From Hepworth, J. (1999) The social construction of anorexia nervosa, London: Sage Publications Inc.

Chapter 4:

Constructions of Gender and Identity in Anorexia Nervosa (ps. 69-80)

Late nineteenth century medical theories about the aetiology of anorexia nervosa heavily drew on the notion of hysteria, saturating the explanation of women, female psychology and particularly the development of women’s identity. Given that the overwhelming majority of diagnoses of anorexia nervosa are of young women I was interested in the ways health care workers constructed gender and identity. I am not suggesting that the prevalence of anorexia nervosa in women does not constitute the overwhelming majority of cases, but that the construction of gender in anorexia nervosa raises key issues for the explanation of women. Two questions are of particular significance to understanding this area. First, how does the construction of anorexia nervosa as a predominantly female condition affect the clinical understanding of anorexia nervosa in males? Second, how do health care workers construct identity in theories of female psychology? In this analysis I argue that historical and social discourses about anorexia nervosa construct a series of limitations in health care workers' explanations of both males with eating disorders and non-pathological theories about women. Accordingly, I begin this analysis by providing four examples of how different health care workers construct anorexia nervosa and male patients. I then summarise the constructions in these accounts and their implications for explaining anorexia nervosa in males and females before moving on to examine anorexia nervosa and identity.

Constructions of gender and anorexia nervosa

The significance of psychiatric co-morbidity

The health care workers who worked within a hospital setting described how anorexia nervosa first came to their notice when a patient presented to the health care system with an associated illness. Anorexia nervosa may be diagnosed in patients who had been admitted to hospital for something to which it was unrelated and the associated illness continued to remain separate from the eating disorder. Here, the illness is not symptomatic of anorexia nervosa except in instances when malnutrition is present. Therefore, the first kind of associated illness, that was usually physical, brought the eating disorder to the attention of health care workers. Alternatively if the associated illness was psychiatric it was discussed alongside the presentation of anorexia nervosa, and could be included within the discussion of the symptomatology of anorexia nervosa. Associated psychiatric illnesses included psychotic disorders; the two main disorders being schizophrenia and manic-depressive psychosis. In the first extract Dr N., a clinical psychologist, presents a case description of her only male patient with anorexia nervosa, and where psychiatric co-morbidity is also significant:

“Yes, well I think that the boy that I treated, I've only really treated one boy with anorexia nervosa, unfortunately he had an extremely disturbed family background. . . . A strong family history of psychiatric illness on both sides, and you know, major problems in his upbringing.

I mean, he was extremely intelligent. . . so, I saw his anorexia as an attempt by him to, sort of, try and get some attention for himself. . . . It was a very destructive attempt, in the end he actually committed suicide. . . . Obviously we did consider whether he might be clinically depressed and did actually treat him with anti-depressants, but, I think, at the end of the day the problem in that instance was a major. . . sort of, intrapersonal and family problem.”

Clearly this passage invokes the representation of a young man who was in a desperate struggle; so desperate that he killed himself. The diagnosis of anorexia nervosa is equated with the boy attempting to get 'some attention for himself' and the attempt is continued into describing the resultant suicide. The suicide also becomes a breaking point for the discussion of anorexia nervosa and the introduction of co-morbidity. The psychologist shifts from talking about a boy with anorexia nervosa to how she and her co-workers had considered 'whether he might be clinically depressed and did actually treat him with anti-depressants'. Suicide is not regarded as a common result of anorexia nervosa in young women whereas depression and anorexia nervosa are strongly linked. The consideration of depression by Dr N. represents an attempt to reconcile the incongruence between her diagnosis of anorexia nervosa and him 'committing suicide'. He was treated with anti-depressants, and in fact she had been treating him for depression, a condition other than that which she had diagnosed; anorexia nervosa. This move towards considering depression makes the suicide congruent with medical diagnosis. However, treatment had failed because he had died. She resolves this, in part, by returning to consider his family and this is similar to her initial description of him trying to get attention for himself. The way in which psychiatric co-morbidity is talked about in this account maintains the separateness between anorexia nervosa and depression.

The problem of self-disclosure

The long-standing status of anorexia nervosa as a predominantly female condition and relationship with a discourse of femininity may create a reluctance to diagnose the condition in males. Dr K., a clinical psychologist, constructs maleness as a barrier to the disclosure and possible diagnosis of anorexia nervosa in males:

“I haven't treated any men with it [anorexia], no. I've had my suspicions occasionally, but I think it's quite difficult to get men to admit to an eating disorder. I can only think of one lad who I saw last year who had a number of again sort of social skills, self-esteem problems, who I feel his eating pattern was probably abnormal, that he was very weedy and so on, but not to the extent that I think he was anorexic, you would not necessarily label it as anorexia.”

In Dr K.'s account anorexia nervosa in males is constructed as an unfamiliar occurrence, and one, in fact, that she has not treated. Although, diagnosis is not straightforward and she says 'I've had my suspicions occasionally', and locates the problem of diagnosis in relation to self-disclosure, 'I think it's quite difficult to get men to admit to an eating disorder'. In recalling a 'lad' who 'was very weedy and so on' she had not regarded the 'label' of 'anorexia' as a consequence of his presentation.

Dr K. continues:

“But I think that may well be increasing. I've certainly read that it is. . . . It wouldn't surprise me. Perhaps the very body conscious, health conscious young male, who again is not quite sure perhaps of their own sexual self identity then I think it may be something to look for and probably not something that we traditionally ask and I think if you don't ask about this problem very often you don't find out because there's a whole web of secrecy around the eating rituals and patterns and thought about that and so on.”

In this extract Dr K. presents identity issues as possibly contributing to anorexia nervosa in males. The problem of diagnosing male anorexia nervosa becomes, paradoxically, one obscured by social perceptions and the cultural representation of women as the group who are mostly affected by the condition which results in males' unwillingness to disclose details about their 'eating rituals'. In Dr K.'s earlier extract she identified self-disclosure as a problem in diagnosing eating disorders, yet discounts this in her diagnosis of a patient. In her second extract she emphasizes that clinicians do not traditionally ask about eating disorders, yet this is a problem already highlighted by the first extract. The extracts illustrate the structuring of the clinical interview in relation to historical and social discourses about gender and anorexia nervosa that position men as unlikely candidates for eating disorders.

Male and female anorexia nervosa

In Nurse R.'s account anorexia nervosa in males is presented in terms of its severity and this differentiates it from anorexia nervosa in females:

“I think it's a lot more severe [in males] in the fact that they can. . . take it on their, out on their bodies quite a lot more harshly so it's a lot more a case of starvation. The case which I saw was a young lad who was very plump, always teased at school and all of a sudden it was just like a crash diet, and that was it, you know, he then turned anorexic, which was a shame. I haven't really seen that many cases of lads, only a couple, but they've always been much more severe and they seem much younger lads. This lad was fourteen, quite young really.”

Nurse R. constructs anorexia nervosa as being different in males by describing a case of a 'young lad' through recalling her observations. She refers to three points to support her position. The severity of anorexia nervosa in males is related to the execution of anorexia nervosa that is carried out on their bodies 'more harshly'. The age of males with anorexia, in this example being fourteen years of age, makes them 'seem much younger lads', and the onset is more sudden than in females, 'and all of a sudden it was just like a crash diet, and that was it, you know, he then turned anorexic, which was a shame'. This construction of male anorexia nervosa engenders a degree of sympathy due to the severity of anorexia nervosa in 'lads', yet, Nurse R. adds the proviso, 'I haven't really seen that many cases of lads. . .', and in so doing her account avoids making generalisations.

The problem of diagnosis

Diagnosis is a fundamental process of medical practice and is fraught with difficulties within the area of mental health. These difficulties arise because psychiatric disorders are not directly observable to the practitioner except through interpretations of symptom groupings, characteristics of specific populations and behavioural classification. Further to this, a phenomenon that is classified as a psychiatric disorder, has a complex history and multiple clinical presentations, does not lend itself easily to diagnosis. Anorexia nervosa is one such phenomenon. The DSM IV (APA, 1994) recognises these multiple presentations and has responded by diversifying the typology of anorexia nervosa to include 'restricting type' and 'binge-eating/ purging type'. Diagnosis is situated within discourses that structure ways of thinking about phenomena and practices, which, in turn, have the effect of maintaining and reproducing clinical practices. In Nurse V.'s account she describes the process of the diagnosis of anorexia nervosa in males and females and symptomatology related to her observation that diagnosis is different according to gender:

“. . . but anorexia in men seems to be diagnosed differently anyway. It's usually put down to depression or. . . endogenous depression. I know a couple of times I’ve seen men with eating disorders and they haven't been diagnosed as having eating disorders. They've been diagnosed as having something like endogenous depression. . . and if you ask the consultant why is that they say, well, they've got disturbed eating patterns so that's a classic symptom, disturbed sleep and all that.”

