Compliance and resistance to treatment in an Italian residential Centre for eating disorders

Abstract

The dominant biomedical model perceives eating disorders as mental disorders and its ‘sufferers’ as people who need to be healed. It follows that people diagnosed with an eating disorder are pressured to accept medical and psychological care due to the moral obligations that are associated with the sick role, as delineated by Parsons. This, however, does not necessarily imply that they are willing to heal. By analysing compliance and resistance to treatment in an Italian residential Centre for eating disorders, this paper suggests that patients may accept medical care in order to achieve objectives other than those for which power is exerted over them. By complying with treatment, patients may in fact attempt to (re)become anorexic or escape from their everyday environment and problems. It is therefore argued that biomedical power can be subverted from within through the adoption of what De Certeau defines as tactics.

Keywords:

• Tactics
• compliance
• eating disorders
• resistance
• biomedical power

I was having a coffee in the kitchen of the Italian residential Centre for eating disorders where I was conducting fieldwork when Carla, one of the professional educators,¹ entered the kitchen and asked if I would like to assist with the admission of a new patient, a twenty-six-year-old woman named Marianna, diagnosed with anorexia nervosa.

Accepting her offer, I went with Carla to the main office. After a few minutes, the new patient entered the room, accompanied by her parents and her sister. Carla explained the approach and aims of the Centre, and everyone listened carefully to Carla’s words, except for Marianna. Her small figure seemed even thinner when seen surrounded by her family. Her green eyes, framed by long, black hair, had such a vacant stare that it was impossible to guess at her feelings. Carla explained to Marianna the rigid rules of the Centre and the fact that Marianna, like all new patients, would not be allowed to meet her friends and family during the first two weeks of her stay.

The conversation was mostly between Carla and Marianna’s relatives. Her relatives requested more information and details about Marianna’s ‘journey’ at the Centre, whilst simultaneously voicing their relief at admitting her to the Centre. During the entire conversation, Marianna stayed silent, unless specifically asked direct questions. She then signed the contract whereby she committed herself to following all the activities and treatments prescribed by staff at the Centre, and promised to abide by the rules. When the meeting was over, Marianna was accompanied to her room so that she could unpack her clothes and say goodbye to her family.

A few days after her admission to the Centre, I asked Marianna whether I could interview her. She shyly accepted and invited me to her room around 6 pm, a time when all the activities were over and just before dinner. She started our conversation by referring to her relationship to food in the following terms:

For me, the way I relate to food has never been a problem. I always thought: ‘that’s the way I am, that’s my personality!’ I always thought it was a normal thing to read calorie labels, not a problem. Before coming here, I just used to eat whatever I wanted, and that was it. I love to nibble [Italian, spiluccare]. I would eat quickly whilst standing up and right after eating, I would keep myself busy doing things in order to lose weight. For example, after eating I would wash the dishes, and clean and tidy up the kitchen. I love eating fruit and vegetables, and don’t eat other food such as pasta or bread crumbs [Italian, mollica del pane]. My aim was not to gain weight, and actually, I was quite happy to lose some more kilos. About one and a half years ago I lost even more weight and my period stopped. Everyone was worried about me and I just couldn’t understand why as I wasn’t feeling ill. My mother started being even more controlling with me and everyone was telling me to eat all the time! I can tell you that I was so sure that nothing was wrong that I also did a pregnancy test. I just couldn’t believe that I had stopped getting my period because of my eating habits.

Although the medical establishment has diagnosed Marianna with an eating disorder, and therefore as sick (APA 2013), she perceived her relationship with food as something normal and a reflection of her personality, a perception that was shared in a similar way among most of my informants diagnosed with anorexia nervosa. By perceiving herself as healthy, Marianna consequently felt that she was in the wrong place at the residential treatment Centre.² This discrepancy reveals the relevance of focusing on the narratives of people diagnosed with an eating disorder and understanding their reactions to treatment.

While medical anthropologists have contributed to the understanding of treatment resistance within eating disorders (Lester 2014; Warin 2010; Gremillion 2003), they did so by focusing on patients diagnosed with anorexia nervosa. This is not surprising considering that such patients are notorious for their resistance to treatment, whereby ‘their noncompliance to treatment is usually explained as a consequence, or even a confirmation, of their illness’ (Gremillion 2003, 3).

