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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
Clin Soc Work J (2016) 44:265–278 267
123
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)
Clin Soc Work J (2016) 44:265–278 269
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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
270 Clin Soc Work J (2016) 44:265–278
123
‘‘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)
Clin Soc Work J (2016) 44:265–278 271
123
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.
References
Ahmad, M. W. (2008, May 10). Guest post: 28 days to a bikini mind.
Shapely prose. Retrieved from http://kateharding.net/2008/05/
20/guest-post-28-days-to-a-bikini-mind/
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Washington, DC: Author.
Association for Contextual Behavioral Science. (2011). Social work
and ACT special interest group. Retrieved from https://
contextualscience.org/Social_Work_ACT_SIG
Bacon, L. (2008). Health at every size. Dallas: BenBella Books.
Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the
evidence for a paradigm shift. Nutrition Journal, 10(9), 2–13.
Bacon, L., & Matz, J. (2010). Intuitive eating: Enjoy your food,
respect your body. Diabetes Self-Management, 27(6), 44–51.
Brownell, K., Puhl, R., Schwartz, M., & Rudd, L. (Eds.). (2005).
Weight bias: Nature, consequences and remedies. New York:
The Guilford Press.
Bruno, B. A. (1996). Worth your weight: What you can do about a
weight problem. London: Routledge Books.
Burgard, D. (2011a). Doorhangers. Retrieved from http://www.
bodypositive.com/doorhangers.htm
Burgard, D. (2011b). Gratitude for this body: A meditation. Retrieved
from http://www.bodypositive.com/meditation_g.htm
Carr, D., & Friedman, M. A. (2005). Is obesity stigmatizing? Body
weight, perceived discrimination, and psychological well-being
in the United States. Journal of Health and Social Behavior,
46(3), 244–259.
Center for Spirituality and Healing [UMNCSH]. (2010, December 22).
Chair yoga (video file). Retrieved from https://www.youtube.com/
watch?feature=player_embedded&v=6mi_2LMJFdo&list=
PL2BDBE9A4EE79CA28
Chastain, R. (Producer). (2012a). Every body dance now beginner’s
class: Love to love you by Candye Kane (video file). United
States: Producer.
Chastain, R. (Producer). (2012b). Every body dance now beginner’s
class: Smoke and leather by Darci Monet (video file). United
States: Producer.
Clark, M. M., Niaura, R., King, T. K., & Pera, V. (1996). Depression,
smoking, activity level, and health status: Pretreatment predic-
tors of attrition in obesity treatment. Addictive Behaviors, 21(4),
509–513.
Durso, L. E., & Latner, J. D. (2008). Understanding self-directed
stigma: Development of the Weight Bias Internalization Scale.
Obesity, 16(S2), S80–S86.
Ellis, A. (1961). The folklore of sex. NYC: Grove Press.
Fitzgibbon, M. L., Stolley, M. R., & Kirschenbaum, D. S. (1993).
Obese people who seek treatment have different characteristics
than those who do not seek treatment. Health Psychology, 12(5),
342.
Forman, E. M., Shaw, J. A., Goetter, E. M., Herbert, J. D., Park, J. A.,
& Yuen, E. K. (2012). Long-term follow-up of a randomized
controlled trial comparing acceptance and commitment therapy
and standard cognitive behavior therapy for anxiety and
depression. Behavior Therapy, 43(4), 801–811.
Friedman, M. A., & Brownell, K. D. (1995). Psychological correlates
of obesity: Moving to the next research generation. Psycholog-
ical Bulletin, 117(1), 3–20.
Friedman, K. E., Reichmann, S. K., Costanzo, P. R., & Musante, G. J.
(2002). Body image partially mediates the relationship between
obesity and psychological distress. Obesity Research, 10(1),
33–41.
Goldsmith, S. J., Anger-Friedfeld, K., Rudolph, D., Boeck, M., &
Aronne, L. (1992). Psychiatric illness in patients presenting for
obesity treatment. International Journal of Eating Disorders,
12(1), 63–71.
Gracia, J. A., Martınez, M., Elia, M., Aguilella, V., Royo, P., Jimenez,
A., et al. (2009). Obesity surgery results depending on technique
performed: Long-term outcome. Obesity Surgery, 19(4),
432–438.
Harding, K. (2008, June 22). If no one mentions it, it doesn’t exist!