Nurse V.'s observations are characterised by the diagnosis of endogenous depression (depression arising from causes inside the body) in males rather than anorexia nervosa. The consultant's diagnosis of depression in the male patient overshadows Nurse V. having 'seen men with eating disorders and they haven't been diagnosed as having eating disorders', and she describes asking the consultant for clarification of the diagnosis. The consultant's reported response to her presented the common symptoms of depression in such a way that the symptoms confirm the diagnosis of depression rather than anorexia nervosa. Nurse V. emphasizes the similarity in the presentation of males and females, yet they become diagnosed differently.

“They usually follow the same pattern as females. ..people who have been diagnosed as anorexics. I mean outwardly they seem to have basically the same symptoms. . . I mean disturbed sleep, disturbed eating patterns, mood swings, lack of motivation, lack of volition, lack of concentration, a very low self-esteem. The outward symptoms seem to be basically the same, but for some reason the diagnoses are different.

The smallest one that I've seen wasn't actually an anorexic patient anyway. He was supposed to be schizophrenic and he was, like, 5 ft 3 inches and 4 stones, but he wasn't, again he wasn't classed as an anorexic. He was classed as schizophrenic.”

Nurse V.'s description of symptoms in males and females demonstrates to her that 'outwardly they seem to have basically the same symptoms', but the 'reason the diagnoses are different' remains unclear to her. Nurse V. in making a distinction between the similarity of 'outward symptoms' leaves the possibility that internal symptoms may differentiate between gender. Nurse V.'s recollection of a male case of severe under-nutrition serves a function of further emphasizing the different diagnosis of anorexia nervosa in males and female.

Constructions of identity and anorexia nervosa

In this section I analyse the way in which health care workers constructed female identity and its relationship to anorexia nervosa. In Part I, I critically discussed the various theoretical explanations of anorexia nervosa and those in which female identity is specifically considered as a causal factor. I investigated constructions of female identity because theories of identity commonly bring the broader social and political dimensions within a concept of identity that is understood as an entity residing within individual women. Therefore, I wanted to examine the ways in which this concept of identity was constructed, its relationship with practice and effects on the representation of women diagnosed with anorexia nervosa.

Identity and control

In the following two extracts Dr M., a clinical psychologist, and Dr J., a general practitioner, present identity as being related to control and an individual's sense of autonomy. Poor control is presented as having negative effects within an anorexic's environment and the re-establishment of control is understood as a means to overcome the symptoms, develop autonomy, and produce a person who is effective within her environment.

Dr M.: I mean, I see the central issue is around control and self-identity and

so on and I would say that probably broadly a psychotherapeutic approach would be likely to bring more long term results and. . . really trying to help the person understand the function of their symptoms and how they're operating in, within their environment and where that may be blocking them from goals to, you know, with the focus on helping them to develop insight in that area. . . .

Dr J: I think the. . . the problem is to become an autonomous adult, someone who is essentially self-governing, making your own decisions about your own life, in your own terms. That is a problem for everyone. . . it's a problem we'd all half like to opt out of because life is actually much easier if other people tell us what to do, but on the other hand it's a problem which we would. . . we also want to be like that because we want to feel we are our own boss. This is the, I mean it's an existential dilemma in fact. . . . Now, I think the. . . anorexic, what happens is. . . I don't think they start off that way but in fact their problems about becoming an autonomous adult start to hinge around the dependency problems and the power struggles over their eating. And, certainly one of the things that happens is they, a lot of them, then use those to avoid becoming an autonomous adult and I think, I mean this fits in with they won't eat because they don't want to grow breasts. . . sort of argument, do you know what I mean?

Dr J. locates the problem of identity in anorexia nervosa in the way the young woman becomes an autonomous adult. In the process of developing autonomy femininity is grappled with and/or rejected resulting in anorexia nervosa as an 'existential dilemma'. Dr J.'s representation of an 'existential dilemma' is at first presented in an apolitical, asexual way and continues to relate autonomy with a traditional psychodynamic explanation of dependency and the rejection of adult female sexuality. In Dr J.'s view for anorexics to achieve the status of becoming an 'autonomous adult' they must accept femininity, and no longer avoid eating because 'they don't want to grow breasts. . .'. Throughout, Dr J. constructs his account in terms of a dominant argument about anorexia nervosa that 'fits in with', 'sort of argument', and what that argument represents.

In Dr M.'s and Dr J.'s accounts control is presented quite differently. For Dr M. control was a pragmatic tool for achieving and securing goals in one's environment, whereas Dr J. talks about control as a manifestation of the anorexic woman's psychodynamics. Neither account of control brings in the social and political dimensions of what is possible or not for young women, rather the accounts located identity within individual women and the 'function of their symptoms', 'psychodynamics' and 'problems about becoming an autonomous adult'.

Identity and abuse of women

Clinical psychologist Dr M. and feminist therapist, N.J., constructed identity in relation to abuse. Dr M.:

“Another link, and I don't know how valid this is and whether I'm just obsessed with this one, but it's been my experience in dealing with people with eating disorders generally is that very often I would be looking for the idea of sexual abuse. Has there been some sort of major disturbance in the sense of identity and whether their body ends and another person, you know, their own boundaries?

This, this terrible sort of. . . almost not listening to sort of internal biological signals and being very confused about body shape and identity and so on. That would be in my mind too, as well.

I think it becomes a sort of false identity, doesn't it, beyond which they can shelter and that is perhaps an avoidant reaction in the same way they are avoiding certain issues that they can't cope with.”

Here, based on Dr M's 'experience in dealing with people with eating disorders', she would be 'looking for the idea of sexual abuse'. Sexual abuse is put forward as being so common that this practitioner looks for it in her consultations where there is a possibility of the diagnosis of eating disorders. The focus of this clinician in looking for sexual abuse is on specific aspects of the individual person, and assumed psychological phenomena that serve as evidence of this abuse, such as 'major disturbance in the sense of identity . . . their own boundaries', 'not listening to sort of internal biological signals. . . being very confused about body shape and identity'. The act of sexual abuse and the perpetration of this abuse by another person is brought within the individual sphere and understood within this extract as an 'avoidant reaction'.

A feminist therapist provides the second example: N.J. who talks about anorexia nervosa and sexual abuse:

“I think it is linked, I mean for example last year in my group of eight women, eight women had been sexually abused, but then if you look at my group this year of eight women none of them have been abused so it's just sort of in a sense I think there has been an awful lot of women who have been abused and I think there is an awful lot of women who have eating problems and I don't think that abuse causes someone to have an eating problem.

I think it is quite a big thing but I don't think it is a general rule. I think there is an awful lot of women who haven 't been abused, sexually abused, but I think that that is just one form of abuse there are many other forms of abuse.

It’s an interesting question, because I suppose what I see is the basic problems that a woman with an eating problem hasn't had for one reason or another enough of her mother, so that when she needs her mother, she tries to get more of her mother by using food. Now it would often be the case that in a family where sexual abuse is going on the mother will either not be around or she is certainly not doing her job in protecting her daughter from the abuse. So there will be an absent mother of some description.”

This health care worker considers several forms of abuse in the development of eating problems, and sexual abuse does not constitute an aetiological factor in anorexia nervosa. The problems that a woman has with eating are directly attributable to the dynamics of the mother-daughter relationship. Sexual abuse, thus, becomes an extension of the fact that the daughter has not had her needs met by her mother. Any discussion of the woman's relationship with male family members or men was absent.

The construction of identity by means of a link with sexual abuse is made sense of in Dr M.'s account by drawing on ideas of individual psychology, whereas N. J.'s account of women and abuse focuses on women's needs that are unmet by their mothers. These accounts construct the relationship between identity and abuse in terms of psychological notions about women and 'false identity', or the psychodynamics of mothers and daughters - 'she tries to get more of her mother by using food' - that maintain a link between the individual woman, anorexia nervosa, and a pathologisation of the social origins of women's abuse.

Identity and the mother-daughter relationship

For Dr J. the mother-daughter relationship is a key site of struggle about food and the developing identity of the daughter. At first he appeals to a common view of 'mums' who 'translate their love for their families into food', and that food and love 'can make you feel nice and warm inside', that establishes the connection between women and food He describes a scenario in which there are 'mum's anxieties', there 'is a tangle of feeling', 'very strong family feelings', that is escalating and circuitous.

