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Botha, D. (2009). Psychotherapeutic treatment for anorexia nervosa: Modernist, structural treatment

approaches, and a post-structuralist perspective. Counselling, Psychotherapy, and Health,5(1), 1-46.

1

Psychotherapeutic treatment for anorexia nervosa: Modernist,

structural treatment approaches, and a post-structuralist

perspective

Derek Botha

MSocSc DCom

Counsellor

Cape Town

Contact:

der ekbot ha1@di s cover ymai l . co. za

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Abstract

Research has indicated that outcomes for psychotherapeutic treatment of anorexia

nervosa are less than favourable, and that persons with anorexia nervosa have indicated

low levels of satisfaction with treatment.

In this context, this article explores the beliefs and assumptions that inform and

shape the nature and strategies of the structuralist models that dominate

psychotherapeutic intervention approaches used for anorexia nervosa. Comparisons with

the assumptions and some strategies that inform a mode of post-structuralist

psychotherapy, namely narrative therapy, used for anorexia nervosa, are presented and

discussed.

Given the significant differences in the two approaches, the article submits that

there is a clear need for further research to assist in the development of improved

psychotherapeutic treatment approaches for persons struggling with anorexia nervosa. It

suggests that this further research explore specifically the accounts of personal

experiences of treatment using experience-centred narratives, and drawing on a

Foucauldian approach for the analysis of the narratives.

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models (Corey, 2005). A fourth form of therapy, namely, family therapy has also been

drawn upon in treatment for persons with anorexia nervosa.

Research has consistently indicated that long-term outcomes for the

psychotherapeutic treatment of anorexia nervosa are often unfavourable (Bergh, Brodin,

Lindberg & Soderstein: 2002; Deter & Herzog, 1994), and that interventions often have

limited success (Button & Warren, 2001; Eckert, Halmi, Marchi, Grove & Crosby, 1995;

Lowe, Zipfel, Buchholz, Dupont, Reas & Herzog: 2001). Furthermore, research reports

have also revealed that those with anorexia nervosa have experienced low levels of

satisfaction with treatments (Newton, Robinson & Hartley, 1993; Rosenvinge &

Klusmeier, 2000).

Given these accounts of outcomes of treatment, the aims of this article are

fourfold; firstly, to explore the beliefs, assumptions, goals and techniques that inform and

shape the four basic intervention models that dominate the structuralist1

1Changes in the configuration of the self that undertook a marked shift from the Middle Ages to

the modern era were reflected and produced by the early modern and enlightenmentphilosophers, such as Descartes, Locke, Hume and Kant. The radical empiricists, like Locke andHume, saw the self as constituted by rationality and the new scientific empirical process. Kantwas concerned by the absence of morality in the empiricists formulations, arguing that theimplications of the empirical line of reasoning would not tell one anything about developing apersonal identity, anticipating the future, or making a moral choice. Kant decided that inherent ineach person were certain mental structures that allowed one to see life in a certain way. Thus,in order to attend to and explain what the empiricists thought unimportant or unexplainable, Kant(1781: 1788: 1790) invented inherent or a priori mental categories. In this way the philosophicalmovement known as structuralismwas born (Cushman, 1995:31-32).

approaches that

have been used with limited success and low levels of satisfaction with persons with

anorexia nervosa; secondly, to discuss the implications and effects of the structuralist

treatment approaches; thirdly, to present comparisons with the assumptions and some

strategies that inform a model of post-structuralist psychotherapy, namely narrative

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therapy, as a possible alternative to the modernist, structuralist treatment approaches for

persons dealing with anorexia nervosa.

The significant differences between the structuralist and post-structuralist

approaches to the epistemology and treatment of anorexia nervosa, provide the

scaffolding for the fourth aim of the article. The article then suggests that these

differences may be presenting an appropriate opportunity to explore patients

perspectives of psychotherapeutic treatment for anorexia nervosa so as possibly to

address improvements to health care services. This suggestion is offered as there is a

lack of research that examines the experiences and perspectives of treatment of those

dealing with anorexia nervosa, drawing on a qualitative paradigm for the research. This

suggestion is made in specific terms in regard to the methodological approach and the

methods. It is submitted that using experience-centred narratives (Squire, 2008) and

drawing on a Foucauldian approach to narratives (Tamboukou, 2008) would provide an

appropriate orientation to explore (1) the experiences of persons who have been subject

to treatment approaches informed by and embedded in the socially constructed dominant

structural knowledges of anorexia nervosa, and, (2) the influence and impact of such

ways of treatment. A research approach that draws on the narratives of those who have

experienced modernist, structural psychotherapeutic oriented treatment approaches for

anorexia nervosa may be able to contribute to alternative knowledges and ways of

treating those dealing with anorexia nervosa.

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2 - Current etiological discourses on anorexia nervosa

The identification of a specific cause of anorexia nervosa has eluded scientific

studies for over a hundred years, yet numerous etiological rationalizations and theories of

its onset exist, such as, for example, genetic, affective, cognitive, systemic, bio-

psychological, psychodynamic, feminist, and socio-cultural (Grothaus, 1998; Hepworth,

1999; Malson, 1998; Malson & Ussher, 1996).

These etiological rationalizations and theories of anorexia nervosa have been

informed mainly by structuralist ideas that are ensconced in epistemological positions of

positivism and/or empiricism (Popper, 1972a; Popper, 1972b), essentially constructs of

the scientific model that have been embraced and applied in the medical, psychiatric and

psychological fields. In spite of the diverse etiologies, explanations and theories within

medicine, psychiatry and psychology, anorexia nervosa has been almost invariably

conceptualised as an internalised, individualised, clinical entity (Gremillion, 1994;

Hepworth, 1999; Malson, Finn, Treasure, Clarke, Anderson, 2004; Malson, 1998; Malson

& Ussher, 1996). Consequently research based on notions of positivism and empiricism

has focused predominantly on examining causes, clinical features and prognoses, and on

assessing treatment in terms of outcomes. The dominant notion of anorexia nervosa as an

internal, individual psychopathology has tended to preclude the exploration of the

meanings or experiences of anorexia nervosa (see, however, Bordo, 1992; Hepworth,

1999; Malson, 1998; Malson, 2000) or of the experiences of the treatment of anorexia

nervosa (see, however, Boughtwood, 2006; Halse, Honey & Boughtwood, 2008; Eivors,

Button, Warner, & Turner, 2003; Gremillion, 2002; Malson et al., 2004; Ryan, Malson,

Clarke, Anderson & Kohn, 2006).

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3 - Structuralist treatment approaches2

2As this article relates to the psychological treatment of persons dealing with anorexia nervosa,

pharmacological treatments are not discussed.

, and assessments of treatment

The etiology of anorexia nervosa in recent times has been understood and

constructed in a variety of medicalised and psycho-pathologised ways. The sets of

diagnostic frameworks that have been formulated and used in practice for anorexia

nervosa, mainly in Western cultures (for example, American Psychiatric Association,

1994: Diagnostic and Statistical Manual of Mental Disorders - hereinafter referred to as

the DSM-IV-TR), have inevitably influenced the array of treatment approaches that have

been used in in-patient, out-patient, community based, specialist and non-specialist

settings (Grothaus, 1998; Malson et al., 2004; Sanders & Gaskill, 2000). These treatment

approaches have included, but have not been limited to, dietetic (Mehler & Crews, 2001),

pharmacological (Treasure & Schmidt, 2001), psychodynamic (Bachar, Latzer, Kreitler,

Berry, 1999; Dare, Eisler, Russell, Treasure & Dodge, 2001), behavioural (Halmi, 1983;

Schmidt, 1989), behavioural and cognitive-behavioural (Dare et al., 2001; Gowers &

Bryant-Waugh, 2004; Vitousek, Watson, Wilson, 1998), family therapies (Dare et al.,

2001; Krusky, 2002), group therapies (Gowers & Bryant-Waugh, 2004), feminist

psychotherapies (Fallon, Katzman & Wooly, 1994; Orbach, 1993), multi-dimensional

approaches (Lacey & Read, 1993), integrated therapies (Steiger & Israel, 1999), and self-

help programmes (Crisp, Joughlin, Halek & Bowyer, 1996). Motivational enhancement,

a mode of therapy that specifically addresses the ambivalence associated with seeking

treatment for anorexia nervosa, has been reported (Vitsousek, Watson & Wilson, 1998).

