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Creative Therapies And Eating Disorders - Introduction

Eating Disorders across the World

Stephanie L. Brooke, PhD, NCC
“Was macht mir umbricht, macht mir starker” Nietze


                Although thought of as typically a women’s disease, eating disorders affect men and women alike as they emerge into culture and society.  Research from the course of the latter half of the 20th Century indicate that eating disorders exist in many corners of the world, even those thought to be protected from such disorders (Nasser, et al., 2001). Why is there an obsession with food across cultures? Why is there an epidemic of suffering among people at a moment when men and women are reaching out to find place for themselves in society?  Some view eating disorders as a inherent struggle with identity (Chernin, 1985). The purpose of this chapter will be to take a look at the research of eating disorders in countries across the world.

                Widely considered a western phenomena, eating disorders are also pervasive in Eastern cultures and appeared in their literature in the 1970s (Soh, Touyz, & Surgenor, 2006). In fact, eating disorders were thought to be rare in non western cultures. However, as far back as the 17th century, eating disorders have been recognized as a problem. For instance, in Japan, the word, fushokubyo or non eating illness was described in Kagaywa in the 17th -18th ceturies (Soh, Touyz, & Surgenor, 2006). Most of the people were women and the illness was though to be psychological in origin.
                Many cross cultural studies will look at ethnicity in relation to the development of eating disorders. Specifically, it is thought that the more acculturated the person, the more likely he or she will develop an eating disorder (Al-Subaic, 2000; Furkawa, 2002). The results in the literature have been quite mixed on this line of thought:

Thus exposure to Western culture is not irrefutably associated with eating disturbances, nor with body image issues and their associated desire for slimness which are commonly appearing variables in etiological models of eating disorders. However, interpretation of the results is hampered as many cross-cultural studies only take ethnicity into account and do not quantitate the degree of acculturation into Western society or the level of retention of traditional values. (Soh, Touyz, & Surgenor, 2006, p. 57)

Culture itself is a complex term referring to language, beliefs, myths, customs and symbols associated with a culture. “The experience and exposure to the difference between two cultures, rather than a particular culture itself, is also hypothesized to contribute to the etiology of eating and body image disturbances” (Soh, Tyouyz, & Surgenor, 2006, p. 58). A class between the traditional culture and the adopted culture may cause a disruption in eating and body disturbance.


                One study used a survey method to establish levels of eating disorders in Black and White female students is South Africa. Young Black females that showed high risk for developing or having an eating disorder were interviewed. Although thought to be a problem of Caucasian South Africans, the survey found that Black girls were as likely as White girls to have eating disorders. The girls ranged in age from 15 -25. In some cases, this was also true of males. As apposed to self-starvation, the common disorder found among Black South Africans was bulimia nervosa. The incidence of eating disorders in young girls from other African countries was rarely reported. The authors mentioned the problems with surveys followed up by interviews. “Relying on self-report measure alone will provide an indication of eating disorder pathology, but not a eating disorder diagnosis” (LeGrange, et al., 2004, p. 440). Therefore, the authors recommend a two stage screening process – surveys followed by interviews.  Out of the rapid socio cultural change in South African, there has been a rise in eating disorders in Black youth. LeGrance and colleagues (2004) found significantly greater eating disorder pathology in Black high school students than their white or mixed race counterparts in South Africa. LeGrange and colleagues postulate several reasons for this emergence of eating disorders. First, the rapid socio-political changes in South Africa have challenged the traditional gender roles leaving Black women unprepared for the new role and thus vulnerable to developing an eating disorder. Second, with the abolition of Apartheid in 1994, there is increased exposure to the Western culture. This has caused a shift from collectivism to individualism.

