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Treating Black Women With Eating Disorders: A Clinician’s Guide Interview

Charlynn Small and Mazella Fuller joined us for an interview on their book, Treating Black Women With Eating Disorders: A Clinician’s Guide. What follows are our questions in italics, and their thoughtful answers.

In Chapter 1 of Treating Black Women With Eating Disorders: A Clinician’s Guide, you highlight the importance of asking the hard questions when working with Black women diagnosed with eating disorders. How does this enhance the therapeutic alliance?

Many healthcare providers continue failing to recognize eating disorders in Black women. One of the main reasons is because they fear asking the hard questions. The ones about racial differences and identity issues can be instrumental in helping them to recognize potentially mediating factors in the development of eating disorders. Successful treatment outcomes with these women begins with a clinician’s willingness, comfort, ability and security to initiate these uncomfortable conversations. These questions have to be asked because often the answers to them are related to the development of the disorder. So much of our lived experience is about colorism at its core. That is, prejudice or discrimination against persons with dark skin – usually within the same ethnic or racial group – by persons with fair skin. However, in as much as these concerns cannot be minimized or marginalized due to a practitioner’s fear of being insensitive or saying something offensive, caution must be used to introduce these topics at the right time to avoid ruptures in the therapeutic alliance.

An awareness and consideration of important factors such as historical oppression, colorism, class, gender identity, and the pain of past relationships are essential in the treatment of Black women with eating disorders. As Dr. Mazella Fuller details in her chapter on “Showing Up” for Therapeutic Healing, all of these complexities will enter the therapeutic space with these clients. A therapeutic approach that underscores a clinician’s understanding that Black women are not monolithic, as well as an acknowledgement of the benefits of a comprehensive, culturally sensitive assessment help to set the foundation for developing a trusting therapeutic alliance, upon which effective treatment can be achieved.    The unique part of treating Black women with eating disorders is in addressing racial issues, as identity really is at the heart of eating disorders.   

What is the current state of research on the impact of Euro-centered standards on African-American women?

In their chapter on the “Evolution of the Fluffy Ideal in Jamaica,” Dr. Venecia Pearce-Dunbar and Dr. Caryl James Bateman discuss the effects of Eurocentric ideals on Afrocentric ideals. The writers state that Jamaicans continue to struggle for a sense of identity 150 years after the abolition of slavery. They describe periods of when they were more conscious and accepting of their heritage, embracing their skin color and full-bodied females. Yet again, Black pride, which has long been considered a protective factor for Jamaicans, has been infiltrated by European standards of beauty. Drs. Pearce-Dunbar and Bateman James state that the influence of European and North American Western ideals on the Jamaican population remains pervasive because of media and exposure from tourism. In discussing further the similarities among African American women and Caribbean Black women, they noted that recent studies have shown that next to African American women Caribbean women have the second highest rates of obesity compared with other ethnic groups (Assari & Caldwell, 2015). Curiously, aside from potential health consequences of obesity, Jamaicans continue to find positivity in embracing their larger bodies and a quest for the ideal.

Intergenerational trauma, eating disorders and Black women – please connect.

In her chapter on “An Integrative Approach to Treating and Understanding Black Women with Disordered Eating,” Dr. Carolyn Coker Ross expertly discusses the ways trauma can define our behaviors, actions and sense of self. She summarizes research on the destructive effects of trauma being passed down from generation to generation in the expression of our DNA and in our cultural nurturing and parental modeling. Intergenerational Trauma studies of the children and grandchildren of Holocaust survivors showed that these persons experienced themselves as “different or damaged” by their parents’ experiences (Sotero, 2006). Dr. Ross also discusses the similar dynamics of the “survivor’s-child complex” of the American Indian/Alaskan Native experience and “historical unresolved grief,” to describe how the losses these groups suffered had never been mourned (Brave Heart & DeBruyn, 2001).

She explains that these experiences are not peculiar to these groups. Dr. Ross explains how these definitions of historical and intergenerational trauma fit the experience of Black people taken from Africa and the Caribbean. She talks about the lasting effects of lost cultures, and lives lost in the Middle Passage and on slave plantations, families being separated by slave owners, and the continuance of trauma through racial oppression, daily acculturative stressors and mass incarceration of Black men. The low self-esteem, racist socialization (e.g., colorism) and sensitivity to disrespect or “shame-proneness” (DeGruy, 2017) are three remnants of the institution of slavery that can contribute to body image issues in Black women, and manifest in eating disorders as well as many other illnesses.

