When I first started working with eating disorders, psychotherapists debated fiercely about what led an anorexic person to experience (not see) themselves as fat. We observe this phenomenon in other starving populations including concentration camp victims and people who deliberately restrict their calories “to prolong their lives”. (Vitousek, 2009). More recently, psychologists in Oxford (Shafran, and others, 2006), have described an attitude distortion known as “thought shape fusion” thinking which is common in people with OCD - i.e. thinking about something is equivalent to doing it.
This means that for restrained eaters, even thinking about food leads someone to the conclusion that they are very likely to get fat or, more strangely that they are fatter. Some people who eat just a piece of Kit Kat feel instantly fatter. This delusion appears in restrained eaters of all weights.
But until very recently, few experts acknowledged the contribution of the Anorexic Voice to the experience of feeling fat and the additional role of this Voice in maintaining the terror of eating for anorexic people.
We all talk to ourselves. Today I told myself that it would be a good idea to clear away the breakfast dishes before starting on this article. Reflecting on this inner conversation led me to the conclusion that it was a fairly quiet neutral whisper inside my head and I was not hearing voices. Many people who are not psychotic hear voices outside themselves. If these voices are not troublesome nor persecutory it’s not a big deal; it’s more normal than we imagine.
But the Anorexic Voice is a different kind of beast. It can only be described as a presence which exists for everyone with anorexia and which offers directions, instructions, (such as running 5 miles daily before breakfast) persuasions and opinions specifically about food, weight and the self. When someone is losing weight the Voice will suggest that the person will feel better if they lost just a little more weight, no matter how thin they already are. The Voice tells them that they are doing well if they comply, but the Voice turns angry if they violate its rules. It may call them fat, a pig, stupid and a failure.
When and if the anorexia begins to hurt the sufferer, for example by making them tired or weak; or if they dimly understand what it is costing them and their loved ones, a person may start to consider trying to get well. The Voice will then inform them that it will punish them for these treacherous opinions and make them suffer if they start to change. It does so in a malevolent manner like an evil spirit trying to wreak vengeance upon them.
We call this presence a “Voice” rather than an idea or thought because as weight decreases it becomes concrete and real. My anorexic clients have taught me that it may lodge inside the head, perhaps in a particular location at the front or back of the head. It can even seem to be outside the head, most usually to the front or side. They have described the Voice as female or male, shrill or deep.
Most people with Anorexia are startled yet relieved when I ask them about this Voice; they are afraid to disclose it willingly since people might think they are insane. It requires us to reflect on whether anorexia is a form of psychosis and some people who support the notion of “forced feeding” indeed describe the illness as “a particular kind of psychosis creating a compulsion to avoid treatment, or to only accept treatment which is designed not to work.”
Knowing about the existence of the Anorexic Voice changes the dynamic between patient and therapist, since we can start to talk to the person who is caught in the grip of the illness and talk in a different way to the Voice - as if they are separate entities. If you fail to do this then the only person you are doing therapy with is the Anorexic Voice. It is this Voice that explains the resistance, the games and the so-called denial that is the hallmark of anorexia.
For this reason I have always said that there are 3 people in the room when I work with anorexia, me, the sufferer and the Anorexic Voice.
Here is what one recovered anorexic lady said to me about the Voice.
He (my doctor) understood that it was not I but the anorexia that he needed to “attack” and make ME strong to be louder than (his) voice. Talking with the doctor I realised for the first time (after 10 years) that it was not that I was bad, but it was anorexia in me who was making me think that I am and I began to understand the anorexia was always there “the voice” and it just grew louder. But this professor’s voice was louder than his - so much louder that it reached ME. And for the first time I experienced a little peace!
The Anorexic Voice is thus partly responsible for the experience of fatness and the dreadful self concept of sufferers. It is woven into the other factors with maintain the illness such as pro-anorexic beliefs, personality and family factors; all providing together a template for existence for the sufferer. It is all these factors which make Anorexia a complex illness, still poorly understood and remarkably difficult to treat. We try to address all the maintaining factors, such as providing useful information, re-feeding the client, fostering flexibility, helping families, confronting perfectionism and so on. But there are many perfectionists, rigid and obsessional people with weight concerns who don’t develop anorexia. For that reason I have often wondered whether the Anorexic Voice is the glue that holds all the other maintaining features together.
