Do you believe recovery just isn’t possible, at least, not for you?

Lessons from ICED 2013

I see 30-40 individuals suffering from anorexia, bulimia, binge eating disorder and disordered eating each week. Men and women, preteens through age 70+.  So short breaks and vacations are, of course, quite refreshing.

But last week’s Academy for Eating Disorders Conference, the International Conference on Eating Disorders (ICED) offered anything but relaxation.

Stimulating, inspiring, fascinating and hopeful—even these words do little justice to the conference presentations. I became pumped, and felt validated that the progress I see with my patients is not random. I was sparked by the incredible research demonstrating the progress in the understanding of eating disorders and their treatment. It only confirmed my belief that there’s reason for you, too, to know that recovery is possible.

Let me tell you about a session I was most excited about—Lisa Dawson, a PhD candidate’s research presentation entitled Recovery From Chronic Anorexia Nervosa: The Tipping Point for Change. You don’t have long-standing anorexia? Don’t stop reading. The lessons from this psychologist’s research are inspiring for all.

Dawson decided to select those individuals who recovered from anorexia—and I mean truly recovered—because by looking at this population we can figure out what elements are critical for recovery in anyone living with an eating disorder. They had to be free of anorexia for 7+ years, in an objectively normal weight range, and free of eating disorder behaviors. “You mean such people really exist?” you’re thinking? You bet. And she identified the common elements that contributed to their movement toward and their ultimate full recovery, based on extensive interviews with the participants. Here are some key points she identifies:

There are 4 stages to recovery, which individuals move through in one direction, and for differing amounts of time:

1. unready/unable to change
2. the tipping point of change
3. active pursuit of recovery
4. reflection and rehabilitation

In the first stage, people feel like they didn’t know why they were doing what they were doing (wrt ED behaviors) but felt they just couldn’t stop. They internalized the eating disorder and they perceived treatment as unhelpful. They felt misunderstood and lacked insight. In summary, recovery seemed impossible; they didn’t feel like anything they did made a difference for recovery, they had low motivation and had a sense of helplessness and hopelessness.

Over time, they realized that their eating disorder wasn’t helping them. Those who recovered also started to experience feeling understood. They were able to externalize the eating disorder and over time gained insight into their condition. They became more worn out by their eating disorder as well. Motivation increased. They started to feel that they had the power to change their situation, that they could impact their curse.

More value was placed on life outside their eating disorder. They learned skills to help them cope as they let go of their eating disorder behaviors.

Self-discovery, self-acceptance, and learning to love oneself were components of the maintenance stage.

It was a long, and slow process. But it happened.

So here’s an email I received this week from a patient of mine who, in spite of living with anorexia for more than 25 years, is now in recovery. The timing couldn't have been more fitting for this post:

"I've been continuing to do well with food.  I know I was upset at my last apt with life in general, but that did not affect my eating.  To date, I still have not purged or restricted or exercised.   Can you believe it? And... I don't want to forget to tell you so I'll share now, re: exercise...  I have been taking walks after dinner with either one of the girls or my husband or all (not every night, but several) and it didn't dawn on me til yesterday that I can go on these walks and I haven't:

• thought about how many calories I'm burning
• gone at fast pace to burn more calories
• obsessed over having to walk each and every night/same time/same pace/same path 

Instead, I:

• go on a walk if I feel like it
• enjoy whatever pace I seem to be going at, without thoughts of burning calories
• actually enjoy being present with the people I'm walking with!!! 

I do not fret if I can't make a walk.  I do not keep track of how many nights I've walked. I do not feel it's necessary if I've eaten a larger dinner. The obsession is not there!  Where did it go? I don't feel it, all I feel is the happiness that I'm going on a walk with a very loved family member where we can chat and talk and laugh. 

Huh? When did this happen?! Although it may not seem big, it really didn't hit me until yesterday that these walks are not the same walks as in the past. Not one bit. I am totally present and I completely enjoy them. And I continue to eat. Normally. I think I now know what normal is. At least, my normal. And I never, ever thought I would find "normal". And "normal" to me means:

I can eat when I'm hungry, know when I'm full, eat what I want in moderation... and because of this, I have not gained 30 lbs in 5 days as previously thought. I have gained weight.  I am working on accepting the feelings that accompany this. I think I'm in a better place to work on this. Nobody likes to gain weight, that's pretty much reality. But... I'm healthy.   

