Tài liệu TREATMENT OF EATING DISORDERS ppt

Author of: Effective Clinical Practice in the Treatment of Eating Disorders: The Heart of the Matter, co-edited with William Davis and Jane Shure Routledge, 2009; The Body Myth: Adult Wo

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Senior Editor

Margo Maine, PhD, FAED, cofounder of

the Maine & Weinstein Specialty Group, is

a clinical psychologist who has specialized

in eating disorders and related issues for 30

years Author of: Effective Clinical Practice in

the Treatment of Eating Disorders: The Heart of

the Matter, co-edited with William Davis

and Jane Shure (Routledge, 2009); The Body

Myth: Adult Women and the Pressure to Be

Perfect (with Joe Kelly, John Wiley, 2005);

Father Hunger: Fathers, Daughters and the

Pursuit of Thinness (Gurze, 2004); and Body

Wars: Making Peace With Women’s Bodies

(Gurze, 2000), she is a senior editor of Eating

Disorders: The Journal of Treatment and

Preven-tion and vice president of the Eating

Disor-ders Coalition for Research, Policy, and

Action A Founding Member and Fellow of

the Academy for Eating Disorders and

a member of the Founder’s Council and

past president of the National Eating

Disor-ders Association, she is a member of the

psychiatry departments at the Institute of

Living/Hartford Hospital’s Mental Health

Network and at Connecticut Children’s

Medical Center, having previously directed

their eating disorder programs Dr Maine is

the 2007 recipient of The Lori Irving Award

for Excellence in Eating Disorders

Aware-ness and Prevention, given by the National

Eating Disorders Association She lectures

nationally and internationally on topics

related to the treatment and prevention of

eating disorders, female development, and

women’s health

EditorsDouglas W Bunnell, PhD, FAED, is

a graduate of Yale University and receivedhis doctoral degree from NorthwesternUniversity He is a clinical psychologist andVice President and Director of OutpatientClinical Services for The Renfrew Center,overseeing the clinical programming andtraining for Renfrew’s eight outpatient treat-ment centers He is the editor of Renfrew’sprofessional newsletter, Perspectives, and co-chairs their research committee He serves

on the editorial board of Eating Disorders:The Journal of Treatment and Prevention AFellow of the Academy for Eating Disorders,

he is a former board president of theNational Eating Disorders Association,

a member of National Eating Disorder ciation’s Founders Council, and is the clin-ical advisor for the National EatingDisorder Association’s Navigator programwhich trains parents and family members

Asso-as resources for newly diagnosed patientsand families Dr Bunnell also remains active

in eating disorders advocacy and awareness

He has written and lectured, nationally andinternationally, on eating disorders treat-ment, research, professional training, eatingdisorders in men, and the challenges of inte-grating science and practice He is also

a member of the Academy for Eating ders credentialing committee, working todevelop practice standards for residentialtreatment of patients with eating disorders

Disor-In addition to his work with Renfrew, theAcademy for Eating Disorders and National

Eating Disorder Association, Dr Bunnell

maintains a private practice in Wilton,

Con-necticut specializing in the treatment of

eating disorders, chronic illness, and the

psychological aspects of Lyme Disease

Beth Hartman McGilley, PhD, FAED,

Associate Professor, University of Kansas

School of Medicine-Wichita, is a psychologist

in private practice, specializing in the

treat-ment of eating and related disorders, body

image, athletes, trauma, and grief A Fellow

of the Academy for Eating Disorders, she

has practiced for 25 years, writing, lecturing,

supervising, directing an inpatient eating

disorders program, and providing

indi-vidual, family and group therapy She has

published in academic journals and the

popular media, as well as having

contrib-uted chapters to several books She is an

editor for Eating Disorders: The Journal of

Treatment & Prevention, and is working on

her first book, a tribute to the patients she

has served over the course of her career

Dr McGilley also specializes in

applica-tions of sports psychology and performance

enhancement techniques with athletes at the

high school, collegiate, and professional

levels She was the sports psychology

consul-tant for the Wichita State University

Wom-en’s Basketball team from 2005 to 2008, and

serves as the co-chair of the Association for

Applied Sports Psychology (AASP) Eating

Disorders Special Interest Group

Dr McGilley co-founded and is the current

President of the Healing Path Foundation,

a non-profit foundation dedicated to the

prevention and treatment of eating disorders

in Kansas She is a recent graduate of the

Kansas Health Foundation Leadership Fellows

Training program Her hobbies include

competitive cycling, hiking, and writing

ContributorsDiann M Ackard, PhD, LP, FAED, ispassionate about helping us be the best that

we can be She is a licensed psychologist inprivate practice, and is an Adjunct AssistantProfessor in the Division of Epidemiologyand Community Health at the University

of Minnesota, and a Research Scientist atMelrose Institute in St Louis Park, Minnesota.She sits on the Boards for the Academy forEating Disorders and Break the Cycle, andco-founded the Trauma and Eating Disor-ders Special Interest Group of the Academyfor Eating Disorders She regularly publishesarticles in peer-reviewed journals andfrequently contributes at meetings andconferences

Drew Anderson, PhD, is an AssociateProfessor in the Department of Psychology

at the University at Albany, State University

of New York His research focuses on ment and treatment of eating disorders,body image disturbance, and psychologicaland medical problems associated withobesity

assess-Amy Baker Dennis, PhD, FAED, is a ical and research psychologist who hasmaintained a clinical practice over 36 years.She was the founding Board Secretary andserved on the Board of the Academy forEating Disorders (AED) for 11 years She isalso a founding member of the EatingDisorder Research Society (EDRS), foundingBoard President of the Eating DisorderAwareness and Prevention (EDAP) and amember of the Founders Council, andcurrently serves on the Board of the NationalEating Disorder Association (NEDA) Shehas published and lectured extensively andreceived numerous awards for her contribu-tions to the field, including the Lifetime

clin-BIOGRAPHIESx

Achievement Award givn by NEDA She is

a certified cognitive therapist and has served

on the faculties of University of South

Flor-ida, Department of Psychiatry and

Behav-ioral Sciences, the Hamilton Holt graduate

school at Rollins College in Orlando, Florida,

and Wayne State University Department of

Psychiatry in Detroit

Judith Banker, MA, LLP, FAED, is the

founder and executive director of the Center

for Eating Disorders, a non-profit outpatient

treatment center in Ann Arbor, Michigan

She is a Past President of the Academy for

Eating Disorders and served as chair of the

Academy for Eating Disorders

Psychody-namic Psychotherapy Special Interest Group

for 10 years With over 35 years of clinical

and training experience, Judith’s teaching

and writing focuses on the integrative

clin-ical treatment of eating disorders and on

research-practice integration in the eating

disorders field

Michael E Berrett, PhD, received his PhD

in Counseling Psychology in 1986 from

Brigham Young University He is CEO,

Director, and Co-founder of Center For

Change in Orem, Utah Dr Berrett has served

as Chief of Psychology at Utah Valley

Regional Medical Center and as Clinical

Director of Aspen Achievement Academy

He has 25 years experience in the treatment

of those struggling with eating disorders

He is co-author of the American

Psycholog-ical Association book Spiritual Approaches in

the Treatment of Women With Eating Disorders

and multiple articles in professional journals

Timothy D Brewerton, MD, DFAPA,

FAED, is Clinical Professor of Psychiatry

and Behavioral Sciences at the Medical

University of South Carolina in Charleston

He is triple board certified in general

psychi-atry, child/adolescent psychiatry and

forensic psychiatry, Distinguished Fellow ofthe American Psychiatric Association andFounding Fellow of the Academy of EatingDisorders Dr Brewerton has publishedover 115 articles and book chapters, is editor

of the book, Clinical Handbook of Eating ders: An Integrated Approach, and serves onthe Editorial Boards of the International Jour-nal of Eating Disorders and Eating Disorders:The Journal of Treatment and Prevention.Judith Brisman, PhD, is Director andCo-Founder of the Eating Disorder ResourceCenter in New York City She is co-author ofSurviving an Eating Disorder: Strategies forFamily and Friends (Collins Living, 2009, thirdedn), is an associate editor of ContemporaryPsychoanalysis and is on the editorial board

Disor-of the journal Eating Disorders: The Journal Disor-ofTreatment and Prevention Dr Brisman is

a supervisor of psychotherapy and a member

of the teaching faculty of the WilliamAlanson White Institute She has publishedand lectured extensively regarding the inter-personal treatment of eating disorders andcurrently maintains a private practice inManhattan, New York

Deborah Burgard, PhD, specializes in thetreatment of eating disorders and bodyimage She created www.BodyPositive.com

and is one of the founding proponents ofthe Health at Every Size model She co-wroteGreat Shape: The First Fitness Guide for LargeWomen, and chapters in Effective ClinicalPractice in the Treatment of Eating Disorders:The Heart of the Matter, Feminist Perspectives

on Eating Disorders, and The Fat StudiesReader Dr Burgard is also a co-author ofthe Academy for Eating Disorder’s “Guide-lines for Childhood Obesity Programs” andco-leads the Sustainable Health PracticesRegistry, research on how people createongoing practices that support their health

Rachel Calogero, PhD, completed her

M.A at The College of William and Mary,

and her doctoral and postdoctoral work in

social psychology at the University of Kent

in Canterbury, England Currently, she is

Assistant Professor of Psychology at Virginia

Wesleyan College Her primary interests

cover a spectrum of socio-cultural factors

that affect women’s health and well-being,

including the role of exercise in eating

disor-ders treatment and recovery, the impact of

sexual and self-objectification in girls’ and

women’s daily lives, and the perpetuation

of fat prejudice and stigmatization She has

published her research widely in

peer-reviewed journals and book chapters, and

is senior editor of the book,

Self-Objectifica-tion in Women: Causes, Consequences, and

Counteractions (APA, 2010) She presents

her research frequently in Europe and North

America, and offers workshops on mindful

excercise in various clinical and community

contexts

Nancy Cloak, MD, attended medical

school at the University of South Florida

and did her psychiatric residency at the

Menninger Clinic, where she was also

a candidate in the Topeka Institute for

Psychoanalysis Following residency, she

worked with eating disorder patients in

a university health center, and then

completed a fellowship in eating disorders

at Sheppard-Pratt Hospital, after which she

returned to Oregon to become the medical

director of RainRock Treatment Center Her

professional interests include

psychody-namic psychotherapy with eating disorder

patients, the neurobiology of weight,

appe-tite, and eating disorders, and medical

complications of eating disorders

Jillian Croll, PhD, MPH, RD, LD, is the

Director of Communications, Outreach, and

Research for the Emily Program She is an

Adjunct Assistant Professor in Department

of Food Science and Nutrition at the sity of Minnesota She completed her MPHand PhD in Public Health Nutrition andEpidemiology at the University of Minne-sota, and her MS in Nutritional Science atthe University of Vermont Her work ineating disorders includes program develop-ment, community education, teaching,research, clinical work, and advocacy.Kimberly Dennis, MD, is the MedicalDirector at Timberline Knolls ResidentialCenter for women with eating disordersand co-occurring disorders, and has a privatepractice with Working Sobriety Chicago Shespecializes in group and individual treat-ment for patients with co-occurring eatingand substance use disorders She maintains

Univer-a holistic perspective, Univer-and brings Univer-an Univer-awUniver-are-ness of the benefits of storytelling, creativity,and play in the recovery process Dr Dennis

aware-is a member of IAEDP, Academy for EatingDisorders, and ASAM She is an editorialboard member for Eating Disorders: The Jour-nal of Treatment & Prevention

