Topic 7 assessment

Journal of Clinical Sport Psychology, 2018, 12, 595–613 https://doi.org/10.1123/jcsp.2018-0030 © 2018 Human Kinetics, Inc. ORIGINAL RESEARCH

Turning the Corner: A Comparison of Collegiate Athletes’ and Non-Athletes’

Turning Points in Eating Disorder Recovery

Jessyca N. Arthur-Cameselle Western Washington University

Molly Curcio William James College

The purpose of this qualitative study was to identify turning points in eating disorder recovery in collegiate female athletes compared to non-athletes. The sample included 12 varsity athletes and 17 non-athlete college students who previously met criteria for Anorexia Nervosa (AN; n = 17); Bulimia Nervosa (BN; n = 3); Binge Eating Disorder (n = 1); or both AN and BN (n = 8). Participants completed individual interviews and responses were analyzed inductively. There was some commonality in the athletes’ and non-athletes’ experiences. For exam- ple, the most frequent turning point for both groups was Insight/Self Realization. Regarding the next three most frequent turning points, athletes reported Sport Performance, Confrontation, and Support/Concern from Others, whereas non- athletes reported Professional Treatment, Hitting a Low, and Support/Concern from Others. This study contributes to the sparse literature on competitive athletes’ recovery. Results indicated that athletes’ turning points differed from non-athletes; therefore, findings are discussed concerning athlete-specific treatment recommen- dations and suggestions for coaches.

Keywords: anorexia, bulimia, motivation, sport, tipping point

It is evident that competitive athletes experience clinical eating disorders (EDs). Out of the broader athlete population, research has demonstrated fairly consistently that female athletes are at higher risk for EDs and disordered eating than male athletes (e.g., Giel et al., 2016) and that athletes who compete in weight- sensitive sports are at higher risk than those from ballgame sports (e.g., Krentz & Warschburger, 2011). There are no known studies that report athlete-specific treat- ment and recovery rate data; however, literature reviews on general ED popula- tions indicate that treatment is only effective for roughly 50 to 70% of individuals with EDs (e.g., Keel & Brown, 2010). For those with Anorexia Nervosa (AN),

Arthur-Cameselle is with the Health and Human Development Department, Western Washington University, Bellingham, WA. Curcio is with the Clinical Psychology Department, William James College, Newton, MA. Address author correspondence to Jessyca N. Arthur-Cameselle at Jessyca. [email protected].

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there may even be strong reluctance to recover (Nordbø et al., 2012), yet it is clear that motivation and readiness for change predicts success in ED treatment (Clausen, Lubeck, & Jones, 2013). Thus, researchers have sought to better under- stand what motivates women to recover and why some are able to begin recovery.

Due to the complex and personal nature of ED recovery, qualitative methods are well suited to explore the topic. Indeed, there is now a large body of qualitative studies on the emotional, personal, and social experiences of (non-athlete) women who have recovered (e.g., Linville, Brown, Sturm, & McDougal, 2012). Though many studies have explored the process and course of recovery, far fewer have focused specifically on the initial motivation to begin recovery. This initial period in the recovery process is referred to in the literature as a turning point or tipping point, described as the “point at which the illness trajectory is interrupted” (Fogarty & Ramjan, 2017, p. 2) so that “the balance finally tipped in favor of pursuing recovery as opposed to continuing with the illness” (Dawson, Rhodes, & Touyz, 2014, p. 499).

Previous qualitative studies on non-athlete female samples have provided information about turning or tipping points as part of broader studies on the entire recovery journey. For example, through interviews with 48 women (average age 27.6) with a variety of EDs, Pettersen and Rosenvinge (2002) found that motiva- tion to recover was most often due to “the desire for a better life” (p. 65) in addition to experiencing negative consequences from the ED. Similarly, Redenbach and Lawler (2003) reported that their five participants (ages 24–51) initiated recovery following physical or medical complications, the desire for an improved life, self- determination, and self-acceptance. Also through interviews, D’Abundo and Chally (2004) found that their 17 participants’ (ages 17–46) ED symptoms esca- lated until the disorder controlled their lives and compromised their health, which was followed by acceptance of each of the following: the ED, others, and spiri- tuality. The nine participants (ages 19–48) in Lamoureux and Bottorff’s (2005) study also began recovery after acknowledging the dangers of AN. Likewise, Nilsson and Hägglöf (2006) reported that all of their 58 recovered participants (median age 30) could identify a turning point, which included negative medical consequences from the ED, new insights, or unexpected life events like a death of a friend. Overall, these studies indicate that participants often turn to recovery after a realization that the ED had compromised their quality of life.

More recent studies have revealed similar findings. For example, for 14 women (ages 23–26) who had recovered from Bulimia Nervosa (BN), turning points included self-realizations, opening up to others, hitting a low, and experienc- ing negative physical and social consequences (Lindgren, Enmark, Bohman, & Lundstrom, 2015). The researchers noted that for most participants, “a crisis or turning point was important to taking the first step” (Lindgren et al., 2015, p. 866). Similar turning points were reported by eight women (ages 31–64) who recovered fromAN, which included feeling exhausted, gaining insight into the function of the disorder, feeling more understood, and newfound agency (Dawson et al., 2014). Moreover, Linville et al. (2012) reported that, in their sample of 22 participants (ages 23–55) with a variety of EDs, recovery was sparked by a desire to repair key relationships. Finally, in narrative-discursive interviews with 14 recovered women (ages 19–49), Moulding (2016) found that participants’ turning points included finding a new sense of belonging, gaining insight into consequences of the

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disorder, becoming self-reliant, and cultivating a new identity. Taken together, these studies indicate that turning points are common, if not somewhat universal, in the recovery journey and that they consistently include internal shifts, acknowl- edging negative consequences of EDs, relationship changes, hitting a personal low, and increased self-reliance.

