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 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). It's clear that this isn't a helpful way of thinking about human health: how is it possible to judge, and apply numerical values to, the relative levels of 'healthiness' of, say, two hypothetical people. 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. Who's to say which person is healthier in percentage terms?
Nonetheless, there is 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. Eating disorders present an interesting boundary case, however, since they are physical as well as mental illnesses - in particular 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.
Eating disorders are also comparable to chemical addiction, of which it's often said 'once an addict, always an addict' - the only option then being to avoid the substance in question for ever. With eating, though this isn't a possibility: we can neither avoid food completely, nor therefore, in the first instance, completely avoid avoiding it.
How, then, do we best go about assessing recovery from anorexia? Most straightforwardly, the two major criteria for diagnosing anorexia must have ceased to be present. These are (taken from Fairburn, 2008: 8):
1. Over-evaluation of shape and weight and their control; that is, judging self-worth largely, or even exclusively, in terms of shape and weight and the ability to control them.
2. Active maintenance of an unduly low body weight (typically defined as maintaining a body weight less than 85% of that expected or a body mass index of 17.5 or below).
(The third criterion listed by Fairburn is (for post-pubertal females) amenorrhea; but he questions the value of its inclusion, on the grounds that 'the majority of females who meet the other two diagnostic criteria are also amenorrheic, and those who are not closely resemble those who are.)
It's clear, though, that a former anorexic might no longer accurately be characterised by the first of these descriptions, but that she might still be far from a state that could be called '100% recovered' - subject, for instance, 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. Eating disorders can induce, coexist with, and be caused by, so many other psychological disorders that recovery from anorexia as the core illness usually doesn't mean an immediate, or even very rapid, return to 'full health'.
Recovery from anorexia is bound to be an ongoing process; 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: 184). Those leaving therapy have to learn to be aware of danger signals in their engagement with food and their own bodies, such as keeping a lookout for frequent body-checking in mirrors, or increased avoidance of certain foods, and so on. It becomes necessary to learn the difference between a 'lapse' and a 'relapse', and to assess minor setbacks 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 a better way of thinking about it is not as a struggle to regain a level of health that the rest of the population never needs to work to achieve, but rather 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 would wish for the misery of an eating disorder, those of us who come out the other side recognise how much that 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 former anorexic can end up 110% recovered, or 120% (or any other figure we 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 I realised that having 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, and all their effects, but this is not, I believe, a prerequisite of recovery - nor is it in any sense possible or desirable.
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. But for the anorexic entering treatment, or unsure of whether she dares to, being robbed of the concept of a possible complete recovery might be unhelpful to say the least.
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.