Beruflich Dokumente
Kultur Dokumente
of Deficiency
Author(s): Nicole Moulding
Source: Feminist Review, No. 75, Identities (2003), pp. 57-74
Published by: Palgrave Macmillan Journals
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75
constructing
in
mental
health
identity,
and
of
the
self
practice:
individualism
the
feminization
deficiency
NicoleMoulding
abstract
Thediscursive production of the 'self' in the context of
mental health care has
potentialimplicationsfor how the subjects of interventioncome to
understandand
experience
themselves. Eatingdisordersprovidean illustrativeexampleof the ways
in
whichconceptualizationsof the self that structure mental
health practices can be
gendered,because they are mainlydiagnosed in womenand dominant
explanationsof
theirorigins are feminized. This discourse analytic study
examines the gendered
natureof mental health workers'constructionsof the
eating-disorderedself through
the psychological construct of 'identity', examining the
dominant discourses
implicatedin the feminizationof deficient identity, and addressing
the implications
ofthis constructionfor mental health practice.
keywords
identity;eating disorders; discourse; gender; feminism
feminist
review 75 2003
www.feminist-review.com
57
introduction
While psychological theories and associated interventions used to explain and
treat 'mental disorders' make claims to gender-neutrality, mental health workers'
assumptions about mental health and illness in women and men are known to be
profoundly gendered (Brovermanet al., 1972). ating disorders provide a useful
illustration of particular ways in which assumptions about gender can structure
explanations and practices in the mental health arena because, firstly, they are
mainly diagnosed in women (American Psychiatric Association, 1994) and,
secondly, dominant conceptualizations of their origins are feminized (Hepworth,
1999). For example, problematic female puberty is seen as central in anorexia
nervosa, despite its diagnosis in males (Crisp, 1979).
The extent to which assumptions about gender underpin theory and practice in
relation to eating disorders has potential implications for the ways in which women
come to understand and experience themselves. 1 Various forms of individual
psychological therapy represent the predominant method of intervention and,
despite relatively poor outcomes (Hsu et al., 1992), there has been little attention
to alternative approaches such as addressing the sociocultural factors widely
implicated in causation (Moulding and Hepworth, 2001). Thus, the main forms of
intervention are individually focused and intrinsically language-based, offering
particular forms of subjectivity to women as the main subjects of intervention.
Drawingon the writings of the Frenchphilosopher Michel Foucault language is 'the
place where actual and possible forms of social organization and their likely social
and political consequences are defined and contested... it is also the place where
our sense of ourselves, our subjectivity, is constructed' (Weedon, 1987: 21).
Subjectivity is, therefore, produced in a range of discursive practices and the
meanings of these can be understood as sites of struggle over power (Weedon,
1987). The discursive practices that constitute interventions for eating disorders
represent such site, offering particular forms of gendered subjectivity and power
setting
dynamics (Turner, 1984; Gremillion, 1992). While the therapeutic
represents only one of many contexts in which the subjectivities of women
diagnosed with eating disorders are produced, it is particularly significant because
of the power dynamics involved. The freedom to position oneself in discourse is
contingent upon access to power (Parker, 1992), and mental health workers have
differential access to the power to position subjects within the discourses
structuring therapeutic interactions by virtue of their status as professionals with
expert knowledge.
method
In order to interrogate the ways in which assumptions about gender might
structure explanations and associated interventions used for eating disorders, a
58 fem i n i st review 75 2 0 0 3
series of interviews were conducted between 1997 and 2000 with a multidisciplinary
sample of 31 health-care workers involved in therapy and prevention in this area.
The health workers were based in three Australian capital cities, and represented a
wide range of disciplines, including, 10 psychiatrists, four social workers, four
psychologists, two community workers, counsellors, nurses, general practitioners
and dietitians and three health promotion workers. The health workers were based
in a variety of settings, including community-based women's health centres,
hospital-based inputient treatment settings, private psychotherapeutic clinics, a
state-wide health promotion programme and community-based self-help groups. A
wide selection of disciplines and settings were chosen to ensure maximum
variability of responses (Kuzel, 1992).
