ORIGINAL PAPER

Health at Every Size and Acceptance and Commitment Therapyfor Obese, Depressed Women: Treatment Developmentand Clinical Application

Margit I. Berman1• Stephanie N. Morton1

• Mark T. Hegel1

Published online: 12 October 2015

� Springer Science+Business Media New York 2015

Abstract Treatments for women with obesity, depres-

sion, and body image concerns are not optimal. Weight loss

programs lead to long-term weight gain for most partici-

pants, and even successful participants typically sustain

only modest weight loss. Psychotherapy for depression is

more effective, but as many as 50 % do not fully remit.

When depression and obesity co-occur in women, out-

comes are even more modest. Innovative treatments are

needed to enhance the physical and mental health of obese,

depressed women. The goal of the current paper is to

describe the development of a treatment that integrates two

innovative approaches for mental and physical self-accep-

tance. The Health at Every Size (HAES) paradigm, used to

enhance physical health without encouraging weight loss,

causes improvements in physical health among overweight

participants that are longer-lasting than weight loss pro-

grams. Acceptance and Commitment Therapy (ACT)

focuses on valued life behaviors and acceptance of painful

emotions. ACT is efficacious for depression and as an

adjunct to obesity treatment, and may be more effective for

treatment-resistant depression than standard approaches.

An integrated HAES/ACT treatment, known as Accept

Yourself! and its manual is described in this paper, with

information about how we adapted HAES and ACT

approaches to create the intervention, as well as clinical

strategies for implementation.

Keywords Health at every size � Acceptance and

commitment therapy � Obesity � Depression

Introduction

More than one third of women are obese [defined by the

Centers for Disease Control as a body mass index

(BMI) C 30; Ogden et al. 2012]. Major Depressive

Disorder (MDD) has a lifetime prevalence of 16.6 %, and

women are 70 % more likely than men to have MDD

(Kessler et al. 2005). Depression is even more common

among obese women (Simon et al. 2008). Obesity is not an

eating disorder, and most obese people do not engage in

recurrent binge eating (American Psychiatric Association

2013). However, obesity is associated with body image

dissatisfaction (Friedman and Brownell 1995), especially

among women seeking treatment (Schwartz and Brownell

2004). Although treatment-seeking obese women may not

meet behavioral criteria for eating disorders, they are much

more likely to be depressed (Fitzgibbon et al. 1993), and

body image dissatisfaction partially mediates their

depressive symptoms (Friedman et al. 2002), suggesting

that cognitive symptoms of eating disorders may affect

depression among this group.

Treatment options for depression and obesity treated as

separate concerns are not optimal. Weight loss strategies

frequently lead to weight gain. Among young women,

weight loss efforts predict long-term weight gain and onset

of obesity, even among the initially normal and under-

weight (Neumark-Sztainer et al. 2006; Stice et al. 1999).

Behavioral weight loss programs evaluated in randomized

controlled trials also have poor outcomes. Most partici-

pants actually regain more weight than they lose in such

programs without experiencing other significant health

& Margit I. Berman

Margit.I.Berman@dartmouth.edu

1 Department of Psychiatry, Geisel School of Medicine at

Dartmouth, Dartmouth-Hitchcock Medical Center, 1 Medical

Center Drive, Lebanon, NH 03756, USA

123

Clin Soc Work J (2016) 44:265–278

DOI 10.1007/s10615-015-0565-y

improvements (Mann et al. 2007). Pharmacotherapies for

obesity are not effective (Rucker et al. 2007), and bariatric

surgery is invasive, with significant health risks (Gracia

et al. 2009). Depression treatments are more promising, but

as many as 50 % of treated patients fail to achieve full

remission (Holtzheimer and Mayberg 2011).

When obesity and depression occur together in women,

the challenges of treatment are even more daunting. Obese

adults are two to four times as likely to be depressed as

those of normal weight (Pagoto et al. 2007; Simon et al.

2008), and obese women presenting for treatment are even

more likely to have significant depressive symptoms

(Fitzgibbon et al. 1993) or a depressive disorder (Gold-

smith et al. 1992). In women, depression and obesity also

have a complex, bidirectional relationship. Obesity is a risk

factor for depression in women (Roberts et al. 2003) and

some research suggests that depression predicts later

weight gain and obesity in women, but not men

(Richardson et al. 2003).

Prescribing weight loss for depressed, obese women is

risky, in part because they experience poorer weight loss

outcomes. Unsuccessful dieting has been associated with

depression in some research (Clark et al. 1996) and some

studies have found that depressed individuals in weight loss

programs lose less weight (Roberts et al. 2003), are more

likely to drop out (Clark et al. 1996), and regain more

weight (McGuire et al. 1999). In addition to the greater risk

of weight gain in depressed, obese women, common

treatments for each condition can worsen the other.

Antidepressant medications may cause weight gain. Diet-

ing, dieting failure, and weight cycling also may play a

causal role in depression, with cognitive, behavioral, and

biological pathways all theorized to explain these effects

(Markowitz et al. 2008; Ross 1994). If dieting increases

risk for depression and causes weight gain, weight loss

interventions may worsen both conditions.

