Famished: Eating Disorders and Failed Care in America

by Rebecca J. Lester

When Rebecca Lester was eleven years old—and again when she was eighteen—she almost died from anorexia nervosa. Now both a tenured professor in anthropology and a licensed social worker, she turns her ethnographic and clinical gaze to the world of eating disorders—their history, diagnosis, lived realities, treatment, and place in the American cultural imagination.
 
Famished , the culmination of over two decades of anthropological and clinical work, as well as a lifetime of lived experience, presents a profound rethinking of eating disorders and how to treat them. Through a mix of rich cultural analysis, detailed therapeutic accounts, and raw autobiographical reflections, Famished  helps make sense of why people develop eating disorders, what the process of recovery is like, and why treatments so often fail. It’s also an unsparing condemnation of the tension between profit and care in American healthcare, demonstrating how a system set up to treat a disease may, in fact, perpetuate it. Fierce and vulnerable, critical and hopeful,  Famished  will forever change the way you understand eating disorders and the people who suffer with them.


 

Genres: Nonfiction, Anthropology, School, Psychology, Research, Ethnography, Health

416 pages, Hardcover

First published November 19, 2019

About the author

Rebecca J. Lester is a medical/psychological anthropologist with a research focus on embodiment, intersubjectivity, and cultural practices of self-cultivation.

Reviews

[Liralen · Rating 4 out of 5]

Lester was uniquely qualified to write this book: an anthropologist by training, she survived a vicious eating disorder as a child/teenager...and, over the course of her research to write this book, trained and qualified as an LCSW and worked as a therapist in an eating disorder treatment centre.

This is not a memoir, either of Lester's own experience with anorexia or of her experience working with eating disorder patients (there are short memoir vignettes of her own anorexia, but they are neither the point nor the strongest parts of the book); rather, it tracks the way the medical system (or, more accurately: the health care system) in the United States fails people with eating disorders—by treating illness as a choice, basically, and withdrawing care prematurely because it's working (must not need it anymore!) or because it's not working yet, or fast enough (must not want it enough!).

Let’s say I have an infection of some sort—pneumonia, for instance. I take a low dose of an antibiotic for two weeks, but the pneumonia remains. The treatment has failed (note that we do not say that I have failed antibiotic treatment, which is the language used when eating disorders treatment is unsuccessful). So how would the medical system react to this? The response, generally, would be to increase the dosage or try a different antibiotic. Certainly, it wouldn’t be to just stop medication altogether and then blame me if I remain ill. But this is precisely what happens with eating disorders under the current conditions of managed care. Occasionally, clients who lapse or relapse are moved to a higher level of care, but more often than not the opposite happens: their ability to access any care at all is put in jeopardy. (259)

I'm not sure who the intended audience is here—most likely academics or professionals treating eating disorders or both—but in many ways I think it would be most useful in the hands of people who are making legislation and funding decisions regarding mental health.

In the United States, fewer than one in ten people diagnosed with an eating disorder will access any kind of mental healthcare, and only 35 percent of those individuals will receive necessary specialized treatment. This means that for every 100 people diagnosed with an eating disorder, only 3.5 will get care by someone who specializes in these conditions. (17)

One study found that only 3 percent of the ninety-eight health plans it investigated would fully cover the APA-recommended treatment protocol for anorexia. (17)

We might expect that such a deadly and widespread set of conditions might be the focus of a massive research effort. But research on eating disorders, like treatment, is shockingly underfunded compared to other conditions. National Institute of Mental Health research dollars spent on Alzheimer’s averaged $2.47 per affected individual in 2017. For schizophrenia, the amount was $69. For autism, it was $82. For eating disorders, the average number of research dollars spent per affected individual was only $1.07. (19)

It's a very thorough portrait—told in the context of a single eating disorder treatment centre—and, while perhaps not accessible to lay readers without previous interest, it's a pretty fascinating read (from a triply qualified perspective) for anyone willing to delve into a bit of academic writing.

[Nina Zhao · Rating 5 out of 5]

oh my goodness. words aren’t enough for me to respond to this book, and i took too many notes to summarize. Lester is uniquely and dare i say ideally positioned to write this book. the perspectives offered by her, the clients, and the clinicians in this ethnography are unique, informative, and powerful, and they come together in a way that is such a well-needed addition and gift to this field. from the organization to the contents of the vignettes to the theory, this is an amazing work. i could cry. love.

[Grace Catherine Beckham · Rating 5 out of 5]

This book was incredible. As someone who has experienced life with an eating disorder and nearly got sent to residential treatment, this book was illuminating and confirming in a plethora of ways. Lester really leveraged her position as anthropologist, therapist, and former sufferer/ED survivor to shape the structure and pathos of the book, wading into deep waters while also making it accessible to readers with any level of knowledge/proximity to eating disorders. I learned a lot more about the American healthcare system and what the treatment system looks like on the inside, while also finding myself resonating with some of the clients Lester references, either seeing things I have unlearned or lingering narratives I'm continuing to unlearn. I am personally in recovery *and* in process, and this book was grounding personally as well as academically. I would recommend it to anyone. And I think there are so many connections — "things behind the things" — that can be drawn through the paradigm of faith as well; ways that the longings expressed are not fundamentally about the physical/tangible ends discussed in those conversations/stories... ways that the lies of the eating disorder reveal its hungers as idols in need of toppling at the hand of God.

