332: The Five Phases of Eating Disorder Recovery

Chris Sandel: Hey! If you want access to the transcripts, the show notes, and the links talked about as part of this episode, you can head to www.seven-health.com/332.

Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I’m a nutritionist and a coach and an eating disorder expert, and I help clients to fully recover.

Before we get on with today’s show, I just want to say that I am currently taking on new clients. If you are living with an eating disorder, irrespective of how long it’s been going on, and you want to reach a place of full recovery, then I would love to help. I know the idea of full recovery can feel like this nebulous concept or something way out in the future or might not even feel possible, but I truly believe that everyone can reach a place of full recovery and that if you do the things, it will occur. It’s not a ‘it might happen’, it’s a ‘it will happen’.

So if you would like to reach a place of full recovery and have the eating disorder truly be a thing of the past, then I would love to help. You can send an email to info@seven-health.com and just in the subject line, put ‘coaching’, and I can then send over the details.

So, on with today’s episode. As part of this one, what I want to go through is the different phases of recovery. This is something that I’ve come to figure out as I’ve been doing this for the last 15-16 years of seeing clients and just realising what it takes to recover – realising that people are at different stages of recovery or in different phases of recovery and that within each of those phases, there are certain symptoms that are going on or there are certain thought patterns that are occurring, and there are also things that are more important at that phase. If you’re in the first phase versus in the fourth phase, there’s things that are going to be drastically different in terms of where to be putting your focus and what is a priority.

So what I want to do as part of this episode is just go through these different phases. This is something that I came up with; this is something I’ve just taken from my Fundamentals programme. I have a programme called The Fundamentals of Full Recovery, and this is something that, when working with clients, they can be doing this while we work together. It’s a six-module programme that goes through so many different aspects of recovery, and it just means that they can be working on this while we’re working together. It’s just one of the components of working together that I offer. So this is taken from there, and what I would suggest is having a listen and seeing for yourself if you can identify which phase you’re in, and based on that, what’s going to be most important for you.

In terms of the five phases, I’ll tell you what they are to start with and then I’ll work my way through them. The first phase I call Stabilization & Foundational Rehabilitation. The second stage I call Quasi-recovery. The third stage is Refinement & Mastery. The fourth stage is From Recovering to Recovered. And then the fifth phase is Fully Recovered.

00:03:18

Phase 1: Stabilization & Foundational Rehabilitation

Starting with this first phase, Stabilization & Foundational Rehabilitation, this is where someone is very much at the beginning of their recovery journey. And when I say beginning, I don’t mean that they’re only just getting started with recovery. People can be at the beginning even though they’ve been trying to recover for a decade, two decades. This is really about where someone’s at from a physical standpoint, a mental standpoint, the kinds of symptoms that are going on, and their ability to make changes, what the changes are, how those changes are then leading to either improvements in their symptoms or not an improvement because it’s not a change that’s been big enough.

So let me just go through what are the characteristics of being in this stage.

At this point, there’s a high level of energy debt or malnourishment. And whenever I say this, people have this idea in their mind that this must be someone who is visibly emaciated and matches up to the stereotype of what we think about when someone hears the word ‘anorexic’. But this is just not true. You can be carrying a huge amount of energy debt, you can be malnourished all across the weight spectrum. This isn’t about someone’s BMI; it’s about how much energy has been coming in versus the energy that the body actually needs to be able to run and function.

When it hasn’t been getting what it needs, the body has to turn down the metabolism. It has to turn down certain functions and turn off other functions. It has to then focus on survival versus thriving. This means that there’s a lot of things that should be happening for us to be happy and healthy and being able to function optimally that just don’t happen. This is where that energy debt accrues because the body hasn’t been able to prioritise these things that are really important as part of true health.

This is where someone is starting. There’s this high level of energy debt, and this is what is then leading to lots of the symptoms. So much of the physical symptoms, so much of the mental symptoms that are going on are connected to the changes that take place in all the various systems within the body, changes to the brain and then the mind. So that’s why there are so many of those symptoms occurring.

But it’s also when there’s a lot of symptoms that can occur when someone starts to make a change. So if you start to make a change, for example, where you’re bringing in more food, that doesn’t instantly start to make everything better. It is the solution, but in the beginning things can get worse when that happens. You could find that your digestion is now worse because your digestion is trying to digest more food, and there can be this lag time before that energy then gets put towards digestion. So yeah, there can be more digestive distress or symptoms that occur. There could be oedema that starts to occur during this stage. There could be someone feeling a lot less energized. There could be more tiredness because of these changes.

So there can be a lot of recovery symptoms that start to occur at this phase.

