AN EXPLORATORY STUDY ON SOCIAL WORK STUDENTS' ATTITUDES ON BODY SIZE
Erin Ahern B.A., Sonoma State University, 2001
April Tally B.A., University of North Carolina at Wilmington, 2004
PROJECT
Submitted in partial satisfaction of the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING 2009 C 2009
Erin Ahern April Tally ALL RIGHTS RESERVED
ii AN EXPLORATORY STUDY OF SOCIAL WORK STUDENTS' ATTITUDES ON BODY SIZE
A Project
by
Erin Ahern
April Tally
Approved by:
, Committee Chair Tania Alameda-Lawson, Ph.D.
Date: 4 30^ 09
iii Student: Erin Ahern April Tally
I certify that these students have met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project.
Sufsan Talamantes Egg h.D., MSW, Graduate Coordinator Date
Division of Social Work
iv Abstract
of
AN EXPLORATORY STUDY OF SOCIAL WORK STUDENTS' ATTITUDES ON BODY SIZE
by
Erin Ahern
April Tally
This study, collaborated equally by both researchers, explored social work students' attitudes, beliefs, and experiences related to body size and body image.
A self-report survey was developed and employed through a web-based service. Data were collected from 115 (44 first year and 71 second year) Masters in social work students from California State University, Sacramento. Beyond descriptive analysis,
Pearson's r correlations as well as linear regression were utilized to analyze the study's data. Results indicate that there is an association between participants' own weight issues and their beliefs related to overweight people's health, happiness, and self-confidence.
This study concludes that issues relating to body size and body image are important social work topics.
Committee Chair Dr. Tania Alameda-Lawson
v DEDICATION
"The education and empowerment of women throughout the world cannot fail to result in a more caring, tolerant, just and peaceful life for all."
- Aung San Suu Kyi, Nobel Peace Prize Laureate, leader of Burma's democracy movement
This project is dedicated to girls and women everywhere. Love your bodies!
- April & Erin
vi ACKNOWLEDGEMENTS
I want to thank first and foremost my thesis partner and best friend, April Tally. I
could not have done this without you, and I would never want to. You have changed my
world and I am better for it. I absolutely love you. We made it, and we didn't get
divorced!
Thanks to Tania Alameda-Lawson for your enthusiasm and help as our adviser.
To Professor Francis Yuen for your unwavering advocacy for students, and your
willingness to help others no matter what. To David Nylund for inspiration and a new way of thinking about social construction and challenging the media. To Ron Boltz for helping shape our project and for throwing fuel on the fire. To Jill Olmstead and Corina
Delfin for being amazing field instructors and good navigators through the social work waters.
I want to thank all the people who supported me through this process. Brian Lilly, you always keep me grounded. Thanks for being a good editor and a great boyfriend. My
mom, Judy, for the constant support and encouragement in academics. I could not have
done any of my schooling without your help and love. To my Dad for mix tapes,
Marygrace for empathy, and Hannah Rose for being the best sissy a girl could ask for. To my dear friends and fellow MSWs Breana Doyle and Melody Antillon-Hazzard for commiseration and giggles. To my loves Kala and Tobiko, thanks for keeping me sane.
The many hours of co-writing this paper has been one of the most challenging and fulfilling experiences of my life. This paper has changed me, and has changed the way I
vii think about social work, the way I think about our society's values, and the way I think about myself. I was lucky to meet my kindred spirit and create this project that I am proud of. I have grown in so many ways because of it, and for that I am thankful.
- Erin
viii ACKNOWLEDGEMENTS
I would like to thank my Mom and Dad, Christine, Brittany, Grandma & Grandpa
Tally, Grandma & Grandpa Wight, Fry, Erin Ahern, Tobiko & Kala, Kimberly Stewart,
Bre Doyle & Jake, Melody Antillon Hazzard, Carole & Kenny Blount, Kendole & Alex
Blount, Paul & Shirley Toomer, Grandma Donna, Dr. Tania Alameda-Lawson, Dr. Lynn
Cooper, Dr. David Nylund, Dr. Joyce Burris, Dr. Janice Gagerman, Dr. Dave Demetral,
LaKeisha Blacks, Kristen Yahn, Jennifer Schultz, Crystal Harding, the Sweeties, all of my peers who participated in our survey, Kimily Gerking, Maria Zastrow, Gordon
Warnock, Evan Boylan, Katie & Brian, the Thursday afternoon girls, Graham Bass, Brian
Lilly, Eric Hazzard, Kate Harding, Joy Nash, Joy Nollenberg, Chrysalis, Kayj, Etta, Nipa,
Deb Bowen, Ettore's Bakery & Cafe, Tim Brown, Bob Erlenbusch, Susanna Curry,
Merril Lavezzo, Julia Acuna, Sacramento Ending Chronic Homelessness Initiative, Laura
Farris, Debbie Morrison, the Mechenbiers, Joe Barbour, Kristin, everyone at El Ranchito de los Ninos, Missy Higgins, Justin Farren, Ingrid Michaelson, Ryan Adams, Julia
Nunes, Bon Iver, Nickel Creek, Neil Gaiman, Jim Halpert, Julia Gulia, Frank Warren... and anyone else who has helped me in this adventure. I love you.
"So keep fightin' for freedom and justice, beloveds, but don't you forget to have fun doin' it. Lord, let your laughter ring forth. Be outrageous, ridicule the fraidy-cats, rejoice in all the oddities that freedom can produce. And when you get through kickin' ass and celebrating' the sheer joy of a good fight, be sure to tell those who come after how much fun it was." -- Molly Ivins, 1944-2007 xoxo, April Ann
ix TABLE OF CONTENTS Page
Dedication ...... vi
Acknowledgments ...... vii
List of Tables ...... xv
Chapter
1. PROBLEM STATEMENT AND OVERVIEW ...... 1
Introduction...... 1
Statement of Collaboration ...... 3
Background ...... 3
Statement of the Problem ...... 5
Purpose of the Study ...... 5
Conceptual Framework ...... 6
Definition of Terms ...... 8
Assumptions ...... 9
Justifications ...... 10
Limitations ...... 10
2. REVIEW OF THE LITERATURE ...... 12
Introduction...... 12
Background ...... 13
Health Risks and Obesity Paradox ...... 14
Media, Body Image and Body Size ...... 17
x Economics, Capitalism and Ideal Body Size ...... 20
Body Politics ...... 22
Eating Disorders ...... 23
Mental Health Issues ...... 30
Mental Health and Relationships ...... 33
Culture and Body Image ...... 35
Socioeconomics ...... 37
Clinical Issues ...... 39
Other Helping Professionals ...... 44
Social Work Research and Body Size/Body Image Issues ...... 46
Conceptual Framework ...... 49
Psychodynamic Perspective: Transference and Countertransference ...... 49
Social Learning Theory ...... 51
Feminist Social Work Perspective ...... 52
Assumptions ...... 58
Research Questions ...... 60
3. METHODOLOGY ...... 61
Purpose of the Study ...... 61
Research Design ...... 61
Instrumentation ...... 61
Sample ...... 62
xi Description of the Sample ...... 62
Inclusion/Exclusion ...... 63
Procedures ...... 63
Recruitment ...... 63
Data Collection ...... 64
Protection of Human Subjects ...... 65
Data Analysis ...... 66
Delimitations ...... 66
Limitations ...... 67
4. RESULTS AND DISCUSSION ...... 69
Results ...... 70
Demographic Characteristics of the Sample ...... 70
Descriptive Statistics ...... 70
Social Work Experience Working With Overweight Clients or Clients With Body Size Issues ...... 70
Body Image Issues and Eating Disorders ...... 71
Confidence Working With Obese Clients ...... 71
Need for Social Work Students to Become Educated About Body Size Issues ...... 72
Awareness of Clients Body Size ...... 72
The Role of Body Size in a Social Work Student's Initial Assessment ...... 73
Body Size as a Factor in Treatment Plan/Goals ...... 73
xii Weight Affecting Motivation in Counseling/Case Management ...... 74
Competence Working With Clients Who Have Body Image Issues ...... 74
Comfort of Student Bringing Up Client's Weight in Session ...... 75
Comfort Working with a Client Who Has a Different Body Size Than Their Own ...... 75
Race/Ethnicity/Culture's Effect on Positive Body Image ...... 76
Media Affect on Construction of Acceptable Body Size ...... 76
Belief of Overweight People Being Just as Healthy as Non-Overweight People...... 76
Belief of Overweight People Being Just as Happy or Self-Confident as Non-overweight People ...... 77
Belief That Body Size/Body Image are Important Social Work Issues ...... 77
Frequency of Body Size/Weight/Body Image Discussion in Class ...... 78
Student's Personal Weight Issues ...... 78
Student's Experience With Dieting ...... 79
Associations Amongst Study Variables ...... 80
Personal Struggles with Weight and Belief that Body Size and Body Image Are Important Social Work Issues ...... 80
Identifying as Overweight and Positive Attitudes about Other Overweight People...... 81
Identifying as Normal Weight or Somewhat Underweight and Positive Attitudes about Overweight People ...... 82
Identifying as Normal Weight or Somewhat Underweight and Negative Attitudes about Overweight People ...... 84
xliii Belief that Body Size and Body Image Are Important Social Work Issues and Experience ...... 85
Additional Findings ...... 87
Discussion...... 88
Research Question 1 ...... 88
Research Question 2 ...... 91
Research Question 3 ...... 94
Discussion of Frequency of I Don't Know Answers ...... 95
Conceptual Framework ...... 99
Closing Observations ...... 101
5. SUMMARY, CONCLUSIONS, AND IMPLICATIONS ...... 103
Summary...... 103
Implications and Recommendations ...... 104
Implications for Social Work Education and Social Work Practice ...... 104
Implication and Recommendations for Social Work Research ...... 107
Reflection...... 109
Appendix A Informed Consent and Questionnaire ...... 110
References...... 115
xiv LIST OF TABLES
Page
1. Table 1 The International Classification Weight According to BMI ...... 14
2. Table 2 Pearson Correlation of Students' Own Struggle with Weight and their Belief that Body Size And Body Image as Social Work Issues ...... 80
3. Table 3 Pearson Correlation of Students Who Identify as Overweight and Positive Attitudes about Overweight People ...... 82
4. Table 4 Pearson Correlation of Students Who Identify as Normal Weight or Underweight and Positive Attitudes about Overweight People ...... 84
5. Table 5 Pearson Correlation of Students Who Identify as Normal Weight or Underweight and Negative Attitudes about Overweight People ...... 85
6. Table 6 Pearson Correlation for Belief in Body Size And Body Image as Social Work Issues and Experience ...... 86
7. Table 7 Person Correlation for Student's Experience and Confidence Level ...... 87
xv 1
Chapter 1
PROBLEM STATEMENT AND OVERVIEW
Introduction
At least 400 million adults worldwide are obese. The World Health Organization
(WHO) projects by 2015, 2.3 billion adults will be overweight and more than 700 million will be obese (WHO, 2006). Recent studies have attributed obesity to a variety of biological, physiological, psychological and/or environmental factors. These include but are not limited to low-fat foods, lack of sleep, ear infections, intestinal bacteria, pollution, plastics, poverty, air conditioners, socializing with obese people, your mother's age when you were born, and your maternal grandmother's diet (Butler, 2009). In 2006, the
Surgeon General Richard Carmona described obesity as "the terror within" and said it could "dwarf 9/11 or any other terrorist attempt" (Pace, 2006). Researchers say obese
Americans contribute disproportionately to global warming by consuming 18% more food and 938 million extra gallons of gas every year (Butler; Edwards & Roberts, 2008).
Sarah Hartshorne, a "plus size" contestant on America's Next Top Model, has a BMI of
21.5, well within the "normal weight" range (Butler). The net worth of White women whose BMI's fall 10 points increase by an average of $11,800 (Butler). Southwest
Airlines requires customers "who compromise any portion of adjacent seating" to buy 2 seats (Butler). Seventy percent of the government's Obesity Task Force's funding comes from the two drug companies that make the popular weight-loss pills Xenical (Alli),
Meridia, and Reductil (Butler). First-time users of Alli, a new over-the-counter fat- blocking pill, are advised to "wear dark pants, and bring a change of clothes with you to 2 work" because of such stated side effects as "gas with an oily discharge" and "hard-to- control bowel movements" (Butler; Mayo Clinic, 2008). Active obese people are almost
50% less likely to die of heart disease than sedentary thin people. Researchers asked
3,000 overweight people how they responded to discrimination; 79% said they ate more
(Butler). According to one study, 56.2% of people with eating disorders (anorexia, bulimia, and binge eating) are experiencing comorbid mental health conditions including anxiety disorder, phobias, depression and other mood disorders, and substance abuse
(Hudson, Hiripi, Pope & Kessler, 2007).
The numbers of obese and overweight people have grown to an astonishing number but the reasons that society attribute to this new epidemic are not always based in scientific research or common sense. Obesity has been equated to terrorism and been blamed for contributing to global warming. Being overweight contributes to being paid less money. Airlines would rather charge overweight customers for an extra seat than make their seats larger. Women will endure embarrassing gastrointestinal issues to conform to the socially constructed ideal body size. These provocative factoids illustrate the wide spread and institutionalized issue regarding weight bias and discrimination.
Western society measures the worth of a person based on their outward appearance. The authors feel that the subjects of body image, social constructed ideal body size, weight discrimination and sizeism are important social work topics, yet ones that are rarely or never discussed in Masters level social work classes. Although weight can be a health issue, there are many studies that show being overweight is not always synonymous with being unhealthy. The authors are interested in investigating whether 3 social work students may have unchecked biases regarding weight and size issues when it comes to working with clients. Many clients who struggle with mental health issues or have socio-economic disadvantages also struggle with weight issues, therefore this is an important and prevalent social work issue.
The writers were told by several social work professors that body size, body image, and sizeism issues were not social work issues. We do not agree. The literature shows that millions of people struggle with weight or body image issues, therefore as social workers it is an issue we must be educated about and have awareness of.
Statement of Collaboration
The researches have worked equally on this project, forming each chapter collaboratively. Equal efforts on behalf of both researchers have been assured entirely in this project. Both researchers implemented concepts from the origins of this topic into the introduction, literature review, methodology, data analysis and conclusion.
Background
Increased exposure to media in modern times has only added to the issue of body size shame and body size discrimination. Many studies report a link between exposure to media and decreased positive body image (Blood, 2005; Jade, 1999; Hesse-Biber, 2006).
Further, many studies indicate that eating disorders are associated with poor body image and media (Hesse-Biber, 1996; Hesse-Biber). It is important for social workers to be aware of the effects media has on our clients, especially in regards to their health and well being. Links between low socio-economic states and increased weight have been 4 made. Billions of dollars are spent by American people on diet and weight loss products
(Hesse-Biber, 2006).
Mental health issues such as depression, bipolar disorder, and schizophrenia have been associated with high risk of weight gain and obesity (Blaine, 2008; Loh, Meyer, &
Leckband, 2007; Simmons-Alling & Talley, 2008). Poor body image can greatly affect client's relationships and possibly lead to difficulties in marriage, intimate partners, and even with friends and family. Studies also show that women who are worried about their bodies have less sexual satisfaction (Ackard, Kearney-Cooke & Pearson, 2000).
Little research about social workers and weight issues could be located. Some social workers have written articles indicating the need for awareness and training, especially regarding transference and countertransference with this issue (Koenig, 2008).
Other research indicated that these same issues among mental health professionals occur between client and worker as it pertains to body size (Drell, 1988; McCardle, 2008).
Multiple studies indicate that helping professionals including therapists, teachers, nurses, and doctors treat patients differently based on appearance and weight (Cash &
Kehr, 1978; Clifford & Walster, 1973; Sperry, Thompson, Roehrig, & Vandello, 2005;
Wright, 1998; Young & Powell, 1985).
There is a lack of research regarding this topic, and, in our experience, the topic is rarely, if ever, discussed in social work classes. One study (McCardle, 2008) examined the attitudes of social work professionals on weight in a clinical setting. The findings showed that social workers did have biases about weight, and their own weight could affect their opinions of clients. Weight discrimination still occurs, and seems to be the 5 last acceptable form of discrimination, especially because it is assumed to be the fault of the person (Cahman, 1968). If social workers are not educated about the issue, and challenge the status quo, we are not ethically serving our clients.
Statement of the Problem
This study aims to explore the attitudes, beliefs, and experiences of masters level social work students at California State University, Sacramento regarding body image and discrimination against body size (sizeism). There is a gap in the research regarding the clinical implications between social workers and sizeism. While some may believe that weight related issues and weight discrimination is not a social work issue, the writers believe that it is a critical issue and research on this topic must be conducted. Inclusion of this subject in curriculum for Masters level social work students is vital for improving the issue. Our study aims to establish this topic as an important social work issue, because social work students are working with clients who experience body image and body size issues, as well as dealing with these issues personally. Social work students may not have the experience or training to use best methods of practice regarding this issue.
Purpose of the Study
The primary purpose of the study is to measure the experiences and attitudes of masters level social work students from Sacramento State regarding the issue of weight and body image. The researchers have sought to measure attitudes about how comfortable and competent social work students feel in clinical settings regarding this issue. Student's personal experience and struggle with weight issues are also being measured, and with this data, the researchers will attempt to make a correlation with 6 personal and clinical experiences. The researchers intend to examine the hypothesis that weight, body size, and body image is not discussed in social work classes, and biases are unchecked even though many students may be working with clients who have these issues. The secondary purpose is to bring a general awareness about the topic of body image, weight issues, and sizeism to social work students and the social work field as a whole. Results of this study may have implications for curricular development regarding this issue in the Division of Social Work at California State University, Sacramento as well as other social work departments in accredited universities. The writers intend to begin to fill a gap in the research on this topic and perhaps demonstrate this is an important social work issue.
Conceptual Framework:
Psychodynamic Perspective, Social Learning Theory and the Feminist Perspective
Three theories comprise this study's conceptual framework. The first is the psychoanalytic perspective. It remains one of the best known theories by the public, and is still commonly taught in foundational psychology academics. Psychodynamic perspectives use an individualist perspective, with little focus on social change (Payne,
2005). Sigmund Freud and psychodynamics greatly emphasize the role of the unconscious mind, where thinking and motivation are often not directly known to ourselves. This assumption underlies many of the concepts of psychodynamics including defense mechanisms, anxiety and ambivalence, personality, relationship issues, and transference and countertransference. Freud first identified transference when working with clients and he noticed clients were unconsciously transferring the feelings and 7 attitudes they had had toward early significant figures in their lives onto him (Freud,
1909). The theory has been expanded by psychoanalysts since Freud, and concluded that transference from therapist to clients is also possible (Payne). Today social work takes many psychodynamic theories and overlays an ecological perspective to better fit with social work values.
The second theory included in the study's conceptual framework is the social learning theory. Social learning theory has its origins with the behaviorists such as
Pavlov, Watson, and Skinner, but was first described in its essence by Albert Bandura in
1977 (Lahey, 1998). Bandura broke with the traditional behaviorists by asserting that people play an active role in determining their own actions rather than being a passive recipient of the environment (Lahey). Social learning assumes that people learn by observing others behaviors as well as the outcomes and consequences of those behaviors.
