Making Prevention Work Together We Can Make a Difference

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"Making Prevention Work Together We Can Make a
Difference"
Michael Levine, Ph.D., FAED Department of
Psychology, Kenyon College, Gambier, OH
43022-9623 March 13, 2008, Bronte Centre
Conference Levine_at_kenyon.edu
POWERPOINTS AVAILABLE FREE at http//psychology.k
enyon.edu/levine/
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Dr. Michael Levine

• 1. Professor of Psychology, Kenyon College BMI
  30.4588 obese
• 2. Ph.D. in Experimental Psychology wife has
  Ph.D. in Medieval history, teaches in Religious
  Studies and WGS and watches Dog the Bounty
  Hunter and shops at Victorias Secret
• 3. Age 58 Really likes Pat Benatar
• 4. No body images issues at all
• Note Rare photo--Michael Levine
• as assistant professor

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Rolling with theRole Model

• Grew up in Southern California in 1950s
• American Idol was
• superstar
• Mickey Mantle

• Alcoholic
• Philanderer
• Non-family man

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GOALS AND OVERVIEW

• Rationale for Prevention
• 2. What is prevention?
• 3. What are we trying to prevent?
• 4. Levines 11 principles of preventions
• 5. A Bolder Model of Prevention

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Rationale forPrevention

• Prevalence, severity vs. person-power shortage
• Multifaceted health promotion
• Evidence - sociocultural basis
• Gender and development
• Historical aspects (Silverstein Perlick, 1995)
• Other social changes in the
• USA (e.g., womens athletics)

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Pervasive, Unhealthy ImpactUSA, Canada, UK,
Australia

• Prevalence of eating disorders (0-4)
• Prevalence of disordered eating (2-5)
• Prevalence of negative body image and unhealthy
  dieting/nutrition (10-15, chronic)
• Use and abuse of steroids and supplements (2-5)
• Correlates of negative body image and
  calorie-restrictive dieting e.g., depression,
  binge-eating
• Rates of obesity for older children and
  adolescents nearing 20

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Prevention, Knowledge, and Research
If you want to truly understand something, try
to change it

• - Kurt Lewin (1890-1947)
• (no date/source, as quoted in)
• APA Policy and Planning Board.
• (2007). Who cares about APA
• Policy and does it have an impact?
• American Psychologist, 62, 491-503.

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Some Things are Like PreventionHard to
Understand How it Could Happen,But It Needs to
be Done
Bring it!
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Prevention is Primary

• Praevenire Latin - come before, anticipate,
  and/or
• forestall What are
  waiting for?
• 1. Evading or forestalling development of
  psychological disorder or unhealthy behavior
• 2. Protect and extend current states of health
  and effective functioning
• 3. Promoting greater well-being and more
  effective coping to strengthen resilience in the
  event of predictable or unforeseen stressors

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Types of Prevention

• --------------------------------------------------
  -----------------------------------------------
  Focus IOM Terminology
  Caplan (1964) Examples
  
  
• --------------------------------------------------
  ------------------------------------------
• Large groups - Universal prevention
  Primary Laws regulating
• healthy people (public health prevention)
  advertising of
  diets
• Smaller groups - Selective prevention
  Primary Programs for
• NS but HR
  children
  entering
• 
  
  elite ballet schools
• Small groups - Indicated or Targeted
  Secondary Programs for
• Very HR - prevention
  
  women with
• clear precursors
  
  severe weight
• 
  
  concerns
• --------------------------------------------------
  -----------------------------------

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Remind Me (Again, Maybe)What Does Nervosa
Mean?

• In the 1870s, why wasnt AN called Anorexica
  Hysterica?
• Why isnt Panic Disorder called Asthmatica
  Nervosa?
• Why do Anorexia Nervosa and Bulimia Nervosa share
  a Nervosa?
• What is the shared Nervosa?

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OK I Dont Really Know Exactly Nervosa Means?

• Underlying psychological characteristics
  Underlying psycho path ology
• Shared Features Psychological
• Undue influence of weight and shape, and control
  of same, on self-concept and identity
• Irrational attitudes (beliefs, feelings,
  behaviors, resistance) in regard to fat and
  fat people
• Glorification of and internalization of
  impossible ideals
• Low and unstable self-esteem (sometimes
  accompanied by musts and shoulds)

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OK So Maybe I Kinda, Like, Know What Nervosa
Means?

• Shared Features Psychological
• Negative body image
• Disconnections from emotions and
• feelings such as anger and fatigue
• Objectification of self and others
• disconnection from same

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Preventing What? And What Does Nervosa Mean,
Anyway?

