An eating disorder develops over time as a result of many factors. Naturally, recovery does not happen overnight. It requires overcoming powerful factors that have been maintaining the eating disorder, some of which may be external to the affected person. Changing eating disorder behaviours is therefore often a slow, non-linear process. Looking at the “stages of change” model can be helpful in developing your understanding of where the person you’re supporting is in terms of their readiness for behaviour change, what to expect, and how you can be supportive during this time. Setbacks can be frustrating and exhausting and they can be used as learning opportunities. With this perspective, it is easier to reframe them as a normal part of behaviour change and to maintain hope about the upward spiral many folks experience in the process of their recovery.
Knowledge of these stages allows caregivers to identify whether their expectations of recovery matches their loved one's. For example, often, caregivers are ready for action and implementing changes from the beginning of treatment; meanwhile, their loved one may not even recognize there is a problem yet, let alone be mentally prepared for changes. In this scenario, the caregiver is at the “action” phase, while the person they’re supporting is in “precontemplation”. When you know where the person you’re supporting is within the “stages of change” model, you can respond more compassionately when conflict and setbacks occur.
“Leave me alone!”
Precontemplation is the stage when an individual is not ready to acknowledge that a problem exists. They may respond to concerns and suggestions with hostility and defensiveness. After enough prodding, someone in this stage may be talked into finding out a little more about it when people in their life are telling them they have a problem. This may include trying to become aware of why they have not identified that a problem is present, and becoming more informed about the behaviour others are telling them to change.
People often enter treatment in this phase, and they may stay here for some time. While treatment providers understand this, it can be helpful to provide continued encouragement and communicate that you support them getting help. Because resistance is high in this stage, depending on your role in their life, you may have to be more direct and hands-on in supporting them in making changes.
As a support person, the precontemplation stage can be both scary and frustrating. Try to stay calm when engaging with the individual and remember that people can and do recover from eating disorders. Talking to the individual about the negative effects the disorder will have on things that matter to them can help them see the bigger picture of what is going on for them and, in turn, lead them to consider positive aspects of change.
“I know I have an eating disorder, but I’m not sure I’m ready to change.”
During this stage, the individual is willing to admit that they have a problem and is now more open to receiving help. However, the fear of change may remain very strong. They can begin to see the benefits of making a change, but are not ready to let go of the eating disorder and the purpose it serves in their life. For some people, the eating disorder is thought of as a friend and something that keeps the individual safe. These conflicting thoughts and feelings can be confusing and perpetuate the fear of change.
As a supporter, you could help them recognize the function of their eating disorder and how it does not serve them the way it used to (i.e. how it may be more harmful than helpful now). If the individual considers the eating disorder a friend, it may be worth gently challenging them to consider how good a friend it actually is if it is causing them physical/mental distress. Encourage them to share their thoughts and feelings about the eating disorder, and let them know you hear what they are saying. It’s important to let them feel in control of their decision for pursuing change, as imposing your beliefs on why they need to change can lead to further resistance. Listen for opportunities to reinforce their openness to taking a recovery-oriented step; if they mention a reason to make a change, reflect it back to them.
“I’m getting ready to make small changes.”
During the preparation stage, the person you’re supporting is ready to change, but perhaps uncertain about how to do it. They might look for you for support and encouragement regarding next steps.
A task that you could take on is collaborating with them on a plan for how they are going to make those changes. This could include establishing specific coping skills such as appropriate boundary setting and assertiveness, effective ways of dealing with negative eating disorder thoughts and emotions, and ways to tend to their personal needs. You can also help them identify potential barriers to change and additional supports that they might need (e.g. connecting with a peer support group and/or professional for guidance; working with friends/family to ensure pets and/or children will be looked after if they enter treatment; generating a list of people to call during times of crisis). Reassure the individual that you will support them through this process and that they aren’t alone.
“I want to stop dieting/bingeing/vomiting/over-exercising/etc.”
The person you’re supporting is ready to implement their plan and confront the eating disorder behaviour head on. They may be engaged in treatment and working hard to change their behaviours, willing to face fears in order for change to occur.
They will likely find the changes difficult and experience distressing thoughts or feelings. Continue to offer reassurance when they become conflicted about what to do (e.g. staying with treatment or not) and encourage them to communicate their thoughts and feelings to their treatment provider(s) and work through them together.
“I’m trying to keep up the changes I’ve made.”
If the individual has sustained the Action stage for approximately 6+ months, they are in the Maintenance stage. They are actively practicing new adaptive behaviours and new ways of thinking, bringing what they learned in treatment or from other resources into everyday life and learning to form an identity separate from the eating disorder. In doing so, they are living life in a more meaningful way. In this stage, ideally, they have a solid relapse prevention plan.
It could be helpful to discuss how you can continue supporting them in learning to live their life away from the eating disorder. Remind them that although setbacks may happen, people can and do recover from eating disorders – and regardless of where they are in their journey, you are proud of them for challenging the eating disorder.
“I’m noticing the disordered thoughts/feelings are getting louder again/more prevalent in my daily life again.”
