Podcast Transcript

Episode 76: Black Women with Eating Disorders: Cultural Humility & Clinical Care with Paula Edwards-Gayfield, LCMHCS, LPC, CEDS-S 

[Bouncy theme music plays.]

Sam: Hey, I’m Sam.

Ashley: Hi, I’m Ashley, and you’re listening to All Bodies. All Foods. presented by The Renfrew Center for Eating Disorders. We want to create a space for all bodies to come together authentically and purposefully to discuss various areas that impact us on a cultural and relational level.

Sam: We believe that all bodies and all foods are welcome. We would love for you to join us on this journey. Let’s learn together.

Sam: Today we’re shining a spotlight on a critical mental health issue that deeply affects Black women, one that’s often misunderstood or dismissed by the broader healthcare system, eating disorders. They aren’t just overlooked, they’re frequently misdiagnosed and minimized, leaving many without the care they urgently need. What’s behind this troubling gap? And how can we reimagine treatment to better serve Black women? In today’s episode, we’re unpacking these difficult yet crucial questions with Paula Edwards-Gayfield. She’s a licensed professional counselor, a clinical mental health counselor supervisor, a certified eating disorder specialist, and a board certified tele-mental health provider. She’s also the Regional Assistant Vice President and Diversity and Inclusion Co-Chair at the Renfrew Center, where she oversees clinical and administrative operations for multiple sites, including Renfrew’s virtual program, Renfrew@Home. With more than 20 years of experience treating eating disorders and co-occurring mental health concerns, she works extensively with adolescents, adults, and families and has spoken nationally on eating disorders, culture, and equity. She currently serves on the board of the National Eating Disorders Association and its Clinical Advisory Council. She sits on the advisory board for eating disorder recovery support and is a board member of Project Blackbird. She’s the co-author of Black Women with Eating Disorders: Clinical Treatment Considerations and a contributing author to Treating Black Women with Eating Disorders, a Clinician’s Guide. Paula is passionate about advancing culturally responsive and inclusive care and continues to amplify the voices and experiences of BIPOC communities in the field.  In this episode, we’re confronting some hard truths. Research suggests that binge eating may be more common among Black women than their white counterparts, yet it often goes unnoticed. And among Black teens, rates of symptoms like binging and purging may be up to 50% higher, but they’re still only half as likely to receive an accurate diagnosis or the care they need. Paula joins us to unpack the complex factors behind these disparities and to offer practical guidance on how mental health and medical providers can provide compassionate care that’s rooted in cultural humility. This conversation isn’t just about numbers and stats, it’s a call to action. Stay with us as Paula breaks down the barriers Black women face and challenges us to transform how care is delivered.

Hello and welcome back to All Bodies, All Foods. I’m Sam, I’m here with Ashley. We are very grateful to have our guest today on the show, the author of Black Women with Eating Disorders: Clinical Treatment Considerations. Welcome back to the show, Paula.

Paula: Thank you. I’m excited to be here.

Sam: You were with us before, I think maybe in our very first season, so we are very fortunate to have you back. And this time we are talking all about your new book, which I’m so excited to dive in. You and Dr. Small wrote this book together, and you mentioned right away in the book that this is a resource for really any professional who is licensed to provide care to black clients. So if you’re a therapist, counselor, dietitian,  dentist, doctor, it doesn’t matter. This episode’s for you. This book’s for you.  And I can’t wait to dive in to hear more about this book and specifically what inspired you to write it. I was wondering, was there a particular moment or experience in your work as an eating disorder provider that really made you realize there’s an urgent need for this. 

Paula: Yes, thank you. Thank you so much. Yeah, I would say that absolutely Dr. Small and I were super excited about doing this book. And I think about like when Dr. Charlene Small and Mozilla Fuller invited me to be a part of the Treating Black Women with Eating Disorders: a clinicians guide, there was already an awareness that a resource focused on treating black individuals with eating disorders was long overdue and just acknowledging that that book was an anthology, you know, several people coming together with different viewpoints.  As you know, there’s still a lot of misunderstanding around eating disorders in general, and especially around who’s affected and what does an eating disorder look like. So the belief that Black women and other people of color don’t struggle with eating disorders or maybe don’t need treatment is still far too common.  And I think it’s a thing that has consistently come up. I’ve even heard black clients sharing that they don’t feel seen or heard or that providers don’t truly understand their experiences. So the need for a resource like this has been evident for a long time.  Now, what’s really interesting about how the book came to fruition is that Dr. Small was actually presented with an opportunity.  Norton had reached out to her to see if she would write a book. I think at the time they really did not want an anthology and so they were asking her as a single author and she was like, there’s no way I am writing a book by myself. And so she asked me if I was interested in co-authoring and it was just an honor for me to be invited to be a part of something that was so meaningful.

Sam: Do you remember, did you get that phone call from Dr. Small? Do you remember?

Paula: It was probably a call. Probably a text. “What are you doing? I need to talk.” And then absolutely a phone call. And of course, I always think about, have you ever smiled when your face hurts? And so it was one of those moments where I appreciated it, but my face hurts.

Sam: Yes. Yes. Well, this resource is so needed and I’m just so happy that it’s available now and that we could use this episode to promote it and talk more about it. So thank you. Thank you for being here.

Paula: Thank you. My pleasure.

