psychological correlates of help seeking for eating-disorder symptoms in female college students

20 Journal of College Counseling ■ Spring 2005 ■ Volume 8

Psychological Correlates of Help Seekingfor Eating-Disorder Symptoms in Female

College Students

Dinah F. Meyer

This study investigated the psychological correlates of treatment seeking for eating disorders infemale college students. Results indicated that 56% of the 106 participants with eating-disordersymptomatology did not believe their behaviors warranted therapy. Women with eating-disordersymptoms who did not believe their behaviors warranted therapy exhibited higher levels of immaturedefenses and lower endorsement of sociocultural norms concerning attractiveness than did womenwho believed treatment was needed. These findings hold implications for the prevention and treat-ment of college women’s disordered eating.

R esearchers and practitioners have long been invested in determining the variables that lead college students to either seek or avoid counseling services. Research suggests that factors preventing students from seeking

treatment include stigma and lack of available services (Ben-Porath, 2002),negative expectations about therapy (Cramer, 1999), fear of treatment (Kushner& Sher, 1989), and discomfort with self-disclosure (Kahn & Williams, 2003).In addition, students often do not perceive their personal difficulties as severeenough for treatment (Cramer, 1999; Oliver, Reed, Katz, & Haugh, 1999).

One area that is of particular interest to college counselors concerns seekingtreatment for eating disorders. Although the prevalence of eating disorders amongcollege women has been widely documented (Kirk, Singh, & Getz, 2001; Mintz& Betz, 1988), data suggest that few of these women receive treatment (e.g.,Cachelin, Rebeck, Veisel, & Striegel-Moore, 2001). Moreover, very little is knownabout the factors that prevent women with eating disturbances from seekingcounseling, and a crucial question that remains unanswered concerns the psy-chological variables that are related to the decision to seek treatment for aneating disorder. In the present study, an effort was made to expand the knowl-edge about these factors by examining the impact of three psychological vari-ables on treatment seeking: fear of treatment, defense style, and internalizationof societal beliefs about attractiveness. For counselors working in university set-tings, a better understanding of the factors associated with women’s reluctanceto seek counseling for their eating disturbance would allow for the developmentof more efficacious interventions and campuswide prevention programs.

Researchers have clearly demonstrated that fears surrounding psychologicalservices often pose a significant barrier to seeking professional help (Kushner& Sher, 1989). Recent research suggests that such fears could be especially

Dinah F. Meyer, Department of Psychology, Muskingum College. Correspondence concerning this article should beaddressed to Dinah F. Meyer, Muskingum College, New Concord, OH 43762 (e-mail: dmeyer@muskingum.edu).

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relevant for women with eating disturbances. For example, several characteris-tics often associated with eating disorders (e.g., being intensely fearful of gain-ing weight) may render an individual resistant to the changes that are pre-sumed to take place in therapy. Counseling would be seen by these women asparticularly threatening because they may be unwilling to risk gaining weight iftreatment entails relinquishing their unhealthy eating behaviors.

Along with a fear of therapy, psychological defense mechanisms may influ-ence an individual’s decision about whether or not to seek treatment for aneating disturbance. Several studies (e.g., Steiger & Houle, 1991; Steiner, 1990)have demonstrated that women with eating-disorder symptoms exhibit higherlevels of immature defenses (e.g., denial, rationalization, projection) and lowerlevels of mature defenses than nonclinical controls. What remains to be inves-tigated, however, is how psychological defenses such as denial affect the deci-sion to seek counseling for eating-disorder symptoms.

A final variable that may affect seeking treatment for an eating disorder in-volves the extent to which an individual endorses societal values about attrac-tiveness and thinness (i.e., being attractive means being thin). Although re-searchers have suggested that college women are often likely to internalizethese values and are, thus, at greater risk for developing eating disorders (Lester& Petrie, 1995; Striegel-Moore, Silberstein, & Rodin, 1986), they have yet toexamine whether women who hold such values also show more resistance toobtaining treatment. It seems plausible that women who have deeply held soci-etal values about beauty may be less likely to see extreme weight control behav-iors and attitudes as disordered and are, therefore, less likely to seek treatment.