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Results of studies assessing treatment efficiency and efficacy for anorexia

nervosa vary considerably, but they strongly agree that outcomes are not

encouraging, in that levels of treatment are unsatisfactory. This is the picture

portrayed from reports of: restricted success rates (Bergh, Brodin, Lindberg &

Soderstein, 2002; Boskind-White, 2000; Button & Warren, 2001; Kaplan &

Garfinkel, 1999; Levenkron, 2000; Richards, Baldwin, Frost, Clark-Sly, Berret &

Hardman, 2000), recovery rates that vary from between 11% to 40% (Richards

et al., 2000; Von Holle, Pinheiro, Thornton, Klump, et al., 2008), problems of

chronic relapse rates (Deter & Herzog, 1994), of those deemed to be recovered

from anorexia nervosa in that weight gains are maintained, but who develop

symptoms of bulimia (Eddy-Kamryn, Keel, Dorer, Delinsky, Franco & Herzog,

2002), of those dealing with anorexia nervosa who have reached acceptable

weight levels, but still experience social and psychological problems (Button &

Warren, 2001; Keel, Mitchell, Miller, Davis, Traci & Crow-Scott, 2000), and the

death rate of those dealing with anorexia nervosa being between 5% to 15%

(Bulik, Sullivan & Joyce, 1999: Emborg, 1999).

Research has also indicated high drop-out rates (Eivors, Button, Warner &

Turner, 2003; Mahon, 2000), and low levels of satisfaction among those who use

treatments (Crowe, 2000; Rosenvinge & Klusmeyer, 2000). These issues imply

that attention to patients perspectives on treatment may be appropriate and

valuable in improving mental health care services (Le Grange & Gelman, 1998;

Mahon, 2000; Malson et al., 2004). However, there remains a lack of research

that investigates patients perspectives of treatments for anorexia nervosa (Le

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Grange & Gelman, 1998: Malson et al., 2004), using qualitative research

approaches (Gremillion, 2002: however, see, Malson et al., 2004).

4 - Beliefs, assumptions, goals and practices of structuralist psychotherapeutic

treatment models 3

These models are termed the first (psychoanalytic), second (cognitive-

behavioural), and third forces (humanistic) respectively, given their contributions to the

paradigm shifts in psychotherapy treatment over time. Today their fundamentals

dominate psychotherapeutic treatments (Corey, 2005). These three models essentially

contain a number of beliefs, assumptions, goals and practices from which the over four

hundred current forms of psychotherapeutic treatment approaches are derived (Peavy,

In the light of these unfavourable discourses on treatment outcomes, as

well the accounts from service users of low levels of satisfaction of treatment

experiences, this section examines the beliefs, assumptions, goals and practices

of the structuralist psychotherapeutic treatment models.

In essence, the multiplicity of current approaches to psyhotherapy has been

significantly informed and shaped by three basic psychotherapeutic treatment models,

namely, the psychoanalytic, the cognitive-behavioural, and the humanistic models

(Corey, 2005). These three models will be examined as persons with anorexia nervosa

would have encountered one, or more, of them, or some forms of therapy based on and

drawn from them, during their treatment experiences (Kaye, 1999).

3 Details of their basic philosophies, key concepts, therapeutic goals, techniques, applications,

contributions and limitations of the approaches are fully presented and discussed in Corey

(2005:470-491).

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4.1 Psychoanalytic model

For anorexia nervosa, the advent of psychoanalysis reaffirmed a shift in focus to

internal psychological factors that gradually replaced the essentially biomedical focus

that originated from the writings of the two physicians, Gull (1868; 1874; cited in

Kaufman & Heiman, 1964), and Lasague (1873a; 1873b; cited in Silverman, 1990;

Silverman, 1995). Freuds psychoanalysis introduced the concept of purely mental,

deeply internal, intra-psychic phenomena, the tripartite theory of id, ego and superego.

According to Peavy, psychoanalytic theory interprets distress and pathology as the

result of internal dynamics originating in childhood, and holds successful adaptation to

reality as the standard of healthy functioning (1996:4).

Psychoanalysis located anorexia nervosa within the person (Gremillion, 1992).

The classic psychoanalytic formulation for anorexia nervosa was that of oral ambivalence

(Freud, 1958), with food refusal understood as a defence against the fantasy of oral

impregnation, the desire for which may be expressed by periodic gorging (followed by

guilt, disgust, and a purification rite such as vomiting) (Gremillion, 1992). This symbolic

scheme explained all symptoms. In the traditional form of psychoanalytic treatment,

clients recited their psychic monologue while the analyst interpreted its meaning. This

process reconfirmed the phenomenon as deeply internal and separable from dialogue or

interpersonal affect (Foucault, 1971). Bruch (1978) has noted, also, that the anorexic

persons sense of inadequacy was confirmed by being told by an authority figure what the

anorexic person really thinks and feels. Gremillion submitted that these features of

psychoanalytic theory and practice, coupled with Freuds theories about the innately

problematic female in generating fantasized problems, reproduces anorexia nervosa as

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the individualistic, self-flagelllating struggle of a powerless and inadequate person in

need of control (1992:62).

The power structures of psychoanalytic therapies are apparent from these

discourses that located the phenomenon within the person dealing with anorexia nervosa.

For the sufferer of anorexia, the understandings of the workings of the mental processes

or forces at play were possible through insight about its history that could only be

provided by the knowledge of the psychoanalytic therapist.

4.2 Cognitive-behavioural models

The second force of psychotherapy is comprised of behaviourism, and its

successor, cognitive-behaviouralism. Behaviourist approaches to anorexia nervosa

became popular in the 1960s, partly in response to the inefficacy of psychoanalytic

approaches (Molodofsky & Garfinkel, 1974). Bruch noted that many persons dealing

with anorexia nervosa who experienced psychoanalytic therapies withdrew even more

from participation in life (1982:1534). The behaviourists argued that an important

factor for this failure was the lengthy process of psychoanalytic treatments (Gremillion,

1992). This fostered a search for rapidly effective treatment programs (Herzog, Hamburg

& Brotman, 1987), supported by the belief that the longer anorexia nervosa was allowed

to continue, the worse the prognosis. This notion indicated attention to explicit, external

control over persons dealing with anorexia nervosa (Gremillion, 1992).

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Behaviourists fully acknowledged that their role was a controlling one. Blinder,

Freeman and Stunkard explained the value of a behaviourist program for anorexia

nervosa as follows:

Hospitalization permits a high degree of control over the patients environment.

Yet until recently the full therapeutic potential of hospitalisation has not been

recognized, The effectiveness of operant conditioning techniques might permitthe utilization of hospitalization to a maximal therapeutic effect (1970:1093).

