Aspects of self concept and eating disorder recovery what

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Journal of Social and Clinical Psychology, Vol. 29, No. 7, 2010, pp. 821-846

SELF-CONCEPT AND EATING DISORDER RECOVERY BARDONE-CONE ET AL.

Aspects of Self-Concept and Eating Disorder Recovery: What Does the Sense of Self Look Like When an Individual Recovers from an Eating Disorder?

Anna M. Bardone-Cone University of North Carolina at Chapel Hill

Lauren M. Schaefer University of South Florida

Christine R. Maldonado University of Missouri

Ellen E. Fitzsimmons and Megan B. Harney University of North Carolina at Chapel Hill

Melissa A. Lawson, D. Paul Robinson, Aneesh Tosh, and Roma Smith University of Missouri School of Medicine

This research examined the relations between aspects of self-concept and various stages of eating disorder recovery. Individuals formerly seen for an eating disorder at a Midwestern clinic were categorized as having an active eating disorder (n = 53) or as partially recovered (n = 15) or as fully recovered (n = 20) using a comprehensive recovery definition whereby full recovery included physical, behavioral, and psychological recovery and partial recovery included only physical and behavioral recovery. The self-concepts of these groups were compared to each other and to 67 controls. The fully recovered group had higher self-esteem, higher

The research reported in this article was supported by the following grants to Anna M. Bardone-Cone: NIH 1 R03MH074861-01A1, University of Missouri PRIME Grant, and University of Missouri Research Council Grant.

Correspondence concerning this article should be addressed to Anna M. BardoneCone, CB #3270 Davie Hall, Department of Psychology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599. E-mail: bardonecone@unc.edu. 821

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self-directedness, and lower levels of the imposter phenomenon than individuals who were partially recovered or those who met criteria for an eating disorder, as well as higher self-efficacy than the active eating disorder group. Fully recovered individuals also looked better in terms of specific domains of self-concept (e.g., intimacy, sociability, etc.) when compared to the active eating disorder group. Results provide evidence that fully recovered individuals were comparable to controls on all measures of self-concept. Partially recovered individuals, however, were more similar to active eating disorder cases, suggesting that improved self-concept may be an integral part of full eating disorder recovery. Additionally, these results provide further support for a more comprehensive definition of recovery which acknowledges the psychological aspects of an eating disorder.

Self-concept disturbances have been theoretically posited as core vulnerabilities for the development and maintenance of eating disorders, as well as for relapse (Bruch, 1981; Daley, Jimerson, Heatherton, Metzger, & Wolfe, 2008; Stein & Corte, 2003). For example, researchers have found that the presence of relatively few positive and more negative self-schemas may be predictive of eating pathology (Stein & Corte, 2007); further, low self-esteem has been associated with poor outcome and relapse in a one-year follow-up of individuals with bulimia nervosa (Fairburn, Peveler, Jones, Hope, & Doll, 1993). Qualitative work also supports an important relation between self-concept and disordered eating, with women in recovery from an eating disorder describing reaching self-acceptance, as well as cultivating and maintaining a sense of self-worth, as critical to attaining and maintaining recovery (Federici & Kaplan, 2008; Patching & Lawler, 2009; Vanderlinden, Buis, Pieters, & Probst, 2007). Those who relapsed identified self-criticism and a pervasive sense of worthlessness as factors hindering their recovery (Federici & Kaplan, 2008). Thus, it appears that a more sustained recovery is more likely among individuals with improved self-concept. Conversely, if self-concept disturbances, such as low self-esteem, persist following recovery of an eating disorder, risk for relapse may be heightened (Daley et al., 2008).

How might ongoing self-concept disturbances contribute to relapse? Those no longer meeting criteria for an eating disorder but with low self-esteem may be at risk for returning to a focus on appearance (and concomitant behaviors, such as dietary restriction for weight loss) as a way to boost self-esteem (Anderson & Maloney, 2001). And recovery with a lingering sense of ineffectiveness (low self-efficacy) may result in small slips via eating disordered behav-

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iors or thoughts snowballing into a more serious return of eating pathology because the individual lacks confidence in her abilities to maintain recovery. Also, given that one's self-image guides behaviors in social interactions and can elicit behaviors that confirm the self-image (Birgegard, Bjorck, Norring, Sohlberg, & Clinton, 2009; Jones, 1986), a poor self-image may generate behaviors that reinforce the negative view of the self, resulting in negative affect which is a robust risk factor for eating pathology (Stice, 2002). In the current study, we investigate what the self-concept looks like at different stages of an eating disorder, with particular interest in how those fully recovered from an eating disorder experience the self.