Kyle P De Young, MA, is currently anadvanced graduate student in clinicalpsychology at the University at Albany, StateUniversity of New York His research inter-ests include the course and outcome of eatingdisorders, exercise, and assessment of eatingand exercise-related constructs

Richard A Gordon, PhD, is Professor ofPsychology at Bard College and a clinicalpsychologist in independent practice Hehas treated patients with eating disordersfor over 25 years He is author of Eating Disor-ders: Anatomy of a Social Epidemic, SecondEdition (Blackwell, 2000), and with MelanieKatzman and Mervat Nasser, Eating Disordersand Cultures in Transition (Brunner Routledge,2001) He was made Honorary Fellow of theAmerican Psychiatric Association for his

BIOGRAPHIESxii

contributions to the social understanding of

eating disorders

Randy K Hardman, PhD, worked as

a psychologist for 26 years He was

a co-founder and director of Center for

Change, where he worked for 11 years Dr

Hardman is currently working with students

in the Counseling Center at Brigham Young

University-Idaho in Rexburg, Idaho He is

a co-author of the book, Spiritual Approaches

in the Treatment of Women with Eating

Disor-ders (American Psychological Association,

2007) He has written and published articles

on spirituality and other related eating

disorder topics

Bethany Helfman, PsyD, is a clinical

psychologist who has practiced in the field

for over 18 years She is currently at Dennis &

Moye & Associates in Bloomfield Hills,

Michigan where she specializes in the

treat-ment of adolescents, adults, and families

affected by eating disorders and their

comor-bidities She is a member of the Academy for

Eating Disorders and the National Eating

Disorder Association Dr Helfman

super-vises other professionals in the field, writes,

lectures, and advocates for change related

to the factors that make recovery from

mental illness more difficult

Anita Johnston, PhD, is Director of the

Anorexia & Bulimia Center of Hawaii, which

she co-founded in 1982, Clinical Director and

Founder of Ai Pono Eating Disorders

Programs in Honolulu, and Senior Advisor

and Clinical Consultant for Focus Center

for Eating Disorders in Tennessee In 1986,

she developed Hawaii’s first in-patient

eating disorders treatment program at Kahi

Mohala Hospital Dr Johnston is the author

of Eating in the Light of the Moon: How Women

Can Transform Their Relationships with Food

Through Myth, Metaphor, and Storytelling

(Gurze, 2000) and an international speaker

and workshop leader with a private practice

in Kailua, Hawaii

Kathy Kater, LICSW, is a St Paul, sota psychotherapist and an internationallyknown author, speaker, and consultantwith over 30 years of experience specializing

Minne-in the treatment and prevention of bodyimage and eating-related disorders Frus-trated that progress in understanding theseproblems has not been matched by effectiveprevention, she authored Healthy Body Image:Teaching Kids to Eat and Love Their Bodies Too,

a primary prevention curriculum for upperelementary school children, and Real KidsCome in All Sizes; Ten Essential Lessons to BuildYour Child’s Body Esteem, a companion guidefor parents

Susan Kleinman, MA, BC-DMT, NCC, isthe dance/movement therapist for The Ren-frew Center of Florida She is a trustee of theMarian Chace Foundation, a past president

of the American Dance Therapy Association,and a past Chair of The National Coalitionfor Creative Arts Therapies She is a co-editor of The Renfrew Center Foundation’sHealing Through Relationship, serves on theeditorial board of the Journal of Creativity inMental Health, and has published extensively

on the use of dance/movement therapy inthe treatment of eating disorders She wasthe American Dance Therapy Associationrecipient of the 2009 Outstanding Achieve-ment Award

Kelly L Klump, PhD, FAED, is an ciate Professor of Psychology at MichiganState University Her research focuses ongenetic and biological risk factors for eatingdisorders Dr Klump has published over 90papers and has received a number of federalgrants for her work She has been honoredwith several awards including the DavidShakow Award for Early Career Contribu-tions to Clinical Psychology from the

Asso-American Psychological Association and

New Investigator Awards from the World

Congress on Psychiatric Genetics and the

Eating Disorders Research Society Dr

Klump is a Past President of the Academy

for Eating Disorders

Francine Lapides, MFT, writes and

teaches from attachment and

psycho-neurobiological theories (including the

arousal and regulation of affect) and their

applications to relational and

psychody-namic psychotherapy and adult romantic

relationships She supervised and taught

psychotherapy through the 1970s and has

been in private practice in Santa Cruz,

California since 1980 She has trained with

Daniel Siegel, is a member of Allan Schore’s

Berkeley study group, and has been strongly

influenced by relational principles

devel-oped at The Stone Center at Wellesley

College She teaches workshops and

confer-ences across the United States and provides

an online seminar atwww.PsyBC.com

Jason M Lavender, MA, is currently an

advanced graduate student in clinical

psychology at the University at Albany His

research interests include the functions of

eating disorder behaviors, the course and

outcome of eating disorders, and the

assess-ment of body image and eating disorder

behaviors

Martha M Peaslee Levine, MD, is

Assis-tant Professor of Pediatrics, Psychiatry, and

Humanities and the Director of the Partial

Hospitalization and Intensive Outpatient

Programs at Penn State Milton S Hershey

Medical Center

Michael P Levine, PhD, FAED, is Samuel

B Cummings Jr Professor of Psychology at

Kenyon College in Gambier, Ohio His

special interest is body image and eating

problems and their links with preventive

education, developmental psychology, and

community psychology His most recentbook is Levine and Smolak’s (2006) ThePrevention of Eating Problems and Eating Disor-ders: Theory, Research, and Practice (LawrenceErlbaum) Dr Levine is a Fellow of theAcademy for Eating Disorders In June

2006 he received the Meehan-Hartley Awardfor Leadership in Public Awareness andAdvocacy from the Academy for EatingDisorders

Richard L Levine, MD, is Professor ofPediatrics and Psychiatry and is the Chief

of the Division of Adolescent Medicine andEating Disorders at Penn State Milton S.Hershey Medical Center

Kimberli McCallum, MD, CEDS, is

a Fellow of the American Psychiatric ation and Associate Professor of ClinicalPsychiatry at Washington University School

Associ-of Medicine She is a psychotherapist with

a broad range of therapy skills, includingdialectic behavior therapy, cognitivebehavior therapy, family-based treatment,Family Systems Therapy, and psychoanal-ysis She received her MD from Yale, generalpsychiatric training at UCLA, and child/adolescent training at Washington Univer-sity Dr McCallum has co-founded severalspecialized eating disorders units, includinginpatient, partial hospital, residential, andintensive outpatient programs Her currentprograms include McCallum Place Treat-ment Center in St Louis, MO, and CedarSprings Treatment Center in Austin, TX.Elisa Mott, MEd/EdS, a certified yogateacher and graduate of University of Flori-da’s Counselor Education program, alsoholds a Spirituality in Health Certificate.She was awarded an International Excel-lence in Counseling Research Grant fromChi Sigma Iota honor society for her studyevaluating the use of yoga to improve well-ness among females and presented this

BIOGRAPHIESxiv

research at the 2010 ACA conference She

served as CSI’s Wellness Committee chair

and has presented on the use of yoga in the

treatment of eating disorders at the

Interna-tional Association for Eating Disorder

Professionals Conference and the University

of Florida’s Professional Development Day

Robbie Munn, MA, MSW, is a clinical

social worker who has spoken and written

widely about the chaotic impact of eating

disorders upon families and the challenges

families face in obtaining appropriate

treat-ment Many women in her family have

been affected by eating disorders, including

her mother and daughter, nieces, and

cousins In 2000 she joined the Board of the

National Eating Disorders Association

(NEDA) as one of its first family members

In 2003 she helped to create and co-chair

the first conference in the field to include

families and individuals along with

clini-cians This has become the esteemed annual

conference hosted by NEDA

Kelly N Pedrotty-Stump, MS, is a

high-school guidance counselor and an Exercise

Consultant at the Renfrew Center She

co-developed the exercise program at Renfrew

Kelly is an experienced speaker on exercise

and the treatment of eating disorders and

has presented at national conferences

including National Eating Disorder

Associa-tion, Academy for Eating Disorders, and

MEDA She has taught workshops on

various topics at West Chester University,

Temple University and Philadelphia College

of Osteopathic Medicine She has published

on the topic of exercise abuse and eating

disorders Kelly is also a certified yoga

instructor

Pauline Powers, MD, FAED, graduated

from the University of Iowa College of

Medi-cine and completed her residency at the

University of California at Davis She is

Professor of Psychiatry and BehavioralMedicine in the Clinical and TranslationalScience Institute at the University of SouthFlorida, Tampa, Florida She was the Found-ing President of the Academy for EatingDisorders and was President of the NationalEating Disorders Association 2005e2006.She has published three books on eatingdisorders and has reported research inseveral journals She is currently Director ofthe University of South Florida Center forEating and Weight Disorders and theDirector of the USF Hope House for EatingDisorders

Adrienne Ressler, MA, LMSW, CEDS,the National Training Director for The Ren-frew Center Foundation, is the 2008e2010president of the International Associationfor Eating Disorder Professionals board.She attended the University of Michiganand served as a faculty member in the School

of Education Her nationally renownedseminars reflect her background in gestalt,transactional analysis, psychodrama, bio-energetic analysis, and Alexander technique.She is published in the International Journal ofFertility and Women’s Medicine, Social WorkToday and authored the chapter BodyMindTreatment in Effective Clinical Practice in theTreatment of Eating Disorders She is thefeatured body-image expert for documen-taries on both cosmetic surgery andmenopause

P Scott Richards, PhD, is a Professor ofCounseling Psychology at Brigham YoungUniversity He received his PhD in Coun-seling Psychology in 1988 from the Univer-sity of Minnesota He is the co-author ofthe book, Spiritual Approaches in the Treatment

of Woman with Eating Disorders (AmericanPsychological Association, 2007) He is alsoco-author of the book, A Spiritual Strategyfor Counseling and Psychotherapy, which was

published in 1997 and 2005 (2nd ed.) by the

American Psychological Association Dr

Richards has published on the topics of

spir-ituality and eating disorders, religion and

mental health, and spiritual issues in

psychotherapy

Jennifer Sanftner, PhD, is a Clinical

Psychologist and tenured Associate

Professor of Psychology at Slippery Rock

University She has been teaching in the areas

of abnormal, clinical, health, and gender

psychology, and directing the undergraduate

practicum program at SRU for the last 8½

years She has researched eating disorders

for 19 years, resulting in publications in

peer-reviewed journals and chapters Her

research focuses on the application of

Rela-tional Cultural Theory to understanding the

etiology and maintenance of eating

disor-ders She is interested in using RCT to

under-stand women’s relationships with their

bodies, with others, and with food, and to

applying our understanding of RCT to

treatment

Lori A Sansone, MD, is a civilian family

medicine physician and the Medical Director

for the Primary Care Clinic at

Wright-Patterson Air Force Base in Dayton, Ohio

She has published over 100 refereed articles

and 24 book chapters; co-authored the

book, Borderline Personality Disorder in the

Medical Setting; co-developed the Self-Harm

Inventory; co-authors a professional column,

The Interface, for the journal Psychiatry, and

co-authors a local monthly newsletter,

Mental Health Issues in Primary Care

Randy A Sansone, MD, is a professor

at Wright State University School of

Medi-cine in Dayton, Ohio, and Director of

Psychiatry Education at Kettering Medical

Center He has published over 225

refereed articles and 33 book chapters;

co-edited the books, Self-Harm Behavior

and Eating Disorders and Personality ders and Eating Disorders; co-authored thebook, Borderline Personality Disorder inthe Medical Setting; co-developed theSelf-Harm Inventory; and co-authors