These research questions are further complicated by evidence suggestingthat eating disorders lie on a continuum of disturbance, such that differencesin eating problems are a matter of degree and not of kind (Scarano & Kalodner-Martin, 1994; Stice, Killen, Hayward, & Taylor, 1998). Current prevalencerates among college women for clinical eating disorders are estimated to bein the .5% to 3% range (American Psychiatric Association [APA], 2000;Hoek & van Hoeken, 2003). However, there is growing recognition thatthere is a group of individuals who do not meet the criteria for an eatingdisorder in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.,text rev.; DSM–IV–TR; APA, 2000) but who nevertheless display symptomsof eating disorders, such as binging twice per month or taking large quanti-ties of laxatives on occasion. Furthermore, evidence suggests that this groupmakes up the majority of students using college counseling services for eating-related concerns (Schwitzer, Rodriguez, Thomas, & Salimi, 2001). Althoughfew would argue with the contention that individuals with anorexia, bulimia, or“eating disorder not otherwise specified” (EDNOS) would benefit from treat-ment, it is not clear whether symptomatic women who possess clusters of eating-disorder symptoms require intervention. However, because longitudinalresearch has shown that subclinical disorders often progress to more severeeating disorders (see Shisslak, Crago, & Estes, 1995, for a review), assessingtreatment-seeking decisions in women who have different degrees of eating

22 Journal of College Counseling ■ Spring 2005 ■ Volume 8

disturbances would allow practitioners to design interventions and preventionprograms for this prevalent, yet often overlooked, population.

The purpose of the present study was to examine the roles of the fear of treat-ment, psychological defenses, and endorsement of sociocultural norms aboutattractiveness in college women’s decision to seek treatment for an eating distur-bance. It was expected that subclinical women and women with eating disorderswould exhibit higher levels of immature defenses and sociocultural beliefs aboutattractiveness than would asymptomatic women. In addition, it was expected thatsubclinical women and women with eating disorders who believed that they didnot need treatment would exhibit higher levels of immature defenses, more fearsabout therapy, and greater endorsement of societal beliefs concerning attractive-ness than women who believed that their behaviors did merit therapy.

Method

Participants

The participants were 294 undergraduate women enrolled in an introductorypsychology course at a large midwestern university. All participants volunteeredfor the study in exchange for course credit. The mean age of the sample was19.33 years (SD = 1.99, range = 17 to 32). Most participants were Caucasian(67%), 15% were African American, 12% were Asian American, 3% were Latina,and 2% identified themselves as other. First-year students constituted the ma-jority of the sample (95%), whereas 3% were sophomores and 2% were juniors.

Measures

Questionnaire for Eating Disorder Diagnoses (Q-EDD). The 50-item Q-EDD (Mintz,O’Halloran, Mulholland, & Schneider, 1997) is a self-report questionnaire thatoperationalizes eating-disorder criteria from the Diagnostic and Statistical Manualof Mental Disorders (4th ed.; DSM–IV; APA, 1994). The Q-EDD measuressymptoms of eating disorders as well as differentiates between eating-disor-dered and non-eating-disordered diagnoses. Diagnostic labels are generated bya series of flowchart decision rules, and respondents are placed into diagnos-tic categories based on these rules. The asymptomatic category comprisesindividuals who report no eating-disorder symptoms. The symptomatic cat-egory comprises individuals who exhibit some eating-disorder symptoms,but not enough to meet DSM-IV criteria for an eating disorder. The eatingdisorder category comprises six specific subcategories: Two reflect the DSM-IVdiagnoses of anorexia and bulimia (with several subtypes), and four reflect theDSM-IV EDNOS diagnoses of subthreshold bulimia, menstruating anorexia,nonbinging bulimia, and binge-eating disorder. Mintz et al. demonstratedconvergent validity by reporting significant correlations between Q-EDDcategories and scores on other established measures of eating-disorder symp-toms (Mintz et al., 1997). Test–retest reliabilities ranged from .54 to .64over a 1- to 3-month period, and interscorer agreement was reported to be

Journal of College Counseling ■ Spring 2005 ■ Volume 8 23

100% for 100 protocols (Mintz et al., 1997). In the present study, interscoreragreement between two independent coders was 100% for 50 protocols.

