Good Girls: A Story and Study of Anorexia

Hadley Freeman (4th Estate, 2023)

It’s not about the food, is Hadley Freeman’s mantra, repeated over and over throughout her new anorexia nervosa memoir, Good Girls.

It’s clear that Freeman has thought about anorexia very hard — unsurprisingly as the illness has taken over much of her life — and she wants to share with others why she thinks someone would embark on self-starvation. Early on Freeman sets out her thesis:

I wrote it for anyone who wants to understand, because I think people do want to understand, and how can they unless those of us who have had it are willing to speak up and say that it really isn’t about the food? It’s about trying to say something without having to speak; it’s about fear of sexualisation and fear of womanhood; it’s about sadness and anger and the belief you’re not allowed to be sad and angry because you’re supposed to be perfect; and it’s about feeling completely overwhelmed by the world so you create a new, smaller world with one easy-to-understand rule: don’t eat.

I’m going to take issue with Freeman’s main conclusion, though — that anorexia nervosa is a metaphor. I’ve heard a variation of the above idea many times by others who are trying to figure out why someone is behaving as they are, what deep-seated angst is causing them to starve themselves. Freeman presents her particular take on it as if the ideas are shiny and new, and to the uninitiated they might seem like it, but really they are probably at least as old as me.

I first heard about the idea that anorexia is borne out of a young girl’s fear of growing up when I had my initial encounter with anorexia. It was not pretty. It was the 1980s and my best friend had inexplicably begun to starve herself. Suddenly she had a sadness in her eyes. She was losing weight rapidly, her features had become drawn, her cheeks hollow. To her close friends it was disturbing and horrific. None of us could understand it. She was the most beautiful of our group, the most popular, the funniest, the most knowledgeable. Everyone loved her. Why would she do this to herself? Why wouldn’t she just eat?

I can’t recall where I heard the idea that perhaps she was afraid of growing up, but it was around this time, from an adult who’d read something about anorexia. Even then, in the 1980s, in a fog of hairspray and Silk Cut, that seemed unlikely. My friend had never shown any fear of the adult world. In fact, she was the one who’d led me to smoke and drink alcohol and watch horror films. She was embracing adulthood and taking us all with her. And we were having quite a lot of fairly innocent fun along the way. Until my friend started obviously lying about why she wouldn’t eat a biscuit (‘I had one earlier’), isolating herself from the group and closely following the antics of the Green Goddess on morning television.

It’s taken me 30 years to understand that what really happened to my friend was probably something quite different.

*

Human beings’ ability to tell stories is one of the things that sets us apart from other animals. And Hadley Freeman is a good storyteller. Good Girls offers a terrifying insight into the mind of someone with anorexia, into the tortuous thought processes that anorexia takes the brain on to justify self-starvation. Freeman describes, with great candour, the ‘black serpent’ of anorexia, how it infected her thinking and persuaded her that eating was bad and starvation was good.

What exactly was my endgame here? Freeman writes about the time shortly after the onset of the illness, ‘I just need to be thin enough so I can eat what I want without getting fat,’ I’d think. But I never asked myself what ‘thin enough’ would be because my brain was too busy revelling in erotic fantasies of the foods I would eat at that magical if unspecified weight…

Freeman talks in detail about her brain’s preternatural preoccupation with food after anorexia set in: how she would think about things she wanted to eat but wouldn’t allow herself to; how she would collect recipes from magazines and read them in bed like pornography; how in the night she would secretly open the fridge door and inhale the smells of the food inside it but never eat it. This behaviour is not unique to anorexia. Food obsession is a classic symptom of starvation.

Unlike my teenage friend, Freeman was hospitalised on several occasions, and she describes the sad stories of some of the other patients she met in the various hospitals she stayed in. They’d all tried to explore their inner selves in an attempt try to get to the root of their illness. Why were they doing this to themselves? Not all of them survived anorexia.

It was in hospital that Freeman learned how competitive anorexia can make you, and this is something that is probably not that widely understood. The dangers of being surrounded by other girls with the same illness quickly became apparent as Freeman learned all kinds of toxic behaviour from the other patients, who were all competing to be the thinnest, to look the most unwell.

