Failing at treatment

So it turns out commitment isn’t enough in the end. I tried my best. I really did, I promise I’m not lying to myself or the world out there when I say that. I ate all the scary things and broke all my rules. I’ve done it day in and day out for the last 7 weeks. I’ve gained a little weight and didn’t freak out about it. I caught myself body checking nearly every time and talked myself out of it. I’ve kept my food diaries and attended my appointments.

But, and this is what it comes down to, I purged three weeks ago once, then again once last week, now this week twice. My therapist was flexible the first two weeks it happened because she could see how hard I was trying but if it happened this week then game over, treatment is done. Its officially not effective for me so there’s no point in me still attending. I will be discharged and that’s it. That’s the way the treatment approach works, that what makes it effective apparently. I’ve had my chances, and I have been very fortunate with all the help I have been offered, I know how lucky I am. But the reality is that the treatment available hasn’t worked for me and I have to accept that now.

I can sound rational about it but inside I’m petrified. When I first sought help my greatest fear was that I would reach out and it wouldn’t make a difference, and in some ways that fear is coming true. But in other ways that’s not actually what’s happened. My life is so much better for the treatment I have received: I am so much more open about my difficulties. My dark little world has lots of wonderful chinks of light in when I look for them. My weight is relatively stable and for the possibly the first time since I was 9 I am not trying to lose weight. I can skip a run when I don’t feel like going. I can keep most foods in my house without binging on them (still not 100% there but so much better), I can eat in restaurants or in others’ houses without purging. I can drink an iced coffee and trust the world won’t end! had an ice cream in the sun last week and didn’t cry! Miracles are happening!

I could lie tomorrow at my session and say nothing happened, that I didn’t use behaviours. Believe me I am tempted to do that, but really what would I gain from that? And I respect my therapist too much to abuse the service in that way. The reality is that the best evidence based treatment there is out there has not worked, and so continuing is just wasting resources that could be spent on someone who does respond to it. I have made so much progress, but I am still purging on a regular basis and maybe now I need to take stock of where I am, make sure I don’t slip backwards, but also accept that maybe this will be a part of my life forever. I can keep fighting to maintain the progress I’ve made, but I think I’m too tired and too beaten to keep trying and failing with getting rid of behaviours completely.

Maybe this will change in the future. Maybe I’ll be ready to try again on my own. I’m not discounting the possibility of full recovery for me, but I can accept that the conditions of the treatment available is to stop purging and I haven’t been able to do that. So I will be honest tomorrow, and I will accept the consequences of failing at treatment for now. But if stop for a moment, close my eyes and take a breath I can find peace with this. I can be okay. I will be okay.

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Challenging fear foods and food rules

Food challenges. Ugh.

This is a part of recovery I’ve only ever touched on, and I think it is one of the main reasons I have been stuck in quasi recovery, taking two steps forward, one back, one forward, two back and on and on.

It is a core part of CBT-E but I’ve yet to had a therapist really push it. Part of this is probably because I’m sneaky and I can look like I’m challenging myself but actually I’m always up against the boundary but never quite over it. I change the rules, I’ll compensate, I’ll hold back just a little or sometimes I’ll outright lie.

The nature of outpatient treatment in the UK is that across the two different services I’ve been with, the four different nurses/counsellors/therapists- none of them have actually seen me eat. They’ve made meal plan suggestions, talked me through the ‘healthy plate’ etc. but have never seen me actually eat. They’ve never even really seen my food- once I showed a counsellor my lunch and she just looked at the different pieces (I was going through a small bits of lots of things phase which involved various Tupperware pots) and labelled it disordered and told me I need to stop that (that really helpful sentence…).

While they’ve certainly stressed the need for structured eating and sufficient calories, the onus on designing the meal plans has always been mine. So a great looking ‘pasta and veg’ on the meal plan actually means a tiny amount of red lentil pasta with mostly veg , chopped tomatoes and herbs if Im feeling wild. ‘Yoghurt and grapes’ as a snack means carefully measured fat free natural yoghurt with 12 grapes. ‘Peanut butter on toast’ means a tiny spread of one brand of peanut butter on one band of bread very carefully worked around my other meals for the week. There is always a rule, always a complex calculation, always an attempt to quieten the voice that tells me I’m a failed anorexic and it doesn’t matter how little I eat I will never be thin but I must keep trying anyway as imagine how huge I’d be if I ate normally.

But this time I am committed, so with that comes a pledge to be honest with my nurse about the rules, the thoughts, the worries, the rituals, that are tied to my approach to food, and to face the horrendous anxiety and panic that this will provoke. The decision to recover is made, and this is part of it, however much I wish it wasn’t. But this might be the key to real freedom, so surely it’s worth a shot.

CBT-T week one

I’m sitting at my desk feeling overly full after lunch, so I’m writing to distract myself from this horribly uncomfortable feeling.

I do think I am physically full, but I know I had a chocolate bar as part of lunch and I think that is adding a dollop of mental fullness too. If I’d had a ‘safe’ food after lunch, say some extra veggies, I don’t know if that would be making me feel this uncomfortable and anxious, so I’m guessing part of this is ED mind games. I’ve been spending a lots of time thinking about ED mind games these last couple of weeks. I’m two sessions into my CBT-T programme (10 weekly sessions of CBT-E) and I have had to be on continuous alert for ED trying to mess things up.

In my first session the ‘homework’ was to write and follow a structured meal plan. It didn’t matter what was in it, but it had to be three meals and 2-3 snacks per day. Had this actually been my first ever session of treatment that would have been an impossible challenge from where I started, but although I was out of structure with my most recent dip, in general I can manage this.