• Prevention will failand may well be harmfulif
  it concentrates solely on the definition of
  clinical syndromes, the portrayal of fascinating
  cases, and the dangers of disordered eating.
• The issue is the cost to individuals and
  society of set of issues, each of which (1)
  relates to negative body image and disordered
  eating and (2) could be seen spectrum or
  continuum
• negative body image internalization
  of impossible ideals
• self-objectification drive for
  thinness/leanness
• fear of fat unhealthy weight
  management
• shaky self-esteem chaotic
  (including binge-) eating
• compensatory extremes of
  activity/exercise
• extremes (perfectionism)

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Interlocking Spectra or Helices of Disordered
Eating
Internalization of Impossible Ideals
Shaky Self-Esteem Compensation
Negative Body Image
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Levines Recommended Principles of Truly Primary
Prevention

• 1. The issue for prevention is us and our
  cultures, not them and their eating disorders
  or their obesity. Thus we must think
  contextually and in terms of how each member of
  the community can contribute

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Principle 1 (continued) Levines
Wrestle-maniaCorrelation does not imply
Causality, But. . . .
1904 American Greeting Cards
2005

• Pronounced gender difference in body image issues
  and disordered eating (8-101)
• Developmental and historical risk points
• The normative discontent
• Hows that War on Obesity
• workin out for ya?
• Emergence of body image problems steroid abuse
  among males

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Do You Think Barbie Still Dreams of Ken?
Barbie Ken (1950s)
Michael Levine as undergraduate in The Iliad
(1968)
Spawn
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Principle 2 Prevention and treatment are not
just a female issue they are a community
issue that involves boys and men in various ways.
Head Optional Whatever. . .

• Blue Oyster Cult Syndrome (BOCS) Im Burning
  for You.

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Challenge in the Differences

• AN BN are rare
• Males are less concerned about weight
• Body talk and fat talk are less normative
• Pubertal challenge is different
• Tricky issues of threatened masculinity
• Increased risk among gay men

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The New Creation-ismAn evolving theory of
magic and hope
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The Adonis Ideal

• Mesomorphic ideal
• Men are defined by size, power, and strength
• Lean muscular attractive
• muscularity manly success
• muscularity health

All Muscle except for Fat in Head
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An Even GreaterAmerican Hero
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Youll Always Be the Object of My Attention
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Principle 3 Targeted Prevention is important --
but its not the only or even the principal answer

• Universal-selective programs can be useful with
  older adolescents. Nevertheless, as children and
  young adolescents get older, one is more likely
  to be addressing and identifying participants who
  already show body image or eating problems and
  hence are appropriate audiences for
  selective-targeted prevention.

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Principle 3 Targeted Prevention is important --
but its not the only or even the principal
answerA Simplified Look at the Rose Paradox
(Austin, 2001 Rose, 1995)

• Number Risk - Disorder N___
  
• 10,000 High
  12 1200
• 90,000 Lower
  2 1800
• 100,000 total Low-mod? 3
  3000

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Sometimes it is Hard to Love the One Body
Youre With
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Pervasive Messages--Multiple Sources

• Health professionals
• Parents
• Educators
• Mass media
• Books
• Peers
• Citizens

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Principle 4 Prevention must be guided by a
Sociocultural Perspective Sociocultural
variables are causal factors in the development
of risk factors (for eating problems and eating
disorders

• Negative body image
• Weight concerns
• Thinness and/or
• muscularity/leanness
• schema

Sociocultural Factors or Pressures
Continuum of Clinically Significant Disordered
Eating
Parents
Parents
Peers

• Negative affect
• Negative self- concept

• Ego deficits
• Emotional instability
• History of overweight
• Impulsive or SS

Media
Other (School, Athletics)
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What A Sociocultural Perspective Is (Smolak,
Levine, Murnen, 2006)

• Focuses on socially constructed or culturally
  endorsed variables
• A transactional approach
• Culture will determine what is ideal for whom and
  how to attain it
• Culture will determine what is normative (even if
  unhealthy) and pathological (templates of
  deviance)
• There will be within- and across-group
  differences based on exposure to various
  sociocultural factors

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A Sociocultural Perspective Does Not

• Deny any role for genetics or neurobiology as
  important but not the only important sources
  of individual differences in vulnerability
• Minimize the seriousness of full-blown eating
  disorders, nor fail to make any distinctions
  between different types or levels of disordered
  eating
• Expect that one model of risk will fit all
  cultures or both genders or all ages

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What About the Rarity of EDs?A Look at Risk
Factors Probability (Hanson, 2004)

• If there were 4 (relatively) independent risk
  factors for bulimia nervosa, then to achieve a
  population frequency of .02 (the point
  prevalence), each would have to occur at a
  frequency of .38 in the population, because .38
  to the 4th power (.384) .0208.
• The factors that lead to schizophrenia, as Dr.
  Gottesman taught us, are multiple. These factors
  must be quite common in the population and thus
  are not necessarily abnormal. We need to get
  out of our mindset of searching for abnormal
  schizophrenia genes and broaden our view to look
  at normal individual genetic variation in
  conjunction with exposure to common environmental
  agents (p. 214)

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Principle 4 continued - Taking on the Hydra

• Weightist prejudice
• Object-ification
• Identity as a Double Bind
• Insecurity trap gt
• Perfection
• Abandonment

Note cool picture of Hydra
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The Real F-Word

• You look great,
• youve put on fat!