Often children and adolescents view the world and its models to see what behavior is acceptable and desirable and often internalize it to create their own behaviors and identity. Bandura also described self-regulation as the act of cognitively reinforcing and punishing our own behavior, depending on whether it meets our personal standards
(Lahey). The writers believe social learning theory is at work when the media and socially constructed ideal body size affect how people think and behave about body size.
The final theory comprising this study's conceptual framework is the Feminist Social
Work Perspective. Feminist perspectives in social work seek to explain and respond to the subjugated position of women in most cultures. Much of social work is done with 8 women, by women. Furthermore, most people who experience issues surrounding body size and body image are women (Payne, 2005).
Definition of Terms
Terms that the authors use to describe people with excess weight include fat, overweight, and obese. The terms overweight and obese have different medical definitions, with someone who is overweight having a Body Mass Index of 15 to 30 and someone who is obese having a BMI over 30 (Brownell, Puhl, Schwartz & Rudd, 2005).
"Obesity is best viewed as having multiple causes: metabolic, neurological, psychological, and socioeconomic. This is like many other disorders in medicine, and especially those in psychiatry; an exact cause-and effect relationship and pathophysiology is unknown" (Kiell, 1973, p ix). The term obese and overweight also has different cultural definitions.
The authors use terms to describe treatment of people with weight issues including bias, stigma, and prejudice. Bias refers to "an inclination of temperament or outlook; especially: a personal and sometimes unreasonable judgment (Brownell et al.,
2005). Puhl, Andreyeva & Bronwell (2008) describes weight bias as a negative attribution toward people who are visually overweight, which can lead to negative consequences in social, work, educational, and health care settings. Stigmatization refers to the rejection and disgrace that are connected with what is viewed as physical deformity and behavioral aberration (Cahnman, 1968, p. 293). Prejudice refers to a judgment or opinion formed without just grounds of before sufficient knowledge (Brownell et al.).
Sizeism is a form of discrimination based on someone's size, and for the sake of this 9 project, that discrimination is based on someone's weight.
Body size refers to the size of one's body, as the person and other people may perceive it-specifically, for the sake of this project, related to body mass and weight, as opposed to height. Body image is defined as the picture that the person has of the physical appearance of his/her own body (Traub & Orbach, 1964). It can also be defined as "the subjective concept of one's physical appearance based on self-observation and the reactions of others" (American Heritage Dictionary, 2006).
Disordered eating is when a person's attitudes about food, weight, and body size lead to very rigid eating and exercise habits that jeopardize one's health, happiness, and safety. Disordered eating may begin as a way to lose a few pounds or get in shape, but these behaviors can quickly get out of control, become obsessions, and may even turn into an eating disorder. An eating disorder is a mental health diagnosis based on the
American Psychiatric Association's Diagnostic and Statistical Manual of Mental
Disorders. An eating disorder diagnosis may be anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified, which can include binge eating disorder
(American Psychiatric Association [APA], 2000). The review of literature includes more in-depth descriptions of these diagnoses.
Assumptions
The writers assume that this is a social work issue. We assume that it is vital for social work students and practicing social workers to have the training and knowledge about working with clients regarding this issue. We assume that social work students may have unchecked biases regarding body size. The authors assume that social work students 10 may have personal issues surrounding their own body size, and perhaps experience body image issues. We assumethat media has a large role on the social construction of body size. The authors assume that the social construction of body size greatly affects the quality of life of millions of people.
Justifications
This research project will benefit the profession of social work by adding to research and literature about the topic of weight, body image, and sizeism. Doing the research may bring awareness about the problem to the social work students at California
State University, Sacramento. The writers hope the professors who are aware of the project will speak to their students about the issue in class discussions. Perhaps the issue can be added to the curriculum and discussed amongst the other issues in the diversity class. The writers also hope that students will discuss important transference/countertransference issues in supervision as an intern or while getting licensed. A greater awareness around this issue may increase training amongst social workers, other mental health professionals, other helping professionals, and the general public.
Limitations
The writers have chosen to focus most of their research on studies reflecting on obese and overweight persons. It is not the writers' intention to ignore the issues surrounding persons who are underweight and persons who have a normal weight
(according to BMI standards). Research shows that greater discrimination occurs with obese or overweight people, as opposed to underweight or normal weight people. While I1 we do not exclusively focus on the female gender, much of the literature focuses on body size and body image issues related to females. Females are judged more by their outward appearance than males, and more of the value of a woman depends on her physical appearance. A major limitation of this study is that there are so many issues related to this topic, from mental health including eating disorders, media, discrimination, socioeconomic factors, body image, cultural issues, and nutrition and wellness, that it became difficult to narrow the scope of the research. There is a great deal of knowledge that the authors chose to leave out of their research. This topic is multi-faceted and multi- dimensional. The writers chose to measure attitudes, beliefs, and awareness of body size issues amongst social work students, as opposed to licensed social workers, other mental health professionals, other helping professionals, the general public or society as a whole. 12
Chapter 2
REVIEW OF THE LITERATURE
Introduction
The project problem discusses how a social worker's own personal body image or biases towards body image may affect their work with clients. In this chapter, the researchers first review the social work literature relevant to this study to examine the history of the social construction of the ideal body size and the significance of body image and size in clinical social work practice. Additionally, where the social work research and conceptual literature appears scant, this chapter will review literature relevant to the topic in other human and/or social service disciplines. Finally, this literature review will also attempt to identify gaps in the social work literature leading the way to this study's assumptions, conceptual framework and research questions.
Addressing body image, sizeism, and weight issues is important for social work because many clients struggle with these issues. Often clients feel their quality of life would be improved if their body more closely resembled the beauty ideal as prescribed by societal norms (Engeln-Maddox, 2006). Karen Koenig, a licensed clinical social worker, addresses this issue by saying "the more we consider issues of eating and weight and how they may play out transferentially in the therapeutic relationship, the better we will be at addressing them with confidence and competence" (Koenig, 2008, p. 1). With more exposure to media in the last few decades, body dissatisfaction, especially among women, has been increasing (Hesse-Biber, 2006; Campbell & Scaffidi, 2007). Research shows that exposure to thin ideal advertisement increased body dissatisfaction, negative 13 mood, weight concerns, and levels of depression and lowered self-esteem (Anschutz,
Engels &Van Strien, 2008; Bessenoff, 2006; Davis, 2008; Field, 2000; Hesse-Biber).
A study finds that weight bias and discrimination is comparable to reported rates of racial and gender discrimination (Puhl et al., 2008). There are no federal laws or legal sanctions against weight discrimination. The same study reports that women are far more likely to experience this discrimination than men are. Men often do not experience weight discrimination until their BMI reaches 35, while women begin experiencing an increase in discrimination at BMI 27, and moderately obese women with a BMI of 30 to 35 are three times more likely than men in the same weight group to experience weight discrimination. (Puhl et al.). Compared to other forms of discrimination in the United
States, weight discrimination is the third most prevalent cause of perceived discrimination among women (after gender and age) and the fourth most prevalent form of discrimination among all adults (after gender, age and race) (Puhl et al.).
Background
The world-wide standard of what is considered underweight, normal weight, overweight, or obese is based on the Body Mass Index (BMI). BMI is based on the ratio of height to weight (kg/m2), a classification developed by the World Health Organization
(WHO) and also accepted by the Centers for Disease Control and Prevention (CDC) at the National Institute of Health. BMI measurements less than 18.50 are considered underweight; between 18.5 to 24.9 are considered with the normal range, between 25 to
29.9 is considered overweight and pre-obese, and any BMI measurements greater than 30 kg/m2 is deemed obese. Table 1 illustrates BMI classifications. 14
Table 1
The InternationalClassification of adult underweight, overweight and obesity accordingto BMI (World Health Orgaanization) CLASSIFICATION BMI(kg/m2) Principal Cut-Off Additional Cut-Off points Points Underweight <18.50 <18.50 Severe thinness <16.00 <16.00 Moderate thinness 16.00 - 16.99 16.00 - 16.99 Mild thinness 17.00 - 18.49 17.00 - 18.49 Normal Range 18.50 - 24.99 18.50 - 22.99 23.00 - 24.99 Overweight >25.00 >25.00 Pre-obese 25.00 - 29.99 25.00 - 27.49 27.50 - 29.99 Obese >30.00 >30.00 Obese class I 30.00 - 34-99 30.00 - 32.49 32.50 - 34.99 Obese class II 35.00 - 39.99 35.00 - 37.49 37.50 - 39.99 Obese class III >40.00 >40.00 Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.
Anthropological studies indicate different types of bodies amongst humans regardless of diet and exercise (Cahnman, 1968). Some people are born with an endomorphic (rounder, softer) body style as opposed to mesomorph (more bone and muscle development) or ectomorph (frail, thin, fragile). These body types are the result of genetics rather than gluttony, laziness, or weak moral character (Cahnman, p. 286).
Health Risks and Obesity Paradox
The CDC cite the following as health risks associated with higher body mass index: coronary heart disease, Type 2 diabetes, cancer (endometrial, breast, and colon), hypertension (high blood pressure), dyslipidemia (for example, high total cholesterol or high levels of triglycerides), stroke, liver and gallbladder disease, sleep apnea and 15 respiratory problems, osteoarthritis (a degeneration of cartilage and its underlying bone within a joint), and gynecological problems (abnormal menses, infertility) (2004).
Underweight clients are more likely to face health risks associated with anemia and nutrient deficiencies, bone loss and osteoporosis, heart irregularities and blood vessel diseases, amenorrhea (loss of periods for women), increased vulnerability to infection and disease, and delayed wound healing (CDC).
While there is a need to recognize these health risks, it is also important to point out the different paradoxes of health that come with being overweight or obese as well as with being underweight. For example, in a study including 108,000 patients with acute heart failure hospitalized in 263 hospitals across the country from October 2001 through
December 2004, the actual mortality rates of "normal" classified BMI patients were higher than "obese" patients (Fonarow, Srikanthan, Costanzo, Cintron, & Lopatin, 2007).
Despite adjusting for every contributing factor, including the client's age, gender, and other health effects, the researchers found that for every five unit increase in BMI the risk of dying from acute heart failure dropped by 10%. In a different study, it was also found that obese or overweight clients are two times more likely to survive hospitalization and invasive treatments than thinner ones (Kang, Shaw, Hayes, Hachamovitch, Abidov,
Cohen et al, 2006). Another study found that obese or overweight persons with hypertension or coronary artery disease were 24-36% less likely to die than their normal weight peers (Uretsky, Messerli, Bangalore, Champion, Cooper-Dehoff, Qian Zhou, et al.
2007). Obesity is also seen as a protective factor for patients on maintenance dialysis for chronic kidney disease (Kalantar-Zadeh, Abbott, Salahudeen, Kilpatrick & Horwich, 16
2005). In another study, it was found that out of over 5000 people surveyed, over 50% of those who were overweight and 31.7 % of those who were obese, had healthy levels of cholesterol, blood sugar, blood pressure and other measures linked to heart disease
(Wildman, Muntner, Reynolds, McGinn, Rajpathak, Wylie-Rosett, et al., 2008). Twenty- three percent of those labeled "normal" had two or more significant health risks linked to heart disease. The CDC claims that the leading health risk for obese and overweight people is heart disease, but these studies indicate that the higher body mass may serve as a protective factor in some cases. This phenomenon has been referred to by some researchers as the "obesity paradox" (Fonarow et al.; Kang et al.; Uretsky et al.).
Within the previously mentioned studies, it was asserted that the location of body fat is a more important factor in determining health of a client, whether visceral fat is located in and among the internal organs and the circumference of the waist (Wildman et al., 2006, Uretsky, et al., 2007). However, it was found in the Wildman's National Health and Nutritional Examination Survey study that more than 36% of the obese people with what should have been dangerously large waists had healthy blood test results. The definition of obese and overweight was set by the BMI, but these persons were metabolically healthier than many of their normal BMI cohorts. This supports that BMI is not the best indicator of health, nor is the obese or overweight label an indicator of the person's actual health.
The obesity paradox is further complicated by the BMI. The CDC refers to BMI as "a reliable indicator of body fatness for most people and is used to screen for weight categories that may lead to health problems." While the CDC explains throughout its 17 website that BMI is not the best assessment of body fat and that it is not a proper diagnostic tool for determining excess body fat, the site also states that "calculating BMI is one of the best methods for population assessment of overweight and obesity. Because calculation requires only height and weight, it is inexpensive and easy to use for clinicians and for the general public. The use of BMI allows people to compare their own weight status to that of the general population" (CDC). In a sense, the CDC is justifying generalization. If BMI is not a proper indicator of health, using it as means to categorize people is not efficient, appropriate or fair. Both underweight and overweight individuals already experience a great deal of discrimination in American society, and if the BMI is used to label a person, or create ideas like the obesity epidemic then the number becomes gratuitous. This is especially important for the social worker to note: If social workers are not aware that their clients' health is determined by more than just their BMI and body size, he or she is not looking at the entire picture.
Media, Body Image and Body Size
Throughout time the image of the ideal body, especially for women, has shifted, with the ideal body size becoming increasingly slimmer (Blood, 2005; Hesse-Biber,
2006; Jade, 1999). During pre-industrial times the ideal woman was full figured and curvy. This is evident in the artwork of famous painters such as Rubens, Renoir,
Botticelli and others who painted women and goddesses as what would now be considered plus sized. Even in prehistoric times sculpture and paintings shows us that the ideal female body had large breasts, large hips, large bellies, and large thighs. This artwork, the media of the time, depicts women who were round and voluptuous, 18 symbolizing fertility and good health. Overtime art and media have shown us that the ideal woman's body is getting slimmer and slimmer, with the most drastic change in the last 60 years (Campbell & Scaffidi, 2007). Victorian hourglass shape gave way to the
1920's thin flapper. In the 1950's, Marilyn Monroe, a size 12, became a new ideal with her curves. By the 1960's a model named Twiggy, with her 911b frame, changed the modeling industry's standards again (Jade). Throughout the 1970's and 1980's women in media become thinner, more toned, and with larger breasts (Jade). In the 1990's the media's heroin chic look -had women resembling pre-pubescent children or someone who was severely malnourished. In the last decade the ideal woman shown in media is still far more underweight than the average woman in America. How did we go from voluptuous goddess to malnourished supermodel?
While art portrayed the ideal body size of women throughout history, media now portrays ideal female body size of modem times. But unlike paintings and statues in history, today's media is broadcast into every room of the home 24 hours a day. The media supplies images and sounds in the form of television shows, commercials, magazines, print ads, and movies. All of the media content is now also accessible over the Internet. It is practically inescapable, from magazines at the check stand of stores to billboards along the highway. The advertising campaigns of yesterday are gone. Today advertising is ubiquitous, there are even commercials at the gas station pump. We no longer try to keep up with the Jones's but now try to keep up with the Hilton's. Within this inescapable media is the mantra that thin is ideal, and if a person is overweight she is making a choice to be lazy and not care for herself or her health (Blood, 2005; Bronwell 19 et al, 2005; Campbell & Scaffidi, 2007; Hesse-Biber, 2006). What went from just a preferred body size has now become a cult of thinness. If a person does not belong, there is an implication that there is something wrong with the person and that they should be ashamed (Hesse-Biber).
Hundreds of studies have shown that media plays a role in the development of poor body image and eating disorders in many populations. These studies have shown that the constant bombardment of media images has affected the level of positive body image among pre-adolescent boys and girls (Allen, Byrne, McLean & Davis, 2008), adolescent boys and girls (Knauss, Paxton, & Alsaker, 2008), Latina adolescents
(Schooler, 2008), African-American adolescents (Botta, 2000), young children (Sheridan,
2008), female athletes (Gibson, 2008), minority women and mature women (Siervo-
Lubian, 2005), gay men (Taylor & Goodfriend, 2008), lesbian women (Farr & Degroult,
2008), and mostly average women in western society (Anschutz, Engels & Van Strien,
2008; Davis, 2008; Field, 2000). In many of these studies the media's effect on body image has been directly linked to eating disorders and depression. The media's ideal body is becoming thinner and more unrealistic, increasing personal shame when one does not match the ideal. This can lead to depression and drastic measures like anorexia or bulimia. One study found that in the past 20 years 70% of Playboy centerfolds, considered to be the pinnacle of ideal woman's beauty, were medically underweight
(Katzmarzyk & Davis, 2001). A study showed that 25% of fashion models meet the
American Psychiatric Association's diagnostic criteria for anorexia nervosa (Byrd-
Bredbenner, Murray & Schlussel, 2005). Studies have also shown the decreasing of body 20 weight among women in the media as time has progressed (Campbell &Scaffidi, 2007;
Jade, 1999; Hesse-Biber, 2006). One study has shown that three minutes spent looking at models in fashion magazines caused 70% of the women to feel depressed and shamed
(Simotnton, 2002).
Even if a woman accepts her overweight body, the media presence is always telling her she is unhealthy, lazy, and should be ashamed. Hollywood portrays overweight people as funny sidekicks, or as dumb, lazy, or slovenly (Brownell et al,
2005). One of the few ways an overweight woman can get on the cover of a magazine is by promising the world to drop 50 pounds as soon as possible. Kirstie Alley, Carnie
Wilson, and Queen Latifah have all been spokeswomen for weight loss products and have all lost and gained the weight back. Magazines are constantly providing tips and tricks on how to have greater self-control over food and lose a bit more weight. Some feminist theorists have suggested that keeping woman occupied with weight keeps them busy enough to not focus on things like making 75 cents per dollar that men make, or that women have unequal government representation. Women are more concerned with taking off 10 pounds than equal representation in politics. Women continue to buy into the notion that female value is wrapped up in our weight and appearance, and everything else, including intelligence, personality, and power, is secondary.
Economics, Capitalism, and Ideal Body Size
Often ideal body size shifts with economics and status. Hundreds of years ago, if a woman was plump it indicated she was healthy, able to afford food, and did not have to work hard jobs (Jade, 1999). If a woman was very thin, she was thought too poor to 21 afford food, likely malnourished, and was not a good choice for a bride (Jade). As time progressed, the industrial revolution changed the way many people live and classes became less distinct. In modem times most people began to claim stake in the middle class. Many factors contributed to the shift of ideal body size. During the 20th century economics and weight ideals switched. Ready-made clothing introduced the idea of standard sizing (Hesse-Biber, 2006). In modem times, people with less money have greater access to processed foods that are heavy with fats and carbohydrates, while their ability to purchase and have access to fresh vegetables, fruits, fish, or meats is decreasing.
Poorer people often do not have the time or money to cook a healthy meal at home or to work out and keep fit. It is estimated that 47.5% of the average American's food dollar is spent on food prepared outside of the home (Hesse-Biber). Additionally, it is estimated that the majority of calories consumed by Americans happens outside the home, with
12% coming from fast food, 10% from restaurants, and 11% coming from other outside sources such as cafeterias, bars, or vending machines (Hesse-Biber). While people with money can have a membership to a gym, have a personal trainer, buy and have time to cook healthy, organic, more expensive foods. Being very thin has become a marker of socioeconomic status in modem western society.
