Therapists' Experiences Treating Asian American Women With Eating Disorders

Summary of Results The therapists reported similarities in their conceptualizationand treatment of clients across cultures. However, they viewedAsian American clients as being under considerably more pressureto be thin and to achieve. They cited gender role, filial piety,collectivism, and a cultural norm of conforming as influential.While both parents and daughters appeared to idealize Westernbeauty norms, intergenerational acculturative stress created com-munication problems and struggles with autonomy. EDs offered away of coping by emotionally disconnecting or expressing distresscovertly. The therapists paid particular attention to shame, even asthey worked to challenge both mainstream U.S. and traditionalAsian norms. Psychoeducation and including parents in the treat-ment plan, although not always successful, was viewed as critical. Discussion and Implications for Practice The present study provides insight into Asian American womenclients with EDs through the perspectives of their therapists andadds to the extant literature by exploring how experienced thera-pists perceive and work with cultural concepts in ED treatment. Asnoted by APAs (2006) Presidential Task Force, clinical expertiseand consideration of cultural contexts are important aspects ofevidence-based practice.Striegel-Moore and Bulik (2007) asserted that although theetiology of EDs is exceedingly complex, the risk of developing EDsymptoms (in mostly White samples) increases with factors ofthin-ideal internalization , dieting , and body dissatisfaction . Al-though similar risk factors are seen across ethnic groups, little isknown about whether certain issues place non-European Americangroups at particular risk (Smolak & Striegel-Moore, 2001). Ther-apists in the present study described their clients as primarilyimpactedbycommonriskfactorsthatareshapedbyculturalnormsin important ways.The therapists stated that their clients experienced inordinatethin idealization and body dissatisfaction, and most believed thatAsian American women experience greater familial and culturalpressure to be thin than do other women. Parents strongly encour-agedthinness,perhapsinfluencedbythebeliefthatitiskeytotheirdaughters success in the U.S. (as suggested by Ting & Hwang,2007); some also encouraged plastic surgery. A number of clientsdisliked their faces to the point of body dysmorphia. The inabilityto meet the dominant cultures definition of beauty may contributeto Asian American womens vulnerability to EDs (Yokoyama,2007); the present study suggests that distress over facial featuresmay be a specific risk factor for some.Smolak and Striegel-Moore (2001) stated that acculturationshould be studied as a possible unique risk factor for ethnicminority women. The research on acculturation is conflictual,indicating that the more acculturated to Western culture, thegreater likelihood of EDs; and conversely, the less acculturated,the more cultural conflict and stress , and the greater likelihood ofED (Smolak & Striegel-Moore, 2001). The present study seems tosupport the latter, as all the therapists reported that the majority oftheir Asian American clients with EDs were first and secondgeneration. Many of these clients were still very much in thestressful process of acculturation, receiving the following mes-sages: adapt to the U.S. mainstream through professional success;conform to Asian gender standards; do not embarrass family bybeing other than very thin; and attract the best possible mate. Mostrelevant to family relationships was the acculturation differencebetween daughters and their parents, resulting in a conflict ofvalues.Although acculturation stress was salient, ED behavior in theseclients may also have been impacted by norms within their cultureof origin. Indeed, although BN appears to be a more recent andmore Westernized phenomenon, there is evidence of purposefulstarvation among adolescent girls across the world (includingAsia) for centuries (Keel & Klump, 2003); and EDs are nowincreasing in affluent societies in Asia (Lee & Katzman, 2002). Furthermore, while little research suggests Asian Americans areactually at greater risk for EDs, Kawamura (2002) speculated thatcollectivistic values (e.g., the individual represents the group) mayexacerbate body dissatisfaction in some Asian women. The datafrom this study would seem to support that: therapists generallybelieved that there was a connection among ED behaviors, bodydissatisfaction, the desire for surgery, and the desire to fit in. Thissuggests that the meaning of thinness for some Asian Americanwomen may involve deeply rooted beliefs of honoring the familythrough ones presentation and achievement, particularly in theprocess of adapting to the U.S., and conforming to both cultures insuch a way that one does not stand out.Most experts agree that full-syndrome EDs involve more thanbody dissatisfaction and the desire to be thin. Reviewing case-control studies, Schmidt (2002) reported that genetic predisposi-tions to thinness and personality traits of perfectionism, obses-sionality, negative self-evaluation, and extreme compliance (p.249) are likely risk factors for AN, as are more general psychiatricfactors, such as childhood trauma. Likely risk factors for BN