This paper contributes to this understanding with an analysis of the tactics of resistance (De Certeau 1984) employed by patients diagnosed with bulimia nervosa who also have a past of anorexia nervosa, who may accept medical treatment in order to (re)become anorexics, and patients with an eating disorder (not necessarily anorexia nervosa) that may decide to be admitted for treatment in order to escape their difficult everyday circumstances. In both cases, such patients subvert medical power without rejecting it, since they comply with treatment without aiming to heal³ from their disorder.

The research

This paper is based on the data collected during my fieldwork in a public residential Centre for eating disorders in Italy between September and December 2012. During this period, I conducted intensive participant observation at the Centre, which has a strong reputation in Italy due to its holistic approach. This research was part of a wider qualitative and comparative project conducted in 2012 and 2013 that aimed to understand the cultural factors leading to the onset of eating disorders in Italy and Malta (Orsini 2017).

Considering the sensitivity of the topic, as well as the vulnerability of the patients residing at the treatment Centre, the research was planned in such a way as to minimise the negative impact on participants. In addition to the approval of the University of Malta Research Ethics Committee, I obtained written consent from all the patients and staff involved in the study. The Director of the treatment Centre also granted me permission to access the institution at my convenience and attend group therapy sessions. All the professionals leading these sessions further allowed for my participation.

Whilst primarily basing my methods on participant observation, I also conducted twenty formal interviews with patients (nineteen women and one man) and fifteen staff members (three psychologists, five professional educators, two dieticians, a nutritionist, a psychiatrist, an art therapist, a music therapist, and a communication therapist).⁴ The semi-structured interviews were aimed to understand the personal perspectives and narratives of people diagnosed with eating disorders. The professional staff were interviewed to better understand their roles within the Centre, whilst simultaneously analysing their perspectives toward eating disorders.

I conducted participant observation on a daily basis during my entire stay. Whilst I attended the therapeutic sessions led by psychologists and medical professionals as an observer, I participated, together with the patients in the activities proposed by other professionals such as the music and art therapists, and spent free time between sessions with the patients and staff members.

This approach allowed me not only to develop a better understanding of my informants’ experiences at the Centre, but also to get close to them. My constant presence at the Centre, as well as my informal, even friendly, relations with patients made some staff members more suspicious and uncomfortable about my research. In some instances, staff did not allow me to audio-record the sessions, although patients did not have any objections to this.

Considering that all the patients residing at the treatment Centre had been diagnosed with an eating disorder, no selection criteria was adopted while recruiting them. The twenty patients interviewed were aged between sixteen and thirty-eight. Three had been diagnosed with binge eating disorder (15%), nine with bulimia nervosa (45%) and the remaining eight with anorexia nervosa (40%). Only one male patient was involved in this study, which also reflects the general epidemiology of the phenomenon (APA 2013). This study is therefore based exclusively on the narratives of my female informants. All interviews were recorded, transcribed and translated from Italian to English, and were supported by fieldnotes. All names of the people involved in the study were changed in order to guarantee anonymity.

The rising number of research studies on eating disorders have resulted in several approaches and treatments including biological (Holland, Sicotte, and Treasure 1988; Strober et al. 1990), psychological (Bruch 1978, 1985; Goodsitt 1997; Rorty and Yager 1996) and psychiatric perspectives (Nunn, Frampton, and Lask 2012), among others.

Despite the vast body of literature, the exact aetiology of the phenomenon remains unclear (Rikani et al. 2013) and the relapse rate for such conditions is very high (Abbate-Daga et al. 2013). Eating disorders (particularly anorexia nervosa) also have elevated mortality rates (Crow 2013), especially when compared to other mental health disorders such as schizophrenia and bipolar disorder (Arcelus et al. 2011). Although psychiatry acknowledges the relevance of socio-cultural factors in the onset of eating disorders, genetic and biological factors are still considered to be crucial (Rikani et al. 2013).

This paper aims therefore to contribute to the understanding of this complex phenomenon by emphasising the crucial role of socio-cultural factors that can lead to the onset and development of eating disorders, as well as the personal views and experiences of those who have been diagnosed with one. Whilst medical anthropologists have contributed in this regard (Cheney 2012; Eli 2018a, 2018b; Lavis 2018; Warin 2010), little attention has been paid to the ways through which patients may comply with treatment without aiming to heal. An understanding of this attitude towards treatment may help professionals dealing with such conditions to better comprehend high relapse rates, which may not be necessarily linked with low compliance with treatment.

