Size Acceptance & Health at Every Size for MFTs

Size Acceptance & Health at Every Size for MFTs

AAMFT 2016

Dr. Sheila Addison

Alliant International University

Objectives1. 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.

Activity 1Write 4 words or phrases that you associate with “fat

people.”

Don’t censor yourself - write whatever comes to mind.

Activity 2Write 4 words or phrases that you associate with your

own body.

Don’t censor yourself - write whatever comes to mind.

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”

How fat is “fat”?

How fat is “fat”?

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. “

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

BMI (body mass index) is weight (in kg) divided by height (in meters) squared

It’s just a height/weight ratio!

“Obesity Epidemic?”BMI for “overweight”

changed from 27 to 25 in 1998

30,500,000 people became “overweight” overnight

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.

Fat stigma & mental healthBias & 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

Fat stigma & mental healthFat 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”

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

Fat stigma & mental healthThe 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

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)

Fat stigma from health professionals

Clear evidence of fat stigma and sizeismDoctors views of fat

patients: unattractivedifficult to work withnon-compliantsloppylazyunpleasant 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.”

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.)

Fat stigma & mental health

Tylka et al, 2014 – Journal of Obesity

Fat stigma from therapistsAs clinicians, teachers, & supervisors,

we are not immune

Fat stigma from therapistsHealth professionals including psychologists

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

Fat stigma from therapistsTherapists 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 biasAlso true for younger doctorsSee Yalom, “Love’s Executioner”

Fat stigma from therapistsSelf-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

Sizeism and fearFear 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

Sizeism and fearFear of giving up on “The Fantasy of Being Thin”

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).

Stigma, discrimination, & mental health

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

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Psychological Risks ofChronic 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


Where does this “I’m not

happy with my appearance” come from?


Ignore/distrust hunger and satiety

Rely on external cues

Develop perfectionist tendencies

Judge foods as good/bad

Tendency to binge

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”

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

Health At Every Size®

Health At Every Size®

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

Basic Principles of Health At Every Size®

Health is multi-faceted and holisticNot simply the presence or absence of something(s)

Health is not a moral imperativeNo 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

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

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.

HAES® is weight-neutral

Good nutritionPleasurable physical activitySocial supportRestful sleepAccess to quality medical careMeaningful workPhysical safetyA clean environmentSocial justiceFreedom from stigma

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.

HAES refocuses us on

Getting on with our lives and the hard, rewarding work in front of us.

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“Do No Harm”?Ethically, therapists 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” 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.”

Weight-neutral careHow 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 dietingPre- or post-bariatric-surgery care

“Loss of desire” blamed on partner’s weight gain

Parents wanting children to lose weightSometimes a split in the parent subsystem over weight

Weight-neutral careHow 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?

Weight-neutral careAssess 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

Weight-neutral careExplore experiences of weight bias,

stigma, discrimination, etc.

Offer resources aligned with SA/HAES

Promote engagement with images of diverse bodies

Weight-neutral careHighlight 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.

Weight-neutral careRe-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

Weight-neutral careWork 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

Weight-neutral careOffer 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

Weight-neutral care

Size Acceptance/HAES® in MFT Training

OpportunitiesAnother dimension of diversity/social justice, particularly

when looked at with an intersectional lensDeeply relevant to a field that is over 80% female and

climbingOpportunities for research on FA/HAES with families, in

couple processes, looking through intergenerational lenses


ChallengesPressures of time/content in courses alreadyFew 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”

Activities 1 & 2Look at your responses from the initial

exercisesWrite 4 words or phrases that you associate with “fat

people.”Write 4 words or phrases that you associate with your

own body.


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

Size Bias at School & WorkWhat 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

Size Bias at School & WorkWhat 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

Size Bias with ClientsWhat 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 stereotypingnon-compliant, undisciplined, poor self-image, etc.


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


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 lossIt might be a sign of physical or mental health

problems!


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 effortsPromise therapy that can help with weight loss

when there is no such thing


marginalizes higher-weight clients?Fail to incorporate an understanding of how weight

bias might influence individual, couple, & family lifeInfluence of weight stigmaParent & 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 bodiesInaccessible bathrooms, furniture, etc.

ResourcesThe Body is Not an Apology

ASDAH – http://www.sizediversityandhealth.org

HAES community – http://www.haescommunity.org

http://www.sizediversityandhealth.org/

http://www.haescommunity.org/

Health & Medicine

Size Acceptance & Health at Every Size for MFTs