What You Can Change and What You Can't

Excerpted From The Book: What You Can Change and What You Can't

There are things we can change about ourselves and things we cannot. Concentrate your energy on what is possible--too much time has been wasted.

This is the age of psychotherapy and the age of self-improvement. Millions are struggling to change. We diet, we jog, we meditate. We adopt new modes of thought to counteract our depressions. We practice relaxation to curtail stress. We exercise to expand our memory and to quadruple our reading speed. We adopt draconian regimens to give up smoking. We raise our little boys and girls to androgyny. We come out of the closet or we try to become heterosexual. We seek to lose our taste for alcohol. We seek more meaning in life. We try to extend our life span.

Sometimes it works. But distressingly often, self-improvement and psychotherapy fail. The cost is enormous. We think we are worthless. We feel guilty and ashamed. We believe we have no willpower and that we are failures. We give up trying to change.

On the other hand, this is not only the age of self-improvement and therapy, but also the age of biological psychiatry. The human genome will be nearly mapped before the millennium is over. The brain systems underlying sex, hearing, memory, left-handedness, and sadness are now known. Psychoactive drugs quiet our fears, relieve our blues, bring us bliss, dampen our mania, and dissolve our delusions more effectively than we can on our own.

Our very personality--our intelligence and musical talent, even our religiousness, our conscience (or its absence), our politics, and our exuberance-turns out to be more the product of our genes than almost anyone would have believed a decade ago. The underlying message of the age of biological psychiatry is that our biology frequently makes changing, in spite of all our efforts, impossible.

Understanding dissociation and its relationship to trauma is basic to understanding the posttraumatic and dissociative disorders. But the view that all is genetic and biochemical and therefore unchangeable is also very often wrong. Many people surpass their IQs, fail to "respond" to drugs, make sweeping changes in their lives, live on when their cancer is "terminal," or defy the hormones and brain circuitry that "dictate" lust, femininity, or memory loss.

The ideologies of biological psychiatry and self-improvement are obviously colliding. Nevertheless, a resolution is apparent. There are some things about ourselves that can be changed, others that cannot, and some that can be changed only with extreme difficulty.

What can we succeed in changing about ourselves? What can we not? When can we overcome our biology? And when is our biology our destiny?

I want to provide an understanding of what you can and what you can't change about yourself so that you can concentrate your limited time and energy on what is possible. So much time has been wasted. So much needless frustration has been endured. So much of therapy, so much of child rearing, so much of self-improving, and even some of the great social movements in our century have come to nothing because they tried to change the unchangeable. Too often we have wrongly thought we were weak-willed failures, when the changes we wanted to make in ourselves were just not possible. But all this effort was necessary: Because there have been so many failures, we are now able to see the boundaries of the unchangeable; this in turn allows us to see clearly for the first time the boundaries of what is changeable.

With this knowledge, we can use our precious time to make the many rewarding changes that are possible. We can live with less self-reproach and less remorse. We can live with greater confidence. This knowledge is a new understanding of who we are and where we are going.

CATASTROPHIC THINKING: PANIC

S.J. Rachman, one of the world's leading clinical researchers and one of the founders of behavior therapy, was on the phone. He was proposing that I be the "discussant" at a conference about panic disorder sponsored by the National Institute of Mental Health (NIMH).

"Why even bother, Jack?" I responded. "Everyone knows that panic is biological and that the only thing that works is drugs."

"Don't refuse so quickly, Marty. There is a breakthrough you haven't yet heard about."

Breakthrough was a word I had never heard Jack use before.

"What's the breakthrough?" I asked.

"If you come, you can find out."

So I went.

I had known about and seen panic patients for many years, and had read the literature with mounting excitement during the 1980's. I knew that panic disorder is a frightening condition that consists of recurrent attacks, each much worse than anything experienced before. Without prior warning, you feel as if you are going to die. Here is a typical case history:

The first time Celia had a panic attack, she was working at McDonald's. It was two days before her 20th birthday. As she was handing a customer a Big Mac, she had the worst experience of her life. The earth seemed to open up beneath her. Her heart began to pound, she felt she was smothering, and she was sure she was going to have a heart attack and die. After about 20 minutes of terror, the panic subsided. Trembling, she got in her car, raced home, and barely left the house for the next three months.

Since then, Celia has had about three attacks a month. She does not know when they are coming. She always thinks she is going to die.