The relationship between depression and obesity in

women is further complicated by the stigma of obesity

(Brownell et al. 2005). Obese individuals experience more

discrimination than normal weight individuals (Carr and

Friedman 2005). Weight stigma can be internalized, such

that obese people endorse negative stereotypes about

themselves (Durso and Latner 2008). Size-based discrimi-

nation and internalized stigma are both associated with

depressive symptoms, binge eating, weight gain, and

worsened physical health (see Puhl and Heuer 2010, for a

review). Weight-based discrimination and/or internaliza-

tion of weight bias may contribute to increased depression,

which in turn may increase risk of poor health (Pearl et al.

2014; Puhl and Heuer 2010).

Despite the evidence for a complex, interactive rela-

tionship among depression, body image dissatisfaction,

stigma, and obesity in women, there is a lack of research on

interventions for co-morbid depression and obesity. Some

behavioral interventions for the comorbid concerns have

been tested (Linde et al. 2011; Pagoto et al. 2013), but have

not shown enhanced efficacy for obesity or depression

beyond existing interventions. Although social workers

have been encouraged to educate themselves about size-

based discrimination in serving their obese clients (Lawr-

ence et al. 2012), no intervention specifically addresses size

discrimination, weight stigma, or body image concerns, nor

do existing interventions ameliorate the risks of prescribing

dieting for depressed women.

Innovative Interventions for Comorbid Depression

and Obesity

Because of the limited efficacy of existing treatments that

focus on controlling depression and obesity, researchers

have begun to develop innovative interventions that focus

on self, body, and emotional acceptance as an alternative

means to improve physical and mental health. These

strategies differ from traditional treatments for depression

and obesity in that the goal of these treatments is not to

control one’s mood, weight, or shape, but instead to learn

to experience, accept, and behave adaptively with fluctu-

ating mood states and negative thoughts and feelings (in-

cluding internalized stigma and other negative thoughts

and feelings about one’s body).

The Health at Every Size (HAES) paradigm is used to

enhance physical health without encouraging weight loss.

The term ‘‘Health at Every Size’’ is a trademark of the

Association of Size Diversity and Health, an organization

for HAES professionals. HAES principles were developed

as a community effort by civil rights groups fighting size

discrimination as well as nutritionists, researchers, and

therapists working on weight management from a non-diet

or intuitive eating perspective (Bacon 2008). Clinical

social workers have been on the forefront developing the

HAES paradigm, through organizations such as the Size

Diversity Coalition of Social Workers as well as the work

of individual social work scholars (e.g., Bruno 1996; Matz

and Frankel 2004). HAES promotes improvements in

physiological health, health behaviors, and psychosocial

outcomes among obese participants that appear to be

longer-lasting than weight loss programs, and participants

are more adherent to HAES (Bacon and Aphramor 2011).

However, HAES does not address depression, nor has it

been studied in depressed women.

Acceptance and Commitment Therapy (ACT) is a form

of psychotherapy that focuses on emotional acceptance

(rather than control) of painful emotions, as well as valued

life behaviors. The goal of ACT is to understand, explain,

and affect private experiences, such as thoughts and emo-

tions, by focusing on an analysis of the functional context

266 Clin Soc Work J (2016) 44:265–278

123

surrounding these experiences (Zettle 2011). Although

social workers were not instrumental in the creation of

ACT, they have been involved in researching and dis-

seminating it (Montgomery et al. 2011), and the Associa-

tion for Contextual Behavioral Science includes a Social

Work and ACT Special Interest Group. ACT is well-suited

to the practice of social work because both share a focus on

context, strengths, and understanding human suffering in

ways that avoid pathologizing individuals and communities

(Association for Contextual Behavioral Science 2011).

ACT has been used for a variety of client problems, and

has shown efficacy for depression, with some research

suggesting that it may be more effective for treatment-

resistant depression (Markanday et al. 2012), and with

longer lasting effects (Forman et al. 2012) than standard

cognitive behavioral therapies. ACT conceptualizes psy-

chopathology as arising not from the experience of nega-

tive mood states, but from inflexibility and maladaptive

efforts to control these negative mood states. Thus,

although ACT focuses on acceptance and flexible behav-

ioral responding to negative mood states, such as sadness,

ACT nevertheless is a treatment for depressive (and other)

disorders, and expected treatment outcomes from ACT

(i.e., depression remission) do not differ from expected

treatment outcomes of other types of psychotherapy. There

is preliminary evidence that integrating ACT with obesity

treatment may improve outcomes and adherence (Lillis

et al. 2009), but no research or published treatment pro-

tocol has integrated the HAES and ACT approaches.

The goal of this paper is to describe the development of

a group-based program to enhance the physical and mental

health of obese women with Major Depressive Disorder.

This program, known as Accept Yourself! adapts existing

ACT and HAES treatment strategies into an integrated

program to enhance mental and physical health. Accept

Yourself! has particular relevance for social workers, as it

avoids stigmatizing or victim-blaming attributions for

obesity and depression, and instead approaches wellness

from a strengths perspective, empowering participants to

fight systemic size discrimination. The model also educates

women on the influence of the media and size discrimi-

nation on their health and wellness, which fits with social

workers’ emphasis on social justice and preserving the

dignity and worth of individuals. No efficacy data about the

Accept Yourself! model are yet available; however, a goal

of the present article is to provide initial information about

participants’ subjective experiences of the program,

including specific interventions and general aspects of

treatment that participants found helpful or unhelpful. In

addition, this article describes the treatment manual and

how we adapted existing strategies to craft the program, as

well as discussing practical aspects of implementing the

treatment. Our aim in publishing this treatment is to

stimulate additional research on acceptance-based approa-

ches to obesity and comorbid depression, as well as to

provide clinicians with an alternative approach for use with

obese, depressed clients for whom traditional treatments

have been ineffective.

