The Half-Baked Cake

When I was at the Congressional Briefing following the EDC Lobby Day this past Tuesday, I heard the clinical director of the Renfrew Center in Bethesda, MD speak. Mainly she spoke about how managed care has dramatically changed the treatment of eating disorders--and not for the better. One of her comments really hit home with me, when she said (approximately) the following:

Normally, you look in a cookbook for how long to bake a cake, and the recipe says to bake at 350 degrees for an hour. Managed care operates under the premises that you can make the cake at 500 degrees for 20 minutes and still have a finished cake. The irony is that often the cake looks done on the outside, but the inside is still completely raw. And if you let the cake sit for any length of time, the uncooked interior causes the whole cake to collapse.

The parallels to eating disorders are obvious: as soon as you start to "look" or outwardly seem better (i.e., the outside of the cake looks baked), the heat is turned off, the support is removed, and the whole thing collapses because it can't yet support itself. The analogy transcends issues related to managed care and really has to do with how we view eating disorders.

We need to start seeing the initial phase of weight restoration and normalization of eating behaviors similar to detox from addictions--it's a necessary first step but far far from the last. Furthermore, intensive, ongoing support is still needed after detox and weight restoration so that brain healing can take place and the person can learn how to overcome their tendency towards substance abuse or eating disorders.

Although the Renfrew director and I differ on why care needs to be continued after initial weight restoration (for her, it's the need to address the root cause of the eating disorder, which I think is mostly bollocks; for me, it's the need to allow ongoing brain healing and begin to learn and use better skills to deal with life), I do agree with her on the priority of weight restoration and the need for intensive support long after you start to look "better."

Maintaining a healthy weight is still hard for me. I have made huge strides, yes, and the higher weight has (I think) really helped to start to cement some of my recovery in my brain. (I kind of wish it didn't, but there you have it.) But I still need a LOT of therapy to help me learn to turn off that knee-jerk response of lose weight-restrict-control-control-control that my brain seems to have when faced with basically any kind of stress. My perfectionism is alive and well--perhaps because I can't bury it exactly six feet under. And the body dysmorphia? Well, let's just say that my mom's suggestion of a soak in our jetted tub to recover from Lobby Day was nice but almost laughable because I close my eyes when I shower so I can avoid seeing myself. A bath is totally out of the question.

My cake isn't fully baked yet, no matter how good the outside looks. I don't blame people for getting impatient- heck, I'm getting impatient. But the cake needs to stay in the oven and my therapy and support need to remain in place until the cake is baked.

And then I'll probably have to frost the damn thing.


Katie Green said...

This post made me laugh, but in a slightly awkward knowing kind of way because its so true. It seems that very few professionals caring for those suffering from eating disorders stick around long enough for the cake to bake. I was lucky enough to find a therapist who understands the baking (but I've had to pay).

I hope you do find the support you need to finish cooking right through to the middle. And I'm afraid you will have to ice it too, but so far for me that's been the fun part :P

Cathy (UK) said...

I really like the analogy this woman presentated, and which you describe Carrie.

One of the reasons why I stuck in anorexia nervosa (AN) for 28 yrs before really making strides in recovery was because all the emphasis in my treatment was placed on weight gain, to the exclusion of other important and relevant matters. Of course, weight gain is vitally important to recovery from low weight AN, but rarely does it completely 'cure' the person's mind and enable them to cope with the stress of life. Once weight restored, the person often needs LOTS of support with managing feelings and developing/learning alternative techniques (that don't involve disordered eating or self-harming behaviours) to cope with the stresses of life.

However, I disagree with your view that the need to address the root cause of the ED is mostly "bollocks". There are almost always root causes of some type. Most often these are co-morbid conditions and inherent traits, such as innate anxiety, obsessionality, perfectionism. Social anxiety, OCD and autistic traits are common in people susceptible to AN and don't disappear with weight gain. The person needs to learn how to deal with these traits which play a role in the root cause of their ED.

