Critiquing the medical model, Ruth Millman suggests that an existential-phenomenological approach can enhance the treatment of anorexia nervosa
The current situation regarding anorexia nervosa (AN) has been described as critical; reviews indicate that treatment is often ineffective (Bortha, 2015) and clinicians can be reluctant to engage in this work (Gilbert, 2014). Recent research suggests that family and interpersonal therapy may be effective for some individuals (Gilbert, 2014). Arguably these findings indicate that a new model of AN, moving away from the current individualised pathology, is needed (Bortha, 2015). Within this essay I will explore some of the criticisms of the current medical model and use of the Diagnostic Statistical Manual (DSM). Supported by research, I will suggest that an existential-phenomenological approach may enhance treatment by enabling essential issues of meaning, relationships and agency to be addressed.
The current conceptualization of AN is based on the medical model, and a positivist and empirical epistemological position (Bortha, 2015). Psychiatry, and consequently the DSM in which AN is defined, can be seen as the agent of this model, profoundly affecting the way the ‘disorder’ is dealt with in clinical and public settings (Pickersgill, 2012). Within these terms, AN is seen as a clinically diagnosable, internal and individualised pathology (Bortha, 2015). Rich (2006) highlights how viewing the disorder in this way has promoted the belief that diagnosed individuals are distinctly different from the undiagnosed population and furthermore that their difficulties are linked to irrationality. Crucially, Rich’s study highlights how women diagnosed with AN report the personal impact of this perspective, describing feeling pathologised and isolated. Arguably the medicalised approach reduces the individual’s experience to objective symptoms, outside of context or personal meaning (Morgan, 2015). The DSM definition of AN focuses on physical symptoms, promoting the notion of AN as purely a matter of weight loss (Rich, 2006). In the face of such discourse, individuals want others to acknowledge the psychological difficulties “that lie beneath the surface features of the ‘body’” (Rich, 2006:290). Medical labels restrict the individual’s identity to being defined solely by AN, ignoring the complexity and personal meaning of their lives (Bortha, 2015). Labels can be internalised, resulting in the person with a diagnosis losing other interpretations of themselves and further identifying with AN (Bowden, 2012). Rich argues that the use of pro-ANA websites is a way of individuals reclaiming their identity from this objectifying and stigmatizing discourse. Moreover, individuals with AN, who already struggle with relationships and connection to their body, are further impaired by a medicalised discourse that separates them from others and objectifies their bodies further.
Within the medicalised model the expert perspective is privileged, seen as the objective and scientific truth (Bortha, 2015). This hierarchy has meant that key facets of the disorder have been overlooked; for example, there has been insufficient research into whether individuals view themselves as restricting their food intake relative to caloric requirements (Herebrand and Bulik, 2011). Furthermore, such a hierarchy devalues and disenfranchises the accounts of individuals and their families, even labelling AN perspectives as evidence of disorder (Bortha, 2015). Morgan (2015) highlights how such discourse forms a broader system of social control over diagnosed individuals, arguably further oppressing those already responding to the social values of beauty and thinness (Kirby, 2016).
A key criticism of the medical model and diagnosis is that it downplays the impact of these cultural and societal factors on the development and interpretation of the disorder (Morgan, 2015). In the 1980s, writers focusing on issues of gender and society argued that anorexia was caused by social and political factors surrounding how obesity was stigmatised and how our bodies, particularly those of women, were evaluated (Turner, 1990). Food is not merely a function of biology; it is linked to “personal status, sexuality and social ability” (Turner, 1990:167). Our body image is in constant flux, dependent on these relational, socio-political factors (Kirby, 2016). Crucially these social values can trigger individuals to become critical and rejecting of their bodies (Kirby, 2016). The increasing prevalence of AN within BME communities and in men, in line with the globalisation of western models of beauty and changing male identity, has been seen as evidence of these societal factors (Gilbert, 2014; Robinson et al., 2012). In Turner’s discussion on the phenomenology of the mouth, he highlights the “intentional linkage” between the “Umwelt (the biological environment) and Welt (cultural world)” (Turner, 1990:167). Consequently, the loss of appetite also represents the inability to be heard within society.