ACT and HAES: An Overview

ACT conceptualizes psychopathology not as the presence

of psychological pain, which is seen as normal to the

human condition, but as psychological inflexibility. ACT

suggests that clients are engaged in a maladaptive struggle

with negative internal experiences, guided by unhelpful

social-verbal rules for living. Therefore, ACT therapists do

not seek to eliminate psychological pain. The main goal of

ACT instead is to help clients develop psychological

flexibility, that is, to weaken the link between negative

internal experiences and maladaptive behavior, and to

strengthen clients’ abilities to behave in line with their

goals and values even when doing so puts them into contact

with unpleasant thoughts, emotions, or sensations. To

increase psychological flexibility, ACT teaches six core

processes: (1) awareness of the self as context, (2) defu-

sion, (3) contact with the present moment, (4) acceptance,

(5) values identification, and (6) committed action (Hayes

et al. 2013).

Similarly, HAES does not conceptualize weight or

obesity as a problem, instead pointing out that the evidence

linking health problems to weight is more tenuous than

many assume, and that it is not clear whether weight loss is

a helpful solution. HAES suggests that well-being and

healthy habits are more important than weight per se, and

teaches four principles: (1) Accept your size and appreciate

the body you currently have; (2) Trust yourself and your

own internal cues to hunger, satiety, and appetite for

guidance about eating; (3) Adopt healthy lifestyle habits

(i.e., strengthening connections with others, seeking pur-

pose and meaning in life, finding the joy in moving your

body and becoming more physically vital, eating pleasur-

able and satisfying foods, tailoring your tastes to enjoy

more nutritious foods, including less nutritious choices in

an overall healthy lifestyle), and (4) Embrace size diver-

sity, finding beauty in and respect for a diversity of body

sizes and shapes (Bacon 2008).

HAES and ACT are readily integrated. HAES’ size

acceptance principle fits well with ACT’s acceptance pro-

cess. HAES’ trust yourself principle can be conceptualized

as an extension of the ACT contact with the present

moment process. HAES tenets regarding adopting healthy

lifestyle habits are often mentioned by participants during

ACT values identification. Finally, the HAES principle of

embracing size diversity includes elements of ACT defu-

sion from prior cultural rules and ‘‘programming’’ about

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the thin-ideal, as well as acceptance and awareness of the

self as context. In clinical application, both HAES and

ACT typically begin with an exploration of participants’

previous efforts at controlling their problem, and in both

cases the focus is on exploring and identifying the inef-

fectiveness of these control strategies. This is accomplished

in ACT through ‘‘creative hopelessness’’ and ‘‘control as a

problem’’ interventions and in HAES through a review of

research on the ineffectiveness of traditional approaches to

weight management and validation of participants’ expe-

riences with weight loss.

Development of the Accept Yourself! Program

In order to create an integrated HAES/ACT treatment for

depression and obesity in women, we developed and are

evaluating a manualized group treatment, called Accept

Yourself! Although the program was designed for group-

based delivery, and we consider a group format optimal,

the program can be adapted for self-help and individual

therapy approaches. The treatment manual was developed

by adapting a variety of existing ACT sources (e.g., Hayes

et al. 1999, 2012; Heffner and Eifert 2004) and HAES and

size-acceptance sources (e.g., Bacon 2008; Harding and

Kirby 2009). Some new material was also developed.

Exercises, discussion, video and reading material were

developed or adapted to meet the needs of obese, depressed

women. Two initial groups of women completed the draft

intervention, and were interviewed about their experiences.

Qualitative analyses of these interviews were used itera-

tively to improve the intervention. For example, women

offered feedback that they wanted a workbook that would

compile the group exercises and allow them to retain

information better. Therefore, a self-help workbook was

developed to adapt all group exercises and discussion into a

format women could use during, in between, and after

group meetings. The manual is still undergoing research

and refinement, and the version presented here should be

considered a work-in-progress open to both clinical and

empirical refinement.

Structure of the Treatment

The current treatment consists of 11 weekly 2-h group

sessions, designed for a group of 10-12 women. Future

iterations to the manual may add a 9-week 60-min physical

exercise ‘‘sampler’’ component, to run concurrently with

the psychotherapy group, as group participants have asked

for this to enhance their physical health. The group is

structured as a closed group with a single facilitator.

Material in each session builds on the previous session. All

sessions include the assignment of behavioral homework,

and each session (except for session 1) includes a

30–60 min review of the previous week’s homework,

where participants report on progress, offer feedback, and

receive assistance with homework implementation. Each

group includes a 5–10 min refreshment break, during

which participants are encouraged to mindfully and non-

judgmentally enjoy a variety of high-quality, minimally

processed refreshments. Sweets or snack foods such as

tortilla chips are available as part of the refreshments at

every group. The remaining 50–85 min include new dis-

cussion and psychoeducational material, experiential

exercises, and homework assignments. Women are

encouraged to offer one another social support outside of

group: They are offered the opportunity to add their name

to a shared ‘‘support list,’’ and the facilitator prompts

women to ask for help or company from group members to

complete homework.

