Psychotherapeutic Treatment For Anorexia Nervosa: Modernist, Structural Treatment Approaches, and A Post-Structuralist Perspective

Botha, D. (2009).
Psychotherapeutic treatment for anorexia nervosa: Modernist, structural treatment

approaches, and a post-structuralist perspective. Counselling, Psychotherapy, and Health, 5(1), 1-46.

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Psychotherapeutic treatment for anorexia nervosa: Modernist,
structural treatment approaches, and a post-structuralist
perspective

Derek Botha
MSocSc DCom
Counsellor
Cape Town
Contact:
der ekbot ha1@di scover ymai l . co. za

Botha, D. (2009). Psychotherapeutic treatment for anorexia nervosa: Modernist, structural treatment

2

Abstract

Research has indicated that outcomes for psychotherapeutic treatment of anorexia
nervosa are less than favourable, and that persons with anorexia nervosa have indicated
low levels of satisfaction with treatment.
In this context, this article explores the beliefs and assumptions that inform and
shape the nature and strategies of the structuralist models that dominate
psychotherapeutic intervention approaches used for anorexia nervosa. Comparisons with
the assumptions and some strategies that inform a mode of post-structuralist
psychotherapy, namely narrative therapy, used for anorexia nervosa, are presented and
discussed.
Given the significant differences in the two approaches, the article submits that
there is a clear need for further research to assist in the development of improved
psychotherapeutic treatment approaches for persons struggling with anorexia nervosa. It
suggests that this further research explore specifically the accounts of personal
experiences of treatment using experience-centred narratives, and drawing on a
Foucauldian approach for the analysis of the narratives.


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Psychotherapeutic treatment for anorexia nervosa: modernist, structural treatment
approaches, and a post-structuralist perspective

1 - Introduction
The eating problem currently known as anorexia nervosa is complex, with a
multifaceted historical and cultural etiology, and, to date, has no efficacious treatment
approach (Bulik, Berkman, Brownley, Sedway & Lohr, 2007; Finelli, 2001). Prior to the
medical discovery of anorexia nervosa in the late 19
th
century (Gull, 1868; Gull, 1874;
cited in Kaufman & Heiman, 1964; Lasegue, 1873a; Lasague, 1873b; cited in Silverman,
1990; Silverman, 1995), the dominant interpretation of self-starvation drew on Western
Christianity for its explanation, and its interpretation of the nature of the relationship
between females and food (Hepworth, 1999). By the close of the 19
th
century anorexia
nervosa had become an established object of psycho-medical discourse. Throughout the
20
th
century anorexia nervosa became the object of an increasing multiplicity of
discourses. Within the disciplines of medicine, psychiatry and psychology, there have
been a variety of ways in which anorexia nervosa has been theorized, researched,
understood, and its nature and etiology explained (Brumberg, 1986; Malson, 1998).
Discourses that have constructed etiological knowledges about anorexia nervosa
have informed and shaped the approaches to psychotheraeutic treatment of persons with
anorexia nervosa, which approaches have been significantly influenced by three basic
models, namely, the psychoanalytic, the cognitive-behavioural, and the humanistic

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models (Corey, 2005). A fourth form of therapy, namely, family therapy has also been
drawn upon in treatment for persons with anorexia nervosa.
Research has consistently indicated that long-term outcomes for the
psychotherapeutic treatment of anorexia nervosa are often unfavourable (Bergh, Brodin,
Lindberg & Soderstein: 2002; Deter & Herzog, 1994), and that interventions often have
limited success (Button & Warren, 2001; Eckert, Halmi, Marchi, Grove & Crosby, 1995;
Lowe, Zipfel, Buchholz, Dupont, Reas & Herzog: 2001). Furthermore, research reports
have also revealed that those with anorexia nervosa have experienced low levels of
satisfaction with treatments (Newton, Robinson & Hartley, 1993; Rosenvinge &
Klusmeier, 2000).
Given these accounts of outcomes of treatment, the aims of this article are
fourfold; firstly, to explore the beliefs, assumptions, goals and techniques that inform and
shape the four basic intervention models that dominate the structuralist
1

1
Changes in the configuration of the self that undertook a marked shift from the Middle Ages to
the modern era were reflected and produced by the early modern and enlightenment
philosophers, such as Descartes, Locke, Hume and Kant. The radical empiricists, like Locke and
Hume, saw the self as constituted by rationality and the new scientific empirical process. Kant
was concerned by the absence of morality in the empiricists formulations, arguing that the
implications of the empirical line of reasoning would not tell one anything about developing a
personal identity, anticipating the future, or making a moral choice. Kant decided that inherent in
each person were certain mental structures that allowed one to see life in a certain way. Thus,
in order to attend to and explain what the empiricists thought unimportant or unexplainable, Kant
(1781: 1788: 1790) invented inherent or a priori mental categories. In this way the philosophical
movement known as structuralism was born (Cushman, 1995:31-32).
approaches that
have been used with limited success and low levels of satisfaction with persons with
anorexia nervosa; secondly, to discuss the implications and effects of the structuralist
treatment approaches; thirdly, to present comparisons with the assumptions and some
strategies that inform a model of post-structuralist psychotherapy, namely narrative

