Why Does Getting Better Feel So Bad?

Optimal Eating's Five Stages of Recovery

By Jane R. Kaplan, Ph.D.

Introduction

"I want to recover from this eating disorder more than anything! I'd do anything to not be bulimic any more." Yes, recovery is the goal. It spells freedom from obsession with food, getting yourself back, getting your life back and having the energy to concentrate on people and things without the haze of body and self-hate clouding the way. There are so many benefits to you, from saving money on binge foods and doctor bills to feeling you can go out to a restaurant with friends and not worry. Recovery is great.

However, recovering from an eating disorder using psychotherapy is also nothing if not a pain in the neck. It takes time, money, perseverance, humor, trust, hope, support, dogged persistence and some really good treatment. Understanding the stages of recovery can make the process more bearable and maybe even interesting.

Of course, there are a lot of theories about recovery and no one person could ever fit any theory to a "T" nor could any theory fit all people.

OPTIMAL EATING's stages of recovery presented here are based on my twenty years of experience helping people recover from eating disorders.

Please note that many people who recover from eating disorders are in "team treatment" which includes medical management by a physician, nutrition management, psychiatric management for medication evaluation, and psychotherapy. This team treatment is, in fact, the state-of-the-art treatment for many people with severe eating disorders. In this article, I am addressing the process of recovery as seen from my point of view as a psychotherapist. I am not addressing the many important aspects of recovery which have to do with medical management and with nutritional management. Also, I'm not discussing other forms of healing which are used in addition to psychotherapy, such as Overeaters Anonymous. Yet, I believe that the other forms of treatment and help listed above can be an integral part of the healing process. The ways team treatment works will be discussed in future articles.

When I discuss these stages with my patients most agree that it fits a part of their experience of recovery, and it also explains why recovery is such a pain in the neck. I hope this overview helps you.

---

Stage One: Pre-Recovery

Compulsive eating, bingeing, purging, and starving are "acting out" behaviors. You are using actions, not words, to express yourself. Conflict or inner need is not dealt with directly, but is shrouded in behaviors like binge eating. The good thing about acting out is that the inner pain is reduced. The troublesome emotions, thoughts, and feelings all get channeled into the actions. Between, for instance, bingeing and purging on the one hand, and self-hate on the other, all kinds of other feelings, even excitement and happiness, are pushed far away. Well, not entirely. Feelings really don't let themselves be pushed that far away....they have a funny way of coming back. But, in some ways, the Pre-recovery stage has the (negative) benefit of keeping troublesome feelings and thoughts away.

Of course, when you overeat or restrict food to cope with problems, avoid painful feelings or maintain a sense of control, there is a real sense of frustration and shame about it. At the same time, since the acting out behavior is strongly in place, it functions to push away problems, including the anxiety and shame about being eating disordered.

People seek help for a variety of reasons. Shame may become overpoweringly strong and the eating disordered person can no longer bear it. Another motivation is the passage of time. When the "I can beat this myself, I don't need help" attitude has lasted several years without results, help might be sought. Time can be an influence in another way, too. Perhaps it was somewhat acceptable to be a binge eater at 22, for it seemed that binge eating would surely be outgrown by 25. At 28, however, it is quite another story and the eating disordered person becomes clear about not wanting to take this problem into her 30s, into her family life, into parenthood.

Another factor is support. A supportive primary relationship or circle of friends may make it possible to consider getting help. Growth of self-esteem in other areas also plays a role. For instance, as esteem grows in the workplace or in a parenting role, there is a sense that "I can tackle my anorexia too" and treatment is sought. Economics, too, are a part of the picture. A new job or new health insurance plan makes treatment more feasible and provides an impetus. Usually, many factors converge to propel a person out of Pre-recovery and into psychotherapy.

People in Stage Two of recovery often look back with nostalgia on their old acting out days. Ignorance is not bliss, but at least it's better than Stage Two Recovery. Anything is better than Stage Two Recovery.

---

Stage Two: The End of Many Illusions

Now we're talking pain in the neck. In Stage Two, you engage in a therapeutic relationship and, of course, try hard to use food less. You try to limit your acting out as you should. However, this often hurts a lot.

Remember, the acting out was used to manage troublesome feelings, and, indeed, all kinds of thoughts and feelings. Now you're not engaging in the eating disordered behaviors, or not engaging as much, and all those feelings are there, with no place to go!

Even if you are engaging in eating disordered behaviors, those behaviors begin to function less well for you. They don't numb your feelings and thoughts as well as they used to. You become more aware of your feelings and thoughts and can't push them away....but you don't yet know what to do with them. Ouchhhh!
 

