Keywords

1 Introduction

Eating disorders are a potentially fruitful area of study for understanding the links between values—in particular cultural values—and mental distress and disorder. Eating disorders show widely different prevalence rates across cultures, and much attention has been given to theories linking these differences with variations in cultural values. In particular, the cultural value placed on ‘fashionable slimness’ in the industrialised world has for some time been identified with the greater prevalence of eating disorders among women in Western societies [1]. Consistently with this view, the growing prevalence of eating disorders in other parts of the world does seem to be correlated with increasing industrialisation [2, 3]. In my review of cultural distribution and historical evolution of eating disorders , I was so struck by its protean nature and its variability of clinical presentations of anorexia nervosa that I renamed this predicament ‘anorexia multiforme’ [4, 5].

The story of Antonella that follows illustrates the potential importance of contemporary theories linking cultural values with eating disorders though also some of their limitations.

2 Case Narrative: Antonella’s Story

Ottawa in the early 1990s. Antonella Trevisan, a 24-year-old woman, was referred to me by an Italian psychiatrist and family therapist, Dr. Claudio Angelo, who had treated her in Italy [6]. When Antonella came to Canada to live with a man she had met through her work, Dr. Angelo referred her to me. Antonella’s presenting problems concerned two areas of her life: her eating problems, which emerged after her emigration from Italy, and her relationship with her partner in Canada.

2.1 Antonella’s Predicament

My initial psychiatric consultation (conducted in Italian) revealed the complexities of Antonella’s life. This was reflected in the difficulty of making an accurate diagnosis. Her food-related problems had some features of eating disorders , such as restriction of intake, the resulting weight loss, and a history of weight gain and being teased for it. What was missing was the ‘psychological engine’ of an eating disorder: a drive for thinness or a morbid fear of fatness. Her problem was perhaps better understood as a food-related anxiety arising from a ‘globus’ sensation (lump in the throat) and a learned avoidance response that generalized from one specific situation to eating in any context.

Although it was clear that her weight gain in late adolescence and the teasing and insults from her mother had sensitized her, other factors had to be considered. Antonella showed an exquisite rejection sensitivity that both arose from and was a metaphor for the circumstances of her birth and adoption. Her migration to Canada also seemed to generate anxieties and uncertainties, and there were hints of conflicts with her partner. Was she also re-enacting another, earlier trauma? In the first journey of her life, she was given up by her birth mother (or taken away?) and left on the steps of a foundry. In the first year of her life, Antonella had shown failure to thrive and developmental delays. And she had, at best, an insecure attachment to her adoptive family, predisposing her to lifelong insecurities.

2.2 A Therapeutic Buffet

After my assessment, we faced a choice: whether to treat the eating problem concretely, in purely behavioral terms, or more metaphorically, with some form of psychotherapy. Given the stabilization of her eating pattern and her weight and the larger context of her predicament, we negotiated to do psychotherapy. There were several components to her therapy. Starting with a psychiatric consultation, three types of therapy were negotiated, with Antonella sampling a kind of ‘therapeutic buffet’ over a period of some 2 years: individual therapy for Antonella, couple therapy for Antonella and Rick, and brief family therapy with Antonella’s adoptive family visiting from Italy.

The individual work with Antonella was at first exploratory, getting to know the complex bicultural world of the Italian Alps, how she experienced the move to Canada, examining her choices to move here and live with Rick. Sessions were conducted in a mix of Italian and English. At first, the Italian language was like a ‘transitional object’ in her acculturation process; slowly, as she gained confidence in her daily life, English began to dominate her sessions. Under stress, however, she would revert to Italian. I could follow her progress just by noting the balance of Italian and English in each session. This does not imply any superiority of English or language preferences; rather, it acknowledges the social realities of culture making its demands felt even in private encounters. This is the territory of sociolinguistics [7, 8]. Like Italian, these individual sessions were a secure home base to which Antonella returned during times of stress or between other attempts to find solutions.

After some months in Canada and the stabilization of her eating problems, Antonella became more invested in examining her relationship to Rick. They had met through work while she was still in Italy. After communicating on the telephone, she daringly took him up on an offer to visit. During her holiday in Canada, a romance developed. After her return to Italy, Antonella made the extraordinary decision to emigrate, giving up an excellent position in industry, leaving her family for a country she did not know well. Rick is 22 years her senior and was only recently separated from his first wife.

