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The Broken Lens: How Anti-Fat Bias in Psychotherapy is Harming Our Clients and What To Do About It
Abstract
Anti-fat bias is a persistent and widespread barrier to body liberation that psychotherapists are ethically bound to do something about. Though academics and clinicians have written about the implications of weight stigma in psychotherapy, the prevalence of anti-fat bias in our profession remains and often goes unexamined. Here we explore the nature of anti-fat bias and reasons to shift to a weight-inclusive stance. We offer examples of how anti-fat bias operates in the therapy room and the harm it causes. Anti-fat bias and body-based oppression as forms of microaggressions are explored, and we make the case for body liberation as a social justice issue. We conclude with recommendations for addressing anti-fat bias, including: developing a liberatory consciousness, the importance of moving from awareness to action, examining our relationship to diet culture, ways to avoid stigmatizing language, bringing a social justice lens into the room, and doing our own work so that we stop locating the problem in people’s bodies and provide truly bias-free psychotherapy.
... Anti-fat bias refers to negative beliefs about and attitudes toward people who are perceived to be fat [90]. Kinavey and Cool [91] suggest that this bias may emerge from societal beliefs about weight and health (e.g., thin = healthy, fat = bad) which position weight and health as individualistic, moral imperatives [91]. Research suggests that anti-fat sentiments are present among various healthcare providers, including ED treatment professionals [92]. ...
... Anti-fat bias refers to negative beliefs about and attitudes toward people who are perceived to be fat [90]. Kinavey and Cool [91] suggest that this bias may emerge from societal beliefs about weight and health (e.g., thin = healthy, fat = bad) which position weight and health as individualistic, moral imperatives [91]. Research suggests that anti-fat sentiments are present among various healthcare providers, including ED treatment professionals [92]. ...
... Research suggests that anti-fat sentiments are present among various healthcare providers, including ED treatment professionals [92]. Kinavey and Cool [91] share examples of anti-fat bias in ED therapy settings, including a 'client [whose] previous therapist had advised her that, when she is bingeing, she should "picture her arms falling off from diabetic necrosis" to shame herself into stopping' (pp. 121) [91]. ...
Background
Eating disorder recovery is a complex phenomenon. While historical understandings focused on weight and behaviours, the importance of psychological factors is now widely recognized. It is also generally accepted that recovery is a non-linear process and is impacted by external factors. Recent research suggests a significant impact of systems of oppression, though these have not yet been named in models of recovery.
Body
In this paper, we propose a research-informed, person-centered, and ecological framework of recovery. We suggest that there are two foundational tenets of recovery which apply broadly across experiences: recovery is non-linear and ongoing and there is no one way to do recovery. In the context of these tenets, our framework considers individual changes in recovery as determined by and dependent on external/personal factors and broader systems of privilege. Recovery cannot be determined by looking solely at an individual’s level of functioning; one must also consider the broader context of their life in which changes are being made. To conclude, we describe the applicability of the proposed framework and offer practical considerations for incorporating this framework in research, clinical, and advocacy settings.
... Western cultural ideals regarding body size place higher value on bodies that are thin, White, and able-bodied (Kinavey & Cool, 2019). People whose bodies fall outside of this cultural ideal often experience various forms of discrimination including weight stigma and anti-fat bias (Brewis et al., 2011;Puhl et al., 2021). ...
... Professional counselors and CITs who are not aware of their own anti-fat bias may inadvertently assign more significant pathology to fat clients (Kinavey & Cool, 2019;McHugh & Kassardo, 2011). Mental health professionals who gain knowledge of anti-fat bias are more likely to develop empathy and create strategies for working with clients who have experienced or are experiencing fat oppression (Kase & Mohr, 2022). ...
... 1. Education. Do your own work to educate yourself about anti-fat bias, fatphobia, sizeism, and the intersections of racism, classism, and sexism (Kinavey & Cool, 2019). If you are unfamiliar with the study of anti-fat bias, explore the resources and references provided within this article. ...
People with larger body sizes are often the target of harmful stereotypes such as being lazy, unattractive, and unintelligent. Such stereotypes are part of an extensive system of oppression often intersecting with racism, classism, and ableism. When counselors and counselors-in-training are unaware of their own biases related to body size, larger bodied clients are at risk for further harm within the very place they are seeking support. This article provides professional counselors and counselors-in-training with the historical knowledge needed to examine their own biases and prejudices around body size and fatness to become better counselors and advocates for all clients. Implications for counseling and counselor training and a brief list of action items are included.
... Both explicit and implicit studies of attitudes have shown that sizeism is common in the United States among the general public (e.g., Crandall, 1994), physicians and nurses (e.g., Foster et al., 2003;Hebl & Xu, 2001), psychotherapists (Agell & Rothblum, 1991;Brown, 1989;Davis-Coelho, Waltz, & Davis-Coelho, 2000;Pratt et al., 2016;Young & Powell, 1985), and even among professionals tasked with assisting people who want to lose weight (e.g., "obesity experts," dieticians, physical education teachers, personal trainers; O 'Brien, Hunter, & Banks, 2007;O'Brien, Puhl, Latner, Mir, & Hunter, 2010;Puhl, Wharton, & Heuer, 2009). Evidence of therapists' sizeism is documented in several articles included in this special issue (see Akoury, Shaffer, & Warren, 2019;Brochu, 2019;Harrop, 2019;Kinavey & Cool, 2019;Meulman, 2019;Scott, 2019), and these are unlikely to be isolated incidents. It is important for psychotherapists and counselors to educate themselves about sizeism and to think about how to avoid enacting it in their practices. ...
... It is important for psychotherapists and counselors to educate themselves about sizeism and to think about how to avoid enacting it in their practices. Questions to ask and steps to take are included in articles in this issue (see Calogero, Tylka, Mesninger, Meadows, & Danielsdottir, 2019;Kinavey & Cool, 2019;Pause, 2019;Scott, 2019). ...
... Furthermore, some "treatment" suggestions (e.g., very-low calorie diets, excessive exercise, ignoring hunger signals) made to "overweight" people result in behaviors that would be considered evidence of pathology (e.g., disordered eating, obsessivecompulsive disorder) in "underweight" people (see Calogero et al., 2019;Harrop, 2019). It is unethical to advise clients to engage in unproductive, and potentially harmful (both psychologically and physically), activities (e.g., dieting) that have been shown repeatedly in scientific studies to result in failure (Calogero et al., 2019;Chrisler, 1989;Chrisler & Barney, 2017;Kasardo & McHugh, 2015;Kinavey & Cool, 2019). It is also unethical to assume that the therapist knows more than the client does about areas in which neither has had professional training (e.g., nutrition, exercise physiology, medicine), and we should all be careful about dispensing advice in areas beyond our scope of practice. ...
The importance of addressing weight bias as a social justice issue in psychotherapy and psychology education and training is introduced. The history of the development of fat studies is briefly reviewed. Current coverage of size and sizeism in psychology is critically examined and contrasted with the increasing adoption of the medical model of “obesity.” Fat shaming in the practice of mental health professionals is examined as a barrier to clients’ physical and mental health. Alternatives to medicalized weight management and fat shaming are introduced. Models that emphasize size acceptance and resist negative embodiment are encouraged. The potential for a future that makes space for every body is assessed.
... 175). As a field that promotes a reflective practice (Ratts et al., 2016), we should acknowledge and challenge our own anti-fat biases and work to shift to a weight inclusive position (Kinavey & Cool, 2019;McHugh & Chrisler, 2019). A weight inclusive position is one in which we recognize and celebrate the diversity of body size and help "disrupt dangerous patterns of body loathing, weight cycling, and body abuse" (Calogero et al., 2019, p. 29). ...
... Calogero et al. (2019) outline three principles that counselors and other mental health professionals should keep in mind as they adopt a more weight inclusive stance: (a) people have the right to be overweight without judgment or bias; (b) wellness should be separated from weight; and (c) we should provide tools that help sustain wellness for people of diverse sizes. A more weight inclusive position includes providing size-inclusive furniture and furniture placement, being mindful of the language used to describe larger-bodied individuals, discussing weight related discrimination and linking clients to weight inclusive medical providers, and advocating for social change regarding sizeism and weight related oppression (Kinavey & Cool, 2019;Matacin & Simone, 2019). ...
... Representations of ideal bodies are synonymous with thinness in the United States healthcare and educational systems. Scholars like McHugh and Kasardo (2012) have described multiple ways in which thinness is conceptualized as the ideal and fatness as pathological (Kinavey & Cool, 2019), unhealthy, immoral, and an indicator of worth and intelligence (Kenney et al., 2015). Multiple studies across the decades have demonstrated that healthcare professionals are not immune to implicit weight bias (Akoury et al., 2019;Puhl et al., 2013;Schwartz et al., 2003;Young & Powell, 1985). ...
