This article can be found at http://pitchfork.com/thepitch/861-we-need-to-talk-about-amy-winehouses-eating-disorder-and-its-role-in-her-death/ It is reposted here in its entirety because it sets forth in an honest and powerful way the insidious nature of eating disorders and the forces that keep them ravaging the lives of those we love.
We Need to Talk About Amy Winehouse’s Eating Disorder and Its Role In Her Death
There is a tacitly accepted set of rules that our culture follows when it comes to women in the spotlight. They are required to be thin. They do not eat a normal diet and that in and of itself is seen as normal, not even dangerous. Disordered eating is so normalized in our culture, especially in celebrity culture, that few people even acknowledge that it’s not healthy, and very potentially fatal. Eating disorders fall in line with what society expects of a celebrity—we love thinness so much, yet we know we’re supposed to be repulsed by the means of achieving that thinness—it’s easier to scrutinize their lifestyle or their partying than ever examine the toll of staying under a certain weight.
Amy Winehouse learned those ugly rules of womanhood early, as footage from Asif Kapadia’s devastating, much-praised documentary Amy reveals. A teenaged Winehouse, snacking with her friends, laments between mouthfuls that she’s a pig and she cannot help herself. In a voiceover during this sequence, the singer’s mother Janis Winehouse recounts the moment a young Amy tells her mother about discovering a great new “diet”—eating and then vomiting—that allows her to eat without gaining weight.
The film avoids editorializing at this point or any other—the format, consistent with Kapadia’s earlier, also critically-acclaimed documentary, Senna, involves audio interviews and raw footage, but no commentary—yet no editorializing is required in order for a viewer to feel distraught—the next few sentences to come out of Janis’s mouth are enough. She muses that she essentially ignored the statement and forgot about it, thinking it was a silly teen girl activity that Amy would soon grow out of. She says that when Amy told her father, Mitch Winehouse, as well, he also dismissed it.
This casual dismissal—the first mention of Amy Winehouse’s eating disorder—is wrenching, and comes almost halfway into the film. For many viewers, this may be the first they have ever heard about Winehouse’s eating disorder. As well-documented as her struggles with alcohol and drug addiction were, the tiny little fact of her severe, untreated, decade-long eating disorder was rarely mentioned. When her thinness was mocked in the media, it was almost always with the implication that hey, addicts are always skinny little wrecks. If her puffy face was ever evaluated—and it was, because every aspect of her physical appearance was eviscerated during the height of the media’s obsession with her—it was through the lens of someone looking for signs of alcohol addiction (which commonly causes bloating in the face) and not signs of self-induced vomiting.
Winehouse’s struggles with substance abuse were highly public and often ridiculed and, as many others have noted, the film does an outstanding job of laying bare the damaging impact that media coverage and celebrity-worship can have on the real, flesh-and-blood artists. She is quite literally attacked by paparazzi during highly personal events such as visits to rehab and her husband’s prison stint.
Amy also documents in thorough detail the many attempts by those surrounding the singer to get her help—both for altruistic reasons (read: because they cared deeply for the sparkling, kind, immensely talented woman) and for selfish motives (read: because they cared deeply about the fame and money that Amy could bring them as long as she was able to comport herself in the studio and on tour).
What the film is surprisingly lacking in, though, is anything beyond passing mentions of her bulimia. That segment transitions into an interview with someone working in the studio while Amy was recording Back to Black. They recount that the (very tiny) singer ate a large meal, disappeared for 45 minutes, and returned with smeared makeup. Some bathroom snooping followed, which revealed that Amy had “redecorated the bathroom,” having vomited up what she’d just eaten. This, the interviewee notes, was a point when she and others involved in the recording process realized something was really wrong. Then the film transitions away from any serious discussion of her eating disorder and never returns, other than in passing mentions perhaps three or four times. The disease is always treated as incidental and almost, to my perception, as something as permanent and untreatable as late-stage cancer, with an air of nothing can be done.
Eating disorders, for the most part, are a highly contained and easily managed means of utterly ruining oneself. A person with bulimia nervosa can carry on bingeing and purging while otherwise maintaining a high level of functionality. The same goes of those with anorexia nervosa, binge eating disorder, and purging disorder. Bingeing, purging, or starving are highly unlikely to put you into debt, and leave you unintoxicated and able to carry out the tasks of a job, and tend to the demands of a relationship and daily chores of life. These facts make it very easy for the friends, family, and colleagues of those with an eating disorder to overlook the disease, as the footage and interviews we see in Amy remind us.
When Amy suffers and survives her first overdose, a close acquaintance summarizes the urgings of a doctor and those around her to explain that a “petite” young girl cannot maintain the level of drug and alcohol abuse that led to the overdose. However, we’ve seen the footage. Amy wasn’t always petite, and would likely not have been referred to that way even at the time she began performing in clubs and signed a record deal. Early videos of her performing for industry folks as an 18- or 19-year-old show her with broad shoulders, a heavy chest, full thighs and torso—generally an “average-sized” woman with a solid frame. This “petiteness” was not natural; it was fought for.
