How people make decisions – why it may be hard to give up anorexia nervosa
People said that having anorexia nervosa could affect whether they felt freedom of choice, particularly for decisions about whether to accept treatment for anorexia nervosa.
Two levels of decision-making
We found that there are two levels of decision-making when it comes to anorexia nervosa:
• ‘Global decisions', the big decisions about whether or not one wants to get better, whether to not to accept treatment; and
• ‘Day to day decisions', such as whether to eat that plate of food, whether to resist desire to go out for a run.
People can have ability to make decisions on one level but not the other; and this can be because the nature of decisions can be different. For example, for some people, a decision to agree to accept treatment might be a ‘rational’ decision made by weighing up the pros and cons and relatively easy, but a decision whether to eat that plate of chips might be one that is driven by desires or feelings of disgust and so impossible to make. For other people, the decision to accept treatment to get rid of anorexia nervosa might be one they are just too scared to take, but once they decide that they are going to have treatment or they get forced to have treatment, they can make decisions to eat that plate of food.
I'm sort of being presented with things and being encouraged and so it's not just me consciously going “right, today I'm going to have six meals!” So I think I do want to but I think if I was at home, if, if this had all been left up to me, I wouldn't have been able to do it myself, even though I wanted to put on weight and gradually get better I don't think I would have been able to do it. 19P |
This can explain why people might need freedom on one level but restrictions on another. For instance, some people need and even want to be made to have treatment, but once that happens they can eat and follow the dietary and behavioural programme (e.g., eating more and exercising less) they might be given relatively easily. Other people might need to make the decision themselves to accept treatment and cannot get better if they are forced to have treatment; but despite having decided to have treatment they find they cannot cooperate with the dietary and behavioural programme and need to be given a lot of help to comply, for instance being admitted to hospital or given a lot of supervision and encouragement.
The ability to choose
Apart from the different types of decisions and how anorexia nervosa can affect them differently, we found that it tended to be only particular sorts of decisions that are problems for people who have anorexia nervosa, namely decisions about eating more and exercising less, and decisions about whether to accept treatment.
We found that the drives of anorexia nervosa may overwhelm any ability to wish to have treatment, and it can also affect wishes and ability to act on wishes in different ways. The person may wish to have treatment but be unable to actually say they want help. Or, a person may think they are choosing freely to not eat in accordance with their own wishes, but might discover when they do try to eat more that they actually cannot. Or, a person may have so much suffering if they choose to go against their drives that they cannot take the punishment that would go with this – so it is a bit like having a gun held to one’s head.
Interviewer: If you wanted to eat more than you do could you actually do it? “Well I always thought that I could, like before I tried it I thought all the time well I could easily eat more and stop this if I wanted. But when I came to try to do that I couldn't.” 21P |