... Mental health professionals in fields adjacent to counseling (e.g., marriage & family therapy, social work) have begun to recognize sizeism as an area of concern that can impact mental health assessment, diagnosis, and treatment (McHugh & Chrisler, 2019). Early research by Young and Powell (1985) described the potential for pathologizing fatness, a conclusion reinforced by Kinavey and Cool (2019). In a recent special issue of Women and Therapy, Akoury et al. (2019) investigated the experiences of women of size in therapy. ...
... The fourth and final component, Holistic Humanity, redefines health and wellness to fit each unique individual and considers the complex, shared human experience of body image concerns (Altman et al., 2017). This component directly challenges healthism, which places the sole responsibility for health on the individual while disregarding contextual factors that significantly impact an individual's health and wellness (Kinavey & Cool, 2019). By recontextualizing Westernized definitions of "health," preadolescent children may develop a more comprehensive conceptualization that includes emotional, psychological, spiritual, physical, and intellectual wellness (Choate, 2005). ...
... Although body image is a fundamentally cognitive construct (Cash, 2004), culturally responsive counselors also consider the impact of sociocultural and contextual factors, such as family, social support, peer groups, media, race/ethnicity, gender identity, and body size (Kinavey & Cool, 2019;Thompson et al., 1999). The MBW model poses significant social justice implications by deconstructing healthism and Westernized body ideals by introducing a more robust understanding of well-being. ...
Researchers have recognized body dissatisfaction (BD) as
a significant risk factor for developing mental illnesses, with BD
emerging as early as middle childhood. Although scholars have
extensively studied body image as a construct, there remains
a shortage of holistic and developmentally focused models to
foster positive body image in preadolescent children across diverse
cultural and gender identities. In response, we propose the
Multidimensional Body Wellness (MBW) model, which is informed
by sociocultural, intersectional, and resilience-based constructs,
such as body image resilience, body compassion, and Health at
Every Size® principles. Using a multifaceted lens, the MBW model
may assist preadolescent children and families with challenging
harmful body ideals, honoring diverse identities, and redefining
traditional perceptions of wellness. We conclude with relevant
interventions across counseling settings, implications for counselors,
and future directions for research.
Journal of Child and Adolescent Counseling: https://doi.org/10.1080/23727810.2022.2135885
... Current treatment methods include liposuction to remove affected tissues, diet, exercise, manual lymphatic drainage, pneumatic pumps, and compression garments to address pain, inflammation, swelling, and weight gain, as well as preserving mobility and quality of life [4,5]. General Practitioners (GPs) play an important role in coordinating multidisciplinary teams to manage lipoedema; however, research shows significant delays in diagnosis and misdiagnosis of lipoedema as lymphoedema or general obesity and may weight shame patients [5][6][7][8]. GPs can support those with lipoedema through counselling referrals [9] and emotional support for their condition [10]. ...
... Many participants reported experiencing being treated badly by their doctor/s due to their weight/lipoedema, consistent with research showing that lipoedema patients report having been blatantly 'weight-shamed' by doctors and told to reduce food intake and increase exercise [6,7]. Our findings provide greater nuance, with results indicating that those of stages 3-4 are more likely to experience mistreatment due to their weight/lipoedema compared to stages 1-2, perhaps related to increased prevalence of comorbid obesity in this group or misdiagnosis/perception of lipoedema as obesity and general lack of awareness of lipoedema as a valid health condition. ...
Purpose
Lipoedema is a progressive adipose (fat) disorder, and little is known about its psychological effect. This study aimed to determine the experiences of physical and mental health and health care across stages of lipoedema.
Methods
Cross-sectional, secondary data from an anonymous survey (conducted 2014-2015) in Dutch and English in those with self-reported lipoedema were used (N = 1,362, Mdnage = 41-50 years old, 80.2% diagnosed). Chi-square analyses of categorical data assessed lipoedema stage groups 'Stage 1-2' (N = 423), 'Stages 3-4' (N = 474) and 'Stage Unknown' (N = 406) experiences of health (physical and psychological), and health care.
Results
Compared to ‘Stage 1–2’, ‘Stage 3–4’ reported more loss of mobility (p = < .001), pain (p = < .001), fatigue (p = .002), problems at work (p = < .001) and were seeking treatment to improve physical functioning (p = < .001) more frequently. ‘Stage 3–4’ were more likely to report their GP did not have knowledge of lipoedema, did not take them seriously, gave them diet and lifestyle advice, dismissed lipoedema, and treated them ‘badly’ due to overweight/lipoedema compared to ‘Stage 1–2’ (p = < .001). ‘Stage 3–4’ were more likely to report depression (p = < .001), emotional lability (p = .033) eating disorders (p = .018) and feeling lonelier, more fearful, and stayed at home more (p = < .001) and less likely to have visited a psychologist (p = < .001) compared to ‘Stage 1–2’.
Conclusions
A divergent pattern of physical and psychological experiences between lipoedema stages reflects physical symptom differences and differences in psychological symptoms and health care experiences. These findings increase the understanding of lipoedema symptoms to inform psychological supports for women with lipoedema in navigating chronic health care management.
... Research has documented widespread oppression of fat 1 people in Western societies. Fat individuals experience discrimination in healthcare , psychotherapy (Kinavey & Cool, 2019), the workplace (Roehling et al., 2007), and educational settings (Phelan, Burgess, Puhl, et al., 2015); sizeism pervades social (Schaefer & Simpkins, 2014), familial (Kraha & Boals, 2011), and romantic (Boyes & Latner, 2009) relationships. Likely because of this antifat environment, fat individuals report high levels of internalized weight bias and distress (Durso & Latner, 2008). ...
... This is perhaps unsurprising, given that respect is an important prerequisite to effective therapeutic relationships (Slay-Westbrook, 2016). Therapists who are committed to treating fat people equitably and who are attuned to the potential for sizeist discrimination in their interpersonal relationships-including the therapy relationship-are likely to work effectively with fat clients (Kinavey & Cool, 2019). In particular, they may share their fat clients' treatment objectives, including coping with pervasive sizeist discrimination. ...
The fat acceptance movement arose to combat the widespread stigmatization of fatness and fat people through personal liberation and political activism. Support for the movement and its underlying ideology has grown rapidly over the past three decades; however, a self-report measure of fat acceptance with strong psychometric properties has not yet been developed. The current studies aimed to develop the Fat Acceptance Scale (FAS), a measure of fat-accepting beliefs, attitudes, and behaviors that was designed to be appropriate for use with people of all sizes. In Study 1, exploratory factor analysis (n = 266) and confirmatory factor analysis (n = 267) supported a three-factor solution assessing fat activism, health beliefs related to weight, and interpersonal respect for fat individuals. In Study 2 (N = 291), FAS scores predicted reactions to fictitious fat women after controlling for an established measure of antifat attitudes. Data from a subsample of 47 participants indicated moderate-to-high stability of the FAS over 4 weeks. In Study 3 (N = 156), health service psychology doctoral students' FAS scores predicted their reactions to a fictional fat psychotherapy client after controlling for antifat attitudes. Taken together, results provided preliminary evidence for the validity and reliability of FAS scores and suggest that the FAS may be a valuable tool for researchers, clinicians, and advocates interested in fat acceptance. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... While therapist matching between patient and therapist based on race and gender has received much scholarly attention, little has been written about therapist matching between fat therapists and fat patients. Fat embodiment in either patient or therapist has been studied (Kinavey and Cool 2019;McHugh and Kasardo 2012;Vocks, Legenbauer, and Peters 2007), though no previous research has looked at fat embodiment when both therapist and patient identify as fat. This manuscript explores the intimacies of the psychological kinship that develops between patients and therapists when both identify as fat, particularly as connected to work on self, body, and family relationships. ...
... The pervasive negativity about fatness can intrude on psychotherapeutic work; this has generated a need for more fat affirmative training for therapists and other mental health professionals (Calogero et al. 2019). Anti-fat bias among mental health practitioners has led to weight stigma in psychotherapy for fat clients seeking therapy (Kinavey and Cool 2019;McHugh and Kasardo 2012). For example, one empirical study found that fat psychotherapy patients were often subjected to therapist's biases about fatness and dieting along with assumptions that fat patients were unhealthy (Davis-Coelho, Waltz, and Davis-Coelho 2000). ...
While therapist matching between patient and therapist based on race and gender has received much scholarly attention, and some work has examined fatness in therapy for either the patient or the therapist, little has been written about therapies that involve fat therapists and fat patients. This manuscript explores the psychological kinship of the patient and therapist relationship when both identify as fat, particularly as connected to therapeutic work on self, body, and family relationships. I draw from four case studies from the last two years of my therapeutic practice (shared within the context of an IRB-approved study) in order to make specific and broader speculations about the ways that being a fat therapist working with a fat patient informed the therapeutic work. Specifically, I discuss six areas of focus in working as a fat therapist with fat patients: food struggles, body image, attachment/loss, medical challenges, fat stigma, and family conflict. Solidarities around fat oppression, reimagining fatness in family and couples dynamics, and situating therapists as needing to do fat-affirmative work were all explored.
