Multicultural Issues & Eating Disorders

Jacquelyn Ekern

Abstract

Eating disorders amongst Caucasian, African American, Native American, Asian, and Pacific Islanders are reviewed considering the values, cultural norms and mores of these groups as they face acculturation into the United States. Cultural influences, physiology and psychology are also examined in light of their contribution to cross cultural eating disorders. Treatment options and techniques are discussed, such as: cognitive behavior therapy, locus of control, and the stages of the counseling relationship as applied to clients struggling with eating disorders.

Multicultural Issues in Eating Disorders

Anorexia nervosa and bulimia nervosa are composed of complex etiologies of developmental, social, and biological processes. How these various factors interact and influence an individual to develop an eating disorder continues to be researched. There is limited evidence that cultural factors are the primary contributor to these disorders. This can be observed in all industrialized countries, where dieting and emphasis on thinness are highly valued(Kaye,W. & Strober, M., 1999). The more a woman, of any ethnicity, rejects her own heritage and identifies with the European American mainstream culture, the more likely that she will prefer a thinner body type and show more signs of an eating disorder (Meshreki, L. & Hansen, C., 2004). Further, when women of all races base their evaluation of their self upon what is considered the culturally ideal body, the incidence of eating disorders increases(Jung, J. & Lennon, S., 2003).

Hispanic Women

Among Hispanic Americans, having an overweight body does not necessarily reflect negatively upon the individual. The determining factor, to the Hispanic mindset, is whether the state of being overweight is the individuals fault or not. For example, if an overweight individual continually overeats and does not exercise, they are more likely to be blamed for their weight and stigmatized. However, if the individual is perceived as fat, through no fault of their own, it is likely to not be judged negatively.

A 1996 study conducted by Christian Crandall and Rebecca Martinez compared attitudes regarding weight amongst students from the United States and Mexico. The United States is considered to be the most individualistic culture in the world. The culture of the United States values independence, and fosters the belief that individuals are responsible for the results in their lives(Grogan, S., 1999). Whereas Mexico offers a culture that values interdependence and connection; emphasizing external influences on behavior. Crandall and Martinez predicted and found that Mexican students, in general, did not blame the individual for being overweight and did not see it as a matter of lack of personal control. The Mexican students also were less likely to stigmatize someone for being overweight or support anti-fat attitudes. While students of the United States viewed being overweight as a sign of weak will power and the fault of the individual. Crandall and Martinez contend that anti-fat attitudes reflect the pervasive Western ideology that individuals determine their own fate(Grogan, S., 1999).

Asian Women

Research shows that white women are more likely to feel fat and diet than are Asian American women. However, because of increasing global acceptance of dominant white socio-cultural values regarding body weight and image, increasingly more Asian Americans and other cultural groups are developing greater dissatisfaction with their weight (Grogan, S., 1999). More Japanese women are expressing dissatisfaction with their bodies and weight - almost to the level of American women(Mukai, Kambara, & Sasaki, 1998).

Some qualitative studies have shown that Chinese women view seeking treatment for an eating disorder as reflecting individual weakness. Even if the disorder is more than the individual can handle, they remain unlikely to pursue treatment(Lai Bovenkerk, 2001; Leung et al., 1978).

Asian American's value loyalty to family and deference to authority. Sharing personal problems with others may bring shame upon the family. The family can often be threatening to the self esteem of an Asian individual, instead of supportive. For example, a female Asian American might be experiencing significant marital and financial problems, but she would not likely speak to anyone, including her family, about her struggles. She believes that others, particularly her family, will lose respect for her if she is unable to solve her problems herself. She may feel greater depression because of her secrecy(Chiu, M., 2002).

The Asian culture values self reliance and maintaining the honor of the family. Therefore, medical and psychological treatments designed to meet the needs of Asian women should strive to avoid blaming or emphasizing that the eating disorder is the result of any personal deficiencies in the individual or the family(Chiu, M. ,2002). Sensitivity toward protecting the pride of the family is important with the Asian culture. Offering anonymous hotlines and websites that inform consumers of treatment options would allow this group to explore treatment and information regarding the eating disorder without fearing that they will bring shame upon themselves or the family. Leaving the choice up to the Asian client of whether or not to more publicly seek out treatment is also important with this group(Sharma and Aradhana, 2000).

