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My First Hospital VisitZenobia
Chan RN PhD candidate
Department of Social Work
The Chinese University
of Hong Kong
9 April 2002 Abstract
This paper reports the findings of the first interview with an aged 14 anorectic
girl in the child psychiatric unit in Hong Kong. Several themes have been discerned:
(1) "I feel I am often monitored"; (2) the girl and Foucault; (3) I
am "AN"? I have my own name; and (4) "How can I have a big belly?
It's so ugly!" The paper closes by pointing that anorexia nervosa remains
an enigma in Chinese context and by suggesting more qualitative research should
be encouraged. My
first hospital visit The following narratives are commonly found
in Hong Kong. Mother: "Look, don't go on a diet
like others. If you become as slender as a skeleton, how terrible you will look!"
Rose, Manager Zhou's secretary: "I can see that film star X has acquired
AN as a result of going on a diet. Look at her tall and slim body…"
Doctor: "Nurse, take good care of that "AN". Be sure that
she doesn't have any food left."
Nurse: "Let's see how much
weight you have gained this week. Oh no, you should eat everything up. You have
anorexia nervosa, so you must eat and eat…" In recent
years, women all over the world pursue slim bodies, and as a result, it is generally
believed that going on a diet leads to anorexia nervosa (AN) (Alma, 1997; Bell,
1985). Hospitals mechanically force patients to eat. I have been in contact with
many patients and their families recently and have found that health professionals
do not have a full understanding of the disease and therefore cannot provide pertinent
care to these patients. At the same time, the misunderstanding and despise over
the patients from the society leave no room for the patients themselves in the
society. People will be astonished to hear the voices of AN patients. Why does
everyone, from scholars to popular TV programs, almost believe that going on a
diet will cause this eating disorder? And why do they claim that they should believe
in the so-called "proof" since we are now in the 21st century? I
who is a registered nurse and doctorate student interviewed a 14-year-old girl
with anorexia nervosa (AN) in an in-patient setting. She made me have a new understanding
of the disease. I hope that my personal experience will bring new ideas to the
readers in Chinese society so that we can re-evaluate the term of AN and do not
look down upon these patients or put social bondage around them. That was
a rainy afternoon. A dilapidated yet populous hospital. The white walls against
the dusty lights were more depressing than the thick clouds outside. I finally
found the ward of the little girl. She has a beautiful name that I will not disclose
publicly here. On seeing her, I said, "Hello, my surname is Chan. Can I have
a chat with you?" She replied, "Sure". "I
feel I am often monitored"
She was very calm, with a long
hair, oval face and big eyes. She gave me the impression that she was full of
art. She possessed a noble quality although she only had on a cotton coat and
patient's garments. We were sitting in a room in the hospital where you could
visit and talk with patients or hold meetings. At the time, the girl's parents
had not arrived yet, and thus I began a talk with this girl first who had AN and
needed to be hospitalized. However, during the 2-hour-talk, I never addressed
her as "an anorectic patient" or "acquired AN" because in
my heart, AN is not a good term. It would pathologize the girl and bind her with
social bondage. Therefore I just told her that her body was perhaps a little slim
compared with others. I told her that I would not call her the anorexic.
I said, "Please sit down, little sister." She was very friendly.
I asked, "Do you know why you are hospitalized?" She paused a
while and said, "I went to see a private doctor and he recommended me here.
I was slim, so I had to stay in the hospital." I replied, "Do
you know what your problem is?" She told with a puzzle look, "I
don't think I have any problem. But they said I was slim and had to stay in the
hospital." I pointed to her again, "Mm. I'd like to know very
much whether the nurses and doctors treat you well here." The girl
replied in a low tone with a long face, "They? They treat me very well. But
I feel sad because they force me to eat things every day. They will watch me eat
them and tell me that I must eat this and that, and I have to meet the nutritionist.
