I'm starting this relapse prevention series by going back to the (very) basics. One of the major points of relapse prevention is to anticipate some of the difficulties you might have and create a plan for how to deal with them so that they don't trip you up too much. I think there's another aspect of relapse prevention planning that doesn't seem to get as much attention: assessing your strengths. What can you call upon when the going gets tough and the recovery gets tougher?

Together these strengths and weaknesses will provide a framwork for your relapse prevention plan.

Here is the list I wrote for myself:

Strengths

• good support system
• good treatment team
• good insight
• motivation to get/stay better
• can draw upon a wide range of skills

Difficulties

• body dysmorphia
• loneliness
• anxiety
• perfectionism
• putting insight into action
• dealing with change

After I made these lists, I then took each one of these difficulties and made a specific list of how to deal with these issues without using the eating disorder. I'll share the list I made for dealing with body dysmorphia, so I have something concrete to turn to when I have a "fat attack."

Plan for body dysmorphia

• focus on what my body can do rather than what it looks like
• participate in sports or dance vs. all solitary exercising
• repeat mantras: My body is healthy and healing at this weight.
• continue CBT work on addressing body dysmorphia
• "objects in mirror are smaller than they appear"
• talk/share my feelings on body dysmorphia and what else is going on
• accept the fact that I still have body dysmorphia and move on
• remind myself: Losing weight won't solve anything. The ED is a short-term solution to a long-term problem

This list isn't going to be the be-all and end-all for dealing with body dysmorphia and relapse--the issue is a pretty major one for me and this list doesn't even come near to covering it all--but it's a start.

Tomorrow, I'll look at another aspect of relapse prevention: Identifying Triggers

• not adding milk to my coffee
• avoiding mealtimes
• hiding food
• exercising in secret
• not taking a day off from exercise
• lying about what I've eaten (yes, even little white lies count!)
• ongoing insomnia (it might be the ED, it might be something else, but lack of sleep is one of my big triggers!)
• counting calories
• visiting calorie count and/or diet websites looking for tips/information
• purging
• subsituting candy for more nutritious food
• drinking calorie-free beverages instead of eating
• deliberately limiting calorie intake
• feeling cold
• extreme surge in anxiety and depression in conjunction with any other red light sign
• extreme fatigue (again, it might not be the ED, but it does need to be looked at)
• mentality of "I can't recover so why bother"

I know, it's cheesy, but I've found the best form of relapse prevention is simply living a fulfilling life outside my eating disorder. This doesn't mean that relapse is impossible, or that slips won't ever happen, because that's not quite true, but what it does mean is this: I have something to lose by giving in to the anorexia. Even last spring when I was relapsing hard-core and was finally aware of it, I didn't care enough to stop. Not eating was the only thing that mattered. If I screwed myself over professionally, so what. I had no real motivation to fight the anorexic thoughts and so I found it so much simpler just to give in.

Part of the reason I was able to hold onto recovery during my year in grad school in Baltimore was that I found my program so remarkably fulfilling. I had found what I wanted to do with my life. I felt reassured that after so much floundering and searching, I had found the perfect profession for me. Not that my time in grad school was ED-free, not by a long shot. I struggled immensely to stay on track, often barely clinging to recovery and the bottom end of my minimum healthy weight. Yet my numerous and rather regular lapses and returns to ED behavior didn't turn into a full-blown relapse, either. I kept my demons in check. I had a fighting chance.

However, as I became disillusioned with my first job out of grad school, the eating disorder crept back in even more. The life I thought I was going to be living turned out to be quite a bit different than I thought it would be, and I began to lose my motivation to fight. Giving into the ED behaviors became the rule rather than the exception, and I slid into utter despair. My life was both still dominated by the eating disorder and anything but fulfilling.

Part of what this last relapse did for me, by being so spectacularly dramatic, awful, and life-shattering, was that it gave me the freedom to start over. I truly had nothing left to lose. My career had already flopped several times--what was one more? I was unable to hold down a regular full-time job (I was living in Michigan and so I knew I wasn't going to find a job, either), I didn't need to pay rent, and I had already screwed up my life so horribly that one more screw up would hardly be the straw that broke the camel's back. With nothing left to lose, I took a chance: I decided to pursue freelance science writing as my full-time career.

What ultimately saved me during my past relapse was my cat. I promised her I would never go away and leave her again, and I was determined to keep that promise. It didn't stop my relapse, but it did keep me alive. Now, when I have ED thoughts or feel tempted to engage in ED behaviors, I know that a relapse would be incompatible with the life I want to live as a writer. I do slip and inadvertently or deliberately restrict or indulge my exercise compulsion or debate about buying laxatives to have on hand "just in case." When I step on the scale at TNT's office, I still hope I have magically lost weight. I body check in the mirror frequently. Writing hasn't made me recovered, but it has helped me keep my eating disorder tightly confined. I want to be a science writer more than I want the comfort of anorexia, of skin and bones, of starvation and compulsion and, ultimately, death.

Recovery and relapse prevention are, as Emily Troscianko writes, not only about stopping starving but also about starting living. It's both the goal and the route to that goal.