Americans spend $50 billion a year on weight loss and dieting every year (Hesse-
Biber, 2006). There is money to be made on women not being happy with their body size and it is in many corporations' best interests to continue the onslaught of creating an ideal body size. Book and magazine publishers, television stations, commercial advertisers, movie studios, diet programs, cosmetic companies, pharmaceutical companies, and food 22 companies all stand to gain money off women's self loathing. U.S. companies spent $118 million on diet program advertisement in 2003; Weight Watchers alone spent $93 million
(Hesse-Biber). In 2005, three million copies of The South Beach diet books and 1 million copies of Dr. Phil McGraw's weight loss book were sold (Hesse-Biber, p. 76).
"Americans spend $12 billion a year on dietary aids, metabolic enhancers, supplements despite health risks and proven false advertisements associated with them" (Hesse-Biber, p. 77). "$132.3 million worth of liquid and powder weight-loss products were sold in
2000, of which $42.1 million resulted from Slim-Fast sales" (Hesse-Biber, p. 68).
Economics play a role in changing ideal body size, but also keeping body size in constant fluctuation. Hesse-Biber describes the "fatten up/slim down" phenomenon with many magazines having advertisements for fast food next to advertisements for diet products.
Corporations want people, especially women, to be starving for the next ice cream while purchasing diet pills. The obesity epidemic is spurred on by many of the same companies that claim outrage over it. It is important for social workers to be aware of this trap that many of our clients and ourselves get caught in.
Body Politics
Research shows that Americans of all ages (children, adolescents, young adults, and adults of both genders and a range of ethnicities) prefer a moderate amount of fat
(ideal body weight) over very thin or overweight (Rand & Wright, 1999). According to the CDC (2004), the average U.S. woman is 5'4", weighs 164.3 lbs., and wears a size
12/14. Yet many women still strive to look like an unrealistic ideal that closer describes a 23 woman who is 5'8"-6'0", 1 15-120 lbs, and wears a size 4/6. Women become weight conscious in a society that focuses on appearance as value.
Eating Disorders
This review of literature focuses on the many dimensions that affect body image formation and identity as well as the need for awareness about body size and body image in social work education. Social work students entering the field will possibly encounter clients who struggle with eating disorders, diagnoses identified by the American
Psychiatric Association based around one's relationship with food and their body. The
APA has determined that there are two eating disorder diagnoses, anorexia nervosa and bulimia nervosa, which are represented in the DSM-IV TR. These diagnoses pathologize certain eating behaviors. It is clear that body image and body size issues can be transferred into a mental health issue. It is important that social work students are aware of these unique diagnoses and the co-morbid diagnoses that often accompany the eating disorder.
Anorexia nervosa is characterized by "a refusal to maintain body weight at or above a minimally normal weight for age and height", and "weight loss leading to a weight at least 15% below minimum healthy body weight" (American Psychiatric
Association [APA], 2000). Anorexia is characterized by a "fear of gaining weight or becoming fat" regardless of being underweight, "distortions in the perception of one's body weight or shape, denial of the seriousness of the current low body weight, and undue influence of body weight or shape on self-evaluation" (APA). Body size and shape becomes the person with anorexia's greatest fixation and food their greatest mechanism 24 of control. "In females who have reached menarche, the absence of at least three consecutive menstrual cycles, or amenorrhea," as a result of weight loss is also cause for diagnosis (APA).
While binge eating disorder is not listed in the DSM-IV TR as an official eating disorder diagnosis, it is listed under the "Eating Disorder Not Otherwise Specified" category and defined as "recurrent episodes of binge eating... characterized by both eating in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances accompanied by a sense of lack of control over eating during the episode"
(APA, 2000). Binge eating episodes are typified by three or more characteristics, including "eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of being embarrassed by how much one is eating, and feeling disgusted with oneself, depressed, or very guilty after overeating" (APA). These behaviors must occur at least 2 days a week for 6 months before diagnosis of binge eating disorder (APA). Higher rates of self-loathing, disgust about body size, depression, anxiety, somatic concern, and interpersonal sensitivity occur in individuals who report these patterns of eating in comparison to those of equal weight who do not report these patterns (APA).
The DSM-JV TR defines the core characteristics of bulimia nervosa as "recurrent episodes of binge eating" followed by "recurrent inappropriate behaviors to prevent weight gain from the binge, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting, or excessive exercise." These episodes are distinguished by "a 25 sense of lack of control" over eating during the episode and excessive guilt and fear of gaining weight associated with the binge (APA). The guilt, fear, and depression that typify the aftermath of the binge find relief in the purging behavior. The DSM-IV requires binge eating and inappropriate purging behaviors to both occur at least twice a week for 3 months on average for diagnosis of bulimia nervosa.
It is believed that more than five million women are suffering from eating disorders of anorexia nervosa or bulimia nervosa in the United States alone (National
Alliance for the Mentally Ill [NAMI], 2003). Another one to two million women are suffering from binge eating disorder. More than 90% of all those who are affected by eating disorders are adolescent and young women (NAMI). Eating disorders are found in men and women of all cultures and ethnicities, young and old, gay and straight.
The National Comorbidity Survey Revisited (NCS-R) is a nationally representative survey of the US household population that was administered face-to-face to a sample of 9,282 English-speaking adults ages 18 and older between February 2001 and December 2003 (Hudson et al., 2007). The survey found that eating disorders frequently and significantly impair the sufferer's home, work, personal, and social life.
The survey determined that lifetime prevalence rates of anorexia nervosa were 0.6% of bulimia were 1.0%, of subthreshold binge eating disorder were 2.85%, and of any binge eating disorder were 4.5% (Hudson et al.). According to the study, subthreshold binge eating disorder is defined as binge eating episodes, that occur at least twice a week for at least 3 months, and not occurring solely during the course of anorexia nervosa, bulimia nervosa, or binge eating disorder (Hudson et al.). The lifetime prevalence rates of these 26 disorders point to the likelihood that a social worker will encounter clients who present with these diagnoses, as 4 people in 100 will experience any binge eating disorder and 1 in 100 will experience bulimia. It is necessary that social work students be aware of the causes and symptoms of these disorders. The National Institute of Mental Health determined that, in their lifetime, an estimated 0.5% to 3.7% of females suffer from anorexia, and an estimated 1.1% to 4.2% suffer from bulimia (American Psychiatric
Association Work Group on Eating Disorders, 2001; National Institute of Mental Health
[NIMH], 2008).
The study also determined from their population that a person with anorexia typically struggles with the disease for 1.7 years (Hudson et al., 2007). The mean number of years a person struggles with bulimia is 8.3, while the average length of binge eating disorder was 8.1 years (Hudson et al.). With the average length of eating disorders being so long, it is appalling that treatment for eating disorders can be so time limited. If a person struggles with bulimia for eight years on average, it probably took another several years of negative self-talk to develop the binging and purging process-it will likely take more than the insurance-allowed 28 days in an in-patient facility to heal the person. The
Mental Health Parity Act of 2008 seeks to address this issue, eliminating discrimination in health care coverage against people suffering from mental disorders.
More than half (56.2%) of respondents of the NCS-R survey with anorexia nervosa, 94.5% with bulimia nervosa, 78.9% with binge eating disorder, 63.6% with subthreshold binge eating disorder, and 76.5% with any binge eating met criteria for at least 1 of the core DSM-IV disorders (mood, anxiety, impulse control, and substance 27 abuse) (Hudson et al., 2007). The survey concluded that eating disorders, although relatively uncommon in the general population, represent a public health concern because they are frequently associated with other mental health diagnoses, and are frequently under-treated for various reasons (Hudson et al.). As a public health concern, this is also a social work concern.
Eating disorders are now the third most common chronic illness in adolescent girls (Adolescent Medicine Committee, 2001). Eighty-one percent of 10-year-olds restrict eating, and at least 46% of 9-year-olds restricted eating (Mellin, Scully & Irwin, 1986).
Fifty-two percent of girls begin dieting before age 14 (Johnson, Lewis, Love, Lewis, &
Stuckey, 1984). In one study, despite only a small percentage of participants being over a healthy weight, 71 % of adolescent girls wanted to be thinner (Paxton, Wertheim,
Gibbons, Szmukler, Hillier, & Petrovich, 1991). The fear of being overweight is so devastating that young girls have indicated in surveys that they are more fearful of becoming fat than they are of cancer, nuclear war, or losing their parents (Berzins, 1997).
Eating disorders have the highest mortality rate of any mental illness-20% of affected individuals without treatment die (NIMH, 2008). The mortality rate drops to two to three percent with treatment (NIMH). The mortality rate among people with anorexia has been estimated at 0.56% per year, or approximately 5.6% per decade, which is about 12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population (Cavanaugh, 1999; NIMH; Sullivan, 1995).
There is movement in social work practice and theory to recenter the body as a focus of theoretical and practical concern (Tangberg & Kemp, 2002). "Relatively little 28 attention is given to issues of the body that transcend actually physical states, including social constructions of the body, mind and body relationships, and the role of power in determining how bodily knowledge and experience are defined, interpreted, and managed" (Tangberg & Kemp, p. 9). Instead, "social work efforts are directed mostly to
[the body's] surface attributes or to managing the consequences of bodily conditions, such as addiction or violence" (Tangberg & Kemp, p. 9). "The individualistic ethos of the
West promotes a view of the self as able to contain and overrule the body and its appetites" through the use of cognitive approaches to control physical urges and behavior, instead of working toward social change in the area of the body, particularly surrounding body work in eating disorders (Tangberg & Kemp, p. 1 1).
Recall the definitions of anorexia nervosa, bulimia nervosa, and binge eating disorder listed earlier. An established theme to disordered eating is the sense that the individual has no control over their eating behaviors. Tangberg and Kemp (2002) suggest that many different kinds of issues that bring clients to social work's attention, including addiction, child maltreatment, sexual acting out, or violence, involve situations in which the body is perceived as being out of control. A guiding assumption is that people should be able to control their bodies, and that the rational self can act as a brake on the body.
The helping professions can assist in the process of getting the body back in line by providing education, skills training, and positive social support (Tangberg & Kemp).
However, eating disorders are pathologized to be a control issue (control about body weight and food intake), but can also be explained as a result of the pressures of society. 29
Education, skills training, and positive social support must be included in treatment, but also advocacy surrounding health and self-acceptance.
Tangberg and Kemp's (2002) article discusses different conceptualizations of the body using social, cultural, and psychological dimensions. Many of these conceptualizations are already cited in this literature review. The women reference
Grosz's two approaches to the body (1994), the lived body, or the body "as it is physically and subjectively experienced" and the inscribed body, or the "view of the body as 'a surface on which social law, morality, and values are inscribed"' (Tangberg &
Kemp, p. 12). The inscribed body of Grosz's approach is what is attacked by the pressures put on women to conform their bodies to a certain look, which may eventually lead to eating disorders.
In 1996, the average American woman was 5'4" tall and weighed 140 pounds, while the average American model was 5'1 1" tall and weighed 117 pounds (National
Eating Disorder Association [NEDA], 2002). Most fashion models are thinner than 98% of American women (NEDA), but the fashion model is held as a standard to strive for in
America's youth and the standard for the beauty ideal.
In eating disorder prevention literature, the focus for prevention has been on reducing the perceived risk for potential eating disorders through increased education.
Young people should be educated about the negative effects of eating disorders. The literature stresses high self esteem, participation in sports, and competency in life skills and social skills as good protective factors, but fails to address why our society has the pressures to conform to a certain look that it does (Wener, 2003). If young women are 30 told why the beauty ideal is the way it is, instead of how to get it and what it looks like, more young women would be striving to be healthy instead of being thin. The beauty ideal is not healthy - a person requires fat on their body to maintain health. Instead of stressing thin andperfect, social workers, and society as a whole, need to keep young people aware of their choices and emphasize being who you are and want to be instead of fitting in with the socially constructed version of beauty.
The development and widespread implementation of interventions that prevent eating disorders is desperately needed. Thorough evaluations are crucial to ensure that programs are implemented as intended, have no unintended harmful effects, and effectively lead to positive changes in weight-related attitudes and issues, self-concept, and behaviors. Prevention at the individual, school, community, and societal level must be a priority. Social workers, psychologists, nutritionists, counselors, and educators everywhere need to take the focus away from the traditional models of addiction treatment and prevention to realize and develop a new ideology for protecting
American's youth from the harmful effects of eating disorders on the individual and society as a whole.
Mental Health Issues
Another reason social workers should be aware of the role body shape and size take in clinical settings is that poor body image has been associated with a number of mental and emotional disorders, including depression and eating disorders, such as anorexia, bulimia, compulsive and binge eating disorders (Blood, 2005; Engeln-Maddox,
2006; Noles, Cash, & Winstead, 1985). The Noles et al. study showed that people who 31 experience depression were less satisfied with their bodies and saw themselves as less attractive than those who were not depressed. Perception of body size and eating disorders has been linked in research as far back as the late 1950s (Blood).
Studies show people with depression are at significantly higher risk for developing obesity, particularly among adolescent girls (Blaine, 2008). Increased BMI has been associated with major depressive disorder, increased suicidal ideation, and suicide attempts (Carpenter, Hassin, Allison, & Faith, 2000). As obesity continues to rise, this means a greater number of people will be at risk of depression. The depression and obesity discussion can be like the chicken and the egg, no one is sure which came first, or if one truly causes the other. Hundreds of studies have proven the link, but many studies contradict the cause. Does being overweight and stigmatized by society cause depression? Does depression cause you to eat more, and be less active, therefore become overweight? All that is known is the high rate of people who experience depression also experience greater weight gain, therefore social workers will work with many people who are depressed and overweight (Carpenter et al.).
People with bipolar disorder are often overweight or obese (Simmons-Alling &
Talley, 2008), and while there are many reasons for this (medications, eating patterns, erratic behavior), the case remains that when working with mental health clients weight issues will be a factor. Obesity has been found to be present in up to 35% of persons with bipolar disorder (Chen & Kovaco, 2003). Eating disorders are often experienced co- morbidly with bipolar disorder. Baldassano (2006) found that 12% of women with bipolar disorder experienced co-morbid bulimia nervosa. Another study found that 32 outpatients treated for bipolar disorder were also found to have coexisting eating disorders: binge eating disorder (18%) and bulimia nervosa (10%) (Ramacciotti, Paoli,
Maracci, Piccini, Burgalassi, Dell'Osso, et al., 2005).
According to a survey of six European countries individuals of normal weight, compared with obese individuals, were more likely to have mood disorder, or more than one mental disorder (Bruffaerts, Demyttenaere, Vilagut, Martinez, Bonnewyn, DeGraaf, et al., 2008). A New Zealand study found obesity was significantly associated with mood disorders, major depressive disorder, and most strongly with anxiety disorders such as post-traumatic stress disorder (Scott, McGee, Wells, & Oakley-Brown, 2007). People with schizophrenia are 46% more likely to be obese than people without, yet they still often express a desire to be thinner like the general population (Loh, Meyer, & Leckband,
2007). These statistics indicate that while working with mentally ill patients many will have co-morbid weight issues that the social worker will need to be competent to work with.
Being judged and measured based on appearance is an issue that many social work clients will be faced with at some point. Unattractive people are viewed more critically than attractive people by peers, which will affect anything from relationships, employment, to a general goodness of fit in society (Cash, Kehr, Polyson, & Freeman,
1977). Stunkard and Mendelson (1973) describe the cycle of emotions, poor body image, and low self esteem that many obese and overweight clients deal with. Their description may describe a client who has come in to seek help from a social worker: 33
"The intensity of the body image disturbances fluctuates widely even over
short periods of time. When things are going well and a person with a
body image disturbance is in good spirits, he may be troubled little or not
at all by his disability, although it is rarely far from awareness. Let things
go badly, however, let a depressive mood ensue, and at once all of the
derogatory and unpleasant things in his life become focused upon his
obesity, and his body becomes the explanation and the symbol of his
unhappiness. A kind of circular relationship obtains between body image
disturbances which predispose to esteem-lowering experiences and
depressive moods which in their turn reinforce the disturbed body image"
(Stunkard & Mendelson, 1973, p. 43).
Mental Health and Relationships
Body image as it relates to body size can have major effects in relationships and in people's sex lives. Internalization of the socially constructed opinion of a "normal" body size can lead to sexual dysfunction (Dove & Wiederman, 2000). Women often rate their own attractiveness based on dissatisfaction of body type in regards to being "too heavy" or parts of the body being too large (Garner, 1991). One study showed that 35% of college women feel self conscious of their body size during intimacy with a male partner (Wiederman, 2000). This body self consciousness leads to lowered sexual esteem, lowered sexual assertiveness, and greater sexual avoidance (Wiederman). Wiederman and Hurst (1998) found that heterosexual women who are heavier (have a higher BMI) may not have the same opportunity for sexual relationships due to lack of interest from 34 male potential partners. These studies lead to the questions "does increased body image self-consciousness place (women) at risk for unwanted sexual practices or unprotected sex due to decreased assertiveness?" (Wiederman, p. 67). Or do body image and body size issues lead to women engaging in unsafe or emotionally unhealthy sexual practices?
These are questions social workers must address in practice.
Many studies have highlighted the role of a shifting body size among older women, especially during menopause. With so many baby boomer women getting older the need to understand women's sexuality is more important for professionals (doctors, nurses, policy-makers, therapists). Many women are diagnosed with sexual dysfunctions during their late 40's through 60's, and often the issue is medicalized, blaming hormones or physical changes (Koch, Kernoff-Mansfield, Thurau, & Carey, 2005). Only recently are studies starting to look at the role that the socially constructed view of body size, as being thin and young, may have on midlife women's sexuality. As women get older the metabolic rate slows down, and women generally gain more fat (Besser, Aydenir, &
Bozkaya, 1994). Women of all ages rate their own attractiveness based on size of their body as it relates to the socially constructed norm. Mid-life women were asked which of their features were least attractive: 36.2% reported stomach/abdomen, 26.5% reported hips, 22.4% reported thighs, and 20.4% reported legs (Koch et al.). Women reported that feeling overweight, frumpy, and matronly often had a role in their sexuality and relationship (Koch et al.). One longitudinal study (Margolin & White, 1987) indicated that weight gain and body shape changes in women resulted in decreased sexual interest and sexual satisfaction among their husbands, but such was not the same with regard to 35 the husbands weight gain and their wive's sexual interest. This indicates that women often feel the impact of being objectified and felt to fit into the ideal body size throughout life.
One study found that women between 14 and 74 years who were more satisfied with their body image reported more sexual initiation, activity, experimentation, and orgasms than those who were dissatisfied (Ackard, Kearney-Cooke & Pearson, 2000).
Women ages 50 to 80 who reported that developing a positive body image and accepting the outward signs of an aging body helped to keep sexual feelings alive (Fooken, 1994).
