It often takes time for people with eating disorders to seek and engage in treatment. It’s important to manage your expectations when your loved one enters treatment. The ‘stages of change’ cycle can be helpful to understand more about where your loved one is in terms of thoughts around behaviour change, and what to expect. It highlights that although recovery is possible, it’s not straightforward, but involves ups and downs.
Setbacks can be used as learning opportunities, and can help your loved one to keep moving in an upward spiral towards recovery.
The cycle can also be helpful when thinking about where you are in terms of your own views about change. Often carers report being in ‘action’ stage from the beginning of treatment, while their loved one is at the ‘pre-contemplation’ stage.
This can cause conflict, so it is important to try to be compassionate in understanding where your loved one is at.
Although the ‘stages of change’ cycle is one way of thinking about recovery and behaviour change, it’s important that the person is both encouraged and supported to make changes early on in treatment.
The Cycle of Change, adapted from work by Prochaska & DiClemente (1983)
More about each stage:
Often people enter treatment while in the pre-contemplation stage – this means that they are likely to be in denial that there is a problem and may be hostile to the suggestion that anything is wrong. Someone may stay at the pre-contemplation stage for some time; however, your loved one’s clinician will work to manage this and help them to still make changes early on in their treatment. If your loved one is in pre-contemplation mode, it is likely that there will be greater resistance to treatment, and you may have to take more of a direct role in supporting them with making changes.
As a carer, the pre-contemplation stage can be both scary and frustrating. Try to stay calm when speaking to your loved one. Remember that people can and do recover from eating disorders, even though that feels quite distant during this stage. It can be beneficial to gently try to help your loved one realise the need for change, and to see the bigger picture of what is going on for them. For example, someone may feel that the eating disorder is giving them control, so it could be useful to softly challenge this by questioning whether it is them or the eating disorder in control.
During the contemplation stage, your loved one will recognise that there is something wrong. They may begin to consider making a change, but not yet be ready to take this further and take action. This can be confusing for them as they can begin to see the benefits of making a change, yet the eating disorder is serving a function and they are not ready to let this go. Often the eating disorder is thought of as the person’s friend and something that is keeping them safe, so letting this go of this can be extremely scary.
It can be helpful to encourage your loved one to share their thoughts and feelings about the eating disorder with you, and let them know you hear what they are saying. If your loved one considers the illness a friend, you may also wish to gently explore how good a friend it is if it is harming them and resulting in their life being consumed by the upsetting thoughts and feelings. Try to encourage and strengthen your loved one’s beliefs that there is a need for change, and let them feel in control of this decision. It can be tempting to impose your own beliefs on why they need to change, but this can lead to increased resistance from the eating disorder.
During the preparation stage, your loved one will decide that they want to change their behaviours, and will be getting ready to do this. They might look to you for support and encouragement on the next steps to take.
Here, you could help them to make a plan for how they are going to make these changes and what next steps are needed (for example, the introduction of feared foods or reduction in certain behaviours). Talk to your loved one about how you can best support them with these steps and what to do if they are struggling to implement these changes. Reassure your loved one that you will be by their side and are there to support them so they are not doing this alone.
During the action stage your loved one will begin to make the changes needed for recovery. They may be engaged in treatment and working hard to change their behaviours.
It is likely that these changes will be difficult for your loved one to make and will result in distressing thoughts or feelings. Some people have reported feeling conflicted between the voice of the eating disorder and the part of them that wants to recover. Remind your loved one that you are there for them, and offer reassurance in those times when they feel conflicted about what to do.
During the maintenance stage, your loved one will work on bringing what they learn in treatment into everyday life, and learn to form an identity away from the eating disorder. They are likely to plan for what to do if they feel that things are slipping in the future, and how to recognise this.
It can be helpful to discuss with your loved one any potential triggers for the future, and to support them in learning to live their life away from the illness. It may be helpful to reflect on any changes to your relationship throughout the recovery process and think about how these may be addressed going forward. It is important to remember that although setbacks may happen, people can and do recover from eating disorders. Take time to work on your own self-care too; supporting a loved one with an eating disorder is not easy.
Recovery is not a linear process, and it is common for setbacks (commonly referred to as lapses and relapses) to occur. Lapses tend to refer to small setbacks or slips, whereas releases tend to refer to a bigger setback in terms of thoughts and behaviours. Although these can be extremely difficult to watch, setbacks can be an opportunity to learn (learning points) and move forward in strengthening recovery. Despite how it may feel, your loved one is never back to the start.
During this stage, it can be helpful to let your loved one know that you are there to support them and that these setbacks are a normal part of the recovery process. Setbacks do not mean that recovery is not possible – sometimes people have to go through this cycle of change a few times before they are able to maintain their recovery.