Download Untitled - Sacramento - California State University

PROFESSIONALS' PERSPECTIVES ON THE IMPORTANCE OF CULTURAL
COMPETENCIES IN WORKING WITH CLIENTS WHO INDICATED BODY
IMAGE CONFLICT
A Thesis
Presented to the faculty of the Division of Social Work
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
by
Shannon Ann St Louis
SPRING
2014
PROFESSIONALS' PERSPECTIVES ON THE IMPORTANCE OF CULTURAL
COMPETENCIES IN WORKING WITH CLIENTS WHO INDICATED BODY
IMAGE CONFLICT
A Thesis
by
Shannon Ann St Louis
Approved by:
__________________________, Committee Chair
Jude Antonyappan, Ph.D
__________________________, Second Reader
David Nylund, Ph.D
____________________________
Date
ii
Student: Shannon Ann St Louis
I certify that this student has met the requirements for format contained in the University
format manual, and that this thesis is suitable for shelving in the Library and credit is to
be awarded for the thesis.
__________________________, Graduate Coordinator
Dale Russell, Ed.D., LCSW
Division of Social Work
iii
___________________
Date
Abstract
of
PROFESSIONALS' PERSPECTIVES ON THE IMPORTANCE OF CULTURAL
COMPETENCIES IN WORKING WITH CLIENTS WHO INDICATED BODY
IMAGE CONFLICT
by
Shannon Ann St Louis
This study examined the importance of cultural competencies among helping
professionals in managing body image and eating disorders from the perspectives of
graduate social work students. The non- probability sample of 54 subjects responded to a
questionnaire based on overall knowledge of factors, terminology, interventions, and
solutions as it pertained to body image issues and eating disorders. Study findings suggest
that the majority of participants had limited knowledge about body image and eating
disorders and only a small percentage of participants had adequate knowledge. However,
a statistically significant association was found between whether body image issues had
been a concern of respondents’ clients and whether or not eating disorder treatment had a
high success rate.
iv
Another statistically significant association was found between whether or not
respondents believed early intervention was the best method for addressing body image
issues and whether or not they believed eating disorder treatment had a high success rate.
Overall, the findings of this study indicate the necessity for more education and training
on the dynamics of body image and eating disorders that may result from body image
conflict.
_______________________, Committee Chair
Jude M. Antonyappan, PH.D.
_______________________
Date
v
ACKNOWLEDGEMENTS
The author would like to acknowledge the Sacramento State Division of Social Work for
helping me succeed in the process of completing this thesis. The author would like to
thank Jude Antonyappan for assisting her through writing this thesis and keeping her on
the right track. The author would also like to thank David Nylund for agreeing to be her
second reader.
The author would like to thank Health and Wellness Promotion at Sacramento State as it
was the internship completed in this department that helped develop her consciousness
about the prevalence of body image issues and eating disorders.
The author would like to personally thank her family and especially her fiancé for his
amazing support and patience through the writing process.
vi
TABLE OF CONTENTS
Page
Acknowledgments..................................................................................................... .. vi
List of Tables ................................................................................................................ x
List of Figures ............................................................................................................. xi
Chapter
1. STATEMENT OF THE PROBLEM …………………………………………1
Background of the Problem ..…………………………………………………2
Statement of the Research Problem………... ………………………....4
Study Purpose……………… ………………………………....5
Theoretical Framework …………..………….………..5
Definition of Terms ……………….…….….….…….11
Assumptions …………………………………………13
Study Limitations ………………………………………………...….14
2. REVIEW OF THE LITERATURE ...................................................................... 15
The Role of Western Media ............................................................................ 15
Cultural Competence and Health Professionals .............................................. 17
Eating Disorders.................................................................................. 19
Successful Model Programs ............................................................... 25
Socioeconomic Status ......................................................................... 25
Gender. ................................................................................................ 26
Sexual Orientation .............................................................................. 28
vii
Western Culture and Acculturation ............................................................... 29
Ethnicity, Race, and Culture ............................................................... 30
Religion ........................................................................................................... 33
Age………………............................................................................. . 34
Intervention ......................................................................................... 35
Summary ........................................................................................................ 35
3. METHODS ........................................................................................................... 37
Study Objectives ............................................................................................. 37
Study Design ................................................................................................... 37
Sampling Procedures ...................................................................................... 38
Data Collection Procedures............................................................................. 39
Data Analysis .................................................................................................. 41
Protection of Human Subjects ........................................................................ 42
4. STUDY FINDINGS AND DISCUSSIONS ......................................................... 44
Profile of Study Subjects and Demographics ................................................. 45
Experience and Education with Eating Disorders and Body Image Issues .... 46
Knowledge on Body Image and Eating Disorders .......................................... 49
Knowledge on How Western Culture Impacts Body Image ........................... 60
Respondents’ Interest in Future Practice ........................................................ 64
Gender and Age Difference in Evaluating Body Image Issues ...................... 66
Summary ......................................................................................................... 72
viii
5.
CONCLUSION, SUMMARY, AND RECOMMENDATIONS ………………74
Conclusions …………………………………………………………………..74
Recommendations …………………………………………………………..76
Implications for Social Work ……………………………………………….80
Appendix A. Human Subjects Approval Letter ........................................................ 83
References .................................................................................................................. 84
ix
LIST OF TABLES
Tables
Page
1.
Distribution of respondent’s gender................................................................ 46
2.
Association between body image issues being a concern of clients and the belief
that eating disorder treatment has a high success rate .................................... 50
3.
Scaled knowledge about eating disorders and participants’ experience with clients
with body image issues that have led to an eating disorder ............................ 52
4.
The association between early intervention in addressing body image issues and
eating disorder treatment having a high success rate ...................................... 55
5.
Participants’ gender and the belief that discrimination exists based on an
individual’s appearance in Western culture ................................................... 67
6.
Mean difference in age between MSW respondents on considerations regarding
body image issues of clients ........................................................................... 68
7.
Interest level working with clients with an eating disorder and participants that
have worked with clients with body image issues that have led to an eating
disorder ........................................................................................................... 70
8.
Scored interest of participants’ learning more about body image issues and eating
disorders and participants’ work with clients ................................................. 71
x
LIST OF FIGURES
Figures
Page
1.
Perceptions of types of mental disorders resulting from negative body image.. 58
2.
Perceptions of interventions to treat eating disorders ....................................... 59
xi
1
Chapter 1
STATEMENT OF THE PROBLEM
Dissatisfaction with body image is an issue reported by recent studies on cultural
factors among different demographic groups. The preoccupation with beauty and thinness
in the United States, perpetuated through the media, has been shown to have damaging
effects on individual’s self-esteem and self-worth (Fernandez & Pritchard, 2011;
Giardino, & Procidano, 2012). These effects are being witnessed not only in native born
citizens but cross-culturally as the process of acculturation expects the integration of
Western beauty ideals (Mussap, 2009a; Akande, 2009). Negative body image can lead to
a number of mental health issues including depression, eating disorders, and reduced
quality of life (Sides-Moore & Tochkov, 2011).
Generally, mental health challenges present themselves in various dimensions as
impacted by the cultural and social conceptions and conditioning of the clients who
experience them. Consequently, body image conflicts are not an exception to this
phenomenon. In body image studies, researchers often hypothesize that the longer an
immigrant (either first or second generational) remains in the United States, the more
likely he or she will acculturate to the Western body ideal and develop body
dissatisfaction and lowered self-esteem (Darlow & Lobel, 2010). Researchers such as
Davey and Bishop (2006), and Sides-Moore and Tochkov (2011), state that issues
surrounding body image tend to manifest between adolescence and college age in male
and female students cross-culturally, and intervention during this time period is critical.
2
Negative body image affects individuals of different sexual orientations, religion, culture,
gender, ethnicity, and socioeconomic status (Aruguete, Nickleberry, & Yates, 2004;
Davey & Bishop, 2006; Kaminski, Chapman, Haynes, & Owen, 2005), leading to the
need for diverse cultural competencies of professionals working with these individuals.
This study focuses on understanding the importance of cultural competencies of
professionals in working with clients struggling with negative body image. This research
question is examined from the perspectives of the professionals who work with clients
who report conflicts with body image.
Background of the Problem
Diversity constructs are integral to the pluralistic societies such as the United
States. Pluralism is consistently acknowledged as a growing and inevitable process of
immigration and integration in the United States. In fact, the U.S. Census Bureau projects
that by 2050 no single culture will dominate. As a result, the U.S. will become a
combination of all cultures from all parts of the world (Cooper, 2012). One aspect of
migrating to the United States that members of other cultures face is the process
acculturation. The process of acculturation involves the integration of the dominant
culture’s language, values, beliefs, choices, and behaviors (Taras, 2008; Sussman, Truon,
& Lim, 2007; Vigdor, 2008). Some effects of acculturation into Western society have
shown to be problematic for other cultures, specifically in evaluating Western culture’s
standards of thinness and muscularity (Darlow & Lobel, 2010; Warren, Gleaves, CepedaBenito, Fernandez, & Rodriguez-Ruiz, 2005). In addition to culture, negative body
image has impacted individuals of different ethnicity and sexual orientation. The largest
3
challenge in treating individuals with negative body image is the range of diversity in
clients as not all clients will respond to certain interventions when compared with others
(Kaminski, Chapman, Hayes, & Owen, 2005). The value of thinness and muscularity in
Western culture is presented through the mass media in the form of magazines, television
shows, newspapers, advertisements, and internet websites and has a powerful effect on a
diverse population (Fernandez & Pritchard, 2011; Juarez, Soto, & Pritchard, 2012).
The California State University in Sacramento represents a microcosm of the
recognizable range of diversity among citizens and was used as the location by the
researcher (Morse, 2009). The researcher examined the extent to which master of social
work students are culturally competent in working with clients with negative body image.
Successful interventions are very important in treating clients inflicted by negative body
image; however, since such diversity exists in evaluating body image issues, it is
important for professionals to be cognizant of the different types of interventions needed.
Historical research evaluating body image has been limited, focusing almost exclusively
on Caucasian, upper to middle class females (Deleel, Hughes, Miller, Hipwell, &
Theodore, 2009). The absences of diversity in body image studies can limit professional’s
knowledge about different interventions. For example, a body image intervention for a
Caucasian female may not be adequate to treat a Latino male with similar body
dissatisfaction. Recent research studies have demonstrated that body image issues affect
individuals of varying ethnicity, gender, religion, age, and socioeconomic status.
4
Statement of the Research Problem
There are many variables that influence an individual’s body image. In the past,
much of the focus in body image studies included white, middle class females in the
United States. However, recent studies suggest that body image issues affect a diverse
group of individuals. Studies now confirm that negative body image influences
individuals of different ethnic background, gender, religion, sexual orientation, age, and
socioeconomic status. As a result, social workers who work with individuals conflicted
by negative body image are expected to understand that range of diversity that exists in
treating these issues. Instruction on matters pertaining to body image is not an area of
focus for MSW graduate students. However it is expected that MSW graduate students
understand correct interventions to use in treatment. The only other way in which MSW
graduate students learn about body image issues is through taking the diagnostic
statistical manual for mental disorders (DSM) course which introduces eating disorders
related to a distorted body image in a clinical context. Furthermore, since the (DSM)
course is not taken by all future social work professionals, it is imperative to find out
what level of knowledge these professionals have about mental health disorders that
result from negative body image. Additionally, it is helpful to examine the level of
competences future social work professionals have about the diversity that exists in
individuals suffering from negative body image as well as possible interventions. It is
also important to gain an understanding of what MSW students do know about how body
image is influenced.
5
Study Purpose. Body image dissatisfaction and eating disorders are included in
the many mental health issues social workers deal with, but social workers may not have
specific knowledge in that area. The primary purpose of this study is for the researcher to
determine what level of competence MSW students have in evaluating negative body
image and eating disorders. The secondary purpose of this study is to gain future social
work professionals’ view on what preventative and intervention measures can be taken to
promote healthy body image in clients.
Theoretical Framework
The theories utilized for the purpose of this study include empowerment theory,
critical race theory, and person-centered theory. These theories will be further discussed
in the recommendations portion of this paper.
Empowerment theory. Empowerment theory was developed out of feminist
theory and is a contextual approach which rejects that universality exists between people
and instead demonstrates that differences in people have to do with time in history, as
well as social and physical environment (Net Industries, 2012). Empowerment is defined
by Gutiérrez (1994) as cited in Schriver (2010) as the “process of increasing personal,
interpersonal, or political power so that individuals, families, and communities can take
action to improve their situations” (p. 202).
Theoretical assumptions. Empowerment can be utilized at a community,
organizational, and individual level. For the sake of this research, empowerment at the
individual level will be the main focus. Zimmerman (1995) describes that empowerment
at an individual level “…integrates perceptions of personal control, a proactive approach
6
to life, and critical understanding of the sociopolitical environment” (p. 581). Part of the
empowerment process includes the opportunities individuals are given to manage their
own lives through the decisions that they make and occur at an intrapersonal,
interactional, and behavioral level. The intrapersonal component includes perceived
competence and control, self-efficacy, and overall motivation. The interactional
component includes understanding causality, the mobilization of resources, and overall
awareness of social and political issues. The behavioral component includes coping
mechanisms and the involvement one has with his or her community or organizations
(1995).
Zimmerman describes further that this process of empowerment includes the
experiences individuals have that help them identify the similarities between their goals
and how to achieve these goals which can be accomplished through “greater access to
and control over resources” (1995, p. 582). The main goal of empowerment includes
skills individuals learn to better manage their own lives. Overall, empowerment at the
individual level is useful in social work because the social worker provides basic tools
and resources needed for the client to thrive. Empowerment theory was created to address
issues of powerlessness by placing the power in the hands of the individual who may be
struggling with issues of power.
Application of theory to body image. In the context of this research, Western
culture beauty ideals lay at the base of the dominant culture’s beliefs. Therefore, the
dominant belief and conflict of powerlessness occurs due to the pressure that people must
abide by societal beauty standards in order to be desirable by others and attain success. It
7
is disempowering to others when they feel as if they do not fit into societal beauty
standards. This disempowerment is being observed in individuals from other cultures as
well. Individuals that migrate to the United States are initially empowered by their own
culture; however, these cultural beliefs are challenged when they experience the process
of acculturation.
Empowerment theory allows individuals to challenge the beliefs of the dominant
culture and reevaluate the fact that since such diversity exists in people; there is no way
of truly knowing what the ultimate form of beauty is. Empowerment can allow
individuals from other cultures to replace erroneous beliefs presented by the dominate
culture and return to their original beliefs about appearance. Once individuals begin
challenging the dominant culture’s standards of beauty, less individuals will be conflicted
with body image and more people will celebrate that beauty exists in all shapes, sizes,
colors, and variations.
Critical race theory. During the civil rights movement of the 1950’s and 1960’s,
critical race theory developed in an effort to acknowledge the oppressive nature of
discrimination and racism (Abrams & Moio, 2009). The critical race theory takes into
account social justice issues surrounding the marginalization of certain groups,
particularly groups that are considered minorities by the dominant culture (Treviño,
Harris, & Wallave, 2008). This theory attempts to understand “…the social construction
of race as central to the way people of color are ordered and constrained in the United
States” (p. 7). The foundation of critical race theory is based on the premise of the
normalcy of racism, the social construction of race, and differential racialization (2008).
8
Theoretical assumptions. The neutrality and color-blindness that often results in
addressing issues of race ignores the “…structural inequalities that permeate social
institutions” and how these inequalities benefit the dominant culture (2009, p. 250).
Through this social construction of race, Whites are viewed as native while other races
are viewed as non-native and in a sense, less than. Therefore, the ideas, beliefs, and value
systems of Whites are driven to be the dominant ideals with little regard for diversity.
The power of the dominant culture is maintained through the social construction
of race, and power of particular racial groups (Whites) is maintained through the
stereotyping of other races, institutional racism, and racial profiling. Critical race theory
takes into account all of these racial inequalities and also incorporates other issues of
oppression such as heterosexism, sexism, ageism, weightism, and ableism (Abrams &
Moio, 2009). The theory also includes social issues such as immigration and sexual
expression. Overall, the premise surrounding critical race theory is to advocate for social
justice for individuals who can be identified as marginalized groups.