Panic attacks are not subtle, and you need no quiz to find out if you or someone you love has them. As many as five percent of American adults probably do. The defining feature of the disorder is simple: recurrent awful attacks of panic that come out of the blue, last for a few minutes, and then subside. The attacks consist of chest pain, sweating, nausea, dizziness, choking, smothering, or trembling. They are accompanied by feelings of overwhelming dread and thoughts that you are having a heart attack, that you are losing control, or that you are going crazy.

THE BIOLOGY OF PANIC

There are four questions that bear on whether a mental problem is primarily "biological" as opposed to "psychological":

Can is be induced biologically?

Is it genetically heritable?

Are specific brain functions involved?

Does a drug relieve it?

Inducing panic: Panic attacks can be created by a biological agent. For example, patients who have a history of panic attacks are hooked up to an intravenous line. Sodium lactate, a chemical that normally produces rapid, shallow breathing and heart palpitations, is slowly infused into their bloodstream. Within a few minutes, about 60 to 90 percent of these patients have a panic attack. Normal controlssubjects with no history of panic-rarely have attacks when infused with lactate.

Genetics of panic: There may be some heritability of panic. If one of two identical twins has panic attacks, 31 percent of the cotwins also have them. But if one of two fraternal twins has panic attacks, none of the cotwins are so afflicted.

Panic and the brain: The brains of people with panic disorders look somewhat unusual upon close scrutiny. Their neurochemistry shows abnormalities in the system that turns on, then dampens, fear. In a`dition, the PET scan (positron-emission tomography), a technique that looks at how much blood and oxygen different parts of the brain use, shows that patients who panic from the infusion of lactate have higher blood flow and oxygen use in relevant parts of their brain than patients who don't panic.

Drugs: Two kinds of drugs relieve panic: tricyclic antidepressants and the antianxiety drug Xanax, and both work better than placebos. Panic attacks are dampened, and sometimes even eliminated. General anxiety and depression also decrease.

Since these four questions had already been answered "yes" when Jack Rachman called, I thought the issue had already been settled. Panic disorder was simply a biological illness, a disease of the body that could be relieved only by drugs.

A few months later I was in Bethesda, Maryland, listening once again to the same four lines of biological evidence. An inconspicuous figure in a brown suit sat hunched over the table. At the first break, Jack introduced me to him-David Clark, a young psychologist from Oxford. Soon after, Clark began his address.

"Consider, if you will, an alternative theory, a cognitive theory." He reminded all of us that almost all panickers believe that they are going to die during an attack. Most commonly, they believe that they are having heart attacks. Perhaps, Clark suggested, this is more than just a mere symptom. Perhaps it is the root cause. Panic may simply be the catastrophic misinterpretation of bodily sensations.

For example, when you panic your heart starts to race. You notice this, and you see it as a possible heart attack. This makes you very anxious, which means your heart pounds more. You now notice that your heart is really pounding. You are now sure it's a heart attack. This terrifies you, and you break into a sweat, feel nauseated, short of breath--all symptoms of terror, but for you, they're confirmation of a heart attack. A full-blown panic attack is under way, and at the root of it is your misinterpretation of the symptoms of anxiety as symptoms of impending death.

I was listening closely now as Clark argued that an obvious sign of a disorder, easily dismissed as a symptom, is the disorder itself. If he was right, this was a historic occasion. All Clark had done so far, however, was to show that the four lines of evidence for a biological view of panic could fit equally well with a misinterpretation view. But Clark soon told us about a series of experiments he and his colleague Paul Salkovskis had done at Oxford.

First, they compared panic patients with patients who had other anxiety disorders and with normals. All the subjects read the following sentences aloud, but the last word was presented blurred. For example:

dying if I had palpitations, I could be excited excited

choking If I were breathless, I could be unfit unfit

When the sentences were about bodily sensations, the panic patients, but no one else, saw the catastrophic endings fastest. This showed that panic patients possess the habit of thinking Clark had postulated.

Next, Clark and his colleagues asked if activating this habit with words would induce panic. All the subjects read a series of word pairs a aloud. When panic patients got to "breathless-suffocation" and "palpitations-dying," 75 percent suffered a full-blown panic attack right there in the laboratory. No normal people had panic attacks, no recovered panic patients (I'll tell you more in a moment about how they got better) had attacks, and only 17 percent of other anxious patients had attacks.

