Zooming Out and Back In: A Cognitive Foundation for Recovery

Being able to put "now" in context is indispensable in recovery from anorexia.

Posted Sep 05, 2019

As I walked into town about 5:15, the last thing I wanted was wasted hours with William the Welsh-Italian: it was meant to be payment for my help with German, but all that’s of value to me is time, and this was only stealing more of it… But as I turned into Radcliffe Square I told myself to pull myself together: I’m being bought a drink in the loveliest city in the world. What is there to be bad-tempered about? (17 January 2009)

I realised some months ago that I use the phrase ‘zoom out’ an awful lot. I use it all the time in my coaching work. I often turned to it instinctively during my own recovery, as in the diary excerpt above (6 months in, almost to the day). I use it or its synonyms or make suggestions that amount to it in most of my blog posts. And yet I’ve never zoomed out on zooming-out and actually written a post on it.

By zooming out I mean what you do when you:

  • make plans for the coming week of your recovery
  • remind yourself that this discomfort will pass
  • consider the effects your illness is having on people other than you
  • ask what you’d be doing now if you didn’t have an eating disorder

And so on. Anything that involves putting the here and now into a broader context. The expansion can be temporal (where do I want to be in ten years’ time?), or spatial (given how much of the human population lives in food poverty, do I really want to pretend to eat this cake and then throw it away later?), or social (the Minnesota volunteers demonstrated what starvation does to the human body and mind, so yes they were men in the 1940s, but maybe I can learn something from their example), or of other kinds.

Construal level theory (CLT) formalises the idea of zooming out into a set of evidence-based predictions for how likely people are to think abstractly versus concretely, given specific prompts: how likely we are to focus on the bigger picture versus the little details. Intriguingly, when people’s perceptions of distance are manipulated, their tendency to think little-detail or big-picture is systematically altered: if you prompt people to adopt greater temporal, spatial, or social distance on something, you make them think more abstractly (Trope and Liberman, 2010). The prompt could be getting someone to think in historical rather than day-to-day time; or reading about outer space or unfamiliar civilisations, or about an event that’s unlikely to happen rather than one that’s almost certain to happen (this is ‘hypothetical distance’). Basically, if you engage with something that expands your mental horizons, you’ll think more abstractly than if you engage with something that contracts them. 

 Public domain, via Wikimedia Commons
Nepalese Mhapuja mandala. Curry and Kasser (2011) found that colouring in mandalas reduces anxiety more effectively than unstructured colouring.
Source: Public domain, via Wikimedia Commons

This cognitive effect is bound to (and has been shown to) affect the actions performed within those horizons too. You’re more likely to interpret a statement like ‘ringing a doorbell’ in terms of ‘moving your finger’ when thinking about doing it this afternoon, but in terms of ‘seeing if someone’s home’ when set a year from now. There are plenty of findings in the CLT literature that are more directly relevant to illness and recovery from an eating disorder. For instance: 

  • An increase in temporal distance makes people more likely to rely on aggregated statistical evidence versus a single person’s opinion (Ledgerwood et al., 2010). People who think more abstractly about their actions (as in the doorbell example) tend to see more consistency amongst their current goals, and to feel more positive and more motivated about them (Freitas et al., 2009). 
  • Adopting a self-distanced perspective reduces experiences of ‘basic emotions’ like sadness and anger, but not of ‘self-conscious emotions’ like guilt and shame, because inherent to these is a perspective that is already self-distanced: they involve self-evaluation, and evaluation of yourself from others’ point of view (Katzir and Eyal, 2013). 
  • And people prompted to think more abstractly aligned more strongly with perceived group norms than those prompted to think more concretely – because they are tuning into social information that tends to be consistent across contexts (Ledgerwood and Callahan, 2012). Interestingly, this also raises the possibility – as yet untested – that if there’s a strong out-group which provides context-consistent information against which to oppose oneself, distance might enhance the divergence from that negative reference group’s opinions (Ledgerwood and Callahan, 2012). 
  • And a colleague and friend of mine, James Carney, who introduced me to CLT many years ago, used CLT as a starting point for thinking about how to select therapeutic texts for people with depression (which may involve over-abstract thought and may therefore be benefited by more concrete stimuli) and anxiety (where the opposite may be true) (you can hear a podcast conversation we had together here).