Australia and Hong Kong

                Sheffield and colleagues (2005) conducted a cross cultural study to test the validity of a biopsychosocial mediation model that hypothesized a variety of biological, psychological, and social variables would have an impact on eating disturbance through the mediation of body image dissatisfaction. Hong Kong has shown a considerable rise in eating disorders. “While Chinese people have traditionally emphasized that attractiveness is based on the beauty of facial features rather than body shape, recent research has shown that young Chinese women in Hong Kong share the same ideal of slimness as Caucasian women in western societies, although relatively few engage in serious deiting” (Sheffield, Tse, & Sofronoff, 2005, p. 114). One hundred Australian females, ranging in age from 17-28, and 48 women from Hong Kong were examined. Although no significant differences were found between the groups of women in levels of body dissatisfaction and eating disturbance, different variables in the biopsychosoical model predicted their risk of developing eating disorders. The researchers found important cultural differences in aspects of dieting and body images between the two groups. For Australian women, body dissatisfaction directly influenced and mediated the effects of self-esteem. For Hong Kong women, body dissatisfaction was no longer a significant predictor of eating disturbance, while self esteem had a direct effect on eating disturbance. “The results indicate that risk factors contributing to body dissatisfaction and eating disturbance are not the same for Australian and Hong Kong women, signifying that cultural differences appear to exist in the prediction of eating disorder symptomotology” (Sheffield, Tse, & Sofronoff, 2005, p. 120).


                A study of 301 Chinese immigrants in New Zealand examined eating disorder symptomotology using the Eating Disorder Inventory (EDI), the Positive and Negative Perfectionism Scale (PANPS), the Multigroup Ethnic Identity Method (MEIM), and the short form of the Marlow-Crown Social Desirability Scale (MCSDS) (Chan & Owens, 2006). As measured by the EDI, negative perfectionism (e.g. drive for thinness, bulimia, and body dissatisfaction) significantly predicted more eating disorder symptoms. Positive perfectionism was associated with some psychological correlates of disordered eating through some components of acculturation and ethnic identity. “The relationship between Negative Perfectionism and disordered eating may be partly explained in the context of Chinese culture, in conjunction with the influence of Confucian heritage. The Confucian emphasis, on social norms and behaviors, should be modeled with reference to ideal types to avoid shame” (Chan & Owens, 2006, p. 60). When immigrating to another country, Chinese women may want to save face by escaping disapproval and avoiding shame, thus eating disorders may develop. There were limitations to this study. The population of New Zealand is diverse making the question of acculturation to the dominant culture complex. The authors admit that the population sample may represent more traditional Chinese values as opposed to those who were acculturated. The study did find some avenues for preventing eating disorders in an at risk Chinese population.


                “As the first non-Western nation in contemporary history to become a major industrialized economic power, Japan is central to the debate on cultural relativism in psychiatric nosologies, and the study of eating disorders in Japan contributes to the complex discussion of the impact of culture and history on the experience, diagnosis, and treatments of such disorders” (Pike & Borovoy, 2004, p. 493). The authors contribute the rise in eating disorders in Japan to increasing industrialization, urbanization, and the breakdown in traditional family forms following World War II. Pike and Borovoy (2004) used a case approach to examine the etiology of eating disorders in Japanese women. Their work analyzed the cultural factors associated with the rise of eating disorders in Japan: (1) dominant cultural expectations for young women in contemporary Japan and models of marriage, gender, and adulthood; (2) cultural dimension of society beauty ideals specifically with respect to weight and shape. Beginning in the 1970, case reports of eating disorders in Japan emerged in the literature. Through the 1980s, documented cases began to grow, increasing two fold from the previous decade. In the 1990s, it increased four fold. “The data from the most recent studies indicate that the number of Japanese women pursuing the thin ideal is still increasing, and such weight data may be intimately linked with increases in eating disorders as well” (Pike & Bovoroy, p. 497).

