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Size Acceptance & Health at Every Size for MFTs


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Size Acceptance & Health at Every Size for MFTs

  1. 1. Size Acceptance & Health at Every Size for MFTs AAMFT 2016 Dr. Sheila Addison Alliant International University
  2. 2. Objectives 1. Participants will understand the principles behind Size Acceptance and Health at Every Size, and their application to a mental health context. 2. Participants will be able to articulate the problems with a weight-focused approach to clients with higher weights. 3. Participants will understand how SA/HAES is being used in therapy with individuals, couples, and families.
  3. 3. Activity 1  Write 4 words or phrases that you associate with “fat people.”  Don’t censor yourself - write whatever comes to mind.
  4. 4. Activity 2  Write 4 words or phrases that you associate with your own body.  Don’t censor yourself - write whatever comes to mind.
  5. 5. Activity 3 GUESS MARIANNE’S HEIGHT & WEIGHT! Marianne Kirby, co-author of “Lessons from the Fat-o-sphere: Quit Dieting and Declare a Truce with Your Body”
  6. 6. How fat is “fat”?
  7. 7. How fat is “fat”?
  8. 8. How fat is “fat”? Marianne says:  “The guesses that most boggled my mind were from men who said I looked like their wives and their wives weighed x number of pounds. Those guesses were all under 200 pounds.”  “There were a lot of guesses that started out, ‘well, you look just like me so….’ and were totally off. But even those guesses, for the most part… were closer to the mark than the guys using their wives’ weights.”  “So: Either these guys are DESPERATELY bad at a game very, VERY few people are good at, or their wives are lying about their weight. “
  9. 9. Why might that be?  Shame - about what it means to be X weight  Stigma - about what X weight looks like/means  Distorted perceptions of self & others
  10. 10.  BMI (body mass index) is weight (in kg) divided by height (in meters) squared  It’s just a height/weight ratio!
  11. 11. “Obesity Epidemic?”  BMI for “overweight” changed from 27 to 25 in 1998  30,500,000 people became “overweight” overnight
  12. 12.  BMI is not magic or even scientific  1998 change was not informed by empirical research - the change was effectively arbitrary  2010 study - BMI poorly predicts health Schneider, H. J. et. al. (2010) "The Predictive Value of Different Measures of Obesity for Incident Cardiovascular Events and Mortality". Journal of Clinical Endocrinology & Metabolism 95 (4): 1777–85.
  13. 13. Fat stigma & mental health  Bias & discrimination aimed at [higher weight] people based on a series of social attitudes that people develop over time, that assumes that there is something wrong with overweight people and they deserve to be punished for their condition. – Rudd Institute
  14. 14. Fat stigma & mental health  Fat shame & stigma  Research suggests they have more health effects than actual weight  Distorted ideas about weight and health  Culture equates “thin” with “healthy” despite evidence to the contrary  “Obesity paradox”
  15. 15. Fat stigma & mental health  “An unintended consequence of [weight loss- focused] policies and programs is excessive weight preoccupation among the population, which can lead to stigma, body dissatisfaction, dieting, disordered eating, and even death from effects of extreme dieting, anorexia, and obesity surgery complications, or from suicide that results from weight-based bullying.” - Ramos-Salas, Canadian Journal of Public Health, 2015
  16. 16. Fat stigma & mental health  The weight “loss” and bariatric industries sell us (and our clients) more of these ideas every day at tremendous financial and personal costs  Yet most weight loss efforts do not succeed  95-99% failure rate
  17. 17. Fat stigma & mental health  “Biology dictates that most people regain the weight they lose, even if they continue their diet & exercise programs.” – Linda Bacon, “Health at Every Size: The Surprising Truth About Your Weight” (2008)
  18. 18. Fat stigma from health professionals  Clear evidence of fat stigma and sizeism  Doctors views of fat patients:  unattractive  difficult to work with  non-compliant  sloppy  lazy  unpleasant to touch  Project Implicit at Harvard – strong implicit and explicit anti-fat bias from doctors  “It is well known that people don’t always speak their minds, and it is suspected that people don’t always know their minds.”
  19. 19. Fat stigma from health professionals  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.)
  20. 20. Fat stigma & mental health Tylka et al, 2014 – Journal of Obesity
  21. 21. Fat stigma from therapists  As clinicians, teachers, & supervisors, we are not immune
  22. 22. Fat stigma from therapists  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).
