This article is based on an original publication on Cultural Considerations in the Treatment of Eating Disorders featured in the American Association for Marriage and Family Therapy’s Family Therapy Magazine, September/October 2021. It centers BIPOC with eating disorders.
Addressing culture is vital to high-quality, ethical, and effective treatment for eating disorders.
Debunking myths of who develops eating disorders (ED)
Eating disorders (ED) are prevalent among Black, Indigenous, and People of Color (BIPOC), yet predominately associated with images of White, young, thin, affluent women (Gordon, Perez, & Joiner, 2002). This myth is influenced by who gets a diagnosis, participates in clinical research, and receives care in treatment settings.
Popular media portrayals of ED and people who have them also perpetuate this myth. These myths persist in the field of ED, with People of Color notably underdiagnosed relative to Whites.
This article provides guidance on cultural considerations in ED treatment. Systemic therapists, and other healthcare providers, play an important role in debunking this myth. Together, we are responsible for advocating for inclusive and culturally affirming ED treatment for BIPOC.
The role of systemic, couple and family therapists
Historical Contributions
Systemic, couple and family therapists have made significant contributions to the field of ED. Family therapy modalities (e.g., structural family therapy) paved the way for integrating family in treatment interventions and exploring family dynamics, particularly for those with anorexia nervosa. The family continues to be a point of intervention through modalities such as family-based therapy for adolescents with anorexia nervosa and bulimia nervosa, and emotion-focused family therapy. These interventions and the research evidence in favor frequently focus on female adolescent clients and two parents as caregivers. This limits the research-based evidence informed options for those with ED outside of these groups.
Opportunities to Address Cultural Considerations in Eating Disorders
Systemic therapists, CFTs, and healthcare providers are influential stakeholders in addressing cultural considerations in ED treatment with BIPOC. In doing so, we challenge treatment access disparities impacting BIPOC and other marginalized groups.
For those of us with social justice backgrounds and training, experience with the person of the therapist training model and cultural genograms (Hardy & Laszloffy, 1995), addressing these disparities can feel familiar. As providers, we are aware of how relationships, power, and privilege impact mental health. We explore privilege, oppression, legacies, and intersectionality throughout our work. We understand the impact these have on our lives, our therapeutic presence, lives of our clients and their healing.
Though the ED field has explored some of these dynamics through theoretical and clinical approaches (i.e., through feminist relational perspectives), culture has been the topic of focus only as it impacts the development of ED in white women. This has been a limitation and criticism towards the ED field, where efforts to treat or prevent eating issues have not been “sufficiently connected to the many systemic roots that determine people’s relationships with food and with their bodies” and with each other (Russell-Mayhew, 2007, p. 1).
Racism, oppression, mental health, and eating disorders
Racism Harms Relationships with Our Bodies
To advance inclusive, just, ethical and equitable care, we must consider the impact that racism and oppression have on mental health and the body. Experiences of racism impact coping, psychological and physiological stress responses (Clark, Anderson, Clark, & Williams, 1999). Experiencing racism is also associated with negative psychological states, such as depression and anxiety, lower well-being, self-regard, and ill health (Okazaki, 2009; Carter, 2007; Clark et al., 1999).
Internalized Pain & Eating Disorders Risk
When considering ED symptoms specifically, experiences of racism and discrimination are associated with higher odds of binge eating disorder (BED) among African Americans. The research suggests a stronger effect on Black women than Black men (Assari, 2018). Racism-related emotional distress, stress, and lifetime experiences of racism significantly predict binge eating among Indigenous People (Clark & Winterowd, 2012). Asian American women who report greater levels of racial teasing or discrimination are more likely to internalize mainstream media portrayals of beauty ideals. This internalization is connected with body shame and disordered eating (Cheng, Tran, Miyake, & Kim, 2017).
Eating Disorders: Used to Manage Pain & Powerlessness At Great Costs
ED behaviors in our BIPOC communities may serve as coping mechanisms for navigating racism and the harmful effects of oppression. Food is a necessity and much more, woven into cultural values, connections, and comfort.
People with ED may engage in manipulating food, exercise, and bodily behaviors as a means of denying personal needs, numb or detach. Eating disorder behaviors can be used to inflict harm upon the body and self, contribute to taking up more or less space, and exert control in a world where we may feel powerless. These behaviors may also be seemingly functional in navigating acculturative stress and culturally conflicting worlds.