I've been working with TNT on developing my own personal, handy-dandy relapse prevention plan. It's far from the first plan that I've worked on, but it's the first detailed plan that I've worked on.

I've gotten emails and feedback on my blog about the need for better relapse prevention planning, and so I thought I would turn my therapy homework and your requests into a blog series on relapse prevention.

I have some idea of what I want to cover, but I also want input from you to see what issues you would like to see covered. It can be mundane--often the things that trip us up are pretty mundane. I can't guarantee that I will cover everything, but I will do my best.

Stay tuned for the first post later today!

Ah yes. Identifying triggers. When I was deep in the eating disorder, pretty much everything triggered eating disordered thinking. Even in early recovery, much of that persisted. A glance at a magazine could trigger a storm of self-loathing. The barest hint of reproach from another person could send me spiraling. And any anxiety-provoking situation would leave me fantasizing about slashing my food intake and increasing my exercise.

Things have improved since then, but there are still any number of situations that amplify the eating disordered thinking and make me ever more vulnerable to relapse. Some of the point of identifying your triggers is to anticipate when you might need extra support. The other point of this is to make what I like to call a "mitigation plan" (it's a term I used when I was working in emergency preparedness, a career move that gave me many ideas into relapse prevention planning) so that you can survive the situation with as little lasting damage as possible.

Here is a (partial) list of my triggers:

• physical illness that affects eating/appetite
• seeing people running/exercising
• moving
• learning of a friend's relapse or weight loss
• weight gain
• new job
• feeling like I don't measure up
• clothes shopping
• getting off my schedule (ie, traveling)
• increase in depression
• increase in anxiety
• financial stress

Some of these triggers can be avoided, many of them cannot. Similarly, some of these triggers can be anticipated, but many cannot. Given that we can't avoid these triggers and we can't anticipate them, what else can we do? Like I did when I worked in emergency preparedness, I had to develop a plan (the mitigation plan) to help deal with them.

I created a general "mitigation plan" for all of my triggers and made certain additions as necessary to fit each particular situation.

My trigger mitigation plan looks like this:

• utilize support system
• increase frequency of therapy appointments
• compare and despair: I am doing the best I can at the moment
• stay to my specific schedule of meals and snacks no matter what
• BE HONEST about urges
• relapse is always there for me- I don't need to act on my urges right this second. I can wait and use my wise mind to think it through, and solicit feedback from others
• distance myself from negative people
• schedule meals and activities with others
• my exercise and eating plan are right FOR ME; it doesn't matter what other people are doing
• relapse only means more clothes shopping so don't go there

Some of these plans are appropriate in a wide variety of situations while others are more specific to certain triggers. The idea is to have a plan that is flexible and can be adapted to a variety of situations but still provide enough guidance on what needs to be done when the going gets tough.

Knowledge is power, they say, and in the case of relapse prevention this is definitely true. The phrase "forewarned is forearmed" is certainly apropos. If, for example, you can anticipate a trigger (maybe having to meet with a difficult family member) then you can start using your mitigation plan even before all hell breaks loose. Even if you can't totally prevent hell from breaking loose, at least you can contain the damage.

So I've gone through my Prelapse Signs, and my red light, yellow light, and green light signs. Although I think it's invaluable to know areas that are likely to trip you up, it's also important to be aware of (to paraphrase Donald Rumsfeld) the things we don't know we don't know are going to sideswipe us.

Case in point: when I was in Europe last month to attend the AED Salzburg meeting and then tool around Austria for a week or two, I got a nasty stomach bug. This meant intense nausea, being unable to eat, and other fun symptoms that I'll leave to your imaginations. As a result, my eating was dramatically diminished for several days and dwindled to apple juice and some pretzels on one day. My mom was, not surprisingly, freaking out until she got what I had and we were both puking.

My mom's concern was that this not eating would make the ED thoughts come roaring back. I vaguely scoffed--the ED thoughts had been no worse than usual during the trip, and I'm doing better than I ever have, recovery-wise--and for much of the time, it was a moot point. I couldn't have eaten anyway. However, as the nausea started to diminish, I was at first very hesitant to start eating more simply because a) I was enjoying the novelty of no nausea and b) I was afraid it would aggrivate my stomach. Then the pushback started to take on a life of its own, and I just didn't want to eat. I started thinking that maybe this would be the perfect opportunity to lose some weight, and...

Yep. I was totally gobsmacked. I was back into full-blown ED thoughts and it seemed there was no "real" trigger. Except that bit about not eating.

Stomach bugs are inevitable, and so (almost certainly) is an inadvertantly missed meal or snack. Here's the thing: before I left treatment, I was warned about all sorts of relapse triggers, such as family problems, reading fashion magazines, hearing people talk about their diets, or other stressors. What no one mentioned was that being unable to eat (whether it was due to a virus, being stuck on a tarmac for 8 hours, whatever) for any period of time could also be a trigger. I never thought it would be such a potent trigger, either. You'll notice most of my relapse prevention plans don't really have much to do with these situations. Some of that is I can't really prevent many of these situations, and the other is that I really don't like that I'm so sensitive to changes in food intake. It really pisses me off! It seems so much less rational than an actual event to set off the ED.

