Sunday, April 22, 2012

Finished Draft!!!!!!!

“Words as Maps”: Rethinking the Collectivity of Women’s Life Writing with Marya Hornbacher’s Wasted: A Memoir of Anorexia and Bulimia

Cassie Ann Kosarek
Bryn Mawr College Class of 2012
23 April 2012
Department of English

Marya Hornbacher’s memoir, Wasted: A Memoir of Anorexia and Bulimia, uses several different pronouns (“I,” “you,” “we”), to present a multiplied identity, and so challenges the conventional boundaries of clinical literature. I read Hornbacher’s memoir, drawing on the fields of medical humanities and disabilities studies, to show how the tradition of women’s life writing can be expanded to describe not only the unified yet fragmented individual, but a unified yet fragmented society.

I. Hornbacher, Eating Disorders, and the Scope of this Project

“The words are purposes.
The words are maps.
I came to see the damage that was done
and the treasures that prevail.”
- Adrienne Rick, “Diving into the Wreck” (1973)

I am interested in the stories that people tell about their lives. It is a longstanding interest, one that has combined with other interests – psychology, medicine, nonfiction – to produce a professional trajectory that aims toward medicine, but which resists science as the only means to get there. When I began to conceptualize my senior thesis, I was certain only of two things: I wanted to work with memoir – with a narrative in which an identity was shaped –, and I wanted to combine my interest in mental health with my training in reading English literature. From the beginning, my thesis was an interdisciplinary project. I wanted it to be an experiment in how literature represents illness, in how psychology explains prose, in how a text might resist linearity and other traditional devices to, as David Shields describes, “dissolve a genre or invent one.” I wanted to see what resulted when the lines between genres are erased. I wanted to consider the broader readership that might result from such a move and the practical implications of using a medicalized narrative to tell a personal life story. In short, I had rather lofty ideas about what I wanted to produce, but then I took a step back and realized I had no primary text.
So I began buying memoirs, using my own interests and abstract ideas about what I wanted to write as a guide to what I read. I learned about schizophrenia and depression, bipolar disorder and substance abuse – but the illness stories that interested me the most, because they seemed to reach beyond a description of a medicalized self, were those about eating disorders. Eating disorders entailed not just individual diagnosis, but also our sociopolitical climate and culture. I was taken, in particular, by the complexity of the narrative in Wasted: A Memoir of Anorexia and Bulimia by Marya Hornbacher, who accounts for her eating disorder in nontraditional terms, and so paints a picture of mental illness that stretches the boundaries of a clinical narrative. Although I was hesitant to work with a memoir that detailed an area of mental health that I knew very little about, the complexity of Hornbacher’s memoir begged to be unraveled.
As I began to reread Hornbacher’s text, I was struck by her wide-ranging pronominal choices. She was “I”, “we,” “she.” At times, she was “you.” What kind of memoir, I wondered, could be written about a self that did no speak with a concrete “I”? How does the prognosis of an eating disorder change when its bearer resists pronominal identity? How do popular culture and diagnostic culture clash in the telling of such a narrative? How might both of my disciplines, English and psychology, be helpful in untangling the maze of pronouns scattered throughout Wasted?
Eating disorders are inherently complex, with etiological roots in neurobiology, social surroundings, individual temperament, and the family climate; a comprehensive view of an eating disorder is complex requires multiple seemingly contradictory theories to explain its many layers. According to the Diagnostic and Statistical Manual of Mental Disorders, Marya Hornbacher would be diagnosed with Anorexia Nervosa – Binge/Purge Subtype. To meet criteria, Hornbacher must maintain a weight at less than 85% of her ideal body weight, must have an intense fear of gaining weight despite being underweight, must have a disturbance in the experience of her body shape and weight, and must have amenorrhea, or lack of a menstrual period (DSM). To meet criteria for the Binge/Purge Subtype, she must also regularly engage in binge-eating or purging behavior, which may include self-induced vomiting and laxative abuse (DSM).
Researchers have identified several environmental and personality traits that many anoretics have in common. The prototypical anoretic is female and comes from an over-involved, enmeshed family, in which there are unclear boundaries between parents and children (Neeren). She perceives herself as having little control over her external environment and thus controls her food intake (Neeren). The anoretic is often perfectionistic, rigid, obsessive, and unwilling to assert her voice or opinion for fear of causing interpersonal upset; those anoretics who also binge and purge are also typically impulsive and thrill-seeking (Neeren). One or more of her relatives may have been diagnosed with an eating disorder, as relatives of people with eating disorders are four times more likely to develop the disorders themselves (Neeren). Further, she likely has a family history of mood disturbances and may have a comorbid depressive or anxiety disorder herself (Neeren). 
I explored a number of different theoretical perspectives on eating disorders, first working my way through the clinical literature on the disorders, before settling on three fields – the medical humanities, disabilities studies, and the tradition of women’s life writing – that were most useful in helping me understand how Hornbacher represents eating disorders. By extension, and in juxtaposition with one another, these three fields also made clear to me how practitioners in the humanities can help those in the medical field better understand their patients.
Narrative medicine offered me an entrée into the field of medical humanities, which enlarges the scope from stories of individual patients to include the story of medicine itself, looking to offer the most comprehensive healthcare through reformed thought about diagnosis and treatment. In particular, Rita Charon’s work in narrative medicine (she trains physicians to attend to the ways in which patients tell their stories, and how those stories can be used to contribute to more accurate diagnoses and treatments as well as greater empathy) gave me a way to read Hornbacher’s clinical explanations of her illness – an enmeshed family pattern, a history of mental illness, an impulsive personality.
Because medical humanities is primarily focused upon reforming from the traditional medical structures from within and because Hornbacher’s text addresses not only medicalized representations of her illness, but the sociopolitical dimensions of it as well, I found it necessary to widen my theoretical scope by considering both field of disabilities studies and the tradition of women’s life writing. Disabilities studies is concerned with the cultural construction of illness, and focuses on the ways in which the structure of abilities that we call disables those with physical and mental differences. Disabilities studies resists medicalization as a particular way of categorizing and coping with such difference. The field draws on the framework of feminist theory (among others), and, in my analysis of Hornbacher’s memoir, I also found myself drawn toward theories about women’s life writing, which both consider the oppression that results from inhabiting a disadvantaged body, and examines how this oppressions (and resistance to this oppression) is represented in the narrative female voice.
In the following project, I seek to follow Rich, using words as “maps” and “purposes” to uncover the “treasures that prevail.” By situating myself within these three theoretical orientations, I suggest that texts like Hornbacher’s map not only individual lives, not only women’s stories, but the particularity of genre in which those stories are told.

