The other day, I did a radio interview with my mother about the decade I spent suffering from anorexia and how it affected us both. Since then, and as I've been responding to comments posted to this blog, I've been thinking about what has allowed me to be in the position to tell the story of my anorexia and to answer people's questions about recovery from anorexia, from the perspective of someone who has recovered, someone for whom that illness is in the past. What is it that allowed me to get better when so many sufferers never do?
With this question in mind, I thought I'd try to compose a list of the factors that I, through my own experience and my understanding of the condition in general, believe are necessary to a full recovery from this most dangerous of mental illnesses. What I will say applies primarily to recovery from a long period of illness. To those of you who haven't been long in the grip of it, and might not acknowledge that any of this applies to you, I can only say: it does. Full recovery will be less easy, in some ways, because the conviction of the destructive nature of anorexia might be less complete for you, but it'll be easier, too, because all the mental and physical habits are less deeply entrenched.
So, what does full recovery require?
1. Letting your body live again. As you start to try to eat again, there will be any number of mental obstacles to eating - internal monologues or dialogues that cripple any attempt to act, fears of change, immovable habits, and so on - but once you offer your body nourishment, it will, without question, respond. It's ready to, at every moment: it's ready to pounce on any food it's given, and start - once there's enough left over after the needs of mere survival are met - to send nutrients to your skin to make it clear and bright again; to your brain, to restore all the depleted fatty acids so it can work and think freely again; to your immune system, so you can fight off viruses and infections without a struggle; to your muscles so you can run up stairs again without dizziness - all this and masses more that isn't making you simply have a bigger tummy or thicker thighs, or whatever it is you fear. Listen to that craving, that longing to get better, and let it help you listen. At first, for me at least, the hunger was frightening in its intensity, and because it no longer felt like something intended, but instead like something unbidden, and my digestive system had trouble coping too. But they're just temporary states in the progress towards the time when your body can run and jump and support you in the all the myriad things that life can offer and that you can't even dream of when you're ill.
Above all, revel in the knowledge that with every bite of extra food (those crucial 500 extra calories a day) you're helping your body regain health and strength: as you bite into this custard tart or steak or banana you're giving your body the nutrients it needs to be your ally instead of your enemy. Doing the radio interview, the part that finally made me burst into tears was recounting the first morning I ate breakfast again, and the delight of tasting the molten chocolate of the pain au chocolat and knowing that an era had drawn to a close. I cried at remembering the feeling of coming from the darkness into the light. I cried at the memory of how I could have eaten ten of them, how every fibre of my body responded to that warm pastry like a sign of forgiveness. The healing process is a lovely one, an easy one in some ways; don't be afraid of delighting in it (in the long calm stretches between the moments of fear and anguish that will come too), just as fully and simply as you would in seeing someone you love heal from injury.
2. Challenging your own resistance. Cognitive behavioural therapy can help a great deal with this, but much of it can also be done on one's own. Challenge the internal voice that tells you it's scary to eat, or weak to eat, by asking what basis this response has:
What is the worst that can happen if I eat?
‘Putting on weight', may come the response.
Why is it frightening to put on weight?
‘Because I'll lose my sense of control.'
Is that sense of control genuine if it's making me live like this - is that not in fact an absence of control?
‘No, it feels like control because feeling hungry is exhilarating. It makes me feel powerful.'
So it's nothing much more than an addiction to a pleasure, like any other, is it? Is being addicted the same as being in control?
‘No, but it feels like more than that. And other people find eating too little really hard; they say it means you're exerting self-control.'
Do you find it hard?
'Sometimes, hideously hard, but mainly easy.'
So you're addicted to something easy, because everything else is too scary and difficult?
'Well, maybe. But it makes me feel good. Safe.'
Really? That safety is bringing you to the very brink of viability.
'But I can't do anything else.'
Once the answer to your challenging questions is reduced to something as nebulous and repetitive as ‘it just feels like it' or ‘I can't help it', you know you've won: the facade has crumbled, and you have the implicit mandate to proceed with proving your strength in a more real way.
This isn't to say that the mantras will die away instantly: I still struggle with the compulsion to check my tummy, usually when I'm finding some situation or other stressful, and want reassurance. Then my critical dialogue goes something like this:
‘I need to check my tummy.'
How will that help?
'It'll make me feel better.'
‘Because it'll reassure me, and I can't find reassurance like that through anything else.'
Why do I need reassurance?
‘Because I'm worried about having eaten too much / about something I've forgotten to do / about something I need to do and find difficult.'
How will assessing the shape of my tummy in the mirror help with any of that?
‘It'll show me I've got control of something, at least that the amount I ate wasn't really too much / that life is possible, even if things are difficult.'
