Relapse: An Inevitability?

We have had members forced to deal with breakups that have resulted in them being slammed against a full-blown relapse. 

And of course, many of our current members are here working on recovery after having found themselves in relapse due to the death of a parent or birth of a child— many times the relapse has occurred after years or even decades of steady and complete remission. 

Gloria, one of our members, commented on the Bulimia? Yes You Too blog post and her experience with relapse is best said in her own words, so I’ll quote her directly:

I struggled with bulimia for over eight years in my teens. When I look back to those years, the emotions that stand out are shame, panic and an unshakeable sense of failure - specifically, of course, Diet Failure: the failure of my body to be thin.

Years later, after a flare of the ED and a lot of weight loss, I came across Shan Guisinger’s research. But it wasn’t really until I stumbled across this site that it all made sense to me…When the ED hit again it shook me because I didn’t understand how the hell it had crept back in…

All the complications of my teens, the thousands and thousands of days spent agonising over WHY I did what I did, and the answer, all along, was so straightforward. I was starving.

Of course, recovery is anything but simple, and I would never suggest otherwise. But I for one found it enormously helpful to see the clear link between hunger and my behaviours - and to hear the plain truth that my brain had “simply” misidentified food as a threat.

Back in my teens I experienced first-hand the strange competitiveness generated by an eating disorder, and the polarity many professionals saw between anorexia and bulimia or “binge-eating”, and this seems to be something that is perpetuated now, in the media as well as the “pro-ana” websites - in the horrendous term “wannarexia”, for example, as well as in the diagnostic criteria. A diagnosis becomes something you can slip inside, safe.

Reading for the first time that all these different behaviours and diagnoses had the same basic source - a misfiring neurotransmitter, that’s all! Could happen to anyone - was, for me, an enormous relief, because I could brush aside everything I’d read that didn’t quite fit about the “psychological” roots of eating disorders, and get down to the nitty-gritty, the real hard work of recovery.

Eating disorders are so shrouded by mythology: that it’s about a desire for purity, for a return to childhood, or a need for control. Strip away all that, and you’re left with the far less glamorous, mysterious reality: something devastating and deadly, yes, but at the end of the day, nothing more or less than a chronic condition.

I for one found that [realization it is a chronic condition] incredibly helpful when tackling my eating disorder, and coming to terms with my past. Bulimia, anorexia, "EDNOS". Nothing to be oddly proud of; certainly nothing to be ashamed of. Just an eating disorder. Know your enemy.

Is Remission Permanent or Not?

That seems horribly depressing, doesn’t it? The idea that you might never be “safe” in your remission seems unfair as well. But therein lie the seeds of resilience and perhaps even a transformation that has eluded you thus far.

All chronic conditions are prone to flare-ups under times of stress and trauma. However one of the values that can be extracted from that fact is that you have your own personal canary in the coal mine that will keel over with the fumes that might kill you, long before you are actually in serious danger*.

(*a reference to the historical practice of miners taking caged canaries into the coal mines with them because the birds would be killed by dangerous and odorless gases before the miners would, allowing the miners time to get out alive).

Chronic, unremitting and out-of-your-control stress is physically very damaging to all humans, but not many of us are given the opportunity to be given a whole pile of early warning systems that explode with noise and urgency, and chronic conditions work exactly like that.

If you respect the flare of your chronic condition as a warning and not as a failure, then it will become your call to action and not an excuse for further self-blame or admonition.

A relapse is never inevitable for any chronic condition, including a restrictive eating disorder. But accepting that you are never cured actually means a full-blown relapse is less likely. 

Ritual Return to Remission

You may think the flares associated with many other chronic conditions (e.g. rheumatoid arthritis, asthma, eczema, fibromyalgia, lupus etc.) would be easier to pull back into remission because they do not involve that additional aspect of fighting your own inner thoughts and feelings.

I go to lay down and my mind just keeps spinning and spinning. I was so tired and frustrated that I just wanted to cry or scream or something! I was so exhausted yesterday I thought I was gonna topple over. And to make matters worse I had to go to a wake. I don't know how I made it through, but I did!! I was supposed to go to the funeral this morning, but I just didn't have the strength. I felt so bad, guilty that I didn't go!! My poor husband had to go without me! I finally slept today, but bones literally are aching! I was curious if any of you get what feels like bone pain? I get a lot of it in my legs!! I also get wicked anxiety, because I know the less I move around the worse it is for my whole body. I feel so stuck and miserable. I just want to be able to get things done. My house is a disaster again, my dogs need baths, car needs cleaning, appointments need to be kept, yard work needs to be done. I just can’t keep up!! I am so frustrated. Help!!”

The above quote is actually from a patient who submitted this on a WebMD forum. She was dealing with a fibromyalgia flare.

