Commentary: Never underestimate the power of a good story

Culture is a concept that everyone intuitively understands. It is also an exceedingly nuanced term that has an infinite number of permutations. By convention, we have historically yoked culture to a geographic region, a shared history of people often identified by customary beliefs, common language, traditions, values and experience. The study of eating disorders has been a study of culture since its inception, with culture recognized as central to the etiology, course and outcome. Modern-day scholarship began with a lens on social context with extensive theory and research focused on the particular features of high-income, Euro-American cultures that increased the risk for developing eating disorders, particularly for young women coming of age. A pioneer in the field, Hilde Bruch rendered in high relief this sociocultural context of increased risk for anorexia nervosa in The Golden Cage: The enigma of anorexia nervosa (1978). Subsequently, with the formal recognition of bulimia nervosa, Striegel-Moore, Silberstein, and Rodin (1986) expanded the sociocultural examination of eating disorders when they posed three fundamental questions, “Why women?” “Why some women and not others?” “And why now?” This early scholarship set the stage for a conceptualization of eating disorders as “culture-bound syndromes” that were the unfortunate consequence of certain toxic features of western culture.

The study of cultural context and the scientific exploration of the etiological risk of culture in relation to eating disorders has increased exponentially over the past fifty years. As the field has matured, our understanding of the complex interplay between biological and environmental factors that increase risk for eating disorders has increased in sophistication as well. We also recognize that, across many cultures, risk for eating disorders is significantly greater than was once thought, with documented eating disorder cases on every major continent save Antarctica. As reviewed by Pike, Hoek and Dunne (2014), this rise of eating disorders in certain non-Western countries initially gave rise to the “Westernization” thesis that was grounded in the assumption that increasing exposure to and interaction with the West – and thus, “Western culture” – resulted in the transmission of EDs to non-Western populations. However, as we identify eating disorders around the globe, we increasingly also recognize the limits of the Westernization thesis as an explanatory framework for understanding eating disorders.

The articles included in this special issue are brilliant in the individual and collective critical thinking that extend the study of culture through careful examination of individual narratives and experiences. They represent scholarship from around the world and give voice to both the common factors of suffering associated with eating disorders and the diversity of individuals who share the experience of eating disorders. The authors in this special issue contribute powerfully to the recognition that the study of culture and eating disorders needs to evolve beyond the thesis of Westernization and their emphasis on narrative and lived experience to expand our understanding of eating disorders today brings a humanity to the growing quantitative database on eating disorders.

The scholarship in this special issue captures the fact that cultures are not static. From a global perspective, we can anticipate that common factors of “cultures in transition” increase risk for eating disorders (e.g., Nasser, Katzman, & Gordon, 2001; Pike & Dunne, 2015). Today, psychological distress and disturbance among individuals across gender and from a wide range of cultural, economic, and ethnic/racial backgrounds are finding expression in eating disorders in low, middle and high-income countries around the world. Moreover, the demographics of individuals presenting with eating disorders in recent years has not only shifted to new parts of the globe, but is also changing within Western, high-income countries where eating disorders were first described. In the U.S., for example, we have increasing recognition of the ways in which diverse ethnic and racial minority groups are increasingly at risk of developing eating disorders (for a review see Pike, Hoek, & Dunne, 2016).

Humans are storytellers. The personal narrative is fundamental to our existential quest to make sense of the mystery of life. The story of culture and eating disorders is the aggregation of individual stories. This special issue captures the essential role of storytelling, the ever-evolving meaning of culture and the untethering of culture from geographically, linguistically and historically defined boundaries to a twenty-first century experience of culture. This evolving construct of culture connects individuals with distinct nationalities, ethnicities, languages and traditions across what must be understood as culture defined by experiences of suffering that are not dependent on latitudinal or longitudinal coordinates.

Karin Eli (this issue) writes about eating disorders as particular experiences of liminality, of living in that in-between space that comes with being inextricably a product of one’s culture and yet no longer being able to live in that space without suffering. The suffering is expressed through eating disorder symptoms. A poetic variant of the idea that ontogeny recapitulates phylogeny, Eli captures the idea that individuals with eating disorders are living in the interstices, a fragile state that is filled with anguish, ambiguity and disorientation about self and place in the world. This narrative of the individual parallels the scholarship on sociological frames of cultures in transition and the inherent risks in the uncertainty of transition and the transition of uncertainty.

Rebecca Lester (this issue) in her exploration of the anthropology and entanglements of care, questions a notion that people generally take for granted and vividly captures the “fraught politics of care” vis a vis eating disorders. Her work expands the notion of culture to astutely describe and importantly challenge the culture of care in the field of eating disorders. Cultural assumptions about the role of the patient, intentions and agency related to risk and recovery wash over care at every level. From the institutions that disempower to the payment models that withhold coverage to the service providers who cap their empathy because they don’t want to be manipulated, Lester makes it eminently clear that we have a professional culture in need of self-reflection and growth to better meet those who are suffering where they are.

Shining a light on the essential power of the narrative, Merav Shohet (this issue) and Connie Musolino, Megan Warin, and Peter Gilchrist (this issue) bring to life the ways that each of us constructs our narratives within a cultural context. Put another way, we are each born into other people’s stories. And thus, because we can only understand our stories in context, “the grammar, lexicon, and structure of a given narrative in the course of the telling may modify a subject’s phenomenological experience and interpretation of the events, feelings, and states of body–mind recounted” (Shohet, p. 508). Shohet’s careful examination of what it means to construct various narratives for meaning and outcomes is illuminating. And her caution that the culture of medicine within which individuals construct their stories may not always convey salutary benefits calls for all of us in healthcare “delivery” to take heed. Similarly, focusing a cultural lens on the “multiplicities of desire,” Musolino, Warin and Gilchrist bring to light a core dimension of experience that has been woefully neglected in our cultural understanding of eating disorders. What it means to experience desire, and understanding how such desire moves and shifts in accordance with gender and different socio-cultural contexts, has the potential to advance constructs about and capacities to achieve recovery.

The complementary discourse advanced by Anna Lavis (this issue) focuses on the meaning and function of (not) eating and examines ways in which starving, calorie counting and thinking about food offer “a critical lens onto what anorexia does for, as well as to, individuals living with the illness.” The paradox of this state of illness is that it both responds to and ameliorates distress, taking us back to Eli’s discussion of liminality. The disorder at once connects and separates, comforts and torments, threatens and protects the individual. Lavis’ case exploration illustrates the potential for healing that comes with honing in on the narratives of distress and exploring the functional role of symptoms for individuals caught in the conflicted state of wanting to recover from an eating disorder and the desire to maintain it.

Together, these works of scholarship take us from the exquisitely personal experience of suffering and struggle to the complex understanding of variants on the construct of culture. No matter how widespread and global eating disorders become, these works remind us that the immense aggregation of data represents individuals whose stories of suffering are experienced and told through eating disorder narratives one life at a time. This body of scholarship underscores the importance and relevance of trauma-informed care, in which eating disorders are understood as locally specific, culturally grounded, and embodied responses to suffering. The focus on culture, the gendered workings of desire, and the individual narrative offer meaningful frameworks for understanding the paradoxical ambivalence that individuals with eating disorders experience towards both relapse and recovery. This special issue should be commended for the compassionate, intellectually challenging and methodologically rigorous scholarship that contributes significantly to advancing our understanding of eating disorders today.