Disor-a professionDisor-al column, The InterfDisor-ace, forthe journal Psychiatry Dr Sansone is alsothe editor of the borderline personalitymodule for the Physician Information andEducation Resource and is on six journaleditorial boards, including Eating Disor-ders: The Journal of Treatment andPrevention

Doris and Tom Smeltzer, are careereducators with master’s degrees in educa-tion and counseling psychology, respec-tively Tom is a college professor and Dorishas taught throughout the K-12 spectrum.When their 19-year-old daughter Andreadied after 13 months of bulimic behaviors,Doris chose to leave her teaching positionand has devoted her life to eating disorderprevention through Andrea’s Voice Founda-tion, the non-profit organization she andTom co-founded Doris is the author ofAndrea’s Voice: Silenced by Bulimia and GurzeBooks’ “Advice for Parents” blog and is devel-oping an educational curriculum for the EDfield based on her Internet radio show.Jacqueline Szablewski, MTS, MAC,LAC, is a psychotherapist and licensedaddictions counselor who resides in Boulder,Colorado Combining study in psychology,counseling, and world religions with a self-designed concentration in pastoral coun-seling, Jackie earned her Masters degree inTheological Studies from Harvard Univer-sity She has worked along the continuum

of care in agency and hospital settings.Specializing in eating disorders, addictionrecovery, and life transitions, particularlywith individuals challenged by concomitantmood disorders, trauma, and grief issues,

BIOGRAPHIESxvi

Jackie has worked in the field for nearly two

decades She has maintained a private

prac-tice in Boulder, Colorado for the last

14 years

Mary Tantillo, PhD, RN, CS, FAED, is the

Director of the Western New York

Compre-hensive Care Center for Eating Disorders,

an Associate Professor of Clinical Nursing

at the University of Rochester School of

Nursing, a Clinical Associate Professor in

the Department of Psychiatry at the

Univer-sity of Rochester School of Medicine, and

CEO/Clinical Director of a free-standing

Eating Disorders Partial Hospitalization

Program, The Healing Connection, LLC

She is a fellow of the Academy for Eating

Disorders, as well as a previous board

member, present chairperson for the

Academy for Eating Disorders Credentialing

Task Force, and co-chairperson for the

Patient/Carer Task Force

Edward P Tyson, MD, has been treating

eating disorders for more than 20 years and

is board certified in both Family Medicine

and Adolescent Medicine After serving as

Director of Adolescent Clinics for the

Department of Pediatrics at Children’s

Hospital of Oklahoma, he opened a private

practice in Austin, Texas specializing in

eating disorders Dr Tyson is an active

member and frequent presenter at the

professional eating disorder organizations

He is an advocate for those with eating ders and teaches residents and medicalstudents, as well as undergraduate andgraduate classes, at the University of Texasabout eating disorders

disor-Kitty Westin is the founder and formerPresident of the Anna Westin Foundation,which has now merged with the EmilyProgram Foundation The Anna Westin Foun-dation was started by Anna’s family afterAnna died in 2000 as a direct result ofanorexia The Westins also started the firstand only residential program to treat peoplewith eating disorders in Minnesota Kitty isalso the past President of the Eating DisordersCoalition for Research, Policy & Action andshe serves on the Academy for Eating Disor-ders Patient/Carer Task Force, and is theCo-chair of the Academy for Eating DisordersAdvocacy/Communications Committee.Jancey Wickstrom, AM, LCSW, is theMilieu Manager and DBT Specialist atTimberline Knolls Residential Center forwomen with eating disorders and co-occurring disorders While a student atUniversity of Chicago, she received training

in DBT at the Emotion ManagementProgram, and maintains a group and indi-vidual DBT practice there Ms Wickstromfirmly believes in the powerful effects ofmindfulness meditation to help everyperson create a meaningful life

AA, Alcoholics Anonymous

ACC, anterior cingulate cortex

ACT, acceptance commitment therapies

ACTH, adrenocorticotropic hormone

ADHD, attention-deficit/hyperactivity

disorder

AN, anorexia nervosa

ANBP, anorexia nervosa, binge purge

subtype of anorexia nervosa

ANS, autonomic nervous system

BED, binge eating disorder

BMI, body mass index

BN, bulimia nervosa

BPD, borderline personality disorder

CAT, cognitive analytic psychotherapy

CBC, complete blood cells

CBT, cognitive behavior therapy

CPT, cognitive processing therapy

CRF, corticotrophin releasing factor

DBT, dialectical behavior therapy

DE, disordered eating

DEX, dysfunctional exercise

DEXA, dual energy X-ray absorptiometry

DMT, dance/movement therapy

DSM, Diagnostic and Statistical Manual

EBP, evidence-based practice

EBT, evidence-based treatment

ED, eating disorder

EDI, Eating Disorder Inventory

EDNOS, eating disorder not otherwise

LH, left hemisphereMAOI, monoamine oxidase inhibitorsMBCT, mindfulness-based cognitivetherapy

MB-EAT, mindfulness-based eating disordertraining

MBSR, mindfulness-based stress reductionMET, motivational enhancement therapy

MI, motivational interviewingMPC, medial prefrontal cortex

NA, narcotics anonymousNES, night eating syndrome

OA, overeaters anonymousOCD, obsessive-compulsive disorderOFC, orbital frontal cortex

OTC, over the counterPET, positron emission tomographyPFC, prefrontal cortex

PM, perceived mutualityPPI, proton pump inhibitorsPTSD, post-traumatic stress disorderRBC, red blood cells

R/M, relational/motivational approachRCT, relational-cultural theory

RCTs, randomized controlled trialsRFS, refeeding syndrome

RH, right hemisphere

SD, standard deviationSIV, self-inflicted violenceSMA, superior mesenteric artery

xix

SOC, stage of change

SOCT, stages of change theory

SNRI, serotonin and norepinephrine

reuptake inhibitors

SRED, sleep-related eating disorder

SSRI, selective serotonin reuptake inhibitorSUD, subjective units of distress

TCA, tricyclic antidepressantsWBC, white blood cells

Eating Disorders as Biopsychosocial Illnesses

The point is that profound but contradictory

ideas may exist side by side, if they are

con-structed from different materials and methods

and have different purposes Each tells us

something important about where we stand in

the universe and it is foolish to insist that they

must despise each other Postman, 1995 , p 107

The idea for this volume, Treatment of

Eating Disorders: Bridging the Research/Practice

Gap, emanated from our experiences as

clini-cians facing the challenge of helping patients

and their loved ones back from the precipice

of self-destruction brought on by eating

disorders (EDs) While we are each very

active in our professional development and

ongoing education, every day we experience

the impact of the significant gap between

what the research in journals, books, and

conference presentations provides and how

our patients present clinically Their needs

rarely match the theories or studies intended

to explain them

For example, although Eating Disorders

Not Otherwise Specified (EDNOS) is the

most commonly diagnosed ED in clinical

settings, ranging from 50 to 70% of all ED

cases (Walsh & Sysko, 2009), research studies

rarely include this diagnostic category

While more recent research is beginning to

explore the complexities of EDNOS (Agras,

Crow, Mitchell, Halmi & Bryson, 2010;

Walsh, 2009; Wildes & Marcus, 2010), little

is yet known about how this largest

subgroup of ED patients progresses through

the illness, responds to treatment, and fares

in terms of outcome Recent data seem to

confirm what we have known clinically:many patients with EDNOS actually havepoorer outcomes and higher mortality ratesthan patients with AN or BN (Crow, Peter-son, Swanson, Raymond & Specker, 2009)

A multitude of other factors contribute tothe research/practice gap Despite the factthat many of our patients suffer from comor-bid conditions, treatment research in ourfield tends to look at these problemsmore singularly (Haas & Clopton, 2003;Thompson-Brenner & Westen, 2005; Tobin,

2007) In clinical practice, it is often thesecomorbid factors, including depression,anxiety, and post-traumatic stress disorder,that dominate the process of therapeuticengagement The process of engagement isknown to be difficult in patients with ED,and adapting to the special demands of

a patient’s comorbidities makes each ment relationship unique This sense ofuniqueness can create the perception thatresearch does not easily, or often, apply tothe individual patient with whom we sit.Furthermore, in clinical research trials, “rela-tively ‘pure’ groups of homogenous patientsare selected for study, and are offered stan-dardized treatment based on structuredmanuals Everyone knows that therapy inthe real world is far messier” (Herbert,Neeren & Lowe, 2007, p 15) We designedthis book with the clear intention of trying

treat-to bridge such gaps so that research canbetter inform clinical work, and clinicalwork can better inform the research agendaand process

xxi

A historical view may help us to create the

most-informed approaches to the field’s

current dilemmas In her review of four

decades of work, Hilda Bruch (1985), the

pioneer to whom the field owes great respect

and gratitude, identified the nature/nurture

debate as a concerning gap In her hopeful

assessment, the two dimensions had finally

found common ground “Recent

explora-tions of the neurochemical processes of the

brain have revealed the close association of

psychological experiences with alterations

in brain metabolism, rendering the old

dichotomy between physiological and

psychological events untenable” (Bruch,

1985, pp 8e9) The biopsychosocial model

(Johnson & Connors, 1987; Lucas, 1981;

Yager, 1982; Yager, Rudnick & Metzner,

1981) advanced this perspective and our

understanding of ED, laying the groundwork

for prolific empirical contributions in the

subsequent decades The field rigorously

researched areas of pressing concern

including, but not limited to: prevention;

medical and psychiatric management;

thera-peutic tools and approaches; neuroscience

and epigenetics; and the essential role of the

family in the ED treatment and recovery

process In the clinical realm, innovative

treatment approaches began to yield more

positive outcomes

The dialectic of the past decade, the

science/practice gap, parallels, if not harks

back to, that of Bruch’s generation of ED

specialists Despite Bruch’s prescient respect

for the neuroscientific basis of psychological

experience, integration of this work, and its

implications for the therapeutic process, is

relatively recent in the ED field Although

we cannot expect neuroscience to be the

ulti-mate mediator for researchers and clinicians

of discrepant viewpoints, it has undoubtedly

provided a language and medium for

profes-sionals in both “camps” to appreciate the

other’s contributions to the understanding

of the etiology and treatment of ED Nearly

30 years have passed since Bruch’s review,and the resurgence of interest in neuroscien-tific applications/understandings of ED, and

in patients’ subjective experiences, providesrich opportunities for collaboration betweenresearchers and clinicians

Today, we have the advantage of a edge base built on many more years ofinquiry than Dr Bruch and the other earlywriters had available to them There arethree scholarly journals dedicated solely toED:Eating Disorders: The Journal of Treatmentand Prevention (EDJTP), the InternationalJournal of Eating Disorders (IJED), and theEuropean Eating Disorders Review Since the1980s, approximately 1000 books have beenpublished specifically regarding ED orclosely related illnesses EDJTP has pub-lished about 750 articles, andIJED has pub-lished approximately 1200 (L Cohn,personal communication, January 28, 2010).Broadening the topic to body image, healthpsychology, obesity, or related areas, thesenumbers would vastly increase, but still donot reflect publications in a wide variety ofbasic science, psychiatric, medical, nutri-tional, and psychological journals The point

knowl-is that the ED field knowl-is relatively young andrapidly developing, with many talentedclinicians and researchers whose contribu-tions have the potential to bridge the currentgaps, better serving the needs of ourpatients

