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Women & Therapy

ISSN: 0270-3149 (Print) 1541-0315 (Online) Journal homepage: https://www.tandfonline.com/loi/wwat20

Size as Diversity Absent from Multicultural Textbooks

Ashley E. Kasardo

To cite this article: Ashley E. Kasardo (2019) Size as Diversity Absent from Multicultural Textbooks, Women & Therapy, 42:1-2, 181-190, DOI: 10.1080/02703149.2018.1524069

To link to this article: https://doi.org/10.1080/02703149.2018.1524069

Published online: 26 Dec 2018.

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Size as Diversity Absent from Multicultural Textbooks

Ashley E. Kasardo

Carruth Center for Psychological and Psychiatric Services, West Virginia University, Morgantown, West Virginia

ABSTRACT The current clinical approach adopted by many mental health clinicians is the medical model, which, in the case of size diversity, has been connected with weight stigma. Mental health practitioners need to be exposed to the critique of the medicalized view that fat is a disease that can be cured through dieting. Weight stigma and fat-shaming may be reduced through adoption of a social justice perspective on sizeism as a form of oppression. An analysis of textbooks designed for use in graduate multicultural courses indicates that size is not currently addressed as a diversity or social just- ice issue within psychology. It is recommended that fat be conceptualized as a social identity that intersects with other diversity dimensions within coursework for mental health trainees as opposed to a sizeist paradigm where fat is depicted as pathological.

KEYWORDS Content analysis; diversity; fat; multicultural counseling; pedagogy; psychology; psychotherapy; graduate textbooks

The stigmatization of fat is pervasive, insidious, and damaging to the well- being of fat individuals (Chrisler & Barney, 2017; Puhl, Andreyeva, & Brownell, 2008). Weight bias is evidenced across employment, education, healthcare, and interpersonal interactions and appears to be particularly detrimental for women (Fikkan & Rothblum, 2012; Puhl & Heuer 2009). Erdman (1995) has argued that people in the helping professions have con- tributed to discrimination against fat people, and psychotherapists have done so by attempting to provide and/or accepting psychological or med- ical explanations for cultural problems. A medicalized perspective conceptualizes fatness as a disease and weight

loss as its cure. A weight-centric model of health assumes that weight is within an individual’s control, equates higher weight with poor health hab- its, and believes weight loss will result in improved health (O’Hara & Taylor, 2014; Tylka et al., 2014; Watkins & Gerber, 2016). These assump- tions persist despite evidence to the contrary (Mann et al., 2007). Multiple critiques of the medicalized view of fat have been published elsewhere (e.g., Bacon & Aphramor, 2014; Kasardo & McHugh, 2015; Puhl & Heuer,

CONTACT Ashley E. Kasardo [email protected] West Virginia University, Morgantown, P.O. Box 6422 390 Birch Street, WV 26506, USA. � 2018 Taylor & Francis Group, LLC

WOMEN & THERAPY 2019, VOL. 42, NOS. 1-2, 181–190 https://doi.org/10.1080/02703149.2018.1524069

2009). Terms such as obese and overweight are medicalized; thus, the word fat will be utilized throughout this article as it is the term activists prefer (Wann, 2009; Watkins & Gerber, 2016).

Fat Bias and Mental Healthcare

Brown and Rothblum’s (1989) special issue of Women & Therapy was among the first to consider fat oppression in psychotherapy. Nearly 3 deca- des later, scholars continue to question psychology’s alignment with the medical model of fat (Brown-Bowers, Ward, & Cormier, 2017; Watkins & Gerber, 2016). Although interdisciplinary fields have gone beyond the med- icalization of size (Nutter et al., 2016), psychology and psychiatry continue to be critiqued for assuming the need for weight management and the cor- rection of fat individuals’ behaviors and cognitions (Tischner, 2013). Although ultimately rejected, “obesity” was considered for inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (Devlin, 2007). Even so, the DSM currently lists “Overweight/ Obesity” as a focus of clinical attention that can be diagnosed as a factor that influences functioning (American Psychiatric Association, 2013, p. 726); “target of perceived adverse discrimination or persecution,” with weight and appearance as examples, is also included as a potential v-code diagnosis (p. 725).

