Author: emilytroscianko

7: Rendering your limits irrelevant

In this series so far, we’ve used the all-inclusive vacation model to illuminate recovery from a restrictive eating disorder: from adhering to a blanket rule of “as little as possible” to incentivizing “more than necessary.”

We’ve reviewed evidence suggesting that “dietary restraint” is counterproductive, atrophying the skill of eating without top-down rules, and often resulting in the opposite of what’s intended (eating lots once any eat-less rule has been broken).

I’ve suggested that the difference between applying rigid rules and “self-regulating” amounts to whether the feedback is meaningfully incorporated into the decision-making system: whether our actions adjust in response to other relevant stuff that’s happening in ourselves or our environments. In this penultimate part, I offer some pointers for how to tell whether you’re operating with meaningful feedback or not and how to start if you’re not.

In a way, the “self” prefix in self-regulation is a misnomer. There is no little homunculus me sitting in my skull, pulling the strings. “Me” includes innumerable inbuilt signaling mechanisms that evolved to guide human eating and movement, plus all kinds of evolutionarily newer factors like social conformity cues stretching far beyond the individual organism.

And, of course, there’s no hard line at the cellular level between these implicit “rules” and the explicit numerical ones we might also cognitively generate—it’s all just stuff arising from the activity of our neurons and all our other cells.

Someone with anorexia knows better than most people—someone in recovery from anorexia, all the more so—just how automatized the “top-down” rules can get, how seamlessly integrated into the self they can become. They come to pass themselves off ever-so-nearly convincingly as “what I really feel like,” e.g., I’m not hungry, I don’t even like ice cream, I feel better this way, ugh, bacon fat is so disgusting. 

Operationally, though, there is that key difference between the rules that work and those that don’t: the former incorporate feedback, the latter don’t. And if that structural difference is hard to spot (because we’re all experts at self-deception), there’s a simple difference you can glean from the outcomes.

If you’re in the ambiguous not-very-ill-but-probably-not-entirely-fine zone (aka quasi-recovery) and want to tell which method you’re operating by, the million-dollar question to ask is: Do I ever eat “too much” or exercise “too little?” More precisely: Do you ever get to the point where all the signals are straightforwardly saying “I don’t want to eat anymore” or “I really want to move just for the sake of it” because you’ve ignored a subset of the signals that were saying you ought to stop eating or start exercising much earlier on?

If the answer is yes and you feel fine when that happens, great, you probably don’t have a problem. If the answer is no, or yes, and you feel awful when it happens, you probably do.

In the dietary restraint experiment described in Part 2, this simplicity is presumably the point the high-restraint (“dieter”) participants got to at the end when they were genuinely full of ice cream. Or maybe they just stopped because their rule-breaking was freaking them out enough that it felt better to stop than carry on. Or maybe some of them actually got to the end of the tub and would have kept eating if they hadn’t.

If these people started making a consistent habit of eating “too much,” that would be a route for them to switch high dietary restraint for low. Contravening the signals that constituted the blanket priority of high restraint would allow them to start letting other measurements take up the slack. 

How do you actually make a habit of rule-breaking, though? When the rules are as pathologically powerful as anorexia’s, you need serious encouragement to transgress. There are plenty of encouragement types, but the simplest and best is often to change the explicit “do not transgress” threshold.

Do the thought experiment: If you have anorexia and you tell yourself, “OK, I now have no limits, I can eat as much ice cream as I like,” what happens? Possibly, you buy yourself a carton, pick up a spoon, and never look back. Probably, you do nothing.

Having no limit is meaningless because you have no idea how to operate without a limitation to butt up against, with hunger, desire, and the self-satisfied sense of being superior to all those people who eat when they’re hungry and stop when they’re not. Your number is how you know how to stop eating, and it is therefore what gives you the confidence to start.

Given this is how your eating operates—given you know exactly what to do with upper limits—it’s far more sensible to make your first step towards losing all the limits by just upping the limit. That, you can work with. 

However acutely or semi-recovered you’re using numerical limits, you can do worse than just increase your current ones by some non-negligible margin and see what happens. (Or the opposite with an exercise compulsion: gradually reduce the minimum per day or per session.)

What happens when you’re patient and determined, is that in the end, you’ll reach the point where you’ve raised the limit high enough that you can’t actually get there (or, with exercise, where it’s reduced to zero)—in other words, all the other ways of deciding when to stop (or start) have taken over.

In other words, you’ve booked yourself an all-inclusive vacation with limitless food and drink and no need to do anything much. All the other mechanisms that show you how to stop and start have been allowed to start doing their job again because the “300 calorie max.” or “30 minutes min.” (or whatever other) rules have been stopped from pre-empting all of them. 

An alternative or complementary strategy is to turn your maximum (for food) into a minimum or your minimum (for exercise) into a maximum. This gives you an additional explicit imperative to act differently and a different route to weakening the previous rule by ignoring it.

Finally, here’s another way of defining the difference between self-regulating with feedback or not: Do I have only one method for deciding when to start/stop eating (or exercising), or do I have many? The more methods you have, the less you’re probably aware of “having” any at all because they’re all kicking in as and when appropriate: hunger/satiety, the appeal of this specific food, social context, today and tomorrow’s activity levels, how much time you have, what happens to be in the fridge, etc. 

If you try out any of these structural encouragements to develop self-regulation, remember that you cannot set too high a numerical open-loop rule for yourself because all you need to do is stop operating by such rules.

You won’t get “unnecessarily” fat by upping your limit too high because “too high” is the structural prerequisite for the rule’s irrelevance—which is where you can really start living. 

