308: Cognitive Impairment, Anticipated Regret, Eating Speed and Her New Book With Emily Troscianko

Chris Sandel: Hey. If you want access to the transcripts and the show notes talked about as part of this episode, you can head over to www.seven-health.com/308.

Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I’m a nutritionist and a coach and an eating disorder expert, and I help people to fully recover.

Before we get on with today’s show, I just want to mention that I’m taking on clients. Despite what your eating disorder may be telling you, I fully believe that you can make a full recovery and that you do not need to spend your days and your life living with an eating disorder. Full recovery is what I help people do, and I’ve been working with clients now for over 15 years.

So if you are sick and tired of living a life that is diminished because of living with an eating disorder, then I would love to help. You can send an email to info@seven-health.com and in the subject line you can put the word ‘Coaching’, and then I can give you details about how we can work together and figure out if we’re a good fit. I can work through the method that I use with working with clients and get you started on the road to full recovery.

So today on the show, it is a guest interview, and it’s actually a guest who is coming back for the second time, and it is Emily Troscianko. Let me just read her bio. Emily is a writer and researcher interested in literary writing, consciousness, and mental health, as well as a work and life coach for individuals in academia and/or focused on writing, and a recovery coach for people with eating disorders. Emily writes about eating disorders under the name The Hunger Artist for Psychology Today.

That is a very brief bio on Emily. She’s someone who is incredibly smart, but also someone with a wide range of interests, and she uses those interests in lots of different ways, in different projects that she does. But if I’m thinking about eating disorder recovery, her blog, The Hunger Artist, is a fantastic tool. She’s been writing it since 2009, when she recovered from anorexia, and this blog has been going on since that time. A lot of it originally was about her journey and now has gone into a lot more of the research around it and a lot of the different ideas that Emily thinks about and brings up as part of it. It is a really incredible resource. It’s something that I use a lot with clients and recommend they go to and read through, because I think Emily has a fantastic way of explaining recovery and explaining all of these different aspects and talking about things that a lot of people aren’t talking about.

The reason why she is on the show today is because she has a new book that has recently come out called The Very Hungry Anorexic. I first interviewed Emily back in early 2022, and she was on the show then, and as part of that conversation we actually talked about the book. She’d written the book and she was in a little bit of a dilemma; she didn’t know if she was going to put it out.

The reason she didn’t know if she was wanting to put it out or it was going to go out was that there had been research done on the harms of reading recovery memoirs, and that actually they didn’t lead to someone making it further along in recovery; it could actually be more of a problem. She was aware of this and didn’t want to then be putting out a book that was going to create more harm than really delivering and helping people to recover.

So, being the researcher that she is, she did a research study to see what happens when people read her book or another book and see if this is a really helpful thing before she put it out into the world. The reason why we’re doing this now is that the book has come out into the world. The research paper that she has done is now finalised and has also been published. We actually recorded this interview back in March time, and we’ve just been waiting for all the pieces to line up and everything to get the go-ahead for me to then be able to release this. So her paper has now been published; the book is now out, and I would thoroughly recommend that you go out and get the book and give it a read, because it is a really great resource.

As part of the interview, as well as talking about the book, I go through some of the topics that she’d written about recently or over the last year or two on her blog or on the blog for Psychology Today. One of these things was looking at cognitive impairment and how cognitive impairment could be impacted by being in an eating disorder. This is actually a topic that I have done a whole podcast on before. I will link to that episode in the show notes. Even in Emily’s article, she made reference to that episode. We look at all the different aspects that she delved into when she wrote this article. I think her article is a four- or five-part series, so it’s a really good article. And I’ll link to all of the articles that we touched on as part of this episode.

We then looked at anticipated regret and how anticipated regret can be used to bolster recovery or support recovery. We looked at eating speed and how eating speed can be impacted upon by recovery or by an eating disorder. This was actually something we’d talked about briefly in the previous conversation, and since then I’d had further thoughts about it and I wanted to get Emily’s perspective on this based on how she uses this with her clients when she’s working on recovery.

That is really what we cover as part of the show. We also talk a little bit about the research paper that she’s done and what was investigated as part of that research paper. But I think this is a really practical episode. You’ll get a lot out of this one.

So, without further ado, here is my conversation with Emily Troscianko.

Hey, Emily. Welcome to Real Health Radio. It’s great to have you on the show again.

Emily Troscianko: Thanks, Chris. It’s lovely to be back.

Chris Sandel: This is the second time that we’re chatting. I think the last one was a bit over two years ago. I actually re-released it fairly recently as a re-broadcast, so if anyone hasn’t listened to that episode, it’s not going to be needed to enjoy this episode, but I would highly recommend going and listening to it because I think it’s a really great episode.

As part of this one, what I wanted to do was talk about some articles that you’ve written and go through in more detail, because I’m a huge fan of your blog, and I will put a link in the show notes for anyone who’s not aware of your Psychology Today Hunger Artist blog. They should go and check it out. So I want to talk about a couple of articles from there. One of your clients suggested a few topics for us to touch on, which I think are good ideas. And then tie up some loose ends from our last conversation. In our last conversation, we talked about a book and a bit of research that you were doing connected to that, and the research is now in and we can have a final conversation about that. So that’s what I want to cover today.

Emily Troscianko: Sounds like a plan.

00:07:20

A bit about Emily’s background

Chris Sandel: Perfect. I guess to start off with, we don’t need to go into this in huge amount of detail because we covered it in a fair amount of detail last time, but just give listeners a bit of background on yourself – who you are, what you do, what training you’ve done, that kind of thing.

Emily Troscianko: I currently describe myself, I suppose, as a coach and writer, and sometimes I also add in researcher, although I feel like I’m in a phase at the moment where I’m trying to dial back on the researcher side of my identity just because things can get overwhelming. But I guess the project that we’ll touch on toward the end is an example of me trying to just be a writer, and then the researcher bit feels like it has to come in anyway.

In terms of the research background, my PhD was in a field usually known as cognitive literary studies, which is basically a fancy name for trying to work out what happens when people read stories.

I worked a lot on mental imagery and on emotional responses in that context, and then at some point, very belatedly in my postdoctoral work, realised that actually it made a lot of sense to start asking health-related questions in that context – not just to ask in general how might readers respond to a particular type of text, but to start asking, if the reader is coming with a particular health condition or having recovered from one some time ago, what difference does that make to the reading experience? And conversely, what effects can reading have on the progression of an illness or recovery process? So that’s where the industry stuff and the eating disorder side of things started to intertwine.

Alongside that, having for a long time been writing the Psychology Today blog, I realised that there was a lot of important stuff that I was doing that was really being pushed into the sidelines of my professional life. I considered training as a therapist and taking that side of things seriously in that particular way, but never quite felt that was right for me. And once I discovered the concept of recovery coaching, it felt like that could be a niche in which I could do some useful stuff for people.

So that came along and joined the researcher/writer parts of my life and work, and that’s been an increasingly rewarding and informative part of everything that I do – getting to work one-to-one with individuals who are making recovery a top priority for them in this phase of their life. As you know, that teaches one a huge amount about the human condition and about everything else one might be interested in. One can be helpful to that other individual in a crucial part of life. So all of the bits find their ways of interacting nicely with each other.

Chris Sandel: Nice. In terms of the coaching, how much of that is how you spend your time? There are all these different buckets that you mentioned; is coaching 20%, 50%? How much of your time is spent doing coaching?

Emily Troscianko: Possibly 40-ish percent, I would say. It varies across the months of the year, but probably about the average ratio. And of course, the boundaries of what counts as coaching are somewhat blurred. But, as I think we touched on in our last conversation, it does feel really important to me still to have things going on that aren’t just the coaching, because those other things directly inform the coaching, and they indirectly mean that stuff is happening that isn’t too eating disorder-centric all the time.

00:11:00

The types of coaching clients Emily works with

Chris Sandel: In terms of the people that you work with, if you were to categorise them, what are some of the things that would come up from your perspective?

Emily Troscianko: I think a large proportion of them have lived with an eating disorder / disordered eating for a long time, and they have probably tried various other ways of resolving the problem – by definition, not with full success, but often with partial success, and often looking for something that I suppose feels more like it’s for them and about them in a way that more mainstream, standardised forms of talk therapy may not. I don’t know, it seems to me at the moment there’s a broader cultural shift, perhaps, away from prototypical kinds of therapy and towards something that might have the label of coaching but feels like it’s probably more behavioural and action-oriented, maybe feels more personalised. I think it has that slightly more trendy feel as well, although therapy has long had a certain cachet in particular social circles.

But I think probably in the field of eating disorders in particular, there are many individuals who’ve had quite negative experiences of a very top-down, didactic form of clinical encounter and treatment. And particularly for older individuals who have a massive life experience, know themselves in many ways extremely well, doing a by-the-book CBT or psychoanalysis or whatever it might be doesn’t really feel relevant. So coaching can be a good fit for such people.

Chris Sandel: Definitely. The reason I’m asking was just to put a little bit of context on some of the things we’re going to talk about today, because I think if I reflect on the clients I work with and how this has progressed over the 15 years that I’ve been doing this, it’s gone much more from the quitting dieting to the disordered eating to the eating disorder to then the longstanding eating disorder where people have been dealing with this for 10, 20, 30, 40 years. That’s a lot more of what I’m seeing at this point. And just from reading what you write about it, I get the same feeling that that’s a lot of the people that you’re also working with.