Eating disorders, I think, can be understood as involving disruptions to the zoomed-out-ness of thought in both directions. In one direction, food- and body-related objects distract from everything else (e.g. one’s mental life and daily routines are cluttered with numbers), i.e. thinking and acting are too zoomed-in. In the other direction, too little acknowledgement is given to bodily sensations as opposed to abstractions (e.g. the actions appropriate as an immediate response to hunger – eating – may be supplanted by an abstract idea of control), i.e. thinking is too zoomed out. Heightened levels of both rumination on eating, weight, and shape, on the one hand, and avoidance of thoughts, feelings, and bodily sensations on the other have been shown to predict the onset and duration of anorexia (Rawal et al., 2010). So it really matters how much or little of the two you do. These examples also make clear that there are different ways of zooming out: the zooming out from the experience of hunger to the abstraction of control is never going to be helpful, whereas the zooming out from the experience of anxiety to the knowledge of your own capacity to survive it may well be.

Original from The MET Museum, Wikimedia Commons via CC BY-SA 4.0
Trellis by William Morris
Source: Original from The MET Museum, Wikimedia Commons via CC BY-SA 4.0

The capacity to switch between levels of cognitive appraisal may also be systematically impaired by starvation. People with anorexia have reliably been shown to demonstrate lower levels of perceptual set-shifting ability (the ability to respond flexibly to changing task demands, specifically in the visual mode) (Roberts et al., 2007; Zakzanis et al., 2010). Deficits in verbal and visual memory and spatial working memory have also been found (Zakzanis et al., 2010; Kidd and Steinglass, 2012), which may interact with short-term cognitive flexibility. Like rumination and avoidance, set-shifting deficits have also been linked to duration of anorexia, as well as to severity of ritualised behaviours (Roberts et al., 2010). Other studies have found deficits in anorexia of central coherence: being biased towards local information, with weaker ability to understand context or grasp gist (Tenconi et al., 2010; Lang et al., 2014a, 2014b; Hirst et al., 2017). Most of these deficits are probably due to malnutrition (and the patterns of deficits for people with bulimia are quite distinct), with less pronounced forms in younger sufferers (Lang et al., 2014b), although smaller deficits in set-shifting have also been found in unaffected sisters (Roberts et al., 2010; Tenconi et al., 2010).

So, the ability to zoom out matters. It matters in both illness and recovery. When starvation is trapping you in the minutiae, an inability to zoom out stops you from appreciating the extent of your illness and its effects, and what it’s making you miss out on. In recovery, failing to zoom out prevents you from connecting the dots between the micro and the macro levels of what you’re doing (how eating this dinner this evening will help make you able to have a romantic relationship, etc.), and so threatens the motivation to keep eating and resting, believing that change will grow from the tiniest alterations to the most all-embracing revolution. Not being able to zoom out prevents you from treating the process as a process, with as much patience as determination. It prevents you from understanding how fortunate you are to be able to say yes to recovery and embrace a rich, interesting life once it’s over. 

Conversely, staying endlessly zoomed out is no more of a solution than staying endlessly trapped in the trivia of weights and measures. If you spend your whole time zoomed out in the disconnected world of what thinness and hunger supposedly mean to you, or even why recovery, in the abstract, is so beautiful a choice, then you never take the here and now seriously enough to do anything about it. And so on.

To recover you will probably have to learn how to do three things: 1) how to switch between zoomed-out and zoomed-in; 2) how to link them meaningfully together; 3) and how to make them the right kind of both.

3) is the easiest. This amounts to: don’t be stupid about it. If zoomed-in means weighing out every chocolate button, and if zoomed-out means ignoring every physical sensation, you’re probably not doing yourself any favours. (They are the ruminationand the avoidanceof the article I mentioned above.) On the other hand, if zoomed-in means making sure you don’t let yourself eat less than you planned today, and zoomed-out means you decide to eat despite not being hungry because you know that’s how to train your hunger to come reliably again one day, you’re on the right track. 

2) is part of how to get 3) right. Linking the levels is something that every single day of recovery requires of you, several times over: the ability to remember that yes eating this sandwich and yes resisting this gym session is what will make next year better than this. And of course some candidates for both levels simply aren’t conducive to constructive connection: studying your tummy or your thigh gap obsessively in the mirror and expecting a focus on that to make your life fulfilled is just a rehearsal of the anorexic logic that got you here. Likewise from the other direction, writing intellectualised or aestheticised descriptions of your illness, or wandering down psychoanalytic rabbit holes pretending to need to find its origin, or daydreaming or praying about how to be ‘in recovery’, won’t get you better either. You may decide to grant yourself a little bit of any of them, but they don’t have the brutal honesty of every meaningful linkage.

