Cover Story

Size does matter, according to recent research that shows therapists' perceptions and prognoses for their obese clients may be swayed by body-size stereotypes.

In fact, studies have shown that therapists expect less positive treatment outcomes for such clients and perceive them as more symptomatic and self-conscious as well as less physically attractive and engaged in treatment than more slender clients.

The biases are a product of a weight-obsessed culture, says Kristen Davis-Coelho, PhD, a clinical psychologist at Washoe Medical Center in Reno, Nev., who has studied the topic. But Davis-Coelho says she hopes that through therapists' self-assessment and education on their size prejudices, the field can become more "fat-friendly."

Hidden bias

Particularly alarming are findings that even specialists in obesity fall prey to negative associations when working with obese patients. For example, a recent study found that even health professionals--including psychologists--who specialize in obesity often used words such as "lazy," "stupid" and "worthless" to describe obese people they come into contact with in their personal and professional lives, according to a September 2003 study published in Obesity Research (Vol. 11, No. 9) by Marlene B. Schwartz, PhD, Heather O'Neal Chambliss, PhD, Kelly Brownell, PhD, Steven N. Blair and Charles Billington, MD. The researchers used a self-report questionnaire and the Implicit Associations Test--a timed measure to test automatic biases--to assess the attitudes of clinicians and researchers who work with obese patients.

Findings from such studies, researchers say, may affect professionals' behavior toward their obese clients. For instance, they may blame patients for their obesity. Moreover, this obesity stigma may cause obese patients to avoid care altogether, the researchers note.

Also, it appears that weight influences patient diagnosis and treatment. In one study, Davis-Coelho found that therapists were more likely to diagnose an eating disorder for fat clients and cite "improve body image" and "increase sexual satisfaction" as treatment goals--even when the clients did not mention sexual difficulties--than for average-weight clients. The research appeared in the December 2000 issue of Professional Psychology: Research and Practice (Vol. 31, No. 6).

For the study, Davis-Coelho sent 500 APA members a questionnaire and photograph of an obese or regular-weight woman with self-descriptions from the "client." She then surveyed the psychologists on their perceptions of the client from the photograph and self-descriptions.

Younger mental health professionals and those with fewer years of experience had the greatest bias in treatment toward fat clients, she found. Davis-Coelho speculates that this is because of experienced therapists' exposure to a broad range of clients, which likely mitigates stereotypical judgments. In addition, she adds, older therapists may have dealt with weight issues themselves, so they may be less prone to biases than younger or less experienced therapists.

Raising awareness

To help counter such biases, three psychology doctoral students at the University of Akron have been speaking at health conferences to raise providers' awareness about fat biases in the hopes of tipping the scales (see page 61). Deb Esty, Claudia Sadler Gerhardt and Sally Diegelman began collaborating a year ago after working separately on eating disorders research.

"We need to talk about size as an issue of diversity where there is discrimination," says Gerhardt, a third-year counseling student. "There needs to be good empirical research going on in this area, and not just through the lens of the medical profession--where obesity equals bad."

Esty says she hopes she and her colleagues will eventually be able to develop a measure of how fat relates to the physical and psychological health of clients, similar to measures developed for racism and feminism in the multicultural literature.

Further Reading

  • Davis-Coelho, K., Waltz, J., & Davis-Coelho, B. (2000). Awareness and prevention of bias against fat clients in psychotherapy. Professional Psychology: Research and Practice, 31(6), 682-684.

  • Schwartz, M., O'Neal Chambliss, H., Brownell, K., Blair, S., & Billington, C. (2003). Weight bias among health professionals specializing in obesity. (9), 1033-1039.