Last modified: Tuesday, September 16, 2003
Conventional anorexia treatments challenged by IUB professor in new book
Procedures can reinforce what they try to remedy
In her new book Feeding Anorexia: Gender and Power at a Treatment Center, Helen Gremillion, the Peg Zeglin Brand Chair in Gender Studies at Indiana University Bloomington, argues that mainstream treatments for anorexia nervosa can actually exacerbate the problem.
Feeding Anorexia challenges prevailing assumptions regarding the notorious difficulty of curing anorexia nervosa, a practice of self-starvation, often coupled with rigorous exercise, occurring primarily among girls and young women. Through a vivid account of treatments at a state-of-the-art hospital program, Gremillion reveals how therapies participate unwittingly in ideals of gender, individualism, physical fitness and family life that have contributed to the dramatic increase in the incidence of anorexia in the United States since the 1970s.
She describes how treatment strategies, which include the meticulous measurement of patients' progress in terms of body weight and calories consumed, ultimately feed the problem, not only reinforcing ideas about the regulation of women's bodies, but also fostering in many girls and women greater expertise in the skills anorexia requires.
"The patients in the program I studied are required to have an exact calorie count every day. There is also detailed attention to even very small weight gains and losses," Gremillion said. "Of course, any treatment program must devise ways to encourage eating and weight gain, but I argue that such careful attention to the numbers plays right into anorexia's hands. The focus of the treatment takes on a life of its own to the extent that it ends up reinforcing the problem."
Gremillion argues that anorexia intensifies dominant ideals of femininity in contemporary U.S. society. She adds to existing literature on this topic by showing how treatments for anorexia can perpetuate these ideals as well.
"Young women today are expected to carefully monitor their consumption of food, and people who struggle with anorexia are caught up in this ideal with particular intensity. Treatment programs that don't recognize this cultural pressure can contribute to it when they require patients to monitor their body size very carefully," Gremillion said. "The goal of weight gain vs. weight loss in treatment pales in comparison to practices of self-control and self-surveillance that both anorexia and mainstream treatments for it require."
"It's a controversial claim since I'm not a mental health practitioner," added Gremillion, a specialist in gender studies, cultural and medical anthropology, and U.S. popular culture. "I'm a disciplinary outsider looking at the treatment of anorexia from a gender studies and anthropological standpoint. This book might appear to be a negative critique, and it does take a critical stance on the standard therapies which I believe feed anorexia. But I don't make the claim that mental health practitioners are consciously trying to feed anorexia. Instead I try to focus on the prevailing assumptions and attitudes that many people have that end up contributing to this very serious problem."
Feeding Anorexia is based on 14 months of ethnographic research in a small inpatient unit located in a major teaching and research hospital in the western part of the United States. Gremillion attended group, family and individual therapy sessions and medical staff meetings; ate meals with patients; and took part in outings and recreational activities. She also conducted over 100 interviews with patients, parents, staff and clinicians.
In her book Gremillion describes a typical day at the treatment center, which is heavily structured around eating and the careful measurement of calorie intake and body weight. In this strict environment, the author discovered that many patients developed various "tricks" to avoid eating and weight gain such as water-loading (drinking extra water to engineer the appearance of a higher body weight) or hiding weights on their bodies before stepping onto the scale. The author also learned that the center had developed several practices in response to these patient techniques, such as measuring the density of patients' urine as a way to detect water-loading and conducting random weight checks, which were called for when a patient was suspected of hiding weights.
Gremillion argues that these practices, while meant to be deterrents, actually underline these various tricks as resources that patients who are resisting treatment can use to continue anorexic practices.
Additionally, Gremillion describes mealtime as a strange and often tense environment in which many patients spend most of their time calculating and recalculating their calories for the day as a way to delay eating. In response to this common occurrence, the hospital instituted a heavy degree of surveillance to ensure the patients would eat the required amount of food.
