Stages of Bulimia Recovery

by | Mar 28, 2024 | Bulimia | 0 comments

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If you think you may have an eating disorder it is important to seek advice from your GP or health professional. The information in this blog post is intended for information purposes only and is not a substitute for personalised clinical advice. 

Wooden steps and green foliage to represent the steps towards bulimia recovery

What are the stages of bulimia recovery? Is it possible to fully recover from bulimia? And how long will it take?

If you are just starting to think about recovering from bulimia you probably want to know what the road ahead might involve.

In this post I will talk about how we define bulimia recovery, the stages of recovery, how people move through the stages towards recovery and why a full recovery is very possible.

Defining bulimia recovery

Before we can talk about the stages of bulimia recovery, we need to know what recovery looks like. Bulimia recovery is not well defined by therapists or researchers. Academics often use different definitions, and this can make the research findings confusing and leave people feeling unsure about whether a full recovery is possible.  

Nevertheless, there have been recent attempts to define recovery and 4 key areas have been identified:

Physical recovery

Physical recovery from bulimia includes resolution of any negative health consequences of the eating disorder. Bulimia can cause a wide range of physical health problems such as, bowel dysfunction, electrolyte imbalance, and bloating.

Physical recovery from bulimia might therefore include the return of normal bowel function after laxative misuse or potassium levels, that are disrupted by frequent vomiting, returning to the normal range.

Physical recovery usually occurs hand-in-hand with behavioural recovery as we cannot recover physically if we are still bingeing and purging.  

Doctor and patient discussing test results of physical health consequences of bulimia

Behavioural recovery

Behavioural recovery happens when someone is able to stop the key behaviours associated with bulimia. For most people this means that they have stopped bingeing and purging (i.e., laxative misuse, vomiting, fasting, diet pills).

In research studies, some studies define behavioural recovery as mostly stopping these behaviours. Where someone does not regularly binge or purge, but may occasionally do this, for example in response to a very stressful event.

My personal opinion is that this should be categorised as partial recovery. We should be optimistic and have high expectations for recovery, you shouldn’t expect to have to “manage” bulimia for the rest of your life.

Psychological recovery

Psychological recovery is the component of recovery that is most often overlooked. Many research studies have excluded psychological recovery even though most people with bulimia would consider psychological recovery to be the main issue.

Couple sitting on a couch with a therapist discussing bulimia recovery

Psychological recovery involves addressing how people think and feel about their eating pattern, weight, and body image. For example, someone might have changed their eating habits but still struggle with guilt about eating or hate how their body looks.

Not achieving psychological recovery can lead to depression and anxiety, as people challenge themselves with behavioural change but are not experiencing psychological relief from eating disorder symptoms.

Psychological recovery tends to happen after physical and behavioural recovery. It seems that these are necessary, but definitely not sufficient, for full psychological recovery. Without psychological recovery people are vulnerable to resuming dieting, binging and purging.

Duration

As well as there being no consensus on the definition of recovery, there is also no agreement on how long people should be in recovery for before being classified as “recovered”.

Research studies have used various recovery criteria ranging between 2 and 12 months. People who have recovered from bulimia describe recovery more as a process rather than a destination and highlight key themes such as self-acceptance and hope. Therefore, it’s likely that definite cut-offs aren’t helpful in understanding what recovery is.

Stages of bulimia recovery

Categorising bulimia recovery stages

Bulimia recovery can be categorised into three main categories: active bulimia, partial recovery, and full recovery:

Active eating disorder

If you are in active bulimia, it means that you meet the full diagnostic criteria for bulimia. You may not feel ready to recovery or might be in the process of preparing for change.

However, you are still binging and purging, and experiencing considerable distress about your weight, food and eating. You are probably also struggling with physical health consensus like bloating or low potassium levels.

Doctor wearing white with a checklist and a pen for diagnosing bulimia

Partial recovery

Partial recovery is defined as having recovered physically and behaviourally, but not yet in psychological recovery. In partial bulimia recovery you will have stopped binging and purging and are no longer experience physical symptoms.

Even if you have stopped the most visible behaviours associated with bulimia, you may notice that you are engaging in more subtle activities. For example, you might still be keeping a strict eye on the foods you allow yourself to eat or weigh yourself very often.

Partial recovery is often the most difficult phase of recovery because you are challenging the eating disorder every day but continue to experience lots of distress about eating and body image.

Partial recovery might be a stage on the way to full recovery, but sometimes people find they get stuck in this stage. People might get stuck if they’ve not had access to the right (or any) therapy, if they are not quite ready to give up the whole eating disorder, or if there are lots of external stressors that are making it difficult to focus on full recovery.

Full recovery

In full recovery you will have recovered physically, behaviourally, and psychologically. People who have recovered from bulimia describe this stage as having “freedom” with food.

In full bulimia recovery you will be able to eat without feeling extreme guilt, feel confident that your weight will not spiral out of control, and have developed a neutral and accepting position in relation to your body.