5
therapy, as a possible alternative to the modernist, structuralist treatment approaches for
persons dealing with anorexia nervosa.
The significant differences between the structuralist and post-structuralist
approaches to the epistemology and treatment of anorexia nervosa, provide the
scaffolding for the fourth aim of the article. The article then suggests that these
differences may be presenting an appropriate opportunity to explore patients
perspectives of psychotherapeutic treatment for anorexia nervosa so as possibly to
address improvements to health care services. This suggestion is offered as there is a
lack of research that examines the experiences and perspectives of treatment of those
dealing with anorexia nervosa, drawing on a qualitative paradigm for the research. This
suggestion is made in specific terms in regard to the methodological approach and the
methods. It is submitted that using experience-centred narratives (Squire, 2008) and
drawing on a Foucauldian approach to narratives (Tamboukou, 2008) would provide an
appropriate orientation to explore (1) the experiences of persons who have been subject
to treatment approaches informed by and embedded in the socially constructed dominant
structural knowledges of anorexia nervosa, and, (2) the influence and impact of such
ways of treatment. A research approach that draws on the narratives of those who have
experienced modernist, structural psychotherapeutic oriented treatment approaches for
anorexia nervosa may be able to contribute to alternative knowledges and ways of
treating those dealing with anorexia nervosa.


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2 - Current etiological discourses on anorexia nervosa
The identification of a specific cause of anorexia nervosa has eluded scientific
studies for over a hundred years, yet numerous etiological rationalizations and theories of
its onset exist, such as, for example, genetic, affective, cognitive, systemic, bio-
psychological, psychodynamic, feminist, and socio-cultural (Grothaus, 1998; Hepworth,
1999; Malson, 1998; Malson & Ussher, 1996).
These etiological rationalizations and theories of anorexia nervosa have been
informed mainly by structuralist ideas that are ensconced in epistemological positions of
positivism and/or empiricism (Popper, 1972a; Popper, 1972b), essentially constructs of
the scientific model that have been embraced and applied in the medical, psychiatric and
psychological fields. In spite of the diverse etiologies, explanations and theories within
medicine, psychiatry and psychology, anorexia nervosa has been almost invariably
conceptualised as an internalised, individualised, clinical entity (Gremillion, 1994;
Hepworth, 1999; Malson, Finn, Treasure, Clarke, Anderson, 2004; Malson, 1998; Malson
& Ussher, 1996). Consequently research based on notions of positivism and empiricism
has focused predominantly on examining causes, clinical features and prognoses, and on
assessing treatment in terms of outcomes. The dominant notion of anorexia nervosa as an
internal, individual psychopathology has tended to preclude the exploration of the
meanings or experiences of anorexia nervosa (see, however, Bordo, 1992; Hepworth,
1999; Malson, 1998; Malson, 2000) or of the experiences of the treatment of anorexia
nervosa (see, however, Boughtwood, 2006; Halse, Honey & Boughtwood, 2008; Eivors,
Button, Warner, & Turner, 2003; Gremillion, 2002; Malson et al., 2004; Ryan, Malson,
Clarke, Anderson & Kohn, 2006).

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3 - Structuralist treatment approaches
2

2
As this article relates to the psychological treatment of persons dealing with anorexia nervosa,
pharmacological treatments are not discussed.
, and assessments of treatment
The etiology of anorexia nervosa in recent times has been understood and
constructed in a variety of medicalised and psycho-pathologised ways. The sets of
diagnostic frameworks that have been formulated and used in practice for anorexia
nervosa, mainly in Western cultures (for example, American Psychiatric Association,
1994: Diagnostic and Statistical Manual of Mental Disorders - hereinafter referred to as
the DSM-IV-TR), have inevitably influenced the array of treatment approaches that have
been used in in-patient, out-patient, community based, specialist and non-specialist
settings (Grothaus, 1998; Malson et al., 2004; Sanders & Gaskill, 2000). These treatment
approaches have included, but have not been limited to, dietetic (Mehler & Crews, 2001),
pharmacological (Treasure & Schmidt, 2001), psychodynamic (Bachar, Latzer, Kreitler,
Berry, 1999; Dare, Eisler, Russell, Treasure & Dodge, 2001), behavioural (Halmi, 1983;
Schmidt, 1989), behavioural and cognitive-behavioural (Dare et al., 2001; Gowers &
Bryant-Waugh, 2004; Vitousek, Watson, Wilson, 1998), family therapies (Dare et al.,
2001; Krusky, 2002), group therapies (Gowers & Bryant-Waugh, 2004), feminist
psychotherapies (Fallon, Katzman & Wooly, 1994; Orbach, 1993), multi-dimensional
approaches (Lacey & Read, 1993), integrated therapies (Steiger & Israel, 1999), and self-
help programmes (Crisp, J oughlin, Halek & Bowyer, 1996). Motivational enhancement,
a mode of therapy that specifically addresses the ambivalence associated with seeking
treatment for anorexia nervosa, has been reported (Vitsousek, Watson & Wilson, 1998).