Application of theory to body image. Much of Western media is designed to
appeal to the dominant culture. Western media portrays ideas and beliefs pertaining to the
wealthy, individuals of European decent, individuals of white race, and appeals almost
exclusively to the male gender. Additionally, there is little if any regard for the diversity
that is present among Americans. Western media can be identified as a form of
oppression in need of change in order to be truly representative of the differences in
people. The ideal woman in advertising is portrayed with light skin, straight hair, and a
very thin body when in reality, women come in all shapes, skin colors, and different
9
textures of hair. Men are equally influenced by images in the media since advertisements
targeting men tend to portray muscular men with almost no body fat when only a very
small percentage of the population is represented in this way. Western media also appeals
to individuals with heterosexual orientation. Overall, these unattainable ideals can lead
people to feel shameful about their appearance and negative body image can result.
Furthermore, Western media demonstrates negative attitudes toward over-weight and
obese individuals creating discrimination in the form of ‘Weightism.’ Overall, critical
race theory can be identified as relevant in the case of Western media since media tends
to act as the oppressor of the many individuals that do not meet the beauty ideals that are
presented as acceptable.
Person centered theory. According to Cherry, the person-centered theory
surfaced out of individual or client-centered therapy. This type of therapy was developed
by a humanist psychologist Carol Rogers during the 1940’s and 1950’s. Rogers was very
insistent in referring to his patients as clients instead of patients. He believed that if he
referred to his patients as clients, he was placing power and responsibility into the hands
of the individuals he served. Additionally, he described that using the word patient
implied that individuals he was seeing were sick and in need of a cure when in reality, he
understood only the individuals had the answers to their own dilemmas. He believed that
individuals were inherently good and that each individual had the power to reach his or
her full potential, and therapy could be identified as a catalyst to get them there. One of
the biggest objectives of this theory is the idea of self-direction. Social workers and
counselors alike are often the initiators in therapy by presenting the necessary conditions
10
for change. These conditions can be accomplished by the social worker or counselor
having a clear and empathetic understanding of the client’s needs through a working
relationship (2013).
Theoretical assumptions. In general, person-centered theory accepts that each
individual person has the innate ability to make positive life choices under favorable
circumstances. Favorable circumstances are often what will be presented while the
individual is in therapy. The main idea of this theory is that people are viewed as strong,
competent, and responsible with the potential to become self-actualized. Individuals can
be described as self-actualized when they have met their full potential (Capuzz & Gross,
2010).
Application of theory to body image. This theory applies to the person in
environment construct. Since body image tends to be a determining factor on how
individuals view themselves and their capabilities, it is easy to identify the issues that can
arise for someone struggling with negative body image. The societal ideals related to
body image can be challenging for individuals that feel they do not fit in. Therefore, they
may be vulnerable to rejecting their own identity and accepting an unattainable idealism.
These dilemmas occur as a result of the mass media promoting a unidimensional
perspective on how individuals should look rather than a multicultural perspective on
how people actually look. Under this theory, individuals are unable to meet their fullpotential when they struggle with negative body image.
11
Definition of Terms
Acculturation. The process of acculturation involves the integration of the
dominant culture’s language, values, beliefs, choices, and behaviors (Taras, 2008;
Sussman, Truon, & Lim, 2007; Vigdor, 2008).
Anorexia Nervosa. Anorexia nervosa is characterized by a debilitating fear of
gaining weight and becoming fat; an unwillingness of the individual to maintain a normal
weight; and caloric restriction tends to be the primary method to lose weight (American
Psychiatric Association, 2000).
Body image. Body image is determined based on how one feels about his or her
body in the form of height, weight, and overall shape. Individuals who have negative
body image tend to view their body as undesirable and in need of change which can have
devastating effects on the individual’s mental state and personal life (National Eating
Disorder Association: Feeding Hope, 2013).
Binge-Eating. Binge-eating disorders are characterized by uncontrolled
consumption of large amounts of food and have been associated with clinical obesity
(NEDA, 2013). However, the individual does not participate in compensatory behaviors
such as self-induced vomiting, compulsive exercising, or substance use (laxatives and
diuretics) following a bingeing episode (American Psychiatric Association, 2000).
Bulimia Nervosa. Bulimia nervosa is characterized by a fear of gaining weight
but the method of weight control is different than Anorexia Nervosa. Individuals
suffering from bulimia tend to consume large quantities of food in a short period of time
and use self- induced vomiting in a ritualistic manner. Additionally, individuals with
12
(BN) attempt to control their weight through the abuse of diuretics, enemas, and laxatives
(American Psychiatric Association, 2009).
Cultural Competence. The enabling of effective cross-cultural work through a
collaborative set of attitudes, behaviors, and policies that attempt to close the disparity
gaps in health and services needed by clients (U.S. Department of Health and Human
Services, 2013).
Eating Disorders. Eating disorders include a range of psychological conditions
and are characterized by atypical or troubled eating habits and include compensatory
behavior, depending on the type of eating disorder (American Psychiatric Association,
2000).
Eating Disorders Not Otherwise Specified (EDNOS). EDNOS are considered in
the diagnosis process when the individual is unable to meet the criteria as defined by the
Diagnostic and Statistical Manual of Mental Disorders (DSM) for anorexia, bulimia, or
binge-eating (American Psychiatric Association, 2000). Other characteristics that fall into
the EDNOS category include chewing and spitting out food, menstruating despite
meeting all other criteria for anorexia nervosa, self-induced vomiting without bingeing,
meeting all criteria for anorexia but maintaining a normal weight, and meeting criteria for
bingeing and purging but behaviors are practiced infrequently (NEDA, 2013; American
Psychiatric Association, 2000).
Muscle Dysmorphia (MDM). Muscle dysmorphia (MDM) is described as a
distorted body image in which men struggle with not feeling muscularly adequate or lean
enough (Giadrino & Procidano, 2012). (MDM) has been identified as reverse anorexia or
13
bigorexia, and resulting behaviors include strict and ritualistic dieting habits, use of
supplements (anabolic steroids, creatine, and protein powders), and excessive working
out and training regiments (Leone, Sedory, & Gray, 2005).
Assumptions
The assumptions that must be considered in this study are that individuals
working within the profession of social work have an understanding of the many mental
health issues that can conflict clients, and body image and eating disorders are assumed
to be a clear part of this understanding. However, with the limited course offerings in
body image and optionality of the DSM course in MSW programs, it is easy to identify
how MSW professionals may have a limited understanding of body image and eating
disorders, specifically in evaluating the great diversity that exists among people
conflicted with negative body image. The researcher assumes that MSW students will
have a limited understanding of body image issues surrounding gender, ethnicity,
socioeconomic status, sexual orientation, and religion which can be problematic in
deciding the proper interventions to treat clients.
The researcher also assumes that MSW students may be limited in their
understanding in the diversity that exists in body image issues. Therefore, there may be
some bias from students toward a certain group, gender, or socioeconomic status that is
assumed to be more affected by negative body image than others.
14
Study Limitations
The limitations of this study are primarily due to the fact that data will only be
collected from volunteering MSW students. The study findings will also be limited by the
small sample size with non-random sampling. A small non-random sample will reduce
the generalizability of the overall findings to other populations.
15
Chapter 2
REVIEW OF THE LITERATURE
Like many other mental health conditions, there are various underlying factors
that influence whether or not an individual has a positive or negative body image. It is
important for professionals to identify the leading causes of negative body image in order
to utilize the most effective interventions for clients. Therefore, this review focuses on
factors related to cultural differences in the context of body image and ethnic groups in
the United States and the role of professionals in understanding the cultural differences
while working with clients who present challenges surrounding body image. This review
will describe the role Western culture plays in body image as well as the consequences
that can result during the process of acculturation. Furthermore, this review will explore
the roles that sexual orientation, socioeconomic status, age, and gender play in body
image as well as the different types of eating disorders that can result from negative body
image.
The Role of Western Media
Western media plays a considerable role in constructing individual’s views of a
desirable body. Media was born out of the industrial revolution during the late 18th and
early 19th century and expanded further during the 20th century, becoming a powerful
entity in American culture. During the early portion of the industrial revolution, the
media was defined by subtle advertisements in newspapers, on billboards, and over the
radio. Advertising was a way to relay information to the American public about goods
and services to promote consumerism (Schwartz-Cowan, 1976).
16
Today, advertising is a big business, and people surrounded by these
advertisements are immersed in the messages being sent and are buying into more than
just the products being advertised; they are buying into the images of beauty being
portrayed (Chapman, 2011; Agliata & Tantleff-Dunn, 2004). Advertising has
accomplished this feat by expanding its market through television, magazines, social
media, websites, and electronic billboards (Aruguete, Nickleberry, & Yates, 2004).
Johnson discovered that the number of advertisements people are exposed to per day
progressed from 500 in 1970 to 5000 today (2009). Since American’s are exposed to this
much advertising, it is easy to identify how advertising can socially construct people’s
reality. According to Lester (1996), the majority of American’s learned knowledge and
beliefs come from media sources. Additionally, the media portrays ideas and beliefs
pertaining to the dominant culture (wealthy, European, white males), with little regard for
the diversity that is present among Americans (Johnson & Rhodes, 2010).
Ultimately, the media and its messages affect people’s body image since the
majority of people are not representations of what is considered ideal in Western culture
(Chapman, 2011; Agliata & Tantleff-Dunn, 2004). Body image includes a person’s
perception based on the thoughts and feelings an individual has about his or her physical
appearance (Bakshi, 2011). Researchers Puhl and Heuer (2010) describe that prevalent in
American society are negative attitudes toward over-weight and obese individuals
creating discrimination in the form of ‘Weightism.’ These negative attitudes about
weight have been created through the media, and these messages are causing public
health problems in the form of eating disorders and psychological harm. Individuals that
17
fail to meet societal weight standards are generalized as unsuccessful, lazy, lack
willpower, and are unable or unwilling to follow weight control guidelines. These ideas
about overweight and obese individuals lead to discrimination in educational institutions,
the workplace, health care facilities, the media, and affect intrapersonal relationships
(2010). Discrimination based on weight is problematic, especially since the media
portrays thinness as normal, and the images relayed to the public often tell people what to
buy and how to look in order to attain success and be socially acceptable (Mussap,
2009a).
Cultural Competence and Health Professionals
Issues related to body image are diverse, and professionals working with clients
conflicted with body image issues must understand the differences in people and groups
as well as the roles the media play (Franko, Becker, Thomas, & Herzog, 2007).
Professionals such as psychologists, social workers, dieticians, and nurses work directly
and sometimes indirectly with individuals struggling with eating disorders and negative
body image (Painter, Ward, Gibbon, & Emmerson, 2010). Although all of these
professionals are very instrumental in treating body image and eating disorders, a social
workers role will be focused on for the purpose of this study.
Generally, one of the many roles social workers are confronted by is working with
mental health challenges faced by clients, and social workers must understand that all
clients are different and interventions must be flexible (Social Work Salary, 2012).
Johnson and Rhodes state “It is important that social work practitioners [and health
professionals] not only tolerate or accept differences, but they must celebrate diversity as
18
a source of strength for individuals, families, and communities, and for our society as a
whole” (p. 109). For social workers, cultural competence through education is mandated
in the Council on Social Work Educational Policy and Accreditation Standards and the
National Association of Social Workers Code of Ethics (Logan, 2013). Furthermore, the
use of multiple frameworks in working with clients should consider “…social
consequences of economic globalization and major demographic and cultural
transformations” (Jani & Reisch, 2011, p. 13). However, social work students in masters
programs are restricted to a broad curriculum with little room for changes due to
accreditation standards (Colby, 2013). For example, Sacramento State students in the
MSW program have the option of taking a (DSM) or Diagnostic and Statistical Manual of
Mental Health Disorders course to gain a better understanding of different mental health
diagnoses. The course briefly touches on the different types of eating disorders, yet does
not provide details as to how populations are affected by body image and eating disorders
(Division of Social Work Website, 2013). More importantly, according to Raphael
(2002), eating disorders and obesity should be identified as social justice issues allowing
for ample opportunities for social workers to advocate for clients, and challenge the status
quo. In addition, there is great importance in continuing education, training, conferences,
and workshops for social workers to be more prepared to work with diverse populations
affected by body image issues and eating disorders (NEDA, 2013, Russell-Mayhew,
2007).
19
Eating Disorders
Eating disorders include a range of psychological conditions and are characterized
by atypical or troubled eating habits (American Psychiatric Association, 2000). Eating
disorders are a common and increasing mental health concern among college students
and younger populations with the majority of these disorders stemming from body
dissatisfaction (Derenne & Beresin, 2006). Researchers Tylka and Subich (2004)
conclude that eating disorders manifest based on three factors: sociocultural, personal,
and relational. Sociocultural factors include pressures to be thin based on family, peer,
and partner interaction and especially media influence. Personal factors include whether
or not an individual internalizes the thinness ideal portrayed through media messages and
social interaction with people. Relational factors take into account an individual’s social
support system; more social support predicts healthy body image even if this support is
perceived (2004). Overall, Sussman, Truon and Lim (2007) and Fillen and Lefkowitz
(2006) found that American women tend to overestimate the size of their bodies whereas
American men underestimate the size of their bodies, leading to body dissatisfaction and
eventually eating disorders.
The National Institutes of Mental Health describe the several types of eating
disorders among college students and youth. The two most common eating disorders
include anorexia nervosa (AN) and bulimia nervosa (BN), and other identified types of
eating disorders include binge-eating disorders (BED), and eating disorders not otherwise
specified (EDNOS) (2013). Although muscle dysmorphia is not currently identified as
an eating disorder in the (DSM-V), its similarity to AN and BN demonstrate the
20
importance of identifying the similarities it shares with classified eating disorders
(Pritchard, 2011; Leone, Sedory, & Gray, 2005)
Anorexia Nervosa. The National Eating Disorder Association (NEDA) illustrate
that anorexia nervosa (AN) has the highest mortality rate when compared to all other
types of eating disorders and between 90-95% of anorexia sufferers are female (2013).
The crude mortality rate for individuals suffering from AN is 4% (Crow et al, 2009). It
has been estimated that between 0.5 and 3.7% of American females will suffer from AN
in their lifetime (NEDA). Anorexia nervosa is characterized by a debilitating fear of
gaining weight and becoming fat; an unwillingness of the individual to maintain a normal
weight; and caloric restriction tends to be the primary method to lose weight (American
Psychiatric Association, 2000). Other indicators include loss of menstrual periods (at
least 3 consecutive periods are absent), social withdrawal, excessive exercise, and the
development of ritualistic eating (rearranging food on the plate and counting the amount
of times one chews food) (NEDA, 2013). Anorexia nervosa has many short and longterm effects on the body. Excessive weight loss can result in weakness, loss of hair, dry
skin and hair, loss of muscle mass, risk for heart failure due to low blood pressure and
low heart rate, kidney failure due to prolonged dehydration, and increased risk for
osteoporosis due to reduced bone density (NEDA, 2013). Unfortunately, Anorexia
Nervosa has a low success rate when it comes to treatment and rehabilitation, and as a
result, twenty percent of individuals suffering from AN will die either from heart
complications or suicide (ANAD, 2013).
21
Bulimia Nervosa. Bulimia nervosa (BN) affects between 1-2% of adolescent and
college aged women. BN affects women more than men as 80% of cases of bulimia are
female (NEDA, 2013). The crude mortality rate for this disorder is 3.9% (Crow et al,
2009). Bulimia nervosa has the highest suicide rate among all eating disorders and this
disorder is most commonly linked with depression (NEDA). Bulimia nervosa is
characterized by a fear of gaining weight but the method of weight control is different
than Anorexia Nervosa. Individuals suffering from bulimia tend to consume large
quantities of food in a short period of time and use self- induced vomiting in a ritualistic
manner. Additionally, individuals with BN attempt to control their weight through the
abuse of diuretics, enemas, and laxatives (American Psychiatric Association, 2009).
Other indicators include large quantities of food missing within a short period of time
from the person’s home, the person takes frequent trips to the bathroom around meal
time, the person may have swelling around the cheeks and jaw area, the person may have
calluses on the hands or knuckles, and the person may have a strict and rigid exercise
routine (NEDA, 2013).
