Thursday, March 2, 2017

You Say I Have a Problem. I Don’t Think So. Now what?

You Say I Have a Problem. I Don’t Think So. Now what?

By Kathryn Cortese, LCSW, ACSW, CEDS
You’ve heard it all – “I’m worried about you.” “You keep going to the bathroom after you eat. Is something going on?” “Why don’t you talk with me anymore?” “You’re looking kinda skinny. Is this a good thing?” “Why are you wearing a sweatshirt? It’s so hot today.” “You seem to be eating more lately.” “Are you sure you really need to go to the gym?” “How come you don’t come out with us anymore?” “How do you stay so thin?” “You mean the plumbing is clogged again?” “Where did the left-overs go?”
And you’ve heard – “I think you have an eating problem … an eating disorder.” “Are you bulimic?” “I don’t know why you think you look fat.” Etc. And, what you know is, “You think I have a problem and I don’t think so.” Now what?
Well, you can do nothing. You can keep secrets. You can sadly suffer silently. You can worry about numbers on a scale. You can stress about your next family gathering. You can try on 10 outfits before you decide what you’ll wear for the day. You can compare your hips to someone else’s. You can go online and look at Facebook and feel inadequate. You can wonder, “Do I look fat?” You can feel guilty because you ate 2 cookies. You can feel shameful because you ate a sleeve of crackers. You can get up at 4:00 am and exercise for 2 hours before work because you “have to.” You can tell yourself not to eat breakfast or lunch because you’re going out with friends tonight. You can remeasure your thighs with your hands. You can tell yourself you’re disgusting because you ate ice cream. You can shame yourself to tears.
But then, you can push the pause button instead and just wonder – wonder why certain people take their time to tell you they care and they are worried about you even though they know: you’ll blow them off, you’ll get annoyed, you’ll be defensive, you’ll leave the room. Why would someone approach you anyway? Can you write down some possible answers? While you’re writing, think about the character of the person who brought their concern to your attention. Is this a decent person? Is this someone with a good heart? Is this someone who would love to give you a hug? Is this someone who matters to you? Is this someone with good judgment and values?
So, why do these people approach you? Is there something in it for them? If so, what would that be?
Now, take a moment and make a list of your safe people. It may be one individual, or a few, or more. Who can you share your thoughts about this essay with? When you think about your safe person or safe people, what do you know about them? In order for a person to be “safe,” you need to feel trust. This is someone you’ve known to show a sense of humanity. This person respects you and sees you as a competent individual with skills and talents. This person walks the walk and lives by what he/she says. This person will tell you the truth, not just what you might want to hear and doesn’t take advantage of you. He/she is strong enough to be there for you, not control or try to control you, and gives you space. While being non-judgmental, this person will share his/her opinions and thoughts. This person makes good decisions which are based on reality. This person is also open-minded and is interested in you and your ideas. This person has earned your trust. Sometimes this “safe person” is a family member, a friend, a professional, someone at your school, someone at work, someone at your house of worship.
What if this is something you choose to do today – pick a person and talk about this essay. Let this safe person know that your goal in your conversation is to exchange ideas, not to agree or disagree. Just to talk. Go ahead. Give it a try.
And remind yourself you are amazing!

