What Does the Mando Method Mean for Independent Recovery?

My last post presented compelling evidence that the Mando method, a treatment which focuses on normalising eating behaviours, works better than CBT for eating disorders as tested in existing clinical trials. This may be partly because almost all existing trials employ laughable definitions of remission and recovery and stop long before participants could realistically be considered stably healthy. But it may also be because the constituents of the Mando treatment that are different from CBT are substantially enhancing its efficacy. In this post, prompted by a reader’s question, I ask what the efficacy of the Mando method means for you if you’re recovering alone without the benefit of a Mando clinic or other therapeutic support for weight restoration.

The main elements of the Mando method are: the Mandometer, which progressively normalises your eating speed and your fullness signalling; rest in a warm room for an hour after eating; and no structured exercise. And because this is a clinic where all food is prepared for you and you eat at set times, you’re also eating ‘normal’ foods at ‘normal’ times. This sounds pretty different from a possible method I’ve described in previous posts (like this one) for starting recovery from anorexia without formal therapeutic or medical support, which can be summarised as: add 500 kcal to your daily intake, and to begin with, don’t worry about changing anything else.

Eating Behaviour or Bodyweight?

What the differences seem to come down to at a theoretical level is a focus on normalising eating behaviour (in the Mando method) and a focus on normalising bodyweight (in what I’ve outlined). The Mando team make clear that their assessment of the evidence favours behavioural normalisation over bodyweight normalisation: their view is that the psychological problems associated with eating disorders are independent of bodyweight per se, and they cite evidence such as the fact that psychological symptoms can be severe, and very similar to anorexia, in bulimia when eating behaviours are dysfunctional but bodyweight is ‘normal’ (e.g. Södersten et al., 2008, p. 458).

When it comes to empirical evidence specifically for the treatment of restrictive eating disorders, however, we don’t yet have detailed enough evidence to separate out the significance of changes to bodyweight and to eating behaviour. In essence, what we know so far is that treatments which normalise neither of the two fail and treatments which normalise both of them succeed. In one sense this is simply a restatement of the fact that in restrictive eating disorders, both eating behaviours and bodyweight are always distorted: by definition, getting better means making what is dysfunctional functional again.

And arguably, there’s no evidence to support the normalisation of eating behaviour independently of bodyweight because beyond a certain point, it’s impossible. If you want your eating behaviour to be truly healthy you have to allow your bodyweight to return to a healthy level; in other words, if you are severely underweight, you can’t eat happily and healthily. (The opposite isn’t true: you can have a healthy bodyweight but be unhappy and unhealthy in your eating habits. This, however, is often an unstable state, leading typically to changes in bodyweight. One can imagine a severe case of orthorexia where obsessively controlling an ultra-‘healthy’ diet allows bodyweight to be physically optimal while psychological suffering reaches extreme levels. But given the way most societies are these days, interpretations of ‘healthy’ are likely to tend towards ‘bodyfat-reducing’, and so to involve instability. As anyone with a restrictive eating disorder knows, it’s very hard to decide on a ‘perfect’ weight/BMI/bodyfat percentage, get there, and be happy. Because, obviously, none of those things makes us happy if we aren’t already.)

So, healthy eating behaviours and bodyweight usually though not always correlate and causally maintain each other. Because they have a feedback relationship to each other, if you change one you tend to change the other. If you want to recover fully from a restrictive eating disorder, you have to sort them both out, and the obvious recovery-relevant question is: what’s the best way of doing so? Do I start with the behaviours or start with the weight? Do I start by eating differently, or by eating more?

Eating Behaviour and Bodyweight

I think the two options aren’t as opposed as they might seem. The outline I’ve given for a possible way of starting independent recovery begins by changing the amount of food and nothing else. Other behavioural changes come later, once eating more for a while has begun to increase physical strength and mental flexibility. Meanwhile, the Mando method prioritises eating differently. But because patients are expected to eat a standard menu (of the ‘meat and two veg’ variety – plus yoghurt, sandwich, and juice for breakfast, and snacks in between) and portion sizes are increased systematically as well (to 350 g per meal over the course of treatment), eating more soon happens too. Thus eating more is part of eating more normally, and so weight gain is generated as one of its outcomes, and BMI is used as one of the criteria for remission and recovery. The Mando team are currently writing up a paper that analyses the effects of increasing portion sizes at different rates (in different clinics where they provide treatment), and their impression at this point is that a rather rapid portion-size increase is probably beneficial. In their 2008 paper (p. 449) they also emphasise the fact that people with severe anorexia can eat normal-sized portions even at a low BMI.

In both, then, the amount that’s eaten and the way eating happens both have to change, and in both they may both change fairly rapidly. So, the starting point (eat more or eat differently) can be seen as a trigger for a new feedback loop that will replace the anorexic one: weight restoration and eating habits and mood and thought patterns all reinforcing each other in a healing direction, not a destructive one. The question is, which is most likely to be an effective trigger?

What we mean by an effective trigger is bound to differ in the clinic and outside it, especially when it comes to the timescale, the complexity, and the difficulty of change.

Recovery in a Clinic and Outside It

In recovery outside the clinic, one of the most important questions we have to ask is: what changes are most likely to be sustained? We can gather all the evidence we like about the efficacy of a particular change in a clinic setting, but if it’s too complicated, frightening, costly, slow to take effect, or otherwise difficult or offputting for someone to do alone, trying to insist on its application in self-help contexts will be counterproductive. If you make a change and nothing else changes for the better, especially if it’s a complicated and/or difficult change, you’re much more likely to abandon it if you don’t have ongoing support to help you understand why and how it really is helping. (This is especially true for anorexia, where there are so many sociocultural influences screaming at us not to eat more.)

We might expect that the solutions to such fundamental questions as whether to change eating behaviours or amount of eating would remain constant across different contexts, but that intuition might not be correct. Given how powerful and complex the feedback relationships are between behaviours, bodily states, and thoughts and emotions (see here for more on this), questions about which comes first in either the onset of the illness or the start of recovery aren’t always easy or even possible to answer: does something change in your thinking followed by a change in your eating followed by a change in bodyweight? Or had you lost or gained weight for some other reason and that changed the thoughts and the behaviours? Or maybe you’d merely started eating less or more and that already changed your thoughts and behaviours even before weight loss or gain kicked in. Or maybe a mood change affected your appetite and made the rest that crucial bit harder or easier. We simplify things for the sake of making and communicating things like recovery plans, but in reality, for the bodily system itself, the lines are never hard.

Because it’s all interconnected, and because behaviour is so crucial to all those connections, I think it’s very likely that incorporating some of the Mando elements into independent recovery would help make independent recovery more reliably successful; I hope the Mando team will expand their work into this area in future.

One focal point for future research concerns specifically this question about environment: what difference it makes being in the clinic or at home. The Mando team suggest that being in a new place helps embed new behaviours, and I speculated in the Mando post on whether some aspects of environmental novelty could perhaps be recreated at home (for example by eating in a different room). The importance of environment comes into play in the treatment elements beyond food too: in the cessation of exercise and the rest in warmth after eating. Stopping formal exercise and keeping yourself warm after (and maybe also during) eating would seem like extremely sensible complements to the directly food-related changes you’ll be making if you’re recovering independently.

Meanwhile, returning to the eating itself: the way I currently see the difference in priorities between self-help and clinic treatment is that in the solo case, starting to eat *more* should come first, and eating *differently* come later.

Three Thought Experiments on Solo Recovery

To see why, try a little series of thought experiments. First, imagine starting recovery on your own, and changing nothing about how much you eat, but starting to use the Mandometer device to change your eating speed and track your fullness. What do you imagine happening? To me, it seems clear that if you’re still eating as little as before, nothing will really improve: you won’t feel reliably more full after eating because you’ll still be eating so inadequately, and even if you do eat faster that change may be sterile because there may be such long gaps between meals that hunger levels have no chance of normalising. None of the physical or psychological effects of malnourishment will be alleviated, and you might even find that an enhanced focus on the pragmatics of your eating makes you feel more obsessive not less.

