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Negotiating Contradictory CulturalPressures: A Treatment Model for BingeEating in Adolescent GirlsLaura Hensley Choate aa Louisiana State University , Baton Rouge, LouisianaPublished online: 03 Oct 2011.

To cite this article: Laura Hensley Choate (2011) Negotiating Contradictory Cultural Pressures:A Treatment Model for Binge Eating in Adolescent Girls, Women & Therapy, 34:4, 377-392, DOI:10.1080/02703149.2011.591668

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Negotiating Contradictory Cultural Pressures:A Treatment Model for Binge Eating

in Adolescent Girls

LAURA HENSLEY CHOATELouisiana State University, Baton Rouge, Louisiana

Today’s adolescent girls experience sociocultural pressures and lifestressors which result in negative mental health outcomes, includingbinge eating. The purpose of this article is to present a model ofpsychotherapy for adolescent girls who engage in binge eating. Thecomponents in this model include: (a) Feminist Therapy to empha-size client empowerment and the importance of socioculturalcontext in understanding girls’ concerns; (b) Cognitive BehaviorTherapy to help clients to eliminate dieting and to cope with pressuresfor attaining the beauty ideal; (c) Dialectical Behavior Therapy toassist clients in coping with emotions; and (d) Interpersonal Therapyto help clients improve relational transitions and disputes.

KEYWORDS adolescent girls, binge eating, mental healthtreatment

While today’s girls and women are achieving at exceptional academic andprofessional levels, they are also increasingly socialized to conform tonarrowly defined ideals regarding how they should look and act (AmericanPsychological Association [APA], 2007; Ward & Friedman, 2006). Girls arelearning that they can be and do anything to which they aspire, but a conse-quence is that they are experiencing pressure to be perfect in all areas: excelacademically, be involved in multiple extracurricular activities, and achieve athigh levels of athletic competence. At the same time, they are socialized to benurturing, empathic, and caretakers in relationships, while also beingcompetitive and often aggressive (Hinshaw, 2009). In addition, girls receivethe message that they must be beautiful, sexy, and thin, and that reaching this

Address correspondence to Laura Hensley Choate, Counselor Education, 122 PeabodyHall, Louisiana State University, Baton Rouge, LA 70803. E-mail: lchoate@lsu.edu

Women & Therapy, 34:377–392, 2011Copyright # Taylor & Francis Group, LLCISSN: 0270-3149 print=1541-0315 onlineDOI: 10.1080/02703149.2011.591668

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ideal is the most important avenue for achieving success and value as awoman (APA, 2007; Lamb & Brown, 2006; Levin & Kilbourne, 2008).

There is evidence that girls internalize these messages from popularculture, making them vulnerable to problems such as depression, self-injury,physical aggression, and eating disorders, which are all on the rise in teenagegirls (Hinshaw, 2009). Binge eating in particular is emerging as an increasingproblem among girls, in part as a means for coping with these often contra-dictory and unrealistic cultural expectations. Binge eating has increasedamong adolescent girls in recent years, with 20% to 60% of girls in communitysamples reporting episodes of binge eating (Ackard, Neumark-Sztainer, Story,& Perry, 2003; Hudson, Hiripi, Pope, & Kessler, 2007; Shisslak et al., 2006;Sierra-Baigrie, Lemos-Giraldez, & Fonesca-Pedero, 2009).