In therapy she not only expressed ambivalence about her situation with Rick but enacted it. She asked for couple sessions to discuss some difficulties in their relationship. Beyond collecting basic information, couple sessions were unproductive. While Rick was frank about his physical attraction to her and his desire to have children, Antonella talked about their relationship in an oddly detached way. She could not quite articulate her concerns. As we got closer to examining the problems of their relationship, Antonella abruptly announced that they were planning their wedding. The conjoint sessions were put on hold as they dealt with the wedding arrangements.

Her parents did not approve of the marriage and boycotted the wedding. Her paternal aunt, however, agreed to come to Canada for the wedding. Since I was regarded by Antonella as part of her extended family support system, she brought her aunt to meet me. It gave me another view of Antonella’s family. Her aunt was warm and supportive of Antonella, trying to smooth over the family differences. A few months later, at Christmas time, her parents and sister visited, and Antonella brought them to meet me. To understand these family meetings, however, it is necessary to know Antonella’s early history.

2.3 A Foundling Child

Antonella was a foundling child. Abandoned on the steps of a foundry in Turin as a newborn, she was the subject of an investigation into the private medical clinics of Turin. This revealed that the staff of the clinic where she was born was ‘paid off to hide the circumstances of my birth.’ As a result, her date of birth could only be presumed because the clinic staff destroyed her birth records. She was taken into care by the state and, as her origins could not be established, she was put up for adoption.

Antonella has always tried to fill in this void of information with meaning that she draws from her own body. She questions me closely: ‘Just look at me. Don’t you think I look like a Japanese?’ She feels that her skin tone is different from other Italians, that her facial features and eyes have an ‘Asian’ cast. With a few, limited facts, and some speculation, she has constructed a personal myth: that she is the daughter of an Italian mother from a wealthy family (hence her hidden birth in a private clinic) and a Japanese father (hence her ‘Asian’ features). It is oddly reassuring to her, but also perhaps a source of her alienation from her family.

At about 6 months of age, Antonella was adopted into a family in the Italian Alps, near the border with Austria. This is a bicultural region where both Italian and German are spoken and services are available in both languages (much like Ottawa, which is bilingually English and French). Her father, Aldo, who is Italian, is a retired FIAT factory worker. Annalise, her mother, who is a homemaker, had an Italian father and an Austrian mother. About her family she said, ‘I had a wonderful childhood compared to what came afterwards.’ Years after her adoption, her parents had a natural child, Oriana, who is 15.

She describes her mother as the disciplinarian at home. Her mother, she said, was ‘tough, German.’ When she visited her Austrian grandmother, no playing was allowed in that strict home. Her own mother allowed her ‘no friends in the house,’ but her father ‘was my pal when I was a kid.’ Although she had a good relationship with her father, he became ‘colder’ when she turned 13. Her parents’ relationship is remembered as cordial, but she later learned that they had many marital problems. Mother told her that she married to get away from home, but in fact she was in love with someone else. Overall, the feeling is of a rigid family organization. Her father is clearly presented by Antonella as warmer and more sociable. She experiences her mother as being ‘tough’. But she is crying all the time, feeling betrayed by everybody.

2.4 A Family Visit from the Italian Alps

When her family finally came to visit, Antonella brought them to see me. At first, the session had the quality of a student introducing out-of-town parents to her college teacher. They were pleased that I spoke Italian and knew Dr. Angelo, who they trusted. I soon found that the Trevisans were hungry to tell their story. Instead of a social exchange of pleasantries, this meeting turned into the first session of an impromptu course of brief family therapy.

Present were Antonella’s parents, Aldo and Annalise, and her sister, Oriana. Annalise led the conversation. Relegating Aldo to a support role. Oriana alternated between disdain and agitation, punctuated by bored indifference. Annalise had much to complain about: her own troubled childhood, her sense of betrayal and abandonment, heightened by Antonella’s departure from the family and from Italy. I was struck by the parallel themes of abandonment in mother and daughter. Mother clearly needed to tell this story, so I tried to set the stage for the family to hear her, what narrative therapists call ‘recruiting an audience’ [9]. I used Antonella, who I knew best, as a barometer of the progress of the session, and by that indicator, believed it had gone well.