Transference and Countertransference in Working with Eating Problems

Transference and Countertransference in Working with Eating Problems – Part 1

By Susan Gutwill, LCSW
(This is the first of a 2-part series on the issues of transference and countertransference. Part II will continue next month in our April ENewsletter.)
The way one has been treated and the feelings it engendered in our formative early histories are repeated in every therapy couple. This is called transference. It is not a conscious process. But it is inevitable. If our patients have been abandoned, denigrated, abused, terrified, blamed, rejected, or taken over in their histories, they will transfer their learning from such relationships past, onto their expectation of us in the important intimacy of their current therapy relationship. Paying close attention to these patient expectations tells us a great deal about our clients’ early lives. ([1]Freud)
Freud established that transference was a critical piece of psychotherapy, similar to dreams, another “royal road to the unconscious”. He considered countertransference the therapist’s response to transference of the client, something about the person of the therapist, which should be explored in the therapist’s personal psychoanalysis and supervision. Many theorists/practitioners have changed and added to that original idea. Today, psychodynamic psychotherapists believe that transference and countertransference are both important tools within psychotherapy proper, as well about the therapist’s private life. We have learned from object relations, relational psychoanalysis, interpersonal, and inter-subjective theories, as well as from evidence based studies, that countertransference is equally inevitable and important to good treatment as is understanding transference. ([2]Racker, Wooley, Mitchell, Gill, Gill & Hoffman, Hoffman, Burke, Tansey & Burke) Feminist psychology, with its emphasis on nurturance, and equality and the anti-authoritarian stance the of the 1960’s and 1970’s have both impacted upon psychodynamic thinking positing that therapy should be based on a real, but bounded relationship. This relationship itself is a major part of the healing and growth our clients need, just as it is the base of all human needs for growth from babyhood throughout our adult lives.
Client’s feelings towards us inevitably pull for our own powerful countertransference feelings as well. Bion, Ogden and Racker, for example, teach us that the therapist’s countertransference response can be concordant or complementary ([3]Bion, Ogden, Racker).
For Racker, concordant countertransference feels like empathy, e.g. “oh how horrible that must have felt for you.” As therapists, our bodies and hearts may feel shaken, like we are sinking into the feelings our clients have. Often, when we share our concordant feelings, our clients feel understood, and grateful for our empathy and recognition. ([4]J. Benjamin)
Additionally, however, clients, (most especially, guarded anorexics), also may feel afraid of being deeply known and, therefore, open to being reinjured in ways they felt earlier in life. The theory of object relations by Ronald Fairbairn is particularly useful in working with eating and body image problems and trauma. He argues that when early dependency experience is very frustrating, even rejecting, we psychically split ourselves in order to accommodate the reality that we still have to depend upon the only caregivers that we have. We adapt by splitting our own ego, and unconsciously fantasize and imagine that we are the failures, ourselves. So, for example, we binge because we are afraid to admit to ourselves how hurt we are. It feels too dangerous to know our only caregivers are not reliable. We fantasize that if only we were better, they would love us, reliably enough. So, if we were only thinner, for example, we might yet be accepted, loved, and noticed. However, we further imagine, and the other side of the split screams at us, that we will never be good enough. There is really no hope. Thus, bad experience is internalized and split in two equally false options, an enticing part (if only I was thin) and a rejecting part (I’m hopeless, I want to shrink away, I am fat and ugly). This then becomes an inner relationship which is isolated, split off, and shut away from real human relationships in a deep freeze of profound fear. Fairbairn’s work in psychodynamic thinking, following earlier work by Ferenczi, opens us to the notion of the dissociative nature of the mind born of severe trauma. ([5]Aron, Ferenczi, Fairbairn, Hainer, Howell)
  1. W. Winnicott, writing at the same time, reminds us that being fed and held at the very beginning is the foundational relational experience required for life itself. Remember, that babies ([6]Spitz) which are fed but not related to, fail to thrive. Eating is a relational experience.
Winnicott, like Fairbairn’s ego objects, talked about an isolated part of self which he called  “the false self.” He meant that we accommodate to early caregiver’s needs to be safe in our dependent attachment. Hence, the goal of therapy is to find the potential to be a “true self,” never fully attainable, but the animus of a rich life which in itself is dependent on a safe early relationship of dependency. ([7]Winnicott)
In Therapy
In treatment, clients may show their fear of being known right away or more slowly and subtly, and they do so repeatedly at different stages of therapy. However and whenever these frightened warning signals become known to client or therapist, therapists may feel either concordant or complementary counter-transference.
Examples of complementary countertransference might look like the following. We sense our client is endlessly compliant and it begins to feel “off,” “unreal,” “impossible.” We ask ourselves, “What am I missing?” Therapists may feel pushed away from the relationship, like “who are you kidding? I don’t believe you.” And often we women therapists feel guilty for having such ‘non-idealized’ suspicious and angry feelings. ([8]Steiner Adair, Gilligan, Ruddick, Eichenbaum & Orbach, Chodorow) Women are supposed to nurture! And yet at this moment “if you keep kissing my rear end, I am going to go nuts!” This may be a case where empathy has flown out the window and a therapist feels controlled and as if they are being forced to live in a lie.
Complementary feelings are often dramatic and negative. Another example might be, “Do I have to hear you complain for the umpteenth time about how much you hate yourself for eating. We have been here so many times and you keep saying the same things, as if we had never worked on this.” Or we may ask ourselves “Why am I not buying this?” Or, “If I am so noxious to you, why don’t you go find someone else to work with?” Or, “You haven’t spoken in months. What are we doing here? Anything?”
Yet another countertransference response may indicate that we are swimming in the same soup as our clients, because of our own unresolved anxieties about eating and living in our bodies, i.e., I call this cultural countertransference and it is rarely discussed. I will expand upon this kind of countertransference in Part II of this series.
All therapists’ countertransference feelings are by definition, powerful. We alternatively may feel guilty, frightened, proud, fearful of confronting our clients, and more. But they all tell a story we need to enter and explore, again and again.
This critical and central piece of all our therapeutic work is carried out by what Harry Stack Sullivan, the father of Interpersonal Psychotherapy, called “detailed inquiries.” ([9]Sullivan) He meant that we “get into it” with patients, that we explore their thoughts, behaviors, and feelings in detail. In a sense, we need to hold the curiosity they do not yet have.
We therapists have to be able to join our clients, again and again and again when they come in telling us they binged, threw up, or ate without hunger. We need to investigate, in great detail, their many moments, or episodes, of hating their bodies, of shaming themselves because of their bodies. The complaints usually begin with the same ritual that sounds depressed and/or like a monotone or super anxiety and are all filled with despair: “I did it again.” “I hate myself.” “I am so fat.” “I feel disgusting.”  They may have eaten an entire pizza or a handful of grapes and a little bag of popcorn that was not on “their program.”
Our job is to bring these repetitive complaints that may sound like whining, alive. My definition of whining, by the way, is complaining without feeling entitled to the underlying pain. That is why they often sound annoying. But it is also hard to stay present when patients are super-anxious. These presentations regularly induce therapists into complementary countertransference responses.  Whatever the presentation, what helps is to ask questions like:
What had happened just before you felt so fat, this time?
What had happened on your way to feeling fat? How did it make you feel?
Do you feel you are entitled to feel that way? No? Why not? How were feelings and especially your feelings treated in your family, your marriage, your friendship group? How do you feel our society feels about these kinds of feelings? Where does that show up in your life?
And where do you feel that in your body? We need to bring our clients into their bodies, where all feelings reside. Sometimes I do an exercise where I ask my clients to close their eyes and feel the couch. I then do a progressive relaxation to help them focus and enter the space of feeling. Or, clients shaping themselves into body sculptures, for example, can enact in their bodies what the inner self looks or feels like. These methods are endless and are personalized to what the therapist knows about a particular client’s history.
A great deal of therapy time brings clients back to the feelings they had when alone, this time with the therapist in accompaniment as witness. After the intense focusing I have suggested, therapists might ask, “so how do you feel now?” This works with compulsive eaters and for binges.
With anorexics, the path is rockier. Their defenses embrace more of their being. In other words, there is less of a healthy central ego/self. Our job is less directive, educational yes, but more focused on their life story, trying to “hold” a space for growth of self-in-relationship.
In doing all this, there is an inevitable transference/countertransference dance that is very challenging and essential to the heart of good therapy. We work in a real relationship where our impatience, horror, love, empathy, and hate, registers and demands to be understood. When we become curious about the details of these feelings, it opens the door to compassion and finally, some dignity to otherwise entirely shameful feelings.
To help with this demanding process, the ethics of psychodynamic therapy ask us to have our own deep psychodynamic therapy as well as clinical supervision. These are required in order to notice and work with what is unconscious and embodied. It is essential that therapists know what this kind of therapy feels like and what it can accomplish. As my first long term therapist put it to me, “I need to be as clean as possible, to know where my own responses are coming from, so that I can help you.” How relieving that felt to hear! She could own her part of our relationship…“response-able.”