These circumstances beg the question, “Are we eating because we are hungry, or because something’s eating us?” Black women use food to comfort themselves. Eating disorders are not about food. They serve to reduce stress, numb negative emotions, distract from the pain of past experiences, and to assuage and allay our worries and fears. Meanwhile, people are depending on us. Our families, our places of employment, and our communities depend on us. We are integral to fully functioning, productive, thriving communities. Dr. Ross explains that as such, we tend to adopt cultural values that increase our risks for emotional eating, such as holding to the “strong Black woman” standard – reluctant to express our feelings and needs, slow to seek assistance for ourselves, and caring for everyone except ourselves.

In relationship to eating disorders, can you please share some of the dangers of taking on the position of “strong Black woman?”

Several of the contributors address this notion of the Strong Black Woman (SBW) and the dangerous impact of taking on this position in relation to eating disorders. The myth of the Strong Black Woman poses perhaps one of the most insidious threats to Black women.Herorigins are rooted in a number of stereotypes, as Dr. Warrenetta Mann explains in her chapter, “The Skin I’m In,” about stereotypes. Mammy, Matriarch, Jezebel and Sapphira are the ones most often cited in the social science literature. Though they each have their own distinct persona, these caricatures deemed representations of Black women encompass a certain aspect of physicality, selflessness and a relational orientation that constricts the humanity and consciousness of any real woman. Dr. Mann writes that these negative stereotypes limit their minds and bodies, trapping Black women in patterns of behavior predetermined to minimize their humanity. In “The Weight of Shame,” Mrs. Paula Edwards-Gayfield states that the SBW myth helps the nation to relieve itself from addressing the enduring gender and racial inequalities endured by Black women.

In her chapter on “Treating Polycystic Ovarian Syndrome in Black Women with Eating Disorders,” Ms. Sasha Ottey discusses the frequently reported burdens associated with the pressures to “stay strong,” as they are encouraged to keep their problems to themselves and to keep their heads held high. Meanwhile, PCOS wreaks havoc on their mental health, contributing to their body image issues and binge eating, as they struggle to make a way out of no way, single-handedly raising kids, and working multiple jobs as Ms. Dawn McMillian writes in her chapter on “Overweight and Obesity.” Good nutrition and exercise take a back seat to survival. And food, she says, which is often used as a tonic, becomes that thing Black women too often turn to for physical pleasure during times of stress.  

What considerations are beneficial when a psychiatrist prescribes psychotropic medications to an African-American woman?

Psychiatrists must absolutely be aware of the barriers created by the historical fear and mistrust many Black persons have of the US mental health care system. In her chapter on the use of “Psychiatric Medications and the Treatment of Eating Disorders in African American Women,” Dr. Rashida Gray explains that this mistrust is connected to a well-founded history of mistreatment, pseudoscience and heinous experimentation by physicians and other healthcare professionals, in hospitals, systems, and institutions, documented as far back as the arrival of the first enslaved Africans. The equally repugnant Tuskegee studies continue to serve as a major deterrent to seeking healthcare for generations of Black persons. Dr. Gray states that avoidance or delays in seeking medical care can easily be mischaracterized as irresponsible or a lack of concern for one’s health if their fears and skepticism are not considered.  

In addition to mistrust of the healthcare system, many people are unfamiliar with what may happen during and following a psychiatric evaluation. Dr. Gray explains the myriad of questions women have regarding the appointment from wondering whether they will be asked to lie on a couch to whether they will be declared crazy. Many have questions about whether they will become zombie-like – Will they be straightjacketed? Will they become dependent on medication? Some wonder about whether about the cultural sensitivity of non-Black psychiatrists. Will a White psychiatrist understand that my cultural paranoia created as a result of experiences of daily microaggressions is real, and that while I may present with certain symptoms of a disorder, I may just be fed up and don’t really need to be medicated? Will they make a nuanced diagnosis in this case? These are all legitimate concerns.