In all, everything is centered on eating. I feel I am often monitored." The
Little Girl and Foucault
On hearing this, I could not help thinking:
Mm, monitoring, Mm, the same as what Foucault said. Foucault was a philosopher
and a historian. He believed that human beings are controlled by power and monitored
by others (Foucault, 1977; 1990). Our bodies are uncontrollable. The little girl
said that she seemed to be monitored, and this reminded me of Foucault's thought.
In fact, monitoring exists everywhere. Some say that hospitals are asking the
patients to do things according to social standards and therefore can make them
rationalized. The little girl emphasized in particular that she did not have any
freedom in the hospital. The girl said, "I am not happy
here. I really want to go home." I said, "But, you are a bit too
weak now. Do you know that?" She sighed, "I also know this. I
know that I am much slimmer." I uttered in a sympathetic voice, "Then,
do you miss home?" The girl answered, "Of course, I miss my father,
mother and my younger sister. I really want to go home, but I cannot see my family
now." The little girl gave me the impression that family
is an important part of her life. But then I thought, family is so important to
her, could her family play a role in making her acquire AN? Or, is AN affecting
her family? From the point of view of family treatment, it is not in a linear
causality. Everything is affected mutually. For example, the family relations
may cause AN, and at the same time, we can also say that this anorectic symptom
may cause many problems in the family. To explain it further, if the marriage
and family relations have problems, the girl could have AN; and vice versa, if
the girl has AN, her parents may have problems coping with each other. Of course,
this is my imagination. I cannot make a blind judgement. This is the spirit of
family systems theory. We must make the clients tell their stories frankly, and
we must listen patiently and interpret their stories carefully. We should not
behave like an expert when meeting with clients or their families or think out
reasons 1, 2, 3 and put forward methods 1, 2, 3 for them. We must know that each
family has its uniqueness. Every family has its own story. We can possibly know
one aspect of it, but many other aspects are left waiting to be disclosed. I
am "AN"? I have my own name!
The little girl is very
special. When I asked her about her hobbies, she told me that she liked to play
the piano and listen to popular songs. In fact, she did not look like one having
some psychiatric diseases or one kind of the so-called mental illnesses. She is
perfectly normal. She looked the same as other young people except that she was
a bit slim. Oh no, she was a little different. She was more mature and profound.
I am not trying to say that AN is a disease of a model child. Neither am I trying
to disguise it as a disease of "a good girl". Nor am I saying that only
excellent people will have this disease. But these are my strong feelings after
all. When I was having the talk with her, She said, "Sister,
you are very different from other people because you don't call me AN patient.
You only say I am a bit slim. I think you really understand me. When other people
call me an AN patient, I feel disgusted: What? Why? I am 'AN?' I have my own name!
Does it mean I hate eating? I don't hate eating. I just don't feel like eating
and I eat a little less. That's all. What wrong have I done?"
I agree with the little girl. She has not done anything wrong. Nor does she have
psychiatric disease. It is a pity that under the present medical treatment system,
patients will be sent to psychiatric department when they are diagnosed AN, i.e.,
their body weight is 15% or more less than normal. Psychiatric Department is not
a "good place", nor is it a "good name". Once you are sent
to psychiatric department, you will be seen as spiritually abnormal or have something
wrong with your mind. The little girl has the same feeling. I then further thought,
is hospitalization a good solution? Do we have other solutions other than hospitalization?
We probably do not have an answer right now. In Hong Kong today, this is the popular
way to treat AN patients. When the girl talked to me, she was very fluent.
On being asked about her grades at school, she said that she always had good grades
at school. She liked her younger sister the best, and she also liked her parents.
But when I asked her how well her father knew her, she said about 50%. And your
mother? About 80%. I then asked, "how well do you think I know you?"
She said 90%. I hoaxed her by asking whether she was flattering me. She said absolutely
not. It is important that I really understand her and understand her ideas on
AN - she never regarded herself as AN. Her words gave me a lot of inspiration:
the society gave the term to them, and at the same time also gave them a lot of
pressure. We gave a certain name to the patients so that it is more convenient
for us to look through their files. Or to put it more beautifully, to offer a
treatment model. The patients are controlled in our hands and we can thus further
deal with their "symptoms". The girl's words reflect her helplessness.