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Results of studies assessing treatment efficiency and efficacy for anorexia
nervosa vary considerably, but they strongly agree that outcomes are not
encouraging, in that levels of treatment are unsatisfactory. This is the picture
portrayed from reports of: restricted success rates (Bergh, Brodin, Lindberg &
Soderstein, 2002; Boskind-White, 2000; Button & Warren, 2001; Kaplan &
Garfinkel, 1999; Levenkron, 2000; Richards, Baldwin, Frost, Clark-Sly, Berret &
Hardman, 2000), recovery rates that vary from between 11% to 40% (Richards
et al., 2000; Von Holle, Pinheiro, Thornton, Klump, et al., 2008), problems of
chronic relapse rates (Deter & Herzog, 1994), of those deemed to be recovered
from anorexia nervosa in that weight gains are maintained, but who develop
symptoms of bulimia (Eddy-Kamryn, Keel, Dorer, Delinsky, Franco & Herzog,
2002), of those dealing with anorexia nervosa who have reached acceptable
weight levels, but still experience social and psychological problems (Button &
Warren, 2001; Keel, Mitchell, Miller, Davis, Traci & Crow-Scott, 2000), and the
death rate of those dealing with anorexia nervosa being between 5% to 15%
(Bulik, Sullivan & J oyce, 1999: Emborg, 1999).
Research has also indicated high drop-out rates (Eivors, Button, Warner &
Turner, 2003; Mahon, 2000), and low levels of satisfaction among those who use
treatments (Crowe, 2000; Rosenvinge & Klusmeyer, 2000). These issues imply
that attention to patients perspectives on treatment may be appropriate and
valuable in improving mental health care services (Le Grange & Gelman, 1998;
Mahon, 2000; Malson et al., 2004). However, there remains a lack of research
that investigates patients perspectives of treatments for anorexia nervosa (Le

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Grange & Gelman, 1998: Malson et al., 2004), using qualitative research
approaches (Gremillion, 2002: however, see, Malson et al., 2004).

4 - Beliefs, assumptions, goals and practices of structuralist psychotherapeutic
treatment models
3
These models are termed the first (psychoanalytic), second (cognitive-
behavioural), and third forces (humanistic) respectively, given their contributions to the
paradigm shifts in psychotherapy treatment over time. Today their fundamentals
dominate psychotherapeutic treatments (Corey, 2005). These three models essentially
contain a number of beliefs, assumptions, goals and practices from which the over four
hundred current forms of psychotherapeutic treatment approaches are derived (Peavy,

In the light of these unfavourable discourses on treatment outcomes, as
well the accounts from service users of low levels of satisfaction of treatment
experiences, this section examines the beliefs, assumptions, goals and practices
of the structuralist psychotherapeutic treatment models.
In essence, the multiplicity of current approaches to psyhotherapy has been
significantly informed and shaped by three basic psychotherapeutic treatment models,
namely, the psychoanalytic, the cognitive-behavioural, and the humanistic models
(Corey, 2005). These three models will be examined as persons with anorexia nervosa
would have encountered one, or more, of them, or some forms of therapy based on and
drawn from them, during their treatment experiences (Kaye, 1999).

3
Details of their basic philosophies, key concepts, therapeutic goals, techniques, applications,
contributions and limitations of the approaches are fully presented and discussed in Corey
(2005:470-491).

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1996). These three models are structuralist in nature in that they all assume, inter alia,
that the human psyche is informed by certain essential and core structures that are
contained within the individual (Gremillion, 1992; Madigan & Goldner, 1999; Malson,
1998; Malson & Ussher, 1996; Hepworth, 1999; White, 1989).
A fourth form of therapy, namely, family therapy, is also briefly presented, as it,
too, may have been a model of treatment for persons dealing with anorexia nervosa. It is
submitted that the notion of the problem being internalised by the individual, who then
becomes pathologised by current diagnostic and treatment discourses, not only applies to
the individual. This notion has also become embraced in family systems constructs and
therapy, as the problem that is internalised into the family as a unit, which unit is then,
in turn, pathologised for treatment. Thus, these treatment approaches are directed not
only to the person, within whom the problem exists, but often also to the family as well,
as the locus of pathology.
Some of the relevant beliefs, assumptions, goals and techniques of the four
models are now briefly explored to facilitate an understanding of the submissions that the
structuralist treatment approaches have tended to conceptualise anorexia nervosa as an
internalised, individualised clinical entity (Gremillion, 1992; Gremillion;, 1994; Lock et
al., 2004; Lock et al., 2005; Malson et al., 2004). Some historical problems are also
mentioned to provide some context.


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4.1 Psychoanalytic model
For anorexia nervosa, the advent of psychoanalysis reaffirmed a shift in focus to
internal psychological factors that gradually replaced the essentially biomedical focus
that originated from the writings of the two physicians, Gull (1868; 1874; cited in
Kaufman & Heiman, 1964), and Lasague (1873a; 1873b; cited in Silverman, 1990;
Silverman, 1995). Freuds psychoanalysis introduced the concept of purely mental,
deeply internal, intra-psychic phenomena, the tripartite theory of id, ego and superego.
According to Peavy, psychoanalytic theory interprets distress and pathology as the
result of internal dynamics originating in childhood, and holds successful adaptation to
reality as the standard of healthy functioning (1996:4).
Psychoanalysis located anorexia nervosa within the person (Gremillion, 1992).
The classic psychoanalytic formulation for anorexia nervosa was that of oral ambivalence
(Freud, 1958), with food refusal understood as a defence against the fantasy of oral
impregnation, the desire for which may be expressed by periodic gorging (followed by
guilt, disgust, and a purification rite such as vomiting) (Gremillion, 1992). This symbolic
scheme explained all symptoms. In the traditional form of psychoanalytic treatment,
clients recited their psychic monologue while the analyst interpreted its meaning. This
process reconfirmed the phenomenon as deeply internal and separable from dialogue or
interpersonal affect (Foucault, 1971). Bruch (1978) has noted, also, that the anorexic
persons sense of inadequacy was confirmed by being told by an authority figure what the
anorexic person really thinks and feels. Gremillion submitted that these features of
psychoanalytic theory and practice, coupled with Freuds theories about the innately
problematic female in generating fantasized problems, reproduces anorexia nervosa as

12
the individualistic, self-flagelllating struggle of a powerless and inadequate person in
need of control (1992:62).
The power structures of psychoanalytic therapies are apparent from these
discourses that located the phenomenon within the person dealing with anorexia nervosa.
For the sufferer of anorexia, the understandings of the workings of the mental processes
or forces at play were possible through insight about its history that could only be
provided by the knowledge of the psychoanalytic therapist.

