Women & Therapy

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Teaching : Integrating Size into Multicultural Education and Clinical Training

Martha Bergen & Debra Mollen

To cite this article: Martha Bergen & Debra Mollen (2019) Teaching Sizeism: Integrating Size into Multicultural Education and Clinical Training, Women & Therapy, 42:1-2, 164-180, DOI: 10.1080/02703149.2018.1524065 To link to this article: https://doi.org/10.1080/02703149.2018.1524065

Published online: 20 Jan 2019.

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Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=wwat20 WOMEN & THERAPY 2019, VOL. 42, NOS. 1-2, 164–180 https://doi.org/10.1080/02703149.2018.1524065

Teaching Sizeism: Integrating Size into Multicultural Education and Clinical Training

Martha Bergena and Debra Mollenb aCounseling and Psychological Services, Texas Woman’s University, Denton, Texas; bDepartment of Psychology and Philosophy, Texas Woman’s University, Denton, Texas

ABSTRACT KEYWORDS Multicultural education, training, and practice have tradition- Ethics; medicalization; ally focused primarily on race/ethnicity with gradual inclusion multicultural education; of , sexual orientation, social class, and age. Issues of sizeism; training size, which intersects with , , and classism, have been notably absent from discussions. Psychologists have typically framed size issues around and adopted a medicalized, individualized perspective that belies data that show traditional approaches to weight management, such as dieting and exercise, are largely ineffective and non-maintain- able. Here, we offer a rationale for including body size as an issue relevant to a multicultural curriculum. Strategies for training psychologists and therapists are delineated.

In 2003, the American Psychological Association (APA) published the first iteration of the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists. A landmark publica- tion, the Guidelines provided direction and suggestions for psychologists working with diverse clients. The Guidelines’ definition of included “the broad scope of dimensions of race, ethnicity, language, sexual orientation, gender, age, , class status, education, religious/spiritual orientation, and other cultural dimensions” (p. 380), but the authors noted a primary focus on race and ethnicity. In 2008, the APA Task Force on the Implementation of the Multicultural Guidelines likewise gave cursory acknowledgement to diverse identities, but ultimately chose to direct its recommendations to work with ethnic and racial minorities. Although the Guidelines were groundbreaking and pivotal in promoting multicultural competence, and although attention to issues that impact racial and ethnic minorities remain critically important, body size was omitted as a dimen- sion of diversity and a cogent facet of identity worthy of inclusion in multi- cultural training.

CONTACT Martha Bergen [email protected] Counseling and Psychological Services, Texas Woman’s University, P.O. Box 425350, Denton, TX 76204, USA. ß 2019 Taylor & Francis Group, LLC WOMEN & THERAPY 165

Although there has been some effort to expand multicultural education to include other facets of identity, such as gender and sexual orientation (Estrada, 2015), recent works in which authors provide practical solutions for multicultural training (Jones, Sander, & Booker, 2013) and evaluate the effectiveness of diversity education (Bezrukova, Spell, Perry, & Jehn, 2016) continue to draw largely from examples of ethnicity and race and assume that multicultural training is devoted primarily to these constructs and the systems in which they are embedded. No attention to issues of size is typic- ally given in multicultural education and training, an omission we seek to address in this article. In contrast to medicalized language such as obese and , we join fat studies scholars and anti-sizeism activists who choose to reclaim fat as a descriptor (Abakoui & Simmons, 2010; Lee & Pause, 2016; McHugh & Kasardo, 2012) with the exception of direct refer- ences to works that retain the former terms.

