Abstract
In Famished: Eating Disorders (EDs) and Failed care in America, Rebecca Lester offers a refreshingly compassionate and cohesive perspective on EDs and how America's current treatment landscape shapes and reproduces them. In this ethnography, Lester entwines case studies, autoethnography, historic and political perspectives of managed care, and feminist theory to make her argument. Utilizing years of rich data collection, including observation of staff meetings, insurance utilization reviews, treatment milieu, therapeutic groups, and interviews with staff, clinicians, patients, and loved ones, Lester argues that the current U.S. medical context fails to treat—and actually perpetuates—these deadly illnesses.
Lester draws on her experiences as a medical anthropologist, clinical social worker, ED specialist, and former patient to weave a picture of the treatment landscape and the economic and neoliberal mechanisms that fuel it. Lester illuminates multiple “double binds” that entrap patients, including how to be the “right kind of patient” when one is the “wrong kind of sick,” the difficulty of “proving” illnesses characterized by denial, and the struggle to be “sick enough” to mandate treatment, while not “too sick” to benefit from intervention. This “ambivalent healthcare culture” (e.g., serving the capitalistic, neoliberal interests of managed care) creates “ambivalent care” at the treatment center level, forcing clinicians and patients to make the best of no-win situations that exacerbate the characteristic ambivalence of EDs. Thus, Lester shows how managed care perpetually underfunds care resulting in a culture of scarcity in care systems that mirrors the ED.
Lester's most important theoretical contribution involves a new understanding of EDs as “technologies of presence” that manifest as affective modulators, permitting patients with EDs to tinker with the affective ways they experience the world and are perceived by the world. Further, she also shows how biomedical and recovery care models conflict and converge untenably in ED treatment. In response, clinicians contort standards of care within the constraints of managed care provisions, and treatment becomes overwhelmingly insufficient, substandard, and often, counterproductive.
Throughout her book, Lester repeatedly shows that when treatment mimics the ED (e.g., culture of scarcity, care ambivalence, number fixation), quality of care suffers, and patients decline. It is here where I would levy my main critique of Lester's work. Lester mentions in her introduction that her analysis reflects the current hegemonic ED treatment climate which mainly serves thin, white, females from heterosexual families, largely neglecting communities that are often socially (economically, culturally) excluded from treatment. Given that Lester argues that EDs offer affective coping with difficult environmental and historical contexts, exploring the lived experiences of more excluded, diverse voices (e.g., patients of color, higher weight patients, queer and trans patients) could enrich and strengthen her argument. Additionally, from a fat and body liberation perspective, some language in the “‘Fat’ is not a Feeling” chapter recreates the fatphobia of the ED, as does Lester's suggestion to integrate ED treatment into current “obesity” initiatives. Reimagining these moments to ensure that certain bodies are not moralized or pathologized could augment her overall argument for ensuring that we (as clinicians and researchers) do not inadvertently contribute to illnesses we endeavor to treat.
In sum, Lester offers one of the most compassionate, realistic, nuanced examinations of the complexity of ED care and patients I have read. Her book presents a much-needed discourse exemplifying how the American treatment landscape fails patients and perpetuates illness. I enjoyed how often I saw my own patients and research participants reflected in the complex themes and theoretical constructs. The margins of my book are riddled with connections to previous patients and research anecdotes evoked by her scholarship—an important experiential aspect of qualitative and theoretical rigor. While this book will most likely appeal most to ED and embodiment scholars, Lester's work also spans disciplines to those interested in medical care and anthropology. Additionally, while a dense read, patients may benefit from reading Lester's understanding of the seemingly paradoxical aspects of their inner experiences. Lester's perspective sheds new light onto why ED treatments so often fail patients, and how the ED field must necessarily shift if we are to move toward a culture of recovery rather than perpetuating harm with a culture of scarcity.
