Fat Studies & Mental Health – A New

Intersectional LensASDAH 2015

Dr. Sheila Addison

Alliant International University

Learning Objectives1. Understand the relevance of Fat Studies,

and SA/HAES, to an intersectional, social justice approach to training students in mental health disciplines.

2. Identify opportunities and strategies for incorporating HAES and SA principles into teaching and training about social justice and mental health.

3. Identify self issues that arise when teaching and training about issues of weight, body size, dieting, and self-acceptance.

Fat stigma & mental health

Distorted ideas about weight and health are pervasiveCulture equates “thin” with “healthy” despite

evidence to the contrary

Fat shame and stigma are pervasiveResearch suggests they have more negative

health effects than actual weight (Ramos-Salas, Canadian Journal of Public Health, 2015)

Discrimination based on weight is pervasiveDiscrimination produces stress.Stress is a risk factor for disease.“Feeling fat” has stronger health effects than being

fat. (Puhl, et al., Int J of Obesity (2008).; Muennig, et al., Am J Pub Hlth (2008).)

Fat stigma from health professionals

Surveys of health professionals reveal clear evidence of fat stigma and sizeismDoctors view fat patients as unattractive, difficult

to work with, non-compliant, sloppy, lazy, and unpleasant to touch. (Project Implicit)

Almost 25% of nurses admitted to feeling “repulsed” by fat patients.

53% of higher-weight women reported receiving inappropriate comments about their weight from health care providers.Higher weight patients who perceive weight

discrimination avoid seeking routine preventative care (e.g. cancer screenings, etc.)

Fat stigma from mental health professionals

Health professionals including psychologists who specialized in obesity often use words like “lazy,” “stupid,” & “worthless” to describe their patients. –Schwartz et al., Obesity Research (2003).

Therapists were more likely to diagnose an eating disorder and to set goals like “improve body image” and “increase sexual satisfaction” for higher-weight clients – even when clients did not express concerns about either. – Davis-Cohelo, Professional Psychology: Research & Practice (2000).

Younger therapists showed the greatest bias. This is also true for younger doctors.

Training materials, when they mention weight, support the “fat = bad” perspective See Yalom’s chapter “The Fat Lady” in “Love’s

Executioner” (1989).

Dieting Hurts Mental Health

“Reinterpreting fat people as chronic dieters puts the psychology of obesity in a whole new light. If dieting is the crucial variable, then the fat do not eat because they hurt inside; rather, they hurt because they are trying not to eat, to make their bodies conform to social norms.” Bennett & Gurin, “The Dieter’s Dilemma”

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Psychological Risks ofChronic Dieting

Preoccupation with food, eating, & weight

Increased response to external vs. internal eating cues

Ignoring/distrusting hunger & satiety

Mood swings

Irritability

Perfectionist tendencies

Poor self-image

Disordered eating

Judging food as good/bad

Apathy/lethargy

Narcissism

Guilt

Depression

Binging

“.…Until we have better data about the risks of being overweight and the benefits and risks of trying to lose weight, we should remember that the cure for obesity may be worse than the condition.”

Editors, New Engl. J. Med. 338, No. 1: 52-54, 1998

Mental health & the “obesity epidemic”

Our field is currently trying to get on board the “obesity crisis” train because there is $$ to be made APA Task Force on Obesity

AAMFT - Clinical Updates on bariatric surgery & dhildhood obesity

Affordable Care Act - recommends “intensive counseling” for all obese adults and requires insurers to pay

Claims that there are “successful” programs that involve “intensive, multi-component behavioral interventions” – where are they? Not in the literature!

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Whatever Happened to “Do No Harm”?

Ethically, health care professionals seek treatments that:Encourage autonomyHelp, not harmDo not discriminate

Show some evidence of working!

When clients ask for our support in weight loss efforts, what are the ethical implications of agreeing when we know they will likely fail and have negative physical & mental health consequences ?

“Do No Harm”Puhl and Brownell, 2006, 2007

“More frequent exposure to stigma was related to more attempts to cope and higher BMI. Physicians and family members were the most frequent sources of weight bias reported. Frequency of stigmatization was not related to current psychological functioning . . .”

“Participants who believed that weight-based stereotypes were true reported more frequent binge-eating and refusal to diet. . . These findings challenge the notion that stigma may motivate obese individuals to engage in efforts to lose weight.”

“Do No Harm” Tylka , 2006

Intuitive eating is associated with psychological well-being. “Women who accept their bodies are more likely to eat healthy.”

Gailey, 2012 “Fat women who are involved in the size-acceptance

movement tend to have a better self-image and sexual relationships.”

Arroyo, 2012 The more often someone engages in “fat talk,” the

lower that person's body satisfaction and the higher the level of depression after three weeks. "It is the act of engaging in fat talk, rather than passively being exposed to it, that has these negative effects.”

Fat is a Social Justice IssueFatness is highly correlated with poverty.