Problems with the Medicalization of Fatness Rather than including size as a component of multiculturalism, APA has adopted a primarily medical model approach to size and embraced a treatment approach that asserts that the roots of obesity lie in individual, alterable factors, such as diet and exercise. In fact, in 2012, when APA ini- tially called for nominations of potential members of the Clinical Guidelines Development Panel—Obesity Across the Lifespan, there was some questioning by Association members who were told, “APA has adopted advancement of both mental and physical health … The steering committee has noted that for much of the population, obesity is associated with disease and mortality. It can be effectively treated through behavior change” (Bukfa, Kurtzman, & Bukfa, 2012). In 2016, APA assembled a team of 13 physicians, psychologists, and social workers to work on devel- oping guidelines for the treatment of obesity. Of note, none of the task force members advances size acceptance nor addresses the problems of sizeism in their work (http://www.apa.org/about/offices/directorates/ guidelines/obesity-panel.aspx). Conceptualizing fatness as a medical and/or psychological disorder or disease to be treated is rife with problems, including ethical considerations that have implications for non-maleficence (Abakoui & Simmons, 2010). The ethics of this matter are especially noteworthy at a time in U.S. culture in which LGBTQ þ rights are at the forefront. APA’s stance on sexual orientation serves as an important analog to size with regard to a shared history in which a medical model was used to focus on individual-level dis- order. The history of pathologizing people who are LGBTQ þ and attempt- ing to treat them via conversion therapy to encourage heterosexuality, 166 M. BERGEN AND D. MOLLEN

which was deemed acceptable and healthy, is one of the most shameful parts of our shared professional legacy. More recently, APA has been an important leader in supporting the rights of LGBTQ þ individuals and has made head- way in correcting mistakes of the past. For example, in 2009, APA’sCouncil of Representatives reaffirmed the stance that a sexual minority identity is not a mental disorder; there are insufficient data to support the effectiveness of conversion therapy approaches aimed at changing sexual orientation, clini- cians should consider the ethics involved in attempting to “treat” same-sex attraction, and provision of affirmative treatment approaches for sexual minorities is appropriate and valued (Anton, 2010). Yet regarding mental health care for people who are size-marginalized, conversion therapy remains the standard approach to treatment. Whereas the field has taken clear steps to denounce conversion therapy for clients who are same-sex attracted, there is still widespread conversion therapy prescribed for clients who are fat. Rather than attending to the cultural constructions of size and health, most psychologists have continued to recommend a non-affirming approach focused on ineffective weight loss techniques that perpetuate stigma based on size. Erroneous assumptions abound that weight loss is good for one’s health, that it decreases mood- related concerns for fat clients, and that it is important to help clients with weight loss goals so that they can lead more fulfilled and happier lives. These beliefs are examples of healthism, the assignment of societal value based on health status and the assumption that health confers a higher level of worth. Chrisler and Barney (2017) described healthism as a “cult of self- improvement” (p. 41) and noted that healthism sends the “message that everyone should strive for a healthy body, which is often framed as a moral obligation” (p. 40). Despite these persistent cultural myths, there is reason to be exceedingly skeptical that one’s fatness can and should be ameliorated with behavioral changes, such as dietary adjustments. Research conducted over the past few decades has clearly established the failure of conventional diets to result in long-term, sustainable weight loss (e.g., Langeveld & DeVries, 2015; Mark, 2006; Rosenbaum, Leibel, & Hirsch, 1997): The overwhelming majority of those who pursue weight loss are likely to regain most, all, or even more of the weight they lost. Dieting, not fatness, is related to poor psychological outcomes, including depression, low self-esteem, the risk for developing an , and negative (Clifford et al., 2015). Even among those who pursue bariatric surgery, weight regain is commonplace (Geraci, Brunt, & Hill, 2015). Responses to weight gain following bariatric surgery engender self-blame, confusion, and depression (Geraci et al., 2015). Despite the dismal record of food restrictive diets and exercise plans, many physicians, nutritionists, psychologists, and other health care WOMEN & THERAPY 167

