Famished

Eating Disorders and Failed Care in America

Rebecca J. Lester

• Editorial: University of California Press
• Año: 2019
• ISBN:
  9780520972902
• Edición: 1
• Categoría: Scienze sociali
• Categoría: Antropologia culturale e sociale

When Rebecca Lester was eleven years old—and again when she was eighteen—she almost died from anorexia nervosa. Now both a tenured professor in anthropology and a licensedsocial worker, she turns herethnographicandclinicalgaze to the world of eating disorders—their history, diagnosis, lived realities, treatment, and place in the American cultural imagination. Famished, the culmination of over two decades of anthropological andclinicalwork, as well as a lifetime of lived experience, presents a profound rethinking of eating disorders and how to treat them. Through a mix ofrich culturalanalysis, detailedtherapeuticaccounts, and raw autobiographical reflections, Famished helps make sense of why people develop eating disorders, what the process of recovery is like, and why treatments so often fail. It's also an unsparing condemnation of the tension between profit and care in American healthcare, demonstrating how a system set up to treat a disease may, in fact, perpetuate it. Fierce and vulnerable, critical and hopeful, Famished will forever change the way you understand eating disorders and the people who suffer with them.

SECTION THREE

Dynamics

In section 1, we looked at how eating disorders are constituted as objects of concern and as the target of specific kinds of intervention. In section 2, we encountered two distinct models of care that come together at Cedar Grove and the kinds of frictions that arise from their competing chronographies, different notions of the will, and divergent ethics of care. We saw in the case of Caleigh how these opposing ways of figuring the patient and the problem could lead to acts of “care” that look like—and feel like—harm and actually provoke the very conditions they are supposed to treat.

The process of recovery within Cedar Grove is meant to move clients out of a state of coagulated being or impasse and into one of growth and change, mobilizing them on a trajectory with both physical and emotional dimensions. In this regard, treatment is a distinctly developmental process in both scope and structure, as clients ideally transform from locally construed “sick” bodies and selves into imagined future “healthy” ones. A double movement of the anticipation of recovery on the one hand and the fear of chronicity on the other hand propels this process, even as it produces frictions, ambivalences, and contradictions that can become its undoing.

In this section, we look more closely at how clients move through the treatment process; how the tensions identified in the last section continually tug on, constrain, and morph this journey; and how clients come to bear the burdens of these (il)logics of care.

BETWIXT AND BETWEEN

Anthropologists have long been interested in how processes of change and transformation crystallize cultural values in profound and often dramatic ways. Anthropologist Victor Turner, best known for his studies of a particular genre of ritual practice that he termed “rites of passage” (building on the work of Arnold Van Gennep¹), described three key phases to such transitions: separation (when people are removed from their prior social role either symbolically or, more often, by being physically sequestered from the larger community in a special space), liminality (the period of being “betwixt and between” two different roles), and reintegration (when individuals are reintroduced into society in their new role state).²

Turner was especially interested in liminality as the phase where ritual transformation occurs and where the work of culture is the most intense and potent. Liminality provides the occasion—and indeed the provocation—for a profound existential reflection on society and on one’s position within it. When initiates have left one social role but have not yet attained another, they are challenged to relinquish their prior worldviews and trappings of identity and to begin to incorporate new ways of understanding the world and their own capacities and responsibilities within it. In the liminal stage, human potentiality is wrested loose from its prior moorings and carefully lead by skilled mentors toward a new tethering. This loosened potentiality, Turner argued, is highly charged, making it both sacred and dangerous—things could go right, or they could go horribly wrong. As such, the process of transitioning from one accepted social role to another is an awesome and monumental task, requiring the skillful attention and care of ritual experts who guide initiates and ensure that this potentiality is properly channeled.

Treatment at a clinic like Cedar Grove is a distinctly liminal phenomenon, in Turner’s sense of the term. Clients have left their everyday lives and entered into a protected space within which they are learning to become new kinds of social beings: people “in recovery.” They become entrained³ in new bodily practices (e.g., healthy eating and sleeping patterns and other basic self-care activities) and learn new forms of knowledge and skills (e.g., how to articulate their feelings in words, how to navigate social relationships) that will prepare them to take on this new role.

But eating disorder patients are also liminal in another sense. Following a separate but related tradition of engagement with the notion of liminality—that of Mary Douglas—we can say that eating disorder patients are also liminal in that they don’t fit cleanly into common biomedical categories that disambiguate the body from the mind.⁴ A person with an eating disorder is therefore “matter out of place.” ⁵ As such, she constitutes a form of “pollution” and is subject to targeted attempts to subsume her firmly within familiar and accepted paradigms.

Like other liminal processes, treatment at Cedar Grove is enervated with potentialities that are powerful as well as dangerous, and treatment is risky on a number of fronts.⁶ It means at least temporarily leaving school or work, absenting oneself from family and friend relationships, and putting oneself at the mercy of a system one might reasonably suspect is motivated as much by economics as by health. Once in treatment, one must make oneself acutely vulnerable to strangers and be willing to uncover and access emotions and experiences that can be profoundly destabilizing and even traumatizing. When treatment ends, one must try to remain healthy after returning to daily life and relationships, which often haven’t changed much. In addition to these risks, treatment is also fraught, as we will see, with challenges, interferences, and roadblocks that continually threaten its ideal(ized) trajectory, rendering the liminal process of treatment as fragile and precarious as it is critical and potent.

