[Report]
Eating Disorder Diagnoses and Treatments: An Educational Symposium
By Susan C. Gardstrom, Hannah Lowe & Meredith Schlabig
Abstract
This report highlights a one-day educational symposium on the topic of eating disorders (EDs), which impact young adults/college students at troubling rates. The goals of the symposium were to increase the attendees' knowledge about EDs and positively impact their attitudes toward individuals with EDs. An estimated 60 people voluntarily attended the event, including but not limited to (1) students and professionals from the fields of music therapy, psychology, health and sports sciences, dietetics, and art therapy; (2) individuals who previously or at the time of the symposium had an ED; and (3) individuals who had a relative or friend with an ED diagnosis. Speakers included a psychologist, a board-certified music therapist (keynote), a registered and licensed dietitian, and a registered and board-certified art therapist. Results of a pre- and post-symposium survey indicate that over two-thirds of the respondents (68%) reported an increase in general knowledge about EDs and an even greater number reported an increase in knowledge about treatments and therapies (89%). Attitudes were positively impacted as well, although changes were small owing to high pre-symposium scores. Narrative feedback was wholly positive and lends support to the numerical data for the perceived importance and value of this event.
Keywords: Eating disorders, anorexia, bulimia
Introduction
The American Psychiatric Association (2013) identifies three types of eating disorders (EDs) as follows: anorexia nervosa (when an individual restricts caloric intake to achieve weight loss); bulimia nervosa (when an individual engages in recurring episodes of binge eating and/or self-induced vomiting to achieve weight-loss); and binge eating disorder (when an individual engages in recurring episodes of over eating). A comprehensive review of a global database of published literature about EDs (Hoek & van Hoecken, 2003) places the annual incidence of anorexia nervosa at 8 cases per 100,000 and the incidence of bulimia nervosa at 12 cases per 100,000. Data from a World Health Organization survey of 12 countries indicate that binge eating disorders appear in between .2% and 4.7% of the population, with Brazil showing the highest rates (Kessler, Berglund, Chiu, Deitz, Hudson, Shahly, Aguilar-Gaxiola, Alonso, Angermeyer, Benjet, Bruffaerts, de Girolamo, de Graaf, Maria Haro, Kovess-Masfety, O’Neill, Posada-Villa, Sasu, Scott, Viana, & Xavier, 2013). Makino, Tsuboi, and Dennerstein (20014) assert that, although ED rates appear to be highest in industrialized nations such as North America, Europe, Australia, New Zealand, Japan, and South Africa, “abnormal eating attitudes in non-Western countries have been gradually increasing” (p. 1).
While they impact many countries and age groups, EDs are a notable problem among college students in the United States (USA), with 86% of those affected reporting onset of symptoms by age 20 (National Association of Anorexia Nervosa and Associated Disorders, 2000). Berg, Frazier, and Sherr (2009) surveyed female students in an North American university twice over a two-month period to investigate the correlation between stressors of college life (e.g., academic stressors, self-esteem, social insecurities) and symptoms of EDs. The first survey indicated that 49% of the respondents engaged in some form of disordered eating at least once per week. In a more recent, random screening on one American college campus, Eisenberg, Nicklett, Roeder, and Kir (2011) found that 13.5% of female and 3.6% of male undergraduate students tested positively for ED symptoms. Only 20% of these individuals had received mental health treatment within the year of the screening.
Our own life experiences contributed to our desire to learn more about various EDs. The three of us have had family members, friends, and acquaintances with EDs. We have watched in distress as these individuals were ignored and even shunned by relatives and friends who did not understand their illnesses. We have seen how this societal stigma and a lack of support prevented these individuals from seeking treatment. In order to reverse this situation, we believe that health and mental health care professionals need to be better educated about EDs and the various treatments available to affected individuals and their loved ones. We also believe that it is critical for the general public—more specifically, for young adults/college students who are profoundly impacted—to have a better understanding of ED diagnoses and treatments.