Semistructured interviews were undertaken in order to obtain extensive and
detailed information about health workers' explanations of 'eating disorders'.
Interviews were loosely structured around a series of questions about how eating
disorders and their causes might be explained and addressed. There was an
assumption of inter-subjectivity and mutual creation of data between the
interviewer and participants (Olesen, 1994). Interviews, ranged between 50 min
and 2 hours, were audiotape recorded and fully transcribed.
Central to this analysis is a post-structural feminist understanding, which
emphasizes the constructive use of language and the ways in which gender
inequalities are reproduced in the structuring of explanations of women through
historical, social and political discourse (Weedon, 1987; McNay, 1992). Discourse
analysis was used to explore the ways health workers' accounts drew on particular
historical, social and political discourse. Whilethere is no one definitive approach
to discourse analysis, Burman and Parker (1993: 3) suggest that ' [d] ifferent
approaches to discourse analysis share a concern with the ways language produces
and constrains meaning, where meaning does not, or does not only, reside within
the individual's head, and where social conditions give rise to the forms of talk
available'. Discourse analysis therefore involves exploration of the ways in which
language constructs, rather than simply reflects social reality, with the associated
implication that 'meanings are multiple and shifting, rather than unitury and fixed'
(Burman and Parker, 1993: 3). In the approach used in this study, there was also
an emphasis on the ways in which subjects (women) as well as objects (eating
disorders) were constructed in discourse, and how language mirrorsand reproduces
wider power relations (Parker, 1992). Thus, the study involved a critical approach,
attending to the ways discourse is shaped by, and reproduces, power relations and
the constructive effects of discourse upon subjectivities (Fairclough, 1992; Parker,
1992). NUDIST,the electronic qualitative data analysis package, was used to
categorize transcribed interview text thematically, and to undertake the initial
stage of analysis. Later stages involved extensive re-readings of thematically
categorized extracts.
NicoleMoulding fe m i n i st rev i ew
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59
in eating disorders
One of the key themes to emerge from the interviews with mental health workers
was that of 'identity'. This concept was used to construct the intrapsychic realm of
the eating-disordered self, and to situate this self in relation to the externally
located social world. The fact that eating disorders are widely understood as
having at least some origin in particular historical and social contexts (cf. Garner
et al., 1983) means that they provide a particularly good illustration of some of
the ways in which individuals are positioned in relation to the social dimension
within the mental health arena. Half of the sample of workers interviewed used the
concept of identity in this way, including most of the disciplines participuting in
the study. Notably, social workerstended not to draw on these ideas and, instead,
employed post-structural, feminist and structural explanations. This reflects the
fact that social work has historically given some emphasis to sociological
perspectives and the broader social aspects of health and welfare problems
(Payne, 1997).
While the construct of identity has been previously identified within UK health
workers' explanations of anorexia nervosa (see Hepworth, 1999), the analysis
presented here focuses specifically on the ways in which the psychological theories
informing mental health workers' accounts of identity in eating disorders are
gendered,and the implications of this for practice. Three key discursive themes
emerging from mentaJ health workers' constructions of identity in this study
included: (1) psychodynumic constructions of identity; (2) autonomy and
connected-ness in identity, and (3) inauthentic identity. xampies of the
discursive themes from the relevant interviews are provided as interview extracts
drawn from a more comprehensive collection of analysed material. Health workers'
numes have been changed to protect their, and their clients', identities.