  23. 23. Fat stigma from therapists  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  Also true for younger doctors  See Yalom, “Love’s Executioner”
  24. 24. Fat stigma from therapists  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.  Fat talk  “Feeling fat”  Histories of dieting & other weight-loss efforts  Experiences of fat stigma  FOO messages
  25. 25. Sizeism and fear  Fear of being unpopular  Fear of being “ugly"  Fear of being shamed  Fear of being the butt of jokes  Fear of being unfeminine or effeminate  Fear of being “too much"  Fear of taking up space  Fear of being “othered”  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  Fear of loss of control over our bodies
  26. 26. Sizeism and fear  Fear of giving up on “The Fantasy of Being Thin”
  27. 27. Stigma, discrimination, & mental health  Discrimination based on weight is pervasive  Employment  Salary  Health care  Public accommodations  Discrimination produces stress.  Stress is a risk factor for disease.  “Feeling fat” has more negative health effects than being fat. - Puhl, et al., Int J of Obesity (2008).; Muennig, et al., Am J Pub Hlth (2008).
  28. 28. Stigma, discrimination, & mental health
  29. 29. 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 & Childhood Obesity  Affordable Care Act - recommends “intensive counseling” for all obese adults and requires insurers to pay
  30. 30. 30 Psychological Risks of Chronic Dieting  Preoccupation with food, eating, & weight  Increased response to external vs. internal eating cues  Mood swings  Irritability  Poor self-image  Disordered eating  Apathy/lethargy  Narcissism  Guilt  Depression
  31. 31. Psychological Risks of Chronic Dieting Where does this “I’m not happy with my appearance” come from?
  32. 32. Psychological Risks of Chronic Dieting  Ignore/distrust hunger and satiety  Rely on external cues  Develop perfectionist tendencies  Judge foods as good/bad  Tendency to binge
  33. 33. 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”
  34. 34. Mental health & the “obesity epidemic”  Body size is a dimension of diversity  Sizeism is a social justice issue  Our students, teachers, supervisors, & clinicians badly need training in a weight- neutral approach  Little or nothing is offered in most mental health programs
  35. 35. Health At Every Size®
  36. 36. Health At Every Size®
  37. 37. Principles of Health At Every Size® 1. Weight inclusivity: Accepting and respecting the diversity of body shapes and sizes 2. Health enhancement: Improving access to information & services; attending to physical, spiritual, social, economic, emotional, & other needs 3. Respectful care: Owning biases, ending weight stigma & discrimination 4. Eating for well-being: Promoting eating in a manner which balances individual nutritional needs, hunger, satiety, nutritional needs, and pleasure 5. Life-enhancing movement: Promoting individually appropriate, enjoyable, life-enhancing physical activity, rather than exercise that is focused on a goal of weight loss
  38. 38. Basic Principles of Health At Every Size®  Health is multi-faceted and holistic  Not simply the presence or absence of something(s)  Health is not a moral imperative  No one owes anyone else pursuit of health  “Healthy” or “unhealthy” is not the same as “moral” and “immoral”  Health is not an outcome or a particular state  A need and a process  Influenced by factors related to privilege & oppression  Weight is not a choice
  39. 39. Why is HAES® Important?  Diets do not work  There is no intervention that has been shown to be safe and effective for the majority of people to lose weight and maintain weight loss
  40. 40. Why is HAES® Important? • All people deserve to enjoy the benefits of positive self- image; attention to self-care; enjoyable, appropriately challenging movement; mental and spiritual well-being; and a diverse diet that meets a variety of needs. • Not just thin people, or those aspiring to become thin. • Many thin people are not practicing HAES either! We just equate health with thinness.
  41. 41. HAES® is weight-neutral  Good nutrition  Pleasurable physical activity  Social support  Restful sleep  Access to quality medical care  Meaningful work  Physical safety  A clean environment  Social justice  Freedom from stigma
  42. 42. HAES refocuses us on:  Helping people make sustainable self-care practices a lasting feature of their day-to- day lives  Teaching children to treasure their bodies and look to them for wisdom about making day- to-day decisions  Transforming a culture of weight obsession into a body positive, realistic celebration of our human diversity.
  43. 43. HAES refocuses us on Getting on with our lives and the hard, rewarding work in front of us.
  44. 44. 45 “Do No Harm”?  Ethically, therapists 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 ?
  45. 45. “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.”
  46. 46. Weight-neutral care  How does weight arise in our work with our clients?  How do we unconsciously collude with the weight stigma and bias our clients come in with?  Requests for help in dieting  Pre- or post-bariatric-surgery care  “Loss of desire” blamed on partner’s weight gain  Parents wanting children to lose weight  Sometimes a split in the parent subsystem over weight
  47. 47. Weight-neutral care How can we respond to the weight- focused concerns of individuals, partners, and parents in a way that is consistent with HAES principles and ethical care of clients?
  48. 48. Weight-neutral care  Assess hx of weight loss efforts (including ED bx)  Explore the meanings of weight gain, weight loss, and current body size  Explore FOO messages about weight and body size
  49. 49. Weight-neutral care  Explore experiences of weight bias, stigma, discrimination, etc.  Offer resources aligned with SA/HAES  Promote engagement with images of diverse bodies
  50. 50. Weight-neutral care  Highlight and challenge language that attaches moral judgment to food choices, body sizes, exercise, etc.  Explore the impact of food/calorie restriction on mood, well-being, thoughts, relationships, etc.
