Making respect the norm: Lessons from the clinic, classroom, Media Smart and beyond

The current climate

The recent reports of sexual assaults in Canberra and elsewhere have been harrowing. 

As a Clinic Director and psychologist working with patients experiencing an eating disorder (ED), I often see people who have experienced sexual assault. Many have not been believed or supported when they disclosed the assault to someone they trusted, while others did not feel safe enough to share the experience in the first place. Thus the untold silent suffering grows. 

In recent weeks patients have commented on how triggering it has been to see these media reports and the response (or perceived lack of) by powerful figures. A common theme from these patients has been the observations that perpetrators “get away with it”. The pain experienced by these patients is immense, tragic and heartbreaking.   

Research indicates that 20-40% of patients with an ED have experienced sexual assault.  EDs are but one possible outcome following sexual assault. Just about every other negative mental health outcome is also at increased risk for victims of such assault (e.g., depression, anxiety, substance abuse, self-harm, suicidality). Many will experience multiple such consequences.

The dreadful suffering these illnesses convey across all aspects of a person’s life as well as their loved ones is a constant reminder that we must do all that we can to prevent EDs from developing and to intervene quickly when warning signs emerge.

To this end, when I am not seeing patients, I develop and evaluate programs to reduce the risk of EDs in schools and online.

Media Smart Schools – more than just an effective body image program

This commitment to prevention and early intervention started nearly 20 years ago with my mentor, Professor Tracey Wade and I developing Media Smart, an 8-lesson school classroom-based curriculum to reduce the risk of body image concerns and EDs. 

At that time, the trend internationally was for such programs to be directed to young-adult females-only who were already displaying ED risk (e.g., dieting). 

Whilst these targeted programs are important and have been found to be beneficial, we wanted to act earlier in young peoples’ lives thus we developed Media Smart for Grade 7 and 8 classes. We also chose to include both girls and boys for two reasons:

1.    An increasing number of males experience body image concerns; and

2.    Males are an important part of the environment of girls, where their inclusion might have flow-on benefits to girls. That is, to identify and challenge misogynistic media (and other) messages and to ensure males are not placing pressure on females regarding appearance or in other areas.

We also took a ‘universal’ approach – i.e., full classes of students regardless of their level of body image concerns. Again, this was with the intention of seeking to improve the peer environment for as many young people as possible.

Internalising media messages of societal ideals of beauty is an ED risk factor. It places a person at greater risk for the core thinking component of an ED - the belief that one’s self-worth is strongly based on one’s body shape or weight. 

This is not to suggest that media is the sole or even main risk factor for EDs. Whilst there are many other risk factors, media is a topic of interest to young people and thus well-suited as a program target. Other ED risk factors (e.g. trauma) whilst critically important, are not well-suited to classroom settings and are best addressed at appropriate health services.

Media Smart content includes: identifying and challenging stereotypes; developing skills in reducing and managing various pressure placed on us; identifying our own values and making choices in line with them; standing up for ourselves; and, communicating our opinions through activism. The key messages include:

-      Our worth as individuals should come from our various personal qualities; skills; relationships and abilities rather than be tied to appearance, body shape or weight

-      That as individuals, we are entitled to make up our own minds on media and other topics and that we are able to express these views

Or to put it another way, treating others and ourselves with respect. 

In large research trials, Media Smart has been found to reduce a range of ED risk factors for both girls and boys. This program has become one of the most highly regarded school body image programs internationally. It is available through Flinders University and is currently used by approximately 50 schools across Australia and in parts of Asia, with additional research being conducted in NZ.

Media Smart Online – prevention and treatment effects

Based on the success of Media Smart Schools we developed Media Smart Online, designed for those already experiencing body image concerns. This was informed by

1.    Australia having multiple effective school-based body image programs but not having focussed as much on targeted programs for those at escalating ED risk.

2.    Research showing body image concerns and ED risk typically continuing to increase throughout adolescence and into young-adulthood.

3.    A 2012 report finding that 913,000 Australians were suffering from an ED annually at a socioeconomic cost of $AUD69.7 billion.