But to anyone other than Amy, it was easy to overlook and intimidating to address. An interview with her brother Alex in the Guardian confirms the known-but-not-discussed quality of Amy’s bulimia: “We all knew she was doing it, but it’s almost impossible [to tackle] especially if you’re not talking about it. It’s a real dark, dark issue.”
Yet, Amy Winehouse’s eating disorder wasn’t simply “yet another bad decision.” The environmental and genetic factors at play in Winehouse’s childhood and adolescence put her at extremely high risk for developing an eating disorder, and the lack of early intervention, education, and stable guidance meant that the disease was able to firmly take root and flourish as she was put in higher- and higher-stress situations. According to the National Association for Anorexia Nervosa and Associated Disorders, “There isn’t one conclusive cause of eating disorders. Multiple factors are involved, such as genetics and metabolism; psychological issues—such as control, coping skills, trauma, personality factors, family issues; and social issues, such as a culture that promotes thinness and media that transmits this message.”
Depression is the most common mood disorder to be comorbidly diagnosed with an eating disorder, and those with eating disorders are commonly known to use their disordered “behaviors”—restricting caloric intake (commonly referred to simply as “restricting”), bingeing (which, by the definition found on the website for the National Eating Disorders Association, is characterized by “frequent episodes of consuming very large amounts of food” and a related “feeling of being out of control during the binge eating episodes”), and purging (which does not always take the form of self-induced vomiting; overexercising and laxative/diuretic abuse are also forms of purging)—as ways to cope with depression, anxiety, manic depression, post-traumatic stress disorder, obsessive-compulsive disorder, and other psychological disorders.
Winehouse was put on antidepressants early in life and, in one interview shown in the film, spoke with a depth of understanding on the subject of depression as a disease.
She said that as a child, “I don’t think I knew what depression was. I know I felt funny sometimes and I was different.” As she grew older and began taking the antidepressants, her understanding clearly deepened, and in the interview she rejects the notion that there’s something wrong with those who suffer from depression: “I’m not like some messed up person, you know? There’s a lot of people that suffer depression that don’t have an outlet.” Her outlet, she says, is playing guitar and writing music. Environmental factors, such as an unstable home life marked by an often-absent father and a mother who admits that it was a struggle to say “no” to her daughter, also likely played a role in Winehouse’s eating disorder.
So, there we have the psychological and genetic risk-factors and the environmental ones, not to mention the ignored cry for help and the implied societal pressures of being a woman at all, let alone a young woman who is growing into a performer on the world stage.
Then there’s the substance abuse.
Winehouse was notorious for her alcohol abuse even early on in her career, and her addictions to crack cocaine and heroin were spurred by her damaging, abusive relationship with eventual-husband Blake Fielder-Civil, whose betrayal spawned the creative high-point during which Winehouse penned all of the breakup-inspired Back to Black.
According to the National Eating Disorder Association, “research suggests that nearly 50% of individuals with an eating disorder (ED) are also abusing drugs and/or alcohol, a rate 5 times greater than what is seen in the general population.” Many people with eating disorders use substances as a form of appetite suppression, while “in other cases, eating disorders and substance abuse can be relied upon for avoidance-based coping.” Additionally they note that “substance abuse can develop before, during, or after treatment for an eating disorder,” and that reliance on drugs and alcohol is “both ineffective and counterproductive in that emotions remain unaddressed, problems go unresolved, and healthy strategies to cope are not developed.”
Winehouse’s many visits to treatment centers and her many attempts to go clean all center on recovering from drug and alcohol abuse, but they seemingly never address the comorbid eating disorder, despite the fact that it was ruinous to her health and was the disease she had been suffering from for the longest amount of time.
At one point, Amy’s manager and others she’s working with even draw up a contract that she must sign, stating that they won’t allow her to attend any events for the Grammy Awards—she was nominated for six—unless she gets and stays clean. At this point, she has already overdosed. She signs and obliges. She is clean during the Grammy Awards. No one in the film considers, mentions or perhaps had any real understanding that she could drop dead because of the severity of her eating disorder. It’s a silent form of destruction, and so it is, tragically, often not considered a “disease” worth treating.
Indeed, even after her death, those in the media were seen expressing resentment at the way Winehouse suffered in public, rather than feeling regretful for participating in the circus that amplified and intensified her diseases. Douglas Wolk, in his review of At the BBC, calls the album “a stinging reminder that she spent the better part of her too-brief career making her audience complicit in her self-destruction.” Yet, extreme fame and media coverage, caretakers who didn’t take care of her, and the aggressive demands of audiences were complicit in her self-destruction.
In early videos, we see Winehouse denigrating her appearance and hiding from the camera. She’s still a huge personality, but when she’s applying makeup, she criticizes her spotty skin, her face. When, after having been asleep in a car with no makeup on, the singer discovers that she’s being filmed, she hides behind blankets and refuses to be seen. She’s in her late teens in these videos, and those familiar with the signs will see on her face the trademark swollen salivary glands of someone who repeatedly self-induces vomiting. A regular viewer, however, might notice nothing except that she’s shy.
Over the course of perhaps two years, roughly gauging based on the footage included in the film, a bulimic Winehouse winnows herself down from the type of figure commonly seen on the sidewalk to the type of figure commonly seen on a red carpet.