I put myself, my body, through hell. Can you imagine deliberately depriving your own body of nutrients it needs to stay alive? Can you imagine the destruction throwing up food causes? Or ingesting a plethora of pills to help further the weight loss process? How good is THAT for your body?! Oh my God, I sit and think how the hell am I still alive!!!  This has been going on for decades!  

I am at a really low point - sad, lost, confused, lost, angry, lost...  I feel like everything is out of control in my life.  Where did I turn for all those years to gain control over something when everything else felt so out of control? Ed. But what is happening now? Everything feels so out of control, yet the ONLY thing that feels IN control is my decision to eat well. Isn't this the complete opposite? What is going on here?  

So, the point of this email is to tell you that I have the strength to continue fighting this and I will succeed.  You are not going to see me relapse. Everything about this eating disorder is finally beginning to make sense. I have so much more to share but I'll save that for our next meeting. 

Lori, boy I can't begin to tell you how everything you've taught me is now landing in place and making sense and how in the world do I thank you for that?I was so, so sick.You saved my life.I still have work to do, I'm a work in progress, but slowly I'm regaining inner strength - which is just what I need to move forward. 

Thank you, thank you, thank you..."

I share this, with her permission, because while recovery is challenging, to say the least, it happens. And what I hear from her and from others confirms what Lisa Dawson shared in her study—that belief that you can recover, that change is in your hands, is essential for recovery. And that working with providers who get it and help you feel understood, and provide hope that full recovery is possible, can make all the difference.

Your thoughts?

Eating Disorder Recovery: Reflections from the Boston Bombing

I listened to the President’s speech at the Memorial Service for the victims of the marathon bombings. And by victims, I mean not just those who were at the finish line and had personally witnessed the explosions; not just those who were injured with shrapnel from nails and ‘BBs’, many of whom lost limbs and their ability to work at their trades. But those of us in the Boston area, and those of you living further from the scene who have lost a piece of our hearts through this trauma.

Maybe I spend too much time addressing eating disorders, and in no way do I intend to minimize the trauma experienced by this horrific event by saying this. But I see so many parallels between this Boston tragedy and living with an eating disorder. Are you thinking I'm crazy yet? After endless hours fixed to the news, here’s what I’ve observed:

• Both events try to steal from us our ability to live normal lives, to be carefree and relaxed.
• Both appear to arise out of nowhere, through no action on our part. We are victims of bombings, and we are victims of our eating disorders. Sure, eating disorders can be triggered by a trauma or even a diet, but only in certain people. Neither advertisements nor parents cause eating disorders. We can be at the wrong place at the wrong time, and we can have the unfortunate genetic makeup combined with triggers that set off our eating disorders.
• Both cause harm that leaves its mark on our memory, which permanently sensitizes us. Of course we may fully recover but both events. But having suffered with an eating disorder we may be more sensitive to others who live with this condition, and we may have a heightened awareness of the triggers which set it off.
• It takes a great deal of support from a range of sources to move on following both this bombing tragedy and an eating disorder—medical experts, mental health counselors, dietitians in the case of an eating disorder, and those whose experience with such traumas allows you to trust that recovering is possible.
• Both require you to realize why it's worth pushing to get through—in spite of the difficulty, the depression, the frustrations, the disappointments.

Yes, you can get through this.

If you’re suffering from the continuing uncertainty of this past week’s events—with a terrorist still at large, or you struggle with anorexia, bulimia, or binge eating disorder, be defiant; do not submit to suffering silently or passively. And do not accept that this is simply the way it has to be, that you are simply doomed to live your life a victim of your disorder.

Be determined to take charge—to not allow your eating disorder or acts of terror to steal your precious life from you. Declare that you'll show up in Boston for the next Marathon to run or to root, and that you'll work to get yourself healthy to not be a victim of your eating disorder.

Intuitive Eating is not for you—maybe not just yet, and maybe not ever.

“Have you lost your mind? You, the anti-calorie-counting dietitian, the believer in legalizing all things chocolate and trusting that everything will be okay? Are you suggesting I should start dieting now, or head to the nearest Weight Watchers meeting and start counting points? Or doing the Paleo thing?”

Nothing of the sort! I’m prompted to write this following two experiences I had at the MEDA conference, that wonderful eating disorder conference held in the Boston area this past weekend. And this pertains to those of you with anorexia as well as those struggling with overeating—compulsive or otherwise.