I talk a lot about polyvagal theory, and I’m not going to go into it in any great detail here. I’ve done a number of podcasts on this, so I will link to them in the show notes. But when I think about this from a polyvagal perspective, someone is spending more of their time in the sympathetic fight-or-flight state or more of their time in the dorsal vagal shutdown state. Basically, the body’s nervous system within this state is on high alert for cues of threats versus cues of safety.

So there’s a lot of cues of threats that the body is picking up, and this makes sense and is why there can be such difficulty when trying to make a change, because whatever change is contemplated or is taking place, the nervous system is registering this as something that is a threat, something that’s going to go wrong, and that’s why there can be these emotions, these sensations, these unhelpful thoughts that arise.

During this phase is when there can be extreme hunger or hyperphagia, or it can be when there’s low hunger and this real need for mechanical eating. When these things occur and in what order will depend on the person, but extreme hunger is something that does occur for a lot of people and it’s a really important thing for the body as a way of starting to drive you towards bringing in more energy so that the body can actually start to heal.

But for many people, they can have a situation where they feel no hunger signals or have this very low appetite, and a lot of this can be connected to the fact that if you have restricted for a long time, if you’ve done lots of exercise for a long time, it can have an impact on your ability to hear hunger signals. Many of the signals that are being sent just get thought about as everyday noise, and you don’t even make that connection between them. The only time there’s this registering of hunger is when it is so blindingly obvious because you’ve got this gnawing sensation in your stomach that you know you must be hungry. And then anything less than that just feels like “I’m not hungry at all.”

So part of this can be just that there’s not enough of an association with what hunger feels like anymore because there’s been this real disconnection. In the beginning, there’s this need for mechanical eating and eating in a structured way, but as time goes on and as more food starts to come in, this can often be when the extreme hunger or the increase in appetite can then start to occur.

I would say that in terms of the thought process around this stage, this isn’t always the case, but I often find this is where people can still be trying to find a way to recover while keeping many of the eating disorder behaviours and beliefs. So “I want to recover but I want to do so without gaining any weight” or “I want to recover but I want to do so without actually making any changes to my exercise” or “I’m going to recover but I’m going to do it in the most incremental way so that I gain the least amount of weight possible”, and there’s all of this really eating disorder thinking in terms of “How could I do the recovery process but still get to avoid so much of the uncomfortableness, whether that’s the uncomfortableness of making this bigger change or my body changing or having a break from exercise.”

There’s a lot of those kind of thoughts that come up, and I think they’re very normal to experience; it’s just, what does someone then do with that? For some people, they stay stuck in that place, trying to find this alternate solution, and can stay there for years or decades, versus “Yes, I’m having these thoughts, and I’ve realised that there is no way to recover without going through. There isn’t an alternative where I get to do recovery where I don’t take this pause on exercise” or “There isn’t a way I can recover without gaining weight.” So there can be this acceptance that then starts to come in, even if it’s begrudging acceptance. There’s just more contact with reality in the situation, even though there can be a lot of these thoughts that are still coming up.

As part of this, there is a high level of eating disorder thoughts, and this is throughout the day. It can be especially high when we’re getting to a meal or we’re getting to a point of making a change. But it’s very normal in this phase to have a high level of eating disorder thoughts.

Really, if we’re looking at someone’s behaviours at this point, there’s a lot of rules. There’s a lot of rigidity. This is what makes making changes so difficult, because there are all these rules that are in place, and even if they aren’t explicit, they become obvious when someone starts to try and make a change of “Oh, I didn’t realise that I actually couldn’t eat earlier than this point” or “I didn’t realise that I had to stop eating before that point. I was just so used to doing those things that now when I try and change it, I realise that there is this rule that is here.” So because of all these rules, it just makes making a change difficult. It doesn’t prevent it; it’s just really common in this phase.

It can be really difficult to make a change without compensatory behaviours and eating disorder behaviours. So “Yes, I increased my breakfast, but now the eating disorder is suggesting that I need to go for a bigger walk later today, or I need to skip my snack in the afternoon.” It feels much more difficult not to do those things. It’s hard to make a change and then just sit with the change and be with that change.

And look, I will say with all of these things, I’m making some generalised comments. For certain people, things will be more difficult; for other people it’s more easy, and there can be reasons for that. It can be just blind luck for why that is occurring. But there is this pull more towards compensatory behaviour in the beginning when making changes. And again, the people who tend to make better, bigger inroads as part of recovery are the ones that are able to have those thoughts come up and then still not do the compensatory behaviours versus the person who is constantly making one change but then compensating in this other way, where they just don’t get any real benefit from that change.

You have all this extra anxiety, all this extra thought about these changes you’re making, but because there’s then this compensation, you’re just not getting a benefit from doing it. And I think that is the worst of all worlds in that situation because at some point, someone thinks “I just can’t recover” or they get burnt out from all of this trying. But really, all of the trying is just a version of the eating disorder.

