RecoverED: an Open Access Handbook for Disordered Eating Recovery

by Dr. Myles Sandoval, DPT

with valued contributions from the community

Note: this is a living, growing document designed to connect anyone struggling with disordered eating to an abundance of high-quality tools for behavioral change, regardless of ability to pay. This book is intended to be compatible with professional help but is not a substitute for professional treatment. Let’s work together to make the best FREE resource for anyone hoping to heal their relationship with food, body, and the self. Please share with anyone who may benefit. Comment freely on this manuscript or email questions, suggestions, or concerns to: myles.a.sandoval@gmail.com

For Pumpkin, who believed in my ability to heal

before I knew it was even possible.

And for all brave souls seeking to transform

 their suffering into a source of strength.

Table of Contents

Introduction

Chapter 1: What is disordered eating?

Chapter 2: Can this handbook really help me change disordered eating?

Chapter 3: Neuroplasticity-informed stages of recovery from disordered eating

Chapter 4: The prevalence of disordered eating in recovery from substance use

Chapter 5: Motivation and commitment for a resilient recovery

Chapter 6: Calming urges

Chapter 7: Befriending thoughts, feelings, and behaviors

Chapter 8: Building a purposeful, passionate life

Chapter 9: Preventing the return of unwanted behavior

Chapter 10: Resources for family and friends

References

Appendix A: Diabetic Exchange List

Appendix B: Meals Beyond Measure (simple guidelines for good food)

Addendum: Harm Reduction Guidance for People with Eating Disorders During COVID-19

Introduction

"Let food be thy medicine, and medicine be thy food." 

-Hippocrates

Welcome! I am so glad you are here. By setting aside the time to explore this handbook, you are already taking a brave and proactive step toward a better future. The purpose of this handbook is to help readers apply easy-to-follow behavioral tools to disordered eating so that food and exercise may become tools for self-healing instead of self-harm.

Many of these tools were originally designed to help people change their habits related to substance use. While recognizing that eating disorders are psychologically and biologically distinct from substance use disorders, the addictive qualities of restricting, bingeing, purging, and/or compulsive exercise are undeniable[1]. If you are struggling to change an ingrained habit related to food, body, or exercise, this book is for you.

This handbook is not to be construed as a substitute for professional medical advice. The handbook is intended as an adjunct to traditional therapy, offering the reader an abundance of information and practical tools to leverage your own recovery and protect against relapse. There is no need to decide between exclusively self-help, peer support, or professional help--a well-equipped toolkit often incorporates multiple layers. Feel free to skip between chapters as needed; certain tools may apply to your situation more than others. As someone smart once said, “Take what you need and leave the rest.”

In Chapter One, you will be given the opportunity to assess your current attitudes about food and body image and learn more about exactly what constitutes disordered eating.

In Chapter Two, the concept of behavioral change in the context of disordered eating is introduced. Once you have set applicable goals for your recovery as it is today (which you will do in this chapter), you can apply any behavioral tool from a number of philosophies to help you realize these goals in daily life.

Chapter Three focuses on the series of changes that take place during recovery from disordered eating. You will learn more about the different factors that positively impact recovery, no matter where you are in the process.

In Chapter Four, you will learn more about the relationship between disordered eating and substance use, including the high incidence of overlap in women and certain minority groups.

In Chapter Five, we discuss ways to build motivation to change your eating behaviors, even when changing such behaviors may lead to outcomes that may initially feel distressing (e.g. new sensations of hunger or fullness). Cultivating commitment in addition to motivation can help you avoid relapse even when you are not feeling particularly motivated.  

In Chapter Six, you will be introduced to the urge surfing tool, which can help you effectively cope with urges throughout the process of recovery.

Chapter Seven focuses on befriending the thoughts, feelings, and behaviors that may arise as part of the process of changing disordered eating habits.

In Chapter Eight, you are invited to consider alternative activities and relationships to improve some of the time you used to spend engaging in disordered behavior. Having meaningful, well-balanced activities in your life can help you build a purposeful, passionate life in recovery.

Chapter Nine discusses long-term recovery and relapse prevention in the context of disordered eating. When appropriate, you are invited to reflect on certain foods that may have been “triggering” in early recovery. This will help you create enough flexibility in your definition of abstinence to allow for real-life situations like eating out or sharing food with loved ones.

Chapter Ten helps you educate family and friends on how to best support your ongoing recovery and connects them to more resources specifically created for loved ones.

Chapter 1: What is disordered eating?

“Why, sometimes I've believed as many as six impossible things before breakfast.”

 -The Queen, Alice in Wonderland

Disordered eating describes a wide range of thoughts, feelings, and behaviors that may include the restriction of calories or certain food groups, the strong compulsion to eat independent of physical or mental hunger, and/or a general preoccupation with food, weight, or body image. The common factor is that each of these thoughts, feelings, and behaviors negatively impact quality of life--often by a significant amount[1]. If your food-related thoughts and behaviors are causing you physical or emotional pain, they are worth transforming. A peaceful and even positive relationship with food paves the way for a positive relationship with yourself.

Unlike diseases, which are typically caused by pathogenic microorganisms, genetic mutations, or immune processes, disorders are described by the thoughts, feelings, and behaviors of the person experiencing them. Think of a disorder as any pattern of problematic thoughts, feelings, and behaviors that are habitually carried out to the point that they change brain structure in a self-perpetuating way, that is to say they become habit.

It sounds scary to think that your behaviors may have changed your brain structure, but this is actually a very normal part of human physiology called neuroplasticity. In fact, this physiological feature can also be harnessed to transform disordered thoughts and behaviors into more adaptive alternatives that create the conditions for happiness in a self-perpetuating way. Happiness, too, becomes a habit!

Lastly, the fact that experience-dependent brain change is entirely normal also means that there is nothing inherently broken or defective about you. Much to the contrary, falling into an addictive pattern of behavior is actually a very common human experience.

So is the process of recovery.

Your individual disordered eating behaviors may or may not constitute an eating disorder based on the DSM-V criteria. The distinction between "disordered eating" and an eating disorder is of little significance to the individual whose quality of life has been impaired by a destructive relationship with food.

However, the presence of a diagnosable eating disorder is significant from a medical perspective, since eating disorders continue to have the highest mortality rates of any psychiatric illnesses, especially in conjunction with substance use[2].

If you are concerned that your eating behaviors may be affecting your quality of life, or may constitute a diagnosable eating disorder, consider taking the Eating Disorder Examination Questionnaire below.

EXERCISE: EATING DISORDER EXAMINATION QUESTIONNAIRE

Instructions: The following questions are concerned with the past four weeks (28 days) only. Please read each question carefully. Please answer all of the questions. Please only choose one answer for each question. Thank you.

Questions 1 to 12: Please circle the appropriate number on the right. Remember that the questions only refer to the past four weeks (28 days) only.

Questions 13-18: Please fill in the appropriate number in the boxes on the right. Remember that the questions only refer to the past four weeks (28 days).

Over the past four weeks (28 days)…….

Questions 19-21: Please circle the appropriate number. Please note that for these questions the

 term “binge eating” means eating what others would regard as an unusually large amount of food for the circumstances, accompanied by a sense of having lost control over eating.

Questions 22-28: Please circle the appropriate number on the right. Remember that the questions only refer to the past four weeks (28 days)

What is your weight at present? (Please give your best estimate).        …………………………….

What is your height? (Please give your best estimate).        …………………………….

If female: Over the past three-to-four months have you missed any menstrual periods? ……………

If so, how many?        …………………………….

Have you been taking the “pill”? …………………..

THANK YOU

EDE-Q reproduced with permission. Fairburn and Beglin (2008). In Fairburn, C. G. (2008). Cognitive Behavior Therapy and Eating Disorders. Guilford Press, New York.

The Eating Disorder Questionnaire or EDE-Q is a standardized tool for assessing the severity of disordered thoughts, feelings, and behaviors. Higher scores typically indicate a higher frequency, intensity, and duration of disordered eating. Low scores do not rule out the presence of disordered eating, which can take many different forms that are not always captured by the EDE-Q.

Below are the average scores for young women. Note that average does not mean ideal. In an optimistic future, the average person will feel more comfortable with his/her own body and flexible in his/her eating patterns.

Unfortunately there is a dearth of data from other demographic groups representing a glaring knowledge gap in the current body of research. If you belong to another group, know that these scores are just a rough approximation of the general population; what matters is your comfort in your body and your relationship with food.

Mean (SD) scores on the EDE-Q for young adult women by age group:

Percentile ranks for EDE-Q subscale scores for young adult women (n=5,255)

Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2006). Eating Disorder Examination Questionnaire (EDE-Q): Norms for young adult women. Behaviour Research and Therapy, 44, 53-62.

The common thread is that these patterns of thoughts, feelings, and behaviors negatively impact emotional and physical well-being, resulting in side effects that can be life-threatening. Regardless of your score, if you are suffering from eating behaviors that are causing you concern or interfering with your daily functioning, please consider seeking an evaluation from a trained mental health professional to determine the most appropriate level of support for your unique situation.

You only get one life--why not use it to live happy and well?

Common patterns of disordered eating

Some people switch from one pattern of disordered eating to another, while others findthemselves mired in a single thought-feeling-behavior loop that gains momentum over time. Let’s have a look at some of these common patterns. Identifying some of the behaviors that led you to this handbook can help you set more actionable goals in recovery.

Restriction

Restriction is the purposeful limitation of the amount of food you eat, especially when unrelated to a religious tradition, allergy, or another medical condition[4]. In the context of disordered eating, restriction may be related to anxieties surrounding food, body image, fear of bingeing, and/or an aversion to certain textures, tastes, temperatures, or smells.

Restriction may take the form of fasting, skipping meals, restricting or eliminating entire food groups such as fat or carbohydrates, counting calories, and/or other rigid rules about what or when foods may be consumed. Restriction may occur in isolation or in conjunction with other behaviors such as bingeing.

Bingeing

Binge eating is characterized by the perceived loss of control over an episode of eating. Binge eating may involve the consumption of large amounts of food, often eating beyond physical satiety (i.e. objective bingeing), or any amount of food that falls outside one’s “food rules” (i.e. subjective bingeing).

In any case, either type of binge is frequently associated with eating much more quickly than usual, eating alone due to embarrassment about what, how much, or how quickly one is eating, and/or feelings of guilt following an episode of binge eating. Binges can also occur secondarily to restriction as a result of the physiological effects of starvation [4].

Purging

Purging refers to any goal-oriented behavior that focuses on compensating for calories consumed. Examples include self-induced vomiting, frequent use of laxatives or enemas, and/or exercise when performed with the intention of being compensatory [4]. When preceded by bingeing as part of a cyclic habit, self-induced vomiting results in the activation of the same brain structures that are implicated in substance use disorder [5].

Preoccupation with food, weight, and/or body image

Disordered eating behaviors can often be approximated into one of the three aforementioned categories, but focusing solely on the behaviors fails to recognize the extent to which obsessive thoughts can disrupt daily life, interfering with lifestyle balance. Preoccupation with food can manifest in a number of ways, including experiencing persistent thoughts about food, watching cooking shows, baking large amounts of food items to give away, or pursuing employment in the food industry. Weight-focus may manifest as frequently weighing oneself or weighing all food items before eating. Preoccupation with body image includes but is not limited to such practices as "body checking" or measuring different body parts, compulsive exercise, and/or frequently asking for external reassurances about appearance e.g. "Do I look okay?" [4].

Other behaviors

Because disordered eating and exercise behaviors can exhibit themselves in so many different ways, it is beyond the scope of this book—and perhaps not in the best interest of its readers—to describe the full spectrum of potentially disordered habits. That being said, if you are engaging in food, body, or exercise-related behaviors that were not discussed in this chapter but are negatively impacting your quality of life, this handbook can still help you. In the next chapter, we will introduce the concept of recovery from problematic behaviors as opposed to addictive substances.

Chapter 2: Can this handbook really help me change disordered eating?

“The best time to plant a tree was 20 years ago. The second best time is now.”

–Chinese Proverb

Whether or not you are an avid book-reader, chances are there are some books or movies that you feel drawn to come back to over and over again. Practical and inspirational books can continue to offer value on the third—or thirtieth—read. This handbook has collected the best tools to help you manifest a resilient recovery from disordered eating, starting from day one. Some tools may be more applicable in early recovery, while others may make more sense after you settle into long-term recovery. The behavioral tools in this handbook focus on:

• Motivation and commitment—invites you to assess whether or not your current behaviors are serving your best interests. Helps you clarify your values to help you stay motivated through the process of active change. Clarifies the role of commitment as a “fail-safe” measure if/when you do not feel very motivated.
• Calming urges—offers a variety of tools to help you calm your urges without engaging in disordered behaviors.
• Befriending thoughts, feelings, and behaviors—teaches practical problem-solving tools to help you respond to real-life problems in ways that are constructive, not destructive.
• Building a purposeful, passionate life—encourages you to find meaningful activities that bring joy, meaning, and connection to a life that may have been previously filled with disordered thoughts and behaviors.

