"Malaysia Prime Minister Mahathir Mohamad and the Sultan of Johor are seen in a blue Proton Saga... "When asked whether there is any tension with the sultan, Dr Mahathir said: “No, I don’t see anything because I went to see him and he drove me to the airport. I don’t want to comment on the sultans because if I say anything that is not good then it’s not nice because he is the sultan”"

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Tuesday, April 14, 2009

"Laughter and tears are both responses to frustration and exhaustion. I myself prefer to laugh, since there is less cleaning up to do afterward." - Kurt Vonnegut

***

An exchange with Breadfly on Anorexia:


Breadfly: I have been through counseling experience myself, where I endeavored very much to make it as 'easy' for the counselor as possible and got Prozac in return. There's actually a lot I want to say about this issue but I believe the essence of it is that counselors are trained to approach us who seek counseling as clients with pathologies. Our symptoms are medicalized, and our experiences and behaviours are seen as a manifestation of an internal incongruence, a disorder that only ourselves (with their, and our parents', help can correct). Counselors are not trained to approach us emphatically; they are trained to be objective and observant. They are not trained to view us and the bodies/minds we embody as in any way socially constructed and regulated - instead, we are seen as objects or at best abjects who have internalized negative experiences and beliefs into the fabric of what was once a 'stable mind/body relationship'. We have upset ourselves, essentially.

I disagree complete with such an essentialization and I often disagreed, rather lucidly, with the 'expert' sitting across from me at the table who firmly believed he knew what was wrong with me. He was right in a sense, because I was a 'picture perfect' anorexic matching ever single physical and psychological symptom (even, morbidly, the degree of 'body image dissonance' I possessed). It had been empirically proven that certain forms of psychological treatment would work. Doctors play safe, their jobs are on the line, when it comes to the crunch, they must pick training over intuition. They must recommend another doctor/drug/treatment. They simply do not dare to deal with it.

I have come out of counseling with a somewhat sympathetic view towards counselors, but also an urgent anxiety about every single individual contemplating counseling or currently undergoing such treatment. 'Anorexia' and 'bipolar' are very crude attempts to approximate and label the manifested effects of negotiations some of us undertake every day within the context of society. Some of us have difficulty imagining and realizing the proper space our bodies should occupy and strive incessantly and pleasurably towards an unattainable ideal. Some of us struggle to make sense of, and find peace within, the hierarchies that dictate who we should we, what we should want and where we should go. None of these are in any way pathological; they are natural processes that are accentuated in some a little stronger than in others.

There are some industries however, who play up these pathologies for their own purposes. Big pharma is one, psychoanalytical treatment and clinical research is another. The beauty industry also feeds of the fears of ordinary humans who are made to believe that their insecurities are particular to themselves and hence require particular solutions to remedy them. They are not shown the ways in which such anxieties develop in society, they are not aware of the prevalence of such anxieties and, indeed, the ways in which their anxieties are manipulated by external forces like industry and the media. They are made to think they are all alone with their issues, that everyone else is perfect and normal and that it is utterly ridiculous to think otherwise.

I am not a former anorexic any more than you are a stuggling bipolar. We're simply [Breadfly] and [Karoshi], people whom, perhaps due to our childhood experiences discovering what we trust and fear, or else negotiating our identities within the subtle violence of familial and peer interaction, or else observing the world around us and the expectations it has of its residents, have come to discover, develop and reinforce certain modes of thinking and patterns of behaviour that are simply there to help us cope with the day-to-day realities we live with. As those realities change, so do we. It's a process of adaptation, or at least I prefer to see it that way, as an evolutionary strategy rather than a deviance, a dis-ease, rather than disease.

Me: Perhaps counsellors are not trained to be emphatic because that would be the role of friends. Their role is to help, not just to listen.

If anorexia and bipolar disorder are not in any way pathological, then why are you seeking professional help in the first place? Just because industries exist to help those with such problems does not mean that the problems are socially constructed by those industries.

If anorexia and bipolar disorder are "an evolutionary strategy rather than a deviance" then they are plainly bad and maladaptive evolutionary strategies, since they reduce the fitness of individuals.

