Written by Jamie-Lee Pennesi PhD, Postdoctoral Research Associate
Eating Treatment Anxiety (EAT) Laboratory (www.louisvilleeatlab.com)
The following post is directed toward someone who has or has previously had an eating disorder in mind, but it can also be helpful for a friend or a loved one, a therapist, or others who wish to support someone with an eating disorder or someone who is recovering from an eating disorder.
In this post I will talk about eating disorder relapse and provide helpful strategies and tips on how to prevent relapse.
Recovering from an eating disorder is not easy. It takes a lot of courage, strength, perseverance, hard work, and support. Most people do not recover from an eating disorder without a few slips or occasional setbacks; that is normal, expected, and okay.
‘Relapse’ is when someone who is in recovery goes back to disordered eating or weight control behaviors. This is different from a ‘lapse’ which is a temporary slip or return to a previous problematic behavior (usually a onetime occurrence). It’s not uncommon for people who have recovered from an eating disorder to relapse. In fact, up to 60% of people who recover from an eating disorder will relapse in the first 1-2 months after treatment.
The best way to prevent a relapse is through ‘relapse prevention’. Relapse prevention is a cognitive-behavioral approach used in treatment to identify and prevent high-risk situations, such as re-emergence of problematic eating and weight control behaviors, or negative thoughts about eating, body, weight, or shape.
Relapse prevention often involves a personalized ‘relapse prevention plan’. A relapse prevention plan is developed during treatment with the therapist and is tailored to you. Here, one size does not fit all. For the best chance of success, a relapse prevention plan should include early warning signs, triggers, and high-risk situations specific to you, so that you can be prepared and ready to deal with any setbacks.
A relapse prevention plan should consider the following issues:
- Times of high risk. Try to identify specific times when you found it harder to stick to your treatment or maintenance plan; times when it felt especially hard for you to manage your disordered eating habits and resist the urge to engage in these behaviors. You’re likely towards the end of treatment at this point, so you may already have an idea of which situations these might be. These situations are known as “at risk” times, and it is likely that these will happen. Times of high risk can involve situations such as: weight gain or weight loss; high stress; exams; feeling sad, anxious, or lonely; loss of a loved one; or the holidays. These situations make it harder to engage in or stick to helpful behaviors that keep you well. For example, it might be harder to challenge negative or unhelpful thinking, or harder to follow the maintenance plan when you are stressed or upset. It’s important to identify times of high risk so that you are prepared to deal with setbacks when they occur.
- Early warning signs. It’s also important to identify early warning signs; signs that warn you of possible setbacks or slipping. These signs warn you that your problematic eating and weight control behaviors are creeping back in and you need to try to prevent them. Recognizing these problems early is essential to keeping you on track. The better you become at detecting these signs, the better your chances of staying well. Some common warning signs may include skipping meals, over exercising, avoiding situations that involve food, weighing yourself more often, thinking of yourself as “fat”, an increasing need for control, or trying to be perfect. Try to identify your own early warning signs. It will be helpful to think about your past experiences: What situations or thoughts did you have right before your last setback? And what about the one before that? What may have triggered your problems? These may be early warning signs.
- Addressing warning signs. It’s important that you create a plan for dealing with early warning signs ahead of time so that you are prepared and ready to face them when they happen. First, you need to identify when to act. Having a clear understanding of your early warning signs will help you to determine when you will need to act. Try to describe each one and be specific and as detailed as you can so you know what to look out for. For example, if a warning sign for you is weighing yourself more often, it may be a problem if you find yourself checking your weight two days in a row. If a warning sign for you is skipping meals, it may be a problem if you skipped two meals in a day. Second, once you recognize the need to act, act immediately. Don’t wait for the problem to get worse. It’s much easier to deal with an early warning sign than it is to deal with a full-blown disordered eating behavior. Third, have a plan. You need to create a personal plan for dealing with your early warning signs. Let’s go back to the previous example of “weighing yourself more often”. Critically examine this behavior. Why are you doing it? Do you need to do it? Does it make you feel better or worse? Is it in line with your maintenance plan? What about if your early warning sign is a thought such as “I’m fat”? Critically examine this thought. Where did this thought come from? Is it rational? Is there evidence to support it? Is it helpful? Use these answers to help you address the warning sign.
- Dealing with setbacks. it is likely that you will experience slips or minor setbacks. It’s important to think about setbacks as a ‘lapse’ and not a ‘relapse’. Just because you have a slip doesn’t mean you have fallen back into your old pattern of disordered eating or weight control behaviors. It also doesn’t mean that you “failed” or “going backwards”. Instead, think about a lapse as temporary slip. Try to take a step back and critically examine the situation. Try to examine your lapse as if you were looking in as an observer watching someone else. What led to the lapse? Were there any early warning signs? What could have been done to prevent the lapse? What could be done better next time? What can be done to get back on track? Use the lapse as a learning opportunity. Try to learn from your mistakes.