Emily Troscianko: Yeah, and I find it really lovely when someone has decided, or at least is on the verge of deciding, “I’m really not going to settle for this anymore. I definitely could settle. No-one else is worried about me. No-one else thinks there’s an issue. I can pass, absolutely. But I decided that I don’t want the rest of my life to be like this, even a tiny bit.” As I say, ‘on the verge’ – it can be such a precarious conviction, that decision. But if one can take what there is and work with it to give it just a tiny bit more strength than the force of the old defaults, then very beautiful things can happen.

Chris Sandel: I totally agree. I think there is so much ambivalence with recovery and ambivalence with the eating disorder, and we’ll get to this a lot when we talk about your book, because I think that really shines a light on all of that in such a lovely way. So I love where someone has been living with this for a very long time, and this shift that is starting to happen of thinking about “This is not where I want to be. If I fast forward five years from now, this is not actually what I want my life to look like” and figuring out ways of “How do we lean into that?” or “How do we get that to expand more so it isn’t just a fleeting feeling, but becomes something that grows and grows?”

Emily Troscianko: Yeah. And maybe that’s a nice link to anticipated regret.

00:14:58

Anticipated regret in eating disorder recovery

Chris Sandel: Yes, let’s talk about that. That was one of the articles that I emailed to you about what I wanted to go through. You wrote a series of articles – I can’t remember if it was three or four – on anticipated regret. Probably when we talk about these articles, I’m going to start bigger picture and let you go, and then I’ll get a little bit more direct with my questioning. So talk about anticipated regret. I guess as a starting point, what made you want to write about this as a topic?

Emily Troscianko: The starting point was, as ever, a mini experiential thing for me. I’d just moved to Santa Barbara in California for a year, and I was very aware right from the outset how fast a year in such a beautiful place would go, and really wanted to do all kinds of things to make the most of it. But the more negative slant on that determination to make the most of it was a very clear sense that a failure mode for this year could be that I get to the end of it and I look back and I think, “Why on earth did I spend so much time at my laptop, feeling like I had to get through my list of things to do this week? And why didn’t I get out in the mountains, on the beach, with people more, do all of that stuff that I couldn’t do in Oxford or anywhere else?”

I just realised that what I was feeling was – I forget whether I’d already labelled it to myself at that point as anticipated regret, but something like that. Expecting and fearing future regret.

Then I thought, ooh, that’s something that often actually comes up in the recovery context – people talking about how they don’t want to be feeling in X weeks, months, years, or the classic on the deathbed moment. Then I just did a tiny bit of googling, wondering whether there was any research on this – and of course, there was an absolute ton, as with anything that you google.

It turns out that anticipated regret, although it seems really abstract and complicated – expecting a particular kind of backwards-oriented feeling in the future – that seems like it should be too arcane to have any purchase on anything real. But actually, it isn’t. It seems to be quite a potent motivator not only of behavioural intentions, but actually of behaviours themselves in particular contexts where it’s been studied.

So yeah, I think the intended mini-post – I always intend to write just 1,000 words and then stop. That’s the limit for Psychology Today now, and they do actually enforce it, unlike in the old days where you could just go on forever. I think this turned out to be a seven-parter or something. [laughs] There was a lot to explore, and I think some of the links with other aspects of the eating disorder experience – particularly perhaps that question of presence, whether you’re really present in your own life and experiences right now – they were really interesting to explore and felt like they were a way of adding something to the existing knowledge base on anticipated regret.

Chris Sandel: It was interesting; when I first started reading the article and saw the headline of what it was, I was interested in “I wonder how this will make sense with eating disorders” just because I think for a lot of people, they feel like “I have so much anticipated regret, but it’s the anticipated regret of what will happen when I eat this bagel or this donut, or if I don’t do this exercise.”

That’s typically where I’m seeing people getting in the anticipated regret, in this very micro or short-term or eating disorder-behaviour-related anticipated regret – versus the much bigger picture, longer term – you referenced on your deathbed, what are the things you’re going to regret? That kind of thinking. Or “In five years from now, if this is what my day-to-day looks like, am I going to regret that that’s the case?” There seems to be this real important delineation between the very micro short-term versus the longer term when we’re thinking about regret. And maybe anticipated regret for that short-term stuff isn’t even anticipated regret, but that was where my head went when I thought about this.

Emily Troscianko: That’s really interesting, because yes, in the article or mini-series or whatever you want to call it, I touch on that. I concluded there – and I’d be interested in your take on this and whether the labels are right – but I concluded that that version is actually not best thought of as regret, but actually anticipated guilt, perhaps.

Guilt is such a poisonous and sort of useless feeling, in the main, and I think the guilt is then masquerading as regret and discouraging all kinds of positive change that would prevent the really existential, awful kinds of regret that you get from a life that has involved a lot of waste. So I think certainly what you say about what changes at the different timescales is crucial. If I’m thinking about this afternoon and the guilt, let’s say, of not having gone for that run or for having eaten that muffin, then that will, if listened to, prevent all the obvious pro-recovery actions that one otherwise might be inclined to take.

Whereas if one can do that zooming out and think about probably even a day hence – certainly I’d have thought a week or a month – what will be the things that you’re glad to have done versus wish you hadn’t? Then it already switches. I guess it’s an interesting question for any individual in any given context; what is that temporal threshold at which it switches from “I wish I hadn’t eaten the thing” to “I wish I had”? Because it’s quite reliable that it does switch at some point.

Chris Sandel: Yes. For me, when I think about it, it switches when you move into that bigger picture. If I move this out of the realm of eating disorders, there could be “I feel really nervous giving a presentation and doing a talk in front of people.” I can get sucked into that feeling of “That’s so scary. No, I want to cancel, I don’t want to do that” versus if I can move out, “What about once you’ve done this three times, or five times, or ten times and that confidence has grown and then this becomes something you’re able to do?” – that then changes how I think about the one-time delivery of that talk.

So I guess my sense would be we need to move the timescale up far enough out that it starts to change where you’re putting the focus.

Emily Troscianko: Yeah, and I think that still raises the question of, how far out is far enough in a particular context? I suppose that depends how big and scary the thing is and how much inherited unease and dissonance there is about it.

In your giving a talk case, is it enough to imagine having done it once more, or just imagining the day after when you don’t care about it anymore? That’s something I find useful for things that I’m nervous about or getting post-hoc anxiety about – “Did I say the wrong thing? Did I sound stupid?” – just to remind myself, in about 48 hours, I won’t care anymore. I’ll have semi-forgotten and it just won’t have that bite anymore. Perhaps for every individual it’s useful to think about, what’s that reliable timescale at which you know it won’t hurt anymore in the same way?

That in itself can be reassuring, and then, as you say, you can also do massive acceleration on that by already within the 48 hours, doing the dumping out deliberately and asking all kinds of bigger picture questions about what really matters.

00:23:20

The importance of action-taking

Chris Sandel: The thing as well that I’ve thought about when going through these articles, and I know this is a big thing that you talk about, is the importance of action-taking. If we often stay in the realm of theory and what may happen, it’s very different to “Actually, I did this thing and this was my experiential experience.” This is something I’m constantly wanting and suggesting and pushing, as gently as I can, with people.

Like, yeah, I know that’s what the eating disorder says and that’s what you imagine; let’s get into the real world and do this thing and then see what happens. Let’s see how uncomfortable it is for you afterwards. And maybe it lasts half an hour, maybe it lasts an hour, maybe it lasts five hours. But at least we’re now dealing with the fact of what happened in that situation as opposed to the imagined what will happen in that situation.

With this, if I’m thinking about this piece, so often what clients tell me is the anticipated anxiety of making a change was way higher than the actual experience of making that change. And then how long the thing lasted in terms of the uncomfortableness afterwards was often some amount of time, but once again, it wasn’t as long as they imagined it would be.

And two, even if it was a long amount of time, they can have the experience of “And then it went away. I had this experience and it lasted two hours, and it was a very unpleasant two hours, and then it went away.” So then we can say, that’s nice. We know that’s what happens. So next time when you’re eating this thing, you have this uncomfortableness for two hours; it will then go away. Again, it moves out of the realm of ‘what ifs’ into the realm of “This is what happens in reality.”

Emily Troscianko: And I think even doing a simple kind of predictive exercise where it’s simply asking the question and answering it: “How many hours do you think it will feel level 10 unpleasant?” and then setting up the possibility of finding out how right or wrong you were – that can be a really nice way to take control within that decision-making process and action-taking process and have that mini curiosity factor as well. “Well, I thought it’d be five hours, but maybe it’s possible that I’m not right.” And often it’s half an hour or something. There’s ways to bring in behavioural experimentation to that particular question of timescales.

Chris Sandel: Definitely. When I’m talking about making a change, I’m always framing it, and I’m suggesting that people frame it in their mind, like “This is an experiment. Let’s run the experiment. You’ve lived with an eating disorder for 20 years; we know how that experiment goes. The data is in on that one. Let’s try a different experiment and see what happens, because we’re never going to know in advance. You can do all the planning, all of the addition, all of the things, but until you actually start making the changes, you’re never really going to know. So let’s do some experimenting and see what happens.”

I think shifting in that way can bring up some curiosity, or it at least removes the “I’ve got to get this right.” It can start to shift how someone thinks about the change.

Emily Troscianko: It seems obvious now that you say it, but I’ve not quite thought of framing the whole past as “That was an experiment, wasn’t it? We have the data already and they don’t look good.” [laughs] Or they have flashes of good, and of course they’re important to acknowledge, but overall, ad nauseum, one has done that kind of test and received those responses, and now it’s time to try a different one.

