An Apple a Day (17 page)

Next was Pramjit, the lovely eating disorders specialist I saw for many years. Our sessions took the form of cognitive behavioral therapy (CBT), in which both faulty thinking (cognitions) and unhelpful behaviors (food dodging) are addressed. It's a proactive approach, based on challenging one's own negative assumptions, breaking out of repetitive, damaging cycles and establishing new behavior patterns. With CBT, I found myself starting to be honest about what I was thinking. Why not be honest? It wasn't anything Pramjit hadn't heard before, and what was the point of pretending I wasn't struggling? I had to admit to all the missed meals, I had to explain why I hadn't eaten that week, what the actual barriers were day-to-day; I had to try to discuss how I might incorporate food into daily life. We would set tangible goals: I would attend the office party and “enjoy” the Christmas dinner, I would try to eat a slice of cake on my birthday. I usually failed but sometimes succeeded.

Treatment with Pramjit was “holistic,” encompassing many aspects of recovery. As well as our weekly CBT sessions, family therapy was suggested (my parents were not keen). Sometimes I had a homeopathic massage with a chatty Irishwoman called Jeannie. Often I had “menu planning” sessions with Marianne the dietitian. (Those food diaries always went in the trash.)

Pramjit was kind and sympathetic, and we grew quite close, but it didn't get me eating again. I watched as she got engaged, then married, and finally left to have her first baby—all while I was stuck in my anorexic cage—and wondered if I'd ever get free.

Without doubt the most effective treatment was my former psychiatrist Dr. Robinson. He retired last year, but for eight years I visited his offices once a fortnight.

* * *

Dr. Paul Robinson was my consultant at the Royal Free Hospital in North London. Every other Tuesday I would start work at 7
AM
so that I could leave a few hours early. I'd kept it vague with colleagues: only my assistant and the department secretary were aware that I had a regular commitment out of the office on these days. I'd had to explain to my boss, of course, but I didn't go into detail about what kind of doctor's appointment it was, just that I was requesting flexitime once a fortnight. Whatever they may say to the contrary, big corporations get very nervous about employees with mental health issues.

It's weird being a “functioning anorexic.” Quite often, in the midst of a hectic Tuesday, I'd wonder why I was going to see Dr. Robinson at all. I didn't feel particularly anorexic rushing around the office—or rather I did, but that was normal to me, not something that needed addressing at that particular point in a busy working day. When I was up against a printer's deadline, checking last-minute proofs or trying to finish off the financial papers for the acquisitions committee, going to see my shrink seemed kind of irrelevant. No matter that it was a medical appointment, no matter that I'd started work hours early, every Tuesday afternoon that I slunk out of the office I felt guilty. Now I know how working mothers feel when they leave to collect their children: there's just
something about walking past everyone else at their desks that makes you feel like a slacker, without fail. Anyway, I'd get on my bike and cycle from Euston Road to Highgate trying to get out of work mode and into treatment mode in my head. The Royal Free Hospital is perched at the top of Haverstock Hill. For each appointment I cycled up that hill, one of the steepest in London, to a place where I was being told to eat more and exercise less. Even burly men get off and push their bikes up that hill, but of course I wouldn't, even in a force-ten gale, because anorexia means never admitting defeat.

Arriving at the Royal Free Hospital, it felt odd locking up my bike and climbing the stairs (anorexics always take the stairs) to the Adult Psychiatry Unit on the third floor. Wearing pinstriped trousers, a crisp shirt in pale pink or blue, and high-heeled black boots, I looked totally out of place. Many of the girls were inpatients, so they shuffled down the corridors in slippers and PJs; who was I to breeze in here, quite a few pounds heavier than they were, all business suit and fresh air and ruddy cheeks from my bike ride? One afternoon, standing in the corridor taking a work call on my cell, a young man crept past me and I noticed his arms were covered in livid, fresh razor cuts.

