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Culturally Sensitive Eating Disorders Treatment for Latinas

Culturally Sensitive Eating Disorders Treatment for Latinas

By Mae Lynn Reyes-Rodríguez, PhD, FAED

Compared with their European White counterparts, the prevalence of eating disorders in Latinxs is equal or greater, particularly with binge-spectrum eating disorders.1-3 However, the lack of representation of the Latino population in clinical trials for eating disorders raises questions about the feasibility and suitability of the current evidence-based treatments that were developed and tested primarily for European Whites. Language barrier, lack of health insurance, and migratory status are some of the contributing factors related to the lack of representation of Latinxs in clinical trials.4 In general, Latinxs have underutilized specialized treatment, particularly mental health services.5 Studies conducted with Latinxs with a history of eating disorders have found that they are less likely to seek professional help compared with non-Hispanic Whites.1,6 The stigma about having an eating disorder, system barriers (e.g., lack of health insurance, language barrier, and clinician bias), and personal barriers (e.g., lack of motivation, family privacy, fears of not being understood, not ready to change, lack of knowledge of resources) are some of the treatment barriers identified by Latinas with a history of eating disorders.7 Therefore, it is important to make treatment more accessible, relevant, and culturally sensitive for Latinxs in order to tackle those treatment barriers and reduce the health disparity.   

Currently, three main studies have been published in the United States focused on cultural adaptations of some form of cognitive behavioral therapy (CBT) for binge-spectrum eating disorders in Latinas.8-11 These studies concur with the feasibility and appropriateness of the use of CBT in Latinas with binge-spectrum eating disorders; however, some cultural adaptations might enhance the treatment and make it more culturally sensitive. Cultural adaptations seem to be more appropriate and needed for Latinxs with a low level of acculturation.12 Moreover, the integration of cultural values into treatment is recommended in order to provide culturally sensitive treatment.13-15 Familism and personalism are some of the cultural values that are relevant in the delivery of the CBT for binge-spectrum eating disorders. Both are core cultural values in the Latino culture. Familism reflects the centrality of family and the interdependency and loyalty among family members independently of the age of family members.16 On the other hand, personalism refers to the emphasis that Latinxs put on close relationships, particularly those that are respectful, caring, and well-meaning.15   

Consistent with familism, these studies have found that adding a family member as a support can enhance engagement and retention10,15,17 and the overall treatment experience.11,17 Usually, family members are willing and want to support the loved one who is struggling with an eating disorder, but the lack of information and understanding on how to provide support increases the frustration in both the patient and the family member.18 Incorporating a family member into treatment has shown multiple benefits.17 First, receiving psychoeducation about eating disorders from a professional can help to address the stigma and provide specific tools regarding how to support the loved one, particularly in the Latino population, where eating disorders aren’t a topic that is openly discussed. Second, in some cases, family members have been key in providing practical support such as transportation or appointment reminders. This practical support can be essential for increasing retention in treatment. Third, the integration of a family member can facilitate positive changes around the eating pattern, as patients can incorporate the recommendations of a meal plan into what the entire family unit eats. To maximize the benefit of the inclusion of a family member in treatment, it would be important to have a collaboration process with the patient to identify the best family member (or significant other) to incorporate and what specific issues the family member can help the patient with.

Although no major changes are suggested in the content of CBT for binge-spectrum eating disorders in the cultural adaptation studies conducted with Latinas, the enhancement of the cultural adaptation seems to be more relevant in the delivery process. In addition to the integration of a family member, considering the value of personalism during the treatment delivery would make the experience more culturally sensitive to Latinxs. Navigating through a different culture with a different language can be very stressful, particularly for those who are less acculturated. Finding ways to provide additional support (e.g., using an interpreter if the provider isn’t bilingual, identifying community resources to supplement treatment, calling for appointment reminders, providing specific instructions to arrive to the clinic, etc.) can be perceived as caring by Latinx patients and, therefore, help with the rapport and therapeutic alliance. Other aspects to take into consideration are the suspicions and fears that undocumented patients have because of their migratory status. Sending a clear message that treatment is a safe space for them would be an important component of developing a trusting therapeutic relationship.

Working with diverse populations, specifically with Latinxs, requires being mindful of cultural values and culturally related stress and context. This population navigates through multiple cultural aspects (e.g., migratory status, acculturation, language barrier, acculturative stress, discrimination, food insecurity, etc.), which adds another level of stress to the treatment process. Although some of these variables are out of our control, just acknowledging and validating the patient’s experience would create a nurturing and warm environment for Latinx patients. Identifying community resources that can provide support on those cultural aspects allows for treatment to focus on the eating disorder component. The lack of health insurance can be a huge barrier for those patients who require a higher level of care, making early detection a key factor in properly identifying and treating the eating disorder symptoms in the Latino population. Raising awareness about eating disorders in Latinxs and providing information about resources available and how and where to seek professional help is a crucial part of decreasing the stigma and augmenting early detection. Due to the low service utilization of specialized treatment in Latinxs, primary care setting detection could be a promising avenue. Providing the tools and skills to primary care physicians to screen for eating disorders and make a referral for specialized treatment can be an important step toward decreasing the health disparity in Latinxs struggling with eating disorders.