Ashley: Paula, I want to dive into some of the statistics that you highlighted in the book.  Some of them are, I would say, deeply concerning and something that I definitely would like to highlight in this podcast.  And I’d love for you to, I don’t know, kind of share your feedback or your thoughts surrounding these. So the first one. Black teens are up to 50% more likely than white teens to engage in binging and purging behaviors.  The rate of binge eating is 5% in black women compared with 2.5% in white women, and although black women develop all forms of eating disorders,  binge eating disorder is the most prevalent. So first of all, I guess you mentioned these and I was curious your thoughts about any of these statistics that you shared?

Paula: Yeah, I think that unfortunately, you know, there’s so much misdiagnosis and underdiagnosis, and I think as various individuals have begun to do a little bit more research, things have been reported, you know, know NEDA oftentimes  reflects statistics on their website, which is where some of this information comes from,  as well as like good at all  in terms of looking at binge eating disorder. I think in many ways binge eating disorder being like the most prevalent eating disorders where how some of those come into play. But I think I question and I think why it’s sort of shocking is because it’s not talked about, you know, if we’re thinking about again being underdiagnosed or under treated for eating disorders, despite having these similar or even higher prevalence rates compared to white individuals. And so we know that some of the factors that contribute as that were highlighted in the book goes back to what are the stereotypes about who develops an eating disorder?  And so with many providers still associating eating disorders with primarily thin white women, but also the stereotype that eating disorders are primarily thought of as like anorexia. You know, we miss binge eating. Binge eating is, you know, just out of control and you need to do better about being in control, but we know that that’s not what it is. But I think in terms of lay people, well as individuals who are not trained in eating disorders.  And so this stereotype just continues to um result in missed symptom presentations, as well as, or even dismissed in black individuals. When I think about some of the cultural stigma around mental health in general and food related concerns in many black communities, there’s still the silence, the shame, hesitation around seeking help for mental health struggles,  including eating disorders, or even just a conversation about eating disorders as overall. I think some of the also factors that could influence like lower rates of diagnosis is provider bias and lack of training as well. Again, acknowledging clinicians may not be trained to recognize some of the cultural factors that can play a role in how eating disorders develop, as well as how they are maintained in Black individuals.  Without that awareness, things like racial stress, cultural body image norms, family food dynamics as well, I think these symptoms, again, can be minimized, misinterpreted, or overlooked.  And oftentimes, it’s coming from implicit or explicit bias.

Sam: Paula, would you want to give an example of how that might play out, you know, say for a therapist and a Black client?

Paula: So two thoughts are going through my mind. One, I was sort of thinking about individuals who say that they don’t treat eating disorders.  And maybe they’re someone who’s coming into a session and they’re presenting with depression, and maybe they’re dropping some hints about food and food related type of concerns.  But does that provider only hear, oh, you just need to be healthier? And first, what are some of those questions that could be addressed that are eating disorder specific, but also getting a picture of what is food like in your family? What do cultural norms look like? What are some of the lived experiences that you have around food, body image, you know, just sort of even connectedness as a family and a sense of others’ beliefs about their bodies that maybe an individual has adopted.  But I think even with individuals who do treat eating disorders, I think if we don’t have the training and if someone isn’t being intentional to encourage them to ask these questions, we’re going to go about treatment as usual. And so it becomes like a lack of culturally responsive care, and unfortunately, that disconnect reinforces the disconnection because, you know, it’s harder to build trust. You don’t feel necessarily safe or stay engaged in treatment if you don’t feel supported and understood.

Sam: Right. Just sort of going along with treatment as usual, following some kind of treatment manual is not going to be always effective depending on the client in front of you. And it’s really important to adapt your modalities based on what your client specifically needs.  And you talk about that in your book, which I think is so important and so amazing. It actually brings me to my next question because I remember in your book, you and Dr. Small outlined eight essential truths every healthcare professional should know when working with black women. And I was thinking to myself, oh my gosh, this is important. We need to talk about this on the show. I was hoping you could share a few of those truths that you feel are especially important and help us understand why they’re so critical to providing equitable and effective care. 

Paula: That is so tough to just name a few, as I was going to add, because it’s almost like they’re all connected, and also because they’re all important. I think that there are a few core truths that I believe are absolutely critical to providing equitable and effective care for black women. Racism being number, you know, not number one, cause they’re all true, but racism I think is definitely high up on that list.  It’s a contributing factor, again, as I mentioned before, in the development and maintenance of an eating disorder for many black women.  If a provider is unable to acknowledge that racism exists, not just on an individual level, but also systematically, it becomes incredibly difficult to offer care that is truly effective or affirming to our clients. Just to be clear, recognizing systemic racism doesn’t mean labeling someone as a racist. It’s about understanding the world our clients are navigating every day. I think colorism also, or it’s an inter-community discrimination, also plays a significant role. The impact of beauty ideals and proximity to whiteness, even within Black communities, can deeply influence an individual’s relationship with body image, identity, as well as food. Ultimately, providing effective care, I think means recognizing the full context of a person’s life that includes the social, cultural, the historical and emotional context each client brings, and ignoring these factors means missing the very kind of things that shape their experience and recovery. I’ll add to that. It’s interesting because I think we try to do that with clients, but we forget that the race part has to be a part of that when we’re talking about clients of color. 

Sam: Absolutely. Therapists who are listening to this episode right now, I imagine, and  talking about race with a client is crucial. I mean, when reading your book, this theme comes up over and over again.  Any guidance you can give to some therapists who are listening right now, how to do that in an effective way?

