Discourse Analysis & Eating Disorder

Journal of Community & Applied Social Psychology J. Community Appl. Soc. Psychol., 14: 473–489 (2004) Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/casp.804

Constructing ‘The Eating Disordered Patient’1: A Discourse Analysis of Accounts of Treatment Experiences H. MALSON1*, D. M. FINN1, J. TREASURE2, S. CLARKE3 and G. ANDERSON3 1 School of Psychology, University of Western Sydney, Bankstown Campus, Locked Bag 1797, Penrith South DC NSW 1797, Australia 2 Department of Psychiatry, 5th Floor Thomas Guy House, Guys Campus, London SE1 9RT, UK 3 Department of Adolescent Medicine, Westmead Hospital, Westmead, NSW 2145, Australia

In this study 39 participants who had all been hospitalized, either in Britain or Australia, at least once for anorexia nervosa and/or bulimia, were interviewed about their experiences of treatment for an eating disorder. Each interview lasted approximately 1 hour and was semi-structured in nature covering: (i) the beginning of participants’ problems and their initial diagnosis; (ii) their history of previous interventions; (iii) their current in-patient treatment episode; (iv) their views on their recovery and future. Interview was audio-tape recorded and transcribed verbatim. The resulting interview transcripts were then analysed qualitatively using a discourse analytic methodology in order to identify the ways in which participants discursively constituted their treatment experiences. More specifically, the article focuses on an analysis of how ‘the eating disordered patient’ was constituted in participants’ accounts both as a self-construction and as a construction attributed to healthcare workers. The implications of these subject im/positions of ‘the eating disordered patient’ are discussed. Copyright # 2004 John Wiley & Sons, Ltd. Key words: eating disorders; patients; subject positions; power; discourse; treatment

INTRODUCTION It is now well-known that eating disorders constitute a major healthcare problem (Becker, Grinspoon, Klibanski, & Herzog, 1999) affecting in particular girls and young women in Western societies (Ben-Tovim and Morton, 1990; Hsu, 1989). Indeed, anorexia has been described as one of the most common chronic illnesses among teenage girls today (Touyz

* Correspondence to: Dr H. Malson, School of Psychology, University of Western Sydney, Bankstown Campus, Locked Bag 1797, Penrith South DC NSW 1797, Australia. E-mail: [email protected] 1 The term ‘patient’ may be considered problematic since it implies ‘traditional’ hierarchical relations of power between providers and recipients of healthcare services. Hence, alternative terms such as ‘client’ and ‘service user’ have been suggested. These terms, however, imply an active and willing consumer-like choice to receive or engage with treatment. Thus, since treatment for eating disorders is often involuntarily or engaged with reluctantly, these alternative terms may obscure the problematic power-relationships involved. We have therefore chosen not to use an alternative to the term ‘patients’ whilst acknowledging the problems associated with its continued use.

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Accepted 14 July 2004

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& Beaumont, 2001). Estimating the prevalence and demographic distribution of the problem is problematic because of, for example, difficulties in determining appropriate definitions of ‘caseness’ (Szmukler, 1985); because of differences in referral practices for different sections of populations (Wardle, Bindra, Fairclough, & Westcombe, 1993); because different studies use different assessment methods and because the results of epidemiological studies vary (Dolan, 1991). However, evidence strongly suggests that the vast majority of those diagnosed as eating disordered are girls and young women (Hsu, 1989; Touyz & Beaumont, 2001) and that diagnoses continue to rise (Lucas, Crowson, O’Fallon, & Melton, 1999) amongst White, middle-class groups and, increasingly, amongst other ethnic and socio-economic groups (Dolan, Lacey, & Evans, 1990; Rhea, 1999; Wardle et al., 1993) and in non-Western as well as Western societies (Nasser, 2000). Thus, questions about eating disorder treatment become evermore pressing particularly as research suggests that treatment is often of only limited efficacy (Deter & Herzog, 1994) and that satisfaction with treatment is often low (Rosenvinge & Klusmeier, 2000). The aim of this article is therefore to investigate eating disorder treatments2 by analysing participants’ accounts of their treatment experiences and, more specifically, through explicating the ways in which ‘the eating disordered patient’ is constituted as a subject position or imposition in these accounts. Researching treatment for eating disorders A range of treatment approaches for eating disorders have been developed (Grothaus, 1998) in in-patient, out-patient, community-based, specialist and non-specialist settings. These include pharmacological, behavioural and cognitive-behavioural approaches, family therapies, individual and group psychotherapies (Newton, Robinson, & Hartley, 1993; Robinson, 1993; Szmukler, Dare, & Treasure, 1998), feminist psychotherapies (Fallon, Katzman, & Wooly, 1994; Orbach, 1993) and multi-dimensional approaches (Lacey & Read, 1993). Treatment approaches have, inevitably, been shaped by the ways in which eating distress, body dissatisfaction and associated body-management practices are understood. ‘Eating disorders’ have been theorized and researched from a variety of perspectives and the now vast literature includes bio-psychological, genetic, cognitive, systemic, psychodynamic, feminist and socio-cultural explanations of their nature and aetiology (see Grothaus, 1998). Within this apparent diversity, however, and particularly within medicine, psychiatry and psychology, ‘eating disorders’ are almost invariably conceptualized within medical or quasi-medical frameworks as ‘real’ individualized clinical entities (see Hepworth, 1999; Malson, 1998; Malson & Ussher, 1996). Thus, whilst the variety of aetiological explanations has resulted in a range of different treatment approaches, the dominant notion of ‘eating disorders’ as individual psychopathologies has tended to preclude exploration of the meanings or experiences of ‘eating disorders’ (see, however, Bordo, 1992, 1993; Hepworth, 1999; Malson, 1998, 2000a) or of treatment (see, however, Eivors, Button, Warner, & Turner, 2003; Gremillion, 1992, 2002). Hence, research has focused overwhelmingly on ‘discovering’ causes, clinical features and prognosis and on assessing treatment in terms of outcomes rather than exploring the discursive productions and regulations of ‘eating disorders’. 2 In addition to clinical services, there is also a range of self-help and ‘alternative’ services that may be available to eating disorder sufferers. However for the purposes of this study, ‘treatment’ is defined as professionally delivered hospital-based interventions.