The residential treatment Centre

The residential treatment Centre for eating disorders where I conducted fieldwork is located in a quiet and isolated area of Italy, surrounded by mountains. The Centre views eating disorders as pervasive disorders [Italian, disordini pervasivi]⁵ and offers a holistic and integrated approach to patient care combining diverse therapeutic methods. As a result, medical, psychological and psychiatric approaches are supported by a wide range of other activities such as music and art therapy.⁶

Each patient undergoes weekly weight checks and medical examinations, attends various group therapy sessions daily, as well as individual weekly sessions with their psychologist and nutritionist. Patients are never left alone during their stay and are assisted by two professional educators at a time on a twenty-four-hour basis.

The Centre’s Director explained that the wide range of activities and treatments aim to heal people with eating disorders through a cognitive behavioural approach, whereby crucial elements in the healing journey [Italian, percorso di guarigione] include a cognitive redefinition of so called dysfunctional behaviours⁷ and thoughts [Italian, comportamenti e pensieri disfunzionali] about food and the body, as well as a change in eating behaviors.

The nutritional approach adopted by the Centre is ‘mechanical eating’ [Italian, alimentazione meccanica], whereby food is presented to patients as the medicine for their disorder. This procedure aims to modify and normalise eating behaviour, while decreasing fear and rituals around food (Leichner, Hall, and Calderon 2005, 408), as one of the professionals at the treatment Centre explained:

It is obvious that to heal from an eating disorder it is necessary to eat regularly and build a healthy relation with food. By explaining to patients that they have to take their therapy if they want to get better [i.e. they have to eat], they actually eat mechanically, without thinking. They eat without focusing on the food they ingest: they think they are just taking a medicine. In this way, they slowly overcome their fears toward food.

Even in the multidisciplinary context of the treatment Centre, eating disorders are approached as illnesses and the biomedical discourse dominates the subject.

Although the treatment center presents all activities and roles in its ‘multidisciplinary approach’ as of equal importance in a patient’s healing process, I noticed during my fieldwork a certain unofficial hierarchy wherein core decisions were taken by medical staff and psychologists, who had the least contact with patients. This was confirmed by other staff members who found it illogical that professionals who spend more time with patients have less power in the decision-making process.

Passive patients or active agents?

From the biomedical approach, treatment resistance is a common feature of eating disorders (Fleming and Szmukler 1992; Halmi 2013; Kaplan and Garfinkel 1999) as well as one of the reasons leading to the low success rates of psychological and medical treatment (Abbate-Daga et al. 2013). Resistance is considered to be more pronounced among anorexics (Nordbø et al. 2012), who are said to deny their condition as a consequence of their mental disorder (Couturier and Lock 2006; Vandereycken 2006a, 2006b).

As opposed to the biomedical and psychological discourses on eating disorders (APA 2013), which perceive the adoption of specific behaviours towards food and the body as the result of serious mental conditions (Morris 2008; Patrick 2002), I consider anorexia nervosa, binge eating disorder, and bulimia nervosa to be the outcome of moral processes of self-transformation (Orsini 2017). All the informants involved in this study recalled a moment in their life when they have felt not ‘good enough’. This moment of self-awareness was followed by a change in behaviour towards food. The narratives of my informants reveal the attempt to morally improve oneself by adopting control over hunger, pleasure and bodily needs as core values, whereby the body becomes the physical symbol of the moral transformation (Orsini 2017).

The idea that women can morally improve themselves by negating their bodily needs reflects the cultural understanding of womanhood in Italy, which is characterised by self-sacrifice and dedication to family (Cheney, Sullivan, and Grubbs 2018; Hunt et al. 2015).

While Cheney (2012, 2013) similarly refers to the crucial role of the cultural local context when discussing disordered eating among Southern Italian Women, her informants displayed discontent and refusal to accept traditional societal expectations towards women. From her analysis, specific behaviours towards food can be adopted in order to distance oneself from traditional gender expectations such as subordination and dependence, whilst embracing self-assertion.