The mouth and voice represent not only our social position but also communication on a relational level. This relational facet of AN is equally neglected within the medical model (Turner, 1990; Kirby, 2016). Fairburn et al. (2003) noted the absence of inter-relational factors in the diagnostic model, and within a challenge to the DSM proposed a transdiagnostic theory, acknowledging the centrality of the interpersonal processes involved in the maintenance of all eating disorders. In MacLeod’s (1981) influential personal account of anorexia, she describes the impact of family relationships on the development of her difficulties. “A mother’s critical eye…an unfriendly comment from a friend” all affect our relationships with our bodies (Kirby, 2016:9). The importance of relational factors has been supported by improved clinical outcomes when using family and interpersonal therapy in recent studies (Bortha, 2015). Lack of consideration of such factors is of particular importance considering that AN is known as difficult to treat and with a high mortality rate (Rich, 2006).
Despite an attempt to improve the description of AN, during the creation of the DSM V the definition has still been criticised as reinforcing the “dominant social construction of anorexia as internally objectified” (Bortha, 2015:331). Although the DSM V removed the pejorative terms “refusal and denial” of food (Herebrand and Bulik, 2011:667) and adapted several diagnosis criteria, the utility of this checklist approach remains questionable (Morgan, 2015). The boundary between what is considered ‘normal’ or ‘markedly low weight’ appears arbitrary, with little (or confusing) guidance as to how to categorise individuals (Herebrand and Bulik, 2011). Furthermore, the clear delineation between bulimia and AN ignores the reality that many individuals experience both (Gilbert, 2014). These fixed definitions can be critiqued for both over-pathologising, crucially reducing the interest in the phenomenological and individual experience of a disorder (Giordano, 2009) and omitting the experiences of others (most notably men) meaning access to treatment can be difficult (Robinson et al., 2012). The fact that it is hard to define such a complex phenomena as disordered eating is not surprising and does not mean that there is no value in a creating a model to assist with treatment. To my mind, the danger is that the medical model purports to hold an objective and empirical truth.
Currently, research into the efficacy of treatment based on the medical model paradigm indicates limited success. Bortha (2015) argues that relapse and chronic symptoms are frequent, and although many engage in treatment, drop-out rates and low satisfaction are high. Over 30 years ago Maine’s research (1985) argued that recovery for those with AN often did not come from formal treatment, but through a healing relationship with others, whether professional or not. Unfortunately, treatment did not radically change in the subsequent years (Bortha, 2015). Recent research has argued that in order to provide more effective support for individuals with AN, the way the disorder is conceptualised and spoken about must be readdressed (Rich, 2006; Bortha, 2015). In particular, there needs to be a shift away from the individualised, physical and pathological idea of AN towards one that incorporates the personal, relational and socio-cultural experience of the individual (Bortha, 2015). Furthermore, listening to and understanding the complex experience “of being anorexic rather than simply having anorexia” (Turner, 1990:166, emphasis added) is essential to counteract the traditional hierarchical nature of medicine (Rich, 2006). Recent studies noting the efficacy of family and interpersonal therapy (Gilbert, 2014) suggest a revision of the DSM’s focus on individual pathology. Merleau-Ponty wrote about this complex interplay between our physical, emotional and relational world (Van Deurzen, 2010). He highlighted that we exist in a physical world as embodied beings, and this holistic perspective is essential when considering AN (Kirby, 2016).