Only a few published qualitative studies have focused solely on turning points, providing more in-depth information about this early stage of recovery. Matusek and Knudson (2009) used co-constructed performance texts to explore the turning points of eight women, though they published only three participants’ accounts (ages 24–57). All three participants described involvement in some kind of larger cause, such as community events, political movements, or spiritual outlets; in addition, participants described internal turning points that occurred almost simultaneously, such as increased self-agency. The authors stated that treat- ment was not critical to participants’ recovery and instead suggested that starting recovery required holistic healing, with attention to community and spiritual connections, not only physical and emotional health (Matusek & Knudson, 2009). Activism or spiritualty reportedly moved participants’ focus away from internal self-criticism, providing a new sense of identity and a commitment to a larger purpose, which allowed them to leave the ED behind. Next, through analysis of 31 autobiographies by authors who had recovered from AN (ages 18–57), Hay and Cho (2013) found that all texts referenced a turning point, including increased self-regard, positive treatment experiences, new or improved relationships, as well as finding personal meaning in hobbies or activities unrelated to AN. Improved self-esteem was key to turning participants toward recovery, which was often a result of self-reflection that did not involve treatment. Like Matusek and Knudson (2009), Hay and Cho (2013) suggested that engaging with spirituality, as well as hobbies that encouraged participants to spend energy on things other than AN, tipped the balance to recovery. Most recently, Fogarty and Ramjan (2017) asked 67 women with AN (average age 25.11 years), via open-ended surveys, to “describe the turning point (or light bulb moment)” (p. 6) in their recovery. Common themes in the responses were: realization of the health consequences from AN, a loss or potential loss of life experiences, or the desire to be healthy for a specific purpose (e.g., becoming a mother). The authors stated that the women needed to lose something personally important before they were truly motivated to recover, yet that loss came in variety of forms depending upon the individual. Based on these more in-depth studies, turning points appear to be comprised of a mix of internal and external experiences, which regularly include a reprioritization of values that is not necessarily connected to experience in professional treatment. These studies also highlight that turning points are complex, demonstrating the importance of qualitative studies that capture rich data on multifaceted influences on recovery.

Though the above studies provide an understanding of turning points for non- athletes, there are few studies that examine any aspect of athletes’ ED recovery or treatment (e.g., Plateau, Arcelus, Leung, & Meyer, 2017) and only two studies, to our knowledge, that reference athletes’ turning points. First, for a male athlete with Bulimia, a serious injury that required him to leave competitive sport was the “key transition” that led to his recovery; specifically, leaving sport afforded him more free time to cope with life stressors (Papathomas & Lavallee, 2006, p. 165). In another qualitative investigation, Arthur-Cameselle and Quatromoni (2014a)

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interviewed 16 female collegiate athletes who had recovered from clinical EDs, inquiring about factors that initiated, assisted, and hindered their recovery. The most commonly reported factor that initiated recovery was negative consequences from the ED. Other turning points included an intervention, wanting a better quality of life, confiding in others, and improved self-esteem. Although these two studies provide some insight into athletes’ experiences, turning points were not the primary focus of either study; thus, very few participant quotes were included and implications of the turning point findings were not elaborated upon. Therefore, athletes’ turning points have not been explored thoroughly enough to understand their experiences or inform practitioners’ work.

At present, there are no published studies that have directly compared the turning points of athletes to those of non-athletes; yet, there are several reasons to expect that athletes may have unique experiences. First, past research indicates that athletes are a unique ED subgroup in that they experience sport-specific weight pressures including revealing uniforms, coach criticism, and team weigh- ins (e.g., Reel, SooHoo, Petrie, Greenleaf, & Carter, 2010). In addition, athletes have reported several sport-specific triggers for disordered eating and clinical EDs, including performance pressure, sport injuries, and changes in coaches (e.g., Arthur-Cameselle, Sossin, & Quatromoni, 2017; Papathomas & Lavallee, 2006, 2014; Sundgot-Borgen, 1994). Although non-athletes certainly experience pressures that contribute to EDs, such as academic pressure, they do not use their bodies for competition like athletes, which may differentially influence athletes’ food choices and eating behaviors. Based on evidence that socio-cultural factors influence EDs (e.g., Matusek & Knudson, 2009; Papathomas & Lavallee, 2014), it is also possible that athletes’ turning points, due to their interactions with coaches, teammates, and competitors within the social world of sport, may differ from non- athletes. Therefore, past non-athlete findings should not be assumed to apply to athletes. Given that motivation for recovery predicts treatment outcomes (Clausen et al., 2013), more precise knowledge of what tips athletes toward recovery could help to design more effective interventions for athletes. Moreover, it is of clinical interest to determine how athletes are able to achieve recovery while still within the competitive sport environment, with its sport-specific weight pressures and triggers. Of course, such information cannot be gleaned from past studies on non-athletes.

