Recovery from anorexia nervosa: A Durkheimian interpretation

Pergamon S0277-9536(96)00088-3

Soc. Sci. Med. Vol. 43, No. 10, pp. 1489-1506, 1996 Copyright © 1996ElsevierScienceLtd Printed in Great Britain. All rights reserved 0277-9536/96 $15.00 + 0.00

RECOVERY FROM ANOREXIA NERVOSA: A D U R K H E I M I A N INTERPRETATION C A T H E R I N E J. G A R R E T T Faculty of Nursing and Health Studies, University of Western Sydney, Nepean, NSW 2747, Australia Abstract--Attempts to explain "eating disorders" in contemporary western society have concentrated on aetiology at the expense of resolution. Most "recovered" anorectics, however, question medical definitions of "anorexia nervosa" and clinical criteria for recovery. This article refers to a study of 32 people at different stages of the recovery process, to reconceptualize the problem in sociological terms. Durkheim's account of asceticism offers a fresh interpretive framework in which anorexia and recovery are understood as the negative and positive phases respectively of a ritual of self-transformation. In western culture, where appropriate myths and rituals of re-incorporation are not readily available following a period of symbolic fasting, it is not surprising that recovery from anorexia is not automatic. Participants in this study referred to anorexia as a spiritual quest and for them recovery involved a re-discovery (or creation) of a threefold connection: inner, with others and with "nature". These connections are, for them, the defining features of spirituality. The negative phase of the ritualistic quest (anorexia) involves a confrontation with the inevitability of death as a condition of the positive phase (recovery) in which people actively choose life. This new theoretical approach provides a non-medicalized understanding of anorexia and simultaneously enables a re-interpretation of the fasting of medieval women saints. Recent scholarship in this area is re-evaluated to demonstrate that the continuity between asceticism and anorexia lies in the use of food as a metaphorical attempt to confront the universal problem of one's own mortality. In certain historical situations, asceticism served a socially valuable symbolic purpose. In contemporary society, however, this meaning is no longer available. Instead, it is recovery which constitutes the active and metaphorical "rebellion" against forces of social control. Finally, the work of Van Gennep is used to explore some of the specific ritual processes through which people effect the self-transformation from suffering to recovery, providing further insights into how recovery takes place from a wide range of other sufferings as well. Copyright © 1996 Elsevier Science Ltd Key words--anorexia nervosa, eating disorders, self-transformation, recovery, spirituality

INTRODUCTION Spiritual pain is not so much a problem to be solved as a question to be lived. (Adapted from R.M. Rilke.) "Mysterious" and "unpredictable" are the words most often employed in clinical research studies to describe the process of recovery from anorexia nervosa [1-18]. Most of these studies focus on the empirical measurement of recovery instead of its phenomenology, The overwhelming majority of books and articles dealing with "anorexia nervosa" itself have been more concerned with its aetiology than its resolution. Even those studies which give greater weight to the words of "patients" [1, 16, 1921] have not been able to explain the complex relationships between self-starvation, religious experience and recovery. A descriptive revelation of the inner world of anorectics does not provide a theory which might help explain how these "anorectics" transform themselves to the point where they claim recovery. Clinical research in this area (by its own admission [8]) has therefore offered little hope to therapists or those they seek to help. The recovery processes considered in this article are broadly similar to processes of recovery from any form of h u m a n suffering, to which the model of ritual is also

applicable. Anorexia nervosa is used here as a representative of such sufferings. As just such a "recovered anorectic" (the inverted commas highlight difficulties of definition discussed below), I undertook a sociological study of the recovery process itself [22] with a special interest in the cultural forces which make recovery possible in the same society which produces self-starvation. The study aimed to examine changes which take place during recovery and practices which both create and reflect its new attitudes. Giving primary conceptual weight to the processes of recovery rather than illness provided a fresh perspective, thereby automatically detaching the inquiry from the medical dominance which has obscured sociological factors involved in eating disorders.

Problems o f definition Problems of definition remained, however, since the terms "anorexia nervosa" and "eating disorders" are themselves medical labels for behaviours which have not, historically, always been seen as illness [23-26] and whose features are constantly changing in response to altered social expectations about diet,

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exercise, fashion and body shape [27]. The study's working "definition" of anorexia itself was provided by the thirty-two participants in the study. These participants were volunteers who responded to an article in The Sydney Morning Herald about my own experience and research plans. All of them had at some time met the medical criteria for anorexia nervosa or bulimia nervosa [28]. Most of them, however, regarded these criteria (and the psychiatric criteria for recovery [2], p. 70) as totally inadequate descriptions of their experience and of its causes. For them, the defining features of anorexia were those which they believed must be overcome in recovery, including self-loathing and dissatisfaction with their bodies, developmental stagnation, ongoing ditticulties with eating, detachment from other people and unresolved questions about death. Most spoke of a hunger for meaning [29, 30] and a form of existential and spiritual pain. Significantly, many of those who now regard themselves as having recovered did so without benefit of clinical intervention. Recovery was defined in very similar terms to "spirituality". "Spirituality" then, also requires definition. The study worked within a phenomenological framework where the meanings given by participants were taken to be those which motivated and explained their actions. "Spirituality" was the word most participants used to explain both anorexia and recovery as sequential parts of an ongoing expansion of consciousness; from a phase involving inner search and social isolation to a new stage they described as a greater awareness of connection with the material and social world and of powers which lay both inside and outside themselves. Their use of the word signals the emergence of new discourses on the sacred in contemporary society; discourses which often have connections with institutional Christianity, Judaism and western adaptations of Eastern religions, but which may also derive from New Age discourses on health and healing, from existential philosophy and from self-realization movements within psychology and counselling. According to Durkheim, all religion is an effect of social forces; divinity is socially created. To the extent that he is correct, discourses on "spirituality" can be seen as socially produced re-enunciations of the importance of sacred social bonds. In this article, however, divinity refers to the moving force of "being" and of history existing within as well as outside individuals. In this formulation, too, there is a dialectical relation between the spiritual and the social; history creates spirit and spirit creates history [31].

Theoretical framework Durkheim's sociology of religion provided a theoretical framework within which to construe the findings of the study. In The Elementary Forms of the Religious Life, Durkheim sought to demonstrate that what he called "the religious", the powerful impetus

towards moral self-improvement, with all its associated ideas and practices, was wholly produced by social forces [32]. Durkheim insisted that the spiritual, whatever its emotive, intellectual and practical power, remains firmly within the social. This formulation helps explain the way people with eating disorders frequently express themselves through religious language and symbolism. In addition, Durkheim's account of asceticism as negative rite offers the possibility that both anorexia and recovery are ritualistic attempts to construct the self, each being a distinct stage in a rite of passage to a new identity: as ritual, anorexia nervosa itself is the separation phase in the initiation of the individual into full selfhood; a chaotic liminal period. During this phase of the ritual, the taboos on certain foods are believed to be purifying; they are attempts to pay homage to social proscriptions on "fattening foods" and to transform oneself, through self-control, into a more worthy person in the eyes of the community. Recovery and the rituals which accompany it are the reconnecting part of the ritual, where the individual is reincorporated into the community, strengthened through suffering [32] (pp. 299-323). The negative cult of anorexia can therefore be understood as a means to an end; a condition of access to the positive cult. The absence of appropriate reincorporation rituals compels "anorectics" to search for and to devise their own means of return from liminality. Where such rituals are not readily available, it is unsurprising that recovery from anorexia is not automatic.

Methodology The methodology used in the study was influenced by feminist research models which attempt to minimize the power relations between researcher and participant, acknowledging their common experiences and conducting an analysis of these experiences in situ [33-36]. Participants recorded conversations with me, usually of two hours in length, in which they were asked to tell their story of recovery and to consider what "recovery" meant to them. They were simply requested to focus on the recovery process rather than on the onset of the problem, to mention stages and turning points and to give an account of how they believed recovery was made possible for them. These were not formal "interviews", since the researcher was a member of the sample and our shared experience of "anorexia" was the explicit focus of the analysis. Instead, they began with a shared experience, working through narrative and comparisons towards new understanding of this experience for participant and researcher. The word spirituality was most often introduced by participants themselves in the course of their narrative. When it was not, they were asked what meaning it had for them and whether it had any meaning in the context of their recovery. Seven participants (Group 1) defined themselves as still suffering from an eating

