Quasi Recovery

Recovery from an eating disorder can be a long, and often unpleasant, journey. But one that is well worth completing.

While it can be easy to imagine that stopping eating disorder habits and behaviours will immediately lead to linear improvements, this is far from the truth.

Recovery is a messy process where symptoms can get worse before they get better. Or you see new symptoms that weren’t present when the eating disorder was at its most active.

But despite the messiness of recovery, if we take a bigger picture view, things are improving. The body is healing and your brain is starting to rewire. And with time, symptoms do improve and you get tangible proof that you are getting better and are on the right track.  

You feel less cold

You’re able to eat foods you couldn’t eat before

You‘re not following a rigid exercise routine anymore, which frees up more time to do what truly satisfies you

You have an increased ability to concentrate and find you’re less irritable

You are, in effect, partially through the recovery process. You find that things aren’t as bad as they were at their worst, but you haven’t yet reached full recovery. This state is usually described by the terms “quasi recovery” or “semi recovery.”  

What turns quasi recovery into a problem is when the process of recovery ceases to move forward. That rather than quasi recovery being a descriptor of the place you are travelling through as part of your recovery journey, it now becomes your destination. 

“But I Just Want To Be Normal Already!”

Recovery is hard. It’s common to start questioning the process and the time it’s taking.  

Why can’t this be it?

Why do I have to keep pushing?

Why can’t I just be a normal person already?

When working with clients I often use the analogy of recovery being like relearning how to walk after an accident. 

In recovery, everyone wants to fast forward to being a normal eater and having all the symptoms be gone. But just like someone who’s been in an accident and needs to relearn how to walk, no amount of “wanting it to be over already“ changes the fact that rehabilitation needs to occur.

You have to do many things that “normal” people don’t have to do. Or experience many challenges that “normal” people don’t have to experience. But there’s no way around this. Like when relearning how to walk, there is no shortcut.

Because of the amount of time it takes and the challenges that have to be overcome, many people stop at a place of quasi recovery. And for many, they may not even know that this is quasi recovery. They may believe this is the best it’s going to get and that this is what “recovered” means for them.

I firmly believe that full recovery is possible for everyone. So, what does full recovery mean? To borrow a definition from Carolyn Costin, an eating disorder therapist:

“Full recovery is when you can accept your natural body size and shape and no longer have a self-destructive or unnatural relationship with food or exercise. Food and weight take a proper perspective in your life and what you weigh is not more important than who you are, in fact, actual numbers are of little or no importance at all. You will not compromise your health or betray your soul to look a certain way, wear a certain size or reach a certain number on a scale.”

Keep this definition in mind as we look at the possible explanations for why many people stop before the actual destination of recovery is reached.

Being “Weight Restored”

There’s often a big focus being placed on “becoming weight restored” as one of the hallmarks of recovery. 

This is especially the case with “restrictive” eating disorders, like anorexia nervosa. I have the word restrictive in quotation marks because while some eating disorders are labelled as restrictive, I believe all eating disorders have restriction at their core.

So even though something like binge eating disorder is thought of as non-restrictive, restriction is actually a big part of what is driving the binges. Something I talk about in detail here. 

But to start with, let’s use the stereotypical view of being “weight restored” and then I can explain why it is a problem for anyone with an eating disorder, not simply for those who are at a low body weight.

When weight is lost as part of an eating disorder (or restriction of any form, like dieting) it is done so because there is insufficient energy coming in for what the body needs. And the reason that weight is lost is that the body is essentially breaking itself down, so that part of it can be turned into energy. 

This energy can come from fat stores, but also muscles, connective tissue, internal organs, and bone (known as fat-free mass). In other words, the body catabolises itself, prioritising short term survival over everything else.

When you regain the weight as part of recovery, your body prioritises fat regain more heavily at first. It doesn’t know when the next famine is coming, so rather than fix all the other systems and organs, it wants to create a buffer or reserve of energy.