“To a large extent. . . I mean there's a very close connection between food and love. . . . Both can make you feel nice and warm inside. . . at a very sort of simple physical level. A lot of. . . a large number of mums particularly. . .translate their love for their family into food and I mean, you know. . . cooking and preparation of food is often a statement of very deep feeling. I mean the adverts on the telly are often saying just that - if you really love your children this is what you'll give them to eat. I think with a lot of anorexics. . . you know, I've seen certainly, there's this sort of sense that. . . that there's some sort of black-mail system. . . has been going on between mother and daughter, and typically between mother and daughter, and it has hinged around food. . . now it's a bit of a chicken and egg problem because whether it is that mum is anxious and pushes the food and the daughter finds this a useful way of manipulating or whether the daughter refuses food for her own personal reasons. . . enhances mum's anxieties I'm never quite sure 'cause what you meet, you know, when there's an established case so to speak, is a tangle of feeling. But out there, certainly there are very strong family feelings and they are of that sort. They are to do with whether, you know, with love and whether you, whether she really loves me, which ever way round that is. I think it's just a system of communication which is, which is not uncommon.”

Dr J's reluctance to define the origin of the problem as being either with the mother or the daughter therefore implicates the nature of the relationship itself as being the site for the struggle. The many aspects to the escalating scenario are simplified by Dr J. finally stating 'it's just a system of communication . . . which is not uncommon'.

Dr C., a clinical psychologist:

“. . . whatever it's worth, the dominance in the family was the mother and the need for the. . . well my guessed need. . . of the daughter to remove herself from the mother's dominating influence, it so happened were factors in both these cases, which were quite different.”

Here, Dr C. tentatively describes dependency needs as a main concern in the mother-daughter relationship. Unlike Dr J. who talked about the dynamics of the relationship, Dr C. clearly identified the mothers' dominance as being the site of the problem in two cases. Dr C. introduced talk about the mother cautiously, for 'whatever it's worth', and marks her discussion of the daughter's need to separate from her 'mother's dominating influence' as the practitioner's 'guessed need' rather than a need that she assumed the daughter had.

Identity and socio-cultural pressures

The construction of identity in anorexia nervosa in relation to socio-cultural pressures presents social issues as a problem in women 's achievement of a sexual identity. Dr I.:

“Women are under more pressure. . . about body shape aren't they? . . . I mean, in that sense, and if you've got a body shape problem. . . it's got to be more likely to be brought out if there's social pressures. I think that's how it is really. I don't think it's more than that.”

In this extract, even though Dr I. first states that women are under more pressure about body shape, he talks about body shape problems as pre- existing problems that are separate from social pressures. The way in which body shape problems relate to social pressures is through their co-existence that makes them 'more likely to be brought out' if there are social pressures.

Dr Q., a general practitioner, presents body image as affecting eating:

“Well, I didn't even treat her. I acquired her. . . . She had got over it already so I didn't actually do anything and she came to me because of another problem. She had enormous breasts and her, because of, her body image was so important to her she had to have something done about this because she found that it was affecting how she felt about eating, because she was so distressed by this.

I must tell you that I have in fact seen two, I had forgotten. I have in fact seen two anorexics who had to have breast reductions and this is terribly unusual. The plastic surgeon, Dr M. at the Accident, who did both operations under the National Health Service, couldn't believe it, and I had them both within a year. Both of them had been anorexic but were well coping with life now in their, sort of early twenties, but had such huge breast development that they just couldn't cope with what they looked like in a mirror. It was. . . affecting them and both of them had breast reductions and were much better afterwards.”

Dr Q. recalls his work with two anorexics in which body image was a central concern. He describes the way he came to see these women, '1 didn't treat her', '1 acquired her', 'she'd got over it already'. He did not primarily treat them for anorexia nervosa, 'she came to me with another problem'. The women had concerns about breast size and body image that also related to eating. The problem of 'huge breast development' was something that the women were not coping with, and it was affecting their sense of who they were, because body image was 'so important to them'. Yet, a relationship between the problem and socio-cultural pressures is not made. Furthermore, the problem of two 'anorexics who had to have breast reductions' is characterised as being 'terribly unusual' and 'the plastic surgeon. . . couldn't believe it', which serves to reinforce the peculiarity of the problem and its relationship to the individual women.

Dr P., a psychiatrist, describes identity and socio-cultural pressures in terms of the effects of the media:

“Obviously there is this sort of. . . pursuit of thinness, that is, sort of, . . . fashionable and idealistic. . . and that. . . teenage girls are more likely to respond to that now because. ..of the, several things, sort of, . . . sexual. . . aspects of being thin and being attractive to men. . . and I think that there is a big media aspect to it. . . . In men I don't think there's the same pressure, because it's very different, they're in a very different. . . sexual position. They don't necessarily have to be. . . terribly attractive in order to go out with girls.”

In this account the problems underlying anorexia nervosa are presented external social pressures that become internal because of the way in which these pressures are responded to by young women, 'teenage girls are more likely to respond to. . .'. Dr P. constructs young women as responding media pressures and a popular definition of attractiveness 'because they in a very different. . . sexual position.' In this sense socio-cultural pressures have a tangible and relatively straightforward relationship to anorexia nervosa because women are trying to be thin; anorexia nervosa becomes a consequence of the 'pursuit of thinness.'

Conversely, Dr M., a clinical psychologist, describes anorexia nervosa as indicative of 'some sort of fundamental conflicts about sexuality', 'a massive complex', 'shaky self-esteem', that come into play during puberty, and draws on the notion that cultural pressures relate to women's 'obsession with their figure' ,that unifies all women:

“I think there are often some sort of fundamental conflicts about sexuality as well, about, you know, the developmental crisis when someone is approaching puberty and so on. So, maybe a massive complex around that may be built on a very sort of shaky self-esteem really or sense of worth and feeling that their lives are very much out of control and this is one area which they can control. Plus, I think you can't afford to ignore the cultural pressures and to some extent the obsession which all women share about their figure, their appearance, their weight and so on.”

The references to sexual conflicts and identity hinge around a developmental argument that assumes puberty to be problematic for women and further obfuscates the relationship between hormonal changes and young women 's developing awareness of socio-cultural expectations.

The constructions of gender and anorexia nervosa in these accounts present male anorexia nervosa as different from its presentation in females drawing on psychiatric co-morbidity, severity of weight loss, problems with self-disclosure and clinicians' questioning, as reasons for this difference. Both male patients and health care workers may be reluctant to discuss or diagnose anorexia nervosa in males due to the long-standing association between anorexia nervosa and women. The problem of self-disclosure and anorexia nervosa also involves a problem about the clinical interview at the extent to which this obscures the diagnosis of male anorexia.

If a male is diagnosed with anorexia nervosa this becomes a discursive problem because the dominant explanation of anorexia nervosa specifically links it with an ideology of femininity that has developed over the last century. One of the functions of using these strategies is that the diagnosis of an overwhelmingly female condition in males is reconciled by the fact that anorexia nervosa is in some way different in males. This construction has the effect of reinforcing the notion of males as unlikely candidates for the diagnosis of anorexia nervosa. Health care workers use different strategies to try to overcome this problem in their explanations of male anorexia. The construction of masculinity in relation to anorexia nervosa, that anorexia nervosa can occur in men but is in some way different and/or more severe, emphasizes the search for different reasons for anorexia nervosa in males and females and that it is diagnosed and/or treated differently.

The constructions of identity and anorexia nervosa refer to control, abuse of women, the mother-daughter relationship and socio-cultural pressures, indicating the breadth and variability between health care workers' accounts. Anorexic women were understood as being 'out of control' of their lives and, therefore, unable to successfully develop a sexual identity, yet 'in control' of eating, to the extent that 'they behave themselves', 'but really they're still anorexic'. The link with sexual development also maintains a link with the notion that women's sexuality is always involved in some way to the onset of physical and psychological conditions. The abuse of women was explained through the notion of 'boundaries', or 'internal biological signals', and in these ways the political and social dimensions of abuse were mediated through an individual and internal dimension that functioned as a site for therapeutic intervention. One of the effects of the construction of identity as 'false identity', 'self -identity', or identity 'boundaries' is that the internal psychological dimension to which these terms refer is accessible only through certain forms of knowledge, particularly psychology and psychiatry, that is practised and maintained through the institutional position of the health professional.

Health care workers were also reluctant, and in some instances, tentative, about what they could say about anorexia nervosa. They avoided making generalisations that displayed a sensitivity to their professional identities. For these reasons the discourse of identity served a function of providing a malleable concept in health care workers' accounts. What was always unresolved in accounts that drew on social discourses of anorexia nervosa was the way in which anorexic women are both 'like all women' (Dr M.) and 'different'. The difference between women is somewhat resolved by the dis- course of identity because the explanation of social pressures on women to be thin is constructed in ways that privilege individual psychology over other explanations. Consequently, the identity of an anorexic woman is constructed as always in crisis and the site where conflict is played out, making individual therapy consistent with explanation. In specific instances, when health care workers described more detail about the theories they drew on to explain anorexia nervosa these reproduced historical and dominant concepts about women, eating and psychopathology. The construction of identity to varying extents problematised women's gender identification and reproduces a pathological framework with which to work with women where identity remains a significant feature of anorexia nervosa.

