Emily T. Troscianko

A Hunger Artist

“I’m Not Sick Enough to Get Better”

Part 1: Paradoxes of self-limitation in anorexia.

Posted Sep 27, 2020

“Nowhere is it written that desires must be fulfilled, and so the torture goes on.” —Paul Auster, Winter Journal

Of all the things I find frustrating about anorexia, and there are many, this must rank near the top: “I’m not ill/underweight/dysfunctional enough to commit to recovery.”

This sort of statement is oddly common amongst people who have restrictive eating disorders, and it’s a nexus of a number of attitudes that conspire against recovery and happiness. Let’s take a look at its basic structure and then at the beliefs and assumptions it’s linked to. 

Statements like this have two essential parts:

  1. My problem is not very serious.
  2. Therefore, I shouldn’t make a serious effort to solve it.

These two statements may have a number of underpinnings. 

Costs and Benefits

The most obvious foundation is a cost-benefit analysis: There are more rewards than costs to being like this (not very unwell), so I should stay as I am. 

This is valid as far as it goes. If retaining the benefits of being thin, exercising arbitrary forms of control over food/body/exercise, keeping your emotional life attenuated and your hormonal and metabolic systems depressed, etc. is more important to you than shedding all the drawbacks (psychological, social, physical, professional) that these limitations entail, it is right that you change nothing.

Of course, this is a biased phrasing of the stakes—biased by my post hoc knowledge of how pathetic the arguments against change look in retrospect. In the midst of illness, they feel different. But in my experience of working with people in recovery, this line of reasoning is fairly uncommon as a consistent and lasting assessment, though it does tend to re-emerge at fragile points in recovery when nostalgia for the devil one knows is most potent. As Lori Gottlieb observes in her book Maybe You Should Talk to Someone: “We can’t have change without loss, which is why so often people say they want change but nonetheless stay exactly the same.”

When loss is imminent, its costs tend to be temporarily far more salient than its benefits, because the costs feel more definable. This is especially true because the loss is inevitable while the gain is unpredictable (I’m losing thinness, but what the hell am I gaining?). It’s also true because all you’ve invested in the status quo (all the opportunities you’ve passed up and ways you’ve in which you’ve set up your life to accommodate your illness) are sunk costs, and humans often find it hard to write those off to maximise future rewards, and easier to keep pouring good resources after bad.

For myself, I think the major argument in favour of stasis was about the extremity of pleasure I experienced in eating: I knew that would be lost if I ate more food and needed it less, and I was right. I didn’t, however, know (or believe) that the kinds of pleasure I would take in eating once not malnourished would be richer on many dimensions I’d long forgotten existed—and I couldn’t believe that life’s many other joys and interests could feel a million times more valuable than the fragile ecstasy of late-night chocolate. Turns out, they do.

What are other possible foundations for a curious statement like “I’m not at death’s door, so I shouldn’t take steps to become healthier and happier”? 

Self-Denial and Self-Punishment

The essence of it may also be a macrocosmic version of the feeling that food itself, the most important medicine for recovery, is excessive, indulgent, something of a class (which may also include all kinds of other pleasant experiences) that merits feeling guilt about. This is, in a sense, a core symptom of any restrictive eating disorder.

The feeling may center on the food itself, or it may be more egocentric: tied to feelings of self-loathing, a desire to self-punish or self-deprive. In both cases, it may manifest as a denial that you “deserve” to eat more (or anything), a phenomenon I explored in my post “You don’t deserve this cake, nor do you not deserve it.” (Up there with “selfish,” “deserve” must be one of my top 10 most useless words. Deserving is a red herring of a concept: You deserve nothing, and you get to aim for anything you want.) 

Of course, given that the start of refeeding tends to bring about an increase in hunger (see here and here), the stakes can easily ratchet up early on in a recovery effort: if I’m inclined to deny myself things I desire, then once appetite is no longer neutralized by consistent neglect, there’s a lot more scope for denying to be done.

Added to all this is often a final exacerbation: the new strength of the hunger, as a basic form of desire, is itself experienced as frightening, and the fear taken as evidence that the hunger should be resisted. Like a skier leaning back because she’s scared at how fast she’s going, instead of leaning forward to get more control, this is obviously counterproductive, but it’s an easy extension of a long-term default in which wanting something automatically means you shouldn’t have it. And thus the decoupling of liking food and wanting it characteristic of anorexia can be intensified into a powerful brake on recovery.

Comparison and Competition

Then there are worries about me versus other people. “Does this thing I have really count as an eating disorder?” is an interestingly prevalent concern. It might be nourished by considerations like “I know so many people who have more extreme versions than this,” “I’m not emaciated and I’ve never been tube-fed, so who am I kidding,” “I’ve been hiding it so well hardly anyone realises there’s anything wrong—so maybe there isn’t,” etc.

This isn’t exactly an anorexia-specific tendency (it’s easy to use uncalled-for comparisons to mess up all sorts of things), but it is abetted by the visible, competitive nature of eating disorders that involve underweight—as well, of course, as their socially validated qualities. There’s a tipping point somewhere on the spectrum from thin to bony to skeletal, or from slim to toned to ripped, or from strict to single-minded to obsessively addicted (with nutrient tracking or with exercise, say) where the validation stops being quite so unambiguous, but its location depends on the company you keep. If you inhabit pro-ana or most bodybuilding sites, for instance, it never comes.

And as with any game that involves you beating other people on a broad and vague dimension—beauty, fitness, success, et al.—there is no way for you to ever win. There will always be someone sicker than you, especially all the dead ones. Comparisons are an unavoidable and sometimes valuable part of being human, but in matters of health and illness, they’re also often a distraction from the real point, which is how your life is going.

One factor that makes the argument “I’m so much less messed up than that girl I knew from school” even more unsound is that many people who say they’re not unwell enough to commit to recovery have previously been more severely ill, made a partial recovery, and then got stuck halfway. If this is you, you’ve generated plenty of proof of your capacity to be “properly” ill, and now you’re punishing yourself again for having made some improvement since then. Yes, anorexia is always great at turning success and failure on their heads, but making partial recovery into an argument against full recovery is mind-bending in its illogic. Meanwhile, if you’re one of those who managed to catch the problem before it deteriorated into severe anorexia and stabilized it somewhere in the territory of “issues around food,” well, self-punishment for that foresight is a sad paradox too.

Finally, more prosaically, the problem is sometimes as simple as “well, my BMI is in/near the healthy range.” Using arbitrary BMI boundaries as arbiters of what makes us well or not is probably the single most common cause of failed and stalled recoveries from anorexia—the responsibility for which often lies with the professionals (this is one of the systematic problems discussed in Troscianko and Leon, 2020).

If your BMI is 20.1 and you still have multiple symptoms of the malnutrition you’ve been suffering with since your BMI was lower, or if this is your low point and you have starved yourself to get here, you need to allow your weight to increase in order to heal. Your weight will probably have to go temporarily higher than where it will ultimately stabilize, and it may need to go higher than the BMIs of many of your friends. Giving permission for this to happen is one of the greatest tests in recovery, and the more meaning you attribute to a population-level round number that has nothing to do with your particular body, the more likely you are to fail it.

Part 2 of this post explores two more foundations for the paradox and some suggestions for escaping from it.

References

Troscianko, E. T., & Leon, M. (2020). Treating Eating: A dynamical systems model of eating disorders. Frontiers in Psychology11. Open-access full text here.