Criticisms of the behavourist approach have been advanced, emphasising some of

the effects of the rationalisations and assumptions of the approach: the inappropriate

emphasis on weight gain itself, the likelihood of a hostile relationship between the client

and mental health staff, and poor results from follow-up studies (Gremillion, 1992). For

example, Bruch has recorded some of her own clients experiences of behaviour

modification treatment:

Anorectic patients have always complained about their hospital experiences, but notwith the same cynical bitterness and sense of utter betrayal expressed by those who

have been exposed to behaviour modification. Uniformly, my patients had

experienced the program as brutal coercion by which they were reduced to utter

helplessness; whatever self-confidence they might have achieved in individualtherapy was nullified. In spite of weight gain, they considered this experience as

anti-therapeutic and spoke of it with real anguish, as unmitigated misery. One

summarised it: It takes no great ingenuity to devise a scheme for forcing someone togain [weight] to escape the situation I left the hospital depressed with my own

body, disoriented, and fell apart completely (1974:1421-1422).

Behaviourism, as an enterprise, tended for some time to be imperialistic. The

initial programme of behaviourism - to provide clear, incontestable, measurable laws of

behaviour - has not been realised (Peavy, 1996).

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Cognitive therapy developed in parallel with behaviour therapy, and, in time,

curbed the imperialism of behaviourism. Cognitive scientists showed convincingly that

there was no such thing as a 'stimulus' apart from what the stimulus event was taken to

mean by the mind of the person stimulated by it (Bruner, 1986). Cognitive theorising

helped to bring consciousness and mind back into play, and thus brought about an

important revision in behaviourist thinking. Cognitive therapists have continued to

protect adaptation to reality as a standard for mental healthiness. There tends to be a

conformity-demanding set of values underlying many therapeutic strategies advocated by

cognitive-behavioural experts (Peavy, 1996). Both behavioural and cognitive-

behavioural therapies tend to be based on assumptions of a form of mechanical

determinism as a model of social life, and the desirability of defining mental health as

conformity to rational, individualistic, materialistic values (Taylor, 1989; Peavy, 1996).

4.3 Humanistic model

The humanistic therapies are termed the third force (Corey, 2005; Peavy, 1996),

and are based in humanistic psychology. They had their origins as a rebellion against

what they characterised as both the mechanistic, formalised, elitist psychoanalytic

establishment, and an overly scientistic, removed, fragmenting cognitive-behaviourism.

With its roots in the values of existentialism and humanism, humanistic psychology

developed a philosophical platform based on (1) a centring of attention on the

experiencing person, (2) an emphasis on human qualities, and, (3) an interest in the

development of the human potential inherent in every person (Buhler & Allen, 1972:1).

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In other words, a person contained endless possibilities for development and simply

needed a nurturing, facilitative environment which fostered growth (Corey, 2005; Peavy,

1996). Although there was little stress on conformity to normative societal values,

standards and forms of behaviour, the stress was transferred to the notion of becoming

whatever you want to become (Peavy, 1996:145). This was based on the philosophy

that each person had natural inner potential to actualise through which, he or she could

find meaning, if provided with the appropriate conditions.

One of the most predominant criticisms of the humanistic approaches to therapies

is their over-reliance on the psychology of individualism, and a disregard of the social

relatedness and the individuals community rootedness (Peavy, 1996).

The three therapeutic models that have been presented, namely, the

psychoanalytic, the cognitive-behavioural and the humanistic, all assume that there are

certain essential and core structures that are within the individual, and are the models

drawn on mainly for individual interventions. However, the notion of a problem being

internalised has also been applied to the family as a unit, thus attributing problems as

being internal to the family system.

4.4 Family therapy

Family therapy is a part of a psychotherapeutic approach referred to as the

systems perspective (Fishman, 1985; Friesen, 1985; Goldenberg & Goldenberg, 2000;

Goldenberg & Goldenberg, 2002; Minuchin, 1974; Minuchin, Rosman & Baker, 1978).

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Today the various approaches to family therapy represent a paradigm shift that might be

called the forth force, and are becoming a major theoretical orientation of many

practitioners (Corey, 2005). Family therapy is a complex and developing field that

includes many approaches to understanding and working with families, with a variety of

intervention models being used in different circumstances (Goldenberg & Goldenberg,

2000), such as the experiential, transgenerational, structural, Milan, strategic, and the

social constructionist models. The intention here is merely to note broad characteristics

of family therapy (see, Goldenberg & Goldenberg, 2002; Corey, 2005), as some forms

thereof are used in the treatment of persons dealing with anorexia nervosa (Fishman,

1985; Schwartz, 1999; White, 1989; White & Epston, 1990).

Family therapy approaches hold that individuals are best understood within the

context of relationships and through assessing the interactions within an entire family.

The perspective that the identified clients problem might be a symptom of how the

family system functions, not just only a symptom of the individuals maladjustment,

history and psychosocial development, is grounded on the assumptions that a clients

problematic behaviour may (1) serve a function or purpose for the family; (2) be a

function of the familys inability to operate productively, especially during

developmental transition; or (3) be a symptom of dysfunctional patterns handed down

across the generations (Corey, 2005). Assumptions on which family therapies are based,

have tended to rely on the modernist notion of structuralist internal states (Bruner,

1990; Morgan, 2002; White, 2004) that are considered to be universal to the human

condition. The assumptions informing family therapy have tended to introduce and

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locate a version of internal state psychology into the family,4

Critics of the structuralist, pathologising notion of family therapy have pointed to

the fact that by focusing exclusively on altering interactions within a family, therapy runs

the risk of neglecting relevant intrapsychic problems of individual members and

overlooking external, culturally sustained power inequalities that affect family

interactions (Green, 1998). Boscolo, Cecchin, Hoffman & Penn have submitted that

and have provided the

foundation for the manufacture of a new range of family pathologies and relationship

dysfunctions (White, 2004; Morgan, 2002). Consequently, family therapy models (see,

Corey, 2005:432-433) have addressed therapy goals, processes of change, and their

techniques to these internal state notions that have been transferred from the individual

to the family, thus introducing anorexia nervosa as the unique problem of certain family

configurations (Gremillion, 1992).

Family therapy approaches to anorexia nervosa view the family as a system unto

itself, separating the realms of public and private (Gremillion, 1992). Systems theory

regards any family as a self-regulatoryand rule-governed system (Selvini-

Palazzoli, 1974:196). Ironically, the anorexic familys very pathology is the fact that it is

a system that has turned in on itself, developing its own microcosm (Minuchin,

Rosman & Baker, 1978:57). The anorexic familial world is seen as pathological

precisely because it is intensely private, and, being locked within itself, cannot examine

the cultural foundations for the rigid separation between the familial world and the

outside world (Gremillion, 1992).

4For example, human expression is interpreted as a surface manifestation of these internal

states - a manifestation of unconscious motives, instincts, drives, traits, dispositions and so on(White, 2004:21)

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changes to this approach cannot be achieved as long as pathology is assumed to be in

a container as in adysfunctional family system (1987:14).

5 - Current psychotherapies as objectifying, pathologising and normalising

practices

Over the past century, Western culture has been pervaded by understandings of

human action as being reflections of internal state identities (White, 2007:102).

Although such understandings have been subject to challenge, they have become

embedded in knowledges that portray human action as surface manifestations of core

structures of a self that is to be found at the centre of identity (White, 2007). White

typifies structuralist analysis in the following way: One characteristic of structuralist

thought is the surface/depth contrast. It is within the terms of this contrast that peoples

expressions of living are taken to be behaviours that are surface manifestations of

particular elements or essences (2000:61).

These understandings have achieved a taken-for-granted status in much of the

professional psychology of the current era. According to this tradition of understanding,

or truth knowledges, the human condition reflects the presence of these internal

elements as being universally present to different degrees. White (2007) submitted that

human identity is therefore derived from either the direct expression of these essences, or

from distortions of these elements - with such distortions often being referred to as

disorders or dysfunctions (White, 2007:101). Foucault (1971; 1976) also held that

such norms of behaviour, and those behaviours that are deemed abnormal, and labelled

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disorders and dysfunctions, had been principally constructed by the professional

disciplines, such as, for instance, psychiatry and psychology (in White, 2007:102-103).

