8 Ways of Responding to Stress
Stress in anorexia, recovery, and beyond.
Posted Jun 23, 2019
A few years ago, I (and the other people involved) saw a counselor about some relationship difficulties. He was great. He swore a lot, he interrupted sometimes, and he made liberal use of a whiteboard, Lego, and metaphor. One of his favorite metaphors was a leaky boat. If your hole is bigger than your pail, you have a serious problem. If your pail is about the same size as your hole, you’re in for a tiring time. If your pail is bigger than your hole, you’re good.
Life being complicated, holes and pails aren’t all there is to it. Possibly because I haven’t felt much lately, I’ve been thinking about stress and how we fend it off or manage it—or fail to. And possibly because I live on one, the boat metaphor feels useful for thinking this through in more detail.
Stress is a well-documented component of eating disorders, and its persistence (and often exacerbation) during recovery can easily compromise the recovery process if left unaddressed. Research makes fairly clear that people with eating disorders have less effective ways of coping with stress than healthy controls. Troop and colleagues (1998), for example, found that people with anorexia were more likely than healthy controls to use avoidance or rumination as coping mechanisms (though also less likely to downplay their problems), while people with bulimia were more likely to blame themselves and less likely to receive support from a ‘core-tie’. Some of the distorted stress response is domain-specific: for instance, Martz and colleagues (1995) found that people with eating disorders experienced more stress than others (both healthy controls and people with other psychiatric conditions) when confronted with threats to traditional feminine gender role commitments (especially those involving fear of physical unattractiveness). But the difficulties also extend out into other areas of life: Tuschen-Caffier and Vögele (2005), for example, found that interpersonal conflict was perceived as more stressful by people with bulimia than by controls, and Sassaroli and Ruggiero (2005) found that low self-esteem, worry, and parental criticisms were correlated with severity of eating-disorder symptoms only in stressful situations (e.g. exam day), whereas concern over mistakes was correlated in both stressful and unstressful situations. Possible vicious circles between various aspects of stress response and the dysfunction, in eating disorders, of hormonal pathways such as the HPA (hypothalamic-pituitary-adrenal) axis have also been proposed (Lo Sauro et al., 2005).
So the nexus of eating disorders and stress is a knotty one which will benefit from some disentangling. In this post, I offer eight nautically themed ways of thinking about your interactions with potential stressors (things that could make you tired, anxious, and/or miserable if you let them). Then I explore the particular spin they’ve had for me in the anorexic, recovery, and post-recovery contexts. And then in the sequel, I expand out from my own experience to consider the broader stress-related principles that apply in recovery and afterward to help you think about what it may mean for you to create a life where the stressors only rarely exceed your ability to take them in stride.
An anatomy of stress response through boating
Prevention is better than cure, and avoidance is a large part of prevention. Avoidance tends to get a bad name, but another name for it is discretion. If you don’t put yourself in the way of obvious stressors, you won’t have to deal with as many: If you don’t steer your boat towards rocks or sandbanks, you won’t get holes in your hull or run aground and wear yourself out getting afloat again. Some common ways of steering around stressors include: not hanging out with troublemakers, not living somewhere frenetic (unless you like frenetic), not choosing a career that makes you tired/anxious/miserable, not having children, and so on. (I’ll come back to the career and children questions in Part II.)
Of course, discretion can start positively, but slide into avoidance. If your primary criterion for life decisions is minimizing stress, you’ll miss out on a lot. You’ll also do what avoidance always does: magnify the perceived threat and belittle your own capacity to deal with it. But if practiced in moderation, discretion also has a triple positive side: not just steering clear of the lurking reefs, not just savoring the peace of the clear, calm waters, but also rising occasionally to the vertiginous fun of the swell far out to sea that you’re well rested enough to delight in.
In life terms, the ideal here equates to appreciating a frequently calm existence and having plenty of spare energy and imagination for taking on fun challenges when you want to.