Treatment Content

An outline of all exercises, psychoeducational content,

metaphors, and other material included in each of the 11

sessions can be found in Table 1, along with sources when

material was adapted from others’ work. (The homework

review at the start of each session is omitted from the

table.) A complete draft treatment manual is available on

request from the authors. Below we discuss the compo-

nents of the integrated treatment, organized by the core

processes and principles of the interventions. It is important

to note that the stated goals for the Accept Yourself! pro-

gram did not include weight loss or elimination of negative

moods. Instead, the goals included acceptance of partici-

pants’ bodies and moods as they are, as well as increased

pursuit of important life values that had been blocked by

negative thoughts, feelings, or experiences with weight,

shape, eating, and moods.

Weight and Mood Control as a Problem

Sessions 1 and 2 focus on ACT creative hopelessness

processes and a review of research on weight and depres-

sion in order to explore how well efforts to eliminate

depression and lose weight have worked. Participants are

asked if the problem has gotten better or worse over time, if

their weight has increased or decreased overall, if their

mood and body image have improved. Their efforts are

validated, and research is reviewed illustrating that wors-

ening problems in these areas despite control efforts are not

unusual.

Awareness of the Self as Context

Many obese women have the experience of living as a

‘‘floating head.’’ As author Kate Harding (2008) describes,

268 Clin Soc Work J (2016) 44:265–278

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Table 1 Description of session content

Session Content and source Description and adaptations

1 Welcome and introductions Participants introduce themselves, read and agree to ground rules, create and circulate

a support list

1 The body disparagement free zone (Burgard

2011a)

Participants discuss that the group is a ‘‘body disparagement free zone’’ and were

given doorhangers. Participants learn that it is possible to have negative body

judgments, but not to act on them

1 Naming problem and costs (p. 114a)

1 Body image timeline (pp. 102–103b) In addition to pointing out values and body image struggles over time, participants are

asked whether weight, depression, and body dissatisfaction have improved or

worsened over time

1 What have you tried? (p. 114)a

2 Creative hopelessness (pp. 95–101a) Effort is validated. Participants evaluate their strategies. Participants write down and

show hands how many years have passed since this problem began. Has it gotten

better, worse, or stayed the same?

2 The casino Facilitator provides this metaphor, which notes that weight loss and mood change

‘‘games’’ may be like casinos, which engender hopes of winning, even though the

game is rigged

2 A surprising review of the research A review and discussion of research and theory on weight loss outcomes, why weight

loss efforts may lead to weight gain, ‘‘healthy eating,’’ obesity mortality, and

depression treatment outcomes

2 The fantasy of being thin and happy (Harding

and Kirby 2009, pp. 211–221)

Adapts Kate Harding’s Fantasy of Being Thin essay to include fantasies of mental

health. For homework, they are asked to read this essay, and to pursue one oftheir ‘‘fantasy’’ elements now

3 Living Your Health Fantasy (Bacon 2008,

286–288; Bacon and Matz 2010)

Participants received results of pre-group physical health screenings (lipids, blood

glucose, blood pressure). Participants with abnormal results receive individualized,

non-weight-loss health suggestions

3 What are the numbers? (pp. 95–101a)

3 Programming (pp. 95–101a) ‘‘Programming’’ is defined as messages we’ve received about body weight, shape,

appearance, and emotions. The Identifying Programming exercise is adapted to

include a variety of sources (e.g., media)

3 Media influences (Ellis 1961; Media

Education Foundation 2012)

Participants view and discuss information about sociocultural influences on women

3 The media diet A one-week ‘‘media diet’’ where participants turn off media and engage in physical

activities

4 Programming changes how we see ourselves

(My Body Gallery 2015)

A web resource for body image comparisons which participants are invited to interact

with as homework

4 What do you really look like? Participants mindfully observe their own faces, writing down thoughts that arise.

Then they describe each other’s faces. Women compare the descriptions: Which is

more accurate? Neither is accurate

4 Volume button metaphor Participants hear that programming can’t be turned off. It will always be chattering.

But, it can be turned down: refused as a guide to life choices. The idea of ‘‘tuning

in’’ via mindfulness is presented

4 Skills for tuning in: nonjudgmental skill

(Linehan 1993, p. 113)

4 Mindfulness (pp. 65–75b)

4 Mindfulness/my body gallery Daily mindfulness using a choice of several audio tracks, and interaction with body

gallery website

5 Let’s begin with mindfulness (p. 73b) An in session mindfulness exercise

5 Is there a bomb in your mind? (pp. 152–153a) Participants ‘‘make’’ and then ‘‘sit with’’ an imaginary bomb, using their

minds/words. A variation on the ‘‘finding a place to sit’’ exercise to introduce

defusion

5 How believable are thoughts? (p. 38b)

5 Introduction to acceptance (pp. 79–80b) Active acceptance is illustrated with a steamroller metaphor, and contrasted with

passive acceptance

5 Self-acceptance with movement: yoga in a

large body (Pugh 2011)

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Table 1 continued

Session Content and source Description and adaptations

5 Committing to Acceptance (p. 128b) Participants are asked to practice willingness to sign and display a ‘‘Commitment to

Self-Acceptance’’

5 Difficult situations (pp. 82–83b) Generate a list of difficult situations for acceptance practice

6 Let’s begin with mindful movement (Pugh

2011)

6 Practice self-acceptance by experiencing (p.

84b)

