Letter the the Editor:Response to Howard Steiger’s review of “Psychiatry as Social Ordering: Anorexia Nervosa”

HELEN GREMILLION

 

I am writing in response to Howard Steiger’s (1993) review of my article, Psychiatry as Social Ordering: Anorexia Nervosa, A Paradigm (Gremillion, 1992). I appreciate this opportunity to clarify my ideas about psychiatric constructions of anorexia, and to respond to Steiger’s criticisms.

First, let me briefly summarize my argument in *Psychiatry as Social Ordering*. In this paper, I write about approaches to understanding and treating anorexia that work with the problem as if it resides within individuals and/or families. These approaches objectify and pathologize anorexia by focusing on a damaged “self” within a damaged body and within a “dysfunctional” family. I argue that, while thisobjectification works to remove anorexia from its cultural context, it is based on ideas that are culturally constructed. For example, objectivist approaches within psychiatry assume a mind/body dichotomy, and also assume an individual/family dichotomy by supporting individuation and individuals’ “separation” from families. These ideas are culturally specific, but are taken to be self-evident.

I argue that these powerful cultural dichotomies provide a context or the emergence of anorexia in the first place. Anorexia is about a struggle with these dichotomies a struggle that is experienced as”internal” to persons and families, just as an objectivist psychiatry would represent it. However, even as anorexia depends on a tacit acceptance of these dichotomies, it also problematizes them by revealingthat they are embedded in gendered power relationships. Treatment approaches that are pathologizing participate in these power relationships by representing anorexia as deviance from a “healthy” norm. In contrast, I try to show how anorexia *challenges* dominant norms of “health” by exaggerating them e.g., control over the body, calculated self-management, individualism. The challenge is that this exaggeration has paradoxical, and horrific, effects: total lack of bodily control, and a profound experience of inefficacy and dependency. I show that treatments for anorexia positing a damaged or deficient self, and prescribing techniques of self-control to overcome this problem, recreate the very conditions of the problem.

Steiger points out that my article reads as a general “indictment” of psychiatry, which implies that treatments for anorexia are never helpful. I agree that my article comes across this way, and if I were tore-write it today, I would be careful to stress that I am writing critically about *objectivist* assumptions and practices within psychiatry, not “psychiatry” in general. While objectivism is powerful within psychiatry, it does not define every aspect of treatment. Also, my paper suggests that “anorectics” struggle with and challenge dominant norms of “health,” but that psychiatrists never do. Clearly, this is not the case. Differing perspectives that are brought to bear within multidimensional treatment approaches mitigate against unified psychiatric conceptualizations of “health” (but see note 2). Also, my paper details historical shifts in psychiatric formulations of anorexia that are due, in part, to the critical re-thinking of previously dominant paradigms (see esp. Bruch, 1974 & 1978; Kog, Vandereycken & Vertommen, 1985; Minuchin, Rosman & Baker, 1978; Selvini-Pallazoli, 1974). So in these ways, thediscipline of psychiatry *has* taken up the difficult questions that anorexia raises. I did not emphasize this point in my article, with the result that “psychiatry” is sometimes equated with “the status quo.”

I should clarify that my paper does not focus on forms of social power that are totalizing and “imposed.” It is not my argument that objectivist treatments for anorexia simply reproduce a pre-given “set” ofsociocultural norms. Rather, I focus on ideas about “health” that are so taken for granted that they insinuate themselves into everyday practice, and appear to be “natural” (Gremillion, 1992: 59). Take as an example the value of “self control.” In my analysis of anorexia, I try to show that self-control is structured by gender, ethnicity and class, and is herefore more available to some than it is to others. But it is a common-sense idea that “appropriate” self control follows “naturally” from a healthy “sense of self”; and, this idea is institutionalized and *made explicit* within objectivist approaches to treatment (Kleinman, 1988). It is in *this* sense that psychiatry participates in dominant forms of social power. Largely implicit cultural assumptions about “healthy” personhood are explicitly articulated as “natural” and “true,” which obscures the *cultural production*, and the differential accessibility, of normative personhood (Gordon, 1988; Scheper-Hughes & Lock, 1991). My point here is that this form of social power is subtle in its operation: it amplifies widely-held cultural assumptions, without questioning orchallenging them (as I think the experience of anorexia invites us to do).

Steiger (1993) reads my argument as a criticism of psychiatry for its participation in “a culture- and gender-determined mission of social control” (p. 347). He understands me to say that objectivist psychiatry is a “victory” of doctor over patient, male over female, mind over body. This assessment makes sense only if these dichotomies are seen as pre-given, and if power is thought to operate in a “top down” fashion. Indeed, Steiger states that my analysis rests on an “absolutistic concept of ‘male/female’ polarities” (p. 351), and suggests that I think only one “side” can “win.” But my paper rests on the idea that these dichotomies themselves, and the power relationships that they specify, are culturally produced (see also Hare-Mustin & Marecek, 1990; Littlewood & Lipsedge, 1987). My argument is that therapies for anorexia participate in the *making* of gender and objectivist ideas, on the part of both therapistsand patients. Within this framework, it is not possible to advocate the position that Steiger attributes to me: “a rejection of ‘male’-ness (and a psychiatry regarded as being influenced by it) to allow for investment in uniquely female expressions” (Steiger, 1993: 349). This stance would assume that “maleness” and “femaleness” are essential qualities, not cultural productions. Rather, the idea that I elaborate in my paper is that, because a struggle with anorexia points to a process of social change, therapists can participate in this change by helping to locate anorexia in its cultural context. In this process, the dichotomies that inform both anorexia and objectivist approaches within psychiatry would no longer represent “natural truths,” but cultural and political categories that are mutable. In addition, the hierarchy of knowledge between “doctor” and “patient” would not be taken for granted, but explored and questioned (Gremillion, 1992: 68; see also Swartz, 1987).