Recovery from anorexia nervosa disorder (although some had moved from anorexia to compulsive eating). Ten (Group 2) believed they had been through a turning point and were "recovering". The remaining fifteen (Group 3) defined themselves as "recovered" for periods ranging from 3 to 22 years. Those in this group stressed that although they would never return to self-starvation, recovery was an ongoing process, since it concerned the resolution of antecedents to anorexia, rather than the overcoming of its "symptoms". The similarities among all their stories justifies the use of such groupings to demonstrate changes in attitude and experience along the continuum from the negative to the positive phase. The use of autobiographical accounts and semistructured conversations was especially appropriate to the task of understanding recovery. First, because autobiographical reflection is the way people create the meaning of their lives [37] and second, because autobiography and its analysis are keys to understanding the relations between individuals and their society. In particular, the analysis of autobiography can demonstrate the ways in which the myths and rituals available in a society are used to construct individual identities and practices. Since autobiography is an attempt to elucidate the present and not the past [38], questions about the "validity" of factual memory were not relevant in my research. Having a coherent story of recovery proved to be the most important index of recovery. Although participants were self-selected, in several important respects they were remarkably similar to groups o f " e x anorectics" in accounts of clinical research on recovery from anorexia, as was the composition of the sample in several other respects; all but two had gone through tertiary education, were high achievers in professional or other aspects of their lives and did not necessarily come from upper-middle class backgrounds (as was originally claimed by clinical researchers who used to see those who could afford to pay). While the study makes no claims to complete generalizability for its findings, it pursues questions about religion and anorexia already raised by writers like Banks [26], extending the notion of religion to the wider one of spirituality which is more appropriate to the variety of their religious experience (if any). It also invites further research concerning the applicability of its findings to a wider group of ex-anorectics. Its Durkheimian formulation, however, suggests that some form of "religion" (or discourse on spirituality) will always be relevant to health and healing and that questions would concern the way in which this discourse is articulated. In this paper, Part 1 explains the meaning participants attached to the notion of spirituality and why ~ description of anorexia and recovery in purely existential terms is not entirely adequate. Part 2 focuses on the negative rite of anorexia itself, revealing the psychological and social processes which underlie its manifestation and finding corn-

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monalities between medieval asceticism and contemporary anorexia which add to existing studies of these connections. In Part 3, parallels are drawn between anthropological descriptions of rites of passage and the process of recovery which I have now termed "the positive rite", showing that my analysis is also applicable to recovery across a wide spectrum of contemporary psychological and psychosomatic distress. PART 1: SPIRITUALITY AND RECOVERY

Participants' accounts of spirituality Anorexia as spiritual quest. The definition of spirituality used here comes from participants themselves (pseudonyms are used throughout this paper). Most were keen to distance their interpretation of spirituality from formal religion, though some had found it expressed there. They spoke of anorexia and recovery as a form of spiritual quest. Those who were still anorexic (Group 1) referred to this quest as repetition and misguided searching, while those who had recovered described their anorexic years as a kind of pilgrimage: I feel I have to do this ritual repeatedly to cleanse myself and get reaffirmation that l'm still a basically intrinsically good person that's not done any wrong .... I have to punish my body and suffer. You do look for enlightenment. You are looking for some sort of salvation ... to unravel your own tortured complexity of your self (Michael, GP1) [39]. There was, during that time, definitely a religious or spiritual searching, definitely (Ilse, GP3). If I had had some kind of faith or some sort of spiritual refuge, I might not have been through such a confusing time (Sally, GP3). As I go along, the more deeply convinced I become that the spiritual aspects really have been at the heart of it (Meredith, GP3). Most participants emphasized the ongoing, non-linear aspects of their recovery and its dependence on the "spiritual" discourses available to them at various points in their lives, including various strands of Buddhism (Zen, Tibetan, Mahayana), Judaism, charismatic Christianity, more traditional Catholicism and Protestantism and New Age spirituality. Simone, for example, anorexic during the late 1960s and 1970s, drew upon ideas available to her in the circles in which she moved, to explain what she was doing then: When I was a hippie, I thought my full potential would be reached if I ate perfectly and ate exactly the right things and fasted; there was stuff in the counterculture about fasting. It was my version of spirituality. It was the best I could do under the circumstances (Simone, GP3).

A threefold connection. Spirituality, for participants, involved a threefold connection; connection within oneself, connection with others and connection with the natural world or the cosmos. Connection with oneself meant a sense of inner linking among different manifestations of the self, including the body, mind and spirit, in contrast with the experience of a "split" self during the anorexic period ("Self'

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should not be taken to imply an "authentic" or "essential" self, but a "polyvalent" or "polycentric" being, engaged in a process of transformation). Participants who saw themselves as "on the way to recovery" had most to say about this inner connection: (Anorexia and recovery have) certainly been a search for the whole person (Marjorie, GP2). The body is sacred. It's not meant to be dirty or unhealthy (Ariel, GP2). I've certainly felt the split, because there are three parts to me, the logical part, the emotional part and the ego. It's as if I've repressed my self for so long and suddenly I've given myself permission to nurture myself (Marilyn, GP2). Those who spoke of themselves as fully recovered were especially emphatic about the reconnection of body and mind and spoke of it in spiritual terms: Connection with my body is being part of God. I discovered, as I recovered, that glorifying God was loving the body and not separating it. And treating it like it was some sort of prayer (Aleisha, GP3). Look--the body and spirituality go hand in hand. After all--and more and more I begin to see this--that Jesus and Buddha and all the great teachers; they are incarnations. They are bodily manifestations! (Meredith, GP3). The second aspect of spirituality to which participants referred was their awareness of connection with others. This included personal (and sexual) relationships and also a sense of community, often with specifically spiritual associations. Ariel, brought up in the Anglican church, has joined a Jewish Synagogue in part because she finds a greater sense of community there: It's a complete way of re-learning a whole lifestyle. I don't have many friends except the people I know at the Temple, whom I can be communal with, to learn more about it. And it's so family oriented. I love it! (Ariel, GP2). Eloise, who has little interest in religion, finds the same connection with people who share her "left-wing, feminist social analysis". This has become a means of creating her own framework of belief and practice: If I want to maintain a sense of recovery and not revert to anorexia, it's had to have been a sense of control over my life outside of just my own body, but actually in my relationships to work or with my friends. And I guess I like seeking out alternative images, as opposed to just staying within the mainstream (Eloise, GP3). For Ceridwen, recovery involved social connection through participating in choral and orchestral groups: I found my community in the music, and the spiritual contexts as well and that was instrumental in my recovery; that I had that community of musicians and of music (Ceridwen, GP3). Kate interpreted the meaning of spirituality as the love she has for other people; something she was incapable of experiencing while anorexic. She speaks of her developing commitment and relationship with her partner as the most spiritual part of her life: I'd say in many ways there was something spiritual about my recovery. I'm uneasy about the world spirituality, but I

guess for me it is tied up with quite a few Christian values. It's that emotional bonding and understanding with people and doing things right by people emotionally that is of paramount significance for me. It's the love I have for someone (Kate, GP3). The third element in these accounts of spirituality was the connection with nature. The sense of reconnection with the body was not only about inner connection, but also about connection with the outside, material world, often experienced as a rediscovery of nature and a sense of participation in it. Aleisha put it this way: I started to believe that my body wasn't separate from nature and I really love nature. I don't think anybody anywhere is separate from nature and your food represents your relationship with the universe. My relationship with the universe is one of acceptance and peace now (Aleisha, GP3). Even those who did not speak directly of nature as "spiritual" emphasized its importance in their ongoing recovery. They spoke, for instance, of urges to go to a beach for periodic mental renewal and of gardening as a form of meditation. A reconnection. In each of these stories of recovery there is the additional element of reconnection. Participants in GP2 and GP3 frequently described their experience of recovery as "like coming home", "reconnection" and "rediscovery", often of feelings evoked by childhood memories. Even people in GP1 were aware of the importance of a return to, and retrospective sanctification of their childhood lives. Jennifer (GP1) expressed this need as a longing to be cared for as if she were a child, when she said: "I want to go back to where I was. I want to go back to being cared for. That would be my way of getting the love I feel I don't have; that love, serenity, family". Patricia (GP1) also longs for a return; "to that highly developed imaginative world I had as a child. That has a reality". In GP3, participants were particularly aware of a return to an earlier balance they had lost while anorexic. They said: "I'm back to where I was before I was anorexic" (Kate, GP3) and "my spiritual experience was like coming home" (Meredith, GP3). Meredith equates spirituality with recovery and recovery with reconnection. She says: When I was anorexic, the biggest affliction was this incredible sense of being cut off. From everything. And yet something in me knew that I was really very deeply connected, but didn't really know what to be connected to ... (Meredith, GP3). Recovery clearly involves more than an existential search for philosophical certainty, because emotions akin to those of religious conversion are involved. Participants' accounts demonstrate that the conviction of a reconnection (inner, with nature, and social) is as much "felt" as "known". At the same time, the period of anorexia from which they recover is also somehow involved in the spiritual quest.