So we have to do something about The Voice in treatment almost right from the start. So what do we have to do about it? One suggestion would be to weaken it, another would be to strengthen the individual so that they can see it for what it is and fight it; a third possibility would be that it may remain where it is but the person doesn’t really respond to it any more- it matters less. In accounts of people who have recovered from Anorexia, they say the Voice tends to ebb and flow, becoming more compelling at times of stress.
What follows is a checklist of things which could be useful in weakening the power of the Anorexic Voice.
1 First getting a good description of it, its location, gender and colour, the qualities of the voice and the words it says. Show that you understand the Voice by saying things like “Some people tell me that they have a Voice telling them that they are fat and weak if they do what the therapist says. It tells you that the therapist just wants to make you fat Is that true for you?”
2 If the client is resisting change in therapy, the therapist can say “The Voice must have been shouting at you particularly hard this week Is that so?”
3 Ask the client what they would like to say to the Voice. The Voice would have been very kind to them when they were losing weight well, it seemed like a friend. Now it became their persecutor. Ask about the qualities of “a good friend” and find out what the client would like to say to “bad friends”. Many anorexic people doesn’t really know the difference between good and bad friends because of bad past experiences.
In addition to this, keep separating the Voice from the person. If someone says “I can’t eat more I will get really fat” (a typical anorexic thought) say, “Now this is what the Voice is saying, what do you think?” Repeat this conversational style over and over again until the patient is doing it for themselves without prompting.
4 If you are skilled in NLP you can play with the qualities of the Voice and see what effect that has on it. Here is an example:
A client of mine felt unable to eat any fat, “not even a walnut.” I asked about the Voice and she described is as being like a big black bowling ball filling her head. You know that one walnut is not a big deal I suggested, where is your voice that talks more common sense? It’s outside my head she said, its like a whisper I can hardly hear.
Lets do a game, I said, try and get the bowling ball out of your head and put it somewhere in the room where you can see it in your imagination. OK? Now can you still hear it? Oh yes, it’s just as bad, she said.
Imagine that you had a dial in your hands that can change the colour of things. Now what happens if you change the ball to yellow? Its weaker she said but still as bad.
What happens if you rotate the yellow ball I said… Oh! She offered, I can’t hear it at all!
And where is your own voice now?
It’s in my head, she said, I can hear it much better. It says walnuts are quite OK.
Next time the Voice starts shouting, perhaps you can do what we just did.
And the girl went home and she ate two walnuts, and seems to be doing very well.
5 I have asked clients to draw a picture of the Voice and something that can attack the Voice. One girl brought in a can of fly spray (which we then painted “Buzz Off” to attack the buzzing voice) and another girl drew a picture of a golden hammer.
6 Third wave therapies are really useful to deal with irrational and delusional experiences such as the Anorexic Voice. This is because irrational ideas with powerful emotional content such as shame, terror and pride are usually not accessible to rational therapies. Here is where EFT and/or Mindfulness skills help the sufferer to cope with the Voice. EFT releases the emotional content of the Voice and its associations with past experiences of failure and lack of coping. Mindfulness skills enable the sufferer to do things differently.
7 Remember that these strategies take time. The lower the BMI, the harder it is for the brain to process and utilise new experiences. The therapist must be patient and work gently to foster the alliance with the patient against the Anorexic Voice which notwithstanding will sometimes and unexpectedly appear in the guise of the client’s best friend - even when things appear to be going well. At such times, do not fight the patient or give up, or think the treatment isn’t working. It is not your job to “win the battle” – because then you can lose it. Take supervision to help you figure out the best way to help the client recognise their bad friend for what it is.
For help and support with anorexia visit http://www.eating-disorders.org.uk or call 0845 838 2040