It is important to bear in mind that you can change your attitudes to food and to your own body, but that it is not an instant process. After all, developing AN in the first place was a gradual process, not something that happened overnight.
It is also important to be aware that, if you have AN, you are likely to be very self-critical and to make unreasonable demands of yourself. When following the self-help program that follows, bear this in mind, and consciously try not to criticize yourself when the going gets tough, or you feel that you have taken one step forward and two steps back. Congratulate yourself on every successful move forward and be easy on yourself for any slips; otherwise you may feel so hopeless that you decide to abandon the attempt altogether.
A key feature of the self-help program is the diary templates printed at intervals through the manual. Extra copies are also printed at the back of the book but you might want to photocopy these so that you have fresh pages at hand when you need them. It is also helpful to have a notebook for recording your progress as you go along, as well as for noting down your current state of mind, what you hope to achieve and what your current patterns of eating and behavior are. It is up to you whether you wish to share your written thoughts with anyone else, but it is important that you are honest with yourself, and feel uninhibited about what you write. This is, first and foremost, a record for you.
To begin with you need to establish where you are now. Take time to read through the following points, and write down your thoughts as they occur to you.
Now try to establish what stage of AN you are at.
If you have put yourself in either of the last two categories, take time to consider what caused you to progress through and beyond the first two stages. Was it simply the passage of time, or did the onset of depressive symptoms reduce your self-confidence and make it hard for you to reverse the process? Or did you develop rituals and obsessions that gradually expanded to dominate your life?
Keep the notes you have made, and add to them as new thoughts occur to you. You may be surprised by seeing it all written down in black and white, and the record may help you to monitor your state of mind in the future.
Most importantly, by tackling this first exercise, and thereby acknowledging that you have a problem, you have taken a giant step toward your recovery.
It is a sensible precaution to seek professional help if you have AN, if only to ensure as you embark on the self-help program that your restricted food intake has not triggered any further medical complications. However, there are some situations in which it is particularly advisable that you consult professional medical practitioners.
It is only realistic to acknowledge that changing your behavior and attitudes is not going to be easy. Reviewing the likely obstacles to change does not mean taking a negative or defeatist attitude: on the contrary, if you take a clear-sighted look at the ways in which resistance to change might affect you, you will be better prepared to deal with them if and when they arise, rather than taking them as reasons to give up.
If this self-help program is to work, you must make a commitment to change. Initially this will seem alarming – even like stepping off a cliff into space – but in fact you are not stepping into the unknown. You have been free from AN before, and there is no reason why you cannot be again.
Be aware of any tendency to procrastinate, and try to stop yourself from reasoning yourself out of making the change now. There will be no time that seems exactly right, so commit yourself to beginning, and stick with that commitment. Keeping a diary, as described below, can help to reinforce commitment; in the following steps of the program you will learn techniques to counteract your wavering, and be able to record your use of them and build on them.
The chances are that your life is completely organized around your AN. In a sense, although you may feel that AN gives you a way of exercising control, it is your AN that has taken over the reins and is controlling you. What you are seeking to do now is to regain genuine control for yourself – even though at times it may not seem that way as you will be faced with challenges that are difficult to overcome, and will have to break your previous strict patterns of rigorous self-control. Try to keep to the forefront of your mind the essential fact that you are not relinquishing control, but restoring it to yourself. Currently, it is not you who are in control – your AN is.
All major life changes can be terrifying – even the positive ones, such as having a child or getting a promotion at work – and yet without change, our lives stultify. For people with AN the fear of change is especially strong because they cannot conceive that it will make them anything other than more unhappy than they are currently. Challenge this thought as it occurs. Even when it is hard to believe, the truth is that you will be happier once you have made, and accepted, these changes. Following this program and combating your AN is one of the most positive and rewarding changes you will ever make in your life.
AN works in a very insidious way, and isolates the person suffering from it. If your AN is reasonably advanced, you may already have withdrawn from social relationships and feel that you have become separated even from close friends and family. However, you are less alone than you think. Those around you may seem distant, but much of this is to do with the fact that they do not know how to approach you, and are frustrated by their seeming inability to help. If you crave support, ask for it. If it is not available close at hand, then seek it from professional services or from an eating disorder support group. Not only will this take you out of your isolation, you will find that you are not the only person in the world to be dominated by anorexic thoughts, and not the only person seeking to be free from them.
Be aware of the fact that your AN is not going to give up without a fight. You have probably already developed a complex system of thought that is hard to break free from, and one aspect of this is a tendency to tell yourself you are not capable of change. Avoid interpreting every setback as proof that you cannot achieve change. Think of the example of a smoker, who quits entirely for three months and then, one night at a party, smokes five cigarettes. Is that single occasion proof that the person is incapable of quitting and should therefore just give in and return to smoking regularly? Of course it is not, and most would-be ex-smokers will recognize this. Learn to concentrate on your successes and count them as proof of your ability to change. Self-defeating mechanisms can themselves be defeated; all you need to do is recognize them for what they are.