Recovery from anorexia nervosa How can we better understand participants' simultaneous equations between anorexia and spiritual search on one hand and recovery and continuing spiritual growth on the other? To solve this problem, I will examine two possible meanings of the "spirituality" participants described; first as a solution to existential dilemmas, then as a form of religious experience, before going on to explore the spiritual meaning of anorexia itself--a meaning which has created difficulties in the scholarly literature and to which the study of recovery makes a significant contribution. Existentialism and spiritual experience Whereas in the 1960s these participants might have spoken of what they were doing in existential terms, whether religious [40-42] or secular [43, 44], in the 1990s the term "spirituality" itself appears to be enjoying a new vogue. Rather than criticize this development as a form of false-consciousness, it is important to seek for the "truth" it conceals, to understand its social sources and to examine its usefulness in explaining how people can "recover" from anorexia nervosa in the same society which gives rise to the phenomenon. A purely existential perspective which does not acknowledge this spiritual element leads to contradiction and paradox. Sheila MacLeod, in The Art o f Starvation, places the problem at the centre of her theoretical and self analysis. According to MacLeod, it is the burden of responsibility for self which is primarily responsible for self-starvation. She writes: The anorexic is someone who doesn't know how to live except by not eating. The fact that she cannot otherwise come to terms with her own life expresses a contradiction, in that non-eating leads to illness and eventually to death; and it expresses a paradox in that her apparent choice of death is in reality a bid for life. Any attempt at cure must involve the resolution of both contradiction and paradox [45] (p. 192). As this passage indicates, the "existential choice" not to eat, carried to its extreme, denies any choice over life and death and makes a mockery of existential responsibility. MacLeod's (apparently) despiritualized existential approach demands that having descended into the negative cult of anorexia, sufferers should then pull themselves out by their own bootstraps, something she concedes to be only partially successful, since at the time she wrote her book, she herself still occasionally went through episodes of self-starvation. The "spiritual" perspective described by participants in my study, however, involves the "myth" of a power beyond individual and social potential and offers an alternative with a lasting effect. The parallels are striking between participants' accounts of recovery and the conversion experiences described in William James' classic The Varieties o f Religious Experience [46]. The Varieties provides fascinating evidence of the part played by spiritual conversions in recovery from

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mental and physical suffering; stories which lend weight to the vitality of the spiritual myths which underlie them. First, he shows that religious experience is frequently associated with some form o f pathology. Second, he describes recovery as conversion. The conversion experiences he analyzes may be instantaneous (crisis) or more gradual (lysis) in the same way that participants described both their recovery from anorexia and the growth of some form of spiritual belief. Third, James describes the spiritual experience as a sensation o f union; of a direct connection with the cosmos, with humanity, with nature and with the Divine Energy [46] (p. 53). This element of union, or reconnection, is an essential feature of the spiritual experience participants describe in my study. Finally, James makes the point that spiritual healing includes "a belief in the reality o f an unseen order and in the human need to be attuned to it" [46] (p. 58). All participants claimed that recovery requires an experience of something (a material reality and/or an energy) beyond the self. They named it "spirituality" or referred to it as "love", as God or as Nature. It is this "reality", apparently once possessed but lost in the descent into anorexia (to which I now turn), which must be rediscovered during the emergence to a fuller way of living.

PART 2: THE NEGATIVE RITE: ASCETICISM AND DEATH

A major problem in analyzing the relationship between spirituality and recovery is that not all "anorectics" recover. (Clinical estimates of recovery vary from 17 to 77% and mortality is estimated to be between 5 and 8% in studies up to 40 years long [14]. Burns and Crisp [l l] suggested the following breakdown: 44% good outcome, 26% intermediate outcome and 30% poor outcome.) Self-starvation itself may be a conscious expression of spirituality or a kind of sainthood may be posthumously bestowed on certain "secular anorectics" (like music star Karen Carpenter) because western culture reveres their apparent self-discipline. Even sociological and feminist explanations have sometimes elevated anorexia to iconic status by treating it as a form of rebellion against patriarchal social control [47-52]. There seems to be a contradiction between this attitude and that of participants in my study, who invariably regarded anorexia nervosa as a distorted form of spirituality and a misguided way of life, even when they were engaged in it. What does this mean and how can the difficulty be resolved? My answer is in four parts: firstly I examine some of the meanings which have been ascribed to the deaths of three people who did not recover; secondly I consider some of the historical evidence about ascetic fasting; thirdly a comparison is made with the views of participants in my study; and finally I suggest a theoretical resolution to the apparent contradictions.

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Not recovering: spiritual asceticism? The life and death of the French philosopher and mystic Simone Weil is a story of non-recovery which, perhaps more than any other this century, contributes answers to the problem. Weil identified with the Gnostic tradition which inspired the fasting of medieval mystics [53], with suffering in all its forms, but especially with hunger [54]. For her, fasting was a way of testing the limits of life and death and hence the limits of earthly reality. One of her meditations on this subject reads: Food is the irreducible element .... the point where the very mind which conceives finds itself degraded to being one out of the number of appearances .... Fasting constitutes an experimental knowledge of the irreducible character of food, and hence of the reality of the sensible universe [53]. Weil valued the Stoic conception of life; the feeling of being at home in the universe whatever it may produce [54] (p. 184). At the same time, inspired by her admiration for the twelfth century Cathars, she held a doctrine of extreme dualism which is reflected in the beliefs and actions of contemporary anorectics: everything carnal and everything social was evil. Weil is justly remembered as a saint for the courage and compassion of her life and, like all "saints" who experience the Grace of which she wrote so eloquently [55], she had faults. These were the personal characteristics which made her able to achieve what she did while at the same time isolating her from her contemporaries in a kind of moral and intellectual superiority. Many people who admired and loved her noted her extreme rigidity, her intransigence; in short, her perfectionism [54] (p. 457). She felt spiritually compelled to maintain the split between her body, her spiritual longing and her critical intelligence as her contribution to the world. In this, her attitude strongly resembles the asceticism of medieval fasting saints whose lives are discussed below. To call Simone Weil's asceticism misguided, a waste of a life, or a distorted form of spirituality would be an intolerable form of spiritual pride. Instead, we are forced to consider the argument that anorexia need not necessarily be viewed as a precursor to recovery, but as a spiritual journey in its own right. The remainder of this paper questions this kind of analysis and suggests some broader alternatives. Not all deaths from anorexia in the twentieth century are so self-consciously spiritualized or intellectualized, but however the meaning of anorexia is expressed, it is always (like Weirs) a struggle between life and death. Catherine Dunbar, who died from anorexia at the age of 23 and whose story has been told by her mother [56], certainly recorded in her diary a kind of spiritual agony which resembles that of her medieval namesake and the physical and emotional "afflictions" of Simone Weil. "I am so scared and mentally torn inside", she wrote, "Dear Jesus, please help me" [56] (p. 58). Her longing for

death was finally accepted by her family and friends, who felt that their only recourse was to assist her to prepare for the end. She had a strong consciousness of the presence of evil and her struggle with anorexia was, as I explain in more detail below, an attempt to confront the meaning of death. The Christian interpretation her family placed upon her peaceful acceptance of death had as powerful a meaning for them within that framework, as did the deaths of ascetic saints within their social context. In contrast, the death of Karen Carpenter seems to have had no articulated spiritual rationale. Her anorexia partly stemmed from her lack of self-confidence and her perfectionism; the desire to be a better person in the eyes of her public. Her death was the abandonment of that moral struggle. Yet she, too, has attained a kind of secular sainthood through her suffering. Inpatients of eating disorder units listen obsessively to her music [57] and in popular culture there is a kind of mystique associated with her tragedy which retrospectively glorifies her pain. It is a complex blend of envy for her thinness, horror at its result and awe at her apparent determination to suicide. Where Weil's anorexia is the object of reverence for some intellectuals, Carpenter's provokes a similar reaction in a wider audience. This response is a kind of identification with a sacrifice taken to exemplify a peculiarly contemporary cultural problem with which people in modern westernized societies can identify; in Weil's case, the sufferings of factory workers and of people in war-torn nations; in Carpenter's, the suffering imposed on women by western expectations of slenderness. These deaths have become cultural icons which are used, differently in different social groups, to represent facets of a collective suppressed fascination with the inevitability of death.

Historical studies of asceticism: continuity or discontinuity? The self-starvation of Weii, Dunbar and Carpenter can be further understood in the light of a growing literature which compares the practices of medieval and later ascetics with contemporary anorexia. Asceticism has been approved in most religions (though not without qualifications) as one of several permissible spiritual paths, but what is its meaning today? Especially among people who are not members of a religious community and do not expect, or find, a religious sanction for their views and actions? The question which has most commonly been asked in this literature is, to put it simply, whether or not medieval fasting women saints were "anorexic" or in what way their fasting might be equated with that of contemporary "anorectics". The more important question, which has not been addressed, is whether and in what sense contemporary anorectics are "saints", or what elements of their behaviour might be better understood through a comparison with their medieval counterparts.