Helene Deutsch, the first psychoanalyst tospecialize in the treatment of women, hasbeen credited with saying, “after all, the ulti-mate goal of all research is not objectivity,but truth” (retrieved from: http://www.brainyquote.com/quotes/authors/h/helene_deutsch.html).Treatment of Eating Disorders:Bridging the Research/Practice Gap bringstogether the expertise of scientists and prac-titioners in an effort to further describe thetruth about ED Readers will find an

unexpected irony: the effect of closing gaps

also expands the realm of influence,

infor-mation, and expertise across disciplines

Researchers will find accounts of the

prac-ticed experience and wisdom of clinicians

who have been operating with skills and

perspectives only partially informed by

science Likewise, clinicians will be exposed

to scientific advances that have enriched our

understanding of the biopsychosocial

complexity of ED Some of this research

has substantiated the central role of the

ther-apeutic relationship (American Psychiatric

Association, 2006), and qualitative research

is now giving the patient/subject an active

voice and presence in the empirical process

Readers will have access to chapters

across a variety of topics where research

and clinical work must come together to

better shape the understanding, treatment,

and outcome of ED In light of the significant

proportion of EDNOS cases, we encouraged

our contributors to take a transdiagnostic

approach (Fairburn & Cooper, 2007) when

possible We are also intrigued by the

proposed alternative system for

classifica-tion, Broad Categories for the Diagnosis of

Eating Disorders (Walsh & Sysko, 2009)

While the American Psychiatric Association

refines its work on the DSM-V, many

diag-nostic issues are being considered, and it is

premature to discuss the changes; however,

we deeply appreciate the efforts of the ED

work group

The collaborative spirit of this book

reflects our view that EDs are complex,

mul-tidetermined illnesses that must be

under-stood and treated in the sociopolitical

context Effective treatment takes ateam that

includes the patient, the family, and a

multi-disciplinary group of clinicians working in

concert Successful recovery takes a village,

interlocking communities of support (e.g

extended family, peers, team-mates, social

networks, professional support) in which

patients practice their recovery skills, andfind vital sources of commonality, connec-tion, optimism, and accountability We hopethat this book conveys respect for thedaunting power of these illness processes,

as well as the healing power of clinicians,researchers, patients, and families combiningforces toward a common goal

Readers will note recurring references tothe importance of the clinical relationship,based on empathy, connection, compassion,respect, and affection, as well as the impor-tance of using that relationship to best imple-ment interventions that have demonstratedeffectiveness (Zerbe, 2008) Furthermore,

we hope a spirit of partnership emergesfrom this bookdpartnership between fami-lies and professionals, and betweenresearchers and practitioners Ideally,Treatment of Eating Disorders: Bridging theResearch/Practice Gap, will help us to tran-scend the historical tensions and competitiverelationships between researchers and prac-titioners in our field (Banker & Klump,

2007), and inspire us to proceed with orative efforts that appreciate and integratethe best from each domain’s perspective Aparadigmatic shift of this magnitude,involving change in attitude and practiceboth within and between disciplines, willrequire more than an academic tomedevoted to its necessity As the final chapter

collab-of this book illustrates, we arecalled to action

or we will remain a field destructivelydivided

As editors, we also are aware of the limits

of this volume For example, the diversity, orthe evolving face, of ED, is a critical issuebeyond the scope of this book Once thepurview of young Caucasian womenfrom higher socio-economic strata in theadvanced technological nations, EDs arenow global conditions occurring in over

40 countries, many of which are developingnations (Gordon, 2001) In their examination

of how culture, ethnicity, difference, and EDs

affect minority and non-western females,

Nasser and Malson (2009)state:

The spread of thinness as a master signifier of

feminine beauty, promulgated by the mass media

and the post-colonial operations of transnational

capital, across all sections of western societies

and across the world has been devastatingly

effective in the ‘globalisation’ of ‘eating

disor-dered’ subjectivities and practices Thinness as

a gendered body ‘ideal’ and a signifier of

a multiplicity of positively construed ‘attributes’

can clearly no longer be considered exclusively

western or white (p 82).

Confirming this significant change in the

face of ED, Grabe and Hyde (2006)

con-ducted a meta-analysis of 98 studies, finding

no significant differences in body

dissatisfac-tion between Caucasian, Hispanic, and

Asian women in the USA Also, Bisaga et

al (2005) found similar rates of disordered

eating (DE) across ethnicities in adolescent

girls Despite clinical impressions clearly

confirmed by research, regarding the diverse

presentation of ED, minority women

experi-ence worrisome barriers to their access to

care, especially due to lack of recognition

by providers (Cachelin & Striegel-Moore,

2006) Many of these same issues are factors

in the underdiagnosis and treatment of men

with ED We must challenge these outdated

stereotypes so all patients will be able to

receive appropriate diagnosis and care

Clearly, the field has much to learn about

how EDs present across culture, country,

ethnicity, and other divisions We must begin

to acknowledge that EDs no longer belong to

a place, but instead inhabit many different

and constantly evolving global social

spheres Nasser and Malson (2009) advise

us to attend to both global and local factors

in our attempts to understand ED They

explain that the “gendered aesthetics of

thin-ness” are not always central to the DE or self

starvation and that other “locally-specific

discursive constructions of self-starvationmay be more relevant” (p 82)

The above findings remind us that ourculture continues to drive vulnerable menand women into DE and ED Although thereseems to be a decreased appreciation forthese sociocultural forces, enduring genderrole stereotypes remain influential Cultureand diversity are enormously complexissues and, while we believe strongly in theirimportance in a discussion about ED, wecould not do them full justice in this volume.Despite this noted limitation,Treatment ofEating Disorders: Bridging the Research/PracticeGap, presents a range of topics criticallyilluminating the challenge of clinical workwith ED patients The informed clinicianneeds to be conversant with multiple litera-tures including research on the cultural,psychological, behavioral, medical, genetic,neurological, and spiritual dimensions of

ED If nothing else, this volume should put

to rest the notion that there is any realdichotomy between the biology and thepsychology of lived experience We believe,also, that there is no validity to the dichotomybetween clinical practice and research; it is,rather, the lack of resources, inadequate dia-logue, disparate languages, and variedsystems of inquiry that create this divisiveimpression (Banker & Klump, 2007) Clini-cians collect data every day informing theirsense of what does and does not help partic-ular patients and families Meanwhile,researchers are developing and refiningmethods of inquiry that allow for more rele-vant applications of evidence-based practicesinto naturalistic settings (Lowe, Bunnell,Neeren, Chernyak & Greberman, 2010).Historical differences between the two campsregarding what constitutes meaningful

“evidence,” or sources of information (e.g.,clinical vs empirical data) have impeded in-tegrative, clinically driven investigations Ad-vances in qualitative and phenomenological

research have begun to mediate this

imp-asse and should be further incorporated into

formal quantitative explorations (Jarman &

Walsh, 1999; Kazdin, 2009) As Banker and

Klump (2007) aptly state, it is time

for a “researcher-clinician rapprochement”

(p 14)

Finally, the need to bridge the science/

practice gap does not devalue either

domain’s distinct and relative merits, nor

does it negate the necessity for

interdisci-plinary debate In fact, as Nobel prize winner

Ilya Prigogine has asserted, a certain degree

of friction is vital for growth:

It is precisely the quality of fragility, the

capacity for being ‘shaken up,’ that is

paradoxi-cally the key to growth Any structuredwhether

at the molecular, chemical, physical, social, or

psychological leveldthat is insulated from

disturbance is also protected from change ( Levoy,

1997 , p 8).

Change, and exchangedin perspectives,

attitudes, and practicesdis the bridge this

volume endeavors to create It is no longer

acceptable to rely on research that does not

reflect clinical realities; thanks to the efforts

of our authors and many other colleagues,

we see promising signs that this gap is

closing Nor is it acceptable for therapists to

base their treatment approaches solely on

their own clinical intuition (Herbert et al.,

2007) The research cited in this volume

sup-porting innovative clinical work

demon-strates the merits of Evidence Based

Treatment (EBT) and the importance of

incor-porating EBT into treatment plans (Haas &

Clopton 2003; Mussell, Crosby, Crow,

Knopke & Peterson, 2000; Tobin, Banker,

Weisberg & Bowers, 2007) Working from

one theoretical perspective because that is

how you were trained is no longer defensible

Clinicians need to be able to explain their

rationale for their treatment approach and

recommendations, and those explanations

need to incorporate both science and clinicalintuition The following contributions seek toinsure that researchers and clinicians arecross-trained in the best practices of ED treat-ment, building bridges that can withstandthe inherent friction required for growth,and paving the way for future advances

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C H A P T E R

1

A Perfect Biopsychosocial Storm

Gender, Culture, and Eating Disorders

Margo Maine and Douglas W Bunnell

Although eating disorder(s) (ED) are multidetermined, biopsychosocial disorders, genderalone remains the single-best predictor of their risk (Striegel-Moore & Bulik, 2007) Mostresearch asserts that anorexia nervosa (AN) and bulimia nervosa (BN) are 10 times morecommon in females than males, and binge-eating disorder (BED) is three times morecommon (Treasure, 2007) While some have argued that one in six cases occurs in males(Andersen, 2002), the gender disparity is still glaring Furthermore, while ED is not theonly gendered psychiatric condition, the degree of gender disparity is much greater than

in most diagnoses (Levine & Smolak, 2006)

Now the third most common illness in adolescent females (Fisher et al., 1995), supersededonly by diabetes and asthma, ED have become a major public health issue, affecting more andmore women of all ages Today they appear in every stratum of American culture and, withthe impact of globalization, in more than 40 countries worldwide (Gordon, 2001) This expo-nential increase in a condition disproportionately affecting women must have its roots in theinterplay of culture and gender, as a genetic mutation has not swept the globe But mediaimages of perfectly crafted female bodies and unprecedented role change have, in fact, sweptthe globe The increased access to education and involvement in the workplace have trans-formed women’s social roles dramatically, with rapid technological and market changesintroducing a powerful global consumer culture and relentless expectations about appear-ance and beauty (Gordon, 2001) As the social changes accelerate, many women seek solaceand mastery by controlling their bodies (Maine & Kelly, 2005)

Quite simply, gender creates risk The World Health Organization’s (WHO) based review of women’s mental health (World Health Organization, 2000) concludes thatgender is the strongest determinant of mental health, social position, and status, as well asthe strongest determinant of exposure to events and conditions endangering mental healthand stability Furthermore, the WHO notes a positive relationship between the frequencyand severity of social stressors and the frequency and severity of mental health problems

evidence-in women Despite the importance of gender disparities evidence-in mental health and risk for ED,the recent emphasis on biogenetic research risks minimizing the importance of the role of

3Treatment of Eating Disorders doi: 10.1016/B978-0-12-375668-8.10001-4 Ó 2010 Elsevier Inc.

culture and gender in their etiology As clinicians, we understand that the biopsychosocialwhole is greater than the sum of its parts, despite the challenges this presents to the tradi-tional research paradigms This chapter explores the interplay of biopsychosocial factorscontributing to the perfect storm of ED, especially examining culture and gender.