2. The happy routines of the voyage
The point of having a boat is to enjoy traveling in her. And much of the fun of any kind of boating is all the little skills and duties that being underway involves, whether it’s gauging how far to lean out against the sail in a dinghy, or dodging hire boats, or running ahead to set the next lock in the canal-boating world.
The equivalents here are the things that help life tick over smoothly and contentedly: having nice routines that please you, having things you do for yourself not just for others, having things that matter to you and make you happy which prevent potential stressors from taking hold, whether because you’re too chilled out for anything of minor-to-moderate potential stressfulness to penetrate, or because you have too varied a range of interests and things you care about for any single one to predominate when things go wrong. This stuff shouldn’t feel like a chore (chores come next!).
The happy boat is well-looked-after: her paintwork gleams, her moving parts are well oiled, her ropes are dry and neatly coiled… maybe she has some pretty flower boxes on her roof. These things serve practical functions: keeping the rust at bay, making sure she can cast off at a moment’s notice. They also contribute to the pleasures of boating, even though in themselves the activities of cleaning and oiling may not be enjoyable. My classic here is putting my hand into the weed hatch to feel for anything caught around the propeller; too often there’s a crayfish lurking spookily in there waiting to pounce.
The parallel here is the unenjoyable, but effective, stress prevention or relief. Maybe you don’t particularly like yoga, but you’ve found it’s great at keeping you flexible and at calming you after a difficult day. Maybe you have to force yourself to sit down to meditate, and usually find the time doing it uncomfortable, but you also usually feel better afterward. Or you know you need to limit your screen time in the evening, even though you’d love not to have to. You may well decide that despite not enjoying these things, they have a valuable place in your life as reliable stress preventers and reducers. That said, if they are anywhere near as many of these as the "happy routines of the voyage," something probably needs reassessing.
4. Fenders and bilge pump
When avoidance and maintenance fail, resilience is needed. The well-equipped boat has strategically placed fenders to minimize the damage from a range of likely impacts, and an efficient bilge pump to get rid of any water taken onboard. The boater might think: Who cares about not crashing into stuff? I have my fenders. Or: It’s no problem if I take on a bit more water; the pumps are working fine. This isn’t sensible. Fender attachments wear out; so do pump motors. And when they break, you’ll have to do without them while you repair or replace them and incur the costs of repair more often. Other kinds of damage also happen, thanks to crashing and taking on water (smashed crockery, rotting bulkheads), which then require more extensive repair.
These are your classic "coping strategies": things you turn to when you need calming down or cheering up. Things you don’t tend to make use of at unstressed times. Things that provide a quick fix rather than longer-term benefits. These are the top candidate for turning into unhealthy dependencies because by definition (and the bilge-pump metaphor doesn’t quite work here!) they give you an immediate reward for using them that can make you think life would be better with lots more such rewards, and with less of the other relatively boring stuff.
5. Engine strain and creaking timbers
Sometimes you can tell a boat isn’t happy. Whether it’s the engine resonance sounding all wrong or the timbers of the hull shifting uneasily, these are your signs to stop doing what you’re doing.
It's the same in life. You will have predictable manifestations of stress: things you do when you’re stressed that are indicators of stress, and responses to it, without alleviating it. Getting good at identifying them helps avoid long periods of getting more and more stressed, and hence helps avoid excessive recourse to those quick-fix coping strategies. Watch out: They may disguise themselves as useful maintenance, when in fact they’re just things you’re too tired or distracted to realize aren’t actually necessary—and so make you more tired still.
6. Time in dry dock
However responsible a boater you are, every few years your boat will need some time out of the water for repairs and pre-emptive maintenance, whether hull-blacking or a full refit. Indeed, doing this isn’t a sign you haven’t been responsible; it’s a sign that you are being.