Social workers can help women normalize feelings surrounding body size, talk about the social construction of body size, and the changing body of women of all ages in order to improve the body image (and sexual lives) of women.
Men are not free from the negative affects of poor body image and body size as it pertains to sexual health. One study showed that homosexual men who were overweight were 3.6 times more likely to engage in unsafe sex then men with better body image
(Kraft, Robinson, Nordstrom, Bockting & Rosser, 2001). Further research on this issue must focus on lesbians, women of color, and men (heterosexual, homosexual, and men of color). Body image and body size issues can affect anyone, especially as media reach grows and a doctrine of "normal body size" spreads.
Culture and Body Image
Social workers should be conscious of the judgments and assumptions around culture, ethnicity, and body size. Often acculturation can lead people of color to adopt body size stereotypes, and have lowered body image. One stereotype is that African 36
American women are less concerned with their body size than White or Latina women.
While this is an interesting issue which many studies show to be true (Akan & Grilo,
1995, Altabe, 1998; Bay-Cheng, Zucker, Stewart & Pomerleau, 2002; Chandler &
Abood, 1997) other studies show African American women being equally dissatisfied with their bodies (Caldwell, Brownell, & Wilfley, 1997; Williamson, Serdula, Anda,
Levy, & Byers, 1992).
The protective factors among African American females must be studied and noted, and this cultural information may be helpful to social workers working with people of all races. One study showed that African American teenagers who had put on weight or were unhappy with their body size experienced depression due to their body size
(Grandberg, Simons, Gibbons, & Nieuwsma-Melby, 2007). A social worker cannot assume that because the client is African American she neither will nor will not be satisfied with her body size. Latinas have often measured equal if not higher body dissatisfaction then White women (Altabe, 1998; Bay-Cheng et al., 2002), disproving the myth that Latinas love their curves. A study measured the correlation of embodied femininity, weight concern, and depressive symptomatology among White, Latina, and
Black women. The study found no significant correlation of weight concerns with depression amongst Black women, but did find it among White and Latina women. While
Latinas scored low on correlation of embodied femininity and weight concerns (they could have weight issues and still feel feminine), they did have the highest correlations of depression and weight concerns (Bay-Cheng et al.). "For White women, thinness is a cardinal feature of the ideal feminine body, and that weight concern, rather than other 37 aspects of embodied femininity, is most centrally linked to their mental health (Bay-
Cheng et al., p. 42)." Over time, this ideal has become thinner and thinner and is therefore even more unattainable (Bay-Cheng et al.).
Fewer studies have been done among Asians and body image, again because stereotypes prescribe that Asian people have few body image issues. But some studies
(Iyer & Haslam, 2003; Reddy & Crowther, 2007) do show that, of course, Asians are not immune to the acculturation factors, and worry about body size and body image as it pertains to the "norm". Those two studies examined how teasing can have an affect on body dissatisfaction and disordered eating among Asian American women. A study of breast and body dissatisfaction among U.S. college women at UCLA showed that Asian women have greater breast and body dissatisfaction when compared to African American women, Hispanic Women, and women of European decent (Forbes & Frederick, 2007).
Another study (Huang-Cummins & Lehman, 2007) highlights the need for further research and treatment on body image and eating disorder issues amongst Asian women.
The socially constructed ideal body penetrates all ages and races.
Socioeconomics
Research has been done on the economic effects of physical appearance, specifically how perceived height and weight affects the wages of workers. A growing body of research shows that overweight people are less likely to be hired (Klesges, Klem,
Hanson, Eck, Ernst, O'Laughlin, et al. 1990; Pingitore, Dugoni, Tindale & Spring, 1994;
Popovich, Everton, Campbell, Godinho, Kramer & Mangan, 1997), perceived as having numerous undesirable traits related to job performance (Klassen, Jasper & Harris, 1993), 38 more harshly disciplined on the job (Bellizzi & Hasty, 1998; Bellizzi & Hasty 2001), assigned to inferior assignments (Bellizzi & Hasty 1998), paid less than ideal weight co- workers (Brownell et al., 2005; Saporta & Halpern, 2002; Sarlio-Lahteenkarova,
Silventoninen & Lahelma, 2004), and even terminated for failure to lose weight at the employer's request (Brownell et al.). One study concluded that people who were taller made 4-6% higher wages than those who were shorter. It also indicated obesity affected wage growth by 5.5% (Seng, 1993). This is discrimination based on appearance and weight issues. "Throughout history people with more wealth were often heavier because they could afford food, where as the poor were often starving and thin. But in modem times in the United States, the opposite has been found to be true (Cahnman, 1968, p.
288)." Over time economics, socioeconomics as well as media availability have changed the attitudes of people about ideal and acceptable weight. If being overweight can affect ability to be employed or be treated fairly, this is clearly an important social work issue.
In the 1960's the Midtown Manhattan Mental Health Study found that the prevalence of obesity was seven times higher among women raised in the lowest social class category as compared with those raised in the highest category (Goldblatt, Moore &
Stunkard 1965; Moore, Stunkard & Scrole, 1962). People from poorer communities may be heavier due to low socioeconomic status, and then are further discriminated against due to weight, making it more challenging to change (Cahnman, 1968). In the 1960s it was found that overweight women were less likely to be accepted to Ivy League universities than equal counterpart normal weight women (Cahnman). Clearly the socialization that fat is bad has been working for decades. 39
Anecdotal evidence indicates that a variety of undesirable characters may be associated with being overweight, including laziness, sloppiness, asexuality, lack of control, argumentativeness, mean-spiritedness, and emotionality (Young & Powell,
1985). Research shows that people who are overweight or obese by means of endocrinological (thyroid) issues are deemed less responsible and therefore less deviant to society and are treated more favorably and stigmatized less (Cahman, 1968). This shows that many people, professionals included, often consider obesity or overweight a symptom of laziness and a lack of personal responsibility.
Clinical Issues
It is important for clinicians to examine possible ingrained biases about body image and size issues. A negative bias can result in countertransference and transference issues between the clinician and client (Drell, 1988; Blood, 2005; Koenig, 2008; Lowell
& Meader, 2005; McCardle, 2008; Wright, 1998; Young & Powell, 1985). Effective therapy with clients requires the management of one's own feelings about size issues the client may have. A therapist's feelings about obesity are partially a product of societal influences and partially the therapist's response to the role of obesity in the patient's psychological makeup (Drell; Koenig). Intense positive or negative countertransference responses that are not recognized or adequately managed can impede the therapeutic process (Drell; Koenig).
Karen Koenig, LCSW, addresses these issues in her article "Weighing the
Possibilities: Transferential Weight Issues in Therapy" that appeared in Social Work
Today magazine (2008). She states "When treating clients with eating and weight 40 problems, transference and countertransference may be overlooked, less acknowledged, or avoided because of the potential discomfort that may arise by addressing them"
(Koenig, p. 1).
Koenig describes the possible transferential issues than can occur in all the weight-match relationships (2008). She discusses overweight therapist and client, underweight therapist and client, overweight therapist and underweight client, underweight therapist and overweight client, and normal weight but eating disordered therapist/client. With the overweight therapist and the overweight client, the client may feel an instant bond with the therapist because their bodies are similar or feel relieved that they won't be judged for their weight. Alternatively, the overweight client may feel disappointed since the overweight therapist has not been able to fix his or her own weight problems. The media pushes anti-fat attitudes and society subscribes to the mindset that thin is healthy, so even overweight people can be fat phobic. Koenig says "clients with weight problems who are fat phobic, thin obsessed, and caught up in the diet mentality may have lethal levels of contempt for large people in general, and themselves in particular, and therapists will be no exception" (p. 1).
The overweight therapist may be more equipped to help the client by showing confidence, humor, and courage while dealing with the weight issue (Koenig, 2008).
Conversely, the overweight therapist may feel fear of helping the client with the weight issue since she was not able to overcome her own weight issue. In this case, the overweight therapist may ignore the client's need for help or minimize the issue, creating a barrier in the relationship and possibly a dangerous situation. Ideally the overweight 41 therapist will be comfortable enough with their body and size to reach out and give clients whatever is clinically required (Koenig).
The underweight therapist and underweight client's relationship may have many of the same strengths and pitfalls as the overweight therapist and client's relationship. If the therapist is slim and the client is underweight with eating issues the client may feel that the therapist values thin and has a bias towards fat, which could exacerbate the eating disorder. The thin therapist may focus too much on nutrition, again making the disordered eating worse rather than better. However, the thin therapist may be able to help the client examine her fat bias and work with her on her fears of being fat, without losing credibility from the client's perspective. Koenig (2008) stresses that a therapist must know herself inside and out. If a thin therapist has fears of becoming fat she should be able to recognize that and help her client explore the issue. The thin therapist should be able help her client find healthy ways of staying slender that avoid eating disorders or over exercise (Koenig).
Koenig (2008) believes that being an overweight therapist serving an underweight client can be a challenging experience. Some overweight therapists may feel shame and self conscious about bringing the issue up with the client, but some may feel confident with their own weight and not take any anti-fat comments personally. Koenig wams that if the therapist is not comfortable with herself or skilled enough to work on issues she is personally unresolved with, it can be a difficult time for everyone involved. An overweight therapist may judge a thin client as being superficial by worrying about her weight or may feel disdain towards this country's obsession with thinness (Koenig). Both 42 of these can create a barrier in the working relationship. The thin client may also feel that an overweight therapist cannot truly help her with healthy nutrition and exercise since she was unable to do it for herself (Koenig). Both parties may try to avoid the subject all together for fear that one cannot serve or be served. In this case the therapeutic relationship cannot fully develop.
When an overweight client is seeking help from a thin therapist, the client may feel the therapist is unable to truly understand the issue (as with the thin client and overweight therapist) (Koenig, 2008). A client may feel ashamed to bring up food or weight issues or fear they will continue to be judged in the therapeutic setting, as they are judged by society outside of the therapist's office. An underweight therapist may avoid bringing up the subject for fear she will be perceived as being judgmental (Koenig). The thin therapist may actually hold stereotypical beliefs and judgments for overweight people and feel the client is less healthy, motivated, or able to participate in counseling. A thin therapist may assume she knows the extent of the problem and want to fix the client with her own solutions rather than letting the client guide the treatment or helping the client discover her own solutions to her issues. A slim therapist who has not struggled with weight may lack empathy when an overweight client talks about wanting to loose weight but also admitting to overeating or not exercising. Koenig insists that the more helpless a clinician feels, the more likely she is to push a diet or exercise program onto the client.
Even therapists and clients who are in the normal weight range can have eating disorders. Perhaps a therapist with restricted eating or overeating has normalized the 43 behavior to the point where it's difficult to see it in a client. A restricted eating therapist may not recognize her problems because the behavior is so socially sanctioned. Likewise, an overeating therapist may not recognize her overeating because the experience is so common (Koenig, 2008). The import thing is that the therapist be able to recognize the eating disorder behavior and treat the client competently.
A therapist of any size must understand this country's obsession with thinness and not judge the client on their weight or on their desire to change their weight. Koenig
(2008) urges therapists to never assume they know the problem or solution and to approach weight issues with slow caution. As with any topic in the therapeutic setting, it is vital that the therapist not come off as judgmental, because judgment damages the therapeutic relationship quickly. Koenig urges therapists to express curiosity in the issue with their clients and always seek out consultation. She states:
"We must deal with our feelings about clients' size. If we have eating or weight
struggles, raising transference issues, which are necessary for client growth, may
make us feel painfully vulnerable and exposed by drawing attention to our less-
than-perfect bodies. We may experience shame, anxiety, sadness, disappointment,
envy, contempt, helplessness, despair, or any mix thereof. Dealing with
transference and countertransference issues often entails in-depth examination of
our cultural biases about weight and our personal current difficulties and troubled
histories" (Koenig, 2008, p. 1).
Obese patients are more likely to terminate prematurely than non-obese patients, which may be attributed to the countertransference issue (Drell, 1988). A study proved 44 that mental health workers were more likely to assign obese clients with mental health related diagnoses and negative psychological symptoms (Young & Powell, 1985). Mental health workers share many of the same negative attitudes towards obese clients that pervade society in general (Young & Powell). It is critical that social workers are educated around their own biases based on the appearance of client's size and their own body image.
A study found undergraduate psychology students deemed psychotherapy was less necessary for persons who were considered attractive as compared with those who were considered unattractive (Cash et al., 1977). The students also found that psychiatric hospitalization was less necessary for attractive patients. This is another example of how a client viewed as unattractive may be labeled with more negative issues and given a dimmer prognosis. Conversely, another study showed that clients favored counselors who were deemed "attractive" over counselors deemed unattractive (Cash & Kehr, 1978). The study found that the subjects believed attractive male counselor to have higher
"intelligence, competence, assertiveness, friendliness, warmth, trustworthiness, and likeability" (Cash & Kehr, p. 337) while unattractive male counselor seemed less optimistic and had a weaker commitment to the client (Cash & Kehr, p. 336). Clearly a transference issue based on appearance is at work.
Other Helping Professionals
Some research has been done surrounding other health and helping workers'
(doctors, nurses, teachers) biases towards obese populations (Young & Powell, 1985;
Wright, 1998). Specifically, one study held structured interviews with nurses to 45 determine the nurses' beliefs about the value of female body size and the professional responses to women who are judged to be overweight (Wright). In this study, the assessment of most patients' body size was arbitrary and subjective, based on a health promotion leaflet, or was not addressed in any formal way. When asked what the potential risks of being overweight were to their patients, nurses cited physiological diseases rather than any psychological, emotional, or social effects. Nurses also described that overweight female patients were more likely to be refused a planned operation or told to go home and lose weight before surgery (Wright). The reason for the patient's weight was not taken into account, nor was the patient's desires taken into account
(whether he/she wants to lose weight or can lose weight). The nurses cited that doctors regularly made negative and discriminatory comments towards obese patients, and obese female patients were regularly subjected to humiliation by medical staff, reflecting society's abhorrence for fat (Wright). This information highlights the fact that educated professionals still have biases and discriminatory practices towards overweight and obese people and underlines the need for social workers to be educated about having sensitivity toward this particular issue and population. If an overweight person feels judged or discriminated against in health care settings, they are less likely to seek out treatment and help, increasing their risk factors. They may have fear of being talked down to by nurses or doctors, fear of being seen without their clothes, fear of being weighed, fear of not being able to use medical equipment (e.g. blood pressure machine), or fear of all of these and more issues. 46
A study of teachers indicates that they perceived attractive children to have higher education potential than unattractive children (Clifford & Walster, 1973). The teachers were shown pictures of attractive and unattractive children, along with basic case information, and rated how high they believed the child's potential IQ could be, the potential for future education of the child, and the parent's interest in the academic achievement of the child. Teachers rated the attractive children higher in all three categories. The study also indicated that teachers believed attractive children would have better relations with their peers (Clifford & Walster), further reinforcing that attractiveness and popularity go hand in hand.
On the other hand, one study (Sperry et al., 2005) indicates that the weight of the communicator, e.g. the therapist or mental health worker, has little effect on the participant's success in an eating disorder program. The research for this study was designed using only pictures of the communicator and a questionnaire. No actual face-to- face interaction occurred between client and clinician. Therefore, no transference or countertransference could be displayed. It would be pertinent for further research in this area, as there are clear limitations in this study. Very little research has evaluated the view and treatment of obese people by mental health professionals (Young & Powell,
1985).
Social Work Research and Body Size/Body Image Issues
There is. a present gap in the knowledge regarding information about future social work practitioners' education, teaching, and training in recognizing their own biases towards client's body size and body image, and further, recognizing how their own body 47 image and body size may play a role in the therapeutic process. The code of ethics for social work states that social workers are to challenge injustice and fight discrimination
(NASW, 1999) and clearly weight bias and discrimination occurs often. Melissa
McCardle, PhD, LCSW, provides research for her doctoral dissertation on weight bias among social workers (2008). She sampled 564 NASW member social workers across the U.S., 82% of which were in direct practice, with a mean average of 24 years in practice. The social workers reported that 20% of their clients are obese and 20% of their direct practice time is spent with obese clients (McCardle). She also surveyed the social workers about their own weight and struggle with weight issues and found that a history of struggling with weight, a family history of obesity, or having more obese friends all correlated with less weight bias (McCardle). Most (68%) of the social workers in the study endorsed a perception of unhappiness in obese people, while at the same time social workers reported that they disagreed with many of the negative stereotypes of overweight people (McCardle). The social workers reported that 63.8% of their clients felt that weight bias is an important issue, yet only 42% of social workers felt that weight bias was an important issue for their own practice (McCardle). It appeared there is a discrepancy between the importance of this issue between clients and social workers.
Little research was found on education for social work students about sizeism, body image, or appearance based discrimination. A search of the Council on Social Work
Education web page yielded only one social work program in West Virginia aiming to educate their students in health and weight issues (Department of Social Work [DSW],
West Virginia State University [WVSU], 2006). This program seeks to address the 48 weight issues among social work students, as well as clients in the community. The
University has developed a project to integrate health and wellness theory and activities into the curriculum and culture of the Social Work Program and the University (DSW,
WVSU). The University also cites the importance of social work's role in helping families develop nutrition, wellness, and all aspects of health in a non judgmental and clinically educated manner, especially among vulnerable low income populations (DSW,
WVSU). Unfortunately, it is the only one of its kind that could be found by the writers.
In California State University, Sacramento's Division of Social Work Diversity class students are taught to examine the dominant paradigm looking at the privileges of the white, upper class, or male. Based on our research, students are not presented with content teaching them how to examine the dominant paradigm of thin, physically attractive people even when the research is clear that they often make more money, have fewer barriers to success, encounter less discrimination, and are more widely accepted in society. We are taught to examine our biases about race, ethnicity, gender, sexuality, religion, and class but never are appearance or size mentioned in any class. We are not taught to practice sensitively in a clinical setting to people struggling with weight issues.
The research for this project aims to explore the attitudes and beliefs of future social workers, examine biases and experiences of social work students currently practicing.
Implications for research in this area could include education by social work faculty about sizeism. Other implications could be simply creating awareness with future social workers about the importance of this issue. 49
Conceptual Framework
Psychodynamic Perspective: Transference and Countertransference,Social Learning
Theory and The Feminist Perspective
Psychodynamic Perspective: Transference and Countertransference
Sigmund Freud is the father of the psychodynamic perspective. Although many of his theories are completely outdated and disregarded, some are still used by other perspectives like clinical psychology. However, the roots of psychodynamic perspective have formed the basis of many theories that have spurred further research and theorists; It is, in essence, the grandfather of many of modem social works theories, whether in imitation or opposition. Psychoanalytic perspective still remains one of the best known theories by the public and is still commonly taught in foundational psychology academics. Psychodynamic perspectives use an individualist perspective, with little focus on social change (Payne, 2005). Today social work takes many psychodynamic theories and overlays an ecological perspective to better fit with social work values.