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The results of studies assessing treatment efficacy vary considerably but strongly indicate that long-term outcome is often unfavourable (Bergh, Brodin, Lindberg, & Sodersten, 2002; Deter & Herzog, 1994) and that interventions are often of only limited success (Eckert et al., 1995; Santonastaso, Pantano, Panarotto, & Silvestri, 1991) with estimated recovery rates of around 30–40% (Richards et al., 2000; see also Kaplan & Garfinkel, 1999). For example, a 10 year follow-up of ‘bulimia nervosa’ patients (Collings & King, 1994) found 48% continued to suffer some symptoms (see also Bergh et al., 2002; Deter & Herzog, 1994). Similarly, a 6 year follow-up study (Smith, Feldman, Nasserbakht, & Steiner, 1993) found 43% of adolescent ‘anorexics’ continued to have an eating disorder and that only 35% had no DSM-III-R diagnosis (see also Richards et al., 2000; Santonastaso et al., 1991). There are also considerable problems of chronic relapse (Deter & Herzog, 1994), of ‘recovered anorexics’ maintaining an acceptable weight but developing ‘bulimic’ symptomatology (Eckert et al., 1995), of weight-restored ‘anorexics’ continuing to experience psycho-social problems (Nilsson, Gillberg, Gillberg, & Rastam, 1999), and of approximately 5–15% of ‘anorexics’ continuing to die from either selfstarvation or suicide (Crisp, Callender, Halek, & Hsu, 1992; Kaplan & Garfinkel, 1999). Moreover, ‘drop-outs’ from treatment are often high and are generally overlooked in research (Eivors et al., 2003; Mahon, 2000). Hence, treatment ‘success’ may well be over-estimated. The potential for increasing treatment efficacy is thus considerable. Indeed, it has been asserted (Ben-Tovim, 2003) that outcomes are no better than they were 50 years ago; that existing treatment for eating disorders may have little if any beneficial effects and, consequently, that new treatment models are urgently required. A substantial body of research has focused on assessing and comparing therapeutic interventions in terms of treatment outcomes (e.g. Lacey, 1983; Mitchell & Carr, 2000). However, comparison between studies and between different forms of intervention is often problematic, firstly, because of the different criteria and (often non-standardized) measures employed in studies (Steinhause, Rauss-Mason, & Seidel, 1991) and, secondly, because quantitative comparison of different interventions may not reveal common or non-specific factors, such as perceptions of patient–therapist relationships, which may well impact significantly upon outcomes (see Andersen, 1998; Le Grange & Gelman, 1998; Lindsay, 1997). Further research has sought to identify patient characteristics such as illness duration (Kennedy & Garfinkel, 1992), time between onset and first admission (Kennedy & Garfinkel, 1992; Steinhausen, 1995), age (Herpertz-Dahlmann et al., 2001; Kennedy & Garfinkel, 1992; Steinhausen, 1995), ‘psychiatric comorbidity’ (Herpertz-Dahlmann et al., 2001; Lacey, 1983) and ‘personality’ (Lacey, 1983; Steinhausen, 1995) thought to predict better or worse prognosis. More generally, researchers have identified clinical features of ‘typical’ patients which may affect treatment. For example, research suggests that those diagnosed as eating disordered may overestimate their body size (WHO, 1992), deny their problem (Kaplan & Garfinkel, 1999) or cherish or feel ambivalent about their ‘anorexic’ status (Malson, 1998; Orbach, 1993). Indeed, some patients may want neither diagnosis nor treatment so that there may be ‘gross disparities’ between the perspectives and goals of patients and healthcare providers (Treasure & Schmidt, 2001; see also Eivors et al., 2003; Robinson, 2000). Perhaps not surprisingly, therefore, many healthcare workers report ‘strong negative feelings’ (Kaplan & Garfinkel, 1999) of, for example, failure, helplessness, frustration, anger, competitiveness, revulsion and exhaustion when working with eating disordered patients (Garrett, 1991; Grothaus, 1998; Kaplan & Garfinkel, 1999; King & Turner, 2000) who, in turn, are often described as ‘hostile’, ‘oppositional’, ‘impervious to Copyright # 2004 John Wiley & Sons, Ltd.