Yet there you have it- the ED is the ED and my triggers are my triggers. It's not like one is "better" or "worse" than any other, and it's not that one trigger will only set off a benign relapse and another will be an utterly wretched relapse. So much of my relapse prevention planning has been coming to learn what my triggers are and accept them at face value, without judgement.

Many of you have been asking for a shakedown of my NEDA talk on relapse prevention.  So, without further ado, here are my thoughts.

I presented on relapse prevention (with the help of some LOLcats), basically using the information from my relapse prevention series from earlier this summer.  Yes, this was deliberate--I knew I would be presenting on the topic and thought I would double dip a bit to get some of my work out of the way and have a good blog series.  The presentation itself was a total rush of adrenaline, and I remember only two things:

1) One of my slides had a typo (it read "you" instead of "your")

and

2) One of the animal pics I used didn't elicit the same laughter as the others.

So yes, I remember the details and negative ones at that.  I do think the talk as a whole went exceedingly well, but much of it was a blur.  I spent the morning guzzling coffee to combat sleep deprivation, and then I had to take some lorazepam before the talk started because I was shaking and nauseous from nerves (and potential caffeine overdose).

My co-presenter and former therapist Stephanie rocked it out--it was so wonderful to work with her as a colleague rather than as just a client.  We made a fantastic team fighting ED, and we made a kick-ass team doing our presentation.

After we got done, my mom came up to the both of us and asked, "So did the two of you have fun?"  I raised and eyebrow and said that "fun" definitely wasn't the word I would have used to describe presenting.  It was, however, very rewarding and enjoyable in its own way.  It's not going to be my career, if for no other reason than public speaking would involve way more traveling than I would like!  I'm hoping to present at other eating disorder conferences, and I hope to meet some of you there!

Technically when you're driving and you see the light turn from green to yellow, you're supposed to slow down and then stop. Yeah right. I don't know about you, but many times when I see a yellow light, I hit the gas and try to cruise through before the light turns red.

For most of my eating disorder, this was how I operated. I saw the warning signs of relapse and I just hit the gas on the eating disorder. Some of this was rooted in the basic neuropsychology of an eating disorder--that whole viscious cycle thing. But some of it was the fact that I really did think I could squeak by the need for more intensive treatment and recovery work if I just timed everything right (and drank enough water before weigh-ins).

Clearly, that hasn't worked out very well.

When I wrote my previous relapse prevention plan and identified my yellow light signs, I was still rather ambivalent about recovery. So my yellow light signs should have been my red light signs and my red light signs should have been flashing lights and sirens. Besides the ambivalence about recovery, I was also a little unprepared for how easily, quickly, and strongly the eating disorder can take over. I (not very wisely) thought I knew enough about eating disorders that I didn't need to be all that worried, right?

A false sense of security is one of the EDs greatest weapons.

Yellow light signs are different than prelapse signs because they have more to do specifically with the ED. Not that they deal solely with ED behaviors, but for me, most of the upticks in ED behaviors come after a time of increased anxiety/depression (although it took me years to figure out that the uptick was in response to this increased anxiety/depression). Not always, which makes the increased anxiety more of a "prelapse" than an actual sign of relapse.

The yellow light signs are, for me, a sign I need to slow down and take a good, hard look at what is going on. They're signs that the ED is returning. If you'll forgive another car analogy, they're like the "check engine light." Your car might be running just fine, but the light is usually an indicator that something is about to go rather wrong.

My Yellow Light Signs are:

• increased paranoia about food (not trusting what others give me, etc)
• looking up nutritional information on the internet
• feeling like everyone is watching every bite I take
• exaggerating what I ate
• rigidity around exercise
• need for precision with measuring food
• extreme irritability
• gnawing doubts about my ability to recover (this is a precursor to the "F*ck recovery!" stage)
• procrastinating on returning messages
• desire to run away and/or hide from life
• urges to purge or hide food

What I found hard with identifying these signs is that my relapses tend to simply leap straight from 0 to 100 with nary a stop in between. I can go from green light signs to red light signs in less than a week. So identifying the yellow light signs is both tricky and crucial. The other issue I struggle with is identifying and acting on the warning signs. Often, I tend to downplay the seriousness of the problem even in my own mind, and so I delude myself into thinking that it will go away or that I can handle it on my own. It's hard. It's damn hard, and I'm not always super-confident in my abilities and judgement on the subject. Which means I am having to accept a big dose of humility in learning how to manage my ongoing recovery.

Part of any good relapse prevention plan should be some ideas for alternate behaviors or activities for when you feel the urges to engage in ED behaviors. Over the years, I've come to realize that this list isn't always enough. When I'm really struggling with urges, some of the suggestions on the list can seem asinine--feel like purging? Knit a scarf. There ya go.--and sometimes you would be happy to knit a scarf if only you had some yarn and a pattern. But you don't.

Enter the Emergency Kit.