The term psychodynamic refers to the assumption that all behaviors and thoughts come from movements in people's mind (Payne, 2005). The theory examines behavior to be used as an indicator that minds are working. Without a foundation of psychodynamic perspectives, cognitive behavioral therapy would be lost. Sigmund Freud and psychodynamics greatly emphasize the role of the unconscious mind, where thinking and motivation are often not directly known to ourselves. This assumption underlies many of the concepts of psychodynamics including defense mechanisms, anxiety, ambivalence, personality, relationship issues, and transference and countertransference. Freud first 50 identified transference when working with clients who he noticed were unconsciously transferring the feelings and attitudes they had toward early significant figures in their - lives onto him (Freud, 1909). The theory has been expanded by psychoanalysts since
Freud and it has been concluded that transference from therapist to clients is also possible
(Payne). Social work theory has broadened the idea even further stating it is simply the
"effect of past experience on present behavior patterns, reflected in the client's behavior in relation with the worker (Payne, p. 74)." Where Freud blamed the client's parental relationships on transference, modern social work theory states that experiences and emotions of any past relationship can affect current behavior and relationships, not solely the therapeutic relationship (Payne). When the worker is aware of the possibility of transference, she is able to find ways to work with the client to overcome past issues that are creating difficulty in the present. This concept is also important for social workers to understand as a client may be reacting negatively to the worker, which can cause a barrier in the relationship and in treatment. Once a worker is aware of this issue (and does not take it personally) they can ask appropriate questions and treatment can move forward instead of being stagnant in a tense relationship. Workers must also be aware of their own personal biases and assumptions and not place them on the client. As humans, workers own past issues, relationships, or past clients can affect judgments made about a client in the present. This is a real and important issue for all therapists to be aware of.
In the literature review research on transference and countertransference among clients and workers with weight issues is examined. A therapist may place biases and assumptions about weight issues onto a client. A therapist may feel that if a client is 51 overweight this is a barrier to treatment, a health issue, a motivation issue, or a self- esteem issue. This may or may not be the case with that client. A therapist who is struggling with her own issues may find it challenging to work with a client who is either underweight or overweight and transfer her own struggles onto the client. The issue of transference and countertransference is addressed in the social work diversity class where students are exposed to many different populations and groups of people to become educated and check their own biases.
Social Learning Theory
Social learning theory has its origins with the behaviorists such as Pavlov,
Watson, and Skinner, but was first described in its essence by Albert Bandura in 1977
(Lahey, 1998). Bandura broke with the traditional behaviorists by asserting that people play an active role in determining their own actions rather than being a passive recipient of the environment (Lahey). Social learning assumes that people learn by observing others' behaviors as well as the outcomes and consequences of those behaviors. The person forms thoughts about the behavior, and often repeats the behavior if the consequences were perceived as beneficial (Payne, 2005). Often children and adolescents view the world and its models to see what behavior is acceptable and desirable and often internalize it to create their own behaviors and identity. Bandura also described self- regulation as the act of cognitively reinforcing and punishing our own behavior, depending on whether it meets our personal standards (Lahey).
The writers believe social learning theory is at work when the media and socially constructed ideal body size affect how people think and behave about body size. A 52 person may observe a role model on television talking about a diet or a doctor talking about BMI and feel that she should diet. A young girl may be exposed to only images of thin or underweight women through media and internalize that this is the only socially acceptable body size to have.
In the literature review the writers address how professionals (teachers, doctors, mental health workers, managers) often treat people who are overweight worse than people who are underweight. People will internalize this behavior by feeling shame for how they perceive themselves and then passing on the behavior by shaming others.
Society reinforces the socially constructed idea of ideal body weight and socially shames those who do not fit into the ideal.
The Feminist Social Work Perspective
The Feminist perspectives in social work seek to explain and respond to the subjugated position of women in most cultures. Much of social work is done with women, by women, and most people who experience issues surrounding body size and body image are women (Payne, 2005).
In feminist social work, four main areas affect therapeutic approaches on women's well being and health (Payne, 2005). According to Orme (2002), these areas include:
1. Women's conditions (women share their experiences of oppression and prejudice in
their lives);
2. Women-centered practice (identifying women's particular needs and responding to
those needs); 53
3. Women's different voice (women experience the world in a different way and have
contrary views from men, particularly involving social and moral concerns); and
4. Working with diversity (under the umbrella of the shared experience of oppression,
women can able to identify, value and respond to social diversity)
Feminist social work links personal and local predicaments with public issues (Dominelli,
2002; Van Den Bergh & Cooper, 1986).
Feminists seek to understand the lives and experiences of women from their own perspectives and values. This perspective is different from men's, as women's history of subjugation and oppression cannot be denied. Feminism avoids being looked at from the point of view of men, but "addresses the future of the planet with implications accruing for males as well as females, for all ethnic groups, for the impoverished, the disadvantaged, the handicapped, the aged, and so on" (Van Den Bergh & Cooper, 1986, p. 2). The current Western beauty standard reflects the point of view of men.
Synonymous with ineptitude, passivity, weakness, laziness, unattractiveness, no willpower, no determination, and sloppiness,fat is a word too often recoiled from for fear that a lack of control where food and life is concerned is contagious. A woman's body is prone to fat storage from birth. Girls have and store more fat than boys naturally, due to hormones. In fact, at puberty, there is an increase in fat tissue on a woman's body, while men increase in muscle mass (O'Sullivan, 2008). This increase is vital to menstruation and eventually childbearing. Fat storage is augmented with each pregnancy (O'Sullivan).
However,fat is still considered a crude word in the United States. In a sense, society is 54 telling women to deny and tame their biology by working to attain the beauty ideal and this is causing more problems than satisfaction.
Feminist theory focuses on a change in language, to renew value in words. A validity comes in this renaming, a sense of owning the word and changing the word's meaning: How one names oneself is highly related to one's identity and sense of self
(Van Den Bergh & Cooper, 1986). The wordfat has been owned by a small group of overweight and obese women. They have begun a Fat Awareness (FA) movement, to change the connotation of the word, empower themselves, and proudly name themselves as fat. Empowerment, or claiming personal power, is a political act because it allows people to have control over their lives and the ability to make decisions for themselves
(Van Den Bergh & Cooper). Communities exist on the internet called fatshionista instead of fashionista, to point plus-sized and average-sized women to clothing stores that would best suit different body types. There are many politically active advocates, including Kate
Harding at Shapely Prose, Joy Nash at the Fat Rant, and Sandy Szwarc at Junkfood
Science, that regularly blog about the myths of obesity and dieting. Feminist social work focuses on consciousness raising as a strategy for stimulating awareness (Payne, 2005).
These women are systematically breaking down the myths and stereotypes surrounding the hatred and discrimination of fat people. These women, and their followers, proudly call themselves fatties, owning their personal experience. The word fat has no power over them, because they have accepted it as a positive identity.
This is not to say that the overwhelming numbers of obese in our country should be ignored. With obesity on its way to overtaking cigarette smoking as the United States 55 major cause of preventable death, there should be cause for alarm (Stein, 2004).
However, the hatred, disgust, and discrimination people who experience obesity or being overweight are receiving from Western society is not acceptable. A first step in regaining power and fighting back against discrimination is to revalidate those words that once had power to condemn.
Individual experiences in the world can be related to systems that are already in place and outcomes of adjusting to those systems. As modern media places high value in a particular body type, and considers others less attractive, that devalues or denormalizes other body types. Feminist theory states that it is up to the person to challenge that power
(Payne, 2005; Van den Bergh & Cooper, 1986). The dynamics of existing practices, policies, and programs that create a sense of powerlessness must be confronted as part of feminist theory.
Susie Orbach (1983), author of Fat is a FeministIssue and a psychotherapist, explains why women are unhappy with their bodies more now than ever before:
"I mean, if voluptuousness was in, this would constitute the same kind of
problem. It's the fact that only one body image is legitimated for women and we
don't see pictures of ourselves in the media, on television, in magazines. We see
images of manicured, preadolescent bodies made up to look like adults. And,
there is nobody to identify in that, it is impossible for almost any woman to see
herself in the pages of a magazine" (Gilday, 1990).
The beauty standard in the United States is the one modeling agencies use: The
Association of Model Agents (AMA) says that female models should have measurements 56 of 34-24-34 inches, a nice long neck, short waist to emphasize long legs, full breasts, symmetrical facial features (including a straight nose, large eyes, and full lips), flawless skin, stand 5'8" tall to 6'0" tall, and weigh under 120 pounds. According to the U.S.
Department of Health and Human Services, the average U.S. woman is 5' 3.7" tall and weighs 152 pounds (2004). She wears a size 12/14, nearly double that of a woman representing the beauty ideal. This beauty ideal is highly unusual, considered rare, grueling, and requires so much airbrushing and preparation work that it is considered to be an illusion. Unfortunately, the illusion associated with the beauty ideal is considered normal. In the documentary film, "The Famine Within" the viewer learns from the head of a modeling agency that out of the 40,000 women who sent in pictures for a job, only four came close enough to the strict, unreasonable standards of beauty required to become a model, and the uselessness of this quest for perfection is hit home (Gilday,
1990).
Regardless of the pointlessness of striving for this image of perfection, one in four college-aged women in the United States are experiencing body image issues or suffering from some form of disordered eating, and some are literally dying to live up to this standard (Anstine & Greinenko, 2000). Eating disorders have gained publicity since the early 1980s (Hesse-Biber, 1996; Brumberg, 1997). Dieting became a "fashionable game" in the 1920s, a preoccupation in the 1960s, and a veritable epidemic in the 1980s
(Brumberg, p. 119). The 1980s marked the first time women were truly more independent. Women were freer to operate in a world outside the home, even expected to have a career. But, with this freedom came the pressure to~conform to a certain look. The 57 cult of the body became, in itself, a new form of oppression. Women receive equal. opportunity, as long as she looks a certain way. Catherine Steiner-Adair, a therapist interviewed in "The Famine Within" reports, "Well, I think it's a brilliant political form of oppression. It think that it is totally not coincidental, that at exactly the same time women are being told they have equal rights and equal access to all professions and all careers that there is a hidden clause that says you have an equal opportunity as long as you have a body size that very few women have and can maintain" (Gilday, 1990).
Postmodern feminism (Healy, 2000; Van Den Bergh & Cooper, 1986) attacks this form of oppression. Postmodern feminism places value in diversity and a woman's individual choice, focusing on the social and cultural factors that create discourses that affect how people behave (Payne, 2005). Social workers may find themselves concerned for a client based on their weight, but, if informed by postmodern feminist theory, cannot look only at the health aspects of this weight issue. The client's emotional needs may be met by eating, and the woman may need to be taught other coping skills to process their emotions. The individual may be overweight as a result of poverty, which may lead the person to eat food with poor nutrition value that may have a cheaper price tag at the store or restaurant. The social worker must be aware of the woman's role in their family and life.
The role of the typical woman in the United States is twofold. She is expected to be career driven, ambitious, controlled, and independent. At the same time, women biologically carry the role of the mother, whose characteristics are on the opposite spectrum, including nurturing, protective, empathic, and caring. No one could argue that 58 these expectations are demanding, as well as confusing. Is it possible for one woman to manage both of these roles? While many women can balance career and parenting, this may lend itself to the confusion of the beauty ideal. Feminist theory also seeks to eliminate the false dichotomy presented here-that a woman cannot effectively be both
(Van Den Bergh & Cooper, 1986).
Instead of blaming the individual for their failure to maintain the proper or normal body type, what is "normal" as a body size in Western society must be questioned. The body itself becomes deeply politicized: In modern social work and feminism, that which is personal becomes political (Payne, 2005; Van Den Bergh & Cooper, 1986). An individual's values, beliefs, goals, dreams, and choices she chooses to make or pursue can be considered a political statement.
Assumptions
This study is premised on the need to investigate that weight and body size issues are important for social work students to become aware of and educated about. The authors assume that many social work students have experience working with clients who have weight issues, body image issues, and/or eating disorders, yet are not educated about working with these clients. The authors assume that social work students may have unchecked biases about people dealing with weight issues, as well as their own personal weight issues that could affect transference or countertransference in clinical settings.
Drawing on the literature review, four assumptions are especially salient.
First, transference and countertransference may occur in the therapeutic relationship with regards to weight and body size differences between the therapist and 59 the client. For example, an overweight client may feel that a normal or underweight therapist will not understand her issues. Likewise, an underweight client may feel that a normal weight or overweight therapist could not be of any help dealing with her struggle with anorexia. On the other hand, with regards to countertransference a therapist may place biases and assumptions about weight issues onto a client. A therapist may feel that a client being overweight could be a barrier to treatment, a health issue, a motivation issue, or a self-esteem issue. This may or may not be the case with that client. A therapist who is struggling with her own issues may find it challenging to work with a client who is either underweight or over weight and transfer her own struggles onto the client.
Second, the issue of transference and countertransference is addressed in the social work diversity class where students are exposed to many different populations and groups of people to become educated and check their own biases. A lack of discussion and education around the issue of body size, weight, or body image leaves social work students with unchecked biases, a lack of education, and at a general disadvantage when working with clients dealing with these issues.
Third, the media, society-at-large, parents, doctors, teachers, and mental health workers often can affect how people feel about their body and weight. These factors all influence a person's self-regulation when thinking or acting on weight related issues. A person may observe a role model on television talking about a diet, or a doctor talking about BMI and feel that she should diet. A young girl may only be exposed to images of thin or underweight women through media and internalize that this is the only socially acceptable body size to have. The writers assume that this is a social work issue. We 60 assume that it is vital for social work students and practicing social workers to have the training and knowledge about working with clients regarding this issue. We assume that social work students may have unchecked biases regarding personal issues/beliefs about body size. We assume that media has a large role on the social construction of body image, and we believe that the social construction of body image greatly affects the quality of life of millions of women.
Research Questions
1. Do social work students have awareness about body size and body image issues?
2. What are social work students' attitudes about people with body size and/or body
image issues?
a. Do social workers have personal body image issues?
b. Do social workers have biases towards body size and weight?
c. Does social workers' biases towards body size and weight or own body image
issues affect their work with clients?
3. Is body size/body image an important social work issues? 61
Chapter 3
METHODOLOGY
Purpose of the Study
The purpose of this research study is to explore Sacramento State MSW student's attitudes on body size and body image as pertaining to working with clients in a professional social work setting. MSWs are trained to be aware of transference and countertransference issues as it pertains to race, ethnicity, gender, sexuality, disability, and other elements of diversity. However, there is little or no emphasis placed on transference or countertransference issues surrounding one's body size and the way one feels about their body. Because it is difficult to measure countertransference, our study seeks to examine attitudes, awareness, and experiences of MSWs.
Research Design
The design of the study is a quantitative, exploratory study using a web-based survey to collect data on student's attitudes. The survey asked social work students questions regarding general attitudes and awareness concerning body size and body image. Specifically the questions address attitudes, awareness and experiences in practice settings, as well as personal weight and body image issues.
Instrumentation
Researchers reviewed surveys including Rupp's survey measuring attitudes of clients towards social workers with disabilities (2004), Crandall's "Antifat Attitudes
Questionnaire (1994)" and Allison, Basile, & Yuker's ","Attitudes Towards Obese
Persons Scale (1991)", and "Belief About Obese Persons Scale (1991). While the 62 researchers did not directly use any of the questions in these surveys they were used as guidelines for the instrument development and design. The survey includes a total of 28 questions; five demographic questions and 23 questions referring to the social workers' experience, attitudes, and beliefs about working with clients who have weight or body image issues as well as their own personal weight and body image issues. Twenty questions were five-part Likert scale with differing levels of frequency or agreement, three questions were yes or no questions (Appendix A).
Sample
This web-based study intended to explore the attitudes, awareness, and experience of Masters' level social work (MSW) students on body size and body image issues.
Approximately 250 social work students currently in practice classes at California State
University, Sacramento had the opportunity to participate. These participants included first year MSW students (MSWI), second year MSW students (MSWII), advanced standing MSWs, and three-year students. The authors' goal was to include graduate level social work students who are enrolled in SWK204ABCD because these students may be working with clients at this time, and many will also be working in clinical practice.
Description of the Sample
Approximately 250 social work students currently in practice classes at California
State University, Sacramento had the opportunity to participate. After visiting the practice classrooms, 168 email addresses of students interested in participating in the study were collected. Each of these individuals was emailed a link to connect to the survey on Survey Monkey. Approximately 15 emails were returned to the researchers as 63 undeliverable, either because the email address written was illegible or because the email address did not exist. One hundred fifteen (68%) individuals responded and agreed to participate in the survey. Forty-four respondents (38%) were first year Masters in Social
Work students. Seventy-one respondents (61%) were second year Masters in Social Work students. Ninety-eight (86%) of the respondents were female, 15 (13.2%) were male, one
(0.9%) identified as gender queer, and one person did not respond. Ninety-seven respondents (84%) graduated with an undergraduate degree in something related to helping fields, including but not limited to child development, education, social work, physical therapy, counseling, or psychology.
Inclusion/Exclusion
The study included only master level social work students from California State
University, Sacramento, Division of Social Work.
Procedures
Recruitment
The authors-contacted practice professors via email requesting permission to make a presentation in their classes during the Fall 2008 semester. The authors hoped that making a brief appearance in the practice classrooms would encourage students to participate in the web-based study.
Students were told that informed consent (Appendix A) would be included on web-based survey. E-mails of willing participants were collected on a sign up sheet.
Participation in the study was voluntary. If the student chose to participate, he or she added their e-mail address to the sign up sheet for the authors to include them in the 64 e-mail distribution list through Survey Monkey. The informed consent on the web-based survey and brief presentation in the practice classes included information about the risk involved in taking the questionnaire.
Data Collection
Once the email addresses were acquired, the authors e-mailed participants a link to the online questionnaire. The participants chose to anonymously click on the link from their personal email and participate in the study without their personal information being recorded or traced. Authors had no way of knowing who chose not to participate once this initial e-mail has been sent, only who chose to take the first step of participation by signing the informed consent.
Once e-mails were sent, participants had another opportunity to choose not to participate by not clicking the link to the study. If participants chose to link to the study, they were reminded that the study is optional and voluntary. The student was not able to participate in taking the questionnaire without consenting to participate in the study online.
Participants were not asked to provide any identifying information besides demographic data (age, race/ethnicity, gender). Only the authors had access to the data through a usemame and password.
After the first batch of emails were sent to those students who signed up to participate, the researchers kept the web-based survey open for several weeks. After five weeks, a second email was sent out to remind the participants about the survey and ask 65 them to take it if they had not yet participated. The survey was available online for a total of eight weeks.
After the reminder emails were sent, the researchers downloaded the survey responses and the responses were erased from the Survey Monkey database.
Protectionof Human Subjects
The Human Subjects Application was submitted and approved by the Research
Committee of the Division of Social Work before the writers contacted any of the professors to collect email addresses for surveys. The application submitted detailed the purpose of the study, study design, and procedures for data collection. The application also contained information regarding the collection of informed consent from participants. The researchers explained how the privacy and safety of the participants would be protected. A copy of a draft of the questionnaire was included with the application. The application included the level of risk posed to participants, as assessed by the researchers as minimal risk.
