There have been many times that a client, fresh from residential treatment or partial hospitalization, has told me that he or she is surprised to return home to find that nothing has really changed. Life around them is still the same. Sure, they learned some skills in treatment but it didn’t solve the life challenges that can be so triggering. Sometimes in the moment emotions are so overwhelming that our first instinct is to return to the coping mechanism that’s become so ingrained in our daily existence. One client actually told me that she didn’t see a point in working so hard on recovery if nothing around her was going to change. She would rather cling to the one thing that’s been consistent in her life: her eating disorder.
Eating disorders are about different things for different people, and at some point in every sufferer’s journey they serve a purpose. For the person who has a difficult home life, the eating disorder may be where she retreats for comfort and control in the chaos. For the person with perfectionistic tendencies who has found that he can’t possibly excel at everything, the eating disorder is something he has complete power over and therefore can excel at. This is part of what makes eating disorders so difficult to give up- underneath the physical and psychological wreckage are definite reasons that hanging on to the illness is reasonable and even necessary.
The problem is that on some level we know that the eating disorder cannot be sustained. We cannot continue to restrict food and expect to live. We cannot binge and purge or over-exercise and expect to lead a healthy, high-functioning life. The physical body clings to every morsel of nourishment and may seem to be able to run on fumes indefinitely. Eventually, the body will crash but the mind will continue to come up with what seem like totally rational reasons to keep pushing. Sometimes, not even hospitalization is enough to spur a leap into recovery.
Life can be a shock for people returning to home, school, or work after inpatient or residential treatment. There is something of a protective bubble in higher levels of care. The intensive treatment provides a safe place for recovery to begin and skills to be learned. It is one thing to apply skills in the treatment milieu or even in family therapy sessions, but it is far another to try to apply them in the overwhelming situations that life can throw at us. According to a study discussed in the Science of Eating Disorders, following intensive residential treatment most women noticed a reduction in behaviors (i.e. they were able to maintain a healthy weight) but cognitive symptoms and thought patterns were still very much present. The cognitive changes that allow us to be able to handle life without the eating disorder take much more time to develop, which is why a solid outpatient program is so important.
The Science of Eating Disorders article lists the major factors that assist people in maintaining recovery:
Social support: maintaining connections with family, friends, and treatment team
Skills application: continued practice of assertiveness, communication, and meal planning skills
Stepping outside oneself: returning to work or school, volunteering, working on higher values all help the focus return to life rather than eating disorder.
Not surprisingly, one major factor that inhibits maintained recovery is loss of support and lack of structure. The importance of these cannot be overstated. People with eating disorders must engage treatment and refuse isolation, even on the worst days. This takes courage and often a profound show of “acting as if” until it becomes easier. Especially as clients return to challenging life situations, the right support can make all the difference.
Science of Eating Disorders (2012). Maintaining Change Following Intensive Eating Disorder Treatment. www.scienceofeds.org