But it won't really tell me any of those things, will it?
And is that really control: to succumb yet again to the urge to look in the mirror?
‘No, but it shows me I do have control in that I'm not getting fat.'
But I know I'm not anyway, without checking, so what more does it tell me than that I'm still feeling compelled to act illogically?
‘Nothing much, it just feels good, briefly.'
Or something along those lines. The more often you can challenge those knee-jerk cognitive responses, the weaker they'll become, till most of them do die out entirely.
3. Turning your proven will power towards the positive. However long it is you've been ill, you've been proving your control, your strength of will, by not eating. Control is meaningful, however, only if it's in the service of a state of being that you believe is worth exerting that control for. Once you've decided - realised - that the anorexic state of being is a hollow semblance of a life, you've also realised that your supposed control is a sham, and that the only way truly to prove your strength and self-control is to turn all that will power towards the task of eating rather than that of starving. There is no reason why those rigid daily routines shouldn't be turned on their head, so as to make the process of growing back into health as unquestionable as was that of dwindling into nothing. In the initial stages it's all about forming new routines, and adhering to them: before you can claim again the privilege of listening to your appetites, you have to train those appetites to come at the right times, in the right ways. This initial stage of eating (say) three meals and three snacks every single day until your weight is back to normal is a stage that, paradoxically, is perfectly suited to be easy for anorexia, in mind and in body: you have tried and tested strength of will, and your body wants food above all else. Of course it's excruciating for anorexia too, because eating more is the last thing anorexia wants, but the implacable structure of early recovery is about co-opting the rigidity that has so long been a destructive force and making it constructive.
4. Not stopping halfway. It is essential that, regardless of which point on the BMI graph you might have reached, you continue to eat until you're no longer thinking about food all day, until you no longer feel weak, until you've simply eaten enough that there is an equilibrium inside you and food no longer matters as it used to. As I discuss here, this may require a temporary 'overshoot' beyond the weight where you'll ultimately be stable. It's terribly tempting to ‘rein oneself in' once that crucial figure of 19 or 20 on the BMI scale has been reached, once one's entered the territory of the supposedly ‘normal' and 'healthy', and to start dieting again. This is like a smoker giving up and then deciding she'll go back on to two cigarettes a day, just so as not to do anything too drastic: it ruins everything. It may avert the worst of the long-term physical damage that comes of a severely underweight state, but all the mental agonies will remain sufficiently intact to keep ruining your life - without even the satisfaction of having a skeletal frame to echo them externally. A BMI of 19 is usually considered the transitional point between the entrapment in the mental rigidity that lower body masses necessarily entail, and the relaxing of this rigidity that comes with refeeding. It's obvious, therefore, that to be hovering forever on the brink is going to be the worst of both worlds: not very thin, but still trapped in an in-between.
5. Imagining making other people happy. Of course your recovery has to happen primarily because you want it to, but the knowledge of what pleasure it will cause other people is bound to be a helping hand along the way. Imagine how it would be to make other people's lives happier instead of, every single day, giving those who love you something to worry about, something to be sad about, when they think of you, or see you; when they can't sleep at night and their minds turn to all the saddest parts of their lives - and you number amongst them. Anorexia is such a lonely illness: it pushes people away because an extremely thin person is usually quiet and reserved and incapable of joining in, whether it's with eating or just with laughing. You know, when you're ill, that anyone who looks at you sees sickness, and this isolates you still further: makes you defensive and proud of your visible status as ill and alien, even while you feel it as a trap. Eventually you will push away from you all those who care, because they can't keep caring, hoping, being patient for ever. The time when this starts to happen almost passes you by, because you don't care much about others any more, but in your bleak moments of the night it will haunt you, your isolation.
6. Not expecting recovery to be instantly complete. There are all sorts of things that will start to resurface, as you gain physical strength, that have been submerged by your weakness. You'll start to feel emotions again, and many of these may be of guilt or sadness about the ‘lost' time - though many of them will also be of gladness and relief and love. You'll have to start addressing all the areas of your life that your illness permitted you to neglect: friends, hobbies, simply time doing nothing, times at which thoughts and feelings can emerge without being instantly covered up again by hunger or hard work or exercise. You'll have to pick up where you left off, in terms of emotionally maturing - and given the fact that anorexia often starts during the teenage years, this can be painful and difficult. It may well take years. But all of these things are ways of finding one's path back to a life that has more in it than self-imposed hunger, and all of them therefore delight and thrill as much as they hurt. Your patience is what will create space for them.
There is no magic formula for full recovery, and some of these things may feel impossibly amorphous, but you will know when you're managing them, and once you have, you'll almost certainly be out on the other side.