Applying Relational-Cultural Theory to Eating Disorder Treatment

Through the theoretical lens of RCT, we focus on ED treatment in two areas, prevention and individual treatment. RCT is well suited to addressing EDs because the therapeutic relationship in RCT focuses not only on collaboration and mutual empathy but also on authenticity in the relationship. In addition, it is helpful for deconstructing and addressing the disconnections that result from a client's relationship and sociocultural contexts. In this section, we address prevention and individual-level ED treatment.


Prevention efforts rely “most heavily on providing information to increase understanding, enhance attitudes, and promote functional behavior while attempting to minimize resistance” (Choate & Schwitzer, 2009, pp. 165- 166). The elements discussed in this section can be incorporated in ED prevention with an RCT focus and may benefit students and clients who are already experiencing problems but who have not yet developed EDs.

Cultural Psychoeducation

Although psychoeducation regarding ED can be an important component of prevention efforts, an RCT approach broadens the focus to the roles of gender, power, privilege, and oppression in development. Walker (2002) suggested that societal power involves those aspects of difference in social identities that the dominant culture values or devalues, including race, sex, gender, physical ability, spirituality, and class, among others (p. 2). According to the controlling image in current society, if a person is the right weight and body shape, relationships will be both possible and fulfilling. Unexamined, these harmful images can cause problems when people experience a cognitive dissonance between their real bodies and the idealized, unattainable, controlling images that the dominant society supports (Trepal et al., 2012, p. 350).

From an RCT prevention perspective, counselors can first talk with clients about their experiences with societal discrimination, exclusion, and trauma related to many aspects of the clients' physical characteristics, including body shape, size, weight, height, and skin color. They can also help them to begin the process of critiquing dominant cultural values and expanding the range of options that are available for clients to be true to their own values. Approaches such as media literacy (Levine & Piran, 2001; Levine, Piran, & Stoddard, 1999), in which students and clients become active and involved consumers of media, can be used to identify, evaluate, deconstruct, and resist images (for examples, see Choate & Curry, 2009).

Second, prevention programs need to aim at promoting positive body image while incorporating culturally relevant values and traditions. One such example is the Beloved Body Soul (2011) program promoting English, Spanish, and bilingual psychoeducation on womens body image. Similar curricula could be used in both community mental health and school counseling settings by including cultural values and traditions relevant to both majority and especially minority groups of men and women in the area of body acceptance. Group curricula can be tailored to member needs on the basis of multiple cultural dimensions, including ethnicity, sexual preference, spirituality, socioeconomic status, national origin, attractiveness, ableism, and body shape and size.

A third area of RCT prevention focus is to promote a counterdialogue for the current thinness-as-health cultural narrative. Along these lines, two emerging critical perspectives are the Health at Every Size (Bacon, 2010) and Fat Acceptance paradigms (National Association to Advance Fat Acceptance, 2012). Weight acceptance, focusing on health, not on appearance, is highly related to increased body satisfaction and decreased drive for thinness (which then decreases dieting, which lowers risk for EDs and obesity). Prevention efforts can focus on health and self-acceptance regardless of whether an individual meets a culturally imposed standard of thinness. As an example, school and mental health counselors can try activities such as having their students, clients, or groups experiment with remaining “fat-talk free” for a certain amount of time. In this activity, people are instructed to pay attention to the times (both internally and externally) when they participate in “fat talk” (e.g., commenting negatively on their own bodies or others' bodies, focusing on weight and size, vilifying certain foods relative to weight and size, and using physical activity related to weight and size). Often, students and clients will report that they are unable to engage in a fat-talk free way of life for long. This activity can promote fruitful discussion on the issue, including examining ways in which the culture promotes a thin ideal and dissatisfaction with real bodies.

Prevention Through Connection

Hartling (2004) asserted that prevention through connection is an important reframing of traditional prevention efforts that emphasize individualistic approaches. Prevention efforts for disorders such as substance abuse have focused on “teaching information or skills to increase an individuals ability to stand alone, think independently, be self-sufficient, and resist peer-pressure – that is, prevention through self-sufficiency, disconnection, or separation” (Hartling, 2004, p. 199). At times, this approach may be useful (e.g., disconnecting from substance-abusing peers). RCT prevention efforts focus less on individualized strategies and more on relational approaches. Thus, from an RCT perspective, effective prevention efforts must take multiple forms of connection into account, including connection to self, others, and the larger community. According to Trepal et al. (2012), building and strengthening community knowledge of and response to ED is a vital prevention component. Prevention through connection initiatives can include intervening at the individual, community (e.g., school, agency), and larger system (e.g., government) levels; all of these initiatives – to some extent – overlap and inform one other. Individual-level prevention programs should present tangible information for developing coping skills, de-stigmatizing mental health services, and maximizing the use of counseling services and related resources. (Trepal et al., 2012, p. 351).

Each of these avenues can contribute to a sense of community building around the topic of EDs. Thus, recognizing that enacting societal change on their own might be impossible, individuals are not expected to act alone (or suffer in silence) and can be encouraged to form connections with others around these issues.

In addition, groups can emphasize social support, which can be highly influential in helping people who have an ED make meaningful change. An example of a more individual-level, long-term prevention program that can be helpful is the Tri Delta Reflections: Body Image Program, a peer-led prevention program involved with sororities around the United States (see Chapter 11, this volume). Other prevention programs that highlight cultural psychoeducation, media literacy, and prevention through connection are Fat Talk Free (Tri Delta Sorority, 2011), an initiative to encourage women to deemphasize discussing weight and negative body talk and Celebrating Eating Disorders Awareness Week (National Eating Disorders Association, 2011), which focuses on EDs and body image issues prevention while reducing the stigma surrounding EDs and improving access to treatment.

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