Thus, there has been an evolution of knowledge of the concept of a self that is

understood to occupy the centre of a persons identity (Cushman, 1995), whereby an

individual can be discovered (diagnosed) to be disordered or dysfunctional.

In this contextual state of understandings, anorexia nervosa has tended to be

conceptualised as a clinical entity residing within the individual and/or families

(Gremillion, 1992: Gremillion, 1994; Malson et al., 2004). It has, thus, attracted

psychoanalytic, cognitive-behavioural, systemic family, and, to a lesser extent,

humanistic based therapies for treatment. These approaches objectify and pathologise

anorexia nervosa by focusing on a damaged self within a damaged body, and/or within

a dysfunctional family. Thus, cultural discourses have provided a context for the

emergence of anorexia nervosa in the first place, where anorexia nervosa is about a

struggle that is experienced as internal to individuals and families. Gremillion (1992;

1994) stated that even as anorexia nervosa depends on a tacit acceptance of these cultural

discourses, it also problematises them by revealing that they are embedded in power

relationships. Treatment approaches that are pathologising, participate in these power

relationships by representing anorexia nervosa as a deviance from normative ideas and

ways of being. Gremillion submitted that there are ways in which these power

relationships are exercised by psychiatry, by labelling, organizing and constructing

anorexia as a reified and bounded condition that is removed from cultural ideologies and

processes as an illness which can be grasped and fixed (1992:59). In this regard, it is

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noted that, by psychiatric definition, mental disorders do not articulate with human

relations or cultural conflict. According to the DSM-IV-TR,

each of the mental disorders is conceptualized as a clinically significant

behavioural or psychological syndrome or pattern that occurs in an individualand isassociated with present distress (eg, a painful symptom) or disability (ie, impairment

in one or more important areas of functioning . Whatever its original cause, it

must currently be considered a manifestation of a behavioural, psychological, orbiological dysfunction in the individual. Neither deviant behaviour (eg., political,

religious, or sexual), nor conflicts that are primarily between the individual and

society are mental disorders unless the deviance or conflict is a symptom of a

dysfunction in the individual (emphasis added, xxxi).

Furthermore, the DSM-IV-TR indicates that what are being classified are

disorders that peoplehave(emphasis added, xxxi). The DSM-IV-TR therefore is also

part of, and contributes to the cultural processes of constructing anorexia nervosa as

internally objectified, by being in the individual, and by being a disorder that people

have.

A further contribution to the dominant discourses on anorexia nervosa has been

the guidelines published by the National Institute for Clinical Excellence (NICE) (2004a;

2004b) in the United Kingdom in regard to the treatment and management of eating

disorders. These guidelines from NICE may well be reflective of the specialist

knowledge and views of the British Psychological Society and the Royal College of

Psychiatrists (Lock et al., 2005). The medical view of anorexia nervosa is illustrated in

the following excerpts from these guidelines:

Anorexia nervosa is an illness in which people keep their body weight low by

dieting, vomiting or excessive exercising. The illness is caused by an anxiety about

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body shape and weight that originates from a fear of being fat or from wanting to be

thin. How people with anorexia nervosa see themselves is often at odds with howthey are seen by others, and will usually challenge the idea that they should gain

weight. People with anorexia nervosa can see their weight loss as a positive

achievement that can help increase their confidence and self-esteem. It can also

contribute to a feeling of gaining control over body weight and shape (NICE,2004a:11).

1.1.6.2 When screening for eating disorders one or two simple questions should beconsidered for use with specific target groups (for example, Do you think you have

an eating problem? and Do you worry excessively about your weight?) (NICE,

2004b:9).

These extracts from the guidelines published by NICE clearly reflect the view that

anorexia nervosa is a medical illness that is identified with the person who has it (Lock

et al., 2005). From these quotations, it could be argued that anxiety, a lack of confidence,

of self-esteem and of agency (control over their bodies and body weight) could be causes

of anorexia nervosa, and the view could be taken that the person who has this illness

(that is, anorexia nervosa), is essentially imperfect (Lock et al., 2005).

In extending this line of discussion in regard to the objectifying, pathologising

and normalising consequences of the power relationships embedded in the

psychoanalytic, cognitive-behavioural, and to a lesser extent, humanistic based therapy

models discussed above, Kaye (1999:20-21) has submitted that these approaches to

psychotherapy are informed by four assumptions, namely, that (1) there is an underlying,

or structural, cause or basis of pathology; (2) the location of this cause is within

individuals (see above, DSM-IV-TR, xxxi; and, NICE, 2004a:11; NICE, 2004b:9; NICE,

2004b:10), or families; (3) the problem is diagnosable; (4) the problem is treatable by the

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use of specifically designed sets of practices. Kaye (1999) stated that, implicit in these

assumptions are the notions of normality and abnormality, and the presumption of a true

root cause that can be objectively established, recognized, and cured.

In this regard, the DSM-IV-TR has stated that the use of definitions of disorders,

has, helped to guide decisions regarding which conditions on the boundary between

normality andpathologyshould be included in the DSM-IV (1994:xxxi - emphasis

added). Within this frame, these psychotherapies that deem the individual as the locus of

pathology, can be seen as active practices that treat what are judged to be mental

disorders, and abnormal or deviant or dysfunctional behaviour. Such treatment would

embrace a restructuring or reprogramming of behaviour in both individuals and

families against some criterion of the normal, the well-adjusted, the deviant, the well-

adjusted, the problematic and non-problematic (Kaye, 1999:21).

Moreover, the conceptualisation of these therapies focuses the search for the

solution within the terms of the therapists theoretical knowledge and practical skills.

Such perceptions and understandings create a hierarchical relationship that privileges the

therapists perspective (Kaye, 1999). This approach reflects the modernist concept of the

therapist as a socially accredited authority who can provide an authoritatively true

account of the clients problem, and who can implement appropriate and prescribed

treatment therapies to remedy it (Kaye, 1999).

In his writings and interpretations of relevant works of Foucault (1976; 1977;

1978; 1980; 1986; 1990), and in his social constructionist formulations of narrative

therapy, White (2002) submitted that the structuralist hierarchical privilege is shaped and

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sanctioned within the modern notion and operation of power in western culture. White

has interpreted this modern notion of power as a mechanism that, inter alia,

establishes social control through a system of normalising judgement that is exercised

by people in the evaluation of their own and each others lives (2002:44), and

employs a technology of power that is characterised by continuums of

normality/abnormality, tables of performance, scales for the rating of human

expression, formulae for the ranking of persons in relation to each other, and specificprocedures of assessment and evaluation that makes possible the insertion of peoples

lives into these continuums, tables, scales and ranking systems (2002:44).

When persons are related to with this objective, modernist approach, they tend

to be regarded as objects, thus inviting them to be positioned in the relationship as

passive, powerless recipients of the knowledge of the expert (Freedman & Combs,

1996). These approaches therefore dishonour the voice of the person subjected to them,

namely, the very person dealing with anorexia nervosa.

6 - An alternative, post-structuralist, treatment perspective

These understandings in regard to the objectifying, pathologising and normalising

notions of the structuralist therapeutic approaches, as well as their consequences of power

in the therapeutic relationships, were meaningfully addressed by Kronbichler (2004) by

employing an alternative post-structuralist treatment approach. The modality that he

drew on was narrative therapy5

5See, Corey (2005) for a brief comment on the key concepts and therapeutic processes of

narrative therapy which he adapted from different works, but mainly from Winslade and Monk(1999), Monk (1997), Winslade, Crocket and Monk (1997), McKenzie and Monk (1997), andFreedman and Combs (1996).

