I think perfectionism is a disease, creeping up on us and spreading into all areas of our lives, colouring and tainting our existence with its demands and judgements. Our professional lives of course, but also our hobbies, our friendships, our intimate relationships and our home life. We need to have the most beautiful house, the most organised schedule, the most finely sculpted body and the fittest mind – honed to within an inch of our lives, most of us are secretly exhausted and longing to take a break.
At least that’s how I felt for much of my life. I was constantly active, competitive, ambitious, and… well, calculating. Even my social life was part of the endless search for acknowledgement and worldly success. I was so focussed on these that I couldn’t make a mistake without feeling crushed. I couldn’t take a holiday without feeling self-indulgent and I couldn’t cultivate friendship without considering if my new friend would be helpful in my search for recognition – it was endless – and lonely.
I was also angry – extremely angry most of the time, because I felt that the world hadn’t given me what I so desperately sought and felt I deserved. I had worked harder than anyone, done all the right things and I believed I was talented – why wasn’t I acknowledged in the ways others had been? Of course, I don’t think I was alone in my skewed vision. Many others were caught up in their own struggles, trying desperately to be heard over the din of voices and claims. Now I understand that they were trying to survive in the only way they knew how – and so was I.
It hasn’t been an easy journey.
That is why I can understand the struggles of young women with eating disorders. Their journey is about control and perfectionism and the fight to be without flaws. As a social work student, I worked with patients who had a diagnosis of anorexia. Beneath the façade of high-achievement it often seemed like they were trying to kill off the part of themselves that was vulnerable, imperfect and shamed – and some of them were successful. Locked in a deadly struggle for life itself, they brought a façade to the world that was highly manipulated and perfected. Armed with worldly success and intellect, anger and hostility seemed to be their primary emotions.
As a student, I found them intimidating.
Now, of course, I realise that they had been so battered by life, so judged and impinged upon, that the only way for them to survive was to become unimpeachable, and their bodies were the arena where this battle took place. They were angry that they hadn’t been allowed, and now couldn’t allow themselves, to just “be”.
Underneath their tightly controlled exterior dwelt an alienated, vulnerable and damaged part of the self that they didn’t want to acknowledge or integrate. Perhaps it was this part of themselves that they were trying to starve to death: the hospital girl and the university student, the dancer and the anorexic, the designer and the girl who vomited up most of her meals. Some were very high achievers, desperate to see themselves defined through the milestones of worldly success – yet they were also overwhelmed by a daily struggle with their bodies – and minds.
I wrote in my journal at the time: “Rather than supporting one another, it seems as if the girls are desperate to compete and display their sickness like a trophy. They are asked to wear baggy clothes, eat pastries and take the lift. So they accumulate tiny victories – surreptitious exercise late at night, or magical kilos stacked on with jugs of water consumed just before the dreaded weigh-in. The ward rounds at the hospital are a nightmare of public failure and vilification, and after these painfully divisive meetings, they sometimes take their feelings out on staff – and on one another. Sometimes it seems like a game. They are resourceful, determined and rebellious. The girls are struggling to maintain their bodies, at war with their physical selves and with the simple health (and joy) of eating well. One girl is so thin, she rarely leaves bed without a blanket which she wraps around her, although the wards are well heated. Often the girls know more about mental health and psychology (in theory) than I do – and yet their own emotions are a mystery (and a danger) to them.”
In an article on anorexia nervosa, Tantillo et al (2013) argue that the ‘essence’ of the illness is the “disconnection that the patient experiences intrapersonally from her/his authentic self and body as well as the disconnection experienced interpersonally with others.” They become alienated from their own hunger and from their authentic selves. In New Ideas about Eating Disorders: Human Emotions and the Hunger Drive, Charles T. Stewart argues that this alienation is often a result of overwhelming emotional experiences associated with eating during infancy and early childhood – emotion is swallowed along with the food. Because these experiences occur at a time when the infant or young child is unable to integrate them successfully they remain in the body and mind and can result in them losing touch with both hunger and satiety.
At one stage during my placement, I was invited into a family session with a girl and her parents. After arriving late, the girl’s father spent much of the session checking his phone and making sure we knew that he had better things to do than spend time trying to understand why his daughter was so unwell. Despite this, I felt hopeful for her – of all the girls in the unit, her anger was closest to the surface – she allowed herself to express her frustration and disappointment rather than burying it in cold rigidity. Again and again I was struck by the lack of real communication in these families. They were evasive and dismissive, lacking the ability or the will to acknowledge the resonance and pain of emotion in one another.
One girl stands out to me, because I could see how the two parts of her were manifesting. I remember thinking how beautiful and sophisticated she seemed when I saw her not long after she was admitted. With her fashionable haircut, friendly demeanour and easy intellect, she stood out. Perhaps the other girls didn’t like her or perhaps her underlying feelings about herself became too much to bear in the face of difficult dynamics and a group of young people struggling with strong emotions. The next time I saw her it was several weeks later and I was shocked out of my complacency. She came to a ward round painfully thin and intensely distressed. Her beautiful hair was falling out in handfuls. There were hints of cyber bullying and I wondered how the dynamics of the ward had impacted on her. The clinicians were concerned that she wasn’t able to accept the help that they were able to offer. She was becoming dangerously unwell and her precarious physical health required an admission to a facility that could offer re-feeding and medical monitoring.
I realise now that her vulnerability was a red flag to the other girls and that she represented a part of them that they despised. For her, though, I am sure the discharge felt like another rejection. Several months later, I saw her again after she had been readmitted. It was near the end of my placement and I was moving on to graduation and hoped-for employment in mental health. She was lying in the sun in the smoker’s courtyard wearing baggy sweats and laughing with the other girls, socialised into the hierarchy of the ward. It was hard to feel optimistic for her.
For many of the girls in the unit, it felt like their anger was so deep inside that I wondered if their vulnerable selves would ever emerge. Those unwanted parts of them seemed to have shrivelled long ago. In the months I spent with them, I often felt estranged and confused by the complex and convoluted dynamics of the unit. I realise now that that was a failing in me and that my fears prevented me from being able to really help them. But now I can.
Unfortunately, we often mistake eating disorders for a physical illness. Certainly, we must treat the disordered eating; making sure sufferers are physically well and strong. But don’t neglect what is at heart a psychological illness. There is a lot of controversy surrounding this debate and I can understand that not everyone wants to be labelled as mentally ill. It is also clear that the starvation itself has an impact on mental health. But girls with anorexia are not people who have just taken their dieting too far. They are not malingering. They are suffering from a pernicious mental illness that can take over their lives and the lives of those who love them. It can also kill. That is why I do not believe that family-based treatment requiring family members to monitor and control the eating habits of the person with anorexia is ever going to work. Just like self-harming behaviour, the disordered eating can become the centre of a power struggle and the need for power and control are a significant part of the illness. We need to recognise the deep hurt and anger that lie at the heart of anorexia and that although families are part of what can go wrong, they are also vitally important to healing. We need to work with them, with every member of these families to try to change unhelpful dynamics and find a pathway to recovery in the face of what can be a fatal illness.