So I set about my first week, determined to give it a good shot. The first thing ED clung on to was that my nurse had said ‘it doesn’t matter about what you eat, it’s just about structure’. All ED heard was ‘it’s fine for you to eat the smallest amounts and restricted in range as otherwise it means you’re greedy and fat and weak’. I couldn’t shout down that argument the first few days, so while I did great with structure, I know I didn’t eat enough calories for my needs.

Originally I thought I would have to wait until the next session to tell my nurse that what she said made it too hard for me to eat more. But as I thought about it more that seemed like a cop out, and a blatant ED excuse. I know how that conversation would go – ‘I tell her that’s what I heard – she’d say that obviously wasn’t what she meant and that was ED voice trying to persuade me- I’d say I know that but it’s hard – she’s say yes it is hard but only I can challenge ED- she can help me but she can’t do it for me’. Why would I waste one of my ten sessions on that conversation when I know the answer already. Sure, it’s easier eating more when someone is telling me to do it, but that is not sustainable for long term recovery.

So I turned it around and upped my calories and ended up with 4 pretty decent days and a week of no purging. This is a big deal given I was back to regular purging in the last relapse. When I showed the meal plan to my nurse she was really proud of me, which meant that I was proud of me too. ED was hating this and shouting out the narrative of ‘you’re not actually proud you’re just relieved you could eat enough and that’s pathetic, and you’re pathetic for not being strong enough to starve’ but I’m working really hard to ignore that. It’s a tired old story and it has no place in my life now.

I’ve gone back and forth so much around recovery but the decision is made now, I am giving it a proper go, and I will make the most of this treatment opportunity. I am trying to become a person without an ED, so I cannot listen to something that I don’t want to exist.

One week done, I’ll remain cautiously optimistic and keep moving forwards.

Commitment

I am committed this time. I can see that what I have tried hasn;t worked and I need to let it go. I’m never going to be the the anorexic I so desperately wanted to be. And that’s okay, well it will have to be okay, because I am so many other things. I have a full life and I do not need my ED in it any longer. I have to make room in my life for ED now, and that is coming from my career, my friendships, my relationships. I am choosing my failing dream of being thin over the potential for a family, my PhD, social experiences, and that is a decision I will surely regret later, so I have to make a different choice.

I dread the inevitable weight gain but I know I can’t fight science and also I feel now that body could do with a chance at being properly healthy (not food restriction ‘healthy’). My mind could also – I am so fed up of feeling so crazy around food. I have been a valuable opportunity at a relatively good time and I need to make the most of this. I need to show I’m grateful by giving it my best shot. I’m nervous as the reality of addressing some food rules which have governed my life for years is likely to be pretty tough, but I’m tough. This is my chance to be free, so yes I am committed this time.

Committing to a final offer of help

I saw my counsellor yesterday and I had to admit what has been going on in terms of my behaviours. It wasn’t exactly fun. We discussed, as we always do, that not eating sufficiently, regularly and with freedom will always bring me back to binge/purging and that there is no way out of this without accepting that I need to expand my eating and I need to tolerate the weight gain. I still get frustrated with these conversations as if I could tolerate the weight gain I wouldn’t be in this mess, but I just can’t seem to manage it. But she’s right in that there is no other magic solution, so I either get disharged or commit to what she is offering.

What is available to me now is a 10 session structured CBT programme as part of research project. It’s based on research showing early success with a ten session version of CBT-E (typically 20 sessions). I have had variations of CBT-E now and when engaged and active with it, I did respond quite well. However, it was always my slightly adapted version in that I while I managed the structured eating of 3 meals and 2/3 snacks (that 3rd one at night is always tricky!), I never committed to extending my diet, and therefore was continuing to restrict. Had I been particularly underweight this might have been addressed, but as I was always teetering around normal no-one ever seemed to challenge it, and therefore ED kept his nasty claws in enough to keep me trapped. My current counsellor is on to this though and has clearly stated that I can choose 3 dislike foods but everything else has to be considered (only 3 – you can imagine my panic levels right now…). The research is solid, or at least as good as it gets in ED outcomes with a 42% abstinence rate from binge/purge behaviours at 3 month follow up and significant improvement in self-reported psychopathology.

I really want to be part of that 42%. I’m sceptical, but that’s perhaps to be expected given my history. But equally maybe my knowledge and skills gained over that history might help. Really, the only thing standing in the way between me and a life free of ED is me.

We had a good (sniffly sobby) discussion and I signed up. I should start in a month or so. I do 4 weeks and if I can’t make the dietary changes and abstain from purging then I am discharged at that point. Tough love, but it makes sense. No point continuing with other aspects if eating commitment doesn’t happen. I’m scared that this is my final offer, and that if it doesn’t work I shall be on my own to figure it out. But at the same time I’m aware that I have been very privileged to have had all this help so far. If I can get to 10 weeks behaviour free (including restriction) that will be the longest period in quite a while, which might just give me the boost to keep it going. I’m mostly petrified and stressed about it, still debating whether I do actually want recovery (as only perhaps other people with EDs will understand) but there is a glimmer of determination that hasn’t been around for a while so hopefully that will grow. We’ll see.

The right question about the wrong behaviour

I’ve just finished writing a progress report for my PhD which had to be submitted today. I’ve known this was due for a month but it has only just got done. In my defence my workload is ridiculous at the moment, but those of here in this little corner of the internet also know that I’ve been wasting plenty of time hiding in my chair and engaging in behaviours. So now it’s sent I’m asking myself why do I do this to myself? but then a little voice of reason pipes up and says maybe I should be asking that about bulimia and not just my study habits. I should be challenging why I spent two hour earlier eating and vomiting  and not just my procrastination tendency.

Why do I do it to myself? My eating disorder. Why do it do it? That’s the topic I should be addressing. Not tonight though, I’m exhausted, but as I summit these work deadlines I need to stop avoiding the real issue and start properly tackling it again.