In the few decades since eating disorders became so prevalent, clinicians and patients have used a series of treatment approaches, ranging from well-reasoned concepts to hackneyed fads. Without any sense of the underlying pathology and few options with known effectiveness, the going has been rough. However, it does no good to tout a new unproven idea just because it sounds appealing. Both logic and evidence of effectiveness are crucial. The old adage applies here: the proof is in the pudding.
One popular new approach is called intuitive eating. Riding the pop culture wave of mindfulness, intuitive eating proposes that the eating disorder patient in recovery can work hard to ignore eating disordered thoughts to restrict or binge by simply following the internal, visceral cues of hunger and fullness. The concept of recognizing hunger and fullness again is perfectly reasonable and must become a part of recovery at some point since learning how to respond to these cues is critical to resume normal eating. The question is when and how to apply them.
Early in treatment, intuitive eating can easily backfire and in fact derail initial attempts to normalize eating, especially in the outpatient setting. Asking an anorexic patient to eat when hungry or a bulimic patient to stop when full is absurd. Their bodies have been trained to ignore hunger and fullness respectively throughout the illness. The brain circuits connecting the eating disorder behaviors with positive reinforcement, be that the high of starvation, the abandon of binging or the relief of purging, are well established. Intuitive eating effectively means asking the patient to just stop the eating disorder, under the guise of a supposedly established treatment program. It's hard to imagine a more demoralizing approach for a patient new to recovery.
Another key point is that hunger and fullness are not nearly as ingrained, automatic responses as intuitive eating implies. Yes, starvation is an all-encompassing experience which overrides all other physical and mental function. When starved, our entire being focuses on finding and eating food to survive. More moderate hunger and fullness are malleable reactions, and even intellectual constructs, based on individual digestion, metabolism, outside influence and personal experience. By framing these internal cues as something specific to the individual, rather than personal failure of the patient with an eating disorder, the goal of intuitive eating becomes a realistic, attainable goal.
Intuitive eating does have two critical places in treatment. Patients generally find the information that hunger and fullness can transform, both in an eating disorder and in recovery, very helpful. Since many people believe they have permanently lost these internal cues, it's a relief to learn that hunger and fullness can be relearned, even after years of being sick. The process of working to eat meals again of normal size and spaced out through the day can reawaken the hunger cues. It's critical to know that hunger and fullness follow establishing and following a regular meal plan, not the other way around. Indeed, the act of being mindful to look out for these cues can help speed along the process. Even if patients know it can take months or years to feel hunger and fullness again, depending on the length of illness, just understanding the full scope of possibility in recovery is often very motivating.
The second component of intuitive eating that aids recovery is all in the timing. Patients lose sight of hunger and fullness so completely that they cannot even recognize the signs anymore. It's almost a rite of passage in recovery for a patient to come into a session worried about new internal sensations such as dizziness or fatigue during the days only to be shocked to realize they are simply experiencing hunger. A clinician aware of this step in treatment can be on the lookout for these new signs of recovery and help the patient relearn how to identify something automatic for someone without an eating disorder but essential in recovery. The connection between the cognitive awareness of the internal cue and the physical sensation is something anyone in recovery can and must relearn.
Ultimately, intuitive eating is a prescient approach that fits in nicely with current trends towards mindfulness in many aspects of our lives. Over-reliance on this treatment approach will quickly backfire. Using the concepts of hunger and fullness to explain recovery, however, is illuminating for someone afraid of permanent physical damage. Even after years of being ill, it's astonishing how much one's body can heal itself with proper nutrition.