Since your individual expression of disordered eating is as unique as your fingerprints, your definition of recovery may appear outwardly different than that of a peer. Furthermore, this definition may become more flexible as you move through the Stages of Change model of recovery developed by James Prochaska and Carlo DiClemente [1].

A more in-depth description of this model can be found in Chapter 3. The common thread is the cessation of behaviors that no longer serve your overall well-being. In this chapter, you will further personalize your definition of recovery for your life right now.

Consider the eating or exercise behaviors that likely caused you to pick up this book in the first place, behaviors that cause you distress or result in negative consequences. Include any food or exercise-related behaviors you act out in secret--that is to say you might feel self-conscious if someone else were to find out about these behaviors.

TOOL: Cost-Benefit Analysis (with example)

Completing a Cost-Benefit Analysis or CBA will help you more accurately assess the costs and benefits of each behavior you choose to evaluate. There may be more than one behavior you are considering eliminating from your life. Disordered eating patterns may fluctuate from restriction to bingeing and/or purging during different periods or your life or even at different times of day. Performing a separate CBA on each will help you recognize which behaviors are causing the most collateral damage to your health, relationships, and mental well-being. Fairly appraising the current and future costs of disordered eating behaviors can help motivate you to commit to making real changes in your life starting today.

The costs and benefits of disordered eating

If you are struggling to think of the "benefits" of restricting, binge eating, or purging, consider the following questions:

• Does this behavior help me escape negative emotions? If so, which feelings?
• Does this behavior give me a sense of control?
• Does this behavior help me feel normal on a day-to-day basis?
• Does this behavior make me feel comfortable eating foods I do not usually allow myself to have?
• Does this behavior have the goal of changing my physical body?

If you are struggling to see the costs of your eating or exercise behavior, try asking yourself the questions below:

• Does this behavior harm my mental, emotional, and/or physical health? If so, how?
• Has this behavior caused me to miss out on enjoying celebrations or social gatherings?
• Have I ever lied about my behavior, breaking trust with others?
• How much money have I spent on binge food, diet pills, laxatives, etc.?
• How do I feel when I am in a situation where I cannot engage in this behavior?
• How does this behavior affect my relationships, including with myself?

The costs and benefits of abstinence from disordered eating

Next, consider the costs and benefits of abstinence from each behavior. Benefits may be related to:

• How would stopping this behavior affect my physical and/or mental health?
• How would stopping affect my ability to participate in celebrations or social events?
• How would stopping affect my relationships?
• How much money would I save if I stopped buying binge food or laxatives, etc. today?
• If I didn't spend so much time thinking about food, what life goals could I pursue instead?
• Would stopping this behavior lead to body changes I might find desirable?

Costs of abstinence may include:

• What issues or feelings would I have to find new ways to cope with?
• What thoughts or emotions would I have to learn to accept?
• Would stopping lead to body changes I might find undesirable?
• Is there anything I would miss about this behavior?

Once you have listed the costs and benefits of continuing your behavior versus abstaining from it, identify each cost and benefit as either short-term (ST) or long-term (LT). Many of the benefits of disordered eating behavior are very short-term, lasting only a few hours, while some of the costs like tooth decay or esophageal rupture can be lifelong or even fatal. On the other hand, the benefits of recovery often encompass long-term improvements in health, closer relationships, and the ability to pursue meaningful activities instead of food-related obsession.

Continuing this behavior (ex: purging)

Stopping this behavior (ex: purging)

Engaging in this behavior (ex: social media scrolling as a form of avoidance)

Not engaging in this behavior (ex: setting social media boundaries)

Because disordered eating does offer some short-term benefits like temporary relief from negative emotions, many people find it helpful to keep their CBAs handy to remind themselves of the short- and long-term costs inherent to continuing these behaviors.

Cessation of disordered eating behavior

The Cost-Benefit Analysis tool can help you recognize the full range of consequences of specific disordered eating behaviors. But exactly when does a bucket of movie theatre popcorn turn into a binge? When does working on an important project through lunch turn into restriction? Especially if you have been engaging in disordered eating habits for some time, it might be difficult to recognize exactly what constitutes disordered behavior, and what healthy eating might look like instead.

Unlike drugs or alcohol, food is an inherent part of everyday life. It is both healthy and normal to have some variation in eating behavior from day to day or week to week. Fortunately, the Cost-Benefit Analysis can also be applied to specific events beforehand to help you make a thoughtful decision about an upcoming situation related to food, body, or exercise.

For example, someone in early recovery from restriction may use a CBA to decide that the social cost of bringing their own pre-made meal to Thanksgiving dinner outweighs the benefit of not having to choose what to eat in real-time. However, someone in early recovery from binge eating may decide to bring their own meal since the risk of binge eating—for that person—far outweighs the potential benefits of sharing a potluck meal. Remember—this is your recovery, no one else’s.

If you identified binge eating as a problematic behavior in your CBA exercise, list any foods that are difficult for you to eat in moderation, that is to say they tend to result in an episode of overeating or binge eating. Focus on specific foods like "peanut butter" rather than large food groups like "carbohydrates.” Feel free to use another sheet of paper as needed:

Somewhat difficult:

Moderately difficult:

Extremely difficult:

If you identified restriction or fasting as a problematic behavior in your CBA, list any foods or substances that you have used to avoid eating well-balanced meals, including gum, diet drinks, or stimulants like caffeine, nicotine, or diet pills:

Are there any foods that you have, currently or in the past, consistently purged through vomiting, laxatives, or exercise? List them below:

By this point you are probably well-versed in your past behaviors related to eating these foods or using these substances. But it is never too late to create a new relationship with these foods for the future!

If there are substances that you have used to make restriction easier in the past (e.g. diet soda, gum), consider running an experiment in which you plan to abstain from these substances for a predetermined length of time. You are simply gathering data on what effect this change might have; there is no pressure to make a permanent decision right now. Think like a scientist!

Graded exposure

If there are foods you find especially difficult to eat in moderation due to urges to binge and/or purge, consider enlisting the help of a trusted friend, family member, or treatment professional to support you during regularly planned, graded exposures to these challenging foods in a new context. Graded exposure means challenging yourself to step just outside your old food rules. If you are wondering why on earth you would purposefully put yourself in a situation like this, remember that this is nothing less than a question of personal freedom.

Over time, repeated, compassionate exposure to moderate amounts of challenging foods will structurally change your brain in ways that “break the spell” that certain foods seem to have cast over you. Desensitization by exposure quells food-related anxiety, allowing you to stay calm when you encounter these foods in daily life. Peanut butter, pastries, or other common “trigger foods” need not hold such power over you in the future!

These planned food exposures might be weekly, biweekly, or on another schedule based on your individual situation and access to resources for external accountability. Waiting until you have a supportive environment ensures that you will be able to confidently refuse to act on any urges that may arise during the process, avoiding further reinforcement of disordered behavior. Chapter 6 will introduce you to some common tools for calming urges.

At the end of this chapter, you will have the opportunity to decide the specifics of your behavioral experiment in goal form. A well-designed experiment aims to gather a large amount of data in order to make an informed conclusion. By making a commitment to challenge past food rules in a supported and realistic way, you are creating a well-designed experiment in recovery. In Chapter 9, you will have the opportunity to re-evaluate whether certain foods are still "trigger foods” by completing a Change-Plan Worksheet at the appropriate time.

Remember, food has no inherent moral value. There are no “good” foods or “bad” foods, nor does eating these foods make you “good” or “bad.” If you choose to temporarily remove certain foods from your daily intake (to later reincorporate them as challenge foods), it is only to help you with the successful cessation of disordered behaviors and to make this experiment in recovery easier on a day-to-day basis.

What do I eat instead?

Whether or not you have a list of “trigger foods,” you might not be sure what to eat in recovery in general. Especially if weight restoration might be warranted to improve your physical health, it is highly recommended that you seek professional guidance to facilitate this process. A Certified Eating Disorder Registered Dietitian or CEDRD can help you challenge food-related anxieties in a safe environment and create a long-term plan for recovered eating.

Find a CEDRD in your area (or via telehealth): https://iaedp.site-ym.com/search/

Note: refeeding syndrome is a potentially life-threatening complication that can occur when individuals who are underweight abruptly change their food intake without consulting a registered dietitian specializing in eating disorders. If you may be underweight, or if you are unable to retain food due to habitual purging, professional medical intervention is imperative to avoid high-risk health complications.

If this does not apply to you, consider incorporating the following foods into your daily diet for general health[2]:

• A variety of vegetables across the color spectrum
• Fruits, especially whole fruits
• Grains, especially whole grains, as well as starchy vegetables
• Calcium-containing foods such as milk, yogurt, cheese (or fortified soy/almond/coconut-based substitutes), leafy greens, and sardines
• A variety of protein foods which may include meat and/or fish, eggs, legumes (beans and peas), nuts, seeds, and soy products
• Oils and fats

These recommendations are based on the REAL Food Guide, the only food pyramid designed specifically for adults with disordered eating. At present there is minimal guidance, a lack of standardized resources for nutritional rehabilitation, and little to no research on how to best educate individuals with disordered eating patterns on a well-balanced diet. The REAL Food Guide was created by a group of research clinicians in an effort to address these very real gaps in evidence-based practice[3]. It addresses both the dietary aspects of nutritional rehabilitation as well as the social components of food culture. See a visual representation of the REAL Food Guide below:

Figure 2.1 The REAL Food Guide

Note: if you feel like eating “fun foods” or shared restaurant meals would precipitate a binge and/or purge, please wait until you have the support and accountability of a safe environment to re-incorporate these foods into your recovery.

The REAL Food Guide marks a milestone in the pursuit of evidence-based nutritional education for individuals with disordered eating. However, due to the noted absence of standardized resources, it is only one of many food plans people have used to discontinue destructive eating patterns and improve their relationship with food.

The best food guide is one fabricated for you by a registered dietitian who has been trained on the specific needs of clients with disordered eating. If you have already found another food guide or meal plan that better meets your nutritional needs, feel free to skip to Chapter 3 to learn more about the prevalence of disordered eating.

Culturally aligned foods

The variety of dishes that can be created by combining different food groups is practically limitless! In fact, there are so many options it can be hard to know where to start. Figuring out how to prepare and season a well-balanced meal might seem daunting if you have not practiced in some time.

The types of foods that are most familiar to you depend on many different factors, one of which is culture. Culture encompasses far more than just demographic information. If you can remember back to a time before disordered thoughts overshadowed your food choices, you may be able to think of several recipes that have been passed down from one generation to the next within your extended family. These dishes are often associated with holidays, celebrations, or other special events.

There are several cultural patterns of eating that both support positive long-term health and accommodate the various food groups, pictured below[4]. Do the foods from one culturally aligned food pyramid look more familiar than those from another?

Figure 2.2 The Mediterranean Food Pyramid

Figure 2.3 The African Heritage Food Pyramid

Figure 2.4 The Latin American Food Pyramid

Figure 2.5 The Asian Food Pyramid

Recovering from disordered eating involves recontextualizing what food means to you. This shift often occurs in two stages--first decoupling food from its negative associations, then ultimately rediscovering the social connection, creativity, and joy that are abundant in a happier relationship with food. As you purchase, plan, and prepare foods in recovery, try incorporating some food items from the cultural food pyramid(s) that look most familiar to you--or simply the one that looks most interesting!

Here you have an opportunity to get reacquainted with foods in a more positive light. Additionally, incorporating these dishes into daily life can minimize food-related anxiety about attending family functions or visiting restaurants where these meals are likely to be served.

Structured eating

By this point, you have been introduced to a few tools to evaluate what types of foods to eat in recovery, but you may not be sure how much of these foods to eat, or even what constitutes a serving size in general.

In conjunction with the American Diabetes Association, the American Dietetic Association has determined a standardized serving size, or “exchange,” for each of the major food groups[5]. Each serving within a food group contains about the same amount of carbohydrate, fat, protein, and calories as the other foods in that group. This system can help break down most types of foods and drinks including restaurant meals, freeze-dried backpackers’ meals, protein shakes, etc. An extensive list of specific foods and their equivalent serving sizes can be found in Appendix A.

Structured eating may be particularly helpful for people whose hunger and fullness cues have been dysregulated by disordered eating behavior. Eating according to a meal plan based on the exchange system can help you reconnect with hunger and fullness cues so that they better align with your circadian rhythm and prepare you to eat more intuitively in the future.

Because structured eating may not always line up with hunger cues as mentioned above, it is highly recommended that you enlist the help of a CEDRD to consider if a meal plan might be a good fit for your recovery.

A sample meal plan based on the diabetic exchange system can be found below. Your nutritional needs may be more or less depending on your individual situation.

Figure 2.6 Meal Plan (example)

When thinking about how these food groups might fit into your life, consider the time, money, and energy you have available to purchase and prepare healthy food. If you only have fifteen minutes to cook dinner, shop for ingredients that take fifteen minutes or less to prepare. If you cannot afford certain expensive foods, leave them out of your food plan for now. The more realistic your food guidelines are, the more likely you are to stick with them.