The final thing Clark told us was the "breakthrough" that Rachman had promised.

"We have developed and tested a rather novel therapy for panic," Clark continued in his understated, disarming way. He explained that if catastrophic misinterpretations of bodily sensation are the cause of a panic attack, then changing the tendency to misinterpret should cure the disorder. His new therapy was straightforward and brief:

Patients are told that panic results when they mistake normal symptoms of mounting anxiety for symptoms of heart attack, going crazy, or dying. Anxiety itself, they, are informed, produces shortness of breath, chest pain, and sweating. Once they misinterpret these normal bodily sensations as an imminent heart attack, their symptoms become even more pronounced because the misinterpretation changes their anxiety into terror. A vicious circle culminates in a full-blown panic attack.

Patients are taught to reinterpret the symptoms realistically as mere anxiety symptoms. Then they are given practice right in the office, breathing rapidly into a paper bag. This causes a buildup of carbon dioxide and shortness of breath, mimicking the sensations that provoke a panic attack. The therapist points out that the symptoms the patient is experiencing--shortness of breath and heart racing--are harmless, simply the result of overbreathing, not a sign of a heart attack. The patient learns to interpret the symptoms correctly.

"This simple therapy appears to be a cure," Clark told us. "Ninety to 100 percent of the patients are panic free at the end of therapy. One year later, only one person had had another panic attack."

This, indeed, was a breakthrough: a simple, brief psychotherapy with no side effects showing a 90-percent cure rate of a disorder that a decade ago was thought to be incurable. In a controlled study of 64 patients comparing cognitive therapy to drugs to relaxation to no treatment, Clark and his colleagues found that cognitive therapy is markedly better than drugs or relaxation, both of which are better than nothing. Such a high cure rate is unprecedented.

How does cognitive therapy for panic compare with drugs? It is more effective and less dangerous. Both the antidepressants and Xanax produce marked reduction in panic in most patients, but drugs must be taken forever; once the drug is stopped, panic rebounds to where it was before therapy began for perhaps half the patients. The drugs also sometimes have severe side effects, including drowsiness, lethargy, pregnancy complications, and addictions.

After this bombshell, my own "discussion" was an anticlimax. I did make one point that Clark took to heart. "Creating a cognitive therapy that works, even one that works as well as this apparently does, is not enough to show that the cause of panic is cognitive:" I was niggling. "The biological theory doesn't deny that some other therapy might work well on panic. It merely claims that panic is caused at the bottom by some biochemical problem."

Two years later, Clark carried out a crucial experiment that tested the biological theory against the cognitive theory. He gave the usual lactate infusion to 10 panic patients, and nine of them panicked. He did the same thing with another 10 patients, but added special instructions to allay the misinterpretation of the sensations. He simply told them: "Lactate is a natural bodily substance that produces sensations similar to exercise or alcohol. It is normal to experience intense sensations during infusion, but these do not indicate an adverse reaction." Only three out of the 10 panicked. This confirmed the theory crucially.

The therapy works very well, as it did for Celia, whose story has a happy ending. She first tried Xanax, which reduced the intensity and the frequency of her panic attacks. But she was too drowsy to work, and she was still having about one attack every six weeks. She was then referred to Audrey, a cognitive therapist who explained that Celia was misinterpreting her heart racing and shortness of breath as symptoms of a heart attack, that they were actually just symptoms of mounting anxiety, nothing more harmful. Audrey taught Celia progressive relaxation, and then she demonstrated the harmlessness of Celia's symptoms of overbreathing. Celia then relaxed in the presence of the symptoms and found that they gradually subsided. After several more practice sessions, therapy terminated. Celia has gone two years without another panic attack.

EVERYDAY ANXIETY

Attend to your tongue--right now. What is it doing? Mine is swishing around near my lower right molars. It has just found a minute fragment of last night's popcorn (debris from Terminator 2). Like a dog at a bone, it is worrying the firmly wedged flake.

Attend to your hand--right now. What's it up to? My left hand is boring in on an itch it discovered under my earlobe.

Your tongue and your hands have, for the most part, a life of their own. You can bring them under voluntary control by consciously calling them out of their "default" mode to carry out your commands: "Pick up the phone" or "Stop picking that pimple." But most of the time they are on their own. They are seeking out small imperfections. They scan your entire mouth and skin surface, probing for anything going wrong. They are marvelous, nonstop grooming devices. They, not the more fashionable immune system, are your first line of defense against invaders.

