Famished: Eating Disorders and Failed Care in America

Lester, Rebecca J. 2021. Famished: Eating Disorders and Failed Care in America. University of California Press.

Famished: Eating Disorders and Failed Care in America is an ethnography of eating disorders, how they are elaborated in a nexus between personal experience, clinical logics, insurance exigencies and research agendas within the US healthcare system. Rebecca Lester tacitly weaves together her ethnographic observations of an American eating disorder clinic, to her clinical work with patients in that clinic, and her own experience, personal struggles and visceral memories of anorexia. Famished initiates us to the existential torment of eating disorders, nourished in the nefarious failures of an irresponsible healthcare system, but ultimately reads as an intimate letter of optimism and hope. It is a brutally beautiful clinical ethnography and an inspiring example of reflexivity and moral engagement.

Famished sets out to explore eating disorders and how they ‘emerge in and through the circulation of knowledge and practices among treatment providers, research agendas, and insurance companies.’ The book is a confluence of ethnographic and clinical vignettes, ranging from case studies of patients, discussions and dialogues between patients and the author, or between clinicians, group therapy sessions, clinical intake notes and reports, and autobiographical flashes. Rebecca Lester shares more than twenty years of material and experiences, while shifting positionalities throughout the book. She approaches eating disorders and their treatment as a medical and psychological anthropologist, working on extreme bodily practices and the meaning they take in cultural settings. As a licensed social worker, she gains unique insights of the clinical work with anorexic patients, the challenges clinicians face in dealing with insurance companies, and the ambivalences in their practice – aspects that would be otherwise obfuscated in a purely ethnographic approach. Finally, as someone who had an ongoing struggle with eating disorders from a young age, she delves into her past to offer us glimpses of what it might mean to experience the ever-presence of an eating disorder from the inside. The writing, organized around four interlaced thematic sections, juxtaposes these different voices that work in synergy to carry us through the book.

In the first section, Provocations, the author introduces us to the world of eating disorders. She considers eating disorders as spaces of knowledge production and clinical diagnosis in Cedar Grove, the clinic within which she conducted her ethnography and practiced as a social worker, but also in the broader context of psychiatry, healthcare and mental health in the US. She asserts that eating disorders are a major public health issue, which is heavily misunderstood, and largely underfunded both in research and caretaking with many patients neither getting enough, nor the right care, as a result of failing managed healthcare in the US. This opens to a discussion on what constitutes an eating disorder and where we might situate the malaise beyond the immediate symptoms. The author convincingly argues that eating disorders are a relational question, more than a medical or psychological one. They occupy spaces of subjectification and deep-rooted, existential and intersubjective struggles with being visible/invisiblespeaking/silent, and an agent/object. Following an exercise in historical epistemology, where the author traces the history of eating disorder, and briefly explains the layered theoretical and clinical approaches (from pre-freudian, psychodynamic and family-based therapies, all the way to biological- and cognitive-centered models), the author discusses eating disorders as an existential project, as technologies of presence– practices for developing subjective and relational senses of being, becoming real, and mattering across affective, personal, structural and social fields.

Frameworks, the second section of the book, unpacks how institutionalized modes of managed care, research practices and clinical traditions concur in the definition of frameworks of care, understandings of eating disorder and the possible ‘horizons of recovery.’ They contribute to the sustainment of attitudes of distrust and suspicion towards eating disorder patients. The author craftily brings to light how the economic interests of insurance companies combine with notions of quantified evidenced-based research and biometric indicators in the treatment of eating disorders to form a looping, self-sustaining circuit of care that ultimately fails the patients. In describing the organization of care in Cedar Grove, the author underlines the importance of milieu therapy (reminiscent of institutional psychotherapy), and how these diffracted frameworks of care carry into specific considerations of temporality and chronicity in eating disorders and their treatment. Particularly, how anticipatory regimes and practical chronographies inevitably structure relationships of care in the clinic, deepening the rift between medical and recovery models of mental illness, and challenging notions of authenticity and the ethics of care – we end up wondering, how might we justify forms of care that ‘look like – and feel like’ more like harm and that perpetuate and reinforce the issues they set up to heal?

