Getting Ready to Recover from an Eating Disorder
First of all, it bears endless repeating: a starved brain is a profoundly malfunctioning organ. I have already spoken of this under the subheading Sensing Impairment in the post: Pro-ana and Pro-mia. The brain has no way to identify its own impairment. So you must take it absolutely on faith that if you are restricting food intake severely and/or creating severe energy deficits through excessive exercise or other compensatory behaviors, then you have to refeed first and foremost. If those around you are worried you seem out-of-it and unable to grasp the dangerousness of your current circumstance, then much as you are convinced you are fine, you have to accept you are not. Just as you would not drive home after a couple of drinks even though you “feel fine,” you have to undergo necessary structured treatment with medical help if those around you are telling you things are bad.
Heading into inpatient treatment is about medical stabilization as well as upping the intake enough that your brain can manage to function a bit better. Recovery to full remission from an eating disorder actually begins once you are discharged from an inpatient setting.
Plenty of you have gone into inpatient; hit that target weight; been discharged; half-heartedly attended the odd outpatient appointment; and then promptly relapsed.
So here are some options for letting go of that cycle and dependency on “target weight,” and embarking on getting the condition into full remission. There is a three-legged stool concept I use where each “leg” of the stool is critical for getting to remission: re-feeding, resting and brain re-training (psychoeducational support). The minute you are discharged from an inpatient setting (or you are already confirmed to be medically stable to begin re-feeding), then you eat the minimum (always more) intake guidelines for your age, height and sex that those without eating disorders eat on average every day (see this EDI paper for details: Homeodynamic Recovery Method, Doubly-Labeled Method Water Trials and Temperament-Based Treatment). You cease all discretionary activities (see here for details: Juggling Recovery, Finances and Commitments as well as the Exercise series: One, Two and Three). And you need to attend to that brain re-training to be ready to continue the recovery process day in and day out from that point forward.
There are two psychotherapeutic tools that are evidence-based for addressing ambivalence and fear: MI and ERP (motivational interviewing and exposure and response prevention, respectively). I have discussed ERP in this EDI entry: Weighing Yourself: Don’t Do It, so you can revisit that post if you want a refresher on ERP. Let’s look MI.
Drs. William Miller and Stephen Rollnick developed MI originally to help those looking to overcome problem drinking. It is now an evidence-based treatment for those with substance use issues. Dr. Janet Treasure, a leading clinician/researcher in the field of anorexia nervosa, in her thorough article on MI, pointed out its value in application for any situation where there might be resistance to change; however she correctly adds that a patient rarely maintains a stable state of motivation, and therefore this manualized approach to helping a patient adopt new behaviours still requires an empathetic and sensitive therapist who can move back and forth along with the patient as she approaches and retreats from new behaviour in nonlinear fashion. [1]
The essence of MI is to help a patient explore any ambivalence they may have toward replacing maladaptive coping mechanisms with adaptive and healthier behaviours. Patients will frequently ask me “Can I eat normally and stay the same?” and I refer to these kinds of questions as bargaining with the eating disorder. Questions such as these really reveal the fact that the patient is dealing with ambivalence. If you are feeling stuck, or have found that the anticipated tomorrow of starting to change behaviour just never seems to arrive, then seeking a counsellor with suitable MI training is a good first step.
If you either cycle through relapses or never quite get beyond tentative efforts at full-fledged recovery, you are not just being held back by the threat response firing up as you try to approach and eat food. You are also held back by the fact that the arc of restrictive eating means that at one point you practiced food avoidance and reinforced it because it generated positive things for you. It may have allowed for you to stop being focused on distressful emotions or interactions in your life; it perhaps provided you with a sense of purpose, control and mastery; and/or it generated improvements in mood and calmness, and made it easier to navigate your world and relationships. Those are just a few of the myriad environmental circumstances that may lead to a reinforcement of restriction once the drive to create energy deficits in the body is activated.
An eating disorder is not a genetic disease. There does appear to be a genetic component for activating a drive to create energy deficits in the body; but the reinforcement and perseveration of those behaviours involves the plethora of anthro-psycho-neuro-immuno-endocrinology inputs (APNIE)—translated this terminology refers to the sociocultural, familial, environmental, psychological, neural, immune and endocrine circumstances and status surrounding and within the patient. APNIE inputs will be unique for each patient.
As restriction is not tenable for life, the modulating benefits of practicing restriction start to recede as the damage and negative impacts of energy deficits in the body start to mount. There is usually a moment where the person in the grips of that downward spiral will try to eat, or the body will force them to eat.
In almost all circumstances, that effort (or force) to stop restricting tends to create absolute chaos. All of the emotions, the difficult interactions with others and the inner mental landscape that were filtered through the deadening power of starvation come roaring back. And on top of that, the misidentification of food as threat (the underlying "engine" of restrictive behaviours even if you don't experience that force consciously at all) means that approaching and eating food ratchets up intense and destabilizing levels of panic. For those that attempt to eat normally again, this will be enough to send them back to restriction, disheartened and feeling more helpless and trapped than before. Those who were forced to eat by the body's drive to survive will return to restriction for the same reasons, and inevitably end up in cycles of restriction/reactive eating and eventually bulimic behaviours will surface.
To be trapped enacting behaviours that you no longer want to apply generates what is called ego dystonia. I describe it this way in Part Four UCSD EDC2014 Review:
“As an example, if I have a self-conception that I am not someone who willfully kills living creatures, then my propensity to use a glass and piece of paper to rescue and free spiders, wasps, or other insects that have entered my home aligns with that self-conception. If I accidentally step on an insect in my home, then I will experience ego dystonia— I have behaved in a way I find repugnant in relation to my self-conception. I will likely reduce that cognitive dissonance by rationalizing that it was an accident and perhaps might redouble my efforts to be careful to avoid an accidental insect death by my hands (or feet) in future.
If, however, I develop a fear of insects, then I might squash the critters as soon as I happen upon them and I will attempt to deal with the ego dystonic reaction with more intense behaviours of avoidance along with more elaborate rationalizations and excuses for not aligning with my self-conception.
Fear is a ruthless taskmaster if it gets a foothold in your sense of self.”
You are not just dealing with the feels-real-but-isn't misidentification of food as a threat; you are also dealing with ambivalence created by ego dystonia where you still hope to experience the benefits of restriction without the progressive damage of using those behaviours to cope with your life.
To be ready to continue towards complete remission of an eating disorder, you will need to grab psychoeducational tools such as MI and ERP if you want to neutralize the crocodiles and keep moving forward.
Treasure, Janet. "Motivational interviewing." Advances in Psychiatric Treatment 10, no. 5 (2004): 331-337.