[nour · Rating 4 out of 5]

Super important and insightful study! Highlights for me were the sections on managed care and how it replicates dynamics of the disorder that it claims to treat. This is a me problem and prob outside the scope of this project but I think it could be pushed a bit more in its “re-imagination” of EDs as I am skeptical of the degree to which we might reconceptualize this issue while remaining within the confines of clinical frameworks. But again really thorough and great, will def be citing it in my lit review.

[Kelsey Crandall · Rating 5 out of 5]

Absolutely fascinating… and infuriating, in light of the realities Lester exposes in this book. Highly recommend, especially for anyone at all interested in caring better for this population!

[Lee Adair · Rating 5 out of 5]

As a person not accustomed to ethnographies, Famished (published November 19, 2019) seemed like a particularly daunting reading choice. However, I was incredibly surprised by the way Lester engages the reader in the topic of eating disorders and treatment structures. Though the style is decidedly academic, it reads like a conversation, almost like a spirited debate. You’re not being talked down at or talked over, which is what some traditional ethnographies feel like. Instead, Lester offers a combination of personal, professional, and critical insights into a system that is frequently overlooked and denigrated by stigma. She examines the intersectional nature of care, illness, and socioeconomic status while also weaving in narratives of actual patients and treatment providers. Most importantly (at least in my opinion), this work makes you feel present in these difficult moments. You, the reader, feel the distinct double binds of patients, feel the pressure, feel the minute highs or distinctive lows. Lester creates a space that highlights the tangle of healthcare and unseen illness and notes its detriment to those most in need of help.
This work is undoubtedly tough, with some of the technical focus on the history of American healthcare initially stalling the pace. But it is necessary to know the history in order to get a better profile of current medical realities, and Lester’s dedication to detail elucidates the consistent failures within the system. I am by no means an expert in medical anthropology, but as a person who has suffered from disordered eating and poor mental health, this ethnography rung unsettlingly true. The book offered me technical language to advocate for myself and reframed the way I addressed my mental health. There were many times Lester was able to put words to feelings I couldn’t explain to anyone else. Her work, at least in my case, was an opportunity to try new approaches to care and better communicate my needs. I’ve been recommending this book to my peers who are interested in healthcare and politics, but I’d really recommend it to anyone who is in the right headspace to face it.
To sum up: yes, it isn’t the most easy or bright summer read, but it is an essential ethnography to consider when investigating the past and current structures in American healthcare. I both liked and needed this book, so I hope that those who need this language, need this context, or need this sense of understanding and frustration, can find this work as well.

[Morgan Parker · Rating 4 out of 5]

Thoughtful, nuanced framing of EDs. Theory heavy at times, but I think it was necessary and enhanced the text. Mind is still thinking a lot about EDs as interpersonal. Also managed care component is infuriating...

4 stars because I would have appreciated more info on demographics of patients at Cedar Grove. Like how do intersections of race, class, gender, sexuality , etc. influence diagnosis/treatment/perception of self and illness? All we are given are age and Dx in the text. From recent literature it's apparent that these identities perpetuate marginalization and think that would've been a good inclusion.

[Marissa · Rating 3 out of 5]

Rounded up from 2.5.
This was pretty technical, and I'm not sure who Lester's intended audience is. She shares accurate and important information about the healthcare system and how it treats those suffering with eating disorders, but not in a terribly lay-person friendly way.

I'd still say it's a good read for those trying to understand the illness and what makes it different from other mental health afflictions as well as why treatment so often fails. The anecdotes of patients and the author herself are compelling and help drive home Lester's points.

[Silly lil goose · Rating 3 out of 5]

3.5/3.6?— the information was insightful and definitely important to read, and I believe every bit played a role in the book. However… it was hard for me to get through and want to even continue. Many parts did not captivate me, and I had to take several breaks to even finish the book. The book was very technical, and it did not leave me wishing for more. Her ethnographic work had my attention but nothing else did.

[Mar Hudson · Rating 5 out of 5]

Famished is a beautiful ethnography, one of very few texts that effectively ventures to criticize the model of recovery imposed on modern American ED patients. People living with eating disorders deserve better, and it’s a big comfort to know that people like Lester are working toward it.

[karen stockwell · Rating 5 out of 5]

added so much depth

As a clinician and as person with lived experience. It provides a lot of validation to limitations on providers and clients, giving words and concepts to things rarely elaborated on

[Bailey Cowen · Rating 4 out of 5]

a really fantastic and important book. Definitely a heavier read and takes a solid academic and anthropological approach to this topic but I think it laid a really solid foundation for my study of this topic and I learned a lot.

[Andreia]

(read for class so no rating)

such an infuriating and frustrating read. the care landscape is damaged beyond reform - it truly needs to be destroyed and rebuilt from the ground up

[Leslie · Rating 5 out of 5]

Necessary read on the policy failures of eating disorder treatment in the states. Great read on the ethical dilemmas providers face with the models we have in the United States for paying for care. I disagree with the author on her views on internal family systems (and some of the controversies behind that model were not addressed.) However, everything else in this book was amazingly insightful and helpful for anyone who has felt frustrated in this broken system.

[Alyssa Murray · Rating 4 out of 5]

this book is necessarily dense, but exceptionally thorough in its examination of how the US healthcare system fails people with eating disorders in their development, treatment, and aftercare through economics, treatment methods, and abandonment. lester's approach to the linguistic treatment of eating disorder patients and the 'looping effects' between how we conceptualize eating disorders and their presentation makes me think differently about how systems and patients are simultaneously at odds and in tandem. this book makes sense of this dialectic if only the reader is willing to put in time to step into the vignettes lester puts on the page.