Overworked Overeaters

Overworked Overeaters

By Tory Butterworth, Ph.D.
As a psychotherapist who leads workshops in emotional eating, participants frequently ask me, “Why do I eat my feelings?” My experience shows there are four different flavors of emotional eating (also known as compulsive overeating or binge eating disorder.) Each of these patterns of overeating has its roots in a different stage of early childhood and requires different strategies to be overcome.
The acronym STOP can be used to remember these four types: Sampling or Grazing, Traumatized Overeating, Overworked overeating, and Picky overeating. In this blog, I’ll describe Overworked overeating, what it looks like, where it comes from, and first steps in making it stop.
Overworked overeaters power through the early part of their day, doing as much as they can and eating as little as possible, until tiredness and hunger overtake them. Many overworked overeaters skip breakfast. If they do eat breakfast, it is a low calorie meal, often lacking in sufficient protein and healthy fat to fuel a demanding work schedule.
Once they get going, overworked overeaters rarely stop to take breaks or eat a snack. Many of them will eat a quick lunch at their desk while continuing with the task at hand. Their first and primary focus is to accomplish as much as possible. Eating, relaxing, and socializing take a back seat to getting work done.
At the end of their workday, overworked overeaters find themselves hungry, tired, and frequently resentful of all the demands placed upon them. Dinner is not enough to fill them and they end up binging, usually in the late evening, on typical snack foods high in carbohydrates, fat, and either sugar or salt.
From a developmental perspective, overworked overeaters have not yet resolved issues which they first encountered when they were two to four years old, sometimes known as the “Terrible Twos.” At this age many children stage temper tantrums, demanding their own way rather than listening to caregivers’ requests. Children are learning about making their own choices and using their power to influence other people. “My way,” can become a frequent refrain of this time period. The terrible twos can be a hard stage for parents and children both.
Toilet training is also an important focus for this age. As children learn to control their bowel movements, they are taking on this task of self-mastery and sticking with it. This can leave them with a feeling of pride and accomplishment, and set the stage for them to take responsibility for other chores as they grow and develop.
But while taking responsibility is a sign of maturity, adults also need to know when to refuse it. Overworked overeaters are known to take on responsibilities at work, at home, with their children, or caring for people in difficult circumstances. If they are not discriminating, these overeaters risk biting off more than they can chew. They frequently have a hard time asking for help from others, or making statements like, “Right now, I just can’t take on one more thing.”
How can overworked overeaters begin to shift their eating habits? They need to practice doing things for themselves rather than others. Taking the time to eat a nourishing and well-rounded breakfast, including protein, a fruit or vegetable, and some healthy fat, is a great place to start.
Actually taking breaks during the work day to get up and walk, eat a healthy snack, or talk to a friend are other ways for overworked overeaters to give to themselves. Taking some “down time” after work to relax or go for a walk can be a great way to recharge before evening activities begin.
Another focus for overworked overeaters is learning to say “No” to some requests. It can be a breakthrough for these overeaters to realize they don’t have to take on everything that someone else left undone. Some projects are just not worth the effort. Sometimes, someone else will volunteer. Beginning to consider whether or not they want to take on a task can be an important step forward for overworked overeaters.
The, “Me, first,” exercise can also be useful for overworked overeaters. Draw a line down the center of a piece of paper to create two lists. The first list consists of the things you do for yourself.  The second list includes tasks you do for everyone else. Just looking at how long the second list is, compared to the first, can be eye-opening. Figuring out how to add to the “Doing for me” column and subtract from the “Doing for others” column can be difficult, but ultimately rewarding for this type of overeater.
Overworked overeaters have a tendency to place high demands on themselves and expect quick, perfect results. While this can be a strength at times, it can become self-defeating when they fail to measure up to their own (impossible) standards. Appreciating what they successfully accomplished at the end of each day, and what kind of difference it made for themselves or others, can keep their motivation high and set them on the road to adding further changes in the future.
Step by step, overworked overeaters can gradually begin creating a life which is about feeding themselves (both physically and emotionally) rather than just feeding others.

