Healthy Behaviors in Recovery: A Question of Balance Moving Toward Improvement, Not Perfection
Timothy D. Brewerton, MD, DFAPA, FAED, DFAACAP, HCEDS
Clinical Professor of Psychiatry and Behavioral Sciences
Medical University of South Carolina, Charleston, South Carolina
I was pleased to be invited to write an article for the Gürze/Salucore Catalogue on the topic of healthy
behaviors in recovery. It gave me an opportunity to gather my thoughts on this important issue and put them in writing. So often in my career, I have been engaged in helping individuals with eating disorders to begin and continue in recovery, and when things go well, to stay well. It is often a long and winding road but well worth the trip despite the common occurrences of lapses and relapses.
For many decades, eating disorders professionals have defined three phases of treatment: 1) nutritional rehabilitation, 2) intensive psychotherapy, and 3) maintenance. These three phases are still just as relevant today as they were decades ago, although the ingredients of each phase have evolved with the explosion of knowledge in the psychological, medical, and neurosciences fields, all of which are interrelated and inform one another.
Nutritional Rehabilitation refers to weight restoration in those with anorexia nervosa and to the normalization of eating behaviors in all eating-disordered individuals. Abstinence from dieting, bingeing, purging, excessive exercise, and the use of appetite suppressants, illicit substances, or calorie-reducing agents are all goals during these initial and subsequent phases. This is irrespective of the type or intensity of treatments—e.g., family-based therapy (FBT), cognitive behavioral therapy (CBT), interpersonal therapy (IPT), specialist supportive clinical management (SSCM), dialectical behavior therapy (DBT), integrated cognitive affective therapy (ICAT), uniting couples in the treatment of anorexia nervosa (UCAN), Maudsley model of anorexia nervosa treatment for adults (MANTRA), etc.—or the level of care—e.g., inpatient, residential treatment, partial hospital program (PHP), intensive outpatient program (IOP), or outpatient. From a broad perspective, fairly substantial changes, or “gross tuning,” mark this phase.
Intensive Psychotherapy overlaps with nutritional rehabilitation as the cognitive and emotional state of the individual begins to improve with enhanced nutrition, markedly decreased compensatory behaviors, and brain-mind-body healing. It continues on well past weight recovery and builds upon prior successes, improved mental and emotional processing, and continued appropriate psychotherapy in a treatment plan that is geared toward the individual’s diagnoses and needs. A key component as recovery from anorexia nervosa proceeds is a specific form of cognitive behavioral therapy called cognitive behavioral therapy-relapse prevention, which has been studied in controlled trials (Carter et al., 2009; Pike et al., 2003). Cognitive behavioral therapy-relapse prevention significantly reduces relapse rates back into anorexia nervosa. Relapse prevention is also a key component of all forms of cognitive behavioral therapy, including those designed for bulimia nervosa, binge eating disorder, and all of the commonly related comorbidities such as major depression, anxiety disorders, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and substance use disorders (SUDs). It is usually positioned as one of the last modules of a course of cognitive behavioral therapy once improvement has been realized. The duration and extent of other treatments during the intensive psychotherapy phase are highly dependent upon the degree and severity of co- occurring psychiatric and medical disorders. In many instances, the individual with an eating disorder and other related disorders must negotiate through the different phases and layers of therapy or therapies.
Maintenance implies complete or nearly complete resolution of symptoms, and it also refers to maintaining the recovery gains attained in earlier phases of treatment. So again, this phase blends into the previous one, and these transitions are ideally gradual ones. Maintenance requires continued efforts toward continual biopsychosocial and psychospiritual growth, which comes from practicing the skills learned, as well as learning new skills that are necessary to deal with related or underlying issues. During this phase of treatment, individuals recovering from an eating disorder often realize the “adaptive function” that can accompany the precipitation and perpetuation of an eating disorder. This is discussed extensively in a recent chapter (Brewerton and Dennis, in press). Adaptive function is often confused with the “cause” of an eating disorder, but they are not the same. Adaptive functioning simply seeks to identify any rewarding or reinforcing aspects of having an eating disorder. Does the eating disorder solve a problem or meet a need?
