Limited information exists on the application of evidence-based treatments for eating disorders among diverse populations. An increasing number of international and immigrant clients provides a pressing need for culturally responsive treatments. This case study highlights an eating disorder treatment that incorporates dialectical behavior therapy and cultural adaptation guidelines. This study explicates a culturally adapted dialectical behavior therapy (DBT) treatment of a 24-year-old female Chinese international student suffering from an eating disorder, depression, and cultural adjustment issues. In particular, this case addresses Chinese cultural values, including conformity, interdependence, and filial piety, and how these values intersect with the client’s presenting issues and treatment. Cultural modifications made to the case conceptualization and dialectical behavior therapy are discussed. The client reported a significant decrease in distress, an increase in the quality of social relationships, and an increase in satisfaction with social roles. These results provide support for the effectiveness and importance of integrating cultural adaptation and evidence-based treatment. Clinical implications and recommendations for clinicians and students are provided.
American Psychiatric Association. (2006). Practice guideline for the treatment of patients with eating disorders (3rd ed.). Washington, DC: Author. doi:10.1176/appi.books.9780890423363
2.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. doi:10.1176/appi.books.9780890415596
3.
BenishS. G.QuintanaS.WampoldB. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling Psychology, 58, 279-289. doi:10.1037/a0023626
4.
BernalG.BonillaJ.BellidoC. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23, 67-82. doi:10.1007/bf01447045
5.
BernalG.Jiménez-ChafeyM. I.Domenech RodríguezM. M. (2009). Cultural adaptation of treatments: A resourse for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40, 361-368. doi:10.1037/a0016401
6.
BloomC.KogelL.ZaphiropoulosL. (1994). Learning to feed oneself: A psychodynamic model. In BloomC.GitterA.GutwillS.KogelL.ZaphiropoulosL. (Eds.), Eating problems: A feminist psychoanalytic treatment model (pp. 83-115). New York, NY: Basic Books.
7.
CarterR. T. (1995). The influence of race and racial identity in psychotherapy: Toward a racially inclusive model. Oxford, UK: John Wiley.
8.
ChangC. Y.O’HaraC. (2013). The initial interview with Asian Americans. Journal of Contemporary Psychotherapy, 43, 33-42. doi:10.1007/s10879-012-9221-9
9.
ChenE. Y.SegalK.WeissmanJ.ZeffiroT.Gallop.RLinehanM. M.. . . LynchT. (2015). Adapting dialectical behavior therapy for outpatient adult anorexia nervosa—A pilot study. International Journal of Eating Disorders, 48, 123-132. doi:10.1002/eat.22360
10.
ChengP. (2014). Examining a sociocultural model: Racial identity, internalization of the dominant White beauty standards, and body images among Asian American women (Unpublished doctoral dissertation). Columbia University, New York, NY.
11.
ChengP.CarterR. T.LeeD. Y. (2015). The relationship between racial identity status attitudes and acculturation among Chinese and Korean Americans: A criterion profile analysis. Journal of Multicultural Counseling and Development, 43, 97-108. doi:10.1002/j.2161-1912.2015.00067.x
12.
Domenech RodríguezM. M.BernalG. (2012). Conceptual framework of cultural adaptation. In BernalG.Domenech RodriguezM. M. (Eds.), Cultural adaptations: Tools for evidence-based practice with diverse populations (pp. 23-45). Washington, DC: American Psychological Association Press.
13.
Domenech RodríguezM. M.WielingE. (2004). Developing culturally appropriate, evidence-based treatments for interventions with ethnic minority populations. In RastogiM.WielingE. (Eds.), Voices of color: First-person accounts of ethnic minority therapists (pp. 313-333). Thousand Oaks, CA: Sage.
14.
FrankJ. D.FrankJ. B. (1993). Persuasion and healing: A comparative study of psychotherapy. Baltimore, MD: Johns Hopkins University.
15.
FruzzettiA. E.WorrallJ. M. (2010). Accurate expression and validation: A transactional model for understanding individual and relationship distress. In SullivanK.DevilaJ. (Eds.), Support processes in intimate relationships (pp. 121-150). New York, NY: Oxford University Press.
16.
Galsworthy-FrancisL.AllanS. (2014). Cognitive behavioural therapy for anorexia nervosa: A systematic review. Clinical Psychology Review, 34, 54-72. doi:10.1016/j.cpr.2013.11.001
17.
GutwillS. (1994). Women’s eating problems: Social context and the internationalization of culture. In BloomC.GitterA.GutwillS.KogelL.ZaphiropoulosL. (Eds.), Eating problems: A feminist psychoanalytic treatment model (pp. 1-27). New York, NY: Basic Books.
18.
HaslamM.MountfordV.MeyerC.WallerG. (2008). Invalidating childhood environments in anorexia and bulimia nervosa. Eating Behaviors, 9, 313-318. doi:10.1016/j.eatbeh.2007.10.005
19.
HaynosA. F.FruzzettiA. E. (2011). Anorexia nervosa as a disorder of emotion dysregulation: Evidence and treatment implications. Clinical Psychology: Science and Practice, 18, 183-202. doi:10.1111/j.1468-2850.2011.01250.x
20.
HaysP. (2001). Addressing cultural complexities in practice: A framework for clinicians and counselors. Washington, DC: American Psychological Association.
21.
HelmsJ. E. (1995). An update of Helms’s White and people of color racial identity models. In PonterottoJ. G.CasasJ. M.SuzukiL. A.AlexanderC. M. (Eds.), Handbook of multicultural counseling (pp. 199-217). Thousand Oaks, CA: Sage.