The third section of the book, Dynamics, focuses on the encounter between eating disorder patients and the clinic. The core of Lester’s ethnography, this section focuses on the experiences of patients with treatment regimes at Cedar Grove. Treatment is divided in three temporal phases, presented in sequence in this section: the initial introduction to the treatment during the first few weeks, the core of the treatment, and a final phase in preparation to leave the treatment and the clinic. After accepting that they are ‘in recovery,’ patients at Cedar Grove will dive into their relationship to food, which in broader terms simply means, into their relationship to others, to human attachment. The journey is neither smooth nor linear, and patients and clinicians will struggle in the renegotiation of relationships and in dealing with their respective existential angst, feelings of anger, shame, pain but also failure. Eating disorder is foregrounded as a ‘strategy of affective regulation and presencing,‘ intertwined to problems of recognition, erasure, and worthiness in relation to social relationships, especially regarding the parents of patients. As such, the clinical space at Cedar Grove is organized as a ‘sort of substitute family system’ aiming at helping the clients develop boundaries and achieve independence and autonomy. Internal Family Systems therapy is enacted at Cedar Grove, and the author details the alternative vision of the self and subjectivity proposed by IFS theory – the self as a distributed network, ‘a system of multiple, relatively differentiated parts,’ closer to the Buddhist vision of the ‘non-self’– and explores issues of moral responsibility and the situation of moral agency within this therapeutic framework.

Therapy in Cedar Grove implicates affective recursions, whereby feelings and experiences are reproduced during the therapy, by being embedded in relational and institutional structures. In this last section, Recursions, the author examines how the economic conditions of care for eating disorders affects the relationship between patients and caretakers, how assumptions of manipulation and authenticity come to occupy the therapeutic relationship. Following the thread of economic consequences and managed care, she discusses both the ingrained culture of therapreuneurism (from therapy and entrepreneurship) among clinicians trying to catch up with the latest trends and demands of a continuously evolving managerial healthcare landscape, and the extensive culture of precarity and dispossession facing the patients, these ‘failed neoliberal recruits’ within the contemporary US healthcare system. The author’s engagement with eating disorders and their treatment, leads to a final chapter detailing concrete steps we could take to remedy some of these problems – admittedly in a managerial system that is unlikely to be abolished any time soon. Her suggestions, as an anthropologist, clinician, and survivor of eating disorder focus on discursive strategies and terminology, education for professionals and the public, much needed concrete research directions, and advice on hands on treatment practices.

What makes Famished an exceptional ethnography, however, is not simply the breadth and depth of the analyses, the multiple perspectives the author takes, or the richness of her twenty-year long observations. Rebecca Lester’s narrative dances to the rhythm of her autobiographical vignettes. Each chapter is preceded by a short episode from the author’s own experience of eating disorders, reaching back to her childhood memories all the way to her twenties, and finally today. The book opens and closes with these vignettes, and they provide the structure, immediacy and intimacy of the story. If you ever wondered how anthropological theorizing, ethnographic descriptions and clinical accounts become embodied, read these passages, slowly and respectfully. They will drive Rebecca’s points right to your gut – ground the ache, uncertainty, self-loath and hope of someone struggling with an eating disorder into your own flesh and blood. Her personal vignettes read like punches.

Famished will leave you satiated. This is an ethnography standing at the core of anthropological engagements with care, ethics, and the body. Scholars interested in medical and psychiatric anthropology, the anthropology of food and the body, as well as the anthropology of ethics and morality, will find little treasures dispersed throughout the book. Finally, it is also another precious case of clinical anthropology, bridging the clinic to ethnography – posing key epistemic and ethical questions on the meddling and complementarity of these roles – while standing as a reminder of how marvelous it is when anthropologists engage personally with their objects of study, blurring the lines between ethnographic and autobiographic experience. This is psychological anthropology at its best.

Christos Panagiotopoulos is a doctoral candidate in anthropology at Cornell University (US) and an invited French Government Scholar at EHESS/CNRS (France). He works at the intersections of psychological anthropology, the anthropology of ethics and morality, and the anthropology of religion, with a particular focus on psychotherapy, mental health and care regimes. For his doctoral thesis he studies conflicting models of care within the juvenile rehabilitation system in France.

© 2020 Christos Panagiotopoulos

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