Category Archives: psychology

Review: From Virtue to Vice

From Virtue to Vice: Negotiating Anorexia

Richard A. O’Connor and Penny Van Esterik. From Virtue to Vice: Negotiating Anorexia. Food, Nutrition, and Culture Series. V. 4. New York: Berghahn Books, 2015.  ISBN: 978-1-78238-455-7 hardback; ISBN: 978-1-78238-456-4 ebook

Richard Zimmer
Sonoma State University

Richard O’Connor and Penny Van Esterik have written an excellent and very readable book on anorexia nervosa using anthropological perspectives.  Anorexia occurs when a person “obsessively chooses” not to eat. A person then puts her/himself at medical and psychological risk. It is extremely difficult to treat. Because anorexia relates to food in general and to many foods in particular, and because anorexia is a very “modern” disease (as is explained by the authors) this book is of importance to those interested in the anthropology of food and nutrition, as well as in medical anthropology and psychological anthropology.  It is also of use to medical and behavioral personnel treating patients/clients with anorexia.  Lastly, because of the way it is formatted, it can serve as a helpful resource for people struggling with anorexia, including those recovering from it.

Before proceeding, I need to make several disclosures.  The first is that I am an anthropologist and a licensed psychologist. In the latter role, I have treated many clients with anorexia.  Whatever the procedures are for treating anorexia, the standard of care mandates that the clinician work with the client’s/patient’s physician because of the health risks involved, including malnutrition.  Furthermore, I also do pre-surgery psychological assessments for gastric bypass surgery for people with severe obesity. This assessment is a necessary pre-condition for getting the surgery. In the near future I will be reviewing another book in the Berghahn series about obesity.  Moreover, I have been a long-time board member for an agency which services people with disabilities–Disability Services/Legal Center, in Santa Rosa, California.  As a board member, a psychologist who works with people with disabilities and as an advocate for people with disabilities, it should be known that the politically correct and acceptable term is “a person with anorexia,” not an anorectic person, the term employed in the book. The reason is simple: the focus is on the person first, the disability second.  For the sake of simplicity and readability, however, I will use “anorectic” or “anorectic person” in this review. Lastly, the question arises: is anorexia a disability?  According to our agency’s legal center, it is, when it actually impacts major life functions.

By taking an anthropological and historical focus, O’Connor and Van Esterik bring a holistic, person-centered, and behavioral dimension to understanding and treating anorexia. Before detailing how they do this, it is important to review some current understandings about the causes and treatments for anorexia–which they review.

1. There is no single accepted etiology for anorexia.
2. There is no single, acceptable cure/treatment for anorexia.
3. Certain kinds of approaches can backfire, worsening the situation.
4. Anorexia is believed to have become a recognized issue in modern times, seemingly starting in the nineteenth century.
5, Anorexia seems to be more common among children/adolescents who are affluent and been given educational opportunities.
6. Conversely, it seems to be less common among less educated and less affluent and in minority communities.
7. While often portrayed in the media as a feminist issue, anorexia is found among teenage boys and young men at significant rates, although it is less prevalent than among teenage girls and young women.
8. While anorexia is often understood as an extreme reaction to modern ideas about body image, especially for girls and women, the subjects/informants that O’Connor and Van Esterik interviewed were less concerned and less influenced by contemporary images. Rather, they were motivated by other considerations, as will be discussed shortly.
9. O’Connor and Van Esterik situate their discussion about anorexia in a larger discussion of the emergence of Cartesian dualism and its effects of splitting mind and body. Anorectics thus act on this split, using mind over body. Coupled with this, anorectics preoccupy themselves with cleanliness, following Mary Douglas’ ideas about purity in general. This preoccupation is complemented with rituality in preparing and eating foods.

These considerations revolve around the idea of control.  Briefly, the young person who is becoming anorectic becomes entranced by the idea of control over her/his body, about the idea of perfecting this control, about the daily process of not eating, of getting “high” from a self-reinforcing feedback loop in the same way the authors say that ascetics do.  The anorectic person eventually loses control of the ability to control–control becomes an end in itself.  The anorectic withdraws from much social interaction, usually rejecting any parental, friendship, and sexual interaction.  According to the informants, this, too, becomes self-fulfilling.

