This is an updated piece I wrote for the Jessie's Legacy blog in 2018. I find it interesting to re-visit some of the things I have written over the years, to see how my views have shifted or grown. I am conscious that the word "choice" can be very loaded for those in recovery (myself included), so please imagine quotation marks around that word (and its synonyms) throughout this piece.
If you struggle with an eating disorder, have a family member or friend who does, or work with individuals who do, you have likely heard or used the phrase - "developing an eating disorder isn't a choice, but recovery is."
Let's take some time to unpack this statement because there are many layers to it.
Choice is a complex and interesting discussion in relation to eating disorders and other mental health issues. It grapples with some of humanity’s most difficult philosophical questions, such as whether or not we have free will.
Philosophical debate aside, we live in a world that functions under the preconception that we do have free will, and are thus, responsible for the choices we make. However, there has been more recognition in recent years that there are factors involved in choice that are beyond an individual’s control. Genetic, socioeconomic, political, -geographical, historical, and environmental factors – all of these play a role in shaping an individual’s choices or access to them. Not only do these broader factors impact whether or not a person may struggle with an eating disorder, they also influence an individual’s recovery from one.
As we unpack this phrase and the concept of choice in recovery, I want to dig deeper, through the layers of complication. The first layer explores the surface and the farther down we go, the more we explore systemic inequalities.
The First Layer of "Choice" - It's More Than One Decision
It is important to realize that there is not just one choice a person makes to recover – there are multiple choices to be made, multiple times a day. To build towards recovery, an individual is faced with fighting their own thoughts and feelings every minute, of every day. Even if that individual has professional and personal supports in place, they are still faced with being alone in this fight against themselves for much of the time. Obviously there are times it is easier than others, but there is still a lot of time a person can spend alone with their struggles.
Those in recovery are faced with multiple emotionally overwhelming moments every day, and intense emotions in a given moment create challenges to making recovery-oriented decisions. This is not to say that there is not an element of personal responsibility to recovery, of course we might strive to make our best attempts at choices that keep us directed towards a future free from our eating disorders and aligned with our higher values. However, it is also important to recognize that choosing recovery is not quite as simple as it sounds.
Along with these many choices, come many emotions for both the individual struggling with the eating disorder and those around them. The individual may feel an overwhelming sense of guilt for struggling, which may add to their sense of being unworthy of recovery. Carrying around that guilt may lead people towards tendencies that hurt themselves in the end because they feel they deserve it.
Of course, eating disorders (and other mental health struggles for that matter) are not excuses for poor, damaging, or abusive behavior, but I think it can help to understand that choice is not a simple thing ,and potentially negative behaviours are often not done with the intention of causing harm. There is a subtle but significant difference between someone causing harm to another as a byproduct of a choice influenced by a mental health state, and a choice made with the intention of causing harm. I do not think that this is an easy thing to determine (where we have personal responsibility and where things might be beyond our control), but I do think that intention is important to acknowledge. That is not to say we should not expect more from someone in recovery, we absolutely should, but hopefully with as much compassion as we can muster. This will always be a complicated issue, as sometimes it may feel incredibly challenging to know how to be in a supportive role for someone recovering. In some ways recovery is as much a journey for loved ones or professionals as it is for the individuals going through it.
An eating disorder is much like a well-worn pathway in the brain. Its familiarity can make it seem natural or normal, and sometimes it can completely inhabit our thoughts, feelings, and consequently, our actions. When we take a different action, we are are in essence paving a new pathway in our brain. This is the wonder of neuroplasticity - a brain that can change depending on the pathways we use (or the pathways that are activated by external factors. More on this later.)
Every moment we have a chance to take a different route than the one that seems simplest or most familiar, is an opportunity to re-shape our brains and our futures. That does not mean it is easy, but it is possible (although it is important to explore the different barriers that make it more challenging for some, which I shall do in the following sections.) Over time, little moments of changed behaviour (that might seem insignificant) begin to add up and build to something more. By exploring new associations we are quite literally changing the way our brain works, and these new pathways strengthen every time we use them. It takes time and practice to develop a new voice and a new direction in our healing. Eventually we can reach a place where it is not a question or something we say with hesitation, rather it can become our new normal.
