Anorexia on. ‘Mainstream health psychology’ being the more

Anorexia nervosa has
become increasingly prevalent in the last 40 years in Western societies,
especially amongst young women.  Even though there have been
papers written about Anorexia Nervosa for over 50 years, we still do not have a
definite explanation or a definite treatment programme.  Traditionally, following the mainstream medical
model, quantitative research methods are used to diagnose and treat individuals
with anorexia. Mainstream health psychology is ‘that which is most often taught
in universities and practised by clinicians, researchers and consultants
(Crossley, 2000, p.2). Critical health psychologists offer an alternative to
this method, and make use of qualitative research methods, which will be
discussed later on. ‘Mainstream health psychology’ being the more traditional,
well known voice, and ‘critical health psychology’, is less known but still
slowly emerging.  In recent years,
critical perspectives with respect to health and wellness have made inroads
into the social sciences (Murray & Chamberlain, 1999). ?

 

The
DSM?IV?TR classifies anorexia as refusal to maintain a normal body
weight (15% below normal weight for age and height), an intense fear of gaining
weight, a distorted perceived body image, amenorrhoea (in post?pubertal
females) and a self?identity reliant on body weight and shape. Anorexia is
characterised by the exertion of discipline and control towards losing weight,
either through self?starvation or through binge?purge cycles, resulting in
being severely underweight.

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Diagnosis
is in a way created through the type of discourse we use that structure ways of
thinking and creating clinical practices. For critical health psychologists,
the concern with diagnosis and classification and psychometric tests is seen as
a big problem as by only using the DSM-5 to classify someone as ‘anorexic’ and
following the medical model of illness, one is treating mental problems in the
same way as physical illness. Hepworth (1999) talks about diagnosis as an
important part of medical process, and that these difficulties occur because
the mental disorders are not straightforwardly evident to the doctor except
through behavioural classification, symptoms and different characteristics.

Anorexia nervosa, in particular, has a long and complex history and is not easy
to understand and is certainly not that easy to diagnose.

 

Additionally,
this mainstream way of thinking presents anorexia as an individual pathology, rather
than the result of other factors such as environmental, social and cultural. With
the type of research methods used in the medical model such as surveys, the
patient is confined to a ready made list of questions were the patient is
unable to give his or her own experience of the disorder. From this outcome,
healthcare services are finding a diagnosis and treating only this, rather than
getting a better understanding of the patient’s experiences of treatment and
focusing on the individual, creating a better relationship with the patient and
therefore improving overall patient satisfaction and adherence to treatment
plans.

 

As
mentioned before, critical health psychologists make use of qualitative
research methods as opposed to quantitative research, such as self-report
questionnaires and statistics. By doing so, the data that is resulted is much
richer in meaning and has a much larger focus on the patient’s own experience.  This is done by making use of discourse
analysis, in which critical
health psychologists can present to the public how reality is constructed
through language in social situations, rather than making claims about the
truth of eating disorders, as they do in the medical perspective.  Discourse analyses emerged in the 1970s and
1980s as a turn to language when social constructionism started to develop. As argued by authors, our
discourse contributes to social action and furthermore community and public
health approaches that draw on critical health psychology theories and methods
(Hepworth, 2004; Murray & Campbell, 2004).  I will be discussing Discursive psychology and Foucauldian discourse
analysis.

 

Discursive
psychology is primarily concerned with the ways in which people speak in
everyday life and institutional settings negotiate meaning, reality, identity
and responsibility.  It places the speaker of the language as active in constructing
discourses in order to achieve goals within their social interactions. Foucauldian discourse analysis focuses
on discursive resources and examines the ways in which discourses construct
objects 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 language
creates its objects, including the speakers themselves. They both share the
view of language as constructing reality, and a general criticism of the methods
of cognitive psychology, but the difference between them is that they both have
their own concept of experience. In contrast to Discursive Psychology,
Foucauldian discourse theories state that discourses constitute subjective
experience. Discursive
research has therefore looked at discourses of treatment experience,
practitioner? patient relationships, and messages in the media and the
social environment.