Stage Two is characterized by:

• The struggle to not act out
   

• A heightened awareness of your eating disorder, which can mean greater awareness of shame about it
   

• A heightened awareness of your feelings, including feelings of low self-esteem, guilt about having an eating disorder, anger and a range of upsetting feelings
   

• A desire to not use food to manage these feelings
   

• Very underdeveloped skills for managing these feelings without food
   

• Increased anxiety that all this is going on
   

• A desire to not use food to deal with the anxiety
   

In addition there is:

• An adjustment to the idea of therapy -- "who is this counselor person and why is she/he helping me...I don't deserve help"
   

• An adjustment to the idea that one cannot do it all oneself, but needs help
   

• Annoyance and relief that a professional counselor is getting to know about your eating problems, which may have been largely secret

And worst of all: Slow, maddeningly, painfully slow progress in developing other skills, in building self-esteem, in learning how to not act out, in learning other, healthier modes of self-expression. You can see that Stage Two is no fun. It is, in my opinion and that of many of my patients, the most difficult stage. It's also the stage where some people drop out of treatment, and it's not hard to see why. Stage One's acting out is much less painful in the short term. Of course, remaining eating disordered is much more painful in the long term.

---

Stage Three: The Payoffs Begin to Arrive

Throughout Stage Two you may have asked yourself, "Why am I doing this?" The only answer that comes back is "because I don't want to be eating disordered for the rest of my life." But, on a day-to-day basis, there were no payoffs--no fun or pleasing things about the recovery. It is dreary.

Stage Three is a lot more fun. Slowly and painstakingly the work on not acting out begins to reap benefits. It's easier to control the eating and/or restricting behaviors. You learn new behaviors, and some of them actually work to make life easier. For instance, a bulimic may binge and purge less. She may find her new yoga class really is soothing. She may find she is less self-critical and there is a better relationship to self. Self-esteem is noticeably, if only a little bit, better. Understanding of the factors which led to the eating disorder in the first place progresses. This understanding helps further reduce self-hate and therefore enhances self-esteem.

Relationships to others become noticeably, if only another little bit, better. There are things to point to, things to feel proud of. Change doesn't feel bad all the time. It feels bad only half the time. The other half of the time, there is a tiny bit of satisfaction, of progress, of relief, "So this is what recovery feels like. It's not so bad. I like feeling a bit more comfortable with others. I like this strange lack of severe self-criticism."

Therapy sessions are not as torturous. In fact, things can feel so good that you can declare, "Therapy's over!" It's not, but there is a light in the end of the tunnel. Therapy won't last forever. As Stage Three progresses, you consolidate these gains. It's easier to not use food to handle problems or feelings. It takes more to trigger a binge or restriction. Regressions or slips are, of course, part of the picture. They are lessons and they show where more work has to be done. Forgiving yourself for slips becomes a tiny bit easier than in Stage Two. There is less all-or-nothing thinking. You learn that a slip is not the end of the world.

Stage Three is characterized by:

• Relief to be out of Stage Two

• Awareness of a diminishment of self-criticism

• Feeling very strange about this diminishment

• Pride in having more control of food

• Feeling good about not thinking in extremes

• Becoming interested in the origins of the problem

• Feeling discouraged because you are not all better

• Nostalgia for Stage One, where acting out still helped

---

Stage Four: Who Am I If Not An Eating Disordered Person?

Throughout stage three, identity has been slipping away.

"If I am not bulimic, then who am I? You go from a primary identity of "I'm the person who isn't nice, isn't deserving and has an eating disorder" to a "transitional identity" of, "I am all those unpleasant things, but I am also a therapy patient. I am working on my recovery." This transitional identity holds for a while until a more major identity is formed. Feelings of low self-esteem are replaced by feelings that you might just be more worthwhile than you had thought.

However, like the roadrunner TV cartoon after the roadrunner gets run over, recovering people can feel flat as a pancake. It takes them a while to "puff up" again. Unlike the roadrunner who just puffs up as if by magic, you must work on cultivating other aspects of yourself which have been squished by the eating disorder.

The inner dialogue begins, "Do I like music, art, sports, books....what do I like? I don't know if I know." Sometimes, old interests are rekindled. Sometimes old interests won't rekindle and new interests must be developed. Activities are tried to see what clicks.

Relationships continue to improve. For those who are dating, healthier partners are chosen. Relationships become based less on caretaking and more on mutuality.

Recovery doesn't seem so bad after all. Food recovery continues. Your eating disordered behavior is less frequent now. "I tried to binge but I couldn't" replaces Stage One and Two "I can't stop myself." You have gathered enough strength so that, to paraphrase Dr. Arnold Anderson's words (Dr. Anderson is a well respected researcher in eating disorders and an expert on men and eating disorders), you have outgrown your eating disorder.

Recovery feels different from what you imagined. Like puberty, you can read about it, but the reality of going through it is different. What was imagined in the acting out time is sometimes the wish to recover from the food problem but have everything else stay the same. It's like putting in an order, " I'll take no bulimia, but give me the same low self and body esteem and the same feelings of not deserving support or relaxation." The reality of change and recovery become clear. "I am different, I am stronger, and yet I am still me."