Beyond the basic requirement of brutal honesty, 3) is to some extent a matter of personal preference. Ever since I was a teenager, I’ve thought of my easy inclination to take the alien’s-eye view of things as a curse and a blessing by turns. A curse because it can prevent deep, sincere engagement in present moments; a blessing because it gives every painful present its future in which the pain will be gone, which makes it already matter less. You’ll have to establish by trial and error what proportion of zoomed-out to zoomed-in works best for you – and expect that it will change as your illness and recovery progress. Before committing to recovery, for example, extreme long-term thinking (e.g. do I want my life to be like this in ten years?) may be helpfully combined with extreme immediate thinking (e.g. how much time have I wasted rehearsing my food intake today?). In early recovery, you may find yourself wanting to engage in cognitive-emotional attempts at solutions (e.g. talking about the problem) when what is really required is practical action (e.g. adding more food to your daily diet) without too much of the longer-term thinking that might generate anxiety about the length and complexity of the process ahead. (For an interesting study on priming health messages for problem-focused versus emotion-focused coping, see Han et al., 2016.) A little later, when your new meal plan and periodic additions to it are relatively well embedded, and your mind is less imprisoned by malnutrition, it may be important for you to reignite motivation and excitement by taking the longer view more often.

The preoccupations of the everyday mean there’s an asymmetry between the zoomed-out and the zoomed-in: it tends to take quite a bit of effort to stay zoomed-out, whereas zoomed-in is usually quite reliably magnetic. So the zooming-out is what takes much more active practice if you’re to be able to switch fluidly between the two. All the more so if starvation is compromising your ability to do anything at all with cognitive fluidity. 

How can you train yourself in the habit? The basic rule to remember is that anything which creates psychological distance makes you think more abstractly. Here are some suggestions:

  • Experimenting with systematic changes to the everyday (however small, this always involves thinking bigger: saying, my day doesn’t need to go like this).
  • Asking yourself at intervals why you’ve decided to recover, or why you’ve decided not to.
  • Asking yourself what thinness has ever done for you, and what it’s cost you. (This relates to the zooming-out importance of treating coping strategies and their side-effects as package deals; see Vitousek et al.’s [1998] excellent article on motivation in long-term anorexia.)
  • Considering your life – how it is, and what you want for it – at different levels (for example, first zooming out to your entire lifetime and writing a few lines about what you desire for it, then gradually zooming back in from the next ten years to the next five, to this year, this month, this week, and back to today).
  • Writing a daily journal of things that have happened today. I like to do this first thing in the morning, in bed with tea, as a way of both recording but more importantly filtering and processing what happened the day before, and what I make of it now, having slept on it. It's always interesting to see what rises to the surface through my pen onto the paper. (I recommend a diary-specific page-a-day volume rather than an empty notebook, to encourage you to do it every day, and to encourage you not to feel you need to write reams.)
  • Seizing opportunities to spend time in other places (even just down the street at your friend’s house for the night), to see your routines anew for their transplantation.
  • Seeking out vast natural spaces that will encourage bigger-picture thinking through a literal perceptual broadening of your horizons. (Even if you live in the middle of a big city, the sky is always here.)
  • Talking to other people (with experience of an eating disorder and without) and listening to their perspectives, both as they resemble your own and as they differ. Imagining or finding out how your eating disorder affects other people.
  • Taking time to appreciate the safety and the quality of the food you can (probably) so easily acquire when you choose to.
  • Reading/listening/viewing widely, on all the wonders of the human and non-human worlds, and marvelling that you exist within them.
  • Staring up at the stars and reminding yourself of how minuscule your suffering is.
  • Acknowledging rather than hiding from the brevity of your existence, and the lives of those you care about. Acknowledging that by next year, you and/or they could be dead. Accepting how sad and senseless it would be to waste any of the time you have left on calorie-counting to keep yourself thin.
  • Making yourself and your life strange to yourself with literature or music or film or visual art. (For literature, scifi and fantasy are obvious candidates here, because they involve systematically increasing spatial, temporal, and/or social and hypothetical distance [Carney, 2017]. Historical fiction obviously does the temporal distancing well. Poetry or other literature with a lot of foregrounded formal innovation that deviates from everyday language use may be able to shift patterns of understanding of phenomena beyond the text (Hakemulder, 2004). And comedy is built on the collision of expectations and actuality – the punchline is where the set-up pivots into the new understanding that creates the shock and hence the laughter, so it would seem a nice testbed for improving set-shifting.) Doing this while eating, as a distraction from the discomfort, is a beautifully apt way of being zoomed out even while doing the zoomed-in thing the zooming-out helps with. (For more on reading-as-self-distraction in the context of mind-body feedback in eating disorders, see Troscianko, 2017.)
  • If you’re a woman, remembering the privilege, and the associated responsibility, of being a woman in the 21st-century ‘West’, who is not a man’s property, who can choose an education and her life’s direction, and resolving not to throw it away.
  • Remembering all the generations of human beings long dead, and all the populations of humans currently living, who would envy you almost everything you have, and resolve to leave behind this suffering you can escape, as opposed to the suffering many cannot.
  • Articulating your personal values. What do you truly care about? What do you want your life to embody? What do you want to be remembered for? What do you stand for?
  • Not taking yourself too seriously. Laugh at yourself, laugh at your anorexia. Laugh at the sheer surreality of being this creature called you.
  • Taking nothing for granted. Neither the suffering that is, nor the release from suffering yet to come.