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8: Beyond eating disorders

In this series, we’ve strayed quite a long way from the Playa del Carmen resort we started at, via milkshakes and open-loop versus closed-loop systems. In the penultimate part we circled right back to it: back to how raising numerical limits lets you rediscover what it’s like to self-regulate in a way that works and feels great. Here are the key takeaways from this series on “self-regulation”, or your body knowing what it’s doing:

• Self-regulation can’t happen without feedback. The system has to be closed-loop, not open-loop.
• Self-regulation can’t happen in the presence of a strong external regulator that overrides feedback (e.g., a rigid, exception-free rule) and makes the system open-loop.
• Open-loop regulation in eating disorders is not only ineffective by all meaningful metrics (health, happiness, etc.), it also misses out on even the benefit of not needing to measure, because measurement is going on all the time, just not of anything useful, and not leading to meaningful adjustments.
• An external open-loop regulator (a rigid rule), once habitual, can’t typically be removed just by declaring it no longer exists or applies.
• Instead, we need to devise a process that makes the external regulator unable to operate. For instance, if its job is to impose a numerical limit (e.g., on calorie consumption), we up the limit so high that it becomes meaningless. Alternatively, if you’re so rule-bound that quantifiably increasing your freedom of movement results in no new movement, you can force the change by converting an upper limit into a lower one.
• Once the limit is high or low enough that other regulators (recalibrated satiety, fatigue, or any of the other richly complex signals that constitute “(not) feeling like it”) can kick back in, the external one will be rendered superfluous—or rather, its historical superfluity will be exposed.

This is the core of the story this series tells about eating disorders. Then, there are some interesting wider speculations that these structural principles around dietary restraint and self-regulation could lead us to. They take us out into eating and exercise habits, weight control, and health and happiness beyond the clinical realm.

It’s easy to argue that the evolved systems for hunger/satiety and bodyweight regulation that used to serve humans well no longer do. The familiar argument is that because there’s now so much more readily available fat and sugar on offer and so little need for most people in post-industrial societies to do anything physical to survive, we need new ways of keeping ourselves regulated. The increasing prevalence of obesity (and metabolic syndrome more generally) is typically cited in support of this argument.

The argument that we need new regulation methods for energy intake/expenditure is the standard justification for introducing more and more open-loop regulators into the spheres of eating and exercise. More of these are imposed into our attentional spheres every year, via governmental and medical guidance on calorie intake and weekly minutes of exercise (such as the CDC’s recommended 150 moderate minutes per week or the NHS’s ridiculously arbitrary “5 a day”), supported by all the conspicuous numerical indicators intended to help people apply these rules: nutritional information and traffic lights on food packaging, calorie counts on menus, calories-burned estimates on treadmills and fitness trackers, etc. The demonstrable failure of all these initiatives to make any significant change of the type intended (see Piwek et al., 2016, Jo et al., 2019) seems to lead only to yet louder calls for more of the same. 

On the logic proposed in this series, however, if external open-loop regulators are the problem, not the solution, one would expect that the more widely they’re promoted, the worse the situation will become. On a population level, their spread will increase the prevalence of poor bodyweight management thanks to actively encouraged over-reliance on open-loop regulators that (as the dietary restraint literature cited earlier in this series suggests) don’t work. Given that this appears to be what we’re seeing, despite few significant changes in food production or availability in post-industrial nations over the past decades, there seems to be some evidence in support of this counter-hypothesis. 

If there’s any truth in it, this shifts the causal burden for increasing the prevalence of obesity from modern changes in diet/exercise incentives to the misguided responses to these changes at the level of standard public health initiatives, as well as individual recourse to diets and tracking technologies. In this story, the rise of the extraneous regulators—a great surge of them, ignited by the popularization of fat-reduced diets from around the 1980s onwards, and catalyzed by the tech explosion on which all forms of (self-)quantification easily piggyback—is what has made and will continue to make people fatter in the long run (Jakicic et al., 2016), not what is valiantly keeping a lid on the “obesity epidemic.”

If this alternative story has any merit, even as a hypothetical, then what we need to do is switch the public health focus away from all the numerical distractions that prevent people from self-regulating effectively (see this New York Times piece for a recent overview), and towards encouragements to optimize closed-loop, self-regulation. This might involve training in fundamentals like interoceptive awareness, eating speed (Troscianko and Leon, 2020), power/skill-oriented movement, and many other easily unlearned instincts. Who knows, maybe treating ourselves, and being treated by our governments, a little more like competent adults might reveal that we were all along?

One final meta-point to wrap up: I love how intellectually generative the two weeks in the Mexican sun turned out to be for me. This series is just one of the things that came out of it, along with a post on reasons to dine out alone, plus lots of ideas for course design that I spent fun time scribbling about on my balcony or by the pool or ocean. These things happened precisely because there was no pressure on any of it (if I’d aimed to write two long blog posts and create outlines for a writing support program and a mind/body course, that would have been a great way to wreck the vacation), and because the everyday “shallow work” had been removed to make space for things that weren’t urgent but were meaningful. 

Deep work can happen when all the usual shallow demands are lifted and idleness is embraced, just as real eating and movement can happen when all the numbers are lifted. The good stuff takes energy, and the energy comes from fuel and from rest—of the kind you get only when you know your body well enough to give it what it needs.

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References

Jakicic, J. M., Davis, K. K., Rogers, R. J., King, W. C., Marcus, M. D., Helsel, D., … & Belle, S. H. (2016). Effect of wearable technology combined with a lifestyle intervention on long-term weight loss: The IDEA randomized clinical trial. JAMA, 316(11), 1161-1171. Open-access full text here.

Jo, A., Coronel, B. D., Coakes, C. E., & Mainous III, A. G. (2019). Is there a benefit to patients using wearable devices such as Fitbit or health apps on mobiles? A systematic review. The American Journal of Medicine, 132(12), 1394-1400. Paywall-protected journal record here.

Piwek, L., Ellis, D. A., Andrews, S., & Joinson, A. (2016). The rise of consumer health wearables: Promises and barriers. PLoS Medicine, 13(2), e1001953. Open-access full text here.

Troscianko, E. T., & Leon, M. (2020). Treating eating: A dynamical systems model of eating disorders. Frontiers in Psychology, 11, 1801. Open-access full text here.

5: Milkshakes and dietary restraint

In the first part of this series, we explored the general idea of linking the “more than you need” structure of an all-inclusive vacation with the “more than you’ve always convinced yourself you need” structure of successful recovery from a restrictive eating disorder. I also described the anorexic version of such a vacation (think nocturnal routines and lots of food hoarding), the pseudo-recovered version (full of “healthy eating/exercise” rules and plenty of body comparison) and the fully recovered blissed-out version that was my reality a few months ago.

You can do the thought experiment yourself, if you like: If you were to book a couple of Caribbean weeks for yourself tomorrow, what would your reality be like? What does that tell you about what you could be prioritizing right now?