Recovery from anorexia nervosa It has been relatively easy for historians to point out that both sets of behaviours are culturally produced and should therefore be regarded as entirely distinct. They have done so on the basis that "anorexia nervosa" is a modern medical diagnosis which did not exist in earlier times and that, in any case, there is insufficient evidence for medical and psychiatric diagnoses to be retrospectively applied to medieval women. They have focused on the meanings which the faster and her society attached to her fasting or, more accurately, on the way historically determined attitudes to food, the body and women helped construct the phenomenon of female fasting. These arguments are entirely compatible with the theory that such fasting is a ritual which constructs meaning for the individual and her society, creating boundaries between the pure and the impure as they are culturally interpreted [58]. They have nothing to say, however, about the meaning of recovery. It is also relatively easy to understand why people might adopt rituals of self-starvation (and there will be different reasons in different cultures), but harder to explain why such people would abandon them. If asceticism is spiritually meaningful, what is the spiritual meaning of recovery? Historians and anthropologists who have addressed the question of continuity or discontinuity between medieval ascetic fasting and contemporary anorexia fall into two camps. I shall first discuss those who argue for "continuity". The earliest of these studies, Rudolph Bell's Holy Anorexia, takes a largely psychoanalytic approach to explain both behaviour patterns as "a desperate effort to establish a sense of self" in societies which deny full selfhood to women [23] (p. 58): The medieval Italian girl, striving for autonomy, not unlike the modem American, British, or Japanese girl faced with the same dilemma, sometimes shifted the contest from an outer world in which she faced seemingly sure defeat to an inner struggle to achieve mastery over herself, over her bodily urges. In this sense the anorexic response is timeless [23] (p. 56). This explanation, while it does suggest the dialectic of domination and liberation which plays a part in anorexia, has little to say about how recovery is also possible in these societies. Holy Anorexia does, however, contain evidence of "recovery" in medieval times. Bell describes how a young woman who used her anorexic behaviour to escape the psychological domination of her father would frequently enter a convent where, in her late twenties or thirties, she would "recover" and become active in the affairs of the convent, often being elected its head. "She would learn to fast rigorously, but in a fully self-controlled way and the 'devils' which plagued her earlier would make way for more reassuring presentiments" [23] (p. 56). Saints who fit this "recovery" pattern include Saint Veronica and Saint Clare. In the process of recovery, Veronica suffered some early relapses, and "she always adhered to the spartan, but not

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unhealthy regimen set out for everyone in her (religious) order", but her later life was considered "wise, moderate, outwardly calm and passive", concentrating solely on her religious devotion, and she warned the sisters of her order against the more extreme manifestations of spirituality [23] (p. 80). Likewise Saint Clare, having recovered from the illness brought on by her not eating, became a prioress and, according to Bell, "explicitly backed away from her earlier excesses, displaying much the same experiential wisdom shown by present-day recovered anorexics" [23] (p. 125). Saint Catherine of Siena, on the other hand, was unrelenting in her asceticism, of which she eventually died. Bell writes that she "courted death" and that despite her strong social and political activism within the Church (like Simone Weil's political activism in the French Resistance), she was eventually "exhausted by her austerities and broken emotionally by her failure to reform the Church" and (like Weil) "her will to live gave way to an active readiness for death" [23] (p. 53). Caroline Banks [26] is more persuasive than Bell in establishing the similarities between medieval asceticism and anorexia. She makes use of interviews with contemporary "recovering religious anorectics" and of material from their diaries, to look for the Christian "cultural norms" which influence contemporary fasting, instead of focusing on the usual assumption of researchers that dieting and secular ideals of slimness are primarily involved. She concludes that "it is an open question ... whether the related processes of medicalization and secularization are complete on a subjective level for all anorectics even in the late twentieth century". Banks' argument and her evidence concern fasting which has an explicitly religious rationale, rather than the wider notion of spirituality employed in my own approach. It is not only the stated religious beliefs of anorectics, however, which make their asceticism "spiritual" but, as I argue more fully below, the relation which both their beliefs and actions bear to cultural ways of dealing with death. They need not emanate from a specifically religious form of discourse. Medicalization and secularization do not eliminate spirituality; they simply contribute to its relocation outside institutional religion or perhaps rediscovery in movements other than religious ones; liberation movements like the environmental movement, feminism, anti-colonialism and the continuing development of the human spirit in art, music and literature. The "culture-bound" nature of the anorexic rationale [26] can be better understood as a "western" failure to provide rituals of social re-incorporation after a period of liminal asceticism; rituals explored in Part 3 of this paper. It is important, however, not to ignore the important cultural and historical differences which mediate the expression of spirituality. The warnings of the "discontinuity" theorists therefore also need close attention. Carolyn Bynum is usually cast as a

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"discontinuity" theorist because of her insistence on the differences between medieval and contemporary fasting. Her Holy Feast and Holy Fast [24] stresses that medieval women's abstinence symbolized collective rather than individualistic values and was associated with a religious imagery of feasting and food which were intrinsic parts of medieval society [24] (p. 93). Yet when she writes that "eating and not eating became more than metaphors for grace and desire; they became actual modes of experiencing", she is describing the same processes which occur in all societies, whereby metaphors (in this case food metaphors) are used in concrete as well as in more abstract artistic and linguistic forms, to effect ritual transformations at the individual and at the social level [59]. Her evidence could therefore be adduced to demonstrate that the continuity between asceticism and anorexia lies in the use of food and fasting as a symbolic attempt to confront the universal problem of one's own mortality. Bynum's justifiable concern in the continuity debate is for historical accuracy. She warns us not to assume that apparently similar behaviours have the same meanings in different historical periods. Specifically, not to apply to the past causal connections derived from contemporary medical and psychological theories. She makes it clear that there were several different ways of interpreting unusual fasting during the medieval period (as, in fact, there are today): it could be viewed as fraudulent, as attention-seeking or as an illness. Saint Catherine of Siena (like Simone Well) spoke of her inability to eat as an infirmity, not a voluntary religious practice [24] (p. 196). Bynum especially wants to emphasize that the particular form taken by fasting behaviour is always "learned from a culture that has complex and long-standing traditions about women, about bodies, and about food" [24] (p. 198); an important reminder never to ignore the cultural context. She stresses that whatever its motivation, medieval "miraculous fasting" was seen as part of suffering and "suffering was considered an effective activity, which redeemed both individual and cosmos" [24] (p. 207). She sees this as a significant difference between the medieval fasting saints and today's anorectics. Yet nothing in Bynum's careful consideration of similarities and differences between medieval female fasting and today's anorexia nervosa contradicts my argument about the spiritual basis of both. My research shows that in some senses, contemporary anorexia nervosa still fulfils the same individual and social purpose as other forms of asceticism but, in most cases, without their religious rationale. Another historical study of women's asceticism further develops the idea of the social significance of suffering. In a re-examination of her previous attitude to the seventeenth century patron saint of South America, Saint Rose of Lima, Sarah Maitland argues that Rose's self-imposed penances (horrific to the modern mind) were not evidence of "the extreme

body hatred and guilt that a patriarchal religion lays upon women". Instead, she says, if we look for the meaning Rose and her culture ascribed to her behaviour, we find that Rose's suffering was highly meaningful in its social context, the recently colonized New World, where she witnessed "some of the most squalid examples of materialism and petty colonialism and also one of the most defeated and culturally mutilated people that history offers us" [60]. Rose's penitential practices gave her an unusual degree of autonomy, were deeply appreciated by her own community and offered her the consolation of believing that she was performing a socially useful task in taking upon herself the sufferings of her fellows; earning their salvation through her selftorture. This interpretation of the meaning of fasting certainly has resonance with the life and expressed motivation of Simone Weil. It also invites us to consider the possibility that the fasting of contemporary anorectics expresses their distress at their own social situation; not only at their lack of control over their personal circumstances, but also a more general introversion of a cultural malaise about death and the mortal body. A further example of an ascetic whose suffering took on an important social meaning is found in Brenda Meehan's account of the life of Russian hermit, ascetic and holy woman Anastasiia Logacheva (1809-1875) [61]. Heavily influenced by the Desert Fathers who were also models for medieval ascetics, Anastasiia withdrew from the world in order to devote herself to the spiritual life: As she emptied herself of bodily longings, she developed the translucent radiance of the true ascetic .... A radical transformation of personality, the goal of monastic and contemplative life, took place within Anastasiia, clearing her of attachments and petty strivings and making her a willing vessel for the divine, a mediator between the temporal and the infinite. She shone with a radiance that attracted followers to her even in the depths of the forest and led many to sense in her the power of a deeper reality. She was sought out as mediator, model, counsellor and holy woman (staritsa) [61] (p. 58). Meehan's beautiful description of Anastasiia's "jarring translucence" is, however, explicitly writtefi "to offer spiritual guidance for today". Her reading of the stories concerning Anastasiia is as much about contemporary spiritual sensibilities as it is about the spiritual iongings of Anastasiia's place and time. Reading Meehan's work in this light uncovers a modern version of longing for transcendence. Meehan makes no claims about anorexia in the present, but she believes that women of the past may have used asceticism as a deliberate means of achieving both spiritual power and temporal influence. She implicitly suggests that asceticism should be taken seriously as a possible spiritual pathway in the late twentieth century. What makes it unlikely that anorexia will be seen in this way, at least in "the west", is that the dominant contemporary discourses on anorexia

