Concern over the increasing numbers of fat people world-wide has become so virulent that it is now commonplace to use the language of disease to describe the 鈥榦besity epidemic鈥�. Indeed, at its 2013 Annual Meeting the American Medical Association came right out and declared obesity 鈥榓 disease requiring a range of medical interventions鈥�.1 It is certainly true that fat is spreading fast. In the UK, for example, a 2012 government study found that 66.6 per cent of men and 57.2 per cent of women in England were overweight or obese. In the UK being fat is now the norm.
It feels appropriate to say something here about the terminology I am using in this piece. The word 鈥榝at鈥� makes a lot of people wince. The obvious alternatives are to use words like 鈥榦verweight鈥� or 鈥榦bese鈥�, but both are associated with medical discourse, being categories of fatness as defined by the Body Mass Index (BMI). The word 鈥榝at鈥�, by contrast, is appealingly direct. It is also a word that has been claimed by the Fat Acceptance movement, which started in the 60s, like lots of other social protest movements, as well as by Fat Studies, which is an emerging and multidisciplinary academic field of study that shines a critical lens on normative social and medical narratives of fatness. Even if it makes some readers uncomfortable, using the word 鈥榝at鈥� allows me to align myself with these perspectives, hence the decision to use this word.
Concern about fat is typically framed in terms of the health and economic burden created by increasing hordes of fatties. Public Health England, which compares obesity to smoking 鈥榠n terms of associated disease burden as a determinant of future health鈥�, states that obesity in adults is linked to greater risk of a swathe of medical conditions, including musculoskeletal, circulatory, metabolic and endocrine, reproductive and urological, respiratory and gastrointestinal problems, as well as liver disease and some cancers.2
All this associated morbidity of fat comes with a cost, and not just to the individual. The direct economic cost of treating fat people in the NHS was estimated at 拢4.2 billion in 2007, while the indirect costs to the economy (eg arising from the health consequences of obesity in terms of sickness absence from work) were estimated to be as high as 拢15.8 billion.3 In addition to the major physical health consequences, there are psychological problems associated with being fat. Considerable empirical evidence suggests that fat people are more likely to be depressed and anxious, although researchers argue that it is likely that the relationship is two-way.
What about fat therapists?
Presumably, if there are more and more fat people, there are also more and more fat therapists. For the profession, for clients, surely this matters? Given all the dire physical and mental health consequences associated with being fat, is it time to ask the question, 鈥楥an a counsellor be too fat to be ethically 鈥渇it鈥� to practise?鈥櫶�
Before we start to get out the scales in job interviews and annual performance reviews, there is another option. That is to consider whether the high degree of public and medical concern about increasing levels of obesity in the population is an expression of an underlying and unacknowledged fat stigma. Consider these three typically accepted 鈥榝at facts鈥�.
Fact 1: It is fat people鈥檚 fault they are fat
A recent newspaper headline declaimed: 鈥業t鈥檚 time fat people started taking responsibility for themselves,鈥� because fat people 鈥榗hoose to eat junk and get fat鈥�. The belief that fat is something for which individual fat people are solely responsible is commonly expressed not just in the media but also implicitly in the scads of research that focus on explaining obesity in terms of individual-level factors only. However, a 2007 UK government report outlined over 100 factors involved in increases in obesity including some, such as genetics, medication side effects and poor health, that operate at the individual level but are not within individual control.3 In addition, many others factors operate at a social or environmental level, including the availability of cheap, healthy food choices and provision of cycle lanes or showers at work, as well as social influences such as the media obsession with celebrity weight gain and loss.
But if fat is not just down to bad individual choices, the 鈥榦besity epidemic鈥� is everyone鈥檚 鈥榝ault鈥� and change will require potentially radical social, cultural and political shifts. It鈥檚 easier really to scapegoat fat people.
