Toward the end of my treatment for an eating disorder, my therapist and I talked about how I’d navigate the real world and keep myself healthy once our therapy came to an end. “Healthy” for me meant eating regular meals, not starving myself and not making myself throw up, habits I’d picked up and put down at various points throughout my adult life.
“If you feel yourself slipping, if you eat a meal and have the impulse to purge, take a moment,” she offered. “Instead of throwing up, write in your journal or do a crossword.”
I looked at her, sitting across from me, smiling kindly. Was she serious?
I understood her larger point: Wait for the moment to pass. Feeling full made me panic. Throwing up offered instant relief. In therapy, I learned that if I waited 15 or 20 minutes, both the fullness and the panic would pass. But you don’t tell someone with a black belt in self-destructive behavior to pick up crossword puzzles instead.
If you have an eating disorder, you can get treatment for it: There are evidence-based methods to help patients ditch their destructive habits and get out of imminent medical danger. But once you make enough progress to be considered “recovered,” there’s not much guidance. It’s a significant deficit in eating disorder care that, 10 years later, I still struggle with.
For me, treatment was triage — to change the harmful behaviors I’d been employing for years. In a warped way, these behaviors had become my coping mechanism. When I felt stressed or anxious, or like I’d lost control over my body or other aspects of my life, I used my eating disorder as a tool to help me feel grounded again. In therapy, I learned healthy techniques to use instead, like keeping a food journal or a log of positive things that happened during the day. But they didn’t provide the same instant gratification. I had to give up my tools, but I didn’t get adequate replacements. When I entered the recovery stage, my health felt precarious. I was supposed to be better. But I just felt adrift.
I don’t know exactly when my eating disorder began. I remember being excited about a diet I started with my friends when I was in eighth grade. A lot of cottage cheese was purchased. Then came years of studying ballet and a brief career in dance, where I adopted the diet of the older dancers around me: frozen grapes and Diet Coke.
Once I hit my mid- to late 20s, and it became harder to maintain a low weight, my already unhealthy habits became more extreme. From the outside, everything looked GREAT! But it was all a lie.
If I went out to eat with friends, I’d watch the clock, making sure I was home within the hour to throw it all up. Sometimes late at night, I’d research eating disorder treatment centers and take online screening tests, all of which ended with some version of “You need help.” I knew the damage I was doing to my body. Anorexia, for one thing, is associated with an increased risk of heart failure, and vomiting can wear down the esophagus and cause it to rupture. Still, I didn’t think my eating disorder was serious enough to warrant professional help. One day, I told myself.
I finally sought treatment after meeting the man who would become my husband. Something about him shook me into honesty. I didn’t want to have secrets between us, so I told him. Then I told my parents and my sister, then one or two close friends.
Treatment involved weekly meetings with a therapist, which were recommended over a residential program so that I could stick to my regular routine. When it comes to eating disorders, there’s no single, gold-standard treatment method or any recognized “cure.” But there is strong research to support the use of cognitive behavioral therapy, as well as dialectical behavioral therapy. DBT employs many aspects of CBT, while additionally teaching mindfulness and regulation of difficult or painful emotions. CBT was popular at the time, so that’s what I chose. (Today, there’s an updated version called CBT-E, for enhanced.)
With CBT, you don’t get caught up in the “whys” of your condition, like its possible origin. Instead, you focus on developing the strategies necessary to stop the disordered behavior and get to a healthy weight. One attribute of CBT and similar goal-oriented therapies is that they’re finite.
During our first session, my therapist instructed me to buy the book Overcoming Binge Eating, which outlines the CBT program we were following.
“But I don’t binge,” I told my therapist. I wanted to be very clear.
“Right, but it’s for anyone suffering from an eating disorder,” she said. “The information’s for everyone.”
It was a genuinely helpful book that supported the work we were doing. But I was in a fragile state. I needed a book called Hey Pretty Ballerina, Everything’s Going to Be OK.
I covered the book with wrapping paper so no one — not even me — could see what it was called. Then, even though I didn’t really want to, I read it. And I wept. Because I saw myself in the pages. It was all me. I came to understand that a “binge” doesn’t have to involve eating four pizzas; it’s how someone with an eating disorder might feel even if they just eat an apple. And when I saw the steps that were outlined for treatment, I actually felt hope.
