The (In)Visible Other: Intersubjectivity, Blackness, and Eating Disorders Treatment
By Marvice D. Marcus, PhD
Identity and Representation
Sociodemographic factors heavily influence our experience of the world. Physical and mental health outcomes are two of the domains in which identity yields fascinating and sometimes harrowing information about individual lives. Arguably one of the most powerful social determinants of life chance is race, an otherwise troublesome organizing principle buttressed by colonial thought. Understood as specious in nature, race as a construct is far-reaching and governs material and immaterial realities. For example, blackness is a sociopolitical construction that engenders a great deal of contested meaning in the public imagination. Historically, the ascription of blackness has translated to (in)visibility and erasure (Gibson, 2010; Westmoreland, 2017), ethnoviolence (Helms, Nicolas, & Green, 2012), pernicious commodification (Leonard, 2006; Lozenski & Chinang, 2019), and general social death (Hartman, 1997; Sexton, 2011). Contextually, research suggests that race, among many identity variables, profoundly dictates unmet mental health needs for Black people (Alang, 2019), with eating disorders treatment being an ongoing topic of discussion in clinical science and education literature (Rodgers, Berry, & Franko, 2018).
Scientific inquiry has produced mixed results with regard to incidence of body image disturbances in Black communities (Udo et al., 2016), and yet a fundamental curiosity remains: To what extent does racial bias compromise the integrity of epidemiological measures, assessment, and intervention, and psychological practice? Smith (2013) and other proponents of rigorous theorizing of culture and human behavior (Hall, 1976) provide concrete tools to critically examine power. Mattering and representation come to exist by way of power and social influence, and thus discussions centered on eating disorders and race must incorporate an analysis thereof. As such, in the sections to follow, salient themes about eating disorders pathology are reviewed as it pertains to Black people, before charting material on intra- and interethnic treatment dyads. Finally, concluding remarks will briefly highlight the significance and utility of advancing criticality principles (e.g., Hall, 1976; Martín-Baró, 1996; Smucker, 2017) in mental health and allied fields.
Noteworthy is the phenomenon of cultural mistrust in Black communities. Whaley (2001) describes cultural mistrust as a form of healthy paranoia, particularly in health care settings, wherein unfair treatment of Black people is rampant. Questions about provider competence and guardedness are often indicative of cultural mistrust. More recently, educators who adopt a critical lens of inquiry have, in many ways, nuanced conversations about cultural mistrust by integrating research on antiblackness (Dumas, 2016; Dumas & ross, 2016). A discussion on antiblack racism (ABR) is pertinent to cultural mistrust in light of deafening neoliberalism, which seeks to rewrite America’s sordid history of race relations and hostility toward difference. In addition, I contend that ABR, a permutation of racism, provides additional clarity on the reasons why Black people avoid coming into contact with systems, including the counseling/psychotherapy enterprise. How, then, does one thoroughly explain the dynamic interaction between Black subjectivity and body image disturbances? A starting point is an embracing of identity, namely blackness, in the counseling discipline. This contention is supported by the vast stock of literature focused on identity formation, as Black individuals customarily privilege race as a central marker of their subjectivity (Lee, 2018).
Stock of Literature
Quantitative (Blostein, Assari, & Caldwell, 2017) and qualitative (Capodilupo & Kim, 2014) methods have been used to examine disordered eating within Black communities. A universal thread within most, if not all, of the studies is inequality and inequity. More specifically, racial subjugation and acculturative stress (Kroon Van Diest, Tartakovsky, aStachon, Pettit, & Perez, 2014) are hallmarks that foreground the ubiquity of Black marginality as interpersonal and systemic indignities. The bulk of research, furthermore, tends to focus on Black women (Ross, Gipson-Jones, & Davis, 2018) and adolescent children (Botta, 2000), with binge eating emerging as the primary concern (Blostein et al., 2017; Taylor, Caldwell, Baser, Faison, & Jackson, 2007; Udo et al., 2016). Body image dissatisfaction, including a slight preference for slenderness, has also been observed (Anderson-Fye, 2018; Capodilupo & Kim, 2014; McKay, Moore, & Kubik, 2018). Some research suggests that ethnic minority boys are at a greater risk for reporting disordered eating (Beccia et al., 2019), although sampling limitations should be considered before overestimating results. At large, eating disorders studies conspicuously focus on White, non-Hispanic women (Palmer, 2007) and elucidate a hegemonic cultural production in the collective unconscious. Critical scholars urge us to interrogate the “normal” as “abnormal” (Martín-Baró, 1996), while bearing in mind the politics of power, representation, and mattering.