4.    Worrying research showing that less than 20% of people experiencing ED symptoms seek treatment.

5.    Waiting lists for specialist ED treatment services can be very long.

In a trial of across Australia and NZ with 575 women aged 18-25 years, Media Smart Online reduced ED onset by 66% (amongst people without an ED at baseline) and increased recovery by 75% (amongst those with an ED at baseline). It also lowered a range of risk factors and prevented onset of serious related symptoms such as depressive symptoms, suicidality and substance use. Thus the findings suggested that Media Smart Online is beneficial as both a prevention and intervention program and can also reduce the risk for multiple other serious mental health outcomes.

The results were that promising that we received an Australian Rotary Health Mental Health Grant to expand the program from 18-25 year-old women to 13-25 year-olds of any gender who wish to improve body image. The result is I am Media Smart, which is now live and available to 13-25 year-olds of any gender across Australia and New Zealand.

The first trial showed that only 14% of participants had spoken with a health professional, despite over two thirds having ED symptoms. This shows how reluctant people can be to seek help. Thus being able to anonymously access an effective, online, free program is of appeal. It also shows how sadly, many people do not see their body image concerns as serious or deserving of help. 

The I am Media Smart trial is suitable across the body image spectrum from those with some worries about their body image (and no ED symptoms) through to people with ED symptoms. 

It is well-suited to those who would like to:

The goals of I am Media Smart are to evaluate:

1.    If Media Smart Online can be effective for younger participants and those of any gender

2.    If there is an optimal rate of delivery of the 8-module program: 1 module per week vs individual chooses their own rate

3.    If Media Smart Online should be made available en masse to reduce the alarming levels of EDs in Australia and accompanying suffering.

Further information about I am Media Smart is available at the study website and links for information specific settings (e.g., schools, health care etc) are available. Sign up is open until the end of May 2021. 

Calls for greater education around consent - Yes, but more is required

In the wake of media reports regarding sexual assaults, misconduct and harassment, dialogue is turning towards the need for greater education around consent. This is highly appropriate, and I would support the use of evidence-based programming to address this.

However, we need to think more broadly than relying on such programs alone. What can be done to make respect the norm?

The Media Smart experience suggests that fostering respectful attitudes towards girls and women, indeed people in general, can occur in a safe, helpful manner with young-adolescents (Grades 6-8). Whilst we have not explicitly measured boys’ attitudes towards girls as a result of completing Media Smart, anecdotal feedback suggests that beneficial impacts could be occurring (e.g., male feedback of “it taught me not to perceive all women the same way”). 

Further, the findings for both Media Smart Schools and Media Smart Online are a reminder that it is possible for programs to reduce the risk for serious problems without directly discussing these topics. For example, there is no overt content in the school program on ED thoughts, depression, perfectionism or amount of screen time, however all have been found to be lower as a result of program participation. Similarly, Media Smart Online has had both preventive and treatment effects for EDs, reduced depression onset, reduced onset of suicidality and substance use all without discussing these topics.

To be clear, I am not an expert in school programs on consent. It is likely that consent programs require overt discussion of key topics to ensure no ambiguity. Again, I fully support the use of evidence-based, age-appropriate programming on consent. 

But let’s ensure there are messages throughout young people’s schooling (and in other parts of life) that form the foundations for treating others with respect as part of promoting wellbeing. 

Media Smart seeks to give the message that we are all worthwhile and worth taking care of. Whilst on one level this should be patently obvious, it is clear that many media and other messages do not communicate this.

Finally, I applaud the efforts of those who are speaking out and leading the way in bringing about change. Whilst these times are bringing up many difficult emotions for my patients, a universal theme is the admiration, appreciation and awe they feel towards those speaking out. I feel the same way. Just as I do for the bravery of my patients.

Dr Simon Wilksch is a Senior Research Fellow in Psychology at Flinders University leading research projects in eating disorder risk factors, prevention, early intervention and improving treatment experience and outcomes for patients and their families. He is also Clinic Director at Advanced Psychology Services, a team of psychologists helping children, adolescents and adults experiencing an eating disorder.