THOSE WHO RECOVER
By Robin L. Shearer M.A., M.P.H., M.F.T., R.N.
Yesterday, a woman identifying herself as Janine visited our office wanting information about eating disorders treatment. Almost immediately in the conversation, she asked the question, “What percentage of the people you see in therapy actually recover from their eating disorder?” This is an important question, one that we frequently hear, and one that can be difficult to answer. People often think you're evading the question when you start off with "Well, it all depends --"
My reply to Janine was, “Virtually everyone we treat, who works hard at their recovery and does not give up, experiences substantial movement toward recovery. The recovery process is long and hard, and many do not recover.” As I said these things, I was also thinking back to my own recovery many years ago, remembering what it took to recover, and what I had needed to hear and believe.
Trying to sound optimistic and at the same time wanting to be absolutely honest with Janine, I couldn't help but notice her tired and worried look as she patiently listened to me explain further. I wanted to challenge her without adding to the discouragement and sense of hopelessness most of our clients experience. Most of all, I wanted her to know that recovery could be hers.
I explained that those who make recovery their number one priority and refuse to give up are far and away the most successful. Unfortunately, many are not ready to recover, and many give up. Nationwide, 50% of anorexics and 80% of bulimics eventually recover. We've been at this a long time and we like to think that our recovery rate is well above average. Still, we’re not going to kid ourselves. Even with the best of treatment, there are casualties. It can be a long and painful process and there are no easy answers.
Janine continued to look anxious. She seemed to be wondering if she could be one of the “special” ones who can hang in there and do the work of recovery. Perhaps she was wondering if recovery was even possible.
It was clearly time to talk for a moment about “recovery.” What does “recovery” mean? Does it mean never overeating or binging again? Does it mean eating with perfect control? Does it mean always eating healthy, well-balanced meals? Does it mean never experiencing feelings of dissatisfaction about your body? Does it mean not thinking about dieting again? No! The answer to all these questions is -- No!
Recovery means making peace with your body, making friends with food, relaxing about imperfections -- real or imagined. It means learning to live a healthy, balanced, satisfying life-style where food and eating assume an appropriate place. It means finding pleasure in the way your body functions, and developing appreciation for its unique beauty.
Janine's facial expression seemed to convey indecision, confusion, and doubt. She stated "I just feel so out of control with food. I don't know if there is anything else going on. I just want to be able to eat like a normal person. I'm so afraid of gaining weight, of being totally out of control, of never being normal."
Janine, like others with an eating disorder was having trouble seeing beyond food and weight issues. To her those issues were all there was. She didn’t realize that her eating disorder was actually serving a purpose of preventing her from having to deal with issues even more overwhelming, issues obscured by an all-consuming focus on food and weight.
Recovery means facing real issues and feeling real feelings. It means dealing with all the things that an eating disorder has pushed into the background. An eating disorder often serves as a distraction, a way of not looking closely at things that might feel truly hopeless, instead focusing full attention and energy on a pseudo-problem that carries with it either the illusion of perfect control or just the numbness that comes from not feeling the painful feelings.
Recovery means facing the tough stuff, and learning how to believe in yourself, in your basic worth as a human being, while feeling optimistic about your ability to take charge of your life. It means being able to say to your self "my ordinary self is enough!" When you fully accept yourself, are aware of your needs and feelings and able to express them without fear and guilt, when you feel empowered, when you are confident and optimistic about your future, you can't possibly continue in an eating disorder.
To arrive at this place of balance and acceptance is hard work for people who have eating disorders. It is frightening, sometimes terrifying. Not everyone is up to it. Not everyone can find the courage, support, or the right therapy guide for the journey.
If recovery is going to take place, the eating disordered person needs to reach what Alcoholics Anonymous refers to as "the bottom." That means getting to the point where there seems to be no place else to go but recovery, if one is to go on living and to have any kind of a life at all. Unfortunately, for eating disorders as in any other addiction, some people never reach bottom. Some suffer for a lifetime and some die.
Then there are those who do recover. I have found there are certain qualities those who recover seem to have when their recovery finally gets going.
Those who recover come to a point in their lives where they feel completely unwilling or unable to continue as before. As Janine exclaimed, “I can’t go on like this any longer!” There was desperation in her voice. She was adamant, “Things have to change!”