The study was determined by the Committee to pose no risk to participants. "The probability and magnitude of harm or discomfort anticipated for participants [while taking the authors' questionnaire is] no greater than what might be encountered in daily life or during the performance of routine physical or psychological examinations or tests," particularly as an MSW student (Policies and Procedure, July 2008).
Informed consent was obtained electronically by the participant reading the details and clicking the "I agree" button before she or he would be allowed to proceed with the rest of the questionnaire. The Consent to Participate as a Research Subject 66 document explained the purpose of the study and detailed the procedures used for the study. Participants were informed that their participation was voluntary, that they may stop taking the survey at any time, and that they may choose to opt out of answering any questions they would prefer not to answer. The informed consent included language that let the participant know that their identity would be kept anonymous and confidential to the degree permitted by the technology used. Because the data were collected using an electronic medium, no absolute guarantees could be given for the confidentiality of the electronic data. Also, once the data were submitted, there was no way to withdraw the response. Participants consented to participating without compensation.
Data Analysis
The authors analyzed the data using SPSS v. 16. Pearson correlations and cross tabs. Frequencies were run for descriptive statistics.
Delimitations
The delimitations of this study include the decision to use only Masters in Social
Work students at California State University, Sacramento. The authors chose to explore this group because we had access to this population. This was somewhat of a convenience factor-we could easily go to classrooms and meet with practice professors if needed. Our peers were our subjects, which it made it more likely that they would respond to our survey. A Masters degree is a professional, often pre-licensure degree, where students will most often be entering that field after graduation. Bachelor's students were excluded based on this premise. Neither researcher had access to a fair sample of practicing social workers in a clinical setting. The researchers were most interested in the 67 awareness students have before they enter the field. Many of our questions directly relate to education and diversity education. The exploration of the awareness and attitudes of students about to enter the field was our objective. The researchers contacted practice professors because every MSW student is required to take a practice class every semester of their program. By choosing only practice professors, we limited our options for professors who would be willing to accept our request to come to class, thus limiting our sample size. Our questionnaire was a web-based survey, which gave students a chance to take the survey in the privacy of their own home or the environment of their choosing.
This may also have decreased the social desirability factor to their answers. However, this may have also limited our sample size, by giving the respondent the freedom to click on a link to participate, instead of turn in a paper survey in a class setting. The researchers did not choose a well-established instrument, instead creating their own. The validity of the instrument is unknown. The questionnaire itself explored attitudes, awareness, and personal experience with people experiencing body size and body image issues. There was not an instrument in existence that met the researchers' needs. There were several instruments that informed the survey; three were statistically valid instruments.
Limitations
The limitations of the research include limited access to two practice classes. One professor did not allow the researchers to come to class, and one professor let the class out before the researchers arrived. This limited our sample size. When the researchers went to classes, some of the email addresses that students shared were not legible or were 68 incorrect. This limited the sample size. Students could choose two times whether or not they wanted to take the survey, which could play a role in a limited sample size. Students may have answered questions in a socially desirable way. Two students agreed to participate, agreed to the informed consent, and only answered a few questions on the survey. The MSW program at California State University, Sacramento is predominantly composed of women in their 20s. This limits the research: It may not generalize to the entire social work population. More MSW II students participated in the web-based survey. Social work students have not worked in the field of social work as long as a professional social worker. Their views may be more progressive, idealistic, or less experience-based or informed. The researchers do not have any control over the experience level of any social work students who participated and have no way of knowing their experience level. The authors use words such as "obese", "overweight", and "body image" in the survey, which may be interpreted differently by the participants.
This may have affected the answers given by participants. 69
Chapter 4
RESULTS AND DISCUSSION
This study explored attitudes, beliefs, and experiences relating to body size and body image of Masters level social work students (MSW) at California State University,
Sacramento. The term participantsrefers to all levels of Masters in social work students who participated in the survey. MSWI refers to first year graduate social work students.
MSWII refers to an advanced standing one year Masters student, a second year Masters student, or a student in the three year Masters in social work part-time program. When percentages are given for a particular group they refer to the percentage within that population, not the entire number of participants in the survey. Not all participants answered every question, which will affect the totals and percentages of some results.
As defined in Chapter 1, body size refers to the size of one's body, as a person and other people may perceive it-specifically, for the sake of this project, related to body mass and weight, as opposed to height. Body image is defined as the picture that the person has of the physical appearance of his/her own body (Traub & Orbach, 1964). It can also be defined as "the subjective concept of one's physical appearance based on self- observation and the reactions of others" (American Heritage Dictionary, 2006).
Since this was an exploratory study the authors' data that follows will reflect descriptive statistics including gender, race/ethnicity, and class level in MSW program.
Descriptive statistics are utilized to illustrate the demographic characteristics of this study's sample. 70
Results
Demographic Characteristicsof the Sample
An introductory description of the sample was provided in Chapter III. Here, the sample is described in more detail. One hundred fifteen (N=1 15) students responded and agreed to participate in the study. Forty-four (38%) were MSWI students and 71 (61%) were MSWII students.
Ninety-eight (86%) of respondents were female and 15 (13.2%) were male. One participant (0.9%) identified as gender queer. One did not respond to the gender question.
Sixty-four (55.7%) participants reported they were Caucasian/White, 13 (11.3%) African
American, 17 (14.8%) Hispanic, 15 (13%) Asian, and three (2.6%) participants reported they were Multi-Ethnic/Mixed Race.
The minimum age of study participants was 22 years old. The maximum age was
61 years old. The mean age was 32.2 years old.
Ninety-seven (84%) of the study participants had an undergraduate degree in a related helping fields, including but not limited to child development, education, social work, physical therapy, counseling, or psychology.
Descriptive Statistics
Social Work Experience with Overweight Clients or Clients with Body Size Issues
Of the 115 study participants, 75 (66.4%) reported they had worked with a client who experienced weight or body size issues. Twenty-eight (63.6%) MSWI students and
47 (66.2%) MSWII students said they have worked with a client who experienced weight issues or body size issues. Twenty-eight (24.8%) participants of the overall sample 71 reported not having worked with a client who is experiencing weight or body size issues.
Only ten students (8.8%) said they were not sure if they had worked with a client who was experiencing weight or body size issues.
Body Image Issues and Eating Disorders
Sixty-three (55.8%) study participants reported they had worked with a client who experienced body image issues or eating disorders. Twenty-five (56.8%) MSWI and 38
(49.4%) MSWII students reported having worked with a client who experienced body image or eating disorders. Thirty-five (31%) said they had not had this experience, while
15 (13.3%) did not know if they have worked with a client who has experienced body image issues or eating disorders.
Confidence Working with Obese Clients
Of the 115 study participants, 91 (81%) reported they were either very confident
(n=23) or confident (n=68) working with an obese client. Thirty-four (77.3%) MSWI students and 57 (74.0%) MSWII students reported they were very confident or confident working with obese clients. Nine (8.0%) participants did not know how confident they would feel working with an obese client. Eleven (9.8%) study participants felt minimally confident, and only one (0.9%) felt not at all confident.
Of the male participants, 14 (82.4%) said they felt very confident or confident working with obese clients. Seventy seven (78.6%) females reported they felt very confident or confident working with obese clients. Fifty (78.1%) White participants, 12
(92.3%) African American, 16 (94.1%) Hispanic, 11 (73.3%) Asian, and one (33.3%) 72 multi-racial MSW student reported that they felt very confident or confident working with an obese client.
Needfor Social Work Students to Become Educatedabout Body Size Issues
Fifty-three (46.9%) participants said they strongly agreedthat similar to culture, gender, and sexuality, social workers need to become educated about body size diversity and/or question their biases towards body size diversity.
Fifty-eight (90.6%) White, 13 (100%) African American, 16 (94.1%) Hispanic, and 14 (93.3%) Asian participants strongly agreedor agreedthat social workers need to become educated about and/or question their biases towards body size diversity.
Awareness of Client's Body Size
Sixty two (54.9%) participants reported being somewhat aware of a client's body size when they meet the client. Thirty-eight (33.6%) participants reported being very aware of a client's body size when they first meet the client. Thirty-one (31.6%) female participants reported being very aware of a client's body size when they first meet a client, and 55 (56.1%) female participants say they are somewhat aware of a client's body size. Of the male participants, seven (41.2%) said they are very aware of a client's body size while seven (41.2%) are somewhat aware of a client's body size. Female participants are very aware or somewhat aware of a client's body size 87.7% of the time, and male participants are very aware or somewhat aware of a client's body size 82.4% of the time. 73
The Role of Body Size in a Social Work Student's InitialAssessment
Forty-six (40.7%) participants said they would sometimes factor body size into an assessment. Thirty-six (31.9%) participants said they would seldom factor body size into an assessment of a client. Fourteen (12.7%) participants said body size would usually play a role in their assessment of a client. Ten (8.8%) participants said they would never factor body size into their initial assessment of a client. Only seven (6.2%) participants said that a client's body size would always play a role in their initial assessment of a client.
Body Size as a Factor in Treatment Plan/Goals
Forty-three (3 8.4%) study participants agreedthat similar to race, ethnicity, and gender, a client's body size should be a factor of consideration when forming a treatment plan and/or goals for the client. Forty two (37.5%) did not know if body size should be factored into a treatment plan or goals for the client. Only nine (8.0%) participants strongly agreedthat similar to race, ethnicity, and gender, a client's body size should be a factor of consideration when forming a treatment plan and/or goals for the client.
Thirty-four (53.2%) White participants, six (46.2%) African American participants, and four (23.6%) Hispanic participants strongly agreedor agreedthat body size should be a factor of consideration for treatment plan or goals. Seven (46.7%) Asian participants agreed and none strongly agreedthat body size should be a factor of consideration. No multi-ethnic participants strongly agreed or agreedthat body size should be a factor of consideration. 74
Weight Affecting a Client s Motivation in Counseling/Case Management
Seventy-two (64.9%) participants report that sometimes they felt that a client's weight could affect ability or motivation to participate fully in counseling. Sixteen
(14.4%) said it usually affects a client's ability to participate in counseling. Thirteen
(11.7%) participants said weight seldom affected a client's ability or motivation to participate in counseling. Seven (6.3%) said it never affected their ability or motivation to participate in counseling. Only three (2.7%) participants said that a client's weight could always affect their ability and/or motivation to participate fully in counseling and/or case management.
Competence Working with Clients who Have Body Image Issues
Only two (1.8%) participants said they felt very competent working with a client dealing with body image issues, while 49 (44.5%) participants said they felt competent.
Twenty-four (54.5%) MSWI students and 27 (38.0%) MSWII students reported they felt very competent or competent working with a client dealing with body image issues.
Forty-two (38.2%) participants said they felt somewhat competent working with a client who is dealing with body image issues. Eleven (64.7%) male participants reported they felt very competent or competent working with a client who is dealing with body image issues, while forty (40.8%) female participants reported they feel very competent or competent working with these clients. Thirty-one (48.4%) White participants, five
(38.5%) African American participants, eight (47.1%) Hispanic participants, five (33.3%)
Asian participants, and one (33.3%) multi-racial participant reported they felt very competent or competent working with a client who is dealing with body image issues. 75
Comfort of Student Bringing Up Client's Weight in Session
Over a quarter (26.6%) participants said they would feel very comfortable or comfortable discussing a client's body size in a session even if the client had not brought the issue up, while 44.3% said they would feel uncomfortable or very uncomfortable bringing up a clients weight or body size before the client did. However, if a client did bring up their weight issues in a session 64% participants (71 students total) answered they would feel very comfortable or comfortable addressing those issues.
Twelve (18.7%) White participants said they would feel comfortable discussing a client's body size in a session even if the client had not brought the issue up in a session.
Five (38.5%) African American participants felt comfortable. Seven (41.2%) Hispanic participants reported they felt very comfortable or comfortable. Five (33.3%) Asian participants felt comfortable. No multi-racial participants felt very comfortable or comfortable bringing up the issue first.
Comfort Working with a Client who Has a Different Body Size Than Their Own
Sixteen (14.3%) participants reported they felt very comfortable and 58 (51.8%) participants reported they felt comfortable working with a client on weight issues if their own body size did not match the client's body size. Thirty-one (27.7%) participants reported they felt adequate, seven (6.3%) participants reported they felt uncomfortable, and no participants reported they felt very uncomfortable working with a client whose body size did not match their own. 76
Race/Ethnicity/Culture's Effect on Positive Body Image
Forty-five (40.5%) participants felt that a client's culture/ethnicity/race very much affects their level of positive body image, while 49 (44%) felt it somewhat affects their positive body image, which brings the total to 84.6% participants believing that ethnicity has an effect on positive body image. Fifty-two (81.3%) White participants, 12 (92.3%)
African American participants, 12 (70.6%) Hispanic participants, 13 (86.7%) Asian participants, and three (100%) multi-racial participants feel culture/ethnicity/race very much or somewhat affects a client's level of positive body image.
Media Affect on Construction ofAcceptable Body Size
One hundred and seven (95.5%) participants feel that the media plays a large role in the construction of acceptable body size a great deal of the time.
Belief of Overweight People Being Just as Healthy as Non-overweight People
Only two (1.8%) participants strongly agreedthat overweight people are just as healthy as non-overweight people, while 25 (22.9%) agreed, and 33 (30.3%) did not know if overweight people were just as healthy as non-overweight people. Forty-one participants (3 7.6%) disagreedthat overweight people are just as healthy as non- overweight people and eight (7.3%) strongly disagreed that overweight people are just as healthy as non-overweight people. Twenty-nine (45.3%) White participants, three
(23.1%) African American participants, six (35.3%) Hispanic participants, seven (46.7%)
Asian participants, two (66.7%) multi-racial participants strongly disagreed or disagreed that overweight people are just as healthy as non-overweight people. The only two 77 participants who reported they strongly agreed that overweight people are just as healthy as non-overweight people were African American.
Belief of Overweight People Being Just as Happy or Self-confident as Non-overweight
People
Forty-six (41.4%) participants strongly agreed or agreedthat overweight people are just as happy as non-overweight people. Forty-nine (44.1%) participants did not know, and 16 (14.4%) participants disagreed or strongly disagreedthat overweight people are just as happy as non-overweight people. Forty-three (38.7%) participants strongly agreedor agreedthat overweight people are just as self-confident as non- overweight people. Forty-one (36.9%) participants don't know, and 27 (24.3%) participants disagree or strongly disagree that overweight people are just as self- confident as non-overweight people.
Belief that Body Size/Body Image Are Important Social Work Issues
Thirty-one (27.4%) participants strongly agreed and 60 (53.1 %) agreed that body size and body image are important social work issues. Thirty-five (79.5%) MSWl and 56
(78.9%) MSWII strongly agreed or agreedthat body size and body image are important social work issues. Twelve (70.6%) male participants and 79 (80.6%) female participants strongly agreedor agreed that body size and body image are important social work issues. Eighteen (15.9%) participants did not know if body size and body image were important social work issues, while four (3.5%) disagreedand no (0%) participants strongly disagreedthat body size and body image are important social work issues. Fifty- five (85.9%) White participants, nine (69.2%) African-American participants, 13 (76.5%) 78
Hispanic participants, ten (66.7%) Asian participants, and two (66.7%) multi-racial
participants strongly agreed or agreedthat body size and body image are important social
work issues.
Frequency of Body Size/Weight/Body Image Subjects Discussion in Class
Twenty-five (22.1%) participants said the subject of weight and/ or body size
and/or body image is never discussed in MSW classes, while 65 (56.6%) participants said
weight or body size or body image topics are seldom discussed in MSW classes. Twenty-
one (18.6%) participants said these topics were sometimes discussed, while two (1.8%)
said it was occasionally discussed, and one (0.9%) said it was frequently discussed in
MSW classes. Fifty-six (78.9%) MSWII students said the topic were seldom or never
discussed in classes, while 14 (19.7%) MSWII students said the topics were frequently,
occasionally or sometimes discussed in MSW classes. Thirty-three (75%) MSWI students
said the topics were seldom or never discussed, while ten (22.7%) MSWl students said
the topics were frequently, occasionally, or sometimes discussed in MSW classes.
Student's Personal Weight Issues
Nine (8.0%) participants considered themselves very overweight, 53 (46.9%)
participants considered themselves somewhat overweight, 47 (41.6%) participants
considered themselves normal weight, four (3.5%) participants considered themselves
somewhat underweight, and no (0%) participants considered themselves very
underweight. Seven male (41.2%) participants and 55 (56.1%) female participants reported they were very overweight or somewhat overweight. Seven (41.2%) male
participants and 40 (40.8%) female participants reported they were normal weight. 79
Thirty-nine (60.9%) White participants, nine (69.2%) African American participants, and seven (41.2%) Hispanic participants reported they were very overweight or somewhat overweight. Six (40%) Asian participants and one (33.3%) multi-racial participants reported they were somewhat overweight.
Twenty-six (23.0%) participants reported that they struggle with their own weight a great deal and 60 (53.1%) participants reported they struggle with their own weight somewhat. That is a total of 76.1% participants who reported that they struggle with their own weight at all. Ten (58.8%) male participants and 76 (77.6%) female participants struggle with their weight a greatdeal or somewhat. Fifty (78.1%) White participants, ten
(76.9%) African American participants, ten (58.8%) Hispanic participants, 11 (73.3%)
Asian participants, and three (100%) multi-racial participants reported they struggle with their weight a great deal or somewhat.
Student's Experience with Dieting
Sixteen (14.2%) participants reported that they are always dieting or trying to lose weight. Forty (35.4%) participants reported they have dieted or tried to loose weight many times and 37 (32.7%) participants reported they have dieted or tried to loose weight afew times. Seven (6.2%) participants reported that they have only dieted or tried to loose weight once. Only 11.5% participants reported they have never dieted or tried to lose weight. Fourteen (82.4%) male participants and 88 (89.8%) female participants reported they have dieted at least once (once! afew times/ many times/ always) in their lifetime. An overwhelming 93.8% White participants, 84.6% African American 80 participants, 76.5% Hispanic participants, 80% Asian participants, 100% multi-racial participants have ever dieted.
Associations amongst Study Variables
Pearson correlation coefficients were conducted to test for relationships between this study's variables.
PersonalStruggles with Weight and Belief that Body Size and Body Image Are Important
Social Work Issues
Data showed a statistically significant positive correlation (r = 0. 196, p [2-tailed]
= 0.037) between students' personal struggles with weight and their belief that body size and body image are important social work issues. That is, those students reporting that they struggled with their own body size and body image issues also tended to report that body size and body image are important social work issues. Table 2 illustrates Pearson correlations between a student's personal struggles with weight and their belief that body size and body image are important social work issues.
Table 2
Pearson Correlationof Students' Own Struggle with Weight and their
Belief that Body Size And Body Image as Social Work Issues
Social Work Issue Struggle with Weight
Pearson Correlation 0.196*
Significance (2-tailed) 0.037
N 113
* Correlation is significant at the 0.05 level (2-tailed). 81
Identifying as Overweight and Positive Attitudes About Other Overweight People
Pearson correlation coefficients were conducted to test for relationships between students who identify as overweight or somewhat overweight and their belief that overweight people can be just as healthy, happy, self confident as non-overweight people.