An existential approach
To my mind, an existential approach could provide the forum to discuss issues of relationships, culture, and society in relation to AN. Maine (1985) also argued that the focus of the existential approach on personal meaning, agency and relation could be helpful. Furthermore, a phenomenological exploration of the personal lived experience of the disorder could facilitate healing:
“If we wish to understand the experience of AN, enabling the development of effective treatments, it is important that we take seriously the descriptions offered by those with the disorder.” (Bowden 2014:367)
Merleau Ponty’s emphasis on life as embodied allows a way of discussing how our relationships with others and society can profoundly affect the experience of our physicality. Giordano (2012) highlights how those living with AN are often fearful of the expectations, demands and power of others, experiencing these as a physical invasion of the self. To manage this experience, the individual reduces their physical size (fat), so that the space “open to invasion” is also reduced (Giordano, 2012:249). Seen in this way the restriction of eating is no longer irrational or pathological, but a purposeful response to the individual’s relational world. Rusca (2003:494) argues that the aim is for an “incorporeal and totally controlled” self that is not subject to the demands of others, instinct or death. Creating a body outside of the grasp of others arguably allows the anorexic to “being-with-others” while avoiding “being-for-others” (Legrand, 2012:245). Paradoxically, however, achieving this freedom results in total subjugation of the self to the self (Rusca, 2003). This theory reflects the well-known difficulties in relating experienced by individuals with AN, as well as the paradoxical tensions that often make treatment difficult (Fox et al., 2011). Again, an existential approach could facilitate discussion around how the physical, social, personal and spiritual worlds are affected in those with AN (Adams, 2013).
A fundamental difficulty regarding treatment is that AN is ego-syntonic and consequently many individuals refuse help. The prevailing cognitive behavioural model of AN views this in terms of irrational thinking. However, this ignores the meaning and purpose which symptoms hold for each person. AN provides a framework for the individual’s experience and their sense of self, which needs to be acknowledged within effective treatment (Warah, 1993). Exploring the value and meaning of AN and the reasons why individuals refuse treatment is undoubtedly crucial to treatment (Fox et al, 2011). Individuals may view their eating disorder as an effective way of managing other stresses, providing control and comfort (Robinson et al., 2012). Warah highlights how hyperactivity, a common feature of AN, can provide a sense of permanence and protection against existential emptiness and negative emotions. Furthermore, individuals living with AN define their way of being in the world with others, providing a way of regulating distance (Santopinto, 1989), which has long been identified as problematic (Turner, 1993). AN also creates a sense of mastery over the body and a defence against death that separates anorexics from others unable to achieve this feat. (Fox et al., 2011; Fox and Diab, 2015). This feeling of conquering the embodied state leads to a superiority over others (Rusca, 2003) that provides a powerful resistance to the pathological positioning within the cultural discourse. Phenomenologically exploring the meaning and role AN holds for an individual can become a useful part of treatment.
An existential therapeutic approach could provide a forum to discuss these issues of embodiment, relation, identity and meaning. Furthermore, existentialism can respond to the contradiction and “paradox of being” manifest in AN (Fox et al. 2011:123). The individual is both “being controlled yet in control”, ambivalent relationally and in terms of treatment (Fox et al., 2011:123). AN is both “empowering and destructive” (Rich, 2003:302). Fox further argues that addressing this ambivalence could help in address resistance to treatment. Van Deurzen (2010) specifically highlights the issue of paradox and contradictions within her description of existential therapy and argues that these are an inevitable part of life. Each element of life, physical, social, personal and spiritual contains these conflicts. Adams (2013) also suggests that existential therapy can address this paradox of control and autonomy within eating disorders through a phenomenological practice and a strong therapeutic relationship.
The current difficulty in treating AN suggests further adaption to treatment is required (Bortha, 2014). The medical model does provide a language for discussing individuals’ difficulties and can be a pathway to treatment. However, this paradigm can also be used to pathologise, disempower and isolate the individual. Examining lived experiences points to the importance of acknowledging the complex and interconnected roles of relationships, culture and personal meaning (Rusca, 2003) as well as fostering acceptance, self-expression, empowerment and autonomy (Maine, 1985; Kirby, 2016; Williams et al., 2000). An existential approach that welcomes discussion of the complex relationship between the physical, social, personal and spiritual dimensions of life could aid individuals in freeing themselves from the many interwoven binds of AN.
Ruth Millman is a trainee counselling psychologist with a particular interest in working with individuals with autism spectrum conditions (ASC). She works at the Claremont and Dilemma Psychotherapy services based in London, and privately as part of a specialist ASC service.