00:27:18

Two types of anticipated regret

Chris Sandel: In the article, you talk about there being two versions with the anticipated regret. You said in the first version, you imagined having got out and your anticipated regret is not having got out sooner. In the second, you imagined a future where you’re still trapped and there’s nothing but regret. Just talk a little about those, because I think these are quite useful to think about. I think both of these pull this out and elongate it out to the more distant future in the way we were talking about that helps anticipated regret be something that is so useful for recovery.

Emily Troscianko: With the first case, this is the lovely problem to have, really, because we’ve all done things in the past that we wish we’d not done, we wish we’d not spent so much time on, given so much energy to. And if you’re in the position of saying, “That was awful, wasn’t it?” but from a position where it’s not your reality anymore – I mean, it’s not always going to be easy to deal with the extent of the waste or loss or however it feels to you, especially if it was many, many years, and everything that goes with many years – many relationships compromised, many opportunities lost or not even noticed – that’s difficult emotional work to be done.

But from what a wonderful platform, which is you did it. You got out, and now what you’re doing is coming to terms with the fact that you didn’t quite manage it five, ten, or just one year sooner. You lost, but you’re no longer losing. That’s intense work, but of a beautiful kind. And very different from the other.

Chris Sandel: Yeah. When you’re saying that, I’m remembering a client interaction connected to this where actually, because they’d been stuck for so long, it was almost the pot-committed fallacy, where it’s like “If I now get out, how do I even deal with the fact that I wasted all this time on it?” It almost strengthened the eating disorder to say “Now I need to stay because otherwise, what a fool I was for all of this to go on for so long.”

When I talk about this, I tie in, yes, there can be the regret piece, but also, what are the amazing things that then can come out of this? What are the things that you’ve now learnt by going through this experience, both with the eating disorder but also recovery, that are really beautiful things in your life?

Even if I’m just thinking about you, you got into doing this incredible coaching work because you had an eating disorder. And it’s highly unlikely that this is what you would be doing if that hadn’t been the case. I’m just saying this because I don’t want the regret to overshadow things and move to become this big black mass that sucks someone in as opposed to saying, cool, there can be this regret and then also can be these great things that come out of this experience, even though you wouldn’t wish it on someone else.

Emily Troscianko: Yes, and I think it’s quite sensible and very natural to have those thoughts about “What an idiot I was!” Because once you see the alternatives and are living the alternatives, there’s very little, usually, that really feels anymore, in a visceral sense, like enough of a reason to have ever been fooled by that for so long. So yeah, there is that “What the hell was I thinking all that time? Why could I not see clearly?”

But as you say, any kind of real change and growth and learning that humans manage to do is amazing. The fact of thinking what an idiot you were before is, in itself, just proof of how much expansion and clarifying you have managed to do that will serve you in all kinds of ways, both directly in the sense that – in my experience, people who have gone through this and come out on the other side have a much more robust way of relating to food, their bodies, all of this stuff than people who’ve never had to go through it.

But also in the indirect sense that you’ve been through something fucking difficult and have managed to extricate yourself. That gives you all kinds of skills and self-knowledge and knowledge about the world that you would’ve lacked otherwise, which you can turn to in all kinds of crazy ways that wouldn’t occur to you right on the cusp of end of recovery to post-recovery life. So there’s no need for the regret to stay that horrible black mass. It can be turned quite readily, I think, into gratitude and maybe repeated amazement at getting to eat lovely food every day without really thinking about it and not have the food also be the centre of everything, but to be thinking about a million other things that are more interesting.

Chris Sandel: Yeah. I’m remembering a client who said, “Now everything else in life feels easy. When work is feeling overwhelming, it’s not really overwhelming. All I have to do is remember what it was like both living with and going through recovery from an eating disorder, and it’s like, everything is a walk in the park now in comparison.” I think there is something to be said from that.

Once you get through this, you do in many ways have some superpowers, like “Okay, I’ve done one of the most challenging things in life” – and I’m thinking again in a broader sense, like friends who’ve gone through divorce and the work that they’ve done post that. It has been one of the best things to have happened to them. And it would be probably a weird thing for them to describe it in that way, but it’s meant that there’s been a lot of personal worth, there’s been a lot of clarifying what’s important to them, and I think that’s very true of recovery. It can cut through all of that and really illuminate what truly is important in your life and how you want to be living it.

Emily Troscianko: Yeah, and make us more alert, probably, to future traps that may not on the surface look anything like this trap, but are also structurally equivalent in that they make us settle for things that don’t in fact serve us. They look like coping strategies in the beginning, let’s say, because they are, and quickly outstay their welcome or start to have a higher cost than benefit. One can be much more beady-eyed, on the lookout for those kinds of deceptions once one has dismantled the whole great edifice of them in the past.

Chris Sandel: For sure.

00:34:43

Why Emily started researching cognitive impairment

Let’s move on to one of the other articles that you wrote. Again, this was a series of articles looking at cognitive impairment. This is something I’ve done a whole podcast on – I think you even linked to my podcast – thank you for that – in the first article, looking at how the brain and the mind is impacted upon by eating disorders. Your focus was much more on someone’s experience and how the mind is working as opposed to real brain functions or regions, but yeah, just as a starting point, what made you want to write on this topic? And then we can get into some of the things that you found as part of going into the research with it.

Emily Troscianko: I think it was one of those topics that had been in my document called ‘Blog Ideas’ for years and that I periodically realised it was odd that I hadn’t written about. I think it was also having encountered your episode on the neurobiology that made me think, “Oh yeah, again, I still haven’t written anything on that, have I?”

Of course, it comes up often in coaching contexts in the sense that there are frustrations about cognitive functioning and how, in a very central sense, it’s one of the factors that’s keeping itself embedded, if you like. The lack of cognitive flexibility is preventing one from imagining life being otherwise, from designing behavioural patterns that are different. It’s the symptom and also the reinforcing factor, and in that sense it’s really sticky, really pernicious, and worth having at least a passing understanding of, I think, in the sense of building motivation to do things differently.

Chris Sandel: Definitely. For me, and why I wanted to do the podcast that I did, it was also because for many people in that situation, when they do a cursory glance of googling research connected to this, a lot of what comes up in the research isn’t great. We can get into this in more detail, but a lot of what is talked about in the research is that when you’ve done this damage through the eating disorder, this is permanent or semi-permanent in that things get a little better, but you’ve created some problems that are never going to be repaired.

I think when people read that kind of thing, it can be very disheartening, and it can make someone think, “If this is as good as it’s gonna get, why would I go through all the torture of recovery and everything that I have to do as part of that? I’m just going to stay put.” So I wanted to do something to really illustrate that that is not the case, that repair does happen, and that you can get back to a much better place. It feels like that was also what you were wanting to highlight as part of your series on this as well.

00:37:54

Problems with existing cognitive impairment research

Emily Troscianko: Yeah. I’m sure we probably touched on this last time, and I’m sure it comes up with your guests – the problems with the experimental protocols in research in this area when it comes to defining ‘recovered’ or ‘in remission’ or the other terms that are used for the comparator group who are past it, if you like. Past the worst. They’re just still so often inadequate. And some of this research that I was referencing is fairly old, so maybe there’s a bit more of an excuse, but not really.

But I think it’s always crucial if one is reading any scientific paper on eating disorder treatment or research more generally to come at it with an informed scepticism about the criteria, particularly the criteria being used for that comparator group. Obviously there’ll sometimes be healthy controls as well – and one could also ask interesting questions about how those healthy controls are selected and how ‘healthy’ is defined there. But much more significantly problematic, I think, is the rather low BMI cutoffs and rather lax other criteria for defining the comparator group that’s meant to be answering that question of “Does it get better when you’re done with the recovery?”

And often one simply can’t conclude anything because they’re clearly mostly still a bit or a lot ill. So I find it deeply irresponsible of such researchers to do what they often seem to be doing, which is just eliding these problems to make the findings neater or more interesting in some way. In fact, a lot of the response that I ended up having to the research in this area, after spending a lot of time digging into it – there’s such a mountain of it – it all ended up just seeming a little bit pointless, somehow.

I say this as someone who’s given a lot of my life to academic research. But at a certain point, I just had the feeling, we don’t need to know another tiny little side alley of precisely how well people with a particular eating disorder at a particular stage do on some particular cognitive test, actually, because can’t we just be putting these resources into actually getting people out of it more effectively? I mean, I know there’s not zero sum there, but a lot of this did feel like quite dead-endy research that is simply continuing because a lot of it has already happened and, well, the next finding is waiting to be uncovered thanks to that history of stuff having been done. I don’t know, maybe that’s too cynical.

Chris Sandel: I have the same kind of cynicism. Especially – I would be more open to it if you’re getting robust people who’ve recovered. But to do this kind of research and then have the people who are supposedly recovered, when you do even the littlest of research into it, the criteria, as you say, is just so low that these people are not fully recovered. So they’re not a good comparison to be saying, “This is what happens before and after”, because they are in no way an ‘after’ group. Maybe they’re a midpoint group in some studies, and in others not even that.

But yeah, if you’re going to do this kind of research, you at least want the people that you’ve picked to be a good representation of what you’re saying they’re meant to be. It really angers me when I see that. It feels like the people doing the research should also be able to notice this. Like, I’m not a researcher – yeah, this is my job and I have spent a lot of time understanding eating disorders, and I would like to think the people who are doing the research on it have also spent a lot of time finding out about eating disorders. So for it to seem so glaringly obvious, that’s just sad for me to see that this is the kind of thing that’s still getting published.