These results are described next.
Identifying as overweight and the belief that overweight people can be just as healthy as non-overweight people. A correlation coefficient was conducted to test for an association between students who identify as overweight and somewhat overweight and those who agree that overweight people are just as healthy as non-overweight people.
This test yielded a statistically significant positive correlation (r = 0.240, p [2-tailed] =
0.012). Those students who identified as overweight and somewhat overweight also agreed that overweight people are just as healthy as non-overweight people.
Identifying as overweight and the belief that overweight people can be just as happy as non-weight people. A Pearson correlation coefficient was conducted to test for relationships between students who agree that overweight people are just as happy as non-overweight people and students who identify as overweight or somewhat overweight. This test yielded a statistically significant positive correlation (r = 0.232, p
[2-tailed] = 0.014). Students who identified as overweight or somewhat overweight also believed that overweight people are just as happy as non-overweight people.
Identifying as overweight and the belief that overweight people can be just as self- confident as non-weight people. A Pearson correlation coefficient was conducted to test for relationships between students who agree that overweight people are just as self- 82
confident as non-overweight people and students who identify as overweight or
somewhat overweight. This test yielded a statistically significant positive correlation (r =
0.23 1,p [2-tailed] = 0.015). Table 3 illustrates correlations between students who identify
as overweight or very overweight and their perceptions of a person's health, happiness,
and self-confidence based on that person's weight.
Table 3
Pearson Correlationof Students Who Identify as Overweight and Positive
Attitudes about Overweight People
IDENTIFYING AS JUST AS JUST AS JUST AS SELF-
OVERWEIGHT HEALTHY HAPPY CONFIDENT
Pearson Correlation 0.240* 0.232* 0.231*
Sig. (2-tailed) 0.012 0.014 0.015
N 109 111 110
* Correlation is significant at the 0.05 level (2-tailed).
Identifying as Normal Weight or Somewhat Underweight and Positive Attitudes about
Overweight People
Pearson correlation coefficients were conducted to test for relationships between
students who identify as normal weight or somewhat underweight and their belief
overweight people can be just as healthy, happy, self confident as non-overweight people.
These results are described next.
Identifying as normal weight or somewhat underweight and the belief that
overweight people can be just as healthy as non-overweightpeople. A correlation 83
coefficient was conducted to test for an association between students who identify as
normal weight and somewhat underweight and those who agree that overweight people
are just as healthy as non-overweight people. This test yielded a statistically significant
negative correlation (r = -0.240,p [2-tailed] = 0.012). Students who identified as normal
weight or somewhat underweight did not believe that overweight people were just as
healthy as non-overweight people.
Identifying as normal weight or somewhat underweight and the belief that
overweight people can be just as happy as non-overweight people. A Pearson correlation coefficient was conducted to test for relationships between students who agree that
overweight people are just as happy as non-overweight people and students who identify
as normal weight and somewhat underweight. This test yielded a statistically significant
negative correlation (r = -0.232,p [2-tailed] = 0.014). Students who identified as being
normal weight or somewhat underweight also did not believe that overweight people
could be as happy as non-overweight people.
Identifying as normal weight or somewhat underweight and the belief that
overweight people can bejust as self-confident as non-overweight people. A Pearson
correlation coefficient was conducted to test for relationships between students who agree
that overweight people are just as self-confident as non-overweight people and students
who identify as normal weight and somewhat underweight. This test yielded a
statistically significant negative correlation (r = -0.231, p [2-tailed] = 0.015). Students
who identified as being normal weight or somewhat underweight also did not believe that
overweight people could be as happy as non-overweight people. Linear regression 84 yielded no statistically significant findings for these study variables (Personal Weight and health, happiness and self-confidence of non-overweight people). Table 4 illustrates correlations between students who identify as normal weight or underweight and their perceptions of a person's health, happiness, and self-confidence based on that person's weight.
Table 4
Students Who Identify as Normal Weight or Underweight and Positive Attitudes about Overweight People
IDENTIFYING AS JUST AS
NORMAL OR JUST AS JUST AS SELF-
UNDERWEIGHT HEALTHY HAPPY CONFIDENT
Pearson Correlation -0.240* -0.232* -0.231*
Sig. (2-tailed) 0.012 0.014 0.015
N 109 111 110
* Correlation is significant at the 0.05 level (2-tailed).
Identifying as Normal Weight or Underweight and Negative Attitudes about Overweight
People
Pearson correlation coefficients were conducted to test for relationships between students who identify as normal weight or somewhat underweight and their negative attitudes towards overweight people. A correlation coefficient was conducted to test for an association between students who identify as normal weight and somewhat underweight and students who disagree that overweight people are just as healthy as non- 85
overweight people. This test yielded a statistically significant positive correlation (r =
0.267,p [2-tailed] = 0.005).
Correlation coefficients were also performed to test relationships between normal
and underweight student and students who disagree that overweight people are just as
happy, as well as just as self-confident, as non-overweight people. Pearson r did not yield
a statistically significant correlation between either of these tests. Table 5 illustrates correlations between students who identify as normal weight or underweight and their
negative perceptions of a person's health, happiness, and self-confidence based on that
person's weight.
Table 5
Pearson Correlationof Students Who Identify as Normal Weight or Underweight
and Negative Attitudes about Overweight People
STUDENTS WHO NOT AS
IDENTIFY AS NORMAL NOT AS NOT AS SELF-
OR UNDERWEIGHT HEALTHY HAPPY CONFIDENT
Pearson Correlation 0.267** -0.003 0.018
Sig. (2-tailed) 0.005 0.973 0.852
N 110 111 110
** Correlation is significant at the 0.01 level (2-tailed).
Belief that Body Size And Body Image Are Important Social Work Issues and Experience
Two Pearson's r coefficients were conducted to test for possible relations between
students who believe that body size and body image issues are important social work 86 issues and students experience with clients with body size and body image issues. Both tests yielded statistically significant positive correlations, with correlation coefficients between experience with body size issues and belief that body size and body image as important social work issues significant at the 0.05 level (r = 0. 190, p [2-tailed] = 0.42) and experience with body image issues and eating disorders and belief that body size and body image as important social work issues significant at the 0.01 level (r = 0.25 1,p [2- tailed] = 0.007). Table 6 illustrates correlations between students who have had clients with body size issues and/or body image issues/eating disorders and belief that body size and body image are social work issues.
Table 6
Pearson Correlationfor Belief in Body Size And Body Image as Social Work
Issues and Experience
SOCIAL WORK ISSUE EXPERIENCE WITH
BODY SIZE ISSUES BODY IMAGE
ISSUES/ EATING
DISORDERS
Pearson Correlation 0. 190* 0.251**
Sig. (2-tailed) 0.042 0.007
N 114 114
* Correlation is significant at the 0.05 level (2-tailed).
** Correlation is significant at the 0.01 level (2-tailed). 87
Additional Findings
Pearson correlation coefficients were conducted to test for relationships between students' experience with people with body size and body image issues and eating disorders and their confidence level working with obese clients. This test did not yield a statistically significant finding.
Pearson r did not yield a statistically significant correlation between experience with clients with body image issues or eating disorders and confidence level working with obese clients. Table 7 presents Pearson's r for experience with body size issues and confidence level with obese persons and experience with body image issues or eating disorders and confidence level with obese persons.
Table 7
Pearson Correlationfor Student's Experience and Confidence Level
EXPERIENCE WITH
CONFIDENCE WITH EXPERIENCE WITH BODY BODY IMAGE OR
OBESE PEOPLE SIZE ISSUES EATING DISORDER
Pearson Correlation 0.164 0.049
Sig. (2-tailed) 0.080 0.600
N 115 115
A Pearson correlation coefficient was conducted to test for associations between students who have worked with clients with body size issues and students who have worked with clients with body image issues and eating disorders. This test yielded a statistically significant positive correlation at the .001 level (r = 0.584, p = 0.000). 88
A Pearson correlation was run and no significant correlation was found on the
participants who answered they believed that a client's weight always or usually affects
their ability and/or motivation to participate fully in counseling and/or case management
and participants who would feel confident working with an obese client.
Pearson correlations were run and no significant correlations were found with
participants who reported that the subject of weight/body size/body image issues were
seldom or never discussed in MSW courses and confidence working with obese clients,
belief in the need for education about these topics, competence working with a client who
is dealing with body image issues, comfort discussing a client's body size in a session if
the client did not bring it up, as well as measures of overweight individuals happiness, health, and self-confidence. Linear regression tests were run for the above mentioned
variables. These tests yielded no statistically significant findings.
Discussion
Research Question 1: Do Social Work Students Have Awareness About Body Size and
Body Image Issues?
An overwhelming majority (78.7%) of study participants indicated that the
subject of body size or body image is seldom or never discussed in Masters social work
classes. This finding may indicate a lack of awareness or knowledge amongst social work
students regarding the topic. Yet, an overwhelming percentage (93.8%) of participants
believe that, similar to culture, gender, and sexuality, social workers need to become
educated about body size diversity and/or question their own biases on this topic. This
would seem to indicate that, while many students believe this issue is important they are 89 not getting the necessary content in social work courses. Moreover, it's interesting to note that there was no statistically significant finding between MSW1 and MSWIIs as it relates to feelings of competence to work with clients with body image issues. Neither
MSWIs nor MSWIIs felt significantly competent.
When an MSW student first meets a client, 33.6% are very aware and 54.9% are somewhat aware of the client's body size. This indicates that social work students admit that they are aware of this issue and it may factor into their working relationship with the client on some level. However, there appeared to be no significant correlation with those students who reported that they were aware of a client's body size and those that agreed that body size would play a role in their initial assessment. This may indicate that while the student is aware of the client's body size it does not mean the student believes that the client's body size must be factored into the initial assessment. The student may need more information about the client before considering it important information for the assessment. This finding may also be explained by factoring in social desirability of answers. It is one thing to admit you are aware of a client's weight or body size, but another to admit you feel their weight should be factored into their assessment.
Likewise, as described in the results above, there was no correlation between the students who reported they were aware of a client's body size and those that agreed that body size should be factored into a treatment plan or goal. The student may not feel comfortable choosing treatment goals without input from the client. Social work best practice respects self determination and allows the client to direct treatment goals and services. 90
Most students indicated that a client's culture, ethnicity, or race could have an
effect on positive body image. This finding confirms what the previous literature
indicates (Akan & Grilo, 1995; Altabe, 1998; Bay-Cheng et al., 2002; Chandler &
Abood, 1997). Other literature points out that people of all ethnicities have issues with
body image and body size issues (Caldwell et al., 1997; Iyer & Haslam, 2003; Reddy &
Crowther, 2007; Williamson et al., 1992). Stereotypes that African American or Hispanic
women all love their curves and have no body image issues may not be entirely correct. It
may be that participants also hold some of these same stereotypes, and therefore may
have a lack of awareness about body image issues amongst different cultures and
ethnicities.
Almost all participants in the survey (99.1%) stated that the media plays a large
role in the construction of acceptable body size. This indicates that students have an
awareness of the effect media can have on body image and the construction of acceptable body size. As indicated in the literature, media has been shown to have drastic affects on
levels of positive body image and the creation of eating disorders (Allen et al., 2008;
Anschutz et al., 2008; Botta, 2000; Davis, 2008; Farr & Degroult, 2008; Field, 2000;
Gibson, 2008; Knauss et al., 2008; Schooler, 2008; Sheridan, 2008; Siervo-Lubian, 2005;
Taylor & Goodfriend, 2008). While there may be a lack of discussion in the classroom
around this issue, it is clear that social work students are at least aware that the media is
at work in the social construction of ideal body size. 91
Research Question 2: What Are Social Work Students' Attitudes About People with Body
Size and/or Body Image Issues?
Do Social Workers Have PersonalBody Image Issues?
The majority of participants who answered our survey, 54.9%, stated that they
consider themselves either very overweight or overweight. This does not signify body
size or body image issues. However, most participants (76.1%) indicated they struggle
with their weight. Twenty-three percent said they struggle with their weight a great deal,
and 53.15% said they struggle with their weight somewhat. A greater percentage of
female participants (77. 6% as compared to 58.8% of male participants) said they struggle with their weight. This echoes the literature that indicated weight and body size
issues often experienced more in women (Payne, 2005). Most women think about and
struggle with their own weight, and this may affect all aspects of life, personally or
professionally. Not surprisingly, 88.5% of social work students have tried dieting at least
once, with 35.4% saying they have dieted many times, and 14.2% saying they are always
on a diet. Again, this supports the literature, indicating that almost everyone has dieted at
least some point in his or her lifetime.
Do Social Workers Have Biases Towards Body Size and Weight?
A significant correlation was found that suggests the more likely a student is to
say they are underweight or normal weight, the less likely they are to agree that
overweight people are just as healthy, or happy, or self-confident. This finding may
indicate a bias among our participants. 92
There is a significant correlation with students who consider themselves very
overweight or somewhat overweight and agreeing that overweight people are just as
healthy, happy, and self-confident as non-overweight people. Students who considered
themselves overweight had a more positive attitude of overweight people. This data
shows that the weight of an MSW student can be associated with their attitude on the
health of an overweight person. The non-overweight students are less likely to agree that overweight people are as healthy, happy, or self-confident as non-overweight people, and
overweight students are more likely to agree that overweight people are as healthy,
happy, and self-confident. As discussed in the literature review, a social worker's own
history of weight struggle related to less weight bias, family history related to less weight bias, but only for parents and grandparents, and more obese friends related to less weight bias (McCardle, 2008). Our data supports McCardle's findings. It seems logical that the personal experience of struggling with your own weight may influence your opinion
about overweight people in general. With personal experience, the social worker would
be more sympathetic to the struggle and understand that the client's weight may have no
bearing on health, happiness, and self-confidence-as the social worker's weight may not
influence those things. Also, the experience of struggling with one's own weight may
give the social worker the resources, knowledge, and, most importantly, empathy of working with that issue.
Conversely, it seems logical that if you lack the experience of struggling with your own weight, you may not be able to understand the intricacies of that struggle.
When you lack the experience of struggling with your own weight, you may not be aware 93
that weight may not play a role in a person's health, happiness, and self-confidence.
Given these issues, this may affect transference and countertransference, as discussed in
Koenig's (2008) article about transferential weight issues in social work therapy. Koenig
postulates that if a social worker does not check their own personal bias or hang ups
related to weight, it may affect their clinical practice. This can play a role in clinical social work, but could also play a role in mezzo and macro levels of social work,
particularly in policy decisions.
Do Social Workers' Biases Towards Body Size and Weight or Own Body Image Issues
Affect their Work with Clients?
The previously mentioned data discusses participants' personal weight struggles
and their view of people with weight issues. While these questions measure opinions
about the health, happiness, and self-confidence of all people, it is likely that these
attitudes would be applicable to clients specifically.
Many participants (82.0%) indicated that weight could affect a client's ability or
motivation in counseling at least some of time. This means that 82% of students in the
California State University, Sacramento MSW program who participated in this survey
believe that how much a client weighs can affect their ability or motivation to participate
in counseling. To the authors this suggests that social work students believe that some
clients are less able to participate in counseling based solely on their weight. This
suggests that social work students believe that some clients are less motivated to
participate in counseling based solely on their weight. Motivation is determined, at least
partially, by the client's weight, based on these findings. This reflects a clear bias or 94
attitude about weight and how it affects the clinical relationship. Social work students
may hold some of the socially constructed beliefs about overweight individuals: People
who are overweight are lazier or less capable than non-overweight people.
There was a significant correlation with participants who said they struggle with
their weight a great deal or somewhat and participants who agree or strongly agree that
body size and body image are important social work issues. While there is no proof that
one causes the other, the authors surmise that experiencing the feelings associated with a
struggle with weight may have an affect on the student's opinion on the subject of body
size and body image as a whole.
Research Question 3: Is body size/body image an important social work issue?
The data yielded that most participants (80.5%) do feel that body size and body image are important social work issues. This confirms the authors' belief, and basis of the
project, that this issue is an important and necessary part of social work.
If 66.4% of all participants have worked with clients who have had weight issues,
and 55.8% participants have worked with clients who have body image issues or eating
disorders, then this is an issue that comes up often social work practice, even as a student
intern. Another 8.8% of participants are not sure if they have worked with a client who
has weight issues, and 13.3% participants are not sure if they have worked with a client
who has body image/eating disorder issues. Many students do not have an awareness on
whether a client has struggled with these issues. Perhaps, if greater importance was
placed on these topics students would have better knowledge of different aspects of body 95
size and body image issues and an ability to recognize whether they have even worked
with clients who have these issues.
Given the aforementioned data showing the lack of participants' awareness about
these issues with their clients, the possible bias amongst social work students, the high percentage of students indicating the issue is important, and how rarely the issue is
discussed in class the authors believe body size and body image are important social
work issues.
Discussion of Frequency of I Don 't Know Answers
Because the authors wanted to create a Likert type scale with a neutral option or
an option if the student did not know the answer, I don 't know was an option on several
of the questions. The authors were surprised at the high percentage of I don't know
answers on some particular questions. This ambivalence may point to a lack of awareness
of body size and body image issues, or may point to the potential for bias against
overweight persons. Some of these questions measured the knowledge, training, or
experience of the participants, while other questions measured the attitudes, biases, or
beliefs of the participants regarding body size and body image. Many participants
selecting I don 't know presents a gap in knowledge and awareness. When more
participants selected I don 't know than other answers in the survey, it may indicate that
participants actually do not know but may also indicate the participants' reluctance to
state their opinions about the given question. The participant may have selected I don 't
know because it was the neutral answer on the Likert scale. Social desirability may have
been a factor in many participants choosing I don 't know as an answer in some questions. 96
The survey item Similar to race, ethnicity, and gender a client's body size should be a factor of considerationwhen forming a treatmentplan/goals had a 37.5% I don 't know response rate. This question may measure knowledge, attitudes, or awareness of the participants. The way the question was worded may have had an effect on the I don 't know answers. Some participants may not agree that body size is similar to race, ethnicity, and gender. The authors were not attempting to rank oppressions, but rather highlighting other topics included in diversity class as important issues in treatment.
Some participants may not feel that body size should be considered for a treatment plan or goals but may still feel body size is a relevant issue. The client may not have any issues with their body size so the participant may have selected I don 't know because they felt they did not have enough information to determine if body size should be included in the formation of treatment plans or goals. An I don 't know answer to this question may be a desirable answer because it may indicate the participant's desire to know more about the client before deciding what should be included in the treatment plan/goals. This is good practice for a social worker since they would be letting the client direct the services, and the treatment plan and goals would be based on the client's needs.