Intuitive eating

[coming soon]

EXERCISE: Setting SMART goals

Now that you have an idea of what food-related behavioral change might look like, it's time to set goals for your recovery. Without well-written goals, it can be difficult to evaluate your progress. Because disordered eating behaviors and the people who experience them are so diverse, there is no single meal plan for recovery. However, creating SMART goals allows you to accurately assess whether or not your current approach to recovery is working.

The acronym SMART reminds us of the different elements in a well-written goal. Effective goals are:

• Specific—be specific about the who, what, when, where, and why of your behavior change.
• Measurable—how will you measure your progress? This could be by quantity (e.g. eating three meals per day), percentage (e.g. eating at least 50% of pre-prepared meals), or some other form of measurement entirely. Note: measuring progress towards a goal does not mean you must measure all of your food. If you are working towards intuitive eating, one of your personal goals may be to stop weighing and/or measuring food items.
• Achievable/agreeable—while you may be working toward more significant changes in the future, make sure your initial goals sound doable to you right now. You can always make new goals at a later date. Goals are meant to inspire motivation, not discouragement. See “Setting up for success” below for more information on selecting a level of challenge that facilitates self-efficacy and growth.
• Relevant—make sure your individual goals are relevant to your overall recovery. If you are working towards the cessation of binge eating, most of your recovery goals should be related to healthy eating practices and binge prevention. That being said, once you begin writing goals, you may realize their utility in other parts of your life! Beyond recovery-related goals, you can also write SMART goals regarding personal health, job success, etc.
• Timely—when do you want to achieve this goal? Setting a deadline can help motivate you to stick with your chosen changes rather than putting them off. If your deadline is more than six months away, consider breaking the goal down into two or more short-term goals to better assess your progress along the way.

Setting up for success

As mentioned above, a SMART goal is a realistic one. Each time you meet a goal you prove a little more self-efficacy, the belief in your own ability to succeed. Self-efficacy can boost your motivation for recovery, which can in turn increase the likelihood of you meeting new goals! Think of self-efficacy like a positive snowball that builds momentum with time.

Part of setting yourself up for success is choosing goals of an appropriate challenge level for your recovery right now. You wouldn’t expect someone who has only practiced skiing on the bunny slope to slalom down a double black diamond trail on the first try, right? In fact, doing so might result in an injury, or at least an injured sense of confidence.

Similarly, it is important to set recovery goals that are reasonably safe, that is to say they are not so distressing that they further reinforce food-related anxiety or disordered behavior. You may have some vision of what long-term freedom from disordered eating means for you. Some common examples are going to a buffet without bingeing or being flexible enough to enjoy local fare while traveling (without packing your own food). Depending on where you are in your recovery, these types of scenarios could be realistic goals or panic-inducing prospects. If those goals sound like a stretch--or simply do not fit with your journey to recovery--can you think of how you might break down a long-term goal into smaller steps? What kind of goals might fall into the “Challenge/Learning Zone” in your life?

Figure 2.7 Safely expanding the boundaries of recovery

The Comfort Zone helps you rest and rejuvenate from the hard work involved in recovery. We all need to spend some time here to recharge. But if you never leave your comfort zone, you are vulnerable for a return to disordered behavior when life becomes stressful.

The Challenge/Learning Zone stretches the boundaries of recovery, teaching you how to return confidently to the places, people, and activities that used to be triggering. When you have access to a low-stress environment, consider trying an advanced strategy for urges like role-play or trigger exposure in a supportive space (see Chapter 6 for more tools for urges). Ex: attending a family event where you don’t know what food will be served, practicing abstinence from “substitute” behaviors like gum-chewing, vaping, etc.

The Danger/High-Risk Zone shows us exactly how resilient we are. Life usually pushes us into these situations (rather than choosing them voluntarily). Ex: unexpected challenges, injury/illness/death of a pet or loved one, traumatic situations. You can learn a lot from these situations, but they can also reinforce situational anxiety or even result in physical harm.

We all spend time in each of these three zones at various points in our lives. There’s no “bad” zone or “good” zone. Each zone plays an important role. By intentionally moving back and forth between the Comfort Zone and the Challenge/Learning Zone, you can create a recovery that is so expansive it becomes boundless. By surviving the Danger Zone, you learn resilience, understanding deeply that you can survive loss, illness, injury, etc. with recovery intact.

Now that you know what makes a goal SMART, let's make some goals to help you define your initial goals for recovery! You can always change these goals or set new ones at a later date as you settle into the habits of recovered living.

Goal #1:

Specific: what, exactly, will you accomplish? ____________________________________________________________________________

Measurable: how will you know when you have reached this goal? ____________________________________________________________________________

Achievable/agreeable: is achieving this goal realistic with effort and commitment? Do you have the resources to achieve this goal? If not, how will you get them? ____________________________________________________________________________

Relevant: why is this goal significant to your life? ____________________________________________________________________________

Timely: when will you achieve this goal? ____________________________________________________________________________

Goal #2:

Specific: what, exactly, will you accomplish? ____________________________________________________________________________

Measurable: how will you know when you have reached this goal? ____________________________________________________________________________

Achievable/agreeable: is achieving this goal realistic with effort and commitment? Do you have the resources to achieve this goal? If not, how will you get them? ____________________________________________________________________________

Relevant: why is this goal significant to your life? ____________________________________________________________________________

Timely: when will you achieve this goal? ____________________________________________________________________________

Goal #3:

Specific: what, exactly, will you accomplish? ____________________________________________________________________________

Measurable: how will you know when you have reached this goal? ____________________________________________________________________________

Achievable/agreeable: is achieving this goal realistic with effort and commitment? Do you have the resources to achieve this goal? If not, how will you get them? ____________________________________________________________________________

Relevant: why is this goal significant to your life? ____________________________________________________________________________

Timely: when will you achieve this goal? ____________________________________________________________________________

Chapter 3: Neuroplasticity-informed stages of recovery from disordered eating

“When we are no longer able to change a situation, we are challenged to change ourselves.” -Viktor Frankl, Man’s Search for Meaning

One of the most common fears in early recovery is the fear that life will be fraught with a seemingly endless stream of overwhelming urges—forever!  

While urges are a common experience during the first few months of recovery, people who sustain their recovery for longer than one year consistently report increased levels of happiness and life satisfaction in general. Furthermore, self-rated happiness and life satisfaction continue to improve for several years afterwards[1]! These established reports of recovery-related quality of life improvements are now being mapped in terms of quantifiable brain changes. Educating yourself on the physiological effects and commonly lived experiences of the different Stages of Change can help you alleviate fears and stay optimistic about your future in recovery.

Currently, you might feel motivated and engaged in the process of active recovery. Or you may simply be tired of repeating the same patterns of bingeing, purging, and/or restricting. Wherever you are right now, you are not alone. As you read about the different Stages of Change below, consider what stage best describes your present moment experience. Remember, recovery is not a linear journey and the stage you’re in may fluctuate from week to week or even from one day to the next.

Certain factors have been found to increase your likelihood of achieving and maintaining recovery, no matter where you are in the process. Consider how you might incorporate more of these elements into your life to smooth out the bumps on the road to recovery. If you are already in the action stage of recovery, keep it up! Most people report that maintaining new, healthy habits becomes easier with continued practice.

Pre-contemplation

During this stage, people are unaware that their behavior is problematic. Pursuing a higher level of care at this stage is often related to an unexpected medical complication or external pressure from a concerned friend or family member.

People in this stage are more likely to move into the next stage when provided with the following resources[2]:

• Comprehensive information on the various pathways to recovery
• Opportunity to reflect on the short- and long-term outcomes of disordered behavior (see Cost-Benefit Analysis in Chapter 2)
• The ability to explore and select their preferred program for professional and/or peer support from several options
• Emotional support instead of pressure to gain or lose weight (see Chapter 6)

Contemplation

Contemplation involves weighing the costs and benefits of continuing the same patterns of disordered behavior. Most people in this stage are aware that their behavior has at least some negative consequences, but may not know how to cope without it or how to find the right resources for recovery.

People in this stage are more likely to move into the preparation stage when provided with the following support[2]:

• Connection to an understanding community that includes people in long-term recovery
• Ability to choose a good program for their specific needs
• Mutual trust with support system and/or treatment providers (see Chapter 10 for more information on educating family and friends)

Preparation

In this stage, people have decided that behavior change is important. They connect with a support system and begin to take small steps toward change on a trial and error basis.

People are more likely to move into active recovery when they[2]:

• Set their own goals (see Setting SMART goals in Chapter 2)
• Assume responsibility for their long-term well-being
• Demonstrate outside interests and passions unrelated to food (see Chapter 9)
• Believe that recovery is possible (see Chapter 6)

Action

People in this stage are actively working to change their problematic behaviors. This stage may occur in residential treatment, outpatient therapy, or simply by working through a handbook like this one. Many of the positive effects of behavioral cessation are specific to the pattern of disordered eating that people leave behind.

Anorexia

As soon as weight restoration (when indicated) is successfully achieved, the brain demonstrates a partial reversal of the brain atrophy that occurs in active anorexia. Additionally, these increases in brain volume are correlated with improvements in eating concerns and body image preoccupation, even during early recovery[3].

In subjective terms, people who successfully achieve weight restoration tend to report a more positive body image than those who don’t. Additionally, people who feel responsible for their own recoveries and supported in their efforts are more likely to stay in recovery than people who feel forced to change or alone in their efforts[2].

Bulimia

After the cessation of bingeing and purging, the brain’s volume deficiencies and abnormal amount of left hemispheric lateralization begin to correct themselves[4]. Fortunately, white matter connections are incredibly responsive to remapping through behavioral change[5]. Although this field of research is still in its infancy, the brain’s distribution and volume of grey and white matter appear similar to the brains of healthy controls after a year of cessation from bingeing and purging[6].

Qualitatively, women who cultivate more self-acceptance, self-efficacy, and hope for the future are more likely to stay in recovery than those who don’t[7].

Binge eating disorder

An abnormal volume of orbitofrontal cortex grey matter has been noted in people with binge eating disorder or bulimia[8]. While there are few studies that focus specifically on binge eating behavior (decoupled from purging), the therapeutic modalities that are effective in treating binge eating suggest that neuroplasticity also plays a central role in binge eating recovery[9].

People who recover from binge eating report that feeling validated and successfully changing their thinking patterns helped them achieve and sustain recovery[10].

Ongoing personal growth

People in long-term recovery from eating disorders demonstrate significant changes in brain structure, many of which make their brains relatively indistinguishable from those of people who have never had an eating disorder. The cluster of brain differences that can persist into long-term recovery suggest that there may be certain biological factors or personality traits (more fixed qualities) that predispose certain people to disordered eating. Possessing these traits does not mean you will relapse. In the future, these biomarkers may be able to help us predict and prevent eating disorders before they even begin!

Anorexia

Adults who achieve weight restoration and maintain recovery for longer than eighteen months can demonstrate a complete recovery of grey matter volume in addition to the resolution of the functional cognitive deficits associated with anorexia[11]. The brain’s ability to recover may be affected by the severity and duration of the disorder.

Qualitatively, people who stay in recovery for longer than one year demonstrate decreased relapse risk and lower rates of depression than those who don’t[12].

Bulimia

As mentioned above, abstaining from binge/purge behavior for longer than one year appears to normalize both brain volume and cerebral blood flow in adults with bulimia[3,13]. The serotonergic deviations that can remain into long-term recovery may relate to common personality traits like harm avoidance[14]. Once again, demonstrating these traits does not mean you will develop an eating disorder, but people with these traits may be at a higher lifetime risk.

People who maintain long-term recovery from bulimia demonstrate lower rates of depression and substance use than those who don’t[15].

Binge eating disorder

While there is little research on long-term recovery from binge eating, partially due to its recent inclusion into the DSM-V, there is evidence to suggest that at least some brain volume abnormalities resolve once people cease a pattern of habitual binge eating[14].

Subjectively, women who have maintained long-term recovery from binge eating tend to report increased quality of life and lifestyle balance when compared to those who don’t[16].

Unplanned return to disordered behavior

Returning to disordered behavior is not necessarily part of the Stages of Change model, but some back-and-forth return to disordered behavior is common during the experience of recovery. If this occurs, it does not mean you have failed or that you have to go back to a previous stage! Instead, see if you can look at the experience as one of the possible “growing pains” that can be associated with such a significant life transition. Can you learn from the experience to avoid a similar one in the future? More on relapse prevention and recovery in Chapter 9.

Chapter 4: The prevalence of disordered eating in recovery from substance abuse

"These pains you feel are messengers. Listen to them." -Rumi

Substance use disorder or SUD does not occur in isolation. Approximately 35% of individuals with substance use disorder also present with a diagnosable eating disorder or ED[1]. Similarly, up to 50% of individuals with diagnosable eating disorders also report behaviors commonly indicative of substance use disorder[1]. Those with both conditions tend to experience more severe symptomatology and poorer outcomes when compared to individuals presenting with either SUD or ED[1].

