The course of an eating disorder from the innocent urge to lose weight to real freedom from the illness is a long road. Each transition between stages of the disease through steps of recovery is a battle. From recognizing the problem, finding good treatment, fully committing to the hard work of getting better and making the personal changes needed for recovery, the path is fraught with hazards and challenges. Unfortunately, the eating disorder treatment community still paints a rosy, unrealistic vision of recovery all too often. Any program that implies that in a few months someone can be mostly recovered is not being truthful. Normal eating patterns can be restored in that period of time, but normal eating and weight only encompass part of a full recovery. It's important to know ahead of time what the path looks like and what each part of treatment entails.
There is frequently a long lag time between the onset of symptoms and entering into treatment. The strong personal attachment to the symptoms, such as the elation of starving or the powerful desire to lose weight, does not lend itself to seeing these desires as anything but natural. An illness is the furthest thing from someone's mind early in an eating disorder. For people with Anorexia, it's as if they have found nirvana: a way to ward off hunger and feel superhuman while miraculously shedding many, many pounds. Years, or a lifetime, can go by before someone recognizes the enormous consequences of this illness. When binging and/or purging are symptoms, shame and guilt serve as significant barriers. Each binge feels like a personal failure, rather than the sign of an illness, and leaves people caught in a struggle between willpower and self-hatred. Seeking help feels like a failure, not acknowledgement of a disease that needs treatment. In fact, on average it takes seven years for someone with Bulimia Nervosa to enter therapy. The time to treatment is shorter with Anorexia due to concern over weight loss, but the intervention is usually based on medical necessity, not any desire of the patient to get better.
The focus of initial treatment is to normalize eating patterns and weight. Clinicians know that a patient needs to resume normal eating to think clearly and reverse any long term medical consequences of the eating disorder. What is frequently not stated early in treatment is that normal eating and weight does NOT mean full recovery. Too many family members, friends and even clinicians equate normal weight with full recovery. My experience is that this false belief is actually counterproductive and prolongs the length of illness. The patient, still struggling with eating daily and the internal turmoil associated with recovery, feels left alone and quickly realizes that only relapsing will cure the loneliness and rally the support again. In fact, a person in recovery needs much more support after eating and weight returns to normal. The eating disorder serves as a very effective coping mechanism, and without it, every patient feels much more afraid and alone and needs extra support to get well.
What makes this second part of recovery, after some improvement in eating behaviors, so challenging is the profound personal transformation that must occur for someone to get better. It's clear from psychiatric research that there is a genetic predisposition to getting sick with an eating disorder. Certain core personality traits predispose someone from the start, but then environmental factors including family dynamics, early exposure to dieting and body obsession and emotional isolation contribute greatly. At some point early in personal development, the eating disorder becomes a central part of that person's identity. As I have stated many times in this blog, the eating disorder starts to feel like much more than an illness; it becomes who you are. Soon after weight restoration and regular meals, the person realizes that the food behaviors only encompass a part of the eating disorder. The thought processes behind the illness, mostly the contradictory sense of superiority about mastering food combined with self-punishment driving every personal decision, have to change drastically in order to get better. This profound realization is always daunting at first. Committing to this transformation means both sustained attention to every meal and snack and the internal psychological work to fashion a new way of seeing oneself in the world. This is clearly a lot to commit to, but with any perspective to see the true nature of these illnesses, committing becomes the only option.
This part of the work of recovery occurs largely as an outpatient in a gradual, fluctuating process over many years. There are periods of significant progress punctuated by stretches that are difficult. Some days or weeks may include stable eating and the personal freedom of living more fully and others days can feel like falling back into the eating disorder again. Maintaining steady treatment, learning how to be resilient and accepting the psychological goals of recovery are all significant challenges yet are also necessary hurdles to recover and be well. When family, friends and clinicians can learn about the nature of eating disorder recovery, the patient will believe she has true, reliable support through this difficult time. It behooves all parties involved to face the reality of the illness and the time of recovery so that the patient suffering has everyone on her side. The goal in eating disorder treatment is not managing a chronic illness. The goal is to get well.