Dr. Gray lists a number of additional considerations when prescribing or discussing psychiatric medications with Black patients including, including asking about the patient and the patient’s family’s perception on mental health care; explaining that medications are more likely to be helpful than harmful, and are rigorously studied for many years before approved for use; discussing realistic expected outcomes, treatment goals and potential side effects; consideration of a combination of therapy and medication; and consideration of the fact that because eating disorders have not historically been associated with Black women, the patient may be quite surprised to receive the diagnosis. Of course, Dr. Gray emphasizes the importance of developing and nurturing a trusting therapeutic relationship.

Please tell us about the acronym BE SAFE.

The BE SAFE (McNeil, 2005) Model of Cultural Competence is a tool we believe clinicians should incorporate as an essential component of their assessment with Black women. The model is based upon six core elements (i.e., Barriers to care, Ethics, Sensitivity of the provider, Assessment, Facts, and Encounters) formulated specifically to address barriers related to cultural practices and the healthcare system. Using this model will facilitate clinicians’ understanding of how a culturally sensitive approach can improve client quality of care and treatment outcomes, while simultaneously decreasing healthcare disparities.

What would you like to see available at every college counseling center for Black women?

Our wish list includes a number of things. Most notably, a racially diverse staff. It is desirable for Black clients to have the option of working with someone with whom they share some commonalities. If that isn’t possible, any therapist of good will, who is culturally sensitive and competent because of ongoing race, diversity, equity and inclusivity training would be appreciated. Our needs require therapists who realize that a colorblind approach to treatment does little more than relieve practitioners of their duty to address racial differences and the impact of racism on our lives. This realization is required because in using such an approach you render invisible what actually may be very important to the etiology of our concerns, thus affecting the most appropriate care plan.

As discussed in her chapter on college students with eating disorders, entitled “Who Should be at the Treatment Table?” Mary Churchill, PhD, details the importance of the multidisciplinary team approach. Despite the relative dearth of literature addressing treatment of Black women college students with eating disorders specifically, Dr. Churchill discusses the approach as among the best practices for these students. She considers the impact of adverse childhood experiences, biology, socio-economics, and the stressors of being on a predominantly White campus. Discussing the impact of these events among a team of professionals also serves to facilitate team member’s understanding of these students’ lived experiences with greater clarity, which improves treatment planning. Desirable treatment options would include access to additional safe spaces for discussions including affinity groups and telehealth options.  

Other things on our short list would include something in the counseling center environment that reflects images of these students’ differences and culture; a magazine in the waiting room covering some of their interests; a picture on the wall depicting people of color; anything that invites them; and something that welcomes them into that space.

About the editors:

Charlynn Small, PhD. Dr. Small began working at CAPS in 2004 as a post-doctoral intern. She serves as chairperson of the University’s Eating and Body Image Concerns (EBIC) team. She is a frequent speaker at national and international conferences, advocating for the awareness of eating disorders affecting Black women, persons of color, and other underrepresented groups. Dr. Small is a member of the national board of directors of the International Association of Eating Disorders Professionals Foundation (iaedp) and is a certified member and approved supervisor (CEDS-S) of iaedp. She co-founded the Foundation’s African-American Eating Disorders Professionals (AAEDP) committee and currently serves on the board of the Richmond Chapter of iaedp.

Dr. Small has also served on the national advisory board for the National Association of Anorexia Nervosa and Associated Disorders (ANAD). Published journal articles focus on multicultural education and on college students with eating disorders. Her co-edited anthology, “Treating Black Women with Eating Disorders: A Clinicians Guide,” Routledge/Taylor & Francis Publishers was released in July 2020.

Mazella Fuller, PhD, MSW, LCSW, CEDS-S is a Clinical Associate on the staff of Counseling and Psychological Services (CAPS) for Duke University. Dr. Fuller has an extensive background in dismantling systems of oppression, supervision, training and curriculum development. She graduated from Smith College for Social Work in Northampton, MA and completed her clinical training at the University of Massachusetts – Amherst. Dr. Fuller is an integrative health coach, a certified member of the International Association of Eating Disorders Professionals Foundation (iaedp™) and completed the Mindfulness-Based Stress Reduction Program through Duke Integrative Medicine/Duke University Medical Center. She is the co-editor of Treating Black Women with Eating Disorders: A Clinician’s Guide. She is also the founding Co-Chair of the African American Eating Disorders Professionals (AAEDP) Committee of iaedpTM and is a member of the Anorexia Nervosa and Associated Disorders (ANAD) Advisory Board. Dr. Fuller is a co-founder of the Institute for Antiracism and Equity.


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