Binge eating, defined in the proposed criteria for Binge Eating Disorderin the forthcoming DSM-5 (American Psychiatric Association, in press), ischaracterized by both objective eating episodes (eating within a discreteperiod of time an amount of food that is definitely larger than most peoplewould eat in a similar time period and under similar circumstances) and lossof control (feeling that one cannot stop eating or control what or how muchone is eating). Binge eating episodes may also be associated with eatingmore rapidly than normal, eating until feeling uncomfortably full, eating inthe absence of hunger, eating alone due to embarrassment over how muchone is eating, or feeling disgust, depression, or guilt after overeating. Whilebinge eating in Bulimia Nervosa is followed by compensatory behaviors (suchas purging through vomiting or laxatives), the binge eating that occurs withBinge Eating Disorder is not associated with purges to compensate for bingeepisodes. Because a large amount of calories are consumed during bingeeating episodes, weight gain often ensues. As such, binge eating is linked withobesity and its associated medical complications. Binge eating is also relatedto body image dissatisfaction, low self-esteem, depression, suicide attempts,medical complications, and increased risk for current and future psychiatricproblems (Ackard et al., 2003; Stice, Marti, Shaw, & Jaconis, 2009; Tanofsky-Kraff et al., 2007). Because binge eating is increasing among adolescent girls,the purpose of this article is to review models for understanding binge eatingonset and to discuss a proposed treatment model comprised of four compo-nents: Feminist Therapy, Cognitive Behavior Therapy (CBT), DialecticalBehavior Therapy (DBT); and Interpersonal Therapy (IPT).

MODELS OF BINGE EATING

There are two primary models to explain the onset of binge eating inadolescent girls: the dietary restraint model and the emotion dysregulationmodel. According to the dietary restraint model, as girls face increasing cul-tural pressures that equate their worth with beauty and thinness, many begin

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to diet in an effort to achieve the thin and sexualized ideal (Stice, Presnell, &Spangler, 2002). Between 60% and 80% percent of middle school and highschool girls report dieting behavior (Lock & LeGrange, 2006). Dieting is astrong predictor of binge eating onset in adolescent girls (Stice, Presnell, &Spangler, 2002). Ultimately, diets cause girls to fail in their attempts to reachan ideal weight or shape, setting them up to lose control and engage in bingeeating (Fairburn, 2008). In fact, girls who engage in the most extreme dietingbehaviors such as fasting are at the highest risk for binge eating (Stice, Davis,Miller, & Marti, 2008).

Research indicates that dieting is generally not sustainable over a periodof time, because when the body experiences deprivation, it responds withstrong urges to overeat, often causing a loss of control when eating is resumed(Fairburn, 2008). Dieting also puts a girl at risk for binge eating due to theabstinence-violation effect (i.e., the belief that once she has violated the rulesof her diet plan, she might as well eat everything she desires). Further, dietingleads a girl away from relying on her physical hunger as a cue for eating.Instead, she begins to rely on cognitive control strategies to regulate whenand what she eats. As cognitive control is highly susceptible to changes in agirl’s thoughts, emotions, and circumstances, binge eating can result whencognitive control strategies are disrupted (Fairburn, 2008).

The emotion dysregulation model explains binge eating as related to anadolescent girl’s inability to regulate her emotions. Research indicates stronglinks between negative affective states and binge eating (Polivy & Herman,1993), as binge eating may serve as a learned coping response for reducingunpleasant emotions. While it has negative long-term consequences, the bingeeating behavior is maintained over time due to its short-term effectiveness intemporarily numbing or decreasing the intensity of uncomfortable emotions(Safer, Telch, & Chen, 2009). In today’s cultural climate in which girls experi-ence contradictory and unfamiliar pressures at young ages, it makes sense thatthey might resort to binge eating as a way to cope with or escape from over-whelming feelings of sadness or powerlessness (Smolak & Murnen, 2004).

Whether or not a girl engages in binge eating to cope with her emotionsor develops binge eating in response to dieting and overvaluation of weightand shape is influenced in part by culture. One study that examined culturaldifferences in maladaptive eating found that Hispanic adolescent girls werethe most likely to report any disordered eating behaviors (e.g., binge, vomit-ing, fasting, using diet pills) (Ackard et al., 2003). Further, compared to otheradolescent girls, African American girls are the least likely to engage in weightcontrol behaviors and appear more comfortable and satisfied with theirbody weight and shape (Chao et al., 2008). However, binge eating is the mostcommon disordered eating pattern among African American women, althoughit manifests differently than for women from other cultural groups. Forexample, when African American and White women with binge eating arecompared, Black women weigh more, report more binge eating episodes,

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and have more realistic perceptions about the importance of weight and shapein determining self-worth. For African American women, binge eating appearsto be a strategy for coping with stressors rather than a response to perceivedpressures for thinness (Striegel-Moore, Dohm, Pike, Wilfley, & Fairburn, 2002).