Emily Troscianko: Yeah, and there are horrible feedback loops in the sense that if the standard definitions of ‘recovered’, let’s say in the clinical trials, are not getting people to actually recovered, then of course there’s a smaller sample to draw on for the kind of non-treatment-based research that we’re talking about here, the people who could’ve been helped to get to full recovery weren’t, so they can’t be participants in these kinds of studies.

Chris Sandel: Yeah.

Emily Troscianko: That isn’t to say that nothing interesting comes out of this work. There were some intriguing findings at a lower level, for example. In some ways, as one might expect, the human mind is very creative, very plastic, and I think one study found that people with anorexia were performing better than expected on some perspective-shifting tasks where two things have to happen. You have to do some switching between perspectives and you also have to inhibit your wrong guesses. It turned out that people with anorexia, although they were completely rubbish at doing the shifting perspectives, they were very good at inhibiting things that might be wrong, so their performance was actually quite decent – even though what they were trying to measure, which is flexibility, was in fact deeply impaired.

So it’s interesting and also a bit depressing how the mind can find these byways to make it look like it’s doing the right thing. I mention that because not only is it an interesting artefact in some experimental tests like this, but I think in real life, it can often be the case that one is deeply impaired in some ways that are not quite perceptible a lot of the time because so many compensation effects have crept in to cover over that glaring hole in the middle, if you like.

So yeah, in some cases the research can remind us of some very important facts about, for example, how easy it is to deceive oneself about the extent of the damage.

00:44:36

Importance of ‘zooming out’ when assessing cognitive impairment

Chris Sandel: And I think kind of like we were talking about with anticipated regret, we need to zoom out to really understand how this is having an impact. There’s a quote here – and I can’t remember if this is a direct quote from you or a quote from one of the papers – that said, “Whilst respondents with anorexia appeared to perform remarkably well in their professional and educational lives, the cognitive difficulties were described as significantly impacting their ability to engage in life, particularly in the context of leisure and socialising.”

I think what we need to do when looking at cognitive impairment and whether the eating disorder is having an impact there is not looking at how well you’re able to manage your tasks at work, but let’s broaden this out. Let’s talk about what happens in terms of relationships. Let’s look at your ability to go on holiday. Let’s look at what happens when you go to a different restaurant. All of these different areas, what happens in terms of your cognitive ability, and also the cognitive flexibility? I talk a lot about psychology flexibility because I think this is the thing that the eating disorder has such an impact on. There’s this real rigidity and so many rules. You’re wanting to have this flexibility. Not just flexibility at work, but flexibility in all of these different realms. And when we add up the sum of all those different realms, then we have a much better idea of how much impact is or isn’t occurring.

Emily Troscianko: Yeah, I think maybe something that I said in the post was distinguishing between the needs and the wants, which is close to what you’ve just said. Sure, it might be very plausible that you’re able to keep doing what you need to, but how much of what you want to is really happening? Of course, the problem there is that if you’re deep enough in it, you may not even want the other things and have almost forgotten how to want any of them. But there are normally ways of igniting a little bit of wanting of something that isn’t quite possible right now and moving forward from that tiny little spark.

So yeah, I think – I guess this is becoming a theme for today’s conversation, but just managing to do that kind of stepping back, zooming out, remembering the other things that exist that aren’t the narrowed-down focal points of the day-to-day or moment-to-moment, that’s where so much of the powerful change potential comes.

Chris Sandel: For sure. Also, when thinking about this topic, one thing that I recognise with many of my clients is that people with eating disorders are often highly intelligent, highly articulate. There are these things that are going on that could, from the outside, look like “Wow, this person’s not being affected. Look at how well they’re able to communicate or how well they’re able to keep up with their work.” And this isn’t always the case, but it can happen in a lot of cases. I guess it’s more looking at, what could actually be the real upper threshold here if someone wasn’t in this depleted state, as opposed to thinking “This person seems very together or very articulate, so clearly it’s not having an impact.”

Emily Troscianko: I think back now to the anticipated regret topic as well and that question of presence that I think I briefly touched on. I mean, sometimes radical life changes do happen; jobs get resigned from and new ones looked out, or relationships get ended and new ones begun. All of that kind of thing can happen during and after recovery.

But I think other kinds of change that are potentially just as experientially significant can be everything actually stays pretty much the same, but you’re now in it. You haven’t got 20%, 30%, 50% of your mind constantly on “What’s for the next meal, did I do enough steps earlier, when can I get the childcare so I can go to the gym” – all of that stuff that means there’s the whole factual infrastructure of a really wonderful life, but none of it can be actually lived because you’re always fretting about those trivia.

Some of what’s needed is the imaginative potential, at least to conceive that there could be an absence of all of that noise. Or if not, at least a certain level of resentment of the fact that it does exist to prompt some kind of changed action.

00:49:30

Using imagination in recovery

Chris Sandel: Yeah. And I guess the difficulty comes with the longer something has gone on, the more difficult it is to pull from past experience versus having to then rely on imagination. If someone’s developed this more recently, you can go back to “Five years ago, you had all these other things that you were able to do and now you’re not”, whereas if you’re working with someone and they’re in their fifties and this thing started in their teenage years, there isn’t this thing to compare to.

So we are then much more in the realm of imagination, which I think, again, is just much more difficult to deal with, with an eating disorder because the eating disorder will always have many, many thoughts that it wants to chime in with when we’re in the place of imagination.

Emily Troscianko: Yeah, and I don’t know whether – I suppose it’s individually variable, but is it easier to imagine radical, tangible changes, like living somewhere completely different, doing a completely different thing for your work, having a different romantic relationship if you don’t, making those big imaginative leaps? Or is it easier to imagine “just like this, but without all the shit, all the mental stuff that ruins it all the time”? Again, I suppose it just depends, but perhaps there can also be a bit of iteration between the two, between imagining those grander changes that may be possible or even necessary during recovery or after it, but also just imagine a day like yesterday, which had such potential loveliness in it, but where everything was likely poisoned by simply not quite being all there.

Chris Sandel: I think your suggestion of flicking between the two can be really helpful. I think there is something – and I’ve even started talking about this with clients when connecting to goals – if we were to imagine some 10x type goal, something just so disproportionately different to what you’re doing now, or if you were to imagine “I’m going to recover in six months; what would I need to do to start to do that?”, you move into a whole different level of thinking. You’re not staying in relative terms to what you’re doing and just doing a little more; you’re like, “We have to think about these things completely differently.”

I think that, for me, is actually quite a useful thought experiment, because it pulls someone out of the regular realm of what I’ve been imagining into “I have to think about things completely differently.” So then switching between the two, like “What would’ve made yesterday that little bit more pleasant and better?” and “If we’re imagining five months from now and things were radically different, what would have to happen?”

Emily Troscianko: Yeah, and I think the imagining then can be, as you’re saying, tied to the scale of the goal-setting as well in behavioural, practical terms. Am I actually just tweaking the breakfast eating to not be in the stupid tiny teaspoon and precious little bowl that you always used when you were ill? If that were just a casually poured bowl of cereal with normal crockery that everyone else in the family would use, maybe that makes a big difference to how your tomorrow unfolds relative to your yesterday. And if you’re imagining the 10x goal as well, maybe that is about booking yourself an actual holiday where you’re throwing yourself out of all kinds of comfort zones and really expecting something very different of yourself.

I guess you can’t get through the entire process with only one extreme of those. You’ve got to mix it up plenty.

Chris Sandel: Yes. And I think the good thing about the extreme version is with the extreme version, then there is the expectation that this is going to be uncomfortable. No-one’s thinking, “Cool, I’m going to book myself a holiday and have a buffet breakfast every day and that’s going to be jus fine.” But for a lot of people, when they’re making smaller changes, there is this feeling of “I shouldn’t be feeling so anxious connected to this” or “I shouldn’t have so much fear come up connected to this” and it feels like “I must’ve picked the wrong thing because if I picked something else, then I wouldn’t have this level of discomfort.”

So you get into all of that, whereas if we’re like, this is a really big change, the expectation is this is going to be uncomfortable. I think that’s a very helpful thing because you’re getting what you’re expecting you’re going to get.

Emily Troscianko: Although, as we touched on earlier, often the expectations are nonetheless massively out of whack with what the reality turns out to be, which is actually, the buffet is great. [laughs] Not necessarily, but often there’s some element of relaxing into the massive differences, which can get you so much further along than the breakfast crockery example – although that can be deeply potent in other ways.

00:54:48

The speed of change in recovery

Chris Sandel: This feels like it goes on nicely with one of the questions that your client or your past client suggested, and this is connected to speed of change in terms of how big changes to make. I think this was something we talked about a little bit on the last time we did the podcast, and oi then wrote an article connected to it afterwards. But I would love to hear your thoughts on this. When working with clients, I know we have to go at the pace that someone is ready to go at in a lot of ways. But if you were to make suggestions and we were doing this in some ideal world, what would you be suggesting of people when making changes?

Emily Troscianko: I see a lot of my role as a role of counteracting the defaults, so trying to help make things possible that wouldn’t be possible without the coaching input, which often means – by definition, I suppose, it means let’s do more, faster than you would be on your own. So I guess that’s the baseline. The default is, because there’s so much discomfort and dissonance and all that stuff associated with changing what you’ve always been doing, to recognise that as a constant brake on the whole thing, so some deliberate efforts at acceleration despite that brake are needed. They can take many forms.

