Über die Autorin bzw. den Autor

Helen Gremillion is Assistant Professor and Peg Zeglin Brand Chair in the Department of Gender Studies at Indiana University, Bloomington.

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"Many have sensed that anorexia makes visible in some way pathologies that are particular to liberal consumer society, but few have grasped its nature and significance as acutely as Helen Gremillion. Her account is as compelling as it is compassionate."--Jean Comaroff, University of Chicago

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Feeding Anorexia

Duke University Press

Chapter One

This chapter explores the ways in which patients diagnosed with anorexia and the clinicians and staff who work with them construe bodies as resources for fitness and health. I situate this corporeal imaginary within advanced capitalist consumer culture in the United States, in which the fit body is an icon for achieving individualism, productivity, and "self-actualization." The crafting of bodies in the treatment process participates in the cultural conditions of possibility for imagining the fit body in these ways and also for the flourishing of eating disorders. Clinicians and staff at Walsh often represent health as an "objective" category, but the ever-negotiated meanings of health on the unit-and the problematic effects of objectivism itself on patients-belie claims that definitions of health are simply the product of a unified "expert opinion" (which is, ideally, to be incorporated cleanly into patients' identities).

I begin with a discussion of how patients' resistance to treatment, which clinicians actually encourage, participates in cultural constructions of feminine fitness that have permeated many treatment programs in the past twenty years. Next I provide a broad social and economic context for understanding the contradictions and difficulties involved in the pursuit of fitness for women and girls in particular. Finally, a case study of one patient's struggles in treatment illustrates the contingent and contested character of bodies and selves in the treatment of anorexia.

"Resourcing" Resistance to Treatment

Patients at Walsh are caught up in discourses of health and fitness in complex ways. They are not only medically stabilized through weight gain and engaged in therapeutic discussions about the psychological meanings of anorexia but are also directly enlisted in the reshaping of their bodies according to parameters that are not of their own choosing. Their active participation in this process, and their resistances against it, are analyzed as part and parcel of their therapy. Thus patients' desires and protests, the micromanagement of patients' bodies, patients' lived bodily experiences, and cultural definitions of ideal and pathological bodies are inextricably intertwined.

I first met Sarah in the outpatient clinic, when she was seventeen years old. She had been admitted to the hospital twice in the past, and like many outpatients who are "old-timers," Sarah had learned to hover just above her admission weight, a weight that would medically justify readmission to the inpatient unit. Several clinicians wanted to find another justification for readmitting Sarah to the inpatient ward so that she would comply with a weight gain program. But her psychiatrist, Mark, decided to devise an outpatient plan for her instead, because she was showing a resistance to her caretakers that he considered to be "healthy." Mark pointed out that Sarah was furious, not passive or helpless, about their insistence that she gain weight. According to Mark, Sarah's anger betrayed an investment in the clinicians' designs for her health but also showed that she was not complying by rote. In other words, Sarah was showing a promising balance between compliance and independence, and Mark thought this meant that she was beginning to develop the healthy "sense of self" that she needed to overcome her anorexia. His theory was that as long as Sarah cared enough about her independence to maintain a weight that would keep her out of the hospital, her resistance was a sign that she was capable of developing the desire to gain more weight on her own. Mark's strategy with Sarah was consistent with most clinicians' belief that resistance to treatment can be seen as a form of psychological "work" that locates responsibility with individual patients. On subsequent visits to the outpatient clinic, when Sarah had not gained enough weight for that day (as determined by her new plan), a common refrain was that "she has work to do," and the frequency of her clinic visits would increase (Sarah hated coming to the clinic, so this move was "incentive" for her to gain weight). When Sarah gained the required weight, she was allowed to come to the clinic less often, and as one clinician put it, "She's working hard; this is hard for her. She's doing this, and her whole being is telling her not to." Sarah did gain weight as an outpatient, but it was slow going, and she remained incredibly frustrating to those who believed that she should be admitted to the hospital again.

