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Recovery from bulimia nervosa 1991

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RECOVERY FROM BULIMIA NERVOSA By LAURIE GAIL TRUANT B.A., Simon Fraser University, 1983 THESIS SUBMITTED IN PARTIAL FULFILLMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Counselling Psychology We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA OCTOBER 1991 ® Laurie G a i l Truant, 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. J Department of C o u n s e l l i n g P s y c h o l o g y The University of British Columbia Vancouver, Canada Date O c t o b e r 3 , 1991 DE-6 (2/88) i i Abstract Current research on formal treatment approaches to normal-weight bulimia presents inconclusive r e s u l t s on the e f f i c a c y of various treatments and l i m i t e d empirical knowledge of the curative mechanisms involved. In the l i t e r a t u r e on therapeutic change agent studies which interviews individuals who have recovered from an eating disorder, only i s o l a t e d aspects of the recovery experience are uncovered so that the meaning and process of recovery are li m i t e d . This case study applied C o l a i z z i ' s (1978) existential-phenomenological approach to elucidate thematic categories underlying the recovery experience as recounted by a former bulimic i n order to provide a more complete and h o l i s t i c understanding of the process and nature of recovery from bulimia. I n i t i a l l y , four individuals who self-reported f e e l i n g genuinely recovered from bulimia were prescreened by an independent rater i n order to ensure that they had a previous diagnosis of bulimia nervosa as defined by the Diagnostic and S t a t i s t i c a l Manual of Mental Disorders. Third Edition Revised (1987) and no previous h i s t o r y of anorexia nervosa, that they were free of bulimic symptoms, and that they exhibited no s i g n i f i c a n t indicators of other active psychological problems since having recovered from bulimia. The four co-researchers described t h e i r recovery experience and each interview was transcribed. Categorical themes were formulated from the r i c h e s t and most comprehensive t r a n s c r i p t and information from another co-researcher's t r a n s c r i p t served to cross-validate the categories. The remaining two t r a n s c r i p t s were not included i n the analysis process. The co-researcher validated the thematic categories and t h e i r descriptions and also v e r i f i e d that the clustered categories c l e a r l y outlined the pattern or meaning of her recovery experience. Results showed that recovery involves a synergetic i n t e r a c t i o n of curative factors both inside and outside of formal therapy. Once the in d i v i d u a l acknowledges her eating problem, her bulimic behaviours begin to decrease as she experiences an increasing sense of e f f i c a c y and self-respect i n areas of her l i f e other than her body weight and shape. Her bingeing and purging gradually diminish to the point where she no longer engages i n them. Aside from an occasional lapse, she now implements other a c t i v i t i e s to deal with uncomfortable emotional states. She f e e l s stronger i n knowing who she i s , she cherishes h e r s e l f as she i s , and she i s eager to affirm her personal growth by sharing her experience with recovering bulimics. In addition to a more comprehensive t h e o r e t i c a l understanding of recovery, t h i s study provided a deepened appreciation of the complexity of the recovery process. I t also underscored the need for a multifaceted and i n d i v i d u a l i z e d treatment approach which i s adjusted throughout the recovery process as the adaptive functions or meanings of c l i e n t s ' eating behaviours change. iv Table of Contents Abstract i i Table of Contents i v Acknowledgement v i Chapter I: Introduction 1 Overview 1 D e f i n i t i o n of Terms 2 Significance of the Study 4 Treatment Outcome Studies 5 Therapeutic Change Agent Studies 8 Assumptions 12 Limitations of the Study 12 Chapter I I : Literature Review 14 Treatment Outcome Studies 14 Psychodynamic Therapy Studies 15 Systemic Family Therapy Studies 18 Cognitive-Behavioural Therapy Studies 24 Therapeutic Change Agent Studies 29 Summary 3 9 My Presuppositions 4 0 Chapter I I I : Methodology 45 Design 45 Co-researcher Selection 47 Procedure . . . . . 53 Analysis 56 Chapter IV: Results 59 Interviews 59 From Transcription to Formulation of Themes 65 The V a l i d a t i o n Interview 66 Clusters of Themes and S i g n i f i c a n t Protocol Statements 67 Condensed Outline of Clustered Themes 68 Exhaustive Description of the Recovery Experience . . 69 Chapter V: Discussion 105 Summary of Results 105 Limitations of the Study 105 Evaluating the Fitness of Theoretical Approaches . . 107 Implications for Counselling 114 Recommendations for Future Research 116 Summary and Conclusions 118 References 120 V Table of Contents (continued) Appendices A. Diagnostic C r i t e r i a for Bulimia Nervosa . . . . 125 B. Diagnostic C r i t e r i a for Anorexia Nervosa . . . . 126 C. Pre-screening Interview Summary Sheet 12 7 D. Contact Letter for Counsellor/Therapist . . . . 128 E. Contact Letter to Volunteer 12 9 F. Advertisement for Subjects 13 0 G. Consent Form 131 H. L.S.'s Protocol 132 J. P.Y.'s Protocol 190 K. Co-researcher's Validation Letter 247 v i Acknowledgement In Man's Search for Meaning. Frankl (1963) quotes Nietzsche's words: "He who has a why to l i v e for can bear with almost any how" (p. 121, 164). This thesis i s dedicated to the women i n therapy who longingly asked me how they would recover from bulimia nervosa. Their question provided the i n i t i a l and continuing i n s p i r a t i o n for me to pursue and complete t h i s research study. I would l i k e to thank my committee members—Dr. Ishu Ishiyama, Dr. Larry Cochran, and Dr. E l l i o t G o l d n e r — f o r t h e i r guidance and v a l i d a t i o n throughout the research process. I am also g r a t e f u l to Beth and Sarah for t h e i r c a r e f u l and thorough work i n the ed i t i n g and typing of the manuscript. The constant undergirding of love and support from my family i s also deeply appreciated. F i n a l l y , I would l i k e to acknowledge the cooperation, courage, and hard work of the co-researchers who shared t h e i r recovery s t o r i e s and wisdom i n analyzing the experience of recovery from bulimia. I am greatly indebted to these women for t h e i r commitment and openness which was foundational to the completion of t h i s project. 1 Chapter I Introduction Overview Bulimia i n normal-weight women without h i s t o r i e s of associated weight disorders f i r s t appeared i n the research l i t e r a t u r e i n 1978 (Oesterheld, McKenna, & Gould, 1987). In 1980, bulimia was acknowledged as a diagnostic e n t i t y (American Ps y c h i a t r i c Association, 1980) , and i n 1987 the diagnostic c r i t e r i a were revised (American Psychiatric Association, 1987). Although Striegel-Moore, S i l b e r s t e i n , and Rodin (1986) observed that the onset of bulimia can occur well a f t e r the young adult years, the disorder usually begins i n la t e adolescence or early twenties. While good epidemiological data i s as yet unavailable (Eating Disorder Task Force, 1989; Tonkin & Wigmore, 1989), s t a t i s t i c s on the prevalence of bulimia as defined by the c r i t e r i a of the Diagnostic and S t a t i s t i c a l Manual of Mental Disorders. Third E d i t i o n Revised (DSM-III R. 1987) range from 1.3% to 5.0% of college women (Drewnowski, Yee, & Krahn, 1988). Since only 10% of bulimics are male (Drewnowski et a l . ) , I w i l l use the feminine pronoun she when r e f e r r i n g to individ u a l s with bulimia. Given that the true incidence of bulimia i s d i f f i c u l t to assess because of the shame and secrecy associated with i t (Newman & Halvorson, 1983) and since many normal-weight women not diagnosed as bulimic report s u f f e r i n g from the symptoms of the disorder (Johnson & Connors, 1987), the extent of bulimia may be far greater than that revealed by current s t a t i s t i c s (Tonkin & Wigmore). 2 In any event, the increased prevalence of bulimia i n the past two decades with i t s deleterious psychological and ph y s i o l o g i c a l health e f f e c t s as well as the s i g n i f i c a n t associated mortality (Herzog, Hamburg, & Brotman, 1987) has spurred research into e t i o l o g i c a l factors, treatment, interventions, and therapeutic change agents. However, the studies to date are inconclusive or a n a l y t i c a l , and a h o l i s t i c understanding of how recovery occurs i s lacking. According to Tonkin and Wigmore (1989) "we are s t i l l struggling with our understanding of eating disorders and how best to help those who s u f f e r from them 11 (p. 147) . Therefore, the purpose of t h i s study i s to investigate the meaning of the recovery experience from the perspective of recovered bulimics by exploring the nature and process of recovery from bulimia. Hopefully, a more comprehensive understanding of recovery w i l l r e s u l t so that t h e o r e t i c a l approaches can be c r i t i q u e d , individuals with bulimia can be primed for therapy, and treatment effectiveness can be enhanced by providing an optimal therapeutic environment. D e f i n i t i o n of Terms According to the DSM-III R (1987), the diagnostic c r i t e r i a for bulimia nervosa are: (a) at least two weekly binge eating episodes for a minimum of 3 months; (b) a f e e l i n g of lack of control during the binges; (c) regularly engaging i n vomiting, use of laxatives or d i u r e t i c s , s t r i c t d i e t i n g or fasting, or vigorous exercise; and (d) preoccupation with body shape and weight. In contrast to the Diagnostic and S t a t i s t i c a l Manual of 3 Mental Disorders, Third E d i t i o n (DSM-III. 1980), the DSM-III R c r i t e r i a are firmer i n that a minimum frequency of binge eating episodes i s stated and the requirement of depressed mood and self-deprecating thoughts following eating binges i s eliminated as i t i s regarded as a common associated feature. Since a l l of the DSM-III R (1987) c r i t e r i a must be met for a diagnosis of bulimia nervosa, an i n d i v i d u a l i s by d e f i n i t i o n recovered from bulimia i f she does not meet any one of the c r i t e r i a . Within the l i t e r a t u r e , there i s no t h e o r e t i c a l d e f i n i t i o n of recovery from bulimia. Recovery i s operationalized using behavioural c r i t e r i a : abstinence from bingeing and purging, or s e l f - r e p o r t of lapses with no perceived loss of control over eating behaviour for at least one year (Brownell, Marlatt, Lichtenstein, & Wilson, 1986; Connors, Johnson, & Stuckey, 1984; Cooper, Cooper, & H i l l , 1989; Johnson & Connors, 1987) . However, as the course of bulimia " i s chronic and intermittent over a period of many years" (DSM-III R, 1987, p. 68), the process of recovery involves episodes of r e m i s s i o n — wherein the frequency of bulimic behaviours i s reduced—as well as periods of relapse. Definitions of relapse include "a return to pretreatment base rate" (Mines & M e r r i l l , 1987, p. 564), bingeing and purging at least eight times a month as t h i s approximates the DSM-III R (1987) frequency c r i t e r i o n (Pyle, M i t c h e l l , Eckert, Hatsukami, Pomeroy, & Zimmerman, 1990), or a "perceived loss of control" over eating behaviours (Brownell et a l . , 1986, p. 766). Within the context of t h i s study, relapse 4 occurs when the ind i v i d u a l experiences a loss of control over her eating behaviours. As there are few studies which examine the recovery experience from the recovered bulimics perspective, studies which interview recovered anorexics are addressed i n order to provide a broader basis for understanding the recovery process. Therefore, the c r i t e r i a for anorexia nervosa according to the DSM-III R (1987) are: (a) maintenance of body weight 15% below that expected; (b) intense fear of gaining weight even though underweight; (c) disturbance i n the way i n which one's body weight, s i z e , or shape i s experienced; and (d) absence of at leas t three consecutive menstrual cycles i n females when otherwise expected to occur. Correspondingly, i f an ind i v i d u a l does not meet any one of these c r i t e r i a , she i s by d e f i n i t i o n recovered from anorexia. Significance of the Study A review of the treatment outcome studies pertaining to normal-weight bulimia showed inconclusive r e s u l t s on the e f f i c a c y of various treatment approaches and lim i t e d empirical knowledge of the curative mechanisms of formal therapeutic interventions. Furthermore, i n the l i t e r a t u r e on therapeutic change agents which interviewed indiv i d u a l s who had recovered from an eating disorder, only i s o l a t e d aspects of the recovery experience are presented such that knowledge of the meaning of the experience and the process of recovery i s li m i t e d . Currently, no research studies e x i s t which provide a h o l i s t i c understanding of the recovery process. Therefore, t h i s study proposes to uncover the 5 thematic categories underlying the experience of recovery i n order to provide a more complete understanding of recovery. Since the etiology and maintenance of bulimia i s multidimensional and involves s p e c i f i c b i o l o g i c a l , psychological, family, and s o c i o c u l t u r a l factors (Schwartz, Barrett, & Saba, 1985; Steiger, 1989; Striegel-Moore et a l . , 1986), the pattern of p r e c i p i t a t i n g and perpetuating factors i s unique for each i n d i v i d u a l . Thus, based on c l i n i c a l observations, a multifaceted and i n d i v i d u a l i z e d treatment approach i s paramount i n which various psychotherapeutic treatments are integrated i n order to address both the bulimic symptoms and the multiple maintaining factors (Herzog et a l . , 1987; Johnson, Connors, & Tobin, 1987; Manley, 1989; Steiger). However, the treatment outcome l i t e r a t u r e abounds with studies comparing the effectiveness of one modality with another with l i t t l e consideration of the perpetuating factors involved. Treatment Outcome Studies Upon reviewing the treatment outcome studies, a l l psychological approaches—psychodynamic, family systems, cognitive-behavioural, cognitive, or behavioural—seem to ameliorate the behavioural symptoms of bingeing and purging with no one modality showing cle a r s u p e r i o r i t y (Cox & Merkel, 1989; Johnson & Connors, 1987; Laessle, Z o e t t l , & Pirke, 1987; Yager, 1988). Furthermore, according to Hudson and Pope (1986) and Johnson and Connors (1987), l i t t l e consensus has been reached concerning which treatment i s most suitable for which subtype of bulimia: bulimia complicated by substance abuse, obsessive- 6 compulsive behaviour, depression, or sexual abuse (Lacey, 1983; Ordman & Kirschenbaum, 1985). In the controlled psychodynamic treatment study by Norman, Herzog, and Chauncy (1986), s t a t i s t i c a l l y s i g n i f i c a n t improvements on measures of disordered eating behaviours were found at a one-year follow-up. Concerning family therapy outcome studies, an uncontrolled study conducted by Schwartz et a l . (1985) which employed s t r u c t u r a l family therapy and symptom- focussed d i r e c t i v e s found that at the end of treatment 66% of the subjects had reduced the frequency of t h e i r bulimic episodes from a mean of 19.3 per week to one or fewer per month. The cont r o l l e d cognitive-behavioural studies also report s t a t i s t i c a l l y s i g n i f i c a n t reductions i n binge/purge behaviours: 80% abstinence at post-treatment (Lacey, 1983), a 60% reduction i n the frequency of vomiting at the three-month follow-up for 77% of the p a r t i c i p a n t s (Kirkley, Schneider, Agras, & Bachman, 1985) , a 50% or greater reduction i n the frequency of bingeing and purging at post-treatment for 55% of the indiv i d u a l s (Connors et a l . , 1984), and 20% abstinence and 55% who had reduced bulimic behaviours to one day per week (Ordman & Kirschenbaum, 1985). F i n a l l y , the outcome res u l t s from studies which compare the e f f i c a c y of d i f f e r e n t treatment modalities are also inconclusive. For instance, i n the study by Fairburn, Kirk, O'Connor, and Cooper (198 6) which compared a cognitive-behavioural approach with short-term psychotherapy, the r e s u l t s indicated that both groups made substantial 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 , Turnbell, and Annandale (1985) found that a l l three t r e a t m e n t s — i n d i v i d u a l psychodynamic, i n d i v i d u a l behavioural, no treatment control g r o u p — e f f e c t i v e l y reduced bingeing and purging. Overall, e f f e c t i v e evaluation and comparison of d i f f e r e n t treatment approaches i s precluded by subject d i v e r s i t y with respect to age of onset, duration of i l l n e s s , method of subject s e l e c t i o n (Ordman & Kirschenbaum, 1985; Johnson & Connors, 1987), and presence of active psychological problems (Lacey, 1983). Another factor which impedes between-study comparisons i s the lack of uniformity i n methodology related to usage of a control group as well as treatment duration, session length, and number of sessions per week (Cox & Merkel, 1989). V a r i a b i l i t y between the studies i n reporting post-treatment r e s u l t s also jeopardizes evaluation: 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 the percentage of subjects who don't respond to treatment i s sometimes neglected (Cooper et a l . , 1989), some studies report reduction i n the actual number of bulimic episodes while others report percentage reductions, and follow-up length i s diverse and short (Herzog, K e l l e r , & Lavori, 1988; Johnson & Connors, 1987). In addition to these inconclusive findings on the e f f i c a c y of various treatment modalities, empirical knowledge of the curative factors of formal therapeutic interventions i s limited. In the family and psychodynamic therapy studies, knowledge of the effectiveness of s p e c i f i c therapeutic interventions i s precluded because a wide var i e t y of interventions were implemented during treatment (Norman et a l . , 1986; Schwartz, 1982; Schwartz et a l . , 8 1985). S i m i l a r l y , with the controlled cognitive-behavioural studies, i t i s impossible to determine the s p e c i f i c interventions of the treatment packages which are responsible for reducing behavioural symptoms (Cooper et a l . , 1989; Fairburn et a l . , 1986; Johnson & Connors, 1987; Kirkley et a l . , 1985). Nonetheless, assumptions about factors which f a c i l i t a t e recovery are inherent i n the various treatment approaches. For example, from a psychodynamic approach, the bulimic symptoms w i l l diminish as underlying intrapsychic c o n f l i c t s are worked through and self-esteem increases. Systemic family therapy proposes that while e f f e c t i v e family restructuring i s necessary for recovery, s p e c i f i c interventions aimed at the bulimic behaviours may also be necessary. F i n a l l y , cognitive-behavioural therapy f a c i l i t a t e s recovery by implementing behavioural techniques to reesta b l i s h control over eating behaviours as well as using cognitive interventions to modify the underlying disturbed thinking and values about body shape and weight. Therapeutic Chancre Agent Studies With respect to q u a l i t a t i v e studies which examine the factors both inside and outside of formal therapy which are f a c i l i t a t i v e of recovery, the body of knowledge i s minimal and a n a l y t i c a l such that only a lim i t e d understanding of the meaning of change events and the process of recovery e x i s t s . Information on the curative factors which "influence the f i n a l r e s u l t as a function of the therapist's actions, the other group members, and the patient h e r s e l f " (Vandereycken, Vanderlinden, & Van Werde, 1986, p. 61) has been gathered by interviewing recovering or 9 recovered bulimics and recovered anorexics about c r i t i c a l change events i n recovery. Hobbs, B i r t c h n e l l , Harte, and Lacey (1989) found that the aspects of group psychotherapy which bulimic c l i e n t s considered therapeutically important d i f f e r e d from those c i t e d by t h e i r therapists. While c l i e n t s reported i n s t i l l a t i o n of hope, vic a r i o u s learning, and u n i v e r s a l i t y as most important, therapists rated s e l f - d i s c l o s u r e and acceptance as more important. However, only a li m i t e d understanding of the therapeutic e f f e c t s i n a group environment i s gained as the meaning of the factors and t h e i r impact on indiv i d u a l s i s sketchy. Stanton, Rebert, and Zinn (1986) interviewed 15 individuals who had recovered from bulimia i n the absence of therapy and had been abstinent from bingeing and purging for an average of 7 months. Factors which i n i t i a t e d change included a desire to improve self-esteem and recognition of the i l l - h e a l t h e f f e c t s of bulimic behaviours. Social support, behavioural strategies, and p o s i t i v e s e l f - t a l k were reported to f a c i l i t a t e change. As with the study by Hobbs et a l . (1989), the meaning and impact of these factors i s li m i t e d . H a l l and Conn's 1983 survey (cited i n H a l l & Cohn, 1986) revealed that of the 30 individuals who reported that they were cured of bulimia or a dual diagnosis of both anorexia and bulimia, professional therapy was rated by 80% as h e l p f u l , friends and family were rated by 54%, and s p i r i t u a l pursuits were rated by 47%. In addition to the fact that the scope of possible 10 f a c i l i t a t i v e factors was lim i t e d to the therapists' perspectives, only l i m i t e d insight was gained into the meaning and impact of these events for the individuals. Kirk (1986) administered a questionnaire of 74 pote n t i a l treatment or recovery methods to 123 recovered bulimics. The 9 items rated as most hel p f u l to more than 50% of the respondents were: "learning why I turned to or away from food when bored, t i r e d , angry" (73.3%), "finding a sense of my true s e l f (no longer standing outside observing my own behaviours)" (69.8%), "learning to c a l l on my inner resources-determination, courage, patience" (64.9%) (p. 65), "learning to control self-defeating thoughts and feelings" (69.2%), "learning not to be over-concerned with other peoples' opinions and reactions" (69.0%), "learning constructive ways to deal with anger" (65.7%), " l e t t i n g go of my should statements" (65.5%), and "widening my range of s o c i a l a c t i v i t i e s " (63.8%) (p. 69). Only one of the most h e l p f u l items was a food issue: "learning to eat a healthy breakfast, lunch, and dinner" was hel p f u l to 66.9% of the respondents" (p. 71). Additional information on f a c i l i t a t i v e factors was also gained from open-ended questions. Trusting and loving relationships with supportive boyfriends, spouses, family members or God helped individuals r e a l i z e that they "had good q u a l i t i e s of [their] own and that [they] didn't have to earn love, friendship and attention" (Kirk, 1986, p. 130). Thus, while 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 were 11 elucidated, no cle a r pattern of the recovery process was presented. Beresin (1985) presented the meaning and impact of some of the curative factors reported by recovered anorexics and sketched a p a r t i a l pattern of recovery. For instance, a v a l i d a t i n g r e l a t i o n s h i p with one's therapist helped i n d i v i d u a l s to i d e n t i f y and t r u s t t h e i r feelings and i n i t i a t e d r i s k taking with other i n d i v i d u a l s . Also, while body image was the most d i f f i c u l t aspect to change, becoming a mother fostered an increased sense of self-worth, and intimate sexual relationships f a c i l i t a t e d the a b i l i t y to appreciate one's body rather than being ashamed of i t . Maine (1985) interviewed 25 recovered anorexics to illumine the treatment and recovery processes, and to uncover the meaning and impact of events which individuals considered f a c i l i t a t i v e of recovery. Factors which f a c i l i t a t e d recovery included personal r e s p o n s i b i l i t y for 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 within formal therapy or within informal relationships, acceptance of the dysfunction within t h e i r family as well as the c o n f l i c t i n g messages from the s o c i o c u l t u r a l system, and self-acceptance. The meaning of each of the factors i s also discussed. For example, i n experiencing a v a l i d a t i n g therapeutic r e l a t i o n s h i p with opportunities for intimacy and interdependence, individuals developed the confidence to est a b l i s h new relationships which required 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 o f f e r s assumptions about the curative factors involved i n recovery and 12 the studies interviewing recovered anorexics have begun to illumine a pattern of recovery. But, to date, none of the studies of normal-weight bulimia have provided a h o l i s t i c synthesis of patterns of meaning of recovery. Therefore, t h i s study proposes to investigate the phenomenon of recovery from bulimia by asking four women to describe t h e i r experience of recovery. Thematic categories underlying the unique recovery experiences w i l l be elucidated and described i n order to render a more complete pattern and understanding of recovering from bulimia. Assumptions The assumptions underlying t h i s study are: 1. The i n d i v i d u a l who has recovered from an eating disorder i s the expert on the meaning and e f f e c t of the variables which were c r i t i c a l i n her recovery (Maine, 1985). 2. The curative factors are not li m i t e d to those inside of formal therapy (Maine, 1985). 3. The therapist and c l i e n t often 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 et 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 that maintain recovery (Brownell et a l . , 1986). Limitations of the Study Self - s e l e c t e d individuals may be d i f f e r e n t from the larger population i n terms of willingness to share personal information with others as well as being psychologically minded and verbally expressive. Therefore, sample bias could be an important factor 13 to consider when applying the resu l t s to the recovery experience for women with normal-weight bulimia (Borg & G a l l , 1983). Furthermore, the pattern of recovery from bulimia may be d i f f e r e n t for males or individuals with obesity. Thus, the res u l t s of t h i s study which describe the pattern of recovery for the one co-researcher may be applicable to some other women with normal-weight bulimia. 14 Chapter II Literature Review What constitutes recovery from bulimia? What factors are f a c i l i t a t i v e of recovery and what i s the process of recovery from t h i s eating disorder? This chapter explores issues related to these questions. The l i t e r a t u r e i s reviewed on treatment outcome studies and studies which examine therapeutic change agents. The l i m i t a t i o n s and assumptions concerning recovery from bulimia inherent i n the various approaches are also discussed. F i n a l l y , based upon the l i t e r a t u r e and my c l i n i c a l experience i n eating disorders, my presuppositions about the nature and process of recovery from bulimia are stated so that they can be set aside during the research process. Treatment Outcome Studies The scope of t h i s part of the l i t e r a t u r e review i s limited to c l i n i c a l studies on t r e a t i n g normal-weight bulimics, and thus excludes studies of bulimics with associated anorexia nervosa or obesity. Furthermore, t h i s review i s confined to non-drug treatment interventions which therapists or counsellors can implement within a c l i n i c a l s e tting. Therefore, i t does not include the many pharmacological studies, most of which indicate the u t i l i t y of t r i c y c l i c antidepressant drug therapy i n the treatment of normal-weight bulimics who manifest depressive symptoms. However, the outcome studies pertaining to psychodynamic and family therapies as well as the controlled group and i n d i v i d u a l cognitive-behavioural treatments have been included. According to Fairburn (1988), these various 15 therapeutic approaches have assumed that the e t i o l o g i c a l variables upon which they are based are also the c a t a l y s t s , change mechanisms, or curative factors i n the recovery process. However, these c l i n i c a l observations have not been rigorously researched. The research on treatment approaches i s very young (Johnson & Connors, 1987); Fairburn's (1981) cognitive-behavioural approach was the f i r s t study on the treatment of normal-weight bulimia. And while a plethora of studies using cognitive- behavioural therapy appeared i n 1984 to 1986, l i t t l e research on the various psychological treatment approaches has been done since then (Johnson & Connors). The trend i n the l i t e r a t u r e seems to be toward the study of drug treatments as well as the personality, family, and socioeconomic correlates of bulimia. Another possible explanation for the s c a r c i t y of treatment research i s that with up to 3-year follow-up periods being included i n the studies, those which began i n 1986 may s t i l l be i n progress (Herzog et a l . , 1988; Johnson & Connors; M i t c h e l l , Pyle, Hatsukami, Goff, Glotter, & Harper, 1989). The following section discusses the psychodynamic, family systems, and cognitive-behavioural theories. The corresponding treatment outcome studies are presented and c r i t i q u e d . Also, the various t h e o r e t i c a l assumptions concerning recovery from bulimia are elucidated. Psychodynamic Therapy Studies The psychodynamic treatment approach stems from the view that psychosomatic disorders are a manifestation of early 16 unresolved unconscious c o n f l i c t s and intrapsychic or underlying d i f f i c u l t i e s (Norman et a l , 1986). The i n d i v i d u a l has a sense of pervasive ineffectiveness which leads to e f f o r t s to gain s e l f - control i n the realm of weight (Yager, 1988). Psychodynamic theory includes, but i s not li m i t e d to, Freudian psychoanalysis and object-relations theory. Thus, treatment addresses the c o n f l i c t s or developmental needs of the i n d i v i d u a l and the function of the bulimic symptoms within her psychological economy (Herzog et a l . , 1987). The l i t e r a t u r e on psychodynamic psychotherapy i s heavily anecdotal and lacks v a l i d i t y i n i t s causal analysis. Empirical outcome studies have been c r i t i c i z e d by Herzog et a l . (1987) because they lack control groups or randomization and also indicate a lack of s i g n i f i c a n t difference i n outcome between patients who received psychotherapy and those who did not" (p. 545). In a controlled follow-up study by Norman et a l . (1986), indivi d u a l s who engaged i n at least 12 weeks of eith e r individual or group insight-oriented therapy were compared to those who had either no treatment or only medical/nutritional follow-up. Using the Eating Attitudes Test, Hopkins Symptom Checklist, and Social Adjustment Scale, re s u l t s at a one-year follow-up showed that psychodynamic treatment was associated with a decrease i n disordered eating behaviours and attitudes, depression, and somatic concerns. However, there was no s i g n i f i c a n t remission on measures of s o c i a l maladjustment, anxiety, interpersonal s e n s i t i v i t y , or obsessive-compulsive t r a i t s . Nonetheless, ind i v i d u a l s i n treatment reported improvements i n t h e i r moods and 17 concerns with relationships and i s o l a t i o n . Norman et a l . suggest that the findings demonstrate a characterological maladjustment that p e r s i s t s i n spite of improved bulimic behaviours and appears to not be d i r e c t l y linked to eating symptomatology. Norman et a l . (1986) underscore the need for follow-up studies to also measure the psychological and s o c i a l components of bulimia i n order to expand our understanding of "the course of the disorder as well as . . . possible r i s k factors for relapse and/or manifestation of other p s y c h i a t r i c disorders" (p. 56). Concerning curative factors, i n spite of the decrease i n bulimic behaviours, knowledge of the effectiveness of s p e c i f i c psychodynamic techniques i s lim i t e d because the psychodynamically-oriented therapists used a v a r i e t y of s t y l e s . From a psychodynamic approach, treatment should involve modifying the underlying c o n f l i c t s , r e s u l t i n g i n improvements i n ov e r a l l psychological functioning and self-esteem, as well as diminished bulimic symptoms (Fairburn, 1988; Norman et a l . , 1986). Issues which may be linked to the disordered eating behaviours include l i m i t e d intimacy with and incomplete autonomy from family, poor peer relationships, loneliness, poor body image, r o l e confusion, and unclear personal goals and values. Although psychodynamic therapy does not engage i n active symptom management, the cognitive alternatives and prompts of the therapist may constitute behavioural contingencies. The therapeutic a l l i a n c e involves empathetically responding to the indi v i d u a l ' s developmental needs i n order to f a c i l i t a t e her awareness and acceptance of her needs and feeli n g s . Forming 18 "achievable goals that w i l l begin to replace the patient's desperate inner struggle for control with a growing sense of mastery" i s also emphasized (Goldman, 1988, p. 566). In addition, the therapeutic r e l a t i o n s h i p e n t a i l s understanding how the ind i v i d u a l i s experiencing her relationship with her therapist. The assumption i s that the individual's interactions i n therapy are a r e f l e c t i o n of how she perceives herself and others as well as in d i c a t i v e of r e l a t i o n a l patterns. Therefore, the therapeutic a l l i a n c e helps the in d i v i d u a l become aware of her b e l i e f s and defensive 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 alternate thinking styles and coping behaviours (Bruch, 1973; Johnson et a l . , 1987; Steiger, 1989). In summary, from the psychodynamic approach, recovery from bulimia e n t a i l s addressing the individual's intrapsychic developmental c o n f l i c t s and i n t e r a c t i o n a l patterns within the therapeutic r e l a t i o n s h i p . Although no d i r e c t symptom management of bulimic behaviours i s involved, the therapeutic a l l i a n c e f a c i l i t a t e s the individual's awareness of maladaptive cognitive patterns and interpersonal interactions so that thinking and behavioural s t y l e s become more functional. Systemic Family Therapy Studies The family therapy studies are based on family systems theory and therefore view the bulimic symptoms as "related to family processes such as overprotectiveness, escalating power struggles, or the i n a b i l i t y of family members to r e a l l y know each other" (Schwartz et a l . , 1985, p. 292). According to Johnson and Connors (1987) and my own search of the l i t e r a t u r e , there are 19 only two outcome studies on the use of family therapy for bulimia: Schwartz (1982) and Schwartz et a l . (1985). This lack of attention to the family context i n bulimia may stem from the fa c t that many bulimics no longer l i v e with t h e i r families of o r i g i n and f e e l that t h e i r families should not be involved i n treatment as they are unaware of the bulimia (Schwartz et a l . ) . Consequently, therapists are less i n c l i n e d to involve families i n the treatment process. Schwartz (1982) described the f i r s t outcome study of family therapy and bulimia. He used Minuchin's (1974, 1978) s t r u c t u r a l family therapy model, making some adaptations s p e c i f i c to bulimia as he worked with a 17-year-old bulimic and her two parents. Therapy involved 31 sessions over a one-year period: one-third were i n d i v i d u a l sessions with Mary and one-quarter were marital sessions with her parents. In Stage 1, interventions were aimed at restructuring the family hierarchy so that Mary became more distant from her parents' relationship and her mother. As she also became more involved with her peers and her father, reduced family enmeshment occurred. When a f t e r 3 months the frequency of bingeing and vomiting had decreased some but was s t i l l an issue, Stage 2 g o a l s — u n i t i n g the parents, disengaging from parents' marital issues, and changing the family's view of Mary's bulimia from an i l l n e s s to a pleasurable habit—were implemented. Owing to t h e i r outrage at the food Mary was wasting, her parents intervened by making food ava i l a b l e only at meal times. From here on, Mary's bulimia ceased. Furthermore, her s o c i a l confidence and autonomy were 20 enhanced by a class graduation t r i p . During t h i s time, her parents discovered they could l i v e together without Mary. Stage 3 of therapy involved marital counselling and i n d i v i d u a l sessions with Mary which focused on l i f e planning rather than family involvements. Once Mary was free of bingeing for 3 months and was involved i n art school, therapy was terminated. At a one-year follow-up, r e s u l t s showed that the improvements were maintained. Mary had established some close female relationships, had begun inter a c t i n g with men, and had disengaged herself from parental marital f i g h t s . Although she binged about once a month when she f e l t uptight, she "was unconcerned about t h i s and f e l t that food was no longer an obsession " (Schwartz, 1982, p. 80). Schwartz et a l . (1985) conducted a study with 30 outpatient bulimic females and t h e i r families i n which s t r u c t u r a l family 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 family of o r i g i n members were not present, therapy was done with the in d i v i d u a l alone or her spouse and/or children. Treatment involved an average of 3 3 sessions over a 9-month period. The stages of therapy entailed (a) priming the i n d i v i d u a l and her family for d i f f e r e n t i a t i o n and f a c i l i t a t i n g the d i f f e r e n t i a t i o n , (b) focusing on the symptom, and (c) consolidating the changes. In Stage 1, Schwartz et a l . challenged family and in d i v i d u a l b e l i e f s and patterns of i n t e r a c t i o n . Also, they emphasized the importance of helping the i n d i v i d u a l acknowledge that she was the one who was bingeing and purging, and of f a c i l i t a t i n g her awareness and experiencing of 21 feelings which the bulimic behaviours helped her avoid. In Stage 2, Schwartz et a l . found that i t was easier for the in d i v i d u a l to l e t go of her symptoms i f she was not l i v i n g i n her parents' home in a dependency s i t u a t i o n . Interventions which helped the in d i v i d u a l gain more control over her bingeing and purging included reframing the bulimic episode as a signal that she wanted to f e e l nurtured, or changing her intrapersonal and/or interpersonal patterns of int e r a c t i o n . In Stage 3, the ind i v i d u a l ' s issues of intimacy, career planning, and assertive behaviour were addressed. When the therapist prescribed a relapse, the i n d i v i d u a l and family often became more aware of how to avoid re-creating the interactions which formed the context of bulimia. At the end of treatment, 66% of the subjects had reduced the frequency of t h e i r bulimic episodes from a mean of 19.3 per week to the f i r s t l e v e l of control over eating behaviours: one or fewer per month. Their attitudes about control were that they f e l t "nearly always i n control" (Schwartz et a l . , 1985, p. 304). Ten percent of the subjects were at the second l e v e l : they had episodes which ranged i n frequency from two per month to one per week and said they f e l t "usually i n con t r o l " (Schwartz et a l . , p. 3 04). At a 16-month follow-up, a l l of the indivi d u a l s at the f i r s t l e v e l had maintained t h e i r improvements. However, two- t h i r d s of the subjects who were at the second l e v e l had relapsed to the t h i r d l e v e l : two to four episodes per week with control being somewhat of a problem. Results of the other outcome c r i t e r i a — c h a n g e i n family relationships, change i n l i f e goals or 22 career, and change i n the individual's behaviour i n e x t r a f a m i l i a l relationships—were not reported. However, Schwartz et a l . found that the obstacle to f e e l i n g i n control of bulimic symptoms was not symptom chroni c i t y but rather l i v i n g at home with parents. Although the outcomes from these two family treatment studies are promising, determining the r e l a t i v e effectiveness or necessity of s p e c i f i c interventions i s precluded because of the wide v a r i e t y of interventions used and the uncontrolled nature of the studies. Clearly more controlled studies to i s o l a t e s p e c i f i c components of family therapy and t h e i r e f f e c t s are required to a s s i s t i n developing a model for t r e a t i n g bulimic f a m i l i e s . The importance of understanding bulimia from a family perspective i s underscored by Schwartz et a l . (1985) who have found i t uncommon that families are unaware of t h e i r daughter's bulimia and even more unusual that they are unwilling to become involved i n therapy. Furthermore, many bulimics are often s t i l l quite t i e d to t h e i r families i n spite of geographical distance from them. The assumptions concerning recovery from bulimia which are inherent i n the family therapy studies are that a cessation of bingeing and purging, or no relapses even though lapses may occur denotes recovery (Schwartz, 1982; Schwartz et a l . , 1985). And while improvements i n the family structure and hierarchy which activate and support the individual's d i f f e r e n t i a t i o n from the family system are necessary and foundational to recovery for most cases, they may not be s u f f i c i e n t . Individuals' ambivalence about giving up t h e i r symptoms and the fear of many families regarding the growing autonomy of t h e i r daughters may contribute 23 to the persistence of the bulimic symptoms i n some individuals in spite of e f f e c t i v e family restructuring (Schwartz et a l . ) - Thus, some form of intensive symptom-specific interventions such as monitoring food consumption or redefining the bulimic episodes may be necessary to eliminate or gain control of the bulimic behaviours (Schwartz; Schwartz et a l . ) . Furthermore, these two studies emphasize the importance of 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 ind i v i d u a l needs to have f i r s t attained a degree of d i f f e r e n t i a t i o n from her family p r i o r to introducing symptom- focused interventions because the bulimic behaviours can be reactivated by family i n t e r a c t i o n a l patterns. F i n a l l y , once the ind i v i d u a l i s less protected by and protective of her family, the extent to which she i s able to develop s a t i s f y i n g and close e x t r a f a m i l i a l relationships i s purported by Schwartz (1982) as c r u c i a l to recovery because "the feedback the patient received from new friends helped to decrease her preoccupation with her weight and with her appearance i n general, a preoccupation that seems highly correlated with the eating disorder" (p. 81). In summary, from the family therapy approach, recovery from bulimia involves changes i n interpersonal interactions within the family and e x t r a f a m i l i a l contexts. Intrapsychic changes i n the emotional and cognitive realms which are effected by the changes i n s o c i a l relationships are also considered to f a c i l i t a t e recovery. And, with some individuals, behavioural interventions aimed at interrupting the bulimic pattern may need to be combined 24 with changes i n the family's functioning and i n t e r a c t i o n a l patterns. Cognitive-Behavioural Therapy Studies Most of the treatment research on bulimia has focused on cognitive-behavioural (CB) interventions i n both group and i n d i v i d u a l contexts. Cognitive-behavioural therapy (CBT) i s based on s o c i o c u l t u r a l and psychological theories which highlight respectively the r i s k factors of s o c i o c u l t u r a l norms for thinness as an indicator of feminine attractiveness, success and control (Striegel-Moore et a l . , 1986), and low self-esteem due to body image d i s s a t i s f a c t i o n (Schwartz et a l . , 1985; Fairburn, 1985). Inherent i n the CB studies i s the notion that recovery i s indicated by freedom from bingeing ad purging, or no relapses (Connors et a l . , 1984; Cooper et a l . , 1989; Johnson & Connors, 1987; Manley, 1989) and a decreased i n t e n s i t y of dysfunctional attitudes toward body shape and weight. This approach advocates that recovery involves addressing the abnormal eating behaviour using predominantly behavioural techniques to e s t a b l i s h some degree of control over eating. Modifying dysfunctional b e l i e f s and values about body shape and weight which perpetuate the bulimic behaviours are also considered necessary for recovery (Fairburn, 1985). CBT i s a "treatment package" involving a v a r i e t y of behavioural and cognitive interventions. Therefore, a change i n disturbed eating habits as well as attitudes towards shape and weight i s necessary for l a s t i n g recovery (Cooper et a l . ) . According to Fairburn (1988), change i n attitude toward body shape and weight i s the best predictor of prognosis. 25 Another assumption of the CB approach i s that the establishment of a t r u s t i n g therapeutic r e l a t i o n s h i p i s paramount to recovery because the therapist i s continually encouraging the i n d i v i d u a l "to take r i s k s i n modifying eating behaviours" (Manley, 1989, p. 153). 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 for progress i s emphasized. According to Fairburn (1985), i n Stage 1 of CBT, interruption of the binge/purge behaviours and regaining control over eating i s f a c i l i t a t e d through techniques such as education about v a r i a b i l i t y i n body weight, weight regulation, the l i n k between d i e t i n g and bingeing and body image misperception. S e l f - monitoring of eating habits and the circumstances associated with binge/purge episodes and p r e s c r i p t i o n of a regular eating pattern are other interventions which are used. Additional behavioural techniques include stimulus control measures which involve 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 eating. In Stage 2, cognitive interventions are employed to i d e n t i f y and modify dysfunctional b e l i e f s and values that one's "shape and weight are of fundamental importance and that both must be kept under s t r i c t c o ntrol" (Fairburn, 1985, p. 161). Therefore, techniques include the gradual introduction of moderate amounts of "fattening foods" and relaxing of control over the content of one's d i e t i n order to challenge the b e l i e f "that c e r t a i n foods are inherently fattening" (Fairburn, 1985, p. 177). Problem- solving t r a i n i n g which helps the i n d i v i d u a l generate alternative 26 ways of dealing with adverse events, thoughts or emotions without resorting to bingeing tends to counter all-or-nothing thinking and decrease t h e i r preoccupation with food and weight. Relaxation and assertiveness t r a i n i n g as well as e f f i c a c y - enhancing imagery may also be included. Cognitive restructuring which involves discussing and generating counter-arguments to dysfunctional b e l i e f s — " I f e e l f a t and therefore I am f a t " and "I must be t h i n , because to be t h i n i s to be successful, a t t r a c t i v e and happy" (Fairburn, 1985, p. 182)—and examining the benefits and costs of adhering to them i s also used. F i n a l l y , i n order to deal with future lapses or relapses so that the episodes do not get out of control, a plan i s devised to anticipate and cope with high r i s k s i t u a t i o n s . Some studies (Wilson, Rossiter, K l e i f i e l d , & Lindholm, 1986) also include Stage 3 which focuses on relapse prevention using "exposure with response prevention" i n which subjects are encouraged to eat forbidden foods, but then to delay or r e f r a i n from purging. Within the empirical research l i t e r a t u r e , the CB treatments are often compared with another group which may receive fewer cognitive or behavioural techniques, or j u s t a purely behavioural treatment. And while these studies demonstrate s t a t i s t i c a l l y s i g n i f i c a n t reductions 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 reduction have not been i d e n t i f i e d . For instance, i n the studies of Kirkley et a l . (1985) and Fairburn et a l . (1986), i t i s impossible to determine which interventions of the CB treatment packages are responsible for the s t a t i s t i c a l l y s i g n i f i c a n t 27 r e s u l t s . Further research using component analyses 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 es s e n t i a l elements so that the s p e c i f i c interventions 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 (Cooper et a l . , 1989; Fairburn et a l . , 1986; Johnson & Connors, 1987; Kirkley et a l . , 1986). Another shortcoming of the CB studies i s that the s c a r c i t y of longterm follow-up research precludes understanding the lon g i t u d i n a l course of bulimia and the nature of the change mechanisms which i n i t i a t e , f a c i l i t a t e , and maintain recovery (Mitchell et a l . , 1989). F i n a l l y , while the studies also measure changes i n assertion (Kirkley et a l . , 1985), self-esteem (Connors et a l . , 1984), depression (Lacey, 1983), s o c i a l adjustment, and attitudes 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 inconsistency of psychosocial outcome c r i t e r i a between the studies. Cognitive-behavioural studies by Fairburn et a l . (1986) and Cooper et a l . (1989) found that the control condition which contained a purely behavioural treatment resulted i n s i g n i f i c a n t improvements i n bingeing and purging behaviours. Consequently, the necessity of the cognitive component i n producing symptomatic change i s questioned. Furthermore, although the behavioural treatment may have produced cognitive change as suggested by improvements on the Eating Attitude Test, further studies are needed to address whether cognitive change i s necessary for recovery. 