Psychotherapy

The American Psychological Association (APA) also maintains a weight- centric model of health (Watkins & Gerber, 2016). For example, APA’s code of ethics does not reference size (Kasardo, 2015). Weight loss contin- ues to be prioritized by psychologists as a treatment goal in psychotherapy (Brown-Bowers et al., 2017); some even suggest that studying anorexia nervosa might yield insight into how “obese” individuals could achieve weight loss (Gianini, Walsh, Steinglass, & Mayer, 2017). Weight-centric and medicalized approaches have consequences for how

clients are treated in psychotherapy. Indeed, fat bias has been demonstrated among mental health care providers (Agell & Rothblum, 1991; Aza, 2009; Davis-Coelho, Waltz, & Davis-Coelho, 2000; Hassel, Amici, Thurston, & Gorsuch, 2001; Pascal & Robinson Kurpius, 2012; Young & Powell, 1985), including eating disorder specialists (Puhl, Latner, King, & Luedicke, 2013). For example, in one study (Young & Powell, 1985), clinicians assigned sig- nificantly greater levels of symptomatology to fat than to non-fat clients, and, in another study (Davis-Coelho et al., 2000), body size was found to impact degree of effort expected from fat clients as well as their prognosis.

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Clinicians will work with fat clients in their practice, and many of those clients will have experienced weight-based victimization (Puhl et al., 2013). Thus, it is important for clinicians to be aware of how to assess and respond respectfully and appropriately to clients of diverse sizes without bias. Psychotherapists have a moral and ethical obligation to strive to cor- rect weight bias instead of contributing to the personal and public health problem of weight discrimination (McHugh & Kasardo, 2012). Given the pervasiveness of fat bias, its severe consequences, and the per-

petration of fat bias by mental health clinicians, it is imperative to consider how to eliminate fat bias in general and in our own professions in particu- lar. Education can be a powerful force to change attitudes toward the meaning of fat (Brownell & Rodin, 1994; McHugh & Kasardo, 2012).

Education

A stigmatizing view of size is evident across undergraduate psychology edu- cation (McHugh & Kasardo, 2012; Watkins & Gerber, 2016). Analyses of introductory psychology (Touster, 2000; McHugh & Kasardo, 2012), abnor- mal psychology (Rothblum, 1999), social psychology (Watkins & Gerber, 2016), and psychology of women (Touster, 2000) textbooks collectively illustrate a medicalized perspective of body size and the absence of a social justice perspective. An important question remains regarding the coverage of fat across

graduate school curricula. This is important because the lack of coverage of fat oppression in psychology courses and the medicalization of size demon- strated in the field overall has critical implications for how clinicians react to, diagnose, conceptualize, and treat fat clients (McHugh & Kasardo, 2012). Lack of diversity training regarding size has been observed in mar- riage and family therapy (Pratt et al., 2015), professional counseling (Adams, 2008), and social work (Aza, 2009). Thus, researchers and clini- cians have advocated for inclusion of fat bias in courses designed to edu- cate students about diversity and oppression (Cravens, Pratt, Palmer, & Aamar, 2016; Matz & Frankel 2014; McHugh & Kasardo, 2012). Education about fat as a social identity is an essential component of graduate training to prepare students to engage in clinical practice. Viewing fat through a social justice lens challenges fat oppression by

respecting size diversity, correcting anti-fat ideology, and advocating for the rights of fat people. This cannot be accomplished if clinicians believe that fat people should (and could) be thin (Calogero, Tylka, & Mensinger, 2016). “Training students to understand the causes, treatment, and social issues related to dieting, eating, body dissatisfaction, and health ensures

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that future clients will receive the support and therapy they deserve” from their therapists (Matz & Frankel, 2014, p. 310). Clinicians have a responsibility to acknowledge the existence of fat

oppression and consider how it may impact clinical work. Including fat as a diversity dimension in a diversity course could allow psychology students to recognize and explore how the thinness ideal is problematic and encour- age them to consider how to cease perpetuating fat oppression. Ignoring size as a diversity dimension perpetuates size stigma and the medicalization of fat. One must consider resources that can be utilized within curricula for mental health professionals and whether size is viewed as disease or social identity.

