The fluctuating nature of AN means that you will experience relapses during self-help or professional treatment. One of the themes of cognitive behavioral therapy is that it is not a cure – for AN or any other disorder – but a set of skills that you will learn during therapy and which you should continue to apply when active therapy is over. This applies to skills learned through self-help, and includes strategies for coping with setbacks. It is not defeatist to expect relapses, only realistic, and you are more likely to overcome these difficulties if you have prepared ways of coping with them in advance.
Donna, a 35-year-old housewife, had suffered from AN for four years before seeking help. She had been shown the ‘principles of normal eating’ but although in theory she found them very sensible, she found it very difficult to put them into practice. She had been able, in the cold light of day, to sit down and write rational alternatives to her negative automatic thoughts but in the heat of the moment often lapsed back into her old ways.
Look back at the anxiety curve which relates to the increasing urge to starve (Figures S8.4 and S8.5, p. 204). Imagine yourself in a situation where you have a very strong urge not to eat what everyone else is eating – or anything at all. You may feel you need to stay in control, and that if you eat normally you might overeat and feel fat and terrible. You may have attempted to rationalize negative thoughts but still the drive to starve is overpowering.
At this point, you need to be able quickly to stop your train of thought and realize that you do actually have a choice in your decision to starve or not; and then to distract yourself from the preoccupation with eating/not eating. Step 3 on negative automatic thoughts should have helped you to be more aware of the ways in which you think and thus make it easier to break the cycle of unhelpful thought patterns. Here we introduce the next step in the coping strategy, which will direct you away from the focus on the drive to starve.
You will need a few small cards – postcards cut in half would do well, or small index cards. What you will do is write on each one a distracting activity that you can do at any time, without preparation. Each activity should fall into one of the three categories listed below, and you should try to think of at least three activities for each category. Some people have found it useful to have different sets of cards – one set for home, and another for work etc. – as some activities (e.g. going to bed!) are not appropriate in all situations. Some examples are given here to help you.
Category 1: Things that you know are helpful, e.g.
Category 2: Things that you enjoy doing, e.g.
Category 3: Things that you must do, e.g.
Put the cards into a box or your handbag, where you can easily get to them as you need them.
The strategy, described above, helps you to discover that you do have a choice and to find out that there are alternatives available to cope with tension and stress. This discovery also helps you to become aware that you have control over your bulimic symptoms.
You may by this time be feeling that you ‘should’ be improving and beginning to reduce your anorexic symptoms, but have perhaps not been able to make any great changes in your behavior. It is normal to feel some distress at the prospect of ‘giving up’ AN – we have seen repeatedly during this manual how it gives people a sense of control that is otherwise lacking in their lives, and how it comes to dominate life. It is difficult to replace the perceived advantages with alternative ways of coping, and you are certainly not a failure if you have not yet managed to do this.
By now you will have developed a better understanding of your AN, and so you will know that eating problems may recur at times of stress. It may be helpful to regard your eating problems as an ‘Achilles heel’ – a vulnerable area, so that this is how you may react at times of difficulty. This does not mean you can never get better; it just means that you might have to be more aware of your reaction to stressful situations.
You will hopefully have discovered while working through this manual that certain strategies help you regain control over eating. These strategies should be reestablished under two sets of circumstances:
At such times there will often be some unsolved difficulty underlying your relapse or fear of relapse. An appropriate response would therefore be twofold:
Set some time aside to re-evaluate your progress every day or so. Some strategies may have worked; some may not. If you find that something isn’t working, don’t berate yourself for failure; try something else.
Take some time just now to highlight which of these strategies are most helpful to you. When you find yourself in difficulties, or going through a relapse, try to use them before seeking professional help; remember, you have used them with benefit in the past. But if you do need further help with your eating problem, do contact your GP or local self-help group. Contact details for some organizations that could put you in touch with a local group are given on p. 243.
Learning to switch off, particularly from our own thought processes, is not as easy as it sounds. It is particularly difficult for someone with AN, as these inner thoughts are very insistent and constant. However, there are many techniques for relaxation, from aromatherapy to yoga, and one of them is going to suit you. Remember, however, that worrying about not being able to relax will jeopardize your chances of any technique being effective.
Before you attempt any of these relaxation techniques, be aware of why you must give time to yourself. Many people with AN make unreasonable demands of themselves, and have little patience with what they perceive as their weaknesses. You must learn to be kinder to yourself, and to see your relaxation periods as an important part of your routine. If you fail to give yourself time to switch off, you may become very distressed and tired, and feel your motivation to change begin to diminish. Try to regard these periods as a form of battery recharging, and as essential to your progress as drinking enough water.
