Wednesday, December 30, 2015

Enabling Anorexia

Everyone in the mental health field knows how difficult it is to treat anorexia. The anorexic refuses to eat. She allows herself to starve. If you leave her to her own devices she will often die. She does so for reasons that may be articulate or that may be inarticulate. She might believe that she is fighting for social justice or she might be suffering from a dieting habit that has gotten out of control.

Over the years many therapists have tried to treat anorexia with one or another version of the talking cure. They have usually failed. They have found, over the years, that what succeeds is something very close to forced feeding. From the Maudsley Hospital in England to many institutions in America, the best treatment seems to be: forcing anorexics to eat, and to eat more than they want to eat.

It is an unpleasant and painful treatment, because by the time these girls become hospitalized they have damaged their digestive systems to the point where they have great difficulty and even pain digesting food. In the end, however, it is better to undergo the treatment involuntarily than to starve to death. In many cases those are the alternatives. Take your choice.

It is fair to say that anorexics are defiant. It is fair to say that they are being deprived of some of their freedom because their choices are killing them. Of course, we can also ask whether their judgment has been impaired by the damage their anorexia might have done to their brains.

Once they get caught up in the anorexia they often seek ways to rationalize it, to make it meaningful. As a civilized society we do not accept that we should allow people to starve themselves to death in order to make a point.

Still, anorexics are defiant. The more defiant they are the more difficult they are to treat. The more defiant they are the more likely they are to become chronically ill, to take up the habit as soon as she leaves treatment… the better to assert what she considers her autonomy and independence.

Anorexics do not need is to hear people praising their defiance, encouraging them to starve themselves, telling them that defiance is a the right thing to do to gain social justice. Yet, that is what a recovering anorexic named Carrie Arnold proposes in an article in Aeon. The article is entitled: “In Praise of Defiance.”

One sympathizes with the fact that Arnold suffered from anorexia herself. Yet, that is not an excuse for writing an article in which she seems to be enabling defiant anorexics.

To be blunt, the article is a wrong-headed muddle, conflating anorexics who are being forced to eat in order to survive with psychiatric prisoners in the Soviet Union and China and also with rioters in America’s inner cities..

In one were to ask why Arnold and the patient she calls Holly continue to be anorexic, the answer is that they are defiant. They value defiance because they think it represents a rebellion against the system. They are willing to sacrifice their health for a principle. They think that they are martyrs for social justice. In truth they are tools of those who overestimate the value of ideals. The one thing that Arnold and Holly do not need is social support and encouragement. They are not prisoners in the Gulag or in a Russian psychiatric hospitals and they are absurdly wrong to confuse their mental health issues with political persecution.

I will admit that treating defiant anorexics is not pretty. Allowing them to starve themselves to death isn’t pretty either. Since Arnold offers no other solution, she should not be defending the mental mechanism that causes these girls to become and to remain anorexic.

How ugly was the treatment? After refusing to eat the last piece of toast Holly was subjected to a gruesome punishment. Arnold describes it:

As a patient at an eating-disorder treatment centre, Holly was required to finish everything on her plate or drink a high-calorie liquid supplement. Already uncomfortably full after eating everything else, she couldn’t finish the slice of toast. A nurse reminded her of the rule: toast or supplement. She tried to explain that it was only her fourth day in treatment and she had already eaten nearly twice what she had been eating at home. The nurse insisted. Finally, Holly admitted: ‘I can’t. I’m scared.’

But the facility didn’t see fear, it saw defiance. In her panic, Holly had pushed a nurse out of the way, which was written down as a physical assault on staff. So the treatment centre transported Holly to a locked psychiatric ward where she was held against her will for the next five days. She was restrained, drugged, and humiliated, all of which gave Holly flashbacks and nightmares. Only after stuffing herself full of food for two days straight to convince the hospital that she wasn’t a danger to herself or to others was she released.

‘Defiant or not, as a patient, I have the right to participate in my own care, and that was taken from me,’ she said.

As I said, it sounds gruesome. Be clear, however. Holly could leave at any time she wanted to… by eating a few meals.

Arnold adds that Holly has been undergoing treatment for depression and anxiety for two decades now. How well has this defiance been working for her? True enough, the treatment appears to be unjust, but people who are a danger to themselves are not allowed to make decisions that will harm them. We do not allow them to slit their wrists either because they believe that it will be a good way to protest injustice.

But, Arnold seems to see Holly as a martyr for freedom. Certainly, that is how Holly sees herself:

In nearly two decades of treatment for depression and eating disorders, Holly has frequently been called defiant. She doesn’t hesitate to stand her ground and state her opinion, even if it makes people uncomfortable. Her shaved head and multiple piercings and tattoos add to her defiant image. Holly doesn’t deny that the word applies to her – after all, she tried to enlist the help of the American Civil Liberties Union in suing her high school on the grounds that their community service requirement violated the 14th Amendment. Her problem is that the only thing people can see is defiance.

Why do people only see defiance? Perhaps because that is all there is to see.

Holly does not need social support. She needs to learn that she should not be martyring herself for a cause. She needs to have less, not more support. She does not need published articles defending her right to starve herself to death. She does not need serious writers encouraging her and other girls to be antisocial. Arnold should not be telling them that they are right to be defiant.

And then, Arnold, who doesn’t think very clearly herself, launches into a litany of grievances, all of which represent society’s unjust repression of people who are rebelling for a good cause.