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Us Weekly The Hyprocritic OathEasily Extracted
Messages

• WEIGHTISM
• Prejudice
• Vilification of fat
• fat people,
• especially females
• Glorification of slenderness

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Fat People Spoil the Environment

• Fat people lack self-control
• Fat people are neurotic and overeat for
  psychological reasons
• Weight and shape are highly malleable

• Fat and weight make you sick thin is healthier
• Fat people cannot be physically fit
• Fat people need to diet, and fatter people need
  to diet a lot (more)

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Beauty Standards1940s 1950s
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Beauty Standards 1950s - 1960s
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Beauty Standards1970s 1980s
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Beauty Standards 1990s
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Beauty Standards 2003
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But. . . But. . . But What?
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Summer 2004 Still the Objectof My Gaze (and
Your Own?)
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No, Really You are Still the Objectof My Gaze
(and Your Own?) 2005

• Bad Ad Contest Winner for 2005, New Mexico
  Media Literacy Project
• www.mnmlp.org
• Submitted by Max Africk. Isidore Newman
  School, New Orleans LATeacher Ann Sayas

Open Season Advertisement for __________?
Everybody wants a piece of Dentyne Gum
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Easily Extracted Messages VIII But. . . But
When Tempted To Overindulge (1930)
We do not say smoking Luckies reduces flesh. We
do say that when tempted to overindulge, reach
for a Lucky instead.
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I know weve come a long way were changing
day-to-day
Woman 112 lbs Body wt 111 lbs Pantsuit 1 lb
BMI at 58 is 16.9
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Return to Gender Address Well Known
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A Recent Media-Based Ericksonian Pscyhosocial
Stage Identity Diffused and Refused and Suffused
Head Optional
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Identity Diffused and Refused and Suffused
(continued ad nauseum)
Any culture that treats its women as children
and its children as women is going to have major
problems with images, bodies, and body images
(Smolak Levine, 1990s)
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Principle 5 Education is a Foundation, not a
Danger

• Content
• The Clash
• Critical analysis
• Gender and identity
• Health and performance ? well-being
• Action and activism
• Media and cultural literacy

• Processes
• Dialogue
• Discovery
• Teaching
• Social norms
• Integration

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Principle 6 The Ecological Necessity ofHealth
Promoting Schools

• School ethos
• School curriculum
• School-community partnerships

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Implications of Current ResearchAn Ecological
Perspective means that we can learn a great deal
from the prevention of cigarette smoking and
other substance use/abuse

• Engaging students
• Normative expectations
• Critical thinking
• Life Skills
• Peer involvement
• School policies
• classroom work
• Community
• programming

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Goldberg et al. (2000) The Adolescents Training
Learning to Avoid Steroids (ATLAS) Program

• Education, media literacy, media advocacy,
  refusal skills, nutrition strength training
• HS football players (vs. controls) 1 year FU
• -- greater knowledge (exercise, AS)
• -- less investment in images of use
• -- less intent to use
• -- less new use
• -- saw coaches as less tolerant
• ATHENA for girls
• http//www.ohsu.edu/hpsm/atlas.html

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Principle 7 Raging Against Cultures Machines
will be Challenging because it inevitably means
confronting and challenging pervasive ecological
messages Gender, Class, Race, and Power

• Womens bodies belong to men
• A woman of substance and power
• is a frightening, ugly thing
• Success is narrowly defined and it
• means being up to date and stylish
• Diversity in physical appearance and
• in culture is undesirable
• Women must negotiate dramatic changes in
  cultures--and do it in a quiet, pleasing way

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Principle 8 Everyday Acts of Rebellion and
Machine-Focused Raging (MFR) Take
OvariesCulture change requires a
critical/analytic perspective, attention to
social justice, and activism--and thus it
requires dialogue, collaboration, and courage.

• This cause is not altogether and exclusively
  womens cause. It is the cause of human
  brotherhood as well as human sisterhood, and both
  must rise and fall together. Woman cannot be
  elevated without elevating man, and man cannot be
  depressed without depressing woman also.
• - Frederick Douglas
• 1848

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Principle 8 Prevention and Education requires
a critical/analytic perspective, attention to
social justice, and activism--and thus it
requires dialogue, collaboration, and courage.
Mae Jemison, M.D. First African American Astronaut

• Elizabeth Cady Stanton
• 1815-1902
• Reformer.