According to data from the American Music Therapy Association Member Survey (2013), a very small percentage of its members work specifically with clients with EDs. This percentage might increase, however, if we also consider practitioners working with clients who exhibit disordered eating behaviors but who do not carry formal diagnoses and clients who hide their diagnoses. In any event, there seems to be some professional interest in this clientele. Regional and national music therapy conferences in the USA occasionally feature presentations about EDs, and there are a handful of peer-reviewed articles and book chapters, as well as a podcast on the topic, representing music therapists’ work in the USA, Australia, the United Kingdom, Norway, and other countries. (See, for example: Bauer, 2010; Heiderscheit, 2008; Heiderscheit, 2009; Hilliard, 2001; Justice, 1994; McFerran, Baker, Patton, & Sawyer, 2006; Nolan, 1989; Parente, 1989a; Parente, 1989b; Rogers, 1995; Trondalen, 2005; and Trondalen 2011). Nonetheless, the aforementioned resources appear limited when compared to those available about other clientele. And so, we began to wonder: Is there anything that we can do to help dismantle myths and lessen social stigmas about EDs? And, is there anything that we can do to help music therapists in training and certified music therapists come to know this clientele, with its unique diagnostic profiles and treatment needs?
Eating Disorders Symposium
We decided to organize and host an educational symposium about EDs. Music therapy symposia have been held on a variety of topics (Murphy & Wheeler, 2005; Wheeler & Grocke, 2001) and have been shown to positively impact learning (Heine, 1996). Our symposium was composed of presentations by health and mental health care professionals who shared statistics related to the disorders, case studies, and anecdotes, artifacts, and research based on their clinical experience.
The overarching goals of the symposium were to increase the attendees' knowledge about EDs and positively impact their attitudes toward individuals with these disorders. In particular, we aimed to (a) promote awareness of the prevalence of EDs, specifically among young adults/college-aged individuals; (b) increase general knowledge of EDs and the treatments available to individuals with these disorders; and (c) improve attitudes toward individuals diagnosed with EDs by eliminating misleading stereotypes and promoting accurate understanding of the disorders.
The symposium was held in an auditorium on the campus of the University of Dayton, Ohio, USA. Speakers included a psychologist, a board-certified music therapist, a registered and licensed dietitian, and a registered and board-certified art therapist. All of the symposium presenters were invited on the basis of their extensive knowledge about and previous and present work with clients with EDs. The presenters were as follows: Rebecca Cook, PhD., a psychologist at the University of Dayton; Rachel Riddiford, MS, RD, LD, a dietitian at Dayton Children’s Hospital; Susan Clark, LPC, an art therapist at the Cleveland Center for Eating Disorders; and the keynote speaker, Dr. Annie Heiderscheit, MT-BC, LMFT, a music therapist at Melrose Center, an eating disorder institute in Minnesota. Additionally, a music therapy major from the University of Dayton shared personal testimony related to her ED.
As the primary audience, we targeted music therapy students from the host university and other universities in the region. We also invited undergraduate and graduate students from various other disciplines and professional music therapists from the local community. An estimated 60 individuals voluntarily attended the symposium to learn more about EDs and related treatments. These individuals included, but were not limited to (a) students and professionals from the fields of music therapy, psychology, health and sports sciences, dietetics, and art therapy; (b) individuals who previously or at the time of the symposium had an ED; and (c) individuals who had a relative or friend with an ED diagnosis.
The interdisciplinary focus was intentional: we especially wanted to expose music therapy clinicians and students to a variety of perspectives in order to stimulate their curiosity and enhance their understanding about various treatment modalities, which might better prepare them for a team approach to treatment with this clientele and incline them toward future professional collaborations. For most of the music therapy students in attendance, the symposium represented their first exposure to a family therapist and the disciplines of art therapy and dietetics. In what are typically jam-packed training curricula, it is helpful to find creative ways to introduce music therapy students to kindred therapeutic modalities.
We collected data pertaining to our goals using a brief, voluntary and anonymous survey consisting of five questions (see Appendix A). Our survey was designed to answer the following research questions:
- What percentage of respondents will report an overall increase in knowledge about ED prevalence, diagnoses, and treatments?
- What percentage of respondents will report overall positive changes in attitude toward individuals with EDs?
The present report summarizes the keynote presentation about music therapy, details procedures for survey data collection and analysis, presents findings, and offers suggestions for future education and training related to this seemingly somewhat-overlooked clientele.