Components of Self-Concept

From a cognitive perspective, self-concept can be defined as "a set of knowledge structures about the self" (Stein & Corte, 2007, p. 59) and encompasses a wide range of constructs (Baumeister, 1999). While these sets of structures may come together to reflect one underlying self-concept, it is informative to look at various aspects of self-concept separately given that they have conceptual differences and that there may be different ways to target these aspects in intervention and prevention approaches. According to Markus and Wurf (1987), self-concept represents a dynamic multifaceted construct, rather than a unitary undifferentiated structure. Self-representations that comprise the self-concept are not all alike; some may be more positive, more negative, more salient, more predictive of future behaviors, or more accurate than others (Markus & Wurf, 1987). Indeed, researchers and clinicians alike have found great utility in parsing out various aspects of self-concept to further elucidate their significance in both the etiology and treatment of eating disorders (Fairburn, 2008; Halvorsen & Heyerdahl, 2006; Jacobi, Paul, de Zwaan, Nutzinger, & Dahme, 2004; Wilson, Fairburn, Agras, Walsh, & Kraemer, 2002; Wonderlich et al., 2008).

The particular aspects of self-concept chosen for examination in this study are those with support for therapeutic relevance in the eating disorders (self-esteem, self-efficacy, and self-directedness) as well as the imposter phenomenon, which is a conceptually compelling, but understudied, way to look at the self. In brief, self-esteem involves an evaluative element and sense of worth, and can be measured globally (e.g., overall, I think I am a pretty good person), as

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well as in specific domains (e.g., I think I'm a good worker). Selfefficacy is the aspect of self-concept that links the self to agency and control (Bandura, 1977; Baumeister, 1999), with individuals high in self-efficacy feeling confident in their abilities to do what is necessary to attain their goals. Relatedly, the concept of self-directedness refers to self-determination and the ability to control, regulate, and alter behavior as needed in pursuing goals (Cloninger, Svrakic, & Przybeck, 1993). Self-directedness also reflects self-acceptance, personal responsibility, resourcefulness, and the perception of the self as integrated and autonomous (Cloninger et al., 1993). Yet another way of studying self-concept is to examine the degree to which individuals experience the self as false, in particular feeling that others see them as competent (exterior self), while they themselves feel inadequate (interior self). This construct has been referred to as the "imposter phenomenon" and "perceived fraudulence" (Kolligan & Sternberg, 1991).

These self-concept constructs have been implicated in therapeutic change in the eating disorders. For example, Fairburn's (2008) "enhanced" version of cognitive behavioral therapy for eating disorders (CBT-E) includes a module targeting low self-esteem, conceptualized as an obstacle to recovery. Additionally, there is evidence that self-efficacy mid-treatment is a mediator of change in eating disorder symptomatology (Wilson et al., 2002) and that increases in self-directedness from pre- to post-CBT are associated with improved eating psychopathology (Grave, Calugi, Brambilla, AbbateDaga, Fassino, & Marchesini, 2007).

Research on the Self and Eating Disorders

There is substantial support for eating disorders being associated with low self-esteem (Gual et al., 2002; Jacobi et al., 2004; Peck & Lightsey, 2008). Regarding the recovery process and self-esteem, there is some support for individuals in remission from bulimia nervosa (BN), defined as the absence of eating disorder symptoms (e.g., binge eating, purging) for six months, having self-esteem scores that are significantly higher than those with current BN, but significantly lower than healthy controls (Daley et al., 2008). In contrast, Blaase and Elklit (2001) found that individuals recovered from an eating disorder were comparable to healthy controls on measures of selfesteem. While little work has examined domain-specific self-esteem

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in relation to eating disorder recovery, there is some evidence that compared to symptomatic individuals, those recovered from BN at an 18-month post-treatment assessment reported greater social selfesteem (Troop, Schmidt, Turnbull, & Treasure, 2000).

