280: Are You Making These Two Mistakes In Recovery?

Chris Sandel: Welcome to Episode 280 of Real Health Radio. You can find the show notes and the links talked about as part of this episode at www.seven-health.com/280.

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 I help clients to fully recover.

Today on the show, it’s another solo episode. It’s another one where I’ve just jotted down some notes and I’m going to just see what comes out. The topic for this one and what I’m going to cover has really come out of a lot of the initial chats that I’ve had with clients or potential clients over the last handful of weeks. I’ve been doing the recovery strategy calls with people and seeing if they were the right fit and if the way that I’m practicing is of interest to them. I’ve signed up all the people that I’m now working with.

As part of doing that, I talk about clients’, or potential clients’, past experiences in terms of recovery. For so many of the people that I work with, this has been going on for a really long time. They’ve been living with this for 10 years, 20 years, 30 years. A lot of the time it started when they were quite young; it started in their teenage years, so I’m definitely not the first person that they’ve tried to work with, and there’s been many different attempts – and different attempts at different levels, whether it be inpatient or outpatient.

When someone applies to have their recovery strategy call, I actually send over an application form, and there’s a number of questions that I want someone to fill out as part of that. One of the questions is, “What has been missing from the previous options that you’ve tried?” The content that I’m going to go through, or what I’m going to talk about now, connects into the responses that I got from that question and the responses I got when I was then talking to the people and elaborating on that.

There’s a couple of different approaches that I want to cover that are often taken in terms of dealing with an eating disorder that don’t seem to be particularly helpful, and don’t seem to be particularly helpful because I think they are just one part of it. So let me just get started with the first one.

00:02:42

Mistake #1: ‘Just get the food in’ approach

The first approach that I see, and I see this as a very common thing, is the idea that if we get this person to eat all the food, and to either go all-in, or we get them to a certain amount of calories and they keep doing that for long enough, that that food in and of itself and eating more is going to fix everything – that the eating disorder is purely biological, and that it’s being driven by someone being in a low-energy state and because of the energy debt that has accrued, and once we can get that person out of that state, then everything will change.

This can be thought about where it doesn’t even matter if the person is on board with this as a concept or as an idea. If we just get the food in, then they will change. And I see this happen a lot in inpatient, and it can happen a lot as someone is younger – that “we just need to get the food in; once we get the food in, everything will change and then they will be thankful that we got the food in.”

I also see this happening where people are almost encouraged to do this on their own, where the advice is “You just need to force-feed yourself. Once you force-feed yourself and you force-feed yourself for long enough, then everything will be fixed.” This just doesn’t typically work for most people. It’s not that it can’t work or hasn’t worked; there are definitely people where this has been the solution for them.

The reason why I think it’s not a solution for the vast majority of people is that eating disorders aren’t purely biological. Yes, the biology piece is a factor, and it’s something that I talk about and work on with clients: that, to actually recover, we do need to change the level of energy debt that they’re in. And the fact that restriction has been occurring for a long time, the fact that there is all of this repair that needs to take place, all of that is 100% true and it is a component connected to the eating disorder – and I don’t think that it is everything.

I also think this approach and way of thinking about it can be very oversold in the sense that once you do this, your problems are going to be solved, that all of your life problems are connected to the fact that you have an eating disorder, and once you do this thing, get over your eating disorder, then everything is going to be much better.

Again, there is some truth to this in the fact that I do think having an eating disorder makes life’s problems much more challenging. It makes life’s problems, on the one hand, feel less significant, because I’m using this thing as a coping mechanism and I can just focus on this thing, so a lot of life problems can drift into the background if I can get my focus here. And at the same time, it can make any disruptions or changes to the way you want your day or your week to run, or “there’s this thing that happened with my sister that now happened” – all of those parts of life or problems that then arise become much more magnified, and even more challenging to deal with than if the eating disorder wasn’t there.

So it’s not that I don’t think that the eating disorder causes problems. I think it causes huge amounts of problems. What I think when I’m thinking of eating disorder recovery is that actually, what it helps someone do is become more resilient to deal with life’s problems – that when you recover from an eating disorder, it’s not that it’s all sunshine and rainbows; it’s that “I now have the capacity to be able to set a boundary” or “I now have the capacity to be able to have that challenging conversation” or “I’m able to deal with the fact that I just had a really tough day at work and I got this email that has really sat with me; I don’t feel like I performed as well as I wanted to in that meeting” or whatever it may be. But there is more of a capacity to be able to deal with the inevitable struggles and pain and uncertainty of life.

