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Paula Joan Caplan's Authors Guild Blog

Why Must People Pathologize Eating Problems?

First published February 15, 2020, at https://www.madinamerica.com/2020/02/pathologize-eating-problems/

 

by Paula J. Caplan, Ph.D., and Jo Watson

 

The latest issue of the Sunday New York Times (February 9, 2020) had a full-page essay in its "Modern Love" series, in which writer Lauren Covalucci, an intelligent, self-aware woman, describes having been shamed since age three in her ballet class because her tights dug into her waist. At age 13, she writes, "my body had stretched and thinned," and her teacher said to her, "You finally look like a dancer." You might think that would be enough to convince her that such intolerable pressures – which pervade not only the ballet studio but the wider societies of many countries across the globe – are unconscionable and that something is wrong with the perpetrators of those pressures, not with those who are made to feel horribly inadequate and even to hate themselves.

Sadly, Covalucci reports that, after she began feeling better about her body thanks to being in a relationship with a man who treated her well – "Another person's comfort with you can make you forget your discomfort with yourself," she says – her therapist announced that she had an "eating disorder." The result of that diagnosis was despair: "That's when I really plummeted…. I spent mornings on the floor in a corner…, wailing because I couldn't speak in complete sentences anymore and my brain, my beautiful, Harvard-trained brain wouldn't work right." As psychologist Michael Cornwall has written, assigning someone a psychiatric diagnosis is the "infliction of what amounts to a medical curse."

 

Covalucci writes that eventually, she got better, and although she started taking psychiatric drugs that she says helped her it was the ongoing love and respect of her partner that made a huge difference. (She later mentions Prozac, which often causes weight gain, and reports that she has become "fat" and is trying to have a positive attitude about that.) Even when at one point her partner mentions that she has gained weight, because of his loving attitude toward her, "The words lost their venom coming from him." What would have helped, she says, is if her therapist had not told her she had an eating disorder, thus making it seem like she was "mentally ill," that there was some kind of internal, individual difficulty she had rather than that she was responding to terrible pressures from her ballet teacher and society in general.

 

Given that the societal factors leading girls and women to panic about their weight are crystal clear, why didn't her therapist address that with her instead of doing the most harmful thing, classifying her as mentally ill? That, too, would have been helpful, as the work of Prof. Carla Rice, former director of the Body Image Project at Women's College Hospital in Toronto showed decades ago. Once girls and women come to understand that they have been acting out impossibly strict societal standards with regard to eating and that their often distorted images of how they look have resulted from those standards, it is easier for them to begin to challenge them, keeping them in acutely conscious view, and to find other ways to feel good about themselves.

 

Indeed, why is it that so many people, even some astute critics of the traditional mental health system who are happy to challenge the pathologizing of emotional distress generally, cling uncritically to the term and concept of "eating disorders"? We come across it all the time and are genuinely confused and frustrated.

 

A Critical Omission
Those who challenge psychiatric diagnoses overall usually do so because on the whole they lack scientific foundation and certainly lack scientific validity, and are in fact constructs invented by committees of people with vested interests!  Unlike physical illnesses such as diabetes and cancer, there are not, never have been, and are never likely to be objective tests for the so-called psychiatric illnesses. Critics of psychiatric diagnoses generally readily acknowledge that, for instance, "Borderline Personality Disorder," "Schizophrenia," and "Attention Deficit Hyperactivity Disorder" are constructs without biological basis and have been invented and promoted by a collective of powerful people with questionable objectives that are mainly concerned with increasing their profits, power, and territory.

 

It is alarming that too often, "eating disorders" diagnoses have been left out of the critical dialogue, leading to a bizarre situation in which almost every class of psychiatric "disorder" is challenged except this one. Why is it alarming? Why indeed would the pathologizing of emotional distress that involves food, eating, and body image be any more acceptable than the pathologizing of emotional distress that gives rise to obsessive thinking, dissociative experiences, or suicidal thoughts and actions? The concept of "eating disorders" is just as dubious as all of the other so-called "disorders."  It is just as much a construct, and it is no more justified to call it "pathological" than, for instance, good old "PTSD."

 

Traditional mental health professionals have capitalized in many ways on pathologizing socially created problems, and the "eating disorders" concept does this especially blatantly, given the well-documented ways that patriarchal society puts intolerable pressure on girls and women to believe they can never be too thin, persuading them that if they weigh "too much," they will be unattractive to and devalued by men specifically and by society generally. In the process, it has become unusual for girls and women to be comfortable with their bodies, even when they become dangerously thin.

So why do some people who otherwise challenge "mental disorders" claim that the label "eating disorders" is legitimate and must be retained? One argument is that "It's a biological problem, fundamentally physiological!" But the fact that depriving oneself of or bingeing on food has physical consequences no more justifies calling such behavior psychiatrically disordered than it would justify creating the concept "sprained ankle disorder."

