Book Review: From Virtue to Vice: Negotiating Anorexia

From Virtue to Vice: Negotiating Anorexia. Richard A. O’Connor and Peggy Van Esterik. New York: Berghann Books, 2015, 252 pages.

From Virtue to Vice is a provocative book on many levels. It aims to challenge received wisdom about anorexia, reframingit as an “activity disorder” thats prings to life subsequent to and from within anorexic behaviors (such as caloric restriction) rather than as a manifestation of a deep prior pathology whose meaning must be decoded from eating behaviors .In other words, the authors contend that anorexia has no history in a person’s life prior to the taking up of anorexia’s ascetic practices.

The big take-home point of the book is that anorexia is development knocked off course by an activity with nomeaning and no prior significance that seizes people out of the blue. Once underway, these practices then take on a momentum and meanings of their own, becoming what is clinically recognized as anorexia.

Such a radical revisioning of such a complex and deeply researched topic is a bold and laudible exercise. And the authors make many insightful points about what happens once anorexia takes hold. Yet, despite what I take to be genuinely good intentions on the part of the authors, From Virtue to Vice is a highly problematic book. It is inconsistently argued, poorly researched, cavalier, and, in my opinion, potentially dangerous. The authors contradict themselves frequently, misrepresent the literature and current stateof information, and twist the practice of ethnography into something unrecognizable to any anthropologist. This is not to say that the book has absolutely nothing to offer.

There are indeed several nuggets of good analysis and insight in the book that deserve due attention. But the bulk of the text is difficult to ollow, misinformed, and misleadingin ways that both silence individuals with eating disorders (despite the authors’claims to do the opposite) and have the potential to set the anthropological engagement with these conditions back several decades.

First, while the idea that anorexia has its own internal momentum and that the behaviors and practices of anorexia take on additional or altered meanings as they are practiced in people’s daily life is important, it is in no way new. It is well known in the clinical and social science world that anorexia has its own biological propulsions and that the activity itself produces many of the features of anorexia that appear on clinical radars. This, indeed, is the very foundation of current best practice treatment approaches. Framing anorexia as emergent in and inextricable from its embodiment and praxis in this way is old news.

What the authors do propose that is new—and highly problematic—is that anorexia has no meaning or history prior to theactive phase of anorexia itself. Anorexia, they claim, has no prior pathology, no originating cause. Anorexia, they say explicitly, means nothing, symbolizes nothing, communicates nothing. I personally know of no clinician or person who has ever had anorexia who would agree with this perspective. But that alone doesn’t make it wrong. To evaluate this claim we must look to the authors’ methodology, data, and structure of argument.

Methodologically, the authors base their analyses on extensive qualitative interviews with 22 individuals they characterize as “recovered” anorexics (i.e., people who struggled with anorexia in the past but report no current involvement witht he behaviors). The interviews are retrospective ,often many years post- recovery, and ask participants to reflect on what led them to anorexia, what their experiences of the illness werelike, and how they moved out of it.

This is an admirable project, and one that has much to offer our understandings of anorexia and its lived experience in people’s daily lives. The interview data are richandfar-reaching.However,wherethe authors misstep is in taking retrospective reflections on an illness experience as the end-allbe-all truth about what those experiences actually were,what they meant to people at the time, and what they indicate about anorexia more generally.

For example, a common theme that emerged from the interviews is that people were often unclear about what,exactly,led them to begin engaging in anorexic behaviors. They remembered being immersed in them, could remember some indexical events or feelings, but were not always able to articulate the specific sequence of events that brought them to the point of self-starvation. The authors then, astonishingly, use this to conclude that nothing did cause the anorexia, that therewere in fact no preceding issues or causes; that it just happens and is accidental, and that it has no history or story or meaning behind it. The authors state this explicitly many places, one of the most troubling being the comment that “practicing anorexics have no story to tell” (p. 117),which, had they actually spoken to practicing anorexics as many ethnographers have (e.g., Eli, Gooldin, Lester, Shohet, Warin), they would know to be untrue.

It is important to emphasize that this does not make theauthors’ retrospective data irrelevant, but it does make them narratives, not ethnography: rich narratives of how people remember (or forget) becoming embroiled in anorexia. What this tells us is how people make sense of their illness experiences in retrospect: an important contribution, but one that is vastly different from substantiating broad and potentially dangerous claims about the lack of historical or life-meaning context to anorexia before it seizes on people out of the blue.

Even more troubling is that such statements simply do not follow from the data presented. The fact that people reflecting on a past illness experience could not identify in detail what got them started on the road to anorexia does not mean there is nothing there to know.

There could be any number of reasons why such antecedents might be difficult to identify. Yet the authors use this to conclude that “our informants’apparently normal and overly successful prior lives argue against any significant prior problem.How serious couldan abnormality be if it did not disrupt their childhood?” (p. 114). This is simply irresponsible. The fact that someone can be highly functioning while also enduring depression, family disruption, anxiety, abuse, neglect, disaffection, isolation, or crippling shame does not make those challenges non-serious.

Furthermore, it is very common for people with anorexia to be highly functioning, “good girls” (or boys) in childhood, and it is known that perfectionism and a drive for achievement are risk factors for anorexia. To assert that because everything looked OK from the outside there must not have been serious issues going on shows a troubling ignorance aboute ating disorders in particular and about psychological distress more generally. These are just two examples of the kinds of potentially dangerous statements that populate this book and which risk silencing anorexic women and men and minimizing and marginalizing their lived experiences.

The authors further misstep by actively contradicting themselves. For example, at one point they make the unusual claim that,because there is disagreement over the causes of anorexia, this must mean that, in fact, “there is no prior pathology” at play (p. 114). But then just three paragraphs later the authors note that there may be a “prior or subsequent pathology that gets drawn into anorexia’s vortex—or vice versa,” noting that, for example, “a sexually abused person may give restricted eating energies that the activity alone cannot explain. Here anorexia acts as an idiom of distress … attracting and expressing other difficulties”(pp.114–115). In other words, they completely undo their argument. Later on the same page they note that their informants stated that their lives felt out of control and that the asceticism of anorexia “conquers that feeling by shrinking life to a discipline. … Monks once fled a sinful world;today anorexics flee our chaotic one”(p. 115). In less than two pages, then, they have argued that anorexia is an accident and has no underlying cause, and then posited a general underlying cause for anorexia. This is but one example of the kinds of analytical problems that plague the book.

In the end, the authors conclude that anorexia is not a disease and that therefore medicalization must be undertaken with caution.While wariness of medicalization is a certainly a healthy critical stance, such a position elides the fraught and troubled history of trying to get anorexia taken seriously as a condition worthy of care. In the state of Missouri, for example, we have just now, in 2015, gotten legislation passed that requires insurance companies to cover eating disorders on par with other mental health conditions. Recognizing anorexia as a serious health problem requiring specialized care is an issue with direct, material import for people.

Contending that anorexia is an accident, has no meaning, and is not a disease potentially undermines all the new and still-tentative hard-won advances made on thisfront.

From Virtue to Vice is a promising project that, unfortunately, falls significantly short. The massive missteps taken in this book as well as its tone, argument, and conclusions are troubling in the extreme. It need not be so.T he authors are well intentioned and accomplished anthropologists. I would love to see them provide a reanalysis of their substantial and rich interview data as culturally located narratives of how people reflect on their eating disorder experiences once they have reached the other side. Much could be gained from such an analysis, and the authors are well positioned to make what could be a significant contribution to the field.

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