NATURE VERSUS NURTURE: A FALSE DICHOTOMY

Delineations between the biological, psychological, and social forces underlying ED arefalse distinctions, as nature and nurture always go hand in hand Genes code RNA andDNA, the building blocks of cells, creating variations associated with risk While they donot code behavior or disease, genes create vulnerabilities which will be tempered or intensi-fied by other factors (Chavez & Insel, 2007), such as the family, early development, socialexperiences and expectations, physical conditions, and gender Increasingly sophisticatedresearch models investigate the complicated interactions in which environmental experiencecan alter gene expression (Hunter, 2005) Although they are not destiny, genes shape vulner-ability and resilience, affecting how we perceive, organize, and respond to experiences, andcontributing to the perfect storm of ED

The rapid decline in the age at which girls enter puberty is an apt example of such a psychosocial storm A century ago, the average age for menarche was 14.2 and now it is 12.3

bio-In the 1970s, the average age of breast development was 11.5, but by 1997, it was less than 10years old for Caucasian girls and 9 years old for African American girls, with a significantnumber developing even before age 8 (Steingraber, 2009) Girls who enter puberty earlierthan peers have more self-esteem issues, anxiety, depression, adjustment reactions, eatingdisorders, and suicide attempts (Graber, Seeley, Brooks-Gunn & Lewinsohn, 2004) Theyare more likely to use drugs, alcohol, and tobacco, have earlier sexual experiences, be atincreased risk of physical violence, and, due to prolonged estrogen exposure, have a higherincidence of breast cancer (Steingraber, 2009)

Early puberty may be best understood as an ecological disorder, an interaction of social, nutritional and environmental triggers, such as pollutants or chemical exposure; whilefamily stress or trauma may also play a part Aptly describing the false dichotomy betweennature and nurture, Steingraber states: “The entire hormonal system has been subtly rewired

psycho-by modern stimuli.female sexual maturation is not controlled psycho-by a ticking clock It’s morelike a musical performance with girls’ bodies as the keyboards and the environment as thepianist’s hands” (2009, p 52)

Sexual maturation brings increased attention to the body, sexuality, and the mental pressures of adolescence, enhancing the impact of other ED risk-factors Natureand nurture interact as girls’ lives unfold

develop-GENDER: DIFFERENCE OR SIMILARITY?

Culturally constructed sexism has led to intense divisions between men and women, asexpressed in common concepts such as “the war of the sexes,” as if gender creates virtuallydifferent species with no hope of understanding each other The media systematically

promulgate gender differences, just as they have contributed to the objectification of womenand sexism Despite the popularity of books like Men Are from Mars, Women Are from Venus(Gray, 1995) and You Just Don’t Understand: Men and Women in Conversation (Tannen, 2001),decades of psychological research suggest that men and women and boys and girls aremuch more alike than different (Hyde, 2005).

In their epic work, The Psychology of Sex Differences,Maccoby and Jacklin (1974)reviewedmore than 2000 studies, dismissing many popular beliefs and identifying only four areas ofdifference: (i) verbal ability; (ii) visual-spatial ability; (iii) mathematical ability; and (iv) aggres-sion In 2005, Hyde’s meta-analysis of the gender difference literature found that 78% of thedifferences are very small, actually close to zero, even in areas where gender differenceshave been consistently considered strong The greatest gender difference is in motor perfor-mance, due to post-puberty differences in muscle mass and bone size Measures of sexuality,especially the frequency of masturbation and attitudes toward “casual sex,” also reveal signif-icant gender differences, but virtually no difference in reported sexual satisfaction The meta-analysis of aggression indicates a strong gender difference in physical parameters, but less sowith verbal aggression Despite the suggestion in the popular press and media that girls have

a higher level of relational aggression, the evidence is mixed

As gender differences fluctuate over the course of development,Hyde (2005)suggests thatthey are not as fixed as many believe She also notes that the surrounding context, such as thewritten instructions, interactions between participant and experimenter, or expectations ofgender differences, significantly affect results The fact that both their strength and theirdirection depends on context challenges the notion of strong, stable gender differences

NATURE, NURTURE, AND THE BRAIN

Research on the brain indicates important gender differences, despite the behavioral larities noted above In a thorough review of gender,Cahill (2006)noted significant genderedpatterns in brain structure and neurochemistry associated with a wide range of emotionaland cognitive functions including learning, emotional and social processing, memorystorage, and decision-making Male and female brains react differently to stress Chronicstress is more damaging to the male brain, particularly to the hippocampal area thought to

simi-be central to memory and learning, while transitory interpersonal stressors result in

a stronger adrenocortical response in women’s brains (Stroud, 1999) At the neurochemicallevel, gender influences the ways in which our brains synthesize, metabolize, and respond

to neurotransmitters such as serotonin, possibly helping to explain differential rates ofmood disorders and substance addiction

Brain differences have been disproportionately attributed to sex hormones, but researchhas now established that other distinctions exist For example, the denser corpus callosum(the band of fibers bridging the brain’s hemispheres) in the female brain allows greaterconnection between the two hemispheres, so women have less lateral specialization, whereasmen have more of a division between the brain hemispheres These neuroanatomical differ-ences may explain women’s superior language skills and men’s superior visual-spatial skills.The neuroanatomy of the hypothalamus, instrumental in hormonal functions and reproduc-tion, is also different, resulting in neurophysiological differences that in turn affect behavior

I BRIDGING THE GAP: THE OVERVIEW

The anterior cingulate gyrus, more active in women, is linked to nurturant social behaviors,while the amygdyla (more active in men) is linked to anger and rage Although statisticallysignificant, these differences are small (Solms & Turnbull, 2002) The environment andculture often intensify these differences with gender-laden messages, attitudes, and expecta-tions, and thereby multiply their expression (Lee, 2007).

While the study of brain gender differences has been enhanced by technological ments, it has, perhaps, been retarded by the viewpoint that differences somehow imply defi-ciency In a patriarchic culture, an androcentric bias may affect how scientific findings andmodels of psychopathology are interpreted

develop-GENDERING: A BIOPSYCHOSOCIAL PROCESS

Is it a boy or a girl? This is often the first question asked about the birth or pending birth of

a baby The answer shapes our reaction and expectations and impacts the child’s life storyand experience in countless ways Simply put, the impact of gender occurs early and often.According to social scientists, “gendering” is “the sum of all influences that channelfemales and males into divergent life situations,” which are then internalized into the self,leading to certain “sex-linked characteristics, cognitions, and interpersonal transactions”(Worell & Todd, 1996, p.135) By age 2, gender identity begins to emerge, with the child con-structing a sense of self as either male or female (Worell & Todd, 1996)

Gender experiences interact with the gendered features of the brain to create a gendered self,and relationships with caregivers are the key arenas for these experiences to play out Illus-trating the intersections of culture, biology, and psychology, parental responses to an infantare driven by the parent’s biology, by their cultural and psychological experiences, and bythe gendered biology of the infant According toWeinberg, Tronick, Cohn & Olson (1999),male and female infants display markedly different levels of emotional expressivity andarousal and evoke different parental reactions Boys, who are less regulated, are actuallymore sociable than girls at this age They seem to pull for more physical touch and perhapsgreater relational involvement from their mothers due to the challenge of maintaining emotionalregulation Weinberg and her colleagues also found that boys and mothers stayed in attachmentsynchrony more than motheredaughter dyads but also took longer times to re-establish thatsynchrony after it had been disrupted Girls, by comparison, require less soothing but alsoseem to present more subtle cues to their caregivers Perhaps our belief that girls and womenare more relational is rooted, at least in part, in the need for closer attention to these subtleexpressions Boys may be less relational because their emotions are so obvious

In order to develop a sense of self, boys must psychologically separate from their primaryattachment, usually their mother, and connect to the same sex figure, the father Girls, on theother hand, must retain the connection to mother as the same sex identificatory figure butconnect to the father in a new affective relationship This developmental challenge places

a premium on relational, as opposed to self-containing and separating, capabilities Girlsbegin to explore who they are and who they want to be by comparing themselves with peers,parents, siblings, and the cultural images available to them (like characters in books ormovies) Boys learn to harden themselves into self-sufficiency, fearful that dependence isshameful

In optimal circumstances, these developmental challenges inter-twine with biologicalendowments and social values in ways that enhance and support healthy maturation Theenvironment can be more or less gendered, either reinforcing stereotypic behavior or allow-ing more room for difference or exploration Individuals can also adjust their gender-typedbehaviors in order to present in a certain way For example, girls may act more typically femi-nine to get approval or attention pending the cues and demands they perceive Whenpsychopathology develops, it may reflect disruptions in this complicated process Whenthe psychopathology occurs at vastly different rates in men and women, the biopsychosocialconstruction of gender may be the source.

PSYCHOLOGICAL DEVELOPMENT IN A GENDERED ENVIRONMENT

Western culture is still androcentric, based on a patriarchy, as seen in our commonlanguage forms (think “chairman” of the board) Such gendered environments exert subtle,subliminal, but constant pressures on both sexes to act in certain ways Gender stereotypesevolve based on a culture’s belief systems regarding the attitudes, behaviors, and other char-acteristics that seem to differentiate the two sexes This section focuses primarily on howgendering affects females, while Chapter 18 (Bunnell) examines the male experience andconsequent risks for ED

Frequent references to “the opposite sex” show our polarizing views of gender Westernculture usually emphasizes socio-emotional and body image (BI) issues when definingstereotypic femininity, and competence and autonomy when defining masculinity Thesestereotypes prescribe certain behaviors: women are to take care of others and attend to theirappearance, while men are to take risks, assume leadership, and focus on success and work.Such dichotomous views of gender give men public power and influence, while limitingthem to women, with far-reaching consequences

The impact of a gendered environment may intensify in the face of biopsychosocial opmental stressors Puberty heralds both internal and external changes, clear markers ofgender For girls, it brings dramatic hormonal changes resulting in menstrual periods, breastdevelopment, and increased body fat Between the ages of 10 and 14, in fact, the average girlgains 10 inches of height and between 40 and 50 pounds Most double their weight by thetime they finish puberty (Friedman, 1997) In addition to the physical events, pubertyinvolves an increased attention to the demands and expectations of the dominant culture,

devel-as, emotionally ready or not, girls move from the safety of childhood into a universe ingly driven by factors outside the family such as peers, school, and the media

increas-This heightened attunement to sociocultural demands or norms creates significant conflictfor girls Absorbing the external message that they need to control their weight and maintain

an attractive, sculpted look, girls may feel unhappy about their body’s natural changes.While body fat may be necessary to physical development, it contradicts the female idealsthey have been taught, so it seems invalidating and frightening

For some girls, this transition into puberty feels like the proverbial fall down a rabbit-hole,just like Alice in Wonderland, landing in a place where things may look the same but feel very,very different One young woman in recovery from bulimia described that she went to bed atnight after playing with dolls, then woke up with breasts, and everyone treated her differently

PSYCHOLOGICAL DEVELOPMENT IN A GENDERED ENVIRONMENT 7

I BRIDGING THE GAP: THE OVERVIEW

With scant permission to explore complicated feelings about their bodies and maturation, and

no rituals of celebration for this new life stage, many girls translate their distress and confusioninto the language of fat (Friedman, 1997) Constant diet ads and messages about the dangers ofobesity, and a weight-loss industry that now accounts for approximately $60 billion per year inthe U.S (Marketdata Enterprises, 2007), only reinforce the language of fat, making dietingnormative Again, the biopsychosocial whole is greater than the sum of the parts: the pressures

to diet add to all the other developmental stressors of puberty, as “gendering” unfolds