Meanwhile, let’s take the next step in the self-regulation part of the argument. All-inclusive resorts give us one angle on what it means to make your own decisions: to self-regulate in ways not constrained by blindly applied rules. Some interesting experiments carried out in the 1970s gave us another. They investigated what “dietary restraint” (DR: using self-control to try to limit one’s food intake) does to people’s eating habits when they’re presented with something they like eating (ice cream) after they’ve already consumed a milkshake they wouldn’t normally.

The way DR survives—and is proliferating—as an approach to eating is that it promises you’ll eat less, or make better food choices, and so end up with a slimmer (read “better”) body. Anorexia nervosa (AN) is DR on steroids. AN gets you thin. And it keeps you not eating very much—until it doesn’t.

Many people diagnosed with AN progress to a bulimia nervosa at some point (and/or progressed to AN from something else), and transitions between diagnostic categories are common in many directions and at many phases of illness and life (Schaumberg et al., 2019).

Just as missing a meal often leads to later eating more than what you missed, so chronic restriction often leads to chronic over-eating—specifically in a way that feels out of control and may culminate in deliberate vomiting or other negation/compensation attempts. Of course, this leaves the others: the people who don’t shift from anorexia to any other eating disorder. They either have lifelong anorexia (which is not a victory for the human host), or they recover fully and permanently—a victory for the human and not for DR (or AN).

In the non-clinical context of people who exert higher or lower levels of dietary restraint, the same kind of picture emerges: restraint can not just be fragile, but create fragility. In Herman and Mack’s (1975) experiment, participants were asked to consume either no milkshakes, one chocolate milkshake, or one chocolate and one vanilla milkshake in a fake taste test acting as a pre-load.

Then everyone was presented with three tubs of ice cream (chocolate, vanilla, and strawberry) with another taste survey and invited to “taste” as much of each as they wanted in ten minutes, supposedly to provide accurate taste ratings. The researchers’ predictions were as follows:

subjects required to consume two milkshakes in addition to their daily quota of calories would be in a position of having exceeded the “permissible” limits of consumption for a restraint-governed daily intake. Normally restrained subjects might be expected temporarily to give up the attempt at restraint, once they had come to perceive themselves as having already “overeaten”.

If such subjects had not consumed a milkshake, their normal restraint would remain intact. Highly restrained subjects, then, were expected to consume more ice cream in the two-milkshake condition than in the zero-milkshake condition.

By contrast, subjects who are normally not restrained would not be “triggered” by the excessive milkshakes. Such subjects should behave internally, eating less ice cream after a larger milkshake preload. For both types of subjects, the one-milkshake preload was expected to have an intermediate effect. (p. 650)

The data were a strikingly good fit for the predictions. The researchers found that the low-restraint eaters would simply eat until they were full, whereas the high-restraint eaters who had already had either one or two milkshakes ate more ice cream than any of the others:

Quite clearly, the data conform strongly to the predicted interaction. High restraint subjects consume more ice cream after the milkshake preload than after no preload at all. Low restraint subjects consume decreasing amounts of ice cream as a function of the size of the preload. (p. 654)

One milkshake seemed to be enough to eliminate restraint in the high-DR participants, presumably through the “what the hell” disinhibition effect that leads to counter-regulation. The “dieters” who drank one or two milkshakes kept eating because they’d already failed by breaking the rule, so they might as well fail big. (This “what the hell” effect is the diet-specific version of the all-or-nothing fallacy so pervasive in eating-disordered forms of thought.)

All results controlled for “acute deprivation” by assessing time since the last eating and rough calories eaten then. And it’s worth noting that there was no difference between the “normal weight” and “obese” (>15 percent overweight) participants’ behaviour: The difference that makes a difference is the one between low “restraint” and high, or being a non-dieter or a dieter. So what we have is oscillation between extremes: from long (or not so long) periods of eating less than one would like to shorter periods of eating as much as one would like—which is a lot because the appetite is typically denied. The oscillation, by definition, precludes getting practice at existing in the middle ground of sensing and responding and adjusting without hard and fast top-down rules.

The dietary restraint metric is hard to measure. Subsequent studies have suggested that the original DR scale may have been tapping a particular combination of high restraint and high susceptibility to disinhibition (Westenhoefer et al., 1994) or of restraint plus negative mood, which has been found to be associated with bingeing, purging, and generally more “disturbed” eating habits (Penas-Lledo et al., 2008).

In general, however, the restraint theory literature speaks to a recurring structural feature of what makes recovery from restrictive eating disorders hard: that withdrawal of rule-based restraint inevitably creates a self-regulation vacuum (at least temporarily), because that responsive middle ground is so unknown.

The middle ground was what used to appall me most about the idea of not being ill. Every day was that radical oscillation from nothing to a lot, but intentionally: fast all day, eat a large meal in the dead of night. I didn’t know how anyone could cope with the dullness of just messing around in the lowlands of neither very hungry nor very full, let alone tell me I ought to. I thought the long deep trough and the ecstatic peak were the best kinds of happiness on offer—or rather, I increasingly knew I hated it but didn’t believe anything else could be less bad.

Being well again is basically about existing in the dietary middle ground—which in turn, as I failed to realize back then, makes exploring the much more interesting extremes of other territories feasible (the highs and lows of love, sex, intellectual curiosity, professional ambition, aesthetic creativity, etc.). But crucially, recovery as the process that gets you here is not initially about inhabiting the middle ground.

I’ve written a bit before about how normality can be a slippery concept in recovery (and the more I think about it, the more misleading a guide it seems). One of the worst mistakes you can make at the start of the recovery process is to imagine that your task is to switch straight from an anorexic way of eating to a “normal” one.

Even if by normal you mean not statistically common but good and sustainable—the happily pragmatic way of eating that will sustain you for the rest of your life—you can’t get there directly because your body is incapable of self-regulating. After all, it’s had zero opportunity to do so as long as you’ve been ill.

In the next section, we’ll go on to explore what this mysterious ideal called self-regulation really is.

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6: Self-Regulation, Plus or Minus Feedback

In the previous section of this self-regulation series, we took a look at some evidence suggesting that if you (1) have strict limits on eating and (2) are temporarily disinhibited for some reason (maybe you flouted a dietary rule in a small way, or you were in an altered state thanks to alcohol or strong emotion), you may well break your food rules by a wide margin. A range of recent studies adds further support to the general idea that dietary restriction impairs behavioural self-control: for example, a study from last year found that 10 days of calorie deprivation reduces people’s food-related but not other types of self-control (Standen and Mann, 2021).