Participants organize their difficult situations list into a hierarchy, and are trained how

to approach these situations. A roller coaster metaphor is introduced to stop

participants from avoiding during acceptance

6 Difficulties with self-acceptance: size

discrimination

Facilitator reviews research on size discrimination. Participants discuss their

experiences. Their experiences are validated and discrimination is described as

wrong and unacceptable

6 Producing your own programming An ‘‘airwaves’’ metaphor is used to help participants envision creating their own

‘‘programming’’ about weight and shape, even while having negative mental chatter

about body image. Resources are provided

6 Homework Continue with mindfulness, face a first difficult situation, and begin to create a self-

judgment-free zone

7 Mindful movement (CSH 2010)

7 Continuing with self-acceptance Offers a ‘‘mountain’’ metaphor for fluctuating emotions as participants face difficult

situations

7 ‘‘Our body is precious. It is our vehicle for

awakening.’’ (Kornfield 1994)

This Buddhist teaching, and the goal of driving your ‘‘vehicle’’ toward the life you

want is discussed

7 The value of nourishing yourself Participants are reminded that food has never been just fuel, and discuss the roles

food can play.

7 How do you want to eat? (pp. 95–101a) Participants learn that food can express programming or values. They are given an

‘‘identifying food programming’’ homework exercise to identify eating-related

programming

7 From diets to foodways The term ‘‘foodway’’ is defined as a conscious way of eating that expresses values

7 What do you want to eat for? Exploration and illustration of values-driven foodways. Brainstorming values to

express through eating

7 Homework Experiment with a foodway, continue mindfulness/difficult situations, and identify

food programming

8 What if food is not something i value? (Sattyr

2015)

Facilitator reminds participants that food ultimately is necessary for life and health.

Definition of normal eating is reviewed and participants to discuss ways their own

eating is ‘‘normal’’ or ‘‘not so normal’’

8 Normal eating: places to start (Bacon 2008,

pp. 193–208; Herrin 2013)

Facilitator reviews guidelines for how to engage in ‘‘normal eating,’’ and encourages

participants who suspect they may engage in binge eating or disordered eating to

begin with Dr. Herrin’s food plan

8 Eating for health (Bacon, pp. 209–253) Facilitator discusses and personalizes guidelines for eating for good health

8 Continuing with self-acceptance

8 Embodying your values Participants are reminded that appearance and activity can reflect programming or

promote values

8 Mindful dance (Chastain 2012a) Participants engage in warm up from this dance video

8 What would you do with your body if you

were thin and happy?

Participants generate (and problem-solve barriers to) physical activities from their

fantasies of being thin and happy

8 Homework Try a foodway or normal eating, continue mindfulness/difficult situations, try a

physical activity

9 Mindful Movement (Chastain 2012a) Entire dance video

9 Continuing with self-acceptance

9 Fashion without self-hatred A collage is shown and discussed of large women in a various fashionable, revealing,

or creative clothes

9 The elephant in drag (Kinzel 2010) Participants read and discuss this passage.

9 Fashion resources Exploration of a range of plus-size retailers and fashion blogs. Participants discuss

their own resources

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‘‘So many of us go through our lives as fat people doing

our very best to ignore our bodies entirely, to pretend

they’re just not there, because thinking about these

shameful vessels we live in is so painful.’’ For these

women, attachment to this conceptualized self may exclude

the body and its experiences, including hunger and satiety

cues, desires for movement, internal cues related to phys-

ical health, and behaviors that render the body visible, such

as revealing clothing. The conceptualized self in depression

may include thoughts about being a failure or worthless

(including being a failure or worthless because of inability

to lose weight). A variety of interventions are used to help

participants connect to the ‘‘observer self,’’ the sense of self

as a vessel for a variety of internal experiences that change

over time. In addition to observing mental experiences,

these interventions help participants observe their bodies’

changing sensations in a nonjudgmental fashion. These

interventions are not presented as a discrete block of

material, because interventions that enhance the sense of

self as context also often enhance contact with the present

moment, acceptance, and defusion (described below) as

well.

Defusion and Embracing Body Diversity

Cognitive fusion, in ACT, refers to the experience of

treating mental and verbal constructs literally, such that

simply thinking the words ‘‘I am a failure’’ leads to

behavioral and other outcomes (e.g., tearfulness, avoid-

ance, depressed feelings) rather than observing that these

words are in fact simply thoughts, not objective realities or

negative experiences in and of themselves. Defusion

involves achieving psychological distance from these

thoughts or feelings, noticing them without responding to

them. Defusion in Accept Yourself! begins with exercises to

help participants identify thoughts they are fused with and

to notice that these are arbitrary pieces of ‘‘programming’’

which they did not choose (e.g., see Table 1 for exercises

such as ‘‘What are the numbers?’’ or ‘‘Programming’’).