Intraethnic Treatment Dyads
The efficacy of therapist-patient matching has long been a topic of conversation and research (Foster et al., 2009; Karlsson, 2005), particularly when confronted with the violence of “racial realism” in the greater polity (Bell, 1992, 2005). Cabral and Smith (2011) conducted a meta-analytic review of studies focused on therapist-client matching along racial/ethnic lines. Data from the study explicated that Black people moderately prefer a therapist with a shared racial identity. Other research (Shin et al., 2005) has produced conflicting data sets pertaining to preference, perception, and outcomes. Therapist-patient matching is emblematic of interpersonal dynamics within complex social milieus, which raises curiosities regarding within- and between-group racial subjectivity. In fact, Hall (1976) hypothesized that cultural subgroups have their own (collective) unconscious. A narrative approach to service (Semmier & Williams, 2000), be it in the form of research or counseling, may assist behavioral scientists and practitioners with making inferences about identity-based ego processes and social functioning. Eating disorders are exceedingly cultural phenomena; therefore, critically interacting with lived stories (e.g., Fraser, 2004; Wolgemuth, 2014) vis-à-vis therapy is a liberationist intervention.
The rapidly changing social fabric of America, including Black communities, gives professionals who specialize in and/or treat eating and body image concerns (EBIC) an opportunity to reflect on how they bring themselves to bear on their work with consumers. Considering the highly relational nature of counseling, examining how and why racial identity and cultural values and priorities emerge during interactions with other Black people underscores the significance of reflexivity—say, in social work practice and education, for instance (D’Cruz, Gillingham, & Melendez, 2007). Aron (2000) provided an excellent articulation of the concept:
Reflexive self-awareness is both an intellectual and emotional process; involves conscious and unconsciousmentation; draws on symbolic, iconic, and enactive representations; and involves the mediation of the self-as-subject with self-as-object, the “I” and the “me,” the verbal and the bodily selves, the other-as-subject, and the other-as-object. (p. 667)
Reflexivity will plausibly include meditation on technical components of prevention, case conceptualization, and intervention. However, it is equally important to consider the more abstract and interpersonal dimensions of identity. This contention is proposed based on relational (Davies et al., 2006) and/or attachment-based EBIC formulations (Tasca, Ritchie, & Balfour, 2011) that, ideally, allow for intersubjective, identity-informed processes.
Clients who present to counseling with florid eating disorders are typically in a great deal of psychic pain or suffering the effects of familial turmoil. The constellation of symptoms—e.g., perfectionism, anxiety, mood lability, compulsive behavior, medical complications, extreme guilt and shame, and dysphoria, to name a few—typically has a stronghold on the counselor’s attention. Though consequential, preoccupation with symptoms eclipses the expression of curiosity, here, between two Black people. Racial/ethnic pairing conceivably sensitizes the therapist to the subtleties that exist within the interplay between race and eating disorders. Where appropriate, careful leveraging of racial homogeneity can illuminate ego processes and contextual factors that otherwise lay dormant in interethnic helping dyads, especially when one considers the life-giving nourishment of ethnic pride (Brown, 2008; Lesane-Brown, 2006; Rodgers et al., 2018) expressed among/between a vast number of Black people. The experience of blackness is innumerable, however, and highly dependent on other identity intersections and social location. Accordingly, racial myopia can conceal difference and ultimately silences a subgroup of people who ordinarily lack voice and agency (Smolak & Munstertieger, 2002). Employing an intersectional analytic (Crenshaw, 1989) within the helping relationship to better understand racial codes of conduct (see Holloway, 1995) and social processes unique to Black people with eating and negative self-concept complaints centralizes human potential.
Interethnic Treatment Dyads
Within the past two decades, a large contingent of scholars and practitioners has put forth concerted efforts to improve accessibility and quality of service for communities of color. Labor in this regard has also included peer-to-peer accountability. Altman (2010) urged therapists to confront personal feelings of the “racial other” to more effectively relate across and between racial lines. The goal, then, is gaining more emotional insight about social exchanges, an otherwise lifelong project of self-discovery that will likely include feelings of guilt, shame, sadness, and anger. Clinically, these feelings can activate attachment anxieties and unresolved relational wounds and, more important, a mourning that unfolds within the therapeutic alliance whereby change occurs vis-à-vis intersubjective dynamics (Stolorow, 1988). Irrespective of whether ethnocultural transference and countertransference is foregrounded in the clinical endeavor, both entities exist. Engaging race within an interethnic dyad can be challenging, specifically when the chasm between Black and White communities is considered. An added layer of complexity is the acute, endogenous, and ego-syntonic nature of eating disorders pathology, which often limits the open-ended aspects of counseling. Disciplined curiosity and process-focused interventions duly become agents of change during interethnic counseling pairings.