providers continue to prescribe these misguided techniques, a troubling fact given the scientific findings. Mark (2006) noted that, despite the ineffective- ness of behavioral approaches to weight loss, they continue to be prescribed due to their profitability. In addition, when “physicians and public health officials are loathe to acknowledge that we do not have effective therapy” (p. 860), it becomes easier to shift the focus and blame to the people we serve (i.e., clients who do not adhere to weight-loss regimens) rather than to the professions’ failure to identify efficacious approaches to care. Arguments that fatness should be treated as a disease or disorder are typically situated in discussions about physical health, particularly risks related to morbidity and mortality. Despite persistent efforts to link phys- ical size exclusively to individual factors, weight and fatness are more com- plex and largely rooted in genetics and systemic, intersectional (e.g., racism, sexism, classism; van Amsterdam, 2013) that are considerably nuanced and challenging to address (see, for example, Bombak, 2014; Mark, 2006; Tischner & Malson, 2012; van Amsterdam, 2013). The com- mon assumption that fat people lack the willpower necessary to sustain weight loss supports belief in a meritocratic system in which individual effort alone determines one’s outcomes in life. Meritocracy is especially pernicious as it involves blaming the victim, such that individuals are held solely responsible for what are perceived as their personal failings (Mijs, 2016) and therefore chastised when they do not achieve sociocultural expectations for achievement (e.g., thinness). Crandall and his colleagues (e.g., Crandall, 1994; Crandall & Martinez, 1996) have demonstrated that anti-fat attitudes function similarly to racist beliefs by (erroneously) attrib- uting controllability to fat people, endorsing belief in a just world, and assuming that weight is easily managed, all of which occur within a culture of blame, which is related to healthism. Within this culture of blame, fat is seen as a lack of “responsible self-management” (Donaghue & Clemitshaw, 2012, p. 416). Sizeism intersects with in conflating health, size, and ability status. In turn, those who are perceived to have made the “right” choices to be thin, healthy, and able-bodied are valued by society, whereas others are marginalized and blamed for their .

Sizeism in a Multicultural Curriculum The most pressing issue facing fat people in the United States unquestion- ably comes from living in a hostile environment, which communicates that fat people “are second-class, too big, not attractive, shouldn’t be here, don’t deserve, offend [and] repulse” (Owen, 2012, p. 294). Weight-based harass- ment, for example, is more prevalent than sexual and socioeconomic-based harassment and is the most common form of harassment experienced by 168 M. BERGEN AND D. MOLLEN

adolescent girls; fat adolescents report higher rates of all forms of harass- ment than their nonfat peers do (Bucchianeri, Eisenberg, & Neumark- Sztainer, 2013). Researchers have reported nearly identical findings among an adult sample as well, with weight especially evidenced among African American women and women in the highest weight catego- ries; women are also penalized for their size at lower weights than men are (Puhl, Andreyeva, & Brownell, 2008). Experiencing size-based discrimin- ation and harassment invariably undermines psychological well-being (Puhl & Peterson, 2014), but researchers (e.g., Muennig, 2008; Schafer & Ferraro, 2011) have also demonstrated a deleterious physical health impact of per- ceived weight discrimination. Schafer and Ferarro (2011) noted “the social processes of perceived weight discrimination are responsible, at least in part, for the deleterious effects of severe obesity on health,” (p. 92, italics in original) which can include mobility and functional disability concerns. Weight itself is not the problem; the larger problem lies in the social construction, stigmatization, devaluation, objectification, and fetishizing of fatness and fat people. Objectification is “the experience of being treated as a body (or collection of body parts) valued predominantly for its use to (or consumption by) others” (Fredrickson & Roberts, 1997, p. 174, italics in original). The literature is rife with examples of deleterious health effects of internalized objectification, including low self-esteem, depression, anx- iety, sexual dysfunction, disordered eating, and decreased creativity and flow (Noll & Fredrickson, 1998; Peat, Peyerl, & Muehlenkamp, 2008; Szymanski & Henning, 2007). For fat people, being aware of the space they take up, vigilant to others’ reactions to their bodies, and anticipating har- assment mean that objectification is inescapable. Sizeism is pervasive and has been observed in an extensive array of set- tings and among a vast array of people, even among those most often entrusted with providing care and support for fat people. For example, in a group of adolescents seeking weight-loss treatment, weight-based victimiza- tion (e.g., teasing, , , physical aggression) was com- monly perpetrated by peers, friends, and adults, including teachers and parents (Puhl, Peterson, & Luedicke, 2013). Weight is well-documented among mental health practitioners, including those who specialize in treat- ing clients with eating disorders (Puhl, Latner, King, & Luedicke, 2014). Gender plays a significant role in size-related discrimination. Fat women report widespread shame and stigma from medical providers that discour- ages them from seeking health care (Chrisler & Barney, 2017; Lee & Pause, 2016), and graduate students in mental health fields endorse negative atti- tudes toward fat women, including the belief that fat women lack self- control, have low self-esteem, and are unattractive (Pascal & Robinson Kurpius, 2012). Fikkan and Rothblum (2012) reviewed the literature that WOMEN & THERAPY 169