The Chinese culture is based upon the teachings of Confucianism and Taoism. The social order of Chinese society is structured upon harmonious interpersonal relationships amongst families. These harmonious relationships are maintained by avoiding conflict; using non-confrontational language, self-discipline, self-restraint, indirect expression of disapproval, and allowing others to save face(Chen, 2002). Chinese families commonly deny any familial problems, and will blame individual problems, such as anorexia, upon the family member. Adolescent individuation and rebellion are typically perceived as a threat to the authority of the parents and risking the harmony of the family. This must be considered when suggesting assertive approaches to Asian clients.

A verse from Xiao Jing(The Classic of Filial Piety) depicts an important Chinese family honor value: "Your body with your hair and your skin is a gift from your parents. You must treasure this gift to be filial"(Xiao Jing, 1960). This teaching can be applied as a double edged sword, on one hand it could encourage the anorexic child to recover, yet on the other hand it could encourage the parents to try to control the child even more than they already do. Individuation is discouraged for Chinese women. These women base their identity upon an idealized woman and mother that is socially construed. Throughout the various stages of life, Chinese women are expected to be submissive, subordinate, and subjugate to the will of the father, the husband, and the son(Ma, J., 2005). Asian adolescent girls and women acculturating to the United States are often torn between the individualistic Western society amidst which they now live, and the self-sacrificing and loyal cultural values of their heritage and family. This can leave Asian females feeling estranged from both cultures and caught in the middle in a state of cognitive dissonance (Ma, J., 2005).

Chinese adolescent females are concerned with maintaining the dignity and pride of the family. They are typically reluctant to seek outside help for eating disorders, because this would involve divulging private family matters to an outsider. Though Chinese parents are more willing to seek outside treatment for eating disorders if they perceive the health of their child to be threatened (Ma & Chan, 2004).

When treating an Asian individual or family for an eating disorder, it is important to recognize that the majority of literature regarding family therapy and eating disorders is written from a Western perspective. The insightful therapist can use the cognitive dissonance created in an Asian individual or family struggling to find a balance between eastern and western thought as an opportunity for the individual and family to explore values and beliefs; as well as reconsider how they relate to one another. The therapist can use this process to build up the family members' confidence and commitment to each other.

Understanding the family background of Chinese parents will empower both the therapist and eating disordered client to understand the parent's personal and social expectations in parenting. This can create important empathy on the part of the eating disordered individual and aid them in collaborating more effectively with their parents in recovery(Ma, J., 2005).

Additionally, when working with Chinese families, the family therapist must search out and acknowledge the subtle indicators of conflict amongst the family. Family conflicts must be patiently approached with observation of nonverbal cues used to indicate conflict(Chen, G., 2002).

African American Women

African American women prefer larger body shapes and report greater satisfaction with their bodies than Caucasian women(Ashley, Smith, Robinson, & Richardson, 1996; Miller, Gleaves, Hirsch, Green, Snow, & Corbett, 2000), and also reported few eating disorders than white women(Abrams, Allen, Gray, 1993; Rucker & Cash, 1992). Further, obese African-American women maintained a more positive body image that Caucasian women(Grogan, 1999). African American women who take pride in their cultural heritage are more likely to refer to the more liberal body ideal of their race when evaluating their own body. However, eating disorders have been found to be more prevalent in African American women who identified with a European American world view. Dissatisfaction with body image was also pronounced in women who had not embraced their heritage and instead tended to view the dominant white culture as superior(Meshreki, L. & Hansen, C., 2004). O'neill, S.(2003) published a compilation of data from 18 studies examining the correlation between eating disorders and ethnicity amongst black and white women. White women were found to be more likely to develop an eating disorder overall. However, bulimia and binge-eating disorder behavior were found to be similarly prevalent in both African American and White women. Additionally, Petersons, Rojhani, Steinhan, and Larkin(2000) found that for African American college women, high socioeconomic status was correlated with eating disturbances.

Pacific Island Women

The American territory of Guam has a significant population of Chamorro females. These women report similar levels of body dissatisfaction and eating disorders as Caucasian women. This is attributed to the American economic and cultural influence upon Guam(Hattori, 2001; Hezel, 1987).