... Sizeism: Perception vs. Reality Hatred Pathologizing fatness (Young & Powell, 1985) Concern trolling (Kinavey & Cool, 2019) Non-accessible seating ...
... • There is only a small body of research on sizeism in the practice of mental health counseling (e.g., Kinavey & Cool, 2019;Smith, 2019). ...
Sizeism is a form of oppression notably absent from textbooks on multicultural counseling (Kasardo, 2019) that negatively impacts people of size in the U.S. and around the world. Although people of color often hold more positive associations with larger body size than people who are white, unrecognized weight biases can still hurt people with intersectional identities in the contexts of housing, employment, and higher education. In the spirit of collegial conversation, presenters will describe sizeism and weight bias and their implications in counselor education and clinical practice, utilizing examples from existing literature on the topic, and offer suggestions for social justice advocacy. Participants will examine two case studies demonstrating how weight biases impact the treatment of clients and the learning of counselors-in-training. In small groups, participants will discuss proactive ways to perform advocacy and pedagogy that confronts sizeism, based on what they have learned.
... The practice of counseling is, unfortunately, not immune to weight-based inequality (Davis-Coelho, Waltz, & Davis-Coelho, 2000;Puhl, Latner, King, & Luedicke, 2014). Scholars have identified ways in which weight bias negatively impacts client care in the counseling context, including negative attitudes of counselors, engagement in a goal of weight loss, disregarding symptoms of an eating disorder due to a client's body size, as well as the size and placement of office furniture (Akoury, Schafer, & Warren, 2019;Kinavey & Cool, 2019). ...
... favors thin bodies (Kinavey & Cool, 2019) or, possibly, challenge client perspectives of themselves that align with dominant framings of body weight and weight bias. Counselors can also engage their clients in conversations about promoting overall health without a focus on weight, consistent with the Health at Every Size paradigm (Matacin & Simone, 2019). ...
Weight bias comprises a multitude of stereotypes about individuals with large bodies, as well as negative attitudes and discriminatory behaviors. In a culture of normative discontent that emphasizes thinness as a social ideal, many counselors will inevitably work with clients who seek assistance with weight loss. Although weight loss may be a client’s identified treatment goal, counselors must consider the potential for harm working toward such a goal in therapy. In this article, we utilize justice motive theory to discuss the potential unintended harm to clients in counseling when weight bias is not considered as part of a case conceptualization. Through the examination of three common social messages related to body weight (i.e., the controllability of body weight, the morality of weight, the social acceptability of weight bias), the justice motive is used to illustrate a case example and the implications for counseling. Considerations for socially just practices in counseling are discussed, as well as future research directions.
... Emily demonstrated curiosity and avoided making assumptive statements regarding Jenna's experiences, understanding the importance of broaching cultural differences in the clientcounselor relationship (Day-Vines et al., 2007). Emily's experience in the ED field prepared her to support clients in challenging diet culture in multiple ways, including discussing the impact of fatoppressive culture on emotional health, being mindful of her language regarding body size, and creating an inclusive office space for clients in different bodies (Kinavey & Cool, 2019). When Jenna shared discomfort in working on body image issues with an individual in a "straight-sized" body, Emily utilized validation and reflecting skills to process these differences in lived body experiences, which helped Jenna feel safe to further process her body image experiences despite their differences. ...
Scholars, practitioners, and clients in the eating disorder (ED) treatment field emphasize the need for more culturally responsive approaches to improve care for marginalized communities. Treatment barriers, such as counselor biases, lack of access to care, and disempowering approaches, perpetuate these gaps across diverse groups with EDs. We propose that Ratts et al.'s (2016) Multicultural and Social Justice Counseling Competencies (MSJCC) can bridge these gaps by assisting counselors and other helping professionals working in ED treatment settings in deconstructing biases and implementing empowering treatment approaches for marginalized individuals with EDs. Using case vignettes, we illustrate how counselors can apply the MSJCC across counseling settings and engage in advocacy with the broader ED recovery community. We conclude by presenting implications for counselors, counselor educators, and supervisors, who all play a role in empowering clients and improving access to ED treatment for diverse populations.
... One study found that patients felt that doctors' advice on diet/exercise reflected ignorance, further postponing diagnosis/treatment (49). Healthcare weight stigma and misinformation must be addressed given their detrimental impacts on care and psychological outcomes (41,74). Disease progression impairs mobility and independence due to accumulating joint deterioration, pain, and fatigue (9,(39)(40)(41). ...
Lipedema is an adipose tissue disorder that principally affects women and is frequently misidentified as obesity or lymphedema. There have been relatively few studies that have precisely defined the pathogenesis, epidemiology, and treatment approaches for lipedema. However, successfully recognizing lipedema as a distinct condition is important for proper management. This review aimed to examine the existing literature on the epidemiology, pathogenesis, clinical presentation, differential diagnosis, and treatments for lipedema. The current research indicates that lipedema appears to be a clinical entity related to genetic factors and fat distribution, although distinct from lymphedema and obesity. Some available treatments include complex decongestive physiotherapy, liposuction, and laser-assisted lipolysis. The management of lipedema is complex and differs from that of lymphedema. Further high-quality randomized controlled trials are urgently needed to continue advancing our understanding of this often neglected disease and exploring optimal medical and surgical treatment regimens tailored specifically for lipedema patients. In summary, despite frequent misdiagnosis, enhanced recognition, and research into customized therapeutic strategies for this poorly characterized but likely underdiagnosed disorder represent promising steps forward.
... Play therapists, like other mental health professionals, must engage in reflection on their relationship with food, body, and exercise (McHugh & Chrisler, 2019). Without ample continuous selfreflection, play therapists can perpetuate thin ideals and sizeist messages and cause harm to their child clients (Kinavey & Cool, 2019). Mental health providers, including play therapists, must engage in ample reflection on their sizeist bias before, during, and after play therapy to support childhood body image dissatisfaction (Bergen & Mollen, 2019). ...
Given that as many as 50% of school-aged children report body dissatisfaction or appearance concerns, it is imperative that play therapists increase their competency to address childhood body image needs. This article provides an overview of the need for play therapy adaptations to meet the body image and related mental health needs of youth. We offer size-inclusivity as a framework for play therapists as they serve children of all body shapes and sizes, including size-inclusive toys, play therapist bias and reflection, assessment, and play therapy process considerations.
... Social justice is a cornerstone of the counseling profession, and there is a need for counselors to understand the deleterious impacts of oppression on their clients' wellbeing (Ratts et al., 2016). Kinavey and Cool (2019) asserted that for therapists to empathically understand their clients, they must strive toward "understanding the suffering that accompanies body-based oppression" (p. 116). ...
... Research with healthcare providers has shown that provider biases can impact the assessment, diagnosis, and treatment of people of size (Kerl-McClain et al., 2022;Puhl et al., 2014;Schwartz et al., 2003). Research on counseling practice has shown that sizeism negatively impacts therapeutic relationships, especially when providers hold biases toward clients of size (Kinavey & Cool, 2019;McHugh & Kasardo, 2012;Smith, 2019). School counseling journals in the U.S. (i.e., Professional School Counseling, Journal of School Counseling) have been nearly silent on this topic, with only one article published in the past decade about sizeism and advocacy (Larrier et al., 2011), and one article published in a school health journal that includes recommendations for school counselors (SCs) regarding sizeism and social support (Wu et al., 2014). ...
This conceptual article explains how school counselors can increase awareness of size discrimination and address sizeist attitudes and biases in U.S. schools. Sizeism can begin in early childhood and continue into young adulthood, with damaging effects on student wellness. Sizeist biases in society are reflected in school systems. Actions school counselors can take to promote equity in education for students of size are suggested, including implementing size-inclusive prevention strategies within a comprehensive school counseling program.
... Despite a client and counselor's mutual investment in a counseling relationship, research about weight bias in counseling has focused solely on counselors' perceptions of clients' weight and its influence on the therapeutic alliance (Kinavey & Cool, 2019;McHugh & Kasardo, 2012;Puhl et al., 2014). Thus, research has insufficiently examined how a counselor's weight may hinder this alliance (Moller & Tischner, 2019). ...
... Furthermore, counselor education programs have historically omitted bodybased oppression and anti-fat bias in their curricula, which is further evidenced in the results of this study. Kinavey and Cool (2019) provide an overview of how anti-fat bias in psychotherapy harms clients, as well as comprehensive recommendations for counselors and psychotherapists to explore and address internalized anti-fat bias and create weight-inclusive practices and practice settings. This is particularly relevant to the work of rehabilitation counselors, for whom collective access is key to creating safe, inclusive, and universally designed practices. ...
Though the importance of the inclusion of multicultural and social justice competencies in rehabilitation counselor education has been attended to for years, we know little about the content, concepts, activities, and assignments included in multicultural counseling courses. This mixed-methods study analyzed 25 multicultural counseling syllabi from CACREP-accredited rehabilitation counseling programs. Results indicated that nearly half of the multicultural counseling syllabi analyzed took an essentialist approach to educate future rehabilitation counselors. Very few syllabi mentioned the immigrant and refugee experience, and no syllabi exploredsize diversity and/or anti-fat bias. Class assignments and activities assigned exercises focused largely on students’ racial and ethnic identities. Additionally, results showed a common theme of ethnographic interviews, cultural site visits, and cultural immersion exercises. A call to action for counselor educators is included.
