fairburn  (1988), these v a r i o u s  15 t h e r a p e u t i c approaches have assumed t h a t the  etiological  v a r i a b l e s upon which they are based are a l s o the  catalysts,  change mechanisms, or c u r a t i v e f a c t o r s i n the r e c o v e r y However, these c l i n i c a l o b s e r v a t i o n s  process.  have not been r i g o r o u s l y  researched. The  r e s e a r c h on treatment approaches i s very young  & Connors, 1987); F a i r b u r n ' s approach was bulimia.  (Johnson  (1981) c o g n i t i v e - b e h a v i o u r a l  the f i r s t study on the treatment of normal-weight  And  behavioural  w h i l e a p l e t h o r a of s t u d i e s u s i n g c o g n i t i v e -  therapy appeared i n 1984  t o 1986,  l i t t l e research  on  the v a r i o u s p s y c h o l o g i c a l treatment approaches has been done s i n c e then  (Johnson & Connors).  The  t r e n d i n the  literature  seems t o be toward the study of drug treatments as w e l l as personality,  f a m i l y , and  socioeconomic c o r r e l a t e s of b u l i m i a .  Another p o s s i b l e e x p l a n a t i o n research  f o r the s c a r c i t y of treatment  i s t h a t with up t o 3-year follow-up  periods  i n c l u d e d i n the s t u d i e s , those which began i n 1986 i n progress  the  (Herzog et a l . , 1988;  being  may  still  be  Johnson & Connors; M i t c h e l l ,  Pyle, Hatsukami, Goff, G l o t t e r , & Harper, 1989). The  f o l l o w i n g s e c t i o n d i s c u s s e s the psychodynamic,  systems, and  cognitive-behavioural theories.  treatment outcome s t u d i e s are presented  and  v a r i o u s t h e o r e t i c a l assumptions concerning  The  family  corresponding  critiqued. recovery  Also,  from b u l i m i a  are e l u c i d a t e d . Psychodynamic Therapy The  Studies  psychodynamic treatment approach stems from the view  t h a t psychosomatic d i s o r d e r s are a m a n i f e s t a t i o n  the  of e a r l y  16 u n r e s o l v e d unconscious c o n f l i c t s and i n t r a p s y c h i c or u n d e r l y i n g difficulties  (Norman e t a l , 1986).  The i n d i v i d u a l has a sense of  p e r v a s i v e i n e f f e c t i v e n e s s which l e a d s t o e f f o r t s t o g a i n s e l f c o n t r o l i n the realm of weight  (Yager, 1988).  Psychodynamic  t h e o r y i n c l u d e s , but i s not l i m i t e d t o , F r e u d i a n p s y c h o a n a l y s i s and o b j e c t - r e l a t i o n s t h e o r y . c o n f l i c t s or developmental  Thus, treatment addresses the  needs of the i n d i v i d u a l and the  f u n c t i o n of the b u l i m i c symptoms w i t h i n her p s y c h o l o g i c a l economy (Herzog e t a l . , psychotherapy  1987).  The l i t e r a t u r e on psychodynamic  i s h e a v i l y a n e c d o t a l and l a c k s v a l i d i t y  causal analysis.  in i t s  E m p i r i c a l outcome s t u d i e s have been c r i t i c i z e d  by Herzog e t a l . (1987) because they l a c k c o n t r o l groups randomization and a l s o i n d i c a t e a l a c k of s i g n i f i c a n t i n outcome between p a t i e n t s who who  d i d not"  or  difference  r e c e i v e d psychotherapy and those  (p. 545).  In a c o n t r o l l e d follow-up study by Norman e t a l . (1986), i n d i v i d u a l s who or group  engaged i n a t l e a s t 12 weeks of e i t h e r  individual  i n s i g h t - o r i e n t e d therapy were compared t o those who  e i t h e r no treatment or o n l y m e d i c a l / n u t r i t i o n a l f o l l o w - u p . the E a t i n g A t t i t u d e s T e s t , Hopkins Adjustment  Symptom C h e c k l i s t , and  S c a l e , r e s u l t s a t a one-year  psychodynamic treatment was  had Using  Social  follow-up showed t h a t  a s s o c i a t e d with a decrease i n  d i s o r d e r e d e a t i n g behaviours and a t t i t u d e s , d e p r e s s i o n , and somatic concerns.  However, t h e r e was  measures of s o c i a l maladjustment,  no s i g n i f i c a n t r e m i s s i o n on  anxiety, interpersonal  s e n s i t i v i t y , or obsessive-compulsive t r a i t s .  Nonetheless,  i n d i v i d u a l s i n treatment r e p o r t e d improvements i n t h e i r moods and  17 concerns w i t h r e l a t i o n s h i p s and i s o l a t i o n .  Norman e t a l . suggest  t h a t t h e f i n d i n g s demonstrate a c h a r a c t e r o l o g i c a l maladjustment t h a t p e r s i s t s i n s p i t e o f improved b u l i m i c behaviours and appears t o not be d i r e c t l y l i n k e d t o e a t i n g  symptomatology.  Norman e t a l . (1986) underscore the need f o r follow-up s t u d i e s t o a l s o measure the p s y c h o l o g i c a l and s o c i a l components of b u l i m i a  i n order t o expand our understanding o f "the course o f  the d i s o r d e r as w e l l as . . . p o s s i b l e r i s k f a c t o r s f o r r e l a p s e and/or m a n i f e s t a t i o n  o f other p s y c h i a t r i c d i s o r d e r s "  (p. 56).  Concerning c u r a t i v e f a c t o r s , i n s p i t e o f t h e decrease i n b u l i m i c behaviours, knowledge o f the e f f e c t i v e n e s s o f s p e c i f i c psychodynamic techniques i s l i m i t e d because t h e psychodynamically-oriented  t h e r a p i s t s used a v a r i e t y o f s t y l e s .  From a psychodynamic approach, treatment should modifying the underlying overall psychological diminished 1986).  involve  c o n f l i c t s , r e s u l t i n g i n improvements i n  f u n c t i o n i n g and s e l f - e s t e e m ,  as w e l l as  b u l i m i c symptoms ( F a i r b u r n , 1988; Norman e t a l . ,  Issues which may be l i n k e d t o the d i s o r d e r e d  eating  behaviours i n c l u d e l i m i t e d intimacy w i t h and incomplete autonomy from f a m i l y , poor peer r e l a t i o n s h i p s , l o n e l i n e s s , poor body image, r o l e c o n f u s i o n ,  and u n c l e a r p e r s o n a l  g o a l s and v a l u e s .  Although psychodynamic therapy does not engage i n a c t i v e symptom management, t h e c o g n i t i v e a l t e r n a t i v e s and prompts o f the t h e r a p i s t may c o n s t i t u t e b e h a v i o u r a l therapeutic  contingencies.  a l l i a n c e involves empathetically  The  responding t o the  i n d i v i d u a l ' s developmental needs i n order t o f a c i l i t a t e her awareness and acceptance o f her needs and f e e l i n g s .  Forming  18 "achievable  g o a l s t h a t w i l l begin t o r e p l a c e the p a t i e n t ' s  desperate i n n e r s t r u g g l e f o r c o n t r o l with a growing sense o f mastery" i s a l s o emphasized  (Goldman, 1988, p. 566).  In a d d i t i o n , the t h e r a p e u t i c r e l a t i o n s h i p e n t a i l s understanding how the i n d i v i d u a l i s e x p e r i e n c i n g w i t h her t h e r a p i s t .  her r e l a t i o n s h i p  The assumption i s t h a t the i n d i v i d u a l ' s  i n t e r a c t i o n s i n therapy a r e a r e f l e c t i o n o f how she p e r c e i v e s h e r s e l f and others as w e l l as i n d i c a t i v e o f r e l a t i o n a l Therefore,  the t h e r a p e u t i c a l l i a n c e helps the i n d i v i d u a l become  aware o f h e r b e l i e f s and d e f e n s i v e  i n t e r a c t i o n a l s t y l e s which  f a c i l i t a t e a l t e r n a t e t h i n k i n g s t y l e s and coping (Bruch,  patterns.  behaviours  1973; Johnson e t a l . , 1987; S t e i g e r , 1989).  In summary, from the psychodynamic approach, recovery b u l i m i a e n t a i l s addressing  from  the i n d i v i d u a l ' s i n t r a p s y c h i c  developmental c o n f l i c t s and i n t e r a c t i o n a l p a t t e r n s w i t h i n the therapeutic relationship.  Although no d i r e c t symptom management  of b u l i m i c behaviours i s i n v o l v e d , the t h e r a p e u t i c  alliance  f a c i l i t a t e s the i n d i v i d u a l ' s awareness o f maladaptive c o g n i t i v e p a t t e r n s and i n t e r p e r s o n a l i n t e r a c t i o n s so t h a t t h i n k i n g and behavioural  s t y l e s become more f u n c t i o n a l .  Systemic Family The theory  Therapy  Studies  f a m i l y therapy s t u d i e s are based on f a m i l y systems  and t h e r e f o r e view the b u l i m i c symptoms as " r e l a t e d t o  f a m i l y processes  such as o v e r p r o t e c t i v e n e s s ,  e s c a l a t i n g power  s t r u g g l e s , o r the i n a b i l i t y o f f a m i l y members t o r e a l l y know each other"  (Schwartz e t a l . , 1985, p. 292). According  t o Johnson and  Connors (1987) and my own search o f the l i t e r a t u r e , t h e r e are  19 o n l y two  outcome s t u d i e s on the use  bulimia:  Schwartz (1982) and  Schwartz e t a l . (1985).  of a t t e n t i o n t o the f a m i l y context f a c t t h a t many b u l i m i c s no longer o r i g i n and  of f a m i l y therapy f o r  i n b u l i m i a may  This  lack  stem from the  l i v e w i t h t h e i r f a m i l i e s of  f e e l t h a t t h e i r f a m i l i e s should not be  treatment as they are unaware of the b u l i m i a  involved i n  (Schwartz e t a l . ) .  Consequently, t h e r a p i s t s are l e s s i n c l i n e d t o i n v o l v e f a m i l i e s i n the treatment  process.  Schwartz (1982) d e s c r i b e d therapy and  bulimia.  the f i r s t outcome study of  He used Minuchin's (1974, 1978)  f a m i l y therapy model, making some adaptations  structural  s p e c i f i c to  as he worked w i t h a 17-year-old b u l i m i c and her two  s e s s i o n s w i t h her p a r e n t s .  one-quarter were m a r i t a l  so t h a t Mary became more  r e l a t i o n s h i p and her mother.  a l s o became more i n v o l v e d w i t h her peers and f a m i l y enmeshment  her  still  the  d i s e n g a g i n g from p a r e n t s '  h a b i t — w e r e implemented.  food Mary was  marital issues,  ceased.  vomiting  and  from an i l l n e s s t o a  Owing t o t h e i r outrage at  wasting, her p a r e n t s i n t e r v e n e d  a v a i l a b l e only at meal times.  and  an i s s u e , Stage 2 g o a l s — u n i t i n g  changing the f a m i l y ' s view of Mary's b u l i m i a pleasurable  she  occurred.  decreased some but was  the parents,  As  f a t h e r , reduced  When a f t e r 3 months the frequency of b i n g e i n g had  one-third  In Stage 1, i n t e r v e n t i o n s were aimed  a t r e s t r u c t u r i n g the f a m i l y h i e r a r c h y d i s t a n t from her p a r e n t s '  bulimia  parents.  Therapy i n v o l v e d 31 s e s s i o n s over a one-year p e r i o d : were i n d i v i d u a l s e s s i o n s w i t h Mary and  family  by making  food  From here on, Mary's b u l i m i a  Furthermore, her s o c i a l confidence  and  autonomy were  20 enhanced by a c l a s s g r a d u a t i o n t r i p .  During t h i s time, her  p a r e n t s d i s c o v e r e d they c o u l d l i v e t o g e t h e r without Mary. Stage 3 of therapy i n v o l v e d m a r i t a l c o u n s e l l i n g  and  i n d i v i d u a l s e s s i o n s w i t h Mary which focused on l i f e p l a n n i n g r a t h e r than f a m i l y involvements. for  3 months and was  terminated.  Once Mary was  f r e e of b i n g e i n g  i n v o l v e d i n a r t s c h o o l , therapy  At a one-year  was  follow-up, r e s u l t s showed t h a t the  improvements were maintained.  Mary had e s t a b l i s h e d some c l o s e  female r e l a t i o n s h i p s , had begun i n t e r a c t i n g w i t h men, disengaged h e r s e l f from p a r e n t a l m a r i t a l f i g h t s .  Although  binged about once a month when she f e l t u p t i g h t , she unconcerned  about t h i s and f e l t t h a t food was  o b s e s s i o n " (Schwartz,  1982,  and  had she  "was  no l o n g e r an  p. 80).  Schwartz e t a l . (1985) conducted  a study w i t h 30 o u t p a t i e n t  b u l i m i c females and t h e i r f a m i l i e s i n which s t r u c t u r a l f a m i l y therapy and s t r a t e g i c symptom-specific  d i r e c t i v e s were used.  In  cases where f a m i l y of o r i g i n members were not p r e s e n t , therapy was  done w i t h the i n d i v i d u a l alone or her spouse and/or c h i l d r e n .  Treatment  i n v o l v e d an average of 3 3 s e s s i o n s over a  9-month p e r i o d .  The stages of therapy e n t a i l e d  (a) p r i m i n g the  i n d i v i d u a l and her f a m i l y f o r d i f f e r e n t i a t i o n and the d i f f e r e n t i a t i o n ,  facilitating  (b) f o c u s i n g on the symptom, and  c o n s o l i d a t i n g the changes.  (c)  In Stage 1, Schwartz e t a l .  c h a l l e n g e d f a m i l y and i n d i v i d u a l b e l i e f s and p a t t e r n s of interaction.  A l s o , they emphasized the importance  i n d i v i d u a l acknowledge t h a t she was  the one who  was  of h e l p i n g the b i n g e i n g and  p u r g i n g , and of f a c i l i t a t i n g her awareness and e x p e r i e n c i n g of  21 f e e l i n g s which t h e b u l i m i c behaviours helped h e r a v o i d .  In Stage  2, Schwartz e t a l . found t h a t i t was e a s i e r f o r t h e i n d i v i d u a l t o l e t go o f h e r symptoms i f she was not l i v i n g i n h e r p a r e n t s ' i n a dependency s i t u a t i o n .  Interventions  which helped t h e  i n d i v i d u a l g a i n more c o n t r o l over her b i n g e i n g i n c l u d e d reframing  home  and purging  the b u l i m i c episode as a s i g n a l t h a t she  wanted t o f e e l nurtured, interpersonal patterns  o r changing h e r i n t r a p e r s o n a l and/or  of i n t e r a c t i o n .  i n d i v i d u a l ' s i s s u e s o f intimacy, behaviour were addressed.  In Stage 3, t h e  career planning,  and a s s e r t i v e  When the t h e r a p i s t p r e s c r i b e d a  r e l a p s e , t h e i n d i v i d u a l and f a m i l y o f t e n became more aware o f how t o a v o i d r e - c r e a t i n g t h e i n t e r a c t i o n s which formed t h e context of bulimia. At t h e end o f treatment, 66% o f the s u b j e c t s had reduced the frequency o f t h e i r b u l i m i c episodes from a mean o f 19.3 per week t o t h e f i r s t l e v e l o f c o n t r o l over e a t i n g behaviours: fewer p e r month.  one o r  T h e i r a t t i t u d e s about c o n t r o l were t h a t they  f e l t " n e a r l y always i n c o n t r o l " (Schwartz e t a l . , 1985, p. 304). Ten  percent  o f the s u b j e c t s were a t the second l e v e l :  they had  episodes which ranged i n frequency from two p e r month t o one per week and s a i d they f e l t 3 04). first  " u s u a l l y i n c o n t r o l " (Schwartz e t a l . , p.  At a 16-month follow-up,  a l l o f t h e i n d i v i d u a l s a t the  l e v e l had maintained t h e i r improvements.  However, two-  t h i r d s o f t h e s u b j e c t s who were a t the second l e v e l had r e l a p s e d to the t h i r d l e v e l : being  two t o f o u r episodes per week w i t h c o n t r o l  somewhat o f a problem.  criteria—change  Results  o f t h e other outcome  i n f a m i l y r e l a t i o n s h i p s , change i n l i f e goals or  22 career,  and change i n t h e i n d i v i d u a l ' s behaviour i n e x t r a f a m i l i a l  relationships—were  not r e p o r t e d .  However, Schwartz e t a l . found  t h a t t h e o b s t a c l e t o f e e l i n g i n c o n t r o l o f b u l i m i c symptoms was not symptom c h r o n i c i t y but r a t h e r l i v i n g a t home w i t h  parents.  Although t h e outcomes from these two f a m i l y treatment s t u d i e s a r e promising, determining t h e r e l a t i v e e f f e c t i v e n e s s o r necessity of s p e c i f i c interventions i s precluded  because o f t h e  wide v a r i e t y o f i n t e r v e n t i o n s used and t h e u n c o n t r o l l e d nature o f the s t u d i e s .  C l e a r l y more c o n t r o l l e d s t u d i e s t o i s o l a t e  specific  components o f f a m i l y therapy and t h e i r e f f e c t s a r e r e q u i r e d t o a s s i s t i n developing  a model f o r t r e a t i n g b u l i m i c f a m i l i e s .  importance o f understanding b u l i m i a  The  from a f a m i l y p e r s p e c t i v e i s  underscored by Schwartz e t a l . (1985) who have found i t uncommon t h a t f a m i l i e s a r e unaware o f t h e i r daughter's b u l i m i a and even more unusual t h a t they a r e u n w i l l i n g t o become i n v o l v e d i n therapy.  Furthermore, many b u l i m i c s a r e o f t e n s t i l l  to t h e i r f a m i l i e s i n s p i t e of geographical The  assumptions concerning  recovery  distance  quite  tied  from them.  from b u l i m i a which a r e  inherent  i n t h e f a m i l y therapy s t u d i e s a r e t h a t a c e s s a t i o n o f  bingeing  and purging,  denotes recovery  o r no r e l a p s e s even though l a p s e s may occur  (Schwartz, 1982; Schwartz e t a l . , 1985).  And  w h i l e improvements i n t h e f a m i l y s t r u c t u r e and h i e r a r c h y which a c t i v a t e and support t h e i n d i v i d u a l ' s d i f f e r e n t i a t i o n from t h e f a m i l y system a r e necessary and f o u n d a t i o n a l cases,  they may not be s u f f i c i e n t .  t o recovery  f o r most  I n d i v i d u a l s ' ambivalence  about g i v i n g up t h e i r symptoms and t h e f e a r o f many f a m i l i e s regarding  t h e growing autonomy o f t h e i r daughters may c o n t r i b u t e  23 t o t h e p e r s i s t e n c e o f the b u l i m i c symptoms i n some i n d i v i d u a l s i n s p i t e o f e f f e c t i v e f a m i l y r e s t r u c t u r i n g (Schwartz e t a l . ) -  Thus,  some form o f i n t e n s i v e symptom-specific i n t e r v e n t i o n s such as m o n i t o r i n g food consumption o r r e d e f i n i n g the b u l i m i c  episodes  may be necessary t o e l i m i n a t e o r g a i n c o n t r o l o f the b u l i m i c behaviours  (Schwartz; Schwartz e t a l . ) .  Furthermore, these two s t u d i e s emphasize the importance o f working i n stages,  a l b e i t d i f f u s e and f l e x i b l e stages.  The  i n d i v i d u a l needs t o have f i r s t a t t a i n e d a degree o f d i f f e r e n t i a t i o n from her f a m i l y p r i o r t o i n t r o d u c i n g symptomfocused  i n t e r v e n t i o n s because the b u l i m i c behaviours can be  r e a c t i v a t e d by f a m i l y i n t e r a c t i o n a l p a t t e r n s . i n d i v i d u a l i s less protected extent  Finally,  once the  by and p r o t e c t i v e o f her f a m i l y , the  t o which she i s able t o develop s a t i s f y i n g and c l o s e  e x t r a f a m i l i a l r e l a t i o n s h i p s i s purported by Schwartz c r u c i a l t o recovery  (1982) as  because "the feedback the p a t i e n t  from new f r i e n d s helped t o decrease her preoccupation weight and w i t h her appearance i n g e n e r a l ,  received with her  a preoccupation  seems h i g h l y c o r r e l a t e d with the e a t i n g d i s o r d e r "  (p.  81).  In summary, from the f a m i l y therapy approach, recovery bulimia  that  from  i n v o l v e s changes i n i n t e r p e r s o n a l i n t e r a c t i o n s w i t h i n the  f a m i l y and e x t r a f a m i l i a l contexts.  I n t r a p s y c h i c changes i n the  emotional and c o g n i t i v e realms which a r e e f f e c t e d by the changes i n s o c i a l r e l a t i o n s h i p s a r e a l s o considered recovery.  to f a c i l i t a t e  And, with some i n d i v i d u a l s , b e h a v i o u r a l  interventions  aimed a t i n t e r r u p t i n g the b u l i m i c p a t t e r n may need t o be combined  24 w i t h changes i n the f a m i l y ' s f u n c t i o n i n g and i n t e r a c t i o n a l patterns. Cognitive-Behavioural  Therapy  Studies  Most o f the treatment r e s e a r c h on b u l i m i a has cognitive-behavioural  (CB)  i n d i v i d u a l contexts.  Cognitive-behavioural  focused  i n t e r v e n t i o n s i n both group therapy  on  and  (CBT)  is  based on s o c i o c u l t u r a l and p s y c h o l o g i c a l t h e o r i e s which h i g h l i g h t r e s p e c t i v e l y the r i s k f a c t o r s of s o c i o c u l t u r a l norms f o r t h i n n e s s as an i n d i c a t o r of feminine (Striegel-Moore  a t t r a c t i v e n e s s , success  et a l . , 1986), and  image d i s s a t i s f a c t i o n  low  self-esteem  (Schwartz et a l . , 1985;  and due  control t o body  Fairburn,  1985).  Inherent i n the CB s t u d i e s i s the n o t i o n t h a t recovery i n d i c a t e d by  freedom from b i n g e i n g  (Connors e t a l . , 1984; 1987;  Manley, 1989)  and  ad purging,  Cooper e t a l . , 1989;  Johnson & Connors,  i n v o l v e s addressing  T h i s approach advocates  the abnormal e a t i n g behaviour  u s i n g predominantly b e h a v i o u r a l  techniques  degree of c o n t r o l over e a t i n g .  Modifying  and v a l u e s  relapses  a decreased i n t e n s i t y of d y s f u n c t i o n a l  a t t i t u d e s toward body shape and weight. that recovery  or no  is  t o e s t a b l i s h some dysfunctional  beliefs  about body shape and weight which p e r p e t u a t e the  b u l i m i c behaviours are a l s o c o n s i d e r e d ( F a i r b u r n , 1985).  CBT  v a r i e t y of b e h a v i o u r a l  necessary f o r  recovery  i s a "treatment package" i n v o l v i n g a and  cognitive interventions.  Therefore,  change i n d i s t u r b e d e a t i n g h a b i t s as w e l l as a t t i t u d e s towards shape and weight i s necessary f o r l a s t i n g recovery al.).  According  to Fairburn  (Cooper et  (1988), change i n a t t i t u d e toward  body shape and weight i s the best p r e d i c t o r of  prognosis.  a  25 Another assumption of the CB approach i s t h a t the  establishment  of a t r u s t i n g t h e r a p e u t i c r e l a t i o n s h i p i s paramount t o  recovery  because the t h e r a p i s t i s c o n t i n u a l l y encouraging the i n d i v i d u a l "to take r i s k s i n m o d i f y i n g e a t i n g b e h a v i o u r s " 153).  (Manley, 1989,  p.  Thus, i n d i v i d u a l r e s p o n s i b i l i t y f o r p r o g r e s s i s  emphasized. According  to Fairburn  (1985), i n Stage 1 of  i n t e r r u p t i o n of the binge/purge behaviours and  CBT,  regaining control  over e a t i n g i s f a c i l i t a t e d through techniques such as about v a r i a b i l i t y  education  i n body weight, weight r e g u l a t i o n , the  between d i e t i n g and b i n g e i n g  and  link  body image m i s p e r c e p t i o n .  Self-  m o n i t o r i n g of e a t i n g h a b i t s and the circumstances a s s o c i a t e d binge/purge episodes and p r e s c r i p t i o n of a r e g u l a r e a t i n g are other  i n t e r v e n t i o n s which are used.  t e c h n i q u e s i n c l u d e stimulus  Additional  with  pattern  behavioural  c o n t r o l measures which i n v o l v e  l i m i t i n g the amount of "dangerous" food  i n the house  and  implementing a l t e r n a t i v e behaviours which are incompatible  with  binge e a t i n g . In Stage 2, c o g n i t i v e i n t e r v e n t i o n s are employed t o and modify d y s f u n c t i o n a l b e l i e f s and v a l u e s weight are of fundamental importance and under s t r i c t c o n t r o l " ( F a i r b u r n , 1985, t e c h n i q u e s i n c l u d e the gradual of " f a t t e n i n g foods"  and  identify  t h a t one's "shape and  t h a t both must be  p. 161).  kept  Therefore,  i n t r o d u c t i o n of moderate amounts  r e l a x i n g of c o n t r o l over the content of  one's d i e t i n order to c h a l l e n g e  the b e l i e f " t h a t c e r t a i n foods  are i n h e r e n t l y f a t t e n i n g " ( F a i r b u r n , 1985,  p. 177).  Problem-  s o l v i n g t r a i n i n g which h e l p s the i n d i v i d u a l generate a l t e r n a t i v e  26 ways of d e a l i n g w i t h adverse events,  thoughts or emotions without  r e s o r t i n g t o b i n g e i n g tends t o counter a l l - o r - n o t h i n g t h i n k i n g and decrease t h e i r preoccupation Relaxation  and  w i t h food and  weight.  a s s e r t i v e n e s s t r a i n i n g as w e l l as  enhancing imagery may  a l s o be i n c l u d e d .  which i n v o l v e s d i s c u s s i n g and g e n e r a t i n g dysfunctional b e l i e f s — " I  efficacy-  Cognitive restructuring counter-arguments t o  f e e l f a t and t h e r e f o r e I am  f a t " and  "I  must be t h i n , because t o be t h i n i s t o be s u c c e s s f u l , a t t r a c t i v e and happy" ( F a i r b u r n , 1985, and  c o s t s of adhering Finally,  p. 1 8 2 ) — a n d examining the b e n e f i t s  t o them i s a l s o used.  i n order t o d e a l with  f u t u r e l a p s e s or r e l a p s e s  so  t h a t the episodes do not get out of c o n t r o l , a p l a n i s d e v i s e d a n t i c i p a t e and (Wilson,  cope with h i g h r i s k s i t u a t i o n s .  Rossiter, K l e i f i e l d ,  Stage 3 which focuses response p r e v e n t i o n " forbidden  foods,  & Lindholm, 1986)  on r e l a p s e p r e v e n t i o n  Some s t u d i e s also include  u s i n g "exposure with  i n which s u b j e c t s are encouraged t o eat  but then t o delay or r e f r a i n from  purging.  W i t h i n the e m p i r i c a l r e s e a r c h l i t e r a t u r e , the CB are o f t e n compared with another group which may c o g n i t i v e or b e h a v i o u r a l treatment.  And  to  techniques,  r e c e i v e fewer  or j u s t a p u r e l y  w h i l e these s t u d i e s demonstrate  s i g n i f i c a n t reductions  treatments  behavioural  statistically  i n binge/purge behaviours,  the e f f e c t s of  s p e c i f i c components of the treatment packages on symptom r e d u c t i o n have not been i d e n t i f i e d . of K i r k l e y e t a l . (1985) and impossible  For i n s t a n c e ,  i n the  studies  F a i r b u r n et a l . (1986), i t i s  t o determine which i n t e r v e n t i o n s of the CB  packages are r e s p o n s i b l e f o r the s t a t i s t i c a l l y  treatment  significant  27  results.  F u r t h e r r e s e a r c h u s i n g component a n a l y s e s i s needed i n  which the comparison form of therapy d i f f e r s i n terms of one  or  more e s s e n t i a l elements so t h a t the s p e c i f i c i n t e r v e n t i o n s or combinations  which are necessary and most e f f e c t i v e i n producing  symptom change can be teased out et  a l . , 1986;  Johnson & Connors, 1987;  Another shortcoming of  longterm  (Cooper e t a l . , 1989; Kirkley et a l . ,  of the CB s t u d i e s i s t h a t the  follow-up r e s e a r c h p r e c l u d e s understanding  Fairburn 1986). scarcity the  l o n g i t u d i n a l course of b u l i m i a and the nature of the change mechanisms which i n i t i a t e , ( M i t c h e l l e t a l . , 1989). changes i n a s s e r t i o n  facilitate,  and m a i n t a i n recovery  F i n a l l y , w h i l e the s t u d i e s a l s o measure  ( K i r k l e y e t a l . , 1985), s e l f - e s t e e m (Connors  et a l . , 1984), d e p r e s s i o n (Lacey, 1983), s o c i a l adjustment,  and  a t t i t u d e s about food, d i e t i n g and body image (Ordman & Kirschenbaum, 1985), comparison of r e s u l t s i s d i f f i c u l t because of  the d i v e r s i t y and  i n c o n s i s t e n c y of p s y c h o s o c i a l outcome  c r i t e r i a between the s t u d i e s . C o g n i t i v e - b e h a v i o u r a l s t u d i e s by F a i r b u r n e t a l . (1986) and Cooper e t a l . (1989) found t h a t the c o n t r o l c o n d i t i o n which c o n t a i n e d a p u r e l y b e h a v i o u r a l treatment  resulted i n significant  improvements i n b i n g e i n g and purging behaviours.  Consequently,  the n e c e s s i t y of the c o g n i t i v e component i n producing change i s questioned. treatment may  Furthermore,  have produced  symptomatic  although the b e h a v i o u r a l  c o g n i t i v e change as suggested  by  improvements on the E a t i n g A t t i t u d e T e s t , f u r t h e r s t u d i e s are needed t o address whether c o g n i t i v e change i s necessary f o r recovery.  28 According  to Fairburn  (1985), c e r t a i n b e h a v i o u r a l  i n t e r v e n t i o n s such as the i n t r o d u c t i o n of a r e g u l a r e a t i n g p a t t e r n and  avoided  foods g i v e i n c r e a s e d c o n t r o l over e a t i n g  which i n t u r n i n c r e a s e one's sense of mastery and  progressively  decrease d i s t u r b e d t h i n k i n g about body weight and  shape.  r e s u l t s are s u b s t a n t i a t e d by Schneider, who  found t h a t decreases i n purging  These  O'Leary, and Agras (1987)  behaviour were s i g n i f i c a n t l y  r e l a t e d t o i n c r e a s e s i n t h r e e domains of p e r c e i v e d  self-efficacy:  c o n t r o l l i n g b i n g e i n g d u r i n g v a r i o u s mood s t a t e s , c o n t r o l l i n g b i n g e i n g u s i n g s t i m u l u s - c o n t r o l techniques, satisfactory social relationships.  and  developing  While the i n c r e a s e d  e f f i c a c y p e r t a i n i n g t o acceptance of body shape was w i t h decreased purging d u r i n g treatment. behavioural  self-  correlated  frequency, i t d i d not change s i g n i f i c a n t l y  Thus, i t seems t e n a b l e t o conclude t h a t  techniques  which decrease purging  enhance the i n d i v i d u a l ' s p e r c e i v e d  behaviours a l s o  s e l f - e f f i c a c y or b e l i e f t h a t  she can use her s k i l l s t o e f f e c t i v e l y respond t o s i t u a t i o n s . However, F a i r b u r n  (1985) advocated t h a t b e l i e f s and v a l u e s  s t i l l be e x p l o r e d  even i f formal  should  cognitive restructuring i s  unnecessary because o f t e n times "although t h e r e has been some c o g n i t i v e change, c e r t a i n core a t t i t u d i n a l a b n o r m a l i t i e s intact"  (p.  remain  183).  In summary, the c o g n i t i v e - b e h a v i o u r a l approach advocates that while behavioural  techniques  c o n t r o l over e a t i n g behaviours, l a s t i n g recovery.  The  are necessary t o r e e s t a b l i s h  they are not s u f f i c i e n t f o r  d i s t u r b e d t h i n k i n g and v a l u e s about body  shape and weight which maintain  the b i n g e i n g  and  purging  29 behaviours must a l s o be m o d i f i e d ( F a i r b u r n , 1985).  through c o g n i t i v e  interventions  F i n a l l y , although t h e CB approach  presents  change as an ordered process with t h e f i r s t stage focused on e a t i n g behaviour and t h e second stage proceeding through an ordered s e r i e s o f w e l l - d e f i n e d  c o g n i t i v e r e s t r u c t u r i n g steps, the  e n t i r e program i s c o g n i t i v e l y o r i e n t e d .  In p r a c t i s e , s i g n i f i c a n t  c o g n i t i v e change o f t e n occurs d u r i n g Stage 1 and t h e e a r l y p a r t of Stage 2 so t h a t t h e course o f formal  cognitive restructuring  "tends t o be h i g h l y v a r i a b l e and e r r a t i c "  ( F a i r b u r n , 1985, p.  183) . Therapeutic  Change Agent  Studies  While the treatment outcome s t u d i e s assume t h a t t h e c u r a t i v e f a c t o r s a r e t h e change mechanisms w i t h i n formal approaches, t h e t h e r a p e u t i c interviewed  therapeutic  change agent s t u d i e s , which  i n d i v i d u a l s who a r e r e c o v e r i n g  o r who have  recovered  from an e a t i n g d i s o r d e r , found t h a t f a c t o r s both i n s i d e and o u t s i d e o f therapy f a c i l i t a t e d recovery.  However, s i n c e the  change agent s t u d i e s uncovered only i s o l a t e d aspects o f the recovery  experience and r e v e a l e d  only p a r t i a l meanings o f some o f  the f a c i l i t a t i v e events f o r some o f the i n d i v i d u a l s , t h e p a t t e r n of t h e p r o c e s s o f recovery  was l i m i t e d and incomplete.  Given t h a t the i n d i v i d u a l who has recovered d i s o r d e r i s t h e expert which were c r i t i c a l  from an e a t i n g  on t h e meaning and e f f e c t o f t h e v a r i a b l e s  i n her recovery  (Maine, 1985), and g i v e n  that  the t h e r a p i s t and c l i e n t o f t e n emphasize d i f f e r e n t c r i t i c a l change e x p e r i e n c e s i n t h e i r assessments o f treatment al.,  (Hobbs e t  1989), only the s t u d i e s which r e p o r t t h e recovered  30 i n d i v i d u a l ' s p e r s p e c t i v e on Therefore, studies  i n which the  curative  f a c t o r s and  included  (Bruch, 1988;  1986;  facilitative  In the  therapist  t h e i r impact on the Erickson,  Maddocks & Bachor, 1986;  f a c t o r s are  1985;  or f a m i l y  reviewed. recounted  the  r e c o v e r y p r o c e s s are  not  Goldman, 1988;  Rabinor, 1986;  Jackson,  Vognsen, 1985).  study by Hobbs e t a l . (1989), t h e r a p i s t s  and  i n d i v i d u a l s w i t h b u l i m i a were asked a t 3-week i n t e r v a l s d e s c r i b e the  events i n group therapy which were  important f o r them.  Judges then a s s i g n e d one  f a c t o r s t o each event. and  acceptance as  vicarious  throughout the  and  self-disclosure  instillation  importance of the v a r i o u s f a c t o r s  10 weeks:  Self-disclosure,  i n the middle phase, and Concerning the  vicarious  e a r l y stage,  instillation  f a c t o r s because of s u b t l e  of hope i n the  "vicarious  learning"  differences  important f o r her.  i s d e f i n e d as  "the  group members ( i n c l u d i n g the t h e r a p i s t ) " And  the  perceives that  f i n a l phase.  research t o o l low.  in reporting.  For  patient  something of v a l u e f o r h e r s e l f through the  627).  and  For  same event t o d i f f e r e n t t h e r a p e u t i c  u s i n g t h i s methodology d i l u t e s the meaning of the i t was  learning  self-understanding  i n t e r r a t e r r e l i a b i l i t y was  i n s t a n c e , judges assigned the  i n d i v i d u a l or why  of hope,  shifted  l i m i t a t i o n s of t h i s study, the  problematic i n that  therapeutic  u n i v e r s a l i t y as most important.  u n i v e r s a l i t y were v a l u e d i n the  was  personally  of ten  valued  important, c l i e n t s r a t e d  learning,  Furthermore, the  While t h e r a p i s t s  to  In  addition,  event f o r  the  example, experiences  o b s e r v a t i o n of  other  (Hobbs e t a l . , 1989,  d e f i n i t i o n of " u n i v e r s a l i t y " i s "the  patient  other group members have s i m i l a r problems  and  p.  31 f e e l i n g s and t h i s reduces her sense of uniqueness" p. 627).  Thus, o n l y a p a r t i a l understanding  the experience  (Hobbs e t a l . ,  of the meaning of  f o r the i n d i v i d u a l i s gained and the impact  event on her r e c o v e r y experience  i s not e l u c i d a t e d .  of the  Further  r e s e a r c h i n t o the nature of t h e r a p e u t i c e f f e c t s w i t h i n s m a l l group treatments Nonetheless,  of b u l i m i a i s t h e r e f o r e r e q u i r e d . Hobbs e t a l . (1989) d i s c u s s e d s e v e r a l  assumptions of recovery i m p l i e d by the r e s u l t s which are noteworthy.  F i r s t , w h i l e d i s c l o s u r e of p e r s o n a l i n f o r m a t i o n can  be important  i n overcoming b u l i m i a , e x p e r i e n c i n g one's s e l f -  d i s c l o s u r e s as accepted by o t h e r s was  paramount t o p e r c e i v i n g  s e l f - d i s c l o s u r e as t h e r a p e u t i c a l l y v a l u a b l e .  Second,  u n i v e r s a l i t y or r e a l i z i n g t h a t o t h e r s have s i m i l a r problems and f e e l i n g s may  enhance an i n d i v i d u a l ' s sense of b e l o n g i n g ,  and/or acceptance  support,  even though she has r e v e a l e d i n f o r m a t i o n about  h e r s e l f which she had c o n s i d e r e d unacceptable. i n d i v i d u a l s shared how  T h i r d , as  t h e i r improvements o c c u r r e d , v i c a r i o u s  l e a r n i n g c o n t r i b u t e d t o a sense of optimism about one's progress or the p o t e n t i a l f o r p r o g r e s s . Stanton e t a l . (1986) e x p l o r e d the nature of s e l f - c h a n g e i n b u l i m i a by i n t e r v i e w i n g and a d m i n i s t e r i n g a m o d i f i e d v e r s i o n of the Processes of Change T e s t t o 15 former b u l i m i c s who recovered i n the absence of formal therapy.  On the  had  average,  i n d i v i d u a l s had been a b s t i n e n t from b i n g e i n g and purging f o r 7 months p r i o r t o the study.  Although  the study uncovers the  c u r a t i v e f a c t o r s i n the "contemplation treatment,  i n s i g h t i n t o the meaning and  and a c t i v e s t a g e s " of impact  of the events i s  32 minimal. Data from the s t r u c t u r e d i n t e r v i e w showed t h a t i n the "contemplation  stage" of r e c o v e r y "a d e s i r e t o improve  s e l f - e s t e e m was eating"  most i n f l u e n t i a l i n i n i t i a t i n g change i n binge  (Stanton e t a l . ,  1986,  p. 921)  and t h a t r e c o g n i t i o n of  the i l l - h e a l t h e f f e c t s i n i t i a t e d change i n p u r g i n g A c c o r d i n g t o Stanton e t a l . ,  these f a c t o r s may  behaviours.  correspond t o the  s u b s c a l e s on the Processes of Change T e s t of s e l f - r e e v a l u a t i o n — "I c o n s c i o u s l y s t r u g g l e w i t h the i s s u e t h a t p u r g i n g c o n t r a d i c t s my view of myself as an e f f e c t i v e person i n c o n t r o l of my life"—and  consciousness r a i s i n g :  "I t h i n k about i n f o r m a t i o n  from a r t i c l e s or ads concerning the b e n e f i t s of q u i t t i n g e a t i n g or p u r g i n g "  own  binge  (p. 919).  