, a form of therapy that can be considered to be positioned

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within the social constructionist domain of social psychology (Besley & Edwards, 2005;

White & Epston, 1990; White, 2007).

Kronbichler worked in Salzburg, Austria, within a psychotherapeutic outpatient

department for children, adolescents and their families. He based his work, research and

publication on meetings with 8 young males and their families over a few years. The

young mens ages were between twelve to fifteen years, and their diagnosis had been that

of anorexia nervosa. Kronbichler described some theoretical ideas and their application

in the practice of working with males struggling with anorexia nervosa, ideas and

narrative ways of working that have been experienced as helpful and effective

(2004:55). In his report he presented a comparison of the structural perspectives and the

post-structuralist ideas and ways of working with persons dealing with anorexia nervosa.

The comparative post-structuralist perspectives indicate the significant differences that

inform and shape the social constructionist beliefs, assumptions and ways of working

with narrative therapy. These comparisons are presented in Table 1.

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Table 1: Comparison of structuralist versus post-structuralist ideas in the treatment ofanorexia nervosa

Structuralist perspective Post-structuralist perspective

Anorexic behaviour as surfacemanifestation of problems in the depth

structure of the person

Anorexia nervosa is located in the

interrelationship between social and

cultural practices and subjectivity

Explanations of anorexia nervosa are to

be found in the psyche and/or the family

dynamics

Exploration of the forces that stand with

anorexia nervosa and those that stand

with a life free from anorexia nervosa

Main focus on weight gain Focus on the effects of anorexia nervosain different dimensions of life

Orientation along normative rulesconcerning eating patterns, relationships

and adolescent development

Orientation alongside the personshopes, dreams, visions, purposes, etc

Centered position of the therapist as

expert

Decentered position of the therapist as

co-researcher

Source: Kronbichler, 2004:58.

The structural perspectives of treatment approaches that Kronbichler (2004)

mentioned, have been incorporated in the earlier discussions of this article. Those

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discussions converged primarily on persons with anorexia nervosa, and the structuralist

treatment approaches to which they were subject. However, it is worth quoting a portion

of Kronbichlers report, as the quoted portion brings in and relates to his personal

experiences, not as a person with anorexia nervosa, but as a mental health practitioner

working in structuralist environments that provided treatments for persons dealing with

anorexia nervosa. His reported experiences and observations reflect significant

validation of much of the earlier critical discussions on the structuralist approaches to

treatment of anorexia nervosa. He says:

My many years of working in state psychiatric hospitals have shown me the effects

of treatment approaches shaped by structuralist ideas, especially in terms of

conversations with family members, both inside and outside of formal therapysessions. Treatment on the basis of such therapies tends to marginalize the voices

of the family members - in particular, that of the person whose life is being

dominated by anorexia. This often leads to conversations in therapy which havefamily members believing that they are being criticized by the therapist, and their

relationships, especially between mother-child, being queried. In this way, the

knowledges of the family members about themselves and their relationships run the

risk of being marginalized. This process, together with its associated configurationof knowledge/power, deprives the family members of their legitimate speaking rights

(Madigan & Goldner, 1998) about matters of their own lives and relationships.

In-patient treatment programs are often organized around surveillance based on

mistrust, following from ideas about the allegedly manipulative personality

structure of persons diagnosed as anorexic. The interactions between nurses anddoctors and the so-called patients intensify around positions of surveillance, reward

and punishment on the part of the helpers; and resignation, rebellion, secrecy and

feelings of not being understood on the part of the patients. In treatment contextsthat are organized around surveillance turn the body into an object of subjugation in

ways that reproduce anorexias politics of oppression and block the way to exploringalternatives for a persons relationship with anorexia (Gremillion, 2003) (2004:57-58).

As indicated, Kronbichler used narrative therapy, an approach that originated

from the writings and works of White and Epston (1990). In addition to subsequent

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works by these two founders (for instance, Epston & White, 1992; White & Epston,

1990; White, 2000; White, 2007), narrative therapy has been further illustrated by a

number of other narrative writers and practitioners (such as Freedman & Combs, 1996;

Monk, Winslade, Crocket & Epston, 1997). Narrative therapy offers a rich cluster of

ideas and ways for working with persons with anorexia nervosa. Kronbichler submitted

that the emphasis of narrative therapy on experience and discourse allows access to

different landscapes of action and identity in the stories of young men who are grappling

with the effects of anorexia in their lives (2004:58).

Finally, Kronbichler submitted that narrative therapy, which is based upon post-

structuralist ideas, is an appropriate alternative perspective to treatments informed by

structuralist ideas and assumptions, and opened up possibilities for entering into more

collaborative alliances with the person struggling with anorexia and his/her family

members (2004:58).

7 - Research issues

This article has noted that the etiological rationalizations and theories of anorexia

nervosa have been informed mainly by structuralist ideas that are based on the rationalist,

scientific model that has been adopted and applied in the psychiatric and psychological

domains. Anorexia nervosa has, thus, been constituted as an internalised, individualised,

clinical entity. In addition, the psychotherapeutic approaches that have been used for

treatments of persons struggling with the effects of anorexia nervosa, have developed

with beliefs, assumptions, goals and techniques that are directed at such perceived

structuralist notions of the self.

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As documented earlier in this article, the results of studies assessing treatment

efficacy and effectiveness for eating disorders have reflected less than satisfactory, and,

sometimes, contradictory outcomes. Users of treatments have indicated low levels of

satisfaction. However, there is a lack of research that explores the experiences of users of

treatment using qualitative research. Interest in qualitative discourse research has,

however, already illustrated how medical, psychiatric and psychological discourses

inform and regulate mental illness (Foucault, 1971; Foucault, 1977; Parker, Georgaca,

Harper, McLaughlin & Stowell-Smith, 1995), and specific types of diagnoses (Stoppard,

2000; Swann, 1997).

Qualitative research, incorporating notions of critical theory, can be constructive

in examining the numerous ways in which power relations and normative cultural values

are embedded in the discursive constructs of anorexia nervosa. Qualitative analyses have

been undertaken of both bulimia nervosa and anorexia nervosa as discursively constituted

diagnostic categories of eating disordered subjectivities and body management practices

(Bordo, 1992; Borda, 1993; Crowe, 2000; Malson, 1998; Malson, 1999; Malson, 2000;

Malson & Ussher, 1996). More recently, researchers have begun to use discourse

analysis to explore patients accounts of treatment for eating disorders (Boughtwood,

2006; Malson et al, 2004), and nurses accounts of nursing eating disordered patients

(Ryan et al., 2006).

The article has also drawn attention to the significant differences in assumptions,

understandings, and practices between structuralist and post-structuralist forms of

psychotherapy. This was done by noting important comparative aspects of approaches to

treatment from a reported analysis of the use of a post-structuralist form of therapy,

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analytic paths in the reading of the experience-centred narratives of persons struggling

with anorexia nervosa. More specifically, using a Foucauldian approach to narratives

will provide an appropriate orientation that would enable analyses of the narratives to: (i)

elucidate the ways in which identities are constituted in an environment of professionally

delivered psycho-medical services; (ii) examine the power relations and normative

cultural values embedded in the discursive constructions of persons subjectivities, and

(iii) explicate the meanings, values, beliefs, ideas and politics that are re-produced in

discursive mental health practices to which the persons are exposed.

