Phase 1: Symptom Development

Phase 1 is the period of time during which the person is experimenting with food- and weight-related behaviors. This phase usually lasts from six months to one year. At the start of this phase, the person does not necessarily have an eating disorder; however, if the behaviors persist, by the end of the phase she/he does. The primary determinant of whether a person develops an eating disorder or not is if the food- and weight-related behaviors yield secondary gains, or benefits. If they do, she/he begins to need her/his behaviors and does not feel capable of changing them.

The process by which the emotional need for the behaviors becomes intertwined with the use of the behaviors as a weight control device is what we term fusion. It is important to note that fusion is a progressive process that takes place throughout the period of symptom development. By the end of Phase 1, the person with the eating disorder has given her/his food- and weight-related behaviors great importance in her/his life and is no longer able to distinguish when she/he uses them for emotional reasons from when she/he uses them for weight management.

Phase 2: Denial

Phase 2 begins when the food- or weight-related behaviors are no longer just behaviors but have taken on the thought patterns and psychological characteristics that meet the criteria for diagnosis of an eating disorder. As previously mentioned, this usually occurs between six months and one year after the onset of the behaviors. The essence of denial is that the person does not perceive that she/he needs the behaviors, viewing them only as a weight control device. Implicit in the person’s denial is the fact that she/he has no conscious awareness of the underlying psychological, relational, and emotional issues that are related to the behaviors.

This phase may last from six months to thirty years or more. During this time the eating disorder behaviors are usually fairly stable. What brings a person out of denial is unclear. We encourage others to confront someone they know in a loving and gentle way if they think she/he might have an eating disorder. Each confrontation chips away at the wall of denial. For some this wall is thicker than for others. Thus one never knows the potential impact such a confrontation may have. Increasing media attention may help as well. It is now more difficult to have a closet eating disorder due to increasing public awareness and continual reminders in magazines and on television.

Phase 3: The Need for the Behaviors

Phase 3 indicates the period in a person’s recovery process during which she/he is ready to learn about recovery and behavior change but is not ready to alter any food- or weight-related behaviors. It begins when the person starts treatment. This usually happens voluntarily, after the emotional and physical distress caused by the eating disorder behaviors becomes, at least for brief periods, greater than the benefits.

This phase is characterized by preoccupation with and obsessive thinking about food, weight, hunger, and body image. On the Recovery Model graph, the line indicating frequency of behaviors during Phase 3 is straight because the person with the eating disorder has a relatively stable, high frequency of behaviors. The person’s obsession for knowledge about food, nutrition, and weight is actually very therapeutic at this point. It provides motivation for her/him to learn the principles that she/he will need to apply later on in order to experience complete recovery.

We define a need, as used in this context, as a psychological adaptation or adaptive mechanism that, although indirect, works to some degree to provide security for the person with the eating disorder. At the same time, unlike more healthy, adaptive techniques, the need has secondary consequences; including potential health problems, further deterioration of relationships, and affective instability.

A person who develops an eating disorder has, for various reasons, not mastered certain developmental tasks, thus lacking healthy, direct ways to perform basic life functions including: developing intimate relationships with other people, establishing sexual boundaries with herself/himself and others, feeling personal security in relationships, and managing and expressing intense feelings assertively. She/he finds in her/his eating behaviors an indirect way to perform these functions.

For example, she/he forms a primary relationship with food rather than other people, uses her/his body weight to set limits in sexual situations or relationships, uses her/his behaviors with food to indirectly make her/his wants and needs known in her/his relationships and anesthetizes intense feelings with her/his behaviors.

Phase 4: Decreasing Need and Habit, Cessation of Food- and Weight-Related Be Behaviors and Recovery

Phase 4 reflects a spontaneous change in the person’s food- and weight-related behaviors and marks the person’s entry into the Decreasing Need for Behaviors phase. This spontaneous change usually occurs when the person has resolved enough of her/his psychological issues to experience a decreased need for her/his behaviors. There are two indicators of this transition: 1) The person with the eating disorder voluntarily explains to the nutrition therapist the decreasing need for changing her/his behaviors (e.g., “I need to or want to gain weight because I want to be able to concentrate better in school”), and 2) there is a marked increase in high-quality protein intake (this is not a sudden but rather a gradual increase).

This change is usually short-lived and rarely, if ever, leads to cessation of behaviors in and of itself. It serves as an indicator that the person is ready to participate in the cognitive restructuring concerning food, nutrition, and weight that is the essence of the nutrition therapy that takes place during this phase. Within this phase of the recovery process, the increasing and decreasing frequency or behaviors are helpful in isolating specific psychotherapeutic issues that require further discussion with the person with the eating disorder.

It is important to note that some people reach the point where there appears to be a decreased need for their behaviors but still do not make any alteration in them. In this situation, it is the responsibility of the therapist or nutrition therapist to evaluate whether the person has progressed sufficiently through the psychotherapeutic process to make changes in behavior. If not, there needs to be more work in therapy before she/he will be ready to make behavioral changes.

Sometimes an issue never before discussed, such as sexual abuse, surfaces at this time. If the treatment team and the individual believe she/he has sufficiently resolved her/his therapeutic issues, this would be a time to explore with her/him whether she/he is focusing on behaviors for some other reason. Behaviors continue during this phase due to a combination of continuing need and habit. The more progress the person makes in therapy, the more the need aspect decreases, so that eventually, only the habitual portion of the behaviors remain. Although still difficult, it is easier to change behaviors at this point than when they were needed emotionally.

Cessation of food- and weight-related behaviors occur before recovery is completed.By this time, the person with the eating disorder is no longer abusing food or weight-related behaviors, is able to maintain a healthy body weight, is eating in a way that is flexible, balanced, and does not call attention to itself, and is exercising moderately.

Now is the time that any remaining psychological, relational or emotional issues need to be addressed and resolved. For most people, there are a number of issues that do not surface until the person is no longer engaging in her/his behaviors. If treatment stops at this point, the person will be vulnerable to relapse in the future.

Thus absence of behaviors does not indicate the end of treatment. All it means is that the person is no longer using food- or weight-related behaviors in an unhealthy way. It is the responsibility of the therapist to discuss with the eating- disordered person what issues remain and why it is important to complete this part of the treatment. It is extremely important to emphasize this point since there is tendency to stop treatment prematurely once the behaviors are under control.

Once recovery is achieved, it is important that the person with the eating disorder continue therapy for a period to discuss issues concerning prevention of relapse and to help her/him weather the first few emotional storms or stressful life events. The frequency of appointments usually decreases to once or twice per month during this time.