Research into Anorexia Treatment

Sophie is writing to you about the research project that she is conducting as part of the Doctorate in Clinical Psychology at UCL. My project aims to explore how Externalisation of Anorexia Nervosa can Help and Hinder Recovery from this Eating Disorder.

She says

We are carrying out this research because although externalisation (viewing and talking about anorexia as a separate entity that is external to the individual receiving treatment) is a widely used therapeutic technique within therapies for anorexia, research exploring how externalisation helps and hinders people’s recovery from an eating disorder is very sparse. Our research aims to further our understanding of people’s experiences of externalisation in treatment for anorexia in order to learn how this approach may or may not support recovery from an eating disorder. We hope that by exploring a common strategy used in therapies for AN, this project will help to inform and improve treatments for anorexia. To help increase people’s chances of recovering fully from an eating disorder, it is important that we understand the views of individuals who have received treatment for anorexia. Therefore, we aim to obtain people’s views through semi-structured interviews which I will be conducting online.  

We are looking for people aged 16 and above who have received at least one or more NICE recommended therapies for anorexia, who may or may not have reached a point of recovery from an eating disorder, and who are familiar with the notion of externalisation in treatment for anorexia.

To recruit participants, I have posted on my linked in, twitter and facebook accounts. However, I would be enormously grateful for any support that NCFED may be able to give to raise awareness of the study among the target population which NCFED have greater access to. I would be happy for you to post about the study or alternatively you can share / retweet my posts. Below I list my accounts on social media, however, please do let me know if there are alternative or additional methods of raising awareness that NCFED may be able to support with. I attach my leaflet for your reference.



Linked  in:

Another Step Another Story for Anorexia Recovery

I’ve been sent a blog about anorexia recovery from Jessica Mell who tells me
“I am inviting you today to view my blog, engage with its content and use the platforms that you have in order to help me communicate with others; ultimately giving hope and support to those that are in need. I am passionate about making a positive difference to the way that mental health issues are viewed in society and to the support that is available”.

So here you are. If you want to take a step into anorexia recovery and start to live you might want to read Jessica’s blog. As I keep saying, it is not a crime to eat. Visit

Recovering From Anorexia And Bulimia

Anorexia Porn: Who Needs All The Grisly Details

During the last year I have read 4 manuscripts by anorexia sufferers who have written about the fine detail year on year of all their suffering. They have asked for my advice about publication.I have also read 3 published books by people who have actually found publishers for their books, to join the list of what some of you might call misery memoirs. These books usually are written after a degree of recovery but they are very tough to read as the behaviour which is a feature of the illness is revealed in all its stark detail.

I have to be honest with you, me and my staff as well,  who know a lot about eating disorders were dismayed (that’s the best way I can put it) by so much reading of the accounts of the things people do to themselves and others with this compulsion to get and stay very thin. We are all suffering from Post Traumatic Anorexia Disorder. It is very hard reading, and a great deal of suffering all round.

As we move into Eating Disorder Awareness Week what really do we want to be aware of, tell me please? What kind of understanding do we seek?  My question is, to what extent is this grisly detail useful for sufferers? For the public?  For therapists?

In her book Almost Anorexic which is a nice book, the Author Jenni Schaefer cautions people from reading accounts of anorexic and bulimic suffering. She says, and I agree,  that it will only increase worry, obsession and activate the competitive instincts of anorexics.

“OMG she got to 35 kilos, it means I’m definitely not thin enough yet!”

“OMG she ran a marathon on nothing but jelly beans, I’m certainly eating way too much!”

“OMG she began to purge, that’s a good idea, I might try that too.”

“OMG I’m not purging, that means I’m greedier than her.”

What is it that drives people with eating disorders to need to set down in writing all this pain. Is it just another form of “look at me” or is it part of the way that they can make sense of what has happened to them and recover. I don’t really know as yet.

But…. I have decided that these accounts do more harm than good to patients and are only useful to therapists who need to read all this to get a proper sense of the demons they are facing. This illness is very, very tough. It is an illness which is invited in and which doesn’t want to leave.

So as the manuscripts pile up on my desk,  I will read them all but heaven knows I need some strength and I probably have seen enough for the moment. I don’t know if reading these memoirs or even broadcasting skeletal images on TV is going to help.   What I really welcome are the accounts of recovery, like the work of Jenni Schaefer and also Emma Woolf;  leaving out the pain of what went on before in all its grisly glory.

Starvation and self harm are not a pretty picture and knowing too much about it can kill.