Anxiety is your mental tongue. Its default mode is to search for what may be about to go wrong. It continually, and without your conscious consent, scans your life--yes, even when you are asleep, in dreams and nightmares. It reviews your work, your love, your play--until it finds an imperfection. When it finds one, it worries it. It tries to pull it out from its hiding place, where it is wedged inconspicuously under some rock. It will not let go. If the imperfection is threatening enough, anxiety calls your attention to it by making you uncomfortable. If you do not act, it yells more insistently--disturbing your sleep and your appetite.

You can reduce daily, mild anxiety. You can numb it with alcohol, Valium, or marijuana. You can take the edge off with meditation or progressive relaxation. You can beat it down by becoming more conscious of the automatic thoughts of danger that trigger anxiety and then disputing them effectively.

But do not overlook what your anxiety is trying to do for you. In return for the pain it brings, it prevents larger ordeals by making you aware of their possibility and goading you into planning for and forestalling them. It may even help you avoid them altogether. Think of your anxiety as the "low oil" light flashing on the dashboard of your car. Disconnect it and you will be less distracted and more comfortable for a while. But this may cost you a burned-up engine. Our dysphoria, or bad feeling, should, sonic of the time, be tolerated, attended to, even cherished.

GUIDELINES FOR WHEN TO TRY TO CHANGE ANXIETY

Some of our everyday anxiety, depression, and anger go beyond their useful function. Most adaptive traits fall along a normal spectrum of distribution, and the capacity for internal bad weather for everyone some of the time means that sonic of us may have terrible weather all of the time. In general, when the hurt is pointless and recurrent--when, for example, anxiety insists we formulate a plan but no plan will work--it is time to take action to relieve the hurt. There are three hallmarks indicating that anxiety has become a burden that wants relieving:

First, is it irrational?

We must calibrate our bad weather inside against the real weather outside. Is what you are anxious about out of proportion to the reality of the danger? Here are some examples that may help you answer this question. All of the following are not irrational:

A fire fighter trying to smother a raging oil well burning in Kuwait repeatedly wakes up at four in the morning because of flaming terror dreams.

A mother of three smells perfume on her husband's shirts and, consumed by jealousy, broods about his infidelity, reviewing the list of possible women over and over.

A student who had failed two of his midterm exams finds, as finals approach, that he can't get to sleep for worrying. He has diarrhea most of the time.

The only good thing that can be said about such fears is that they are well-founded.

In contrast, all of the following are irrational, out of proportion to the danger:

An elderly man, having been in a fender bender, broods about travel and will no longer take cars, trains, or airplanes.

An eight-year-old child, his parents having been through an ugly divorce, wets his bed at night. He is haunted with visions of his bedroom ceiling collapsing on him.

A housewife who has an MBA and who accumulated a decade of experience as a financial vice president before her twins were born is sure her job search will be fruitless. She delays preparing her resumes for a month.

The second hallmark of anxiety out of control is paralysis. Anxiety intends action: Plan, rehearse, look into shadows for lurking dangers, change your life. When anxiety becomes strong, it is unproductive; no problem-solving occurs. And when anxiety is extreme, it paralyzes you. Has your anxiety crossed this line? Some examples:

A woman finds herself housebound because she fears that if she goes out, she will be bitten by a cat.

A salesman broods about the next customer hanging up on him and makes no more cold calls.

A writer, afraid of the next rejection slip, stops writing.

The final hallmark is intensity. Is your life dominated by anxiety? Dr. Charles Spielberger, one of the world's foremost testers of emotion, has developed well-validated scales for calibrating how severe anxiety is. To find out how anxious you are, use the self-analysis questionnaire beginning on page 38.

LOWERING YOUR EVERYDAY ANXIETY

Everyday anxiety level is not a category to which psychologists have devoted a great deal of attention. Enough research has been done, however, for me to recommend two techniques that quite reliably lower everyday anxiety levels. Both techniques are cumulative, rather than one-shot fixes. They require 20 to 40 minutes a day of your valuable time.

The first is progressive relaxation, done once or, better, twice a day for at least 10 minutes. In this technique, you tighten and then turn off each of the major muscle groups of your body until you are wholly flaccid. It is not easy to be highly anxious when your body feels like Jell-O. More formally, relaxation engages a response system that competes with anxious arousal.