4.2 Cognitive-behavioural models
The second force of psychotherapy is comprised of behaviourism, and its
successor, cognitive-behaviouralism. Behaviourist approaches to anorexia nervosa
became popular in the 1960s, partly in response to the inefficacy of psychoanalytic
approaches (Molodofsky & Garfinkel, 1974). Bruch noted that many persons dealing
with anorexia nervosa who experienced psychoanalytic therapies withdrew even more
from participation in life (1982:1534). The behaviourists argued that an important
factor for this failure was the lengthy process of psychoanalytic treatments (Gremillion,
1992). This fostered a search for rapidly effective treatment programs (Herzog, Hamburg
& Brotman, 1987), supported by the belief that the longer anorexia nervosa was allowed
to continue, the worse the prognosis. This notion indicated attention to explicit, external
control over persons dealing with anorexia nervosa (Gremillion, 1992).

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Behaviourists fully acknowledged that their role was a controlling one. Blinder,
Freeman and Stunkard explained the value of a behaviourist program for anorexia
nervosa as follows:

Hospitalization permits a high degree of control over the patients environment.
Yet until recently the full therapeutic potential of hospitalisation has not been
recognized, The effectiveness of operant conditioning techniques might permit
the utilization of hospitalization to a maximal therapeutic effect (1970:1093).

Criticisms of the behavourist approach have been advanced, emphasising some of
the effects of the rationalisations and assumptions of the approach: the inappropriate
emphasis on weight gain itself, the likelihood of a hostile relationship between the client
and mental health staff, and poor results from follow-up studies (Gremillion, 1992). For
example, Bruch has recorded some of her own clients experiences of behaviour
modification treatment:

Anorectic patients have always complained about their hospital experiences, but not
with the same cynical bitterness and sense of utter betrayal expressed by those who
have been exposed to behaviour modification. Uniformly, my patients had
experienced the program as brutal coercion by which they were reduced to utter
helplessness; whatever self-confidence they might have achieved in individual
therapy was nullified. In spite of weight gain, they considered this experience as
anti-therapeutic and spoke of it with real anguish, as unmitigated misery. One
summarised it: It takes no great ingenuity to devise a scheme for forcing someone to
gain [weight] to escape the situation I left the hospital depressed with my own
body, disoriented, and fell apart completely (1974:1421-1422).

Behaviourism, as an enterprise, tended for some time to be imperialistic. The
initial programme of behaviourism - to provide clear, incontestable, measurable laws of
behaviour - has not been realised (Peavy, 1996).

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Cognitive therapy developed in parallel with behaviour therapy, and, in time,
curbed the imperialism of behaviourism. Cognitive scientists showed convincingly that
there was no such thing as a 'stimulus' apart from what the stimulus event was taken to
mean by the mind of the person stimulated by it (Bruner, 1986). Cognitive theorising
helped to bring consciousness and mind back into play, and thus brought about an
important revision in behaviourist thinking. Cognitive therapists have continued to
protect adaptation to reality as a standard for mental healthiness. There tends to be a
conformity-demanding set of values underlying many therapeutic strategies advocated by
cognitive-behavioural experts (Peavy, 1996). Both behavioural and cognitive-
behavioural therapies tend to be based on assumptions of a form of mechanical
determinism as a model of social life, and the desirability of defining mental health as
conformity to rational, individualistic, materialistic values (Taylor, 1989; Peavy, 1996).

4.3 Humanistic model
The humanistic therapies are termed the third force (Corey, 2005; Peavy, 1996),
and are based in humanistic psychology. They had their origins as a rebellion against
what they characterised as both the mechanistic, formalised, elitist psychoanalytic
establishment, and an overly scientistic, removed, fragmenting cognitive-behaviourism.
With its roots in the values of existentialism and humanism, humanistic psychology
developed a philosophical platform based on (1) a centring of attention on the
experiencing person, (2) an emphasis on human qualities, and, (3) an interest in the
development of the human potential inherent in every person (Buhler & Allen, 1972:1).

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In other words, a person contained endless possibilities for development and simply
needed a nurturing, facilitative environment which fostered growth (Corey, 2005; Peavy,
1996). Although there was little stress on conformity to normative societal values,
standards and forms of behaviour, the stress was transferred to the notion of becoming
whatever you want to become (Peavy, 1996:145). This was based on the philosophy
that each person had natural inner potential to actualise through which, he or she could
find meaning, if provided with the appropriate conditions.
One of the most predominant criticisms of the humanistic approaches to therapies
is their over-reliance on the psychology of individualism, and a disregard of the social
relatedness and the individuals community rootedness (Peavy, 1996).

The three therapeutic models that have been presented, namely, the
psychoanalytic, the cognitive-behavioural and the humanistic, all assume that there are
certain essential and core structures that are within the individual, and are the models
drawn on mainly for individual interventions. However, the notion of a problem being
internalised has also been applied to the family as a unit, thus attributing problems as
being internal to the family system.