There are many health consequences that can result from untreated Bulimia
Nervosa. The constant behavior of self-induced vomiting can lead to damage of the
digestive system which may lead to rupturing of the esophagus. Electrolyte imbalance is
another major concern that occurs from vomiting and laxative abuse because this
imbalance can lead to an irregular heartbeat and ultimately heart failure. Damage to tooth
enamel and irreversible tooth decay can result from stomach acids spending so much time
22
in the mouth. Also, intestinal issues such as chronic constipation can arise from the abuse
of laxatives (NEDA, 2013).
Binge-eating. Binge-eating (BED) disorders tend to affect women (60%) more
often than men (40%) and are closely linked to depression. Binge-eating disorders impact
1-5% of the general population (EDNA, 2013). Binge-eating disorders are problematic in
that these disorders can go on untreated since individuals with the disorder often maintain
a healthy weight, or are overweight, or obese (EDNA). Binge-eating disorders are
characterized by uncontrolled consumption of large amounts of food and have been
associated with clinical obesity (NEDA, 2013). However, the individual does not
participate in compensatory behaviors such as self-induced vomiting, compulsive
exercising, or substance use (laxatives and diuretics) following a bingeing episode
(American Psychiatric Association, 2000). Bingeing episodes are described as an out
control feeling for the individual followed by feelings of guilt. These individuals often eat
when they are not hungry and eat alone in order to avoid being judged for the amount of
food they consume (NEDA, 2013).There are many health consequences that can result
from BED and include type II diabetes, stress on the muscular skeletal system from
weight gain, high cholesterol, high blood pressure, and gallbladder disease (NEDA,
2013). Many of these health issues can result in cardiovascular complications, leading to
a premature death (Mandal, 2013).
Eating disorders not otherwise Specified (EDNOS). EDNOS have a crude
mortality rate of 5.2% since these types of disorders cover a vast sum of behaviors (Crow
et al, 2009). EDNOS are considered in the diagnosis process when the individual is
23
unable to meet the criteria as defined by the Diagnostic and Statistical Manual of Mental
Disorders (DSM) for anorexia, bulimia, or binge-eating (American Psychiatric
Association, 2000). Other characteristics that fall into the EDNOS category include
chewing and spitting out food, menstruating despite meeting all other criteria for anorexia
nervosa, self-induced vomiting without bingeing, meeting all criteria for anorexia but
maintaining a normal weight, and meeting criteria for bingeing and purging but behaviors
are practiced infrequently (NEDA, 2013; American Psychiatric Association, 2000).
Health complications for EDNOS are similar to that of individuals suffering from AN
and BN since many of the behaviors are similar but may vary in severity (NEDA, 2013).
Muscle Dysmorphia (MDM). Muscle dysmorhphia (MDM) is a common problem
among college males and is characterized by a male’s preoccupation to become more
muscular. Although preoccupation with muscularity or muscle dysmorphia is an
increasing problem among college aged males, these terms are not currently recognized
exclusively as eating disorders in the (DSM-V), but MDM is identified in the (DSM-V)
as an obsessive compulsive disorder (Pritchard, 2011; Leone, Sedory, & Gray, 2005).
However, researchers Murray, Reiger, Touyz, and De La Garza Garcia (2010) predict
that muscle dysmorphia will soon be recognized as its own diagnosis because of its
similarity to anorexia in that ritualistic behavior, diet consciousness, and compulsive
exercise is identical between both disorders but eating behaviors are reversed (more
calories consumed versus calories restriction). Muscle dysmorphia is described as a
distorted body image in which men struggle with not feeling muscularly adequate or lean
enough (Giadrino & Procidano, 2012). MDM has been identified as reverse anorexia or
24
bigorexia, and resulting behaviors include strict and ritualistic dieting habits, use of
supplements (anabolic steroids, creatine, and protein powders), and excessive working
out and training regiments (Leone, Sedory, & Gray, 2005). Muscle dysmorphia in men
and eating disorders in women can lead to irreversible damage to the skeletal system and
other organ systems if these behaviors are continued (Fernandez & Pritchard, 2012).
Therefore, the intervention of professionals is imperative in treating all of these
disorders. Currently, one of the greatest challenges in evaluating eating disorders crossculturally is the bias that exists. Researchers Franko, Becker, Thomas, and Herzog (2007)
found that eating disorders are often overlooked in other cultures and ethnicities since
eating disorders have been coined a phenomenon only affecting white, middle and upperclass females. However, Franko, Becker, Thomas, and Herzog suggest that body image
issues and eating disorders challenge many populations regardless of ethnicity,
socioeconomic status, and gender, demonstrating a need for change (2007).
Treatment. According to Russell-Mayhew (2007), there are two competing
models in how professionals work with individuals with body dissatisfaction and eating
disorders. The medical model emphasizes psychophysiological disorders and only
focuses on the individual. The political model focuses on external factors such as the
internalization of gender norms and norms related to appearance. The medical model is
very narrow in how it deals with these disorders because it allows for blaming of the
victim since the context of the situation is not evaluated (Evans, Evans, & Rich, 2003;
Srebnik & Saltzberg, 1994).
25
Successful Model Programs
Sjostrom and Steiner-Adair (2005) emphasize the importance of prevention.
Through their research they discovered that intervening while boys and girls are young is
an effective way to create positive body esteem. The successful intervention they created
included eight sessions in a program titled “Full-of-ourselves.” The program focused on
“weightism” as a social justice issue, life skills, health promotion, and developing
positive body image. Since body dissatisfaction can lead to disordered eating, it is
important that interventions occur as early as possible (2005).
Socioeconomic Status
Researchers Deleel, Hughes, Miller, Hipwell, & Theodore (2009) point out that
the majority of research on body dissatisfaction and eating disorders have been on middle
to upper class white females. However, they found through their own research that body
image issues and eating disorders affect all classes equally. An Australian research study
found that Caucasian individuals of higher socioeconomic status preferred to be thinner
than their current body size which was hypothesized to have resulted from family and
media pressure, and these ideals are put forth as the dominant culture (Wang, Byrne,
Kenardy, & Hills, 2005). The same study found that all young boys of lower
socioeconomic status found their bodies to be too thin. However, overall, the study found
no linear relationship between body image and socioeconomic status, demonstrating that
socioeconomic status could not be used exclusively as a predictor for eating disorders
(2005).
26
Researchers Gard and Freeman (1996) focused on a few variables in an attempt to
associate socioeconomic status with negative body image. First, they described the long
history that has created stereotypes about which ethnicities and socioeconomic groups
were most influenced by body image issues and eating disorders. They found an
association between educational attainment in non-whites and a desire for thinness which
deviates from previous assumptions. Reasons explaining this phenomenon have to do
with the exposure non-whites have to the dominate culture in the education system. Prior
research has assumed that socioeconomic status of the parent may have an influence on
the development of eating disorders in children; however, repeatability of these studies
has been inconclusive. Also, in assessing socioeconomic status and eating disorders, there
have been no studies on evaluating homeless individuals for eating disorders (1996).
Gender
In evaluating physical appearance for women, Chapman (2012) and Kite (2012)
conclude that the ideal woman in advertising is portrayed with light skin, straight hair,
and a very thin body. Thinness happens to be the most influential of all the images
presented to women, and attitudes women have about themselves and others can be
determined based on the thinness ideal. Thinness is identified as the key to desirability
for women and represents success. Sjostrom and Steiner-Adair found that women
generally measure their level of worth by their physical features, and when women feel
they do not measure up to beauty standards, their mental health suffers (2005). Therefore,
women who internalize this thin ideal are more likely to suffer low self-esteem in which
eating disorders and exercise compulsions can result (Darlow & Lobel, 2010). In
27
evaluating physical appearance for men, researchers Giadino and Procidano found that
men are equally influenced by images in the media (2010). Advertisements targeting men
tend to portray muscular men with almost no body fat. Men that buy into this muscular
ideal tend to develop low self-esteem, social anxiety, and depression (Agliata & TantleffDunn, 2004).
Other studies based on feminist theory demonstrate that women who over identify
with what is socially accepted as the feminine role are at higher risk for developing eating
disorders (Boskind-Lodahl, 1976). Conversely, researcher Steiner-Adair proposed that
eating disorders occur based on discrepancy theory; women with low masculinity are
more likely to struggle with positive body image (1986). Although both theories have
validity, researchers have found a combination of both theories to be true (Gillen &
Lefkowitz, 2006). In general, Gillen and Lefkowitz conclude that women who identify as
feminine are more likely to accept cultural expectations in evaluating appearance, and by
looking the part, women feel more likely to be socially successful in the future. Research
evaluating men and body image found that men that did not meet cultural expectations of
masculinity or were not masculine enough were more likely to suffer from negative body
image, leading to anxiety and depression (O’Heron & Orlofsky, 1990).
Although both genders are influenced equally through media images and
messages, the desired look portrayed to both genders tends to be absolutely unattainable
by anyone (Juarez, Soto, & Pritchard, 2012). Unfortunately, these media messages about
body image are negatively affecting young individuals, particularly college students.
Researchers O’Dea and Abraham (2002) found that 9% to 12% of male college students
28
were dissatisfied with their body appearance, leaving these students to use extreme diets
and exercise regiments in an attempt to meet their goals. A Cornell research study found
that 80% of female college students were dissatisfied with their bodies, and the majority
of these students longed to be thinner even if the students were below or within a normal
weight range (Neighbors & Sobal, 2007).
Sexual Orientation
Since negative body image affects individuals no matter the gender,
socioeconomic status, or ethnicity it is also important to consider sexual orientation.
Peplau et al (2009) conducted a research experiment comparing body satisfaction and
body evaluation between heterosexual and homosexual males and females. Heterosexual
men were found to be more satisfied with their bodies when compared to heterosexual
women, Lesbians, and gay men. Heterosexual women were found to be less satisfied with
their bodies when compared to heterosexual men. The study found no difference between
Lesbian and heterosexual women in appearance evaluation and how body image
impacted quality of life. Heterosexual women were found to be more preoccupied with
being overweight. Overall, twenty-five percent of both Lesbian and heterosexual women
exhibited harmful effects related to body image (eating disorders, compensatory
behavior, and low self-esteem). Researchers conclude that Lesbian women were just as
likely to develop body dissatisfaction as heterosexual women. The same study
demonstrated that heterosexual men were less preoccupied with weight, had a higher
appearance evaluation than gay men. Additionally, gay men were found to be at a higher
risk for body dissatisfaction when compared to heterosexual men (2009). Shernoff (2002)
29
found that pressures exist among the gay community to remain physically fit, and these
pressures may explain why gay men are more likely to struggle with body dissatisfaction.
The ideal body for a gay male includes low body fat percentage and more muscle mass
(Levesque & Vicheskey, 2006; Kaminski, Chapman, Haynes, & Own, 2005). Dillon,
Copeland, and Peters (1999) found that gay and bisexual men were more likely to use
steroids to increase muscle mass than heterosexual men.
Western Culture and Acculturation
The United States is becoming more diverse with each passing day. Martin and
Midgley (2010) conclude that an average of 104,000 people from all over the world
migrate to the United States every day. Therefore, the constant intermingling of cultures
is occurring regularly, and Western culture tends to have a powerful influence on other
cultures (Vigdor, 2008). The ideas of Western culture are not only observed in the U.S.;
Western culture ideals are witnessed globally, showing the magnitude of the soft power
of the United States (Joffe, 2006).
Preoccupation with weight, dieting, eating disturbances, and the use of
supplements to attain perceived perfection are purely specific to Western culture
(Warren, Gleaves, Cepeda-Benito, Fernandez, & Rodriguez-Ruiz, 2005). In fact, Prince
found that eating disorders associated with poor body image are considered a culturebound syndrome. This culture-bound syndrome affects other cultures during the process
of acculturation. Researchers Taras (2008) and Sussman, Truon and Lim (2007) describe
acculturation as the process that involves the integration of the dominant culture’s
language, values, beliefs, choices, and behaviors.
30
Ethnicity, Race, and Culture
Although the mainstream media tends to drive the dominate culture’s (white,
middle class Americans) messages, other cultures can be equally influenced depending
on the level of acculturation and acceptance or rejection of body image norms. However,
much of the literature suggests that there are differences in how body image is viewed by
each ethnicity, culture, and the level of acculturation depends on how connected
individuals remain to their own culture (Darlow & Lobel, 2010). Interestingly, nonWestern cultures have very different ideas about what is considered physically attractive.
Bakhshi describes that Arabic cultures do not value thinness; they identify larger body
size as symbols of fertility in women. Chinese and Indian cultures identify larger body
shapes as symbols of health, a longer life, and affluence (2011). A larger body in women
is more socially acceptable in African American and Latino cultures (Demarest, & Allen,
2000; Fitzgibbon, Blackman & Avellone, 2000).
African American. African American women and women from African countries
tend to exhibit higher self-esteem and positive body image when compared with
Caucasian women in research studies (Aruguete, Nickleberry, & Yates , 2004).
Additionally, studies show that African American women and Afro-Caribbean countries
identify a larger body size as more attractive whereas Caucasian women identify a
smaller body size as more attractive (Sussman, Truon, & Lim, 2007). More importantly,
Stodghill found that African American women are less likely to internalize the thin ideal,
and women of different sizes tend to be more socially accepted among this group.
African American women do not associate weight with self-esteem as do Caucasian
31
women. One explanation for this phenomenon has to do with the absences of African
American women in the mainstream media, allowing African American women to create
their own definitions of what it means to be beautiful (2012). Although there is limited
research on the prevalence of eating disorders and body image issues among African
American males, these issues do exist among this population. Loren found that the media
tends to play an equal part in affecting African American males to attain a muscular body
and limit body fat when compared to their Caucasian counterparts (2011).
Asian. Traditionally, heavy women in Chinese cultures have been valued and
even current ideas of female attractiveness embrace a larger body size (Chen & Swalm,
1998, Nasser, 1988). Current studies evaluating Japanese and Chinese women and body
dissatisfaction show that culture tends not to be a protective factor for these women but
rather increases vulnerability. Wildes, Emery, and Simons found that Asian women are
more likely to have low self-esteem and express higher levels of body dissatisfaction than
other ethnicities (2001). On the other hand, there were no differences between Asian men
and Caucasian men based on body image. Researchers Mintz and Kashubeck (1999)
found that Asian and Caucasian men were similar in views based on an interest in gaining
more muscle and reducing body fat percentage.
East Indian. Mussap described the effects of Western culture on body attitudes
and eating disturbances in Muslim women. The research study demonstrated that the
more Muslim woman integrated into mainstream society, the more likely Muslim women
internalized the thin ideal and developed poor body image as a result. However, religious
affiliation and heritage identification served as protective factors for these women and
32
promoted positive body image (2009a). Interestingly, researchers Sjostedt, Schumakes,
and Nathawat (1998) found that Indian men had similar attitudes about body image when
compared with women of Western countries. The differences among Indian men about
body image attitudes are related to cultural guidelines. In East Indian culture, keeping
one’s body in healthy condition through thinness is highly emphasized. According to
researchers Gandhi, Appaya, and Machado (1991), a body that is thin is looked upon
more for health reasons rather than meeting a societal standard.
Latino. Research on body dissatisfaction in Latina women is mixed. Researchers
Warren, Gleaves, Cepeda-Benito, Fernandez, and Rodriguez (2005) found that Caucasian
women were more dissatisfied with their bodies than Latina women. Other studies have
found that Latina women were more dissatisfied with their bodies than other ethnicities
(Gillen & Lefkowitz, 2006). In general, the longer Latinos are exposed to the American
ideals of appearance, the more likely Latinos will develop decreased body satisfaction.
Thinness in Latino males females and muscularity in Latino males correlates with the
level of acculturation each individual possessed (Warren, Castillo, & Gleaves, 2010).
Other. There is limited research on certain ethnicities, specifically within the
American Indian/Native American, Alaskan Natives and Native Hawaiians communities.
Unfortunately, the primary focus on these populations has been the obesity epidemic that
has become a major public health crisis among this group (Striegel-Moore et al, 2011).
