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, where Black people are notably underdiagnosed, relative to Whites, Latinas (Gordon, Brattole, Wingate, & Joiner, 2006), and other People of Color. The following provides guidance on cultural considerations in ED treatment, noting the role systemic therapists play in debunking this myth and advocating for ED treatment for BIPOC.
The role of systemic, couple and family therapists
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 struggling 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. However, these interventions and the research evidence in favor frequently focus on female adolescent clients and parents as caregivers, limiting evidence-based options for those struggling with ED outside of these groups.
Systemic therapists and CFTs are well-positioned to address cultural considerations in ED treatment with BIPOC and challenge the disparities impacting treatment access for these and other marginalized groups given their social justice orientation. Awareness of how relationships, power, and privilege impact mental health is valuable, cultivated in many programs through the person of the therapist training model and cultural genograms to explore privilege, oppression, legacies, and intersectionality (Hardy & Laszloffy, 1995). 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 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
To advance inclusive, socially just, and equitable care for BIPOC at risk for or struggling with ED, 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). Experiences of racism are 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).
Manipulating food, exercise, and bodily behaviors can be used to deny personal needs, numb or detach, 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.
When considering ED symptoms specifically, experiences of racism and discrimination are associated with higher odds of binge eating disorder (BED) among African Americans, with a stronger effect on women than men (Assari, 2018). Racism-related emotional distress, stress, and lifetime experiences of racism are also significant predictors of 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).
ED behaviors in our 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. Manipulating food, exercise, and bodily behaviors can be used to deny personal needs, numb or detach, 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 functional in navigating acculturative stress and culturally conflicting worlds. ED behaviors may also establish 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 proximity to power.
Cultural considerations in eating disorders detection
A full review of cultural considerations in ED detection is beyond the scope of this article. In the interest of brevity, three areas are important to highlight. First, we should not conflate being BIPOC with being economically marginalized, food insecure, or being a person in a larger body. Members of a racial group are not a monolith. There are within- and clinically relevant between-group differences. Second, we must be aware of our biases and manage them. Clinician biases play a significant role in referral to ED treatment. BIPOC are less likely to receive a referral to ED treatment relative to their White counterparts (Sinha & Warfa, 2013). Thirdly, therapists outside of the ED field can support continuity of care, assessment, and connection with an ED specialist. This role may include exploring the client’s relationship with their body and food, exercise and movement patterns, and any compensatory behaviors (e.g. purging, use of diuretics, enemas, limiting fluid consumption, intermittent fasting) and following up with an ED specialist about the frequency and impact of these on the client’s well-being.
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 integrate this into ED treatment with BIPOC. 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).
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, incorporating the needs of the client, their identity, and cultural values. They may also consider specific modalities and alternative healers that align closely with cultural values and needs (e.g., therapy through group, community, or faith-based settings, contemporary and alternative medicine).
Addressing client barriers is also significant to facilitate treatment engagement and address healthcare disparities in treatment access. Therapists are encouraged to take a collaborative and responsive approach in addressing stigma, shame, and financial constraints with clients. Shorter or less frequent sessions may be helpful. Understanding the client within their cultural context may also assist in addressing barriers, as therapists understand 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. They may 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 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. Therapists should conduct a thorough assessment of the impact of trauma, including racial trauma. They should consider the compounding effects of racism, how this may activate or exacerbate typical PTSD symptoms, and assess how racism and witnessed events have impacted the client and their connection with self and the body, especially if these have been targets. Therapists should also explore ethnic identity, acculturation, and acculturative stress.
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 can provide psychoeducation to increase awareness of ED, their prevalence, and warning signs, and to the community to challenge myths about who is impacted by ED, what they look like, and why they occur. 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. 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.
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. We are well-equipped to address ED as a social justice issue, given our conscientiousness through training models like person of the therapist. We can put our advocacy to use by dispelling myths about who is impacted by ED and advancing awareness of ED among BIPOC and other marginalized communities. We are well-positioned to challenge ourselves, each other, and colleagues in the eating disorders field to better address 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.
Experiences of racism are also associated with negative psychological states such as depression and anxiety, lower well-being, self-regard, and ill health.
Ashley Acle, MFT, LMFT, is an AAMFT Professional Member and holds the Clinical Fellow designation. Acle aspires to address the current healthcare disparities, build effective treatment methods to reduce the burden of mental health and mortality rate associated with eating disorders, and bridge the research-practice gap. Her clinical research experience includes family therapy with marginalized suicidal adolescents, emotionally focused therapy with marginalized couples, and eating disorders.
REFERENCES
Academy for Eating Disorders. (2015). Nine truths about eating disorders. Retrieved from https://www.aedweb.org/resources/online-library/publications/nine-truths
Acle, A., Cook, B. J., Siegfried, N., & Beasley, T. (2021). Cultural considerations in the treatment of eating disorders among racial/ethnic minorities: A systematic review. Journal of Cross-Cultural Psychology, 52(5), 468-488. https://doi.org/10.1177/00220221211017664
American Psychiatric Association. (2013). Cultural formulation interview. Washington, DC: Author.
Assari, S. (2018). Perceived discrimination and binge eating disorder; Gender difference in African Americans. Journal of Clinical Medicine, 7(5), 89. PubMed. https://doi.org/10.3390/jcm7050089
Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35(1), 13-105. https://doi.org/10.1177/0011000006292033
Cheng, H.-L., Tran, A. G. T. T., Miyake, E. R., & Kim, H. Y. (2017). Disordered eating among Asian American college women: A racially expanded model of objectification theory. Journal of Counseling Psychology, 64(2), 179-191. https://doi.org/10.1037/cou0000195
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Hardy, K. V., & Laszloffy, T. A. (1995). The cultural genogram: Key to training culturally competent family therapists. Journal of Marital and Family Therapy, 21(3), 227-237. https://doi.org/10.1111/j.1752-0606.1995.tb00158.x
Okazaki, S. (2009). Impact of racism on ethnic minority mental health. Perspectives on Psychological Science, 4(1), 103-107. https://doi.org/10.1111/j.1745-6924.2009.01099.x
Russell-Mayhew, S. (2007). Eating disorders and obesity as social justice issues: Implications for research and practice. Journal for Social Action in Counseling & Psychology, 1(1), 1-13. https://doi.org/10.33043/JSACP.1.1.1-13
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