My kit is an old shoebox that I decoupaged in treatment and inside I keep my list of alternate behaviors, and I also keep some supplies for these alternate behaviors. Some of these supplies include a bottle of bubbles, a skein of funky yarn, a rubber ducky, some meaningful mementos, phone numbers of friends/family, and a $5 Starbucks gift card. I also have a really hard jigsaw puzzle, but that's in my closet, not the box. When I'm really wanting to act out on the eating disorder, it's all well and good to think that standing on the back deck and blowing bubbles would make you feel better, but you also need to know where those bubbles are and (this is just as important) have them available for easy access. At these times, I have minimal frustration tolerance, and rooting through drawers and boxes is not going to be helpful. Hence the Emergency Kit. Everything is all together and easily accessible.

My list of alternate behaviors includes the following:

• crochet
• blogging
• sudoku
• reading
• heavy-duty cleaning
• snuggling with Aria
• listening to my iPod
• taking a shower
• looking at travel websites
• lighting candles
• take a nap
• deep breathing

These alternate behaviors are also alternates for other less-than-helpful behaviors, such as marinating in my own anxiety and that depressive perseveration. The list originally came from the distress tolerance module of dialectical behavioral therapy that I worked on in treatment. I initially targeted it towards ED behaviors, but I found it helpful in pretty much any situation. I've added to it over the years, and crossed out a few items.

Ditto for the emergency kit. I have a few items I'd like to add, such as Silly Putty, Play-Doh, and Legos. But the contents have remained remarkably stable over the years (this either means I picked good items or I'm frighteningly consistent).

The other key factor is to actually use your emergency kit. I used to tell myself that this wasn't a real emergency and I should save the yarn, bubbles, whatever, for an actual emergency. I've had to tell myself, over and over, that any thoughts of turning to my emergency kit are an actual emergency. I wasted my money if all the stuff does is sit there and collect dust.

What sorts of items do you want to include in your emergency kit? Share your responses in the comments!

I'm going to indulge my geeky side here briefly, as I stumbled across a research article about the use of exposure and response prevention for anorexia.

The International OCD Foundation describes exposure and response prevention as:

The "Exposure" in ERP refers to confronting the thoughts, images, objects and situations that make a person with OCD anxious.

The "Response Prevention" in ERP refers to making a choice not to do a compulsive behavior after coming into contact with the things that make a person with OCD anxious.

This strategy may not sound right to most people. Those with OCD have probably confronted their obsessions many times and tried to stop themselves from doing their compulsive behavior, only to see their anxiety skyrocket. With ERP, a person has to make the commitment to not give in and do the compulsive behavior until they notice a drop in their anxiety. In fact, it is best if the person stays committed to not doing the compulsive behavior at all. The natural drop in anxiety that happens when you stay "exposed" and "prevent" the "response" is called habituation.

It's primarily used to treat people with OCD, but since there is an overlap in many of the symptoms of OCD and eating disorders--"The overlap between AN and anxiety disorders suggest a model of AN in which baseline anxiety features yield eating related fears, avoidance behaviors, and ritualized safety behaviors that promote the underweight state and the perpetuation of the disorder."--the authors thought that ERP, as it's commonly known (because if the psychotherapy community loves one thing more than couches, it's acronyms), might be helpful in relapse prevention. Their guess was right.

This blog post isn't about the study- I'm trying to stay committed to my pledge not to intellectualize my illness. But as I was in the bakery today, I was thinking about this study. Why? For one, I had lots to do and very few customers, which meant my mind was free to wander about. For another, I got offered a sample today, this time by the cheese people. I was offered a piece of queso manchego, and I took a teensy little piece. I didn't know if I would like it, and also that whole eating disorder thing I've been telling you about. The cheese lady asked me what I thought, and I nodded and said "Pretty good." And the cheese was. So the cheese lady said, "Here, have a bigger piece." I just about flipped the shit on that one--two pieces of cheese in one day?!?--but I also knew that my recovery depended on saying yes and so I did say yes and had the second piece of cheese.

Which is just about when I started freaking out. I had every imaginable thought running through my head, ranging from "Everyone is going to think I'm a PIG!" to worries about massive weight gain from a small piece of cheese. This is why I avoid samples, I thought, because it's so freaking stressful.

Once I calmed down a bit, I was able to talk myself off the ledge of oh-shit-I-ate-too-much and I got a wry chuckle out of how much exposure to my ED fears this job is giving me. And cue thoughts of the study I cited above.

Although I don't think an eating disorder is "about" control, I certainly would say that it's a major theme in many people's eating disorders, including mine. I did some exposure work with fear foods in the past, but that exposure was always on my terms. I made sure I was never in a situation in which I couldn't get out of eating. More than that, I did my damnedest to make sure that I wouldn't be in a situation in which I'd be offered food without my being aware of it (I fully expected to be offered hors d'ouerves at a cocktail party, or even a meeting over coffee, so I could "plan" or restrict accordingly if I couldn't get out of it). Even in the bakery, I still have control. No one is making me try things. I won't get sacked because I don't/won't/can't sample the eclairs or the cannoli. I could make up a dairy allergy, a wheat allergy, a calorie allergy to look less like a freak.* But I know that recovery means learning to live with offers of food without my fight or flight response kicking in.

So I said yes to the second (fairly sizable) slice of cheese.