00:07:33

Simply eating enough food may not resolve all issues

The other part connected to this as well is that many of the issues that happen in an eating disorder can predate the eating disorder. Digestive issues are a perfect example. There’s lots of people who have digestive issues that predate the eating disorder, and in a lot of those cases, it’s trying to do things to mediate those digestive issues that leads someone down the path of developing an eating disorder.

The same with anxiety. For most people who develop an eating disorder, their average anxiety is higher than the general population. It’s by trying to do things to manage that anxiety that the eating disorder often then takes hold. I think being aware of this and knowing that actually, when you get over the eating disorder, it’s likely that a lot of that stuff is still going to be there – and yes, having an eating disorder in the long run is making the anxiety worse. Yes, you can have this honeymoon period where it feels like it’s got better, but in the long run it’s making the anxiety worse. Same with digestive issues. In the short term, it could feel like it was helping, and then as you’re getting more and more depleted, that has the opposite effect, and now digestion is even worse or it’s worse if I deviate from the way that I always have to do things.

But getting over the eating disorder isn’t going to change those facts, and you may still have issues with your digestion because it wasn’t the eating disorder that caused that.

I think this approach is – and I kind of talked about this already, but it’s especially an issue when it goes against someone’s will or desire. An inpatient facility is one of those places, because there’s many clients that I’ve worked with who have gone to inpatient, they’ve done this, but they didn’t want to be doing this. They did it because this is what they had to do, or they did it because they’re like, “I know I can do this so that then I will be released from this place.” So they’ll keep it up for the six weeks or the six months or however long they have to do it for, but it doesn’t lead to any lasting change because they didn’t want this thing to be happening to them. There was no amount of food that was going to come in that was going to change that for them, and as soon as they got out, they went back to restricting in the way that they were doing before.

The other part connected to this as well is I think it then keeps the focus solely on the food or the weight or the exercise or all of the other things that are connected just to the energy component, and that then is the issue to be solved. Again, yes, that is part of it, but it is not everything. Eating disorders have lots of different functions and there’s lots of different reasons they occur. They can be a coping mechanism, and someone’s most favoured and only coping mechanism. They can be connected to anxiety, as I’ve already talked about.

In a lot of ways, behaviours with food and exercise and weight are more symptoms as opposed to being the real cause. Again, it’s not that we don’t want to change those ways of behaving, but I think there can be this misunderstanding where all of the focus is just on the food, or all of the focus is just on the exercise, when there are all of these other components that are really important that need to be dealt with.

It can also create this way of just focusing on eating more food, and more food being the solution – it creates this false dichotomy of whether you are or you aren’t doing recovery. So if you’re not immediately eating all the food, then you’re not actually recovering. I’ve had lots of people really internalise this message, where they feel like they’re a failure and they feel like they mustn’t really be doing recovery because they haven’t got their calorie intake up to X number of calories, whatever they believe they need to be doing to qualify for getting in enough food to fix everything.

Recovery looks different for different people. I’m not against someone really embracing eating all the food. If that is what is working for someone, if that is the route they want to take with this, then I am all on board with that. And I’m not going to say to someone who’s not doing that that they’re not really doing recovery, because I’ve had many people who I’ve helped recover where we’ve done it in a more piecemeal fashion. We’ve done it more slowly and more gradually, because that was what was required and needed for them.

I often say the best plan is the plan that someone will actually follow. So even if I will agree on paper the best way is getting in more food and doing it as quickly as possible, if someone’s unable to do that for a variety of reasons, whether that be purely psychological, whether that be because their digestion genuinely is not allowing them to be able to get that amount of food in, it’s unhelpful and also inaccurate to say that that person is not doing recovery.

This is one of the areas where people had talked about, “This is an approach I’ve taken before” or “This is an approach that was forced on me before when I was an inpatient, and it really just didn’t work for me.”

00:13:39

Mistake #2: Therapy-only approach

The other approach feels like it’s at the other end of the continuum, but I don’t think that’s actually true because I think there’s multiple ways of doing recovery. But this other approach is very much focusing on the therapy side, but without really making any changes to the eating disorder or the eating disorder behaviours. So “Let’s do a lot of exploring about your childhood upbringing” or “Let’s do a lot of exploring about your relationship with your parents or your relationship with your mother or your father” or “Let’s talk about these things that happened in your childhood.” It’s a very exploratory thing, but it’s not really action-based.

I’ve even had clients tell me that they were explicitly told not to make changes until they’re really feeling safe to do so, and that if something feels like it’s challenging, they need to be doing more therapy work first.