The construction of gender and identity in these accounts maintains a representation of anorexia nervosa as a condition that is inextricably linked with being female and female psychology. For this reason these constructions demonstrate aspects of the discourse of femininity discussed in Chapter 2 whereby there is something essential to female psyche that pre- disposes women to develop anorexia nervosa. Finally, the status of not knowing the answers to questions about anorexia nervosa was emphasized by the health care workers. It is clear from these accounts that health care workers grappled with many issues of anorexia nervosa that present to them as anomalies during clinical practice.

From Hepworth, J. (1999) The social construction of anorexia nervosa, London: Sage Publications Inc.

Chapter 5:

The Multiplicity and Diversity of the Causes of Anorexia Nervosa (ps. 81-89)

In the previous chapter I analysed constructions of gender and identity and their effects on the capacity to explain males with anorexia nervosa and non-pathological aspects of anorexia nervosa. Many of the issues that I discussed are also relevant to the numerous endeavours made by researchers, medical scientists in particular, to locate the cause of anorexia nervosa. Femininity and/or being female is a predisposing factor for diagnosis and female identity is a key construct in articulating the development of psychopathology that maintains the anorexic state. These areas of enquiry are elaborated on throughout this chapter on the multiplicity of causes of anorexia nervosa. The identification of a specific causation of anorexia nervosa has eluded scientific studies for over a hundred years, yet numerous theories of the medical, physiological, psychological, social and cultural nature of its onset exist. These theories reflect the diversification of the human sciences over the course of the twentieth century. In this chapter I analyse health care workers' constructions of anorexia nervosa in terms of explaining its causation and how they account for this diversity. In particular I focus on medical and feminist constructions of causation, and I then go on to summarise the issues that these perspectives raise for the explanation of women and treatment practices.

Medical and psychiatric perspectives on the causation of anorexia nervosa

The identification of the causes of physical and psychiatric conditions is fundamental to medical practice in order to establish appropriate treatments. The difficulties in identifying the causation of psychiatric conditions are notorious. Consequently, treatment decisions are often made post-hoc, based on conclusions drawn from observing the effects of medications or practices that are available to a practitioner. I asked each health care worker why do people starve themselves? Each person replied by emphasizing the difficulty of the question, but answered by recalling a plethora of 'factors', its 'multifactorial' nature, and tension between biomedical and social theories. Dr J., a general practitioner, considered whether anorexia nervosa was a psychiatric disorder in his account of causes:

“I don't know. I really don't know. I'm not convinced that it is in itself psychiatric. I'm really not. I don't think it, it's certainly not. . . psychiatric in the sense that someone with a high level of anxiety becomes distressed because, they either, their anxiety becomes very evident or becomes attached to a particular activity. It's not like that. It doesn't seem to me psychiatric in the sense that, that a depression which responds to anti-depressants is.”

In this account Dr J. constructs anorexia nervosa in terms of why it is not a psychiatric disorder by characterising two conditions which are psychiatric and how anorexia nervosa does not fit these characterizations. The responsiveness of conditions, like depression, to medication is significant to this understanding of psychiatric classification and used to justify why anorexia nervosa is not a psychiatric condition. Dr J.:

“I'm sure some of it is genetic. I'm sure some of it is related to family dynamics. I mean. . . but to describe it as a psychiatric condition with the sort of notion that somehow if you could understand the psychodynamics that have led up to it then they'll get better I think is a nonsense.”

Dr J.'s elaboration of two possible causes, genetic and family dynamics, introduces the notion of multiple and conflicting theories of anorexia nervosa, and returns to his argument against it being a psychiatric condition by characterising another feature of psychiatric conditions, that knowing the psychodynamics means that they will get better.

Dr J. elaborates on his observations of anorexia nervosa:

“. . . 'cause, I mean others I've known over the years, I mean some of them stop. . . but they're still anorexics really. They control their eating. They behave themselves. They do it, but really they're still anorexic. They still think they're unbelievably fat. But there are others who have given it up and I think the girl I spoke to, the one I said, who came back with her two children, I don't think she is anorexic any more, truly not anorexic. . . she's very slightly plump, I mean very nicely plump, just right you could argue, but she is slightly plump and she thinks she's the right thickness.”

Dr J. differentiates between anorexics in terms of those who are 'still anorexics really' and an example of a 'girl' who was 'truly not anorexic' and 'came back [to him] with her two children'. Dr J., in stating 'they control their eating', 'they behave themselves', 'they do it, but really they're still anorexic. They still think they're unbelievably fat' introduces an issue of deceit in the anorexic women's 'behaviour' and ‘thinking' that the medical practitioner has identified. The key feature of the recovered state is being 'very nicely plump' and the apparent agreement between Dr J. and the woman that she is the 'right thickness' enables the relinquishment of the diagnosis of anorexia nervosa.

Dr a., a general practitioner, states:

“I don't know. I don't know if anyone knows. I mean maybe it's this. . . distorted body image, thing, striving for perfection in what you look like.”

Dr P., a psychiatrist:

“I would view it as being really multiple causes. I have some difficulty in seeing it purely as an organic brain disorder with disturbance of hormones. I think that may be a result of rather than a cause of anorexia nervosa. There's no doubt that there is hormonal disturbance and that it is in the hypothalamic pituitary axis, but it is very difficult to actually say with any degree of certainty that is the actual cause of it.”

In this account Dr P. uses a justificatory position for the lack of an identifiable causation that states what anorexia nervosa is not rather than attributing it to a hormonal cause. Dr P.'s notion that there are multiple causes results in her viewing anorexia nervosa as a 'multifactorial condition'. The comparison of anorexic symptomatology with paranoid delusion functions to maintain a psychiatric framework through which anorexia nervosa is understood by this psychiatrist. By employing the criteria for paranoid delusion, anorexia nervosa is made explicable to this health care practitioner, and the uncertainty about the multifactorial nature and the complexity that that presents for interventions is, in part, overcome. Dr P. again:

“There are the sort of intrapersonal and interpersonal causes which I think have to be taken into consideration so I really view it as a multifactorial condition, rather than a single, biological entity. To me there is very little difference between this distortion of body concept which all anorexics have and someone with a paranoid delusion who holds on to it, believes in it firmly, cannot be rationalised out of it, and is unprepared to believe there is any other explanation for it. I mean, this distortion of body image fits the criteria for delusion, so I certainly feel that is delusion.”

The identification of perceptual distortion is a common factor associated with anorexia nervosa. Other interpretations of perceptual distortion as a distortion of body concept related to socio-cultural expectations of young women to be slim/thin and that encourage constant dissatisfaction with body size is absent. Dr P., like Dr J. earlier, attempts to explain anorexia nervosa by referring to another psychiatric category. Dr P. compares the similarity between one symptom of anorexia nervosa, distortion of body concept, with paranoid delusion, associated with either schizophrenia or manic-depressive psychosis. In making this comparison Dr P. identifies the medication chlorpromazine, a treatment for psychoses, as a treatment for anorexia nervosa:

“Chlorpromazine, for example, is in fact an anti-psychotic as well as a major tranquilliser, but it's not really used for that because I don't think that most psychiatrists, don't view this distorted body image as delusional.”

[Interviewer: If psychiatrists treated it as delusional would they use chlorpromazine?]

“Well, you could use more potent anti-psychotics, but of course they would have side-effects and then you also have to deal with the other problems of weight. But I have often wondered what would happen if I actually gave someone a very potent anti-psychotic. . . particularly if they were inpatients.”

Despite being unsure about the causes and symptoms of anorexia nervosa Dr P. has an interest in investigating the relationship between a potent anti-psychotic drug and anorexia nervosa. Psychiatric discourse maintains this practice of investigation by developing an understanding of conditions by observing their responsiveness to medication.

In the following extracts health care workers put forward the multi- factorial model in responses to the definition of causation. These responses result in an oscillation between the singularity and multiplicity of causation. Dr H., a psychiatrist, describes a multifactorial theory of anorexia nervosa:

“. . . very difficult question [causation]. I wish I could answer that. . . straightforward, simple answer is I don't know the correct answer, but I think it's a multifactorial causation. There are certainly psychological factors, social factors and maybe an organic factor.