documents widespread and persistent disadvantages for fat women, includ- ing in employment (e.g., wage discrimination), romantic relationships, health and mental health care settings, and the media, where they are typic- ally depicted pejoratively, if depicted at all. Sizeist attitudes impact most people; even thin people often endorse a fear of fat and voice highly critical comments about their own perceived fatness in conversations with peers and strangers (i.e., fat talk). Indeed, among women enrolled in college, fat talk is widespread and so common- place that it is often seen as unremarkable and accordingly goes unchal- lenged. Though women in particular may engage in fat talk in an effort to connect with others and have their concerns about fatness assuaged, researchers have established a causal link between fat talk and body dissat- isfaction, as well as a relationship between fat talk and guilt (Salk & Engeln-Maddox, 2011, 2012; Shannon & Mills, 2015). Issues related to sizeism, then, should be included as a compelling and vital component of multicultural education and training, particularly for psychologists and other mental health practitioners who are concerned with their clients’ well-being and who value the development of a practice grounded in social justice. This is especially important given consideration of ways that size intersects with gender, race/ethnicity, age, ability status, and class (Fikkan & Rothblum, 2012; Kwan, 2010; van Amsterdam, 2013); including size as a dimension of diversity infused in multicultural educa- tion and training is cogent, urgent, and an ethical imperative.

Strategies for Training Psychologists and Therapists Given the clear need for size-affirmative education within multiculturalism in the fields of applied psychology, the most basic, yet important, task for educators and trainers is to acknowledge size as a vital diversity variable and conceptualize sizeism as a system of oppression that functions similarly to, in conjunction with, and as a multiplier of other similar systems. As Saguy (2012) noted, “fatness, like blackness and femaleness, is a dimension of social inequality” (p. 604). Thus, feminist scholarship on size should be included in multicultural classes in graduate-level education and in training settings for psychologists and other psychotherapists. Therapists should include size as a relevant construct when discussing case conceptualizations. Psychologists should infuse size as a diversity variable alongside other important diversity concerns. The field must cease relegating size to the medical profession, stop pathologizing size, and advance an invaluable con- textual lens to give size its due. Integrating size in multicultural education is especially important because fat continues to be a vital feminist issue (Saguy, 2012). Orbach’s(1978) 170 M. BERGEN AND D. MOLLEN

original claim that fat is a feminist issue referred to women who binge eat as a way to cope with sexist oppression. This view perpetuates sizeist oppression by assuming that higher weight and weight gain are inherently bad. More recent scholars (e.g., Fikkan & Rothblum, 2012; Saguy, 2012) have argued that fat is feminist because “fat women are subjugated to bias, discrimination, and abuse precisely because they are fat women” (Saguy, 2012, p. 601). Saguy (2012) argued that weight bias is a problem in general, but intersections with gender, sex, race, class, and sexual orientation com- pound the problem. The multicultural movement and APA’s(2010) Ethical Principles of Psychologists directs psychologists to affirm and celebrate diversity, treat others with dignity and respect, and work toward justice. Thus, feminist, multicultural psychology is ideally situated– and called for- ward –to work toward amelioration of size-based oppression. Here we outline strategies and suggestions to consider in creating and conducting sizeism workshops for students, trainees, professionals, and community members.