You can see that a great portion of her experience closely mimics that of a flare of a restrictive eating disorder. 

Tremendous guilt, frustration and general feelings of being overwhelmed and anxious are common to the flares of any chronic condition.

Therefore much of the effort to push back to a remission is also something all chronic conditions share:

Rest. Do less, not more.

Return to routines that are required for the lessening and eventual cessation of symptoms associated with the flare.

Follow-through on those routines despite their unappealing nature.

Do not let the emotions of the circumstance that may have triggered the flare interfere with a dogged determination to administer self-compassion every single day.

Practice Self-Compassion

Of the above list, the most challenging one by far is to administer self-compassion. The administration of self-compassion is not feeling sorry for yourself. It is rather doing the things that you would want a good friend to do for herself when she is hurt, overwhelmed, traumatized and generally struggling.

I once had a dear friend whose relationship fell apart. At the time she spoke of making the commitment to herself to attend to her health and wellbeing because she knew that the breakup was likely going to compromise both of those things in the short term.

That has stuck with me all these years. Not surprisingly she eventually became, years after that event, an accomplished mindfulness counselor and practitioner.

I already refer everyone to self-compassion.org but here is Dr. Kristin Neff’s clear definition of self-compassion, for those who may be confusing it with self-actualization and/or self-worth.

She begins by explaining what compassion is:

First, you must notice the suffering in another.

Second, you must feel moved by that suffering— your heart responds to his or her pain.

Thirdly, you wish to help and offer understanding and kindness.

Fourthly, compassion (compared to pity) involves recognition that suffering, failure and imperfection are part of a shared human experience.

Now you turn this process to yourself:

I notice I am having a hard time right now.

The pain I feel over my situation is what anyone would feel and I accept and understand this.

I will protect myself from further damage just as I would try to do for a good friend in this same circumstance.

I am going to make an effort to pursue my remission because I accept my inherent value as a human being facing shared experiences in the challenge of living life.

[Definition of Self-Compassion, Kristin Neff, 2012]

You may find this tough to apply if you are feeling rejected due to a breakup. However, the point is that it is not meant to be tough. The great thing about practicing self-compassion is that you cannot beat yourself up over not getting it right!

The essence of self-compassion is to keep trying to ease up on judgment and treat self-care and nourishment for what they are— critical elements of administering self-compassion.

Fake It ‘Til You Make It

Don’t interpret this phrase as a concept of having a façade and appearing brave when you are not.Rather it means that you should follow through on the basic rituals associated with recovery from a flare even when you think you cannot possibly eat recovery guidelines, or when you are sure you will feel safer and less battered if you stay well within the eating disorder jail-cell walls.

As beat up as you may feel, nothing will take the boots to you harder and faster than allowing the eating disorder room to make you feel worse.

Eat. Get up whenever you happen to get up in the day and eat. Keep eating. Cry. Eat. Sleep. Eat. Have a bath. Cry some more. Call a friend. See a friend. Eat with a friend. Eat when you can’t sleep. Sleep when you can.

Re-adopt wholesale the routines that you had right in the middle of your past recovery effort. Ensure you eat the minimum intake. Remember it doesn’t matter that you are your optimal weight now because the body needs that amount of energy every single day both pre and post remission.

You will not keep gaining weight but you will ensure there is enough energy to stave off a chattery and nasty ED voice as well as support your immune function under the stress associated with your current circumstance.

Return to your therapist (if you liked him or her) or find any counseling services that can help and fit within your budget. Pull out a journal and start writing. See your doctor if things have slipped and you are restricting and losing weight again, or struggling with purging, abusing laxatives, cutting, etc. etc. 

Above all, don’t just let friends and family in, but also reach out to them and short-circuit any ingrained feelings that you should somehow be managing and that you do not need support.

Seeds of Resilience

There are many patients who experience long periods of remission, usually after recovering from an active restrictive eating disorder in adolescence. And whether that effort to get to remission was somewhat seamless or whether it had numerous ups and downs, generally the remission lacks a depth and resiliency that will come from reaching a remission after encountering a flare due to a life event and crisis of some sort.

This is of course a gross generalization, and each patient experiences a distinct expression of his or her chronic condition. Also, it is not a competition and therefore you are not looking to view your remission as “better or worse” than someone else’s! 

Nonetheless, just like many other aspects of maturation, a more mature and adult brain makes the process of pursuing and attaining remission in some ways much more deeply understood.

No matter what, it is likely safe to say that you will find little in common when you compare your first effort at getting to remission with attempting to achieve remission from a flare that has been triggered by a challenging life event.

You will also find that the remission that you re-achieve will feel very different as well. It will feel more deep-rooted and more robust. And it will almost certainly feel more self-defining and self-transforming as well.

So, to those facing a flare, the next remission is so very worth it.

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