The Social Construction of Anorexia Nervosa (review)

Julie Hepworth.The Social Construction of Anorexia Nervosa. London: Sage, 1999. 146 pp. $74.00 cloth.

Julie Hepworth's often intriguing book will appeal to scholars interested in the promise of poststructuralist analysis for studies of health care. It is also--or perhaps mainly--intended for practitioners who are familiar with and engaged by such approaches as narrative therapy and who seek a critical perspective on their own practices.

The Social Construction of Anorexia Nervosa has three parts. The first two analyze historical and contemporary discourses about self-starvation; the third asks how an evaluation of language and postmodern ideas about anorexia nervosa might help reconceptualize therapeutic practices around this disorder, thus dealing with it as a "public rather than an individual problem that requires a participatory approach to changing health care practices" (9). Hepworth focuses on discourses about this illness, its causes, and its implications because, as she says, "Discourses privilege one way of explaining a phenomenon over another during different historical periods, and by examining discourses we understand how human actions are structured, explained, maintained, reproduced and changed" (9).

Parts 2 and 3 are by far the most original and fascinating sections of Hepworth's book. In part 2, she interviews a variety of British health care workers who treat people with anorexia nervosa, and asks them to explain this illness: "Why do people starve themselves?" Her close analysis of their responses demonstrates a real variety in the ways in which health care workers conceptualize this problem. Some fell back upon psychological theories about mother-daughter relationships, others on the stresses of gender roles and cultural conventions, and still others pinpointed a combination of individual psychopathology, familial relationships, and cultural positions. Hepworth does an especially good job of showing how uncertainty and frustration lurk within these practitioners' responses. Their accounts, she suggests, give voice to a pervasive tension over whether anorexic women are like all women or not--a tension which, in the end, roots this disorder within individual psychopathology. Hepworth is also quite good at helping readers see what explanations are not given for self-starvation, what factors are not said to be responsible for anorexia nervosa according to these practitioners. After all, discourse analysis is as much about what is not said as what is said. Hepworth would like us to see how in their everyday practice these well-intentioned and concerned caregivers tend to situate the causes of anorexia nervosa primarily in the individual or the family rather than (as Hepworth would have them) in larger cultural systems and social pressures.

Part 3 examines the implications of new ways of thinking about self-starvation, the body, and the individual for therapeutic practice. How, Hepworth asks, has the poststructuralist emphasis on language as constitutive of identity reshaped therapeutic interactions, and how could it reshape them even more thoroughly and beneficially? She argues that narrative therapy, which claims to help patients "re-author personal stories," still focuses on the individual without sufficient attention to the power of broader social structures. This type of therapy is an advance in that it "create[s] possibilities for women diagnosed with anorexia nervosa to move beyond the language of psychopathology" (123). But where a real attention to poststructuralism can be helpful, she suggests, is in a more thorough conceptual shift, not just beyond individual psychopathology, but to "the understanding of food refusal in relation to social practices" (124). This, she argues, has the potential to help those diagnosed with anorexia nervosa move beyond a limited, prescribed, individualistic subject position as psychiatric patient to participate "as citizens within the broader structures of health care" (125). Indeed, Hepworth suggests, the ultimate lesson of this analysis is that it is therapists who must change, who must "reevaluate their roles in the administration of health and participate within the broader explicit politics of the production of knowledge" (130).

I suspect that historically minded readers will, like me...