I would say that there’s a lot of justifying and rationalising in this phase as well – and really justifying and rationalising “why I should be able to keep up this eating disorder behaviour or this compensatory behaviour.” The eating disorder is very good at using logic with this stuff, whether it’s about health, whether it’s about “This would be really good for my mental health” or “I really suffer with anxiety when I try and do this thing.” Whatever the reason may be, it feels really justifiable. And again, the more someone is able to have that thought and still do the pro-recovery choice versus the person who has that thought and gets hooked by it, that’s where people have very divergent experiences in terms of their recovery. One person’s making real inroads and then someone else is feeling stuck as part of that.

So those are a lot of the characteristics of this Phase 1 of recovery. As part of this phase, you’re then starting to make changes to move you out of this phase. And with all of the phases, there can be many shades within those phases. You go from the very beginning point to the end point to then move on to that next phase.

What I would also add is commonly, when people tell me, “I’m in quasi-recovery”, when I actually look through what’s going on, my reflection is you’re not in quasi-recovery. You’re still very much within this first phase, the stabilization and foundational rehabilitation stage. The reason for their belief that they are now in quasi-recovery is because of this idea of “Well, things used to be so much worse. I used to be exercising so much more than this, or I used to be eating so much less than this.” There’s all these reasons given about “what I could do” or “what I couldn’t do”.

It’s true that they may be in a better spot than they were before, and when I look at what’s going on, they’re still within this first phase. There are still so many symptoms going on, there is still so much eating disorder noise that’s getting in the way of things, and it’s still clear that they’re still very much at this beginning phase of things.

00:15:37

Key areas of focus in Phase 1

So when I think about what is most important for this stage, it is getting out of the energy debt that has accrued so that changes can then start to occur. And when I say changes, I mean changes in terms of physical symptoms in the physical body, changes in terms of the brain and the mind. So really, we need to be focusing on nourishment and repair. How do we bring in more energy? How do we have more rest so that the body can then start to change, which is driving so much of the thoughts and feelings and beliefs because of the state that it’s in.

As part of this phase, yes, we’ll start to look at what are different coping skills that someone can then learn to deal with uncomfortable thoughts that come up or difficult emotions that come up, but so much of the coping skills at this point are just how they can then be used to allow you to make the recovery changes. Because as we go on, there’s a lot of stuff that is useful in recovery but then becomes so much broader and is useful for the rest of your life. We’re learning different skills and practices that you can use for the rest of your life.

Some of the stuff that we learn in this phase is truly about the rest of your life, but it’s very much geared towards “We’re doing this so you can take the next right pro-recovery action.”

00:17:06

Phase 2: Quasi-recovery

The next stage or phase is quasi-recovery. This is what I think of as the second stage as part of recovery. The word ‘quasi’ means partial, so really this just means that some recovery has taken place. And when I say some, I’m meaning that there’s been a decent chunk of recovery that has taken place. And how we’re able to know that that has occurred is that there’s less physical symptoms than there were before. This either means that “This symptom I was getting has now completely disappeared” or “This symptom that I was getting has now greatly reduced.”

It might be that “I wasn’t getting my period and now my period is coming back.” That could be an indication of being in quasi-recovery. And I want to just say that people get so hung up on the importance of getting a period back. And yes, it can be important; it can be important for reproduction, but it can be important for so many functions within the body, because what we think of as reproductive hormones are not just about reproduction. They’re important for pretty much every system within the body. But I think there can be this misunderstanding that “If I get my period back, that means recovery is fully done, that my body’s healed”, this idea that getting your period back is going to be the last thing that your body ever prioritises. And that’s just not true at all depending on the individual, depending on how early or late this comes back.

I’ve worked with clients where their eating disorder got to a stage where they were being tube-fed, and yet their period was still there. And I’ve had other clients where their period was one of the first things to go and it had disappeared before really any other symptoms had started to occur. So when thinking about the period, we need to be thinking about it in conjunction with all of these other symptoms, in conjunction with eating disorder thoughts, with all of these other things, not just that the period is this one defining thing that tells us exactly where someone is in recovery.

People in this phase are more accepting of recovery. What I would say is this doesn’t mean that they like every part of recovery. There can still be difficulties with it. There can still be body image struggles or there can still be challenges with this thing or that thing. But I would say what is part of this phase is there’s much more of an acceptance of it. So there’s less of the magical thinking that can be associated with Phase 1, where someone’s really trying to search for all these other ways of being able to do this as opposed to you just have to go through these certain aspects of recovery.