Wednesday, February 1, 2017

#DearNYFW - It's Time to Prioritize Health & Diversity!



New research published today in the International Journal of Eating Disorders confirms what we’ve all known for years - models are being pressured to lose weight or change their body shape/size, and as a result, disordered eating and full-blown eating disorders are rife in the industry. 
Pressure to conform to the ultra-thin beauty ideal hurts not only models but consumers as well. So, in advance of New York Fashion Week, NEDA has teamed up with the researchers, the Model Alliance, and more than 30 leading models - including Iskra Lawrence, Jennie Runk, Sabina Karlsson, and Geena Rocero – to call on the fashion industry to put health first! 
In the open letter we released today, these amazing models challenged the American fashion industry to make a serious commitment to promote health and diversity on the runway. Now we need you, as a consumer, to stand with them and make it clear that health and diversity on the runway are important to us all. 
Sign the public petition today and challenge the fashion industry to…
  • Make a serious commitment to promote health and diversity. 
  • Uphold the understanding that models under age 16 do not belong on the runway. 
  • Observe child labor laws in New York State, which require that models under 18-years-old have proper documents and schedules. 
  • Review the latest research on eating disorders and unhealthy weight control practices in the fashion industry and commit to working collaboratively with industry stakeholders and medical experts.
P.S Don't forget to spread the word and amplify the campaign on social media with #DearNYFW!

Influence of culture and ethnicity on eating disorders: Part 2 of 2

Cultivating Curiosity in the Treatment of Eating Disorders

By Malak Saddy RDN, LD
(This is second of a 2 part series on multiculturalism and diversity in the eating disorder community. To read part 1, click here)
As my sixth year in the role of a dietitian comes to a close, I am continually confounded at the under representation of cultural awareness and sensitivity in the treatment and handling of patients with eating disorders. Unfortunately, these significant areas are pretty much overlooked in our field.
One of the most common questions I’m often asked is, “How does an eating disorder begin?” Of course, the contributing factors of an eating disorder can be multifaceted and wide-ranging. Causes can be biological (genetic or hormonal imbalance), psychological (depression, anxiety, or low self-esteem) and social/cultural (environmental). This article explores the traditional food habits of different cultures and religious groups and how those customs have been adapted here in the United States. It focuses mainly on the Hispanic American and Asian American populations. It also touches on some of the religious sensitivities and food intake practices of the Jewish, Seventh Day Adventist, Muslim, and Hindu faiths, while also talking about some of the common challenges these populations may face, such as lack of acculturation, longer length of stay in treatment, decreased intake of traditional foods, and both nutritionally and non-nutritionally related health problems.
Culture is one of the most defining aspects of a society. It encompasses a complex system of beliefs, customs, dress, art, rituals, values, and even daily behaviors. Through culture, members often relate and identify themselves. Cultural intricacies and standards affect their lives from birth and are passed on to subsequent generations. In regards to eating disorders, it can have a profound effect on how the client sees his/her disorder, and how an individual reacts to treatment. Acquiring a better understanding and appreciation of different cultures and religious practices (essentials) will perhaps aid clinicians in understanding the behaviors, values, traditions, and beliefs of some of the various racial, ethnic, and religious groups they encounter.
Cultural competencies, which are defined by having “the ability to understand and respond effectively to the cultural and linguistic needs of patients or clients” (Brannon, 2004), are becoming necessary in educating clients. Gaining insight to these competencies helps ensure effective support and counseling and is accomplished by showing a professional attitude and appropriate communication skills. “Cultural competency is not an optional skill to learn; it is a necessity for all dietitians and healthcare professionals, regardless of their specialty” (Brannon, 2004). It is also important to develop personal cultural competencies: recognizing your own personal cultural biases and preconceived ideas or opinions; learning about and becoming involved with people from diverse cultures; seeking out and increasing your knowledge about other cultures; and learning and developing multicultural communication and counseling skills.
One common thread that runs across cultures around the world is food.  It is consumed for sustenance of course, but it also can indicate status, education, and position in a society. Food has the power to instigate and strengthen bonds among individuals, communities, and even countries with different traditions and customs. It can be pervasive with effects and connotations in many of the social, economic, and political aspects of a culture. Food related behaviors take on daily routines and in some cultures, specific rituals from cultivating to choosing, preparing, and then consuming the food are part of their mainstream lives. Harvests are celebrated across the world in some fashion or the other and bring joy to the community. Holidays, whether religious or secular, are celebrated with food. Each celebration is associated with different foods and tastes, that in turn are interconnected to the geography of the land, the seasons, and the customs.