psychodynamic constructions
of identity
The psychological concept of 'identity' has its origins in psychodynumic theory and
rikson's (1980) proposal that 'ego identity' involves 'the immediate perception of
one's selfsameness and continuity in time' and a 'perception of the fact that
others recognize one's sameness and continuity' (rikson, 1980: 22). rikson (1980)
also suggests that the individual gains a 'sense of reality from the awareness that
his [sic] individual way of mustering experience, his [sic] ego synthesis is a
successfuJ variant of a group identity', and this is understood as conferring 'status
and stature' on the individual (rikson, 1980: 21-22). Thus, identity is understood
within rikson's conceptualization as 'a theory one has about oneself' (Marcia,
1987: 165), involving both a continuous sense of self, self-mustery and a
recognition of this by others. In Iine with this, Robyn, a psychiatrist providing
therapy for young women diagnosed with eating disorders, emphasizes
60 teminist review 75 2 0 0 3
NicoleMoulding
feministreview75 2003
61
in Rebecca's account,
suggesting
relationship,
inner world':
...it seems very often ... [.] ...quite a well meaning family to the outsiders. The fact is
ultimatelyto damage the emergenceof the child's sense of their own innerworld.Andwhat
happenswith the, you know,the characteristicof anorexianervosa is that there is nothing
inside. She can talk about nothing She's, you know,the whole worldis impingingupon her
and she has no agency, not even a sense of control over her own thought processes. So it
seems to me that the notion of control whicharises ... [.] ... control over her own body, and
what goes into it, is in a perverseway an attempt some how or other to maintaina kind of
agency which is part of the system itself... [.} ...that
Continuity is therefore
and complete
functional
to be essential
of a
to the development
Further,
ric suggests that 'damage' results in the anorexic individual lacking an identity or
sense of self completely,
the eating disorder functions as a way for the individual to 'maintain some kind of
agency', and therefore some form of ego identity, albeit a dysfunctional
eating-disorder
one. The
(see
becomes,
non-contradictory
al.J
assumed that the healthy personality is 'developed' through childhood, after which
the individual is a coherent self, with an identity that is continuous
and place.
The concept
of 'agency'
disorder becomes
selfhood.
and understood
to be
is also emphasized
across time
to maintain
agency
the individual
and,
is therefore
(Henriques et
62
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by
by
1991).
Thus, the humanist view of the relationship between the individual and society is
dualistic. The idea of the unitury, sovereign individual at the centre of humanist
thought has been widely challenged by post-structural theorists, particularly
Foucault, who emphasizes the idea of discontinuity and contradiction as
constitutive of individual subjectivity (Foucault, 1972). This challenges notions
of progressive, linear development resulting in a unitury, coherent identity and,
instead, views identity as a phenomenon that is contingent on social practices
and, therefore, inherently unstable (McNay, 1992). The individual-society dualism
structuring humanist accounts is consequently challenged in post-structural
thinking because identity is understood as produced through language and
discourse, rather than as residing within individuals' heads.
NicoleMoulding feminist
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fe m i n i st re v i e w 75
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coped with the concept that everybodywon't like them, no matter what they do, no matter
how wonderfulor good they might be, that everybodyisn't going to like them, and that
that's okay... [ . ] ...So I guess they're quite immature...
(Vivien, Psychiatrist)
In this account, anorexic individuals are portrayed as fundamentally overconnected to, and affected by, others because they conceptualize relationships
like a 'see-saw', and are therefore 'immature' because they have failed to
individuate. Further, Vivien constructs the behaviour of anorexics as 'trying to
manipulate . . . change things' so they will feel 'liked', 'accepted' and 'approved of',
constructing anorexic individuals as experiencing themselves only in relation to
others. This is portrayed as a deficit in the individual, and as underpinning their
disorder.
In the following extract, Sarah, also a survivor of an eating disorder, introduces
the idea that eating-disordered individuals have weak boundaries around the self
as an explanation for over-connectedness to others and the outside world more
generally. The concept of weak boundaries is introduced through the idea that
eating-disordered individuals 'lack a bit of a buffer' from the outside world:
. . . these people tend to be quite perceptive, and sensitive people. And that's a great
quality to have, you know, it's very useful. But this society is a very kind of competitive,
hard, anxiety-riddenculture. Those people cannot then just crumblebecause... [.] ... being
[.] perceptive or considerate can be a bit too much. Sometimes you need to have a little
bit of a buffer. yOu need to step back. These people often feel that they're somehow
responsiblefor fixing everything... [.] ...this belief that somehowyou are in a position to
fix other things aroundyou.