1. Include relevant and accurate information. Because myths about health and size abound and are erroneously maintained as deeply held truths, inaccurate information perpetuates size oppression. Sizeism is a topic for which a critical lens is decisively needed to counteract the dominant discourse of a disease model. Research and support for the Movement (HAES) is flourishing and provides an important alternative to the medical model of fatness (Bacon et al., 2002; Chrisler & Barney, 2017). This perspective aims to decentralize size in health, which in turn decreases the shame often associated with a large body size. It takes weight out of the equation and offers an empowering approach to health. HAES takes into consideration myriad factors that impact size and instead encourages people to eat and move their bodies mindfully; it takes the healthism (Chrisler & Barney, 2017) out of the pursuit of wholistic mind-body health. 2. Consider experiential activities. Not only are experiential exercises engaging and fostering of audience involvement, these strategies can also serve to increase empathy and compassion regarding size oppres- sion. Privilege exercises (e.g., a privilege walk based on McIntosh, 1998, 2015) are useful in illustrating the discrimination, oppression, and har- assment that fat people experience, which remain largely out of aware- ness for those with smaller bodies. These activities also illustrate the diversity of experiences among larger bodied people and can be tailored to address intersections of oppressed identities, such as size with disabil- ity, age, class, gender, and race/ethnicity. Other experiential activities might utilize imagery or narrative and can be adapted for a focus on WOMEN & THERAPY 171

size from diversity-focused trainings related to other areas. For example, the “Coming Out Stars” activity is used in Ally or Safe-zone trainings in many university counseling centers (Pierce, n.d.). In this exercise, par- ticipants are given different colored stars and asked to write on each leg of the star different parts of their lives (e.g., the name of a close friend, a career aspiration, a community to which they belong). Facilitators read through a script in which different outcomes take place depending on the color of the star. The goal is to illustrate experiences of oppres- sion and assist participants in connecting emotionally with what that experience might be like. Brainstorming activities using a chalkboard or whiteboard also can be engaging and effective in assisting participants in identification of about fat and thin bodies. Although ini- tially hesitant, participants tend easily to identify the many positive and negative associations with size once sufficient encouragement and frame setting is provided. Intersections with race, gender, social class, ability status, age, and education can easily emerge in discussions of the stereo- types participants identify. Discussions aimed at exploration of the sour- ces of sizeist messages can also be powerful and promote insight among participants (i.e., messages from family, friends, media, religion, other cultural systems). 3. Use language intentionally. In workshops, consider deliberate use of the word “fat” instead of any number of euphemisms often used to describe fatness (e.g., big boned, fluffy). Avoid words that convey that fat is “too much” (e.g., plus-size, overweight) and avoid use of the word “obese” as it conveys a medicalized, stigmatized view of size and fatness. Workshop participants may be initially shocked or uncomfortable with brazen use of the “f-word.” However, doing so de-pathologizes fatness and takes power away from fat as a slur that should be avoided. Reclaiming language has a longstanding tradition in other marginalized communities (Galinsky et al., 2013). However, as Root (1993) outlined in her Bill of Rights for People of Mixed Heritage, it is important to honor every person’s right to self-determination in choosing language to describe their identities. This is true for multiethnic people as well as fat people, who may prefer different terms to describe their bodies; these preferences should be acknowledged and respected. Not all larger bodied individuals feel comfortable with reclaiming the word fat, and the choice to use this language should be carefully considered. Use of the word fat may also have different implications or impacts depending on in- and out-group membership of workshop presenters and audi- ence members. 4. Utilize media and online resources. Members of the are advancing fat as powerful and beautiful. Videos and 172 M. BERGEN AND D. MOLLEN