Thoughts About Psychotherapy Survey (TAPS). The 19-item TAPS (Kushner & Sher,1989) measures participants’ fears of psychological services and concerns with therapistresponsiveness, image, and coercion. Total scores range from 19 to 95, with higherscores demonstrating greater concerns. Reliability estimates were reported to be .93(Kushner & Sher, 1989); coefficient alpha was .90 in the present study.

Beliefs About Attractiveness Scale–Revised (BAA-R). The BAA-R (Petrie, Rogers,Johnson, & Diehl, 1996) is a 19-item questionnaire that measures the degreeto which women endorse U.S. societal values concerning thinness and attrac-tiveness. Total scores range from 19 to 133, with higher scores indicative ofgreater endorsement of sociocultural norms. Petrie et al. demonstrated twostable factors: Importance of Physical Fitness and Importance of Being Attrac-tive and Thin. Cronbach alphas for the Full Scale and two subscales were .92,.88, and .89, respectively (Petrie et al., 1996). Internal consistency scores were.87, .90, and .90 respectively in the current study. Scores on the BAA-R corre-lated with bulimic symptoms assessed by the BULIT-R (Thelen, Farmer, Wonderlich,& Smith, 1991; rs = .40 and .46). Scores also correlated with concerns aboutbody size and shape (rs = .44 and .42; Petrie et al., 1996), as measured by theBody Shape Questionnaire (Cooper, Taylor, Cooper, & Fairburn, 1987).

Defense Style Questionnaire–40 (DSQ-40). The 40-item DSQ-40 (Andrews, Singh,& Bond, 1993) assesses immature, mature, and neurotic psychological defensestyles, defined as conscious derivatives of unconscious mechanisms. In the presentstudy, only the 24-item Immature Style Defense Scale was deemed to be relevantto the research questions, and the scales measuring maturity and neuroticismwere not used. Total scores on each scale range from 1 to 9, with higher scoresindicative of greater defenses. The Immature Style Defense Scale includes itemsrepresenting such defense mechanisms as projection, passive aggression, denial,dissociation, somatization, displacement, and rationalization. Coefficient alphafor the Immature Style Defense Scale was .80, indicating adequate internal con-sistency (Andrews et al., 1993); in the current study, coefficient alpha was .73.

Demographics and questions related to eating concerns. Participants were askedquestions regarding their age, year in college, and ethnicity. Treatment seekingfor an eating disorder was assessed by two questions that were based on thoseused by Fairburn and Cooper (1982): (a) “Are you currently seeing a counse-lor or psychotherapist for your dieting/body image concerns or eating distur-bance?” and (b) “Do you feel that you need counseling or therapy for yourdieting habits, body image concerns, or eating disturbance?” Participants werealso asked whether they had previously seen a therapist for an eating distur-bance and whether they were currently in counseling for any other reason.

Procedure

Participants were tested in one of several group sessions, during which theygave consent and were informed that all responses were anonymous. The or-

24 Journal of College Counseling ■ Spring 2005 ■ Volume 8

der of the instruments was counterbalanced to preclude order effects. Aftercompleting the instruments, participants received written debriefing materialsthat listed local sources of support for eating disorders. Of the 302 participantswho completed instruments in the group sessions, 8 were eliminated due tomissing data, leaving a final participant pool of 294.

