Numbers – a Catch 22

I read this post on Dads and Daughters With Eating Disorders: Eating Disorders – Weights & Scales

To summarize:

Because her health is directly related to her weight.  Measured by scales.
Her recovery is directly related to her weight.  Measured by scales.
Her life is directly related to her weight.  Measured by scales.
Weight matters.
And scales matter because they measure weight.

I posted a comment on this post, which hasn’t been approved yet, but I decided that I wanted to discuss the issue on Grey Thinking anyway.

Yes, weight is inexorably tied to health and to recovery.  Weight restoration is vitally important to recovery.  You can’t be recovered and still be below the healthy weight range.  Professionals need to monitor weight.  Some treatment decisions need to be made based on weight.  In short, I am not at all arguing that weight is unimpotant for recovery.

With all of that said… I find a lot of diagnostic criteria and treatment approaches to be contradicting and frustrating.  In therapy, you’re told that you are not a number.  That you are lovable regardless of what the number on the scale says.  That coping with food / weight is not okay.  That eating should be mindful and emotional eating is unhealthy.  You don’t have to be sick to deserve care.

But think — how is your health measured?

• weight, BMI, % of IBW
• calories, exchanges, % of meal plan completed
• heart rate, blood pressure, potassium, electrolytes
• # of binges / purges, # of laxatives, # of diet pills
• hours exercised

… see my point?  Everything is measured in numbers.

I have an issue with your mental health being measured in numbers.  From this point of view, gaining weight = a good week and losing weight = a bad week.  That has just never been a linear relationship for me.  I have bad weeks and gain weight, and vice versa.  Sometimes I follow my meal plan and lose weight, and other times I restrict and gain weight.  The system reinforces the necessity of communicating through your eating disorder.  If you’re feeling crappy but follow your meal plan, then obviously you weren’t really feeling bad — if you were, you would have restricted.  Plus, when you are at a healthy weight — ta da, end of treatment!  You’re all better!  Even if you feel as crappy as ever, you’re not sick anymore, so…..

Thankfully not all professionals practice this way, but measuring your progress in recovery by numbers is not unusual.  I feel strongly that weight is just a piece of the puzzle… and while weight and eating are core components to eating disorders, by basing treatment on just these factors you are really limiting treatment.  There are people who will stay sick because the system inforces that they need to be to get help.  And that’s unfair…

You as your own case manager

“I wish that all these guys were going to stay clean, I really do. I’ve just seen it so many times that I can tell when someone’s really willing to do whatever it takes and when someone’s willing to do what they think it should take. And it’s just not going to work like that, unfortunately.”

–Shelly, Celebrity Rehab with Dr. Drew 2

I was watching Celebrity Rehab 2 online tonight (since I’m a little behind), and these words from Shelley really caught my attention. There are so many similarities between drug/alcohol recovery and eating disorder recovery…

I think that the eating disorder fools you into only doing what you “think it should take.” To give you some examples…

1. Target weight – “There is a healthy weight range, right? It’s easy to think that anywhere in this range is good enough. So what if it’s five pounds less than your target weight… it’s still healthy.”
2. Level of care – “I am fine with outpatient treatment – I don’t need IOP (intensive outpatient treatment). I’ll talk with a therapist once a week and that will help me to be accountable. I’ve had enough treatment and I know what I need to do. Now it’s just up to me to do it.”
3. Unhealthy environments – “So working as a waitress probably isn’t the best job for ED recovery… but I think I’m really a lot better now and will be able to handle it. Besides, I need to work. I’ll use the coping strategies that I’ve learned and will be fine.”

These are all easy arguments that the eating disorder makes… but what are wrong with these decisions?

1. The “healthy weight” zone is not the same as the “statistically most successful for ED recovery” zone. Besides, your body has some catching up to do and some damage to repair… all of which is going to probably require being above 85%. Maintaining a weight below your target weight doesn’t give you much room for error, either.
2. Why err on the side of not-enough treatment? If you start IOP and they tell you that you are great and don’t need that much support, then you can quit. Why risk your health and take the chance of it not being enough?
3. Putting yourself back in an unhealthy environment is just asking for trouble. You’ll need the coping strategies to just deal with new healthy environments. You need to at least set yourself up to be successful.

There are a couple of factors that separate “what it should take” and “what I think it should take”:

1. Giving up trying to control your treatment
2. Really being committed to getting better
3. Putting recovery FIRST in your life.

Probably the biggest problem with all of my examples is that the person with the disorder is making all of the decisions. You should not be your own case manager. Unfortunately, this is a tricky area because treatment is so variable and it’s not unlikely that you will run into a lousy treatment professional. Regardless, you can pretty much assume that whatever individual treatment decisions you want to make are a bad idea. The eating disorder is so manipulative and you’re not the best person to judge what you need. As hard as this is, you really do need to give up trying to control your treatment and just do what your team tells you to do (again, assuming that you have a good team).

It’s hard to tell whether or not you’re really committed to recovery. Sometimes I feel 100% committed… I’ll go to therapy, I’ll follow my meal plan, I’ll do whatever. But… if my treatment team were to decide to raise my target weight by a couple of pounds, I would probably be very resistant. Instead of thinking “I’ll do whatever the professionals think is best for me,” I’m thinking “That’s not fair. That wasn’t the original deal. I am not okay with raising that weight.” Clearly I am not 100% committed.

Putting recovery first is a sticky subject. I’ve gone through periods of feeling like recovery really was counter-productive because it was getting in the way of real life. Going inpatient means you’re not going to school or work — both things that create structure in your life, can be healthy outlets for anxiety, and can give you a sense of accomplishment outside of your disorder. Quitting so that your entire day can revolve around food and therapy sounds like a step backwards…. and maybe sometimes, it is. However, if your work is incompatible with your recovery (as maybe being a waitress would be), then you need to find another job.

It is so hard to trust your treatment to act in your best interest. Of course you want to make some of the decisions… you know yourself best, right? So often though, that’s the eating disorder talking. And while there are unhelpful professionals out there who may lead you down the wrong path (I once had a nutritionist tell me that I was “cured” and didn’t need any more help, 3 months out of inpatient.), you know when you are working with a good team. And in that case, they know what you need to do to recover. You just think that you know — and, as Shelly states, “it’s just not going to work like that.”

Amenorrhea — not just about the weight

The relationship between ghrelin, amenorrhea, and eating disorders has been examined time and time again. The consensus seems to be that persistent amenorrhea is likely attributed to disordered eating rather than low body weight. I’ll admit that I am particularly interested in this subject because I do have hypothalamic amenorrhea. This finding is interesting for a few reasons:

1. Return of menses is often a benchmark of physical recovery. Goal weights are subject upon your menstrual cycle… if you’re still not getting your period, then you still don’t weigh enough.

2. If you really are at a healthy weight and still don’t get your period, then it just needs to be “jump-started.” I was told this for years without the professional questioning my current ED behavior.

3. I’ve known several eating disordered women who lost their period well within (or above) the healthy weight range. This study clearly shows how possible that is.

4. If you read the study, those with hypothalamic amenorrhea actually consumed MORE calories than those with normal menses. Granted they score higher on the EAT, but still… I wish someone would explain how this is possible — aside from basing it purely on purging behavior. I just have this cartoon image in my head of my body trying to communicate that it disapproves of food rituals 🙂

Now, I realize the adaptive value of this condition… from an evolutionary perspective, not enough expendable energy = not a good time to get pregnant. If you put a modern twist on this, nature seems to be saying: Hey, you’re still not taking care of yourself — no way should you be influencing a kid! You know… kinda limiting the anorexic/bulimic population…

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