22.
HwangW. C. (2006). The psychotherapy adaptation and modification framework: Application to Asian Americans. American Psychologist, 61, 702-715. doi:10.1037/0003-066x.61.7.702
23.
HwangW. C. (2012). Integrating top-down and bottom-up approaches to culturally adapting psychotherapy: Application to Chinese Americans. In BernalG.Domenech RodríguezM. M. (Eds.), Cultural adaptations: Tools for evidence-based practice with diverse populations (pp. 179-198). Washington, DC: American Psychological Association Press.
24.
LaiK. (2000). Anorexia nervosa in Chinese adolescents—Does culture make a difference?Journal of Adolescence, 23, 561-568. doi:10.1006/jado.2000.0343
25.
LambertM. J.HansenN. B.UmphressV.LunnenK.OkiishiJ.BurlingameG. M.RiedingerC. R. (1996). Administration and scoring manual for the Outcome Questionnaire. Stevenson, MD: American Professional Credentialing Services.
26.
LambertM. J.HarmonC.SladeK.WhippleJ. L.HawkinsE. J. (2005). Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 16, 164-174. doi:10.1002/jclp.20113
27.
LeeE.MockM. (2005). Chinese families. In McGoldrickM.GiordanoJ.Garcia-PretoN. (Eds.), Ethnicity & family therapy (pp. 302-318). New York, NY: The Guilford Press.
28.
LeeJ. J.RiceC. (2007). Welcome to America? International student perceptions of discrimination. Higher Education, 53, 381-409. doi:10.1077/s10734-005-4508-3
29.
LeeS. (1995). Self-starvation in context: Towards a culturally sensitive understanding of anorexia nervosa. Social Science, 41, 25-36. doi:10.1016/0277-9536(94)00305-d
30.
MaJ. (2011). Anorexia nervosa and family therapy in a Chinese context. Hong Kong: The Chinese University Press.
31.
MaJ.ChanZ. (2003). The different meanings of food in Chinese patients suffering from anorexia nervosa: Implications for social work practice. Social Work in Mental Health, 2, 47-70. doi:10.1300/j200v02n01_04
32.
MakW.ChenS.LamA.YiuV. (2008). Understanding distress: The role of face concern among Chinese Americans, European Americans, Hong Kong Chinese, and Mainland Chinese. Counseling Psychologist, 37, 219-248. doi:10.1177/0011000008316378
33.
MirandaJ.BernalG.LauA.KohnL.HwangW.La FramboiseT. (2005). State of the science on psychosocial interventions for ethnic minorities. Annual Review of Clinical Psychology, 1, 113-142. doi:10.1146/annurev/clinpsy.1.102803.143822
34.
RootM. P. P. (2001). Future consideration in research on eating disorder. The Counseling Psychologist, 29, 754-762. doi:10.1177/0011000001295007
35.
SaferD. L.JoB. (2010). Outcome from a randomized controlled trial of group therapy for binge eating disorder: Comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy. Behavior Therapy, 41, 106-120. doi:10.1016/j.beth.2010.04.001
36.
SibeoniJ.HarfA.HuangY.MoroM. (2014). Child psychiatry in the Chinese setting. Child Adolescent Social Work Journal, 31, 329-337. doi:10.1007/s10560-013-0322-4
SueD. W.SueD. (2013). Counseling the culturally diverse: Theory and practice (6th ed.). Hoboken, NJ: John Wiley.
39.
SueS. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53, 440-448. doi:10.1037/0003-066x.53.4.440
40.
SueS. (2015). Therapeutic harm and cultural oppression. The Counseling Psychologist, 43, 359-369. doi:10.1177/0011000014565731
41.
TangN. M. (1997). Psychoanalytic psychotherapy with Chinese Americans. In LeeE. (Ed.), Working with Asian Americans: A guide for clinicians (pp. 323-341). New York, NY: The Guilford Press.
42.
TelchC. F.AgrasW. S.LinehanM. M. (2000). Group dialectical behavior therapy for binge-eating disorder: A preliminary, uncontrolled trial. Behavior Therapy, 31, 569-582. doi:10.1016/s0005-7894(00)80031-3
43.
TozziF.SullivanR.FearJ.McKenzieJ.BulikC. (2003). Causes and recovery in anorexia nervosa: The patient’s perspective. International Journal of Eating Disorders, 33, 143-154. doi:10.1002/eat.10120
44.
U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity—A supplement to mental health: A report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, Public Health Services, Office of the Surgeon General.
45.
WatsonH.BulikC. (2013). Update on the treatment of anorexia nervosa: Review of clinical trials, practice guidelines and emerging interventions. Psychological Medicine, 43, 2477-2500. doi:10.1017/s0033291712002620
46.
WendtD. C.GoneJ. P.NagataD. K. (2015). Potentially harmful therapy and multicultural counseling: Extending the conversation. The Counseling Psychologist, 43, 359-369. doi:10.1177/0011000014565731
47.
WilsonG.GriloC.VitousekK. (2007). Psychological treatment of eating disorders. American Psychologist, 62, 199-216. doi:10.1037/0003-066x.62.3.199
48.
WisniewskiL.SaferD.ChenE. (2007). Dialectical behavior therapy and eating disorders. In DimeffL. A.KoernerK. (Eds.), Dialectical behavior therapy in clinical practice: Applications across disorders and settings (pp. 174-221). New York, NY: The Guilford Press.
