2.4 Applying a critical approach
A critical approach to young people's health sounds fine in the abstract, but what might it mean in practice? How can such a framework help us to make sense of young people's actual experience of physical and mental distress?
To explore these questions, we will look at the apparent increase in the incidence of eating disorders, especially among young women. One of the advantages of this example is that it combines concerns about physical and mental health. This discussion will draw on a research study carried out by John Evans, Emma Rich and Rachel Holroyd with young women in the UK. In an article summarising their research the authors explore the link between the development of eating disorders such as anorexia nervosa and the ‘practice and processes’ of formal education. The article analyses the part played by what the authors term the ‘performance codes’ and ‘perfection codes’ deriving both from school culture and from wider social trends (Evans et al., 2004, p. 127).
The study is an attempt to go beyond accounts of eating disorders that see them as having a purely psychological origin. Instead, the article places the development of anorexia within the varied contexts and settings of young people's lives. The authors focus on the ordinary experience of women and girls, not on the extraordinary ‘disorder’ which they claim is often the object of discussion. They see the key to understanding eating disorders in ‘the varied, complex and socially conceptualised experience of individual girls and women’ (p. 124).
Evans et al. examine the influence of what they describe as ‘the enduring and powerful notions of body control through the marketing of a slender, or thin, ideal and its spread within and beyond the Western world’ (p. 125). This is reflected in the following extract from one of their group interviews:
Lauren: You can't look through the pages of something like the Daily Mail without coming across ‘The Little Black Dress Diet’ or something like that.
Ellie: They say things like ‘Lose weight, Feel Great, Keep it Off’, it's always things like that.
Carrie: Yeah, and they always have comments from people who say, ‘Oh, it changed my life, I feel like a better person’.
Ellie: And they have before and after pictures of people and they always make them look really horrible beforehand, like miserable and with bad clothes.
Carrie: They use pictures of naturally skinny people all of the time too, so it gives you the impression that if you do what they say that you will end up looking like that, and that's not the case.
(Evans et al., 2004, pp. 133–4)
This extract demonstrates the power of media images and discourses in shaping young women's ideas of what their bodies should look like. However, the authors are also concerned to explore how this ideal ‘finds its way into the socio-cultural fabric of schools’ and how it intersects with the structures of contemporary schooling, particularly for middle class young women. In this context, being anorexic can be a way of achieving popularity and attention:
Hayley (15): I always used to look at my friends and think that I wanted to be as good, or as pretty, or as clever as them. So I decided that not eating was a way that I could maybe achieve that.
(Evans et al., 2004, p. 137)
Paradoxically, not eating can become a way of taking control over one's body and ‘achieving self-determination within the culture of the school’ (p. 136). As the authors put it, some of the girls were simply ‘hungry to be noticed’.
Evans et al. examine the way that health promotion has been woven into the school curriculum and how it legitimises what they call the ideology of ‘healthism’, oriented to ‘making young people more active, “fit” and thin, with young people responsible for their own health and “making healthy choices”’ (p. 130). They claim that ‘healthism’ constructs the body as imperfect and unfinished, threatened and in need of being changed, and they make a connection between these ‘perfection codes’ and the ‘performance codes’ of the school, which create intense pressures on young women to succeed.
The argument set out in the article is distinctive in the way that it moves beyond conventional approaches to eating disorders which see them as rooted in the psychology of the individual ‘sufferer’, and considers the influence of wider contextual factors. The authors show that the ways in which this wider context operates is complex and multi-layered, interweaving the expectations of the immediate institutional context (in this case the school) with wider cultural images and discourses (reflected, for example, in advertisements). They see gendered power relations, and the ways that young women struggle for empowerment within them, as of vital importance in trying to understand how eating disorders develop.
Evans et al. also suggest that there are contradictions between different strands of government policy concerning the wellbeing of young people: for instance, between a wish that all young people should ‘achieve’ at school, and a desire to promote young people's physical and emotional health. The researchers see the intense pressures on young middle class women to succeed at school, combined with peer pressure to be popular, as at least contributing to the development of eating disorders. At the same time, they argue that the very health promotion agenda that aims to improve young people's wellbeing is in fact inculcating an ideology of ‘healthism’ which encourages a neurotic obsession with body image.
Evans et al. emphasise the part played by gender in the development of eating disorders, and they touch briefly on the way that gender intersects with class in framing young women's ideals and expectations. Other researchers adopting a critical approach to young people's wellbeing have placed a greater emphasis on class as a key factor in shaping young people's experience of physical and mental health. In their study of transitions to adulthood in poor neighbourhoods in the north east of England, Robert MacDonald and colleagues emphasise the importance of high rates of morbidity and mortality in structuring the lives of disadvantaged young people (MacDonald and Marsh, 2005; Shildrick et al., 2005). They found that ‘narratives of personal and family ill-health’ were very frequent in their interviews with young people in poor areas, and that physical and psychological ill health, both of the young people and of their families and friends, were ‘common but often incidental’ elements in the interviews (Shildrick et al., 2005, p. 5). Ill health often had a negative impact on young people's ‘school to work’ careers, as shown by the following quotation from Chrissie, aged 25:
At the moment I'm suffering from depression, cos I've applied for loads of jobs and then you just don't get them, so you start feeling really, really low … your chances are getting slimmer and slimmer because you hear about people closing factories down and all them people are looking for work.
(Shildrick et al., 2005, p. 6)
The researchers conclude that mortality and morbidity are ‘significant elements of multiple social problems that affect young people in poor neighbourhoods – and their transitions to adulthood’ (p. 15).
This research is another important reminder that young people's health is produced in and by diverse and unequal social contexts. A critical approach, by attending to the ways in which factors such as class and gender structure young people's experience of physical and mental wellbeing, undercuts the attempts to generalise either about the state of young people's health or about its causes that we saw exemplified in the media ‘scare stories’ quoted in the course overview.
A holistic model of young people's wellbeing, linking mental, physical and social dimensions, has begun to replace traditional medical models, which tended to promote an individualistic model of health.
While this holistic model has positive aspects, it can be criticised for setting up an impossible ideal and placing responsibility for good health on the individual.
The current UK government model of the healthy young person, while acknowledging a social dimension, replaces welfarist ideas with an individualistic vision of the active, achieving and enterprising individual.
All definitions of wellbeing for young people need to be seen in their cultural and historical context and as embodying particular social and political priorities.
A critical perspective sees young people's health as enmeshed in institutional and social structures and shaped in complex ways by relationships of power and difference.