The beauty industry is different because - except in extreme circumstances - those who patronise it are not pathological (or not seen as such, in any way.

If psychiatry is mostly a sham then we should shut down most aspects of the profession.

But we don't.

Breadfly: Certainly, I went for counseling for help thinking it was the only 'solution' at the time, the consequence of what I do now recognize as self-recognition of a 'condition' that is in no way stable or void of social construction. The entire structure of a counseling session, and the counseling industry in generally, posits certain assumptions about an individual's psychology; namely, a mind/body dualism (in the case of anorexia, the mind is believed to be disordered/malignant and responsible for generating negative and inaccurate perceptions of an 'objective' body) and the presence of a psychological equilibrium to strive towards (in the case of anorexia, an alignment between the my mind and the 'natural self-interest of my body' - namely, sustainable health). Such a conception effectively puts the 'fault' of anorexia (and other psychological disorders) on the individual, necessitating individualistic remedies which I begun to find exceedingly unhelpful and consequently quit.

This isn't a fault of the industry and neither do I wish to accuse the entire discipline of psychology as narrow-minded at all, as these are indeed theories that, to some extent, have been empirically tested (notwithstanding the criticism on empiricism) and after all serve as one way of the viewing the world that can neither be proven or negated in the absence of absolute certainty about things. However, what I argue is that beginning with such assumptions and approaches is not necessarily helpful to helping an individual understand the causal and contributing factors that have resulted in his/her current state of mind and being, whether or not diagnosed as pathological or not. The fact that the entire counseling process is highly uplifting for some and highly depressing for others, shows that it may in fact be a self-selecting tool: there are some for whom a treatment within the frame of pathology-resolution is aligned with their own belief systems and therefore facilitates resolution

Yet for others, such a conception is completely unaligned with their beliefs and/or intuition regarding their present condition, and they are thus confused and oppressed by the counseling system. A wider appreciation of the various reasons why one may develop symptoms resembling a psychologically-defined 'pathology' provides a greater range of acceptable options to individuals: failing 'counseling', they may take to meditation, peer-facilitated therapy (say, in the case of Alcoholics Anonymous which is not strictly counseling and in that of a few female support groups I'm attending in London who comprise of no 'trained' individual whatsoever) or even reading social and psychological theory. I would qualify though that it is certainly true that I have only begun to contemplate on counseling and the psychological condition AFTER undergoing a personal experience of counseling and hence, for those who feel a 'condition is out of control', counseling may indeed be a useful first step.

On the second point, regarding viewing conditions such as anorexia and bipolar as evolutionary, I take 'evolutionary' in a very particular sense of the term, namely as a process of adaptation one develops in the course of one's life rather than as an inbuilt blueprint that is someone activated in response to a particularly 'nasty' life condition or whatever. In addition, I argue that seeing anorexia and bipolar as maladaptive to evolution itself assumes that the goal of the body is to be healthy and reproductively effective, and the goal of the mind is to enable to body to achieve this function. This assumption of a stable and purposeful body ignores the ways in which we actively shape our bodies as well as our conceptions of them. I'm sure homosexuals (and people possessing alternative sexualities), as well as chaste religious traditions would not see themselves as maladaptive despite the fact that their bodies clearly do not conform to standard expectations of biological reproduction

Let me give an example from anorexia since it is the most familiar case study to me. The foundation of 'anorexia' has itself been called into question by the discipline of psychology itself with the tacit acknowledgment among practitioners that there are multiple causes and contributing factors towards an individual's self-starving and self-denial behaviour. In different times in history, and in different circumstances, self-starving itself has had different names and connotations: for religious reasons it is fasting; in the aftermath of a tragedy, it is mourning; in 'anorexia', it is a malignant psychological condition that prevents an individual from seeing that self-starvation is detrimental to the body. Well indeed, an anorexic patient may very well want to cause detriment to the body as he/she firmly believes such an approach is beneficial to them - often after rational consideration!