Other strategies for preventing a relapse:
- Develop a support system. It’s important to surround yourself with people who care, love, encourage, and support you, and have your best interests in mind. These people may be friends, family, loved ones, or even your care providers. It may be helpful if one or more of these people are aware of your eating disorder journey (or better still, are aware of your maintenance or relapse prevention plan), however this is not essential; even just having a supportive people around you will be incredibly valuable. They will be able to help you when you are struggling or going through a difficult time. It may not always be easy to reach out, but it’s important that you reach out and ask for help when you need it.
- Have realistic expectations. Once you have overcome your eating disorder, it’s likely that you want to put it behind you and never think about it again. Unfortunately, your vulnerability to disordered eating and weight control behaviors will likely last forever. It’s almost as if the eating disorder is a webpage that you visited and even though you’ve closed the webpage, it’s still in your browser history and you can’t delete it. While you may have stopped engaging in the problematic behaviors, you will always have to be on the lookout for warning signs that these behaviors are creeping back. When these behaviors re-emerge, you will need to be prepared and ready to face them.
- Go easy on yourself. As you know, recovering from an eating disorder is not easy; neither is staying in recovery. It’s important that you be mindful of not overdoing it. Don’t try to push yourself too hard too soon. Putting too much pressure on yourself may lead to a lapse or re-emergence of the disordered eating habits you worked so hard to overcome. It’s okay if it takes some time for things to go back to where they were before your eating disorder, a lot may have happened since then. Give yourself as much time as you need. Take it one step at a time and go easy on yourself.
- Eat meals regularly. It’s likely that you developed a regular eating or meal plan early on during treatment. Continuing to eat meals and snacks regularly and sticking to your meal plan during recovery will help to prevent you from slipping back into disordered eating and weight control behaviors. Try to eat 3 meals and 2-3 snacks every day, at regular intervals (about every 3-4 hours). Maintaining a consistent eating schedule will be helpful for you physically and mentally. If possible, try to eat meals with others often to encourage you to stay on track and re-establish a healthy relationship with food. Remember a car can’t run without gas or fuel. Try to think about food as “fuel for the body”, your body can’t function without food and energy to keep it going. Fueling your body will help to keep you well.
- Make time for yourself. It’s important to make time to do something kind or rewarding for yourself every day. This won’t come easily for everyone, especially if this is something you’re not used to doing or if you are going through a difficult time, or if you are busy, but making the time for yourself is important. Self-care is important. It doesn’t have to be anything big or too time-intensive, it could simply be taking a moment to relax or reflect on the day. It could be reminding yourself of what you achieved that day, such as eating all your meals and snacks, not engaging in purging behavior, or not having negative or unhelpful thoughts about your body. Other examples might include, doing some yoga or meditation, going for a walk, taking a bath, writing in a journal, reading, drawing, painting, or listening to music. No matter what you choose, remember that you are important, and you deserve to take a little time out of your day to do something that is just for you.
- Get involved. Try to get involved in a hobby or activity that you enjoy. This could be anything from playing a musical instrument, to doing arts and crafts, to reading a book, to being in nature, to joining a club, to spending more time with family or friends, to volunteering. Making the time to get involved in things that you enjoy doing or things that are important to you will help to shift the focus away from your eating disorder and help you to start to reconnect with your surrounds and the people in your community. But remember to go easy on yourself and be realistic about how much you can take on. Don’t try to do too much.
- Have a coping toolbox. It’s likely that you talked about using coping strategies in treatment. Coping strategies are the behaviors, thoughts, and emotions that you can use to help you to deal with a stressful or unpleasant situation such as the re-emergence of unhelpful eating disorder thoughts. Some common coping strategies may include calling a friend, taking a walk, using breathing techniques, lighting a scented candle, having a warm shower/bath, writing in a journal, or listening to music (you may notice that some of these strategies are the same as the self-care strategies listed above). You may have used some of these coping strategies or others in the past and you may already know which ones work best for you. It’s important to keep in mind that the same coping strategy (or strategies) may not work every time or in every situation. You may need to use different coping strategies in different situations. For some situations you might need to use more than one coping strategy to help to manage the situation; if the first strategy doesn’t help, use another one. It’s important that you have a “toolbox” of different coping strategies that you can draw from when you need to. Remember, the coping strategies that work for you may not be the same coping strategies that work for someone else.
I hope this blog has provided you with important information about eating disorder relapse and given you useful strategies and techniques to consider using to prevent relapse.
If you are looking for additional support or know someone who might need it, you may be interested to learn about our Online Eating Disorder Relapse Prevention Study. For more information or to schedule a phone screening, please contact us at onlinerelapsepreventionstudy@gmail.com or (502) 822-6778. Further information can also be found on our website at www.louisvilleeatlab.com/online-relapse-prevention-study.
References:
BC Children’s Hospital, Kelty Mental Health Resource Centre (n.d.). Relapse prevention. Retrieved from December 8, 2021, from https://keltyeatingdisorders.ca/recovery/relapse-prevention/
Fursland, A., Byrne, S., & Nathan, P. (2007). Overcoming disordered eating. Perth, Western Australia: Centre for Clinical Interventions.
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Walsh, B. T., Xu, T., Wang, Y., Attia, E., and Kaplan, A. S. (2021). Time course of relapse following acute treatment for anorexia nervosa. American Journal of Psychiatry, 178(9), 848-853. https://doi.org/10.1176/appi.ajp.2021.21010026