Aromatherapy has become incredibly popular over the last few years, and aromatherapy products are now widely available. The basic principle of aromatherapy is that the fragrances of essential oils can be used to improve health, and it has been shown to be particularly effective when dealing with stress and anxiety. Camomile and lavender oils are particularly good for treating anxiety and aiding relaxation, and blend well together. However, when using pure essential oils it is important to avoid the undiluted oils making contact with the skin; and they should never be taken internally.
A good way to use them is to run a warm bath and add five drops of each to the running water. Alternatively, you could buy ready-made bath oils and bubble baths, which are available from most department stores and pharmacies, and are ready formulated to treat particular conditions.
Another excellent method is to invest in an aromatherapy oil burner, which allows the scent vapours to permeate the room. If you choose this method, you will need to invest in a carrier oil, such as wheatgerm, to dilute the main oil. Add two teaspoons of carrier oil to three drops of camomile and two of juniper, which has a very clean, peaceful scent.
Oils and oil burners are available from most health shops, as are books that give further details of the properties of essential oils and how to use them. If you feel that aromatherapy is particularly suited to you, you would be well advised to consult a trained aromatherapist who can prescribe the oils that are especially suited to you and your needs. An aromatherapist will also take into consideration your lifestyle and circumstances, and the fact that you are seeking to combat AN, when prescribing treatment.
Despite its image as the practice of bearded mystics, meditation need have no religious or cultish overtones at all. Nor does it affect normal thought processes. In face, when you are meditating, you are intensely aware of yourself and your surroundings, but in a way that might appeal to the person with AN, in that it teaches you to focus within yourself, rather than on your physical body. As you become expert in meditation, you will be able to stop the flow of negative and self-defeating thoughts that dominate your consciousness, and this can provide a tremendous feeling of release. It will also enable you to examine the way that you think in a more dispassionate way, rather than being at the mercy of it.
Being taught is the ideal way to learn this art, though it is important to find a teacher who is trained and whom you trust. Self-help guides are also available. Meditation requires 100 per cent concentration, and may be based on a visual image or a repetition of sounds or words, known as a mantra. This need have no significance other than that the sound appeals to you and induces a sense of peacefulness. Many who have learned to meditate report increased feelings of self-confidence as well as vastly reduced anxiety and susceptibility to stress. Furthermore, as you are undergoing a period of great change in your life, regular practice of meditation will help you to feel more in control of your situation and more ‘grounded’.
Another useful feature of meditation is that, once you have mastered it, you will be able to devise ‘quick fixes’ for yourself. For example, if you know that your anxiety levels will rise prior to a meal, even to the extent that it just seems easier to avoid the whole thing altogether, you could devise a five-minute meditation, perhaps based on an image or a mantra, that will release that anxiety and allow you to face the task ahead.
There are many excellent relaxation tapes available, with soundtracks varying from whale song to spoken journeys. If you find it hard to relax and to concentrate on abstract sound, a spoken relaxation tape will probably suit you. You can buy a pre-recorded one, or you can record your own. Below is an example of a relaxation script which you can adapt to suit your tastes, or use as a springboard for creating your own. Remember to choose images and sensations that appeal to you, and that you associate with being relaxed.
Close your eyes and imagine yourself standing on a newly mown lawn on a warm summer’s morning. You can feel the springy grass, still slightly wet from the dew, beneath your feet. You can feel the sun, already warm, across the back of your shoulders. Take a deep breath and suck in the smell of the grass and the sunlight on your skin. Through your closed eyelids the sunlight seems red.
As you breathe out you become aware of the sounds of birds singing in the trees, and in the far distance you can hear the hum of a lawnmower. Otherwise there is silence all around. Look around you and see that you are standing on a lawn before a magnificent country house. Look at the way the sun lights up the stonework, and at the clear blue sky above it. In the distance you can see the road leading from the house through lush green parkland. In the far, far distance is the sea, glittering at the horizon. Your body feels very light and clean, and you move easily, almost without effort.
Take another deep breath and begin to walk away from the house. Feel the grass under your feet give way to sun-warmed stone, and see that you are standing at the top of a shallow flight of stone steps. These steps lead down to an ornamental garden. As you slowly descend them, you begin to hear the splashing of a fountain. The sound is very cool and light, and makes you feel refreshed.
As you reach the bottom step, you breathe in the fragrance of summer flowers. All around you is vibrant colour – bright yellows and violets and pinks and reds. Stems reach up from stone urns and from flower beds. You walk along the stone-flagged paths that surround these flower beds. Trail your fingers across the heads of the flowers and feel the softness of the petals. Breathe deeply. Take slow, langorous steps and allow yourself to sink into the atmosphere. Stay as long as you like.
When you are ready to move on, take the right-hand path from the garden and let it lead you through the trees. Under their canopy it is very cool, and the noise of the water becomes louder. As you emerge into the sunlight, you are standing in front of a stone fountain, set in the middle of an ornamental lake. The water rises high, and you can feel flecks of spray on your arms and face. Take a seat beside the lake and let the spray cool your shoulders as you turn your face to the sun. Take a deep breath and smile. This is your own, peaceful place, and you can stay as long as you wish.