God, I felt so “well”—and I mean that in the sense of fat (as in when someone tells you you're looking
well
, and they mean
ample, bouncing, plump
). I was convinced they could all see what a fake I was, how fraudulent my so-called anorexia was. If I was really sick then why had I scarfed that entire banana at lunchtime? I've always felt deeply uneasy around fellow anorexics, and for me the Eating Disorders Unit waiting room of the Adult Psychiatry Department was torture. I know that many sufferers feel the same way—it's almost as if we can read each other's shameful secrets. Just once in all the years I was there did I see a terribly obese woman—Eating Disorder Units treat those with obesity as well as
anorexia—and her discomfort was truly awful. She stared at the floor, ashamed to meet anyone's eyes, clearly going through far worse horrors than I was in that waiting room . . . All in all, it was a relief to be called in to see Dr. Robinson.

It's perhaps an indicator of our good relationship that I was able, many times, to walk into his office and say, “I feel a complete fraud next to all your skinny girls.” No matter that Dr. Robinson is a rather formal, old-school psychiatrist, no matter that he shuffled those case files around so that I never knew whether he quite remembered who the hell I was—despite that, he was frank with me and I was with him.

I remember our very first appointment, when he kept me waiting for an hour and a half. By the time he called me in I was quite seriously pissed off. I soon got used to it—he gave each patient far longer than the inadequate ten-minute slots allocated by the health care system so his appointments were always running ludicrously late. (I used to wonder whether he was still there at 9
PM
, catching up with his afternoon appointments.) I soon learned to take a good book and to turn up an hour after the scheduled time.

This prolonged delay also enabled patients to consume the requisite three or four bottles of water. Water-loading is one of the techniques we used—as well as coins and keys in pockets, wearing thick socks and heavy belts—to artificially boost our weight before climbing onto the scale. It was tricky, waiting hours with a bursting bladder, but a couple of liters of Evian can add precious pounds to your weight chart.

Despite being hopeless at timekeeping, Paul Robinson was also one of the leading specialists in the field of eating disorders. After my experience at the Tavistock Clinic I was wary of all mental health professionals—whether psychologist, psychiatrist, or psychoanalyst—but I was very lucky to have been referred to him. There is good and bad news with this illness, and Dr. Robinson
was honest with me from the start. Unlike other eating disorders counselors I'd seen over the years—with their kind words and gentle encouragement—he didn't offer me cups of tea or boxes of Kleenex, and he didn't allow me to feel powerless about anorexia. Indeed, I often felt I was wasting his time. I suppose I was wasting his time, and my time too, sitting in his office, talking about gaining weight and continuing to starve myself. But he never saw me as a hopeless case: he knew and I knew that I could beat anorexia. I think it was his no-nonsense, scientific approach that helped more than anything. I'm someone who prefers to know the facts, however scary they might be—hoping, I suppose, to scare myself into action. Dr. Robinson always told me the truth.

I had not menstruated for years, which meant that I was probably not ovulating, which explains why I am currently infertile. But the good news was that this was mostly reversible. Almost all women with anorexia regain their fertility when they return to a normal weight. When I first started seeing Dr. Robinson, the fertility thing was never my main concern. As I sit here, aged thirty-three, I realize that in my twenties it didn't bother me at all. Sure, the absence of periods was an indication that all was not well, but who really minds not having periods? It only began to bother me when I turned thirty. The weird thing is I never seriously imagined not having children. Was that colossal self-deceit, my mind shutting itself off to the facts? I always assumed it would work itself out in the end.

Dr. Robinson was a good doctor in another way too, in that he referred me for regular tests. One of the most important was the DEXA (dual-emission X-ray absorptiometry), a scan that measures bone mineral density. It's well known that being underweight and without periods is a major risk factor for osteoporosis, but I only recently found out that up to 90 percent of anorexics will show some degree of bone loss. And so it was
with me: the DEXAs revealed I had osteopenia (the precursor to full-blown osteoporosis) in my left hip and spine, and my T-scores were deteriorating over the years. How foolish: to be confronted with the truth, the proof of what I was doing to myself, that I could see the frightening results of those bone scans, and still not give up anorexia. While Dr. Robinson's tests didn't cure me, they sure as hell reminded me of the invisible damage anorexia was doing—and more importantly he reminded me that I could do something about it. For women, the twenties are a crucial life stage for building bone mass—perhaps I couldn't reverse the damage completely but I could have helped myself a little more. Except, of course, I couldn't. As always, anorexia was stronger.