(For simplicity, I use assume a female in my examples, but these can be equally applied to males.)

For a girl chastised as being 'fat' by her classmates and told by her parents that she 'takes up too much space', the visuality and excess of her body is reinforced frequently. She begins to view her body as a barrier to social/peer acceptance and parental approval. The consequent attempt to reduce the size of her body is to her a perfectly legitimate reason to self-starve and indeed, by making her more socially acceptable (in her opinion), perfectly in line with the notion of adaptation.

For a girl who was raped or beaten up by a girl gang for 'lookin', the potential of her body's appearance to capture the unwanted attention of others and result in hurt is made violently apparent. She begins to view her body as dangerous, something to be feared and hidden as often as possible and may take to self-starving to literally shrink that body, or else make it as unattractive as possible.

To conclude, an individual's resort to anorexia can be seen in many ways to be an adaptive and explicitly bodily response to situations in an individual's experience that have led them to reach certain beliefs about their bodies, the 'problems' of these bodies and the perceived 'solution' to these problems, namely self-starvation. In many ways, these resembles a dialectical process in operation on a more personal scale. Hence, an effective solution for some anorexics may NOT be to view their anorexia as a mere symptom, and to find a more appropriate and less destructive 'solution' to their perceived 'underlying problems' of self esteem and trauma, but indeed to better understand how such a dialectical process was set up in the first place (some counselors DO succeed at helping 'anorexics' see this, in fact, and some non-counselors too, like moms).

Neither I am saying that a social-adaptive process alone is at work of course; there are also biological studies of how certain mechanisms kick in at various stages of starvation to sustain the malnourished body. One of these is the diminishing of the appetite which, consequently, for those hoping to starve to death, reinforces the condition and can be truly fatal. Such mechanisms are possibly grounded in evolutionary mechanisms as well - in response to incidences of famine and seasonal hunger still faced by countless human populations worldwide.

Me: Certainly reality is not stable. Yet, in order to deal with reality we need to categorise things. Indeed, cognition /is/ classification, so to approach everything as free-form leaves us unable to do anything.

Certainly, flexibility is needed, but it helps to approach things with a framework so you do not need to reinvent the wheel. Indeed this is probably helpful for most patients, as by definition theories (if correct) apply to the majority of individuals.

I do not think the study of anorexia ignores the role of social construction, but in counselling/psychology they are trying to help an individual rather than overhauling an entire society (which cannot work anyway - look at what happened to Communism).

While 'normality'/sustainable health is not a state of equilibrium surely anorexia is even less of an equilibrium (or at least of a healthy one) than the state of health.

And while anorexia has its effects on the body, it is mind-centred - damage to the body is a side-effect/consequence of the individual's inaccurate perception of body image and her actions resulting from this misperception.

It is unsurprising that the perspective of a counsellor is unaligned with that of the patient - the counsellor, being positioned on the outside and having more experience (and presumably knowledge) is able to take a more objective view of the situation, which must complement the patient's subjective view. If the counsellor is oppressive in his approach, that is a fault of the counsellor, rather than the profession. Yes, counselling is not for everyone, which is why a good counsellor should bear these alternatives in mind (while not automatically resorting to them - as there is a duty of care to the patient).

If you do not assume that "the goal of the body is to be healthy" (we can leave aside reproduction for simplicity) and that "the goal of the mind is to enable to body to achieve this function", then just what is it?! While there are certainly individuals who would wish ill-health upon themselves, we cannot allow them (or concern for them) to hijack the emphasis of the system upon restoring to health the bulk of patients who want to be healthy.

If anorexics, after rational consideration, feel that starving their bodies is good, more power to them. I am given to understand, though, that the vast majority of them have concerns arising from body image and delusions about body form (as your example shows; there is a difference between wanting to lose weight and starving yourself).

In a similar vein, I would not prevent someone from killing himself - as long as it was the result of careful and prolonged consideration (rather than being a rash gesture, perhaps based on incomplete or inaccurate information).

It is all very well to theorise about social construction, but when the result is that real people have to suffer (or even die) unnecessarily, that is assuredly unjust.

