Solutions to Disempowering Drab: Exploration and Inoculation

In the first and second parts of this miniseries, I argued that eating disorder treatment (and mental healthcare more generally) needs to be radically more individualized and less drab, and in part 3, I explored some scenarios for making it so. What might happen if we expanded this line of thinking beyond “cure” to prevention, by imagining a non-drab version of what it takes to help individuals not develop eating problems in the first place? Here, we might usefully enlist the twin principles of exploration and inoculation.

For example: How about a school program that wouldn’t talk down to kids, but would instead give them credit for being able to understand that life has lovely things in it, that life has hard things in it, that one will seek out coping strategies, that all of these will have cost/benefit profiles, and that one needs to discover for oneself what those are for oneself? This form of health education as personal exploration wouldn’t exclude the safe, sensible tools that school programs currently include—the mindfulness techniques, the signposting to counsellors, the exam coping strategies—but it would acknowledge that as adults (and probably already as teenagers), most individuals will have recourse to strategies that are far less tame. And that some of these work fine for a long time—maybe a whole lifetime; some work fine for a while but then start causing problems; and some devolve into full-blown illnesses and addictions.

Exploration would include personal reflection and theoretical testing of one kind or another, and it would necessarily also include active, literal experimentation—with possible personal strategies in supported environments. Not by literally taking drugs in class, but possibly through microdosing of one kind or another. Imaginatively mediated methods might work well as a halfway house here, including potentially via VR, but more accessibly through encounters with literary/filmic worlds and characters and with real live individuals for whom a given strategy has worked some mixture of well and badly.

In turn, the invitation to conduct meaningful personal exploration would create the potential for individually tailored inoculation. All of this works particularly well for eating disorders because there are fewer legal questions to get entangled in. So let’s imagine this exploration-plus-inoculation process step by step.

Imagine that as a 14-year-old, in the context of this program, you go through a reflective process—including information-giving and experience-sharing by others as well as structured prompts to reflect on your own experiences and aspirations and values—exploring what you instinctively turn to when you get stressed out, what other options appeal to you, and which strike you as more or less likely to turn out well or badly.

Imagine that this process leads you to conclude that the hunger high is something you might be susceptible to as an appealing coping strategy for difficult times.

Imagine that you, therefore, carefully design a behavioural experiment in eating less than usual for a day. In the experimental design, you include your precise parameters (how much less, of what), your predictions (maybe in the form of a dominant and a counterbelief), and your bail-out clauses (could anything happen that would mean you should abandon the experiment before the end?).

Imagine that the day of skipping breakfast or cutting out the nicest bits of lunch comes around, and that sometime later in the day you do feel those inklings, so common in the stories of those who tell of the beginnings of their anorexia, of how light and powerful and untouchable more-intense-than-usual hunger makes you feel.

And then imagine that the morning after, you have structured opportunities to reflect on these inklings and everything else that you felt in the day (maybe having food preoccupations that interfered with reading the book you’re enjoying, or feeling colder than usual and wishing you’d brought a jacket). You reflect, with the help of some open-ended and forced-choice questions in writing, and in a short one-on-one chat with a program facilitator, on what was exciting in these experiences and what was frightening; on what you’d predict if you repeated this experiment for a second day, and a third. You’re given information about metabolic downregulation and habituation effects that tend to make the high rapidly more elusive, and you get to read about others’ experiences of living lives geared around deliberately unsated hunger, and these feed into your longest-term predictions: about an entire way of life that involved frequent attempts to recapture the exhilaration you felt a little of yesterday. You crystallize what, in explicit terms, you have learned from doing this.

And finally, imagine that you then have help to decide what you want to do with these observations. Do you want to change anything about how you’ve been eating (or doing anything else), in times of low stress or high? Do you want to protect what’s already good (e.g. you love not feeling hungry all morning until it’s time for lunch!) or get something working better (e.g. this makes you realize that your day-to-day was feeling a bit flat, and that you want to try out some other options getting a bit more exhilaration into schooldays)?

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Crucially, of course, it must be possible for you to conclude: that hunger high was amazing and I want lots more of it, soon. This is only metaphorical inoculation: Its efficacy rates will be lower than for medical vaccination. This conclusion from a student should lead to more information-giving and open-ended exploration, before and after they take this course of action. But it should not lead to prohibition or even to “We don’t think you should do that”-style advice-giving, i.e. to prohibition lite. (One reason for this is that if that’s going to be the institutional response, the obvious decision for the teenager is to lie.) My prediction would be that if you went down this route and developed a restrictive eating disorder, then given how the world is, that was going to happen at some point anyway. I would predict that your route through the disorder would be shorter and smoother than it would have been for the 14-year-old alter ego who discovered the hunger high accidentally, messed around with it confusedly, and got her information about it from pro-ana forums.

I would also predict that this kind of unpreachy inoculation would forestall many eating disorders that would otherwise have taken hold; that many teenagers who had the benefit of it would be better protected from the pressures of diet culture that so easily piggyback on natural teenage experiences of eating and not-eating than their peers who receive only the blandness of standard healthy-eating guidance—which these days seems to basically reduce to “don’t eat too much”. And I would also fairly confidently predict that the majority of individuals would be better protected by this version of the program than those given only the blander version of individualized exploration: encouragement to try out only the things that are meant to be good for us. If I’m right, then that version would seem lower-risk, but by leaving risks unacknowledged rather than helping young people to navigate them with their eyes open, it would be only superficially more innocuous and ultimately less safe.

I conclude this series by considering what it could mean for all of us to be invited and helped to ask real un-infantilizing questions about our current and potential coping strategies and pleasures—and why eating disorders might be a particularly good place to start testing it all out.