"The problem with this whole environment is that it's all about power and control," Gremillion said. "On the one hand, you have a hospital that is very meticulous in calculating how many calories these girls are consuming. On the other hand, you have the patients who spend entire meals adding the numbers, as a form of resistance to treatment. Then you have the heavy surveillance, which contributes to a feeling the girls already have that everyone is looking at them. Again, it's a case of the current treatment feeding the problem. In essence, the treatment is recreating the struggles that patients are already dealing with."
Gremillion said that the treatment program she observed was designed to serve as a substitute family for patients and that parents were expected to distance themselves from their daughters' struggles with their bodies by encouraging "separation and individuation." In the current setting, parents are given very little information about their daughters' progress in treatment, so that staff and clinicians can work to "break" destructive patterns of behavior in families.
The author argues that the treatment team's attempts at corrective parenting and creating a "therapeutic family" can actually perpetuate the problems in families that clinicians diagnose. In particular, she argues that cultural assumptions about ideal motherhood that are deeply embedded in our society form part of the context for both illness and treatment. The message to mothers is to "back off" and stay out of their daughters' lives. Yet mothers are also expected to know how to love and care for their daughters. Mothers are caught in a Catch-22 about caretaking that, Gremillion argues, is part and parcel of the problem. Interestingly, fathers manage to escape the harsh criticisms frequently leveled at mothers, who are often cited as the cause of their daughters' problems.
"One mother was actually told to love her daughter and leave her alone. How do you perform this type of minimal mothering when you are culturally mandated to be a nurturer and the primary caregiver of your family?" she asked. "I argue that assumptions about motherhood have shifted (since the 1950s and '60s), but have not radically changed."
As for fathers, Gremillion said they are expected to be a part of their daughters' lives, but are often let off the hook if they choose to be distant from them. The choice to be involved is "extracurricular," Gremillion said, "and some people are inadvertently pleased if the dads are distant and removed because it's thought that they'll be able to help the mom find a necessary distance."
In the book, Gremillion addresses several other issues pertaining to the mainstream treatment of anorexia and her time spent within the hospital, including:
-- The challenges she faced as an observer of the hospital program and how clinicians, patients and their families responded to her presence. She also discusses her reaction to being labeled by some doctors as a "soft scientist."
-- Why most patients diagnosed with anorexia are white and middle-class.
-- The characteristics that, according to clinicians, distinguish those patients who are diagnosed with borderline personality disorders from more "normal" patients.
-- Her caution about the classification of anorexia as a disease.
-- The relationship between anorexia and femininity and how current treatments account for this relationship.
-- The relationship between anorexia, its treatment and ideals of physical and mental "fitness" in contemporary consumer culture.
-- The "revolving door" phenomenon of multiple repeat admissions.
-- A movement toward more outpatient and partial hospitalization services to treat anorexia.
-- The ways in which relationships among doctors, nurses and psychologists can recreate the problems diagnosed in so-called "anorexic families."
While Gremillion admits she doesn't have a quick and easy solution to curing anorexia, she supports alternative treatments such as narrative therapy, which she writes about in her book. She believes narrative therapy has the potential to dismantle some of the problematic assumptions underlying more mainstream treatments. "Narrative therapy de-pathologizes problems like anorexia and depression," she said. "It gets away from absolute distinctions between normal and abnormal by locating problems in their political and social context. The idea is to 'narrate' an illness experience or a stressful experience in such a way that problems are separated from clients' identities, so that clients can begin to imagine a sense of self that is not taken over by a given problem."
For example, a narrative therapist might ask a client who struggles with anorexia, "Who formed the idea that women and girls should be a certain size?" and "How do you think anorexia gets people to go to their death beds smiling?" Gremillion said that "these kinds of questions allow people to gain a critical perspective on anorexia without having to indict themselves for participating in anorexic behaviors. Self-scrutiny and self-regulation often just make the problem worse. But narrative therapy is not about removing responsibility from individuals. Rather, it opens up new possibilities for action against problems like anorexia, which many acknowledge is very complex and is culturally and historically specific."
Feeding Anorexia: Gender and Power at a Treatment Center, published by Duke University Press, will arrive in bookstores this month. To schedule an interview with Gremillion, contact Ryan Piurek, IU Media Relations, at 812-855-5393 or rpiurek@indiana.edu.