MEDIA IMAGES, GENDER, AND OBJECTIFICATION THEORY

Experimental and correlational studies, prospective research, and clinical accounts allvalidate that media images and influences are major factors in the etiology of ED(Levine & Smolak, 2006) American television and other popular media promulgate thestrong message that women attract men through appearance The media objectify womenmuch more frequently than men and portray them as unrealistically thin (Engeln-Maddox,

2006) Meta-analytic reviews of research demonstrate that the contemporary cultural riences of girls and women contribute to both BI dissatisfaction and to disordered eating(DE) (Murnen & Smolak, 2009) Exposure to mass media (Groesz, Levine & Murnen,2002; Murnen, Levine, Smith & Groesz, 2007) increases the risk for ED, as do attempts tocomply with traditional expectations regarding femininity (Murnen & Smolak, 1997) Inessence, Western media systematically and relentlessly objectify and sexualize girls’ andwomen’s bodies, at great cost to their emotional and physical health (Maine, 2009).Rapid social change, provocative media images, and pressures to attain the perfect body coa-lesce in the perfect storm of an ED A dramatic example of the interplay of these factors occurred

expe-in Fiji after television was expe-introduced ED were basically non-existent there expe-in 1995, but after lessthan three years of limited exposure to Western network television shows, they were rampant.Fijian girls had not spoken of diet or weight concerns previously but, by 1998, 11% used self-induced vomiting, 29% were at risk for ED, 69% had dieted to lose weight, and 74% felt “toofat.” Watching popular female images on television seemed to have created a desire for theapparent life and presumed power of these stars and a commitment to change their bodies toget it Once a culture where large female bodies were valued for their strength and contribution

to the family and community life, and where food was celebrated and enjoyed with rich tions and meanings, the Fijian experience demonstrates how rapidly cultural influences canoverturn strong local cultural traditions and values, profoundly altering a woman’s relationship

tradi-to her body and tradi-to food (Becker, Burwell, Gilman, Herzog & Hamburg, 2002)

The media’s objectification and sexualization of the female body has a lasting impact,persistently pressuring girls and women to assume an external view of themselves and oftheir value as people In turn, they are less able to identify, express, process, or respect theiremotions, thoughts, and instincts Messages from the outside eclipse any inner life; in thisway, social expectations regarding appearance, weight, and shape become pre-eminent,trumping women’s appreciation for their natural bodies and paving the way for BI preoccu-pation and dissatisfaction, and eating pathology

Contemporary culture’s consistent sexualization of girls and women exerts a variety ofindividual harmful effects such as impaired cognitive functioning due to intrusive and

negative thoughts, emotional distress, body dissatisfaction, negative self image, ED, andhealth problems (American Psychological Association [APA], 2007b) Objectification theory(Frederickson & Roberts, 1997) explains the lasting negative outcomes of such sexualization,especially the impact of media images and portrayals of women and the power of the sexualgaze Girls come to see themselves as objects to be looked at and judged based on theirappearance Internalization of an external standard results in constant monitoring andself-scrutiny, so the individual has fewer resources for awareness of internal body statesand experience Thereby, the culture disrupts the connection to inner experience leading to

a pervasive experience of disembodiment (Piran & Cormier, 2005), including denial of basicneeds such as hunger and thirst

GENDER DISTINCTIONS AND THE OUTCOME

OF OBJECTIFICATION

Gender significantly affects the experience and outcome of objectification According to

Murnen, Smolak, Mills & Good (2003), children as young as 7 idealize objectified mediaimages Girls, however, are more likely to internalize and try to meet these idealized stan-dards Starting in childhood, girls are constantly exposed to criticisms and comments abouttheir bodies, and not just in the media Even in elementary school, boys feel free to disparagegirls’ bodies in their presence (Murnen & Smolak, 2000) With both anonymous and deeplypersonal messages conveying a constant stream of criticism, the average American girl strug-gles to simply feel safe in her own skin

Studying children at age 11 and then at 13,Grabe, Hyde & Lindberg (2007) report thatobjectification appears to affect the emotional well-being of girls but not of boys Adoles-cence and pre-adolescence are critical developmental periods for girls in their relation-ship to their bodies and their experience of objectification Adolescent girls enduremuch more self-objectification, body shame, rumination, and depression than theirmale peers In desperation, they internalize and try to meet the external standards, hop-ing to find safety and self-acceptance Instead, they become deeply disconnected fromtheir bodies, creating fertile ground for an ED

Bandura’s (1991) groundbreaking research demonstrates that when people fail to meetcultural ideals, intrusive thoughts can undermine cognitive functions For women, suchfailure has a higher price, literally and figuratively Cultural standards for appearance,weight, and beauty are much more rigid for women, so they experience more BI dissatisfac-tion than men (Ricciardelli & McCabe, 2004) In addition to their bodies being treated sodifferently, women also earn less, have less status and power, and are more likely to be victims

of abuse and physical violence (Bordo, 1993) Intrusive and obsessive self-disparagingthoughts, absent from other areas in which they feel successful, can easily compromise theirsense of self as well as their cognitive and emotional functioning

According to Tiggemann and Slater (2001), the cumulative effect of self-objectificationcreates risk for three psychological issues: depression, sexual dysfunction, and ED Self-objectification may become an internalized and long-lasting feature of the self, co-existingwith many risk factors associated with ED, including diminished interoceptive awareness,poor self-esteem, body shame, and DE (Piran & Cormier, 2005) The internalization of the

GENDER DISTINCTIONS AND THE OUTCOME OF OBJECTIFICATION 9

I BRIDGING THE GAP: THE OVERVIEW

thin ideal, a predictable indirect result of self-objectification for girls in contemporary culture(Levine & Smolak, 2006), is one of the strongest predictors for BI distress and DE (Stice, 2002).The effects of culture’s objectification of girls and other prominent gender stereotyping notonly harm girls; they foster a sexist or patriarchal culture that tolerates sexual harassment,violence, abuse, rape, and exploitation of girls and women (APA, 2007b) Sexism, however,

is truly “a two-edged sword” (Sadker, Sadker & Zittleman, 2009, p 208), victimizing boysand men as well If girls must be objectified, boys must be objectifying, insensitive, anddismissive; if girls are to be harmed, then boys must harm through aggressive, insensitive,angry, and rejecting behaviors Pushed to be independent, competitive, athletic, and discon-nected from their own inner states much of the time, boys are also harmed by the culture’ssexualization and objectification of women

FEMINIST PERSPECTIVES: PROTECTION IN THE FACE

OF OBJECTIFICATION?

Murnen and Smolak (2009)suggest that women who identify with feminism may be moreresilient and less likely to succumb to concerns about BI or eating Their hypothesis, that a femi-nist perspective may help girls resist objectification and other cultural forces that create risk for

ED, has important implications for treatment and prevention A feminist perspective mayenable women to conceptualize objectification and cultural pressures related to weight, shape,and appearance as examples of the oppression of women, and may foster a critical perspective

of media images for women, encouraging women to reject these messages or to limit exposure tothem When experiencing sexual harassment or any form of sexual discrimination, a feministconsciousness may help the individual to contextualize and externalize the experience ratherthan internalize or blame herself This mindset also empowers a woman to define herself inareas of strength, rather than by focusing on imperfections, and to value internal attributesmore than appearance They also may be more capable of asserting themselves, expressing theirbeliefs, and avoiding the self-silencing that can lead to DE (Smolak & Munstertieger, 2002)

In focus groups, college-aged women who endorsed a feminist perspective were morelikely to embrace body diversity and to be aware of the negative messages women receiveabout their bodies (Rubin, Nemeroff, & Russo, 2004) Feminism allowed them to resist theobjectifying and sexualizing male gaze, to be more confident of their bodies, and to redefinebeauty Yet, despite such resilient attitudes, these women still felt pressured to comply withcultural values regarding women and weight Other research using quantitative measureshas been inconsistent Tiggemann and Stevens (1999) reported a moderate positive associa-tion between feminist identity and BI, whileCash, Ancis & Strachan (1997)reported only

a minimal association

To shed light on the protective potential of feminism,Murnen and Smolak (2007)conducted

a meta-analysis of 26 studies examining the link between feminism and BI, concluding thatfeminist identity and a lower drive for thinness go hand in hand Adoption of a feministperspective seemed to immunize women against the internalization of unhealthy attitudesabout their bodies Older feminists, lesbians, women’s studies students, and activists derivethe most benefit from their association with feminism, while younger women, or those lessconnected to feminism, struggle more with the pressures to be thin A consolidated feminist

identity, however, appeared to be a protective factor against dieting and ED symptoms, gesting the value of a feminist-informed approach to treatment and prevention.

sug-While the medical model focuses on the individual woman as sick or defective andattempts to subdue her disease, the feminist framework literally frames the woman’s EDand behavior in the context of her cultural experience (Maine, 2009) Feminist-informed ther-apists recognize that the common issues prompting women to seek therapy are often related

to powerlessness, experiences of trauma, low self-esteem, and the idealization of masculinequalities and the devaluation of feminine ones (Katzman, Nasser & Noordenbos, 2007) Inother words, sexism and oppression bring women into treatment

The feminist frame conceptualizes an ED as a solution to these problems, rather than beingthe problem itself Moving far beyond symptom management, feminist-oriented treatmentrequires exploring the impact of gender-prescribed roles in contemporary culture and ofthe idealization of the masculine and devaluation of the feminine Rather than pathologizing,

a feminist approach is strength-based so women’s needs for emotional connection and dependence are seen as assets, not signs of weakness or dependency (Katzman et al., 2007;Sesan, 1994) These strengths are incorporated into treatment plans by encouraging interper-sonal connections, utilizing group therapies, and including natural support systems such asfamilies or friends Furthermore, to counter the impact of objectification, involvement incollective social action may enhance recovery, restoring power and voice to the individualand a sense of connection to other like-minded people

inter-The feminist frame is also attuned to power, acknowledging the clinician’s implicit powerand the patient’s likely chronic experiences of disempowerment (Sesan, 1994) Strategies tominimize the power differential include constant collaboration between the clinician and thepatient and psycho-education, so the patient can make informed decisions about her treatment

GENDER-INFORMED TREATMENT

Each patient brings her own rich constellation of biology, psychology, and culture intotreatment, as does each clinician Mature therapists learn to distinguish between acculturatedreactions and their own idiosyncratic reactions by examining questions like: “How am I as

a therapist different with male and female patients?” or, “What biases color my reactions?” and,

“What gendered expectations do patients have of me?” Male therapists need to introduce thesetopics into their work with their female patients with ED Female therapists must modelhow to work through their own gender biases and experiences and to be open to theirpatients’ perceptions of body, maternality, sexuality, and experiences of power differentials(Piran, 2001)

Even in same sexed therapistepatient pairs, assumptions, values, and biases will shapethe relationship Psychotherapy research suggests that gender-stereotypes in diagnosis andtreatment endure, although these may be more subtle than in the past Women, for instance,are more likely to be diagnosed with Axis II disorders than men (APA, 2007b) and less likely

to be diagnosed with PTSD They also have higher rates of anxiety and depression and otherinternalizing disorders (Blatt, 2008) Clinicians may tend to attribute women’s psychologicaldisorders to endogenous or intrapsychic factors and minimize the centrality of externalforces On a more subjective level, many still label a female patient’s emotional expressive-ness as “needy” or “dependent.”