It is important to remember that AN may have helped to solve many of your problems. You didn’t develop AN because you are crazy, neurotic or self indulgent. You developed it because it was a solution to many of your problems or feelings that were present before the AN started. Looking at the advantages of having AN symptoms may help you understand why the disorder developed and why it is so hard to consider giving it up.
Make a detailed list of all the advantages of having AN. Don’t be defensive about this. Remember that developing AN was an adaptive solution to your problems at the time. Always start with the advantages first. Then make a list of all the disadvantages. It is likely that at this stage the pros will outweigh the cons. If this is the case don’t panic. It merely emphasizes that AN was an adaptive and understandable solution for you. If you find it difficult to do this exercise enrol the help of a trusted friend or relative. Ask them what they see as the advantages and disadvantages for you. Again, urge them to be open and honest. Encourage them to put points in both columns. Listed on p. 127 are some typical advantages and disadvantages that AN sufferers often report.
First, simply making the list may help you look differently at your current situation. Maybe writing down all the disadvantages will help you realize how hard it is to maintain the AN. The list will give you lots of experiments you can do using the cognitive techniques described later in this book. Take each statement in turn and look at it in detail. Re-phrase each statement as a question, for example, ‘Does starvation really improve my mood?’ and then test it out over a few days keeping note of what evidence you find.
Perhaps it is the case that the advantages clearly outweigh the disadvantages just now. Try imagining what it would be like in one year, two years, five years or ten years’ time. A good way of doing this is to imagine a meeting with a close friend who doesn’t have AN. At each meeting, imagine that you are the same, and that you have to say what you’ve been doing and what has been happening in your life since the last meeting. Then turn things around and imagine what he or she might say. If you cannot do this on your own, try it for real, with a close friend. Some times it is only when you can look five or ten years ahead and see how much of life you may have missed out on because of the AN that it will really come home to you that you do need to change. For example, in ten years’ time you might still be saying ‘Well, I’ve still got anorexia nervosa; I’m still very thin; I’m still in control; it is still a battle every day; I haven’t formed any new close relationships; I never completed college. My life revolves around food and dieting.’ In contrast, your friend might be saying that she has a new job and is about to get married; that she is moving to a different part of the country; she has developed a new circle of friends; and that she had a really good trip around Europe last summer with her fiancé.
If you do finally decide to change, giving up AN will not be easy. You may go through a period of grief or a sense of loss, as the AN may have served you well over a number of years. One way of coping with this is to write a letter to your AN as though it were a friend you were saying goodbye to and will never see again. Write about all the good times you have had together, what you will miss, and how you will cope without it. This exercise might help you distance yourself from your AN and come to regard it as something that is separate from you, rather than an integral part of you.
It might also be useful when you have written the letter to do something symbolic with it, such as put it in an envelope and seal it up and put it away, or to burn it. Sometimes keeping the letter and re-reading it may be helpful. Following is an example of a letter written by a patient of mine who eventually decided to change after 10 years of severe AN.
Dear Anorexia Nervosa
I am sorry that we have to part. You have been my best, most loyal and most trusted friend for the past ten years. You have never let me down, always been there for me, and I could always turn to you when I was most distressed.
No one else has stood by me like you, day in day out, year after year.
I don’t know how I will cope without you, but I am determined to try. I feel very frightened about not being able to turn to you in future.
I also feel angry with you. I thought that I could control you, but gradually you came to control me. You never left me alone, even when I thought I was coping without you, you tormented me and tricked me back into your grasp. At times I really hate you for what you have done to my life. Maybe I will cope without you. I am certainly going to try. I want you out of my life. I want you separate from me, I want peace from you, leave me alone.
I’ll miss you.
Love, Anna
In many cases, this section might be better entitled ‘The Family’s Guide to Coping with You’. The following paragraphs are written under the assumption that you live at home, though the suggestions made can easily be adapted to help you cope with your family (and them with you), no matter what your family circumstances are. The idea is to encourage you to do some preparatory work, including considering a number of questions about your close relationships, before you move on to the next step of the program. In this way you can start to change your environment in such a way as to support you better as you set about making changes in your behavior and attitudes.
Consider what would change for the positive within your family if your AN disappeared this instant.
Now consider what negative changes might occur if your AN did not exist. If you cannot think of any, cast your mind back to the first few weeks and months of your AN and try to remember the differences between then and now.
The actual process of formulating a plan can be of enormous benefit, particularly for family members who feel frustrated and helpless in the face of AN. It is important to be assertive when formulating this plan; allowing yourself to be bamboozled into doing what others want may only exacerbate your condition by increasing the desire to assert control over your life through food.