. . . discarding all this it may have an organic basis, mainly because some of the symptoms, like mainly the cessation of menstruation and. . . some of these features could be an endocrine or hormonal imbalance in some way causing the problems. So, in fact, I'm really not sure what the actual causation. . . but it seems to be very many factors and it's a very complex problem that we are dealing with, and quite often in treating the anorexic the main problem is that we do not know which area to stress or where to treat.”

Here, Dr H. avoids specifying a cause, he says '1 don't know', '1 think it's . . . multifactorial', and lists several possible causes, he uses 'may', 'could be' to describe and play down biological bases of anorexia. These ways of talking produce an account in which not knowing is restated. The strategy of not knowing is evident, and his reference to 'actual causation' is used as a contrast and upshot of his deliberations, together with 'it's complex', as a warrant for not knowing. In these ways the accounts do not reinforce a single causative theory of anorexia nervosa.

Clinical psychologist Dr M. talks about multifactorial causes: Oh, dear me! I wish I knew. I wish I knew about that actually. . . I think it's many and various. I mean there is this sort of hypothesis isn't there and there's some sort of biological link . . . not wonderfully convinced of that idea. I mean I think there are central issues around personal control, how someone sees control. The whole issue of controlling their lives which I think it seems to be more of a problem for women. Though I think it would be unlikely if that problem did not develop within the context of some quite stirred family relationships. . . . I think there are often some sort of fundamental conflicts about sexuality as well, about, you know, the developmental crisis when someone is approaching puberty and so on. So, maybe a massive complex around that may be built on a very sort of shaky self-esteem really or sense of worth and feeling that their lives are very much out of control and this is one area which they can control. Plus, I think you can't afford to ignore the cultural pressures and to some extent the obsession which all women share about their figure, their appearance, their weight and so on. This is where I have in mind, you know, you have to look at things like a spectrum condition. It may well be that what maintains it I don't know, I mean you probably know more about this than I do, but this idea of a high, you know, that if you do lose weight or go without food for a while that maybe there's a certain biochemical kind of aspect which comes into it and it's also a very powerful way to, sort of, control relationships indirectly for somebody who is. . . whose assertion skills are not particularly well developed in other areas.”

Dr M.'s account of the causes of anorexia nervosa involves a similar pattern to that of Dr H. For Dr M. some of the factors that contribute to anorexia nervosa include 'personal control', 'family discord', 'sexuality' and 'cultural pressures', and the biological link is understood as a factor that maintains rather than causes anorexia nervosa. The notion of factors that maintain behaviours contrasts with the common cause-effect relationship within medical science. The interrelations between physiological and psychological processes become clearly positioned in these extracts and related to either causative or maintenance roles in anorexia nervosa. The diverse explanations of the causes and symptoms of anorexia nervosa contribute to its status as a complex condition. This complexity becomes compounded through multiple explanations of causes, factors and symptoms, as being either primary or secondary to the onset of anorexia and understood within the specific disciplinary frameworks of different health care workers.

In clinical psychologist Dr C.'s account 'different factors', 'cultural conditions', 'psychological influences' and 'family dynamics' may be important in anorexia nervosa.

“I'm not sure. I think there are a lot of factors involved and different factors play a different. . . importance for people who experience anorexia. I think there's a general cultural background, particular socio-cultural pressures on women in terms of valuing themselves in terms of their body. On top of these cultural conditions I think there's various. ..kind of psychological influences, for example, family dynamics may be important. ..some people argue for a genetic component. I am sceptical about that.”

As well as drawing on a multifactorial model of anorexia nervosa Dr C. also uses a socio-cultural explanation with reference to body image, rather than perceptual distortion. Dr C. introduces the notion that different factors have different importance for people. The notion of relative factors contrasted with the traditional view that the aetiology of anorexia nervosa is 'discoverable' shows how the search for a causation for anorexia nervosa may also mask a consideration of the relative significance of factors in relation to individual cases.

I asked two psychiatric nurses who worked as primary nurses to patients diagnosed with anorexia nervosa, Why do people starve themselves? In Nurse T.'s account media influences on people in terms of what 'you have to be' becomes translated into individual behaviour. Media pressures advocate that eating little is being 'good', 'trim' and 'fit', and this is translated into 'they all seem to be vegetarians', 'they quite often go into a gym', but they become unlike other people who do this because people with an eating disorder 'go over the top'.

“From the various people I've seen which I consider to just have an eating disorder I would say there's quite a lot of, at the moment, sort of media influence. You have to, have to be good and trim, fit and, you know, eat healthily and they all seem to be either vegetarians, vegans, into wholefood diets. . . . They quite often go into a gym, into keeping fit, jogging, whatever. So they seem very, sort of, influenced by today's trends if you like, but go over the top.”

In Nurse X.'s account anorexia nervosa is 'a way of getting attention within a family that's having problems'.

“here's no hard and fast aetiology. There's a lot of causes from what I've seen anyway. Usually they're overweight or have been overweight at some point in their lives, or some people say it's due to attention seeking. It's a way of getting attention within a family that's having problems. The father's away a lot or the mother's away a lot. I know at the clinic where I work. . . about 80 per cent of the girls that I've seen with anorexia, it's strange that their fathers work abroad a lot or have got jobs where they're away from home a lot.”

The patient is brought within the clinical domain through the notion that anorexia nervosa has multiple causes, complexities and uncertainties that manifest within individual psychology. In this way there is consensus between health care workers' accounts of what constitutes anorexia nervosa. A major distinction between the nurses' articulation of anorexia nervosa and earlier accounts made by medical practitioners and psychiatrists is that the nurses drew on their direct observations of patients. Unlike medical accounts the nurses did not refer directly to psychopathological explanations.

A feminist perspective on the causation of anorexia nervosa

The following extracts are from an interview with a feminist therapist from the Women's Therapy Centre (WTC) in London, UK. The work of Susie Orbach and co-therapists forms a key theoretical foundation to the work at the Centre. During the initial part of the interview the therapist, N.J., defined her therapy for me as being a combination of art therapy and feminist therapy that has a psychoanalytic orientation. Because N.J. has particular expertise in the provision of therapy for eating disorders I asked her the question: Why do people starve themselves?

“That's a jolly big question. Well, in a nutshell I would answer you by saying I think it's to do with the mother-daughter relationship and that's a fairly classic feminist psychotherapy viewpoint, I fairly closely follow Susie [Orbach] or I sort of agree with her analysis of the problem. Within a context of a patriarchal society, I mean I think trying to kind of pull teeth out with threads with all of that is quite tricky. I suppose what I think is that because we live in a patriarchal society where men at least hold the external power in relationships between men and women, women then get locked into a position of both taking care of others and therefore their own needs get put aside, and so I think their needs kind of get split off, and thought of as bad.”

N.J.'s account of self-starvation is explicitly situated with reference to theory. She makes this theoretical framework clear in her explication of the mother-daughter relationship, patriarchal social structure, and women's denial of their needs, focusing on the denial of nutrition needs. In this account she privileges the mother-daughter relationship as the nexus for the psychoanalytic interpretation of anorexia nervosa. N.J. continues:

“I mean, I think it also is very much wound up with Christian ethic and I think that the myth of creation has a lot to answer for. I think it's very deeply embedded in the way in which we view black and white for example, and sexuality and pleasures of the flesh and I think women end up being the scapegoats for, well if you like, being the ones in a sense who are seen to be the temptresses. Men can go off and enjoy themselves and it's absolutely fine, a stud, but for a woman to do that she is seen as a whore and somehow this whole business is, we've got to keep the lid on women's power. We've got to reduce their appetites. We've got to reduce both their eating appetites and their sensual and sexual appetites. I think in the last century, their sexuality was very much sort of bound up, tied up, cut off, surgically removed.”

In this extract morality and women's sexuality presents a social dilemma Women's power, situated within female sexual consciousness, is defined by males in patriarchal societies in such a way whereby women's sexuality ends up being regarded negatively and something that should be contained. The result, N.J. states, is that 'women end up as scapegoats' for the behaviour of men. The process of scapegoating is a strategy that enables the ills of a society to be made attributable to an object or social group. From a feminist psychoanalytic perspective, therapist N.J. explicates the effects of patriarchal society as imposing the need to reduce women's appetite for both eating and sexuality, that is successfully achieved through the subjugation of women.

Feminist therapist N.J. continues:

“So in a very subtle way, I think women's power is thought of by the whole society I think as very frightening in the image of this huge devouring mother, where and which everyone comes from and somehow everyone is scared of that and wants to push that image away, so that it would get reduced in size, they want to reduce their power, feel bad about their power, feel bad about their needs, feel bad about depending. And how that then ties into the mother- daughter relationship and working with that on a very personal basis in therapy.