You may have tried and tested methods of your own for achieving these effects (in the recovery context or any other); I’d love to hear them if so. 

Meanwhile, here are a few ways to prevent yourself from managing to zoom out:

  • Immersing yourself in material or social spheres that are likely to push you deeper into a details-obsessed mindset, whether that’s social media saturated with body aesthetics, or the company of people preoccupied with nail varnish or diets or gym routines.
  • Choosing any form of mental activity that is neither mindful acceptance nor zooming out, but a deceptive middle space of distracted proximity. As I argue here, phones are a great way to get sucked into this, which is one reason why I think recovery is more likely to be successful if phone use is actively limited for a time (and one reason why inpatient clinics often insist on it).

Finally, what about making sure you’re able to zoom back in again? 

I think the two most helpful skills here are mindfulness and good planning. Mindfulness to ensure you know how to actually inhabit the now; planning so you have a structured nowto return to – that is, a now that extends into the near and further futures, by virtue of the pragmatic connections it makes between this fraught meal of ‘too much’ and the capacity to eat future larger meals with relaxed appreciation. To help you, you could try:

  • Practising meditation. Here are some simple guided meditations I like. And here is a definition I like:

Being mindful is 

paying attention 

on purpose 

in the present moment 

with curiosity and kindness 

to things as they are. 

(from a mindfulness session led by Kitty Wheater)

Practise appreciating the raisin or the meal for what it is. Draw on that skill when you need to bring yourself back from the expanded vistas to the here and now.

  • Making explicit what zooming-out taught you, including its direct relevance to the zoomed-in state. You could make notes, for instance, on what the film you’ve just watched made you think and feel, and what it means you need to do the rest of today, to further the goals or values or vision the film made you realise matter to you. 
  • Letting yourself respond to the clash of levels. The zooming-out can be overpowering, in the contrast it lays bare between what is and what could be. But emotion allowed to express itself has a reliable way of wearing itself out and leaving calm in its wake. So try allowing yourself to cry, or scream or shout, or laugh hysterically, or punch your pillows. In the worn-out calm that follows, take a few moments just to exist, listening to your breath, and then remind yourself of what needs doing, and go and start doing it.

Every time you ground yourself again in the reality that is currently yours, know that this is part of your important training in cognitive agility, precisely because it clarifies your vision of what now is, and what isn’t.

Public domain, via Wikimedia Commons
Detail from The Soul of the Rose, by John William Waterhouse, 1903
Source: Public domain, via Wikimedia Commons

The idea of mindfulness is often bandied about these days as a solution to every psychological problem imaginable. But mindful acceptance of the present moment is only half the story. Not being totally mindfully acceptant is what makes human progress possible, on any scale. But if you can never zoom back in again, progress will be meaningless for you, and not grounded in anything that ever had meaning. Treading the tightrope between mindful acceptance of what is and the vision to demand something better for yourself – this is one of the great balancing acts of being human.

And actually we stayed till 9, drinking, and sharing a crayfish and bacon pizza, and then a latte each – and he listens so attentively, and argues thoughtfully, and reveals things of personal consequence – I badly underestimated him, as it were. And all unthinkable a very little while ago. So, got home to make hot chocolate drink and put some vegetables in the oven to roast – and now have a tuna and tomato sauce simmering too. Life is real, and civilised, and enjoyable, and meaningful in the most simple secular way – when one just has strength to live, rather than to subsist, and to be constantly wondering why one makes such an effort to do so. (17 January 2009)

References

Carney, J. (2017). The space between your ears: Construal level theory, cognitive science, and science fiction. In M. Burke and E.T. Troscianko (Eds), Cognitive literary science: Dialogues between literature and cognition (pp. 73-92). New York: Oxford University Press. Google Books preview here.

Curry, N. A., & Kasser, T. (2005). Can coloring mandalas reduce anxiety? Art Therapy22(2), 81-85. Paywall-protected journal record here. Direct PDF download here.