Emma Woolf Lets Go And Heals

Emma Woolf, author, journalist and journeywoman of Supersize and Superskinny fame has written an inspirational book about her updated journey into recovery: Letting Go: How To Heal Your Hurt, Love Your Body and Transform Your Life. The title of the book means what it says, because Emma has discovered how to transform apparent recovery into real healing. Recovery means getting well, healing is something else, it is about making real caring amends to body, mind, soul and other people who have been blighted by the illness. It is about living a life which is not dominated by anorexic rituals and thoughts. True transformation isn’t about gaining weight – we all know that. It is about being free. I urge all people with eating disorders to read this book and be inspired by someone who has been there before you. Emma my friend, good for you.

Weight Restoration: Guest Blog

I just love your thoughts and contributions to our website. Here is one from Hannah Brown celebrating her recovery from anorexia. I hope that this will help some of our readers and is offered with love. Here it is…

Weight Restoration Vs. Weight gain- the importance of semantics.

As anybody knows the crux of the journey back from the depths of anorexia is to restore weight after what will have probably been quite a dramatic loss.

Previously, weight gain has been the concept favoured by professionals. ‘Gaining weight’…the one thing that sufferers have been trying to desperately avoid in previous years- now suddenly gaining weight is the only option.

In my latest admission however the concept has changed to WEIGHT RESTORATION. A one word difference, surely it can’t make that much difference?

Consider for a moment the art of restoring a stately home, restoring it to it’s former glory. Bringing life back into a shell, giving it a personality and a purpose.

For me I know the importance of gaining weight, not only for the physical benefits but I know that my cognitive abilities will greatly improve once I have weight restored. My brain, is after all a muscle, it needs fuel and energy to work and for someone who works hard academically, my brain is possibly my most important muscle so I need it to be switched on and ready.

Fighting Anorexia is incredibly difficult but by WEIGHT RESTORING  I believe that I am restoring my frame to it’s former glory. It is more than simply gaining weight, it is so much more than watching the figure on the scale go up every week.

In todays society weight has become an obsession, and this is echoed in recovery. Often I feel that I might as well walk around the ward with my weight tattooed on my forehead.

I am weight restoring, but this process means that I am restoring myself to my former glory. I am bringing life into my once tiny frame, and giving myself the sparkle of life. My eyes are shining, my hair is glowing and my skin is healing. I have strength and power and am restoring my personality. The segments of my life are falling back into place, piece by piece. Just like the house being restored to a home. I am gaining character and wellbeing.

Day by day,

Hour by Hour

The process of restoration, of a home or of ones self requires many actors. Builders, architects and designers… Similarly in restoring myself I need the support and help of many:  Doctors, parents, friends and Partners. Weight gain implies something quite independent and almost simplifies the process… Restoration is a project, a long term dedication. It requires hard work and is quite frankly exhausting. Often the process can take  months, years even and very often there are huge hurdles to climb, obstacles to negotiate and the unexpected to face.

But is it worth it?  At the end of the house restoration you are left with a beautiful home, tailored to your needs and your creative ideals. It is your home and your sanctuary.

Ones body is exactly the same, it deserves the love and passion necessary to restore it back to its full potential. To give it life, colour and vibrancy.

It is definitely worth it, so, so worth it.

I Am Not My Eating Disorder! And I’m Better!

Here is what one of our people has written about her recovery with one of our therapists.

When my journey with H began in May/June 2013 my life revolved completely around my compulsive disordered eating behaviour. I was caught up in a relentless ritual of binging and purging averaging 30 times a day, which had persisted for nearly 10 years. This had pretty much robbed me of my twenties, and I had been told by a GP that I was to quote; ‘a hopeless case’ and ‘would be inflicted with my disorders’ for the rest of my life.  My health, studies, finances and relationships were in constant jeopardy. It seemed both my secretive and public displays of compulsive binge eating had robbed me of any dignity and self-worth. I was also engaged in cycles of dangerous binge drinking behaviours around every 6-8week. These resulted in week long black outs, which rendered me bed ridden and often in various A&E departments through physical injury or dehydration.

Below I have summarised a non-exhaustive list of treatments I had received in the 10 years of being afflicted with my bulimia/compulsive binge-purge behaviour. None of these really had any significant impact on my rituals or associated psychology, some even had a negative impact.