On the contrary, my informants’ attitudes towards food reflect not only the acceptance of traditional and conservative societal expectations towards women in Italy, but also the will to embody them. While all my informants shared the values symbolically expressed through thinness, their behaviours may not be aligned with such values.

Consequently, while my informants who were diagnosed with anorexia nervosa expressed feelings of great satisfaction at their new achieved moral selfhood, those diagnosed with bulimia nervosa expressed negative feelings such as guilt and shame. Their inability to self-deny pleasure and their basic needs was in fact experienced to be at odds with the perceived social expectations towards Italian women, and the moral values associated with them. Hence, while Eli (2018a) suggests that bulimic identities are non-conforming, subversive, and therefore acting against gender expectations, it is precisely due to the will to conform that my informants experienced shame and guilt rather than pride (Frey 2020).

I therefore consider different eating disorders within the Italian context as consequences of differential achievements in their quest to an ideal moral selfhood, and refer to ‘achieved moral conversion’ in the case of anorexia nervosa, ‘attempted moral conversion’ in the case of bulimia nervosa and ‘rejected moral conversion’ in the case of binge eating disorder (Orsini 2017).

By highlighting the embodied morality of eating disorders, I do not want to diminish or dismiss the sufferance of people with an eating disorder or the medical and psychological consequences of such phenomenon. However, in line with the findings of Cheney, Sullivan and Grubbs (2018), I believe that such an approach may help to reconsider biomedical definitions and perceptions of eating disorders that tend to ignore patients’ perspectives on their own condition as well as the crucial role of the historical and socio-cultural context in shaping such views.

Not surprisingly, all the patients involved in my study, expressed a direct correlation between their body size and moral state. To them, body size was a tangible sign of their own moral state. In this sense, it is possible to interpret eating disorders within the considered socio-cultural context, as an unofficial hierarchy, where anorexia nervosa represents the ideal selfhood, due to the coherence between moral values and behaviours (Orsini 2017).

Achieving and maintaining an ideal moral selfhood (embodied with anorexia nervosa) is not an easy process and requires continual work (Lavis 2018). Not surprisingly, the majority of my informants diagnosed with bulimia nervosa had a past history of anorexia nervosa. All of them expressed a sense of failure and frustration at not having been able to maintain their strict practices and negate their bodily needs and hunger. This reveals the fluidity of eating disorders within the Italian context and the shared moral values at their core.

Considering eating disorders, within the considered socio-cultural context, as processes of moral conversions also helps us to understand the differences regarding compliance with treatment as well as demand for professional help.

My informants diagnosed with bulimia nervosa or binge eating disorder experience relief to be labelled as ‘ill’, since their actions can be interpreted as the result of a disorder rather than in terms of a failed attempt at moral redefinition. On the other hand, those diagnosed with anorexia nervosa tended to be most resistant to their pathologisation, as it was very difficult for them to consider their ‘new’ satisfactory personhood as the result of a mental disorder (Orsini 2017).

It is therefore not surprising that all of the informants I met who had been diagnosed with bulimia nervosa or binge eating disorders had sought professional help without being forced by other people. In turn, only one of the eight women diagnosed with anorexia nervosa had sought professional help on her own volition. The remaining seven women claimed that they had been persuaded or obliged to be admitted to the treatment Centre by other people, like clearly stated by Marianna:

My mother tried to made me eat, but I lost even more weight. I then saw the doctor who told me “that’s enough … you are getting worse!”. After seeing the doctor my mother told me: “I let you do whatever you wanted until now, but that’s it” … I had a huge crisis because they [her parents] told me that I had to come here … I couldn’t stop crying. I had a huge crisis because the treatment Centre was not the right place for me, I didn’t need it. I didn’t have an illness … They forced me to come here.

My informants diagnosed with anorexia nervosa also manifested a greater degree of non-compliance to the treatment and were often ostracised by other patients for not being willing to heal [Italian, non voler guarire].

Although my findings reflect the biomedical view that people with anorexia nervosa are difficult patients to treat, I argue that this is the result of a satisfactory moral self-transformation that entails a strong sense of agency, rather than the passive victimisation of the disease itself.