Fact 2: Weight loss is simple 鈥� eat less and exercise more
On the one hand this is clearly true. However research suggests that for many, many fat people diets do not work. To quote one research paper: 鈥極n average, overweight and obese participants in multidisciplinary behavioral weight trials lose about seven pounds, or 7鈥�10 per cent of their excess weight, and between 20 and 40 per cent of patients sustain their weight loss for two years or more.鈥�4 In other words, even in well-supported research contexts the majority of those who lose weight do not sustain the weight loss and the amount of weight lost is not enough to actually move them out of the category of 鈥榦verweight鈥� or 鈥榦bese鈥�. The intent here is not to dismiss the potential health benefits of even small amounts of weight loss but rather to emphasise that the assumption that it is easy for fat people to lose weight if they choose to is a damaging myth.
Fact 3: Being fat is really unhealthy
The connection between fat and poor health is a widely accepted fact but there is academic debate on this topic 鈥� with an entrenched and vocal camp of what has been termed 鈥榓larmists鈥� pitted against a small but increasingly vocal group of 鈥榮ceptics鈥�. The grounds for the debate vary 鈥� for example, a long tradition of feminist scholarship argues that concern about women鈥檚 weight has to be understood within the context of a patriarchal society. There is also, however, debate within the more conventional medical literature, as shown by the controversy stirred by a research study in a prestigious US medical journal that concluded that overweight people had lower mortality than people of normal weight.5
Obesity and fat stigma
Even most sceptics agree that being fat (and higher levels of obesity in particular) may increase some health risks; what they object to is the sometimes hysterical level of concern that is voiced about fat. Remember here that in 2006 the US Surgeon General declared that obesity was a worse public threat than terrorism. And if part of you is insisting, 鈥榊es, but I still can鈥檛 believe that being fat is not really unhealthy,鈥� remember too that, even with the dramatic rises in obesity, globally there are 40 per cent more people with malnutrition than people who are obese and although, to quote the World Food Organization, 鈥榟unger kills鈥�, politicians and journalists don鈥檛 talk about a 鈥榮tarvation epidemic鈥�. Remember also the quote from Public Health England cited earlier in this article that obesity has a comparable health risk to smoking; why then is it social blasphemy to be fat but still cool in some circles to smoke, as a study on the association between smoking and popularity in teens showed recently?6 Bottom line, there may be health risks from being fat, but the heightened level of concern seems like a cultural phenomenon.
Why is fat stigma not more widely recognised? Few people today would openly make comments about individuals on the basis of their race, gender or sexuality, but these categories are all part of the list of legally protected characteristics covered by the UK鈥檚 2010 Equality Act. There is however nothing in law to stop anyone acting in a discriminatory manner against a fat person. Indeed, fat stigma has been described as 鈥榦ne of the last socially acceptable forms of discrimination鈥�.7 And like obesity, fat stigma is increasing globally. In fact research suggests that in the US it is increasing even faster than obesity itself, up from seven per cent in 1996 to 12 per cent in 2006. In one large US study women ranked being overweight as the third most common cause of discrimination, with 21 per cent of moderately obese women reporting experiences of discrimination, rising to 45 per cent among those with higher BMIs (35+).8
How does fat stigma affect fat people?
Research suggests that fat people are seen as (among other things) lazy, undisciplined, lacking will power, unmotivated, non-compliant, less healthy, lower in self-esteem, sloppy, unattractive, untidy, less sexually attractive/active and disagreeable. They are seen as thinking more slowly, having poorer work habits and attendance and generally being less competent in the workplace.9 They are also seen as less likely to benefit from counselling.10
There is a growing body of research that evidences the impact of these beliefs in a wide array of contexts. For example, in the context of employment, weight-based discrimination has been found to influence hiring, promotion and pay, with fat individuals in large scale surveys earning significantly less than their thin counterparts, even when other factors (such as education or training) are accounted for. There is accumulating evidence that fat stigma plays out in educational settings too, with teachers endorsing fat stereotypes, fat school children and college students reporting experiences of bias in educational settings and data suggesting that the educational attainment of fat students is lower, even when things like parental income and intelligence are taken out of the analyses.