28 According to Fairburn (1985), c e r t a i n behavioural interventions such as the introduction of a regular eating pattern and avoided foods give increased control over eating which i n turn increase one's sense of mastery and progressively decrease disturbed thinking about body weight and shape. These re s u l t s are substantiated by Schneider, O'Leary, and Agras (1987) who found that decreases i n purging behaviour were s i g n i f i c a n t l y r elated to increases i n three domains of perceived s e l f - e f f i c a c y : c o n t r o l l i n g bingeing during various mood states, c o n t r o l l i n g bingeing using stimulus-control techniques, and developing s a t i s f a c t o r y s o c i a l r elationships. While the increased s e l f - e f f i c a c y pertaining to acceptance of body shape was correlated with decreased purging frequency, i t did not change s i g n i f i c a n t l y during treatment. Thus, i t seems tenable to conclude that behavioural techniques which decrease purging behaviours also enhance the individual's perceived s e l f - e f f i c a c y or b e l i e f that she can use her s k i l l s to e f f e c t i v e l y respond to s i t u a t i o n s . However, Fairburn (1985) advocated that b e l i e f s and values should s t i l l be explored even i f formal cognitive restructuring i s unnecessary because often times "although there has been some cognitive change, cert a i n core a t t i t u d i n a l abnormalities remain i n t a c t " (p. 183). In summary, the cognitive-behavioural approach advocates that while behavioural techniques are necessary to r e e s t a b l i s h control over eating behaviours, they are not s u f f i c i e n t for l a s t i n g recovery. The disturbed thinking and values about body shape and weight which maintain the bingeing and purging 29 behaviours must also be modified through cognitive interventions (Fairburn, 1985). F i n a l l y , although the CB approach presents change as an ordered process with the f i r s t stage focused on eating behaviour and the second stage proceeding through an ordered series of well-defined cognitive restructuring steps, the entire program i s cognitively oriented. In practise, s i g n i f i c a n t cognitive change often occurs during Stage 1 and the early part of Stage 2 so that the course of formal cognitive restructuring "tends to be highly variable and e r r a t i c " (Fairburn, 1985, p. 183) . Therapeutic Change Agent Studies While the treatment outcome studies assume that the curative factors are the change mechanisms within formal therapeutic approaches, the therapeutic change agent studies, which interviewed i n d i v i d u a l s who are recovering or who have recovered from an eating disorder, found that factors both inside and outside of therapy f a c i l i t a t e d recovery. However, since the change agent studies uncovered only i s o l a t e d aspects of the recovery experience and revealed 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 for some of the individuals, the pattern of the process of recovery was lim i t e d and incomplete. Given that the ind i v i d u a l who has recovered from an eating disorder i s the expert on the meaning and e f f e c t of the variables which were c r i t i c a l i n her recovery (Maine, 1985), and given that the therapist and c l i e n t often 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 et a l . , 1989), only the studies which report the recovered 30 i n d i v i d u a l ' s perspective on f a c i l i t a t i v e factors are reviewed. Therefore, studies i n which the therapist or family recounted the curative factors and t h e i r impact on the recovery process are not included (Bruch, 1988; Erickson, 1985; Goldman, 1988; Jackson, 1986; Maddocks & Bachor, 1986; Rabinor, 1986; Vognsen, 1985). In the study by Hobbs et a l . (1989), therapists and i n d i v i d u a l s with bulimia were asked at 3-week i n t e r v a l s to describe the events i n group therapy which were personally important for them. Judges then assigned one of ten therapeutic factors to each event. While therapists valued s e l f - d i s c l o s u r e and acceptance as important, c l i e n t s rated i n s t i l l a t i o n of hope, vicario u s learning, and u n i v e r s a l i t y as most important. Furthermore, the importance of the various factors s h i f t e d throughout the 10 weeks: Self-disclosure, vicarious learning and u n i v e r s a l i t y were valued i n the early stage, self-understanding i n the middle phase, and i n s t i l l a t i o n of hope in the f i n a l phase. Concerning the l i m i t a t i o n s of t h i s study, the research tool was problematic i n that i n t e r r a t e r r e l i a b i l i t y was low. For instance, judges assigned the same event to d i f f e r e n t therapeutic factors because of subtle differences i n reporting. In addition, using t h i s methodology d i l u t e s the meaning of the event for the i n d i v i d u a l or why i t was important for her. For example, "vicarious learning" i s defined as "the patient experiences something of value for herself through the observation of other group members (including the t h e r a p i s t ) " (Hobbs et a l . , 1989, p. 627). And the 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 perceives that other group members have s i m i l a r problems and 31 feelings and t h i s reduces her sense of uniqueness" (Hobbs et a l . , p. 627). Thus, only a p a r t i a l understanding of the meaning of the experience for the i n d i v i d u a l i s gained and the impact of the event on her recovery experience i s not elucidated. Further research into the nature of therapeutic e f f e c t s within small- group treatments of bulimia i s therefore required. Nonetheless, Hobbs et a l . (1989) discussed several assumptions of recovery implied by the r e s u l t s which are noteworthy. F i r s t , while disclosure of personal information can be important i n overcoming bulimia, experiencing one's s e l f - disclosures as accepted by others was paramount to perceiving s e l f - d i s c l o s u r e as therapeutically valuable. Second, u n i v e r s a l i t y or r e a l i z i n g that others have s i m i l a r problems and feelings may enhance an individual's sense of belonging, support, and/or acceptance even though she has revealed information about herself which she had considered unacceptable. Third, as in d i v i d u a l s shared how t h e i r improvements occurred, vicarious learning contributed to a sense of optimism about one's progress or the p o t e n t i a l for progress. Stanton et a l . (1986) explored the nature of self-change i n bulimia by interviewing and administering a modified version of the Processes of Change Test to 15 former bulimics who had recovered i n the absence of formal therapy. On the average, in d i v i d u a l s had been abstinent from bingeing and purging for 7 months p r i o r to the study. Although the study uncovers the curative factors i n the "contemplation and active stages" of treatment, insight into the meaning and impact of the events i s 32 minimal. Data from the structured interview showed that i n the "contemplation stage" of recovery "a desire to improve self-esteem was 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 eating" (Stanton et a l . , 1986, p. 921) and that recognition 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 purging behaviours. According to Stanton et a l . , these factors may correspond to the subscales on the Processes of Change Test of s e l f - r e e v a l u a t i o n — "I consciously struggle with the issue that purging contradicts my view of myself as an e f f e c t i v e person i n control of my own l i f e " — a n d consciousness r a i s i n g : "I think about information from a r t i c l e s or ads concerning the benefits of q u i t t i n g binge eating or purging" (p. 919). In the subsequent "active change stage" of recovery, t e s t r e s u l t s revealed that the factors which were used most frequently i n overcoming bulimic behaviours were " s e l f - l i b e r a t i o n ('I t e l l myself I am able to quit purging i f I want t o ' ) , counterconditioning ('I do something else instead of binge eating when I need to relax or deal with t e n s i o n 1 ) , . . . [and] helping rel a t i o n s h i p s ( 11 can be open with at least one s p e c i a l person about my experiences with my eating h a b i t s 1 ) " (Stanton et a l . , 1986, p. 919). In 1983, H a l l and Cohn (cited i n Hall & Cohn, 1986) surveyed 217 recovered and recovering b u l i m i c s — j u s t over half of whom had also had a n o r e x i a — t o uncover factors that were he l p f u l i n recovery. Individuals ranked 10 therapy options and 13 he l p f u l a c t i v i t i e s on a 5-point scale with 1 = no help and 5 = most help. 33 Of the 3 0 indivi d u a l s who reported that they were cured, 80% stated that professional therapy was "most h e l p f u l " , 54% rated friends and family 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 pursuits, 40% acknowledged pr o f e s s i o n a l l y - l e d groups, and 27% referred to s e l f - l e d support groups. Results from the 3 0 recovered in 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 included: t a l k i n g about bulimia (80%), physical exercise (80%), relaxation techniques (67%), reading a newsletter from a s e l f - h e l p organization (63%), and journal writing (60%). Im p l i c i t i n t h i s study i s the assumption that recovery involves factors both inside and outside of formal therapy. However, given the close-ended nature of the questionnaire format, minimal insight was gained into the meaning of these events for the individuals and how they impacted the process of recovery. For example, only the meaning of s p i r i t u a l pursuits was further explored. S p e c i f i c r e l i g i o n s and practises were reported to give individuals a sense of comfort, peace, and security as they experienced being loved unconditionally regardless of how they looked or what the did. Furthermore, the scope of curative factors was limited as possible factors which the recovered individuals considered h e l p f u l were not included i n the questionnaire. Instead, only the therapists' perspectives on f a c i l i t a t i v e events were used to design the survey. Kirk (1986) administered a questionnaire comprised of 74 po t e n t i a l treatment or recovery methods i d e n t i f i e d i n the l i t e r a t u r e to 123 recovered bulimics i n order to ascertain what they "[perceived] as s i g n i f i c a n t factors i n t h e i r recovery" (p. 34 11). Open-ended questions were also used i n order to e l i c i t f a c i l i t a t i v e factors not included i n the questionnaire. In addition, Kirk conducted a structured personal interview with consenting indiv i d u a l s i n order to gain insight into self-image changes since having recovered, confidence i n maintaining freedom from bingeing and purging, and current coping mechanisms. Results showed that 3 of the 10 items rated as most help f u l to more than 50% of the respondents were concerned with exploring the issues underlying the bulimic behaviours: "learning why I turned to or away from food when bored, t i r e d , angry" (73.3%), "finding a sense of my true s e l f (no longer standing outside observing my own behaviours)" (69.8%), and "learning to c a l l on my inner resources-determination, courage, patience" (64.9%) (Kirk, 1986, p. 65). Cognitive-behavioural techniques found to be most he l p f u l to the majority of individuals included "learning to control s e l f - defeating thoughts and feelings" (69.2%), "learning not to be over-concerned with other peoples' opinions and reactions" (69.0%), "learning constructive ways to deal with anger" (65.7%), " l e t t i n g go of my should statements" (65.5%), and "widening my range of s o c i a l a c t i v i t i e s " (63.8%) (Kirk, 1986, p. 69). Only one of the most help f u l items was a food issue: "learning to eat a healthy breakfast, lunch, and dinner" was help f u l to 66.9% of the respondents" (p. 71). Additional information on f a c i l i t a t i v e factors was gained from the open-ended questions. Trusting and loving relationships with supportive boyfriends, spouses, family members, or God 35 helped i n d i v i d u a l s r e a l i z e that they "had good q u a l i t i e s of [their] own and that [they] didn't have to earn love, friendship and attention" (Kirk, 1986, p. 130). Also, s p i r i t u a l 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 groups such as Overeaters Anonymous decreased i n d i v i d u a l s ' preoccupation with food as they concentrated on a s p i r i t u a l power and l e t "go of the control [they] thought [they] needed i n l i f e to a higher power (God)11 (Kirk, p. 13 0). In turn, they gained control over t h e i r eating behaviours. With respect to information c u l l e d from the personal interviews, respondents reported "an increase i n self-esteem a f t e r recovery: They [were] more in touch with t h e i r feelings and [had] confidence i n themselves" (Kirk, 1986, p. 134). Furthermore, 10 of the 12 respondents indicated "that they were f a i r l y to very confident that they [would] not return to the binge-purge cycle" (p. 134). Current coping mechanisms included increased communication with others, exercise, and finding time for relaxation within a busy schedule. Thus, as i s c h a r a c t e r i s t i c of the therapeutic change agent studies, 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 for some of the indiv i d u a l s were explored and no cl e a r pattern of the process of recovery was uncovered. Beresin (198 5) conducted a p i l o t study i n which a group of recovered anorexics and a control group of anorexics were interviewed and asked to complete several scales. Findings indicated that the recovered anorexics showed improvement on the extended family subscale of the Social Adjustment Scale and on 36 the perfectionism subscale of the Eating Disorders Inventory. Factors i n formal therapy which were reported as f a c i l i t a t i v e of recovery included a non-judgmental therapist who was both empathic and confrontative, and with whom they f e l t validated for who they were. This therapeutic r e l a t i o n s h i p helped individuals to i d e n t i f y and t r u s t t h e i r feelings and to begin taking r i s k s with others. Through therapy, they also r e a l i z e d t h e i r families* contribution to t h e i r eating disorder, family members became more aware of each others' feelings, and i n d i v i d u a l s began to p h y s i c a l l y and emotionally separate from t h e i r families and to de-idealize and forgive t h e i r mothers. Curative factors within group therapy or s e l f - h e l p groups included f e e l i n g supported and understood by others struggling with the same feelings, and owning t h e i r feelings without shame or fear. As out-of-therapy experiences were rated as important as in-therapy experiences, Beresin (1985), as does Maine (1985), assumes that recovery involves an i n t e r a c t i o n of both types of curative factors. Personal experiences of s e l f which f a c i l i t a t e d recovery include getting bored with anorexia, expressing feelings to others, gaining a sense of independence through a r e b e l l i o u s act, self-acceptance and l e t t i n g go of perfectionism, and finding an i d e n t i t y other than that of being an anorexic. Interpersonally, individuals reported that being a mother increased self-worth and that intimate sexual relationships helped one to take pleasure i n rather than be ashamed of her body. And, i n d i v i d u a l s began to f e e l a greater sense of achievement and s a t i s f a c t i o n through school and career pursuits 37 rather than through food and weight. F i n a l l y , i n d i v i d u a l s reported that body image was the most d i f f i c u l t aspect to change as well as obsessive thoughts and behaviours pertaining to food and weight. And, recovery involved "retaining excessive concern about food and weight but no longer being obsessed by them" (Beresin, p. 12). In summary, while Beresin's (1985) study gave some ins i g h t into the meaning of the curative factors and attempted to sketch a pattern of recovery, knowledge of the recovery process i s limited. Unlike the studies of recovering or recovered bulimics and anorexics (Beresin, 1985; Hall & Cohn, 1986; Hobbs et a l . , 1989; Kirk, 1986; Stanton et a l . , 1986), Maine (1985) elucidated more f u l l y the meaning and impact of the curative factors for in d i v i d u a l s and began to outline a more complete pattern of recovery. Maine's study suggested that recovery involved an i n i t i a l awareness of personal r e s p o n s i b i l i t y and self-motivation for getting better. Despite warnings from medical s t a f f and family members regarding the severity of t h e i r disorder, in d i v i d u a l s a c t i v e l y decided to recover only when they had panicked at the r e a l i z a t i o n that they did not have the strength to walk or the a b i l i t y to eat. This s e l f - r e s p o n s i b i l i t y paved the way for recognition of distorted thinking patterns. Feeling validated within a therapeutic r e l a t i o n s h i p was another e s s e n t i a l agent i n recovery. A v a l i d a t i n g , affirming, and accepting rel a t i o n s h i p with a therapist provided a sense of unconditional acceptance so that they could 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 tendencies for gaining acceptance and allow 38 themselves to experience opportunities for "self-exploration, sharing, intimacy, and 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). This foundation of respect and intimacy gave in d i v i d u a l s the confidence to t r u s t others enough to reach out to them. Finding companionship more rewarding than being i s o l a t e d spurred individuals to improve t h e i r health and n u t r i t i o n so that they could maintain t h e i r r e l a t i o n s h i p s . S i m i l a r l y , informal supportive relationships with extended family and friends was c i t e d as a major factor that was f a c i l i t a t i v e of recovery. Unlike the anorexics' families who were r e l a t i n g only to t h e i r disorder and i n s i s t i n g that they eat, supportive others provided a f f e c t i o n and self-worth by "[treating] them as whole people and [giving] acceptance and encouragement" (Maine, 1985, p. 51) i n a non-judgmental and non- threatening manner. Consequently, feelings of loneliness, i s o l a t i o n , and self-doubt decreased and a sense of control and autonomy rather than powerlessness was fostered. As a r e s u l t , i n d i v i d u a l s were often able to eat within these relationships and to hear the concern regarding t h e i r physical functioning. Acceptance of the d i f f i c u l t i e s within the family system and the pressures from the s o c i o c u l t u r a l system were also essential i n the recovery process. I n i t i a l l y , i ndividuals gained insight into family communication patterns and roles, acknowledging t h e i r impact on t h e i r l i v e s . As they came to accept that they could not change t h e i r families by losing another pound, they recognized that they could only change themselves. So, instead 39 of using food to express emotions and unmet needs, indivi d u a l s accepted themselves and the fact that they had to f i l l t h e i r own needs. As a r e s u l t , they began to move away from t h e i r s e l f - destructive symptoms and l i v e more f u l l y . Likewise, as the i n d i v i d u a l s accepted the c u l t u r a l system with i t s emphasis on slimness, "they recognized t h e i r d i e t i n g as a f u t i l e attempt to be perfect, to deny t h e i r feelings, and to gain control over t h e i r l i v e s " (Maine, 1985, p. 52). This r e a l i z a t i o n engendered self-acceptance, self-esteem, and more r e a l i s t i c goal-setting. F i n a l l y , given that factors both inside and outside of formal therapy were reported 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 that the curative factors are not l i m i t e d to those inside of formal therapy. Furthermore, the pattern of recovery underscores the synergetic i n t e r a c t i o n of curative factors both inside and outside of formal therapy. Summary Upon comparing the assumptions regarding recovery purported by the treatment outcome studies and studies on therapeutic- change agents, several common perspectives are apparent. According to the Random House College Dictionary (1975), recovery i s defined as "restoration or return to health or a normal condition, as a f t e r sickness or d i s a s t e r " (p. 1104). Within the CB studies, t h i s perspective on recovery was most s a l i e n t as emphasis was placed on reestablishing control over eating behaviours. The therapeutic change agent studies also proposed that recovery entailed r e i n s t i t u t i n g a previous l e v e l of functioning purporting that the curative factors were "essential 4 0 to the progression toward health-restoration and recovery" (Maine, 1985, p. 51). However, l i k e the psychodynamic and family therapy studies i n which p r i o r optimum l e v e l s of intrapsychic and interpersonal functioning were not assumed, the CB studies acknowledged that thinking patterns needed to be challenged. Furthermore, Maine (1985) i d e n t i f i e d factors 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 fostered intimacy and interdependence that were not previously 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, family systems, and cognitive-behavioural approaches and some of the therapeutic change agent studies suggested that the recovery process was future-oriented and developmental. Thus, while recovery was viewed as a r e h a b i l i t a t i o n process to restore individuals to a previous l e v e l of functioning, psychosocial development and moving beyond the p r i o r developmental stage was also inherent i n most of the studies. My Presuppositions Concerning my presuppositions on the d e f i n i t i o n and nature of recovery from bulimia, since a l l of the DSM-III R (1987) c r i t e r i a must be met for a diagnosis of bulimia nervosa, an in d i v i d u a l i s by d e f i n i t i o n recovered from bulimia i f she does not meet any one of the c r i t e r i a (see Appendix A). Furthermore, since the usual course of bulimia i n c l i n i c samples " i s chronic and intermittent over a period of many years" (DSM-III R, 1987, p. 68), I adhere to Johnson and Connor's (1987) suggestion of at lea s t a one-year posttreatment period i n which the in d i v i d u a l 41 reports e i t h e r abstinence from bingeing and purging, or no relapses wherein relapse i s defined as "perceived loss of c o n t r o l " over eating behaviours (Brownell et a l . , 1986, p. 766). I concur with Schwartz et a l . (1985) who view bulimia as "a r i g i d and extreme pattern of thinking, f e e l i n g , and r e l a t i n g to others: a self-image and a l i f e o rientation that develops i n c e r t a i n family and s o c i o c u l t u r a l contexts" (p. 280). Furthermore, the functioning of the bulimic's l i f e context and her bulimia are maintained by an interplay of b i o l o g i c a l , intrapersonal, interpersonal, and s o c i o c u l t u r a l factors (Schwartz et a l . ) . Given that bulimia i s a psychosomatic disorder whereby the behavioural symptoms of bingeing and purging are a manifestation of underlying biopsychosocial factors, I subscribe to the "two-track approach" to treatment i n which both the disordered eating behaviours and factors maintaining them are addressed (Johnson et a l . , 1987; Manley, 1989; Schwartz, 1982; Schwartz et a l . ) . This two-track approach evolved from poor outcome re s u l t s when only one treatment approach was used. For instance, "high relapse rates were being reported i n behavioural treatments that focused on target symptoms without regard to underlying dynamics" (Johnson et a l . , 1987, p. 668). And i n psychodynamic treatment with no active symptom management, disturbed eating behaviour resulted i n l i f e - t h r e a t e n i n g side e f f e c t s as underlying c o n f l i c t s and issues were not s a t i s f a c t o r i l y resolved. In addition, t h i s therapeutic stance, with i t s de-emphasis on the eating problems, often re-created for individuals t h e i r "early experience of 42 f e e l i n g that they were expected to meet t h e i r n a r c i s s i s t i c parents* needs and that t h e i r s p e c i f i c , i n d i v i d u a l needs were neither seen nor attended to" (Goldman, 1988, p. 565). Thus, I believe that abstinence from bingeing and purging i s enhanced when the change mechanisms inherent i n the psychodynamic, family systems, and cognitive-behavioural approaches are integrated into an i n d i v i d u a l i z e d approach. Therefore, I view recovery as involving changes i n eating behaviours as well as improvements i n the s p e c i f i c realms which perpetuate the bulimic behaviours for each i n d i v i d u a l : dysfunctional b e l i e f s about shape and weight, unresolved emotional c o n f l i c t s , and interpersonal patterns of r e l a t i n g . Also, these changes may occur through both formal therapeutic mechanisms and out-of-therapy experiences. Although the factors which p r e c i p i t a t e bulimia are not necessarily the factors which maintain i t , the e t i o l o g i c a l theories assume that the p r e c i p i t a t i n g factors are also the factors involved i n recovery. Therefore, knowledge of the incidents involved i n the onset of one's bulimia may provide some insight into the recovery process. F i n a l l y , I believe that s p i r i t u a l changes may also be an aspect of recovery. The s p i r i t u a l dimension of individ u a l s includes one's awareness of God as each person understands Him, meaning and purpose i n l i f e , and values such as hope, compassion, and j u s t i c e (Chapman, 1987). As Cassell (1976) says, through the experience of i l l physical health and recovery, the c l i e n t ' s sense of meaning i n l i f e w i l l change which may r e s u l t i n changed values and p r i o r i t i e s . 43 In summary, my presuppositions on the nature and process of recovery from bulimia are: 1. An i n d i v i d u a l i s by d e f i n i t i o n recovered from bulimia i f she does not meet any one of the DSM-III R (1987) c r i t e r i a for bulimia nervosa. 2. Abstinence from bingeing and purging or freedom from relapse i s enhanced when the change mechanisms inherent i n the psychodynamic, family systems, and cognitive-behavioural approaches are integrated into an i n d i v i d u a l i z e d approach (Herzog et a l . , 1987; Johnson et a l . , 1987; Manley, 1989; Steiger, 1989). 3. Recovery involves changes i n eating behaviours as well as improvements i n the s p e c i f i c realms which perpetuate the bulimic behaviours for each i n d i v i d u a l : unresolved emotionai c o n f l i c t s , interpersonal patterns of r e l a t i n g , and dysfunctional b e l i e f s about shape and weight (Johnson et a l . , 1987; Manley, 1989; Schwartz, 1982; Schwartz et a l . , 1985). 4. Behavioural and psychosocial changes may occur through both formal therapeutic mechanisms and out-of-therapy experiences (Maine, 1985). 5. Recovery may also e n t a i l s p i r i t u a l changes pertaining to one's awareness of God as each person understands Him, meaning and purpose i n l i f e , and values of hope, compassion, and j u s t i c e (Chapman, 1987). In using the existential-phenomenological approach to examine the meaning of the phenomenon of recovery from bulimia from the co-researcher's perspective, i t i s imperative for the researcher to be d i s c i p l i n e d i n guarding against the interference 44 of personal biases. Therefore, by stat i n g my presuppositions at the beginning of the present study, I attempted to minimize the influence of my biases during the interview and analysis process i n order to ensure a f a i t h f u l and objective expression of the phenomenon. 45 Chapter III Methodology This chapter summarizes the existential-phenomenological approach to human experience and outlines subject s e l e c t i o n and research procedures. Although the phenomenological approach served as a s t a r t i n g point, the focus of t h i s study s h i f t e d from simply looking at the meaning of the phenomenon to a r t i c u l a t i n g a more coherent conceptual understanding of the process of recovery from bulimia. Design As the purpose of t h i s study i s to understand the meaning of the event or phenomenon of recovery from bulimia, the existential-phenomenological approach as described by C o l a i z z i (1978) was employed as a guideline for examining the recovery experience. This approach with i t s emphasis on understanding the meaning of phenomena as they are l i v e d i s derived from e x i s t e n t i a l i s m and phenomenology. Ex i s t e n t i a l i s m views human experience i n the world as s i g n i f i c a n t , and as "legitimate and necessary content for understanding human psychology" ( C o l a i z z i , p. 52). Phenomenology i d e n t i f i e s and describes phenomena as they are l i v e d and experienced by the individual i n the world. Phenomena can be facts, events, occurrences, or experiences (Stein, Hauck, & Su, 1975). Existential-phenomenological research seeks to understand human experience i n a manner that i s free from the s p l i t s between subject and object, experience and behaviour, and l i n e a r cause and e f f e c t ( C o l a i z z i ) . Since existential-phenomenological psychology views the i n d i v i d u a l and 46 the world as interdependent, people are not merely acted upon by outside forces. Instead, they are pa r t l y active and p a r t l y passive: They are confronted with situations i n the world within which they are free to make choices (Valle & King, 1978). As the existential-phenomenological researcher seeks to understand the phenomenon, she or he "thinks meditatively (Heidegger, 1966) about i t s meaning" ( C o l a i z z i , 1978, p. 68) by asking, "How does the in d i v i d u a l experience recovery: What does recovery involve?" The t o t a l i t y of the person should be explored: "his [or her] perceptions and cognitions, emotions and attitudes, h i s t o r y and predispositions, aspirations and experiences, and patterns, sty l e s , and contents of behavior" ( C o l a i z z i , p. 70). As variations of the phenomenon are described by d i f f e r e n t individuals, the researcher looks for the common pattern or structure of human experience which reveals i t s e l f as the meaning of a human experience. With ca 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, the meaning i s thoroughly described and disclosed by the researcher a f t e r having been v e r i f i e d by the ind i v i d u a l s . However, before the information i s analyzed, the phenomenological perspective advocates that human experience be investigated objectively by f a i t h f u l l y expressing whatever phenomenon i s present. The researcher l i s t e n s r e s p e c t f u l l y "to what the phenomenon speaks of i t s e l f " and refuses "to t e l l the phenomenon what i t i s " ( C o l a i z z i , 1978, p. 52). Being "content to understandingly dwell" ( C o l a i z z i , p. 68), the researcher does not seek to control or dominate the information that i s 47 encountered. In order to adopt t h i s stance and guard against the interference of personal biases, one's presuppositions must be c l e a r l y stated or bracketed at the beginning of and throughout the research process. F i n a l l y , t h i s type of d i a l o g a l research "takes place only among persons on equal l e v e l s , without the divisiveness of s o c i a l or professional s t r a t i f i c a t i o n s " ( C o l a i z z i , 1978, p. 69). Thus, Fr i e r e (cited i n Colaizzi) uses the term "co-researchers" (p. 69) i n l i e u of researchers and subjects. Furthermore, since co-researchers disclose t h e i r personal presuppositions, f u l l p a r t i c i p a t i o n i n the research requires r e l a t i n g as persons within a m i l i e u of t r u s t . Co-researcher Selection Co-researchers were volunteers, 19 years or older, who were recruited through advertisement notices (see Appendix F) placed at Simon Fraser University, Burnaby, B.C., The University of B r i t i s h Columbia, Vancouver, B.C., and Vancouver community centres. Notices were also placed i n two Vancouver community newspapers—The Courier and The West Ender—and i n Kinesis, a l o c a l newspaper sponsored by the Vancouver Status of Women. In addition, therapists working with eating disordered c l i e n t s were contacted by phone and sent a contact l e t t e r explaining the nature of the study (see Appendix D) and l e t t e r s for pot e n t i a l p a r t i c i p a n t s (see Appendix E). According to C o l a i z z i (1978), the necessary and s u f f i c i e n t c r i t e r i a for s e l e c t i n g co-researchers are "experience with the investigated topic and articulateness" (p. 58). Therefore, 48 s e l e c t i o n c r i t e r i a included: (a) a previous diagnosis of bulimia nervosa as defined by DSM-III R (1987) (see Appendix A), (b) no previous h i s t o r y of anorexia nervosa as defined by the DSM-III R (see Appendix B) or dual diagnosis of anorexia nervosa and bulimia nervosa, (c) a s i g n i f i c a n t period of time without any behavioural symptoms of bulimia, (d) a self-reported f e e l i n g of being genuinely recovered from bulimia, and (e) an a b i l i t y to a r t i c u l a t e t h e i r experience of recovery and elaborate on t h e i r descriptions. In order to guard against "symptom transformation" (Vognsen, 1985) i n which bulimic symptoms are replaced by other active psychological problems—such as drug or alcohol abuse, depression, obsessive-compulsive disorder, or impulsive behaviours l i k e s h o p l i f t i n g , promiscuity or s e l f - m u t i l a t i o n — a s i x t h s e l e c t i o n c r i t e r i o n was added. This c r i t e r i o n states that since having recovered from bulimia, the i n d i v i d u a l has not developed psychological problems which meet the DSM-III R (1987) c r i t e r i a for other major p s y c h i a t r i c disorders on Axis I. As I screened the telephone c a l l s of p o t e n t i a l co-researchers, further s p e c i f i c a t i o n of the t h i r d c r i t e r i o n — a s i g n i f i c a n t period of time without any symptoms of bulimia—was required. While my co-researchers needed temporal closeness to t h e i r recovery experience i n order to r e c a l l s i g n i f i c a n t d e t a i l s , they also needed enough distance to have a h o l i s t i c perspective on i t . However, several issues arose related to the amount of time which constituted a s i g n i f i c a n t period free of bulimic symptoms. F i r s t , no d e f i n i t i v e time period i s stated i n the 49 l i t e r a t u r e : Johnson and Connors (1987) suggest at l e a s t a one-year posttreatment period i n which the i n d i v i d u a l reports eit h e r abstinence from bingeing and purging or no relapses; Herzog, Franko, and Brotman (1989) recommend at l e a s t 18 months; and Brownell et a l . (1986) propose a 3-year period. Second, as complete abstinence i s d i f f i c u l t to maintain, Brownell et a l . (1986) d i f f e r e n t i a t e between relapse and lapse: Relapse i s defined as "perceived loss of control" and lapse i s "a s l i p or mistake" (p. 766) i n which control over eating behaviour i s not completely l o s t . Therefore, even i f an i n d i v i d u a l has lapsed, she i s s t i l l considered free of bulimic symptoms provided she f e e l s she has not relapsed. Therefore, when an i n d i v i d u a l telephoned and reported a 3-month period of abstinence, she was excluded from the study because she didn't meet the minimum one- year posttreatment period. Once I f e l t that 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 , we met together so that I could more f u l l y describe the purpose of the research project, what t h e i r p a r t i c i p a t i o n i n the study would involve, and the research methodology. During t h i s i n i t i a l informal meeting, I explained to each co-researcher that although I had not had an eating disorder, my i n t e r e s t i n recovery was sparked by having counselled women who were asking how they could recover from bulimia. With research studies providing neither a h o l i s t i c understanding of the recovery process nor i t s meaning for the i n d i v i d u a l , I was inspired to seek out knowledge that 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 to more f u l l y grasp the process of recovering from bulimia so that the conditions which 50 f a c i l i t a t e recovery could be maximized. Since the four in d i v i d u a l s had been recruited through advertisement notices and therefore had not received the contact l e t t e r to the volunteer (see Appendix E), I gave each person a copy. Referring to the l e t t e r , I explained that a f t e r an i n i t i a l prescreening interview with Dr. E. M. Goldner, she would have an audiotaped interview with myself i n which she would be asked to describe her recovery experience i n as much d e t a i l as possible. Furthermore, she could use other relevant sources of information such as personal journals or photographs during the interview. We would then meet several more times to v e r i f y the transcribed interview and themes, and the f i n a l narrative account. In order to ensure that each woman was distant enough from her recovery experience to be able to see i t as a whole but also close enough to remember s i g n i f i c a n t d e t a i l s , we informally discussed some of the turning points i n her recovery process. One of the women—L. S. — r e g r e t t e d that she had not kept a personal journal to f a c i l i t a t e r e c a l l of in d i v i d u a l therapy sessions and she wondered about accessing the records kept by her therapist. After encouraging each woman to ask any questions she might have, v e r i f y i n g that each in d i v i d u a l was s t i l l interested i n being a co-researcher, and establishing that we both f e l t comfortable working with each other, the ind i v i d u a l read and signed the consent form (see Appendix G). A prescreening interview time was then arranged for each po t e n t i a l co-researcher with Dr. E. M. Goldner who i s a p s y c h i a t r i s t and eating disorder expert i n the Eating Disorders 51 C l i n i c at St. Paul's Hospital, Vancouver, B.C. The purposes of t h i s screening interview were to v e r i f y that co-researchers had a previous diagnosis of bulimia nervosa as defined by the DSM-III R (1987) with no previous history of anorexia nervosa, to assess the current status of t h e i r eating behaviour, and to ensure that they exhibited no s i g n i f i c a n t indicators of other major p s y c h i a t r i c disorders on Axis I of the DSM-III R since having recovered from bulimia. Within t h i s study, since a l l of the DSM-III R c r i t e r i a must be met for a diagnosis of bulimia nervosa, i f an i n d i v i d u a l does not have any one of these c r i t e r i a she i s by d e f i n i t i o n recovered from bulimia. None of the co- researchers were previous treatment contacts of Dr. Goldner. During the half-hour, unrecorded screening interview conducted at St. Paul's Hospital, Dr. E. M. Goldner asked the following semi-structured questions i n a straightforward manner, c l a r i f y i n g responses and asking for elaboration as necessary: 1. Describe the course of your eating behaviour beginning from when you f i r s t noticed any eating problems and ending with a description of your present eating pattern. 2. S p e c i f i c a l l y describe your weight his t o r y ; h i s t o r y of binge eating, vomiting, food r e s t r i c t i o n , laxative use; menstruation; body image disturbance; mood; substance abuse. Dr. E. M. Goldner noted the i n d i v i d u a l s ' responses on the prescreening interview summary sheets (see Appendix C), contacted me by phone to elaborate upon the interview information, and mailed me the summary sheets. Based upon his assessment, Dr. Goldner was s a t i s f i e d that each i n d i v i d u a l met the c r i t e r i a of 52 having recovered from bulimia nervosa and did not qu a l i f y for any ps y c h i a t r i c disorders on Axis I as defined i n the DSM-III R (1987). However, the acceptance of one co-researcher—P. Y.—was i n i t i a l l y questionable as she met the DSM-III R (1987) c r i t e r i a for Late Luteal Phase Dysphoric Disorder, commonly referred to as Pre-Menstrual Syndrome. But a f t e r Dr. E. M. Goldner r e a l i z e d that t h i s disorder was described i n the Appendix of the DSM-III R—meaning that i t was not yet considered an accepted p s y c h i a t r i c d i s o r d e r — h e v e r i f i e d that P. Y. met the sel e c t i o n c r i t e r i a . During her interview, P. Y. referred to the uncertainty surrounding her inclu s i o n i n the study saying, " . . . even though he [Dr. Goldner] didn't think that I was gonna be able to be a part of t h i s study" (Appendix J, p. 201). Once the four co-researchers had been selected and interviewed, other background information arose as each woman t o l d her recovery story. So, while the following demographic information was not part of the co-researcher s e l e c t i o n c r i t e r i a , I c u l l e d these facts from the protocols i n order to provide a context for more f u l l y understanding each woman's recovery experience. At the time of the i n i t i a l interview, the ages of S. T., L. S., P. Y., and S. H. were respectively early f o r t i e s , early t h i r t i e s , early t h i r t i e s and early twenties. As reported to Dr. Goldner, S. T., L. S., and P. Y. had been free of bulimic symptoms for the past 4 to 5 years; S. H. reported a 2-year length of abstinence from bingeing and purging. The duration of bulimia was 27 years for S. T., 10 years for L. S., 2 years for 53 P. Y., and 6 years for S. H. The recovery p e r i o d — t h e time span from the f i r s t i nklings of change to the cessation of bulimic symptoms—was respectively 19 years, 8 years, 6 months, and 5 months for S. T., L. S., P. Y. and S. H. Procedure Having established that the four indiv i d u a l s f u l f i l l e d the c r i t e r i a for i n c l u s i o n i n the study, each was contacted by telephone to arrange an interview time. The interviews took place i n the co-researchers* homes during July, August, and September of 1990. The interviews were not time l i m i t e d and each co-researcher was encouraged to speak for as long as she wanted ( C o l a i z z i , 1978). Therefore, the length of the interviews varied: 1 hr 50 min, 2 hr 10 min, 2 hr 35 min, and 2 hr 7 min. P r i o r to the tape recording of each interview, my co-researcher and I spent some time establishing rapport and I answered any questions about the format of the interview or the study i n general. Once she was ready to begin, I read the following preamble o f f an index card: The purpose of t h i s study i s to gain a more complete understanding of the experience of recovery from bulimia by exploring what i t means to women who have recovered. Together we're searching for a deeper understanding and you have personal knowledge about t h i s experience. As you t e l l me your story i n as much d e t a i l as possible, t r y to remember what you were thinking, f e e l i n g , and doing at the time. I'd l i k e you to describe your recovery experience beginning from when you f i r s t noticed inklings of change, continuing with experiences that f a c i l i t a t e d recovery, and ending with a des c r i p t i o n of your l i f e at the present time. As you speak, I ' l l r e f l e c t your thoughts and feelings, and ask questions to c l a r i f y and elaborate upon what you're saying. Do you have any questions? The interview format was unstructured so that the co-researcher could recount her story f r e e l y and i n an unbiased 54 manner, without my asking leading questions. As she spoke, I r e f l e c t e d her thoughts and feelings, c l a r i f i e d statements, and asked probing questions i n order to more f u l l y e l i c i t the meaning of events for her. In order to check the p o s s i b i l i t y of asking s p e c i f i c questions i n order to validate my assumptions about the meaning of the recovery experience, I bracketed my presuppositions (see Chapter II) and so stayed with her experiences by "[ r e s p e c t f u l l y ] l i s t e n i n g to what the phenomenon speaks of i t s e l f " ( C o l a i z z i , 1978, p. 52). In essence, I adopted Sheridan's stance of imaginative l i s t e n i n g (cited i n Co l a i z z i ) i n which I was " t o t a l l y present to . . . [her]" (p. 64) and "attentive to . . . [her] nuances of speech and gestures" (p. 62) . At the end of the interview, I summarized the essence of the session with the co-researcher as a means of v e r i f y i n g the information and any inconsistencies were explored. I also asked s p e c i f i c research questions which were based on my presuppositions about the meaning of the recovery experience ( C o l a i z z i , 1978). Not a l l of the following questions needed to be asked at the end of the interview since some were addressed by the co-researchers as they t o l d t h e i r recovery s t o r i e s and some were asked during the interview when i t seemed appropriate. The research questions are as follows: 1. Did you share your experience of bulimia or recovery from bulimia with others? I f so, what was important about this? 2. Was there anything else that would have helped you i n your recovery process? 55 3. When and how did you know that you had recovered from bulimia? 4. In comparison to when you were bulimic, do you f e e l you are d i f f e r e n t now either i n t e l l e c t u a l l y , emotionally, s o c i a l l y , or s p i r i t u a l l y ? I f so, how do you account for these changes? 5. Describe the events which played a r o l e i n the onset of your bulimia. 6. Would you l i k e to c l a r i f y or add anything else to your recovery story? After the interview, I transcribed the audiotape verbatim i n order to preserve the cadence and tone of the dialogue. In order to maintain c o n f i d e n t i a l i t y , any i d e n t i f y i n g information i n the t r a n s c r i p t s was anonymously presented by substituting i n i t i a l s for names. Each co-researcher was then given the opportunity to read the typed t r a n s c r i p t for c l a r i f i c a t i o n or addition of further information. I used C o l a i z z i ' s (1978) existential-phenomenological approach to analyze the t r a n s c r i p t s i n order to elucidate the themes or patterns of meaning of the recovery experience. During the analysis process, i t became apparent that information from two of the four t r a n s c r i p t s lacked richness and depth. Consequently, 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 from L. S.'s t r a n s c r i p t as i t was the most detailed. Statements from P. Y.'s t r a n s c r i p t served to cross-validate the findings. In September 1991, my co-researcher, L. S., and I met for 1 hr 45 min to validate the themes and c l u s t e r s of themes. I 56 consulted her for wisdom as to whether the phrasing of the themes accurately described her experience and whether there were any errors of omission or commission. Based upon her feedback, I made the necessary revisions so that the description of the pattern of the recovery experience was an accurate and complete account of her experience. Analysis In analyzing the co-researchers' t r a n s c r i p t s or protocols, I used C o l a i z z i ' s (1978) existential-phenomenological approach as a guideline to explicate the meaning of the recovery experience. The following steps outline the process of analysis. 1. I reread the typed protocols " i n order to acquire a f e e l i n g for them, a making sense out of them" ( C o l a i z z i , 1978, p. 59) . 2. Beginning with the r i c h e s t and most comprehensive protocol, I extracted s i g n i f i c a n t phrases or sentences which pertained d i r e c t l y to the experience of recovery from bulimia. Repetitious statements within a protocol were eliminated. The s i g n i f i c a n t statements from each protocol were written on coloured index cards representative of each co-researcher. 3. I formulated the meaning of each s i g n i f i c a n t statement by making the implied meaning e x p l i c i t . Creative insight was involved i n moving beyond what the co-researchers said "to what they [meant]" ( C o l a i z z i , 1978, p. 59) while s t i l l staying with the o r i g i n a l information. In order to optimally "allow the data to speak for i t s e l f " ( C o l a i z z i , p. 59), the co-researcher's own words were used whenever possible. Once a meaning was 57 illuminated, I wrote the words on a l a b e l which was a f f i x e d to the corresponding statement on the index card. Cards with the same or s i m i l a r meaning-labels were f i l e d together and I t r i e d to keep them i n t h e i r narrative order as much as possible. 4. A f t e r each theme was formulated from the meaning of s i g n i f i c a n t statements i n L. S.'s protocol, I referred back to the o r i g i n a l protocol i n order to ensure that the themes completely and accurately described the experience contained i n the t r a n s c r i p t . I then l i s t e d the themes and t h e i r descriptions (see Chapter IV). In order to cross-validate these findings, corroborating statements from P. Y.'s t r a n s c r i p t were noted a f t e r the description of each theme. 5. The themes were then organized into c l u s t e r s of themes according to t h e i r meaning for the co-researcher. The clust e r s corresponded approximately to the order i n which the co-researcher experienced them. Validation of the cl u s t e r s occurred by r e f e r r i n g again to the o r i g i n a l protocol. 6. I returned to the f i r s t co-researcher, L.S., for v a l i d a t i o n of the accuracy and appropriateness of the wording of the thematic categories. 7. As the clustered themes provided an exhaustive des c r i p t i o n of the experience of recovery from bulimia which c l e a r l y i d e n t i f i e d the structure of the experience i n a chronological and u n i f i e d manner, I omitted C o l a i z z i ' s (1978) step of compiling the theme descriptions into a narrative. 8. I summarized my exhaustive description of the recovery experience into a condensed outline of the clustered themes which s u c c i n c t l y and c l e a r l y reveals the meaning or fundamental structure of the experience (see Chapter IV). 59 Chapter IV Results Interviews At the beginning of each interview, my co-researcher and I spent some time establishing rapport i n order to f a c i l i t a t e disclosure of her story i n as much d e t a i l as possible. A sense of mutual rapport occurred quickly as a foundation had already been l a i d by p r i o r telephone c a l l s and our i n i t i a l introductory meeting. Furthermore, our working rela t i o n s h i p was enhanced by our common goal of searching for further knowledge that would a s s i s t other women to overcome bulimia. While I did not select my co-researchers according to the nature of the events which f a c i l i t a t e d recovery, t h e i r s t o r i e s revealed a wide var i e t y of helping contexts: i n d i v i d u a l outpatient therapy, eating disorder support groups, and informal therapeutic relationships. As each woman spoke, her authentic tears, the in t e n s i t y of her voice and the attention paid to d e t a i l s indicated that she was emotionally involved i n r e l i v i n g her experience. P.Y.'s comment—"You remember a l o t of things just t a l k i n g about i t " (Appendix J, p. 244)—was another ind i c a t o r of being personally involved during the interview. The importance of r e f l e c t i n g upon the recovery experience was expressed by 3 of the co-researchers. For instance, S.H. wanted more insight into why her recovery process unfolded as i t did, S.T. desired a deeper understanding of recovery because she wanted to work i n the eating disorder f i e l d , and P.Y. was curious to compare her experience and present state of recovery with 60 others' s t o r i e s . While a l l of the women had disclosed t h e i r eating disorder to others either during or a f t e r recovery, none had recounted t h e i r recovery story i n as much d e t a i l as they did during our interview. In fact, S.H., S.T., and P.Y were surprised that they had approximately 2 hours worth of information to r e l a t e ! At the end of our interview, P.Y. said, "That's the most I've ever said about i t i n my whole l i f e (laugh)" (Appendix J, p. 245). Throughout the interviews, I was awed by each woman's personal investment and openness i n r e l a t i n g information. I l e f t each co- researcher's home f e e l i n g closer to her than when I had f i r s t entered and I f e l t honoured to have been privy to such a secretive and tender part of each one's l i f e . According to C o l a i z z i (1978), dial o g a l research f a c i l i t a t e s " e x i s t e n t i a l insight" by allowing "the co-researchers to illuminate e x i s t e n t i a l dimensions of t h e i r l i v e s which previously could not be f a c i l e l y questioned but which now can be interrogated and hence r a t i f i e d , rejected, or modified" (p. 69). During a telephone conversation with S.T. i n which I was updating her on the progress of the study, she commented that a f t e r having t o l d her recovery story she r e a l i z e d that she was a strong person to have overcome so many addictions. For P.Y., her sense of being genuinely recovered from bulimia was strengthened as she recounted her recovery experience: She r e a l i z e d that her increased s e n s i t i v i t y towards balanced meals and a range of acceptable weights were healthy attitudes and not indicators of being overly concerned about body shape and weight. 61 None of my co-researchers mentioned r e f e r r i n g to personal journals or other tangible sources of information i n preparation for our interview, and during the interview they spoke spontaneously without any outside resources. Given the shame and secrecy associated with bulimia, i t i s understandable that the fear of others possibly discovering t h e i r eating disorder by happening upon personal journals would serve as a deterrent to writing down such information. Each co-researcher seemed distant enough from her experience to have a h o l i s t i c perspective on i t , and yet also close enough to v i v i d l y r e c a l l s i g n i f i c a n t events. Of course, there were instances when the women with r e l a t i v e l y longer recovery periods—L.S. and S.T.