When I was in grad school, I started doing quite a bit of reading about eating disorders. Some of that interest was personal, as I developed (relatively late) a rather serious obsession with food and exercise in college. Some of it was intellectual, as it intersected nicely with my interest in women’s studies. At one point, back in 1992-93, I got involved in an outpatient treatment program for folks with disordered eating at UCLA’s Neuropsychiatric Institute. It was a mixed-sex group, and I was one of only two guys in a group of about fifteen students who met weekly with a clinician.
I remember that no topic came up as often as did parents. And the clinician, at least, generally asked questions about mothers. Indeed, I heard her once say something like “The first question I ask most women who have eating disorders is: ‘what is your relationship like with your mother’?” Most of the research done on anorexics and bulimics has been done on women; indeed, it’s only been relatively recently that we see a formal acknowledgement that eating disorders are becoming more prevalent among men. And for over a century, the assumption of therapists and doctors has been that a young woman’s disordered eating is almost always tied up in the invariably complex and entangled relationship she has with her mother. As Joan Brumberg illustrates in her essential monograph, Fasting Girls: A History of Anorexia Nervosa, as early as the 1870s doctors suggested that food refusal in middle-class girls was a form of quiet rebellion against the strictures and limitations for women modelled by their mothers.
There’s a lot to be said for that analysis, but it often has the unfortunate tendency to let dads off the hook. In her wonderful Perfect Girls, Starving Daughters, Courtney Martin offers a chapter called “The Male Mirror: Her Father’s Eyes”. Some of what she says is new, some of it has been said before, but her analysis of the role of the father-daughter relationship and its role in the development of eating disorders is very good, and it offers a special challenge to those of us eager to help adult men transform the ways in which they relate to young people, particularly their own teenage children.
Courtney connects the classic paradigm of “fun Dads” and “strict Moms” to young women’s own dismal sense of themselves and their roles:
…fathers often play the role of risk taker and rule-bender. “Don’t tell Mom” is a playful instruction thrown around by workaholic fathers who want to bond with their children without putting in real time. The father of a friend of mine would fill the house with junk food when her mom went away on business, allowing the kids to indulge in everything they wanted. When Mom came home, the fun came to an end.
This may be many fathers’ method for livening up houses where rules and responsibilities get too heavy, but the burden of figuring out what it all means ultimately falls on the children. Mom puts in the time, but she also restricts and restrains. Dad is rarely around, but when he is, it is a laugh a minute, a real party time. As a result, femaleness is equated with restriction in many little girls’ minds. Maleness is about wild abandon, sweetness, fun.
Bold mine. While not everyone grew up with such a dynamic, the experiences of the kids I’ve worked with tend to validate Courtney’s thesis. And this is enormously toxic for young women. When fathers create a dynamic in which they are the lighthearted providers of fun, they force their wives to be the boundary-setters. After all, at least one parent must make and enforce rules: when fathers delegate that responsibilty to wives, they force mothers into the classic female role of “gate-keeper.” It’s similar to the awful dynamic, set up by an anxious and sexist culture, that teaches young girls that it is always their responsibilty to say “No”, because Lord knows, boys “lack the self-control” to do so. Rooted in a myth that men are fundamentally weak, teenage girls are forced to be the sole arbiters of sexual boundaries and far too many mothers are forced to be the sole “rule-enforcers” in the household.
If Courtney’s right — and I think she is — then it’s a reminder that fathers and other adult men have a more pivotal role in the development of young women’s sense of themselves than we may have previously understood. We already know how disastrous it is when fathers react badly to the onset of puberty in their daughters. If the worst thing a father can ever do is make sexual advances to his daughter, the second worst mistake he can make is to withdraw affection as a result of his own discomfort with her changing body. (Ask a group of girls or adult women about this; you’ll get countless anecdotes of how their fathers stopped hugging them or became more distant when adolescence kicked in.) But there’s more to being a good Dad than keeping a safe, close, intimate bond after the onset of puberty. What both girls and boys need to see in their fathers (or other adults, like youth pastors, coaches, and teachers) is a willingness to model two things simultaneously: emotional availability and self-discipline.
Eating disorders are about many things, but frequently, they are rooted in a powerful desire for control. While a culture that celebrates an impossible beauty standard for women plays a major role in triggering food refusal and disordered eating in girls, men’s refusal to set and maintain good, loving boundaries with those around them is an underestimated factor in women’s struggles with food. Whether in the back seat of cars or around the family dinner table, when we maintain a cultural dynamic that teaches that “women make rules, men break them” we teach young girls that rigorous self-control is at the heart of what it means to be female. When we teach young women that men are foolish, impulsive, playful and irresponsible we do more than warn them against being taken advantage of; we suggest to them that their future happiness and safety relies on their own ability to make rules for themselves and others. It’s a given that in adolescence, one of the few things that can be reliably controlled is what goes in the mouth — and hence it’s little wonder that so many young women, having learned this dismal and depressing lesson about what gender roles mean, become obsessed with mastering their own flesh.