TREATMENT MODEL FOR BINGE EATING IN ADOLESCENT GIRLS

Based on research findings regarding binge eating in adolescent girls, isimportant for therapists to introduce counseling strategies designed to addressboth subtypes of binge eating identified in the literature (Grilo et al., 2009;Stice et al., 2002): (a) the overvaluation of weight and shape and problemswith dieting to achieve the thin cultural ideal, and (b) the use of binge eatingto cope with emotions. The components in this proposed model include ele-ments from psychotherapy approaches designed to address these concerns.The model includes: (a) Feminist Therapy approaches which emphasizeclient empowerment and which recognize the importance of socioculturalcontext; (b) CBT to address the elimination of dieting, introduce regulareating patterns, decrease the overvaluation of weight and shape, andstrengthen cognitive coping skills for challenging negative societal messagesfor girls and women; (c) DBT to teach mindfulness, emotion regulation, anddistress tolerance skills that enhance a client’s ability to identify, regulate, orexpress her emotional experiences; and IPT to address relational concerns,including family, friendships, and romantic relationships, and to assist girlsin more effectively expressing emotions in their relationships.

Empowerment Component: Feminist Therapy

Feminist Therapy approaches to working with girls and women assert thattherapists should understand the impact of gender as well as the influencesof other social variables such as social class, race=ethnicity, health status,and sexual orientation on women’s development. Feminist therapies alsoassert the importance of understanding clients’ unique experiences withinthe context of larger social forces that shapes their private lives, recognizingthat women’s individual problems cannot be separated from their sociocul-tural context (Piran, Jasper, & Pinhas, 2004; Worell & Remer, 2002). Thesesocial forces include the effects of media in popular culture; the contradictorysocial messages that girls and women receive, and the emphasis on weight,shape, and appearance as the determinants of women’s self-worth (APA,2007). Because of these influences, the therapist understands that many ofthe client’s maladaptive behaviors may be viewed as ways to cope withoppressive societal conditions. For example, binge eating is reframed as anunderstandable method for coping with the myriad of contradictory culturalmessages and life stressors that are harmful to girls and women.

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Feminist therapy approaches also emphasize client empowerment, sothat the client is viewed as her own expert who may be in need of supportand information in order to find her own answers. To promote client empow-erment, feminist therapists promote egalitarian relationships both within andoutside of therapy. They emphasize ways to share powerwith the client ratherthan asserting power over the client (Cummings, 2000) by demystifying thecounseling process, working collaboratively in setting treatment goals, andworking to decrease the power differential in the relationship whenever poss-ible (Worell & Remer, 2002). Adolescent girls in particular may be strugglingwith issues of autonomy and control and in maintaining an authentic voicewithout resorting to self-silencing in order to protect their relationships(Gilligan, 1991). Therefore, allowing the client to have a voice, to makechoices, and to share power in treatment is an important first step towards cre-ating an alliance and in empowering her to reach her goals (Piran et al., 2004).

Therapists can also work to value girls’ and women’s strengths and per-spectives that are often devalued by the larger culture. This includes empha-sizing the importance of relationships as central to women’s development andreinforcing qualities such as empathy, nurturance, cooperation, intuition, andinterdependence (Piran et al., 2004; Worell & Remer, 2002). As girls learn tovalue these strengths, they can develop coping skills for challenging limitinggender role expectations and for freeing themselves from roles that do not fitwith their own personal values (Choate, 2008). Because feminist principlesare foundational to therapy with girls and women, these tenets can be appliedthroughout the three components described in the paragraphs to follow.