Results

Descriptive Statistics and Eating-Disorder Categories

Inspection of the eating-disorder categories designated by the Q-EDD revealedthat 11% (n = 32) of the sample met the criteria indicative of anorexia (n = 3),bulimia (n = 9), or EDNOS (n = 20) and were placed in the eating-disordergroup. Most participants who were in the EDNOS group (n = 16) reported bulimicsymptomatology. Approximately 25% (n = 74) of the sample were classified assymptomatic, and most of these participants (n = 58, 78%) exhibited some type ofbulimic symptomatology. Sixty-four percent of the sample (n = 188) were asymp-tomatic and reported no eating disturbance. Therefore, 36% (n = 106) of the totalsample reported some degree of eating-disorder symptomatology.

Of the 32 participants in the eating-disorder category, 5 reported that theywere currently seeing a therapist for their eating disorder, and 2 of the 74participants in the symptomatic group reported that they were seeing a thera-pist for their eating concerns. Fisher’s Exact Test was significant at the .05level, indicating that participants with an eating disorder were more likely tobe in psychotherapy than were the participants in the symptomatic group whoexhibited less severe eating-disordered behaviors. No participants reportedever previously seeing a therapist for an eating disturbance, and 2 participants(both asymptomatic) were currently in treatment for other reasons.

Participants in the eating-disorder and symptomatic groups did not differ in re-sponse to the question, “Do you feel that you need counseling or therapy for youreating/dieting behaviors?” Eighteen (56%) of the participants in the eating-disorder group and 29 (39%) of the participants in the symptomatic group an-swered “yes.” Furthermore, the 5 participants in the eating-disorder group andthe 2 participants in the symptomatic group who reported that they were currentlyseeing a counselor responded affirmatively to this question. Thus, 44% (n = 14) ofparticipants in the eating-disorder group and 61% (n = 45) of participants in thesymptomatic group did not believe that their behaviors warranted therapy.

A multivariate analysis of variance (MANOVA) was conducted to compare theasymptomatic, symptomatic, and eating-disorder groups on the three dependentvariable measures (see Table 1 for mean scores and standard deviations). TheMANOVA was significant, Wilks’s lambda = .90, F(3, 291) = 5.45, p = .0001,η2 = .05. Two follow-up analyses of variance (ANOVAs) were significant: TheImmature Style Defense Scale of the DSQ-40, F(2, 293) = 6.94, p < .001,η2 = .05, and the BAA-R, F(2, 293) = 11.82, p < .0001, η2 = .07. Scheffétests (p < .05) indicated that the symptomatic group scored significantly higher

Journal of College Counseling ■ Spring 2005 ■ Volume 8 25

than the asymptomatic group on the Immature Style Defense Scale (η2 = .05),indicating higher levels of immature defenses. On the BAA-R, the symptomaticand eating-disorder groups significantly differed from the asymptomatic group(η2 = .07), such that participants with eating-disorder symptoms endorsed higherlevels of sociocultural values concerning attractiveness.

Relations Between Eating-Disorder Level, Treatment-Seeking Attitude, and Dependent Measures

To examine the relationship between eating-disorder level, treatment-seeking atti-tude, and psychological defenses, a 2 (eating disorder level: symptomatic or eatingdisorder) × 2 (perception of need for treatment) MANOVA was computed. Therewas no significant main effect for eating-disorder level, nor was there a significantinteraction between eating-disorder level and perception of need for treatment.However, a significant main effect was obtained for perception of need for treat-ment, F(3, 103) = 3.05, p < .05, η2= .08. Follow-up ANOVAs indicated that theneed effect was attributed to the Immature Defense Style Scale, F(1, 102) = 5.79,p = .01, η2 = .05, and the BAA-R, F(1, 102) = 4.29, p < .05, η2 = .04. Post hocanalyses indicated that the participants in the eating-disorder and symptomaticgroups who believed they did not need treatment engaged in higher levels of im-mature defenses (M = 3.30) than did participants who believed that treatment wasneeded (M = 2.67), η2 = .05. Furthermore, among participants in the symptomaticand eating-disorder groups, those who saw no need for treatment were less likelyto endorse sociocultural norms (M = 70.50) than those who believed that treat-ment was needed (M = 78.00), η2 = .04. No significant main or interaction effectswere observed for scores on the TAPS.