Germany and Japan

                Kusano-Schwartz and von Wietersheim (2005) compared data for women with bulimia nervosa and to a healthy control group for both Germany and Japan. They used the Eating Disorder Inventory (EDI-2). Interestingly, the Japanese control group showed significantly higher values on nearly all EDI scales as compared to the German control group. Comparing the German and Japanese bulimia nervosa patience, Kusano-Schwartz and Wietersheim (2005) found that Japanese women showed higher scores on three EDI scales compared to the German group but these results were negligible. The authors concluded that sociocultural factors, specifically, the dependence on social norms, may have contributed to the high EDI values in Japanese women. In German culture, society values independence, self-assertion, self-confidence, and individuality. Whereas in Japanese culture, attentiveness, modesty, and respect toward other people are important values. Both societies may deal differently with the value of slimness. The study did have weaknesses such as the lack of matching samples and the fact that the EDI Japanese version was not validated.


                In a non urban area, Michoacan, Mexico, Bojorquez and Unikel (2004) found a dangerously high incidence of eating disorders among teenage girls. Using a sample of 458 girls, 27.9% were seriously concerned about weighing too much, 14.3% were dieting or fasting to lose weight, and 2.4% binged and vomited. This was significantly higher than a representative group of Mexico City girls. They propose that culture is a important risk factor in the development of eating disorders. “The ED/culture relationship could be better understood if we stopped using the concept of culture in its vaguest sense in favour of a more precise definition. The use of analytical tools such as concepts of ideology, gender construction and gender demonstration would allow a more useful vision of the relation between cultural values and individual practices” (Boroquez & Unikel, 2004, p. 2001).


                “As more eating disorder cases are identified around the globe, certain identifiable risk factors (e.g. female gender) and social conditions (industrialization, democratization, and rapid social change) appear to be common denominators in setting the stage for the development of eating disorders (Pike & Borovoy, 2004, p. 4949). Psychological, developmental, and biological individual differences interact with cultural dimensions to account for the reason why people develop eating disorders. This chapter is by no means a comprehensive view of all cultures but is meant to give a glimpse of cultural issues and eating disorders around the world.

                This book will take a look at the use of the creative therapies as a possible treatment option for working with clients who are diagnosed with eating disorders.  For instance, art therapy with people with eating disturbance reveals body image disturbance, depression, and obsessive compulsive features in the art work (Acharya, Wood, & Robinson, 1995). Chapters two through five cover art therapy.

                Using a case approach, play therapy has been used to treat very young children with eating problems (Honjo, et al., 2005). Chapter 6 covers play therapy and discusses sandtray work.  Chapter 7 provides an overview of play therapy techniques with children who have been diagnosed with eating disorders.

                Cognitive behavioral music therapy as been used in a women’s residential treatment facility for eating disorders (Hillard, 2001). “Quite often, primary therapists reported that patients retold incidents of when music therapy assisted them through a crisis helped them challenge cognitive distortions, and gain insight (Hillard, 2001, p. 112). Chapters 8 through 10 cover music therapy. In addition, Chapter 10 discusses the use of poetry therapy in treating eating disorders. Woodall (1983) found that poetry therapy produced significant change in anorexic patients.

Drama therapy has been used in the treatment of eating disorders (Jacobse, 1995).

By setting less rigid boundaries, the anorexia nervous patient will extend her role repertoire. By setting clearer boundaries, the bulimia nervosa patient will learn to avoid melting into her role, the scenery or other actors. The contrasts in particular between the two patient groups, mean that the two groups have a lot to offer to and learn from each other. (Jacobse, 1995, p. 142)

Callahan (1989) used psychodrama in the treatment of bulimia. “I have found psychodrama techniques to be highly effective for many bulimic clients, in particular, helping people in their efforts to overcome blocks to emotional experience and to gain access to hidden parts of the self” (Callahan, 1989, p. 106). Chapters 11-14 cover drama therapy.

                “The symptoms of eating disorders serve to disconnect affect from the body, particularly as sexuality, trauma, and cultural influences contribute to conflict in the woman’s developmental struggle for self-identity” (Krantz, 1999). Krantz used dance therapy to help eating disordered clients reconnect the body with feelings, to recognize meaning in behavior, and to develop psychophysical unity. Chapters 13 and 14 combine drama and movement therapy for treating eating disorders.