It’s such a difficult skill in any life context, really, to balance determination and a kind of good, productive impatience with the necessary patience of it’s a huge thing that needs to happen and it will take a medium or large amount of time. And maybe, again, it’s about the iteration. It’s not about choosing; it’s about “If I feel myself in a moment today or this week where I’m so bloody sick of the whole thing, I just want to be doing big, smashing-through-things type radical actions”, let us run with that and let it help get us further.

If we’re in a phase where everything just feels too much and the only things that feel possible are smaller and slow, well, okay, let’s go with that for a bit. Part of what’s needed, then, is enough self-awareness, which can be enhanced by certain kinds of prompts, to recognise particularly when one of those reckless, ‘want to throw it all to the winds’ kind of phases is emerging, just so it doesn’t get lost and wasted.

Chris Sandel: One of the things I’ve talked about recently is eating disorders do take a long time to recover from, and let’s not make it longer than it needs to be. I think there can be this feeling of “Well, it’s going to take quite a long time, so let me do it really slowly.” It’s like, then it’s going to take a much longer time than it really needs to.

I think, as you say, there are definitely different phases. There are times where it does feel easier to embrace making more radical changes, and then there are times where it feels less easy to do that. The way I often articulate these is there are times where you make lots of progress and then there are times where it is much more about damage minimisation. When in that damage minimisation phase, it is very much, “These need to be the minimum. We are not going below this. This thing can’t drop out, or this thing must happen, even though it’s challenging.” There are some non-negotiables that still need to happen.

But this other thing I’ve been thinking about and talking about more is, if I’m thinking about changes, even just contemplating a change is accounting for the vast majority of the anxiety or the worry about it. I actually did this in a bar graph, but we’re on the podcast so I’ve got no bar graph. But if you were to do a bar graph, just thinking about a change, we’re already 7 out of 10 in terms of anxiety. If we then do a small change, maybe we’re at 7.5 out of 10. A medium change, maybe at 8. A large change, maybe at 9. But even just thinking about the change is already accounting for 7 of those anxiety points.

I think this is a really important thing to remember because it means that actually, the difference between a big change and a small change isn’t like 0 to 9. It’s actually from 7 to 9, or 7.5 to 9. It’s a much smaller thing. Often what people try and do is “How do I make a change that takes that 7 down to a 3?” It’s like, you’re never going to get it that comfortable because even just thinking about this is bringing all of these things up. So rather than “How do I reduce this so that I’ve got no uncomfortableness?”, it’s like “How do I make the most of this uncomfortableness? How do I get the biggest return on my investment for putting up with this level of anxiety, which is largely unavoidable?”

Emily Troscianko: Yeah, so expect some quite large amount of horrible and make sure that it’s the kind of horrible that counts. Put the expiry date no such feelings of horrible for doing something perfectly ordinary, really, like having lunch or whatever it may be.

Chris Sandel: Yes, getting some return. I think what often happens is “I had all this anxiety come up, I thought about having this new lunch for about four hours; I then chickened out and I didn’t have it, and then I felt bad that I didn’t have it but I also felt relieved that I didn’t have it. I then had this day of very high anxiety, but in terms of actual recovery, I’ve gained nothing from that” versus “Yeah, I had a day of high anxiety, and the benefit was I actually ate that lunch and I got to be with some friends. And yeah, it was hard for me to be present in that meal, and I want things to be different, but I actually got to have that experience.”

If I’m comparing those two scenarios where they were both high anxiety, I know which one is much better for your long-term recovery.

Emily Troscianko: Yeah, so thinking about the rhythms of ability or willingness or that mixture of the two, I guess, to do big things or not – I suppose it’s also important to be on the lookout for overextension of those times where you don’t feel capable of doing anything big, because that probably means that something else in the life context needs to change such that maybe there are fewer daily stressors or you’re managing to get more sleep or something else is changing so that you’re putting yourself in a state where more of the willingness to do big things is possible. If you’re trying to cope with too much else at the same time, then it’s possible you will never be able to make the kind of scale of progress that really gets you to the end.

Chris Sandel: Yeah. I think, as you said, there are other things outside of the eating disorder that could be having an impact.

The other piece – and this has come up a lot with clients – is often when there is this increased worry or fear of “Oh, I can’t make these bigger changes”, when we start to look at what’s been going on, there has been often unintentional pulling back. So the worry and the fear has ramped up not because you’re starting to do more in terms of recovery, but actually you’ve started to do less. You’ve got into more of an energy depleted state. Maybe the walking has increased, or whatever has occurred, you are now further back.

I tend to think with recovery, you’re either spiralling up or you’re spiralling down. You’re not really standing still. So something has started to occur that you’re starting to come back down even though you haven’t recognised it. That’s often one of the areas I will immediately look, because it’s so common where these things start to become much bigger in someone’s mind as they get into more of that depleted state, even though that’s not how they would think about it.

Emily Troscianko: Yeah, there are so many little traps to fall into, aren’t there? Just in case we’re at risk of making this all sound more complicated than it is, I guess I would like to reassure, perhaps on your behalf as well, that the essence of it is simple, actually. You just do the eating, you do the things you don’t want to do enough, and it will work.

Chris Sandel: Yes. This is one of the things you’ve talked about in the book, and you’ve talked about it many times on your blog. Recovery is not easy, but in terms of what you need to do, it is fairly simple and straightforward. You need to have more food coming in and you need to have more rest and allow the body to repair, and that is it in a nutshell. We don’t really need to make it more complicated than that, apart from “Okay, how do we formulate those steps to get there?”

But yes, I think often the eating disorder wants to complicate it more and more because the more you complicate it, the more it’s likely to lead to overwhelm and lead to actually nothing changing. So yes, I’m always like, “Let’s simplify this so that it becomes much easier to understand what you need to do in this moment.”

Emily Troscianko: Yeah, absolutely.

01:05:00

Eating speed connected to eating disorders

Chris Sandel: One of the other things that we didn’t get to cover in very much detail last time – during our call, we spoke about a paper that you wrote with Michael Leon called ‘Treating Eating: A Dynamical Systems Model of Eating Disorders’. We touched on many of the ideas in this article, but not all of them in detail.

One of the things that you touched on in that article was relating to eating speed and how it’s connected to anorexia. So I would love for you to be able to chat about this – I guess to start with, just bigger picture and how it connects, but then from a coaching perspective, how do you deal with this from a practical standpoint, what you do with this.

Emily Troscianko: Yeah. I never thought about eating speed at all before I encountered the Mando team based in Stockholm, but they’re really hardline behavioural people who do lots of denying that anyone needs any therapy for anything. That’s their public-facing take. Actually, you talk to them and they do talk all kinds of stuff about motivation and getting people ready and all of that. But the essence of their treatment protocol, which is highly controversial, and I’ve dug a lot into their papers reporting on their findings, and although they’re not always the best at presenting them in a transparent manner and they’re certainly not always as diplomatic as they might be to get other researchers onside, I do think actually their findings are legit and really something that many other treatment providers could learn a lot from, particularly when it comes to emphasizing the behavioural, the ‘B’ in CBT, which so often gets sidelined in favour of the very interesting ‘C’.

One major plank of their behavioural intervention is sorting out eating rate. The basic starting point is that people with restrictive eating disorders tend to eat too slowly; people with eating disorders involving overeating eat too quickly; and both tend to eat with a linear rate, so starting at the same pace that they finish, as opposed to a decelerated rate where you start faster and as you get fuller, you slow down because you’re nearly full. So their treatment will involve bringing up the rate of one, bringing down the rate of the other group, and getting them all into that nice decelerated curve. And they do this with below the plate, with a thing called the Mandometer.

The reasons why eating rate seems to be important are partly to do with neural reward mechanisms, so the reward processing areas of the brain seem to have more receptivity when eating rate is slowed. So that’s one side of it. And then the other side is related to gut hormones and how they’re secreted. Eating rate seems to change those such that if you’re eating too slowly, for example, you’ll become disproportionately full relative to the amount that you’ve actually eaten, and if too quickly, not proportionately sated enough.

Yeah, there’s all kinds of interesting and still evolving findings around that. Of course, a lot of the research now is being done in the context of concerns about overeating, but a lot of it can be flipped on its head for the undereating context.

When it comes to the implementation of this, I think they have been trying to develop a publicly available Mandometer app for probably more the weight loss side of things is what they’re focusing on initially, but it would be cool if they created something that worked for the restrictive eating disorder side of things.

Chris Sandel: Yeah. And I have to say, when I first came across this and started reading this stuff, there were definitely things that were red flags for me. I very much come from a Health At Every Size approach when dealing with eating disorders, and there was a lot of stuff in their languaging that didn’t sit particularly well with me. Even just the way they talk about anorexia and the BMI and all of this. There was stuff in there that was like, I feel uncomfortable with this, truthfully. And it was really only because of seeing you talk about them and write about them that I dug into it a little more and became a little more interested.

I do honestly feel uneasy where you have people who are treating weight loss and eating disorders at the same time, because I think this sends a very mixed message.

Emily Troscianko: Yes. I can’t actually speak much to what they’re doing on the commercialization side of it. In fact, I think they may have abandoned that. I think one of the things that seems something of a shame in the way that the two lead clinicians and researchers in Stockholm, Cecilia and Per, the way they’re doing things is they very much have a rigid method and they’re going to stick to it, come hell or highwater.

