Unraveling the Gift of Relapse

A quick search in the dictionary offers the following definition of relapse: “Suffer deterioration after a period of improvement.” At a simple glance, this seems somewhat discouraging and emphasizes the negative side of relapse. Would it be more constructive for a patient suffering from an eating disorder to view relapse with fright and a sense of failure or, rather, to shift the view to one that can help him/her grow? In this sense, it seems that embracing relapse is an oxymoron—that deterioration is actually a necessary experience for growth and learning.

As clinicians, we are taught and trained to fix, cure, remove ailment and restore health. The responsibility of the process is, to a certain degree, put on ourselves. No wonder facing relapses can be quite challenging for us!

At the beginning of my career, relapse had the power to make me question my efficacy as a nutrition therapist and could even spiral me down the road of lingering with inadequacy and frustration. From that time, I remember Christina, who had been in residential treatment for restrictive anorexia nervosa. After discharge, she was having a hard time going back to her normal routine and had begun restricting several of her meals. To my regret, I acted judgmentally when I started questioning her as to why she insisted in hurting herself—despite everything I was doing for her! In a sense, I processed her restrictive behaviors as an attack on me and experienced substantial countertransference. In my view, I had taught her the step by step process she needed to follow to prevent relapse. By engaging in the restrictive behaviors, I felt she was letting me down. I was making the process about me as a clinician and was missing her own suffering and struggle! I pushed Christina so hard to commit to not restricting anymore, that she actually cancelled a few of our upcoming nutrition therapy sessions. Once she resumed therapy, we processed her relapse and my reaction to it. I disclosed a little about my frustrations and that I was willing to put my own feelings aside to help and accompany her throughout the process, no matter what.

By embracing relapse, the patient can create awareness of what is happening here and now and view herself from a distinctive perspective. By guiding my patients, holding their hands and walking with them through the ups and the downs, along uncharted territories, relapse offers a possibility for transformation. I often use an analogy to illustrate relapse to my patients: If you were watching a young girl (a younger version of yourself or your daughter) learn how to ride a bike, and she suddenly lost her balance and fell, what would you do? Would you tell her: “I think biking isn’t for you after all. You should quit because you’re no good.” Or would you patiently and compassionately remark: “Don’t worry about it, this happens to everyone; it’s part of the learning process. Let’s see what you can do differently next time and chances are, you’ll do better.” Same experience, different response, distinctly different results. The same is true with relapse and eating disorder recovery. Which approach would you prefer?

A constructive view of relapse implies that I adjust my vision so my patients can become more empowered and gain independence and self-accountability. Sometimes, patients have been exposed to experiences that bring them shame or judgment. This may happen when a person with atypical anorexia nervosa is told “Your weight is fine, you can’t be sick,” or when a patient with binge eating disorder is told by her doctor “to just stop eating and use willpower.” By shifting my view to an embrace of relapse, I am better able to understand the challenging nature of the disorder and sit with the patient as she is, regardless of clinical presentation or number of relapses.

I have found that working with relapse is a deeply powerful experience in the recovery process and to navigate through it, as an eating disorder nutrition therapist, I try to:

• Be sensitive to the bias sometimes present around eating disorders and the possibility that my patients may have been exposed to it.

• Have an attitude of curiosity.

• Bring an open heart and a willingness to connect with my patient.

• Be mindful and aware of my own reactions, sensations and emotions regarding relapse.

• See the patient as a whole—as mind, body and spirit converge to create health and well-being.

• Have a whole bunch of compassion and empathy, as this experience is powerful and likely to bring out intense feelings and sensations in both my patients and myself.

• Offer a sense of support and direction to provide the structure and guidance necessary to move forward despite setbacks.

My own experience with an eating disorder during my teen years taught me a lot about relapse. As an overachiever and perfectionist, I was used to getting things done my own way and excelling in almost everything I did. To my surprise, this didn’t apply to the eating disorder! It wasn’t until I shifted my view of relapse from an experience of failure and loss to one that allowed me to get to know myself and to acknowledge my own journey, that I learned about resilience, persistence and triumph. My relapse didn’t take me back to the beginning, but, rather, allowed me to reconstruct my way armed with new tools and a new vision of my reality. Rising after every relapse taught me to believe in myself and my inner voice, and to challenge my personal constructs about what could and couldn’t be achieved.

Unfortunately, some of my adult patients, who have battled for years with their eating disorders, have often been labeled as “chronic” and “incurable.” This leaves them with a sense of powerlessness, shame and lack of hope. Ana, who was in her thirties when I first met her, had been battling with bulimia since she was a teenager. She had a long line of therapists but had decided to quit after her last relapse. She had never visited a nutrition therapist, in part, because she was warned that dietitians were no good. Although she was done with trying, she came to me as a favor to her family.

I vividly remember something she said in our first session: “I do not know what you intend to do for me, as I will never recover—I am doomed to die like this.” Clearly, she felt no hope and believed her behaviors defined her. She felt addicted to the eating disorder, and she would count the number of days she was clean (of behaviors)—only to repeatedly disappoint herself when she purged or restricted. She felt no possibility of reclaiming her life.

I explained to Ana we would be working as a team, and there would be no judgment, criticism or fatalistic prognosis. I immediately introduced her to the concept of relapse—and the beauty of recovery, which could be at her grasp—with hard work and intention. Over the next years, we worked together to rebuild her confidence in herself and to understand the meaning of her behaviors. She had been living with the eating disorder for so long that she had disconnected from herself and her eating identity. For me, eating identity is a term I use to describe one’s own preferences, instincts about food (likes and dislikes) and a special way of honoring one’s body through food.

Ana patiently started to weave together the fine threads of loving self-care. For example, she began allowing herself to be flexible with her food choices, truly connecting to what she liked and disliked and letting go of guilt and negative views of food. Thus, she began feeling true pleasure while she ate. She also was able to reconnect with her body’s hunger and satiety signals, which allowed her to strengthen her intuition and eat accordingly. Relapses, though quite frequent at the beginning of Ana’s recovery, evolved over time from frightening and disheartening events to opportunities for exploration, unraveling and reconnecting. Despite setbacks, Ana kept coming back. She made a point to remind me that if she hadn’t given herself another chance after relapse, she would never have had the possibility of recovering and reclaiming her life back.

Like the butterfly endures a metamorphosis from its earlier caterpillar stage, by embracing relapse my patients undergo a transformation that allows them to become the best version of themselves. I hope to help them unravel this gift.