The acknowledgement of gender identity, sexual orientation, race, ethnic background and cross-cultural differences is necessary and vital to building the therapeutic relationship. All of these things contribute towards one’s identity and, in my experiences as a clinician, are always present in the room with clients.
This blog is offered as a collaborative piece between an alumna of Reasons and myself, one of her therapists in the program. We hope to address some of these issues of “sameness” and “differentness” and the experience of being part of marginalized groups from both the clinician’s and client’s points of view.
The Client Perspective:
Tell us about the importance for you of working with someone from a similar racial or ethnic background?
It’s very important to me to work with someone with a similar racial or ethnic background. I have no one that looks like me in my community that is willing to admit to the same struggles. Being Black with an eating disorder is just a running joke a lot of times. Brown and Black people generally have a lot of pride, so to admit a weakness that isn’t visible is not a common thing. Talking to someone that looks similar to me I feel more comfortable because I feel they understand the extra layer to my struggle: admitting I have a problem and then seeking help. In addition, during the entire time while in treatment I most always was the only Black girl; it’s comforting to not feel like a minority on my one on one sessions. A big part for me is not feeling like an outsider in a disorder that already leaves you as an outsider.
How are mental health issues (eating disorders) treated/viewed in your community?
Growing up the media only showed me that there was one type of girl who deals with what I was dealing with, and it left me feeling like it was unacceptable, or even that I was aspiring to be something I’m not. Despite this, I found myself struggling with the same issues. Also, in my community mental health, especially eating disorders, are taboo. If it’s not something that can be fixed with God, Robitussin, or a nap then it isn’t real. I grew up seeing people struggling with mental illness outcast from the family, no one bothering to help because it was something they caused on themselves.
When struggling with any type of mental illness, everything goes back to my faith not being strong enough in God. Everyone’s grandmother had a harder life than them, going all the way back to slavery, and no one sought a therapist or medicine: they were strong people. My life is easy compared to everyone else before me, so why am I being dramatic or complaining? Having a diagnosed mental illness and receiving help leaves me, every day, feeling less than, as if I am in some way an embarrassment to my family and culture: a defective Black woman because stereotypically we are supposed to be strong and resilient. Even to this day these feelings make me resistant towards receiving help or admitting that help is needed, because I too want to be considered strong like my mom, grandmother, and great-great grandmothers. Also, because being a Black woman, we are praised a lot for our curves. How odd I am to partake in a disorder that stereotypically aspires toward the opposite body type.
What was your experience of entering treatment?
My first 10 min walking into treatment I panicked because I felt like an imposter. I told the Clinical Director “I don’t belong here, I’m Black”. Those were some of the first words I uttered. I’m sure she said some consoling words that I have completely zoned out and no longer recall, but I do remember her saying I have a dietitian and therapist that will be good for you. Not realizing what she was referring to I later got to see what she meant. I got assigned two Black females as my new dietitian and therapist. Still feeling like I didn’t belong most times, I looked forward to letting down my guard during my hour sessions with them. When they would lead groups, I would feel more comfortable in sharing my opinions. Even during meals I felt a little less alone if they were at my table. Just relating to random subjects made me feel a little more at home and less like I was in a lifetime movie were I was cast as the token Black patient. I don’t think I would have made the progress I did if I wasn’t constantly placed with women that I could relate to each time. That’s even includes the nurses and MHWs, just having random conversations during downtime with people that related to my background or culture made treatment much more tolerable.
What has been your experience of being a woman of color and struggling with an Eating Disorder? What do you want treatment providers to know?
I feel constantly like I’m defective, as if I should be returned back to sender: I never have a sense of belonging. I don’t have many friends because I can’t confide in them without feeling judged, misunderstood, or not taken seriously. I constantly get comments such as, “You don’t look like you have an eating disorder,” when I tell people. Most times I assume it’s a weight oriented comment, but sometimes I wonder if it’s also because my melanin doesn’t equate as someone struggling with an eating disorder. It leaves me constantly feeling like I have something to prove, not only to everyone else, but to myself. I constantly question my own reality, as if I may be living a lie, and I’m interpreting it all to mean that I in fact do not have a problem. Constantly, my inner self tells me to just stop faking: there is absolutely nothing wrong with you. When I look in the mirror and analyze myself the conclusion is almost always that I don’t have a problem. I look healthy, and look at me I’m Black, I can’t have a problem… I don’t have a problem. But I do…
The Therapist Perspective:
As a woman of color and treatment professional, what is important for you to keep in mind/understand while working with other people of color?
I have found that human nature leads us to look for both similarities and differences in one another. In my experience this is something that tends to come up often in therapeutic relationships. While noting these similarities and differences is completely normal and can be useful, it can also lead to an array of presumptions on the part of the therapist. I have found that it is incredibly important to be self-aware and conscious of your own biases that may impact how you relate with another.
