Psychiatry as social ordering: anorexia nervosa, a paradigm

Beyond the Revolving Door: Long-Term Lived Experience of Eating Disorders and Specialist Service Provision

In this study, we undertook a narrative analysis of participants' long-term lived experience of eating disorders and specialist service provision. Eight participants were recruited with service experience across five National Health Service (NHS) Trusts in the United Kingdom. All participants had a minimum of 10 years self-reported experience living with an eating disorder. The data are presented across different temporal stages that demonstrate the development of participants' self-construct in relation to their first contact with specialist services, what had happened in their lives for this to become necessary, and their current relationships with services, before exploring what participants need from services to help them feel heard going forward. Findings suggest that current methods of service delivery result in delayed and inappropriate supports and a consequent "battling" against professionals, which can provide an obstacle to compassionate and collaborative working and promote "revolving door" experiences.

Constructing the Self in Mental Health Practice: Identity, Individualism and the Feminization of Deficiency

The discursive production of the ‘self in the context of mental health care has potential implications for how the subjects of intervention come to understand and experience themselves. Eating disorders provide an illustrative example of the ways in which conceptualizations of the self that structure mental health practices can be gendered, because they are mainly diagnosed in women and dominant explanations of their origins are feminized. This discourse analytic study examines the gendered nature of mental health workers’ constructions of the eating-disordered self through the psychological construct of ‘identity’, examining the dominant discourses implicated in the feminization of deficient identity, and addressing the implications of this construction for mental health practice.

Anthropological Perspectives on Eating Disorders: Deciphering Cultural Logics

In the last three decades, anthropological analyses of eating disorders have peeled away layers of 'common sense' to reveal tacit and often contradictory forces that inhere in people's bodies, practices, and lives. From investigations of institutional practices to analyses of embodied experiences, anthropologists have developed insightful accounts of how local, shared worlds shape disordered eating, and of the grounding of disorder in social structures and relationships that tend to be obscured in clinical and popular interpretations. In this introductory essay, we offer a brief review of anthropological work on eating disorders, with particular emphasis on studies published in the last decade. Attending to person, structure, and bodily being-in-the-world, these anthropological studies reveal multiple cultural logics within which disordered eating practices are embedded. The deciphering of cultural logics forms the basis for this special issue, whose constituent papers interrogate recurring and ongoing eating disorders, with analyses that focus on relapse, ambivalence toward treatment, and the persistence of disordered eating practices. In their shared focus on long-term eating disorders, the papers offer anthropological responses to clinical questions about the low rates of treatment success. As such, the special issue conveys the potential for new productive collaborations between anthropology, policy, and clinical research and practice for the prevention of and effective intervention in eating disorders.

“It Wasn’t About Being Slim”

This article explores how women understand and experience the relationship between physical, sexual, and emotional abuse and the emergence of an eating disorder in their lives. The past three decades have seen increased attention to the links between abuse and eating disorders; however, the social contexts of abuse, the specific emotions involved, and how these might link to an eating disorder have not been explored. Through an in-depth interview study with 14 women, narrative-discursive analysis reveals how socially situated, abuse-related emotions, such as shame and self-contempt, can play out in an eating disorder and are located within social power relations framed primarily by gender but also by race and class.

'Healthy anorexia': The complexity of care in disordered eating

This paper examines how contemporary understandings of 'health' and 'care' are engaged with and practiced by women with disordered eating. Based on findings from an Australian study investigating why people with disordered eating are reluctant to engage with treatment services (March 2012 to March 2015), we demonstrate how young women use elements of a 'health habitus' and 'care' to rationalise and justify their practices. Moving beyond Foucauldian theories of self-discipline and individual responsibility we argue that Bourdieu's concept of habitus and ethnographic concepts of care provide a deeper understanding of the ways in which people with disordered eating embody health practices as a form of care and distinction. We demonstrate how eating and bodily practices that entail 'natural', medical and ethical concerns (in particular, the new food regime known as orthorexia) are successfully incorporated into participants' eating disorder repertoires and embodied as a logic of care. Understanding how categories of health and care are tinkered with and practiced by people with disordered eating has important implications for health professionals, family members and peers engaging with and identifying people at all stages of help-seeking.