—expressed that t h e i r memory of cer t a i n events or the sequence of events was sketchy. Nonetheless, t h e i r clear memories of certai n c r i t i c a l events enhanced the understanding of aspects of the recovery experience that the other women had also described. For instance, although L.S. f e l t that her recounting of her therapy sessions was not complete, she was a r t i c u l a t e about what behavioural strategies she had implemented to gain an increased sense of control over her bulimic symptoms. She was also cl e a r about the process of change i n her thoughts, feelings, and actions pertaining to food, eating habits, and body image. Also, L.S.'s story provided a deeper understanding of how d i s c l o s i n g one's bulimia to others enhances motivation and commitment to change. Concerning the sequencing of interview questions, in the f i r s t two interviews with S.H. and S.T., rather than asking them to begin t h e i r recovery story at the point when they f i r s t 62 noticed inklings of change with respect to t h e i r bulimia, I asked them to f i r s t describe the events which contributed to the onset of t h e i r bulimia and then to continue recounting t h e i r recovery experience. I asked my questions i n t h i s sequence as I f e l t that r e c a l l of events would be f a c i l i t a t e d by chronologically r e l a t i n g one's experience with bulimia, and because one of my presuppositions was that the p r e c i p i t a t i n g factors are often the factors involved i n recovery. And although L.S. confirmed that "chronological progression . . . i s easier . . . to remember things i n " (Appendix H, p. 143), I f e l t that the richness and depth of the recovery events were compromised i n the interviews with S.H. and S.T. because a f t e r discussing the p r e c i p i t a t i n g events they had less energy to f u l l y r e l a t e the core of t h e i r recovery experience. Consequently, i n the subsequent interviews with L.S. and P.Y., we began at the point when they f i r s t noticed inklings of change, and the p r e c i p i t a t i n g events were addressed either during the interview as they arose or at the end of the interview. From reading the protocols of L.S. and P.Y., the d e t a i l s of the recovery events were q u a l i t a t i v e l y r i c h e r than those described by co-researchers S.H. and S.T. In s p i t e of having r e a l i z e d the importance of i n i t i a l l y addressing the recovery question beginning from when changes were f i r s t noticed, my tendency towards chronologically related s t o r i e s i s p a r t i c u l a r l y evident i n P.Y.'s protocol. Although she immediately begins her story at the point of f i r s t being aware of some change, I focus i n on information p r i o r to t h i s experience 63 by asking, "Can you just sort of f i l l me i n who Dr. B. i s , and how . . . you got to see him and sort of t e l l him about things, and then how a l l t h i s came about?" (Appendix J, p. 190). Although we eventually came back to address the i n i t i a l change experience, the interview environment could further f a c i l i t a t e the understanding of recovery by more c l o s e l y following the co- researchers' leads. With respect to the co-researchers* perceptions of the beginning of the change process, the s t o r i e s of L.S. and P.Y. are diverse. For L.S., the f i r s t inklings of change occurred when she r e a l i z e d that her bulimia was c o n t r o l l i n g her l i f e and i n t e r f e r i n g with school a c t i v i t i e s . She continued on with describing changes related to eating behaviour: s t a b i l i z a t i o n of frequency of bingeing and purging, delaying bulimic behaviours, and eventually some decreased frequency of bingeing and purging. L.S. marked the beginning of the "actual recovery" (Appendix H, p. 160) period at the point where the frequency of her bingeing and purging began to diminish st e a d i l y and she r e a l i z e d she had enough control to eat dinner without bingeing or purging. In contrast, the f i r s t inklings of change for P.Y. were indicated by a decreased frequency of purging followed by a decrease i n the s i z e of binges. As the interview became focussed on the time following decreased frequency of bingeing and purging, each co-researcher became less descriptive about events. P.Y.'s statement i s representative of how the co-researchers i n i t i a l l y referred to t h i s phase of the recovery process: "And I can't remember how 64 long a time i t was though u n t i l I stopped completely" (Appendix J, p. 190). P.Y. also i l l u s t r a t e s how t h i s phase of the recovery period with i t s s p e c i f i c i t y of d e t a i l s over a gradual period of time required more r e f l e c t i o n for the co-researchers. She says, So l i k e part of i t [the factors which contributed to decreased bingeing and purging] was the support, and part of i t too was natural consequence, you know. I f you take away the vomiting, then you have to deal with that h o r r i b l e f u l l f e e l i n g . And i t ' s t e r r i b l e . I t just, you, i t wipes you out for the rest of the day. So then the next time you binge, you tend to binge a l i t t l e l e s s . And, so the bingeing gets less just because you don't have that same way of getting r i d of i t . (Appendix J, p. 217) Consequently, I found myself more intensely probing t h i s aspect of the recovery experience i n order to examine the occurrences as f u l l y as possible. Once again, t h i s observation underscores the importance of i n i t i a l l y addressing the point when change was f i r s t noticed. Understandably, studying t h i s phase of change i s hard work and thus requires the optimal amount of time and emotional energy. As I began analyzing the t r a n s c r i p t s , i t became apparent that one of my s p e c i f i c research questions—What else would have helped you i n your r e c o v e r y ? — d i d not provide statements d i r e c t l y pertinent to recovery. Nonetheless, I would s t i l l include t h i s question i n future interviews as i t provided an opportunity for co-researchers to summarize and bring closure to t h e i r recovery story, and then move beyond i t to the future. For example, after L.S. said that she wished she had attended more of the ANAD support group meetings, she mused about possibly being involved i n them now so that she could share her experience and learning to perhaps "help somebody get through i t [bulimia] more quickly" 6 5 (Appendix H, p. 182). From Transcription to Formulation of Themes I found the transcribing of each co-researcher's audiotape to be a very demanding process. I spent approximately 2 weeks tra n s c r i b i n g each tape. With each t r a n s c r i p t i o n , I found myself deeply involved both emotionally and i n t e l l e c t u a l l y . As I r e l i v e d each recovery story, I began to connect more deeply with each woman's experience and to r e f l e c t upon my own l i f e experiences as I was reminded of them. During t h i s t r a n s c r i p t i o n process, the meaning of many statements became cle a r to me and I wrote the words i n the margin. Although I had lis t e n e d to the tapes twice and f e l t quite f a m i l i a r with each co-researcher's story, I found the process of extracting s i g n i f i c a n t statements onto index cards and formulating t h e i r meanings to be phys i c a l l y demanding but also i n t e l l e c t u a l l y stimulating as I thought about how each event was a part of and contributed to the co-researcher's recovery experience. After completing t h i s process with the tra n s c r i p t s of L.S. and P.Y., I f e l t excited and s a t i s f i e d as aspects of recovery that were common to both women began to emerge. As I began to formulate themes from the meanings common to both co-researchers, i t became apparent that L.S.'s statements provided a more comprehensive description of the themes. Statements from P.Y. confirmed aspects of L.S.'s experience. Consequently, themes were formulated only from the meaning of L.S.'s s i g n i f i c a n t statements and the corroborating statements of P.Y. were noted a f t e r the description of each theme. 66 Formulating the themes and describing them required both intense concentration and i n t u i t i o n as I continually checked back to the o r i g i n a l protocol to ensure that the themes f u l l y described the co-researcher's experience. I was assisted i n t h i s process by an experienced Public Health Nurse who confirmed or helped me r e f i n e my description of the themes. With my f i r s t attempt at formulating themes, I described very precise aspects of the recovery experience such that genuineness, r i s k i n g , and unconditional acceptance were separate themes. However, with t h i s p r e c i s i o n the thread of the experience seemed l o s t . After reviewing the protocols and re-thinking the themes, I saw that several themes could be viewed as aspects of a single theme. For instance, being genuine and taking r i s k s resulted from f e e l i n g unconditionally accepted. This r e v i s i o n of themes provided a more coherent and illuminating understanding of the recovery experience. The V a l i d a t i o n Interview Before returning to my primary co-researcher, L.S., for v a l i d a t i o n of the themes and clusters of themes, I noted any themes that I p a r t i c u l a r l y wanted to check the phrasing of. As she read the themes and s i g n i f i c a n t protocol statements to herself, I asked her to note any changes, additions, or comments she wanted to make and to indicate whether the pattern of recovery f i t t e d her experience. L.S. c a r e f u l l y read the description and ensured that the themes were c o r r e c t l y clustered under the four categories. She underscored the importance of Theme A2 which emphasized the 67 causal l i n k between f e e l i n g increasingly controlled i n an interpersonal r e l a t i o n s h i p and an increase i n bulimic behaviours. L.S. also c l a r i f i e d the meaning of one of her statements i n Theme B2 pertaining to the impact of p o t e n t i a l l y f e e l i n g ashamed i f she didn't follow through on changing her eating behaviour while she was i n therapy. I rephrased the sentence i n accordance with her feedback. We also discussed the positioning of Theme C 5 — Awareness of relapse—under Cluster C: Awareness of evolving s e l f and changes i n eating behaviours. L.S. f e l t that Theme C5 could f i t under Cluster B—Openness and readiness for c h a n g e — i f the emphasis was placed on how her relapse propelled her to seek treatment again. However, she v e r i f i e d that the placement of the theme was accurate because her awareness of having relapsed also reminded her that she had made some changes and was previously more involved i n l i f e than she currently was. Overall, L.S. f e l t that the pattern of recovery was an accurate description of her experience. She also stated that the outline of the themes "helped c l a r i f y the process better for [her]" (Appendix K, p. 247). She noted that aside from her i n i t i a l querying of Theme C5, the cl u s t e r i n g of themes seemed appropriate and i n t u i t i v e l y f i t t e d the chronology of her experience of recovery. From our v a l i d a t i o n meeting, I f e l t assured that my a r t i c u l a t i o n of the process of L.S.'s recovery experience was accurate and appropriate. Clusters of Themes and S i g n i f i c a n t Protocol Statements This section presents a condensed outline of the clustered themes. Clusters emerged as themes with related meanings became 68 evident. While some themes such as an increasing sense of e f f i c a c y reappeared throughout the recovery experience, a clear chronological pattern was apparent. An exhaustive description of the developmental process inherent i n the experience of recovery follows the condensed outline. Based upon the meaning of the s i g n i f i c a n t protocol statments, the themes are described i n an atheoretical manner which accurately r e f l e c t s the co-researcher's experience as she and I understood i t . Consequently, the inte r p r e t a t i o n of the res u l t s may be described d i f f e r e n t l y by others. Condensed Outline of Clustered Themes A . R E A L I Z A T I O N O F E A T I N G P R O B L E M AND A M B I V A L E N C E A B O U T C H A N G E 1. Awareness of an eating problem. 2. Awareness of the association between one's eating problem and emotional issues. 3 . Diagnostic awareness of one's eating problem. 4. Acknowledgement of need for outside help. 5. Awareness of obstacles to action. B . O P E N N E S S AND R E A D I N E S S F O R C H A N G E 1. Breaking the secrecy. 2. Disclosure of bulimia to therapist. 3 . Remission. C . A W A R E N E S S O F E V O L V I N G S E L F AND C H A N G E S I N E A T I N G B E H A V I O U R S 1. Increasing sense of e f f i c a c y . 2. Interruption of eating patterns. 3 . Symptom substitution. 4. Increasing intimacy with s e l f and others. 69 5. Awareness of relapse. 6. Separation of s e l f from bulimia. 7. De-idealizing and forgiving family of o r i g i n . 8. Verbally acknowledging bulimic behaviours. 9. Permission to eat previously forbidden foods and to f e e l f u l l . 10. I d e n t i f i c a t i o n with and acceptance by other bulimics. D. E M E R G E N C E O F A NEW S E L F A N D NEW V A L U E S 1. Accountability to s i g n i f i c a n t others. 2. Responsibility for offspring. 3. New appreciation and understanding of her physical body. 4. Expanding sense of s e l f and b e l i e f i n s e l f . E . T H E N A T U R E AND M A I N T E N A N C E O F R E C O V E R Y 1. Counting the cost of returning to the bulimic behaviours. 2. Processing lapses. 3. Increased self-knowledge and acceptance. 4. Authenticity with others. 5. Balancing work and play. 6. Altruism. 7. Certainty of recovery. Exhaustive Description of the Recovery Experience A . R E A L I Z A T I O N O F E A T I N G P R O B L E M AND A M B I V A L E N C E A B O U T C H A N G E 1. A w a r e n e s s o f a n e a t i n g p r o b l e m . She knows that something i s seriously wrong with her eating behaviour because the frequency of bingeing and purging has 70 s t e a d i l y escalated to the point where these behaviours are c o n t r o l l i n g and dominating her l i f e . She feels desperate and powerless as she r e a l i z e s that her d a i l y a c t i v i t i e s and goals are compromised and thwarted because bingeing and purging consumes a l l her time and energy. (See Appendix J, #028 for P.Y.'s corroborating statement.) Well, I guess inside I'd always known that something was very wrong. But the, those 2 years of u n i v e r s i t y saw a very steady urn progression of i t [bingeing and purging] such that by the end of my second year I j u s t barely fi n i s h e d the year. You know, I guess I had to reach a point where I'd r e a l l y h i t bottom to r e a l i z e that t h i s [bingeing and purging] was probably the cause i n that these a c t i v i t i e s were, were becoming the most important factor i n my l i f e . Uh, t h i s , t h i s sort of thing had taken over my l i f e and that i n order to continue doing anything I had to address i t . (Appendix H, p. 132, #001) 2. Awareness of the association between her eating problem and emotional issues. She r e a l i z e s that her f e e l i n g of loss of control during eating episodes i s more intense than the lack of control she experiences i n other areas of her l i f e . While she knows that her desire to control her weight i s one reason why she binges and purges, she senses that these eating behaviours are somehow linked to f e e l i n g insecure about herself and not i n control of her l i f e . She becomes more clear about the connection between bingeing and purging and emotional issues when she sees that a worsening of her eating behaviours coincides with f e e l i n g more controlled i n a relationship. She now knows that she i s the one responsible for overcoming her bingeing and purging by addressing how she f e e l s about herself. Well, I've always been urn, not very happy with myself, not very secure i n myself, and always eager to please others and 71 to be led by others without much confidence myself. And, so in some ways I often f e l t as i f I weren't i n control of my l i f e anyway. Urn, but t h i s [bingeing and purging] just was l i k e a, a, that aspect i n t e n s i f i e d a hundred times. (Appendix H, p. 133, #003) So I guess I kind of knew that uh i t [bingeing and purging] wasn't just a, a way to control weight: that the fact that I was involved with t h i s meant, meant something more. I mean I knew that i t was, i t wasn't j u s t the fact that I would eat and vomit. There was a, there was a reason for that, somehow, beyond j u s t wanting not to be f a t again. And I think, I r e a l i z e d that i t was urn, i n some way connected to my feelings about myself and my lack of, of r e a l l y f e e l i n g of control over myself, or wanting to have control, or fe e l i n g that I was worth urn having control on so I could make something out of my l i f e . And there were other factors i n those 2 years of university that have i n t e n s i f i e d i t i n that I was i n a relationship that wasn't, that wasn't a good one, urn and I l e t myself be controlled by that person too. So you see they almost, as that r e l a t i o n s h i p progressed so did the condition. So there were a l o t of factors sort of pointing i n the same d i r e c t i o n that I had to uh, I knew I had to t r y and touch base with, with myself i n some ways. (Appendix H, p. 133, #004) 3. Diagnostic awareness of her eating problem. Knowing that her eating problem i s a documented c o n d i t i o n — bulimia—which other people have decreases her sense of i s o l a t i o n and deepens her acknowledgement that she has a problem. Since professionals are f a m i l i a r with her problem, she fe e l s hopeful about gaining a clearer understanding of i t and getting some help to improve her eating behaviours. (See Appendix J, #027 for P.Y.'s corroborating statement.) But um, I was aware of i t at that point; I knew i t wasn't anorexia. And I knew that i t was a documented condition. And that was i t s e l f kind of a r e l i e f : I t ' s l i k e other people do t h i s , you know. So that was, I think i t may have helped to know that there was a name for what I had, and that other people had i t , and there may be some recourse. (Appendix H, p. 159, #030) 4. Acknowledgement of need for outside help. Her bingeing and purging has paralyzed a l l areas of her 72 l i f e . She fe e l s defeated as she r e a l i z e s she has " h i t bottom". She knows that she needs some help to stop bingeing and purging so that she can engage i n other a c t i v i t i e s . Although uncertain about whom to contact, she feels urged to get some outside support because her previous attempts at overcoming her bulimia have shown her that she i s unable to stop bingeing and purging on her own. (See Appendix J, #029 for P.Y.'s corroborating statement.) And I think i t was, i t probably was the fact that things kind of came crashing down before I came home that summer af t e r second year that made me r e a l i z e , or i t made me take that step of ac t u a l l y seeking help. And i t was s i m i l a r when I, when I went for 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, there's something rea l wrong and i t ' s me, and I need help." Because hitherto, and, and a f t e r that too, I would, you know, a f t e r a p a r t i c u l a r l y bad period I'd say, "O.K."-- and I think, 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, overnight maybe, that resolution. And so the r e a l i z a t i o n that I couldn't do i t myself was important. And the fact that I had that support. (Appendix H, p. 144, #008) 5 . Awareness of obstacles to action. She i s ambivalent about giving up her bulimic behaviours. Although she desires to be free of bingeing and purging, her commitment to re l i n q u i s h them i s low because they s t i l l serve some p o s i t i v e functions for her: a mechanism for escaping and reducing tension, and a part of her s e l f - d e f i n i t i o n . Her reluctance to seek outside 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 her bulimia. Knowing that she must confront the underlying emotional issues i n order to t r u l y overcome her bulimic behaviours, she feels apprehensive about entering therapy a second time. She i s t e r r i f i e d of confronting 73 her sense of emptiness and doubtful about her a b i l i t y to deal with the pain that w i l l be unleashed when she s t a r t s t a l k i n g about her feelings about herself. (See Appendix J, #002 and #039 for P.Y.'s corroborating statements.) And i t [bulimia], i n some ways s t i l l , I didn't want to give i t up. I guess maybe because i t was, i t was an escape, i t was a release of tension, i t was part of how I defined myself, i t was a habit, i t was you know a shameful thing to reveal: a l l of those things put together. (Appendix H, p. 161, #034) [When I contacted the therapist] I was t e r r i f i e d cause i t was sort of l i k e "well t h i s i s i t again." T e r r i f i e d i n terms of, of to 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 that I'd have to s t a r t dealing with i t ; you know, the implications of that were, were great. [I would have to look at myself] . . . and could I do i t ? (Appendix H, p. 160, #032) Urn, but I s t i l l , I don't think I was s t i l l yet at the point of t r u l y being able to work through i t . Like I wanted t h i s thing to go away, I wanted to be O.K., but I didn't r e a l l y want to put into i t what I knew I would have to. Because on one l e v e l , I think I understand very well that the bulimia i t s e l f , i t was just a set of symptoms, that there were, there were deeper things that were r e a l l y causing a l l of that. Urn, so. (Appendix H, p. 132, #002) Yes, urn, because for me anyway, there was such a lack of um, l i k e part of me was scared that i f I did examine myself I wouldn't f i n d anything there. You know, because I didn't have any re a l sense of myself or of no strong grounding i n myself. So part of the running away from i t was—running away from dealing with the bulimia—was the knowledge that I'd have to do self-examination and my god, what would, at t h i s point, what would I f i n d there? I mean there would be nothing, I didn't f e e l there'd be anything to work on. (Appendix H, p. 148, #014) B. OPENNESS AND READINESS FOR CHANGE 1. Breaking the secrecy. Although she i s f e a r f u l about seeking help, her desperation propels her to begin searching out the necessary resources and people. Not knowing who to contact, she feels bewildered. With 74 much apprehension, she rehearses her request for help before she begins contacting Telephone Information, the Association of Anorexia Nervosa and Associated Disorders, a therapist, and a physician. With each successful contact, she f e e l s progressively determined to f i n d the appropriate therapeutic milieu and her self-confidence increases as she sees herself e f f e c t i v e l y taking action. Furthermore, as she discloses her secret to each resource person she gains more courage to face her bulimia. Her commitment to change and to a c t i v e l y p a r t i c i p a t e i n therapy grows. (See Appendix J, #026 for P.Y.'s corroborating statement.) So I c a l l e d , the only thing, I didn't know what to do and I looked up "B" i n the phone book. (Laughs.) There's nothing that says, you know, Bulimia Support Group or anything. So I c a l l e d um, I think i t ' s V. Information Number. And I just said, "Is there any number for, for, to help somebody with an eating disorder?" And she referred me to ANAD [Association of Anorexia Nervosa and Associated Disorders], and I c a l l e d them, and I found out about the sessions. But s t i l l , i t was at that point where I didn't r e a l l y want to l i k e come t o t a l l y out of the closet. I knew I needed help, but I wasn't about to sort of announce i t to everybody. But they also gave me the name of a therapist at that point, Dr. T. And I um c a l l e d her and she managed to f i t me i n . (Appendix H, p. 160, #031) So i t was a very frightening thing. It took me a long time to a c t u a l l y c a l l Information. It took me, you know a l l these steps took quite a while. I t ' s sort of getting up the courage, and I'd rehearse them over and over. (Appendix H, p. 161, #033) Yah, and that was hard. That was r e a l l y hard. Um, and maybe you know in terms of your looking at the steps, I don't know how that, I don't, I don't suppose that could ever be overcome, that kind of um apprehension and the steps that need to be gone through. I think that's maybe part of the process i s the actually getting yourself together enough to go through those steps. Maybe i f i t were easier people wouldn't be at a point where they'd a c t u a l l y be able to follow through on i t . I don't know. (Appendix H, p. 162, #035) 75 2. Disclosure of bulimia to therapist. As she discloses her bulimic behaviour to her therapist, she fee l s l i b e r a t e d from the c a p t i v i t y of her i s o l a t i o n which she created by hiding her secret. Feeling supported and accepted, she i s re l i e v e d to address her secret rather than hiding and running from i t . In examining her eating behaviour with her therapist, she experiences a sense of calmness as she steps back and begins to more c l e a r l y see what her bulimia i s a l l about. She now fe e l s accountable to someone else to take some constructive action. As she contemplates the shame associated with 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, her sense of r e s p o n s i b i l i t y and commitment to changing her eating behaviour increases. (See Appendix J, #007, #030, #031, #032, and #033 for P.Y.'s corroborating statements.) And I think another important aspect of that [therapy] was the fact that you're breaking the i s o l a t i o n , breaking the secrecy and l e t t i n g someone else 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 that you need the support. But i t ' s also that by breaking out of that um c i r c l e of, of secrecy that you create, you're almost i t ' s l i k e l e t t i n g a chink of daylight i n . It's l i k e , you know, i t ' s a connection between sort of you and the outside world, i n on, on who you are and your secret. And I, I believe very strongly that that's a v i t a l part of i t . At le a s t i t was for me. I know i t was a v i t a l part for me because i n the subsequent therapy, I think the biggest step was taken when I t o l d my husband about i t , and the most d i f f i c u l t . So I think part of the reason that there was some improvement during that time was that I had t o l d somebody else about i t . I mean he [therapist] was the f i r s t person I t o l d about i t . And that, um, I, I would say that i s very important. (Appendix H, p. 145, #009) [Disclosing my bulimia to my therapist was] Very p o s i t i v e . I mean that was r e a l good. I t ' s , you know, i t eases the burden that you carry. It also allows you to t a l k about i t because you're not going to s i t by yourself and t a l k about i t , and t r y and lay i t a l l out and understand i t . At least I wasn't, cause you're so caught up i n i t a l l . (Appendix H, p. 145, #010) 76 It was a s i m i l a r element to the other sessions of therapy that I underwent here i n V . — t h a t I think did help me urn overcome t h i s [bulimia]—was that i n looking at i t as we went on I saw that very often he was just allowing me to put things out and he would arrange them so that I could see act u a l l y what I was saying and thinking. So he was very good about not t r y i n g to impose um hi s own ideas on me, rather making suggestions that, upon r e f l e c t i o n , would have been apparent i n what I said. So i t was very much a way of um, of of just a i r i n g , a i r i n g myself and allowing myself to look at myself. You know, i t was just , i t was sort of a self-examination thing. (Appendix H, p. 135, #005) Yes. Because i t wasn't just me. And that for me, that the shame of i t a l l was so ho r r i b l e , was so t e r r i b l e , that again l e t t i n g someone else i n on that presupposes that then you're going to do something about i t . You have to now cause you can't look at that person i n the eye knowing that, you know, you're going to be running to the bathroom. So that, for me that was r e a l l y important. (Appendix H, p. 146, #011) 3. Remission. Having few expectations i n therapy except to address her bulimia, her fears of f a i l u r e are minimal and she experiences an increased sense of control over her bingeing and purging. Although the frequency of her eating behaviours doesn't decrease, they are arrested at t h e i r current i n t e n s i t y . As such, the previous escalating frequency of bingeing and purging i s s t a b i l i z e d and she i s able to resume her d a i l y a c t i v i t i e s . The being able to focus on the problem and have no other expectations—which I wanted, but i t was better that I didn't have them—contributed something to perhaps a b i t of remission during that period of therapy. (Appendix H, p. 144, #007) I think i t [bulimic behaviours] had [changed]. As I said, I think that the therapy had some, had some benefits. Um, I'm pretty sure I was s t i l l bingeing and purging. But I think there was a b i t of an element of control, a b i t . (Appendix H, p. 143, #006) It was [ d i f f e r e n t ] . You know I do look at the f i r s t 2 years [of university] as being sort of a, the time during which I kind of plummeted. And then i t kind of, the therapy I think sort of arrested that um d i r e c t i o n . And then I sort of see the other years as more or less a plateau. I t didn't get 77 worse than that. I t didn't notably get better. Um, but I was able to maintain things on a more even keel. (Appendix H, p. 151, #017) C . A W A R E N E S S O F E V O L V I N G S E L F A N D C H A N G E S I N E A T I N G B E H A V I O U R S 1. I n c r e a s i n g s e n s e o f e f f i c a c y . Her external environment becomes more stable and secure as she i s no longer 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 and as she begins to esta b l i s h a career d i r e c t i o n which she enjoys. She i s more autonomous and does not depend on others as much to structure her d a i l y a c t i v i t i e s . She experiences a sense of control i n her l i f e . Feeling competent i n her career f i e l d provides an accomplishment which c l e a r l y delineates an aspect of her s e l f and allows her to f e e l more certa i n i n knowing who she i s . In the realm of career, her self-worth i s enhanced and she fe e l s better about herself. (See Appendix J, #003 and #006 for P.Y.'s corroborating statements.) So that was s t i l l a l l going on [bingeing and purging] but um, I was out of that relationship. I think that made a b i t of a difference. I was a l i t t l e more autonomous that way. Um, I was defining more sort of what my d i r e c t i o n was i n school. I had established you know, the Russian major and I knew more or less I was good at i t , even though I I thought I was only good because the competition wasn't there. So I had a l i t t l e niche, you know, and that helped. I t wasn't so much ju s t f l a i l i n g around. (Appendix H, p. 152, #018) I think the key element there was that I f e l t that I was doing something that was more or less worthwhile, that I was, I thought I was f a i r l y good at i t . So i t gave me sort of that approval and I was able to sort of define myself more. Like I could say that, um you know, I'm studying Russian and I could have that um as something that was me. It was a very much me that during those 4 years i t pretty well, you know, took up most of my time. So I suppose i n a way that's again there was issues I wasn't addressing. You know I never did go back and do the sort of soul searching and house cleaning that I thought that I should do i n order to r e a l l y be well. And I s t i l l had, you know, there's s t i l l a l o t of underlying lack of confidence and self-hatred and a l l that sort of s t u f f . But at least on that plane I f e l t 78 some element of performance and an element of success. So I think that's why things were large l y better. (Appendix H, pp. 155-156, #022) 2. Interruption of eating patterns. As she begins to spend more time i n areas of her l i f e where she f e e l s successful, she experiences subtle changes i n her eating patterns. In addition to occasionally eating a normal meal without purging, she i s increasingly able to delay her urge to binge and purge such that the behaviors are contained within c e r t a i n time periods. Although the frequency of her bulimic behaviours remains r e l a t i v e l y unchanged, she interrupts her eating pattern i n order to have time to engage i n productive a c t i v i t i e s . As she feels less ruled by her eating behaviours, she gains more confidence i n her a b i l i t y to engage i n other a c t i v i t i e s . Over time, her sense of competence, s t a b i l i t y , and commitment to her career increases and she notices a gradual improvement i n her bulimic behaviour as the frequency of bingeing and purging decreases s l i g h t l y . (See Appendix J, #047, #048, and #049 for P.Y.'s corroborating statements.) Well as I said, I'm pretty sure that um I could, i f I r e a l l y wanted to, could keep a meal down. And the other thing I can determine i s that there could be, uh the whole eating thing wasn't, didn't have me by the throat so much. Like there, I could at least time i t . l i k e put i t i n special pockets. I could um—not a l l the time and not nearly successfully enough—but I could. you know. Like fourth year I l i v e d with a roommate and we could do study sessions before an exam without my, you know. I could do that. And I could, i t wouldn't be such a d r i v i n g thing to be doing continually. Because as I, as I look back on i t now—I could be wrong—I just seem to think of those 2 years as being a continuous cycle of bingeing and purging. And i t seems to me that I was able t o — i t s t i l l happened and maybe as fr e q u e n t l y — b u t at least I could take periods of time where I, that I could do something with. (Appendix H, p. 153, #019) 79 And as I did more and had to do more, the time for me to engage i n , um you know, weird eating behaviours was lessened, was decreased. And uh, so I think the demands were more but for some reason I wasn't panicking as much, and I was able to do what I had to do to meet those demands. (Appendix H, p. 156, #023) But um, at that point I was just, I'd done a l o t of teaching that year and I was r e a l l y excited 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 that I was good at 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 think i t may, had I continued on that track, who knows, but i t could have been that things [bingeing and purging] would have j u s t continued slowly to get better on t h e i r own. (Appendix H, p. 157, #027) 3. Symptom substitution. Although the i n t e n s i t y of her bulimic behaviours has subsided, she notices an increase i n her alcohol consumption. Drinking allows her to disengage from her anxieties and fears so that she f e e l s comforted and secure. She becomes aware that she uses both alcohol and binge eating to help her escape from d i s t r e s s i n g situations and emotions. And you know, again the d e t a i l s I'm unclear of. I know that I was um, that I substituted drink [alcohol] uh, and to some respect, extent, for that. I don't think I ever had what you c l a s s i f y as an alcohol problem. But I know that I came to the r e a l i z a t i o n that alcohol could i n some ways do the same things the bingeing could. It was almost l i k e a cycle. I t would take um. When you're engaged i n that a c t i v i t y , you can't r e a l l y be engaged i n anything else. So i t ' s the sole focus. So when you have r e a l worries, and anxieties, and feelings of fear and s t u f f , i t ' s almost l i k e a a reassuring cycle to get into because i t takes you away from having to deal with those. And drinking did the same thing. (Pause.) So I think um, I think that uh, I know I didn't l i k e i t you know wasn't l i k e drinking on a continual basis. But I, I do think that I came to that r e a l i z a t i o n at that point, um for whatever that's worth. (Appendix H, pp. 153-154, #020) 4. Increasing intimacy with s e l f and others. She begins to f e e l weary from secretly hiding parts of he r s e l f or creating new ones i n order to gain the approval of 80 others. Her awareness of her needs and how she fee l s towards others i s increasing. Desirous of opening herself up to others, she chooses individuals with whom she feels validated and s e l f - confident when i n relationship with them. Feeling freer from the burden of pleasing others, she feels energized and excited as she i s able to reveal more of her true s e l f to others and connect more deeply with them. She also invests herself i n an intimate, committed re l a t i o n s h i p . Although she doesn't disclose her bulimia to these s i g n i f i c a n t others, she begins to t r u s t that they accept parts of her and she feels more valued by them. She begins to consider that she i s acceptable to others as she i s and that she doesn't need to a l t e r who she i s . (See Appendix J, #051 for P.Y.'s corroborating statement.) But, yah, and I would be very, l i k e I didn't have good friends because there was so much of me that I thought I had to create for others and so much of me that I had to hide. So I was always very I think kind of anxious around people and l i k e who am I supposed to be for t h i s person kind of thing. 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 to create a part of myself to please them. So i t ' s a t e r r i b l y , I think a very t i r i n g thing because you're carrying around these secrets, you're carrying around a l l your d i f f e r e n t i d e n t i t i e s that you're t r y i n g to portray to d i f f e r e n t people so that y o u ' l l please them. (Appendix H, p. 150, #015) I also i n t h i r d year um, there was a, I think I was also very frightened of of entering into another rel a t i o n s h i p because I knew that I would again be controlled. Like I couldn't, and i t was too much of a s t r a i n to t r y and keep up some kind of facade for someone on such a close basis. Um, so there was, there was a um, um a boy who, you know, wanted to develop a relationship with me. And I remember being very um, very much not wanting that, I think, because I f e l t much closer to him than I did with the guy that I was with for the f i r s t 2 years of university. And therefore the chances of his having to discover t h i s about me were that much greater. So I do remember subsequently being very, you know, standoffish i n that regard. Um, I did have a friendship with a, with a woman during my fourth year; we roomed together. That was good. I t was almost l i k e the 81 f i r s t friendship that I had that I thought I could reveal some of myself to which was nice. (Appendix H, p. 154, #021) Because I had just, at that point you know, I f e l t that I'd made a commitment [to my boyfriend] I think i n some ways. And you know, I mean love was c e r t a i n l y involved. But beyond that um, I think I f e l t that I had made a commitment. You know, we'd been sort of "long distancing" i t for 4 years at that point and I f e l t that you know t h i s i s what we've had; I was going to do i t [marry him]. (Appendix H, p. 157, #026) 5. Awareness of relapse. When she relocates to a new geographical area, she feels lonely and i l l at ease. Bereft of the support and security of her job, family, and friends, her growing sense of competence and self-confidence begins to crumble. She feels immobilized and unable to f i n d ways of regaining or rebuilding her sense of emotional security. Insidiously, the frequency of her bingeing and purging increases u n t i l once again the behaviours are consuming a l l her time. When she returns to her f a m i l i a r surroundings she remembers a previous time when she was involved with others, engaged i n productive a c t i v i t i e s , and f e l t an element of control over her bulimic behaviours. Poignantly aware of the contrast between her old and new l i f e , she r e a l i z e s that her bulimia i s out of control and i s again impeding her a b i l i t y to function. She i s spurred to confront her problem again by seeking outside help. But what I do know i s um coming here then that summer was um, was r e a l l y bad because I kind of dropped into [a void], you know, I didn't have a master's degree and I didn't. Well, I just f e l t that I'd dropped into nothing. And um, you know t r y i n g to fi n d some kind of work and you know, my husband being very involved i n hi s , was again I was suddenly face to face with myself again without any of the external, you know, pluses and strokes and s t u f f . And, i n some ways i t might have been a very good thing. Because what i t did 82 was i t yanked that i d e n t i t y [from my work] away from me. And I wasn't a strong enough person, or a f o r c e f u l enough person, or a person who believed i n themself enough to sort of kick and scream and f i g h t for that i n t h i s environment. So, things deteriorated r e a l l y quickly over that summer and the f a l l . And I was sort of picking r i g h t back up on the same old habits. I would spend the day—you know, with A. gone and not r e a l l y knowing anybody or not many people h e r e — i s o l a t e d and again going r i g h t back into the bingeing and purging. (Appendix H, p. 158, #028) Both. [The frequency of bingeing and purging began increasing and I began to f e e l a loss of control over my eating behaviours.] Yup. And that was r e a l scary. And again i t wasn't something that um, I think I faced up to u n t i l i t got r e a l l y bad. And I think that, I think the r e a l i z a t i o n that things were bad (laugh) came to me cause we went to my family's place back home i n I. for Christmas that year. And i t was l i k e seeing that environment that I used to be i n , that I f e l t that I was f l o u r i s h i n g i n — y o u know i t was the same c i t y that I had been i n school i n — a n d suddenly seeing the way I was. And I think i t was over that Christmas that I r e a l i z e d that when I got back I had to do something. Because I think I r e a l i z e d that I'd taken some steps and that, you know, things were better but that since my environment had changed, I had just sort of crumbled. And um,I had to deal with i t . (Appendix H, pp. 158-159, #029) 6. Separation of s e l f from bulimia. She experiences a close a f f i n i t y with her therapist and a deep sense of t r u s t because they share a common c u l t u r a l background and in t e r e s t s . Feeling respected and valued i n spite of her eating disorder, she i s freed to be open and vulnerable with her therapist. As she focuses on her issues underlying the bulimic behaviours and i s reassured that these behaviours are symptomatic, she feels l i b e r a t e d as she begins to separate her bingeing and purging from her sense of who she i s . Although at times she fe e l s consumed by her bulimia, she feels empowered and more hopeful about gaining control over her eating behaviours knowing that they w i l l subside once she begins dealing with her self-hatred and lack of confidence. Her shame and preoccupation 83 with her eating disorder continue to d i f f u s e as she recognizes that she has personal and interpersonal a b i l i t i e s and strengths i n other areas of her l i f e . And while she acknowledges her achievements, she knows that i n order to recover she has to respect and cherish herself as she i s without any of these external achievements. (See Appendix J, #004, #008, #009, #03 5, and #075 for P.Y.'s corroborating statements.) I mean I knew, you know, she [therapist] was good. Um and I remember your saying once that um too often people say, "Oh, i t was ju s t because I had a great therapist that I recovered." I think there has to be that personal uh. If I hadn't l i k e d her and respected her then I couldn't have done that [recovered]. So knowing that she obviously accepted i t [bulimia] because she worked with people l i k e me and that we were s t i l l able to to get along on on a personal l e v e l , and laugh. And you know she was, she's C. so my int e r e s t i n Russian studies. You know, so we had sort of a personal r e l a t i o n s h i p that I f e l t was sort of beyond that. You know, I f e l t very comfortable with her. I think i t would have been impossible, had I not had that, to r e a l l y you know. Because that's maybe what happened with Dr. C.: that I just wasn't able to to r e a l l y open up. So that was important. (Appendix H, pp. 167-168, #045) I think she approached i t very much from a point of view of working on yourself, and t h i s only being symptomatic. And that c e r t a i n l y work would have to be done on behaviour modification—your, you know, attitude towards food and s t u f f — b u t that r e a l l y i t was, i t was much deeper than that. And I think that made a t e r r i f i c impact. You know something that I think I'd known, but to act u a l l y t a l k about that was important. You know, going back i n i n my past and t a l k i n g about things that, that had to do just with me and not with any eating disorder. That was important. Um, and then l a t e r on she talked about, yah, l i k e writing down times that I would binge and why, or what I had ju s t eaten and what I was f e e l i n g . I don't think I actually did that. I remember thinking about i t , but I never actually committed i t to writing. Um, so a l o t of, um, examination of s e l f rather than examination of t h i s , t h i s part of myself. (Appendix H, p. 164-165, #040) I think that's what I l i k e d most of a l l . Because I'd always known, I mean why should, you know, why should I have those feelings about myself? And I always knew that a rea l healthy person wouldn't do t h i s [binge and purge]: l i k e a person who f e l t good about themselves. And i t always 84 occurred to me that i t [recovery] had so much to do with knowing who I was (eyes become moist). Like without anything else i n the world—what I was doing, or parental approval, or straight A's, whatever—that I was O.K. And that i n some respects, what I did was secondary. You know, I think I ' l l always be a sort of goal-oriented person and wanting to be doing things t h a t ' l l make me f e e l good. But that's not what I b u i l d my whole s e l f on. (Appendix H, p. 165, #041) 7. De-idealizing and forgiving family of o r i g i n . In her innermost being she holds a l o t of anger towards her mother for having played a part i n the development of her bulimia. However, she f e e l s g u i l t y about expressing her anger because she i s a f r a i d that she w i l l blame her mother s o l e l y i f she begins to explore the negative aspects of t h e i r r elationship. Although she i s i n i t i a l l y shocked at her therapist's suggestion that she i s s t i l l angry with her mother, she i s released to i d e n t i f y and express her anger. She verbalizes her anger towards her mother's and society's overvaluation of thinness and acknowledges that these messages were harmful to her. As a r e s u l t , she becomes less consumed and driven by her anger towards these past events. She r e a l i z e s that even though her mother made some mistakes which contributed to developing an eating disorder, her mother i s not s o l e l y responsible for her bulimia. Letting go of past hurts and anger, she moves forward to the present and assumes more r e s p o n s i b i l i t y for overcoming her eating disorder. (See Appendix J, #073, #074, #076, #077, and #078 for P.Y.'s corroborating statements.) Except she seemed, her focus was more on the f a m i l y — t h e mother-daughter re l a t i o n s h i p — w h i c h i n some ways I rejected because I didn't want to. I think 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 think back on things and a l l I could see was the negative aspects of having interacted with her. So I didn't r e a l l y 85 want to put t h i s i n her lap, you know, i n terms of well because of t h i s , t h i s happened to me. You know I s t i l l don't, I think there are some aspects of that that are good to examine. D e f i n i t e l y . But I r e a l l y don't think i t ' s such a good thing to t r y and f i n d a finger to point. And I don't think Dr. T. was t r y i n g to do that. But I know that I re s i s t e d i n some respects that, that approach because I f e l t that that was t r y i n g to point the finger of blame at her, you know. (Appendix H, p. 162, #036) And I do remember a comment that she [therapist] made that r e a l l y h i t home. I think i n t a l k i n g about i t , and again sort of t r y i n g to sh i e l d her [mother], I don't know what I said, but her [therapist] r e t o r t was. Or i n saying, I guess expressing my g u i l t toward her [mother] and s t u f f and her. (Appendix H, p. 163, #037) My mother. Yes. And Dr. T.'s r e t o r t was, "Then you haven't forgiven her." And I had to r e a l i z e the v a l i d i t y of that. That maybe there was some blame that I was subconsciously a t t r i b u t i n g to her and the environment i n terms of, you know, what happened, i n terms of my bulimia. So i t was a matter of t r y i n g to, I think there was a process of l e t t i n g go of a l l of that; of being able to say, to look back on those things i n order to l e t them go, and and any anger that you might f e e l at um, um f i n a l l y developing a distorted body image, you know. In other words, just taking your r e s p o n s i b i l i t y for "the here and now." (Appendix H, p. 163, #038) 8. Verbally acknowledging bulimic behaviours. When she i d e n t i f i e s her eating behaviours using the terms "bingeing" and "vomiting" rather than speaking of them euphemistically, she draws closer to the r e a l i t y of her behaviours. As she verbalizes and names her actions, she i s moved to confront them rather than minimize them. She experiences a deeper sense of owning her behaviours, and i s aware of t h e i r severity and the fact that she no longer has control over them. She r e a l i z e s that her "perfect" solution to weight control i s imperfect. Something else just occurred to me. I remember, I think I used to t a l k i n euphemisms a l o t , i n terms of l i k e what I would ac t u a l l y do. And I think part of i t [therapy] was sort of to force me to act u a l l y dare f e e l what i t was about: 86 you know, gorging and vomiting. Like I remember her t a l k i n g , her end goal was to make me ac t u a l l y say the word "vomit", and I kept using euphemisms and not understanding what, why she meant, what she meant when she would ask me to be more cl e a r about i t . And f i n a l l y when I had to say that word, i t was l i k e again coming (slaps hands together) face to face with what i t a c t u a l l y was. So, so part of i t too was was r e a l l y examining behaviour and what i t was, not hiding, not hiding from the r e a l i t i e s of i t . (Short pause while tape i s turned o f f to answer the phone.) (Appendix H, pp. 166-167, #043) 9. Permission to eat previously forbidden foods and to f e e l f u l l . She begins to reorganize her categories of "O.K. foods" and "binge foods". As she allows herself to eat "binge foods" without eating to excess and purging, she f e e l s more relaxed and experiences a sense of control over her eating behaviour. She r e a l i z e s that she can eat the previously forbidden foods i n moderation and s t i l l maintain her weight. Furthermore, when she eats an average amount of food and f e e l s f u l l , she a l l e v i a t e s some of her anxiety and prevents a binge-purge cycle by reassuring h e r s e l f that she has not overeaten and by progressively delaying purging by engaging i n other a c t i v i t i e s . As the frequency of her bingeing and purging and her thinking about them continue to decrease gradually, she f e e l s more i n control of her eating behaviours. She i s reliev e d and secure i n knowing that her body i s s i m i l a r to others' bodies i n that her food intake nourishes her body and i s e f f i c i e n t l y metabolized. She i s more hopeful and confident about recovering and she begins to care for herself more by opening up her l i f e through structuring time to s o c i a l i z e with others and engaging i n previously enjoyable a c t i v i t i e s . (See Appendix J, #001, #005, 87 #019, #020, #036, #037, #038, #040, #067, and #068 for P.Y.'s corroborating statements.) She also talked about feelings o f — o r I did, whatever—we talked about um l i k e d i v i d i n g foods into O.K. foods and foods that i f you eat t h i s i t means you're on a binge: things l i k e l i k e ice cream or spaghetti. Like i n order to to maintain your weight you can't eat things l i k e that ever cause i f you do, then you might as well j u s t you know gorge and get i t a l l up. So you know, your r e l a t i o n s h i p to food c e r t a i n l y played a part. (Appendix H, p. 166, #042) But um, l i k e for example I would allow myself to eat spaghetti, or have an ice cream cone, or a cookie, or something without that automatically meaning I'd had just, you know, started the whole cycle. So i t was allowing myself c e r t a i n foods. I t was allowing myself to eat a meal, l i k e a dinner especially, 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 allowing myself to experience that f e e l i n g of fu l l n e s s , normal f u l l n e s s , without that having to lead to such anxiety that I have to just continue. (Appendix H, p. 17 0, #050) One thing [that 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 ust wait." Like a l o t of 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." Like i t wasn't for a long time that I was able to eat more than I should have eaten and s t i l l be able to keep i t down. So I would eat what I knew—I mean I could, I could write i t out, I could see i t , I knew that 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 anxious—and able to say, "Well l e t ' s j ust wait. O.K., I ' l l purge but I won't purge for a half-hour. I'm not going to puke for a half-hour." And then i n a half-hour, "Well, we'll wait another half-hour and l i k e take a walk or something." And then I re a l i z e d I didn't have to anymore. (Appendix H, p. 170, #051) I [ f e l t confident about changing my bulimic behaviour when], I think I f e l t elements of control coming back. Um, I think I would, I can't pinpoint i t , but I believe i t would have been at the time where I was able to stop something that would normally, l i k e stop a binge i n progress. Or to act u a l l y say, "No" to a time when I would normally have binged. You know, to s t a r t having some control back, which was great. (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 issue, suddenly r e a l i z i n g that, "My god, I'd gone for a day without bingeing, oh my god, I'd gone for a week." You know, of knowing that um, i t wasn't a minute by minute, day by day issue anymore. And that was a tremendous f e e l i n g when I knew that I could, I could eat three meals a 88 day and, by eating three meals a day or two or whatever, I wouldn't blow up. Like I was normal i n that regard too. It wasn't l i k e by eating one b i t e I'd suddenly gain 20 l b . So i t wasn't such a forbidden area. Food became more of a functional thing rather than t h i s whole issue of weight and g u i l t . and you know, a l l these other things that i t had had. (Appendix H, pp. 177-178, #072) So i t ' s a matter of of being able to do other things. I mean you get so, when you're, when you're l i f e i s sort of taken over by t h i s , everything else drops away: I mean everything you used to do for enjoyment. So i t was a matter of r e a l i z i n g there's, I mean there's always time that you could l i k e spend with others now that you f e e l more comfortable around i t , d i f f e r e n t things you can do, and things you can do even for yourself, I mean. You know that's l i k e a notion you never had before 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 with and acceptance by other bulimics. Regardless of whether she has personal contact with other bulimics or hears accounts of them from a secondary source, knowing that her eating behaviours are shared by others decreases her anxiety about her abnormal eating habits. As she r e a l i z e s that her bulimia i s a condition which others also have, her sense of shame continues to diminish and her disgust with her bingeing and purging lessens. When she perceives that her disclosure of bulimia i s accepted by others, she fe e l s understood and experiences a sense of belonging. From observing that other group members appear normal i n spite of being bulimic, she r e a l i z e s that she too probably appears normal to other i n d i v i d u a l s . As a re s u l t , she feels more accepting of herself even though she i s s t i l l bingeing and purging. Her feelings about he r s e l f are less governed by her bulimia. That's r i g h t . That's r i g h t . And not that we talked that much about other people [with eating disorders], but the fact that I knew they existed. And you know, she'd say things about, you know, what happened with t h i s person or something, you know, that that made i t . I t put i t sort of 89 into perspective more I guess. I t ' s just t h i s b eing—as you said I think at one p o i n t — p a r t of me, but not l i k e that was jus t what I was. That there were other, you know human beings that that had t h i s as part of them as well. So i t was again that i d e n t i f y i n g with (laugh), with humanity i n a way. You know, seeing yourself as part of i t ; you're not so iso l a t e d . I'm t r y i n g to remember, for some reason I remember that moment r e a l l y well which means that 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 that um (pause) part of i t was um then i f others, i f you could accept yourself enough to open yourself to others and they