As previously mentioned, the “face of eating disorders” is troublesome in that the maldistribution of attention, a seemingly benign matter, represents a sociopolitical issue for Black people with mental health concerns. Albeit intangible, attention communicates importance, assigns social capital, and ultimately begets material advantage for White individuals. A firm commitment to social justice requires members of this subgroup to take stock of exclusionary epistemologies and practices, as role complexity has increased with changing ecological factors (see, e.g., Melton, 2018). How would it look, and what would it mean, for White professionals to catalyze a movement in dialoguing about the racialized nature of eating disorders treatment in an effort to develop an allyship praxis (Clark, 2019) for/with Black people?
Working across difference, here, within the Black-White ontology, tasks the latter group with combating the denigration and erasure of the former group. Body aesthetics and standards of attractiveness (Rubin, Fitts, & Becker, 2003) are clinically relevant domains to rigorously assess. An additional focus is how and why eating disorders become instruments for surviving racism (McKay, Moore, & Kubik, 2018; Thompson, 1996). An important consideration in examining the contours of identity alongside body image disturbances, particularly with Black people, is the elevated risk of essentializing both the eating disorder and race. Strous (2006) developed a model to assist White counselors with their reflexivity in what is partly described as “multicultural counseling.” The simultaneous and mutually constitutive property of identity (Crenshaw, 1989) correlates with disordered eating (e.g., Beccia et al., 2019; Watson, Veale, & Saewyc, 2017). These types of biopsychosocial correlates necessitate clinical sophistication in dialoguing about and connecting to social markers that inform intra- and intersubjective relationships. A relational-cultural (Trepal, Boie, & Kress, 2012)) or interpersonal approach (Murphy, Straebler, Basden, Cooper, & Fairburn, 2012) can help to create a context for racial examination and identity negotiation; the latter theory has been shown to be effective in addressing binge-eating behaviors.
Concluding Remarks
There has been a long-standing need for clinicians—Black and White, among others—to seek professional development opportunities in treating eating disorders in underserved and/or ethnically diverse populations (Taylor et al., 2007). Successful outcomes in working with Black patient populations are good inasmuch as knowledge production and clinical practice abandon settler colonialism (Glenn, 2015), antiblackness, and one-dimensional interpretations of identity and behavior. This paper offers a rationale as to why addressing (racial) identity in eating disorders treatment promotes healing for those afflicted, in addition to a critique of (strategic) identity neutrality. Closeness and collaboration are basic building blocks of the therapeutic alliance. Using racial identity as a gateway to access emotions and strengths gives Black clients an opportunity to provide a cultural and contextual interpretation of their eating-related concerns. The vulnerability is likely emblematic of a fragmented self-concept and an inability to adaptively cope with trauma, including racism. There is a dire need to humanize people with eating disorders. It stands to reason that a barrier to this aspirational end is racial valence, at least as it pertains to Black individuals, who continue to pursue civil liberties that fully recognize their humanity (Mills, 1997). To not, in some way, grapple with the complexities and social significance of race in eating disorders treatment broadly, and with Black people in particular, is a disservice. Obasogie (2010) found evidence to suggest that “even [visually] blind people, in a conceptual sense, ‘see’ race” (p. 585), owing in part to interpersonal factors, socialization, and social practices. Obasogie poignantly outlined how racial division is socially created and experienced with the body, the senses. Reimagining eating disorders treatment as a resource that moves beyond symptom management creates space for human potential and identity development, both of which are needed to transcend and transform suffering.
About the author:
Dr. Marcus is a Staff Psychologist and Assistant Director of Training Programs at Duke University Counseling and Psychological Services. He earned a Ph.D. in Counseling Psychology from Washington State University and completed a predoctoral internship at Duke University. Dr. Marcus has primarily worked in university mental health, spanning three regions of the United States. Additionally, Dr. Marcus maintains a small private practice in his free time, working towards becoming a Certified Eating Disorders Specialist (CEDS), and focusing on a wide variety of presenting concerns.
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