Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Mental disorder wikipedia , lookup
Anorexia nervosa wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Child psychopathology wikipedia , lookup
Externalizing disorders wikipedia , lookup
History of mental disorders wikipedia , lookup
Eating disorders and memory wikipedia , lookup
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.