From an FBT perspective for children and adolescents, the maintenance phase involves “getting back on track” developmentally and learning how to handle the kinds of interpersonal challenges of growing up and maturing that are inherent in everyday life for us all. Development of self certainly does not stop at age 18 or 21 or 61. This is especially clear now that we know about the brain’s “plasticity” throughout life. It used to be thought that the brain was a static machine that could not regenerate or rewire itself, but we now know this is definitely not the case. Even when there is extensive damage to one or more areas of the brain, the brain can rewire itself such that other living neural tissue in other regions can take on new functioning (Doige, 2007, 2015). The phrase, “Neurons that fire together wire together,” helps to capture this reality of how new learning takes place. There is no doubt that it may take a tremendous amount of effort and practice to forge and form new pathways, but performing new skills in a systematic manner will show the way. A good example of this in the world of psychotherapy is that of mindfulness and mindfulness meditation, which was ultimately derived from Buddhist psychology and spiritual practice. Mindfulness has quickly become an important component of a number of effective approaches in Western medicine and psychiatry (Wisniewski et al., 2014). Practicing mindfulness meditation regularly has been shown to actually change the function and structure of the brain (Tang et al., 2013). At this level, we are fine-tuning our nervous systems. Specifically, the brain regions that have been found to be most implicated in mindfulness meditation include some of the brain regions involved in attention control (the anterior cingulate cortex and the striatum), emotion regulation (multiple prefrontal regions, limbic regions, and the striatum), and self-awareness (the insula, medial prefrontal cortex, posterior cingulate cortex, and precuneus). It is worth noting that these are many of the very same brain regions (and their associated circuitry) that have been shown to be disturbed or dysfunctional in individuals with eating disorders. Put more precisely, psychotherapeutic interventions clearly alter brain function and structure. In a mirror fashion, rational evidence-based psychopharmacological interventions alter psychological functioning in major, life-altering ways.
Having said that, it cannot go unstated that one very important healthy behavior for many people traveling along the road to recovery is to take (the right) prescribed medications. Of course, the adage that “food is medicine” has been the mantra of eating disorder professionals for decades, but in addition to the right foods in the right doses at the right times, many people do significantly better taking one or more psychotropic medications as part of their recovery treatment plan. So often I hear from patients and their families that they do not like or want or even need medications, despite the clear clinical indications. They often state that they want to “do it on my own,” sometimes despite quite a lot of evidence to the contrary that they have not done it or cannot do it without significant pharmacological assistance. Given the almost universal propensity toward anxiety and harm avoidance in those suffering with eating disorders—usually as a premorbid or pre-existing condition—as well as in a large number of family members, clinical research has shown that the brain’s fear circuitry is turned up and on in these individuals, and that there is a hypersensitivity to the perceived threat of harm. As a result, psychopharmacological interventions that can be not only helpful, but sometimes lifesaving, are refused as part of a purist, perfectionistic, and sometimes stoic or ascetic stance. To admit the need for medications is to admit being “flawed” and imperfect (as we all are). And often with this comes the sense of failure and shame. These kinds of issues are often in need of being “worked through” in psychotherapy or psychospiritual practice with the help of good psychoeducation about the real benefits and potential risks. Psychotropic medications can also be essential to managing OCD, attention deficit hyperactivity disorder (ADHD), PTSD, SUD, and/or recurring bouts of major depression or anxiety. Moving toward forgiveness (of self for being flawed) and acceptance (of self and others) is often an important parallel process to recovery. Surrendering to doing whatever one needs to do to get well goes a long way, while resistance keeps us stuck. Along with this realization comes letting go of the shame and self-blame, and then the attainment of true peace and contentment. To put it in terms of Maslow’s Hierarchy of Needs, once we meet our basic needs, then we are able to progress up the ladder to meet our higher growth needs, and to move toward our own sense of truth, self-actualization, and purpose in life. As one of my patients (who knows I love dolphins) once said, “You gotta find your porpoise in life.”
