I have known this post has needed to be written for a few months now. I have frankly dreaded it. It will likely generate misunderstanding for the majority of those in recovery for whom this post is actually completely irrelevant.
Nonetheless, I think that one concerned forum member very accurately has crystalized the problem, paraphrasing her comment to me: dogma has no place in the application of the Homeodynamic Recovery Method Guidelines.
So I will don my bee-keeping suit and approach the hornet’s nest now.
Art for Game GameDesign: Flickr.com
Both forum members, and concerned parents of forum members, have flagged with me the concern that the Homeodynamic Recovery Method Guidelines can very readily be misinterpreted, and are often applied such that they actually worsen anxiety rather than alleviate it.
We all know that in the first few weeks of re-feeding, most patients certainly do not feel hungry for the minimum intake for their age/sex and height. There is a certain amount of having to eat despite feeling bloated, uncomfortable and perhaps even sometimes nauseous that is really difficult to manage.
However, once the patient is two to three months in then one of two things is going to be happening: 1) she comfortably eats the minimum but has not found herself hungry for more just yet (or perhaps at all), or 2) she has entered a period of extreme hunger and finds herself consuming thousands of calories above the daily minimum.
Extreme hunger can hit at any point along the recovery process, often multiple times, and as long as the patient responds to that hunger, she allows the process of recovery to continue.
Here is the most important point to incorporate about this approach to treating an eating disorder:
The goal of applying the Homeodynamic Recovery Method Guidelines in a recovery process is to connect to hunger, not allow anxiety to interfere with hunger.
Whack-a-Mole
The brain must also be treated in a recovery process, and re-feeding and rest efforts alone are usually insufficient in helping a patient reach remission.
Anxiety interferes with hunger when you have an eating disorder. In fact, it might be best to simply view an eating disorder as a kind of anxiety disorder. But anxiety states don’t just magically go “poof!” simply because you are now resting and re-feeding.
When you tell someone with an active eating disorder that she just needs to eat what she is hungry for, what happens? She eats very little. She is hungry but cannot connect to the hunger because the eating disorder fires up anxiety responses and it results in a drive to avoid food.
But there is another less obvious version of this anxiety interference that may appear once you commit to recovery: force feeding and remaining still. There are patients for whom the anxiety will manifest in a novel way once they begin to re-feed.
Some of you with a predisposition to apply obsessive behaviors to alleviate anxiety, might find that these behaviors, and the accompanying compulsive thoughts, seem to worsen as you begin to re-feed. Others might find they begin to drink more alcohol, or their blazing habit increases (Alcohol, Weed and Recovery). And of course, we all know that many attempting recovery can easily re-feed but cannot give up the activity and exercise (Insidious Activity).
That is why therapy is a non-negotiable component of applying the Homeodynamic Method Guidelines. You need to learn to identify the firing up of your anxiety response so you do not get caught out playing whack-a-mole with your anxiety rather than reaching your goal of remission from an eating disorder.
By learning how to identify the anxiety rising in you; learning how to apply adaptive responses to that anxiety; and then finding that those responses actually ease the anxiety rather than allow it to pop up somewhere else, you can put down your mallet altogether and get on with your fabulous in-remission life.
A Mole That Rarely Pops Up
In Bulimia? Yes, You Too. I mention three cases where patients developed a specific anxiety while attempting recovery:
“The facets of anxiety on eating enough food involved panic if food was not readily at hand; hoarding and stealing food and eating in secret; and some elements of using food consumption as an expression of individuality and separation from parents (rebellion). All three switched out their psychotherapeutic practitioners and subsequently all three recovered from the compulsiveness and drive to avoid any period of not eating.”
There have likely been two or three more cases since that time of which I am aware. So while it is far more common to see patients with worsening OCD as they attempt recovery, this particular anxiety “mole” can pop up for a very small minority of patients.
Here are the telltale signs that your original food avoidance-based anxiety has popped up as this 'rare mole' rather than been properly addressed through CBT or an equivalent therapeutic treatment approach:
- you find yourself avoiding moving around, walking to class, doing the laundry or anything beyond sitting or lying down;
- you think that you should eat more than the minimum intake every day even when you are clearly not in a period of extreme hunger, and you force yourself to eat well above the minimum intake every day because you are fearful of not getting "recovery right" and want the process to be perfect;
- you are experiencing intense interoception (it's the sense of what is going on in your body) where every twitch and twinge makes you think that your recovery effort is going wrong and that you are not doing it right;
- you get highly anxious if you cannot eat for a period of 2 hours;
- And you find yourself worrying about overshooting your optimal weight set point if you fail to eat and rest constantly.
These signs indicate you have inadvertently started to apply the Homeodynamic Recovery Method Guidelines in the same manner as how you might have once applied extreme exertion (exercise) and food avoidance.
