Monday, May 9, 2011

The Cultural Causes of Anorexia

Unless you live there you are probably not too worried about the incidence of anorexia in Hong Kong.

Unless you have spent some time pondering the origin of psychoanalysis, you have probably not given too much thought to the incidence of hysteria among European women in the 19th century.

Unless you were affected, directly or indirectly, you have probably not spent too much time asking why there was an outbreak of bulimia in Great Britain during the 1990s.

Truth be told, epidemiology is not the most compelling subject.

Yet, epidemiology can give us a fascinating insight into certain types of mental illness.

Such was the wager that Ethan Watters accepted when he started researching his book, Crazy Like Us.

I have already posted about Watters here, but I am returning to his work because I consider it to be exceptionally important.

More than that, I think that there is every risk that we ignore its highly inconvenient truths.

In my view the book’s title does it little justice. Crazy Like Us sounds like the title a stand-up comic’s memoir, lacking the seriousness that the subject deserves. The title is too glib, too tongue-in-cheek to communicate Watters’ concept.

If and when you read the chapter on how anorexia came to Hong Kong, you will see how a campaign to increase the awareness of the risk of anorexia provoked a rash of new cases. It may be counterintuitive, but the evidence is clear.

This means, Watters continues, that the psychiatrists and the media mavens who assert that increased public awareness can serve as a prophylactic measure against mental illness are in fact contributing to the problem that they believe they are solving.

When Watters asks psychiatrists how they feel about being the germ as much as the medicine, they become decidedly uncomfortable, even embarrassed.

Physicians are supposed to cure illness, not help it to spread. Given the embarrassment they feel, it should hardly be surprising that psychiatrists prefer to ignore the subject.

Surely, those who go on television talk shows to warn people about the dangers of anorexia or bulimia are not going to give up a great marketing technique. Even if they know that they are contributing to the problem, they are too self-interested to avoid the spotlight.

You can imagine the play of conflicting emotions that accompanies the realization.

Aside from the fact that good intentions do not always produce good results, and that we should never use our good intentions to excuse our failures, the root of the problem lies in the metaphor of mental illness.

Our insistence on thinking that mental illnesses are real illnesses has caused us to imagine that if increased public awareness can help people to avoid physical illnesses it can do the same with mental illness.

Being more aware of the risk of skin cancer leads people to use more sunscreen or to spend less time in the sun.

But, when we arrive at mental illnesses, the same rule does not pertain.

Watters reports on the following thesis. Anorexia, among other mental illnesses, begins with a feeling of anomie, of social dislocation, of rejection, of loneliness.

The person beset with anomie wants to belong. Being a member in good standing of a community, practicing its rules and rituals, its customs and mores, is the solution to the problem.

Those who do not feel that they can be part of the everyday social whirl have a last recourse; they seek to become part of the group of people suffering from mental illness. In order to be a member in good standing of that community, they adopt-- unconsciously-- the cluster of symptoms that the culture recognizes as meaningful.

Back in the old days anorexia was unknown in Hong Kong. Then one girl fell ill and died and the media starting writing about anorexia. The more the media and the medical community became aware of the illness, the more girls became anorexic.

Something similar happened in Europe during the Victorian era. In that case social mobility produced different forms of social dislocation and fed into an outbreak of what was then called hysteria.

In the 1990s, Princess Diana made clear to the world that she was suffering from bulimia. Perhaps she wanted to increase awareness of the affliction. What she did do was to provoke a rash of new cases of bulimia.

Watters explains: “A recent study by several British researchers showed a remarkable parallel between the incidence of bulimia in Britain and Princess Diana’s struggle with the condition. The incidence rate rose rapidly in 1992, when the rumors where first published, and then again in 1994, when the speculation became rampant. It rose to its peak in 1995 when she publicly admitted the behavior. Reports of bulimia started to decline only after the princess’s death in 1997.”

For those who had believed that Diana’s willingness to exhibit her emotional problems in public had something of a salutary effect, this information should produce anguish.

This view of symptom formation implies, quite clearly, that these psychiatric symptoms are NOT expressions of unresolved infantile mental conflict. They do not mean that the young woman was improperly breast fed or that she suffered from bad mothering or that she suffered a sexual trauma.

If a woman chooses the symptoms that tell the woman that the therapy world will take her seriously,  they are not going to be resolved by assuming that they express an unspeakable thought or feeling or fantasy.

Forget about hidden meanings; forget about root causes. Girls stop eating for completely other reasons.

When it comes to anorexia, the mental health profession has not been the sole, or perhaps, the most important contributor to the new cases of anorexia.