In life, this can take various forms, some more responsive, some more pre-emptive. The pre-emptive ones may be vacations and retreats; the responsive ones perhaps also involve retreats or courses, but more serious time out structured by sick leave or therapy, too. How bad the problems have gotten, and/or how clearsighted a view you have of what will forestall potential problems on the horizon, determines which course is necessary.
7. Boat Safety Certificate
Many waterways require you to pass a regular inspection and be insured to use them. Even if they didn’t, such an inspection would make sense as a way of identifying potential problems before they develop. The inspection is often the trigger for some dry-dock time for repairs or for improvements to meet new regulations.
The physical equivalent here is the annual physical with your doctor (if you have that kind of health care); the psychological parallel is the regular review of how life is going. Because no one else tends to insist on the latter on your behalf, it’s easy not to do it, or to do it in only the narrow way an employer requires, but doing it in a way that’s meaningful for you is a crucial part of living well. It makes the time out more likely to be pre-emptive and restorative, and less likely to be a palliative upheaval, as well as sharpening your focus on all the other elements of your stress responses.
8. Going out in bad weather
If you do some of all this, you can take advantage now and then of the risky pleasure (or necessity) of doing something a little reckless with your boat, whether going out on the river when it’s yellow boards and flood conditions are predicted, or setting sail when there are white horses on the water. All your experience and your care the rest of the time makes these adventures less foolish than they’d be otherwise—and makes you more open to enjoyment.
There are two possible parallels here: the obvious one is the exhilarating adventure, but the other is the thing that’s meaningful enough to choose despite its stresses. This brings us around full circle: Part of discretion, after all, is knowing when not to avoid. Whether it has short- or longer-term consequences, knowing you have good reasons to embrace something that will probably also create stress for you is an important part of knowing yourself.
Changes in anorexia, recovery, and beyond
So, we’re quite a distance away from our simple hole and pail analogy, but the basics of that still apply: If your bailing-out strategies exceed the stuff that needs bailing out, you’re sorted. If the opposite, you have a problem. Perhaps the most important spin on this that the anatomy of boating suggests, though, is that you don’t want to be actually relying on the pail (or bilge pump). Knowing they’re there is nice, but by the time you’re using them, the water is already in your boat, which is where it shouldn’t be. So if a pail/bilge pump is your primary anti-stress tactic, I think you have a problem regardless of whether it does (for now) manage to keep the water level down.
And this is where we get to anorexia. Living with anorexia is like bailing frantically to keep your head above water, ignoring the gaping hole at your feet. In other words, anorexia is a conglomerate of coping strategies turned into dependencies. Things that initially seem to help deal with problems—channeling your attention into being good at losing weight instead of stressing about school, focusing on calorie counting when everything else feels too complicated—become the problem. In a strange way, then, what seemed like it was the pail actually turns out to be the hole, and the more you bail out, the more you make bailing out your only possible activity, thus contributing to the gradual growth of the hole. Not a happy circumstance!
I’ll illustrate this with a reference to the eight parts of boating in my anorexic life.
- Avoiding social contact and all the unpredictability it involves
- Avoiding change of all kinds
- Monitoring changelessness (e.g., by weighing myself)
Enjoyable routine (happy routines of the voyage):
- Eating (especially eating everything all in one go, to have it to look forward to, and eating lots of sweet stuff right at the end before sleep)
Unenjoyable maintenance (weed hatch):
- Daily bike rides. (I don’t know really whether these did me more harm than good. They never increased in length or intensity over the years, and I think on balance getting out into the fresh air for a little time every day using some muscles and not staring at my laptop was probably a benefit. The fact that unless the weather was lovely, I vaguely dreaded and longed for them to be over for the day may or may not support this view.)
Quick-fix coping strategies (fenders and bilge pump):
- Working longer hours to avoid thinking about anything else
- Freighting the late-night eating with even more "looking-forward-to" significance
- Checking my tummy and other parts of my body for thinness in a mirror. (More often the more stressed I was.)