It’s a good argument, but the problem I have is that I just don’t see it in practice. My friends from group therapy tend to reflect the SES/ethnic composition of my area: upper-middle class first-generation Americans. And like most first-generation Americans, our familial dynamics don’t quite match white Americana’s. If this were the case, then how does it explain the rise of EDs immediately after the adoption of American mass media? Family dynamics don’t change in response to new media (or immersion in a new culture) that quickly — but peer group constructions of value do.
Eating disorders are about many things, but frequently, they are rooted in a powerful desire for control.
Value =/= Control. Control is a means to an end, not the end itself.
This is what drives me bats*** insane about discussions of EDs: mental health professionals won’t let us out of the hospital until we adopt their explanation. In the process, we learn to abandon our own. I think it’s why I was so disappointed in Courtney’s book: she should have focused on the women before they’re exposed to the psychiatric Kool Aid, not those who’ve already imbibed.
Now, I don’t doubt that the control narrative helps some women — but the relapse rate suggests that it’s not helping nearly enough. Doesn’t that suggest that it’s time for mental health professionals to start listening to how patients construct their illness experiences before attempting to rewrite the patients’ narrative in their theoretical framework?
Once I realized that I actually started making progress. Mental health professionals didn’t cure my bulimia — Twisty Faster did.
Now, I don’t think that feminism is the cure for every person’s eating disorder; however, it was definitely a lot more helpful for me than the tripe served by my psychs. As I see it now, the problem with psychology is that it de-emphasizes the role environment plays in constructing personhood. Consequently, it a) implicitly blames the victim; b) privileges family dynamics over far more powerful peer dynamics; c) doesn’t really teach us how to restructure our lives in a healthier manner; and d) to borrow a metaphor from Dr. Beverly Tatum about racism, it doesn’t teach us how to spot cultural “smog,” let alone how to challenge it without inhaling it.
Lil Ol:
I think the tendency is always to focus on one particular dynamic (cultural, psychological, physiological) at the expense of others. Almost everyone who writes about eating disorders does this — when of course, it’s a constellation of factors, all working together in different ways. Families do trigger disordered eating, the media does, peer culture does — and as many have shown, religion has.
Which is why, of course, a holistic approach that empowers those who struggle to fight back on multiple fronts is best. And I’m delighted Twisty worked so well for you!
Almost everyone who writes about eating disorders does this — when of course, it’s a constellation of factors, all working together in different ways.
I don’t doubt this. But if family dynamics really is as important as you, Courtney Martin, and pretty much every other mental health professional I’ve ever interacted with says it is, then how do you explain the diversity of family dynamics? How does it account for the fact that one twin can get an ED, but not the other?
Families do trigger disordered eating, the media does, peer culture does — and as many have shown, religion has.
I agree with you on media and peer culture. I’m not sure if I know enough about the role between religion and food to really gauge whether or not religion causes EDs. The only book on religion’s role in EDs I’ve read is Bynum’s Holy Feasts and Holy Fasts, and I thought that was more about interpreting the meaning of voluntary starvation in medieval women rather than an argument that religion caused voluntary starvation in medieval women.
Families, I really doubt. Before being forced to drink the Kool Aid, family problems really only entered into our explanation of why we were hospitalized, not why we had the disorder. I suspect doctors miss the subtle distinction because Freud’s shadow continues to distort the professional lens through which they view clients. Although Luhrmann maintains that this common for psychiatric disorders without effective pharmacological interventions, I suspect it’s even more pronounced with EDs because of their gendered nature.
Here’s my really big question, though: how do the existing familial explanations differ from evolutionary just-so stories? Virtually all* of the research I’ve read supporting the idea of familial contributions is not only methodologically shoddy,** but also subject to a Judith Rich Harris-esque critique. If peer groups and media account for the domestic and international trends, then what are familial explanations explaining? Instead of causal explanations leading to the development of effective ED therapies, are they ultimately morality vignettes about what the role of women and children in families should be?
*The exception that proves the rule is the research on how family counseling to help teenagers reintegrate into their pre-hospitalization/treatment life. However, familial support during and after psychiatric treatment does not imply that flawed familial dynamics triggered the ED in the first place. It just implies that social support helps mental health.
**I am fully aware of how silly this sounds from someone in a profession that privileges arguments from authority.
Last time I checked, one twin can become an alcoholic and not another — and virtually everyone who works in the recovery field regards family dynamics as ONE vital component in explaining addiction. When I think about my own eating disorder, it’s impossible for me NOT to think about it in terms of a constellation of factors — including my own relationship with my parents.
Of course when we think about our illnesses, we do so in a multifaceted way. After all, illness is part of life and we think about life in a multifaceted way. And in that sense, you’re right: because ED psychotherapy is still so Freudian, it really underestimates the role men play in the family dynamic. I also agree with the implication that EDs don’t really fit with the biomedical conception of a disease.
The problem is that making a fatally flawed theory “less bad” doesn’t make the theory less fatal. Or in the case of my ED treatment, less expensive: my parents effectively wasted $100k on treatment that’s as effective as a placebo. If mental health really matters, then mental health professionals really need to start holding themselves to the same standards the rest of medicine does. Otherwise, insurers are perfectly justified in refusing to cover non-pharmacological therapies.