blogs about fat-shaming, microaggressions, myths, and stereotypes abound and are an engaging way to present these topics. Examples include Joy Nash’s “Fat Rant” video (2007)andRagenChastain’s media presence and advocacy work. The fatosphere of fat acceptance blogs (Harding & Kirby, 2009)offers“a powerful counter to the widespread cultural insistence that fat bodies are pitiable and pathological” (Donaghue & Clemitshaw, 2012, p. 422). These online communities provide a wealth of information to be shared. Excellent films to consider for use in teaching or outreach include Fattitude, a documentary film that focuses on an intersectional critique of current mainstream ideas about size (Averill & Lieberman, 2016)andJean Kilbourne’s(2010) Killing Us Softly 4. 5. Consider the audience. In preparing workshops for community mem- bers, consider including information about health and size-affirming practices. Consider the interests of the general public and use that to your advantage: potential for desire to be healthy, to attend to physical health practices, and to lose weight/engage in diets in order to pursue these desires. Challenge myths and bring information that can free up misguided efforts placed health practices that do not work. Empower community members and the general public to digest the scientific lit- erature on best practices for health – psychological, emotional, spiritual, physical, and relational health. Consider sharing the “Food for Thought” pyramid as a useful illustration of holistic health (McKibbin, 2008). This handout demonstrates, in a visual and amusing way, what really goes in to health versus an over-simplified focus on calories in, calories out. Psychologists have a unique opportunity to provide needed re-framing to health-focused behaviors and increase motivation from an authentic place of self-love as opposed to the shame incited by a thin- obsessed, sizeist culture. For college students, consider their developmental level and unique life contexts, including role strain as they balance school with other life demands. Consider unique challenges to engaging in weight-neu- tral health practices, including pressures associated with age, gender, and dating relationships. College students are often targets for adver- tisement of a “spring break body” and jokes about the “freshman [sic] 15.” The intersection of size and this unique stage in develop- ment is important to consider in creating targeted outreach materi- als. College students can also be a resource of positive energy for body image campaigns. The Body Project program (http://www.body- projectcollaborative.com/) is an excellent example of a dissonance- based peer mentorship prevention program that teaches participants to challenge fat talk and size negativity. Consider bringing a program like this to college campuses and into the general community as an WOMEN & THERAPY 173

evidenced-based campaign (Stice, Marti, Spoor, Presnell, & Shaw, 2008). For psychology graduate students, include information from Fat Studies and the Fat Acceptance Movement that challenges the dominant medical paradigm (e.g., Bacon & Aphramor, 2011; Bacon et al., 2002; Rothblum & Solovay, 2009). For therapists and therapists in training, include applications for practice, especially case conceptualization and ethical considerations. With regard to research, discuss areas for future study needed to bolster a size-positive approach to mental and medical health care for fat people. We discuss additional ideas specific to training psychology graduate students in a later section. For physicians and others in the medical community, include research regarding minority stress and the impact of stigma on physical health (Muennig, 2008; Schafer & Ferraro, 2011). Keep in mind that there will likely be resistance to social justice oriented perspectives and be prepared to challenge ideas stemming from healthism (Chrisler, 2012).

6. Be cognizant of size diversity in the audience and in the leaders. In any diversity-related workshop or presentation, especially when the focus is on a sensitive topic like size, we encourage leaders to reflect on diversity variables among audience members. Consider making an opening state- ment that acknowledges the complexity and difficulty of the topic, nor- malizes various emotional reactions that may be evoked by the material to be discussed, and acknowledges the similarities and differences across the body size spectrum in the room. This type of preface can ease ten- sion and increase safety for audience members to be more open to new ideas and more vulnerable and authentic in their participation. It also sets a frame for respect by noting differences in the makeup of the audi- ence across experiences including privilege and oppression or marginal- ization. In addition, employing a preface provides a degree of informed consent: If they find the material too challenging, participants should be encouraged to take care of themselves, participate to the extent they choose, and take breaks, including ending their participation if needed. We also encourage workshop leaders to consider other ground rules to outline at the outset of a presentation or outreach on this topic: confi- dentiality, stepping out of one’s comfort zone, trust, using respectful language, and being open to new ideas. Attention to the size of the workshop leaders is also a key consider- ation. We encourage reflection on the impact of the presenter’s body size: What is the impact of a within-group member speaking about size marginalization? What might it mean for a person with thin privilege to speak about sizeism? In some regard, presenters with smaller bodies and 174 M. BERGEN AND D. MOLLEN