In addition, there is a need for turning point research on younger samples. As indicated above, most studies on turning points have utilized samples with a very wide variety in age, regularly including women between 30 to 50 years old, who arguably have much different life circumstances than typical competitive athlete samples, who are more likely to be in their teens and twenties. As such, it is unclear if insights from these studies are relevant for competitive college-aged athletes. Again, because social worlds influence turning points (e.g.,Matusek&Knudson, 2009)more homogeneous samples in terms of age and social environment are needed.

Finally, there is a need for research on clinical-level EDs in athletes. Although there are many studies on the efficacy of ED prevention programs for athletes (see Bar, Cassin, & Dionne, 2016 for a review) as well as in-depth analyses of dis- ordered eating in athletes (e.g., Papathomas & Lavallee, 2010, 2014), there is still relatively little information on athletes’ recovery from clinical EDs. Therefore, studies are needed that directly compare the recovery experiences of athletes with clinical EDs to a group of non-athletes who are similar in terms of other key

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demographics such as age, education level, and experience with treatment. If sub- group differences exist, such information could inform athletes’ clinical ED treatment as well as coach education programs.

In sum, there is a need for research on athletes’ turning point experiences, particularly since they report sport-specific ED onset triggers. Researchers have called for more in-depth understanding of the personal experiences of athletes with EDs (e.g., Papathomas & Lavallee, 2014). Yet, there remains a dearth of research on athletes’ turning points and relatively few studies on any aspect of recovery in athletes with clinical EDs. There is also a lack of research on turning points in young adults. Therefore, the purpose of this qualitative study was to identify turning points that initiated recovery from clinical EDs in a sample of collegiate female athletes compared to a group of non-athlete college student peers, to determine if any subgroup differences were evident. The inclusion criteria required that all participants were female college students, over 18 years old, who had experienced a clinical level ED for six or more months, had attended professional treatment, and had experienced at least three months of recovery. The focus of this study was on women because they more frequently experience EDs than men (American Psychiatric Association [APA], 2013) and because there is a more much substantial body of previous research on female non-athletes’ tipping points. Thus, a focus on women in the current study allowed for a richer comparison of findings from this study to past research, which could help to elucidate any sport-specific findings in the current results.

Method

Participants

The sample included 29 women (12 varsity collegiate student-athletes, 17 non- athletes) who attended colleges on the east coast of the United States. They were, on average, 20.1 years old (athletes’ mean = 20.5 years; non-athletes’mean = 19.8 years) and identified as White (n = 28) or Hispanic/White (n = 1). Athletes com- peted in varsity sports at the Division I (n = 10) or Division III (n = 2) levels of the National Collegiate Athletic Association (NCAA) in track& field and cross-country (n = 4), track & field only (n = 4), basketball (n = 1), crew (n = 1), soccer (n = 1), or tennis (n = 1). Participants previously met Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) criteria for Anorexia (AN), Bulimia (BN), or Binge Eating Disorder (BED) and all had attended professional treatment. The athletes previously experienced AN (n = 8, 66.7%), BN (n = 2, 16.7%), or AN fol- lowed by BN (n = 2, 16.7%); the non-athletes previously met criteria for AN (n = 9, 53%), BN (n = 1, 6%), BED (n = 1, 6%), or AN followed byBN (n = 6, 35%). At the time of the interview, all participants were in a self-defined period of “recovery” and also no longer met DSM-5 criteria for any ED. On average, the athletes’ recovery period was 10.4 months long and non-athletes’ recovery was 14.4 months long.

Procedure

Participants were recruited for a two-part interview study. They were initially located through fliers posted on college campuses on the East Coast of the United

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States as well as emails to athletic directors. All procedures received institutional ethical approval and participants provided informed consent. The first author, a licensed psychologist, conducted all interviews and confirmed by way of diag- nostic questions that participants previously had met DSM-5 criteria (APA, 2013) for an ED and that they no longer met criteria for any ED. They then responded to questions for a study regarding the onset of EDs (Arthur-Cameselle et al., 2017). All participants who completed the portion of the interview related to ED onset continued to respond to questions for the current investigation on turning points. Therefore, the researcher had already established rapport and had an understanding of the circumstances associated with the onset of each participant’s ED before exploring turning points.

For this study, the interview was semi-structured and began with open-ended questions about the duration and details of the participants’ symptoms. After describing their ED history, most participants spontaneously began talking about what initially motivated their recovery. If they spontaneously discussed a turning point, the interviewer encouraged elaboration and followed-up with neutral probes for additional details and reflection. The first follow-up probe was, “What do you think helped you to begin recovery at that time?” and after participants had appeared to finish responding they were asked, “Were there any other things that contributed to your recovery starting at that time?” If participants finished dis- cussing symptoms without talking about turning points, the interviewer asked them to describe any turning points, which were defined using the description from Dawson et al. (2014, p. 499). The interviewer used the same follow-up probes with all participants. Otherwise, the interviewer allowed participants to tell their stories at their own pace and interjected only for points of clarification.

Interviews ranged from 29 to 44 minutes for this portion of the research (64 to 78 minutes total for both segments). Each interview was recorded and transcribed verbatim; only filler words such as “um” and “like” were removed. All partici- pants were offered their interview transcript and were asked to report any inac- curacies; none requested changes. Despite claims that there may be limited utility in sending participants their transcripts to enhance data analysis (Thomas, 2017), we believed it demonstrated respect for participants and displayed our commitment to informed consent. Past researchers have sent transcripts for similar reasons (Thomas, 2017).

