The study aimed to explore the views of former AN patients on how they engage with treatment and how they define recovery. This study joins the small number that recruited from the community to consult former patients (e.g. de la Rie, Noordenbos, Donker, & van Furth, 2006
), and as such, the sample represented a wide range of treatment approaches, modalities and settings. Mean scores for this sample indicated a motivation to change and a quality of life that is comparable to those observed in inpatient samples. In addition, about half of the participants scored in the clinical range for eating symptomatology. This is both context and caveat for the qualitative findings since this level of persistent symptomatology may be unusually high as other studies with similar follow-up periods report recovery rates of about 85% (Couturier & Lock, 2006b
The hypothesis that a lack of a sense of volition in engaging in treatment may relate to poor motivation was supported by this study, which found evidence of a significant relationship between autonomy and stage of change. There was also a significant relationship between having more volition in treatment choice and psychopathology. These findings fit with a self-determination perspective on motivation, however, numbers are very small and so the finding should be interpreted with caution and replicated within a larger sample, ideally with measures that quantitatively assess these factors. Interestingly, the inclusion of close family members in the broad categorization of autonomy as distinct from external factors appears to be appropriate and suggests that family involvement may have less impact on an individual’s sense of autonomy or sense of volition in treatment choice. Recalling their treatment history, most participants reported that they had not been involved in decisions regarding treatment. Since all but one participant had child or adolescent onset this may have been a necessary step in seeking treatment in many cases. Individuals may be able to internalize this reasoning more readily than the recommendations of clinicians or constraints of health insurers.
Participants’ goals were diverse and most notable for their lack of alignment with those commonly proposed by treatment providers (e.g. weight targets, restoration of menses, etc.). A sizeable portion of participants articulated that they did not have any goals upon entering treatment that any desired achievements had been their parents’ and not their own. This suggests the extent of individuality in the perceived needs of the patient at commencement of treatment and at the potential clinical usefulness of investing in collaborative approaches to enhance engagement through listening to the patient’s concerns, and guiding them through the rational and potential usefulness of treatment. Twenty per cent of the sample was explicit in citing that to be listened to was what they had wanted most from treatment.
While the majority of participants incorporated at least one symptom-focused factor in their conception of recovery, the variation in responses was unexpected, with more than a third identifying unique (‘other’) factors. The relatively frequent miscellaneous responses when asked about goals and recovery suggest the individual nature of participants’ motivation to engage in the treatment process. This has implications for motivational enhancement interventions, as well as for the therapeutic process itself and suggests that individuals may be more engaged in treatment by being engaged in a discussion around aims that are tangible and meaningful to them.
It is perhaps noteworthy that few of the factors that previous reports have found to be important in the process of recovery—e.g. the development of a separate identity, emotional factors, desire to have children or the development of a supportive relationship (Federici & Kaplan, 2008
; Keski-Rahkonen & Tozzi, 2005
)—were important in participants’ conceptualizations of recovery. In many cases this would be expected. For example, while several studies have found that motivation to change is an important factor in the process of recovery (Federici & Kaplan, 2008
), it does not necessarily follow that the state of recovery includes an element of motivation. The findings here suggest that how patients operationalize the end point of recovery is distinct from the factors they report to be important to the process. A reasonable question is to what extent participants’ operationalizations of recovery map onto definitions of outcomes commonly applied in the literature? Participants most commonly cited the resolution of eating-related anxiety and cognitive disturbance, as well as physiological symptoms. This appears to fit well with commonly applied definitions of remission and recovery—a combination of dietary restraint (measured by the EDE) and weight within a normal range (Couturier & Lock, 2006a
) though there are many other factors that form the overall concept.
The extensive amount of ambivalence around the concept of recovery is a concern as it suggests that it may remain intransigent even after having experienced treatment where one would expect at least some thinking around this topic. It may be reflective of an ambivalence that is a result of the illness state itself since a similar proportion of participants’ EDE scores were indicative of severity warranting a diagnosis of AN. Nonetheless, this suggests that exploring this topic itself, in addition to motivational enhancement, may benefit patients in providing a personal and meaningful focus to strive toward in the long term. In particular, some participants may benefit from learning that people can and do recover.
The most commonly cited reason for dropping out or the desire to do so was a specific therapist or therapeutic rupture. This is similar to one previous study that implicated patient–therapist factors as being important (Clinton, 1996
). Participants generally cited factors that were specific to the treatment setting, rather than personal factors. This is contrary to the literature on dropout that has tended to report patient characteristics such as demographic, clinical features or personality factors (Vandereycken & Vansteenkiste, 2009
). Future studies should include variables related to therapeutic alliance and the treatment setting in future investigations of treatment engagement.
The strength of the study is also a limitation. Relying on participant’s recall and impression is subject to bias but provides rich data from which we may draw hypotheses for further study. Future research could minimize the impact of bias when assessing reasons for dropout, for example, by limiting the study to those that have dropped out in the past year. In general, the large amount of unique and individual responses that failed to form into coherent themes could be a reflection of a recovery state—whereby behaviour and experience look less similar than when in an illness state when variation tends to narrow into definable processes—the range of the morbid being narrower than the range of the non-morbid (Palmer, 2003
). However, it may also reflect a true variation in the needs of individuals at the time of their treatment and implicates the need for individualized care, and collaborating with the patient to foster a sense of autonomy in standard clinical practice.