Moving Around
While dancing may not be on the to-do list for while during a recovery process, unless your medical team advises otherwise, no patient must remain bed-ridden while applying the Homeodynamic Recovery Method Guidelines. The guidelines incorporate a low average amount of non-exercise-based movement throughout the day.
You can walk the campus, or head to work, and manage some of your daily chores. Your hunger will communicate the necessity of upping your intake if you have had to be out and about a bit too much on any given day.
Now I know full well, that the vast majority of those dealing with compulsive exercise as part of their eating disorder are going to likely interpret this post as a blessing to go forth and maintain their usual activity levels— “Hey, walking isn’t exercise, right?”
I am going to try to appeal to everyone’s inner sense of whether this post even applies to you or not.
If you use your activities and exercise as a way to alleviate the mounting anxiety, and/or they are used to rationalize the food intake, then this post is not for you.
If however, you are holed up in your house terrified to load the washing machine because you will have to eat another sandwich to make up for the energy depletion of that activity, then this post is for you.
Food Intake
Again, I’ll remind everyone that if your eating disorder still generally runs the anxiety show in your mind, then this next section can readily be applied to leverage a relapse. Be careful how you interpret this material and seek advice and input from your family, friends and health care professionals.
If you are not hungry for more than the minimum intake, then do not force it. Extreme hunger is not subtle and you will know when you need way more than the minimum. The idea is to trust the body, not override it.
But what if you are not even hungry for the minimum guideline intake for your age/sex and height and you are six or more months into the recovery process?
Then you apply a well-known technique found in many psychotherapeutic models: test your understanding and assumptions.
As someone with an eating disorder, the first line of inquiry when you are not hungry for even the minimum guideline for food intake, is to determine whether anxiety or stress might actually be jamming your natural hunger signals.
Alongside that inquiry, consider whether you are still dealing with a narrow list of foods and too many forbidden foods still off your regular food roster— meaning that the eating disorder is still running the show. Your lack of interest in eating to the minimum intake may be a signal that you need to broaden radically the types of food you are eating.
Then, if you have ruled out underlying stress, anxiety and/or a diet that is too narrow in scope and excitement (hopefully with some guidance and inquiry with your therapist or counselor) then you move on to test your actual hunger level.
As you know, moving to eating to your hunger cues and away from either counting calories or applying a meal plan is the final stage in the recovery process. But you can always test your ability to connect to your hunger cues at any point along the recovery road.
When you are energy balanced, your daily intake will not hit the minimum intake every single day. Energy balanced people average that minimum intake and that means some days are much higher, some days are right on the dot and other days are lower. However, for most with a history of an eating disorder, under eating in any single day tends to trigger relapse. So you may be energy balanced, but you will have to apply more vigilance than someone with no history of an eating disorder.
If you are six months or more into the recovery process and you’ve found yourself unhappy with having to eat to the minimum intake, then eat to hunger cues for three to five days. Log all the food you eat in those days and at the end of the test phase, add up all the calories and average the intake out to arrive at your daily average.
If the daily average appears within 200 or so calories of the minimum intake guideline for your age/sex and height, then try another five-day test period in the same way. If you see no progressive restriction in your intake, then Huzzah! You are likely in remission.
If you start to note and also feel that the eating disorder is rearing its ugly head as you attempt to eat using hunger cues alone, then you simply return to making sure you eat to the minimum intake yet again and keep working with your therapist or counselor on your anxiety modulation.
Your Body Is Mighty Resilient
There is no way to ruin a recovery effort. Say it with me: “There is no way I can ruin my recovery effort.” You can always return from a relapse, and slips and slides are all part and parcel of a normal recovery effort.
You cannot prevent an overshoot of your optimal weight set point in recovery. Yes, that sucks, but the body has to manage its fat mass to fat free mass adjustments in its own way. Stop trying to mess with your fat organ— it only makes things worse.
An overshoot is not an automatic outcome for everyone in recovery, but if you are not working with a therapist to help you through accepting the process as it comes and wherever it takes you, then you are leaving yourself open to the dangers of both perfectionism and disappointment.
Respect your hunger. Respect the vagaries, and ups and downs of the process.
A perfect recovery process is not your goal.
And if you suspect that you have found yourself playing whack-a-mole with anxiety rather than progressing towards remission, then seek out some appropriate therapy or counseling service.
One final reminder: the input you receive from other members on theforums is absolutely genuine and well meaning, but as confident or reassuring as it might appear, those responses are no substitute for working with professionals who have the benefit of meeting, questioning and examining you in person.
The same caution must be applied to the blog posts you find on this site as well. The information here is meant to be reviewed and discussed with those who have the benefit of actually advising you in relation to your specific situation and condition.
If you don’t like or trust your current roster of advisors, then fire them and hire a new bunch— but never treat anything on this entire site as a valid substitution for proper in-person professional advice.