Coverage of Size in Multicultural Textbooks

I conducted a critical review of 29 single-authored and edited textbooks published after 2000 and designed for use in graduate multicultural coun- seling courses (Kasardo, 2015). A list of index terms based upon Touster’s (2000) analysis were used to search the textbooks: anti-fat bias, body image, body fat, body shape, body mass index, body weight, dieting, eating, eating disorder, eating habits, fat, fat acceptance, fat bias, fat oppression, Health at Every Size (HAES), obese/obesity, overeating, overweight, person of size, size, sizeism, size acceptance, size counseling, weight, weight bias, weight control, weight loss, and women. The HAES model (trademarked by the Association for Size Diversity and Health) promotes a holistic perspective of health without a focus on weight loss (O’Hara & Taylor, 2014; Tylka et al., 2014). If index terms were present, those sections of textbooks were read and

analyzed thematically utilizing a coding manual constructed prior to review. I noted whether themes were present or absent across each textbook. The following themes were developed: set point, BMI, unreliable BMI, genetics/ biology, thin ideal/cultural values, obesity as a health condition, benefits of dieting, diet failure/critique of medicalization, cultural fat prejudice, profes- sional fat prejudice, myths/stereotypes about fat, intersectionality, HAES eating habits, HAES physical activity, HAES appreciation of body diversity, HAES separating fat from health, the negative effect of body image, improving body image, body acceptance, and eating disorders. The HAES paradigm was separated into specific tenets in order to better analyze how (if at all) the HAES paradigm was represented across texts. The thin ideal/ cultural values theme referred to whether cultural ideals of beauty were described and whether pressures to conform to body ideals were addressed. Cultural fat prejudice referred to stigma and bias against fat individuals;

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professional fat prejudice referred to acknowledging ways that professionals have demonstrated fat bias. Inter-rater reliability for index terms and thematic coverage was calcu-

lated with a second rater. Interrater reliability for index terms was found to have very good agreement, j ¼.92, 95% CI [.803, 1.03], p < .001. The interrater reliability for thematic concepts was also found to have very good agreement, j ¼ .81, 95% CI [.668, .958], p < .001. It was hypothesized that the thematic analysis would indicate how size is

viewed across textbooks, including the possibility of it not being covered at all, being covered with a tone of medicalization (e.g., BMI, obesity as a health condition, benefits of dieting, eating disorders), or including size as a form of diversity (e.g., set point, unreliable BMI, genetics, diet failure/cri- tique of medicalization, fat prejudice, body acceptance, HAES themes, intersectionality). It was hypothesized that size as a diversity dimension would not be present across textbooks. Eleven textbooks contained none of the index terms identified. The three

most frequently occurring index terms were women (14 books), body image (6 books), and eating disorders (6 books). The most frequently occurring thematic concepts across textbooks included the thin ideal/cul- tural values (10 books), eating disorders (8 books), intersectionality (7 books), negative effects of poor body image (7 books), obesity as a health condition (4 books), and cultural fat prejudice/discrimination (4 books). Congruent with the hypothesis, size as a diversity concern was not fre-

quently present across diversity textbooks. Only one text referenced the set point, none discussed unreliable BMIs, two discussed genetics/biology, three critiqued medicalization of size, four discussed cultural fat prejudice, three discussed professional fat prejudice, two discussed elements of HAES, and two mentioned body acceptance. It was surprising that only eight of the textbooks discussed the preva-

lence, symptoms, and treatment of eating disorders. No textbook featured benefits of dieting. Ten textbooks mentioned that thin ideal/cultural values impact how women evaluate their bodies. Seven textbooks referenced the negative impact of a poor body image. Two textbooks (Enns & Williams, 2013; Ponterotto, Casas, Suzuki, & Alexander, 2010) specifically mentioned that women face more pressure and stigma regarding weight and size as compared to men. Although both cultural and professional fat prejudice/discrimination

were found in four textbooks, coverage was limited to a few sentences, and only one textbook (Cornish et al., 2010) featured multiple studies that dem- onstrate the existence and prevalence of fat bias. Brammer (2012) noted that using weight as a treatment goal could result in shame for the client. Fawcett and Evans (2013) encouraged practitioners to reflect on their own

