The Impact of Client Race on Clinician Detection of Eating Disorders

Transcription

1 Behavior Therapy 37 (2006) The Impact of Client Race on Clinician Detection of Eating Disorders Kathryn H. Gordon, Marissa M. Brattole, LaRicka R. Wingate, Thomas E. Joiner Jr. Florida State University Eating disorders are thought to occur less among African- American women than among women of other ethnic groups. Ninety-one clinicians read 1 of 3 passages (differing only with regards to the girl s race: African-American, Caucasian, or Hispanic) describing disturbed eating patterns of a fictional character named Mary. Participants were then asked to indicate if they thought Mary had a problem and to rate her anxiety, depression, and eating disorder symptoms based upon the passage they had read. The results suggest that clinicians may have race-based stereotypes about eating disorders that could impede their detection of symptoms in African-American girls. S OME STUDIES have found that levels of eating disorder symptoms are similar among ethnic minority women and Caucasian women (Abrams, Allen, & Gray, 1993; Gray, Ford, & Kelly, 1987; Jones, Fox, Babigan, & Hutton, 1980; Lester & Petrie, 1998). Yet, other studies have found that ethnic minority women have lower rates of eating disorders than Caucasian women (Gross & Rosen, 1988; Joiner & Kashubeck, 1996; Lachenmyer & Muni-Brandr, 1988; Perez & Joiner, 2003; Perez, Voelz, Pettit, & Joiner, 2002). While studies attempting to estimate eating disorder incidence among ethnic minority populations have yielded varied results, it is important to note that no study has found an absence of eating disorders among ethnic minority groups. Still, the stereotype that ethnic minority women are extremely unlikely to have eating disorders persists (Gordon, Perez, & Joiner, 2002). Stereotypes about eating disorders may have negative implications for certain ethnic minority groups. Address correspondence to Thomas Joiner, Department of Psychology, Florida State University, Tallahassee, FL , USA; joiner@psy.fsu.edu /06/ $1.00/ Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved. Clinicians may be less likely to adequately recognize eating disorder symptoms, make a diagnosis, and prescribe appropriate treatments. Caucasian women may be assumed to be more vulnerable to the development of eating disorders because of their desire to achieve American ideals of thinness. In contrast, minority (in particular, African- American) women are viewed as largely protected from eating disorders as a result of their culture s acceptance of larger body types. This distinction is supported by studies that ask participants to select a silhouette representing their culture s ideal body type (Gray et al., 1987; Joiner & Kashubeck, 1996; Perez & Joiner, 2003; Perez et al., 2002). Despite the differential cultural views of beauty, minority women are often exposed to the same American ideals of thinness as Caucasian women. Accordingly, minority women may adopt American standards of thinness. As they internalize mainstream American notions of thin as beautiful, minority women may become susceptible to body dissatisfaction and low selfesteem (Stice, Schupak-Neuberg, Shaw, & Stein, 1994), which have been consistently linked to eating disorders (Katzman & Wolchik, 1984; Vohs, Bardone, Joiner, Abramson, & Heatherton, 1999). Some researchers have suggested that the idea about eating disorders being restricted to Caucasian women might be due to the underrepresentation of ethnic minorities in clinical samples (Cachelin, Rebeck, Veisel, & Striegel-Moore, 2001). Recent studies that have attempted to uncover obstacles to treatment among ethnically diverse samples of women with eating disorders have not found significant differences between the help-seeking behaviors of Caucasian women and minority women (Becker, Franko, Speck, & Herzog, 2003; Cachelin et al., 2001). This suggests that barriers to treatment may lie in the differential behavior of clinicians toward minority groups rather than differential client behavior among minority groups. In fact, one study found that minority participants