 

In
studying 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 socially
constructed through social and historical messages, family communication, and
perpetuated through treatment practices. Discursive research looks at discourses
of treatment experience, practitioner? patient relationships, and
messages in the media and the social environment.

 

The
social construction of anorexia nervosa

The
feminist post-structuralist authors promoted the belief that eating
disorders are constructed through culturally and historically-specific
discourses (Hepworth, 1999). The feminist writings are of considerable
importance because they introduced a conceptualization of anorexia nervosa that
drew directly on women’s experiences of themselves and social relationships
(Hepworth, 1999. pg 45), especially of living in the Western world, the effects
of the subordinate social position and the denial of food by women.

 

Rather
than only focusing on anorexia being a naturally-occurring disorder, critical
health psychologists highlight that we must not ignore the different pressures
that women and men are suffering from society. Female power is mainly centred
by 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 controlling
themselves not to eat, women are in a way creating a superficial identity of
discipline as a substitute for the imbalance of power between male-female
relations and as Orbach argued that the ‘self-starvation in anorexia represents a struggle for autonomy,
competence, control and self-respect’ (as
cited in Till, 2011, p. 5).  The pressure and to be both
successful in their careers, as well as desirable and feminine.

 

The
thin body is construed as a controlled body and looked at as strength, success
and perfection. On the other hand, being ‘fat’ is looked as bad and wrong, as
though one has no control or order in their life. The language that is used is
served 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 this
notion of ‘healthy weight’ which surely serves as a reason for the ‘anorexic
boom’ and disordered eating.  

 

We must
remember it is only considered an eating disorder in cultures where there are
no food shortages such in the Western consumerist society, where anorexia and bulimia
are most prominent.

 

Many
studies include the individual family cultures as a factor for increasing the
likelihood of eating disorders and cultural pressures for ‘thinness’, and the
problems related to it such as maternal criticism, negative and unhelpful communication
and the culturally fixed discourses that is present concerning femininity,
physical appearance and power relations. The particular trend about anorexia
that traces factors within the relationship between the person diagnosed with
anorexia and his or her mother. This may be due to the role of the mother to
provide the food for the family, developed historically the 1990’s there was
talk of the relationship of anorexia and patriarchy by Bryan Turner about
Bruch’s work. For feminist writers, the articulation for this relationship was limited
as an explanation for anorexia nervosa, depicting these women as struggling
because of problems and difficulties. As Lawrence states: ‘I can say with
certainty that I have never worked with an anorexic woman who had a
straight-forward relationship with her mother’ (1984: 67). Presnell et al., (2004)
indicate that weight and appearance pressures from families are not significant
in the prediction of eating disorders, whereas pressures from peers were found
to be significant.  As Garner and Garfinkel () rightly said, anorexia cannot be understood if
not within its socio-cultural context, were thinness is the perfect ideal of a
woman.

 

Eating
disorders are gender neutral, but they are usually thought of as ‘women’s
problems’.  The clinical understanding of
anorexia nervosa as a predominantly female condition has surely had an effect
on the clinical understanding of it in males. Men are often underdiagnosed and
misunderstood by many health professions and have a harder time fighting this
intense stigma of suffering from anorexia. Therefore, health clinicians working
in this area should be more aware of the gender roles and differences in
determining the presence or absence of disordered eating, and males and females
may be treated with distinctive approaches (Pritchard, 2008).

 

 

 

 

 

Treatment

 

The
medical model’s main aim of treatment for the patient is to gain weight, and
that their eating pattern is re-established, but many patients relapse after
being sent home and end up being re-admitted time after time (Deter &
Herzog, 1994).  Therapeutic interventions
with mainstream practice remain held to notions such as “eating”, “disorder”,
“objective body”, “body mass index”, “distorted self-image”, which in turn
further promotes and confirms anorexia nervosa and makes the person imprisoned
in their colonization of the disorder.  This
clearly shows that this type of treatment is not working and more research must
be done in order to help improve service given to these patient suffering from
eating disorders such as anorexia. 

