Teaching Sizeism: Integrating Size Into Multicultural Education and Clinical Training

Women & Therapy ISSN: 0270-3149 (Print) 1541-0315 (Online) Journal homepage: https://www.tandfonline.com/loi/wwat20 Teaching Sizeism: 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. Submit your article to this journal Article views: 134 View Crossmark data Citing articles: 1 View citing articles 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 gender, sexual orientation, social class, and age. Issues of sizeism; training size, which intersects with racism, sexism, and classism, have been notably absent from diversity discussions. Psychologists have typically framed size issues around obesity 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 multiculturalism included “the broad scope of dimensions of race, ethnicity, language, sexual orientation, gender, age, disability, 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 multicultural 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 typically given in multicultural education and training, an omission we seek to address in this article. In contrast to medicalized language such as obese and overweight, 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 developing 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 disorder. The history of pathologizing people who are LGBTQ þ and attempting 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 eating disorder, and negative body image (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

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