Saturday, October 29, 2016


Last evening I watched the 2006 Lauren Greenfield film "Thin." Afterwards I read as many of the reviews and comments as I could find online. Virginia Heffernan's New York Times review, which referred to the film as  “One Flew Over the Cuckoo’s Nest” for women, certainly captured my reaction to the movie. I was also taken with the number of women who posted statements expressing gratitude for the treatment they received at this facility. Having practiced psychiatry for forty years and read the critics from Foucault on, I think it is fair to say this kind of polarization is present, not only with regard to inpatient treatments for anorexia, but for all psychiatric treatments. What should one make of such polarized views of a psychiatric treatment?
I think this is a question that has deep historical and philosophical roots.
On the same day that I saw 'Thin' I happened to be reading a wonderful book by Brian Nance, "Turquet de Mayerne as Baroque Physician." I was particularly interested in his description of the change in the relationship between the concepts of sign and symptom that occurred during the nineteenth century. While I was taught in medical school to accept the term sign as referring to objective finds and symptom as referring to subjective experience. In the late 16th and early 17th century, when Turquet de Mayerne was practicing this was not the case. "A signum was something," Nance points out, "indicative of any hidden process or event taking place in the body while a symptoma was produced specifically by a disease [Nance, 2001, 72]." For Turquet de Mayerne signs and symptoms had equivalent epistemological status. For us the data given by  signs clearly trumps the evidence produced by symptoms.
As I see it this shift in the relative epistemological weights of signs and symptoms indicates a shift in the weighting of the knowledge produced by the observations of doctors in relation to the knowledge produced by the experience of patients. This shift has profound implications. It is baked into every encounter between a medical professional and a patient.
Most of the time we take this for granted. The doctor reads the x-ray and the patient accepts the results.
In psychiatry this is more complicated. While a psychiatrist's observations may be called signs, they are not so obviously of greater epistemological value than a patient's observations of his/her inner life. While Freud certainly had no doubts about whose observations were worth more in his consulting room, to their credit, psychoanalysts have made real efforts to level the field.
When one speaks about an inpatient treatment facility for a disorder with manifest and serious issues of self-deception such as anorexia the gap in the value given to what therapists see and what patients say grows.
As I see it, much of the Cuckoo's Nest quality of the treatment portrayed in 'Thin' arises from the acceptance of this distinction between the treatment team's perspective and that of the patients. I have worked in facilities that bear some resemblance to the one portrayed in the film.  I can remember the struggle between wanting to believe that I knew best and accepting what the patient said at face value. The 'sicker' the patient the easier it was to opt for the former and dismiss the patient as 'deluded.'
I think that this is a struggle that is unavoidable in contemporary psychiatry. For individual therapists working with relatively healthy patients it is fairly easily resolved. For people working in institutions, like the one depicted in the film, with sicker patients the pull to doctor-knows-best is and will remain hard to resist.
We can criticize the treatment shown in 'Thin,' but we should not forget that some of what we object to in that treatment is simply baked into our way of offering medical care. And we shouldn't forget all the women who say that they found this treatment helpful. Perhaps some of the empathic capacities of the caregivers managed to break through the cultural grip of our ideas about medical knowledge.