Steiger (1993) also writes about recognizing the “imbalance of power” in therapeutic relationships, which, for a person struggling with anorexia, invokes a history of “well-justified fears about others’potential intrusions” (p. 349). Steiger argues that, in the case of anorexia, the “self” has been “damaged” through familial and/or social abuses of power, which leads to “defenses aimed at limiting futureintrusions from external forces” (pp. 348-349). For Steiger, the therapeutic work to be done here involves a clarification and understanding of the resulting resistance to treatment. The therapist’s task is to create an environment in which the person seeking help can “develop a solid enough experience of ‘self’ to run the risk of allowing others ‘in’… ” (p. 355). As Steiger points out, there is some commonground here with my own position. The difference is that I am analyzing the psychiatric category of “the self” as a cultural category. Steiger adopts a “biopsychosocial” model , arguing that “damaged selves” are vulnerable to social and cultural “processes” that “contribute” to anorexia. In contrast, one of the central points of my paper is that anorexia challenges us to question dominant cultural definitions of the*healthy* self. If, for Steiger, the goal of the therapeutic process is to enable a damaged “self” to let the therapist “in,” my suggestion is that therapists allow a contextual understanding of anorexia “in,” toexamine any normative assumptions about “healthy selfhood” that they may have. Otherwise, therapists run the risk of representing themselves as the keepers of “health,” as if health were an acultural and politically neutral category that some persons simply “possess.”

Steiger’s support of the “biopsychosocial” model points to the different concepts of culture and personhood that he and I employ. He raises important issues about defining “culture” in an analysis ofanorexia: rigid sociological definitions of ethnicity and class cannot account for the fact that anorexia is beginning to cut across ethnic and class boundaries, and an understanding of anorexia in males requires “a definition of ‘gender’ that reaches beyond biology… ” (Steiger, 1993:351). He argues that my concepts of “culture-specific determinants” are “absolutistic,” and therefore cannot address these issues. For Steiger, what is needed instead is a definition of “culture- and class-based boundaries… based on the notion of ‘sociocultural influence’…” (p. 350). Steiger’s assumption is that there are fixed categories of persons (e.g., males and females) who are “influenced” by cultural “factors” (e.g., ideas about maleness and femaleness). In contrast, anthropological research shows that it is not possible to categorize persons “outside” of cultural categorizations. To continue with the example of gender, the idea that male/female is a “natural” dichotomy is specific to Euro-American conceptualizations, and has particular sociocultural and political effects (Schneider, 1980/1968; Yanagisako & Collier, 1987). But my assumption that personhood is always culturally constructed does not mean that the categories I employ are “absolutistic,” as Steiger suggests. On the contrary, my paper shows that it is the belief in anacultural “layer” of personhood that risks inhibiting the construction of new identities. Again, my point is that because ideas about personhood are culturally produced, they are mutable.

White & Epston (1990) elaborate an approach to therapy that develops this idea, and they also spell out some important implications for the therapist’s role. The “narrative” approach they describe works to”externalize” problems that have been experienced as internal to persons, so that the active, collaborative, and ongoing work that is involved in both the construction of and resistance to problems is more apparent. White and Epston reject the idea that therapists have any access to “objective” knowledge about the problems, or preferred identities, of persons who seek their help (even for one “factor” of the treatment process), because such a stance implies that therapists can see “outside” of the narratives and practices that constitute persons’ lives and relationships. They further suggest that, while such a claim to “expert knowledge” is often couched as culturally and politically neutral, it has the effect of reinscribing dominant cultural assumptions defining illness and health as qualities that are internal to persons (qualities that can be objectified and discerned by “experts”). These ideas help to clarify my criticisms of objectivist approaches to anorexia. The stance of the “expert” risks actively recreating experiences of self-objectification and self-criticism that support the anorexia.

Finally, I would like to address Steiger’s point that my own argument is not immune from objectivist ideas. In my article, I refer to persons who struggle with anorexia as “anorectics,” and Steiger writes that this term “objectifies and depersonalizes” (Steiger, 1993: 351). The point is well-taken, because this label identifies the problem with the person. But Steiger suggests that if I am not completely free of this way of thinking, it is hypocritical of me to criticize it. On the contrary, I do not think it is possible, or desirable, for anyone working with the problem of anorexia to avoid the powerful sociocultural norms that constitute anorexia. My position is that an active engagement and struggle with these norms holds out the greatest possibility of transforming them. In this spirit, I appreciate Steiger’s criticism. So to address the title question of his article “Anorexia Nervosa: Is it the Syndrome or the Theorist that is Culture- and Gender- Bound?” my answer is, “both.”

 

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