Paula: You know, interestingly, uh providing supervision to staff, you know, I  really just believe it’s in the room, acknowledge it, you know, even in the first session, acknowledging what’s it like, or do you have any concerns to work with me as,  you know, me as a Black therapist asking a Black individual, what’s it like for you to work with me? Do you have any concerns or questions? And I think for our White clinicians to do that with clients of color, but also any clinician, because I am not the expert on a Black person. Like, sure, I may know some things, but my lived experience is very different from the Black client that could be sitting in front of me or another person of color. So I think it’s just so important to incorporate that in general. What I have heard is that, oh, no, it’s not a problem. You know, the clients are like, no, I’m OK with it. That’s great. Bring it back up again. Not that you have to get up again in that session, maybe not even the second session, but acknowledging that I see you and I see the difference and creating the space. And I believe that even just by communicating the openness to talk about it, the client can feel more invited to do that.  Acknowledging culture, what’s this like? We asked about things related to families.  What’s this like in your family? Has culture influenced that in some sort of way?  I dare say, I also believe that everybody has culture. And I think sometimes some white individuals don’t acknowledge that they have culture.  And so I think even if we can adopt that like that might even be an easier way that they’re inviting, you know, that they’re opening the door for those conversations as well. 

Sam: This is so helpful, and the idea of  just bringing it up  once might not be enough. I mean, that is such helpful guidance that I think there are some clinicians that may say to themselves, well, I already did that. So I don’t have to revisit it.  And you’re saying, bring it up again and maybe even again, because it’s that important.

Paula:  And it really,  I really believe it communicates to a person, even if at its most basic level, I see you, I notice the difference.  And I’m also acknowledging if we’re treating the whole person, you’re still a Black individual, you’re still a Black woman or, you know, that’s sitting in front of me.  And so who are you as the whole person, which means I have to bring in what your experiences are as a person of color.

Ashley: This is making me think a lot of the, is it the APA cultural formulation interview that  is encouraged to utilize too when we’re doing an intake with clients? Do you know what I’m talking about, Paula?

Paula: Yes, I’ve heard of that. But yeah, it does. It really brings in this sense of, because I know they think outlined, right? The last interview.

Ashley: Yeah, they have outlines that are,  it’s very similar to what you’re saying. So what does food look like in your family or what do emotions look like in your family system?  Or how would somebody in your family system or your friend group categorize what they’re seeing, right? And I think just continuing to, I assume, like humbly approach this subject and just continue to remind ourselves, because I think speaking as a provider, I do think that we can get kind of in that laser focus, like treat everybody or like, oh, this is a case of anorexia. It’s just going to be, do you know what I’m saying?  So it’s really lovely. 

Paula: And not that that’s the intention, but we’re treating the symptom.

Ashley: Exactly. So it’s great.  It’s great reminders, like you and Sam were saying, to continue to bring this stuff into the room, not only for our client, but also to make sure that we are essentially being appropriate with them and providing the best care that we can for them.

Paula: And I think in that way, what are the things that we take advantage of as providers for our own learning? Because whether that’s reading, consultation groups, networking opportunities, also to take advantage of your own opportunities to increase your awareness.  And then I think maybe as you are comfortable, it becomes a little bit more comfortable.  Acknowledging, if I may, another thing that I kind of tell my staff, just thinking about this in groups, is we’re not waiting for that representative  of a  marginalized population to be present. We should be talking about that all the time. The only way you get better and more comfortable at talking about something is talking about it.  And so if you’re doing groups, then there could be, you know, what are some of those examples or, you know, just bring it in wherever you can.

Ashley: Yeah, that’s awesome. Paula, OK, so I kind of want to shift just a little bit.  In your book, you all shared some really powerful examples,  some case examples. And so I was curious if we could discuss this, of how eating disorders  can uniquely present in black women. So thinking about binge eating disorder as an example, I’m curious if you could speak to how it shows up differently in the lived experience of a Black woman and why those differences are important for us as providers to recognize.

Paula: Yes, thank you.  So when we talk about binge eating disorder, you know, the core behaviors, eating large amounts of food in a short period of time, feeling out of control, you know, that’s going to look similar across racial groups.  But what’s often overlooked is the why behind those behaviors.  And that part can be very different for black individuals.  What we see is that that emotional distress that could be fueling the binge, whether that’s feelings of worthlessness, perfectionism, self-criticism, may be compounded by the racialized messages of not just, am I good enough, but  am I good enough as a black person?  This goes beyond that internal struggle. Again, shaped by societal pressures, racialized beauty standards, and stigma. On top of that, I think about factors like adultification of Black girls or being over-sexualized and misunderstood can also feed into these feelings of shame and invisibility or wanting to be invisible. And so does the binge eating serve a purpose in that way? These are not just emotional struggles, they’re lived realities that really do impact how and why disordered eating develops and persists. I will say this, while the behaviors may align with what we expect clinically,  the context is what’s different and context matters, as you all know.  Going beyond surface-level symptoms, as we were just mentioning, Ashley, going beyond surface-level symptoms and considering the racial and cultural experiences that are so often overlooked in eating disorder care, race, culture, identity,  they are such a part of the clinical picture.