Freitas, A. L., Clark, S. L., Kim, J. Y., & Levy, S. R. (2009). Action-construal levels and perceived conflict among ongoing goals: Implications for positive affect. Journal of Research in Personality, 43(5), 938–941. Paywall-protected journal record here. Direct PDF download here.

Hakemulder, J. F. (2004). Foregrounding and its effect on readers' perception. Discourse Processes38(2), 193-218. Paywall-protected journal record here.

Han, D., Duhachek, A., & Agrawal, N. (2016). Coping and construal level matching drives health message effectiveness via response efficacy or self-efficacy enhancement. Journal of Consumer Research43(3), 429-447. Open-access full text here.

Hirst, R. B., Beard, C. L., Colby, K. A., Quittner, Z., Mills, B. M., & Lavender, J. M. (2017). Anorexia nervosa and bulimia nervosa: A meta-analysis of executive functioning. Neuroscience & Biobehavioral Reviews83, 678-690. Paywall-protected journal record here.

Katzir, M., & Eyal, T. (2013). When stepping outside the self is not enough: A self-distanced perspective reduces the experience of basic but not of self-conscious emotions. Journal of Experimental Social Psychology49(6), 1089-1092. Paywall-protected journal record here. Direct PDF download here.

Kidd, A., & Steinglass, J. (2012). What can cognitive neuroscience teach us about anorexia nervosa?. Current Psychiatry Reports14(4), 415-420. Open-access full text here.

Lang, K., Lopez, C., Stahl, D., Tchanturia, K., & Treasure, J. (2014a). Central coherence in eating disorders: An updated systematic review and meta-analysis. The World Journal of Biological Psychiatry15(8), 586-598. Paywall-protected journal record here.

Lang, K., Stahl, D., Espie, J., Treasure, J., & Tchanturia, K. (2014b). Set shifting in children and adolescents with anorexia nervosa: An exploratory systematic review and meta‐analysis. International Journal of Eating Disorders47(4), 394-399. Paywall-protected journal record here.

Ledgerwood, A., & Callahan, S. P. (2012). The social side of abstraction: Psychological distance enhances conformity to group norms. Psychological Science23(8), 907-913. Paywall-protected journal record here. Direct PDF download here.

Ledgerwood, A., Trope, Y., & Chaiken, S. (2010). Flexibility now, consistency later: Psychological distance and construal shape evaluative responding. Journal of Personality and Social Psychology99(1), 32. Open-access full text here.

Rawal, A., Park, R. J., & Williams, J. M. G. (2010). Rumination, experiential avoidance, and dysfunctional thinking in eating disorders. Behaviour Research and Therapy48(9), 851-859. Open-access full text here.

Roberts, M. E., Tchanturia, K., Stahl, D., Southgate, L., & Treasure, J. (2007). A systematic review and meta-analysis of set-shifting ability in eating disorders. Psychological medicine, 37(8), 1075-1084. Paywall-protected journal record here. Direct PDF download here.

Roberts, M. E., Tchanturia, K., & Treasure, J. L. (2010). Exploring the neurocognitive signature of poor set-shifting in anorexia and bulimia nervosa. Journal of Psychiatric Research44(14), 964-970. Paywall-protected journal record here. Direct PDF download here.

Tenconi, E., Santonastaso, P., Degortes, D., Bosello, R., Titton, F., Mapelli, D., & Favaro, A. (2010). Set-shifting abilities, central coherence, and handedness in anorexia nervosa patients, their unaffected siblings and healthy controls: exploring putative endophenotypes. The World Journal of Biological Psychiatry11(6), 813-823. Paywall-protected journal record here. Direct PDF download here.

Trope, Y., & Liberman, N. (2010). Construal-level theory of psychological distance. Psychological Review117(2), 440. Open-access full text here.

Troscianko, E.T. (2017). Feedback in reading and disordered eating. In M. Burke and E.T. Troscianko (Eds), Cognitive literary science: Dialogues between literature and cognition (pp. 169-194). New York: Oxford University Press. Google Books preview here.

Vitousek, K., Watson, S., & Wilson, G. T. (1998). Enhancing motivation for change in treatment-resistant eating disorders. Clinical Psychology Review18(4), 391-420. Paywall-protected journal record here.

Zakzanis, K. K., Campbell, Z., & Polsinelli, A. (2010). Quantitative evidence for distinct cognitive impairment in anorexia nervosa and bulimia nervosa. Journal of Neuropsychology4(1), 89-106. Paywall-protected journal record here. Direct PDF download here.