would accept you, then i t would j u s t be confirmation that you were O.K. But you had to be able to accept yourself enough or accept t h i s , t h i s thing enough to be able to t e l l somebody about i t i n a way: l i k e to know that by act u a l l y revealing that, they wouldn't t o t a l l y destroy you. (Appendix H, p. 167, #044) So that I think i n both instances, both sort of um steps, was, was just the act of t e l l i n g was r e a l l y important. And I guess that's why—I'm jumping the gun, the gun a b i t — b u t that's why I think groups must be important i n the process too. Because again you're, not only have you t o l d others and they, you know, don't run away screaming or something; you're s t i l l a person to them. But also you see others who seem to you quite, I mean they look l i k e people, l i k e they have i t a l l together. Yet they carry t h i s too. So I think that whole element of sharing i s i s so important. (Appendix H, p. 147, #013) And I did go to ANAD a couple of times, as I said. I t would probably have been that spring and summer that I was f i r s t seeing Dr. T. I probably went about three times. And i t was good, um. I was doing a l o t of tutoring i n the evening and I think that's p a r t i a l l y why I didn't do i t l i k e on a regular basis. Um, and I found that to be good. Again to walk into a room of people that I f e l t , "Gee, I could walk by (laugh) these women on the street and I'd never know. So other people must see me and they don't look at me and think yuck." You know that (a) you know, other people have i t , so i t ' s not such a ho r r i b l e thing, and (b) that other people sort of wouldn't look at 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 just a thing, yah. It was jus t a, you know, an eating disorder (laugh). Cause again, you're putting i t i n perspective. And as i t l o s t sort of i t s ultimate control of my l i f e , I was able to put i t more in perspective. (Appendix H, p. 175, #065) 90 D. E M E R G E N C E O F A NEW S E L F A N D NEW V A L U E S 1. A c c o u n t a b i l i t y t o s i g n i f i c a n t o t h e r s . As she begins to accept herself more and fe e l s more confident i n her a b i l i t y to overcome her eating behaviours, she begins to f e e l uneasy about hiding her bulimia from s i g n i f i c a n t others. Since she desires to be her genuine s e l f i n rela t i o n s h i p s , she fe e l s challenged to share her hidden bulimic part. When an intimate other acknowledges her disclosure without becoming overly concerned or overly c r i t i c a l , she fe e l s r e l i e v e d and loved. Her overwhelming sense of abnormality and shame i s diffu s e d and she values herself more knowing that she i s unconditionally accepted by a s i g n i f i c a n t other. Feeling strengthened and supported, she i s more determined to overcome her bingeing and purging because she doesn't want her bulimia to poison t h e i r r e l a t i o n s h i p or for them to f e e l burdened by i t . (See Appendix J, #041, #042, #053, and #054 for P.Y.'s corroborating statements.) Yah, and that i t [bulimia] didn't a f f e c t h i s [my husband's] feelings about me at a l l . You know, so that was r e a l l y important. And I think I was only able to t e l l him, um you know, at a moment, at a time when we were f e e l i n g you know r e a l l y close, and I r e a l l y f e l t that, "Yah I r e a l l y want to share t h i s thing with t h i s person because I don't want to keep t h i s from t h i s person anymore." Not as i f i t were a big deal that I'd t o l d him the facts, but the fact that I was withholding something became important. That I'd never had a rela t i o n s h i p with someone where I wasn't holding back t h i s , and creating t h i s , and hiding and deciding how to be. And so that, for the reason, i t was a big step too. (Appendix H, pp. 168-169, #047) [His reaction to disclosure of bulimia was] Very low key. Very low key. Um i n fact he even made some jokes about i t — l i k e during that conversation—"well, that's a great way to lose weight, I should think about that." You know, s t u f f l i k e that. So i t was as i f I was thinking, "god, a l l t h i s time and i t r e a l l y i s n ' t such a big deal." Like I mean he 91 thought i t was weird and a l l and and I'm sure he knew that i t was i n d i c a t i v e of of problems and s t u f f . But he was very, very sort of matter of fact about i t . And just very glad that I had t o l d him because now he wouldn't have to wonder why. He was very, I think, worried that I was seeing someone for, you know, goodness knows what reasons. (Appendix H, p. 168, #046) Well, and also to have someone, someone else accept i t , uh and not um; i t j u s t l e t s you know that maybe you're not such a monster. You know that someone else could hear t h i s part of you and s t i l l , and s t i l l accept you. You know es p e c i a l l y i n terms of you know, the person that you're l i v i n g with. And you know, supposedly you've known t h i s person for however many years—4 or 5 years—and that's the one secret you've never t o l d them. You know so, i t ' s , i t also allows you to f e e l more l i k e a human being. Again, the whole um breaking out of the i s o l a t i o n , and that even the fact that you do that doesn't mean that you're such a rotten person. (Appendix H, pp. 146-147, #012) Um, and also, I had to be at a point where I f e l t f a i r l y confident of succeeding, of going to him and succeeding, because I couldn't t e l l him and then intend to continue with the behaviour. I mean I knew that i t would s t i l l continue for a while, but at least that attention would be there to work through i t and stop i t , and that i t would always be getting better. And I knew I couldn't t e l l him i f I f e l t that I couldn't succeed because then I couldn't look him i n the eye and to f e e l , you know, r e j e c t e d — l i k e I guess that's self-imposed—to f e e l um g u i l t y about that i n regards to another person. You know, I I couldn't do that. I was bad enough doing i t with myself sort of. So I had to be at a cer t a i n l e v e l of s t a b i l i t y with i t before I could t e l l him. And then t e l l i n g him increased that l e v e l of s t a b i l i t y [confidence i n her a b i l i t y to make changes]. (Appendix H, p. 169, #048) 2. Responsibility for o f f s p r i n g . When she discovers that she i s pregnant, her anxiety over not being more i n control of her eating behaviours i s i n t e n s i f i e d . She i s spurred to continue working at overcoming her bulimic behaviours so that she can responsibly provide an optimal pre-natal environment and the necessary nutrients for her baby. Furthermore, she i s committed to f u l l y attending to her newborn and she r e a l i z e s that her present time involvement with 92 bingeing and purging would compromise her time with her baby. She f e e l s confident that she can continue working towards gaining more control of her eating behaviours and increasing her current l e v e l of contro l . Although she does not abstain from bingeing and purging during pregnancy, she experiences a continued decrease i n the frequency of these behaviours. (See Appendix J, #050 and #052 for P.Y.'s corroborating statements.) Um, and to f e e l that there was another reason why I had to get myself well. You know, there was a baby and there was, you know. (Appendix H, p. 172, #057) I mean quite apart from a l l t h i s , l i k e i t [being pregnant] wasn't a planned thing and i t was sort of uh. But, above and beyond that, I r e a l l y thought to be a mother you had to be a f a i r l y whole person. And you know, so there's a l o t of fear of you know, you know, "I've got to get my act together." There was even more reason to get my act together because there was so much, there was more at stake now [such as another l i f e ] . (Appendix H, p. 172, #058) Well another l i f e . You know, I couldn't have a c h i l d and and. There was, i t was one more element that would um make, make i t harder for me to continue i f I f e l t I had to continue bingeing and purging. Um, and from the point of view of that c h i l d ' s well-being, I mean to have a mom doing that would not be good. Like I didn't want to um, you know, f a i l i n that respect, you know. (Appendix H, p. 172, #059) M-hm, that I had to. Yah because, you know, I knew at least I had to have control of i t . Um, because i t ' s j u s t one more um thing that, l i k e i t ' s a very t o t a l thing that you have to do: bring up a c h i l d . And even before I had one I guess I re a l i z e d that (laughs): c e r t a i n l y do now. But uh, and I knew I couldn't r e a l l y do i t i f I were out of control with t h i s thing. I mean I couldn't: I knew that. So, but I must have, I'm sure that I had inklings and and some feelings of control before the pregnancy occurred. Otherwise I think I would have just freaked r i g h t out, you know, ju s t knowing I can't handle t h i s . So there must have been part of me that thought that I could probably handle i t at l e a s t well enough. (Appendix H, pp. 172-173, #060) You know, I didn't, l i k e for those 9 months I was s t i l l bingeing and purging, but not as much. You know things just , i t was sort of again a gradual progression of get, getting better. (Appendix H, p. 173, #061) 93 3. New appreciation and understanding of her physical body. Upon becoming pregnant, she r e f l e c t s on her body's reproductive capacity and i s awed by i t s a b i l i t y to nurture a new l i f e . She experiences her body as serving a useful function and having an important purpose, and she begins to appreciate and respect i t more. When her body shape changes and her weight increases, she i s at ease because she expects these changes to occur during and af t e r pregnancy. As she fe e l s freer from s t r i c t l y c o n t r o l l i n g her food intake and weight gain, she no longer denies herself the food she craves. As a re s u l t , her bingeing and purging continue to decrease and she fe e l s p h y s i c a l l y strong and healthy. She continues to t r u s t her body's capacity to e f f i c i e n t l y metabolize her food intake without r i g i d l y monitoring what she eats. Her drive to a t t a i n a t h i n body decreases as her focus s h i f t s to the importance of having a healthy body. She accepts the weight she gained throughout her two pregnancies and she i s confident that she can gradually lose the extra weight by becoming more ph y s i c a l l y active rather than by resorting to her bulimic behaviours. (See Appendix J, #013, #014, #015, #016, #017 and #018 for P.Y.'s corroborating statements.) Um, and then, the thing that I think happened when I got pregnant that was neat was that hey I r e a l i z e d I had an appreciation for my body: just i n the mechanical aspect! Like i t was incredible I could do t h i s thing! I didn't r e a l l y f e e l I had that much involvement. You know, I knew I had to keep myself healthy. But to watch i t sort of do i t s thing was r e a l l y neat! And also to f e e l so healthy! You know, I had an easy pregnancy and I f e l t so strong and healthy. You know, I was you know as big as a truck and i t didn'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 begin um, a r e a l l y useful 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 didn't 9 4 bother me at a l l . I kind of reveled i n i t because for the f i r s t time i n my l i f e I could eat what I wanted and i t didn't show, you know, that kind of s t u f f . (Appendix H, p. 176, #066) As I said um, I, well I became pregnant. That was another thing of allowing myself to have that body image and have that be fi n e . (Appendix H, p. 171, #054) Then being able to accept you know the the b e l l y of pregnancy and s t u f f and not, you know, r e a l l y be concerned, not be that anxious about i t . (Appendix H, p. 17 2, #056) And then a f t e r the pregnancy, um, I had put on quite a b i t of weight. And i t didn't, I guess i t didn't bother me as much. Like i t didn't r e a l l y bother me. I didn't look at myself i n the same way, looking for that l i t t l e tummy. (Laughs.) Cause now I had quite a tummy, you know. And, and breast-feeding and a l l that. I t ju s t again, an appreciation of a healthy body rather than i t ' s only, um, i t only e x i s t i n g to see how t h i n you could make i t , and how much l i k e a model you could make i t , and r e a l i z i n g that health was important. (Appendix H, p. 176, #068) And since, you know, then we had another baby about a year and a h a l f a f t e r that. And, um, you know, from those, I put on a b i t of weight with each, each c h i l d . So that a f t e r the 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 lb more than I am now: 15 lb or maybe even 2 0 l b . And again, that didn't cause the anxiety. Like my weight wasn't such a big deal anymore. . . . Well, I knew that I was a mom; there was a reason for t h i s . (Appendix H, p. 177, #069) When a f t e r the second one was born and I took a year out at home and r e a l l y kept that weight, I was doing aerobics and s t u f f , but I didn't r e a l l y lose i t . I f e l t better about myself when I got back to work and and kind of l o s t i t . But i t wasn't l i k e a big, i t wasn't what i t was. . . . That's r i g h t . And I didn't have to, you know, go back into old patterns to t r y and lose i t . (Appendix H, p. 177, #071) 4. Expanding sense of s e l f and b e l i e f i n s e l f . As she takes on the roles of mother and wife, she feels more peaceful and secure i n knowing who she i s . Her confidence and self-respect grow as she successfully c a r r i e s out her r e s p o n s i b i l i t i e s i n these areas. As she also f e e l s stronger i n her a b i l i t y to regulate her eating habits, she i s challenged to 95 re-enter the work force. She no longer f e e l s that she needs the support and v a l i d a t i o n of her therapist. As she gains more of her self-worth from these new roles, she focusses less on her body shape and weight as a source of her worth and value. Her relat i o n s h i p s with family members and work colleagues take on an increased importance and she invests more of her time with them. As a r e s u l t , she has less time to be preoccupied with weight and food issues and less time to engage i n bingeing and purging behaviours. Knowing that her bulimic behaviours would be a deterrent to functioning optimally, she fe e l s assured that she i s well on the road to recovery when she does not desire to engage in bingeing and purging. In fact, her bulimic behaviours are an old response which now require e f f o r t and planning to engage i n . (See Appendix J, #043, #044, #045, #046, #055, #056, #057, #063 and #064 for P.Y.'s corroborating statements.) I knew that there were other things that I could use for 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 that I did, my family, and knowing that I was, you know, f e e l i n g better about myself. So I didn't have to just look at that [my weight], you know. Um, and you know r e a l i z i n g that uh, well again, you know, a c e r t a i n difference 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 tryi n g , who was I r e a l l y t r y i n g to impress i n the way I looked? You know, just took a b i t of a d i f f e r e n t perspective. I didn't f e e l , you know I f e l t much better. (Appendix H, p. 177, #070) And then when I came back, she was born. And she was about 3 months old, and I got a job opportunity and did that. So again i t was, i t was l i k e the the i n i t i a l um, um, s t a b i l i t y , control f e e l i n g , you know, good f e e l i n g about yourself. Something has to happen f i r s t I think. And then for me anyways, i t was important to almost put that into r e a l i t y by taking on the r e s p o n s i b i l i t i e s that would prove to me that I was getting better, that would diminish the time that I could indulge i n an eating disorder: you know put more things that I had to do on me. Um, but there was that core that had started there, you know, that wasn't there. . . . That core of self-knowledge, and self-acceptance, and 96 strength. And, and, you know, knowing that 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 to look, you've got, I think i t ' s a r e a l luxury to have that time-out out of l i f e i n a way of self-examination and a l l t h i s other s t u f f . But then, you've got of kind of put i t i n practise, you know. It' s got to be ju s t a, just a part, just a time that helps you a c t u a l l y do what you want to do and not l i k e a, you know, ongoing crutch. You know, cause that means you haven't r e a l l y made that f i n a l t r a n s i t i o n which i s putting, j u s t incorporating a l l those things i n part of your l i f e without, you know. (Appendix H, p. 174, #063) Um, getting a f u l l - t i m e job where i n the daytime hours I couldn't do i t anyway. So i t would have to be r e s t r i c t e d to nighttime a f t e r work. You know so that, and I f e l t confident enough that I'd be able to handle the job and do the work. You know, that had to be there f i r s t . And then to a c t u a l l y do the work and have so much of your time taken up. (Appendix H, p. 171, #055) But then also I think taking on the work and s t u f f l i k e that was very important because i t would be, you r e a l i z e that you know, "Gee, there's an 8-hour day and i t hasn't even occurred to me once. It's not something that I would want to do or would even occur to me to do because I couldn't function and a l l those other things." So that would have been, you know, about a year I guess from s t a r t i n g to see Dr. T. (Appendix H, p. 179, #074) But I think one sort of point [that marked recovery] i s suddenly when you r e a l i z e that, you're actually, to binge and purge i s much more conscious than not to. Like before i t ' s j u s t a part of your l i f e , and you do i t a l l the time, and you have to r e a l l y concentrate not to do i t . And then i t ' s l i k e an a c t i v i t y that you engage i n sometimes, but i t ' s a very conscious thing. And I think that's a r e a l , um, point 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 that I'd want to act u a l l y binge because I'm f e e l i n g anxious about something but i t would have to be something that I'd have to arrange rather than something I'd have to f i g h t o f f . (Appendix H, p. 178, #073) E. THE NATURE AND MAINTENANCE OF RECOVERY 1. Counting the cost of returning to the bulimic behaviours. When she experiences the urge to binge, she steps back from her cravings and r e f l e c t s upon the consequences of her behaviour: 97 wasted money, i s o l a t i o n , and no return on the energy invested. Feeling drained and d i s s a t i s f i e d as she considers the option to binge, she decides to abstain from the bulimic behaviours and involve herself i n other a c t i v i t i e s . She fe e l s r e l i e v e d and proud of herself for having implemented an alternate behaviour. (See Appendix J, #021, #022, #062, #070, #071, and #072 for P.Y.'s corroborating statements.) And another thing that happened further down the 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 possible for me to binge and for some reason I'm having feelings that I want t o — i s to stop and think back and think: Well i f I'm going to binge now, you're probably going to spend, i t ' d be a t o t a l of l i k e $10 worth of food. I'm going to have to s i t here by myself without pretty time, not do anything, s t u f f myself, and then I'd have to go and and t r y and vomit, and make sure that I vomit i t a l l out. And that just, that prospect i s exhausting and i t ' s not very appealing to me. So i t ' s sort of l i k e thinking i t through, rather than just l e t t i n g yourself be caught r i g h t up i n i t . And knowing that, "No, I r e a l l y do not want to do that, or, I'm having." (Tape ends here.) (Appendix H, pp. 170-171, #052) 2. Processing lapses. Occasionally when she feels 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 present circumstances, or bloated from overeating, she has an incident of bingeing and purging. However, unlike previous bulimic episodes, she experiences a sense of control over the eating behaviours and does not continue to engage i n them. After a lapse, she feels discouraged but not defeated because she i s confident that she can cope with emotionally s t r e s s f u l situations by resorting to a c t i v i t i e s other than bingeing and purging. Furthermore, since her lapses are so infrequent, she fe e l s distant from her bulimic behaviours and no longer considers them 98 a part of her l i f e . (See Appendix J, #058, #065, #066, and #069 for P.Y.'s corroborating statements.) As I said I s t i l l w i l l have incidents of i t [bingeing and purging], you know, even now, but i t ' s l i k e , i t ' s just a d i f f e r e n t thing. (Appendix H, p. 176, #067) I can't r e a l l y understand i t [occasional bulimic episodes]. It a c t u a l l y um, I guess often when i t happens i t ' s not l i k e a conscious cycle. I t ' s more l i k e f or some reason I've l e t myself r e a l l y eat, overeat so much that i t ' s almost l i k e an escape mechanism i f I know that i t ' s been. Like I can overeat, l i k e I can eat too much and f e e l , "Oh, what a pig and s t u f f . " But the occasional time when um i t jus 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 cycle that I have to go through. But s t i l l , parts of i t are s t i l l there that I think I use or something. I mean i t ' s r e a l weird. But I don't have to. So i t i s quite a conscious thing. (Appendix H, p. 187, #090) Although I did f i n d during the year I stayed at home that, um, there, the incidents [of lapses] were more frequent. And when I r e a l i z e d that, I made, I had to make an e f f o r t again to sort of eliminate i t , you know. So I know that for whatever reason i t ' s r e a l l y much better for me to be out and involved i n things and, you know, busy. And i t ' s not good for me to s t a r t having negative feelings l i k e , "I'm not doing anything or have too much time." You know what I mean? (Appendix H, p. 188, #093) And I guess i t ' s [lapses are] just a fe e l i n g , a negative f e e l i n g that manifests i t s e l f i n a way. Because I did notice during that year, there was a point where I real i z e d , you know, i t [lapses] was s t a r t i n g to happen: s t a r t i n g to, not s t a r t i n g to happen again but i t was l i k e i t , I I could see the frequency was going up. And that, that distressed me. But then I was able to, you know. I had to exercise w i l l but then i t was, i t was defeatable. It was a funny thing. (Appendix H, pp. 188-189, #094) Well the thing i s , i t [bulimic episode] doesn't, i t doesn't touch me that much. Like i t ' s not something that i s l i k e a l i g h t thing to do or i t doesn't matter. But, I know that those a c t i v i t i e s , um, are not something I have to do: i t i s n ' t r e a l l y me anymore. So i t ' s not a thing that i n retrospect I l i k e . I t ' s j u s t l i k e , "What did I do that for? You know, that was, that was stupid; that 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 just be something else to say, you know, "I f e e l badly about myself because of." 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 , there's the, the neighbour's dog scares the heck out of you. And every time you walk past i t your heart i s going l i k e t h i s ( l i g h t l y pounds heart). And then when you get older i t ' s sort of l i k e he could jump out at you and maybe scare you once, but i t ' s j u s t an old dog. You know, sort of l i k e a t o t a l l y d i f f e r e n t thing about i t . So yah, i t ' s not something I l i k e , or something I'm proud of, or um. But i t doesn't, i t doesn't seem to be a big deal, you know. (Appendix H, p. 187, #089) It' s sort of l i k e I guess l i k e smoking. You're sort of l i k e , "ah, t h i s i s sort of needless." But um, no, there's no longer, you know, there i s a f e e l i n g of control. I t ' s a, i t ' s a funny thing to even t a l k about now because i t ' s so incongruous but. (Appendix H, p. 188, #091) Well, i t ' s l i k e an old carry over from the past i n a way, you know, because i t i s n ' t l i k e a part of my l i f e or a necessary part of. I wouldn't even consider i t r e a l l y much in thinking of myself these days. (Appendix H, p. 188, #092) 3. Increased self-knowledge and acceptance. As she becomes more secure i n acknowledging her values and p r i o r i t i e s , she feels freer from the contradictory s o c i e t a l messages about motherhood and career. She feels stronger i n knowing who she i s and she cherishes herself rather than seeing her values and dreams as a d i s t o r t i o n . She r e a l i z e s that l i f e holds both joyous and sad feelings, and when she feels vulnerable and s e l f - l o a t h i n g she embraces these feelings and experiences a sense of control over them. She either accepts that, for the moment, she cannot change an uncomfortable emotional state, or she engages i n behaviours that enhance her feelings about her s e l f . She respects herself as she i s and she does not f e e l driven to s t r i v e for perfection or u n r e a l i s t i c ideals and goals. As she l i s t e n s to her feelings rather than seeking others' approval, she begins to discern what her feelings are saying and she begins to act upon them. She tr u s t s her feelings enough to 100 explore new options and challenges as she feels led. (See Appendix J, #034, #080, #081, #082, #083, and #084 for P.Y.'s corroborating statements.) I was saying that i f I were the person that I am now, i f I were that, had been that person then, i f I'd had the, I think I believe i n myself a b i t more and I know better who I am. (Appendix H, p. 157, #025) Like the year I was home with the 2 children was not, I think i t wasn't a t e r r i b l y happy year. I just, that's I guess the way I am. And I no longer see i t as a negative thing of having to define myself by what I'm doing; that's ju s t who I am. And I believe that other people are l i k e that too. I t ' s my personality rather than i t being a d i s t o r t i o n . I think i t was a d i s t o r t i o n before; i t was ca r r i e d to the extreme. And now I'm able to say, "I'm t h i s way, and I'm that 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 part of me. I ' l l never be an overly self-confident person. And there's there's times now where, you know, where I f e e l r e a l , r e a l l y negative about myself and, you know, I hate myself and wish I was anybody else i n the world. You know, but i t ' s not everything anymore. So I guess i t ' s too, able to say, "This i s the way I am. I ' l l always have these aspects of my character, but I can deal with them now." Or I can choose not to deal with them and say, "Well i t ' s there, there's nothing I can do about i t . " (Appendix H, p. 180, #076) And also what's come up i n the l a s t f a i r l y recently—which I think i s i n some ways part of 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 great, but i t hasn't been, l i k e I haven't r e a l l y gotten o f f on a new, a big new di r e c t i o n since the whole Russian thing. And I'm now exploring, you know, the idea of going back to school and s t u f f l i k e that. So i t ' s neat. So I'm no longer defining myself as "Gee, I was, I was a Russian teacher and now I'm not, you know. So I'm, therefore I'm nobody." So i t ' s sort of s t a r t i n g with something new again. (Pause.) Again more l i s t e n i n g to me, I'm fine, and knowing what I'm saying. (Appendix H, p. 180, #077) And also the a b i l i t y to maybe do things to please yourself: for nothing other than that reason. [Just the sheer enjoyment of i t without any] goal that has been set by somebody, that you want to achieve. (Appendix H, p. 184, #083) 101 4. Authenticity with others. As she comes to know herself better and respect herself more, she fe e l s more comfortable and at ease with people. She acknowledges that she has po s i t i v e a t t r i b u t e s and talents to share with others and she no longer f e e l s i n f e r i o r to others. Feeling more confident and competent, she interacts with others on a more equal l e v e l rather than being passive and devaluing he r s e l f . There i s l i t t l e discrepancy between the s e l f she knows and the s e l f she i s presenting to others and she i s relieved to no longer f e e l a f r a i d of disappointing others. She i s encouraged knowing that her open and d i r e c t way of intera c t i n g with others w i l l allow her to develop more intimate personal relationships and be more e f f e c t i v e i n teaching others. And I think I'm a l o t more um. I deal 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) Well, you know. I f e e l that. I'm s t i l l not a person that has many close friends. And again, I've decided that's part of me and not, you know, for any other reason. But, I'm able to be, you know f e e l that I'm more myself with others and be more relaxed, and you know deal with them as I f e e l other people must have always dealt with other people. And so that's good. And you know, the work that I do now and I suppose any kind of work I do w i l l be with people, and w i l l hopefully be from a perspective of t r y i n g to give them something through teaching or whatever. And I f e e l that, you know, I can do that 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 the people that I f e l t I could be close to, those were the ones that I wanted to push furthest 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 to be close enough I would i n f e c t them with whatever sickness I had. Like um, I f e l t l i k e a p i l e of cut glass and anybody who touched would would, you know, cut themselves on. So, you'd sometimes surround yourself by people, but you wouldn't you know, you didn't have that much to do, or i n common with. So, you know, i t ' s a question of the friends that you choose would be more real friends. (Appendix H, pp. 184-185, #086) 102 I know something. I know something. Again, i n my re l a t i o n s h i p with people, I think I always wanted the other p e r s o n — i n whatever the rel a t i o n s h i p was—to be i n control. You know, for reasons that I think you probably understand: a lack of s e l f - d e f i n i t i o n etcetera and wanting to j u s t sort of h i t c h myself on to somebody else. And you know that analysis of relationships that's, you know, parent, c h i l d , and peer. I think I would always d e l i b e r a t e l y set up a r e l a t i o n s h i p with others i n that I was the c h i l d and they were the parent. And I'd always t r y and um, uh, I think put myself forward as a b i t of an "airhead". Like 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 didn't a c t u a l l y anyways. (Tape ends here.) The whole image of, um, not being equal with others: always putting yourself on the down side, um, not being assertive, um, and not believing that others w i l l take you seriously. So there's a cert a i n amount of, of um, again almost t r y i n g to r e l i n q u i s h control of the s i t u a t i o n when you're with other people. So I think I deal 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 pro f e s s i o n a l l y I can t a l k to people as I imagine an adult would t a l k to another adult and not the way I used to. So that's a, that's a big difference as well. (Appendix H, p. 185, #087) That's r i g h t . And I believe now I'm able to see some good i n myself and see "Yah, I can do that well. I t ' s not just, I was just, somehow got through i t and I fooled them t h i s time. God, w i l l I be able to fool them again?" That, you know, h o r r i b l e tension that everything you do then having more expectations and being r e a l l y scared of i t even though you have to have those expectations: They have to be there. So i t ' s a l o t , um, easier now i n fac t . (Appendix H, pp. 185-186, #088) 5. Balancing work and play. Her a b i l i t y to concentrate on work issues or to engage i n r e f l e c t i o n and contemplation i s strengthened now that she i s no longer thinking about bingeing and purging. As a r e s u l t , she i s able to more f u l l y invest herself 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 while also being less obsessed and driven by them. She takes time for l e i s u r e without f e e l i n g g u i l t y because she enjoys and i s nurtured by time away from work. Feeling i n control of her eating behaviours, she i s at ease with l e i s u r e time and sure that she w i l l not f i l l i t with her previous bulimic 103 behaviours. (See Appendix J, #079 for P.Y.'s corroborating statement.) But I also r e a l i z e d what an e f f e c t bulimia had on your a b i l i t y to think, just i n terms o f — i t ' s not j u s t the amount of time—but 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 think 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 think were I to, i f I were to s t a r t on some kind of school program, um, I think that i n many ways, um, I don't want to say I'd do better, but i t would just be, i t would be a more balanced thing. It wouldn't be such a focused thing. So maybe I wouldn't do um, something l i k e standardized grades and s t u f f , I might not do better. But I think I would be able to put more into i t because I'd have more of myself to devote to i t . (Appendix H, p. 183, #081) I could concentrate. I mean i t was l i k e I could never concentrate before 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 to concentrate that would usually mean I'd be o f f doing some work, whatever, studying or whatever. And that would be a prime time to binge, and I usually would. So there wouldn't be periods of concentration or r e f l e c t i o n . Like I was a f r a i d just to s i t back and think about things and not do anything, from many points 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 that would be a prime time to binge]. But also, I didn'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 desires to share her recovery experience with others who are struggling to overcome an eating disorder. She f e e l s confident that she w i l l be able to empathize deeply with them and provide information which may help them i n t h e i r recovery process. She also trusts that the individuals w i l l i d e n t i f y with her and be encouraged about t h e i r potential for improvement from seeing that not only c e l e b r i t i e s but also "ordinary" people recover from bulimia. In r e l i v i n g her recovery experience, she expects to aff i r m her courage and strength and to acknowledge the personal growth and maturity which resulted from her struggle to overcome bulimia. (See Appendix J, #024 and #025 for P.Y.'s 104 corroborating statements.) Yah, M-hm. (Pause.) And I wish [that as part of my recovery], yah, I wish I had been more involved i n ANAD, and I, I s t i l l have feelings now. I think I'd l i k e to t r y going back and seeing i f there's any capacity that I could be involved or help out or something. I think that's part of, I think part of i t i s , um, once you've worked through i t , being involved somehow i n helping others or with, you know. (Appendix H, p. 181, #078) You see I think that's i t . And I think, um, i n i n examining i t since I've talked with you and, you know, thought about i t more than I've thought about i f for a long time, i s to r e a l i z e that that [helping out at ANAD] might be another important sort of l a s t step. (Appendix H, p. 182, #079) I'm hoping to help others through what I went through. I think also, i t ' s i t ' s not so much from a point of s e l f - examination cause I r e a l l y f e e l that you can never work things through to the l a s t "dotting of the l a s t i . " You know, when you do that with yourself, you might as well die (laugh), cause i t ' s l i k e put i t a l l i n a box. But I think there's maybe some element i n that, but I think most of i t i s f e e l i n g that you have something to contribute, you know. And, and, and s t i l l remembering how awful i t was and hoping that maybe what you can do can help somebody get through i t more quickly. (Appendix H, p. 182, #080) 7. Certainty of recovery. While she fe e l s confident that she w i l l not s l i d e back into bulimic behaviours because she i s now more aware of who she i s and more self-respecting, she acknowledges the p o s s i b i l i t y of a recurrence of bulimia. From her experience, she knows that she i s not t o t a l l y immune to a relapse. (See Appendix J, #010, #011, #012, #023, #059, #060, and #061 for P.Y.'s corroborating statements.) I could revert [to bulimia] I suppose i f I, yah. Although I r e a l l y don't think I could ever r e a l l y get back into that s i t u a t i o n . I don't know. I can't even conceive of i t . (Appendix H, p. 189, #095) It was a d i f f e r e n t person doing i t . (Appendix H, p. 189, #096) 105 Chapter V Discussion The behavioural and psychosocial changes inherent i n the process of recovery from bulimia occurred through both formal therapeutic mechanisms and out-of-therapy experiences. This broad scope of f a c i l i t a t i v e factors represented by the two co-researchers' s t o r i e s provided a comprehensive and integrated basis for understanding the experience of recovery. In t h i s chapter, the findings on the pattern 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. Further, the t h e o r e t i c a l and counselling implications of the r e s u l t s are discussed with recommendations for future research. Summary of Results This study elucidated the pattern or meaning of recovery from bulimia from the f i r s t co-researcher's experience of recovery. Information from the second co-researcher's t r a n s c r i p t was used to cross-validate the themes. Twenty-nine factors representing the process and nature of recovery from bulimia were i d e n t i f i e d and subsumed under f i v e major categories: "(A) Rea l i z a t i o n of Eating Problem and Ambivalence About Change, (B) Openness and Readiness for Change, (C) Awareness of Evolving Self and Changes i n Eating Behaviours, (D) Emergence of a New Self and New Values, and (E) The Nature and Maintenance of Recovery." Limitations of the Study The i n t e r n a l v a l i d i t y of the research findings i s high because pote n t i a l bias i n the assessment of the co-researchers' degree of recovery was controlled for; the independent rater who 106 i s a p s y c h i a t r i s t with expertise i n eating disorders had no previous treatment contact with any of the women. Further, the res u l t s of t h i s case study represent an application of the existential-phenomenological approach. S p e c i f i c a l l y , the findings did not re-create the immediate meaning of the co-researcher's experience but a r t i c u l a t e d a conceptual understanding of the raw, v e r i d i c a l recovery experience. The findings are based on a small sample siz e of two co-researchers and the extracted thematic categories were presented only to the primary co-researcher for v a l i d a t i o n of the accuracy and appropriateness of the wording of the categories. As such, t h i s pattern of recovery may be considered true for the one woman and i t may also be applicable to some other women struggling to overcome normal-weight bulimia. In addition, s e l f - selected ind i v i d u a l s may be d i f f e r e n t from the larger population i n terms of willingness to share personal information with others as well as being psychologically minded and verb a l l y expressive. Therefore, volunteer co-researchers may represent those who f e e l comfortable with themselves and others, have experienced a sense of achievement i n overcoming bulimia, and f e e l motivated to be involved i n existential-phenomenological research. Consequently, sample bias could be an important factor to consider when applying the re s u l t s to the recovery experience for women with normal-weight bulimia (Borg & G a l l , 1983). Furthermore, the pattern of recovery from bulimia may be d i f f e r e n t for males or indi 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" ( C o l a i z z i , 1978, p. 70). Therefore, with a l l phases of t h i s research project, there were no established guidelines which marked a termination point. As C o l a i z z i (1978) predicted, at the end of each phase I had "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 of being s a t i s f i e d that . . . [each] phase [was] adequate i n the f a c t of simultaneously experiencing the tension of i t s not r e a l l y being complete or f i n a l " (p. 70). Therefore, i t i s suggested that the certainty of these findings be held with reservations. Evaluating the Fitness of Theoretical Approaches In Chapter II, the assumptions concerning the nature and process of recovery from bulimia inherent i n the empirical studies of the psychodynamic, family systems, and cognitive- behavioural treatment approaches were outlined. This section discusses the present research findings i n l i g h t of the current t h e o r e t i c a l knowledge on recovery. As the purpose of t h i s study i s to explore the meaning of the recovery experience, t h i s evaluation of the f i t n e s s of t h e o r e t i c a l approaches i s for exploratory purposes. A basic p r i n c i p l e of treatment which i s i m p l i c i t i n a l l of the theories as foundational i n the change process i s supported by the f i v e themes which are clustered under Category A. "Realization of Eating Problem and Ambivalence About Change." These themes are: "(1) Awareness of an eating problem, (2) Awareness of the association between one 1s eating problem and emotional issues, (3) Diagnostic awareness of one's eating problem, (4) Acknowledgement of need for outside help, and (5) 108 Awareness of obstacles to action." Theme C8 ("Verbally acknowledging bulimic behaviours") also confirms the ro l e of insight and acknowledgement of one's problem which i s alluded to by the theories. For instance, the psychodynamic theory addresses the unconscious role of ego-defense mechanisms such as denial and projection i n denying or d i s t o r t i n g r e a l i t y (Corey, 1986). Family systems theory also recognizes the imperativeness of the i n d i v i d u a l r e a l i z i n g that she has an eating problem and that she i s ambivalent about giving up the problem (Schwartz et a l . , 1985). S i m i l a r l y , Fairburn's (1985) cognitive-behavioural approach emphasizes the necessity of cognitive change pertaining to body weight and shape. Thus, CBT stresses that the individual must f i r s t acknowledge that she has an eating disorder and that she f e e l s ambivalent about changing her eating behaviours. However, Themes A l , A2, A3, A4, A5, and C8 seem to indicate more s p e c i f i c psychological processes, beyond what i s suggested by these theories. Thus, the themes enrich our t h e o r e t i c a l knowledge about the i n i t i a l phase i n recovery. For example, Theme A3 ("Diagnostic awareness of one's eating problem") and Theme C8 ("Verbally acknowledging bulimic behaviours") highlight the mechanisms by which an individual's thinking about her eating behaviours i s changed. Knowing that other people engage i n si m i l a r behaviours and using the terms "bingeing" and "vomiting" reinforce her recognition that she has a problem, and also provide hope for overcoming her problem. In addition, Theme A2 ("Awareness of the association between one's eating problem and emotional issues") emphasizes the key underlying psychological 109 issues which c l a r i f y for the ind i v i d u a l the seriousness of her eating problem and point the way to recovery. F i n a l l y , Theme A5 ("Awareness of obstacles to action") a r t i c u l a t e s the adaptive functions of bulimia which contribute to the ind i v i d u a l ' s ambivalence about giving up her eating behaviours. Regarding the psychodynamic theory, Themes A2, CI, C5, C6, C7, D2, D3, and D4 support t h i s theory's assumptions of recovery. In Theme A2 ("Awareness of association between one's eating problem and emotional issues"), the co-researcher a r t i c u l a t e s her underlying feelings of insecurity, powerlessness, engulfment by others, and s e l f - c r i t i c i s m . Theme CI ("Increasing sense of e f f i c a c y " ) , Theme C5 ("Awareness of relapse"), and Theme C6 ("Separation of s e l f from bulimia") underscore the causal l i n k between intrapsychic c o n f l i c t s and disordered eating behaviours and reinforce that psychological functioning and bulimic behaviours improve as the ind i v i d u a l experiences a sense of s e l f - respect and self-confidence. Theme C7 ("De-idealizing and forg i v i n g family of origin") describes how the in d i v i d u a l begins to take more of an active role i n her recovery once she deepens her emotional separation from her mother by no longer blaming her mother for her eating disorder. Reorganization of self-perception i s r e f l e c t e d i n Theme D2 ("Responsibility for off s p r i n g " ) , Theme D3 ("New appreciation and understanding of her physical body"), and Theme D4 ("Expanding sense of s e l f and b e l i e f i n s e l f " ) . That i s the indiv i d u a l ' s self-worth increases, and the frequency of bulimic behaviours decreases as her perception of herself and her body i s c l a r i f i e d by her roles as 110 mother, wife, and employee. Although the l i t e r a t u r e indicates no empirical research studies pertaining to the e f f i c a c y of an object-relations t h e o r e t i c a l approach to treatment, several themes i d e n t i f i e d i n t h i s study support the theory. According to Bruch, and Mahler, Pine, and Bergman (cited i n Johnson & Connors, 1987), object- r e l a t i o n s theory focuses on the ego weaknesses and interpersonal disturbances of an ind i v i d u a l with an eating disorder. Her capacity for s e l f - r e g u l a t i o n i s i n s u f f i c i e n t : She i s unable to "accurately i d e n t i f y needs and e f f e c t i v e l y organize 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 interoceptive awareness and i s d e f i c i e n t i n her sense of separateness of s e l f from others. She also feels i n e f f e c t i v e or controlled by others. At an early developmental stage, the infant's undifferentiated n u t r i t i o n a l and emotional needs are inappropriately responded to by the primary caregiver such that when the c h i l d i s older, she i s "not able to discriminate between being hungry or satiated, or between n u t r i t i o n a l need and some other discomfort or tension" (Bruch, 1973, p. 56). She i s also l i k e l y to misinterpret t h i s confusion of her body-self concept as externally induced. Thus, the bulimic i n d i v i d u a l uses food or binge eating as an external means for tension reduction and self-soothing. Given t h i s t h e o r e t i c a l understanding of the development of bulimia, the object-relations theory holds that recovery results from the c l i e n t ' s r e a l i z a t i o n that her d i f f i c u l t emotional feelings are appropriate and not i n d i c a t i v e of being out of I l l c o n t r o l . Furthermore, i t i s necessary for the i n d i v i d u a l to be part of an intimate rel a t i o n s h i p wherein she f e e l s psychologically attended to and assured that others are capable and desirous of responding to her needs (Johnson & Connors, 1987). Themes A4, B l , B2, C4, C6, CIO, Dl, E3, E4, E5, E6, and E7 give p a r t i a l support for object-relations theory. They represent an increasing move from i s o l a t i o n towards psychologically connecting with others even though she f e e l s ashamed, and towards a deepened sense of t r u s t i n g that others w i l l be able to meet her needs. As a r e s u l t , her bulimic behaviours begin to diminish. However, while the themes describe a strengthening of disturbed interpersonal relationships, they do not provide causal support for the i n d i v i d u a l acknowledging the importance of addressing her caregiver's emotional u n a v a i l a b i l i t y i n order for her to recover. For instance, none of the themes allude to the i n d i v i d u a l r e a l i z i n g that she has to deal with the lack of love she experienced as an infant i n her r e l a t i o n s h i p with her mother by either gently confronting her mother or i n t e r a c t i n g with others i n a way which i s more intimate than how she interacts with her mother. Nonetheless, these p a r t i c u l a r themes enhance our understanding of recovery from bulimia from an object-relations perspective. For instance, her perception of he r s e l f begins to change when she begins to f e e l accepted by others and r e a l i z e s that she i s acceptable as she i s . She becomes aware that she does not need to engage i n bulimic behaviours i n order to a l t e r her physical s e l f or to meet her emotional needs. Her sense of 112 s e l f or i d e n t i t y develops and grows stronger as she experiences that she can be involved i n intimate relationships while maintaining her sense of who she i s as separate from them. Thus, her i n d i v i d u a l i d e n t i t y as a person with unique a b i l i t i e s and strengths becomes constant and not dependent on others 1 approval of her. She i s able to set l i m i t s for herself and nurture her s e l f i n healthy ways. 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 as a recovered i n d i v i d u a l by affirming to herself and other recovering indi v i d u a l s that her increased sense of s e l f and s e l f - respect b o l s t e r her confidence i n her a b i l i t y to maintain abstinence from bingeing and purging. With respect to family systems theory, none of the themes d i r e c t l y addresses the curative mechanism of family restructuring i n order to create more adaptive patterns of i n t e r a c t i o n which support the ind 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 family system (Schwartz, 1982; Schwartz et a l . , 1985). The i n d i v i d u a l did not volunteer information which would support a systemic change factor. For instance, she did not indicate that her mother inter a c t s d i f f e r e n t l y with her now or that she relates d i f f e r e n t l y to her mother. However, Theme C7 ("De-idealizing and fo r g i v i n g family of origin") extends the meaning of establishing an i d e n t i t y independent of the family. S p e c i f i c a l l y , the i n d i v i d u a l deepens her emotional separation from her family of o r i g i n once she decides to take r e s p o n s i b i l i t y for overcoming her bulimia rather than blaming her mother for her eating disorder. With respect to the cognitive-behavioural theory, Themes B3, C2, C3, C5, C9, D4, E l , E2, E6, and E7 confirm t h i s theory's 113 assumptions as indicated by Fairburn (1985). As outlined respectively by Themes B3, C2, and D4 ("Remission," "Interruption of eating patterns," and "Expanding sense of s e l f and b e l i e f i n s e l f " ) , the in d i v i d u a l r e a l i z e s that she can e f f e c t i v e l y gain a sense of control over her bulimic behaviours by engaging i n alternate a c t i v i t i e s . Her sense of e f f i c a c y continues to increase now that she knows how she can regain control of her eating behaviours when she relapses. Correspondingly, as det a i l e d by Theme C3 ("Symptom subs t i t u t i o n " ) , she i s aware of also s u b s t i t u t i n g her bulimic behaviours with other addictive substances. Theme C9 ("Permission to eat previously forbidden foods and to f e e l f u l l " ) explains the cognitive restructuring of "O.K. foods" and "binge foods" and recounts the indiv i d u a l ' s insight that her body can e f f i c i e n t l y metabolize a normal intake of food without her needing to s t r i c t l y control what she eats. However, the in d i v i d u a l does not use s e l f - t a l k to challenge her b e l i e f that c e r t a i n foods are inherently fattening. Instead, she discusses with her therapist that a l l foods i n moderation are good, and then she begins to gradually incorporate the previous "binge foods" into her d i e t . Theme C9 also alludes to the technique of "exposure with response prevention" i n which ind i v i d u a l s are encouraged to eat forbidden foods but then to delay or r e f r a i n from purging (Wilson, Rossiter, K l e i f i e l d , & Lindholm, 1986). She implements the 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 that she can delay her purging behaviour. F i n a l l y , Themes E l , E2, E6, and E7 ("Counting the cost of returning to the bulimic behaviours," "Processing lapses," 114 "Altruism," and "Certainty of recovery") focus on the cognitive interventions which the ind i v i d u a l implements to prevent a relapse from occurring: doing a cost-benefit analysis of her eating behaviours, using s e l f - t a l k to remind herself of her growth and development, and implementing alternate a c t i v i t i e s . In summary, the pattern of recovery which emerged from t h i s study supports the t h e o r e t i c a l assumptions of recovery from bulimia outlined by the psychodynamic, object-relations, and cognitive-behavioural approaches to treatment. The themes i d e n t i f i e d i n t h i s study also provided further insight into the meaning and impact of some of the formal therapeutic curative factors and deepened our understanding of the i n i t i a l phase of recovery described by Category A. "Realization of Eating Problem and Ambivalence About Change." F i n a l l y , the co-researcher's perspective on the c r i t i c a l change factors i n recovery supports the current multifaceted and integrated therapeutic approach used i n t r e a t i n g bulimia (Herzog et a l . , 1987; Johnson, Connors, & Tobin, 1987; Manley, 1989; Steiger, 1989). The curative impact of out-of-therapy experiences has also been confirmed i n t h i s study. Implications for Counselling This section discusses the p r a c t i c a l implications of the pattern of recovery from bulimia which emerged from t h i s study. The present analysis of recovery themes from the c l i e n t ' s perspective has the following three important implications for counselling practice. 1. The pattern of recovery as discussed i n t h i s thesis gives 115 a more complete and h o l i s t i c understanding of the process and nature of recovery than what has been known previously. The meaning of the recovery events throughout the ent i r e process i s examined and the synergetic e f f e c t of curative factors both inside and outside of formal therapy i s revealed. Therefore, c l i e n t s may be encouraged to increase out-of-therapy corrective experiences as p o t e n t i a l l y valuable adjuncts to formal therapy. 