4.4 Family therapy
Family therapy is a part of a psychotherapeutic approach referred to as the
systems perspective (Fishman, 1985; Friesen, 1985; Goldenberg & Goldenberg, 2000;
Goldenberg & Goldenberg, 2002; Minuchin, 1974; Minuchin, Rosman & Baker, 1978).

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Today the various approaches to family therapy represent a paradigm shift that might be
called the forth force, and are becoming a major theoretical orientation of many
practitioners (Corey, 2005). Family therapy is a complex and developing field that
includes many approaches to understanding and working with families, with a variety of
intervention models being used in different circumstances (Goldenberg & Goldenberg,
2000), such as the experiential, transgenerational, structural, Milan, strategic, and the
social constructionist models. The intention here is merely to note broad characteristics
of family therapy (see, Goldenberg & Goldenberg, 2002; Corey, 2005), as some forms
thereof are used in the treatment of persons dealing with anorexia nervosa (Fishman,
1985; Schwartz, 1999; White, 1989; White & Epston, 1990).
Family therapy approaches hold that individuals are best understood within the
context of relationships and through assessing the interactions within an entire family.
The perspective that the identified clients problem might be a symptom of how the
family system functions, not just only a symptom of the individuals maladjustment,
history and psychosocial development, is grounded on the assumptions that a clients
problematic behaviour may (1) serve a function or purpose for the family; (2) be a
function of the familys inability to operate productively, especially during
developmental transition; or (3) be a symptom of dysfunctional patterns handed down
across the generations (Corey, 2005). Assumptions on which family therapies are based,
have tended to rely on the modernist notion of structuralist internal states (Bruner,
1990; Morgan, 2002; White, 2004) that are considered to be universal to the human
condition. The assumptions informing family therapy have tended to introduce and

17
locate a version of internal state psychology into the family,
4
Critics of the structuralist, pathologising notion of family therapy have pointed to
the fact that by focusing exclusively on altering interactions within a family, therapy runs
the risk of neglecting relevant intrapsychic problems of individual members and
overlooking external, culturally sustained power inequalities that affect family
interactions (Green, 1998). Boscolo, Cecchin, Hoffman & Penn have submitted that
and have provided the
foundation for the manufacture of a new range of family pathologies and relationship
dysfunctions (White, 2004; Morgan, 2002). Consequently, family therapy models (see,
Corey, 2005:432-433) have addressed therapy goals, processes of change, and their
techniques to these internal state notions that have been transferred from the individual
to the family, thus introducing anorexia nervosa as the unique problem of certain family
configurations (Gremillion, 1992).
Family therapy approaches to anorexia nervosa view the family as a system unto
itself, separating the realms of public and private (Gremillion, 1992). Systems theory
regards any family as a self-regulatoryand rule-governed system (Selvini-
Palazzoli, 1974:196). Ironically, the anorexic familys very pathology is the fact that it is
a system that has turned in on itself, developing its own microcosm (Minuchin,
Rosman & Baker, 1978:57). The anorexic familial world is seen as pathological
precisely because it is intensely private, and, being locked within itself, cannot examine
the cultural foundations for the rigid separation between the familial world and the
outside world (Gremillion, 1992).

4
For example, human expression is interpreted as a surface manifestation of these internal
states - a manifestation of unconscious motives, instincts, drives, traits, dispositions and so on
(White, 2004:21)

18
changes to this approach cannot be achieved as long as pathology is assumed to be in
a container as in adysfunctional family system (1987:14).

5 - Current psychotherapies as objectifying, pathologising and normalising
practices
Over the past century, Western culture has been pervaded by understandings of
human action as being reflections of internal state identities (White, 2007:102).
Although such understandings have been subject to challenge, they have become
embedded in knowledges that portray human action as surface manifestations of core
structures of a self that is to be found at the centre of identity (White, 2007). White
typifies structuralist analysis in the following way: One characteristic of structuralist
thought is the surface/depth contrast. It is within the terms of this contrast that peoples
expressions of living are taken to be behaviours that are surface manifestations of
particular elements or essences (2000:61).
These understandings have achieved a taken-for-granted status in much of the
professional psychology of the current era. According to this tradition of understanding,
or truth knowledges, the human condition reflects the presence of these internal
elements as being universally present to different degrees. White (2007) submitted that
human identity is therefore derived from either the direct expression of these essences, or
from distortions of these elements - with such distortions often being referred to as
disorders or dysfunctions (White, 2007:101). Foucault (1971; 1976) also held that
such norms of behaviour, and those behaviours that are deemed abnormal, and labelled

19
disorders and dysfunctions, had been principally constructed by the professional
disciplines, such as, for instance, psychiatry and psychology (in White, 2007:102-103).
Thus, there has been an evolution of knowledge of the concept of a self that is
understood to occupy the centre of a persons identity (Cushman, 1995), whereby an
individual can be discovered (diagnosed) to be disordered or dysfunctional.
In this contextual state of understandings, anorexia nervosa has tended to be
conceptualised as a clinical entity residing within the individual and/or families
(Gremillion, 1992: Gremillion, 1994; Malson et al., 2004). It has, thus, attracted
psychoanalytic, cognitive-behavioural, systemic family, and, to a lesser extent,
humanistic based therapies for treatment. These approaches objectify and pathologise
anorexia nervosa by focusing on a damaged self within a damaged body, and/or within
a dysfunctional family. Thus, cultural discourses have provided a context for the
emergence of anorexia nervosa in the first place, where anorexia nervosa is about a
struggle that is experienced as internal to individuals and families. Gremillion (1992;
1994) stated that even as anorexia nervosa depends on a tacit acceptance of these cultural
discourses, it also problematises them by revealing that they are embedded in power
relationships. Treatment approaches that are pathologising, participate in these power
relationships by representing anorexia nervosa as a deviance from normative ideas and
ways of being. Gremillion submitted that there are ways in which these power
relationships are exercised by psychiatry, by labelling, organizing and constructing
anorexia as a reified and bounded condition that is removed from cultural ideologies and
processes as an illness which can be grasped and fixed (1992:59). In this regard, it is