The second technique is regular meditation. Transcendental mediation (TM) is one useful, widely available version of this. You can ignore the cosmology in which it is packaged if you wish, and treat it simply as the beneficial technique it is. Twice a day for 20 minutes, in a quiet setting, you close your eyes and repeat a mantra (a syllable whose "sonic properties are known") to yourself Meditation works by blocking thoughts that produce anxiety. It complements relaxation, which blocks the motor components of anxiety but leaves the anxious thoughts untouched.

Done regularly, meditation usually induces a peaceful state of mind. Anxiety at other times of the day wanes, and hyperarousal from bad events is dampened. Done religiously, TM probably works better than relaxation alone.

There's also a quick fix. The minor tranquilizers--Valium, Dalmane, Librium, and their cousins--relieve everyday anxiety. So does alcohol. The advantage of all these is that they work within minutes and require no discipline to use. Their disadvantages outweigh their advantages, however. The minor tranquilizers make you fuzzy and somewhat uncoordinated as they work (a not uncommon side effect is an automobile accident). Tranquilizers soon lose their effect when taken regularly, and they are habit-forming--probably addictive. Alcohol, in addition, produces gross cognitive and motor disability in lockstep with its anxiety relief. Taken regularly over long periods, deadly damage to liver and brain ensue.

If you crave quick and temporary relief from acute anxiety, either alcohol or mi nor tranquilizers, taken in small amounts and only occasionally, will do the job. They are, however, a distant second best to progressive relaxation and meditation, which are each worth trying before you seek out psychotherapy or iii conjunction with therapy. Unlike tranquilizers and alcohol, neither of these techniques is likely to do you any harm.

Weigh your everyday anxiety. It it is not intense, or if it is moderate and not irrational or paralyzing, act now to reduce it. In spite of its deep evolutionary roots, intense everyday anxiety is often changeable. Meditation and progressive relaxation practiced regularly can change it forever.

DIETING: A WAIST IS A TERRIBLE THING TO MIND

I have been watching my weight and restricting my intake--except for an occasional binge like this--since I was 20. I weighed about 175 pounds then, maybe 15 pounds over my official "ideal" weight. I weigh 199 pounds now, 30 years later, about 25 pounds over the ideal. I have tried about a dozen regimes--fasting, the Beverly Hills Diet, no carbohydrates, Metrecal for lunch, 1,200 calories a day, low fat, no lunch, no starches, skipping every other dinner. I lost 10 or 15 pounds on each in about a month. The pounds always came back, though, and I have gained a net of about a pound a year--inexorably.

This is the most consistent failure in my life. It's also a failure I can't just put out of mind, I have spent the last few years reading the scientific literature, not the parade of best-selling diet books or the flood of women's magazine articles on the latest way to shut down. The scientific findings look clear to me, but there is not yet a consenus. I am going to go out on a limb, because I see so many signs all pointing in one direction. What I have concluded will, I believe, soon be the consensus of the scientists. The conclusions surprise me. They will probably surprise you, too, and they may change your life.

Hear is what the picture looks like to me:

Dieting doesn't work.

Dieting may make overweight worse, not better.

Dieting may be bad for health.

Dieting may cause eating disorders--including bulimea and anorexia.

ARE YOU OVERWEIGHT?

Are you above the ideal weight for your sex, height, and age? If so, you are "overweight. What does this really mean? Ideal weight is arrived at simply. Four million people, now dead, who were insured by the major Americani life-insurance companies, once weighed and had their height measured. At what weight on average do people of a given height turn out to live longest? That weight is called ideal. Anything wrong with that?

You bet. The real use of a weight table, and the reason your doctor takes it seriously, is that an ideal weight implies that, on average, if you slim down to yours, you will live longer. This is the crucial claim. Lighter people indeed live longer, on average, that) heavier people, but how much longer is hotly debated.

But the crucial claim is unsound because weight (at any given height) has a normal distribution, normal both in a statistical sense and in the biological sense. In the biological sense, couch potatoes who overeat and never exercise can legitimately be called overweight, but the buxom, "heavy-boned" slow people deemed overweight by the ideal table are at their natural and healthiest weight. If you are a 135-pound woman and 64 inches in height, for example, you are "overweight" by around 15 pounds. This means nothing more than that the average 140-pound, 64-inch-tall woman lives somewhat longer than the average 155-pound woman of your height. It does not follow that if you slim down to 125 pounds, you will stand any better chance of living longer.

