Perspective: The Indifference Point
This morning, I am thinking about loss while I review a new manuscript submission about grief and delay discounting.
Delay discounting is the tendency for people to prefer immediate rewards and devalue future rewards even if the objective gain is greater. Importantly, we can plot a hyperbolic curve showing the mathematical indifference point: an inflection where people stop preferring the smaller, sooner reward. To study the phenomenon in the lab, research participants are usually asked to weigh hypothetical gains and/or losses over time. Usually, the rewards are monetary — would you rather receive $10 today, or $20 in three months? How about $20 next week versus $80 in six months?
How long would you be willing to wait? How great does the reward have to be to make it worth waiting for?
I am a clinical psychological scientist who studies trauma and grief. Temporal discounting is altered in certain psychological disorders. For example, people with prolonged (or “complicated”) grief show steeper discounting – the tendency for rewards to lose value more quickly, compared to peers with a more typical grief trajectory. Many with prolonged grief find it difficult to imagine the future or to access specific details of their past. Without the stable sense of self that we get from autobiographical knowledge, or when the future seems vague or unreliable, it makes perfect sense to take whatever you can get now. In contrast, reward value degrades more slowly over time in people with anorexia nervosa (AN) than in people without eating disorders. In U.S. culture, where consumerism, greed, and instant satisfaction is all too common, delaying gratification is often considered the “adaptive” choice, a virtue of self-control and temperance. But people with AN disallow ourselves reward — of satiety, connection, presence; of not feeling like shit all the time — for so long that our definition of “reward” distorts, and a state of perpetual loss becomes mundane.
But people with AN disallow ourselves reward — of satiety, connection, presence; of not feeling like shit all the time — for so long that our definition of “reward” distorts, and a state of perpetual loss becomes mundane.
In the lab, we simplify scenarios so they become just workable and observable under an experimental setting. Outside of the lab, there is no clear indifference point. Every choice we make means giving something else up — now or later. In my role as a therapist, this is a theme across clients, settings, identities, diagnoses: “There are no ‘wrong choices’,” I say. “We can talk about the options, but at the end of the day, it’s your life and YOU get to decide what matters to you.” I tell my clients, “It doesn’t really matter what you choose; the point is that you can be the one choosing.” From my side of the therapy room, I can’t promise anyone that a risky new choice will pay off, or that a seemingly safe choice will buffer them from pain. There is only an inflection point, where we commit and — act.
2008 is one of my inflection points.
Six months before my second hospitalization for an eating disorder at age 21, I had written in my journal:
There’s a strong possibility that I’ll be spending the summer in treatment again. This is the way it goes; you do inpatient and get out and relapse and do the whole thing again.
I truly never thought I would be that person. (February 4, 2008)
I was right: Eventually, people (again) stopped buying my arguments that I could fix this myself, get out of my business, leave me alone.
When I walked into the hospital for the second time that July, I immediately saw two patients that had been there during my last admission, playing the same Bananagrams on the same dingy carpet of the day room. Same thick sheaf of paper menus with options to circle, same groups, same groggy 5 am weights and vitals, same “bathroom privileges" and blurry shatterproof mirrors, same being granted a few hours out “on pass” and walking a little too much, same earnestly telling our treatment teams that we meant it this time, we were really going to do it right once we got out of here. The same push and pull of the desire to self-destruct in peace versus the desire for care and safety: institutionalization can be a relief when one’s internal world feels profoundly unsafe and out of control. The center for eating disorders only admitted young patients, 14-23 years old, but many of my peers were returning to a “higher level of care” for their second, third, fourth, fifth time.
The concept of “recovery” mostly felt itchy and confusing: What is recovery? Hitting a magic number? No longer having *visible* symptoms? Returning to some idealized state of “before”?
As in my first hospitalization a year prior, once my weight inched into the bottom of the “normal” gradient on the BMI chart, health insurance decided I should be done with all that. (Eating disorders are durable as hell; I was not, in fact, done with all that). I moved back to New York City. The concept of “recovery” mostly felt itchy and confusing: What is recovery? Hitting a magic number? No longer having *visible* symptoms? Returning to some idealized state of “before”? Mental illness had been a part of my life, in one way or another, for as long as I could remember. There was no idyllic “before” to go back to.
After leaving the hospital, I spent eight hours a day, five days a week in an intensive day treatment program at the insistence of my therapist, who still was too concerned about medical liability to see me outpatient. Even before I formally thought of myself as a scientist, I noticed patterns in the data. Here, I observed the inward contracture of lives, self-definition coalescing around patient-hood: identities built on (a) having an eating disorder, (b) being in treatment for one, and/or (c) recovering from one. I thought about a quote from the neurologist Oliver Sacks, who wrote in his book on encephalitis lethargica, Awakenings, "Health is infinite and expansive in mode, and reaches out to be filled with the fullness of the world; whereas disease is finite and reductive in mode, and endeavors to reduce the world to itself." I realized that I would become yet another revolving-door patient, unless I made a radical change.
This is the moment when the logical choice was to buckle down and do the work in treatment. Instead, I got a job at Starbucks for the minimum wage of $7.25 an hour. When treatment wouldn’t accommodate my work schedule, I quit treatment altogether. No more program. No more appointments. I decided it would be less demoralizing to just try to find a “reasonable” level of disorder that I could live with, than to spend my one life trying and repeatedly failing at recovery. Underneath what appeared to be resignation, I had an implicit sense that focusing on adding to my life, not subtracting symptoms, would be my way out. But there was no room for this line of thinking as an identified patient.