- Practically orientated "damage-limitation" counseling (during the final year of undergrad)
Manifestations of stress (engine strain / creaking timbers):
- Plucking my eyebrows more
- Resisting my obsessive-compulsive habits less (counting, memorizing, checking and rechecking, etc.—never of anything meaningful)
- Writing more in my diary
- Working longer hours (because my efficiency was reduced, but thereby only reducing it further)
Periodic overhaul (dry dock):
- Returning to my parents’ homes during the vacations
- Taking a year out (at my mother’s home) between undergrad and my Master's
(Neither of these did much for me except mitigate acute exhaustion, probably because I didn’t have a plan for anything more.)
Regular appraisal (boat safety certificate):
- The occasional visit to my doctor
- The occasional long conversation with my mother
Enjoyable/meaningful risk-taking or stress-welcoming (going out in bad weather):
Here you can see there’s not much of anything constructive. Almost all the stress-related work is being done by avoidance, in the form of resistance to change. And if there’s one thing that sets you up well for failure in life, it’s that. Then all the weight of enjoyment falls on eating; the unenjoyable stuff is just exercise. And when avoidance fails, coping is more of the same: yet more weight on eating, plus a bit of body criticism. The exceptions are the bits of counseling and the doctor’s visits, but they didn’t achieve much beyond helping my anorexic routines feel marginally more viable.
In recovery, things started to shift and expand. By definition this was a time in flux, but here are some of the alterations that happened.
- Avoiding (or if that wasn’t possible, just not responding to) people who talked about diets, weight loss, guilt about eating, etc. (as, for example, in a couple of episodes I wrote about at the time, here and here)
- Making time for recovery (e.g., by expecting less long work hours of myself)
- Making time for myself and (later) for a new relationship (e.g., by going on trips and spending evenings and weekends doing nice things)
- Eating (especially experimenting with new or long-forgotten flavors, e.g., by excavating ancient things from my kitchen cupboards; later being cooked for by other people, mainly my new partner)
- DVDs in bed
- Not writing a diary any more (it had become a trap)
- Powerlifting (after weight restoration was over)
Unenjoyable but effective:
- CBT sessions (sometimes I enjoyed them, often not, but they helped regardless)
Quick-fix coping strategies (in times of stress):
- Reverting to more predictable and solitary ways of eating
- Checking my tummy and other parts of my body for thinness in a mirror, or weighing myself (more often when more stressed)
- Shutting down emotionally (e.g., during or after arguments)
Manifestations of stress:
- I don’t quite remember. I think most of my responses fell into the previous category.
- Taking the first real vacations I’d had in years
- CBT served this function too, but I didn’t do anything more personally structured.
Enjoyable or meaningful risk-taking:
- Starting skiing again
- Going out to nightclubs again (despite the tired, hungover depression tending to be difficult the next day)
- Inviting my new partner to go away with me and then to move in with me, soon after we got together
Here food and the body are still recurrent themes, but you can see that other things are starting to creep in too. And here the centrality of food is neither surprising nor negative: As starvation stops being the unquestioned default, of course, everything about eating is bound to be salient, and letting it be salient is great if it means actually eating lots. For me, the novelty of eating a large amount was only slightly stranger than the novelties of resting and having fun: All were critical and long-unpracticed.
Since then (and this summer marks almost exactly 10 years since the end of my weight restoration), the landscape has grown wider and more colorful. These changes have happened mostly gradually, as a result of plenty of trial and error preceded by realizations that what I had before wasn’t working.
- Stopping aspiring to an academic career
- Creating a career that allows me a lot of temporal and geographical freedom
- Not having children
- Spending a quarter to a third of my time in California, where the external demands on me are far fewer
- Living on a boat on a river the rest of the time
- Having a pot of tea in bed while I write my diary every morning
- In L.A., lunchtime pool time (swimming and sunbathing) and/or evening hot tub time
- In L.A., mountain walking
- Having fairly regular massages and visits to my osteopath
- Eating well, cooking from scratch
- Eating outdoors as much as possible
- Structuring my work time (planning, timing, etc.)