When I saw them again some 10 days later, I was stunned by the turn of events. Oriana had assaulted her parents. The father had bandages over his face and the mother had covered her bruises with heavy make-up and dark glasses. Annalise was very upset about Oriana, who was defiant and aggressive at home. For her part, Oriana defended herself by saying she had been provoked and hit by her mother. Worried by this dangerous escalation, I tried to open some space for a healthy standoff and renegotiation.

Somehow, the concern had shifted away from Antonella to Oriana. Antonella was off the hook, but I waited for an opening to deal with this. I first tried to explore the cultural attitudes to adolescence in Italy by asking how the Italian and the German subcultures in their area understood teenagers differently. What were Oriana’s concerns? Had they seen this outburst coming? The whole family participated in a kind of sociological overview of Italian adolescence, with me as their grateful audience. The parents demonstrated keen insight and empathy. Concerned about Oriana’s experience of the session, I made a concerted effort to draw her into it. Eventually, the tone of the session lightened. Knowing they would return to Italy soon, I explored whether they had considered family work. Since they had met a few times with Dr. Angelo over Antonella’s eating problems, they were comfortable seeing Dr. Angelo as a family to find ways to understand Oriana and her concerns and for Oriana to explore other, nonviolent ways to be heard in the family. I agreed to meet them again before their departure and to communicate with Dr. Angelo about their wishes. On their way out, I wondered aloud about the apparent switch in their focus from Antonella to Oriana. The parents reassured me that they were ready to let Antonella live her own life now.

When they returned to say goodbye, we had a brief session. Oriana and Antonella were oddly buoyant and at ease. The parents were relieved. Antonella had offered the possibility of Oriana returning to spend the summer in Canada with her. I tried to connect this back to the previous session, wondering how much the two sisters supported each other. I was delighted, I said emphatically, by the family’s apparent approval of Antonella’s marriage to Rick. It was striking that, even from a distance of thousands of miles away, Antonella was still a part of the Trevisan family. And Rick was still not in the room.

3 Discussion

In this section, I will consider the impact of cultural and other values on Antonella and those around her and then look briefly at the wider implications of her story for our understanding not only of eating disorders but of mental distress and disorders in general.

3.1 Antonella: Life Before Man

The key to understanding Antonella’s attachments was her passion for her Siberian huskies. In the language of values-based practice , it was above all her huskies that mattered or were important to her. And it is not hard to see why. From the beginning of her relationship with Rick, she used her interest in dogs as a way for them to be more socially active as a couple, getting them out of the house to go to dog shows, for example. As her interests expanded, she wanted to buy bitches for breeding and to set up a kennel. Rick was only reluctantly supportive in this. Nonetheless, they ended up buying a home in the country where she could establish a kennel. Her haggling with Rick over the dogs was quite instrumental on her part, representing her own choices and interests and a test of the extent to which Rick would support her.

Yet the importance to Antonella of her huskies rests I believe on deeper cultural factors, both negative and positive. As to negative factors , these are evident in the fact that from the first days of her life, Antonella was rejected by her birth parents, literally abandoned and exposed, and later adopted by what she experienced as a non-nurturing family. Positive cultural factors , on the other hand, are evident in the way that having thrown her net wider afield, she looked initially to Canada, and to Rick, for nurturance and for identity. Then, finding herself only partly satisfied, she turned to the nonhuman world for the constancy of affection she could not find with people. Her huskies gave her pleasure, a task, and an identity. She spent many sessions discussing their progress, showing me pictures of her dogs and their awards. As it happened, my secretary at the time was also a dog lover who raised Samoyed dogs (related to huskies) and the two of them exchanged stories of dog lore.

As to positive factors , again, is there something, too, in the mythology of Canada that helps us understand Antonella? Does Canada still hold a place in the European imagination as a ‘New World’ for radical departures and identity makeovers? Or does Canada specifically represent the ‘malevolent North,’ as Margaret Atwood [10] calls it in her exploration of Canadian fiction? Huskies are a Northern animal, close to the wolf in their origins and habits. Bypassing the human world, Antonella finds her identity within a new world through its animals. If people have failed her, then she will leave not only her own tribe (Italy), but skip the identification with Canada’s Native peoples, responding to the ‘call of the wild’ to identify with a ‘life before man’ (to use another of Atwood’s evocative phrases, [11]), finding companionship and solace with her dogs.