                Chapter 15 is a unique work focusing on the use of spirituality as a creative modality for treating eating disorders. Chapter 16 covers supervision issues and the Therapeutic Spiral Model. And last, Chapter 17 discusses ethical considerations when using the creative therapies to treat people with eating disturbances.

Appendix - Terms

Acculturation - The modification of the culture of a group or individual as a result of contact with a different culture. The process by which the culture of a particular society is instilled in a human from infancy onward. http://www.answers.com/topic/acculturation

Anorexia nervosa - Anorexia nervosa is an eating disorder that occurs primarily among girls and women. It is characterized by a fear of gaining weight, self-starvation, and a distorted view of body image. The condition is usually brought on by emotional disorders that lead a person to worry excessively about the appearance of his or her body. There are generally two types of anorexia: one is characterized by strict dieting and exercising; the other type includes binging and purging. Binging is the act of eating abnormally large amounts of food in a short period of time. Purging is the use of vomiting or other methods, such as laxatives, to empty the stomach. An individual who suffers from anorexia is called anorexic. http://www.faqs.org/health/Sick-V1/Anorexia-Nervosa.html

Bulimia Nervosa – Bulimia is an illness defined by food binges, or recurrent episodes of significant overeating, that are accompanied by a sense of loss of control. The affected person then uses various methods -- such as vomiting or laxative abuse -- to prevent weight gain. Many, but not all, people with bulimia may also suffer from anorexia nervosa, an eating disorder involving severe, chronic weight loss that proceeds to starvation. http://www.nlm.nih.gov/medlineplus/print/ency/article/000341.htm

Collectivism - Collectivism is defined as the theory and practice that makes some sort of group rather than the individual the fundamental unit of political, social, and economic concern. In theory, collectivists insist that the claims of groups, associations, or the state must normally supersede the claims of individuals. http://freedomkeys.com/collectivism.htm

Culture - (from the Latin cultural stemming from colere, meaning "to cultivate"), generally refers to patterns of human activity and the symbolic structures that give such activity significance. Different definitions of "culture" reflect different theoretical bases for understanding, or criteria for evaluating, human activity.  http://uk.answers.yahoo.com/question/index?qid=20070122130531AASvfzM

Cultural relativism - Different cultural groups think, feel, and act differently. There are no scientific standards for considering one group as intrinsically superior or inferior to another. Studying differences in culture among groups and societies presupposes a position of cultural relativism. It does not imply normalcy for oneself, or for one's society. It, however, calls for judgment when dealing with groups or societies different from one's own. Information about the nature of cultural differences between societies, their roots, and their consequences should precede judgment and action. Negotiation is more likely to succeed when the parties concerned understand the reasons for the differences in viewpoints. http://www.tamu.edu/classes/cosc/choudhury/culture.html

Individualism - Individualism is at once an ethical-psychological concept and an ethical-political one. As an ethical-psychological concept, individualism holds that a human being should think and judge independently, respecting nothing more than the sovereignty of his or her mind; thus, it is intimately connected with the concept of autonomy. As an ethical-political concept, individualism upholds the supremacy of individual rights. http://freedomkeys.com/collectivism.htm


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Stephanie L. Brooke, Ph.D., NCC, teaches sociology and psychology online at the University of Phoenix, Excelsior College, University of Maryland, and Capella University. She also has written books on art therapy and edits books on the use of the creative therapies. In October 2006, she was the chief consultant for the first Creative Art Therapy Conference in Tokyo, Japan. Dr. Brooke continues to write and publish in her field. Further, Dr. Brooke served on the editorial boards of PSYCCritiques and the International Journal of Teaching and Learning in Higher Education. She is Vice Chairperson for ARIA (Awareness of Rape and Incest through Art). For more information about Dr. Brooke, please visit her web site:  http://www.stephanielbrooke.com

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