- Doing a regular personal and professional review
- Talking things through with people
- Drinks with friends/colleagues
- Plenty of time alone together (when in LA) or talking and working together on Skype (when in Oxford) with my partner
Listening to football commentary, usually while cooking
- Watching a DVD or streamed episode before sleep
- Reading fiction, especially before sleep
- The odd night out late dancing
- Sleeping as much as I want, rarely using an alarm
Unenjoyable but effective:
- Sometimes lifting (sometimes I don’t feel at all like going, but usually I feel better for doing so)
- Keeping my living and working spaces (relatively!) clean, tidy, and uncluttered
- Keeping phone/email use constrained (starting again after letting it slide isn’t enjoyable, but soon it grows to be)
- Talking to my partner, or occasionally a close friend, about what’s been difficult
- Alcohol (e.g., looking noticeably forward to a drink at the end of a long week)
- Food (e.g., looking noticeably forward to dinner or chocolate or some other evening snack more if it’s been a demanding day)
Manifestations of stress:
- Emotionally shutting down. (I've moved this from quick fix to ineffective symptom because I think in recovery shutting down was really all I could manage, so was genuinely protective, whereas now I'm capable of more constructive responses.)
- Checking my phone more
- Ski trips
- Relationship counseling
- I do weekly(ish) ones, but currently nothing bigger-picture.
Things I do because they’re fun/meaningful/otherwise important, even though they’re also sometimes stressful:
- Having more than one partner
- Having a long-distance relationship
- Having a portfolio career
One point worth flagging here concerns the fact that food and exercise still play stress-relevant roles for me, if in very different ways from how they used to. I think that’s perfectly fine as part of a recovered life, but there’s more to be said about why, and where the boundary is with not fine.
Another is the importance of seeing the long-term view. For me, creating an alternative to the standard, full-time academic career had three phases with different kinds and amounts of stress. The first was spurred by the desire to reduce my stress and unhappiness; in the second, working out an alternative generated a whole lot of stress of its own; and now, in the third phase, the alternative both allows for beautifully destressed habits in many respects (e.g., working where and when I like) and also entails some fundamental stressors (e.g., frequent decision-making about directions and emphases).
And this leads on to the third main point I’d like to touch on, which is that most of the big, meaningful things in our lives are both stress avoiders/relievers and stress generators. So the trick is to recognize that reality and then work constructively with it.
But this post is long enough already, so the fleshing-out of these three points can wait for the sequel. There I’ll discuss why recovery is so damn stressful and how to make it less so, and then set out some questions and suggestions centered on how to think about stress, and its avoidance and alleviation, in recovery and beyond.
Read on here.
Martz, D. M., Handley, K. B., & Eisler, R. M. (1995). The relationship between feminine gender role stress, body image, and eating disorders. Psychology of Women Quarterly, 19(4), 493-508. Direct PDF download here.
Sassaroli, S., & Ruggiero, G. M. (2005). The role of stress in the association between low self‐esteem, perfectionism, and worry, and eating disorders. International Journal of Eating Disorders, 37(2), 135-141. Direct PDF download here.
Sauro, C. L., Ravaldi, C., Cabras, P. L., Faravelli, C., & Ricca, V. (2008). Stress, hypothalamic-pituitary-adrenal axis and eating disorders. Neuropsychobiology, 57(3), 95-115. Direct PDF download here.
Troop, N. A., Holbrey, A., & Treasure, J. L. (1998). Stress, coping, and crisis support in eating disorders. International Journal of Eating Disorders, 24(2), 157-166. Paywall-protected journal record here.
Tuschen-Caffier, B., & Vögele, C. (1999). Psychological and physiological reactivity to stress: An experimental study on bulimic patients, restrained eaters and controls. Psychotherapy and Psychosomatics, 68(6), 333-340. Direct PDF download here.