This issue has come up enough times that I want to address it on the blog. Recovery is a very tough process and many folk simply have to navigate it alongside keeping a roof over their heads and I will address that process in another blog post in the future. For this post I want to focus on just those navigating college or university while attempting to get to remission from an active eating disorder.
In most cases, these individuals have not developed active restrictive behaviors for the very first time when entering their first year of university. Perhaps some have actually been in and out of inpatient care during middle or secondary school, or have been in and out of university due to medical crises associated with active restrictive behaviors as well. Given that these scenarios are the most common ones, I’ll address them.
Determination and willpower have almost no bearing at all on getting to remission from an eating disorder, and going it alone will make your chance of ultimate success vanishingly small.
If you want to remain in university while recovering then you will want to develop a very detailed plan of what you will implement this time that is different from how you might have tried to balance coursework and recovery in the past.
You know the old adage—doing exactly the same things and expecting a different result is the definition of madness—so you have to conscientiously choose to apply different things this time around.
One of the most corrosive aspects of living with a chronic condition of any kind (including eating disorders) is to assume that your conscious mind has the wherewithal to overcome its existence in your life. The rebound effect of inevitably failing to “power through” has you falsely attributing your failure to your lack of determination and willpower. That stokes the fires of self-loathing and removes you from any self-compassion. Self-compassion is needed far more than determination and willpower when it comes to getting to remission and staying there.
I talk about self-compassion, and refer to Dr. Kristin Neff’s research on the topic often, but what is self-compassion really? Self-compassion presumes a pre-existing foundation of compassion. If you tend not to have compassion for others, then it would be tough to develop the skill towards yourself. With the exception of psychopaths, most of us experience genuine compassion towards others on some level. We will all tend to outwardly express compassion to others, but our inner dialogue might diverge from that outer shell of appropriate behavior. To develop self-compassion, you have to connect to the compassion you inwardly feel towards another (be it an animal, a child, a specific loved-one…). In other words, if you are busy outwardly comforting a friend who has just lost her job, but you inwardly believe she deserved to be fired as she was constantly arriving late, then that puts you in an inner judgmental frame of mind and does not reflect genuine compassion. You need to think about a time where you really believed a bad thing happened to a completely undeserving person or creature.
You have done nothing to deserve an eating disorder and at the same time you are not its helpless victim either. That’s actually a really important dialectic to accept before you can address a recovery effort, and that’s what self-compassion is all about. We are so used to the “war on” rhetoric that we have internalized it to the point that our only job is to “beat” the chronic conditions we might develop. We give no room to anyone in our society to feel sad, angry, frustrated or hard done by when they are unlucky enough to develop any chronic condition. And these violence analogies mean that any kind of realistic adjustment or retreat in order to realize remission of the condition is viewed as a weak surrender assuring that person’s failure in all things from that point forward. We are all supposed to slap on a crazed grin, scream bloody murder and flail away at a regular existence until we vanquish the condition by the sheer force of our gory determination.
No, no and nope. It won’t work. What follows are some suggestions to review with your treatment team or therapist if you remain undeterred and plan to stay at school while trying to navigate a recovery effort to remission.
First up, it’s best to go to the campus mental health services to get a referral to a therapist who offers cognitive behavioral therapy (CBT) and is familiar with motivational interviewing (MI) and exposure and response prevention (ERP). If your family has the wherewithal, you can always go off campus to see a private therapist as that way you may have more choice for finding one you like.
Being convinced that this time you are ultra-committed and you are really, really tired of self-administered starvation will get you only a few weeks into re-feeding and resting. And then, as per usual, the anxiety will start to mount as you keep dependably approaching and eating food. Without a therapist or counselor to help teach you how to keep approaching and eating food even as the anxiety mounts, you will relapse at that point.
