This week is, apparently, a good week for infuriating emails and blog posts. I've written about the email that had me scratching my head (or, more accurately, banging it against my desk). Now it's time to write about the blog post that has me doing the same.
Today, I read the latest blog post from fellow Psychology Today blogger Emily Troscianko, aka The Hunger Artist, who is herself in recovery from anorexia. In the title of her post, she posed the following question:
Is Anorexia a Disease, a Series of Bad Decisions, or Both? Writes Toscianko
A reader recently made a comment which prompted me to write this post. She said that 'anorexia, despite being a "disease", also involves a series of very bad decisions, for which we as the sufferers must bear some responsibility'. This made me reflect on my own experience, and the various 'points of no return' at which the development of full-blown anorexia became significantly more likely...At any of these moments - before leaving the house for school before the non-breakfast, when at the Swiss supermarket or in the kitchen on my boat in Oxford - I could have identified the danger in what I was contemplating doing, and decided otherwise. In the first of these three examples, I had the 'excuse' of really not knowing where this could lead, although I knew that lying to my family about how I was living couldn't be a good thing; but in the second two examples I knew perfectly well what the consequences would be, and went ahead regardless. Yes, numerous physiological, situational, and emotional factors were contributing in each instance to that decision - a decision is not a freely willed thought act detached from its embodied context - but I did nonetheless have the capacity to do otherwise. Whether that doing-otherwise would on its own have significantly slowed or even halted the progression of the anorexia is impossible now to say, but it's clear that all three decisions did have the opposite effect. ...Expressing personal responsibility through action against anorexia is an act of freedom and of self-understanding. The striking simplicity of what is at the heart of any such step towards rejecting anorexia - the simple act of eating - was what made slipping into illness so easy, and is now what makes climbing out of it a process that is constituted primarily of those trivial-seeming daily decisions. Sitting down now with the meal which you have planned to eat, and deciding to take the first bite, may not be an easy decision to make, but the effects both of doing so and of not doing so are very clear, and the moment at which the decision needs to be made - does this fork go into my mouth now, will I swallow now? - equally evident. All the things that have led you to be sitting here at this table contemplating this plate of food are complex and often opaque, but now that you are here, right now, you can make a good decision or a bad one, and however much an inner voice may whisper afterwards to confuse you, you know which is which.Here's the thing: anorexia isn't a choice. It's not a decision. It's an illness. Which Troscianko admits. The problem is that these types of beliefs about anorexia and recovery--that the sufferer must actively choose and want recovery--don't always lead to the best outcomes.
For years, I felt like a treatment failure because I couldn't simply make the choice to get better. At the beginning, I couldn't see that there was anything to recover from. As the years passed, I started to see that the eating disorder was becoming very problematic, but I couldn't understand why I was still stuck. After all, I didn't want to live this way, I just couldn't figure out how to untangle myself. I couldn't figure out how to choose to get well.
I might not have been able to choose recovery, but I do have to continually choose to stay in recovery. It's a recovery that, now healthy, I am capable of making. It's a choice I have to make many times each day, and will everyday for the rest of my life. I have to take responsibility for my ongoing recovery, and I have.
An eating disorder isn't an illness of bad decisions. Bad decisions are things like buying a pair of Crocs and thinking you'll look stylish. Or buying a house in 2008 thinking it will make a good investment. We all make bad decisions in lif, and most of the time they come to bite us in the ass. This isn't to say that the innocent-seeming decisions we make in the course of everyday life have nothing to do with whether or not we will develop anorexia. The question to ask about some of my seemingly insane ideas and decisions during anorexia is this: was I actually capable of behaving differently? Not in the metaphorical or existential sense; if you look on paper, of course, I could have put food on my plate. But in the thick of the terror and the throes of anorexia, could I have actually done so? Most of the time, I would say no.
Researchers have found that, in the brains of people with active anorexia, reasoning abilities are significantly impaired (
McCormick et al., 2008 ). Which means that the ability of someone with an eating disorder to be able to make rational decisions like eating more, not throwing up, or going into a hospital program pretty limited. It's not impossible--I've known many people who have done the hard and heroic work of having to choose recovery.
Still, current treatment systems for eating disorders (where they exist) are predicated on the patient's ability to choose recovery. "If you don't want to get better," patients are told, "then we can't help you." Of course, everyone's job would be lots easier if eating disorder patients wanted to get better, just as everyone's life would be easier if cancer cells stopped multiplying, psychotic patients stopped hearing voices, and a diabetic's pancreas started producing insulin again. The difference is that
we don't view these failures as willful behaviors. We don't sit around and wonder whether it was a bad decision on the part of your lung cell to start dividing and not stop. Or whether someone who is acutely psychotic should try and stop paying attention to those imaginary idiots giving them directions. We understand (okay, at least some of us do) that this is just the limitations of the illness.
If people with anorexia could simply stop making the bad decision of not eating, then it wouldn't be an illness and there wouldn't be a million-dollar treatment industry.
The problem with believing that anorexia is a choice is that we leave sufferers to
die alone in their apartments after years of illness . We discharge long-term sufferers to either
figure out how to live with their illness or die . We tell them
it's their choice whether or not to use behaviors . These are the bad decisions, not the eating disorder itself.
I'm not saying that people have no responsibility for their health, nor that people can't choose to recover. The thing is this: we shouldn't rely on it, nor should we expect it. Someone who is drunk can't drive properly, and we know this. We don't expect someone who is slurring their words after 10 beers to be able to drive a car. They might be able to get home safely. But we still tell them to call a cab. It's like that for eating disorders.
The real bad decisions, in my mind, are in the hands of treatment providers who expect that their eating disorder patients are fully competent and capable of making good decisions. Maybe they are, maybe they're not. But the desire to recover shouldn't be necessary for treatment.