Fatness and poverty can often be used as synonyms.“While there is evidence that poverty is fattening,

a stronger case can be made for the converse: fatness is impoverishing.”- Glen Gaesser, Fat Studies Reader

Significant evidence of weight bias in employment:Higher weight applicants rated lower on

supervisory potential, professional appearance, hygiene, & physical abilities when applying for white-collar jobsMore harshly disciplined on the jobGiven inferior assignmentsPaid lessViewed as liabilities for employee health benefitsFired for not losing weight

Rothblum et al. International Journal of Eating Disorders (2008).; Fikkan & Rothblum, in “Bias, Stigma, Discrimination, & Obesity” (2005)

Mental health training & multicultural competence

APA, CACREP, COAMFTE, CSWE all require multicultural information infused into coursework

All require development of culturally competent, culturally-appropriate skills for working with diverse populations

All codes of ethics bar discrimination against stigmatized groups

All codes of ethics require clinicians to work inside their “scope of competence” – e.g. have appropriate training & supervision for specific populations & issues

Why isn’t sizeism & weight stigma addressed?Significant mental health, social, relational

impacts

Significant intersection with other axes of privilege & oppressionSESDisabilityAgeRace/Ethnicity

Whole chapter of the DSM on disordered eating, so why the silence on clients’ bodies?

Mental health is FAILING students, clients

Body size is a dimension of diversity

Sizeism is a social justice issue

Little or nothing is offered in most mental health program

Programs & supervisors are reinforcing weight stigma & stereotyping

Our students, teachers, supervisors, & clinicians badly need training in a weight-neutral approach

Fat Studies comes to mental health

In 2009, Alliant International University began offering a 1-unit elective, “Fat Acceptance and Health at Every Size,” to its PhD and PsyD Psychology students

Offered at the San Francisco campus as a 2-day weekend intensive

Students were asked to do all assigned reading prior to class

Based on ideas from “Fat Studies” classes taught in other disciplines elsewhere

Research on Fat Studies in Mental Health Training

Qualitative study of students who have completed the 1-unit elective course and agreed to participate in 2-hour interviews

Interviews are guided by the question “how has the FA/HAES class impacted you?”

Research on Fat Studies in Mental Health Training

N=6 thus far; goal is for N=8-12

Participants thus farMixture of male and femaleMixture of body sizesRange in age from 26 to 50All participants so far ID as WhiteOne IDs as Latino/Hispanic

Research on Fat Studies in Mental Health Training

Participants have discussedHow they chose to take the classExpectations/assumptions about the class and

classmatesMemorable parts of the classInteractions with peers/colleagues in the classAwareness of their own biases about body sizeAwareness of stigma & micro-aggressions

from others

Research on Fat Studies in Mental Health Training

Important emerging themes re: class impact:

Their own body imageRelationships with peersRelationships with partners/sig. othersRelationships with parents, siblings, & other familyRelationships with friends, roommates, partner’s

friends, etc.Perception of their clients & training sitesConflict over how much of an “activist” to become

Research on Fat Studies in Mental Health Training

Participants have NOT noted an impact of the class on the general atmosphere at school

Conversations in the halls/break areasConversations about food, bodies, dieting when food is

brought to classesFat-stigmatizing comments from faculty in other classesWeight/body size generally not included in “dimensions

of diversity” conversationsHigher-weight students have not felt comfortable

challenging privilege of lower-weight studentsNot sure how to initiate conversations with clients

about weight, self-image, dieting hx, weight-neutral perspective

Mental health training must include FA/HAES

OpportunitiesAnother dimension of diversity/social justiceWe will continue to experience pressure to “treat” the

“obesity epidemic”Built into the Affordable Care ActEmployers think it will hold down health care costsClients continue to subscribe to the “fantasy of being

thin”Partners & family members continue to pressure higher-

weight people to lose weightOur guilds want to compete with Big Pharma

Deeply relevant to a field that is over 80% female and climbing at the MA level; 60%+ for psychologists

Opportunities for research on individual, couple, & family functioning

Mental health training must include FA/HAES

ChallengesPressures of time/content in courses alreadyFew academic resources that directly address body

size/weight and mental health from a HAES perspectiveBody size is not included as a dimension of diversity in

any multicultural/diversity texts (e.g. McGoldrick’s “Family Life Cycle,” Sue & Sue, etc.)

Resistance, from students & faculty - weight stigma is still seen as “useful” and “virtuous”

Funding for research on weight is nearly all controlled by weight “loss” & bariatric industries

Remains to be seen how open mainstream journals will be to publication

Mental health training must include FA/HAES

• Discuss the clinical background of obesity, noting the various definitions.

• Discuss the epidemiology of overweight and obese individuals in the United States, based on age, race, and socioeconomic status.

• Describe the pathophysiology of obesity, including genetic and environmental factors.

• Identify the risk factors for and comorbidities of obesity.

• Explain the various treatment modalities for overweight/obese patients.

• Describe dietary and physical activity recommendations.

• Discuss available pharmacological agents, including indications and adverse reactions, used to treat obese/overweight patients.

• Discuss surgical options, including restriction and bypass operations.

• Explain the reimbursement climate for overweight/obesity treatments.

• Outline considerations necessary when caring for patients for whom English is a second language.

Mental health training must include FA/HAES

Outline the epidemiology and consequences of childhood overweight and obesity.