The submissions for a need to analyse at these narratives as ways of

understanding experiences and constructed subjectivities are further supported by the

unique knowledges in personal stories that those dealing with anorexia nervosa have

published (see for instance, Epston, 2000; Kraner & Ingram, 1998; Shelley, 1997). They

are also bolstered by a notion that informs the practice of narrative therapy, namely, that

the person dealing with anorexia nervosa would have a more experience near (Geertz,

1983) grasp of their own situation, than others would have. In this context Epston (2000)

has stated that:

I know of no problem as lethal as anorexia/bulimia, given what I have seen

with my own eyes and heard tell that is so misrepresented. And those whosuffer are equally misrepresented. Once provided with the means to speak

against anorexia/bulimia, almost to a person everyone has railed against most

of the psychological/psychiatric constructions of them as anorexics or

bulimics. The stories - from the insiders - are incomparable to the storieswritten about them by outsiders.

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References

American Psychiatric Association, (1994), (4th

ed), (Text Revised)Diagnostic and

Statistical Manual of Mental Disorders,APA, Washington DC.

Bachar, E., Latzer, Y., Kreitler, S. & Berry, E.M. (1999). Empirical comparison of two

psychological therapies: self-psychology and cognitive orientation in the

treatment of anorexia and bulimia,Journal of Psychotherapy Practice and

Research, 8(2), 115-128.

Belsey, A.C., & Edwards, R.G. (2005). Editorial: Poststructuralism and the impact of the

work of Michel Foucault in counselling and guidance,British Journal of

Guidance and Counselling,33(3), 277-281.

Bergh, C., Brodin, U., Lindberg, G. & Sodersten, P. (2002). Randomised control trial of a

treatment for anorexia and bulimia nervosa, PNAS,99(14), 9486-9491.

Blinder, B., Freedman, D. & Stunkard, A. (1970). Behaviour therapy of anorexia nervosa:

effectiveness of activity as a reinforcer of weight gain,American Journal of

Psychiatry, 126(8), 1093-1098.

Bordo, S. (1992). Anorexia nervosa: psychopathology as the crystallization of culture. In

H. Crowley & S. Himmelweit, (Eds.)Knowing women: feminism and knowledge,

Open University Press, Cambridge.

Boscolo, L., Cecchin, G., Hoffman, L. & Penn, P. (1987).Milan systemic family therapy:

Conversations in theory and practice,Basic Books, New York.

Boskind-White, M. (2000).Bulimia/Anorexia: The binge/purge cycle and self-starvation,

Norton, New York.

8/10/2019 v5_1_Botha

33/45



33

Boughtwood, D. (2006).Anorexia nervosa in the clinic: Embodiment, autonomy and

shifting subjectivities, Unpublished Doctor of Philosophy degree, University of

Western Sydney, Sydney.

Bruch, H. (1974). Perils of behaviour modification in the treatment of anorexia nervosa,

Journal of the American Medical Association, 230(10), 1419-1422.

Bruch, H. (1978). Obesity and anorexia nervosa, Psychosomatics,19(4), 208-212.

Bruch, H. (1982). Anorexia nervosa: Therapy and theory,American Journal of

Psychiatry,139(2), 1531-1538.

Brumberg, J.J. (1986). Fasting girls: Reflections on writing the history of anorexia

nervosa as a modern disease,Monograph for the Society for Research in Child

Development, 50(4-5), 93-104.

Bruner, J. (1986).Actual minds: Possible worlds,Cambridge, MA. Harvard University

Press.

Bruner, J. (1990)Acts of meaningCambridge, MA: Harvard University Press.

Buhler, C.M. & Allen, M. (1972).Introduction to Humanistic Psychology, Brookes/Cole,

Monterey.

Bulik, C.M., Sullivan, P. & Joyce, P. (1999). Temperament, character and suicide events

in anorexia nervosa, bulimia nervosa and major depression,Acta Psychiatra

Scandinavica, 100(1), 27-32.

Bulik, C.M., Berkman, N.D., Brownley, K.A., Sedway, J.A. & Lohr, K.N. (2007).

Anorexia nervosa treatment: A systematic review of randomised controlled trials,

International Journal of Eating Disorders, 40(1), 310-320.

8/10/2019 v5_1_Botha

34/45



34

Button, E.J. & Warren, R.L. (2001). Living with anorexia nervosa: The experience of a

cohort of sufferers from anorexia nervosa 7.5 years after initial presentation to a

specialized eating disorders service,European Eating Disorders Review, 9, 74-96.

Corey, G. (2005). Theory and practice of counseling and psychotherapy(7th

ed.),

Thomson Learning, Belmont, CA.

Crisp, A.H., Joughlin, N., Halek, C. & Bowyer, C. (1996).Anorexia nervosa - the wish to

change, Psychology Press, London.

Crowe, M. (2000). Constructing normality: A discourse analysis of the DSM-IV,Journal

of Psychiatric and Mental Health Nursing,7,69-77.

Cushman, P. (1995). Constructing the self, constructing America: A cultural history of

psychotherapy, Addison-Wesley, Reading, Mass.

Dare, C., Eisler, I., Russell, G., Treasure, J. & Lodge, L. (2001). Psychological therapies

for adults with anorexia nervosa: Randomised control trial of outpatient

treatments,British Journal of Psychiatry,178, 216-221.

Deter, H. & Herzog, W. (1994). Anorexia nervosa in long-term perspective,

Psychosomatic Medicine.56,20-27.

Eckert, E., Halmi, K., Marchi, P., Grove, W. & Crosby, R. (1995). Ten year follow-up on

anorexia nervosa: clinical course and outcome,Psychological Medicine, 25(1),

143-156.

Eddy-Kamryn, T., Keel, P.K., Dorer, D., Delinsky, S., Franco, D., & Herzog, D. (2002).

Longitudinal comparison of anorexia nervosa types,International Journal of

Eating Disorders, 31(2), 191-201.

8/10/2019 v5_1_Botha

35/45



35

Eivors, A., Button, E., Warner, S. & Turner, K. (2003). Understanding the experience of

drop-out from treatment for anorexia,European Eating Disorders Review, 11, 90-

107.

Emborg, C. (1999). Mortality and causes of death in eating disorders in Denmark 1970-

1993,International Journal of Eating disorders,25(3), 243-251.

Epston, D. (2000). The history of the archives of resistance - anti-anorexia/anti-bulimia,

available online at:

(accessed 12 May 2008).

Epston, D. & White, M. (1992).Experience, contradiction, narrative and imagination,

Dulwich Centre Publications, Adelaide.

Fallon, P., Katzman, M.A., & Wooly, S.C. (eds.), (1994) Feminist perspective on eating

disorders,Guildford Press, New York.

Finelli, L.A. (2001). Revisiting the identity issue in anorexia,Journal of Psychosocial

Nursing, 39, 23-29.

Fishman, H.C. (1985). Diagnosis and context: An Alexandrian quartet. In R. L. Ziffer,

(ed.),Adjunctive techniques in family therapy, Grune & Stratton, New York.

Foucault, M. (1971).Madness and civilization: A history of insanity in the age of reason,

Tavistock, London.

Foucault, M. (1976). The birth of the clinic: The archaeology of medical perception,

Tavistock, London.

Foucault, M. (1977).Discipline and Punish: The Birth of the Prison, (A.M. Sheridan-

Smith, trans.), Allen Lane, London.

8/10/2019 v5_1_Botha

36/45



36

Foucault, M. (1978). The history of sexuality, volume 1: I introduction, (R. Hurley,

trans.), Random House, London.

Foucault, M. (1980). Power/Knowledge. In C. Gordon, (ed.), Power/knowledge: Selected

interviews and other writings by Michel Foucault, 1972-1977,Pantheon Books,

New York.

