Eating Disorders: Recovery-focused Psychological Treatment


I guess recovery for me is basically a chance at life that you never thought. But on another level because you start to appreciate it. You never thought that you were going to get to this point. So it’s about being free, being happy and basically living the life that you never thought that you would. I’m at university. I’m almost finished my degree which I never thought was possible. I always thought that I was dumb but didn’t realize that was a result of starvation from the brain. So it’s nice to be able to use my brain now and know that it wasn’t anything about me as a person, it was something that the eating disorder took away. I’m a mum. I have a 3 year old little girl. And there have been many opportunities in my life and they keep happening. I think it’s quite magic actually because I feel like recovery is still a journey and I like to call it discovery in the sense that I’ll hit a point in my life and go “Never thought I’d see that happening.” So it’s quite an adventure and it’s good to be around for. When I first started thinking about recovery my first step was just to approach my GP. I didn’t know what support was available. I didn’t even know if I did have an eating disorder. I didn’t know that binge eating disorder was even an actual real thing. I knew that I had disordered eating habits and I knew that it was out of control and that I couldn’t cope with my life anymore and I knew that I needed help. Well I think there are a few core areas in recovery which match the multi-disciplinary team in a way. One is physical. We need to make sure that we’re helping people get back to physical health, good heart function, good electrolytes, good all that sort of stuff. So that’s a really important one. There’s the behavioural one by which I kind of mean looking at normalising eating patterns. So helping someone eat more. Maybe helping someone eat less, eat more regularly. That’s a really important pattern. And it’s really important that the behavioral part is kept in a therapy at some level at some time when it’s kind of needed and appropriate, but it has to be in there for recovery. There needs to be a thinking part of it, a cognitive part of it. I think all too often we have a weight recovery. And not thinking recovery. So if you’re at a normal weight but still thinking “I hate my body I hate myself. I need to lose weight. That’s the only thing that’s important to me,” you might have a recovery for a period of time but eventually that’s going to just wear you down. There’s something about the thinking that has to change and not just thinking about food and weight and shape I don’t want to narrow eating disorders down to that at all. How you think about yourself as a person and how you think about your worth as a person. And there’s also I think a social part of recovery. So there’s helping somebody like re-enter into the the social world. Like for as simple as someone who is a kid at school and is possibly known as that kid that doesn’t eat at school. As part of recovery they’re going back to slowly start eating. But we also need to kind of think about how to help them integrate into that, how to help a family deal with what often is a really traumatic experience for them of helping their kid go through an eating disorder and also just integrating back into the wider wider world. The really important end stage of therapy or weaved throughout therapy is actually helping people just eat more socially but actually just interact more socially. Yeah it’s it’s definitely odd. Because, like, you know, I kind of talked about before, you feel like you’re alone when you’re going through that. And, yeah. To my surprise, you know, a few of my mates were battling their own mental health problems at the same time. And, you know, they had no idea about mine and I had no idea about theirs. So, and it just showed that once someone opens up and makes themself vulnerable and starts that conversation, instantly everyone else kind of feels that comfortability and, you know, it’s that kind of sense of “Yeah, wow, I’m not alone.” You know, and it prompts them to, you know, maybe wanna talk up about it and, you know, potentially seek their own help as well. It’s really interesting to think about how does a person actually move through the predicament that they’re in when they have this mental illness through to recovery. The wonderful thing about eating disorders is that you can do that. You can move entirely through this sequence and have a life entirely free of an eating disorder. And what happens is that the person’s sense of self-worth becomes so tied up with these issues, and this has to do with the mental illness, that their weight and shape or the control of the weight and shape if you ask them will be taking up like 70, 80, 90 per cent of their headspace, over their emotional space as a human being. So they’re trapped in it and they find it very, very difficult to come out of it. So the person is in a kind of trap and our job in recovery is to help them start to be able to see outside that and move through it. I guess there is a fear that things will spiral out of control. You will arise in situations that you’re not able to handle and the eating disorder was always a safety net. If you stay in that then everything is in order. Everything’s in its place. You don’t feel happy but at least you felt safe. I think let’s think about a few different steps. So the first step is actually creating the support circle around the person. So they need to have that medical and psych support and hopefully the people in their lives also understand what’s going on. And we might need to help them do that. So that everybody who’s around them is understanding what’s happening and what the next steps are going to be. So that they’re supported because it’s really, really hard to get better from eating disorder on your own because what you have to do is change your eating patterns and it’s