Rules and self-regulation

One way to interpret this type of evidence is that dietary rules prevent effective self-regulation. What exactly do I mean by self-regulation in this context? I guess I mean stopping and starting eating because of a sensitive, adaptable set of instincts, not a rigid and arbitrary set of requirements.

Think of the milkshake drinkers we met in Part 2, who normally exercise high dietary restraint: All they’re doing is applying an input rule, and, once it’s broken, they’re lost. Once some researchers have induced them to have the milkshake, but their rule says not to, then the rule is useless to them because it’s already broken. And so they often end up compounding their rule-breaking by eating significantly more than they would have if the rule to eat less had never existed and (maybe most paradoxical of all) more than if they hadn’t eaten anything beforehand. They do so because (1) they have an awful lot of unfed hunger generated by following the rule, and (2) what the hell, there’s no difference between a rule broken by a millimetre or a mile; it’s still a failure. As soon as the boundary of the permitted is transgressed, there’s nothing left to support the supposedly desirable behaviours and resulting experiences. You’re at sea with your standard compass useless to you. 

Closed loop versus open loop

In structural terms, this neatly illustrates the difference between a closed loop and an open loop. In an open loop, you have a rule (say, eat 2,000 calories a day, or run 2 x 20 minutes a day) and you apply it regardless of changes in state. This may have the advantage of simplicity: You don’t need to make adjustments based on a range of measurements. But it also means that uncertainty about the things that matter gets amplified as time passes. You can’t correct for mistakes, either because you have no idea where you are (because you’re taking no measurements of anything meaningful—e.g., you’re blind to how well or badly your life and health are panning out) or because you’re not acting properly on the measurements you are taking (e.g., because you’re afraid to do anything differently, even though you see how badly what you’re doing is serving you). You have no robustness to perturbations, in your environment or in yourself, because you have no way of even gathering the relevant information effectively, let alone acting on it to reliably counteract instability.

This is anorexia nervosa. The main form of measurement going on that’s allowed to have any appreciable effect on anything is the measuring of the input variable to which the rule attaches (e.g., you measure calories consumed so far today to decide whether to eat any more this evening). Other measuring (e.g., of bodyweight or calories in or out), even if it’s as obsessive-compulsive as the behaviour-guiding kind, probably makes no difference to the application of the rule (you eat/exercise the same regardless of your weight, or you eat the same regardless of your exercise, say). If these secondary forms of explicit measurement do have effects, it’s by supplanting any other information you might have gathered about your current state (e.g., feeling tired or unwell, being injured, being hungry).

Thus, returning to the milkshake and ice cream experiment, things get eaten or not eaten depending on (say) a daily calorie rule, and if this rule is prevented from being applied (e.g., some calorie value is concealed from you) or is broken (e.g., overshot because some nasty experimenter induces you to have something all sugary and fatty and unnecessary), the whole thing collapses, because there was never anything else to turn to. As with cruise control that isn’t actually measuring vehicle speed and/or is assuming no disturbances (by road surface, gradient, etc.), the system is fundamentally fragile. It may be stable for a while by accident, but it won’t stay that way for long in the real world.

By contrast, in a closed-loop system, the information gathered is used to determine the next action. For example, say in the open-loop context you have a fixed exercise routine that proceeds every single morning regardless of physical or mental state, location, busyness, etc. The rule (e.g., x reps by y sets @ intensity z) is always obeyed and never changes. In a closed loop, the type, length, intensity, and sheer presence or absence of the routine adjust to all the relevant factors in the organism and its environment. The things being measured are dynamic; the measurements are about assessing the current state in order to be able to act in line with it. 

Most of the closed-loop measurements don’t even feel like measurements in the numerical sense that explicit rule following requires, because they’re automated by evolved biological mechanisms that support performance within acceptable homeostatic bounds (e.g., via ghrelin and leptin secretion, metabolic modulation, force of muscular contraction under load), as well as by automatically introspected inclinations and sensations (anything from musculoskeletal mobility to lethargy to personal/professional priorities for today). All of this is compromised if top-down exercise rules are imposed without acknowledgment of the relevant signals that could prompt self-correction.

In reality, of course, the distinction isn’t absolute. The open-loop version doesn’t manage to entirely override all the equilibrium-geared control systems of the human body. It may also incorporate limited feedback, in the form of compensation for some episodes of rule-breaking, though this is still irrespective of the wider causes and effects. Meanwhile, the closed-loop version has rules of thumb, input defaults that mean, in absence of any off-the-charts measurements of other kinds (e.g. serious DOMS [delayed onset muscle soreness], coming down with a cold), the habitual behaviour will occur, within standard bounds. This reduces the cognitive load of having to make every decision from scratch every time. But all kinds of micro-adjustments (e.g., in amount of warmup, rest time between sets, whether to go for your personal best today), are happening more effectively for the fact that the open-loop rules aren’t constantly trying to override everything else.

If you’re operating open-loop, or attempting to, in the realm of food (or any other life domain I can think of), you’re probably not living very happily, even when you’re not transgressing. So, in the penultimate part of the series, we’ll take a look at what your options are if this open-loop state sounds like you, and you’d like it not to be.

Read on to the final instalment here.

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References

Herman, C. P., & Mack, D. (1975). Restrained and unrestrained eating. Journal of Personality, 43(4), 647-660. Paywall-protected journal record here.

Peñas-Lledó, E. M., Loeb, K. L., Puerto, R., Hildebrandt, T. B., & Llerena, A. (2008). Subtyping undergraduate women along dietary restraint and negative affect. Appetite, 51(3), 727-730. Full PDF download here.

Schaumberg, K., Jangmo, A., Thornton, L. M., Birgegård, A., Almqvist, C., Norring, C., … & Bulik, C. M. (2019). Patterns of diagnostic transition in eating disorders: A longitudinal population study in Sweden. Psychological Medicine, 49(5), 819-827. Open-access full text here.

Standen, E. C., & Mann, T. (2021). Calorie deprivation impairs the self-control of eating, but not of other behaviors. Psychology & Health. Paywall-protected journal record here.

Westenhoefer, J., Broeckmann, P., Münch, A. K., & Pudel, V. (1994). Cognitive control of eating behavior and the disinhibition effect. Appetite, 23(1), 27-41. Paywall-protected journal record here.

