Using Social Influence to Improve Eating Disorder Treatment Centers

It's estimated that 8 million Americans have eating disorders, most of them women. A study by the National Association of Anorexia Nervosa and Associated Disorders reported that 5-10 percent of anorexics die within 10 years due to health problems caused by the disease. That number climbs to 20 percent after 20 years. Only 30-40 percent of anorexics ever recover, leaving a huge percentage of people whom the system has failed. Traditional group treatment of eating disorders, and addiction treatment in general, is flawed. The current system focuses too much on forcing the patient into compliance, and not enough on other forms of social influence.


Traditional eating disorder treatment centers involve grouping eating disorder patients into one home, or center, and treating them as a group. Treatment of an eating disorder in the U.S. ranges from $500 to $2000 per day. It's estimated that patients need anywhere between 3-6 months of treatment. The purpose of these treatment centers are to use social influence to discourage the eating disorder from continuing. Doctors, counselors and other staff use their authority and knowledge in order to persuade patients to no longer continue eating disorder patterns, but despite its high cost; there are many flaws.

Some of the biggest pitfalls of this system are due to grouping patients together in the same treatment center. The side-effects caused by these individuals being grouped together are numerous. Many times, these effects can be dominant over the intended effects of the treatment center. Ultimately, it causes many people to “slip through the cracks” that otherwise wouldn't have, if they were to be treated differently. The current system fails to acknowledge that not everyone is the same, and therefore some patients won't respond as well to this “one size fits all” approach.

People have a powerful need to belong. Because the patient is placed into a group of other individuals with eating disorders, him/her not having an eating disorder makes him/her the odd one out, and potentially lead to social exclusion. One of the main reasons for many patients having eating disorders in the first place are to avoid such things. Essentially, these patients are being “thrown out of the frying pan and into the fire.” In the world outside of the treatment center, not everyone has a strong belief that people must be thin to be attractive. Inside the treatment center, every patient either strongly believes that only thin people are attractive, or behaves in a manner that conveys they value being thin. The group may exert pressure on the individual to stay thin, which may be stronger than pressure from doctors and staff.

In an experiment by Soloman Asch, the power of the group exerting pressure on the individual was put to the test. Asch did so by presenting very basic and solvable problems to subjects and documenting their responses. He placed the subject into a room along with a few paid confederates (people who pretend to be part of the study but are actually in on it.) He then told the confederates to publicly agree on an obviously incorrect answer when asked questions. In this experiment, Asch found that about 35 percent of overall responses conformed to the incorrect judgement of the majority. This experiment has been replicated many times, even with highly educated individuals, and has produced similar results, repeatedly. If we apply what we've learned from these experiments to the treatment center, we can assume that a percentage of the patients in the center will continue their eating disorders merely because of the group's influence on him/her.

People's strong need to belong, along with the grouping of individuals with like-minds, may lead to “groupthink.” The definition of groupthink, according to Webster's, is a pattern of thought characterized by self-deception, forced manufacture of consent, and conformity to group values and ethics. Groupthink may become so dominant that individuals will continue to secretly avoid reality, despite outward appearance of conformity. Groupthink will lead individuals to conform more strongly to the group's values, and refrain from voicing disagreeable opinions around the group. Certain individuals will even become “mindguards,” people who actively censor contradictory information. These behaviors will occur when the group is away from the authority of the staff.

Despite all this influence from the group, influence from authority will also be strong. In an experiment conducted by Stanley Milgram, the strength of influence from authority was put to the test. Person A was instructed to ask person B questions, and shock them each time they gave an incorrect response. The teacher (the person giving the shocks) and the learner (the person getting shocked) were placed in two separate rooms where they wouldn't be able see each other. What person A didn't know was that person B was actually a paid confederate, and never really felt any of those shocks. The subject shocked the confederate until the screams from the confederate sounded as if he/she was in a lot of pain, and the strength of the volts grew stronger and stronger. Whenever the subject expressed any signs that he no longer desired to continue the experiment, the authority figure (ie a scientist in a white coat) would push him/her to continue and sometimes even result to saying, “You have no choice, you must continue.” The results of the experiment showed a strong positive correlation between authority influence and conformity of the subject. Around 65 percent of individuals would deliver the final massive 450 volt shock, that would probably lead to death if it were real.

If we apply these results to the treatment center, we can see that most of the patients will respond very strongly to pressure put upon them by doctors and staff (who are positioned as authority figures.) However, there are many people who don't respect authority, and many who actively rebel against it. Individuals with this type of cognition will most likely not respond very well to a treatment designed around authority. There are people who automatically act contrary to the desires and expectations of authority. These people will also “fall through the cracks,” which could be big or small percentage depending on the percentage of people with eating disorders who also have issues with authority.