Although current popular opinion is that EDs are brain illnesses that are not caused by trauma, it is ignorant and also soul-destroying for individuals whose EDs were triggered by trauma (and who have co-morbid PTSD) for professionals to dismiss the importance of such trauma. Trauma (childhood bullying and sexual abuse by people outside of my family) played a big role in the development of my AN by triggering depression and exacerbating my pre-existing anxiety. As an 11-yr old I restricted food and over-exercised as self punishment, because bullying and abuse had led me to hate myself. Food restriction and over-exercising triggered AN, but weight gain didn't remove my PTSD. I just became a heavier person who was so terrified of the world that I started to restrict again.

I can understand why people with EDs who have never suffered trauma may dismiss the hypothesis that trauma can trigger EDs. Likewise, I can understand why parents of children with EDs also wish to dismiss the role of trauma, lest they be implicated in some way. I don't blame my parents for my ED in any way, but I do know that trauma work has played a vital role in my recovery from AN.

Mamie said...

I LOVE this post! Such a good metaphor for how I feel about the whole thing. People want to rush progress- I want to rush progress, too!- but the mind is slower to catch up than the body. My goal isn't to only gain weight, but to gain weight and feel good, happy and proud of it. And that's the difficult part. Feeling okay about it. x

Libby said...

That is one fantastic analogy.

Anonymous said...

I love this analogy! It made me laugh, but it is so true. I haven't looked at recovery after managed care that way (I did go inpatient last year), but it makes complete sense... and it is nearly exactly the way you described. Seems like we both have some more baking to do.

Anonymous said...

I love this analogy as well! I've been in the hospital and refed so many times and almost immediately I relapse as soon as I'm home. And I think part of it is because most of the time I was not able to afford an outpatient dietitian or therapist to help keep the processes going. I'm also an adult with anorexia, so there isn't the parental support that younger people (teens and college age students) have. I'm thrown back into the world on my own, and in the end, the only thing that changed at the hospital was my weight. And that clearly was not enough.

Maddi said...

wow, perfect analogy. The reason I relapsed the first time I think is because the cake was baked on the outside but I got soooo impatient so i pulled it out of the oven, and basically had to start all over! This time around i am trying to fight thru this relapse, and hold on till ED is no more. I have come up with several new methods to help me cope with stress. I think i will be ok!
Thanks for the great post!

Secret said...

"And then I'll probably have to frost the damn thing."

:) I laughed reading that, but only because I agree so wholeheartedly with everything you said in this post and know firsthand how true it all is.
I tend to get annoyed with even the idea of having a "recipe" to start with (I guess I'm actually like this with my cooking, too) because something that works for someone else may not work for me at all without a significant amount of tweaking. Forget the recipe...start with a basic understanding of what works and then take baby steps from there, one ingredient at a time, constantly re-evaluating, until you have something that will nourish you in just the way you need. (Now if only the cost of the ingredients wasn't so tricky...)

Anonymous said...

I agree with you on addressing root causes being bollocks. However, my reasoning for this is less because I don't believe in addressing root causes, but because of how this is actually carried out. I don't know that my experience is indicative of a general trend, but most therapists who have tried to address root causes with me have gotten it all wrong. They see the one thing in my past that looks like trauma, and they want to focus on that as the sole root cause. Yes, that one trauma thing is a root cause, but it is one of a complex intermingling of root causes. Furthermore, not all root causes can be worked through in therapy such that they are no longer an issue, some root causes are things that I will have to continue to deal with because I cannot get away from them or make the situation any better.

Also, I also close my eyes while showering! I thought I was the only one.

Angela E. Gambrel Lackey said...

That's the mistake I made. I thought because I had gained some weight and was out of the danger-zone in that area, I was okay and recovery was just around the corner. I hope I don't make the same mistake again.

I'm not sure how I feel about finding the root causes of my AN. But I come from an unique perspective; I developed AN at age 41 and I do want to know why why why? Why at that age? What were the triggers? I feel like the oddball in the world of eating disorders.

But I also question how helpful knowing the answers will be, or will the answers just create more problems? My therapist and I are carefully exploring trauma-based origins and past eating behaviors which might have been considered disordered but undiagnosed. But will knowing all this be helpful in recovery? I don't know.

Pre-anorexia, I always found the frosting was the best part of the cake (if it was good frosting; not that icky, goopy lard-based kind.) Try a light drizzle of dark chocolate maybe, and have some wine with the cake. Celebrate once the cake is fully baked. :)

Laur said...

great metaphor!

I'm posting this to facebook!

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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