1: Introducing the all-inclusive resort analogy

In October/November I spent 15 nights in Playa del Carmen to circumvent the US travel ban and get into the US to see my partner for the first (non-Zoom/WhatsApp) time in 13 months. I decided to splash out, and spent far more on this holiday than I ever have on any trip in my life—especially one on my own.

It struck me right from the moment of typing in my credit card details that this was a nicely anti-anorexic thing to be doing: 1) Spend a lot of money, just on myself, and not because I “had” to, i.e. buying myself something more than I “had” to. What I didn’t realize at that point was how much broader the implications of the all-inclusive vacation model could be for thinking about how to do eating disorder recovery successfully—and maybe even about broader questions around how to do healthy eating and exercise successfully.

Here’s the thesis in brief. All-inclusive is the epitome of incentivizing “more than necessary”: You’re paying to encourage yourself to have as much as possible. You’re paying to put the limits (on eating, drinking, and whatever else your package includes) so high as to be practically irrelevant (I guess you could camp out at the resort bar or restaurant and eventually get told you can’t have any more? but probably not until after you passed out / threw up). The idea is that this is beneficial (e.g. relaxing) because then you get to self-regulate without some major standard constraints (e.g. cost) getting in the way.

In this miniseries I’ll argue that the all-inclusive framework is, structurally speaking, the same framework that’s needed to recover from a restrictive eating disorder (or from chronic dieting): the limit is raised high enough to be irrelevant. (The same applies for a compulsive exercise problem, but switched around: Here the limit is made low enough to be irrelevant.) Only then can you start self-regulating, i.e. start using feedback (e.g. on how you feel, what other outcomes you’re getting), rather than blindly applying rules (e.g. how many calories or minutes or kilometres regardless of everything else).

Of course, the all-inclusive benefits may not, in the vacation or the recovery context, be immediate. Self-regulation may take time to be learnt—maybe a lot of time. I guess some people do all-inclusive and binge-eat/drink in a way that makes them miserable, and some others do it in as miserly a way as if they were paying for every drink and meal, and some people do it just fine but don’t enjoy themselves because too many other things are wrong. Equally, learning how to self-regulate in recovery, and then getting the payoffs for the rest of life, obviously isn’t instant—although in some cases, the instincts for how to do it may snap back into place a lot more quickly than expected.

Letting internal regulation take over.

Following step 1 (spend a lot of money on something where everything is included, i.e. the incentive is now to consume more not less) allows for the magic of step 2: Let the self-regulation happen. For me this autumn, the eating-specific effects weren’t particularly salient, because I’m already self-regulating happily in that realm, but the way eating and drinking adjusted effortlessly to the absence of ordinary constraints was a pleasant part of a broader ease in adapting to having pretty near zero limitations or responsibilities. The most strikingly beautiful part of this holiday—even more so than the blue-green Caribbean water, the palm trees, and the ocean sunrises from my balcony—was how everything simply took care of itself, effortlessly, in the absence of almost all readymade guidelines. 

I don’t recall any time in my adult life when there were so few requirements on me—self-imposed or otherwise. I had a few coaching calls in the calendar, but I deliberately cleared other work commitments for this fortnight, so otherwise it was empty. And this being all-inclusive, there was nothing practical (shopping, cooking, cleaning, etc.) to think about. There were no pre-decided boundaries in my day. Being on my own, there weren’t even anyone else’s preferences to accommodate. There were, basically, no “should”s.

So, what happens when you take the ought out of your life?

In many senses, of course, two weeks lounging around in a swanky hotel has little to do with the rest of life. But it can provide some important illumination for the rest—clarifying it ex negativo, through the absence of what’s ordinarily present. What it does is remove almost all the accreted habits that normally prevent us from answering that question from scratch. There’s never a blank slate, but the slate is a lot freer of old scrawls when everyday busyness is prevented from fooling us into believing we have no options.

“Ditching the ought” has to become a reflex in recovery from anorexia. For a while, a new version of “ought” (eat more, move less) has to replace the old; later, the whole idea of “ought” has to change its nature, become more malleable by context. This progression obviously applies to the diet and exercise specifics, but it’s also about much broader questions concerning how we choose to live and why—which are what the great excitement of fully recovering really amounts to. Now that I get to choose how to live, rather than an illness always already having dictated 90% of the answer, how do I in fact choose to?

If this still feels a million miles away from you, trudging across the endless grey tundra of recovery, this series may serve two purposes: 1) illustrate the basics of how to make recovery work, via the all-inclusive vacation analogy; 2) encourage you to try out such a vacation for real, as a pleasurably literal way to accelerate the process. At the end I’ll also offer some observations relevant to eating well (in the fullest sense of that term) in the absence of an eating disorder but the presence of all the screechy sociocultural signals that can make it feel so hard to find and maintain personal equilibrium.

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2: The anorexic vacation

Unless you’re far more profoundly motivated by the desire not to waste money than most people are, there’s not much point in doing the literal all-inclusive vacation with full-blown anorexia if you’ve done none of the analogous practice of lifting constraints and shifting incentives beforehand. I can imagine with tedious ease exactly what this Mexican fortnight would have been if anorexia had still been running the show. The “oughts” would have kept doing what they always did. 

First of all, I would have had to be brought kicking and screaming (well, the pallid, flaccid anorexic version of that) here in the first place. There’s not much point in someone with anorexia actively choosing a place that costs a lot and is remotely worth the cost only if you enjoy eating and drinking plenty, at civilized times of day. I would have been horrified by everything from the price tag to the idea of eating every meal in a restaurant (though I guess I’d have approved of the fridge and coffee machine in the room, the former topped up by a man with a trolley full of cold cans and snacks every day, the latter adaptable to make tolerable cups of tea). So, I would have needed a really compelling reason to do this at all. Let’s say a parent generously gave this to me, hoping it would do me good.

So I’m here. I arrive on a Sunday evening; the bellboy shows me to my room. Despite the long trip and jetlag I force myself to stay up long enough to have several hot drinks as a prelude to my nighttime meal. I’ve obviously brought lots of special foods with me, probably including cereal bars, cereal, maybe some soy milk to tide me over before I find a shop, maybe bread and/or margarine and lettuce, and of course lots of chocolate and other extremely sweet things. And I’ve gathered up all the plane food to eat tonight—not the main course, which I worried about getting through customs or spilling in my bag, but the bread rolls and the brownie dessert and the mini butters and everything. And I have my electronic kitchen scale (and I’ve probably emailed the hotel in advance to ask whether they have body scales) and I work out how to incorporate these into the immovable framework for my single meal of the day. And that meal is an urgent ecstasy, as always. And I sleep deeply until lunchtime at the earliest. 