In spite of the insouciance with which dieting advice is dispensed, no one has properly investigated the question of whether slimming down to "ideal" weight produces longer life. The proper study would compare the longevity of people who are at their ideal weight without dieting to people who achieve their ideal weight by dieting. Without this study the common medical advice to diet down to your ideal weight is simply unfounded.

This is not a quibble; there is evidence that dieting damages your health and that this damage may shorten your life.

MYTHS OF OVERWEIGHT

The advice to diet down to your ideal weight to live longer is one myth of overweight. Here are some others:

Overweight people overeat. Wrong. Nineteen out of 20 studies show that obese people consume no more calories each day than nonobese people. Telling a fat person that if she would change her eating habits and eat "normally" she would lose weight is a lie. To lose weight and stay there, she will need to eat excruciatingly less than a normal person, probably for the rest of her life.

Overweight people have an overweight personality. Wrong. Extensive research on personality and fatness has proved little. Obese people do not differ in any major personality style from nonobese people.

Physical inactivity is a major cause of obesity. Probably not. Fat people are indeed less active than thin people, but the inactivity is probably caused more by the fatness than the other way around.

Overweight shows a lack of willpower. This is the granddaddy of all the myths. Fatness is seen as shameful because we hold people responsible for their weight. Being overweight equates with being a weak-willed slob. We believe this primarily because we have seen people decide to lose weight and do so in a matter of weeks.

But almost everyone returns to the old weight after shedding pounds. Your body has a natural weight that it defends vigorously against dieting. The more diets tried, the harder the body works to defeat the next diet. Weight is in large part genetic. All this gives the lie to the "weak-willed" interpretations of overweight. More accurately, dieting is the conscious will of the individual against a more vigilant opponent: the species' biological defense against starvation. The body can't tell the difference between self-imposed starvation and actual famine, so it defends its weight by refusing to release fat, by lowering its metabolism, and by demanding food. The harder the creature tries not to eat, the more vigorous the defenses become.

BULIMIA AND NATURAL WEIGHT

A concept that makes sense of your body's vigorous defense against weight loss is natural weight. When your body screams "I'm hungry," makes you lethargic, stores fat, craves sweets and renders them more delicious than ever, and makes you obsessed with food, what it is defending is your natural weight. It is signaling that you have dropped into a range it will not accept. Natural weight prevents you from gaining too much weight or losing too much. When you eat too much for too long, the opposite defenses are activated and make long-term weight gain difficult.

There is also a strong genetic contribution to your natural weight. Identical twins reared apart weigh almost the same throughout their lives. When identical twins are overfed, they gain weight and add fat in lockstep and in the same places. The fatness or thinness of adopted children resembles their biological parents--particularly their mother--very closely but does not at all resemble their adoptive parents. This suggests that you have a genetically given natural weight that your body wants to maintain.

The idea of natural weight may help cure the new disorder that is sweeping young America. Hundreds of thousands of young women have contracted it. It consists of bouts of binge eating and purging alternating with days of undereating. These young women are usually normal in weight or a bit on the thin side, but they are terrified of becoming fat. So they diet. They exercise. They take laxatives by the cup. They gorge. Then they vomit and take more laxatives. This malady is called bulimia nervosa (bulimia, for short).

Therapists are puzzled by bulimia, its causes, and treatment. Debate rages about whether it is an equivalent of depression, or an expression of a thwarted desire for control, or a symbolic rejection of the feminine role. Almost every psychotherapy has been tried. Antidepressants and other drugs have been administered with some effect but little success has been reported.

I don't think that bulimia is mysterious, and I think that it will be curable. I believe that bulimia is caused by dieting. The bulimic goes on a diet, and her body attempts to defend its natural weight. With repeated dieting, this defense becomes more vigorous. Her body is in massive revolt--insistently demanding food, storing fat, craving sweets, and lowering metabolism. Periodically, these biological defenses will overcome her extraordinary willpower (and extraordinary it must be to even approach an ideal weight, say, 20 pounds lighter than her natural weight). She will then binge. Horrified by what this will do to her figure, she vomits and takes laxatives to purge calories. Thus, bulimia is a natural consequence of self-starvation to lose weight in the midst of abundant food.