2 320 gordon et al. were significantly less likely than Caucasians to be asked by a physician about eating disorder symptoms and were significantly less likely to be referred by clinicians for further treatment. Both of these findings were robust after controlling for client symptom severity (Becker et al., 2003). There may be some basis for beliefs about African-American women being buffered from eating disorders as compared to Caucasian women. Some research reveals that African-American women are less likely to diet (Akan & Grilo, 1995) and have more positive views of their bodies than Caucasian women (Abrams et al., 1993; Perez et al., 2002; Akan & Grilo, 1995). Relatively few studies have directly compared Hispanic, African- American, and Caucasian groups from the same population on eating disorder indices. One exception to this is a study that compared eating disorder symptom measures among the three ethnic groups in an undergraduate population and found that African-American women exhibited significantly fewer bulimic symptoms and reported lower levels of body dissatisfaction than Caucasian and Hispanic women (Perez et al., 2002). Collectively, these studies indicate that it is possible that ideas about African-American women s relative invulnerability to eating disorders may stem from actual cultural differences. Still, it is clear that eating disorder symptoms do exist among some African-American women (Abrams et al., 1993; Gray et al., 1987; Gross & Rosen, 1988; Jones et al., 1980; Lachenmyer & Muni-Brandr, 1998; Lester & Petrie, 1998; Perez & Joiner, 2003; Perez et al., 2002). The first experimental study that examined racial stereotypes about eating disorders involved the distribution to an undergraduate sample of a passage about a fictitious adolescent girl named Mary who exhibited eating disorder symptoms (e.g., skipping meals). Participants received one of three passages that differed only with regard to the girl s identified race. The results indicated that participants were significantly less likely to recognize an eating disorder syndrome when Mary was identified as a minority than when Mary was identified as Caucasian (Gordon et al., 2002). That is, when participants were asked if they thought Mary had a problem, they were more likely to respond no if she was portrayed as a minority than when she was portrayed as Caucasian. Interestingly, this occurred despite the fact that there were no statistical differences on measures of individual eating disorder symptoms (i.e., the Drive for Thinness from the Eating Disorder Inventory [EDI]; Garner, 1991). Therefore, it seemed that participants recognized that Mary exhibited eating disorder symptoms, but were less likely to consider it an eating disorder syndrome when they thought that she was an ethnic minority. The aim of the current study was to replicate Gordon et al. s (2002) study in a sample of mental health practitioners. To our knowledge, no experimental study focusing on clinician bias about eating disorders in ethnic minority clients has been conducted in the past. It was predicted that clinicians would be less likely to recognize eating problems in a passage about an African-American girl than a passage about a Caucasian or Hispanic girl, perhaps because of racial stereotypes about who is affected by eating disorders. Similarly, it was predicted that clinicians would rate an African- American girl as having less severe eating disorder symptoms than a Caucasian or Hispanic girl. We also evaluated whether Mary s race would have effects on clinician appraisal of anxiety or depression (cf. Hartman, 2002). Finally, we predicted that clinicians would be more likely to recommend mental health treatment for Mary when she was identified as Caucasian or Hispanic than when she was identified as African American. Method participants The participants were 22 clinical psychology graduate students and 69 trained clinicians with mental health graduate degrees (n=91). The majority of participants held either a master s (37.1%) or doctoral (39.3%) degree. Years of experience ranged from 0 to 43 (M=7.12, SD=8.30). Regarding participant ethnicity, the sample was 89.0% Caucasian (n = 81), 4.4% Hispanic (n = 4), 2.2% African American (n=2), 3.3% other (n=3), and 1.1% did not identify their ethnicity (n=1). In terms of clinician orientation, 58.2% identified themselves as cognitive-behavioral (n = 57); 12.2% as eclectic (n=12); 5.1% as psychodynamic (n=5); 5% as cognitive (n=5); 4% as other (n=4); 3.1% as interpersonal (n=3); 2% as behavioral (n=2); and 1% as humanistic (n=1). procedure Participants were ed a letter requesting participation in the study along with an attachment including a consent form, a passage with a brief demographic profile (Caucasian, Hispanic, or African-American 16-year-old female), and questionnaires. The passage included a concise description of daily information about Mary s school-related activities and eating habits. The African-American version of this passage can be viewed in the Appendix. Participants were asked to their consent forms and responses to the