II. Placing Hornbacher in “The Field”

A. Medical Humanities           
As Evans et al. explains in their overview, Medical Humanities: A Practical Introduction, in the 1960s, questions arose about the “underlying authority of modern scientific medicine” (3), which at the time was grounded in “biomedicine,” or “the overall trend . . . for the patient narrative gradually to disappear in favor of technical investigation, for symptoms to give way to disease entity, and for treatment to become non-negotible” (11). This crisis was fed by
the emergence of the anti-psychiatry movement; the inability of science and technology to deal effectively with many chronic and disabling conditions, despite escalating levels of public expenditure on healthcare; and an awareness of the personal insensitivity of much of modern medicine and its failure to take account of the patient’s perspective (13).

A growing movement toward reform of medical practice catalyzed the development of the field of medical humanities.
David Greaves defines the humanities as “subjects concerned with the uniqueness of individuals rather than generalization” (15). This definition of the humanities, when taken in a medicalized context, challenges the depersonalization and institutionalization of diagnosis and begs for a return to individual narratives. Greaves “equates” the medical humanities “with the medical arts” (18), to which the practices of science and technology are subordinated (14). Greaves depicts these medical arts as a counterbalance to biomedicine, and conceptualizes medical practice as a balance of arts and science that
focuses on the human as relevant to the whole of medicine and so cuts across the traditional formulation of western medicine as comprising separate realms of art and science, with the human aspects restricted mainly, if not exclusively, to the former (18).

By defying the binary between the sciences and the arts, the medical arts offer “an innovative and unified approach” to medicine that reconsiders medical theory and urges “practitioners to develop a more rounded and humane attitude to their practice” (Greaves 19). Just as Greaves considers both the macro- and microscopic implications of involving the humanities in science, I will consider the implications of a reformed medical narrative on both an individual and societal level in my analysis of Hornbacher’s text.
 Richard Edwards also identifies the medical humanities as responding to generalized and impersonal theories of medicine. Edwards points out that evidence-based medicine leads to generalizations that do not necessarily match the needs or situation of the individual, and that “even in ideal circumstances,” when the individual does meet a generalized clinical picture of an illness, “it remains imperative to address and respond sympathetically to the emotional consequences of diagnosis and treatment” (238). Medical humanities aims to remedy such problems arising from clinical generalization.
            Edwards reports a variety of ways the medical humanities works to reform the existing structure of medicine. First it provides a language for patients to communicate more effectively with their physicians, allowing them both to verbalize their emotions concerning diagnosis and treatment and to create narratives exploring possible courses of action (241). Next, these narratives and emotional depictions of disease provide frameworks for evidence-based theory, allowing physicians to reassure patients by exploring the benefits and drawbacks of a treatment from both theoretical and emotional perspectives. Finally, the medical humanities build upon “problem-based learning” (245); they beg for a “questioning,” critical approach that “promote[s] reflective practice and learning” (242). Such a complete evaluation is conducive to exploring of alternative and complementary therapies for illness, including treatments not as often empirically validated, such as those associated with eastern medicine (242). Edwards also argues that it is useful
to employ published narratives or artistic representations of ill health as qualitative input alongside actual patients’ narrative, to widen perspective and facilitate a more sympathetic understanding of the ‘human condition’ (237).