Adams, M., 2013. A Concise Introduction to Existential Counselling. London: Sage.
Botha, D., 2015. Anorexia nervosa: A fresh perspective. Theory & Psychology, 25(3), pp. 328.
Bowden, H., 2014. Is Anorexia Nervosa a Passion? Philosophy, Psychiatry, & Psychology, 20(4), pp. 367-370.
Bowden, H., 2012. A Phenomenological Study of Anorexia Nervosa. Philosophy, Psychiatry, & Psychology, 19(3), pp. 227-241.
Fairburn, C.G., Cooper, Z. and Shafran, R., 2003. Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment. Behaviour research and therapy, 41(5), pp. 509-528.
Fox, J. R. E. and Diab, P., 2015. An Exploration of the Perceptions and Experience of Living with Chronic Anorexia Nervosa While an Inpatient on an Eating Disorder Unit: An Interpretative Phenomenological Analysis (IPA) Study. Journal of Health Psychology, 20(1), pp. 27-36.
Fox, A.P., Larkin, M. and Leung, N., 2011. The Personal Meaning of Eating Disorder Symptoms: An Interpretative Phenomenological Analysis. Journal of Health Psychology, 16(1), pp. 116-125.
Gilbert, S., 2014. Therapy for Eating Disorders. 3rd Edition edn. London: Sage.
Giordano, S., 2012. Understanding Anorexia Nervosa: A Phenomenological Analysis of the Body and the Mirror. Philosophy, Psychiatry, & Psychology, 19(3), pp. 247-249.
Hebebrand, J. and Bulik, C.M., 2011. Critical appraisal of the provisional DSM-5 criteria for anorexia nervosa and an alternative proposal. The International journal of eating disorders, 44(8), pp. 665.
Kirby, J.K., 2016. An Existential-Phenomenological Investigation of Women’s Experience of Becoming Less Obsessed with their Bodily Appearance. Indo-Pacific Journal of Phenomenology, 16, pp. 1-15.
Legrand, D., 2012. Objects and Others: Diverting Heidegger to Conceptualize Anorexia. Philosophy, Psychiatry, & Psychology, 19(3), pp. 243-246.
Macleod, S., 1981. The art of starvation. London: Virago
Maine, M., 1985. Effective Treatment of Anorexia Nervosa: The Recovered Patients View. Transactional Analysis Journal, 15(1), pp. 48-54.
Morgan, A., 2015. Is psychiatry dying? Crisis and critique in contemporary psychiatry. Social Theory & Health, 13(2), pp. 141-161.
PickersgillI, M., 2012. What is psychiatry? Co-producing complexity in mental health. Social Theory & Health, 10(4), pp. 328-347.
Rich, E., 2006. Anorexic dis(connection): managing anorexia as an illness and an identity. Sociology of health & illness, 28(3), pp. 284-305.
Robinson, K.J., Mountford, V.A. and Sperlinger, D.J., 2012. Being men with eating disorders: Perspectives of male eating disorder service-users. Journal of Health Psychology, 18(2), pp. 176-186.
Rusca, R., 2003. An existentialist approach to anorexia nervosa. American Journal of Psychotherapy, 57(4), pp. 491.
Turner, B.S., 1990. The talking disease: Hilda Bruch and anorexia nervosa. Australian and New Zealand Journal of Sociology, 26(2), pp. 157.
Van Deurzen, E., 2010. Everyday mysteries: a handbook of existential psychotherapy. 2 edn. GB: Routledge Ltd.
Warah, A., 1993. Overactivty and Boundary Setting in Anorexia Nervosa: An Existential Perspective. Journal of Adolescence, 16, pp. 93-100.
Williams, G. C., Franke, R. M., Campbell, T. L. and Deci, E. L., 2000. Research on Relationship-Centred Care and Healthcare Outcomes from the Rochester Biopsychosocial Program: A Self-Determination Theory Integration. Families, Systems and Health, 18(1), pp. 79-90.
Image: Anorexia by Benjamin Watson