  • CBT & CAT (NHS)
  • 1 outpatient treatment admission (4 weeks – NHS)
  • 4 x Inpatient admissions (Woodbourne Priory –for 9 months, QEPH for 1 month (+ 2 x self-discharge short stays))
  • Counselling (private, NHS, University practitioners)
  • Hypnotherapy (4 x practitioners)
  • Homeopathy and acupuncture
  • Anti-depressant and anxiolytic drug therapy (x6 flavours)
  •  Alcoholics Anonymous and Over Eaters Anonymous

Below I have outlined the main areas in which my work with H has helped transformed me from the former shadow of myself into the person I could and should really be. This is my path from up to £30 of food consumption, <8h binges and <50 vomits DAILY, to someone at a consolidation phase of full recovery.  Structure – and commitment to it!

From my first session working with H I understood that beating this problem was going to be a team effort! I had to commit to my part of the deal – keeping organised, documented and structured eating times. I also had to abstain from highly refined sugars and carbs (which by my own admission I was addicted to).  The former is something I found particularly challenging, but even when I didn’t succeed the process knowing I had a plan to stick to really helped me get ‘in the moment’ about what and when I was eating. A large part of this work involved breaking habits (eating whilst driving, stopping for food at service stations and works canteen).  What really helped me with this at first (and still does), is having all the meals and snacks I need for the day prepared and taken with me for the day in discrete packages. I got my partner involved with this process; I trust his judgement implicitly so I know his definition of a ‘snack’ or ‘meal’ portion is going to be about right for my needs. This stopped all the canteen visits and unnecessary trips to the supermarket. 

The psychology of ‘taking control’ of my own recovery early on in the process gave me great confidence, and stood me in an empowered frame of mind for the more emotional work to come later.

 I am not my eating disorder – I am me, and I am OK!

I think a significant portion of work I have done with H has been focused around re-establishing my identity. I learned to acknowledge that my eating disorder was simply an exhibited behaviour and did not define me or reflect who I was. This freed me from punishing self-judgement and was very important re-establishing my confidence. Additionally, I learned that I should not define myself my successes or failures in life. I have come to understand the importance of being authentic and free to be myself, free from the fear of failure and the burden of perfectionism.

On a related theme, much work has been based upon how I respond to the opinions or comments of those around me. I have been learning to embrace the fact that I cannot change how other people chose to respond or behave towards me. I am free to vocalise my thoughts and feelings assertively and with immediacy in any situation. This approach reduces the probability of harbouring resentments the associated frustrations that comes with bottling emotions.

 I also need to be aware of getting ‘hooked in’ to peoples comments or opinions and that I have a choice as to how to respond. In short, I alone have control over my own emotions and how I feel about things. Ultimately whatever I feel about things should not lead on to negative behaviours such as binge eating/drinking. The Thought → Feeling → Behaviour pattern is something H has worked quite closely with me on, and having the ability to modulate my thought processes has certainly helped level out my mood states which have progressively improved over time.

 Tolerance! – ‘I can bear this!’

Tolerance of situations and circumstances that I find uncomfortable has been a significant work focus over the last 10 months. My perceived inability to cope with difficult circumstances has historically led to a heightened anxiety and an apparent need to comfort eat in order to ‘cope’. My tolerance of boredom and motivation to do tasks I find particularly challenging or difficult has in the past led me to use excessive eating as a procrastination tool and form of avoidance tactic.  Heather has helped me become aware of triggers which might lead me towards such a negative mind-set, and also evaluate previous similar situations as evidence that in reality I really can cope. Instilling an ‘I have done it before, I can do it again’ kind of mind-set is the best way I can describe it. I have a simple mantra of ‘I can bear this’ and ‘I am capable’ ‘just get on with this task’, which really helps stop me catastrophizing situations that really aren’t that big of a deal.


I have a tendency to be really hard on myself and can be quite self-punishing if I do not achieve my own personal expectations (or what I perceive others expectations to be). In session we have touched on the concepts of being compassionate to oneself (and others), and being vigilant about squashing negative internal dialogues. I have been encouraged to be aware of what kind of a story I am telling myself in my thoughts; is it unhealthy or unkind? Would I expect this of someone else? Am I viewing this in the right way? This has helped me be a little kinder to myself and be mindful about unhelpful thinking patterns. I am also aware of triggers that might lead me down such pathways (e.g. running a bad race, an experiment going wrong at work) and allow myself extra processing time to deal with them.

 Feel the fear and do it anyway

I think this heading is covered by little segments of all of the above sections. In a nut shell, FEAR doesn’t lead to FOOD (or any other emotion for that matter!). I can tolerate uncomfortable feelings, I practice uncomfortable situations with assertiveness and I bear misplaced feeling of hunger I understand are only in my head. I have learnt (and continue to learn) tools and techniques for dealing with my thoughts that have essentially made the eating behaviour redundant. I do not need it, it has become an unnecessary pathway and the less I use it the more unnatural it becomes. I am currently in the phase of relapse prevention, where I’m being shown how to deal with mishaps with compassion and re-assert eating structure quickly and effectively.  