Published narratives of illness work, on a grander scale than do oral, unpublished patients’ narratives, to promote change within western medicine. In publishing such narratives, patients develop a voice apart from medical generalizations, fitting their personalized medical stories into the existing clinical literature, thus expanding clinical language beyond objective descriptions of their conditions. In published personal discourses of illness that combine clinical and personal narratives, the field of medical humanities is made visible. It is in such a space that I situate my own analysis of such a narrative. 
B. Disabilities Studies
            But the space created by the medical humanities is not quite large enough for the work I want to do with Hornbacher’s memoir. When disabilities studies scholar Margaret Price visited the Bryn Mawr College campus in February, she made a distinction to several of us over lunch between the fields of medical humanities and disability studies. While the medical humanities arose from within medical schools and thus look to reform medicine from the inside, disabilities studies is the academic branch of a social activist movement that both models itself on past movements (such as those for civil and women’s rights) and positions itself uniquely, and primarily, as a critique of the “medical model” of disability. As Lennard Davis elaborates on this distinction, disabilities studies is “both an academic field of inquiry and an area of political activity” that “aims to challenge the received in its most simple form – the body – and in its most complex form – the construction of the body” (xv-xvii). Even more broadly, Susan Wendell explains, the field critiques the belief that “the world [is] structure[d] for people who have no weaknesses” (243); it posits, instead, that weakness is a socially constructed paradigm, based upon an unspoken, implicit archetype of the “perfect” body that all humans strive to achieve.
Only in the past few decades have disabled individuals begun to organize themselves politically; a major accomplishment of the Disability Rights movement was the passage of the Americans with Disabilities Act in 1990 (xvi). Emerging work in disabilities studies drew both on this social movement and on academic work in feminist studies, sociology, and philosophy, by scholars such as Jacques Derrida, Judith Butler, Susan Bordo, Erving Goffman, and David Rothman (Davis xvii). As Davis explains, the “work of a newer generation of writers and scholars looks toward feminist, Marxist, postmodern, and cultural studies models for understanding the relation between the body and power” (xvii).
But this next generation of writing is also distinct in that it “tends to be created from within the boundaries of disability” (xvii). It does not attempt to “share” the disabled experience with normative audiences, but rather shuns the inherently unequal balance between disabled and able-bodied that occurs when works are “sensitized” so as to evoke sympathy from a normative audience (xvii). By upending this power dynamic, disabilities studies scholars avoid the “advocacy trap” that promotes emotive, sympathetic understanding at the cost of reinforcing cultural conceptions of disability as weakness and as disadvantage. It thereby creates room for critical inquiry into difference
Davis explains that disability has traditionally “been seen as eccentric, therapeutically oriented, out-of-the-mainstream, and certainly not representative of the human condition” (xv); it has been treated much in the way that “race, class, and gender have been theorized” (xvi), placed in a unique sociopolitical cultural context and understood as a request for special needs. The field of disability studies constructs a counter-narrative by placing individual difference in social and political context, and identifying oppression as a social construction that needs to be de-institutionalized. The field focuses on the power dynamics between the social norms of ability and individuals unable to meet those norms, who are thus exposed “to inspection, interrogation, interpretation, and violation of privacy”; “people with anomalous bodies are often called upon to account for them, sometimes quite explicitly: they may be asked, ‘What happened to you?’ ” (Couser 400).
            Susan Wendell points out that the given definitions of “disability” and “handicap” are dependent on recognition of the normative (245), and that “[p]aradigms of health and ideas about appropriate kinds of levels of performance are culturally dependent” (245). The United Nations defines disability as “[a]ny restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being” (244). Handicap, which refers to the social disadvantage resulting from disability, is “the loss or limitation of opportunities to take part in the life of the community on an equal level with others” (24s4). Thus, social function is inextricably linked to social constructs, like disability, that allow for “normative” experiences of society. Wendell explains that because social conceptions of disability are so dependent on context, “we might eliminate the category of the ‘disabled’ altogether, and simply talk about individuals’ physical abilities in their social context” (245). Disabilities studies examines functionality within cultural confines and asks how degrees of functionality may contribute to a given culture.
            This is the particular focus of Ray McDermott and Herve Varenne, who show how, when a culture selects certain features that it values, such as academic achievement, it disables those who cannot achieve in that arena. For example, the advent of the radio presumed that the normative, able-to-hear majority would benefit from receiving information in this manner – and thus excluded those who were deaf from a new source of news and entertainment. McDermott and Varenne argue that such social inventions, which enable one portion of the population, disable others by denying them some degree of social functionality.
            According to other disability studies scholars, the field of medicine is particularly egregious in this regard. Wendell shows how contemporary medicine “plays into and conforms to our cultural myth that the body can be controlled” (249). Doctors are “trained to do something to control the body” (250) – the body must bend, under various therapies, to the will of the physician, who aims to return the body to a cultural norm. Wendell labels this the “heroic approach to medicine” (250), a method in which “[m]edical professionals have been given the power to describe and validate everyone’s experience of the body” (253).
Feminist disability theory has been particularly crucial in advancing this argument. As Rosemarie Garland-Thompson explains, “The fundamental premise of Disability Studies is that disability is a culturally fabricated narrative of the body, a system that produces subjects by differentiating and marking bodies” (1). Her analysis of the field draws together feminist rejection of the cultural narrative of the female identity and body with disabilities studies’ rejection of the narrative of the disabled identity and body:  both force us “to realize that other people have more social authority than you do to describe the experience of your own body” (254).
Combining the two fields into what she refers to as “feminist disability critical theory,” Garland-Thompson outlines a methodology for reading the narratives of disabled women, which draws on these fundamental premises:
that representation structures reality; that the margins define the center; that gender and disability are ways of signifying relationships of power; that human identity is multiple and unstable; and that all analysis and evaluation has political implications. (6)

It is this approach to the disabled female condition – that society has constructed gender as a disability, and that a disabling gender and a traditional disability are inseparable when critically viewing a disabled woman – on which I will draw in my examination of Hornbacher’s memoir. In my reading of Wasted, I will use disabilities studies as a reflective field that sheds light on the constructions that either name or cause disability. For the purposes of my paper, disabilities studies will be a means of explaining eating disorders outside of the clinical literature. It helps explain how culture is constructed in such a way as to facilitate the development of these disorders, and to explore how society might cope with these disorders in non-clinical ways.
            Disabilities studies has a particularly useful relation to theories of autobiography and representation. As Couser explains, the “cultural representation of disability has functioned at the expense of disabled people, in part because they have rarely controlled their own images” (399). In contrast to these historic practices, disabled people have more recently “initiated and controlled their own narratives” (399). This writing, Couser suggests, should be considered a “retort” to “misrepresentation of disability”: the writing resists the cultural narratives that are “inscribed” on the bodies of the disabled (400). Margaret Price illustrates Couser’s idea by describing the ways in which, by showing a multiplicity of selves through the deliberate confusion of a narrative “I,” autobiographical writing by disabled individuals creates a culture of counter-diagnosis that defies the framework contributing to the institutionalization and oppression of individual difference.
Integrated with cultural and personal narratives of disability and gender, and challenging of traditional medical structures, disabilities studies contributes some key insights to my interpretation of Hornbacher’s representation of eating disorders, which stretch beyond the clinical and the personal. I use disabilities studies as a lens that expands medical humanities to include the sociopolitical and cultural aspects of illness. Trained on the genre of women’s autobiographical writing, both fields enable me to show how medicalized narratives might be expanded to consider a larger range of diagnostic implications.
C. Women’s Life Writing
            Theorists of feminist autobiography include various nonfictional forms – memoir, letters, diaries, and autobiography – in the overarching genre of life writing (Smith and Watson). The subtitle of Wasted: A Memoir of Anorexia and Bulimia deliberately situates Hornbacher’s work within the genre of women’s life writing. Women’s life writing is derived from the male autobiographical tradition, which stresses “the defense and glorification of a man, career, a political cause, or a skillful strategy” (Benstock 8). For many centuries, female autobiography reflected a reinforcement of the “token woman” – the inevitable response to the “masculine man” as presented in male autobiography –  (Heilbrun 16) and a continuation of the “one plot” available to women, which ended either in marriage or death (17). Women’s autobiography was traditionally “sentimental and passive” (19), bringing out only the expected behaviors for the public to see, while keeping private all messier goals, hopes, and angers.
            The tradition of women’s life writing, however, developed another stream – that of confessional writing, which, with its emotive and tell-all nature, defied the conventional male literary script within which women’s autobiography operated. Writing confessions enabled women to express their “uninhibited autobiographical impulses” (23). Such writing created a “rhetoric of uncertainty” (18) that today often characterizes women’s life writing. Unlike male autobiographical writing, women’s life writing “has become an exploration of painful experience rather than denial of pain and struggle” (25), moving outward from introspection and extending their experience to a larger population (Heilbrun 24, Benstock 8).
            In its defiance of the masculine autobiographical tradition, feminist scholars see women’s life writing as inherently politicized. The act of confession, of making the private public, turned women’s autobiography into feminist discourse by integrating the political and the personal dimensions of life writing. According to Estelle Jelinek, women’s “self-portraits” have long been distinguished from men’s by their “irregularity rather than orderliness” (17), which has expanded to include writing that seems like “a jungle of fragments”: truncated sentences without proper subjects, perhaps consisting only of a phrase, or even a single word, resembling “the kind of shorthand writing characteristic of diaries and notebooks,” and perhaps interrupted by passages that are “chronological, progressive, and strictly grammatical” (171). These stylistic trends of women’s life writing, Jelinek argues, politicize female texts. Other stylistic choices, including the multiplicity of the singular subject, which Benstock places in direct contrast to the male resistance of the “discordant ‘I’ ” (8), indicate that women have developed means of representing their coherent, fractured, and multiplied selves outside of the traditional prescriptive male forms.
            Yet, Helen Buss argues, because the autobiographical tradition still begs for the singular self as subject, the female autobiographer faces a unique challenge: experiencing herself as “fragmented, decentered, and dominated by forces largely beyond her control,” while nonetheless presenting her autobiographical self in a “stable, unified” way (97). Buss calls this the “doubled discourse” of women’s life writing (97). Women must strive to satisfy the demands of the genre while faithfully representing their politicized bodies and identities. The fragmentation in women’s life writing, then, reflects the feminine politicized self, acknowledging a history of oppression and disabling cultural forces while speaking for both the unified “I” and a larger female majority.
I here consider Hornbacher’s memoir as an example of this kind of complexly negotiated women’s life writing, and will evaluate it within this history, as an example and possible extension of a genre with a long historical lineage. The tradition of women’s life writing represents the theoretical capstone to my three areas of interest, as I will use it to explain how Hornbacher’s text ultimately represents an expanded form of clinical literature.