The will to heal

The residential treatment Centre mostly acts as an educational total institution (Goffman 1961) that aims to correct and normalise deviant bodies and minds through discipline, rather than as an institution that heals mental illnesses. The disciplinary power exerted over patients ‘is concerned not with repressing, but with creating. It is disciplinary power, through the surveillance and subsequent objectification of the body, which actually serves to fabricate the body in the first place’ (Armstrong 1994, 23).

To be admitted to the Centre, patients have to demonstrate a will to heal. The fact that the will to heal is a crucial aspect of the recovery process is not surprising, since it is part of the obligations that come with the sick role. According to Parsons (1951), ill persons temporarily abandon their usual roles by acquiring the role of the sick person. Since diseases prevent ill people from fulfilling their everyday activities and responsibilities, they are considered by Parsons as constituting a form of deviancy that requires intervention in order to re-establish ‘normal’ roles. As a consequence, ill people are expected not only to seek professional help, but also to show a will to get better.

However, voluntary admission is not an easy choice because of the regulation and structure of the treatment Centre. My informants often voiced their objections to the rules imposed upon them by the Centre, which made them feel like they were ‘living in a prison’. This was expressed during a group therapy session by Lara, a twenty-seven-year-old who was diagnosed with bulimia nervosa and also had a history of anorexia nervosa:

All of us [patients] have signed that paper [the admission agreement] to get better. Actually, we have all signed that paper to deprive ourselves of our freedom. Ultimately, you are locked up [Italian, rinchiuso]. (…) I still remember at the beginning of my stay, I would just repeat to myself: ‘do you realise where the fuck you have ended up?’ I couldn’t stop thinking that I had signed away my freedom, my car, my job … my bad habits [the eating disorder], that in my mind were actually healthy habits. The fact that you cannot go out, the fact that you have to spend all fucking day with other people. People that you didn’t choose to be with. I don’t even have the freedom to choose with whom I want to share a common area, not even my bedroom! Here you don’t even have the freedom to move. They are always telling me ‘don’t move! sit down!⁸’.

Although all my informants noted their difficulties in following the Centre’s rules, the majority of them claimed to have understood the need for such rules. As pointed out by Lara and several other informants, it was the structure of the Centre as a total institution (Goffman 1961), rather than its rules per se, that made their stay at the Centre particularly difficult.

It is evident that my informants had accepted the Centre’s approach to the extent that none of them left due to an aversion to the regulations and surveillance imposed over them.

Given the pressure to conform, and that being ‘a good patient’ is perceived as a moral imperative, it is not surprising that all informants claimed, when asked, that they were complying with the Centre’s regulations. Any patients who did not follow regulations, as well as those who behaved in ‘dysfunctional’ ways, were isolated and criticised by other patients.

Since patients diagnosed with anorexia nervosa manifested a greater degree of non-compliance with treatment and regulations, they were often ostracised by other patients. The view of Vanessa, thirty-eight years old and diagnosed with binge eating disorder, clearly summarises the perception of my informants towards patients diagnosed with anorexia nervosa:

Like all the others, I have problems here in following the rules. It has been hard for me. However, when I see them [patients diagnosed with anorexia] I really get pissed off. Right from the start I sought help, I trusted them [the staff at the Centre]. They don’t. They only trust themselves and they obviously don’t want to change!

Non-compliant patients were often singled out and criticised by other patients during mealtimes. The dieticians and professional educators changed the seating positions at tables daily, with patients hoping not to be seated next to a ‘dysfunctional’ patient [Italian, paziente disfunzionale].⁹ All my informants experienced anxiety and stress when sitting next to these patients, as explained by Viviana, sixteen years old and diagnosed with bulimia nervosa, with a past history of anorexia nervosa:

At the beginning it was awful. You eat with people that you don’t even know … and I used to eat alone! I didn’t want anyone to look at me. […] In addition to this you see people hiding food everywhere and other disgusting things. I used to do the same when I was home. And that’s why it is stressful. […] In the beginning I tried not to look at them but you cannot. It’s impossible.

The distress experienced by my informants when seeing ‘dysfunctional’ patients reveals a fear of being triggered, against their will to heal, into desiring ‘dysfunctional’ behaviours. As pointed out by Musolino, Warin and Gilchrist (2018: 535) ‘triggering itself is not desire, but produces movements of desire that are experienced as ambivalent and compelling’.