Happy woman who has recovered from bulimia, pouring a drink for family

Stages of change in bulimia recovery

We have talked about what recovery is, and the stages of recovery, but how do people move through the stages? The stages of change model by Prochaska & DiClemente (1983) provides us with a framework for understanding how people move towards recovery.

To help illustrate how this process works in practice I have included a case study, Hayley.

Hayley is 31 and has had bulimia since she was in her late teens. She grew up in a small suburban town in Hertfordshire and has two younger brothers. Hayley first started to pay attention to her body when she was 11 and moved to secondary school. She developed relatively early in her class she saw herself as fat compared to her friends. She started dieting when she was 13 and started binging and vomiting when she was 17.

Cycle of change infographic for stages of recovery from bulimia

The Cycle of Change, adapted from work by Prochaska & DiClemente (1983)

Precontemplation: “I don’t have a problem”

Precontemplation is the stage of recovery before people agree or realise, they have a problem. If you are reading this, you probably aren’t in precontemplation.

People in the precontemplation stage do not see their eating pattern as problematic and therefore it might be the people around them (e.g., family, friends, colleagues) that are the most worried.

Bulimia might not always be visible to people around you though, so they might not even be aware that their loved one is struggling.

When Hayley was 17, she didn’t see her eating as a problem with eating. She definitely did not like bingeing and felt incredibly guilty afterwards. But she believed that vomiting was an effective way of getting rid of the food and she wasn’t concerned about the health effects.

Sometimes Hayley would also make herself sick after eating “fattening” foods like takeaway pizza, even if this wasn’t part of a binge. Part of Hayley was pleased as she felt she had found a way to eat foods she liked without gaining weight.

Contemplation: “I think I might have an eating disorder”

During the contemplation stage people start to believe there is a problem but are not yet ready to make any change. If you are in this stage of recovering from bulimia you might feel very conflicted about the idea of getting better.

Repeated cycles of bingeing and purging can become physically and emotionally exhausting. You might have believed that you were once in control of your eating but increasingly feel that you are trapped in this pattern.

On the other hand, you may not feel ready to give up dieting or worry that if you tried to recover from bulimia, you would gain lots of weight. Bulimia might also serve a function for you, for example coping with intense emotions or a history of trauma.

At age 20, after 3 years of bingeing and purging, Hayley started to feel like her eating may be a problem. She used to think that she could stop bingeing and purging if she chose but now, she was bingeing and purging every night.

Hayley could no longer hide her eating disorder from her parents, and they were extremely worried. She felt extremely guilty about this and wished they didn’t know.

Part of Hayley was worried about her future and whether she would permanently damage her health. After a gap year she decided to train to be a nurse and hopes to work with children once she qualifies.

But another part of her was adamant that she couldn’t let herself recover at her current weight and believed if she could lose 5kg she could think about recovering then.

Preparation: “I want to recover”

In the preparation the person has decided that they want to recover and are now making plans to change. If you are in this stage, you might be looking up bulimia online, looking for a therapist, or speaking to your family or partner about how to get support.

You may still feel conflicted about recovery. Sometimes people feel they really do want to get better, but they are not confident in their ability to do so. You may experience a definite “turning point” and want to recover, but many people decide to take the leap despite having some doubts still.

Woman research eating disorder recovery on laptop with notepad

Hayley is now 29. She has graduated university and has been working as a nurse in her local paediatric hospital for the past 5 years. Hayley loves her job, but it is also very stressful, she works long hours and needs to remain focussed for long periods of time. She has also moved in with her boyfriend Ben, and they have recently got engaged.

Hayley’s bulimia has fluctuated over time, sometimes she has binged and purged daily, sometimes it is only once a week. Currently she is back to bingeing every day. Ben knows about the eating disorder, but he isn’t sure how best to help.

Hayley decides that it is worth trying to get better properly, she wants to enjoy her wedding, she knows her eating disorder is giving her brain fog at work and she wants to be well enough to have children of her own in the future.

Action: “I am actively working on recovery”

The action stage consists of making the necessary steps to move towards recovery. This can look different for people depending on their circumstances but might include talking to your GP, meeting with a therapist, seeing a dietitian and following a meal plan, and implementing regular eating.

Recovering from bulimia can be really difficult. There will be days where you binge still, but during this phase these episodes can be used to understand your eating disorder and make plans for how to tackle things in the future.

You may still feel conflicted. As you work hard in therapy or on changing your eating, you should see a reduction in symptoms. This often gives people a sense of hope that change is indeed possible and pushes them to keep going.

Friends having a picnic outside in summer

Hayley speaks to her GP who refers her to her local specialist eating disorders team. They do an assessment and diagnose her with bulimia. It feels strange to her to receive the diagnosis. Even after years of struggling, part of her worried that she wouldn’t be taken seriously.

Whilst Hayley waits for therapy, she meets with a mental health nurse who supports her with a meal plan, and some build some coping skills.