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treatment’ (Kaplan & Garfinkel, 1999), unco-operative, untrustworthy, untrusting, frustrating and difficult to treat (Garrett, 1991; Kenny, 1991; King & Turner, 2000; Lindsay, 1997). Yet, despite this troubling picture of limited treatment efficacy, negative portrayals of patients, and healthcare workers’ reporting negative feelings towards patients, the research focus in this field has tended to remain on outcomes rather than on the ways in which ‘eating disorders’ are constituted, experienced and practiced (see, however, Bordo, 1992, 1993; Burns, 2004a; Hepworth, 1999; Malson, 1998, 1999, 2000a) on constructions and experiences of treatment (see, however, Burns, 2004b; Eivors et al., 2003; Gremillion, 1992, 2002) or the power-relationships embedded therein. The necessity of attending to patients’ perspectives on eating disorder treatments is further indicated by research into treatment acceptability. Whilst there has, to date, been relatively little research into eating disorder treatment acceptability (Newton et al., 1993; Sturmey, 1992), research demonstrates relatively low levels of satisfaction amongst service users. For example, Newton et al. (1993; see also Crowe, 2000; Yager, Landsverk, & Edelstein, 1989), surveying 1638 British service users, found that whilst perceived helpfulness varied considerably for different interventions, all interventions were rated as ‘unhelpful’ or ‘making the situation worse’ by at least 17% of respondents, a figure that rose to 69% for out-patient behaviour therapy and similar levels of dis/satisfaction have been found amongst Norwegian patients (Rosenvinge & Klusmeier, 2000). Such dissatisfaction suggests that attention to patients’ perspectives on treatment may be valuable in improving eating disorder healthcare services (Le Grange & Gelman, 1998; Mahon, 2000). Yet there is very little research which investigates patients’ perspectives (Le Grange & Gelman, 1998) or which deploys qualitative or critical methodologies in researching this field. As Gremillion (2002, p. 383) has noted, ‘[t]he cultural production of [anorexic] bodies [either in everyday life or in treatment] remains almost entirely untheorised within biomedicine’ and remains marginal within psychology and psychiatry. Critical and feminist qualitative research has already elucidated how medical, psychiatric and psychological discourses constitute and regulate ‘mental illness’ (Foucault, 1967/ 1985; Parker, Georgaca, Harper, McLaughlin, & Stowell-Smith, 1995) and its specific categories of diagnosis such as ‘schizophrenia’ (Boyle, 1990), ‘depression’ (Nicolson, 1986; Stoppard, 2000) or premenstrual syndrome (Swann, 1997) in particular ways. A wealth of post-structuralist, anti-psychiatrist, feminist and other texts have deconstructed ‘mental illness’ and re-theorized the psy institutions not as loci of scientific objectivity and humanitarian intervention but as rather more problematic institutions of social regulation operating to safeguard a political status quo (e.g. Parker et al., 1995) and a culturally dominant, but nevertheless tenuous, notion of the (ideally masculine) ‘sovereign rational individual’ (Foucault, 1967/1985). As this growing body of work demonstrates, critical theory and qualitative research are particularly useful in exploring the multiple, often contradictory ways in which clinical diagnoses are constituted and experienced; in elucidating the power-relations and normative cultural values imbricated in these discursive constructions; and in explicating the meanings, values and politics that are re-produced in the discursive practices of treatment (e.g. Parker et al., 1995). Whilst there are now several qualitative analyses of ‘bulimia’ (Burns, 2004a, 2004b) and ‘anorexia’ as discursively constituted diagnostic categories and of ‘eating disordered’ subjectivities and body-management practices (Bordo, 1992, 1993; Crowe, 2000; Hepworth, 1999; Malson, 1998, 1999, 2000a; Malson & Ussher, 1996), there has been considerably less research here into patients’ accounts of treatment for eating disorders. More recently, however, researchers have begun to explore treatment issues using Copyright # 2004 John Wiley & Sons, Ltd.

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qualitative methods such as discourse analysis (Burns, 2004b; Hepworth, 1999), ethnography (Gremillion, 2002) and social constructionist grounded theory (Eivors et al., 2003) to analyse patients’ accounts. This article aims, therefore, to build on this work and to contribute to knowledges of eating disorder treatment by deploying a discourse analytic methodology to explore participants’ accounts of their treatments experiences and, in particular, to elucidate the ways in which ‘the eating disordered patient’ is constituted both in terms of participants’ self-constructions and of constructions of ‘the patient’ that are attributed to healthcare workers.

METHOD Theoretical framework The project was conducted using a discourse analytic methodology to analyse 39 in-depth, semi-structured interviews with recipients of eating disorder treatments in the UK and Australia. The term ‘discourse analysis’ covers several language-oriented approaches which, broadly speaking, are concerned with analysing talk, text, and other signifying practices (Burman & Parker, 1993; Potter, 2003; Potter & Wetherell, 1987). Within this methodological framework ‘discourse’ is viewed not as a transparent medium which could unproblematic reflect some underlying reality. Rather, discourse is understood as constitutive of reality (Burman & Parker, 1993; Potter & Wetherell, 1987) such that discourses systematically constitute objects, events, identities and experiences in particular context-specific ways (Foucault, 1972, p. 49). And in doing so discourses also thereby produce particular ‘regimes of truth’ and relations of power (Foucault, 1972). Thus, in line with other discourse analytic studies, it is the participants’ accounts themselves rather than any putative reality ‘behind’ the discourse which are our objects of investigation. Importantly, therefore, whilst this study aims to ‘give a voice’ to participants in that it is their accounts which are the focus of investigation, the adoption of a discourse analytic methodology also means that the study cannot be viewed as unproblematically ‘patientcentred’. As Widdicombe (1993, pp. 109–110; see also Burman, 1990) has argued: because [discourse analysis] entails talking to people, it goes some way towards giving a voice to those hitherto silenced and in a sense helps ‘empower’ the subjects of traditional social science research (c.f. Bhavnani, 1990). There is, however, a certain irony in this approach and its objectives. In an important sense the participants themselves are irrelevant because it is the language they speak that is the site of investigation . . . . It is therefore questionable whether the ‘democratic’ underpinnings of this research can ever be fully realised in practice.