From an outside perspective, my actions appear driven by disordered thinking, poor insight, and the ego-syntonic nature of eating disorders. It was a flawed decision. And in retrospect, I can draw a map connecting that decision to everything good and meaningful that came after. I slowly discovered who I am, what I care about, what my purpose is — knowledge previously inaccessible to me. In the beginning, I simply had a job and thus a reason to get out of bed. My coworkers liked me(!) I started taking undergraduate classes.
I’m on the seventh floor of Hunter North, looking out the window over the tops of apartment buildings at the sun setting and the sky turning colorless. I love my classes - I have a brain, I can think, I can know things and form thoughts and ideas, and get excited and interested about things! This all feels very new. (February 8, 2009).
And at the same time, I wrote again and again in my journal about how I didn’t feel real, wasn’t sure that I existed outside of the eating disorder.
I haven't felt real for the past couple of days. Whatever makes up “I” feels tenuous, insubstantial, inconclusive. I don't think about killing myself anymore because “myself”, as a concept, lacks weight and reality. I don't feel concrete. The world slips around and over me; my heart races, my head spins, I stumble on my broken shoe and trip going up the stairs from the subway, I walk the same 20 blocks for hours, I eat, I fade in and out of public bathrooms. None of it feels like it is really happening. (September 16, 2009)
I wrote about shame, and about the times that people I loved told me “I can’t be around you like this” or asked me to leave. How I wanted to be better but couldn’t make it work.
[My best friend asked me to move out of our shared apartment]. She “can’t watch me hurt myself like this anymore.” I don't even conceptualize it as hurting, this is just how I live in my body nowadays. I am “sick,” she says. Am I sick, or is this me? (May 8, 2010)
I’m sad today. Went to S.'s going-away party on Saturday and shouted till I was hoarse about social work with a friend of hers. Talking about our areas of interest, eating disorders came up (also schizophrenia & CBT [Cognitive Behavioral Therapy], addiction, various social justice things; reading recommendations were exchanged.) If everyone has a past brush with an eating disorder and can chalk it up to being stupid and female and young and superficial, what the fuck is my problem. These are smart, socially-aware women. What the fuck is my problem? (October 11, 2011)
And there was the ferocious sadness with which I hated myself for my inability to cope with a basic biological need (even newborn infants know how to eat, how the hell am I an adult and haven’t figured this out yet?? This is SO STUPID), and also hated myself for having needs at all.
Where is the point where I can definitively say yes, in the long run, the reward was worth all of the loss?
For any choice, there is always the counterfactual. Maybe there is an alternate universe where I stayed in treatment, actually worked on getting well, and avoided years of unnecessary suffering. (Maybe the suffering just happened in a different way.)
Consequences and tradeoffs. I made an unconventional choice to preserve my agency, autonomy, independence, and hope — and this meant that I continued to be severely ill for the next decade(ish). But during that time, I also discovered a love of research, learned to let other people in, and found value in myself and in my work. Where is the point where I can definitively say yes, in the long run, the reward was worth all of the loss?
These days, I try to hold both sides. I somehow accomplished enough during all the chaos to be admitted to a highly competitive doctoral program, and it took me a year of grad school before I stopped staying in the lab till 8 or 9 pm because I couldn’t sit with myself at home. I was awarded an NIH fellowship for my affective neuroscience-focused dissertation and there are studies showing that chronic AN is associated with atrophy of the brain’s gray matter. I have more medical bills than many people in their mid-30’s, and I know that I can survive to create a life worth living even when the present is a wasteland.
The past overlays painful echoes of every prior loss onto milder recent losses (moving multiple times as an academic, living alone during a pandemic, a breakup) and it makes me deeply value the relationships I have built in my life since then.
The interpersonal losses are harder: I lost a lot of people while I spent years isolated by the depression and eating disorder fog. It’s hard to accept that you had a pernicious effect on others, simply by being who you are. How many relationships are acceptable as collateral damage? The past overlays painful echoes of every prior loss onto milder recent losses (moving multiple times as an academic, living alone during a pandemic, a breakup) and it makes me deeply value the relationships I have built in my life since then.
Clinical psychology is, ironically, a field that stigmatizes lived experience of psychopathology. Part of this is a lack of space for the complexity of illness and recovery beyond a binary of “sick–dysfunctional” and “healthy–functional”. When I applied to Ph.D. programs in 2014, I accepted the idea that my history would be “a kiss of death” if anyone were to find out.
In writing this piece, I am choosing certain rewards over my fears that I will no longer be seen as professional, capable, and competent. Some of these rewards are immediate: the hope on a younger mentee’s face when they learn that someone like “Dr. Seeley” shares some of their experiences, and they begin to believe in their belonging. Some rewards are more distant: The vision of a clinical psychological science where lived experience is valued for its strengths, not only seen as a shameful limitation. Indeed, attitudes in the field are slowly improving (though we are still far from full inclusion of people with more severe psychopathology or stigmatized diagnoses). It is possible that linking this story to my name is another flawed decision. But just as 2008-me knew implicitly what to value, the person I am today knows how to weigh the choice in front of me.