Cognitive-Behavior Component: Cognitive Behavioral Therapy

CBT is the best researched and supported psychotherapy for the treatment ofbinge eating (American Psychiatric Association, 2006). The overall goal ofCBT for binge eating is to support the client to eliminate dieting, normalizeher eating patterns, and change her maladaptive thinking around the impor-tance of weight and shape (Fairburn, 1995; 2008). CBT is recommended as thefirst step in treatment for adolescent girls who are engaged in a cycle of dietingand binge eating and who over-evaluate the importance of weight and shapein determining their identity and worth as a person (Fairburn, 2008). As statedpreviously, some girls do not struggle with these issues and would be able tobegin therapy by focusing on the DBT and IPT strategies which follow thissection.

In Fairburn’s treatment manual for eating disorders (2008) and self-helpmanual for binge eating (1995), a pattern of regular eating is the mostimportant CBT technique for addressing the elimination of dieting behavior.To normalize eating, clients are assisted in planning and eating three mealsper day plus two snacks, with no more than a 4-hour interval between eating.If necessary, therapists can assist clients in planning their eating routine, as

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many clients have dieted for so long they may have difficulty in contemplatinghow to eat meals and snacks that do not involve dieting or subsequent binge-ing. If necessary, psychoeducation regarding healthy eating and exercisehabits can be introduced. The client can also develop a list of situations thatmight typically trigger a binge. She can then create a coping plan for manag-ing each of these situations effectively. This might involve engaging in activi-ties that are incompatible with binges (e.g., going for a leisurely walk with afriend; leaving the house after eating so that she won’t be around foods thatmight lead to a binge, or limit availability of high risk foods; Pike, Loeb, &Vitousek, 1996; Wilson, Fairburn, & Agras, 1997). While these strategies mightrequire direction and information from the therapist, the client should be sup-ported in making as many decisions as possible about her new eating plan. Asshe begins to eat on a regular schedule and to use these behavioral strategies,she may no longer experience a sense of deprivation or hunger, so her urgesto binge will be highly reduced. Further, she can begin to recognize that evenwith the elimination of dieting she will not gain weight and that by eating on aregular basis her weight will stabilize around a range that is physiologicallymost optimal for her (Fairburn, 2008).

As the client begins to eat on a regular basis, she is likely to have morephysical energy and be able to think more clearly. At this point, she may beready to begin focusing on changing her beliefs around pursuit of the thin,beautiful, and sexualized cultural ideal. She may have internalized the culturalmessage that the quickest way to validation and success as a woman isthrough modeling her appearance after narrowly defined cultural standards.To assist her in identifying the priority she gives to her appearance, therapistscan use a self-evaluation pie chart. The therapist can ask the client to thinkabout all areas of her life upon which she judges herself or that cause herto feel good or badly about herself (e.g., school, sports, appearance, family,friends) and then complete the pie with appropriately proportioned slicesfor each life area (Fairburn, 2008). The pie chart provides her with a visualrepresentation of the need for reducing the importance of appearance inher life and for increasing the proportion of other areas that will contributeto more of a sense of meaning and purpose.

To begin changing the importance of weight and shape in her life, thetherapist can assist a client in examining negative cultural pressures for today’sgirls and how these might be influencing her current thought patterns. Using afeminist framework, therapists can explore examples of harmful messagessuch as: Girls should be perfect in all areas, achieve at high levels, do every-thing boys can do, but above all else, also look ‘‘hot’’ and sexy (Hinshaw,2009). They should claim ‘‘girl power’’ but also allow others to treat them assexual objects (APA, 2007). Girls also learn that they should be caretakingand conforming in order to preserve their relationships, but at the same timethey should be competitive and demand what they want with an aggressiveattitude (Garbarino, 2006). Further, they learn that to be acceptable they

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should appear effortlessly sexy, but not to be overtly sexual or to be seen aspromiscuous (Hinshaw, 2009).