It is the discourses articulated by the participants rather than the participants themselves (as psychologized individuals) which are the sites of investigation here. Moreover, these accounts are not taken at ‘face value’ as self-evidently ‘true’ in the empiricist sense. The analysis cannot therefore be viewed as ‘patient-centred’ (in the liberal humanist sense) since it is discourse-centred.3 Nor can it be viewed as empowering participants 3 To the extent that the notion of ‘patient-centredness’ is premised on the notion of an (authorial) individual existing independently of and anterior to the discourses they articulate (and are articulated by), then the ontological assumptions about the nature of subjectivities on which patient-centred research are based can be seen as being entirely at odds with a critical view of subjectivity as constituted and regulated within and by discourse and discursive practice (see Malson, 2000b). From this latter perspective a patient-centred and a discourse-centred analysis might be said to converge since discourse is the site of production of subjectivity.

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if empowerment is equated with ‘giving a voice’ to and privileging an account as objectively true. Arguably, however, such a notion of empowerment is problematic not only because it tends to assume a notion of objective or quasi-objective truth, but because it also thereby occludes the micro-processes of domination that are constituted in and through the discursive production of ‘realities’, subjectivities, experiences, and practices both inside of and outside of hospitals (see Foucault, 1972). Thus, whilst considering (liberal humanist) notions of ‘patient-centredness’ and ‘empowerment’ to be problematic, this study is nevertheless concerned with making visible participants’ (discursively constituted) experiences of treatment and with analysing the micro-physics of power (and resistance) which operates within this discursive field. Participants The 39 participants were 38 girls and women and one young man, aged between 14 and 45 years, the majority being in their teens and early twenties. They had all been diagnosed as ‘anorexic’ and/or ‘bulimic’ and had all been hospitalized at least once for their eating disorder with a mix of voluntary and involuntary admissions. For the majority this was their first hospital admission but for some there had been up to three previous hospitalizations. Thirty-one of the 38 participants were in-patients at the time of the interview. Participants were recruited primarily from a specialist eating disorder in-patients ward at a psychiatric hospital in London (n ¼ 16) and an adolescent medicine ward of a general hospital in Sydney specializing in the treatment of eating disorders (n ¼ 16). Of the remaining seven participants, one was contacted by telephone after being discharged, one was recruited to the study via a personal contact and five were contacted through a local self-help group. Participants were recruited to the study by one of the two researchers who conducted the interviews, neither of whom were involved in participants’ treatment or employed by the hospitals where the research was conducted. Participants who were in-patients at the time of the study were approached on the ward and invited to participate. They were given a brief verbal description of the study as well as a written information sheet, a consent form and a copy of the interview schedule. The researcher explained that participation was voluntary and that, should they choose to participate, anything they said would be treated in strict confidence. The research team includes university-based researchers and healthcare workers involved in participants’ care. However, to ensure confidentiality, it was agreed that as well as anonymizing interview transcripts, only the university-based researchers would have access to audio-tapes of the interviews and to whole interview transcripts. Hospital-based research team members only had access to anonymized short excerpts from transcripts and this was also explained to potential participants. Potential participants were then asked to consider whether or not they would like to participate and for those who indicated that they would, a second meeting was arranged to conduct the interview. Participants who were not in-patients at the time of the study were approached and recruited in a similar way. Of those approached the vast majority were willing and often expressed enthusiasm to participate. Since potential participants were assured that non-participation (or withdrawing from the study at any time) need not be justified, those who declined to participate were not asked to explain their decision. Procedure Participants took part in a one-to-one semi-structured interview lasting approximately 1 hour. At this stage too the interviewer provided a brief description of the study; the Copyright # 2004 John Wiley & Sons, Ltd.

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voluntary nature of participation was stressed; confidentiality was assured and participants were asked if they had any further questions about the study. Several participants were, understandably, concerned to have confirmed the assurances that what they would say would not be made available to healthcare workers except in anonymized form. That participants frequently offered highly critical as well as positive comments about their treatment experiences; that they often provided accounts of their own and others’ apparently undetected ‘rule-breaking’ and that several participants commented that they saw the interview as an opportunity to give ‘their side of the story’ might, we would argue, be taken as indicating that they viewed participation positively. The interview schedule covered four broad areas: (i) the beginning of participants’ problems and their initial diagnosis; (ii) their history of previous interventions; (iii) their current treatment; and (iv) their views on their recovery and future. Whilst each interview followed the interview schedule, participants were also encouraged to discuss any issues they considered to be significant. Interviews were audio-tape recorded and transcribed verbatim4 and the resulting transcripts were then analysed using a discourse analytic methodology. In the preliminary stage of analysis transcripts were repeatedly read and re-read and prominent features—topics, themes and issues—recorded. From this preliminary analysis 23 coding categories were developed which were then used to systematically code the transcripts. Working with the coded transcripts we then proceeded to a more detailed analysis of the different categories, attending to the specificities of participants’ talk and to variations as well commonalities in the ways in which a particular topic, theme or issue was construed. ANALYSIS As noted earlier, eating disorder patients have frequently been characterized negatively. Hence, conflict between ‘patients’ and healthcare workers is often explained, at least implicitly, in terms of patients’ characteristics (e.g. Kaplan & Garfinkel, 1999). An analysis of participants’ accounts of their treatment experiences suggests, however, a more complex situation where participants articulated multiple, shifting and often contradictory self-constructions. Negotiating the im/position of ‘the patient’ Whilst there were numerous instances within the transcripts where participants construed themselves as having an eating disorder they also frequently articulated constructions of themselves as ‘normal’, ‘healthy’ and problem-free. For example: Emily: I still don’t see there being anything wrong with me as such. (T9A) Clare: Well people tell me I’ve got an eating disorder. /Int: okay/ They tell me I’ve got anorexia. Int: Right. (.) And um who was it that first diagnosed you with anorexia? Clare: (.) My GP. 4 In the interview extracts that follow all names and identifying details of participants and of people referred to have been changed. Italics are used to show where words have been stressed by the speaker. Non-words and colloquialisms are written phonetically, for example, ‘cos umm that’s all it’s gonna be’. Pauses are indicated by (.) and . . . indicates that part of the transcript has been omitted. Where words have been altered or where explanatory notes have been added these are contained within square brackets. Interjections are enclosed by slashes, for example, ‘you won’t find/Int: mm/anything wrong with me’. Transcripts are numbered and identified according to location, e.g. T1A for Australian transcript no. 1.