In the subsequent " a c t i v e change stage" of r e c o v e r y , t e s t r e s u l t s r e v e a l e d t h a t the f a c t o r s which were used most f r e q u e n t l y i n overcoming b u l i m i c behaviours were " s e l f - l i b e r a t i o n myself  ('I  tell  I am a b l e t o q u i t purging i f I want t o ' ) ,  counterconditioning  ('I do something e l s e i n s t e a d of binge e a t i n g  when I need t o r e l a x or d e a l w i t h t e n s i o n ) , . . . [and] h e l p i n g 1  relationships  ( 1 can be open w i t h a t l e a s t one s p e c i a l 1  about my  e x p e r i e n c e s w i t h my  1986,  919).  p.  In 1983, 217  eating h a b i t s ) " 1  person  (Stanton e t a l . ,  H a l l and Cohn ( c i t e d i n H a l l & Cohn, 1986)  surveyed  recovered and r e c o v e r i n g b u l i m i c s — j u s t over h a l f of whom had  a l s o had a n o r e x i a — t o uncover f a c t o r s t h a t were h e l p f u l i n recovery.  I n d i v i d u a l s ranked  10 therapy o p t i o n s and  13  helpful  a c t i v i t i e s on a 5 - p o i n t s c a l e with 1 = no h e l p and 5 = most h e l p .  33 Of t h e 3 0 i n d i v i d u a l s who r e p o r t e d t h a t they were cured, 80% s t a t e d t h a t p r o f e s s i o n a l therapy was "most h e l p f u l " , 54% r a t e d f r i e n d s and f a m i l y as h e l p f u l , 47% i d e n t i f i e d s p i r i t u a l p u r s u i t s , 40% acknowledged p r o f e s s i o n a l l y - l e d groups, and 27% r e f e r r e d t o s e l f - l e d support groups.  R e s u l t s from the 3 0 recovered  i n d i v i d u a l s concerning h e l p f u l a c t i v i t i e s i n c l u d e d :  talking  about b u l i m i a (80%), p h y s i c a l e x e r c i s e (80%), r e l a x a t i o n techniques  (67%), r e a d i n g a n e w s l e t t e r from a s e l f - h e l p  organization Implicit  (63%), and j o u r n a l w r i t i n g (60%). i n t h i s study i s the assumption t h a t r e c o v e r y  i n v o l v e s f a c t o r s both i n s i d e and o u t s i d e o f formal However, g i v e n the close-ended  therapy.  nature of t h e q u e s t i o n n a i r e  format, minimal i n s i g h t was gained i n t o t h e meaning o f these events  f o r t h e i n d i v i d u a l s and how they impacted  recovery.  t h e process of  F o r example, only t h e meaning of s p i r i t u a l p u r s u i t s  was f u r t h e r e x p l o r e d .  S p e c i f i c r e l i g i o n s and p r a c t i s e s were  r e p o r t e d t o g i v e i n d i v i d u a l s a sense of comfort,  peace, and  s e c u r i t y as they experienced being l o v e d u n c o n d i t i o n a l l y r e g a r d l e s s of how they looked o r what the d i d .  Furthermore, the  scope o f c u r a t i v e f a c t o r s was l i m i t e d as p o s s i b l e f a c t o r s which the recovered i n d i v i d u a l s c o n s i d e r e d h e l p f u l were not i n c l u d e d i n the q u e s t i o n n a i r e .  Instead, only t h e t h e r a p i s t s ' p e r s p e c t i v e s on  f a c i l i t a t i v e events were used t o d e s i g n the survey. Kirk  (1986) a d m i n i s t e r e d a q u e s t i o n n a i r e comprised  p o t e n t i a l treatment  o f 74  o r recovery methods i d e n t i f i e d i n t h e  l i t e r a t u r e t o 123 recovered b u l i m i c s i n order t o a s c e r t a i n what they " [ p e r c e i v e d ] as s i g n i f i c a n t f a c t o r s i n t h e i r r e c o v e r y " (p.  34 11).  Open-ended q u e s t i o n s were a l s o used i n order t o e l i c i t  f a c i l i t a t i v e f a c t o r s not i n c l u d e d i n the q u e s t i o n n a i r e . a d d i t i o n , K i r k conducted  In  a s t r u c t u r e d personal interview with  c o n s e n t i n g i n d i v i d u a l s i n order t o g a i n i n s i g h t i n t o  self-image  changes s i n c e having recovered, c o n f i d e n c e i n m a i n t a i n i n g freedom from b i n g e i n g and purging, and c u r r e n t coping mechanisms. R e s u l t s showed t h a t 3 o f the 10 items r a t e d as most h e l p f u l t o more than 50% o f the respondents  were concerned  the i s s u e s u n d e r l y i n g the b u l i m i c behaviours: turned t o o r away from food when bored, " f i n d i n g a sense of my t r u e s e l f o b s e r v i n g my own b e h a v i o u r s ) "  tired,  with exploring  " l e a r n i n g why I angry"  (73.3%),  (no l o n g e r s t a n d i n g o u t s i d e  (69.8%), and " l e a r n i n g t o c a l l on  my i n n e r r e s o u r c e s - d e t e r m i n a t i o n , courage, p a t i e n c e " (64.9%) ( K i r k , 1986, p. 65). C o g n i t i v e - b e h a v i o u r a l techniques  found t o be most h e l p f u l t o  the m a j o r i t y of i n d i v i d u a l s i n c l u d e d " l e a r n i n g t o c o n t r o l d e f e a t i n g thoughts over-concerned (69.0%),  and f e e l i n g s "  (69.2%),  self-  " l e a r n i n g not t o be  w i t h other peoples' o p i n i o n s and r e a c t i o n s "  " l e a r n i n g c o n s t r u c t i v e ways t o d e a l w i t h anger"  " l e t t i n g go o f my should statements" range o f s o c i a l a c t i v i t i e s "  (65.7%),  (65.5%), and "widening  (63.8%) ( K i r k , 1986, p. 69).  one of t h e most h e l p f u l items was a food i s s u e :  my  Only  " l e a r n i n g t o eat  a h e a l t h y b r e a k f a s t , lunch, and d i n n e r " was h e l p f u l t o 66.9% of the respondents"  (p. 71).  A d d i t i o n a l i n f o r m a t i o n on f a c i l i t a t i v e f a c t o r s was from the open-ended q u e s t i o n s .  T r u s t i n g and l o v i n g  w i t h s u p p o r t i v e b o y f r i e n d s , spouses,  gained  relationships  f a m i l y members, o r God  35 helped i n d i v i d u a l s r e a l i z e t h a t they "had good q u a l i t i e s of [ t h e i r ] own  and t h a t [they] d i d n ' t have t o earn l o v e , f r i e n d s h i p  and a t t e n t i o n " ( K i r k , 1986,  p. 130).  r e l a t i o n s h i p s and a c t i v i t i e s through Anonymous decreased  Also,  spiritual  groups such as  Overeaters  i n d i v i d u a l s ' p r e o c c u p a t i o n w i t h food as they  c o n c e n t r a t e d on a s p i r i t u a l power and l e t "go of the [they] thought ( K i r k , p. 13 0).  control  [they] needed i n l i f e t o a h i g h e r power  (God)  11  In t u r n , they gained c o n t r o l over t h e i r e a t i n g  behaviours. With r e s p e c t t o i n f o r m a t i o n c u l l e d from the p e r s o n a l i n t e r v i e w s , respondents a f t e r recovery: and  r e p o r t e d "an i n c r e a s e i n s e l f - e s t e e m  They [were] more i n touch w i t h t h e i r  [had] c o n f i d e n c e i n themselves"  (Kirk, 1986,  Furthermore, 10 of the 12 respondents f a i r l y t o v e r y c o n f i d e n t t h a t they binge-purge c y c l e "  (p. 134).  p.  feelings  134).  i n d i c a t e d " t h a t they were  [would] not r e t u r n t o the  Current coping mechanisms i n c l u d e d  i n c r e a s e d communication w i t h o t h e r s , e x e r c i s e , and f o r r e l a x a t i o n w i t h i n a busy schedule.  finding  time  Thus, as i s  c h a r a c t e r i s t i c of the t h e r a p e u t i c change agent s t u d i e s , only p a r t i a l meanings of some of the f a c i l i t a t i v e events  f o r some of  the i n d i v i d u a l s were e x p l o r e d and no c l e a r p a t t e r n of the of r e c o v e r y was Beresin  process  uncovered.  (198 5) conducted  a p i l o t study i n which a group of  recovered a n o r e x i c s and a c o n t r o l group of a n o r e x i c s were i n t e r v i e w e d and asked t o complete s e v e r a l s c a l e s .  Findings  i n d i c a t e d t h a t the recovered a n o r e x i c s showed improvement on the extended f a m i l y s u b s c a l e of the S o c i a l Adjustment S c a l e and  on  36  the p e r f e c t i o n i s m s u b s c a l e of the E a t i n g D i s o r d e r s  Inventory.  F a c t o r s i n formal therapy which were r e p o r t e d as f a c i l i t a t i v e of recovery  i n c l u d e d a non-judgmental t h e r a p i s t who  empathic and c o n f r o n t a t i v e , and with whom they who  they were.  was  both  f e l t validated for  T h i s t h e r a p e u t i c r e l a t i o n s h i p helped i n d i v i d u a l s  t o i d e n t i f y and t r u s t t h e i r f e e l i n g s and t o begin t a k i n g r i s k s with others.  Through therapy,  they a l s o r e a l i z e d t h e i r  families*  c o n t r i b u t i o n t o t h e i r e a t i n g d i s o r d e r , f a m i l y members became more aware of each o t h e r s ' f e e l i n g s , and  i n d i v i d u a l s began t o  p h y s i c a l l y and e m o t i o n a l l y  from t h e i r f a m i l i e s and  d e - i d e a l i z e and group therapy  separate  f o r g i v e t h e i r mothers.  Curative factors within  or s e l f - h e l p groups i n c l u d e d f e e l i n g supported  understood by others s t r u g g l i n g with the same f e e l i n g s , owning t h e i r f e e l i n g s without As o u t - o f - t h e r a p y  assumes t h a t recovery curative factors.  and  and  shame or f e a r .  experiences  i n - t h e r a p y experiences,  recovery  to  Beresin  were r a t e d as important  (1985), as does Maine  as  (1985),  i n v o l v e s an i n t e r a c t i o n of both types  Personal experiences  of s e l f which  i n c l u d e g e t t i n g bored with anorexia,  of  facilitated  expressing f e e l i n g s  t o o t h e r s , g a i n i n g a sense of independence through a r e b e l l i o u s a c t , s e l f - a c c e p t a n c e and  l e t t i n g go of p e r f e c t i o n i s m , and  an i d e n t i t y other than t h a t of being an  finding  anorexic.  I n t e r p e r s o n a l l y , i n d i v i d u a l s r e p o r t e d t h a t being a mother i n c r e a s e d s e l f - w o r t h and t h a t i n t i m a t e sexual r e l a t i o n s h i p s helped  one  body.  And,  t o take p l e a s u r e  i n r a t h e r than be ashamed of her  i n d i v i d u a l s began t o f e e l a g r e a t e r sense of  achievement and  s a t i s f a c t i o n through school and c a r e e r p u r s u i t s  37  r a t h e r than through  food and weight.  r e p o r t e d t h a t body image was  And,  individuals  the most d i f f i c u l t aspect t o change  as w e l l as o b s e s s i v e thoughts and weight.  Finally,  and behaviours  p e r t a i n i n g t o food  recovery i n v o l v e d " r e t a i n i n g e x c e s s i v e  about food and weight but no l o n g e r being obsessed ( B e r e s i n , p. 12).  In summary, w h i l e B e r e s i n ' s  concern  by them"  (1985) study gave  some i n s i g h t i n t o the meaning of the c u r a t i v e f a c t o r s  and  attempted t o s k e t c h a p a t t e r n of recovery, knowledge of the r e c o v e r y process i s l i m i t e d . U n l i k e the s t u d i e s of r e c o v e r i n g or recovered b u l i m i c s and anorexics K i r k , 1986;  ( B e r e s i n , 1985;  H a l l & Cohn, 1986;  Hobbs e t a l . ,  1989;  Stanton e t a l . , 1986), Maine (1985) e l u c i d a t e d more  f u l l y the meaning and impact  of the c u r a t i v e f a c t o r s f o r  i n d i v i d u a l s and began t o o u t l i n e a more complete p a t t e r n of recovery.  Maine's study suggested  t h a t r e c o v e r y i n v o l v e d an  i n i t i a l awareness of p e r s o n a l r e s p o n s i b i l i t y and s e l f - m o t i v a t i o n for  getting better.  Despite warnings from medical  staff  and  f a m i l y members r e g a r d i n g the s e v e r i t y of t h e i r d i s o r d e r , i n d i v i d u a l s a c t i v e l y decided t o r e c o v e r o n l y when they  had  panicked a t the r e a l i z a t i o n t h a t they d i d not have the s t r e n g t h to walk or the a b i l i t y t o eat. the way  T h i s s e l f - r e s p o n s i b i l i t y paved  f o r r e c o g n i t i o n of d i s t o r t e d t h i n k i n g p a t t e r n s .  Feeling validated within a therapeutic relationship another  e s s e n t i a l agent i n recovery.  A validating,  was  affirming,  and a c c e p t i n g r e l a t i o n s h i p with a t h e r a p i s t p r o v i d e d a sense of u n c o n d i t i o n a l acceptance  so t h a t they c o u l d r e l i n q u i s h  p e r f e c t i o n i s t i c t e n d e n c i e s f o r g a i n i n g acceptance  and  allow  38 themselves t o experience o p p o r t u n i t i e s s h a r i n g , intimacy, and  for  "self-exploration,  interdependence . . . [which] were  q u a l i t a t i v e l y d i f f e r e n t from t h e i r l i v e s i n t h e i r f a m i l i e s " (Maine, 1985,  p.  51).  gave i n d i v i d u a l s the out  t o them.  T h i s f o u n d a t i o n of r e s p e c t and  intimacy  c o n f i d e n c e t o t r u s t o t h e r s enough t o  Finding  companionship more rewarding than being  i s o l a t e d s p u r r e d i n d i v i d u a l s t o improve t h e i r h e a l t h n u t r i t i o n so t h a t they c o u l d m a i n t a i n t h e i r  and  f r i e n d s was  U n l i k e the  were r e l a t i n g only t o t h e i r d i s o r d e r  and  them as whole people and  encouragement" (Maine, 1985,  i s o l a t i o n , and autonomy r a t h e r  p.  51)  i n s i s t i n g that self-worth  [giving]  s e l f - d o u b t decreased and than powerlessness was  i n the  into family  fostered.  As  As  non-  and  a result,  these r e l a t i o n s h i p s  the  and  functioning. family  system  and  essential  i n d i v i d u a l s gained  communication p a t t e r n s and  impact on t h e i r l i v e s . not  Initially,  and  loneliness,  s o c i o c u l t u r a l system were a l s o  recovery process.  eat,  by  a sense of c o n t r o l  concern r e g a r d i n g t h e i r p h y s i c a l  p r e s s u r e s from the  they  acceptance  Consequently, f e e l i n g s of  Acceptance of the d i f f i c u l t i e s w i t h i n the  who  i n a non-judgmental and  i n d i v i d u a l s were o f t e n a b l e t o eat w i t h i n t o hear the  was  anorexics' families  s u p p o r t i v e o t h e r s p r o v i d e d a f f e c t i o n and  t h r e a t e n i n g manner.  w i t h extended  c i t e d as a major f a c t o r t h a t  f a c i l i t a t i v e of r e c o v e r y .  "[treating]  and  relationships.  S i m i l a r l y , informal supportive r e l a t i o n s h i p s family  reach  insight  r o l e s , acknowledging t h e i r  they came t o accept t h a t they c o u l d  change t h e i r f a m i l i e s by  l o s i n g another pound, they  r e c o g n i z e d t h a t they c o u l d only change themselves.  So,  instead  39 of u s i n g food t o express emotions and unmet needs,  individuals  accepted themselves and the f a c t t h a t they had t o f i l l needs.  their  As a r e s u l t , they began t o move away from t h e i r  d e s t r u c t i v e symptoms and l i v e more f u l l y .  own  self-  L i k e w i s e , as the  i n d i v i d u a l s accepted the c u l t u r a l system w i t h i t s emphasis on s l i m n e s s , "they r e c o g n i z e d t h e i r d i e t i n g as a f u t i l e attempt t o be p e r f e c t , t o deny t h e i r f e e l i n g s , and t o g a i n c o n t r o l their lives"  (Maine, 1985,  p. 52).  over  T h i s r e a l i z a t i o n engendered  s e l f - a c c e p t a n c e , s e l f - e s t e e m , and more r e a l i s t i c g o a l - s e t t i n g . F i n a l l y , g i v e n t h a t f a c t o r s both i n s i d e and o u t s i d e of formal therapy were r e p o r t e d as f a c i l i t a t i v e of recovery,  the  r e s u l t s of Maine's (1985) study imply t h a t the c u r a t i v e f a c t o r s are not l i m i t e d t o those i n s i d e of formal therapy. the p a t t e r n of r e c o v e r y underscores  Furthermore,  the s y n e r g e t i c i n t e r a c t i o n of  c u r a t i v e f a c t o r s both i n s i d e and o u t s i d e of formal  therapy.  Summary Upon comparing the assumptions r e g a r d i n g r e c o v e r y by the treatment change agents,  purported  outcome s t u d i e s and s t u d i e s on t h e r a p e u t i c -  s e v e r a l common p e r s p e c t i v e s are  apparent.  A c c o r d i n g t o the Random House C o l l e g e D i c t i o n a r y  (1975),  r e c o v e r y i s d e f i n e d as " r e s t o r a t i o n or r e t u r n t o h e a l t h or a normal c o n d i t i o n , as a f t e r s i c k n e s s or d i s a s t e r "  (p. 1104).  W i t h i n the CB s t u d i e s , t h i s p e r s p e c t i v e on r e c o v e r y was s a l i e n t as emphasis was e a t i n g behaviours.  p l a c e d on r e e s t a b l i s h i n g c o n t r o l  most over  The t h e r a p e u t i c change agent s t u d i e s a l s o  proposed t h a t r e c o v e r y e n t a i l e d r e i n s t i t u t i n g a p r e v i o u s l e v e l of f u n c t i o n i n g p u r p o r t i n g t h a t the c u r a t i v e f a c t o r s were " e s s e n t i a l  4  to the progression  0  toward h e a l t h - r e s t o r a t i o n and recovery"  (Maine, 1985, p. 51). However, l i k e t h e psychodynamic and f a m i l y therapy  studies  i n which p r i o r optimum l e v e l s o f i n t r a p s y c h i c and i n t e r p e r s o n a l f u n c t i o n i n g were not assumed, t h e CB s t u d i e s acknowledged t h a t t h i n k i n g p a t t e r n s needed t o be c h a l l e n g e d .  Furthermore, Maine  (1985) i d e n t i f i e d f a c t o r s such as a v a l i d a t i n g r e l a t i o n s h i p which f o s t e r e d intimacy  and interdependence t h a t were not p r e v i o u s l y  part of i n d i v i d u a l s ' interpersonal r e l a t i o n a l s t y l e s .  Therefore,  the psychodynamic, f a m i l y systems, and c o g n i t i v e - b e h a v i o u r a l approaches and some o f t h e t h e r a p e u t i c change agent s t u d i e s suggested t h a t t h e recovery developmental.  process was f u t u r e - o r i e n t e d and  Thus, w h i l e recovery  was viewed as a  r e h a b i l i t a t i o n process t o r e s t o r e i n d i v i d u a l s t o a p r e v i o u s of f u n c t i o n i n g , p s y c h o s o c i a l  level  development and moving beyond the  p r i o r developmental stage was a l s o i n h e r e n t  i n most o f t h e  studies. My  Presuppositions Concerning my p r e s u p p o s i t i o n s  of recovery  on the d e f i n i t i o n and nature  from b u l i m i a , s i n c e a l l o f t h e DSM-III R (1987)  c r i t e r i a must be met f o r a d i a g n o s i s i n d i v i d u a l i s by d e f i n i t i o n recovered not meet any one o f the c r i t e r i a s i n c e t h e u s u a l course o f b u l i m i a and  o f b u l i m i a nervosa, an from b u l i m i a  (see Appendix A ) .  i f she does Furthermore,  i n c l i n i c samples " i s c h r o n i c  i n t e r m i t t e n t over a p e r i o d o f many y e a r s "  (DSM-III R, 1987,  p. 68), I adhere t o Johnson and Connor's (1987) s u g g e s t i o n  of at  l e a s t a one-year posttreatment p e r i o d i n which t h e i n d i v i d u a l  41 r e p o r t s e i t h e r abstinence  from b i n g e i n g  and purging,  r e l a p s e s wherein r e l a p s e i s d e f i n e d as " p e r c e i v e d c o n t r o l " over e a t i n g behaviours (Brownell  others:  l o s s of  c e r t a i n f a m i l y and  and  p.  766).  view b u l i m i a as  extreme p a t t e r n of t h i n k i n g , f e e l i n g , and a self-image  no  e t a l . , 1986,  I concur with Schwartz e t a l . (1985) who r i g i d and  or  "a  r e l a t i n g to  a l i f e o r i e n t a t i o n t h a t develops i n  s o c i o c u l t u r a l contexts"  (p.  280).  Furthermore, the f u n c t i o n i n g of the b u l i m i c ' s l i f e context  and  her b u l i m i a are maintained by an i n t e r p l a y of b i o l o g i c a l , i n t r a p e r s o n a l , i n t e r p e r s o n a l , and et  al.).  s o c i o c u l t u r a l f a c t o r s (Schwartz  Given t h a t b u l i m i a i s a psychosomatic d i s o r d e r whereby  the b e h a v i o u r a l manifestation  symptoms of b i n g e i n g  and purging  of u n d e r l y i n g b i o p s y c h o s o c i a l  are a  factors, I  subscribe  t o the "two-track approach" t o treatment i n which both the d i s o r d e r e d e a t i n g behaviours and  factors maintaining  addressed  Manley, 1989;  (Johnson et a l . , 1987;  them are  Schwartz,  1982;  Schwartz e t a l . ) . T h i s two-track approach evolved when o n l y one  treatment approach was  r e l a p s e r a t e s were being r e p o r t e d focused  from poor outcome r e s u l t s used.  For i n s t a n c e ,  i n behavioural  treatments t h a t  on t a r g e t symptoms without regard t o u n d e r l y i n g  (Johnson e t a l . , 1987,  p. 668).  And  "high  dynamics"  i n psychodynamic treatment  w i t h no a c t i v e symptom management, d i s t u r b e d e a t i n g behaviour r e s u l t e d i n l i f e - t h r e a t e n i n g s i d e e f f e c t s as u n d e r l y i n g and  i s s u e s were not s a t i s f a c t o r i l y r e s o l v e d .  t h e r a p e u t i c stance, often re-created  with  conflicts  In a d d i t i o n , t h i s  i t s de-emphasis on the e a t i n g problems,  f o r i n d i v i d u a l s t h e i r " e a r l y experience  of  42  f e e l i n g t h a t they were expected  t o meet t h e i r  parents* needs and t h a t t h e i r s p e c i f i c ,  narcissistic  i n d i v i d u a l needs were  n e i t h e r seen nor attended t o " (Goldman, 1988, p. 565). Thus, I b e l i e v e t h a t a b s t i n e n c e from b i n g e i n g and p u r g i n g i s enhanced when t h e change mechanisms i n h e r e n t i n the psychodynamic, f a m i l y systems, and c o g n i t i v e - b e h a v i o u r a l approaches a r e i n t e g r a t e d i n t o an i n d i v i d u a l i z e d approach.  T h e r e f o r e , I view r e c o v e r y as  i n v o l v i n g changes i n e a t i n g behaviours  as w e l l as improvements i n  the s p e c i f i c realms which perpetuate the b u l i m i c behaviours f o r each i n d i v i d u a l :  d y s f u n c t i o n a l b e l i e f s about shape and weight,  u n r e s o l v e d emotional relating.  c o n f l i c t s , and i n t e r p e r s o n a l p a t t e r n s o f  A l s o , these changes may occur through  both  t h e r a p e u t i c mechanisms and o u t - o f - t h e r a p y e x p e r i e n c e s .  formal Although  the f a c t o r s which p r e c i p i t a t e b u l i m i a a r e not n e c e s s a r i l y the f a c t o r s which m a i n t a i n i t , t h e e t i o l o g i c a l t h e o r i e s assume t h a t the p r e c i p i t a t i n g f a c t o r s a r e a l s o the f a c t o r s i n v o l v e d i n recovery.  T h e r e f o r e , knowledge o f the i n c i d e n t s i n v o l v e d i n the  onset o f one's b u l i m i a may p r o v i d e some i n s i g h t i n t o t h e recovery process. Finally,  I b e l i e v e t h a t s p i r i t u a l changes may a l s o be an  aspect o f r e c o v e r y .  The s p i r i t u a l dimension  of individuals  i n c l u d e s one's awareness o f God as each person understands meaning and purpose i n l i f e , and j u s t i c e  (Chapman, 1987).  Him,  and v a l u e s such as hope, compassion, As C a s s e l l  (1976) says, through the  e x p e r i e n c e o f i l l p h y s i c a l h e a l t h and recovery, t h e c l i e n t ' s sense o f meaning i n l i f e w i l l change which may r e s u l t i n changed v a l u e s and p r i o r i t i e s .  43 In summary, my recovery  p r e s u p p o s i t i o n s on the nature  of  from b u l i m i a are:  1. An  individual  i s by d e f i n i t i o n recovered  she does not meet any one bulimia  and process  of the DSM-III R  from b u l i m i a i f  (1987) c r i t e r i a f o r  nervosa.  2. Abstinence  from b i n g e i n g and purging  or freedom from  r e l a p s e i s enhanced when the change mechanisms i n h e r e n t i n the psychodynamic, f a m i l y systems, and  cognitive-behavioural  approaches are i n t e g r a t e d i n t o an i n d i v i d u a l i z e d e t a l . , 1987;  Johnson e t a l . , 1987;  Manley, 1989;  approach  S t e i g e r , 1989).  3. Recovery i n v o l v e s changes i n e a t i n g behaviours improvements i n the s p e c i f i c realms which perpetuate behaviours  f o r each i n d i v i d u a l :  unresolved  (Herzog  as w e l l as  the b u l i m i c  emotionai  conflicts,  i n t e r p e r s o n a l p a t t e r n s of r e l a t i n g , and d y s f u n c t i o n a l b e l i e f s about shape and weight Schwartz, 1982;  (Johnson e t a l . , 1987;  Manley,  1989;  Schwartz e t a l . , 1985).  4. B e h a v i o u r a l  and p s y c h o s o c i a l changes may  occur  both formal t h e r a p e u t i c mechanisms and o u t - o f - t h e r a p y  through experiences  (Maine, 1985). 5. Recovery may  a l s o e n t a i l s p i r i t u a l changes p e r t a i n i n g to  one's awareness of God and purpose i n l i f e ,  as each person understands Him,  meaning  and v a l u e s of hope, compassion, and  justice  (Chapman, 1987). In u s i n g the e x i s t e n t i a l - p h e n o m e n o l o g i c a l  approach t o  examine the meaning of the phenomenon of recovery from the c o - r e s e a r c h e r ' s  from b u l i m i a  p e r s p e c t i v e , i t i s imperative  r e s e a r c h e r t o be d i s c i p l i n e d  i n guarding  f o r the  a g a i n s t the i n t e r f e r e n c e  44 of p e r s o n a l b i a s e s . the b e g i n n i n g  T h e r e f o r e , by s t a t i n g my p r e s u p p o s i t i o n s a t  o f the p r e s e n t study,  I attempted t o minimize the  i n f l u e n c e o f my b i a s e s d u r i n g t h e i n t e r v i e w and a n a l y s i s process i n o r d e r t o ensure a f a i t h f u l and o b j e c t i v e e x p r e s s i o n o f t h e phenomenon.  45 Chapter I I I Methodology T h i s chapter summarizes the e x i s t e n t i a l - p h e n o m e n o l o g i c a l approach  t o human experience and o u t l i n e s s u b j e c t s e l e c t i o n  r e s e a r c h procedures.  Although the phenomenological  and  approach  served as a s t a r t i n g p o i n t , the focus of t h i s study s h i f t e d  from  simply l o o k i n g a t the meaning of the phenomenon t o a r t i c u l a t i n g a more coherent conceptual understanding of the p r o c e s s of r e c o v e r y from b u l i m i a . Design As the purpose  of t h i s study i s t o understand the meaning of  the event or phenomenon of r e c o v e r y from b u l i m i a , the e x i s t e n t i a l - p h e n o m e n o l o g i c a l approach (1978) was experience.  as d e s c r i b e d by  employed as a g u i d e l i n e f o r examining  Colaizzi  the r e c o v e r y  T h i s approach with i t s emphasis on understanding the  meaning of phenomena as they are l i v e d i s d e r i v e d from existentialism  and phenomenology.  Existentialism  views human  e x p e r i e n c e i n the world as s i g n i f i c a n t , and as " l e g i t i m a t e and necessary content f o r understanding human psychology" p. 52).  (Colaizzi,  Phenomenology i d e n t i f i e s and d e s c r i b e s phenomena as they  are l i v e d and experienced by the i n d i v i d u a l  i n the world.  Phenomena can be f a c t s , events, occurrences, or e x p e r i e n c e s (Stein,  Hauck, & Su, 1975).  Existential-phenomenological  r e s e a r c h seeks t o understand human experience i n a manner t h a t i s free  from the s p l i t s between s u b j e c t and o b j e c t , experience and  behaviour, and l i n e a r cause and e f f e c t  (Colaizzi).  Since  e x i s t e n t i a l - p h e n o m e n o l o g i c a l psychology views the i n d i v i d u a l  and  46 the world as interdependent, outside forces. passive:  people a r e not merely a c t e d upon by  Instead, they a r e p a r t l y a c t i v e and p a r t l y  They a r e c o n f r o n t e d w i t h s i t u a t i o n s i n t h e world w i t h i n  which they a r e f r e e t o make c h o i c e s ( V a l l e & King,  1978).  As t h e e x i s t e n t i a l - p h e n o m e n o l o g i c a l r e s e a r c h e r seeks t o understand  t h e phenomenon, she o r he " t h i n k s m e d i t a t i v e l y  (Heidegger,  1966) about i t s meaning" ( C o l a i z z i ,  1978, p. 68) by  a s k i n g , "How does t h e i n d i v i d u a l experience r e c o v e r y : recovery involve?" explored:  What does  The t o t a l i t y o f t h e person should be  " h i s [or her] p e r c e p t i o n s and c o g n i t i o n s , emotions and  a t t i t u d e s , h i s t o r y and p r e d i s p o s i t i o n s , a s p i r a t i o n s and e x p e r i e n c e s , and p a t t e r n s , s t y l e s , and contents o f b e h a v i o r " ( C o l a i z z i , p. 70). As v a r i a t i o n s o f t h e phenomenon a r e d e s c r i b e d by d i f f e r e n t i n d i v i d u a l s , t h e r e s e a r c h e r l o o k s f o r t h e common p a t t e r n o r s t r u c t u r e o f human experience which r e v e a l s i t s e l f as the meaning o f a human experience.  With c a r e f u l r e f l e c t i o n on  the i n d i v i d u a l s ' experiences, t h e meaning i s thoroughly d e s c r i b e d and d i s c l o s e d by t h e r e s e a r c h e r a f t e r having been v e r i f i e d by the individuals. However, b e f o r e t h e i n f o r m a t i o n i s analyzed, t h e phenomenological p e r s p e c t i v e advocates  t h a t human experience be  i n v e s t i g a t e d o b j e c t i v e l y by f a i t h f u l l y e x p r e s s i n g whatever phenomenon i s p r e s e n t .  The r e s e a r c h e r l i s t e n s r e s p e c t f u l l y " t o  what t h e phenomenon speaks o f i t s e l f " phenomenon what i t i s " ( C o l a i z z i , to  and r e f u s e s " t o t e l l t h e  1978, p. 52). Being  "content  u n d e r s t a n d i n g l y d w e l l " ( C o l a i z z i , p. 68), t h e r e s e a r c h e r does  not seek t o c o n t r o l o r dominate t h e i n f o r m a t i o n t h a t i s  47 encountered.  In order t o adopt t h i s stance and guard a g a i n s t the  i n t e r f e r e n c e of p e r s o n a l b i a s e s , one's p r e s u p p o s i t i o n s must be c l e a r l y s t a t e d or bracketed the r e s e a r c h  a t the beginning  of and  throughout  process.  F i n a l l y , t h i s type of d i a l o g a l r e s e a r c h "takes p l a c e only among persons on equal l e v e l s , without or p r o f e s s i o n a l s t r a t i f i c a t i o n s " Friere  the d i v i s i v e n e s s of s o c i a l  (Colaizzi,  1978,  p. 69).  ( c i t e d i n C o l a i z z i ) uses the term " c o - r e s e a r c h e r s "  i n l i e u o f r e s e a r c h e r s and s u b j e c t s .  Thus, (p.  69)  Furthermore, s i n c e  co-researchers d i s c l o s e t h e i r personal presuppositions,  full  p a r t i c i p a t i o n i n the r e s e a r c h r e q u i r e s r e l a t i n g as persons w i t h i n a m i l i e u of t r u s t . Co-researcher  Selection  Co-researchers  were v o l u n t e e r s , 19 years or o l d e r , who  r e c r u i t e d through advertisement  n o t i c e s (see Appendix F) p l a c e d  a t Simon F r a s e r U n i v e r s i t y , Burnaby, B.C., B r i t i s h Columbia, Vancouver, B.C., centres.  were  The U n i v e r s i t y of  and Vancouver community  N o t i c e s were a l s o p l a c e d i n two  Vancouver community  newspapers—The C o u r i e r and The West E n d e r — a n d i n K i n e s i s , a l o c a l newspaper sponsored by the Vancouver S t a t u s of Women.  In  a d d i t i o n , t h e r a p i s t s working with e a t i n g d i s o r d e r e d c l i e n t s were c o n t a c t e d by phone and sent a c o n t a c t l e t t e r e x p l a i n i n g the nature o f the study participants  (see Appendix D) and  letters for potential  (see Appendix E ) .  According to C o l a i z z i  (1978), the necessary  and  c r i t e r i a f o r s e l e c t i n g c o - r e s e a r c h e r s are "experience i n v e s t i g a t e d t o p i c and a r t i c u l a t e n e s s " (p. 58).  sufficient with  Therefore,  the  48 s e l e c t i o n c r i t e r i a included:  (a) a p r e v i o u s  nervosa as d e f i n e d by DSM-III R previous  h i s t o r y of anorexia  d i a g n o s i s of b u l i m i a  (1987) (see Appendix A),  behavioural  nervosa  and  (c) a s i g n i f i c a n t p e r i o d of time without  symptoms of b u l i m i a ,  being g e n u i n e l y  recovered  any  (d) a s e l f - r e p o r t e d f e e l i n g of  from b u l i m i a , and  a r t i c u l a t e t h e i r experience  no  nervosa as d e f i n e d by the DSM-III R  (see Appendix B) or dual d i a g n o s i s of anorexia b u l i m i a nervosa,  (b)  of recovery  and  (e) an a b i l i t y e l a b o r a t e on  to  their  descriptions. In order t o guard a g a i n s t "symptom t r a n s f o r m a t i o n " 1985)  (Vognsen,  i n which b u l i m i c symptoms are r e p l a c e d by o t h e r a c t i v e  p s y c h o l o g i c a l p r o b l e m s — s u c h as drug or a l c o h o l abuse, depression,  obsessive-compulsive  d i s o r d e r , or  behaviours l i k e s h o p l i f t i n g , p r o m i s c u i t y s i x t h s e l e c t i o n c r i t e r i o n was s i n c e having  recovered  added.  impulsive  or s e l f - m u t i l a t i o n — a  This c r i t e r i o n states that  from b u l i m i a , the i n d i v i d u a l has  not  developed p s y c h o l o g i c a l problems which meet the DSM-III R criteria  (1987)  f o r other major p s y c h i a t r i c d i s o r d e r s on A x i s I.  As I screened the telephone c a l l s of p o t e n t i a l co-researchers,  f u r t h e r s p e c i f i c a t i o n of the t h i r d  s i g n i f i c a n t p e r i o d of time without any required.  While my  t h e i r recovery  co-researchers  experience  criterion—a  symptoms of b u l i m i a — w a s  needed temporal c l o s e n e s s  i n order t o r e c a l l s i g n i f i c a n t  they a l s o needed enough d i s t a n c e t o have a h o l i s t i c  to  details,  perspective  on i t . However, s e v e r a l i s s u e s arose r e l a t e d t o the amount of time which c o n s t i t u t e d a s i g n i f i c a n t p e r i o d f r e e of b u l i m i c symptoms.  First,  no d e f i n i t i v e time p e r i o d i s s t a t e d i n the  49 literature:  Johnson and  Connors (1987) suggest a t l e a s t a  one-year posttreatment p e r i o d i n which the i n d i v i d u a l r e p o r t s e i t h e r abstinence  from b i n g e i n g  Herzog, Franko, and and  and purging  relapses;  Brotman (1989) recommend a t l e a s t 18 months;  Brownell e t a l . (1986) propose a 3-year p e r i o d .  complete a b s t i n e n c e  i s d i f f i c u l t t o maintain,  (1986) d i f f e r e n t i a t e between r e l a p s e and d e f i n e d as " p e r c e i v e d mistake"  (p. 766)  completely she  or no  lost.  is s t i l l  Therefore,  l a p s e i s "a s l i p  even i f an i n d i v i d u a l has  or  lapsed,  f r e e of b u l i m i c symptoms p r o v i d e d  not r e l a p s e d .  telephoned and  Relapse i s  i n which c o n t r o l over e a t i n g behaviour i s not  considered  f e e l s she has  Brownell e t a l .  lapse:  l o s s of c o n t r o l " and  Second, as  Therefore,  she  when an i n d i v i d u a l  r e p o r t e d a 3-month p e r i o d of abstinence,  she  was  excluded from the study because she d i d n ' t meet the minimum  one-  year posttreatment p e r i o d . Once I f e l t t h a t a c a l l e r f i t a l l the s e l e c t i o n c r i t e r i a , met  together  we  so t h a t I c o u l d more f u l l y d e s c r i b e the purpose of  the r e s e a r c h p r o j e c t , what t h e i r p a r t i c i p a t i o n i n the study would i n v o l v e , and  the r e s e a r c h methodology.  i n f o r m a l meeting, I e x p l a i n e d I had  not had  recover  to each c o - r e s e a r c h e r  an e a t i n g d i s o r d e r , my  sparked by having  initial t h a t although  i n t e r e s t i n recovery  c o u n s e l l e d women who  from b u l i m i a .  During t h i s  were a s k i n g how  was  they c o u l d  With r e s e a r c h s t u d i e s p r o v i d i n g n e i t h e r a  h o l i s t i c understanding of the recovery f o r the i n d i v i d u a l , I was  process  nor  i t s meaning  i n s p i r e d t o seek out knowledge t h a t  would a s s i s t the p r a c t i t i o n e r and c l i e n t t o more f u l l y grasp process  of r e c o v e r i n g  the  from b u l i m i a so t h a t the c o n d i t i o n s which  50 f a c i l i t a t e r e c o v e r y c o u l d be maximized. i n d i v i d u a l s had been r e c r u i t e d through  Since the four advertisement  n o t i c e s and  t h e r e f o r e had not r e c e i v e d t h e c o n t a c t l e t t e r t o t h e v o l u n t e e r (see Appendix E ) , I gave each person a copy. letter,  R e f e r r i n g t o the  I e x p l a i n e d t h a t a f t e r an i n i t i a l p r e s c r e e n i n g i n t e r v i e w  w i t h Dr. E. M. Goldner, w i t h myself experience  she would have an audiotaped  interview  i n which she would be asked t o d e s c r i b e h e r recovery i n as much d e t a i l as p o s s i b l e .  Furthermore, she c o u l d  use o t h e r r e l e v a n t sources o f i n f o r m a t i o n such as p e r s o n a l j o u r n a l s o r photographs d u r i n g t h e i n t e r v i e w .  We would then meet  s e v e r a l more times t o v e r i f y t h e t r a n s c r i b e d i n t e r v i e w and themes, and t h e f i n a l n a r r a t i v e account. In order t o ensure t h a t each woman was d i s t a n t enough from her r e c o v e r y experience t o be a b l e t o see i t as a whole but a l s o c l o s e enough t o remember s i g n i f i c a n t d e t a i l s , we i n f o r m a l l y d i s c u s s e d some o f t h e t u r n i n g p o i n t s i n h e r r e c o v e r y One  process.  o f t h e women—L. S . — r e g r e t t e d t h a t she had not kept a  personal journal t o f a c i l i t a t e r e c a l l of i n d i v i d u a l  therapy  s e s s i o n s and she wondered about a c c e s s i n g t h e r e c o r d s kept by her therapist.  A f t e r encouraging  each woman t o ask any q u e s t i o n s she  might have, v e r i f y i n g t h a t each i n d i v i d u a l was s t i l l  interested  i n b e i n g a c o - r e s e a r c h e r , and e s t a b l i s h i n g t h a t we both  felt  comfortable working w i t h each other, t h e i n d i v i d u a l read and s i g n e d t h e consent  form (see Appendix G).  