Last time I checked, one twin can become an alcoholic and not another
…Which also doesn’t follow from combining the biomedical model of disease* with psychoanalytic views of family dynamics.
*I could explain more about the difference between mono/mono, mono/di, and di/di identical twins and their implications for neurological and psychological research, but that would probably be too tangential. Like many of my professional cousins in domestic mental health law and policy, I’m a tad skeptical about defining EDs, addictions, and PTSD, and most forms of depression as diseases instead of as illnesses. They seem to be oddly rational adaptations to toxic social values and situations more than anything else.
fwiw, there is a massive push in MH services around the country for evidence based practices. agencies cant’ get government funds or from most grantors unless they are using evidence based practices.
I obviously don’t know where you have been treated, but finding many Freudian therapists is not that easy anymore. Freud is taught but even his adherents have moved on. of course Freudian types are the farthest from using research and evidence in their work. I’ve not heard that any sort of Freudian style is the preferred treatment method for any problem. psychoanalysis is old school, and not in a good way.
mental health or illness is multi causal, always has been. there is likely more than one cause for most mental illnesses. An ED is more of a cluster of symptoms that has several possible and common causes. it is likely that some people have more of genetic predisposition than others which makes the research difficult along with mixing in different cultures, etc.
I obviously don’t know where you have been treated, but finding many Freudian therapists is not that easy anymore. Freud is taught but even his adherents have moved on.
Not exactly. Traditional Freudian psychoanalytic schools are rare, but psychoanalytic training is still a key component of psychiatric residencies — which is probably why neo-Freudian familial explanations are still so dominant in ED treatment. I don’t know about you, but I get nervous when I see arguments that bear an uncanny resemblance to evolutionary just-so stories.
agencies cant’ get government funds or from most grantors unless they are using evidence based practices.
Yup — which is why my parents wound up spending 100k+ on ineffective therapy. Wouldn’t that have been much better spent on abandoned Indian girls’ educations?
I’m referring to family dynamic explanations of EDs generally, not Hugo’s in specific. (Which is a significant improvement.)
And let me also add, entirely tangentially, that psychoanalysis (the formal deal, three days a week on a couch for two years) did a lot of good for me. Was it worth the investment? Hard to tell. But it was one leg in a multi-legged stool of healing.
Hugo: that is the peculiar bind for therapists, they are supposed to use evidence based practice, which almost never/never includes psychoanalysis. however many people have found it, like many other psychological theories, to very useful. it is rare to find psychoanalysis in any non-private agency. all my experience is in poorly funded public agencies so i have never actually seen anybody do real psychoanalysis.
all my experience is in poorly funded public agencies so i have never actually seen anybody do real psychoanalysis.
I’m referring to modern psychotherapy as a whole.
For some reason, people think that modern psychotherapy is completely unrelated to psychoanalysis. One is the other’s grandchild. The vast majority of psychiatric residencies still require traditional psychodynamic training, which is normally learned before cognitive and behavioral theories. Although the precise amount of time varies, most residents spend more time on psychoanalytic theories, if only because a lot of residents stop reading for lectures a few months into the program. Clinical psychologists, of course, spend even more time on psychoanalytic ideas than their medically-trained siblings. But all the programs I’m aware of teach psychoanalytic theories before they teach cognitive and behavioral theories. Even then, clinical psychology programs wind up spending more time on cognitive/behavioral/whatever-the-new-secular-Buddhism’s-theory-name-is,
I’m not sure it really eradicates Freud’s influence — especially not in very gendered disorders like EDs.
That said, there’s always discussion about changing the curriculum to include more evidence-based medicine, and I think they just instituted something this past year. Fortunately, I’ve been out of the psychiatric game for a few years now so I’m not terribly up to date.
The reason why even Harvard psychiatry professors believe that talk therapy works due to the placebo effect is because a) none of the different types of talk therapies perform better than any of the other talk therapies,* b) the Eysenck research on psychoanalysis has not only been repeated, but is also been supported by research using similar designs to test the efficacy of modern psychotherapies, and c) studies comparing different varieties of talk therapies to “placebo doctors” (i.e., confederates paid to dress up in white coats and pretend they’re doctors) suggest that psychiatric and psychological training doesn’t improve patient outcome.
The thing is placebos really do work; patients really do get better.
The problem is that the majority of patients wind up like my parents — $100k+ in the red. And, statistically speaking, the only thing worse than debt for mental health is death.
I suspect that these structural relationships contribute to women’s comparatively poor mental health. I agree that there’s quite a bit of truth to the adage “men with mental illnesses get sent to prisons, while women get sent to physicians,” but I suspect the long-term financial hit that long-term talk therapy requires is still corrosive in its own right.
*Exception to the rule: phobias. Desensitization therapy does produce a statistically significant improvement than other types of psychotherapies. There’s probably more, but it’s 2:15 a.m. EST and I can’t sleep because there’s a six-inch gigantic flying cockroach in my apartment. While I have many, many mental health issues, surprisingly I’m not phobic. (Because D.C. used to be a swamp, we get the creepifying flying tropical cockroaches. They’re so huge that even my cats run away from them.)
/threadjack