Asian American 

The Asian culture revolves around respect for authority, especially toward the elderly, who are revered and held in high esteem. Women in most Asian societies are taught to be submissive and obedient. Punctuality and precision in any task or job are of utmost importance. Education is an integral part of the culture and is pursued by the majority of the people. Asian American women who have eating disorders may struggle with assimilating into a westernized culture. In a study comparing college women from China, Korea, and the U.S., Korean women showed the greatest degree of body dissatisfaction and disordered eating behaviors, followed by Chinese women, and lastly, U.S. women.

Hispanic 

Hispanic families are a close-knit group and they place great value on appearance, reputation, parents, and pride. More than 90 percent of Hispanics are Catholic and religion plays a significant role in their day-to-day life. Researchers at Harvard Medical School researched food behaviors in five generations of Mexican American women and found that second generation women exhibited the highest level of disordered eating behaviors. Due to the stereotype that eating disorders may only affect Caucasian adolescent girls, the diagnosis of an eating disorder in the Hispanic population is often under diagnosed and left undetected. Traditional foods include rice, beans, tortilla, avocado, corn, and tomato based foods and less milk and dairy options.
While motivation and hope from clients wanting recovery comes in different forms, faith can have a significant role in their recovery. A patient can seek conventional practices as well as rely on faith and a higher power for guidance. A study conducted in 2003 found that increases in spiritual wellbeing over the course of treatment resulted in healthier attitudes towards eating, improved body image, improvement in psychological symptoms, and less interpersonal conflict.

Judaism

Dietary laws play a significant role in the Orthodox Jewish faith, and keeping kosher can create barriers to clients getting treatment as well as the strong stigma surrounding mental health illnesses. In a study of ultra-orthodox and Syrian Jewish community in Brooklyn, 1 out of 19 girls were diagnosed with an eating disorder, a rate about 50% higher than the general U.S. population (Sacker, 1996). To keep kosher includes three basic rules: avoid any non-kosher animals (shellfish, land animals that do not both chew their cud and have cleft hooves), avoid eating meat and dairy together, and eat only meats slaughtered by Kosher guidelines. Food is in bountiful amounts during Shabbat and Jewish holidays, each holding their own specialty and heritage. Similarly, with the Arab culture, there is a constant pressure for women of marrying age to be thin and free of any mental health issues, therefore creating barriers against receiving treatment and an under-diagnosed population.

Islam

In the Islamic world, food traditions are often based around the concepts of halal (permitted) and haram(prohibited). Haram foods and drinks are mainly pork, pork products (ham, ribs, pepperoni, bacon, sausage, some gelatin), and alcohol. Halal meats refer to the slaughter of animals according to the Islamic rule; it also includes those animals that are hoofed herbivores. All able bodied and mentally stable adult Muslims are encouraged to fast during the month of Ramadan. It is a time of self-purification and reflection. In the case of patients with eating disorders, this can trigger and heighten the condition in clients who are Muslim. A clinician can recommend that the client abstain from other things such as social media or volunteer and help the needy to participate in the holy month. One can also speak to an imam to have this person provide their support in refraining from fasting from food/water especially during their illness.

Seventh Day Adventist

Other religions that have dietary laws include Seventh Day Adventist and Hinduism. Members practicing in the Seventh Day Adventist faith are a member of the Protestant sect and consider Saturday the day of Sabbath. Typically, Adventists are vegetarian or vegan, however, some may eat meat and it must be “clean” (chicken, beef, venison, lamb, and goat). There are eight basic principles for a healthy lifestyle and these include fresh air, sunshine, abstemiousness (self-discipline in abstaining from alcohol, caffeine, sugar, and drugs), rest, exercise, water, nutrition, and trust in Divine Power.