After examining these cultural messages, the therapist can help a clientto separate these external expectations from her personal beliefs. The clientcan explore what it would be like to trust her own values regarding how sheshould look and act. She can begin to recognize that she does have a choicein how she allows sociocultural pressures to influence her sense of self-worthand her lifestyle. As she begins to develop an internally derived value systemand an internal locus of control, she can begin to rely less on others’ opinionsregarding the importance of appearance (Choate, 2008).

It is also helpful to provide her with psychoeducation to assist her inmaking informed choices about her beliefs related to the beauty ideal. Mostgirls do not realize that the weight gains that occur in puberty are normal, withthe average adolescent girl gaining between 30 to 50 pounds during thepubertal period (Levine & Smolak, 2002). It is also helpful for her to learnabout the social construction of beauty in Western culture and how the idealhas changed historically. When she looks at magazines, watches television,movies, and videos, or sees billboards, she needs to know that all of theimages representing the beauty ideal are created through digital editing,soft-focus cameras, or through the models undergoing cosmetic surgery(Groesz, Levine, & Murnen, 2002). She can learn to recognize that these repre-sentations are unrealistic and are unattainable for the vast majority of women,for even models themselves do not look like these digitally enhanced images.

Another way to work with a client in decreasing the importance ofappearance is to assist her in appreciating and enhancing other life areas.She can identify strengths in multiple dimensions, including spiritual, intellec-tual, social, and physical competence (Choate, 2008; Myers & Sweeney, 2005).It may be particularly beneficial for adolescent girls to spend time with femalerole models who are appreciated for their accomplishments and whorepresent a diversity of body shapes and sizes. Instead of focusing solely onher physical appearance, she can learn to appreciate her body for how it func-tions and for what it can do (McKinley, 2002). The client can learn that heridentity and worth as a person extend far beyond her appearance and thather life has inherent meaning and purpose. As she learns to appreciate herunique strengths and abilities, she can be encouraged to dedicate her timeand energy to activities, pursuits, and goals that are not based upon appear-ance or adherence to the beauty ideal.

Emotional Component: Dialectical Behavior Therapy

While some clients will need to begin therapy with CBT to address theirdieting behaviors and maladaptive cognitive patterns regarding identityand worth, other clients do not have these concerns. These clients can bene-fit from starting the therapy process with learning to cope with emotional

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reactions to the stressors of adolescence. Regardless of whether or not it isaddressed first or during a later phase, emotion regulation is a key compo-nent that drives binge eating in many adolescent girls and should be con-sidered as an important element of therapy (Safer, Telch, & Chen, 2009).DBT, a form of behavioral therapy originally developed for work with clientswith borderline personality disorder (Linehan, 1993), specifically focuses onbuilding skills for emotion regulation and has recently garnered recentsupport for its application to the treatment of binge eating (Safer et al.,2009). It differs from CBT in that while CBT is most effective for helpingclients to change eating behaviors and thought patterns related to identityand self-worth, DBT is targeted to assisting clients with understanding,tolerating, and regulating their emotional reactions to daily life stressors.

DBT assumes that girls who binge eat may not have developed skills forcoping well with daily stressors of adolescence, for regulating their often tur-bulent emotions, or for tolerating uncomfortable, painful feelings (Crowther,Sanftner, Bonifazi, & Shepherd, 2001; Safer et al., 2009). Disordered eatingsymptoms such as binge eating become a girl’s attempt to regulate strongemotions and to cope with stressors (Telch, Agras, & Linehan, 2000).Through therapy, clients are taught skills to enhance their ability to monitor,evaluate, and modify their emotional reactions and to accept and toleratefeelings in stressful situations. It is assumed that with the use of these strate-gies, the need for binge eating will be eliminated. As also suggested byFeminist Therapy, the approach also assumes a collaborative therapist-clientstance and a commitment to accepting the client where she is, while alsostrongly encouraging her to make changes to improve the quality of her life(Safer et al., 2009). A detailed description of the DBT treatment manual (Saferet al., 2009) is beyond the scope of this article; I provide only a summary ofcore DBT skills in the paragraphs to follow.