In the context of interpersonal relationships, many fat people report that they have experienced fat bias from family and friends and their fat means they are less likely to be seen by others as an attractive romantic partner. There is also lots of evidence that doctors, nurses, medical students, fitness professionals and dieticians endorse anti-fat views, and there is growing evidence that fat stigma negatively influences medical professionals鈥� weight management practices. Perhaps unsurprisingly, perceptions of fat stigma from doctors and other medical professionals also make fat patients less likely to seek medical attention. There is even some evidence that fat stigma plays out in mental health settings, with a handful of studies finding that fat clients are seen as more pathological and having more and worse symptomology, as well as being more emotionally unstable, impulsive and intolerant of change than clients considered to be of normal weight.
It is worth noting the overlap between the earlier cited 鈥榝acts鈥� about fat people and the research findings about the impact of fat bias. For example, poorer health outcomes for fat patients may be partly related to the impact of fat stigma on their medical treatment and use of medical services. In the same way, while research links being fat to depression, research also links perceived experience of fat stigma with increased likelihood of depression. Fat stigma has also been linked to reduced self-esteem, poor body image and, ironically, maladaptive eating and less physical activity. In other words, fat stigma is itself a potential risk factor for obesity. Overall, it is possible that the link between poor outcomes and being fat is strongly mediated by fat stigma, so it is the stigma about fat rather than the fat itself that is responsible for the negative outcomes.
Fat in the counselling room
But how does fat affect counselling? Therapy has a long history of replicating the prejudices of the outside world in the therapy room, to the detriment of clients 鈥� see, for example, the 鈥榤icroaggressions鈥� literature on the impact of racial and heterosexist prejudice in counselling. Irvin Yalom鈥檚 case study 鈥楾he Fat Lady鈥�11 could be seen as an example of the impact of fat stigma for clients; Yalom writes plainly about his disgust of fat women (which it turns out was crystal clear to his fat client), and he never questions that therapeutic success is measured in terms of his client鈥檚 weight loss. There is however thus far a notable lack of research on how fat clients experience counselling.
What about fat therapists? There is a small theoretical and case study literature that argues that the body shape/weight of a therapist does matter to clients. For example, Gubb12 suggests that, because there is a prohibition on the therapist sharing personal information, the body assumes additional importance for clients, offering a place to read information about the therapist and a rich site for transference. There is also a tiny research base on the impact of therapist weight/shape on clients with eating disorders, which provides evidence that therapist weight/shape can be important for clients. Online discussion of one of these papers13 provides further anecdotal evidence: 鈥楾his was a major issue with all of my therapists and many times we (patients) spent time talking to each other about our therapists鈥� weight/size and feeling uncomfortable with their advice because of it.鈥� In addition, there is a little research focused on fat doctors and nurses14 and this suggests that fat medical professionals are likely to be seen by both medical professionals and patients as less credible and trustworthy, with the consequence that it is assumed that patients will be less likely to follow their professional recommendations.
However, as with clients, we do not really know how a therapist being fat affects therapeutic interactions as research is 鈥� again 鈥� lacking. One can however extrapolate from all the research on fat stigma that being a fat therapist is likely to evoke fat stigma in at least some clients, which in turn may affect the therapeutic alliance, itself a robust predictor of client outcome. Or to put it another way, fat stigma may mean that fat counsellors are less effective counsellors.
Colleagues and I asked a group of over 200 young adults (aged 16鈥�24) to respond to a story completion task about a fat therapist. Our aim was to explore how a group that is particularly prone to body pressures might make sense of fatness in the counselling room. We are still analysing the data but preliminary findings show clearly that participants interpret therapist fatness as a sign of physical and psychological ill health. The assumption is that fat therapists are fat not only because they take no exercise and gorge on junk food but also because they engage in emotional eating, and if they are doing that they must be psychologically troubled in some way. Fatness thus becomes a signifier of mental instability and this, given the professional context, is fatally discrediting. In the words of one participant: 鈥楬ow could that help me?鈥� What our study thus seems to suggest is that, while fat stigma may operate across varied employment contexts, it may be particularly negative for therapists.
Our study involved a story stem where the client Kate enters the counselling room and immediately thinks: 鈥楳y counsellor is fat!鈥� This exclamation could be seen as a statement of shock, horror, disgust or joy, but the vast majority of our participants assumed the thought was negative. Many immediately sought to un-write the apparent expression of fat stigma by telling stories in which Kate realises that it is not nice to judge people on appearances. It appears that expressions of fat stigma for this group are rude, even in the context of an entirely anonymous, non-autobiographical storytelling task.