Women and the LGBT communities are at particularly high risk for concurrent substance use and eating disorders. Among women in residential treatment for substance abuse, the incidence of comorbidity jumps to nearly 60%[2]. These reports fail to include individuals with subclinical disordered eating, which can still significantly interfere with long-term quality of life and physical health.

While there is little evidence to support the idea that addiction can be truly “transferred” from substances to food[3], there may be several underlying genetic factors that predispose certain individuals to use either substances or foods as tools for emotional regulation[4]. People who rely on escapism as a coping tool may notice an increase in the tendency to use food, social media, shopping, or other distraction-oriented behaviors as a form of self-soothing during early recovery from drugs and/or alcohol.

Cultivating an expanding toolbox of healthy coping skills unrelated to food or substances can help supplant this temporary uptick in self-soothing through escapist behavior. Without the development and application of new distress tolerance skills, maladaptive food behaviors may increase in frequency, intensity, and duration after the cessation or moderation of alcohol or drug use[5].

Fortunately, many of the same tools people have used to successfully achieve long-term recovery from substance use can be applied to disordered eating. If you have previously recovered from the problematic use of drugs or alcohol, you have already proven to yourself that change is possible! If you are concurrently working to change drug or alcohol use and also struggle with disordered eating, each tool you learn can now work double duty.

Ready to learn more about these terrific tools? Read on!

Chapter 5: Motivation and commitment for a resilient recovery

“Commitment is what transforms a promise into reality.” -Abraham Lincoln

If the SMART goals you made in Chapter 2 are the vehicle for long-term behavior change, motivation is the fuel that sparks everything into motion. Motivation lends an energy boost to kick-start these actions into daily life. Simultaneously cultivating commitment will allow you to follow through with these promises when motivation runs low.

In addition to the physical effects, disordered eating behavior often becomes a “time-thief,” occupying more and more of daily living until friends, family, hobbies, humor, and meaningful activities are pushed aside. If nothing is changed, disordered eating behavior can steal the better part of your days, months, years--or ultimately your life. Getting reacquainted with your values and purpose can help you recognize how significant these seemingly small goals actually are.

Whether or not you realize, working through this handbook is an outward expression of motivation. You did not have to pick up this workbook at all, and you certainly did not have to do any of the exercises. Knowing that, what moved you to do those things anyway? This chapter will help you build on the foundational motivation that caused you to pick up this book in the first place to ensure you have plenty of “fuel” for your ongoing recovery journey.

TOOL: Hierarchy of Values (with example)

Whether or not we have ever identified them, we all have internal values that motivate us to act in certain ways. The Hierarchy of Values tool can help you formally identify the factors that matter most to you.

Using a blank sheet of paper, write down as many of your core values as you can think of. If you have trouble getting started, try choosing from the list below. Remember that values are usually abstract concepts like honesty, integrity, loyalty, learning, freedom, creativity, respect, compassion, etc. Once you have written as many as you can in five minutes, see if you can narrow your list down to the five most important core values in your life.

Core values

1. Accuracy
2. Achievement
3. Adaptability
4. Altruism
5. Awareness
6. Bravery
7. Calm
8. Capable
9. Certainty
10. Challenge
11. Cleanliness
12. Comfort
13. Commitment
14. Community
15. Compassion
16. Consciousness
17. Consistency
18. Control
19. Conviction
20. Cooperation
21. Courage
22. Creativity
23. Curiosity
24. Decisiveness
25. Dependability
26. Discipline
27. Discovery
28. Efficiency
29. Empathy
30. Endurance
31. Enjoyment
32. Equality
33. Excellence
34. Experience
35. Fairness
36. Family
37. Fame
38. Fortitude
39. Freedom
40. Friendship
41. Fun
42. Generosity
43. Grace
44. Gratitude
45. Growth
46. Happiness
47. Hard work
48. Harmony
49. Health
50. Honor
51. Hope
52. Humor
53. Imagination
54. Independence
55. Individuality
56. Innovation
57. Insight
58. Integrity
59. Intuition
60. Joy
61. Justice
62. Kindness
63. Knowledge
64. Lawfulness
65. Leadership
66. Learning
67. Love
68. Loyalty
69. Mastery
70. Meaning
71. Mindfulness
72. Moderation
73. Openness
74. Optimism
75. Order
76. Originality
77. Passion
78. Patience
79. Peace
80. Persistence
81. Playfulness
82. Power
83. Productivity
84. Professionalism
85. Prosperity
86. Purpose
87. Reason
88. Respect
89. Responsibility
90. Restraint
91. Reverence
92. Security
93. Self-reliance
94. Selflessness
95. Sensitivity
96. Service
97. Significancy
98. Simplicity
99. Sincerity
100. Skill
101. Spirituality
102. Spontaneity
103. Stability
104. Status
105. Strength
106. Succes
107. Sustainability
108. Teamwork
109. Timeliness
110. Toughness
111. Tradition
112. Transparency
113. Trust
114. Truth
115. Understanding
116. Uniqueness
117. Unity
118. Valor
119. Victory
120. Vitality
121. Wealth
122. Wisdom
123. Wonder

Figure 5.1 My Hierarchy of Values (example)

Your own list may look a lot like the example, or it may be very different. There is no right or wrong as core values are highly individual. Take a moment to consider your list. Do you notice anything missing? People rarely identify food as the most important value in their life, although their actions may suggest that it is. Few people identify physical appearance as a core value either, even though much of their day may be filled with thoughts about their body or its outward appearance.

Think about how your disordered eating/exercise behavior has impacted each of your values. Every time you binge at home instead of going out to dinner with friends, you miss out on the opportunity to nurture close friendships. Every time you choose to engage in compulsive exercise instead of taking a much-needed nap, you choose disordered behavior over physical health. Anytime you lie about your eating habits to a concerned friend or family member, you compromise your personal integrity and dependability in relationships.

The purpose of this exercise is not meant to shame you for any past behaviors. The drive to binge, purge, and/or restrict can be incredibly strong. If it were so easy to stop, you probably wouldn’t be reading this handbook.

Instead, this exercise is meant to show you how pervasively disordered eating interferes with a balanced, meaningful life. When urges arise, it is easy to forget the larger context in which our behaviors take place. Carrying a copy of your Hierarchy of Values can help remind you of the “why” behind your commitment to recovery, especially when urges strike. Your core values may change over time, and your Hierarchy of Values can be updated accordingly.

Being in touch with your core values can help you restructure your time to better align with these important qualities. Still, identifying your values does little to help if you cannot see a path from where you are now to a life where you are guided by these ideals, that is to say a value-driven life. Next, let’s talk about overcoming some of the roadblocks on this journey.

Roadblocks to motivation

After reflecting on the extent to which disordered eating behaviors have caused you to violate several deeply-held values, you may be feeling especially motivated to recover. Unhelpful beliefs can make it difficult to turn this motivation into action by undermining a sense of confidence in your ability to change. Beliefs may be more specific, pertaining to a single situation, or more general, underlying the way you look at the world at large. Oftentimes, situational beliefs can be matched with one or more of these deeper core beliefs.

What are beliefs, anyway?

Beliefs are cognitive interpretations of our internal and external experiences. It is important to note that emotions are catalyzed by our beliefs about our experiences--not by the events themselves.

Why do you think some people stay calm in traffic while others get “road rage”? It’s not the traffic, since some people stay calm while others yell, swerve, or tailgate on the same rush-hour roads. However, holding certain beliefs about the traffic like, “I shouldn’t have to deal with this!” or, “It’s not fair that there’s so much traffic at 2PM!” can provoke feelings of frustration and subsequent “venting” behaviors.

Alternative self-talk like, “I’ll get there when I get there” or “I can appreciate this alone time to listen to music” tends to lead to a much different emotional landscape, making it easier to avoid speeding or swerving.

Fortunately beliefs can be changed over time, but we must first be able to recognize them for what they are. Beliefs may feel very real in the moment, but they are only thoughts--never absolute truths. The next time you notice an internal dialogue playing out, see what happens when you preface each message with, “I am noticing the thought that…”

Immediately, the intensity of the message becomes a bit softer.

Let’s consider some of the most common unhelpful core beliefs. Do any of these resonate with you?

• “There is something deeply wrong with me.”
• “I am worthless.”
• “I am incompetent/incapable.”
• “If people only knew the real me, they would leave me/hate me.”
• “I am not--and will never be--enough.”
• “I am not even sure I exist.”
• “I am--and will always be--alone.”
• “I am incomplete; there is something missing.”
• “I am powerless/helpless/a victim of life.”
• “I am unlovable.”
• “The way I am today is somehow not okay.”
• “I am not sure that I can survive without this person.”

If none of these sound like part of your inner dialogue, can you think of another statement or belief that may have historically held you back from pursuing your life goals? These beliefs typically finish the statement, “I couldn’t do that because I am too…”

While these types of core beliefs are often formed during childhood, they are worth exploring in adult life. If we continue to look at the world through the lens of an unhelpful belief, it can easily turn into a self-fulfilling prophecy!

For example, if you believe that you are incompetent, you may avoid applying for interesting jobs that you are actually well-qualified for, preferring instead to stick to work you “know you can’t screw up.” If you believe that you are worthless, you may stay in relationships with people who treat you that way. This is not to lay blame on past patterns of behavior; acting according to these beliefs tends to reinforce them further as previously described.

When we look closely at these ideas, however, we see that they are rarely accurate assessments of our situation. Once we recognize that these sorts of beliefs are not helpful, rational, or least of all true, we can adopt new beliefs that instead encourage us to take positive steps toward a better future.

TOOL: Disputing Unhelpful Beliefs (DUBs)

Disputing unhelpful beliefs (DUBs) can help you examine problematic beliefs that may have hamstrung previous attempts at recovery. Unhelpful beliefs can also amplify the experience of emotional discomfort. By asking yourself three simple questions, you can begin to loosen your conviction for the unhelpful beliefs that can sabotage your recovery. You may be surprised to find some strongly held beliefs begin to fall apart under careful consideration.

Unhelpful beliefs are:

• Not true—there is little evidence to support them
• Nonsensical—not logical, or do not follow Occam’s Razor
• Harmful—not helpful to your long-term interests or overall well-being

By contrast, helpful beliefs are:

• True—realistic and supported by real-world evidence
• Reasonable—logical, and likely consistent with Occam’s Razor
• Helpful—conducive to positive life change

By asking ourselves if our “old” beliefs are true, reasonable, and helpful, we can begin to dispute these beliefs and make room for new, more adaptive ideas. Rational beliefs in turn cultivate healthy emotions that lead to constructive (versus destructive) behaviors. We’ll learn more about how DUBs relates to emotions and behaviors in Chapter 7.

TOOL: The ABCs (with example)

Fortunately, unhelpful beliefs can be changed through intentional consideration. The ABC tool is a helpful framework to help you amend any ideas that are preventing you from reaching a balanced, peaceful life in recovery.

Figure 5.2 The ABCs (example)

Now it’s your turn to try the ABCs! If you have noticed any fears about recovery, this is a great opportunity to ask yourself, “Why do I feel afraid of [changing my eating habits/calling a therapist/asking my spouse for help/etc.]?”

My ABCs

As you may have already realized, the DUBs and ABC tools can be applied to many different types of situations. In the next chapter, you will explore how disputing beliefs can also help defuse urges and ultimately turn away from maladaptive behaviors.

Performing a single ABC can be very helpful in changing the situational beliefs, emotions, and behaviors of everyday living. If you are feeling discouraged because a single ABC exercise did not shift one of your more pervasive core beliefs (e.g. “I am worthless”), remember how many times you have told yourself this negative message over the years. It may take more than a few repetitions to meaningfully transform a core belief.

Do not lose hope! With consistent revision, negative core beliefs can be molded into a much gentler stream of self-talk (e.g. “I am doing my best with what I have”). If it is available to you, enlisting the help of a mental health professional supports many people along this part of the journey.

Commitment

When you are feeling motivated, taking proactive steps toward recovery can feel encouraging and exciting! But what about when you do not feel particularly motivated? You may find that your motivation waxes or wanes with certain milestones in recovery, or even certain times of day.

Commitment is the solid foundation that can help you keep your behaviors in line with your values during times of low motivation. You may have some ambivalence about the process or outcomes of recovery, which we acknowledged in Chapter 2’s Cost-Benefit Analysis.

Fortunately, commitment is not black-and-white. By committing to your SMART goals instead of a vague idea of “recovery,” you are simply gathering good data on the outcomes of behavior change. There is no need to definitively answer any existential questions about whether you are “committed enough” to recover.

In the next chapter you will be introduced to some practical tools to help you stick to these commitments, whether or not you are feeling motivated at the time.