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biases about fat as this might impact clients they treat or students with whom they work. Only one textbook provided an in-depth discussion (a 35-page chapter)

about size as a diversity concern (Cornish et al., 2010). This chapter fea- tured information on sizeism, refuted negative stereotypes about fat, listed multiple client vignettes, encouraged readers to consider how clinicians’ size might impact treatment, and provided supervision considerations. Sample topics to include in diversity seminars were included, as was a list of resources for clinicians. Although less in-depth in terms of coverage, Fawcett and Evans (2013), a text that featured experiential exercises, included a one-page HAES exercise about sizeism and provided further resources for clinicians. Unlike other textbooks, Brammer (2012) contained a chapter entitled

“The Culture of Appearance.” The chapter contained a weight/height/ beauty subsection that consisted of three paragraphs. This section was contradictory in that it discussed “obesity” statistics (e.g., rates of “obesity” are increasing, “obese” individuals are more likely to miss work), yet also acknowledged the existence of size prejudice. Four textbooks discussed obesity as a health condition (Brammer, 2012;

Lee, 2013; Ponterotto et al., 2010; Slattery, 2004). Three textbooks included a critique of medicalization (Cornish et al., 2010; Enns & Williams, 2013; Fawcett & Evans, 2013). Enns and Williams (2013) specifically stated that criteria for anorexia nervosa, including overvaluing thinness and fearing fat, are actually health policies that some nations employ regarding “healthy” weight management. Intersectionality in this analysis was coded to include any reference to

body/size in conjunction with other diversity dimensions (e.g., ethnicity, class). Seven textbooks included examples of these criteria. Cross-cultural data were included in one book to compare eating concerns across various ethnic groups (e.g., Choudhuri, Santiago-Rivera, & Garrett, 2012), and another included an example that discussed a client’s size in conjunction with her Latinx heritage and sexual orientation (Cornish et al., 2010). Jun (2010) encouraged readers to question what messages they have received about their body in relation to other diversity dimensions, such as race, class, gender, sexual orientation, religion, age, and region. Overall, in-depth examples (i.e., multiple pages, multiple examples, extended analysis of multicultural considerations) regarding intersectionality of size and other diversity dimensions were not included across the textbook sample. Although it was encouraging that some texts acknowledged sizeism, this

was not present across the majority of books, and the books typically did not include size as a diversity issue. Themes about eating disorders, although also not present across a majority of texts, did outnumber

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discussions about fat bias. This is concerning, given that size is either ignored across texts or is referenced in terms of eating disorders, including “obesity” as a health condition. Evidently, educators cannot rely solely on graduate textbooks to provide adequate coverage of size as a form of diver- sity or to be sufficient to train students effectively with knowledge, aware- ness, and practice of psychotherapy with clients who are fat. Multicultural courses in graduate curricula might emulate didactic meth-

ods from Fat Studies (Cameron, 2015; Cameron & Russell, 2016; Watkins & Concepcion, 2014; Watkins, Farrell, & Doyle-Hugmeyer, 2012). Several articles within this special issue include suggestions about how to improve training of future mental health professionals (see Bergen & Mollen; Brochu; Meulman; Rothblum & Gartrell). One strategy is to supplement course material, including, for example,

writings by fat individuals, to help challenge medicalized perspectives of size (Cameron, 2015). There is, however, limited research on fat women’s experience in psychotherapy (but see, in this issue, Akoury, Warren, & Shaffer; Harrop; Meulman). Honoring these voices is critical for clinicians to consider as part of their practice, as well as attending to fatness as a social identity and how it has impacted clients’ developmentally. As Cooper (2016) asserted, “fat people are a fact of life, part of the fabric

of humanity” (p. 1). It is recommended that this perspective be included across the multicultural counseling curriculum to allow clinicians-in-train- ing the opportunity to view size as a social identity.

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