Ashley:  I was writing down a quote when you were talking because this is so good and  I just want to remember this.  So, so often when I talk about eating disorders, I talk about them as emotional disorders, right?  And you just said they’re not just about emotional struggles, but about the lived realities of our patients, and I think that that is so important for us  to remind ourselves of. It’s not just about the anxiety. Sure, there’s anxiety there, but like, what is the lived experiences that this individual is bringing into the room and the lived like cultural experience? Like, again, like what have they been told? Or I think of like Whitney Houston when  she was going through all of her problems, you know, and I’ve seen so many documentaries,  but one of the times kind of like discussing and feeling like she wasn’t representing the black community good enough or well enough, right?  Like that has got to be, I don’t know that Whitney Houston had an eating disorder, but I would imagine that that lived experience of what you were talking about could be something that could be a catalyst into an eating disorder.

Paula: It’s not an uncommon experience for a person of color, you know, especially a black individual that that really, you know, it’s not just because I think about other marginalized identities who I can hide what that may or may not be,  but I cannot hide that I’m a black woman. And so that goes with me wherever I go.  And so because of that, you know, I’m in spaces where those questions could show up, you know, am I too much of this or not enough of that? Am I being trained? Those questions are, I think, pretty, I was going to say ever present, but I was a pretty present for a lot of black individuals.

Sam: Paula, you mentioned adultification, and there might be some listeners who want to know more about that. Would you be willing to talk a little bit more about that and its connection to eating disorders?

Paula: Yeah. Essentially, it’s applying  adult or sexualized characteristics to younger girls, and it happens way too often with Black girls. I mean, you kind of think about missing people and you see the billboards and  there could be one individual same age and there’s like all points bullets and there’s this search that’s coming out for that person, but someone else maybe the same age, oh, they ran away or maybe that, you know, it’s this sense of, you know, these behaviors that sort of get attributed to.  I think also when, you know, when I think about adultification and some of the sexualized things as well, it  just creates a sense of a younger or same-aged child, I want to say it that way, that is Black can be identified as more responsible. They should have known better or they’re seen a certain way a little bit more permissively than what their age may be that’s white, even if they’re doing the exact same behaviors. 

Sam: So there’s this blame.

Paula: Absolutely.

Sam: Right. And that blame, someone carries with them even into adulthood.

Paula: What did I do? I must have done something wrong. You were flirting. You knew not to sit on uncle’s lap and tell us that. Then you were flirting versus, he was my uncle. What do I do? Versus the other one seeing them a little bit more as the victim versus they did something to warrant the behavior or the assault or something to occur.

Sam: Right. I can see how clearly that connects with eating disorders as they’re often rooted in shame and internalized blame, and it’s so important for clinicians to be aware of those experiences.  I was hoping we could also talk about body image because this is a theme we go back to over and over on this podcast. And in chapter four, there’s a really powerful quote. It said, “ for Black women, body image is not just about size, shape, and weight. Body image incorporates overall appearance.  And providers who maintain a narrow view of body image may affirm feelings of invisibility and inferiority.”  And so with that quote in mind, how should clinicians be thinking about and approaching body image when working with Black clients?

Paula: Great question. You know, I automatically go to, when we think about body image, it’s like, especially in the context of I think eating disorders, it’s not just how someone sees themselves, it’s also how we believe others see ourselves or see us. And for black clients, I think that perception, again, shaped by our racial experiences, cultural messages, as well as those lived experiences that the providers may overlook. And so if we start by really seeing our clients, not just physically,  but in their full context, I think that’s the part that creates like, what do I see? What are those factors that sort of make you who you are?  Acknowledging that these realities and the messages that they’ve internalized about their body.  I know Tally Rand in 2017, offered some helpful guiding questions  that helped to center a client’s voice. And I believe one of the most important is a sense of what does body image mean to you as a black woman? Because again, if the client, I think about our client, the client is the expert on themselves, and so how can I get some information from them?  But that question opens up the door for clients to start to define their experiences in their own words, what they believe is problematic or challenging instead of applying this generalized lens  that is rooted in Eurocentric ideals or assumptions about eating disorder presentations. We can have that in the back of our mind and thinking about what else is there.  Other questions that we could be asking is how have appearance-related experiences shaped the way that you see yourself?  What messages, whether they’re spoken or unspoken, have influenced how you feel in your body?  And I think ultimately our work should focus on listening and affirming and honoring our clients’ experience, not reducing them to some clinical checklist, because these conversations help us treat the whole person. I have a comment I wanted to share. It is not 100 percent about body image, I think it reflects the importance. When I was very young in this field, and treating eating disorder years ago, I had a black client that I was trying to send a residential. She didn’t want to go. But we had gotten to the point of her agreeing to go, and one of the questions she said to me was, Paula, what am I going to do about my hair?  What am I going to do about my hair in residential?  And I was like, well, our chief clinical officer at the Renfrew Center is a Black woman.  Let me call her because I’m going to make sure we figure something out.  And we did. And that was really important to her. But, you know, here’s this like 19 year old, you know, young adult. Absolutely. And she’s not wrong because that is exactly what my question would be.  What am I going to do about my hair? You know, only like physically what I would do about it, but are there products that support like the strength and the growth of my hair as well that are available to me?  And keep in mind, this is pre-Amazon days, so, you know, she can adjust my order.

Sam: Yeah.  Wow. That, I mean, thank you so much for sharing that because it’s such a good example. And there may be a clinician who doesn’t understand the importance of that culturally and could really do harm in that moment by saying something like, you know, don’t worry about that, worry about recovery. Thank you for, mean, that’s such a helpful example. Thank you.  And I can acknowledge that person may have been well intended, but you’re right, Sam. They could have done, still have done some harm.