The informants interviewed in this book were drawn from Canada and the US.  The authors give these informants the opportunity to express themselves at length throughout each chapter, addressing different aspects about their anorexia, including their family life, their starting point for not eating, their social life, their decision to address their condition, and their recovery. They all said that they enjoyed experimenting with food, including eliminating fats, sugars, and eating more vegetables and fruits.  To paraphrase the authors, the anorectic becomes what s/he eats and does not eat.

Because this is a contemporary study, these anorectics indulged in “Virtuous Eating (Chapter 10.)” They thus shared the modern preoccupation with food–what to eat, what not to eat, how many calories, how large the proportions should be, and the provenance of the food. As Poulain notes, the anorectic fits into the category of the “fearful eater” (2017:165.)

This preoccupation with the kinds of food one ate in the West arose from historical movements begun in the early nineteenth century, such as those started by William Kellogg and Sylvester Graham:  “Diet reform emerged from a distrust of 19th century medical practices, as well as the temperance movement led by Protestants which gained popularity in the United States at the same time (https://www.lib.umich.edu/janice-bluestein-longone-culinary-archive/diet-reform-and-vegetarianism.)” Moreover, as Jonathan Kauffman notes throughout his book, Hippie Food (2018), modern and post-modern society promotes experimentations with food as a virtue in and of itself.  Consequently, the anorexia informants in this book talk endlessly about which foods to eat and how much of them they eat.

These extremes of virtuous eating were coupled with religious beliefs and asceticism. For many they were tied up with ideas about “purity” and “danger,” after Mary Douglas. They were also tied up with notions of attractiveness and thinness (Chapter 12). Thinness became another virtue for people, particularly women in many Western societies after WWI.  One need only look at the Flapper craze in the 1920’s.

The authors note that the informants said that they began their practice of control in their adolescence.  Whatever the causes, the informants noted that they saw their practice as an emerging practice of creating identity, one that differentiated them from their families and friends because of the prime focus on what they ate and did not eat.  So-called “traditional” societies, where one has a socially given identity and close monitoring, do not see the presence or rise of anorexia as modern societies do.  Furthermore, the authors note that the prevalence of anorexia increased in post-modern times in part because the number of different identities available to an adolescent multiplied. The anorectic person is the one who does not eat, just as the Goth dresses in black.  What is striking, from a psychological point of view, at least for the informants in their survey, is that they were all “good” kids, not prone to rebellion, successful in school, and most were involved in sports or dance.

The informants the authors have chosen have all recovered. They do note that their sample is skewed. (It would probably be difficult to find anorectics who have not recovered and who would be so willing to talk about their history, a point they address as well). The lessons learned from this sample, because not all anorectics do recover fully or partially, are that recovery is an individual choice.  No one intervention worked to get someone to change.  Overmedicalization and stigmatization were counter-productive.  Sometimes it was just “accidental”–the person decided one day that not eating was not working for her or him.

These lessons are clinically useful because they enable the physician and therapist to see the person as a whole trying to form an identity, rather than as a problem with medical issues.  The professional can have the anorectic strike a path forward that s/he chooses, giving that person agency.  The self-reports of the informants give those who treat anorectics sensitive ways to help the person.   The case examples, including statements about reasons to change and successful outcomes, provide resources that speak to the anorectic in language and sentiment to help her/him become their own change agent.

 

BIBLIOGRAPHY

n.d.  https://www.lib.umich.edu/janice-bluestein-longone-culinary-archive/diet-reform-and-vegetarianism (accessed March 5, 2019.)

2018 Kauffman, Jonathan. Hippie Food: How Back-To-Landers, Longhairs, and Revolutionaries Changed the Ways We Eat.  Harper Collins. New York.

2017 Poulain, Jean-Pierre. The Sociology of Food: Eating and the Place of Food in Society.  Bloomsbury: New York.

 

 

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Review: The Psychology of Overeating

Psych of overeating cover

Cargill, Kima. 2015. The Psychology of Overeating. Food and the Culture of Consumerism. London/New York: Bloomsbury Academic (216 pp).