Freeman writes with pathos, and often a dark humour, when talking about her younger self and the early years of what would become a prolonged illness. She describes her anorexia as her self being suddenly split in two after she decided to lose weight following an innocuous comment — that she was ‘normal’ in comparison to a skinny friend. It was such a seismic self-splitting that when I look back on the summer of 1992 I think I can almost hear it.

Prior to that day Freeman describes herself as a relatively carefree young teenager, albeit a little sensitive and anxious. Suddenly her body became her only focus, and food — or abstaining from it — her only interest.

In the most horrific paragraph of this book, Freeman talks about the possibility of her dying of her illness, and reveals the grotesque ‘logic’ of a mind in the grip of severe anorexia:

I imagined how people would feel if I starved myself to death: OK, they’d be a bit sad, but surely they’d also feel some awe, like how people spoke about explorers who died on a mission, or astronauts who perished in space. Wasn’t I doing what everyone wanted to do but was too weak to manage?

Surely this paragraph should be required reading for any judge determining whether someone with anorexia has the ability to decide whether they should have treatment withdrawn, and it should also be considered deeply by anyone promoting the idea of ‘terminal anorexia’.

*

Freeman devotes a chapter to mothers in this book, which is unsurprising. In conversations around anorexia, historically mothers have taken centre stage. Since psychoanalyst Hilde Bruch (oft quoted in this book) and beyond, people have looked at mothers to understand why their children started to starve themselves. I’ve written about some of the bizarre leaps Bruch made to fit the idea to the reality. And these ideas around women, of course, have less to do with anorexia than they do with misogyny.

…just because your daughter develops anorexia, it doesn’t mean you’ve failed as a parent, says Freeman. I wish I could paint that in red across the sky.

It’s a statement I wholeheartedly agree with. But then she proceeds to blame some mothers, sort of, for hindering their children’s recovery:

I’ve met mothers who’ve quit work to look after their daughter; mother’s who’ve divorced their husband because he’s not sympathetic to their daughter’s difficulties; mothers who’ve made it their mission to cure anorexia in general, starting up support groups and writing impassioned blogs and newspaper articles. They make anorexia — and their daughter — their job…

…But if those around the sufferer collude in making her world just about anorexia, how will she know there is a life beyond it?

Freeman goes on to write that this is what she says to parents who ask her for advice:

I always say the same thing: get professional help as soon as you can, and don’t become her caregiver. Don’t let your relationship with her revolve entirely around anorexia, and don’t be the food police. All parents want to save their children, but in this case, you save her by handing her over to someone else so that you can still be her mother. It is not a failure. It just means she is sick, like so many other girls have been before her.

This is not good advice. Not only is it an extraordinarily privileged take — most parents in the UK have no choice but to become their child’s caregiver because waiting lists are so long and most can’t afford to pay for private treatment — but if the parents don’t become the ‘food police’, who will? And if you wait and wait and wait for treatment, all that will happen is that more weight will be lost, the illness will become entrenched and it will be much, much harder to recover from. Oh, and your child might end up dead.

Not only that but Family Based Treatment (FBT) is currently the most successful treatment for adolescents with anorexia that we have. Prior to the development of FBT, it was considered wise to remove the child from the family and often to take a psychoanalytic approach to try to understand why they are behaving as they are. FBT sees the parents as the child’s best allies against the illness. It also, most importantly, puts food at the centre of recovery. It involves the parents re-nourishing their child with the supervision of professionals. It’s hard, it can be pretty traumatic and sometimes it’s not delivered well by professionals (as our experience showed). But in many, many cases it is successful. And it can mean the difference between a short illness and one that goes on for decades. Your relationship with your child is unlikely to be harmed. In fact, like Kinsey’s story shows, they may well thank you for saving their life.

We learn in this book that, according to genetic studies, eating disorders have a 60 per cent rate of inheritability, higher than depression. Freeman quotes psychiatric geneticist Professor Gerome Breen: “I’m not saying the environment, the culture experiences and so on — are irrelevant in regards to why someone develops anorexia. I’m saying they might not be the most important factors.’

Inexplicably, Freeman discounts this in her family’s case, despite describing several family members who have had eating disorders, including her mother, who also developed anorexia. Freeman chooses to believe that the genetic factor was not the most important thing, that there was a more significant sociological explanation:

…when I think about my mother’s anorexia, and my grandmother’s anxiety about fatness before her, I think less about genetics and more about these generations of women who were so bright and not able to channel it in satisfying ways. They were trapped in their biological sex, and so they attacked themselves.