She did not like the place in the hospital. Her only impression here was to be
fed, fed, and fed. In fact, if she is willing to eat things and becomes plump,
she will not have AN. If she gets plump by force in the hospital, what will happen
to her after she leaves for home? Does the key lie in eating? Can eating
solve the problem of AN? What are the causes of her AN if she does not have biological
diseases such as severe chronic diseases, lung diseases or cancer? Is it because
she has problems getting along with her family? Why should we always ask: Have
you eaten all your nutritious meals? Have you drunk up the milk? Have you had
enough? Why don't you gain on weight? Mm, you have gained a pound. Good, but our
aim for this week is 2 pounds, and next week 2 more pounds. What kind of method
is this? What kind of action? I cannot tell. From the point of view of a social
worker, we will put human beings at the basis and will look at personal needs
and the relationship between man and his environment. Man has a very close relationship
with his families. We are closely related and mutually dependent. What has happened
in the family will make her unwilling to eat as a way of chronic suicide. She
will let her mechanism collapse slowly, regarding as a childish game to attract
others' attention or as a weapon to threaten others or obtain some power to satisfy
the patient's own needs.
How can I have a
big belly? It's so ugly!
AN will cause malnutrition, make your
heart atrophy, and tardy your thought (American Psychological Association, 1993).
It can also cause loose bone structures, therefore people with AN are more eligible
to bone fracture and the deterioration of mechanism (Amara & Cerrato, 1996).
I noticed some hair on the girl's arms. As described in some documents, people
with AN will grow hair and their faces will become pale (Apostolodes, 1998). I
also noticed that her skin was as dry as a tree trunk and she was very bony. I
was afraid that she would have a bone fracture immediately if she fell onto the
ground. I also thought, would she feel uncomfortable to sit since she had such
a think skin and almost no muscle? In fact, she looked as if her whole body was
crying helplessly, as if she were being tortured, not by others, but by itself,
i.e., the soul of the body. The girl maltreated herself by refusing to eat. What
after all has made her do so? What miseries did she have? What motives? Out of
curiosity, I could not help asking her, "Sister, what makes you most unhappy?"
I knew she could not give me an answer if I asked her why she acquired this disease.
Therefore I simply asked her what has made her most miserable in her life. Suddenly
tears ran out of her eyes: "My pet died."
"When
did it die?" I handed her a napkin.
"About half a year ago. I was
very sad after it died. I missed it very much."
"Then when did you
feel not like eating?"
"Soon after it died."
"You
are fed up with eating now. How much do you think this accounts for the reason?"
"About 20%. I didn't feel like eating because it died." She said so
while wiping away her tears.
"You said that about 20% of the reason is
because your pet died. What are the other reasons?"
"I am afraid
of growing a big belly. I will not look pretty if I have a belly. I don't want
to have one."
"Oh, so that's the reason. But I can see you are very
slim. You are about 5 feet tall, but you are only 60 pounds. How can you grow
a big belly?" I felt that her worries were out of place.
"I don't
have one now, but I am afraid that I will have one if I become plump." Speaking
of belly, she stopped crying.
"Why are you so afraid of big bellies?
Do you think you are pretty if you are as thin as a skeleton?"
"I
don't mind if my hands and legs are a bit thin. But I cannot have a big belly.
How ugly I will look if I have one! You know, many popular dresses today are vests
or trousers with a hole in the belly button area. How can I wear such dresses
if I have a big belly?"
"Can you tell me what influences a big belly
can bring you?"
"I just feel it is ugly." She insisted. "My
classmates all like to be slim. All the popular stars I like the best are very
slim. So I won't feel happy if I have a belly."
"Mm. Did you try
to lose weight before by doing physical exercises?"
"Yes, I did."
"Are you still doing such exercises here in the hospital?"
"Yes,
I do sit-ups dozens of times every day."
"But you know you have
to take a good rest and do little exercises so that you will recover your mechanism."
"I know. But I have to do it, otherwise I will have a big belly."