Recovery from anorexia nervosa (medical, psychiatric, psychological and, increasingly, feminist) do not include the possibility of religious sainthood. As a consequence, women seeking spiritual pathways today are finding ways to transform the negative cult of fasting practices into the positive cult of bodily, environmental and social connection in order to reach the kind of spiritual fulfilment which a life of asceticism currently denies them; since spiritual fulfilment usually requires the element of community recognition and approval. Whereas medieval religious ascetics were often explicitly presented as role models for young women, contemporary anorectics, even when they draw upon religious discourses to rationalize their actions (as do those in Banks' article [26]), are not given religious validation in western culture. Instead, the respect and even envy they sometimes command is in tune with twentieth century individualistic competition and achievement. While carefully controlled fasting and renunciation of material goods are still considered worthy ideals for those whose lives are entirely dedicated to the religious life, extreme forms of asceticism like the starvation and self-mutilation of Rose of Lima or Anastasiia Logacheva are not. Excessive fasting today constitutes a parody of contemporary values in relation to the body, thereby revealing the splits such values create between body, self and spirit. The anorexic quest is not always "religious", but as a search for reconnection, it is always "spiritual". Participants' views: asceticism as distorted spirituality? The problem remains that participants in my study, recovered or not, spoke of their anorexia as a distortion of the kind of life they thought most valuable. If Simone Weil's choice of asceticism as a way of life is to be accepted as a valid spiritual pathway, what should we make of participants' assertions to the contrary? In GP1 (not recovered), those who practise an ascetic way of life, with or without a theological rationale, acknowledge its problems and long for an alternative. Others in this group have been unable to sustain their asceticism and have abandoned it for an equally self-hating pattern of compulsive eating. In common with Weil, their anorexia is part of a quest, but unlike her, they have no conviction that it is somehow divinely ordained. The examples of Michael and Philip will serve to show the attitude of this group to their own asceticism. Michael consciously identifies with Weil (having seen the BBC TV documentary on her life), at the same time admiring and questioning the logic of her sacrifice and his: You feel you don't merit any more. If the children in occupied France can survive with this diminished food intake, why can't you? Purposely and deliberately you reduce your amount. It's an absurd sort of parallel, but it's true. The key word is sacrifice. You feel you've got to make

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this sacrifice in going without, because maybe you haven't merited any more. It's a discipline. You feel you're living under wartime conditions (Michael GPI, my emphasis). Like Weil, Michael believes he is testing the limits of life and death. Both self-starvation and the mountain climbing which accompanies it express an ascetic impulse; a way of living out his questions about the value of his own existence: I like this exciting risk area, but not to the point of danger. It's like traversing a glacier where there's a crevasse, but not naively plunging down one. I like crossing this voyage of the unknown, too, because it heightens your sense of your own awareness and you learn from it. But you've got to be in very rigorous body mode; fired up for it and not carrying any excess weight (Michael, GPI). Weil made her historical contribution in spite of her lifestyle, but Michael recognizes that his way of life actually prevents him from contributing much to the world. He says "I'm dreadfully immature", "I don't know why I'm doing it", "there's no capacity for change". A part of him also wants to recover. He asks me "how did you recover?" then says "I envy you". But he concludes "I don't feel sorry for myself. I've learned to bear it. It's nay burden in life. It's the cross I have to carry". Is this meaningful sacrifice, or a sadly distorted spirituality'? Michael seems to think it is the latter; an "absurdity", as he implies above. He also refers to the triviality of most social relationships and concerns as the worldly domain he wishes to transcend rather than as the sociality which might give a new meaning to his spirituality. Philip, too, is in no doubt that his position is "distorted"; that his practice does not accord with his belief. His professed Christianity leads him to conclude that his own behaviour is wrong but he simply does not know how to escape from the contradiction. He admires people like Cherry Boone-O'Neill [62] who speak of their Christian faith as the key to recovery, but he has not found a way to apply his beliefs to his own situation: I think (her book) is great, because that's what the Christian faith is all about. God in his wisdom doesn't want us to be sick and really when you are doing that, starving yourself, you're committing a sin against the Holy Spirit, so therefore you should be treating your body like the temple of God. That makes sense to me, that I should be treating my body correctly (Philip, GPI). When I ask him whether he thinks he is doing this, he says "I don't know" and immediately excuses his eating patterns on the grounds of his celibacy ("a woman would make me eat"), in an instructive linking of his refusal of food with the denial of his sexuality which parallels Weil's refusal to participate in the body of Christ (social, as well as mystical communion), or enjoy any bodily pleasure (her aversion to anything sexual is amply documented) [54] (pp. 193-194). In the group of participants who have just begun to recover, there is also a condemnation of their own earlier fasting behaviour. Lauren (GP2) thinks that

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her anorexia has been a denial of spirituality through an excessive respect for rationality. For her, recovery involves a movement away from logic towards greater acceptance of what she calls "the emotional level". She describes the struggle between these two levels in these terms: Much to my horror--I really don't like the thought of having done that--I really have worked largely at the intellectual level, and the logical level, rational level--But logically and rationally I know what I've done is wrong, what I'm doing is wrong. So I've been trying to open up my imagination a lot more to let my emotions out, by doing a lot of relaxation-type techniques. I do talk openly about the spiritual and the emotional level and all that sort of thing and the universal power and the energy. And there have been times when I have actually used it and it has worked (Lauren GP2, my emphasis). Participants in GP3, unsurprisingly given the choice of spiritual path they have now made, look back on their anorexic period as a necessary, but temporary, "distortion". Eloise (GP3) speaks of her behaviour then as "self-destructive", "misdirected energy" and "confused". She captures the spiritual longing to develop soul (as the opposite of ego [31]), when she says: I think that on one level, I was quite energetic, but not at all to my potential. My desire to be involved in so many things was enormous. My desire to actually BE. And my desire to achieve was extreme. But it was going in hand with something that was quite destructive (Eloise GP3, my emphasis). Jodie (GP3) also speaks of her incredible energy and occasional heightened awareness during those years as a frenetic and somehow desperate way to be, in contrast with the peace she now experiences as her more usual mode of being: I had something then, it was just going in the wrong direction. When you're really hungry, your awareness of things is heightened, so it was appreciation, but it wasn't joy like what I have now; it wasn't comfortable or peaceful; it was agitated, hyperactive (Jodie GP3, my emphasis). "Going in the wrong direction, frenetic, destructive, incomplete, absurd, sinful, wrong" are not descriptions of an ultimately satisfying, empowering experience. However, we must also consider that the very availability of alternative stories--stories of recovery--forces these participants, recovered or not, to reconstruct their story in this negative mode. But is this all that is involved? Just as the key to Weil's "sacrifice" was in her intellectuality (she chose logical thought over the body and the emotions and stoicism over epicureanism), perhaps the key to participants' negative interpretations of their asceticism is in their awareness of an alternative, broader form of rationality which takes account of the body and the emotions and is made available to them in part through "New Age" ideas. There are at least three possible reasons why participants in my study experience or remember their asceticism as spiritual distortion. They do so firstly because all discourses on their behaviour today

construct it as a form of pathology, even when (as in feminist discourse) the intention is to criticize the medical formulation. Secondly, they do so because there are no theological rationales for such extreme forms of behaviour which would make it acceptable (though still unusual) in contemporary society: controlled fasting for limited periods may be acceptable in certain religious communities, but sustained starvation is not (e.g. in the Catholic Church, extreme self-starvation has always been regarded as an aberration, and, since the second Vatican Council, strongly discouraged. When individuals in religious communities fast to excess, they are counselled and supported towards "recovery"). Finally, participants' awareness of the emerging discourse on recovery (if only through their contact with me) has suggested alternative ways of creating meaning in their lives. For them, the development of spirituality seems to require acceptance and nurture of the body rather than its transcendence; more direct communion with others than solitary meditation, and a belief in a bodily, rather than abstract, connection with nature. Contemporary meanings o f asceticism: evaluating the theories

Having examined a variety of arguments and evidence concerning the ascetic element in anorexia, I return to my original questions about the meaning of spirituality in the lives of self-starving people: is contemporary anorexia the expression of a meaningful asceticism or a distorted form of spirituality? and are today's anorectics the analogues of medieval fasting saints? I shall consider the merits of four possible explanations which I have called (a) "the clinical response", which adopts a psychoanalytic interpretation, (b) "symbolic social suffering", in which anorectics take on the sufferings of the world, (c) "hidden death themes", in which they play out the unwillingness of western society to face death, (d) "exceptions to the rule", in which asceticism is an inevitable by-product of particular social conditions for certain individuals. Finally, I offer a new account, "from negative to positive cult", in which anorexia is part of a ritual movement designed to resolve all of the previous possibilities. Clinical responses: the ascetic "ego ideal". In this explanation, anorexia is interpreted psychoanalytically as one manifestation of adolescent developmental crisis (at whatever age it takes place, for developmental stages need not be firmly associated with chronological age). Clinical "specialists in eating disorders" have favoured this model in their attempts to find similarities and differences between their clients' behaviour and religious asceticism. The feminist psychotherapist Marilyn Lawrence [63], for example, points to the moral kudos associated with ability to limit food intake, at least in the western tradition. This is one of its attractions for adolescents in search of social acceptability and self-regard.

Recovery from anorexia nervosa Mogul [64] also suggests that anorexia nervosa may be a more pronounced version of "normal" adolescent asceticism--a youthful response to the existential dilemmas faced in adolescence. Rampling [65] explores the ascetic dimensions of anorexia within a psychiatric model of explanation. He postulates the same "ego-ideal" for both asceticism and anorexia, but does not take into account the possibility of "soul" with which this ego (and its ideal) might be in conflict. These analyses, illuminating as they are in many respects, fail to explain why some adolescents might carry their ascetic experimentation to such extreme conclusions while others appear to abandon it and "recover". To resolve this problem, a more detailed understanding of asceticism is required.