For those who don't have issues with authority, their conformity to desired behaviors will be very likely. Doctors and staff will tend to use their authority in order to get patients to comply with certain tasks. In other words, staff will provide a reward for good behavior and, sometimes, a punishment for bad behavior. Doctors may elevate individual patients to different “statuses” with more prestige, authority, or freedom for their “good” behavior. At the same time, they may scold, talk down to, shame or just convey a general disappointment in the patient as a punishment (sometimes doctors may even do this subconsciously.)

Patients will most likely respond to this social influence, but its effects will be mostly temporary. Once the individual leaves the treatment center, and there is no longer a reward or punishment for certain behaviors, conformity will most likely cease. It would be the equivalent of removing the cheese at the end of a rat maze. The rat will no longer have an incentive to journey through the maze. Or your boss at work telling you that he can't pay you anymore. You would most likely not continue showing up to work. Without the possibility of some kind of reward, both animals and humans will stop complying with their “expected behaviors.”

However, this type of social pressure can sometimes lead to “desired” behaviors if the act of compliance leads to internalization. In other words, if the individual comes to believe that ridding him/herself of eating disorder patterns would be the right thing to do. This would occur through secondary gain. If the individual discovers that their new habits lead to worthwhile benefits, or avoid enough consequences, then the individual may continue their behavior in order to receive those secondary gains, and not the original gains manufactured by doctors and staff. It's possible that patients will discover that they feel more alert, strong, less stressed, etc, and enjoy it, and as a result will continue desired behaviors. Although, compliance by itself will not produce a permanent change in patients' behavior, if the patients experience enough secondary gains that he/she values, it may lead to new behavioral patterns being established through internalization.

Temporariness of desired behavioral patterns by patients can be reduced by using a few techniques. If the patient were to continue interacting with the doctors and staff after he/she is out of the treatment center, that would be positive for the patient. This would act a as reminder to the patient about his treatment and would also serve as emotional support. Having patients publicly commit to their goals and decisions would also strengthen conformity, perhaps by having the patient create a public personal blog about his/her goals and experiences while in treatment. Studies have shown that people are more likely to follow through with their decisions when they're publicly announced for many to see.

Another way to limit failure in rehabilitation is to isolate the individual from as many additional influences as possible, and surround the patient with influences that convey the behavior and beliefs you would like them to conform to. This would mean limiting the consumption of media, and surrounding the individual with a unanimous group of people who exhibit healthy behaviors about eating and their body image. Essentially, You would be creating a group that the individual would benefit being pressured by. Patients will also have the opportunity to identify with individuals within the group, and take them on as role models. If the patient finds the group or person within the group attractive, he/she will accept influence from that person or group and absorb their values and attitudes. This is much more effective than using only compliance techniques.

In an experiment by Geoffrey Cohen and Michael Prinstein, high school students were asked to participate in online chat rooms with other students. In one condition, the students were led to believe that they were chatting with popular kids in their school. In the other condition, students were led to believe they were chatting with students of average popularity. When the popular and admired kids said they would smoke marijuana, subjects also said they would smoke marijuana. If the admired kids said they would refuse to smoke marijuana, students would also agree and say they would refuse. This phenomenon was not evident when the subjects spoke to students of average popularity. Essentially, students were more likely to adopt opinions of people they personally admired through identification. Unlike the Asch experiment, in which individuals were only complying, the effects of this type of influence are longer lasting. When students were later asked about their opinions on marijuana in private, it was found that they tended to keep the opinions the received through influence of the “cool kids.”

If we could create a center that replicates these conditions, we would have a much higher success rate (which is currently only at about 50 percent.) When the patient sees other people eating comfortably, he/she will be more likely follow if she thinks these people are "cool." When the patient sees other people adopting the rules given by the staff, he/she will also be more likely to do so. The patient is no longer merely complying, and is now both complying to authority and identifying with others. However, it would be beneficial to remind the patient what an eating disorder is (perhaps by placing an image of a person with an eating disorder in a prominent place) so that the patient can contrast to the norms of the group. If there is no reminder of eating disorders, then the patient will probably not think about the norms of the group and contrast them with their own. (eating comfortably and not obsessing over body image).

While the patient is living with this new group, it would also help to provide the patient with lectures provided by "credible" people. People who are considered both trustworthy and expert by the individual. For some, a scientist may be used, and for others a priest. The patient would be influenced because we all have a desire to be right, and if we are lectured by a trustworthy expert on a subject, we tend to internalize the information presented by him/her in order to also be right. The patient would potentially integrate the information or behaviors presented by the expert into his/her system of values. This is the most powerful form of social influence.

The current system needs to focus a lot more on using group pressure to positively influence the patient. Ultimately, it would be more beneficial for the patient if we focus more on different types of social influence, and eliminate influences that could cancel out efforts to rehabilitate. This means creating an environment in which the patient is required to comply to authority, has the opportunity to identify with peers and role models, and internalizes thoughts and behaviors from credible people.


Other topics you might want to read about:

What is Identification?
What is Compliance?
What is Internalization?