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

1. Fat Studies & Mental Health
– A New Intersectional Lens
ASDAH 2015
Dr. Sheila Addison
Alliant International University

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. 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. 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. 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. 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
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. “.…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. 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
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. “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. “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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Contact information
 Dr. Sheila Addison
sheila.m.addison@gmail.com
http://www.drsheilaaddison.com
 Dr. Michael Loewy
mloewy@alliant.edu
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