III. Explaining Pronomial Use in Wasted

            In Wasted: A Memoir of Anorexia and Bulimia, Marya Hornbacher claims that she is committing “cultural heresy” (5). Through her analysis both of her eating disorder and what it takes to recover, she violates long-standing ideas about femininity and wellness in order to embrace a clinical picture of her disorder that encourages her to say, “I will eat what I want and look as I please and laugh as loud as I like and use the wrong fork and lick my knife” (5). Much of what Hornbacher accomplishes in this clinical depiction of herself as an eating-disordered patient, and her rejection of cultural standards in favor of biological health, stems from her interchangeable usage of first-, second-, and third-person voices, which aim to shed light on the texture of eating disorders as both mental illness and cultural phenomenon. The memoir never settles on a distinct pronominal “I.” Rather, the text speaks to “you”, the reader(s); to “her” or “them,” the eating-disordered individual(s); to “us” or “we,” the eating-disordered collective or community. “I,” the ostensible bearer of the narrative, seems to surface only when particular details of the life in question are too specific to be attributed to “you,” “her,” “them,” “we” or “us.” 
            I will examine a few exemplary passages in which this pronominal switching is particularly important and apparent, although Hornbacher employs the technique regularly throughout the memoir, following a fairly consistent pattern.
            The first passage I want to discuss occurs early in the memoir, in the introduction, and so functions as evidence of how quickly Hornbacher delves into this unique pronominal usage. Hornbacher begins her first description of the cognitions and cultural influences behind eating disorders in second-person, thereby both tagging us readers as eating-disordered, and telling us what we think about “our” shared condition. An eating disorder, she explains,
is . . . an attempt to find an identity, but ultimately strips you of any sense of yourself, save the sorry identity of “sick.” It is a grotesque mockery of cultural standards of beauty that wind up mocking no one more than you. It is a protest against cultural stereotypes of women that in the end makes you seem the weakest, the most needy and neurotic of all women. It is the thing you believe is keeping you safe, alive, contained . . . An eating disorder is in many ways a rather logical elaboration on a cultural idea. While the personality of an eating-disordered person plays a huge role – we are often extreme people, highly competitive, incredibly self-critical, driven, perfectionistic, tending toward excess - . . . I do believe that the cultural environment is an equal . . . culprit in the sheer popularity of eating disorders. . .  I chose an eating disorder. I cannot help but think that, had I lived in a culture where “thinness” was not regarded as a strange state of grace, I might have sought out another means of attaining that grace, perhaps one that would not have so seriously damaged my body, and so radically distorted my sense of who I am (6-7).  