20
noted that, by psychiatric definition, mental disorders do not articulate with human
relations or cultural conflict. According to the DSM-IV-TR,

each of the mental disorders is conceptualized as a clinically significant
behavioural or psychological syndrome or pattern that occurs in an individual and is
associated with present distress (eg, a painful symptom) or disability (ie, impairment
in one or more important areas of functioning . Whatever its original cause, it
must currently be considered a manifestation of a behavioural, psychological, or
biological dysfunction in the individual. Neither deviant behaviour (eg., political,
religious, or sexual), nor conflicts that are primarily between the individual and
society are mental disorders unless the deviance or conflict is a symptom of a
dysfunction in the individual (emphasis added, xxxi).

Furthermore, the DSM-IV-TR indicates that what are being classified are
disorders that peoplehave (emphasis added, xxxi). The DSM-IV-TR therefore is also
part of, and contributes to the cultural processes of constructing anorexia nervosa as
internally objectified, by being in the individual, and by being a disorder that people
have.
A further contribution to the dominant discourses on anorexia nervosa has been
the guidelines published by the National Institute for Clinical Excellence (NICE) (2004a;
2004b) in the United Kingdom in regard to the treatment and management of eating
disorders. These guidelines from NICE may well be reflective of the specialist
knowledge and views of the British Psychological Society and the Royal College of
Psychiatrists (Lock et al., 2005). The medical view of anorexia nervosa is illustrated in
the following excerpts from these guidelines:

Anorexia nervosa is an illness in which people keep their body weight low by
dieting, vomiting or excessive exercising. The illness is caused by an anxiety about

21
body shape and weight that originates from a fear of being fat or from wanting to be
thin. How people with anorexia nervosa see themselves is often at odds with how
they are seen by others, and will usually challenge the idea that they should gain
weight. People with anorexia nervosa can see their weight loss as a positive
achievement that can help increase their confidence and self-esteem. It can also
contribute to a feeling of gaining control over body weight and shape (NICE,
2004a:11).

1.1.6.2 When screening for eating disorders one or two simple questions should be
considered for use with specific target groups (for example, Do you think you have
an eating problem? and Do you worry excessively about your weight?) (NICE,
2004b:9).

These extracts from the guidelines published by NICE clearly reflect the view that
anorexia nervosa is a medical illness that is identified with the person who has it (Lock
et al., 2005). From these quotations, it could be argued that anxiety, a lack of confidence,
of self-esteem and of agency (control over their bodies and body weight) could be causes
of anorexia nervosa, and the view could be taken that the person who has this illness
(that is, anorexia nervosa), is essentially imperfect (Lock et al., 2005).
In extending this line of discussion in regard to the objectifying, pathologising
and normalising consequences of the power relationships embedded in the
psychoanalytic, cognitive-behavioural, and to a lesser extent, humanistic based therapy
models discussed above, Kaye (1999:20-21) has submitted that these approaches to
psychotherapy are informed by four assumptions, namely, that (1) there is an underlying,
or structural, cause or basis of pathology; (2) the location of this cause is within
individuals (see above, DSM-IV-TR, xxxi; and, NICE, 2004a:11; NICE, 2004b:9; NICE,
2004b:10), or families; (3) the problem is diagnosable; (4) the problem is treatable by the

22
use of specifically designed sets of practices. Kaye (1999) stated that, implicit in these
assumptions are the notions of normality and abnormality, and the presumption of a true
root cause that can be objectively established, recognized, and cured.
In this regard, the DSM-IV-TR has stated that the use of definitions of disorders,
has, helped to guide decisions regarding which conditions on the boundary between
normality and pathology should be included in the DSM-IV (1994:xxxi - emphasis
added). Within this frame, these psychotherapies that deem the individual as the locus of
pathology, can be seen as active practices that treat what are judged to be mental
disorders, and abnormal or deviant or dysfunctional behaviour. Such treatment would
embrace a restructuring or reprogramming of behaviour in both individuals and
families against some criterion of the normal, the well-adjusted, the deviant, the well-
adjusted, the problematic and non-problematic (Kaye, 1999:21).
Moreover, the conceptualisation of these therapies focuses the search for the
solution within the terms of the therapists theoretical knowledge and practical skills.
Such perceptions and understandings create a hierarchical relationship that privileges the
therapists perspective (Kaye, 1999). This approach reflects the modernist concept of the
therapist as a socially accredited authority who can provide an authoritatively true
account of the clients problem, and who can implement appropriate and prescribed
treatment therapies to remedy it (Kaye, 1999).
In his writings and interpretations of relevant works of Foucault (1976; 1977;
1978; 1980; 1986; 1990), and in his social constructionist formulations of narrative
therapy, White (2002) submitted that the structuralist hierarchical privilege is shaped and

23
sanctioned within the modern notion and operation of power in western culture. White
has interpreted this modern notion of power as a mechanism that, inter alia,
establishes social control through a system of normalising judgement that is exercised
by people in the evaluation of their own and each others lives (2002:44), and

employs a technology of power that is characterised by continuums of
normality/abnormality, tables of performance, scales for the rating of human
expression, formulae for the ranking of persons in relation to each other, and specific
procedures of assessment and evaluation that makes possible the insertion of peoples
lives into these continuums, tables, scales and ranking systems (2002:44).