So yeah, we can say there’s more acceptance, even begrudging acceptance, but more acceptance is here at this phase. From my perspective, when I’m working with someone and we’re setting goals and working on things, people at this stage often just tend to get on with things a little easier than before.

In this phase, there can be where we’ve now got past the really obvious extreme eating or extreme hunger phase, and often what can happen in this phase, there can be this feeling of “I feel bored with food.” When I’m starting to look at this and looking at the different symptoms that are going on, this is often a lot more about anxiety that is blunting this rather than truly someone needing less energy. When we start to look at it in terms of if someone’s eating drops down for a couple of days, we just notice how much things can rebound from an eating disorder perspective and how much body image can really tank very quickly, or how much cravings can suddenly rush back or someone feels like they’re starting to get extreme hunger again very quickly.

It’s important at this phase, even when someone’s feeling like “I’m just not as hungry as I was before, I’m just getting quite bored with food”, still really keeping up with the structure in terms of the eating and still having the same level of food coming in, just because I want people to start to use intuitive eating, I want people to notice hunger and fullness; it’s just at this stage – and again, quasi-recovery is a whole stage and you can be at the beginning part or you can be at the end part, but especially at the beginning parts and until we get to the end part, I don’t think that someone’s hunger is always the most reliable indicator of how much they should be eating at this phase.

So really important with keeping up the structure and still having the meals and snacks, even if I don’t necessarily feel like them.

During this phase, there can still be lots of fears, and this can be fears about weight or fears about how life is going to end up or how recovery’s going to end up or the uncertainty of recovery. That’s definitely not disappeared by this second phase. I think that’s still there, and for a lot of people they then experienced some of the things that were scary or they thought were going to be scary as part of recovery, and their experience with this could be very different. There could be the fear that I was going to gain weight and then as part of this phase, that has actually happened, and there can be the recognition of, “Okay, I’m able to handle this maybe a little better than I thought” or “This is challenging but I’m able to navigate it” – and yet there can still be the fear of “But where is this going to end up and how will this end up?”

But even though there are these fears there, someone is still being able to make these changes, and they still keep going with their recovery.

I would say that people in this phase start to spend a little more time in ventral or safe & social. Again, I’m using the parlance of polyvagal theory. This is where we’re starting to get more of those cues of safety and having those be experienced through coregulation or finding different practices that help it. We’re still in a phase where that can be hard to be staying there all the time, and there can still be a lot of dropping down the polyvagal ladder and still having challenges around this. But if I compare this phase in quasi-recovery versus the previous phase, we are spending a little more time with those moments of safe & social, those moments where we are seeing more cues of safety.

I would say that here, people are able to make changes just a little easier. Even though making a change can still feel like a really big deal, and depending on what the change is, it could still feel very challenging, it tends to be a little easier here. And I think part of that is because by this stage, someone has started to see the benefits of making changes in their recovery. In the first phase, it is a little bit of a leap of faith. I don’t think it’s a complete leap of faith, especially if someone is making meaningful changes; within a couple of weeks, someone can start to notice some meaningful changes in terms of various symptoms.

And it’s not that things completely go away, but someone’s able to notice, “Hey, I’ve got a little more ability to be present than I was before” or “I’m able to rest in a way that I couldn’t before.” So being able to notice that there are these glimmers of things that have changed – and even things that might not necessarily feel like a win, but someone’s able to recognise that they are a win. So “I’m feeling a lot more emotions, and that could mean that I’m having moments of laughter that I haven’t had before, but it also means that there’s a lot more crying than I was doing before. That feeling of numbness that I had has now disappeared.”

So someone’s able to recognise that “The changes I’m making in terms of my eating and my exercise and all the things to help me get out of that low-energy state are actually translating into really important changes in terms of my symptoms and my quality of life.” It’s not that someone is fully there; it’s just that they’re able to recognise that there is this cause-and-effect relationship between those two things, so that’s then what’s helping continuing to make those changes.

In this phase, there’s less eating disorder thoughts, and/or an increased capacity to see through those thoughts. Maybe the thoughts are the same amount; it’s just I’m not impacted by them in the same way.

But I would say still within this phase, people can very much be triggered by comments or situations or events, and this is where it can still be pretty difficult. So “That thing at work where everyone was talking about their dieting, that was really hard for me to deal with” or “We went out for a meal and it was just so hard for me to really be present on the meal because I felt like people were judging what I was eating or I was so unsure about what to order.” So there are still events that can be very triggering and difficult to deal with.

I’m just saying this because if you feel like “Hey, I’m so much further along in my recovery; why is this stuff still bothering me?”, this is still pretty normal at this phase. And it’s not like this forever. It does get better, and I’ll talk about that in a moment. But I do think that that is something that someone needs to be able to look out for, and this is the kind of thing that we then have conversations around, like how to deal with those certain situations and be able to come out of them as unscathed as possible.