Keynote Presentation
As music therapy students were the primary targeted audience, we invited board certified music therapist, Dr. Annie Heiderscheit, to serve as the keynote speaker at the symposium. Dr. Heiderscheit is a licensed marriage and family therapist and a Fellow of the Association of Music and Imagery who has worked for many years with clients who have EDs. She practices a holistic approach, which places value on the healthy development and balance of the mind, body, and spirit. In her presentation, Dr. Heiderscheit discussed the negative impact of EDs, explained the interventions that she employs with clients using anecdotes and artifacts, and demonstrated receptive, re-creative, and improvisational interventions with audience participation.
EDs can be fatal. In fact, crude mortality rates for various EDs have been calculated to range from 3.9% to 5.2% (Crow, Peterson, Swanson, Raymond, Specker, Eckert, & Mitchell, 2009). This suggests the importance of physical stabilization prior to psychotherapeutic intervention. Once an individual is ready for psychotherapy, emotional needs can be targeted. Two fundamental needs of individuals with EDs are (1) to discover and adopt healthy ways to express their emotions, and (2) to manage the emotional discomfort (i.e., anxiety) that accompanies the disorders themselves as well as the process of change, rather than resorting to familiar self-harming thoughts and behaviors. Dr. Heiderscheit noted that the process of change can be difficult and frightening for clients, but progress in emotional expression and management of anxiety are critical steps in the healing process. Music therapy can help address these needs in a variety of ways.
Dr. Heiderscheit often invites her clients to create mandalas. Mandalas are circle drawings that are used as expressive and diagnostic tools. A client’s mandalas are thought to represent his or her psychological experience, revealing both conscious and unconscious emotions (Giuseppe, 2001). The presenter showed examples of mandalas created by her clients while they listened to therapist-selected, recorded music and reflected on their disorders. The symposium audience identified reoccurring elements in each mandala, including heaviness, isolation, darkness, and depression. As noted above, having a means to express these difficult emotions is imperative to change, and mandalas provide one nonverbal option for such expression.
Dr. Heiderscheit also discussed the power of songs in the change process. Songs can help clients to recount the “stories of their lives”, provide inspiration, and shift their experience of emotions. Dr. Heiderscheit explained how lyrics and music have the power to raise difficult questions that challenge the listeners’ disordered thinking, yet do not require them to provide a direct answer. As an example, she played the songs “Change” by Tracy Chapman and “I’m Movin’ On” by Rascal Flatts. The lyrics of “Change” require the listeners to reflect on the question posed throughout the song: “If you knew that you would die today, would you change?” In “I’m Movin’ On,” the lyrics and music help the listeners to reflect on how to cope with and ultimately overcome negative experiences. The presenter noted that the process of listening impacts everyone differently, yet many songs—the latter, in particular—are broad enough to encompass the clients’ various personal experiences.
Furthermore, Dr. Heiderscheit explained the importance of musical elements in songs, such as tempo, timbre, and so forth. These elements provide support to the lyrics and suggest emotional content. In the song “Change,” the musical elements are congruent with the lyrics: The driving rhythm incites movement, thus matching the motivational intent of the text. “I’m Movin’ On” begins with piano accompaniment and a solo vocalist, which implies feelings of quiet contemplation. As the song progresses and transitions into the chorus, the texture thickens to include multiple instruments and voices, implying the singer’s strength and perseverance through difficult times.
Dr. Heiderscheit turned next to the method of composition and described its therapeutic benefits. As she uses it, songwriting aims to help clients with EDs grow in their creative abilities and experience creative processes. The nature of songwriting is such that it places particular demands on the participants, such as facing perfectionistic and anxious tendencies. Songwriting in a group setting provides individuals with the opportunity to support one another throughout the creative process and ultimately celebrate together completion of the product.
Dr. Heiderscheit also introduced the attendees to the benefits of instrumental improvisation, and specifically how it can provide an outlet for intense emotions that clients may not be able or willing to verbalize. Referential improvisation provides clients with an opportunity to depict specific emotions using their voices and instruments. Not only can they experience certain emotions in the moment, but they also may experience a release of these emotions – a musical catharsis. Through the method of improvisation, clients learn how to release emotions such as fear, anger, sadness, and disgust in healthy ways rather than regressing to the maladaptive coping behaviors associated with their EDs. And, as with songwriting, improvisation allows clients to explore new and unpredictable situations and to tolerate the accompanying discomfort.