When persons are related to with this objective, modernist approach, they tend
to be regarded as objects, thus inviting them to be positioned in the relationship as
passive, powerless recipients of the knowledge of the expert (Freedman & Combs,
1996). These approaches therefore dishonour the voice of the person subjected to them,
namely, the very person dealing with anorexia nervosa.

6 - An alternative, post-structuralist, treatment perspective
These understandings in regard to the objectifying, pathologising and normalising
notions of the structuralist therapeutic approaches, as well as their consequences of power
in the therapeutic relationships, were meaningfully addressed by Kronbichler (2004) by
employing an alternative post-structuralist treatment approach. The modality that he
drew on was narrative therapy
5

5
See, Corey (2005) for a brief comment on the key concepts and therapeutic processes of
narrative therapy which he adapted from different works, but mainly from Winslade and Monk
(1999), Monk (1997), Winslade, Crocket and Monk (1997), McKenzie and Monk (1997), and
Freedman and Combs (1996).
, a form of therapy that can be considered to be positioned

24
within the social constructionist domain of social psychology (Besley & Edwards, 2005;
White & Epston, 1990; White, 2007).
Kronbichler worked in Salzburg, Austria, within a psychotherapeutic outpatient
department for children, adolescents and their families. He based his work, research and
publication on meetings with 8 young males and their families over a few years. The
young mens ages were between twelve to fifteen years, and their diagnosis had been that
of anorexia nervosa. Kronbichler described some theoretical ideas and their application
in the practice of working with males struggling with anorexia nervosa, ideas and
narrative ways of working that have been experienced as helpful and effective
(2004:55). In his report he presented a comparison of the structural perspectives and the
post-structuralist ideas and ways of working with persons dealing with anorexia nervosa.
The comparative post-structuralist perspectives indicate the significant differences that
inform and shape the social constructionist beliefs, assumptions and ways of working
with narrative therapy. These comparisons are presented in Table 1.


25

Table 1: Comparison of structuralist versus post-structuralist ideas in the treatment of
anorexia nervosa
Structuralist perspective Post-structuralist perspective

Anorexic behaviour as surface
manifestation of problems in the depth
structure of the person

Anorexia nervosa is located in the
interrelationship between social and
cultural practices and subjectivity

Explanations of anorexia nervosa are to
be found in the psyche and/or the family
dynamics

Exploration of the forces that stand with
anorexia nervosa and those that stand
with a life free from anorexia nervosa

Main focus on weight gain

Focus on the effects of anorexia nervosa
in different dimensions of life

Orientation along normative rules
concerning eating patterns, relationships
and adolescent development

Orientation alongside the persons
hopes, dreams, visions, purposes, etc

Centered position of the therapist as
expert

Decentered position of the therapist as
co-researcher

Source: Kronbichler, 2004:58.

The structural perspectives of treatment approaches that Kronbichler (2004)
mentioned, have been incorporated in the earlier discussions of this article. Those

26
discussions converged primarily on persons with anorexia nervosa, and the structuralist
treatment approaches to which they were subject. However, it is worth quoting a portion
of Kronbichlers report, as the quoted portion brings in and relates to his personal
experiences, not as a person with anorexia nervosa, but as a mental health practitioner
working in structuralist environments that provided treatments for persons dealing with
anorexia nervosa. His reported experiences and observations reflect significant
validation of much of the earlier critical discussions on the structuralist approaches to
treatment of anorexia nervosa. He says:

My many years of working in state psychiatric hospitals have shown me the effects
of treatment approaches shaped by structuralist ideas, especially in terms of
conversations with family members, both inside and outside of formal therapy
sessions. Treatment on the basis of such therapies tends to marginalize the voices
of the family members - in particular, that of the person whose life is being
dominated by anorexia. This often leads to conversations in therapy which have
family members believing that they are being criticized by the therapist, and their
relationships, especially between mother-child, being queried. In this way, the
knowledges of the family members about themselves and their relationships run the
risk of being marginalized. This process, together with its associated configuration
of knowledge/power, deprives the family members of their legitimate speaking rights
(Madigan & Goldner, 1998) about matters of their own lives and relationships.

In-patient treatment programs are often organized around surveillance based on
mistrust, following from ideas about the allegedly manipulative personality
structure of persons diagnosed as anorexic. The interactions between nurses and
doctors and the so-called patients intensify around positions of surveillance, reward
and punishment on the part of the helpers; and resignation, rebellion, secrecy and
feelings of not being understood on the part of the patients. In treatment contexts
that are organized around surveillance turn the body into an object of subjugation in
ways that reproduce anorexias politics of oppression and block the way to exploring
alternatives for a persons relationship with anorexia (Gremillion, 2003) (2004:57-
58).

As indicated, Kronbichler used narrative therapy, an approach that originated
from the writings and works of White and Epston (1990). In addition to subsequent

27
works by these two founders (for instance, Epston & White, 1992; White & Epston,
1990; White, 2000; White, 2007), narrative therapy has been further illustrated by a
number of other narrative writers and practitioners (such as Freedman & Combs, 1996;
Monk, Winslade, Crocket & Epston, 1997). Narrative therapy offers a rich cluster of
ideas and ways for working with persons with anorexia nervosa. Kronbichler submitted
that the emphasis of narrative therapy on experience and discourse allows access to
different landscapes of action and identity in the stories of young men who are grappling
with the effects of anorexia in their lives (2004:58).
Finally, Kronbichler submitted that narrative therapy, which is based upon post-
structuralist ideas, is an appropriate alternative perspective to treatments informed by
structuralist ideas and assumptions, and opened up possibilities for entering into more
collaborative alliances with the person struggling with anorexia and his/her family
members (2004:58).

