Back in the day therapists, especially those of the Freudian persuasion, assumed that anorexia was the product of an unresolved developmental conflict. They believed, because their theory told them so, that anorexia represented a fixation at the oral stage of development. Perhaps these patients had been starved for nourishment when they were infants. Perhaps they were overnourished. Perhaps they were weaned incorrectly and were trying to master their anguish by willfully choosing not to eat.
It sounded great on paper, but it failed to produce good clinical results. It produced no clinical results at all. Thus, therapists moved on to other treatments.
Where psychoanalytically influenced therapy assumed that symptoms were expressions of unresolved mental conflicts, cognitive and behavioral therapists believed that symptoms were bad habits. Those who took their cues from Aristotle asserted that the best way to treat bad habits was to replace them with good habits.
I had assumed that this was established within the field. Apparently, not as well as I had thought. Now, researchers have announced that anorexia has nothing to do with willpower, but is really a bad habit. A summary article appears in the New York Times. I am not sure who thought that the problem was willpower, but I am happy to see that the research has gotten to a more solid theoretical ground. If I had to guess I imagine that therapists who believe that their work on the mind could teach patients how to control their impulse to starve themselves were calling it a question of willpower.
The new research explains that once anorexics develop the habit of eating low calorie and diet foods, to say nothing of not eating at all, they keep doing it without thinking about what they are doing. They do it automatically, even if they have pledged to stop doing it, even if they really, really want to stop doing it.
This ought not to be very surprising. Addictions like alcoholism and drug abuse have long been considered to be bad habits. When alcoholics are treated by 12 Step programs they learn to replace bad habits with good habits. That means, instead of going to the local bar they go to an AA meeting.
Beyond being a bad habit, alcoholism involves behaviors. The alcoholic might belong to a social scene where others drink. He organizes his time to ensure that he can participate in the scene. If he drinks alone at home, he will work to hide his drinking from others. The genius of 12 step programs is that it attacks the behaviors that constitute the illness and does not just limit itself to self-discipline. In fact, it begins by saying that willpower is for nothing in the fight against alcoholism. It even suggests that the intervention of a higher power is required. Unless a therapist can figure out how to break down the different behaviors that constitute the habit, he will not be very successful treating alcoholism.
And now that we have learned that alcohol produces feelings that are akin to empathy, the problem will be more difficult to treat in a culture that has mistakenly made empathy into the psychotropic medication of choice.
Of course, you can live without alcohol or gambling or many kinds of illicit drugs. You cannot live without food. Thus, anorexia is a special kind of addiction.
Many clinics today use a modified version of the approach developed by the England’s Maudsley Hospital. They force anorexics to eat, often large quantities of food. By definition, the treatment modality assumes that these patients do not have the willpower to choose to eat the right foods. Thus, they are fed, whether they like it or not.
I would add, for my part, and without pretending to possess anything like knowledge about the matter, that anorexia must also compromise the body’s biochemistry, the digestive system, metabolism,the way that the digestive system sends to the brain, and perhaps even the structure of the brain and its ability to process information.
Without knowing how chronic malnourishment affects those aspects we will still have a great deal of difficulty understanding the illness.
It is also true that the habit of anorexia is sustained and supported by cultural cues, by the media and by friends and family. In a culture that obsesses over eating disorders the anorexic will find herself the center of a great deal of attention and worry. She might even find the illness empowering. In a culture that bombards people with messages about weight loss, diet foods, calorie counts, the virtue of thinness… the anorexic will find her choices affirmed. Obviously there are websites encouraging anorexia; women who become skeletal do receive reinforcement from fellow sufferers who will stop them on the street to tell them how good they look.
The Times explains the problem that therapists face:
In the case of anorexia, therapists often feel helpless to interrupt the relentless dieting that anorexic patients pursue. Even when patients say they want to recover, they often continue to eat only low-fat, low-calorie foods.
Therein lies the problem. Whatever techniques therapists have do not seem to work. When these patients are allowed to choose what they will or will not eat, they will choose salad and turkey breast. If we assume that they do not lack the will to recover, they must lack the good habits that constitute good health.
If this is the case, as sad as it is to say, treatment should limit the anorexic’s ability to choose what she will or will not eat. She should eat at a dinner table where everyone eats what he or she is served. To some this will sound quaint. To others it will be commonplace.
How many children today sit down to family dinners where they are obliged to eat what they are served? How many of them—called picky eaters-- are allowed to choose what they will or will not eat? How many of them request special orders? How many of them eat alone, from a take-out menu?
Treating anorexia means creating a social context in which people sit down together to eat dinner (or breakfast or lunch) and feel obligated to eat what everyone else is eating. Hopefully, the dinner table will be a place where people eat a balanced diet, in moderation.
If anorexia is so hard to treat, that is, if the habit of anorexia is hard to break, the reason must lie in the media discussions of eating disorders, the media obsession with diet and weight-loss, and the culture’s failure to foster stable families that have healthy social eating rituals.