Today, I read the latest blog post from fellow Psychology Today blogger Emily Troscianko, aka The Hunger Artist, who is herself in recovery from anorexia. In the title of her post, she posed the following question: Is Anorexia a Disease, a Series of Bad Decisions, or Both?
Writes Toscianko
A reader recently made a comment which prompted me to write this post. She said that 'anorexia, despite being a "disease", also involves a series of very bad decisions, for which we as the sufferers must bear some responsibility'. This made me reflect on my own experience, and the various 'points of no return' at which the development of full-blown anorexia became significantly more likely...At any of these moments - before leaving the house for school before the non-breakfast, when at the Swiss supermarket or in the kitchen on my boat in Oxford - I could have identified the danger in what I was contemplating doing, and decided otherwise. In the first of these three examples, I had the 'excuse' of really not knowing where this could lead, although I knew that lying to my family about how I was living couldn't be a good thing; but in the second two examples I knew perfectly well what the consequences would be, and went ahead regardless. Yes, numerous physiological, situational, and emotional factors were contributing in each instance to that decision - a decision is not a freely willed thought act detached from its embodied context - but I did nonetheless have the capacity to do otherwise. Whether that doing-otherwise would on its own have significantly slowed or even halted the progression of the anorexia is impossible now to say, but it's clear that all three decisions did have the opposite effect.
...Expressing personal responsibility through action against anorexia is an act of freedom and of self-understanding. The striking simplicity of what is at the heart of any such step towards rejecting anorexia - the simple act of eating - was what made slipping into illness so easy, and is now what makes climbing out of it a process that is constituted primarily of those trivial-seeming daily decisions. Sitting down now with the meal which you have planned to eat, and deciding to take the first bite, may not be an easy decision to make, but the effects both of doing so and of not doing so are very clear, and the moment at which the decision needs to be made - does this fork go into my mouth now, will I swallow now? - equally evident. All the things that have led you to be sitting here at this table contemplating this plate of food are complex and often opaque, but now that you are here, right now, you can make a good decision or a bad one, and however much an inner voice may whisper afterwards to confuse you, you know which is which.
Here's the thing: anorexia isn't a choice. It's not a decision. It's an illness. Which Troscianko admits. The problem is that these types of beliefs about anorexia and recovery--that the sufferer must actively choose and want recovery--don't always lead to the best outcomes.
For years, I felt like a treatment failure because I couldn't simply make the choice to get better. At the beginning, I couldn't see that there was anything to recover from. As the years passed, I started to see that the eating disorder was becoming very problematic, but I couldn't understand why I was still stuck. After all, I didn't want to live this way, I just couldn't figure out how to untangle myself. I couldn't figure out how to choose to get well.
I might not have been able to choose recovery, but I do have to continually choose to stay in recovery. It's a recovery that, now healthy, I am capable of making. It's a choice I have to make many times each day, and will everyday for the rest of my life. I have to take responsibility for my ongoing recovery, and I have.
An eating disorder isn't an illness of bad decisions. Bad decisions are things like buying a pair of Crocs and thinking you'll look stylish. Or buying a house in 2008 thinking it will make a good investment. We all make bad decisions in lif, and most of the time they come to bite us in the ass. This isn't to say that the innocent-seeming decisions we make in the course of everyday life have nothing to do with whether or not we will develop anorexia. The question to ask about some of my seemingly insane ideas and decisions during anorexia is this: was I actually capable of behaving differently? Not in the metaphorical or existential sense; if you look on paper, of course, I could have put food on my plate. But in the thick of the terror and the throes of anorexia, could I have actually done so? Most of the time, I would say no.
Researchers have found that, in the brains of people with active anorexia, reasoning abilities are significantly impaired ( McCormick et al., 2008 ). Which means that the ability of someone with an eating disorder to be able to make rational decisions like eating more, not throwing up, or going into a hospital program pretty limited. It's not impossible--I've known many people who have done the hard and heroic work of having to choose recovery.
Still, current treatment systems for eating disorders (where they exist) are predicated on the patient's ability to choose recovery. "If you don't want to get better," patients are told, "then we can't help you." Of course, everyone's job would be lots easier if eating disorder patients wanted to get better, just as everyone's life would be easier if cancer cells stopped multiplying, psychotic patients stopped hearing voices, and a diabetic's pancreas started producing insulin again. The difference is that we don't view these failures as willful behaviors. We don't sit around and wonder whether it was a bad decision on the part of your lung cell to start dividing and not stop. Or whether someone who is acutely psychotic should try and stop paying attention to those imaginary idiots giving them directions. We understand (okay, at least some of us do) that this is just the limitations of the illness.
If people with anorexia could simply stop making the bad decision of not eating, then it wouldn't be an illness and there wouldn't be a million-dollar treatment industry.
The problem with believing that anorexia is a choice is that we leave sufferers to die alone in their apartments after years of illness . We discharge long-term sufferers to either figure out how to live with their illness or die . We tell them it's their choice whether or not to use behaviors . These are the bad decisions, not the eating disorder itself.
I'm not saying that people have no responsibility for their health, nor that people can't choose to recover. The thing is this: we shouldn't rely on it, nor should we expect it. Someone who is drunk can't drive properly, and we know this. We don't expect someone who is slurring their words after 10 beers to be able to drive a car. They might be able to get home safely. But we still tell them to call a cab. It's like that for eating disorders.
The real bad decisions, in my mind, are in the hands of treatment providers who expect that their eating disorder patients are fully competent and capable of making good decisions. Maybe they are, maybe they're not. But the desire to recover shouldn't be necessary for treatment.