Participants then mindfully observe this programming

(including that which relates to body image and weight

stigma, e.g., ‘‘Media Influences on Self Image’’), and the

concept of defusion is introduced (‘‘Is there a bomb in your

mind?’’). Finally, participants are encouraged to embrace

size diversity by producing their own programming,

Table 1 continued

Session Content and source Description and adaptations

9 Fashion without self-hatred: Ideas for

experimenting (Ahmad 2008)

Facilitator encourages weaving acceptance with fashion by wearing clothes they

‘‘can’t wear’’ or feel uncomfortable wearing, and gives guidelines/resources

9 Homework Continue previous week’s homework, try a self-presentation experiment, read Ahmad

essay

10 Mindfulness (Burgard 2011b)

10 Continuing self-acceptance (p. 248a) A ‘‘swamp’’ metaphor is offered to illustrate how acceptance can move you closer to

values

10 Revisiting the fantasy of being thin and happy Participants review their fantasy to uncover values. They create a collage using

attractive photos of large women engaging in activities as well as other photos to

imagine the life they’d like to be living now

10 Valuing (pp. 105–107b) Values are defined, distinguished from goals, and the ‘‘compass heading’’ metaphor is

provided to explain how values and goals relate. Participants complete the values

narrative as homework

10 Values and barriers (Harding 2009,

pp. 229–230a; Pausch 2008)

Barriers to valued living are discussed using ‘‘bubble in the road’’ and ‘‘brick wall’’

metaphors. An essay example is provided. Participants identify and schedule valued

physical and other activities

10 Your next adventures Participants identify aspects of the group they want to continue to practice after group

10 Homework Experience their next difficult situations, complete the values assessment, engage in a

valued activity, read the essay, practice activities they want to continue, and to bring

to the last group a treat to share

11 Mindful dance party (Chastain 2012b) The intention is set that the final group be a celebration of participants. Participants

dance together

11 The big look (pp. 371–372a)

11 Moving forward/keeping in touch Participants schedule activities they want to continue and discuss how to keep in

touch

Bold type identifies homework assignments assigned at sessionsa An exercise adapted from Hayes et al. (1999)b Adapted from Heffner and Eifert (2004)

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responding to stigmatized cultural messages with values-

driven messages of their own. A variety of diverse images

of fat women engaging in valued life activities are pre-

sented throughout the group, to increase defusion from

shame-based images and enhance participants’ ability to

embrace size diversity.

Contact with the Present Moment and Learning to Trust

Internal Cues

Mindfulness skills are taught as a foundation for accep-

tance practice, and to counteract the experience of being a

‘‘floating head.’’ Mindfulness exercises practiced in and

outside of group include mindful awareness of physical

sensations, movement, and eating. These exercises help

participants connect with the present moment in their

bodies and minds. By learning to experience and inhabit

their bodies, participants are also taught to trust internal

cues for experiences such as hunger, fullness, satiety,

craving for particular foods, desires to move, and internal

sensations in response to movement.

Self-Acceptance

Self-acceptance skills are the core of Accept Yourself!

Experiential acceptance of negative moods, thoughts, and

sensations is fostered via creation of an acceptance hier-

archy (Difficult Situations, adapted from Heffner and Eifert

2004) that helps participants identify and experience situ-

ations they are avoiding related to food, body image, and

moods. Difficult thoughts are also identified and mindfully

observed, and participants sign and prominently display a

commitment to self-acceptance. Size discrimination is

discussed as a potential barrier to acceptance practice and

valued living, and participants troubleshoot how to respond

to discrimination. The emphasis is on accepting one’s body

and emotions as they are, and treating oneself with

compassion.

Committed Action Toward a Valued Healthy Lifestyle

Obese, depressed women have fantasies about how their

lives would improve if only their weight, shape, and moods

could be controlled. The group uses Kate Harding’s essay,

the Fantasy of Being Thin (Harding and Kirby 2009), to

discuss these dreams. Participants’ Fantasies of Being Thin

and Happy are a rich source of information about their

values, and include dreams related to a variety of valued

behaviors, such as having sex, dating, engaging in sports or

outdoor activities, wearing fashionable clothing, or being

free to eat delicious foods. The goal of pursuing these

valued domains of life directly, without waiting for weight

loss or perfect mental health as a prerequisite, is presented

early in the group. Through a variety of experiential

activities, participants pursue their fantasies and navigate

barriers to attain a valued lifestyle that includes the HAES

principles of strengthening connections with others, seek-

ing purpose and meaning in life, finding the joy in moving

their bodies and becoming more physically vital, eating

pleasurable and satisfying foods, and tailoring their tastes

to include a balance of more nutritious and less nutritious

foods. The valued domains of eating, physical activity,

fashion and self-presentation are each the focus of one

group session, with an additional session focused on

identifying and committing to values-driven behaviors in

other life domains.

Clinical Considerations and Challenges

Implementing Accept Yourself! provided potential benefits

to participants, and gave rise to some challenges. We will

discuss practical clinical considerations, as well as how we

managed these challenges, below.

Benefits of the Group Format

Although the manual could be adapted for self-help or

individual therapy, we consider group delivery optimal.

Participants experience the self-acceptance message of the

group as novel, even countercultural. A group of peers who

have faced (and sometimes conquered) similar struggles

helps participants undertake acceptance and committed

action behaviors. For example, one participant noted that

her Fantasy of Being Thin and Happy included getting a

massage, but that she had never done this, because she did

not want to subject the massage therapist to her ‘‘disgust-

ing’’ body. A second participant responded by giving her

the card for her massage therapist, explaining that she had

gotten massages regularly, and the therapist had never

shamed her body. This kind of peer-to-peer support for

valued behavior is highly compelling. In addition, the

creative hopelessness intervention is more powerful when

experienced in a group. Participants who are fused with the

idea that they remain fat and depressed because of their

inherent laziness and lack of motivation are able observe

that others’ lists of ineffective strategies to lose weight and

feel better represent substantial, even Herculean, effort, and

that if these strategies have not worked for anyone in the

group, perhaps it is the strategies and not the participants

who are to blame.