The transition can seem unexplainable in words. It can feel like "it just happened." At times recovered people express thoughts such as, "I don't know how I did it. I can't tell you how it happened. I just got better." Really each person is doing a lot; gaining strength and skill along many important dimensions, replacing old behaviors with new ones, replacing unhealthy control of food with healthier forms of self-control, gaining the ability to tolerate conflict, uncertainty, feelings, thoughts, relationships and change. The recovery is part of a process of tremendous personal growth.

As recovery proceeds, those people in group therapy think of ending group. After all, why be in a bulimia group if you are not bulimic? Goodbyes to trusted group members can be sad, but the pride of recovery and seeing oneself as an inspiration to other group members is satisfying. Those in individual therapy think of ending treatment and some do. Others continue to work on improving and strengthening relationship to self and others still more.

It is not uncommon for an unattached person to enter a period of dating; or for a new, positive, intimate relationship to form. As the eating disorder continues to wane, how to form and maintain healthy relationships becomes the goal of recovery and therapy. In fact, this time of work on health in relationships is Stage Five.

---

Stage Five: Who Are These Other People And How Do I Deal With Them? Also, How Do I Date?

There is little or no eating disorder now, but there are many questions. Now you are contemplating dating, dating or in a long term relationship as a person without an eating disorder. Relationships feel very different at this stage. The eating and/or restriction used to function as a back-up plan. If something went wrong in a relationship and you experienced hurt feelings or guilt, there was always the eating disorder to help you escape. Now, conflicts in relationships are clearer. Even if you have dated and have had long term relationships, you may now feel exposed, inexperienced, and insecure.

This stage could be named "friendships and dating therapy" since so much of the emphasis is on how to form and maintain healthy relationships. Many people experience a new level of clinginess to their therapist. Frightened, they ask, "How do I deal with those human beings out there? " Sessions can be filled with questions about what's normal and reasonable in relationships. Those who have suffered childhood or other sexual abuse learn and integrate new rules for relating.

Slowly, skills are honed. Assertion is often one of the most important. Another is to become more self-focused in your thinking--to think in terms of strategies which take you closer to your goals in regard to a relationship. Many people with eating disorders think in terms of meeting others' goals and sometimes can't define their own goals at all. For instance, a recovering person may be dating and have the goal of forming a committed relationship, but may be unable to focus on her goal. Rather, she may focus on her partner's goal, which could be to further his career or improve his self-expression.

As Stage Five continues, insight develops into why certain relationships haven't worked out. Patterns are explored and changes are made. Though anxiety-provoking at first, Stage Five often ends with a lot of satisfaction as patterns unfold and changes are made. As you learn healthy ways for you to be in relationship, you realize you can apply them to many relationships, from work to your personal life. "People are strange, but I think I'm getting the knack of relating to them," is a feeling typical at the end of Stage Five.

It is not uncommon in Stage Five for people who are dating to meet more equal and adequate partners. Some cannot believe that they have met and are dating such nice people. They didn't think it would ever be their fate. The "pinch me" feeling prevails. Over time, the unbelievable becomes believed. Those in committed relationships often work hard to change the status quo and shape the relationship into more of what they need. It is an especially joyous time when Stage Five ends in the fulfillment of a much-desired goal.

As you progress through the five stages, you are completing a major piece of work. You have every reason to feel proud of a job well done. You are yourself, but you have been transformed. You have developed a voice to express and take care of yourself. You no longer use food to speak for you.

---

How To Find A Therapist To Help You With Your Eating Disorder

To engage in psychotherapy for the treatment of eating disorders, it is important to locate a well-qualified mental health practitioner. Here in California we have psychiatrists, psychologists, social workers and marriage and family counselors, all of whom are licensed to perform psychotherapy. Other states use different titles for counselors.

It is best to look for a licensed and experienced practitioner; someone who either specializes in helping those with eating disorders or who has worked extensively in this field. Local eating disorders treatment programs as well as local hospital and physicians' offices can often provide names. Your local psychological association (here in California, it's the California Psychological Association 1-800-735-0272), social work, counselors or psychiatric association can help provide referrals.

After calling and, perhaps, meeting a few different practitioners, you make a decision about who is best for you. You are looking for someone with whom you feel comfortable and whom you feel understands you and can help you. During the process of therapy, feel free to talk with your practitioner about your feelings and your progress. You are in therapy to work hard to get better. As you go through treatment, there should be signs of progress which you recognize. If there aren't, bring this up directly with your practitioner. Therapy should, among other things, be a dialogue in which your concerns are addressed in a straightforward and productive way.

Good luck with your recovery.

Copyright © 2011 by Jane Rachel Kaplan. Published at www.optimaleating.com.