I would say with this one, there’s a greater capacity to stop certain behaviours and to not be using eating disorder behaviours in certain situations, and as this phase goes on, that capacity just continues to grow.

00:27:32

Key areas of focus in Phase 2

When I’m thinking about what’s most important here, one, it’s still the same stuff as the first phase: continuing the nourishment and repair. We’re still needing to bring in more energy, we’re still needing to have more rest so that the body can do the repair. And as we’re going through this phase, more of that repair is taking place.

We can also at this point start to be a little more intentional about working through different food fears or food rules. And I think at this point, we can start to do some of the work around developing tools that are about recovery but moving outside of just recovery. So looking at how to truly develop psychological and emotional and connective resilience – and again, these are things I talk about as part of the programme and the way that I work with people, but really starting to work on some of this.

The body image piece and the body acceptance piece, this is probably where I spend a little more time on this. I think if someone’s in the very early stages, there’s so much that is being impacted upon just by the state that they’re in that it’s hard to really do that work. And it’s not that we can’t have conversations around it, but again, so much of it is geared towards “We need to be doing the things to take action.”

So I think it’s more at this phase, and especially as this phase goes on, that we can start to have more meaningful discussions around this piece, because it feels like I’m able to talk to someone who isn’t just having threats go off left, right, and centre. They’re able to be a little more rational about things. They’re less impacted upon by the eating disorder.

00:29:16

Phase 3: Refinement & Mastery

The next phase is then refinement & mastery. As part of this phase, things have really improved. When I think about that eating disorder thoughts, they have significantly reduced, and even if they are there, someone’s very good at being able to take action irrespective of them. It’s not that it’s perfect; there can definitely be things that still come up and still derail someone and still have “I had this difficult afternoon or I had this difficult week” or whatever it is, but they’re in a much more stable place to be able to recognise these thoughts and still be able to take the action that is required.

By this stage, most of the physical symptoms have either completely improved or are most of the way there. That means that when I start working with someone, I go through all the symptoms that are going on, and they have noticed by doing the reduction and stopping of exercise, by increasing food intake, that this stuff has improved.

The thing I always say with this is doing recovery doesn’t take everything away. For a lot of people, before the eating disorder started, there were problems with digestion. So as the eating disorder improves, there can still be problems with digestion. Just being able to keep this in perspective of if there were things that were going on before the eating disorder started, then they’re probably still going to be going on even through recovery, and there are things that are going to take much longer to heal.

Like if someone has osteoporosis or osteopenia, then it’s going to take quite a while for that stuff to repair and improve, and depending on how old someone is when they’re doing recovery, that stuff may never completely improve. But if someone’s in their early twenties and they’re doing this work, then I do truly believe that their bone health can get back to a very good place. That’s just going to take longer. But if I’m thinking about this phase, a lot of the symptoms have drastically improved.

At this point, this is typically where the weight gain piece or the weight gain starts to level off and either then comes back down a little bit or this is where it stops in terms of increasing. When I say stops increasing, it’s not because someone has intentionally started to intervene. It’s not that “I think I’ve gained enough weight, so I’m just not going to do the things I was doing before.” It’s that even when we’re still not exercising, even when we’re still eating a high number of calories, I’m just not gaining weight anymore. The body is now prioritising repair as opposed to weight gain at this point.

I would say at this point there can be a craving of a wider variety of foods and just needing less food at this stage than in earlier stages. And again, this is dictated by the body and not by you. It’s not deciding, “Oh, I shouldn’t have any more.” It’s really, “I’ve eaten so much peanut butter, I just can’t stand any more peanut butter. I’m so sick of it.” I would say by this stage that hunger and fullness have become a much more reliable indicator than previously, and this doesn’t mean they are the only things that someone focuses on in terms of their judgments around what to eat and how much to eat and what they should be eating, but it can be one of the things that they can start to look at.

And when I think about intuitive eating, this is probably the point where all 10 of the principles are applicable or open to exploring. The thing with this stage, and the reason I call it refinement and mastery, is someone is now at a phase where we can start to play around with things and see what happens.

For example, we can go from “We’ve been doing this very structured way of eating; we don’t have to completely remove the structure, but let’s see what happens when for the next three days, you start to use your hunger a little more in terms of your decision-making. We’re still going to have the meals at the same time, but maybe you have a little less for your lunch if you’re not as hungry. Maybe you have more for your lunch if you’re hungry. But let’s see what happens in terms of using hunger and fulness as your guide.”

And we don’t have to say we’re doing that now forever; it can be, “We’re going to do this for three days and see what you notice. And then after those three days, go back to what we were doing before and let’s compare and contrast.”