Striegel-Moore et al conducted a study based on eating disorder prevalence in Native
American populations and compared those findings to similar studies on white
populations. The findings included that Native American’s were more likely to report
33
overeating when compared to their white counterparts. Native American women were
more likely than Native American men to exhibit disturbed eating patterns. More Native
American women met the criteria for binge-eating disorders and had a higher body mass
index (BMI) than whites. Overall, Native American women were diagnosed with eating
disorders as often as women in white studies. Native American males had increased body
dissatisfaction when compared to whites. Native American males had higher BMI in
comparison to whites and were more likely to perceive themselves as overweight and
were more likely to engage in extreme weightloss regiments including self-induced
vomiting (Neumark-Sztainer, Croll, Story, Hannan, French, & Perry, 2002; Story et al,
2001). In evaluating muscularity and steroid usage, Native American men were more
likely than whites to use steroids (Handlesman & Gupta, 1997).
Religion
Among various research studies evaluating body image and religion, religion has
been found to be an integral part of cultural identity; cultural identity results from the
affiliation and strength of one’s religious faith (Abdollahi & Mann, 2001, Madanat,
Hawks, & Brown, 2006, Mussap, 2009b). In the many denominations of Christianity,
research studies on body image showed that biblical descriptions of salvation included a
thin physique, particularly for women. In other words, the value of vanity and thinness
can date back to the existence of Eve (Bloom, 2011). Additionally, depending on the type
of bible used to follow, the female body is identified as sinful which can result in poor
body image and disordered eating (Body Image in Religion, 2013). In studies evaluating
body image among Muslim versus non-Muslim women are mixed. Some studies
34
illustrated that Muslim women in Western culture had greater body satisfaction when
compared with non-Muslim women. Other studies illustrated evidence of thin ideals
being internalized with disordered eating at similar rates to non-Muslim women
(Abdollahi & Mann, 2001; Madanat, Hawks, & Brown, 2006).
Age
Although body image issues and eating disorders can begin during adolescence,
there is a higher risk for these obstacles as young people attend college. According to
Hudson, Hiripi, Pope, and Kessler, the median onset of eating disorders pertaining to
negative body image begins between the ages of 18 and 21 years which is generally
college age (2007). Research has shown that the increased pressure of leaving home to
attend college and exposure to peers through attending classes and living in dormitories
impacts student’s level of body satisfaction (Gillen & Lefkowitz, 2006). Part of the
socialization process for students attending college is conforming to peer norms. Peer
norms are defined by the level to which peers believe thinness and muscularity to be
attractive and the level to which peers believe certain measures to stay physically
attractive (dieting, exercise, and eating disorders) are acceptable (Giles, Helme, &
Krcmar, 2007; Quenqua, 2012). Unfortunately, negative body image can cause many
life-long psychological and health consequences without the proper intervention (Franco,
2012).
35
Intervention
According to the National Association of Anorexia and Associated Disorders,
eating disorders have the highest mortality rate when compared with other mental health
disorders (2013). Additionally, muscle dysmorphia in men and eating disorders in women
can lead to irreversible damage to the skeletal system if the behavior is continued
(Fernandez & Pritchard, 2012). Therefore, colleges must have intervention strategies in
place to address negative body image for both male and female college students.
Counselors must be educated on the types of behaviors associated with these disorders,
and most importantly, college students must be educated that media images are not reality
and are unattainable (Derenne & Beresin, 2006).
Summary
Unfortunately, the majority of historical research has been narrow in its focus
(Caucasian, upper to middle class females), making it challenging for professionals to
work successfully with a diverse population inflicted with body image issues.
Additionally, research studies pertaining to culture, ethnicity, religion and eating
disorders and the professionals’ competence regarding diversity of perceptions in the
body image field are nonexistent. Negative body image and subsequent eating disorders
are a very serious issue; not only do these mental health challenges present a lowered
quality of life, these challenges can have deadly consequences to the individuals who
struggle. As a result, it is important for professionals to be aware of the diversity that
exists. Overall, issues surrounding body image are diverse and interventions for body
image issues should be diverse as well. Although there is existing research evaluating the
36
role diversity (gender, ethnicity, religion, age, socioeconomic status) plays in body image
issues, there are few studies that evaluate the importance of cultural competence of
professionals. Therefore, there is a great need for evaluating cultural competence among
professionals working with clients conflicted by negative body image. Cultural
competence in evaluating body image is the best way to ensure that professionals
successfully treat clients. First, it is important to gain an understanding of what degree
social work professionals deal with clients affected by negative body image and
subsequent eating disorders. Next, it is important to evaluate a social work professional’s
perspective on what factors affect the formation of body image. The existing literature
suggests that factors such as ethnicity, religion, gender, age, socioeconomic status,
acculturation, and exposure to western media all play a role in body image. Therefore, it
is important to determine whether or not social work professionals have an understanding
of the role these factors play in body image.
37
Chapter 3
METHODS
This chapter reviews the methods used to conduct this study. Sections addressing
the study design, study population and sample, study questions, human subject’s
protocol, the data collection process, and the plan for data analysis are presented.
Study Objectives
The objective of this study was to analyze participants’ responses to questions
pertaining to knowledge and level of experience when evaluating body image and eating
disorders. The researcher utilized a non-probability purposive sample of 54 MSW
students as the source of analysis. There were a total of 32 questions on the survey; there
were seven open-ended, there were fourteen yes and no questions, and there were
fourteen likert scale questions. Additionally, there were three questions pertaining to the
demographics of the sample such as gender, profession and age. The study questions
were designed to gain a better understanding of MSW student’s experience, knowledge,
and understanding as it relates to body image and eating disorders.
Study Design
This study included a descriptive quantitative study design. A descriptive study
design was used to describe the knowledge level and competencies of MSW students at
CSUS. According the Engel and Schutt (2009), descriptive research “…involves the
gathering of facts” (p. 18) and “It begins with data and proceeds only to the stage of
making empirical generalizations based on those data” (p. 54). Although there is
beginning to be a number of research studies that evaluate the diversity that exists in
38
body image issues, there is limited research on the preparedness of mental health workers
that assist clients with these body image issues. Therefore, the specific type of descriptive
research that will be used for this study is the survey method (Jackson, 2009). The survey
method allows for open-ended, closed-ended, or rating scale.
Sampling Procedures
Although there are a range of professionals that work with mental health issues
such as negative body image, master of social work students will be the main focus by
the researcher. Social workers in general provide an array of different services to clients,
but for the most part, mental health services are a large part of their job description. In
fact, the National Association of Social Workers found that 60% of mental health
professionals within the United States are clinically trained social workers (2013). Since
the majority of mental health workers are social workers, it is easy to identify the skills
these individuals would need to carry out successful mental health practice. Additionally,
clinically trained social workers function at a master’s level of education (2013). The
two-year master’s of social work program is offered uniformly throughout U.S. colleges
and universities. Colby describes that the first year of social work master’s program are
centered around foundation while the second year is focused on specialization. Colby
describes the rigidity of these programs in the fact that accreditation standards make it
difficult for students to explore a variety of specialties, limiting students in their learning
experience (2013).
The MSW curriculum at California State University, Sacramento offers a mental
health stipend program to second year students, but only admits a limited number of
39
students. Therefore, these students may be expanding their area of expertise more so than
standard curriculum students. Additionally, MSW students are given the opportunity to
take a diagnostic statistical manual class, but it is not a requirement (2013).
Consequently, many social work students in this program may have little to no
experience or knowledge in body dissatisfaction and eating disorders, yet they are
expected to understand these dynamics upon graduation. Therefore, the researcher will
attempt to understand what level of expertise MSW students have about body image
issues and eating disorders.
Data Collection Procedures
The participants in this study included first and second year graduate students in
the social work program at California State University, Sacramento. The participants in
this study were voluntary; potential participants were given a consent form and a survey
and those who signed the consent form, participated in completing the survey used for
this research. When participants were finished completing the survey, they were required
to place their consent form and completed survey in two separate envelopes, ensuring the
anonymity and confidentiality of the students. Overall, there were 60 participants in this
study. The researcher did not offer any incentives for filling out the survey; however, the
consent form explained the usefulness of students participating in this study.
The study sample consisted of a non-probability purposive sample of graduate
students in the maser of social work program from California State University,
Sacramento. According to Engel and Schutt, non-probability sampling is sampling that
does not utilize a random selection procedure when choosing research participants.
40
Purposive sampling includes the choosing of specific participants within a subset of a
population to satisfy the research question. Overall, purposive sampling “…targets
individuals who are particularly knowledgeable about the issues under investigation” (p.
134, 2009). In the case of this research topic, master of social work students were chosen
to gain their perspectives on working with individuals conflicted with negative body
image and eating disorders.
The researcher collected data on three different dates; November 19thand
December 14th and 15th from MSW I and II students from California State University,
Sacramento. On November 19th, December 14th and 15th, the researcher visited the
SWRK 250 policy classes and SWRK 501 Integrative Capstone Project class with 22
informed consent forms, 22 surveys, and two large envelopes for the completed surveys.
The survey for this research will use a combination of open-ended and likert scale
questions. Open-ended questions allow for a greater understanding of participants
knowledge and are more flexible. However, open-ended questions are more difficult to
analyze statistically. Likert scale questions help ease the process of statistical analysis but
may limit participants’ responses. Therefore, the combination of both survey question
methods will allow the researcher to evaluate responses in multiple ways to gain a better
general understanding. Once participants answer all questions on the questionnaire, the
researcher can then analyze and describe the overall findings. However, descriptive
research cannot come to any generalizable conclusions, it can only describe findings. The
researcher described to the potential participants that their participation was completely
voluntary, the information would be kept confidential and locked up when not in use, and
41
would be destroyed by the researcher upon completion of data analysis. The researcher
described that the results of the research may determine what level of expertise social
work professionals have about treatment, interventions, and success rates of rehabilitating
clients conflicted with negative body image and eating disorders. Additionally, the
researcher described that the study results would be used to gain a social work
professional’s view on what preventative measures can be taken to promote healthy body
image at a macro level. The researcher also explained that it may take participants
approximately 15 minutes to complete the survey. Once this explanation was given, the
researcher stepped out of the classroom to allow students to decide whether or not they
wanted to participate.
When students finished signing the informed consent form and completing the 32
question survey, they placed the papers in the corresponding envelopes labeled “Informed
Consent Forms” and “Surveys.” The survey’s contained open-ended, likert scale, yes/ no,
and circle a selection and explain questions.
Data Analysis
The data collected from this study was analyzed using SPSS software and content
analysis. The qualitative data were analyzed with the use of thematic procedures;
common themes were identified during the content analysis process. Data collected from
the three social work classes was organized by the researcher into qualitative and
quantitative categories. The open-ended questions and short responses were analyzed in
an effort to find particular themes. Overall, the researcher analyzed data through the use
of summaries, cross tabulation, and frequencies for nominal data. For variables measured
42
at the ordinal level, the researcher utilized association such as Chi-Square and
Spearman’s rho. Variables measured at the interval level were calculated using pearsons r
and correlation. The researcher also used independent sample T-tests to identify different
mean values among variables. Findings for the data collected in this study are presented
in the next chapter.
Protection of Human Subjects
The required protocol for protection of human subjects at California State
University, Sacramento was to submit a human subject’s application by the researcher to
the institutional review board (IRB) through the division of social work. The researcher
submitted an application on October 11th 2013, and the application was approved on
October 29th 2013 with a protocol number of 13-14-021.
The researcher visited three classes to collect data; two SWRK 250 policy classes
and one SWRK 501 class titled Integrative Capstone Project. The researcher passed out
surveys and informed consent forms to all students in the classes and described that
participation was completely voluntary. The researcher provided two large envelopes for
the signed consent forms and completed surveys in order to protect the identity of the
participants. Individuals who read and signed the consents forms, agreed to participate in
the study. The researcher was not present in the room when consent forms and surveys
were being filled out, and the researcher provided an email and phone number in case any
of the participants had questions or concerns.
The completed consent forms were kept completely confidential and remained
locked in a safe when the researcher was not using them to analyze data. The researcher
43
destroyed all of the signed consent forms and completed surveys as soon as data
collection was complete.
44
Chapter 4
STUDY FINDINGS AND DISCUSSIONS
This study collected qualitative and quantitative data by using a structured survey
on professionals’ perspectives on the importance of cultural competencies in working
with clients who indicate body image conflict was administered in three different classes
including thirty-four first-year Master of Social Work (MSW) respondents and twenty
second year MSW respondents from California State University, Sacramento (CSUS).
The data collected was analyzed utilizing Statistical Package for the Social Sciences
(SPSS) and Microsoft Excel software. This chapter provides the findings related to
respondents’ level of knowledge as it relates to body image and eating disorders and
discusses the relevance of the findings in the context of the study question.
Dissatisfaction of body image in the United States has become a major problem
for many individuals of not only native born citizens but cross-culturally as the process of
acculturation expects the integration of Western beauty ideals (Sides-Moore & Tochkov,
2011; Mussap, 2009a; Akande, 2009). This preoccupation with beauty and thinness in the
United States, perpetuated through the media, has been shown to have damaging effects
on individual’s self-esteem and self-worth, leading to mental health issues such as
depression, eating disorders, and reduced quality of life (Fernandez & Pritchard, 2011;
Giardino, & Procidano, 2012; Sides-Moore & Tochkov, 2011). Additionally, the
diversity that exists in treating eating disorders and body image issues are particularly
challenging in the mental health community, making knowledge of eating disorders and
body image issues an absolute necessity for successful treatment (ANAD, 2013).
45
Profile of Study Subjects and Demographics
This section presents the demographic details of the study population. Overall,
trained social workers make up 60% of mental health professionals within the United
States (National Association of Social Workers, 2013). Since the majority of mental
health workers are social workers, it is easy to identify the skills these individuals would
need to successfully treat individuals with eating disorders and body image issues.
Therefore, this chapter will attempt to evaluate what level of knowledge CSUS MSW
respondents have on eating disorders and body image, overall knowledge on body image
and eating disorders, interventions for eating disorders and body image, overall
knowledge of how Western culture and media impact body image, and future practice
and macro level solutions to promote positive body image.
Table 1 identifies the gender distribution of the respondents at California State
University, Sacramento (CSUS) that participated in this study. The gender distribution of
this sample population included 20.4% (n=11) of respondents that identified as male,
77.8% (n=42) of respondents that identified as female, and 1.9% (n=1) of respondents
that identified as other. Additionally, the average age of the participants in this sample
was 34.5 years old with a standard deviation of 10.075. The youngest participant in this
sample was 22 years old while the oldest participant was 59 years old. Of the 54
participants in this study, 100% identified social work to be their profession.
46
Table 1:
Distribution of respondents’ gender
Frequency
Percent
Valid Percent
Male
11
20.4
20.4
Female
42
77.8
77.8
Other
1
1.9
1.9
Total
54
100.0
100.0
Experience and Education with Eating Disorders and Body Image Issues
Respondents were asked whether or not body image issues were a concern of their
clients and were to respond by circling either yes or no, and 53.7% (n=29) stated yes it
was a concern of their clients while 46.3% (n=25) stated no it was not a concern of their
clients. More than half of the respondents identified that body image issues were a
concern of their clients, confirming Sides-Moore and Tochkov’s research on the
prevalence of body image issues in the United States (2011). Additionally, individuals
with body image issues have a higher likelihood of developing eating disorders (ANAD,
2013). Next, respondents were asked whether or not they had worked with clients with
body image issues that have led to an eating disorder. The percentage of respondents that
had worked with clients with body image issues that have led to an eating disorder was
33.3% (n=18) of the total sample. The percentage of respondents that had not worked
with clients with body image issues that had led to an eating disorder was 66.7% (n=36)
of the total sample. In the information provided by the National Eating Disorders
Association (2013), only a small percentage of the population is affected by eating
disorders (between 0.5 to 10.7% when all eating disorders are accounted for). Therefore,
47
the fact that over a third of respondents identified that they had worked with a client with
body image issues that have led to eating disorders is consistent with information
provided by National Association of Eating Disorders that individuals with negative body
image tend to develop eating disorders (2013).