Despite these risks, such a radical removal from life-as-usual may be necessary to enable someone to redirect their energies and move forward. As we saw with Miranda stopping on the highway (described in chapter 6), people can become so entrenched in their behavioral, thought, and affective patterns that they cannot, of their own accord, wrest themselves free from them. It takes concentrated outside intervention and a great deal of structural and therapeutic action to disrupt these patterns and help people form new ones.

In the United States, this process happens in the context of significant material risk and precarity due to the insurance climate. This insecurity and instability has become folded into understandings of eating disorders themselves such that overcoming such obstacles and dangers can be considered to be part of the “achievement” of transformation and recovery. “How they [patients] handle the insurance situation tells us a lot about their progress,” Zoë, a therapist, explained to me. “It [insurance] is largely out of their control. They have to practice their new skills of letting go and distress tolerance, and stay focused on recovery. It’s not easy, but it gives us good information about where they are in their process.” Eating disorders treatment, like the kinds of liminality Turner describes, is a time of radical unmooring, transformation, and retethering in ways that make acutely visible the cultural and social meanings and values that enable and constrain local ways of being.

LIMINALITY AND AFFECT

Specifically, during the liminal period of treatment, key capacities having to do with regulating affect—its direction, amplitude, and saturation—are drawn out, foregrounded, and shaped in new ways. Notably, these modulations can be variously interpreted in the clinic either as healthy expressions of a “recovered” self or as pathological manifestations of a self that remains ill. Contradictions between the views of the recovery model and the medical model shape such interpretations, and when and how such distinctions are made has direct impacts on the course and outcome of treatment.

Treatment, in short, is a time of gathering potentiality, when all of a person’s resources—emotional, physical, relational, and financial—are decoupled from their prior moorings, harnessed, and directed at the identified problem (the eating disorder), with the aim of restarting the client’s life along a new trajectory. It is a time of dismantling, reconfiguring, and rebuilding, of radical dislocation from a world of illness, pathology, and misery and relocation (if all goes well) within a world of hope, growth, and health.

Far too often, however, things go terribly, terribly wrong.

DYNAMICS OF CHANGE

Like Turner and Douglas, I am interested in the concept of liminality. Specifically, I am concerned with the liminal dimensions of treatment at Cedar Grove—how the clinic conceptualizes and operationalizes the transition from “sick” to “recovered”—as a way of examining key cultural meanings and beliefs that shape local ways of being. Eating disorder patients disrupt and trouble existing categories of knowledge, even while, in other ways, treatment for eating disorders works to reinscribe them.

The chapters in this section conceptualize the treatment process as pivoting on three main “movements”: unmooring, recalibration, and retethering.⁷ While these movements in some ways resonate with Turner’s stages of separation, liminality, and reintegration, I want to be clear that I am interested in what happens within treatment itself and in the clinic as a liminal space.⁸ In other words, what I describe here are microprocesses within the liminal stage. At each of these junctures, we will see how understandings of what an eating disorder is and what kinds of care it requires are negotiated. We will see how key developmental tasks are put to the clients and how clients are scaffolded through them, and also how each is fraught with a series of ambivalences and contradictions that often place clients in untenable situations. Specifically, I direct our attention to the multiple and often contradictory messages and expectations that are communicated to clients at various stages of this process, disjunctures that then become sites of elaboration as clinicians and insurance companies try to make sense of why treatment isn’t progressing as planned and clients try to figure out how to make it through one more day.

These tasks can be roughly mapped onto the two primary systems of measuring progress in the clinic—the “phase system” (loosely based on James O. Prochaska and Carlo C. DiClemente’s stages of change model⁹) and the “treatment plan” (based on a biomedical model)—which share some overlap but are not isomorphic. The phase system is an older structure at the clinic and reflects the concerns and priorities of a recovery-based model. At the time of my research, Cedar Grove identified four phases—stabilization, initiation, recovery, and transition—each with its own parameters and attendant privileges and restrictions. Coexisting with the phase system, but more consistent with a medical model paradigm, the treatment plan is fine grained and problem oriented and breaks down the treatment approach according to the categories of nutrition, medical, therapeutic, and school/work functioning.

The tasks I discuss in this section resonate in different ways with both the phase system and the treatment plan modes of tracking progress. Like the phase system, these tasks sketch a developmental trajectory in that each requires and builds on the ones prior to it. Like the treatment plan, they entail specific indicators of “success” to which clients and clinicians alike appeal.

Rather than simply describe the phase system and treatment plan as separate technologies, then, I use the tasks identified above—unmooring, recalibrating, and retethering—as a way of considering how these different forms of reckoning illness and healing constitute eating disorders as different sorts of entities and examining the kinds of contradictions, paradoxes, and ambivalences this produces for clinicians and clients alike.

SEVEN

Loosening the Ties That Bind

UNMOORING

I just got here. But then I tell myself, or Ed [my eating d...