Six bites of the elephant

Lessons from the best book I've ever read on anxiety

I cried reading How to Eat an Elephant. Multiple times. It is the most helpful book I have ever read on how to navigate, manage and make friends with your anxiety. It was illuminating, comforting and more than a little confronting: wrestling the elephant takes work.

Since I was a small child, and first took the elephant’s trunk in my hand (how far can I take this metaphor), my life has been shaped by anxiety. It’s why I have always read excessively; books quell my quivering mind. Anxiety is not entirely bad. It can work in tandem with plenty of good qualities: vigilance, attentiveness, care, empathy. But it is a warning system that should be deployed in moderation. No-one wants to be fire-hosed in cortisol just crossing the road.

Journalist India Sturgis has spent the last 6 years writing this non-fiction book, with extraordinary care. I am thrilled that she has allowed me to extract some of the book, along with six of her learnings, exclusively for Books+Bits readers. I hope that those of you that need it, find it a salve. If you did, I’’d love to hear from you in the Comments. Over to India.

It’s a grey and wet Thursday afternoon in North London when I see it. I’ve dodged sheets of rain to arrive in the waiting room of a psychotherapist, the latest person on whom I’ve rested all hope. I’m alone. A tea station is filled with optimistically coloured packets of tea, all greens and yellows. There’s a bin, empty and fluffed to perfection with a new plastic liner. It’s all awful. I’m awful. I’m out of place. I don’t know what to do with myself. I can’t sit down and, if I were to, I worry about leaving a dent in the beautifully plumped sofa. My heart races. Nothing else moves. Nothing is possible.

Things are not going well. I haven’t slept in days. I’ve been trying and failing to ‘get better’ for months, if not years, and am becoming increasingly frightened by what is happening to my mind and body. Nothing so far has worked for any real length of time: not therapy, hypnotherapy, sleeping pills, telling myself how irrational I am being, or changing jobs. On a good day, I believe my husband will divorce me, my nine-month-old baby will be taken away, I will never work again and I have cancer. Standing in the waiting room, frenetically motionless, I look up and see a piece of paper pinned to a cork noticeboard. How do you eat an elephant? The answer to that question is the first thing in as long as I can remember to cut through, showing me a way out that I might actually be capable of.

How do you eat an elephant?

One bite at a time.

The saying, an ancient African proverb linked to Desmond Tutu and St Francis of Assisi, among others, was a miniature injection of hope. It was a parting of the clouds. It caused my shoulders to drop for the first time in weeks and something, albeit very small, to recede just an inch. Like all the best things, it’s simple and obvious: our largest, most daunting and impossible challenges are best approached bit by bit. To hear it then was deeply comforting.

To me, anxiety was an elephant in so many ways. It was a gigantic heavy beast on my chest, weighing me down, taking up all space in my life and trampling all over it. It was the elephant in the room, the thing eclipsing all else. How could I go up against something so big, so enveloping and destabilising? This, whatever this was, was bigger than me and no matter how hard I tried to control it, it seemed to be growing. I’d ignored it, got angry with it and tried to out-think it. This showed another way – a stealthier, slower route.

***

The day before my thirty-second birthday, I officially became one of the one in three people who will be affected by an anxiety disorder in their lifetime. A few weeks after seeing the elephant question on the cork noticeboard, I ended up as an emergency inpatient, which, in clinical terms, meant I was deemed a threat to myself. I had been admitted to The Priory in Roehampton, a psychiatric hospital in London, where I would stay for a month as an in-patient and two months as an out patient.

By this point, stress, anxiety and insomnia had percolated, fed off each other and imploded. I was going whole nights awake, in batches, and increasingly losing my grip on reality. I was terrified of not sleeping, something which (cruelly) became self-fulfilling as my nervous system revved into seventh gear, and was having intrusive thought about suicide and self-harm. In the weeks before I was admitted to hospital I had panic attacks quietly and alone at night in an upstairs bedroom so as not to wake my husband or baby.

What happened to me had been about seven years in the making, at least. This wasn’t a product of becoming a new parent, or due to post-natal depression, an instance of trauma or abuse. In some ways, at my worst, I believed that would have been easier. At least that would have been explainable, understandable, reasonable. How did someone who was fortunate and privileged in so many respects, who presented like a ‘normal’, functioning human being, get to such a state of mental disrepair? The word my new psychiatrist diagnosed me with would apparently explain everything: anxiety – a generalised anxiety disorder, to be precise, with chronic insomnia, post-traumatic stress disorder and a side order of depression. From that moment, hospitalised and medicated, I gave in. I knew I was ill and was going to have to do something different, because carrying on was impossible.