Respondents were asked if they had received training or continuing education
regarding body image. Potential Likert scale responses included a great deal, adequate,
somewhat, little, or never. Of the total participants, 1.9% (n=1) stated that he or she had
received a great deal of training or continuing education regarding body image, 5.6% (n=3) stated that they had received adequate training or continuing education regarding
body image, 35.2% (n=19) stated that they had received some training or continuing
education regarding body image, 33.3% (n=18) stated that they had little training or
continuing education regarding body image, and 24.1% (n=13) stated that they had never
received training or continuing education regarding body image. Overall, the findings
demonstrate that the respondents of this study do not have adequate training or
continuing education as it relates to body image. As another means of measuring
student’s competencies, they were asked whether or not their college classes covered
body image topics. Potential Likert scale responses included strongly agree, agree,
neutral, disagree, or strongly disagree. The percentage of respondents that strongly agreed
that their college classes covered body image topics was 3.7% (n=2) of the total sample.
The percentage of respondents that agreed that their college classes covered body image
topics included 14.8% (n=8) of the total sample. The percentage of respondents that were
neutral to whether or not their college classes covered body image topics was 22.2%
48
(n=12) of the total sample. The percentage of respondents that disagreed that their college
classes covered body image topics was 35.2% (n=19) of the total sample. The percentage
of respondents that strongly disagreed that their college classes covered body image
topics was 24.1% (n=13) of the total sample. As stated in previously, limited course
offerings and the under emphasis on body image and eating disorders within the MSW
curriculum at CSUS is demonstrated through this data. Therefore, only a small
percentage of respondents are trained and educated enough to work with clients with
body image issues and eating disorders.
The lack of knowledge in eating disorders was further understood when
respondents were asked to characterize their knowledge about eating disorders. The
researcher placed respondents’ knowledge into categories such as poor, some, fair,
adequate, and superior. The percentage of respondents that characterized their knowledge
of eating disorders as poor was 27.8% (n=15) of the total sample. The percentage of
respondents that characterized their knowledge as having some knowledge of eating
disorders was 25.9% (n=14) of the total sample. The percentage of respondents that
characterized their knowledge of eating disorders as fair was 29.6% (n=16) of the total
sample. The percentage of respondents that characterized their knowledge of eating
disorders as adequate was 13% (n=7) of the total sample. The percentage of respondents
that characterized their knowledge of eating disorders as superior was 3.7% (n=2) of the
total sample. Therefore, only 16.7% of participants had adequate to superior knowledge
of eating disorders and the other 83.3% had poor to fair knowledge, demonstrating the
need for more education and training as it pertains to body image and eating disorders.
49
One of the few courses offered in the MSW program that provides information
about body image issues and eating disorders is the DSM (Diagnostic Statistical Manual)
course. The percentage of respondents that did not respond to whether or not they took
the DSM course was 1.9% (n=1) of the total sample. The percentage of respondents that
did take a DSM course throughout their educational career was 31.5% (n=17) of the total
sample. The percentage of respondents that had not taken a DSM course throughout their
educational career was 66.7% (n=36) of the total sample. Therefore, only approximately
one-third of student had taken the DSM course. The percentage of respondents that
planned to take a DSM course before graduating was 72.2% (n=39), respondents that did
not plan to take a DSM class before graduating was 20.4% (n=11) and the remaining
7.4% (n=4) did not reply as to whether or not they were planning to take the course.
Therefore, approximately three-quarters of student that had not taken the DSM course
planned to take it, increasing the likelihood that more respondents would learn about
body image and eating disorder issues.
Knowledge on Body Image and Eating Disorders
Table 2 represents a cross tabulation between whether respondents believed
treating eating disorders had a high success rate and whether or not eating disorders had
been a concern of their clients. The percentage of respondents that stated that yes body
image issues had been a concern of their clients and believed that treating eating
disorders had a high success rate was 11.1% (n=6) of the total sample. The percentage of
respondents that stated that yes body image issues had been a concern of their clients and
did not believe that treating eating disorders had a high success rate was 22.2% (n=12) of
50
the total sample. The percentage of respondents that stated yes body image issues had
been a concern of their clients but were not sure if treating eating disorders had a high
success rate was 14.8% (n=8) of the total sample. The percentage of respondents that
stated that body image issues had not been a concern of their clients but believed that
eating disorder treatment had a high success rate was 35.2% (n=19) of the total sample.
The percentage of respondents that stated body image issues had not been a concern of
their clients and did not believe that treating eating disorders had a high success rate was
9.3% (n=5) of the total sample. The percentage of respondents that stated that body image
issues had not been a concern of their clients and were not sure if eating disorders had a
high success rate was 1.9% (n=1) of the total sample. The percentage of respondents that
did not respond to either question was 5.6% (n=3) of the total sample.
________________________________________________________________________
Table 2:
Association between body image issues being a concern of clients and the belief that
eating disorder treatment has a high success rate
Belief that eating disorder treatment has
a high success rate
Missing
Body image issues been a concern of
Yes
respondents’ clients
No
Total
Yes
No
Not sure
Total
3
6
12
8
29
5.6%
11.1%
22.2%
14.8%
53.7%
0
19
5
1
25
0.0%
35.2%
9.3%
1.9%
46.3%
3
25
17
9
54
5.6%
46.3%
31.5%
16.7% 100.0%
51
The chi square test of association was used to estimate statistical significance of
association between whether body image issues have been a concern of respondents
clients and whether or not eating disorder treatment had a high success rate showed a
strong association between these two variables (χ2=17.889, df=3, p<.000).
Further, the researcher attempted to gain a better understanding of respondents’
knowledge about body image and eating disorders. Respondents gave their opinions on
how important they believed positive body image was to good mental health. Possible
responses to this question included very important, important, neutral, somewhat
important, and not important. The percentage of participants that believed positive body
image was very important to good mental health was 63% (n=34) of the total sample. The
percentage of participants that believed positive body image was important to good
mental health was 27.8% (n=15) of the total sample. The percentage of participants that
were neutral as to whether or not positive body image was important to good mental
health was 7.4% (n=4) of the total sample. The percentage of participants that believed
that positive body image was somewhat important to good mental health was 1.9% (n=1)
of the total sample. None of the participants believed that it was not important to have
positive body image for good mental health, demonstrating that participants understood
the connection between positive body image and good mental health. Researchers SidesMoore and Tochkov confirm that negative body image can lead to mental health issues
such as depression, anxiety, muscle dysmorphia, and eating disorders; therefore,
confirming the importance of body image as it relates to good mental health (2013).
52
Table 3 represents an independent sample t-test that was coordinated to see if
there was a difference between the average scaled knowledge of participants (1-poor, 2some, 3-fair, 4-adequate, 5-superior) in their understanding of eating disorders and
participants experience with clients with body image issues that have led to an eating
disorder. Participants that worked with clients with body image issues that have led to an
eating disorder had higher mean average of knowledge (n= 18, Mean = 2.556) when
compared with participants that had not worked with clients with body image issues
(n=36, 2.3056). It would make sense that individuals with experience with body image
issues would have a higher scaled knowledge about eating disorders in general. However,
the independent samples t-test output generated (t=0.757, df=52, p> 0.453),
demonstrating that the test was not statistically significant. Overall, the average mean
score demonstrated that participants had knowledge of eating disorders ranging between
some and fair, illustrating the lack of knowledge they had about eating disorders
regardless of having worked with clients with eating disorders.
______________________________________________________________________________
Table 3:
Scaled knowledge about eating disorders and participants’ experience with clients with
body image issues that have led to an eating disorder
Experience with clients
N
Mean
Std. Deviation
with body image issues
Std. Error
Mean
that have led to an eating
disorder
Scaled knowledge about
Yes
18
2.5556
1.09664
.25848
eating disorders
No
36
2.3056
1.16667
.19444
53
Since multiple factors play into body image, respondents were asked what factors
they believed affected an individual’s body image, including socioeconomic status,
ethnicity, age group, religion, and national background. The percentage of respondents
that believed religion affected body image was 24.1% (n=13) of the total sample. As
confirmed by researcher Adollahi and Mann, there are particular ideologies in religion
that impact body image, but for the most part, religion has not been found to be an
overwhelming factor in body image (2001). Yet, nearly a quarter of participants believed
religion to be a major factor in body image. The percentage of respondents that believed
national background affected the formation of body image was 40.7% (n=22) and the
percentage of respondents that believed ethnicity affected the formation of body image
included 61.1% (n=33) of the total sample. The research suggests that the definition of
body image is portrayed differently depending on one’s ethnicity, and these differences
directly impact the formation of body image (Darlow & Lobel, 2010) which 61.1% of
participants identified in their questionnaire responses.
The percentage of respondents that believed that socioeconomic status affected
body image included 57.4 % (n=31) of the total sample. Researcher Deleel, Hughes,
Miller, Hipwell, and Theodore (2009) confirm that body image issues can influenced by
clients of any socioeconomic background, and over 50% of participants understood that
aspect. The percentage of respondents that believed age group affected body image was
79.6% (n=43) of the total sample, demonstrating the participants understanding of the
vulnerability of age. All participants that chose age as a factor described that younger
54
individuals were at highest risk for body image issues. In fact, Hudson, Hiripi, Pope, and
Kessler affirm that the median age of eating disorder onset ranges from 18 to 21 (2007).
Table 4 illustrates a cross-tabulation between whether or not MSW respondents
believed early intervention to be the best method for addressing body image issues and
whether or not they believed eating disorder treatment had a high success rate. The
percentage of respondents that felt early intervention was the best method for eating
disorder and did not reply to whether or not eating disorder treatment had a high success
rate was 5.6% (n=3). The percentage of student that believed early intervention was the
best method for addressing body image issues and that eating disorder treatment had a
high success rate was 44.4% (n=24). The percentage of student that believed early
intervention was the best method for addressing body image issues but did not believe
eating disorder treatment had a high success rate was 31.5% (n=17). The percentage of
student that believed early intervention was the best method for addressing body image
issues but were not sure if eating disorder treatment had a high success rate was 11.1%
(n=6). Two respondents (3.7%) did not reply as to whether or not they felt early
intervention was the best method for addressing body image issues and were not sure if
eating disorder treatment had a high success rate. The percentage of student that did not
believe early intervention was the best method for addressing body image issues but
believed eating disorder treatment had a high success rate was 1.9% (n=1). The
percentage of student that were not sure if early intervention was the best method for
addressing body image issues and were not sure if eating disorder treatment had a high
success rate was 1.9% (n=1). The Pearson Chi-Square results demonstrated a statistically
55
significant p-value of 0.049 with a df= 9 between whether or not respondents believed
early intervention was the best method for addressing body image issues and whether or
not they believed eating disorder treatment had a high success rate. Participants
demonstrated an understanding that early intervention is important in evaluating body
image, but the majority of participants did not understood that treatment of eating
disorders has a low success rate. Researchers Sides-Moore and Tochkov (2011) confirm
that early intervention is the best method for successful treatment of body image issues,
preventing the development of an eating disorder. Lack of early intervention can result in
eating disorders which tend to have a low success rate in treatment (NEDA, 2013).
________________________________________________________________________
Table 4:
The association between early intervention in addressing body image issues and eating
disorder treatment having a high success rate
Eating disorder treatment has a high success rate
Missing
Early intervention is
the best method for
addressing body
image issues
Yes
No
Not Sure
Total
Total
Missing
Yes
No
Not sure
0
0
0
2
2
% of Total 0.0%
0.0%
0.0%
3.7%
3.7%
Count
24
17
6
50
% of Total 5.6%
44.4%
31.5%
11.1%
92.6%
Count
1
0
0
1
% of Total 0.0%
1.9%
0.0%
0.0%
1.9%
Count
0
0
1
1
% of Total 0.0%
0.0%
0.0%
1.9%
1.9%
Count
25
17
9
54
46.3%
31.5%
16.7%
100.0%
Count
3
0
0
3
% of Total 5.6%
Pearson’s correlation product-moment test was conducted between participant’s
knowledge of eating disorders and whether or not participant’s college classes covered
56
body image topics. There was a weak correlation (r=-0.174) between participant’s
knowledge of eating disorders and whether or not participant’s college classes covered
body image topics. Additionally, there was no statistical significance between the
variables (p>0.05), illustrating that there was no difference between participants
knowledge of eating disorders and whether or not participant’s college classes covered
body image topics. One would assume that if an individual had a college class covering
body image topics, this same individual would have a greater knowledge of eating
disorders. However, the findings demonstrate that college classes that may cover body
image topics seem to be insufficient in creating a better understanding of eating disorders.
Understanding eating disorder and body image terms. Respondents were
asked if they understood the difference between the terms pertaining to eating disorders
and body image issues. Respondents were asked to if they understand the difference
between anorexia nervosa and bulimia nervosa. The percentage of respondents that
understood the difference between anorexia nervosa and bulimia nervosa was 79.6%
(n=43), the percentage of respondents that were not sure what the difference was between
anorexia nervosa and bulimia nervosa was 16.7% (n=9), and the percentage of
respondents that did know the difference between anorexia nervosa and bulimia nervosa
was 3.7% (n=2) of the total sample. Anorexia and bulimia tend to be the most well know
types of eating disorders and are regularly covered in news and media (NEDA, 2010)
which could explain why participants understood the difference between the two eating
disorders.
57
Respondents were asked whether or not respondents knew what the term bingeing
meant. The percentage of student that knew what the term bingeing meant was 92.6%
(n=50), and the percentage of respondents that did not know what the term bingeing
meant was 7.4% (n=4) of the total sample. Obesity has become a serious public health
issue that has had media coverage over the past decade, and binge-eating is often
associated with obesity (EDNA, 2013). This media exposure could explain the high
percentage of respondents understanding what binge-eating means.
Respondents were asked if they knew what the term body dysmorphia meant by
answering either yes or no. The percentage of respondents that knew what the term body
dysmorphia meant was 63% (n=34) of the total sample. The percentage of respondents
that did not know what body dysmorphia meant was 37% (n=20) of the total sample.
Respondents were asked whether or not they knew what the term bigorexia meant.
Possible responses to this question were either yes or no. The percentage of respondents
who knew what bigorexia meant was 3.7% (n=2) of the total sample. The percentage of
respondents who did not know what bigorexia meant was 96.3% (n=52) of the total
sample.
Figure 1 titled Perceptions of types of mental disorders resulting from negative
body image represents participant’s responses as to what types of mental disorders they
believed result from negative body image. The researcher analyzed the different written
responses and found that the most common responses included depression, eating
disorders, personality disorders, and a combination of depression, eating disorders, and
personality disorders. The percentage of respondents that did not know what types of
58
mental disorders result from negative body image was 11.1% (n=6) of the total sample.
The percentage of respondents that believed depression result from negative body image
was 14.8% (n=8) of the total sample. The percentage of respondents that believed eating
disorders result from negative body image was 22.2% (n=12) of the total sample. The
percentage of respondents that believed personality disorders result from negative body
image was 3.7% (n=2) of the total sample. The percentage of respondents that believed
that a combination of depression, eating disorders, and personality disorders result from
negative body image was 48.1% (n=26) of the total sample.
________________________________________________________________________
Figure 1: Perceptions of types of mental disorders resulting from negative body image
___________________________________________________________________
Figure 2 represents participant’s knowledge of interventions used to treat eating
disorders. The percentage of respondents that did not know of any interventions used to
treat eating disorders was 83.3% (n=45) of the total sample. The percentage of
59
respondents that believed that CBT, DBT, and narrative therapy were interventions used
to treat eating disorders was 5.6% (n=3) of the total sample. The percentage of
respondents that believed medication was an intervention used to treat eating disorders
was 1.9% (n=1) of the total sample. The percentage of respondents that believed
education and prevention were interventions used to treat eating disorders was 3.7%
(n=2) of the total sample. The percentage of respondents that believed a mixture of all
(CBT, DBT, narrative therapy, medication, and education and prevention were
interventions used to treat eating disorders was 5.6% (n=3) of the total sample.