Along with the gone-to-sleep ovaries and crumbling-spine charts, Dr. Robinson and I would have discussions about the nature of selfhood and denial, control and sexuality, femininity and family. I would sometimes talk about wanting children and he'd say, “But do you really want to be a mother, Emma?” He would call me on lazy assumptions I was making, he would catch me up when I wasn't being honest with myself. It's easy to
say
you want children—that's what most girls are brought up to say—but it's a lot harder to think about why, and how it might not be easy, or to admit that you have doubts. Even now, writing about my desire to get pregnant in a national newspaper, I still have real fears about how life will change with a baby and the freedom I'll have to give up.

For a bearded, middle-class, gray-suited man in his late fifties, Dr. Robinson seemed to have an instinctive understanding of women: of eating and anxiety and bodies and babies. I talked to him as easily as I might to talk to my mother—more honestly perhaps. Whether I was gaining or losing weight (and mostly I was losing), I just found our sessions intensely interesting.

One Tuesday afternoon in early November, he casually observed that in the Middle Ages I might have been a nun, an ascetic
devoted to denying the demands of the flesh. I knew instantly what he meant (I have always identified with Dorothea Brooke in
Middlemarch
). We talked about this many times—the pain and reward of self-denial, and why it appealed to me.

It was raining heavily as I left the hospital, but I cycled home in a trance. All the way, I thought of the medieval literature I'd studied at Oxford; I conjured up vivid images of Julian of Norwich, Margery Kempe, those nuns and mystics mortifying the flesh, starving and praying in their lonely cells. Dr. Robinson had identified something about me I'd never realized: that the anorexia (even more than thinness) satisfies a yearning for something clean and empty. A part of me fears being womanly, fleshy, excessive: I like to be lithe and compact, I like my tone and muscle. I like to run for miles and feel that I am contained in a neat, athlete's body. Being a woman is messy: being a woman involves blood and fat. Anorexia seems very pure and I like that.

I've since found out that my “purity” feeling does make sense. There was a research study in Ghana several years ago that investigated secondary school girls with abnormally low body weight (Bennett et al.,
The British Journal of Psychiatry
, 2004). None of these underweight girls displayed a desire to be thin or a morbid fear of fatness—and, even weirder, none reported amenorrhoea. The study reports that they viewed their food restriction positively and in religious terms; they believed in self-control and denial of hunger, but without the typical anorexic concerns over weight and shape. In other words the Ghanaian girls didn't have any problem with body image; they just wanted to be more religious and holy.

Although Dr. Robinson didn't ultimately cure me, I enjoyed exploring these cultural and social ideas with him, ideas beyond the usual bland eating disorders narratives. It's important to have some insight into what is, after all, a serious mental illness. I have
lived with this for a third of my life. For me it's normal, but it makes normal life impossible. Succumbing to hunger is weak: that is the basic rule by which I live. After thirty years in the field, Dr. Robinson understands this. It's a relief to be able to talk about it, when so much of this illness is secrecy and deception.

There would come a point, for all our talk, when I would have to shut up and be weighed. The fear of not gaining weight and the much greater fear of gaining would crystallize into those few moments where he would close my file and say, “Right, let's weigh you.” I would slip off my shoes or unzip my boots and step onto the digital scale in the corner of his office.

The scales in Eating Disorder Units are terrifyingly precise. They are checked and recalibrated once a week—I imagine only the grand pianos in the Royal Opera House have as much finetuning. I was aware of them throughout every appointment, those terrible scales, crouched in the corner, waiting to judge me.
I step onto the scale and everything goes silent, I close my eyes and open them slowly, and watch the green digits flicker up and down, 101, 104, 105, 103 . . . before they settle and flash twice and hold, pronouncing on my fate, whether I am a failure, whether I am a winner. For however much I tell myself that it's not about the numbers, it's not about my physical weight, at some level it is
. So he would weigh me and note down the numbers in my notes, and compare it to the previous fortnight's tally, and we'd discuss why I wasn't making progress. Again he would explain what I had to do, and again I would promise to do it.