When I wake up, I consult Maps to find an acceptable walk to take me to a supermarket to buy more “essentials” and keep me walking for long enough to be comparable to the daily bike ride at home. And when that’s all done and there are maybe a few daylight hours left, I might lie out in the sun on the beach or balcony, self-conscious about my thinness if in public, probably chilled by the slightest warmest breeze. And I feel guilty or at least on edge the whole time about not being productive, and I have some work-related book to read that I’m making faint pencil marks in the margins of (since it’s a library book), and I’m bored by all of them and maybe grant myself a half hour for something I wanted to read, like fiction, but only once it’s night again. 

And because I’m obsessed with not wasting money (I don’t care very much about other people’s money, but still a little bit), I go to the “barefoot bar” and order a wrap or a panini and factor it into my late-night meal, and I go to the café every day to get free coffees and eye up all the cakes and pastries and get several of them every day to have at the nightly high point of my life: eating fat and sugar. 

And the days pass, and I stay in my haze, and my skin gets a tiny bit of colour but I miss half the daylight hours, and I bless the brief respite from serious cold but keep my body unable to insulate itself, and I turn a short daily sea swim into a non-negotiable ordeal, and I don’t speak more than a few words to anyone but make a whole lot of people feel vaguely sad or uncomfortable, and so my time in sunnier climes comes to an end. And I go home the same sad person who spends 21 hours of her day wishing time onwards just so she can eat.

I shudder to imagine this. I drafted this section over wine in between courses and banter with the waiters at the breezy outdoor restaurant. It was hard to write because I wasted so many holidays this way. And I defended the waste, for fuck’s sake. That’s what’s really so infuriating and incomprehensible about this illness: how it makes its hosts think their life is better without it, not so much worse it barely counts as living.

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3: The recovered vacation

So take instead the reality. Not the version where every new possibility is already precluded by a “no”, every old habit already insisted on by an “it couldn’t be any other way”. The version where the decisions make themselves—as they always in reality do, but in all the beauty of their self-determining nakedness. The version where days start at 6 or 7 or 8 or whenever I happen to wake up, and where I maybe start reading a bit of one of my holiday paperbacks (Anne Tyler, Yan Hang, Muriel Spark) in bed, or more likely get straight up, take a quick peek out from behind the net curtain to check the state of the sky, pull on a minimal negligee (I’d always rather be clothes-free), put a teabag and water in the coffee machine, go to the loo, clean my teeth and face, and go onto the balcony to sit watching the sunrise sea while I write my diary and drink my tea. And then most mornings I go to 8am yoga, and usually to some other class later (it was fun to try all kinds of things I never would otherwise: HIIT boxing, TRX, a crazy fitness challenge thing on the main lawn in full view of all the pool-goers), and after yoga I have some variants on eggs, cheese, and meat in the outdoor restaurant, and then the rest of the day is a lazy, soft-edged mixture, drifting between balcony, pool, and beach; between reading, writing, email, work/pleasure Zooms, dozing, eating, drinking, swimming, wandering into town for something. There are few set times for anything, only pretty capacious meal deadlines (breakfast by 10:30, lunch by 4, sometimes a dinner booking); and instead there have been instincts that have come and gone: to drift into a fictional world for a while, to crystallize a new bit of a course idea in writing; to get coffee and a cake (going into the café and not handing over money in return for a latte just doesn’t get old!); maybe to go and lift something a bit heavy in the gym; to have an evening swim in the uplit pool or to sit on the balcony with a beer and salty snacks instead. The extreme luxury of 14 whole days of this feels almost surreal. I don’t talk to a great many people beyond the waiters, but I get lots of cheery hair compliments and have a few interesting chats with waiters and other guests.

And imagining it being gently poisoned from the start is easy—just as easy as imagining it being utterly annihilated by severe anorexia. Take pseudo-recovery, the place so many people stop. What version do you get here? 

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4: The pseudo-recovered version

If you’ve stopped halfway in recovery, you get the version where you do a lot of comparing of how much you’re eating and exercising with how much you would do at home. Where you need to get your daily exercise in before you can relax. Where you think about calories when choosing from menus. Where if you had just the couscous and chicken salad for lunch one day you go without the panini or the wrap every day after that because the lower precedent has now been set (and the same with adding flour tortillas to breakfast, or cake to coffee, or dessert at dinner). Where you have to have a certain number of swims per day, of a certain length, aimed at calorie burning or muscle maintenance (which is all really aimed at how slim or toned you look). Where you limit yourself to alcohol x days a week rather than deciding whether or not you feel like it. Where once you’ve found out about the fitness class schedule, you have to go to all of them, or some subset non-negotiably. Where you spend a lot of time looking at your swimsuited self in mirrors and comparing your body with other people’s. 

(Or, at a slightly more advanced stage of pseudo or partial recovery, where you manage to resist some or all of these instincts but you still feel a lot of guilt and doubt and preoccupation as you do so.)

And this version is a bit less hard to get frustrated or angry about, because it’s easier to see how you kid yourself it’s decent. But it makes me just as sad to think about, maybe more so, because it has even more of an inbuilt self-perpetuation mechanism than the acute-AN version. This is the “stopping halfway” that I’ve written about before, and that many readers said they felt powerful recognition of. (PT removed all comments from all blog posts last year, but I have a copy of the hundreds that were posted in response to the “stopping halfway” piece, and all the others.)

This is the state that tries to pass itself off as the best of both worlds—still relatively thin and relatively free—rather than the worst: not particularly thin, still deluded that thinness matters, and not remotely free.

I guess it looks a lot—at least if you squint and look away pretty quick—like the best you can reasonably expect to get, because pseudo-recovery and normality are getting harder and harder to tell apart. But if you’re in the former camp, you have one great advantage over those in the latter. You know that this is part of a process that you’ve begun and that you can decide to resume and complete. You’ve already got from 0% to 80% or 90% recovered; you can certainly manage the last 10% or 20%. 