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Int: Right, okay. And how did that diagnosis make you feel? Clare: (.) I thought he was mad. (T2UK) Julie: I wasn’t sick before I came here. I was like healthy. I was just like any other normal teenager . . . I feel well like I just think why the hell am I here [in hospital]? (T7A)

Thus, Emily, Clare and Julie all firmly reject any suggestion that there might be ‘anything wrong’. Clare, for example, construes her GP as ‘mad’ for diagnosing her as ‘anorexic’ whilst Julie implies that if she is ‘sick’ it is only because she has been hospitalized since she was a ‘healthy . . . normal teenager’ before. Such statements might be read as denials of a problem but, equally importantly, they also function rhetorically to render participants’ hospitalization and treatment inappropriate. Thus, Julie asks ‘why the hell am I here?’ Participants’ ‘denials’ of a problem might then be read not so much as simple self-perceptions (or mis-perceptions) than as ways of problematizing their treatment. Indeed, participants frequently articulated multiple, conflicting constructions of themselves as ‘anorexic’ and ‘normal’, ‘ill’ and ‘healthy’; having and not having problems; wanting and not wanting treatment such that any attempt to interpret the transcripts in terms of participants’ ‘true’ or unitary self-perceptions would obscure the complexities of their accounts. Participants frequently articulated complex and ambiguous self-constructions which were open to multiple and contradictory interpretation and which incorporated a variety of subject positions and perspectives. Emily quoted above, for example, having said that she does not see ‘there being anything wrong . . . as such’ goes on to give an account of her psychological and physical distress: Emily: I still don’t see there being anything wrong with me as such, only that, well I’m still not happy with the way I look and I have the wrong attitudes towards food. But in a way it [being in hospital] has made me feel better, like physically better. . . . When I was brought in / Int: mm / I was taken over to the emergency ward / Int: right / and I had severe, I was like having like really bad headaches, like blinding headaches. I couldn’t breathe properly, I had severe chest pains, I ha’, my muscles ached. I couldn’t, you know, / Int: right / couldn’t breathe and I felt like I was just like about to fall in on myself. . . . Int: Do you want to put on weight now? Emily: I definitely don’t [giggles] . . . But the only way I can put on, the only way I can feel better is by putting on weight. / Int: mm / So it’s sort of a, I don’t know, what would you say, Catch 22? (T9A)

Whilst Emily ‘still do[es]n’t see there being anything wrong with [her] as such’ she also portrays herself as ‘not happy with the way [she] look[s]’, as having ‘the wrong attitudes towards food’ and as having been seriously physically ill as a result of her weight-loss. She construes herself here as simultaneously having and not having problems and whilst she ‘definitely do[es]n’t’ want to gain weight she also implies that she considers weight-gain to be a good idea when she says that ‘putting on weight’ is ‘the only way [she] can feel better’. Whether ‘feel[ing] better’ is read in terms of ameliorating physical symptoms, improving psychological wellbeing or some combination of both, Emily figures in her account as someone occupying and torn between a multiplicity of conflicting subjectivities and desires. Explaining participants’ objections and resistances to—or engagements with—treatment in terms of unitary self-perceptions or attitudes is thus rendered problematic since participants took up multiple, shifting, ambiguous and contradictory subject positions in relation to their diagnosis, to the prospect of change and to their treatment. Mirror mirror on the ward: other constructions of ‘the eating disordered patient’ Participants’ self-constructions were, however, not the only constructions of ‘the eating disordered patient’ which appeared in the transcripts. In talking about their treatment Copyright # 2004 John Wiley & Sons, Ltd.

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experiences participants frequently discussed the ways in which they felt themselves to be understood by healthcare workers. That is, ‘the eating disordered patient’ also featured as a construction attributed to healthcare workers who thus functioned in participants’ accounts like mirrors, reflecting or projecting an image of ‘the patient’ which might be ‘recognized’ or ‘refused’ by participants. In the following extracts, for example, a construction of ‘the patient’ which is attributed by healthcare workers is resisted by participants. Jacqui: It’s sort of like speaking to him [a doctor] is like bashing your head up against a wall. / Int: right / Because everything you say is part of the disease. No matter what it is, / Int: right / it’s part of the disease . . . And you’re like: I’m a person. There’s a personality in here you know? It’s not just, / int: mm / you know I’m not just anorexic kind of thing / Int: right, yeah / which is really tough. (T6A) Elizabeth: I also think talking down to us, like everything is your anorexia and having everything you do analysed as anorexic pattern is very destructive. / Int:mm / I know that they are desperate to find why people are ill and to challenge everything because of that, but there are ways of doing it. (T13UK)