... Weight bias perpetuates negative stereotypes and attitudes towards larger sized people that lead to discrimination (Carel & Latner, 2016). Weight bias is not immune in healthcare settings (Kinavey & Cool, 2019), and research suggests that providers may see patients as lazy or gluttonous leading to encouraging a treatment goal of weight loss and to overlook eating disorder symptomology (Akoury et al., 2019). The idea that weight is controllable, otherwise termed as 'obesity discourse' simply by intake and expending calories (Bombak, 2014), oversimpli es the complexities of eating and weight struggles. ...
Background: Communities of color have been under-assessed and under-diagnosed with eating disorders. Most of the previous research on BIPOC communities has focused mainly on eating pathology as it relates to food insecurity. The purpose of this study was to explore whether the incidence of eating pathology and intense body dissatisfaction in poorer communities of color was comparable to the incidence reported by the National Institute of Mental Health and National Eating Disorder Association. The data outcomes may be relevant to community based mental health clinics and their partners as it will potentially highlight gaps in research, diagnostic assessment, and treatment interventions specific to eating disorders in marginalized communities.
Methods: The data was collected from 309 individuals seeking mental health treatment in a community based mental health clinic in East Harlem NYC. Two separate assessments were utilized. The first assessment was conducted at intake within the comprehensive psychosocial assessment. It was a self-reported measure that assessed frequencies of 5 types of eating pathology: 1.) restricting, 2.) restricting/binging 3.) restricting/purging, 4.) binge/purging, and 5.) binging. Body and Weight Attitude Likert assessment scale, a 14-item measure was created based on 5 sub-scales: 1.) income 2.) restricting eating and obsessive thought behavior 3.) body dissatisfaction 4.) binge-eating and compensatory behavior 5.) emotional distress.
Results: This is the first study to investigate rates of eating pathology and attitudes around body image and weight in a poorer community with the majority of the community identifying as people of color. What we found was high rates of body dissatisfaction and high incidence of eating pathology which is not only comparable to the NIMH and NEDA’s data for a white population but is higher than what the current data supports for any racialized group. Our data also shows higher rates of eating disorder diagnosis, particularly for AN, AAN, and EDNOS than what is supported in either NIMH and NEDA for any racialized group We discovered the incidence of frequency of restricting food was highest in the Black and mixed-Race participants. Black participants had the highest rate of diagnosis of an eating disorder of restricting type, which is much higher than the national incidence. Body dissatisfaction is the most notable risk factor in the development of eating disorders. The mixed-race group (n=97) rated highest on intensity of body dissatisfaction. This study highlights the need for further investigation, so we don’t perpetuate the neglect of these communities in both mental and medical health care.
... 102). Examples relevant to ED treatment may include gender roles and expectations, Westernized beauty ideals, diet culture, and weight bias (Jordan, 2010;Kinavey & Cool, 2019;Trepal et al., 2012). ...
Marginalized populations have been historically underrepresented in
eating disorder (ED) research. A more robust, culturally responsive framework is needed to bridge ED research and counseling practice gaps.
Therefore, we propose an integrative approach using Relational Cultural
Therapy and self-compassion principles to provide a strengths-based
and socially just conceptualization of ED clients with marginalized identities. We conclude with a case illustration, implications for counselors,
and future research directions.
... 21,23 Dietitians are not truly seeing their clients if they do not seek to understand the suffering that accompanies body-based oppression. 24 Dietitians need to develop a deeper and broader understanding of how weight stigma shows in the world, in their communities, and in practice spaces. 13,20 The initial part of this study aimed to examine whether New Zealand registered dietitians and student dietitians possess a weight bias as assessed by the fatphobia scale. ...
Aim:
This study explored demographics and three characteristics of registered dietitians-optimism, perfectionism, and weight bias and whether they affect three components of dietetics practice-dietetics assessment, dietetics recommendations, and dietitian's perception of the client's success.
Methods:
A self-administered questionnaire was completed by 109 registered dietitians and student dietitians in New Zealand to assess explicit weight bias. Participants were randomised to receive a case study for a condition unrelated to weight accompanied by a photo of a woman with either a smaller or a larger body. Participants then assessed the client based on data provided, provided recommendations, and rated their perception of the client.
Results:
Mean (±SD) scores indicated mild fatphobia (2.63±0.39) in participating dietitians. Dietitians presented with the photo of a larger client assessed the client to have lower health and were more likely to provide unsolicited weight management recommendations. Additionally, dietitians rated the larger client as less receptive and motivated, and less likely to understand the recommendations adequately, with a lower ability to comply with and maintain these recommendations.
Conclusions:
Dietitians and student dietitians in New Zealand may practise in a manner that could be perceived as influenced by negative implicit weight bias, despite the explicit fatphobia scale scores assessing only mild fatphobia. Further research examining the extent of the problem in New Zealand, how it impacts client outcomes, and possible solutions are required.
... The Academy of Eating Disorders recommends that all health professionals evaluate their own weight stigma with an online tool [172]. While some people with eating disorders may experience improved health with weight loss, to appropriately assess and treat people with eating disorders who are of higher weight, it is recommended that health professionals adopt a weight-inclusive or weight-neutral stance, advocating for increases in health behaviours and decreases in disordered eating, instead of a focus on weight loss, which can be perceived as inherently weight stigmatising [for a detailed analysis of how weight stigma can generate stress, disordered eating and further weight gain, see 9,173]. To examine levels of internalised weight bias in people of higher weight, the Modified Weight Bias Internalisation scale [WBIS-M; 174] may be used to document links with eating disorder psychopathology. ...
Introduction:
The prevalence of eating disorders is high in people with higher weight. However, despite this, eating disorders experienced by people with higher weight have been consistently under-recognised and under-treated, and there is little to guide clinicians in the management of eating disorders in this population.
Aim:
The aim of this guideline is to synthesise the current best practice approaches to the management of eating disorders in people with higher weight and make evidence-based clinical practice recommendations.
Methods:
The National Eating Disorders Collaboration Steering Committee auspiced a Development Group for a Clinical Practice Guideline for the treatment of eating disorders for people with higher weight. The Development Group followed the 'Guidelines for Guidelines' process outlined by the National Health and Medical Research Council and aim to meet their Standards to be: 1. relevant and useful for decision making; 2. transparent; 3. overseen by a guideline development group; 4. identifying and managing conflicts of interest; 5. focused on health and related outcomes; 6. evidence informed; 7. making actionable recommendations; 8. up-to-date; and, 9. accessible. The development group included people with clinical and/or academic expertise and/or lived experience. The guideline has undergone extensive peer review and consultation over an 18-month period involving reviews by key stakeholders, including experts and organisations with clinical academic and/or lived experience.
Recommendations:
Twenty-one clinical recommendations are made and graded according to the National Health and Medical Research Council evidence levels. Strong recommendations were supported for psychological treatment as a first-line treatment approach adults (with bulimia nervosa or binge-eating disorder), adolescents and children. Clinical considerations such as weight stigma, interprofessional collaborative practice and cultural considerations are also discussed.
Conclusions:
This guideline will fill an important gap in the need to better understand and care for people experiencing eating disorders who also have higher weight. This guideline acknowledges deficits in knowledge and consequently the reliance on consensus and lower levels of evidence for many recommendations, and the need for research particularly evaluating weight-neutral and other more recent approaches in this field.
... We must acknowledge that weight bias does not exist independently of sexism, racism, ableism, homophobia, classism, etc., and will certainly affect pregnant individual's clinical encounters and physical/emotional outcomes during and after pregnancy. 31,32 ...
This article addresses obesity in pregnancy, the inherent risk it poses for increased complications, and ways to reduce weight bias and provide evidence-based care for this patient population.
... , for example, researching transgender clients, found that mental health providers who allowed their personal biases to influence treatment plans caused higher rates of depression, mental health issues, and suicide for such clients. In another study, Kinavey and Cool (2019) found that anti-fat bias harmed clients when HSPs assumed a client's physical weight was the root cause of mental health issues and failed to accurately diagnose and treat the actual issue. These and other situations demonstrate the importance of human services faculty teaching students about their ethical obligations. ...
This qualitative phenomenological study explored the mental health services utilization
experiences of African American emerging adults and investigated the barriers and encumbrances interviewees experienced while seeking mental health support. An inductive thematic analysis revealed six themes: (a) hesitancy-acceptance conflict, (b) positive encounters with mental health services utilization, (c) intersectional barriers to seeking mental health services, (d) resource awareness and navigation, (e) help-seeking motivators, and (f) pastoral guidance and counseling. Interviewees emphasized financial factors, services affordability, and resource knowledgeability as prominent barriers to mental health services utilization, denoting familial, peer, and culturally driven faith influences as double-edged motivators and hindrances to help-seeking. Initial implications for community and college human services providers recommend mental health advocacy promotion through increased on-campus services visibility, off-campus resource accessibility, and culturally attuned collaborations.