3 racial bias, eating disorder recognition 321 experimenters. They were assured that their responses to the questionnaires would remain anonymous. It was not possible to track response rates because s went to listserves (Division 12 of the American Psychological Association, Society for a Scientific Clinical Psychology, and to various Directors of Clinical Psychology Training), a key limitation to this study. One of three versions of the passage about Mary (differing only with regard to her race) was randomly distributed among the participants through . Eighteen participants read the passage about Caucasian Mary, 37 participants read the passage about Hispanic Mary, and 36 participants read the passage about African-American Mary. After reading the passage, participants were asked the open-ended question, Do you think Mary has any problems and, if so, what are they? They were then asked to complete the EDI (Garner, 1991) as they believed Mary would fill out the form. The EDI consists of 64 questions about eating attitudes and behaviors. The participants were asked to rate symptoms on a scale from 1 to 6 (1 = never, 2 = rarely, 3 = sometimes, 4 = frequently, 5=usually, 6=always). The EDI yields eight subscale scores: Drive for Thinness, Perfectionism, Bulimia, Body Dissatisfaction, Ineffectiveness, Interpersonal Distrust, Interoceptive Awareness, and Maturity Fears. We focused on the Drive for Thinness subscale (alpha coefficient = 0.86) in this study because it best captures the symptoms that Mary exhibits in the passage. Next, the participants filled out the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) as they believed Mary would fill it out. The BDI-II is composed of 21 questions about various depression symptoms. Participants were asked to read a series of statements for each item, varying in severity from 0 to 3. They were instructed to endorse the statement that best represented Mary s feelings about herself and her future. Alpha coefficient for the BDI-II in this sample was Then, participants were asked to complete a Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988), which consists of 21 cognitive and physiological symptoms related to anxiety. The participants were instructed to indicate the degree to which the anxiety symptoms affected Mary on a scale from 0 to 3 (0=not at all,1=mildly,2=moderately, 3=severely). Alpha coefficient for the BAI in this sample was To reiterate, participants were instructed to respond to questionnaires as they believed Mary would. Finally, participants were asked, What should be done to help Mary? in order to evaluate whether Mary s race had an effect on clinician referral decisions. The participants were asked to choose one of the following: nothing is wrong with her, she should talk to a friend, family, or clergy member, or she should seek mental health treatment. We predicted that participants would recommend that Mary seek mental health treatment less often when she was identified as African- American than when she was identified as Caucasian or Hispanic. Results preliminary analyses Clinician experience (median-split) did not have a significant effect on questionnaire ratings (EDI, BDI-II, and BAI, respectively; F=0.01, df=1, 80, p=0.94; F=0.27, df=1,84, p=0.61; F=0.48, df=1, 83, p = 0.49) or treatment recommendations (chisquare = 1.50, df =1, p = 0.22). Similarly, clinician orientation (cognitive-behavioral, cognitive, and behavioral versus others) did not have a significant effect on ratings (EDI, BDI-II, and BAI, respectively; F=0.66, df=1, 81, p=0.42; F=0.13, df=1, 85, p= 0.72; F=3.09, df=1, 83, p=0.08) or treatment recommendations (chi-square = 1.06, df = 1, p = 0.30). Clinician s educational degree (i.e., bachelor s vs. master s vs. doctorate) also did not have a significant effect on ratings (EDI, BDI-II, and BAI, respectively; F = 0.96, df = 1,81, p = 0.43; F = 1.48, df=1, 85, p=0.21; F=1.55, df=1, 83, p=0.20). Thus, these variables are not considered further. relationship between mary s race and clinician recognition of eating problems Chi-square analyses were run on the responses to the open-ended question following the passage: Do you think Mary has any problems and, if so, what are they? The participants answers were coded into a dichotomous variable, depending on whether participants recognized Mary s disturbed eating patterns (yes vs. no). The results indicated that Mary s race influenced clinician response to this question. When Mary was Caucasian, 44.4% of the participants recognized the symptoms. Similarly, when Mary was identified as Hispanic, 40.5% of the participants recognized that she had an eating problem. In contrast, only 16.7% of the participants stated that Mary had an eating problem when she was identified as African American (v 2 =6.42, df=2, p=.04). Three one-way analyses of variance (ANOVA) were then performed on the EDI Drive for Thinness scale, BDI-II, and BAI scores, with Mary s race as the independent variable. A Bonferroni correction was