Along with this feeling of inability to continue their lives as before is the newfound belief things can be better. Many of our clients start their recovery journey feeling hopeless, unable to believe the future can be any different from a painful past and distressing present. Much of what we do is instilling hope, then providing a direction. We help our clients have a vision of recovery along with a roadmap so they can see where they've been, where they are on their journey, and the challenges and milestones on the road ahead. Most of all, we want them to see a future that is whole and healthy -- and achievable!
Linda, a forty-four old receptionist, felt hopelessly stuck for about three of her four years of therapy. She told me she wanted to overcome her compulsive eating, but would follow that with, “What’s the use? I’ve been fat and thin and fat, and my life is always the same. I am never going to get what I want in life anyway, so why try to make things better?”
It took a long time, a lot of hard work, and required a complete shift in her thinking, but little by little Linda began to believe in herself and her capacity for change. Pessimism born of a diet mentality gave way to making peace with food, developing compassion for self, and learning how to appreciate an imperfect but healthy and functional body. She began to view the future with optimism, cautiously at first and then with the growing momentum that comes with steadily achieving successes generated by the new way she was learning to view herself.
Once she developed the strong belief she could make changes in her life, that she had the power to make things better and get more of what she wanted, she got excited and her recovery took off. Henry Ford once said "Whether you believe you can or you believe you can't -- you're right!" If you believe in yourself, you can do just about anything, including recover from an eating disorder.
Of course, almost all of our clients strongly resist change in the beginning. Resisting change is a natural behavior for humans. Change is frightening. Many of us prefer known misery to unknown horrors.
Largely because of these fears, most begin therapy without total commitment. There are almost always strong doubts and reservations. As we have previously stated, for many of our clients, it is a case of needing the problem more than wanting the solution, as an eating disorder protects from unpleasant feelings and having to make risky major life decisions. Success in therapy proceeds along a different pathway, one that seems strange and unfamiliar at first and often lonely and scary. You have to feel in order to heal, and keep moving ahead when everything in you is wanting to go back. What's needed is the realization that the only way beyond present misery is through it, facing the fear and moving ahead anyway. That's what therapy is about. Therapists are trusted guides and keepers of the vision until their client has claimed the vision for herself, as she must if she is to recover.
On the bumpy, often uncertain road to realization of the vision, therapy is a difficult process of unlearning and relearning. There needs to be a major shift in thinking, a "paradigm shift" if you will. To think your knight in shining armor will arrive and save you, or your ship will come in laden with riches and then life will be wonderful is pure fantasy. No other person, place, object, achievement, future event, or gifted therapist will fill the emptiness and make life come out right. These things are external and incidental to recovery. There is no substitute for reaching a point of solid commitment to the vision, a point where you find yourself proclaiming ownership of your life, empowering yourself to take direct action NOW! It means having a direction and being absolutely unwilling to let anything get in the way.
Taking responsibility for strong and consistent personal action is essential. Those who recover do not waste much time in wishful thinking, expect miracles, or hope for someone else to do it for them.
Anne, a young mother, came to our center after a hospitalization for bulimia. She had been struggling with her eating disorder since her teen years. She had seen at least two therapists in the past. Even though Anne felt overwhelmed by her bulimia, and barely able to carry on her daily activities, she took responsibility for her recovery. At first, she came to therapy twice a week (sometimes three if she was in crisis). Her husband came with her for many of her sessions. If I suggested she read a certain book, she got the book and was reading it by her next session. She began journaling and would bring her notes for us to process at her sessions. She attended group. She faithfully wrote out at least ten Rational Emotive Therapy (R.E.T.) sheets a week (a cognitive behavioral therapy tool). Once in a while she would complain. “If I have to look at another R.E.T. sheet, I think I’ll scream!” Then she would sigh. “But I know they are important; they do help me get control of my feelings. Sometimes I just have to make myself do them when I don’t want to.”
Anne worked, worked, worked - and worked some more. She worked her therapy at every opportunity. Those who recover develop a strong “work ethic” toward recovery. They show up faithfully for their sessions. They read and attend group, seminars, and workshops. They learn all they can about living balanced lives. They become committed to doing something every single day to facilitate recovery.