_____________________________________________________________________
Figure 2: Perceptions of interventions to treat eating disorders
________________________________________________________________________
Respondents were asked whether or not they believed early intervention was the
best method for addressing body image issues. Possible answers to this question includes
yes, no, or not sure. Of the total responses, (2, 3.7%) of respondents did not answer this
question. The percentage of respondents that believed early intervention was the best
60
method for addressing body image issues was 92.6% (n=50) of the total sample. The
percentage of respondents that did not believe that early intervention was the best method
for addressing body image issues. The percentage of respondents that were not sure if
early intervention was the best method for addressing body image issues was 1.9% (n=1)
of the total sample.
The researcher examined whether or not respondents believed that eating
disorder treatment had a high success rate by allowing participants to respond yes, no, or
not sure. The percentage respondents that did not respond to the question was 5.6% (n=3)
of the total sample. The percentage of respondents that believed that eating disorder
treatment had a high success rate was 46.3% (n=25) of the total sample. The percentage
of respondents that did not believe that eating disorder treatment had a high success rate
was 31.5% (n=17) of the total sample. The percentage of respondents that were not sure
if eating disorder treatment had a high success rate was 16.7% (n=9) of the total sample.
Knowledge on How Western Culture Impacts Body Image
Respondents were asked to define to what extent respondents believed Western
culture impacted people’s body image. Potential likert scale responses included a great
deal, much, somewhat, little, or never. The percentage of respondents who believed
Western culture impacted people’s body image a great deal was 90.7% (n=49) of the total
sample. The percentage of respondents that believed Western culture impacted people’s
body image much was 7.4% (n=4) of the total sample. The percentage of respondents that
believed Western culture impacted people’s body image somewhat was 1.9% (n=1) of the
total sample. None of the respondents chose little or never as a response.
61
Respondents were asked whether or not they believed discrimination exists based
on an individual’s appearance in Western culture. Possible responses to this question
included yes, no, or both. The percentage of respondents that believed discrimination
existed based on an individual’s appearance in Western Culture was 96.3% (n=52) of the
total sample. The percentage of respondents that did not believe discrimination existed
based on an individual’s appearance in Western culture was 1.9% (n=1) of the total
sample. The percentage of respondents that believed that both yes and no discrimination
existed based on an individual’s appearance in Western culture was 1.9% (n=1) of the
total sample.
Respondents had the opportunity to give their opinion on how they felt Western
culture portrayed women overall. The researcher grouped the responses into different
categories such as skinny, perfect, big breasts and butt, blonde and White, tall, big eyes,
and hypersexualized. The percentage of respondents that felt that Western culture
portrayed women as having large eyes was 7.4% (n=4) of the total sample. The
percentage of respondents that felt that Western culture portrayed women as
hypersexualized was 13% (n=7) of the total sample. The percentage of respondents that
felt that Western culture portrayed women as having big breasts and butt was 24.1%
(n=13) of the total sample. The percentage of respondents that felt that Western culture
portrayed women as have blonde hair and white skin was 24.1% (n=13) of the total
sample. The percentage of respondents that felt that Western culture portrayed women as
being perfect and flawless was 37% (n=20) of the total sample. The percentage of
respondents that felt Western culture portrayed women as being tall was 37% (n=20) of
62
the total sample. The percentage of respondents that felt Western culture portrayed
women as being skinny or thin was 77.8% (n=42) of the total sample.
Respondents had the opportunity to give their opinions on how Western culture
portrays men. The researcher grouped the most popular results into different categories
such as white and blonde, no body fat, big and strong, tall, and muscular and fit. The
percentage of respondents that believed Western culture portrayed men as white and
blond was 7.4% (n=4) of the total sample. The percentage of respondents that believed
Western culture portrayed men as having no body fat was 7.4% (n=4) of the total sample.
The percentage of respondents that believed that Western culture portrayed men as big
and strong was 14.8% (n=8) of the total sample. The percentage of respondents that
believed Western culture portrayed men as being tall was 20.4% (n=11) of the total
sample. The percentage of respondents that believed that Western culture portrayed men
as being muscular and fit was 72.2% (n=39) of the total sample.
Respondents were asked to give their opinions on how they felt Western media
and culture portrayed people who do not measure up to ideal beauty standards. The
researcher grouped the responses into categories such as ugly, fat, funny, lazy and
unmotivated, and unworthy. The percentage of respondents that felt that Western media
and culture portrayed people who do not measure up to ideal beauty standards as ugly
was 5.6% (n=3) of the total sample. The percentage of respondents that felt that Western
media and culture portrayed people who do not measure up to ideal beauty standards as
fat was 11.1% (n=6) of the total sample. The percentage of respondents that felt that
Western media and culture portrayed people who do not measure up to ideal beauty
63
standards as funny was 16.7% (n=9) of the total sample. The percentage of respondents
that felt that Western media and culture portrayed people who do measure up to ideal
beauty standards as lazy and unmotivated was 33.3% (n=18) of the total sample. The
percentage of respondents that felt that Western media and culture portrayed people who
do not measure up to ideal beauty standards as unworthy was 48.1% (n=26) of the total
sample.
Respondents were asked whether or not they believed Western media portrayed
diversity with a yes or no possible response. Of the total sample, one (1.9%) individual
did not respond to the question. The percentage of respondents that did feel that Western
media portrayed diversity was 25.9% (n=14) of the total sample. The percentage of
respondents that did not feel that Western media portrayed diversity was 72.2% (n=39) of
the total sample.
Respondents were asked their opinions on whether or not they agreed level of
acculturation into Western culture impacted people’s body image in the United States.
Possible responses to this question included strongly agree, agree, neutral , disagree, and
strongly disagree. Of the total sample, one student did not respond to this question. The
percentage of respondents that strongly agreed that level of acculturation into Western
culture impacted people’s body image in the United States was 50% (n=27) of the total
sample. The percentage of respondents that agreed that level of acculturation into
Western culture impacted people’s body image in the United States was 37% (n=20) of
the total sample. The percentage of respondents that were neutral on level of
acculturation into Western culture impacting body image in the United States was 7.4%
64
(n=4) of the total sample. The percentage of respondents that disagreed that level of
acculturation into Western culture impacted people’s body image in the United States
was 1.9% (n=1) of the total sample. The percentage of respondents that strongly
disagreed that level of acculturation into Western culture impacted people’s body image
in the United States was 1.9% (n=1) of the total sample.
Respondents’ Interest in Future Practice
Respondents were asked whether or not they were interested in learning more
about body image issues and eating disorders. The possible likert scale responses
included very interested, interested, fairly interested, somewhat interested, and not
interested. Of the total sample, one student did not reply to this question. The percentage
of respondents that revealed that they were very interested in learning more about body
image issues and eating disorders was 45.3% (n=25) of the total sample. The percentage
of respondents that revealed that they were interested in learning more about body image
issues and eating disorders was 25.9% (n=14) of the total sample. The percentage of
respondents that were fairly interested in learning more about body image issues and
eating disorders was 13% (n=7) of the total sample. The percentage of respondents that
were somewhat interested in learning more about body image issues and eating disorders
was 7.4% (n=4) of the total sample. The percentage of respondents that were not
interested in learning more about body image issues and eating disorders was 5.5% (n=3)
of the total sample.
Respondents were asked whether or not they were interested in working with
clients conflicted with body image issues resulting in an eating disorder. Possible likert
65
scale responses included very interested, interested, fairly interested, somewhat
interested, not interested. One student did not answer this question. The percentage of
respondents that were very interested in working with clients conflicted with body image
issues resulting in an eating disorder was 33.3% (n=18) of the total sample. The
percentage of respondents that were interested in working with clients conflicted with
body image issues resulting in an eating disorder was 22.2% (n=12) of the total sample.
The percentage of respondents fairly interested in working with clients conflicted with
body image issues resulting in an eating disorder was 20.4% (n=11) of the total sample.
The percentage of respondents somewhat interested in working with clients conflicted
with body image issues resulting in an eating disorder was 9.3% (n=5) of the total
sample. The percentage of respondents not interested in working with clients conflicted
with body image issues resulting in an eating disorder was 13% (n=7) of the total sample.
Respondents were asked how important they felt cultural competency was in
dealing with body image issues. The possible likert scale responses included very
important, important, neutral, somewhat important, and not important. Of the total
sample, two (3.7%) respondents did not answer this question. The percentage of
respondents who felt cultural competency was very important in dealing with body image
issues was 64.8% (n=35) of the total sample. The percentage of respondents who felt
cultural competency was important in dealing with body image issues was 25.9% (n=14)
of the total sample. The percentage of respondents that were neutral to the importance of
cultural competency in dealing with body image issues was 3.7% (n=2) of the total
sample. The percentage of respondents who felt cultural competency was somewhat
66
important was 1.9% (n=1) of the total sample. None of the respondents felt that cultural
competency was not important in dealing with body image issues.
Respondents were asked to provide macro level solutions that could be
implemented to promote positive body image and stop negative body image. The
researcher categorized the most popular responses which included banning Photo
shopping, providing education on positive body image, including more diversity in
media, and stricter media policies which includes banning Photoshop, including diversity,
and stopping the promotion of unrealistic models. The percentage of respondents that
believed banning Photo shop would be a strategic move to stop negative body image was
13% (n=7) of the total sample. The percentage of respondents that believed education
would be a macro level approach to stopping negative body image was 18.5% (n=10) of
the total sample. The percentage of respondents that believed including more diversity in
media would help stop negative body image was 24.1% (n=13) of the total sample. The
percentage of respondents that believed stricter media policies overall would be a
strategic move to reduce negative body image was 42.6% (n=23) of the total sample.
Gender and Age Differences in Evaluating Body Image Issues
Table 5 represents a cross tabulation between respondents’ gender and their
opinions on whether or not they believed discrimination existed based on an individual’s
appearance in Western culture. The percentage of males that believed discrimination
existed based on an individual’s appearance in Western culture was 18.5% (n=10) of the
total sample. The percentage of males who did believe that discrimination existed based
on an individual’s appearance in Western culture was 1.9% (n=1) of the total sample. The
67
percentage of females that believed discrimination existed based on an individual’s
appearance in Western culture was 75.9% (n=41) of the total sample. The percentage of
females that did not believe discrimination existed based on an individual’s appearance in
Western culture was 0%. Individuals that identified as other gender that believed
discrimination existed based on an individual’s appearance in Western culture was 1.9%
(n=1) of the total sample. Individuals that identified as other gender that did not believe
discrimination existed based on an individual’s appearance in Western culture was 0%.
Only two participants (one male, one identified as other) did not agree that discrimination
existed based on appearance, demonstrating that the majority of participants understood
that discrimination does exist based on appearance in Western culture. Puhl and Heurer
confirm that negative attitudes about over-weight and obese individuals result in
discrimination in the workplace and even on a personal level (2010).
________________________________________________________________________
Table 5:
Participants’ gender and the belief that discrimination exists based on an individual’s
appearance in Western culture
Belief that discrimination exists based on an individual's
appearance in Western culture
Gender
Male
Count
% of Total
Female
Count
% of Total
Other
Count
% of Total
Total
Count
% of Total
Yes
No
Both
Total
10
1
0
11
18.5%
1.9%
0.0%
20.4%
41
0
1
42
75.9%
0.0%
1.9%
77.8%
1
0
0
1
1.9%
0.0%
0.0%
1.9%
52
1
1
54
96.3%
1.9%
1.9%
100.0%
68
Table 6 represents the mean age and difference between the average age of
graduate social work respondents who considered body image issues as a concern of their
clients and those who did not consider body image issues as a concern of their clients.
The independent t-test output generated t=1.029, df=52, p>.05 with a mean difference of
the average age of these two groups equaling 2.828; the mean difference not being
statistically significant (p>0.05). Therefore, there was no difference between the mean
age of the participant and whether or not the participant considered body image issues to
be a concern of their clients.
_____________________________________________________________________________________
Table 6:
Mean difference in age between MSW respondents on considerations regarding body
image issues of clients
Body image issues have been a
N
Mean
Std. Deviation
Std. Error Mean
concern of clients by age
Yes
29
35.83
11.084
2.058
No
25
33.00
8.737
1.747
The researcher attempted a Pearson’s product moment correlation estimation
between the score on the inclusion of body image topics in participant’s classes and score
on agreement about level of acculturation into Western culture as it impacts people’s
body image in the U.S. The data demonstrated a weak correlation of r =- 0.149 (n=54)
between the inclusion of body image topics and whether or not participants believed level
69
of acculturation impacted individual’s body image. The p value was found to be
insignificant (p>0.05).
Correlations between participants that have taken the DSM course and knowledge
of the types of mental disorders that result from negative body image demonstrated a
non-existing correlation of -0.038 (n=54) between participants that took the DSM and
knowledge of the types of mental disorders that result from negative body image.
Table 7 represents an independent sample t-test that was conducted to see if there
was a difference between the scored interest in participants wanting to work with clients
conflicted by body image issues resulting in eating disorders and participants that have
worked with clients with body image issues that have led to an eating disorder.
The level of interest in working with clients conflicted by body image issues
resulting in eating disorders was demonstrated by the corresponding numbers (1-very
interested, 2-interested, 3-fairly interested, 4-somewhat interested and 5-not interested).
Individuals with a lower mean average showed more interest in working with these types
of clients. Participants that have worked with clients with body image issues that have led
to an eating disorder had more interest in working with clients conflicted with body
image issues resulting in an eating disorder (n= 18, 1.889), demonstrating participants
were interested to very interested. Individuals that had not worked with clients with body
image issues leading to an eating disorder had a higher mean average of interested to
fairly interested(n=36, 2.667), demonstrating that these individuals were less interested in
working with this type of clientele. Overall, the independent samples t-test output
generated (t=1.945, df=52, p< 0.05), demonstrating that the test was statistically
70
significant. Therefore, there was a difference in level of interest between participants
having worked with clients with body image issues leading to an eating disorder and
participant’s interest in working with clients with body image issues leading to an eating
disorder. These results show that participants were more interested in working with
clients with body image issues leading to an eating disorder when they had experience
working with this population. The National Eating Disorders Association confirms that
treating individuals with eating disorders is very difficult for individuals who do not have
experience with this type of mental illness (2013). Therefore, participants that have
worked with these types of clients have an understanding of the difficulty in treating
eating disorders which may be why these individuals want to gain more experience in
continuing to work with this population.
________________________________________________________________________
Table
7:
Interest level working with clients with an eating disorder and participants that have
worked with clients with body image issues that have led to an eating disorder
Participants that have
worked with clients with
body image issues that have
led to an eating disorder
Scored interest of participant
Yes
in working with clients
conflicted by body image
issues resulting in eating
No
disorders
N
Mean
Std. Deviation
Std. Error Mean
18
1.8889
1.23140
.29024
36
2.6667
1.45406
.24234
The researcher conducted an independent sample t-test to see if there was a
difference between mean scores on level of interest participants had in learning more
about body image issues and eating disorders and whether or not participants worked
71
with clients with body image issues that have led to an eating disorder. Level of interest
was defined by corresponding numbers (1-very interested, 2-interested, 3-fairly
interested, 4-somewhat interested and 5-not interested), so a lower mean score represents
a higher level of interest. The participants that had worked with clients with body image
issues that led to an eating disorder had a mean score of 1.6111 (n=18), and the number
of participants that had not worked with clients with body image issues that led to an
eating disorder had a higher mean score of 2.111 (n=36). Therefore, participants that had
worked with clients with body image issues showed slightly higher interest in learning
more about body image issues when compared participants that had not worked with
individuals with body image issues.
The mean difference represented in table 8 generated (t=1.434, df=52, p>0.157),
demonstrating that the test was not statistically significant. Although the test was not
statistically significant, the findings suggest that participants that have worked with
clients with body image issues that have led to an eating disorder were more interested in
working with these types of clients based on a mean score that represented more interest.