... Healthism suggests that the responsibility to prevent disease relies on the individual and their choice to change their own circumstances (Crawford, 1980). Similar to Saint Catherine's attempts to attain purity through starvation (Bell, 1985), healthism posits that the pursuit of health is a means to elevate oneself (Kinavey & Cool, 2019). However, such an approach is reductionist in nature and does not consider the unique and intersectional influences of environment, culture, and economic means, amongst others, on one's food choices and behavior. ...
Orthorexia Nervosa (ON) is a term describing a fixation on food purity, involving ritualized eating patterns and a rigid avoidance of “unhealthy foods.” Those self-identified as having ON tend to focus on food composition and feel immense guilt after eating food deemed “unhealthy.” Although not formally recognized as a psychiatric disorder by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ON has received increasing attention since its identification in 1997. There is ongoing work to establish diagnostic and empirical tools for measuring ON; embedded in this is the question as to whether or not ON is a new eating disorder. In this paper, we argue ON is not a new psychiatric disorder but rather a new cultural manifestation of anorexia nervosa (AN). We begin by providing an overview of historical representations and classification of eating disorders, with a specific focus on AN. This is followed by discussion of the rise in diet culture and healthism since the 19th century. We conclude by examining the diagnostic validity and utility of ON through a discussion of empirical evidence. Classifying ON under the diagnostic umbrella of AN may improve our understanding of factors underlying restrictive eating behaviors.
... Despite being at greater risk of subthreshold and clinical EDs (Lipson & Sonneville, 2017), symptoms of EDs often go unrecognized in this population or may even be lauded as appropriate weight management behavior (LaMarre et al., 2017;Lebow et al., 2015), in effect reducing access to treatment and prolonging distress (Gotovac et al., 2020;Sim et al., 2013). A robust body of research has identified widely-held stigmatizing attitudes toward higher weight individuals in ED research and praxis (Calogero et al., 2016;Kinavey & Cool, 2019). Although barriers to appropriate treatment clearly exist at point of access to healthcare, there is a dearth of experimental research on the role of weightstigmatizing assumptions in lay perceptions of ED-related distress in higher weight individuals. ...
The present study examined how weight status would affect lay perceptions of a White female student presenting signs of eating disorder-related distress. We recruited a mixed-gender, weight-diverse U.S. community sample through Mechanical Turk (N = 130; 49.2% female) to complete an online survey. Participants were randomly assigned to one of two conditions in which they read a personal statement section of a college application revealing eating disorder-related distress from a student who was either ‘overweight’ or ‘underweight.’ Participants evaluated the student on need for support, behavioural prescriptions for eating and exercise, and personal qualities. Although participants recognized a serious mental health concern in both conditions, they were more likely to prescribe eating disorder behaviors to the higher weight student. Findings suggest that weight stigma may bias lay perceptions of and even reinforce an eating disorder when exhibited by higher weight individuals.
... More is needed. Educational interventions focusing on weight bias should not only be incorporated in the classroom, but in all aspects of clinical training (e.g., practicum, supervision, therapy), and not only for trainees but for practicing professionals, supervisors, and faculty through continuing education (Calogero et al., 2019;Kinavey & Cool, 2019;McHugh & Kasardo, 2012;Rothblum & Gartrell, 2019). This involves mental health trainees and professionals gaining awareness of their own weight biases, educating themselves about the complexity and controllability of weight, health, and weight loss, and advocating to reduce weight bias, such as by speaking out when they witness injustice and building a consensus that weight bias is not acceptable. ...
Weight bias is a neglected issue in the health professions, including mental health training programs. Even though mental health professionals exhibit many of the same weight biases that are seen at the societal level and among other health professionals, mental health programs rarely provide training on weight bias, weight diversity, or critical weight science. No study to date has tested the effectiveness of a weight bias reduction intervention in a mental health setting. The purpose of this study was to examine the efficacy of a weight bias seminar informed by the attribution‐value model of prejudice. Using a pretest‐posttest design, 45 clinical psychology trainees completed measures of weight controllability beliefs, anti‐fat attitudes, and attitudes toward fat clients 1 week before and 1 week after the weight bias seminar. After the weight bias seminar, participants reported weaker weight controllability beliefs, anti‐fat attitudes, and negative client attitudes. Furthermore, weight controllability beliefs mediated the effect of the weight bias seminar on participants’ general anti‐fat attitudes and client‐specific attitudes. Thus, this study identifies weight controllability beliefs as a potential mechanism underlying the efficacy of educational weight bias interventions in mental health training programs. Future weight bias educational interventions may benefit from application of the attribution‐value model of prejudice.
Diversity, equity, inclusion, belonging, and social justice are values at the center of effective and ethical counselor education. Best practices, ethical codes, textbooks, and research articles all discuss how important these topics are. However, there can be a gap between how DEIBASJ are discussed and how these dynamics are displayed in the profession. As a result, CES’ can find themselves in complex situations while navigating these dynamics. This chapter discusses how doctoral learners, clinical supervisors, and counselor educators with historically marginalized identities can successfully navigate these political, social, and professional power structures and how counselor education professionals can work to dismantle oppression across multiple roles. The authors include voices and contributions from people with intersecting cultural identities and experiences to help provide concrete guidance on maintaining wellness in the profession. Further, the authors of this chapter make every effort to abide by best practices as defined through the lenses of critical race theory, intersectionality, and social justice as defined in the introduction of this text.
While eating disorders have been estimated to affect at least 4% of the Australian population, research demonstrates that feeding difficulties and eating disorders are overrepresented in neurodivergent people, including in autism, ADHD, intellectual disability, giftedness, and Tourette’s disorder. However, despite there being a substantial body of literature spanning decades evidencing links between neurodivergence and eating disorders, awareness among clinicians and researchers of this existing knowledge base is only emerging in Australia.
NEDC commissioned Eating Disorders Neurodiversity Australia (EDNA) to write a report, Eating Disorders and Neurodivergence: A Stepped Care Approach, that synthesizes research and lived experience evidence regarding the prevention, early identification and treatment of eating disorders and disordered eating for neurodivergent people.
This report aims to encourage collaboration among stakeholders to co-produce and co-design appropriate, effective, culturally valid, and safe neurodiversity-affirming support systems and care pathways. It is designed for the use of a wide range of stakeholders, especially health care professionals (e.g., psychiatrists, psychologists, dietitians, general practitioners, paediatricians, occupational therapists), researchers, academics, educators (e.g., teachers), service managers, and lived experience experts.
This report draws on fundamental constructs relating to human rights, bioethics, humanistic psychology, phenomenology, and social justice. It challenges traditional understandings of neurodivergence as pathological. It seeks to destigamtise neurodivergent body awareness and image, feeding, and eating experiences and behaviours. It is a call to action for all eating disorder stakeholders to engage in a radical rethink of how neuronormative feeding and eating practices, which influence research and clinical practice across all levels of eating disorder care, may prove harmful for neurodivergent people.
Internalised oppression, which occurs within individuals and groups of people experiencing oppression, is defined as the internalisation of the ideology of inferiority that is directed at the oppressed group by the dominant group. Internalised oppression can contribute to anxiety, depression, identity confusion, and feelings of inferiority, among other mental health concerns. While the field of body psychotherapy offers models for using somatic approaches to address the traumatic impact of oppression, there is a gap in understanding and addressing the embodied experience of internalised oppression. This paper will explore, discuss, and offer ideas for how the somatic psychotherapy interventions of body awareness, sensation tracking, and somatic resourcing can address internalised oppression and support clients in developing increased capacity for regulation, self-love, and empowerment in the face of ongoing oppression. Composite cases are used to illustrate this clinical approach.
Social aspects of dieting are discussed in the extant feminist literature. However, despite frequent use of the term ‘diet culture’ in online communities critical of weight-loss dieting and popular books about the harms of restrictive eating, academic studies have not yet investigated its meaning holistically. We used thematic analysis to examine how those in the broad ‘anti-diet movement’ have challenged norms representing ‘diet culture,’ and how the term can be used to unite feminist researchers, activists, and health professionals. One-hundred and eighteen online qualitative survey participants (94.92% female; 37.29% health professionals; 51.70% anti-diet activists; Mage = 36.67) characterised ‘diet culture’ as ‘health myths about food and eating,’ and a ‘moral hierarchy of bodies’ driven by ‘systemic and structural factors.’ Feminist researchers, activists, and health professionals can use ‘diet culture’ to challenge myths and misconceptions about dieting and health, as well as the broader systems and structures that perpetuate these myths.