CORE MINDFULNESS SKILLS

Mindfulness involves paying attention to one’s emotions, thoughts, andphysical experiences without necessarily trying to end them, numb them,or avoid them. It involves observing, describing, and experiencing emo-tions in the moment and learning to be in control of one’s attention. Asa client becomes more mindful of the present, she learns to understandthe ebb and flow of her emotions (McCabe, LaVia, & Marcus, 2004). Spe-cific skills requiring mindfulness are listed here: mindful eating (i.e., givingfull attention and awareness to eating by savoring and fully tasting the foodbeing eaten), urge surfing (i.e., observing urges to binge in a detached,objective way, without following through on the urges), and alternaterebellion (i.e., instead of using binges as a way to rebel against others,the client learns to rebel in a more creative manner that honors her rightsand quality of life).

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EMOTION REGULATION SKILLS

These are strategies for reducing emotional vulnerability and for changingintense and painful emotions. As she practices emotion regulation, the clientrecognizes that she does have control over how she reacts to emotionalexperiences and that she can change her level of emotional reactivity. Shebegins to learn the function of her emotions and develops strategies forincreasing the amount of positive emotions she experiences in her life. Somespecific skills for emotion regulation include identifying the trigger of theemotion (i.e., identifying the prompting event that contributed to the emo-tion, analyzing her interpretation of the event, her associated physical andbody changes, her actual emotional expression, and any aftereffects of theemotion), reducing vulnerability (i.e., decreasing the likelihood of negativeemotions by caring for herself physically, eating a balanced diet, gettingenough sleep and exercise, and avoiding mood-altering drugs), increasingpositive emotions (i.e., increasing daily pleasant events that do not involvefood), building mastery (i.e., completing daily activities that contribute to asense of competence and mastery), and acting opposite to current emotions(i.e., learning to change her emotional reactions by acting in a manneropposite to the emotion she is currently experiencing, such as approachinga feared situation instead of avoiding it).

DISTRESS TOLERANCE SKILLS

Distress tolerance is the ability to effectively tolerate emotional pain in situa-tions that cannot be changed, at least in the present moment. By accepting asituation that cannot be changed and not struggling against it, a client is ableto cope with it more effectively (Safer et al., 2009; Wisniewski & Kelly, 2003).Distress tolerance skills are divided into two components: skills for acceptingreality and skills for crisis survival. Accepting reality skills assist clients inaccepting life in the moment, just as they are, even when it is painful oruncomfortable. These skills include observing one’s breath through deepbreathing and half-smiling (triggering positive emotions associated with asmile). Skills for crisis survival involve engaging in activities that helps a cli-ent remain functional without resorting to behaviors that make things worse.These might include ways to comfort and provide self-nurturance, includingrelaxation, mental imagery, and other self-soothing techniques (e.g., listeningto music, taking a bubble bath). It could also involve doing activities toimprove the moment in a small way, whether it is through prayer, taking abreak, or using positive thoughts.

While Safer and colleagues developed the DBT treatment protocol forgroup therapy, therapists can also adapt this model to work with clients onan individual basis when groups are not available (Safer et al., 2009; Safer,Lock, & Couturier, 2007). These skills are particularly helpful for empoweringadolescent girls as they cope with not only with the stressors of adolescence

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but also with obstacles they increasingly face in contemporary family life(e.g., poverty; parental divorce; parental substance abuse or mental illness;physical, sexual, or emotional abuse).