When you are ready to go, return through the trees to the garden. Feel the cool stones under your feet and smell the flowers as you pass. Climb slowly back up to the lawn. Take your time. As you emerge from the top step you note that the sun is higher in the sky, and the grass is warmer and drier beneath your feet. As you walk closer to the house, you see that the hallway looks cool and dark and inviting. Walk slowly toward the house, feeling the sun on your face. Hear the birds in the trees and the distant lawnmower, almost imperceptible now. Look up and see the faraway glitter of the sea. As you walk, get ready to say goodbye to the garden. As your feet touch the smooth flagstones of the hall floor, slowly open your eyes.
At the end of the ‘relaxation journey’, always give yourself a couple of minutes to readjust to where you are.
If you prefer to construct your own journey, cast your mind back to a time and place where you were happy. Maybe you would prefer to imagine yourself on a beach, with the sand between your toes and the sound of the waves in your ears. Maybe you like mountains or rivers. Don’t worry about creating perfectly detailed pictures in your mind’s eye. The important thing is that you can, even to a small extent, sink into this imaginative landscape and recreate, in your imagination, sounds and scents. If the first time is a little disappointing, don’t be discouraged. You will improve with practice. The important thing is to set aside some time, probably 15–20 minutes, every day for this exercise.
Yoga is a wonderful way of learning to relax as it requires total concentration. It is also beneficial for the person with AN in that it helps you to develop excellent posture and muscle tone, which in turn can assist the development of a more positive body image. Ideally, you should be taught by a teacher, either individually or as part of a class. If the idea of learning such a physical art in front of others makes you feel too self-conscious, then you could try teaching yourself using a self-help guide.
As with the relaxation tape, you must find a regular slot in the day to practise and be able to do so without distraction or interruption. You will also have to be patient, as the benefits of yoga take at least a few sessions to become apparent. However, once you become adept at it, it is an excellent means of switching off from your thoughts and worries.
Gentle exercise is beneficial to relaxation, so long as it is undertaken for the purposes of winding down, rather than burning off calories. Reading can also be effective if it is done purely for enjoyment. Alternatively, you might want to consider taking up a new hobby. Try to find something that does not require vast amounts of preparation or money. Ideally, you want something which you can pick up at any point during the day. Resist the notion that it must be educational or improving in some way; this is something just for you. Even completing jigsaw puzzles might do the trick, if it is absorbing enough to distract you from worries and negative thought patterns.
There is no easy solution to the problem of backsliding, that is, reverting to old ways of thinking and old routines. We noted at the very beginning of this step that it would be unrealistic to expect never to relapse. Sometimes you will feel that you have achieved nothing, and are as trapped by your AN as you were when you started trying to change. Try not to let these feelings overwhelm you, and keep to the forefront of your mind that what you are trying to achieve is not easy. The following summary points may help you to get back on track and persevere with your efforts.
You may have very high expectations of yourself, and expect yourself to be able to achieve whatever you set your mind to. You can overcome your AN; but you may not be able to do it as quickly and smoothly as you would wish. If there are issues that you stumble over, such as that of breaking the habit of constantly weighing yourself, do not give up. Begin each stage of change, even if you are doing so for the umpteenth time, in the state of mind in which you first approached it. You will have breakthroughs, and you will make progress. The hard part is accepting that sometimes this progress will be slow, and sometimes it will seem to be non-existent.
Sometimes you may find yourself becoming reabsorbed into your old anorexic ways of thinking. If this happens, look back over your diary and, if necessary, work through Steps 3 and 4 again on ‘Challenging the Way you Think’. It is hard to change the way you see things, but it is far from impossible. However, be wary of the tendency to revert out of the fear of change. You will be happier, and more in control of your life, without your AN; so resist any notion that AN is something that offers you refuge and safety.
Constant or increasing depression will hinder your attempts to change, as it will rob you of motivation and make you feel that your efforts are hopeless. If you find this to be the case, consult your GP or a counsellor, who will be able to offer advice on how to treat your depression. Don’t fall into the trap of thinking that you will work on your AN once your depression has lifted. Remember that there will never be a time that seems ‘right’ for making these difficult changes, and once you have made the commitment to change, don’t let anything stand in your way.
Many people feel very stressed by change, whether it takes the form of a new job, a new member of the family, or a move of house. In such situations, we often reach out for the familiar, clinging to old routines and behaviors, and in most cases this is a harmless part of the readjustment process. However, for the person with AN, it is not harmless, and could be the beginning of your sliding back into the grip of the disease. Be kind to yourself, and aware that lifestyle changes are stressful for everyone. Keep going with your efforts; remember that being free from AN will leave you much better equipped to cope with life events, including further changes of circumstance, in the future.