Anorexia nervosa hasbecome increasingly prevalent in the last 40 years in Western societies,especially amongst young women. Even though there have beenpapers written about Anorexia Nervosa for over 50 years, we still do not have adefinite explanation or a definite treatment programme. Traditionally, following the mainstream medicalmodel, quantitative research methods are used to diagnose and treat individualswith anorexia. Mainstream health psychology is ‘that which is most often taughtin universities and practised by clinicians, researchers and consultants(Crossley, 2000, p.2).
Critical health psychologists offer an alternative tothis method, and make use of qualitative research methods, which will bediscussed later on. ‘Mainstream health psychology’ being the more traditional,well known voice, and ‘critical health psychology’, is less known but stillslowly emerging. In recent years,critical perspectives with respect to health and wellness have made inroadsinto the social sciences (Murray & Chamberlain, 1999). ? TheDSM?IV?TR classifies anorexia as refusal to maintain a normal bodyweight (15% below normal weight for age and height), an intense fear of gainingweight, a distorted perceived body image, amenorrhoea (in post?pubertalfemales) and a self?identity reliant on body weight and shape. Anorexia ischaracterised by the exertion of discipline and control towards losing weight,either through self?starvation or through binge?purge cycles, resulting inbeing severely underweight.
Diagnosisis in a way created through the type of discourse we use that structure ways ofthinking and creating clinical practices. For critical health psychologists,the concern with diagnosis and classification and psychometric tests is seen asa big problem as by only using the DSM-5 to classify someone as ‘anorexic’ andfollowing the medical model of illness, one is treating mental problems in thesame way as physical illness. Hepworth (1999) talks about diagnosis as animportant part of medical process, and that these difficulties occur becausethe mental disorders are not straightforwardly evident to the doctor exceptthrough behavioural classification, symptoms and different characteristics.Anorexia nervosa, in particular, has a long and complex history and is not easyto understand and is certainly not that easy to diagnose. Additionally,this mainstream way of thinking presents anorexia as an individual pathology, ratherthan the result of other factors such as environmental, social and cultural.
Withthe type of research methods used in the medical model such as surveys, thepatient is confined to a ready made list of questions were the patient isunable to give his or her own experience of the disorder. From this outcome,healthcare services are finding a diagnosis and treating only this, rather thangetting a better understanding of the patient’s experiences of treatment andfocusing on the individual, creating a better relationship with the patient andtherefore improving overall patient satisfaction and adherence to treatmentplans. Asmentioned before, critical health psychologists make use of qualitativeresearch methods as opposed to quantitative research, such as self-reportquestionnaires and statistics. By doing so, the data that is resulted is muchricher in meaning and has a much larger focus on the patient’s own experience. This is done by making use of discourseanalysis, in which criticalhealth psychologists can present to the public how reality is constructedthrough language in social situations, rather than making claims about thetruth of eating disorders, as they do in the medical perspective. Discourse analyses emerged in the 1970s and1980s as a turn to language when social constructionism started to develop. As argued by authors, ourdiscourse contributes to social action and furthermore community and publichealth approaches that draw on critical health psychology theories and methods(Hepworth, 2004; Murray & Campbell, 2004). I will be discussing Discursive psychology and Foucauldian discourseanalysis.
Discursivepsychology is primarily concerned with the ways in which people speak ineveryday life and institutional settings negotiate meaning, reality, identityand responsibility. It places the speaker of the language as active in constructingdiscourses in order to achieve goals within their social interactions. Foucauldian discourse analysis focuseson discursive resources and examines the ways in which discourses constructobjects and subjects and create, in this way, certain versions of reality,society and identity as well as maintaining certain practices and institutions(Willig, 2008). In this case, this type of discourse proposes that languagecreates its objects, including the speakers themselves. They both share theview of language as constructing reality, and a general criticism of the methodsof cognitive psychology, but the difference between them is that they both havetheir own concept of experience. In contrast to Discursive Psychology,Foucauldian discourse theories state that discourses constitute subjectiveexperience.