Recovery of muscle, connective tissue, internal organs, and bone does also occur but this process takes more time, and different people gain different amounts of weight before all these systems and organs have completed their repair.

What determines how much weight gain is needed is solely up to your body and what your body chooses to do. This is something I cover in detail on this podcast on the Minnesota Starvation Experiment.   

The problem with the concept of being “weight restored” is that simply looking at someone’s weight, we have no idea where they are in the recovery process. We can’t tell what level of repair to organs or connective tissue has already taken place.

This is a major failing of many recovery centres or providers. They focus on weight as being the ultimate determiner of when recovery is complete. To the extent that people are often told that they are now “weight restored” and therefore don’t need to gain any more weight.

But if your body is only 50% through with its recovery when you’re told that you’re “weight restored,” where does that leave you? Back in a place of restriction. But now doing so under the guise that this is what you should be doing because recovery is complete (or at least the weight gain part of recovery is complete).

Sometimes, however, it isn’t necessarily just a recovery provider saying this to you, but you’re telling yourself this as well. You believe and tell yourself that you can’t possibly need to put on any more weight. That this must be it.

And this is exacerbated for anyone who doesn’t fit the stereotype of what their body’s manifestation of “being underweight” looks like, which is nearly everyone who suffers from an eating disorder. So you rationalise that full physical recovery and restoration must have occurred, solely because of your size. Or that because of your weight, it can’t be true that you were ever malnourished in the first place.

So the first reason why it’s likely you get stuck in quasi recovery is when a certain number on the scale is being equated with recovery.

Binging And/Or Purging Has Stopped  

For many people, a big part of their eating disorder is episodes of binges and/or purges. At its worst, this could be occurring daily or even multiple times a day. It could also be happening once or a few times every week.

Through recovery and with enough time, the binges and purges can stop. This can be connected to more food coming in on a consistent basis.

This could also be due to more allowance in the types of food coming in or being more flexible around mealtimes, as well as the allowance of extra snacks when hungry. 

But just because the binges and purges have stopped, doesn’t mean that recovery is complete. There can still be much more healing that the body needs to do. There can also be many rules and habits and restrictive tendencies that need to be broken.

The cessation of the binges and/or purges is simply an indication that the body is in a better state than it was before.

Extreme Hunger Has Stopped 

When restriction is ended and the body is given permission and allowance to eat, there can be a sharp increase in hunger.

For some, this happens immediately. While for others, it is after some level of physical recovery that the extreme hunger hits.

Now, understandably, this can be scary or even terrifying. This is the antithesis of everything you’ve been trying to do up to this point.

This may even be what your eating disorder has used as a warning to keep you trapped.

That if you do allow yourself, the floodgates will open.

That you will lose all control and you’ll just continue eating like this and gaining weight forever.   

Despite the fears and what your eating disorder says, this isn’t a forever thing. As you eat more, the body uses this energy to recover. And with time, your appetite decreases and you are no longer in a state of extreme hunger. 

As is true with other single indicators of recovery, extreme hunger ending doesn’t mean that recovery is complete. There can be plenty that still needs to be done, it’s just that your body isn’t in the same state of energy debt that it was in before. 

Reproductive Function Has Returned

For many female clients, one of the consequences of their eating disorder is that menstruation has ceased. For some, it never completely stops, and they have irregular cycles or anovulatory cycles (having a period but not ovulating). But for most of my female clients, cycles have ceased, a symptom that is known as hypothalamic amenorrhea. 

For male clients, they cease getting erections. Throughout the night time, as part of REM sleep, men will have erections at different points. And it’s normal to have an erection when waking in the morning. For male clients, this ceases to happen. 

Throughout the recovery process, this changes. And it’s a reliable indicator that recovery is on the right track when periods return or erections start to occur in the morning. And in both cases, there can also be an increase in libido and interest in sex connected to these changes. 