Like most people who take comfort in being psychiatrically labeled, some women and men may suppose that the therapist gave them a label because he or she believes they are suffering. But that validation could be achieved by the statement, "I believe you are suffering," which would not add to their burden by conveying the notion that they are also "sick."

Besides masking the powerful social factors causing eating problems, to diagnose someone with an eating "disorder" is to make it extremely likely that they will be told something is wrong with their brain and that they need psychiatric drugs. Also, because severe restriction of food can have, at worst, fatal effects, caring family members may understandably agree to have the diagnosed person hospitalized, and sometimes even ask for this. But once hospitalized, in far too many cases, the person is increasingly medicated and stripped of their sense of agency.

 

Case Study
Consider the not unusual case of a teenage girl who had starved herself in reaction to her parents' ignoring her pleas that they get a divorce because she could not bear their constant fighting and her father's demeaning of her mother. Her parents resisted, though both of them longed to be out of the marriage, instead of staying together "for the daughter's sake." Talk about turning her reality upside down! When she was hospitalized in a psychiatric ward, her therapist advised her parents to forbid her to participate in the extracurricular activities she adored, where her immersion in the arts and her warm friendships were important in giving her strength to endure her difficult home life.

 

Allowing her to go home on a brief visit, the therapist also told the parents, "If you put 15 grapes on her plate, you have to make her eat all 15 grapes." Thus, she was deprived of her sources of emotional sanctuary and infantilized, just as her parents' and the doctor's pathologizing of her as the source of the problem involved a stunning lack of respect and regard for the suffering caused by her home situation. And all the while, no one addressed the forces that led to her using starvation as a coping mechanism: her father's demeaning views of real women and society's message that the route to happiness and regard is through weight loss. Many unhappy women go on strict diets when they feel that important parts of their lives are beyond their control, but dieting is something they can control.

 

What would likely have helped that young woman would have been if first her parents and therapists had really listened to the pain that her parents' awful relationship and her father's demeaning view of women were causing her, and then had worked with her to find ways to reduce that pain. Both parents could have considered her needs rather than the abstract principle that even a terrible marriage should continue because it is better for the child than a divorce. The psychiatrist could also have helped the daughter to spend more time and energy in rewarding activities like her choir practice rather than forbidding them unless she ate what the therapist considered to be "enough." He could also have helped her find ways to gain a sense of agency, given how helpless she was feeling, living with parents who were miserable and a father who demeaned women. And he could have helped her find ways to earn friendship, love, and respect other than by trying to become impossibly thin.

 

A New Perspective
The Power Threat Meaning Framework for considering emotional suffering could offer an infinitely more hopeful and respectful way of responding to eating distress than the traditional illness narrative imposed by psychiatry.  Lucy Johnstone, lead author of the article "The Power Threat Meaning Framework: An Alternative Nondiagnostic Conceptual System" published in the Journal of Humanistic Psychology, includes this advice:

"The Power Threat Meaning Framework can be used as a way of helping people to create more hopeful narratives or stories about their lives and the difficulties they have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient or 'mentally ill'."


This framework is a way to understand that "what may be called psychiatric symptoms are understandable responses to often very adverse environments and that these responses, both evolved and socially influenced, serve protective functions and demonstrate the human capacity for meaning-making and agency." The adverse environments of the woman and the girl described above were clear and starving themselves was in both cases a way to try to take some control over how people evaluated and treated them. So helping them to understand that the adverse factors in their environment were unreasonable, inhumane, and harmful; to consider other ways to think about themselves; and to find different, life-enhancing, life-enriching, self-respecting, safe ways to feel a sense of belonging, being loved, and caring for themselves would have been natural outgrowths of a Power Threat Meaning approach to so-called eating disorders.

 

The Power Threat Meaning Framework would suggest that eating problems should be understood not as a symptom of an illness but as a reaction to difficult experiences, as a threat response, a way of surviving the intolerable, that will on every level make sense. The Framework is ultimately about the process of that sense being made, and surely few would disagree that there are always reasons, always stories behind every type of eating problem.

 

We both remember too many reasons and stories, just as we remember too many women who we've come across over the years who had internalized the belief that they had/have an "eating disorder."  Just like any other psychiatric diagnosis, it has all too often robbed them of their power, taken away their agency, stolen their hope. The diagnosis of "eating disorder" in all its forms is as much a curse of psychiatry as any of its numerous others. Isn't it time we called it that?

