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Fat Studies & Mental Health – A New Intersectional Lens


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A discussion of the need for infusing Fat Acceptance, Health at Every Size, and weight-neutral views into mental health training curricula.

Published in: Health & Medicine
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Fat Studies & Mental Health – A New Intersectional Lens

  1. 1. Fat Studies & Mental Health – A New Intersectional Lens ASDAH 2015 Dr. Sheila Addison Alliant International University
  2. 2. Learning Objectives  1. 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.
  3. 3. Fat stigma & mental health  Distorted ideas about weight and health are pervasive  Culture equates “thin” with “healthy” despite evidence to the contrary  Fat shame and stigma are pervasive  Research suggests they have more negative health effects than actual weight (Ramos-Salas, Canadian Journal of Public Health, 2015)  Discrimination based on weight is pervasive  Discrimination 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).)
  4. 4. Fat stigma from health professionals  Surveys of health professionals reveal clear evidence of fat stigma and sizeism  Doctors 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.)
  5. 5. 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).
  6. 6. 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”
  7. 7. 7 Psychological Risks of Chronic 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
  8. 8. “.…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
  9. 9. 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!
  10. 10. 10 Whatever Happened to “Do No Harm”?  Ethically, health care professionals seek treatments that:  Encourage autonomy  Help, not harm  Do 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 ?
  11. 11. “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.”
  12. 12. “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.”
  13. 13. Fat is a Social Justice Issue  Fatness 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 jobs  More harshly disciplined on the job  Given inferior assignments  Paid less  Viewed as liabilities for employee health benefits  Fired for not losing weight Rothblum et al. International Journal of Eating Disorders (2008).; Fikkan & Rothblum, in “Bias, Stigma, Discrimination, & Obesity” (2005)
  14. 14. 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
  15. 15. Why isn’t sizeism & weight stigma addressed?  Significant mental health, social, relational impacts  Significant intersection with other axes of privilege & oppression  SES  Disability  Age  Race/Ethnicity  Whole chapter of the DSM on disordered eating, so why the silence on clients’ bodies?
  16. 16. 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
  17. 17. 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
  18. 18. 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?”
  19. 19. Research on Fat Studies in Mental Health Training  N=6 thus far; goal is for N=8-12  Participants thus far  Mixture of male and female  Mixture of body sizes  Range in age from 26 to 50  All participants so far ID as White  One IDs as Latino/Hispanic
  20. 20. Research on Fat Studies in Mental Health Training  Participants have discussed  How they chose to take the class  Expectations/assumptions about the class and classmates  Memorable parts of the class  Interactions with peers/colleagues in the class  Awareness of their own biases about body size  Awareness of stigma & micro-aggressions from others
  21. 21. Research on Fat Studies in Mental Health Training  Important emerging themes re: class impact:  Their own body image  Relationships with peers  Relationships with partners/sig. others  Relationships with parents, siblings, & other family  Relationships with friends, roommates, partner’s friends, etc.  Perception of their clients & training sites  Conflict over how much of an “activist” to become
  22. 22. 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 areas  Conversations about food, bodies, dieting when food is brought to classes  Fat-stigmatizing comments from faculty in other classes  Weight/body size generally not included in “dimensions of diversity” conversations  Higher-weight students have not felt comfortable challenging privilege of lower-weight students  Not sure how to initiate conversations with clients about weight, self-image, dieting hx, weight-neutral perspective
  23. 23. Mental health training must include FA/HAES  Opportunities  Another dimension of diversity/social justice  We will continue to experience pressure to “treat” the “obesity epidemic”  Built into the Affordable Care Act  Employers think it will hold down health care costs  Clients continue to subscribe to the “fantasy of being thin”  Partners & family members continue to pressure higher- weight people to lose weight  Our 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
  24. 24. Mental health training must include FA/HAES  Challenges  Pressures of time/content in courses already  Few academic resources that directly address body size/weight and mental health from a HAES perspective  Body 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
  25. 25. 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.
  26. 26. 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.
  27. 27. Fat Studies in Training  Discussion 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?
  28. 28. 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”
  29. 29. What drives our “isms”?  Healthism, Ableism  Fear of aging  Fear of illness  Fear of death  Fear of being marginalized  Fear of being left out/excluded  Fear of loss of control  Fear of losing our power  Fear of being “othered” – so we “other” others’ bodies.
  30. 30. 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
  31. 31. Sizeism, Ableism, Healthism at School & Work  What 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
  32. 32. Sizeism at School & Work  What 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
  33. 33. Sizeism at School & Work  What do we do in our places of work & training that marginalize fat people?  Defining higher-weight students & colleagues as the ones with problems  Holding 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 activities  Eat well  Exercise  Take vacations
  34. 34. Sizeism with Clients  What 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 stereotyping  Non-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
  35. 35. Sizeism with Clients  What 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 efforts  Promise 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 weight  Promote or support bariatric surgery and dieting as a way to “health”  Support partners & parents who shame higher-weight clients  Set weight-loss goals for clients that are not their own
  36. 36. Sizeism with Clients  What 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 bodies  Fail 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
  37. 37. 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.
  38. 38. Contact information  Dr. Sheila Addison  Dr. Michael Loewy Download this presentation at: