I called this section “brain” for alliterative purposes – I couldn’t think of another word even remotely related to emotions/psychology beginning with B, to go with body and behaviour! Apologies in equal parts for obsessiveness/lack of neuroscience.
In this section I am not going to talk about specific difficulties like body image or trauma recovery, I am going to focus on psychological topics and tactics which can be generalised to help with many triggers for eating disordered behaviours: finding and keeping motivation in recovery, fighting eating disordered thoughts, dealing with distressing emotions without using self destructive behaviours, and therapy and support. This was the hardest section for me to write because it’s not as easily quantifiable as physical or behavioural recovery, so let me know what you think 🙂
Finding a reason to recover
If you are recovering on your own (or trying to maintain your weight after leaving IP) the most important thing to hang on to and nurture is your motivation for doing so. It is often helpful to try and work out what your barriers to recovery are. If there was nothing holding you back, you would be better by now! People with eating disorders are not vain or stupid, they are suffering from a serious illness, one of the symptoms of which is a fear of what they imagine recovery to be. I wrote a post on what I saw as my own obstacles to recovery when I started trying to get better, and about eight months later I wrote two replies (1, 2) to that post, going through those fears point by point and describing how things actually turned out in recovery. My obstacles were all things that I felt had contributed to my anorexia at some point. Eating disorders have a large biological component and between 50-80% of the risk for developing anorexia is genetic, but psychological triggers and maintaining factors also play an important part. I knew my triggers needed to be addressed if I was going to stay in recovery this time.
There was a theme to my obstacles, and writing them down helped me realise that I was hanging on to my anorexia partly through a sort of misguided survival instinct. Everything I was worried about, when extended to the worst case scenario, ended in me not being able to cope and going crazy or killing myself. I was anxious in particular about the depression which had plagued me for over a decade coming back (and not being able to cope), about losing support from other people if I didn’t look ill (and not being able to cope alone), about losing my number one coping mechanism (and not being able to cope without it), about being desensitised to being at a low weight so potentially hating how I would look at a healthy weight (and…I’m sure you get the point!), and mostly about putting a huge amount of time and effort into rebuilding my life, only for something out of my control to go wrong and ruin it all again. All this meant that I got stuck in a state of ambivilence for years – I clung on to my eating disorder because it felt like the only safe, consistent, predictable thing in my life. As long as I was restricting and underweight I had rules to live by, a reason to get up in the morning, short and long term goals, I didn’t care that I was socially isolated because I was too tired and obsessed with the eating disorder to want to be around other people, I had a source of self esteem and achievement from losing weight, I had an identity, and I had a group of other eating disordered people online who I could talk to and was guaranteed to have something in common with. I had meaning, purpose and direction. My life made sense. I wasn’t even scared of dying – I knew it might be an end result of my anorexia eventually, but I felt like at least by starving myself I was partly in control of my death, it wasn’t just going to come out of the sky and land on me while I was having a good time. I was doing it to myself, it wasn’t being done to me.
Basically it came down to this: if I don’t hope, I can’t be crushed. If I don’t want or need anything or anyone, I can’t be disappointed. If I am already close to rock bottom, nothing that life throws at me can hurt me, because I don’t really have all that far to fall. I was so scared of putting effort into recovery and finding that it was worse than life with my eating disorder, that I ended up paralysed by fear and just carried on the way I was. At least I had the anorexia – if I let go of that, I wouldn’t have anything. Apathy, ambilivence and fear can keep people stuck in their illnesses for their entire lives.
What changed in my head to help me make the initial decision to start trying to recover was hard to pin down. I wrote about it here almost a year later, and this next bit is from that post:
I wanted to avoid hospital and I was becoming angry at what the illness had done to my health, my personality and my life, but the real thing that got me was the sudden understanding that this could be my life. Doctors and hospitals and relapses and weight loss and wasting muscles and being bruised by my mattress when I slept and walking and walking and having to sit down on the pavement when my blood pressure crashed and not being able to hold a conversation with another human being because my head was too full of food and my body too empty of it and regrets and anger and self hatred and forgetting that I was ever a person, that I was ever interesting and fun and creative and that I was ever loved or could love or do any fucking thing other than starve myself. I don’t know the details of treatment in other countries really but in the UK is it easy to maintain a dangerously low weight without any interference from the professionals. It is possible to survive at a very low weight for a very long time. I would probably die at the age of 50 rather than 80, but no one would try to stop me. That was the lowest weight I had been in the 12 years I’d had an eating disorder and I was a mess, but I could stay at that weight for decades longer and no one would care. No one would save me from myself. I was essentially alone. It was my life and my body and that was it.