By page six, Hornbacher conflates herself, an eating-disordered individual as “you,” with a layered narrative identity. Her claim that the consequences of her eating disorder “radically distorted my sense of who I am” (7) create the space for her to oscillate between narrative identities, allowing her to become, by turns, the patient, the feminist, and the pedestrian onlooker all working against containment within one memoric self.
            Traditionally, non-feminized forms of autobiography and its subgenre, memoir, contain the life narratives of a singular person. By using multiple pronouns to tell her narrative, Hornbacher challenges this traditional masculine sense of memoir, embracing instead what Jelinek describes as the tradition of presenting “a multiplicity of selves” within a feminine autobiographical text. Hornbacher extends her experience to the reader by demanding that “you” emotionally empathize with the consequences of distorted eating-disordered cognitions, which in this passage are cast as general thoughts characteristic of all eating-disordered patients. Hornbacher does not write, “I felt safe in my eating disorder;” she asserts instead that “you” are “safe,” “alive,” and “contained” (6), thereby forcing her audience to emotionally identify with her experience. Hornbacher thereby creates an emotionally shared narrative, thus including multiple identities – her own and those of her readers – into her work in an act that makes explicit the multiplicity of identities that characterizes women’s life writing.
            Hornbacher’s “you” extends the “disabling” cognitions of having an eating disorder to the  “non-disabled” majority. “You” is used empathetically, forcing readers to share the experiences of an eating-disordered individual, to explore the cognitions and the unarticulated emotions that come with those cognitions. It is not Hornbacher or a woman in inpatient treatment who seems the “most weakest” (6) – it is “you.” The reader is forced to become an anoretic, to adopt the “sorry identity of ‘sick’ ” (6). Hornbacher links this explicit demand that the reader empathize with – if not actually become – eating-disordered, with a brief mention of the “cultural standards of beauty” (6) that reinforce eating-disordered behavior. In doing so, she builds on what McDermott and Varenne argue in “Culture as Disability,” that culture constructs disability to show that both “you” and “I” experience social disability in the same way.
            Although Hornbacher uses the pronouns “you” to force her readers into occupying the space of disability with her, she turns to “we” in the same passage, and thereby pushes us away, inviting “you” to become a voyeur of “our” competitive perfectionism. Throughout her memoir, she draws the picture of an eating-disordered community – in her words, a group of “extreme people” (6) whose intensity not only feeds into their athletic, creative, occupational, and academic lives, but into honing their eating disorder. Amy Neeren, my psychology professor at Haverford College, told me that, in her clinical practice, she sees a tendency of eating-disordered individuals to compete with each other to “perfect” their disorders. They want to have the “best” eating disorders. They want to be the thinnest, eat the least, and, most notably, they want to exclude others who do not possess like disordered behaviors and cognitions. As Hornbacher implies when her pronouns shift from “you” to “we”, outsiders do not combine self-starvation or purgation with self-criticism and perfectionism. Outsiders do not attain “grace” (7) in the difficult-to-maintain self-destruction of “true” eating-disordered individuals. In beginning this passage with the pronoun “you,” Hornbacher signals that we readers are affected by the disabling cultural ideals that catalyze disordered eating. But in shifting quickly to “we,” Hornbacher breaks down the empathetic connections she’s just built with her readers, excluding “us” from her elite, discrete community. She thus isolates eating disorders as an abnormal response to the collective culture in which “you all” live. “You” do not have the personality, the family climate, the sheer drive needed to maintain eating disorders. “You” are invited to behold “we,” but clearly do not participate in “our” thoughts and behaviors. 
            As the passage continues, Hornbacher continues to narrow the experiential component of her narrative, switching next from first person plural to first person singular voice, lighting momentarily on “I” to describe her own particular experience. The use of “I” denotes the kind of agency that, clinically, is not supposed to be present in the development of an eating disorder. By stating, “I chose an eating disorder” (6), Hornbacher explicitly claims that she made an active choice, as if she had surveyed the field of clinically disordered behaviors from which she could choose and found an eating disorder to be the most suitable. Hornbacher reports that she experimented with a plethora of behaviors in her adolescent years (including but not limited to promiscuity, illicit drug use, and self-mutilating behaviors), so it is possible that she actively rejected such activities in favor of an eating disorder. But, given the clinical evidence Hornbacher presents about eating-disordered “personalities” – that they are “highly competitive, incredibly self-critical, driven, perfectionistic, tending toward excess” (6) – it is unlikely that a personality so specifically predisposed could actually be said to “choose” to be eating-disordered. A clinical view of Hornbacher’s “I” – with its explicit claim of an agential self –represents the delusional sense of control associated with eating disorders. Noting an “I” arguably prone to delusional beliefs and Hornbacher’s follow-up statement that her eating disorder “radically distorted my sense of who I am” (7), a reader trained in clinical psychology would interpret the effects of her “rather logical elaboration on a cultural idea” (6) as pathological. But a disabilities studies scholar would highlight instead the causal relationship between the culture in which “you” live, which disables the “I.” “You” is thus both distinguished from “we,” and yet linked to the “I” that is part of “us.” By connecting her pronouns circularly in this way, Hornbacher encourages a less medicalized, more socially determined understanding of eating disorders.
The nature of Hornbacher’s “I” shifts, however, as the memoir continues. No longer decisive and forceful, “I” becomes fitful and visceral in its actions, a catalogue of the more mundane moments of the life the memoir is chronicling. This is the “I” that dominates the majority of the memoir.
In a much later passage in which this less decisive “I” appears, Hornbacher again uses pronouns interchangeably yet skillfully, to slightly different effects:
You go insane about now. You understand, it just happens. Crazy isn’t always what they say it is. It’s not always the old woman wearing sneakers and a skirt and a scarf, wandering around with a shopping cart, hollering at no one, nothing, tumbling through years in her head . . . No. Sometimes it is a girl wearing boots and jeans and a sweater, arms crossed in front of her, shivering, wandering through the streets at night, all night, murmuring to no one, nothing, tumbling through the strange unreal dimensions in her head. . . Bedtime, and the house falls darker still. I sit at the window, waiting for the mutterings and shufflings to slow and stop. . . I hold the back of the chair with one hand, do exercises endlessly, waiting for one o’clock. Only four hours till morning, I think. (171-172).