The therapist's task is to get the patient to stop dieting and become comfortable with her natural weight. He should first convince the patient that her binge eating is caused by her body's reaction to her diet. Then he must confront her with a question: Which is more important, staying thin or getting rid of bulimia? By stopping the diet, he will tell her, she can get rid of the uncontrollable binge-purge cycle. Her body will now settle at her natural weight, and she need not worry that she will balloon beyond that point. For some patients, therapy will end there because they would rather be bulimic than "loathsomely fat." For these patients, the central issue--ideal weight versus natural weight--can now at least become the focus of therapy. For others, defying the social and sexual pressure to be thin will be possible, dieting will be abandoned, weight will be gained, and bulimia should end quickly.

These are the central moves of the cognitive-behavioral treatment of bulimia. There are more than a dozen outcome studies of this approach, and the results are good. There is about 60 percent reduction in hinging and purging (about the same as with antidepressant drugs). But unlike drugs, there is little relapse after treatment. Attitudes toward weight and shape relax, and dieting withers.

Of course, the dieting theory cannot fully explain bulimia. Many people who diet don't become bulimic; some can avoid it because their natural weight is close to their ideal weight, and therefore the diet they adopt does not starve them. In addition, bulimics are often depressed, since binging-purging leads to self-loathing. Depression may worsen bulimia by making it easier to give in to temptation. Further, dieting may just be another symptom of bulimia, not a cause. Other factors aside, I can speculate that dieting below your natural weight is a necessary condition for bulimia, and that returning to your natural weight and accepting that weight will cure bulimia.

OVERWEIGHT VS. DIETING: THE HEALTH DAMAGE

Being heavy carries some health risk. There is no definite answer to how much, because there is a swamp of inconsistent findings. But even if you could just wish pounds away, never to return, it is not certain you should. Being somewhat above your "ideal" weight may actually be your healthiest natural condition, best for your particular constitution and your particular metabolism. Of course you can diet, but the odds are overwhelming that most of the weight will return, and that you will have to diet again and again. From a health and mortality perspective, should You? There is, probably, a serious health risk-from losing weight and regaining it.

In one study, more than five thousand men and women from Framingham, Massachusetts, were observed for 32 years. People whose weight fluctuated over the years had 30 to 100 percent greater risk of death from heart disease than people whose weight was stable. When corrected for smoking, exercise, cholesterol level, and blood pressure, the findings became more convincing, suggesting that weight fluctuation (the primary cause of which is presumably dieting) may itself increase the risk of heart disease.

If this result is replicated, and if dieting is shown to be the primary cause of weight cycling, it will convince me that you should not diet to reduce your risk of heart disease.

DEPRESSION AND DIETING

Depression is yet another cost of dieting, because two root causes of depression are failure and helplessness. Dieting sets you up for failure. Because the goal of slimming down to your ideal weight pits your fallible willpower against untiring biological defenses, you will often fail. At first you will lose weight and feel pretty good about it. Any depression you had about your figure will disappear, Ultimately, however, you will probably not reach your goal; and then you will be dismayed as the pounds return. Every time You look in the mirror or vacillate over a white chocolate mousse, you will be reminded of your failure, which in turn brings depression.

On the other hand, if you are one of the fortunate few who can keep the weight from coming back, you will probably have to stay on an unsatisfying low-calorie diet for the rest of your life. A side effect of prolonged malnutrition is depression. Either way, you are more vulnerable to it.

If you scan the list of cultures that have a thin ideal for women, you will be struck by something fascinating. All thin-ideal cultures also have eating disorders. They also have roughly twice as much depression in women as in men. (Women diet twice as much as men. The best estimator is that 13 percent of adult men and 25 percent of adult women are now on a diet.) The cultures without the thin ideal have no eating disorders, and the amount of depression in women and men in these cultures is the same. This suggests that around the world, the thin ideal and dieting not only cause eating disorders, but they may also cause women to be more depressed than men.

THE BOTTOM LINE

I have been dieting off and on for 30 years because I want to be more attractive, healthier, and more in control. How do these goals stack up against the facts?

