How people make decisions – why having anorexia nervosa might make you less free
In the interview studies, we found that there are many ways in which anorexia nervosa can affect whether people decide to have treatment. One of the main problems was that once you have anorexia nervosa, it may become very hard to give it up. There are three different ways this can happen:
• Reasons to keep anorexia nervosa
• Values affecting treatment decisions: the meanings attached to fatness, weight and body shape
• The effect of anorexia nervosa on personal identity
Reasons to keep anorexia nervosa :
There are many reasons to keep anorexia nervosa, when seen from the point of view of the person who has anorexia nervosa. This would make it difficult to decide to have treatment, even if the person is suffering and dislikes some aspects of being ill, because these reasons to keep anorexia nervosa may be very powerful and difficult to ignore.
There are both advantages to having anorexia nervosa, and some important functions it fulfils for people who have it.
Some advantages and functions are relevant to people in general, not just for those with anorexia nervosa. For example, the ability that anorexia nervosa brings to lose a large amount of weight rapidly whenever one wants to is a skill/talent that most people in the general public would love to have.
Some advantages and functions are relevant to people suffering from mental distress or low self-esteem but may not be advantages for other people. For example, anorexia nervosa can provide a focus to distract individuals from their other problems, which is useful if life is very difficult or painful at the time.
Finally, there are advantages and functions that are only relevant within the context of anorexia nervosa; that is, these are advantages as perceived by someone with anorexia nervosa, which would not be thought of as advantages by most other people. For example, some people with anorexia nervosa see suffering from physical consequences of malnutrition as good, because it is seen as a measure of success.
Interviewer: So it sounds like there's something that feels good about losing weight. Yeah, you feel empty. Interviewer: Oh, how is that a good feeling? I don't know you just feel light, you just, you can go to bed and you can just, you just don't feel anything inside you, you just feel, and you feel hungry, but you just, it just feels quite good but at the same time it feels awful but it does feel good at the same time. 29P |
Value systems , and how they can change due to anorexia nervosa
With anorexia nervosa, being thin and losing weight / exercising become really important – this means that other important things in life become less important, as the value placed on thinness exceeds everything else, even the value placed on life itself. There can also be new (or stronger) meanings attached to issues of fatness and thinness. For example, fatness may be seen as loss of control, greediness, laziness, failure, and being contemptible to others; while thinness may be seen as control, success, satisfaction, social acceptance and approval.
Other values can also appear in anorexia nervosa. Thinness can also be seen as being ‘less of me' or literally ‘wasting less space', a desirable thing especially if a person has feelings of low self-esteem.
| “Although I didn't mind dying, I really didn't want to, it's just I wanted to lose weight, that was the main thing.” 09P |
The effect of anorexia nervosa on personal identity
Anorexia nervosa can feel like part of the self; this has implications for accepting treatment, because asking someone to accept treatment to get rid of anorexia nervosa might feel like asking him or her to decide to be somebody else.
Developing anorexia nervosa can be part of issues with development and growing up; at the same time, developing anorexia nervosa can also lead to delays in growing up through missing out on life, normal social activities, leaving home etc. So people who have been ill for a while since teenage years often need to catch up on development, and might feel very immature and inexperienced with life.
Anorexia nervosa can be experienced in several ways:
• It can be experienced as something separate, like an alien presence;
• It can be experienced as distinct, but also part of the self – for instance, as ‘anorexic Jane' versus ‘Jane Jane', both of which exist in Jane who has anorexia nervosa; and finally,
• It can be experienced as totally mixed into the sense of self and indistinguishable from the self.
There are particular problems if anorexia nervosa is acquired in adolescence (especially if early adolescence, and long duration). An adult patient who has had anorexia nervosa since early adolescence might feel she has no sense of a normal ‘adult Jane' to go back to if well. Such a patient might feel she needs to reconstruct a new sense of self, which is a massive and scary task, much bigger than just deciding to get better.
“I haven't been severely anorexic for all the time since I was 12, but I thought about what I'm eating and I've been worried about my weight all that time since then. Because I've had it twice, and it's just become my way of thinking and that's who I am. I mean I don't know any other, I don't know who I am other than I have anorexia.” Interviewer: Do you think that's relevant to the issue about making decisions about treatment, this thing about people not knowing who they are? “Yeah, because I was too scared to give it up, to make the decision. I was too scared because that was who I was, I was the anorexic and I couldn't, I was, even though I knew I wanted, I didn't know I wanted to give it up, I was too scared, and, because I'd be losing me . Who would I be if I didn't, if I wasn't that? I was too scared to make that decision to give it up.” 12P |