Symbolic social suffering. The Varieties of Religious Experience [46] gives us a more precise definition of asceticism. James, trying in his own way to be as scientifically objective as the clinical paradigm, wants to avoid pathologizing asceticism and to rehabilitate its religious meaning. He admits that "the scrupulosity of purity may be carried to fantastic extremes", but even in these he sees a kind of social usefulness, for the ascetic mortification of the flesh is "one response to the problem of evil in the world": It symbolizes, lamely enough no doubt, but sincerely, the belief that there is an element of real wrongness in this world, which is neither to be ignored nor evaded, but which must be squarely met and overcome by an appeal to the soul's heroic resources, and neutralized and cleansed away by suffering [46] (p. 281). The ascetic, according to James, finds "a profounder way of handling the gifts of existence" and symbolically takes on the sufferings of the world. His explanation accords with the meaning I have ascribed to the lives of saints like Rose of Lima and Anastasiia Logacheva, and even Simone Weil; but it does not go very far in explaining how this symbolic purpose comes to be understood as such in the minds of their contemporaries, nor how this might differ in different epochs and societies. If contemporary anorexia nervosa does fit this description of asceticism, however, it does so unconsciously for the anorectic, for whom fasting is most likely to be about individual redemption from guilt and salvation through self-perfection (as described, from a sociological perspective, in the work of Max Weber) [66]. Hidden death themes. Another model too, expands our view of the psycho-social processes involved in the symbolism of anorexia. Craig Jackson [67, 68] has elaborated a carefully documented argument that anorexia results from the contemporary western denial of death and its symbolic equivalents--separation, loss, unresolved grief and severe trauma. Jackson [68] (p. 1) argues that the anorectic's apparent courting of death is in reality "a meticulous denial of death" which "buys freedom from anxiety about death" [67] (p. 1). He suggests SSM 43/I0---C

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that eating is inevitably about death, since we eat dead material and since not eating results in death. In her refusal to eat, the anorectic therefore acts out the twin meanings of a social taboo. He believes that his analysis of anorexia has been ignored by researchers because of their own resistance to dealing with death-related issues. Jackson cites several empirical studies in support of his theory: McAII [69], a doctor of medicine, believes that inadequately mourned grief leads to anorexia. He has reported his successful treatment of anorexic patients using a Christian mourning ritual, claiming an 83% recovery rate in a 4 year follow-up. Identification with the dead, especially the mother, has often been found to be related to the genesis of anorexia [70--72]. The desire to understand death and a consequent longing for death are simply the other side of existential questions about life. Hence to recognize death in a formal way is also to value life and this is probably what McAll's ritual achieved. "Cognitive restructuring" alone would not have had the same effect. The purpose of the grieving ritual, especially since it involved the physical reality of shared bread and wine, was to provide the bodily and emotional dimensions of mourning; the symbolic creation, by material means, of links between life and death. In Jackson's argument, the individual with an eating disorder is similarly conceptualized as a survivor by proxy of a relative (usually the mother) who is the original survivor of traumatic events. Carolyn Quadrio [73] has also written of the links between survival and anorexia in her discussion of anorexic daughters of holocaust survivors. She emphasizes the way in which "family ghosts" of continuing fear and survivor guilt can haunt the following generations. The crux of Jackson's work is its focus on a neglected aspect of the anorexic experience; the importance of social attitudes to death. He too, however, concentrates on anorexia to the exclusion of recovery. For him, anorexia is still a pathology. He writes: Most non-traumatized individuals with healthy psychological defences remain blithely unaware of the close interdependence of life with death and death with life--they are able to transcend this harsh reality [67]. This approach ignores the value of a direct confrontation with death, as in near-death experiences [74-76] and anorexia; experiences which convince those who have them that their life is meaningful, thereby enabling them to live fully and confidently in the present. Transcendence does not mean escape, but integration, and it is this integration of death into life which is the outcome of recovery from anorexia. All societies need rituals which enable them to acknowledge death and make it serve socially positive and transcendent purposes [77]. Our own society, in which "death is the great unmentionable,

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the imperative taboo" has been less than successful in elaborating such rituals [77] (p. 15). Anorexia, and more particularly recovery, are made to serve this purpose (among others) in western societies today. Exceptions to the rule. The problem of "spiritual distortion" remains: can asceticism ever be considered a valid form of spirituality and under what conditions might this be its meaning? The difficulty arises from the definition of spirituality which I have adopted in which the movement towards greater spirituality and less of its opposite, Ego, requires an integration of self, body, nature and society. This is not the meaning of spirituality for the committed ascetic, for whom the body is inherently sinful--to be controlled and transcended. As well as awe and reverence, asceticism has always attracted the charge of heresy. Weirs confessor and friend, Father Clement, did not conceal from her his opinion that she was a heretic [54] (p. 458). It is a lack of balance; an aberration from a "normal" pattern. There is, however, a sense in which asceticism as heresy is of social, value, for heresies at least challenge established doctrines (if only through parody) and force us to confront and re-evaluate "acceptable" behaviours. Participants in my study, in speaking about their anorexic stage, were actually "confessing to a heresy" in the same way that the body reduction and diet industry forces its many acolytes to "confess excess" [78]. The symbolic value of anorexia as a parody of western attitudes to the body is not to be denied, but for the symbolism to acquire its full "spiritual" value, it requires the completion of recovery; the re-acceptance of the body with all its messiness and unpredictability, including the inevitability of death. It is tempting to include acceptance of the body as an irreducible element of spirituality, but recognizing that "transcendence" may also be achieved through confrontation with the terror of non-being [31] (p. 134), we must also allow that for some human beings, under certain circumstances, the latter pathway may be the only one open to them [31] (pp. 160-161). Any analysis of eating disorders must therefore recognize that in the absence of opportunities for recovery (its "myths" and "rituals") death may be the only possible spiritual pathway--as the writings of Weil and Dunbar [56] insist. Death and rebirth: from negative to positive cult The most convincing explanation for the asceticism of anorexia comes from a Durkheimian perspective. I have already argued that anorexia nervosa can be viewed as a form of individual ritual with social purposes. Durkheim's conception of ritual, however, is also capable of accommodating the process of recovery. His concept of the negative cult as a necessary prelude to the positive cult achieves this accommodation in the following way. First, he emphasizes that fasting, like all rituals, has more than one meaning. "Fasting is an expiation and a penance;

but it is also a preparation for communion; it even confers positive virtues". This means that it may be understood, by the individual involved and by onlookers, as the "negative" phase in a purity ritual which is an essential prelude to the "positive" rite of initiation into the deeper mysteries of life and death. This formulation also explains the different historical meanings attributed to ascetic fasting in different historical periods (the problem in the continuity and discontinuity debate canvassed above). For Durkbeim, the same rite takes on different functions in different historical and cultural circumstances. It produces effects which are "interpreted differently according to the circumstances in which they are applied" [32] (p. 386). From this perspective too, the lifelong asceticism of the medieval fasting saints can be regarded as a permanent form of liminality, (A discussion of liminality in anorexia nervosa is reserved for the next part of this article.) It follows that our interpretation of extreme asceticism will be strongly conditioned by the period and society in which we make our judgments; hence our unwillingness in the 1990s to view fasting as a positive good. Durkheim's analysis accounts for those who do view it positively as follows. First, he makes a strong distinction between the religious and the profane world. (This is the very dualism which my "myth" of recovery is keen to dispel, but it is an undeniable feature of the anorexic perspective which involves the splitting of the world into pure and impure components.) From this sacred/profane distinction, he argues: ... comes the mystic asceticism whose object is to root out from man all the attachment for the profane world that remains in him. From that come all the forms of religious suicide, the logical working-out of this asceticism; for the only manner of fully escaping the profane life, is, after all, to forsake all life [32] (p. 40). Normally, asserts Durkheim, the negative cult (anorexic fasting) is only a preparation for the positive cult (recovery into a reconnected form of spirituality), but occasionally the negative cult "exaggerates itself to the point of usurping the entire existence". This "hypertrophy of the negative cult" in some historical circumstances, as Maitland [60] and Meehan [61] have argued, leads to high religious prestige, conferring moral and social "powers and privileges". Such people, in such circumstances, fill a useful social function, argues Durkheim, because they act as models to incite effort in other people and to "raise us above ourselves" [32] (pp. 311, 316), presumably reminding us of the need for self-transformation. (The same argument for asceticism is made by William James.) Thus asceticism, for Durkheim, is an integral part of human culture. It is in its more ordinary form as prelude to the positive cult, however, that ascetic fasting is normally found. Mogul's [64] suggestion that anorexia is an exaggeration of adolescent self-initiation practices follows this line of thought. This idea also explains