Before you go patting me on the back too much, know that I had packed a string cheese with my dinner, and I substituted the queso manchego for the string cheese. If I didn't have an item that was quite so equivalent, I probably would have backed out. But I accepted the cheese and ate it and found that it was actually quite good- a lot like Parmesan but less crumbly and pungent. I didn't plan on having the cheese, I didn't know the exact calorie count, and I accepted a sample at the bakery--all of which are anxiety provoking things for me.

In ERP, the therapist usually asks you to create a hierarchy of anxiety-provoking tasks for you to accomplish, starting from the least anxiety-provoking to the most. And then you systematically begin exposing yourself to the items at the bottom of the heirarchy, and work your way to the top. Today's cheese incident was probably fairly low on the heirarchy- maybe not the lowest, but definitely not at the top.

And I ate the cheese. And I survived. I didn't restrict, I didn't purge. I am exhausted and frustrated (dude--it's cheese!), and I hate to think that this ERP party is just getting started, but I suppose it is what it is.

*"I'm allergic to food."
"So what do you eat, then?"
"Diet Coke, black coffee, and mustard."
*headdesk*
Don't think I haven't seriously debated using this line! LOL

• flexible about meals (quantities, portions, etc)
• minimal anxiety eating at restaurants
• in regular contact with friends and family
• exercise no more than X days per week (I don't want to trigger anyone, so I edited the number)
• not spending hours doing grocery shopping
• not letting body dysmorphia unduly influence clothes choice
• able to eat without knowing precise calorie counts
• no body checking
• experimenting in the kitchen
• engaged in reading, other activities
• minimal ED thoughts, no strong urges to engage in behaviors
• tracking my food intake via my meal plan (NOT counting calories, fat grams, fiber, sugar, etc)
• normalized consumption of sweets

On Saturday, I shared some of my recovery green light signs, which was a list of thoughts, behaviors, etc, that were indicating my recovery was going along well. I am going to share my yellow light signs (warning signs of relapse) and red light signs (take action now, do not pass go, do not collect $200). But somewhere in between green light and yellow light are the signs of prelapse. If yellow light are the signs preceding a relapse, then prelapse consists of the signs before the signs.

I realize I haven't really defined some terms, so that we all know we're referring to the same idea, here are some (brief) definitions:

lapse: a one-time return to ED behaviors. It means you purged once, or skipped a meal, and so on.

relapse: an ongoing return to ED behaviors.

prelapse: the indication that you might be be heading for a lapse or at high risk for a lapse. It doesn't mean a return to ED behaviors.

Some of my prelapse signs are very related to the eating disorder (urges to skip meals, increase in body dysmorphia) but many of them aren't. Although I'm not sure that eating disorders have nothing to do with food, many of my vulnerabilities to anorexia and to returning to anorexia have nothing to do with food.

Here is my list of prelapse signs:

• preoccupied with food/eating
• avoiding friends and family
• urges/compulsions to overexercise
• increased rigidity in life and activities
• thoughts/urges to skip meals
• increased preoccupation with body image
• lingering sadness and depression
• feelings of restlessness
• return of OCD behaviors
• difficulties sleeping
• intense feelings of guilt and worthlessness

Many of the things on my list of strategies to deal with these prelapse signs are similar to what I wrote in an earlier post on identifying your triggers.

• deep breathing
• reduce stress
• ensure adequate sleep
• make plans with friends and family even if I don't feel like it
• snuggle with Aria
• work on creative projects (crochet, jewelry, etc)
• practice opposite action (watch a funny movie when I'm feeling down)
• eat several tablespoons of peanut butter before bed
• practice self-compassion
• increase appointments with treatment team
• BE HONEST about urges

Please share some of your prelapse signs in the comments section!

As the economy began it's nausea-inducing nosedive at the end of 2008, many US banks and insurance companies were loaned money by the government because they were "too big to fail."

This week, as I have been on my own and trying to bull my way through piles of writing and work, I have been hearing the siren call of AN. I wasn't looking for the call, I wasn't seeing it out. But with my routine shaken up a bit with my parents out of town and then visiting my friend for the weekend, I got off track. And sleeping through breakfast yesterday meant that I felt pulled to skip breakfast this morning. Surely it won't make a difference, will it? And lunch. Who really needs lunch, anyway. Think of all of the writing I could get done.

I did eat breakfast, and lunch, but not nearly enough. I knew this should have been a big red flag--a red light sign in my relapse prevention plan--but I felt strangely not bothered by this. I wasn't particularly hungry, and eating seemed like such a damned inconvenience.

Apparently, I was bothered by this at least somewhat because I mentioned it to TNT at our session today. Not in the on-my-way-out-the-door, at least I can assuage my guilt about lying sort of way (admit it--you've done it, too!), but in a way where I actually sought out feedback about what was happening. We discussed what I needed to do to get back on track (eat a meal plan compliant dinner and evening snack, both of which I did) and then plan out my meals for tomorrow.

We also discussed where I was in recovery, about my blossoming writing career and all that I want to do professionally. About the fact that I really, really want to get my own place and pick out paint colors. About how I want to travel to the Galapagos and Australia. I have a fighting chance at a real life now.