Neither of these extracts involves a disputed diagnosis. Jacqui, in arguing that she is ‘not just anorexic’ implies that she is, amongst other things, ‘anorexic’ whilst Elizabeth’s objection is not so much to idea that ‘people are ill’ but to the ‘ways’ in which healthcare workers ‘challenge everything because of that’. These are not accounts in which treatment is construed as wrong or inappropriate on the grounds that there is no problem requiring intervention. They are, nevertheless, accounts which problematize treatment and which do so specifically through problematizing a particular construction of ‘the eating disordered patient’ that is attributed to healthcare workers. It is a construction in which ‘the patient’ is constituted as entirely encompassed by ‘the disease’ such that ‘everything you say is part of the disease’ and ‘everything you do [is] analysed as anorexic’. In Jacqui’s extract earlier, for example, she articulates a desire to be understood as ‘not just anorexic’ but also as ‘a person’ with ‘a personality’. What is construed here as ‘really tough’ might, therefore, be not so much treatment per se but a particular im/position of ‘the patient’ in which ‘everything is your anorexia’ (emphasis added). The analysis here, thus, resonates with that of Eivors et al. (2003) where participants expressed concerns about treatment focusing on symptoms to the exclusion of understanding patients and the meanings of their ‘symptoms’. In the following extracts this same construction of ‘the patient’, constituted as entirely pathologized, emerges again and functions here as the basis upon which Polly dismissed her psychiatrist’s advice, Simone evaluated her treatment as ‘a crock of shit’ and Clare ‘question[s] whether this is the right sort of treatment for [her]’. Polly: I thought he [a psychiatrist] was pigeon-holing me. / Int: right, as an anorexic? / Yeah, yeah. And all anorexics think this and do this / Int: right/so you must be like that . . . I didn’t trust any of his advice / Int: right / because I felt he was telling me about what, um, you know, your classic anorexic ought to do. / Int: mm / And I always felt well he doesn’t know me. So / Int: right / he’s just seeing the illness part of me. He’s not taking me as a whole. (T8UK) Simone: Within the first 2 days I said: I have, this is a crock of shit. I said this man [a doctor] doesn’t know me, he hasn’t come up and said to me: what are your interests, this this and this. / Int: mm / And he’s judging me by what’s written down and these measurements, that kind of thing. (T5A) Clare: I question whether this is the right sort of treatment for me because I feel that my problems aren’t addressed at all and I’m just um (.) being treated as a case book, study sort of thing, out of a textbook. (T2UK) Copyright # 2004 John Wiley & Sons, Ltd.

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In these extracts a distinction is made between two kinds of knowledge of ‘the patient’. There is a medical knowledge of ‘the illness part of me’, ‘what’s written down and these measurements, that kind of thing’ in which, by implication, ‘the patient’ is constructed only in terms of her pathology. And, in contrast, there is a second kind of knowledge which ‘tak[es] me as a whole’; a knowledge which involves, in Jacqui’s extract earlier, knowing her ‘personality’ and, in Simone’s, her ‘interests’. In Polly’s extract this distinction between these two kinds of knowledge is further emphasized by construing the psychiatrist’s knowledge as a ‘one-size-fits-all’ stereotyping where any specificities of Polly’s ‘anorexia’ are lost in a knowledge ‘about what, um, you know, your classic anorexic ought to do’. As with Clare’s account, the construction of ‘the eating disordered patient’ as a case ‘out of a textbook’ is contrasted with a more personalized and individuated knowledge of ‘the patient’ ‘taken as a whole’. In each extract, then, participants articulated a particular construction of ‘the patient’ constituted only in terms of pathology and it is this particular depersonalized construction which is again construed as unacceptable. What these extracts suggest therefore may be that in talking about resisting treatment participants are not so much objecting to the im/position of ‘the eating disordered patient’ per se. Rather, the objection is to a particular de-personalized and un-individuated construction of ‘the patient’ as ‘just [an] anorexic’, devoid of (nonpathological) ‘personality’ and ‘interests’. Pathology, power and ‘patienthood’ The extracts below similarly evidence this construction of ‘the patient’ in which ‘everything [she] say[s]’ is construed as a symptom of her ‘eating disorder’. What emerges as problematic here, however, are the power-relations between patients and healthcare workers entailed in this construction. Julie: Everything I say he [a doctor] just like, he laughs at you kind of thing. Like you say one thing and he just laughs and he goes: Oh it’s not her talking, it’s the illness. (T7A) Jessica: And they don’t listen to you at all. And whenever you try and like rationalize anything with them they just, you get told to sort of shut up because it’s the illness talking and you can’t possibly know any better than them because otherwise you wouldn’t be in here in the first place. / Int: mm / [sighs] And there’s like no compromise or anything. You’re not allowed to have like choices or preferences. (T14UK)

These extracts again illustrate a construction of ‘the patient’ as an entirely pathologized subjectivity. In these accounts there appears to be no possibility of thinking or saying anything which will not be (taken to be) a symptom of pathology and which will not also thereby be disqualified as invalid. Thus, where ‘the eating disordered patient’ is construed as thoroughly pathological ‘she’ is also thereby constituted as powerless since there is no place or space within this construction of ‘the patient’ from which ‘she’ can articulate a valid view. The possibility of ‘her’ being taken seriously and being able to negotiate treatment decisions is precluded by the particular way in which ‘she’ is constructed. In Jessica’s account, for example, she is, she says, disenfranchized from the decision-making process in her own treatment precisely because she is a patient: she ‘can’t possibly know any better than [healthcare workers] because otherwise [she] wouldn’t be in here in the first place’. In this context then a refusal to take up the position of ‘patient’ might be interpreted not so much as a denial of illness or problem than as a resistance to the particular power-relations implied in this construction of ‘the patient’. Our analysis again resonates with Eivors et al.’s (2003) Copyright # 2004 John Wiley & Sons, Ltd.