Data Analysis

We used the inductive coding protocol outlined in Consensual Qualitative Research (CQR) for analysis (Hill et al., 2005; Hill, Thompson, Williams, 1997), which is recommended for research on psychological experiences. The research team included the primary author, who is a licensed psychologist and professor, as well as two senior undergraduate student researchers (one man, one woman) who had completed coursework in abnormal psychology, sport psychology, and re- search methods. The primary author trained them in CQR and the team completed practice coding on sample data prior to this analysis. In line with CQR protocol, we set inclusion criteria at the outset of the study, did not begin analysis until all interviews were complete, did not use a theory to frame the analysis, and made all coding decisions by consensus.

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Each member of the research team inductively coded responses individually. We then met to discuss coding decisions. When the research team has undergrad- uate coders, Hill et al. (1997) suggest taking steps to minimize power differentials; therefore, we used a rotation system so that for each new segment, a different researcher began the discussion and shared their coding decisions. After discus- sion, we achieved consensus before assigning a final code. Our initial analysis resulted in 53 turning point codes. We used the constant comparison method (Strauss & Corbin, 1998) to condense the codes to 11 themes that we then grouped into four superordinate categories (see Table 1). As is typical in CQR, we reported the frequency of each coded theme.

Trustworthiness

We attempted to enhance the trustworthiness of the analysis throughout the study. First, there were no interview questions about the role of sport or being an “athlete.” In addition, participants were not aware that the analysis included a comparison of athletes to non-athletes. Therefore, the interviewer did not prime the athletes to discuss the influence of the sport environment. Moreover, the same non- leading follow-up probes were used for all participants. Next, we used low infer- ence coding to stay as close to participants’ words as possible. Finally, there was evidence of data saturation in both subgroups, indicating adequate sample size.

Results

All participants described multiple turning points. Broadly, all themes were classified as either an Internal or External turning point. Those categories were

Table 1 Themes to Describe Participants’ Turning Points Toward Eating Disorder Recovery

Superordinate Themes Related Sub-Themes

Internal/Autonomous Shifts Insight/Self Realization (A = 92%, NA = 82%)

Diet/Exercise Changes (A = 0%, NA = 29%)

Internal/Acknowledging Consequences

Hit a Low (A = 33%, NA = 41%)

Sport Performance (A = 50%, NA = 12%)

Medical Consequences (A = 25%, NA = 12%)

External/Direct Influences Others’ Support/Concern (A = 50%, NA = 41%)

Treatment (A = 17%, NA = 65%)

Intervention (A = 50%, NA = 24%)

ED Role Model (A = 0%, NA = 24%)

External/Indirect Influences Environment Change (A = 17%, NA = 24%)

Relationship Changes (A = 0%, NA = 12%)

Note. The percentage of participants who reported each theme is reported for athletes (A) and non- athletes (NA). The percentages for each subgroup total to over 100% because each participant’s narrative included at least two themes.

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further delineated into four superordinate themes, with 11 related sub-themes (see Table 1). The frequency that each theme was mentioned by athlete (A) and non- athlete (NA) participants is included for comparison.

Internal Turning Points: Autonomous Shifts

Nearly all participants’ narratives included the role that their own autonomous, self-determined shifts played in initiating recovery. In fact, the most frequently identified theme across all participants’ transcripts was the fact that a new Insight or Self-Realization (A = 92%, NA = 82%) about the role of the ED in their life, their sense of identity, or their priorities acted as a turning point. A non-athlete (p#11) recalled the distinct moment she committed to recovery:

I’m looking around my room and I have posters of these gorgeous women and I had tacked to my wall all of my favorite little exercise things that I had ripped out of Cosmo and I was just like, “I hate this. This isn’t fair.” : : : I just got mad at society for making women feel this way. And it was just this decision that for all of womanhood, I need to beat this : : : and I remember that I refused to let [the ED] win from that moment forward.

Three non-athletes reported that they had a realization that they would rather put their energy into causes like animal rights and veganism instead of an ED. As such, becoming a vegan helped them to adopt a new, healthier identity that they were proud of. For example:

I wanted to be a good advertisement for vegans. Because you are not going to promote veganism if you are like a sickly, tiny, little waif. You want to be healthy and strong so that people can see like, ‘Ok vegans can be healthy.’ (p#8)

Athletes also shared insights about reformed identity and a shift in their priorities that sparked recovery. A Division III runner who had restricted her food intake for a prolonged period in an effort to enhance her performance, explained that a turning point was realizing that:

I definitely didn’t want to be a person with an eating disorder : : : that’s not part of my identity : : : I started to really realize that I’m a really great person : : : There was just this moment of realizing that I’m not going to be running competitively for the rest of my life. To make choices that were, that are gonna really affect me, suddenly didn’t make sense anymore : : : I always will love running and I always will do it : : : I just realized that there’s nothing real at stake for me to be putting my whole body through it. (p #23)

The other autonomous shift for some non-athletes was making Diet or Exercise Changes (A = 0%, NA 29%). Self-determined changes like reduced calorie counting after becoming a vegan and varying one’s exercise routine to include activities other than running (e.g., weight training) served as turning points. For Participant #4, a diet change was key to starting recovery:

[After eating] milk and dairy products I would either throw up, get diarrhea, get nauseous and bloated : : : So, associated with the lactose in my diet, I was

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getting very bloated, which made me look bigger, which made me want to not eat. As soon as [I] cut lactose out : : : the bloating went down and I wasn’t having problems anymore : : :That was a turning point.