But just because these changes have occurred, does not mean that recovery is complete. It’s not that reproduction is the final stop of recovery and that if it returns, this signifies the completion of the recovery process. But for many, they can feel like they are done because of this change.

I actually cover the many reasons for irregular cycles, anovulatory cycles and hypothalamic amenorrhea as part of this podcast episode. I also talk about the ceasing of erections and the reduction in male reproductive hormones as part of my episode on the Minnesota Starvation Experiment.

Blood Markers Have Improved

When you get a blood test done, the results that come back are known as biomarkers. 

A biomarker, like total cholesterol or blood glucose, is our way of estimating the likelihood of a certain outcome. So testing different biomarkers allows us to make estimates about the state and trajectory of a person’s health

And these various estimates are known as surrogate endpoints. Rather than being a real endpoint, like having a heart attack or a stroke, they are used as a guess as to how likely it is that a real endpoint will occur.

The body likes to keep levels of different substances (biomarkers) in a fairly narrow range. Its goal is homeostasis, and when something pushes us out of this normal range, the body will make changes to get us back there. 

Blood markers can be a somewhat unreliable indicator with eating disorders. For some clients, there can be clear changes on a blood test that indicate that there are issues occurring.

But for others, even when they are plagued with symptoms and are clearly suffering, their blood tests can come back as “normal”.

And this is because their body is better at keeping biomarkers in a specific range. Now, this doesn’t mean that damage isn’t occurring, it just means that the markers we use to estimate health outcomes are less reliable as indicators. 

So, if you have been struggling with an eating disorder but your blood work is “normal,” this isn’t an indicator that everything is fine and your body is unscathed.

Now, let’s look at someone whose blood work does indicate issues.

Maybe total serum protein is low, which is connected to malnutrition.

Or ALT and AST are elevated. These are both enzymes that are present in skeletal muscle, the liver, heart, kidneys and lungs. They are liberated into the bloodstream following cell damage or destruction. So again, they are going to be higher with malnutrition and catabolism.

When this person starts to recover, eats more food, stops exercising and is getting more sleep, and then gets the same test done nine months later, their total serum protein, AST and ALT may now all be in the normal range.

But again, this doesn’t mean recovery is complete. Blood biomarkers can improve because of the increased calories and the decreased energy debt, but it’s likely that much of the recovery process still lies ahead. 

I should also mention that in recovery, blood markers can go in many directions. Many people start recovery with “normal” numbers but through recovery, they see the “worsening” of their markers. This isn’t an indicator that your health is worse or that you are doing recovery wrong, it simply means that your body is still in the midst of repair.

Like when you try and tidy up a room, you’ll find that at the midpoint there probably are piles of boxes and junk everywhere. But with time, it comes together, and by the end, the place is tidier than when you started. 

This is the blood marker equivalent. And it is worth keeping in mind because your eating disorder wants to keep you stuck and will use any excuse to make you question recovery.

The topic of biomarkers and health, particularly in recovery, is one area I cover with Fiona Willer as part of this podcast.

Cessation Or Reduction Of Exercise Has Occurred  

For people with eating disorders, exercise has often turned into a very difficult topic and something that impedes their health. While exercise can start out as something healthy, it has often morphed into something completely different. 

For many, exercise has become a compulsion and something that’s difficult to not do. And anytime that this person increases what they’re doing, this new higher amount immediately turns into their new norm. The amount of exercise generally increases, while the quality of life decreases.

Often exercise is used as a method of purging. It’s used to “make up” for eating more than planned. Or it is used as a prophylactic method, say, when a person has dinner plans and wants to burn calories in advance, a phenomenon that is often called event restriction.  

This means that as part of recovery, changes have to occur with both the amount of exercise and the relationship with it.

Yoga instead of running 

Going for walks instead of going to the gym

Or, at best: Cutting out exercise completely. Outside of going to work or the grocery shop, there is no extra movement anymore. 

All of these changes to exercise will assist in recovery. But, again, just because they have occurred, doesn’t mean that recovery is complete. 