I think there would’ve been all kinds of potential for them to roll out and adapt these very interesting core methods to have wider applicability in eating disorder recovery. And maybe also – there are reasons for people to change their diet in ways that aren’t eating disordered, or not from that starting point. Goodness knows what other things they could’ve done. But I think there is a certain kind of ideological rigidity in what they do, which as I say, is a bit of a shame.

01:10:48

How Emily works with clients on eating speed

Chris Sandel: Then for you as the coach, how are you using this when working with people? Because as far as I know, as you said, the plate sits on this thing that they have that’s then weighing the plate and then there’s data that’s pulled from that, and that’s how they’re doing it in their inpatient facilities. But for you, I’m assuming you don’t have one of those things that you’re sending out to clients. So how are you doing this yourself?

Emily Troscianko: Yeah, they’ve got the plate thing and then they’ve got two lines, basically, on a display, where one is the eating rate you’re meant to be trying to follow and the other is the satiety curve that you’re meant to be trying to gradually train your body to align with. I don’t have anything of that kind.

I guess one of the benefits of having engaged with those individuals and learnt about their methods is that it’s on my radar at all that eating speed is a thing that one might care about. Simply to check in with it I think is often a useful step and sometimes all that’s needed, actually – to ask the client what’s their sense of whether they’re eating at a different rate from the people around them or a rate that’s different from how they did pre-eating disorder, if they remember – whether they think it’s an issue at all. As I said, sometimes that can be enough, combined with maybe some little reminders to speed up a bit or slow down a bit in a particular context. Then nothing more potentially needs doing.

I would say also adaptive response. This stuff doesn’t happen accidentally. If you’re in a context where you’re eating far too little, then it makes sense that you would try to drag out the eating to not be desperately short, to try and magnify, artificially if you like, the satiety response so that it’s not quite as miserably inadequate as it would’ve been otherwise. Of course, once someone is giving themselves permission to eat more, than naturally things can start to improve of their own accord. You’re getting more into that way of living a day that is about a meal is a defined part of it, it’s a thing that happens and then it’s over, rather than trying to drag it out over potentially many hours or at least a longer time than is justified by the amount of food.

So those are some simple considerations. Other ways that I have touched on it – one question that I quite like to ask of clients now and then, normally in the context of the weekly reviews that we’ll do together, where I pose questions and they’ll answer them before a session, for example, is “If I were a fly on the wall and got to see you going about your day, including your eating, anything else that you’re doing, what do you think I would be surprised by, whether pleasingly or otherwise?” People often hate this question but also find it kind of useful as well.

Sometimes this type of thing will come up either directly but more often indirectly. I mentioned the tiny teaspoon thing earlier. It might be “Oh yeah, I think you’d probably not be that impressed that I was using all this weird special cutlery and utensils of various kinds and being really fussy with them, or that I maybe was taking really tiny mouthfuls of everything or having these other odd delaying tactics around the eating itself.” So yeah, those kinds of things, sometimes there are ways of bringing them into focus or defamiliarizing them in a way that might not otherwise have been happening so we can let them do something about them. And sometimes, as I say, they will turn out to be about rate of eating, ways of, again, artificially slowing down, even if it doesn’t feel like that’s what the point of those behaviours is.

Sometimes then we might even go a step further and actually do some filming of the eating happening. Sometimes I will just eat together with clients in sessions, but if it feels more useful to do some observation in their real-world environment, then that can be a really, again, uncomfortable but rather revealing thing. They’ll make the film and then we’ll watch it, usually separately, and ask questions about it and make comments. A lot of what tends to come up with such recordings is all those little things that just creep in to basically slow things down. To make things weird, yes, but the net effect is often just make it slower than it should be.

And/or the water drinking, which is often a common interruption. Repeated insertion between mouthfuls is obviously doing both distorting jobs. It’s slowing eating rate by spacing out the bites more, and that’s increasing disproportionately the amount of satiety, but then it’s also obviously filling you up with water so you’re getting that filled up version of full. Just identifying those kinds of things, really making them salient to both of us, can be a useful part of what allows something different to be tried out.

Chris Sandel: Nice. I love your ‘fly on the wall’ question. I think that’s a really nice way of eliciting some things. And I also like the way that you’ve been able to take this bit from the Mando method and bring it into your coaching, because I think, as you talked about, one of the problems they face is their rigidity and saying “It has to be done this exact way, and no, no-one needs therapy.”

That stuff, again, does not make me feel good because I’m open to really everything. Like, let’s figure out what works, and for some people they’ll need more of this and for others they’ll need more of that. But I don’t want to be in a situation where we’re just tossing all of these things out and saying they’re not important when actually they could be really useful. So as you said, looking at, can we start to notice what’s going on in terms of eating speed?

One of the things that came up when you were talking is just knowing if someone’s having set meal times and they know “If I get through this meal really quickly, I’m going to have to wait four hours for my next meal, whereas if I elongate this out, maybe I’ll only have to wait three” – it makes sense why someone’s doing that. Not just from this has an impact on the satiety hormones, just purely from a time experience. Like “I’ve now reduced the amount of time I have to wait.” So yeah, I think us being able to have this conversation and making people aware of it, I’d say for the listener, if this is something you are struggling with in terms of an eating disorder, notice what happens in terms of your eating speed and what happens with your meals and your snacks and that kind of thing.

Emily Troscianko: Yeah, and as you imply, sometimes you may not be able to just say “I should be eating faster, so let me.” It may be a question of “I need to put another snack in my day; otherwise I can’t bear that feeling of the abyss between lunch and dinner and how long I’m going to have to be hungry for.” So to get creative in that way can be helpful.

And you can use other kinds of tricks as well. One client mentioned that she found a series of something that the episodes were just the right length, that she would make sure she’d finished the eating by the time the episode finished. So you can find little tactics like that that help too.

Chris Sandel: Perfect. I’m in agreement on that. Again, I think there can be lots of people who are like, “No, you need to be present with your meal, you need to be not having any distractions.” I’m like, no, whatever helps someone to eat, I’m good with. If you want that to be watching something or listening to a podcast, go for it. If that then also helps with your timings, all the better.

01:19:06

How Emily’s book The Hungry Anorexic came about

I want to now talk about your book. There’s obviously the book and then the paper you wrote connected to the book. Do you have a sense of what would be a better way of dealing with this, in what order it would make sense to talk about this?

Emily Troscianko: I guess I could just tell a mini version of the story of how both came about, and you could take it from there. For ages, I thought about writing a book based on my blog, partly because readers have kindly asked over the years, “Is there a book? I’d love it” or whatever. So in 2015, I started trying to write a book from the blog, which I imagined being a very easy book – just basically take my favourite posts or the posts that’ve been the most popular and top and tail them a bit and done.

That really didn’t feel like it was making a book. I took advice from my mother’s literary agent, for example, and from others, and the basic consensus seemed to be “You need to have some kind of narrative going on if it’s an actual book.” So I started trying to put in bits of autobiographical stuff around the thematically oriented blog posts, and that was just making a complete mess of everything.

At some point, I was just getting deeply despondent about the whole thing, and was contemplating the chatter on anorexia and control, which I’d sort of been dreading because it’s such a big topic and I didn’t know how to do justice to it, or how to tackle it at all, really. And I thought, what about ta Q&A? Just have some questions, have some answers to them. That should keep it manageable.

So I started trying to write something like that about the control question, and it worked really well. I just liked writing it and I felt like some useful rhetorical things were happening in that sense that although Q&A sounds like it could be “Here I am with the answers to these questions that are being asked from a point of ignorance”, actually it gradually started to shift into more like a conversational thing where answers are being explored but different questions are coming up, and there is no necessarily singular right answer. That seemed really useful because it’s messy and complicated and who knows what the right answers are.

Ultimately, I ended up going back and rewriting the whole thing in dialogue form, which was a very weird thing to do, because I never thought I could really write dialogue, and it’s notoriously one of the hardest things to actually do well. But it is a fun thing to practice, and I did quite a lot of reading of what I’d written out loud, just trying to make it feel plausibly spoken, almost.

Different voices emerged and things happened. It really evolved in directions that I had not anticipated, to the point where I realised at the end, this is not anymore a kind of discursive, thematically oriented book about anorexia; this is basically a recovery memoir. It’s funny that you can write a whole book like that and then only realise at the end what genre it fits into. But I was so dismayed when I got to the end, because I do not have a lot of time for anorexia recovery memoirs. It is not a genre that appeals to me or the type I admire in general. It was quite – again, sounds stupid, but quite an unsettling feeling to realise that I’d just written one of these things.

Then I had to work out, okay, how do I feel about this and what happens next? And because of the research that I’d previously done that suggested very clearly that reading eating disorder themed narratives in a context where you have an eating disorder is probably a lot more likely to do harm than good, to me, some research was needed here before publication. This comes back to what I said earlier about not managing to not be a researcher, because at some point I just concluded, “Shit, I have to do an experiment here, don’t I?” [laughs]

That was how the idea of running an experiment to find out, does this book do harm to people who have an active eating disorder, came about.

Chris Sandel: Nice. I know I said this before I hit record; I’ve read about a third of the book and then I skimmed through the rest in preparation for this, and then I read through the paper connected to this. In terms of the book, I really love the fact that it is this dialogue form. My feeling when reading it was like, I’m reading a movie script or I’m reading a play. There was something very different about that, but different in a very good way.

As you said, there’s just so many questions that then could come up, and one of the things that stood out for me when going through this was just how much ambivalence, how contradictory in nature eating disorders are, where “It feels like I made this point, but then let’s go down a couple of pages and actually, we’re kind of making the opposite point.” I think it’s a really good illustration of just how jumbled-up all of these thoughts are when we’re thinking about both the eating disorder but also about recovery.