Hinduism

Hinduism has over 900 million followers and is the major religion in South Asian countries including Nepal, India, Sri Lanka, Malaysia, and Pakistan. Hindus practice following a strict vegetarian diet forbidding the consumption of eggs as well. Unlike most religions, Hinduism has no single founder or scripture and no commonly agreed set of teachings. Some Hindus practice specific dietary rituals including sprinkling water around their plate for purification, refusing food that is not offered to God first and, therefore, having God’s blessing, and saving five pieces of food to acknowledge the debt owed to the divine forces.
Barriers to treatment and lack of support from family all are similar within the cultures and religions. Literacy in English is a highly significant barrier to appropriate health care and education. Education among immigrants is low and many find jobs that are directed towards the auto industry, simple business, and unskilled jobs. This is gradually changing, as children of immigrants are seeking and obtaining higher education and life standards. Lack of transportation within families can impede appropriate health care delivery. Due to low literacy rates and lack of resources, most don’t feel comfortable taking public transportation. Insurance coverage is limited and financial resources can be barriers that also affect preventative health care.
Different cultures, religions, and ethnicities are becoming more exposed in the United States, and in order to provide appropriate health care and education, clinicians are learning how to meet their needs. While many immigrants assume exceptions to be made to their cultural norms, many do adopt the American lifestyle including food portion sizes and fast food menus, while still trying to maintain their own cultural food habits.

Influence of culture and ethnicity on eating disorders: Part 1 of 2

The Little Girl with the Hummus Lunch
By Malak Saddy, RDN, LD
***This is the first of a two-part series that addresses the significance of culture and ethnicity in eating disorders treatment.
Food, religion, culture, and traditions are part and parcel of humans’ daily lives. It is perhaps the most unifying aspect of humanity. Past our bodily needs for nourishment, and sustenance, what, where, how, and perhaps with whom we eat, identifies us. Throughout history religious holidays worldwide have been celebrated with different foods and traditions as part of the gatherings and festivities, with each holiday having its soul dish, or dishes, reflecting that culture’s resources and the ethnicity of its people. Yet, for me it took two decades to appreciate being that unique individual.
The scene at the elementary cafeteria table was always awkward, cautiously pulling out my piece of pita bread, and tub of hummus from my lunchbox, and explaining it to all the girls sitting around me. I winced at the smell of fresh garlic while they were eating their crust-less peanut butter and jelly sandwiches, and sipping on Hawaiian Punch. I was always trying to avoid their repulsion, and stares, finally swallowing it down as quickly as possible in a private moment of humiliation. I wanted so desperately just to have a simple white bread sandwich in my lunchbox, or at least a cool name for the creamy mush that I brought in, almost every day.
Socializing outside of school was similarly loaded. On the rare occasion my parents would let me go to a friend’s birthday party, I quickly learned that the cheese pizza would vanish first and I would almost never get enough. Chuckie Cheese’s pizzas were always layered with loads of pepperoni and ham and as a Muslim, I couldn’t eat it—there’s a dietary prohibition on pork in Islam. I learned later, after experience and a couple of misses, to always leave my game machine no matter how close to winning I was, and be one of the first ones at the table, so I could get first dibs on a slice of cheese pizza.
My childhood insecurities were my earliest cognizance of the implications food has in our culture and our lives. My childhood home’s food supply was ruled by an American-Lebanese health nut (my mother) who only gave us cookies from packages scrawled with the words “oatmeal” and “flaxseed,” and always made sure we had protein for breakfast before going to school, even if that protein came from a can of tuna at 7 a.m.! She took advantage of our Middle Eastern ethnicity (hence the hummus for lunch), using that cuisine’s traditional ingredients like olive oil, cracked wheat, and plain yogurt, and infusing them with some of the American recipes she would find in health magazines. The results, always beautiful homemade meals, and the aroma of freshly cooked ingredients, welcomed us every afternoon coming back home from a long day at school.
Her nutritional awareness, and cautiousness, stuck with me. Preventing my father’s organs from being ravaged by diabetes was dependent on the foods we ate as a family. As his children, we are also genetically predisposed to diabetes, so nutritional meals and good eating habits were of utmost importance.
The positive and negative of that food equation mattered, I realized. I used that realization, but not always in a productive way. My later relationship with food was altered by the culture and media around me. Regardless of the foundation my parents instilled in me as a child, the media was more powerful and had the upper hand. Magazines, television ads, and billboards always displayed the skinniest, most beautiful girls, even if the ad was for dog food! There was no escape. I didn’t know how I could channel my good and bad experiences about food until I decided I wanted to become a dietitian with a focus on eating disorders.
Upon agreeing to write this article, I decided to dig a little deeper past my own personal definition of culture. When you Google the word “culture,” multiple definitions come up: top stories on how MTV is gearing more towards the young culture; creating positive cultures in the work place; culture of cheese; and the biological culture of bacteria. The definition that held true throughout my research, and was pertinent to this article was “culture is a way of life of a group of people—the behaviors, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next.”(https://www.tamu.edu/faculty/choudhury/culture.html)
Food consumption, restrictions, variety, and resources in a society, all affect that culture. As dietitians, therapists, or clinicians in this field, we must be thoroughly aware of our clients’ religious, and cultural backgrounds, to help build their trust in us, and be able to eventually help themselves through their personal recovery process. In my next part of this series, I will discuss the Hispanic and Asian ethnicities touching on cultural norms, dietary values, and common ingredients and foods used within each group. Religious sensitives of the Muslim, Jewish, Seventh Day Adventist, and Hindu population will also be broken down all in part to better prepare us before meeting with clients who identify to a specific faith or culture.