4 322 gordon et al. used to correct for inflation due to Type I error. That is, the p-value was required to be less than.02 in order to be considered statistically significant. Despite the fact that Mary s race appeared to influence detection of a global eating syndrome, her race did not appear to influence clinician ratings on the EDI Drive for Thinness scale. The analysis yielded results that were not statistically significant (F =2.34, df = 2, 84, p =.12). Regardless of Mary s race, participants assigned her relatively high scores (overall mean was 28.55, SD=4.63; usual mean score in late adolescent women on this subscale is approximately 21). Thus, participants appeared to have attended to Mary s specific eating symptoms (as evidenced by EDI ratings) regardless of her race. This stands in contrast to participants global views about whether Mary displayed an eating disorder syndrome, which appears to have been influenced by Mary s race. Specifically, when Mary was identified as African American, clinicians were significantly less likely to say that she had eating problems than when she was portrayed as Caucasian or Hispanic. Similarly, the BAI (F=2.52, df=2,76, p=0.09) and BDI-II (F=2.95, df=2,80, p=0.06) ratings did not differ significantly by Mary s race. Once again, we note that the participants were filling out the questionnaires as they thought Mary would rather than rating their own eating disorder, depression, and anxiety symptoms. Finally, in order to determine whether Mary s race had an effect on clinician referral decisions, we evaluated responses to the question, What should be done to help Mary? The participants were asked to choose one of the following: Nothing is wrong with her, She should talk to a friend, family, or clergy member, or She should seek mental health treatment. We predicted that participants would recommend that Mary seek mental health treatment less often when she was identified as African American than when she was identified as Caucasian or Hispanic. Unfortunately, a chi-square test could not be used for this analysis because the cell sizes were too small. However, it appears that clinicians were more likely to suggest that Mary did not need to seek any form of help when she was portrayed as African American (16.7%, 6 of 36) than when she was portrayed as Caucasian (5.6%, 1 of 18) or Hispanic (0.0%, 0 of 37). Discussion The aim of the current study was to evaluate whether race-based stereotypes affect clinician ability to recognize eating disorder symptoms in African-American girls. Consistent with previous work (Gordon et al., 2002), our findings suggest that race-related bias about eating disorder patients may exist among some mental health practitioners. Clinicians tended to recognize an eating disorder syndrome in Mary when she was portrayed as Caucasian or Hispanic at higher rates than when she was portrayed as African American. Interestingly, clinician ratings of individual eating disorder symptoms did not appear to be affected by race. Therefore, it appears that the clinicians were recognizing that Mary had individual eating symptoms but were less likely to conceptualize them as an eating disorder syndrome when she was portrayed as African American. Clinician ratings of anxiety and depression symptom ratings indicated no main effect of Mary s race on BAI or BDI-II ratings. Finally, clinicians were less likely to refer Mary for help if she was portrayed as African American than if she was portrayed as Caucasian or Hispanic. The findings suggest that clinicians may recognize eating disorder syndromes to a lesser degree in African-American girls than Caucasian or Hispanic girls, perhaps due to racial stereotypes about African-Americans being relatively invulnerable to eating disorders. It could be argued that racial stereotypes about eating disorders reflect actual cultural differences, in which African American women have lower rates of eating disorders and related symptoms (Abrams et al., 1993; Akan & Grilo, 1995; Gray et al., 1987; Gross & Rosen, 1988; Jones et al., 1980; Lachenmyer & Muni- Brandr, 1988; Lester & Petrie, 1998; Perez & Joiner, 2003; Perez et al., 2002). However, no study has found a total absence of eating disorder symptoms in African-American women, and the