thin privilege have an opportunity to use that privilege to shed light on an important topic and may be taken more seriously because of their privilege. Presenters who identify as fat have an opportunity to human- ize the experience of sizeism and defy stereotypes about fat people as lazy, unmotivated, or unintelligent. Furthermore, larger bodied present- ers can choose to use themselves by sharing experiences of sizeism they have experienced personally, which can add to the impact, bring infor- mation to life in an immediate way that can increase empathy from smaller bodied audience members, and be validating and connecting for those in the audience who have also experienced sizeism.

7. Be prepared for varied audience reactions. Size is a lightening-rod topic in U.S., and it typically evokes an array of reactions in training and workshops. Audience members may be relieved and share reactions of gratitude for sensitive discussion of this underrepresented topic. However, in our experience, some participants’ reactions are likely to be conflicted, challenging, or defensive. This is an area of diversity in which every person has an intimate relationship with the material at hand. No matter one’s body size, every person has a body size, which comes with an internalized construction of the meaning of that body size. It is wise to anticipate that some people may not understand, dis- pute evidence presented, feel emotionally triggered, and struggle with internalized sizeist beliefs. In our experiences of presenting on this topic, the following themes across resistant reactions have emerged: (a) Benevolent sizeism – reac- tions that suggest that disdain for large bodied people is coming from a place of care. These reactions are often paternalistic and moralistic in nature, yet shrouded with an air of care and concern: “I just care about their health”; (b) Outright (or hostile) sizeism – forthright comments of disgust and condemnation that blame larger bodied people for their plight: “If they were not so lazy, they would not be such a drain on health care in the U.S.”; (c) Healthism-based remarks – commentary on the health-based concerns about being fat that come from a medical- frame that does not address the sociocultural impact of discrimination and ignores the impact of minority stress. This includes comments that size is not a multicultural or diversity issue, but rather a medical issue; (d) Internalized sizeism – responses that include “yes, but,” in which audience members share a belief that oppression is wrong, but state that their own desire to be thin is unique or personal rather than a reaction to sociocultural pressures; (e) Omission – perhaps the largest category of resistance to these types of workshops. It includes people who avoid attendance, conference program committees who reject WOMEN & THERAPY 175

programming on size-related topics, and graduate programs and clinical training sites that omit size as a diversity variable. In our experience in managing these various types of resistance, the following ideas have been helpful. First, keep trying. Despite negative reac- tions you might encounter, keep developing programming, trainings, and proposals on topics related to size and weight discrimination. Continue to speak up and use your sphere of influence wisely. Next, when you encoun- ter challenging interactions during presentations, work to maintain a stance of curiosity. This can be quite challenging as a typical reaction to sizeist backlash may be sadness or anger. Be prepared to manage your own feelings and stay grounded. By responding to resistance in your audi- ence with curiosity and a desire to understand different perspectives, you can open up these potential responses and gently challenge them in a way that may bring about change. Defensiveness begets defensiveness, and, as a leader in the room, you have an opportunity to break that cycle and invite reflection, introspection, and understanding. Also, know the research. Prepare carefully, use up-to-date research, and return to the literature as your primary source of preparation. Size discrimination, the negative impact of sizeism, and the ineffectiveness of diet culture are not matters of opinion; science is our best route to truth. Last, and most important, engage in self-care practices and seek out safe spaces for assistance, care, and backing. Ensure that you have a network of professional and personal support to process any backlash you experience. If possible, present with a colleague and allow time afterward to debrief together. Finally, we present strategies and suggestions to consider in training about size-affirmative clinical practices.