I could see that the little girl was very stubborn and therefore believed that
it would be useless to argue with her. I'd better take the opportunity to ask
her more questions. Then I asked her how she was doing at school. She said she
was always the 1st in class. I asked, "Oh? Have you always been the 1st in
class from primary school?" She said, "No, I was among the top students
in class when I was in primary school, but I was the 1st after entering high school."
I then said, "It is not easy. What hobbies do you have?" She said she
liked to play the piano and had reached Grade 6. I asked her whether staying at
hospital would affect her studies. She gave me a certain answer and then said
that was why she felt unhappy. She liked to go back home and to go to school.
She complained that she was always being asked why not eat this or that and why
eat so little, so she was very unhappy. AN remains
an enigma
The parents of the little girl came in. The interview
left me with a very deep impression because the girl struck me as very intelligent
and mature. It seemed that she knew her situation very well. Those who have AN
will feel at a loss. I don't know. But I feel that her goal and ideas are much
clearer than people of her age. What is after all her problem? What has made her
endure the hunger and not eat? This remains an enigma. We will try to find a solution
to this enigma, not out of curiosity or entertainment, but because we want to
have a full understanding of other people's feelings so that we will improve our
knowledge and help those who suffer. This is the purpose of my visit. There is
no clear answer yet, but I want to emphasize that most of the people believe that
AN is the result of going on a diet and losing weight. Even if the girl reiterated
that she was afraid of having a big belly, I still do not believe that she would
endure hunger simply because she wanted to lose weight. This was only our first
meeting, and I could not find the true reasons. Maybe sometimes she really lost
herself, and she did not even know it herself. I will not force her to admit anything.
I just hope that I will find out some day how she looked at her slim body and
why she refused to eat. Conclusions
This first interview has given me three pieces of information: Firstly, the little
girl struck me as a very intelligent, mature and lovely girl, not different from
other girls except that she was rather slim; Secondly, when we looked at her and
thought she was slim, she did not look at herself in this way. Therefore we have
to see from whose perspective we are talking and what standards we are using;
Thirdly, in the interview I did not call her an AN and just said she was slim,
she said this was very important. I did not label her or regard her as a patient
so that she did not feel a pressure. Many theories remain argumentative such as
psychoanalysis, family psychopathology, genetic explanation and socio-cultural
perspectives of the development of anorexia nervosa (American Psychiatric Association,
1994; Bemis, 1978; Bordo, 1989; Bruch, 1978). What is more important, we should
not be bound within the term "AN"; nor should we simply regard it as
a problem of eating and not eating. To explain and understand it fully still needs
further time and research. References
Alma, E. (1997). Healthwatch KIDS AND FAMILY Weighty problem can have lifelong
effects Extra pounds call for easy-does-it strategies, exercise. The Atlanta Journal
Constitution, B, 1-4. Amara, A., Cerrato, P. L. (1996). Eating disorders-still
a threat. Medical Economics Publishing Co., Inc., 59(6), 30-35. American
Psychiatric Association. (1994). Practice Guideline for eating disorders. Washington,
D. C.: American Psychological Association. Apostolodes, M. (1998). Inner
hunger: A young woman's struggle through anorexia and bulimia. New York: W.W.Norton
& Company. Bell, R. M. (1985). Holy Anorexia. Chicago: University of
Chicago Press. Bemis, K. M. (1978). Current approaches to the etiology and
treatment of anorexia nervosa. Psychological Bulletin, 85(3). Bordo, S.
R. (1989). The body and the reproduction of femininity: A feminist appropriation
of Foucault. London: Rutgers University Press. Bruch, H. (1978). The golden
cage: The enigma of anorexia nervosa. Cambridge: Harvard University Press. Foucault,
M. (1977). Discipline and punish: The birth of the prison. A Sheridan (Trans.).
London: Penguin. Foucault, M. (1990). The History of Sexuality. Vol.1. New
York: Vintage Books.
"I
would like to be known as a person who is concerned about freedom and equality
and justice and prosperity for all people."
- Rosa Parks
Feminist Women's Health Center |