***

So it was that I began a long and arduous journey back towards myself. It has been a road that has bypassed medication and psychotherapy; cognitive behavioural therapy; learning about anxiety as a clinical condition, how it winds around the mind and body (very helpful); art and drama therapy; neurofeedback; exercise (yoga, walking, running, cold swimming, among others); group therapy and social prescribing. I’ve learned more about breathing and carbon dioxide, and how breath-holding can affect our physiology when looking at screens. I’ve explored slowing down, the brain’s default mode network, how to approach the concept of ‘recovery’ and whether anxiety can ever really be cured. Incidentally, Rollo May, American psychologist and philosopher, who wrote the 1950 book, Meaning of Anxiety, speaks to this last point very well:

“Anxiety cannot be avoided, but it can be reduced. The problem of the management of anxiety is that of reducing anxiety to normal levels, and then to use this normal anxiety as stimulation to increase one’s awareness, vigilance, zest for living.”

At some point in all of this, when coming out of the real doldrums of mental health crisis, it occurred to me that I was in a unique position. Having worked as a journalist for well over a decade, I was well placed to interview world leading experts on anxiety. I’d seen anxiety from within, miserably up close and personal. And, having been in hospital for so long, I now had a number of supremely anxious friends who had fascinating and, ultimately, helpful insights into this horrific mental illness. At any given time, according to recent data by the Adult Psychiatric Morbidity Survey 2023/24, more than one in ten of us will be affected by an anxiety condition, a figure that makes clinical anxiety more prevalent that diabetes.

Timely support and information about anxiety is incredibly hard to access if you don’t have money, insurance or the right people around you. Currently, there are 1.8 million people on a waiting list for NHS mental health treatment. Even if it was a drop in the ocean, I committed to putting some of what I have learned down on paper - in the hope it would help others with anxiety, or those close to them, as well as continue to help me, which it has. The result has been several years of work speaking to psychiatrists, psychotherapists, counsellors and neuroscientists as well as those from all different walks of life who have experienced severe anxiety, for this book.

In the spirit of its title - and for Books+Bits readers only - here are six of my personal favourite bites of the elephant, gleaned from experts and my own experience. Some are big, some are tiny, all can be useful.

1.) A Thought is Not a Fact

A mental pickaxe that worked hard against my insomnia when it was at its worst, was regularly and quickly challenging the negative automatic thought ‘I am not going to sleep’ with the statement, ‘a thought is not a fact’. You may have heard of this. ‘A thought is not a fact’ is a common cognitive behavioural therapy (CBT) tactic and a method of thought-defusing. Despite its seeming obviousness – we all know (if we think about it) that thoughts are not necessarily facts – it has power. When I felt doomed and full of panic about not sleeping, I started to remind myself that this was only a thought and, even if I 100% believed it in the moment, it was still not a fact. The result was, and still is if I need it, minutely calming: a counter argument to the anxious status quo. It helps stop you leaning into such wholly negative spirals.

2.) Breathing

I realise how annoying this subhead is. We all know how to breathe. What I didn’t know was how quickly and dramatically we breathe can affect our physiology, right down to a cellular level, within seconds. A few minutes of low and slow belly breathing can relax you more fundamentally and faster than anything else. No one had told me that it’s the out-breath – not the inhale – that matters more for anxiety because it helps activate the vagus nerve, the longest cranial nerve in our body, which stretches from our face down to our colon and reaches out to almost every organ in the body on its way – and contains approximately 75% of parasympathetic nerve fibres.

One study by the University of South Carolina divided 20 healthy adults into two groups. One group was instructed to do two sets of 10-minute breathing exercises while the other read a text of their choice for 20 minutes. Saliva was taken from volunteers throughout and tested. The breathing group’s saliva had significantly lower levels of three cytokines – protein molecules that immune cells produce and secrete to communicate with other immune cells – associated with inflammation and stress.

Nowadays, if I feel anxiety flare episodically, I do a minute or two of slow, deep belly breathing (with a slightly longer out-breath) - or, occasionally, seven minutes before bed (ten minutes feels too long for me). For someone with a history of anxiety and catastrophic sleep patterns, this has become a useful tool.

3.) Routine

For some, having a routine and sticking to it can be the difference between putting stabilisers on an anxious brain or letting it freewheel downhill with its eyes closed. A routine sinks you into a predictable pattern of behaviour that is settling in itself. Anxiety loves uncertainty: What do I do next? What if it’s the wrong choice? Will I be safe? What if I do something wrong? What is X happens? A routine, even if small or not always adhered to, provides a counterpoint to uncertainty. It offers structure and comfort and prevents extra decision-making, which can be a balm. A routine allows you to make time for things that actually matter and it helps with sleep. Maintaining a steady rhythm was one thing my psychiatrist recommended in the early days post-hospital: take medication on time and stick to a routine, she advised. It makes sense to keep road bumps to a minimum during times of emotional upheaval or change in other areas of your life.