current study concerns a girl who is exhibiting eating disorder symptoms. Therefore, when symptoms are present, clinicians may underestimate the severity of an eating problem in an African-American patient. Relatedly, previous studies have been unable to identify differential treatment-seeking behaviors by ethnic minority women as compared to Caucasian women (Becker et al., 2003; Cachelin et al., 2001), yet clinicians are significantly less likely to ask minority patients about eating disorder symptoms and to make a referral for further treatment, even after controlling for client symptom severity (Becker et al., 2003). In the current study, an experimental design was utilized to test the effect of Mary sraceon clinician assessment, with the ability to completely control for symptom severity. That is, the symptoms were identical for each patient assessed; the only difference was the identified race of Mary. The results indicate that Mary s race, despite identical symptom presentation, appeared to have a main effect on clinician assessment, such that Hispanic and Caucasian girls were more likely to be labeled by clinicians

5 racial bias, eating disorder recognition 323 as having an eating disorder syndrome than African- American girls. Furthermore, it appears that African- American girls were less likely to be recommended to seek help for problems. The current findings, along with previous research (Becker et al., 2003; Cachelin et al., 2001), suggest that clinicians may underestimate the severity of eating disorder symptoms in African-American patients. There are several important limitations that must be highlighted in the current study. First of all, the majority of the clinician participants (89%) were Caucasian. Future research would benefit from more ethnically diverse samples of clinicians. However, the previous study in an undergraduate sample found no effect for participant race on the recognition of eating disorder symptoms (Gordon et al., 2002). Secondly, the sample was recruited through various listserves, and clinicians decided whether or not they wanted to participate. Because random selection could not be assured, there may have been a selection bias. This may be of particular concern since twice as many clinicians participated in the African-American and Hispanic Mary conditions as the Caucasian Mary condition. Those who participated could be systematically different in some way from those who declined to participate in the study. However, it seems unlikely that this would explain away the results, because the clinicians were from a variety of orientations, levels of experience, and specialty areas. Future studies in the area should take measures to reduce the possibility of such a selection bias. Finally, the racial bias was inferred from clinician detection of an eating problem. One plausible alternative explanation for the results is that clinicians are familiar with the research that suggests that there are lower rates of eating disorders among African-American girls. They may have appropriately used base rate information in making their diagnostic decisions. Future studies would benefit from the inclusion of a measure used to specifically tap racial stereotypes about eating disorders to rule out this alternative explanation. To our knowledge, there is no existing measure designed to tap this construct, but one could perhaps be developed that asks people about their beliefs about certain ethnic groups and rates of eating disorders. Although no previous research, to our knowledge, has systematically examined the potential underdiagnosis of eating disorders in African-American populations, previous research has found a tendency for clinicians to overdiagnose African Americans with schizophrenia as compared to Caucasian patients (Neighbors, Jackson, Campbell, & Williams, 1989; Strakowski et al., 1996a; Strakowski, McElroy, Keck, & West, 1996b6; Worthington, 1992). The cause of this phenomenon is unknown, but two hypotheses are (a) differential case presentations of disorders among ethnic minority groups (the cultural relativity hypothesis; Whaley, 1997), and (b) racial stereotypes that impede clinician detection of psychiatric disorders (the clinician bias hypothesis; Whaley, 1997). The current study supports the clinician bias hypothesis with regard to eating disorders. However, there is also some support for the cultural relativity hypothesis from a study that found that binge eating disorder tends to have a differential presentation in African-American women as compared to Caucasian women. Interestingly, in this study, African Americans and Caucasians