About the author:

Mae Lynn Reyes-Rodríguez, Ph.D., FAED is clinical associate professor at the Center of Excellence for Eating Disorders in the Psychiatry Department of the University of North Carolina at Chapel Hill. She is fellow of the Academy for Eating Disorders (AED) and Expert of Content for the National Center of Excellence for Eating Disorders (NCEED). As a researcher and clinical psychologist, she has devoted her clinical research career to adapt eating disorders treatments for the Latino population in Puerto Rico during her early career and later with Latinos in the mainland, particularly in Central North Carolina. She has published numerous papers and book chapters on cultural adaptation for depression and eating disorders. Dr. Reyes-Rodriguez is the current Editor-in-Chief of the Puerto Rican Journal of Psychology. She is actively involved in the Latino community as a columnist in one of the main Latino Newspapers in NC, La Noticia in which she provides psychoeducation on mental health in order to raise the awareness and reduce the health disparities.

References:

1. Marques, L., Alegria, M., Becker, A. E., Chen, C. N., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders, 44(5), 412-420.

2. Perez, M., Ohrt, T. K., & Hoek, H. W. (2016). Prevalence and treatment of eating disorders among Hispanics/Latino Americans in the United States. Current Opinion of Psychiatry, 29(6), 378-382.

3. Udo, T., & Grilo, C. M. (2018). Prevalence and correlates of DSM-5-defined eating disorders in a nationally representative sample of U.S. adults. Biological Psychiatry, 84(5), 345-354.

4. Reyes-Rodríguez, M. L., & Franko, D. L. (2020). Cultural adaptations of evidence-based treatments for eating disorders. In C. C. Totolaini, A. B. Goldschmidt, & D. Le Grange (Eds.), Adapting evidence-based eating disorder treatments for novel populations and settings: A practical guide (pp. 3-30). Routledge.

5. Alegria, M., Chatterji, P., Wells, K., Cao, Z., Chen, C. N., Takeuchi, D., Jackson, J., & Meng, X. L. (2008). Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatry Services, 59(11), 1264-1272.

6. Coffino, J. A., Udo, T., Grilo, C. M. (2019). Rates of help-seeking in US adults with lifetime DSM-5 eating disorders: Prevalence across diagnoses and differences by sex and ethnicity/race. Mayo Clinic Proceedings, 94(8), 1415-1426.

7. Reyes-Rodríguez, M., Ramírez, J., Patrice, K., Rose, K., Bulik, C. M. (2013). Exploring barriers and facilitators in the eating disorders treatment in Latinas in the United States. Journal of Latina/o Psychology, 1(2),112-131.

8. Cachelin, F. M., Shea, M., Phimphasone, P., Wilson, G. T., Thompson, D. R., & Striegel, R. H. (2014). Culturally adapted cognitive behavioral guided self-help for binge eating: A feasibility study with Mexican Americans. Cultural Diversity & Ethnic Minority Psychology, 20(3), 449-457.

9. Cachelin, F. M., Gil-Rivas, V., Palmer, B., Vela, A., Phimphasone, P., de Hernandez, B. U., & Tapp, H. (2019). Randomized controlled trial of a culturally-adapted program for Latinas with binge eating. Psychological Services, 16(3), 504-512.

10. Reyes-Rodriguez, M. L., Watson, H. J., Smith, T. W., Baucom, D. H., & Bulik, C. M. (2021). Promoviendo una Alimentacion Saludable (PAS) results: Engaging Latino families in eating disorder treatment. Eating Behaviors, 42, 101534.

11. Shea, M., Cachelin, F. M., Gutierrez, G., Wang, S., & Phimphasone, P. (2016). Mexican American women’s perspectives on a culturally adapted cognitive-behavioral therapy guided self-help program for binge eating. Psychological Services, 13(1), 31-41.

12. Griner, D., Smith, T. B. (2006). Culturally adapted mental health interventions: A meta-analytic review. Psychotherapy: Theory, Research, Practice, Training, 43(4), 531-548.

13. Bernal, G., & Domenech Rodríguez, M. (Eds.). (2012). Cultural adaptations: Tools for evidence-based practice with diverse populations. American Psychological Association.

14. Bernal, G., & Scharrón-del-Río, M. R. (2001). Are empirically supported treatments valid for ethnic minorities? Toward an alternative approach for treatment research? Cultural Diversity & Ethnic Minority Psychology, 7(4), 328-342.

15. Reyes-Rodríguez, M. L., Baucom, D. H., Bulik, C. M. (2014). Culturally sensitive intervention for Latina women with eating disorders: A case report. Mexican Journal of Eating Disorders, 5(2), 136-146.

16. La Roche, M. J. (2002). Psychotherapeutic considerations in treating Latinos. Harvard Review of Psychiatry, 10(2), 115-122.

17. Reyes-Rodríguez, M. L., Watson, H. J., Barrio, C., Baucom, D. H., Silva, Y., Luna-Reyes, K. L., & Bulik, C. M. (2019). Family involvement in eating disorder treatment among Latinas. Eating Disorders, 27(2), 205-229.

18. Guadalupe-Rodríguez, E., Reyes-Rodríguez, M., & Bulik, C. M. (2011). Puerto Rican eating disorders treatment: The role of family. Revista Puertorriqueña de Psicología, 22, 7-26.

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