Foucault, M, (1986). The care of the self. The history of sexuality, volume 3, (R. Hurley,

trans.), Pantheon Books, New York.

Foucault, M. (1990). The history of sexuality: An introduction, vol 1, Penguin,

Harmondsworth.

Freedman, J. & Combs, G, (1996).Narrative therapy: the social construction of

preferred realities,Norton, New York.

Freud, A. (1958). Adolescence, Psychoanalytical Study of the Child,13, 255-278.

Friesen, J. D. (1985). Structural strategic marriage and family therapy, Gardner, New

York.

Geertz, C. (1983).Local knowledges: Further essays in interpretive anthropology,Basic

Books, New York.

Goldenberg, H. & Goldenberg, I. (2000). Family therapy: an overview (2nd

ed.), CA:

Brooks/Cole, Pacific Grove.

Goldenberg, H. & Goldenberg, I. (2002). Counseling todays families (4th

ed.), CA:

Brooks/Cole, Pacific Grove.

Gowers, S. & Bryant-Waugh, R. (2004). Management of child and adolescent eating

disorders: The current evidence base and future directions,Journal of Child

Psychology and Psychiatry, 45(1), 63-83.

8/10/2019 v5_1_Botha

37/45



37

Green, R.J. (1998). Race and the field of family therapy. In M. McGoldrick, (ed.),

Revisioning family therapy: Race, culture, and gender in clinical practice,

Norton, New York.

Gremillion, H. (1992). Psychiatry as a social disorder: Anorexia nervosa, a paradigm,

Social Science and Medicine, 35(1), 57-71.

Gremillion, H. (1994). Response to Howard Steigers review-essay Anorexia nervosa: Is

it the syndrome or the theorist that is culture- and gender-bound? Transcultural

Psychiatric Research Review, 31, 314-320.

Gremillion, H. (2002). In fitness and in health: Crafting bodies in the treatment of

anorexia nervosa, Signs,27(2), 381-596.

Gremillion, H. (2003). Feeding anorexia,Duke University Press, London.

Grothaus, K. (1998). Eating disorders and adolescents,Journal of Child and Adolescent

Psychiatry,11(4), 146-151.

Gull, W.W. (1868). The address on medicine. In H. Kaufman & M. Heiman, (1964),

(eds.),Evolution of psychosomatic concepts. Anorexia nervosa. A paradigm,

International Universities Press, New York.

Gull, W.W. (1874). Anorexia nervosa. In H. Kaufman & M. Heiman, (1964), (eds.),

Evolution of psychosomatic concepts Anorexia nervosa: A paradigm,

International Universities Press, New York.

Halmi, K.A. (1983). Advances in anorexia nervosa,Advances in Developmental and

Behavioural Paediatrics4, 1-23.

Halse, C., Honey, A. & Boughtwood, D. (2008). Inside anorexia: The experiences of

girls and their families,Jessica Kingsley, London.

8/10/2019 v5_1_Botha

38/45



38

Hepworth, J. (1999). The social construction of anorexia nervosa,Sage, London.

Herzog, D.B., Hamburg, P. & Brotman, A. (1987). Psychotherapy and eating disorders:

An affirmative view,International Journal of Eating disorders, 6(4), 545-550.

Kant, I. (1781). Critique of Pure Reason.(Trans. W.S. Pluhar & P. Kitcher, 1996),

Hackett, Indianapolis.

Kant, I. (1788). Critique of Practical Reason.(Trans. W.S. Pluhar, 2002), Hackett,

Indianapolis.

Kant, I. (1790). Critique of Judgment.(Trans. W.S. Pluhar,. 1987), Hackett, Indianapolis.

Kaplan, A.S. & Garfinkel, P.E. (1999). Difficulties in treating patients with disorders: A

review of patient and clinical variables, Canadian Journal of Psychiatry, 44, 665-

670.

Kaye, J.D. (1999). Toward a non-regulative praxis. In I. Parker, (ed.),Deconstructing

psychotherapy, Sage, London.

Keel, P.K., Mitchell, J.E., Miller, K., Davis, T.L., Traci, L. & Crow-Scott, J. (2000).

Social adjustment over 10 years following diagnosis with bulimia nervosa,

International Journal of Eating Disorders, 27(1), 21-28.

Kraner, M. & Ingram, K. (1998). Busting out - breaking free: a group programme for

young women wanting to reclaim their lives from anorexia nervosa. In C. White

& D. Denborough, (eds.),Introducing narrative therapy: A collection of practice-

based writings,Dulwich Centre Publications, Adelaide.

Kronbichler, R. (2004). Narrative therapy with boys struggling with anorexia The

International Journal of Narrative Therapy and Community Work, 4, 55-70.

8/10/2019 v5_1_Botha

39/45



39

Krusky, M. (2002). Women and thinness: The watch on the eve of the feast, therapy with

families experiencing troubled eating,Journal of Systemic Therapies,21(1), 58-

76.

Lacey, J.H. & Read, T. (1993). Multi-impulsive bulimia: An inpatient eclectic treatment

programme,European Eating Disorders Review, 1(1), 22-32.

Lasegue, C. (1873a). On hysterical anorexia. Medical Times and Gazette. 6 September,

265-266; 27 September, 367-369. Cited in J.A. Silverman. (1990) Anorexia

nervosa in the male: early historic cases. In A.E. Andersen, (ed.),Males with

eating disorders, Brunner/Mazel, New York.

Lasegue, C. (1873b). De lanorexie hysterique. Archives generales de medicine. 1

(April), 385-403. Cited in J.A. Silverman. (1990) Anorexia nervosa in the male:

early historic cases. In A.E. Andersen, (ed.),Males with eating disorders,

Brunner/Mazel, New York.

Le Grange, P.D.F. & Gelman, T. (1998). Patients perspectives of treatment in eating

disorders: a preliminary study, South African Journal of Psychology,8(3), 182-

186.

Levenkron, S. (2000).Anatomy of anorexia,Norton, New York.

Lock, A., Epston, D. & Maisel, R. (2004). Countering that which is called anorexia

Narrative Inquiry,14(2), 275-301.

Lock, A., Epston, D., Maisel, R. & De Faria, N. (2005). Resisting anorexia/bulimia:

Foucauldian perspectives in narrative therapy,British Journal of Guidance and

Counselling, 33(3), 315-332.

8/10/2019 v5_1_Botha

40/45



40

Lowe, B., Zipfel, S., Buchholz, C., Dupont, Y., Reas, D. & Herzog, W. (2001). Long

term outcome of anorexia nervosa in a prospective 21 years follow up study,

Psychological Medicine, 37(5), 881-890.

Madigan, S. & Goldner, E. (1998). A narrative approach to anorexia: Discourse,

reflexivity, and questions. In M. Hoyt, (ed.), The handbook of constructive

therapies,Jossey-Bass, San Francisco.

Mahon, J. (2000). Dropping out from psychological treatment for eating disorders: What

are the issues?European Eating Disorders Review, 8, 198-216.

Malson, H. (1998). The thin woman: Feminism, post-structuralism, and the social

psychology of anorexia nervosa,Routledge, London.

Malson, H. (2000). Discursive constructions of anorexic bodies and the fictioning of

gendered beauty, Psychology, Evolution and Gender, 1(3), 297-320.

Malson, H. & Ussher, J.M. (1996). Body poly-texts: Discourses in the anorexic body,

Journal of Community and Applied Psychology, 6, 267-280.

Malson, H., Finn, D.M., Treasure, J., Clarke, S. & Anderson, G. (2004). Constructing

The eating disordered patient: A discourse analysis of accounts of treatment

experiences,Journal of Community and Applied Social Psychology,14, 473-489.