Now, secondly, imagine using the Mandometer device and changing the type of food you eat and the times of day, and not the amount. It’s quite likely there would be some improvements: you’d be eating a wider range of things at sensible mealtimes and at an increased speed with an increasingly confident sense of how your satiety changes during meals. But at some point the amount will need to change too, otherwise you’ll stay chronically hungry, cold, irritable, and everything else that starvation makes you.

And thirdly, imagine using the Mandometer device and changing the type of food you eat and the times of day, and also the amount you eat. This is very likely to bring about significant improvements; indeed it does by definition, because almost everything about your eating habits has changed. The question now is whether this is feasible for someone recovering on their own to 1) initiate and 2) maintain independently.

My hunch is that trying to make this scale of changes all at once without being in a clinic or having intensive professional support of some kind is unlikely to be possible for many people. My hunch is also that a change in the amount eaten is likely to be not just the most feasible change to make independently, but also the quickest to drive initial changes that will help generate and solidify motivation. Eating normalisation in the Mando clinic tends to take 4-5 months on average. The rapid changes that a little more food can make to energy levels, warmth, sometimes mood, and so on, in a matter of days and certainly weeks, are significant in creating a sense that things are changing for the better and this really is worth carrying on with.

One Change Leads to Another…

The Minnesota Starvation Study, which I’ve discussed in detail on two occasions before (on how anorexia is a physical illness of starvation, here, and on how metabolic rate changes in illness and recovery, here), found that the physical and psychological effects of semi-starvation were profound, and improved at varying rates once rehabilitation began. Many aspects of the changes caused by semi-starvation took a long time to reverse (and the rate of improvement increased once the men were allowed to move from the controlled rehabilitation diet to unrestricted eating; see also my post on metabolic rate). But ‘recovery from dizziness, apathy, and lethargy was most rapid’ (Keys et al., 1950, vol. 2, p. 828). Not that tiredness or weakness disappeared; far from it: overall, when the men first began to eat more (in a highly controlled way) ‘the expected “new lease of life” did not materialise’ (p. 838). But these positive changes began very early on, and the emotional difficulties the men experienced during the refeeding phase were greatest for those in the two groups with the lowest energy intake, suggesting that had intake been higher for them all, earlier, many of the most pronounced difficulties could have been reduced and/or curtailed.

Overall, then, the physical effects of starvation will be alleviated and ultimately eliminated by some relationship between an immediate increase in energy intake and a long-term increase in bodyweight. These physical changes are intimately related to the psychological changes that will happen too: an increase in energy levels and body temperature with increasing sociability, for example, or increasing interest in non-food-related aspects of life. To that extent, my sense is that the Mando team’s distinction between the physiological and the psychological effects of eating more/differently is not tenable in reality, and that whenever you change something that changes either, you change the other too.

You may also find, as I and others have done, that merely deciding to eat more, and starting to, affects other aspects of food-related behaviour: a reader who commented on my original Mando post observed that merely making the decision to increase her intake by 500 kcal a day seemed to allow her to eat more quickly; and I found myself able, in my very first week of eating more, to eat new things at new times in social and professional situations that had been impossible for years, even though again all I’d committed to was the 500 kcal extra, in a very regimented form. So changing one thing can often be like pulling out a single contributor to a precarious house of cards – and although it matters that you choose well, there are quite a few good candidates in anorexia, and eating more will always be in a crucial position somewhere right near the bottom of the house.

Failure and Frivolity

Meanwhile, the other side to the question of what Mando means for solo recovery concerns the fact that discouraging any kind of eating, whether of particular food types or at particular times of day, is a risky thing when it comes to anorexia. Imagine a scenario where someone (say, me) starting recovery alone had been eating most of her daily intake late at night, and eating a mixture of very low-calorie ‘filler’ foods and very densely calorific sweet things. The Mando approach would recommend normalising these aspects by splitting the meal up into smaller amounts, and exchanging the cabbage and the chocolate bars for meat, potato, and – well, maybe still cabbage. If the person either felt unable to make those changes, or made them and failed to sustain them, (s)he would be left with feeling 1) that (s)he’d failed, and 2) that it’s counter to recovery to eat in the way (s)he was eating. Again, in the clinic this danger is less: there’s continual support on hand to make sure the new eating routines are adopted. Outside, there’s the risk of no stable new routine but now distrust of the old. Yet being OK with eating (say) sugary foods is not just important in helping ensure the iterative normalisation of bodyweight restoration and eating behaviours; it’s also an essential part of challenging the old anorexic rules.