How Treatment Providers Can Undermine Access to Care for Binge Eating Disorder

How Treatment Providers Can Undermine Access to Care for Binge Eating Disorder

By Cyndi Eddington, Ashley Solomon, Psy.D., and Angela Woods
Over the last several years, laws in the United States have expanded insurance coverage and made treatment more accessible to individuals with binge eating disorder. While true parity and access to care for marginalized populations remains unrealized, we have seen strides in our country. Providers have in many cases been vocal advocates and helped to push important legislation and change forward. Unfortunately, however, there are still many ways in which providers may inadvertently be working against the process. If you are invested in being one of these individuals, follow our how-to guide below.
  1. Failing to recognize how being underinsured may impact your patients.
While the Affordable Care Act has increased access to health insurance in the United States, over 31 million insured Americans continued to face underinsurance through 2014 (Commonwealth Fund, 2015). Even those with plans through their employer are increasingly likely to be underinsured. Being underinsured means that, despite having health insurance, an individual cannot adequately afford the deductibles or other out of pocket costs associated with the plan. The result of this is that even those with health insurance are not accessing care when they need it. We know that patients with binge eating disorder face a myriad of barriers to accessing care, such as lack of early identification and social stigma, and underinsurance is a very real and prevalent barrier as well. For those patients who do start treatment, recognize that underinsurance may play a role in early termination of care or refusal to seek higher levels of care even when needed. Perhaps most frustratingly, dropping out of treatment due to resource constraints like underinsurance further undermines patients’ confidence that treatment could eventually be feasible or effective.
  1. Don’t attempt to specialize. Why limit yourself?
Not only do our patients deserve expert care, but we elevate the standards and enhance the legitimacy of our work when we support specialization. Insurance companies take our field more seriously when we can demonstrate the specialized education and training required to effectively treat this population. Even in the absence of “requirements,” we can enhance our own specialization by obtaining additional education through workshops and conferences, attending webinars, reading journal articles and books, obtaining supervision, participating on listservs, and joining consultation groups. Becoming the most knowledgeable clinician you can be is a gift to yourself and to patients with binge eating disorder.
  1. Turn a blind eye to the most up-to-date evidence on treatment efficacy. What’s an “RTC” anyway?
Research has limitations, such as, at times, failing to include diverse populations and failing to capture important aspects of the work. However, dismissing the evidence in favor of what we feel works is doing no service to our patients. Many of us get caught in doing the familiar – what we trained on many years ago or what fits best with how we see ourselves. There, of course, needs to be a match between therapeutic style and intervention, but we also must stay abreast of the latest evidence base. The advances in neurobiology and behavioral science are accelerating, and to turn a blind eye means our patients may not be getting the most effective and evidence-based care. It also leads to insurance companies questioning our interventions, and perhaps rightly so in some cases.
  1. Assume that obesity and binge eating disorder are essentially the same issue. It makes life easier.
Conflating obesity and binge eating disorder does a disservice to everyone. We’ve observed providers utilizing inaccurate codes, for example that do not appropriately reflect the patient’s diagnosis or work that they are doing. While this may seem to help this particularly patient in accessing the care that they need, it perpetuates dangerous myths, such as that medical issues are of primary importance and behavioral health is secondary. It also leads to inaccurate assumptions, such as that all patients with binge eating disorder are obese or that all obese individuals have binge eating disorder. We know these are not true statements, and it limits our ability to have a more appropriate understanding of each of these realities.
  1. Come up with your own criteria for what level of care your patients need.
The American Psychiatric Association’s level of care guidelines (2000) were admittedly not written with patients with binge eating disorder in mind. However, they can be utilized as a valuable resource in conceptualizing a patient’s ability to function and interrupt their symptoms at each level of care. Frequently, patients with binge eating disorder are under-treated for their conditions, due to both difficulty for the patient in honestly disclosing their challenges, as well as providers continuing to treat patients even when the current level of care has failed the patient. Staying attuned to the level of care guidelines can help avoid patient frustration and exacerbation of symptoms, as well as help support our field as a whole in advocating for the appropriate coverage of the necessary levels of care.
  1. Treatment plans are for trainees. You know what you’re doing.
Having a formalized process for documenting your planned interventions is imperative. It helps to organize and keep you on track as a clinician. It gives the patient a tangible road map of their care, which they deserve to have. And, it helps us stay accountable to payors and other stakeholders that we are holding ourselves responsible for doing what works. Treatment plans will need to evolve as the treatment progresses and are not meant to be artificially limiting. Everyone involved in the patient’s care deserves to have an outline of what to expect and what you can offer.
  1. Just write down the bare minimum. You don’t want those notes subpoenaed!
Some clinicians express concern that more thorough documentation of the care will put patients at risk for confidentiality issues. In fact, some clinicians elect to not accept insurance for just this reason – they cannot guarantee that patient’s records will be kept confidential. On the flip side, there are many cases in which patients rely on accurate and comprehensive documentation, whether for their own understanding, appealing insurance decisions, or for legal matters. It is my belief that judicious and thorough documentation is a benefit to the patient and helps to accurately demonstrate the care that is being undertaken. If it’s not written down, it didn’t happen, after all!