Hornbacher here again fragments her narrative self – she is first “you,” then “she,” finally again “I.” But all three of the pronouns she uses to describe herself are clearly differentiated from another “crazy”-appearing group, which includes the old woman with a shopping cart. By first distinguishing aspects of herself from one another but then posing them collectively as distinct from another group of behaviors, Hornbacher finds a subtle, complex pronominal way of negotiating the dilemma articulated by Buss: that the female memoirist must present herself as stable and unified while acknowledging herself as “fragmented [and] decentered” (97).
Hornbacher creates a boundary between the narrator (whom she refers to variously as “you,” “she” and “I”) and the woman with the shopping cart, as well as other characters in the book by means of a distanced perspective on the latter. The narrator has no apparent insight as to why the woman with the shopping cart is “hollering” or what she thinks as she “tumbles through the years in her head” (171). The narrator does not empathize with this “crazy” woman. Because the narrator has no insight into the experience of the woman with the shopping cart and like characters, there is distance between the pronouns of Hornbacher’s narrator and this “crazy”-appearing group, thus helping to stabilize the narrator as a coherent identity that can be separated from others.
Buss’ ascribes the dilemma of the female memoirist to all women, whether able-bodied or not. Hornbacher’s memoir answers Buss’s challenge, in part by complicating it with her illness; eating disorders give a very particular “turn” to the female memoirist’s dilemma. Couser explains that autobiographical texts about illness may be written as a “retort” to the “misrepresentation of disability” (400). Hornbacher makes this retort explicit when she redefines “crazy” as something other than the conventional conception: not “always the old woman . . . hollering. . . tumbling. . .” (171), it may well be exemplified by the ‘normal’-looking girl who defies the social depiction of mental disability. In casting herself as “crazy,” Hornbacher attempts to shatter preconceived notions about the face of mental illness.
By starting the passage with “you,” Hornbacher resists all conventional social constructions distinguishing the crazy from the sane, those who are eating disordered from those who are not. Mental illness, Hornbacher implies, can develop in a ‘normal’ girl in a sweater: as it enveloped the “I,” so can it emerge in “you.”
Using these three pronouns, first identifying them as discrete from one another then intertwining them in contrast to an “other,” Hornbacher contributes to what Margaret Prices calls a “counter-diagnostic” culture (243). She not only challenges conventional representations of her own mental illness, but also the social framework in which such representations occupy a particular role. By stating that “crazy” is not only the woman with the shopping cart, Hornbacher calls into question our contemporary diagnostic culture, which only recognizes insanity within a narrow range of abnormal behaviors, specifically, those outlined by the DSM-IV-TR. Insanity, Hornbacher’s text implies, is hard to recognize: it encompasses behaviors not necessarily stereotyped as indicative of disorder.
Hornbacher’s pronominal plurality both solves the conventional female autobiographical dilemma and rebuffs the cultural construction of mental illness. Her complex use of pronouns extends the concerns of clinical diagnosis to include the political dilemmas of gender. Since “she” refers to a “girl wearing boots and jeans and a sweater” (171), and since “she” is connected both to “you” and “I,” all three pronouns are implicitly feminized. Hornbacher thereby makes it clear that she is exploring the impact of mental disability, especially the most feminized of all mental illnesses on a female subject.
Hornbacher writes that she “sit[s] at the window, waiting for the mutterings and shufflings to slow and stop” (171). She – I – You cannot leave the house until morning. It is not permissible for her to leave the house until morning because it is not appropriate for a woman to wander alone at night, and it is not appropriate for a severely ill psychiatric patient to leave her place of care without apparent reason. This nocturnal waiting makes apparent the narrator’s social confines. Here, as in Charlotte Perkins Gilman’s infamous story about madness, “The Yellow Wallpaper,” the house acts metaphorically, representing both the long history of female domestic confinement and the confinement of the mentally ill in asylums. In the morning – when it is allowed – she will emerge. Her actions are governed by what Wendell calls “cultural authority,” which strips the individual of a narrative deviating from ‘proper’ cultural representation (243).
This cultural confinement, ultimately resulting in her inability to decide a course of action for herself, may also be the reason why Hornbacher’s use of  “I” is weakened in this passage. In contrast to her earlier, extremely decisive claim – “I chose an eating disorder” (6) –, the “I” in this passage in the memoir is paired with sedentary verbs. Whereas the first “I” “chose,” “think[s],” “believe[s],” and “sought” (6-7), this “I” can only “sit” and “hold.” It is only in waiting – in the “four hours till morning” (172) that the narrator “think[s]” (172). Confined, this “I” waits for morning by engaging in one of the few activities lying within the conventional cultural narrative of the female body – that of exercising. Confined, “I” thereby further confines her body to cultural standards. Her exercises are done on a chair; even they are sedentary. As “I” follows these cultural prescriptions, “I” bows to the intertwined – and insistently “disabling” scripts written both for mental illness and the feminine gender.
In highlighting the cultural constructions that gave rise to and defined her behaviors, Hornbacher’s memoir contributes to the critique, offered by disabilities studies, of the medical construction of illness. And yet Hornbacher also describes her narrator’s behavior in clinical language, thereby reinforcing the medical framework she critiques elsewhere in the same passage. In doing so, she is also contributing to the field of the medical humanities by using, in Edwards’ terms, language to describe her experience with illness in a way that the medical community can understand (241). By juxtaposing the cultural constructions of her illness within clinical language, Hornbacher exemplifies one way that medicine might incorporate broader causes for illness into its diagnostic framework.
In the space of a few sentences, Hornbacher triangulates three distinct theoretical lenses.  She embraces a diagnostic framework while refusing its constriction. She identifies several selves within one narrator and feminizes each self in the process, while constructing a distinction between this “I-you-she” and the “crazy” woman with the shopping cart. Hornbacher straddles the line between individual and collective experience, using a feminized “you” to draw her reader into a collective experience of disabled and confined femininity. She draws eating-disordered individuals together into a discrete diagnostic category, and she draw disabled persons into a collective social constriction.
Yet, by virtue of the personal details she uses to construct this genre, Hornbacher also emphasizes her experience as individualistic. A singular individual sits in a specific house, waiting for specific people to stop shuffling. A singular individual waits “four hours till morning” (172). Such details define her work as memoir in the traditional masculine sense while her narrative multiplicity resists the traditional masculinized form of her chosen genre.
And yet the identity of her main character remains ambiguous as the memoir draws to a close. In the final sections, Hornbacher describes her “limbo period after leaving the hospital the last time” –
I was grasping at straws. . . If you do that long enough, you eventually get a hold of some, enough, anyway, to keep going. I no longer had anything that I understood or could believe in. The situation I was in then is not at all uncommon. The experts say, What did you do before your eating disorder? What were you like before? And you simply stare at them because you can remember no before, and the word you means nothing at all. Are you referring to Marya, the constellation of suicidal symptoms? Marya, the invalid? Marya, the patient, the subject, the case study, the taker of pills, the nibbler of muffins, the asexual, the encyclopedia, the pencil sketch of the human skeleton, the bearer of nightmares of hunger, the hunger itself? (279).