Chapter 6: Calming urges

“Sometimes we say, ‘I didn’t want to do it, but it’s stronger than me, it pushed me.’ [T]hat is a habit energy that may have come from many generations past. We can smile at our habit energy. With awareness, we have a choice; we can act another way. We can end the cycle of suffering right now.” -Thich Nhat Hanh, Reconciliation: Healing the Inner Child

At this point you have probably identified one or more behaviors you would like to extinguish, as well as several meaningful reasons for making those changes. You may not be sure how to avoid the pull of strong urges to engage in maladaptive behaviors.

Note: not everyone who recovers from disordered eating struggles with urges to return to old, maladaptive eating behaviors; there is no right or wrong here. If the experience of urges does not resonate with you, feel free to skip to Chapter 7 where you will learn more skillful means for channeling troubling thoughts and feelings into healthy behaviors.

However if you are like the majority of people recovering from disordered eating, you are already familiar with the overwhelming desire to binge, purge, compulsively exercise, and/or the intense aversion to violating any “food rules” that characterizes restriction. In the moment, the desire to binge, purge, or restrict can feel downright excruciating. It may be hard to focus on anything else.

Luckily, this craving is physically harmless. Even though the experience of an urge can be intensely uncomfortable, urges cannot hurt you. With practice, you can become adept at riding out the desire to engage in maladaptive behaviors and instead stick with the goals you created in Chapter 2. Furthermore, most people find that their urges begin to decrease in frequency, intensity, and duration over time. Many people who have achieved long-term recovery report that urges are no longer even a part of everyday life. The more you know about urges, the better equipped you will be to calm them when they arise. Read on to equip your urge-soothing toolbox!

What is an urge?

Over time, habitually disordered eating behavior results in structural and functional brain changes collectively called behaviorally-induced neuroplasticity. These brain changes can be detected on functional magnetic resonance imaging or fMRI. People with eating disorders demonstrate increased activation of certain brain areas implicated in addiction when presented with pictures of highly salient foods (cakes, cookies, pastries, etc.)[1]. People with anorexia additionally demonstrate decreased activation of other brain areas that process sensory stimuli[2], which may be related to the behavior of restriction.

Subjectively, the experience of being exposed to triggers but not acting on them is usually described as aversive (that is to say, it does not feel very good). However, people tend to overestimate how long their urges will last[3]. In fact, most urges usually pass within twenty minutes if we do not feed them with unhelpful beliefs.

Common unhelpful beliefs about urges include thoughts like:

• “I can’t stand this!”
• “I’ll go crazy if I don’t give in!”
• “I can’t take another minute of this!”

Fortunately, the DUBs and ABC tools from Chapter 5 can help you examine the veracity of these beliefs (spoiler: none of these are true). Once you can identify that these “old” beliefs actually intensify your cravings, you can create new, more effective beliefs that help you confidently refuse your urges.

Some examples of effective new beliefs include:

• “This might be uncomfortable, but nobody has ever died from being uncomfortable”
• “I know how to handle this.”
• “Here is a new opportunity to practice urge surfing.”

EXERCISE: Identifying triggers

Triggers are external or internal stimuli that catalyze urges to engage in disordered eating behavior. Your triggers may include certain images, smells, a specific time of day, a certain emotion like loneliness, etc. Everyone’s triggers are a little bit different.

By identifying your most common triggers and practicing proactive self-care, you can circumvent many urges before they even arise. Practicing incremental exposure to unavoidable triggers and then refusing to act allows you to walk into stressful situations without fear of relapse.

To identify your own unique triggers, think about the external and external circumstances that elicit cravings to binge, purge, restrict, or compulsively exercise. Since you already listed your food triggers in Chapter 2, focus on the emotions, people, times of day, or situations that consistently kindle urges. The example below may help you get started on your own list. The more you can identify, the better equipped you will be to handle them when they arise.

Figure 6.1 Identifying triggers (example)

Identifying my triggers

One of the most common triggers in disordered eating recovery is physiological hunger and/or fullness. Rating your hunger on the scale below before and after every meal in early recovery can help you recognize patterns of urges related to hunger and/or fullness. Healthy eating patterns help people stay between 3-7 on the hunger scale most of the time, minimizing hunger-related urges.

Note: certain disordered eating behaviors can interfere with the body’s ability to differentiate internal hunger cues. A registered dietitian who specializes in the treatment of eating disorders is the best resource for addressing hunger cue dysregulation.

Figure 6.2 Hunger and fullness scale

Once you recognize a pattern, you may be able to avoid hunger-or-fullness-related urges altogether by adding a well-timed daily snack or subtracting one that consistently leaves you feeling overstuffed and unwell. Additionally, tracking hunger and fullness can help reacquaint you with the sensation of healthy physiological cues. In long-term recovery, many people choose to return to intuitive eating based on hunger cues so that they do not need to worry about a meal plan for the rest of their lives.

Not all urges are related to physical hunger, however. Developing a deeper understanding of the actual experience of an urge can help you learn to better tolerate any kind of urge—without giving in.

EXERCISE: Urge surfing

Urge surfing is a mindfulness practice that can help you reduce the intensity and duration of urges in real time. When you try to suppress urges or pretend they don’t exist, you can actually increase their intensity and duration, making it more difficult to stick with the recovery-related goals you set in Chapter 2. Mindfulness invites you to acknowledge and accept the fact that you are experiencing an urge, allowing it to naturally diffuse and ultimately pass, usually within twenty minutes or less.

The next time you experience an urge, try saying to yourself, “I notice an urge arising.” To practice urge surfing, focus your attention on the natural rhythm of the breath as it enters and exits your nose and/or mouth. There is no need to force yourself to breathe faster or slower. You might notice the appearance of certain urge-related thoughts or bodily sensations like muscle tension or restlessness. During urge surfing, you simply acknowledge the presence of these thoughts and feelings, understanding deeply that they are both temporary and physically harmless.

Focus on one area of the body where you notice a physical sensation associated with the urge. Notice the quality, location, and intensity of the sensation. Does it feel tight or loose? Does it have a temperature? Is the sensation localized or more generalized? How does the sensation vary with each breath?

Repeat the above process with each part of the body involved, with a curious, non-judgmental attitude. Allow your fear of the urge to subside as you continue to develop an interest in the sensation as it unfolds in real time. You might imagine the urge’s intensity as a wave that rises, crests, and then inevitably falls away on its own. Similarly, we don’t need to squash our urges or flee from them; they will soon pass through us with little effort on our part if we allow them to.

When you find yourself at risk of being knocked down by an urge’s intensity, simply pause to acknowledge the upsetting thoughts before refocusing your attention on the ebb and flow of each breath.

Tips for success

• Practice surfing one urge at a time. Although we can build up our reserves over time, willpower is a limited resource. If you expose yourself to many triggers at once, you may deplete your self-regulation reserves and run the risk of relapse.
• Willpower is strengthened the more we practice self-regulation. With practice, you will become more skilled at urge surfing and the process will become easier.
• Praising yourself for trying even if you do experience a lapse will help you to stay motivated in order to continue working toward your long-term goals.

Chapter 7: Befriending thoughts, feelings, and behaviors

“Nothing can survive without food. We ruminate on suffering, regret, and sorrow, chew on them, swallow, bring them back up, eat[ing] them again and again. When we feel loneliness and despair, we seek to cover them up and pretend they’re not there. We fear that we’ll be overwhelmed by the suffering, despair, anger, and loneliness inside. [But] when we bring our mind home to our body, something wonderful happens; our mental discourse stops chattering. The process of healing begins when we mindfully breathe in.” -Thich Nhat Hanh, No Mud, No Lotus

As you learned in Chapter 5, it’s not the actual events of our lives that create our feelings—it’s our beliefs. For many people, these beliefs have snowballed into an ever-present internal dialogue that some people call the “eating disorder voice” or “ED-voice.”

This voice usually screams its irrational beliefs loudest during early recovery. While the experience cannot be described as pleasant, it is important to remember it is ultimately temporary. By disputing and amending unhelpful beliefs as you learned how to do in Chapter 5, you are training your brain to adopt a more positive—or at least neutral—internal dialogue. With practice, patiently and persistently replacing beliefs with more adaptive alternatives allows many people to permanently transform their inner dialogue. In fact, many people in long-term recovery report they no longer experience the “ED-voice” phenomenon.

What is hopefully an encouraging message to hear at any stage of recovery may not be much comfort to anyone who currently feels overwhelmed by the seemingly omnipresent nature and painfully loud volume of their “ED-voice.”

Taming our thoughts

If your mind feels like too much of a battleground to isolate and dispute any single belief, thought-stopping in combination with mindfulness of breath can help silence the “ED-voice” when its presence has grown from an occasional visitor to a permanent resident.

EXERCISE: Thought-stopping with mindfulness of breath

Thought-stopping is a technique that allows us to manually push pause on the chatter in our minds, if only briefly. Adding mindfulness of breath gives us something to pay attention to instead, preventing a resurgence of negative thoughts when we lift our metaphorical finger away from the pause button.

Thought-stopping

If we wanted to stop a door from closing, we would first need to catch it by quickly extending a hand or foot. This immediate action is akin to the thought-stopping part of this bipartite coping tool. To practice thought-stopping, imagine a big, red stop sign in your mind’s eye the next time you feel distracted by internal chatter. The more vivid and colorful the image, the more it will fully occupy your mind. You might try saying the word “STOP!” quietly or even loudly (if you are alone). The idea is to briefly and intensely occupy your imagination with something besides the “ED-voice.”

Once you have interrupted the continuous monologue—no matter how briefly—you have the opportunity to refocus your attention onto something else, which will prevent the “ED-voice” from swooping back into the silence.

Mindfulness of breath

For this secular mindfulness practice, we focus our attention wholeheartedly on the experience of breathing. We may not always pay attention to it, but there is a lot that goes into each cycle of respiration!

Literally anytime and anywhere, we can choose to notice the air moving in and out of our nostrils, slightly warmer air moving through the back of the throat, and the gentle rise and fall of the chest with each breath cycle. Without forcing anything, can you notice whether the breathing is shallow or deep? Regular or irregular? Fast or slow? Are there any accompanying sounds? Smells? When we open ourselves to the entire experience, we retrain our brain to stay grounded in the present moment. Eventually, we can learn to approach the world around us with a similar sense of curiosity instead of fear.  

The rich sensory landscape provided by the breath cycle can fully occupy our attention if we stay inquisitive. By spotlighting the breath in our awareness, we simultaneously prevent the “ED-voice” from stealing the spotlight.

Most people find better success by following mindfulness of breath with an engaging real-world activity. It could be anything from jumping into a cold shower to cracking open a new book or magazine you’ve been meaning to read. Good self-care activities occupy our thoughts and invite subjectively positive emotions like curiosity, engagement, or creativity.

Observing thoughts without judgment

Our thoughts and beliefs can have a profound effect on our emotional landscape, as we discussed in Chapter 5. If we subsequently judge these emotions as “good” or “bad,” they can give rise to secondary emotions--e.g. feeling guilty for the fact that you feel jealous about a situation.

Temporarily suspending judgment about your thoughts and feelings can give you a chance to perform an ABC tool (see Chapter 5) to evaluate the underlying belief(s) that catalyzed the initial emotional experience. While there is no right or wrong way to feel about a given situation, it may be worthwhile to explore the rationality of your belief(s) about the issue at hand. Amending problematic beliefs early can be a form of preventative self-care, allowing you to transform your emotional landscape before you even feel the desire to engage in destructive behavior.

Healthy versus unhealthy emotional discomfort

It’s entirely normal to experience difficult emotions at times--even in recovery. For example, grief is a natural response to losing a relationship. Feelings of disappointment or betrayal are reasonable responses to finding out you were deceived. In general:

• Healthy emotional discomfort tends to arise from an adaptive underlying belief and usually motivates you to take actions that reflect compassion and assertiveness. Adaptive emotions in this category include anger when your boundaries are violated, remorse for past mistakes, and empathy for another’s suffering, among others. While they may not feel very comfortable in the moment, these subjectively negative experiences can also give you the confidence to protect your boundaries, the determination to follow through with meaningful behavior change, or the courage to reach out to a loved one who might be struggling--all constructive actions for the circumstances.
• Unhealthy emotional discomfort results from an unhelpful underlying belief and often invites you to engage in self-defeating behaviors that will not resolve the issue at hand. Maladaptive emotions include shame about who you are, worrying about problems that cannot be fixed, and unhealthy or possessive jealousy, among others. These subjectively negative experiences often make it more difficult to move forward with positive behaviors and can give rise to self-destructive urges.

Healthy emotional regulation depends on responding effectively to these emotions as they arise, not attempting to eliminate them. While it is impossible (and in fact undesirable) to stamp out all emotional discomfort, you can learn to transform unhealthy emotional discomfort with practice. By investigating problematic beliefs in the moment, you might even be able to transmute a newly blossoming feeling--before it snowballs into an unhealthy emotional pattern.

Of course, once an emotion is here, there is no use in fighting with its existence. The way you feel is simply the way you feel! See if you can be gentle with yourself as you explore the ebb and flow of different feeling-states.