What are the implications of this for a counselling interaction? Notably, many of the stories that expressed this politeness dictum also expressed fat stigma by, for example, describing in unattractive detail the fat therapist鈥檚 jowls, rolls of flesh and rivulets of sweat. Further, given the argument made here about the pervasiveness of fat stigma, it seems implausible that a counsellor being fat will not have an impact, even if a client is too polite to mention it directly to their therapist.
To come back to the questions posed earlier, does it matter to the profession if therapists are fat? My thought is that fatness in therapists 鈥� as well as fatness in clients 鈥� is likely to affect counselling, and not in positive ways, given fat stigma. On this basis I suggest that it matters to the profession that there is so little research on these topics.
As to whether it is possible to be too fat to be ethically 鈥榝it鈥� to practise, I would suggest that it is highly likely that some clients and some counsellors may judge fat therapists so. However, rather than simply and uncritically swallowing the current obesity discourse, I would suggest that the profession needs to think about raising awareness of fat stigma as an issue of social justice and ethical concern.
Dr Naomi Moller is a self-proclaimed 鈥楩at Therapist鈥� and psychology lecturer at the Open University. Trained as a counselling psychologist, Naomi has worked as a counselling trainer and counsellor.听
References
1. American Medical Association. AMA adopts new policies on second day of voting at Annual Meeting.Press release. 18 June. Chicago: AMA; 2013.
2. Public Health England. About obesity. [Online.] (accessed 11 November 2014).
3. Butland B, Jebb S, Kopelman P, McPherson M, Thomas S, Mardell J, Parry V. Foresight: tackling obesities: future choices. Project report (2nd ed). London: Government Office for Science; 2007.
4. Bean MK, Stewart K, Olbrisch M. Obesity in America: implications for clinical and health psychologists. Journal of Clinical Psychology in Medical Settings 2008; 15(3): 214鈥�224. doi:10.1007/s10880-008-9124-9.
5. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 2013; 309(1): 71鈥�82. doi:10.1001/jama.2012.113905.
6. Valente TW, Fujimoto W, Soto D, Ritt-Olson A, Unger JB. A comparison of peer influence measures as predictors of smoking among predominately Hispanic/Latino high school adolescents. Journal of Adolescent Health 2013; 52(3): 358鈥�364. doi:10.1016/j.jadohealth.2012.06.014.
7. Puhl R, Brownell KD. Stigma, discrimination and obesity. In: Fairburn CG, Brownell KD (eds). Eating disorders and obesity: a comprehensive handbook (2nd ed). New York: The Guildford Press; 2002 (pp108鈥�112).
8. Puhl RM, Andreyeva T, Brownell KD. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. International Journal of Obesity 2008; 32: 992鈥�1000. doi:10.1038/ijo.2008.22.
9. Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity 2009; 17: 941鈥�964.
10. Davis-Coelho K, Waltz J, Davis-Coelho B. Awareness and prevention of bias against fat clients in psychotherapy. Professional Psychology: Research and Practice 2000; 31: 682鈥�684. doi: 10.1037//0735-7028.31.6.682.
11. Yalom ID. The fat lady. In: Yalom ID. Love鈥檚 executioner and other tales of psychotherapy. New York: Basic Books; 1989 (pp87鈥�117).
12. Gubb K. Re-embodying the analyst. Psycho-analytic psychotherapy in South Africa 2013; 21(1): 1鈥�27.
13. Rance NM, Clarke V, Moller NP. 鈥業f I see somebody鈥� I鈥檒l immediately scope them out:鈥� anorexia nervosa clients鈥� perceptions of their therapist鈥檚 body. Eating Disorders 2014; 22 (2): 111鈥�120.
14. Puhl RM, Gold JA, Luedicke J, DePierre JA. The effect of physicians鈥� body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice. International Journal of Obesity 2013; 37 (11): 1415鈥�1421.