If it helps, start planning a vacation like this (or not at all like this, but dreamily different from the everyday and opening up the space for self-regulation in whatever way works for you) and remember how elusive but how entirely unfakeable the difference is between the experience you get if you complete this process versus if you don’t. 

It’s not quite like being a child again, the good version, but it also kind of is: It’s doing what you want, when you want, and not even any parents to tell you not to, because now you know enough to sense when you want and need your own bedtime to be.

Read on to a milkshake-themed Part 2 here.

Reasons to schedule solo restaurant meals into your recovery, or your life.

When did you last eat out alone?

Until last month, for me the answer would have been “I have no idea—not for years, maybe never.” That’s if you mean doing it properly: going into a restaurant on your own, ordering an entire multicourse meal, and eating it alone.

Done properly, eating out alone ticks a bunch of big anti-anorexic boxes: Eating unfamiliar foods; eating foods prepared by other people; likely eating more than usual; eating around other people; doing nothing else whilst eating; spending “unnecessary” money on food; spending “unnecessary” money on yourself.

This autumn, the perfect chance for a crash course in solo dining came up. The US travel ban meant I hadn’t been able to see my partner (who used to live in Pasadena, now New York) in person for a year, and although the internet was constantly full of mutterings about the ban being relaxed, it kept not actually happening (it finally did last week). In the end I decided it was worth doing the “standard” workaround: Spend 14 days in a non-banned country and enter the States from there. Mexico seemed like a good bet, and I spent ages on TripAdvisor et al. trying to choose a hotel.

All-inclusive seemed a nicely low-hassle way to do things, and I ended up splashing out on 15 nights at a swanky beach resort south of Cancun. Unless you want to go wild on room service, doing all-inclusive means eating a lot in restaurants, and unless you’re keen on making fast friends, doing all-inclusive on your own means eating a lot in restaurants on your own.

I was interested in how this would go. I had some predictions, most of them not particularly optimistic, e.g.:

1. Assuming hardly anyone else will be on their own, I’ll feel self-conscious or even embarrassed about it.

2. It’ll feel weird/difficult to not be doing anything else while I’m eating—but I also don’t want to be reading a book or on my phone, especially in the evening.

3. It’ll feel like a waste of time to do this several times a day; it’ll be boring.

4. It’ll get easier with practice.

If this hadn’t been all-inclusive, the final prediction would have been:

5. This will feel like a colossal overindulgence and waste of money.

The last prediction was actually one of my reasons for choosing this format: I wanted to give myself a strong incentive to do all the nice things without money being an issue.

As it turned out, my first three pessimistic predictions were miles off. The fourth was, as usual, spot on.

I arrived mid-evening (after a 16-hour journey plus 6 hours of jet lag) so having dinner straightaway made sense to kickstart the timezone adjustment. I’d had the sense in advance that it would be important to begin well: to make doing this restaurant thing the norm from the outset. I chose from the six or seven resort restaurants at random, kept it to one course (plus bread and wine), and was tired enough that my main feeling was gratitude for the wine and the simplicity of being brought things that tasted nice. I was soon done and off to bed.

The next morning, the outdoor place for breakfast was a delight—and remained that way for all my 14 mornings. It was lovely to sit down and be brought limitless decaf refills, feel the Caribbean warmth, and admire the blue skies beyond the covered terrace. That first morning I was a bit zonked from the travel and the heat and humidity, and simply from being in a different country after all this time stuck in Britain, and my huevos rancheros went down extremely well.

As the days and meals passed, I learnt the breakfast menu off by heart, stopped bothering with other restaurants because this was the only one with proper outdoor seating, and got friendly with the morning and the evening waiters. At breakfast I sometimes read the New York Times morning briefing or similar on my phone, or brought a magazine with me. At dinner I rarely used my phone (occasionally for a few WhatsApp messages or something—or to take these photos!) and sometimes took my notebook to scribble in.

At lunch I used the sandwich bar for panini, wraps, etc., and the novelty of getting a latte and a cake from the café and handing over no money never got old. I saw I think a total of two other people eating on their own—it was a very couply place, and mostly a bit older than me—but I never once felt remotely uncomfortable about it. Indeed, the luxury of eating this way is a big part of what made the trip a bright serene oasis in my year, in the living and the remembering.

I thoroughly recommend dining out alone as a way to accelerate your recovery or just to acquire the skill of taking pleasure in something you might otherwise never have realized you could. The more conflicted you feel about trying it, the more good it may do you. To make the case and give my top tips, here’s what I learnt from my two weeks of solo eating out:

1. Using your phone defeats the entire purpose of practising being alone. I therefore recommend a strict no-phone rule to begin with. The rule can be relaxed once phone-free has become a comfortable default. (See this post for more on why phone-free time matters so much in recovery.)

2. Doing nothing else while eating needn’t be a rule, in recovery or the rest of life, but with encouragement it can become a nice default. (I’m now deliberately not getting something to read or listen to while eating when alone at home. It feels nice for the baseline to be no accompaniment.)

3. It is possible to be gently aware of your surroundings and other people without feeling like (or giving the impression that) you’re either staring at people or ignoring them. I shared some smiles and other nice little acknowledging kind of interactions with people (and once joined a couple for tequilas at their table), but on the whole just got on with my thing as they did theirs.

4. The typical lack of awareness of one’s surroundings when in a group or (especially) a couple is very noticeable when you’re observing from the outside. (No real point to this other than: Being alone really does enhance a certain kind of mindful embodied presence.)

5. Time passes. An evening meal, for example, has lovely natural rhythms: water, wine, ordering, bread and butter, starter, main, maybe pudding. These rhythms take over; they look after you. Curated mealtime structures become part of the rhythms of a day that is begun and ended and punctuated with them.

6. If you don’t do anything else with this time, it can become time for experiencing and for thinking that would not have existed otherwise. I had some interesting and important thoughts whilst sitting and sipping and taking mouthfuls of things. None of us is bored nearly enough these days, and new thoughts tend to come only when we’re a bit bored, i.e. where there’s not yet another thing keeping us occupied. A mealtime setting (eating and drinking to be doing, but nothing else) is a nice way to create a state that’s “boring” enough to be fertile but not so much so that we resent and curtail it.

7. Having a table at the edge of the room, looking inwards, helps. (Once I sat in the middle and had a slightly uncomfortable feeling of not knowing what was going on behind me. I’m sure this would improve with practice too.)