It is also incumbent upon me to acknowledge my privileges and to be transparent with my clients about them. A common experience I have had as a therapist is clients making the assumption that because I am female, or because I am brown, I know or can understand their experience in the world as a woman or a person of color.
As a woman of color, I have experienced racism, discrimination, and sexism. But I am also aware that while I have experienced racism, I have not experienced the racism others have faced. While I have experienced sexism and discrimination, I do not know how others have experienced them. As a therapist an essential part of our job is to be curious, and to allow for the stories of our client’s to be heard, validated, and not minimized by our own experiences and the ways in which we may assume someone has felt because we have felt those ways in similar situations. I think it can be easy as a therapist to utilize similarities to establish a connection in way that may not be fully authentic. While connection can definitely be nurtured through finding similarities, the acknowledgement of a client’s differences and rejected pieces of themselves is where growth and connection can really begin.
What are some factors important to consider in providing culturally competent treatment for eating disorders?
Eating disorders don’t fit in just one box, and as therapists it is incredibly important that we continue to educate and break down stereotypes about the kinds of people who have eating disorders. Sometimes we do this through community outreach, or directly to our patients or to their support people. We must remember that the relationship our patients have with food and their behaviors can stem from many things including their cultural experience, and that a lot of shame is tied into not fitting in to one’s cultural norm. We must respect who our patients are and where they come from without unconsciously trying to get them to ascribe to our cultural norm. The one word that comes to mind when I think of providing cultural competent treatment is “intentional”. One must be intentional throughout their work with a client as well as the work within themselves.
In what way could a therapist’s racial or ethnic difference impact assessment, treatment and therapeutic goals of minorities with EDs?
A lack of awareness of one’s own racial or ethnic differences or that of others can have significant and meaningful implications when providing treatment to minorities with eating disorders. This is something that can definitely present itself when working with families as well. The various ways in which members engage with one another across different families can be very different from what a therapist has experienced with their own family. Ethnic differences often present themselves in this context, and a lack of understanding and curiosity can lead to misdiagnosis and inaccurate assessments, which in turn can lead to treatment goals with which a client might not resonate. A therapist may also unconsciously place expectations on clients based on their own experiences if the therapist feels as though they “know” or can connect with the patient to having racial or ethnic similarities.
What are some of the barriers to treatment that might affect someone from a marginalized group of which it would be important for all therapists to be cognizant?
I often find myself living in a bubble of “therapy is great, everyone benefits from it!”. Yet many people coming from marginalized groups are also coming from communities where therapy is believed to be for the weak, a betrayal of family, and unnecessary. As a therapist we must always be conscious of the immense bravery it can take for someone to seek out care. At times it means that someone has left their community, their “safe place,” in order to seek out healing which can mean losing integral parts of their support systems. Treatment may also not be as easily accessible for certain clients whether it be geographical, financial, etc. Being immersed in the world of therapy/treatment can lead to forgetfulness regarding how difficult it can be for some of our patients to seek help and the lack of support they may have outside of the treatment bubble.
Why might it be important for there to be increased diversity among professionals in the treatment of eating disorders?
I imagine anybody from a marginalized group can think of a time in which they have felt that they are “odd one out” or “the only one”. Diversity among professionals can reduce that experience of “being the only one, the odd one out”. Increased diversity among professionals in the treatment of eating disorders is vital in creating a space that is accepting, welcoming, and empowering for all. I can recall various conversations I have had with patients regarding their life experiences and the issues that come up surrounding issues of diversity, including feeling “less than,” and having experiences where authority figures, therapists, doctors, dietitians, teachers, even friends etc. were primarily White. Coming into treatment and fully engaging in that treatment requires a tremendous amount of vulnerability, so imagine meeting your treatment team and realizing that “you” might not represented. Diversity in all its meanings creates room for conversation, for curiosity, and for learning. As clinicians we often ask our patients to dig deeper, to look at all their different parts, I think this holds true for what we can bring to the table as a treatment team, taking a look at all our different parts, how they represented and how they can deeply impact our clients.
This post is part of the Marginalized Voices Campaign, a collaboration between the National Eating Disorders Association and Reasons Eating Disorder Center, which confronts prevailing myths about eating disorders and underscores that everyone’s experience is valid and deserves care and recovery.
About the authors:
Christina Ojeda, LMFT was born and raised in Southern California with strong connections to her Colombian heritage. She is aLicensed Marriage and Family Therapist and been working in the Eating Disorder field since 2011 in various roles,including primary therapist and program manager, and is passionate about her work. Christina loves traveling,horseback riding, and spending time with family.
Yari Hall is a 30-year-old African American woman. Born and raised in South Central Los Angeles California. She is a mother, sister, daughter and wife.