In discussing phases of eating disorder treatment, I am also reminded of Prochaska and DiClemente’s (1983) stages of change model in which people evolve from precontemplation (no intention to change) to contemplation (aware problem exists but with no commitment to action) to preparation (intent on taking action to address the problem) to action (active modification of behavior) to maintenance (sustained change; new behavior replaces old) and (all too often) to relapse (fall back into old patterns of behavior). The latter phase can include lapses, which are slips back into behaviors, but which do not constitute full relapses into a complete recurrence of the disorder. When new behaviors are sustained, then the disorder, in this case the eating disorder, is said to go into remission. Sustained remission is of course desired, which at some point years down the road some will call “recovered.” Recovered vs. recovering is really a semantic argument at best. I think most experienced professionals and recovering/recovered individuals know that the road to recovery is a bumpy one, with lapses and relapses being more the rule than the exception. However, a sustained and even prolonged period free of symptoms and disorder can and does occur.
An important part of change theory is that each lapse or relapse is an opportunity to learn from one’s mistakes and use that information to progress forward. No one is perfect, and this is an especially important lesson for individuals with eating disorders, who often think that they “should be” perfect. Subsequently, this leads to perceived failure, self-blame, and deprecation when mistakes inevitably happen and “all or nothing” thinking takes its toll. Therefore, practicing cognitive behavioral strategies aimed at challenging these assumptions is an essential routine that successfully recovering/recovered individuals consistently use.
A related concept to the continued cognitive processing that accompanies healthy recovery is the DBT dialectical principle of simultaneously moving toward acceptance (of what is) and change (which is constant). Although these goals may seem contradictory, it is only apparently so. Instead, understanding and practicing the skills that embody this paradox can be lifesaving. Simultaneously, one works toward acceptance of one’s self and the world as it is in the moment, while at the same time moving toward and accepting of change (and the ability to engage in action).
There are several core skills that form the basis of DBT: 1) mindfulness: awareness of self and surroundings with no judgment (compassion); 2) emotional regulation; 3) distress tolerance; and 4) interpersonal effectiveness (see Linehan, 2014). Each of these core skills has certain exercises created specifically to facilitate the development of these abilities. DBT skills training has been shown to be effective for bulimia nervosa, borderline personality disorder, and SUD, and has generalized applicability for a variety of related problems. As noted previously, negative affect, or negative emotions, has been shown to be a common trigger for binge eating, purging, restricting, and excessive exercising. Therefore, treatment and the maintenance of treatment gains depend on the ongoing ability to manage negative emotions. CBT and DBT skills are but only two approaches that can be used to cope with negative emotions. There are many others that work for different individuals. Others use various forms of spiritual practice, such as yoga and prayer, to cope with life’s difficulties.
Another treatment approach developed by Stephen Wonderlich and colleagues at the University of North Dakota is ICAT (2014), which addresses not only the cognitive or thinking aspects related to EDs, but also the affective dysregulation that is also very characteristic and connected with them.
So here is a partial list of healthy behaviors of recovery:
Eating behavior: Abstain from dieting, bingeing, and purging, and follow a well-balanced meal plan that maintains the body’s nutritional needs. Here I am reminded of the story of “Goldilocks and the Three Bears,” in which the bed one lies in should not be too hard and not too soft, but “just right”; likewise, when it comes to eating behavior, we need to strive for not too much and not too little, but just right and balanced. In other words, find the middle road and avoid “all or nothing” thinking patterns and behaviors.
When it comes to compensatory behaviors, especially purging behaviors, when they recur, it is helpful to ask oneself the following questions: What is it that one can’t stomach or digest (emotionally)? What is the nature of the negative feelings that one is trying to numb? What is the trigger or triggers for my behaviors, and how can I handle my responses to them better? Should I always avoid specific triggers?
