What does ‘recovery’ look like in practice?
In my 15 years of experience with more clients than I can count, I have come up with an adage - Recovery is a series of freak-outs. I say this at the front end and numerous, numerous times after, so that my clients are not surprised by the fact that they have to encounter yet another scary number, food or feeling , as they go through the process. If an eating disorder achieves its purpose, as is most obvious in deep Anorexia, a person is squeezed into a tight corner where there is little connection with emotions, body or life. I know it is the case for all my BN and BED clients as well, albeit less obvious. Such a deep eating disorder develops from a place of great emotional discomfort that evolves into fear of all things unfamiliar and ultimately avoidance that escalates to include almost everything - food, people and self. Recovery from this very tight corner, supported by very rigid rules, requires slow, meticulous and patient work that addresses behaviours as well as the deep-seated fear of life (represented by food). The question “ How long will it take ?” is moot.
The therapist and the client have to take care to “stay interested” in the process of recovery. Staying interested or maintaining focus for a very long time, sometimes years, is an exhausting task. However, in my opinion, giving up does not result in anything “easy”. There is nothing easy about an eating disorder. If recovery is not easy, living a compromised, cornered, secret life is even less easy. So my clients do not consider ‘giving up’ in treatment because there is an ‘easier’ option. I used to work in a women’s shelter, once upon a time. I saw women come to shelter and be overwhelmed by the numerous choices they had to make, sometimes with a couple of small children. Even with supportive workers around them, the unfamiliarity of it all and the weight of the situation they were in, caused the women to go back to the abusive situation a few times - back and forth, back and forth - till they shored up their resources and familiarized their nervous system with the reality of the decision they had to make. The confirmation that the relationship is simply not working and the frustration with a stagnant life would finally tip the scale towards liberation. It is not much different with an eating disorder.
Sometimes it is a couple of years before I see that light in a client’s eyes. Those years are not “wasted”. I know that the client is weighing their options and creating little inner stepping stones towards the goal. At some point the scale tips towards a greater, perceivable momentum. When you think about it, recovery from an eating disorder encompasses all the lessons anybody needs to learn in making major changes in their lives. This gestational period holds a lot of back and forth movement while the person tests out all their alternative theories. Personally, I am in agreement with a client exhausting their arsenal before agreeing to recovery. During this bargaining period, I start talking about the “back door”. All my clients know what I am talking about - the secret agreement between the person and themselves that if things get bad enough, I can go back and practice at least parts of my ED. Sometimes a person talks in frustration about how hard they have worked for the last two years and nothing has changed. In exploration , it comes out that they have decided to keep a few parts of the ED and not try for full recovery yet. A big part of the process is finding language for and articulating all the unspoken ( secret) agreements in the person’s mind.
A few common ones are -
I can do this on my own. I don’t want to be a burden. I don’t want to bother anybody.
I will do it my way ( maybe I will keep just a little bit of restriction and a little bit of exercise, who would know?)
If I search hard enough, I can come up with another formula that will work.
I would like to get better to go back to my way of life (which brought me here in the first place)
I know what a meal plan looks like, so I don’t really need to see a dietitian. I just have difficulty doing it.
I don’t really need to eat bread and butter and cake. I really like salads.
I explain to my clients that it doesn’t really matter to me if they eat cake or avocadoes or salads. In an eating disorder, all fears and challenges in life are expressed in terms of food. What a person does with different foods is a metaphor for the parts of life that are as yet not dealt with.
An eating disorder seems to start as an intention to lose weight or diet well. It would be a mistake to understand the ED in such a narrow way. Even when a client presents at 35, I know the anxiety of stepping into and existing with the challenges of an adult world can be traced all the way back to where it started - the grand metamorphosis of teenage, the biggest internal / external transition any of us will ever experience in our lives. An ED does not start just because I stopped dancing or just because I worked at a pizza place and ate too much or just because I was trying to exercise well. Looking for a simplistic explanation invites simplistic answers that get in the way of the deep effort required for a sustainable recovery.
Ultimately, there is no magic way.
A way of thinking that includes magical thinking belongs to childhood. The feeling that somebody out there will make it all go away or “I will wake up and it will be better or I can recover without actually doing the scary work of the meal plan with a discerning dietitian” is a misunderstanding of how things work in real adult life. I use the word “adult” not in the chronological sense but more in an internal reality sense. I meet many chronological adult people in their 30’s, 40’s and 50’s who continue to internally hold a belief that something will change outside themselves that will make things better. To this I can only say , I am always willing to be surprised. This does not exist in my lived experience. The ED starts out with a purpose in a person’s life and becomes a habitual way of dealing with stress. The work to substitute the ED with other habits that will serve the same purpose and to cultivate these new habits has to be very conscious and mindful. The therapist and the client have to engage in this process with care to stay alert and awake to the goal, day after day, week after week , year after year. Like climbing a mountain patiently, resting on a plateau on occasion and climbing again. If we climb one step at a time, with patience and intention, it is almost impossible not to reach the goal.
Family Work - It may come as a surprise to parents that when they have teenagers with ED , they are a part of this long , interested, curious process. Family therapy includes the dynamic of the parents’ relationship, the parenting relationship and the child’s relationship with each parent. Therapy is guided by what is significant in the child’s world. The therapist just follows the anxiety in the family system and works to restore the order of the relationships thereby removing the function of the ED in this family.
Family Therapy is different from Family meetings and Case management. Meetings with a family where weight and food are discussed are “family meetings” to get caught up with information. Case management meetings deal with the direction and next steps of treatment on a broad scale - is your child going to hospital, is she going to a different school, is the family moving, can she handle the stress, does she need additional support ? Family therapy looks at the emotional structure of a family system and helps restructure and organise family relationships in a way that addresses the stressors in this family system. The therapist also interprets the ED and what it is expressing at all stages to the parents.
The Family Therapist works very closely with a Dietitian who is well-versed in the connection between food and feelings. The dietitian also stays in touch with the doctor who monitors the child. In this way all arenas of emotions, food and health are covered and there is no lost information, no cracks where the ED is a mystery and can thrive. This structure of treatment is a non-negotiable for successful recovery whether the client is in a program or in the community.Each discipline has its purpose in the treatment pathway. Lack of communication between the disciplines and the parents hinders the path of recovery.
The ED is the voice of the client. “ I am not doing well. Life, as it is right now, is too much for me”. Finding vocabulary as the process goes on decreases the cliet’s need to express her distress through the ED presentation.
