The March BABCP Article of the Month is from the Cognitive Behaviour Therapist (tCBT) and is entitled “Equitable access to evidence-based treatment for eating disorders for patients with low-income: identifying barriers and exploring solutions” by Suzanne Bailey-Straebler, Deborah R. Glasofer, Jessica Ojeda and Evelyn Attia

Eating disorders are serious mental health conditions associated with numerous medical complications and psychological distress. Although recommended treatments such as Cognitive Behavioral Therapy for Eating Disorders (CBT-ED) exist, few patients receive these interventions. Individuals with low-income are especially at risk and face disproportionate challenges in accessing evidence-based care. This disparity stems from a complex intersection of economic vulnerability and various other factors that compound the issue.

Studies have consistently shown that individuals with low-income are at an increased risk for mental health disorders (Ridley et al., 2020), including eating disorders. Despite this heightened risk, they are less likely to seek treatment (Sonneville & Lipson, 2018) and, when they do seek help, they are more likely to encounter a multitude of barriers. Research indicates that individuals with low-income often have limited access to education, belong to historically marginalized racial or ethnic groups, identify as sexual or gender minorities, have limited proficiency in English, and may experience acculturative distress related to immigration status. These factors, in turn, contribute to poorer mental health outcomes among this population (Cervantes et al., 2019; Kivimäki et al., 2020).

Our clinic sees many patients with low-income. We provide them, and all of our patients, with well implemented evidence-based treatment. It felt essential to write this paper to share that it is possible to provide evidence-based treatments to patients of all socioeconomic backgrounds. We argue that providing equitable accommodations offers all patients access to the same content, as opposed to treatment modifications that could potentially dilute the effects of evidence-based treatment.

In the paper, we identify eight barriers encountered by our patients. Some of the barriers are more general and not specific only to those with low-income, though are encountered more frequently by patients with low-income. Barriers include mis/under-diagnoses, low numbers of trained therapists, therapists lacking cultural humility, and limited access to treatment materials in preferred languages. Other barriers are more specifically related to income, including the cost of treatment materials, travel costs, loss of income to attend sessions, and the cost of food. Through illustrative composite cases, we share how our treatment team identifies these barriers and supports patients in overcoming them.

We hope that our paper raises awareness of the challenges faced by patients with low-income in accessing evidence-based treatments. We urge therapists to consider the impact of these barriers and advocate for systemic changes to promote equitable access to effective treatment. Ultimately, we hope this paper initiates a dialogue surrounding the need for inclusive and accessible healthcare practices.

References:

Cervantes, R. C., Gattamorta, K. A., & Berger-Cardoso, J. (2019). Examining difference in immigration stress, acculturation stress and mental health outcomes in six Hispanic/Latino nativity and regional groups. Journal of Immigrant and Minority Health, 21(1), 14–20. https://doi.org/10.1007/s10903-018-0714-9

Kivimäki, M., Batty, G. D., Pentti, J., Shipley, M. J., Sipilä, P. N., Nyberg, S. T., Suominen, S. B., Oksanen, T., Stenholm, S., Virtanen, M., Marmot, M. G., Singh-Manoux, A., Brunner, E. J., Lindbohm, J. V., Ferrie, J. E., & Vahtera, J. (2020). Association between socioeconomic status and the development of mental and physical health conditions in adulthood: A multi-cohort study. The Lancet Public Health, 5(3), e140–e149. https://doi.org/10.1016/S2468-2667(19)30248-8

Ridley, M., Rao, G., Schilbach, F., & Patel, V. (2020). Poverty, depression, and anxiety: Causal evidence and mechanisms. Science, 370(6522), eaay0214. https://doi.org/10.1126/science.aay0214

Sonneville, K. R., & Lipson, S. K. (2018). Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity, socioeconomic background, and sex among college students. International Journal of Eating Disorders, 51(6), 518–526. https://doi.org/10.1002/eat.22846

From Richard Thwaites, Editor-in-Chief of tCBT: Why I chose this article

Two of the key values of tCBT are captured in this paper which focuses on both the delivery of evidence-based treatments but also how these can be offered equitably (including for those with lower incomes). This is an underdiscussed area and we are pleased to highlight this with reference specifically to eating disorders although much of the content is relevant to those working with other disorders.

Author Bios:

Jessica Ojeda, Sc.B., has been a research assistant at Columbia University’s Center for Eating Disorders since 2022. She graduated from Brown University (2021) and will pursue a doctoral degree in clinical psychology starting this fall.

Suzanne Bailey-Straebler, PhD, PMH-BC, is the Clinical Director of the Center for Eating Disorders Partial Hospital Program and Outpatient Specialty Clinic at Weill Cornell Medicine/ New York Presbyterian Hospital. Prior to this, she was a Senior Research Clinician at the Centre for Research on Eating Disorders at Oxford University and an Honorary Psychological Therapist for the NHS. She is a founding member of the CBT-ED special interest group at the Academy for Eating Disorders.