Distinguish various obesity trajectories and their differential diagnostic and treatment issues.

Evaluate salient factors when assessing the overweight or obese child, including components of the interview process.

Recommend treatments based on the category of childhood overweight/obesity.

Describe importance of collaborating with the multidisciplinary team when caring for the overweight or obese child.

Fat Studies in TrainingDiscussion must start with the students & faculty

themselves What do our own self-of-therapist issues on this

topic look and feel like?

What is your personal history with dieting efforts and weight loss, weight gain, weight cycling?

What stereotypes and stigma do you subscribe to regarding fat people?

What was your family of origin’s culture regarding food, weight, etc.?

What is the culture of our school & program regarding fatness, dieting, eating, etc.?

What beliefs or fears do you have about embracing Fat Acceptance & Health at Every Size?

What drives our “isms”?Sizeism – fear of fatness

Fear of being unpopular Fear of being “ugly" Fear of being shamed Fear of being un-sexy Fear of being un-feminine or un-masculine Fear of being “too much" Fear of taking up space Fear of being un-virtuous Fear of being labeled “lazy” or “weak-willed" Fear of shaming our families Fear of losing our lovers’ attention Fear of being seen as a bad parent Giving up on “The Fantasy of Being Thin”

What drives our “isms”?Healthism, Ableism

Fear of aging  Fear of illness Fear of death Fear of being marginalized Fear of being left out/excludedFear of loss of controlFear of losing our power

Fear of being “othered” – so we “other” others’ bodies.

Fat Studies in Training Critical analysis of research on weight loss efforts & the

conflation of body weight with health

Narratives from people who have experienced weight stigma Dieting/bariatric surgery

Body positivity

Other body stigma – “thin-shaming,” men & muscle development, trans* and GLB people

Explore intersections w/race, SES, gender

Weight-neutral responses in therapy & techniques for cultivating body acceptance

Teaching students to see & respond to sizeist micro-aggressions - advocacy

Sizeism, Ableism, Healthism at School &

WorkWhat do we do in our places of work & training

that marginalize fat people?Chairs that don’t fit/lack of accessible seating in

classrooms and offices

Recommending “self-care” that comes with micro-aggressions

Admitting/hiring only people who “fit the culture” - which opens the door to sizeism (also ableism, healthism).

School & work events that assume a certain level of fitness/ability

Sizeism at School & WorkWhat do we do in our places of work & training

that marginalize fat people?Fat-shaming posters, articles, etc.  

Health care policies that penalize people for weight, not engaging in “enough” exercise, etc.

Weight loss “challenges”

T-shirts that only come in certain sizes Environments that tolerate “fat talk” and fat shaming –

school & workplace bullying

Sizeism at School & WorkWhat do we do in our places of work &

training that marginalize fat people?Defining higher-weight students & colleagues as the

ones with problemsHolding pathologizing attitudes“Concern trolling”

Assuming people who are at higher weights aren’t doing self-care

Work cultures that don’t have any flex or redundancy in them so people can do HAES activitiesEat wellExerciseTake vacations

Sizeism with ClientsWhat do we do in our clinical work that

communicates micro-aggressions about body size? Use sizeist language

“Obesity epidemic,” “overweight,” “unhealthy weight” Equate weight with physical health Equate weight with mental health

Diagnosing depression, binge eating, addiction - or anorexia/bulimia based on body size

Engage in stereotypingNon-compliant, undisciplined, poor self-image, etc.

Praise fat people for doing things that we would label “unsafe” or “disordered” in slim people

Compliment weight loss without knowing cause

Sizeism with ClientsWhat do we do in our clinical work that

communicates micro-aggressions about body size?Fail to be honest with clients about the truth

about weight loss effortsPromise therapy that can help with weight loss when there

is no such thing Imply that treating mental health (e.g. depression, binge

eating) will reduce weightPromote or support bariatric surgery and dieting as a way to

“health”Support partners & parents who shame higher-

weight clientsSet weight-loss goals for clients that are not their

own

Sizeism with ClientsWhat do we do in our clinical work that

communicates micro-aggressions about body size?Fail to educate ourselves about how activities of

daily living, family life, parenting, sex, etc. might need to be adapted for people with bigger bodiesFail to incorporate an understanding of how weight

stigma might influence daily interactions Caregiver/partner, family tensions Minority stress

Maintain inaccessible and/or hostile spaces Magazines that promote disordered images of bodies,

weight stigma Art that only features slim, able-bodied people

Self-of-the-teacher/supervisor

As clinicians, teachers, & supervisors, we are not immune.

Self-of-the-therapist: We have bodies, and weight histories, and feelings about them, which must be addressed in order to confront our own sizeism. Engaging in “fat talk” as a way of bonding

Relationship with our bodies - “feeling fat”

Histories of dieting & other weight-loss efforts

Histories of shame from parents, partners, etc.

We also have to confront the racism & classism tied up in fears of fatness.

Contact informationDr. Sheila Addison

sheila.m.addison@gmail.comhttp://www.drsheilaaddison.com

Dr. Michael Loewymloewy@alliant.edu

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