As a consequence, whilst most of my informants spoke of a general will to get better by incorporating the biomedical discourse of eating disorders, the hostility towards ‘dysfunctional’ patients reveals ambivalent desires and feelings towards eating disorders (Warin 2010; Lavis 2011, 2018) and recovery (Lester 2014; Musolino, Warin and Gilchrist 2018).

Tactics of resistance

All the patients I met at the treatment Centre could be seen as ‘good patients’ in that they followed the proposed treatments and the Centre’s rules. This, however, does not mean that all of them did so to heal from their eating disorder. Some of the patients conformed to the Centre’s disciplinary techniques in order to achieve objectives other than those for which the power was exerted over them, making these techniques into tactics (De Certeau 1984, xiii).

Megan Warin (2010) discusses a number of tactics employed by patients with anorexia nervosa in order to subvert the power exerted over them without being noticed. The tactics of concealment discussed in her work are commonly referred to as ‘anorexic tricks’ that ‘enable persons with anorexia to conceal and cloak their real intention, losing weight’ (Warin 2010, 85). While her approach brings to light the ways that patients resist treatment, the tactics employed by her informants infringe the rules of treatment settings, and as such must be employed in secrecy.

In contrast, the tactics I observed during my fieldwork are consistent with the approach and regulations of the treatment Centre, and are actually effective precisely because of them. It follows that through such practices ‘power is subverted not because rejected, but because accepted and used ‘with respect to ends and references foreign to the system’ (De Certeau 1984, xiii).

Some of the patients diagnosed with bulimia nervosa, and with a past history of anorexia, had admitted themselves in order to (re)become anorexics, rather than to heal from their disorder. This is not surprising considering the unofficial hierarchy amongst eating disorders discussed above, as well as the idealisation of thinness as a powerful moral statement amongst my informants.

That was the case for Marta, seventeen years old, who disclosed her intention to leave the Centre in tears, after having spent two months at the treatment Centre. She claimed she could no longer continue to fool [Italian, prendersi gioco] the professionals and the other patients. She told me that she did not want to heal but as a former anorexic she wanted to become anorexic again. Everyone was astonished not so much by Marta’s decision in itself but by her honesty and frankness. Marta was the only one whilst I was at the Centre who was so blatant about her desire to become anorexic again, even though she was far from being the only such case.

Paradoxically, the treatment Centre is a perfect site for individuals with bulimia to regain their lost sense of self and moral worth, a consequence of straying from the anorexic path.

While patients must eat five meals per day according to a fixed schedule, they are not allowed to bring their own food to the Centre, and they cannot use the bathrooms for two hours after lunch and dinner, and one hour after breakfast and snacks. In addition to this, patients are strictly forbidden from staying in their bedrooms during the day. This prevent them from isolating themselves and from going to the bathroom after meals and potentially purging. The prevention of binge eating through rigid and regimented mealtimes served to create new routines and reinforce a sense of control over food which is a crucial aspect of an anorexic’s lifestyle. It follows that individuals diagnosed with bulimia nervosa who aim to become anorexics can take advantage of such approaches in order to regain control over their daily food intake.¹⁰

While I would not suggest that all patients diagnosed with bulimia nervosa who also have a history of anorexia nervosa aim to regain the status of anorexics, it is significant to note that all my informants matching this profile told me that they would have never sought medical or professional help during their anorexic period. This was the case with Anita, twenty years old who explained that she had no expectations for her time at the treatment Centre other than losing weight.

The fact that the treatment Centre’s rigid structure may actually be instrumental for people with bulimia to (re)become anorexics is in line with the findings of Gremillion (2003) and Warin (2005). Both authors point out how treatment programmes are crucial factors in perpetuating a number of attitudes central to eating disorders. Warin (2005) shows how anorexics and bulimics subject to residential care are often allocated individual rooms, which are soon transformed into personalised bedrooms while imposing a regimen of solitary eating. These apparently harmless conditions enable the reproduction of practices adopted at home that maintain the eating disorder. Gremillion’s ethnography (2003) among young anorexics in a psychiatric treatment programme in North America similarly shows how the rigid planning of food consumption, based on the calculation of calories associated with physical exercises, reproduces a particularly obsessive controlling relationship with the body.