A p r e s c r e e n i n g i n t e r v i e w time was then arranged  f o r each  p o t e n t i a l c o - r e s e a r c h e r w i t h Dr. E. M. Goldner who i s a p s y c h i a t r i s t and e a t i n g d i s o r d e r expert i n t h e E a t i n g D i s o r d e r s  51 C l i n i c a t S t . Paul's H o s p i t a l , Vancouver, B.C.  The purposes of  t h i s s c r e e n i n g i n t e r v i e w were t o v e r i f y t h a t c o - r e s e a r c h e r s had a p r e v i o u s d i a g n o s i s of b u l i m i a nervosa  as d e f i n e d by the DSM-III R  (1987) w i t h no p r e v i o u s h i s t o r y of a n o r e x i a nervosa, the c u r r e n t s t a t u s of t h e i r e a t i n g behaviour,  t o assess  and t o ensure t h a t  they e x h i b i t e d no s i g n i f i c a n t i n d i c a t o r s of o t h e r major p s y c h i a t r i c d i s o r d e r s on A x i s I of the DSM-III R s i n c e having recovered from b u l i m i a .  W i t h i n t h i s study, s i n c e a l l of the  DSM-III R c r i t e r i a must be met nervosa,  f o r a d i a g n o s i s of b u l i m i a  i f an i n d i v i d u a l does not have any one  she i s by d e f i n i t i o n recovered from b u l i m i a . r e s e a r c h e r s were p r e v i o u s treatment  criteria  None of the co-  c o n t a c t s of Dr.  During the h a l f - h o u r , unrecorded conducted  of these  Goldner.  screening interview  a t S t . Paul's H o s p i t a l , Dr. E. M. Goldner  asked  the  f o l l o w i n g s e m i - s t r u c t u r e d q u e s t i o n s i n a s t r a i g h t f o r w a r d manner, c l a r i f y i n g responses  and a s k i n g f o r e l a b o r a t i o n as  necessary:  1. D e s c r i b e the course of your e a t i n g behaviour from when you  beginning  f i r s t n o t i c e d any e a t i n g problems and ending with a  d e s c r i p t i o n of your present e a t i n g p a t t e r n . 2. S p e c i f i c a l l y d e s c r i b e your weight h i s t o r y ; h i s t o r y of binge e a t i n g , vomiting, menstruation;  food r e s t r i c t i o n ,  use;  body image d i s t u r b a n c e ; mood; substance  Dr. E. M. Goldner  abuse.  noted the i n d i v i d u a l s ' responses  p r e s c r e e n i n g i n t e r v i e w summary sheets me  laxative  on the  (see Appendix C), contacted  by phone t o e l a b o r a t e upon the i n t e r v i e w i n f o r m a t i o n , and  m a i l e d me  the summary sheets.  Goldner was  Based upon h i s assessment,  s a t i s f i e d t h a t each i n d i v i d u a l met  Dr.  the c r i t e r i a of  52 having recovered from b u l i m i a nervosa and d i d not q u a l i f y f o r any p s y c h i a t r i c d i s o r d e r s on A x i s I as d e f i n e d i n t h e DSM-III R (1987). However, t h e acceptance  o f one c o - r e s e a r c h e r — P .  Y.—was  i n i t i a l l y q u e s t i o n a b l e as she met the DSM-III R (1987) c r i t e r i a for  Late L u t e a l Phase Dysphoric D i s o r d e r , commonly r e f e r r e d t o as  Pre-Menstrual  Syndrome.  But a f t e r Dr. E. M. Goldner  realized  t h a t t h i s d i s o r d e r was d e s c r i b e d i n t h e Appendix o f t h e DSM-III R—meaning t h a t i t was not y e t c o n s i d e r e d an accepted d i s o r d e r — h e v e r i f i e d t h a t P. Y. met t h e s e l e c t i o n  psychiatric  criteria.  During h e r i n t e r v i e w , P. Y. r e f e r r e d t o t h e u n c e r t a i n t y surrounding her i n c l u s i o n i n t h e study s a y i n g , " . . . even though he  [Dr. Goldner]  d i d n ' t t h i n k t h a t I was gonna be a b l e t o be a  p a r t o f t h i s study"  (Appendix J , p. 201).  Once t h e f o u r c o - r e s e a r c h e r s had been s e l e c t e d and i n t e r v i e w e d , o t h e r background i n f o r m a t i o n arose as each woman t o l d her recovery s t o r y .  So, w h i l e t h e f o l l o w i n g demographic  i n f o r m a t i o n was not p a r t o f t h e c o - r e s e a r c h e r s e l e c t i o n  criteria,  I c u l l e d these f a c t s from t h e p r o t o c o l s i n order t o p r o v i d e a context f o r more f u l l y understanding experience.  each woman's recovery  A t t h e time o f t h e i n i t i a l  i n t e r v i e w , t h e ages of  S. T., L. S., P. Y., and S. H. were r e s p e c t i v e l y e a r l y  forties,  early t h i r t i e s ,  e a r l y t h i r t i e s and e a r l y t w e n t i e s .  to  S. T., L. S., and P. Y. had been f r e e o f b u l i m i c  Dr. Goldner,  As r e p o r t e d  symptoms f o r t h e past 4 t o 5 y e a r s ; S. H. r e p o r t e d a 2-year l e n g t h o f a b s t i n e n c e from b i n g e i n g and p u r g i n g .  The d u r a t i o n of  b u l i m i a was 27 years f o r S. T., 10 years f o r L. S., 2 years f o r  53 P. Y.,  and  6 years f o r S. H.  from the f i r s t  The recovery p e r i o d — t h e time  span  i n k l i n g s o f change t o the c e s s a t i o n of b u l i m i c  symptoms—was r e s p e c t i v e l y months f o r S. T.,  L. S.,  19 years, 8 y e a r s , 6 months, and 5  P. Y. and S.  H.  Procedure Having e s t a b l i s h e d t h a t the f o u r i n d i v i d u a l s f u l f i l l e d c r i t e r i a f o r i n c l u s i o n i n the study, each was telephone  t o arrange an i n t e r v i e w time.  The  contacted  c o - r e s e a r c h e r was (Colaizzi, varied:  1978).  The  by  i n t e r v i e w s took  p l a c e i n the c o - r e s e a r c h e r s * homes d u r i n g J u l y , August, September of 1990.  the  and  i n t e r v i e w s were not time l i m i t e d and  each  encouraged t o speak f o r as l o n g as she wanted T h e r e f o r e , the l e n g t h of the i n t e r v i e w s  1 h r 50 min,  2 hr 10 min,  2 h r 35 min,  and 2 hr 7 min.  P r i o r t o the tape r e c o r d i n g of each i n t e r v i e w ,  my  c o - r e s e a r c h e r and I spent some time e s t a b l i s h i n g r a p p o r t and I answered any q u e s t i o n s about the format of the i n t e r v i e w or the study i n g e n e r a l .  Once she was  ready t o begin, I read the  f o l l o w i n g preamble o f f an index c a r d : The purpose of t h i s study i s t o g a i n a more complete understanding of the experience of r e c o v e r y from b u l i m i a by e x p l o r i n g what i t means t o women who have recovered. Together we're s e a r c h i n g f o r a deeper understanding and you have p e r s o n a l knowledge about t h i s experience. As you t e l l me your s t o r y i n as much d e t a i l as p o s s i b l e , t r y t o remember what you were t h i n k i n g , f e e l i n g , and doing a t the time. I'd l i k e you t o d e s c r i b e your recovery experience b e g i n n i n g from when you f i r s t n o t i c e d i n k l i n g s of change, c o n t i n u i n g w i t h experiences t h a t f a c i l i t a t e d recovery, and ending w i t h a d e s c r i p t i o n of your l i f e a t the p r e s e n t time. As you speak, I ' l l r e f l e c t your thoughts and f e e l i n g s , and ask q u e s t i o n s to c l a r i f y and e l a b o r a t e upon what you're s a y i n g . Do you have any q u e s t i o n s ? The  i n t e r v i e w format was  u n s t r u c t u r e d so t h a t the  c o - r e s e a r c h e r c o u l d recount her s t o r y f r e e l y and  i n an  unbiased  54 manner, without my  asking leading questions.  r e f l e c t e d her thoughts  As she spoke, I  and f e e l i n g s , c l a r i f i e d statements,  and  asked p r o b i n g q u e s t i o n s i n order t o more f u l l y e l i c i t the meaning of events f o r her.  In order t o check the p o s s i b i l i t y of a s k i n g  s p e c i f i c q u e s t i o n s i n o r d e r t o v a l i d a t e my  assumptions about the  meaning of the r e c o v e r y experience, I b r a c k e t e d presuppositions  my  (see Chapter II) and so stayed w i t h her  e x p e r i e n c e s by " [ r e s p e c t f u l l y ] l i s t e n i n g t o what the phenomenon speaks of i t s e l f "  (Colaizzi,  1978,  p. 52).  Sheridan's stance of i m a g i n a t i v e l i s t e n i n g which I was  In essence,  I  adopted  (cited i n Colaizzi) in  " t o t a l l y present to . . . [her]"  (p. 64)  and  " a t t e n t i v e t o . . . [her] nuances of speech and g e s t u r e s " (p. 62) . At the end of the i n t e r v i e w , I summarized the essence s e s s i o n w i t h the c o - r e s e a r c h e r as a means of v e r i f y i n g i n f o r m a t i o n and any i n c o n s i s t e n c i e s were e x p l o r e d . s p e c i f i c r e s e a r c h q u e s t i o n s which were based on  1978).  the  I also  asked  my  p r e s u p p o s i t i o n s about the meaning of the recovery (Colaizzi,  of the  experience  Not a l l of the f o l l o w i n g q u e s t i o n s needed t o  be asked a t the end of the i n t e r v i e w s i n c e some were addressed  by  the c o - r e s e a r c h e r s as they t o l d t h e i r r e c o v e r y s t o r i e s and some were asked d u r i n g the i n t e r v i e w when i t seemed a p p r o p r i a t e .  The  r e s e a r c h q u e s t i o n s are as f o l l o w s : 1. Did you share your experience of b u l i m i a or r e c o v e r y b u l i m i a with o t h e r s ? 2. Was  I f so, what was  important about t h i s ?  t h e r e anything e l s e t h a t would have helped you i n  your r e c o v e r y process?  from  55 3. When and how  d i d you know t h a t you had recovered  from  bulimia? 4. In comparison t o when you were b u l i m i c , do you f e e l are d i f f e r e n t now or s p i r i t u a l l y ?  e i t h e r i n t e l l e c t u a l l y , emotionally, I f so, how  do you account  you  socially,  f o r these changes?  5. D e s c r i b e the events which p l a y e d a r o l e i n the onset of your b u l i m i a . 6. Would you l i k e t o c l a r i f y or add anything e l s e t o your recovery story? A f t e r the i n t e r v i e w , I t r a n s c r i b e d the audiotape verbatim i n order t o p r e s e r v e the cadence and tone of the d i a l o g u e . t o m a i n t a i n c o n f i d e n t i a l i t y , any t r a n s c r i p t s was f o r names.  In order  i d e n t i f y i n g i n f o r m a t i o n i n the  anonymously presented by s u b s t i t u t i n g  Each c o - r e s e a r c h e r was  initials  then g i v e n the o p p o r t u n i t y to  read the typed t r a n s c r i p t f o r c l a r i f i c a t i o n or a d d i t i o n of further information. I used C o l a i z z i ' s  (1978) e x i s t e n t i a l - p h e n o m e n o l o g i c a l  approach t o analyze the t r a n s c r i p t s i n order t o e l u c i d a t e the themes or p a t t e r n s of meaning of the r e c o v e r y experience. the a n a l y s i s p r o c e s s , i t became apparent two  t h a t i n f o r m a t i o n from  o f the f o u r t r a n s c r i p t s l a c k e d r i c h n e s s and  Consequently,  During  depth.  only the two more comprehensive t r a n s c r i p t s of  L. S. and P. Y. were analyzed.  Themes were formulated  L. S.'s  t r a n s c r i p t as i t was  P. Y.'s  t r a n s c r i p t served t o c r o s s - v a l i d a t e the  In September 1991,  my  the most d e t a i l e d .  c o - r e s e a r c h e r , L. S.,  from  Statements from findings. and  I met  1 hr 45 min t o v a l i d a t e the themes and c l u s t e r s of themes.  for I  56 c o n s u l t e d her f o r wisdom as t o whether the p h r a s i n g of the themes a c c u r a t e l y d e s c r i b e d her experience and whether t h e r e were any e r r o r s o f omission o r commission.  Based upon her feedback,  I  made the necessary r e v i s i o n s so t h a t the d e s c r i p t i o n o f the p a t t e r n o f the r e c o v e r y experience was account  of her  an a c c u r a t e and  complete  experience.  Analysis In a n a l y z i n g the c o - r e s e a r c h e r s ' t r a n s c r i p t s or p r o t o c o l s , I used C o l a i z z i ' s  (1978) e x i s t e n t i a l - p h e n o m e n o l o g i c a l approach as a  g u i d e l i n e t o e x p l i c a t e the meaning o f the r e c o v e r y experience. The  f o l l o w i n g steps o u t l i n e the process of a n a l y s i s . 1. I r e r e a d the typed p r o t o c o l s " i n order t o a c q u i r e a  f e e l i n g f o r them, a making sense out of them" ( C o l a i z z i ,  1978,  p.  59) . 2. Beginning w i t h the r i c h e s t and most comprehensive p r o t o c o l , I e x t r a c t e d s i g n i f i c a n t phrases or sentences which p e r t a i n e d d i r e c t l y t o the experience of r e c o v e r y from b u l i m i a . R e p e t i t i o u s statements  w i t h i n a p r o t o c o l were e l i m i n a t e d .  s i g n i f i c a n t statements  from each p r o t o c o l were w r i t t e n on  The  c o l o u r e d index cards r e p r e s e n t a t i v e of each c o - r e s e a r c h e r . 3. I formulated the meaning of each s i g n i f i c a n t statement making the i m p l i e d meaning e x p l i c i t .  Creative insight  by  was  i n v o l v e d i n moving beyond what the c o - r e s e a r c h e r s s a i d "to what they  [meant]"  ( C o l a i z z i , 1978,  the o r i g i n a l i n f o r m a t i o n . t o speak f o r i t s e l f "  p. 59) w h i l e s t i l l  s t a y i n g with  In order t o o p t i m a l l y " a l l o w the data  ( C o l a i z z i , p. 59), the c o - r e s e a r c h e r ' s  words were used whenever p o s s i b l e .  Once a meaning  was  own  57 i l l u m i n a t e d , I wrote t h e words on a l a b e l which was a f f i x e d t o the c o r r e s p o n d i n g statement  on t h e index c a r d .  same o r s i m i l a r meaning-labels  Cards w i t h the  were f i l e d t o g e t h e r and I t r i e d t o  keep them i n t h e i r n a r r a t i v e order as much as p o s s i b l e . 4. A f t e r each theme was formulated from t h e meaning o f s i g n i f i c a n t statements  i n L. S.'s p r o t o c o l , I r e f e r r e d back t o  the o r i g i n a l p r o t o c o l i n order t o ensure t h a t t h e themes completely and a c c u r a t e l y d e s c r i b e d t h e experience c o n t a i n e d i n the t r a n s c r i p t . (see Chapter  I then l i s t e d t h e themes and t h e i r d e s c r i p t i o n s  IV).  In order t o c r o s s - v a l i d a t e these  c o r r o b o r a t i n g statements  findings,  from P. Y.'s t r a n s c r i p t were noted  after  the d e s c r i p t i o n o f each theme. 5. The themes were then o r g a n i z e d i n t o c l u s t e r s of themes a c c o r d i n g t o t h e i r meaning f o r t h e c o - r e s e a r c h e r . corresponded  The c l u s t e r s  approximately t o the order i n which the  c o - r e s e a r c h e r experienced them.  V a l i d a t i o n of the c l u s t e r s  o c c u r r e d by r e f e r r i n g a g a i n t o the o r i g i n a l  protocol.  6. I r e t u r n e d t o t h e f i r s t c o - r e s e a r c h e r , L.S., f o r v a l i d a t i o n o f the accuracy and a p p r o p r i a t e n e s s o f t h e wording of the thematic c a t e g o r i e s . 7. As t h e c l u s t e r e d themes p r o v i d e d an e x h a u s t i v e d e s c r i p t i o n o f the experience o f recovery from b u l i m i a which c l e a r l y i d e n t i f i e d the s t r u c t u r e o f the experience i n a c h r o n o l o g i c a l and u n i f i e d manner, I omitted C o l a i z z i ' s (1978) s t e p o f c o m p i l i n g t h e theme d e s c r i p t i o n s i n t o a n a r r a t i v e . 8. I summarized my exhaustive d e s c r i p t i o n of t h e recovery experience i n t o a condensed o u t l i n e of t h e c l u s t e r e d themes which  s u c c i n c t l y and c l e a r l y r e v e a l s the meaning o r s t r u c t u r e o f the e x p e r i e n c e (see Chapter I V ) .  fundamental  59  Chapter IV Results Interviews At t h e beginning o f each i n t e r v i e w , my c o - r e s e a r c h e r and I spent some time e s t a b l i s h i n g r a p p o r t i n order t o f a c i l i t a t e d i s c l o s u r e o f h e r s t o r y i n as much d e t a i l as p o s s i b l e .  A sense  of mutual r a p p o r t o c c u r r e d q u i c k l y as a f o u n d a t i o n had a l r e a d y been l a i d by p r i o r telephone meeting.  c a l l s and our i n i t i a l i n t r o d u c t o r y  Furthermore, our working r e l a t i o n s h i p was enhanced by  our common g o a l of s e a r c h i n g f o r f u r t h e r knowledge t h a t would a s s i s t o t h e r women t o overcome b u l i m i a . While I d i d not s e l e c t my c o - r e s e a r c h e r s a c c o r d i n g t o the nature o f t h e events which f a c i l i t a t e d recovery, t h e i r r e v e a l e d a wide v a r i e t y o f h e l p i n g c o n t e x t s : o u t p a t i e n t therapy,  stories  individual  e a t i n g d i s o r d e r support groups, and i n f o r m a l  therapeutic relationships.  As each woman spoke, h e r a u t h e n t i c  t e a r s , t h e i n t e n s i t y o f h e r v o i c e and t h e a t t e n t i o n p a i d t o d e t a i l s i n d i c a t e d t h a t she was e m o t i o n a l l y i n v o l v e d i n r e l i v i n g her e x p e r i e n c e .  P.Y.'s comment—"You remember a l o t o f t h i n g s  j u s t t a l k i n g about i t " (Appendix J , p. 244)—was  another  i n d i c a t o r o f being p e r s o n a l l y i n v o l v e d d u r i n g the i n t e r v i e w .  The  importance o f r e f l e c t i n g upon t h e recovery experience was expressed  by 3 of t h e c o - r e s e a r c h e r s .  For i n s t a n c e , S.H. wanted  more i n s i g h t i n t o why her recovery process u n f o l d e d as i t d i d , S.T.  d e s i r e d a deeper understanding  o f recovery because she  wanted t o work i n t h e e a t i n g d i s o r d e r f i e l d ,  and P.Y. was c u r i o u s  t o compare h e r experience and present s t a t e o f r e c o v e r y w i t h  60 others'  stories.  While a l l of the women had d i s c l o s e d t h e i r e a t i n g d i s o r d e r to  o t h e r s e i t h e r d u r i n g or a f t e r recovery, none had  recounted  t h e i r r e c o v e r y s t o r y i n as much d e t a i l as they d i d d u r i n g interview.  In f a c t , S.H.,  had approximately  S.T.,  were s u r p r i s e d t h a t they  2 hours worth of i n f o r m a t i o n t o r e l a t e !  end of our i n t e r v i e w , P.Y. about i t i n my whole l i f e  ( l a u g h ) " (Appendix J , p.  said  245).  awed by each woman's p e r s o n a l  and openness i n r e l a t i n g i n f o r m a t i o n .  I left  r e s e a r c h e r ' s home f e e l i n g c l o s e r t o her than when I had entered and  At the  s a i d , "That's the most I've ever  Throughout the i n t e r v i e w s , I was investment  and P.Y  our  each cofirst  I f e l t honoured to have been p r i v y to such a  s e c r e t i v e and tender p a r t of each one's l i f e . According to C o l a i z z i  (1978),  d i a l o g a l research  facilitates  " e x i s t e n t i a l i n s i g h t " by a l l o w i n g "the c o - r e s e a r c h e r s t o i l l u m i n a t e e x i s t e n t i a l dimensions of t h e i r l i v e s which p r e v i o u s l y c o u l d not be f a c i l e l y questioned but which now i n t e r r o g a t e d and hence r a t i f i e d , During a telephone  can  be  r e j e c t e d , or m o d i f i e d "  c o n v e r s a t i o n with S.T.  (p. 69).  i n which I was  updating  her on the p r o g r e s s of the study, she commented t h a t a f t e r  having  t o l d her recovery s t o r y she r e a l i z e d t h a t she was  person  to  have overcome so many a d d i c t i o n s .  For P.Y.,  b e i n g g e n u i n e l y recovered from b u l i m i a was recounted her recovery experience:  a strong  her sense of  strengthened  as  she  She r e a l i z e d t h a t her  i n c r e a s e d s e n s i t i v i t y towards balanced meals and a range of a c c e p t a b l e weights were h e a l t h y a t t i t u d e s and not i n d i c a t o r s of b e i n g o v e r l y concerned  about body shape and weight.  61  None o f my c o - r e s e a r c h e r s mentioned r e f e r r i n g t o p e r s o n a l j o u r n a l s o r o t h e r t a n g i b l e sources o f i n f o r m a t i o n i n p r e p a r a t i o n for  our i n t e r v i e w , and d u r i n g t h e i n t e r v i e w they spoke  spontaneously  without any o u t s i d e r e s o u r c e s .  Given t h e shame and  s e c r e c y a s s o c i a t e d with b u l i m i a , i t i s understandable  that the  f e a r o f o t h e r s p o s s i b l y d i s c o v e r i n g t h e i r e a t i n g d i s o r d e r by happening upon p e r s o n a l j o u r n a l s would serve as a d e t e r r e n t t o w r i t i n g down such i n f o r m a t i o n .  Each c o - r e s e a r c h e r seemed d i s t a n t  enough from h e r experience t o have a h o l i s t i c p e r s p e c t i v e on i t , and y e t a l s o c l o s e enough t o v i v i d l y r e c a l l s i g n i f i c a n t Of course, t h e r e were i n s t a n c e s when t h e women with  events.  relatively  l o n g e r r e c o v e r y p e r i o d s — L . S . and S . T . — e x p r e s s e d t h a t t h e i r memory o f c e r t a i n events o r t h e sequence o f events was sketchy. Nonetheless,  t h e i r c l e a r memories o f c e r t a i n c r i t i c a l  enhanced t h e understanding  o f aspects o f the r e c o v e r y  t h a t t h e o t h e r women had a l s o d e s c r i b e d . L.S.  events experience  For i n s t a n c e , although  f e l t t h a t h e r r e c o u n t i n g o f h e r therapy s e s s i o n s was not  complete, she was a r t i c u l a t e about what b e h a v i o u r a l  strategies  she had implemented t o g a i n an i n c r e a s e d sense o f c o n t r o l her b u l i m i c symptoms.  She was a l s o c l e a r about t h e process o f  change i n h e r thoughts,  f e e l i n g s , and a c t i o n s p e r t a i n i n g t o food,  e a t i n g h a b i t s , and body image. deeper understanding  over  A l s o , L.S.'s s t o r y p r o v i d e d a  o f how d i s c l o s i n g one's b u l i m i a t o o t h e r s  enhances m o t i v a t i o n and commitment t o change. Concerning  t h e sequencing  of i n t e r v i e w q u e s t i o n s , i n the  f i r s t two i n t e r v i e w s with S.H. and S.T., r a t h e r than a s k i n g them to  b e g i n t h e i r recovery s t o r y a t t h e p o i n t when they  first  62  n o t i c e d i n k l i n g s of change w i t h r e s p e c t t o t h e i r b u l i m i a , I asked them t o f i r s t d e s c r i b e the events which c o n t r i b u t e d t o the onset of t h e i r b u l i m i a and then t o continue r e c o u n t i n g t h e i r r e c o v e r y experience.  I asked my  q u e s t i o n s i n t h i s sequence as I f e l t  r e c a l l o f events would be f a c i l i t a t e d by c h r o n o l o g i c a l l y one's e x p e r i e n c e with b u l i m i a , and because p r e s u p p o s i t i o n s was  that  relating  one of my  t h a t the p r e c i p i t a t i n g f a c t o r s are o f t e n the  f a c t o r s involved i n recovery.  And although L.S. confirmed t h a t  "chronological progression . . .  i s easier  t h i n g s i n " (Appendix H, p. 143), I f e l t  ...  t o remember  t h a t the r i c h n e s s and  depth of the r e c o v e r y events were compromised i n the i n t e r v i e w s w i t h S.H.  and S.T.  because  a f t e r d i s c u s s i n g the p r e c i p i t a t i n g  events they had l e s s energy t o f u l l y r e l a t e the core of t h e i r recovery experience. Consequently, P.Y.,  i n the subsequent  i n t e r v i e w s w i t h L.S.  and  we began a t the p o i n t when they f i r s t n o t i c e d i n k l i n g s of  change, and the p r e c i p i t a t i n g events were addressed e i t h e r d u r i n g the i n t e r v i e w as they arose or a t the end of the i n t e r v i e w . r e a d i n g the p r o t o c o l s of L.S. and P.Y.,  From  the d e t a i l s of the  r e c o v e r y events were q u a l i t a t i v e l y r i c h e r than those d e s c r i b e d by c o - r e s e a r c h e r s S.H.  and  S.T.  In s p i t e of having r e a l i z e d the importance  of  initially  a d d r e s s i n g the r e c o v e r y q u e s t i o n beginning from when changes were f i r s t n o t i c e d , my  tendency towards c h r o n o l o g i c a l l y  s t o r i e s i s p a r t i c u l a r l y e v i d e n t i n P.Y.'s p r o t o c o l .  related Although  she  immediately begins her s t o r y a t the p o i n t of f i r s t b e i n g aware of some change, I focus i n on i n f o r m a t i o n p r i o r t o t h i s experience  63 by a s k i n g , "Can how  you j u s t s o r t of f i l l  me  i n who  Dr. B. i s , and  . . . you got t o see him and s o r t of t e l l him about t h i n g s ,  and then how Although we  a l l t h i s came about?"  (Appendix J , p.  190).  e v e n t u a l l y came back t o address the i n i t i a l  change  experience, the i n t e r v i e w environment c o u l d f u r t h e r f a c i l i t a t e the understanding  of recovery by more c l o s e l y f o l l o w i n g the  co-  researchers' leads. With r e s p e c t t o the c o - r e s e a r c h e r s * p e r c e p t i o n s of the b e g i n n i n g of the change process, the s t o r i e s of L.S. diverse.  For L.S.,  the f i r s t  c o n t r o l l i n g her l i f e  i n t e r f e r i n g with school a c t i v i t i e s .  and  She continued on with  d e s c r i b i n g changes r e l a t e d t o e a t i n g behaviour:  s t a b i l i z a t i o n of  of b i n g e i n g and purging, d e l a y i n g b u l i m i c behaviours,  and e v e n t u a l l y some decreased  frequency  of b i n g e i n g and  L.S. marked the beginning of the " a c t u a l r e c o v e r y " p. 160)  are  i n k l i n g s of change o c c u r r e d when  she r e a l i z e d t h a t her b u l i m i a was  frequency  and P.Y.  p e r i o d a t the p o i n t where the frequency  purging.  (Appendix H,  of her b i n g e i n g  and p u r g i n g began t o d i m i n i s h s t e a d i l y and she r e a l i z e d she enough c o n t r o l t o eat d i n n e r without b i n g e i n g or p u r g i n g . c o n t r a s t , the f i r s t a decreased  i n k l i n g s of change f o r P.Y.  frequency  had In  were i n d i c a t e d  of purging f o l l o w e d by a decrease  i n the  s i z e of b i n g e s . As the i n t e r v i e w became focussed on the time f o l l o w i n g decreased  frequency  of b i n g e i n g and purging, each c o - r e s e a r c h e r  became l e s s d e s c r i p t i v e about events. r e p r e s e n t a t i v e of how  P.Y.'s statement  the c o - r e s e a r c h e r s i n i t i a l l y  t h i s phase of the recovery p r o c e s s :  "And  is  r e f e r r e d to  I can't remember  how  by  64 long a time i t was J,  p. 190).  P.Y.  though u n t i l I stopped completely" a l s o i l l u s t r a t e s how  (Appendix  t h i s phase of the recovery  p e r i o d w i t h i t s s p e c i f i c i t y of d e t a i l s over a g r a d u a l p e r i o d of time r e q u i r e d more r e f l e c t i o n f o r the c o - r e s e a r c h e r s .  She  says,  So l i k e p a r t of i t [the f a c t o r s which c o n t r i b u t e d t o decreased b i n g e i n g and purging] was the support, and p a r t of i t too was n a t u r a l consequence, you know. I f you take away the v o m i t i n g , then you have t o d e a l w i t h t h a t h o r r i b l e f u l l feeling. And i t ' s t e r r i b l e . I t j u s t , you, i t wipes you out f o r the r e s t of the day. So then the next time you binge, you tend t o binge a l i t t l e l e s s . And, so the b i n g e i n g gets l e s s j u s t because you don't have t h a t same way of g e t t i n g r i d of i t . (Appendix J , p. 217) Consequently, of  I found myself more i n t e n s e l y p r o b i n g t h i s aspect  the r e c o v e r y experience i n order t o examine the occurrences  f u l l y as p o s s i b l e . importance first  Once again, t h i s o b s e r v a t i o n underscores  of i n i t i a l l y  noticed.  a d d r e s s i n g the p o i n t when change  Understandably,  the  was  s t u d y i n g t h i s phase of change i s  hard work and thus r e q u i r e s the optimal amount of time emotional  as  and  energy.  As I began a n a l y z i n g the t r a n s c r i p t s , t h a t one of my  i t became apparent  s p e c i f i c r e s e a r c h q u e s t i o n s — W h a t e l s e would have  helped you i n your r e c o v e r y ? — d i d not p r o v i d e statements p e r t i n e n t t o recovery.  Nonetheless,  I would s t i l l  directly  include t h i s  q u e s t i o n i n f u t u r e i n t e r v i e w s as i t p r o v i d e d an o p p o r t u n i t y f o r c o - r e s e a r c h e r s t o summarize and b r i n g c l o s u r e t o t h e i r recovery s t o r y , and then move beyond i t t o the f u t u r e . L.S.  after  s a i d t h a t she wished she had attended more of the ANAD  support group meetings, i n them now to  For example,  she mused about p o s s i b l y being i n v o l v e d  so t h a t she c o u l d share her experience and  perhaps "help somebody get through  learning  i t [ b u l i m i a ] more q u i c k l y "  65  (Appendix  H, p.  182).  From T r a n s c r i p t i o n t o Formulation o f Themes I found t h e t r a n s c r i b i n g o f each c o - r e s e a r c h e r ' s to  be a v e r y demanding p r o c e s s .  t r a n s c r i b i n g each tape.  audiotape  I spent approximately  With each t r a n s c r i p t i o n ,  2 weeks  I found  deeply i n v o l v e d both e m o t i o n a l l y and i n t e l l e c t u a l l y .  myself  As I  r e l i v e d each r e c o v e r y s t o r y , I began t o connect more deeply with each woman's experience and t o r e f l e c t upon my own l i f e e x p e r i e n c e s as I was reminded o f them.  During t h i s  transcription  p r o c e s s , t h e meaning o f many statements  became c l e a r t o me and I  wrote t h e words i n t h e margin. Although  I had l i s t e n e d t o t h e tapes twice and f e l t q u i t e  f a m i l i a r w i t h each c o - r e s e a r c h e r ' s s t o r y , I found t h e process of e x t r a c t i n g s i g n i f i c a n t statements  onto index cards and  f o r m u l a t i n g t h e i r meanings t o be p h y s i c a l l y demanding but a l s o i n t e l l e c t u a l l y s t i m u l a t i n g as I thought  about how each event was  a p a r t o f and c o n t r i b u t e d t o t h e c o - r e s e a r c h e r ' s recovery experience. of  A f t e r completing t h i s process with t h e t r a n s c r i p t s  L.S. and P.Y., I f e l t e x c i t e d and s a t i s f i e d as aspects o f  r e c o v e r y t h a t were common t o both women began t o emerge. As I began t o formulate themes from the meanings common t o both c o - r e s e a r c h e r s , i t became apparent  t h a t L.S.'s  statements  p r o v i d e d a more comprehensive d e s c r i p t i o n o f t h e themes. Statements from P.Y. confirmed aspects o f L.S.'s experience. Consequently,  themes were formulated only from t h e meaning of  L.S.'s s i g n i f i c a n t statements P.Y.  and t h e c o r r o b o r a t i n g statements of  were noted a f t e r t h e d e s c r i p t i o n o f each theme.  66 Formulating t h e themes and d e s c r i b i n g them r e q u i r e d both i n t e n s e c o n c e n t r a t i o n and i n t u i t i o n as I c o n t i n u a l l y checked  back  t o t h e o r i g i n a l p r o t o c o l t o ensure t h a t the themes f u l l y d e s c r i b e d t h e c o - r e s e a r c h e r ' s experience.  I was a s s i s t e d i n t h i s  p r o c e s s by an experienced P u b l i c H e a l t h Nurse who confirmed o r helped me r e f i n e my d e s c r i p t i o n of the themes. attempt  With my  first  a t f o r m u l a t i n g themes, I d e s c r i b e d v e r y p r e c i s e aspects  of t h e r e c o v e r y experience such t h a t genuineness, u n c o n d i t i o n a l acceptance  were separate themes.  r i s k i n g , and  However, with  t h i s p r e c i s i o n t h e t h r e a d of the experience seemed l o s t .  After  r e v i e w i n g t h e p r o t o c o l s and r e - t h i n k i n g the themes, I saw t h a t s e v e r a l themes c o u l d be viewed as aspects of a s i n g l e theme. i n s t a n c e , b e i n g genuine and t a k i n g r i s k s r e s u l t e d from u n c o n d i t i o n a l l y accepted.  For  feeling  T h i s r e v i s i o n of themes p r o v i d e d a  more coherent and i l l u m i n a t i n g understanding  of t h e recovery  experience. The V a l i d a t i o n  Interview  Before r e t u r n i n g t o my primary c o - r e s e a r c h e r , L.S., f o r v a l i d a t i o n o f the themes and c l u s t e r s of themes, I noted any themes t h a t I p a r t i c u l a r l y wanted t o check the p h r a s i n g o f .  As  she read t h e themes and s i g n i f i c a n t p r o t o c o l statements t o h e r s e l f , I asked her t o note any changes, a d d i t i o n s , o r comments she wanted t o make and t o i n d i c a t e whether the p a t t e r n of r e c o v e r y f i t t e d her experience. L.S.  c a r e f u l l y read the d e s c r i p t i o n and ensured t h a t the  themes were c o r r e c t l y c l u s t e r e d under t h e f o u r c a t e g o r i e s . underscored  t h e importance  of Theme A2 which emphasized the  She  67 c a u s a l l i n k between f e e l i n g i n c r e a s i n g l y c o n t r o l l e d i n an i n t e r p e r s o n a l r e l a t i o n s h i p and an i n c r e a s e i n b u l i m i c L.S.  behaviours.  a l s o c l a r i f i e d t h e meaning o f one o f h e r statements i n Theme  B2 p e r t a i n i n g t o t h e impact o f p o t e n t i a l l y f e e l i n g ashamed i f she d i d n ' t f o l l o w through on changing h e r e a t i n g behaviour w h i l e she was i n therapy. feedback.  I rephrased t h e sentence i n accordance with her  We a l s o d i s c u s s e d  t h e p o s i t i o n i n g o f Theme C 5 —  Awareness o f r e l a p s e — u n d e r C l u s t e r C: Awareness o f e v o l v i n g and  changes i n e a t i n g behaviours.  L.S. f e l t t h a t Theme C5 c o u l d  f i t under C l u s t e r B—Openness and r e a d i n e s s emphasis was p l a c e d treatment again.  self  f o r c h a n g e — i f the  on how h e r r e l a p s e p r o p e l l e d h e r t o seek  However, she v e r i f i e d t h a t t h e placement o f the  theme was a c c u r a t e  because h e r awareness o f having r e l a p s e d  also  reminded h e r t h a t she had made some changes and was p r e v i o u s l y more i n v o l v e d i n l i f e than she c u r r e n t l y was. O v e r a l l , L.S. f e l t t h a t t h e p a t t e r n o f recovery accurate  d e s c r i p t i o n of h e r experience.  was an  She a l s o s t a t e d t h a t the  o u t l i n e o f t h e themes "helped c l a r i f y t h e process b e t t e r f o r [her]"  (Appendix K, p. 247). She noted t h a t a s i d e from h e r  i n i t i a l querying appropriate  o f Theme C5, t h e c l u s t e r i n g o f themes seemed  and i n t u i t i v e l y f i t t e d t h e chronology o f her  e x p e r i e n c e o f recovery.  From our v a l i d a t i o n meeting, I f e l t  assured t h a t my a r t i c u l a t i o n o f t h e process o f L.S.'s e x p e r i e n c e was accurate  and a p p r o p r i a t e .  C l u s t e r s o f Themes and S i g n i f i c a n t P r o t o c o l T h i s s e c t i o n presents themes.  recovery  Statements  a condensed o u t l i n e o f t h e c l u s t e r e d  C l u s t e r s emerged as themes with r e l a t e d meanings became  68 evident.  While some themes such as an i n c r e a s i n g sense o f  e f f i c a c y reappeared throughout t h e recovery experience, c h r o n o l o g i c a l p a t t e r n was apparent. the developmental process  An exhaustive  d e s c r i p t i o n of  i n h e r e n t i n the experience  f o l l o w s t h e condensed o u t l i n e .  a clear  o f recovery  Based upon the meaning o f the  s i g n i f i c a n t p r o t o c o l statments, the themes a r e d e s c r i b e d i n an a t h e o r e t i c a l manner which a c c u r a t e l y r e f l e c t s the c o - r e s e a r c h e r ' s experience  as she and I understood i t .  Consequently, t h e  i n t e r p r e t a t i o n o f the r e s u l t s may be d e s c r i b e d d i f f e r e n t l y by others. Condensed O u t l i n e o f C l u s t e r e d Themes A.  REALIZATION  OF  EATING  PROBLEM  C.  AMBIVALENCE  ABOUT  CHANGE  1.  Awareness o f an e a t i n g problem.  2.  Awareness o f the a s s o c i a t i o n between one's e a t i n g problem and emotional  B.  AND  issues.  3.  D i a g n o s t i c awareness o f one's e a t i n g problem.  4.  Acknowledgement o f need f o r o u t s i d e h e l p .  5.  Awareness of o b s t a c l e s t o a c t i o n .  OPENNESS  AND  READINESS  FOR  CHANGE  1.  Breaking  2.  Disclosure of bulimia to t h e r a p i s t .  3.  Remission.  AWARENESS  OF  the secrecy.  EVOLVING  SELF  AND  CHANGES  IN  EATING  1.  I n c r e a s i n g sense o f e f f i c a c y .  2.  Interruption of eating patterns.  3.  Symptom s u b s t i t u t i o n .  4.  I n c r e a s i n g intimacy with s e l f and o t h e r s .  BEHAVIOURS  69 5.  Awareness o f r e l a p s e .  6.  Separation  7.  D e - i d e a l i z i n g and f o r g i v i n g f a m i l y o f o r i g i n .  8.  V e r b a l l y acknowledging b u l i m i c b e h a v i o u r s .  9.  Permission feel  10. D.  o f s e l f from b u l i m i a .  t o eat previously forbidden  foods and t o  full.  I d e n t i f i c a t i o n w i t h and acceptance by other  EMERGENCE  OF  A  NEW  SELF  AND  NEW  bulimics.  VALUES  1.  Accountability to significant  others.  2.  Responsibility for offspring.  3.  New a p p r e c i a t i o n and understanding o f her p h y s i c a l body.  4. E.  THE  1.  Expanding sense o f s e l f and b e l i e f i n s e l f . NATURE  AND  MAINTENANCE  OF  RECOVERY  Counting the c o s t o f r e t u r n i n g t o t h e b u l i m i c behaviours.  2.  Processing  lapses.  3.  Increased  4.  A u t h e n t i c i t y with  5.  Balancing  6.  Altruism.  7.  C e r t a i n t y o f recovery.  self-knowledge and acceptance. others.  work and p l a y .  E x h a u s t i v e D e s c r i p t i o n o f the Recovery Experience A.  REALIZATION  1.  Awareness  She  of  OF an  EATING eating  PROBLEM  AND  AMBIVALENCE  ABOUT  CHANGE  problem.  