Julie Starr
Hamilton College

In The Psychology of Overeating Kima Cargill, a practicing clinical psychologist and professor of psychology, argues that overeating is a by-product of the American propensity to overconsume. Situating her account of unhealthy eating habits within the ‘culture of consumption’—our endless desire to have or purchase ‘more’—Cargill illustrates how the accumulation of empty calories parallels that of unnecessary goods. This book is Cargill’s (personal) attempt to convince her patients, students, and a general audience that overconsumption is toxic to our bodies and psyches and, far from fulfilling our lives, induces the modern malaise of the ‘empty self.’

The book’s main protagonist is Cargill’s patient, Allison, who is obese and unhappy. Allison feels isolated and wants to lose weight in order to improve her social/dating life but is caught in an endless loop of seeking out new products to facilitate her efforts. From expensive juicers and nutritional supplements, to super foods and gym memberships, Allison’s attempts at weight loss are mitigated by her purchases and are short lived; they are interspersed with binge eating episodes and breakdowns. Cargill’s efforts to convince Allison of the futility of her approach are ineffective, in part giving rise to Cargill’s desire to write the book.

The book consists of eleven short chapters, beginning with an introduction in which we come to know Allison and learn of the main problem Cargill hopes to tackle in the book: the powerful forces of consumerism that lead most of us to overeat. She then turns her attention to a general discussion of consumerism: it’s rise in the U.S. (Chapter 2) and the psychological distress it causes (Chapter 3) before tackling consumerism and food (Chapter 4) and the way the food industry is tricking/manipulating its consumers into eating more (Chapter 5). For Cargill, the culprit of our malaise is sugar, the overconsumption of which she links to its historical rise as a commodity (Chapter 6) and our biological propensity to enjoy it, a fact that the food industry preys upon to create ‘hyperpalatable’ and addictive foods (Chapter 7).

These first seven chapters set the stage for the most interesting (and most anthropological) part of the book, in which Cargill gives an account of the newly designated psychological disorders of Binge-Eating and Hoarding (Chapter 8). In support of her main thesis, both ‘overconsumption’ disorders emerged at the same time, in 2013 with the publication of the updated Diagnostic and Statistical Manual 5 (DSM), the handbook of all disorders penned by the American Psychiatric Association. In her discussion of the manual, Cargill draws our attention to the way that treating Binge-Eating and Hoarding as psychological disorders blames the “bounded individual, decontextualized from surrounding cultural and economic forces” (114). She recognizes the power the DSM has in establishing psychological norms, which shapes the experience, diagnoses, and treatment of psychological disorders. But a Foucaultian she is not; after recognizing issues with taxonomy, she is quick to defend the ‘purity’ of the scientific method (128) and views the adulteration of it as stemming from the pursuit of profit.

The fact that overeating is now considered a psychological disorder sets the stage for her discussion of how Big Food and Big Pharm are working together to create and then medicate consumer-driven problems (Chapter 9), which the FDA has little power to monitor or quell (Chapter 10). In an all too familiar tale, then, Cargill presents another case in which consumer culture aids corporations in seeking profit at the cost of consumer health. She concludes the book with some tips on how to consume less and more wisely, in order to regain control of our eating and consumption habits and reverse “the course of Empty Selfhood” (154).

The strength of the book is no doubt the way that Cargill seeks to situate psychological disorders and the problem of overeating within the larger cultural context of consumption, a necessary step to understanding the dilemmas individuals face in our society. But in some ways the book fails to deliver on its promise, mostly due to a lack of theoretical framework (e.g. practice) through which to integrate psychology, biological and ‘unconscious’ drives, positionality, the pressures of consumer life, and the marketing tricks and ploys used to sell products. As such, the chapters move between historical accounts, personal anecdotes, popular culture, philosophy, evolutionary psychology, social theory, personal opinions, and Allison’s (and other quickly introduced and then forgotten patients and acquaintances’) perils. This ad hoc approach undermines analytical cohesion as anecdotes work against and often contradict previously established arguments.

