There’s a lot of confusion about what it really means to recover from an eating disorder. To get some clarity and insight, I spoke with eating disorder specialist Sarah Ravin, Ph.D. And I’m thrilled to present part one of that Q&A today.
Dr. Ravin is a clinical psychologist in Coral Gables, FL, who also specializes in working with teens and young adults with body image issues, self-injury, anxiety, depression and obsessive-compulsive disorders. Plus, she writes a fantastic blog (see here), which I highly recommend reading.
What I think is particularly great about Dr. Ravin is that she stays up-to-date on the latest research in the ED field, which she uses to inform her clinical work. On her blog, she writes, “A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment.”
Below, we talked all about eating disorder recovery, what the research shows, how recovery is defined in the ED field and how Dr. Ravin helps her clients silence the ED voice. Stay tuned for part two of our interview tomorrow!
What are some common misconceptions about recovery?
a.) One never fully recovers from an ED.
b.) A person needs to “choose” to recover.
c.) A person stops restricting / purging / bingeing when she is “ready.”
d.) Inpatient treatment is necessary in order to recover.
e.) Weight restoration cures anorexia nervosa (AN).
f.) AN can be treated in the absence of full nutrition and weight restoration (this is the opposite of myth e).
g.) The “underlying issues” must be dealt with before a person can stop restricting, bingeing, or purging.
How is recovery defined in the eating disorder field? Is there a consensus on this definition?
There is very little consensus about anything in the ED field. We don’t agree on what should constitute diagnostic criteria for AN and BN and EDNOS (Eating Disorder Not Otherwise Specified). We don’t agree on how to treat EDs. We don’t agree on the role of the family in the etiology or treatment of EDs. And no, there is no clear definition of recovery.
Some research studies loosely define recovery as no longer meeting full criteria for the eating disorder. For example, recovery from AN could involve restoring weight to the point that the person is above 85% of IBW (Ideal Body Weight) and menstruating. Other research studies define recovery from AN as being at 95% of IBW or 100% of IBW and getting regular periods. Bulimia nervosa (BN) recovery is typically defined as abstinence from bingeing and purging, or infrequent bingeing and purging (e.g. once a month).
Many research studies fail to consider the cognitive and emotional aspects of recovery, which usually persist for at least a few months after weight restoration and cause a tremendous amount of distress for the sufferer. In addition, many behavioral symptoms may persist (e.g. avoidance of fats, food rituals, rigid or excessive exercise regimens) long after the person is weight restored and no longer bingeing or purging.
The cognitive and emotional symptoms of EDs are difficult to quantify, which makes them hard to study, which is why researchers often ignore them in their definitions of recovery. Further, ED patients are notoriously poor historians and often mislead people about the true nature of their symptoms, either intentionally or unintentionally. Therapists, more so than researchers, physicians, or dieticians, usually tend to be more attuned to the cognitive and emotional symptoms, but may overlook or minimize the physical symptoms and behaviors.
Some researchers, clinicians, and treatment centers will measure recovery using the Eating Disorder Inventory (EDI) or a similar self-report questionnaire, which is empirically validated and does cover the cognitive and emotional symptoms. The shortcoming with questionnaires is that they rely on self-report, which, as I mentioned previously, can be problematic with eating disorders.
How do you define recovery? For instance, are there gradients of recovery? Many individuals seem to use the term “strong recovery” to differentiate it from “full recovery.”
The definition of full recovery that I use can best be explained on the FEAST (Families Empowered and Supporting Treatment for Eating Disorders) website.
Yes, there are gradients of recovery. This is just my perspective, as there is no consensus in the field. Diagnostically, a person can be said to have “AN or BN, in partial remission” if the person no longer meets full criteria, or “AN or BN, in remission” if the person no longer meets any criteria. But this is very technical, and doesn’t convey much useful information about the person’s psychological functioning.
I would say that a person in “strong recovery” has been in treatment for their ED for a while, is weight-restored, has a good handle on her behavioral symptoms and is able to eat properly and independently, demonstrates good judgment and insight, and is very committed to overcoming her ED, but still struggles daily with urges to restrict, binge, or purge, has a poor body image, and suffers from some distorted thinking (but usually resists engaging in ED behaviors).
A person who is fully recovered is weight-restored, does not engage in any ED behaviors, has realistic thoughts and behaviors surrounding food, has a realistic body image and accepts her body (even though she may not like it), practices good self-care, engages in proactive relapse prevention, and does not struggle with ED cognitions or emotions. She is cognizant of her underlying predisposition and thus must avoid dieting, fasting, high-stress environments, etc. She may have a better body image, better eating habits, and better psychological functioning than her peers as a result of her treatment.
I’ve heard many individuals with eating disorders talk about hearing the voice of ED, even while they’re working toward recovery. How do you help your clients to silence this voice or manage it?
It is important for clients and their families to know, immediately upon seeking treatment, that mental recovery typically lags far behind physical recovery. Clients must be taught that their physical body has to heal first, through full nutrition and abstinence from bingeing and purging, before their mental symptoms (including the ED voice) begin to subside. It is ineffective, medically dangerous, and unethical to delay physical recovery while working on cognitive recovery.
Using the Ancel Keys (1950) Minnesota Starvation Study and other more recent scientific research, I teach clients that many of their mental and emotional symptoms, including the ED voice, are caused or exacerbated by insufficient nutrition or chaotic nutrition, and will abate naturally once they are well nourished for a number of months.
When the time comes to focus on cognitive recovery, I help clients learn to separate the ED voice from their own healthy voice. This can be difficult, as most clients have great difficulty distinguishing the two voices in early recovery. Often, the process of differentiation involves a homework assignment called the “two column exercise” in which the client writes the words of the ED voice on the left column and comes up with their own healthy alternative thoughts on the right. Through this process, I help them learn that the ED voice is not their friend, and that listening to it and acting on it brings relief in the short-term, but will inevitably lead to a life of physical and mental illness in the long-run.
Irrespective of any psychotherapy, the ED voice will persist as long as the person is undernourished or bingeing and purging. ED behaviors quiet the ED voice temporarily but strengthen it over time, whereas healthy behaviors cause a flare-up of the ED voice initially, but over time, tend to quiet the voice.
I teach clients distress tolerance skills to help them cope with the raging ED voice during recovery. The voice really cannot be silenced right away. In fact, the ED voice temporarily gets louder and more aggressive as clients are going through re-feeding and adjusting to healthy eating habits and healthy body weight. The goal in early recovery is to live with the voice but not act on it. I help clients learn to engage in enjoyable, meaningful activities, take care of their bodies, and live a valued life despite the raging ED voice. Over time, the voice diminishes.
The ultimate goal is to extinguish the ED voice. The ED voice will dissipate over time with a steady combination of good nutrition, good therapy, and excellent self-care. I make this very clear to clients in order to instill hope for a full recovery. People who claim to be “recovered” from EDs but still struggle with the ED voice are not actually recovered.
Thank you so much, Dr. Ravin, for an incredibly informative interview. Remember to stay tuned tomorrow for part two of the Q&A!
What does eating disorder recovery mean to you? How do you define recovery?