The Second Layer of Choice - What Happened to You?
It is well documented that early childhood experiences play a huge role in the brain's development. Adverse childhood experiences, early trauma, and the degree of connectedness (to family, community, and culture) shape the way in which people experience the world and react to it. Instability, lack of connection, and constant stress influence which pathways in our brain are strengthened and which are diminished. Many of these factors are well beyond the control of the individual.
Many individuals who struggle with eating disorders and other mental health issues have experienced trauma, early adverse events, and/or disconnectedness. There are very few longitudinal studies and the statistics vary, but the prevalence of traumatic experiences in individuals with Binge Eating Disorder (BED), Bulimia Nervosa (BN), and Anorexia Nervosa (AN) are startling. BED and BN have particularly high rates of reported childhood sexual or physical abuse, but more research is needed to look at different forms of trauma in various eating disorder diagnoses.
If you have been primed to experience the world in a certain way, before you have ever had the awareness of the damage you may have experienced, you are more vulnerable to further damaging events. As Dr. Bruce Perry notes "we elicit from the world what we project into the world; but what you project is based upon what happened to you as a child."
Later events in life also influence our neural pathways and response patterns, but not as significantly as events that happen in the first few months of life. These influential events are not necessarily brutal; even unintentional mis-attunement in a parent-child relationship in early life can influence the child's development (for example, post-partum depression is well beyond the mother's control, but it can still negatively impact the child.) Exploring how a parent might be even subtly mis-attuned to a child's cues, whether that stems from factors within the parent or the child (e.g. they are a single parent, have a stressful job, are healing from their own trauma, maybe the child is adopted, or maybe the child is born with a particularly sensitive temperment, etc.) is not about blame or shame, it's about supporting the parent with their own challenges so that they can be better attuned to their child's particular needs.
This is why support for parents (and even pre-natal support) are so critical for raising healthy and resilient children. Targeting stresses that the parents experience, particularly the mother, is key. These stresses can occur after birth, but even in pregnancy, research has shown that a stressful environment can influence the epigenetics of the child.
If the individual is fortunate enough to have the opportunity to reflect on and explore early life events, they can begin to unlearn patterns of behaviour. This is where some degree of choice may enter the picture, and individuals can begin to pave new pathways in their brain. This can be achieved through various forms of therapy. Many people think of therapy as undoing what has been done to them, but this is not the case. "Whatever the past experiences created in your brain, the associations exist." Therapeutic techniques are various approaches to making new associations; creating new, healthier default pathways. This takes an immense amount of work and because the opportunity to explore this kind of work is not accessible to everyone, we cannot simply say that it is a choice. This is where we enter the next layer of this conversation, understanding recovery as a privilege.
The Third Layer of Choice - Understanding Recovery as a Privilege
While there are indeed elements of recovery that are a choice, recovery is also a privilege. For many individuals, there are systemic factors that make this journey much more challenging. These factors can include socieconomic status, financial status, colonialism, political factors, environmental factors, racism, etc.
It is very commonplace in mental healthcare (and other aspects of Western society) for the responsibility of healing to be put back onto the individual. Doing so never truly allows us to explore the critical context of how these struggles (eating disorders, addiction, generational trauma, etc.) often arise in the first place.
As discussed above, adverse childhood experiences and early life trauma (or even later experiences of trauma) play a critical role in shaping the brain. But even more influential, is an individual's connectedness to family, community, and culture. For those who have unstable connections or whose cultures are being constantly eroded and erased by war, genocide, racism, and colonialism, the accessibility of healing is vastly different than for those who possess different degrees of privilege.
While personal empowerment is an important part of recovery, to truly create choices for those trying to heal, we have to dig deeper into systemic inequalities. We have to address barriers that go beyond the individual. There is no healing without community healing and addressing systemic inequalities. Until then we are just pulling people out of a river of struggle without looking at why they are falling in, in the first place.
Resources
"What Happened to You?" - Oprah Winfrey and Dr. Bruce Perry
"Trauma-Informed Approaches to Eating Disorders" - (Eds.) Andrew Seubert and Pam Virdi
- S.
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