For example, in addition to education and policy change, one remedy Cargill suggests for fighting the forces of consumerism is for individuals to use their ‘common sense.’ She writes: “With the notable exception of children, no matter how little education someone has, no matter how little nutritional literacy one has, there is still common sense. None of us is forced to eat junk food and it doesn’t take a college degree or even a high school diploma to know that an apple is healthier than a donut” (59). Setting aside the way she ignores how common sense is itself a product of power relations, Cargill’s book is full of examples where she is the only one with such ‘common sense.’ Indeed, we are presented example upon example where Cargill is ‘surprised’ and ‘puzzled’ by her (educated!) friends, students, and patients, and their lack of knowledge about simple nutrition. According to Cargill, this is due mostly to the way our psychological defenses allow us to “conveniently deny” (73) food’s unhealthy properties.

Although she seeks to integrate psychology with cultural context, Cargill inevitably returns to the individual to account for why we overconsume. This is most apparent in her conclusion, where she offers advice on how to consume less and more wisely. But by focusing on consumption practices, in an odd way Cargill aligns with the very system she seeks to critique: agency comes through what we choose to buy (or not buy) rather than our activity in social and political life.

As a whole, this book is best suited for those struggling to control their desire to overeat and looking for inspiration to cut back on consumption. Some should consider supplementation to better control their appetite check the user review when in doubt about a product and do your research! In an academic setting, Chapter 8 would make a nice addition to an undergraduate course on Medical Anthropology; Chapters 7, 9, and 10 could be useful on a syllabus for an undergraduate course on food and health.

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Some Food Issues for Some Developmentally Disabled People

I am both an anthropologist and a clinical psychologist.  In my latter role, I have treated people from many different populations. Some of them are marginal in many ways. In this post, I want to refer to a special population with whom I have worked—the developmentally disabled.  This population has been interesting from an anthropological perspective for a long time.  One should go to medical and psychological anthropologist Robert Edgerton’s The Cloak of Competence: Stigma in the Lives of the Mentally Retarded (University of California Press, revised edition 1993).  This anthropologically groundbreaking work focused on how developmentally disabled people coped with being labeled and  excluded, as well as not being able to function at the same level as other people.  Anthropologists concern themselves with populations at the borders of society; consequently, developmentally disabled people are deserving of study in terms of social issues.

In this post, I am drawing on my work with people who are medium to high functioning.  This is my clientele.  They live either in group homes, worthy of study as a social institution in their own right, with parents even as adults, or independently. They have some food problems which I think may be of interest to anthropologists of food and nutrition.  Moreover, they share some behaviors with other populations which put them at health risk, which is of interest to medical anthropology, medical personnel, and policy makers.

First, many developmentally disabled people are significantly under or overweight.  (For a discussion of obesity among the developmentally disabled, click here.) There may be a variety of reasons for this condition.  Developmentally disabled people may have significant genetic or hormonal imbalances, which then lead to weight problems.  A person may have Williams Syndrome, for example, which can involve hypercalcemia syndrome and hypertension. Williams people may have shorter lifespans as well.

Second, a person may have poor impulse control.  Part of this lack of impulse control may result in the need for instant or quick satisfaction.  I’ve noticed many of my clients tend to eat fast food and a lot of it.  It’s salty, greasy, without fruits and vegetables, and often not especially nutritious.  Moreover, in many areas, those who live “independently” live in apartments close to fast food restaurants and, if they are lucky, near supermarkets.  Other researchers have seen that this pattern of residential dwelling and food consumption leads to obesity (cf. Hurvitz et al.: 2009).

Third, quite often, many developmentally disabled people have been sexually molested.  Sexual molestation can lead to a variety of eating disorders, including obesity, anorexia, bulimia, and self-injurious behavior (for more information on the connection between sexual abuse and eating disorders, see Cohen n.d.  http://www.edreferral.com/sexual_abuse_&_ed.htm).

The result is that person may have significant food-related problems.  These problems raise the risk of food-related diseases, including Type II diabetes, back, and joint problems.  Furthermore, given the frequent lack of impulse control, a person may aggravate these conditions by not eating correctly and not following doctor’s orders.  If a person is taking some antidepressants, the person may experience weight gain.  The additional weight may also aggravate many medical conditions.