knows t h a t something i s s e r i o u s l y wrong with her e a t i n g  behaviour because the frequency o f b i n g e i n g  and purging has  70 s t e a d i l y e s c a l a t e d t o the p o i n t where these behaviours are c o n t r o l l i n g and dominating her l i f e .  She  f e e l s desperate  and  powerless as she r e a l i z e s t h a t her d a i l y a c t i v i t i e s and g o a l s are compromised and thwarted because b i n g e i n g and p u r g i n g consumes a l l her time and energy. corroborating  (See Appendix J , #028 f o r P.Y.'s  statement.)  W e l l , I guess i n s i d e I'd always known t h a t something was v e r y wrong. But the, those 2 years of u n i v e r s i t y saw a very steady urn p r o g r e s s i o n of i t [ b i n g e i n g and purging] such t h a t by the end of my second year I j u s t b a r e l y f i n i s h e d the y e a r . You know, I guess I had t o reach a p o i n t where I'd r e a l l y h i t bottom t o r e a l i z e t h a t t h i s [ b i n g e i n g and purging] was probably the cause i n t h a t these a c t i v i t i e s were, were becoming the most important f a c t o r i n my l i f e . Uh, t h i s , t h i s s o r t of t h i n g had taken over my l i f e and t h a t i n o r d e r t o continue doing anything I had t o address i t . (Appendix H, p. 132, #001) 2.  Awareness of the a s s o c i a t i o n between her e a t i n g problem emotional  and  issues.  She r e a l i z e s t h a t her f e e l i n g of l o s s of c o n t r o l d u r i n g e a t i n g episodes i s more i n t e n s e than the l a c k of c o n t r o l e x p e r i e n c e s i n other areas of her l i f e . d e s i r e t o c o n t r o l her weight purges,  she  While she knows t h a t her  i s one reason why  she binges  and  she senses t h a t these e a t i n g behaviours are somehow  l i n k e d t o f e e l i n g i n s e c u r e about h e r s e l f and not i n c o n t r o l of her l i f e .  She becomes more c l e a r about the c o n n e c t i o n between  b i n g e i n g and p u r g i n g and emotional i s s u e s when she sees t h a t a worsening  of her e a t i n g behaviours c o i n c i d e s w i t h f e e l i n g more  controlled in a relationship. r e s p o n s i b l e f o r overcoming how  she f e e l s about  She now  knows t h a t she i s the  one  her b i n g e i n g and p u r g i n g by a d d r e s s i n g  herself.  W e l l , I've always been urn, not very happy w i t h myself, not v e r y secure i n myself, and always eager t o p l e a s e o t h e r s and  71 t o be l e d by others without much confidence myself. And, so i n some ways I o f t e n f e l t as i f I weren't i n c o n t r o l o f my l i f e anyway. Urn, but t h i s [bingeing and purging] j u s t was l i k e a, a, t h a t aspect i n t e n s i f i e d a hundred times. (Appendix H, p. 133, #003) So I guess I k i n d o f knew t h a t uh i t [bingeing and purging] wasn't j u s t a, a way t o c o n t r o l weight: t h a t t h e f a c t t h a t I was i n v o l v e d with t h i s meant, meant something more. I mean I knew t h a t i t was, i t wasn't j u s t t h e f a c t t h a t I would e a t and vomit. There was a, t h e r e was a reason f o r t h a t , somehow, beyond j u s t wanting not t o be f a t again. And I t h i n k , I r e a l i z e d t h a t i t was urn, i n some way connected t o my f e e l i n g s about myself and my l a c k of, o f r e a l l y f e e l i n g of c o n t r o l over myself, o r wanting t o have c o n t r o l , o r f e e l i n g t h a t I was worth urn having c o n t r o l on so I c o u l d make something out o f my l i f e . And t h e r e were other f a c t o r s i n those 2 years o f u n i v e r s i t y t h a t have i n t e n s i f i e d i t i n t h a t I was i n a r e l a t i o n s h i p t h a t wasn't, t h a t wasn't a good one, urn and I l e t myself be c o n t r o l l e d by t h a t person t o o . So you see they almost, as t h a t r e l a t i o n s h i p progressed so did the c o n d i t i o n . So t h e r e were a l o t o f f a c t o r s s o r t of p o i n t i n g i n t h e same d i r e c t i o n t h a t I had t o uh, I knew I had t o t r y and touch base with, with myself i n some ways. (Appendix H, p. 133, #004) 3.  Diagnostic  awareness o f her e a t i n g problem.  Knowing t h a t h e r e a t i n g problem i s a documented c o n d i t i o n — b u l i m i a — w h i c h other people have decreases h e r sense o f i s o l a t i o n and  deepens h e r acknowledgement t h a t she has a problem.  Since  p r o f e s s i o n a l s a r e f a m i l i a r w i t h h e r problem, she f e e l s hopeful about g a i n i n g a c l e a r e r understanding o f i t and g e t t i n g some help t o improve h e r e a t i n g behaviours. P.Y.'s c o r r o b o r a t i n g  (See Appendix J , #027 f o r  statement.)  But um, I was aware o f i t a t t h a t p o i n t ; I knew i t wasn't anorexia. And I knew t h a t i t was a documented c o n d i t i o n . And t h a t was i t s e l f k i n d o f a r e l i e f : I t ' s l i k e other people do t h i s , you know. So t h a t was, I t h i n k i t may have helped t o know t h a t t h e r e was a name f o r what I had, and t h a t other people had i t , and t h e r e may be some recourse. (Appendix H, p. 159, #030) 4.  Acknowledgement o f need f o r o u t s i d e Her  bingeing  and purging  help.  has p a r a l y z e d  a l l areas o f h e r  72 life. She  She f e e l s defeated  as she r e a l i z e s she has " h i t bottom".  knows t h a t she needs some h e l p t o stop b i n g e i n g and purging  so t h a t she can engage i n other a c t i v i t i e s .  Although u n c e r t a i n  about whom t o c o n t a c t , she f e e l s urged t o g e t some o u t s i d e support  because h e r p r e v i o u s attempts a t overcoming h e r b u l i m i a  have shown h e r t h a t she i s unable t o stop b i n g e i n g and purging on her own.  (See Appendix J , #029 f o r P.Y.'s c o r r o b o r a t i n g  statement.) And I t h i n k i t was, i t probably was t h e f a c t t h a t t h i n g s k i n d o f came c r a s h i n g down b e f o r e I came home t h a t summer a f t e r second year t h a t made me r e a l i z e , o r i t made me take t h a t step o f a c t u a l l y seeking h e l p . And i t was s i m i l a r when I, when I went f o r therapy i n V. (Appendix H, p. 151, #016) But a c t u a l l y stopping and saying, "Whoa, wait a minute, you know, t h e r e ' s something r e a l wrong and i t ' s me, and I need help." Because h i t h e r t o , and, and a f t e r t h a t too, I would, you know, a f t e r a p a r t i c u l a r l y bad p e r i o d I'd say, "O.K."-and I t h i n k , I'm sure everybody does t h i s — " T h i s has got t o stop! Dadu dadu dadu dada." And i t would l a s t , you know, o v e r n i g h t maybe, t h a t r e s o l u t i o n . And so t h e r e a l i z a t i o n t h a t I c o u l d n ' t do i t myself was important. And t h e f a c t t h a t I had t h a t support. (Appendix H, p. 144, #008) 5.  Awareness o f o b s t a c l e s t o a c t i o n . She  i s ambivalent about g i v i n g up h e r b u l i m i c  behaviours.  Although she d e s i r e s t o be f r e e o f b i n g e i n g and purging, her commitment t o r e l i n q u i s h them i s low because they s t i l l some p o s i t i v e f u n c t i o n s f o r her:  serve  a mechanism f o r escaping and  r e d u c i n g t e n s i o n , and a p a r t o f h e r s e l f - d e f i n i t i o n .  Her  r e l u c t a n c e t o seek o u t s i d e help i s i n t e n s i f i e d because she i s ashamed about d i s c l o s i n g h e r b u l i m i a . c o n f r o n t t h e u n d e r l y i n g emotional  Knowing t h a t she must  i s s u e s i n order t o t r u l y  overcome h e r b u l i m i c behaviours,  she f e e l s apprehensive about  e n t e r i n g therapy  She i s t e r r i f i e d o f c o n f r o n t i n g  a second time.  73 her sense of emptiness and d o u b t f u l about her a b i l i t y t o d e a l w i t h the p a i n t h a t w i l l be unleashed when she s t a r t s about her f e e l i n g s about h e r s e l f .  talking  (See Appendix J , #002 and #039  f o r P.Y.'s c o r r o b o r a t i n g statements.) And i t [ b u l i m i a ] , i n some ways s t i l l , I d i d n ' t want t o g i v e i t up. I guess maybe because i t was, i t was an escape, i t was a r e l e a s e of t e n s i o n , i t was p a r t of how I d e f i n e d myself, i t was a h a b i t , i t was you know a shameful t h i n g to reveal: a l l of those t h i n g s put t o g e t h e r . (Appendix H, p. 161, #034) [When I contacted the t h e r a p i s t ] I was t e r r i f i e d cause i t was s o r t of l i k e " w e l l t h i s i s i t a g a i n . " Terrified in terms of, of t o t e l l somebody about i t . T e r r i f i e d i n terms of r e a l i z i n g t h a t I'd have t o s t a r t d e a l i n g with i t ; you know, the i m p l i c a t i o n s of t h a t were, were g r e a t . [I would have t o look at myself] . . . and c o u l d I do i t ? (Appendix H, p. 160, #032) Urn, but I s t i l l , I don't t h i n k I was s t i l l y e t at the p o i n t of t r u l y being a b l e t o work through i t . L i k e I wanted t h i s t h i n g t o go away, I wanted t o be O.K., but I d i d n ' t r e a l l y want t o put i n t o i t what I knew I would have t o . Because on one l e v e l , I t h i n k I understand very w e l l t h a t the b u l i m i a i t s e l f , i t was j u s t a s e t of symptoms, t h a t t h e r e were, t h e r e were deeper t h i n g s t h a t were r e a l l y c a u s i n g a l l of that. Urn, so. (Appendix H, p. 132, #002) Yes, urn, because f o r me anyway, t h e r e was such a l a c k of um, l i k e p a r t of me was scared t h a t i f I d i d examine myself I wouldn't f i n d anything t h e r e . You know, because I d i d n ' t have any r e a l sense of myself or of no s t r o n g grounding i n myself. So p a r t of the running away from i t w a s — r u n n i n g away from d e a l i n g with the b u l i m i a — w a s the knowledge t h a t I'd have t o do s e l f - e x a m i n a t i o n and my god, what would, at t h i s p o i n t , what would I f i n d there? I mean t h e r e would be nothing, I d i d n ' t f e e l t h e r e ' d be anything t o work on. (Appendix H, p. 148, #014)  B.  OPENNESS AND  READINESS FOR  1.  Breaking  secrecy.  the  Although she  CHANGE  i s f e a r f u l about seeking help, her  p r o p e l s her t o begin s e a r c h i n g out the necessary people.  Not  knowing who  t o c o n t a c t , she  desperation  resources  f e e l s bewildered.  and With  74 much apprehension, she r e h e a r s e s her request begins c o n t a c t i n g Telephone Information, A n o r e x i a Nervosa and A s s o c i a t e d physician.  determined t o f i n d the a p p r o p r i a t e s e l f - c o n f i d e n c e i n c r e a s e s as she  the A s s o c i a t i o n  Disorders,  With each s u c c e s s f u l c o n t a c t ,  f o r help before of  a t h e r a p i s t , and she  t h e r a p e u t i c m i l i e u and  sees h e r s e l f e f f e c t i v e l y  her taking  Furthermore, as she d i s c l o s e s her s e c r e t t o each  resource  person she gains more courage t o face her b u l i m i a .  grows.  a  feels progressively  action.  commitment t o change and  she  Her  t o a c t i v e l y p a r t i c i p a t e i n therapy  (See Appendix J , #026 f o r P.Y.'s c o r r o b o r a t i n g  statement.) So I c a l l e d , the only t h i n g , I d i d n ' t know what t o do and I looked up "B" i n the phone book. (Laughs.) There's nothing t h a t says, you know, B u l i m i a Support Group or anything. So I c a l l e d um, I t h i n k i t ' s V. Information Number. And I j u s t s a i d , "Is t h e r e any number f o r , f o r , t o help somebody with an e a t i n g d i s o r d e r ? " And she r e f e r r e d me t o ANAD [ A s s o c i a t i o n of Anorexia Nervosa and A s s o c i a t e d D i s o r d e r s ] , and I c a l l e d them, and I found out about the s e s s i o n s . But s t i l l , i t was at t h a t p o i n t where I d i d n ' t r e a l l y want t o l i k e come t o t a l l y out of the c l o s e t . I knew I needed help, but I wasn't about t o s o r t of announce i t t o everybody. But they a l s o gave me the name of a t h e r a p i s t at t h a t p o i n t , Dr. T. And I um c a l l e d her and she managed t o f i t me i n . (Appendix H, p. 160, #031) So i t was a very to a c t u a l l y c a l l these steps took courage, and I'd p. 161, #033)  frightening thing. I t took me a long time Information. I t took me, you know a l l quite a while. I t ' s s o r t of g e t t i n g up the rehearse them over and over. (Appendix H,  Yah, and t h a t was hard. That was r e a l l y hard. Um, and maybe you know i n terms of your l o o k i n g a t the steps, I don't know how t h a t , I don't, I don't suppose t h a t c o u l d ever be overcome, t h a t k i n d of um apprehension and the steps t h a t need t o be gone through. I t h i n k t h a t ' s maybe p a r t of the p r o c e s s i s the a c t u a l l y g e t t i n g y o u r s e l f t o g e t h e r enough t o go through those s t e p s . Maybe i f i t were e a s i e r people wouldn't be at a p o i n t where they'd a c t u a l l y be able t o f o l l o w through on i t . I don't know. (Appendix H, p. 162, #035)  75 2.  Disclosure of bulimia to therapist. As  she d i s c l o s e s h e r b u l i m i c behaviour t o h e r t h e r a p i s t , she  f e e l s l i b e r a t e d from t h e c a p t i v i t y o f h e r i s o l a t i o n which she c r e a t e d by h i d i n g h e r s e c r e t . she  F e e l i n g supported and accepted,  i s r e l i e v e d t o address her s e c r e t r a t h e r than h i d i n g and  running from i t .  In examining h e r e a t i n g behaviour with h e r  t h e r a p i s t , she experiences a sense o f calmness as she steps back and begins t o more c l e a r l y see what h e r b u l i m i a She  i s a l l about.  now f e e l s accountable t o someone e l s e t o take some  constructive action.  As she contemplates t h e shame a s s o c i a t e d  w i t h not a c t i v e l y p a r t i c i p a t i n g i n therapy, h e r sense o f r e s p o n s i b i l i t y and commitment t o changing her e a t i n g behaviour increases.  (See Appendix J , #007, #030, #031, #032, and #033 f o r  P.Y.'s c o r r o b o r a t i n g  statements.)  And I t h i n k another important aspect o f t h a t [therapy] was the f a c t t h a t you're breaking the i s o l a t i o n , breaking t h e secrecy and l e t t i n g someone e l s e i n on i t . I t ' s , i t ' s t e l l i n g you know, i t ' s r e a l i z i n g t h a t you need t h e support. But i t ' s a l s o t h a t by breaking out o f t h a t um c i r c l e of, of secrecy t h a t you c r e a t e , you're almost i t ' s l i k e l e t t i n g a c h i n k o f d a y l i g h t i n . I t ' s l i k e , you know, i t ' s a c o n n e c t i o n between s o r t o f you and t h e o u t s i d e world, i n on, on who you a r e and your s e c r e t . And I, I b e l i e v e very s t r o n g l y t h a t t h a t ' s a v i t a l p a r t o f i t . A t l e a s t i t was f o r me. I know i t was a v i t a l p a r t f o r me because i n t h e subsequent therapy, I t h i n k t h e b i g g e s t step was taken when I t o l d my husband about i t , and t h e most d i f f i c u l t . So I t h i n k p a r t o f the reason t h a t t h e r e was some improvement d u r i n g t h a t time was t h a t I had t o l d somebody e l s e about i t . I mean he [ t h e r a p i s t ] was t h e f i r s t person I t o l d about i t . And t h a t , um, I, I would say t h a t i s very important. (Appendix H, p. 145, #009) [ D i s c l o s i n g my b u l i m i a t o my t h e r a p i s t was] Very p o s i t i v e . I mean t h a t was r e a l good. I t ' s , you know, i t eases t h e burden t h a t you c a r r y . I t a l s o allows you t o t a l k about i t because you're not going t o s i t by y o u r s e l f and t a l k about i t , and t r y and l a y i t a l l out and understand i t . A t l e a s t I wasn't, cause you're so caught up i n i t a l l . (Appendix H, p. 145, #010)  76 I t was a s i m i l a r element t o t h e other s e s s i o n s o f therapy t h a t I underwent here i n V . — t h a t I t h i n k d i d h e l p me urn overcome t h i s [ b u l i m i a ] — w a s t h a t i n l o o k i n g a t i t as we went on I saw t h a t v e r y o f t e n he was j u s t a l l o w i n g me t o put t h i n g s out and he would arrange them so t h a t I c o u l d see a c t u a l l y what I was s a y i n g and t h i n k i n g . So he was very good about not t r y i n g t o impose um h i s own i d e a s on me, r a t h e r making suggestions t h a t , upon r e f l e c t i o n , would have been apparent i n what I s a i d . So i t was v e r y much a way of um, o f o f j u s t a i r i n g , a i r i n g myself and a l l o w i n g myself t o l o o k a t myself. You know, i t was j u s t , i t was s o r t o f a self-examination thing. (Appendix H, p. 135, #005) Yes. Because i t wasn't j u s t me. And t h a t f o r me, t h a t the shame o f i t a l l was so h o r r i b l e , was so t e r r i b l e , t h a t again l e t t i n g someone e l s e i n on t h a t presupposes t h a t then you're going t o do something about i t . You have t o now cause you can't look a t t h a t person i n t h e eye knowing t h a t , you know, you're going t o be running t o t h e bathroom. So t h a t , f o r me t h a t was r e a l l y important. (Appendix H, p. 146, #011) 3.  Remission. Having few e x p e c t a t i o n s i n therapy except t o address her  b u l i m i a , h e r f e a r s o f f a i l u r e a r e minimal and she e x p e r i e n c e s an i n c r e a s e d sense o f c o n t r o l over h e r b i n g e i n g and p u r g i n g . Although t h e frequency o f h e r e a t i n g behaviours doesn't they a r e a r r e s t e d a t t h e i r c u r r e n t i n t e n s i t y .  decrease,  As such, t h e  p r e v i o u s e s c a l a t i n g frequency o f b i n g e i n g and purging i s s t a b i l i z e d and she i s a b l e t o resume h e r d a i l y  activities.  The b e i n g a b l e t o focus on the problem and have no other e x p e c t a t i o n s — w h i c h I wanted, but i t was b e t t e r t h a t I d i d n ' t have t h e m — c o n t r i b u t e d something t o perhaps a b i t of r e m i s s i o n d u r i n g t h a t p e r i o d o f therapy. (Appendix H, p. 144, #007) I t h i n k i t [ b u l i m i c behaviours] had [changed]. As I s a i d , I t h i n k t h a t the therapy had some, had some b e n e f i t s . Um, I'm p r e t t y sure I was s t i l l b i n g e i n g and p u r g i n g . But I t h i n k t h e r e was a b i t o f an element o f c o n t r o l , a b i t . (Appendix H, p. 143, #006) I t was [ d i f f e r e n t ] . You know I do look a t t h e f i r s t 2 years [of u n i v e r s i t y ] as being s o r t o f a, t h e time d u r i n g which I k i n d o f plummeted. And then i t k i n d of, t h e therapy I t h i n k s o r t o f a r r e s t e d t h a t um d i r e c t i o n . And then I s o r t o f see the o t h e r years as more o r l e s s a p l a t e a u . I t d i d n ' t get  77 worse than t h a t . I t d i d n ' t n o t a b l y g e t b e t t e r . Um, but I was a b l e t o m a i n t a i n t h i n g s on a more even k e e l . (Appendix H, p. 151, #017) C.  AWARENESS  1.  Increasing  Her  OF  EVOLVING  sense  of  SELF  AND  CHANGES  IN  EATING  BEHAVIOURS  efficacy.  e x t e r n a l environment becomes more s t a b l e and secure as  she  i s no longer  and  as she begins t o e s t a b l i s h a c a r e e r d i r e c t i o n which she  enjoys.  involved i n a c o n t r o l l i n g intimate r e l a t i o n s h i p  She i s more autonomous and does not depend on others as  much t o s t r u c t u r e her d a i l y a c t i v i t i e s . of c o n t r o l i n her l i f e . provides  She e x p e r i e n c e s a sense  F e e l i n g competent i n h e r c a r e e r  field  an accomplishment which c l e a r l y d e l i n e a t e s an aspect o f  her s e l f and allows her t o f e e l more c e r t a i n i n knowing who she is.  In t h e realm o f c a r e e r , her s e l f - w o r t h  f e e l s b e t t e r about h e r s e l f . P.Y.'s c o r r o b o r a t i n g  i s enhanced and she  (See Appendix J , #003 and #006 f o r  statements.)  So t h a t was s t i l l a l l going on [bingeing and purging] but um, I was out o f t h a t r e l a t i o n s h i p . I t h i n k t h a t made a b i t of a d i f f e r e n c e . I was a l i t t l e more autonomous t h a t way. Um, I was d e f i n i n g more s o r t o f what my d i r e c t i o n was i n school. I had e s t a b l i s h e d you know, the Russian major and I knew more o r l e s s I was good a t i t , even though I I thought I was only good because the competition wasn't t h e r e . So I had a l i t t l e niche, you know, and t h a t helped. I t wasn't so much j u s t f l a i l i n g around. (Appendix H, p. 152, #018) I t h i n k t h e key element t h e r e was t h a t I f e l t t h a t I was doing something t h a t was more or l e s s worthwhile, t h a t I was, I thought I was f a i r l y good a t i t . So i t gave me s o r t o f t h a t approval and I was able t o s o r t o f d e f i n e myself more. L i k e I c o u l d say t h a t , um you know, I'm s t u d y i n g Russian and I c o u l d have t h a t um as something t h a t was me. I t was a very much me t h a t d u r i n g those 4 y e a r s i t p r e t t y w e l l , you know, took up most o f my time. So I suppose i n a way t h a t ' s again t h e r e was i s s u e s I wasn't a d d r e s s i n g . You know I never d i d go back and do the s o r t o f s o u l s e a r c h i n g and house c l e a n i n g t h a t I thought t h a t I should do i n order t o r e a l l y be w e l l . And I s t i l l had, you know, t h e r e ' s s t i l l a l o t o f u n d e r l y i n g l a c k o f confidence and s e l f - h a t r e d and a l l that s o r t of s t u f f . But a t l e a s t on t h a t plane I f e l t  78 some element of performance and an element of success. So I t h i n k t h a t ' s why t h i n g s were l a r g e l y b e t t e r . (Appendix H, pp. 155-156, #022) 2.  I n t e r r u p t i o n of eating patterns. As she begins t o spend more time i n areas of her l i f e where  she  f e e l s s u c c e s s f u l , she experiences  eating patterns.  s u b t l e changes i n her  In a d d i t i o n t o o c c a s i o n a l l y e a t i n g a normal  meal without purging,  she  i s i n c r e a s i n g l y a b l e t o d e l a y her urge  t o binge and purge such t h a t the behaviors c e r t a i n time p e r i o d s .  are contained  Although the frequency of her  behaviours remains r e l a t i v e l y unchanged, she  within  bulimic  i n t e r r u p t s her  e a t i n g p a t t e r n i n order t o have time t o engage i n p r o d u c t i v e activities.  As she  f e e l s l e s s r u l e d by her e a t i n g  she gains more confidence activities.  behaviours,  i n her a b i l i t y t o engage i n other  Over time, her sense of competence, s t a b i l i t y ,  commitment t o her c a r e e r i n c r e a s e s and  she n o t i c e s a  gradual  improvement i n her b u l i m i c behaviour as the frequency of and p u r g i n g  decreases s l i g h t l y .  #049 f o r P.Y.'s c o r r o b o r a t i n g  and  bingeing  (See Appendix J , #047, #048, and  statements.)  Well as I s a i d , I'm p r e t t y sure t h a t um I c o u l d , i f I r e a l l y wanted t o , c o u l d keep a meal down. And the other t h i n g I can determine i s t h a t t h e r e c o u l d be, uh the whole e a t i n g t h i n g wasn't, d i d n ' t have me by the t h r o a t so much. L i k e t h e r e , I c o u l d at l e a s t time i t . l i k e put i t i n s p e c i a l pockets. I c o u l d um—not a l l the time and not n e a r l y s u c c e s s f u l l y enough—but I c o u l d . you know. L i k e f o u r t h year I l i v e d with a roommate and we c o u l d do study s e s s i o n s b e f o r e an exam without my, you know. I c o u l d do t h a t . And I c o u l d , i t wouldn't be such a d r i v i n g t h i n g t o be doing continually. Because as I, as I look back on i t n o w — I c o u l d be w r o n g — I j u s t seem t o t h i n k of those 2 years as being a continuous c y c l e of b i n g e i n g and purging. And i t seems t o me t h a t I was able t o — i t s t i l l happened and maybe as f r e q u e n t l y — b u t a t l e a s t I c o u l d take p e r i o d s of time where I, t h a t I c o u l d do something with. (Appendix H, p. 153, #019)  79 And as I d i d more and had t o do more, the time f o r me t o engage i n , um you know, weird e a t i n g behaviours was lessened, was decreased. And uh, so I t h i n k the demands were more but f o r some reason I wasn't p a n i c k i n g as much, and I was able t o do what I had t o do t o meet those demands. (Appendix H, p. 156, #023) But um, a t t h a t p o i n t I was j u s t , I'd done a l o t of t e a c h i n g t h a t year and I was r e a l l y e x c i t e d by i t and I suddenly r e a l i z e d that I loved t h i s . And I suddenly r e a l i z e d t h a t I was good a t i t , you know, which i s a tremendous r e a l i z a t i o n . And so um I, I don't know but I t h i n k i t may, had I continued on t h a t t r a c k , who knows, but i t c o u l d have been t h a t t h i n g s [bingeing and purging] would have j u s t continued s l o w l y t o get b e t t e r on t h e i r own. (Appendix H, p. 157, #027) 3.  Symptom s u b s t i t u t i o n . Although the i n t e n s i t y of her b u l i m i c behaviours  subsided,  has  she n o t i c e s an i n c r e a s e i n her a l c o h o l consumption.  D r i n k i n g a l l o w s her t o disengage from her a n x i e t i e s and t h a t she  f e e l s comforted and  secure.  She  f e a r s so  becomes aware t h a t  she  uses both a l c o h o l and binge e a t i n g t o help her escape from d i s t r e s s i n g s i t u a t i o n s and  emotions.  And you know, again the d e t a i l s I'm u n c l e a r o f . I know t h a t I was um, t h a t I s u b s t i t u t e d d r i n k [ a l c o h o l ] uh, and t o some r e s p e c t , extent, f o r t h a t . I don't t h i n k I ever had what you c l a s s i f y as an a l c o h o l problem. But I know t h a t I came t o the r e a l i z a t i o n t h a t a l c o h o l c o u l d i n some ways do the same t h i n g s the b i n g e i n g c o u l d . I t was almost l i k e a c y c l e . I t would take um. When you're engaged i n t h a t a c t i v i t y , you can't r e a l l y be engaged i n anything e l s e . So i t ' s the s o l e focus. So when you have r e a l w o r r i e s , and a n x i e t i e s , and f e e l i n g s of f e a r and s t u f f , i t ' s almost l i k e a a r e a s s u r i n g c y c l e t o get i n t o because i t takes you away from having to d e a l with those. And d r i n k i n g d i d the same t h i n g . (Pause.) So I t h i n k um, I t h i n k t h a t uh, I know I d i d n ' t l i k e i t you know wasn't l i k e d r i n k i n g on a c o n t i n u a l b a s i s . But I, I do t h i n k t h a t I came t o t h a t r e a l i z a t i o n a t t h a t p o i n t , um f o r whatever t h a t ' s worth. (Appendix H, pp. 153-154, #020) 4.  I n c r e a s i n g i n t i m a c y with s e l f and She  others.  begins t o f e e l weary from s e c r e t l y h i d i n g p a r t s of  h e r s e l f or c r e a t i n g new  ones i n order t o g a i n the approval  of  80 others.  Her awareness o f h e r needs and how she f e e l s towards  others i s increasing.  Desirous o f opening h e r s e l f up t o o t h e r s ,  she chooses i n d i v i d u a l s with whom she f e e l s v a l i d a t e d and s e l f c o n f i d e n t when i n r e l a t i o n s h i p w i t h them.  F e e l i n g f r e e r from the  burden o f p l e a s i n g o t h e r s , she f e e l s e n e r g i z e d and e x c i t e d as she i s a b l e t o r e v e a l more o f h e r t r u e s e l f t o o t h e r s and connect more deeply with them. committed r e l a t i o n s h i p .  She a l s o i n v e s t s h e r s e l f i n an i n t i m a t e , Although  she doesn't  d i s c l o s e her  b u l i m i a t o these s i g n i f i c a n t o t h e r s , she begins t o t r u s t t h a t they accept p a r t s o f her and she f e e l s more v a l u e d by them.  She  begins t o c o n s i d e r t h a t she i s a c c e p t a b l e t o o t h e r s as she i s and t h a t she doesn't  need t o a l t e r who she i s .  (See Appendix J , #051  f o r P.Y.'s c o r r o b o r a t i n g statement.) But, yah, and I would be very, l i k e I d i d n ' t have good f r i e n d s because t h e r e was so much o f me t h a t I thought I had t o c r e a t e f o r others and so much o f me t h a t I had t o h i d e . So I was always very I t h i n k k i n d o f anxious around people and l i k e who am I supposed t o be f o r t h i s person k i n d of t h i n g . Um, and so I never um had what I would have c a l l e d " r e a l r e l a t i o n s h i p s " because I was always t r y i n g t o c r e a t e a p a r t o f myself t o p l e a s e them. So i t ' s a t e r r i b l y , I t h i n k a v e r y t i r i n g t h i n g because you're c a r r y i n g around these s e c r e t s , you're c a r r y i n g around a l l your d i f f e r e n t i d e n t i t i e s t h a t you're t r y i n g t o p o r t r a y t o d i f f e r e n t people so t h a t y o u ' l l p l e a s e them. (Appendix H, p. 150, #015) I a l s o i n t h i r d year um, t h e r e was a, I t h i n k I was a l s o v e r y f r i g h t e n e d o f o f e n t e r i n g i n t o another r e l a t i o n s h i p because I knew t h a t I would again be c o n t r o l l e d . Like I c o u l d n ' t , and i t was t o o much o f a s t r a i n t o t r y and keep up some k i n d o f facade f o r someone on such a c l o s e b a s i s . Um, so t h e r e was, t h e r e was a um, um a boy who, you know, wanted t o develop a r e l a t i o n s h i p with me. And I remember being v e r y um, very much not wanting t h a t , I t h i n k , because I f e l t much c l o s e r t o him than I d i d with t h e guy t h a t I was with f o r t h e f i r s t 2 years o f u n i v e r s i t y . And t h e r e f o r e t h e chances o f h i s having t o d i s c o v e r t h i s about me were t h a t much g r e a t e r . So I do remember subsequently being very, you know, s t a n d o f f i s h i n t h a t r e g a r d . Um, I d i d have a f r i e n d s h i p w i t h a, with a woman d u r i n g my f o u r t h year; we roomed t o g e t h e r . That was good. I t was almost l i k e t h e  81 f i r s t f r i e n d s h i p t h a t I had t h a t I thought I c o u l d r e v e a l some o f myself t o which was n i c e . (Appendix H, p. 154, #021) Because I had j u s t , a t t h a t p o i n t you know, I f e l t t h a t I'd made a commitment [to my b o y f r i e n d ] I t h i n k i n some ways. And you know, I mean l o v e was c e r t a i n l y i n v o l v e d . But beyond t h a t um, I t h i n k I f e l t t h a t I had made a commitment. You know, we'd been s o r t o f "long d i s t a n c i n g " i t f o r 4 years at t h a t p o i n t and I f e l t t h a t you know t h i s i s what we've had; I was going t o do i t [marry him]. (Appendix H, p. 157, #026) 5.  Awareness o f r e l a p s e . When she r e l o c a t e s t o a new g e o g r a p h i c a l  l o n e l y and i l l a t ease. her job,  area,  she f e e l s  B e r e f t o f t h e support and s e c u r i t y o f  f a m i l y , and f r i e n d s , h e r growing sense o f competence and  s e l f - c o n f i d e n c e begins t o crumble.  She f e e l s immobilized  and  unable t o f i n d ways o f r e g a i n i n g o r r e b u i l d i n g h e r sense o f emotional s e c u r i t y . and  purging  I n s i d i o u s l y , t h e frequency o f h e r b i n g e i n g  i n c r e a s e s u n t i l once again t h e behaviours a r e  consuming a l l h e r time.  When she r e t u r n s t o h e r f a m i l i a r  surroundings she remembers a p r e v i o u s with others,  engaged i n p r o d u c t i v e  time when she was i n v o l v e d  activities,  and f e l t an  element o f c o n t r o l over h e r b u l i m i c behaviours. of t h e c o n t r a s t between h e r o l d and new l i f e , her b u l i m i a to function. seeking  i s out o f c o n t r o l and i s again She i s spurred  outside  Poignantly  aware  she r e a l i z e s t h a t  impeding h e r a b i l i t y  t o c o n f r o n t h e r problem again by  help.  But what I do know i s um coming here then t h a t summer was um, was r e a l l y bad because I k i n d o f dropped i n t o [a v o i d ] , you know, I d i d n ' t have a master's degree and I d i d n ' t . W e l l , I j u s t f e l t t h a t I'd dropped i n t o nothing. And um, you know t r y i n g t o f i n d some k i n d o f work and you know, my husband being very i n v o l v e d i n h i s , was again I was suddenly face t o face with myself again without any o f t h e e x t e r n a l , you know, p l u s e s and s t r o k e s and s t u f f . And, i n some ways i t might have been a very good t h i n g . Because what i t d i d  82 was i t yanked t h a t i d e n t i t y [from my work] away from me. And I wasn't a s t r o n g enough person, o r a f o r c e f u l enough person, o r a person who b e l i e v e d i n themself enough t o s o r t of k i c k and scream and f i g h t f o r t h a t i n t h i s environment. So, t h i n g s d e t e r i o r a t e d r e a l l y q u i c k l y over t h a t summer and the f a l l . And I was s o r t o f p i c k i n g r i g h t back up on t h e same o l d h a b i t s . I would spend t h e d a y — y o u know, w i t h A. gone and not r e a l l y knowing anybody o r not many people h e r e — i s o l a t e d and again going r i g h t back i n t o t h e b i n g e i n g and purging. (Appendix H, p. 158, #028) Both. [The frequency o f b i n g e i n g and purging began i n c r e a s i n g and I began t o f e e l a l o s s o f c o n t r o l over my e a t i n g behaviours.] Yup. And t h a t was r e a l s c a r y . And again i t wasn't something t h a t um, I t h i n k I faced up t o u n t i l i t got r e a l l y bad. And I t h i n k t h a t , I t h i n k the r e a l i z a t i o n t h a t t h i n g s were bad (laugh) came t o me cause we went t o my f a m i l y ' s p l a c e back home i n I . f o r Christmas t h a t year. And i t was l i k e seeing t h a t environment t h a t I used t o be i n , t h a t I f e l t t h a t I was f l o u r i s h i n g i n — y o u know i t was t h e same c i t y t h a t I had been i n s c h o o l i n — a n d suddenly s e e i n g t h e way I was. And I t h i n k i t was over t h a t Christmas t h a t I r e a l i z e d t h a t when I got back I had t o do something. Because I t h i n k I r e a l i z e d t h a t I'd taken some steps and t h a t , you know, t h i n g s were b e t t e r but t h a t s i n c e my environment had changed, I had j u s t s o r t o f crumbled. And um,I had t o d e a l w i t h i t . (Appendix H, pp. 158-159, #029) 6.  Separation She  o f s e l f from b u l i m i a .  e x p e r i e n c e s a c l o s e a f f i n i t y with h e r t h e r a p i s t and a  deep sense o f t r u s t because they share a common c u l t u r a l background and i n t e r e s t s .  F e e l i n g respected  and valued  i n spite  of h e r e a t i n g d i s o r d e r , she i s f r e e d t o be open and v u l n e r a b l e with her t h e r a p i s t .  As she focuses  b u l i m i c behaviours and i s reassured  on h e r i s s u e s u n d e r l y i n g the t h a t these behaviours a r e  symptomatic, she f e e l s l i b e r a t e d as she begins t o separate h e r bingeing  and purging  from her sense o f who she i s .  times she f e e l s consumed by h e r b u l i m i a , more h o p e f u l  Although a t  she f e e l s empowered and  about g a i n i n g c o n t r o l over h e r e a t i n g behaviours  knowing t h a t they w i l l subside once she begins d e a l i n g with her s e l f - h a t r e d and l a c k of confidence.  Her shame and  preoccupation  83 with h e r e a t i n g d i s o r d e r continue t o d i f f u s e as she r e c o g n i z e s t h a t she has p e r s o n a l and i n t e r p e r s o n a l a b i l i t i e s and s t r e n g t h s i n other areas o f h e r l i f e .  And w h i l e she acknowledges h e r  achievements, she knows t h a t i n order t o r e c o v e r she has t o r e s p e c t and c h e r i s h h e r s e l f as she i s without e x t e r n a l achievements. and  any o f these  (See Appendix J , #004, #008, #009, #03 5,  #075 f o r P.Y.'s c o r r o b o r a t i n g statements.) I mean I knew, you know, she [ t h e r a p i s t ] was good. Um and I remember your s a y i n g once t h a t um too o f t e n people say, "Oh, i t was j u s t because I had a g r e a t t h e r a p i s t t h a t I recovered." I t h i n k t h e r e has t o be t h a t p e r s o n a l uh. I f I hadn't l i k e d h e r and r e s p e c t e d h e r then I c o u l d n ' t have done that [recovered]. So knowing t h a t she o b v i o u s l y accepted i t [ b u l i m i a ] because she worked with people l i k e me and t h a t we were s t i l l able t o t o g e t along on on a p e r s o n a l l e v e l , and laugh. And you know she was, she's C. so my i n t e r e s t i n Russian s t u d i e s . You know, so we had s o r t o f a p e r s o n a l r e l a t i o n s h i p t h a t I f e l t was s o r t o f beyond t h a t . You know, I f e l t very comfortable with her. I t h i n k i t would have been i m p o s s i b l e , had I not had t h a t , t o r e a l l y you know. Because t h a t ' s maybe what happened with Dr. C.: t h a t I j u s t wasn't a b l e t o t o r e a l l y open up. So t h a t was important. (Appendix H, pp. 167-168, #045) I t h i n k she approached i t very much from a p o i n t o f view of working on y o u r s e l f , and t h i s only being symptomatic. And t h a t c e r t a i n l y work would have t o be done on behaviour m o d i f i c a t i o n — y o u r , you know, a t t i t u d e towards food and s t u f f — b u t t h a t r e a l l y i t was, i t was much deeper than t h a t . And I t h i n k t h a t made a t e r r i f i c impact. You know something t h a t I t h i n k I'd known, but t o a c t u a l l y t a l k about t h a t was important. You know, going back i n i n my p a s t and t a l k i n g about t h i n g s t h a t , t h a t had t o do j u s t with me and not with any e a t i n g d i s o r d e r . That was important. Um, and then l a t e r on she t a l k e d about, yah, l i k e w r i t i n g down times t h a t I would binge and why, o r what I had j u s t eaten and what I was f e e l i n g . I don't t h i n k I a c t u a l l y d i d t h a t . I remember t h i n k i n g about i t , but I never a c t u a l l y committed i t t o writing. Um, so a l o t of, um, examination o f s e l f r a t h e r than examination o f t h i s , t h i s p a r t o f myself. (Appendix H, p. 164-165, #040) I t h i n k t h a t ' s what I l i k e d most o f a l l . Because I'd always known, I mean why should, you know, why should I have those f e e l i n g s about myself? And I always knew t h a t a r e a l h e a l t h y person wouldn't do t h i s [binge and purge]: like a person who f e l t good about themselves. And i t always  84 o c c u r r e d t o me t h a t i t [recovery] had so much t o do with knowing who I was (eyes become m o i s t ) . L i k e without anything e l s e i n the w o r l d — w h a t I was doing, or p a r e n t a l a p p r o v a l , or s t r a i g h t A's, w h a t e v e r — t h a t I was O.K. And t h a t i n some r e s p e c t s , what I d i d was secondary. You know, I t h i n k I ' l l always be a s o r t of g o a l - o r i e n t e d person and wanting t o be doing t h i n g s t h a t ' l l make me f e e l good. But t h a t ' s not what I b u i l d my whole s e l f on. (Appendix H, p. 165, #041) 7.  