Creating a Body Disparagement Free Zone

The group encourages participants to create a Body Dis-

paragement Free Zone (Burgard 2011a). Participants are

asked to notice that even though their minds may produce

272 Clin Soc Work J (2016) 44:265–278

123

negatively judgmental ‘‘chatter’’ about their own and oth-

ers’ weight, shape, eating, and movements, it is possible to

witness these thoughts without acting on them by voicing

them aloud. Participants are given the Body Disparagement

Free Zone doorhangers and are asked to hang them at

home, and a similar doorhanger is hung on the group door

during sessions. However, participants do make body dis-

paraging comments about themselves and others during

group. This is mostly either self-directed or directed at

photographs displayed during group, but can include

invalidating comments about other participants, as well.

For example, a larger participant may comment disparag-

ingly about a smaller participant’s ‘‘feelings of fatness.’’

When any form of this occurs, the group facilitator points it

out, stops the behavior, and asks participants to observe

these thoughts as thoughts without acting on them, creating

a norm within the group that such comments are not

acceptable, although the thoughts that give rise to them are

to be expected (and accepted). In addition, when such

comments are directed at peers or photographs, they rep-

resent an opportunity to discuss how participants wish to

approach size diversity within the group, and what their

values are related to making comments about other

women’s appearance. Therapist comments about these

participant comments can be experienced as embarrassing,

an emotion which participants can be encouraged to

experience and tolerate in service to their values. For

example, one participant described this as follows (‘‘P’’

refers to participant; ‘‘T’’ to therapist; comments are

derived from qualitative interviews described below):

P: ‘‘This was exactly what I needed: A little slap on my

hand to sometimes close my mouth and not to say

something that really might have been hurtful to other

women there. I thought about it at home a lot. This was

when you were showing women, fat women, some of

them just with their underwear and they looked kind of

…. you know…. not too aesthetic. You know. But I

thought that at that time; now I don’t.’’

T: ‘‘Sounds like you were hurt at that time.’’

P: ‘‘Yeah. I think I may have offended other people and I

didn’t think about it.’’

Inadequate Social Support and Size Discrimination

Institutionalized size stigma means that participants often

have little support for efforts to engage in acceptance

exercises or healthful behaviors. Behaviors such as wearing

a bathing suit, going to a gym, or eating feared foods in

public may expose participants not only to negative inter-

nal experiences, but to external discrimination and criti-

cism. Accept Yourself! includes strategies, validation, and

discussion of these experiences, and participants are

encouraged to use one another to enhance willingness to

engage in difficult behaviors. For example, participants can

wear swimsuits and go to the beach together, if they are

unwilling to engage in this behavior alone. As one partic-

ipant described it, ‘‘And if you were gonna hike or go

shopping, there was always somebody who volunteered to

come with you and it was… I think that’s very helpful.’’

Waiting for a Control Strategy that Never Comes

Participants in our research program were screened for

willingness to engage in a non-diet, non-weight loss

approach to health, and such willingness was an inclusion

criterion for study participation. Nevertheless, treatment-

seeking depressed obese women expect to be prescribed

weight loss, and they may consider weight loss a prereq-

uisite for mental and physical health. Participants often did

not believe that weight loss was not an aim of the program,

nor that engaging in treatment would not cause weight loss,

regardless of how many times this was discussed in group.

Some participants remained fused with the idea that weight

loss was necessary to achieve health even despite group

participation. For example, when asked about unhelpful or

detrimental aspects of the program, one participant

responded:

P: ‘‘Um. I wouldn’t say detrimental. I think the

acceptance, that you’re not gonna change, you’re not

gonna get thin, this is not about losing weight. That’s the

hardest one to take, and you, you think you’re there, and

then you get knocked back down. … Um, it, it’s not

detrimental, but it was the hardest part, is the actual

acceptance, like, oh, this is how I am, and this is fine,

and I don’t need to work so hard to try to change it

because it’s not gonna change.’’

T: ‘‘Uh huh. Well, sounds like that was a really difficult

mental shift to make.’’

P: ‘‘Well, I never…I don’t remember hearing you say

that it wasn’t about weight loss. I, the whole time, was

thinking, okay, where’s the trick?’’

Ongoing creative hopelessness strategies, enthusiastic

support for body diversity and display of a variety of

images of fat women engaging in valued health behaviors,

and clear communication about the aims of the group may

help to address this problem. Having fat female facilitators

may also make this message more persuasive.

Depressing Stressors

Group members are often coping with depressogenic life

events outside of group. Caregiving for elderly family

members, family drug addiction, financial limitations,

relationship conflicts, loneliness, and other stressors

Clin Soc Work J (2016) 44:265–278 273

123

unrelated to body image were issues raised in our pilot

groups. Such stressors contribute to participants’ pain, and

yet the nature of the manualized treatment means there is

limited time to discuss them. For example, one patient,

when asked what might have helped her more in the group

stated,

P: ‘‘Maybe talking more about what was, you know,

what the main issues were. And less about weight.’’

T: ‘‘So that sounds like, for you, if you could have talked

more about what was going on with your [family

member] and some of those other issues and gotten some

support earlier that might have helped more.’’

P: ‘‘I think, yeah.’’

Participants can be encouraged to use one another for

social support around stressors, and discussion of stressors

in group can include how to implement mindfulness,

acceptance, and committed action with them.