A word of caution if you use mental health services on campus: it’s best to indicate you do not want a referral to a psychiatrist* and you do not want any prescriptions for psychoactive drugs (i.e. antidepressants and the like). If you are already on such prescriptions, then don't come off them; but if you are not currently taking such drugs then they are inferior for the treatment of eating disorders when compared to numerous psychotherapeutic options (but they are still zealously prescribed for patients with eating disorders, so just be aware of that). 1
Second up is the challenge of resting. You should be exhausted. Getting to classes and grinding through study and assignments will be exceedingly tough. Full blown recovery efforts are actually very isolating for quite some time—recovery is such an all-consuming effort of healing that your life consists of eating and sleeping for quite a few months. Any social interaction tends to come at a price (meaning you feel more exhausted after socializing) and if you are naturally an extravert, then this period in recovery is doubly hard. And within a university setting, where socializing is an integral part of the undergrad experience, you will find your isolation really burdensome, or you will try to maintain social contact and thereby compromise your recovery effort.
Eating and resting in recovery really is a full-time job. If you don’t feel as if you’ve been hit by freight train’s worth of aches and exhaustion, then chances are the eating disorder is still running the show. Many believe they do not have the option to disconnect from their studies and for some the reasons might even be valid. However, for many more the reasons are the result of wishful thinking and denial.
I would encourage anyone facing this decision to take a moment to be brutally honest about whether they are squeezing their eyes shut because they don’t want to make a tough but necessary decision. If you already have prior withdrawals from your studies due to relapse, then it’s not likely going to be “second or third time's the charm” because unlike the stock market, human past behaviors are indeed predictive of future behaviors.
So were I in your shoes (and I’m not, so take this with a huge grain of salt), I would be dispassionately pruning my decision tree to maximize the true order of my priorities. Firstly, I am in school not as an end-state; it’s a path towards some long-term interests and perhaps a future career I have in mind. Secondly, without an eating disorder fully in remission, then my future is at risk every step of the way (not just in school, but more importantly with my long-term career goals and interests). Thirdly, as per past experience, I have rapidly relapsed upon returning to university. Now what?
With that clear in my mind, I’d gather my posse to discuss next steps. I’d talk to my parents, my doctor, my past therapist and trusted friends who have watched me struggle with this condition in the past. I’d ask for their opinion on what they think would be my best way forward. I’ll get lots of conflicting advice and input (of course) and then I’d use my instincts to sift through their observations.
Chances are pretty good that your trusted advisers would recommend medical dispensation from university so you can focus on your recovery effort. However, our loved ones will always rate our safety well above our autonomy because, well, they love you and want you around. It’s still okay to go against their advice if your instincts are telling you that, but by incorporating their opinions you can find ways to up your chances of success.
Consider using contracts with your parents and your therapist as a way to keep yourself well away from the wishful thinking that spirals into relapse. You’ll find an example of such contracts on mirror-mirror.org. Of course, if you intend to use the Homeodynamic Recovery Method then you will be using the minimum intake guidelines that match doubly-labeled water method confirmed intake levels for age, sex and height matched healthy controls, and you will not be involved in athletics, team sports or exercise (see: here, here and here.). And you're also fully aware that the minimum intake guidelines are not the expected intake if you hope to reach remission, you will need much more than minimum intake of course.
Develop your relapse reversal intervention kit (explained in more detail in the Recovery Journal) as a physical memento box that stores treatment team contact information, meal plan requirements, letters to yourself explaining your reasons for needing remission, etc.
Write out what your weekday and weekend routines look like. You are looking to create a step-by-step how-to daily plan that ensures you are eating all day long and sleeping when you are not in class or studying. If your completed plan is not unappealing, then chances are you are not being realistic enough, so go through what you think you can accomplish with your therapist to get a solid second opinion.
It’s okay to try and it’s okay to fail. The only thing that isn’t okay is denying the risks of living with an active and untreated eating disorder. Having your autonomy is never worth your life so listen to your loved ones and friends if they are telling you that it’s time to step back and work on your recovery full-time.
*Psychiatrists are an absolute necessity for the diagnosis of eating disorders and I am not suggesting they are not helpful in the treatment of eating disorders, they are. But rather than receiving a referral to one via an on-campus mental health services facility, consider discussing options with your medical doctor and family first.
1. Peterson, Carol B., and James E. Mitchell. "Psychosocial and pharmacological treatment of eating disorders: a review of research findings." Journal of clinical psychology 55, no. 6 (1999): 685-697.