I’ve just written about denial in eating disorders and something has led me to a great deal of thinking about the difference between treatment and recovery in eating disorders and anorexia in particular.
Focusing on anorexia for the moment; Professor Chris Fairburn has described 3 phases of treatment, the first being getting the person to accept there is a problem and weight restoration; the second being psychological support and the third is prevention of relapse– with overlaps between these processes.
This is all very well if you are working in a treatment setting and wanting quick results or any results at all. But this doesn’t quite meet the needs of someone with a long standing problem who decides to get better on their own.
I meet many people who have had an eating disorder for a very long time. They may have been in treatment for a very long time as well. It seems to me as if this “treatment” has largely been focused on helping the person to WANT to get well. In other words, all the re-feeding, trips backwards and forwards to hospital, conversations, explorations of the past and meetings with the family, swapping of psychotherapists and encouragement from dieticians are just stepping stones in a process whose end point is helping the person to want to do things which are impossible with anorexia – such as eat with other people, or, have a child.
I am known for not caring whether someone is fat or thin and I don’t pat people on the back for eating more. At the end of the day, whether someone is able to eat more is their choice and their fate. Some people can function well, sleep well and lead a normal life at any weight.
But, if you have had anorexia it is ONLY weight restoration to a BMI above 20 that will even start to reduce some of the symptoms of anorexia (obsessions, excess hunger, feeling fat, sleeplessness, low mood and infertility). And it is only staying at a higher BMI for quite a long time that will make these symptoms go away. The bottom line for this awful illness which is not about food is, “stay thin, stay ill, no matter how much psychotherapy you do”.
While anorexia is not about food and weight “underneath” it takes a sustained period of eating to start the process of recovery.
So once a person has reached the turning point of wanting to get well, recovery is much, much harder than staying in the golden cage of the illness. For example; weight seems to go on first on the tummy and then will go to where it looks best after a while. Eating will be very scary. How on earth can someone do this on their own?
Recovery isn’t just about eating more calories, whether someone gets better depends on how that nutrition is delivered. This must be done really caringly, to ensure that the right balance of carbs proteins and omega fats are eaten. Depression is more likely to set in if the balances aren’t correct.
I have also found that people want to recover while continuing to avoid meat, eggs or fish. For people with eating disorders, vegetarianism is usually a symptom of anorexic thinking which can make it very hard to get all the right nutrition and “food for the brain”. Recovery thus also means targeting orthorexic thinking which is possibly the hardest thing of all and most fiercely resisted by the person who is trying to get well. This is denying the need to confront the orthorexia, which is the anorexia in another guise.
So how can we help people who have decided to do it on their own? Time and time again I find that people start strong and slip back when the going gets tough or when they confront the predictable effects of eating more for a while. Without the right support, they may go back to wanting to recover instead of doing the hard work which recovery entails. Denial sets in, like going on holiday without planning how to keep an eating plan on track.
What then is the right kind of support? I suppose I would have to ask the person what kind of support they really need. How do we get the balance right with giving the right kind of empathy, time and guidance together with some hard talk - such as “beware of pretending to yourself that this or that (like orthorexia or planning to run a marathon for charity) is not a problem.
Recovery from anorexia and fighting the anorexic voice is the bravest thing one can do. It’s like asking a mouse to fight a lion. Why aren’t there more websites giving active 24/7 support for people who have engaged with that fight instead of all those other awful sites.