Ashley: Right. Paula, in your book, you share a meaningful definition of cultural humility  from the Kirwan Institute for the Study of Race and Ethnicity.  So the definition states, “cultural humility is a reflective process of understanding one’s own biases and privileges,  managing power imbalances and maintaining a stance that is open to others  in relation to aspects of their cultural identity  that are most important to them.”  So especially given the lack of diversity within the eating disorder field,  cultivating cultural humility feels more essential than ever. I’m curious what are some practical ways providers can begin to practice cultural humility in their work?

Paula: Yeah. I think that, this is such a great question, I think a few tips that providers could start to practice cultural humility would really be engaging in self-reflection. I think that’s where it has to begin, being aware of their own beliefs, their own values, as well as their implicit biases, and being open and willing to recognize what you don’t know and being open to learning as much as you can.  I will stress every single person has biases, but you can want to not have them, you can actively be working to address them, but we have them. I think is sort of a human nature thing. But also being open to other people’s identities and empathizing with that individual’s life experiences. And I think that’s one of the ways that how cultural humility helps to, know, how can I still, even if I don’t understand it, I can make space for having some empathy for what your experience may be.  I also think most important, importantly, acknowledging that the client, again, the client is their own best authority, not you as the provider. We learn and grow from people as we know. And so when we are interacting with people whose beliefs and values and worldviews differ from our own, that openness is really the key to the work that we’re doing with our clients of color and all clients realistically.

Ashley: I will say I remember, oh my goodness, this was years ago with Renfrew at this point, I imagine that they do it every so often, the entire staff, we had to do implicit bias training. Do you all remember this? We had to take those tests and then come together. Like every site, every group came together and we discussed that.  And honestly, it was the first time I had taken an implicit bias test.  I was really shocked and floored at some of the results for myself and my peers. And that is something that I actually go back to every now and then. I’m a supervisor for licensed professional counselors, and so that is actually a resource that I’m always talking about is  it is imperative  that you take those implicit bias tests. And I think Harvard still has one in like multiple categories. But eh I mean, that self-reflection and being able to acknowledge, yeah, just kind of, I guess like how we’ve come to view the world is really, really important in working with our clients.

Paula: It really is. And I imagine, I don’t know if you, Ashley, or if you, Sam, have taken this, I know when I’ve done it, I was like, no, I’m not. Let me retake those. And so it is that awareness that we do still have though. And then like you stated, what’s the conversation that follows? How am I addressing this? And how does it show up in interactions, not just professionally, you know, personally, interpersonally, in social settings and with peers as well. And gosh, that is so important. I love that you do that. Like with your supervisees, thank you.

Sam: Ashley, I’m just really glad you brought this up. I remember reading an interesting article. I can’t remember who wrote it. If someone remembers, like, please put it in the comments. You know, about this test specifically, that even  if it comes back that you don’t have that much bias,  that it is not actually even a predictor that you’re not acting out in harmful ways anyway. Yeah. That kind of blew me away when I heard that because I think sometimes people think maybe they’re off the hook because it’s like they came back low on something. But it’s not always going to be a reflection of your actual behavior as a clinician.

Paula: That’s so important. Thank you for sharing that, Sam.

Ashley: Well, because also if we’re brought up in a certain culture as a clinician and we haven’t been exposed or been around or seen another culture as a clinician, of course, we can certainly do harm.

Paula: Yeah, because you can be operating on stereotypes. Right. absolutely, unintentionally, but still the behavior. Yeah.

Sam: Yes. I wish I could remember that author, but I wanted to bring that up. But thanks for the reminder.

Paula: Someone comments, please let me know, because that’s a fact. 

Sam: Well, moving on to  my next question. I love this book so much because there are so many practical examples of questions we can ask, things we can actually do. I love when there’s concrete guidance. I remember in chapter five, you and Dr. Small recommended asking eight questions to help better understand and connect with Black clients.  And I was hoping we could maybe share a few examples of what those questions are and why they’re important to ask.

Paula: Yeah. I think going again back to understanding Black clients and checking our own implicit biases, we really have to get real. We have to be real, you know, with the clients in the room. And even if they feel hard, I’m just going to encourage you that you are demonstrating care, like you are showing that you care, and you’re really curious, you know, about your Black client. And so I think a few that I would consider are, and these are in no order of importance, but absolutely just a few, what’s most important to you about your culture or ethnicity? Because again, as we’re navigating the world,  the worlds in which we may exist in, whether it’s professionally or school or even at home and what that’s like, what was it like growing up in a culture shaped by racism?  Maybe they didn’t see it overtly. Maybe they felt it systematically.  Maybe they didn’t experience it or don’t even realize the experience until they got older. So I think absolutely it kind of delves into like who the person is and what their experiences are. And also again, ‘cause body image is so important to me, how has gender, hair, skin tone shaped your body image or experiences with beauty standards, as well, I think is really important. Again, I think that helps to give information to that provider about where a client is coming from, especially when we’re thinking about body image concerns. If you can remember that these questions are not just about gathering facts, it’s about building trust and honoring the person that’s in front of you. 

Ashley: That’s a great reminder there.

Sam: Yeah, that’s a great way to put it. 

Ashley: So moving forward from kind of that gaining trust and getting to know your client,  I want to talk about evidence-based approaches to treating eating disorders. Right. And we know that many of them were developed and tested primarily with European white populations. So in light of this, what are some ways clinicians can thoughtfully support Black clients when these treatment models may not fully reflect their unique needs and experiences?

