Recovery is tough. I regularly say to clients that it will probably be the most challenging thing you ever do.
It’s truly heartbreaking that such a high percentage of people never recover, end up relapsing or get stuck in a permanent place of quasi recovery. And while it saddens me that this is the case, there are many reasons why full recovery is so elusive.
In my recent podcast with Emily Troscianko, she talked about her recovery experience and there was one point that especially stood out to me.
She’d been eating more and gaining weight for many months. Her weight had now entered into the supposed “healthy” BMI range. And because of this, her clinician said it was now time to do maintenance.
Maintenance involved being more careful with portions. Switching back to low-fat milk and other calorie-sparring changes.
Unsurprisingly, Emily quickly recognised that her eating disorder thoughts and behaviours were increasing. That it was easier to skip a snack or not have dessert with a meal.
Thankfully, Emily was able to recognise how much of a problem this was. That her progress was slipping and that the eating disorder was again getting stronger. So, despite the advice that she should be doing maintenance, she continued to eat as she had been.
There is a happy ending to this story. Her weight continued to go on and her recovery continued to happen. This makes sense because eating disorder recovery weight gain is what is meant to happen. But to make the decision that Emily did is not the path most would have taken. Even Emily can’t fully explain how she did it.
I want everyone to have a happy ending to the story of their eating disorder. But advice to do maintenance just because some BMI threshold has been crossed is clearly a block to this.
I got an email from a client last week. She’s someone who has been living with anorexia for nearly two decades and doubts she can fully recover.
She’s been having memory issues for a while and they are getting worse. This is especially troubling at work: she’ll write a brief and then a week later when her boss asks her about it, she can’t remember what she wrote.
I explained that this is a function of the eating disorder. Because of her current energy depleted state, it affects her brain. When the energy debt improves and she recovers, so will her memory. Eating disorder recovery weight gain is what will make this happen.
She then shared this research article with me. The article looked at how the memory of those who recovered from anorexia (or weight-restored, to use the parlance of the article) did not improve.
That the memory issue is, to quote the article, “either a stable trait characteristic or a scar effect of chronic starvation that may play a role in the development and/or persistence of the disorder.”
This client is someone who truly values her brain. Her work is the most important thing in her life. So, reading this information was disheartening. It also added further fuel to the fire, adding credence to her assessment that there’s no point in recovering because it won’t make a difference.
So, I decided to read the article and was also rather disheartened, but for a completely different reason.
The criteria for being used in the study as someone who was weight-restored in anorexia (and therefore demonstrating being recovered) was: “a history of DSM- IV anorexia and a body mass index (BMI)> 18.5 kg/m2, with regular menstruation and no contraceptive medication, and normal eating patterns for at least 12 months.”
When I saw this, my alarm bells went off. This is an incredibly low bar for inclusion to be considered recovered. As I touched on in this podcast on brain changes in eating disorders, it can take many years for brain repair to take place. And just because someone has scrapped into the supposedly “normal” category of the BMI scale, does not indicate that this repair has taken place.
If we go back to Emily, she may have been able to keep up maintenance for a year. She would have been able to participate in a study of this kind and her eating would have been considered “normal”. But clearly, recovery would not have occurred. What truly led to Emily’s eating disorder recovery was further weight gain.
And this also becomes clear when I read on with the research article. It stated that: “Despite a significant improvement in mental morbidity, weight-restored AN patients [the supposedly recovered group] continued to show significantly higher levels of eating-disorder psychopathology and anxiety as compared with healthy controls.”
And again, this raised huge red flags for me about how recovered this group of subjects truly are. There are going to be traits that persist after an eating disorder. For example, someone who develops anorexia may have always had higher anxiety than the population average and this is still the case after recovery.
But to have significantly higher scores on the Eating Disorder Inventory, which is the questionnaire used to determine eating-disorder psychopathology, indicates that there is still further recovery that needs to happen. So these weight-restored anorexia patients from my perspective still needed further weight gain to happen for eating disorder recovery to take place and they were in no way fully recovered.
The sad part is, for many people struggling with an eating disorder, if they read this paper (or most probably just the abstract, I had to find the full paper for my client and me to be able to read the whole thing), they walk away with the wrong conclusion. They believe that things aren’t going to get better and that weight gain won’t lead to eating disorder recovery, so why bother.
Which is exactly the conclusion that Emily Troscianko may have reached if she hadn’t disregarded the advice to do maintenance. She would have thought that this is how my thoughts are always going to be and this is the best it will get.
And when you stay in that place long enough, regression is likely. And so quasi recovery quickly becomes a re-immersion into the full force of the illness.
There is a tendency to shut up shop with recovery way before the actual process is finished. And while there are many reasons why this occurs, let me mention two.
The first is that we, as a society, have a skewed view of what constitutes a “healthy weight.” We’ve been so hijacked by the moral panic of the “obesity epidemic” that it infiltrates research and practices when it comes to eating disorders.
BMI is a terrible yardstick for health when it comes to the general population. And it’s even worse when it comes to eating disorders.
Recovery is about nutritional rehabilitation and the repair of all body systems. It’s about the changing of thoughts, behaviours and beliefs. It’s not about hitting the low end of the BMI “normal” range and doing maintenance; weight gain in eating disorder recovery needs to go further than this.
The other reason why it’s common, and this is something that Emily and I talk about, is a mistaken belief about the fragility of the eating disorder sufferer. That they simply won’t be able to cope if their weight increases too much, so let’s not put them through it.
This is playing squarely into the eating disorder’s hands because this is exactly what the eating disorder tells them. Much like someone in an abusive relationship being told that no one else will ever love them and they need to stay because this is the best they can hope for.
What I have noticed through working with clients is that this fear of weight gain is a function of the eating disorder. People can and do tolerate weight gain; they learn to see that their life is infinitely better than when their weight was lower and they were obsessively preoccupied with it.
This isn’t always linear and there can be times in recovery where the discomfort connected to weight gain is more or less difficult. But with enough time, clients can see that a low weight as being the ultimate determiner of them having a happy life, is false.
And the only way to actually get to this place is through eating disorder recovery weight gain.
Unfortunately, this isn’t something I can convince you of before it happens. I can tell you that this will be your experience, but you’ll only truly believe it after you’ve gone through it.
As I said at the start, recovery is tough. Weight gain in recovery can be incredibly challenging. But full recovery is made even less likely when people are given incorrect information about what to expect or at what point they are “recovered.”
And getting stuck in quasi recovery isn’t a substitute for a full recovery. Because it skews your perception about what truly can be achieved. And it makes it more likely that whatever gains have been made, will ebb away.
If you want help getting started with recovery or you’ve been doing it for a while but are stuck, I’d love to help.
You can click here to register for a free initial chat, or if you want to read more about working together, click the link below.
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