To close, the presenter engaged a handful of volunteers from the audience in an instrumental improvisation role-play. She used a structure that she has found to be beneficial with clients and their family members, called Music-Centered Family Sculpting. In this experience, the designated client first assigns a musical instrument to each of his or her family members and selects a participant and instrument to represent the eating disorder itself. The client then instructs all participants where and how to position themselves relative to the client and how to play their assigned instruments. The instruments themselves and the particular means of sounding them are meant to reflect the roles of the eating disorder and each family member within the ED paradigm. Once the improvisation is over, Dr. Heiderscheit facilitates a discussion regarding family relationships and what issues need to be addressed in order to improve family health.
Data Collection and Analysis
We employed a pretest-posttest survey design. Some attendees stayed for only one or two presentations, while others attended the entire symposium. For this reason, at the very start of the symposium and again at the start of each presentation throughout the day, we invited attendees to complete the pretest. The posttest was identical to the pretest, except that it included an “Additional Comments” section, which allowed the attendees to offer their personal reactions to the symposium in narrative form. At the end of each presentation and again at the very end of the symposium, we invited those who were leaving to complete the posttest and place it in a box located in the back of the auditorium. This box had a lid to protect the anonymity of the attendees who chose to complete the survey.
Forty-seven attendees completed the survey. For data analysis, each survey was identified by a letter or group of letters (A through E) representing the five symposium presentations in chronological order. This coding system enabled us to track which presentation or combination of presentations might have yielded the greatest changes in the desired directions. Once the surveys were labeled and sorted by presentation attendance, the differences between the pretest and posttest scores for each survey question were tallied. For example, in response to the question “Rate your knowledge about diagnostics/general knowledge of eating disorders”, one respondent indicated a 2 on the pre-test and a 4 on the post-test, representing a difference of +2. These data yielded overall percentages of increase, decrease, or no change for each survey question across all respondents.
Results
Total percentages of respondents indicating an increase, a decrease, and no change to each of the five survey questions appear in Table 1, below.
| Questions | Increase | Decrease | No Change | |||
|---|---|---|---|---|---|---|
n |
% |
n |
% |
n |
% |
|
| Knowledge | ||||||
| 1. Diagnoses/general information | 32 |
68 |
0 |
0 |
15 |
32 |
| 2. Treatments and therapies | 41 |
89 |
0 |
0 |
5 |
11 |
| Attitude | ||||||
| 3. Nonjudgmental | 17 |
36 |
1 |
2 |
29 |
62 |
| 4. Concerned | 11 |
24 |
2 |
4 |
33 |
72 |
| 5. Sympathetic | 16 |
34 |
0 |
0 |
31 |
66 |
Discussion
Based on the survey data, it would appear that this one-day educational symposium was effective in increasing attendees’ knowledge. Just over two-thirds of the respondents (68%) reported an increase in general knowledge about EDs (prevalence, diagnoses, etc.), and an even greater number reported an increase in knowledge about ED treatments and therapies (89%). In most cases, increases were incremental; however, two respondents increased their knowledge score by 4 points, moving from a 1 at pretest to a 5 at posttest. As might be expected, no respondents reported decreases in knowledge after attending the symposium.
It would seem also that this symposium was somewhat effective in improving attendees’ general attitudes toward individuals diagnosed with EDs. Across all three dimensions of attitude (judgment, concern, sympathy), some attendees reported positive attitudinal shifts toward individuals with EDs (46%), while other attendees’ attitudes were reportedly unchanged (54%). The latter percentage can be explained by high pre-symposium attitudinal scores: 62% indicated pretest scores of 4 or 5, and only one pretest score across all attitudinal dimensions was lower than 4. As with knowledge, changes were small, except in one case in which a respondent shifted in a positive direction by 4 points (nonjudgmental). We found no obvious differences between scores of individuals who attended the music therapy presentation and those who did not, except that a slightly higher percentage of respondents in the former group who attended the music therapy presentation only (n = 10) indicated positive attitudinal shifts (nonjudgmental and concerned) as compared to those who attended just one other presentation (n = 5). No respondents reported a decrease in positive attitude across all three attitudinal dimensions.