The World Thinks You Are Recovered 

The world at large is pretty terrible with its understanding of eating disorders.

This is because most people aren’t trained or haven’t read much on the topic. They also don’t know much about other mental health diseases, like borderline personality disorder, bipolar disorder, or body dysmorphic disorder, so it’s not much of a surprise that they are largely in the dark when it comes to understanding eating disorders.

It’s also because much of the health and food advice commonly heard in our society is disordered to begin with. Problematic ideas about “healthy” eating, weight, exercise, and dieting are so ubiquitous that they are just seen as normal.

For many people with an eating disorder, there were times when certain habits were praised. They were complimented on losing weight or having such “willpower” or “discipline” in regards to their exercise or eating behaviours.

At some point, this praise might have turned to concern. It may have become apparent to friends and family that this person had crossed some line. That this isn’t “healthy” anymore, it’s a problem. 

This can be when someone seeks treatment. Or more often, if they are still in adolescence, they are sent to treatment. And for many this treatment “works”. They are eating more, the exercise decreases, and their weight goes up.

These changes are then enough for the outside world to think that this person is now recovered. Which can be an easy message to internalise. Because as I said at the start, recovery is difficult. 

So let’s say, this person is you: if everyone is suddenly off your back and thinks that you’re recovered, then this can be a narrative you are only too happy to take on board. 

Now, for most people, this point of people being concerned actually never arrives. Because of how misguided we are about what an eating disorder “looks like”, it is only the sufferers who match the common stereotype who get their behaviours identified as a problem that they need help for. 

And if someone doesn’t reach this point, their behaviours continue to be encouraged, which allows the disorder to take an even firmer grip on them.

Which again, can be a narrative that can easily be internalised. A common thought could be “I obviously don’t have a problem because no one is worried about me. On the contrary, most people are praising me or encouraging me to keep up what I’m doing”. This is something we cover in this podcast.

Indicators That Recovery Isn’t Complete

I want to be clear: I’m not against all of the above things occurring. In fact, most of them are part of recovery or an indicator that recovery is happening. What I am against is using those markers as the sole determiner that recovery has occurred, in terms of full recovery. 

And the reason for this is because even when all those changes have occurred, the eating disorder can still be present. Probably not to the extent that it was before. But it’s still not eradicated and so you are in a place of quasi recovery.

One way of checking this is to look at particular behaviours. Behaviours that, if you are fully recovered, will no longer be occurring. Below is a non-exhaustive list of indicators that recovery is still not complete:

• You still use calories to determine how much you are allowed to eat
• You struggle to go over a specific number of calories for a snack or a meal. Or you struggle to eat above some amount at certain points of the day i.e. saving calories for the evening
• You struggle to eat if someone else isn’t eating. Or to eat more than someone if you are eating with them
• You still pick the diet, low fat or low carb version of certain foods
• You still avoid many foods. You’ve eaten some fear foods once or twice but have now decided you don’t want or “need” them in your life
• You have many foods or even whole food groups that cause you anxiety. There are foods that you associate with binges and still fear that if you have them it will happen again
• There is a strong focus on “health” but in reality, this focus is detached from something that genuinely supports your health and recovery, and is much more about fear and what feels safe to you
• You still delay your eating when you’re hungry. You enjoy the feeling of going a long time between meals or believe you should only eat when you’re really hungry
• You still feel regret or guilt if you eat more than a certain amount or find yourself overfull
• You often struggle with indecision when making food choices
• You still weigh yourself. Or if you don’t weigh yourself, you still body check. And the feedback you get from this impacts your choices and/or your mood
• You are ok at this weight, but the thought of being any bigger scares you. And this impacts your choices and/or mood
• There is a weight you tell yourself, that if weighed that much, you could never be happy
• You still dream about being thinner and tell yourself that being thinner will make you happier. While you can sometimes leave this thought to dissipate on its own, you mostly still believe it’s true and it impacts your behaviours
• Thoughts about your body are mostly negative and the concept of body acceptance is something you’re still grappling with. When these thoughts come up, it’s difficult to just move on
• You still have a compulsion connected to exercise or moving your body. While it’s easy to think “but I love exercise,” the fact that you struggle to have time off implies there is more to this than just a love of exercise
• Hearing about someone else’s exercise habits and/or current diet is triggering and impacts your own choices and/or mood
• You still have a hard time trusting your body. This can be from a hunger and fullness perspective, but also in regards to whether your body is trying to sabotage you (which often comes down to a fear of weight gain)
• You have different thoughts or beliefs that are ok for other people, but not ok for you. It’s ok for others to be a certain weight, eat a certain food, only exercise a specific amount or wear a certain type of clothing, but this is not ok for you
• Numbers take up a lot of space in your head. Calories, weight, steps, exercise time, allowable meal times – these thoughts crop up constantly and often impact your choices and/or mood
• Deviating from plans – whether this is meal timing, the type of food, your usual exercise routine – is incredibly difficult and rarely happens