Like the banks that were too big to fail, I have too much to lose now.

Before, all of these wishes and dreams were so nebulous and ephemeral that I could shrug off their loss. I mean, I'm not going to own a Mercedes, either, and I'm not exactly bothered by that. But now, my dreams and my life are so much closer. They're realer (if that's a word). I'm making them happen, right now. I can't continue to make them happen when I am deep into ED. I won't be researching how bacteria can smell, I will be looking up calories in food and determining how much I need to exercise and staring at recipes all day long.

My last relapse brought me face to face with the stark reality that I couldn't have what I wanted in life and also have my eating disorder. I had to choose.

And I chose life.
I chose life and I didn't look back.
At least, I haven't looked back very often.

TNT told me I had worked my ass off to get where I am in recovery (I turned around, looked down, and said, "No, I didn't. My ass is sadly still there."). There's the reality that I always have another relapse in me, but I don't know if I have another recovery.

So I ate.
And hated myself.
And then forgave myself.

Eating can be an inconvenience, but relapse is a bigger one for me right now. I have stories to write and condos to find and places to go and dreams to fulfill. My ED is not part of this--it never was.

It's once again time for your weekly Sunday Smorgasbord, where I trawl the web for the latest in ED-related news, research, and more, so you don't have to.

Low Food Intake Predicts Suicide Risk in Body Dysmorphic Patients.

Persistence, perseveration and perfectionism in the eating disorders.

Anxious girls' brains work harder.

Beyond Picky Eating: Avoidant/Restrictive Food Intake Disorder.

Body Image Booster: Adjusting Our Stories.

Positive cognitive coping strategies and binge eating in college women.

Ten Steps of Co-occuring Disorders Recovery.

Plasma, salivary, and urinary oxytocin in anorexia nervosa: A pilot study.

Sign the petition: Empowering Families workshops to carers of people with eating disorders.

The comorbidity between eating disorders and anxiety disorders: prevalence in an eating disorder sample and anxiety disorder sample.

Intriguing study unlocks the mechanism of taste--taste is a perception that originates in the brain, NOT the mouth.

Young adults with diet-related chronic health conditions are at higher risk for EDs.

Exercise is not an unmitigated good.

What can Cognitive Neuroscience Teach us about Anorexia Nervosa?

How to tell when the "healthy ideal" masquerades as the "thin ideal".

A prospective study of predictors of relapse in anorexia nervosa: Implications for relapse prevention.

Anxiety May Hinder Your Sense of Danger.

CBT4BN versus CBTF2F: Comparison of online versus face-to-facetreatment for bulimia nervosa.

New study finds that consumers link eating meat with their concept of masculinity.

When working out is too much of a good thing.

Many Mysteries Unsolved in Binge-Eating Disorder.

Earlier today, Laura wrote that insight and eating disorders might be overrated. In many senses, she has a point. Often as a patient, therapists and treatment providers would ask me why they thought I was going downhill but made no real move to stop me from going downhill. "What's really bothering you?" they would ask me. "I dunno," I would say. I felt guilty about slacking off on exercise, so I tried to make up for lost time. I felt I ate too much, so I started cutting back. "No, no," they responded. "What's underneath that?" "Um...I dunno." And my task for the next week would be to figure out what was really going on. That, and try to cut back on the exercise.

No kidding.

Often, I had insight--or at least enough insight to start parroting back to my treatment team what they wanted to hear so they would stop asking me such asinine questions. Insight wasn't really my problem. I knew I had issues with depression and anxiety and perfectionism that was a big part of my eating disorder. I could talk to you at length about obsessions and compulsions and neurobiology and all of that. Still, I remained afraid of eating and entrenched in my eating disorder.

No amount of insight would have gotten me better. I wavered between extreme denial and anosognosia (I'm fine, there's nothing wrong) and pretty good insight. But insight is as insight does. I didn't stop being afraid of food until I was forced to eat 5-6 times every day, and do it over and over and over again. I'm still wary around food. But I'm not terrified of it. That wasn't insight. That was eating.

My insight often frustrated me. I knew that starving and overexercising and purging were ruining my health and making me miserable. Yet I also knew that stopping would make me more miserable. I knew that my symptoms were helping me deal with unbearable anxiety and depression. And what of it? I knew all of this, and I had been taught that this knowledge should have been enough. It wasn't. That's where I often got frustrated and gave up.

I'm not anti-insight, though. I think developing insight is a very important part of the recovery process. I haven't found much use in finding insight into why my ED developed--I know that I used my symptoms to self-medicate for anxiety and depression, and that explanation is fine for me. I know others have found such insight very useful, and that's great. What I have found insight very useful for is relapse prevention.

Eventually, I came to realize that very stressful situations--exam time at school, applying for jobs, moving, family issues--were major ED triggers. My brain could only cope with so many stressful things at once. Since recovery was stressful (and, in my eyes, often stupid and therefore optional), it was the first thing to get jettisoned. Enter relapse, stage left. It took me a long time--remember, I have a very thick skull, osteoporosis be damned--to realize that in these times of stress, when I felt that therapy and eating were the last things I had time for, therapy and eating needed to be at the top of my list. (I'm still not very good at this, to be honest.)

