Phenomenology and Psychiatry: Enhancing our Understanding of Anorexia Nervosa Treatment
Treating Anorexia Nervosa (hereafter ‘AN’) is complex, with unfortunately high relapse rates at 35 to 41 % in an average follow-up period of 18 months. Relapse prevention is a matter of essence considering only half of all anorectics receiving AN treatment achieve full recovery after 4 to 10 years (Steinhausen, 2002). Exploration into why treatment is so ineffective, and how it could improve, is therefore also necessary. At the very least, alternative—multidisciplinary—forms of treatment deserve to be considered in the dire AN treatment setting. Philosophy, for example, may show how Phenomenology can develop our current characterisation of AN, thus in turn enhancing our understanding of effective treatment for AN, namely exercise therapy despite its historic bad press.
Anorexia Nervosa and Current Treatment
Firstly, whereas Anorexia refers to loss of appetite, Anorexia Nervosa refers to the psychiatric disorder (Bowden, 2012) and is the focus of this article (starting with diagnosis). Indeed, to be diagnosed with AN, the diagnostic criteria—set out in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, i.e., the DSM-5—must be met:
Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental history, and physical health.
Intense fear of gaining weight or becoming ‘fat’ (despite being significantly underweight.)
Disturbance in the way in which one’s body weight or shape is experienced. - Undue influence of body weight or shape on self-evaluation.
Denial of the seriousness of the current low body weight.
(American Psychiatric Association, 2013.)
A diagnosis, based on such criteria, proves particularly important since it facilitates treatment. The kind of treatment used depends on various factors. For patients diagnosed with AN who are over 18 years, for example, talking therapies are offered to help manage feelings about food and eating. This includes Cognitive Behavioural Therapy (CBT), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), or Specialist Supportive Clinical Management (SSCM). As for individuals under 18 years, the kind of treatment offered might include Family Therapy or Adolescent-focused Psychotherapy, to name a few examples. Let's briefly consider the effectiveness of the most common treatment: MANTRA. Introduced in 2006, MANTRA considers predisposing personality traits to be key in an individual’s vulnerability to AN and is designed to help patients understand what causes their illness. With a large focus on what is important to the individual personally, MANTRA encourages one to change their behaviour when they’re ready. Indeed, the so-called ‘Maudsley Method’ can be characterised by an intensive outpatient treatment where patients are integrated as an active and positive role.
Fortunately, and as Ulrike Schmidt et al (2015) note, MANTRA in several studies shows not only significant and stable improvements in eating disorder ('ED') psychopathology and BMI (i.e., body mass index), but also high treatment acceptability and low drop-out rates. MANTRA, unsurprisingly, is therefore often the ‘preferred’ treatment for AN and has proved to be a highly effective and tailored therapy. As a specialist integrative therapy, however, MANTRA—like many of the therapies available for AN—excludes exercise therapy. Exercise is simply not often prescribed in the clinical management of anorectics (Ng and Wong, 2013). This of course doesn’t come as a surprise since AN is an eating disorder often proceeded by excessive physical activity. The prevalence of AN, for instance, is approximately 0.2% to 0.9% with 40 to 80 % of anorectics exercising excessively (Ng and Wong, pp.1, 2013). Hence exercise as treatment for AN has historically received negative attention. Though this is understandable, and at face value exercise does not appear conventional or even appropriate as treatment for AN, this is only because exercise therapy is often misunderstood. Indeed, the kind of exercise that could be included in treatment is what’s important here, id est, supplementary supervised and adapted exercise. Exploration into the benefits and effectiveness of this treatment is clearly worthwhile—or perhaps simply needed—since rates of relapse remain so high despite treatments like MANTRA.