I BRIDGING THE GAP: THE OVERVIEW

These issues have particular power when treating women with ED Culture and ence infuse the genetic vulnerabilities of these women with criticism and self-loathing, espe-cially for the body Consequently, feelings of fatness, fear of weight gain, the over-valuation ofthinness, and the panic of fullness evoke a sense of being flawed or unacceptable Experi-ences of helplessness, oppression, bias, violence, and trauma all affect self-concept (APA,2007b) The internalization of the thin body ideal can be equally damaging, as seen in everytreatment encounter with ED women.

experi-The importance of gender is immediately apparent in the examination of the specificpsychopathology of ED (Fairburn, 2008) Young girls are taught to use restraint, especially

“dietary” restraint, and to monitor their value by body checking and constant self-scrutiny.While the over-evaluation of thinness, central in the cognitive model of eating pathology,appears to be relevant for both sexes, it is most consistent with the values of the femaleculture Any effort to challenge this requires exploration of that patient’s sense of herown gender Other aspects of eating psychopathology (food avoidance, desire for empti-ness, adherence to strict rules, fear of loss of control, avoidance of social eating, guilt andshame about eating) also reflect a gendered indoctrination regarding acceptable femalebehavior Conforming to the thin body ideal provides a degree of stability and certaintyand choosing to relinquish an ED comes at a high price including mourning, identity confu-sion, and ambiguity As, historically, women have paid dearly for such non-conformity, timespent in psychotherapy on the exploration of the social context of gender and ED is timewell spent

Psychotherapy must help patients make sense of the biopsychosocial storm that led totheir ED, through explicit discussion of what it means to be a woman with all its associatedvalues, dreams, aspirations, hopes, fears, and anxieties While directive, symptom-focusedapproaches have demonstrable power to help establish stability and normalization of eating,longer term recovery requires something more subjective How can patients explore thesignificance of pleasure, desire, emotional intimacy, and safety if they only talk about eating,weight, and shape? Providing empathy and connection are rarely enough either Effectivetreatment demands an integration that simultaneously sustains a collaborative allianceand an explicit push for change The heart of the psychotherapeutic art conveys empathicacceptance while simultaneously pushing for things to be different Although researcherscontinue to explore the power of the therapeutic alliance, we, to date, lack the quantitativesophistication to capture this core feature of therapeutic effectiveness (Maine, 2009).Typically, clinical training and empirical treatment research have focused on the measur-able behaviors and symptoms of DE It is less clear how we can assess the role of relationalconnection or attachment, flexibility and adaptability in self evaluation, awareness of internalexperiences, and issues such as trust, desire, intimacy, values, meaning, and spirituality Allthese have a significant connection to gender and may have as much to do with full recovery

as does the elimination of specific behaviors (see McGilley and Szablewski, Chapter 12)

ENHANCING GENDER COMPETENCE

As gender is a force in all relationships, including psychotherapy, and a core ingredient ofthe perfect storm of ED, we must appreciate, understand, and use it to enhance recovery

Acknowledging its importance in psychological development and well-being, the AmericanPsychological Association (APA, 2007a) has created guidelines for gender informed treat-ment, addressing eleven key features of gender “competence.” Each of these dimensionshas direct implications for both the specific aspects of eating psychopathology and moregeneral aspects of psychological functioning such as self esteem, trust, safety, and intimacy.The APA stresses that clinicians must attend to these contextualizing factors and evaluatetheir conceptualizations, etiological models, and treatment approaches using these princi-ples This is especially critical when treating women with ED Below we list the core compe-tencies as proposed by APA and relate them to the treatment of ED.

• Effects of socialization, stereotyping, and unique life events Case formulations need to includeconsideration of gender socialization and stereotyping How does a woman’s strugglewith weight, shape, and eating reflect her sense of being female?

• Effects of oppression and bias As noted earlier, we are at risk for minimizing the effects ofoppression and disempowerment on the social, gender, and sexual identity development

of our patients with ED Therapists, too, must stay aware of how these forces impact ourown sense of self and our therapeutic interactions

• Bias and Discrimination These forces have demonstrable effects on physical and mentalhealth As we evaluate our patients, we need to explore the role of these experiences Is thelack of research and treatment resources for ED an example of bias and discrimination?

• Gender Sensitive and Affirming Procedures Therapists must incorporate explicit techniquesthat affirm and support girls and women We should also be continually evaluating ourtheories and treatment models for negative gender bias

• Impact on Therapist’s Practice This guideline emphasizes the importance of therapistgender and self awareness How do our own gender biases and experiences influence ourwork? Their influence is inevitable but we can monitor their effects and become moregender-sensitive

• Evidence Based on Gender Sensitive Research The APA guidelines stress the importance ofusing gender sensitive research methods Most of what we know about ED has, obviously,been based on research on women But, are our methods free of bias? Perhaps the relativede-valuation of qualitative research reflects gender bias that undermines the field’sknowledge and treatment approaches

• Promote Initiative and Empowerment This is particularly relevant in that recovery from an

ED requires a shift in self evaluation Expanding the range of choices and opportunities forwomen enhances this shift away from a focus on weight, shape, and body as the

foundations for self esteem

• Assessment and Diagnosis Sociocultural values may skew assessment of things likeemotionality, dependency, lability, and affective intensity This may affect diagnosis ofpersonality disorder in particular As these features often accompany eating pathology, EDclinicians must be especially vigilant to their own biases, beliefs, and practices regardingassessment and diagnosis

• Sociopolitical context What starts as a sociocultural attitude or trend can become aninternalized constant In addressing issues of body, eating, self-concept, femininity, orrelationships, therapists need to keep their ears open for connections to their patients’external cultures How have our patients taken in the messages from the culture and made

I BRIDGING THE GAP: THE OVERVIEW

them their own? How can we best increase their awareness of the power of the

sociocultural context?

• Identifying Resources for Support In asking our patients to relinquish their ED, we need tohelp them incorporate other sources of support into their lives This guideline pushes thegender sensitive clinician to identify these alternative sources in patient’s relationshipsand community

• Challenging Institutional Bias This final guideline encourages therapists to actively engage

in challenging institutional bias and barriers Women with ED are marginalized anddiminished by the culture Treatment is hard to access and difficult to afford Research isunderfunded Even to this day, families, and mostly mothers, are still treated as the cause

of ED (Maine, 2004) Therapists must look for opportunities to challenge these biasesthrough advocacy, education, eating disorder prevention, or research For some patients,the final phase of real recovery may require their own efforts to speak out and challengethe culture in some broader way

CONCLUSION

Gender is a critical factor in ED, as being born female remains the greatest risk factor ciated with these diagnoses It may, however, be both a chicken and an egg, simultaneouslycreating critical biopsychosocial realities and reflecting them As contemporary culturepromotes an overevaluation of thinness, excessive self-criticism, and disembodiment inwomen, culture and gender create an essential context for women with ED; therapistsmust explicitly acknowledge and attend to that context

asso-To explore and acknowledge the power of external factors in the etiology and maintenance

of eating pathology does not ignore the significance of biological and genetic vulnerabilities

We miss important aspects of our patients’ lives and of their individual psychology if weminimize the power of the gendered context, including the effects of bias, marginalization,trauma, discrimination, and the roles and rights of women Effective treatment requires

a balance between individual adaptation and cultural gender awareness, and a deep ciation for all the biopsychosocial elements of the perfect storm of eating disorders

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Tiggemann, M., & Slater, A (2001) A test of objectification theory in former dancers and non-dancers Psychology of Women Quarterly, 2, 57e64.

Treasure, J (2007) The trauma of self-starvation: Eating disorders and body image In M Nasser, K Baistow, &

J Treasure (Eds.), The female body in mind: The interface between the female body and mental health (pp 57e71) London, England: Routledge.

Weinberg, M., Tronick, E., Cohn, J., & Olson, K (1999) Gender differences in emotional expressivity and regulation during early infancy Developmental Psychology, 35, 175e188.

self-Worell, J., & Todd, J (1996) Development of the gendered self In L Smolak, M P Levine, & R Striegel-Moore (Eds.), The developmental psychopathology of eating disorders: Implications for research, prevention, and treatment (pp 135e156) Mahwah, NJ: Lawrence Erlbaum Associates.

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C H A P T E R

2

What’s Weight Got to Do with It?

Weight Neutrality in the Health at Every Size Paradigm

and Its Implications for Clinical Practice

Deborah Burgard

My new client, who is fat, walks into the room, sits down across from me, and says, “Well,

as you can see, I’m a compulsive eater.”

I am still brought up short by this fairly common opening line “Ah, well, that is not thing one can see with the naked eye,” I say “Tell me about it.”

some-Our therapy is off and running, characterized from the start by the oppression my clienthas internalized about her body She has felt the need to say first what she fears I am diag-nosing simply by looking at her Not knowing quite what to make of my comment, shegoes on to tell the story of her problem as she understands it: that despite trying many diets,she has never been able to maintain any lost weight; that she despises herself for not havingthe control to keep restricting herself on a diet; that her body must be punishing her bymaking her fat; that she can’t figure out why she can plan to have a “good” day with foodand then find herself binging in front of the TV after her roommates have gone to bed; andthat she is here because she hopes that understanding the reasons behind her eating habitswill allow her to finally be thin and have the life she has dreamed of She believes that there

is something wrong with her self-control that therapy can fix, and her body and her life will

17Treatment of Eating Disorders doi: 10.1016/B978-0-12-375668-8.10002-6 Ó 2010 Elsevier Inc.

people will keel over and die, and right living will make everyone thin Even though I amchallenging those beliefs, and my patient is bemused, tolerant, or even agreeing with mewhile she is in my office, when she gets out the door she defaults back to the dominantcultural views.

Several months later, I discover my client’s reaction to my initial comment, when sherelates a recent conversation with her mother:

I told my mom, when we met that first time, you didn’t assume that I overate It was so weird, I went home wondering if you knew what you were doing I mean, how could you not know that I must be overeating, after treating people with eating disorders? But I just felt kind of lighterdit was hard to explain I guess it felt like maybe there was hopedlike you saw me, not some Big Fat Couch Potato who eats all day.

THE PANIC ABOUT FAT

The list of beliefs my patient voices is the same list most people, including health sionals, hold about fat and fat people At various times, I have observed clinicians andresearchers expressing the following:

profes-• Body Mass Index (BMI) is a decent proxy for health, and existing categories of BMIaccurately reflect risks for health problems and premature death

• Behavioral interventions (diet and exercise) will result in weight loss

• Health risks for reduced-fat people are the same as those who were never fat

• People can maintain weight loss if they try hard enough

• Fat people’s bodies, or certainly their appetites, or surely their intake, must be

pathological

• Fat people are walking time bombs for heart attacks and diabetes

BOX 2.1

W H A T I S H E A L T H A T E V E R Y S I Z E ?