8. Waiters being lovely helps.

9. Alcohol helps 🙂

10. Taking the money out of it (except tips, sadly) helps.

11. Everything gets easier with repetition. And for me at least, this proved to be one of the many things that get ultra-easy with very few repetitions.

12. Morning scrambled eggs are improved by the addition of black bean sauce.

13. Nightcap sambuca is not improved by the addition of coffee beans.

If you give this a go, I strongly recommend doing it more than once (if not 28 times) before drawing your conclusions.

My conclusions are: Eating out alone is a liberated luxury, and it’s lovely to be able to experience it as such. Trying it out could be a great way to test the strength of your recovery, and to strengthen it further.

Doing this experiment has also given me an idea I wouldn’t have had otherwise. Editing this post, it just occurred to me that there could be no more fitting way to remember my father on the tenth anniversary of his death than to eat rare rib-eye and béarnaise and fries and drink claret at the place where I did so with him back in 2008, a few months into my recovery. Being alone feels right for this, because I won’t be.

Help shape the future of an unpublished book about recovery from anorexia.

A new study investigates the effects of reading a book about recovery from anorexia designed specifically to encourage positive therapeutic effects and discourage harmful responses.

I’m excited to announce an opportunity to take part in an experiment investigating how reading habits and eating disorders intersect. As I outlined in my post on “Consuming fictions”, when it comes to narrative reading and eating disorders (or illness in general) the assumptions far outweigh the known facts. There’s quite a bit of evidence on the benefits of self-help bibliotherapy (reading a relevant self-help book with or without professional guidance), but we know very little about books in other genres, like novels, short stories, or memoirs. This feels to me like a gap that needs filling (Troscianko, 2018a).

Previous research

The empirical eating disorder-specific research that’s been done so far has, to my knowledge, mainly been conducted by me and by my colleague Rocío Riestra Camacho. In a large-scale survey study published in the Journal of Eating Disorders in 2018 (Troscianko, 2018b), I found that fiction about eating disorders (which in practice our respondents, most of whom had personal experience of an eating disorder, also took to include memoir) was perceived to have had almost universally negative effects on all the dimensions we investigated, sometimes thanks to deliberate self-triggering. By contrast, fiction that has nothing to do with eating disorders was generally perceived as having been neutral or positive in its effects. 

In a more recent study conducted as part of her PhD, Rocío presented her cohort of healthy volunteers with two works of young adult sports fiction by Miranda Kenneally: one group read both as published, the other group with a reading guide (presented via pop-up messages in the margin) specially designed to help readers draw out positive lessons from the texts with respect to eating, the body, and exercise. The choice of genre was an interesting one: Sports fiction obviously thematizes food, exercise, and the body, but in a context quite different from an eating disorder. The study found a significant difference between groups on level of espousal of gendered body stereotypes, which reduced for the group reading with the guide. There were also statistically nonsignificant trends towards improved results on the EAT-26 (a standard measure of eating disorder susceptibility) in the reading-guide group and towards worsened results in the control group who read the books in their standard form. You can hear more about how Rocío designed the experiment and what she learned in a recent Textual Therapies podcast episode.

Thus the little evidence we have highlights the real potential for reading to have eating disorder-relevant effects, in both desired and undesired ways. As far as I know, however, no experimental research has been conducted involving participants with an active eating disorder reading an entire book that isn’t a self-help book. Memoirs are a troublesome genre: They may often or usually be written with the professed aim of being useful to readers, yet the same authors often also remark that reading other people’s memoirs about eating disorders exacerbated their illness (Jones, 2020). Memoirs may of course be written with “usefulness” aims that aren’t therapeutic—most often, with a vague “awareness raising” intention (which may or may ever get meaningfully furthered). Or the intent may be explicitly or implicitly self-therapeutic, or “cathartic”: more about what the writing process does for the writer than about what the finished product may or may not do for its readers. In any case, most authors don’t attempt to systematically find out, before or after publication, what uses readers put their books to, or what responses they may have elicited in readers, inadvertently or otherwise.

This experiment

This study, on which Rocío and I are collaborating, will be the first to assess the effects of reading a book about recovery from anorexia versus the effects of reading a book with no relation to eating disorders (though with structural and thematic similarities in other respects). The book about recovery is called The Hungry Anorexic. The book hasn’t yet been published, and the experiment will determine whether it gets published—in its current form, in an edited form, or not at all. Precise statistical cutoffs have been specified in advance, and if the book “fails” these tests, it will not be released. If specific elements turn out to be significantly problematic, they will be revised. 

This project invites a new kind of readerly involvement in the authorial process, and I’m excited to find out what happens when readers get to shape the publication trajectory of a text.

The experiment involves reading one of the books (you’ll be assigned randomly to one group or the other) within a roughly 2-week period, and completing some questionnaires and open-ended questions 1 week before, at intervals during, and 2 weeks after. You’ll be asked not to read any other books about eating disorders during the 5 weeks of the study. If you’re interested in taking part, and you’re 18 or over, currently have a restrictive eating disorder or are recovering from it, have a BMI of 15 or over, and are fluent in English, as well as identifying as female, you’re warmly invited to read more and consider signing up to take part. Everyone who completes the study can choose to be entered into a prize draw to win one of four prizes of GPB 100 (roughly USD 140).

You can read more and sign up for the study here: https://oxford.onlinesurveys.ac.uk/eating-disorder-narrative-study. Do get in touch with me via the contact form if you have any questions not addressed by the information sheet.

And if you’re interested in reading in the recovery context, but don’t want or aren’t able to take part in this experiment, you might like to check out the final section of the post I mentioned earlier for some recommendations on how to read in recovery. Tldr: Read things you love that have nothing to do with eating disorders, and keep eating!

References

Jones, K. (2020). Representing young men’s experience of anorexia nervosa: A French-language case study. Medical Humanities. Direct PDF download (preprint) here.

Troscianko, E.T. (2018a). Fiction-reading for good or ill: Eating disorders, interpretation and the case for creative-bibliotherapy research. Medical Humanities, online first 21 April. Direct PDF download here.

Troscianko, E.T. (2018b). Literary reading and eating disorders: Survey evidence of therapeutic help and harm. Journal of Eating Disorders, 6, 8. Open access here.