This is the case with lots of different aspects of recovery. For example, this could be the point where someone starts to bring in exercise and starts to try bringing in exercise. Again, we can do this in a fashion that is appropriate for someone – I’ve done a whole podcast on exercise and exercise in recovery, and I’ve talked about bringing it back in, but this is where we would then start to explore that. And if things start to go a little sideways when we do that and now there’s more fears around weight gain again and there’s more body image struggles and “I’m now having these concerns about my eating again”, okay, maybe we need to put a pause on this. We’ll go back to what we were doing before, and in two weeks’ time, in a month’s time, at some point in the future, we’ll re-try doing this again and see what happens.

This is why, again, I call it refinement and mastery, because you’re trying things out. You’re refining you getting back to having a healthy relationship with food and with movement, and being able to do these things in a much more freeform way because you’re able to really, truly listen to your body and what it needs.

I would say here is when we’re bringing in and someone’s able to do spontaneity much easier. They’re able to spontaneously eat with either minimal fear, or even if there is fear, they have the capacity to be able to do it fairly easily. So “Even if there was that initial anticipation anxiety, when I actually get there and I start doing it, I’m fine with doing it.”

I would also say here is where those things that used to really trigger someone are no longer a trigger for them. For example, hearing about someone’s diet talk at work or if the person in recovery, you, are eating and other people aren’t eating, that’s not a problem for you. Or if you’re eating and you’re eating much more than someone else, that’s not a problem for you. Or you order a dessert even though someone doesn’t order a dessert and that’s not an issue. Or you notice that someone’s exercising or you hear about someone’s exercise practice. All of these different things that can be very triggering at this point are just not triggering. Maybe there’s this initial thought that comes up, but “I’m able to put it to the side very quickly.”

Or “I’ve gone from this place of when I used to hear this, initially it used to be so triggering and I used to want to do it myself. Then the next phase was I would hear this and I would get so angry that other people get to do this thing and I don’t get to do this thing, and that just seemed so unfair to me, to then getting to the point of, my God, I’m so glad that’s not me. Man, when I hear about that person doing this thing, I’m not envious or jealous; I’m just glad that I’m not having to put myself through that anymore, because I realise how much that was impacting me in a negative way, that was sucking the joy out of my life. I like how I’m now spending my time.”

And look, it’s not going to be always 100% perfect like that. There can be ambivalence with some of these things, so “I can recognise that thing and at the same time there can be still a little bit of grief ocnencted to my past ability to do certain things or my past body.” But there’s just, again, much more acceptance of these things, and when these things happen, it’s not this big trigger where it’s really difficult to deal with. It’s something that is able to come up and someone’s able to navigate their way through it pretty easily.

00:37:39

Key areas of focus in Phase 3

When I’m thinking about the most important things at this stage, it’s still we need to be getting in the right amount of food and rest for what we need, but that now just becomes the baseline and someone knows how to do that. They’re now working through the remaining food rules and food fears. These might not feel quite as daunting or as big as before, but “I still recognise that I haven’t had that food yet, or I haven’t had that food before this point of the day yet, or I haven’t had that four times in a day yet because I have this rule that I’m not allowed to have it that many times.” So being able to work through these things.

This is where someone is really testing their recovery. They’re testing it in terms of bringing back in movement, or they’re testing it by putting themselves in more challenging situations or more challenging environments, and we’re doing this at this point because we’ve done the more important piece with creating the right foundation for this, and now someone’s at a point where we can do these challenges and they’re not going to be as impacted so quickly as if they were in Phase 1.

For example, doing a challenge for three days – if we do that in Phase 1 where someone starts to eat a little less over those three days, within the end of that third day, it’s like, “This is the new norm. This is what I do.” It feels so hard to then do anything different from that versus by this phase, if we do something for three days and someone’s able to recognise it’s actually not good for them in terms of their recovery, to be able to course-correct is just much easier. You’re not affected in the same way. This is why we can start to do some of those challenges that allow someone to be expanding the things that they’re able to do.

And really, the final piece connected to this one is really strengthening the structure of someone’s day, where it’s very much focused on “These are the things I need to be including in my day or in my life to truly serve me in terms of my recovery, but also giving me the quality of life I want to have.” There can be a lot of writing or exploring around this type of stuff, and then getting someone to really be implementing this.

00:39:55

Phase 4: From Recovering to Recovered

Then the next stage or phase is from recovering to recovered. This is really the phase where someone’s starting to work through all the remaining bits of recovery. By this stage, things like food and movement and numbers and eating disorder behaviours, when we think about eating disorder behaviours in terms of stuff around food or exercise or the very obvious things – these are just no longer an issue for someone. They’ve really moved past those kinds of things.