Discursiveresearch has therefore looked at discourses of treatment experience,practitioner? patient relationships, and messages in the media and thesocial environment. Instudying anorexia nervosa, the use of discourse analysis is important. Since eating is a social phenomenon,discourse analysis allows us to examine how eating disorders may be sociallyconstructed through social and historical messages, family communication, andperpetuated through treatment practices. Discursive research looks at discoursesof treatment experience, practitioner? patient relationships, andmessages in the media and the social environment.
Thesocial construction of anorexia nervosa Thefeminist post-structuralist authors promoted the belief that eatingdisorders are constructed through culturally and historically-specificdiscourses (Hepworth, 1999). The feminist writings are of considerableimportance because they introduced a conceptualization of anorexia nervosa thatdrew directly on women’s experiences of themselves and social relationships(Hepworth, 1999. pg 45), especially of living in the Western world, the effectsof the subordinate social position and the denial of food by women. Ratherthan only focusing on anorexia being a naturally-occurring disorder, criticalhealth psychologists highlight that we must not ignore the different pressuresthat women and men are suffering from society. Female power is mainly centredby the physical appearance, this has a big impact on the strive to be thin,whereas males are more pressured to be physically strong and muscly. By controllingthemselves not to eat, women are in a way creating a superficial identity ofdiscipline as a substitute for the imbalance of power between male-femalerelations and as Orbach argued that the ‘self-starvation in anorexia represents a struggle for autonomy,competence, control and self-respect’ (ascited in Till, 2011, p. 5).
The pressure and to be bothsuccessful in their careers, as well as desirable and feminine. Thethin body is construed as a controlled body and looked at as strength, successand perfection. On the other hand, being ‘fat’ is looked as bad and wrong, asthough one has no control or order in their life. The language that is used isserved as an emphasise for these power relations in our society (Hepworth,1999), especially the binaries that exist in language. Example: fat/thin,good/bad, self-control/indulgence, weak/strong.
The media largely promotes thisnotion of ‘healthy weight’ which surely serves as a reason for the ‘anorexicboom’ and disordered eating. We mustremember it is only considered an eating disorder in cultures where there areno food shortages such in the Western consumerist society, where anorexia and bulimiaare most prominent. Manystudies include the individual family cultures as a factor for increasing thelikelihood of eating disorders and cultural pressures for ‘thinness’, and theproblems related to it such as maternal criticism, negative and unhelpful communicationand the culturally fixed discourses that is present concerning femininity,physical appearance and power relations.
The particular trend about anorexiathat traces factors within the relationship between the person diagnosed withanorexia and his or her mother. This may be due to the role of the mother toprovide the food for the family, developed historically the 1990’s there wastalk of the relationship of anorexia and patriarchy by Bryan Turner aboutBruch’s work. For feminist writers, the articulation for this relationship was limitedas an explanation for anorexia nervosa, depicting these women as strugglingbecause of problems and difficulties.
As Lawrence states: ‘I can say withcertainty that I have never worked with an anorexic woman who had astraight-forward relationship with her mother’ (1984: 67). Presnell et al., (2004)indicate that weight and appearance pressures from families are not significantin the prediction of eating disorders, whereas pressures from peers were foundto be significant. As Garner and Garfinkel () rightly said, anorexia cannot be understood ifnot within its socio-cultural context, were thinness is the perfect ideal of awoman. Eatingdisorders are gender neutral, but they are usually thought of as ‘women’sproblems’. The clinical understanding ofanorexia nervosa as a predominantly female condition has surely had an effecton the clinical understanding of it in males. Men are often underdiagnosed andmisunderstood by many health professions and have a harder time fighting thisintense stigma of suffering from anorexia. Therefore, health clinicians workingin this area should be more aware of the gender roles and differences indetermining the presence or absence of disordered eating, and males and femalesmay be treated with distinctive approaches (Pritchard, 2008).
Treatment Themedical model’s main aim of treatment for the patient is to gain weight, andthat their eating pattern is re-established, but many patients relapse afterbeing sent home and end up being re-admitted time after time (Deter &Herzog, 1994). Therapeutic interventionswith mainstream practice remain held to notions such as “eating”, “disorder”,”objective body”, “body mass index”, “distorted self-image”, which in turnfurther promotes and confirms anorexia nervosa and makes the person imprisonedin their colonization of the disorder. Thisclearly shows that this type of treatment is not working and more research mustbe done in order to help improve service given to these patient suffering fromeating disorders such as anorexia. Inresearch by Malson, Finn, Treasure, Clarke, & Anderson (2004),they made astudy on the patient’s experiences of treatment using discourse analysis.