Discussion

Consistent with findings in previous research (Steiger & Houle, 1991; Tylka &Subich, 1999), more than twice as many college women were classified as symp-tomatic than eating-disordered in this study. Indeed, 25% of the sample exhibited

TABLE 1

Mean Scores on Dependent Measures for Asymptomatic,Symptomatic, and Eating-Disordered Women

Measure

Immature defensesTAPSBAA-R

M

3.8456.5463.96

Note. Immature defenses = Immature Style Defense Scale; TAPS = Thoughts About Psy-chotherapy Survey; BAA-R = Beliefs About Attractiveness Scale–Revised.

SD M SD M

4.3062.7273.88

4.0059.3173.28

0.9316.6516.03

0.8115.4016.95

0.9316.5018.15

SD

Asymptomatic(n = 188)

Symptomatic(n = 74)

Eating-Disordered(n = 32)

26 Journal of College Counseling ■ Spring 2005 ■ Volume 8

subclinical manifestations of eating-disorder symptoms. Furthermore, 78% ofparticipants in the eating-disorder category and 78% of the participants in thesymptomatic category exhibited some form of bulimic symptomatology. Thesefindings are congruent with earlier research (Kirk et al., 2001; Stice et al., 1998)and suggest a fairly high level of binging and compensatory behaviors in femalecollege students. However, the finding of an 11% prevalence rate for the mostsevere eating disturbance is discrepant from the rates previously reported (e.g.,Hoek & Van Hoeken, 2003). It is likely that this difference is primarily attribut-able to the reliance upon self-report symptomatology in the present study.

The hypothesized relationship between eating-disorder level, treatment-seekingattitude, and psychological defenses was partly supported by the results of thisstudy; women in the eating-disorder and symptomatic groups who believedthat they did not need treatment exhibited higher levels of immature defenses(e.g., denial) than participants who believed they did need treatment. An im-portant finding of this study was that only 15% of the participants in the eating-disorder group and 3% of participants in the symptomatic group reported thatthey were seeing a therapist for their eating concerns, and most of the partici-pants who were in the eating-disorder and symptomatic groups did not believethat therapy was needed. Given the strong denial that many women with eatingdisorders seem to possess, it is critically important for college counselors to bevigilant for these symptoms in all of their female clients. In an attempt toprotect themselves, women with eating disorders may seek counseling withother issues as their presenting problem (Oliver et al., 1999). Therefore, anaccurate assessment of symptoms must be based on a foundation of goodrapport and trust, and specific questions about strict dieting, preoccupationwith weight, body dissatisfaction, and purging behaviors should be asked atdifferent points during the course of treatment.

Contrary to expectations, women in the symptomatic and eating-disorder groupswho saw no need for treatment evidenced less internalization of societal beautyideals than those who believed that they needed treatment. Because those partici-pants who believed that treatment was not needed also exhibited higher levels ofimmature defenses, it is possible that they used a defense mechanism like denialto downplay the influence of social norms on their body image. More surprisingwas that fears about therapy were not related to treatment-seeking attitude forwomen in either the the eating-disorder or symptomatic groups. For this col-lege sample, however, it may be that the TAPS did not assess the fears abouttherapy that may be specific to women with eating disorders. For example, womenmay fear that counseling will cause them to gain weight or give up their pursuitof a thin body, concerns that are not addressed by questions in the TAPS.

Limitations of Study and Implications forFuture Research

The results of this study are limited by a reliance on self-report data from aself-selected sample. Another limitation involves the use of a primarily Cauca-

Journal of College Counseling ■ Spring 2005 ■ Volume 8 27

sian college sample from a single university; therefore, caution must be usedwhen generalizing these results to other college populations. Finally, treatment-seeking behavior for eating disorders was assessed in this study by means oftwo direct questions in the demographic questionnaire. A need exists for apsychometrically sound measure that can assess treatment-seeking attitudesfor eating disorders as well as actual treatment-seeking behaviors.