 

In
research by Malson, Finn, Treasure, Clarke, & Anderson (2004),they made a
study on the patient’s experiences of treatment using discourse analysis.  The study resulted in the patient’s
dissatisfaction coming from the construction of the ‘eating disordered patient’
from the healthcare workers. In the study, the patients show how they felt like
they 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 the
cultural construction of femininity as ‘deviant and deficit’.  This results
in inequality within power relations between the healthcare workers and the
patients.  Power is very important in critical health
psychology. ‘It is instrumental in the promotion of wellness, in resisting
oppression and in striving for liberation’ (Prilleltensky & Prilleltensky,
2003, p. 198). Here healthcare workers are presenting an invisible barrier
between 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 circumstances
were they cannot help the patient and human suffering that cannot be adhered
to. These power relations within treatment mirror power relations that already
exist in our society today.  Therefore,
as Spiro said we should place emphasis on ‘the importance of a sustained and
and meaningful relationship between the doctor and the patient’ (Crossley,
2000, pg 142) which works as a placebo-effect to help physicians ‘recover a
sense of the person in the patient’ (Spiro, 1986, p. 3)

 

On a
day 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, how
much they must weigh in order to be discharged from treatment etc.  In real, everyday life, we are judged on our
appearance and not by numbers and so when patients are discharged they are
faced to deal with this practice of calorie counting, only resulting in
obsessing over how much they eat and how much they eat, once again. The lives
of patients in treatment can be seen as a very routine-based place, where they
must follow strict eating regimes at certain times and eat certain types of
meals.  This choice of food which is
available when outside of the treatment centre is the total opposite and are the
patients not prepared for this, exacerbating their perceived lack of control. From
a critical perspective, maybe the patients should be allowed to have a choice
of what to eat and when they would like to eat it in order to prepare them for
real social life.  Another final issue
identified was that meals were repetitive and bland, and the relentless focus
on food for the function of gaining weight, quelled their appetite for food
(Boughtwood & Halse, 2008). Treatment should aim to make food desirable to the
patients, rather than something forced upon them as medicine, hopefully
resulting in internalisation of the behaviour.

                              

Kleinman,
(as cited in Crossley, 2000, p. 130) emphasized the
importance of the doctor’s ability to interpret the patient’s and family’s
perspective on
illness.  At the heart of this endeavour
is empathic listening, translation and interpretation – ‘the craft of the
clinician who treats illness, not just disease’. He feels that our modem
medicine seems to ‘disable the healer’ and ‘disempowers the chronically ill’.

This type of care for the patient must be ‘one of the clinician’s chief
therapeutic tasks’.  By objectifying the person and our bodies in this way, we are
encouraging the fragmented relationship between nature and society, pathology
and normality, clinician and patient, between anorexia nervosa as an illness
and anorexia nervosa as a human experience (Sanz & Burkitt, 2001).

 

To
conclude, although Critical Health Psychology maintains
a constant criticism of Mainstream Health Psychology, it should not condemn it
to the side-lines forever, to being always ‘on the edge of mainstream looking in’ as stated
by Marks, (cited in Fox, Prilleltensky, &
Austin, 2009, p. 154).  Even though we should focus a
little more on the critical health approach, because sometimes the mainstream
view has too much of an institutionalised vision of promoting human well-being
in this field, it is still important that a mixed approach is used in this area
of research as we cannot deny the fact that we are mortal beings and we need
energy and fuel to stay alive.  Therefore,
biological treatments of malnutrition should not be ignored as the health of
the patient is what’s most important. As Hepworth said, ‘we need to work across
disciplines to further strengthen critical approaches to health (as cited in Fox,
Prilleltensky, & Austin, 2009, p. 155)

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