So I was casually walking in the hall after the keynote presentation by Dr. Roberto Olivardia just killing time until the next break when I’d be selling my book. And I overhear two women, representatives from two respectable eating disorder programs chatting up their programs. “We use an intuitive eating approach with our patients”, she stated. “We don’t use meal plans, but instead have them listen to their body…” Ok, anorexic readers and eating disorder professionals, anything strike you as a bit problematic here? Let’s start with a handy, wiki definition:

“Intuitive eating is a nutrition philosophy based on the premise that becoming more attuned to the body's natural hunger signals is a more effective way to attain a healthy weight, rather than keeping track of the amounts of energy and fats in foods. It's a process that is intended to create a healthy relationship with food, mind and body, making it a popular treatment for disordered eating and eating disorders…”

For starters, to learn to be more attuned to your hunger, to begin to trust it, you need to be able to sense it. Most individuals, by the time they make it to see me, no longer really notice their hunger—not if they’re restricting and not if they are frequently binge eating. With the metabolic slowdown characteristic of food restrictors, hunger gets suppressed, and so that handy cue to get you to eat, that signal you’re supposed to be trusting—it’s largely disappeared! And that “healthy relationship with food” which we all aspire to is just not going to happen with all those unhealthy and distorted thoughts about food and eating and your appearance. Further, if you’ve never had a healthy relationship with food—never trusted your hunger because you went from overeating to undereating, it’s mighty challenging to just start trusting yourself. And for good reason, given your past experience with food and self-regulating.

When I shared my opinions (you didn’t expect I’d just casually stroll past, did you?) the program rep agreed, acknowledging that intuitive eating is an approach they address much later in recovery. We both agreed that normalizing eating under someone else’s direction (a dietitian with eating disorder expertise, for instance), needs to happen first, much before an intuitive eating approach. You can’t expect to be an intuitive eater when you can’t discern hunger and fullness, or when the disordered or diet thoughts are so loud that you can’t trust your physical sensations.

But wait, there’s more.

There were two experiences I wanted to share, remember? The second involves the presentation by Dr. Olivardia, mentioned above, who spoke about ADHD and eating disorders. He highlighted that a very high percentage of obese individuals have undiagnosed ADHD, and identified characteristics of this condition that make it oh-so-challenging to just do it, to follow seemingly reasonable nutrition and behavior recommendations.

For instance, impulsivity. Perhaps if you don’t have ADHD it’s challenging, but manageable, to take a break and have an internal discussion about whether or not you really want to be eating the whole package of cookies, to not respond to your impulse to eat. But in those with impulse control, that discussion comes a bit late. If you struggle with this, you may find yourself eating mindlessly before you’ve even gotten to check in with your signals. And if you eat rather fast, as is typical, you’ll take in a lot of extra calories before the signal of fullness has hit.

Then there’s boredom. Are you still with me? Those with ADHD have a much harder time tolerating boredom. If you struggle with sitting with feeling bored, it may be more difficult to simply acknowledge that you’re not hungry and redirect. Eating to manage this boredom might be the action of choice. Not a very intuitive eating supportive choice!

And while we often think those with attention issues as struggling to stay focused, Dr. Olivardia points out that these very individuals also get hyper-focused on the things they are interested in. This can explain the failure to listen to their hunger, perhaps when they are over-focused on other things. By the time they do respond to their physical hunger they may be ravenous, contributing to overeating. Or maybe there’s an OCD component, with a focus on calories and calorie counting, which may stand in the way of responding to physical cues. Again, making intuitive eating quite a challenge.

To be a successful intuitive eater, you need to be mindful of what you are consuming. Not so easy of you have ADHD and your norm is to multitask! My typical recommendations to separate eating from distractions may not be realistic for those living with ADHD, those for whom multitasking is simply the norm.

What now?

For the record, I am a big advocate of intuitive eating and for years have recommended a fabulous book on the subject by RDs Evelyn Tribole and Elyse Resch. Do take a look for more guidance on learning to be an intuitive eater.

Surely it’s not hopeless if you fit the descriptions above. To become a more intuitive eater requires more organization to your eating, including preplanning eating times and even meals. Organizational skills may not come so easy, so use tools like alarm reminders, such as on your phone or computer, and make shopping lists. Arrange eating times with friends or family for greater accountability, too. Utilize simple, easy-to-follow cookbooks, where close-to-immediate gratification occurs (with recipes taking 20 minutes or less, for instance.) Yes, Food to Eat fits the bill! And seek the guidance of an ADHD expert like Olivardia, along with an RD with a behavioral focus.

And please be realistic—and less harsh—if you’re prone to berate yourself for being lazy. There may be good reasons why you’re falling short with your follow-through with intuitive eating.

Thoughts? Comments? I’d love to hear what you’re thinking.