After all, what ‘healthy eating’ means in recovery from anorexia is clearly not merely nutritional/physiological, but also psychological. It is not possible to fully recover from an eating disorder by religiously following the best nutritional guidelines available, because being fully recovered from an eating disorder means eating in ways that may sometimes be guided by the science of nutrition (bad as that science often is [Taubes, 2012]), but is usually also guided by appetite and personal preference, social and work priorities, cultural context, financial constraints, and all the rest. Knowing that it’s all right to eat whatever you eat is crucial in the early stages of recovery. Later, yes, there may be some active work needed to shift starvation-learned preferences towards greater breadth and balance – but much of this will happen of its own accord as the body leaves malnutrition further behind.

I’ve also written in another post about the importance for me, in late recovery, of little food habits that were ‘unhealthy’ in gently flagrant ways, like having a biscuit or two with tea in bed before breakfast for some months. That was good and right for me then, although and because it was never going to be a lifelong thing. (I say ‘it was never going to be’ with the benefit of hindsight; at the time, it was crucial not to put a time limit on it, not to treat it as anything other than ‘this is good’.) Learning how to allow yourself to eat biscuits in bed, or whatever your personal equivalent is, is a crucial part of the process of discarding all that anorexia means for your life.

I’m sure everyone who comes out of the Mando clinic signed off as in remission, and who gets confirmed as fully recovered five years later, and who leads a life thereafter in which eating is a source of happiness and stability, learns many such happy lessons in rule-breaking and its liberating effects. The precise timeline for doing more of this kind of rebellion, or attending more to your speed of eating speed or your feelings of fullness, or just focusing on eating more, is both only very partially understood and bound to vary depending on the individual and their context. As I’ve explained here, I’m not of the opinion that eating limitlessly from the outset is likely to be conducive to full recovery, but I do absolutely think that deliberately frivolous foody additions to a daily routine can be worth their weight in cookie dough.

Now and Forever; You and Everyone Else

In all of this, I think we end up confirming a principle that so often seems key to what recovery from anorexia is: don’t expect now to be forever. In other words, don’t expect recovery to be immediate. Or, different rules apply now from those that will later.

And there’s another central principle too, one which can feel equally uncomfortable at times: generalisations can be made, but only up to a certain point. Or: you are neither completely different from everyone else, nor completely the same. This means we can perceive layers of generality on top of which sit layers of contextual and individual variation. One of the key contextual layers must be the recovery format: solo or medically/therapeutically supported. We shouldn’t expect the optimal solutions for the two to be identical, just as we shouldn’t expect them to be unrelated. And for the solo context, other individual factors will carry more weight, because more depends on the individual: so personality variables, financial situation, living environment, other health problems, etc. will all shape what changes can be undertaken and maintained to full recovery. And of course, not least of these is the fact that an individual who has the support of a therapist, counsellor, nutritionist, or other helpful person will be able to take on different types and amount of change at different times from the person who doesn’t. There is no universal solution, but equally there are common principles that do always apply, and need to be operationalised in a context-sensitive way. Even the most systematic treatment protocol will have some degree of individualisation in some of its details.

In Conclusion

The upshot is, then: please seek out professional help if you can. Seek out evidence-based professional help if you can. And if you need some way to get started in the absence of such help, there are probably few better ways than simply starting eating more and carrying on doing so until you feel able to make other changes too.

The difference between eating differently and eating more isn’t as great as it might seem, not just because the body and its behaviours are so tightly interlinked, but because after all, eating more is eating differently – and eating differently in the way anorexia hates most. Embrace it and marvel at the new shapes and colours that come into being when you make this little turn of the kaleidoscope.