As anorexia recedes further into my past, I often find myself reflecting on the wonderful fact of being free of it, and rarely feel still defined by it. Nonetheless, the question often arises - for me and for people who write to me: is it really possible to be 100% recovered from an eating disorder such as anorexia?
Of course, the phrasing of the question presupposes a perfectly healthy state (100% better) against which all degrees of sickness can be measured (so that 99% better is still 1% ill, or 1% defective). This is probably not a helpful way of thinking about human health: if we try to judge, and apply numerical values to, the relative levels of 'healthiness' of two hypothetical people, we soon run into trouble. Let's say the first is someone who spends most of every day hungry on a calorie-restricted diet, and thus may prolong her life or keep her blood pressure lower, compared with someone who eats more. The second person eats when she's hungry and until she's sated, of a wide variety of foods, and thus safeguards her mental equilibrium as well as, for instance, her bone and muscle health, but she also eats sugary foods when she wants to, with the possible metabolic and hormonal negatives they entail. Who's to say which person is healthier in brute percentage terms? Which dimensions trump which others?
Even if numerical answers may never be completely meaningful, there is nonetheless a valid question here, and one that seems to be raised far more often with mental than with physical disorders. This isn't surprising, given that it's much harder to assess the health of someone's thoughts than it is their bone density or cardiovascular system. Numbers work OK for many biological facts, but when you treat health as it should be treated - as encompassing psychological realities too - they show their weaknesses. Eating disorders offer excellent proof of the meaninglessness of any attempt at a hard-and-fast mind/body distinction, since they are so obviously as much physical as mental illnesses - in particular perhaps anorexia, which is as much a physiological illness of starvation as it is a cognitive compulsion to starve. This means that there are markers of recovery as objective as the numbers on the scales - although of course these don't constitute the entire diagnosis. Physical (including weight) restoration is necessary but not sufficient for full recovery.
Another point of reference when thinking about eating disorders and recovery is the comparison with chemical addiction. The cliche there is 'once an addict, always an addict' - the only option supposedly being to avoid the substance in question for ever. Whether eternal abstinence is always the best or only aim in recovery from addition is questionable (Jaffe, 2011). With eating, though, it's more than that: it's clearly nonsensical. We can neither avoid food completely nor, in the first instance, completely avoid avoiding it.
How, then, do we best go about assessing recovery from anorexia? Most straightforwardly, we might ask whether the standard diagnostic criteria used for diagnosing anorexia have ceased to be present. These are (taken from the Diagnostic and Statistical Manual of Mental Disorders V)
1. Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health). (The previous numerical specification - maintaining a body weight less than 85% of that expected or a body mass index of 17.5 or below - has now been removed, as has the amenorrhoea criterion.)
2. Either an intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight).
3. Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Setting aside questions about the validity of these characterisations, it's clear that although someone who used to have anorexia might no longer accurately be characterised by these descriptions, (s)he might still be far from a state that could be called '100% recovered'. (S)he might, for instance, be subject to frequent attacks of emotional blankness resulting from long starvation, or still dominated by anxiety and perfectionism in areas other than food and body image. Most typically, (s)he might no longer have 'intense fear' of growing bodily bigger or fatter, but still in subtle ways arrange his or her life around avoiding doing so. (I discuss this all-too-common in-between state, which many people treat as the best they can hope for, in this post.) Eating disorders can induce, coexist with, and be caused by, so many other psychological disturbances and imbalances (see this post for more on the positive feedback loops, or vicious circles, by which anorexia entrenches itself) that recovery from anorexia as the core illness usually doesn't mean an automatic or very rapid return to 'full health'.
Recovery from anorexia is bound to be a process that extends beyond the point at which a therapist is willing to sign you off as (triumphantly) failing to meet all three diagnostic criteria. Patients completing a course of CBT, for example, might be told: 'Although treatment has ended, it is not the end of your progress in overcoming the eating disorder'. Or 'It is usual to continue improving after the end of treatment. This is especially true of concerns about shape and weight'. Or 'This is a good time to practise making use of all the things learned in treatment without outside help' (Fairburn, 2008, p. 184). Those leaving therapy have to learn to be aware of danger signals in their engagement with food and their own bodies: keeping a lookout for frequent body-checking in mirrors, for instance, or for stressors that might make them inclined to lapse back into avoidance of certain foods. And those who never have professional help have even fewer apparently neat boundaries to encourage or mislead them. Everyone has to find their own ways to tell the difference between a 'lapse' and a 'relapse', and to assess minor setbacks, or echoes of the past, with the pragmatism and optimism they merit.
Given such complexity, is it plausible to expect that the process could ever be completed? Perhaps not. But perhaps we need not think of recovery as a struggle to regain a level of health that the rest of the population never needs to work to achieve. Perhaps instead we're justified in thinking of it as hard work that results in a self-awareness and stability that most of the population are never forced to make the effort to achieve. Although no one who's been through it could easily say whether the wisdom gained is worth the misery endured, those of us who come out the other side recognise how much the eating disorder has taught us, both during the suffering and during the recovery.
In this sense, I believe that if we want to retain the metaphor of percentages, the person who used to have an eating disorder can end up 110% recovered, or 120% (or any other figure we might choose arbitrarily to attach to the new state). This may take months of therapy and years of independent work thereafter. But at some point last year (it's now three and a bit years since I started recovery) I realised that because I've been compelled to confront the consequences of self-starvation, the emptiness of the 'thinner is better' myth, and my own susceptibility to certain kinds of stress, I'm in a much stronger position as regards body image and diet than many of the women I know.
This isn't to say that I have erased the years of my life that were eclipsed by anorexia, or all their effects, but this is not, I believe, a prerequisite of recovery - nor is it in any sense possible or desirable. We get truly better by acknowledging, incorporating, not denying: by metabolising the poison and developing strong immune responses to it, not by trying forever to avoid it.
Another way of putting it might be that aspiring to total recovery is misguided, and that we should instead think of the eating disorder, like any other life event, as a mixture of negative and positive effects, as something to be learnt from, and as something whose proportions of positive and negative are defined primarily by oneself. On the other hand, if you're entering treatment, or unsure of whether you dare to, being robbed of the concept of a possible complete recovery might be unhelpful to say the least. Certainly my hackles rise whenever I encounter an argument for rejecting the concept and term recovery in favour of remission. The evidence for defining an eating disorder as a 'chronic neurobiological condition' (Olwyn, 2013) is far too patchy and problematic to justify this choice of terminology. Life is not an aftermath to illness, spent waiting and wondering whether it will return. The words we choose matter, and no life is enhanced by an umbrella as bleak as remission.
However you prefer to think of it: if it doesn't kill you, it will make you stronger. Death isn't an idle metaphor here, and nor is strength.
Fairburn, C.G. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford. Google Books preview here.
Jaffe, A. (2011). Abstinence is not the only option. Psychology Today, 9 March. Full text here.
Olwyn, G. (2013). Remission accomplished: What does it signify? The Eating Disorder Institute, 14 May. Full text here.