The above five points perhaps only scratch the surface of how working with Heather has helped me over the last year, but it has been a positive experience for me to consolidate what has been important to me in my recovery. I hope it provides insight into what kind of therapeutic approaches have been so profoundly beneficial for me in this wonderful year of personal growth. I am now in a position where I am for the most part completely free from bulimic and compulsive eating and drinking behaviours. Recently I have averaged around one vomit per month, which compared to 30+ daily is nothing short of miraculous and has far exceeded my wildest dreams in terms of recovery. I am also T-total in terms of alcohol, and have had no drinking episodes for a considerable time period. My physical health has recovered rapidly, I have more energy and concentration to focus on my studies. I enjoy running and cycling with my partner and a local club, and am competing in my first triathlon on Sunday. 

One final point I’d like to mention as it’s particularly striking for me is that with H’s work, it is not just the eating/drinking behaviour that has been abolished but all the compulsive thought patterns and emotions that accompanied it. Sadly, I have come across a lot of extremely miserable T-total alcoholics and people in recovery in the past. I had feared that if I recovered I would be the same; lost, empty and unfulfilled, like that part of their psychology persisted and just wouldn’t let them go. Reality has proven to be the complete opposite for my journey; I have so much head space to just be happy and free! I don’t crave binge eating/vomiting in the slightest, I don’t miss it, I don’t even think about it going about my daily business. It’s like that part of my life never existed, and it’s just awesome!

Tips For Working With Anorexia

A “Positive Disposition to Recover”.

Even if someone volunteers for treatment, if is often to seek relief from preoccupation with food, depression or physical symptoms. It could be due to rising concern about the risks of anorexia or to avoid the side effects such as infertility.  Does this represent a real positive disposition to recover from the illness (whatever that means)?

Recovery from anorexia  is not just about gaining weight. In many cases being willing to gain some weight is “conditional” on continuing to eat a very limited diet, often vegetarian or low in carbohydrate and fat. 

Eating more is often conditional on continuing to exercise a great deal. There  is a great debate about what constitutes “excessive exercise” and our opinions are clouded by views about the dangers of sedentary behaviour and the general approval which is given to people who “go to the gym”. 

So what is really a positive disposition to recover?  Many of the features of anorexia just will NOT go away if someone remains underweight. Cravings, depression, preoccupation with food and health risks do not go away if weight remains low. Many people want rid of the bad aspects of anorexia while continuing to have its benefits like staying abnormally  thin. That’s not easy to work with. People will not want to look like you.

A “positive disposition” should include the desire to be free from compulsion to exercise, and the ability to eat a wide diet, with other people, and freedom from the constant chatter about what foods can and cannot be eaten. A positive disposition will include the desire to welcome the feeling of food inside your stomach. This will never be possible if weight is low.

 Secretly though, I wonder how possible this kind of recovery really is –  because all  of these recovery outcomes are inconsistent with what gets someone into anorexia into the first place. The anorexic  desire for simplicity, the fearfulness, the ascetic drives –  are not features that can just “disappear”. These are aspects of personality which must persist forever. You cannot argue someone out of their basic personality.

So I’m not sure that I can demand a positive disposition to recover in what would suit me, and my expectations cannot be too high. I think that people and therapists must come to some sort of compromise with anorexia over what will be kept and what can go away for someone to live more happily. Experts might disagree with me.

Force Feeding The Anorexic

Anorexia And “Force Feeding”- Self Determination Or Self Annihilation

A while ago I was listening to LBC radio. The subject was  a decision in favour of the so-called force feeding  of patient E.  On Saturday Norman Lamont suggested that the decision to force feed could be an intrusion on her right to self determination . What complicates this case is that the parents of this young medical student,- anorexic since eleven  years of age-wants their daughter to be left to die with dignity.

There is nothing dignified about anorexia or any other mental health condition for that matter. Also, I just wish that people would STOP using the term “force feeding”, which reminds us of the traumas inflicted on suffragettes on hunger strike to obtain the vote for British women. I just wish that people would use the proper term, which is ENTERAL FEEDING.

Many clinicians have been writing in favour of the judge’s decision on Linked In.  We talk to each other about things we know, which is that low weight impairs the ability to think clearly. That at low weights the anorexic voice drowns out logic, reason and happiness.

