by: Mae Lynn Reyes-Rodriguez, Ph.D.
October 31, 2019
The demographic population of the United States has transformed to a more diverse landscape over the past years and it is expected that, by 2043, it will, for the first time, become a minority-majority nation (Colby & Ortman, 2014). Therefore, the likelihood of having an encounter with a client/patient from diverse racial/ethnic backgrounds has increased. Although it is not expected that a clinician would have expertise in every potential cultural background, in order to provide culturally competent care for our patients, being well-informed about culture, race, ethnicity, national origin, and language is essential for the effective implementation of services (APA, 2003 & 2017). Research on ethnicity-based healthcare disparities highlights three main issues: a) poor fit of psychiatric diagnostic categories with ethnically diverse explanatory models and presentations of illness, b) differential help-seeking patterns for illness across racial/ethnic groups and, c) clinician error or bias due to misperception (Alegria et al., 2006 & 2008; Becker et al., 2003). Although some national prevalence studies have documented a similar or higher prevalence of binge-type eating disorders (Marques et al., 2011; Udo & Grilo, 2018), service utilization and access to care in diverse populations are limited (Marques et al., 2011). The misconception that eating disorders are confined to white females has contributed to the stigma among members of diverse groups and to clinician bias. Raising awareness among individuals from diverse racial/ethnic backgrounds and among providers it is the first step toward destigmatization of eating disorders. Screening for eating disorders in all patients—regardless of their race or ethnicity—should be an integrative step care in primary care settings and specialized services. Particularly, the implementation of regular screening practices in primary care settings is highly relevant for the Latinx and Black populations due to their underutilization of specialized services.
Providing culturally competent care for patients from diverse racial/ethnic background requires that clinician/providers perform a self-examination of their own beliefs and biases. Importantly, individuals from the dominant culture are encouraged to reflect on how being from a different race/ethnic group, which may be associated with power and privilege, could interfere with the therapeutic relationship with patients from different backgrounds. Only through open and honest communication and willingness to learn from each other, we can create a safe environment for those who have experienced discrimination or mistreatment due to their status as being part of a “minority” population or struggling with the stigma of suffering from a disorder that has been associated with White culture. Unfortunately, the research on evidence-based treatments that are culturally adapted in the United States for diverse populations is extremely limited. Cognitive behavioral therapy (CBT) and self-guided CBT for binge-type disorders have been adapted for Latinas (Reyes-Rodriguez et al., 2014, 2019; Shea et al., 2012, 2016), and one study conducted with African American women used CBT-based treatment to teach adherence to hunger and satiety (Goode et al., 2018). In addition to more work on the Latinx and Black population, additional work is needed with other diverse populations such as Native Americans and Asian Americans.
Despite the vacuum of culturally sensitive evidence-based treatments for eating disorders, it is also essential to incorporate cultural values and elements in the assessment and treatment process that are relevant for members of different cultures. For example, in the assessment phase, in addition to collecting the history of the eating disorder, exploring acculturation, acculturative stress, the role of food or differences in eating patterns in the specific culture, food insecurity, trauma history, and comorbid conditions are important. For those patients coming from different countries, exploring language barriers and migration status could help to identify potential barriers to engagement and retention. In the absence of an adequate evidence base, regarding treatment, the use of evidence-based treatments combined with the integration of cultural values seems appropriate. In the experience of adapting CBT for binge-type eating disorders with Latinas, the most relevant cultural adaptation has been in the delivery process rather than in the content of the treatment. For example, when working with Latinx population, specific cultural values such as familismo (the strong sense of identification with and loyalty to nuclear and extended family) and personalismo (Latinxs promote close relationships, especially with those who demonstrate respect, caring, and well-meaning) are essential for a culturally sensitive treatment (Reyes-Rodriguez et al., 2014). The incorporation of the family as part of the treatment seems to boost engagement and retention, particularly when working with adult Latinas. A careful identification of who could serve as a source of support for the patient is important. For those less acculturated, matching the patient with a provider who speaks the same language and who has a better understanding of patient’s cultural background is the best option. However, the use of an interpreter is sometimes inevitable. When working with an interpreter, it is important to be mindful of the additional layer of complexity it adds to the treatment process, and the effects it may have on the therapeutic alliance and treatment fidelity. The use of a minor, either patient or sibling as an interpreter for parents should be avoided.
As discussed in this blog, the increased representation of individuals from diverse backgrounds in the United States presents unique challenges when providing culturally-appropriate mental health care. Recognizing the importance of integrating cultural values as part of care is essential. Patients are not expecting providers to know everything about their culture, but they deserve validation and recognition that their culture is an integral part of who they are. It is fine to ask if we do not know, but it is wrong to ignore their culture values. Close collaboration between provider and patient can help providers navigate through unfamiliar and for some, uncomfortable processes, but with the best intention to learn from each other and to provide the best care for our patients.
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