Traditional women from the Pacific Islands appreciate a rounded female shape. They view the curvaceous and robust woman as exuding health, power and strength(Becker, 1995). Several studies report higher BMI levels among individuals from the Pacific Islands(Brewis, McGarvey, Jones, & Swineburn,1998; Craig, Halavatau, Comino, & Caterson, 1999; Metcalf, Scragg, Willoughby, Finau & Tipene-Leach, 2000). Interestingly, Samoans residing in Samoa and New Zealand preferred ideal body shapes smaller than their actual bodies, but did not view overweight bodies negatively(Brewis, et al. 1998). Fijian woman prefer a medium range body type for females. However, they are accepting of obese females, too. These women expressed contentment with their weight and body shape. Even if these women were obese and preferred a smaller frame, they were unlikely to be disappointed in their shape or try to diet. As the Pacific Islands become more influenced by Western culture, studies have shown that admiration of the thin female body image is becoming more prevalent(Craig, Swinburn, Matenga-Smith, Matangi, & Vaughn, 1996; Craig, Halavatau, Comino, & Caterson).

Native American Women

American Indian and Alaska Native adolescents are increasingly unhappy with their body weight and using unhealthy means to lose weight. In a study of 545 multicultural participants, American Indians exemplified the most eating disordered attitudes and behavior. A high level of bulimic behavior was identified amongst this group. Racism, low self esteem, and pressure to look like the American ideal female may be the leading cause of developing eating disorders amongst Native Americans. To compound matters, frequently American Indians of both genders and all age groups are overweight(American Indian, 2005).

The extended family is the core family unit for most American Indians. Children may stay in various households of the extended family. This could be difficult for a western therapist to understand because typically American children are raised solely in the home of their parents, with occasional visits to grandparents and uncles and aunts. Whereas, it is not uncommon for American Indian children to stay at a distant cousin's home or even friends who are considered part of the extended family.

American Indians value sharing, this is in sharp contrast to the American value of accumulating goods. It would be important for the therapist to recognize that sharing is a cultural norm amongst Indians, and perhaps be more open to receiving small gifts from this client group.

Cooperation and the avoidance of discord are valued by Native American Indians. This would need to be considered by the therapist when addressing conflicts within families. Though Americans typically value confrontation and assertiveness, this direct approach might be harmful to an American Indian individual. Rather, amongst Indians, noninterference is valued. Respecting the rights of others is important. For example, a Native American Indian might be reticent to report spousal abuse of a neighbor or family member, because of this value. It would be important for the therapist to respect the underlying value system operating in the American Indian client's reluctance to step forward in such a situation.

Harmony with nature is desired by American Indians, rather than the American tendency to dominate the environment (Sue & Sue, 2003). This fundamental difference may influence the overall perspective of the American Indian, perhaps causing them to have a far more relaxed approach to addressing problems than the aggressive mentality of many western mental health practitioners.

The time orientation of American Indians differs greatly from that of the dominant American culture. Future planning is not valued for Indians; rather living fully in the moment takes precedence(Sue & Sue, 2003). Punctuality is not highly valued by this group either, which is different than the norms of American culture. A therapist would need to be sensitive to this and not over react to a late arrival of a client, misinterpreting it as passive aggression rather than a difference in cultural paradigms about time.

One generic counseling characteristic is to value emotional expression, and its perceived cathartic benefits. However, most American Indians and Alaskan Natives are understated in emotional expression(Sue & Sue, 2003). An overzealous western therapist could cause the American Indian/Alaskan Native client to feel uncomfortable and forced to put on theatrics. It is important to respect the emotional expression norms of the culture that the practitioner is treating.

Another commonly valued generic counseling tool is in-depth discussions regarding deeply personal matters in the life of the client. However, privacy is valued by this group, and not revealing personal matters outside the extended family is the norm(Sue & Sue, 2003). Thus, opening up to a therapist and discussing issues would likely require a significant investment of time beforehand. Even then, it might be a far less intimate discussion than the therapist would like, because the American Indian/Native Alaskan client might not be willing to reveal too much. Disharmony is the commonly attributed cause of mental/emotional or physical illness amongst this group(Sue & Sue, 2003). Therefore, the common therapeutic approach of confrontation would likely be inappropriate for the American Indian/Native Alaskan client. Disregarding the cultural emphasis on disharmony and continuing to emphasize individualism and confrontation would be deeply unsettling to this client. Rather, recognizing the value of interdependent relationships amongst the extended family might be the first step. This group has the strength of many individuals to draw from to meet their needs. Therefore, they might be able to reconsider getting needs met by other individuals than the one that the therapist might have initially suggested confronting. Instead, they might work on accepting that flawed individual (as we all are flawed) and honoring what they do get from that relationship, and then moving on to others in their rich environment of extended family to meet their other needs.