There are still occasionally eating disorder thoughts, but they’re much more rare and infrequent, and when they do occur, someone’s able to instantly recognise them for what they are, or they occur and someone’s able to take a pause and think, “Okay, what’s going on? I haven’t had this come up for a while. Why may this be happening?” It could be because of the busyness of work and life that they’ve got into a little bit of a lower energy state, and this is why these thoughts are coming up.

Or there could be the recognition of, “Yes, actually, I’ve got that new job application and interview next week, and whenever things get really challenging or I feel a little bit stressed or I feel a little bit overwhelmed or there’s a little bit of that imposter syndrome that comes up, that’s where there’s this real transference onto my body and wanting to change my body or use these past eating disorder behaviours.”

So just being able to have a lot more equanimity in terms of emotions and awareness of “Hmm, isn’t it interesting that that thing has come up?” I think as someone is getting to this much further place in recovery, they’re able to notice these things and not freak out, but just notice them and be able to reflect on them, and then make the change that needs to be made.

At this point, the body really has physically repaired from the eating disorder, and this is including the brain and the mind. Again, it’s not that someone can’t be experiencing any symptoms; it’s just that we’re not chalking them up to the fact that someone is still in this depleted state. It could be just to do with we all, as we get older, have different symptoms that come up, or this thing really predates the eating disorder. But it’s not the eating disorder that is driving these symptoms, apart from, as I said earlier on, if we’re looking at something like bone health; that can take a lot longer to heal.

Really, from this phase, this is where I’m thinking about doing recovery in all of the other aspects of life that we don’t necessarily think of as being impacted upon by the eating disorder. So many of the things that someone does from a behavioural standpoint or from an identity standpoint or all of these other areas of their life. Looking at things like someone’s relationships and how they’re able to set boundaries or how they’re able to have difficult conversations, or someone’s relationship with sex or their relationship with money or spending or their role and relationship as a parent or their connection to work or overwork.

All of these different ways that the eating disorder can morph and have these effects in these other areas – because for a lot of people, they can get over their eating disorder and then five years later, when they reflect on it, they’re like, “Yeah, I got over the eating disorder but I just completely threw myself into work, and I was actually using work as my way of avoiding certain things in my life”, and work then became their way of doing a lot of the things that the eating disorder was doing before.

So really starting to look at all of the ways that the eating disorder either can or has infiltrated someone’s life and starting to work on that.

I would say that in this phase, it’s really continuing to prioritise a life that is in alignment with your values and is providing meaning and purpose. This can happen in lots of different ways. This isn’t because you’ve gone off and started a nonprofit or that you’ve gone and you’re helping sick people in this part of the world. It could be that “Hey, I’m prioritising being the best mum that I can be” or “I’m prioritising my relationship” or “I’ve still got the same job that I was doing before, but I found these other hobbies that feel like they’re providing my life with meaning and purpose.”

I would just say that in this phase, as with life after recovery, you’re continuing to prioritise committed action instead of avoidance in all areas of life.

00:44:40

Key areas of focus in Phase 4

So when I’m thinking about what is most important for this stage, I really want people to recognise at this point that they are still at high risk for relapse and to really continue to cement recovery, and making it through these challenging life events that will occur without using the eating disorder, and to instead keep up with recovery.

I often get asked, “How do you know if someone’s fully recovered?” or “At what point is someone fully recovered?”, and my honest response to people is normally, if you think you are fully recovered, add on another 18 months and then let’s talk about it.

And the reason I say that is I want you to have things happen in your life that test your recovery, where there is a death in the family, where there is a pet that dies, where you do get made redundant, where there’s this really challenging thing that happens in your relationship, where there’s challenges with kids at school – there’s all of these things in your life that come up. And I’m not wishing those things on you; it’s just this is what happens being an adult and being a human in this society. Things will happen in our life, and you have all of those things happen in your life and still, even when all of those things get thrown at you, you’re still not going back to the eating disorder. You’re still continuing on with the things that are about your recovery.

This is why I call this ‘From recovering to recovered’, because it’s through going through this phase that you’re, one, working on all of the extra areas that the eating disorder has infiltrated, but two, you’re continuing to do the things that cement and cement and cement your recovery so that you get to a point where it just feels like “I’m never going to relapse here because I’ve just proved that I’ve gone through this difficult thing and this difficult thing and this difficult thing, and none of those things derailed me. I was able to lean into the things that truly do support me in those moments, and I have developed all these tools and this resilience and ways of being.”

So that’s this stage 4 of recovery.

00:46:52

Phase 5: Fully Recovered

And then the final phase is just being fully recovered. When I think about this phase, you have a relaxed and a free relationship with food and exercise.