Name it to tame it: accurately identifying feelings

Naturally, it helps to know what kind of feeling(s) you are working with. People with disordered eating frequently have difficulty identifying their emotions[1]. This is problematic because effective self-regulation often depends on the emotion presenting itself. Some self-regulation tools are more universal while others are more nuanced. For example, feelings of loneliness are most directly soothed by connecting with a loved one, while feelings of anger are better tamed by creating physical and mental space between you and the object of your anger: two different responses for two different emotions.

But if you cannot identify the emotion beyond feeling bad, you might not know how to respond besides numbing out through maladaptive behaviors. The next time you notice you are feeling “off,” try picking from between the two categories of dysregulation on the window of tolerance.

Window of tolerance

The window of tolerance is a model for conceptualizing physical arousal (no, not that kind of arousal!) into one of three categories, which can be easier to differentiate than individual emotions. Inside the window of tolerance, you might experience a number of different emotions. The important thing is that they all feel relatively manageable and you are able to exercise self-regulation tools as needed to bring yourself back to baseline.

When life’s challenges exceed your ability to cope, you may find yourself in a state of hypo-arousal or hyper-arousal. Hypo-arousal is characterized by feeling sluggish, shut down, or even dissociated from your own body. Hyper-arousal may be experienced as feelings of anxiety or panic and may be associated with a pounding heartbeat, dry mouth, or shaking hands. These states are not specific emotions but recognizing them is still good practice. It can be very hard to “keep your hands on the steering wheel” and choose conscientious actions when you are in a state of hypo- or hyper-arousal. If you learn to recognize when you might be at the edge of your window of tolerance, you may be able to avoid falling off either end!

Figure 7.1 Window of tolerance

Identifying more subtle emotional nuances will become easier with practice. As you get (re)acquainted with your own emotional landscape, try checking in regularly with your body for physical cues like chest tightness or a fluttery feeling in your stomach. Matching these signals with a corresponding emotion can help you get in touch with your unique emotional experience on a day-to-day basis. You might also rate the intensity of the experience on a scale from 0-100 when you first notice it. This will come in handy in a moment when we talk about how to effectively move through emotions without reacting to them.

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As you can tell, the potential for emotional variation is quite rich! (This list is not even exhaustive.) If you practice naming emotions as they arise, you can learn to match a given emotion to the self-regulation tool that works best for you.

Don’t get too caught up in trying to figure out the difference between “irritation” and “agitation” (which could easily become a frustrating experience in and of itself)! Emotion identification is a skill that improves with practice. Fortunately, many tools for self-regulation can be effectively applied to any number of emotions that fall within one or more of the more general categories of feeling-states:

• Happiness-includes emotions like bliss, calm, interest, joy, and satisfaction, among others.
• Sadness-includes emotions like disappointment, heartbreak, grief, and melancholy, among others.
• Anger-includes emotions like agitation, frustration, irritation, and rage, among others.
• Fear-includes emotions like anxiety, hesitation, horror, and panic, among others.

Basic emotional regulation skills

Some aspects of emotional regulation are universal, while others are particularly helpful for one family of emotions or another.

Acceptance is a universal principle for effectively moving through emotions related to sadness, anger, or fear. With low-intensity emotions (subjectively rated from 0-25/100), sometimes a willingness to tolerate discomfort for twenty minutes or so is all it takes to resolve the feeling--as long as you do not ruminate about a person or situation related to the feeling. (If you struggle with rumination, check out the Thought-stopping tool described earlier in this chapter.)

Employing coping thoughts can help you tolerate this kind of discomfort, strengthening your ability to ride out feeling-states that can be uncomfortable or even painful at times. Coping statements or other affirmations usually work best when they feel authentic. See if any of the following coping thoughts ring true for you:

• “It might not feel good, but I know this sadness/anger/fear won’t kill me.”
• “Riding out this discomfort is how I regain my freedom.”
• “It’s okay to feel sad/angry/afraid sometimes; this is just one of those times.”
• “I’ve survived this feeling before, and I know I can do it again.”
• “I might prefer to feel differently right now, but I know I can tolerate this.”
• “This too shall pass.”
• “Just keep swimming, just keep swimming…”

...or try making up your own!

Self-compassion is a universal principle that captures how to effectively move through emotions like sadness, anger, or fear. Rather than “white-knuckling” your way through a difficult experience, try repeating one or more coping thoughts to yourself while giving yourself full permission to spend twenty minutes on one of the following enjoyable activities[2]:

Enjoyable activities

1.  Tend the garden.

2.  Listen to music.

3.  Read a book.

4.  Go for a walk in a natural setting, such as the woods or a park.

5.  Watch a TV show.

6.  Help someone.

7.  Watch sports.

8.  Exercise (if healthy).

9.  Play a board game.

10.  Watch children play.

11.  Play cards.

12.  Ride a bicycle.

13.  Go for a jog or walk.

14.  Visit a friend.

15.  Call someone on the phone.

16.  Sing a song.

17.  Play a musical instrument.

18.  Play a computer game.

19.  Surf the internet.

20.  Watch the sun rise or set.

21.  Draw or paint outdoors.

22.  Take photographs.

23.  Write a letter to someone you love.

24.  Get a massage.

25.  Visit a new place.

26.  Go to an amusement park.

27.  Dance.

28.  Go for a car ride.

29.  Build a model.

30.  Fix something that is broken.

31.  Work on your car.

32.  Attend a lecture.

33.  Go to a museum.

34.  Enroll in a class.

35.  Learn a new craft.

36.  Walk on the beach.

37.  Solve a brain-teaser.

38.  Make a videotape.

39.  Go to the library.

40.  Go to a cafe.

41.  Prepare a healthy meal.

42.  Meditate.

43.  Listen to a relaxation tape.

44.  Go hiking.

45.  Go fishing.

46.  Go swimming.

47.  Attend a political rally.

48.  Pray.

49.  Have a pleasant daydream.

50.  Make love.

51.  Take a bath.

52.  Contemplate your career path.

53.  Start a collection (of books, coins, dolls, etc.).

54.  Go shopping for new clothes.

55.  Go to a comedy club.

56.  Go camping.

57.  Arrange flowers.

58.  Chop wood.

59.  Go to a concert.

60.  Redecorate a part of your home.

61.  Follow the financial markets.

62.  Educate yourself in some aspect of your profession.

63.  Go to the racetrack.

64.  Go to a casino.

65.  Go to a nightclub.

66.  Write a poem.

67.  Play with an animal.

68.  Go to a party.

69.  Sit on the porch.

70.  Do volunteer work.

71.  Go bowling.

72.  Go to the theatre.

73.  Get dressed up.

74.  Play chess.

75.  Go skating.

76.  Go sailing.

77.  Plan a trip.

78.  Join a club.

79.  Play a musical instrument.

80.  Go sightseeing.

81.  Go to the beauty parlor.

82.  Join a discussion group.

83.  Go out to a restaurant to eat.

84.  Have a sexual fantasy.

85.  Write in your journal.

86.  Go on a picnic.

87.  Do a crossword puzzle.

88.  Read the bible.

89.  Go to a religious service.

90.  Go horseback riding.

91.  Put together a jigsaw puzzle.

92.  Study your schoolwork.

93.  Birdwatch.

94.  Make a fire in the fireplace.

95.  Repair something.

96.  Participate in a discussion.

97.  Read the newspaper.

98.  Do an activity with children.

99.  Play a game of pool.

100.  Perform a community service.

101.  Look at the night sky.

102.  Go out for tea.

103.  Have a glass of fine wine (if you do not have a drinking problem).

104.  Figure out how something works.

105.  Go skiing.

106.  Go look at new cars.

107.  Go to a country inn.

108.  Go rock climbing.

109.  Play golf.

110.  Go boating.

111.  Walk around the city.

112.  Go to the zoo.

113.  Go to the aquarium.

114.  Go to a mall.

115.  Invite a friend to visit.

116.  Go to the mountains.

117.  Tell a joke.

118.  Do yard work.

119.  Play a word game.

120.  Play frisbee.

121.  Go to the library.

122.  Smoke a pipe or cigar.

123.  Sew.

124.  Attend an auction.

125.  Give to charity.

126.  Do woodworking.

127.  Watch television.

128.  Listen to talk radio.

129.  Look at the stars through a telescope.

130.  Have your fortune told.

131.  Brush your hair.

132.  Join a political group.

133.  Go to a twelve-step meeting.

134.  Go out on a date.

135.  Practice yoga.

136.  Go to a martial arts class.

137.  Rake the leaves.

138.  Go to a bookstore.

139.  Go window shopping.

140.  Finish some task you have been putting off.

141.  Fly an airplane.

142.  Observe animals in the wild.

143.  Go to the ballet.

144.  Fly a kite.

145.  Have a conversation.

146.  Learn a new song.

147.  Build a bonfire at night.

148.  Sit on the porch and watch the world.

149.  Organize something (your closet, books, music, tools, etc.)

150.  Send someone an email.

151.  Go to sleep on clean sheets.

152.  Manage your finances.

153.  Invent a healthful drink.

154.  Visit a planetarium.

155.  Play tennis.

156.  Play a lawn game (croquet, badminton).

157.  Experience your five senses, one by one.

158.  Dress up in a disguise.

159.  Smile.

160.  Light a candle and watch the flame.

161.  Prepare a lovely table for a meal.

162.  Look at beautiful pictures in a book.

163.  Hug someone.

164.  Make tea or hot chocolate.

165.  Sit in the lobby of a beautiful old hotel.

166.  Listen to the rain.

167.  Walk in the rain, stepping in puddles.

168.  Skip.

169.  Go on the swings.

170.  Eat something sweet.

171.  Take a sauna.

172.  Buy or make someone a present.

173.  Throw a party.

174.  Prepare an elaborate holiday celebration.

175.  Buy or make yourself a present.

176.  Play with a pet.

177.  Go for a long walk with your dog.

178.  Tinker with an electronic device.

179.  Install a new computer program.

180.  Read the encyclopedia.

181.  Refinish a piece of furniture.

182.  Play baseball.

183.  Have a barbecue.

184.  Act.

185.  Play football.

186.  Put lotion on your body.

187.  Take a shower.

188.  Go to a video arcade.

189.  Bake.

190.  Play volleyball.

191.  Get a good night's sleep.

192.  Stay up all night watching movies.

193.  Carry out an assertiveness exercise.

194.  Go for a train ride along a scenic route.

195.  Visit a relative.

196.  Talk politics.

197.  Conduct an experiment.

198.  Play soccer.

199.  Practice listening well to another person.

200.  Make someone laugh.

When time is up, check in with your body. Do you notice any changes in your bodily experience? How does the emotion’s current intensity compare with your initial rating on a scale of 0-100? If it has decreased in intensity--even by a little--remember this for the next time you notice an emotional wave rising! Many feeling-states naturally recede or pass in twenty minutes or less.

Not every one of these activities may appeal to you (or even be feasible). The point is to have several positive activities to choose from the next time you are feeling bored or unwell. Choosing from a pre-written list can help you circumvent the mental “tug-of-war” of deciding whether or not to engage in maladaptive food-related behaviors as an attempt to emotionally regulate.

Additionally, this list can help you explore some pleasant activities you might later decide to regularly incorporate into recovered living. Many people with disordered eating report that they have lost touch with the hobbies they used to enjoy. By picking a new activity from the list each time, you might accidentally discover a new hobby in the process!

Sitting with sadness

As mentioned earlier, the family of emotions related to sadness encompasses a number of more nuanced experiences including grief, melancholy, heartbreak, dejection, etc. Everyone experiences these feeling-states slightly differently, but many people describe sadness as a lethargic and withdrawn experience.

In addition to cultivating acceptance and self-compassion for this emotion, it’s important to know that feelings related to sadness, especially grief, may come and go in waves. When a wave of sadness rises, think back to the urge surfing exercise from Chapter 6. Just like urges, emotions like sadness can be effectively “surfed” and need not leave you feeling engulfed.

If you can excuse yourself to a private area, crying can be a remarkably effective form of self-soothing that often curbs the intensity of the sadness[3]! If you do not feel that you are able to cry, there are many other self-care activities that can help you pass the time while the emotion subsides on its own. Refer back to the list of enjoyable activities if you are not sure where to start.

Alleviating anger

[coming soon]

Facing fear

[coming soon]

Befriending behaviors

Sometimes you might feel like you are sitting in the driver’s seat, choosing your behaviors on a day-to-day basis. Other times it might feel like someone else must be driving!

Chapter 8: Building a purposeful, passionate life

[coming soon]

Chapter 9: Preventing the return of unwanted behavior

[coming soon]

Chapter 10: Resources for family and friends

[coming soon]

References

Introduction

1. Bocarsly, M. E. (2016). Food Addiction: Applying Substance Use Disorder Criteria and Characteristics to Identify Instances of Addictive-Like Eating. In Neuropathology of Drug Addictions and Substance Misuse (pp. 1008-1018). Academic Press.