Internal Turning Points: Acknowledging Negative Consequences

For almost all participants, acknowledging the negative consequences from their ED was a crucial turning point; however, those consequences took various forms. More than a third of participants were not motivated to recover until they psy- chologically Hit a Low (A = 33%, NA = 41%). Responses in this theme included descriptions of depression, loneliness, or a sense of lost identity, which reached a point that was intolerable. A Division I tennis player (p#25) explained:

I was so, so unhappy. I just I thought a lot about running away. I thought a lot about hurting myself. I think that I realized one day that it was not going down a good path and so I told my mom. I was like, “I need to get help. I’m really scared of what I’m going to do to myself : : : .and I want to get better.” : : : bulimia was not working for me anymore.

A non-athlete similarly noted:

It was the first day of the New Year, and I remember turning to my mom and saying “I’m through with this : : : I cannot have this eating disorder anymore. It’s fucking up my life and I hate it.”And it was that point, exactly pivotal, like 360, I turned it around. (p#6)

In addition to awareness of negative psychological experiences, acknowledg- ing physical consequences also stimulated recovery. For example, reduced Sport Performance (A = 50%, NA = 12%) acted as a motivator. Two participants, who were not college athletes, said that their reduced performance in high school dance (p#1) or crew (p#21) motivated recovery, whereas half of the college athlete participants, from both the Division I (n = 5) and Division III (n = 1) levels, noted that concern about their sport performance in college was a turning point. A Division I soccer player (p#26) who had anorexia said, “I lost confidence and I played really small too.” Acknowledging that her reduced performance was due to being underweight and underfed was the critical turning point for her. She said, “It was just the harshest realization that probably saved my life : : : . I want to be strong” (p#26). A Division I distance runner (p#15) shared a comparable turning point after she was unable to compete due to AN, “I wanted to eat, to be stronger, to be able to run again.” A Division I track and field athlete similarly said:

I had no energy : : : I was always a power athlete, and I had no power. I could only do about 6 jumps in a training session, when I was used to doing over 30. And it was that moment that I just went, ‘no. I can’t do this [ED] any- more. I want to get back to where I was’ : : :That was definitely the turning point. (p#13)

A Division I basketball player described a key turning point in her recovery:

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I had a meeting with all four of my [college] coaches and we talked about my performance : : : and how disappointed they were and what a big impact I could have on the program : : : I hadn’t put two and two together that my performance had declined and my performance was directly correlated to my eating disorder. (p#20)

Finally, for some, it was negative Medical Consequences (A = 25%, NA = 12%) of the ED that acted as a tipping point. Being “cold all the time” (p#6, NA) due to weight loss and susceptibility to colds were most common. A Division I track and field athlete also shared:

I also got really sick to the point where : : : I got up to go to the bathroom and I almost passed out from dehydration and then my mom rushed me to the hospital : : : that was the main factor in me being like, ‘Ok. Maybe you should start eating more.’ (p#19)

External Factors: Direct Social Influences

Participants’ interpersonal relationships and interactions with others often included direct discussions about ED symptoms. For both subgroups, Others’ Support and Concern (A = 50%, NA = 41%) operated as a turning point. Participant #10, a non- athlete, noted that, “feeling that love and support [from my peers] is something that I don’t really feel like I got a lot of when I was younger, and I think that I really responded well to that.” Another shared her turning point:

The main thing that made me stop was my family and my friends, seeing my dad cry, seeing mymom cry : : : I loved these people too much, even if I didn’t love myself. I needed to suck it up because I couldn’t do it to them anymore. (p#16, NA).

Although all participants had attended treatment for their ED, Professional Treatment (A = 17%, NA = 65%) was only reported as a turning point for some. Non-athletes more commonly stated that they were not able to make progress toward recovery until they sought treatment or that, despite not being initially motivated or able to reduce ED behavior when they began treatment, a particular provider helped them to interrupt the ED cycle. For example, one non-athlete said, “the day I started treatment and got a plan of what to eat and became—started to become more healthy, that was the beginning of my recovery” (p#12). Another explained:

The point at which binging and purging started to not happen anymore was almost immediately after I started family therapy : : : It really amazed me, because it’s just talking. Talking to my mom candidly about emotions fixed things almost immediately. (p#18)

Although some participants sought treatment or began recovery on their own, others reported that a confrontation or Intervention (A = 50%, NA = 24%) from family, friends, or a coach was key to stimulating recovery. Interventions operated as either a wake-up call about the severity of their ED behavior or the intervention included an ultimatum, such as not being allowed to compete, which motivated

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participants to start treatment or recover. Several athletes were particularly influenced by interventions from their college coaches. One shared, “My coach just literally sat me down one day and he said, “Do you want to be back where you were [with elite sport performance]?” And I said, “yes.” And he said, “You won’t be unless you start eating” (p#13, Div. I, track and field). A Division I rower had not made any attempt to recover until:

[My coach] called me out on it, and we had multiple talks and he pointed out, “you’re losing weight. Your scores are going down. You take things too seriously. Maybe you need to see a therapist.” : : : all of this made me question what I was doing. (p# 28)

A final direct social influence was guidance, support, and a sense of universality provided byEDRecovered RoleModels (A = 0%,NA = 24%), whowerementioned only by non-athletes. Participant #2 said, “I started talking to my cousin : : : I had someone that was almost like a sister telling me that she had the same problem and I listened.” Joining Overeaters Anonymous was a turning point for Participant #5, who said it “changed my life : : : . It was never as bad because : : : I was able to be around other people that talked about food in the ways that I behaved.”