Recovery from anorexia nervosa the general agreement among participants in my study that their anorexic years had been, though painful, necessary for their subsequent self-transformation. As Durkheim would say: "the suffering which privations impose is not arbitrary and sterile cruelty; it is a necessary school, where (men) form and temper themselves" [32] (p. 316). The negative rite of anorexic asceticism is thus an initiation and a metamorphosis of the personality which forces a confrontation with death in order to make the choice of life a more conscious one. The initiation is into the mystery of symbolic death and rebirth. Like the so-called "primitives" who were the objects of Durkheim's study, modern day anorectics take all this, not in a merely symbolic sense, but "literally" [32] (p. 39) and it is this literalism which effects the change in their personality. At the same time anorexia and recovery, like all rituals, involve and transform the body. In addition to the mythological elements of narrative, recovery involves practices which I suggest are of a ritualistic nature with (unconscious) ritual intent. That this is a convincing reading of anorexia and recovery is borne out by the usual sequence of events in the recovery process: the acute anorexic period can be viewed as the "preliminary initiation which introduces the initiand into the sacred world" through fast, retreat and silence, which are "no more than certain interdictions put into practice" [32] (p. 310) (in this case social interdictions against particular foods regarded as fattening and consequently unhealthy and impure). The initiation therefore begins with the separation phase when the fasting rituals begin to take place. This much has already been suggested in relation to anorexia, in the work of Chernin [79]. The recovery phase, which is equally capable of this kind of anthropological interpretation, has received far less attention. This is one possible reason why recovery rates are not greater than they are. Unless the "anorectic" is unable or chooses not to move out of this phase, the next stage in the ritual is the phase of reincorporation into the community, accompanied by a gradual resumption of normal eating patterns for that community and greater participation, as a full member of the society, in its activities. In between these phases, however, there is a period ofmarginality or liminality (very roughly corresponding to the stage reached by GP2 in my study) when the newly initiated person is still fragile and disoriented following her ordeal. "When the individual is no longer what he or she once, and quite recently, was but is not yet what he or she, emerging from this intermediary and literally transient state, will soon become" [77] (p. 139). Durkheim writes of religious (hence spiritual) impulses as being highly contagious. This, too, may be part of the explanation for the common phenomenon of "copy-cat anorexia" [25, 80]. The fear of contagion is also partly responsible for the

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frequent remark that people in an anorexic phase resemble ghosts, appearing to be not quite embodied or present in the physical or social world. Kessler describes these "ghost-like" liminal beings in all initiations in this way: Hovering on the outskirts of everyday society from which they have separated themselves, the initiands are a shadowy or ghostly presence. Not really present in society or part of its continuing life, they are somehow not fully alive, and are thus regarded in some ways as dead. Moreover, in close contact with powerful spiritual forces that ordinary mortals must treat with great care, they are both vulnerable and also, as potential bearers of those forces, endangering; in their spiritually exposed condition, unprotected by mundane social identities or routines, they are both susceptible to and also contagious bearers of potentially death-dealing forces [77] (p. 141, my italics). The analysis of anorexia and recovery as parts of a ritual initiation process is a valuable way of understanding some of the means whereby life and death are individually and socially managed. Understanding recovery in this way helps resolve the problem of"whether anorectics are saints" because it shows the underlying meaning of all asceticism which is the necessary confrontation with death. Anorectics are like saints (rather than ascetic saints like anorectics), but so are we all to some extent, as we engage in practices which transform our being in the encounter with our own mortality. Durkheim's analysis also helps eliminate the apparent contradiction between "meaningful" and "distorted" forms of spirituality. It allows the possibility that asceticism has different meanings for different people at different times and that, in some circumstances, the exaggeration of the negative cult which results in a lifelong asceticism or early death, might be of great social value. Most importantly, a Durkheimian analysis suggests that stories which emphasize recovery (the re-emergence from the separation and liminality of anorexia) are those which are most necessary to the contemporary self-starving initiand. PART 3: THE POSITIVE RITE: RITUALS OF SELFTRANSFORMATION

In Durkheim's analysis, myth is always accompanied by ritual, for the latter is the physical expression of the former. Recovery from an eating disorder requires more than new theories and fresh narratives. It always includes changes in bodily practices. Anthropological accounts of rites of passage can contribute to our understanding of the particular practices which bring about and consolidate recovery. Rites o f passage

The "classical" description of ritual, upon which much subsequent anthropological thinking has been based, is found in van Gennep's Rites o f passage [81], published, in fact, 6years before Durkheim's

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Elementary Forms. An analysis of his description reveals that anorexia and recovery share the following elements in common with other rites of passage: (a) Like initiation rites, they are not just about physical puberty, but about social maturity. (b) The initiand withdraws from society during the pre-liminal phase for the purpose of "self-scrutinization of the central values and axioms of the culture in which (this withdrawal) occurs". This scrutiny is what is referred to in the feminist and sociological arguments about anorexia itself as social "rebellion". If we now consider recovery as the next phase in the rebellion, it becomes clear that from this scrutiny emerges a different way of living from that prescribed in "normal" social relations; the recovered anorectic rejects the social imperative to constant vigilance over her shape and size. (c) During the withdrawal period, initiands frequently adopt masks (of animals, nature spirits or witches), or go naked, to demonstrate that as liminal beings they have no status, property, insignia, etc. In a similar way, the anorexic mask is what is most obvious to observers: it conceals and protects the developing person within. Anorexia, rather than stripping the body of its clothing, strips the body of its flesh to reveal its essential vulnerability. In recovery, the anorexic mask is discarded and a wider range of personae becomes possible. (d) Also, during this period, the paradoxes created in social relations are exhibited and symbolically challenged. The paradoxes which are ritually challenged by anorexia involve the current social demands for women to be slim yet fertile; submissive yet autonomous; simultaneously mothers and high achievers in the workforce. (e) Dietary taboos are frequently involved. In the case of anorexia, the taboos being followed are those of the society in which she lives. In addition to the reduction in amount of food eaten, particular foods are avoided as "unhealthy" and the interpretation of "unhealthy" varies from decade to decade following the dictates of the discourse on diet [82]. (f) Sexual prohibitions are involved in order to create a condition of "purity" which will enable access to the sacred, in cultures where sexuality implies impurity. In my study two participants (those who did not associate sexuality with the impure) remained sexually active and two (who were married) "tolerated" sexual activity, while none of the others engaged in sexual relationships. This strongly suggests that social rather than uniquely hormonal factors are involved and that there is a reciprocal connection between them. (g) Initiation rites often involve status reversals in which the initiands, especially when they are young, "mobilize affect-loaded symbols of great power" to test their strength in relation to superiors, particularly parents. The anorexic refusal to eat is

such an "affect-loaded symbol" which also acts as a dramatic means of questioning adult authority over that particular individual. When this authority has not been sufficiently tested in adolescence, anorexic behaviour may be the means of challenging the "authority" of dead parents or of other authority figures in that person's life. (h) "Life-crisis liminality", in the Christian tradition, has often been preached as the pathway to salvation. This perspective views life itself as a liminal period before the "reincorporation" of the risen body into eternal life. It is therefore not surprising that in western culture, which is so heavily based on Christian values, asceticism should be chosen for this purpose and (in earlier times) understood as a permanent way of life. Anorexia draws upon this understanding, whereas recovery appears to understand "salvation" to be obtainable during an earthly lifetime.

Ritual self-healing While anorexia and recovery can be thought of as parts of an initiation process, recovery itself may also be seen as a healing ritual. It shares many of the elements of ritual healing found in studies by Glik [83-86] and McGuire [87]. Descriptions of "western" healing rituals occurring in non-medical religious settings (as described in sociological and anthropological studies) offer the closest parallels with the recovery rituals of participants in my study. "Spiritual" interpretations of experience are one possible "sub-universe of reality" or "finite province of meaning" in terms of which individuals organize their world and which make it possible for individuals to interpret or reinterpret their illness [88]. These spiritual meanings are prominent in many of the recovery stories in my study. Even where they are less pronounced, the ritual actions used in recovery strongly resemble processes of ritual healing, drawing on the same "rhetorical structure" including a "resacralization of the individual's past", "changing its meaning in the present" and "healing oppression" (in whatever form it has occurred). Ritual healing, even when performed in the presence of only one or two others, always assumes the presence of a wider community which provides the system of thought within which the healing ritual can be understood

[89]. Participants in my study made use of meditation, art work, music, etc. In ritual healing such processes are often activated by persuasion or suggestion from a healer. For my participants, some form of psychotherapy was often (but not always) an important catalyst. Often the relationship with a therapist, or another important relationship, served as the "community", validating the meanings participants created through other processes, but always within a broader social context which recognizes the value of the therapy and the creative and physical acts which accompany it; for as Csordas

Recovery from anorexia nervosa argues; "a comprehensive account of therapeutic effectiveness must find its locus elsewhere than in the transference activated in dyadic patient-therapist interaction" [89] (pp. 336-337). The work of Jungian therapists Shorter [90] and Woodman [91-93] is particularly helpful in demonstrating how women create their own rituals of initiation and carry them out in solitude. Shorter discusses the stories of five women, encountered in her therapeutic practice, who devised their own forms of ritual initiation into full womanhood. For Shorter: Ritual springs from a deep psychological necessity. This could equally well be called a religious necessity for ritual is a confrontation between an "I am" and a frightening "I am not" .... Ritual is a ceremony enacted with a sacred purpose or intent. Here one is always subject to an overwhelming numinous power capable of destroying or re-creating the individual [90] (p. 45). Shorter stresses the religious nature of self-initiation rituals, their close connection with the body, their inseparability from relationships with others, the way in which they authorize "letting go" of past attachments to embrace more appropriate new ones and the presence of "dark gods". Shorter also points out that while male initiation rituals are replete with death and rebirth imagery, the test for a girl is to discover and relate to a spiritual principle already implanted symbolically in her own body. This is one possible reason why the majority of those who choose an eating disorder as their spiritual path are women. A final contribution she makes to our understanding of the rituals of recovery is that although (as I have shown) recovery is not a linear process, neither is it circular, because "it achieves a centre; the constantly changing, but integrated, self" [90] (pp. 40-52, 79-82).