The Centers for Disease Control and Prevention and the World Health Organization have documented an increase in fat people in recent decades, which is being met with a backlash of anti-fat biases, or fatmisia. Fatmisia is prevalent in most aspects of society, especially among fat people who have internalized fatmisia. Utilizing a diagnostic questionnaire in combination with the Fat Phobia Scale–Short Form and the Weight Bias Internalization Scale, this study explored the relationship between client body size, the presence of a major depressive disorder (MDD) diagnosis, and if applicable, the severity of MDD symptoms assigned by counselor trainees (N = 113). Results were analyzed using one-way analysis of variance and covariance. This sample (N = 113) significantly differed in diagnoses assigned to obese clients by assigning more severe MDD. Study limitations and implications are discussed.
This research presents an in-depth idiographic study that illustrates how learning to eat intuitively involves socio-cultural challenges, strategies of resistance and self-actualising processes. Interviews were conducted with eight women who had been practising intuitive eating (IE) for at least 1.5 years. Data was analysed using IPA and four themes were drawn inductively from the data: IE as an ongoing process, perceived judgement of others, strategies of resistance and processes of self-actualisation. Further research is needed to explore experiences of learning to eat intuitively amongst different samples and with different cultures, and to further investigate the relationship between IE and the actualising tendency.
Background
Obesity is a stigmatized disease. Patients are devaluated and disadvantaged by the general population and also in the healthcare system.Objective
Summary of the literature on the consequences of stigmatization and discrimination of patients with obesity and augmented by the results of a recent survey of women with obesity.Methods
Literature search, descriptive and inference statistical analyses in a representative German sample of n = 500 women with obesity.ResultsWeight-based stigmatization and discrimination are more often reported by women. These experiences are associated with negative consequences that can contribute to perpetuating the disease. Patients can also internalize negative stereotypes. Patients with a higher body mass index (BMI) report weight-based stigmatization more often, even in the healthcare setting. The self-perception of weight is particularly inaccurate in patients with severity class I obesity (BMI 30–34.9 kg/m2).Conclusion
The elevated prevalence of psychiatric disorders in patients with obesity can partly be attributed to weight-based stigmatization. Stigmatization and the subsequent internalized stigma need to be sensitively addressed especially in the setting of psychotherapy.
This is a commentary on Ward and McPhail’s (2019 Ward, P., & McPhail, D. (2019). Fat shame and blame in reproductive care: Implications for ethical health care interactions. Women’s Reproductive Health, 6, 225–241. doi:10.1080/23293691.2019.1653581[Taylor & Francis Online] , [Google Scholar]) article “Fat Shame and Blame in Reproductive Care: Implications for Ethical Health Care Interactions.” Here I note the importance of good mental health to positive pregnancy and childbirth experiences and consider whether psychologists and other mental health professionals share medical providers’ tendencies to blame and shame their fat clients (they do). I discuss the absence of coverage of sizeism (fat prejudice) in textbooks used to train psychology graduate students, students’ and trainees’ resistance to discussions of sizeism in classes and workshops, and the importance of intersectionality and consideration of fat as a social identity. Resources for teaching and practicing fat-affirmative psychotherapy are provided.
This article reports the results of a Foucauldian-informed discourse analysis exploring representations of fatness embedded within an empirically based psychological treatment manual for binge eating disorder, a condition characterized by overvaluation of weight and shape. Analyses indicate that the manual prioritizes weight loss with relatively less emphasis placed on treating the diagnostic symptoms and underlying mechanisms of binge eating disorder. We raise critical concerns about these observations and link our findings to mainstream psychology’s adoption of the medical framing of fatness as obesity within the “gold standard” approach to intervention. We recommend that psychology as a discipline abandons the weight loss imperative associated with binge eating disorder and fat bodies. We recommend that practitioners locate the problem of fat shame in society as opposed to the individual person’s body and provide individuals with tools to identify and resist fat stigma and oppression, rather than provide them with tools to reshape their bodies.
In 2015, the 3rd Annual International Weight Stigma Conference was held in Reykjavik, Iceland.1 One of the highly anticipated sessions of the 2-day event was a roundtable discussion on terminology used in weight stigma research and professional practice to describe higher-weight bodies and to identify best practice—how to engage in the conversation without being part of the problem. We tried to include a range of voices on the panel, including weight stigma researchers from health and social sciences, a bioethicist, a journal editor, a representative of an obesity organization, and a size-acceptance activist. At the end of the hour, the only thing that everybody agreed on was that there was no simple answer, other than to respect and honor the wishes of the person or people we were speaking to or about in any given situation.
Making the transition to a weight-neutral worldview is a daunting task. Such a perspective is a decidedly minority position, in opposition to broadly held cultural assumptions, and will most likely be under assault for years to come. Members of oppressed groups make social progress and improve their mental and physical health by rejecting the negative and stigmatizing messages, paying attention to the truth of their own experience, comparing notes with other members of their group, and identifying the stereotypes, stigma, violence, and discrimination they face. Discrimination based on weight is as common as discrimination based on race and age, and more prevalent than that based on sexual identity, disabilities, and religious beliefs. The correlation between higher weight and a lower socio-economic status seems to be causal in both directions in that poverty tends to restrict opportunities for safe physical activity and access to good nutrition, and discrimination against fat people in hiring and retention lowers their income. Public health interventions must address social justice issues like inequality, discrimination, and poverty, not just focus on individual choices. For people to do the hard work of caring for themselves, defending themselves, or loving and advocating for themselves, they have to believe they are worth caring for. Caring for bodies is hard work, and some environments make it especially difficult. The first order of business is to understand that all bodies, of all sizes and all socio-economic classes, are precious and deserve care.
Delineations between the biological, psychological, and social forces underlying eating disorder (ED) are false distinctions, as nature and nurture always go hand in hand. Genes code RNA and DNA, the building blocks of cells, creating variations associated with risk. While they do not code behavior or disease, genes create vulnerabilities that will be tempered or intensified by other factors, such as the family, early development, social experiences and expectations, physical conditions, and gender. Although they are not destiny, genes shape vulnerability and resilience, affecting how we perceive, organize, and respond to experiences, and contributing to the perfect storm of ED. Early puberty may be best understood as an ecological disorder, an interaction of psychosocial, nutritional, and environmental triggers, such as pollutants or chemical exposure; while family stress or trauma may also play a part. The entire hormonal system has been subtly rewired by modern stimuli. Female sexual maturation is not controlled by a ticking clock. It is more like a musical performance with girls' bodies as the keyboards and the environment as the pianist's hands. Sexual maturation brings increased attention to the body, sexuality, and the developmental pressures of adolescence, enhancing the impact of other ED risk factors.
As rates of obesity have increased throughout much of the world, so too have bias and prejudice toward people with higher body weight (i.e., weight bias). Despite considerable evidence of weight bias in the United States, little work has examined its extent and antecedents across different nations. The present study conducted a multi-national examination of weight bias in four Western countries with comparable prevalence rates of adult overweight and obesity.
Using comprehensive self-report measures with 2866 individuals in Canada, the U.S., Iceland, and Australia, the authors assessed 1) levels of explicit weight bias (using the Fat Phobia Scale and the Universal Measure of Bias) and multiple socio-demographic predictors (e.g., sex, age, race/ethnicity, educational attainment) of weight-biased attitudes, and 2) the extent to which weight-related variables, including participants' own body weight, personal experiences with weight bias, and causal attributions of obesity play a role in expressions of weight bias in different countries.
The extent of weight bias was consistent across countries, and in each nation attributions of behavioral causes of obesity predicted stronger weight bias, as did beliefs that obesity is attributable to lack of willpower and personal responsibility. Additionally, across all countries the magnitude of weight bias was stronger among men and among individuals without family or friends who had experienced this form of bias.
These findings offer new insights and important implications regarding sociocultural factors that may fuel weight bias across different cultural contexts, and for targets of stigma-reduction efforts in different countries.International Journal of Obesity accepted article preview online, 26 March 2015. doi:10.1038/ijo.2015.32.
USING AN ETHICAL LENS, THIS REVIEW EVALUATES TWO METHODS OF WORKING WITHIN PATIENT CARE AND PUBLIC HEALTH: the weight-normative approach (emphasis on weight and weight loss when defining health and well-being) and the weight-inclusive approach (emphasis on viewing health and well-being as multifaceted while directing efforts toward improving health access and reducing weight stigma). Data reveal that the weight-normative approach is not effective for most people because of high rates of weight regain and cycling from weight loss interventions, which are linked to adverse health and well-being. Its predominant focus on weight may also foster stigma in health care and society, and data show that weight stigma is also linked to adverse health and well-being. In contrast, data support a weight-inclusive approach, which is included in models such as Health at Every Size for improving physical (e.g., blood pressure), behavioral (e.g., binge eating), and psychological (e.g., depression) indices, as well as acceptability of public health messages. Therefore, the weight-inclusive approach upholds nonmaleficience and beneficience, whereas the weight-normative approach does not. We offer a theoretical framework that organizes the research included in this review and discuss how it can guide research efforts and help health professionals intervene with their patients and community.