3.2 Wider Implications of Antonella’s Story

Antonella may seem on first inspection something of an outlier to the human tribe. Orphaned from her culture of origin, she finds her place not in another country but by identification with another and altogether wilder species, her husky dogs. Yet, understood through the lens of values-based practice Antonella’s story has, I believe, wider significance at a number of levels.

First, Antonella’s story is significant for our understanding of the role of values – of what is important or matters to the individual concerned – in the presentation and treatment of eating disorders , and, by extension, of perhaps many other forms of mental distress and disorder. Specifically, her story provides at least one clear ‘proof of principle’ example supporting the role of cultural values.

As noted in my introduction, much attention has been given in the literature to the correlations between the uneven geographical distribution of eating disorders and cultural values. Correlations are of course no proof of causation. But in Antonella’s story at least the role of cultural values seems clearly evident. They were key to understanding her presenting problems. And this understanding in turn proved to be key to the cultural family therapy [12] through which these problems were, at least to the extent of her presenting eating disorder, resolved.

The cultural values involved, it is true, were not those of fashionable slimness so widely discussed in the literature. But this takes us to a second level at which Antonella’s story has wider significance. For it shows that to the extent that cultural values are important in eating disorders , their importance plays out at the level of individually unique persons. In this sense, social stresses and cultural values are played out in the body of the individual suffering with an eating disorder, making her body the ‘final frontier’ of psychiatric phenomenology [13]. Yes, there are no doubt valid cultural generalisations to be made about eating disorders and mental disorders of other kinds. And yes, these generalisations no doubt include generalisations about cultural values—about things that matter or are important to this or that group of people as a whole. Yet, this does not mean that we can ignore the values of the particular individual concerned. It has been truly said in values-based practice that as to their values, everyone is an ‘n of 1’ [14]. Antonella, then, in the very idiosyncrasies of her story, reminds us of the idiosyncrasies of the stories of each and every one of us, whatever the culture or cultures to which we belong.

Antonella’s identification with animals , furthermore, to come to yet another level at which her story has wider significance, was a strongly positive factor in her recovery. As with other areas of mental health, it is with the negative impact of cultural values that the literature has been largely concerned: the pathogenetic influences of cultural values of slimness being a case in point in respect of eating disorders . Antonella’s story illustrates what has been clear for some time in the ‘recovery movement’, that positive values are often the very key to recovery. Not only that, but as Antonella’s passion for her husky dogs illustrates, the particular positive values concerned may, and importantly often are, individually unique.

Not, it is worth adding finally, that Antonella’s values were in this respect entirely unprecedented. Animals , after all, are widely valued, positively and negatively, and for many different reasons, in many cultures [11]. Their healing powers are indeed acknowledged. Just how far these powers depend on the kind of cross-species identification shown by Antonella, remains a matter for speculation. But, again, her story even in this respect is far from unique. Elsewhere, I have described the story of a white boy with what has become known as the ‘Grey Owl Syndrome’ , wishing to be native [12, chapter 5]. Similarly, in Bear, Canadian novelist Marion Engel [15] portrays Lou, a woman who lives in the wilderness and befriends a bear. Lou seeks her identity from him: ‘Bear, make me comfortable in the world at last. Give me your skin’ [15, p. 106]. After some time with the bear, the woman changes: ‘What had passed to her from him she did not know…. She felt not that she was at last human, but that she was at last clean’ [15, p. 137]. It was perhaps to some similarly partial resolution that Antonella came.

4 Conclusions

Antonella’s story as set out above goes to the heart of the importance of cultural values in mental health. Her presenting eating disorder develops when, displaced from her culture of origin in Italy, and in effect rejected by her birth family, she finds healing only through cross-species identification with the wildness of husky dogs in her adoptive country of Canada. Although somewhat unusual in its specifics, her story illustrates the importance of cultural values at a number of levels in the presentation and management of eating and other forms of mental distress disorder.

And Antonella? I met her again in a gallery in Ottawa, rummaging through old prints. She was asking about prints of dogs; I was looking for old prints of Brazil where my father had made a second life. How was she, I asked? ‘Well …,’ she said hesitantly. Was that a healthy ‘well’ or the start of an explanation? ‘Me and Rick are splitting up,’ she said without ceremony, ‘but I still have the huskies.’ For each of us, the prints represented another world of connections.