‘‘Comforting’’ One Another

When emotion arises during group, participants sometimes

seek to control their own distress about this by encouraging

peers to stop displaying emotion, for example by speaking

to them, ‘‘comforting’’ them, passing tissues, etc. This

behavior can be gently noted and stopped by the facilitator,

and used as an opportunity for everyone to observe and

experience the difficult emotions that arise when we wit-

ness pain.

Participants’ Experiences with the Program

Twenty-one women in two groups have completed the

Accept Yourself! program as part of a research project

refining and pilot testing the intervention. The research

project was approved by our institution’s Institutional

Review Board, and informed consent was obtained from all

participants. Participants were required to be English-

speaking obese (BMI C 30) adult women who met criteria

for Major Depressive Disorder and were at least moder-

ately depressed. Participants were excluded if they were

currently abusing substances, had a history of psychosis,

were at high risk of suicide or self-harm, were unwilling to

try a non-dieting approach to health, were currently in a

weight-loss program or psychotherapy, had weight loss

surgery in the past year, or could not postpone other weight

loss or depression treatment. Participants who had made

recent changes to their medications or were taking

antipsychotic, tricyclic, or oral corticosteroid medications

were also excluded. Participants’ mean age was 49 (range

23–66), and their mean BMI was 37 (range 31–50). They

were 91 % White.

After completing the group, participants were asked a

series of qualitative interview questions about their expe-

riences. Specifically, they were asked: (1) What aspects of

this program have you found helpful? Why? (2) What

aspects of this program have you found unhelpful or

detrimental? Why? (3) Which aspects of this program did

you think were most important for making life changes? (4)

How did this program compare to other treatments for

depression or obesity you have had? (5) Apart from things

you experienced in the program, what would have helped

you improve your mental and physical health even more?

What did you wish we had included in the program? and

(6) What did you think of the patient handouts, presenta-

tions, or other materials you received during the program?

What would you improve? Are you still using any of these

materials? How?

To assist with manual development, a list of all activi-

ties, handouts, and major concepts (items) covered in the

group was created. Participant answers to the qualitative

interview questions were tabulated according to how many

participants mentioned each item as helpful (i.e., helpful,

important for making life changes, still in use) or unhelp-

ful. A net helpfulness score was generated for each item by

subtracting the number of unhelpful mentions from the

number of helpful mentions. Items participants suggested

we add to the program were tabulated separately.

Figure 1 displays the specific interventions participants

mentioned as helpful or unhelpful. Figure 2 displays other

aspects of group, apart from the specific interventions, that

were identified as helpful or unhelpful. Figure 3 displays

the changes participants requested to the program. Partic-

ipants voiced a high level of satisfaction with the inter-

vention, identifying few aspects as unhelpful. In terms of

specific interventions, participants identified mindfulness,

the difficult situations exercise, and the review of research

on weight, shape, and mood as most helpful. The most

helpful general aspect of the intervention was the mutual

support from group members. A focus on self-acceptance

rather than shame or stigmatization was a major theme

participants emphasized as helpful, especially in compar-

ison to other treatments. In the first iteration of the group,

the most requested change to the program was for a note-

book that included all materials, notes, and space to jour-

nal, which led to the development of a comprehensive

patient self-help workbook, with adaptations of all mate-

rials (available in draft form upon request from the first

author). Women in both groups mentioned wanting more

time with the intervention, in the form of a longer group, a

‘‘graduates group,’’ and/or additional time outside of group

to do activities together. As described above, we are con-

sidering adding a group activity and movement component

that would address this suggestion.

274 Clin Soc Work J (2016) 44:265–278

123

Fig. 1 Specific group activities

and interventions described as

helpful or unhelpful by

participants. Activity labeled

‘‘Group 1’’ was changed for the

second group, and all

helpfulness data displayed here

for that activity come from

Group 1

Clin Soc Work J (2016) 44:265–278 275

123

Limitations and Future Directions

Although participants generally expressed satisfaction with

the intervention and described many elements as helpful,

this offers little information about the clinical outcomes or

potential risks, if any, of group participation. In addition,

we collected no data on the presence or absence of eating

disorders in our participants. We are currently pilot-testing

and refining Accept Yourself! in a series of small groups

assessed prior to and after the group, and at a three-month

follow up visit. We plan to conduct a small randomized

controlled trial comparing Accept Yourself! to weight loss

as a treatment for depression and enhanced physical health

(e.g., improved metabolic fitness, increased physical

activity), and we plan to include assessment of eating

disorders in that trial. The qualitative feedback reviewed

Fig. 2 General, non-specific

aspects of group identified as

helpful or unhelpful. Aspect

labeled ‘‘Group 2’’ was only

available for the second group

of women, and all mentions

came from this second group

Fig. 3 Changes participants

requested to the program.

Change labeled Group 1 was

implemented for the second

group, and all mentions of this

change therefore came from

Group 1

276 Clin Soc Work J (2016) 44:265–278

123

here suggests that participants considered the program

helpful, and future research should validate this impression

in terms of clinical efficacy. In addition, research on the

applicability of Accept Yourself! for women with comor-

bid eating disorders as well as depression, would enhance

our knowledge of the utility of this approach.

Acknowledgments This research was supported in part by a Grant

from the Geisel School of Medicine Department of Psychiatry.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflict

of interest

Ethical Approval All procedures performed in this study were in

accordance with the ethical standards of our institutional review board

and with the 1964 Helsinki declaration and its amendments or com-

parable ethical standards.

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