2. The recovery pattern provides a useful framework for counselling individuals who are recovering from bulimia. I t outlines the factors which are most f a c i l i t a t i v e of recovery and also indicates the associated physical, cognitive, emotional, s o c i a l and s p i r i t u a l changes. For example, the r e s u l t s reinforce that before change can occur, the i n d i v i d u a l must r e a l i z e that she has an eating disorder and that i t i s i n d i c a t i v e of underlying emotional issues and interpersonal c o n f l i c t s . I t i s also imperative that she acknowledges her need for outside help and her ambivalence about change. The importance of addressing both the disordered eating behaviours and the ind i v i d u a l • s sense of s e l f throughout therapy i s also underscored. In addition, the developmental process involved i n overcoming bulimia i s highlighted by the self-exploration and ri s k - t a k i n g a c t i v i t i e s which contribute to the individual's growing perception of s e l f and increased sense of e f f i c a c y and self-respect. 3. The r e s u l t s may also contribute to the development of a c l i n i c a l approach to bulimia by emphasizing the need for a multifaceted, integrated, and i n d i v i d u a l i z e d treatment approach which i s adjusted throughout the recovery process as the adaptive 116 functions or meanings of c l i e n t s 1 eating behaviours change. Hopefully, the individual's unique way of perceiving r e a l i t y and her sense of agency w i l l be highlighted as the therapist s t r i v e s to know how to most e f f e c t i v e l y work with those who are recovering from bulimia. In addition to sharing the c l i e n t ' s world view i n terms of mutually i d e n t i f y i n g the adaptive function or underlying causes of the c l i e n t ' s bulimic symptoms, dialoguing with her as to what aspects of therapy she finds h e l p f u l may decrease the p o s s i b i l i t y of relapse or symptom transformation occurring once the bulimic symptoms have subsided (Vognsen, 1985). Recommendations for Future Research The following recommendations for future research are based upon the findings and research methodology used i n t h i s study, as well as the current l i t e r a t u r e on recovery from bulimia. 1. In order to increase g e n e r a l i z a b i l i t y of the present findings and v a l i d i t y of the f i v e categories, further q u a l i t a t i v e studies are needed to more f u l l y explicate the meaning of the recovery events from the perspective of the i n d i v i d u a l who has recovered from bulimia. Studies of t h i s type w i l l enhance the current knowledge of the longitudinal nature of the behavioural and psychosocial changes involved i n recovery. Additional insight could be gained into the meaning of the curative mechanisms inherent i n formal therapeutic treatment approaches for both indiv i d u a l s and groups. 2. Q u a l i t a t i v e researchers need to focus more attention on the i n i t i a l phase of recovery when inklings of change are f i r s t 117 noticed by the i n d i v i d u a l with an eating disorder. Although the factors which lead to the onset of bulimia may be the factors involved i n recovery, the richness and comprehensiveness of the information i s compromised i f the p r e c i p i t a t i n g factors are discussed p r i o r to addressing the time when change was f i r s t experienced. Since the nature of the p r e c i p i t a t i n g factors or t h e i r importance i n maintaining bulimic behaviour may change throughout the course of the eating disorder, one a l t e r n a t i v e way of studying the phenomenon i s to begin the research process at the point where the in d i v i d u a l f i r s t became aware of change. Researchers must guard against the interference of extraneous variables such as the presupposition that the p r e c i p i t a t i n g factors are often the factors involved i n recovery as well as personal biases towards s t o r i e s being t o l d i n a chronological fashion. 3 . The g e n e r a l i z a b i l i t y of the themes of the recovery experience needs to be tested by r e p l i c a t i n g t h i s study with greater numbers of recovered individuals and returning to them for v a l i d a t i o n of the themes. Researchers may not exclude recovered bulimic males and individuals with p r i o r concomitant obesity. 4. Researchers may develop a survey questionnaire for both c l i n i c a l and research purposes by using the themes as categories which are f a c i l i t a t i v e of recovery i n order to explore the meaning of the recovery events i n more depth. Such a c h e c k l i s t may be used to heighten c l i e n t s * awareness of recovery factors and to also i d e n t i f y possible patterns of recovery related to 118 prognostic indicators such as age of onset, duration of eating disorder, and severity. 5. Since l i t t l e consensus has been reached concerning which treatment i s most suitable for the various subtypes of bulimia (e.g., bulimia complicated by substance abuse, obsessive- compulsive behaviour, depression, or sexual abuse) more knowledge may be gained from further q u a l i t a t i v e studies which interview in d i v i d u a l s with these additional psychological problems. (Hudson & Pope, 1986; Johnson & Connors, 1987). Summary and Conclusions The r e s u l t s of the present study provide a more complete and h o l i s t i c understanding of the structure or process of recovery from bulimia and examine the synergetic e f f e c t of curative factors both inside and outside of formal therapy. Further, the categorical themes contribute to a more comprehensive th e o r e t i c a l conceptualization of the recovery process which i s lacking i n the current l i t e r a t u r e on recovery from bulimia. S p e c i f i c a l l y , our knowledge of the i n i t i a l phase i n recovery ( i . e . , "Realization of Eating Problem and Ambivalence About Change") i s extended by the theme descriptions. The findings also underscore c l i n i c a l observations which advocate the necessity of a multifaceted and i n d i v i d u a l i z e d approach to treatment i n which various therapeutic approaches are integrated i n order to address both the bulimic behaviours and the multiple perpetuating factors (Herzog et a l . , 1987; Johnson, Connors, & Tobin, 1987; Manley, 1989; Steiger, 1989). In p a r t i c u l a r , t h i s study suggests that the object- r e l a t i o n s approach may be a useful model for understanding the 119 importance of focusing on the intrapersonal and interpersonal patterns of r e l a t i n g . Techniques from the psychodynamic, family systems, and cognitive-behavioural approaches can then be implemented to address the bulimic behaviours as well as the underlying intrapsychic c o n f l i c t s , maladaptive patterns of int e r a c t i o n , and dysfunctional b e l i e f s about body shape and weight. 120 References American Psyc h i a t r i c Association. (1980). Diagnostic and s t a t i s t i c a l manual of mental disorders (3rd ed.). Washington, DC: Author. American Ps y c h i a t r i c Association. (1987). Diagnostic and s t a t i s t i c a l manual of mental disorders (3rd ed. rev.). Washington, DC: Author. Beresin, E. V. (1985). [The process of recovering from anorexia nervosa]. Unpublished raw data. Borg, W. R., & G a l l , M. D. (1983). Educational research: An introduction (4th ed.). New York: Longman. Brownell, K. D., Marlatt, G. A., Lichtenstein, E., & Wilson, G. T. (1986). Understanding and preventing relapse. American Psychologist. 42., 765-782. Bruch, H. (1973). Eating disorders: Obesity, anorexia nervosa, and the person within. New York: Basic Books. Bruch, H. (1988). Recovery: Rediscovering the s e l f . In D. Czyzewski & M. A. Suhr (Eds.), Conversations with anorexics (pp. 185-210). New York: Basic Books. Ca s s e l l , E. J . (1987). The healer's a r t : A new approach to the doctor-patient re l a t i o n s h i p . Philadelphia: J . B. Lippincott. Chapman, L. S. (1984, F a l l ) . Developing a useful perspective on s p i r i t u a l health. American Journal of Health Promotion, 12- 17. C o l a i z z i , P. F. (1978). Psychological research as the phenomenologist views i t . In R. S. V a l l e & M. King (Eds.), Existential-phenomenological alternatives for psychology (pp. 48-71). New York: Oxford University Press. Connors, M. E., Johnson, C. L., & Stuckey, M. K. (1984). Treatment of bulimia with b r i e f psychoeducational group therapy. American Journal of Psychiatry. 141, 1512-1516. Cooper, P. J . , Cooper, Z., & H i l l , C. (1989). Behavioral treatment of bulimia nervosa. International Journal of Eating Disorders. 8, 87-92. Corey, G. (1986). Theory and practise of counseling and psychotherapy (3rd ed.). P a c i f i c Grove, CA: Brooks/Cole. 121 Cox, G. L., & Merkel, W. T. (1989). A q u a l i t a t i v e review of psychosocial treatments for bulimia. The Journal of Nervous and Mental Disease. 177, 77-84. Drewnowski, A., Yee, D. K., & Krahn, D. D. (1988). Bulimia i n college women: Incidence and recovery rates. American Journal of Psychiatry. 145. 753-755. Eating Disorder Task Force. (1989). The p r o v i n c i a l task force eating disorder report (Vol. 1). Vancouver, B r i t i s h Columbia, Canada: McCreary Centre Society. Erickson, M. (1985). The case of Barbie: An Ericksonian approach to the treatment of anorexia nervosa. Transactional Analysis Journal. 15, 85-92. Fairburn, C. G. (1981). A cognitive behavioral approach to the treatment of bulimia. Psychological Medicine. 11. 707-711. Fairburn, C. G. (1985). Cognitive-behavioral treatment for bulimia. In D. M. Garner & P. E. Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia (pp. 160- 192). New York: Guilford Press. Fairburn, C. G. (1988). The uncertain status of the cognitive approach to bulimia nervosa. In K. M. Pirke, W. Vandereycken, & D. Ploog (Eds.), The psychobiology of bulimia nervosa (pp. 129-136). New York: Springer-Verlag. Fairburn, C. G., Kirk, J . , O'Connor, M., & Cooper, P.J. (1986). A comparison of two psychological treatments for bulimia nervosa. Behaviour Research and Therapy, 24, 629-643. Frankl, V. (1963). Man's search for meaning. New York: Washington Square Press. Freeman, C., S i n c l a i r , F., Turnbull, J., & Annandale, A. (1985). Psychotherapy for bulimia: A controlled study. Journal of P s y c h i a t r i c Research, 19, 473-478. Goldman, H. E. (1988). Does she deserve to l i v e ? A psychodynamic case study of an anorexic mother and her young c h i l d . International Journal of Eating Disorders. 7, 561-566. H a l l , L., & Cohn, L. (1986). Bulimia: A guide to recovery. Santa Barbara, CA: Gurze Books. Herzog, D. B., Franko, D. L., & Brotman, A. W. (1989). Integrating treatments for bulimia nervosa. Journal of the American Academy of Psychoanalysis, 17(1), 141-150. Herzog, D. B., Hamburg, P., & Brotman, A. W. (1987). Psychotherapy and eating disorders: An affirmative view. International Journal of Eating Disorders, 6, 545-550. 122 Herzog, D. B., K e l l e r , M. B., & Lavori, P. W. (1988). Outcome i n anorexia nervosa and bulimia nervosa: A review of the l i t e r a t u r e . Journal of Nervous and Mental Disease. 176. 131- 143. Hobbs, M., B i r t c h n e l l , S., Harte, A., & Lacey, H. (1989). Therapeutic factors i n short-term group therapy for women with bulimia. International Journal of Eating Disorders. 8, 623- 633. Hudson, J . I., & Pope, H. G. (1986). Treatment of bulimia: A review of current studies. New Directions for Mental Health Services, 31, 71-85. Jackson, S. (1986). Therapeutic change and anorexia nervosa: Views of a family and a therapist. Australian and New Zealand Journal of Family Therapy, 7, 69-74. Johnson, C , & Connors, M. E. (1987). The etiology and treatment of bulimia nervosa: A biopsychosocial perspective. New York: Basic Books. Johnson, C., Connors, M. E., & Tobin, D. L. (1987). Symptom management of bulimia. Journal of Consulting and C l i n i c a l Psychology. 55, 668-676. Kirk, M. (1986/1987). Recovery from bulimia: A descriptive survey (Doctoral d i s s e r t a t i o n , West V i r g i n i a U n i v e r s i t y ) . Dissertation Abstracts International, 48, 342A. Kirkley, B. G., Schneider, J . A., Agras, W. S., & Bachman, J . A. (1985). Comparison of two group treatments for bulimia. Journal of Consulting and C l i n i c a l Psychology, 53. 43-48. Lacey, J . H. (1983). Bulimia nervosa, binge eating and psychogenic vomiting: A controlled treatment study and long- term outcome. B r i t i s h Medical Journal, 286, 1609-1613. Laessle, R. G., Zoet t l , C., & Pirke, K. M. (1987). Metaanalysis of treatment studies for bulimia. International Journal of Eating Disorders. 6, 647-653. Maddocks, K. M., & Bachor, D. G. (1986). The case of "Kim": The feelings and experiences of a bulimic. Canadian Journal of Counselling. 20, 66-72. Maine, M. (1985). E f f e c t i v e treatment of anorexia nervosa: The recovered patient's view. Transactional Analysis Journal, 15, 48-54. Manley, R. S. (1989). Anorexia and bulimia nervosa: Psychological features, assessment, and treatment. BC Medical Journal. 31. 151-154. 123 Mines, R. A., & M e r r i l l , C. A. (1987). Bulimia: Cognitive- behavioural treatment and relapse prevention. Journal of Counselling and Development. 65, 562-564. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Minuchin, S., Rosman, B. L., & Baker, L. (1978). Psychosomatic fam i l i e s : Anorexia nervosa i n context. Cambridge, MA: Harvard University Press. M i t c h e l l , J . E., Pyle, R. L., Hatsukami, D. K., Goff, G., Glotter, D., & Harper, J . (1989). A 2-5 year follow-up study of patients treated for bulimia. International Journal of Eating Disorders. 8, 157-165. Neuman, P. A., & Halvorson, P. A. (1983). Anorexia nervosa and bulimia. A handbook for counsellors and therapists. New York: Van Nostrand Reinhold. Norman, D. K., Herzog, D. B., & Chauncy, S. (1986). A one-year outcome study i n bulimia: Psychological and eating symptom changes i n a treatment and non-treatment group. International Journal of Eating Disorders. 5, 47-57. Oesterheld, J . R., McKenna, M. S., & Gould N. B. (1987). Group psychotherapy of bulimia: A c r i t i c a l review. International Journal of Group Psychotherapy. 37, 163-184. Ordman, A. M., & Kirschenbaum, D. S. (1985). Cognitive- behavioral therapy for bulimia: An i n i t i a l outcome study. Journal of Consulting and C l i n i c a l Psychology, 53., 305-313. Pyle, R. L., M i t c h e l l , J. E., Eckert, E. D., Hatsukami, D., Pomeroy, C., & Zimmerman, R. (1990). Maintenance treatment and 6-month outcome for bulimic patients who respond to i n i t i a l treatment. American Journal of Psychiatry, 147. 871- 875. Rabinor, J . R. (1986). The bulimic obsession and the struggle to separate. The Psychotherapy Patient. 2(2), 59-71. Schneider, J . A., O'Leary, A., & Agras, W. S. (1987). The role of perceived s e l f - e f f i c a c y i n recovery from bulimia: A preliminary examination. Behaviour Research and Therapy. 25, 429-432. Schwartz, R. (1982). Bulimia and family therapy: A case study. International Journal of Eating Disorders. 2.(1), 75-82. Schwartz, R. C., Barrett, M. J., & Saba, G. (1985). Family therapy for bulimia. In D. M. Garner & P. E. Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia (pp. 280-307). New York: Guilford Press. 124 Stanton, A. L., Rebert, W. M., & Zinn, L. M. (1986). S e l f - change i n bulimia: A preliminary study. International Journal of Eatina: Disorders. 5, 917-924. Steiger, H. (1989). An integrated psychotherapy for eating- disordered patients. American Journal of Psychotherapy, 43., 229-237. Stein, J . , Hauck, L. C., & Su, P. Y. (Eds.). (1975). The Random House college dictionary (rev. ed.). New York: Random House. Striegel-Moore, R. H., S i l b e r s t e i n , L. R., & Rodin, J . (1986). Toward an understanding of r i s k factors for bulimia. American Psychologist, 41, 246-263. Tonkin, R. S., & Wigmore, E. J. (1989). Epidemiology, c l a s s i f i c a t i o n , and diagnosis of eating disorders. BC Medical Journal. 31(3), 147-150. Va l l e , R. S., & King, M. (1978). An introduction to existential-phenomenological thought i n psychology. In R. S. V a l l e & M. King (Eds.), Existential-phenomenological alt e r n a t i v e s for psychology (pp. 3-17). New York: Oxford University Press. Vandereycken, W., Vanderlinden, J . , & Van Werde, D. (1986). Directive group therapy for patients with anorexia nervosa or bulimia. In F. E. F. Larocca (Ed.), Eating disorders: E f f e c t i v e care and treatment (pp. 53-69). St. Louis, MO: Ishiyaku EuroAmerica Inc. Vognen, J . (1985). Brief, Strategic treatment of bulimia. Transactional Analysis Journal. 15, 79-84. Wilson, G. T., Rossiter, E., K l e i f i e l d , E. I., & Lindholm, L. (1986). Cognitive-behavioral treatment of bulimia nervosa: A controlled evaluation. Behavior Research and Therapy, 24., 277-288. Yager, J . (1988). The treatment of eating disorders. The Journal of C l i n i c a l Psychiatry, 49(Suppl. 9), 18-25. 125 APPENDIX A DSM-III R (1987) Diagnostic C r i t e r i a for Bulimia Nervosa A. Recurrent episodes of binge eating (rapid consumption of a large amount of food i n a discrete period of time). B. A f e e l i n g of lack of control over eating behavior during the eating binges. C. The person regularly engages i n either self-induced vomiting, use of laxatives or d i u r e t i c s , s t r i c t d i e t i n g or fasting, or vigorous exercise i n order to prevent weight gain. D. A minimum average of two binge eating episodes a week for at lea s t three months. E. Persistent overconcern with body shape and weight (p. 68- 69) . 126 APPENDIX B DSM-III R (1987) Diagnostic C r i t e r i a for Anorexia Nervosa A. Refusal to maintain body weight over a minimal normal weight for age and height, e.g., weight loss leading to maintenance of body weight 15% below that expected; or f a i l u r e to make expected weight gain during period of growth, leading to body weight 15% below that expected. B. Intense fear of gaining weight or becoming f a t , even though underweight. C. Disturbance i n the way i n which one's body weight, size, or shape i s experienced, e.g., the person claims to " f e e l f a t " even when emaciated, believes that one area of the body i s "too f a t " even when obviously underweight. D. In females, absence of a lea s t three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea). (A woman i s considered to have amenorrhea i f her periods occur only following hormone, e.g., estrogen, administration.) (p. 67) 127 APPENDIX C Pre-screeninq Interview Summary Sheet Name: 1. Duration of eating disorder 2. Primary eating disorder symptoms 3. DSM-III R diagnosis 4. Current status re: eating behaviour 5. Degree of recovery < > 1 2 3 4 5 No S l i g h t Moderate Major Profound Improvement Improvement Improvement Improvement Improvement 6. Length of recovery 7. Other active psychological problems ( i . e . , substance abuse, mood disorder, anxiety disorder, etc.) 128 APPENDIX D Contact Letter to Counsellor/Therapist Research Study: Recovery from Bulimia Dear Counsellor/Therapist: As a graduate student i n the Counselling Psychology Department at the University of B r i t i s h Columbia, I am conducting a research project f o r my master's thesis on recovery from bulimia. This study w i l l be b e n e f i c i a l i n contributing to the development of a c l i n i c a l approach to t r e a t i n g bulimia. I am interested i n interviewing three individuals who meet the following c r i t e r i a : (a) a previous diagnosis of bulimia nervosa as defined 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 period of time without any symptoms of bulimia; (c) no s i g n i f i c a n t indicators of other active psychological problems; (d) self-reported f e e l i n g , of no s p e c i f i c time period, of being genuinely recovered from bulimia; and (e) an a b i l i t y to a r t i c u l a t e t h e i r insights and elaborate on t h e i r descriptions. Individuals may refuse to p a r t i c i p a t e or withdraw from the study at any time without jeopardizing any potential future treatment. A l l information 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 participants w i l l be screened i n an unrecorded interview at St. Paul's Hospital, 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 eating disorder expert. He w i l l ask each individual to recount the development of her eating problems/symptoms, her weight and medical history, and her current eating behaviour. Then, i n an unstructured, audiotaped interview with myself, each p a r t i c i p a n t w i l l be asked to describe the events which prec i p i t a t e d the onset of her bulimia and to t e l l her story of recovery. Other relevant personal documents ( i . e . journals) may be used. In addition, each i n d i v i d u a l and myself w i l l meet several additional times i n order to v e r i f y the transcribed interview, themes, and f i n a l narrative account. A t o t a l time commitment of approximately f i v e to seven hours w i l l be required. I f you have any questions about the study or i n d i v i d u a l s who you f e e l would be interested i n contributing to a deeper understanding of the process of recovering from bulimia, please contact me at the above address/phone number. Thank you for your time and i n t e r e s t . Sincerely, Laurie Truant 129 APPENDIX E Contact Letter to Volunteer Research Study: Recovery from Bulimia Dear Volunteer: As a graduate student i n the Counselling Psychology Department at the University of B r i t i s h Columbia, I am interested i n gaining a deeper understanding of the process of recovering from bulimia. This study w i l l be b e n e f i c i a l i n contributing to the development of a c l i n i c a l approach to tr e a t i n g bulimia. 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 voluntary and you can refuse to p a r t i c i p a t e or withdraw from the study at any time without jeopardizing any pot e n t i a l future treatment. A l l information 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 previous diagnosis of bulimia with no h i s t o r y of anorexia nervosa, currently f e e l genuinely recovered and w i l l i n g to discuss your insights into what f a c i l i t a t e d your recovery, I would enjoy speaking further with 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 involve an unrecorded pre-screening interview at St. Paul's Hospital, Vancouver, B.C. with 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 eating disorder expert. He w i l l ask you to recount the development of your eating problems/symptoms, your weight and medical history, and your current eating behaviour. Then, i n an unstructured, audiotaped interview with myself, you w i l l be asked to describe your recovery experience and make use of other relevant personal documents. In addition, we w i l l meet several additional times i n order to v e r i f y the transcribed interview, themes, and f i n a l narrative account. The t o t a l time commitment w i l l be approximately f i v e to seven hours. I hope that 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 that the information w i l l be b e n e f i c i a l both to you and to other women struggling to overcome bulimia. If you have any questions about the study or would l i k e to p a r t i c i p a t e , please contact me at the above address/phone number. Thank you for your time and int e r e s t . Sincerely, Laurie Truant 132 APPENDIX H L.S.'s Protocol L.S. O.K. So you want me to, so what I w i l l do i s s t a r t with, um, the onset and t r y and be quite b r i e f about the onset and development of, of the bulimia, and concentrate on the recovery. L.T. M-hm. L.S. I t , I think i t f i r s t began when I was about 18, 17 or 18 in high school and r e a l l y progressed uh quite dramatically when I went away from, for 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 of u n i v e r s i t y — t h a t would have put me about 2 0 years old I g u e s s — I did uh go, I did f i n a l l y at that point r e a l i z e d there was something very, very much wrong. And I went, when I was home for the summer, I went to um a p s y c h i a t r i s t who was a fri e n d of my father for some therapy. L.T. How did you know that something was r e a l l y wrong? What made you think that at the time? 0 0 1 L.S. Well, I guess inside I'd always known that something was very wrong. But the, those 2 years of univ e r s i t y saw a very steady um progression of i t [bingeing and purging] such that by the end of my second year I just barely f i n i s h e d the year. You know, I guess I had to reach a point where I'd r e a l l y h i t bottom to r e a l i z e that t h i s [bingeing and purging] was probably the cause i n that these a c t i v i t i e s were, were becoming the most important factor i n my l i f e . Uh, t h i s , t h i s sort of thing had taken over my l i f e and that i n order to continue doing anything I had to address i t . 0 0 2 Um, but I s t i l l , I don't think I was s t i l l yet at the point of t r u l y being able to work through i t . Like I wanted t h i s thing to go away, I wanted to be O.K., but I didn't r e a l l y want to put into i t what I knew I would have to. Because on one l e v e l , I think I understand very well that the bulimia i t s e l f , i t was just a set of symptoms, that there were, there were deeper things that were r e a l l y causing a l l of that. Um, so. L.T. And, and how did you have that awareness? Had you read anything, or talked with other people, or what made you think that? L.S. To know that I had bulimia? 133 L.T. No, to, to, um make you aware that there may have been issues underlying i t ? How did you know about i t ? 003 L.S. Well, I've always been um, not very happy with myself, not very secure i n myself, and always eager to please others and to be led by others without much confidence myself. And, so i n some ways I often f e l t as i f I weren't i n control of 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, that aspect i n t e n s i f i e d a hundred times. L.T. O.K. 004 L.S. So I guess I kind of knew that uh i t [bingeing and purging] wasn't just a, a way to control weight: that the fact that I was involved with t h i s meant, meant something more. I mean I knew that i t was, i t wasn't just the fact that I would eat and vomit. There was a, there was a reason for that, somehow, beyond j u s t wanting not to be f a t again. And I think, I r e a l i z e d that i t was um, i n some way connected to my feelings about myself and my lack of, of r e a l l y f e e l i n g of control over myself, or wanting to have control, or f e e l i n g that I was worth um having control on so I could make something out of my l i f e . And there were other factors i n those 2 years of univer s i t y that have i n t e n s i f i e d i t i n that I was i n a relat i o n s h i p that wasn't, that wasn't a good one, um and I l e t myself be controlled by that person too. So you see they almost, as that r e l a t i o n s h i p progressed so did the condition. So there were a l o t of factors sort of pointing i n the same d i r e c t i o n that I had to uh, I knew I had to t r y and touch base with, with myself i n some ways. But at that point, I wasn't ready t o t a l l y to do that. 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 pretty overwhelming. You knew that something was wrong and you had a keen sense that you'd have to do some work and deal with the underlying things. L.S. Very hard work. Yah. But, so that's I was very unclear about i t a l l but I knew that there was something very wrong. L.T. M-hm. L.S. But I wasn't r e a l l y able to admit to myself. I mean as I say on one l e v e l I knew i t was me, there was something with me that would cause t h i s whole thing to develop i n the f i r s t place. But I guess I wasn't r e a l l y ready i n 134 some way to deal with that. So I went for a period of t i m e — i t was only about a month—to see t h i s guy. And I'd see him on a d a i l y basis. And i t was funny because i t was treated I think more as anorexia than bulimia. L.T. Now t h i s was a p s y c h i a t r i s t , a fr i e n d of your father? L.S. My father's: i n the medical faculty of that u n i v e r s i t y and he was the head of Psychiatry there. L.T. M-hm. And so how, how did i t happen that you were connected with 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 father. I, I t o l d my parents that there, I was, I was experiencing some, some problems, some emotional problems. I didn't, up u n t i l that point, I didn't t a l k to them about any kind of eating disorder and I didn't know whether or not they were aware of one. And I t o l d them I r e a l l y needed to t a l k to somebody, and so they recommended uh Dr. C. to me. And so I went and saw him. And I started out by describing a l l the surrounding things such as I would, you know, I couldn't keep things together, I couldn't f i n i s h things. And then very shortly I t o l d him that, you know, I would, I would eat and throw up. But I didn't know what i t was a l l about, I couldn't put a name on i t . But I think he treated i t more as anorexia because I was quite underweight at that time. So we talked a l o t about uh body image, and weighing i n and that kind of s t u f f , rather than um t a l k i n g about the reasons why t h i s would have developed i n the f i r s t place. Well, we did t a l k about body image and self-image and s t u f f . But the focus was as much on sort of behaviour modification i n terms of eating and forcing myself to eat and keep i t down, than on r e a l l y digging things up. So that combined with the fact that I didn't think, you know, there's a part of me that didn't want to dig i t up, I think made i t , made for i t to be unsuccessful. And I pretended that i t was and that things were better. L.T. Pretended that things were successful? L.S. M-hm. T e l l i n g him that things were d e f i n i t e l y getting better. He had prescribed a mood s t a b i l i z e r or e l e v a t o r — I forget what i t was—to me uh which I took for a period and discontinued. Uh, but I had, I had another goal for that summer. I was always I guess latching onto things that I would do, and i n doing things and achieving goals set for me by these things and these people that was how I defined myself. And the goal of that summer was to go to a — I was studying R u s s i a n — i t was to go to a Slav i c i n s t i t u t e i n B.I. which i s very, was very well-respected and was a very, sort of i t would have been a "good feather i n my hat." So I r e a l l y had a focus of getting t h i s thing out of the way so I could do i t . And there was some 135 question by Dr. C. as to whether i t would be good to undertake that at t h i s time. But, "Oh no, things were getting better and I'm sure, you know, I'm sure I could." And i t was a way of jumping from the work that I knew I had to do on myself to again into another um external uh set of expectations that I could meet and therefore get po s i t i v e reinforcement. L.T. Can you t e l l me a b i t more about the sessions that you had with him. As you think back, what, what were they l i k e for you? You know i t ' s funny. I don't know i f t h i s happens with, with everybody or with many people who have been involved with t h i s kind of 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 there. And so often when I think back I have flashes but I don't, I don't see much continuity i n there. And T don't know i f that was a l i k e a self-defense mechanism because things were so t e r r i b l e f or so long or i f . I don't know um. In any event, so what I'm going to say about the sessions I know i s not complete but i t ' s what I remember of them. L.T. M-hm, sure. And that's a l l that, that you know, i s important r e a l l y and s i g n i f i c a n t to you w i l l probably be things that you remember: the s i g n i f i c a n t things. L.S. But I guess what I'm also saying i s that there's a l o t that I mean people w i l l t a l k about during say those u n i v e r s i t y years that I w i l l have no r e c o l l e c t i o n of at a l l . That's a very funny thing. Um, the sessions were, I, I would go into his 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 to the other sessions of therapy that I underwent here i n V . — t h a t I think did help me um overcome th i s — w a s that i n looking at i t as we went on I saw that very often he was just allowing me to put things out and he would arrange them so that I could see actually what I was saying and thinking. So he was very good about not tr y i n g to impose um his own ideas on me, rather making suggestions that, upon r e f l e c t i o n , would have been apparent i n what I said. So i t was very much a way of um, of of just a i r i n g , a i r i n g myself and allowing myself to look at myself. You know, i t was just, i t was sort of a self-examination thing. We would weigh i n um, because as I said that was an important thing, i t seemed an important thing from his standpoint. And he did set a certa i n weight, and I forget what i t was, that were I to dip below that that they might L.S. 1 3 6 consider h o s p i t a l i z a t i o n etcetera and what went on during the enforced h o s p i t a l i z a t i o n . Um he did, he O.K., so we would weigh i n and i t was the, the expectation was that I would be gaining a certa i n amount of weight per week which I never r e a l l y f i l l e d . I remember at the, at, I mean as the sessions ended, as my date for leaving approached—and I was very anxious to make sure that everything seemed to be hunky-dory from h i s a s p e c t — I was coming up for a period. And so I gained 5 lb and I never t o l d him that you know. But that was seen as being a success. So I was r e a l l y t r y i n g to um hide the fact that things weren't getting that much better. L.T. M-hm. So towards the end then you gained a whole bunch of weight so that you could say to him and maybe to yourself that, "Hey, I've succeeded at t h i s , t h i s b i t of therapy." L.S. M-hm. But i t was a fa l s e gain. I mean I l o s t that r i g h t . That was just because of the water retention from the period. And, I mean, I knew that very well but I didn't t e l l him. But um, so i t would be large l y devoted to ta l k i n g about myself and I think my family. I don't have much r e c o l l e c t i o n of exactly what we talked about. This was i n 1978 so i t ' s quite a while ago. Um, he didn't prescribe any reading or um anything of t h i s nature. No, there wasn't any support group or anything of that that should've went on. And also, I think the fact that i t wasn't stressed that I take t h i s outside of the o f f i c e I think had something to do with i t because therefore I could keep i t again sort of as my secret. And as long as I didn't have to l e t anybody i n on i t then I wasn't faced with any other motivation than my own to work on i t . For example, I could s t i l l be a home with my parents and s t i l l go through you know bingeing and purging cycles because as long as I could fool myself into b e l i e v i n g that they didn't know about i t , I could get away with i t . L.T. Because i t was just between you and the p s y c h i a t r i s t and. L.S. Uh-huh. Uh-huh. L.T. So that was O.K. to have i t that way. L.S. And i t ' s an int e r e s t i n g thing because i f you um, i f you in t e n t i o n a l l y overeat during a meal—and i t ' s very easy to do at a family meal when someone else i s paying for the food and i t ' s a l l there—and then you have to go to the bathroom soon afterwards, you know i f they're aware of what's going on then should you somehow happen to overeat, even i f you weren't t r y i n g to you couldn't, that escape valve wouldn't be open to you. Because i t would be very d i f f i c u l t to go through that when you knew that they knew. L.T. Right. 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 didn't go through with i t and and r e a l l y overcome i t , I could s t i l l continue i t which i s I think what I wanted to do. L.T. And so your parents at t h i s time then are not aware that you're bingeing and purging. They j u s t know that there's some emotional problem as you had t o l d them? L.S. I think t h a t — I can't remember—I think that I did t e l l them there was an eating disorder involved. I pretty sure I did. But I know I didn't go into any d e t a i l about i t with them. I, they may have thought i t was anorexia, they may well have known everything and I ju s t didn't want to admit that. But I know we didn't, I didn't involve my parents i n terms of 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 occurred. L.T. So, the bottom l i n e i s that you f e l t they r e a l l y didn't know exactly what you were doing and so therefore. L.S. That's r i g h t . L.T. I t was s t i l l a secret between you and the p s y c h i a t r i s t . L.S. So, so when I went to t h i s program, things were better. Actually that was, at least I'd faced up to the fact that I had a problem, that i t was an i d e n t i f i a b l e problem, and that I knew I needed to work on i t more. L.T. What, just before you move into the program, what happened at the end of therapy then? And, and also how long were you, you said you were going every day but I wasn't sure for how long? L.S. I think I went d a i l y and then we dropped i t back to maybe every other day or something. I t was about a period of 6 weeks, perhaps to 2 months, because as I remember the program was the l a s t month or so of the summer and I was home since May. So i t would have been within 2 months at any rate. L.T. That was f a i r l y intensive then going everyday and then every second day for about 6 weeks. L.S. M-hm. Maybe we dropped i t back to once a week. See these are the d e t a i l s I can't remember. L.T. M-hm. Well that's O.K. L.S. M-hm. 138 L.T. Um, but i t sounds l i k e the beginning part was quite intensive anyways for you. L.S. Yes. L.T. And i n terms of your eating, what sort of things did you discuss with him and how did you implement them or did you implement them? L.S. Well, I. What I remember of i t i s that um, I don't remember r e a l l y discussing what bingeing was a l l about, l i k e you know just the awful d e t a i l s that I think i t ' s important to get out when you're t r y i n g to deal with i t . Um, I do remember you know t a l k i n g about writing down a d a i l y l i s t of say what you were going to eat and writing down what you had eaten, almost as a d i e t e r does. Or um, I think we were looking at i t i n the reverse perspective of a person who i s t r y i n g to put on weight so that eating should be a conscious process um, rather than dictated by j u s t yourself, that you'd actually plan i t out. I don't remember much more beyond that. L.T. And so did you do those things and s i t down, l i k e make up menu plans? L.S. Well, I think I did half-heartedly, but I didn't r e a l l y do i t c a r e f u l l y . Again I was, I was kind of sabotaging i t I think from the beginning. L.T. And so you may have done these meal plans but s t i l l continued on with the behaviour. L.S. Yes, I probably would have, I think I probably would l i e to him. L.T. M-hm. So you were able to maintain your weight at the low l e v e l i t was by continuing on with the purging and not eating a whole l o t . L.S. That's r i g h t . I don't think, 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 think I was away, um, I don't think my weight continued to go down below that. I was d e f i n i t e l y underweight although I didn't see myself as being that way. Like i t was s t i l l ludicrous for me to 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 asking me why. He talked, I remember t h i s , he talked a l o t about body image in the sense of being proud to be strong, and you know how a beautiful body was a um, a strong one and not an emaciated one. And asking me about um why I would wear sort of baggy clothes. And of course the reason why I wore them because, was because I was overweight. And his suggestion that I wore them to hide how t h i n I was, I never could, I could not accept that. 139 Like I never believed that I was t h i n enough to want to hide i t , hide my state. So that, I was s t i l l operating from a perspective of being overweight and being ashamed of myself because I was overweight. But I do remember his t a l k i n g about um one's image of, of the way other people look. And that beauty being um a, a well-proportioned body, and a f i t body, and not ju s t t r y i n g to achieve thinness. And I do, another thing I do remember his t a l k i n g about, we must've talked about, I, I know we did, we talked about um my lack of i d e n t i t y and my insecurity and such. And he was t a l k i n g about, um, almost being able to see that on a person's face, l i k e how formed the person's face was. L.T. How? L.S. How formed and how much character would come out. And the fact that um he thought that towards the end of the sessions that my face looked better. I think, I mean he was probably r i g h t . I think I probably had, you know, made progress during that time but just was not allowing i t to go further than I wanted i t to go. L.T. M-hm. You f e l t safe to the point that you had gone and didn't want to progress beyond that. L.S. That's rig h t , yes, yes. I think that's probably what i t was. L.T. So you're f e e l i n g overweight i n spite of the fact of him t e l l i n g you that you're underweight. And did, did his sort of comments about what a f i t body was l i k e , how did they impact on you at the time? L.S. Well, i n a sense of there's always s e l f and others. Like I could look at another person and say, "yah, that person i s a bea u t i f u l person." But I could never accept myself as I suppose ever having the hope of being a beautiful person. L.T. Who, who would be beautiful people to you then? L.S. Then? L.T. Yah. L.S. Oh, the t r a d i t i o n a l , you know, people that are held up as supposedly b e a u t i f u l , you know: models and movie stars and that kind of thing. You know, you always I think, part of the problem i s comparing yourself to an u n r e a l i s t i c goal. Like I would never take myself and say, "well, how could I make myself beaut?" You know, I just had t h i s idea of a very, you know, s e l f - l o a t h i n g . And I think, i n some ways, perhaps some of t h i s i s almost l i k e 140 punishing yourself, you know, because there i s nothing about you that you l i k e both inside and out. So my um, the only way I f e l t approval towards myself, towards my physical appearance, was l i k e not to have any tummy. You know, i f there was any bulge there i t r e a l l y upset me. Um, so yes I could see beauty i n others but I could, I couldn't apply that to myself. I remember my mother when I was b a c k — I suppose the f i r s t time I was back at Christmas when I had dropped so much weight—saw me without my clothes on and l a t e r on she said that she l a t e r on burst into tears because I looked l i k e someone from Dachau or something. And of course I didn't f e e l that way. I f e l t "Gee, you know t h i s i s , I'm so much better than I used to be; I'm not f a t . " So there was a complete d i s t o r t i o n there. L.T. Did your mom ever make any comments to you at the time? L.S. When I f i r s t , the f i r s t Christmas I think everyone was quite concerned, although I wasn't r e a l l y aware of i t . I know my older brother was i n medical school then and had said something about anorexia to my mother, looking at me. And I know that my mother was sort of appearing at my elbow with 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 that food was held back, was a wonderful sense of my mother bringing me food. You know, so I think i t , i t , some of i t I think also was was a desire for attention and, and, and being mothered and a l l that, being taken care of. You know knowing on some l e v e l that I was sick and i f I could show i t to others then they would take care of me. L.T. So i t f e l t good i n fact that your mom at that Christmas knew what a low weight, was bringing you food, that you found that quite acceptable. L.S. Oh yes! And also to be t o l d that I was t h i n . I loved that! I just loved that! L.T. M-hm. Cause when you were young you said 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 quite chubby. And up u n t i l about the summer af t e r Grade 8, I l o s t weight. And I, and I, upon looking at pictures of myself a f t e r that point, I can see that I r e a l l y wasn't overweight. I was just a b i t large. Um, so again my, my self-image was already s t a r t i n g to become distorted at that time. And I think my idea l would have been to have been a small f r a g i l e person 141 rather than the large um, I guess healthy looking person. I remember my father, when oh gosh, Grade 7 or Grade 8, taking me to one of those l i t t l e dances they have and asking him um, "Dad do you think I ' l l ever be pretty, or do you think I'm pretty now?" And he's a, a very honest person, l i k e i t ' s not i n his character to l i e . And he, his answer was, "Well, I think you w i l l have a kind of Brune Hilda type of beauty, large and strong." And of course that was, that stayed with me as being the ant i t h e s i s of what I wanted you know. So, yes my mother commented um, not very much though. Like she would say, and I would say on occasion during those years when I was so underweight, she would say things um i n a very sort of sad way. But I think she didn't want to l e t me know or didn't, I don't know i f she didn't know what to say or thought that her interference would be negative or what, but she didn't l i k e , you know, s i t me down and say I need to t a l k to you about t h i s . Maybe i t was s e l f - d e n i a l on her part, I don't know. In any event, she didn't say anything to you about your being underweight. As I said, l i t t l e things but not, she wasn't making a big deal about i t . M-hm. O.K. Or maybe i t ' s a fact that i f she were to have said anything, I would interpret that as a compliment. And I don't remember that now. She repeated to me something my l i t t l e brother said um upon seeing me at the a i r p o r t . He said, "Oh, her hands look l i k e claws, you know, she's so t h i n . " And I remember her saying that to me that he had said that. M-hm. And at the time you took that as a compliment or something that you loved. Oh I l i k e d i t . And s t i l l they didn't mean i t as such, but I l i k e d i t . Right. Just when you think back to your ideal image of someone being r e a l l y thin, where, where do you f e e l you got that sort of ideal image from? Cause your dad had said that he, sounds l i k e that he r e a l l y l i k e d people who were stronger and bigger, so I'm wondering where that came from for you? Well, I think probably a multitude of places. I think that for, I tend to believe i n a person having a, a cer t a i n character, a ce r t a i n element of character that's consistent throughout t h e i r l i f e . So I think i f a c h i l d , 142 and I don't think I every r e a l l y was a very confident c h i l d either: In some ways I was, s o c i a l l y I never was. So I think i f you take that character and then you have something that makes that 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 interpret i t i n a negative way. So that, you know, going through t r y i n g to d i e t as a young, not as a young c h i l d but you know, i t was always an issue that L. was a b i t overweight and she should t r y and work on i t . I think that had something to do with i t . But I think even more importantly um was the fact, the whole media g l o r i f i c a t i o n of them, of the perfect woman. And i t was during the time of Twiggy r e a l l y and that whole image. So everywhere you look, you see exactly what i s be a u t i f u l . And i f you're not a person to believe i n oneself and look at oneself and fi n d beauty i n oneself, then that's what you're going to latch onto again are external images. And of course you know, the teenage and preteen years, everybody i s tr y i n g to achieve that look. So the people that you respect around you—your p e e r s — a l l look more or less l i k e that too. So I think from the family, from your own fe e l i n g of insecurity, and from the media. I would say those are the three big areas. L.T. O.K. So your ideal image then i s of someone who's r e a l l y t h i n . And even though the p s y c h i a t r i s t had t o l d you that he f e l t that people could be beautiful with a bigger body that, you know, and a well-proportioned body, somehow you only h a l f believed him or. L.S. Well, no. I believed him. I mean I could see a picture of someone overweight, underweight, and r e a l i z e that person was not bea u t i f u l . That yes, you were supposed to be t h i n and f i t but no you're not supposed to be so emaciated that your knees bruise each other at night when you l i e down on your side. But I could j u s t never see myself as being anything but overweight and needing to lose more weight. You know, I couldn't see myself as I was. So, and I suppose I could've even have seen um a woman athlete, maybe a very muscular woman athlete l e t ' s say, and, and recognize the beauty i n that. But I ce r t a i n l y couldn't see a person who was considered overweight and consider that a t t r a c t i v e at a l l . L.T. M-hm. So i t was hard for you to r e a l l y look at yourself as you said e a r l i e r . L.S. Impossible. Impossible. I remember occasionally getting a glimpse of myself—before I knew I was seeing myself i n l i k e a shop window—and having for a s p l i t second the knowledge that that was a, a th i n person, u n t i l i t c l i c k e d i n that that was me. And then that idea was out of my head. 143 L.T. M-hm. M-hm. That's me and I'm not t h i n , never t h i n enough. L.S. That's r i g h t . Ergo, that r e f l e c t i o n i s n ' t t h i n . L.T. M-hm. O.K. How are we doing with the story? Now I've asked you a number of questions and sort of got us back and now. L.S. No I think, no I think i t ' s good because t h i s sort of chronological progression I think i s easier for me to remember things i n . Um, I could t a l k more about why I f e l t that, you know, how the whole process started, but you could weight that i f you wanted, that doesn't matter so much. L.T. No. No, I think that I, I have enough of the key things to, for us to move on i f , i f you f e e l you'd l i k e to now and your rest of the story. L.S. M-hm. So. O.K. so a f t e r that therapy then I just continued on and things um, I think 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 thing keeps going through my mind i s that when t h i s tape f i n i s h e s , there's t h i s r e a l l y loud beep and I just thought. L.S. We're not supposed to jump, ri g h t . (Laughs.) L.T. (Laughs.) Well, you can jump, no, but I just always forget to warn people. That just keeps going through my head as we're t a l k i n g . Um, so anyways, we've come to 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 to that program and um, I think that I r e a c t e d — i t was a pretty s t r e s s f u l program—and I think I reacted by getting r i g h t back on into the same behaviour pattern. L.T. Had i t changed somewhat then L.? 006 L.S. I think i t had. As I said, I think that the therapy had some, had some benefits. Um, I'm pretty sure I was s t i l l bingeing and purging. But I think there was a b i t of an element of control, a b i t . L.T. How, how do you r e c a l l that there was a b i t of control? What makes you think that there was some control for you? 144 L.S. Because I remember the um, you know, bingeing during the program. And I don't have r e c o l l e c t i o n s of that kind of r e a l , r e a l l y being out of control during that period. L.T. O.K. M-hm. L.S. And I think i t was um a reaction to again the fear. You know the expectations, I, I r e a l l y craved them, yet I was always a f r a i d that I was going to f a i l . And um, I remember bingeing as a d i r e c t reaction of that during that, during the program. So I think something about the lack of. 007 The being able to focus on the problem and have no other expectations—which I wanted, but i t was better that I didn't have them—contributed something to perhaps a b i t of remission during that period 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 school, and then you went into the program. L.S. M-hm. That's r i g h t . L.T. So that change was h e l p f u l to you i n gaining more control over your bingeing. L.S. That was for the period that i t lasted, but i t didn't carry over. L.T. M-hm. And you said "remission." Do you, do you f e e l that that was a time during which you recovered, i n part, or, or how would you describe i t ? L.S. I would say that's the f i r s t time that, i t was a f i r s t step. I t was a, a, an acknowledgement of the problem both to myself and to someone else, and r e a l i z i n g that I had to look at myself for the answers. L.T. Mmm. L.S. Um, and so I think that was an important. 008 But actually stopping and saying, "Whoa, wait a minute, you know, there's something r e a l wrong and i t ' s me, and I need help." Because hitherto, and, and a f t e r that too, I would, you know, a f t e r a p a r t i c u l a r l y bad period I'd say, "O.K."—and I think, 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, overnight maybe, that resolution. And so the r e a l i z a t i o n that I couldn't do i t myself was important. And the fact that I had that support. 