Unrecoverable? Prescriptions and Possibilities for Eating Disorder Recovery

Abstract

Introduction: In Western psychology, post-structural feminist scholarship on eating disorders (EDs) has brought to light three key differences between critical and conventional frameworks: differences in understandings of causation and course, in conceptualizations of the normal/pathological divide, and in attendance to lived experiences as a source of scholarly and clinical knowledge and insight.

Main Body: Situating these tensions in our current cultural milieu, which imbues bodies with moral meanings, a possible next step in illuminating ED etiology and recovery is attending to embodied experiences. In this chapter, we examine tensions between biomedical discourses around health/well-being circulating in mainstream culture and prescriptions for ED recovery found in treatment settings. Stepping outside of a biomedical frame, we outline key contributions from post-structuralist feminist perspectives and offer promising directions for future research in this area: rethinking EDs in the context of biopedagogies, or the moralizing instructions for bodies and health that circulate in biomedicalized and neoliberalized contexts such as our own.

Discussion: Noting the ways in which biopedagogies for health differ markedly from instructions for ED recovery, we suggest that there exists, within biomedical treatment regimes, a biopedagogy of recovery that may contribute to the difficulty of “achieving recovery”.

Implications: For those whose bodily experiences do not fit the “expected” course of having/recovering from an ED, attempting to follow a recovery biopedagogy may bring individuals face to face with some of the problematics of (Westernized) societal expectations for “healthy bodies”.

Response

• Merryl Bear 

1. National Eating Disorder Information Centre, Toronto, ON, Canada

   Merryl Bear

Prescriptions for Recovery: Hard to Swallow?

For over 20 years, I’ve begun most educational workshops on body concept and self-esteem by examining the societal messages contained in the words “fat” and “thin,” demonstrating that language is not neutral and may hold prescriptions for acceptability. The chapter spurred me to reexamine the role of prescriptions in ED treatment. Taking as point of reference mainstream Anglo culture and practice, I focus on some of these prescriptions and the challenges they may pose for individuals, treatment providers, and significant others supporting the recovery process.

What Is the Problem?

Healthy eating, mechanical eating, and normal eating: For the purpose of this piece, “mainstream” prescriptive language arises out of biopedagogies where the dominant discourse is around individual responsibility for attaining a healthy body. By obeying certain rules for eating and physical activity, one can achieve the desired/promised outcome of a normal weight as determined by the BMI, with a preference for a slender, toned body. Dichotomous and moralizing language seeps into these instructions: foods are either “good” (nutrient packed, low calorie) or “bad” (nutrient poor, high calorie); similarly, there are good and bad eating and physical activity patterns. Ultimately, they endorse a narrow prescription for the way in which the “healthy eater” attains a “healthy weight” and hence a “healthy body”.

Alternative discourses about women’s weight and eating behaviors do exist, including an array of feminist theories, which may inform treatment (Jasper, 2015, in print). One that is gaining traction is the Health At Every Size (HAES) model. This holistic approach builds on Ellyn Satter’s definition of normal eating as “flexible and varying in response to your hunger, your schedule, your proximity to food and your feelings” (www.EllynSatter.com). It includes occasional over eating or under eating while trusting that one’s body will self-regulate over time. To enhance well-being, HAES encourages individuals to engage in behaviors: normal, flexible eating, enjoyable, sustainable physical activity, and overall caretaking and respect for one’s body. Body size is not seen as an arbiter of health, and proponents advocate for an end to weight discrimination and the fetishization of thinness. How this approach may be taken up in practice and influence the outcome of ED treatment is yet to be determined.

Prescriptions for Body Practices to Support Recovery

For the individual being coached into ED recovery, normalizing eating typically requires, in biomedical terms, “mechanical” eating: food is viewed as medicine, taken in prescribed quantities and including all the food groups. This prescription follows mainstream nutritional injunctions in that eating is instrumental and focused on health. In one significant respect, however, it is counter cultural: it usually demands the consumption of high-calorie, often low-nutrition edibles which are generally eliminated from the individual’s ED diet or are “trigger” items on which binges are based.

Fear for the affected individual’s life likely helps family members/significant supporters initially align themselves with the injunctions. Likely familiar and largely replicating mainstream notions of healthy eating and weight, these prescriptions may make it easier for those providing treatment and support to encourage or even coerce compliance.

Eat More, Eat Less

However, when treatment prescriptions for recovery are counter cultural, how might family members and other support providers respond? They too are located within mainstream body politics. Attempts by the treatment team to explicate the relationship between the individual’s dichotomous eating disorder thoughts and feelings and their eating practices may unwittingly trigger discomfort or denial in family members who may themselves hold such eating practices (though perhaps less extreme) as good and normal. Cognitive dissonance and discomfort with treatment team recommendations that conflict with internalized biopedagogies may make it difficult for family members to fully support the new rules instituted for recovery, and likely more so if the body of their loved one is at a size seen as desirable, healthy or already “too big”.

Be More Active, Be Less Active

The same can be said about treatment prescriptions pertaining to physical activity. In the mainstream, commitment to regular, limit-pushing exercise in the interests of health manifests in body shaping; weight control is admired and endorsed as a lifestyle choice with moral superiority. In traditional ED treatments, physical activity is often restricted to limit the risk of medical complications or impediment to the recovery of developmental processes in children and adolescents. Managing access to physical activity may also be seen as prescribing balance or as a lever for treatment compliance. However, family members and significant others may view high degrees of physical activity to be essential, healthy outlets for the individual, as well as promoting a strong, healthy physique.

Get the Ideal Body, Get the Best Body

The prevailing body ideal of any given time is experienced differently by individuals based on their intersecting identities and social location. EDs occur in individuals along the full continuum of sizes and shapes, and of all races and genders. Treatment prescriptions for individuals who are fat, have physical disabilities, are racialized or who are queer, and/or trans-identified need to be examined to see how they maintain or subvert power relations.

Where to from Here?

ED treatment providers may overestimate the neutrality of their prescriptive practices and underestimate the impact of their social locations and those of individuals with EDs, family members, and intimate others, including intimates’ cultural practices around food and weight. Unless these factors are addressed in treatment, the individual may return to an environment which un/wittingly undermines her recovery processes, already at odds with mainstream messaging. There are promising articulations of ecological, feminist, and emotion-focused theories and practices, which centralize embodiment in ED health promotion, prevention, and treatment (e.g., Lafrance Robinson & Dolhanty, 2013; Neumark-Sztainer et al., 2010; Piran & Teall, 2012). Recovery from eating disorders will remain a Herculean—or Sisyphean—task without a radical re-visioning of girls’ and women’s rights to live fully and with acceptance in the bodies that they inhabit.