Again, it’s not that I totally disagree with this; I want to be building in more safety cues with clients. I want them to be able to have tools to be able to call on. And the reality is, there is no amount of work that you can do in preparation that is going to mean that you will feel completely safe when you then attempt to make a change. The nervous system has, in a sense, been hijacked by the eating disorder so that when you are put in a situation where you’re making a change – and that change can be eating a food that you feel is a fear food or is an unsafe food, it could be making a change to exercise or walking – and it’s not even happening at a conscious level that you’re thinking in this way; your body has the neuro-reception of ‘this activity, this change, is danger’. There is then that response that happens.

It’s through doing the thing again and again that your body relearns that “This isn’t unsafe in the way that I’ve been reacting, and it was really challenging to eat pizza, but I’ve now done it enough times that actually it’s not challenging. I’m not getting that nervous system response.” It’s through the taking of action that this changes.

But the idea that if we do enough work upfront, that we can save someone from that uncomfortableness – that, from my perspective, keeps people stuck. It keeps people talking about lots of different things and exploring lots of different things, but actually not taking the action that they’re going to need to take for the eating disorder thoughts and behaviours to actually change.

I’ve said it on the podcast many times before, I’ve written about it a lot; I really believe that action creates clarity – that we do not think our way into acting differently, we act our way into thinking differently. So any kind of therapy or any kind of exploratory work like this, from my perspective, wants to be connected to some kind of action-taking. And if it’s not, it can very easily turn into a lot of navel-gazing but without really changing anything.

If you’re doing any of this kind of stuff – and again, I’m not against any of this, but it needs to then be moving away from theory and dealing with real life, dealing with what happens when changes start to occur. So what are the feelings or the sensations or the emotions that come up when the change is starting to occur? Or what’s happening when I’m now doing this thing or not doing this thing that is changed from how it was before?

I would also add with so much of the therapy type work, so much of what’s truly helpful about therapy work can’t be done with a person in a starved and depleted state. It just doesn’t stick, or they will suffer with anosognosia, where there’s damage to the brain that is reversible, but it’s damage to the brain that is there because of being in that starved state. What that means is there can be an awareness in that moment of having that conversation and then that just goes, and it’s like the conversation in a lot of ways didn’t really even occur. That’s because the brain is just not in a place to be able to take on board a lot of those things.

So I think that the therapy work is helpful, but a lot of it needs to be done often further down the line, and a lot of the therapy work in the early stages is much more about “How do I deal with the uncomfortableness in the moment so I can be then taking the actions that really lead to the kind of changes that I want and the quality of life that I want?”

It also depends on what therapy someone is doing. I use acceptance and commitment therapy with clients, and I think tis I really helpful because of what I just talked about there. It helps to be able to have techniques and practices to then be able to deal with when certain thoughts and feelings and emotions arise when it’s connected to making changes or when it’s connected to thinking about making changes and then helping someone to actually make that change.

00:19:45

The problem with some cognitive behavioural therapy

A lot of what is being used, unfortunately, keeps people in their head. I’ve had a lot of people report about CBT. CBT is a very broad thing in terms of there’s lots of different ways to apply CBT, which is cognitive behavioural therapy, so it’s not that I’m throwing all of CBT under the bus; I think it can be helpful when it is applied in the right way. But so much of it in the way it’s often being applied is that if your mind comes up with this thought, you want to come up with a more helpful thought.

It’s a lot of keeping people in their heads, keeping people in a place of coming up with better arguments for why there is this thought that’s unhelpful, and unfortunately, what happens is it just becomes an arms race in the mind. You come up with a thought, the mind originally generates a thought, you come up with this counterargument, the mind then comes up with another counterargument, and it just goes on and on and on.

In a place where someone wants, to really help with recovery, to get out of their head and back into their body and back into listening to their true intuition and all these things, the place that we want to get someone, to then have them spending all of this time in their head doesn’t typically lead to a place of recovery or a good place.

00:21:15

A caution about therapists’ biases

The other one I would say with this – this can be true whether someone’s working with a therapist or with a dietitian or with a doctor. I’ve had this come up a lot with clients who’ve worked with therapists around this stuff. Often, therapists will bring their own biases into the session and they will bring their own diet culture beliefs into the session. This is true even for people who are advertised as eating disorder therapists or that they’re eating disorder aware and this is their specialty. The amount of times that clients have told me about therapists who’ve made very triggering comments, who’ve told them to do things that are basically in alignment with their eating disorder – and again, idk if this really does fit in this category, but the amount of horror stories that I’ve heard from clients who have seen therapists who really should know better.