I honestly think that thought alone was all the motivation I needed to start detaching myself from the anorexia. I was sick of being controlled and trapped and paralysed with fear. I am not saying I’d reached rock bottom physically because I don’t think that is essential for recovery and I remember being aware that I could continue to lose weight, I wasn’t scared of dying then and I could have kidded myself that I would avoid hospital somehow. But I chose not to go over the edge, because I didn’t think I would be able to come back by myself if I did, and I didn’t want to live my whole life that way. I grabbed that moment of clarity and held on to it as tightly as I could.
You need to find your own initial motivator – anything will do to start off with, however small. A lot of people think they need to wait until they feel ready to recover, but in reality nobody feels ready when they start. For me it was a huge leap of faith: I was terrified of the idea of letting go of the anorexia and was pretty much convinced that my depression and anxiety would overwhelm me if I wasn’t starving myself. However, it had gotten to the point where my life was completely empty – I felt like I had no reason to live. For some reason, instead of becoming suicidal as I had in the past, I decided that if I had nothing to lose I might as well start from scratch and make a genuine attempt at recovery. And by that I meant getting to a truly healthy weight, cutting out all ED behaviours, going back into therapy and trying to sort out my PTSD, teaching myself new healthy coping mechanisms, and generally doing everything I could think of that would give myself more of a chance of fully recovering. I didn’t want to go at it half heartedly just so I could say I tried and it didn’t work out, I wanted to give it a real shot. I gave myself a provisional five years. I told myself that I would do everything I could to try and recover in those five years, and if I was still a suicidal wreck at the end of that time then I would let myself give up. That was actually a really calming thought at the time – bearing in mind that I was really ill and not really thinking logically! – but now I am two years into my recovery attempt, I don’t need to tell myself this anymore. I’m doing well 🙂
Other helpful motivational exercises I’ve used in the past are pros and cons lists (of staying ill, of beginning to recover, of being recovered) and writing two letters to myself imagining that five years have passed and I am a) still ill and b) recovered.
Maintaining motivation and fighting eating disordered thoughts
Recovery from eating disorders is hard. I’m not going to lie to you, there are incredible amounts of anxiety and discomfort involved. I frequently felt trapped, depressed, scared, helpless, hopeless and like I generally wanted to rip my skin off and run away in the opposite direction as quickly as possible. I was not able to recover because I found it easy. I was able to gain weight because I finally recognised that it was my illness causing these things – I was not really hopeless and powerless, I was just ill. I also recognised that giving in to the eating disordered thoughts made things a hundred times worse. Say you have a bad day, you decide to give yourself a ‘day off’ and restrict a bit to make yourself feel better. How are you going to feel the next day? Will it be easier to get back on track – or harder, because your eating disorder will want you to keep up that degree of restriction? This is important: putting recovery off makes it harder, not easier. Taking days off makes it harder. Telling yourself that it’s acceptable to use ED behaviours occasionally to make yourself feel better makes it harder.
Eating disordered behaviours are exactly the same as any other addictive behaviour. They make you feel calmer in the short term, but in the long term they are decreasing your tolerance for distress and leaving you able to cope with less and less anxiety without using your behaviour. The only way to give yourself a chance to genuinely feel better in the long term is to recover. It feels like hell when you’re going through it, but that is not a sign that you will always feel that way or that you’re not cut out for recovery, it’s a natural part of learning to deal with distress without self destructing. Everyone in recovery goes through it at some point. I can’t emphasise this enough, because so many people seem to blame recovery for their anxiety. It gets to a point where you find yourself thinking of the eating disorder with longing, remembering how much ‘better’ you felt when you did what it told you to. But that’s all an illusion. You felt better because eating disordered behaviours make people numb, not because they are a cure for anxiety or depression. The only way to be genuinely OK is to recover.