Once in a while, early on in treatment, I’d decide to starve myself and notice the calm it brought me. I mostly did it when I had to deal with something especially stressful, like preparing to host Thanksgiving. It felt good to actively make the choice to deprive myself of food. It also helped me see how I used starvation to cope; not eating became a way to impose structure on my life when I felt like I’d lost control of it.
When I started treatment, I was starving myself and routinely purging, and weighed less than 100 pounds. My therapist gave me “homework” assignments that included trying foods I’d previously eliminated from my diet, like bread and pancakes, and noticing what happened after I ate a piece of pizza — or really, what didn’t happen: My world didn’t implode. After a month or two of therapy, I was eating three small meals a day and rarely throwing up.
I’ve relapsed many times since “graduating” from treatment 10 years ago, but I’ve never told anyone.
My therapist also weighed me weekly. As the number on the scale passed 110 and then 120, we worked together to unpack the panic I felt. These weigh-ins were partially designed to help me separate my weight from my sense of worth — to make that number just another physiological metric, like a blood pressure reading. My therapist advised me to think of food as medicine. I was supposed to eat something small even if I wasn’t hungry, which I never was because years of extreme dieting and purging had thrown my body’s hunger-regulating mechanisms out of whack.
In all, therapy lasted four or five months. By the end of it, I was excited to be done but nervous to be out in the world, and clinging to my wrapping paper-covered copy of Overcoming Binge Eating. Relapse rates for eating disorders hover around 40 percent, according to some studies — a stat that only accounts for the relapses patients report to professionals. Based on my own experience, I imagine the rate is much higher. I’ve relapsed many times since “graduating” from treatment 10 years ago, but I’ve never told anyone.
An estimated 30 million people in the U.S. suffer from eating disorders, which have the highest mortality rate of any mental illness. According to the National Eating Disorder Association, “eating disorder researchers have yet to develop a set of criteria to accurately define what factors are necessary to maintain recovery.” (Funding for eating disorder treatment is scant. Last year, the National Institutes of Health spent $31 million on eating disorder research about the same amount they spent on back pain, which kills no one. Complementary and alternative medicine research, by comparison, received $448 million in federal funds.)
Recovery from eating disorders is set against the backdrop of a culture that prizes thinness and fitness. Remembering what I learned in treatment, I stop when I catch myself creating made-up food rules, like “no carbs this week.” I also constantly second-guess myself: If I decide to cut out carbs, is that my eating disorder rearing its head? Or is it OK to give up at white bread because most of it is processed crap?
With so many voices inside and outside my head, it can feel impossible to know which ones I should listen to.
Emerging programs like The Body Positive give me hope. Its 5 Competencies, a series of skills to build and hone, focus on helping people examine and quiet their inner critics, develop deep self-care practices, expand their definitions of beauty, and create supportive in-person and online communities. The Body Positive also holds workshops, both virtually and in person across the country, and trains educators and treatment providers. Much of the organization’s work is rooted in the Health at Every Size paradigm, which focuses on body acceptance, self-care, and eating for health and well-being as opposed to dieting. The goal is to “disentangle the value individuals hold toward themselves as people and their adherence to social pressures to fit an ideal aesthetic,” and some studies have found the approach leads to improvements in both physical and psychological well-being.
Community may be the crucial element that so many of us are missing after treatment ends.
Recently, I read a Washington Post article about “The 10-Day Detox Diet.” The reporter who tried it said he lost weight and saw his cholesterol drop. That day, I ordered the book and informed my husband that we were going to do the diet ourselves. I was excited. He looked concerned. “What’s going to happen in 10 days?” he asked me.
I looked back at him with condescending sympathy — didn’t he understand Science? “It’s a de-tox,” I explained slowly, as if to a child. “It recalibrates the body’s insulin … ”
I stopped. What was I saying? I was parroting the back cover of the book! My husband smiled. I returned the book. (For the record, plenty of other reporters did the same diet and didn’t lose a pound, but did become cranky and miserable.)
Today, I weigh a little more than I’d like to, but I exercise regularly, cook at home most nights and maintain a nutritious, vegan diet. I also still scour photos of myself for flaws and feel guilty if I overeat. If a friend uses the word “keto” too many times in a sentence, I ask her to stop, please. But I find that most of the people I surround myself with these days aren’t looking to lose weight. They’re looking to live.
When I do something I enjoy — spending time with family and friends, yoga, reading — the critical voice goes quiet, and I truly feel at peace. I suppose these are some of my new tools. I’m making this up as I go.