Inviting Culture into Eating Disorder Treatment
By Ashley Acle, LMFT
With the devastating effects of systemic racism harming our communities of color, clinicians are tasked with addressing racial inequities in treatment, psychological research, and leadership (Abrams, 2020). To do this, exploring and addressing other cultural factors (e.g. ethnicity, nationality, class, gender, education, spirituality, sexual orientation, age, ability, et.c) in conjunction with race are necessary to create and deliver socially just practices. The field of eating disorders has struggled to integrate cultural factors into treatment, while progress has been made in culturally sensitive interventions for the treatment of anxiety, depression, and suicide, among others. This article highlights how clinicians can use their own cultural exploration, self-awareness, and intentional preparation to engage when their biases contribute to oversight and, therefore, invite culture into eating disorder treatment.
With benefits found in several fields of practice, clinician self-awareness and personal cultural exploration are key to inviting culture in the treatment of eating disorders. Self-awareness and cultural identity have been found to reduce clinician bias in medicine (White et al., 2018). Within family therapy and social work, cultural awareness and sensitivity are cultivated using a cultural genogram. Cultural genograms are aimed at developing consciousness and appreciation for how culture influences the therapeutic process and how clinicians relate to clients (Hardy & Laszloffy, 1995). This learning comes from a focused exploration of the clinicians’ cultural identities. Clinicians’ experiences of cultural pride, shame, conflict, and the related components of power, privilege, and marginalization are also explored (Hardy & Laszloffy, 1995).
This and other forms of experiential learning through “cultural plunges” (Laszloffy & Habekost, 2010) with supervisor and peer feedback offer avenues for enhancing cultural sensitivity. By affectively processing and dialoguing with colleagues about their lived experiences, clinicians can deepen their self-reflections about culture. A clinician’s capacity to manifest sensitivity is greatly influenced by their personal, introspective work on understanding how dimensions of diversity have shaped their cultural identity (Laszloffy & Habekost, 2010). Therefore, clinicians who have done their cultural work have an increased potential to authentically engage clients from a place of empathetic understanding.
With an understanding of the clinician factors brought into the therapeutic interaction, clinicians can explore the client’s cultural experiences and the layers that impact their experiences of distress, their strengths, supports, and conceptions of healing and recovery. Clinicians can apply insights from their cultural exploration to thoughtfully navigate through the client experiences and the intricacies and nuances of cultural areas of pride, shame, and conflict. Clinicians may be curious about cultural values and beliefs the client explicitly brings into the therapeutic process and which cultural identities are disowned or negatively internalized. Conversations about power and privilege and their impact on the therapeutic relationship may arise or be worth exploring specifically. For example, what is the client’s experience working with a therapist who holds privileged identities, when they hold those that are marginalized? What is it like to worth with a therapist who holds marginalized identities and yet holds “authority” in their working relationship? Clinicians may also want to consider how a collaborative therapeutic stance may facilitate cultural exploration and how verbal and non-verbal communication (e.g. eye contact, silence) can facilitate connection and understanding.
Clinicians who have developed insight into their personal experiences of culture are better equipped to repair relational ruptures when they have made a mistake, assumption, or otherwise unintentionally jeopardized the therapeutic relationship. Clinicians’ initial responses to cultural differences and attempts at dialoguing about culture in treatment may be awkward or unintentionally slight the client’s lived experience (Laszloffy & Habekost, 2010). These moments are valuable in learning sensitivity and promoting growth (Laszloffy & Habekost, 2010). Clinicians may also want to consider their motivations for working through mistakes and disconnection, and resources for consultation.
Inviting culture into the treatment of eating disorders is a critical step towards eating disorder treatments that are increasingly respectful and culturally safe for those who have been marginalized. Though these components are described briefly, these layers of understanding are not linear or static. Cultural sensitivity, humility, respect, and safety require continuous learning, self-reflection, and critical conscientiousness (Curtis et al., 2019). Consultation with professionals from diverse cultural backgrounds is integral to this process. Clinicians dedicated to socially just work may also want to delve into understanding the intricacies of their respective cultural identities to cultivate sensitivity to how these impact life, relationships, and healing.
As clinicians, we are tasked with the honor of caring, advocating for, and advancing this field to be increasingly inclusive and understanding of our diverse clients. To understand and empathetically connect with our clients, we must first understand ourselves. With this understanding and self-awareness, we can more thoughtfully (re)engage with clients and explore their cultural experiences, sources of pride, shame, conflict, and how these inform experiences of dis-ease and recovery. I am hopeful that intentionally inviting culture can open our capacity to meet the needs of underserved communities, especially our communities of color struggling with eating disorders, and create a more inclusive field that supports treatment for our clients in their cultural entirety.
About the author:
Ashley Acle, LMFT is the California Regional Compliance Manager and Intersectionality Chair for the Social Justice Task Force at Alsana: An Eating Recovery Community. Her research and clinical interests include eating disorders, suicidality, emotional expression, and the influence of contextual factors on these presentations. Ashley is passionate about integrating culture in mental health, specifically in the treatment of eating disorders among ethnic and racial minorities, and has brought this unique perspective to previous roles as Director of Clinical Services and Program Director. She has worked with diverse individuals, families, and couples struggling with suicidality, acute psychosis, homicidality, eating disorders, mood disorders, and co-occurring relational distress for the last 10 years. Ashley is committed to increasing access to quality mental health care for marginalized and underserved populations using technology and increased community awareness.
Abrams, Z. (2020, September). APA calls for true systemic change in U. S. Culture. Monitor on Psychology, 51(6). http://www.apa.org/monitor/2020/09/systemic-change
Curtis, E., Jones, R., Tipene-Leach, D., Walker, C., Loring, B., Paine, S.-J., & Reid, P. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: A literature review and recommended definition. International Journal for Equity in Health, 18. https://doi.org/10.1186/s12939-019-1082-3
Hardy, K. V., & Laszloffy, T. A. (1995). The Cultural Genogram: Key to Training Culturally Competent Family Therapists. Journal of Marital and Family Therapy, 21(3), 227–237. https://doi.org/10.1111/j.1752-0606.1995.tb00158.x
Laszloffy, T., & Habekost, J. (2010). Using Experiential Tasks to Enhance Cultural Sensitivity among MFT Trainees. Journal of Marital and Family Therapy, 36(3), 333–346. https://doi.org/10.1111/j.1752-0606.2010.00213.x
White, A. A., Logghe, H. J., Goodenough, D. A., Barnes, L. L., Hallward, A., Allen, I. M., Green, D. W., Krupat, E., & Llerena-Quinn, R. (2018). Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine. Journal of Racial and Ethnic Health Disparities, 5(1), 34–49. https://doi.org/10.1007/s40615-017-0340-6