I understand it as being passed down, generation to generation, and that I, as a therapist and as a feminist therapist, it is my job to somehow try and enable that woman through my relationship with her to understand how she is re-enacting this with her mother to somehow try and get her out of that a bit, but also to put it in a context in a very subtle way of the society to help her to understand that she is not this isolated being.”

In N.J.'s extracts the symbolic dimension of anorexia nervosa is a dram related to women 's social position and played out within the mother-daughter relationship. Because of the focus on the mother-daughter relationship I asked N.J. the following question: What do you think about the criticism of this approach because it seems to blame the mother for the daughter's conflict? She replied:

“I don't really blame them. You see I think this is very interesting the word 'blame', and a lot of my clients can't talk about how their mothers treated them because they are so scared of blaming them, and it's like remove the word blame, well this is what happened and no one is ready to blame but let's look at your feelings about what happened.

I see anorexia as being literally a self-imposed starvation. I mean there is all sorts of physical symptoms that come with that which I don't necessarily ask a woman about or look for, I mean, like the menstruation stopping. I mean I suppose I just look for when a woman is obviously starving herself. I see this as being like a continuum. I see anorexia as being the most extreme in the sense that I think the woman is very much cut off and trying to make some kind of, trying to build herself a completely self-contained world, so that she doesn't need anything from anyone else, but of course, her dependency needs are enormous and so she creates a situation so that eventually she probably gets hospitalised or she then gets herself into a situation where she actually has to be looked after by other people round the clock. Then I would see the movement bulimia as being the point at which actually she can't deny any longer and so bingeing breaks out. I would see a movement into bingeing and vomiting as progress and also that would also symbolise capacity for her to actually take things in, relationship wise, so that if she started to come to see me as a therapist then her movement and bingeing would also symbolise her capacity to relate to me and that something has penetrated her from the outside world so to speak.”

N.J. describes how a woman 's symbolic use of food involves a continuum of eating disorders. Anorexia nervosa is at one end of the spectrum and symbolic of unmet needs and the self-imposed isolation from the woman's need to ask for anything and draw attention to her needs when in fact she has enormous needs. Bulimia nervosa is construed as movement, and 'vomiting as progress. . . that would also symbolise capacity for her to actually take things in, relationship wise'. In contrast to the construction of anorexia nervosa through symbolic interpretations and a continuum of eating disorders, psychiatric discourse constructs these disorders as separate conditions and categories. A patient who is diagnosed as suffering from one category may have symptoms of another, but they are not generally considered together. Interestingly, N.J. constructs bulimia nervosa as being a 'progression' in the woman's development.

Health care workers' accounts constructed anorexia nervosa in ways that avoided specifying a causation. The various strategies that health care workers' used were 'not knowing' the cause of anorexia nervosa, with an emphasis on '1 don't know if anyone knows' as an appeal to the overwhelming nature of the problem. Anorexia nervosa was constructed in terms of a multifactorial causation or model, or a list of the possible causes, including hormonal dysfunction, genetic, socio-cultural pressures and family dynamics. Terms such as 'may' or 'could be' were used to describe and play down the biological bases of anorexia nervosa. The status of anorexia nervosa as being 'complex' was a key justification for 'not knowing.'

Also anorexia nervosa was constructed in terms of its status as a psychiatric condition, that involved various characterizations of psychiatric categories in order to compare the symptoms rather than the causes. For example, perceptual distortion, a symptom of anorexia nervosa, was compared with paranoid delusion and psychotic conditions. The construction of causation and symptomatology of anorexia nervosa through multiple dis- courses creates and maintains the status of anorexia nervosa as a 'complex' condition. This complexity has the effect of justifying the investigation of new ideas about causation. These investigative or other practices will be consistent with the discourse within which the ideas emanate, and in the instance of psychiatry, take the form of investigating the responsiveness of anorexia nervosa to anti-psychotic medication. In contrast, feminist therapist, N.J., constructed anorexia nervosa in terms of a symbolic interpretation of women 's unmet needs. Feminist discourse was structured in this account in ways that involved broader social and political dimensions of anorexia nervosa, yet, like medical and psychiatric discourses, brought women within the clinical and therapeutic arena for treatment of individual psychology.

All the health care workers drew on the separation between individuals and social practices. In medical and psychiatric accounts of the causation of anorexia nervosa there is an assumed and individualised psychopathology/psychology of the patient where socio-cultural factors, such as the family arena or social pressures, are external influences. The separation between individual and society and anorexia nervosa is particularly problematic. While there is a shifting consensus from various disciplines towards the social explanation of anorexia nervosa there is a lack of social theorisation within medical psychiatric and feminist discourses about changing therapeutic practices. Social factors are regarded as influences on the individual that cause distress and psychological dysfunction. Further to this, the management and explanation of anorexia nervosa are continually bound together within medical discourse because the physical complications arising from malnutrition require necessary medical assistance. The confusion surrounding the primary or secondary onset of physical symptoms within medical discourse continues to complicate the socio-cultural explanation of anorexia nervosa. A major consequence of this is that while anorexia nervosa continues to be managed by the medical and psychiatric professions social explanations and practices remain on the periphery.

From Hepworth, J. (1999) The social construction of anorexia nervosa, London: Sage Publications Inc.

Chapter 6: Clinical treatments for Anorexia Nervosa

Extract from the Eating Disorder Inventory

1 = Always, 2 = Usually, 3 = Often, 4 = Sometimes, 5 = Rarely, 6 = Never

1 I eat sweets and carbohydrates without feeling nervous.

3 I wish that I could return to the security of childhood.

50 I feel that I am a worthwhile person.

(From the Eating Disorder Inventory, Garner et al, 1983)

I critically examined the emergence of the clinic and modern hospital in Chapter 1 and the way in which the hospital facilitated the medical and psychiatric management of anorexia nervosa. This form of institutional management of anorexic women remains today although the restructuring of psychiatric services during the 1980s has created a shift in policy away from hospital care towards 'community care'. Women and men who refuse food to varying extents and have significant weight loss, after no organic causation is found, may be diagnosed with anorexia nervosa. Most commonly this diagnosis is based on the classification of anorexia nervosa provided in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders IV (1994). Those with less severe weight loss are also managed through the hospital as outpatients, yet, like inpatients, their weight loss is clinically monitored and severe loss remains the major criterion for admission to hospital.

The range of health care workers who are involved in the clinical management of a person diagnosed with anorexia nervosa, commonly include two or more of the following: general practitioner, consultant/psychiatrist, psychiatric nurse, psychologist, social worker, dietician and counsellor. Medical practitioners authorise the type of clinical management, determine referral processes, treatment interventions, and hospital admission and discharge. However, the diagnosis and clinical management of anorexia nervosa is not a simple reflection of medical procedures rather, these procedures are constructed in specific ways and position the person who is diagnosed as a subject of institutional practices. I was interested in the construction of clinical practices and ways in which institutional structures, such as the hospital, continued to facilitate the management of anorexia nervosa and the effects on patients. During the interviews health care workers provided descriptions of their clinical practice that related to three main areas; (1) hospital admission and procedures, (2) therapies, and (3) recovery, and their accounts demonstrate the ways in which the clinic is maintained as a key site for treatment.

Hospital admission and procedures

Severe weight loss precipitates the admission of a person to hospital and the diagnosis of anorexia nervosa. The general practitioner, hospital physician and/or a psychiatrist make the diagnostic decision. Hospitalisation can be voluntary or, for example, in the UK involuntary hospitalisation is secured under the 1983 Mental Health Act. In the following accounts two psychiatric nurses construct clinical treatments for anorexia nervosa characterised by two main objectives: observation and assessment of patients and establishment of weight gain. Nurse X. describes the admission of anorexic patients.

“Well, when they come in they're usually assessed for the first few days to take a baseline really, . . . all their behaviour, their eating behaviour especially, to see how much they eat, when they eat, and things like moods and sleep. Then, after that. . . we usually draw up a menu. . . . I mean food is a central part of their treatment and they draw up menus of things that they like and dislike. Then, they're usually isolated in a room. . . the bathroom doors are locked, someone sits with them 24 hours a day. . . special nursing it's called. . . and they start off with small portions and the portions get bigger. It starts off with three light dinners, then the portions and the meals themselves get more substantial as they improve.”

Basically it revolves around getting them to eat and getting them to keep the food down because apparently they. . . the consultants' main worry is the deviousness of them. . . . Because they claim that they're devious and somebody needs to sit with them after they've eaten at least for one hour afterwards. . . because they will regurgitate this food or they take laxatives or they'll exercise, you know, burn off this, all this food. The main emphasis in the treatment really is to get them to keep food down, to get them to put on weight and weight gain is a measure of success of treatment really.”