If any or many of these are occurring, it would indicate that recovery isn’t complete. This isn’t necessarily a bad thing, if you are still pushing ahead with your recovery. But it’s a concern if these are present and yet you believe that this is the best it is going to get.

And one of the big reasons that this is a concern is because relapse is very likely in quasi recovery.

Which makes sense, because the neural rewiring hasn’t fully taken place. You are still engaging in disordered thoughts and behaviours. 

Now, most of the time, a relapse occurs unintentionally. A stressful event happens. Or the desire to restrict becomes too enticing. And before you know it, you are backsliding. 

In the beginning, this can feel like bliss. There is this honeymoon period that occurs as part of this descent into the darkness where it initially feels great. More energy, more focus and concentration, a high of sorts.

But this only lasts so long, before the benefits disappear and you are simply back in a place of being stuck. And more stuck than you’ve felt in a long while.

This is why making it through this quasi recovery is so important. So, you can reach a place where you are solid in your recovery. Where things aren’t precarious and on a knife-edge.

Reaching Full Recovery

This is why full recovery is always the goal. Not some half measure where, for the rest of your life, you are still stuck with the eating disorder, albeit in a less extreme state. Or a state where you are likely to slip back into relapse. We want to aim for full recovery.

At the start, I shared a definition for fill recovery as:

“When you can accept your natural body size and shape and no longer have a self-destructive or unnatural relationship with food or exercise. Food and weight take a proper perspective in your life and what you weigh is not more important than who you are, in fact, actual numbers are of little or no importance at all. You will not compromise your health or betray your soul to look a certain way, wear a certain size or reach a certain number on a scale.”

As part of this article, I talk about other indicators that can signify you are out of the place of quasi recovery.

Breaking Through Quasi Recovery 

Quasi recovery is a place that you need to go through on your journey to leave your eating disorder behind. It’s natural and is simply a descriptor that recovery is only semi-complete.

But it’s actually a difficult phase. Because things are better and it’s hard to keep pushing. Or, if you’ve been in inpatient treatment, it is normally at the point of quasi recovery that you are discharged. Now you don’t have the round the clock support/monitoring that you had before and you’re largely on your own. 

If you find yourself in the place of quasi recovery, I would love to help. This is the case whether you are still making progress with recovery but feel like you need guidance and support. Or if your recovery has stalled and you don’t know how to get it moving again.

I’m a leading expert and advocate for full recovery. I’ve been working with clients for over 15 years and understand what needs to happen to recover.

I truly believe that you can reach a place where the eating disorder is a thing of the past and I want to help you get there. If you want to fully recover and drastically increase the quality of your life, I’d love to help.

Want to get a FREE online course created specifically for those wanting full recovery? Discover the first 5 steps to take in your eating disorder recovery. This course shows you how to take action and the exact step-by-step process. To get instant access, click the button below.