The work towards full recovery: school, exercise, appetite, relapse-prevention and the rest (Phase 2)

Last updated on October 11th, 2021

This is a section from Chapter 10 of 'Anorexia and other eating disorders – how to help your child eat well and be well'

This chapter really matters as this phase of the treatment is often badly done. If you're tired of reading you can hear me cover the main bits in my Bitesize audios. You can also jump onto my next 'Phase 2′ workshop':

Once eating and weight gain are secure, what else do we need to do? How do we guide our children towards normality and autonomy? What is too much, too soon? What safeguards are needed as we experiment?  We look at school, exercise, holidays, recovering ‘normal’ eating, behaviours, beliefs and body image, preparation for college, relapse prevention, and total recovery.

Steps to independence and total recovery

Anorexia: should my child go to school?
Return to school?

So far we’ve addressed the first phase of treatment, where we take charge of meals and of any behaviours that affect our child’s health. The ultimate aim is for our children to have age-appropriate independence and to be free of the eating-disorder mindset. This takes practice, experimenting, monitoring, and correcting. Both body and mind need time for healing and consolidation.

Someone with a broken leg can’t and shouldn’t run as soon as the cast has gone. Likewise, there has to be a period of learning, practicing and consolidating after refeeding. Here are some milestones to recovery, or reasons why your child may be stuck:

  • Her weight or fat/muscle ratio might need to be higher (her personal needs – not BMI charts – are what matters)
  • If you were refeeding for weight recovery, she’ll have learned that eating without restriction causes weight gain. Now she needs to experience that when she eats freely (and without compensating with exercise), her weight stays stable.
  • She needs to experience that it’s safe (and lovely) to eat a wide variety of normal foods in normal (or festive) quantities.
  • She needs to experience the pleasure of exercise that is not about body shape or weight-control.
  • Her metabolism may not return to normal for a while, so she may need to continue eating similar amounts as she did when weight gain was the goal. Indeed she may still be very hungry and she needs to experience that eating when hungry is safe.
  • She may not have normal satiety cues for a (long) while, so she needs guidance to choose sufficient quantities. Otherwise she may involuntarily lose weight.
  • She may need to maintain the snack habit, because a long gap between meals can re-activate the eating disorder.
  • She needs time to experience that her body shape is fine, that it doesn’t define her, and that there’s a wonderful life to be lived beyond the world of shape and of food rules. She also needs time to develop wisdom and resilience in a world that is weight and diet-obsessed.
  • If in spite of all this she continues to suffer from anxiety or depression, or if she has had traumas in her early life, she may now benefit from psychotherapy.
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You’re in charge of your child’s independence

Too often, treatment stops shortly after refeeding or weight-recovery. Therapists discharge the child from care, as though there was no more work to be done. Parents dutifully back off. Youngsters leave home. When the person goes downhill, people call it ‘relapse’, when actually the treatment was never completed.

You should continue to be in charge, but now you are experimenting with returning small amounts of independence to your child. Compile a list of all the ‘normal’ things that have been derailed by the illness and work your way through it. For instance you might ask your child to choose between two foods, building up to the day she can choose from a restaurant menu. You could let her select her snacks. If a main course is accompanied by peas, you could have her help herself to an adequate portion of those, while you serve the rest. You could ask her if she fancies a second helping. At first, you will be watching closely. Keep your authority to guide and correct. If the outcome is negative, no great harm will have been done. Take back control and retry days or weeks later. Don’t blame your child. Keep your cool. It was just an experiment.

Some children need parents to stay in charge of some areas a long time. If they’re young, there should be no pressure to rush the process, and indeed some children show little desire to make their own food choices. Be guided by their needs, capabilities and emotional age more than by their calendar age. At the other end of the spectrum there are youngsters who demand more freedom than they can safely handle.

Don’t assume your child can suddenly handle any situation wisely. Don’t assume they will tell you the truth if they fail. Early on your child needs to know they cannot misuse their freedom, because others are monitoring for you. For instance I describe further down how meals in school can be supervised. Later you can take more risks (such as allowing meals out with friends) while monitoring that weight, behaviours, beliefs and mood are improving. Eventually, your monitoring will be done discreetly, with a light touch, so that your child can take pride in their autonomy and in their ability to take good care of themselves.

Practice ‘normal’

This whole phase of treatment and consolidation rests on principles of exposure (Chapter 9). Behaviours become normal and safe as they are repeated and the brain rewires itself. If your son or daughter is soon due to leave for college, you may speed up their autonomy by systematically working on exposure to everything they will need to do independently. If they can’t keep up, better you find out now than after they’ve left. […]

Too soon or too fast

Much of what I’ve described is covered by Phase II of Family-Based Treatment (FBT). It’s shocking how often children are discharged from treatment upon weight-recovery, as though this phase didn’t exist. Another common problem is when therapists rush through Phase II without consulting the parents, pushing for the child’s independence too early or too fast. Yet according to the FBT manual, if the patient returns to dieting or loses weight, therapists should swiftly motivate parents to re-establish control over eating. So in principle you’re on the same team. Sometimes a therapist doesn’t have the complete picture. If they’re not consulting you, perhaps all they see is a smart kid who presents well and who complains that their parents are overbearing. I suggest you meet the therapist alone and describe your child’s behaviours.