Relational Component: Interpersonal Therapy

Feminist Therapy emphasizes the importance of relationships as central inwomen’s lives (Worell & Remer, 2002) and as relationships with family,friends, and potential dating partners become more complex during theadolescent period, girls need the skills to be able to build a positive supportsystem and to communicate their relational needs effectively (Piran et al.,2004). IPT, a treatment originally developed for the treatment of depression(Klerman, Weissman, Rounsaville, & Chevron, 1984), focuses on assisting cli-ents in making improvements in their interpersonal relationships. Researchindicates that IPT is effective in the treatment of binge eating, with outcomessimilar to CBT (Wilfley et al., 2002). IPT assumes that as a client expresses heremotions more openly, takes steps to improve communication in her relation-ships, and strengthens her support system, her binge eating will decrease(Wilfley, MacKenzie, Welch, Ayers, & Weissman, 2000).

While research has not been conducted to indicate when a client willbenefit more from DBT or from IPT, it is recommended that IPT can beincorporated into therapy when a client has significant impairment in herrelationships, when she lacks support, and when she possesses ineffectivecommunication skills for expressing her feelings openly with others (Wilfleyet al., 2000). Because adolescent girls commonly have problems in these areas,therapists can consider incorporating the relationship-specific IPT strategiesdescribed in the paragraphs that follow with the more general emotion-regulation DBT skills previously discussed. IPT focuses treatment on one of fourproblem areas: grief, interpersonal disputes, interpersonal transitions, and inter-personal deficits. Because of their specific relevance to adolescents and bingeeating, only interpersonal disputes and transitions are discussed here.

INTERPERSONAL ROLE DISPUTES

Previous research indicates that interpersonal role disputes is the most com-mon IPT problem area for clients with binge eating (Fairburn, 1997). Relation-ships become more conflicted in adolescence, as many girls highly value theirrelationships and are socialized to be passive and quiet in order to keeptheir relationships intact and conflict-free. Many girls do not develop the skillsnecessary for resolving their conflicts in a direct, assertive manner, oftenresorting to manipulative, relationally-aggressive methods of communicatingnegative feelings such as anger (Crick & Grotpeter, 1995; Underwood, 2003).At the same time, today’s girls are socialized to be physically aggressive oreven violent with others in order to receive attention and to get their needs

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met (Garbarino, 2006). These contradictory messages can be confusing togirls, and both communication styles contribute to inauthentic relationshipsand are ineffective in resolving conflicts.

In the IPT approach, the counselor should first assist the client in asses-sing the history of her specific relationship conflict. The counselor can askthe client to describe her expectations for each of the important relationshipsin her life, how she communicates her needs, and the ways in which she hasalready tried to resolve the conflict (Fairburn, 1997; Weissman, Markowitz, &Klerman, 2000). Next the counselor can help her to determine the particularstage of her dispute with significant others: negotiation (ongoing attempts toimprove the relationship), impasse (neither individual is attempting tochange), or dissolution (the relationship is beyond repair). She can thendevelop different coping strategies depending upon the stage of her dispute.She can examine the unhealthy ways in which she responds to conflict: pass-ive responses (internalizing her anger), relational aggression (indirect,passive-aggressive responses), or physical aggression (inauthentic, aggress-ive responses). The client might also benefit from changing her expectationsregarding her relationships if these have been unrealistic.

If a client is at the impasse stage in her relationship, she can generatealternatives for making a decision to either move her relationship backtowards negotiation or to facilitate its movement towards dissolution. Tomove towards negotiation, she might have to invest more into the relation-ship, take more risks in sharing her feelings, and open up the conflict inorder to resolve it. As stated previously, this may be difficult for many girlswhen they believe that asserting their opinions or feelings will result in theloss of her relationship. In contrast, some girls may resort to aggressive beha-viors, but this also does not move her towards healing her relationship ortowards ending it in a healthy manner.