There may be also additional complications. According to Bouverie Dental, often the person has poor dental hygiene problems. S/he may rarely brush and/or floss and rarely see a dentist or dental hygienist.  Some relatively recent research that poor dental practices can intensify the risk of Type II diabetes (See this web posting for a longer discussion of this issue: http://www.dentalclinicofmarshfield.com/poor-dental-hygiene-leads-other-health-problems.)  Medicaid cuts worsen the dental situation; they also reduce the possibility of seeing physicians and specialists.

Some states have regional centers or similar programs which help higher functioning people live either in group homes or on their own.  Some philanthropists have started to donate small buttons that seniors can signal their need for help, the medical alert reviews show that seniors in distress with such technology have a much greater chance of getting the help they need by the time they need it. Caregivers or provider agency staff can help the person maintain better food buying and cooking practices.  Often, however, people go out on their own and “binge eat” terribly.  Ideally, they can get further help by going to psychological therapy, most often behaviorist-focused.

Thus, this special population incurs special risks.  As anthropologists, we need to be alert to the personal and policy needs of these people.

Comments by Richard Zimmer

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Reflections on Food and Gastric Bypass Surgery Assessments

I’m writing this piece wearing two hats.  Yes, I am a card-carrying anthropologist with all that entails.  I’m also a licensed clinical psychologist.  In the latter role, I’ve been doing psychological assessments for gastric bypass and laparoscopy. These surgeries are increasing in number.  Furthermore, they are being given to teenagers and contemplated for younger children.  For many years, a patient who was going to get these surgeries had to go through a psych assessment before proceeding. I wanted to tell you what I do in these assessments. My questions involve food and the person’s relationship to food.

First, the intake questions focus on the person’s family history.  How does the patient view food culturally? How does it fit into their social life?  What specifically do they eat that we can see as “culturally-based eating?” Is the person’s family of origin prone to obesity?  (BTW, the politically correct term is severe, not morbid, obesity.)

Is there a psychiatric history of the person and family members? At times I’ve given a test to assess stability. Then I’ve asked what medications the person is taking.  This last point is crucial, because many medications, such as anti-depressants put on weight.  Is there a family history of Type II diabetes?   Has the person gone to the primary care physician and been tested for any kind of thyroid abnormalities?  What natural supplements are the person taking (and have they told their physician), since these supplements, too, can have side effects affecting weight, diet, and other medical conditions?

Second, the questions focus on the success or failure of different kinds of diets.  For the most part, the person has gone through many diets, none of which has worked.  The question is why.  Yes, the patient has told the doctor this.  But I ask them about their present eating habits.  I review their daily meals.  Despite the fact that they are preparing for surgery, many of them are still eating “badly” too much fat, salt, and random and inadequate meals.  Many people tend to drink caffeinated drinks.  Even though they don’t have sugar, caffeine can stimulate a sugar response as well as a cycle of highs and lows.

Third, the questions focus on whether the person has had a significant psychiatric and substance abuse history. Quite often, for example, the person has been sexually abused.  The purpose of these questions is to find out whether the person will follow instructions post-surgery, since violating instructions, i.e., eating too much and the wrong kinds of food can put the surgery at risk.

Fourth, the questions focus on how the person chooses to get medical information.  Does the person want it in written form, orally, and/or visually? Does the patient want a friend to come to the doctor’s office to help them with information?

Fifth, the questions focus on who is going to help the person post-surgery.  This is particularly important since the person may be incapacitated for a while.  Equally important, the patient is queried on family dynamics. One often finds that a patient’s partner “enables” the obesity by wanting the person to be overweight. There are lots of reasons for this.  The partner may want a larger person as their significant other.  The partner and the patient may be avoiding having sex because of the weight issue and other factors. I also ask the patient how s/he will deal with their new body at work and in their social life.  As is often the case, obese people are ignored, and changing one’s weight makes a person visible.  My impression after doing these assessments for over ten years is that this is a more sensitive issue for women than men. Men tend to be seen as more visible, women, less so.  Again, this gender difference worsens as people get older, more so for women.

I follow up several months later to see how the person is doing.  The follow-up reviews both weight and food compliance and family dynamics.   The purpose of the follow-up is to help the person maintain compliance and achieve success.

I’ve tried to be general here.  I look forward to specific comments and questions, because there are more physical and psychological concerns that are involved.  I’ve noticed that they can affect each gender differently.

Comments by Richard Zimmer

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