terrifying. That’s hard to understand how terrifying that is if you haven’t experienced it. I was terrified of not, yeah, of not having it there which sounds so silly because that is ultimately the thing that’s causing all your problems. But it’s terrifying to imagine life without that there. Yeah, it’s like a shield I guess you’re using it to protect yourself. The next important step is that the person does need to challenge their eating behaviors, they need to change how they eat. And ultimately regular eating is kind of the Holy Grail here. We need to retrain the body and the mind to accept the need for regular eating. It’s a little bit like having a broken arm: you have to put it in the cast for a while. It’s sort of like we need to to have a kind of a structure around eating to help the person retrain themselves. But what’s going to happen as we do that process of helping with their eating, so they’re going to be regular eating, if they’re bingeing they’re going to need to learn how to manage those binges. And that’s going to involve them in what it feels like and how awful it feels when they’re in that place. We’re gonna be helping them with how they can manage that. So they’re getting their eating back towards a more normal and more natural pattern but through highly structured work. But for some people there is another step to recovery which is beyond the normalisation of eating and their behaviours and their general mindset towards eating and body image, and it kind of comes into “how am I organized in the world? How can I be safe without this coping mechanism that the eating disorder may have become for me?” And it becomes really about self understanding and understanding different parts of yourself and being able to see that you’re bigger than the eating disorder is a really big part of it. Being able to separate yourself from the eating disorder a bit and say “okay, I can see, I can try things that way, I’ve done it that way, but I can see there’s another part of me that’s really scared about, I don’t know, life. Am I good enough?” It might be, or things like that and start to get some self understanding around all of that. Hopefully if that’s happened, if we’ve normalized the eating and at whatever depth the person needs to go to we’ve kind of contextualized and understood the eating disorder, the person is equipped to sort of relive their life, to reconnect with people in a good way that might have got stuck, to sort of develop relationships, romantic relationships, to feel more confident in their work, to reconnect and make their life bigger again. And it’s lovely watching and participating with people as they do that because it’s a such an enlivening kind of process. Meet them as the person that they are. I always felt that I was ineffective, that I couldn’t relate to anyone and eventually it was finding health professionals that I could relate to because they would see beyond the illness and see me as a person. And I remember being in some sessions where and I’d walk away and I would feel uplifted not in the sense that we discussed anything to do with the eating disorder or how we were going to advance here but it helped with my own recovery being with a health professional because we spoke about options, about life and who I was as a person. People who’ve been through this process will have experienced some really hard stuff, really hard stuff. So it may be that they’re more empathetic and compassionate than the average person their age, you know, that they have a degree of self understanding that might be a little bit unusual depending on where they are in their life cycle and things like that. So they’re able to take the experience of the eating disorder,now that they’ve moved away from it, and they’ve sort of learned that they’re bigger than it and kind of use that, too, now into the new life that they’re moving into. And I think that’s when we’re really getting a recovery that’s very rich. Seeing someone recover is a really inspiring thing, you know. And because it takes courage in the person and hard work. But then, you know, sometimes the things they discover about life after that, like, just really simple things like “I can be content. I can be content! I can sit and read a book and be happy and content and in my life,” you know. Or “it’s possible for me to have a relationship. I can. I didn’t think I could. I thought it was a person who’d always be like, Oh my God, you know. Life is more than what I thought.” So participating in that process is is inspiring. I think change is so frightening for someone just starting their recovery journey because the eating disorder is your safe place. That’s your best friend. That’s your only friend usually, depending how far into the eating disorder you are. It was my only friend at the time and it was my only comfort. The only time I felt joy. Although, paired with that joy was extreme lows and depression. But I was terrified of losing that barrier The most common emotion that patients tell me about when when we’re working together is they just feel so lonely. Often the eating disorder might come about to, like, solve or block out the loneliness. But it is such a socially isolating thing that the loneliness gets worse. But then the eating disorder will go to you “but you have a solution. You have a relationship with me.” So sometimes the function of the illness is very complicated. But what’s really important and what makes treatment individualized is actually for that person I want to understand why this behavior is important to you, why holding onto this thing that you kind of already hate because you’re my office, why do you hold onto it? When people are ambivalent about change, they have two sides – the part that wants to change and the part that is against change. Motivational interviewing helps clients explore and resolve this ambivalence. By actually understanding that you’re dealing with something that feels helpful – might not be helpful but it