In this late passage, Hornbacher unmasks her convention of pronominal switching, revealing it as an attempt to negotiate fractured, often antithetical identities. To use a clinical term, Hornbacher’s narrator is dis-integrated (Gasker 8). She exists as several identities – some assigned to her by her disease and by medical professionals, others developed in an attempt to relate her experience in an understandable way – and the close of her narrative makes it clear that the entirety of her work is the product of these interrelated selves. Hornbacher here uses her own first name, Marya, not to mark one discrete identity, but rather as the label that unifies all of her identities. Hornbacher’s first name has no single referent, its repeated evocation functioning rather as evidence that her identity can no longer be referred to in the singular. The experts ask “you” what “you” were “like before” (279), but the narrator, struggling to find a coherent identity, can only reference a cluster of behaviors, abstract terms (‘hunger”), and medical terminologies. Amidst these complexities, the “you” fails to become an “I.”
            This complex construction follows a single-sentence paragraph which asserts that “[t]here is, in fact, and incredible freedom in having nothing left to lose” (2790. That line constitutes a declarative pseudo-philosophical statement, lacking all personal identification. The following paragraph betrays the unsteady ground on which the narrator stands by testifying to the singular experience of her often transient “I.” The “I’ has just left the hospital. The “I” is disoriented and “grasping at straws” (279). The “I” uses unsure words – “limbo,” “grasping,” a negated “believe” (279). “I” attempts to normalize her situation –  “The situation I was in then is not at all uncommon” (279) – as a way of showing that her pronominal identity cannot stand by itself. Almost immediately, the “I” is traded for an empathetic “you,” which functions both to eradicate the personal details from the prose and to place the reader in the place of the narrator. The “you” handles the “I’s” uneasiness, as it is “you” who “get[s] a hold of some [straws] . . . to keep going” (279). In switching from the personal “I” to “you,” Hornbacher clearly blurs the blurs the boundaries between the “normal” and the disabled. In fitting “you” so easily into this situation that is “not at all uncommon” (279), Hornbacher makes “you” as disabled as “I” is.
The pronoun “you” fulfills a strong function as both a normalizing and empathetic vehicle. But Hornbacher then places “you” in a state of uneasiness similar to that of “I.” Instead of deliberately projecting “you” onto the reader, and so forcing “you” to participate in the activities described in the text, Hornbacher incorporates the pronoun into the direct address of medical professionals who now enter the paragraph and draw the “you” into a medicalized, therapeutic situation. If “I” is subject to the uncertainty of external forces, “you” is subject to the uncertainty experienced by patients imbricated in medical discourse. Edwards argues that traditional medicalized discourse disallows effective communication between medical professionals and their patients (241). Such ineffectiveness is certainly apparent in this passage when professionals ask “you’ what “you” did “before your eating disorder,” (279) and “you,” flummoxed by her awareness of multiple selves, can only stare back because “the word you means nothing at all” (279).
Applied to herself, “you” no longer has any meaning for the narrator. So she “aims” the pronoun “back at” the medical professionals who are questioning her, shifting its referent from the narrator to the medical community: “Are you referring to Marya, the constellation of suicidal symptoms?” (279). Does this shift thereby project the identity assigned to her by the medical community unto the medical professionals themselves? If “you” means “nothing at all” (279), “you” can be anyone – or no one.
By so closely juxtaposing her normalized, empathetic “you” with a “you” applied to the medical practitioners, Hornbacher refuses the identities ascribed to her throughout treatment by ascribing them to her medical caretakers. “How do you understand yourself in the context of these labels?” she seems to ask.  In her conflation of two ascriptions of “you,” Hornbacher forces medicalized identities back onto the professionals who assigned them, and so reflects common professional misunderstanding of her all-too-common condition. By responding to the medical professionals with a rhetorical question employing “you,” Hornbacher re-casts their question, “What did you do before your eating disorder?” (279), as ludicrous.
In these multiple ascriptions, the ever-shifting and illusive referent “you” answers the political challenge of women’s life writing, as Buss described it (97).  Here the referent for “you” is uncertain – it means nothing, or it means everything, as Hornbacher applies it to various people in turn. The “you” as the narrator, then the reader, then again the medical professional, is variously directed back by each of these in turn. The reader may choose to empathize with “you,” while the medical professionals ascribe various identities to “you.” In this shift of referents, “you” represents the disabling effects of a culture that limits the gendered body by subjecting it to external forces – most notable, the medical interpretation and treatment of a distinctly feminized illness.
            Near the end of this passage, Hornbacher refers to “Marya” as a third-person singular character whose identity never settles on any one of the terms applied to her by the medical community. After the “I” emerges from the hospital, after the “you” displays confusion, after all the clinical evaluations and labels, the name of the narrator means little in relation to the various social constructions of her illness. Through illness and treatment, the narrator has lost any sense of a coherent self.
            The final pages of Horbacher’s memoir offer no resolution to the dis-integration that she has so minutely described. The narrator is at turns dismissive (declaring that “[w]anting to be healthy is seen as really weird” (283)), “healed” (“You fix yourself. It is the hardest thing I have ever done” (284)), and unsure (the section entitled “Present Day” recounts the still very active struggle she has with Anorexia Nervosa). In the context of such a tumultuous disease, the narrator’s identity has become dis-integrated. The many selves that lie within the individual can no longer be described in a narrative with a multi-faceted, yet unified narrator.  Because she lacks coherence, the narrator offers the projective surface of the female body, on which western medicine and culture both play out conventional power dynamics. Both medicine and culture vie to be the source of unification for the dis-integrated narrator. Medicine provides a story of diagnosis and treatment; culture, a story of expectations for gender performativity. In both of these narrative frameworks, the dis-integrated individual is stripped of the ability to negotiate her own coherent self.
Hornbacher ends her memoir with a testimony to her loss of agency: “And then it [my heart] tumbles into sleep, grabbing me by the hair and pulling me down into these watery sleeps that are so terribly deep and cold” (289). In the end, it is this larger medical discourse – the one that has literally defined the workings of her body, the one that has told her that her hearts beats are irregular – that maintains control over “me.”