McKenzie, W., & Monk, G. (1997). Learning and teaching narrative ideas. In G. Monk,

J. Winslade, K. Crocket D. & Epston, (eds.),Narrative therapy in practice: The

archaeology of hope,Jossey Bass. San Francisco.

Mehler, P. & Crews, C. (2001). Refeeding the patient with anorexia nervosa,Eating

Disorders,9, 167-171.

8/10/2019 v5_1_Botha

41/45



41

Minuchin, S. (1974). Families and family therapy, Harvard University Press, Cambridge,

MA.

Minuchin, S., Rosman, B.L. & Baker, L. (1978). Psychosomatic families: Anorexia

nervosa in context,Harvard University Press, Cambridge, MA.

Molodofsky, H. & Garfinkel, P.E. (1974). Problems of treatment of anorexia nervosa,

Canadian Psychiatric Association Journal, 19, 169-175.

Monk, G. (1997). How narrative therapy works. In G. Monk, J. Winslade, K. Crocket &

D. Epston, (eds.),Narrative therapy in practice: The archaeology of hope, Jossey

Bass, San Francisco.

Monk, G., Winslade, J., Crocket, K. & Epston, D. (1997), (eds.),Narrative Therapy in

Practice: The archaeology of hope,Jossey Bass, San Francisco.

Morgan, A. (2002). What is narrative therapy? An easy to read introduction, Dulwich

Centre Publications, Adelaide.

National Institute for Clinical Excellence (NICE). (2004a).Eating disorders: Core

interventions in the treatment and management of anorexia nervosa, bulimia

nervosa and related eating disorders Understanding NICE guidance: a guide

for people with eating disorders, their advocates and carers, and the public,

Clinical Guideline,London: available online at:

www.nice.org.uk/CG009NICEguideline(accessed 26 May 2008).

National Institute for Clinical Excellence (NICE). (2004b).Eating disorders: Core

interventions in the treatment and management of anorexia nervosa, bulimia

nervosa and related eating disorders, Clinical Guideline 9, London: available

online at: www.nice.org.uk/CG009NICEguideline (accessed 26 May, 2008).
http://www.nice.org.uk/CG009NICEguidelinehttp://www.nice.org.uk/CG009NICEguidelinehttp://www.nice.org.uk/CG009NICEguideline

8/10/2019 v5_1_Botha

42/45



42

Newton, T., Robinson, P. & Hartley, P. (1993). Treating for eating disorders in the

United Kingdom, Part II: Experiences of treatment: a survey of members of the

eating disorders association,European Eating Disorders Review, 1(1), 1-21.

Orbach, S. (1993).Hunger strike, Hammondsworth: Penguin.

Parker, I., Georgaca, E., Harper, D., McLaughlin, T. & Stowell-Smith, M. (1995).

Deconstructing psychopathology, Sage, London.

Peavy, V. (1996). Counselling as a culture of healing,British Journal of Guidance and

Counselling,24(1), 141-159.

Popper, K.R. (1972a). The logic of scientific discovery,Hutchinson, London.

Popper, K.R. (1972b). Conjectures and refutations: The growth of scientific knowledge,

Routledge, London.

Richards, P.S., Baldwin, B.M., Frost, H.A., Clark-Sly, J.B., Berret, M.E. & Hardman,

R.K. (2000). What works for treating disorders? Conclusions of 28 outcome

reviews,Eating Disorders, 8, 189-206.

Rosenvinge, J.H. & Klusmeier, A.K. (2000). Treatment for eating disorders from a

patient satisfaction perspective: A Norwegian replication of a British study,

European Eating Disorders Review, 8, 293-300.

Ryan, V., Malson, H., Clarke, S., Anderson, G. & Kohn, M. (2006). Discursive

constructions of eating disorders nursing: An analysis of nurses accounts of

nursing eating disorder patients,European Eating Disorders Review,14, 125-135.

Sanders, F. & Gaskill, D. (2000). Body image and eating disorders: Implications for

policy. In D. Gaskill & F. Sanders, (eds.), The encultured body: Policy

8/10/2019 v5_1_Botha

43/45



43

implications for healthy body image and disordered eating behaviours,

Queensland University of Technology, Brisbane.

Schwartz, R.C. (1999). Narrative therapy expands and contracts family therapys

horizons,Journal of Marital and Family Therapy, 25, 263-267.

Schmidt, U. (1989). Behavioural psychotherapy of eating disorders,International Review

of Psychiatry,1, 245-246.

Selvini-Palazzoli, M. (1974). Self-starvation: From the intra-psychic to the transpersonal

approach in anorexia nervosa,Human Context Books, London.

Shelley, R. (ed), (1997).Anorexics on anorexia, Jessica Kingsley Publishers, London.

Squire, C. (2008). Experience-centred and culturally oriented approaches to narrative. In

M. Andrews, C. Squire & M. Tamboukou, (eds.),Doing Narrative Research,

Sage, London.

Steiger, H. & Israel, M. (1999). A psychodynamically informed, integrated

psychotherapy for anorexia nervosaJournal of Clinical Psychology, 42(2), 229-

237.

Stoppard, J.M. (2000). Understanding depression: Feminist social constructionist

approaches,Routledge, New York.

Swann, C. (1997). Reading the bleeding body. In J.M. Ussher, (ed.),Body talk: The

material and discursive regulation of sexuality, madness and reproduction,

Routledge, London.

Tamboukou M, (2008). A Foucauldian approach to narratives. In M. Andrews, C. Squire

& M. Tamboukou, (eds),Doing Narrative Research, Sage, London.

8/10/2019 v5_1_Botha

44/45



44

Taylor, C. (1989). Sources of the self: The making of the modern identity, Harvard

University Press, Cambridge, MA.

Treasure, J. & Schmidt, U. (2001). Ready willing and able to change,European Journal

of Eating Disorders Review,9, 4-18.

Vitousek, K.B., Watson, S. & Wilson, G. (1998). Enhancing motivation for change in

treatment resistant eating disorders, Clinical Psychology Review, 18(4), 391-420.

Von Holle, A., Pinheiro, A.P., Thornton, L.M., Klump, K.L., Berrettini, W.H., Brandt,

H., Crawford, S., Crow, S., Fichter, M.M., Halmi, K.A., Johnson, C., Kaplan,

A.S., Keel, P., LaVia, M., Mitchell, J., Strober, M., Woodside, D.B., Kaye, W.H.

& Bulik, C.M. (2008). Temporal patterns of recovery across eating disorder

subtypes,Australian and New Zealand Journal of Psychiatry, 42, 108-117.

White, M. (1989). Selected papers,Dulwich Centre Publications, Adelaide.

White, M. (2000). Reflecting team-work as a definitional ceremony revisited. In M.

White,Reflections on narrative practice: Essays and interviews,Dulwich Centre

Publications, Adelaide.

White, M. (2002). Addressing personal failure, The International Journal of Narrative

Therapy and Community Work, 3, 33-76.

White, M. (2004). Folk psychology and narrative practices. In L.E. Angus & J. McLeod,

(eds.), The handbook of narrative and psychotherapy, Sage, London.

White, M. (2007).Maps of narrative practice,Norton, London.

White, M. & Epston, D. (1990).Narrative means to therapeutic ends,Norton, New York.

Winslade, J. & Monk, G. (1999).Narrative counselling in schools,Sage, Thousand Oaks,

CA.

8/10/2019 v5_1_Botha

45/45



Winslade, J., Crocket, K., Monk, G. (1997). The therapeutic relationship. In G. Monk, J.

Winslade, K. Crocket & D. Epston, (eds.),Narrative therapy in practice: The

archaeology of hope,Jossey Bass, San Francisco.

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