Now, with TNT, I'm working on developing insight into the depth of my negative self-talk. I often don't realize that I'm engaging in such self-hatred because it's such a part of my inner monologue that I don't think about it. And then developing insight to see the subtle ways it plays into my ED thinking. If I usually think of myself as a lazy pig, then it's not a hard leap to see how restricting food (negating the "pig" bit) and increasing exercise (negating the "lazy" bit) might make me feel better.

Of course, feeling like a lazy pig doesn't mean I am a lazy pig. I understand how that applies in other people, but I don't have much insight into why that wouldn't apply to me.

So yes, insight. It is useful, and it can be a good goal. But it often isn't enough to get someone over the initial hump of moving towards recovery. For me, it took having no other choice than to eat. Others have found different ways and different motivations. Insight can be a part of that, too. But I have found insight more useful later, after my thinking had cleared a bit, when I can look back at the craziness and be more rational about what the hell I had been thinking.

Sunday was my last group therapy session with TNT.  As much as I disliked the idea at first--I would be the fattest one there, I was either not sick enough or too sick to be helped--I really came to enjoy the group.  One of the requirements was that you had to be in active recovery.  That meant you couldn't be actively involved in ED symptoms.  A slip up didn't mean you would be asked to leave, but you had to have significant abstinence from the eating disorder.

That last little bit was some of what made the group really helpful.  I'd done support groups before that ended in what can only be described as a hot mess.  I quit going because it was so hard to continue my recovery in that environment.  All people would talk about is how much weight they had lost, how many times they threw up, and so on.  File under: Pointless, Definition of.

I had groups when I was in treatment, and many of those were, in fact, helpful.  Learning DBT skills in a group setting, doing relapse prevention with others, learning from each other was remarkably helpful.  I was lucky, too, in that most of these groups were led by good clinicians who could keep things on track.  Other groups I went to outside of treatment were at best a waste of time and at worst directly harmful.

So yes, I was wary, both from ED-related reasons and from experience.  I tried to remember that the ED blog community is kind of like group therapy (well, there is a group of us and blogging is therapeutic), and I've never regretted getting involved in that.  TNT asked me to commit to one month, which I did.  I figured if things really went to hell in a handbasket, I could discuss it with her and leave sooner if I really had to.

The women in the group ranged in age from mid-twenties to mid-fifties.  And the wonderful thing was that we all related to each other so well.  I didn't know anyone's diagnosis, although after the first few weeks I had a guess.  In the end, though, it didn't really matter.  Not age, not diagnosis.  Many of us had similar problems in figuring out life after the eating disorder.  How do you manage urges?  How do you decide who to tell?  How do you handle the holidays? 

I'm going to miss my group.  I actually began looking forward to Monday nights.  TNT tried to find someone else to take over the group after she left, but she couldn't find anyone.  There's no group closer to home--at least, no other similar group.

I'm really grateful I got this chance, though, and maybe one day I'll get another chance.

Seeing as I have finally (!) found a new therapist in my new location (who also accepts my insurance and is only an hour drive away), who I meet with on Saturday, and there have been several good posts about finding a good therapist and effective treatment, I decided a blog post would be appropriate.

Dr. Sarah Ravin has a list of five questions to ask a potential therapist when seeking treatment:

In regards to your question, here are the five important questions (in my opinion) that one should ask a potential therapist when seeking treatment for a serious, long-standing eating disorder:

1.) In your opinion, what causes eating disorders?

(Make sure they have a science-based explanation that involves neurobiology, genetics, personality traits, and the role of malnutrition. It’s OK if she mentions societal pressures for thinness as triggers, so long as that’s not the ONLY thing she mentions.)

2.) Describe your philosophy of treatment for eating disorders.

(Make sure she emphasizes full nutrtion and weight restoration to ideal body weight (for AN) and nutritional stability / cessation of binge-purge behaviors (for BN) as the first step in treatment. Make sure she also emphasizes the acquisition of coping skills, learning to eat healthfully and independently, self-care, treatment of co-morbid conditions, and relapse prevention)

3.) Describe your training and experience in empirically-supported treatments.

(Make sure she has some training and/or experience with CBT, DBT, ACT or other third-wave behavior therapies, and/or Maudsley FBT).

4.) How many patients with eating disorders have you treated in the past three years? How many of these patients have fully recovered?

(Make sure she’s seen at least a few other people with EDs, and make sure that the majority of them are fully recovered (or at least well on their way to recovery).

5.) What is your opinion on the involvement of family members and significant others in the treatment of eating disorders?

(If she advocates parentectomies or exclusion of family members, or implies that families cause EDs, this is bad news. If she views family members as potential emotional or nutritional support for the patient, this is good news).

If there is one word in reading about a therapist's history and treatment philosophy that gives me the heebie-jeebies and automatically makes me click "NEXT!" is this: eclectic. I shudder just typing it. To me, eclectic says "I do whatever I feel like doing" or is kind of like commitment-phobia for the potential therapist. You're a professional- tell me what works and why. There's a difference between "eclectic" and "I have been trained in approaches A, B, and C and can help tailor therapy to you and your situation." I have found a combination of CBT, DBT, and FBT to be helpful at various stages in my recovery, so I'm not all-or-nothing about types of therapy. But eclectic? Ick.