She writes:

And when the defiant ones are locked up in prisons and hospitals, they are unable to force changes in the status quo – not only do they lack control over the treatment dispensed, they are also unable to express their change-making views on culture and the world. And what a loss: without people protesting police shootings of unarmed black men in Ferguson and Baltimore, racial violence will continue. Without sexual assault victims speaking out against how they were blamed for crimes committed against them, rape culture will go on. Defiance forces us to chip away at the cornerstones of our culture, but it’s all too easy to turn our discomfort into the defiant ones’ psychiatric disease.

As you can see Arnold has embraced the dogmatic beliefs of the crackpot left. She sounds like a standard issue grievance monger.

What happened in Ferguson, MO has nothing to do with what she says happened. If she believes that the protests and riots are going to stop racial violence, she is obviously out of touch with reality. By now, everyone should know that most of the violence in those communities is produced by minority group members themselves. And that demonizing the police has caused more, not less violence.

As for the rape culture meme, Arnold shows herself to be equally empty headed. If she does not understand the complex causes for rape culture on and off campus and does not understand how many times men have been unjustly accused of rape and expelled from school for it, she understands nothing. And she certainly does not see that rape is a relatively rare occurrence on college campuses, compared with other parts of our society.

Naturally, she rallies to the cause of one Emma Sulkowicz, the mattress girl who insisted that she had been raped. Both Arnold and Sulkowicz are so defiant that they refuse to accept the administrative and legal judgments about the validity of Sulkowicz’s charge. It could be that Sulkowicz was right and that every objective individual who evaluated her claim was wrong. Should we praise her defiance for believing that her feelings and beliefs should trump the rule of law.

Arnold writes:

Acts of defiance can be solitary or small. High-school students defy social norms by openly defining themselves as gay, bisexual or transgender. Office workers defy corporate culture by brightly decorating their cubicles. Fat-acceptance activists refuse to change their weight for the sake of appearance. Defiance defines the visual arts student Emma Sulkowicz, who carried her mattress around Columbia University in New York City in protest at how they handled her sexual assault.

Keep in mind, Sulkowicz also produced an explicitly pornographic video of what she said happened to her. Again, she wanted to martyr herself for a cause, but no officials, either within the college or the police, found her claim to be credible. In the meantime she allowed the world to see her as a political fanatic. Surely, it will have an effect on her future prospects, both dating and employment prospects. We ought not to extol her, to make her a role model for young women everywhere. Unless we want to be enablers.

Let’s try to shed some reason on this. When it comes to schizophrenia and certain other kinds of mental illnesses, it is extremely difficult to commit patients involuntarily. Surely, this is not a good thing. When the civil libertarians took control of the commitment process, they threw up obstacles to the involuntary commitment of people like Adam Lanza, Jared Loughner and James Holmes. All of them were clearly schizophrenic. People around them knew that they needed to be treated, against their defiant will. Tragically, the law made it that nothing could be done.

Holmes’s psychiatrist knew what was coming but could not get him committed against his will. Lanza’s mother knew what was happening, but in Connecticut it was very difficult to have her son committed.

For now, it is easier to commit and to treat adolescent girls who are suffering from eating disorders.

While you are singing the praises of the defiantly mentally ill, keep in mind that defiance is not an unalloyed virtue. There is no real virtue to starving yourself to death or to burning down your neighborhood. 


Ares Olympus said...

Stuart: As a civilized society we do not accept that we should allow people to starve themselves to death in order to make a point.

The word "allow" is an interesting question to me, and "make a point" is also strange. What does a person really want? If you agree "Yes, the world is unfair" will that enable them to stay a martyr unless the world conforms to their sense of justice?

Even in cases of drug abuse, we seem to "allow" an awful lot. If someone is in denial, social interventions are very difficult. Its very hard and unclear success when you FORCE people to do what they don't want to do, although we do force our children, and we do end up forcing elderly adults, like to sell their homes when they can no longer care for them.

So it seems the first step of "human dignity" is to do exactly that - "allow people their own path to death", and give them the autonomy they crave, at long as other vulnerable people are not being taken down in the process.

Self-destructiveness is a weird place, and probably we have to acknowledge some sense of psyche disintegration is involved, so the side that wants pain and death is not able to interact with the side trying to live.

So for me intervention means forcing a person to acknowledge consequences of their actions, to recognize negative consequences, NOT to force them to do things they don't want to do. But if someone's denial of facts is in charge, I don't have any answers except putting up boundaries.

Jonathan said...

My behavior-analysis instructor argued that anorexia is a way for nice girls to control the people around them without seeming pushy. By coincidence one of my flatmates during my last months as an undergrad turned out to be anorexic. She had some kind of relationship with an older man whom she controlled by occasionally threatening suicide. On one occasion she didn't emerge from her room for many hours, and her male friend called on our communal phone (this was before cell phones) and told me to enter her room to make sure that she was OK. I demurred but he insisted, telling me there was a danger of suicide. So I checked and she was OK. It was impossible not to get sucked into the ongoing drama and I moved as soon as I could.

Nowadays the Internet facilitates attention seeking, but perhaps it also makes it more difficult for an individual to stand out from the other attention seekers. Maybe mere anorexia isn't enough anymore: one has to be defiant as well, or, if not defiant, something equally attention-getting (though maybe not tattooed, since anorexics are nice girls).

CJ said...

They say a stopped clock is right twice a day. She is wrong about so much, but she was right about her high school's "community service" requirement.

Happy New Year!