Paula: This doesn’t 100% answer your question, but do more research and incorporate people of color into these studies. Yeah, when an evidence-based treatment, I think, doesn’t fully reflect the needs of a Black client, it is essential for us to consider the cultural adaptation that could help improve the relevance and effectiveness of that treatment approach.  And I think that is just asking yourself as the provider, does this approach align with your client’s cultural background, their values and their lived experiences? And so there may be some aspects of what that treatment approach  states that you don’t do. You remove that.  I think, and this is a general statement and please no one kill me, that’s a CBT therapist out there. I think also CBT. Like reframing from me is like, oh, or excuse me, even distorted thoughts. Distorted thoughts and reframing have always been something that I really struggled with.  Because if I think that there’s already something wrong with me, why am I going to tell the client there’s something more like wrong you, you when you’re thinking about disordered thoughts. And so I think even things like that, we do it with eating disorder clients often, you know, I think as we need to do the same thing when we’re looking at clients of color, but also the integration of frameworks like humanism and relational cultural theory can offer that support. I think it becomes really powerful  when these approaches can compliment an evidence-based approach.  And when they’re combined, I think the space that it creates to address unique cultural, social, psychological realities of Black clients and ultimately enhancing their outcomes.  If I can say at Renfrew, the Relation of Practice Groups is one of my favorite groups that we offer because it does just that. It creates this opportunity to talk about marginalized identities. It brings in people’s different experiences and viewpoints. And I think that’s what becomes really important with what relational cultural theory can do when combined with some evidence-based approaches.  But again, avoiding these conversations on race and therapy can unintentionally reinforce the feeling of being unseen.  And so even though you may be fearful of saying the wrong thing that’s completely understandable, clients are often grateful when their racial identity is acknowledged with care and respect. And I think using humanistic approaches like that can do that.  I would always say as a reminder, just remember being Black isn’t something I can leave at the door. It’s a core part of who I am and how I move throughout the world. And that’s what your clients are experiencing.

Ashley: That’s so helpful to remember. I know we’ve said this multiple times, but just like every individual that comes in our door is an individual.  And we really have to see them that way and connect with them that way and listen to their story and their lived experience in order to work with them.

Paula: We’re so avoidant of race, that topic of race. And I think, again, even well intended, to do all the other things and not talk about race, you’re missing a part of who your client is. And I almost feel repetitive when I’m saying like cultural, you know, like thinking about racism and the impact of that and cultural identities.  But again, it’s who they are. It’s who you take with you everywhere you go. 

Sam: Paula, you talked about cognitive distortions. And I’m sure there’s some clinicians out there thinking, oh, shoot, that’s like my go-to. 

Paula: Sorry. Not checking anyone.

Sam: See, this is why this is so helpful. Because when we talk about these cultural adaptations, I was wondering, do you have some examples of how we could do that? Like say with cognitive distortions in CBT, how might that be adapted?  How might that cause harm? And how can a clinician do it differently?

Paula: So being with Renfrew acknowledging my mind automatically goes to our treatment approach. And I think part of that being the connectedness with a relational cultural model and the unified treatment model that we do, I guess in some ways it’s a softer language, but it still communicates the same thing.  It’s normalizing. I think like we, instead of cognitive distortions,  we’re talking about thinking traps and we can all fall into those thinking traps. And it’s, but it acknowledges are the things that have influenced our thoughts now, whether that’s culture, race,  interpersonal, anything, you know, it doesn’t mean that it’s only about racism, but it acknowledges that something has shaped how we think about things. And if we can explore what that, what those things are, those factors that have influenced those thoughts, maybe it’s then creating some space for some cognitive flexibility, not automatically naming every situation as the same thing and acknowledging that even those thinking traps and the cognitive distortions could still be the jumping to conclusions. It could still be the catastrophizing. But I think creating language or creating space where people can feel heard and not again judged I think is what some of these humanistic and relational cultural  models do when combined.  What I think about, okay, we’re considering all language, culture, context, age, compatibility with the individual’s cultural patterns, the meanings that they bring to the world and their values, as well as their developmental stage. I mean, we wouldn’t say to a five-year-old, so those kind of distortions. And I know we can see we’re making those adjustments because of age, but also just think about other factors at play that reinforce populations who’ve been told that they’re wrong.  When I think about in practice though, adaptations in, I think you referenced this a little bit earlier, can happen across a few areas where they are therapist-led or therapist-related adjustment. That is going to be matching, well, excuse me, it could be matching clients with providers of color or accounting for language proficiency. Now, I will say that a person of color may not be the best therapist for another, for a person of color, but maybe if that’s what needs to happen for that individual, it’s being aware of, is this an adaptation that could occur and that may be needed? I think also content related, we sort of talked about using  some culturally sensitive terms, ensuring that materials are translated when needed. I think that’s one of the things I’ve also heard from clients of color. And then what are the organization level changes too?  And that means how are we evaluating the culture of the setting, the culture of any of our locations or the organization top down is respect embedded, and how care is delivered and how do we define respect as well. I think we can probably say we all know how to define it, but in practice, what does that look like? And then also just again, are the organization’s approaches aligned with the client’s values, the culture of patterns, as well as their developmental needs? So I think that’s how we can really truly create some culturally responsive and affirming care. 

Sam: Wow. Yes. Thank you so much. These are such helpful examples all the different ways that things can be adapted. We’re not just talking about adapting one intervention like cognitive distortions. We’re talking about an entire organization.  How do we make sure that we are individualizing care for every client in front of us? 

