Recommendations for Counselors

Conceptualization of Eating Disorders

Debate is ongoing as to the role of genetic and neurochemical factors versus sociocultural factors in the development and maintenance of EDs. The evidence we review in this chapter has clearly suggested that cultural definitions of ideal body shape, as conveyed and enforced by the media, parents, and peers, contribute to EDs in many cases. Pressure from these social forces facilitates the development of important risk factors for EDs, especially body dissatisfaction and thin-ideal internalization (e.g., Wertheim et al., 2009). Sociocultural factors have been directly linked to symptoms of EDs (e.g., dietary restriction, binge eating, or purging). The idea that this perfect body is attainable may also mesh with the need for control that is part of many EDs. However, personality characteristics (e.g., high negative affect or high need for approval) and neurochemistry, both of which may be genetically influenced, also likely increase vulnerability to these messages (Kaye, Fudge, & Paulus, 2009; Strober & Johnson, 2012). Trauma, which may alter neurochemistry, may also make people more vulnerable to social messages emphasizing self-control of one's body (Smolak, 2011).

Thus, EDs are likely best conceptualized as having biological, psychological, social, and cultural risk factors and components. Because this chapter is focused on the sociocultural risk factors, we limit our comments concerning treatment to those factors. First, clients should be encouraged to examine their assumptions about the normative nature of thinness (or, for men, muscularity). As part of this, they should examine the sources of those beliefs. People often underestimate the influence of the media and particularly the media's impact on them. The evidence concerning media effects is especially strong for body image dysfunction. Thus, body image issues should be clearly integrated into ED treatment, an integration that is actually fairly rare in the existing literature. Cognitive-behavioral approaches may then be useful to undermine the belief system that thinness (or muscularity) is important to success and self-worth (Jarry &Cash, 2011).

Second, given that the environment fosters body image and eating problems, changes in the sociocultural milieu may be useful in treating or preventing EDs. For example, women might be encouraged to make conscious choices about watching television shows that glorify thinness or to at least recognize the unrealistic, damaging messages these shows send. In addition, feminist theorists have often suggested that women actually challenge these messages, an exercise that facilitates a sense of control in addition to possibly removing or limiting some of the toxic messages (Smolak & Piran, in press).


Several assessment tools are available to evaluate exposure to and investment in media, parent, or peer factors. By far the most commonly used media measure is the Sociocultural Attitudes Toward Appearance Questionnaire (Thompson, van den Berg, Roehrig, Guarda, & Heinberg, 2004). Its Internalization subscale is particularly widely used to measure how much someone has adopted the media standards as their own. Internalization is a more critical variable in the development of disordered eating than is sheer exposure (Thompson & Stice, 2001). Versions of this scale are available for use with women, men, adolescents, and athletes. It is short, the questions are easy to answer, and it is widely available.

The McKnight Risk Factor Survey (Shisslak et al., 1999) has subscales for parents and peers as well as media influences. Stice's 10-question measure of sociocultural pressures focuses on peer and parent influence (Stice &

Bearman, 2001). A relatively new scale to measure parental modeling and direct comments separately is also available (Abraczinskas et al., 2012). The Perception of Teasing Scale (Thompson, Cattarin, Fowler, & Fisher, 1995) can be used to retrospectively assess a client's exposure to teasing. It also measures the respondent's reaction to these experiences. This measure may be helpful in identifying people whose body image and body self-esteem were shaped by negative peer and parent comments about weight and shape.

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