External Factors: Indirect Influences

A final superordinate theme was used for external events that indirectly became turning points. Some participants’ recovery was, in part, spurred by Environmental Changes (A = 17%, NA = 24%), such as moving out of their parents’ house or having a shared bathroom in college. For example, a Division I tennis player said that recovery began when, “I moved out of my house : : : I definitely could not get better in that environment” (p#25). A non-athlete who recovered from bulimia stated, “I didn’t really feel comfortable purging in [the suite bathroom] because someone might walk in” (p#21). Finally, for two non-athletes, romantic Relation- ship Changes (A = 0%, NA = 12%) stimulated recovery. Although their romantic partner did not directly discuss the ED, the relationship still offered a turning point. A non-athlete shared, “I started dating somebody and I wanted to be healthy enough to be in a relationship” (#14).

Subgroup Comparison of Turning Points

There were some commonalities in the subgroups’ themes. Both groups most commonly cited Insight/Self-Realization (A = 92%, NA = 82%) as a turning point and reported a relatively similar frequency of Others’ Support/Concern (A = 50%, NA = 41%) as well as Hitting a Low (A = 33%, NA = 41%). There were also several sub-group differences. Athletes were more than four times as likely to report that they initiated recovery because of desire to improve Sport Performance (A = 50%, NA = 12%) and twice as likely to cite an Intervention (A = 50%, NA = 24%) as a turning point. For non-athletes, it was much more common that Professional Treatment (A = 17%, NA = 65%) ignited recovery. In addition, there were three themes that were only present in non-athletes’ narratives, including: Diet/Exercise Changes (A = 0%, NA = 29%), EDRole Models (A = 0%, NA = 24%), and Relationship Changes (A = 0%, NA = 12%).

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Discussion

This study compared athletes’ and non-athletes’ turning points in the ED recovery journey. For clinicians who work with clients who are not motivated to recover or are not yet able to reduce ED behaviors, knowledge of turning points and what motivates change is critical in order to facilitate early recovery, especially given that longer duration of symptoms is related to worse long-term outcomes (Fichter, Quadflieg, & Hedlund, 2006; Reas, Williamson, Martin, & Zucker, 2000). The results of this study are novel in two ways. First, the findings shed light on young women’s experiences with turning points, as most studies have been conducted on older samples. Second, this is the first study to offer an in-depth analysis of athletes’ turning points in recovery.

In the overall sample, qualitative analysis of participants’ narratives yielded many similar themes to past non-athlete research, which has identified internal turning points like experiencing negative consequences from the ED (D’Abundo& Chally, 2004; Fogarty & Ramjan, 2017; Lamoureux & Bottorff, 2005; Lindgren et al., 2015; Moulding, 2016; Nilsson & Hägglöf, 2006; Pettersen & Rosenvinge, 2002; Redenbach & Lawler, 2003), hitting a low (Lindgren et al., 2015) as well as new insight or self-realizations, particularly about one’s identity or priorities (Dawson et al., 2014; Hay & Cho, 2013; Lindgren et al., 2015; Matusek & Knudson, 2009; Moulding, 2016; Nilsson &Hägglöf, 2006; Redenbach & Lawler, 2003). An external turning point from past studies that also appeared in the current results was the role of support or connection to others (D’Abundo & Chally, 2004; Dawson et al., 2014; Hay & Cho, 2013; Lindgren et al., 2015; Linville et al., 2012; Matusek & Knudson, 2009; Moulding, 2016). Some non-athletes in the current study also described shifting their identity to someone who spends their energy on animal rights and veganism, rather than an ED, which was similar to the identity changes described by Matusek and Knudson’s (2009) participants. However, contrary to past reports, participants in our study did not describe external turning points related to religion and spirituality (D’Abundo & Chally, 2004; Matusek & Knudson, 2009) or life events like the death of a friend (Nilsson & Hägglöf, 2006). It is possible that some of these differences are explained by the fact that many participants in previous studies were in their forties and fifties and therefore may have had quite different life experiences than our college-aged participants. Overall, our results align with past research on non-athletes in that turning points were not exclusively internal or external in nature; rather, several internal and external factors coalesced to tip the balance toward recovery.