Anorexia nervosa is constructed as a problem of weight loss and the hospital treatment programme is structured in ways that facilitate patients' weight gains. On admission to hospital, as Nurse X. described, 'they're usually assessed. . . all their behaviour, their eating behaviour especially', 'we draw up a menu', '1 mean food is a central part of their treatment'. While the main focus of treatment is on the patient's increased food consumption, 'getting them to keep food down' is presented as a major problem. The notion of 'special nursing' is introduced and has a range of functions that revolve around surveillance including, and for obvious reasons, monitoring severely low weight patients. However, the practice of surveillance is based on the health care workers' distrust of anorexic patients because they are 'devious', 'they will regurgitate this food or they take laxatives or they'll exercise'. The nurse also becomes a subject of this representation of anorexics by having to carry out practices to prevent them from not keeping food down, or as punishment for their deceit. The practices described as follows, 'they're usually isolated in a room. . . the bathroom doors are locked, someone sits with them 24 hours a day', are justified in these accounts because patient characteristics are presented as being inherent to a psychopathology of anorexia nervosa.

The emphasis on food and weight gain is characterised by a psychological struggle between these nurses and patients. Psychiatric Nurse T. describes her work with an anorexic woman:

“. . . with the anorexic patient, or a patient with an eating disorder, we tend to find that even though we do work on the primary nurse system we have to keep the other staff totally informed of every development, because we found that manipulation is a particularly difficult aspect. There was a lot of manipulation, hence we found one girl to have kidney beans at the bottom of her locker, raw kidney beans which she fed herself on, 'cause it's a good, you know, laxative. Also, sending other patients down the shops for laxatives, having loads and loads and loads of fruit and bread, bingeing at night in order that she could be weighed the next day so that she would gain the weight she'd have a bottle of Perrier water plus a loaf of bread the night before a weigh. Hence we had to make sure that we had different weight days. We could never tell her when she was going to be weighed. So you always come across these conditions which you're never really prepared for as a nurse, you just can't think ahead of them so you've always got to think, come across them and then have to eradicate the problem like we do. . . . You would have to sit her down, ask her why, if she'd got any more. . . search her room with her and another nurse, . . . with her permission, if, you know, it's. . . it's very difficult, especially as that time, sort of, building up a relationship with her and then you've got to do that.”

Clinical treatment is defined by the antagonism between the nurse and patient in which there is a struggle over weight gain, eating, and 'keeping food down'; the antithesis of anorexia nervosa. Nurse T. describes how this treatment regime is practised and is again justified in terms of the patient's characteristics, 'because we found that manipulation was a particularly difficult aspect'. The vivid description of 'one girl' who had 'kidney beans at the bottom of her locker' reinforces the difficulty of patients that the nurse works with as well as the implications that this has for the nurse in building a relationship with the patient. The focus on food and weight gain constructs an elaboration of eating rituals, food avoidance, weight gains and surveillance that is structured through hospital procedures and clinical goals.

Therapies

Two forms of therapy are used with anorexic patients; naso-gastric feeding/drugs and/or psychotherapy. The clinical focus on patients establishing weight gain is highlighted in the following accounts where the practices of patient bed rest, to minimise the expenditure of calories, and behavioural therapy are presented by psychiatric Nurse T:

“Well, I’ll take the one recent case. What we did for her, which was probably best really. She was extremely underweight. . . . She really wasn't eating adequately so we made sure a nursing point of view, monitoring her weight initially. We liaised with the doctor. The doctor was quite firm, took the firm approach really, because she was literally on death's door. If she'd lost any more weight then she'd end up in - Hospital being tube-fed. We've never tube-fed here, as such, what we were doing was saying look, you know you've got to rest. So she had a single room. We confined her to that room. She rested on her bed for the majority of the time. She only came out for eating. . . . She, she was occupied, but didn't really restrict her movements too much, we just didn't like her moving around too much 'til she gained the weight. We liaised with the dietician to make sure that she got high protein foods. She was prescribed Fortical. . . . She was prescribed all sorts of vitamin tablets. She had Build-Up at regular intervals. She had snacks and the kitchens were very good. We had to liaise with the kitchens in order that they could bring special food.”

In this account the nurses' practices are presented as a result of a physician's decision about treatment, 'the doctor was quite firm, took the firm approach really, because she was literally on death's door'. The patient is isolated, her movements restricted and she is fed milk-based meal replacement drinks such as 'Fortical' and 'Build-up'. The 'firm approach' is one characterised by practices focused exclusively on weight gain and control of the patient, 'so she had a single room', 'we confined her to that room', 'we just didn't like her moving around too much 'til she gained the weight', and in which the patient is positioned as a passive recipient of this clinical regime. Nurse T. continues:

“From there, once she had gained the weight and we knew she had a target weight. She knew the weight she had to gain, she could come out more and she liked that better. She could move around the ward. So we were acting on like a reward basis really. Once she could move around the ward, then we had another target weight when she could go down to the telephone and. . . . If she didn't reach this couple of pounds target weight then that privilege would be taken away. And she did strive to gaining, say, a healthy, reasonable weight. She didn't improve drastically, but it was healthier.”

Nurse X. elaborates on the reward system:

“If they put on weight they can have certain privileges, like, if they put on, say 4-5 lbs by the end of the week then they're allowed to go home for the weekend or they're allowed to do something that they like doing.”

The behavioural approach to the treatment of anorexia nervosa is based on the most simplified form of conceptualising human actions. A person is housed in an environment of deprivation only to make additions to this state through compliance with designated rules. A system of privileges and rewards is offered to the patient for exhibiting specific behavioural goals, in this instance those being food consumption leading to weight gain, but these rewards are then withdrawn if an observation of non-compliant patient behaviour is made. The relationship between the nurse and the anorexic woman is structured vis-a-vis weight gain, 'she knew the weight she had to gain, she could come out more and she liked that better. She could move around the ward. So we were acting on like a reward basis really', in which the patient becomes isolated, observed, measured and governed, according to a schedule of clinically determined goals. 'Once she could move around the ward, then we had another target weight when she could go down to the telephone and. . . . If she didn't reach this couple of pounds target weight then that privilege would be taken away.'

The hospital structures the treatment of patients around food and weight related behaviours as individual entities and in doing this drastically limits the type of information and knowledge that both clinicians and patients draw on to make decisions about food, weight, and body size. These practices allow for the monitoring and intense surveillance of the patient, yet simultaneously displace the complexities and breadth of the patient's life.

One of the greatest obstacles to the adoption of a behavioural approach is the patient's agreement. The 'contract' is a common means of introducing the patient to treatment as psychiatrist, Dr P., describes in his account:

“I mean, if they were seriously, very much underweight and any physical activity was going to be detrimental then obviously we would have to have a contract whereby they actually did remain in bed, and that their meals were supervised. I mean, certainly I do believe in the contract basis because I think that it's very, very difficult to engage any anorexic in. . . treatment. They are usually extremely resistant to any kind of treatment and so I think that the contract is one way of trying to. . . let them know that they can have choice in what. . . or not.

. . . t would be based on behavioural methods whereby they would be rewarded and obviously we have to find out what sort of things they like, in terms of activities, or in terms of. . . foods, or, you know, something specific that they really enjoy doing or having. . . and that, you know, can be built into the whole contract contingent on weight gain. They do need to understand that ...not so contingent on eating meals, but contingent on gaining a certain amount of weight which is agreed with them. . . beforehand.

One thing. . . maybe I should mention. . . . The one thing that I have come across in common with most of the anorexics is. . . resistance to whatever you have to offer. I think if you can overcome that resistance. . . working with them it is much easier, but resistance is something I've found in common to all of them and rather difficult to overcome. . . and if you had a way of overcoming that, if there was a simple way of getting over that initial, . . . then treatment would become much easier.”

Nurse T.:

“She always knew what she was striving for, what goal we had and it was always a goal which was discussed with her. We said four pounds and she felt it was unrealistic then we would try and come to a happy medium, 'cause it's no good if she didn't agree.”

Clinical treatment is presented as being underpinned by the notion that a patient has a choice about its course and is agreed upon through the use of the contract. 'They are usually extremely resistant to any kind of treatment and so I think that the contract is one way of trying to. . . let them know that they can have choice in what. . . or not.' The difficulty of working with anorexics is emphasized in these accounts through their representation of being 'resistant'. Of course, the 'contract' only works with 'compliant' patients and dilemmas arise when a patient will not enter into any negotiation about weight gain. This approach compresses a number of moral, social and ethical aspects of clinical interventions into a form whereby patients are evaluated in terms of the framework of normative behaviourism. The use of the contract thereby reduces the complexities of anorexia nervosa and its treatment to a model of human behaviour where the complications become replaced within the clinic by a set of requisite conditions that need to be met for a successful outcome. Resistance to treatment as demonstrated in these extracts presents a profound dilemma for the medical profession when the patient is at a very low body weight and at risk of dying.

