“I’m Not Sick Enough to Get Better”

Part 2: How to break the deadlock.

Posted Sep 28, 2020

In Part 1 of this post, I asked how it is that the belief "I'm not very sick" should lead so often, in anorexia, to the conclusion "therefore I should stay as I am". I discussed three possible reasons:

  1. a cost-benefit analysis coming out in favour of stasis
  2. the dynamics of self-denial as they coalesce around hunger
  3. the dangers of using other people as comparators to assess your own sickness or health or the rightness or wrongness of your body.

In this second part, I consider a second plank of the "me versus other people" problem (what it means to try to optimize your own life) as well as taking a quick look at the question "does this kind of suffering really count?", before suggesting some practical routes out of the paralysis that can easily be the upshot of these patterns of thought and behaviour.

Investing in you, deciding for yourself

A fourth common basis for the “I’m not ill enough to get better” statement is an unease with the idea that this is all about you. For a “Western” culture supposedly founded on principles of individualism, there seem to be an awful lot of people who subscribe to some version of the idea that it’s decadent or melodramatic or self-indulgent to devote time and energy to personal development of any kind that doesn’t fit neatly into the good old “humans as economic resources” mould: formal education and professional training. In this sense, resisting the investment (maybe financial, but certainly energetic, emotional, etc.) in recovery is a microcosm of a broader reluctance to devote time, energy, and creativity to life design in general.

Sure, “life design” (a term I borrow from the excellent Stanford Life Design Lab) is a 21st-century concept that’s easily mocked—but probably only if you’re of the view that if life isn’t nasty, brutish and short, it’s weak and degenerate. That said, if some of the basics of your life and those around you are far from sorted—if you or those close to you experience violence, abuse, coercion, environmental threats, or fear of these or any other oppression—it might seem reasonable to put an aspiration like recovery from an eating disorder onto the back burner. I think it’s still probably a mistake, since no other problem is going to be more readily dealt with while you’re unwell. But that’s easy to say from a position of freedom from such threats. In any case, it often takes time for the true costs to become apparent amidst the temporary or apparent solutions.

Alternatively, the sticking point may be more about over-acquiescence in other people’s values or expectations than specifically about denigration of your own. You may not have been brought up to understand that you are the best person to make decisions about your life. You may be subject to persuasion—knowing or otherwise—by people who think they know what it’s like to be you, or think you’re fine, or think that for you, this problem you have is the lesser of alternative evils. Or you may feel a fatalistic sense that this is my lot and I must bear it rather than change it – perhaps even a religiously infused sense that there’s a grand plan behind this sickness of yours. (There isn’t.) Or maybe it’s a simple lack of imagination, a failure to conceive of alternatives to your current reality—one basic form of cognitive flexibility that (in another vicious circle) is made more likely by malnutrition (Tchanturia et al., 2012).

Physical and other pain

Finally, maybe underlying a lot of this is the “mental illness” classifier. If you’ve been trained by whatever means to believe that psychological pain isn’t as important as physical pain, an illness which has significant psychological components is going to be tough for you to recover from, because you’ll be inclined to believe it doesn’t matter whether you do, because after all, this isn’t cancer or a broken leg. There’s a bit of research on the so-called “hierarchy of pain”, and interestingly, if you ask a woman what’s the worst pain that can be suffered, she might well say emotional pain rather than physical (Biedma-Velázquez et al., 2018). This forms an odd contrast with the observation of how disinclined so many people are to take their own non-physical suffering seriously enough to do anything about—though part of the problem is that what to do is often non-obvious. (Anorexia has a huge advantage here: the medicine is extremely obvious.)

More broadly, difficult questions arise when we ask what counts as pain, and what reality bereavement, say, has relative to a headache, but there’s plenty of evidence that psychological suffering involves physiological changes (e.g. patterns of neural activation) comparable to those involved in suffering as a result of physical damage (Biro, 2010). Dismissing any kind of suffering as “all in the head” is ironically nonsensical, given the role of your brain in mediating every kind of pain. In the end, given that the only way to define pain is subjective (Blackmore and Troscianko, 2018), there is really nothing to be done with pain other than decide how you intend to respond to it. 

Possible responses

Whatever the major ingredients are for you, if you’re feeling some version of this hesitation about recovery, you needn’t just accept your ambivalence as your fate. What can you do instead?