D e - i d e a l i z i n g and In her  innermost being  mother f o r having bulimia.  played  However, she  because she  f o r g i v i n g f a m i l y of o r i g i n . she holds a l o t of anger towards her  a p a r t i n the development of  f e e l s g u i l t y about e x p r e s s i n g  Although she  is initially  is s t i l l  i d e n t i f y and  aspects  of t h e i r r e l a t i o n s h i p .  shocked at her t h e r a p i s t ' s  angry with her mother, she  express her anger.  her mother's and  suggestion  i s released to  She v e r b a l i z e s her anger towards  s o c i e t y ' s o v e r v a l u a t i o n of t h i n n e s s  acknowledges t h a t these messages were harmful t o her. result,  her anger  i s a f r a i d t h a t she w i l l blame her mother s o l e l y i f  she begins t o e x p l o r e the negative  t h a t she  her  and As a  she becomes l e s s consumed and d r i v e n by her anger towards  these p a s t events.  She  r e a l i z e s t h a t even though her mother made  some mistakes which c o n t r i b u t e d t o developing  an e a t i n g d i s o r d e r ,  her mother i s not s o l e l y r e s p o n s i b l e f o r her b u l i m i a . o f p a s t h u r t s and  L e t t i n g go  anger, she moves forward t o the present  and  assumes more r e s p o n s i b i l i t y f o r overcoming her e a t i n g d i s o r d e r . (See Appendix J , #073, #074, #076, #077, and corroborating  #078 f o r P.Y.'s  statements.)  Except she seemed, her focus was more on the f a m i l y — t h e mother-daughter r e l a t i o n s h i p — w h i c h i n some ways I r e j e c t e d because I d i d n ' t want t o . I t h i n k I f e l t a l o t of g u i l t towards my mother because of the way I was. And I mean I'd t h i n k back on t h i n g s and a l l I c o u l d see was the negative aspects of having i n t e r a c t e d with her. So I d i d n ' t r e a l l y  85 want t o put t h i s i n h e r l a p , you know, i n terms o f w e l l because o f t h i s , t h i s happened t o me. You know I s t i l l don't, I t h i n k t h e r e a r e some aspects o f t h a t t h a t a r e good t o examine. D e f i n i t e l y . But I r e a l l y don't t h i n k i t ' s such a good t h i n g t o t r y and f i n d a f i n g e r t o p o i n t . And I don't t h i n k Dr. T. was t r y i n g t o do t h a t . But I know t h a t I r e s i s t e d i n some r e s p e c t s t h a t , t h a t approach because I f e l t t h a t t h a t was t r y i n g t o p o i n t t h e f i n g e r o f blame a t her, you know. (Appendix H, p. 162, #036) And I do remember a comment t h a t she [ t h e r a p i s t ] made t h a t r e a l l y h i t home. I t h i n k i n t a l k i n g about i t , and again s o r t o f t r y i n g t o s h i e l d h e r [mother], I don't know what I s a i d , but h e r [ t h e r a p i s t ] r e t o r t was. Or i n saying, I guess e x p r e s s i n g my g u i l t toward h e r [mother] and s t u f f and h e r . (Appendix H, p. 163, #037) My mother. Yes. And Dr. T.'s r e t o r t was, "Then you haven't f o r g i v e n her." And I had t o r e a l i z e t h e v a l i d i t y o f t h a t . That maybe t h e r e was some blame t h a t I was s u b c o n s c i o u s l y a t t r i b u t i n g t o h e r and t h e environment i n terms o f , you know, what happened, i n terms o f my b u l i m i a . So i t was a matter o f t r y i n g t o , I t h i n k t h e r e was a p r o c e s s o f l e t t i n g go o f a l l o f t h a t ; o f being a b l e t o say, t o look back on those t h i n g s i n order t o l e t them go, and and any anger t h a t you might f e e l a t um, um f i n a l l y developing a d i s t o r t e d body image, you know. In other words, j u s t t a k i n g your r e s p o n s i b i l i t y f o r "the here and now." (Appendix H, p. 163, #038) 8.  V e r b a l l y acknowledging b u l i m i c b e h a v i o u r s . When she i d e n t i f i e s h e r e a t i n g behaviours u s i n g t h e terms  "bingeing"  and "vomiting"  euphemistically, behaviours.  r a t h e r than speaking o f them  she draws c l o s e r t o t h e r e a l i t y o f h e r  As she v e r b a l i z e s and names h e r a c t i o n s , she i s  moved t o c o n f r o n t  them r a t h e r than minimize them.  She  e x p e r i e n c e s a deeper sense o f owning her behaviours, and i s aware of t h e i r s e v e r i t y and t h e f a c t t h a t she no longer has c o n t r o l over them.  She r e a l i z e s t h a t her " p e r f e c t " s o l u t i o n t o weight  c o n t r o l i s imperfect. Something e l s e j u s t occurred t o me. used t o t a l k i n euphemisms a l o t , i n would a c t u a l l y do. And I t h i n k p a r t s o r t o f t o f o r c e me t o a c t u a l l y dare  I remember, I t h i n k I terms o f l i k e what I o f i t [therapy] was f e e l what i t was about:  86  you know, g o r g i n g and v o m i t i n g . L i k e I remember her t a l k i n g , her end g o a l was t o make me a c t u a l l y say the word "vomit", and I kept u s i n g euphemisms and not understanding what, why she meant, what she meant when she would ask me t o be more c l e a r about i t . And f i n a l l y when I had t o say t h a t word, i t was l i k e again coming ( s l a p s hands together) face t o f a c e w i t h what i t a c t u a l l y was. So, so p a r t of i t too was was r e a l l y examining behaviour and what i t was, not h i d i n g , not h i d i n g from the r e a l i t i e s of i t . (Short pause w h i l e tape i s turned o f f t o answer the phone.) (Appendix H, pp. 166-167, #043) 9.  P e r m i s s i o n t o eat p r e v i o u s l y f o r b i d d e n foods and t o  feel  full. She begins t o r e o r g a n i z e her c a t e g o r i e s of "O.K. "binge foods".  As she a l l o w s h e r s e l f t o eat "binge  foods"  and  foods"  without e a t i n g t o excess and purging, she f e e l s more r e l a x e d and e x p e r i e n c e s a sense of c o n t r o l over her e a t i n g behaviour.  She  r e a l i z e s t h a t she can eat the p r e v i o u s l y f o r b i d d e n foods i n moderation  and s t i l l m a i n t a i n her weight.  e a t s an average  Furthermore,  amount of food and f e e l s f u l l ,  some of her a n x i e t y and prevents a binge-purge  she  alleviates  c y c l e by  r e a s s u r i n g h e r s e l f t h a t she has not overeaten and p r o g r e s s i v e l y d e l a y i n g purging by engaging  when she  by  i n other  activities.  As the frequency of her b i n g e i n g and purging and her t h i n k i n g about them continue t o decrease g r a d u a l l y , she f e e l s more i n c o n t r o l of her e a t i n g behaviours.  She  i s r e l i e v e d and secure i n  knowing t h a t her body i s s i m i l a r t o o t h e r s ' bodies i n t h a t her food i n t a k e n o u r i s h e s her body and i s e f f i c i e n t l y She to  metabolized.  i s more h o p e f u l and c o n f i d e n t about r e c o v e r i n g and she c a r e f o r h e r s e l f more by opening up her l i f e  through  s t r u c t u r i n g time t o s o c i a l i z e w i t h o t h e r s and engaging p r e v i o u s l y enjoyable a c t i v i t i e s .  begins  in  (See Appendix J , #001,  #005,  87 #019,  #020, #036, #037, #038, #040, #067, and #068 f o r P.Y.'s  c o r r o b o r a t i n g statements.) She a l s o t a l k e d about f e e l i n g s o f — o r I d i d , whatever—we t a l k e d about um l i k e d i v i d i n g foods i n t o O.K. foods and foods t h a t i f you e a t t h i s i t means you're on a binge: t h i n g s l i k e l i k e i c e cream o r s p a g h e t t i . L i k e i n order t o to m a i n t a i n your weight you can't e a t t h i n g s l i k e t h a t ever cause i f you do, then you might as w e l l j u s t you know gorge and g e t i t a l l up. So you know, your r e l a t i o n s h i p t o food c e r t a i n l y played a part. (Appendix H, p. 166, #042) But um, l i k e f o r example I would a l l o w myself t o e a t s p a g h e t t i , o r have an i c e cream cone, o r a cookie, o r something without t h a t a u t o m a t i c a l l y meaning I'd had j u s t , you know, s t a r t e d t h e whole c y c l e . So i t was a l l o w i n g myself c e r t a i n foods. I t was a l l o w i n g myself t o e a t a meal, l i k e a d i n n e r e s p e c i a l l y , and keep i t down, and wake up the next morning, you know, s t i l l f e e l i n g . And and a l l o w i n g myself t o experience t h a t f e e l i n g o f f u l l n e s s , normal f u l l n e s s , without t h a t having t o l e a d t o such a n x i e t y t h a t I have t o j u s t continue. (Appendix H, p. 17 0, #050) One t h i n g [ t h a t I t o l d myself when I f e l t f u l l a f t e r a meal] was, "Wait, l e t ' s j u s t wait." L i k e a l o t o f i t would be, "O.K. I've eaten t h i s much, l i k e i n t e l l e c t u a l l y I know I haven't overeaten." L i k e i t wasn't f o r a long time t h a t I was a b l e t o e a t more than I should have eaten and s t i l l be a b l e t o keep i t down. So I would e a t what I k n e w — I mean I c o u l d , I c o u l d w r i t e i t out, I c o u l d see i t , I knew t h a t I hadn't overeaten even though I f e l t you know t e r r i b l y f u l l and a n x i o u s — a n d able t o say, "Well l e t ' s j u s t wait. O.K., I ' l l purge but I won't purge f o r a h a l f - h o u r . I'm not going to puke f o r a h a l f - h o u r . " And then i n a h a l f - h o u r , "Well, w e ' l l wait another h a l f - h o u r and l i k e take a walk o r something." And then I r e a l i z e d I d i d n ' t have t o anymore. (Appendix H, p. 170, #051) I [ f e l t c o n f i d e n t about changing my b u l i m i c behaviour when], I t h i n k I f e l t elements o f c o n t r o l coming back. Um, I t h i n k I would, I can't p i n p o i n t i t , but I b e l i e v e i t would have been a t t h e time where I was a b l e t o stop something t h a t would normally, l i k e stop a binge i n p r o g r e s s . Or t o a c t u a l l y say, "No" t o a time when I would normally have binged. You know, t o s t a r t having some c o n t r o l back, which was g r e a t . (Appendix H, p. 169, #049) But I do remember (laugh) when i t was s t i l l , you know, very much more an i s s u e , suddenly r e a l i z i n g t h a t , "My god, I'd gone f o r a day without b i n g e i n g , oh my god, I'd gone f o r a week." You know, o f knowing t h a t um, i t wasn't a minute by minute, day by day i s s u e anymore. And t h a t was a tremendous f e e l i n g when I knew t h a t I c o u l d , I c o u l d e a t t h r e e meals a  88  day and, by e a t i n g t h r e e meals a day o r two o r whatever, I wouldn't blow up. L i k e I was normal i n t h a t regard too. I t wasn't l i k e by e a t i n g one b i t e I'd suddenly g a i n 20 l b . So i t wasn't such a f o r b i d d e n area. Food became more o f a f u n c t i o n a l t h i n g r a t h e r than t h i s whole i s s u e o f weight and g u i l t . and you know, a l l these other t h i n g s t h a t i t had had. (Appendix H, pp. 177-178, #072) So i t ' s a matter o f o f being able t o do other t h i n g s . I mean you g e t so, when you're, when you're l i f e i s s o r t o f taken over by t h i s , e v e r y t h i n g e l s e drops away: I mean e v e r y t h i n g you used t o do f o r enjoyment. So i t was a matter of r e a l i z i n g t h e r e ' s , I mean t h e r e ' s always time t h a t you c o u l d l i k e spend with others now t h a t you f e e l more c o m f o r t a b l e around i t , d i f f e r e n t t h i n g s you can do, and t h i n g s you can do even f o r y o u r s e l f , I mean. You know t h a t ' s l i k e a n o t i o n you never had b e f o r e i n such a long time. (Appendix H, p. 171, #053) 10.  I d e n t i f i c a t i o n w i t h and acceptance by other Regardless o f whether she has p e r s o n a l  bulimics.  contact with  other  b u l i m i c s o r hears accounts o f them from a secondary source, knowing t h a t h e r e a t i n g behaviours a r e shared by o t h e r s her a n x i e t y  about her abnormal e a t i n g h a b i t s .  that her bulimia  bulimia  As she r e a l i z e s  i s a c o n d i t i o n which others a l s o have, h e r sense  of shame continues and purging  decreases  t o d i m i n i s h and h e r d i s g u s t w i t h h e r b i n g e i n g  lessens.  When she p e r c e i v e s  i s accepted by others,  that her d i s c l o s u r e of  she f e e l s understood and  e x p e r i e n c e s a sense o f belonging.  From observing  that  other  group members appear normal i n s p i t e o f being b u l i m i c , she r e a l i z e s t h a t she t o o probably appears normal t o other individuals.  As a r e s u l t , she f e e l s more a c c e p t i n g  even though she i s s t i l l  bingeing  and purging.  of h e r s e l f  Her f e e l i n g s  about h e r s e l f a r e l e s s governed by h e r b u l i m i a . That's r i g h t . That's r i g h t . And not t h a t we t a l k e d t h a t much about other people [with e a t i n g d i s o r d e r s ] , but t h e f a c t t h a t I knew they e x i s t e d . And you know, she'd say t h i n g s about, you know, what happened w i t h t h i s person o r something, you know, t h a t t h a t made i t . I t put i t s o r t o f  89  i n t o p e r s p e c t i v e more I guess. I t ' s j u s t t h i s b e i n g — a s you s a i d I t h i n k a t one p o i n t — p a r t o f me, b u t not l i k e t h a t was j u s t what I was. That t h e r e were other, you know human beings t h a t t h a t had t h i s as p a r t o f them as w e l l . So i t was again t h a t i d e n t i f y i n g w i t h (laugh), w i t h humanity i n a way. You know, s e e i n g y o u r s e l f as p a r t o f i t ; you're not so isolated. I'm t r y i n g t o remember, f o r some reason I remember t h a t moment r e a l l y w e l l which means t h a t i t must have been f a i r l y s i g n i f i c a n t . (Appendix H, p. 164, #039) And t h a t um (pause) p a r t o f i t was um then i f o t h e r s , i f you c o u l d accept y o u r s e l f enough t o open y o u r s e l f t o others and they would accept you, then i t would j u s t be c o n f i r m a t i o n t h a t you were O.K. But you had t o be a b l e t o accept y o u r s e l f enough o r accept t h i s , t h i s t h i n g enough t o be able t o t e l l somebody about i t i n a way: l i k e t o know t h a t by a c t u a l l y r e v e a l i n g t h a t , they wouldn't t o t a l l y d e s t r o y you. (Appendix H, p. 167, #044) So t h a t I t h i n k i n both i n s t a n c e s , both s o r t o f um steps, was, was j u s t t h e a c t o f t e l l i n g was r e a l l y important. And I guess t h a t ' s why—I'm jumping t h e gun, t h e gun a b i t — b u t t h a t ' s why I t h i n k groups must be important i n t h e process too. Because again you're, not only have you t o l d others and they, you know, don't run away screaming o r something; you're s t i l l a person t o them. But a l s o you see others who seem t o you q u i t e , I mean they look l i k e people, l i k e they have i t a l l t o g e t h e r . Yet they c a r r y t h i s too. So I t h i n k t h a t whole element o f s h a r i n g i s i s so important. (Appendix H, p. 147, #013) And I d i d go t o ANAD a couple o f times, as I s a i d . I t would probably have been t h a t s p r i n g and summer t h a t I was f i r s t s e e i n g Dr. T. I probably went about t h r e e times. And i t was good, um. I was doing a l o t o f t u t o r i n g i n t h e evening and I t h i n k t h a t ' s p a r t i a l l y why I d i d n ' t do i t l i k e on a r e g u l a r b a s i s . Um, and I found t h a t t o be good. Again t o walk i n t o a room o f people t h a t I f e l t , "Gee, I c o u l d walk by (laugh) these women on t h e s t r e e t and I'd never know. So other people must see me and they don't look a t me and t h i n k yuck." You know t h a t (a) you know, other people have i t , so i t ' s not such a h o r r i b l e t h i n g , and (b) t h a t other people s o r t o f wouldn't look a t me and know how bad I was. You know what I mean? (Appendix H, p. 175, #064) That's r i g h t . I t wasn't. I t was j u s t a t h i n g , yah. I t was j u s t a, you know, an e a t i n g d i s o r d e r (laugh). Cause again, you're p u t t i n g i t i n p e r s p e c t i v e . And as i t l o s t s o r t o f i t s u l t i m a t e c o n t r o l o f my l i f e , I was a b l e t o put i t more in perspective. (Appendix H, p. 175, #065)  90 D.  EMERGENCE  OF  A  1.  Accountability  NEW to  SELF  AND  NEW  significant  VALUES  others.  As she begins t o accept h e r s e l f more and f e e l s more c o n f i d e n t i n her a b i l i t y t o overcome h e r e a t i n g behaviours,  she  begins t o f e e l uneasy about h i d i n g her b u l i m i a from s i g n i f i c a n t others.  Since she d e s i r e s t o be her genuine s e l f i n  r e l a t i o n s h i p s , she f e e l s c h a l l e n g e d part.  t o share h e r hidden b u l i m i c  When an i n t i m a t e other acknowledges h e r d i s c l o s u r e without  becoming o v e r l y concerned o r o v e r l y c r i t i c a l , and  loved.  she f e e l s r e l i e v e d  Her overwhelming sense o f abnormality  and shame i s  d i f f u s e d and she v a l u e s h e r s e l f more knowing t h a t she i s u n c o n d i t i o n a l l y accepted  by a s i g n i f i c a n t o t h e r .  Feeling  strengthened and supported, she i s more determined t o overcome her b i n g e i n g poison  and purging  because she doesn't want her b u l i m i a t o  t h e i r r e l a t i o n s h i p o r f o r them t o f e e l burdened by i t .  (See Appendix J , #041, #042, #053, and #054 f o r P.Y.'s corroborating  statements.)  Yah, and t h a t i t [bulimia] d i d n ' t a f f e c t h i s [my husband's] f e e l i n g s about me a t a l l . You know, so t h a t was r e a l l y important. And I t h i n k I was only a b l e t o t e l l him, um you know, a t a moment, a t a time when we were f e e l i n g you know r e a l l y c l o s e , and I r e a l l y f e l t t h a t , "Yah I r e a l l y want t o share t h i s t h i n g with t h i s person because I don't want t o keep t h i s from t h i s person anymore." Not as i f i t were a b i g d e a l t h a t I'd t o l d him the f a c t s , but the f a c t t h a t I was w i t h h o l d i n g something became important. That I'd never had a r e l a t i o n s h i p with someone where I wasn't h o l d i n g back t h i s , and c r e a t i n g t h i s , and h i d i n g and d e c i d i n g how t o be. And so t h a t , f o r the reason, i t was a b i g step t o o . (Appendix H, pp. 168-169, #047) [His Very like lose like time  r e a c t i o n t o d i s c l o s u r e o f b u l i m i a was] Very low key. low key. Um i n f a c t he even made some jokes about i t — d u r i n g t h a t c o n v e r s a t i o n — " w e l l , t h a t ' s a g r e a t way t o weight, I should t h i n k about t h a t . " You know, s t u f f that. So i t was as i f I was t h i n k i n g , "god, a l l t h i s and i t r e a l l y i s n ' t such a b i g d e a l . " L i k e I mean he  91 thought i t was weird and a l l and and I'm sure he knew t h a t i t was i n d i c a t i v e o f o f problems and s t u f f . But he was very, v e r y s o r t o f matter o f f a c t about i t . And j u s t very g l a d t h a t I had t o l d him because now he wouldn't have t o wonder why. He was very, I t h i n k , w o r r i e d t h a t I was seeing someone f o r , you know, goodness knows what reasons. (Appendix H, p. 168, #046) W e l l , and a l s o t o have someone, someone e l s e accept i t , uh and not um; i t j u s t l e t s you know t h a t maybe you're not such a monster. You know t h a t someone e l s e c o u l d hear t h i s p a r t of you and s t i l l , and s t i l l accept you. You know e s p e c i a l l y i n terms o f you know, t h e person t h a t you're l i v i n g w i t h . And you know, supposedly you've known t h i s person f o r however many y e a r s — 4 o r 5 y e a r s — a n d t h a t ' s t h e one s e c r e t you've never t o l d them. You know so, i t ' s , i t a l s o allows you t o f e e l more l i k e a human b e i n g . Again, t h e whole um b r e a k i n g out o f t h e i s o l a t i o n , and t h a t even t h e f a c t t h a t you do t h a t doesn't mean t h a t you're such a r o t t e n person. (Appendix H, pp. 146-147, #012) Um, and a l s o , I had t o be a t a p o i n t where I f e l t f a i r l y c o n f i d e n t o f succeeding, o f going t o him and succeeding, because I c o u l d n ' t t e l l him and then i n t e n d t o continue with the behaviour. I mean I knew t h a t i t would s t i l l continue f o r a w h i l e , but a t l e a s t t h a t a t t e n t i o n would be t h e r e t o work through i t and stop i t , and t h a t i t would always be g e t t i n g b e t t e r . And I knew I c o u l d n ' t t e l l him i f I f e l t t h a t I c o u l d n ' t succeed because then I c o u l d n ' t look him i n the eye and t o f e e l , you know, r e j e c t e d — l i k e I guess t h a t ' s s e l f - i m p o s e d — t o f e e l um g u i l t y about t h a t i n regards t o another person. You know, I I c o u l d n ' t do t h a t . I was bad enough doing i t w i t h myself s o r t o f . So I had t o be a t a c e r t a i n l e v e l o f s t a b i l i t y with i t b e f o r e I c o u l d t e l l him. And then t e l l i n g him i n c r e a s e d t h a t l e v e l o f s t a b i l i t y [confidence i n h e r a b i l i t y t o make changes]. (Appendix H, p. 169, #048) 2.  Responsibility for offspring. When she d i s c o v e r s t h a t she i s pregnant,  h e r a n x i e t y over  not being more i n c o n t r o l o f h e r e a t i n g behaviours i s intensified.  She i s spurred t o continue working a t overcoming  her b u l i m i c behaviours so t h a t she can r e s p o n s i b l y p r o v i d e an o p t i m a l p r e - n a t a l environment and t h e necessary n u t r i e n t s f o r her baby.  Furthermore,  she i s committed t o f u l l y a t t e n d i n g t o her  newborn and she r e a l i z e s t h a t h e r present time involvement  with  92 b i n g e i n g and purging would compromise h e r time with h e r baby. She  f e e l s c o n f i d e n t t h a t she can continue working towards g a i n i n g  more c o n t r o l o f h e r e a t i n g behaviours l e v e l of control.  Although  and i n c r e a s i n g h e r c u r r e n t  she does not a b s t a i n from b i n g e i n g  and p u r g i n g d u r i n g pregnancy, she experiences decrease  i n t h e frequency  o f these behaviours.  a continued (See Appendix J ,  #050 and #052 f o r P.Y.'s c o r r o b o r a t i n g statements.) Um, and t o f e e l t h a t t h e r e was another reason why I had t o get myself w e l l . You know, t h e r e was a baby and t h e r e was, you know. (Appendix H, p. 172, #057) I mean q u i t e apart from a l l t h i s , l i k e i t [being pregnant] wasn't a planned t h i n g and i t was s o r t o f uh. But, above and beyond t h a t , I r e a l l y thought t o be a mother you had t o be a f a i r l y whole person. And you know, so t h e r e ' s a l o t of f e a r o f you know, you know, "I've got t o g e t my a c t together." There was even more reason t o g e t my a c t t o g e t h e r because t h e r e was so much, t h e r e was more a t stake now [such as another l i f e ] . (Appendix H, p. 172, #058) Well another l i f e . You know, I c o u l d n ' t have a c h i l d and and. There was, i t was one more element t h a t would um make, make i t harder f o r me t o continue i f I f e l t I had t o continue b i n g e i n g and purging. Um, and from t h e p o i n t of view o f t h a t c h i l d ' s w e l l - b e i n g , I mean t o have a mom doing t h a t would not be good. L i k e I d i d n ' t want t o um, you know, f a i l i n t h a t r e s p e c t , you know. (Appendix H, p. 172, #059) M-hm, t h a t I had t o . Yah because, you know, I knew a t l e a s t I had t o have c o n t r o l o f i t . Um, because i t ' s j u s t one more um t h i n g t h a t , l i k e i t ' s a v e r y t o t a l t h i n g t h a t you have t o do: b r i n g up a c h i l d . And even b e f o r e I had one I guess I r e a l i z e d t h a t ( l a u g h s ) : c e r t a i n l y do now. But uh, and I knew I c o u l d n ' t r e a l l y do i t i f I were out o f c o n t r o l with t h i s t h i n g . I mean I c o u l d n ' t : I knew t h a t . So, but I must have, I'm sure t h a t I had i n k l i n g s and and some f e e l i n g s o f c o n t r o l before t h e pregnancy o c c u r r e d . Otherwise I t h i n k I would have j u s t freaked r i g h t out, you know, j u s t knowing I can't handle t h i s . So t h e r e must have been p a r t o f me t h a t thought t h a t I c o u l d probably handle i t at l e a s t w e l l enough. (Appendix H, pp. 172-173, #060) You know, I d i d n ' t , l i k e f o r those 9 months I was s t i l l b i n g e i n g and purging, but not as much. You know t h i n g s j u s t , i t was s o r t o f again a gradual p r o g r e s s i o n o f g e t , getting better. (Appendix H, p. 173, #061)  93 3.  New a p p r e c i a t i o n and understanding o f h e r p h y s i c a l body. Upon becoming pregnant, she r e f l e c t s on h e r body's  reproductive life.  c a p a c i t y and i s awed by i t s a b i l i t y t o nurture  a new  She e x p e r i e n c e s h e r body as s e r v i n g a u s e f u l f u n c t i o n and  h a v i n g an important purpose, and she begins t o a p p r e c i a t e and respect  i t more.  increases,  When h e r body shape changes and h e r weight  she i s a t ease because she expects these changes t o  occur d u r i n g  and a f t e r pregnancy.  s t r i c t l y c o n t r o l l i n g her food  As she f e e l s f r e e r from  i n t a k e and weight g a i n , she no  l o n g e r d e n i e s h e r s e l f t h e food she craves. bingeing  and purging  As a r e s u l t , h e r  continue t o decrease and she f e e l s  p h y s i c a l l y s t r o n g and h e a l t h y .  She continues  t o t r u s t her body's  c a p a c i t y t o e f f i c i e n t l y m e t a b o l i z e h e r food i n t a k e without r i g i d l y m o n i t o r i n g what she e a t s .  Her d r i v e t o a t t a i n a t h i n  body decreases as h e r focus s h i f t s t o t h e importance o f having a h e a l t h y body. two  She accepts t h e weight she gained throughout her  pregnancies and she i s c o n f i d e n t t h a t she can g r a d u a l l y  lose  the e x t r a weight by becoming more p h y s i c a l l y a c t i v e r a t h e r than by r e s o r t i n g t o h e r b u l i m i c behaviours.  (See Appendix J , #013,  #014, #015, #016, #017 and #018 f o r P.Y.'s c o r r o b o r a t i n g statements.) Um, and then, t h e t h i n g t h a t I t h i n k happened when I got pregnant t h a t was neat was t h a t hey I r e a l i z e d I had an a p p r e c i a t i o n f o r my body: j u s t i n the mechanical aspect! L i k e i t was i n c r e d i b l e I c o u l d do t h i s t h i n g ! I didn't r e a l l y f e e l I had t h a t much involvement. You know, I knew I had t o keep myself h e a l t h y . But t o watch i t s o r t o f do i t s t h i n g was r e a l l y neat! And a l s o t o f e e l so h e a l t h y ! You know, I had an easy pregnancy and I f e l t so s t r o n g and healthy. You know, I was you know as b i g as a t r u c k and i t d i d n ' t r e a l l y bother me. So i t was a d i f f e r e n t view of my body as b e g i n um, a r e a l l y u s e f u l t o o l . And I f e l t good about i t : I mean I knew what I looked l i k e and i t d i d n ' t  9 4  bother me a t a l l . I k i n d o f r e v e l e d i n i t because f o r t h e f i r s t time i n my l i f e I c o u l d e a t what I wanted and i t d i d n ' t show, you know, t h a t k i n d o f s t u f f . (Appendix H, p. 176, #066) As I s a i d um, I, w e l l I became pregnant. That was another t h i n g o f a l l o w i n g myself t o have t h a t body image and have t h a t be f i n e . (Appendix H, p. 171, #054) Then being a b l e t o accept you know t h e t h e b e l l y o f pregnancy and s t u f f and not, you know, r e a l l y be concerned, not be t h a t anxious about i t . (Appendix H, p. 17 2, #056) And then a f t e r t h e pregnancy, um, I had put on q u i t e a b i t of weight. And i t d i d n ' t , I guess i t d i d n ' t bother me as much. L i k e i t d i d n ' t r e a l l y bother me. I d i d n ' t look a t myself i n t h e same way, l o o k i n g f o r t h a t l i t t l e tummy. (Laughs.) Cause now I had q u i t e a tummy, you know. And, and b r e a s t - f e e d i n g and a l l t h a t . I t j u s t again, an a p p r e c i a t i o n o f a h e a l t h y body r a t h e r than i t ' s only, um, i t o n l y e x i s t i n g t o see how t h i n you c o u l d make i t , and how much l i k e a model you c o u l d make i t , and r e a l i z i n g t h a t h e a l t h was important. (Appendix H, p. 176, #068) And s i n c e , you know, then we had another baby about a year and a h a l f a f t e r t h a t . And, um, you know, from those, I put on a b i t o f weight with each, each c h i l d . So t h a t a f t e r t h e second one, S., was born, you know, I was not l i k e heavy, but I had, I was probably about you know 15 l b more than I am now: 15 l b o r maybe even 2 0 l b . And again, t h a t d i d n ' t cause t h e a n x i e t y . L i k e my weight wasn't such a b i g deal anymore. . . . W e l l , I knew t h a t I was a mom; t h e r e was a reason f o r t h i s . (Appendix H, p. 177, #069) When a f t e r t h e second one was born and I took a year out a t home and r e a l l y kept t h a t weight, I was doing a e r o b i c s and s t u f f , but I d i d n ' t r e a l l y l o s e i t . I f e l t b e t t e r about myself when I got back t o work and and k i n d o f l o s t i t . But i t wasn't l i k e a b i g , i t wasn't what i t was. . . . That's right. And I d i d n ' t have t o , you know, go back i n t o o l d p a t t e r n s t o t r y and l o s e i t . (Appendix H, p. 177, #071) 4.  Expanding sense o f s e l f and b e l i e f i n s e l f . As she takes on t h e r o l e s o f mother and wife,  peaceful  and secure i n knowing who she i s .  she f e e l s more  Her confidence and  s e l f - r e s p e c t grow as she s u c c e s s f u l l y c a r r i e s out h e r r e s p o n s i b i l i t i e s i n these areas.  As she a l s o f e e l s s t r o n g e r i n  her a b i l i t y t o r e g u l a t e h e r e a t i n g h a b i t s , she i s c h a l l e n g e d t o  95 r e - e n t e r t h e work f o r c e .  She no longer  support and v a l i d a t i o n o f h e r t h e r a p i s t . her s e l f - w o r t h  f e e l s t h a t she needs t h e As she gains more o f  from these new r o l e s , she focusses  l e s s on h e r  body shape and weight as a source o f h e r worth and v a l u e . r e l a t i o n s h i p s w i t h f a m i l y members and work c o l l e a g u e s increased  Her  take on an  importance and she i n v e s t s more o f h e r time w i t h them.  As a r e s u l t , she has l e s s time t o be p r e o c c u p i e d with weight and food  i s s u e s and l e s s time t o engage i n b i n g e i n g  behaviours.  and purging  Knowing t h a t h e r b u l i m i c behaviours would be a  d e t e r r e n t t o f u n c t i o n i n g o p t i m a l l y , she f e e l s assured t h a t she i s w e l l on t h e road t o recovery in bingeing old  and purging.  when she does not d e s i r e t o engage  In f a c t , her b u l i m i c behaviours a r e an  response which now r e q u i r e e f f o r t and p l a n n i n g  t o engage i n .  (See Appendix J , #043, #044, #045, #046, #055, #056, #057, #063 and  #064 f o r P.Y.'s c o r r o b o r a t i n g  statements.)  I knew t h a t t h e r e were other t h i n g s t h a t I c o u l d use f o r my s e l f - d e f i n i t i o n than how t h i n I was. Um. . . . Such as the work t h a t I d i d , my f a m i l y , and knowing t h a t I was, you know, f e e l i n g b e t t e r about myself. So I d i d n ' t have t o j u s t look a t t h a t [my weight], you know. Um, and you know r e a l i z i n g t h a t uh, w e l l again, you know, a c e r t a i n d i f f e r e n c e i n l i f e too: Here I was about 30 and I wasn't l i k e 2 2 anymore. And, I wasn't t r y i n g , who was I r e a l l y t r y i n g t o impress i n t h e way I looked? You know, j u s t took a b i t of a d i f f e r e n t perspective. I d i d n ' t f e e l , you know I f e l t much b e t t e r . (Appendix H, p. 177, #070) And then when I came back, she was born. And she was about 3 months o l d , and I got a j o b o p p o r t u n i t y and d i d t h a t . So again i t was, i t was l i k e t h e t h e i n i t i a l um, um, s t a b i l i t y , c o n t r o l f e e l i n g , you know, good f e e l i n g about y o u r s e l f . Something has t o happen f i r s t I t h i n k . And then f o r me anyways, i t was important t o almost put t h a t i n t o r e a l i t y by t a k i n g on t h e r e s p o n s i b i l i t i e s t h a t would prove t o me t h a t I was g e t t i n g b e t t e r , t h a t would d i m i n i s h t h e time t h a t I c o u l d i n d u l g e i n an e a t i n g d i s o r d e r : you know put more t h i n g s t h a t I had t o do on me. Um, but t h e r e was t h a t core t h a t had s t a r t e d t h e r e , you know, t h a t wasn't t h e r e . . . . That core o f self-knowledge, and s e l f - a c c e p t a n c e , and  96 strength. And, and, you know, knowing t h a t you weren't such a t e r r i b l e person. (Appendix H, p. 173, #062) M-hm. Because you know, you've got t o look, you've got, I t h i n k i t ' s a r e a l l u x u r y t o have t h a t time-out out o f l i f e i n a way o f s e l f - e x a m i n a t i o n and a l l t h i s other s t u f f . But then, you've got o f k i n d o f put i t i n p r a c t i s e , you know. I t ' s got t o be j u s t a, j u s t a p a r t , j u s t a time t h a t helps you a c t u a l l y do what you want t o do and not l i k e a, you know, ongoing c r u t c h . You know, cause t h a t means you haven't r e a l l y made t h a t f i n a l t r a n s i t i o n which i s p u t t i n g , j u s t i n c o r p o r a t i n g a l l those t h i n g s i n p a r t o f your l i f e without, you know. (Appendix H, p. 174, #063) Um, g e t t i n g a f u l l - t i m e j o b where i n t h e daytime hours I c o u l d n ' t do i t anyway. So i t would have t o be r e s t r i c t e d t o n i g h t t i m e a f t e r work. You know so t h a t , and I f e l t c o n f i d e n t enough t h a t I'd be able t o handle the j o b and do the work. You know, t h a t had t o be t h e r e f i r s t . And then t o a c t u a l l y do t h e work and have so much o f your time taken up. (Appendix H, p. 171, #055) But then a l s o I t h i n k t a k i n g on t h e work and s t u f f l i k e t h a t was very important because i t would be, you r e a l i z e t h a t you know, "Gee, t h e r e ' s an 8-hour day and i t hasn't even o c c u r r e d t o me once. I t ' s not something t h a t I would want t o do o r would even occur t o me t o do because I c o u l d n ' t f u n c t i o n and a l l those other t h i n g s . " So t h a t would have been, you know, about a year I guess from s t a r t i n g t o see Dr. T. (Appendix H, p. 179, #074) But I t h i n k one s o r t o f p o i n t [that marked r e c o v e r y ] i s suddenly when you r e a l i z e t h a t , you're a c t u a l l y , t o binge and purge i s much more conscious than not t o . L i k e before i t ' s j u s t a p a r t o f your l i f e , and you do i t a l l t h e time, and you have t o r e a l l y concentrate not t o do i t . And then i t ' s l i k e an a c t i v i t y t h a t you engage i n sometimes, but i t ' s a v e r y conscious t h i n g . And I t h i n k t h a t ' s a r e a l , um, p o i n t when you r e a l i z e t h a t — y o u know, you know way back when—when I'd r e a l i z e t h a t I'd want t o a c t u a l l y binge because I'm f e e l i n g anxious about something but i t would have t o be something t h a t I'd have t o arrange r a t h e r than something I'd have t o f i g h t o f f . (Appendix H, p. 178, #073)  E.  THE NATURE AND MAINTENANCE OF RECOVERY  1.  