IV. Women’s Life Writing, Extended

            Marya Hornbacher’s memoir closes with a six-page bibliography of “book-length texts” (291), which excludes many other sources: “the articles in scholarly, medical, and psychiatric journals consulted . . . would be too numerous to cite” (291). The presence of such an extensive body of research, as well as various citations and footnotes throughout her text, situated Hornbacher’s memoir within a large body of clinical literature. In its attention to the narrator’s social and political climate, the text also challenges the boundaries of clinical literature, extending the scope of that genre by drawing on the resources of the tradition of women’s life writing. In her introduction, Hornbacher describes that the narrative that follows as is stereotypical of eating-disordered patients: “female, white young, middle-class” (7). By creating a narrative belonging to “the stereotype,” Hornbacher casts her text as a case study. By reading her memoir as a case study, we can come to understand, in clinical terms, how an eating disorder might manifest itself in an individual life.
            And yet immediately after she claims that her story is “stereotypical” – and so perfectly exemplary of a documented disorder – Hornbacher resists the confines of the clinical structure within which she presents herself: “I wrote this because I object to the homogenizing, the inaccurate trend in the majority of eating disorders literature that tends to generalize the part from the whole” (7). Instead, Hornbacher explains, she will present her disorder as “an attempt to find an identity” (6). Hornbacher’s introduction thus sets up her narrative as a negotiation between genres. She works within the genre of the clinical case study, personalizing it, extending it to a larger audience, and adding the political and sociocultural realms that such studies generally eschew; she does so by interweaving clinical “objectivity” with subjective techniques drawn from the literary genre of memoir.
            Hornbacher’s text exemplifies the “rhetoric of uncertainty” which Heilbrun describes as central to autobiography; it does so by moving from introspection “outward” (18, 24). Benstock identifies this “outward” gesture as the embrace of personal experience by a larger population (8); women’s autobiography, according to her description, encapsulates not only the self but the political collective of which the self is a part. It is this move that, I argue, Hornbacher accomplishes.
Hornbacher capitalizes on the multiplicity inherent in this interpretation of the tradition of women’s life writing by using multiple pronouns throughout her text. “I”, or the self specific to the narrator who owns the details of her particular life, goes to her aunt and uncle’s house for a meal of French bread and spaghetti (175). This “I” specifically remembers buttering that French bread and then throwing it up later in the evening, before she sleeps on her mother’s lap (175). “You” and “we,” in contrast, are used to mark “ownership” of nonspecific details applicable to a larger community. “We” refers to patients who are eating disordered: “we” have “assertiveness groups”  and “nutrition classes” (155), “we” are “[a]noretics [with] strange shopping lists” (237). By and large, “we” represents a collective outside of the presumed normal; it is often through “we” that the “I” projects a singular experience, thus multiplying and depersonalizing it. “You” is often broader than “we”: “you” forces every reader to occupy the place of “I.” Chapter 4 of Wasted, for example, opens with eight pages in which the only pronoun is “you.” In these pages, “you” are taken through a hospital stay, given slippers, figure out which nurses to dislike, and are stripped of “forbidden things . . . [r]azors, matches, cigarettes” (145, 149). Telling the reader what is happening to “you” extends the clinical experience beyond both that of the singular “I” and of the collective “we”: it makes the reader to occupy the space of being disabled.
            By constantly shifting the pronouns in this autobiographical writing, Hornbacher effectively reframes a singular experience both as clinical and sociopolitical. By making not just “you” ill, but the entire communal “we” disabled, Hornbacher redefines eating disorders: rather than only psychiatric problems requiring medical treatments, she represents them as conditions situated within a cultural context that propagates their development and prolongation. Wendell argues that “[p]aradigms of health and ideas about appropriate kinds and levels of performance are culturally dependent” (245). Because society is organized around normative behavior, it treats difference as a problem requiring alteration. As McDermott and Varenne show, the structure of ability we call “culture” thus both creates and maintains disability; Hornbacher’s pronominal use highlights this debilitating consequence of the construction of the normative. By applying disability first to “you,” then marking it powerful enough to create a communal “we,” Hornbacher’s prose makes the constructed-ness of disability transparent by refusing any pronominal divide between the normative and the disabled, between the experience of the patient and of the “well.”
In refusing divides between herself, her audience, and a larger community by employing varied pronouns, Hornbacher, in addition to telling the story of her own multiple selves, creates a cultural narrative that also negotiates the challenge of stability versus multiplicity. Buss explains that the challenge of the female autobiographer is presenting a decentered, multiplied self as unified in the context of external, dominating forces.  Hornbacher’s “I” situates the author’s multiplied individual self within a coherent narrative, drawing on stable personal details of her one, specific life to unify the chaos brought by the cultural interpretations of her feminized body and illness. Thus, the “I” shows Hornbacher’s individual negotiation of the challenge of women’s life writing.
Extending this negotiation is Hornbacher’s remaining pronouns, which work to break the divide between the pathology of the individual and that of society. In extending her individual pathology to “you,” “we,” “her,” and “them,” Hornbacher exemplifies a way in which women’s life writing becomes less individual and more collective. All of her pronouns are collected under the same cultural forces, and all are interrelated, switching referents as Hornbacher uses them interchangeably, to highlight the multiplicity of all individuals within society.  Hornbacher thus not only tells her own story in a unified, multiplied way, but she also tells a larger cultural story of stability in the presence of multiplicity by eliminating the boundary between individual and collective pathology. Hornbacher’s pronominal switching then highlights an expanded negotiation of Buss’s dilemma and brings a greater emphasis on society at large to the genre of women’s autobiographical writing. 
By reframing the clinical experience as sociopolitical and by doing so in the context of the memoiric genre and shifting pronouns, Hornbacher reframes the scope of women’s life writing, extending what once historically focused on the masculinized, individualized, unified autobiographical self to a collective societal narrative that focuses on the stability and multiplicity of us all.

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