Most patients diagnosed with anorexia resist gaining weight, and Mark's ideas about Sarah's treatment illustrate how some contemporary approaches to treatment have drawn on psychological theory to respond to this problem. Programs like the one where I conducted my research include various psychotherapies designed to facilitate patients' autonomy. For these programs, the ultimate goal of treatment is not just weight gain but also "self-development" and "self-actualization." Generally speaking, contemporary psychological theory about anorexia suggests that the problem results from an inadequate sense of self and that it functions as a kind of substitute identity that is an overrigid, highly controlled "pseudoautonomy" (Crisp 1996; Garner and Garfinkel 1997). As discussed in the introduction, imposed weight gain only seems to heighten patients' experiences that they are not in control of their own identities. Thus treatment focuses increasingly on creating the desire for health. With this approach, resistance to treatment is often seen as a sign of healthy independence and is even encouraged. Clinicians often draw on patients' resistance as a way to create a desire for health by tapping into patients' extreme devotion to a work ethic. Clinicians use resistance to treatment as leverage for transforming an "anorexic" work ethic into a "healthy" one, converting a relentless striving for weight loss into effort toward weight gain. This focus on patients' independence and self-determination, and even on their resistance to medical authority, appears to allow patients more freedom than treatment approaches that focus solely on weight gain. However, "cutting-edge" psychiatric treatments for anorexia have medicalized and invigorated cultural ideals of feminine fitness, ideals that have informed anorexia's recent increase in incidence. Anorexia exaggerates specifications for feminine fitness, and representations of health as an object of patients' resistance-requiring hard work, bodily transformation, and self-development-also adopt the terms of these cultural ideals.

Before I analyze discourses of fitness within psychiatric practice, let me provide some theoretical context for understanding anorexia in terms of fitness ideals. A number of feminist scholars argue that anorexia crystallizes contradictions that many young women experience in striving for individual achievement through physical fitness. While a slender and fit body signifies autonomy and success for women, it also implies dependence on others' approval. In addition, controlling bodily needs through dieting and exercise paradoxically calls attention to these needs. Anorexia highlights this contradiction; food refusal and compulsive exercising are forms of self-control that continually create the very desires that seem to require control. Of course, dominant cultural representations of fitness obscure this contradiction: fitness naturalizes the values of willpower and self-control by construing the body as a kind of personal natural resource for creating a powerful, fit, and achieving self. At the same time, however, it seems that special efforts are required to create a fit female body. Fitness gendered female is culturally coded as an unending struggle; as I will discuss, women and girls experience a profound contradiction between the injunction to diet in order to create a fit body, on the one hand, and incitements to consume and to serve food, on the other.

Those who live with anorexia experience this problem acutely; every day, they confront a body that appears as an enemy of willpower. Even after patients reach drastically low body weights, they feel compelled to maintain or even intensify their dieting and exercise regimes. Anorexia challenges the idea that achievement comes "naturally" through practices of fitness by revealing that the female body is imagined not only as a resource but also as an obstacle in the pursuit of fitness, an intractable other to an achieving identity. The anorexic's experience of a control paradox reveals this problem with particular clarity: with every "success" in one's efforts to control the body through dieting and exercise, the body threatens a loss of control (Bordo 1993a; Bruch 1978; Lawrence 1979, 1984). Dieting and exercise then take on a life of their own and become overwhelming preoccupations.

Contemporary psychiatric treatments for anorexia participate in the contradictions of feminine fitness by representing patients' bodies and psyches as simultaneously opposed to one another and dynamically interrelated. Clinicians determine biomedical criteria of health, such as specific weights to be reached in a given time period; but at the same time, the ultimate goal of treatment is for patients to work willingly toward these markers of health. In treatment, patients' bodies are managed through a calculated balance of caloric intake and exercise, which is not up to individual patients' determination. But the body is also seen as personalized raw material (a personal "resource") that patients shape and develop in enacting a "will to health." A person who lives with anorexia is already familiar with this contradiction, "willfully" engaging in forms of bodily regulation and control that, paradoxically, highlight and create hungers and needs that threaten this control precisely because they appear to lie outside of it (as "resources" for continued body work).