In one interview, Winehouse’s former bodyguard recounts how close they were. She used to tell him all the things a young girl might talk to a parental figure about—including worries such as why she no longer gets her period and secrets like the fact that she can never have children. Amenorrhea, the absence of menstruation, and infertility are both symptoms of a severe eating disorder, and amenorrhea in particular is used as a factor in the diagnosis of anorexia nervosa. Not so with bulimia nervosa; the two diseases share many of the same symptoms, including the loss of a menstrual period, but this is not a diagnostic criteria for bulimia, the reason being that, again, those with bulimia are rarely severely underweight.
During Winehouse’s “clean” period, when she is living in St. Lucia and is not abusing drugs but is still drinking large amounts of alcohol, the press jumped on her “recovery” and crafted it into a redemption story. The whispers of her bulimia were allowed to be more directly addressed now that she was ostensibly “better,” and this coverage reveals in yet more ways how misunderstood eating disorders are.
One article in The Daily Mail contains photographs of Winehouse in St. Lucia, sporting a bloated stomach, which can accompany severe cases of eating disorders due to malnutrition and internal injury. In some of the photographs, she is eating, and one caption reads “Healthy appetite: Amy Winehouse looks well on the way to recovering her curves on a holiday on the Caribbean island of St Lucia.”
The article includes quotes from a man Winehouse was seeing at the time, which indicate a very limited diet and extreme malnutrition, punctuated by occasions of bingeing and purging:
She lived off Crunchie bars—up to 10 at a time—packets of Haribo sweets and bottles of orange Lucozade Sport…She would have a massive McDonalds and then throw it all up in the bathroom. I found my toothbrush covered in sick, and asked her about it.
The inclusion of these details in the article reveal how morbidly fascinated society is with the gory details of eating disorders and how utterly misinformed we are about the facts of them. Photographs of a person with bulimia—who is known to eat large portions of fast food and then throw it up—”polishing off nearly a full plate of food” are not at all a sign of recovery, as they may well be bingeing on food that they will then purge.
One of the biggest challenges when attempting to treat a patient with an eating disorder is the fact that EDs are egosyntonic, that is, the patient views the eating disorder as being in harmony with the rest of his/her personality and ego—it is an acceptable and positive part of the self. Many sufferers don’t want to get better.
According to Psychiatric Times (and anyone who has ever had an eating disorder), “Patients with eating disorders are notoriously difficult to treat and are also known to have high relapse rates.” This can be attributed to a number of factors—many of which have been addressed earlier in this piece—such as the facts that: eating disorders are misunderstood, the treatment of them is incomplete, the doctor and patient do not address the core issues at play, and of course, the disease itself is egosyntonic.
There’s substantial evidence in the film that Amy wanted to receive treatment for her drug and alcohol addictions, such as a moment when she muses that she likes it in the rehab center, as well as her willingness to sign her managerial ultimatum. None exists, at least not in the film or any documents I’ve found online, that suggests she felt the same about treating her eating disorder. And this is not surprising. She started the behaviors when she was a teenager, was not discouraged when she revealed her eating disorder to her parents, and continued the behaviors into an adulthood that demanded a very specific body type, which would be picked apart by literally billions of witnesses.
Eating disorders are hard to handle. They’re extremely difficult to treat, have high rates of relapse, are often invisible and rarely impugn on a sufferer’s ability to carry on a normal life, are often kept a secret, have causes and effects that are consistently misunderstood, and are rarely cited as an actual cause of death.
Amy Winehouse’s official cause of death was alcohol poisoning, but this can be understood as the equivalent of someone with AIDS who has died of complications from pneumonia. Similar to the way HIV compromises a body’s ability to fight infections, bulimia damages the body to the point where it is no longer able to keep up basic functions and is more susceptible to external threats.
The National Association of Anorexia Nervosa and Associated Disorders describes this phenomenon thusly:
Although eating disorders have the highest mortality rate of any mental disorder, the mortality rates reported on those who suffer from eating disorders can vary considerably between studies and sources. Part of the reason why there is a large variance in the reported number of deaths caused by eating disorders is because those who suffer from an eating disorder may ultimately die of heart failure, organ failure, malnutrition or suicide. Often, the medical complications of death are reported instead of the eating disorder that compromised a person’s health.
A doctor interviewed in the film describes Winehouse’s death as a combination of alcohol poisoning and the weakened state of her body due to an eating disorder, but that assertion never made it into the official “cause of death” statement released to the public after Winehouse’s passing.
The impact of such technically accurate but holistically incomplete reporting is that the general population is not conditioned to perceive eating disorders—especially bulimia—as deadly.
Had Winehouse’s cause of death included the phrase “complications from bulimia,” the world would likely—or hopefully—have begun to engage in some very different, more complete conversations about health. The more our body-obsessed culture acknowledges the realities of eating disorders, the more we can hope to put the world on a path to a better and more accurate understanding of this devastating set of diseases, as well as the illnesses’ unique, complex sufferers. The unwillingness to truly regard Amy Winehouse’s eating disorder shows that we still have a long way to go.