Emily Troscianko: Yeah, I think for me, I had the great advantage of, as you just said and as I touched on earlier, not needing to have a singular voice of authority anywhere. There’s clearly one voice that is more the voice of reason and hope and not being an idiot, but that voice is not some infallible, godlike figure. There’s all kinds of shifting the balances amongst the different voices.

I suppose this is why it occurred to me only belatedly that perhaps I should do some empirical research to check whether this is okay to publish, but I had increasingly become quite confident that having this kind of dialogical format is likely to forestall a lot of the worst self-triggering impulses that people might come to such books with. It became clear in previous research that a lot of times people are just seeking out eating disorder narratives to deliberately make themselves worse, to get themselves more embedded in that mindset of “Let me restrict more, get thinner”, all of that.

I hope – and I suppose the experimental results to some extent bear this out – that it’s harder to do that if you’ve, yes, got the, if you like, more anorexia, more stuck, more fearful voice being expressed, but you’ve also never got it expressed without the inflections of the other voice that’s coming in and saying, “Yeah, but what else?” and just opening up that space again is not just – one of the things that infuriates me about many published memoirs in this area is that they’re tagged as recovery. But you’ll have 398 pages of illness and then 2 very unconvincing pages at the end about “And then I got therapy and then it was all great.” [laughs]

I really wanted it to not be about that, because recovery is ultimately so much more interesting than illness and deserves so much more exploratory time. So this is meant to be redressing that balance, and even in the chronological parts of the book that are not yet recovering, to be already constantly asking those questions, constantly trying to get movement into the stasis, not accepting the hard ideological line, if you like, of the anorexia, but already prodding at it and making it uncomfortable and showing up its stupidities.

Chris Sandel: Which I, again, really like. So often, as you say, there isn’t that more healthy self coming through, asking those kind of questions. To see it there in the book from page 1 is really useful. It’s not that we have to, as you said, get to the end of the book and then find it, and so often you get to the end of the book and you’re like, “There’s like an epilogue of three pages talking about the fact that you got to recover, and we don’t have any details about that.” So yes, having that be there from page 1 I think is really useful.

Also, just reading through it – because I think so often, even if it’s done unintentionally, there can be this real glorifying of the eating disorder. And maybe I’m the wrong person to ask because I’m not in an eating disorder and I’ve never had an eating disorder, but it didn’t feel like there was much glorification because any assertion of that, there would instantly be holes poked into that. Very immediately, there would be “What about this and this and this?” So anything that could feel like “Oh, that’s a really valid thing and why I want to keep this going” instantly got cut down at the knees, which I think is again really important because it’s not you have to make it to the end of the book to find out those extra bits. You’re getting that instantly. So I think that is where it is very different to your regular book.

When I read through it, I could understand why it took you a while to cotton on to this being an eating disorder memoir, because it doesn’t feel like that. It doesn’t really feel like anything else I’ve read in this space. The one that I could remember reading – there’s a book called The Courage to Be Disliked. Have you read that before?

Emily Troscianko: No.

Chris Sandel: It’s about a particular type of therapy, and I’m blanking on the type of therapy that it is, but the whole book is done in this question-answer type format where it’s this person going and meeting up with this guy and them having these conversations. That’s the only other book that I can think of that had the same feel to it, where you get a lot out of those conversations and you get a lot out of these questions. But these questions about these little aspects that then lead on to this other thing, and it just naturally evolves.

Emily Troscianko: I shall definitely look at that book. I love the title.

Chris Sandel: Yes.

Emily Troscianko: I guess part of it is also about illustrating that there will always be ambivalence, and there will always be, whether or not they feel real psychologically to you, multiple voices. For many people they probably don’t, but change can happen within the ambivalence, and in reality that’s the only place it ever happens, because you’re never going to feel 100% convinced about anything.

I enjoyed your recent post – or maybe not that recent – on stop trying to convince yourself fully, that being convinced isn’t necessary; you’ve just got to be up for something new just enough to do a tiny bit of it and learn. That’s what we talked about earlier with the experimenting.

01:30:29

An eating disorder is like an abusive relationship

Chris Sandel: Yes. There was a bit in the book where you talked about the eating disorder being like an abusive relationship. This is something I’ve said before. Louis Theroux, I heard him doing – he’s done a couple documentaries on eating disorders – some parts I like, some parts I don’t, but I heard him interviewed once and him talking about eating disorders are like being groomed. I think it’s a really good analogy.

In the beginning, it feels like this is something that’s great, it’s wonderful, there’s all these things on offer, everything’s going to get so much better – and then the point at which you realise that’s not the case is the point at which you are already so far embedded in this thing that it’s now a challenge to get out of. I think of it like an abusive relationship or like being in a cult – these things where enough things have happened that you’ve now moved far enough along down a line that it’s not just an instantaneous “That was a bad idea, I’m going to leave now.” Things have happened that means that it takes effort to extricate yourself.

Emily Troscianko: Yeah, and that reminds me of one of the episodes in the book which is perhaps most fully illustrative of that kind of abuse, which is an episode describing some of the OCD behaviours that aren’t actually at all food-related. For me, it was things about having to memorise number plates on the cars on the track back from the toilet block in the marina and having to check that I’d watered all the plants and done all the boat ropes properly before – well, they were eating-related in the sense that all of that had to happen before eating was allowed to happen.

That, for me, was a set of phenomena that most obviously made me realise that of course I’m not in control here, and I think maybe that’s the silver lining of it. It can be so blatantly abusive or self-abusive, I guess, that you can wake up to that as well and realise it’s just a complete joke, this whole thing that I’ve been telling myself about me exercising iron will and being above all these other people who need things and all of that. Complete rubbish, because here I am, not being able to close down my laptop until I’ve memorised all these word counts on these 10 documents that I had open. What the fuck? There is zero point to this.” It’s not even relevant for the minutes in which it’s happening, let alone at any point afterwards, and yet – well, the relevance that it’s been given in the eating disorder context is you won’t be able to enjoy your food if you don’t do this.

But beyond that, that factor is only existing because that idea is allowed to remain existing.t here’s no reason why knowing word counts should enhance food enjoyment. [laughs] So I think the extremity of such abuse is also its death knell, given some other twist that allows you to just recognise it and then say, “No more.”

Chris Sandel: Yeah. I’ve had conversations with clients when there is all of this resistance to that, like “Would you recommend this for a friend? This life that you’re living that you’re so afraid to give up, would you want to recommend this to a friend, to your son, your daughter, to someone else?” And often that pretty quickly cuts through to “Actually, no, I wouldn’t. This is not how I want to be living, it’s not how I want someone else to be living.”

So yeah, it’s justified that you have these fears about making changes, but let’s call a spade a spade, and let’s talk about this as a fear as opposed to creating some narrative about how wonderful life is at this point when it’s truly not wonderful.

Emily Troscianko: Yeah, and I suppose that comes back to what you said earlier about it’s hard to realise that you’ve been doing that story-spinning to yourself for so long. Once you stop doing it, you’ve got to do the acceptance of what bullshit it was for all that time, and that has its own version of hard. As we said also, it’s a much better version of hard than just continuing with the sunk cost after sunk cost. There will have to be the nastiness, briefly.

01:35:02

Realistic depiction of recovery

Chris Sandel: One of the other things that I liked about the book – and again, this is missing when most recovery memoirs have so little on the actual recovery process – is you can see your resolve getting better as you eat more food. It’s not that then every interaction goes well. There are interactions you have with people where you’re like “I can’t believe they said that” or “Why did I say that?” It’s not that everything is then sunshine and roses; it’s that “I had this thing not go well; previously I would’ve retreated into my eating disorder, and now I’m not doing that. I’m continuing on with the recovery process.”

I think it’s really helpful to be able to see that, because a lot of the way that I’m framing recovery now and talking about it is through the lens of developing resilience, and resilience from a physiological standpoint but also psychologically, emotionally, connection, lots of other aspects. And when I read the book, that’s what really stands out; your strength grows as you start consistently eating more and more food. I really want people to see that because I think that’s, again, so missing in most of the memoirs.

Emily Troscianko: I’m glad that it came through for you in this book. There’s so much, of course, simple physical strength that comes from the eating. The brain is just another organ that is also getting repaired from the food directly. But yeah, again, coming back to failures of imagination, it’s so hard to really believe before doing it that those kinds of strength and resilience will arise simply from the eating of the croissant or whatever it is. But how could they come from any other source, if you think about it reasonably? This is the fuel that you’ve been denying yourself. It’s the fuel that’s needed, the fuel that has been lacking.

Perhaps a part of what’s needed to get the fuel coming in is to pretend that it is already more straightforward than it is. Coming back to eating rate, I often think about deceleration or artificially slow actions in other contexts within eating disorders as well – not just the eating itself, but also certainly food preparation. I often think of how quick and simple it is just to get an olive oil bottle and just pour into a pan or whatever, and how different that is from the kind of millimetre by millimetre, checking that it’s not coming out too fast and how much is in there and should it be that circumference – all of that stuff that if you can just channel the playacting of “I’m just going to do this like someone who doesn’t care”, then actually that can bring about – the playacting can sometimes turn into real acting of “I’m here, I’m happy to be going to eat this yummy thing or making this nice thing for myself to eat. I’m eager to just get on with it, get on with my day.”