I interviewed Viviana a few days before she was discharged from the treatment Centre. When I asked her why she decided to seek treatment she confessed to me that she did it because she wanted to become anorexic again. She then quickly added that however, as time went by at the treatment Centre, she eventually changed her mind. It is difficult to assess whether or not she felt she had to qualify her statements due to my ambiguous role within the Centre. She did however refer to the first period of her stay at the treatment Centre in the following terms:

In the beginning, I was easily conditioned by those who cut up their food into small pieces, and I started to do it as well. I came here actually wishing to become anorexic again. That feeling lasted for a few months. I remember at first, I was always asking dysfunctional questions of the anorexics. For example, I would ask them how they managed to become so skinny and stuff like that. I wanted to know all their tricks!

While some of my informants had accepted to be admitted to the Centre in order to rebecome anorexics, others had decided to do so in order to escape from their difficult everyday realities, rather than to heal from their eating disorder.

Rebecca, sixteen years old and diagnosed with bulimia nervosa, explained to me that she decided to get admitted to the treatment Centre in spite of her scepticism regarding its effectiveness, in order to find a refuge from an intolerable domestic situation:

Actually, I came here without any expectations. I wanted to be better but I was very sceptical. Then after a while I started to realise that I was enjoying my stay here because I was away from home. That was the main reason, my desire to escape from my home. In the end, it was convenient for me to stay here, because I wasn’t there any longer. My expectations? I knew I was coming here to try to solve my problems, but I didn’t arrive here thinking: ‘I am here, I’ll solve everything, and then I’ll go back home, feeling as good as new’. I never expected this.

Like Rebecca, Marta told me during one of our conversations that she preferred to be at the treatment Centre rather than at home, where she lived with her mother, father, and grandmother:

I much prefer to be here rather than at home. At the Centre, there is always something to do! When I am at home, I sleep or walk around the house, and that’s it. You know my mother is crazy [Italian, è pazza], she is schizophrenic so there is always someone screaming at home. Another reason I want to get away is because my parents are always at home. My mother is incapable of working and my father is unemployed.

Many of my informants have difficult family situations and had often experienced or witnessed domestic violence. For many patients, the treatment Centre is therefore a refuge, a safe place, where professionals are at their disposal twenty-four hours per day.

In such cases staff members have to deal with more than the eating disorder itself, and the situation is of course much more difficult for the minors at the Centre. Some of the staff members believe that this might be one of the reasons that some patients manifest a lack of will to heal:

You probably wonder why certain patients, who don’t appear to have any motivation at all to change are here. Well, for them it is simply to escape from their real life. As you may have noticed this is a very secure environment […] Obviously, most of our patients are here because they want to heal. However, a few of them are here because they just want to escape, at least for a little while, from difficult circumstances, negative environments or dysfunctional familial situations.

Other scholars highlighted not only the presence of oppressive and violent life conditions when considering the narratives of people with an eating disorder, but also their crucial role in the onset and maintenance of such conditions. Eli (2018b) stated that people may actively strive for liminality through eating disorders in order to disconnect from painful and unbearable life circumstances. Similarly, Lavis (2018: 457) claimed that anorexia may be interpreted as a ‘paradoxical mode of self-care in a world of painful interpersonal relationships and traumatic life events’.

Food refusal has also been interpreted as an agentic practice that reconfigures and renegotiates conflictual and oppressive familial relationships (Cheney 2013). In this sense, specific behaviours towards food have been described as paradoxical copying mechanisms that may also alter power relations within the family system.

Considering the narratives of my informants, violent, painful, and oppressive life experiences had a crucial role in the onset of an eating disorder amongst those who had a negative moral self-perception as a consequence of such circumstances.

This was the case with Francesca, thirty-one years old and diagnosed with anorexia nervosa. Before becoming anorexic, she felt unloved by her parents. In her opinion, her exuberant personality was not consistent with the idea of the ‘polite daughter’ her parents expected her to be:

I never felt loved, I have never felt like someone was taking care of me, I have never felt like someone was supporting me. I have always felt only tolerated [Italian, mi sono sempre sentita solo sopportata].

It was her attempt to ameliorate herself that led her to make drastic changes in her behaviour towards food and her body.

Whilst it is impossible to identify which of my informants decided to stay at the treatment Centre in order to escape from their domestic environments, as a general rule they all considered the treatment Centre, as a safe and sheltered space where they could find comprehension and assistance.

