A few months ago there was a discussion on the Academy of Eating Disorders website on the pace of refeeding and weight restoration for sufferers of anorexia nervosa. Medical safety is always of primary concern and physicians must carefully monitor the sufferer for potential medical complications throughout the refeeding and weight restoration process.
What most interested me was the discussion of the psychological implications of different rates of weight restoration. Is it better to encourage a more rapid pace which enables the sufferer to work on the multiple underlying contributants to her/his illness and to deal with body image concerns sooner? Is it preferable to allow for a slower weight gain with the idea that the sufferer grapples with the underlying emotions at the same time as the weight restoration? Will more rapid refeeding traumatize the patient, causing her or him to drop out of treatment, relapse, and then be reluctant to engage in therapy in the future?
Some clinicians hold strong beliefs favoring one approach over the other and some clinicians may offer their patients a choice. Many sufferers deny or minimize the severity of their anorexia. They are often forced into treatment by their families, leaving the sufferer feeling like she/he has no control. Giving sufferers a choice might help them to feel more a part of their therapy and are not merely having the treatment imposed on them.
As I read through the different opinions I asked myself, “Had I been given the choice, which option would I have chosen?” Like most anorexia sufferers, I was terrified of gaining weight and especially of full weight restoration. Hoping to delay that anxiety as long as possible, I would have believed that a slower pace was better.
From a clinician’s point of view, is it better to get the weight gain over as quickly as possible, like ripping a band-aid off a wound or preferable to gain at a slower pace? I now believe that there is no one answer. Just as I learned to relinquish the rigidity of the anorexia, I am more flexible in my thinking about treatment. There is no one right path to recovery. There are many.
Gaining weight, no matter the pace, feels tortuous. Although I hated the gnawing starvation in the pit of my stomach, grew tired of the isolation and loneliness I felt, and was exhausted by the many miles I forced myself to run and swim each day, eating meals and feeling full was very anxiety-producing. I remember feeling so stuffed that I could not sit down and so anxious that I felt like I would crawl out of my skin.
If a client were to now ask me which is better, a faster or slower weight gain, my answer would depend on the client and several key elements. I have seen that a faster pace of refeeding is more tolerable when the sufferer and her/his family have a treatment team whom they all trust. The changes required for recovery are challenging and often feel threatening to everyone involved, Change for the anorexia sufferer is especially difficult. The individual and the family must feel safe enough with their treatment team in order to make the difficult changes within themselves and the family system. The family’s ability to be firm yet empathic can also help the sufferer bear the disequilibrium and anxiety that accompanies the refeeding and weight restoration process. No matter the pace, therapy which includes learning new ways of expressing oneself and of learning how to tolerate uncomfortable feelings is essential. This process takes time and often includes one step backwards for every two steps ahead.
Faced with refeeding at the onset of my illness I was not offered a choice. Weight restoration was rapid and I did not have the psychological support I needed. It felt like my security blanket, which was my anorexia, had been ripped away. I had not learned how to live without it. Without my illness, how would I feel special? How would I express my anger, anxiety, fear, and sadness? I ended up losing the weight all over again.
For me, and for many of my patients, family therapy where the family learns new ways of communicating and interacting with one another was a significant part of the recovery process. My therapist was critical to my recovery. Not only did I feel heard and understood by her, but she helped me to learn new ways of expressing myself and of communicating with my family. She also taught them new ways to hear and respect me. It took me many years to truly believe that I was more than my illness and that I did not need the identity of anorexia.