Just little bits of simulation, I guess, that make that mode of experience more accessible. They do often have a lot to do with actual speed, just getting on with it, at the micro and then at the many more macro levels of getting on with it and stopping accepting just messing about. So I guess there’s multi layers of that happening in the text as well.

Chris Sandel: Yes, definitely. And also, if you’re talking about adding in some more oil, when I think of oil, it’s going to enhance the flavour of a meal. I think sometimes this can be the problem, like “I made my meal bigger, but I’ve now had some more of something that was already pretty bland and unappetizing to start with” versus “I’ve swapped out what I was having and now I’m having something that is much more palatable.” And yes, it might be the case that you still feel unsatisfied at the end of that meal because it’s still not enough food; you’re at least giving yourself the best chance that there’s going to be a higher level of satisfaction because you’re eating things that are genuinely enjoyable and genuinely going to be tasting nice – which, again, is often the fear, like “I don’t want to do that because that’s going to open some kind of pandora’s box.”

But it does then make the difference. And again, if I’m going to have the extra anxiety, I’ll have the extra anxiety because I actually enjoyed this thing.

Emily Troscianko: Yeah, and I liked your post also on satisfaction versus fullness and the importance of paying attention to both. That relates to not fooling yourself as well – trying to fill yourself up with roughage or with liquid that has no energy content or whatever, you’re just trying to trick yourself, basically. I think, again, coming back to the acting as if or the playacting, a real casualness and a carefreeness and a relaxedness with food and what you’re doing with it – you can’t actually fake that. Once that’s there, it’s really there.

Well, maybe that’s going against what I just said, which is that you need to fake it to begin with, but I think it very rapidly makes itself real. Once you’ve poured the oil haphazardly a few times, you know it doesn’t matter and that you can just do that, and that it doesn’t need to be that huge part of your day that you thought it used to be.

So much of this, in a more existential sense, of course, is about stopping the self-deception and starting to live in line with what you truly value and believe. But in all those tiny behavioural ways as well, just don’t be fretting around with fakery. Instead, just do the real things. Get on with them. Do something else after. [laughs]

Chris Sandel: Definitely in agreement. One question that one of the characters, Greg, in the book posed was “What’s in favour of starting this thing?” and I think that had a really nice set of responses afterwards. I think that’s important, because I think so often it’s framed as, “What are all the reasons why this would be a bad idea to get started or do anything?”, and that’s perpetually what’s in mind. So to have this other person asking you this question and you then giving some very honest responses about it was really useful and refreshing to read.

I do think that if someone is being honest about their current situation, they will relate to a lot of what is being shared there. People have their different flavours depending on their own stuff, but I think starting to ask better quality questions is a really important thing. And again, not getting into the “I need to convince myself” because that’s unlikely, but if I can ask myself better quality questions, I’m at least going to get some better quality responses.

Emily Troscianko: Yes, and I’m very grateful to the real-life version of Greg, who did ask me some questions along those lines, and I came up with, I don’t know, seven or eight reasons why it might be actually a good idea. In the coaching context, of course, just asking the right questions – or indeed, not asking them at particular moments – is crucial. But we can do a lot of it for ourselves as well with journalling or with conversations, if we happen to be lucky enough to have people around us who can let go of what they think they know for long enough to help us ask them for real.

01:43:03

Emily’s research on effects of reading about eating disorders

Chris Sandel: The final thing I want to ask, just to tie this up for people with the research you did on this – what were the results of people reading your book versus reading another text and comparing the two? What happened?

Emily Troscianko: Well, luckily nothing awful happened, so the book gets to be published. Actually, to my pleasure and some extent surprise, perhaps, good things happened. We pre-registered criteria for effects that would mean the book should not be published, and that was kind of scary in itself, because it was a real “this matters, this will have consequences.” The only requirement was ‘do no harm’, if you like, rather than expecting anything positive to result.

But yeah, interestingly – the way we set up the experiment, after much dithering about what format would be best, was with The Hungry Anorexic, the book in question, versus a control text, a book written actually by my mother, Sue Blackmore, called Ten Zen Questions, which is thematically nothing at all to do with eating disorders. It’s exploring ten Zen weird, slightly trippy questions that you might ask yourself in a meditation context. But it has some of the structural qualities of this dialogical form in the sense that she’s doing lots of thinking around these difficult issues and asking herself questions and so on. So that was an attempt to hold that structural stuff a bit constant, but also get away from the thematic domain of eating disorders.

Surprisingly, on both of the two standardized measures that we used, one being the EDEQ, which is a standard measure of eating disorder severity, the other being the Anorexia Specific Stages of Change questionnaire, which gets at your stage in motivation / taking action, that arc of attitudes about illness and recovery. On both those measures, significant improvement was generated pre- versus post-reading in both cases, whether people had read the anorexia memoir or the other book. And the effect sizes were pretty large, actually. These were not weird little artifacts.

So that raises some questions about what’s going on here in the sense that maybe the effects are being driven by some quality that the books share, which may be to do with the dialogic form or something stylistic of that kind – or maybe it’s actually not about the book itself, but about something else about the intervention.

One hypothesis that never occurred to me when we were designing the experiment, but in retrospect I should’ve thought about, is that the reading was fairly structured. At the end of each chapter in the case of The Hungry Anorexic and every few chapters for the other book, we asked a series of open-ended questions of readers: “How’s your day going? How are you feeling about illness and recovery right now? How did you find reading this section of the book?”

Coming back to asking good questions, just the fact of being asked those simple, open-ended recurring questions at regular intervals actually seemed quite salient to people, quite important experientially as part of their participation in this. They enjoyed the answering, in some cases at least, and found it really changed the reading experience quite a lot. It’s such a classic thing that happens when you’re trying to measure something; the way that you do the measure changes the thing that you were trying to measure in the first place. But I really think that we might’ve significantly changed the reading experience by just trying to get at those qualitative things that were going along during, not just have the pre and post quantitative measures.

So it would be very cool to do some replications that, for example, maybe just did the question asking intervals without anything being read. Would that actually have some really positive effects as well? Or could it be a completely different type of book that doesn’t even have the psychological complexities of these two? As with every experiment that one conducts, many questions are posed as well as some answered.

But there is some suggestion in other research in this area that actually, when you are getting positive effects related to reading, they may be attributable, at least partially, to what’s happening in the post-processing sense. So maybe more about how you talk about it in the book club versus what actually happened while you were reading. As I say, the ratios of those contributing factors are still up for grabs. But yeah, the stuff that was going alongside the reading here maybe was actually quite important to those positive outcomes.

Chris Sandel: Nice. I do get how this has now opened up lots of other questions. And even just the idea that you’re reading something and then you’re reflecting on it, and you’re actually putting that reflection down on paper – you’re in a sense encouraging someone in a structured way to do journalling, and there’s so much research on the benefits of journalling. It’s like, was the journalling the thing that’s moving the needle? Was it the book? Was it actually a combination of both?

I’m thrilled that it had a positive impact and that it means this book is going to see the light of day. How are people able to get it? When is it going to be available? Where can people go, that kind of thing?

Emily Troscianko: I hope it’s going to be available very soon. I don’t know when this episode will actually be broadcast, but hopefully before then. If you google something like ‘Emily Troscianko’ – although you may not be able to spell my name – or ‘Emily Hunger Artist’ – and if you want the book specifically, it’s called The Hungry Anorexic. You should stumble across it on my website. I’d be thrilled for any additional feedback from any of your listeners if they decide to give it a read.

I suppose when it comes to what was doing the good, it’s always a bit of everything, but it would be lovely to keep learning more about the relative proportions of different factors. I think I will be encouraging readers to do a bit of that adjacent processing, maybe do some journalling alongside it, just to see, can you enhance the potential of what you’re reading here for making good things happen in your life.

Chris Sandel: Definitely. I’m thinking a workbook version of the text or a separate workbook version would be great just to enhance or structure that reflection process.

Emily Troscianko: That’s a cool idea. I may pick your brain about that at some future date.

Chris Sandel: Perfect. Thank you so much for coming on the show again. Always a very easy conversation, and I always love to hear what you have to say. I love reading your blog. It’s highly recommended with clients. So yeah, thanks for coming on again.

Emily Troscianko: The time always passes very quickly when we’re chatting. Thanks for all the excellent questions.

Chris Sandel: So that was my conversation with Emily Troscianko. I hope you enjoyed it. I always love getting to chat with Emily. I think she’s a really intelligent human being. She’s got huge heart, and she’s really good with getting people to recover and helping people in this space. I highly recommend her book. As we talked about in this episode, it’s not your usual recovery book, but she does such a great job with it, and I think that everyone who’s in recovery should give it a read, or everyone who’s contemplating recovery should give it a read.

That is it with this week’s episode. As I mentioned at the top, I’m currently taking on clients. If this is something that you would like help with, you can send an email to info@seven-health.com and just put ‘Coaching’ in the subject line, and then I can get the details over to you.

So yeah, that is it for this week’s episode of the show. I will be back next week. Until then, take care of yourself, and I’ll see you soon.

Thanks so much for joining this week. Have some feedback you’d like to share? Leave a note in the comment section below!

If you enjoyed this episode, please ~~share~~ it using the social media buttons you see on this page.

Also, please leave an honest review for The Real Health Radio Podcast on Apple Podcasts! Ratings and reviews are ~~extremely helpful~~ and greatly appreciated! They do matter in the rankings of the show, and we read each and every one of them.

Listen on:

Here’s what we talk about in this podcast episode:

Intro