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where participants expressed concerns about ‘lack of negotiation’ (p. 98) and ‘feelings of powerlessness’ (p. 102) in treatment. In the extracts above this construction of ‘the patient’ as thoroughly pathologized is attributed to healthcare workers and resisted by participants. There were, however, several instances where a very similar construction was articulated as a self-construction (see also Malson, 1998). For example: Barbara: [T]hat was my total identity. Like I remember at one point in hospital I wasn’t actually able even to read a book or do anything like that because, um, for the internal dialogue of um: well I have to be one hundred per cent anorexic and produce anorexic behaviour at all times. (T14A)

The construction of ‘the patient’ as entirely pathologized, as ‘one hundred per cent anorexic’ or ‘bulimic’, is not, therefore, a construction attributed only to healthcare workers. It also appeared as a self-construction. Yet, whether framed as self-construction or attributed to healthcare workers, it is equally problematic. When attributed to healthcare workers it is, as the above analysis indicates, constituted as depersonalized and disempowering and is embedded in accounts of resisting treatment. As a self-construction it is a subject position which appears to close off the possibility of ‘recovery’. If the speaking subject construes herself as ‘one hundred per cent anorexic’ then the possibility of ‘recovery’ collapses into the threat of self-annihilation. Elaborating the construction of ‘the patient’ In the following extract this construction of ‘self’ as entirely pathological is again articulated as a self-construction: Int: Is there anything that the nurses say that kind of, or do, that makes you feel more like putting weight on or eating more? Alice: . . . just knowing that there’s a lot more to life than I s’pose eating disorders. / Int: mm / Cos well you just get to a point where you think that’s your whole life and that’s all it’s gonna be. (T12A)

Thus, Alice articulates a subject position (which she implies she has, at some time, inhabited) which is entirely encompassed by ‘eating disorders’ and which is thus entirely devoid of non-pathological attributes. Significantly, this construction of herself as thoroughly pathologized (‘that’s your whole life’) again figures as a position which closes off the possibility of ‘recovery’: ‘that’s all it’s gonna be’. This extract includes the same institutional positions—patients and healthcare workers—and the same two conflicting constructions of ‘the patient’—as ‘one hundred per cent anorexic’ and ‘not just anorexic’—as those discussed earlier. However, in contrast with the earlier extracts, healthcare workers are portrayed here, not as imposing this subject position on the patient, but as challenging it by ‘knowing that there’s a lot more to life than . . . eating disorders’. That Alice is responding to a question about what ‘nurses say . . . or do, that makes [her] feel more like putting weight on or eating more’ suggests that their ‘knowing’ this is constituted here as a therapeutic intervention; an intervention which enables Alice to produce a different, more elaborated construction of herself which moves beyond a totalized subjectivity where the parameters of ‘anorexia’ are equated with the parameters of permitted or imagined subjectivity such that ‘that’s your whole life and that’s all it’s gonna be’. Thus, the assertion ‘that there’s a lot more to life than . . . eating disorders’ functions here to disrupt the subjectivity of the ‘one hundred per cent anorexic’ and enable its elaboration beyond the parameters of ‘eating disorders’ to re-open the possibility of ‘recovery’. Copyright # 2004 John Wiley & Sons, Ltd.

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CONCLUSIONS In deploying a discourse analytic methodology to analyse participants’ accounts of their experiences of treatment for eating disorders this article has sought to contribute to the growing body of critical, qualitative research into health, mental health (e.g. Parker et al., 1995; Stoppard, 2000; Swann, 1997) and particularly into eating disorders (Bordo, 1992; Burns, 2004a, Hepworth, 1999; Malson, 1998) and their treatment (Burns, 2004b; Eivors et al., 2003; Gremillion, 2002; Le Grange & Gelman, 1998). More specifically, we have sought to explore some of the specificities and complexities that emerged in participants’ accounts of their treatment experiences and to explore how ‘the eating disordered patient’ was discursively constituted in these accounts of resistance to and engagement with treatment. In the first part of our analysis, focusing on participants’ self-constructions, we elucidated how participants frequently shifted through multiple, often contradictory subject positions in relation to their diagnoses and treatment. Like other discourse analytic studies (e.g. Burman & Parker, 1993), our analysis thus presents a view of participants’ not as ‘sovereign individuals’ with more or less unitary and stable attitudes and beliefs (about themselves or about treatment) but as complex collectivities of often contradictory, discursively constituted subject positions whose accounts could be viewed, not as simple reflections of internal/psychological or external ‘realities’, but as instances of social practice in which the nature of ‘reality’ (of themselves and of their treatment experiences) were actively constituted and negotiated in the context of a wider discursive field of medical and psychological discourses, institutionalized hospital practices and so on. And in elucidating this multiplicity of subjectivities our analysis thereby suggests that explanations of patients’ resistance to or engagement with treatment in terms of unitary self-perceptions or attitudes may gloss over the complexities to be found in patients’ accounts of treatment. In the second part of our analysis our focus shifted to participants’ talk about how they were viewed by healthcare workers. As a discourse analysis of patients’ accounts, our analysis cannot address questions about the relationship(s) between what participants have said about how they are viewed by healthcare workers and what healthcare workers might say about their views of patients. Neither can it address questions about the relationship(s) between these accounts and the various linguistic and non-linguistic discursive practices on hospital wards or in other treatment contexts. Additional research is clearly required to address these questions. The aim of analysis in this present study, however, was to explore participants’ accounts themselves (regardless of how they might compare with other accounts). This part of our analysis might appear awkward in that it is concerned with accounts about ‘what Alice says healthcare workers think Alice is like’—a kind of hall-of-mirrors or refracted discursive surfaces where ‘the eating disordered patient’ appears as a figure imported into these accounts from other texts. ‘She’ is constituted inter-textually as an interpretation of an interpretation of a patient. These accounts could, therefore, be viewed as difficult sites for analysis since they are concerned with healthcare workers’ views but are not themselves healthcare workers’ accounts and since the relationship(s) between participants’ and healthcare workers’ accounts or between these accounts and some putative ‘reality’ remains distinctly uncertain. However, whilst the accounts may seem epistemologically ‘messy’ because of their obvious inter-textuality (they are interpretations of interpretations), this cannot be said to set them apart from any other text which always inevitably refers implicitly or explicitly to further texts outside of itself. A text’s ‘frontiers . . . are never clear cut: . . . it is always caught up in a system of references’ Copyright # 2004 John Wiley & Sons, Ltd.