The psychiatric representation of "the anorexic"-in particular, the anorexic body-as a pathologized object of therapeutic knowledge and practice re-creates the culturally dominant idea that the female body is an obstacle in the making of fitness/health, and it also reinforces patients' perceived dependence on others even as they seek self-control. And just as patients exaggerate the terms of feminine fitness, they often exaggerate the terms of treatment when they are asked to incorporate biomedical criteria of health into their identities. Sarah, for example, understood her admission weight quite literally: she saw it as a cutoff point for how little she could weigh and still stay out of the hospital, where she would be required to gain more than this. Sarah was thereby subverting her treatment plan-using it to support her anorexia-even as she highlighted one literal meaning of her admission weight, reading it as (just below) an acceptable maximum, rather than minimum, weight. This situation raises the question, How do we understand a form of subversion that exaggerates the very criteria that are being subverted? More generally, how do we make sense of the fact that anorexia disturbs discourses of fitness and health without escaping them?

Cultural anthropologist Lila Abu-Lughod (1990) has suggested that resistance is best understood as "a diagnostic of power" (42). This means that resistance is neither located "outside" of power nor merely a predetermined effect of power. This latter idea is compelling in an analysis of anorexia, since resistance through anorexia is clearly self-defeating and because clinicians explicitly condone resistance to treatment as a way ultimately to convince patients to accept health as the treatment program defines it. In my earlier work (Gremillion 1992), I adopted the idea that anorexia is difficult to treat because psychiatric practices reproduce wholesale the specifications of personhood that lead to anorexia and impose these specifications in a top-down fashion. But as I discuss in the introduction, this approach cannot explain patients' resistance to treatment, and it also assumes that these specifications of personhood are totalizing and are fully formed prior to their articulation in practice. My more recent research for this book shows that patients and clinicians help create, and continually negotiate, culturally dominant understandings of subjectivity, embodiment, and health. In both adopting and disrupting treatment practices and protocols, women and girls who struggle with anorexia reveal that discourses of feminine fitness are not pregiven but achieved; even in their dominance, they are unstable.

We can interpret clinicians' encouragement of patients' resistance in this light. Given the lengths to which many anorexic patients will go to resist treatment and their frequent appropriation of treatment protocols to this end, clinicians work with these forms of resistance and even interpret them positively. For example, because patients' weight and calorie intake are monitored so closely, it is no surprise to clinicians that patients will try to take back control over these intimate details of their lives that they have worked so hard to master. Although most clinicians argue that patients cannot simply be left to their own devices in these matters (because they may continue to lose weight and even risk death), patients cannot be expected to give up control over their bodies completely, or they will never learn to care for themselves outside the program. So clinicians consider resistance that incorporates the terms of treatment progress, as the following case study illustrates.

One sixteen-year-old inpatient I knew well, who asked to be called Maude Evans, agreed that she should gain weight but had difficulty doing so, and she thought that her weight criterion for discharge from the hospital was set too high (by less than half a pound). She told me that she planned to lose this much weight once she got home so that she could regain it her "own way." A member of the nursing staff remarked during rounds one day that Maude's attitude was a good sign, because she had entered the so-called legalistic phase of treatment. This phase extends over most of any given patient's history with the treatment program. A psychiatrist in the program explained treatment phases to me: "At first, patients are mousy and compliant. Then they become very legalistic, arguing the fine points of their programs and resisting you tooth and nail. Finally, they start getting better, because they decide that it's not worth their time to hang out in the hospital and talk to us." In this view, nurturing patients' resistance to treatment protocols is the bread and butter of therapy.

I first began to understand that patients' resistance is not a matter of rebellion or "manipulation," as some treatment programs today (and most programs prior to about 1980) would represent it, after getting to know Maude over the course of several hospital admissions and through a series of interviews. But neither was Maude's resistance simply a self-conscious assertion of willpower, a sign of progress toward a healthy self. Maude showed me that patients' resistance to treatment was less a sign of therapeutic "progress" than it was an indication of contradictions within psychiatry that can be used to support anorexia, contradictions that shed light on the psychiatric production of bodies as resources for self-transformation.

Continues...

Excerpted from Feeding Anorexiaby Helen Gremillion Copyright © 2003 by Helen Gremillion. Excerpted by permission.
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