Self-efficacy also has a long-standing relationship with eating disorders, with historical reports identifying low levels of self-efficacy as a striking feature of eating disorder patients (e.g., "paralyzing sense of ineffectiveness;" Bruch, 1962, p. 191) and research finding that eating disorder individuals report greater levels of personal ineffectiveness and lower general efficacy compared to healthy controls (Etringer, Altmaier, & Bowers, 1989; Jacobi et al., 2004; Peck & Lightsey, 2008; Wagner, Halmi, & Maguire, 1987). Studies assessing ineffectiveness and eating disorder recovery have yielded mixed results with some studies finding no differences between individuals recovered from an eating disorder and controls (Brambilla et al., 2003; Lilenfeld et al., 2000) and other studies finding that recovered individuals reported a greater sense of ineffectiveness than controls (Kaye et al., 1998; Stein et al., 2002). There is also some evidence for the prognostic value of ineffectiveness; high initial ineffectiveness has been associated with poor prognosis for patients with anorexia nervosa (AN; Bizeul, Sadowsky, & Rigaud, 2001).

Self-directedness appears to be low across all eating disorder types (Cassin & von Ranson, 2005). Klump et al. (2004) found that women with current eating disorders and women recovered from an eating disorder scored significantly lower on self-directedness than controls. However, other work has found that individuals fully recovered from an eating disorder have significantly higher levels of self-directedness when compared to those partially recovered or with an active eating disorder (Bloks, Hoek, Callewaert, & van Furth, 2004; Bulik, Sullivan, Fear, & Pickering, 2000). From a prediction perspective, pre-treatment and end-of-treatment self-directedness appear to predict symptomatology in AN patients (Bloks, Hoek et al., 2004).

Although minimal research exists on the imposter phenomenon and eating disorders, this construct is conceptually compelling since individuals with eating disorders often strive to conceal their disordered eating behaviors (e.g., binge eating, vomiting, extreme restriction), which may contribute to a disconnect between their public and private selves. Striegel-Moore, Silberstein, and Rodin (1993) found that women with BN reported greater perceived fraudulence than a nonclinical group with elevated eating disorder symptoms,

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who in turn reported more perceived fraudulence than controls. To our knowledge, no research has examined the imposter phenomenon across stages of recovery.

Defining Eating Disorder Recovery

The findings reviewed related to recovery must be understood within the context of how recovery from eating disorders has been defined. Until recently, the established norm has been to define recovery based on physical measures (e.g., weight, menses) and behavioral measures (e.g., no binge eating) with no explicit assessment of psychological aspects related to eating disorders (e.g., how individuals think about food, eating, and their bodies). Indeed, most of the work reviewed that included a recovery group did not include a psychological piece of recovery. Not assessing psychological recovery may produce a pseudorecovery state (Keski-Rahkonen & Tozzi, 2005) where individuals are walking the walk but internally talking the same eating disordered talk. The presence of lingering eating disorder attitudes is not trivial, since elevated anorexic attitudes and residual concerns about weight and shape predict relapse (Carter, Blackmore, Sutandar-Pinnock, & Woodside, 2004; Channon and deSilva, 1985; Federici & Kaplan, 2008). Indeed, some researchers note that presence of residual symptoms, including body image disturbance, among those "recovered" from an eating disorder may reflect an inadequate definition of recovery (Keel, Dorer, Franko, Jackson, & Herzog, 2005).

Building on work by Couturier and Lock (2006) and Bachner-Melman, Zohar, and Ebstein (2006), we propose a definition of eating disorder recovery that uses physical, behavioral, and psychological criteria, and that has been validated using other disordered eating measures (Bardone-Cone et al., 2010). According to our definition, individuals who no longer meet criteria for an eating disorder are fully recovered if they have a body mass index of at least 18.5 kg/ m2, exhibit no binge eating, purging, or fasting in the past three months, and score within 1 SD of age-matched community norms on all subscales of the Eating Disorder Examination-Questionnaire (EDE-Q; Fairburn & Beglin, 1994). In contrast, a partially recovered group will be defined as exhibiting physical (BMI) and behavioral (no binge eating, etc.) recovery, but not psychological recovery (one

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