That honor belongs to feminism.

Watters writes: “To begin with, there is no doubt that anorexia became iconic, a cause celebre, within the feminist movement of the 1970s and 1980s. Whatever else can be said about the disorder, anorexia packs a wallop of a metaphoric punch. As the feminist philosopher Susan Bordo pointed out, anorexia calls attention to ‘the central ills of our culture.’ In various writings on the topic, anorexia has been used to decry unrealistic body image standards, patriarchal family structures, the subjugation of women by post-industrial capitalism, unrealistic ideals of perfection, and more.”

Being accepted among the psychiatric patient population is one thing. Imagine how much more powerful an incentive it was for young girls when they learned that having an eating disorder would make them martyrs to the feminist cause.

They could in their person assert the truth of the feminist vision of patriarchal oppression, the beauty myth, and society's campaign against women's orgasms.

Eating disorders do not derive, as feminists and other ideologues have stated, from the way the patriarchal, capitalist West treats women. They do not come from the way the culture defines female beauty. Nor do they arise from the culture’s obsession with dieting.

It has arisen out of feminist ideology, and especially the way feminism happily used women’s bodies to provide an irrefutable critique of a culture that they were trying to deconstruct.


Assistant Village Idiot said...

Here's an important bit that Watters neglects, and by extension, you miss as well.

Borderline Personality Disorders tend to pick up whatever is in the air around them, as they scramble for explanations of why they feel bad. Being impaired in their boundaries, they pick up symptoms from their friends, or from Oprah, or Seventeen magazine, or whatever. This does not mean that in the absence of those posited diagnoses they would have had no symptoms whatsoever. They would have had other symptoms. They would have found another sexiest disease of the decade. Most eating disorder clients I deal with are also BPD or PTSD. I don't think that is accidental. They are suggestible.

Folks with OCD who obsess about germs would still have the disorder had we not developed germ theory. They would simply have found some other uncleanness to obsess about. Those who develop schizophrenia, paranoid type, these days are likely to believe that someone has planted a chip in their brain. If there were no technology remotely like this, no RFID's, no bar codes, no pet identification, they would still be schizophrenic.

I agree that much psychological pain is iatrogenic, or otherwise caused by external suggestion. I have never encountered a multiple personality, for example, who did not "discover" that they had this illness under the tender ministrations of a therapist who believed the condition is underdiagnosed and wanting to set them all free. (Before that, they just had poor boundaries, which is easier to treat, frankly).

But I don't think that road goes forever. That expression of symptoms is flexible does not mean that the condition is elective.

Anonymous said...

I'm confused by this whole discussion; the type of anorexia in Hong Kong is generally considered a different variety than that in the US. Additionally, very most work out of North America now looks at anorexia as more of an addictive or compulsive behavior than a cultural artifact. What environmental factors there are are as much a health anxiety response to growing obesity rates as to media standards. This kind of work seems to be a bit outdated.

Stuart Schneiderman said...

Thanks, AVI, and Anon. I would mention that Assistant Village Idiot has an excellent blog, which is linked here and on my blogroll.

Actually, I think that our opinions converge here. I did not want to suggest that the people who contract these afflictions are suffering from nothing. I said that they suffer from a form of anomie, a social dislocation.

Given their underlying distress they dip into what Watters and the researchers call a symptom pool and unconsciously select out different symptoms, the ones that they believe will be recognized and get them admitted into treatment.

I think that your example of BPD is inspired, because they tend to have multiple symptoms, almost as though they were guaranteeing that they would be recognized for their suffering.

Underlying the condition is an inability to deal with rejection. I don't think that this is controversial. But other forms of mental illness display an inability to handle rejection also. Only, as you say, and as I agree, they choose different symptoms.

If we are looking at the question of whether or not these people would have no symptoms, that question can only be addressed by asking whether the culture that these people belong to offers other means to deal with anomie.

If it does, if it is strong and coherent and provides a social support system, I would say that these people might well avoid falling ill.

But then, psychiatric diagnosis and the therapy culture affect the way these people choose to deal with their distress or anomie. If the rest of the culture tends to ignore or reject them, suggesting that they need counseling, then clearly it will be pushing them in the direction of developing a recognizable psychiatric illness.

I consider schizophrenia to be a brain disease, as does everyone else, I believe. Thus, no one is suggesting that schizophrenics would not be psychotic in a different culture. Watters does, however, suggest that the way cultures deal with schizophrenics does influence the course of the illness.

Hester said...

Thanks for the article, very effective information.