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Mary Cain. Allie Ostrander. Molly Seidel.
As these elites share their experiences with eating disorders publicly, they spark conversations—and questions—about treatment and recovery. Is eating disorder recovery possible? Yes, say experts. How? It’s complicated, especially for runners with deep-seated athletic identities and strong relationships with exercise on top of multifactorial illnesses with genetic, neurobiological, and environmental roots.
Recovery (and whether someone keeps running in or through it) depends on a variable checklist. But it’s possible.
“My participants yelled that loud and clear in studies,” says Jessyca Arthur-Cameselle, associate professor of sport and exercise psychology and co-director of the Center for Performance Excellence at Western Washington University. She’s been studying collegiate and older athletes who have experienced eating disorders (EDs) since 2007. In fact, they ask her to be sure to share what they say: “Hey athletes, you can recover. Please tell athletes it is possible, even if you feel bad right now.” She points to studies showing the progress people have made after treatment, some results even matching control groups who’ve never had an ED. She’s also witnessed full recoveries in her role as a clinician.
Among athletes she’s interviewed in research, many describe triggers in sports. Paradoxically, though, up to about half the athletes she’s interviewed in research say it was the sport that helps them recover, in particular when their training suffered and performance dipped due to their EDs.
To be clear, EDs are complex mental health issues with serious consequences, including death. Their implications span most aspects of life: physical and mental health, emotional well-being, social experiences. They exist, as diagnosable medical and psychiatric conditions, on one end of a spectrum of food and body issues. On the other end are disordered eating patterns (see: restriction, anxiety, dieting) that also pose risks.
Paula Quatromoni, registered dietitian and associate professor and chair of the department of health sciences at Boston University, teaches an ED treatment and prevention course. “The whole first half of the course is about the medical complications. I told my students, ‘My job right now is to scare you. I want you to take very seriously all of these consequences because you need to help patients and parents understand.’…They have no idea of the devastation.”
Despite common misconceptions and other barriers, the evolving field of ED recovery sparks hope and shows potential, especially for endurance athletes. ED specialists might not be able to draw a single course map for recovery, but they share insights into what, exactly, recovery takes and how it impacts runners.
Recovery is … well, it depends. In academic research and clinical settings, diagnostic criteria set medical definitions around specific behaviors, like eating and compulsive exercise. But ED experts lean towards a more holistic definition.
In Arthur-Cameselle’s research, for example, she looks at how athletes themselves define ED recovery. “It’s more than just weight and physical and behaviors,” she says. The psychological aspect, she says, seems to play an important role in recovery. Researchers are working on new ways to measure that progress.
At Opal Food and Body Wisdom, an eating disorder treatment center in Seattle, co-founder and clinical director Kara Bazzi describes recovery another way: “Having ease and flexibility with food and movement and body…An absence of fear. Even in that, the act of eating, the participation of eating, the changing that comes with eating, the changing that comes with body, the changing that can come with movement through injury or changes in one’s body…that doesn’t mean there isn’t going to be emotion, because we are emotional people,” she says.
Bazzi, like others, emphasizes that recovery is unique to an individual, especially when ED providers take harm-reduction approaches. “Some people decide that they have gotten to a place that is as far as they want to go [in recovery],” says Bazzi. For example, a person may be medically stable and not disrupted by symptoms, but might still have food rules or restrained eating.
“Even within the eating disorder field, there’s difference of opinion,” says Bazzi. “I’m very much in the camp that there is ‘recovered,’ period, done. It’s not to set an expectation or shame people for what recovery looks like and being recovered, it’s offering the hope that it is possible. That is not what everybody’s experience will be in their lifetime, but that is actually an option that is viable and realistic and feels really important.”
Quatromoni, on the other hand, says, “People don’t usually say ‘I am recovered from an eating disorder.’ They say ‘I am in recovery’ because it is a perpetual state that people move in and out of. They continue to deal with us pretty much the rest of their life, but they’ve learned how to manage the thoughts and manage the impulses. There’s so many different measures of recovery.”
When it comes to insurance companies “that pay for treatment, oftentimes people are discharged and treatment ends way before people achieve recovery. They scratch the surface of that weight restoration and they’re out,” says Quatromoni. “It’s very, very heterogeneous in terms of how complete treatment is that people get. But only one in 10 people affected with eating disorders even gets treatment. So it’s getting into treatment, but then it’s getting complete treatment, and then it’s continuing with treatment, or at least some type of support.”
Relapses are normal and expected with EDs, says Quatromoni, especially with life events like pregnancy, menopause, or ending a career. “Are you likely to re-engage with treatment? Those parameters are going to affect how recovered, or how long, a person is able to sustain a period of recovery.”
Support systems, like seeing a therapist and dietitian, and practices like journaling and affirmations can help athletes maintain recovery, Quatromoni says. In her research, she’s seen that, after treatment, relapsed patients don’t get kicked back all the way to the starting line.
Essentially, EDs are coping mechanisms, ways to deal with stress—in and out of sport. “Until a runner develops healthy coping mechanisms, which is the focus of treatment, they’re going to be vulnerable,” she says. “That’s why we always say food’s really not the problem. It’s just the symptom. It’s the thing people are trying to take control of…the competitive pressures in the elite environment ramps this up in a way that, but it’s all grounded in the social, cultural norms of our society and magnified for women. But again, men are not immune by any stretch.”
En Route to Eating Disorder Recovery
“There are so many paths to recovery,” says Bazzi. Professional treatment ranges from outpatient programs (1:1 or group work in an office setting) and partial hospitalization programs to residential and hospital-level care. Within those environments, treatment methods vary, too. Some focus on cognitive techniques, others on somatic or body-focused practices, and all of the above. Opal, for example, uses exercise and sport therapy.