Counting the c o s t o f r e t u r n i n g t o t h e b u l i m i c b e h a v i o u r s . When she e x p e r i e n c e s t h e urge t o binge, she steps back from  her c r a v i n g s  and r e f l e c t s upon t h e consequences o f h e r behaviour:  97 wasted money, i s o l a t i o n , and no r e t u r n on t h e energy i n v e s t e d . F e e l i n g d r a i n e d and d i s s a t i s f i e d as she c o n s i d e r s t h e o p t i o n t o binge, she d e c i d e s t o a b s t a i n from t h e b u l i m i c behaviours and i n v o l v e h e r s e l f i n other a c t i v i t i e s .  She f e e l s r e l i e v e d and  proud o f h e r s e l f f o r having implemented an a l t e r n a t e  behaviour.  (See Appendix J , #021, #022, #062, #070, #071, and #072 f o r P.Y.'s c o r r o b o r a t i n g statements.) And another t h i n g t h a t happened f u r t h e r down t h e l i n e — a n d s t i l l happens now l i k e i f I'm, i f I'm i n a s i t u a t i o n where um i t ' s p o s s i b l e f o r me t o binge and f o r some reason I'm having f e e l i n g s t h a t I want t o — i s t o stop and t h i n k back and t h i n k : Well i f I'm going t o binge now, you're probably going t o spend, i t ' d be a t o t a l o f l i k e $10 worth o f food. I'm going t o have t o s i t here by myself without p r e t t y time, not do anything, s t u f f myself, and then I'd have t o go and and t r y and vomit, and make sure t h a t I vomit i t a l l out. And t h a t j u s t , t h a t p r o s p e c t i s exhausting and i t ' s not v e r y a p p e a l i n g t o me. So i t ' s s o r t o f l i k e t h i n k i n g i t through, r a t h e r than j u s t l e t t i n g y o u r s e l f be caught r i g h t up i n i t . And knowing t h a t , "No, I r e a l l y do not want t o do t h a t , o r , I'm having." (Tape ends here.) (Appendix H, pp. 170-171, #052) 2.  Processing lapses. O c c a s i o n a l l y when she f e e l s i n e f f e c t i v e , d i s s a t i s f i e d  with  her p r e s e n t circumstances, o r b l o a t e d from o v e r e a t i n g , she has an i n c i d e n t o f b i n g e i n g and purging.  However, u n l i k e p r e v i o u s  b u l i m i c episodes, she experiences a sense o f c o n t r o l over t h e e a t i n g behaviours and does not continue t o engage i n them.  After  a l a p s e , she f e e l s d i s c o u r a g e d but not d e f e a t e d because she i s c o n f i d e n t t h a t she can cope w i t h e m o t i o n a l l y s t r e s s f u l  situations  by r e s o r t i n g t o a c t i v i t i e s o t h e r than b i n g e i n g and purging. Furthermore,  s i n c e h e r l a p s e s a r e so i n f r e q u e n t , she f e e l s  d i s t a n t from h e r b u l i m i c behaviours and no l o n g e r c o n s i d e r s them  98 a part of her l i f e . for  (See Appendix J , #058, #065, #066, and #069  P.Y.'s c o r r o b o r a t i n g  statements.)  As I s a i d I s t i l l w i l l have i n c i d e n t s o f i t [bingeing and p u r g i n g ] , you know, even now, but i t ' s l i k e , i t ' s j u s t a different thing. (Appendix H, p. 176, #067) I can't r e a l l y understand i t [ o c c a s i o n a l b u l i m i c e p i s o d e s ] . I t a c t u a l l y um, I guess o f t e n when i t happens i t ' s not l i k e a conscious c y c l e . I t ' s more l i k e f o r some reason I've l e t myself r e a l l y eat, overeat so much t h a t i t ' s almost l i k e an escape mechanism i f I know t h a t i t ' s been. L i k e I can overeat, l i k e I can e a t t o o much and f e e l , "Oh, what a p i g and s t u f f . " But t h e o c c a s i o n a l time when um i t j u s t , I don't know. I t ' s , i t ' s almost l i k e an escape mechanism i f I r e a l l y f e e l I have overeaten. You know what I mean. So i t ' s l i k e , i t ' s not l i k e a c y c l e t h a t I have t o go through. But s t i l l , p a r t s o f i t a r e s t i l l t h e r e t h a t I t h i n k I use or something. I mean i t ' s r e a l weird. But I don't have t o . So i t i s q u i t e a conscious t h i n g . (Appendix H, p. 187, #090) Although I d i d f i n d d u r i n g t h e year I stayed a t home t h a t , um, t h e r e , t h e i n c i d e n t s [of l a p s e s ] were more frequent. And when I r e a l i z e d t h a t , I made, I had t o make an e f f o r t again t o s o r t o f e l i m i n a t e i t , you know. So I know t h a t f o r whatever reason i t ' s r e a l l y much b e t t e r f o r me t o be out and i n v o l v e d i n t h i n g s and, you know, busy. And i t ' s not good f o r me t o s t a r t having negative f e e l i n g s l i k e , "I'm not doing anything o r have t o o much time." You know what I mean? (Appendix H, p. 188, #093) And I guess i t ' s [lapses are] j u s t a f e e l i n g , a negative f e e l i n g t h a t m a n i f e s t s i t s e l f i n a way. Because I d i d n o t i c e d u r i n g t h a t year, there was a p o i n t where I r e a l i z e d , you know, i t [ l a p s e s ] was s t a r t i n g t o happen: s t a r t i n g t o , not s t a r t i n g t o happen again but i t was l i k e i t , I I c o u l d see t h e frequency was going up. And t h a t , t h a t d i s t r e s s e d me. But then I was able t o , you know. I had t o e x e r c i s e w i l l but then i t was, i t was d e f e a t a b l e . I t was a funny thing. (Appendix H, pp. 188-189, #094) Well t h e t h i n g i s , i t [ b u l i m i c episode] doesn't, i t doesn't touch me t h a t much. L i k e i t ' s not something t h a t i s l i k e a l i g h t t h i n g t o do o r i t doesn't matter. But, I know t h a t those a c t i v i t i e s , um, a r e not something I have t o do: i t i s n ' t r e a l l y me anymore. So i t ' s not a t h i n g t h a t i n retrospect I l i k e . I t ' s j u s t l i k e , "What d i d I do t h a t f o r ? You know, t h a t was, t h a t was s t u p i d ; t h a t was unnecessary." But i t doesn't r e a l l y traumatize me. I f I'm f e e l i n g r e a l l y badly about myself anyway, i t would j u s t be something e l s e t o say, you know, "I f e e l badly about myself because o f . " But i t r e a l l y i s , um, i t ' s almost l i k e when you're a small  99 c h i l d , t h e r e ' s the, t h e neighbour's dog s c a r e s t h e heck out of you. And every time you walk p a s t i t your h e a r t i s going l i k e t h i s ( l i g h t l y pounds h e a r t ) . And then when you g e t o l d e r i t ' s s o r t o f l i k e he c o u l d jump out a t you and maybe s c a r e you once, but i t ' s j u s t an o l d dog. You know, s o r t o f l i k e a t o t a l l y d i f f e r e n t t h i n g about i t . So yah, i t ' s not something I l i k e , o r something I'm proud o f , o r um. But i t doesn't, i t doesn't seem t o be a b i g d e a l , you know. (Appendix H, p. 187, #089) I t ' s s o r t o f l i k e I guess l i k e smoking. You're s o r t o f l i k e , "ah, t h i s i s s o r t o f n e e d l e s s . " But um, no, t h e r e ' s no l o n g e r , you know, t h e r e i s a f e e l i n g o f c o n t r o l . I t ' s a, i t ' s a funny t h i n g t o even t a l k about now because i t ' s so incongruous but. (Appendix H, p. 188, #091) W e l l , i t ' s l i k e an o l d c a r r y over from t h e p a s t i n a way, you know, because i t i s n ' t l i k e a p a r t o f my l i f e or a necessary p a r t o f . I wouldn't even c o n s i d e r i t r e a l l y much i n t h i n k i n g o f myself these days. (Appendix H, p. 188, #092) 3.  I n c r e a s e d self-knowledge and acceptance. As she becomes more secure i n acknowledging  priorities,  h e r v a l u e s and  she f e e l s f r e e r from t h e c o n t r a d i c t o r y  messages about motherhood and c a r e e r .  societal  She f e e l s s t r o n g e r i n  knowing who she i s and she c h e r i s h e s h e r s e l f r a t h e r than s e e i n g her v a l u e s and dreams as a d i s t o r t i o n .  She r e a l i z e s t h a t  life  h o l d s both joyous and sad f e e l i n g s , and when she f e e l s v u l n e r a b l e and s e l f - l o a t h i n g she embraces these f e e l i n g s and e x p e r i e n c e s a sense o f c o n t r o l over them.  She e i t h e r accepts t h a t , f o r t h e  moment, she cannot change an uncomfortable emotional s t a t e , o r she engages i n behaviours t h a t enhance h e r f e e l i n g s herself.  about  She r e s p e c t s h e r s e l f as she i s and she does not f e e l  d r i v e n t o s t r i v e f o r p e r f e c t i o n o r u n r e a l i s t i c i d e a l s and g o a l s . As she l i s t e n s t o her f e e l i n g s r a t h e r than s e e k i n g o t h e r s ' a p p r o v a l , she begins t o d i s c e r n what h e r f e e l i n g s a r e s a y i n g and she begins t o a c t upon them.  She t r u s t s h e r f e e l i n g s enough t o  100 e x p l o r e new o p t i o n s and c h a l l e n g e s as she f e e l s l e d .  (See  Appendix J , #034, #080, #081, #082, #083, and #084 f o r P.Y.'s corroborating  statements.)  I was s a y i n g t h a t i f I were t h e person t h a t I am now, i f I were t h a t , had been t h a t person then, i f I'd had the, I t h i n k I b e l i e v e i n myself a b i t more and I know b e t t e r who I am. (Appendix H, p. 157, #025) L i k e t h e year I was home w i t h t h e 2 c h i l d r e n was not, I t h i n k i t wasn't a t e r r i b l y happy year. I j u s t , t h a t ' s I guess t h e way I am. And I no l o n g e r see i t as a n e g a t i v e t h i n g o f having t o d e f i n e myself by what I'm d o i n g ; t h a t ' s j u s t who I am. And I b e l i e v e t h a t o t h e r people a r e l i k e t h a t t o o . I t ' s my p e r s o n a l i t y r a t h e r than i t b e i n g a distortion. I t h i n k i t was a d i s t o r t i o n b e f o r e ; i t was c a r r i e d t o t h e extreme. And now I'm a b l e t o say, "I'm t h i s way, and I'm t h a t way, I'm another way" and not l i k e "god, what, what am I ? " (Appendix H, p. 179, #075) I mean t h a t ' l l always be a p a r t o f me. I ' l l never be an o v e r l y s e l f - c o n f i d e n t person. And t h e r e ' s t h e r e ' s times now where, you know, where I f e e l r e a l , r e a l l y n e g a t i v e about myself and, you know, I hate myself and wish I was anybody e l s e i n t h e world. You know, but i t ' s not e v e r y t h i n g anymore. So I guess i t ' s too, a b l e t o say, " T h i s i s t h e way I am. I ' l l always have these a s p e c t s o f my c h a r a c t e r , but I can d e a l w i t h them now." Or I can choose not t o d e a l with them and say, "Well i t ' s t h e r e , t h e r e ' s n o t h i n g I can do about i t . " (Appendix H, p. 180, #076) And a l s o what's come up i n the l a s t f a i r l y r e c e n t l y — w h i c h I t h i n k i s i n some ways p a r t o f the p r o c e s s — i s you know, I've been doing t h i s work, i t ' s been g r e a t , but i t hasn't been, l i k e I haven't r e a l l y g o t t e n o f f on a new, a b i g new d i r e c t i o n s i n c e the whole Russian t h i n g . And I'm now e x p l o r i n g , you know, t h e idea o f going back t o s c h o o l and stuff l i k e that. So i t ' s neat. So I'm no l o n g e r d e f i n i n g myself as "Gee, I was, I was a Russian t e a c h e r and now I'm not, you know. So I'm, t h e r e f o r e I'm nobody." So i t ' s s o r t of s t a r t i n g with something new a g a i n . (Pause.) Again more l i s t e n i n g t o me, I'm f i n e , and knowing what I'm s a y i n g . (Appendix H, p. 180, #077) And a l s o t h e a b i l i t y t o maybe do t h i n g s t o p l e a s e y o u r s e l f : f o r n o t h i n g o t h e r than t h a t reason. [Just t h e sheer enjoyment o f i t without any] g o a l t h a t has been s e t by somebody, t h a t you want t o a c h i e v e . (Appendix H, p. 184, #083)  101 4.  A u t h e n t i c i t y with  others.  As she comes t o know h e r s e l f b e t t e r and r e s p e c t h e r s e l f more, she f e e l s more comfortable  and a t ease with people.  She  acknowledges t h a t she has p o s i t i v e a t t r i b u t e s and t a l e n t s t o share w i t h others and she no longer f e e l s i n f e r i o r t o o t h e r s . F e e l i n g more c o n f i d e n t and competent, she i n t e r a c t s with on a more equal herself.  others  l e v e l r a t h e r than being p a s s i v e and d e v a l u i n g  There i s l i t t l e d i s c r e p a n c y between t h e s e l f she knows  and t h e s e l f she i s p r e s e n t i n g t o o t h e r s and she i s r e l i e v e d t o no l o n g e r f e e l a f r a i d o f d i s a p p o i n t i n g o t h e r s .  She i s encouraged  knowing t h a t h e r open and d i r e c t way o f i n t e r a c t i n g with  others  w i l l a l l o w h e r t o develop more i n t i m a t e p e r s o n a l r e l a t i o n s h i p s and be more e f f e c t i v e i n t e a c h i n g  others.  And I t h i n k I'm a l o t more um. I d e a l with people on a t o t a l l y d i f f e r e n t l e v e l now. (Appendix H, p. 184, #084) W e l l , you know. I f e e l t h a t . I'm s t i l l not a person t h a t has many c l o s e f r i e n d s . And again, I've decided t h a t ' s p a r t of me and not, you know, f o r any other reason. But, I'm a b l e t o be, you know f e e l t h a t I'm more myself with others and be more r e l a x e d , and you know d e a l with them as I f e e l other people must have always d e a l t with other people. And so t h a t ' s good. And you know, t h e work t h a t I do now and I suppose any k i n d o f work I do w i l l be with people, and w i l l h o p e f u l l y be from a p e r s p e c t i v e o f t r y i n g t o g i v e them something through t e a c h i n g o r whatever. And I f e e l t h a t , you know, I can do t h a t much more e f f e c t i v e l y . (Appendix H, p. 184, #085) But um, i t was almost as i f t h e people t h a t I f e l t I c o u l d be c l o s e t o , those were t h e ones t h a t I wanted t o push f u r t h e s t away because I f e l t l i k e I would i n f e c t other people: I f I allowed them t o be c l o s e enough I would i n f e c t them with whatever s i c k n e s s I had. L i k e um, I f e l t l i k e a p i l e o f c u t g l a s s and anybody who touched would would, you know, c u t themselves on. So, you'd sometimes surround y o u r s e l f by people, but you wouldn't you know, you d i d n ' t have t h a t much t o do, o r i n common with. So, you know, i t ' s a q u e s t i o n o f t h e f r i e n d s t h a t you choose would be more r e a l friends. (Appendix H, pp. 184-185, #086)  102 I know something. I know something. Again, i n my r e l a t i o n s h i p with people, I t h i n k I always wanted the other p e r s o n — i n whatever the r e l a t i o n s h i p w a s — t o be i n c o n t r o l . You know, f o r reasons t h a t I t h i n k you probably understand: a l a c k of s e l f - d e f i n i t i o n e t c e t e r a and wanting t o j u s t s o r t of h i t c h myself on t o somebody e l s e . And you know t h a t a n a l y s i s o f r e l a t i o n s h i p s t h a t ' s , you know, parent, c h i l d , and peer. I t h i n k I would always d e l i b e r a t e l y s e t up a r e l a t i o n s h i p w i t h o t h e r s i n t h a t I was the c h i l d and they were the parent. And I'd always t r y and um, uh, I t h i n k put myself forward as a b i t of an " a i r h e a d " . L i k e I never would t r y and put myself forward as somebody who knew anything about anything because they would probably f i n d out I d i d n ' t a c t u a l l y anyways. (Tape ends here.) The whole image of, um, not being equal w i t h o t h e r s : always p u t t i n g y o u r s e l f on the down s i d e , um, not being a s s e r t i v e , um, and not b e l i e v i n g t h a t o t h e r s w i l l take you s e r i o u s l y . So t h e r e ' s a c e r t a i n amount of, of um, a g a i n almost t r y i n g t o r e l i n q u i s h c o n t r o l of the s i t u a t i o n when you're w i t h o t h e r people. So I t h i n k I d e a l with people, l i k e you know, on a much d i f f e r e n t l e v e l now. I mean p r o f e s s i o n a l l y I can t a l k t o people as I imagine an a d u l t would t a l k t o another a d u l t and not the way I used t o . So t h a t ' s a, t h a t ' s a b i g d i f f e r e n c e as w e l l . (Appendix H, p. 185, #087) That's r i g h t . And I b e l i e v e now I'm a b l e t o see some good i n myself and see "Yah, I can do t h a t w e l l . I t ' s not j u s t , I was j u s t , somehow got through i t and I f o o l e d them t h i s time. God, w i l l I be a b l e t o f o o l them again?" That, you know, h o r r i b l e t e n s i o n t h a t e v e r y t h i n g you do then having more e x p e c t a t i o n s and being r e a l l y scared of i t even though you have t o have those e x p e c t a t i o n s : They have t o be t h e r e . So i t ' s a l o t , um, e a s i e r now i n f a c t . (Appendix H, pp. 185-186, #088) 5.  B a l a n c i n g work and p l a y . Her a b i l i t y t o c o n c e n t r a t e on work i s s u e s or t o engage i n  r e f l e c t i o n and contemplation  i s strengthened now  l o n g e r t h i n k i n g about b i n g e i n g and purging.  t h a t she i s no  As a r e s u l t , she i s  a b l e t o more f u l l y i n v e s t h e r s e l f i n t e l l e c t u a l l y i n her work a c t i v i t i e s w h i l e a l s o being l e s s obsessed She takes time f o r l e i s u r e without enjoys and  and d r i v e n by them.  f e e l i n g g u i l t y because she  i s n u r t u r e d by time away from work.  Feeling in  c o n t r o l of her e a t i n g behaviours, she i s a t ease w i t h time and sure t h a t she w i l l not f i l l  leisure  i t w i t h her p r e v i o u s b u l i m i c  103  behaviours.  (See Appendix J , #079 f o r P.Y.'s c o r r o b o r a t i n g  statement.) But I a l s o r e a l i z e d what an e f f e c t b u l i m i a had on your a b i l i t y t o t h i n k , j u s t i n terms o f — i t ' s not j u s t the amount of t i m e — b u t i t r e a l l y has, you know, i t r e a l l y damages you p h y s i c a l l y and s t u f f , and I t h i n k i n t e l l e c t u a l l y because you're so weakened and s t u f f . So I t h i n k were I t o , i f I were t o s t a r t on some k i n d of s c h o o l program, um, I t h i n k t h a t i n many ways, um, I don't want t o say I'd do b e t t e r , but i t would j u s t be, i t would be a more balanced t h i n g . I t wouldn't be such a focused t h i n g . So maybe I wouldn't do um, something l i k e s t a n d a r d i z e d grades and s t u f f , I might not do b e t t e r . But I t h i n k I would be a b l e t o put more i n t o i t because I'd have more of myself t o devote t o i t . (Appendix H, p. 183, #081) I could concentrate. I mean i t was l i k e I c o u l d never c o n c e n t r a t e b e f o r e cause t h i s was always on my mind. And i f I were i n a p o s i t i o n t o concentrate t h a t would u s u a l l y mean I'd be o f f doing some work, whatever, s t u d y i n g or whatever. And t h a t would be a prime time t o binge, and I u s u a l l y would. So t h e r e wouldn't be p e r i o d s of c o n c e n t r a t i o n or reflection. L i k e I was a f r a i d j u s t t o s i t back and t h i n k about t h i n g s and not do anything, from many p o i n t s of view, because i f I weren't doing anything then I wasn't j u s t i f y i n g myself [or t h a t would be a prime time t o b i n g e ] . But a l s o , I d i d n ' t have any l e i s u r e , i n t e l l e c t u a l or otherwise, to do things. (Appendix H, p. 183, #082) 6.  Altruism. She  d e s i r e s t o share her recovery  experience  are s t r u g g l i n g t o overcome an e a t i n g d i s o r d e r .  with o t h e r s  She  who  feels  c o n f i d e n t t h a t she w i l l be able t o empathize deeply with them and provide process.  i n f o r m a t i o n which may She  h e l p them i n t h e i r  recovery  a l s o t r u s t s t h a t the i n d i v i d u a l s w i l l  identify  with  her and be encouraged about t h e i r p o t e n t i a l f o r improvement from s e e i n g t h a t not only c e l e b r i t i e s but a l s o " o r d i n a r y " people recover  from b u l i m i a .  In r e l i v i n g her recovery experience,  expects t o a f f i r m her courage and  she  s t r e n g t h and t o acknowledge the  p e r s o n a l growth and m a t u r i t y which r e s u l t e d from her s t r u g g l e t o overcome b u l i m i a .  (See Appendix J , #024 and  #025 f o r P.Y.'s  104 corroborating  statements.)  Yah, M-hm. (Pause.) And I wish [ t h a t as p a r t o f my r e c o v e r y ] , yah, I wish I had been more i n v o l v e d i n ANAD, and I, I s t i l l have f e e l i n g s now. I t h i n k I'd l i k e t o t r y going back and seeing i f t h e r e ' s any c a p a c i t y t h a t I c o u l d be i n v o l v e d o r help out o r something. I t h i n k t h a t ' s p a r t o f , I t h i n k p a r t o f i t i s , um, once you've worked through i t , being i n v o l v e d somehow i n h e l p i n g o t h e r s o r with, you know. (Appendix H, p. 181, #078) You see I t h i n k t h a t ' s i t . And I t h i n k , um, i n i n examining i t s i n c e I've t a l k e d with you and, you know, thought about i t more than I've thought about i f f o r a l o n g time, i s t o r e a l i z e t h a t t h a t [ h e l p i n g out a t ANAD] might be another important s o r t o f l a s t step. (Appendix H, p. 182, #079) I'm hoping t o help others through what I went through. I t h i n k a l s o , i t ' s i t ' s not so much from a p o i n t o f s e l f examination cause I r e a l l y f e e l t h a t you can never work t h i n g s through t o t h e l a s t " d o t t i n g o f t h e l a s t i . " You know, when you do t h a t with y o u r s e l f , you might as w e l l d i e (laugh), cause i t ' s l i k e put i t a l l i n a box. But I t h i n k t h e r e ' s maybe some element i n t h a t , but I t h i n k most of i t i s f e e l i n g t h a t you have something t o c o n t r i b u t e , you know. And, and, and s t i l l remembering how awful i t was and hoping t h a t maybe what you can do can h e l p somebody get through i t more q u i c k l y . (Appendix H, p. 182, #080) 7.  C e r t a i n t y o f recovery. While she f e e l s c o n f i d e n t t h a t she w i l l not s l i d e back i n t o  b u l i m i c behaviours because she i s now more aware o f who she i s and more s e l f - r e s p e c t i n g , she acknowledges t h e p o s s i b i l i t y o f a recurrence is  of bulimia.  From h e r experience,  not t o t a l l y immune t o a r e l a p s e .  she knows t h a t she  (See Appendix J , #010, #011,  #012, #023, #059, #060, and #061 f o r P.Y.'s c o r r o b o r a t i n g statements.) I c o u l d r e v e r t [ t o b u l i m i a ] I suppose i f I, yah. Although I r e a l l y don't t h i n k I c o u l d ever r e a l l y g e t back i n t o t h a t situation. I don't know. I can't even conceive o f i t . (Appendix H, p. 189, #095) I t was a d i f f e r e n t person doing #096)  it.  (Appendix H, p. 189,  105 Chapter  V  Discussion The b e h a v i o u r a l and p s y c h o s o c i a l changes i n h e r e n t i n the p r o c e s s of r e c o v e r y from b u l i m i a o c c u r r e d through  both  formal  t h e r a p e u t i c mechanisms and o u t - o f - t h e r a p y e x p e r i e n c e s .  This  broad scope of f a c i l i t a t i v e f a c t o r s r e p r e s e n t e d by the  two  c o - r e s e a r c h e r s ' s t o r i e s p r o v i d e d a comprehensive and i n t e g r a t e d b a s i s f o r understanding  the experience of r e c o v e r y .  In t h i s  chapter, the f i n d i n g s on the p a t t e r n of recovery are b r i e f l y summarized and the l i m i t a t i o n s of t h i s study are  addressed.  F u r t h e r , the t h e o r e t i c a l and c o u n s e l l i n g i m p l i c a t i o n s of the r e s u l t s are d i s c u s s e d with recommendations f o r f u t u r e r e s e a r c h . Summary of R e s u l t s T h i s study e l u c i d a t e d the p a t t e r n or meaning of r e c o v e r y from b u l i m i a from the f i r s t c o - r e s e a r c h e r ' s experience  of  recovery.  transcript  was  Information from the second c o - r e s e a r c h e r ' s  used t o c r o s s - v a l i d a t e the themes.  Twenty-nine f a c t o r s  r e p r e s e n t i n g the process and nature o f r e c o v e r y from b u l i m i a were i d e n t i f i e d and subsumed under f i v e major c a t e g o r i e s :  "(A)  R e a l i z a t i o n of E a t i n g Problem and Ambivalence About Change,  (B)  Openness and Readiness f o r Change, (C) Awareness of E v o l v i n g S e l f and Changes i n E a t i n g Behaviours, New  Values, and  (D) Emergence of a New  Self  and  (E) The Nature and Maintenance of Recovery."  L i m i t a t i o n s of the Study The  i n t e r n a l v a l i d i t y of the r e s e a r c h f i n d i n g s i s h i g h  because p o t e n t i a l b i a s i n the assessment of the c o - r e s e a r c h e r s ' degree of r e c o v e r y was  c o n t r o l l e d f o r ; the independent r a t e r  who  106 i s a p s y c h i a t r i s t w i t h e x p e r t i s e i n e a t i n g d i s o r d e r s had no p r e v i o u s treatment  c o n t a c t w i t h any o f t h e women.  Further, the  r e s u l t s o f t h i s case study r e p r e s e n t an a p p l i c a t i o n o f t h e e x i s t e n t i a l - p h e n o m e n o l o g i c a l approach.  S p e c i f i c a l l y , the  f i n d i n g s d i d not r e - c r e a t e t h e immediate meaning o f t h e c o - r e s e a r c h e r ' s experience b u t a r t i c u l a t e d a c o n c e p t u a l understanding The  o f t h e raw, v e r i d i c a l r e c o v e r y e x p e r i e n c e .  f i n d i n g s a r e based on a s m a l l sample s i z e o f two  c o - r e s e a r c h e r s and t h e e x t r a c t e d thematic c a t e g o r i e s were p r e s e n t e d o n l y t o t h e primary c o - r e s e a r c h e r f o r v a l i d a t i o n o f t h e accuracy and a p p r o p r i a t e n e s s o f t h e wording o f t h e c a t e g o r i e s . As such, t h i s p a t t e r n o f recovery may be c o n s i d e r e d t r u e f o r the one woman and i t may a l s o be a p p l i c a b l e t o some o t h e r women s t r u g g l i n g t o overcome normal-weight b u l i m i a .  In a d d i t i o n ,  self-  s e l e c t e d i n d i v i d u a l s may be d i f f e r e n t from t h e l a r g e r p o p u l a t i o n i n terms o f w i l l i n g n e s s t o share p e r s o n a l i n f o r m a t i o n w i t h others as w e l l as b e i n g p s y c h o l o g i c a l l y minded and v e r b a l l y e x p r e s s i v e . T h e r e f o r e , v o l u n t e e r c o - r e s e a r c h e r s may r e p r e s e n t those who f e e l c o m f o r t a b l e w i t h themselves  and o t h e r s , have experienced a sense  of achievement i n overcoming b u l i m i a , and f e e l motivated t o be involved i n existential-phenomenological research. sample b i a s c o u l d be an important  Consequently,  f a c t o r t o c o n s i d e r when  a p p l y i n g t h e r e s u l t s t o t h e recovery experience f o r women w i t h normal-weight b u l i m i a (Borg & G a l l ,  1983).  Furthermore, t h e  p a t t e r n o f r e c o v e r y from b u l i m i a may be d i f f e r e n t f o r males o r i n d i v i d u a l s with obesity. F i n a l l y , because no person can be thoroughly  researched,  107 "research  can never exhaust the investigated, phenomenon"  (Colaizzi, research  1978,  p. 70).  point.  of each phase I had  being  s a t i s f i e d that  As C o l a i z z i  (1978) p r e d i c t e d , a t  "a c e r t a i n empty but d i s t i n c t f e e l i n g  . . . [each] phase [was]  f a c t of simultaneously being  w i t h a l l phases of t h i s  p r o j e c t , t h e r e were no e s t a b l i s h e d g u i d e l i n e s which  marked a t e r m i n a t i o n end  Therefore,  experiencing  complete or f i n a l "  (p. 70).  of  adequate i n the  the t e n s i o n of i t s not Therefore,  the  really  i t i s suggested  t h a t the c e r t a i n t y of these f i n d i n g s be h e l d w i t h  reservations.  E v a l u a t i n g the F i t n e s s of T h e o r e t i c a l Approaches In Chapter I I , the assumptions concerning p r o c e s s of recovery  from b u l i m i a  inherent  the nature  i n the  s t u d i e s of the psychodynamic, f a m i l y systems, and behavioural  treatment approaches were o u t l i n e d .  d i s c u s s e s the present  research  i s to explore  exploratory  cognitiveThis section  experience,  study  this  f i t n e s s of t h e o r e t i c a l approaches i s f o r  purposes.  A b a s i c p r i n c i p l e of treatment which i s i m p l i c i t the t h e o r i e s as f o u n d a t i o n a l by the  current  As the purpose of t h i s  the meaning of the recovery  e v a l u a t i o n of the  empirical  f i n d i n g s i n l i g h t of the  t h e o r e t i c a l knowledge on recovery.  and  i n a l l of  i n the change p r o c e s s i s supported  f i v e themes which are c l u s t e r e d under Category  A.  " R e a l i z a t i o n of E a t i n g Problem and Ambivalence About Change." These themes are:  "(1) Awareness of an e a t i n g problem,  (2)  Awareness of the a s s o c i a t i o n between o n e s e a t i n g problem 1  emotional i s s u e s , problem,  (3) D i a g n o s t i c  and  awareness of one's e a t i n g  (4) Acknowledgement of need f o r o u t s i d e h e l p ,  and  (5)  108 Awareness o f o b s t a c l e s t o a c t i o n . "  Theme C8  ("Verbally  acknowledging b u l i m i c behaviours") a l s o confirms t h e r o l e o f i n s i g h t and acknowledgement o f one's problem which i s a l l u d e d t o by t h e t h e o r i e s .  For i n s t a n c e , t h e psychodynamic  theory  addresses t h e unconscious r o l e o f ego-defense mechanisms such as d e n i a l and p r o j e c t i o n i n denying o r d i s t o r t i n g r e a l i t y 1986).  Family systems theory  also recognizes  (Corey,  t h e imperativeness  of t h e i n d i v i d u a l r e a l i z i n g t h a t she has an e a t i n g problem and t h a t she i s ambivalent about g i v i n g up t h e problem al.,  1985).  S i m i l a r l y , Fairburn's  (1985)  (Schwartz e t  cognitive-behavioural  approach emphasizes t h e n e c e s s i t y o f c o g n i t i v e change p e r t a i n i n g t o body weight and shape. must f i r s t she  Thus, CBT s t r e s s e s t h a t t h e i n d i v i d u a l  acknowledge t h a t she has an e a t i n g d i s o r d e r and t h a t  f e e l s ambivalent about changing h e r e a t i n g b e h a v i o u r s . However, Themes A l , A2, A3, A4, A5, and C8 seem t o i n d i c a t e  more s p e c i f i c p s y c h o l o g i c a l processes, by these t h e o r i e s .  Thus, t h e themes e n r i c h our t h e o r e t i c a l  knowledge about t h e i n i t i a l Theme A3 ("Diagnostic Theme C8 ("Verbally  beyond what i s suggested  phase i n recovery.  For example,  awareness o f one's e a t i n g problem") and  acknowledging b u l i m i c behaviours") h i g h l i g h t  the mechanisms by which an i n d i v i d u a l ' s t h i n k i n g about h e r e a t i n g behaviours i s changed.  Knowing t h a t other people engage i n  s i m i l a r behaviours and u s i n g t h e terms " b i n g e i n g "  and  "vomiting"  r e i n f o r c e h e r r e c o g n i t i o n t h a t she has a problem, and a l s o provide  hope f o r overcoming h e r problem.  In a d d i t i o n , Theme A2  ("Awareness o f t h e a s s o c i a t i o n between one's e a t i n g problem and emotional i s s u e s " )  emphasizes t h e key u n d e r l y i n g  psychological  109 i s s u e s which c l a r i f y f o r t h e i n d i v i d u a l t h e s e r i o u s n e s s e a t i n g problem and p o i n t the way t o recovery. ("Awareness o f o b s t a c l e s t o a c t i o n " )  of her  F i n a l l y , Theme A5  a r t i c u l a t e s t h e adaptive  f u n c t i o n s o f b u l i m i a which c o n t r i b u t e t o t h e i n d i v i d u a l ' s ambivalence about g i v i n g up h e r e a t i n g b e h a v i o u r s . Regarding t h e psychodynamic theory, C7,  D2, D3, and D4 support t h i s theory's  Themes A2, CI, C5, C6, assumptions o f recovery.  In Theme A2 ("Awareness o f a s s o c i a t i o n between one's e a t i n g problem and emotional i s s u e s " ) , t h e c o - r e s e a r c h e r underlying others,  a r t i c u l a t e s her  f e e l i n g s o f i n s e c u r i t y , powerlessness, engulfment by  and s e l f - c r i t i c i s m .  Theme CI ("Increasing  sense o f  e f f i c a c y " ) , Theme C5 ("Awareness o f r e l a p s e " ) , and Theme C6 ("Separation o f s e l f from bulimia")  underscore t h e c a u s a l  between i n t r a p s y c h i c c o n f l i c t s and d i s o r d e r e d and  reinforce that psychological  link  e a t i n g behaviours  f u n c t i o n i n g and b u l i m i c  behaviours improve as t h e i n d i v i d u a l e x p e r i e n c e s a sense o f s e l f r e s p e c t and s e l f - c o n f i d e n c e .  Theme C7 ( " D e - i d e a l i z i n g and  f o r g i v i n g f a m i l y o f o r i g i n " ) d e s c r i b e s how t h e i n d i v i d u a l begins t o take more o f an a c t i v e r o l e i n h e r recovery her emotional s e p a r a t i o n  once she deepens  from h e r mother by no longer blaming her  mother f o r h e r e a t i n g d i s o r d e r .  Reorganization  of  s e l f - p e r c e p t i o n i s r e f l e c t e d i n Theme D2 ( " R e s p o n s i b i l i t y f o r o f f s p r i n g " ) , Theme D3 ("New a p p r e c i a t i o n and understanding o f her p h y s i c a l body"), and Theme D4 ("Expanding sense o f s e l f and belief in self"). and  That i s t h e i n d i v i d u a l ' s s e l f - w o r t h  increases,  t h e frequency o f b u l i m i c behaviours decreases as h e r  perception  o f h e r s e l f and h e r body i s c l a r i f i e d by h e r r o l e s as  110 mother, w i f e ,  and employee.  Although t h e l i t e r a t u r e i n d i c a t e s no e m p i r i c a l  research  s t u d i e s p e r t a i n i n g t o t h e e f f i c a c y o f an o b j e c t - r e l a t i o n s t h e o r e t i c a l approach t o treatment, s e v e r a l themes i d e n t i f i e d i n t h i s study support t h e theory. Pine,  According  t o Bruch, and Mahler,  and Bergman ( c i t e d i n Johnson & Connors, 1987),  r e l a t i o n s theory disturbances  focuses  on the ego weaknesses and i n t e r p e r s o n a l  o f an i n d i v i d u a l w i t h an e a t i n g d i s o r d e r .  capacity f o r self-regulation i s i n s u f f i c i e n t : "accurately  object-  Her  She i s unable t o  i d e n t i f y needs and e f f e c t i v e l y o r g a n i z e  adaptive  need  g r a t i f y i n g responses" (Johnson & Connors, 1987, p. 89). She experiences a d e f i c i t  i n i n t e r o c e p t i v e awareness and i s d e f i c i e n t  i n her sense o f separateness o f s e l f from o t h e r s . i n e f f e c t i v e o r c o n t r o l l e d by o t h e r s . stage,  She a l s o f e e l s  A t an e a r l y developmental  t h e i n f a n t ' s u n d i f f e r e n t i a t e d n u t r i t i o n a l and emotional  needs a r e i n a p p r o p r i a t e l y responded t o by t h e primary  caregiver  such t h a t when t h e c h i l d i s o l d e r , she i s "not a b l e t o d i s c r i m i n a t e between being hungry o r s a t i a t e d , o r between n u t r i t i o n a l need and some other d i s c o m f o r t 1973,  or tension"  p. 56). She i s a l s o l i k e l y t o m i s i n t e r p r e t t h i s  of h e r b o d y - s e l f bulimic  concept as e x t e r n a l l y induced.  (Bruch, confusion  Thus, the  i n d i v i d u a l uses food o r binge e a t i n g as an e x t e r n a l means  f o r t e n s i o n r e d u c t i o n and s e l f - s o o t h i n g . Given t h i s t h e o r e t i c a l understanding o f t h e development o f b u l i m i a , t h e o b j e c t - r e l a t i o n s theory  h o l d s t h a t recovery  from t h e c l i e n t ' s r e a l i z a t i o n t h a t her d i f f i c u l t f e e l i n g s are appropriate  results  emotional  and not i n d i c a t i v e o f being  out o f  Ill control.  Furthermore,  i t i s necessary f o r the i n d i v i d u a l t o be  p a r t of an i n t i m a t e r e l a t i o n s h i p wherein  she  feels  p s y c h o l o g i c a l l y attended t o and assured t h a t o t h e r s are capable and d e s i r o u s of responding t o her needs (Johnson & Connors, 1987).  Themes A4,  B l , B2,  C4, C6, CIO,  D l , E3, E4, E5, E6,  E7 g i v e p a r t i a l support f o r o b j e c t - r e l a t i o n s t h e o r y .  and  They  r e p r e s e n t an i n c r e a s i n g move from i s o l a t i o n towards p s y c h o l o g i c a l l y c o n n e c t i n g w i t h o t h e r s even though she  feels  ashamed, and towards a deepened sense of t r u s t i n g t h a t o t h e r s w i l l be a b l e t o meet her needs. behaviours b e g i n t o d i m i n i s h .  As a r e s u l t , her b u l i m i c However, w h i l e the themes d e s c r i b e  a s t r e n g t h e n i n g of d i s t u r b e d i n t e r p e r s o n a l r e l a t i o n s h i p s , they do not p r o v i d e c a u s a l support f o r the i n d i v i d u a l acknowledging importance  of a d d r e s s i n g her c a r e g i v e r ' s emotional  i n o r d e r f o r her t o r e c o v e r .  the  unavailability  For i n s t a n c e , none of the themes  a l l u d e t o the i n d i v i d u a l r e a l i z i n g t h a t she has t o d e a l with the l a c k of l o v e she experienced as an i n f a n t i n her r e l a t i o n s h i p w i t h her mother by e i t h e r g e n t l y c o n f r o n t i n g her mother or i n t e r a c t i n g w i t h o t h e r s i n a way  which i s more i n t i m a t e than  how  she i n t e r a c t s w i t h her mother. Nonetheless, these p a r t i c u l a r themes enhance our understanding of r e c o v e r y from b u l i m i a from an o b j e c t - r e l a t i o n s perspective.  For i n s t a n c e , her p e r c e p t i o n of h e r s e l f begins t o  change when she begins t o f e e l accepted by o t h e r s and t h a t she i s a c c e p t a b l e as she i s .  realizes  She becomes aware t h a t  she  does not need t o engage i n b u l i m i c behaviours i n o r d e r t o a l t e r her p h y s i c a l s e l f or t o meet her emotional needs.  