Whose Culture is it Anyway? Disentangling Culture and Eating Disorders – Part 3

The articles I’ve looked at so far in this series (Becker, in part 1, and Keel and Klump in part 2) give us some insight into the idea that the link between “Western” societies and eating disorders is more complex than a simple matter of media exposure. But, having read these studies, I was still left a bit wanting in terms of unpacking that black box of “culture” that gets tossed around in scholarly and popular literature. What, exactly, are we talking about when we talk culture in eating disorders?

Rebecca Lester, who is quite a prolific social anthropologist and who has written about eating disorder treatment systems in the USA and Mexico, makes the argument that “culture” is too often used as an umbrella term for semi-related but not-entirely-synonymous factors. This makes me wonder: is it possible that in latching on to the media side of Becker’s findings, for example, there has been too little attention paid to the other systemic factors that are indeed tied to culture- but not culture as it is generally attended to?

In 2007, Lester wrote an article in which she “complicates the acculturation hypothesis” made by historian Joan Brumberg (2000). Brumberg and others argue that when Western cultural values are exported to developing countries, we see an uptick in disordered eating. Note that Lester isn’t doing away with the idea that eating disorders might accompany cultural shifts; on the contrary, she is adding complexity to this idea, in part by asking what we mean when we say culture. But why? Didn’t we see from Becker’s work that though the link might not be solely linked to sociocultural artifacts like media, it still exists?

The problem, according to Lester, is that looking at “transport” of cultural values involves using categories that are specific to cultures (created within a specific culture), like DSM diagnoses, to explain what is happening in other societies. This exploration might also help to shed some light on Keel and Klump’s findings about the culture-boundedness of BN (i.e., that the metrics we are using to judge behaviour might not capture similar but not quite the same behaviours).

Clear as mud? Essentially, Lester’s argument here is that using (in this case Western) categories to evaluate impact on other cultures means imposing a certain understanding of culture onto another society.

In this article, Lester explores:

• How embodied experience of eating disorders differ across contexts
• How people in therapeutic environments frame these issues and the people who experience them differently according to “local clinical cultures”

She wonders how “similar existential struggles about gender and embodiment might be differently expressed in the two contexts” (p. 370); so, the same/similar underlying thoughts being expressed and/or responded to in different ways. This fascination seems to stem from an observation she had over the course of her field work in Mexico and the US: clinicians in the US and Mexico respond to eating disorders and facilitate recovery in different ways, despite being faced with strikingly similar sets of behaviours.

THE STUDY

This article is based on a part of a large-scale (15 year) anthropological study including (among other things) participant observation, interviews, and “event narratives” (getting multiple perspectives on a single issue). In this article, Lester presents two cases wherein clinicians discussed an issue that had arisen with a patient. She notes that this is not meant to be a direct comparison of the two, but that looking at each reveals specific messages espoused by treatment team members that reflect broader social context.

In the first, Lester presents the USA treatment team’s response to a patient who had brought in a laptop and had used it to look at pro-ana sites. What unfolded in the team meeting was essentially a splitting between those who suggested taking a “hard line” and banning the computer, and those who wanted to let the girl make her own choices (“soft peddlers”).

Lester describes these perspectives as emblematic of the broader currents that have framed (problematically, I might suggest) eating disorders in the US:

• An (old-school) perspective on the causes of eating disorders where they are seen as “a struggle for autonomy” rooted in enmeshment, perfectionism, control, rejection of womanhood
• The subsequent positioning the treatment team as a “substitute family” that can eventually nurture the individual with an eating disorder toward autonomy

Importantly, these discourses that position eating disorders as a) choice-based and b) rooted in family dynamics have been quite harmful for people with eating disorders and their families. I reproduce them here only to illustrate how they were described in the article. While I do believe the majority of treatment providers would have moved past this point of view since the time of Lester’s fieldwork, it is interesting that these discourses loomed in the treatment team’s discussion of this case. And while we have (hopefully) moved past this family-blame style message, other parts of the message remain quite intact; notably, the privileging of “individual” and “autonomous” style of life and the discourse of “free choice” linked to neoliberalism.

In the case study of the Mexican clinic, Lester describes other patients’ and clinicians’ responses to a new patient who entered the clinic. Notably clinicians described a disconnect between what they had learned about eating disorders in training (i.e. that they had much to do with autonomy and choice) did not match patient presentation, in their view.

Instead, clinicians in Mexico turned to look at how people with eating disorders experience others in their lives, and what kinds of impact their behaviours have on others. Interestingly, Lester notes, this resulted in what a USA based clinic might see as a well-developed understanding of the eating disorder being seen in a negative light, interpreted as selfishness instead of insight.

One of the most interesting things about Lester’s analysis is how it reveals some paradoxes in the treatment styles imposed in US and Mexican contexts:

• In Mexico, this discourse of codependency (relying on others) actually requires change on the part of the individual, in contrast to the discourse of social relationship inherent in Mexican culture
• In the US, the development of autonomy and individuation is strongly girded in a paternalistic system, perhaps at odds with the discourse of individuality

What does this mean for our understanding of eating disorders as culture-bound?

Both Becker and Lester explored eating disorders in the context of societies undergoing what might be seen as “Westernization.” Of course, saying this presupposes that all societies are on a similar course, that is, one leading toward capitalist, and consumerist, values that prize individualism, autonomy, and freedom of choice.

Lester’s account in particular reveals how importing treatment systems into other cultures might not be so easily done and might even lead to providers feeling ill equipped to manage patients’ presenting concerns, which are at odds with what they expect to encounter. She notes that it might be a useful line of inquiry to look at how eating disorders are diagnosed (the process of seeing and responding to symptoms) and how different contexts lead to different interpretations of similar sets of behaviour.

What does this say about culture and eating disorders? Complicating the “culture” void allows us to look beyond the obvious manifestations of culture and toward other facets of life that might lead to distress, help to support people as they seek to recover, or open up space for new ways of understanding eating disorders.

We could also look, taking Lester’s suggestion further, at how “culture” within contexts might change how people engage with the commonly used categories we use to understand eating disorders. For example, might individuals who have immigrated experience a disconnect between what is normal in their culture of origin and what is being deemed disordered in mainstream society?

Also interesting are the inconsistencies between goals and styles of treatment. Is there a way to better match the desired outcome to the goals of the treatment, in line with the cultural context(s) at play? Does promoting individuality, for example, require a paternalistic “substitute family,” as is implicitly present in many treatment settings? Is there a way to work beyond this implicit pursuit of individualistic values even within Western societies? What could cross-cultural considerations look like if we didn’t assume that all societies were moving toward capitalism and neoliberalism?

I find I am often unsatisfied with the equating of “culture” and “society” precisely for the reasons I suggested above: a “society” can have many cultures, and culture is bandied about as a term in a way that suggests its use as synonym for society, media, family, and political-economy, spheres that intersect to create a context, but that bear exploration in their own right and in those intersections. Yay intersectionality! Let’s start walking the talk.

I had originally intended on this post being the last in the series, but due to popular demand, there will be another one (possibly 2) coming; I’ll look at 2 studies from Africa to expand on some of the complexity around “culture bound” and culture-within-culture dynamics.

References

Lester, R.J. (2007). Critical therapeutics: cultural politics and clinical reality in two eating disorder treatment centers. Medical anthropology quarterly, 21 (4), 369-87 PMID: 18074903