________________________________________________________________________
Table 8:
Scored interest of participants’ learning more about body image issues and eating
disorders and participants’ work with clients
Participants that have
worked with clients with
eating disorders
Scored interest of
Yes
participants learning more
about body image issues and
No
eating disorders
N
Mean
Std. Deviation
Std. Error
Mean
18
1.6111
.97853
.23064
36
2.1111
1.30445
.21741
72
Summary
This chapter presents findings in the context of 54 respondents’ knowledge and
perceptions about body image and eating disorders and how this knowledge or lack of
knowledge impacts working with clients affected by body image issues and eating
disorders. In evaluating experience and knowledge, it appeared that there was an overall
lack of experience with clients and classes and training that covered body image and
eating disorders. Of the total sample, only one-third of participants worked with clients
with body image issues leading to an eating disorder; however, 53.7% agreed that body
image issues were a concern of their clients. Additionally, the findings demonstrate that a
small percentage of participants felt that they had adequate to superior knowledge about
body image and eating disorders. The majority of respondents agreed that they had not
received proper training and continuing education based on body image issues and eating
disorders. Overall, 83.3% of participants described having poor to fair knowledge in the
area of eating disorders and body image issues.
The researcher obtained some statistically significant and not statistically
significant inferential findings utilizing independent t-test and Chi-Square tests. A ChiSquare test of association showed statistical significance in association between body
image issues being a concern of respondents’ clients and whether or not eating disorders
had a high success rate. A Pearson Chi-Square result demonstrated that participants
understood the importance of early intervention but did not have a clear understanding of
the fact that eating disorder treatment had a low success rate. An independent sample ttest showed no difference between the average age of respondents who considered body
73
image issues to be a concern of their clients versus those who did not consider body
image issues to be a concern of their clients. An independent sample t-test between the
scored interest in participants wanting to work with clients conflicted by body image
issues resulting in eating disorders and participants that have worked with clients with
body image issues that have led to an eating disorder demonstrated statistical significance
in that respondents’ that worked with clients with negative body image and eating
disorders were more interested in working with these types of clients when compared
with respondents who had not worked with this population. A correlation test between
participants having taken the DSM class and knowledge of types of mental disorders
resulting from negative body image did not show statistical significance. However, the
findings suggest that respondents who took the DSM class were no more likely than those
who had not taken the course to have knowledge about types of mental health disorders
resulting from negative body image and eating disorders. Additionally, an independent ttest between respondents having worked with clients with body image issues leading to
an eating disorder and level of interest of learning more about body image and eating
disorders was not statistically significant; however, the findings demonstrate that
respondents who had worked with clients with body image issues were more interested in
learning more about eating disorders and body image. Overall, the findings demonstrate
that the respondents in this study do not have adequate training or continuing education
as it relates to body image. The next chapter will discuss overall conclusions and
recommendations as it relates to social work.
74
Chapter 5
CONCLUSION, SUMMARY, AND RECOMMENDATIONS
Conclusions
This study generated findings on the academic preparedness of respondents in
working with individuals conflicted with negative body image and eating disorders.
Additionally, this study assessed the knowledge-base of graduate social work students
when evaluating factors impacting body image, treatments, interventions, cultural
competency, and specific terms related to body image and eating disorders. Although
body image issues and eating disorders are becoming a major public health issue, there
are limited class offerings and trainings that allow MSW students to become more
competent in this topic area. However, MSW students are still required to work with
individuals affected by negative body image and eating disorders. There have been few
research studies that evaluate the competencies of MSW students when it comes to
understanding, evaluating, and treating negative body image and eating disorders. This
section will address the conclusions based on findings from Chapter 4.
In analyzing the responses of 54 participants, it appeared that there was an overall
lack of experience with clients as well as classes and training that covered body image
and eating disorders. Of the total sample, only 33.3% of participants worked with clients
with body image issues leading to an eating disorder; however, 53.7% agreed that body
image issues were a concern of their clients. Additionally, the findings demonstrate that
16.5% of participants felt that they had adequate to superior knowledge about body image
and eating disorders, and 59.3% of participants disagreed or strongly disagreed that they
75
received training and continuing education based on body image issues and eating
disorders. Overall, 83.3% of participants described having poor to fair knowledge in the
area of eating disorders and body image issues, demonstrating deficiency in this topic
area.
The overall assumption of the researcher was that respondents had limited
knowledge about body image and eating disorders. However, there was a great deal of
information that the respondents did understand. Respondents understood the connection
between positive body image and good mental health as 91.8% of respondents found
positive body image to be important to very important to good mental health.
Respondents understood that multiple factors influence body image such as religion,
socioeconomic status, ethnicity, age group and national background. In fact, the majority
of respondents (79.6%) clearly understood the vulnerability of age as it pertains to
negative body image. Almost all participants (92.6%) understood that early intervention
was important to preventing negative body image and eating disorders. In evaluating
terms pertaining to eating disorders, 79.6% of participants understood the difference
between anorexia nervosa and bulimia nervosa, 92.6% understood what the term
bingeing meant, 63% of participants knew what body dysmorphia meant. In evaluating
mental health issues resulting from negative body image, 48.1% understood that multiple
types of mental disorders result from negative body image such as depression, eating
disorders, and personality disorders. In evaluating Western culture’s impact on body
image, 100% of participants felt that Western culture impacted body image adequately to
a great deal, and 96.3% understood that discrimination existed based on overall
76
appearance, 72.2% agreed that Western media did not portray diversity, 87% agreed to
strongly agreed that level of acculturation into Western culture impacted body image. In
evaluating working with clients with body image and eating disorders, 90.7% of
participants believed cultural competency was important to very important.
On the other hand, there were some deficiencies in the reported knowledge of the
respondents. One of the most surprising findings was the 83% of participants did not
know of types of interventions utilized to treat eating disorders, and 63.1% of participants
did not understand that eating disorder treatment had a low success rate. Furthermore, a
sample t-test demonstrated that respondents’ knowledge about body image and eating
disorders was no different whether respondents worked with client with body image
issues or eating disorders or not. Also, there was no difference between whether or not
participant’s classes covered body image topics and participant’s knowledge of eating
disorders.
Furthermore, respondents did show interest in working with individuals conflicted
with body image issues and eating disorders as 71% were interested in learning more
about body image issues and eating disorders and 75.9% were fairly to very interested in
working with clients conflicted by body image issues.
Recommendations
The recommendations that result from this study are presented within different
levels of social work including micro, mezzo and macro level practice. Hopefully, these
recommendations can offer ways that help prepare master’s level social work students
better in regards to treatment and prevention of body image issues and eating disorders.
77
Negative body image can lead to many mental health consequences when proper
interventions are not implemented. For this reason, it is important for MSW students to
have a broad understanding of the underlying factors that affect body image, the
terminology as it relates to eating disorders, and proper intervention programs and
treatment.
In order to engage in direct practice at the micro level, it is important for MSW
students to receive continuing education toward cultural competency as it relates to body
image. As discussed previously, the development of body image is influenced by
ethnicity, sexual orientation, age group, religion, national background, gender, and
socioeconomic status. Since body image is impacted differently by these factors
depending on the individual, it is important for MSW students to recognize these issues.
Once MSW students have a clear understanding of the underlying factors contributing to
negative body image, they can then begin to understand how to intervene. Understanding
these underlying factors plays into the importance of cultural competency. Cultural
competency through education is mandated in the Council on Social Work Educational
Policy and Accreditation and National Association of Social Workers Code of Ethics
(Logan, 2013). Additionally, it is important for MSW students to understanding the great
impact Western media plays in encouraging body shaming and inadequacy among
clients.
At the micro level, there are two theoretical frameworks that can help guide
MSW students in future practice and include empowerment theory and person-centered
theory. As discussed in chapter 1, empowerment theory can be used to help clients
78
develop coping mechanisms in an effort to ward-off negative thinking when it comes to
body image. Empowerment and a person-centered approach can allow clients to
recognize and accept all forms of beauty, specifically ways in which a client can begin to
identify him or herself as beautiful. Types of therapeutic modalities at the micro level
should include Cognitive Behavioral Therapy, Narrative Therapy, and Dialectical
Behavioral Therapy.
Additionally, classes within the MSW program should place value on educating
students about types of interventions and treatments for clients conflicted by body image
and eating disorders. The only class that currently addresses body image issues and eating
disorders is the DSM class; however, this class only covers the criteria necessary to
diagnose someone with a disorder and does not address treatment or intervention.
Therefore, it would be helpful if practice classes from now on included reading materials
and other media (online trainings, videos, and vignettes) on how to properly treat
negative body image and eating disorders.
When evaluating mezzo level social work, it is vital for students to understand the
importance of group work and community work as effective forms of intervention. As
described in Chapter 2, proper intervention while individuals are young is an important
predictor of whether or not individuals will develop body image issues and eating
disorders later on in life. One of the most influential ways to stop the development of
negative body image is utilizing education and awareness as forms of prevention. Social
work students that work on all levels of education (primary, secondary, and higher
education) must understand the power of small group therapy. Therefore, it is important
79
for MSW students to develop positive self-esteem and body-esteem groups for boys and
girls at all age levels. Since mass media and social media in Western culture play a large
role in the development of negative body image, a constructivist theoretical framework is
important for MSW students to keep in mind since the media’s ideals of beauty are
socially constructed. The media’s definition of what is physically attractive is often
skewed and does not reflect reality, and an open interpretation of what is beautiful should
be encouraged among youth.
Media awareness can be one technique used in groups to help youth understand
that many forms of beauty are not reflected in the mass media, and advertising for diet
and beauty products is designed to make people feel inadequate so that these companies
make money. Social work students must also understand the value in involving the
families of youth struggling with negative body image, specifically families of different
ethnic backgrounds. The critical-race theory framework can be used to allow diverse
families to understand the damage that can be caused by the media since the media only
reflects beauty in the context of the dominant culture. For example, young boys and girls
of color may want to lighten their skin to look more like their favorite characters in the
mass media; therefore, there is great importance in intervention during this time. Social
work students need to be able to educate parents about the influence the mass media can
have on their children’s self-esteem and body image so that parents can understand the
positive influence they can have on their children.
On a larger scale, social work students need to understand the level of influence
they can have at the macro level. The most popular answers from respondent’s in this
80
study in regards to macro level solutions to negative body image and eating disorders was
stricter media policies, exposure to more diversity within in the media (people of all
different weights, shapes, colors as well as other forms of beauty), outlawing photoshopping, positive body image campaigns and education. Therefore, MSW students in
this study appear to have a clear understanding of how to make change using a
constructivist theoretical framework. One area of research that may assist social workers
in developing stricter media policies is evaluating the affects the mass media and social
media in Western culture have on youth. If enough evidence supports that exposure to the
mass media is detrimental to individuals health, social workers can use this evidence in
making their case against large media conglomerates and government agencies that have
regulatory power. Social workers can also work with advertisements companies to
educate them about the danger of photo-shopping and how all photo-shopped images
should have a disclaimer to consumers about the altering of the original photo. Future
research on body image can be focused on the growing public health concerns related to
body image such as eating disorders, physical health risk, depression, anxiety, and
suicidality. In the future, expansion of the Affordable Healthcare Act could potentially
include allocated funds for research as it relates to treatment and prevention of negative
body image and eating disorders.
Implications for Social Work
Based on the above recommendations, there are many opportunities for social
workers at the micro, mezzo, and macro levels when addressing negative body image and
subsequent eating disorders. These recommendations may be helpful in increasing MSW
81
students’ level of cultural competency, understanding of factors contributing to the
development of negative body image and knowledge about interventions and treatment
for negative body image. Since negative body image is a growing problem that impacts
the mental health status of individuals, there is great importance for social workers to be
competent in working with individuals conflicted with negative body image.
Although MSW students have a broad curriculum, there are limited class
offerings and continuing education opportunities for students when it comes to learning
more about body image. As noted in the findings and conclusions of this study, MSW
students did not have adequate knowledge about body image and eating disorders,
specifically in the realm of interventions and treatment. Therefore, it is the hope of the
researcher that body image issues will be considered in future classes and learning
opportunities. It is also the hope of the researcher that there will be future educational
opportunities for students to help them better understand how body image develops from
a cultural standpoint to increase levels of cultural competency. Respondents in this study
understood the importance of cultural competency in dealing with body image, but there
are currently no educational opportunities on body image to increase this level of cultural
competency.
According to the National Association of Anorexia and Associated Disorders,
eating disorders have the highest mortality rate when compared with other mental health
disorders (2013), and muscle dysmorphia in men and eating disorders in women can lead
to irreversible damage to the skeletal system if the behavior is continued (Fernandez &
Pritchard, 2012). Therefore, it is of great importance that social workers working with
82
children understand how to intervene while individuals are young. Social workers in
elementary schools, middle/high schools, counseling agencies that work with youth and
diverse setting and communities can be instrumental in reversing the negative thinking
that often coincides with negative body image. Overall, the greatest tool in addressing
negative body image and eating disorders is prevention. As a result, social workers can
play a prominent role in program development, media awareness, and advocacy at the
macro level to reduce the number of client’s impacted by negative body image.
83
APPENDIX A
Human Subjects Approval Letter
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
DIVISION OF SOCIAL WORK
To: Shannon St. Louis
Date: October 29, 2013
From: Research Review Committee
RE: HUMAN SUBJECTS APPLICATION
Your Human Subjects application for your proposed study, “Professionals' Perspectives
on the Importance of Cultural Competencies in Working with Clients who Indicated
Body Image Conflict”, is Approved as Exempt. Discuss your next steps with your
thesis/project Advisor.
Your human subjects Protocol # is: 13-14-021. Please use this number in all official
correspondence and written materials relative to your study. Your approval expires one
year from this date. Approval carries with it that you will inform the Committee
promptly should an adverse reaction occur, and that you will make no modification in
the protocol without prior approval of the Committee.
The committee wishes you the best in your research.
Research Review Committee members Professors Maria Dinis, Jude Antonyappan, Serge Lee, Francis Yuen, Kisun
Nam, Dale Russell,
Cc: Antonyappan
84
References
Abdollahi, P., & Mann, T. (2001). Eating disorder symptoms and body image concerns in
Iran: Comparisons between Iranian women in Iran and in America. International
Journal of Eating Disorders, 30, 259–268.
Abrams, L., & Moio, J. (2009). Critical race theory and the cultural competence
dilemma in social work education. Journal Of Social Work
Education, 45(2), 245-261.
Agliata, D., & Tantleff-Dunn, S. (2004). The impact of media exposure on males’ body
image. Journal Of Social & Clinical Psychology, 23(1), 7-22.
Akande, A. (2009). The self-perception and cultural dimensions: cross-cultural
comparison. Educational Studies (03055698), 35(1), 81-92.
doi:10.1080/03055690802470209
American Psychiatric Association (2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th edition, Washington, DC; American Psychiatric
Association.
Aruguete,. M., Nickleberry, L., & Yates, A. (2004). Acculturation, body image, and
eating attitudes among black and white college students. North American Journal
Of Psychology, 6(3), 393-404
Bakhshi, S. (2011). Women's body image and the role of culture: A review of the
literature. Europe's Journal Of Psychology, 7(2), 374-394.
Bloom, A. (2011). Body Image: The model for religion. Thought Catalog. Retrieved
from http://thoughtcatalog.com/2011/body-image-the-model-religion/
85
Boskind-Lodahl, M. (1976). Cinderella’s stepsisters: A feminist perspective on anorexia
nervosa and bulimia. Signs, 2, 243-355.
Capuzz, D. & Gross, D. (2010). Counseling and Psychotherapy: Theories and
Interventions, Alexandria, VA: Pearson Prentice Hall.
doi:10.1177/0886109902239092/
Chapman, T. (2011). Women in American media: A culture of misperception. Student
Pulse. Retrieved from http://www.studentpulse.com/articles/548/2/women-inamerican-media-a-culture-of-misperception
Chen, W., & Swalm, R. (1998). Chinese and American college students’ body image;
Perceived shape and body affect. Perceptual Motor Skills, 87, 395-403.
Cherry, K. (2013). Client-centered therapy. About.com. Retrieved from
http://psychology.about.com/od/typesofpsychotherapy/a/client-centeredtherapy.htm
Colby, I. (2013). Rethinking the MSW curriculum. Journal Of Social Work Education,
49(1), 4-15. doi:10.1080/10437797.2013.755404
Cooper, M. (2012). Census officials citing increasing diversity, say U.S. will be a
‘plurality nation.’ The New York Times. Retrieved from http://www.nytimes.com
/2012/12/13/us/us-will-have-no-ethnic-majority-census-finds.html?_r=0
Crow, S., Peterson, C., Swanson, S., Raymond, N., Specker, S., Eckert, E., Mitchell, J.