1. Address size alongside other diversity variables in training seminars and in supervision discussions. Including size consistently and purposefully as a diversity identity in trainings will increase awareness and consider- ation given to size by staff and trainees. 2. Explore about size within supervision. Just as supervision can be an important space for exploration of countertransference concerns, personal reactions, and beliefs about other diversity identities, supervi- sion can be used well to explore internalized myths trainees might hold regarding size. Exploring our own biases is an important place to start in clearing our own house of oppressive, internalized sizeist and health- ist beliefs. 3. Provide accurate information regarding health and size to counteract any misinformation trainees might hold. In educating trainees on their own biases, supervisors and trainers help their students to practice therapy more ethically and more competently. In turn, trainees can deliver 176 M. BERGEN AND D. MOLLEN

size-affirmative care rather than inadvertently perpetuate harmful practi- ces and perspectives with their clients. 4. Consider size in case conceptualization. Even in cases where size may seem irrelevant at first glance, giving consideration to the diverse sta- tuses and identities a client holds, including size, can enrich under- standing of the client’s phenomenological worldview and experience of psychological distress. Take, for example, a client who presents with chronic depression. To exclude size as a factor in depression ignores the impact of minority stress or social identity threat on the client’s experi- ence (Chrisler & Barney, 2017). It isolates the problem at the individual level rather than considering systemic factors that contribute to the cli- ent’s depression. Focus on the individual level could result in the loss of rich feminist treatment options, such as deconstructing sociocultural factors, challenging social norms, and empowering the client’s intrinsic value outside of appearance and size. 5. Avoid pathologizing size or overestimating the importance of size in case conceptualization. Although it is important to take size and experiences of minority stress associated with sizeism into account, we advise thera- pists not to conflate fatness with mental illness or physical disease. To assume fat clients’ presenting concern is due to their size reflects pos- sible bias on the part of the clinician. According to Chrisler and Barney (2017), “medicalization and the duty to ‘treat’ may be considered forms of benevolent sizeism” (p. 41). Being chastised as incompetent or foolish and having one’s medical or mental health issues blamed on size not only prevents clients from obtaining appropriate treatment, but also engenders more shame. Fat shaming keeps people further mired in dis- tress and is likely to decrease exercise, compromise responding naturally to one’s appetite, and perpetuate weight gain (Chrisler & Barney, 2017). Clinicians should consider weight-neutral, body-acceptance, and non- diet approaches to health (Bacon et al., 2002) as size-affirming alterna- tives that foster self-compassion (Neff, 2011). 6. Reflect on the ethics of size-related beliefs and weight loss counseling in clinical work. Consider working with a fat woman whose goal for ther- apy is to lose weight. She is fully aware of the unfairness of sociocultural standards for beauty, palpably conscious of the problems of sizeism, and understands that she should not have to lose weight to be treated with dignity and respect. Yet, her treatment goal remains to lose weight in order not to have to deal with harassment and discrimination. On the one hand, supporting this client’s autonomy and right to self- determination is important. However, psychologists have a call first to do no harm in our efforts to do some good. Ensuring the efficacy of our treatments is essential to the aim of beneficence and non- WOMEN & THERAPY 177

maleficence (APA, 2010). Research on the success of weight-loss treat- ment shows it to be abysmal at best (Langeveld & DeVries, 2015; Mark, 2006; Rosenbaum et al., 1997). As conversion therapy for other identi- ties is now widely considered to be unsupported by the scientific litera- ture, we should be skeptical of conversion therapy as the gold standard for treating fatness. Psychologists also have an ethical responsibility to work outside the therapy room to change unhealthy systems in which our clients live. As the risk for mental health problem associated with fatness is due to the discrimination and stigma associated with weight, not to fatness itself, ethical practice compels us to work toward changes in culture and social systems.

Conclusion We have explored considerations for incorporating size into multicultural and clinical training with the hope that more clinicians, educators, supervi- sors, and presenters will give space to this important aspect of oppression in the work they do. Multicultural education, training, and practice in psychology have come a long way with the inclusion of diverse identities, yet size typically remains a notable omission that must be rectified. Mental health practitioners, especially feminist and multicultural psychologists, have an opportunity to lead with size-affirmative education and practice and to challenge commonly held misconceptions about size within the medical and psychological community as well as society as a whole. The time is long past due to give size a place at the table.

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