Apart from genetics, Freeman gives little more than a nod to biological explanations of anorexia nervosa. She mentions research around metabolism, for example, but gives far more weight to psychoanalytical explanations throughout the book. This feels like an opportunity missed.

Because Freeman is so confident that it’s not about the food, she also takes the long road when thinking about her teenage diet.

Vegetarianism is not an eating disorder, she writes, but studies have shown that people who have an eating disorder are exponentially more likely to have tried vegetarianism than those who don’t. Yes, it can be a healthy way to eat, but it’s also a legitimised way of excluding food.

Freeman ignores the rather obvious fact that not eating enough of some food groups may well have an affect on the body and also the brain, dismissing such ideas in favour of the psychological, as usual:

Vegetarianism was almost certainly my gateway drug into anorexia, because it was the first manifestation of my association between food and self-identity and control.

A vegetarian diet is not necessarily inherently dangerous. Most people who are vegetarian don’t develop anorexia. My schoolfriend did though. She too excluded meat and fish prior to the onset of the illness. It was hard for her to eat a sufficient amount in the school canteen or at friends’ houses because there wasn’t normally a vegetarian option back in the 1980s. So she’d eat what she could. And I suspect that she slowly slipped into energy deficit — her body was running on fewer calories than it needed to be healthy — and her thinking started to change as a result.

Many people now believe that it is energy deficit that sets off the bomb of anorexia in someone with a biological susceptibility. It’s the lack of food that triggers the desire not to eat not the other way around. This makes sense because while many develop anorexia after embarking on a restrictive diet, many develop it after illness, dental work or some other issue that makes eating difficult or causes weight to be lost.

I believe we’ve been looking at anorexia upside down for so long that it’s hard to get people to look at it the right way up. Because there doesn’t have to be a reason for behaviour outside the biological. There really doesn’t. We need to stop asking why someone is doing this to themselves and start looking at why their brain is doing this to them.

After the Second World War in Minnesota an experiment was carried out on 36 men. They were systematically semi-starved to see what this did to them physically and mentally. One of the most striking things about the results of the study are the psychological effects of starvation and how these occurred rapidly as food was reduced. The men didn’t develop anorexia nervosa as such, but much of their behaviour is similar to the behaviour of people with the illness.

And humans aren’t the only species who behave oddly when food is limited. Studies on mice have shown that if you restrict food and provide a running wheel, and isolate the mice, some begin to lose weight and run more, forgoing food even when it’s freely available (at certain times). The theory is that an ancient starvation response is activated in these animals when the conditions are met. The animals are compelled by their biology to eat less and move more, in search of of a sustainable food source.

It’s easy to forget that we’re not all that different from our four-legged cousins. Humans are animals. And if you mess with our food intake, is it too great a leap to think that this might activate an ancient starvation response in some of us, too?

Early in the book, Freeman says: Anorexia is, in my experience, an astonishingly consistent disease, in its message and expression…

Anorexia nervosa is an illness. It doesn’t have to have a message, any more than asthma or leukaemia or Covid-19 has a message. People waste years in therapy trying to figure out what the root cause of their illness is. The truth is, there probably isn’t one other than a biological susceptibility. And even if there were, I don’t know of anyone who’s had an epiphany in the therapist’s chair, walked out of the office, gone into McDonald’s and ordered a burger and fries, miraculously gaining the ability to eat normally again.

It’s fascinating that Freeman describes finally freeing herself from the illness by eating, through food, taking almost exactly the same approach as any good, modern treatment, including Family Based Treatment. Eat. Eat. Eat. And if weight gain and normalising eating are the key to recovery, isn’t it just possible that not eating enough is the thing that sparks it all? Maybe, just maybe, it is about the food after all, at least in part.

I’m truly happy that Hadley Freeman survived anorexia and that she is finally able to live a normal life. Many others aren’t so lucky. It is a shame that her recovery took so long, and for that I blame poor treatment and a general lack of understanding of what this illness is. But I’m afraid this book is unlikely to further the public’s knowledge of anorexia nervosa, relying so heavily as it does on old psychoanalytical explanations. Good Girls is a great book if you want to understand what it’s like to have anorexia. But if you want to understand anorexia, this is probably not the book for you.