  51. 51. Weight-neutral care  Re-frame the desire for weight change in terms of what the client hopes it would do for them, and work toward that goal  “I would feel more comfortable in my body”  “I would feel able to let go during sex”  “I would be able to look at photos of myself without feeling bad”  “I would be able to go running with my best friend”  Develop tools for body acceptance and self-advocacy regardless of body size
  52. 52. Weight-neutral care  Work with clients & partners to develop a positive, embodied relationship with their bodies, using techniques from sex therapy & somatic approaches  Educate partners about the effects of dieting on mood, cognition, etc. and the value of developing a healthy relationship with food & eating
  53. 53. Weight-neutral care  Offer psychoeducation to parents about weight stigma, bias, “obesity paradox,” and best practices (e.g. Ellyn Satter’s “division of responsibility in feeding”)  Work with parents on their own fears & stigma about having a child with a higher weight  Encourage families to use HAES principles to pursue overall wellness, satisfying movement, eating, etc. that meets each person’s needs
  54. 54. Weight-neutral care
  55. 55. Size Acceptance/HAES® in MFT Training  Opportunities  Another dimension of diversity/social justice, particularly when looked at with an intersectional lens  Deeply relevant to a field that is over 80% female and climbing  Opportunities for research on FA/HAES with families, in couple processes, looking through intergenerational lenses
  56. 56. Size Acceptance/HAES® in MFT Training  Challenges  Pressures of time/content in courses already  Few academic resources that directly address mental health - body size is not included in Family Life Cycle, other multicultural/diversity texts  Funding for research on weight is nearly all controlled by weight “loss” & bariatric industries  Resistance, from students & faculty - weight stigma is still seen as “useful” and “virtuous”
  57. 57. Activities 1 & 2  Look at your responses from the initial exercises  Write 4 words or phrases that you associate with “fat people.”  Write 4 words or phrases that you associate with your own body.
  58. 58. Size Acceptance/HAES® in MFT Training  Our own self-of-therapist issues?  THINK:  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?  PAIR:  What beliefs or fears do you have about embracing Fat Acceptance/Health at Every Size?  What is the culture of your workplace, school, or community regarding fatness, dieting, eating, etc.?  What is like for you to take a look at these attitudes and beliefs?  SHARE: with the group
  59. 59. Size Bias at School & Work  What do we do in our places of work & training that marginalize body size and physical disability?  Lack of accessible seating in classrooms and offices  Bathrooms that are too small or inaccessible  Weight loss “challenges"  Work events that assume a certain level of fitness/ability (e.g. trampoline house, hikes, etc.)  T-shirts that only come in certain sizes
  60. 60. Size Bias at School & Work  What do we do in our places of work & training that marginalize body size and physical disability?  Fat-shaming posters, articles, etc.  “Guilt-free” treats.  Health care policies that penalize people for weight, not engaging in “enough” exercise, etc.  Recommending “self-care” that comes with micro- aggressions  Hiring only people who “fit the culture” - which opens the door to sizeism, ableism, healthism
  61. 61. Size Bias with Clients  What do we do in our clinical work that marginalizes higher-weight clients?  Equate weight with 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.
  62. 62. Size Bias with Clients  What do we do in our clinical work that marginalizes higher-weight clients?  Praise fat people for doing things that we would label “unsafe” or “disordered” in slim people  Support those who shame higher-weight clients  Treating pressure for weight loss as neutral in CT and FT  Set weight-loss goals for clients that aren’t their own  Support weight-loss goals for clients without discussing its cost and likely failure
  63. 63. Size Bias with Clients  What do we do in our clinical work that marginalizes higher-weight clients?  Promote or support bariatric surgery and dieting as a way to “health,” without considering impacts on physical, mental, spiritual, community health  Use sizeist language - “obesity epidemic,” “overweight,” “unhealthy weight"  Compliment weight loss  It might be a sign of physical or mental health problems!
  64. 64. Size Bias with Clients  What do we do in our clinical work that marginalizes higher-weight clients?  Promise or imply that treating mental health issues (depression, binge eating) will result in weight loss  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
  65. 65. Size Bias with Clients  What do we do in our clinical work that marginalizes higher-weight clients?  Fail to incorporate an understanding of how weight bias might influence individual, couple, & family life  Influence of weight stigma  Parent & partner tensions over weight  Maintain inaccessible and/or hostile spaces  Magazines that promote disordered images of bodies, weight stigma  Art that only features certain types of bodies  Inaccessible bathrooms, furniture, etc.
  66. 66. Resources  The Body is Not an Apology  ASDAH –  HAES community –