If the cost-benefit analysis is your thing, it’s worth redoing at intervals. Small extraneous changes can tip it decisively towards recoveryThe seductions tend to stop seducing eventually.

Whichever of the variants above seem closest to yours, keep your mind open to all the ways in which your life could be different: by reading, watching, listening, talking, make it harder for the cognitive rigidity of malnutrition to kid you into believing this is as good as it gets. Cultivate your attunement to your dreams; don’t just analyse what stifles them.

Practice making and embedding small changes in your habits and seeing how powerful they can be. To do this effectively, ditch the self-discipline, and let hedonic payoff be your guide: what single thing, done differently, could make your tomorrow feel better than your yesterday? It might be using a foam roller or doing a tennis ball massage when you get up (a simple physical state change like reduced muscle soreness can be surprisingly potent in changing psychological and behavioral states and capacities); it might be switching your phone off before you watch an episode in bed. What does doing this thing differently tell you about your capacity to embark on greater kinds of change?

Beyond this, cultivate any other habits that will make you more likely to take your life into your own hands, especially: associating with other people who do. (90 minutes of Peter Attia interviewing Lori Gottlieb may be a nice place to start.) Whose attitudes to their own life do you admire or aspire to? Seek them out and learn from them.

In the end, if you don’t decide you want more than what you have now, no one else can decide for you. They can be disappointed or sad for you, but that doesn’t mean much if you don’t share their sense of the unnecessary constraints your life is currently subject to. The flipside of this is that if you hang around waiting for someone else to care enough about you to sort your life out for you, you’ll be waiting forever, or get yourself into worse trouble: you really don’t want to be with the kind of person who makes you their salvation project. 

Rejecting the syllogism “I’m not very near death, therefore, I’m fine” is about asserting ambition: maybe professionally, maybe romantically, maybe experientially. On whatever dimension, for you, is the most capable of making you stop accepting the status quo as a life sentence.

In the end, no one else gets to tell you what is or isn't a problem for you; why would you let them? Two people could have exactly the same eating and exercise routines and one be well and the other deeply unwell. Someone who didn't know you could look at your body and your meals and say, well, yeah, sure, she’s a bit thin and she doesn't eat much, but she looks all right to me, what's the problem? Someone who knew you well could observe you and your life and not fully understand which precise things were really keeping you trapped. But if it's a problem for you, it's a problem for you. And you get to decide to solve it. 

And bear in mind: once you decide this, the relief of cognitive dissonance elimination is profound. Knowing you’re not fine while pretending you are is exhausting: it takes all kinds of cognitive and behavioural tricks to sustain the “I’m fine (enough)” myth, and admitting that these are all self-deceits is tough. But once you’ve done it and can start to realign the dissonant beliefs, by accepting that you’re not fine and thereby starting to make becoming fine possible, there’s a great sense of liberation. At long last, a fiction is not the structure of your existence. Thoughts and actions can start to be rewired.

This is your fate as long as you keep saying it is. And after that, it won’t be anymore.

This is your life, and it was short even before it started: now it’s maybe twice as short, and high time to dive in.

***

If you're ready to do something, seek out a professional (via a referral from your doctor if need be), and read this series of posts on how to start eating in a way that will bring about change.

And let me know in the comments (click on the speech bubble at the bottom) which of these versions of "I'm not sick enough to get better" resonates with you, or if there are any I missed.

References

Biedma-Velázquez, L., García-Rodríguez, M. I., & Serrano-del-Rosal, R. (2018). Social hierarchy of pain and its connection to the memory of previously suffered pain. Journal of Pain Research11, 2949. Open-access full text here.

Biro, D. (2010). Is there such a thing as psychological pain? And why it matters. Culture, Medicine, and Psychiatry34(4), 658-667. Open-access full text here.

Blackmore, S., and Troscianko, E.T. (2018). Consciousness: An Introduction. Abingdon: Routledge. Google Books preview here.

Tchanturia, K., Davies, H., Roberts, M., Harrison, A., Nakazato, M., Schmidt, U., ... & Morris, R. (2012). Poor cognitive flexibility in eating disorders: examining the evidence using the Wisconsin Card Sorting Task. PloS one7(1), e28331. Open-access full text here.