Attractiveness. If your attractiveness is a high-enough priority to convince you to diet, keep three drawbacks in mind. First, the attractiveness you gain will be temporary. All the weight you lose and maybe more will likely come back in a few years. This will depress you. Then you will have to lose it again and it will be harder the second time. Or you will have to resign yourself to being less attractive. Second, when women choose the silhouette figure they want to achieve, it turns out to be thinner than the silhouette that men label most attractive. Third, you may well become bulimic particularly if your natural weight is substantially more than your ideal weight. On balance, if short-term attractiveness is your overriding goal, diet. But be prepared for the costs.

Health. No one has ever shown that losing weight will increase my longevity. On balance, the health goal does not warrant dieting.

Control. For many people, getting to an ideal weight and staying there is just as biologically impossible as going with much less sleep. This fact tells me not to diet, and defuses my feeling of shame. My bottom line is clear: I am not going to diet anymore.

DEPTH AND CHANGE: THE THEORY

Clearly, we have not yet developed drugs or psychotherapies that can change all the problems, personality types, and patterns of behavior in adult life. But I believe that success and failure stems from something other than inadequate treatment. Rather, it stems from the depth of the problem.

We all have experience of psychological states of different depths. For example, if you ask someone, out of the blue, to answer quickly, "Who are you?" they will usually tell you--roughly in this order--their name, their sex, their profession, whether they have children, and their religion or race. Underlying this is a continuum of depth from surface to soul--with all manner of psychic material in between.

I believe that issues of the soul can barely be changed by psychotherapy or by drugs. Problems and behavior patterns somewhere between soul and surface can be changed somewhat. Surface problems can be changed easily, even cured. What is changeable, by therapy or drugs, I speculate, varies with the depth of the problem.

My theory says that it does not matter when problems, habits, and personality are acquired; their depth derives only from their biology, their evidence, and their power. Some childhood traits, for example, are deep and unchangeable but not because they were learned early and therefore have a privileged place.

Rather, those traits that resist change do so either because they are evolutionarily prepared or because they acquire great power by virtue of becoming the framework around which later learning crystallizes. In this way, the theory of depth carries the optimistic message that we are not prisoners of our past.

When you have understood this message, you will never look at your life in the same way again. Right now there are a number of things that you do not like about yourself and that you want to change: your short fuse, your waistline, your shyness, your drinking, your glumness. You have decided to change, but you do not know what you should work on first. Formerly you would have probably selected the one that hurts the most. Now you will also ask yourself which attempt is most likely to repay your efforts and which is most likely to lead to further frustration. Now you know your shyness and your anger are much more likely to change than your drinking, which you now know is more likely to change than your waistline.

Some of what does change is under your control, and some is not. You can best prepare yourself to change by learning as much as you can about what you can change and how to make those changes. Like all true education, learning about change is not easy; harder yet is surrendering some of our hopes. It is certainly not my purpose to destroy your optimism about change. But it is also not my purpose to assure everybody they can change in every way. My purpose is to instill a new, warranted optimism about the parts of your life you can change and so help you focus your limited time, money, and effort on making actual what is truly within your reach.

Life is a long period of change. What you have been able to change and what has resisted your highest resolve might seem chaotic to you: for some of what you are never changes no matter how hard you try, and other aspects change readily. My hope is that this essay has been the beginning of wisdom about the difference.

What Can We Change?

When we survey all the problems, personality types, patterns of behavior, and the weak influence of childhood on adult life, we see a puzzling array of how much change occurs. From the things that are easiest to those that are the most difficult, this rough array emerges:

Panic: Curable; Specific Phobias: Almost Curable; Sexual Dysfunctions: Marked Relief; Social Phobia: Moderate Relief; Agoraphobia: Moderate Relief; Depression: Moderate Relief; Sex Role Change: Moderate; Obsessive-Compulsive Disorder: Moderate Mild Relief; Sexual Preferences: Moderate Mild Change; Anger: Mild Moderate Relief; Everyday Anxiety: Mild Moderate Relief; Alcoholism: Mild Relief; Overweight: Temporary Change; Posttraumatic Stress Disorder (PTSD): Marginal Relief; Sexual Orientation: Probably Unchangeable; Sexual Identity: Unchangeable.

Self-Analysis Questionnaire

Is your life dominated by anxiety? Read each statement and the mark the appropriate number to indicate how you generally feel. There are no right or wrong answers.

1. I am a steady person.

Almost Never | Sometimes | Often | Almost always | 4 3 2 1

2. I am satisfied with myself.

Almost Never | Sometimes | Often | Almost always | 4 3 2 1

3. I feel nervous and restless.