145 L.T. O.K. those were two key things i n your therapy. L.S. M-hm. L.T. And huge steps, as you say, to beginning to make some changes. L.S. Right. L.T. Was the recognition of i t and seeing that you couldn't do i t alone. (Tape ends here.) 009 L.S. And I think another important aspect of that [therapy] was the fact that you're breaking the i s o l a t i o n , breaking the secrecy and l e t t i n g someone else 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 that you need the support. But i t ' s also that by breaking out of that um c i r c l e of, of secrecy that you create, you're almost i t ' s l i k e l e t t i n g a chink of daylight i n . I t ' s l i k e , you know, i t ' s a connection between sort of you and the outside world, i n on, on who you are and your secret. And I, I believe very strongly that that's a v i t a l part of i t . At least i t was for me. I know i t was a v i t a l part for me because i n the subsequent therapy, I think the biggest step was taken when I t o l d my husband about i t , and the most d i f f i c u l t . So I think part of the reason that there was some improvement during that time was that I had t o l d somebody else about i t . I mean he [therapist] was the f i r s t person I t o l d about i t . And that, um, I, I would say that i s very important. L.T. Because you're f e e l i n g less alone and less i s o l a t e d and what impact did that have on you or how did you feel? 010 L.S. Very p o s i t i v e . I mean that was r e a l good. I t ' s , you know, i t eases the burden that you carry. I t also allows you to t a l k about i t because you're not going to s i t by yourself and t a l k about i t , and t r y and lay i t a l l out and understand i t . At le a s t I wasn't, cause you're so caught up i n i t a l l . But when someone else, you have to, you know, t e l l them about i t , then you have to examine i t . That's where, you know, that's the wall. It ' s sort of l i k e you run up to t h i s wall and you say, "O.K. t h i s i s , now I have to just turn around and face the hounds that have been chasing me in a way." And when you're just on your own, you can just keep running and running. L.T. So i t was having someone there then who, i n a sense, gently helped you confront the issue and helped you look at yourself more c l e a r l y . 146 L.S. Yes. And the therapy aspect was, was that you know, helping me look at i t more c l e a r l y . But, you know, i t ' s j u s t the act of t e l l i n g somebody. Because when I t o l d A., my husband, I never, I have since, you know, talked to him about i t a b i t . I t wasn't so much that he could do anything for me. It's just the fact again there was someone else involved beside me. And I couldn't, even i f I wanted to, i t would no longer be a t o t a l secret that I could revert to. So you know i t ' s , and I guess you know stopping a stranger on the street and saying, "I throw up" (laugh), you know, wouldn't be the same thing because that person wouldn't be a part of your l i f e . L.T. Right. L.S. So that you could just seal up the wall again r e a l l y e a s i l y . Oh my metaphors, I'm getting them mixed: putting down a wall, having to turn and face i t , and sealing yourself up. But I think you can follow i t . So I r e a l l y think i t ' s , i t ' s what that person, the fact that the person can help you examine i t a l l . But I think i t ' s jus t , i t ' s just breaking that, that h o r r i b l e f e e l i n g of being so cut o f f from everybody else. And i f once somebody else i s privy to that secret, you have to address i t too. L.T. Mmm. L.S. Because you can't keep, you can't say, "Oh, I do t h i s , " um and, and intend to go on doing that. There has to be some kind of attention then that you're going to deal with i t . At l e a s t I couldn't. And i t ' s the shame of i t a l l . L.T. M-hm. Is i t almost l i k e i t made you more accountable i n a sense? 011 L.S. Yes. Because i t wasn't just me. And that for me, that the shame of 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 , that again l e t t i n g someone else i n on that presupposes that then you're going to do something about i t . You have to now cause you can't look at that person i n the eye knowing that, you know, you're going to be running to the bathroom. So that, for me that was r e a l l y important. L.T. M.-hm. Sounds l i k e i t gave you that extra b i t of motivation. L.S. M-hm. L.T. To r e a l l y begin to think about doing something. 012 L.S. Well, and also to have someone, someone else accept i t , uh and not um; i t just l e t s you know that maybe 147 you're not such a monster. You know that someone else could hear t h i s part of you and s t i l l , and s t i l l accept you. You know es p e c i a l l y i n terms of you know, the person that you're l i v i n g with. And you know, supposedly you've known t h i s person for however many year s — 4 or 5 years—and that's the one secret you've never t o l d them. You know so, i t ' s , i t also allows you to f e e l more l i k e a human being. Again, the whole um breaking out of the i s o l a t i o n , and that even the fact that you do that doesn * t mean that you're such a rotten person. L.T. You f e l t r e a l l y accepted then when you t o l d the p s y c h i a t r i s t and also when you t o l d your husband. L.S. M-hm. Yah i t was an element of, of being accepted to know that you didn't necessarily have to keep t h i s secret. Cause i t ' s funny you, I think, for me anyway, I knew on some l e v e l that I'd have to be working with someone, I'd have to t e l l someone. Um, but, I l o s t my t r a i n of thought. I would have to t e l l someone about i t i n order to deal with i t . Um, but (pause) i f , gosh there's something I wanted to say. I f that person were not to have accepted i t , i t would have been just the worst thing. Something else has escaped me and I might remember i t l a t e r . L.T. Sure, that's f i n e . (Pause.) With the r e l i v i n g of i t and tr y i n g to sort of pick apart l i t t l e d e t a i l s i s quite, and and they're so intertwined as well. L.S. They are very much so. L.T. In many ways that i t ' s hard to get a l l of them as you r e l i v e i t , I'm sure. L.S. So that I think i n both instances, both sort of um steps, was, was just the act of t e l l i n g was r e a l l y important. 013 And I guess that's why—I'm jumping the gun, the gun a b i t — b u t that's why I think groups must be important i n the process too. Because again you're, not only have you t o l d others and they, you know, don't run away screaming or something; you're s t i l l a person to them. But also you see others who seem to you quite, I mean they look l i k e people, l i k e they have i t a l l together. Yet they carry t h i s too. So I think that whole element of sharing i s i s so important. L.T. M-hm. It's almost l i k e i t ' s not the sole focus of one's, of one's l i f e . Like i t ' s part of i t but there are other things as well that make them human. 148 014 L.S. Yes, um, because for me anyway, there was such a lack of um, l i k e part of me was scared that i f I did examine myself I wouldn't f i n d anything there. You know, because I didn't have any r e a l sense of myself or of no strong grounding i n myself. So part of the running away from i t was—running away from dealing with the bulimia—was the knowledge that I'd have to do self-examination and my god, what would, at t h i s point, what would I f i n d there? I mean there would be nothing, I didn't f e e l there'd be anything to work on. L.T. So that must have been incredibly scary then to even entertain the thought of therapy. L.S. Very much so. Yah, i t was a very frightening thought of act u a l l y dealing with i t . L.T. M-hm. Coupled with the whole sense of shame and having to t e l l another person about your behaviour and then they'd also f i n d out about yourself, and who knows what that would a l l involve. L.S. That's r i g h t . That's just i t . You, I think I always had the very firm b e l i e f , sort of l i k e the Groucho Marx saying, that I wouldn't belong to any club that would have me as a member. You know that i f someone were to r e a l l y know me, I mean, I, I knew myself and I hated myself. So i f someone else were to know me, my god, you know the chances of they're l i k i n g me would be so much, they just wouldn't ex i s t . So you know i t ' s keeping up t h i s , t h i s sort of front that you've created (a) i n terms of pretending that you're normal regarding your eating but then everything else that you're just 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 real s t r a i n I think when you have a l l t h i s sort of eating away at you: the fact that you think you're h o r r i b l e and I mean you're convinced that you're h o r r i b l e because of 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 thing with regards to eating. And also i n my case um, I did other things that would sort of reinforce, I think i n a way, t h i s negative self-image. I was involved i n s h o p l i f t i n g um ju s t a, l i k e I couldn't r e a l l y say here, here are my standards and I uphold them because I didn't, I couldn't have any standards because there was no person to set standards. See what I mean? L.T. M-hm. L.S. So i n a way, and i t was always that f e e l i n g of g u i l t for everything that you did because you knew that things you did were wrong, or ways that you were were wrong. But you 149 didn't f e e l that there was a s o l i d core there of yourself to set standards for and then have the i n t e g r i t y to uphold. Like the, the idea of of succeeding and doing that and just l i v i n g sort of a moral l i f e was t o t a l l y out of my grasp. So i t was always a , sort of a facade of, you now, being a decent person doing t h i s um that you had to uphold at a l l times i n addition to the whole eating disorder secret. L.T. Is i t l i k e , and correct me i f I'm wrong, but i t sounds l i k e there's two sides and on one of them you're t r y i n g to portray to the outside world a r e a l l y upright, moral kind of person. L.S. M-hm. L.T. But inside you're f e e l i n g l i k e there i s n ' t any person so there's no point setting standards. And therefore i t ' s r e a l l y easy to just break them. L.S. That's r i g h t . Also I think, i n my case anyway, I mean I came from a pretty you know upright 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 es p e c i a l l y i n regards to myself. Um you know, I didn't do l i k e h o r r i b l e things but there were things that I did that I knew were not r e a l l y me. Uh, and I think i n some ways doing that uh, perhaps i s a c a l l for help or attention. But also i s , i t just, at least you're r i g h t i n something. At least you're r i g h t i n how bad you are. I t , i t reinforces t h i s idea, you know. So i t s almost l i k e a you've uh at least chosen, there's at least one thing that you're very clear about because look at what I do. L.T. M-hm. Something that you could 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 the time I knew i t wasn't me. Like I knew that wasn't, wasn't r e a l l y me but I knew that I was a not a good person e s p e c i a l l y since I would do these things. You see what I mean? So there's always that dichotomy between what I r e a l l y knew my moral standards were or my you know whatever, what my personality was, and looking at the way I thought I was es p e c i a l l y as r e f l e c t e d by my actions. I don't know i f that makes any sense. L.T. I t , i t does. But the part where I get confused though i s where you said that you f e l t l i k e that you sort of didn't have an id e n t i t y , therefore you didn't need to set any standards. But i t sounds l i k e you act u a l l y have set some standards. L.S. You had, yes, I mean I had standards. But because I had such a poor self-image I didn't r e a l l y think that I could 1 5 0 ever l i v e up to them anyway. See what I'm saying? So, i t ' s l i k e , i t was sort of l i k e um t r y i n g to be beautiful or t r y i n g to be whatever, l i k e I knew because I was the way I was, I could never be that way. So i t was i n a way almost I thought I could t r y , you know. Because I knew, I guess I knew that no matter what I did, um I would s t i l l not l i k e myself. So, i n some ways i t didn't matter as much what I did because I knew that I could succeed i n here and I could get A's i n there, and I could do t h i s , but I knew that that core would s t i l l not l i k e me, you know. L.T. Didn't matter what you did then. L.S. No. I t ' s funny because i t did and i t didn't. I had to, in i n things that other people saw I had to achieve c e r t a i n goals for any kind of s e l f - d e f i n i t i o n . Yet, since I had no s e l f - d e f i n i t i o n , (laugh) t h i s i s getting crazy, since I had no s e l f - d e f i n i t i o n I could, the other things I'd do when nobody else knew, i t didn't matter because I was only accountable to me. I wasn't strong enough to have sort of standards of accountable to my own s e l f . L.T. M-hm. M-hm. L.S. Because i f you can pretend to the world that you're a normal human being but then i n i s o l a t i o n you can binge and purge, i t ' s i t ' s almost l i k e every other part of your l i f e follows that that pattern. L.T. I t must have been a rea l r e l i e f to you though to have that place where you didn't have standards, where people didn't know about the bingeing and purging. L.S. I think i t must have been. I mean i t caused tension because every time you did i t you knew what a h o r r i b l e thing i t was to do. 015 But, yah, and I would be very, l i k e I didn't have good friends because there was so much of me that I thought I had to create for others and so much of me that I had to hide. So I was always very I think kind of anxious around people and l i k e who am I supposed to be for t h i s person kind of thing. Um, and so I never um had what I would have c a l l e d "real r e l a t i o n s h i p s " because I was always t r y i n g to create a part of myself to please them. So i t ' s a t e r r i b l y , I think a very t i r i n g thing because you're carrying around these secrets, you're carrying around a l l your d i f f e r e n t i d e n t i t i e s that you're t r y i n g to portray to d i f f e r e n t people so that y o u ' l l please them. L.T. That's a l o t to keep track of. 151 L.S. Yah, i t i s . L.T. I'm sure. You know, i n addition to doing a l l the other things of going to school and um being i n a family, and and you know a l l the r e s p o n s i b i l i t i e s that j u s t go along with that as well. L.S. M-hm. 016 And I think i t was, i t probably was the fact that things kind of came crashing down before I came home that summer a f t e r second year that made me r e a l i z e , or i t made me take that step of ac t u a l l y seeking help. And i t was s i m i l a r when I, when I went for therapy i n V. But anyway, I guess to catch the thread um. So my l a s t couple of years of university were s i m i l a r to my f i r s t , except I think you know I did carry something with me from those sessions. And I was able to, I think um, to keep things together a l i t t l e b i t better. Although anytime I would stray beyond very cut and dried expectations that you know I'd meet, then I'd f a l l apart. Like independent work was r e a l l y hard for me. I f someone said t h i s had to be done, I'd do i t . But i f I had to be doing research sort of of f hours, um, research for a professor or something, i t just would never get done because, because you completed what you had to complete and there was nothing, you couldn't hold yourself together enough to go further than that. You couldn't structure yourself independently. I keep saying "you"; I mean " I " . L.T. M-hm. And that was, a somewhat d i f f e r e n t than the f i r s t 2 years then for you. 017 L.S. I t was. You know I do look at the f i r s t 2 years [of university] as being sort of a, the time during which I kind of plummeted. And then i t kind of, the therapy I think sort of arrested that um d i r e c t i o n . And then I sort of see the other years as more or less a plateau. I t didn't get worse than that. I t didn't notably get better. Um, but I was able to maintain things on a more even keel. L.T. Can you give me an example of what was happening with your eating behaviour during t h i s time? L.S. During those other 2 years? L.T. Yah, t h i r d and fourth year. L.S. I t was the same kind of pattern, um, of of a l o t of um bingeing and purging, and and i n a b i l i t y to eat normally. You know to, what others might consider a normal meal, I 152 would be incapable of keeping down, my anxiety would get r e a l l y high, um, I would f e e l dreadfully bloated and awful. Um, so I wasn't able to eat normally and I would binge a l o t e s p e c i a l l y i f I was alone. You know, that reinforces the solitude too because i t has to be a, an a c t i v i t y you engage i n alone. So there has to be, there have to be periods of time that you know you're going to be alone, you know; that's what you sort of crave. You can j u s t do i t . 018 So that was s t i l l a l l going on [bingeing and purging] but um, I was out of that r e l a t i o n s h i p . I think that made a b i t of a difference. I was a l i t t l e more autonomous that way. Um, I was defining more sort of what my d i r e c t i o n was i n school. I had established you know, the Russian major and I knew more or less I was good at i t , even though I I thought I was only good because the competition wasn't there. So I had a l i t t l e niche, you know, and that helped. I t wasn't so much just f l a i l i n g around. L.T. You f e l t more secure i n yourself then, i s i s that what you're saying? L.S. A l i t t l e more [secure]; not so much i n myself and my own core but uh, sort of i n the external. I was, I kind of knew what I was doing, I was doing Russian and I was doing pretty well. I mean I got, I got the good grades and everything. And uh, so I could i d e n t i f y myself, again sort of "hang my hat" on just one thing and know that I was doing that pretty well. So I think the underlying issues were s t i l l there but I was able to sort of s t a b i l i z e because of being i n a more stable s i t u a t i o n . L.T. M-hm. O.K. So, the years seem a l i t t l e b i t d i f f e r e n t because external things have changed: that you have more of a major and f e e l a b i t more secure i n some of the things. L.S. M-hm. L.T. And, but you're s t i l l bingeing and purging and not being able to keep down normal meals. L.S. That's r i g h t . L.T. Is the eating d i f f e r e n t i n t h i r d and fourth years than i t was i n the f i r s t 2 years? L.S. I t h i n k — I don't remember—I think they were, they were very s i m i l a r . But I think I may have been able, i f I r e a l l y wanted to, to keep down a meal because there would be very few meals that I'd be able to keep down at a l l , i n 153 in addition to the bingeing and s t u f f . So I think, I think I would be able to get through a meal and um not overeat to a, you know, gross extent so that I could keep i t down. But I know that (pause) didn't happen that often anyway. But I think i t could happen at that point. L.T. Did i t happen as you r e c a l l ? I guess I'm j u s t t r y i n g to focus i n . You said that the years were d i f f e r e n t , and and I can see i n terms of um studies and sort of how things are progressing academically for you. But I'm s t i l l not c l e a r i f the eating, i f you f e l t d i f f e r e n t about i t i n any ways? 019 L.S. Well as I said, I'm pretty sure that um I could, i f I r e a l l y wanted to, could keep a meal down. And the other thing I can determine i s that there could be, uh the whole eating thing wasn't, didn't have me by the throat so much. Like there, I could at least time i t , l i k e put i t i n special pockets. I could um—not a l l the time and not nearly successfully enough—but I could, you know. Like fourth year I l i v e d with a roommate and we could do study sessions before an exam without my, you know. I could do that. And I could, i t wouldn't be such a d r i v i n g thing to be doing continually. Because as I, as I look back on i t now—I could be wrong—I just seem to think of those 2 years as being a continuous cycle of bingeing and purging. And i t seems to me that I was able t o — i t s t i l l happened and maybe as frequently—but at least I could take periods of time where I, that I could do something with. L.T. O.K. So there were o t h e r — I was going to say p r i o r i t i e s — but there were other things. L.S. I was able to,yah, I was able to, to do other things. L.T. M-hm. I t didn't, the bingeing and purging didn't t o t a l l y control your l i f e to the extend that i t had i n f i r s t and second year. L.S. I don't believe so. I don't believe i t did. (Pause.) 020 And you know, again the d e t a i l s I'm unclear of. I know that I was um, that I substituted drink [alcohol] uh, and to some respect, extent, for that. I don't think I ever had what you c l a s s i f y as an alcohol problem. But I know that I came to the r e a l i z a t i o n that alcohol could i n some ways do the same things the bingeing could. I t was almost l i k e a cycle. I t would take um. When you're engaged i n that a c t i v i t y , you can't r e a l l y be engaged i n anything else. So i t ' s the sole focus. So when you have r e a l worries, and anxieties, and feelings of 154 fear and s t u f f , i t ' s almost l i k e a a reassuring cycle to get into because i t takes you away from having to deal with those. And drinking did the same thing. (Pause.) So I think um, I think that uh, I know I didn't l i k e i t you know wasn't l i k e drinking on a continual basis. But I, I do think that I came to that r e a l i z a t i o n at that point, um for whatever that's worth. L.T. I t , i t was, you're r e f e r r i n g to alcohol when you say drinking then and not ju s t extra quantities of. L.S. Oh no, no, no. Alcohol. Yah. L.T. O.K. And that was something that was d i f f e r e n t than f i r s t and second year for you? Like you began to drink more i n , in t h i r d , t h i r d year, t h i r d and fourth year? L.S. Yah, I think so. M-hm. I think so. 021 I also i n t h i r d year um, there was a, I think I was also very frightened of of entering into another relat i o n s h i p because I knew that I would again be controlled. Like I couldn't, and i t was too much of a s t r a i n to t r y and keep up some kind of facade for someone on such a close basis. Um, so there was, there was a um, um a boy who, you know, wanted to develop a relationship with me. And I remember being very um, very much not wanting that, I think, because I f e l t much closer to him than I did with the guy that I was with for the f i r s t 2 years of university. And therefore the chances of his having to discover t h i s about me were that much greater. So I do remember subsequently being very, you know, standoffish i n that regard. Um, I did have a friendship with a, with a woman during my fourth year; we roomed together. That was good. It was almost l i k e the f i r s t friendship that I had that I thought I could reveal some of myself to which was nice. You know, so here were a multitude of things, d i f f e r e n t things going on during that period. But I think on the whole things were, there was a small amount, element of control that wasn't there (pause) subsequently or before that. (Pause.) So, but s t i l l i t was you know, i t was s t i l l very much there. L.T. So you're s t i l l taking time out to be by yourself to keep up with bingeing and purging, and um s t i l l t r y i n g to maintain yourself and to move throughout u n i v e r s i t y which you were able to do i n spite of i t a l l . 155 L.S. Yes. M-hm. So I finished and um, then there were, l e t me see, 4 years I guess a f t e r u n i v e r s i t y before I went into therapy: 4 or 5. And during that period I did some graduate studies and 2 years abroad. And again, the eating problem continued throughout a l l that time. But, maybe because I f e l t more established i n what I was doing- -that I was doing graduate studies i n Russian—and I thought for the f i r s t time i n my l i f e that maybe I could do something well, and and r e a l i z e that I l i k e d i t . Um, es p e c i a l l y when I began, began teaching I r e a l i z e d I r e a l l y l i k e d i t . And I think that had a l o t to do with the fact that that element of control and s t a b i l i t y was growing: I t was growing. I never finished my master's th e s i s ; that was funny that you were t a l k i n g about that. L.T. (Laughs.) L.S. I did, you know, very well i n everything. But again, when, I think for two reasons. The s t i l l that that desire to f i l l others' expectations by, you know, teaching and doing course work and t h i s and that with very l i t t l e l e f t over, you know, not much l e f t over for me. Um, and I guess wanting i t that way cause i t was easy to get the, the approval which I needed without, where I was doing my own work was just more or less for me. Um, and also, um the fact that the eating was s t i l l , was s t i l l um, the eating problem was s t i l l very much there. And i t ' s incredible how much time and energy that takes up, you know. So, but things were better. L.T. How did you know things were better? L.S. Because I was able to um. Just i n terms of the eating behaviour? L.T. Well that, that as well as whatever you mean by "things were better." 0 2 2 L.S. I think the key element there was that I f e l t that I was doing something that was more or less worthwhile, that I was, I thought I was f a i r l y good at i t . So i t gave me sort of that approval and I was able to sort of define myself more. Like I could say that, um you know, I'm studying Russian and I could have that um as something that was me. It was a very much me that during those 4 years i t pretty well, you know, took up most of my time. So I suppose i n a way that's again there was issues I wasn't addressing. You know I never did go back and do the sort of soul searching and house cleaning that I thought that I should do i n order to r e a l l y be well. And I s t i l l had, you know, there's s t i l l a l o t of underlying lack of confidence and self-hatred and a l l that sort of s t u f f . But at lea s t on that 156 plane I f e l t some element of performance and an element of success. So I think that's why things were large l y better. 023 And as I did more and had to do more, the time for me to engage i n , um you know, weird eating behaviours was lessened, was decreased. And uh, so I think the demands were more but for some reason I wasn't panicking as much, and I was able to do what I had to do to meet those demands. L.T. You f e l t more able to do your work and i t almost seems l i k e i t then began to encroach on time that you could use for your eating. L.S. That's r i g h t ! That's r i g h t ! And I see that pretty strongly i n when I f e e l the r e a l recovery came too um i n terms of the f u l l - t i m e employment that I got. That r e a l l y took way, you know; you couldn't, you couldn't do that and hold down a job. So, but there must have been, you know, I think there's an element of s e l f - d e f i n i t i o n too because i f that hadn't of been there, then I don't think I would have been able to have changed ever so, even i f i t ' s subtly, my eating patterns. So I think i t ' s a sort of a combination of things of of again too external to be that good. You know i t should be pretty an i n t e r n a l sort of core of s e l f and of self-knowledge and self-worth. But the fact that that was there brought to me more of an element of of self-worth and and an element of s t a b i l i t y . And so now I'm f e e l i n g , i n some way, I was O.K. L.T. M-hm. Things started from the outside then to b u i l d you up. L.S. Yes. L.T. And to, to help you move away from the eating. L.S. M-hm. Yah. So they did get better. During those 4 years I was uh f i r s t year i n grad school i n I., and then i n F., and then i n R., and then back that l a s t year i n graduate school i n I: And things were, things were better. Um then, and I guess t h i s i s a mirror of what happened when I l e f t home to go to university. Um, I married a Canadian that I had known in undergraduate school, and uh l e f t , and came to Canada. And I l e f t without f i n i s h i n g my thesis which i s a big. Yah, I thought, "Oh I ' l l do i t l a t e r , " and I s t i l l haven't which i s s t i l l a big, you know, re a l sore spot. But (pause), well t h i s i s a l l r e a l l y interwoven with things that have nothing whatsoever to do with an eating disorder but. L.T. That's O.K. T e l l them i f you l i k e because you know sometimes i t ' s , i t ' s amazing how they kind of are 157 pe r i p h e r a l l y related. L.S. Well, I ' l l t e l l what I think i s related. L.T. O.K. L.S. I think that the fact that I married, and i n a very r e a l sense abandoned what was becoming a career track for me and came here, had a l o t of e f f e c t on what happened next. Because I was i n some ways reverting to the same patterns of (a) relinquishing control of my l i f e , um and of not believ i n g i n myself enough to, to keep that going. In retrospect, you know, i t was a t e r r i b l e thing to have done. Although the whole aspect of marriage and s t u f f i s , you know, a d i f f e r e n t thing. I mean there was love and other things that go into i t . But i n terms of where I was. I mean I look back now and I don't think i f I were the person I am now (laughs). (Tape ends here.) 02 5 I was saying that i f I were the person that I am now, i f I were that, had been that person then, i f I'd had the, I think I believe i n myself a b i t more and I know better who I am. If I were that person at that point, I don't think I would have taken that step. Um. L.T. Of getting married? L.S. Yah, and of e f f e c t i v e l y leaving what I was doing. 026 Because I had just, at that point you know, I f e l t that I'd made a commitment [to my boyfriend] I think in some ways. And you know, I mean love was ce r t a i n l y involved. But beyond that um, I think I f e l t that I had made a commitment. You know, we'd been sort of "long distancing" i t for 4 years at that point and I f e l t that you know t h i s i s what we've had; I was going to do i t [marry him]. 027 But um, at that point I was just, I'd done a l o t of teaching that year and I was r e a l l y excited 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 that I was good at 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 think i t may, had I continued on that track, who knows, but i t could have been that things [bingeing and purging] would have just continued slowly to get better on t h e i r own. I don't know that and that's second guessing. But as i t was um, I kind of l e f t that and dropped into a void here. 158 L.T. What makes you think that things may have j u s t gotten better on t h e i r own? L.S. Because of the slow improvement over those 4 years. L.T. You could see progress so you expected that i t would, could continue i n the same way. L.S. Yah, perhaps. As I said i t was s t i l l there and there were s t i l l things that needed to be addressed, I'm sure, I mean I know. But, I tend to think that um (pause), that i f I'd gone on i t could've been maybe I would have folded. Maybe I would've, you know, i f the pressure I'd f e l t the pressure i n say a Ph.D. [Doctorate of Philosophy] program was too great I would've, I'd folded and t o t a l l y reverted to that, I don't know. But i t could be that had I gone on and experienced more success that t h i s would become less and less important, and kind of wither up l i k e the state i s supposed to do under communism and f a l l o f f l i k e a t a i l no longer used. Um, I don't know that. 028 But what I do know i s um coming here then that summer was um, was r e a l l y bad because I kind of dropped into [a void], you know, I didn't have a master's degree and I didn't. Well, I just f e l t that I'd dropped into nothing. And um, you know tr y i n g to f i n d some kind of work and you know, my husband being very involved i n h i s , was again I was suddenly face to face with myself again without any of the external, you know, pluses and strokes and s t u f f . And, i n some ways i t might have been a very good thing. Because what i t did was i t yanked that i d e n t i t y [from my work] away from me. And I wasn't a strong enough person, or a f o r c e f u l enough person, or a person who believed i n themself enough to sort of kick and scream and f i g h t for that i n t h i s environment. So, things deteriorated r e a l l y quickly over that summer and the f a l l . And I was sort of picking r i g h t back up on the same old habits. I would spend the day—you know, with A. gone and not r e a l l y knowing anybody or not many people h e r e — i s o l a t e d and again going r i g h t back into the bingeing and purging. L.T. M-hm. You began, i t began increasing, or you began to fe e l that loss of control that you had f e l t before. 029 L.S. Both. [The frequency of bingeing and purging began increasing and I began to f e e l a loss of control over my eating behaviours.] Yup. And that was real scary. And again i t wasn't something that um, I think I faced up to u n t i l i t got r e a l l y bad. And I think that, I think the r e a l i z a t i o n that things were bad (laugh) came to me cause we went to my family's 159 place back home i n I. for Christmas that year. And i t was l i k e seeing that environment that I used to be i n , that I f e l t that I was f l o u r i s h i n g i n — y o u know i t was the same c i t y that I had been i n school i n — a n d suddenly seeing the way I was. And I think i t was over that Christmas that I r e a l i z e d that when I got back I had to do something. Because I think I re a l i z e d that I'd taken some steps and that, you know, things were better but that since my environment had changed, I had ju s t sort of crumbled. And um,I had to deal with i t . You saw a r e a l l y marked difference then i n a short period of time, and going back to I. sort of reinforced the fact that you had at one time been functioning at a more um, health i e r maybe l e v e l or. That's r i g h t . That's r i g h t . You had f e l t better about yourself anyways. Yah. That's r i g h t . And so, I guess that was the "bottoming out" that I needed to go through to act u a l l y do something about i t . So when I came back um. Again, I mean I hadn't talked to anybody about t h i s . But when I came back (pause), I c a l l e d uh, I didn't know what to do. At that point I knew the name of what I had, you know. How, how did you know that you had bulimia? How did that happen? Bulimia? Well because i t started to be um, publicized a l i t t l e b i t . Like you'd see a r t i c l e s about i t and I was aware that Jane Fonda had i t . And I thought that was pretty "cool". Um, and I think I may have done a b i t of active reading about i t . I t , from what, what I remember i s just things that I'd chance upon and I read. Like I wouldn't go to the l i b r a r y and research bulimia. I didn't do that t i l l l a t e r . But um, I was aware of i t at that point; I knew i t wasn't anorexia. And I knew that i t was a documented condition. And that was i t s e l f kind of a r e l i e f : I t ' s l i k e other people do t h i s , you know. So that was, I think i t may have helped to know that there was a name for what I had, and that other people had i t , and there may be some recourse. M-hm. A clearer sense then of of what you were struggling with, and maybe again that decreased sense of i s o l a t i o n . Yes. Yes, very much so. V 160 031 So I c a l l e d , the only thing, I didn't know what to do and I looked up "B" i n the phone book. (Laughs.) There's nothing that says, you know, Bulimia Support Group or anything. So I c a l l e d um, I think i t ' s V. Information Number. And I ju s t said, "Is there any number for, for, to help somebody with an eating disorder?" And she referred me to ANAD [Association of Anorexia Nervosa and Associated Disorders], and I c a l l e d them, and I found out about the sessions. But s t i l l , i t was at that point where I didn't r e a l l y want to l i k e come t o t a l l y out of the closet. I knew I needed help, but I wasn't about to sort of announce i t to everybody. But they also gave me the name of a therapist at that point, Dr. T. And I um c a l l e d her and she managed to f i t me i n . And that would have been January, February, something l i k e that. L.T. And t h i s i s about how many years? Or can you kind of give me a time frame? L.S. Well we were married i n 1984, the spring of 1984. We came up here then. So i t was the f a l l of 1984 that r e a l l y was bad. So i t must have been early 1985. And I think I saw her, started seeing her early that spring. So i t was l i k e 5 years ago, around i n there. So, now we're at the point where we should have been at the beginning. But I mean, you see I think that there was a l o t of things that went into the recovery that happened p r i o r to what I would c a l l the actual recovery that were r e a l l y important. L.T. Sure. Yup. L.S. So um. So I c a l l e d her and I started seeing her. And that was probably the biggest step towards the, the recovery period. L.T. As you look back on that time of phoning her up and sort of making contact with her, how do you f e e l about that, or or what sort of things were happening at that time for you? 032 L.S. [When I contacted the therapist] I was t e r r i f i e d cause i t was sort of l i k e "well t h i s i s i t again." T e r r i f i e d i n terms of, of to 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 that I'd have to st a r t dealing with i t ; you know, the implications of that were, were great. [I would have to look at myself] . . . and could I do i t ? L.T. You knew i t was going to involve a l o t of work i n looking at yourself cause you. 1 6 1 L.S. Oh. yah. And could I do i t ? And a l l that s t u f f . 033 So i t was a very frightening thing. I t took me a long time to actually c a l l Information. I t took me, you know a l l these steps took quite a while. I t ' s sort of getting up the courage, and I'd rehearse them over and over. And then a f t e r that the thing that I would rehearse over and over was how I was going to t e l l A. about i t . Cause I knew that I'd eventually have to t e l l him about i t . You know, so i t was very frightening a l l those things. So that's why I think, for me anyway, things had to come to a a pretty desperate point before any of those measures would be taken. L.T. Because you knew what was at stake. And i t sounds l i k e you f e l t committed—once you actually t o l d someone and got in to see someone—to do something. L.S. M-hm. When I was there. Yah. And then I'd know I'd have to give i t up. 034 And i t [bulimia], i n some ways s t i l l , I didn't want to give i t up. I guess maybe because i t was, i t was an escape, i t was a release of tension, i t was part of how I defined myself, i t was a habit, i t was you know a shameful thing to reveal: a l l of those things put together. And I knew I'd have to face i t up once somebody else was there t o — a s you s a i d — h o l d me accountable, which i s , for me, i t was a very important part. So I had been encouraged to go to ANAD. I didn't then. L.T. Encouraged by? L.S. Well, when I c a l l e d up. I can't remember her" name. Um, you know, she t o l d me about the sessions and said, "come down." But that was just too scary. That was too scary. I wanted that one on one. And another, I remember I started to go to Dr. T. and then she t o l d me I'd have to get a r e f e r r a l from my physician. So i t was another, you know, traumatic experience to have to go i n and t e l l her. L.T. M-hm. M-hm. L.S. So there were a l o t of steps of bringing i t out before the actual, you know, therapy began i n earnest. L.T. M-hm. Making contact with d i f f e r e n t people and l e t t i n g them know what you had before you were even able to begin making changes. 162 035 L.S. Yah, and that was hard. That was r e a l l y hard. Um, and maybe you know i n terms of your looking at the steps, I don't know how that, I don't, I don't suppose that could ever be overcome, that kind of um apprehension and the steps that need to be gone through. I think that's maybe part of the process i s the actually getting yourself together enough to go through those steps. Maybe i f i t were easier people wouldn't be at a point where they'd actually be able to follow through on i t . I don't know. L.T. Sounds l i k e for you, as you were saying, you had to come to a r e a l l y low point that you knew you had to do something about i t . And um that whatever i t took, that you would do i t . I f i t meant having to t e l l people f i r s t to get into therapy, then the desire, that's what you would want to do. L.S. M-hm. So I tend to believe that that as much as what happened subsequently, that's as important I think as what happened subsequently. And you know, so the therapy was good. Again i t was very much, you know, self-examination and um. 03 6 Except she seemed, her focus was more on the f a m i l y — t h e mother-daughter re l a t i o n s h i p — w h i c h i n some ways I rejected because I didn't want to. I think 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 think back on things and a l l I could see was the negative aspects of having interacted with her. So I didn't r e a l l y want to put t h i s i n her lap, you know, i n terms of well because of t h i s , t h i s happened to me. You know I s t i l l don't, I think there are some aspects of that that are good to examine. D e f i n i t e l y . But I r e a l l y don't think i t ' s such a good thing to t r y and f i n d a finger to point. And I don't think Dr. T. was t r y i n g to do that. But I know that I res i s t e d i n some respects that, that approach because I f e l t that that was t r y i n g to point the finger of blame at her, you know. L.T. You didn't want to involve your mom i n i t then to any great extent i f you could possibly avoid i t . L.S. I think not. I think not. I think I could see that sure there are aspects of family l i f e and my relat i o n s h i p with my mom that could have contributed. But I didn't r e a l l y want to um, to only look at i t from that point of view. L.T. Did you do some work around your rela t i o n s h i p with your mom? Was that s i g n i f i c a n t i n , i n therapy for you? L.S. Yes, i t was, i t was. 163 037 I t was a s i g n i f i c a n t aspect. And I do remember a comment that she [therapist] made that r e a l l y h i t home. I think i n t a l k i n g about i t , and again sort of t r y i n g to sh i e l d her [mother], I don't know what I said, but her [therapist] r e t o r t was. Or i n saying, I guess expressing my g u i l t toward her [mother] and s t u f f and her. L.T. Towards your mom? 038 L.S. My mother. Yes. And Dr. T.'s r e t o r t was, "Then you haven't forgiven her." And I had to r e a l i z e the v a l i d i t y of that. That maybe there was some blame that I was subconsciously a t t r i b u t i n g to her and the environment i n terms of, you know, what happened, i n terms of my bulimia. So i t was a matter of t r y i n g to, I think there was a process of l e t t i n g go of a l l of that; of being able to say, to look back on those things i n order to l e t them go, and and any anger that you might f e e l at um, um f i n a l l y developing a dist o r t e d body image, you know. In other words, jus t taking your r e s p o n s i b i l i t y for "the here and now. " L.T. What, do you r e c a l l what happened when Dr. T. said that? L.S. I ju s t remember i t sort of being l i k e a shock. Like my f i r s t reaction was, "What do you mean?" And then i t was l i k e "Wait a minute, I've never looked at things from that point of view." L.T. Cause you were always t r y i n g to not bring your mom into i t cause you f e l t too g u i l t y i n terms of saying well my mom may have contributed. L.S. That's r i g h t . L.T. But now Dr. T. was saying well maybe you s t i l l have some anger towards your mom. Was that, was that i t ? L.S. M-hm. Yah, very much so. Yah. L.T. So you were shocked to r e a l i z e that maybe you hadn't dealt with some of the anger towards your mom. L.S. M-hm. That's r i g h t . That's r i g h t . So there was, you know, there was examination of that, that relationship, and then the family, and and a l l of that s t u f f that I think were good. L.T. As you think back during that time i s there anything that comes to mind as having had a big impact on you, that was s i g n i f i c a n t to you? 164 L.S. (Pause.) There was that; that was s i g n i f i c a n t . There was. L.T. Realizing that you had some anger towards your mom. L.S. M-hm. Um, I remember, and and again the whole thing of of r e a l i z i n g that, that you're not such a, such a beast; that t h i s i s a condition; that other people have i t ; t a l k i n g about i t more, about the condition and and and other people that are involved i n i t , and um. L.T. How did you know there were other people? Oh, cause of the support group. I get i t . And the books. L.S. The support group. But also the fact that she, that was her area of s p e c i a l i z a t i o n . So I knew that she had seen a l o t of. L.T. Other people. 039 L.S. That's r i g h t . That's r i g h t . And not that we talked that much about other people [with eating disorders], but the fact that I knew they existed. And you know, she'd say things about, you know, what happened with t h i s person or something, you know, that that made i t . I t put i t sort of into perspective more I guess. I t ' s just t h i s being—as you said I think at one p o i n t — p a r t of me, but not l i k e that was just what I was. That there were other, you know human beings that that had t h i s as part of them as well. So i t was again that i d e n t i f y i n g with (laugh), with humanity i n a way. You know, seeing yourself as part of i t ; you're not so iso l a t e d . I'm t r y i n g to remember, for some reason I remember that moment r e a l l y well which means that i t must have been f a i r l y s i g n i f i c a n t . L.T. M-hm. L.S. Um, and as I said she did t a l k about things from that point of view a l o t . Um, she did t a l k about, um, how I f e l t others saw me. And the r e a l i z a t i o n that they, I wanted them to see, I wanted to create for them what they wanted to see, you know. And about my, my self-image. A l o t of t a l k about my self-image, and how I f e l t about myself, and why, you know. So r e a l l y s t a r t i n g with something very basic and working up to um, more external things were there. For example, when she did suggest that I go down to the, saw a d i e t i t i a n at...to t a l k , you know, maybe about behaviour modification i n terms of the eating and s t u f f . But she didn't r e a l l y dwell on that. 040 I think she approached i t very much from a point of view of working on yourself, and t h i s only being 165 symptomatic. And that c e r t a i n l y work would have to be done on behaviour modification—your, you know, attitude towards food and s t u f f — b u t that r e a l l y i t was, i t was much deeper than that. And I think that made a t e r r i f i c impact. You know something that I think I'd known, but to actually t a l k about that was important. You know, going back i n i n my past and ta l k i n g about things that, that had to do just with me and not with any eating disorder. That was important. Um, and then l a t e r on she talked about, yah, l i k e writing down times that I would binge and why, or what I had just eaten and what I was fe e l i n g . I don't think I actually did that. I remember thinking about i t , but I never actually committed i t to writing. Um, so a l o t of, um, examination of s e l f rather than examination of t h i s , t h i s part of myself. L.T. I t sounds l i k e you f e l t r e a l l y um, you enjoyed that part of therapy. L.S. Very much, very much. L.T. And i t was very important to you. L.S. Very much. 041 I think that's what I l i k e d most of a l l . Because I'd always known, I mean why should, you know, why should I have those feelings about myself? And I always knew that a r e a l healthy person wouldn't do t h i s [binge and purge]: l i k e a person who f e l t good about themselves. And i t always occurred to me that i t [recovery] had so much to do with knowing who I was (eyes become moist). Like without anything else i n the world—what I was doing, or parental approval, or straight A's, whatever—that I was O.K. And that i n some respects, what I did was secondary. You know, I think I ' l l always be a sort of goal- oriented person and wanting to be doing things t h a t ' l l make me f e e l good. But that's not what I bu i l d my whole s e l f on. L.T. Not now you don't b u i l d yourself on those things. L.S. No. That's ri g h t . And that was very, very l i b e r a t i n g , you know. And the whole process was very l i b e r a t i n g . I t was l i k e a, a f e e l i n g I could breathe. I t was a fe e l i n g of openness and a fe e l i n g of relaxation to know that, you know to be able to s t a r t giving up t h i s , t h i s secret, and st a r t giving up what s t a r t s out as a, as a release from tension. Like she talked about that as being a t r i g g e r mechanism: that tension because of anxieties you had because of certa i n things. But of course i t j u s t causes 166 more tension, you know, because you're caught up i n the cycle that you cannot control then. She talked, about um the the t r i g g e r that would cause a cycle to suddenly pick up where I had no more control, as opposed to normal eating. And why would that t r i g g e r sometimes happen, you know, or always happen and then usually happen and then sometimes happen. And to r e a l l y examine that part where i t became a binge that would have to lead to a purge as opposed to eating a meal or having a snack. 042 She also talked about feelings o f — o r I did, whatever—we talked about um l i k e d i v i d i n g foods into O.K. foods and foods that i f you eat t h i s i t means you're on a binge: things l i k e l i k e ice cream or spaghetti. Like i n order to to maintain your weight you can't eat things l i k e that ever cause i f you do, then you might as well j u s t you know gorge and get i t a l l up. So you know, your rela t i o n s h i p to food c e r t a i n l y played a part. But, you know, she did, i t was almost as i f she worked i n layers. Like s t a r t i n g back with yourself more and then progressing from there: your s e l f and your family, your s e l f and what you do, your s e l f and food. So they became working sort of from the inside out which I thought was, for me that seemed to work. L.T. Sounds l i k e i t was a r e a l l y enjoyable experience for you, d i f f i c u l t I'm sure but also very l i b e r a t i n g . And even as you t a l k about i t now i t seems l i k e i t ' s s t i l l r e a l l y touching, and s t i l l a r e a l l y precious part of the therapy for you, and something that made a major impact on you: to be accepted just for who you were, s i t t i n g there and looking at yourself without a l l the external things that had been r e a l l y a big part of defining you and saying that you were O.K. L.S. M-hm. I t was to be accepted but more importantly to accept yourself, to learn how to accept yourself, accept myself. L.T. And how did that happen for you then? L.S. Let me say one more thing f i r s t . L.T. O.K. Sure. 043 L.S. Something else just occurred to me. I remember, I think I used to t a l k i n euphemisms a l o t , i n terms of l i k e what I would ac t u a l l y do. And I think part of i t [therapy] was sort of to force me to actually dare f e e l what i t was about: you know, gorging and vomiting. Like I remember her t a l k i n g , her end goal was to make me actually say the word "vomit", and I 167 kept using euphemisms and not understanding what, why she meant, what she meant when she would ask me to be more cle a r about i t . And f i n a l l y when I had to say that word, i t was l i k e again coming (slaps hands together) face to face with what i t actually was. So, so part of i t too was was r e a l l y examining behaviour and what i t was, not hiding, not hiding from the r e a l i t i e s of i t . (Short pause while tape i s turned o f f to answer the phone.) L.T. Yah, I guess um, how—we were t a l k i n g about sort of accepting y o u r s e l f — a n d and how did you sort of come to that r e a l i z a t i o n that i t was accepting yourself? How did that happen for you? L.S. Um, that, I think that happened pretty um, pretty, pretty s w i f t l y because I think i t became very apparent and was something that I kind of knew anyway: that most of t h i s came, not most of i t , but a certa i n part of i t came from self-image, and and and not l i k i n g yourself, and not being able to f i n d yourself just i n i n terms of yourself. 044 And that um (pause) part of i t was um then i f others, i f you could accept yourself enough to open yourself to others and they would accept you, then i t would just be confirmation that you were O.K. But you had to be able to accept yourself enough or accept t h i s , t h i s thing enough to be able to t e l l somebody about i t i n a way: l i k e to know that by actu a l l y revealing that, they wouldn't t o t a l l y destroy you. And opening yourself to the p o s s i b i l i t y that the person just , you know, t o t a l l y shutting himself or herself o f f to you because of t h i s t h i s t h i s part of you. So yah the fe e l i n g accepted was r e a l l y important. 045 I mean I knew, you know, she [therapist] was good. Um and I remember your saying once that um too often people say, "Oh, i t was just because I had a great therapist that I recovered." I think there has to be that personal uh. I f I hadn't l i k e d her and respected her then I couldn't have done that [recovered]. So knowing that she obviously accepted i t [bulimia] because she worked with people l i k e me and that we were s t i l l able to to get along on on a personal l e v e l , and laugh. And you know she was, she's C. so my intere s t i n Russian studies. You know, so we had sort of a personal r e l a t i o n s h i p that I f e l t was sort of beyond that. You know, I f e l t very comfortable with her. I think i t would have been impossible, had I not had that, to r e a l l y you know. Because that's maybe what happened with Dr. 168 C.: that I just wasn't able to to r e a l l y open up. So that was important. Then, as I said, I think t e l l i n g my husband was probably the biggest step. Um, and I did t e l l him that I was i n some kind of therapy. Um, I think because of some scheduling, or something. But I knew that once I t o l d him that, eventually I would have to t e l l him why; you know that was j u s t a given. So by t e l l i n g him that, that was l i k e the f i r s t step. I knew I had to t e l l him almost gradually that I was i n therapy. And then oh, i t was a month or 2 down the road before I a c t u a l l y t o l d him why. But that was, a c t u a l l y saying that was the f i r s t time I had said to a nonprofessional, l i k e a person that I just had a personal contact with, about t h i s part of me, t h i s thing. And that was a tremendous um, you know his acceptance of i t . I think i f i t had been d i f f e r e n t , his reaction would have been d i f f e r e n t , i t might have had a very d i f f e r e n t e f f e c t on me; i t would have. But his um, acceptance of that was, you know, made a huge difference to me. L.T. What was his reaction? 