And look, what I want to say with all of this – especially with this final phase – is I want people to be realistic about this. I know the society that we live in and how it talks about bodies, how it talks about exercise, what is presented to us on social media, what is presented to us in the media more generally. With everything I’m going to say here, I don’t want to create this impossibly high bar where someone believes “I can never have a challenging day, I can never have a bad body image moment, I can never have these experiences because that means I’m not recovered.”

I think it’s human to go through so many of these experiences because of the society we live in. So what I’m saying is that someone has a relaxed and free relationship with food and exercise, even though there can be moments where things can be a little difficult. That someone has made peace with their body and are accepting of it, even though there can be challenges. And depending on the size of body someone is in, depending on the ableism of the body someone is in, it can then have an impact on what peace and acceptance really means for that person.

It’s someone who is acting and behaving in a way as if they had never had an eating disorder. And when I say never had an eating disorder, it’s not that someone hasn’t learnt lessons from this experience. I think there is a huge amount that someone can take from this experience of having an eating disorder and then the recovery process.

So someone has learnt a ton by going through all of that, but in terms of someone’s day to day, if someone was to look in – or probably more accurately, if I was to look in, because I think for a lot of society, when they look at what someone’s doing, they’re not going to necessarily have red flags go off or be concerned. But if I was to look in and follow you for a week or a month with a video camera, there’s nothing that is going on that would give me pause and think “I wonder if this person is still dealing with eating disorder thoughts and they’re getting the better of them and they’re doing this thing as a way of compensating and those kind of things.”

It’s just the person is living a life where it is very obvious that they no longer have an eating disorder. And really, no matter what happens in life, no matter how challenging it gets, they don’t turn to their eating disorder. Even if, as I said before, you can notice in certain moments those thoughts start to come up more, or there is more of a pull towards doing this kind of thing, there’s the recognition and the ability to pause and just notice, “Oh, isn’t that interesting? I wonder what that tells me.”

Really, full recovery is prioritising action-taking instead of avoidance so you consistently do this even when it’s uncomfortable. I talk about eating disorders as being anxiety disorders, and all anxiety disorders being about avoidance. So really, recovery – both the recovering process, but also when we get to a place of full recovery – it’s that I’m consistently choosing taking action over avoidance.

And again, there will be times when things do get avoided. “This is a really difficult conversation to have” or “There’s this thing going on with my mum and I just don’t know how to deal with it.” That does come up, and just because that happens, doesn’t mean that someone is relapsing or doesn’t mean that they haven’t got to this place of full recovery. But I think the more those things start to happen in terms of more of the avoidance starts to happen, even if it’s not stuff around specific ‘eating disorder’, so it’s not about the food stuff or the exercise stuff, I am then a little more concerned of like, okay, where does this start to lead? Because I really want someone to be having their default way of being is “I’m going to choose uncomfortable action over avoidance.”

00:51:16

Why knowing the phases is important

So that is how I think about the phases of recovery and going from being in this very starting place through to being at a place of full recovery. This isn’t an exact science with this stuff. There can be times where I’m not sure if you’re in Phase 1 or Phase 2, and in that situation, it doesn’t really matter, because there’s a lot of the same stuff that’s important in both of those phases. But I can definitely tell the difference when someone’s in Phase 1 versus Phase 3. It’s very obvious the shifts that have occurred between those two things.

Why I think this is important is, one, it can really help in terms of managing expectations. If I’m in Phase 1, yeah, it’s normal to have challenges be difficult. Yes, it’s normal to have lots of eating disorder thoughts. Yes, it’s normal to have discomfort – physically, emotionally, mentally, when I eat this particular food. So managing expectations of “That’s what’s meant to happen in the phase that you’re in.”

But two, understanding then what is important as part of this. People talking about, “But I thought it’s healthy to exercise.” Yes, it can be really healthy to exercise, and it can be a really wonderful thing for someone to do for their physical health, their mental health, for enjoyment, for joy, for lots of different reasons. And if someone’s in Phase 1, those things don’t apply because it’s not doing those things for that person. It’s not adding to the quality of their health because actually, what they need more than anything is to get out of the low-energy state that they’re in.

So really understanding “What phase am I in?” to know what is really important at this phase versus “I need to just put that to the side for now because that’s actually not where I need to be putting my attention.”

So, that is it for this week’s episode. I hope you found it useful. As I said at the top, I’m currently taking on new clients. If you want help to reach a place of full recovery, if you would like support and guidance as you work through all of these different phases, I would love to provide that for you. You can send an email to info@seven-health.com. Put ‘coaching’ in the subject line and I can then get back to you on that.

Alright, that is it for this week’s show. I will catch you again next week. Until then, take care, and I will see you soon!

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Here’s what we talk about in this podcast episode:

Intro