While some treatment programs now incorporate exercise, this hinges on clearance from the treatment team. Registered dietitian Megan Medrano says it must be safe, medically and physiologically. At McCallum Place, for example, they don’t introduce fitness if someone is medically unstable (see: abnormal vital sign and labs), not eating or hydrating adequately, unable and unwilling to take rest days, struggling with compulsive exercise, unable to stay safe when exercising, or unable to accept limits around workouts.
The key? Finding health. As Molly Seidel, Olympic marathon bronze medalist who has struggled with an eating disorder, told Women’s Running, “That’s been one of the harder things about my story, is a lot of people want to look to these things I’ve accomplished since treatment as this success story…I think a lot of people then forget the interim, that the point of getting healthy is just to live as a human. If you’re focusing the whole time that you’re going through treatment or trying to get through mental health issues on, ‘how is this going to make me a stronger athlete,’ it’s like, no, you have to focus on just straight up being healthy first—let that stuff come after. Because that actually inhibits healing fully a lot of the time.”
Bazzi says most people at Opal start with minimal clearance for activity. “We do want them to have that opportunity to pause,” she says. “There’s so much learning to be had when you do something really different and it’s for such a brief period of time—not to be punitive but to understand the intense athletic identity,” she says, a part of targeting the underpinnings of the compulsive mindset.
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When runners struggling with EDs need to take a break from running, Amanda Schlitzer Tierney, director of The Victory Program and Fitness at McCallum Place, reframes it as a voluntary pause or sabbatical to reevaluate the value it brings to life, anticipated challenges, and sustainability of running in the individual’s athletic goals and overall life.
Returning to Running
“Once once in a solid, sustainable place in recovery, the sky’s the limit. Having a balanced relationship with fitness training and running is absolutely possible when it is integrated in a safe and intentional way with the support of their specialized treatment team,” Tierney says, alongside her team, which includes exercise physiologist Hannah Frazee and clinical and sport psychological resident Savannah Fernandez.
A prerequisite for running, says Bazzi, is enjoying it, especially at a competitive level. “Passion and joy has to be a part of that equation for it to be healthy.” So, too, does food competency and a well-rounded self-worth.
Between seeking treatment and the sky, though, is starting. ED specialists agree that this should be a team decision, even if a doctor (say, a collegiate team’s sport medicine doc) is technically the one to sign off. That means registered dietitians, therapists, and others should weigh in. Coaches and athletic trainers should be looped in, too. Quatromoni recommends using treatment contracts to get everyone on the same page.
Ever-Evolving Eating Disorder Recovery Field
More than two decades ago, when Quatromoni started working with athletes with EDs, the concept of multidisciplinary treatment teams was just emerging (Think: doctor, psychologist, registered dietitian, athletic trainer, strength and conditioning coaches, and other eating-disorder focused pros working together).
When Opal opened in 2012, it was non-traditional to let people exercise in higher levels of ED care. Since then, other treatment centers have started to offer movement, therapeutic and otherwise. Opal also reevaluated use of traditional Dialectic Behavioral Therapy and adopted Radically Open Dialectical Behavior Therapy—a shift to meet clients with overcontrolled personalities (characterized by excessive self-control) .
Also over the last decade, athlete-specific treatment programs have emerged, including Walden Behavioral Care GOALS, McCallum Place’s Victory, and EDCare’s Athlete programs. Although many health care providers are silo’d in their specialties, ideally athlete-specific programs include sport-specific expertise. As Medrano says, for example, dietitians learn in very narrow boxes, as with the niches of sport nutrition and EDs.
Many credit Mary Cain, among other elites, for pushing the conversation about eating disorders forward.
“Mary Cain did open something. Maybe we trace it back to Me Too, and athletes starting to speak up and take those risks,” says Bazzi. “I felt like I was kind of on an island for so many years trying to make things happen and then I didn’t have to try as hard anymore. It got taken more seriously and there’s more power being transitioned to athletes, with social media [and] more opportunity for a voice and maybe less fear or repercussion or more willingness to be brave,” she says. “There’s still tons of fear of what’s going to happen if I speak out.”
Same goes for Relative Energy Deficiency in Sport (RED-S), the syndrome caused by low energy availability (aka not enough food to support sport on top of daily needs). “More people know about RED-S,” says Bazzi. “That is getting disseminated more, which is wonderful, and helps with detection, identification, and is more inclusive of the genders and gets at the psychological and physiological impact.”
Tierney says ED recovery and treatment is ever-evolving. “It has been encouraging to see that there is more recognition regarding the importance for inclusivity in fitness and running spaces, an intersection of health at every size, all bodies, genders, and abilities being represented, accessibility to safe, supportive and non-judgmental movement spaces,” she says. “My hope would be that this new awareness will spark more opportunities and calls to action for greater levels of support and treatment.”
Of course, the eating disorder field faces obstacles, including lack of inclusive research, barriers to treatment, and lack of awareness, detection, and referrals. What’s more, sport-specific misconceptions—think “Lighter is faster” and “Losing a period is a sign of fitness”—fuel disordered eating and symptoms.
Quatromoni’s most pressing request is that nutrition, eating disorder prevention, and mental health be top of mind. “It’s been not even on the list and off the radar screen for way too long. And now we have an opportunity to change that and make it a part of the international conversation around what it takes to be an elite successful athlete and to get peak performance,” she says. “I think it’s an exciting time and an exciting opportunity.”