Or should I selectively and systematically expose myself to stimuli and monitor my reactions carefully? Who can I get support from? Who can I talk to? What are my feelings now exactly? Is there anything that I am being or have been exposed to that is harmful or toxic? What exactly is not sitting right with me right now?
Exercising in moderation is generally a good idea as long as one is not undernourished and is healthy. Exercising for health rather than weight control is a positive behavior that can help to manage negative affect, including depression and anxiety.
How do I handle my emotions? It is important to allow them, acknowledge them, name them, honor them, and accept them, and to also express them in a way that is non-harmful, tactful, assertive, and respectful. Find one’s “voice,” verbally and/or in writing. Often this can be facilitated by some movement or physical activity.
One of the issues that can plague individuals recovering from an eating disorder, especially one with bulimic symptoms, is working through one’s traumatic experiences, whether it be big “T” traumas or little “t” traumas. Trauma is best defined by not just the offending event or events, but also one’s experiences in response to the event(s), as well as the effects of the experiences of these events. One of the findings from a wealth of research is that processing the trauma through “exposure work” is usually necessary to extinguish or come to terms with these events.
Comorbid disorders: So even though the eating disorder may be controlled and goes into remission, it is important to recognize the other commonly associated and often underlying comorbid disorders, i.e., anxiety disorders, mood disorders, SUDs, PTSD or partial PTSD, dissociative disorders, impulse control disorders, OCD, and ADHD. Although some of these conditions, such as depression, may improve with nutritional rehabilitation, it is also quite common for there to be a worsening, uncovering or elucidation of symptoms.
ADHD is real and occurs more frequently in individuals with eating disorders. Treatment works, although stimulants can promote weight loss and aggravate anxiety. Nevertheless, this condition is real, and it is important to identify and treat.
Personality: In large measure, our personality traits are hereditary and biologically determined (Bulik et al., 2007). This is particularly true for obsessionality and perfectionism, which are reported to be present more often in individuals with eating disorders, as well as a sizable proportion of first-degree relatives. In addition, sensation-seeking and impulsivity are common personality traits seen in individuals with bulimic symptomatology (Brewerton et al., 1993; Pearson et al., 2014, 2015). Interestingly, restriction, weight loss, binge eating, and purging often aggravate and exacerbate these attributes.
Overall, a goal for the recovering/recovered eating disorder individual is to enhance overall adaptability, to “go with the flow” and to “let go.” I am reminded of the serenity prayer, which is not just for addicts; it applies to us all: “God (or one’s own notion of a ‘higher power’), grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”
Finally, don’t forget to have fun and enjoy life! Life is short, and ideally we should enjoy the ride even though it may be pretty bumpy at times. Best wishes to all those on the path of recovery. Keep in mind that we are all works in progress, moving toward improvement—not perfection.
About the author –
Timothy D. Brewerton, MD, DFAPA, FAED, DFAACAP, HCEDS is Clinical Professor of Psychiatry & Behavioral Sciences at the Medical University of South Carolina in Charleston, where he is also in private practice. He is board certified in general, child/adolescent and forensic psychiatry, as well as addiction medicine. He is a Distinguished Fellow of the American Psychiatric Association and the American Academy of Child Adolescent Psychiatry; a Founding Fellow of the Academy of Eating Disorders; former president of the Eating Disorders Research Society; author of approximately 150 articles/book chapters; Editor of the Clinical Handbook of Eating Disorders: An Integrated Approach (2004), Co-editor of Eating Disorders, Addictions, and Substance Use Disorders: Research, Clinical and Treatment Perspectives (2014). Dr. Brewerton has reviewed for over 50 scientific journals and serves on the Editorial Boards of the International Journal of Eating Disorders, Eating Disorders: The Journal of Treatment and Prevention, and Current Food and Nutrition Science. He has received numerous awards recognizing his accomplishments, including the 2013 Craig Johnson Award for Clinical Practice and Training by NEDA and the Honorary Certified Eating Disorder Specialist award by IAEDP.
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