Paula: You can imagine, again, we have a system of treatment facilities. So to go to one and then step down to another, that experience can be so different for clients. If we’re individualizing care and we’re taking into consideration all of these things, hopefully the systemic cultural approach is kind of, I don’t want to say that you’re going down from res, but it’s evident in each of the programs, whether it’s virtual or a non-residential site or a residential location. What is with the individual providers that we may be referring out to as well?

Ashley: Paula, there’s an entire chapter on helping Black clients reimagine a healthier relationship with food and their bodies  that highlights the often overlooked challenges. What are some of the unique struggles that women face, that Black women face around food? And how can eating disorder providers offer culturally responsive care?

Paula: Yes. So I’ll start with, I think, not only just black women, but anyone that may not have a healthy relationship with food. I think it’s about starting with raising awareness about the harm of any diet culture, restrictive eating, overeating, the harm of not getting the nutrients that your body needs. I think also diet culture is so normalized that many people don’t even realize that they’re engaging in it. And so I think about messages like, whether it’s like eating clean or cutting back, oh, this is my cheat day. It’s so present. And even though they might say the cheat day, they may not even say they’re on a diet. But you know, or it’s just that they have allowed themselves to be good, you know, throughout the week.  So I think part of our work is really helping them question any of those norms, reconnecting with their hunger fullness cues and bringing flexibility back into eating in general. And so that might mean,  you know, we’re asking like, what am I eating for? What am I actually hungry for? Like really thinking what else is going on, getting connected back to the emotional uh occurrences that may be present.  And it also means making sure cultural foods are included and respected as part of a healthy relationship with food.  You know, it’s oftentimes you hear, you know, so frequently, oh, well, soul food and it’s like unhealthy and it’s this and not only from non-Black individuals, but also from Black individuals. They’ve really adopted those messages.  But how, if we can remember that eating disorders are not truly about food, so then for Black women, I go back to what are the unique stressors that it’s layered in?  How do we navigate racial and gendered identities? We’re in that world where we cannot hide being Black and that they’re under constant pressure, this undercurrent of pressure. And one of the things I was thinking about was code switching. You know, so when I think about if somebody’s had to experience this all day, where they’ve had to code switch, whether it was school or at work, then what might happen once they leave work and, you know, they get home? It could be that then it could be the binge eating episodes, but code switching is adjusting how you speak or act to fit in to avoid or to avoid stereotypes. And that’s the main way in which they may adapt, but  it comes at a cost, right?  It’s conflict stress, it’s identity conflict, it’s even self-rejection.  And so I think sometimes at the end of the day, now what? How do I deal with all of that that I’ve just endured? And then to start tomorrow in the same way. I think also when oppressive ideals are rooted in whiteness or maleness are internalized, they get absolutely deep in body shame,  as well as the erosion of individual self-worth too. Think about it, these pressures start early and they persist across the lifespan,  increasing vulnerability, not only to physical health, but mental health. So in truly supporting black women and healing their relationship with food, can’t just focus on the plate, we have to understand the lived realities that they are carrying into the room.

Sam: Can’t just focus on the plate. I love that. Yes, yes.

Paula: Maybe that’s the title of my next book.

Sam: I was just thinking that. That’s the title of the sequel. So this is a serious question and I was hoping we could dig in a little bit here because your book really sheds light on the very long and painful history of medical mistreatment and historical trauma experienced by Black communities. And these are factors that understandably contribute to all the medical distrust that we see today. And so in the context of eating disorder care, what do you think is essential for providers to understand about this history? And how can it inform the work that we’re doing?

Paula: Yeah. Just thinking about this question, when I think about the history of medical maltreatment, I find myself thinking about just an eating disorder treatment. Like we work to support our clients. We want to help them build their capacity to navigate emotional discomfort. Part of that therapeutic process is helping not just our clients, but their families understand that experiencing or expressing emotion isn’t to be suppressed or avoided. It’s not a flaw. It’s not something wrong. We’re encouraging it. And then I started thinking about conversations around size stigma are increasingly highlighting  the systemic bias within healthcare where larger body individuals face institutional neglect and misdiagnosis, inadequate care, and medical systems are slowly beginning to confront some of the embedded bias, weight bias. And yet I come back to how often black people are told to sort of move on or let it go, especially when it comes to medical harm. And so, you know, you hear stories that are historic and, you know, that, you know, individuals have endured,  but the truth is, it’s not just history, it’s still happening now. They’re not isolated stories from decades ago. They’re real ongoing experiences being overlooked, dismissed, or mistreated in healthcare.  And when it comes to racism, there’s still this tendency to downplay experiences or to treat our pain like it’s imagined or exaggerated, but it’s not. And just acknowledging that the harm is real and it has real consequences. And I think that’s why it’s essential for providers to understand if we don’t acknowledge the history and how it continues to show up today, we risk replicating harm. Building trust with black clients requires, again, cultural humility, self-awareness, and a willingness to examine the systems that we’re a part of. I think we’ve all heard cases with like Serena Williams and other Black individuals who shared experiences more recently as they’ve gone in for treatment.  I think one of the things that Charlotte and I’ve talked about and probably other presenters as well is that black bodies historically were just that black bodies.  They were the bodies that were being tested on. They weren’t getting, you know, oh anesthesia. They weren’t getting, you know, some of these things. I think about some of the earlier procedures that were occurring, but then they would go over into Europe and then white women would get the procedure,  you know, with anesthesia. But they were testing it out on black bodies. And that has just been ongoing for forever.