 

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The Truth About Trump and Psychiatric Diagnosis — The Lightbulb Has to Want to Change

Originally published 02/20/2017 10:34 pm ET @ http://www.huffingtonpost.com/entry/58abb3b0e4b0417c4066c22b

Once you know a crucial fact about what gets called mental illness, the debate about whether or not President Donald J. Trump is mentally ill disappears, and what is left is what really matters. What really matters is that President Trump apparently has no desire to change behavior that has been described as totally self-absorbed, self-referential, misogynist, racist, xenophobic, and otherwise abusive.

It’s ironic that the arguments on both sides of the debate about whether or not Trump is mentally ill are based on the one “alternative fact”: that deciding who is mentally ill is a science. That could not be farther from the truth.

Those who are arguably the world’s most powerful psychiatrists — those who periodically create and publish a new edition of the psychiatric handbook called the Diagnostic and Statistical Manual of Mental Disorders (DSM) — typically acknowledge that the foundational premise of the entire book, that it is possible to define “mental illness” in an adequate, appropriate, and useful way, is wrong. In each edition of the DSM, the new set of arbiters tries to create a definition of “mental illness,” since the book consists of hundreds of alleged categories and subcategories of mental illness and thus depends on their getting that primary definition right. Each time, they have acknowledged their failure to do so. Even Allen Frances, who oversaw creation of the DSM edition that held sway from 1994 to 2013, famously called psychiatric diagnosis “bullshit” (cited in Gary Greenberg’s excellent Book of Woe from his article in Wired based on his interview with the psychiatrist).

As far as I can tell, no one else weighing in on the debate about the President has served on a DSM Task Force...and then felt they had to withdraw because of what they had learned. I spent two years as an insider on Allen Frances’s Task Force, where I learned that — despite what is widely assumed to be true — psychiatric diagnostic categories are not scientifically derived but are constructed, made up by the handful of people with the most power in the DSM hierarchy. When Frances in various media currently gives the impression that he is uniquely qualified to judge President Trump because he wrote the criteria for Narcissistic Personality Disorder (NPD), the label that many therapists have recently applied to him, Frances neglected to note that the criteria for NPD change with every edition. Frances changed them somewhat from the DSM edition that came before his, and the NPD criteria in the edition subsequent to his — the currently in use DSM-5 — differ from his. These changes reflect the moving-target nature of this label.

The changes over time in how NPD is defined are important, because to debate about whether or not the President has NPD is to reify misguidedly and harmfully the notion that there is a scientific way to find out. I resigned from the DSM-IV Task Force because I could not participate in the creation of a book that would be marketed as scientific when I knew that it was not — and that would garner more than $100 million for its publisher, the American Psychiatric Association, and help Big Pharma earn billions of dollars for psychiatric drugs marketed as curing the ever-growing number of manufactured categories.

Some people try to prove that Trump does not have NPD on the grounds that his self-centeredness and so on do not cause him to suffer; but even that argument is irrelevant, because no version of NPD has specified that in order to “qualify” for this label, one has to be suffering because of its features.

Do people suffer and deserve help to alleviate that suffering? Of course, they do, and that is the subject of many books and other articles. But the research about how that is best done — what behavior, feelings, and/or thoughts can be changed — and what cannot is a side issue for our purposes here, because there is not a shred of evidence that President Trump wants to change. Remember that old joke: “How many therapists does it take to change a light bulb?” “One. But the lightbulb really has to want to change.”

There is great debate among therapists about whether or not any personality disorders belong in the manual of mental illnesses, since it is an arbitrary decision left to each individual therapist whether or not a particular patient’s personality is extreme enough to qualify as a disorder. To engage in the attempt to decide whether or not President Trump has NPD is to act as though that label is clearly a description of a mental illness, however one defines “mental illness.”

Some believe that if they were to prove that the President is mentally ill, it would be easier to turf him out of office. But it was morally wrong that Senator Thomas Eagleton was removed as George McGovern’s vice presidential running mate in 1972 when it became publicly known that he had suffered from bouts of depression and had been hospitalized for that reason, because what should have mattered for him and should matter for all elected officials is how well they can do their jobs. Eagleton had been a great Senator. Whether or not one believes that Trump is doing his current job well depends partly on whether or not you share his views of the world, partly on whether or not he is truthful with the people of this nation (many Presidents have not been), and partly on how he manages his various tasks.

At this crucial time in our nation’s history, the last thing we need is to let debates about whether or not the President is mentally ill divert us from deciding whether or not he is doing his job, whether or not we like what he is doing, and whether or not what he is doing is dangerous or evil.

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Author’s note: I am the author of They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal, which is my insider’s description of the process of creating the book that is called the psychiatrist’s “Bible” and is used to determine who is mentally ill. I am editor of Bias in Psychiatric Diagnosis and have written many articles and book chapters about psychiatric diagnosis, which I would be happy for people to read.
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