The Cleveland Center for Eating Disorders blog "Living With Food" has this advice for seeking evidence-based treatment:

1.Remember that there are very few evidence-based treatments for eating disorders. If you are not receiving cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, or family based therapy, then the odds are very high that you are not getting evidence-based care.

2.Your primary care physician is likely to have experience with patients who have done different types of treatment in your community. Your primary care physician is therefore a critical resource.

3.When you are in a provider’s office and they are discussing care options with you, never hesitate to ask for all of the evidence behind what they are saying. At this point in time, all practitioners in eating disorder treatment should be able to back up what they are saying in a straightforward and understandable manner.

4.Finally, while doing research on treatment for eating disorders, the Internet, while helpful, may not provide definitive answers (and may be more confusing than anything). There are certain organizations that we feel are trustworthy. We highly recommend NEDA, AED, Maudsley Parents, ED Recovery, The Freed Foundation, Are you eating with your anorexic, The F-Word, NAMI, Life After Recovery, and FEAST as reliable organizations and blogs where you can learn about evidence-based care and communicate with other patients and families that may be struggling with an eating disorder.

Off course, point #2 assumes your PCP/GP isn't a total bonehead and doesn't blow off your concerns. Still, they should know something about community resources or have a referral to someone who isn't a total bonehead. When all else fails, go straight to point #4.

There are plenty of other barriers to finding quality ED care, not the least of which are: geography, therapist's availability, insurance coverage, wait lists, finances, you name it.

What criteria do you use when looking for a therapist (or what criteria would you use)? Do you have any words or phrases that are a therapist "turn off"?

This week's smorgasbord is going to be a little shorter than usual- I worked a full shift today and yesterday and I am falling over with exhaustion.

The Bananas of Slip/Lapse/Relapse Prevention

Anti-Obesity Drugs Unlikely to Provide Lasting Benefit

Suppressing emotions increases desire to binge in women with BED

Depression moderates sociocultural influences on ED symptoms in adolescent females and males

Unstable emotions and binge eating in women with bulimia (from Psychotherapy Brown Bag)

Free webinar on the media and mental health recovery (via The F Word)

Pledge for Wellness: National Call to Action for Wellness of People with Mental Illness

When a parent has an eating disorder

Thin Wallets, Thick Waistlines: New U.S.D.A. Effort Targets Link between Obesity and Food Stamps

Body's anticipation of a meal can be a diabetes risk factor

Allocentric vs. egocentric frame of reference in body perception in anorexia

BBC News: Why Diets are Doomed to Fail

And, just for some random fun: The Sound of Jelly Wobbling was recorded for the very first time in 2008

Tomorrow I will return with another one of my Roadblocks to Recovery posts!

This year's National Eating Disorders Association in New York will be my fourth- it's turned into an annual mommy-daughter trip, combined with a weekend of learning and a big ED family reunion. So yeah, it's one of the highlights of my year. It's nice to have a weekend where I don't feel I have to hide my eating disorder, nor is that what really defines me. I am known for my advocacy work and NOT for my eating disorder, because at NEDA, having an eating disorder isn't exactly novel.

But this year, I have something even more exciting to look forward to. After many years of submitting proposals and being rejected, I finally finally get to present this year with my former therapist Stephanie Milstein* on utilizing family and friends in relapse prevention. I was also super excited to learn that Harriet Brown will be presenting with Walt Kaye this year, too.

The NEDA Conference webpage can be found here. I will add updates as soon as the program information becomes available. Registration generally opens in May/June. I would love to plan a meet and greet with others who are going, whether it's a brief "hi, how are you?" or something more lengthy.

*It's an awful picture that's all stretched and pixel-y, and I can vouch that her hair looks much better in person! LOL

It's once again time for your weekly Sunday Smorgasbord, where I trawl the web for the latest in ED-related news, research, and more, so you don't have to.

Eating Disorder Recovery: Courage In The Everyday.

Cognitive flexibility and clinical severity in eating disorders.

Teens & Stress: for moody teens, its all in the head.

Suicide attempts in anorexia nervosa subtypes.

The benefits and risks of online therapy.

One of the reasons why relapse is so common: Our brains can't ignore 'rewarding' objects.

Psychosocial Correlates of Shape and Weight Concerns in Overweight Pre-Adolescents.

DBT developer Marsha Linehan talks about her own experiences overcoming suicidality.

E-health for individualized prevention of eating disorders.

Anorexia: How 15-year-old Sophie fought and won her battle.

Virtual reality exposure in patients with eating disorders: influence of symptom severity and presence.

Stanford program takes aim at eating disorders.

Adolescents' dieting and disordered eating behaviors continue into young adulthood. Interestingly (though not surprisingly) most media outlets said the study looked at eating disorders, not disordered eating. There is a difference, people.

Estrogen replacement increases bone density in adolescent girls with anorexia nervosa.