Ashley: And just talking about that, I mean, that presently occurring still, guess, like  the medical harm, aren’t Black women the highest population of maternal birth deaths? Am I saying that correctly?

Paula: Yeah. And part of that is even just reporting, having concerns, and maybe not getting the treatment. So it could be a thing about access to care and not having benefits, but also not being believed. It feels like something is going on or something’s wrong because maybe it isn’t quite showing up on a test. I’ve been really hypervigilant about breast cancer. Going back a little bit, I have a family history, but you know how if it’s not your mom, even if it’s not in your family, or it’s not like you’re not at higher risk.  I’ve just always been super vigilant about it. My sisters and I and the birth order of my mom and her sisters, there’s three of them. So alike, everything like so alike, it’s scary. Like each of us should have been their daughter.  And there are some things medically that occurred with my aunt that I’ve experienced and I’m like, this is freakishly weird.  But because of that, my amazing doctor has always listened to me, and so I proactively just get stuff done to make sure, you know, that I am okay. Two years ago, I was tested for BRCA1 and 2. I am negative.  I do something every six months just to make sure. My mom was diagnosed with breast cancer earlier this year.  And it was like, wait, what?  And so when she was tested, her doctor did some gene testing.  And the gene that came back, she said that one of my grandparents had to have had this gene.  And so the recommendation was that all of my aunts and uncles get tested and all of me and my sisters had to get tested.  The gene increased risk for breast cancer and increased risk for pancreatic cancer as well as ovarian cancer. But because my mom has breast cancer, that increase is greater.  Now, that being said, even though it’s going through the appeals process, our insurance denied the testing because it said there wasn’t enough evidence.

Ashley: Oh my goodness.

Paula: I’m like, so my mom is not enough evidence that this is a concern. Unfortunately, my two sisters have also tested positive for this gene.  And so now beginning to explore this process of like what’s sort of next. And so I think about that in this, you know, if I wasn’t who I was, you know, and really pushing this and making sure and asking questions and fighting insurance companies, you know, like what could happen if I were someone who wasn’t aware of these things?  And this is the stuff that it makes me think about when we talk about medical maltreatment, you know?

Ashley: Well, and the fact that that is just now being encouraged also, that gene testing, when they’re saying that that would have come from your grandparents potentially.

Paula: Well, and unfortunately, right, because if they didn’t show, if they didn’t have it, you know, no one had cancer. So that’s where it becomes like the, I mean, thankfully, no one had cancer, hate that my mom has cancer, but no one knew, you know, that that was something. And like I said, I would have been operating like I’m okay. I did the testing that they recommend, BRCA1 and 2, and I’m negative for it. So, but yeah, positive for this other gene.

Ashley: Wow, Paula.

Paula: And that’s why, again, I think when we don’t know these things, and you don’t know, you don’t know, but also once you know, then how do you advocate for treatment and have people who advocate for you. And I really appreciate that I do and that I’m aware of what to do.

Ashley: So I just want to highlight one thing that you did and just remind folks listening, you continue to advocate for yourself with insurance and folks that are listening out there, you can do that. You can call them back. You get a provider on. There are ways that you can advocate for yourself as far as insurance is concerned.

Paula: Yeah, absolutely. And if you don’t know, reach out. Ask someone. I think that’s probably my next mission in life is to be an advocate for something. I don’t know. But yeah, so definitely ask someone.

Sam: And at the same time, yes, you can advocate. And it’s still not right or fair that you have to do that. Exactly. Well, Paula, thank you for sharing that personal story, and it really paints a very clear picture of the fight, the energy, the mental load that is rooted in all of this historical trauma.

Paula: And I appreciate, as I refer to it, the tribe that I have around my sisters and my mom and my cousins who are so supportive, because I acknowledge that like some of the things that we’re doing, it’s because we have the tribe, you know?

Sam: The tribe, yeah.

Ashley: Paula, we have to wrap up now.

Paula: No worries.

Ashley: But, okay, for all of those, all of us that are going out there, we’re picking up the book. For those of us that are listening today, a takeaway. What is one thing that you want us to leave here with today?

Paula: One thing? As much as I’ve chatted, one thing?

Sam: One thing is buy the book.

Paula: I know.

Ashley: Yeah, one thing is buy the book. 

Paula: Buy the book. There you go. I guess my last few messages I hope readers take is that the client is the expert on themselves. I really believe that.  And while we often say this, like in our work, it’s important to recognize that much of our training and our treatment approaches are still rooted in Eurocentric frameworks. Without realizing it, we can impose these ideas onto clients of color,  particularly our black clients, without fully considering the significance  of culture, community, and lived experience. Thinking about colonialism. I think if we truly believe that our clients are their own experts, then we have to commit to seeing them in their full context, as I mentioned earlier, asking those questions. What are the cultural values that shape you? What family dynamics are at play? How did history and identity inform your struggle and your strengths as well? And like I said, it may not sound like more than just one takeaway, but to me, it all comes down to honoring the whole person and not just the symptoms that we’re trying to treat.

Sam: Wonderful, beautiful takeaways. For our audience, the book is called Black Women with Eating Disorders: Clinical Treatment Considerations. Paula, we’re eternally grateful for you. Thank you for being here.

Paula: Thank you. Thank you all for the opportunity.

Ashley: Thank you for listening with us today on All Bodies. All Foods. presented by the Renfrew Center for Eating Disorders.

Sam: We’re looking forward to you joining us next time as we continue these conversations.

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