Physiology

In addition to cultural factors, there likely is a significant genetic influence in the etiology of anorexia and bulimia. Several studies have demonstrated that an individual is 7 to 12 times more likely to develop an eating disorder if it runs in the family. It is hypothesized that something goes awry in the neurotransmitter modulation in appetitive behaviors. This matter is complicated by the fact that the very dietary restrictions and abnormal behaviors inherent in anorexia and bulimia could cause monoamine or neuropeptide disturbances. That being said, abnormal serotonin(5-HT) is the neurotransmitter frequently blamed for contributing to eating disorders. Disturbance of serotonin activity, due to a gene that codes for an abnormal serotonin receptor, has been found in several studies of individuals with anorexia. Compared to a placebo control group, individuals taking antidepressants, specifically selective serotonin reuptake inhibitors, reduced their binge eating and vomiting. Additionally, SSRI's can reduce weight obsession and even encourage weight loss amongst eating disordered individuals. The SSRI's seem to aid the neurotransmitter system in modulating mood and impulse control. However, a severely emaciated anorexic is unlikely to see any improvement in her symptoms of anorexia from simply being treated with a selective serotonin reuptake inhibitor. This is due to the starving brain operating from a place of deficiency in serotonin to begin with. However, once the anorexic is recovering, eating a healthy diet and has obtained a healthy weight, then the serotonin level is likely to naturally increase within the brain; selective serotonin reuptake inhibitors may then help the anorexic to avoid relapse(Kaye, W. & Strober, M., 1999).

When addressing physiology and medication with ethnically diverse populations, present the facts and allow the individual and family time to process this information through their own individual and cultural filters. They may need to pursue their own channels of advice and counsel before considering this option. The therapist should maintain a respectful appreciation of the individual and families right to accept or reject western medical practices.

Psychology

In addition to cultural influences and physiological predisposition, many eating disorder researchers have concluded that a disturbance in the self is the cause of anorexia and bulimia. These individuals are often dependent upon environmental cues for self esteem rather than an inherent sense of worth. Self schemas are a complex array of memories that the individual draws upon to define the self. These schemas cover the gamut from skills and personality traits to physical characteristics. It has been suggested that eating disordered individuals suffer from more negative self schemas, thus resulting in depression and a desire to isolate. For example, this group is likely to have a fat self schema that haunts them and drives their eating disordered behaviors. Cognitive behavior therapy is frequently used in eating disorder treatment to reframe these self schemas(Stein, K. and Nyquist, L., 2001).

Treatment

The treatment of eating disorders amongst a multicultural population is challenging. For example, a multicultural limitation of rational emotive behavior therapy(the grandfather of cognitive behavior therapy) is that it emphasizes independence. Many cultures value interdependence and thus this theory can be disconcerting and threatening if applied insensitively to all cultures.

It has always seemed that Eastern and Western philosophy contradicted each other. The focus on control, conquering, and individuality of Western thought is incongruent with much of the Eastern thought that leans toward acceptance, working with nature, and interdependence with others. However, there is value to both schools of thought, and they can be successfully integrated when approached with sensitivity and caution. For example, in some cultures, folk healers represent the spiritual dimension of healing. Many of the great philosophers have sought to integrate the spiritual and logical when evaluating the human experience. Martin Buber, Christ, Carl Rogers and others recognized the indivisibility of the spiritual and logical aspects of man. If approached mindfully, therapists, shaman, folk healers and doctors have much in common. They all focus on healing the being. The being consists of physical, emotional, spiritual and intellectual components. Thus, it is logical to conclude that addressing all aspects of the individual would lead to the greatest healing. Unfortunately, many problems can arise when working with multicultural spiritual practioners as consultants. The training and education of the folk healer can be questionable, causing the therapist to lack trust in the suggestions of the spiritual advisor, no matter how sincere their desire to help. Also, the realm of uncredentialed spiritual healers can draw some unstable individuals that could unintentionally inflict harm upon a mutual client. The prudent therapist would respect the client's desire to gain spiritual insight, honor that, and yet maintain a professional distance from the spiritual advisor. The therapist would be wise to instruct clients to use both their intuition and intellect when evaluating potential spiritual advice and healing. Donald Meichenbaum designed cognitive behavior modification therapy. This theory is based upon cognitive restructuring which means to restructure one's self-dialogue and thus one's behavior. Clients must become aware of their scripted behavior patterns and what the underlying self dialogue is, so that they can recognize what is motivating their behavior. Then change is possible. Meichenbaum emphasizes treating behavior problems such as impulsive and aggressive behavior by teaching clients to develop healthier coping skills. He outlined a specific treatment model of self- observation, creating a new internal dialogue and learning and implementing new skills. Meichenbaum developed a three-stage coping skills program entitled stress inoculation. This program consists of three techniques (1)the conceptual phase: where the therapist and client work together to comprehend the stress inducing issue and attempt to reframe the stressful event conceptually, (2) Skills-acquisition and rehearsal phase: is about direct actions. Clients acquire and rehearse new self-dialogue techniques and stress management skills, (3) application and follow through phase: is emphasizing implementing the skills learned in therapy into the real world. Meichenbaum's cognitive behavior therapy is often ineffective for Middle-Eastern or Asian cultures. Disputing a motive or belief of a male in these societies is unacceptable. A therapist would need to be aware of this and modify their technique accordingly.