As I mentioned on the behavioural page, I developed my own ways of maintaining my motivation. I carry around my recovery revision cards still, and sometimes I really do need to read through them to calm myself down. I also keep a copy of my list of things to remember pinned to the wall by my bed. Fighting eating disordered thoughts is hard because they can seem like things you believe yourself, and before you know it they can have you doubting yourself or changing your behaviour. One exercise which started to change this for me was from a group at the EDU I used to go to a couple of years ago. We had a list of things like family, friends, social life, career, education etc, and we had to write down what we valued in each of those areas. So for example, in terms of friends I would say I wanted to be loyal, tolerant, supportive, fun, etc. Then we had to decide how close we were to living to these values at the moment. Of course, when I was very underweight I was irritable, stressed, obsessed with food, exhausted all the time and frequently felt about as antisocial as you can get without turning into an axe murderer! So the anorexia took me further from my values, not closer to them. I wrote about this exercise in this post.
Something that a lot of people do in the mistaken belief that it will help is try to argue or reason with their eating disordered thoughts. My previous therapist taught me that this is actually not very helpful. She said she understood how that seemed like arguing should work, but by arguing with those thoughts you are effectively putting the idea in your head that there is some truth in them, that they are worth arguing with, or that they can be reasoned with. Even worse, it keeps the thoughts in your head, because you have to think about them even more to work out ways of counteracting them. It makes you obsess over them for longer and in more depth. And if you start a screaming match with them in your head, usually they just scream back louder. It’s like trying to deal with a toddler having a tantrum: you will not calm or quiet them down by shouting back at them because that increases their anxiety and anger and to be honest, there is no logic in the world that will get through to a 2 year old having a screaming fit, they just want their way and want it now. Eating disorders are like that. If you give them an inch they take 30lbs! If you actually engage with them, even to try and disagree with them, they somehow manage to worm their way deeper into your mind. I tried to fight them off like that when I was younger and generally, half an hour later I would find myself convinced that actually I needed to lose weight rather than gain!
I learned a different way of coping with my eating disordered thoughts, similar to the method Jenni Schaefer describes in “Life Without Ed”. She learned to think of her eating disorder as being like an abusive boyfriend. When she had an urge to restrict or binge and purge, she would tell herself that this was ‘Ed’ being unhelpful again, disagree with him and try to disobey him. I wasn’t keen on the abusive relationship model, but I did manage to generalise the basic idea to fit my personality better. Because I’m quite a scientific person, I started practising telling myself that my eating disordered thoughts were symptoms of anorexia, not indicative of reality. So, for example, if I was having a really hard day and felt like giving up, quite often I would notice thoughts like these going through my head: things were much easier when I was anorexic, I can’t do this, it’s too hard, I don’t want to recover, I want to lose weight again, I can’t cope with gaining anymore, and so on. When this happened I would tell myself that everyone who has an eating disorder thinks things like this sometimes, it’s not something that’s true, it’s just a symptom of the illness. Basically I stopped believing a large proportion of my thoughts!
This was made a little easier by the fact that a few years previously I had finally taught myself to deal with panic attacks. This involves sitting down somewhere and telling yourself that you are OK, this is just a panic attack, it’s an overexcitable fight-or-flight reaction, it doesn’t mean you are in danger or you’re going to die. You teach yourself not to buy in to the thoughts, and to keep yourself emotionally calm until the physical symptoms die down. I still get anorexic thoughts now sometimes, but I don’t get anxious or upset over them, because I see them as the product of my illness, not as facts. I separate them from myself and discard them. This didn’t feel like a ‘fake it till you make it’ approach to me because I wasn’t pretending that these thoughts were not distressing or that I should ignore them because they were stupid, I was accepting that they were in my mind, stepping back from them and seeing them for what they really were, and letting them go. This was probably the most helpful skill I learned this time in recovery.