4.) Medication

While we are getting better at accepting the necessity of medication for stabilising mental health, especially when symptoms are severe, the thought of swallowing a pill that changes how you feel and how your brain actually functions feels unnerving – even for those without anxiety. What if you turn into a numbed-out zombie? What about side-effects? Putting on weight? Addiction? Dependence? What if it doesn’t work? What will your friends or family think?

Requiring drugs to feel normal can feel like failure on some basic human level, which is ludicrous given we take brain-tweaking medication unthinkingly and without stigma for far less: paracetamol, for one, which affects connections in the anterior cingulate cortex, brain areas associated with pain-signalling. Alcohol is another example of a brain altering substance we don’t think twice about.

For many, medication is vital and I can’t imagine how I would have got better without it. I remember being in the office of a psychiatrist being prescribed antidepressants for the first time and her calmly telling me that she wasn’t going to give me anything addictive, or that would cause weight gain or change my personality; it stumped me completely – I assumed all three were non-negotiable.

5.) The Everyday Big Three

Another of the most helpful bits of advice I received is that as a feeling, anxiety has three main day-to-day triggers. These are, in no particular order: hunger, tiredness and substance abuse (alcohol or drugs). When you are running low on fuel, are tired, or are depleted through reaching for artificial highs, your mind and body may be quicker to switch into anxious fight-or-flight state. If you’re in the throes of any of the above, your nervous system knows you are at a lower ebb and a predator would have an easier time with you. The trigger switch for survival mode is more sensitive than usual, which makes sense from an evolutionary point of view but it’s less useful when you’re watching reruns of Friends on the sofa after a late night and your heart explodes out of your chest every time a motorbike backfires. Not everyone is as sensitive, but realising that food, sleep or a hangover can impact nerves and how you feel to such a degree, can be useful.

6.) Saying No

For some, saying ‘no’ is as easy as putting one foot in front of the other – for those, I’d argue, less plagued by stress and anxiety. For the rest of us, articulating those two little letters can feel like nails on a blackboard. Saying yes doesn’t disappoint, cause conflict or tension, and is positive. It makes others happy and gets things done. But saying no is a well-known stress-management tool because it does a number of things: it stops you spending time on things you’d rather not; it is protective; establishes boundaries; increases confidence and the respect of others. Plus, the more we say yes the less we say no and, like a wasted muscle, the more difficult it becomes to use.

I attended one two-hour group therapy class about assertiveness where I had to practise saying ‘no’ in a role-play scenario with a partner, which was as horrific as it sounds. We were told two things: you always have a right to say no (even if it feels like you don’t or that it will come with consequences) and saying no doesn’t mean you are rejecting someone, you are simply refusing their request. There are, it turns out, a few ways you can coach yourself to say no better.

• The straight ‘no’ - ‘No’ is a complete sentence; it doesn’t necessarily require padding out with an apology, explanation or justification. Said alone it’s effective and unambiguous. Are you finished with that sandwich? No.

• The ‘no’ with a reason – A no with a short (emphasis on short) and genuine reason behind why you are saying no. Are you finished with that sandwich? No, I am giving the leftovers to my guinea pig.

• The broken-record ‘no’ – A personal favourite and something I use regularly with children of all ages. Repeat the same ‘no’ alongside the same brief refusal statement as many times as necessary. It doesn’t matter that it never changes. Eventually, the person accepts it or at least accepts that you aren’t going to change your mind. Are you finished with that sandwich? No. (Two minutes later.) Are you finished with that sandwich? No. (Two minutes later.) Are you finished with that sandwich? No. Etc.

• The rain-check ‘no’ – A soft no: a no with the possibility of becoming a yes. Are you finished with that sandwich? No, but circle back in five minutes and I might be.

• The Can-I-Think-About-It-No – Technically, not a no. You are asking for more time or information before giving your answer. Almost always acceptable, unless in a life threatening emergency, and people respect it. Are you finished with that sandwich? Mmmmmm, I’m not sure. Can I have a bit more time with my sandwich to think about it?

***

Today, I am significantly less affected by anxiety. I no longer have GAD, insomnia or depression. But I also know that anxiety is my Achilles heel: something I will always be watchful of returning. As I’ve come to see it, living with an anxiety condition is not an exact science or an easy ride and while dissecting things in the past or worrying about the future can be helpful, the present is the most rewarding place to live.

Mental health is never really about one thing (if only). It is not a Pilates class, probiotics, giving up booze, forgiveness or self-compassion, although all those things may help you. There is no magic silver bullet. More often it is a combination of little things, spread wide and far. An unhurried sea of change. It’s the many little bites taken when you feel well or hungry enough that can help you to feel better, and keep you well.