A Clinician’s Guide to Acceptance-Based Approaches for Weight Concerns

The Accept Yourself! Framework

Margit Berman

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351654272
• Edition: 1
• Topic: Psychologie
• Subtopic: Abnormale Psychologie

This clinician manual presents the Accept Yourself! Program, which is derived from empirically supported interventions (including Acceptance and Commitment Therapy and Health At Every Size) that have a demonstrated ability to enhance women's mental and physical health. This book offers a clear, research-based, and forgiving explanation for clients' failure to lose weight, helpful guidance for clinicians who are frustrated with poor client weight loss outcomes, as well as a liberating invitation to clients to give up this struggle and find another way to achieve their dreams and goals.

Part 1

Why Use an Acceptance-Based Approach to Weight Management?

Introduction

Choosing and Using a Self-Acceptance-Based Approach: Cautions and Language

This book is written for clinicians who help clients with body image and weight concerns, and who have watched clients try and fail at various behavioral strategies to lose weight and feel better about themselves and their bodies. If you are frustrated with your inability to help clients achieve lasting improvement in their weight and body image concerns, this book is for you. You may already know that both you and your clients need a new path to wellness and self-acceptance. This book shows you that path. Inside this book you will find a clear, research-based, and forgiving explanation for clients’ frequent failures to lose weight and keep it off, as well as helpful guidance for how to respond effectively to these poor outcomes, without frustration or increasing clients’ shame. Finally, this book offers you and your clients a liberating invitation to give up ineffective struggles with weight loss and body image. In its place, you will be provided with a powerful and unexpected new route to help your clients achieve their dreams, wellness goals, and hope for healthy body image and self-esteem.

Part 1 of this book provides a rationale for a self-acceptance-based approach to client weight concerns and helps you understand why a radically different approach to these concerns may offer greater improvement for your clients. In Part 1, you’ll find an overview of research on this and alternative approaches, as well as exercises to help you identify and remove any barriers you may have to offering self-acceptance-based treatments skillfully and ethically.

Part 2 provides a guide to conducting self-acceptance-based treatment. You’ll find information and exercises to help your clients develop a new acceptance of their bodies and their relationship with food. Techniques to help clients identify and commit to their values related to food, body image, movement, and life in general are taught, including guidance to help clients tackle their most troublesome mental and practical barriers along the way.

Part 3 focuses on special problems you might encounter when implementing Accept Yourself! How to conduct informed consent for this treatment and effectively manage your clients’ weight loss expectations are covered here, as well as termination issues at the end of treatment, and when to consider group-based versus individual treatment. This section will help you troubleshoot common problems that arise in Accept Yourself! treatment, and also help you address the common situation where clients have comorbid weight-related physical health concerns for which weight loss is often recommended.

When to Choose Accept Yourself!

Accept Yourself! is a novel treatment approach. There is preliminary evidence, reviewed in Chapter 3, to suggest that it is feasible, safe, and may be efficacious as a treatment for depression, when delivered in a group format to women with both depression and obesity. Accept Yourself! draws on both Acceptance and Commitment Therapy and Health At Every Size® treatment paradigms. These two treatment paradigms, also reviewed in detail in Chapter 3, have some evidence to suggest they may be efficacious as treatments for weight management, eating disorders, and enhancing physical wellness in a variety of populations. As such, it appears reasonable to offer the Accept Yourself! approach to clients presenting with these concerns. However, Accept Yourself! explicitly does not promise or expect client weight loss, and both clients and clinicians must understand and accept this prior to engaging in this treatment strategy. Both Chapter 4 and Chapter 13 provide clinician strategies for conducting informed consent about the Accept Yourself! approach. These chapters explore both how to help clients identify appropriate and worthwhile treatment goals, as well as how to help clients develop realistic expectations about weight loss. However, Accept Yourself! is not appropriate for clients who remain exclusively committed to weight loss as a goal following an informed consent process and completion of the strategies in Chapter 4. Such clients may benefit from a different therapeutic strategy or referral for additional help with their goals.