Dealing with emotions
People often see their eating disorders as coping mechanisms, and whilst this is not the whole picture it is definitely true that eating disordered behaviours are very effective at relieving distress in the short term. They make things ten times worse in the long run, but knowing that is not much good when you are climbing the walls NOW. I always thought when I was a teenager that one day something would click into place in my head, I would be ready to recover and I’d be able to cope with life just like that. That didn’t happen. What I found out was that people who recover don’t find it easy or suddenly discover brilliant coping skills they never knew they had before – they have to learn them as they go. This feels akin to trying to learn how to swim when you are stuck in the middle of river rapids and about to drown. As I keep saying though, it is possible.
When I started gaining weight I didn’t have the concentration to read or watch movies, for obvious reasons I couldn’t go to the gym or for a run, I didn’t have any local friends and I was rather dreadful at asking for help, however bad I felt. So when I felt like I was going crazy with anxiety, I had to learn how to deal with it fast. Some of the things I tried were:
* Watching Friends or Scrubs on DVD – the episodes are short so they weren’t too tough to concentrate on
* Baking cakes (not such a good idea if you have problems with bingeing and purging and are having a bad day)
* Looking through self help/workbooks for exercises that might help
* Making jewellery
* Going for short walks/stomps!
* Going into town and wandering around the shops (compensating for calories burned afterwards, of course)
* Listening to music
* Being around my family rather than hiding in my room (sometimes made things better, sometimes worse, but anything is worth a try)
* Blogging! Planning future blog posts as well
* Writing down how I felt, what I thought might be causing it and brainstorming solutions
* Talking to friends online
As I started getting better the range of activities I could do increased dramatically. I rewarded myself for every whole BMI point I gained, and one of those rewards was a car. Having my own transport for the first time was great, I discovered that I really enjoy driving and it made developing my social life much easier.
Sometimes distraction was what was needed, and all of the above helped me at various points in my recovery. However, I also needed to learn to tolerate anxiety and distress. While I was ill nothing really affected me emotionally. It wasn’t until about six months into recovery that emotions other than anxiety started turning up again. Sometimes the most healthy thing you can do at that moment is cry, and I was so scared of letting that happen because every time I felt sad I was reminded of how awful the worst of my depression was. Everyone feels like crap sometimes but it’s particularly frightening learning to cope with that without overreacting if you know exactly how low a person can get. It took me a few months of forcing myself to stay calm and repeating to myself over and over that sadness does not equal depression before I started trusting that my low moods would pass. I had a few weeks in September-October last year when I felt like I was never going to stop crying, I didn’t want to do anything other than hide in my room and I did give in to self harm urges once, which made me feel so angry and hopeless because I hadn’t done that for two years. But after a while I realised the problem was that I didn’t know what to do with myself now I had gotten to a healthy weight at last. My big project was over, I felt like I had lost all sense of purpose and direction in my life. I was really scared that after doing all this work in recovery, living without my eating disorder was going to prove too hard to handle.
Funnily enough, once I realised this and started telling myself that I wasn’t helpless or hopeless, of course it was scary but I could carry on taking things at my own pace, my mood lifted again. I think this is a really common experience, I have heard so many people say that things got really, really tough just before they started getting better. The next few months were still difficult – I had some pretty incredible hormone-induced mood swings 😉 – but they slowly started getting easier, and now I think I’m definitely over the worst.
Distress tolerance and emotion regulation are two modules in Dialectical Behaviour Therapy which can prove particularly useful to people who are in recovery from eating disorders or any addictive behaviour, and when I was feeling really bad I found this workbook very helpful. Distracting yourself and learning to sit with distress is hard, but the more experience you gain of dealing with bad days, the more confident you become in your ability to cope.
Therapy and other support
I think it’s possible to recover without therapy, but personally I have found it very valuable. Having said that, there are some weird people out there. When I was still very underweight and looking for a therapist in April 09 one woman I saw told me she didn’t know anything about BMI, but that I shouldn’t put pressure on myself to gain weight, just make sure half of my meals were green leafy vegetables. That is pretty much the opposite of helpful for an anorexic. My poor digestive system was having enough trouble without me attempting to eat a kilo of lettuce every day! As a teenager I was also told by a social worker that if I really wanted to lose a few pounds, I should go on a healthy eating diet with my mum. I was at my adult height then and my weight was at the lower end of the healthy range, but took me the best part of 10 years before I allowed my weight to get that ‘high’ again. Not so smart, people.