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to other texts (Foucault, 1972, p. 23). And precisely because of their inter-textuality, because they are participants’ accounts of healthcare workers’ views of patients, these account thereby articulate a ‘folding in’ of other texts (and discursive practices) into participants’ accounts. They articulate some of the discursive ‘folds’—the sites of interpolation and resistance—in which the speaking subject is ‘caught’ and constituted by discourse. In exploring these accounts our analysis elucidated a particular construction of ‘the patient’ attributed to healthcare workers: a construction of ‘the patient’ as entirely pathologized which was construed by participants as inadequate and unacceptable, firstly, through contrasting it with a more elaborated and personalized construction of ‘the self’ as ‘not just anorexic’ and, secondly, through objections to the power-relations that are constituted by this all-encompassing pathologization of ‘the patient’ whereby if ‘everything you say is part of the disease’ you are disqualified from negotiations about your treatment because ‘it’s the illness talking’. In these accounts participants’ talk about conflict and resistance in treatment thus focused not on disputing the identification of a problem requiring intervention but on critiquing a particular (depersonalized and disempowered) construction of ‘the patient’ attributed to healthcare workers. Thus, in explicating the specificities of participants’ accounts, our analysis problematizes explanations which view resistance to treatment as symptomatic of pathology by elucidating talk about resistance to treatment in terms of reasoned and understandable critiques of this particular construction of ‘the patient’. Our analysis thus suggests that, in understanding and addressing the well-documented issues of conflict and resistance in treatment, it is important for healthcare workers to attend to the specificities of that which is being resisted and to address the ways in which they (as well as their patients) construe their patients and the ways in which these constructions of ‘the patient’ are constituted and re-constituted, interpreted and re-interpreted in the interactions between healthcare worker and patient. Our analysis also indicates the importance of challenging a restricted focus on pathology and ‘eating disorder symptoms’ and of asserting a more elaborated construction of the patient that would incorporate non-pathological attributes, not only because ‘the one hundred per cent anorexic’ was rejected as a subject im/position (when it was articulated as a subject position imposed by healthcare workers) but also because (whether attributed to healthcare workers or articulated as a self-construction) it appeared to close off the possibility of ‘recovery’. By equating the parameters of acknowledged, permitted or imagined subjectivity with the parameters of ‘anorexia’, the construction of ‘the patient’ as ‘one hundred per cent anorexic’ (or ‘bulimic’) entailes a collapse of ‘recovery’ into selfannihilation. In emphasizing the significance of a more elaborated, personalized and empowered construction of the patient, our analysis also resonates with that of Gremillion (2002) who has raised concerns about the consequences of a too-narrow focus on food, eating and body-weight. She argues that such a regime can be seen as re-enacting and consolidating rather than challenging ‘anorexic’ and ‘bulimic’ pre-occupations and practices. Eivors et al. (2003) similarly warn against focusing on ‘symptoms’ to the exclusion of understanding the patient and the meanings of ‘symptoms’ for the patient. Thus, in line with current treatment guidelines (NICE, 2004, p. 11) advocating ‘a focus on . . . wider psychosocial issues’ as well as on ‘eating behaviour and attitudes to weight and shape’, Eivors et al. argue that, in addition to food and weight management, ‘one of our aims in therapy [should be] to enhance a sense of self apart from that defined by the eating behavior’ (p. 104). Copyright # 2004 John Wiley & Sons, Ltd.

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Moreover, again converging with the analysis presented in this article, Eivors et al. (2003) also highlight patients’ concerns about feelings of powerlessness in treatment, arguing that treatment may ‘reinvoke feelings of powerlessness’ (p. 102) which ‘eating disordered’ practices may have served to mitigate so that treatment ‘may inadvertently contribute to the maintenance of behaviour they ostensibly wish to change’ (p. 102). As the above analysis suggests, where ‘the patient’ is constituted as entirely pathologized, ‘she’ is thereby disqualified from negotiations about her treatment. Powerlessness is thus an integral aspect of that subject position since expressions of resistance, ambivalence or attempted negotiation immediately become constituted as symptoms of pathology. Our analysis thus suggests that the construction of ‘the patient’ as ‘one hundred per cent anorexic’ not only closes off the possibilities of imagined subjectivities beyond the parameters of ‘eating disorders’ but also contributes to a sense of powerlessness which may be neither politically not therapeutically acceptable. By seeking to emphasize and enhance a more elaborated subjectivity that is not constrained by the parameters of pathology, healthcare workers might thereby address this ‘disqualification’ of patients’ views as well as opening up the possibilities of non-anorexic, non-bulimic subjectivities and body-management practices.

ACKNOWLEDGEMENTS We are grateful to all the participants who made this project possible by taking part in interviews and talking candidly about their views and experiences of treatment. Thanks also to Anna Strong who conducted and transcribed some of the interviews with British participants and to Fay Murphy for her help in co-ordinating access to participants. Thanks also to the reviewers for their helpful comments on an earlier draft of this article. This research was supported by grants from the Department of Psychology, University of East London, UK and from the University of Western Sydney, Australia.

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