feels helpful for the individual – is a huge hurdle for therapists to get. And once you get that, and once you can convey that you get why. I get why you need to have this illness. The person with the eating disorder might at that point go, “But do you also get why don’t want this illness?” And then what you’ve done is started to create some ambivalence. You’ve gone from “I’m not going to change, I really need this” to “Maybe I can start thinking about change.” It wasn’t until I was into my mid 20s when physiologically things started to not work like they used to with the eating disorder, where this initial chemical experience I believe was no longer fun for me. I wasn’t as effective as I was. I started to develop depression. I started to become very anxious and basically it was a time where things did click over for me. And realizing that the eating disorder wasn’t fun, this has essentially taken away my life and my best years. And that wasn’t for quite a number of years after where I realized that I was stuck and I really needed help and I didn’t know how You do a lot of this. I hear that there are these reasons to stay where you are and there are these reasons to change. Let’s talk about that. How does that kind of work? And it can be simple and concrete. It can be like, “I really like achieving at school and I can’t concentrate very well.” Great. OK, so the perfectionism we could see that as a strength and your determination is a strength. So let’s kind of work with how the eating problem is getting in the way with that. It might be, “I want to be the best mum that I can be. I want to be a great role model to my kids but I can’t sit down with them and eat with them.” And that might be like looking at breaking down what what being a good mum looks like. What being a good student looks like. What being a good dad kind of looks like. Breaking down what makes this person tick. Like, what are they bringing, what is their reason, is usually the first step into shifting the ambivalence around change. I’m asking them to do something that is terrifying. You actually have to help the person find a damn good reason to do that. And it’s there. And a lot of the work that you do, a lot of the motivational work, a lot of the therapy work, that you do with somebody presenting with an eating disorder is just sitting in that stage, keeping reflecting the reasons to change just a little bit more than the reasons to stay where you are. I guess the difference, yeah, between the eating disorder voice and the healthier self. It’s quite complex. It’s sometimes hard to recognize which one’s, kind of, you know, feeding that thought. I guess the eating disorder voice for me at least is very selfish. Just, you know, it’s… you feel like it’s encouraging you and motivating you to, you know, maybe better yourself physically, but really. And you know, it’s letting you know that making those social sacrifices is what you need to do to reach your goals. But they’re not really like your goals. It’s the eating disorder’s goals. And it’s just a constant battle of going back and forth with that. And the amount of times that I just sat in my computer chair at home for two hours, contemplating whether I’m going to go to the gym or you’re gonna go to your mate’s house and just just chill out there. When the person gets really, really scared about making changes or getting back to regular eating, for example, things like that, the fear will grow and they’ll tend to get more scared and the eating disorder will get stronger again. There’ll be other times when it’s possible for it to be really clear “Oh, now it’s okay.” The person can see the eating disorder and can be more aware of what’s going on. Another word that’s often used to sort of describe this process is more or less insight. So it’s understood when we can more see the self that can see the eating disorder and take an understanding of it we’re saying oh the person has more insight. What’s gonna make you kind of feel better about yourself that, like that. So I guess kind of trying to reframe the thoughts as well into a positive light. And, yeah, you know, reminding myself that there is a life outside of the gym, there is a life outside of eating disorder and that, you know, the gym always be there. But, you know, those moments with families and friends, they’re not always going to be there. I started to make these very uncomfortable baby steps and it felt sometimes like one step forward seven times back. And just this whole squiggly skewed mess of thinking “surely there has got to be something better on the other side of this.” And started to gather these I guess I like to call them “aha” moments where it wasn’t a day, it wasn’t a week but in a moment something felt right and I wanted to keep continuing. So it was kind of putting your foot out there and taking a risk. You’ve got to get to a point to go “Life can not get worse than this. What if I actually try?” Probably depends on what your training is, what that therapy might look like. It might look like a cognitive behavioural therapy. It might look like family based therapy. It might look like lots of different types of therapy. You need to have a protocol. that’s probably – you can’t sit there and be fluffy bunny. You have to have a protocol that is sensible, that is likely to kind of work and derives on core principles like “we need to do something about your medical status, your eating behaviors, your thinking, your emotions and the wider world.” And if the therapy that you’re trained in has that stuff, which it will, that’s the stuff that you do. What we usually would do is, depending on the treatment kind of modality that you’re working in and remembering again that if the person is under 18 it’s really going to be their family that provide the impetus and the drive and the guts to sort of get that person eating and hopefully that person is going to be able to trust their family enough so that they’re going to be able to get that change, that