The survey item How comfortable would you feel discussing a client's body size in a session if the client did not bring it up? had a 29.2% I don't know response rate. This question measures the knowledge of the participant because a participant's training on the subject may affect their comfort level when discussing a client's body size in a session without the client bringing it up first. A participant may lack training on body size/body image issues and not be sure if they should bring up this issue. A participant may choose 97
I don 't know because, similar to question above, they do not feel they have enough information about the client to be able to measure their own comfort level. The, question also may measure a participant's attitude about body size because the student may feel that the client's body size is a risk factor that needs to be addressed immediately in session. A participant may feel a client's health may be at risk and want to bring up the issue yet still feel ambivalent about bringing it up. Therefore, the participant may choose
I don 't know as an answer.
The survey item Overweight people arejust as healthy as non-overweight people, had a 3 0.3% I don 't know response rate. This question primarily measures attitudes but may also measure the participant's knowledge of health and weight. As indicated in the literature review, several studies (Fonarow et al., 2007; Kang et al., 2006; Kalantar-Zadeh et al., 2007; Uretsky et al., 2007; Wildman et al., 2008) show the obesity paradox. The obesity paradox indicates that being overweight or obese can be a protective factor for many diseases. Contrary to popularly held beliefs, being overweight or obese does not necessarily indicate a lack of health. Participants may select I don 't know because many truly do not know if overweight people are just as healthy as non-overweight people. A participant may have chosen I don 't know due to ambivalence about admitting they think an overweight person is just as healthy as someone who is not overweight. Social desirability may play a role in this question again. The way the question is worded "just as healthy" may indicate that the participant believes the people are equally healthy, which is difficult to determine. The wording non-overweight people may have indicated 98 to the participant that group includes underweight people who may not be as healthy as normal weight or overweight individuals.
The survey item Overweight people arejust as happy as non-overweight people had a 44.1% I don 't know response rate. This was by far the largest amount of I don't know answers for any question in the survey. Measuring happiness is a difficult task; it is hard to operationalize. Social work students may take a more neutral stance on this question because it is difficult to measure happiness among people. Happiness is something that fluctuates and may or may not be affected by a person's weight.
Participants may have selected I don 't know because they cannot determine happiness based on weight. This question measures the attitudes of participants on how weight can affect perceived levels of happiness. The participant may feel that overweight people are not just as happy as non-overweight people but social desirability prevents them from choosing that answer, therefore they choose the neutral answer.
The survey item Overweight people arejust as self-confident as non-overweight people had a 36.9% I don 't know response rate. While the percentage is slightly smaller for this question the reasons for the I don 't know answer on this question are similar to the question above. Once again, it is difficult to operationalize and measure self- confidence in people, regardless of weight or body size. It is interesting to the authors that fewer participants answered I don 't know to this question than the question about happiness. This may indicate that more participants feel sure that overweight people may be equally as happy but not equally self confident as non-overweight people. More participant's indicated that they disagree that overweight people are just as self confident 99 than they disagreed they are just as happy. This may indicate the student's sensitivity to overweight people as it pertains to person-in-environment or societies pressures on overweight people.
The survey item Body size and body image are important social work issues had a
15.9% I don't know response rate. While most participants indicated that they agreed that this is a social work issue, the fact that some student did not know if it was a social work issue may indicate a lack of education about how multi-faceted this issue is. Participants indicated that these topics are rarely discussed in Masters social work classes. This lack of education may cause some participants to choose I don 't know for this answer. The authors believe that body size and body image are important social work issues because these issues encompass health, mental health, socio-economics, addiction, interpersonal relationships, discrimination, and transference/counter transference issues.
Conceptual Framework
Social learning theory, psychodynamic perspectives, and feminist theory informed this study, were introduced in Chapter I, and extrapolated upon in Chapter II. These theories help to inform the following interpretation of the study's findings.
The findings of the study indicate that participants have a bias about weight issues. Social learning theory could play a role in many participants' feeling that overweight people are not as healthy, happy, or self-confident as non-overweight people.
Almost all participants indicate that media plays a large role in the social construction of body size, yet some go along with the media's portrayal of overweight people as less healthy, happy, and self-confident (Blood, 2005; Hesse-Biber, 2006; Jade, 1999). Many 100 people are exposed to weight discrimination and sizeism on a daily basis from the media, family, friends, coworkers, and even health care professionals. Participants learn that weight discrimination is rampant, acceptable, and, at times, scientifically fueled. It takes active learning and critical thinking to check our own attitudes about the bias we have been exposed to throughout our lives.
Social learning theory likely plays a role in the high number participants who indicate they struggle with their own weight and who have dieted. As the literature points out, the weight loss industry is pervasive (Blood, 2005; Hesse-Biber, 2006). Participants are part of a social environment that rewards weight loss and obsesses about weight.
Their experience is not separate from the rest of the world.
Psychodynamic theory helps to inform the findings because it indicates that a person's own attitudes can play a role in transference issues with a client. Our findings indicated that participants do have particular attitudes about weight and body image and there is a possibility this could affect transference or countertransference issues with clients. As Koenig (2008) suggests, a social worker should be aware of how weight can affect transferential issues.
Many more female social work students participated in the survey than male students. Nearly all of the students who participated in the survey answered that media plays a role in the social construction of ideal body size. Feminist theory teaches us to question media and the roles it plays in our lives (Healy, 2000). Feminist theory was where social constructivist theory was born and social workers must learn how to help their client's rewrite their experiences of weight issues. Feminist theory may explain 101 some of the I don 't know answers in that perhaps some of the participants did not want to make a decision without the full picture because they did not want to be the expert in the client's life. The client should always have the power in the therapeutic relationship (Van
Den Bergh, 1995). A social worker informed by feminist theory knows to question any power imbalances.
Closing Observations
Exploratory and descriptive research studies are a practical necessity when a new research area is developing. Exploratory and descriptive research often raises as many questions as it answers, and clearly, this study is a case in point. With this beginning research the authors have attempted to fill a gap in social work research. We find ourselves with more questions than answers but we have found many significant and interesting associations:
1. A student's own weight is associated with their belief about the health, happiness, and
self-confidence of overweight individuals
2. The more a student struggles with their own weight the more likely they are to
believe body size and body image are important social work issues
3. Students who have experience working with clients who have body size or body
image issues or eating disorders are more likely to believe that body size and body
image are important social work issues, and
4. Counter-intuitively, students who have experience working with clients who have
body size or body image issues or eating disorders are not more likely to report
feeling confident working with obese people. 102
It is likely that just by participating in the survey social work students in the
Masters in social work program became more aware of these issues in their own practice.
With these associations the authors can advocate for a change in curriculum, further trainings for licensed clinicians, and a greater awareness of the issue in the social work profession. 103
Chapter 5
SUMMARY, CONCLUSIONS, AND IMPLICATIONS
Summary
Poor body image has been associated with a number of mental and emotional disorders, including depression and eating disorders, such as anorexia, bulimia, compulsive and binge eating disorders (Engeln-Maddox, 2006; Blood, 2005, Noles et al,
1985). This study explored how social workers' personal body image, or biases towards body image, and personal body size may affect their work with clients. It also explored social workers' knowledge and practice experience with clients who face body size and body image issues.
Using a web-based survey, data were collected from 115 Masters in Social Work students from California State University, Sacramento. Forty-four first year and 71 second year students comprised the study's sample. A self-report survey was developed for this study. Beyond descriptive analysis techniques, Pearson's r correlations as well as linear regression techniques were utilized to analyze the study's data.
This study's findings suggest that similar to culture, gender, and sexuality, social workers need to be aware of biases toward body size and body image. Results also indicate that there seems to be an association between participants' own weight issues and their beliefs related to overweight people's health, happiness, and self-confidence.
Study results also indicate that body size and body image were rarely or never discussed in Masters social work classes. This study concludes that issues relating to body size and body image are important social work topics. 104
Recommendations and implications for social work education and social work practice are discussed. More precise specifications and robust measures of perceptions of body size and body image are needed.
Implications and Recommendations
Implicationsfor Social Work Education and Social Work Practice
This study has many implications for the field of social work. One implication of this study is a need for change in the training and education curriculum of social work students. We believe that changing social work curriculum to include more information about body size, weight, body image, eating disorders, and body dysmorphic disorder would improve awareness of these issues. In addition, the curriculum should include information about the media's effects on body image, countertransference and transference issues related to body size and body image, nonjudgmental health and nutrition, poverty's effects on the body, socioeconomic factors related to body size and body image, food addiction, self-esteem issues, internalized shame related to body size issues, mental health issues related to body size, relationship issues, sexual health issues, the social construction of acceptable body size, ethniciiy's effect on body image, and how body image and body size issues have different effects and different meanings amongst gender, culture, ethnicity and sexual orientation. It is important that this information leads to more effective interventions, goal-setting, non-judgmental treatment plans, and greater empathy. Trainings about working with people who may have these issues would benefit the profession of social work at all levels, macro, mezzo, and micro. These topics should be discussed in clinical supervision of working social workers, as well for future policy 105 changes. Specializations in the field of social work related to eating disorders, food addiction, or body size and body image issues would also help improve the awareness of these issues in the profession and how they affect our clients' lives.
A greater sensitivity towards people who may experience these issues, and to our own personal body image or body size issues is needed in the profession as a whole. We can be examples to the rest of society. As social workers, we are advocates for fair, sensitive, and quality treatment of the most vulnerable, voiceless people. In addition, the professional social worker needs to bring a greater sensitivity to the idea of fat discrimination a whole. We are not trying to rank oppressions, as we have said, but it is undeniable that our society treats overweight people as second-class citizens. Overweight people have become a joke, and it has become acceptable to talk about fat people in an outwardly discriminatory way. A person cannot read the headlines of major news sources without seeing an article about obesity causing any number of atrocities, including the financial meltdown, global warming, or the cause of American's expensive dysfunctional health care system. Overweight people have recently been labeled as having lower cognitive abilities, lazy, and less productive than non-overweight people. Studies may somehow show that people who are overweight call in sick to work more often, but it does not take into account a variety of reasons why this would be the case. It creates a hurtful, discriminatory environment. When society and social workers ingrain these beliefs it creates room for discrimination against people based on how they look. Social workers must be aware of their own biases and be educated about sizeism and weight related discrimination. 106
Media is selling a lifestyle that says that overweight people cannot be happy, normal, functioning members of society unless we fit in a certain stencil of a way to be.
The feminist perspective helps us realize that we must question the prescribed ways of being, particularly those that do not consider the perspective of a woman. Women are socialized from a very young age to pay attention to fat and calories, to dress a certain way and act a certain way, to be desirable, or make other people happy, instead of focusing on things in her life that are actually important. Women are so caught up with this weight and body game that they are ignoring the fact that women make 77 cents on the dollar as compared with men (Regnier & Gengler, 2006), and that only 17% of the
U.S. Congress and 17% of the U.S. Senate are women (ThisNation.com, 2009). There is so much violence against women across the entire globe-and violence is objectified, institutionalized, sexualized, and considered acceptable (as seen in movies, comic books, books, music, etc.). Why is this not our obsession? Why is our focus turned to our bodies and not our inequalities?
We recommend the social work profession adopt the recovery model, which keeps the focus of recovery on the client's needs. If your overweight client does not seem to find their body size as something that is holding them back, do not assume that it is.
Do not assume that they may be less happy or self-confident because they happen to be overweight. Do not assume that they're less healthy either. The client should always direct interventions, and the treatment goals should be their goals.
We also recommend that social work therapists include narrative therapy in their cognitive interventions: The media has to be held accountable for the pressures it puts on 107 people to conform to the ideal body size, and social workers should work with clients to hold the media accountable. Social workers should help their clients rewrite their story about their bodies and their personal relationship with their bodies. Social workers can help their clients look at things in a different way. The narrative therapy could address many of the dimensions of the problem.
Implications and Recommendationsfor Social Work Research
With this research, we hope to bring more awareness to the Masters of social work program at California State University, Sacramento, as well as to the entire social work profession that these are issues that social workers need to consider as important.
These issues play a large role in our clients' lives and we must be aware of how we think about a person's body size and how that may affect the client-social worker relationship.
Wider spread, more in-depth, longitudinal research related to the social work field and issues related to body size and body image is necessary.
It would be beneficial to know what methods of statistics were going to be used before the development of the survey. When the authors developed the survey we were attempting to explore the subject in general. Our questions came from our own curiosities about the subject. Now that we have finished this research we have many more questions.
We have the foreknowledge of having gone through this process and if we were to continue research on this topic we would approach it differently. We could potentially write a questionnaire that would build in opportunities for other analysis methods, different correlations, and perhaps yield further significant findings. If more correlations can be found and if there is a chance for more significant associations between particular 108 issues, it would continue to stress the need for awareness about these issues as a social worker. For example if we could find statistical significance between a persons own body size and how they work with a client that would indicate countertransference issues that are not talked about in the education and training of social workers. There is no perfect way to test for countertransference issues, but there are other ways to explore the issue.
Perhaps research with pictures or mock clinical settings could uncover further countertransference issues with body size and body image. Further research could examine attitudes and beliefs of clients about social workers and weight and body image.
Very little research has evaluated the view and treatment of obese people by mental health professionals (Young & Powell, 1985). Our survey touched on so many different issues related to body size and body image that we could zero in on any number of particular areas of interest and expand the research on these specific areas.
We asked the question Is body size and body image an important social work issue? because we wanted to know what our colleagues thought about the issue. This research question is very basic but is the heart of our study.
In our diversity classes in the MSW program at California State University,
Sacramento, we are asked to question our bias and preconceived beliefs about people based on race, ethnicity, gender, sexual orientation, and ableness. Even amongst social work professors at California State University, Sacramento, the idea that body size and body image are important social work issues were questioned. They were not considered valuable issues or viable research topics. 109
Reflection
The two authors have collaborated on this topic for the past year. We feel like we have only uncovered part of the multi level, wide spread issue. The literature that was reviewed was intended to cover a variety of topics that influence this issue, but it did not go into great depths on any one aspect. We had to force ourselves to limit our research because the more we uncovered about weight and body image the more it brought up further implications for causes and effects of these issues. Our relationship with our body is a life long experience. Western values have socialized us to think of our minds and bodies as separate entities. We believe social work should encourage the belief that our bodies and minds are part of us and to work together. We are only given this one body, and this one life, and focusing on all of our body's imperfections leaves us feeling empty.
What we perceive as imperfections are just the differences that make us human. What we define-as flaws are actually the things that make us special and individual. How can we have a full life if there is a part of us that always hates ourselves? If we could stop being worried about what we look like or how much we weigh, what would life look like for us? We would feel less shame, less stress, less sadness, less self hatred, more hopeful, greater self-esteem, more balanced, more healthy, and have more energy to tackle all the other problems of life. Without the constant reminders that our bodies are being judged and that women are being valued on appearance, it would open up new realms of life.
The cult of thinness must come to an end and we must spend time nourishing our bodies and our souls instead of constantly worrying about how we can deprive ourselves. 110
APPENDIX A
Informed Consent and Questionnaire
Informed Consent - I agree to participate in research which will be conducted by Erin
Ahern and April Tally, Masters students in Social Work at California State University,
Sacramento. The web-based study will investigate factors related to social work students' attitudes towards, and experiences with, clients in a therapeutic setting in regards to weight and body size issues.
The results of this survey will help the researchers identify the attitudes of MSW students concerning diversity issues surrounding body size and the way a person feels about her or his body. It will also provide insight into MSW students' awareness on this diversity issue. Potentially, the results of this survey may benefit the profession, by highlighting the need for training and education for MSWs regarding body size and body image issues while working with clients. My responses will be kept confidential to the degree permitted by the technology used. If I complete this anonymous survey and submit the survey on the online forum, the researchers will be unable to remove the anonymous data from the database should I wish to withdraw it. The authors will go to whatever lengths possible to ensure that my data is kept anonymous and confidential. If I have any questions about this research, I may contact Erin and April at mswbodyimage~gmail.com. My participation in this research is entirely voluntary. I will answer the questions to the best of my knowledge. I will consent to taking the survey, by clicking "I agree." ill
2. What level of Masters in Social Work Student are you?
MSW I, MSW II
3. What is the gender you identify with?
Female, Male, Other [fill in the blank]
4. What is the ethnicity (or ethnicities) you identify with?
[fill in the blank]
5. What is your age?
[fill in the blank]
6. Was your undergraduate degree in something related to helping fields, including but not limited to child development, education, social work, physical therapy, counseling, or psychology?
Yes, No
7. Have you worked with a client who experiences weight issues or body size issues as one of their concerns?
Yes, I don't know, No
8. Have you ever worked with a client with body image issues or eating disorders?
Yes, I don't know, No
9. How confident would you feel working with an obese client?
Very confident, confident, I don't know, minimally confident, not at all confident
10. How often has the subject of weight/body size/body image issues been discussed in your MSW classes?
Frequently, occasionally, sometimes, seldom, never 112
11. Similar to culture, gender, and sexuality, social workers need to become educated
about/question their biases towards body size diversity.
Strongly agree, agree, I don't know, disagree, strongly disagree
12. When you first meet a client, how aware of the client's body size are you?
Very aware, somewhat aware, I don't know, minimally aware, not aware
13. How often would a client's body size play a role in your initial assessment of a
client?
Always, usually, sometimes, seldom, never
14. Similar to race, ethnicity, and gender, a client's body size should be a factor of
consideration when forming a treatment plan/goals.
Strongly agree, agree, I don't know, disagree, strongly disagree
15. Do you feel a client's weight could affect their ability and/or motivation to participate fully in counseling and/or case management?
Always, usually, sometimes, seldom, never
16. How competent would you feel working with a client who is dealing with body
image issues?
Very competent, competent, I don't know, minimally competent, not at all
competent
17. How comfortable would you feel discussing a client's body size in a session if the client did not bring it up?
Very comfortable, comfortable, I don't know, uncomfortable, very uncomfortable 113
18. If a client does bring up their weight issues, how comfortable would you feel addressing those issues?
Very comfortable, comfortable, adequate, uncomfortable, very uncomfortable
19. If a client's body size did not match your body size, how comfortable would you feel working with the client on weight issues?
Very comfortable, comfortable, adequate, uncomfortable, very uncomfortable
20. Do you feel a client's culture/ethnicity/race affects their level of positive body image?
Very much, somewhat, I don't know, a little, not at all
21. Does media play a large role in the construction of acceptable body size?
A great deal, somewhat, I don't know, not much, not at all
22. Overweight people are just as healthy as non-overweight people.
Strongly agree, agree, I don't know, disagree, strongly disagree
23. Overweight people are just as happy as non-overweight people.
Strongly agree, agree, I don't know, disagree, strongly disagree
24. Overweight people are just as self-confident as non-overweight people.
Strongly agree, agree, I don't know, disagree, strongly disagree
25. Body size and body image are important social work issues.
Strongly agree, agree, I don't know, disagree, strongly disagree 114
26. To the best of your understanding, would you consider yourself:
very overweight
somewhat overweight
normal weight
somewhat underweight
very underweight
27. Do you struggle with your own weight?
A great deal, somewhat, I don't know, not much, not at all
28. Have you ever dieted/tried to lose weight?
Always, many times, a few times, once, never 115
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