Breadfly: I have always begun on the premise of preventing an unnecessary death, especially in the case of mental illnesses which can be fatal. I agree that categorizing helps with both diagnosis and general treatment and (as stated previously), these methods have been empirically tested and are definitely preferable to trying to randomly guess what a person needs. What I question is the danger in not questioning such categorizing on a professional level; I have personally experienced being almost totally convinced about being in a possession of a 'medicalized identity' (being an anorexic) during the counseling process. This was delibitating, depressing, and did not help me one bit in coming to terms with either my condition, or help me find a reasonable way out. I have now come to understand that I, in no way, had any misperceptions about my body image at all: I have been learning about the boundaries of my body from the language used by others to describe it.

These include ‘being obese’, ‘taking up space’, ‘having a fat disease’, ‘always bumping into me’, etc. voiced at various points throughout my formative years and henceforth shaped the way I thought about my body prior to anorexia; namely, as clumsy, ungainy but, mainly, way too big. How would one come to understand where one ends and the Others begin? A mirror? Language, as above-mentioned, is one; observation and tactile experience (e.g. people avoiding you, staring at you, hugging you) is another. Looking in the mirror you do not see a reflection of someone as he/she objectively ‘is’ (height, weight, etc.) but a someone who understand his/her body in relation to other people and other spaces. Or at least, the latter seems more important since that is the body you have to ‘live with’, regardless of what you actually think (or purportedly ‘know’) your body to objectively be.

There can be no general goal of the body because the body has different functions for different people. For a model, it may be more important that the body be aesthetic than it be healthy - this keeps the food on her table, ironically and she would be very reluctant to give up her body. For a prospective wife in Mauritiana, getting a fat body from force-feeding is a prerequisite for marriage and, although abhorrent, may be deemed by the girl herself as possibly the wisest option in the long run. For avid piercers, tattooers and transsexuals, "harming the body" may be an important part of identity formation. These are not trivial bodily perceptions and manipulations; they are what makes the bodies of thee different people and, whether one agrees with what they do or not (that depends on one's own definition of the 'right body', after all). So as not to allow this to descend into, well then, a body can be food for dogs, items for sadistic experimentation, etc.,

It is of course imperative to look at agency as well. Are models, Mauritianian wives, transsexuals, piercers, etc. are complete control of their actions? If they are, under what circumstances they still retain the right to define their own bodies? More importantly, who has the right to come in and tell them, NO that's immoral. Don't do that. Do we then ban high fashion, piercing and sex change, or 'reform' Mauritianian society to fit our norms? I completely agree with you that we are in no such position at all.

Health, and especially mental health, is a more difficult issue because it is a concept that has great currency in moral society. However, who is defining what is healthy? Why is it that the proportion of anorexics and overweight people has gone up almost in tandem within the last decade despite the proliferation of medical treatment that is becoming increasingly accessible and affordable? Why is that the proportion of people diagnosed with medical health problems rises in tandem with the availability of psychiatric drugs? Are our 'solutions' faulty? Is our diagnosis of the 'problem' with ourselves faulty? Are people opposed to their own health most of the time (which seems ludicrous, but just take note of how many 'unhealthy' things one does in a day anyway: eating 'junk' food, watching too much TV, drinking too much, smoking, etc.)?

I feel we need to regain trust in ourselves and work at understanding why we come to the decisions we do. Here, there are many experts WHO do help such as good counselors and dieticians (as you've mentioned), but there are also many experts who don't from the very same industries. Relegating the responsibility for curing ourselves to experts, blaming them when we/they fail, diagnosing our problems and seeking solutions from every 'other' expert (such as magazine DIY columns, the news, etc.)...everyone but ourselves (since obviously, we believe our failure to be absolute - well we've screwed up, obviously we can't help ourselves!) is, I believe, ultimately ineffective in achieving the very aim of medicine - to help people feel better. Health magazine make you feel like a lazy fat fuck the way women's magazines make you feel frumpy and envious. Are these healthy feelings? These people don't know shit.
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