But not-one said it better than Kate, who came nervously to the radio to express her point of view. Kate has been anorexic since age 9 and in hospital many times during her young years. She said “I have no idea why I just didn’t want to eat, but I didn’t, and there were times when I would have been very happy to just fade away.

But they didn’t let me, and there were times when I was on a section and they threatened me with the tube…. No it wasn’t a threat, it was just something they said would happen but it felt like a threat at the time. Having no control over what they put in it was the worst thing imaginable for me.

But I somehow got to the age of 20 and I said to myself, I’m sick and tired of this anorexia. It took 11 years for me to admit I had a problem. So I made myself start to eat. I’m 24 now and life is so much better.  Life isn’t a bed of roses but anorexia is very hard work; and I had enough.

I spoke to my father about it and he admitted that he had something like me when he was in his teens, but being a man nothing was said or done about it.”

The interviewer asked, “Everyone is saying that it’s all the pressure on young girls to be slim, in magazines and so on?”

“Oh no”, she said, “When I was nine I hadn’t even seen a magazine. It’s nothing to do with magazines and models, it’s just the way the brain is wired”.

So there you have it from the people who really count. Clinicians know very little. Listen to the people who have looked into the pit and been dragged into the light, kicking and screaming. At all costs we have to arbitrate in favour of the wish to live.

Does Anorexia Ever Really Go?

In the Times way back in August 2013 Lizzie Porter wrote movingly about the after-effects of the illness, which are still with her.

In her book about Anorexia, Emma Woolf also writes movingly about her struggle to get well. Despite being able to move away from the cachexia of severe anorexia, she documents in her column An Apple A Day how residual anorexic thinking prevents her from being able to eat cheese. Her recovery  is conditional upon maintaining an orthorexic relationship with food.

I was, oh so briefly anorexic  years ago, and now I eat a very broad diet. Only yesterday  I dug happily into  a meringue made by one of my friends. I stir fry quite a lot of food. I have butter on my jackets.  But I do eat more healthfully and in smaller quantities than most of my friends.  Even now, after all these years,  you won’t see me tucking into the canapes at parties. I drink very little alcohol and rarely want  dessert, only ice cream, perhaps one boule.  I eat cheese although dainty little chunks. I’m not very interested in food.  Am I just looking after my health, or, does anorexia ever really go?

Lizzie Porter’s account of her 10 year struggle with anorexia needs to be read by all eating disorder professionals who feel stuck after working with a young patient for 2 or 3 or even 10 years.  While it is clearly a mental disorder, the manipulation of food has very physical effects. Perhaps the physical effects of eating trump the emotional ones and make it easier for someone to become or stay anorexic rather than  depressed or psychotic. Lizzie writes about all the medicines she has to take to manage indigestion, cramping,  bloating and nausea. Is this an effect of the anorexia or did it make the anorexia happen?

In my case for example, from as early as I can remember, I couldn’t eat large platefuls of food. The usual party food loved by kids made me queasy when I was very young.  I was only interested to eat fish and chips when I went out.  I only wanted to drink milk or bitter lemon. I couldn’t stomach biscuits or coloured ice creams. Unlike other kids, I was not interested in food. My tummy is very unhappy if I eat a lot of fat or drink more than half a glass of wine. That was there before I had any concerns about weight.

Lizzie says that the anorexia is still with her long after therapists think her treatment is done. Until recently she says, the idea of sex was repulsive but she seems to have dragged herself out of that. What an effort everything is for her, although outwardly she seems to be successful, she is still secretly weighing food and scheduling her day around mealtimes.  She wishes to be free of the fears  of food and its effects  like occasional dizzy spells while and enjoys being thin.

I would say to Lizzie that anorexia never really goes, but as one gets older, one becomes more forgiving.  We learn to be “anorexic” and also well. We can learn to live without thinking about food at all. We can have fat moments and fat days and give them no attention at all.

So to therapists who agonise about the extent to which someone is stuck with their anorexia I would say this. If the patient is bulimic, they need constant care since they are those most likely to be very, very sick.  But if  your patient is safe and functioning reasonably well, endless therapy probably isn’t going to do much at all other than provide the illusion that something is being done.  Anorexia isn’t a quick fix, a life sentence or something that has to be chewed on by well meaning therapists until someone is maintaining a totally normal weight .

Many therapists might disagree with me and argue in favour of treatments that represent a complete cure. This is ideal, but is it possible if anorexia doesn’t really ever go?  I’ve met some eating disorder experts running well known treatment services who are still extremely thin.  YES,  YOU KNOW WHO YOU ARE…. They argue in favour of health. But has their anorexia ever really gone?