Findings from the current study appear to be quite similar to results of the only other published studies that have referenced athletes’ turning points. Like Arthur- Cameselle and Quatromoni’s (2014a) participants, athletes in the current study reported that negative consequences of the ED, interventions, or a change in thinking were key turning points. Such similarities in findings indicate that these experiences for female athletes are somewhat consistent. However, the current study provided a more comprehensive analysis. For example, though Arthur- Cameselle and Quatromoni (2014a) indicated that negative consequences acted as a turning point, the current investigation further clarified that for athletes, reduced Sport Performance was the most common negative consequence (50%), as compared to Hitting a Low (33%) psychologically or general Medical

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Consequences (25%). In addition, perhaps because of more in-depth questioning, athletes in the current study were more likely to discuss key Self-Realizations (92%) that sparked recovery. Reprioritization of values, namely reclaiming their role as a strong and capable athlete, appeared critical for many athletes in this study to successfully begin recovery. Female athletes with disordered eating in past studies have similarly described internal conflict over the discrepancy between their disordered self and their athletic self (Papathomas & Lavallee, 2010). For half of the current athletes, acknowledging such discrepancy led to reclaiming their athletic identity through recovery. Reduced sport performance as a result of ED related behavior or weight loss appears to be a sport-specific form of loss, which supports Fogarty and Ramjan’s (2017) claim that personal loss may operate as a crucial turning point. In contrast to our finding on the importance of sport in sparking recovery, the male athlete in Papathomas and Lavallee’s (2006) case study indicated that leaving sport due to injury helped him to begin recovery, as he was better able to manage stress without the added pressures of sport. Given these differing reports, further investigations are needed to understand the role of athletic identity in ED recovery.

This study offers something novel to the literature on turning points in that our methodology allowed for a direct comparison of collegiate athletes’ and non- athlete college students’ experiences. Past research on athletes’ experiences with the onset of clinical EDs (Arthur-Cameselle et al., 2017) and recovery (Arthur- Cameselle & Quatromoni, 2014a, 2014b) have suggested that athletes may be a unique ED subgroup. The current study’s results align with such claims in that key subgroup differences emerged in athletes and non-athletes’ turning points. For example, after Insight/Self-Realization, non-athletes’ most frequent turning point was Treatment (65%) whereas athletes reported Sport Performance (50%), and Intervention (50%). Both of these factors, which were reported by athletes at both the Division I and III levels, included sport-specific elements. For example, all but one of the athletes’ Interventions was initiated by a coach. In addition, reflections about the key influence of caring coaches were also included under the Support/ Concern theme. These findings align with past research on the helpful role coaches can play related to athletes’ EDs (Sherman, Dehass, Thompson, & Wilfert, 2005). Unfortunately, non-athlete college students may not have someone who is in a similar position to intervene. It is important to note that the athletes were not prompted to discuss sport or being an athlete and were unaware of the study’s non- athlete comparison group, yet their narratives still contained a high frequency of sport-related themes; this suggests that athletes’ turning points meaningfully differ from non-athletes.

Given that all participants had attended treatment as per inclusion criteria, it is noteworthy that non-athletes (65%) were far more likely to have a turning point as a result of Treatment than athletes (17%). Similarly, ED Role Models were not influential for athletes (0%), yet 24% of non-athletes mentioned them. Perhaps these differences can be explained by findings from a recent study in which athletes reported that ED treatment programs were ineffective because their needs were different from their non-athlete peers and the staff did not address sport-specific ED triggers (Plateau et al., 2017). Based on this finding, in combination with our results, athlete-specific ED treatment may be most effective, particularly for group modalities.

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Moreover, the current results indicate that, because EDs threaten something that athletes highly value (i.e., sport performance), athletes may have intrinsic motivation for recovery and experience turning points prior to entering treatment, compared to non-athlete peers who were much more likely to report that they had a turning point while engaging in treatment. Although non-athletes in previous studies have mentioned that academic or work consequences from EDs were turning points (e.g., Lindgren et al., 2015), such effects were only reported by one non-athlete in the current study, who noted that feeling lightheaded from her AN made it hard to focus in class. Since shifts in identity appear key as turning points (Matusek & Knudson, 2009; Moulding, 2016), athletes may have an easier time transitioning their focus away from the ED, because they can shift back to the identity of being an “athlete” when they begin recovery.

Limitations

Though this study contributes to the small body of work on athletes’ recovery from EDs, several limitations were evident. First, we used convenience sampling, which could make our results vulnerable to volunteer bias. Also, there was an uneven sample size between the two subgroups. However, there was evidence of data saturation in both groups, thus indicating that the sample size was adequate. The smaller athlete sample is explained by the fact that the inclusion criteria were stringent; athlete participants had to be a varsity level collegiate athlete who had experienced a clinical ED, engaged in professional treatment, and had achieved a period of recovery. Based on the specificity of these criteria, the sample size of 12 can actually be viewed as a strength. In addition, our overall sample of 29 was also larger than many past studies on tipping points in non-athletes and we had a higher degree of homogeneity in participant experiences (particularly in age) than many past studies. However, the various ED diagnoses in our sample is an area of het- erogeneity that is a limitation. Although several previous studies on tipping points have used mixed ED samples (D’Abundo & Chally, 2004; Linville et al., 2012; Matusek & Knudson, 2009; Moulding, 2016; Pettersen & Rosenvinge, 2002), it would be preferable to focus on one disorder. We chose not to analyze the data broken down by ED diagnosis because eight participants (27.6% of the sample) had met criteria for two different eating disorders. Past studies indicate that people with AN often later meet criteria for BN (Keel & Brown, 2010), as has been the case in samples from previous studies on turning points (Moulding, 2016; Redenbach & Lawler, 2003). Finally, although all participants were in a period of recovery during their interviews, it is unknown if they will maintain long-term recovery.