The body in self-transformation The rituals of anorexia and recovery, like all rituals, involve and transform the body. Each of these rituals is a creative means of self-transformation. Some of the rituals I will be describing took place during the liminal period of emergence from anorexia. Others have become ongoing ways of recreating the self. Participants' stories were full of transformative rituals like painting, music-making, writing, meditation, gardening and, of course, vast alterations in their rituals of eating, with others and alone. The examples I have chosen to illustrate here, however, are bodily rituals of weighing and exercising, in order to show the importance of the body in the processes of recovery. Weighing. Weighing is one of the rituals through which, in the acute phase of anorexia, most "anorectics" remind themselves to be forever vigilant in the control of their bodies. It may involve stepping on the scales many times a day, or it may be a highly sacred moment of revelation, charged with enormous significance and dread. It encapsulates the "instrumental rationality" to which several social theorists

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now ascribe a variety of contemporary mental ills. The way in which this ritual is practised during an anorexic phase is the antithesis of connection with self, others and the natural world; as Victoria, who is still anorexic, reveals: I feel happier when I'm not eating, so when I was pregnant and they had to weigh me, that was a source of great trauma. Especially as when you are pregnant your weight is so much higher than you're anticipating seeing on the scale. So, with this pregnancy, I got sick and dropped down to 5 kilos below my starting weight and I was just delighted with all that because it meant I'd shed all this extra weight. Had a very small premmie baby. I was lucky he lived at all (Victoria). It would be too simple to say that people in recovery give up weighing themselves, although most said they rarely did so. In fact they often still speak in the language of the scales because in western culture weighing oneself, even daily, is thought of as normal, health-promoting behaviour, especially for women. But for those who say they have recovered, at least weight gain does not hold the same terrible meaning as it did as a negative rite. When Kate, for instance, describes her relationship with the scales, it is to exhort herself to gain a little more weight. She says: In some ways, I should just completely and utterly not weigh myself for ten years and just say "I will be whatever I would have been if I hadn't been anorexic". I think 58 (kilos) looks pretty fantastic for me and I'm 56 now. 58 is my real number of the real woman (Kate).

Exercise. Similarly, physical exercise holds a vastly different meaning for recovered participants from that which it held when they were anorexic. Then, it was described as "frantic" and "driven", part of the splitting of body from self and the attempt of the mind to dominate the "profane" body. Now, exercise has acquired a different kind of sacredness as the means of nurturing the whole self. Thus the meaning of rituals of weighing and exercising shift as people move through the process of recovery. In these rituals during recovery there is a sense of participating in time and space rather than desperately seeking to dominate them. In Durkheim's terms, exercise has become part of a positive, rather than a negative cult. Rosalie describes swimming as a sacred time she sets aside, literally to recreate herself: We've got a sizeable pool in the back yard that I like to swim up and down every day. But it is because I love that sense of well-being. I find when I've been fiddling around the house doing all the sorts of things you have to do as a mother and housewife, it's nice to get in there and just swim up and down and leave all the rest of it. It's not just the physical activity in swimming; as well it's the fitness. Doing that actually gives me more energy (Rosalie). Kate's story includes her discovery of the sensual pleasures of surfing and boogie-boarding with her partner. In these experiences she recaptures the fluidity and the feeling of being upheld which are part of the oceanic myth. Jodie, who is aiming for the Olympic bike-racing team, sees a huge difference between the "exercising" of her bulimic years and her

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current "training". While it could be argued that one form of obsession has replaced another, the end is no longer weight-loss and self-denial, but the construction of a strong body through paying careful attention to her physical and emotional needs. Jacqueline, still recovering, describes the difference between her former "iron-willed" exercise patterns and the new discoveries she is making through dance: 1 did a dance workshop recently. We were doing chaotic movement and I was really terrified, thinking I would be self-conscious; but instead, what came out of it was pure joy. I just had such a revelation that I'd been holding back and what was I frightened of?. I was frightened of joy and pleasure (Jacqueline). For Diana, a late development in her recovery has been the adoption of belly-dancing as a means of altering her awareness of her body and her sexuality. She says; I still have big problems with ... things like dance, and lack of physical inhibition ..... What specifically I'm after in belly dancing is the sexual--it's hips. It's the fact that I've got large hips and I want to find out what they're about (Diana). "Finding out what hips are about" is an example of the way in which the imaginary body is involved in the self-transformations of recovery, as I will demonstrate shortly. Yoga. Yoga is also one of the rituals which several participants have discovered as a means of reinventing themselves and their bodies. In yoga the emphasis is on what the body can do, rather than on its outward appearance or as the enemy; an appendage to the self. Yoga is a way of learning about parts of oneself and the feelings associated with them. It is performed in sacred time, outside ordinary everyday activities. It places great stress on the breath as the connection between body and mind; that which enables both to realize soul, just as the imagination is the inspiration for poetic truth which has the capacity to reveal the unconscious. Yoga is still highly disciplined, in the sense that the more frequent and careful the practice, the greater the learning which takes place. But the discipline is that of substantive rather than instrumental rationality; it is about balance and connectedness, not weighing and measuring. It is one of the many ways in which people conceptualize and construct their own recovery; a very different approach from the positivist attempts of clinical studies to pin down the meaning of recovery. Most importantly, the language and practice of yoga create a new imaginary body inseparable from self and the environment. The key to the bodily transformations of recovery and to their social source is, therefore, the imaginary body; the body as it is reconceptualized through practices like swimming, dance and yoga and the language which accompanies them. Much recent theory of the body has been concerned with the ways in which our bodies are controlled, marked, and "inscribed" by the operations of power upon them

(as objects) and the ways (as subjects) they resist power. This approach has tended to regard anorexia itself as a form of unconscious bodily resistance to power. I am interested in how we also "resist" this social inscription through recovering from anorexia; in the means by which people teach themselves to experience and use their bodies with conscious self-direction in life-enhancing ways. Iris Marion Young has argued that Women in sexist society are physically handicapped. Insofar as we learn to live out our existence in accordance with the definition that patriarchal culture assigns to us, we are physically inhibited, confined, positioned, and objectified. As lived bodies, we are not open and unambiguous transcendences which move out to master a world that belongs to us, a world constituted by our own intentions and projections [94]. I am suggesting that recovery from anorexia nervosa, itself sometimes regarded as a metaphor for the social condition of women, involves the development of greater openness and more "moving out" into a world we increasingly constitute for ourselves and I have also shown how rituals of self-transformation are utilized in this process. CONCLUSIONS This article has argued that anorexia and recovery can be thought of as "negative" and "positive" parts of the same ritual practices of ongoing initiation into maturity and a consciously fuller way of living, through a symbolic encounter with death. To apply the concept of "ritual" to the practices of anorexia and recovery is to open up new possibilities for understanding recovery in general (from addictions, "risk-taking behaviour", some forms of depression and attempted suicide); understandings which go beyond currently available interpretations of these practices. Many of the sociological problems which "anorexia" presents converge in the question of continuity or discontinuity between medieval and contemporary self-starvation. In particular, the question of whether to remain anorexic is to choose a distorted form of spirituality. A focus on recovery within a Durkheimian framework suggests a solution to these problems. If voluntary fasting is the initial stage in an existential confrontation with death, and recovery is the denouement and integration of this confrontation, then both medieval and modern fasting are important individual and social rituals brought on by encounters with mortality. Each era, however, has placed a different interpretation upon such fasting. While medieval fasting served as a respected form of symbolic social suffering, contemporary anorexia is regarded as a medical and psychiatric phenomenon. For this reason, the more socially valuable rituals today are the rituals of recovery, and stories of recovery therefore need to be made more widely known. Understanding the

Recovery from anorexia nervosa recovery process adds to our knowledge about anorexia nervosa in ways which are impossible when the focus remains upon aetiology. The most valuable theories concerning eating disorders are those which articulate the meaning, not of the problem, but of its resolution.

Acknowledgements--This article was written with the assistance of a scholarship from the University of Western Sydney, Nepean, who provided a semester's leave for the completion of the doctoral dissertation from which it is drawn. I would also like to thank Dr Andrew Metcalfe, Associate Professor Ann Daniel, Professor Joel Kovel and anonymous reviewers for their comments on earlier drafts. REFERENCES

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