Recovery is a movement from rigidity to flexibilty.
In the field of Eating Disorders, the topic of recovery is a contentious one. The statistics that do exist are not optimistic and we end up talking about mortality rates, perhaps because it is the more measurable number on the landscape. The truth is that while death is a possibility in the worst cases, it is not a good measure for the real casualty of eating disorders - a life of compromised mental and physical health that leads to a life of compromised options and delight. There is a great gap between the assessment of an eating disorder and death. I think it is difficult for statisticians to capture this in all its complexity. In turn, it clouds our capacity to define recovery as well.
What is an Eating Disorder and what , therefore, might the loss of this ( i.e. recovery) look like? What is a good measure?
In asking this question ( if you notice) I did not say , what might the loss of this behaviour look like? An eating disorder presents as an unhealthy obsession with numbers about calories, clothes sizes and weight attached to a conviction that any change in the specific formula will be absolutely intolerable. With the advent of life-like images and social media, the language of “abs, muscles not fat and flat stomach” has been added. The quest for the symmetrical body has become a normalized desire and possibility in every household. It would be a mistake to think that an eating disorder is a ‘phase’ or really about the behaviours attached to food and weight. Underneath this tiny visible tip of the iceberg is the mountain of anxiety associated with a deep mistrust of people, of the body and of life. As we all know, these are three major areas in our lives - the physical, mental and emotional - and they are all fluid entities where change is the norm.
There is no room for fluidity or flexibility in an eating disordered mind. The hallmark of an eating disorder , besides secrecy and denial, is the deep-seated rigidity that is most visible in Anorexia and present out-of-sight in Bulimia and Binge-eating Disorder. It is helpful , as a clinician , to think of these diagnoses not as separate entities but as part of a continuum operating out of what I call the “restrictive mentality”. The rigidity is connected to a simplistic ‘black-and-white’ , ‘good and bad’ thinking of food that simplifies life and promises “safety”. We are mistaken to think that the “safety” applies to food though it seems that way. The ‘safety’ is connected to all things anxiety-provoking in life - the transitions of growing up and moving out into the world. The struggle to stay afloat and the grappling with anxiety simmers below the surface long before the behaviours surface. Once apparent, the connection between food rules and behaviours become obvious. “If anything rocks my emotional boat, I will simply focus on restricting better, exercising more and losing a few pounds.” The target always moves till the person is caught in a tight circle of restriction and compensation that ends in isolation or hospital.
It is important to find a definition for “recovery” that makes sense because it is important to offer the individual a sense of the end goal ; the lighthouse that identifies we are on the right track as we navigate through the treacherous waters of daily challenges and terrifying long-term overall change. It is also important to be clear about what we are trying to change, to attain recovery that is sustainable. One often hears people talk about themselves as being ‘recovered’ for a period of time and then the “ED coming back” , like an external force. This is disheartening to everybody because it makes the ED sound magical and something that can possess you , unbeknownst to even the person themselves. In my experience, of course, this is a manner of speaking, not what actually happens. (I will come back to this later. *)
In the eating disordered world, if anxiety is the problem, control is the solution. (However it is important to understand that this dance between anxiety and control is not particular to eating disorders. )
All of us have anxiety and feel anxious about various things at various times of our lives. The level of control a person practices externally is directly proportionate to the level of their anxiety. Anxiety presents as an unpleasant physical feeling in the body that all of us dislike and will do anything to get rid of. It is the visceral experience of anxiety that propels us to some kind of action. Anxiety can be controlled internally or externally. If a person learns how to regulate their anxiety internally and tolerate the unpleasant visceral feeling, they are able to live in the world without the impulse to control things externally. The anxiety is managed at its source. When these internal skills are not developed, a person frantically grabs around for some methodology to manage the very unpleasant and scary visceral feelings that anxiety creates. Once a connection has been made between an external behaviour and anxiety, the mechanism is in motion.
There is a hierarchy and competition inside the ED world that is not known to the lay person outside of it. The individual with Anorexia has succeeded to the greatest degree in achieving the much coveted “control” over food and hunger. The individual , at some point , loses sight of ‘self’ ( the emaciated body at risk of dying and the loss of life) and guards this control above everything else. The ED at this point has achieved its purpose, i.e. disconnection from all feelings - bad and good. This is the actual objective and success.
The person with Bulimia also works from a restrictive mentality and tries very hard to “eat healthy, be good and restrict”. However, at some point, the body struggles with the lack of nutrition and delight and ‘caves’ into a binge. The hallmark of a binge is the loss of control the person experiences during a binge. The person experiences intense shame after a binge for this loss of control and engages in a compensating ( sometimes punishing ) behaviour of vomiting or exercising or both. The control or restriction is restored till the next binge. and the cycle continues. Most often , people who binge and purge do not see the restriction as a problematic behaviour or as the precursor of the binging behaviour. In their minds, the ‘control’ is idealized and continuously pursued.
The person who ends up with Binge-Eating Disorder also constantly pursues the same control and restriction mentally but feels intense shame at having ‘failed’ at both restriction and compensation. Besides the original motivating factor of anxiety, the intense shame also now provokes binge-eating and the person is caught in a cycle where food is the source of comfort from both anxiety and shame.