eating normalization operating from that point of view. If the person is older than that usually what we try and do from a CBT-E perspective would be create a formulation that expresses its coda between, you know, the clinician and the person that kind of expresses the cycle of the eating disorder. So we can look at it together and say “Aah, so because I think this then I do that. And then that happens and oh gosh that leads that to that.” So we start to understand together. You know how I said it’s like a trap? We start to understand together exactly how the trap is constructed, meaning how the eating disorder is maintained. And that’s quite freeing because then we can see it from the outside and we can say, oh okay, and then we start to think about how is it gonna be possible for that person that we’re talking to to free themselves and how we’re going to work on that. Key concepts behind family engagement include that: families are the key resource in helping the person recover; families have critical roles in early identification, in treatment support and in support after treatment; families are not to blame for the development of the eating disorder; and all supports need to work together. I guess just me becoming more open with them and being more honest about, you know, my recovery and, you know, when I was having down periods during my recovery, you know, talking to them about that and informing them about it was kind of what they needed just to stay in the loop. My mum here and there talked to my psychologist, would get updates here and there about me and what was going on which I think, yeah, also really helped her. So apart from that just kind of staying in the loop. Yeah. They, you know, they seemed to manage. So I think I would know if I was suffering with a relapse just from all my treatment. I feel like I have such a heightened sense of self-awareness and I can acknowledge when my mental health is not great. I can acknowledge when I am having the feelings that I want to binge eat. I feel like I’ll always have a part of my eating disorder. I feel like there will be a part of that that will never go away. I feel like I do consider myself recovered now and I don’t binge eat anymore but I definitely still get intense urges where I do want to binge eat. And especially if I’m having an emotional time or something is triggering me, I will have the thought that you know I really want to go and binge eat. And I acknowledge that that’s, you know, that’s not the way that I need to deal with what’s happening. So I guess from all the treatment that I’ve had and the behavioral therapy I just know a better way to deal with that now. And I like to think that if I was starting to binge eat again that I know exactly where all the support networks are and I know how to reach out to them. And I know that I’ve got my GP and and my dietitian and my psychologist and anyone that I can reach out to at a moment’s notice and ask for their help. There’s also an emotional block to recovery which is “how else might I deal with how I feel if when I’m physically healthy, I’ve gained weight, initially I’m probably going to feel really, really bad about that through the whole process. I’ve actually felt really, really bad about it, in fact probably even before I got the eating disorder or developed the eating disorder I felt really bad, I didn’t really know how to deal with that.” So if I’m going to take away the core strategy that someone has to deal with how they’re feeling which is often one way of thinking about an eating disorder, we need to help them with different ways to cope with their emotions. So if I was to experience a relapse or to start develop sometimes thoughts which could be quite normal in the recovery process if your trigger did come up again, it would be checking in with myself and I guess gravitating to knowing what made me feel good again. It’s really common that if life gets really hard, you know, a period somewhat out from recovery, that the person might feel really tempted or pulled to that coping mechanism, going back to the kind of pseudo control and sense of sort of competence and everything that you might get by over-control of your eating weight and shape. And they might, you know, with the pain of whatever it is that’s occurring in their life, might feel really tempted to go back. So you know the classic thing to do is plan for that really overtly before the person leaves. It’s quite personal really about what signs they’ll notice. But they’ll notice pushing back into needing and wanting to control eating, perhaps isolating from other people when they’re eating, starting for their eating to be secret again, starting for the food rules to sort of build up again, starting to not be able to go, you know, to say “oh no, I’m not going to go to the gym today because I’m going to go and see my mate,” start to feel like “no, if I don’t go…” you know. So the person will have a series, a list for themselves of things that are indicators for them that things aren’t going well and we would then even have a plan for what are you going to put into place out of all of the things we’ve worked on so far, what’s going to work for you? So for example for many people starting monitoring their food again, so writing down what they’re eating and how much they’re exercising, can be enough to just bring that meta awareness, that clarity, that capacity to look at it from an insightful outsider’s view and say “oh, this is what’s happening.” So monitoring might be enough or they might need to come back and see a person again or, you know, that people have a plan. So we don’t leave blithely. We leave with a sense that it’s more than possible that this might happen and that it’s okay because we can contain it. You know. It’s gonna be okay. Like, I mean, I’d like to think that I’m, you know, I guess recovered from my eating disorder. But I still think it’s good, you know, I still check in with her every few months or whatnot. Yeah, just