Mainstream dietetics buttresses a conventional weight management agenda that is associated with weight preoccupation, body dissatisfaction, size oppression, and troubled eating. Coterminous with this agenda is healthism, which taken together, impede dietitians’ engagement with a health at every size (HAES) paradigm, a paradigm driven by concern for equality. Yet, HAES has also been critiqued for having healthist tendencies. The purpose of this paper is to explore how HAES might be reimagined through the lens offered by relational cultural theory (RCT) to offer a radical and more socially just vision of dietetic practice. We posit relational–cultural theory as a complementary theoretical perspective to deepen understandings and to politicize HAES-based dietetic practice. We suggest that RCT permits a critical, relational, and political revisioning of the weight-centred canon and elaborates HAES by emphasizing mutual empathy and reciprocal growth within and between the client and practitioner concomitantly. Moreover, questions of power, ethical survival, and knowledge emerge which is what we contend makes it possible for a socially just, nonhealthist HAES practice to flourish.
This article presents arguments for and against weight loss counseling in feminist therapy. Conflicts between feminist therapy and weight loss counseling are explored and the implications of counseling and not counseling on women's empowerment are considered. Although each case requires an individual ethical decision, the author, a feminist therapist who has done weight loss counseling in the past, concludes that the answer to the title question should, in general, be "no."
Are the psychotherapeutic experiences of fat clients negatively affected by the cultural bias against fat people? This empirical study demonstrates that clients' weight may negatively affect psychologists' clinical judgments of and treatment planning for fat clients. Strategies to combat fat bias are presented for both training programs and clinicians. Information provided for training programs includes specific guidelines for curriculum development. Strategies presented for clinicians include assessment of one's own bias, self-education, treatment alternatives, and practice recommendations.
This study investigated whether psychologists who practice therapy stereotype obese clients negatively. A sample (
N = 282) of APA Division 29 (Psychotherapy) members responded to a case history that depicted a client as either obese or nonobese, and as either male or female. Psychologists rated obese clients as more physically unattractive and more embarrassed than nonobese clients, but also as softer and kinder than nonobese clients. There were no significant effects for weight on therapy recommendations, although female clients were viewed as more motivated and as less severely impaired. Implications for obese clients are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Current guidelines recommend that "overweight" and "obese" individuals lose weight through engaging in lifestyle modification involving diet, exercise and other behavior change. This approach reliably induces short term weight loss, but the majority of individuals are unable to maintain weight loss over the long term and do not achieve the putative benefits of improved morbidity and mortality. Concern has arisen that this weight focus is not only ineffective at producing thinner, healthier bodies, but may also have unintended consequences, contributing to food and body preoccupation, repeated cycles of weight loss and regain, distraction from other personal health goals and wider health determinants, reduced self-esteem, eating disorders, other health decrement, and weight stigmatization and discrimination. This concern has drawn increased attention to the ethical implications of recommending treatment that may be ineffective or damaging. A growing trans-disciplinary movement called Health at Every Size (HAES) challenges the value of promoting weight loss and dieting behavior and argues for a shift in focus to weight-neutral outcomes. Randomized controlled clinical trials indicate that a HAES approach is associated with statistically and clinically relevant improvements in physiological measures (e.g., blood pressure, blood lipids), health behaviors (e.g., eating and activity habits, dietary quality), and psychosocial outcomes (such as self-esteem and body image), and that HAES achieves these health outcomes more successfully than weight loss treatment and without the contraindications associated with a weight focus. This paper evaluates the evidence and rationale that justifies shifting the health care paradigm from a conventional weight focus to HAES.
Prejudice against those who are perceived as 'fat' or obese (anti-fat prejudice) is rife, increasing, and associated with negative outcomes for those targeted for such treatment. The present review sought to identify and describe published research on interventions to reduce anti-fat prejudice. A systematic search of relevant databases (e.g. PsychInfo, PubMed, Scopus) found 16 published studies that had sought to reduce anti-fat prejudice. Most notable was the lack of research on interventions for reducing anti-fat prejudice. Methodological problems that limit the interpretability of results were identified in the majority of studies found. Interventions employing more rigorous experimental designs provided at best mixed evidence for effectiveness. Although several studies reported changes in beliefs and knowledge about the causes of obesity, reductions in anti-fat prejudice did not typically accompany these changes. Anti-fat prejudice interventions adopting social norm- and social consensus-based approaches appear encouraging but are scarce. The lack of prejudice reduction following most interventions suggests that psychological mechanisms other than, or additional to, those being manipulated may underpin anti-fat prejudice. New directions for researching anti-fat prejudice are suggested. Given the strength of antipathy displayed toward those who are perceived as 'fat' or obese, research in this area is urgently required.
Was the sixties activist merely acting out unresolved Oedipal conflicts? Is the analyst who interprets the activist's neurotic conflicts actually "neutral"? Issues from the sixties debate are relevant to today's discussion of activism in public mental health. For instance, why, at a time of shrinking public service budgets and unprecedented suffering on the part of mental patients, have the providers and consumers of public mental health services not become more active in struggles to reorder our unfortunate social priorities? The discussion proceeds to an exploration of the therapeutic effect of activism.
To investigate whether negative implicit attitudes and beliefs toward overweight persons exist among health professionals who specialize in obesity treatment, and to compare these findings to the implicit anti-fat bias evident in the general population.
Health care professionals completed a series of implicit and explicit attitude and belief measures. Results were compared to measures obtained from a general population sample.
A total of 84 health professionals who treat obesity (71% male, mean age 48 y, mean body mass index (BMI) 25.39).
Participants completed an attitude- and a belief-based lmplicit Association Test. This reaction time measure of automatic memory-based associations asked participants to classify words into the following target category pair. 'fat people' vs 'thin people'. Simultaneously, the tasks required categorization of words into one of the following descriptor category pairs: good vs bad (attitude measure) or motivated vs lazy (stereotype measure). Participants also reported explicit attitudes and beliefs about fat and thin persons.
Clear evidence for implicit anti-fat bias was found for both the attitude and stereotype measures. As expected, this bias was strong but was lower than bias in the general population. Also as predicted, only minimal evidence for an explicit anti-fat bias was found. Implicit and explicit measures of the lazy stereotype were positively related although the attitude measures were not.
Even health care specialists have strong negative associations toward obese persons, indicating the pervasiveness of the stigma toward obesity. Notwithstanding, there appears to be a buffering factor, perhaps related to their experience in caring for obese patients, which reduces the bias.
Obesity in the United States has increased dramatically during the past several decades. There is debate about optimum calorie balance for prevention of weight gain, and proponents of some low-carbohydrate diet regimens have suggested that the increasing obesity may be attributed, in part, to low-fat, high-carbohydrate diets.
To report data on body weight in a long-term, low-fat diet trial for which the primary end points were breast and colorectal cancer and to examine the relationships between weight changes and changes in dietary components.
Randomized intervention trial of 48,835 postmenopausal women in the United States who were of diverse backgrounds and ethnicities and participated in the Women's Health Initiative Dietary Modification Trial; 40% (19,541) were randomized to the intervention and 60% (29,294) to a control group. Study enrollment was between 1993 and 1998, and this analysis includes a mean follow-up of 7.5 years (through August 31, 2004).
The intervention included group and individual sessions to promote a decrease in fat intake and increases in vegetable, fruit, and grain consumption and did not include weight loss or caloric restriction goals. The control group received diet-related education materials.
Change in body weight from baseline to follow-up.
Women in the intervention group lost weight in the first year (mean of 2.2 kg, P<.001) and maintained lower weight than control women during an average 7.5 years of follow-up (difference, 1.9 kg, P<.001 at 1 year and 0.4 kg, P = .01 at 7.5 years). No tendency toward weight gain was observed in intervention group women overall or when stratified by age, ethnicity, or body mass index. Weight loss was greatest among women in either group who decreased their percentage of energy from fat. A similar but lesser trend was observed with increases in vegetable and fruit servings, and a nonsignificant trend toward weight loss occurred with increasing intake of fiber.
A low-fat eating pattern does not result in weight gain in postmenopausal women. Clinical Trial Registration ClinicalTrials.gov, NCT00000611.
The prevalence of obesity and its associated health problems have increased sharply in the past 2 decades. New revisions to Medicare policy will allow funding for obesity treatments of proven efficacy. The authors review studies of the long-term outcomes of calorie-restricting diets to assess whether dieting is an effective treatment for obesity. These studies show that one third to two thirds of dieters regain more weight than they lost on their diets, and these studies likely underestimate the extent to which dieting is counterproductive because of several methodological problems, all of which bias the studies toward showing successful weight loss maintenance. In addition, the studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change. In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.
Preventing childhood obesity has become a top priority in efforts to improve our nation's public health. Although much research is needed to address this health crisis, it is important to approach childhood obesity with an understanding of the social stigma that obese youths face, which is pervasive and can have serious consequences for emotional and physical health. This report reviews existing research on weight stigma in children and adolescents, with attention to the nature and extent of weight bias toward obese youths and to the primary sources of stigma in their lives, including peers, educators, and parents. The authors also examine the literature on psychosocial and physical health consequences of childhood obesity to illustrate the role that weight stigma may play in mediating negative health outcomes. The authors then review stigma-reduction efforts that have been tested to improve attitudes toward obese children, and they highlight complex questions about the role of weight bias in childhood obesity prevention. With these literatures assembled, areas of research are outlined to guide efforts on weight stigma in youths, with an emphasis on the importance of studying the effect of weight stigma on physical health outcomes and identifying effective interventions to improve attitudes.
