The Deep End of Eating Disorder Recovery

Many patients have described to me the time they stepped into recovery from an eating disorder as jumping into the deep end of the pool. The sudden moment of panic. The desperation of the urgency of life and death. The gasping for air and the frantic flailing. It's an image which helps others understand what recovery truly feels like. 

Those first few seconds in the pool are excruciating but in recovery the time last for weeks or even months. It's an extremely long time to tolerate the panicky feelings, but for those who can, the result is truly getting well. Their minds and bodies adapt to the food and feelings just as the panicked swimmer learns the comfort of treading water. The recovered person starts to structure the day from meal to snack to meal to snack, adjusting to the waves of hunger and fullness just as the swimmer learns to relax and float, buoyed by the water, soothed by the sounds of tiny waves gently lapping against the wall of the pool.

It can take people many attempts at recovery before they can jump in the deep end. Sometimes fear gets in the way. Other times it's the intensity of the eating disorder thoughts, other psychiatric symptoms or the inability to see life beyond the illness. As a clinician, I feel confident that the people who jump in have a much higher chance at escaping the clutches of their illness but also know not everyone is ready for that moment when they walk in the door for an appointment. 

Those who don't jump in the deep end can still very much be in recovery, but their progress is more like dipping a toe in the water. The water may be bracingly cold or refreshingly warm. It may bear the anticipation of actually getting in the water without having to do so, or it can be a matter of pleasing others by at least testing the water temperature. Dipping a toe does not lead to panic about actual events occurring at that moment but about what might happen in the future. There is progress, but that person is always on safe ground knowing their eating disorder symptoms are well within reach. 

And after testing the water enough times, it's always possible someone will jump in.

In eating disorder recovery, this safer step involves adding small amounts of food per day or trying challenging meals a few times per week. It may lead to times of more exploration in therapy while allowing the imminent use of eating disorder symptoms to wash away the feelings that come up in a hard session. It's a way of testing recovery out and making clear, steady progress without being fully ready to embrace recovery. 

As a therapist, I struggle with how to conceive of the model of testing the waters. There is no doubt that people who dip their toe in the water can better their lives. It enables them to improve nutrition, to lessen the psychological and physical effects of the eating disorder and to make room for more in their lives.

The hardest part is that it's not clear to me if the people who delay jumping in the deep end get fully well. The eating disorder symptoms remain crucial to functioning in daily life. There's no urgent need to find other things to replace the eating disorder, and the ups and downs are not emotional struggles with recovery as much as the ebb and flow of the eating disorder symptoms. On the other hand, that slower process also helps people come to terms with saying goodbye to their illness, a necessary part of jumping in the water.

I vacillate on the issue and there's little research to help with these long term treatment decisions. I worry that my optimism clouds my judgment and allows me to sit with people who are very ambivalent about getting well. But ultimatums just don't help people stay in recovery either, so abandoning treatment for those who need help dipping their toe in the water seems cruel and punitive. However, without jumping in the deep end, the person in recovery can always quickly fall.

The best conclusion is that there are no real answers. Recovery from and eating disorder remains very gray, not black-and-white at all. Although jumping in the deep end is clearly a more significant step to recovery, clinicians need to meet people where they are in the process and work towards more significant steps forward. The kindness and compassion of sticking with someone through their journey in recovery, using the best knowledge of treatment, ultimately means much more than following a specific structure guideline.

And I always encourage and hope that person will walk up to the edge of the pool, summon up the courage and take the plunge.