Book Review: Starving To Live: The Paradox of Anorexia

Lemma-Wright aims with this slender volume to provide "a brief but comprehensive overview of anorexia, covering research, theory and practice", and further to set this within "the context of an existential analysis of anorexia".

The overview of anorexia provides perhaps the most accessible introduction to this important and controversial subject currently available and is admirable in both vividness - significantly assisted by the insertion throughout the text of appropriate case study material drawn from the author's own practice - and comprehensiveness. Such a clear and concise organization of the material will be invaluable to any student considering research on an aspect of anorexia (or bulimia, on which she touches briefly and about which she provides useful information which helps clarify the similarities and distinctions between what she refers to as "probably related and overlapping 'disorders' of eating").

Given the constraint imposed by a mere ninety pages of text, it is difficult to see how this overview could have been bettered: moreover Lemma-Wright achieves possibly the most important goal of an introductory text - that of engaging and enthusing the reader so that he or she will be encouraged to read further and in greater depth.

The book is not, however, entirely without its difficulties and these become especially apparent once Lemma-Wright embarks on the fourth of her seven chapters, in which she attempts to go beyond the labels and the research findings which she has presented in earlier chapters by stressing "the importance of gaining insight into the client's experience of herself and her world"..."by attempting to think in terms of the anorectic's 'worldview'".

It should be immediately apparent that there exists a fundamental contradiction between an openness on the part of the therapist to the client's own experience of herself and the concept of the anorectic's worldview: at the very least we should be alerted to the danger, which we all must live with in our practice, of attempting to fit the client into some pre-conceived category, thus effectively losing sight of their individuality, the unremitting attempt to engage with which is a necessary condition of the existential approach. Certainly it is difficult to see how an I-Thou relatedness could develop out of a situation in which the client is perceived as a member of a category or type.

Perhaps in making this observation we are speaking to the converted for, after all, Lemma-Wright states quite clearly in her first chapter that labels and the information they contain greatly influence how we see and understand that which the label purports to describe. Further, she notes that some labels "implicitly assume that the cause of...behaviour and distress is 'an illness of some kind'". Nevertheless Lemma-Wright goes on, despite misgivings, to use 'anorectic' for purposes of 'clarity', offers a working definition of anorexia nervosa, and writes of the difficulty in diagnosing anorexia, of pathology, and of aetiology. She also speaks of 'ontological insecurity', a concept which is highly problematic - as Cohn reminds us in

this Journal (6.1), " 'Being' is, inevitably insecure, there cannot be such a thing as ontological security".

We are moved to ask why she takes this course. Perhaps in answer to this question it is important to acknowledge Lemma-Wright's struggle with a problem which particularly impacts upon practitioners who have chosen to pursue a career within the medical establishment, whether NHS or private. Such practitioners are free to critique the concept 'anorexia' but, in the final analysis, are expected to work with it as part of a team for whom the medical model provides, by and large, a bedrock of certainty about their role in relation to the patient who is conceptualized as in need of treatment and, where possible, cure. Seen from this perspective Lemma-Wright's book is ground-breaking and thought-provoking. From the perspective of, as it were, the converted, the language of the medical model and the existential-phenomenological approach are essentially incompatible so that though we may be able to comprehend the 'why' of this language in the sense of Lemma-Wright's motivation for retaining it, the 'what' as in what as existential practitioners we can take from the book for our own work is severely trammelled.

Should this seem too exacting, we need only observe the logistical problems which arise in the text. Lemma-Wright writes, for instance, of the difficulty for the anorectic of finding an answer to the conflict between autonomy and dependency, and states that the answer is to be found in the integration of these two polarities. But they are not, at least in the existential schema, polarities but paradoxes, and there are no answers to paradoxes - a paradox you live with.

The experiences of a client are quite frequently summed up in a single word, phrase or metaphor and the reader is left to ponder whether this word, phrase or metaphor was the client's own and, if so, what might have been gained by further exploration of it. If, as Lemma-Wright reports, a client refers to herself as a 'nothing' we immediately have the opportunity of exploring her sense of being-in-the-world simply by enquiring what she means by a 'nothing'. Another client is afraid to venture out in case she is robbed of her 'self'. What, we wonder, was this 'self' for her? It is, after all, the meaning which we ascribe to the world, not the illness category which is ascribed to us, which brings us closest to the sense of self which is experienced by the client as problematic. If we regard language as a prime tool in such an exploration we must be concerned about the closure placed on our appreciation of the client's experience by medical model categories.

In similar vein, the client who feels proud and that she has 'done good' when she loses weight is referred to as euphoric - a state characterised by heightened emotional arousal. So, again, an experience is subsumed in a condition or category. Yet such feelings are ordinarily related to our satisfaction at making progress in the pursuit of some task or project. Viewed thus our attention alights on the client's intentions rather than on her 'symptoms'. If we follow this line the client's behaviour appears more meaningful, as a project more about living to starve than starving to live.

Lemma-Wright's text, then, serves the dual role not only of providing an excellent introduction to anorexia nervosa but also an example worthy of serious attention of the tension between the existential approach and the broadly psychodynamic approach and medical model so prevalent in the field of mental health care. She has highlighted an important debate and one which, given the increasingly high profile of the existential approach, is likely to become more pressing in future years as increasing numbers of qualified practitioners begin to take up positions in the NHS and private health services. And this is not a problem of language merely for, as Lemma-Wright so astutely observes, labels can determine "how we approach the individual and how we define our roles and responsibilities as practitioners".

Simon Du Plock