Tracey came to our center from out of state. She had been in treatment in Phoenix for about a year. Her husband’s job transfer meant a move to southern California. At our second session, as she told me about her husband’s excessive alcohol use and his emotional and verbal abuse of her, I became convinced that Tracey could not fully recover and stay in the relationship as it was. A this point, she seemed unaware of how her marriage was contributing to the continuance of her anorexia. She believed if she could just be the perfect wife, pleasing Tom in everyway, he would treat her well. It was her fault he was uncaring towards her. She resented having sex with him because of the way he treated her when he was drinking. On some level, she was hoping to become unattractive to him by getting rid of feminine curves. Then maybe he would leave her alone. As we talked, she became aware of the double-bind she had created for herself. It was not possible for her to overcome anorexia without changing her beliefs.
Marci was involved in a church that practiced “toxic religion.” The members of this church were treated like children who were told how to dress, how to style their hair, and what friends to have. They had to request permission in order to be absent from one of the four or five weekly services. There were strict rules regarding permissible activities outside of church. From the pulpit, the members were frequently “called out” or given public reprimands. These were very humiliating. Judgment and punishment were routine themes stressed by the sermons. Marci felt worthless as a person while she was a member of this congregation. It was impossible for her to make progress in her recovery while she was in attendance there.
Those who recover remove themselves from destructive, abusive relationships and environments--whether an intimate relationship, a friendship, a work relationship or environment, or church environment. In Tracey’s case, both partners were strongly committed to the marriage. Tom was willing to take a look at his behaviors. As he dealt with issues and as they worked on the marriage, Tracey was finally able to change her belief system and let go of her chronic dieting.
Building honest, supportive nurturing relationships is an important part of recovery. We have our clients assess their support systems. Three different elements are needed in a balanced support system: comforters, clarifiers, and confronters. One person does not a support system make. We need at least three or four. More is better. These people may be family, neighbors, co-workers, fellow church members, schoolmates, etc. The important thing is there are several people making up your support system, and all three elements are present. People who produce shame, guilt, or are non-nurturing do not belong in a support system. Neither do people who are still caught up in their own eating disorder and unwilling to recover
Along with our intensive and structured therapy groups, we also facilitate a self-help eating disorders recovery group (ANAD). Each Friday evening at the end of the meeting, we give the group members an affirmation to write down and use throughout the coming week. Those who recover use affirmations regularly. Affirmations are invaluable. Most of us grew up with negative messages. We have unconsciously incorporated these messages into our belief system and ongoing self-talk. It is necessary to have an arsenal of accurate and believable positive messages or affirmations to shoot down the negative and inaccurate ones we habitually give ourselves. Writing out affirmations on 3x5 cards, placing them on the mirror, the fridge, the dashboard, places where they will be seen several times throughout the day, can be helpful. They are like signposts helping us to stay on track.
Those who recover learn to use positive self-talk almost exclusively, replacing the automatic negative self statements. Early on in our work with eating disordered clients, we give them R.E.T. sheets. R.E.T. is an abbreviation for Rational Emotive Therapy. These forms are used by the client to identify the negative self-message or belief that precedes an upset. We tell our clients to make copies of the R.E.T. sheets and to use them daily. By the time a client has filled out a multitude of R.E.T. sheets, she has become aware of how negative self-talk affects her feelings and often leads to binging, purging, or starving. By doing these exercises, she learns to quickly identify the negative self-talk and replace it with rational, positive messages. Positive self-talk eventually becomes a habit.
Susan had been bulimic for more then twenty years. Her entire life revolved around her daily binging and purging. She worked part-time, an every-other-day schedule. She would spend several hours in the afternoon and evening binging and purging after returning home from work. Then she would have the next day off to recover from the puffiness and discomfort the binge-purge produced. Her husband, Ted, traveled frequently with his work. Susan looked forward to his absences so that she could fully enjoy her binges and purges. Their lives continued like this for the fifteen years of their marriage.