Her sense of  112 s e l f or i d e n t i t y develops and grows s t r o n g e r as she  experiences  t h a t she can be i n v o l v e d i n i n t i m a t e r e l a t i o n s h i p s w h i l e m a i n t a i n i n g her sense of who  she i s as separate from them.  her i n d i v i d u a l i d e n t i t y as a person w i t h unique  abilities  s t r e n g t h s becomes c o n s t a n t and not dependent on o t h e r s of her.  She  i s a b l e t o s e t l i m i t s f o r h e r s e l f and  h e r s e l f i n h e a l t h y ways.  1  Thus, and  approval  nurture  F i n a l l y , she s o l i d i f i e s her i d e n t i t y  a r e c o v e r e d i n d i v i d u a l by a f f i r m i n g t o h e r s e l f and  as  other  r e c o v e r i n g i n d i v i d u a l s t h a t her i n c r e a s e d sense of s e l f and  self-  r e s p e c t b o l s t e r her c o n f i d e n c e i n her a b i l i t y t o m a i n t a i n a b s t i n e n c e from b i n g e i n g and  purging.  With r e s p e c t t o f a m i l y systems theory, none of the themes d i r e c t l y addresses the c u r a t i v e mechanism of f a m i l y r e s t r u c t u r i n g i n o r d e r t o c r e a t e more a d a p t i v e p a t t e r n s of i n t e r a c t i o n which support the i n d i v i d u a l ' s d i f f e r e n t i a t i o n from the f a m i l y system (Schwartz,  1982;  Schwartz e t a l . ,  1985).  The  i n d i v i d u a l d i d not  v o l u n t e e r i n f o r m a t i o n which would support a systemic change factor.  For i n s t a n c e , she d i d not i n d i c a t e t h a t her mother  i n t e r a c t s d i f f e r e n t l y w i t h her now d i f f e r e n t l y t o her mother.  or t h a t she  However, Theme C7  f o r g i v i n g f a m i l y of o r i g i n " ) extends an i d e n t i t y independent  relates ( " D e - i d e a l i z i n g and  the meaning of e s t a b l i s h i n g  of the f a m i l y .  Specifically,  the  i n d i v i d u a l deepens her emotional s e p a r a t i o n from her f a m i l y of o r i g i n once she d e c i d e s t o take r e s p o n s i b i l i t y f o r overcoming her b u l i m i a r a t h e r than blaming her mother f o r her e a t i n g d i s o r d e r . With r e s p e c t t o the c o g n i t i v e - b e h a v i o u r a l theory, Themes B3, C2,  C3,  C5,  C9,  D4,  E l , E2, E6, and E7 c o n f i r m t h i s  theory's  113 assumptions  as i n d i c a t e d by F a i r b u r n (1985).  As o u t l i n e d  r e s p e c t i v e l y by Themes B3, C2, and D4 ("Remission," of e a t i n g p a t t e r n s , " and "Expanding  "Interruption  sense o f s e l f and b e l i e f i n  s e l f " ) , t h e i n d i v i d u a l r e a l i z e s t h a t she can e f f e c t i v e l y g a i n a sense o f c o n t r o l over h e r b u l i m i c behaviours by engaging i n alternate a c t i v i t i e s .  Her sense o f e f f i c a c y c o n t i n u e s t o  i n c r e a s e now t h a t she knows how she can r e g a i n c o n t r o l o f h e r e a t i n g behaviours when she r e l a p s e s .  C o r r e s p o n d i n g l y , as  d e t a i l e d by Theme C3 ("Symptom s u b s t i t u t i o n " ) , she i s aware o f a l s o s u b s t i t u t i n g h e r b u l i m i c behaviours w i t h o t h e r a d d i c t i v e substances.  Theme C9 ("Permission t o e a t p r e v i o u s l y f o r b i d d e n  foods and t o f e e l f u l l " ) e x p l a i n s t h e c o g n i t i v e r e s t r u c t u r i n g of "O.K. foods" and "binge foods" and recounts t h e i n d i v i d u a l ' s i n s i g h t t h a t h e r body can e f f i c i e n t l y m e t a b o l i z e a normal i n t a k e of food without h e r needing t o s t r i c t l y c o n t r o l what she e a t s . However, t h e i n d i v i d u a l does not use s e l f - t a l k t o c h a l l e n g e h e r b e l i e f t h a t c e r t a i n foods a r e i n h e r e n t l y f a t t e n i n g .  Instead, she  d i s c u s s e s w i t h h e r t h e r a p i s t t h a t a l l foods i n moderation a r e good, and then she begins t o g r a d u a l l y i n c o r p o r a t e t h e p r e v i o u s "binge foods" i n t o h e r d i e t .  Theme C9 a l s o a l l u d e s t o t h e  t e c h n i q u e o f "exposure w i t h response p r e v e n t i o n " i n which i n d i v i d u a l s a r e encouraged  t o e a t f o r b i d d e n foods but then t o  d e l a y o r r e f r a i n from p u r g i n g (Wilson, R o s s i t e r , K l e i f i e l d , & Lindholm,  1986).  She implements t h e s e l f - i n s t r u c t i o n a l technique  of t e l l i n g h e r s e l f t h a t she can d e l a y h e r p u r g i n g behaviour. F i n a l l y , Themes E l , E2, E6, and E7 ("Counting t h e c o s t o f returning t o the bulimic behaviours," "Processing lapses,"  114 "Altruism,"  and " C e r t a i n t y o f recovery") focus on t h e c o g n i t i v e  i n t e r v e n t i o n s which the i n d i v i d u a l implements t o prevent a relapse  from o c c u r r i n g :  e a t i n g behaviours, u s i n g  doing a c o s t - b e n e f i t a n a l y s i s o f her s e l f - t a l k t o remind h e r s e l f o f h e r  growth and development, and implementing a l t e r n a t e  activities.  In summary, the p a t t e r n o f recovery which emerged from t h i s study supports t h e t h e o r e t i c a l assumptions o f r e c o v e r y from bulimia  o u t l i n e d by the psychodynamic, o b j e c t - r e l a t i o n s , and  cognitive-behavioural  approaches t o treatment.  i d e n t i f i e d i n t h i s study a l s o provided  The themes  f u r t h e r i n s i g h t i n t o the  meaning and impact o f some o f the formal t h e r a p e u t i c  curative  f a c t o r s and deepened our understanding o f t h e i n i t i a l phase o f recovery described and  by Category A. " R e a l i z a t i o n o f E a t i n g  Ambivalence About Change."  perspective  Problem  F i n a l l y , the co-researcher's  on the c r i t i c a l change f a c t o r s i n r e c o v e r y supports  the c u r r e n t m u l t i f a c e t e d in t r e a t i n g bulimia  and i n t e g r a t e d t h e r a p e u t i c  approach used  (Herzog e t a l . , 1987; Johnson, Connors, &  Tobin, 1987; Manley, 1989; S t e i g e r ,  1989).  The c u r a t i v e  impact  of o u t - o f - t h e r a p y e x p e r i e n c e s has a l s o been confirmed i n t h i s study. Implications  f o r Counselling  This section discusses  the p r a c t i c a l i m p l i c a t i o n s o f t h e  p a t t e r n o f r e c o v e r y from b u l i m i a which emerged from t h i s study. The  p r e s e n t a n a l y s i s o f recovery themes from the c l i e n t ' s  perspective  has the f o l l o w i n g t h r e e  important i m p l i c a t i o n s f o r  counselling practice. 1. The p a t t e r n o f recovery as d i s c u s s e d  i n this thesis  gives  115 a more complete and h o l i s t i c understanding  of the process  nature of r e c o v e r y than what has been known p r e v i o u s l y . meaning of the r e c o v e r y events throughout  The  the e n t i r e p r o c e s s i s  examined and the s y n e r g e t i c e f f e c t of c u r a t i v e f a c t o r s i n s i d e and o u t s i d e of formal therapy i s r e v e a l e d . c l i e n t s may  and  both  Therefore,  be encouraged t o i n c r e a s e o u t - o f - t h e r a p y  corrective  e x p e r i e n c e s as p o t e n t i a l l y v a l u a b l e a d j u n c t s t o formal therapy. 2. The r e c o v e r y p a t t e r n p r o v i d e s a u s e f u l framework f o r c o u n s e l l i n g i n d i v i d u a l s who  are r e c o v e r i n g from b u l i m i a .  It  o u t l i n e s the f a c t o r s which are most f a c i l i t a t i v e of r e c o v e r y a l s o i n d i c a t e s the a s s o c i a t e d p h y s i c a l , c o g n i t i v e , s o c i a l and s p i r i t u a l changes.  and  emotional,  For example, the r e s u l t s  reinforce  t h a t b e f o r e change can occur, the i n d i v i d u a l must r e a l i z e t h a t she has an e a t i n g d i s o r d e r and t h a t i t i s i n d i c a t i v e of u n d e r l y i n g emotional  i s s u e s and i n t e r p e r s o n a l c o n f l i c t s .  It is  a l s o i m p e r a t i v e t h a t she acknowledges her need f o r o u t s i d e h e l p and her ambivalence  about change.  The  importance  of a d d r e s s i n g  both the d i s o r d e r e d e a t i n g behaviours and the i n d i v i d u a l • s of s e l f throughout developmental  therapy i s a l s o underscored.  sense  In a d d i t i o n ,  the  process i n v o l v e d i n overcoming b u l i m i a i s  h i g h l i g h t e d by the s e l f - e x p l o r a t i o n and r i s k - t a k i n g  activities  which c o n t r i b u t e t o the i n d i v i d u a l ' s growing p e r c e p t i o n of s e l f and i n c r e a s e d sense of e f f i c a c y and 3. The r e s u l t s may  self-respect.  a l s o c o n t r i b u t e t o the development of a  c l i n i c a l approach t o b u l i m i a by emphasizing m u l t i f a c e t e d , i n t e g r a t e d , and which i s a d j u s t e d throughout  the need f o r a  i n d i v i d u a l i z e d treatment  approach  the r e c o v e r y process as the a d a p t i v e  116 f u n c t i o n s or meanings of c l i e n t s Hopefully,  1  e a t i n g behaviours change.  the i n d i v i d u a l ' s unique way  of p e r c e i v i n g r e a l i t y  and  her sense of agency w i l l be h i g h l i g h t e d as the t h e r a p i s t s t r i v e s t o know how  t o most e f f e c t i v e l y work with those who  recovering  from b u l i m i a .  are  In a d d i t i o n t o s h a r i n g the  world view i n terms of mutually  client's  i d e n t i f y i n g the a d a p t i v e  function  or u n d e r l y i n g causes of the c l i e n t ' s b u l i m i c symptoms, d i a l o g u i n g w i t h her as t o what aspects  of therapy she  finds helpful  decrease the p o s s i b i l i t y of r e l a p s e or symptom  may  transformation  o c c u r r i n g once the b u l i m i c symptoms have subsided  (Vognsen,  1985). Recommendations f o r Future The  Research  f o l l o w i n g recommendations f o r f u t u r e r e s e a r c h are based  upon the f i n d i n g s and  r e s e a r c h methodology used i n t h i s study,  w e l l as the c u r r e n t l i t e r a t u r e on recovery  as  from b u l i m i a .  1. In order t o i n c r e a s e g e n e r a l i z a b i l i t y of the  present  f i n d i n g s and v a l i d i t y of the f i v e c a t e g o r i e s , f u r t h e r q u a l i t a t i v e s t u d i e s are needed t o more f u l l y e x p l i c a t e the meaning of recovery recovered  events from the p e r s p e c t i v e of the i n d i v i d u a l who from b u l i m i a .  changes i n v o l v e d i n recovery.  i n s i g h t c o u l d be gained mechanisms i n h e r e n t for  behavioural  Additional  i n t o the meaning of the c u r a t i v e  i n formal t h e r a p e u t i c treatment approaches  both i n d i v i d u a l s and  groups.  2. Q u a l i t a t i v e r e s e a r c h e r s the i n i t i a l  has  S t u d i e s of t h i s type w i l l enhance the  c u r r e n t knowledge of the l o n g i t u d i n a l nature of the and p s y c h o s o c i a l  the  phase of recovery  need t o focus more a t t e n t i o n on  when i n k l i n g s of change are  first  117 n o t i c e d by the i n d i v i d u a l w i t h an e a t i n g d i s o r d e r . f a c t o r s which l e a d t o the onset of b u l i m i a may  Although  be the  the  factors  i n v o l v e d i n r e c o v e r y , the r i c h n e s s and comprehensiveness of the i n f o r m a t i o n i s compromised i f the p r e c i p i t a t i n g f a c t o r s are d i s c u s s e d p r i o r t o a d d r e s s i n g the time when change was experienced.  S i n c e the nature of the p r e c i p i t a t i n g f a c t o r s or  t h e i r importance throughout of  first  i n m a i n t a i n i n g b u l i m i c behaviour may  change  the course of the e a t i n g d i s o r d e r , one a l t e r n a t i v e  way  s t u d y i n g the phenomenon i s t o begin the r e s e a r c h process a t  the p o i n t where the i n d i v i d u a l f i r s t became aware of change. Researchers must guard a g a i n s t the i n t e r f e r e n c e of  extraneous  v a r i a b l e s such as the p r e s u p p o s i t i o n t h a t the p r e c i p i t a t i n g f a c t o r s are o f t e n the f a c t o r s i n v o l v e d i n recovery as w e l l as p e r s o n a l b i a s e s towards s t o r i e s being t o l d i n a c h r o n o l o g i c a l fashion. 3.  The g e n e r a l i z a b i l i t y of the themes of the r e c o v e r y  experience needs t o be t e s t e d by r e p l i c a t i n g t h i s study with g r e a t e r numbers of recovered i n d i v i d u a l s and r e t u r n i n g t o them f o r v a l i d a t i o n of the themes.  Researchers may  not  r e c o v e r e d b u l i m i c males and i n d i v i d u a l s w i t h p r i o r  exclude concomitant  obesity. 4 . Researchers may  develop a survey q u e s t i o n n a i r e f o r both  c l i n i c a l and r e s e a r c h purposes which are f a c i l i t a t i v e  by u s i n g the themes as c a t e g o r i e s  of recovery i n order t o e x p l o r e the  meaning of the r e c o v e r y events i n more depth. may  be used t o h e i g h t e n c l i e n t s *  Such a c h e c k l i s t  awareness of r e c o v e r y  factors  and t o a l s o i d e n t i f y p o s s i b l e p a t t e r n s of r e c o v e r y r e l a t e d t o  118 p r o g n o s t i c i n d i c a t o r s such as age of onset, d u r a t i o n of e a t i n g d i s o r d e r , and  severity.  5. S i n c e l i t t l e consensus has been reached c o n c e r n i n g which treatment  i s most s u i t a b l e f o r the v a r i o u s subtypes  of b u l i m i a  (e.g., b u l i m i a complicated by substance abuse, o b s e s s i v e compulsive may  behaviour,  d e p r e s s i o n , or sexual abuse) more knowledge  be gained from f u r t h e r q u a l i t a t i v e s t u d i e s which i n t e r v i e w  i n d i v i d u a l s w i t h these a d d i t i o n a l p s y c h o l o g i c a l problems. & Pope, 1986; Summary and  (Hudson  Johnson & Connors, 1987).  Conclusions  The r e s u l t s of the present study p r o v i d e a more complete and holistic  understanding  of the s t r u c t u r e or p r o c e s s of recovery  from b u l i m i a and examine the s y n e r g e t i c e f f e c t of c u r a t i v e f a c t o r s both i n s i d e and o u t s i d e of formal therapy.  F u r t h e r , the  c a t e g o r i c a l themes c o n t r i b u t e t o a more comprehensive t h e o r e t i c a l c o n c e p t u a l i z a t i o n of the recovery process which i s l a c k i n g i n the c u r r e n t l i t e r a t u r e on recovery from b u l i m i a . knowledge of the i n i t i a l phase i n recovery  Specifically,  (i.e.,  " R e a l i z a t i o n of  E a t i n g Problem and Ambivalence About Change") i s extended theme d e s c r i p t i o n s .  The  f i n d i n g s a l s o underscore  o b s e r v a t i o n s which advocate  our  by the  clinical  the n e c e s s i t y of a m u l t i f a c e t e d and  i n d i v i d u a l i z e d approach t o treatment  i n which v a r i o u s t h e r a p e u t i c  approaches are i n t e g r a t e d i n order t o address both the b u l i m i c behaviours and the m u l t i p l e p e r p e t u a t i n g f a c t o r s 1987; 1989).  Johnson, Connors, & Tobin, 1987;  (Herzog e t a l . ,  Manley, 1989; S t e i g e r ,  In p a r t i c u l a r , t h i s study suggests t h a t the o b j e c t -  r e l a t i o n s approach may  be a u s e f u l model f o r understanding  the  119 importance o f f o c u s i n g on the i n t r a p e r s o n a l and p a t t e r n s of r e l a t i n g .  Techniques from the psychodynamic,  systems, and c o g n i t i v e - b e h a v i o u r a l implemented  interpersonal family  approaches can then be  t o address the b u l i m i c behaviours as w e l l as the  u n d e r l y i n g i n t r a p s y c h i c c o n f l i c t s , maladaptive p a t t e r n s of interaction, weight.  and d y s f u n c t i o n a l b e l i e f s about body shape and  120 References  American P s y c h i a t r i c A s s o c i a t i o n . (1980). D i a g n o s t i c and s t a t i s t i c a l manual of mental d i s o r d e r s (3rd e d . ) . Washington, DC: Author. 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The J o u r n a l of C l i n i c a l P s y c h i a t r y , 49(Suppl. 9), 18-25.  125 APPENDIX A DSM-III R (1987) D i a g n o s t i c C r i t e r i a f o r B u l i m i a Nervosa A.  Recurrent episodes of binge e a t i n g  ( r a p i d consumption  of a  l a r g e amount of food i n a d i s c r e t e p e r i o d of t i m e ) . B.  A f e e l i n g of l a c k of c o n t r o l over e a t i n g b e h a v i o r d u r i n g the eating binges.  C.  The person r e g u l a r l y engages i n e i t h e r  self-induced  v o m i t i n g , use of l a x a t i v e s or d i u r e t i c s , s t r i c t d i e t i n g or f a s t i n g , or v i g o r o u s e x e r c i s e i n o r d e r t o prevent weight gain. D.  A minimum average of two binge e a t i n g episodes a week f o r a t l e a s t t h r e e months.  E.  P e r s i s t e n t overconcern w i t h body shape and weight 69) .  (p. 68-  126 APPENDIX B DSM-III R (1987) D i a g n o s t i c C r i t e r i a f o r A n o r e x i a Nervosa A.  R e f u s a l t o m a i n t a i n body weight over a minimal normal weight f o r age and h e i g h t , e.g., weight l o s s l e a d i n g t o maintenance of body weight 15% below t h a t expected; o r f a i l u r e t o make expected weight g a i n d u r i n g p e r i o d o f growth, l e a d i n g t o body weight 15% below t h a t expected.  B.  Intense f e a r o f g a i n i n g weight o r becoming  f a t , even though  underweight. C.  D i s t u r b a n c e i n t h e way i n which one's body weight, s i z e , o r shape i s experienced, e.g., t h e person c l a i m s t o " f e e l f a t " even when emaciated, b e l i e v e s t h a t one area o f t h e body i s "too f a t " even when o b v i o u s l y underweight.  D.  I n females, absence o f a l e a s t t h r e e c o n s e c u t i v e menstrual c y c l e s when otherwise expected t o occur (primary o r secondary amenorrhea). amenorrhea  (A woman i s c o n s i d e r e d t o have  i f h e r p e r i o d s occur o n l y f o l l o w i n g hormone,  e.g., e s t r o g e n , a d m i n i s t r a t i o n . )  (p. 67)  127 APPENDIX C Pre-screeninq  Interview  Summary Sheet  Name: 1. D u r a t i o n  of eating  disorder  2. Primary e a t i n g d i s o r d e r symptoms  3. DSM-III R d i a g n o s i s  4. Current  s t a t u s r e : e a t i n g behaviour  5. Degree o f recovery  <  1 No Improvement  2 Slight Improvement  3 Moderate Improvement  4 Major Improvement  >  5 Profound Improvement  6. Length o f recovery  7. Other a c t i v e p s y c h o l o g i c a l problems ( i . e . , substance abuse, mood d i s o r d e r , a n x i e t y d i s o r d e r , e t c . )  128 APPENDIX D Contact L e t t e r t o  Research Study: Dear  Recovery from  Counsellor/Therapist  Bulimia  Counsellor/Therapist:  As a graduate student i n the C o u n s e l l i n g Psychology Department at the U n i v e r s i t y of B r i t i s h Columbia, I am conducting a r e s e a r c h p r o j e c t f o r my master's t h e s i s on recovery from b u l i m i a . This study w i l l be b e n e f i c i a l i n c o n t r i b u t i n g t o the development of a c l i n i c a l approach t o t r e a t i n g b u l i m i a . I am i n t e r e s t e d i n i n t e r v i e w i n g t h r e e i n d i v i d u a l s who meet the following c r i t e r i a : (a) a p r e v i o u s d i a g n o s i s of b u l i m i a nervosa as d e f i n e d by the DSM-III R (1987) with no h i s t o r y of anorexia nervosa; (b) a s i g n i f i c a n t p e r i o d of time without any symptoms of b u l i m i a ; (c) no s i g n i f i c a n t i n d i c a t o r s of other a c t i v e p s y c h o l o g i c a l problems; (d) s e l f - r e p o r t e d f e e l i n g , o f no s p e c i f i c time p e r i o d , of being genuinely recovered from b u l i m i a ; and (e) an a b i l i t y t o a r t i c u l a t e t h e i r i n s i g h t s and e l a b o r a t e on t h e i r descriptions. I n d i v i d u a l s may r e f u s e t o p a r t i c i p a t e or withdraw from the study at any time without j e o p a r d i z i n g any p o t e n t i a l f u t u r e treatment. A l l i n f o r m a t i o n i s c o n f i d e n t i a l and data w i l l be presented anonymously. I n i t i a l l y , p o t e n t i a l p a r t i c i p a n t s w i l l be screened i n an unrecorded i n t e r v i e w a t S t . Paul's H o s p i t a l , Vancouver, B.C. by Dr. E l l i o t Goldner who i s a p s y c h i a t r i s t and e a t i n g d i s o r d e r expert. He w i l l ask each i n d i v i d u a l t o recount the development of her e a t i n g problems/symptoms, her weight and medical h i s t o r y , and her c u r r e n t e a t i n g behaviour. Then, i n an u n s t r u c t u r e d , audiotaped i n t e r v i e w with myself, each p a r t i c i p a n t w i l l be asked t o d e s c r i b e the events which p r e c i p i t a t e d the onset of her b u l i m i a and t o t e l l her s t o r y of recovery. Other r e l e v a n t p e r s o n a l documents ( i . e . j o u r n a l s ) may be used. In a d d i t i o n , each i n d i v i d u a l and myself w i l l meet s e v e r a l a d d i t i o n a l times i n order t o v e r i f y the t r a n s c r i b e d i n t e r v i e w , themes, and f i n a l n a r r a t i v e account. A t o t a l time commitment of approximately f i v e t o seven hours w i l l be r e q u i r e d . I f you have any q u e s t i o n s about the study or i n d i v i d u a l s who you f e e l would be i n t e r e s t e d i n c o n t r i b u t i n g t o a deeper understanding of the process of r e c o v e r i n g from b u l i m i a , p l e a s e c o n t a c t me a t the above address/phone number. Thank you f o r your time and i n t e r e s t . Sincerely, L a u r i e Truant  129 APPENDIX E Contact L e t t e r t o V o l u n t e e r  Research Study:  Recovery  from B u l i m i a  Dear V o l u n t e e r : As a graduate student i n the C o u n s e l l i n g Psychology Department a t the U n i v e r s i t y of B r i t i s h Columbia, I am i n t e r e s t e d i n g a i n i n g a deeper understanding of the process of r e c o v e r i n g from b u l i m i a . T h i s study w i l l be b e n e f i c i a l i n c o n t r i b u t i n g t o the development of a c l i n i c a l approach t o t r e a t i n g b u l i m i a . Your p a r t i c i p a t i o n i n t h i s study i s e n t i r e l y v o l u n t a r y and you can r e f u s e t o p a r t i c i p a t e or withdraw from the study a t any time without j e o p a r d i z i n g any p o t e n t i a l f u t u r e treatment. A l l i n f o r m a t i o n i s c o n f i d e n t i a l and data w i l l be presented anonymously. I f you had a p r e v i o u s d i a g n o s i s of b u l i m i a with no h i s t o r y of a n o r e x i a nervosa, c u r r e n t l y f e e l g e n u i n e l y recovered and w i l l i n g t o d i s c u s s your i n s i g h t s i n t o what f a c i l i t a t e d your r e c o v e r y , I would enjoy speaking f u r t h e r w i t h you. Your i n i t i a l p a r t i c i p a t i o n i n the study w i l l i n v o l v e an unrecorded p r e - s c r e e n i n g i n t e r v i e w a t S t . Paul's H o s p i t a l , Vancouver, B.C. w i t h Dr. E l l i o t Goldner who i s a p s y c h i a t r i s t and e a t i n g d i s o r d e r e x p e r t . He w i l l ask you t o recount the development of your e a t i n g problems/symptoms, your weight and medical h i s t o r y , and your c u r r e n t e a t i n g behaviour. Then, i n an u n s t r u c t u r e d , audiotaped i n t e r v i e w w i t h myself, you w i l l be asked to d e s c r i b e your r e c o v e r y experience and make use of o t h e r r e l e v a n t p e r s o n a l documents. In a d d i t i o n , we w i l l meet s e v e r a l a d d i t i o n a l times i n o r d e r t o v e r i f y the t r a n s c r i b e d i n t e r v i e w , themes, and f i n a l n a r r a t i v e account. The t o t a l time commitment w i l l be approximately f i v e t o seven hours. I hope t h a t you w i l l f i n d your p a r t i c i p a t i o n i n t h i s study i n t e r e s t i n g and t h a t the i n f o r m a t i o n w i l l be b e n e f i c i a l both t o you and t o o t h e r women s t r u g g l i n g t o overcome b u l i m i a . I f you have any q u e s t i o n s about the study or would l i k e t o p a r t i c i p a t e , p l e a s e c o n t a c t me a t the above address/phone number. Thank you f o r your time and i n t e r e s t . Sincerely, L a u r i e Truant  132 APPENDIX H L.S.'s P r o t o c o l L.S.  L.T.  O.K. So you want me t o , so what I w i l l do i s s t a r t with, um, t h e onset and t r y and be q u i t e b r i e f about t h e onset and development of, o f t h e b u l i m i a , and c o n c e n t r a t e on the recovery. M-hm.  L.S.  I t , I t h i n k i t f i r s t began when I was about 18, 17 o r 18 i n h i g h s c h o o l and r e a l l y progressed uh q u i t e d r a m a t i c a l l y when I went away from, f o r u n i v e r s i t y when I was 18 years old. And a f t e r um, my second year o f u n i v e r s i t y — t h a t would have put me about 2 0 years o l d I g u e s s — I d i d uh go, I d i d f i n a l l y a t t h a t p o i n t r e a l i z e d t h e r e was something very, very much wrong. And I went, when I was home f o r the summer, I went t o um a p s y c h i a t r i s t who was a f r i e n d of my f a t h e r f o r some therapy.  L.T.  How d i d you know t h a t something was r e a l l y wrong? made you t h i n k t h a t a t t h e time?  001  L.S.  002  What  Well, I guess i n s i d e I'd always known t h a t something was very wrong. But the, those 2 y e a r s o f u n i v e r s i t y saw a very steady um p r o g r e s s i o n o f i t [bingeing and purging] such t h a t by t h e end o f my second year I j u s t b a r e l y f i n i s h e d t h e year. You know, I guess I had t o reach a p o i n t where I'd r e a l l y h i t bottom t o r e a l i z e t h a t t h i s [bingeing and purging] was probably t h e cause i n t h a t these a c t i v i t i e s were, were becoming t h e most important f a c t o r i n my l i f e . Uh, t h i s , t h i s s o r t o f t h i n g had taken over my l i f e and t h a t i n order t o continue doing anything I had t o address i t . Um, but I s t i l l , I don't t h i n k I was s t i l l y e t a t the p o i n t o f t r u l y being able t o work through i t . L i k e I wanted t h i s t h i n g t o go away, I wanted t o be O.K., but I d i d n ' t r e a l l y want t o put i n t o i t what I knew I would have t o . Because on one l e v e l , I t h i n k I understand very w e l l t h a t t h e b u l i m i a i t s e l f , i t was j u s t a s e t o f symptoms, t h a t t h e r e were, t h e r e were deeper t h i n g s t h a t were r e a l l y causing a l l o f t h a t . Um, so.  L.T.  And, and how d i d you have t h a t awareness? Had you read anything, o r t a l k e d with other people, o r what made you think that?  L.S.  To know t h a t I had b u l i m i a ?  133 L.T.  No, t o , t o , um make you aware t h a t t h e r e may have been i s s u e s u n d e r l y i n g i t ? How d i d you know about i t ?  003  L.S.  L.T.  O.K.  004  L.S.  Well, I've always been um, not very happy w i t h myself, not very secure i n myself, and always eager t o p l e a s e others and t o be l e d by o t h e r s without much confidence myself. And, so i n some ways I o f t e n f e l t as i f I weren't i n c o n t r o l o f my l i f e anyway. Um, but t h i s [bingeing and purging] j u s t was l i k e a, a, t h a t aspect i n t e n s i f i e d a hundred times.  So I guess I k i n d o f knew t h a t uh i t [bingeing and purging] wasn't j u s t a, a way t o c o n t r o l weight: t h a t the f a c t t h a t I was i n v o l v e d with t h i s meant, meant something more. I mean I knew t h a t i t was, i t wasn't j u s t t h e f a c t t h a t I would e a t and vomit. There was a, t h e r e was a reason f o r t h a t , somehow, beyond j u s t wanting not t o be f a t again. And I t h i n k , I r e a l i z e d t h a t i t was um, i n some way connected t o my f e e l i n g s about myself and my l a c k of, o f r e a l l y f e e l i n g o f c o n t r o l over myself, o r wanting t o have c o n t r o l , o r f e e l i n g t h a t I was worth um having c o n t r o l on so I c o u l d make something out of my l i f e . And t h e r e were other f a c t o r s i n those 2 y e a r s o f u n i v e r s i t y t h a t have i n t e n s i f i e d i t i n t h a t I was i n a r e l a t i o n s h i p t h a t wasn't, t h a t wasn't a good one, um and I l e t myself be c o n t r o l l e d by t h a t person too. So you see they almost, as t h a t r e l a t i o n s h i p progressed so d i d t h e c o n d i t i o n . So t h e r e were a l o t o f f a c t o r s s o r t o f p o i n t i n g i n t h e same d i r e c t i o n t h a t I had t o uh, I knew I had t o t r y and touch base with, with myself i n some ways.  But a t t h a t p o i n t , I wasn't ready t o t a l l y t o do t h a t . I was s t i l l so concerned about running away from i t a l l , you know. L.T.  Cause i t was p r e t t y overwhelming. You knew t h a t something was wrong and you had a keen sense t h a t you'd have t o do some work and d e a l w i t h t h e u n d e r l y i n g t h i n g s .  L.S.  Very hard work. Yah. But, so t h a t ' s I was very u n c l e a r about i t a l l but I knew t h a t t h e r e was something very wrong.  L.T. L.S.  M-hm. But I wasn't r e a l l y a b l e t o admit t o myself. I mean as I say on one l e v e l I knew i t was me, t h e r e was something w i t h me t h a t would cause t h i s whole t h i n g t o develop i n the f i r s t p l a c e . But I guess I wasn't r e a l l y ready i n  134 some way t o d e a l with t h a t . So I went f o r a p e r i o d o f t i m e — i t was o n l y about a m o n t h — t o see t h i s guy. And I'd see him on a d a i l y b a s i s . And i t was funny because i t was t r e a t e d I t h i n k more as anorexia than b u l i m i a . L.T.  Now t h i s was a p s y c h i a t r i s t , a f r i e n d o f your  father?  L.S.  My f a t h e r ' s : i n t h e medical f a c u l t y o f t h a t u n i v e r s i t y and he was t h e head o f P s y c h i a t r y t h e r e .  L.T.  M-hm. And so how, how d i d i t happen t h a t you were connected w i t h t h i s p s y c h i a t r i s t then l i k e ?  L.S.  Through my f a t h e r . I, I t o l d my p a r e n t s t h a t t h e r e , I was, I was e x p e r i e n c i n g some, some problems, some emotional problems. I d i d n ' t , up u n t i l t h a t p o i n t , I d i d n ' t t a l k t o them about any k i n d o f e a t i n g d i s o r d e r and I d i d n ' t know whether o r not they were aware o f one. And I t o l d them I r e a l l y needed t o t a l k t o somebody, and so they recommended uh Dr. C. t o me. And so I went and saw him. And I s t a r t e d out by d e s c r i b i n g a l l t h e surrounding t h i n g s such as I would, you know, I c o u l d n ' t keep t h i n g s together, I couldn't f i n i s h things. And then very s h o r t l y I t o l d him t h a t , you know, I would, I would e a t and throw up. But I d i d n ' t know what i t was a l l about, I couldn't put a name on i t . But I t h i n k he t r e a t e d i t more as anorexia because I was q u i t e underweight a t t h a t time. So we t a l k e d a l o t about uh body image, and weighing i n and t h a t k i n d o f s t u f f , r a t h e r than um t a l k i n g about t h e reasons why t h i s would have developed i n t h e f i r s t p l a c e . W e l l , we d i d t a l k about body image and s e l f - i m a g e and stuff. But t h e focus was as much on s o r t o f behaviour m o d i f i c a t i o n i n terms o f e a t i n g and f o r c i n g myself t o e a t and keep i t down, than on r e a l l y d i g g i n g t h i n g s up. So t h a t combined w i t h t h e f a c t t h a t I d i d n ' t t h i n k , you know, t h e r e ' s a p a r t o f me t h a t d i d n ' t want t o d i g i t up, I t h i n k made i t , made f o r i t t o be u n s u c c e s s f u l . And I pretended t h a t i t was and t h a t t h i n g s were b e t t e r .  L.T.  Pretended t h a t t h i n g s were s u c c e s s f u l ?  L.S.  M-hm. T e l l i n g him t h a t t h i n g s were d e f i n i t e l y g e t t i n g better. He had p r e s c r i b e d a mood s t a b i l i z e r o r e l e v a t o r — I f o r g e t what i t w a s — t o me uh which I took f o r a p e r i o d and d i s c o n t i n u e d . Uh, but I had, I had another goal f o r t h a t summer. I was always I guess l a t c h i n g onto t h i n g s t h a t I would do, and i n doing t h i n g s and a c h i e v i n g g o a l s s e t f o r me by these t h i n g s and these people t h a t was how I d e f i n e d myself. And t h e g o a l o f t h a t summer was t o go t o a — I was s t u d y i n g R u s s i a n — i t was t o go t o a S l a v i c i n s t i t u t e i n B.I. which i s very, was very w e l l - r e s p e c t e d and was a very, s o r t o f i t would have been a "good f e a t h e r i n my hat." So I r e a l l y had a focus o f g e t t i n g t h i s t h i n g out o f t h e way so I c o u l d do i t . And t h e r e was some  135 q u e s t i o n by Dr. C. as t o whether i t would be good t o undertake t h a t a t t h i s time. But, "Oh no, t h i n g s were g e t t i n g b e t t e r and I'm sure, you know, I'm sure I c o u l d . " And i t was a way o f jumping from t h e work t h a t I knew I had t o do on myself t o again i n t o another um e x t e r n a l uh s e t o f e x p e c t a t i o n s t h a t I c o u l d meet and t h e r e f o r e g e t p o s i t i v e reinforcement. L.T.  Can you t e l l me a b i t more about t h e s e s s i o n s t h a t you had w i t h him. As you t h i n k back, what, what were they l i k e f o r you?  L.S.  You know i t ' s funny. I don't know i f t h i s happens with, w i t h everybody o r with many people who have been i n v o l v e d with t h i s k i n d o f behaviour but I f i n d my memory i n some ways i s very sketchy. I t ' s as i f I've, I l o s t about 4 years t h e r e . And so o f t e n when I t h i n k back I have f l a s h e s but I don't, I don't see much c o n t i n u i t y i n t h e r e . And T don't know i f t h a t was a l i k e a s e l f - d e f e n s e mechanism because t h i n g s were so t e r r i b l e f o r so long o r if. I don't know um. In any event, so what I'm going t o say about t h e s e s s i o n s I know i s not complete but i t ' s what I remember o f them.  L.T.  M-hm, sure. And t h a t ' s a l l t h a t , t h a t you know, i s important r e a l l y and s i g n i f i c a n t t o you w i l l probably be t h i n g s t h a t you remember: t h e s i g n i f i c a n t t h i n g s .  L.S.  But I guess what I'm a l s o s a y i n g i s t h a t t h e r e ' s a l o t t h a t I mean people w i l l t a l k about d u r i n g say those u n i v e r s i t y years t h a t I w i l l have no r e c o l l e c t i o n o f a t all. That's a very funny t h i n g . Um, t h e s e s s i o n s were, I, I would go i n t o h i s o f f i c e , i t was one on one, and we would, we would t a l k . And what I l i k e d about i t and what I.  005  I t was a s i m i l a r element t o t h e other s e s s i o n s o f therapy t h a t I underwent here i n V . — t h a t I t h i n k d i d h e l p me um overcome t h i s — w a s t h a t i n l o o k i n g a t i t as we went on I saw t h a t very o f t e n he was j u s t a l l o w i n g me t o put t h i n g s out and he would arrange them so t h a t I c o u l d see a c t u a l l y what I was s a y i n g and t h i n k i n g . So he was very good about not t r y i n g t o impose um h i s own ideas on me, r a t h e r making suggestions t h a t , upon r e f l e c t i o n , would have been apparent i n what I s a i d . So i t was very much a way of um, o f o f j u s t a i r i n g , a i r i n g myself and a l l o w i n g myself t o look a t myself. You know, i t was j u s t , i t was s o r t o f a s e l f - e x a m i n a t i o n t h i n g . We would weigh i n um, because as I s a i d t h a t was an important t h i n g , i t seemed an important t h i n g from h i s standpoint. And he d i d s e t a c e r t a i n weight, and I f o r g e t what i t was, t h a t were I t o d i p below t h a t t h a t they might  136  c o n s i d e r h o s p i t a l i z a t i o n e t c e t e r a and what went on d u r i n g the enforced h o s p i t a l i z a t i o n . Um he d i d , he O.K., so we would weigh i n and i t was the, t h e e x p e c t a t i o n was t h a t I would be g a i n i n g a c e r t a i n amount o f weight p e r week which I never r e a l l y f i l l e d . I remember a t the, a t , I mean as the s e s s i o n s ended, as my date f o r l e a v i n g a p p r o a c h e d — a n d I was very anxious t o make sure t h a t e v e r y t h i n g seemed t o be hunky-dory from h i s a s p e c t — I was coming up f o r a period. And so I gained 5 l b and I never t o l d him t h a t you know. But t h a t was seen as being a success. So I was r e a l l y t r y i n g t o um h i d e t h e f a c t t h a t t h i n g s weren't g e t t i n g t h a t much b e t t e r . L.T.  M-hm. So towards t h e end then you gained a whole bunch o f weight so t h a t you c o u l d say t o him and maybe t o y o u r s e l f t h a t , "Hey, I've succeeded a t t h i s , t h i s b i t o f therapy."  L.S.  