Although we did not collect demographic data, it appeared that all of the respondents who attended only the music therapy presentation (n = 10) were music therapy students at the university who had been encouraged by their professors to attend the keynote address, even if they could not stay for the entire symposium. Upon analysis of the narrative data collected from these attendees, we discovered several overlapping themes. These themes included having a friend or family member with an ED and a related desire to become more educated about EDs to help these loved ones, aspirations toward a career with individuals with EDs, and a sincere appreciation for the emotional depth of Dr. Heiderscheit’s presentation. We can infer confidently that the music therapy students who attended this presentation found it to be a highly impactful and positive experience.
The overall narrative feedback was wholly positive and lends support to the numerical data for the perceived importance and value of this symposium. A sample of responses appears below:
This symposium helped me realize how serious and prevalent EDs really are. I feel like they are simply not talked about enough.
Fantastic speakers! I learned so much. It was great to see the different approaches outside music therapy and to see how all the professionals agree on the need to work together. It was also wonderful to meet other students and faculty and see how they interact. I loved being here and learning things I probably never [would] have learned in class.
I am so glad this incorporated so many different professional perspectives on EDs and ED treatment and therapies. It really helped me get a more well-rounded understanding of EDs and how treatment is a multifaceted process. I especially enjoyed having an art therapist speak. I learned so much about incorporating different methods and techniques in my own therapy practice, and I know I can take what I learned and apply it to working with a wide variety of client populations and settings. Thank you so much!
Certain comments aligned with the personal experiences that served as our primary impetus for organizing the symposium. They also reflected a profound concern for loved ones who had been impacted by EDs:
I have a sibling who has been struggling with an eating disorder for 9 years. Even though I have been surrounded by her disorder for so long, the complexity and multiple etiologies is something I am still learning about. Thank you for spreading awareness.
My cousin passed away one year ago after suffering with an eating disorder since she was thirteen. Her eating disorder was accompanied with alcoholism. I witnessed her desperately try to seek treatment and saw what her illness did to my family. She was never able to capture and defeat the demons that took over and destroyed her life at only age twenty-nine.
In high school I had multiple friends with eating disorders, some of whom were hospitalized for it. So, I have been around eating disorders a lot but never knew how to help them.
As we appraised the event, we noted several positive aspects, as well as features that could have been improved. The college campus location and weekend time were relevant and convenient, as college students were the targeted audience. Further, all presenters were perceived as knowledgeable and well prepared. Many attendees commented favorably about the interactive styles of the presenters and the variety of topics.
The music therapy keynote was the only presentation with a true experiential component. Future symposia might include more experiential methods of learning, as the benefits of such pedagogies in music therapy pre-professional education and training have been well substantiated (Bruscia, 2013; Murphy, 2007; Murphy & Wheeler, 2005). And, in that an event such as this may evoke difficult emotions among the attendees, it may be valuable to include a debriefing session or some other opportunity for these emotions to be processed. Our results should be interpreted with caution for, although we consulted a few standardized scales in preparation for the event, our survey tool was neither standardized nor piloted. In addition, had we begun planning and advertising earlier, we may have been able to attract a larger contingent of music therapy students from other universities in the region. Of course, with recent advances in technology, such symposia can be delivered easily and inexpensively to large numbers of music therapy students and clinicians all over the globe. Finally, our advocacy aims may have been more effectively addressed had campus media relations covered the event.
Conclusion
Our hope was that symposium attendees—both those from the discipline of music therapy and those from related health and mental health care disciplines—would increase their knowledge about EDs and improve their attitudes toward individuals who carry these diagnoses. Equipped with accurate knowledge and a positive perspective, we may be able to improve our clinical services and more effectively advocate for affected individuals and their loved ones. Our findings have strengthened not only our belief in the value of educational symposia toward these aims but in the unique and powerful impact of the arts. One respondent nicely summed it up:
Individuals with eating disorders need the support of others as they walk through their journey of healing. Arts based creative therapies can play an integral role in this process.
Acknowledgements
The symposium was made possible through a University of Dayton Learn, Lead, and Serve grant and a University of Dayton Health and Wellness Promotion grant. Further support came from the University of Dayton Departments of Music and Psychology.
The researchers acknowledge and thank the Symposium Student Steering Committee members who helped to organize the event and all symposium presenters. We also extend appreciation to Professor Wiebke Diestelkamp, PhD, for her assistance with data analysis.
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