There are some great therapists and doctors around though. If you are in the UK and can’t find adequate NHS support for whatever reason, the British Association of Counselling and Psychotherapy is a brilliant resource. BACP is an organisation which therapists can join as proof that they have accredited qualifications and practise ethically. I found my current therapist through their “Find a Therapist” search tool. The largest eating disorder charity in the UK is b-eat, and their website has a helpfinder directory specifically for finding eating disorder treatment. I am not sure how this sort of thing works in other countries, but the recovery website Something Fishy provides a comprehensive treatment finder which mostly covers the USA, but also contains listings for Canada, Australia and other larger countries.
When I first started going to therapy at 16 I was under the impression that my psychologist would say something which provoked an amazing insight and I would magically be better. I think I was probably hoping for a little bit too much there! After a few years of seeing various people I realised that actually, I knew exactly what the psychological triggers for my eating disorder and the things keeping me ill were. I didn’t have particularly bad self esteem, I didn’t hate my body and I was quite assertive. I was in a happy relationship and doing well at school. But I was still anorexic. It was all very confusing. I was a non fat-phobic anorexic, which in my case meant that I didn’t feel like I was overweight or needed to lose weight to be attractive, I was hanging on to my anorexia because restricting made me feel numb, calmed my anxiety, flattened out my mood swings and gave me something concrete to focus on – food, weight, calories.
Of course, these were not the CAUSES of my anorexia, they were triggers, which is a different thing – the causes are biological, but the triggers are often environmental or traumatic. Theoretically speaking, if you don’t have the genetic predisposition for anorexia starvation will not be comforting, it will be excruciating. For me, it felt like I was permanently on tranquilisers. There were psychological issues that needed to be addressed, but to start off with I used my therapist as support for the difficult process of becoming physically stable. I would ramble on about my week, get ideas on ways to cope or possible solutions for problems. Later on, once I was at a healthy weight, I started tackling my post-traumatic stress disorder, which was triggered by my being raped at 18. At the moment I’m not really focusing on any one thing, I’m in a rambling period again 😛 but whether I have any big pressing issues or not, I find therapy useful because it’s a place where I can talk about things without being judged, and it’s a way for me to calm down for an hour a week and think about how I am doing and what – if anything – I need to change.
Utilise any support you can find if you are recovering in the community, whether that’s family, friends, a local ED support group, your GP, a helpline like the Samaritans, whatever. One thing I would be careful about is – and this probably a bit of a strange thing for a blogger to say – the internet. There are a lot of ED support forums out there, and some of them are not terribly helpful. I belonged to several over a period of nine years. The one I stuck with the longest was not pro-anorexic, but it also didn’t have an emphasis on recovery. I made some amazing friends there, some who I hope to be in contact with for the rest of my life. However, being there also made me desensitised to the reality of eating disorders. I didn’t feel like I was all that ill because other members were much more underweight than I was and still alive. I didn’t believe that full recovery was possible because here were thousands of people with eating disorders who lived with them and didn’t seem too bothered by that. I was reluctant to think about recovery partly because all my friends were ill, and I didn’t want to lose the initial thing I had in common with them. I basically saw eating disorders as no worse than, say, binge drinking or smoking heavily. I knew it would probably cut a couple of decades off of my life but I thought that was a small price to pay, because I was very entrenched in the illusion of safety and comfort my anorexia provided. It took me a long time before I realised that actually, eating disorders are illnesses. You don’t control them, they control you. They kill people at all ages and all weights. And full recovery is possible. I don’t mean living at a healthy weight and still hating your body, or purging sometimes, or overexercising, or restricting ‘just a bit’. I mean working towards and eventually becoming physically and mentally healthy, not using eating disordered behaviours and not wanting to. I am not an anorexic in a weight restored body. I am recovering from all aspects of anorexia, and in doing so I am discovering that the world and my life are so much more fulfilling and interesting without my eating disorder.