Hayley then starts CBT-E for bulimia. After a month of therapy Hayley has only binged twice, and none in the past 2 weeks. With her therapist Hayley explores the origins of her struggles with body image and self-esteem.

She starts asking loved ones for support when she needs it, and practices soothing and distraction techniques for times when she gets the urge to binge.   

Maintenance: “I am sustaining recovery”

In the maintenance phase of change people are working on maintaining the changes they have made to their eating and integrating these new skills into daily life. The eating disorder related thoughts and feelings have improved, and things are generally moving in a positive direction.

In this stage of bulimia recovery, you might be reconnecting with the things that are important to you, and making a plan for how to deal with any setbacks that might come up in the future.

Hayley has now had 20 sessions of therapy and has two follow-up sessions coming up over the next few months. She hasn’t binged in several months now, is starting to trust her body more and know that she can eat regularly without her weight spiralling out of control.

She is nervous that her wedding in 6 months’ time will throw off her recovery, but she is determined to keep going. Together with her therapist she makes a relapse prevention plan, and she has a joint session with Ben to share the plan and reflect on her progress.

Relapse & setbacks

Recovery almost always includes some setbacks. This could be a few bad days, or a more prolonged period of relapse. Whilst these can be very difficult times, they also provide information and can be useful learning points.

Has work been too stressful? Have you been skipping meals (intentionally or unintentionally)? Do you need to reach out and ask for help with responsibilities at home?

Therapy session to analyse bulimia recovery setback

Hayley is now 31 and recently found out she was pregnant. She is very excited to be having a baby and is well supported by Ben. She is also extremely nervous about the upcoming changes to her body. Hayley notices that she has started restricting her breakfast portions again and skipping some snacks.

Hayley takes the plunge and lets Ben know what is going on. They book an appointment with her midwife who refers her to the specialist mental health midwife. They also revisit her therapy blueprint and Hayley shares the strategies she finds most helpful. Together they create a supportive plan to help her manage weighing during pregnancy and focus on her excitement for her new baby.

Termination: “I am recovered”

This is the final stage of change. It describes a period of time with no eating disorder behaviours or associated thoughts or feelings. Recovery no longer feels like something that needs to be actively managed and you are confident that, even if something difficult were to come up, you wouldn’t return to the eating disorder to cope.

The new coping strategies have become largely default modes of being. Meaning they are somewhat automatic and feel natural.

At age 36 Hayley feels she has fully recovered. She has given up dieting and no longer thinks about whether or not she should try to lose weight. Her daughter is now 4 and Hayley is pregnant with her second child.

She feels confident she can cope with the changes in her body and has a genuine appreciation for the amazing feats her body has accomplished in creating two lives. She no longer finds herself triggered when other people talk about weight, and she is looking forward to her future as a family of 4.

How long does bulimia recovery take?

The length of time it takes to recovery will vary significantly depending on the person. Some people struggle with eating for years and even decades before seeking support. Whereas some people receive support within a few months.

Once you are in treatment, it’s recommended that you receive about 20 sessions of therapy spread out over approximately 20 weeks. In my experience therapy provides the foundation for a long-term recovery, and that full and lasting recovery is a gradual evolution that develops over time.

Can you fully recover from bulimia?

People often talk about bulimia recovery as something you “manage” for the rest of your life. I firmly believe that this does not have to be the case.

We know from research that people do go on to live full lives without an eating disorder, including a full psychological recovery.  About 45% of people with bulimia will make a full recovery, 27% will make significant improvement (but may experience residual symptoms), and 23% struggle chronically.

You might feel dismayed or optimistic reading these figures. The important factor to consider if how much you throw yourself into treatment. The more you can do this, the more you will get out of it. You can completely recover from bulimia, and this is a realistic goal for most people.

Two happy friends lying on the ground together in summer

References

Bardone-Cone, A. M., Hunt, R. A., & Watson, H. J. (2018). An overview of conceptualizations of eating disorder recovery, recent findings, and future directions. Current psychiatry reports20, 1-18.

de Vos JA, LaMarre A, Radstaak M, Bijkerk CA, Bohlmeijer ET, Westerhof GJ. (2017) Identifying fundamental criteria for eating disorder recovery: a systematic review and qualitative meta-analysis. J Eat Disord. 5(1), 34.

Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. Guilford Press

Mander, J., Wittorf, A., Teufel, M., Schlarb, A., Hautzinger, M., Zipfel, S., & Sammet, I. (2012). Patients with depression, somatoform disorders, and eating disorders on the stages of change: validation of a short version of the URICA. Psychotherapy49(4), 519.

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 psychology51(3), 390.

Statistics for journalists. BEAT. (n.d.). https://www.beateatingdisorders.org.uk/media-centre/eating-disorder-statistics/


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About

Welcome. I'm Dr Jenny Davis, a Clinical Psychologist with a special interest in eating disorders. I'm passionate about helping people recover and build a healthy relationship with food. 

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