What’s too early? According to the FBT manual, Phase II can’t begin until the child’s weight has reached a minimum level, and until parents report no significant struggles with meals, and demonstrate a sense of relief that they can manage the illness. […]

[Jumping to another section of the chapter…]

What to do about school?

Schools have a huge role to play. I’ll describe teamwork between parents, clinicians and school, from the early refeeding days all the way to recovery.

Is school a mood-booster for your child?

Your immediate priority in the early phase of treatment is nutrition and health. If school gets in the way of that, then your child shouldn’t be in class. As soon as possible, though, we want our children to be engaged in normal life and friendships, as this is part of the treatment too. Usually this requires the school to join in the teamwork.[…]

[Jumping to another section of the chapter…]

‘Health promotion’ in schools: why, oh why?

I’ll try and keep this short or I fear it will turn into a rant.

Schools commonly have ‘healthy eating’ and exercising on their curriculum. Food is labelled as ‘healthy’ or ‘junk’, ‘good’ or ‘bad’. You can never eat lean enough, you can never exercise too much. Thinness is holy, while a large body is a sure sign of sloth and bad health. Schools are forced by government to weigh children, who get the idea that a low number is best. Parents receive letters informing them their child is ‘obese’ and should lose weight, purely on the basis of a statistical BMI calculation. Clinicians and parents often lament how health promotion messages are a top precipitating factor for a child’s eating disorder.

In school my daughter has been told that sweets are bad (yet received them as a reward for good work). She’s had to keep a food diary, to read nutritional labels, to count dietary fat units, and to watch a ‘gross’ liposuction video. I bet you have your own horror stories.

What are your options? […]

[Jumping to another section of the chapter…]

Rule-based or intuitive eating?

It’s likely that your child will need rule-based eating for at least a year after you hand over control to them. During that time, neither their biology nor their mind are capable of intuitive eating. We know it can take a year for the hormones that regulate appetite to stabilise after a weight-loss diet (a physiological reason why diets don’t generally work in the long term). In addition, your child’s mind needs time and practice to be aware of hunger and fullness cues and to trust them. While the eating disorder raged, all their brain knew was to fight the body’s signals. So rules for balanced, regular, sufficient eating are essential at first, and gradually you will see which can safely be shed or lightened. Ideally rules will morph into rough guidelines, and in some years your child may realise that their intuition is a reliable friend. Don’t rush it. Treat it like a series of small, low-risk experiments. If something goes wrong, go back to what worked, and wait a while before trying again. […]

[Jumping to another section of the chapter…]

Fixing your child’s mindset

You are probably familiar by now with how our children improve as we help them through their fears and get them to practice ‘normal’. As healthy behaviours are repeated over and over again, the brain rewires itself, making those behaviours the new normal. It’s like ever-deepening tracks in the snow. And at the same time the body and brain are getting the message that the period of famine (or irregular nutrition) is over, which allows normal functions (like hunger and fullness cues) to come back online. All this takes time. It’s rare for an eating disorder to disappear as soon as there’s weight recovery. […]

[Jumping to another section of the chapter…]

Relapse prevention, plans and contracts

When my daughter was discharged at age 12, we discussed relapse prevention. As she never wanted to have anorexia ever again, she easily embraced these precautions: […]

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Safeguards as your child leaves the nest

Is your child ready to leave home?

Is your child’s recovery stable enough for him to safely leave home? Is the treatment finished? How’s the preparation for independence going? Has he had, say, a good six months symptom-free? If yes, he’s probably as ready as he’ll ever be and you can be really positive. If not, the risk is that by Christmas he’ll need to be rescued back into your care and he will miss out on the rest of the year.

[End of extract from the chapter]

In this chapter:

  • What to do about school?
  • Re-introducing exercise
  • Activities
  • Eating out
  • Holidays and school trips: risky or beneficial?
  • Rule-based or intuitive eating?
  • When to ditch the scales?
  • Addressing depression, OCD and other anxiety disorders
  • Trauma and re-engaging with life to the full
  • Normal teenage behaviour or eating disorder?
  • The balance of autonomy and containment
  • Caution versus your child’s self-confidence
  • Fixing your child’s mindset
  • Towards a relaxed body image
  • Letting time do the healing
  • Dealing with relapse
  • Events that rock the boat
  • Relapse prevention, plans and contracts
  • Prepare your child for independence
  • Safeguards as your child leaves the nest
  • Is there such a thing as total recovery?
  • What’s the future like for the parents?

* Go to: Table of contents *

* See also: Guidance for schools *

* See also: School trip or Summer camp flowchart *

* Next: Chapter 11: Parents, friends, family and work: help or hindrance? *

And here are some more resources for you:

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