Some staff members felt that the Centre was overprotective and might paradoxically counter the aim of producing healthy, well-adjusted individuals. This feeling resonated with my informants, all of whom feared leaving the Centre after their stay.

The perception towards the Centre as a safe space, as well as the fear expressed by many informants of going back home, reveals the suffering and anxiety experienced by many of them in relation to their violent and oppressive familial context. In this sense, as discussed by Eli (2018b), many informants involved in this study required not only psychological and medical treatments, but also help for their violent and oppressive familial relationships.

Conclusions

Eating disorders are considered by the biomedical and psychological establishments as difficult conditions to treat (Fassino and Abbate-Daga 2013). Patients diagnosed with an eating disorder, especially with anorexia nervosa, are typically considered to resist medical treatment and medicalisation (Abbate-Daga et al. 2013; Halmi 2013). This perception is attributed to the mental disorders under consideration; in other words, people with an eating disorder are considered passive victims of their own conditions. Through the analysis of the data gathered during my fieldwork, I have discussed how such an approach may be misleading, as it tends to conceive patients’ behaviours as symptoms, decontextualising the behaviour from the social and semantic context, while ignoring patients’ perspectives.

In contrast to such a perspective, I have pointed out the active role of patients with eating disorders, when considering their own condition as well as their reaction to and demand for treatment. Considering anorexia nervosa, bulimia nervosa and binge eating disorder, within the considered socio-cultural context, as the result of processes of self-moral transformation, helps us to understand the very demand for treatment, as well as the high level of resistance to treatment characterising patients diagnosed with anorexia nervosa.

The analysis provided reveals that patients may subvert the biomedical power exerted over them through the adoption of different tactics. Patients diagnosed with an eating disorder can therefore approach medical institutions without aiming to heal, but in order to reach different objectives, such as (re)becoming anorexics or escaping their everyday problematic reality. In such cases, the very structure of the treatment Centre considered, characterised by rigid rules and an overprotective environment, may be counterproductive to the Centre’s aim to heal people with an eating disorder.

In sum, considering the difficulties in treating eating disorders, as well as the severe medical consequences and suffering related to such conditions, I argue it is crucial to acknowledge and understand the active role of patients, their own perspectives, as well as the local socio-cultural context, in order to provide effective interventions and treatments.

Acknowledgements

The research work disclosed in this publication is partially funded by the Strategic Educational Pathways Scholarship (Malta). This Scholarship is part-financed by the European Union – European Social Fund (ESF) under Operational Programme II – Cohesion Policy 2007-2013, ‘‘Empowering People for More Jobs and a Better Quality Of Life”.

Ethical approval

The methodology adopted in this research study has been approved by the Maltese University Research Ethics Committee.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1 Professional educators have completed a university degree or master programme. Through their practical and theoretical knowledge, they help persons with psychological or medical issues, as well as persons facing social exclusion, to develop their personalities, facilitating at the same time their social reintegration. For further details, see Favretto (2003, 35–37).

2 All my informants were admitted by their own volition.

3 Throughout the paper I use the term heal, rather than recovery, as this was term used by the staff and patients at the residential treatment Centre [guarire].

4 The research study was carried in Italian, my native language.

5 This concept, used by several staff members, highlights how eating disorders compromise several aspects and functions of patients’ minds and bodies, not only food behaviours (Morris 2008; Patrick 2002).

6 I do not specify all the activities carried out at the Centre in order to guarantee anonymity.

7 At the treatment Centre, all behaviours thought to maintain and reinforce an eating disorder (e.g. exercising, reading newspapers about diets,…) were labelled as dysfunctional.

8 Staff members are always preventing patients from too much movement, as this is a form of hyperactivity which they identified with weight loss behaviour.

9 This concept was used by staff members and patients as well.

10 Whilst the category of anorexia nervosa also includes the binge-eating/purging type (APA 2013), none of the informants involved in this study who were diagnosed with anorexia nervosa referred to such practices when explaining their relationship with food. Although the binge-eating/purging subtype of anorexia nervosa may seem to blur the distinction between anorexia nervosa and bulimia nervosa, my informants referred to anorexia nervosa and bulimia nervosa as two distinct and remarkably different conditions.