046 L.S. [His reaction to my disclosure of bulimia was] Very low key. Very low key. Um i n fact he even made some jokes about i t — l i k e during that conversation— "well, that's a great way to lose weight, I should think about that." You know, s t u f f l i k e that. So i t was as i f I was thinking, "god, a l l t h i s time and i t r e a l l y i s n ' t such a big deal." Like I mean he thought i t was weird and a l l and and I'm sure he knew that i t was i n d i c a t i v e of of problems and s t u f f . But he was very, very sort of matter of fact about i t . And just very glad that I had t o l d him because now he wouldn't have to wonder why. He was very, I think, worried that I was seeing someone for, you know, goodness knows what reasons. L.T. He appreciated then that you had t o l d him, and seemed to, and he seemed to accept i t um as something that you were working on and, and that was that almost. 047 L.S. Yah, and that i t [bulimia] didn't a f f e c t his [my husband's] feelings about me at a l l . You know, so that was r e a l l y important. And I think I was only able to t e l l him, um you know, at a moment, at a time when we were fe e l i n g you know r e a l l y close, and I r e a l l y f e l t that, "Yah I r e a l l y want to share t h i s thing with t h i s person because I don't want to keep t h i s from t h i s person anymore." Not as i f i t were a big deal that I'd t o l d him the facts, but the fact that I was withholding something became important. That I'd never had a rel a t i o n s h i p with someone where 169 I wasn't holding back t h i s , and creating t h i s , and hiding and deciding how to be. And so that, for the reason, i t was a big step too. M-hm. A major change i n how you were r e l a t i n g to um close relationships i n your l i f e . M-hm. M-hm. Yah, i t was very symbolic because i t l e t me know that perhaps people could know me and l i k e me, you know. Um, and also, I had to be at a point where I f e l t f a i r l y confident of succeeding, of going to him and succeeding, because I couldn't t e l l him and then intend to continue with the behaviour. I mean I knew that i t would s t i l l continue for a while, but at least that attention would be there to work through i t and stop i t , and that i t would always be getting better. And I knew I couldn't t e l l him i f I f e l t that I couldn't succeed because then I couldn't look him i n the eye and to f e e l , you know, rejected- - l i k e I guess that's self-imposed—to f e e l um g u i l t y about that i n regards to another person. You know, I I couldn't do that. I was bad enough doing i t with myself sort of. So I had to be at a certa i n l e v e l of s t a b i l i t y with i t before I could t e l l him. And then t e l l i n g him increased that l e v e l of s t a b i l i t y [confidence i n her a b i l i t y to make changes]. M-hm. How did you know that you were at um a stable enough l e v e l that success was, you know, f a i r l y probable? L.S. I, [ f e l t confident about changing my bulimic behaviours when] I think I f e l t elements of control coming back. Um, I think I would, I can't pinpoint i t , but I believe i t would have been at the time where I was able to stop something that would normally, l i k e stop a binge i n progress. Or to actually say, "No" to a time when I would normally have binged. You know, to s t a r t having some control back, which was great. How, how were you able to stop a binge i n process? You had talked e a r l i e r about t a l k i n g with Dr. T. about um tri g g e r s and and that sort of thing, um, but I wasn't sure of the s p e c i f i c s of that. Well she talked a l o t about um having people around when you ate. But I never did that cause I didn't r e a l l y have enough friends that I could always be with when I ate and s t u f f . And so that made i t more d i f f i c u l t . She talked about things l i k e that: l i k e external things that you could impose, and writing things down, and setting aside 170 your meals beforehand so that's a l l you would eat and you wouldn't just be grabbing what things. You know, she talked about strategies l i k e that which I didn't r e a l l y impose, l i k e I wasn't structured enough to r e a l l y do i t that way. 050 But um, l i k e for example I would allow myself to eat spaghetti, or have an ice cream cone, or a cookie, or something without that automatically meaning I'd had jus t , you know, started the whole cycle. So i t was allowing myself c e r t a i n foods. I t was allowing myself to eat a meal, l i k e a dinner 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 allowing myself to experience that f e e l i n g of fu l l n e s s , normal f u l l n e s s , without that having to lead to such anxiety that I have to just continue. L.T. Do you remember what you were t e l l i n g yourself at that time cause that, that's a major change from, um you know, before you entered therapy? 051 L.S. One thing [that 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." Like a l o t of 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." Like i t - wasn't for a long time that I was able to eat more than I should have eaten and s t i l l be able to keep i t down. So I would eat what I knew—I mean I could, I could write i t out, I could see i t , I knew that 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 anxious—and able to say, "Well l e t ' s just wait. O.K., I ' l l purge but I won't purge for a half-hour. I'm not going to puke for a h a l f - hour." And then i n a half-hour, "Well, we'll wait another half-hour and l i k e take a walk or something." And then I r e a l i z e d I didn't have to anymore. 052 And another thing that happened further down the 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 in a si t u a t i o n where um i t ' s possible for me to binge and for some reason I'm having feelings that I want t o — i s to stop and think back and think: Well i f I'm going to binge now, you're probably going to spend, i t ' d be a t o t a l of l i k e $10 worth of food. I'm going to have to s i t here by myself without pretty time, not do anything, s t u f f myself, and then I'd have to go and and try and vomit, and make sure that I vomit i t a l l out. And that just, that prospect i s exhausting and i t ' s not very appealing to me. 171 So i t ' s sort of l i k e thinking i t through, rather than just l e t t i n g yourself be caught r i g h t up i n i t . And knowing that, "No, I r e a l l y do not want to do that, or, I'm having." (Tape ends here.) 053 So i t ' s a matter of of being able to do other things. I mean you get so, when you're, when you're l i f e i s sort of taken over by t h i s , everything else drops away: I mean everything you used to do for enjoyment. So i t was a matter of r e a l i z i n g there's, I mean there's always time that you could l i k e spend with others now that you f e e l more comfortable around i t , d i f f e r e n t things you can do, and things you can do even for yourself, I mean. You know that's l i k e a notion you never had before i n such a long time. L.T. M-hm. M-hm. L.S. So, you know, opening up your l i f e a b i t more, getting involved i n things, getting busier. 054 As I said um, I, well I became pregnant. That was another thing of allowing myself to have that body image and have that be fi n e . 055 Um, getting a fu l l - t i m e job where i n the daytime hours I couldn't do i t anyway. So i t would have to be r e s t r i c t e d to nighttime a f t e r work. You know so that, and I f e l t confident enough that I'd be able to handle the job and do the work. You know, that had to be there f i r s t . And then to ac t u a l l y do the work and have so much of your time taken up. L.T. M-hm. Was there a progression i n that from when you were t e l l i n g me about the the sort of the "stop and think through i t , " and getting pregnant, and beginning work? Like how, how did those things a l l f i t together? L.S. I think I was able to s t a r t l i k e thinking, t r y i n g to avoid binges and how I'd set up my time, and being able to experience the f e e l i n g of fu l l n e s s and deal with that, and being able to maybe s t a r t a binge as i t started, stop a binge as i t started: that happened before. Like I mean I became pregnant by accident. I t wasn't as i f I'd intended that. But that um happened before the um. That was sort of the f i r s t step: the small elements of control. Even though, I mean, the cycles were s t i l l continuing and a l l that. But the small l i t t l e elements of control started f i r s t and then um, and. 172 056 Then being able to accept you know the the b e l l y of pregnancy and s t u f f and not, you know, r e a l l y be concerned, not be that anxious about i t . 057 Um, and to f e e l that there was another reason why I had to get myself well. You know, there was a baby and there was, you know. Then when baby was born, then I worked, you know. L.T. What, what was that l i k e when you found out that you were pregnant and you, I I assume sort of began to think about some of the effects? Sorry, I mean l i k e what was happening at that time? L.S. Yah. Well again i t was r e a l l y scary because um i t was l i k e , I wasn't t h r i l l e d with the idea for a l o t of d i f f e r e n t reasons. But, you know. L.T. T h r i l l e d with the idea of? L.S. Of being pregnant. 058 I mean quite apart from a l l t h i s , l i k e i t [becoming pregnant] wasn't a planned thing and i t was sort of uh. But, above and beyond that, I r e a l l y thought to be a mother you had to be a f a i r l y whole person. And you know, so there's a l o t of fear of you know, you know, "I've got to get my act together." There was even more reason to get my act together because there was so much, there was more at stake now [such as another l i f e ] . L.T. Such as? 059 L.S. Well another l i f e . You know, I couldn't have a c h i l d and and. There was, i t was one more element that would um make, make i t harder for me to continue i f I f e l t I had to continue bingeing and purging. Um, and from the point of view of that c h i l d ' s well-being, I mean to have a mom doing that would not be good. Like I didn't want to um, you know, f a i l i n that respect, you know. L.T. You were r e a l l y concerned then about being t o t a l l y there for your baby and that you couldn't be i f you were s t i l l bingeing and purging. 060 L.S. M-hm, that I had to. Yah because, you know, I knew at least I had to have control of i t . Um, because i t ' s j u s t one more um thing that, l i k e i t ' s a very t o t a l thing that you have to do: bring up a c h i l d . And even before I had one I guess I r e a l i z e d that (laughs): c e r t a i n l y do now. But uh, and I knew I 173 couldn't r e a l l y do i t i f I were out of control with t h i s thing. I mean I couldn't: I knew that. So, but I must have, I'm sure that I had inklings and and some feelings of control before the pregnancy occurred. Otherwise I think I would have j u s t freaked r i g h t out, you know, just knowing I can't handle t h i s . So there must have been part of me that thought that I could probably handle i t at leas t well enough. L.T. And what happened then with your eating, um, as you were carrying your baby then? L.S. There was s t i l l , i t was s t i l l um present. 061 You know, I didn't, l i k e for those 9 months I was s t i l l bingeing and purging, but not as much. You know things just, i t was sort of again a gradual progression of get, getting better. And then when, during the f a l l - s e e she was born i n January—so during the f a l l I went back to v i s i t my parents i n I. and t h e i r Russian Department needed a, a f i r s t year Russian teacher for that f a l l . So I stayed on and I taught. And i t was wonderful! And I was doing um, inter p r e t i n g for a Soviet broadcast and s t u f f . I t was a r e a l l y neat, neat time. So again I was r e a l l y busy. Um, I didn't, i t was s t i l l present, you know, the eating disorder was s t i l l present. But again, or not again, but even more so I was able to control i t more and more, and perform, you know, f u l f i l l my commitments to perform and fe e l good about that. 0 62 And then when I came back, she was born. And she was about 3 months old, and I got a job opportunity and did that. So again i t was, i t was l i k e the the i n i t i a l um, um, s t a b i l i t y , control f e e l i n g , you know, good f e e l i n g about yourself. Something has to happen f i r s t I think. And then for me anyways, i t was important to almost put that into r e a l i t y by taking on the r e s p o n s i b i l i t i e s that would prove to me that I was getting better, that would diminish the time that I could indulge i n an eating disorder: you know put more things that I had to do on me. Um, but there was that core that had started there, you know, that wasn't there. . . . That core of self-knowledge, and self-acceptance, and strength. And, and, you know, knowing that you weren't such a t e r r i b l e person. L.T. And during t h i s time that you were pregnant, had you finis h e d therapy or were you s t i l l i n therapy, or? 174 L.S. I saw, I'm just t r y i n g to think. I started seeing her probably about February or so. Um that spring, near right before Easter, I did 6 weeks i n B. i n a native, I was doing a native teacher assistant program up there. So I was away for that period. I hope I'm not a year out on t h i s : 1984, got married; 1985, started seeing Dr. T. I think I may be a year out. Just a minute, because, yah, I wasn't, i t didn't just happen l i k e that. That's r i g h t cause I saw her through that spring f a i r l y i n tensively. And then that summer I was seeing her but we were already s t a r t i n g to drop o f f . L.T. Summer of 1985. L.S. That's r i g h t . And then the f a l l of 1985 I was doing tutoring and s t u f f , not f u l l - t i m e . I must have been seeing her. Um, and then i t was that f a l l and spring: I was s t i l l seeing her, but i t had r e a l l y dropped back; that I did the B. thing; and I got pregnant. And then went back i n the f a l l and taught. L.T. 1986? L.S. Came back here and had baby, 1987 i t would have been. And then started my job that spring. O.K. So i t , i t was r e a l l y a year from the time I f i r s t saw her to the point at which these other, you know, pregnancy and and working and s t u f f , came i n . So i t must have been, i t was that spring and summer [1985] that I was seeing her pretty intensively and then you know, backing o f f from there. L.T. M-hm. O.K. And you were saying then that there was sort of a core of self-acceptance that was beginning to b u i l d and then a l l the other things came: the opportunity to begin teaching and things l i k e that. L.S. Yah. Yah. I didn't create those things but the fact that they, they came I think was very opportune at that point. L.T. M-mm. M-hm. They were rea l sort of b i t s of encouragement for you. 063 L.S. M-hm. Because you know, you've got to look, you've got, I think i t ' s a r e a l luxury to have that time- out out of l i f e i n a way of self-examination and a l l t h i s other s t u f f . But then, you've got of kind of put i t i n practise, you know. It's got to be just a, j u s t a part, just a time that helps you actually do what you want to do and not l i k e a, you know, ongoing crutch. You know, cause that means you haven't r e a l l y made that f i n a l t r a n s i t i o n which i s putting, just incorporating a l l those things i n part of your l i f e without, you know. 175 0 64 And I did go to ANAD a couple of times, as I said. I t would probably have been that spring and summer that I was f i r s t seeing Dr. T. I probably went about three times. And i t was good, um. I was doing a l o t of tutoring i n the evening and I think that's p a r t i a l l y why I didn't do i t l i k e on a regular basis. Um, and I found that to be good. Again to walk into a room of people that I f e l t , "Gee, I could walk by (laugh) these women on the street and I'd never know. So other people must see me and they don't look at me and think yuck." You know that (a) you know, other people have i t , so i t ' s not such a ho r r i b l e thing, and (b) that other people sort of wouldn't look at me and know how bad I was. You know what I mean? L.T. M-hm. A l i t t l e b i t more of a r e a l i s t i c perspective then on how other people would see you and i t wasn't that t e r r i b l e . 065 L.S. That's r i g h t . I t wasn't. I t was just a thing, yah. It was just a, you know, an eating disorder (laugh). Cause again, you're putting i t i n perspective. And as i t l o s t sort of i t s ultimate control of my l i f e , I was able to put i t more i n perspective. L.T. M-hm. I wanted to, how are we doing for time? It's 2:55 p.m. I ju s t checked a couple times. I ju s t wanted to ask you a few more questions and then see i f there was anything else that you wanted to add. L.S. M-hm. Go ahead. L.T. Um, O.K. Let, l e t me know when time has run out, O.K. (Laughs.) L.S. Well, by 3:15 p.m. we should, we should probably stop. L.T. O.K. Um, as you think back to being pregnant and afterwards, are, was there any sort of l i n k s between that and your eating disorder? I mean what was happening for you i n terms of the, the progression there? I mean you t o l d me that you were s t i l l bingeing and purging about as frequently, but had more of a sense of who you were during the time that you were pregnant. L.S. Well, no. I wasn't bingeing and purging as frequently when I was pregnant. I was just getting my years overlapped. During that f i r s t spring and summer [1985] I was s t i l l bingeing and purging, the frequency was st a r t i n g to diminish, you know; I was s t a r t i n g to f e e l a l i t t l e b i t better about myself. And then, I think the f a l l was just a continuation of that. I can't remember many highlights of that f a l l . I was doing a l i t t l e more tutoring work— 176 f e e l i n g better about t h a t — d o i n g a b i t of t r a n s l a t i n g , you know that kind of s t u f f . Um, and then, the thing that I think happened when I got pregnant that was neat was that hey I r e a l i z e d I had an appreciation for my body: j u s t i n the mechanical aspect! Like i t was incr e d i b l e I could do t h i s thing! I didn't r e a l l y f e e l I had that much involvement. You know, I knew I had to keep myself healthy. But to watch i t sort of do i t s thing was r e a l l y neat! And also to f e e l so healthy! You know, I had an easy pregnancy and I f e l t so strong and healthy. You know, I was you know as big as a truck and i t didn'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 begin um, a r e a l l y useful 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 didn't bother me at a l l . I kind of reveled i n i t because for the f i r s t time i n my l i f e I could eat what I wanted and i t didn't show, you know, that kind of s t u f f . So during the pregnancy the bingeing i t , you know, i t ' s , ever since I got therapy i t ' s sort of been you know going l i k e t h i s (makes a downward slope with hand). As I said I s t i l l w i l l have incidents of i t , you know, even now, but i t ' s l i k e , i t ' s just a d i f f e r e n t thing. And when I was pregnant, i t was, you know, getting less and less frequent and. But the thing about the pregnancy was that appreciation of my body. And then a f t e r the pregnancy, um, I had put on quite a b i t of weight. And i t didn't, I guess i t didn't bother me as much. Like i t didn't r e a l l y bother me. I didn't look at myself i n the same way, looking for that l i t t l e tummy. (Laughs.) Cause now I had quite a tummy, you know. And, and breast-feeding and a l l that. I t just again, an appreciation of a healthy body rather than i t ' s only, um, i t only e x i s t i n g to see how t h i n you could make i t , and how much l i k e a model you could make i t , and r e a l i z i n g that health was important. M-hm. So health took more of a focus for you. Yah. That became more meaningful for you now to, uh, to be healthy so that you could look a f t e r t h i s baby. Is that right? M-hm. M-hm. That's r i g h t . 177 0 69 And since, you know, then we had another baby about a year and a ha l f a f t e r that. And, um, you know, from those, I put on a b i t of weight with each, each c h i l d . So that a f t e r the 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 or maybe even 20 l b . And again, that didn't cause the anxiety. Like my weight wasn't such a big deal anymore. . . . Well, I knew that I was a mom; there was a reason for t h i s . 07 0 I knew that there were other things that I could use for 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 that I did, my family, and knowing that I was, you know, f e e l i n g better about myself. So I didn't have to just look at that [my weight], you know. Um, and you know r e a l i z i n g that uh, well again, you know, a ce r t a i n difference i n l i f e too: Here I was about 30 and I wasn't l i k e 22 anymore. And, I wasn't tryi n g , who was I r e a l l y t r y i n g to impress i n the way I looked? You know, just took a b i t of a d i f f e r e n t perspective. I didn't f e e l , you know I f e l t much better. 071 When af t e r the second one was born and I took a year out at home and r e a l l y kept that weight, I was doing aerobics and s t u f f , but I didn't r e a l l y lose i t . I f e l t better about myself when I got back to work and and kind of l o s t i t . But i t wasn't l i k e a big, i t wasn't what i t was. . . . That's r i g h t . And I didn't have to, you know, go back into old patterns to t r y and lose i t . L.T. M-hm. Do you remember the time as the bingeing and purging, or do you remember some of the times or events when the bingeing and purging almost ceased or disappeared? L.S. Well yah, I mean that's what, for the past, I can't even put a number of years on i t . 072 But I do remember (laugh) when i t was s t i l l , you know, very much more an issue, suddenly r e a l i z i n g that, "My god, I'd gone for a day without bingeing, oh my god, I'd gone for a week." You know, of knowing that um, i t wasn't a minute by minute, day by day issue anymore. And that was a tremendous fe e l i n g when I knew that I could, I could eat three meals a day and, by eating three meals a day or two or whatever, I wouldn't blow up. Like I was normal i n that regard too. I t wasn't l i k e by eating one bi t e I'd suddenly gain 20 l b . So i t wasn't such a forbidden area. Food became more of a functional thing rather than t h i s whole issue of weight and 178 g u i l t . and you know, a l l these other things that i t had had. L.T. And was that a gradual process? L.S. Yes. L.T. Or was there a time that you can say, "I kind of r e a l i z e d t h i s i n that whole progression"? L.S. I would say yes to both of those because "a progression" i n the sense that those times became more frequent and for more longer periods. But I do remember, I mean I can't say the exact day, but I do remember, i t would have been that spring, that summer, when I was f i r s t seeing Dr. T. when i t was l i k e , "I got through the whole day and i t wasn't such a big deal." You know, or the f i r s t couple of times that I was able to eat dinner and that was fin e you know. So yah, that was, i t was l i k e a highlight, but i t was just a continuation i n a way. L.T. M-hm. M-mm. O.K. And so af t e r you had. I guess, I'm ju s t t r y i n g to sort of focus i n . I understand how i t was a gradual progression. L.S. M-hm. L.T. But was there a time that you would say that um you were no longer um sort of bingeing and purging, or you were less preoccupied with i t ? Or, or how would you define l i k e (snaps fingers together) that recovery time? Or i s there a recovery time? L.S. I guess, you know what. That's a hard one. I think i t i s such a process because i t ' s , so much i s involved i n i t . 073 But I think one sort of point [that marked recovery] i s suddenly when you r e a l i z e that, you're actually, to binge and purge i s much more conscious than not to. Like before i t ' s just a part of your l i f e , and you do i t a l l the time, and you have to r e a l l y concentrate not to do i t . And then i t ' s l i k e an a c t i v i t y that you engage i n sometimes, but i t ' s a very conscious thing. And I think that's a r e a l , um, point 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 that I'd want to act u a l l y binge because I'm f e e l i n g anxious about something but i t would have to be something that I'd have to arrange rather than something I'd have to fi g h t o f f . L.T. M-hm. M-hm. O.K. And was there any s p e c i f i c time that seemed to be, um, r e a l l y clear to you, now as you think back? 179 L.S. (Pause.) Well, no not r e a l l y . I f there was anything I think i t would be (pause) I think during that spring and the summer and the f a l l : That f i r s t , you know, three- quarters of a year [1985] when I was seeing Dr. T., the r e a l i z a t i o n that, you know, "I can get through a day, I can get through a week or something" was there. And I think a f t e r when I got caught up i n other things such as, um, you know, work or something, that during my working hours or whatever hours i t would j u s t cease to be there. So I think i t was a matter of uh, i t tapering o f f and r e a l i z i n g that periods of time could go by. 07 4 But then also I think taking on the work and s t u f f l i k e that was very important because i t would be, you r e a l i z e that you know, "Gee, there's an 8-hour day and i t hasn't even occurred to me once. It's not something that I would want to do or would even occur to me to do because I couldn't function and a l l those other things." So that would have been, you know, about a year I guess from s t a r t i n g to see Dr. T. L.T. So other issues just became more important for you and i t became. L.S. I was able to l e t go of i t . L.T. Almost a chore, i t sounds l i k e to, to have to f i n d the time to do i t . L.S. That's r i g h t . That's r i g h t . So for me, part of the whole process of i t was was getting involved i n other things. Cause I know—I must just be t h i s way apart from anything e l s e — I function much better when I have these things to do. 07 5 Like the year I was home with the 2 children was not, I think i t wasn't a t e r r i b l y happy year. I jus t , that's I guess the way I am. And I no longer see i t as a negative thing of having to define myself by what I'm doing; that's j u s t who I am. And I believe that other people are l i k e that too. It's my personality rather than i t being a d i s t o r t i o n . I think i t was a d i s t o r t i o n before; i t was c a r r i e d to the extreme. And now I'm able to say, "I'm t h i s way, and I'm that way, I'm another way" and not l i k e "god, what, what am I?" L.T. You're clearer now then as to who you are and i t sounds l i k e you're r e a l l y are not so dictated by society and a l l the d i f f e r e n t sort of attitudes about "You should stay home, you shouldn't stay hone, well maybe you should stay home." 180 L.S. No. But that too. 076 I mean t h a t ' l l always be a part of me. I ' l l never be an overly self-confident person. And there's there's times now where, you know, where I f e e l r e a l , r e a l l y negative about myself and, you know, I hate myself and wish I was anybody else i n the world. You know, but i t ' s not everything anymore. So I guess i t ' s too, able to say, "This i s the way I am. I ' l l always have these aspects of my character, but I can deal with them now." Or I can choose not to deal with them and say, "Well i t ' s there. there's nothing I can do about i t . " L.T. They j u s t don't become such a major focus and you continue on doing your other d a i l y a c t i v i t i e s and things. L.S. That's r i g h t . That's r i g h t . 077 And also what's come up i n the l a s t f a i r l y recently :—which I think i s i n some ways part of 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 great, but i t hasn't been, l i k e I haven't r e a l l y gotten o f f on a new, a big new d i r e c t i o n since the whole Russian thing. And I'm now exploring, you know, the idea of going back to school and s t u f f l i k e that. So i t ' s neat. So I'm no longer defining myself as "Gee, I was, I was a Russian teacher and now I'm not, you know. So I'm, therefore I'm nobody." So i t ' s sort of s t a r t i n g with something new again. (Pause.) Again more l i s t e n i n g to me, I'm fine, and knowing what I'm saying. L.T. Being aware of that. L.S. That's r i g h t . L.T. And not being so pulled by the past, and and looking at what you wished you had done or hadn't done. L.S. That's r i g h t . That's r i g h t . I mean, you know, y o u ' l l always have regrets i n the decisions you make, but i t ' s not l i k e "god, i f I'm not that I'm nobody," which i t was for quite a while. L.T. M-hm. M-hm. L.S. So I r e a l l y , I guess my whole viewpoint on recovery i s not "recovery", i t ' s i t ' s recovery i n a broad sense of. Because when you're t a l k i n g about changing parts of yourself, or working on parts of yourself, i t ' s such a long, gradual, slow process, and yet there are high points that you can pinpoint. But, I just see i t as being a very 181 long continuum. L.T. M-hm. O.K. Um, anything else that, that you want to add at a l l ? I think you've pretty much covered my few s p e c i f i c questions here. Um, (pause), except I do have two more short ones. (Laughs.) L.S. Go ahead. L.T. Um, was there anything else that would have helped you in your recovery, do you feel? Like anything that you r e a l l y f e l t was lacking or wished would have been there. L.S. I think i t would have been good had Dr. T. l i k e , um, said to me, "As part of our therapy you must go to these ANAD sessions." I think i t would have been good because again i t was sort of an avoidance, i n some ways, of, i n dealing with i t and facing i t . You know what I mean, on an ongoing basis apart from the therapy. So I think bringing more parts of your l i f e into the whole recovery process would have been good. Um, I think maybe, um, had t h i s been available, I think maybe bringing parents or spouses or something into the therapy sessions might not have been a bad idea. L.T. You would have l i k e d to have had the opportunity to bring A. then? L.S. I probably would have said I wouldn't have. But I think i t would have been a good thing. L.T. M-hm. And i f someone had suggested i t to you at the time, do you f e e l you would have? L.S. No. But i f they'd said i t was a very important part of the process, I would have. L.T. O.K. I f they sort of t o l d you the benefits of i t . 078 L.S. Yah, M-hm. (Pause.) And I wish [that as part of my recovery], yah, I wish I had been more involved in ANAD, and I, I s t i l l have feelings now. I think I'd l i k e to t r y going back and seeing i f there's any capacity that I could be involved or help out or something. I think that's part of, I think part of i t i s , um, once you've worked through i t , being involved somehow i n helping others or with, you know. L.T. What would be the—by the way they, they always are looking for people who have recovered and would love to come and be part of, um, of the sessions. L.S. Are they? 182 L.T. Yah. The V. one: B and T. L.S. Yes, those are the names. L.T. Yah, cause I was speaking with them about a month and a b i t ago and they were saying that once people, you know, f i n i s h our program l i k e they never come back. They just want to put the fact that they were bulimic t o t a l l y out of t h e i r l i f e . 079 L.S. You see I think that's i t . And I think, um, i n i n examining i t since I've talked with you and, you know, thought about i t more than I've thought about i f for a long time, i s to r e a l i z e that that [helping out at ANAD] might be another important sort of l a s t step. L.T. M-hm. So, so they're looking for people i f you're interested. L.S. M-mm, that's good. L.T. Yah. And what, what would you hope to get out of that experience? 080 L.S. I'm hoping to help others through what I went through. I think also, i t ' s i t ' s not so much from a point of self-examination cause I r e a l l y f e e l that you can never work things through to the l a s t "dotting of the l a s t i . " You know, when you do that with yourself, you might as well die (laugh), cause i t ' s l i k e put i t a l l i n a box. But I think there's maybe some element i n that, but I think most of i t i s f e e l i n g that you have something to contribute, you know. And, and, and s t i l l remembering how awful i t was and hoping that maybe what you can do can help somebody get through i t more quickly. L.T. So that d e f i n i t e l y you have some information to pass on which could be b e n e f i c i a l to certa i n people. L.S. M-hm. M-hm. L.T. And i t sounds l i k e that r e a l l y wasn't something that you had from j u s t lay people. Like you almost went through the whole recovery experience on your own. L.S. I didn't know anybody with an eating disorder. The only people I ever ever see with (laugh) eating disorders are the few times when I was i n ANAD. L.T. M-hm. M-hm. Or the people who were l i k e the big c e l e b r i t i e s and s t u f f . 183 L.S. Like Jane Fonda, that's r i g h t . L.T. Yah. So you f e e l i t would be important to have someone who i s a so c a l l e d "ordinary i n d i v i d u a l " , um, t e l l i n g t h e i r story so that people can r e l a t e . L.S. I think so. I think so. L.T. M-hm. (Pause.) As you think back on, on your recovery experience, are there any differences, or ways that you f e e l you're d i f f e r e n t now than when you were b u l i m i c — s a y , you know, emotionally, i n t e l l e c t u a l l y , um, what else, s p i r i t u a l l y — t h a t , that we haven't already touched on? Cause you've r e a l l y been t a l k i n g about that, but I'm just wondering i f there's anything else that comes to mind. L.S. (Pause.) Well, i n t e l l e c t u a l l y I would say that um, I mean I c e r t a i n l y , i t was the years I was at school that I f e l t I was using my brain the most. 081 But I also r e a l i z e d what an e f f e c t bulimia had on your a b i l i t y to think, just i n terms o f — i t ' s not just the amount of time—but 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 think 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 think were I to, i f I were to s t a r t on some kind of school program, um, I think that i n many ways, um, I don't want to say I'd do better, but i t would just be, i t would be a more balanced thing. I t wouldn't be such a focused thing. So maybe I wouldn't do um, something l i k e standardized grades and s t u f f , I might not do better. But I think I would be able to put more into i t because I'd have more of myself to devote to i t . L.T. So one of the difference then i s that now you f e e l you could put more of yourself into i t , give more um. 082 L.S. I could concentrate. I mean i t was l i k e I could never concentrate before 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 to concentrate that would usually mean I'd be o f f doing some work, whatever, studying or whatever. And that would be a prime time to binge, and I usually would. So there wouldn't be periods of concentration or r e f l e c t i o n . Like I was a f r a i d just to s i t back and think about things and not do anything, from many points 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 that would be a prime time to binge]. But also, I didn'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. 184 So that's a, a big change now. I mean i f you f e e l not so driven to always be f i l l i n g your time that, as you say. Cause you were scared when you didn't, you knew what would happen. M-hm. M-hm. L.S. And also the a b i l i t y to maybe do things to please yourself: for nothing other than that reason. [Just the sheer enjoyment of i t without any] goal that has been set by somebody, that you want to achieve. So that. And I think I'm a l o t more um. I deal 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. In what way? How? L.S. Well, you know. I f e e l that. I'm s t i l l not a person that has many close friends. And again, I've decided that's part of me and not, you know, for any other reason. But, I'm able to be, you know f e e l that I'm more myself with others and be more relaxed, and you know deal with them as I f e e l other people must have always dealt with other people. And so that's good. And you know, the work that I do now and I suppose any kind of work I do w i l l be with people, and w i l l hopefully be from a perspective of t r y i n g to give them something through teaching or whatever. And I f e e l that, you know, I can do that much more e f f e c t i v e l y . Now? M-hm. Cause you're not so concerned about others' evaluations of you and. Is that part of i t ? And also, do you remember when I was t a l k i n g about the t h i r d year university, when I said that r e l a t i o n s h i p had ended and there was somebody who I f e l t wanted a rela t i o n s h i p . Well, i t was r e a l l y funny because he had been going through some psychological problems. And I think had, had everything been d i f f e r e n t , then i n many ways we were very suited to each other apart, I mean, apart from his l i t t l e neuroses there. But um, i t was almost as i f the people that I f e l t I could be close to, those were the ones that I wanted to push furthest 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 to be close enough I would i n f e c t them with whatever sickness I 185 had. Like um, I f e l t l i k e a p i l e of cut glass and anybody who touched would would, you know, cut themselves on. So, you'd sometimes surround yourself by people, but you wouldn't you know, you didn't have that much to do, or i n common with. So, you know, i t ' s a question of the friends that you choose would be more re a l friends. L.T. M-hm. Now, than back then. L.S. M-hm. L.T. Any other differences at a l l that you f e e l were, are sort of, r e a l l y had a major impact as you think back? (Pause.) You've touched on a quite a few things: l i k e a d i f f e r e n t l i f e s t y l e and um, d i f f e r e n t ways that you look at goals. 087 L.S. I know something. I know something. Again, i n my rela t i o n s h i p with people, I think I always wanted the other p e r s o n — i n whatever the rel a t i o n s h i p was— to be i n control. You know, for reasons that I think you probably understand: a lack of s e l f - d e f i n i t i o n etcetera and wanting to ju s t sort of hit c h myself on to somebody else. And you know that analysis of relationships that's, you know, parent, c h i l d , and peer. I think I would always de l i b e r a t e l y set up a relat i o n s h i p with others i n that I was the c h i l d and they were the parent. And I'd always t r y and um, uh, I think put myself forward as a b i t of an "airhead". Like 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 didn't a c t u a l l y anyways. (Tape ends here.) The whole image of, um, not being equal with others: always putting yourself on the down side, um, not being assertive, um, and not believing that others w i l l take you seriously. So there's a cer t a i n amount of, of um, again almost t r y i n g to rel i n q u i s h control of the s i t u a t i o n when you're with other people. So I think I deal 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 profes s i o n a l l y I can t a l k to people as I imagine an adult would t a l k to another adult and not the way I used to. So that's a, that's a big difference as well. L.T. I t ' s a major change. L.S. Yah. L.T. For sure, because i t sounds l i k e now you f e e l that you have something to contribute and therefore y o u ' l l speak when you have something that you r e a l l y want to communicate to people. 186 088 L.S. That's r i g h t . And I believe now I'm able to see some good i n myself and see "Yah, I can do that well. I t ' s not just, I was just , somehow got through i t and I fooled them t h i s time. God, w i l l I be able to fool them again?" That, you know, ho r r i b l e tension that everything you do then having more expectations and being r e a l l y scared of i t even though you have to have those expectations: They have to be there. So i t ' s a l o t , um, easier now i n fact. L.T. Cause there's a sense now that you're more yourself and you don't have to worry about fo o l i n g people because what they see i s r e a l . L.S. Is r e a l . That's r i g h t . That's r i g h t . And that's, that's r e a l good! L.T. I'm sure that's an incredible r e l i e f . L.S. M-hm. L.T. I t takes l o t s of stress and, and energy out of l i f e . L.S. Oh yah. Oh yah. That's r i g h t . L.T. When you think of i t just, you know, pervades every aspect of everything we do. L.S. Oh i t does, i t does. I think the d i s t r e s s i n g feature of, of something l i k e t h i s — i f i f other people are l i k e I w a s — i s the fact that i t just, there's no part of yourself that i t doesn't, doesn't flood. I t ' s l i k e a piece of f e l t : You know, you touch one corner to water and the water j u s t sucks a l l the way through. I t ' s l i k e there's nothing that I can i d e n t i f y that wasn't dramatically changed or a l t e r e d — n o t due to t h i s involvement because what you are causes t h i s whole syndrome—but, you know, there was nothing that was, not even a corner of my l i f e during that time that was untouched by i t . And that's, you know, t e r r i b l y overwhelming. L.T. And so then recovery, how does that um occur for you? L.S. It' s almost l i k e pushing the water out of the b l o t t e r . You know, slowly you gain a l i t t l e corner more and more t i l l you push i t , not t o t a l l y out, but just that l i t t l e corner i s wet. You know, something l i k e that. I t ' s sort of l i k e that image of of emerging from the water, emerging from: a whole part of you comes out and hopefully you get your whole s e l f out of i t . L.T. M-hm. And, and now how—this i s my absolutely f i n a l l a s t question (laugh)—and now how do you feel? Like, l i k e 187 you've said that sometimes there are occasional binges for you. And, and what's that l i k e for you i n terms of, um, how you f e e l about things and, um, how you think of recovery? 089 L.S. Well the thing i s , i t [bulimic episode] doesn't, i t doesn't touch me that much. Like i t ' s not something that i s l i k e a l i g h t thing to do or i t doesn't matter. But, I know that those a c t i v i t i e s , um, are not something I have to do: i t i s n ' t r e a l l y me anymore. So i t ' s not a thing that i n retrospect I l i k e . I t ' s just l i k e , "What did I do that for? You know, that was, that was stupid; that was unnecessary." But i t doesn't r e a l l y traumatize me. If I'm f e e l i n g r e a l l y badly about myself anyway, i t would just be something else to say, you know, "I f e e l badly about myself because of." 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 c h i l d , there's the, the neighbour's dog scares the heck out of you. And every time you walk past i t your heart i s going l i k e t h i s ( l i g h t l y pounds heart). And then when you get older i t ' s sort of l i k e he could jump out at you and maybe scare you once, but i t ' s just an old dog. You know, sort of l i k e a t o t a l l y d i f f e r e n t thing about i t . So yah, i t ' s not something I l i k e , or something I'm proud of, or um. But i t doesn't, i t doesn't seem to be a big deal, you know. L.T. I t ' s j u s t kind of a habit that's there and sometimes i t comes. L.S. I guess. 090 I can't r e a l l y understand i t [occasional bulimic episodes]. I t actually um, I guess often when i t happens i t ' s not l i k e a conscious cycle. I t ' s more l i k e for some reason I've l e t myself r e a l l y eat, overeat so much that i t ' s almost l i k e an escape mechanism i f I know that i t ' s been. Like I can overeat, l i k e I can eat too much and f e e l , "Oh, what a pig and s t u f f . " But the occasional time when um i t just, 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 cycle that I have to go through. But s t i l l , parts of i t are s t i l l there that I think I use or something. I mean i t ' s r e a l weird. But I don't have to. So i t i s quite a conscious thing. L.T. M-hm. And i t sounds l i k e there's that element of control and that you don't sort of b u i l d up to i t and i t doesn't continue. 188 No. But i t ' s more of an isola t e d incident. Yah. And, um, i t sounds l i k e you know why you're using i t and choose. Yah. I t ' s sort of l i k e I guess l i k e smoking. You're sort of l i k e , "ah, t h i s i s sort of needless." But um, no, there's no longer, you know, there i s a f e e l i n g of control. I t ' s a, i t ' s a funny thing to even t a l k about now because i t ' s so incongruous but. With, with what i s i t not congruous with? L.S. Well, i t ' s l i k e an old carry over from the past i n a way, you know, because i t i s n ' t l i k e a part of my l i f e or a necessary part of. I wouldn't even consider i t r e a l l y much i n thinking of myself these days. M-hm. It's r e a l l y something then from the past. Yes. And you ju s t kind of use i t now and again and um, that sort of l i k e "so what." Yah. Although I did fin d during the year I stayed at home that, um, there, the incidents [of lapses] were more frequent. And when I re a l i z e d that, I made, I had to make an e f f o r t again to sort of eliminate i t , you know. So I know that for whatever reason i t ' s r e a l l y much better for me to be out and involved i n things and, you know, busy. And i t ' s not good for me to s t a r t having negative feelings l i k e , "I'm not doing anything or have too much time." You know what I mean? M-hm. M-hm. L.S. And I guess i t ' s [lapses are] just a fe e l i n g , a negative f e e l i n g that manifests i t s e l f i n a way. Because I did notice during that year, there was a point where I real i z e d , you know, i t [lapses] was st a r t i n g to happen: s t a r t i n g to, not s t a r t i n g to happen again but i t was l i k e i t , I I could see the frequency was going up. And that, that distressed 189 me. But then I was able to, you know. I had to exercise w i l l but then i t was, i t was defeatable. I t was a funny thing. L.T. You d e f i n i t e l y have replaced i t with other things i t sounds l i k e . L.S. M-hm. L.T. And during that year when a l o t of things had changed for you, you r e a l i z e d that, and quickly. 095 L.S. I could revert [to bulimia] I suppose i f I, yah. Although I r e a l l y don't think I could ever r e a l l y get back into that s i t u a t i o n . I don't know. I can't even conceive of i t . L.T. M-hm. I t just seems l i k e t o t a l l y . 096 L.S. I t was a d i f f e r e n t person doing i t . L.T. M-mm. M-hm. L.S. That's i t . L.T. Now, for sure? L.S. Right. (Laughs.) L.T. O.K. Well um, I don't have any more questions at a l l . Is there anything else that you want to add or? L.S. No, I think you've been quite complete. L.T. O.K. Good. L.S. Good timing. 190 APPENDIX J P.Y.'s Protocol L.T. O.K. So wherever, you know, you'd l i k e to s t a r t from when you f i r s t began to notice l i t t l e b i t s of change. P.Y. On the recovery or on getting i t ? L.T. Um, well once you've had i t for a while. P.Y. O.K. L.T. And sort of i f you can, you know, jump into the recovery part. I know that's hard sometimes. 001 P.Y. O.K. Um, r e a l l y the key thing that I remember i s um, I, when I would go to t a l k to Dr. B. and he would say uh that I had to learn to l e t myself f a i l . And i t didn't r e a l l y c l i c k u n t i l we put i t into ways l i k e um j u s t because you've binged doesn't mean you have to go and purge afterwards. So um, that was a rea l struggle and I had a l o t of anxiety over i t . But that seemed to me r e a l l y what helped me because i f , always i t was the r e l i e f of throwing up afterwards. You know that, that was um, i f you didn't have that, you weren't as l i k e l y to eat as much. So there was a few times when I would eat t i l l I just thought I was going to explode but then I didn't l e t myself go and throw up. And I f e l t h o r r i b l e but then afterwards i t was l i k e a v i c t o r y even though I had s t i l l consumed as much food as I, you know, did normally on a binge. But um that's kind of how I. And then when I could cut down on the number of times that I threw up, slowly I cut down on how big the binges were because i t was such an uncomfortable f e e l i n g being that f u l l , you know, l i k e r e a l l y f e e l i n g l i k e you were going to explode. So i f you didn't have the, kind of that out, you know, to get r i d of i t a l l , then you would cut back that way. So, I don't know, that's, that's pretty much um, what I remember of i t you know. And I can't remember how long a time i t was though u n t i l I stopped completely. L.T. Can you ju s t sort of f i l l me i n who, who Dr. B. i s , and how, how you got to see him. P.Y. Oh. (Laughs.) L.T. And sort of t e l l him about things, and then how a l l t h i s came about? 191 P.Y. O.K. Um, actually, uh he was a patient at the dental o f f i c e that I worked at i n S. And um, as i t turned out, I'm the one that does medical h i s t o r i e s on people when they come i n . So I happened to meet three or four people that had bulimia and they a l l t o l d me that they saw Dr. B. And of course none of them knew that I had bulimia (laugh). And they would a l l t e l l me how wonderful he was and how he l p f u l he'd been. So uh, then he i n turn came into the o f f i c e as a p a t i e n t — I didn't know he was a patient when I'd been hearing t h i s about him—and I thought he seemed l i k e a pretty nice person (laugh). So then I started seeing him as a physician and, and uh I t o l d him ri g h t away, you know, that I had bulimia. And t h i s was a f t e r I had already seen Dr. T. o f f and on for, oh I guess about a year. But I, I didn't r e a l l y f i n d that um, I improved at a l l when I saw Dr. T. I don't know, I thought, I thought maybe that I was uh. I guess I thought when I saw Dr. T.—you know I heard that he was l i k e world renowned and he was the guy to see and eve r y t h i n g — I thought I would go and see him and 2 weeks l a t e r I'd be cured and. But i t , I didn't r e a l l y f i n d that I got any better at a l l so. I don't know i f i t was just the personality thing or what. But i t ' s r e a l l y , with Dr. B. that uh. Maybe i t was just the timing too, maybe that was par t l y i t . L.T. M-hm. So when you went to see Dr. T. you were how old and? P.Y. I guess I started seeing him (pause) i n the spring of 1983. So I was not quite 23: about 22^. L.T. And so you didn't f i n d that that was very e f f e c t i v e . But you went to see him for a while and, and you say that you f e l t you didn't improve at a l l . P.Y. Oh, I know I didn't improve. I mean he uh. L.T. How, how did you know that, that you didn't improve? P.Y. Well, because I was, I was s t i l l bingeing once, twice, three times a day. I mean, you know, for me to, I couldn't go a day without bingeing. I t , i t ju s t um, i t jus t didn't, there was no stopping of anything. I mean (pause) I guess I didn't f i n d him encouraging. And uh, I don't know, maybe I, you know, I needed someone to pamper me a b i t or something. He was not a "pamperer" at a l l . Like I can remember one time I was i n his o f f i c e and one of his patients c a l l e d and he was going to commit suicide. And I was s i t t i n g i n the chair, he was s i t t i n g at the desk beside me, and uh he b a s i c a l l y said, "Well 192 that's fine, I'm with someone else r i g h t now. I f you want to do that you go ri g h t ahead. Goodbye now." And he hung up. And I said, "Listen I can go i f , you know." "Oh no, no." And then he turned to me and he said, "You know we're r e a l l y a l l just l i k e f l i e s , you know. We're here today, gone tomorrow; i t doesn't r e a l l y matter." And I thought, "Oh good (laugh). Why am I coming to you, you know?" So, I don't know. Like he, he wasn't an unpleasant person but he ju s t um, he was ju s t so matter-of-fact about i t you know. And, I guess too because he's a very round person. So when you have an eating disorder that's one of the f i r s t things you notice. So when I f i r s t met him I thought, "Oh yah, sure, you're going to help me to eat properly (laugh)?" L.T. You didn't have a whole l o t of confidence then i t seems. P.Y. Well no. But I s t i l l , you know, I s t i l l kept hearing that. Like I would, you know, i f I read anything about i t , I would read h i s name, or you know, hear h i s name on the radio and things. But (pause) I mean I'm sure he's helped a l o t of people but he just wasn't the person that could help me. And he uh, he and his wife started a s e l f - h e l p group for people with eating disorders. And I thought "Oh t h i s w i l l be great", as I'm sure we a l l did. And we'd meet there: Oh I think there was probably about 25 or 30 of us. And we'd meet i n t h i s room and i t was l i k e , you know, we could a l l "out eating disorder" each other, you know, cause that's kind of part of the eating disorder. So we'd go in there supposedly to support and encourage one another. But r e a l l y what we were doing was, you know, giving each other more ammunition: "Oh, I never thought of doing i t that way." Or l i k e there was one g i r l who had, she'd had anorexia and bulimia o f f and on for over 20 years and her body was i n such a state that she very proudly said that, you know, she couldn't, her weight could not fluctuate more than 10 lb because her heart couldn't take the stress anymore. And i t was l i k e the looks on everyone's faces was l i k e wow, you know: l i k e we were a l l s t r i v i n g to be that good at i t , kind of. So I don't know, maybe sel f - h e l p groups can be good i n a l o t of things but I don't know that eating disorders i s r e a l l y one of them. Unless you're already to the point where you're recovering. But we were a l l r i g h t i n the thick of i t , you know. And, and uh i t r e a l l y was l i k e , you know, t h i s person had done t h i s , well t h i s person had done one better. We could always "one better". And you know as each week went on, I mean i t just got ri d i c u l o u s 193 you know, the, the lengths people would go to and they j u s t . L.T. Sounds l i k e i t was a pretty discouraging experience then because you weren't r e a l l y getting any other focus. I t was a l l j u s t on an eating disorder. 