diagnosed with binge eating disorder were equally likely to receive treatment for a weight problem, yet Caucasian women were significantly more likely than African-American women to receive treatment for a disordered eating problem (Pike, Dohm, Striegel-Moore, Wilfley, & Fairburn, 2001). In summary, speculations about the obstacles that might hinder African-American women from access to proper treatment for eating disorders include differential access to health care (Becker et al., 2003; Cachelin et al., 2001), biased clinician assessment (Becker et al., 2003; Whaley, 1997), and differential cultural presentations of psychiatric disorders (Pike et al., 2001; Whaley, 1997). The goal of this study was to investigate the presence of possible race-based stereotypes among clinicians in their assessment of eating disorder patients. Given our findings along with those of other researchers (Becker et al., 2003; Cachelin et al., 2001; Gordon et al., 2002), it is suggested that efforts be made to educate clinicians about the possible existence of such biases. In addition, clinician training may benefit from a focus on disambiguating clinical symptom profiles from demographic data. Bias in clinical judgment has long been recognized as a potential problem in the course of treatment for mental disorders (Meehl, 1954). Calling attention to the potential danger of stereotypes in the treatment of particular patient populations may be a step toward resolving such problems. Appendix A. Please read the following passage, and then answer the questions according to the instructions mary, 16-year-old african-american Monday: She woke up and took a shower. Mary tried on three different outfits before choosing what she was going to wear. Did her hair twice before leaving to school. For breakfast, she had a banana. Mary went to

6 324 gordon et al. school. During lunch she ate three rice cakes and had apple juice. After school, Mary had soccer practice for 2 hours and then went home. When she got home she took a shower. She next did her homework. For dinner Mary ate salad and a baked potato. She watched TV for 2 hours and then went to bed. Tuesday: She woke up and took a shower. Mary tried on several different shirts before choosing which one she was going to wear. She spent half an hour curling her hair. She didn t have time for breakfast so drank some orange juice. Mary went to school. During lunch she ate some pretzels, soda, and a pear. After school, Mary had soccer practice for 2 hours, and a 1-hour meeting for Key Club. When she got home, she drank some water and took a shower. She next did her homework. For dinner, Mary ate a small bowl of vegetable soup with crackers and drank a diet soda. She studied for a test for 2 hours, picked out her clothes for the next day for half an hour, and then went to bed. Wednesday: She woke up and took a shower and got dressed. Did her hair for 20 minutes. She had a piece of toast and some apple juice for breakfast. Mary had a test in the morning for which she felt she did poorly on and was upset. Instead of eating lunch, she did her homework. After school, Mary had soccer practice for 2 hours and then went home. When she got home she drank some diet soda. She then took a shower and watched TV. For dinner, Mary ate some crackers, a salad, and drank some water. Mary watched TV for 2 hours, talked on the phone for 1 hour and a half, and then went to bed. Thursday: She woke up and took a shower. She took 1 hour to get dressed and did her hair for 20 minutes. For breakfast, she ate an apple. She went to school. For lunch, she had a granola bar, an orange, and some skim milk. She gave a 2-minute presentation in an afternoon class. After school she had soccer practice for 2 hours and then went home. When she got home she didn t eat anything and just took a shower. She talked on the phone for 2 hours and watched some TV. For dinner, Mary drank some water and had a bag of chips. She then watched TV and had some raisins before going to bed. Friday: She woke up and took a shower. She took half an hour to get dressed and just brushed her hair. For breakfast she had a grapefruit. She went to school and found out she did poorly on the test she took on Wednesday and was upset. During lunch she ate an egg salad and some grape juice. After school, Mary had soccer practice for 2 hours and then went home. She went home and took a shower. She watched TV. For dinner she ate some black beans and rice with water. She then went to the movies with her friends. References Abrams, K. K., Allen, L., & Gray, J. J. (1993). 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