Anorexia nervosa: the diagnosis. A postmodern ethics contribution to the bioethics debate on involuntary treatment for anorexia nervosa

This paper argues that there is a relationship between understandings of anorexia nervosa (AN) and how the ethical issues associated with involuntary treatment for AN are identified, framed, and addressed. By positioning AN as a construct/discourse (hereinafter "AN: the diagnosis") several ethical issues are revealed. Firstly, "AN: the diagnosis" influences how the autonomy and competence of persons diagnosed with AN are understood by decision-makers in the treatment environment. Secondly, "AN: the diagnosis" impacts on how treatment and treatment efficacy are defined and the ethical justifiability of paternalism. Thirdly, "AN: the diagnosis" can limit the opportunity for persons with AN to construct an identity that casts them as a competent person. "AN: the diagnosis" can thus inherently affirm professional knowledge and values. Postmodern professional ethics can support professionals in managing these issues by highlighting the importance of taking responsibility for professional knowledge, values, and power and embracing moral uncertainty.

THE CULTURAL POLITICS OF BODY SIZE

Scholarly interest in body size has increased in concert with recent efforts to shape and assess bodies in particular ways within industrialized social contexts. Attending to both overt and covert references to Eurocentric body projects, this chapter reviews literature in anthropology, sociology, and cultural studies that addresses the cultural politics of body size in various parts of the world. It begins with a discussion of biocultural paradigms, which accept certain biomedical categories even when challenging or reconfiguring their hegemonic power. Next is a survey of works analyzing body size within “non-Western” groups as well as European and North American subgroups. These studies often employ culturally powerful “Western” constructs as foils, an approach that risks cultural othering. The analysis then turns to the extensive literature that unpacks dominant Euro-American body practices and discourses. Here, diverse perspectives on several key concerns in sociocultural anthropology are considered; concepts of culture and power, theories of the body and embodiment, and understandings of human agency vary in instructive ways. The chapter concludes with a review of scholarship on postcolonial processes and representations that incorporates a critical perspective on Eurocentric preoccupations with body size.

Disciplining the feminine: the reproduction of gender contradictions in the mental health care of women with eating disorders

This paper provides insights into the way gendered assumptions operate within health care interventions for women with eating disorders. A multidisciplinary sample of Australian health care workers were interviewed about their approaches to treatment, and discourse analysis was used to uncover the discursive dynamics and power relations characterising their accounts of intervention. The paper demonstrates a contradictory positioning of anorexic patients in relation to autonomy and control within the two common psychiatric interventions of bed rest intervention and psychotherapy. The paper argues that this is based on gendered assumptions about selfhood and femininity in eating disorders that are reproduced in the therapeutic relationship through the operation of a gendered parent-child dynamic, with the health care worker as father or mother, and the anorexic patient as daughter. One of the main effects of this is to re-inscribe rather than challenge the discursive 'double bind' of femininity that has been widely implicated by post-structural feminists in producing eating disorders in the first place. The paper also considers the widely acknowledged problem of resistance to treatment in anorexia as a function of controlling treatments, and discusses psychiatrists' perspectives on addressing this dilemma. Finally, the paper examines the potential of feminist-informed understandings of eating disorders for overcoming the gendered dilemmas inherent within the dominant psycho-medical treatment paradigm.

Reconsidering the status of anorexia nervosa as a western culture-bound syndrome

Based on Ritenbaugh's 1982 definition, this essay reconsiders the status of anorexia nervosa as a Western culture-bound syndrome (CBS). It argues that anorexia nervosa, in its culturally reconstructed fat phobic form, is no longer bound to specific Western localities. Instead, it may be conceived as being grounded in the transnational culture of 'modernity', characterized by an internationalised socio-economic stratum now found in many rapidly urbanising parts of the world, and composed of increased affluence, as well as the globalization of fat phobia and diffusion of biomedical technology. Although the treatment implication of Ritenbaugh's CBS concept may appear to be misplaced from the clinician's pragmatic perspective, its salience for clarifying the interaction of individual and cultural concerns in self-starvation, as well as for fostering a needed self-scrutiny in psychiatry, is affirmed. A critique of the dialectical relationship between culture and psychopathology is then put forward. This addresses the apparently conflicting role of anorexia nervosa in enacting as well as combating the cultural pursuit of thinness, and ends by highlighting the inadvertent influence of the biomedical establishment in propagating the condition with measures intended, ironically, for preventing it.