Exercise therapy has the potential to provide an effective and innovative form of treatment for AN. As Heather Hausenblas (2008) writes,
The by-product of the dominant view of exercise as negative in the context of ED is a lack of understanding of how exercise can be moderated (when excessive) or promoted (when either low or non-existent) under appropriate conditions (e.g., stabilisation of weight and medical clearance from a physician). ( pp.44 )
Thus, it is certainly not the case that every type of exercise can be used to treat all individuals with AN. Burning calories is of course not the objective. Alternatively, exercise incorporated into treatment must be moderated. Physical activity such as resistance work, light yoga, or stretching, if incorporated into treatment at the right time proves particularly effective as treatment. The general psychological benefits of exercise, broadly speaking, also apply to AN. Hausenblas, for instance, writes that “patients with ED may experience improved self-esteem, body image, and mood, as well as a reduction in the uncomfortable sensations of bloating and distention during eating.” Further, since exercise is known to promote self-regulation, “exercise may reduce bodily tensions and negative mood and increase tolerance to everyday stress [in AN patients], which are all triggers for binging and purging” (Hausenblas, pp.44, 2008)
Psychologically, exercise results in improvements in the malleable ED risk and maintenance factors of self-esteem, depression, negative mood, and body image. Exercise also results in improved social bonds and relations (Carron, Hausenblas, and Mack, 1996) and may therefore aid in improving social behaviours since patients with AN so often experience disturbed relations such as isolated eating and reduced social contact (American Psychiatric Association, 2013.) In sum, exercise therapy that's in moderation, nutritionally supervised, and adapted to an individual with AN at a safe time may prove particularly valuable. Evidence only supports such therapy, despite any misunderstanding of how exercise could treat AN amongst the public. Phenomenology enhances our understanding of how this is so.
Phenomenology of The Body
First, let's make clear the bridge between Philosophy, Phenomenology, and Psychiatry. As a well-respected tradition within Philosophy, Phenomenology (of the body) explains how the internal perception is formed and why it is internal and not external. The 'own' body, according to Phenomenological study, is not constituted as an object of external perception (i.e., as a physical or natural body), because the subject perceives her body as belonging to herself (Fuentes, 2017). What is more, and as introduced by Merleau-Ponty (2013), the body according to Phenomenology is seen as a subject inhabiting the world and may be referred to as the lived body, with mind and body being intertwined. Phenomenology of the body which may incorporate such concepts indeed centres around the subjective experience of an individual. Hence Phenomenology may therefore centre around the subjective experience of a patient in Psychiatric practice. Such an approach to psychiatry aims to improve treatment outcomes by prioritising patient accounts over a standardised “checklist” of symptoms.
Though the phenomenological tradition is well-respected within Philosophy, the same does not apply to Psychiatry despite the use of Phenomenology at revealing the conscious experience of mental disorders. Phenomenology indeed can make it easier to understand what it is like to experience AN. This research, Phenomenology of The Body, is presented by Thomas Fuchs (2021), and allows for a more developed understanding of AN prior to diagnosis and treatment. Such phenomenological research, along with Merleau-Ponty and Drew Leder's body philosophy, may be represented in several research studies which point to the effectiveness of exercise as a form of treatment. Let's first look at Fuchs' work in greater detail, which may genuinely enhance our understanding of the role of the body (i.e., how the body is experienced) in AN, thus in turn enhancing (I) our characterisation of AN and (II) how to treat AN.
Fuchs (2021) begins by pointing out the importance of how the body is experienced in AN. Fuchs writes that, unlike Phenomenology, “the DSM-5 overlooks the profound changes in bodily self-awareness in anorexic patients.” (Fuchs, pp.109, 2021.) It is therefore overlooking what patients have to say about their experience of AN. Consider the detail of what an anorexic patient after a binge eating attack reported:
I was disgusted with myself, with my stuffed body. (...) The taste of rotten eggs rose in me. I imagined how everything in me must have gone into a process of decay. (pp.109)
The DSM-5 characterisation of AN perhaps doesn’t consider the Phenomenology—or lived experience—of the body like described in the quote above. Many descriptions of the AN ‘lived’ bodily experience are unfortunately not often reflected by the DSM-5 criteria which is rather simplistic compared. It is therefore important to consider how Phenomenology could better our current understanding of AN which is based on/influenced by the DSM-5 characterisation. As seen in Fuchs’ (2021) work, for instance, Phenomenology may describe AN as a disorder of embodiment. This involves extensive investigation into AN, including what it means for AN patients to experience radicalisation and reversal periods. Fuchs (2021) found that “in the foreground, the anorexic pursues the ideal of thinness; however, her ‘hidden agenda’ is actually another” (pp.111). Further:
The anorexic gives a radical, even counterphobic answer to the dilemma of adolescence, namely the conflict between the bodily self and the body-for-others. (...) She does not find a balance between the body-for-others and the lived body; instead, she makes her body the object of self-mortification and thus of desexualisation.” The body “appears only as an alienated object of control, indeed increasingly as a hated adversary. (pp.112)
Fuchs is suggesting that the actual conflict in AN consists in a fundamental ‘alienation’ of the self from the body. Such conflict arises in adolescence, where the body becomes an object of other peoples’ gaze in a particular way. Although this is initially an attempt to comply with an ideal body image, it becomes a fight against one’s dependency on their body and the inevitable processes this might encompass (i.e., “above all its hunger and femininity”.) To feel as though they’re both in control and independent from their body, the anorectic increasingly fights their bodily nature. Hence “in striving for autonomy and perfection, the anorexic patient alienates herself from embodiment.” (Fuchs, pp.109, 2021).