M-hm. But i t was a f a l s e g a i n . I mean I l o s t t h a t r i g h t . That was j u s t because o f t h e water r e t e n t i o n from t h e period. And, I mean, I knew t h a t very w e l l but I d i d n ' t t e l l him. But um, so i t would be l a r g e l y devoted t o t a l k i n g about myself and I t h i n k my f a m i l y . I don't have much r e c o l l e c t i o n o f e x a c t l y what we t a l k e d about. This was i n 1978 so i t ' s q u i t e a w h i l e ago. Um, he d i d n ' t p r e s c r i b e any r e a d i n g o r um anything o f t h i s nature. No, t h e r e wasn't any support group o r anything o f t h a t t h a t should've went on. And a l s o , I t h i n k t h e f a c t t h a t i t wasn't s t r e s s e d t h a t I take t h i s o u t s i d e o f t h e o f f i c e I t h i n k had something t o do w i t h i t because t h e r e f o r e I c o u l d keep i t again s o r t o f as my s e c r e t . And as long as I d i d n ' t have t o l e t anybody i n on i t then I wasn't faced w i t h any other m o t i v a t i o n than my own t o work on i t . For example, I c o u l d s t i l l be a home w i t h my p a r e n t s and s t i l l go through you know b i n g e i n g and purging c y c l e s because as long as I c o u l d f o o l myself i n t o b e l i e v i n g t h a t they d i d n ' t know about i t , I c o u l d g e t away w i t h i t .  L.T.  Because i t was j u s t between you and t h e p s y c h i a t r i s t and.  L.S.  Uh-huh.  L.T.  So t h a t was O.K. t o have i t t h a t way.  L.S.  And i t ' s an i n t e r e s t i n g t h i n g because i f you um, i f you i n t e n t i o n a l l y overeat d u r i n g a m e a l — a n d i t ' s very easy t o do a t a f a m i l y meal when someone e l s e i s paying f o r t h e food and i t ' s a l l t h e r e — a n d then you have t o go t o t h e bathroom soon afterwards, you know i f they're aware o f what's going on then should you somehow happen t o overeat, even i f you weren't t r y i n g t o you c o u l d n ' t , t h a t escape v a l v e wouldn't be open t o you. Because i t would be very d i f f i c u l t t o go through t h a t when you knew t h a t they knew.  L.T.  Right.  Uh-huh.  137 L.S.  You know so i t was almost as i f i t l e f t me an "out"; i f I d i d n ' t go through w i t h i t and and r e a l l y overcome i t , I c o u l d s t i l l continue i t which i s I t h i n k what I wanted t o do.  L.T.  And so your p a r e n t s a t t h i s time then a r e not aware t h a t you're b i n g e i n g and purging. They j u s t know t h a t t h e r e ' s some emotional problem as you had t o l d them?  L.S.  I t h i n k t h a t — I can't remember—I t h i n k t h a t I d i d t e l l them t h e r e was an e a t i n g d i s o r d e r i n v o l v e d . I p r e t t y sure I d i d . But I know I d i d n ' t go i n t o any d e t a i l about i t w i t h them. I, they may have thought i t was anorexia, they may w e l l have known e v e r y t h i n g and I j u s t d i d n ' t want t o admit t h a t . But I know we d i d n ' t , I d i d n ' t i n v o l v e my p a r e n t s i n terms o f s i t t i n g down and saying, "Look t h i s i s what's going on, t h i s i s what has been going on, and t h i s i s what I'm working on." That never o c c u r r e d .  L.T.  So, t h e bottom l i n e i s t h a t you f e l t they r e a l l y d i d n ' t know e x a c t l y what you were doing and so t h e r e f o r e .  L.S.  That's r i g h t .  L.T.  I t was s t i l l  L.S.  So, so when I went t o t h i s program, t h i n g s were b e t t e r . A c t u a l l y t h a t was, a t l e a s t I'd faced up t o t h e f a c t t h a t I had a problem, t h a t i t was an i d e n t i f i a b l e problem, and t h a t I knew I needed t o work on i t more.  L.T.  What, j u s t before you move i n t o t h e program, what happened at t h e end o f therapy then? And, and a l s o how long were you, you s a i d you were going every day but I wasn't sure f o r how long?  L.S.  I t h i n k I went d a i l y and then we dropped i t back t o maybe every other day o r something. I t was about a p e r i o d o f 6 weeks, perhaps t o 2 months, because as I remember t h e program was t h e l a s t month o r so o f t h e summer and I was home s i n c e May. So i t would have been w i t h i n 2 months a t any r a t e .  L.T.  That was f a i r l y i n t e n s i v e then going everyday and then every second day f o r about 6 weeks.  L.S.  M-hm. Maybe we dropped i t back t o once a week. are t h e d e t a i l s I can't remember.  L.T.  M-hm.  L.S.  M-hm.  a s e c r e t between you and t h e p s y c h i a t r i s t .  Well t h a t ' s  O.K.  See these  138 L.T. L.S.  Um, but i t sounds l i k e the b e g i n n i n g p a r t was i n t e n s i v e anyways f o r you.  quite  Yes.  L.T.  And i n terms of your e a t i n g , what s o r t of t h i n g s d i d you d i s c u s s with him and how d i d you implement them or d i d you implement them?  L.S.  W e l l , I. What I remember of i t i s t h a t um, I don't remember r e a l l y d i s c u s s i n g what b i n g e i n g was a l l about, l i k e you know j u s t the awful d e t a i l s t h a t I t h i n k i t ' s important t o get out when you're t r y i n g t o d e a l w i t h i t . Um, I do remember you know t a l k i n g about w r i t i n g down a d a i l y l i s t of say what you were going t o eat and w r i t i n g down what you had eaten, almost as a d i e t e r does. Or um, I t h i n k we were l o o k i n g a t i t i n the r e v e r s e p e r s p e c t i v e of a person who i s t r y i n g to put on weight so t h a t e a t i n g should be a conscious process um, r a t h e r than d i c t a t e d by j u s t y o u r s e l f , t h a t you'd a c t u a l l y p l a n i t out. I don't remember much more beyond t h a t .  L.T.  And so d i d you menu plans?  L.S.  W e l l , I t h i n k I d i d h a l f - h e a r t e d l y , but I d i d n ' t r e a l l y do i t c a r e f u l l y . Again I was, I was k i n d of sabotaging i t I t h i n k from the b e g i n n i n g .  L.T.  And so you may have done these meal plans but continued on w i t h the behaviour.  L.S.  Yes, I probably would have, I t h i n k I probably would l i e t o him.  L.T.  M-hm. So you were able t o m a i n t a i n your weight a t the l e v e l i t was by c o n t i n u i n g on with the purging and not e a t i n g a whole l o t .  L.S.  That's r i g h t . I don't t h i n k , a f t e r I dropped i n i t i a l l y the the very f i r s t semester I t h i n k I was away, um, I don't t h i n k my weight continued t o go down below t h a t . I was d e f i n i t e l y underweight although I d i d n ' t see myself as being t h a t way. L i k e i t was s t i l l l u d i c r o u s f o r me t o hear Dr. C. t a l k about me as being t h i n or anybody t a l k i n g about being t h i n . And I do remember a comment he made a s k i n g me why. He t a l k e d , I remember t h i s , he t a l k e d a l o t about body image i n the sense of being proud t o be s t r o n g , and you know how a b e a u t i f u l body was a um, a s t r o n g one and not an emaciated one. And a s k i n g me about um why I would wear s o r t of baggy c l o t h e s . And of course the reason why I wore them because, was because I was overweight. And h i s suggestion t h a t I wore them t o hide how t h i n I was, I never could, I c o u l d not accept t h a t .  do those t h i n g s and  s i t down, l i k e make up  still  low  139 L i k e I never b e l i e v e d t h a t I was t h i n enough t o want t o h i d e i t , hide my s t a t e . So t h a t , I was s t i l l o p e r a t i n g from a p e r s p e c t i v e o f being overweight and being ashamed of myself because I was overweight. But I do remember h i s t a l k i n g about um one's image of, o f t h e way other people look. And t h a t beauty being um a, a w e l l - p r o p o r t i o n e d body, and a f i t body, and not j u s t t r y i n g t o a c h i e v e thinness. And I do, another t h i n g I do remember h i s t a l k i n g about, we must've t a l k e d about, I, I know we d i d , we t a l k e d about um my l a c k o f i d e n t i t y and my i n s e c u r i t y and such. And he was t a l k i n g about, um, almost being able t o see t h a t on a person's face, l i k e how formed t h e person's face was. L.T.  How?  L.S.  How formed and how much c h a r a c t e r would come out. And the f a c t t h a t um he thought t h a t towards t h e end o f t h e s e s s i o n s t h a t my face looked b e t t e r . I t h i n k , I mean he was probably r i g h t . I t h i n k I probably had, you know, made progress d u r i n g t h a t time but j u s t was not a l l o w i n g i t t o go f u r t h e r than I wanted i t t o go.  L.T.  M-hm. You f e l t s a f e t o t h e p o i n t t h a t you had gone and d i d n ' t want t o progress beyond t h a t .  L.S.  That's r i g h t , yes, y e s . I t h i n k t h a t ' s probably what i t was.  L.T.  So you're f e e l i n g overweight i n s p i t e o f t h e f a c t o f him t e l l i n g you t h a t you're underweight. And d i d , d i d h i s s o r t o f comments about what a f i t body was l i k e , how d i d they impact on you a t the time?  L.S.  W e l l , i n a sense o f t h e r e ' s always s e l f and o t h e r s . Like I c o u l d look a t another person and say, "yah, t h a t person i s a b e a u t i f u l person." But I c o u l d never accept myself as I suppose ever having t h e hope o f being a b e a u t i f u l person.  L.T.  Who, who would be b e a u t i f u l people t o you then?  L.S.  Then?  L.T.  Yah.  L.S.  Oh, t h e t r a d i t i o n a l , you know, people t h a t a r e h e l d up as supposedly b e a u t i f u l , you know: models and movie s t a r s and t h a t k i n d o f t h i n g . You know, you always I t h i n k , p a r t o f t h e problem i s comparing y o u r s e l f t o an u n r e a l i s t i c goal. L i k e I would never take myself and say, " w e l l , how c o u l d I make myself beaut?" You know, I j u s t had t h i s idea o f a very, you know, s e l f - l o a t h i n g . And I t h i n k , i n some ways, perhaps some o f t h i s i s almost l i k e  140 p u n i s h i n g y o u r s e l f , you know, because t h e r e i s nothing about you t h a t you l i k e both i n s i d e and out. So my um, the only way I f e l t approval towards myself, towards my p h y s i c a l appearance, was l i k e not t o have any tummy. You know, i f t h e r e was any bulge t h e r e i t r e a l l y upset me. Um, so yes I c o u l d see beauty i n others but I c o u l d , I c o u l d n ' t apply t h a t t o myself. I remember my mother when I was b a c k — I suppose t h e f i r s t time I was back a t Christmas when I had dropped so much w e i g h t — s a w me without my c l o t h e s on and l a t e r on she s a i d t h a t she l a t e r on b u r s t i n t o t e a r s because I looked l i k e someone from Dachau o r something. And o f course I d i d n ' t f e e l t h a t way. I f e l t "Gee, you know t h i s i s , I'm so much b e t t e r than I used t o be; I'm not f a t . " So t h e r e was a complete d i s t o r t i o n there. L.T.  D i d your mom ever make any comments t o you a t t h e time?  L.S.  When I f i r s t , t h e f i r s t Christmas I t h i n k everyone was q u i t e concerned, although I wasn't r e a l l y aware o f i t . I know my o l d e r b r o t h e r was i n medical s c h o o l then and had s a i d something about anorexia t o my mother, l o o k i n g a t me. And I know t h a t my mother was s o r t o f appearing a t my elbow w i t h l i t t l e snacks and s t u f f which, i n my mind as as c h i l d , as an overweight c h i l d and always f e e l i n g t h a t food was h e l d back, was a wonderful sense o f my mother b r i n g i n g me food. You know, so I t h i n k i t , i t , some o f i t I t h i n k a l s o was was a d e s i r e f o r a t t e n t i o n and, and, and being mothered and a l l t h a t , being taken care o f . You know knowing on some l e v e l t h a t I was s i c k and i f I c o u l d show i t t o others then they would take care o f me.  L.T.  So i t f e l t good i n f a c t t h a t your mom a t t h a t Christmas knew what a low weight, was b r i n g i n g you food, t h a t you found t h a t q u i t e a c c e p t a b l e .  L.S.  Oh yes! And a l s o t o be t o l d t h a t I was t h i n . that! I j u s t loved t h a t !  L.T.  M-hm. Cause when you were young you s a i d you were overweight, r i g h t .  L.S.  Yes.  L.T.  What do you mean by overweight?  L.S.  Never obese but I was q u i t e chubby. And up u n t i l about the summer a f t e r Grade 8, I l o s t weight. And I, and I, upon l o o k i n g a t p i c t u r e s o f myself a f t e r t h a t p o i n t , I can see t h a t I r e a l l y wasn't overweight. I was j u s t a b i t l a r g e . Um, so again my, my self-image was a l r e a d y s t a r t i n g t o become d i s t o r t e d a t t h a t time. And I t h i n k my i d e a l would have been t o have been a small f r a g i l e person  I loved  141 r a t h e r than t h e l a r g e um, I guess h e a l t h y l o o k i n g person. I remember my f a t h e r , when oh gosh, Grade 7 o r Grade 8, t a k i n g me t o one o f those l i t t l e dances they have and a s k i n g him um, "Dad do you t h i n k I ' l l ever be p r e t t y , o r do you t h i n k I'm p r e t t y now?" And he's a, a very honest person, l i k e i t ' s not i n h i s c h a r a c t e r t o l i e . And he, h i s answer was, "Well, I t h i n k you w i l l have a k i n d o f Brune H i l d a type o f beauty, l a r g e and s t r o n g . " And o f course t h a t was, t h a t stayed w i t h me as being t h e a n t i t h e s i s o f what I wanted you know. So, yes my mother commented um, not very much though. L i k e she would say, and I would say on o c c a s i o n d u r i n g those y e a r s when I was so underweight, she would say t h i n g s um i n a very s o r t o f sad way. But I t h i n k she d i d n ' t want t o l e t me know o r d i d n ' t , I don't know i f she d i d n ' t know what t o say o r thought t h a t h e r i n t e r f e r e n c e would be negative o r what, but she d i d n ' t l i k e , you know, s i t me down and say I need t o t a l k t o you about t h i s . Maybe i t was s e l f - d e n i a l on h e r p a r t , I don't know. In any event, she d i d n ' t say anything being underweight. As I s a i d , l i t t l e t h i n g s but not, d e a l about i t . M-hm.  t o you about your  she wasn't making a b i g  O.K.  Or maybe i t ' s a f a c t t h a t i f she were t o have s a i d anything, I would i n t e r p r e t t h a t as a compliment. And I don't remember t h a t now. She repeated t o me something my l i t t l e b r o t h e r s a i d um upon seeing me a t t h e a i r p o r t . He s a i d , "Oh, h e r hands look l i k e claws, you know, she's so thin." And I remember her s a y i n g t h a t t o me t h a t he had said that. M-hm. And a t t h e time you took t h a t as a compliment o r something t h a t you loved. Oh I l i k e d i t . And s t i l l I liked i t .  they d i d n ' t mean i t as such, but  Right. J u s t when you t h i n k back t o your i d e a l image o f someone being r e a l l y t h i n , where, where do you f e e l you got t h a t s o r t o f i d e a l image from? Cause your dad had s a i d t h a t he, sounds l i k e t h a t he r e a l l y l i k e d people who were s t r o n g e r and bigger, so I'm wondering where t h a t came from f o r you? Well, I t h i n k probably a m u l t i t u d e o f p l a c e s . I think t h a t f o r , I tend t o b e l i e v e i n a person having a, a c e r t a i n c h a r a c t e r , a c e r t a i n element o f c h a r a c t e r t h a t ' s c o n s i s t e n t throughout t h e i r l i f e . So I t h i n k i f a c h i l d ,  142 and I don't t h i n k I every r e a l l y was a v e r y c o n f i d e n t c h i l d e i t h e r : In some ways I was, s o c i a l l y I never was. So I t h i n k i f you take t h a t c h a r a c t e r and then you have something t h a t makes t h a t c h i l d uh f e e l more d i f f e r e n t , the c h i l d w i l l always i n t e r p r e t i t i n a n e g a t i v e way. So t h a t , you know, going through t r y i n g t o d i e t as a young, not as a young c h i l d b u t you know, i t was always an i s s u e t h a t L. was a b i t overweight and she should t r y and work on i t . I t h i n k t h a t had something t o do with i t . But I t h i n k even more i m p o r t a n t l y um was t h e f a c t , t h e whole media g l o r i f i c a t i o n o f them, o f t h e p e r f e c t woman. And i t was d u r i n g t h e time o f Twiggy r e a l l y and t h a t whole image. So everywhere you look, you see e x a c t l y what i s beautiful. And i f you're not a person t o b e l i e v e i n o n e s e l f and look a t o n e s e l f and f i n d beauty i n o n e s e l f , then t h a t ' s what you're going t o l a t c h onto again a r e e x t e r n a l images. And o f course you know, t h e teenage and preteen years, everybody i s t r y i n g t o achieve t h a t look. So t h e people t h a t you r e s p e c t around y o u — y o u r p e e r s — a l l look more o r l e s s l i k e t h a t too. So I t h i n k from t h e f a m i l y , from your own f e e l i n g o f i n s e c u r i t y , and from the media. I would say those a r e t h e t h r e e b i g areas. L.T.  O.K. So your i d e a l image then i s o f someone who's r e a l l y thin. And even though t h e p s y c h i a t r i s t had t o l d you t h a t he f e l t t h a t people c o u l d be b e a u t i f u l with a b i g g e r body t h a t , you know, and a w e l l - p r o p o r t i o n e d body, somehow you o n l y h a l f b e l i e v e d him o r .  L.S.  W e l l , no. I b e l i e v e d him. I mean I c o u l d see a p i c t u r e of someone overweight, underweight, and r e a l i z e t h a t person was not b e a u t i f u l . That yes, you were supposed t o be t h i n and f i t but no you're not supposed t o be so emaciated t h a t your knees b r u i s e each o t h e r a t n i g h t when you l i e down on your s i d e . But I c o u l d j u s t never see myself as being anything but overweight and needing t o l o s e more weight. You know, I c o u l d n ' t see myself as I was. So, and I suppose I could've even have seen um a woman a t h l e t e , maybe a very muscular woman a t h l e t e l e t ' s say, and, and r e c o g n i z e t h e beauty i n t h a t . But I c e r t a i n l y c o u l d n ' t see a person who was c o n s i d e r e d overweight and c o n s i d e r t h a t a t t r a c t i v e a t a l l .  L.T.  M-hm. So i t was hard as you s a i d e a r l i e r .  L.S.  Impossible. Impossible. I remember o c c a s i o n a l l y g e t t i n g a glimpse o f m y s e l f — b e f o r e I knew I was s e e i n g myself i n l i k e a shop window—and having f o r a s p l i t second t h e knowledge t h a t t h a t was a, a t h i n person, u n t i l i t c l i c k e d i n t h a t t h a t was me. And then t h a t i d e a was out o f my head.  f o r you t o r e a l l y look a t y o u r s e l f  143 L.T.  M-hm. M-hm. enough.  That's me  and  I'm  not t h i n , never t h i n  L.S.  That's r i g h t .  L.T.  M-hm. O.K. How are we doing with the s t o r y ? Now I've asked you a number of questions and s o r t of got us back and now.  L.S.  No I t h i n k , no I t h i n k i t ' s good because t h i s s o r t of c h r o n o l o g i c a l p r o g r e s s i o n I t h i n k i s e a s i e r f o r me t o remember t h i n g s i n . Um, I c o u l d t a l k more about why I f e l t t h a t , you know, how the whole process s t a r t e d , but you c o u l d weight t h a t i f you wanted, t h a t doesn't matter so much.  L.T.  No. No, I t h i n k t h a t I, I have enough of the key t h i n g s to, f o r us t o move on i f , i f you f e e l you'd l i k e t o now and your r e s t of the s t o r y .  L.S.  M-hm. So. O.K. so a f t e r t h a t therapy then I j u s t continued on and t h i n g s um, I t h i n k at l e a s t I was able to f i n i s h my courses and, you know, the l a s t couple of years. Um.  L.T.  So you're s t i l l . One t h i n g keeps going through my mind i s t h a t when t h i s tape f i n i s h e s , t h e r e ' s t h i s r e a l l y loud beep and I j u s t thought.  L.S.  We're not supposed t o jump, r i g h t .  L.T.  (Laughs.) Well, you can jump, no, but I j u s t always f o r g e t t o warn people. That j u s t keeps going through my head as we're t a l k i n g . Um, so anyways, we've come t o the end of, of therapy then with your p s y c h i a t r i s t and you're s t i l l underweight.  L.S.  M-hm. Then I went t o t h a t program and um, I t h i n k t h a t I r e a c t e d — i t was a p r e t t y s t r e s s f u l program—and I t h i n k I r e a c t e d by g e t t i n g r i g h t back on i n t o the same behaviour pattern.  L.T.  Had  006  L.S.  L.T.  How, how do you r e c a l l t h a t t h e r e was a b i t of c o n t r o l ? What makes you t h i n k t h a t t h e r e was some c o n t r o l f o r you?  Ergo, t h a t r e f l e c t i o n i s n ' t  i t changed somewhat then  thin.  (Laughs.)  L.?  I t h i n k i t had. As I s a i d , I t h i n k t h a t the therapy had some, had some b e n e f i t s . Um, I'm p r e t t y sure I was s t i l l b i n g e i n g and purging. But I t h i n k there was a b i t of an element of c o n t r o l , a b i t .  144 L.S.  Because I remember the um, you know, b i n g e i n g d u r i n g the program. And I don't have r e c o l l e c t i o n s of t h a t k i n d of r e a l , r e a l l y being out of c o n t r o l d u r i n g t h a t p e r i o d .  L.T.  O.K.  L.S.  And I t h i n k i t was um a r e a c t i o n t o again the f e a r . You know the e x p e c t a t i o n s , I, I r e a l l y craved them, y e t I was always a f r a i d t h a t I was going t o f a i l . And um, I remember b i n g e i n g as a d i r e c t r e a c t i o n of t h a t d u r i n g t h a t , d u r i n g the program. So I t h i n k something about the lack of.  007  M-hm.  The being a b l e t o focus on the problem and have no o t h e r e x p e c t a t i o n s — w h i c h I wanted, but i t was b e t t e r t h a t I d i d n ' t have t h e m — c o n t r i b u t e d something t o perhaps a b i t of r e m i s s i o n d u r i n g t h a t p e r i o d of therapy.  L.T.  M-hm. I t was a l i t t l e b i t of a time-out from what you had been doing at s c h o o l , and then you went i n t o the program.  L.S.  M-hm.  L.T.  So t h a t change was h e l p f u l t o you over your b i n g e i n g .  L.S.  That was f o r the p e r i o d t h a t i t l a s t e d , but i t d i d n ' t c a r r y over.  L.T.  M-hm. And you s a i d " r e m i s s i o n . " Do you, do you f e e l t h a t t h a t was a time d u r i n g which you recovered, i n p a r t , or, or how would you d e s c r i b e i t ?  L.S.  I would say t h a t ' s the f i r s t time t h a t , i t was a f i r s t step. I t was a, a, an acknowledgement of the problem both to myself and t o someone e l s e , and r e a l i z i n g t h a t I had to look a t myself f o r the answers.  L.T. L.S. 008  That's r i g h t . i n g a i n i n g more c o n t r o l  Mmm. Um,  and  so I t h i n k t h a t was  an  important.  But a c t u a l l y stopping and s a y i n g , "Whoa, wait a minute, you know, t h e r e ' s something r e a l wrong and i t ' s me, and I need h e l p . " Because h i t h e r t o , and, and a f t e r t h a t too, I would, you know, a f t e r a p a r t i c u l a r l y bad p e r i o d I'd say, "O.K."—and I t h i n k , I'm sure everybody does t h i s — " T h i s has got to stop! Dadu dadu dadu dada." And i t would l a s t , you know, o v e r n i g h t maybe, t h a t r e s o l u t i o n . And so the r e a l i z a t i o n t h a t I c o u l d n ' t do i t myself was important. And the f a c t t h a t I had t h a t support.  145 L.T. L.S. L.T. L.S.  O.K. those were two key t h i n g s i n your therapy. M-hm. And huge steps, as you say, changes.  t o b e g i n n i n g t o make some  Right.  L.T.  Was t h e r e c o g n i t i o n o f i t and s e e i n g t h a t you c o u l d n ' t do i t alone. (Tape ends here.)  009  L.S.  L.T.  Because you're f e e l i n g l e s s alone and l e s s i s o l a t e d and what impact d i d t h a t have on you o r how d i d you f e e l ?  010  L.S.  And I t h i n k another important aspect o f t h a t [therapy] was t h e f a c t t h a t you're breaking t h e i s o l a t i o n , breaking t h e secrecy and l e t t i n g someone e l s e i n on i t . I t ' s , i t ' s t e l l i n g you know, i t ' s r e a l i z i n g t h a t you need t h e support. But i t ' s a l s o t h a t by breaking out o f t h a t um c i r c l e of, o f secrecy t h a t you c r e a t e , you're almost i t ' s l i k e l e t t i n g a chink o f d a y l i g h t i n . I t ' s l i k e , you know, i t ' s a connection between s o r t o f you and t h e o u t s i d e world, i n on, on who you a r e and your s e c r e t . And I, I b e l i e v e very s t r o n g l y t h a t t h a t ' s a v i t a l p a r t o f i t . A t l e a s t i t was f o r me. I know i t was a v i t a l p a r t f o r me because i n t h e subsequent therapy, I t h i n k t h e b i g g e s t step was taken when I t o l d my husband about i t , and t h e most d i f f i c u l t . So I t h i n k p a r t o f t h e reason t h a t t h e r e was some improvement d u r i n g t h a t time was t h a t I had t o l d somebody e l s e about i t . I mean he [ t h e r a p i s t ] was the f i r s t person I t o l d about i t . And t h a t , um, I, I would say t h a t i s very important.  Very p o s i t i v e . I mean t h a t was r e a l good. I t ' s , you know, i t eases t h e burden t h a t you c a r r y . I t a l s o allows you t o t a l k about i t because you're not going t o s i t by y o u r s e l f and t a l k about i t , and t r y and l a y i t a l l out and understand i t . A t l e a s t I wasn't, cause you're so caught up i n i t a l l .  But when someone e l s e , you have t o , you know, t e l l them about i t , then you have t o examine i t . That's where, you know, t h a t ' s t h e w a l l . I t ' s s o r t o f l i k e you run up t o t h i s w a l l and you say, "O.K. t h i s i s , now I have t o j u s t t u r n around and face t h e hounds t h a t have been chasing me i n a way." And when you're j u s t on your own, you can j u s t keep running and running. L.T.  So i t was having someone t h e r e then who, i n a sense, g e n t l y helped you c o n f r o n t t h e i s s u e and helped you look at y o u r s e l f more c l e a r l y .  146 L.S.  Yes. And t h e therapy aspect was, was t h a t you know, h e l p i n g me look a t i t more c l e a r l y . But, you know, i t ' s j u s t t h e a c t o f t e l l i n g somebody. Because when I t o l d A., my husband, I never, I have s i n c e , you know, t a l k e d t o him about i t a b i t . I t wasn't so much t h a t he c o u l d do anything f o r me. I t ' s j u s t t h e f a c t again t h e r e was someone e l s e i n v o l v e d beside me. And I c o u l d n ' t , even i f I wanted t o , i t would no longer be a t o t a l s e c r e t t h a t I c o u l d r e v e r t t o . So you know i t ' s , and I guess you know s t o p p i n g a s t r a n g e r on t h e s t r e e t and saying, " I throw up" (laugh), you know, wouldn't be t h e same t h i n g because t h a t person wouldn't be a p a r t o f your l i f e .  L.T.  Right.  L.S.  So t h a t you c o u l d j u s t s e a l up t h e w a l l again r e a l l y easily. Oh my metaphors, I'm g e t t i n g them mixed: putting down a w a l l , having t o t u r n and face i t , and s e a l i n g y o u r s e l f up. But I t h i n k you can f o l l o w i t . So I r e a l l y t h i n k i t ' s , i t ' s what t h a t person, t h e f a c t t h a t t h e person can h e l p you examine i t a l l . But I t h i n k i t ' s j u s t , i t ' s j u s t breaking t h a t , t h a t h o r r i b l e f e e l i n g o f being so c u t o f f from everybody e l s e . And i f once somebody e l s e i s p r i v y t o t h a t s e c r e t , you have t o address i t too.  L.T.  Mmm.  L.S.  Because you can't keep, you can't say, "Oh, and, and i n t e n d t o go on doing t h a t . There k i n d o f a t t e n t i o n then t h a t you're going t o At l e a s t I c o u l d n ' t . And i t ' s t h e shame o f  L.T.  M-hm. I s i t almost l i k e i t made you more accountable i n a sense?  011  L.S.  L.T.  M.-hm. Sounds l i k e i t gave you t h a t e x t r a b i t o f motivation.  L.S.  I do t h i s , " um has t o be some d e a l with i t . it all.  Yes. Because i t wasn't j u s t me. And t h a t f o r me, t h a t the shame o f i t a l l was so h o r r i b l e , was so t e r r i b l e , t h a t again l e t t i n g someone e l s e i n on t h a t presupposes t h a t then you're going t o do something about i t . You have t o now cause you can't look a t t h a t person i n t h e eye knowing t h a t , you know, you're going t o be running t o t h e bathroom. So t h a t , f o r me t h a t was r e a l l y important.  M-hm.  L.T.  To r e a l l y begin t o t h i n k about doing something.  012  L.S.  Well, and a l s o t o have someone, someone e l s e accept i t , uh and not um; i t j u s t l e t s you know t h a t maybe  147 you're not such a monster. You know t h a t someone e l s e c o u l d hear t h i s p a r t o f you and s t i l l , and s t i l l accept you. You know e s p e c i a l l y i n terms o f you know, t h e person t h a t you're l i v i n g w i t h . And you know, supposedly you've known t h i s person f o r however many y e a r s — 4 o r 5 y e a r s — a n d t h a t ' s t h e one s e c r e t you've never t o l d them. You know so, i t ' s , i t a l s o a l l o w s you t o f e e l more l i k e a human being. Again, t h e whole um b r e a k i n g out o f t h e i s o l a t i o n , and t h a t even t h e f a c t t h a t you do t h a t doesn * t mean t h a t you're such a r o t t e n person. L.T.  You f e l t r e a l l y accepted then when you t o l d t h e p s y c h i a t r i s t and a l s o when you t o l d your husband.  L.S.  M-hm. Yah i t was an element of, o f being accepted t o know t h a t you d i d n ' t n e c e s s a r i l y have t o keep t h i s s e c r e t . Cause i t ' s funny you, I t h i n k , f o r me anyway, I knew on some l e v e l t h a t I'd have t o be working w i t h someone, I'd have t o t e l l someone. Um, but, I l o s t my t r a i n o f thought. I would have t o t e l l someone about i t i n order t o d e a l w i t h i t . Um, but (pause) i f , gosh t h e r e ' s something I wanted t o say. I f t h a t person were not t o have accepted i t , i t would have been j u s t t h e worst t h i n g . Something e l s e has escaped me and I might remember i t later.  L.T.  Sure, t h a t ' s f i n e . (Pause.) With t h e r e l i v i n g o f i t and t r y i n g t o s o r t o f p i c k a p a r t l i t t l e d e t a i l s i s q u i t e , and and t h e y ' r e so i n t e r t w i n e d as w e l l .  L.S.  They a r e v e r y much so.  L.T.  I n many ways t h a t i t ' s hard t o g e t a l l o f them as you r e l i v e i t , I'm sure.  L.S.  So t h a t I t h i n k i n both i n s t a n c e s , both s o r t o f um s t e p s , was, was j u s t t h e a c t o f t e l l i n g was r e a l l y important.  013  L.T.  And I guess t h a t ' s why—I'm jumping t h e gun, t h e gun a b i t — b u t t h a t ' s why I t h i n k groups must be important i n t h e process t o o . Because a g a i n you're, not o n l y have you t o l d o t h e r s and they, you know, don't run away screaming o r something; you're s t i l l a person t o them. But a l s o you see o t h e r s who seem t o you q u i t e , I mean they look l i k e people, l i k e they have i t a l l t o g e t h e r . Yet they c a r r y t h i s t o o . So I t h i n k t h a t whole element o f s h a r i n g i s i s so important. M-hm. I t ' s almost l i k e i t ' s not t h e s o l e focus o f one's, of one's l i f e . L i k e i t ' s p a r t o f i t but t h e r e a r e other t h i n g s as w e l l t h a t make them human.  148 014  L.S.  Yes, um, because f o r me anyway, t h e r e was such a l a c k o f um, l i k e p a r t o f me was s c a r e d t h a t i f I d i d examine myself I wouldn't f i n d a n y t h i n g t h e r e . You know, because I d i d n ' t have any r e a l sense o f myself or o f no s t r o n g grounding i n myself. So p a r t o f the running away from i t w a s — r u n n i n g away from d e a l i n g w i t h t h e b u l i m i a — w a s t h e knowledge t h a t I'd have t o do s e l f - e x a m i n a t i o n and my god, what would, a t t h i s p o i n t , what would I f i n d t h e r e ? I mean t h e r e would be nothing, I d i d n ' t f e e l t h e r e ' d be a n y t h i n g t o work on.  L.T.  So t h a t must have been i n c r e d i b l y s c a r y then t o even e n t e r t a i n t h e thought o f therapy.  L.S.  Very much so. Yah, i t was a very f r i g h t e n i n g thought of a c t u a l l y d e a l i n g with i t .  L.T.  M-hm. Coupled w i t h t h e whole sense o f shame and having t o t e l l another person about your behaviour and then they'd a l s o f i n d out about y o u r s e l f , and who knows what t h a t would a l l i n v o l v e .  L.S.  That's r i g h t . That's j u s t i t . You, I t h i n k I always had the v e r y f i r m b e l i e f , s o r t o f l i k e t h e Groucho Marx s a y i n g , t h a t I wouldn't belong t o any c l u b t h a t would have me as a member. You know t h a t i f someone were t o r e a l l y know me, I mean, I, I knew myself and I hated myself. So i f someone e l s e were t o know me, my god, you know t h e chances o f t h e y ' r e l i k i n g me would be so much, they j u s t wouldn't e x i s t . So you know i t ' s keeping up t h i s , t h i s s o r t o f f r o n t t h a t you've c r e a t e d (a) i n terms o f p r e t e n d i n g t h a t you're normal r e g a r d i n g your e a t i n g but then e v e r y t h i n g e l s e t h a t you're j u s t a, a normal person, you're j u s t you know l i k e any other "Joe." Um, and i t , i t becomes, you know, a r e a l s t r a i n I t h i n k when you have a l l t h i s s o r t o f e a t i n g away a t you: t h e f a c t t h a t you t h i n k you're h o r r i b l e and I mean you're convinced t h a t you're h o r r i b l e because o f you don't, you know, you don't have any s e l f - d e f i n i t i o n , you do t h i s h o r r i b l e t h i n g with regards t o e a t i n g . And a l s o i n my case um, I d i d other t h i n g s t h a t would s o r t of r e i n f o r c e , I t h i n k i n a way, t h i s n e g a t i v e s e l f - i m a g e . I was i n v o l v e d i n s h o p l i f t i n g um j u s t a, l i k e I c o u l d n ' t r e a l l y say here, here a r e my standards and I uphold them because I d i d n ' t , I c o u l d n ' t have any standards because t h e r e was no person t o s e t standards. See what I mean?  L.T. L.S.  M-hm. So i n a way, and i t was always t h a t f e e l i n g o f g u i l t f o r e v e r y t h i n g t h a t you d i d because you knew t h a t t h i n g s you d i d were wrong, o r ways t h a t you were were wrong. But you  149 d i d n ' t f e e l t h a t t h e r e was a s o l i d core t h e r e o f y o u r s e l f t o s e t standards f o r and then have t h e i n t e g r i t y t o uphold. L i k e the, t h e idea o f o f succeeding and doing t h a t and j u s t l i v i n g s o r t o f a moral l i f e was t o t a l l y out of my grasp. So i t was always a , s o r t o f a facade o f , you now, being a decent person doing t h i s um t h a t you had t o uphold a t a l l times i n a d d i t i o n t o t h e whole e a t i n g disorder secret. L.T.  L.S.  I s i t l i k e , and c o r r e c t me i f I'm wrong, but i t sounds l i k e t h e r e ' s two s i d e s and on one o f them you're t r y i n g t o p o r t r a y t o t h e o u t s i d e world a r e a l l y u p r i g h t , moral k i n d of person. M-hm.  L.T.  But i n s i d e you're f e e l i n g l i k e t h e r e i s n ' t any person so t h e r e ' s no p o i n t s e t t i n g standards. And t h e r e f o r e i t ' s r e a l l y easy t o j u s t break them.  L.S.  That's r i g h t . A l s o I t h i n k , i n my case anyway, I mean I came from a p r e t t y you know u p r i g h t background and a l l t h i s , so I c e r t a i n l y knew what was r i g h t and wrong and e s p e c i a l l y i n regards t o myself. Um you know, I d i d n ' t do l i k e h o r r i b l e t h i n g s but t h e r e were t h i n g s t h a t I d i d t h a t I knew were not r e a l l y me. Uh, and I t h i n k i n some ways doing t h a t uh, perhaps i s a c a l l f o r help o r a t t e n t i o n . But a l s o i s , i t j u s t , a t l e a s t you're r i g h t i n something. At l e a s t you're r i g h t i n how bad you are. It, i t r e i n f o r c e s t h i s i d e a , you know. So i t s almost l i k e a you've uh a t l e a s t chosen, t h e r e ' s a t l e a s t one t h i n g t h a t you're very c l e a r about because look a t what I do.  L.T.  M-hm. Something t h a t you c o u l d grasp onto and say, "Hey t h i s i s what I do, t h i s i s perhaps me."  L.S.  M-hm. (Pause.) Yah. But a l l t h e time I knew i t wasn't me. L i k e I knew t h a t wasn't, wasn't r e a l l y me but I knew t h a t I was a not a good person e s p e c i a l l y s i n c e I would do these t h i n g s . You see what I mean? So t h e r e ' s always t h a t dichotomy between what I r e a l l y knew my moral standards were o r my you know whatever, what my p e r s o n a l i t y was, and l o o k i n g a t t h e way I thought I was e s p e c i a l l y as r e f l e c t e d by my a c t i o n s . I don't know i f t h a t makes any sense.  L.T.  I t , i t does. But t h e p a r t where I g e t confused though i s where you s a i d t h a t you f e l t l i k e t h a t you s o r t o f d i d n ' t have an i d e n t i t y , t h e r e f o r e you d i d n ' t need t o s e t any standards. But i t sounds l i k e you a c t u a l l y have s e t some standards.  L.S.  You had, yes, I mean I had standards. But because I had such a poor self-image I d i d n ' t r e a l l y t h i n k t h a t I c o u l d  1 5 0  ever l i v e up t o them anyway. See what I'm saying? So, i t ' s l i k e , i t was s o r t o f l i k e um t r y i n g t o be b e a u t i f u l or t r y i n g t o be whatever, l i k e I knew because I was t h e way I was, I c o u l d never be t h a t way. So i t was i n a way almost I thought I c o u l d t r y , you know. Because I knew, I guess I knew t h a t no matter what I d i d , um I would s t i l l not l i k e myself. So, i n some ways i t d i d n ' t matter as much what I d i d because I knew t h a t I c o u l d succeed i n here and I c o u l d get A's i n t h e r e , and I c o u l d do t h i s , but I knew t h a t t h a t core would s t i l l not l i k e me, you know. L.T.  Didn't matter what you d i d then.  L.S.  No. I t ' s funny becau