Recovery is not a linear process. It is normal and expected to encounter setbacks. A slip-up or smaller setback is often referred to as a lapse, while a bigger setback regarding thoughts or behaviours tend to be referred to as a relapse. While very difficult for the support person to witness and frustrating for the person affected to experience, setbacks can be learning opportunities that push an individual forward in strengthening recovery.
They might feel like they are going in circles, but when we look at it sideways, it is an upward spiral – meaning they are not at the same place as where they started. Recovery is still possible. Sometimes people need to go through this cycle multiple times before they are able to maintain recovery. Offering this perspective and reminder can help in normalizing this upsetting process. Accepting this as a part of the recovery experience can strengthen their ability to practice self-compassion and remain hopeful and motivated for change.
“The eating disorder no longer interferes with my life.”
Recovery looks and feels different for everyone. For some, it is an ongoing process of healing. Some get to a point of being recovered that they define as a state in which they occasionally experience eating disorder symptoms but feel like they can live a full and satisfying life. Many people recover to the point where they no longer struggle with disordered thoughts, feelings, and behaviours related to food and their body – widely considered to be fully recovered.
Regardless of how the person you’re supporting conceptualizes recovery, celebrate their resilience and continued hard work. Throughout the recovery process, it’s important to recognize and accept your limitations, seek your own support, and take “time-outs” from the helping role; this will help you avoid emotional burnout.
Mealtimes can be riddled with conflict and intense emotions for both those affected with an eating disorder and those supporting them. Here are some strategies that can help make things more comfortable. Remember that different tactics will work for different people at different times.
It is common for people with eating disorders to withdraw from social activities. Taking steps to stop them from isolating themself and to make them feel included helps promote recovery.
Eating disorders can make people behave in ways that seem out of character. They might respond emotionally or aggressively to others’ concern and attempts to help, especially when they feel challenged or pushed into a corner. Here are some tips that may help prevent further escalation of the situation.
While many comments may be well intended and come from a place of caring, the eating disorder can skew the way in which the person you're supporting interprets what is said to them. It’s understandable if you feel uncertain of what to say in fear of further perpetuating the eating disorder. Here are some examples of helpful language.
Just eat normally.
What may be heard: “You’re not trying hard enough”; “It’s not hard to eat / stop eating”; “You are greedy”; “Binge eating isn’t a problem”; “You are making this up”; “You want attention”; “You are the problem”; “You are a burden”.
Alternative: Eating disorders are complex mental illnesses. It’s not helpful to diminish one’s experience by offering a simple and reductionary solution – this can amplify feelings of shame. Demonstrate your understanding of eating disorders by validating their concerns and showing support.
You look well.
What may be heard: “You look fat”; “You’re healthy now so things are easy for you”.
Alternative: Affected individuals often take comments that relate to looking “healthier” or “better” to mean they have gained weight, which can heighten disordered thoughts and feelings. Give non-appearance-based compliments or focus on an item/accessory they own. It’s also nice to ask how they are, rather than making a statement rooted in appearance-based assumptions.
Wow, you've lost weight!
What may be heard: “You look better now that you're thinner”; “It's not okay to have a bigger body”.
Alternative: Commenting on weight loss, even if intended as a compliment, conveys a bias against larger bodies and can heighten disordered thoughts and feelings. Give non-appearance-based compliments or ask how they are doing, rather than making a statement rooted in appearance based assumptions.
I wish I had your willpower / control / self-discipline / your body.
What may be heard: “It’s good to be obsessive with food, weight, and shape”; “You are in control of the eating disorder”; “The eating disorder is a blessing”; “You need to keep doing the disordered behaviours”.
Alternative: Because disordered behaviours are often used as coping mechanisms, it is extremely difficult to fight the intense thoughts, feelings, and experiences that drive someone to engage in disordered eating and to change their habits. Don’t make statements that imply the eating disorder is the person’s choice. Avoid commenting on ways you want to change your weight and shape. If you want to talk about body image, food, or exercise, make sure you are not putting pressure on them to feel a certain way about their body, and that you’re emphasizing all the ways food and movement can fulfill our lives, rather than connecting it to physical appearance.
Get well soon.
What may be heard: “It’s easy to overcome this”; “You aren’t trying hard enough”; “You’re a burden”; “Hurry up and get better”.
Alternative: Reassure them that you will support them throughout this process even when it is difficult. Validate their strength, patience, and bravery for challenging the eating disorder.
I know exactly how you feel – I can easily finish a box of cookies.
What may be heard: “It’s not a ‘real’ problem because everyone eats this way”; “It’s normal to binge eat”; “You don’t deserve support”.
Alternative: While everyone overeats on occasion and may engage in emotional eating at times, these behaviours are concerning when accompanied by frequent feelings of guilt and shame or a feeling of being out of control with one’s relationship with food, or when eating is one’s sole coping mechanism. While it’s good to validate and demonstrate understanding, do not trivialize or over-simplify what the person is going through and assume you completely understand their feelings and situation.