(Sarah, CommunityWorker)
NicoleMoulding fe m i n i st rev i ew
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Melissa argues that it is the 'different sense of boundaries' that individual girls
have that leads some to take things 'personally'. Thus, girls prone to eating
disorders are less bounded from the effects of female body appraisal than other
girls. In this extract, boundaries are defined in two ways. Firstly, they are located
around the body, in that 'you can touch someone, but not touch someone else.'
Secondly, they are located around the self, because 'you can say one thing to one
person, but not to another one.' For some individuals, comments penetrate weak
boundaries and are internalized, while they fail to penetrate those individuals
whose boundaries are more firmly delineated. The notion that the self is bounded
also derives from psychodynamics, where 'ego boundaries' are understood as
providing 'shock-absorbing delineation' from the outside world (Erikson, 1980: 42).
In the individual with an incomplete ego identity, this protection is absent. One of
the foremost early theorists on eating disorders, Bruch(1974), centred the concept
of diffuse ego boundaries in her account of anorexia nervosa. In common with
these ideas, Sarah's and Melissa's accounts construct eating-disordered
individuals as less bounded, less self-contained, and as therefore more vulnerable
to incursions from outside.
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Nicole Moulding fe m i n i st
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health in women are inherently conflicted and contradictory because women are
concurrently constructed through fundamentally contradictory discourses. While
femininity discourse confers 'feminine' qualities, these are rendered deficient
through psychological theories embedded a discourse of individualism that is
predicated on masculinist assumptions of idealized selfhood.
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I think [body image disturbance has] risen much more in recent times when there's a
tendency for people to be fairly anonymous,whereas perhaps in times gone past they'd be
part of an extended community,an extended family, [and] their identity was more from
being known.Um, now perhapsthere is a tendency more to be knownby howyou look or by
your money, or by your success...
(Paul, Psychiatrist)
Thus, being 'known by how you look' is a superficial, fulse identity in contrust to
being known for your true inner self. Clare also uses a similar notion of true and
fulse identity in body image problems:
...there's not an acceptance of people for the size they are. There'snot an acceptance of
the person for who they are. It's really much more conditional on meeting certain kinds of
stereotypes than that...
(Clare, Psychologist)
In this account, 'certain kinds of stereotypes' represent the world of external, fulse
identity, while true identity involves individuals being accepted for 'who they are'.
Malson (1998) also identifies similar themes of true/internal and superficial/
external identity in women's explanations of their experiences of anorexia nervosa.
She argues that the intersection of these metaphors with constructions of
'feminine' identity are problematic because dominant constructions of femininity
centre physical appearance and beauty practices. The location of authentic
identity within the internal depths of the individual is therefore 'profoundly at
odds' with the superficiality of this construction of 'femininity', which becomes
'the other of identity' (Malson, 1998: 149). The notion of superficial identity
serves, then, to feminize inauthentic identity, just as the privileging of autonomy
feminizes incomplete identity.
NicoleMoulding fe m i n i st rev i ew
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conclusion
A focus on the internally located and supposedly gender-neutral construct of
identity obscures the profoundly gendered nature of discourse and subjectivity. It
is imperative that practitioners take critical account of the gendered nature of
dominant discourses structuring theory and associated practices used in relation
to eating disorders. Post-structural feminist interpretations offer radically
different possibilities for practitioners and women to challenge constructively
NicoleMoulding fe m i n i st revi ew
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author biography
Nicole Moulding is currently completing doctoral research into constructions of
gender, self and society in mental health practice in the Department of Social
Inquiryand Department of Public Health at the University of Adelaide. She has
long-standing interests in gender and mental health, both academically and as a
professional social worker in the field. Her previous publications include a critical
analysis of a mental health promotion programme addressing body image and
eating problems among women.
voknowledgements
I thank the health workers who took part in this study. I also thank Dr Margie
Ripper for her insightful comments and feedback on earlier drafts of this paper.
This study was conducted as part of the author's Doctoral research, and was
supported through a University of Adelaide scholarship, a Health Enhancement
Research Grant from the South Australian Department of Human Services and a
grant from SmithKline, Beechum.
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