When Susan drew a self-portrait, she drew a big B for “bulimic.” That was the sum of her identity. She had no life apart from her eating disorder. In recovery, she learned how important it is to create balance. She needed to develop other ways of nurturing and caring for herself. She discovered she enjoyed gardening and the challenge of mountain climbing. She and Ted recognized the importance of working together on improving their relationship; they developed interests they could share. She changed jobs and started being real with her co-workers instead of appearing perfect at all times. She continued to work an every-other-day schedule, but the difference now was she recognized her need for time to de-stress from work. She used her time off to nurture herself rather than recover from a binge-purge. As she developed honest relationships with others, her support system began to grow. Through reading and meditation, she attended to her spiritual needs. She began to pay attention to her body cues -- resting when she was tired, eating when she was hungry, changing activities when she felt bored, and exercising to increase her energy level. Susan, like others who recover, learned to create balance in her life.
Ed had been a competitive wrestler in high school. As a result of the pressure to “make weight” before a match, he began purging. This eventually led to binges following a competition. When I met Ed, he was in his twenties and working as a fitness trainer. Even though it has been six or seven years since he had competed in wrestling, he still had bulimic episodes once or twice a week. He desperately wanted to stop binging and purging. Even though Ed had a job with a focus on fitness and health, he was not treating his own body well. He worked out daily, often pushing himself to near exhaustion, ignoring aches and pains. “No pain, no gain” was his philosophy. His diet was not balanced, and he took large quantities of vitamins and protein drinks to make up for his poor eating.
As Ed worked at overcoming his bulimia, he began to take better care of his body. He regularly ate balanced meals and cut down his intake of vitamin supplements. He quit punishing his body. He learned to rest and relax. He decided it was time to get a routine physical exam, something he had not done since his junior year in high school. Those who recover learn to treat their bodies well - just like Ed now does.
When Bill and I conduct eating disorder therapy groups, one of the assignments we give is to write a poem. This poem is to be about self-nurturing. We give the first few lines as an example to help our group members get started: “When I think of nurturing myself, I think of sitting in a rocking chair, stroking my cat’s soft fur, and listening to him purr. I think of a gentle summer breeze, humming birds at my window feeder, or sitting by a warm fire with a new novel on a chilly autumn evening, etc.” The idea is to get people thinking of all the pleasures that bring joy, fun, warm feelings, in other words, ways to self-nurturance. This is a difficult exercise for some. Many of the people we work with have few, if any, self-soothing or self-nurturing activities. Those who recover learn to bring beauty and pleasure into their lives daily.
After an initial assessment, one of the first things we do with our clients is to develop recovery goals. Those goals are individualized. One copy is given to the client, and one goes into his or her file. Periodically, the goals are reviewed in session, and progress is noted. In the recovery process, goals keep the client and therapist on target. A client may ask herself, “What is it I really want?” or “What is important here anyway?” or “What is in my best interest in the long term?” Her goals help her find the answers. Those who recover focus intently on their goals, seeing clearly how achievement of those goals fits solidly into their recovery "roadmap."
Even though we at Alternative Group are very goal oriented, we stress recovery as a process, a journey. It is not a destination at which an individual arrives and the work is finally finished. A client does not just “recover” from an eating disorder; she is “recovering” her life.
Life is difficult. It is full of challenges, crises, and conflicts. Really living life requires work and dedication. We are continually faced with the struggle to effectively and realistically manage stress, keep things in balance, attend to our needs, nurture our relationships, reach goals, and set new ones. These demands can create problems for us. Recovery is learning to face life’s problems and deal with them. Those who recover develop strong “struggle muscles,” yet, they discover the pleasure and excitement of life’s journey. They give themselves grace. They view themselves as lovable human beings, who are capable of journeying successfully.
When our daughter, Laurel, was small and learning to ride a horse, she became frustrated and upset because she could not get her horse to canter. I decided to offer my assistance and proceeded to instruct her in giving the correct canter cue. It seemed as if she could not get it together--the proper aids with just the right timing. She was dissolving into tears, ready to scream with frustration. I was afraid she might give up. At that moment, her older brother (who was a beginning rider himself) came upon the scene and offered this admonition: “You know Laurel, quitters never win and winners never quit!” (Gee-wonder where he learned that?)
That’s right! My clients hear that one frequently. There is hope for recovery as long as a person is still working at it. Never give up!
Robin L. Shearer, MFT
Robin L. Shearer M.F.T., R.N., M.A., M.P.H.