7 - Research issues
This article has noted that the etiological rationalizations and theories of anorexia
nervosa have been informed mainly by structuralist ideas that are based on the rationalist,
scientific model that has been adopted and applied in the psychiatric and psychological
domains. Anorexia nervosa has, thus, been constituted as an internalised, individualised,
clinical entity. In addition, the psychotherapeutic approaches that have been used for
treatments of persons struggling with the effects of anorexia nervosa, have developed
with beliefs, assumptions, goals and techniques that are directed at such perceived
structuralist notions of the self.

28
As documented earlier in this article, the results of studies assessing treatment
efficacy and effectiveness for eating disorders have reflected less than satisfactory, and,
sometimes, contradictory outcomes. Users of treatments have indicated low levels of
satisfaction. However, there is a lack of research that explores the experiences of users of
treatment using qualitative research. Interest in qualitative discourse research has,
however, already illustrated how medical, psychiatric and psychological discourses
inform and regulate mental illness (Foucault, 1971; Foucault, 1977; Parker, Georgaca,
Harper, McLaughlin & Stowell-Smith, 1995), and specific types of diagnoses (Stoppard,
2000; Swann, 1997).
Qualitative research, incorporating notions of critical theory, can be constructive
in examining the numerous ways in which power relations and normative cultural values
are embedded in the discursive constructs of anorexia nervosa. Qualitative analyses have
been undertaken of both bulimia nervosa and anorexia nervosa as discursively constituted
diagnostic categories of eating disordered subjectivities and body management practices
(Bordo, 1992; Borda, 1993; Crowe, 2000; Malson, 1998; Malson, 1999; Malson, 2000;
Malson & Ussher, 1996). More recently, researchers have begun to use discourse
analysis to explore patients accounts of treatment for eating disorders (Boughtwood,
2006; Malson et al, 2004), and nurses accounts of nursing eating disordered patients
(Ryan et al., 2006).
The article has also drawn attention to the significant differences in assumptions,
understandings, and practices between structuralist and post-structuralist forms of
psychotherapy. This was done by noting important comparative aspects of approaches to
treatment from a reported analysis of the use of a post-structuralist form of therapy,

29
namely, narrative therapy, that was found to have been helpful and effective
(Kronbichler, 2004:55). The significant differences between structural and post-
structural approaches to the epistemology of anorexia nervosa, as well as the treatment
thereof, may imply that attention to patients perspectives on treatment may be
appropriate and valuable in addressing improvements to mental health-care services.

8 - Suggestions for the way forward
Given the submissions and arguments in the article, it is suggested that further
research be undertaken, research that could address, more specifically, issues relating to
the experiences of treatment for those grappling with the effects of anorexia nervosa. In
this regard it is important to note that there has been no reported research specifically into
accounts of personal experiences of treatment for anorexia nervosa using the research
methodology and methods of experience-centred narratives (Squire, 2008), drawing on a
Foucauldian approach to the narratives (Tamboukou, 2008). Such an approach would
analyse, from a post-structural, social constructionist point of view, the accounts of the
discursive worlds persons struggling with anorexia nervosa inhabited when being treated
for anorexia nervosa. This process could elucidate, by means of personal narratives, the
implications of the experiences on the construction of persons identities, both their self-
constructions, and through the constructions that are attributed to the mental health
professional (Malson et al., 2004).
A Foucauldian approach to narratives would enable the drawing from
Foucauldian genealogical strategies (Tamboukou, 2008) as research tools to open up the

30
analytic paths in the reading of the experience-centred narratives of persons struggling
with anorexia nervosa. More specifically, using a Foucauldian approach to narratives
will provide an appropriate orientation that would enable analyses of the narratives to: (i)
elucidate the ways in which identities are constituted in an environment of professionally
delivered psycho-medical services; (ii) examine the power relations and normative
cultural values embedded in the discursive constructions of persons subjectivities, and
(iii) explicate the meanings, values, beliefs, ideas and politics that are re-produced in
discursive mental health practices to which the persons are exposed.
The submissions for a need to analyse at these narratives as ways of
understanding experiences and constructed subjectivities are further supported by the
unique knowledges in personal stories that those dealing with anorexia nervosa have
published (see for instance, Epston, 2000; Kraner & Ingram, 1998; Shelley, 1997). They
are also bolstered by a notion that informs the practice of narrative therapy, namely, that
the person dealing with anorexia nervosa would have a more experience near (Geertz,
1983) grasp of their own situation, than others would have. In this context Epston (2000)
has stated that:

I know of no problem as lethal as anorexia/bulimia, given what I have seen
with my own eyes and heard tell that is so misrepresented. And those who
suffer are equally misrepresented. Once provided with the means to speak
against anorexia/bulimia, almost to a person everyone has railed against most
of the psychological/psychiatric constructions of them as anorexics or
bulimics. The stories - from the insiders - are incomparable to the stories
written about them by outsiders.


31


32

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Psychotherapeutic Treatment For Anorexia Nervosa: Modernist, Structural Treatment Approaches, and A Post-Structuralist Perspective

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