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Collaboration is Key OR How Many Levines Does
It Take to Change A Culture?
Michael - Ohio
Paula- Miami, FL
Richard Hershey, PA
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Principle 9 The 5 Cs of Preventionafter
Sigall Pabst, 2000

• - Consciousness-raising
• - Competence
• - Connection
• - Change
• - Choices

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Cultural Literacy, the Critical Perspective, and
Prevention
Sociocultural influences
Unhealthy Messages
Negative Effects
Consciousness- raising Choice
Competence Connection Change

• Analysis
• Fair?
• Function?
• Who benefits?

Activism Advocacy
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Its Time to Dream Envisioning An Example of
Ecological Change

• Mental Health Association
• Education
• Advocacy
• Prevention

• Peers
• Decreasing teasing
• objectification
• Collaboration
• Social marketing

Microsystems
Exosystems

• Religious Organizations
• Self-respect
• Tolerance
• Health
• Leadership and
• service

• Youth Organizations
• (e.g., Scouts, 4-H)
• Peer leadership training
• Programs with awards
• Media literacy for adults

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Easily Extracted MessagesIndulge a Little
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Principle 10 - Multifaceted Health
PromotionPrevention of negative body image and
disordered eating can be integrated with the
prevention of obesity On Shared Ground

• Body dissatisfaction ?life dissatisfaction
• Disturbances of interoceptive awareness
• Unhealthy dieting
• Maladaptive weight management
• Binge-eating and chaotic food consumption
• Inadequate nutrition
• Dealing with culture(s) and cultural change
• Unhealthy relationships with media and
  activity/exercise

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Multifaceted Health PromotionNegative body
image, disordered eating, and obesity On
shared ground HAES Philosophy (Robison, 2003)

• Self and diversity acceptance, supported
  supported by people who care about you as a whole
  person
• Enjoying physical activity and a more active
  lifestyle in accord-ance with needs and rights
• Making more peaceful, social, and celebratory
  relationships with nutritious, nourishing food
• Living better through critical consciousness and
  everyday acts of rebellion

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Culture and Body Image

• Somebody ought to do something

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Principle 11 --Implications of a Sociocultural
Perspective A Bolder Model of Prevention
(Irving, 1999)

• "Each of us must be the change we want to see
  in the world
• - Mohandas K. Gandhi

• Personal
• Professional
• Political

Maine (2000) see www.gurze.com
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A Bolder Model of Prevention (Irving,
1999 Levine, Piran, Stoddard, 1999 Levine
Smolak, 2006 Maine, 2000 Piran, 2001 Sigall
Pabst, 2005)


5 Components of Effective Prevention
Cultural Literacy

Personal

Collaboration Consciousness-Raising Competencies
Choices and Changes adapted from gender
literacy work of Sigall Pabst
Awareness Analysis Activism and
Advocacy Access (e.g., to media)

Professional
Political
You must be the change You wish to see in the
world - Ghandi
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Implications of a Sociocultural Perspective
Critical Reflection Life-LongLiteracy

• A democratic civilization will save itself only
  if it makes the language of the image into a
  stimulus for critical reflection--not an
  invitation for hypnosis

-- Umberto Eco
Quotation appropriated from Media Education
Foundation
Quotation appropriated from Media Education
Foundation
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Media Literacy and the 5 As The Cycle -- from
GO GIRLS!TM www.nationaleatingdisorders.org
Embedded in a Sociocultural Context...
Critical Awareness Analysis in a Relational
Context
Fat is bad/ Thin is good
Unhealthy relationship to food
Consciousness-raising through Connection Competenc
ies Choices for Change
Actions May involve gaining Access to mass media
Competition between women
Rigid, limited gender roles
Advocacy Access Including actions taken USING
media
Activism Including actions taken TOWARD media
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One Person in a Small Town Can Begin the Process
of Making a Difference

• A great model an ongoing narrative of
  courage, resistance, and change is the Red
  Wing, MN non-profit organization described at
  Higherself.com, which grew out of the GO GIRLSTM
  program guided by
• Sarah Stinson

• High school girls who have
• Protested
• Taught
• Advocated
• Testified in the US congress
• Formed a non-profit corporation

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Conclusions

• Prevention is absolutely necessary
• There is evidence to support the effectiveness of
  prevention efforts
• There is no single approach that works but
  theory and evidence point to the value of a
  Critical Social Perspective and the 5 Cs of
  Prevention

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Conclusions

• An ecological perspective Absolutely necessary,
  bewilderingly absent
• There is help for this effort in the fields of
  psychology and public health (e.g., substance
  abuse prevention)
• Selective-targeted (more secondary) prevention
  is, thus far, more efficacious (i.e., has better
  outcomes) than universal-selective (more primary)
  prevention, but it cannot be the answer
• Prevention is potentially harmful if done poorly,
  but so is wood-working, therapy, medicine,
  marriage. . . .