Use your answers from the assessment above to help you. For instance, if you feel that one of the positive aspects of not having AN would be being able to have normal meals with your family, then this should be written down as an aim. Discuss this issue with your family, and set yourself a target of, perhaps, sitting down with them to one meal per week. At first you may be unable to eat exactly as your family do, but keep in mind that that is what you are working towards. Perhaps they could meet you halfway, by eating a meal which you could comfortably share.
Though it may seem a little scary at first, it can be a tremendous relief to engage with your family in this way, and to allow them to help you loosen your self-control – and your isolation.
If you found that one of the negative aspects of being free from AN was that you would receive less attention from your family, then request the time to discuss this with them. Do other family members feel this way? Is yours a family in which only negative behavior and events get attention, while good things are ignored? If so, try to think of ways in which the focus can be turned toward the positive. Instead of empha-sizing where problems lie, and devoting energy to lamenting situations, try emphasizing the good aspects of situations, focusing on achievements and successes.
When implementing a plan of action, try to approach it in a reasonably businesslike way. Take it seriously, and take note of its progress. It is unlikely to go 100 per cent smoothly, and you may suffer setbacks, but don’t let this put you back at square one. The very fact that you are involving your family is a step forward, and you may make unexpected leaps and bounds as they become more involved.
Some people with AN use the disorder as a stick with which to beat their family. It may be that the family focuses on the negative, as described above, and that the individual with AN feels that she has been consistently ignored in favour of siblings/relatives/parents who are ill/in trouble/in distress. In some cases this can result in a sibling developing AN in response to another family member’s AN.
Alternatively, someone may feel that she is expected to conform to a family pattern, such as high academic achievement, and develop the illness as a way of declaring her individuality and rebelling against constraining expectations.
If you feel that your AN is in some way a weapon, it is important to establish, even if only in your own mind, why this is so. If you want to broach the issue with your family but feel that they won’t listen to you, or simply that you don’t know how to begin talking to them about such issues, then family therapy may help. A family therapist can act as an intermediary, helping you and your family to articulate how you feel and assisting in negotiation.
As in relation to obstacles generally, awareness of the factors affecting your family relationships is extremely important, and can be a vital first step in tackling AN. The next stage is to act on it rather than hide behind your AN. However angry or impotent you feel, be aware that holding on to your AN, though it can be a powerful weapon and can produce the responses you want, is only a temporary expedient. You are only treading water emotionally if you stop here.
Anorexia can be enormously destructive to relationships outside as well as within the family, whether with friends or partners. AN can halt any kind of natural development in partnerships, and make the partner feel very hopeless and isolated. Many people with AN find that, due to a chronically poor self-image, they become reluctant to have sex, and may terminate the physical side of the relationship altogether. Naturally this can be devastating for the partner, who feels rejected.
The most destructive effect of AN on a relationship is that the partner may feel responsible, and is almost certain to feel in the dark. This can result in showdowns about eating and weight, which have little effect other than to put further strain on the relationship.
The first step here is to enlighten your partner, as far as you are able. Explaining how you feel and why you are driven to restrict food intake to such an extent will ease some of the strain; setting ground rules, such as requesting that your eating patterns are not interfered with, can go some way to re-establishing links. If your partner feels uncomfortable discussing your AN, which can happen if they are fearful or reluctant to acknowledge the existence of the disorder, then a therapist who can talk to you both may be helpful.
When you are ready to make changes, enlist your partner’s support. Not surprisingly, they are usually more than happy to help. The important thing is to make it clear at what rate you intend to make these changes, and that you should not be criticized when you lapse. Above all, keep open the lines of dialogue.
We had reached a stalemate. My husband asking for sex, and my avoiding it. Occasionally this would erupt into a confrontation, and I could see that he felt hurt and rejected, but he couldn’t see that, as I lost more and more weight, I felt increasingly disgusted with my body and found the thought of intimacy unbearable. I did try to explain how I felt but he didn’t want to hear it. He would listen in stony silence and say nothing. I began to realize that he was frightened of the idea that I wasn’t ‘normal’.
When I asked my GP to refer me to a therapy group, I told my husband, but he seemed uninterested. He would drive me to the group, wait outside for me, and drive me home, all the time saying nothing.
After a few weeks, he wanted to know why I wasn’t getting better!
The breakthrough, such as it was, came in fits and starts. I was learning assertiveness techniques, and how to articulate what was happening with me, through talking to other people with AN. It began with me making long, rambling speeches and him listening, silently. Finally I asked him to help me by reading through my plan of action. I wanted to stop thinking along anorexic lines, and to do so meant that I had to face the fact that weight gain was necessary. I told him that I found the idea frightening, and that I needed someone to reassure me. He promised to help me. Though he found it awkward, and would refer to the difficulties I was having as ‘the problem’, we did start to feel more at ease with each other, and my AN stopped being something that kept us at arm’s length and began almost to be something that made us closer.
Angela