Disordered Eating and Mental Health in a Post-COVID World
Part 2: Avoidance, exposure, and a new world order for mental health?
Posted Jul 02, 2020
In Part I, I discussed the apparent discrepancy in responses to the pandemic between eating disorders and other mental illnesses. In this second part, I ask what we can learn from the difference, and what awaits us once the first wave of the pandemic recedes.
In lockdown attitudes to both food and exercise, we see in even starker outlines than usual the pervasiveness of ways of thinking and acting that bear close resemblance to eating-disordered ways, and easily become sources of exacerbation for those who already have an eating disorder. Exercise in particular is performative in this social sense, as a way of modeling health and good sense: people don't just want to be slim or toned or ripped, they want to be seen performing the actions they think (and they think others think) will result in those outcomes. These priorities are getting a boost at the moment from the fact that it is actually very important for most people who are stuck indoors, often in small spaces, to have movement and exertion in their days, for cognitive as well as physical reasons. Sitting still most of the day every day is clearly no good for most people.
So I don't mean that no one should be talking about exercise. But as ever, many people seem to care primarily about body fat reduction, with a thin veneer of the wider set of reasons why movement is good for us. And this neatly mirrors eating-disordered reasons for exercising: pretend it's for your health, do it because you want to control your body. And as with the explicitly eating-disordered version, so in wider lockdown exercise patterns this priority often results in poor choice of movement: it's been a grim kind of entertainment watching the towpath on the opposite bank of the river five times denser than usual with unhappy joggers whose form is so poor that they're doing themselves active harm, as well as missing out on opportunities for kinds of movement that could be both enjoyable and beneficial. The creeping disordering of society as a whole, in which food choices are based primarily on numbers in (and usually one specific type of number, the kcal) and exercise choices on numbers out, has been thrown into relief by the pandemic, and so those who already experience these habits as pathological are bound to be affected, one way or another.
Given the nature of these dynamics, I'd be surprised if the pandemic fallout weren't generating a lot of movements from somewhere on the vaguely disordered spectrum to a full-blown eating disorder, as well as plenty of relapses from semi-recovery. And this leads me back to the contrast I observed (in Part I) that there seems to be between eating disorders and other mental illnesses. With anxiety and depression, in people with clinical conditions and the wider population, there are some surprising indications of some improvement, or at least not radical worsening, despite widespread “worsening” in many of the conditions of modern life (see Part I for references). To the extent that they exist, many improvements in anxiety and some in depression are probably due primarily to symptom relief: you're not encountering the triggers of the anxiety, not worn down by the maintaining factors in the depression, so these conditions feel like less of a problem. In normal times, avoidance is the worst way to get over anything involving fear, because all you're doing is reinforcing the fact that the feared thing deserves fearing and that you do better in its absence. There are differences between individually chosen and collectively enforced avoidance, but the effects of both may be similar: you get even more out of practice at the feared/avoided thing, so you (rightly) fear it even more because you're less well equipped to deal with it, so you avoid it more and the spiral tightens—and then eventually you have to deal with the thing because avoidance is never total, and then you deal with it badly and that reinforces your fear of ever dealing with it again. In normal times, controlled exposure is the only effective way to reduce fear (Black, Farrell, and Waller, 2019).
But these aren't normal times. The standard problems with avoidance apply because the thing to be avoided (because it is feared) still exists to be avoided and feared. There's an open question about this in the current context: we don't know precisely which kinds of our prior normality are going to reappear, or when, or for how long. It's quite possible that some aspects of daily life, particularly around working and socializing, may for many of us look quite different for a long time to come, perhaps forever. This means that the structures of things to be avoided have changed, perhaps permanently. And this in turn means that what may look like superficial symptom relief is actually a profound change to the sociocultural structures that contributed to generating the problem in the first place. Society often feels concretely resistant to all significant change: we still aren’t responding to the climate emergency in more than trivial ways, and only time will tell whether COVID was the catalyst Black Lives Matter needed to effect lasting change. But with the pandemic itself, fear has won out over economics far more resoundingly than usual, and drastic, rapid change has actually happened (presumably because humans are far better evolved to respond appropriately to disease risk than to more diffuse, slower-burning threats).
The world has changed, so the structures of avoidance and exposure have changed. This means that what might in stable times have been superficial symptom relief (from the anxiety of crowds or the exhaustion of the long commute) is actually a profound change to the sociocultural structures that elicited the problem in the first place. One common criticism of therapy and self-help is that they “do not talk about altering social conditions; rather, they deal with altering the individual who suffers from them” (Watkins, 2008, p. 17). In many cases, arguably what needs changing is the society rather than the individual, and ignoring this can result in assigning personal blame rather than directing the critical attention where it ought to be: on the institutions, structures, and conventions that are far beyond individual control but have profound individual effects. One example is the Black person who sees a therapist to deal with the racist abuse and discrimination, while the sources of those problems remain unaddressed. For some people, COVID has changed this too: in this New York Times piece, Ernest Owens describes the relief of being locked down as an escape from everyday racism and homophobia. Of course, the pandemic isn’t a panacea: some people of color I’ve spoken to report exacerbation of the problem, because less contact overall means the racist encounters are all the more dominant. But COVID may yet prove to be the intensification that was needed to make a difference in this realm, at least in the United States. Meanwhile, more broadly we can observe the potential for lasting social change to change the landscape of mental health and illness. In this context, just as in many other areas from travel to work to leisure, the chance of these changes to be positive is non-negligible.
With eating disorders, I’m much less optimistic. Why? The most fundamental reason is that “Western” societies appear to value forms of behavior out of which eating disorders naturally grow. You could say this is true of something like perfectionism too, but I think there’s a difference: with perfectionism, it's the supposed end result that is valued (the impressive output), but not the processes involved in attempting, counterproductively, to generate that result (the up-all-night hand-wringing exhaustion). You might say there’s social validation of certain forms of anxiety and OCD now that hand-washing and mask-wearing have come centre-stage, but these are perceived more as a necessary evil that people will probably be delighted to ditch as soon as they're no longer seen as necessary. By contrast, the ways eating disorders start are the ways so many people are acquiescing in behaving and thinking, from treating eating and exercise as a numbers-in-numbers-out game to treating body shape and size as the answer to the riddle of how to be happy.
As ever, though, where there’s potential to be dragged down, there’s also the opportunity to refuse to be. You can let yourself be cast further into obsessiveness and illness by all this. But you could also do something rather different. If you had an eating disorder before all this began, the conditions in which your eating disorder took hold no longer exist. This means you have an opportunity to be a different person in this changed world. And I think in all kinds of areas, including recovery from eating disorders, some people are seizing this opportunity to address problems that can no longer be ignored, and to make the start of this new world era the start of a new life phase too.
Whether you've already started recovery or only thought about it, short-term intensification of the awfulness of having an eating disorder is also, as with any other life circumstance that becomes obviously more intolerable, a chance to see the problem more clearly and take action that wouldn't otherwise have seemed necessary yet. A pandemic is a brilliant opportunity to learn the lesson (really learn it) that obsessive development of control in one or two specific areas (food intake, body size, etc.) results in loss of control in all others; that when anything changes you are then robust to nothing; that you're immune-compromised and systemically fragile; that having a smaller body doesn’t give you the things you care about; that you're incapable of being the kind of person you want to be in a time when it matters. That when social crises are spotlit and galvanized by health crises, you don't want to be cowering in your kitchen huddled over the weighing scale, or worrying about when you can get back to expending as much energy as possible on the treadmill. You want to be feeling good and robust and energised and imaginative, and helping make the world different.