A phenomenological understanding of the body is particularly illuminating, especially when characterising AN. Phenomenology listens to the anorectics’ experience of the body thus enhancing our understanding of AN, perhaps even better than the DSM-5 description does. With a better characterisation and understanding of AN comes an enhanced understanding of what treatments are effective, namely exercise therapy when supplementary to talking therapies. Exercise is of course body orientated. Meanwhile, Phenomenology notes the importance of the experience of the body in AN. A programme of Adapted Physical Activity (APA), as investigated by Liv Duesund and Finn Skårderud (2003), thus provides interesting evidence of the effectiveness of such phenomenological research. The phenomenological study of the body investigates how social interaction in activities could shift negative attention from the objectified anorectic body to a more profound and subjective experience of one’s own body (Duesund and Skårderud 2003). It reveals that APA may represent a therapeutic access to AN, as supplement to psychotherapy. APA is rather like an example of phenomenology enhancing our understanding of effective treatment for AN. APA notably differs to a number of other fitness activities. One adapts the activity to the performer – not the other way round. The activities involve contextual experiences with people and animals, nature, sounds, and smells. Also, staff present are instructed to avoid making comments about looks and/or weight (Duesund and Skårderud 2003). APA is often conducted outside and involves the patients deciding how much they’d like to participate. The activities included are not physically demanding, and patients are encouraged to take it easy.
The phenomenological study’s qualitative findings are linked to the question of whether APA can help to reduce the negative attention towards the body itself among individuals suffering from AN. The findings are notably written in accordance with Merleau-Ponty and Leder's body philosophy. The study, for example, found that all patients pointed to horse-riding as a suitable activity for changing focus, supporting the use of phenomenological research such as Leder's (1990) concept of the Ecstatic Body. The concept alludes to the body being absent from attention, and is based on what Merleau-Ponty calls our body phenomenological being-to-the-world. Duesund and Skårderud (2003) offer a direct comment from a patient which compliments this Phenomenological ideal:
Anna: “It is so unbelievably good to sit there and feel it. You are using your body even though it is not your own decision. It is the rhythm of the horse which decides that you are there. I feel that I am on the inside of myself, because as a rule I feel myself to be on the outside". (pp.64)
The experience described by Anna emerges from the context of the interview that she does not feel her ‘anorectic corporeity’ but senses her own body in a different and more open way. Within the body-phenomenological tradition, AN can be described as a closing up in relation to the lifeworld. The body is objectified, and there is a loss of basis for openness. Horse-riding, used as APA for anorectics, contributed to a shift in attention and is undeniably supported by phenomenological theorising. Phenomenological enquiry may enhance our understanding of the effectiveness of APA here due to the advantageous shift of attention and ‘self-forgetting’ amongst individuals with AN.
The phenomenological view of the body may genuinely enhance our understanding of the success of body-oriented treatment for AN. Anorectics by definition are underweight, but this shouldn’t imply that exercise therapy is therefore ineffective or wrong. Phenomenology is the kind of research that could enhance our understanding of this, by also illuminating AN as consciously experienced. Fuchs' work, for instance, genuinely may apply to the success of APA in Psychiatry. It must of course also be noted that this is as a supplement to talking therapies, and that the APA treatment is offered as evidence of the usefulness of Phenomenology. Unlike the current criteria provided by the DSM-5, the phenomenological research considered in this article takes note of the bodily experience of AN which may allow us to recognise the use of body-orientated treatment.
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Cover Image. StickyKitties Art Gallery (2022.) Anorexia Recovery. [Illustration]. Retrieved from: https://www.etsy.com/listing/909179515/anorexia-nervosa-art-anorexic-recovery
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