ED behaviors may also establish a facade of proximity to power by aligning with mainstream diet culture, body ideals and avoiding weight stigma/fatphobia based in racial origins embedded within the foundation of our society in the United States (Strings, 2019). Other forms of body and appearance-altering behaviors, such as skin lightening and plastic surgery to modify racialized features, may also serve a similar purpose for establishing a facade of proximity to power.
Given negative mental health effects of racism and the persistence of significant treatment disparities, it is essential that CFTs and healthcare providers engage in anti-racist and culturally sensitive practices.
Cultural considerations in eating disorders treatment
Culture is integral to the treatment of ED, yet there is limited research that provides guidelines on how to address cultural considerations. A recent systematic literature review consolidated the current literature into 11 core themes of recommendations for integrating culture in ED treatment (Acle, Cook, Siegfried, & Beasley, 2021). These reflect practices evidenced to improve outcomes in other areas of mental health and coincide with the Cultural Formulation Interview added to DSM-5 (American Psychiatric Association, 2013).
The Importance of Culturally Sensitive Interventions
First and foremost, therapists should use culturally sensitive therapeutic interventions when treating BIPOC with ED. This is difficult, as there are few culturally sensitive, evidence-based interventions currently.
Therapists should evaluate the strengths and limitations of the available interventions. We should incorporating the needs of the client, their identity, and cultural values. Incorporating specific modalities and collaborating with alternative healers that align closely with cultural values and needs is also valuable (e.g., therapy through group, community, or faith-based settings, contemporary and alternative medicine).
Collaboratively Addressing Barriers & Cultural Context
Addressing client barriers is also significant to facilitate treatment engagement and address healthcare disparities in treatment access. In our work with clients, taking a collaborative and responsive approach can address stigma, shame, and financial constraints. Shorter or less frequent sessions can be helpful.
Understanding the client within their cultural context assists in addressing barriers. Doing so facilitates therapist understanding of how the client makes sense of their world, their ED behaviors, and cultural norms. Therapists can also create avenues to explore what function the client sees their behaviors communicating or serving.
Therapists can also consider the inclusion of family/social supports to address these barriers and to participate in the ED treatment and recovery process.
Exploring Contextual Factors & Intersectionality
Exploring contextual factors also facilitates the integration of culture in ED treatment. The literature reviewed highlights exploring gender identity, cultural background, values, class, and educational attainment (Acle et al., 2021). Other factors to consider include ability, body shape and size, sexual orientation, immigration status, and an intersectional approach to understanding contextual factors as they impact the client.
Assessing for Racial & Systemic Trauma
Therapists should conduct a thorough assessment of the impact of trauma, including racial trauma. The compounding effects of racism, how this may activate or exacerbate typical PTSD symptoms should be assesed. It is important that we understand how racism and witnessed events have impacted the client, their connection with self and the body. Therapists should also explore ethnic identity, acculturation, and acculturative stress.
A Non-Judgmental Therapeutic Stance
Recommended provider factors include a non-judgmental approach. Therapists should understand nuances that impact clinical presentations (e.g., sub-threshold symptoms, variations in weight and body image concerns, age of ED onset, and trajectory).
Therapists should become educated about working with BIPOC to understand and cater their interventions and education to these communities. A culturally flexible diagnostic model that considers cultural factors (e.g., the reason for food refusal, variations in thin internalization, weight ideals, and fatphobia) is also important.
Promoting Education about Cultural Considerations in Eating Disorders
Therapists can provide psychoeducation to increase awareness of ED. By providing education on eating disorders prevalence and warning signs, we empower community members to assist with early detection and intervention. Education about eating disorders about what they look like and why they occur can reduce myths, stigma and shame. Nine Truths about Eating Disorders (Academy for Eating Disorders, 2015), educational shorts, and brochures may be accessible ways to provide this information.
Therapists may also consider providing names of celebrities and other icons from BIPOC communities who have talked about body image and recovery from ED.
Conclusion
Systemic, couple and family therapists bring a much-needed approach to integrating cultural considerations in ED given our relational orientation and exploration of contextual factors on mental health and therapy.
Eating Disorders as Social Justice Issues
Eating disorders are social justice issues that intersect with food, water and health access and multiple systems. CFTs, given our training, are well-equipped to address eating disorders as they impact individuals, relationships and systems. By advancing awareness of ED among marginalized communities and debunking myths about eating disorders, we can improve diagnostic accuracy. We can advance health equity, holding ourselves and colleagues accountable in better addressing cultural considerations and healthcare disparities impacting BIPOC.
I am hopeful we can make meaningful contributions together to increase the integration of culture in the treatment of ED.
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