In addition, Accept Yourself! has not been tested as a treatment for eating disorders, such as anorexia nervosa or bulimia nervosa, and the treatment strategies contained in this book may not be sufficient to effectively treat these disorders. Because clients presenting for weight loss help or with body image concerns are likely to be at increased risk of eating disorders, clinicians should screen clients for these disorders, and may wish to refer them for multidisciplinary eating disorders treatment either in lieu of or concurrently with using the Accept Yourself! approach. The Eating Disorder Diagnostic Scale (Stice, Telch, & Rivzki, 2000) is a free brief screening tool clinicians may find helpful in identifying clients who would benefit from eating disorders treatment.

A Word about Language

Choosing appropriate, non-judgmental, comfortable language to describe clients’ bodies and their emotions and thoughts related to their bodies is complex and can be awkward. In this book, I use the word “obesity” or “obese” (or, more rarely, “overweight”) when discussing research findings or classifications based on Centers for Disease Control cutoffs for body mass index (BMI) classification (see Chapter 1). These cutoffs are somewhat arbitrary and have varied substantially over time (Kuczmarski & Flegal, 2000). Apart from when I use these words in reference to the research literature which makes use of them, they are not used in this text, and I do not recommend their use with clients, although clinicians are often comfortable with these “clinical” words. The word “obesity” is problematic because it implies that obesity is in and of itself pathological, and represents a disease state. The American Medical Association did, indeed, vote in 2013 to classify obesity as a disease, hoping to increase insurance company reimbursement for obesity treatments. However, it did so against the recommendation of its own Council on Science and Public Health, which it had commissioned to study the issue and make recommendations, and the decision to classify obesity as a disease remains controversial (Stoner & Cornwall, 2014). Given that many individuals who meet the current classification for obesity in terms of BMI are metabolically (and otherwise) healthy, use of the word obesity to describe clients’ body size is inappropriate. Similarly, the word “overweight” implies that, for a given individual, there is a known, optimal weight for health, which that individual exceeds. As will be discussed further in Chapter 1, evidence supporting this claim is thin, making the word “overweight” inappropriate.

In general, in this book, the words “fat” or “larger-bodied” are used to describe individuals with larger-than-average body sizes. Like “short,” “tall,” or “slender,” “fat” can be a simple descriptive word to denote body type. However, it is also a stigmatized word that can be used, by itself, as a slur. There is a movement among size acceptance activists to “take back” this word, as lesbian, gay, bisexual, and transgender activists took back the word “queer,” and I am in support of this effort. Therefore, the word “fat” is used frequently, and non-judgmentally, throughout the book. It is the position of this treatment program that being fat is not inherently problematic or pathological, and thus not a state that needs to be changed. Instead, fat is a body type, like tall, or short, that can be referred to lightly, in passing, as one might describe one’s own height. Clients may or may not wish to use this word for themselves, and their wishes should be elicited and respected, although clinicians may want to discourage clients self-identifying as “overweight” or “obese.” A variety of other non-judgmental or positive terms for a larger-than-average body are also possible, including “larger-bodied” (used frequently in this text as a non-judgmental synonym for “fat”), “abundant,” “plus-sized,” “curvy,” etc. In general, words that convey judgment of body size, whether positive or negative, are avoided in this book, although positively valenced words may have clinical value for clients who have been taught that fatness is disgusting or objectionable. However, words like “abundant” or “curvy” are not used in this book or its accompanying self-help book, both because the treatment program treats weight as a neutral (neither positive nor negative) human characteristic, and because the use of euphemisms can imply judgment about the word (“fat”) being avoided by their use. In addition, this book occasionally uses the term “average-weight,” to describe body sizes that are close to the numerical mean for Americans (a BMI of 27 for both men and women, which the Centers for Disease Control classifies as “overweight”). Words that denote larger-than-average body size are obviously not accurate for average-weight individuals, regardless of BMI category.

Clinicians using the Accept Yourself! approach should choose a non-judgmental, non-pathologizing word or set of words to use to describe client body size and shape, and should discuss their word choices with clients, who can be surprised or distressed if the clinician refers to them as “fat” without prior discussion and consent. Using positive or neutral words suggested by the client, and offering a brainstorm of possibilities, can also enhance therapeutic alliance and help encourage self-acceptance.