How do we understand this need for control? Is it a particular pathology?
It is very important to understand that, without help, the person with the eating disorder also does not have a clear understanding or explanation for what they find themselves doing . Families often look at the person with exasperation and the individual looks back with shame and confusion. The clinician , in this space, becomes the interpreter and de-coder for the eating disorder, with objective and subjective knowledge of the symptoms. Helping the individual and family see the eating disorder through the lens of rigidity being an outcome of anxiety , is a good start. The intensity of rigidity and compensation is directly proportionate to the anxiety beneath. And now , we try to make sense of the anxiety to loosen the individual’s grip on their protected formula i.e. the food rules that make up what we call the Eating Disorder.
Anxiety is not a particular pathology. As children, we are not in control of our lives and all children have anxiety, however wonderful and “happy” they seem. Attachment theorists say that there is no such thing as just a child, there is always a child AND a caregiver. This helps us to always see any person in context. Anxiety is best understood in context. Besides the everyday tasks of growing a child, one of the main functions of this relationship is “soothing” and “emotion-regulation”. Both of these tasks rely on the caregiver’s capacity to ATTUNE. Attunement is a small word that captures a very complex ability in the parent to “notice, attend and be available” to the emotional needs of each particular child in its own particular way. The parent is the “secure base”. This base is reliable, predictable and available. The truth of life is that while all parents will insist that they love their children, love has little to do with attunement. Attunement is like a finely tuned instrument - the parent is one string and the child another and they twang in harmony, like the strings of a well-tuned guitar. In attachment theory, attunement is a parent’s capacity to read the inner workings of a child that allows a child to feel “known”. We don’t need to be experts to notice a wrong note in a song. On some level, we all know what dissonance feels like, with our own parents and our children. In this dissonant space is the beginning of mistrust and anxiety. Children love and need their parents SO much that they learn very quickly what their parents can “handle” or not. Often parents are not aware that children are watching and adjusting as much as they are. When children learn to not express anxiety and keep it to themselves, timely soothing and regulation does not happen. Anxiety that is not named, felt and attended to in a timely way, accumulates and builds insidiously. There are small signs - nail biting, bed-wetting, leg shaking, cleaning and organizing, restlessness - things we hope children will “grow out of”. The transition between schools and developmental stages is where anxiety has a tendency to ‘bloom’. The onset of puberty is an experience of change internally and externally and one of the biggest transitions we all have to survive in our lives. What makes this so significant and difficult is that everything is changing and with such global change comes the feeling of loss of control. A young teenager does not know when the changes will end and where everything will land at that point. What does it mean to be an adult? Will I be tall? Will I be cool? Will I fit in ? What if I don’t?
In the absence of a well-oiled anxiety regulating relationship, this time of global change is fertile ground for the young person to look around and grab any coping mechanism that fits the bill to feel in control of their anxiety. Sometimes I meet adults who say their ED started when they were 30. A tracking of events shows us that the anxiety underlying dates back to these pre-teen times. The behaviours simply show up on the landscape in noticeable ways later, for many different reasons.
I will not go into the details of treatment here. But in a nutshell, effective treatment involves helping the client track and understand the experience and evolution of their anxiety, the stories and beliefs attached to it and cultivating a current relationship with body, food and feelings in a flexible way. Reduction of anxiety leads to a relaxation in the need for control / rigidity and therefore , a new tolerance and capacity to be flexibile with the big picture of life. Life becomes less about the 725 calories and more about the delight of everyday experiences.
* Why / How does an Eating Disorder “return” ?
The relationship with the ED is deep and personal. In my experience, people often conspire to ‘keep’ some part of two favoured areas - restriction and exercise. The adult or the family of the young adult is often so happy that most of the ED has disappeared and the individual is having a ‘normal’ life overall, that everyone goes back to a non-vigilant life. “Phew!” The nature of anxiety is to get bigger when it is humoured. The ED can grow back like a cactus, from one leaf, when the time is right. Careful restriction and exercise can take over when life circumstances change. And we can trust that life circumstances will change. Life is not always polite and a manicured ED will expand when the careful balance is tipped. When this is made obvious, people have told me that they were aware of their secret connection and had found themselves postponing giving up all corners of their food and exercise rules.
Recovery, therefore, cannot be defined by the fact that I allow myself to eat 2 slices of pizza every Friday or whether I allowed myself to gain 15 lbs. This is why, in my experience, recovery is best defined by the flexible relationship that the person has with food and body and life. The shift from rigidity to flexibility is an internal one. It is not easy for people to believe that they will be able to manage when they let ALL aspects of their relaible ED go. This is where it becomes imperative that the therapist knows the nature of anxiety and does not underestimate the hidden corners and resilience of an eating disorder as a resource, in the mind of a client.
To the question of whether recovery is possible, I will answer “Yes”. The probablility of each person achieving it depends on numerous subjective factors in that person’s life. I also tell every person I meet that an eating disorder can stay in their lives forever, if it is humoured. Giving up rigidity, for a young person , relies on building trust that their caregivers can help soothe and carry scary feelings with them. For an adult, it is learning that with making necessary changes and practising co-regulation with a therapist, they are capable, in time, to breathe through each scary wave of anxiety and live in the ocean of everyday life.