Regardless of the stage of the dispute, an adolescent girl could benefitfrom discussing cultural pressures that provide girls with limited optionsfor voicing her authentic self in relationships. In addition, the therapistmay need to assist her in developing assertiveness skills, taking the time topractice the differences between being passive, assertive, and aggressive.Ultimately, she can learn to express herself in an authentic way, understand-ing that she does have the right to directly assert herself, to ask for what shewants in relationships, and to say no to requests, as long as this does notharm the rights of others. Through this process, she can become empoweredto take control in her life and to deal directly with conflicts rather thanturning to food to numb her feelings or to avoid problems.

ROLE TRANSITIONS

Like role disputes, role transitions are common difficulties in individuals withbinge eating (Fairburn, 1997; Wilfley et al., 2000). Role transitions include

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difficulties in letting go of a previous life role and in embracing a new one,such as those that girls experience in adolescence. Girls undergo manytransitions simultaneously: starting new schools with increased academicand extracurricular pressures, dealing with pubertal changes, handling theonset of dating, managing changes in their parental relationships, and losingold friends=gaining new ones. In addition, they receive negative culturalpressures around the transition from girlhood to womanhood, leading toconfusion around gender roles. In the IPT approach for resolving role transi-tions, a therapist will first assist the client in clearly identifying the old andnew roles. Once the roles are defined, she can focus first on her old role, fullyexploring her feelings about it, and mourning the loss of a role that iscomfortable and familiar. She can also explore how the loss affects her senseof identity and relationships with others (Wilfley et al., 2000).

The therapist can then help her to examine her feelings about the newrole. For example, if she is transitioning to a school with increased academicand athletic pressures, what in particular is causing her to experience anxietyor ambivalence about the new school? What are her strengths that shealready brings to the new role? What are the potential benefits that thenew role may yield? How do the opportunities at the new school fit withher overall life goals? The next step will be for her to examine the actualdemands of her new role. In this example, what will it require for her tobe successful as a student and an athlete? How can she develop the necessaryskills? Does she need to change her study habits or practice requirements?Finally, she can examine her support system, including her parents andfriends, and discover ways in which she may need to ask for help as shetransitions to her new role (Wilfley et al., 2000).

As the client identifies her problem area, develops new skills forexpressing her feelings, sorts through her ambivalence and fears around ado-lescent transitions, develops a strong support system, and makes active stepstowards improving her relationships, the IPT approach assumes that the needfor binge eating will be eliminated. As adolescent girls thrive in the context ofsupportive relationships with parents, peers, and adult role models (Jordan,2003), the IPT approach can be important in empowering girls to strengthentheir existing relationships and in developing relational competence.

CONCLUSION

Adolescent girls are faced with multiple and contradictory pressures that theymust negotiate in order to reach their potential as successful women intoday’s complex cultural environment. These extreme expectations influencegirls to believe that they should look and act according to narrowly-definedstandards which are impossible to obtain, ultimately setting them up forfailure. It is understandable that many girls turn to binge eating to cope with

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these pressures and the multiple stressors of adolescence. Effective therapyfor girls should be tailored to their unique lived experiences, including thesecultural influences and life stressors. The proposed treatment model in thisarticle was designed to include components of four treatments that are parti-cularly relevant for girls’ needs and which are effective in the elimination ofbinge eating. First, Feminist Therapy principles are to be considered founda-tional to empowering adolescent girls as they negotiate cultural pressuresand stressors. Second, CBT is likely to be effective for clients who needspecific assistance in eliminating diets and reducing the overvaluation ofweight and shape in defining overall identity and self-worth. Third, DBT isrecommended for adolescent female clients to assist them in understanding,monitoring, and regulating their emotions. Finally, IPT might be incorporatedfor girls who need specific skills in improving their communication skills,expressing their feelings in the context of significant relationships, and indeveloping a strong support system. Rather than using binge eating as anunderstandable but harmful mechanism for coping with cultural pressuresand painful emotions, it is hoped that this model of therapy will helpempower girls with the confidence and skills they need to cope more effec-tively with contemporary life demands.

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