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1. Anderson, M. (2018). What is Disordered Eating? Academy of Nutrition and Dietetics. Retrieved from https://www.eatright.org/health/diseases-and-conditions/eating-disorders/what-is-disordered-eating
2. Herzog, D. B., Greenwood, D. N., Dorer, D. J., Flores, A. T., Ekeblad, E. R., Richards, A., ... & Keller, M. B. (2000). Mortality in eating disorders: a descriptive study. International Journal of Eating Disorders, 28(1), 20-26.
3. Garner, D.M., et al. (1982). The Eating Attitudes Test: Psychometric Features and Clinical Correlates. Psychological Medicine, 12, 871-878
4. Hagman, J. (2013). Eating Disorders in Childhood and Adolescence (4th ed.), Eating Disorders, 21:5, 460-462, DOI: 10.1080/10640266.2013.828529
5. Bocarsly, M. E. (2016). Food Addiction: Applying Substance Use Disorder Criteria and Characteristics to Identify Instances of Addictive-Like Eating. In Neuropathology of Drug Addictions and Substance Misuse (pp. 1008-1018). Academic Press.

Chapter 2

1. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: toward an integrative model of change. Journal of consulting and clinical psychology, 51(3), 390.
2. Dietary Guidelines for Americans. (2015). Retrieved from https://health.gov/dietaryguidelines/2015/guidelines/
3. Hart, S., Marnane, C., McMaster, C., & Thomas, A. (2018). Development of the “Recovery from Eating Disorders for Life” Food Guide (REAL Food Guide)-a food pyramid for adults with an eating disorder. Journal of eating disorders, 6(1), 6.
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5. Khan, M. C. A. (2017). Exchange List: A systematic review with emphasis on history and development of a meal-planning exchange list with cultural relevance. European International Journal of Science and Technology, 6(6).

Chapter 3

1. Reese, B. (2017). Length of Recovery as a Predictor of Happiness in Alcoholics. In Poster presented at the International Positive Psychology Association (IPPA) 5th World Congress on Positive Psychology, Montreal, QC, Canada.
2. Fogarty, S., & Ramjan, L. M. (2016). Factors impacting treatment and recovery in Anorexia Nervosa: qualitative findings from an online questionnaire. Journal of eating disorders, 4(1), 18.
3. Martin Monzon, B., Henderson, L. A., Madden, S., Macefield, V. G., Touyz, S., Kohn, M. R., ... & Hay, P. (2017). Grey matter volume in adolescents with anorexia nervosa and associated eating disorder symptoms. European Journal of Neuroscience, 46(7), 2297-2307.
4. Wang, L., Bi, K., An, J., Li, M., Li, K., Kong, Q. M., ... & Si, T. M. (2019). Abnormal structural brain network and hemisphere-specific changes in bulimia nervosa. Translational psychiatry, 9(1), 1-11.
5. Beck, R. W., & DACNB, F. (2016). Neuroplasticity of asymmetric cortical function. Neuroplasticity in Learning and Rehabilitation, 101.
6. Wagner, A., Greer, P., Bailer, U. F., Frank, G. K., Henry, S. E., Putnam, K., ... & Kaye, W. H. (2006). Normal brain tissue volumes after long-term recovery in anorexia and bulimia nervosa. Biological psychiatry, 59(3), 291-293.
7. Lindgren, B. M., Enmark, A., Bohman, A., & Lundström, M. (2015). A qualitative study of young women's experiences of recovery from Bulimia Nervosa. Journal of advanced nursing, 71(4), 860-869.
8. Schäfer, A., Vaitl, D., & Schienle, A. (2010). Regional grey matter volume abnormalities in bulimia nervosa and binge-eating disorder. Neuroimage, 50(2), 639-643.
9. Burgess, E.E., Sylvester, M.D.,  Morse, K.E., Amthor, F.R., Mrug, S., Lokken, K.L., Osborn, M.K., Soleyman, T., Boggiano, M.M. (2016). Effects of transcranial direct current stimulation (tDCS) on binge-eating disorder. International Journal of Eating Disorders. DOI: 10.1002/eat.22554
10. Seitz, J., Herpertz-Dahlmann, B., & Konrad, K. (2016). Brain morphological changes in adolescent and adult patients with anorexia nervosa. Journal of Neural Transmission, 123(8), 949-959.
11. Lord, V. M., Reiboldt, W., Gonitzke, D., Parker, E., & Peterson, C. (2018). Experiences of recovery in binge-eating disorder: a qualitative approach using online message boards. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 23(1), 95-105.
12. Khalsa, S. S., Portnoff, L. C., McCurdy-McKinnon, D., & Feusner, J. D. (2017). What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa. Journal of eating disorders, 5(1), 20.
13. Frank, G. K., Kaye, W. H., Greer, P., Meltzer, C. C., & Price, J. C. (2000). Regional cerebral blood flow after recovery from bulimia nervosa. Psychiatry Research: Neuroimaging, 100(1), 31-39.
14. Sjögren, M. (2017). An update on genetic and serotonergic biomarker findings in Bulimia Nervosa. Ec Neurology, 7(3), 107-116.
15. Haltia, L. T., Viljanen, A., Parkkola, R., Kemppainen, N., Rinne, J. O., Nuutila, P., & Kaasinen, V. (2007). Brain white matter expansion in human obesity and the recovering effect of dieting. The Journal of Clinical Endocrinology & Metabolism, 92(8), 3278-3284.
16. Krentz, A., Chew J., & Arthur, N. (2005). Recovery from binge eating disorder. Canadian Journal of Counseling and Psychotherapy, 39(2).

Chapter 4

1. Gregorowski C., Seedat S., & Jordaan G.P. (2013). A clinical approach to the assessment and management of co–morbid eating disorders and substance use disorders. BMC Psychiatry, 13(1), 289.
2. Robinson, L. D., Kelly, P. J., Deane, F. P., & Reis, S. L. (2019). Exploring the Relationships Between Eating Disorders and Mental Health in Women Attending Residential Substance Use Treatment. Journal of dual diagnosis, 15(4), 270-280.
3. Koball, A. M., Glodosky, N. C., Ramirez, L. D., Kallies, K. J., & Gearhardt, A. N. (2019). From substances to food: an examination of addiction shift in individuals undergoing residential treatment for substance use. Addiction Research & Theory, 27(4), 322-327.
4. Munn-Chernoff, M. A., Johnson, E. C., Chou, Y. L., Coleman, J. R., Thornton, L. M., Walters, R. K., ... & Medland, S. E. (2019). Shared Genetic Risk between Eating Disorder-and Substance-Use-Related Phenotypes: Evidence from Genome-Wide Association Studies. bioRxiv, 741512.
5. Glovsky E., et al. (2007). Healthy habits in recovery: Dietary study methods in substance abuse treatment centers. IRis, Northeastern University, Bouvé College of Health Sciences, Boston, MA.

Chapter 6

1. Schienle, A., Schäfer, A., Hermann, A., & Vaitl, D. (2009). Binge-eating disorder: reward sensitivity and brain activation to images of food. Biological psychiatry, 65(8), 654-661.
2. Santel, S., Baving, L., Krauel, K., Münte, T. F., & Rotte, M. (2006). Hunger and satiety in anorexia nervosa: fMRI during cognitive processing of food pictures. Brain research, 1114(1), 138-148.
3. Sayette, M. A., Loewenstein, G., Kirchner, T. R., & Travis, T. (2005). Effects of smoking urge on temporal cognition. Psychology of Addictive Behaviors, 19(1), 88.

Chapter 7

1. Bydlowski, S., Corcos, M., Jeammet, P., Paterniti, S., Berthoz, S., Laurier, C., ... & Consoli, S. M. (2005). Emotion‐processing deficits in eating disorders. International journal of eating disorders, 37(4), 321-329.
2. McKay, M., Wood, J.C., Brantley, J. (2007). The Dialectical Behavior Therapy Skills Workbook. Oakland, CA: New Harbinger Publications, Inc.
3. Gračanin, A., Bylsma, L. M., & Vingerhoets, A. J. (2014). Is crying a self-soothing behavior?. Frontiers in Psychology, 5, 502.

Addendum

1. Stewart, W. The Role of Perceived Loneliness and Isolation in the Relapse from Recovery in Patients with Anorexia and Bulimia Nervosa. Clinical Social Work Journal 32, 185–196 (2004). https://doi.org/10.1023/B:CSOW.0000024327.55424.a9
2. Blanchet, C., Mathieu, M., St-Laurent, A. et al. A Systematic Review of Physical Activity Interventions in Individuals with Binge Eating Disorders. Curr Obes Rep 7, 76–88 (2018). https://doi.org/10.1007/s13679-018-0295-x
3. Simon, M. (2020.) Are food deliveries and groceries safe during coronavirus pandemic? Yes, experts say. https://www.cnn.com/2020/03/20/health/food-safety-groceries-coronavirus-wellness/index.html

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Appendix A: Diabetic Exchange List

[THE DIABETIC EXCHANGE LIST (EXCHANGE DIET)]

Appendix B: Meals Beyond Measure (simple guidelines for good food)

Rediscovering the fun and flexibility in cooking can help loosen some of the rituals surrounding food preparation that often accompany disordered eating. The following recipes have been collected for their forgiving nature. No measuring cups, food scales, or fancy ingredients are needed to concoct these simple creations, and the recipes are quite “loose” so you can try adding or subtracting optional ingredients as desired. If your recovery is at a stage where cooking is right for you, try experimenting with one or more of the following dishes--or add your own to the mix! Recipes are split between meals (containing multiple food groups) and snacks primarily consisting of a single food group because any food can be “dinner food” if you eat it for dinner! Common allergens/notable ingredients are listed at the end of each recipe for quick reference.

Meals

Banana Oat Bars

Ingredients (in order of appearance):

-3 large bananas or 4 medium bananas

-2:1 ratio of oats:wheat flour

-spoonful of baking powder

-½ spoonful of salt

-1 scoop protein powder (pea, whey)

-1 egg or 2 egg whites

-sweetener of choice (honey, piloncillo)

-milk (almond, soy, coconut)

-(optional) chocolate chips, peanut butter, chopped nuts

Directions:

1. Mash bananas
2. Mix all dry ingredients together and mix into mashed bananas
3. Whisk egg or add liquid egg whites to mixture
4. Add milk until the dough attains the consistency of a thick stew
5. Pour into a bread pan and bake at 350F for 10-15 minutes, until the top is browned but not burnt/black
6. Cool and slice into squares.

Contains: eggs, (optional) dairy

Shepherd’s Pie

Ingredients (in order of appearance):

Filling

-cooking oil (e.g. canola, olive)

-powdered or minced garlic

-diced onion

-diced vegetable(s) of choice (carrots, mushrooms, canned lentils, and peas all do nicely here)

-1:1 ratio of tomato sauce:veggie broth

-(optional) Worcestershire sauce, barbeque sauce, or soy sauce

-rosemary

-thyme

-sea salt

Potatoes

-(optionally peeled) Yukon gold potatoes cut into large chunks

-milk (cow’s milk and coconut milk do well, while almond and soy tend to leave a funny taste)

-powdered or minced garlic

-sea salt

-pepper

Directions:

1. Add cooking oil, garlic, and onion to a cast iron skillet or Instant Pot with “saute” function until onions begin to become translucent (~5 mins).
2. Add vegetables of choice, tomato sauce, veggie broth, and other sauces (if using). Simmer for 5 mins more.
3. Shake as much rosemary, thyme, and sea salt over the filling as you like.
4. Meanwhile, cover the potatoes with water and a dash of salt in a large pot and boil for 10-20 minutes. If you do not have access to a full kitchen, you can instead microwave the water and potatoes in a glass bowl for 8-12 minutes, until the chunks can be cut easily with a butter knife.
5. Once the potatoes are soft enough to be easily sliced with a butter knife, drain water from the potatoes and mash with a potato masher or wooden spoon. (A fork will also work in a pinch.)
6. Begin adding milk, garlic, salt, and pepper until they reach the desired consistency. Some people like a chunkier texture while others want them to be soft and fluffy. Some people like the added texture from the potato peels while others prefer a more smooth, uniform consistency. Which kind do you prefer?
7. Spoon the mashed potatoes over the filling layer in the Instant Pot or cast iron skillet.
8. Transfer cast iron skillet to a 425F oven for 10-15 minutes to brown the potatoes. If using an Instant Pot, cook on “Manual” at high pressure for 5 minutes before quick-releasing the pressure. Note: finishing this dish in the Instant Pot will not result in the same crispiness as a pie finished in the oven, but do not worry; it is still fully cooked!
9. Enjoy!

Contains: (optional) dairy

Tamale Pie

Ingredients (in order of appearance):

-cooking oil (e.g. canola, olive)

-powdered or minced garlic

-diced onion

-diced vegetable(s) of choice (e.g. bell peppers, tomatoes, zucchini, and/or yellow squash)

-canned enchilada sauce or 1:3 ratio of whisked red chile powder:water

-sea salt

-cumin

-(optional) Mexican oregano

-(optional) cheese (e.g. quesadilla, asadero, or other)

-1:2:2 ratio of corn:masa:water

-pinch of baking powder

Directions:

Add cooking oil, garlic, and onion to a cast iron skillet or Instant Pot with “saute” function until onions begin to become translucent (~5 mins).