as, kind of, you know, to keep me on track and, you know, someone to talk to. I think I’d be more open to asking for help and quicker this time as well. Obviously the first time I had the eating disorder I struggled for years to ask for help. It took me years to acknowledge what was happening and to understand what was happening and to look for the right help. And I think now that I’ve had that help once and I know I’ve recovered and I know that I can do it. I feel like it will be easier to access if that did happen again. What I would say to a health professional who wants to help someone with an eating disorder, I would just ask that they listen and they really hear what the patient is saying and listen to what they need because everyone has individual needs and every person’s situation is different. I guess in a way this is about the values that we ourselves as clinicians bring to the work that we do with people with eating disorders and I think it’s probably worth acknowledging that we do live in somewhat of a toxic culture ourselves in issues around food and weight and shape and appearance. So we’re not any different from anyone else. We have our own concerns, our own vulnerabilities and our own way of managing what that is because everybody who lives in the 21st century has to do that. So it’s kind of good to have some awareness of how you’re managing that yourself, what your own body image issues are if you have some, or, you know, what that’s like for you, so that you don’t unconsciously kind of just project those into the work with the client. So, for example, a really important question to ask ourselves is “how am I with people who are living in larger bodies?” If I’m going to be working in this field I’m going to be working with people with an absolute range of bodies. And bodies from very tiny and very underweight through to much larger bodies can be quite triggering and quite powerful to to be with. So we need to talk to ourselves about that and formulate what we’re thinking about that. So with larger bodies I think we need to be saying, see through the larger body, with the larger body, that is that person, and see through to what’s what’s happening with them. Don’t get caught up in weight stigma, basically. Don’t get caught up in thinking “that body is a problem and I’ve got to solve that body.” That is not your job. You know, your job is to encounter that person in that body and work with their eating disorder. Down the other end, when somebody is extremely thin, you can get just really scared and really kind of almost hypnotized by that. Again you need to kind of manage your own reaction to what that is and do all the professional things that you need to do to ensure the person’s safety and to get them on the road to recovery. So that would be one example. I think it’s really important to remember that eating disorders aren’t anyone’s fault. They aren’t the person’s fault. Because there are kind of, you know, echoes of cultural myths there that kind of say “oh maybe eating disorders you’re a bit self-indulgent. They’re not real mental illnesses, are they? Really the person’s just being vain or something like that.” Now nothing in the research, nothing in the outcomes for people with eating disorders allows us to hold that position. They are very serious mental illnesses in the same sort of frame as major mood disorders and psychotic disorders. That’s what they are. So we need to be really aware this is not this person’s fault Really treating the eating disorder as a mental health issue, as it is, you know. And referring to other health professionals as well so that there is a support team. So it’s not just one doctor that they’re seeing. So that they’ve got, you know, a whole team of professionals working with them for their recovery The kind side is we also really need to look after ourselves, because it’s a therapeutic process in which we need to be sort of patient and we need to handle hard emotions as they come up. And, you know, it’s not always easy to hold our fears for our clients or our concerns that maybe they’re not going to get better and I’m not doing a good job, because we so much want people to have a good outcome. So supervision, being able to kind of talk to other people, being involved in a care team so that we understand fully that our role is only one role in what’s happening to this person. It’s an important role. It’s one role in a cohesive whole and with that person themselves at the center of it. So that we keep a sense of perspective about that. But also that we are actually kind to ourselves. That we are compassionate to ourselves, that our inner voice around our work is kind and that’s something that’s really important with our clients as well. So that’s something that we can always be working on and sharing with our clients, because that kind inner voice, that compassion is actually crucial to eating disorder recovery as well as to our own work as clinicians. Eating Disorders is core business. Like, it’s a cliche but every therapist has skills that will be really helpful in treating somebody with an eating problem. There are always going to be referral pathways, there’s always going to be patients that we get stuck with. And so I think if you’ve got an understanding of eating disorders and training in eating disorders, I think every clinician has the tools to be able to start. Every clinician can make a good therapeutic relationship and can make an assessment of where what the person in front of them matches their skills. But the message is that you have the skills to be able to help. We are all humans. We all have difficulties and it’s working through all of these together that is different from recovery when you’re still learning about yourself and you feel like you’re the only one who has ever felt like this. So it’s quite nice to be on the other side and reflect back and, I guess, realize that this is living.

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