So that is also something – I’m always wanting a client to be having more than just me if they can, to have a support team, to have people who have these skillsets. And I’m always wary and wanting someone to really vet the person that they’re going to be working with so that it doesn’t really derail them because someone is giving them advice or making suggestions that aren’t actually leading to a better place but is more just ‘health’ type comments that are dressed up as trying to be helpful or healthy but are really just dieting or ‘eating disorder lite’ type comments.

So those are the two areas that came up a lot when I was doing these calls of this is what has happened with lots of the clients and potential clients and why they’re wanting something different. The reality is that eating disorders are complex and that eating disorders, with everyone I work with, are different. Yes, there are lots of similarities, there’s lots of commonalities, there’s lots of overlap – and there is nuance to this as well.

00:23:40

My perspective on recovery + building resilience

I’ve been really reflecting on this, and also just reflecting on what I do and how I help clients, and also when I reflect on the fundamentals of full recovery programmes that I’ve just finished, what that’s truly about. I think I’ve talked before about it being action-taking and how to help someone take action instead of doing avoidance, where eating disorders are typically about avoidance and avoiding uncomfortable thoughts and feelings and doing things or not doing things as a way of avoidance. I think that in a lot of ways does encapsulate a lot of what I work on.

But I think another way I’ve been thinking about it is that what I’m helping people do is build resilience. When I say ‘resilience’, I think that word can bring up different connotations, and sometimes resilience can have this meaning of being this lone person who does everything on their own, and they’ll just keep walking and keep moving and keep pushing through whatever happens. That’s not what I mean when I say resilience.

I’m talking about true psychological resilience, true emotional resilience, true physical resilience. How do we create a body that has got the energy that it needs to be able to function properly and to be able to repair properly? How is the body getting the rest that it needs to be able to function properly? Physical resilience can very much mean getting more sleep, can mean eating more food, can mean taking time out for exercise.

But resilience also means support and community and more than just you. I had an interaction with a client this week where she’s been able to reach out for support in a way that she hadn’t done before. I was like, “This is great. This is showing a really big change, that you’re not isolating, you’re not shutting down, you’re not trying to do this on your own or pretending that this thing isn’t happening; you’re saying ‘Hey, I’m struggling here, this is difficult’ and reaching out for support,” and having that support be there in a way that she hadn’t anticipated in a really beautiful way.

That is, from my perspective, what recovery is really about. It’s about building resilience and where this then extends for the rest of your life, because that resilience is then going to be important well after you’re fully recovered, because there’s going to be heartaches. There’s going to be death. There’s going to be financial situations. There’s going to be struggles. It’s then, how do you have that ability and capacity to deal with that?

And that can mean as part of recovery that you are bringing in a lot of food and that you are focusing on the energy part of recovery and how that’s having an impact on the eating disorder thoughts and the eating disorder patterns and behaviour. And it can mean looking at things like upbringing and relationships with parents and talking about emotions – but where that is very action-based and leads to meaningful change as opposed to just lots of talking.

I think really, for me, the take-home message with this is really that recovery can look lots of different ways. There isn’t one way to do recovery or one way that if you’re doing this, then you are recovering, and if you’re not, then you’re not. And recovery should be thought about as resilience-building, and that’s what it’s really about. I think that can often be helpful, because I think the thoughts can start to arise of, “Do I really need this amount of energy? Do I really need to eat this X food?”

There’s a couple of ways to answer that, and the first is, yes, you truly do need the energy from these foods because you’re needing to repair. But even if we say, “I don’t know if you truly need that energy”, the fact that there is such a dilemma and the fact that there is such questioning and unsureness around eating this particular food tells me that it is still worth you eating this particular food. The fact that someone has brought in cake to work or that you’re having a meal out with a friend and there’s dessert being ordered – all of these things can happen very naturally and it is just food.

So really connecting to the fact that this is about building resilience as opposed to just “Have I got out of the level of energy that I was in and have I just crossed over that line so that now I shouldn’t be having this food or that food?”, it’s about “How do I really get to a place of freedom with food and movement and body in that area, but also with work and relationships”, and really all of the things that life can throw at us.

So that is it for this week’s episode. I hope my ramblings were coherent and helpful. I will be back next week with another episode, but until then, take care and I’ll catch you soon.

Thanks so much for joining this week. Have some feedback you’d like to share? Leave a note in the comment section below!

If you enjoyed this episode, please ~~share~~ it using the social media buttons you see on this page.

Also, please leave an honest review for The Real Health Radio Podcast on Apple Podcasts! Ratings and reviews are ~~extremely helpful~~ and greatly appreciated! They do matter in the rankings of the show, and we read each and every one of them.