Two key psychological constructs, locus of control and locus of responsibility, as outlined by Kluckhohn and Strodtbeck's world-view model(Sue & Sue, 2003), can be useful in evaluating a client's level of acculturation. For example, a Japanese American client might present for treatment with a desire to fit in; thus rejecting her heritage and seeking to identify with the American culture. She may also view herself as a Japanese woman through the critical perception of an ethnocentric American rather than the culturally aware and sensitive woman that she has the potential to be. This client would benefit from encouragement to examine her beliefs about herself and her culture, and encouragement to question the paradigms that she has chosen for her worldview. The therapist would want to pose key questions regarding assimilation, such as: Why does she feel it is so important to fit in with the dominant culture? What value does her family place on their heritage? Additional important questions to be posed by the therapist regarding acculturation are: what does she like and dislike about the dominant culture and why? What benefits does she recognize in the dominant culture over her own heritage? What disadvantages? The therapist might also address her feelings of control and responsibility by posing questions, such as: How is she able to identify with the American cultural value of internal control? Did she feel that the Japanese culture failed to recognize the wisdom of the American emphasis on control? Or had she considered that perhaps an external locus of control might be a more accurate description of reality?

The capacity to accept oneself and take pride in oneself seems to be a cross cultural need of all people. Feeling shame or embarrassment about one's heritage can lead to insecurity. The beauty of worldviews, paradigms and other theories is that they can be changed. We, as growing human beings, can re-examine our assumptions and attitudes and reframe our perspectives.

An ideal therapist treating a multicultural population would embody Carl Rogers(1967) core facilitative conditions of congruence, empathy and unconditional positive regard. Congruence would inspire trust in clients, as most cultures are likely to trust an individual capable of living at their highest level of integrity and demonstrating behavior, choices and attitudes consistent with their internal value system. Empathy would be valuable because it would provide the client the opportunity to feel heard, understood, and accepted. Ideally, this client might feel that the therapist could see things from their perspective. Finally, unconditional positive regard would offer the client a safe and nurturing environment to explore themselves and deepen their self acceptance.

The helping process stages consist of five areas: relationship building, assessment, goal setting, intervention and action, outcome evaluation and termination(Young, M., 2005). Initially, the rapport building of the therapist would be paramount to a new client of a different cultural background. The established quality of that relationship would be the foundation upon which the evolving stages of the relationship would rest. The therapist should be attentive and demonstrate that they understand the client's situation through reflective and advanced reflective skills. In the assessment stage, the therapist should be efficient in gathering pertinent data, and choose open ended questions that delivered the maximum amount of needed tedious detail without making the client feel interrogated. It would be wise for the therapist to take notes, and later familiarize themselves with the client's data, so that they do not have to re-explain their story. The therapist should be sensitive to the client's need for encouragement and support; infusing the assessment stage with some of these nurturing qualities. The therapist should be enthusiastic and hopeful in the goal setting stage. After the counselor had adequately ascertained the clients problems and pertinent background issues (Young, M. 2005), the therapist should provide assistance in setting realistic goals to change what the client has control over. In drawing up the treatment plan, specific behavioral changes should be detailed that would bring about the clients goals. During the intervention and action stage, the therapist and client should rely upon the strength of the counseling relationship, the personal importance of the goals to the client, and use therapeutic measures instigated by the therapist that are acceptable, not necessarily comfortable, for the client(Young, M. 2005). Finally, the therapist and client should engage in the outcome evaluation and termination stage, where together they would evaluate the progress made toward the client's goals and whether continuing treatment was needed.

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