• Accepting and respecting the diversity of

body shapes and sizes

• Recognizing that health and well-being

are multi-dimensional and that they

include physical, social, spiritual,

occupational, emotional, and intellectual

aspects

• Promoting all aspects of health and

well-being for people of all sizes

• Promoting eating in a manner whichbalances individual nutritional needs,hunger, satiety, appetite, and pleasure

• Promoting individually appropriate,enjoyable, life-enhancing physicalactivity, rather than exercise that isfocused on a goal of weight loss

ASDAH, Health at Every Size (HAES)Principles,www.sizediversityandhealth.org

• Fat people are weak and self-indulgent; or, in clinical language, they must be moreimpulsive or less able to inhibit themselves

• Therapy will allow people to achieve a “normal” weight by addressing their “issues”

• The most important intervention for a fat patient is to help her lose weight, so her life can

be worth living

When one begins from a neutral position on these statements, however, and asks forevidence, very little is available; in fact considerable evidence contradicts these assumptions.Many of the assumptions have not been adequately tested because people presume them to

be true and not necessary to test in the first place Others have been inadequately testedbecause of some common methodological problems: for example, attributing causality to

a correlation; not understanding the magnitude of statistical relationships; or using clinicalpopulations and generalizing to fat people in general And most bewildering, many of theassumptions that have been proven wrong over and over never seem to die

An adequate review of these issues is beyond the scope of this chapter, butBacon (2008),Campos (2004), andGaesser (2002)have provided comprehensive analyses of the relevantliterature Their work challenges us to face some important facts about “obesity” if wehope to provide ethical, effective, and safe health care:

• No known interventions lead to the long-term achievement of “normal” weight for thegreat majority of people classified as “obese,” including weight loss surgery (Friedman,2009; Mann et al., 2007)

• The people in the “overweight” and “mildly obese” BMI categories live the longest (Flegal,Graubard, Williamson & Gail, 2005; Orpana et al., 2009) For older adults (>69 years ofage), higher BMI is a protective rather than a risk factor for mortality (Flegal et al., 2005;Tamakoshi et al., 2009)

• The diseases and conditions more highly correlated with higher weight occur across theweight spectrum and are known to vary with many confounding factors, such as: socio-economic status (SES) (Ernsberger, 2009); weight cycling (Kruger, Galuska, Serdula &Jones, 2004); stigma (Puhl & Heuer, 2009); disparities in access to medical care (Amy,Aalborg, Lyons & Keranen, 2006); and physical activity (Williamson et al., 1993)

• Most healthcare providers, including (especially!) clinicians who work with fat patients,are weight biased and feel frustrated by interactions with fat patients (Puhl & Heuer, 2009)

• Most fat people do not have eating disorders (ED) (Hudson, Hiripi, Pope & Kessler, 2007)

• Most fat people do not have psychiatric problems (Friedman & Brownell, 2002; Marcus &Wildes, 2009; Simon et al., 2006) A substantial proportion of fat people, especially women,

do not have and never go on to develop diabetes, high blood pressure, high cholesterol, orheart disease (Sims, 2001; Wildman et al., 2008)

• When fat people make sustainable changes in their health practices, they reduce oreliminate the risk factors and health conditions associated with high BMI even when theirweights do not change (Bacon, Van Loan, Stern, & Keim, 2005)

Weights have indeed risen in the past generation, by about 10e15 pounds on average(Flegal et al., 2005) The group of the very heaviest people (BMI>40; as an illustration,

a 50400woman who weighs 234 pounds), although few in number, is now double the size itwas in 1988 (5.9 vs 2.9% of the adult population) according to theCenters for Disease Control

I BRIDGING THE GAP: THE OVERVIEW

(2008) The percentiles established in the 1970s for children’s weights, when the 95thtile represented the heaviest 5%, have been continued in use even though now there is14e19% (depending on the age group) in the “95thpercentile” (Centers for Disease Control,

percen-2010) Since 2004e2005, the weight gains seem to be leveling off (Centers for Disease Control,

2008) and we have no evidence for interventions that make lasting weight changes; still,proposals and policies for the “War on Obesity” continue to proliferate

The conflating of “normal” BMI with health leads to statements like, “If all U.S adultsbecame nonsmokers of normal weight by 2020, we forecast that the life expectancy of an18-year-old would increase by 3.76 life-years or 5.16 quality-adjusted years” (Stewart, Cutler

& Rosen, 2009) But there is no evidence that: (1) people who have reduced their weight havethe same health risks as those who were never heavier; (2) the higher health risks for higher-BMI people are caused by higher weight rather than the confounding variables; and (3) there

is a way for fat people to become and remain “normal weight.” It is similar to telling poorpeople that they really should consider making a US$1 million, because millionaires havebetter health profiles and live longer

The neutral facts about weight changes in our population are not met with scientific osity Instead, they are assumed to herald a growing (and impending) disaster for health, theeconomy (Finkelstein, Trogdon, Cohen & Dietz, 2009), even the global climate (Edwards &Roberts, 2009) Perhaps, like our ED patients, most people in our culture turn to trying tocontrol weight when faced with dread and anxiety about forces that seem outside our control

curi-ABOUT THE DATA

One thread of my conversation with this patient concerns the nature of evidence How do

we know what (we think) we know about weight? And, what motivates us to maintain thesebeliefs?

Starting from scratch, we have just the fact of a person’s weight, but not an assumptionabout it Body size has acquired different meanings in different cultures, and at differenttimes in history At one point in time, fatness implied wealth; in our time, it implies beinglower class (Ernsberger, 2009; Klein, 2001) These meanings are specific to time and place;they have no intrinsic relationship to fatness itself

Examining my own beliefs and the evidence that shapes my thinking about weight, I havefound several major sources One is my personal experience growing up as a “90thpercen-tile” child in height and weight I know what it felt like to be weighed in front of the otherkids, how I compared myself to the more delicately-built girls, and how it felt to have myparents fret about my weight I also experienced the anguish of people in my family whohad ED, with deeply held beliefs about weight I was in the minority in rejecting the process

of dieting at 19, though the other members of my family came to embrace a focus on healthpractices rather than weight in the decades that followed

A second major source of evidence has been my clinical experience The fact that I work withpeople with ED across the weight spectrum, as well as with people of all weights who arethriving and happy, has allowed me to test the hypothesis that fat is a proxy for ill health, depres-sion, and overeating I am privileged to see a greater range of health, moods, eating styles, andweights, than the vast majority of people do, and to get to know these people intimately The

truth is, people who binge come in all sizes People who restrict come in all sizes People whopurge come in all sizes Despite my decades of experience, I really cannot look at someoneand know what they are going to tell me about what they are doing with food and exercise.Moreover, as an ED specialist, I have been trained to challenge the beliefs of thin peoplewho overvalue thinness and dread fatness I have seen my patients’ lives resume a normaldevelopmental course when they can allow themselves to eat enough and let their bodies’genetic inheritance determine their “healthy” weight I have seen that their weight-basedbeliefs were part of the problem, an uncontroversial and empirically supported aspect of

ED treatment (Wilson & Fairburn, 1993)

Oddly enough, the very same beliefs about weight are somehow not seen as part of theproblem if the patient is fat In fact, some suggest that if fat people do not see themselves

as sufficiently pathological, professionals should “educate” them to abhor being fat and toengage in the same weight loss attempts as the culturally dominant (white, professional)group (Bryner, 2009) Anyone who has worked with upper-middle class white women knowsthat this is not the group to use as role models for positive body image

Finally, the third source of evidence is the vast number of studies from the ED, “obesity,”and health fields that contribute to our understanding of weight dynamics, eating practices,and health In my reading of this literature over 30 years, I have tried to capture and utilizethe evidence that is solid, and maintain an agnostic stance toward the research that is toobiased or too incomplete to provide answers

THE VALUE OF A WEIGHT NEUTRAL STANCE: PART 1

Making the transition to a weight neutral world view is a daunting task Such a perspective

is a decidedly minority position, in opposition to broadly held cultural assumptions, and willmost likely be under assault for years to come Why even try to swim upstream against thecultural current?

The answer is that, over and over again, we have seen that members of oppressed groupsmake social progress and improve their mental and physical health by rejecting the negativeand stigmatizing messages, paying attention to the truth of their own experience, comparingnotes with other members of their group, and identifying the stereotypes, stigma, violence,and discrimination they face Discrimination based on weight is as common as discrimina-tion based on race and age, and more prevalent than that based on sexual identity, disabil-ities, and religious beliefs (Latner, O’Brien, Durso, Brinkman & MacDonald, 2008; Puhl,Andreyeva & Brownell, 2008) The correlation between higher weight and a lower SES seems

to be causal in both directions (Ernsberger, 2009) in that poverty tends to restrict ties for safe physical activity and access to good nutrition, and discrimination against fatpeople in hiring and retention lowers their income Public health interventions must addresssocial justice issues like inequality, discrimination, and poverty, not just focus on individualchoices For people to do the hard work of caring for themselves, defending themselves, orloving and advocating for themselves, they have to believe they are worth caring for Caringfor our bodies is hard work, and some environments make it especially difficult The firstorder of business is to understand that all bodies, of all sizes and all socio-economic classes,are precious and deserve care

opportuni-THE VALUE OF A WEIGHT NEUTRAL STANCE: PART 1 21

I BRIDGING THE GAP: THE OVERVIEW

Historically we have witnessed oppressed groups move through a process where theytransform shame into pride, and society’s view changes from devaluing them to seeingthe value of human diversity Body size is a biological trait bound to vary widely in a pop-ulation with a diverse ancestry It is not due to any kind of pathology, but stems fromhaving evolved from ancestors who survived by adapting to many different environments.Rather than understanding the global nature of our population, we still have a village-scaleview of the issue of body size, where one group decides what is “normal” for “us,” and therest of the people (“they”) are sick/wrong simply because they are fatter But what if wehumans did not have some people who are gifted at making fat from food? Are we soadvanced that we can confidently predict that we will never need such a capacity forhumans to survive in the future? Is such a capacity better labeled a pathology, to bedispensed with through “treatment,” through surgery or medications or genetic manipula-tions, in order to satisfy the temporary esthetic ideals of the twenty-first century Westernworld? Would it not be better to preserve our capacities but continue to find ways of treat-ing diseases?

We know that stigma itself causes ill health (Puhl & Latner, 2007), and that many of theheaviest people have weight cycled the most (Weiss, Galuska, Khan & Serdula, 2006).They are also poorer than thinner people (Ernsberger, 2009) But studies do not alwayscontrol for SES, and none has controlled for weight cycling or stigma Thus, we do notever know when a health finding correlated to BMI is really caused by the numerous vari-ables that co-vary with BMI If, for example, weight cycling causes hypertension, and weconclude that because higher BMI is a risk factor for hypertension we should prescribeweight loss, and prescribing weight loss is, in essence, prescribing weight cycling, we aregoing to make people sicker and fatter with our “treatment.”

In the realm of “obesity” treatment, the solution to being stigmatized is seen as weightloss: remove the person from the stigmatized group, and the assumption is that there is nolonger a problem But we do not understand the identification process with our bodiesvery well if we imagine that weight loss “removes” the “fat self” or the memories and expec-tations of being treated as fat In fact, we should know from treating thin people with ED that

a person may never have been fat at all to have a very strong identification with a “fat self”that is despised, feared, and rebelliously embraced by turns

Cultural Meanings of Fat and Thin

Our culture associates fat with certain feeling states, causing us to act out complicatedinteractions with our bodies that really represent conversations and struggles we are havingwith disowned parts of ourselves

Table 2.1illustrates how our “fat” can denote literal evidence of vulnerable and shamefulfeeling states Thin people are seen as free from these burdens, and more protected frombeing exposed, but the public relentlessly projects these stereotypes onto fat people Whetherthey happen to feel depressed today or not, fat people do have a very real challenge, day inand day out, navigating these endless projections, assumptions, stereotypes, and objectifica-tions based on body size Because we all learn to associate certain emotional states with fat,fatness is “read” as tangible evidence of these vulnerable feelings It is seen as shameful, andwhile such feelings are part of the human repertoire and thus experienced by all, it is the fat