002 P.Y. Well r i g h t . And but the s i l l y part of i t i s i t wasn't r e a l l y that discouraging while you were there because being i n the eating disorder, I mean sure you've got t h i s part of you that wants to get better, but you've also got t h i s part of you that c l i n g s to that, you know. So when you're around other people that a l l have that same thing i t ' s l i k e um, you know, i t ' s l i k e a bunch of drunks going to the bar together, you know. The only thing that was missing there was a big vat of chips and dip i n the middle, you know. Like i t just, I don't know, l i k e I, I think probably because i t was the f i r s t s e l f uh kind of a support group they had started, obviously they had to work out the "bugs". And I think that was one of them that, you know, they didn't, they didn't r e a l l y (pause) esta b l i s h , you know, that you had to be on the road to recovery. So i t was, you know, i t was just a bunch of people thrown i n together that a l l had a l o t of r e a l l y major problems and we were supposed to be helping each other but. L.T. I t wasn't working. 003 P.Y. No. No. And I, I can remember one g i r l t e l l i n g me that um I should quit my job and go on welfare. You know, I mean for her I guess that was an answer but to me I thought, "No, you know, l i k e that's giving up the one l a s t thing I have that I, I am, have control over and I'm doing O.K. with i t , you know." Like I thought, "boy." But she just thought that was the way to go and then you just kind of s i t back and wallow i n having an eating disorder and being taken care of, you know. So, I don't know. There was d i f f e r e n t things l i k e that. L.T. Both those experiences then—the in d i v i d u a l with Dr. T. and the group—seemed not to help you decrease your bingeing and purging. P.Y. No. L.T. At a l l then. P.Y. Well Dr. T. um he t r i e d hypnosis and uh I'm not very receptive to that. I mean at t h i s point i n my l i f e I would just out and out refuse. At that point i n my l i f e , 194 I didn't know. You know, l i k e I thought, "Well O.K., I ' l l t r y i t . " You know and uh, but I, I never, he, he didn't hypnotize me. And he would give me um a tape that I was supposed to take home and play. But I just , i t just didn't f e e l r i g h t , you know. And so I didn't, I never played the tape and that's, I don't know. It was just l i k e (pause) I would go there and, and uh I was supposed to say something good about myself. I mean I guess that's one good thing cause that, I found that hard to do. You know, so that was probably good pra c t i s e going i n and seeing him, and, and every time I'd have to say something that I had done well or, you know. So that part of i t was probably h e l p f u l . But, but s t i l l i t didn't um, i t never got to the point where i t affected my eating habits at a l l , so (pause). I don't know, that probably sounds l i k e a r e a l l y awful thing to say because obviously he must have helped a great deal of people for people to say that he's um, you know, an expert i n the f i e l d or whatever. L.T. But for you, sounds l i k e you didn't f e e l that he was a credible person for you because of his , the way that he looked and, and you weren't happy with his techniques of hypnosis. But. P.Y. Yah. L.T. The p o s i t i v e affirmations that he had you do were h e l p f u l . P.Y. Yah. And i t wasn't even though, l i k e I mean that almost sounds l i k e I thought he was just a quack. I didn't think that. I mean he, I thought he was professional but I didn't think he could empathize. L.T. M-hm. P.Y. And then, and I guess i t was when I was there and he had that s u i c i d a l person c a l l i n . Then I just thought a f t e r that, "He r e a l l y doesn't care. I mean t h i s i s just a job to him; i t ' s just a paycheck." You know, and I didn't want to f e e l l i k e that. I mean I know i n the big scheme of things obviously doctors don't get attached to t h e i r patients or they shouldn't and there's a l l that professional part of i t . But i t , I didn't want to f e e l . I mean I just f e l t l i k e my whole l i f e was going down the tubes, and I wanted someone to help p u l l me out. And I just f e l t l i k e i f he l o s t one, he l o s t one: no big deal, you know. And so that kind of made me f e e l a b i t panicky, you know l i k e , "He's not going to help me." And I guess that was one of his things too was that he expected you to do i t . And I know i n the end you do have to do i t . But (pause) I guess because i t ' s such a secretive thing, you 195 know, when you f i n a l l y go to see someone about i t you want to pour your guts out to them and, and f e e l l i k e they're behind you kind of, you know. But I ju s t f e l t l i k e , "Next." (Laugh.) So. L.T. I t was almost, would i t be f a i r to say you almost f e l t i n s i g n i f i c a n t with him, l i k e you r e a l l y didn't matter a whole l o t to him. P.Y. Well. Yah, because I'm sure (pause). When I would go i n to see him. I mean the f i r s t time you go i n you're supposed to stand up, turn around, so I guess he can see you know do you, are you t e r r i b l y , t e r r i b l y underweight, or t e r r i b l y , t e r r i b l y overweight, you know. And there was a whole bunch of l i t t l e stigmas about. I mean one thing was because he sp e c i a l i z e d i n people with eating disorders, you know, i t ' s l i k e you'd walk into his o f f i c e and you wondered i f the people going down the h a l l were going, "M-mm, I wonder which eating disorder she has?" Well at that time I don't think anyone had r e a l l y heard much about bulimia. But then you would go i n the waiting room, and you knew that everybody i n the waiting room, you know, had some kind of eating disorder. So then i t was l i k e "gee", you know (laugh); you were t r y i n g to imagine what t h e i r l i f e was l i k e , you know. Or, "Oh, she doesn't look so bad" or "Gee, there's a guy here, you know!" (Laughs.) L.T. What was that l i k e for you s i t t i n g i n his waiting room and, and looking at a l l these people? P.Y. I t was awful. I mean you f e l t , I don't know. It just f e l t r e a l l y conspicuous. Like I guess that was one thing too when I went to see Dr. B. because he was a G.P. [General P r a c t i t i o n e r ] . I mean I could have been there for a sore throat. L.T. Oh. P.Y. I mean I could have been there for a sore throat, you know. Like i t , there was no stigma to i t at a l l . And, and he also um (pause), I guess maybe l i k e i t was something d i f f e r e n t for him. You know, l i k e he dealt with sore throats, and stubbed toes, and sicknesses a l l day long and, and uh he r e a l l y seemed to get something out of i t when, when he would, you know, do the counselling. So, and, and he b a s i c a l l y just made himself available which I know you should not expect someone to do. But uh, for me i t meant a l o t that he would do that even though I never ever c a l l e d him at absurd hours or anything l i k e that. But i f I c a l l e d , you know, and I would, I would just t e l l him, you know, I needed to t a l k to him. Or, or sometimes I would give other reasons: "Oh, you know uh, I've got a 196 rash or something." And oh, then I'd show him my l i t t l e rash (laugh) and then we'd t a l k about what I r e a l l y came for. And he didn't mind that and he would take the time, you know. So (pause) I, I think j u s t to f e e l l i k e there was somebody that um (Pause): He f e l t responsible I guess. You know, l i k e he, he t o l d me about um, he had a patient that he saw for years, and she had an eating disorder and he didn't know i t . And a f t e r she'd had the eating disorder for a r e a l l y long time, she t o l d him. And, and he f e l t t e r r i b l e that he'd been seeing her a l l t h i s time and he'd never picked up on i t . And then he looked back on, you know, a l l the times she'd come i n and how he should've known and how he should've picked up on i t . And a f t e r that, that's how he f i n a l l y got into, to counselling people with eating disorders. So i t was never that, I don't. And then i t , i t just spread—word-of-mouth I think—among people with eating disorders. 004 I mean that's, that's how I heard about i t [Dr. B.] was by someone else that had been helped by him. And I guess that was the thing too i s that how I heard about him was from someone that had seen him and f e l t l i k e they had improved, you know. And, and with Dr. T., I just kept hearing about how great he was, how wonderful he was. And I kept meeting a l l his patients and they were a l l wonderful anorexics and bulimics. But obviously I wouldn't meet the ones that were cured. But I never did meet someone that recovered and could say, "Well yes, i t ' s thanks to whatever was done at, you know, Dr. T.'s o f f i c e . " So. L.T. A b i t more hope for you then i n seeing Dr. B. cause you had met people who had seen him and had changed. P.Y. M-hm. Yah! L.T. Because of seeing him. P.Y. Yah. Yah, that's true (pause). So I, I don't know. I, I guess i t i t ' s l i k e you close yourself o f f so much, you know. Like I know myself, I had bulimia for so long before I t o l d anyone and no one knew, you know. And, I mean I can remember the g i r l s I used to work with would uh, they would just laugh and joke, but I'm sure they had no idea about how often I went to get groceries. Because I, I worked ri g h t across the street from the mall so at lunch hour I would go over and get l i k e three (laugh) or four bags of groceries. 197 L.T. M-hm. P. how long did you have bulimia for before you started going to see Dr. B.? P.Y. I guess about a year and a h a l f . L.T. M-hm. O.K. So then people started coming into your o f f i c e and t e l l i n g you that they had bulimia, that they had recovered or that they had seen some changes i n themselves from seeing him. P.Y. M-hm. L.T. You went and saw him and what happened? P.Y. Gee. (Pause.) I can't even remember very much about the f i r s t time I went to see him except for him t e l l i n g me about that patient that he hadn't know. And then, I don't know, he just kind of, he just talked to me just l i k e a person, you know. Like he wasn't constantly taking notes on everything I said. But um, I guess r e a l l y he just encouraged me, you know. Like he also would get me to say um, you know, something good that had happened that week, or you know l i k e . And then he would pick up on the good, good things. He wouldn't say "Well how many sandwiches did you eat?" (Laugh.) Or, you know, or, "Gee that's too bad." Like, I don't know. I t ' s , i t ' s hard to say. I don't know i f i t was just h is personality or what. But when I went to see him, I f e l t l i k e he was kind of spurring me on, you know. And i f I, i f I would go back and I'd say that, "Oh, I didn't do very well," he'd say, "Well that's O.K.," you know. And then, he would get me on to other things. And, I don't know, I guess i t , i t started to make me f e e l l i k e my whole l i f e didn't focus on just what I ate and how I got r i d of i t . 005 And i t , i t didn't matter i f I, you know, l i k e . I guess i t was always him um t e l l i n g me that I could do that, you know. Like obviously I, for me, I would make r e a l l y absurd goals, you know: Like every night i t was, "Oh, I'm not going to eat anything." And then as soon as I'd have a couple of r a i s i n s or whatever—something r e a l l y s m a l l — I ' d just go over the deep end. So, I think the big thing was him just encouraging me that I could eat and I could eat more than maybe an average person would, and I d e f i n i t e l y shouldn't be making these, these goals not to eat. And i f I did break these promises to myself that didn't mean i t was part and parcel of, "Oh you binge, you have to throw up." So, I don't know, I guess i t a f t e r . I didn't even r e a l l y see him that 198 long: probably only 6 months, or something l i k e that. L.T. Sounds l i k e he was r e a l l y accepting of your bingeing and purging. And i f you had some relapses i n there, or s l i p s , or whatever, that that wasn't of great, great concern. P.Y. M-hm. L.T. He ju s t accepted i t as part of the process of you [recovering]. 00 6 P.Y. Yup. And I guess, I don't know. Gee looking back, maybe too because, um, he was a patient at the o f f i c e I worked at, and he showed respect for me and my a b i l i t i e s . You know, l i k e he would s t i l l come i n and I would clean his teeth and, you know, I would be (laugh) showing him how to take care of his mouth. And he would be very attentive and l i k e he wasn't condescending at a l l . He was very much "I'm here and you're here too" kind of. L.T. You f e l t on an equal l e v e l with him, maybe. P.Y. Yah! Yah. Yah, more, yah I think that's, that's probably part of i t because he wasn't a re a l um, I don't know, he wasn't my image of what a doctor, you know, s u i t and t i e and briefcase. And, he ju s t uh was um kind of a very understanding person, I think. So. L.T. M-hm. And what was important about that since he was so d i f f e r e n t than Dr. B. uh? P.Y. No, Dr. T. L.T. Dr. T. What was important to you about being more on an equal l e v e l with him and fe e l i n g accepted by him? 007 P.Y. I think because I hadn't t o l d any of my family or any of my friends that I had t h i s eating disorder. But I r e a l l y , I needed someone to confide i n . And I didn't want to confide i n my family because uh, well l o t s of reasons: I mean I don't want to l e t them down, I don't want them to worry, and I don't want to prove I've f a i l e d because I had ju s t come from a f a i l e d marriage. And I knew my family was a l l r e a l l y worried about me, and that i f I had another c r i s i s I mean i t was, would just be too d i f f i c u l t to face them. And I didn't f e e l l i k e they would look at me the same way. 008 So to meet him and even though i t was a professional relationship, to be able to go i n and t a l k to him and not f e e l l i k e um (pause) he was looking down on 199 me or thought that I was an oddity. You know that, j u s t that I had a value, you know and, and uh he jus t talked to me l i k e a regular person. Like i t , i t was not l i k e the eating disorder was incidental but he just t r i e d to, to uh. Like he didn't think that was the f u l l focus and, and he didn't think that I should f e e l that was the f u l l focus of my l i f e either, you know. And, and I guess I, l i k e I think t h i s i s probably common, but your self-image i s l i k e way down i n the t o i l e t . And just, I don't know what i t i s he said but he made me see that there were other things I could do, that I could do well, you know. And just because of t h i s one area of my l i f e was kind of out of control didn't mean my whole l i f e was out of control, which i s how I f e l t , you know. Like i t ' s , I j u s t f e l t l i k e i t , I don't know, i t ' s so a l l consuming. Like my l i f e j u s t revolves around what I'm going to eat. So. L.T. M-hm. Even now as you t a l k i t sounds l i k e he s t i l l has a r e a l l y , had a r e a l l y big impact on you; that you f e l t r e a l l y close to him and um. P.Y. Yah. And yet, you know, I wonder l i k e i f I went back to his o f f i c e now, he'd probably remember my face but I don't know for sure that he'd remember my name. You know l i k e i t , i t ' s , i t ' s not that we had a re a l friendship or anything, but he, he just um, he was just a very respectful person. You know and l i k e I, I hated f e e l i n g l i k e um when I would go to Dr. T.'s and he would ask me questions, and then he'd kind of lean over and he'd j o t some things down. And I'd want to say, "Give me that book and l e t me (laugh) see what you wrote about me!" L.T. (Laughs.) M-hm. P.Y. So. I don't know. L.T. That was too secretive for you and you f e l t l i k e you were being almost treated l i k e a patient or someone who didn't know what was happening to you? 009 P.Y. Yah! Like yah. Like um, l i k e j ust because I, I, had, go crazy with my eating doesn't mean I am crazy, you know. And, and you can t e l l me things and, and you can t a l k to me and, and you can reason with me. You know, I'm i n t e l l i g e n t , I'm (pause). L.T. M-mm. P.Y. I don't know. I, I just f e l t l i k e a number I guess. And I mean I, I don't want to make him sound l i k e he's a bad 200 doctor cause I'm sure he must be good. He must be. I mean have you heard of him? L.T. M-hm. but P.Y. (Laughs.) So. L.T. But you know, good doctors, not every good doctor works well with every person. So, you know. P.Y. Yah. Yah, that's true. So and, and you know even l i k e when I came to see you, I think part of i t i n me was just that I wanted to hear someone t e l l me that I was recovered too. You know, so l i k e when I went to see Dr. Golberg? L.T. Goldner. P.Y. Goldner. I bet he gets that mistake a l o t . L.T. M-hm. 010 P.Y. I t was such a r e l i e f for me, even though he didn't think that I was gonna be able to be a part of t h i s study. For him to say to me, "It's very c l e a r to me that you did have an eating disorder, and i t ' s also very clear to me that you're completely cured." Like i t was l i k e (sigh). (Laugh.) You know l i k e I, I, part of me reasoned that I was, but part of me thought, "Well, you know, maybe you ju s t are so 'out to lunch', you just can't be objective, and you don't know what's normal and what's not normal. I mean maybe, you know, maybe you're s t i l l not recovered or whatever." 011 I mean even though I, I know that I don't binge l i k e I used to, you know, i s , you s t i l l always have that part of you that worries about um, about d i e t i n g and food and things. 012 Like I t r y not ever to weigh myself because I don't want to think, "Oh no, I'm, you know, I've gained 10 lb or I've gained 15 l b ; I'm gonna have to get r i d of i t . " Cause I, for me to go on a die t , I just couldn't do i t . I t would (pause), i t would be too s t r e s s f u l , you know. Like I'd be so a f r a i d that I'd s l i d e back into old habits again. So I think i n that way, I don't know. Like I don't know i f other people that have recovered f e e l t h i s way but you know, i t ' s always haunting me a l i t t l e b i t , you know. And l i k e i n my own daughters, I worry about them too. You know, I r e a l l y watch for things. Like my oldest daughter i s getting to be a b i t of a "junk food junkie" and, and i t makes me worry a b i t , you know l i k e . But I don't know i f that's normal or 201 i f that's not normal, you know, i t ' s hard to, i t ' s hard to know. L.T. M-hm. Um, so now then you don't, you don't d i e t at a l l . And can you t e l l me a l i t t l e b i t about the focus on your weight or l i k e how, how do you deal with that whole realm of d i e t i n g , not dieting, food, weighing, um? P.Y. Well I, I don't d i e t . And I, I, you know I say I t r y not to weigh myself, and I do t r y not to. But I do weigh myself. You know, sometimes I have to look and uh. L.T. I mean how often do you do that now about? P.Y. I don't know, i t varies. Sometimes I ' l l weigh myself everyday and then sometimes I ' l l go for 6 months and I won't weigh myself. So, you know, i t goes i n l i t t l e spurts. And then I always say, "Oh the scale's wrong anyways" which half the time i t probably i s . But I never know i f i t ' s too heavy, too l i g h t . So, you know, about the only way I, I set the scale i s when I take the kids to the doctor, have them weighed, and then I take them (Laugh) home and set them on the scale and, and set i t . 013 But um, I guess i t , you know, l i k e I, I don't know i f I ' l l ever be a 100% s a t i s f i e d with the way I look. But then I don't know i f anyone i s , you know. And there's, there's the, also the element of I'm 3 0 now, I'm not 18. You're not gonna look l i k e you're 18 when you're 30. You know, so, there's that part of i t . 014 And (pause) I don't know, I just started t r y i n g to exercise a l i t t l e b i t . But that I also didn't do because I was r e a l l y a f r a i d of going overboard. You know, so now I'm t r y i n g to um l i k e I don't go to aerobics or, or anything l i k e that. I t r y not to exercise with my goal being to exercise cause I don't want to get caught up on how many sit-ups or how many miles, or whatever. L.T. So that's a fear for you that i f you got into exercise I mean i t could become r e a l goal oriented which. P.Y. Right. L.T. I t was i n the past? Is that? 015 P.Y. Yah. Yah, i t was: Not, not for the entire time I had bulimia for, but for the f i r s t several months I was pretty f a n a t i c a l about exercising. And uh, I don't know, I just don't want to get into that again. But (pause) I, there's also (laugh) the part of me that knows r e a l i s t i c a l l y , "You've got to 202 exercise." You know, so, my husband's r e a l l y good that way. I mean l i k e on Saturday I couldn't sleep i n the morning so I got up and I did go for a run. And he said, "Good. Go. We'll see yah; have fun." You know, but that's the f i r s t time I've gone running i n years. And i t was l i k e huh run a block (breathes heavily); huff and puff for three blocks (laugh). But you know, I, now I'm t r y i n g to be more aware of ju s t my health, you know l i k e . I f I don't exercise, I'm going to pay for i t down the l i n e . You know, i f you're going to stay healthy you have to exercise to a certai n degree. 016 And l i k e , with eating too, you know even though sometimes I ' l l even i f I haven't been eating well that day, I won't not eat supper. I ' l l make sure that I eat a supper that has vegetables and f r u i t and the things that I didn't get during the day. So in that way I'm conscious l i k e I, even though, you know, when you look at what I ate at each time i t might look l i k e a "screwball" way of eating sometimes: not a l l days but some days. In the long run y o u ' l l see foods from each food group tucked i n somewhere there. So, that way I t r y and be conscious. But I don't, don't r e a l l y count c a l o r i e s , you know. I don't know. L.T. O.K. You more go by the four food groups then. And, and how about i n terms of how much you eat and? Cause i t sounds l i k e although you don't weigh yourself, l i k e you're conscious of a weight that you f e e l comfortable at, are you? Or, can you t e l l me a b i t more about weight? P.Y. Yah. Yes and no. I mean I don't (pause), I don't r e a l l y know. 017 I mean I guess somewhere around the weight I, I am. I mean I, i t probably wouldn't, i t probably wouldn't hurt i f I was maybe 5 to 7 lb l i g h t e r . I wouldn't want to go any heavier but I probably, I wouldn't want to go any l i g h t e r than that much l i g h t e r either. And I don't um, I wouldn't say that I cut down so that I can get down to that weight or anything. I t ' s just that I've seen my weight slowly creeping up over the years. So I, I just want to stop i t from creeping any further than i t ' s creeped, you know. And, and I don't know i f that's f a n a t i c a l or not. I mean i t ' s , i t ' s not l i k e I get stressed out over everything I eat. But i t ' s , i t ' s [weight increase i s ] just kind of i n the back of your mind, you know l i k e . L.T. You don't want to go past where you are now and so you're aware of that and. 203 018 P.Y. Well, and i t ' s , and i t ' s not only that too. I t ' s that I want to eat normally, you know. So i t ' s not necessarily l i k e , "Oh, I want to cut back on the c a l o r i e s , " but i t ' s i f I look at the way I've eaten that day, you know. One thing i s when I work, my lunch hours: I work 8 a.m. to 1 p.m. straight through. So then maybe I ' l l get a chance for lunch, maybe I won't. But I ' l l be hungry, so I ' l l grab something. And so then at the end of the day when I look back, I ' l l think, "O.K. what did I grab?" You know l i k e sometimes i t w i l l be junk food, you know. And then that w i l l make me want to compensate for i t . You know sometimes I ' l l , I ' l l get a chance to go across to the d e l i and I ' l l get a sandwich or something which i s obviously a better way to go. But, you know, part of that i s just the way my work day i s too. Like on days l i k e t h i s when I don't work, then I ' l l have l i k e a normal lunch with the kids. But, you know, the days that I work i t ' s l i k e I f i n i s h at 1 p.m., I pick up K., I've got t h i s errand and that errand, and i t ' s j u s t grab something on the run. And you just grab the f i r s t thing that you come across: You know, i t might be a twinkie. You know (laugh), so. I t r y , you know, I, I guess that's i t : That I want to eat normally and I don't think that that's normal or that should be. (Tape ends here.) L.T. O.K. Just l e t me ask you a few more things i n the dieting area and uh (pauses to look at written questions). Um. O.K. So you're wanting to eat more normal meals. And you have a sense that your weight i s creeping up and so you're more aware of that now; you're just beginning to think about doing some exercise as a way to control your weight? Or, how does the exercise come in? P.Y. No, not r e a l l y to control my weight. L.T. No? O.K. P.Y. Just, I worry about a r t h r i t i s and things l i k e that, you know. Like I, um, I just want to be not a "slug". I, you know, l i k e I have back problems and things l i k e t h a t — p o s t u r e r e l a t e d — a n d I know that i f I exercise, that w i l l help that. I mean, i t ' s just things, you know, I, I guess 30 i s n ' t very old, but 3 0 i s n ' t a teenager anymore. And j u s t thinking about how healthy I'm going to be, you know. Like I do want to be healthy and I don't think I can be healthy i f I never exercise. And I also know that that's, you know, being extreme: refusing to exercise for fear of, you know, overdoing i t . And uh, now i t ' s been so long since I've exercised, when I was out running I thought, "What am I worried about? There's no way I could 204 overdo (laugh) i t anyway i n only one, two blocks." (Laughs.) L.T. Yah. So h i t t i n g 30, I i d e n t i f y with that too. There's a few more concerns and you're sort of beginning to look at, "M-mm, maybe exercise might be h e l p f u l ! " P.Y. "Not a bad idea!" (Laughs.) Yah. L.T. M-hm. And, and so then when you act u a l l y do go out and do i t , you r e a l i z e that perhaps some of those fears you have about going to the extreme might not be um r e a l i s t i c fears, at t h i s point anyway. P.Y. Yah. L.T. At t h i s stage anyway. P.Y. Yah, e s p e c i a l l y because I'm finding I r e a l l y hate (laugh) exercise. So I'm thinking, "How could I get obsessed with i t . (Laughs.) Just l e t me go home and have a hot bath!" But um, my husband and I go out and play v o l l e y b a l l once a week and I r e a l l y l i k e that. And that's, you know, i t ' s not extreme exercise but i t ' s a l o t more than what I was doing. And I don't know, just t r y i n g to make a point of i f I'm home with K. to go out with her for a walk, or for a bike ride, or something just to get out and do something where I get my limbs moving a l i t t l e b i t . But I'm c e r t a i n l y not vigorous to the point where I'm sweating buckets or anything (laugh) l i k e that: nothing r e a l a t h l e t i c . L.T. And then the focus too for you i s more on eating balanced meals and so that you don't count c a l o r i e s . And how does that r e l a t e with um your concern about your weight and where i t i s now? P.Y. M-mm. Well, there's kind of two sides. There's, I, I tend to eat more starchy things: I mean I always have my whole l i f e . I just tend to l i k e pasta and things l i k e that. So there's the part of me that w i l l think, "Well, no wonder your weight i s creeping up." But then there's the other, other part of me that says, "Well, i t ' s not creeping up that f a s t . " You know, and I don't know. It , i t ' s a l i t t l e b i t t r i c k y too because my husband i s a r e a l l y picky eater: l i k e h e ' l l only eat ground beef. He won't eat chicken, he won't eat f i s h , he won't eat roast. He, he r e a l l y won't eat any other kind of meat but ground beef. So, you get a l i t t l e t i r e d of, you know, cooking ground beef for one thing and thinking of d i f f e r e n t things to do with i t . And also, because of the ages of my kids, they don't have r e a l l y varied appetites yet. So I think as they get older and they eat a more varied d i e t , my diet 205 w i l l also be more varied. So at t h i s point i n my l i f e , i t ' s probably starchier than uh—you know, I don't know— than I'd l i k e i t to be, I guess. You know i t , i t tends to be a b i t , the vegetables are snuck i n on the side. I can get them to eat celery i f I put cheese whiz on i t , you know. And i f I cook any vegetable that's green, they're a l l gone from the table (laugh). L.T. O.K. So your weight i s something—like most of u s — t h a t we're concerned about when we see i t , you know, beginning to increase a b i t . But at the same time you f e e l that there's some reasons and that. P.Y. M-hm. L.T. Sounds l i k e you probably, you have a good idea as to why i t might be increasing a b i t , and you see that changing as your kids get older. And um. P.Y. M-hm. I hope (laugh). As long as my metabolism doesn't come to a dead stop (laugh). L.T. Yah. There's some concern but s t i l l focussed on the healthy eating and, and balanced meals. P.Y. M-hm. Yah. You know, and I guess I worry about being obsessed with i t . And I, you know, I do think about i t kind of i n the back of my mind. But when, l i k e even when I walk my daughter up to the school, when I hear people that as far as I know haven't ever had an eating disorder, I mean t h e i r , the conversation often revolves around diets and you know. So then I think, "Well, I'm not as obsessed as they are and they haven't had (laugh) an eating disorder." So I, I guess that's the thing i s that you lose your o b j e c t i v i t y about i t , you know, because well no one i n my family has proper eating habits. You know l i k e , well I shouldn't, I mean my kids have kids* eating habits, you know. And my husband has t e r r i b l e eating habits and that's who I l i v e with. So that also doesn't help, you know. But I think as they grow up, I ' l l probably f e e l more comfortable too l i k e . Because I, you can kind of weigh how you think by what other people think, you know. So you can adjust i t or, you know, l i k e i t ' s j u s t I don't have any gauge to measure i t by except my immediate family here because the rest of my family doesn't l i v e close by. So, so I guess that's one thing, you know. That, that's why I tend to sneak i n the, the carrots and things because I ' l l think, "Gee, you know, did, did I feed them well today? Well here, have another carrot (laugh); have another piece of celery." (Laughs.) 206 L.T. O.K. Um (pause). Any, anything else i n that area at a l l that you want to add about your current eating habits, or weight, or um? 019 P.Y. I guess the only thing i s that um, I s t i l l tend to be a b i t of an emotional eater. Like i f I'm stressed, I ' l l go for the junk food but not to extremes l i k e I did. I wish that I didn't do that. And sometimes that makes me f e e l a l i t t l e b i t uptight. But uh, see whereas when I had the eating disorder, i f I, i f I went to the junk food i t would make me f e e l uptight and then I'd r e a l l y go for the junk food: And I'd ju s t go crazy. I don't do that anymore. And I wouldn't, I think what would be a binge now, I mean (laugh), doesn't measure up at a l l , you know. 02 0 Like I had a s t r e s s f u l lunch hour with the kids t o d a y — a f t e r K. peed a l l over the bed (laugh)—and I went down and I had one of those l i t t l e chocolate bars (laugh). But I only had one, you know. And so part of me thought, "Now why did I go and do that? I didn't have to do that." And the other part of me thought, "Yah, but I only had one." You know so, i t , i n a way i t ' s a loss, and i n a way i t ' s a v i c t o r y because I could stop. And that was the thing before: I couldn't stop. I would just eat myself to pieces (laugh). L.T. M-hm. So sometimes now you eat for emotional reasons. P.Y. M-hm. L.T. I f you're uptight, or. P.Y. M-hm. L.T. Feeling stressed out. But i t ' s very d i f f e r e n t than before because i t sounds l i k e you have a rea l sense of control i n there. 021 P.Y. More so. Yah, more so. I mean there's, you know, one um. I have t h i s PMS [Pre-Menstrual Syndrome] thing and, and one of the things i s craving chocolate. So uh, sometimes that makes me f e e l a l i t t l e b i t panicked. But i f I don't keep chocolate i n the house, at those times, i t ' s not as big a deal. And also, a f t e r that week i s over, the craving's gone too. So I can look back and say, " I t was just PMS. I t wasn't that my whole l i f e has gone crazy." And uh, even i n those times I don't, I don't binge, but I just w i l l tend to eat more junk food type things. And uh, you know, from anyone I've talked to that's had PMS, i t ' s the same thing 207 they go through. So, that's a r e l i e f for me because. L.T. M-hm. 022 P.Y. In that way I, I do know, you know, several other women that have PMS. So again, you know, I gauge myself o f f them. So I can say, "Oh, well that happens to them too. So i t ' s not something coming back from my eating disorder. I t ' s ju s t , you know, i t , that's just the way my hormones are at that time or whatever." So I'm hoping that as I get my PMS under control I ' l l see that go away, you know. 023 I guess uh the thing that's on your back of your mind a l l the time i s , "I don't want to ever be l i k e that again, you know. I don't want to be obsessed." So even, you kind of become s l i g h t l y obsessed with not being obsessed, you know, so. But I don't know i f that part every goes away. You know, l i k e i t ' s , i t ' s not l i k e , i t ' s at the front of my mind a l l the time and i t ' s not l i k e I do conscious things. But every now and then I think about i t , you know, because you eat every day, you know. It ' s not l i k e you, you know, i f you stop drinking you just don't go near alcohol again: I mean, you know, i t ' s off your mind. I t ' s , you're always being faced with uh- -es p e c i a l l y as a mom—you're faced with having to cook meals for your family: And are they balanced? And are they nutritious? 02 4 And you know, gee, I, I just want to make sure that I'm, I'm uh not only n u t r i t i o n a l l y giving them [my children] what they need but also s e t t i n g an example of what kind of foods to choose. So that's why when I see my oldest daughter, i n boredom, go for junk food, you know, i t makes me f e e l a l i t t l e b i t anxious just because I know the pressures that are out there, you know, and I just don't want to see her f a l l into the same trap that I did. L.T. M-hm. Sounds l i k e you f e e l there's a f a i r b i t of r e s p o n s i b i l i t y on you to be a model for other people around you i n terms of good eating and. P.Y. I think mostly for my daughters, you know. I, and I probably f e e l that way because my mom was so unaware, you know. And, and even when I t r i e d to explain to her, she, she r e a l l y couldn't grasp what i t was a l l about. And my dad, i t was just more than he could handle. He just l e f t the room; he couldn't l i s t e n . And, i t wasn't that he wasn't, he didn't want to be supportive. I t ' s just, I mean no one had ever: My mom kept saying, "What's the name of that disorder you have again?" You know l i k e she, 208 she just, you know, a l l , i n her mind she just kept thinking, "Well we gotta make sure she eats." You know, so she'd bring me, you know, 20 lb of potatoes, and a big sackful of bread, and 75 chocolate bunnies at Easter: A l l the things I didn't need (laugh). But she didn't understand. 025 You know, and I guess, for me, having daughters and knowing the pressures there were when X was a teenager, and knowing the pressures that they're i n for, I ju s t want to make sure that they don't get caught up i n that, I guess. You know cause even at 9, my daughter just yesterday said, "Gee I'm f a t . " And she's not. I mean she's not the lea s t b i t f a t : She's 52 l b , I mean. And, I don't know, i f even one time she came home from gym and t o l d me she wasn't supposed to eat butter on her popcorn because s h e ' l l become a fat gymnast. I mean t h i s i s the kind of s t u f f , at age 5, that i s being tossed t h e i r way. So, s t u f f l i k e that tends to make me r e a l l y (pause) anxious and angry kind of too. L.T. M-hm! P.Y. Because I don't know i f people r e a l i z e the pressure that they put on kids. So, i f I had sons, I probably wouldn't worry so much, you know. But, daughters: I don't know what i t i s about g i r l s , I guess. L.T. M-hm. There i s a l o t of immediate things happening around you that are reminders of your eating disorder and make you aware of, of. P.Y. M-hm. L.T. How easy i t i s to—because of a l l the pressures out there- how easy i t i s to. P.Y. M-hm. L.T. You know, perhaps get back into i t . I mean, you know. P.Y. Yah. L.T. There's always that p o s s i b i l i t y and, and you're conscious of i t . P.Y. M-hm. L.T. Um, and um sounds l i k e work r e a l l y hard towards t r y i n g to moderate your eating and your daughters' eating, and um, and having healthy anger towards people who seem to be quite f a n a t i c a l about the information they give out. 209 P.Y. M-hm. Yah, I guess because they j u s t don't understand, you know. And, the other thing too i s i t ' s not l i k e you wake up one day and say, "Oh, I'm gonna go out and eat, you know, two bags of groceries and then go make myself get s i c k ! " I t ' s just one day you suddenly discover that i t ' s j u s t beyond your control and you can't do anything to stop i t . You know, and to see how, when I think back, I can think back to the very day that I became b u l i m i c — t h e very moment. you know—and just s l i d into i t : How quickly and how e a s i l y i t happened. You know and, and I j u s t wanna protect my kids I guess, you know and. L.T. M-hm. P.Y. I don't, you know, i t ' s funny l i k e i t , yes I t r y and, and moderate what, what they eat and everything. But um, my s i s t e r - i n - l a w — t h e y just l i v e a couple blocks away—she tends to be a very f a n a t i c a l "exerciser" person, and she's a vegetarian and. So they always joke about our house being the junk food house, eh (laugh), cause we have a junk food cupboard. I mean there's v i r t u a l l y nothing i n i t r i g h t now. But, but we do tend to be more that way, I mean pa r t l y because my husband has poor eating habits. I mean he's not fat and he doesn't eat a l o t of sweets. But i f he doesn't want to have supper, he won't have supper. H e ' l l just have a bowl of popcorn, righ t , or that kind of s t u f f , you know. So i n a way, I get a l i t t l e b i t (pause) frustrated with him. I mean I don't, I don't say anything about i t because i t ' s not worth i t . But, I guess just that I wish he had r e a l l y good eating habits so that he was s e t t i n g a good example. I t just makes me f e e l more responsible that well i f he's not gonna to set the example, I have to r e a l l y make sure I do. So. L.T. M-hm. Yah, you have to bear more of the load i n , i n . P.Y. Yah. L.T. That area then, and be more concerned. And, also because i t sounds l i k e you're the one who does most of the cooking, that you're responsible for the planning of things as well. P.Y. M-hm. Yah. Yah, I always know i f , i f he's cooking, we're having Kraft Dinner. (Laughs.) M-mm. L (Laughs.) O.K. So, that's sort of where we are at present day here. And I'm wondering i f , i f , i s there anything else that you want to add around present day and um (pause), and how things are i n terms of eating for you? P.Y. I don't think so. (Pause.) 210 L.T. O.K. Could you pick up the thread for me back with Dr. B. there? And, I understand how you went to see him and that. But now did i t happen that—people were coming into the o f f i c e — a n d l i k e how, how did you decide? P.Y. I don't know. I mean that part i s r e a l l y uh. I have never once since that time had a patient come i n to the o f f i c e and say, "Yes, I'm, I'm a recovered bulimic." Or, "I have bulimia." L.T. M-mm. P.Y. Never, ever. But i n that, I worked for that woman for 2 years and I, I bet you I had four people come i n and t e l l me. I mean that j u s t floored me that they would o f f e r that information. L.T. M-mm. P.Y. That would be the day that I would go into my dental o f f i c e and say, "Yah do you wanna check my teeth for erosion; I've got bulimia." (Laughs.) L.T. M-hm. So some of these women were recovered but some of them weren * t? 026 P.Y. They were a l l on the road. They were a l l improved or, you know, I can't remember i f they were completely recovered but they a l l had progressed. So, and that was one of t h e i r concerns was the erosion on t h e i r teeth. They wanted to make sure t h e i r teeth hadn't eroded (laugh). Oh . . . . L.T. M-hm. And so you head t h i s and though? 02 6 Well then I, you know, and I would ask who t h e i r (cont'd) physician was and usually then they would t e l l me that they had bulimia. Uh, with one g i r l I remember I said, "Oh, I do too." You know, and she (pause), she looked surprised and uh then, you know, i t was kind of l i k e we had t h i s common bond, you know (laugh). We both had t h i s thing, but don't t e l l anyone, you know. L.T. Was that the f i r s t time you had t o l d someone cause you said that your close family didn't know and your friends didn't know? P.Y. No. Um, the f i r s t time I, I uh t o l d anyone um that was a very kind of unpleasant thing. 027 Um I had heard about Dr. T. on the radio and I thought, "Aha! That's the name of the thing I've 211 got and that's who I have to see." So I made an appointment to see him. L.T. How, how did you know you had to go and see him? Like what made you think that? 028 P.Y. Well I knew that something was wrong with the way I was eating. But I didn't know, I had never heard of bulimia at that point. I ju s t knew that I was uh devouring my paycheck and throwing i t up down the t o i l e t every, every week day. 02 9 So uh, I knew something was wrong but I didn't know where to go. And I wasn't gonna t e l l anyone about i t . So one day at work they had a t a l k show on the radio, and t h i s g i r l came on the radio. And she was ta l k i n g about um her eating disorder, and who she saw, and she mentioned his name. So I went and phoned. And uh, I think i t was that day that (pause). Oh no, i t wasn't that day. I t was af t e r I'd seen Dr. T. several times. I was t a l k i n g to one of my g i r l f r i e n d s who happens to be a r e a l motherly type person: a r e a l caretaker, eh. She was always taking care of me. And uh, I, I can't even remember how the conversation went. She was asking about how my l i f e was. She r e a l l y wanted to know, you know: make sure I was O.K. And, and uh, I think I said something to the e f f e c t of, "Well, I had one l i t t l e area of, of concern or something, but I've taken care of that now" or something. And she immediately, I didn't back. I thought, "Oh, I shouldn't have said anything." Then she was just pumping me for information and I didn't want to t e l l her. So we hung up the phone and I went to sleep. And a couple of hours l a t e r — b a n g , bang, bang, bang, bang (laugh) on my door—here i t was my g i r l f r i e n d . She was so worried about me and she had c a l l e d my then boyfriend. And there they both were, and they wanted to know what was going on, and what was wrong, and oh, boy. And they just would not leave. They were there for, I don't know, probably an hour and a ha l f . They just would not go home. And i t was so la t e , and I had to work the next day, so I f i n a l l y j u s t t o l d them (laugh). But I r e a l l y didn't want to and I, I was r e a l l y angry that they would push me for information when I didn't want to t e l l them. But they, you know, they were, they were both fine about i t . And uh, I mean I think S. didn't r e a l l y , she was very supportive and everything. But I always f e l t l i k e there was part of her that thought, "That's r e a l l y odd." (Laughs.) You know, and even now, I mean she's s t i l l a r e a l l y good fri e n d and, and uh, you know we never t a l k about my bulimia anymore. But um, I always f e l t i t 2 1 2 probably wasn't her, but me that looked at her looking at me d i f f e r e n t l y . You know what I mean? I t probably, she's, looking back she was f i n e . But i t f e l t , i t made me fe e l awkward, you know. L.T. M-hm. You f e l t uneasy with having to t e l l her. P.Y. Well, yah. I couldn't, I, you know, I couldn't go to her house for supper anymore without worrying that they were watching (laugh) what I was eating, you know, and seeing i f I went to the bathroom afterwards. So, but that was, you know, I'd had the eating disorder for a long time by then. L.T. Did t e l l i n g S. play any ro l e i n going for therapy, or? P.Y. No. L.T. Did you, you had already been seeing Dr. T. at that point? P.Y. Yah. I'd, yah. L.T. O.K. P.Y. No, i t didn't a f f e c t i t at a l l . I t was uh, i t was a part of my l i f e that I didn't want anyone close to me to know about or have to deal with. And I guess because I needed to f e e l l i k e they s t i l l f e l t I was normal. And when you go t e l l i n g people that, you know, "Here look at t h i s huge bag of food. I can eat a l l t h i s at one s i t t i n g and then watch me go throw up." I mean l i k e i t ' s , you, people are (pause), i t r e a l l y makes them uncomfortable. You know, and I, I just (pause), I didn't want to have to deal with that, so. L.T. M-hm. You f e l t people just wouldn't be able to understand i t and that they would think i t was so unusual and. P.Y. Well yah. You know. And even now, l i k e um, my husband's brother, I don't, I don't think he r e a l i z e s . Well he probably does now because. Actually he has two brothers that l i v e together. And one time T. was over and, and uh, I was t e l l i n g him the story about that, when that guy who was s u i c i d a l phones, and the guy said, "no big deal." And he said, "Wait a minute. You were seeing a p s y c h i a t r i s t ? " And then he wanted to know why. And I thought he knew. And he didn't. So I t o l d him, "Oh, I had an eating disorder." (Laughs.) So he's probably t o l d h is other brother cause he l i v e s with him. But, B.'s other brother w i l l often, l i k e i f he sees someone that's fat, i n his eyes that's t h e i r f a u l t ; they can do something about i t . Like he r e a l l y has no comprehension, you know. And I think, I r e a l l y l i k e him a l o t . But i f he, i f I were to ever s i t down and t a l k to him about me having had an eating disorder, he could never be the same around me. I mean even though he 1s now kind of heard about i t through the grapevine, he's never had to face me about i t , you know. I don't know, people tend to be that way. They, they just think that, "Well, do something about i t , you know, l i k e stop doing i t then." Like they, they r e a l l y don't understand that, that f e e l i n g of um (pause) just being out of control. So. T e l l i n g people that were close to you then f e l t l i k e i t , i t wouldn't be a worthwhile thing to do for you at a l l . Oh, no. M-hmm-mm. O.K. So and, and you t o l d me about seeing Dr. T. and the things that weren't very p o s i t i v e about that experience for you. M-hm. And then going and seeing Dr. B. M-hm. Um, because you had been recommended by some people who were on the road to recovery. M-hm. And you had f e l t r e a l l y supported by him. M-hm. And that he was an equal, and um. And you knew him as a patient. P.Y. Yah. You know maybe that was i t that I didn't wanna r i s k my family and friends by t e l l i n g them. But I found someone who I respected and l i k e d , that I could t e l l , and would s t i l l respect me, you know. M-mm. P.Y. So i t was kind of l i k e finding someone to f i l l i n that gap for. You know, l i k e I guess i d e a l l y you always would l i k e to t e l l — i f , you have a problem— you'd l i k e to t e l l someone you're r e a l l y close to. Like my s i s t e r and I are very close, you know, and she would have been the person of choice. But I jus t didn't want to lower myself i n her eyes, or, or worry her anymore. Or, you know, I didn't want to add to her burden kind of thing. So, to f i n d Dr. B. was l i k e finding someone that I could l i k e , and I 2 1 4 could t a l k to comfortably, and I could pour my guts out to. But I hadn't r e a l l y risked anything, you know, because there was s t i l l the professional ethics part that he would never, you know, see me on the street and say to h i s s e l f , "Yah, that's the woman with bulimia I was t e l l i n g you about", you know (laugh). L.T. M-hm. M-hm. P.Y. So, you know, i t was safe to t e l l him. I wasn't r i s k i n g any part of my l i f e by t e l l i n g him. But I just , I could never ever. I mean my, you know, my family knows that I, I've had the eating disorder. But I'm sure that they have a c u r i o s i t y about i t because I never talked about i t , at great length about i t . I mean, you know, to t e l l them, I could never say, "Oh, see t h i s whole table of food, I could eat that." I, you know, l i k e even when I would t e l l them, i t ' s l i k e I was watering i t down a b i t because I, I jus t couldn't bear to t e l l them about i t . L.T. M-hm. P.Y. You know, and how intense i t r e a l l y was. Um be, I think be, just because people can't um, i t just "grosses" them out. They just, they don't want to have to deal with i t , you know, so. L.T. And yet you f e l t that Dr. B. could handle a l l that, and that he would s t i l l — i n s pite of what you t o l d h i m — s t i l l respect you, and be there for you. P.Y. M-hm. M-hm. L.T. And i t sounds l i k e that was incredibly important for you and a r e a l bond with him. P.Y. Yah, you know! And I'm sure more. Like I had the bond more than he did; I'm sure of i t . I mean he, he was uh, you know—when B. and I were married—he, he was B.'s doctor too, you know, because uh I t o l d B. how great he was. And B. went there, and B. l i k e d him. But I guess that was just the thing i s you weren't a number going through. But he wasn't someone that I would ever have to see on a s o c i a l basis; l i k e there just was no r i s k to t e l l i n g him. You know, and there was, there was no r i s k going into his o f f i c e that I was gonna be found out. I mean, you know, the, the g i r l s at the front desk would always. When you phoned i n , of course, you'd have to say why you were, why you were coming i n to see him. And I, I can't remember i f I ever ac t u a l l y admitted to them that I was coming i n (laugh) to t a l k to him cause I had bulimia, or not. I bet 215 ya I didn't, j u s t because I didn't wanna have to look them in the eye and have them think, "Oh, so you're the one with the eating disorder." (Laughs.) You know. (Pause.) L.T. M-hm. M-hm. P.Y. There i s such a stigma to i t , you know. L.T. M-hm. And so you said that you saw him only for about 6 months. And can you, sort of, i f you think back to those 6 months when you were seeing him, how, can you describe how things happened? You t o l d me about him um, you know, saying that you could sort of stop the binge h a l f way through, or you could eat but not throw up afterwards. P.Y. I never stopped a binge half way through. L.T. O.K. P.Y. I would always complete the binge (laugh). L.T. O.K. So just, you know, i f , i f you could just kind of t e l l me how things happened as much as you remember i t , i n , i n a sequence, um, you know: things he said to you, or you said to him, or how you f e l t during the times that you saw him. P.Y. Gosh, you know, i t ' s so hard. L.T. O.K. P.Y. I was ju s t thinking about what I said, "I would never stop a binge half way through." I never stopped the binge half way through, but as I did the binge without throwing up, the binges would become smaller, um, just, just because of that uncomfortable f e e l i n g , you know. L.T. How, I mean how did i t happen? Like you were saying you were bingeing two or three times a day and purging a f t e r each one of those. P.Y. M-hm. L.T. Uh, and then you went to see Dr. B. Now how, how did things begin to change? What happened? 032 P.Y. (Pause.) M-mm. I r e a l l y think that um a l o t of i t was just confiding i n him. So i n that way I'd lessen my burden because I f e l t l i k e I was walking around carrying t h i s burden. L.T. M-mm. M-hm. 216 P.Y. When I went to see Dr. T., I f e l t l i k e I was t a l k i n g to him but he wasn't hearing me. He didn't understand how desperate I f e l t . although he would say, "Yes I know," you know, "you f e e l t h i s way or you f e e l that way." But he didn't say i t with f e e l i n g i n his voice, you know. 033 So, when I went to t a l k to Dr. B., i t ' s l i k e I l e f t a l o t of i t there cause I would t e l l him about i t and I would pour my heart out. And i t ' s l i k e , you know, when you're r e a l l y mad, when you don't t e l l anyone about i t , you stay r e a l l y mad and i t ' s r e a l l y hard to get over i t . But i f you t e l l someone what you're r e a l l y mad about or you ju s t blow up, then i t ' s over with and you can get on with i t . So I f e l t l i k e for most of that time, I walked around with i t a l l kind of bottled up inside me, a f r a i d to t e l l anyone or, you know, and ju s t getting i n deeper and deeper. But when I would go see him, we would get that part over with: I mean he would ask me and I would t e l l him, "Oh, I did r e a l l y , r e a l l y poorly t h i s week. I did t h i s , I did t h i s , I did t h i s . " And then the conversation would ju s t kind of turn a b i t , you know. Like he would be r e a l l y interested and, and r e a l l y supportive and that. And then he would just ask me about other parts of my l i f e , you know, and. L.T. Such as (pause) what things? P.Y. Oh, my daughter, my job, my chu