Why It’s a Problem That Healthcare Is So Drab

In the first part of this series, we thought about the ways in which care can become unintentionally disempowering. Another angle on this that I’d like to introduce in this part of the series is one that my chat with anthropologist Neil Armstrong alerted me to: the fact that care can easily become terribly boring.

In bureaucratized health-care settings, “drab and beige is the answer to everything,” as he put it. He remarked, too, that “being mad is interesting,” and that this is another reason why care can fail: because not everyone wants to swap interesting for dull, even if dull is supposedly safer or otherwise better.

This made me wonder how interesting or otherwise the “madness” of an eating disorder is. If I compare it with what I know (not firsthand) about bipolar disorder, for example, or schizophrenia, anorexia seems the epitome of drab—and worse, the kind of drab that’s great at disguising its danger. Perhaps bulimia has a bit more excitement in it; the sating of the “hedonic hunger” (Witt & Lowe, 2014; Parker et al., 2021) has sharper contours than in anorexia. But all eating disorders get very samey pretty quickly.

Then again, modern life may, for many people, have a structure of low-risk monotony that leads to the kind of boredom that we alleviate with confected risks, some of which get called recreational, some pathological. Someone who starves themselves or binges and purges or gets addicted to psychoactive substances—or even spends too much time compulsively engaging in a "healthy" activity, like running—may do so in the desire to create some sort of neurotransmitter-mediated narcotic spike, a flash of risky pleasure in a world that’s always pushing us towards colourlessness.

And of course, this is not just a world where everything comes with insurance and everything looks more and more safely similar; it’s also one where real but almost completely uncontrollable dangers (wars, political or economic catastrophes, natural disasters, climate change) seem ever greater. If the everyday is too vanilla and the bigger picture feels terrifying, maybe there’s a tempting sweet spot in the kinds of private risk that feel (initially at least) controllable without being bland. If this has been your intuitive calculus, a nutritionist telling you to eat what they’ve calculated with the help of an “energy-density value food chart” (Yang et al., 2021, p. 7) may not quite cut it.

Most of these problematic habits start innocuous and slowly or swiftly become less so. From what I’ve observed of people who exercise too much, for instance, their habits often ramp up particularly quickly and get particularly ingrained; the evolutions of dietary restriction and excesses seem more variable. All of them may have a particular appeal for those of us who naturally incline towards high conscientiousness.

For myself, one of the early hooks was how light and untouchable an experience of accidentally extended hunger made me feel. And by the end, ten years later, the most hateful thing about contemplating recovery was the horror of giving up the radical contrast between daytime hunger and the nighttime sating of it for the gentle undulations of normal meals and appetites. There hadn’t been any hunger high for years; hunger grind was omnipresent. But that still felt preferable to the in-between of never-very-hungry and never-very-ecstatically-sated.

Even if you don’t experience much hedonic reward in your eating disorder, the prospect of exchanging riskier drab for safer drab isn’t necessarily much of an incentive. Many humans care less about safety than we’re supposed to. So perhaps one problem with current methods of health-care (especially “mental” health-care) is the sheer tedium of institutional care: the sensible pastel-coloured information sheets, the facts and figures that are meant to be motivating, the rating scales with their uninspiring normal ranges, and with eating disorders all the weighing and measuring that sometimes seems more aligned with the fixations of the disorder itself than with anything that feels like freedom.

What links all this with agency and the accidentally coercive aspects of a certain kind of care? Well, in our encounters with well-meaning drabness and earnest caregiving, sometimes we may find arising in ourselves a sort of teenage truculence, a pushing-back almost for the sake of it. We might find ourselves overcome by a sense of absurdity, a wave of “Why does it even matter whether or not I keep doing this thing you’re telling me is awfully bad for me?”

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Perhaps there’s even a sense that if I’m going to relinquish my agency to anything, I’d rather it be this narcotically spiky behaviour I’ve found for myself than the sensible doctor or nurse who thinks I need them. If there’s going to be any helplessness, maybe I’d rather it be in the form of a voluntary-feeling surrender to a substance or a behaviour than a coerced-feeling capitulation to “the system.”

The connections with behaviour and identity (the other two factors that in part 1 I suggested are crucial to successful recovery) are clear here too. The egosyntonic (self-image-consistent) strands of an eating disorder have an easier time snaking their way into our minds and lives when the alternatives seem in glaring ways not designed for us. And the behavioural side of things can then easily be reduced to a repetition of the rituals of illness that—even though they grow rapidly stale, even though the habituation effects mean you need more and more of them to get even a ghost of the old high—are at least in some sense yours.

Thus, the discovery, through personally designed actions, of who one is and can be in the absence of this reactive coping mechanism is blocked. The liberation of the spacious middle ground in which one is neither starving nor gorging oneself on easily digestible sugar is never reached nor believed in.

Maybe some of this is in play when inpatient, daypatient, and outpatient treatments for eating disorders fail to do what they’re meant to—or when they look like they’ve succeeded only for rapid relapse to happen (Troscianko & Leon, 2020) once the individual is out again in the big complicated potentially colourful world where no one is telling them what to do anymore.

In the next part of the series, I’ll suggest some ways out of the impasse for eating disorder treatment.

**I’m grateful to James Carney for inspiring thoughts about the “narcotic spike”, the “flash of significance”, and “adolescent truculence”.