Add vegetables of choice and saute for 5 mins more.

Add enchilada sauce or pre-mixed red chile powder and water to stew-like consistency.

Add salt, cumin, and Mexican oregano to taste (oregano is listed as optional as its flavor can be a little strong for some).

If using cheese, sprinkle a layer of cheese over vegetables and sauce.

Blend corn and part of water reserved for masa until liquefied in a blender or food processor. Whisk the rest of the masa, water, and a pinch of baking powder to the blended corn until it forms a dough-like consistency.

Pour blended masa, water, and corn mixture in a thin layer over cooked vegetables in cast iron skillet or Instant Pot.

If using an Instant Pot, cook on “Manual” at high pressure for 20 minutes before quick releasing the pressure. If using a cast iron skillet, cover the skillet and move to a 375F oven for 30 mins. Note: oven-baking will give this pie more of a cornbread consistency and less of the traditional steamed tamale texture created by the Instant Pot. Try both and see which you prefer!

Enjoy!

Contains: (optional) dairy

Curtido Cole Slaw

Ingredients:

-1:1 ratio of apple cider vinegar:water

-sea salt

-thinly sliced onion

-grated carrot

-(optional) diced jalapeno

-powdered or minced garlic

-pepper

-(optional) Mexican oregano

-cumin

-finely chopped cabbage

-cilantro

-(optional) sugar or honey

Directions:

1. In a saucepan, bring apple cider vinegar and water to a boil with a pinch of sea salt. This can also be done with a glass bowl in the microwave.
2. Pour the warm vinegar mixture over diced onions, grated carrot, and jalapeno if using.
3. Add garlic, pepper, oregano, and cumin to the bowl and allow to cool for at least 30 minutes. This part of the recipe can be stored in the fridge for up to 48 hours if preparing beforehand.
4. Before serving, add the cabbage, cilantro, and a pinch of sugar or honey and toss to combine.
5. Enjoy! Curtido can be enjoyed fresh or cold. Store leftovers in the fridge for up to a week.

Contains: no common allergens

Seafood Puttanesca

Ingredients:

-cooking oil

-powdered or minced garlic

-diced onion

-canned tomato puree

-cherry tomatoes

-sea salt

-black pepper

-frozen seafood mix defrosted in fridge overnight (or fresh shrimp, calamari, and scallops)

-capers

-olives

-(optional) marinated artichokes

-boxed pasta of choice

-parsley

-(optional) crushed red pepper flakes

Directions:

1. Add cooking oil, garlic, and onion to a cast iron skillet or Instant Pot with “saute” function until onions begin to become translucent (~5 mins).
2. Add tomato puree, cherry tomatoes, salt, and pepper and allow to simmer for ~10 mins, mashing tomatoes with a spatula or wooden spoon if desired.
3. Add defrosted seafood, capers, olives, and artichokes (if using) and cook for 5 mins more.
4. In another pot, boil a generous amount of water and a small amount of salt before adding pasta of choice for 8-10 minutes. Drain before serving.
5. Top pasta with seafood mixture, garnishing with fresh parsley and crushed red pepper flakes before serving.

Contains: seafood

Addendum: Harm Reduction Guidelines for People with Eating Disorders During COVID-19

These harm reduction guidelines were adapted from Yale University’s COVID-19 Guidance for Substance Users During COVID-19/Coronavirus. The purpose of these “recovery-neutral” guidelines is to help anyone with disordered eating minimize the exacerbation of ED behaviors and side effects during the COVID-19/coronavirus pandemic. “Recovery-neutral” does not mean pro-ana/pro-mia. These common-sense guidelines are inclusive towards people in and out of recovery to help reduce harm and encourage universally positive practices for good health.

What is COVID-19?

COVID-19, or coronavirus, is an illness that can cause respiratory infection leading to secondary health problems. It’s usually mild and most people recover quickly, but it can be very serious for people with stressed immune systems or underlying conditions, so it’s important to stay informed and prepared.

COVID-19 is spread from person to person by coughing or sneezing and getting exposed to droplets that have virions (virus particles) in them. There are no known risk factors that appear to make a person more or less vulnerable to getting infected with the virus, but people with compromised immune systems may suffer more severe symptoms. The main risk is close contact with someone who has it.

What are the symptoms of COVID-19?

The main symptoms might feel like the flu or a really bad cold:

• Fever
• Cough
• Shortness of breath/difficulty breathing
• Fatigue
• Muscle or body aches
• Headaches
• New loss of taste or smell
• Sore throat
• Congestion
• Nausea/vomiting
• Diarrhea

These symptoms typically show up between 2 and 14 days after you’ve been exposed to the virus.

How can I prevent COVID-19?

• Wash your hands often with soap and water for at least 20 seconds. Using an alcohol-based hand sanitizer can also kill the virus.
• Avoid close contact with people who are sick. Keep your hands away from your eyes, nose, and mouth.
• Practice social distancing. Avoid crowds, separating yourself from the people around you by at least 6 feet. Social distancing does not mean emotional isolation! Read on to learn how video calls, texts, and creative board games online can help you stay connected.
• Stay (or get) physically healthy. If your eating disorder has compromised your physical health, you may be at an increased risk of experiencing more severe symptoms if you contract COVID-19. It is never too late to begin practicing healthy habits to improve your immune system and overall physical health.

What’s not helpful during COVID-19?

There is a lot of misinformation from various news media surrounding coronavirus. Some of this misinformation can be particularly harmful to people with disordered eating who may have pre-existing anxiety related to perceived food contamination. It is important to choose high-quality sources of information when educating yourself. Stick to .gov sites like https://www.cdc.gov/coronavirus/2019-nCoV/index.html when educating yourself on the most current regulations and recommendations. Let’s clarify some of the most common misconceptions that may interfere with your mental health:

Fear: going to the grocery store will make me sick.

Fact: by going during off hours and maintaining social distancing, it is highly unlikely that you will catch COVID-19 at the grocery store. Standard precautions like wearing a mask and wiping down your cart with an alcohol-based sanitizer may help put your mind at ease. "As a good friend used to say, the risks of not eating [anything] still outweigh the risks of eating," the food science specialist Don Schaffner says[3].

Fear: eating food from a grocery store or take-out restaurant will make me sick.

Fact: according to Dr. Ian Williams, chief of the Outbreak Response and Prevention Branch of the US Centers for Disease Control and Prevention,"There is no evidence out there that [COVID-19 is] foodborne-driven or food service-driven. This really is respiratory [spread by coughing]. At this point there is no evidence pointing us towards food [or] food service as ways that are driving the epidemic[3].”

Fear: eating food prepared by someone else in my household will make me sick.

Fact: if your household is self-quarantined and no one has exhibited active symptoms, the risk of contracting coronavirus from someone in your household is extremely low. Coronavirus cannot spread except through direct or indirect contact with an infected person[1]. If having someone else prepare your food helps support you during mealtimes, don’t stop this type of family-based meal support due to coronavirus-related concerns.

Fear: if the gyms stay closed for months, I will get fat/weak/useless (insert “ED-voice” pejorative here).

Fact: while your old exercise routine may have been disrupted by the mandated closure of public and private gyms, there are still many ways to stay active in your own home or out-of-doors. Having to adapt your exercise routine does not automatically mean you will get fat/weak/etc. If you notice a particularly loud “ED-voice” monologue in this regard, see Chapter 7 for more on how to refocus your attention away from such negative messages.

Even people without eating disorders are reporting fears related to perceived food contamination during this historical event. If anxiety-driven comments from someone in your household are triggering, remember that facts fight fear. You may not be able to change your loved one’s opinions (and would be hard-pressed to try), but you can manage your own anxiety by disputing beliefs with evidence-based information. See page 25 of this handbook for more information on how to dispute unhelpful beliefs.

If I’m feeling sick, what should I do?

Stay home if you are sick. If you don’t have a place to stay, try to minimize close contact with other people. Monitor your fever at home and avoid others for at least 24 hours after your temperature returns to normal. If you have to be around other people, wear a mask if you have one so that you don’t infect others in your household.

If you self-quarantine, attend to your physical and mental health. Ensure you have access to basic necessities to help you stay calm and comfortable (e.g. food, hygiene products, medications, finances, entertainment, etc.).

If you are feeling sick, call your medical provider before driving to the clinic to see if it would be better to seek care or stay home and rest. It is best to avoid using the urgent care or emergency room for minor illness or injury to preserve these resources and minimize your risk of contracting COVID-19.

Note: if you are experiencing a life-threatening medical emergency, always call 911 immediately!

How will COVID-19 affect my eating disorder?

There is no way to say for sure how COVID-19 will affect your eating disorder. As of October 2020, most states are re-opening on staged or variable timelines. Many recommendations for decreasing the spread of COVID-19 can make balanced nutrition and emotional hygiene more challenging. For example, feelings of isolation are a well-known factor that increase relapse risk for people in recovery from anorexia and bulimia[1]. Stay-at-home recommendations can also disrupt regular physical activity, which may interfere with positive mood-states and/or increase relapse risk for people with binge eating disorder[2].

If you are in recovery, know that relapse is not inevitable! Whether or not you are in recovery, there are several steps you can take to preserve your emotional and physical health during the pandemic:

• Connect. In order to prevent feelings of emotional isolation as a result of social distancing, reach out regularly to friends and family members through text, phone, or video call. You can even play board games or card games online for free through websites like: http://playingcards.io/
• Ask for help. Especially if you do not have a good support network of friends and family, consider reaching out for professional help, or temporarily increasing your level of care. Many treatment programs and other professionals now offer virtual visits to meet the needs of those who may need extra support at this time. (More on virtual recovery coaching at: www.drmylessandovaldpt.com)
• Share free peer support. There are a number of free online peer support groups that offer voice and video meetings including “Recovering Joy: peer support for a resilient recovery”: a free guided meditation and discussion group focused on creating a joyful life in recovery every Thursday 8-9:30PM ET:

• one-click Zoom link: https://us02web.zoom.us/j/177914252
• Zoom app from phone: meeting ID 177 914 252

Facebook community: www.facebook.com/groups/rec0veryistheway 

I hope to see you on Thursday! If you don’t click with the group, check out some of your other options for peer support here: https://www.recoveryanswers.org/resource/peer-based-recovery-support/

Whatever group you connect with, make sure the community feels supportive and motivating, not hopeless or defeatist!

• Limit news consumption. At a certain point, reading more news makes you no safer and only contributes to feelings of anxiety. Consider limiting your consumption of COVID-19 news briefings to once daily for fifteen minutes.
• Stay (or get) healthy. Preserve or adapt established habits to help you stay physically healthy. For example, physical activities like moderate yoga can be practiced at home instead of in a studio. Maintain a consistent sleep-wake schedule and practice good sleep hygiene, limiting “screen time” an hour before bed. Continue taking your medications as prescribed, ensuring you have a 90-day supply if available.

Help! I can’t find my safe foods at the grocery store!

Stock up. If your current diet is limited to a number of safe foods that you are confident you will not binge on, consider stocking up on “safe foods” in order to ensure that you do not run out of foods you feel comfortable eating. If they are perishable, freeze some for later in case they sell out at your local grocery store.

Help! I can’t stop bingeing on my food supply!

Avoid bingeing. Try not to stock up on foods that you are likely to binge on. If you find that you struggle not to binge on a specific food, consider temporarily purchasing it only in single-serve quantities. Your preferred brand or type of food may not always be readily available during this time, but there are plenty of other choices that will meet your needs. The exact timeline is uncertain, but remember that these shortages are temporary; your brand will not be sold out forever. Thinking with a “scarcity mindset” is particularly problematic for people with eating disorders.  

Help! The gym is closed and I don’t know what to do!

Get flexible. Stretching helps, too! Although flexible thinking can be challenging for people with disordered eating, we have to be willing to adapt our exercise habits if our old routine depended on gym access. Whether or not you decide to go back to the gym will depend on your individual comfort level and the regulations and recommendations in your area.

If exercise is part of your regular routine, consider your options for moderate physical activity during shelter-in-place:

• Online yoga:

• Yoga with Adriene (positive & beginner-friendly): https://www.youtube.com/user/yogawithadriene
• Leigha Butler (positive & best for intermediate): https://www.youtube.com/user/butlerl2
• David O Yoga (calming & various levels): https://www.youtube.com/channel/UCdidjk9lSYhLqUMrYjYhpLA

• YouTube exercise videos
• Outdoor activities

If you’re not sure whether your old gym routine was more helpful or harmful, consider writing a Cost-Benefit Analysis on your exercise habits. See page 10 for more detailed instructions on how to complete this activity. This can be a good opportunity to reflect on what has been working or not working in your life.

Whether or not you are in recovery, you may find yourself in a situation where the only foods or activities available to you are outside your comfort zone. Know that you are capable of stretching the boundaries of your recovery. Don’t be afraid to ask for help if you need it!