(2009). Increased mortality in bulimia nervosa and other eating disorders.
American Journal of Psychiatry 166, 1342-1346.
86
Darlow, S., & Lobel, M. (2010). Who is beholding my beauty? Thinness ideals, weight,
and women's responses to appearance evaluation. Sex Roles, 63(11/12), 833-843.
doi:10.1007/s11199-010-9845-8
Davey, C., & Bishop, J. (2006). Muscle dysmorphia among college men: An emerging
gender -related counseling concern. Journal Of College Counseling, 9(2), 171180.
DeLeel, M., Hughes, T., Miller, J., Hipwell, A., & Theodore, L. (2009). Prevalence of
eating disturbance and body image dissatisfaction in young girls: An examination
of the variance across racial and socioeconomic groups. Psychology In The
Schools, 46(8), 767-775.
Demarest, J., & Allen, R. (2000). Body Image: Gender, ethnic, and age differences. The
Journal of Social Psychology, 140 (4), 465-472
Derenne, J., & Beresin, E. (2006). Body image, media, and eating disorders. Academic
Psychiatry, 30(3), 257-261.
Dillon, P., Copeland, J., & Peters, R. (1999). Exploring the relationship between male
homo/bisexuality, body image and steroid use. Culture, Health, & Sexuality, 1,
317-327.
Division of Social Work website. (2013). Master of social work. California State
University, Sacramento. Retrieved from http://www.csus.edu/HHS/SW/Programs/
Master%20of%20Social%20Work.html
Engel, R., & Schutt, R. (2009). The Practice of Research in Social Work 2nd edition,
Thousand Oaks, CA: Sage Publications, Inc.
87
Evans, J., Evans, B., & Rich, E. (2003). ‘The only problem is, children will like their
chips’: Education and the discursive production of ill-health. Pedagogy, Culture
& Society, 11(2), 215-240
Fernandez, S., & Pritchard, M. (2012). Relationships between self-esteem, media
influence and drive for thinness. Eating Behaviors, 13(4), 321-325.
doi:10.1016/j.eatbeh.2012.05.004
Fitzgibbon, M., Blackman, L., & Avellone, M. (2000). The relationship between body
image discrepancy and body mass index across ethnic groups. Obesity
Research, 8 (8), 582-589.
Franco, K. (2012). Eating disorders. Cleveland Clinic. Retrieve http://www.cleveland
meded.com/medicalpubs/diseasemanagement/psychiatry-psychology/eatingdisorders/
Franko, D., Becker, A., Thomas, J., & Herzog, D. (2007). Cross-ethnic differences in
eating disorder symptoms and related distress. International Journal Of Eating
Disorders, 40(2), 156-164. doi:10.1002/eat.20341
Gandhi, D., Appaya, M., & Machado, T. (1991). Anorexia nervosa in Asian children.
British Journal of Psychiatry, 159, 591-592.
Gard, M., & Freeman, C. (1996). The dismantling of a myth: A review of eating
disorders and socioeconomic status. International Journal Of Eating Disorders,
20(1), 1-12.
88
Giardino, J., & Procidano, M. (2012). Muscle dysmorphia symptomatology: A crosscultural study in Mexico and the United States. International Journal Of Men's
Health, 11(1), 83-103. doi:10.3149/jmh.1101.83
Giles, S., Helme, D., & Krcmar, M. (2007). Predicting disordered eating intentions
among incoming college freshman: An analysis of social norms and body esteem.
Communication Studies, 58(4), 395–410
Gillen, M., & Lefkowitz, E. (2006). Gender role development and body image among
male and female first year college students. Sex Roles, 55(1/2), 25-37.
doi:10.1007/s11199-006-9057-4
Handlesman, D., & Gupta, L. (1997). Prevalence and risk factors for anabolic-androgenic
Steroid abuse in Australian high school students. International Journal of
Andrology, 20, 159-164.
Hudson, J., Hiripi, E., Pope, H., & Kessler, R.(2007). The prevalence and correlates of
eating disorders in the National Comorbidity Survey Replication. Biological
Psychiatry, 61, 348–358, http://dx.doi.org/10.1016/j.biopsych.2006.03.040.
Jackson, S. (2009). Research methods and statistics: A critical thinking approach 3rd
Edition. Belmont, CA: Wadsworth.
Jani, J., & Reisch, M. (2011). Common human needs, uncommon solutions: Applying a
critical framework to perspectives on human behavior. Families In Society, 92(1),
13-20. doi:10.1606/1044-3894.4065
89
Juarez, L., Soto, E., & Pritchard, M. (2012). Drive for muscularity and drive for thinness:
The impact of pro-anorexia websites. Eating Disorders, 20(2), 99-112.
doi:10.1080/10640266.2012.653944
Joffe, J. (2006). The perils of soft power. The New York Times. Retrieved from
http://www.nytimes.com/2006/05/14/magazine/14wwln_lede.html?
pagewanted=all&_r=0
Johnson, C. (2009). Cutting through advertisement clutter. CBS News. Retrieved from
http://www.cbsnews.com/8301-3445_162-2015684.html
Johnson, M. & Rhodes, R. (2010). Human Behavior and the Larger Social Environment,
Boston, MA: Pearson Education, Inc.
Kaminski, P., Chapman, B., Haynes, S., & Own, L. (2005). Body image, eating
behaviors, and attitudes toward exercise among gay and straight men. Eating
Behaviors, 6, 179-187.
Kite, L. (2012). Beauty whitewashed: How white ideals exclude women of color.
Everyday Feminism. Retrieved from http://everydayfeminism.com
/2012/11/beauty-whitewashed/
Leone, J., Sedory, E., & Gray, K. (2005). Recognition and treatment of muscle
dysmorphia and related body image disorders. Journal Of Athletic Training,
40(4), 352-359.
Lester, M. (1996). Images that injure: Pictorial stereotypes in the media, Westport, CT:
Praeger.
90
Levesque, M., & Vichesky, D. (2006). Raising the bar on the body beautiful: An
analysis of the body image concerns of homosexual men. Body Image, 3, 45-55.
Logan, S. (2013). Cultural competence and ethnic sensitive practice. Oxford
Bibliographies. Retrieved from http://www.oxfordbibliographies.com/
/view/document/obo-9780195389678/obo-9780195389678-0060.xml
Lorber, J., & Martin, P. (2007). The socially constructed body: Insights from feminist
theory.Sagepub.com. Retrieved from http://www.sagepub.com/upmdata/16568_Chapter_8.pdf
Loren, A. (2011). Black men and eating disorders. Frugivore Magazine. Retrieved from
http://frugivoremag.com/2011/09/black-men-and-eating-disorders/
Madanat, H., Hawks, S., & Brown, R. (2006). Validation of the sociocultural attitudes
towards appearance questionnaire-3 among a random sample of Jordanian
women. Body Image, 3, 421–425.
Mandal, A. (2013). Obesity and heart disease. News Medical. Retrieved from
http://www.news-medical.net/health/Obesity-and-heart-disease.aspx
Martin, P., & Midgley, E. (2010). Population bulletin update: Immigration in America
2010. Population Reference Bureau. Retrieved from. http://www.prb
org/Publications/PopulationBulletins/2010/immigrationupdate1.aspx
Mintz, L., & Kashubeck, S. (1999). Body image and disordered eating among Asian
American and Caucasian college students. Psychology Of Women
Quarterly, 23(4), 781.
91
Morse, R. (2009). Which colleges have the most student diversity.U.S. News and World
Report.Retrieved from http://www.usnews.com/education/blogs/college-rankingsMurray, S., Rieger, E., Touyz, S., & De la Garza García, L. (2010). Muscle dysmorphia
and the DSM-V conundrum: Where does it belong? A review paper. International
Journal Of Eating Disorders, 43(6), 483-491.blog/2009/08/27/which-collegeshave-the-most-student-diversity
Mussap, A. (2009a). Acculturation, body image, and eating behaviours in MuslimAustralian women. Health & Place, 15(2), 532-539.
doi:10.1016/j.healthplace.2008.08.008
Mussap, A. (2009b). Strength of faith and body image in Muslim and non-Muslim
women. Mental Health, Religion & Culture, 12(2), 121-127.
doi:10.1080/13674670802358190
Nasser, M. (1988). Culture and weight consciousness. Journal of Psychosomatic
Research, 32, 573–577.
National Association of Anorexia and Associated Disorders. (2013). Eating disorder
statistics. Anorexia and Associated Disorders, Inc. Retrieved from
http://www.anad.org/get-information/about-eating-disorders/eating-disordersstatistics/
National Association of Social Workers. (2013). Mental health. Social Workers.
org. Retrieved from http://www.socialworkers.org/pressroom
pressroom/features/issue/mental.asp
92
National Eating Disorders Association: Feeding Hope. (2013). Types and symptoms
of eating disorders. National Eating Disorders.org. Retrieved from
http://www.nationaleatingdisorders.org/
National Institutes of Mental Health. (2013). Eating disorders. U.S. Department of
Health and Human Services. Retrieved from http://www.nimh.nih.gov/health
/publications/eating-disorders/eating-disorders.pdf
Neighbors, L., & Sobal, J. (2007). Prevalence and magnitude of body weight and shape
dissatisfaction among university students. Eating Behavior, 8(4): 429-439.
Net Industries. (2012). Theories of development-The- contextualist worldview.
Social.jrank.org Retrieved from http://social.jrank.org/pages/657/TheoriesDevelopment-Contextualist-Worldview.html
Neumark-Sztainer, D., Croll, J., Story, M., Hannan, P., French, S., & Perry, C.
(2002). Ethnic/racial differences in weight-related concerns and behaviours
among adolescent girls and boys: Findings from project EAT
Journal of Psychosomatic Research, 53, 963–974
O'Dea, J., & Abraham, S. (2002). Eating and exercise disorders in young college men.
Journal of American College Health, 50, 273.
O’Heron, C. A., & Orlofsky, J. L. (1990). Stereotypic and nonstereotypic sex role trait
and behavior orientations, gender identity, and psychological adjustment. Journal
of Personality and Social Psychology, 58, 134–143.
93
Painter, E., Ward, W., Gibbon, P., & Emmerson, B. (2010). The eating disorders
outreach service: enabling clinicians statewide to treat eating disorders.
Australasian Psychiatry, 18(1), 49-52. doi:10.3109/10398560903287524
Peplau, L., Frederick, D., Yee, C., Maisel, N., Lever, J., & Ghavami, N. (2009). Body
image satisfaction in heterosexual, gay, and lesbian adults. Archives Of Sexual
Behavior, 38(5), 713-725. doi:10.1007/s10508-008-9378-1
Prince, R. (1985). The concept of culture-bound syndromes: Anorexia nervosa and brainfag. Social Science &Medicine, 21, 197–203.
health. American Journal of Public Health, 100(6), 1019-1028.
doi:10.2105/AJPH.2009.159491
Quenqua, D. (2012). Muscular body image lures boys into the gym, and obsession.
The New York Times. Retrieved from http://www.nytimes.com/2012/11/19
health/teenage-boys-worried-about-body-image-takerisks.html?pagewanted=all&_r=0
Raphael, D. (2002). Social justice is good for our hearts: Why societal factors – not
lifestyles- are major causes of heart disease in Canada and elsewhere.
CSJ Foundation for Research and Education. Retrieved from
http://www.cwhn.ca/sites/default/files/resources/heart_health/justice2.pdf
Russell-Mayhew, S. (2007). Eating disorders and obesity as social justice issues:
Implications for research and practice. Journal for Social Action in Counseling
and Psychology, 1(1), 1-13.
94
Schriver, J. M. (2011). Human Behavior and the Social Environment. Boston, MA:
Pearson
Schwartz-Cowan, R. (1976). The “Industrial Revolution” in the home: Household
technology and social change in the 20th century. Technology and Culture,17(1),
1-23.
Sides-Moore, L., & Tochkov, K. (2011). The Thinner the better? Competitiveness,
depression and body image among college student women. College Student
Journal, 45(2), 439-448.
Sjostedt, J., Schumaker, J., & Nathawat, S. (1998). Eating disorders among Indian and
Australian university students. Journal Of Social Psychology, 138(3), 351-357.
Sjostrom, L., & Steiner-Adair, C. (2005). Full of ourselves: A wellness program to
advance girl power, health & leadership: An eating disorders prevention program
that works. Journal Of Nutrition Education & Behavior, 37S141-S144.
Social Work Salary. (2012). Licensed clinical social worker (LCSW) career job
description. Word Press. Retrieved from http://
thesocialworkersalary.org/licensed-clinical-social-worker/
Srebnik, D., & Saltzberg, E. (1994). Feminist cognitive-behavioral therapy for
negative body image. Women & Therapy, 15(2), 117-133.
Steiner-Adair, C. (1986). The body politic: Normal female adolescent
development and the development of eating disorders. Journal
of the American Academy of Psychoanalysis, 14, 95–114
95
Story, M., Steven, J., Evans, M., Cornell, C., Gittelsohn, J., Going, S., Clay, T., &
Murray, D. (2001). Weight loss attempts and attitudes toward body size, eating,
and physical activity in American Indian children: Relationship to eight status and
gender. Obesity Research, 9(6). 356–363.
Stodghill, A. (2012). African-American woman heavier, but have higher self-esteem than
white counterparts. NBC Universal. Retrieved from
http://thegrio.com/2012/02/29/african-american-women-heavier-but-have-higherself-esteem-than-white-counterparts/
Striegel-Moore, R., Rosselli, F., Holtzman, N., Dierker, L., Becker, A., & Swaney, G.
(2011). Behavioral symptoms of eating disorders in Native Americans: Results
from the add health survey wave III. International Journal Of Eating Disorders,
44(6), 561-566. doi:10.1002/eat.20894
Sussman, N., Truong, N., & Lim, J. (2007). Who experiences “America the beautiful”?:
Ethnicity moderating the effect of acculturation on body image and risks for
eating disorders among immigrant women. International Journal of Intercultural
Realtions,31, 29-49
Taras, V. (2008). Instruments for measuring acculturation. Haskayne School of Business.
Retrieved fromhttp://ucalgary.ca/~taras/_private/Acculturation_Survey
_Catalogue.pdf
Treviño, A., Harris, M. A., & Wallace, D. (2008). What's so critical about critical race
theory?. Contemporary Justice Review, 11(1), 7-10.
doi:10.1080/10282580701850330
96
Tylka, T., & Subich, L. (2004). Examining a multidimensional model of eating
disorder symptomatology among college women. Journal Of Counseling
Psychology, 51(3), 314-328. doi:10.1037/0022-0167.51.3.314
U.S. Department of Health and Human Services. (2013). What is cultural competency?
The Office of Minority Health. Retrieved from http://minorityhealth.hhs.gov/
templates/browse.aspx?lvl=2&lvlID=11
Vigdor, J. (2008). Measuring immigrant assimilation in the United States. Manhattan
Institute for Policy Research. Retrieved from http://www.manhattaninstitute.org/html/cr_53.htm
Wang, Z., Byrne, N., Kenardy, J., & Hills, A. (2005). Influences of ethnicity and
socioeconomic status on the body dissatisfaction and eating behaviour of
Australian children and adolescents. Eating Behaviors, 6(1), 23-33.
doi:10.1016/j.eatbeh.2004.05.001
Warren, C., Castillo, L., & Gleaves, D. (2010). The sociocultural model of eating
disorders in Mexican American women: Behavioral acculturation and cognitive
marginalization as moderators. Eating Disorders, 18, 43-57. doi:
10.1080/10640260903439532
Warren, C., Gleaves, H., Cepeda-Benito, A., Fernandez, M., & Rodriguez-Ruiz, S.
(2005). Ethnicity as a protective factor against internalization of a thin ideal and
body dissatisfaction. International Journal of Eating Disorders, 37, 241–249.
97
Wildes, J., Emery, R., & Simons, A. (2001). The roles of ethnicity and
culture in the development of eating disturbance and body dissatisfaction: A
meta-analytic review. Clinical Psychology Review, 21, 521–551.
Zimmerman, M. (1995). Psychological empowerment: Issues and illustrations. American
Journal Of Community Psychology, 23(5), 581.