References

Kuczmarski, R. J., & Flegal, K. M. (2000). Criteria for definition of overweight in transition: Background and recommendations for the United States. The American Journal of Clinical Nutrition, 72(5), 1074–1081.

Stice, E., Telch, C. F., & Rizvi, S. L. (2000). Development and validation of the Eating Disorder Diagnostic Scale: A brief self-report measure of anorexia, bulimia, and binge-eating disorder. Psychological Assessment, 12(2), 123–131.

Stoner, L., & Cornwall, J. (2014). Did the American Medical Association make the correct decision classifying obesity as a disease? The Australasian Medical Journal, 7(11), 462–464.

1The Science of Obesity and Weight Loss

Why Weight Control Doesn’t Work

Client Weight Loss Goals: Changing the Conversation

Clients often present to treatment hoping to lose weight. In the U.S., weight loss goals are normative in women and very common in men: 57 percent of American women and 40 percent of men report trying to lose weight within the past year (Yaemsiri, Slining, & Agarwal, 2011), and the prevalence of weight loss efforts have increased over time (Montani, Schutz, & Dulloo, 2015). Thus, therapists and helpers can expect to see clients frequently who want behavioral help with weight loss efforts. And therapists have reason to be concerned about those efforts and their role in facilitating them, because weight loss efforts affect clients’ mental and physical health. Dieting failures increase clients’ risk of depression (Markowitz, Friedman, & Arent, 2008) and eating disorders (Stice, 2002), as well as worsened cardiometabolic health (Montani et al., 2015). Encouraging clients to engage in weight loss efforts that are not likely to be successful thus raises important ethical questions. An unsuccessful weight loss attempt is likely to have negative effects beyond simply not achieving its aims. Thus, it is important that if clinicians offer clients weight loss help, they should have confidence that the weight loss intervention is evidence based, with data to show that it will lead to substantial long-term weight loss in line with the clients’ goals. Non-evidence-based interventions, or interventions with demonstrated lack of long-term weight loss efficacy, potentially put clients’ physical and mental health at risk.

What do we have to offer clients in the way of evidence-based interventions for weight loss? Both you and your clients may be surprised to discover what the scientific literature has to say about evidence-based weight loss, as well as about the causes and consequences of overweight and obesity.

If Our Clients Feel like Failures, They’re in Good Company

All weight loss interventions except bariatric surgery have poor long-term efficacy. Longitudinal, naturalistic studies of weight loss efforts undertaken by people in the “real world” find that weight loss efforts predict long-term weight gain and the onset of obesity even in previously normal or underweight individuals (Neumark-Sztainer, et al., 2006; 2012; Stice, Cameron, Killen, Hayward, & Taylor, 1999). Unhealthful or eating disordered behaviors, such as fasting, self-induced vomiting, or use of laxatives, predict greater weight gain, but all efforts, even more appropriate or healthful behaviors like exercise or eating more fruits and vegetables (if these behaviors are done in order to lose weight), predict weight gain (Neumark-Sztainer et al., 2006).

However, results from longitudinal, naturalistic studies cannot tell us that weight loss efforts actually cause weight gain. It’s possible that biases in self-reporting dieting behavior affect the results, or that a third variable causes both dieting and weight gain, even in thin individuals. Or, it is possible that weight loss efforts do cause weight gain in naturalistic samples, but only because they are poorly implemented in uncontrolled settings. To evaluate these questions it is reasonable to look at the randomized controlled trial (RCT) literature on weight loss interventions.

An important caveat in analyzing the results of RCTs for any intervention is that RCTs likely overstate the benefits of any intervention, for several reasons. First, full-scale RCTs are expensive and difficult to conduct, and typically require grant funding resources to accomplish. Funders, such as the National Institutes of Health, typically require pilot trials or other concrete evidence that the intervention researchers are seeking to evalu...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Part 1 Why Use an Acceptance-Based Approach to Weight Management?
• Part 2 Accept Yourself! Skills and Techniques
• Part 3 Special Situations in Treatment
• Index