Clinical Implications

The results of this study offer insight for practitioners who treat athletes with EDs. First, the current findings support past claims that athletes are a unique ED population (Arthur-Cameselle et al., 2017) in that their turning point patterns were in many ways distinct from the non-athlete comparison group. Next, it was evident that in order to turn the corner and actively pursue recovery, participants had to hit a threshold of internal frustration over the consequences of their ED while simultaneously having a supportive external environment. Specifically,

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internal motivation to recapture physical health and reclaim a more stable identity was nearly universal. For those who have not yet had a turning point, the results of this study indicate that Motivational Interviewing techniques (Miller & Rollnick, 1991) may be useful to help athletes to articulate the way that their ED affects their performance, which was a key motivator for our athlete participants. Indeed, past research indicates that motivation for change is predictive of ED treatment success (e.g., Clausen et al., 2013), thus raising motivation is critical. For clinicians and researchers who want to formally assess clients’ readiness for recovery, a recent study found that participants’ scores on the Eating Disorder Readiness Ruler (ED-RR), which assesses readiness for change, predicted decreases in ED symp- toms over time in treatment (St-Hilaire, Axelrod, Geller, Azanek-Antunes, & Steiger, 2017). A tool like the ED-RR, which appears to be appropriate for clients with AN or BN (St-Hilaire et al., 2017), could help clinicians to determine when to focus primarily on building motivation for change and when there may be suf- ficient client readiness to begin strategies to reduce maladaptive eating and exercise behaviors.

The results of this study indicate that athletes in need of treatment should be referred to a provider who is knowledgeable of the sport environment or to an athlete-specific ED group or inpatient treatment center (for those who require intensive care), given that sport performance was so often a turning point for recovery. This recommendation is supported by past evidence that participation in competitive sport is connected to the onset of EDs (Arthur-Cameselle et al., 2017; Sundgot-Borgen, 1994) and that athletes have been dissatisfied with treatment that does not acknowledge their athlete identity (Plateau et al., 2017). As such, athletes may benefit fromAcceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999), which encourages clients to identify personal values and refocus energy toward achieving goals that are in their control. This recommendation is supported by studies that have shown that ACT had slightly more positive effects than treatment as usual in a residential ED program (Juarascio et al., 2013a) and was more effective than standard cognitive behavioral therapy (CBT) in a ran- domized control trial (Juarascio, Forman, & Herbert, 2010). Researchers noted that ACT might be particularly effective for EDs, compared to CBT, because it more directly addresses motivational issues (Juarascio et al., 2010). Juarascio et al. (2013b) published group session outlines, which may be of use to practitioners who want to incorporate ACT into treatment. However, it should be noted that there are not yet studies on ACT in athlete samples.

Additionally, the results of this study highlight the critical role coaches can play in supporting athletes with EDs. As such, athletic departments should provide more training on the signs of EDs, particularly since past educational programs have effectively increased coaches’ knowledge on the topic (e.g., Martinsen, Sherman, Thompson, & Sundgot-Borgen, 2015). Clinical providers are encour- aged to build relationships with coaches and should offer resources to help coaches better understand EDs. For example, Selby and Reel’s (2011) guide for coaches offers ideas of how to interact with an athlete with a suspected ED, including the suggestion to avoid using the term “eating disorder”with them and to instead focus on concerns like the athlete not having “as much energy” as they used to (p. 107). The results of the current study certainly support this suggestion. Specifically, participants responded positively when coaches brought reduced performance to

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their attention. Notably, none of the athletes mentioned that their low body weight or appearance motivated their recovery. Thus, coaches’ comments about appear- ance or weight loss may be less effective than performance focused comments.

Conclusions and Future Directions

This is the first study to explore athletes’ turning points in ED recovery in com- parison to a non-athlete sample. The presence of sport-specific turning points, including sport performance and coach interventions, provides credence to past claims that athletes have unique ED recovery experiences (Arthur-Cameselle & Quatromoni, 2014a). Overall, the results suggest that although many internal, autonomous shifts help to tip the balance toward recovery, relationships are also critical. Thus, treatment providers and coaches can help athletes turn the corner to recovery.

Several important questions about athletes’ ED recovery remain. First, it would be useful to conduct studies that focus either on athletes with one ED diagnosis or competitors from one category of sport, such as weight-sensitive sports, to determine if differences emerge based on these demographic groups. Additionally, the extant literature includes relatively few studies on male athletes’ ED experiences. Knowledge of turning points could also be expanded by tracking athletes over time to determine if particular turning points, for example internal/ self-determined as compared to external/relationship, are associated with sustained recovery or are instead associated with relapse. In addition, since athlete parti- cipants in this study were motivated to recover because of reduced sport perfor- mance, it is important to determine how ED recovery is affected after retirement from sport. Retired collegiate swimmers with disordered eating reported that it took them a substantial amount of time to adjust to new caloric needs after their sport career was over (Cooper & Winter, 2017) and an elite female basketball player reported that her disordered eating worsened after leaving sport (Papathomas & Lavallee, 2014). Female athletes who recover from clinical level EDs may face similar challenges in retirement, but their experiences have not yet been explored. Finally, it would be of utility to interview coaches who have confronted athletes with EDs to better understand what leads to a successful intervention, as coaches are in a key position to help athletes with EDs tip the balance toward recovery.

Acknowledgments

We would like to acknowledge the work of Michael Alcaraz for his role as a member of the data coding team for this study.

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