Part 1 of this article features the Counselors for Social Justice (CSJ) Code of Ethics formally endorsed in 2010. The ethical standards for practice, advocacy, assessment and diagnosis, supervision, research, and professional relationships, including consultation are outlined. In Part 2, following the presentation of the Code of Ethics, the mission and goals of CSJ as well as the process, and the development of the CSJ Code of Ethics are described.
In all the ways it matters, fat is a feminist issue. Yet, we find this perspective is absent within the mainstream weight stigma literature. In this chapter, we apply a feminist lens to render visible the problems inherent in the mainstream weight stigma research, with particular attention given to the ways in which this scientific discourse serves as a form of structural stigma, and thus as an agent of weight stigma itself. We consider the assumptions, mixed messages, and gaps embedded in this literature and situate weight stigma more centrally within an intersectional and social justice context. The chapter concludes with several recommendations for advancing a more critical and inclusive psychological science of weight stigmatization.
The family therapy field encourages commitment to diversity and social justice, but offers varying ideas about how to attentively consider these issues. Critical informed models advocate activism, whereas postmodern informed models encourage multiple perspectives. It is often not clear how activism and an emphasis on multiple perspectives connect, engendering the sense that critical and postmodern practices may be disparate. To understand how therapists negotiate these perspectives in practice, this qualitative grounded theory analysis drew on interviews with 11 therapists, each known for their work from both critical and postmodern perspectives. We found that these therapists generally engage in a set of shared constructionist practices while also demonstrating two distinct forms of activism: activism through countering and activism through collaborating. Ultimately, decisions made about how to navigate critical and postmodern influences were connected to how therapists viewed ethics and the ways they were comfortable using their therapeutic power. The findings illustrate practice strategies through which therapists apply each approach.
Discrimination based on weight is a stressful social experience linked to declines in physical and mental health. We examined whether this harmful association extends to risk of mortality. Participants in the Health and Retirement Study (HRS; N = 13,692) and the Midlife in the United States Study (MIDUS; N = 5,079) reported on perceived discriminatory experiences and attributed those experiences to a number of personal characteristics, including weight. Weight discrimination was associated with an increase in mortality risk of nearly 60% in both HRS participants (hazard ratio = 1.57, 95% confidence interval = [1.34, 1.84]) and MIDUS participants (hazard ratio = 1.59, 95% confidence interval = [1.09, 2.31]). This increased risk was not accounted for by common physical and psychological risk factors. The association between mortality and weight discrimination was generally stronger than that between mortality and other attributions for discrimination. In addition to its association with poor health outcomes, weight discrimination may shorten life expectancy.
This study aimed to assess weight bias among professionals who specialize in treating eating disorders and identify to what extent their weight biases are associated with attitudes about treating obese patients.
Participants were 329 professionals treating eating disorders, recruited through professional organizations that specialize in eating disorders. Participants completed anonymous, online self-report questionnaires, assessing their explicit weight bias, perceived causes of obesity, attitudes toward treating obese patients, perceptions of treatment compliance and success of obese patients, and perceptions of weight bias among other practitioners.
Negative weight stereotypes were present among some professionals treating eating disorders. Although professionals felt confident (289; 88%) and prepared (276; 84%) to provide treatment to obese patients, the majority (184; 56%) had observed other professionals in their field making negative comments about obese patients, 42% (138) believed that practitioners who treat eating disorders often have negative stereotypes about obese patients, 35% (115) indicated that practitioners feel uncomfortable caring for obese patients, and 29% (95) reported that their colleagues have negative attitudes toward obese patients. Compared to professionals with less weight bias, professionals with stronger weight bias were more likely to attribute obesity to behavioral causes, expressed more negative attitudes and frustrations about treating obese patients, and perceived poorer treatment outcomes for these patients.
Similar to other health disciplines, professionals treating eating disorders are not immune to weight bias. This has important implications for provision of clinical treatment with obese individuals and efforts to reduce weight bias in the eating disorders field. © 2013 Wiley Periodicals, Inc. (Int J Eat Disord 2013).
This article will examine the responses of other feminist therapists to the author's anti-fat-oppressive stance. These reactions will be used as a base from which to generate some hypotheses regarding the difficulties that continue to be faced by women therapists in attempts to identify and reduce internalized fat-oppressive attitudes regarding their own bodies and those of their women clients. Suggestions for heightening personal awareness regarding internalized fat oppression, and strategies for reducing fat-oppressive attitudes as a therapist will be presented.
Does promoting weight loss improve health? This paper draws on diverse writings in empowerment, social justice, critical obesity literature, feminism and stress biology to challenge the appropriateness of the continued reliance on a reductionist metaphor of energy balance in understanding fatness. It examines some of the scientific and philosophical premises underlying mainstream UK dietary anti-obesity guidelines and argues that the evidence supporting a link between promoting weight-loss and improving health is, at best, contentious. A central theme is that the current weight-loss schema helps to naturalise a fatness discourse that not only represents large people in offensively stereotyped ways but also fails to integrate people's lived experience as gendered, situated bodies in an inequitable world.Social Theory & Health (2005) 3, 315340. doi:10.1057/palgrave.sth.8700059
The competence-promoting and the empowermentoriented perspectives build on established social work knowledge and wisdom to bring new and positive outlooks on contemporary practice issues. However, there is still little consensus on the meaning of competence and empowerment, and their relationship has received scarce attention. This paper seeks to clarify the concepts, to explore their relationship and to identify the conditions which, in the practice of social work, will promote competence and lead to empowerment.
The field of critical psychology is exerting an influence in the way various sub-disciplines within psychology operate. In this article we use a critical psychology framework to review the field of health psychology. Through the use of values, assumptions and practices we review progress in health psychology and offer recommendations for aligning contemporary practices with current thinking in critical psychology. We discuss typical expectations, critical formulations and critical practice for interventions with individuals, groups and communities along these dimensions.
This study was undertaken to determine whether a client's weight influences the clinical judgments of mental health practitioners. We used an analogue approach in which 120 mental health workers evaluated a case history that included a photograph of the client. Using the photographic process ECRM, we altered the image of a single photograph of a middle-aged woman to produce three pictures: best-weight model, overweight model, and obese model. Results show that mental health workers are more likely to assign negative psychological symptoms to the obese model than to the overweight or best-weight model. In addition, male respondents are less harsh than females in their assessment of the obese client, indicating that a sex-by-obesity interaction effect occurs. Similarly, older mental health workers are less likely than their younger peers to assign negative symptoms to the obese client. Finally, a client's-weight-by-respondent's-weight interaction, influencing certain diagnostic judgments, is detected. Overweight mental health workers are less predisposed to differentiate between obese, overweight, and best-weight clients than are their less heavy contemporaries. These findings indicate that diagnosis is affected, or confounded, by the weight of the client.
This article considers some implications of the new health consciousness and movements--holistic health and self-care--for the definition of and solution to problems related to "health." Healthism represents a particular way of viewing the health problem, and is characteristic of the new health consciousness and movements. It can best be understood as a form of medicalization, meaning that it still retains key medical notions. Like medicine, healthism situates the problem of health and disease at the level of the individual. Solutions are formulated at that level as well. To the extent that healthism shapes popular beliefs, we will continue to have a non-political, and therefore, ultimately ineffective conception and strategy of health promotion. Further, by elevating health to a super value, a metaphor for all that is good in life, healthism reinforces the privatization of the struggle for generalized well-being.
What’s the skinny on fat women in psychotherapy: Mental health clinicians’ countertransference with women of size. (Unpublished master’s thesis)
- M N Aza
Retrieved from: Retrieved from UNLV Theses, Dissertations, Professional Papers, and Capstones
- K J Schafer
Traumatic stress, systemic oppression and resilience in post-Katrina New Orleans
- R D Goodman
- C A West-Olatunji
Teaching for diversity and social justice: A sourcebook
- B Love
Fat stigma in therapy
- N Moller
Counselors for social justice: Ethical standards
- F A Ibrahim
- J Dinsmore
- D Estrada
- M Andrea
Microaggressions in everyday life: Race, gender, and sexual orientation
- D W Sue
Microaggressions and their effects on the therapeutic process
- N Granger
Challenging fat oppression: Fat stigma in therapy
- J Reader
Effecting change in public health
- L Aphramor
The ethics of helping clients with weight loss in psychotherapy
- M I Berman
Diet culture upholds capitalism
- M Fabello
Ethics and activism: Theory, identity politics, conscious acts, and ethical aspirations
- E Roffman
Weight-based microaggressions experienced by obese women in psychotherapy. (Doctoral Dissertation)
- K J Schafer