The study resulted in the patient’sdissatisfaction coming from the construction of the ‘eating disordered patient’from the healthcare workers. In the study, the patients show how they felt likethey were treated as a merely their eating disorder not a person with feelings.In another study done by Malson and Ryan (2008), the treatment done on the patients reconstitutes thecultural construction of femininity as ‘deviant and deficit’. This resultsin inequality within power relations between the healthcare workers and thepatients.
Power is very important in critical healthpsychology. ‘It is instrumental in the promotion of wellness, in resistingoppression and in striving for liberation’ (Prilleltensky & Prilleltensky,2003, p. 198). Here healthcare workers are presenting an invisible barrierbetween themselves and the patient to make it evident who the one in power is,to protect them from feelings of guilt or helplessness for some circumstanceswere they cannot help the patient and human suffering that cannot be adheredto. These power relations within treatment mirror power relations that alreadyexist in our society today. Therefore,as Spiro said we should place emphasis on ‘the importance of a sustained andand meaningful relationship between the doctor and the patient’ (Crossley,2000, pg 142) which works as a placebo-effect to help physicians ‘recover asense of the person in the patient’ (Spiro, 1986, p. 3) On aday to day basis, patient’s lives’ are run around numbers; how much they weigh,how much weight they need to put on, how many calories they must consume, howmuch they must weigh in order to be discharged from treatment etc.
In real, everyday life, we are judged on ourappearance and not by numbers and so when patients are discharged they arefaced to deal with this practice of calorie counting, only resulting inobsessing over how much they eat and how much they eat, once again. The livesof patients in treatment can be seen as a very routine-based place, where theymust follow strict eating regimes at certain times and eat certain types ofmeals. This choice of food which isavailable when outside of the treatment centre is the total opposite and are thepatients not prepared for this, exacerbating their perceived lack of control. Froma critical perspective, maybe the patients should be allowed to have a choiceof what to eat and when they would like to eat it in order to prepare them forreal social life. Another final issueidentified was that meals were repetitive and bland, and the relentless focuson food for the function of gaining weight, quelled their appetite for food(Boughtwood & Halse, 2008).
Treatment should aim to make food desirable to thepatients, rather than something forced upon them as medicine, hopefullyresulting in internalisation of the behaviour. Kleinman,(as cited in Crossley, 2000, p. 130) emphasized theimportance of the doctor’s ability to interpret the patient’s and family’sperspective onillness. At the heart of this endeavouris empathic listening, translation and interpretation – ‘the craft of theclinician who treats illness, not just disease’. He feels that our modemmedicine seems to ‘disable the healer’ and ‘disempowers the chronically ill’.This type of care for the patient must be ‘one of the clinician’s chieftherapeutic tasks’.
By objectifying the person and our bodies in this way, we areencouraging the fragmented relationship between nature and society, pathologyand normality, clinician and patient, between anorexia nervosa as an illnessand anorexia nervosa as a human experience (Sanz & Burkitt, 2001). Toconclude, although Critical Health Psychology maintainsa constant criticism of Mainstream Health Psychology, it should not condemn itto the side-lines forever, to being always ‘on the edge of mainstream looking in’ as statedby Marks, (cited in Fox, Prilleltensky, &Austin, 2009, p. 154). Even though we should focus alittle more on the critical health approach, because sometimes the mainstreamview has too much of an institutionalised vision of promoting human well-beingin this field, it is still important that a mixed approach is used in this areaof research as we cannot deny the fact that we are mortal beings and we needenergy and fuel to stay alive. Therefore,biological treatments of malnutrition should not be ignored as the health ofthe patient is what’s most important.
As Hepworth said, ‘we need to work acrossdisciplines to further strengthen critical approaches to health (as cited in Fox,Prilleltensky, & Austin, 2009, p. 155)