  1. Leave it to your patients to figure out how to advocate with their insurance companies. It’s not your job to deal with that.
When insurance fails to cover treatment, not only does it potentially prevent or halt the important care that a patient is receiving, but it sends a subversive message to the patient: your illness isn’t serious enough to cover. This is one of the many reasons that a provider must support a patient in advocating for the necessary care. As providers, we are not simply sounding boards; we are active change agents that have the privilege and duty to advocate for those in our stead. We can do this from the outset of treatment by creating a process to explain insurance to our patients in understandable and empowering terms. If challenges do arise with coverage, help guide patients through the process and understand their rights as a consumer. As we know this process can be overwhelming, strive to involve support persons in the process, as well. And make yourself available for writing a letter, conducting an appeal via phone, or talking through the process.
  1. Stay siloed in your office and complain about insurance companies on Facebook.
Just as we instill in our patients, change – both at the individual and social level – begins with action. Our frustration with the insurance process will leave us – well, frustrated – unless we harness our energy to elicit real change. This means, first and foremost, getting educated on our healthcare system. Understand your own and your patients’ rights as healthcare consumers. 2016 saw landmark progress in mental health reform in large part because the eating disorder community was advocating tirelessly on its behalf. Real change happens when we educate ourselves, connect with others who are passionate as well, and use our voices.
  1. You don’t understand insurance, it’s way too complicated – that’s not what you went to school for! You want to provide therapy, not file insurance claims.
How much do you charge for your most utilized service? How much does your most utilized insurance company pay for that service? We have been living in an age of health insurance transition for the past few years, and we have been promised further transition in the future. Oftentimes, providers will be separated from the billing and insurance process. As providers, we can relate to the consistently confounding task that can follow health insurance coverage. Similar to the old saying, ‘it takes a village to raise a child,’ the same group effort requirement is felt when attempting to understand today’s health field. Transparency can start at the reception desk, but it should continue in the doctor’s office. We would not only be advocates for good mental health and well-being, we would also benefit our patients by providing reliable information about our own billing process.
Next, we need to help our neighbors understand insurance and billing procedures. What are the best sources for reliable updates on the health field and the mental health field? Share them with your fellows. What benefits or concerns are coming from the most recent legislation passed? Offer training for your coworkers, or put together a quick webinar for anyone interested. By working together, we can help each other understand, at the very least, how much we don’t know. Read insurance guidelines, build relationships with the insurance utilization reviewers, celebrate the calls that get coverage, and appeal, appeal, appeal.
Many difficulties are coupled to the Binge Eating Disorder that are not immediately evident. Fewer earnings, diminished workplace productivity, and lower probability of being employed are all potential by-products of the Binge Eating Disorder. The best way to recommend and advocate for appropriate treatment is to understand what it means clinically, as well as financially for the patient. Insurance is supposed to ease this stress, yet the utilization review process can often be a stress-inducing part of treatment. We cannot truly advocate for well-being if we are ignoring the highly stressful process of insurance authorization, finances, and appeals.
  1. Patients using their insurance should be very concerned about a mental health diagnosis being listed in their permanent record. That’s a primary reason not to work with insurance, we need to protect our clients.
As healthcare providers we should question how helpful and perhaps antiquated it is to endorse shame, fear, and concerns of self-incrimination for doing what individuals do every day – use their insurance to assist in payment for medically necessary care by healthcare experts.  The medical community does not villainize the ICD-10 and, conversely, the behavioral health community should not utilize DSM 5 as a tool for fear mongering.   Continued endorsement of this credence only serves to further stigma and shame for those needing mental health care.  As reported by Psychological Medicine, 2014, stigma ranked as the 4th highest of 10 barriers to mental health care.
  1. The insurance panels are full and they pay poorly. It’s impossible to work with them.
How much medical care would you and your family receive if you didn’t use your insurance to pay for services provided by participating providers, e.g., family practice doctor, pediatrician, orthopedist, cardiologist?  Likely, many of us would not be receiving necessary medical care.  The same is true for those needing quality mental health care – in the February 2014 issue of JAMA Psychiatry, Bishop et al., found that in 2009/2010 a lower percentage of office-based psychiatrists accepted health insurance (55.3%) compared to other office-based specialist physicians (88.7%). Bishop et al. also report the rate of participation in health insurance networks has declined faster among psychiatrists in recent years than among other specialists. We need to improve access for those clients who need your expertise.
Specialty medical providers often create IPA’s (individual practitioner associations) which support investments in improving contractual reimbursement, streamlining credentialing, and insurance communication.   It is time for eating disorder experts to band together and advocate for reasonable reimbursement for expert care at all levels of service.  Remember, “There is always strength in numbers.  The more individuals or organizations that you can rally to your cause, the better.” Author Mark Shields.
Disclaimer:  Numbered statements are intended to be provocative and exaggerated as a means of engaging the reader in the subject matter.  The authors have the utmost respect for the professionals who provide care on a daily basis to those with Binge Eating Disorder.