The results of this study also suggest that subsequent research should investi-gate other variables that are related to the treatment-seeking process of bothclinical and symptomatic women. As such, a better understanding of the fac-tors that prevent women from seeking treatment could assist counselors indesigning programs to increase students’ use of counseling services. Further-more, in agreement with the findings of Schwitzer et al. (2001), the results ofthe present study suggest that both subclinical eating disturbances and EDNOSare more prevalent than full-syndrome anorexia or bulimia in college women.Because research on these eating disturbances is lacking, it seems clear thatmuch remains to be learned about this underrecognized group of women.

Implications for College Counselors

The findings of this study have several implications for practice and outreachon college campuses. Perhaps most critically, the finding that 25% of the samplewere classified as symptomatic and exhibited subclinical manifestations of eat-ing disorders suggests that counselors may need to screen all of their femaleclients for signs of an eating disturbance. For example, brief questions regard-ing binge eating episodes, compensatory behaviors such as vomiting or use ofdiuretics, and dietary restrictions could be easily incorporated into the standardintake session. The results of this study also point to the importance of ad-dressing a student’s psychological defense style in individual counseling ses-sions. Because disordered eating is often associated with unhealthy regulationof negative emotions and poor conflict management (Steiger & Houle, 1991),it is crucial for counselors to focus on helping clients learn more mature, adap-tive defenses in order to better cope with the many developmental issues facedby college students.

Regarding outreach, researchers (e.g., Mintz et al., 1997) have suggested thatsymptomatic women might benefit more from preventative psychoeducationalinterventions than from individual therapy. For example, college counselors canbe active in presenting educational programs to high-risk groups (e.g., sorori-ties, athletes) about nutrition, dieting, and the unattainable, unrealistic images ofwomen in the media. Furthermore, outreach programs can be beneficial in rais-ing campus awareness of the risks and symptoms of eating disorders. Cautionmust be exercised, however, in planning primary and secondary prevention pro-grams designed to teach women the symptoms of eating disorders that meritintervention, because research has shown that some women who participate insuch outreach may instead learn and adopt the unhealthy weight control behav-iors that the programs are designed to prevent (Mann et al., 1997). As an alter-

28 Journal of College Counseling ■ Spring 2005 ■ Volume 8

native, it may be just as important for counselors to develop workshops, semi-nars, and support groups that focus on the developmental and adjustment issuesthat may be precursors to disturbed eating. For instance, educational programson self-esteem, stress management, interpersonal conflict, and assertiveness canteach college women critical skills that could reduce the incidence of maladaptiveeating without exposing them to the problematic behaviors.

A final psychoeducational intervention involves efforts to destigmatize coun-seling services, psychological illness, and help seeking in general. Recent re-search (Gonzalez, Tinsley, & Kreuder, 2002) with college students has shownthat such interventions are associated with improved attitudes and expectationsabout counseling. Counselors might make presentations about counseling ser-vices in 1st-year orientation classes, sponsor an exhibit at an activities fair, andmaintain high visibility at campus events. Students are more likely to seek outneeded services when they are supported by an overall campus climate that isaccepting of help seeking (Levine, 2003).

Finally, college counselors have a crucial training role in the prevention andtreatment of eating disorders. Given that college women usually turn first totheir friends for help with an eating problem instead of using professional re-sources (Prouty, Protinsky, & Canady, 2002), programs can be developed toteach resident assistants, sorority officers, and other student leaders the risksand symptoms of eating disorders. Counselors can teach these students notonly the appropriate steps for referral, but also encourage them to be rolemodels and set good examples of healthy attitudes toward eating and bodyimage. Student health clinic physicians can also be trained by counseling centerstaff to screen students for eating disorders, and a four-question, rapid screen-ing instrument has recently been developed for use during routine physicalexams (Anstine & Grinenko, 2000). In addition, counselors can offer in-service programs to educate staff, faculty, and coaches about the signs anddangers of eating disorders in their students. Thus, by raising campus aware-ness and providing a range of programs and services, counseling centers canensure that young women with eating disturbances have access to the resourcesthat are the most necessary for their treatment.

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