Psychiatrist, Dr H., describes the time when a physician has to decide about whether to intervene with a re-feeding programme, and introduces the problematic issue of 'naso-gastric' or 'force-feeding':

“Very severe cases with gross weight loss which could be almost life-threaten- ing at that stage I'd prefer to treat them on a medical ward with the help of a physician. . . there the emphasis would be on the patient regaining some of the weight that has been lost. . . and at that stage maybe more psychological forms of treatment can be undertaken, but, initially the primary concern would be to get some weight back on so that it doesn't lead to more physical problems.

. . . it may even be intravenous nutrition at some stage where. . . they are not given oral food or nutrition and. . . also orally a strict regime, sometimes even by gastric feeding to get their weight back to normal, back to some sort of acceptable level.

. . . it may even be tube-feeding with some very severe cases, but generally that may not be necessary. They will be able to eat under supervision and regain their weight, but I'm talking about extreme cases where they may need tube-feeding, yes.”

Dr H. talked about acute cases of anorexia nervosa when the use of tube feeding is considered. The objective of tube feeding was for him to: 'get some weight back on' to avoid 'more physical problems'; get weight back to 'some sort of acceptable level'; and to be used with 'extreme cases'. The patient's weight, in these extracts, is clearly pivotal for Dr H. choosing a treatment option. The separation of very low weight anorexics from others also involved a demarcation between the psychiatrist and when he worked with a physician.

Psychiatrist Dr P. talks reservedly about tube-feeding:

“If it were that bad then they would clearly need to be in. . . a medical unit. . . but actually I would have grave doubts about pushing the whole tube-feeding business. I think that it isn't very easy, it isn't easy, to sort of watch someone starving themselves. . . but, equally, how much of. . . force-feeding, as it were, is actually going to help them to see things differently. I don't know there's a major, sort of, ethical and moral aspect to this and I don't have any . . . answers to it. There's obviously many different views on it.”

In contrast to Dr H., Dr P. introduced the ethical and moral aspects of force- feeding and expressed reservations about its use because he does not know to what extent this practice affects the patient's thinking about eating, whether it will help, 'them to see things differently', and its use in this account is not only related to the clinical imperative of patient weight gain. The administration of force-feeding is also presented as an ultimatum given to patients who are at risk of losing more weight as Nurse T. describes:

“She came here on the understanding that if she lost any more weight then she would go to - Hospital and be tube-fed or she could accept help and come as an informal patient here and more or less have counselling. . . . “

Here, force-feeding is used as an instrument of punishment, as the most severe intervention, if the patient lost any more weight. The patient's acceptance of the clinical alternative, 'counselling', is presented as a way of preventing this from happening to her, and 'she could accept help and come as an informal patient'.

One psychiatric nurse explained to me outside the interview that thirty five kilos and below was proposed as the working definition of when an individual's life was considered as being under threat from starvation. At this weight a medical practitioner is able to enforce compulsory treatment in the UK by 'sectioning' an individual under the Mental Health Act, 1983. With the authorisation of a medical officer the patient can be legally held within a psychiatric/general hospital for 72 hours and given treatment ranging from drugs to one prescribed treatment of electro-convulsive therapy.

Recovery

Within the clinic weight gain is the most significant treatment outcome. The measurement of recovery is relative to the establishment of weight within an approximate range for age and height, as well as the duration of its maintenance. The notion of recovery from anorexia nervosa is complex. In the clinic recovery from anorexia nervosa involves a major distinction between short term and long term outcomes. Psychiatrist Dr H. states:

“I think. . . in long-term recovery or the long term it has generally been not very good. . . . In the immediate, if you look at maybe their putting the weight back on or doing well for the short term, yes, it's been reasonable, with various strict regimes. But, in the long term, I think it's generally been disappointing.”

Clinical Psychologist Dr M.:

“I certainly have been involved in the sort of analysis of. . . some people who have presented with problems of anorexia but my success rate on it I think is . . . fairly low. I found that either people tend to drop out of treatment or haven't been particularly responsive to the kind of approach that I've adopted . . . which has made me a little bit pessimistic in parts l guess. . . .”

In these extracts two possibilities about recovery from anorexia nervosa are proposed, one that confirms the poor long term outcome of recovery, the other is linked to people tending to 'drop out' or 'haven't been particularly responsive to the kind of approach' adopted by the clinician. The lack of treatment success is not presented clearly as a problem of the limits of treatment. In the extract below Dr H. is responding to my question about whether any patients had died.

“No, not any of mine. No. No. That is generally because of other complications because quite a few of them seem to have other difficulties. There are other problems. . . deliberate self-harm apart from anorexia, depressive illness coinciding with anorexia. So, I think even when that happens it's, it's maybe because of other complications, other co-existing problems.”

Dr J.'s, a general practitioner, response to this question was:

“I mean, anorexia is life-threatening. I've known a patient die of anorexia when I was at the - Hospital. They had someone die. . . If you, if you don't take, . . .you know, you'll lose them.”

Dr H.'s talk about fatality and anorexia nervosa uses a strategy that separates the possibility of death from anorexia nervosa by attributing examples of fatality to other complications, 'other problems. . . apart from anorexia', 'other co-existing problems' and not as a result of anorexia. Anorexia nervosa, in this example, is constructed like earlier examples in such a way that maintains a separation between it and other problems or psychiatric categories. In contrast to this Dr J. talks about death from anorexia nervosa being a very real possibility. However, both medical practitioners, having many years' experience, gave no account during the interviews of any complications arising from the management of anorexic patients, particularly in relation to the practice of gastric feeding or when there is no patient consent to treatment. Further to this, Dr J. decided to provide more detail to me when the audio tape-recorder was turned off, and I was taking only field notes. Dr J., described the complications that had arisen from tube-feeding one of his patients that he had mentioned earlier. She had weighed approximately twenty nine kilos on the commencement of tube-feeding. She had not eaten regular meals for a very long period of time, and was used to surviving on small intakes of food and drinks. On her admission to hospital she was prescribed naso-gastric feeding with a high calorie milk based food substitute which caused gastric and intestinal complications and was shortly followed by her death. The expression of this detail is significant due to the practitioner's choice of timing when to speak about his patient, and his accompanying sadness as he recalled this young woman.

By examining these accounts I have shown the ways in which health care workers construct their clinical practices and the various strategies that are used to justify, maintain, and reproduce clinical treatments for anorexia nervosa. The hospital admission and procedures reproduced a regular system of clinical observation and surveillance practices that were presented as being particularly necessary with anorexic patients. The key focus of clinical treatment was the establishment of weight gain. The practice of introducing small amounts of food to patients, that were slowly increased, coupled with bed rest, demonstrate the continuation and maintenance of late nineteenth century clinical practices within the modern hospital previously discussed in Chapter 2.

The severity of weight loss was a key factor in the psychiatrists' decision to transfer the patient to a medical ward or physician. The severity of a patient's weight loss was emphasized through reference to, 'if it were that bad', 'extreme', and 'severe' cases, and this decision also involved ethical and moral aspects for the clinician. The hospital maintained a link between medical and psychiatric discourses through the need to transfer patients for expert management in gastric feeding programmes. The threat of the patient dying underscored the need to refer to a gastric feeding programme, and like behavioural programmes, the isolation and confinement of patients, and searching of their rooms, presented difficulties and dilemmas to health care workers within the therapeutic relationship.

Anorexic patients become subjects of the practices of surveillance because of the clinical objective of establishing weight gain. These practices, referred to as 'special nursing', involve a nurse's continuous observation of a patient because of her 'unpredictable behaviour'. This practice has similarities with late nineteenth century 'moral attendants' who sat beside the bedside of women patients. The surveillance of anorexic patients is accepted as being necessary because of their need for salvation, whether that need derives from earlier ideas about women's fall from 'moral rectitude', and vulnerability to nervous diseases, or later ideas of women's susceptibility to develop specific psychiatric disorders, such as anorexia nervosa. Anorexic women are characterised by their 'resistance', it is 'one thing in common with all the anorexics', and contrasted with the practitioners' attempts to treat them. This representation of women functions as a clear justification for clinical interventions in which health care workers are positioned as having both the institutional authority and expertise to effect change.

References

American Psychiatric Association (1994) Diagnostic and Statistical Manual of the American Psychiatric Association, fourth edition, Washington, DC: American Psychiatric Association

Garner, D.M., Olmstead, M.P. & Polivy, J. (1983) The development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia, International Journal of Eating Disorders, 2, 15-34.