Shapely prose. Retrieved from http://kateharding.net/2008/06/
22/if-no-one-mentions-it-it-doesnt-exist/
Harding, K. (2009, April 10). Bachelorettes, bathing suits, etc.
Shapely prose. Retrieved from http://kateharding.net/2009/04/
10/bachelorettes-bathing-suits-etc/
Harding, K., & Kirby, M. (2009). Lessons from the fat-o-sphere: Quit
dieting and declare a truce with your body. NYC: Penguin
Perigee.
Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., &
Pistorello, J. (2013). Acceptance and commitment therapy and
contextual behavioral science: Examining the progress of a
distinctive model of behavioral and cognitive therapy. Behavior
Therapy, 44(2), 180–198.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance
and commitment therapy: An experiential approach to behavior
change. NYC: Guilford Press.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance
and commitment therapy (2nd ed.). NYC: Guilford Press.
Heffner, M., & Eifert, G. H. (2004). The anorexia workbook: How to
accept yourself, heal your suffering, and reclaim your life.
Oakland: New Harbinger.
Herrin, M. (2013). Herrin food plan. Retrieved from http://www.
eatingdisorderguides.com/HerrinFoodPlan.2013.pdf
Holtzheimer, P. E., & Mayberg, H. S. (2011). Stuck in a rut:
Rethinking depression and its treatment. Trends in Neuro-
sciences, 34(1), 1–9.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R.,
& Walters, E. E. (2005). Lifetime prevalence and age-of-onset
distributions of DSM-IV disorders in the National Comorbidity
Survey Replication. Archives of General Psychiatry, 62(6), 593.
Kinzel, L. (2010, January 28). Q&A: On dressing femme, being a bad
fat, and changing the FA blogosphere. Two whole cakes. Retrieved
from http://blog.twowholecakes.com/2010/01/q-a-on-dressing-
femme-being-a-bad-fat-and-changing-the-fa-blogosphere/
Kornfield, J. (1994). Buddha’s little instruction book. New York:
Bantam.
Clin Soc Work J (2016) 44:265–278 277
123
Lawrence, S. A., Hazlett, R., & Abel, E. M. (2012). Obesity related
stigma as a form of oppression: Implications for social work
education. Social Work Education, 31, 63–74.
Lillis, J., Hayes, S., Bunting, K., & Masuda, A. (2009). Teaching
acceptance and mindfulness to improve the lives of the obese: A
preliminary test of a theoretical model. Annals of Behavioral
Medicine, 37, 58–69.
Linde, J. A., Simon, G. E., Ludman, E. J., Ichikawa, L. E.,
Operskalski, B. H., Arterburn, D., et al. (2011). A randomized
controlled trial of behavioral weight loss treatment versus
combined weight loss/depression treatment among women with
comorbid obesity and depression. Annals of Behavioral Medi-
cine, 41(1), 119–130.
Linehan, M. (1993). Skills training manual for treating borderline
personality disorder. New York: Guilford Press.
Mann, T., Tomiyama, A. J., Westling, E., Lew, A. M., Samuels, B., &
Chatman, J. (2007). Medicare’s search for effective obesity
treatments: Diets are not the answer. American Psychologist,
62(3), 220–233.
Markanday, S., Data-Franco, J., Dyson, L., Murrant, S., Arbuckle, C.,
McGillvray, J., & Berk, M. (2012). Acceptance and commitment
therapy for treatment-resistant depression. Australian and New
Zealand Journal of Psychiatry, 46(12), 1198–1199.
Markowitz, S., Friedman, M. A., & Arent, S. M. (2008). Under-
standing the relation between obesity and depression: Causal
mechanisms and implications for treatment. Clinical Psychol-
ogy: Science and Practice, 15(1), 1–20.
Matz, J., & Frankel, E. (2004). Beyond a shadow of a diet: The
therapist’s guide to treating compulsive eating disorders. New
York: Routledge.
McGuire, M. T., Wing, R. R., Klem, M. L., Lang, W., & Hill, J. O.
(1999). What predicts weight regain in a group of successful
weight losers? Journal of Consulting and Clinical Psychology,
67(2), 177–185.
Media Education Foundation (ChallengingMedia). (2012, August 24).
Killing us softly 4: Advertising’s image of women (trailer).
Retrieved from https://www.youtube.com/watch?v=jWKXit_
3rpQ&feature=iv&src_vid=PTlmho_RovY&annotation_id=anno
tation_493134379
Montgomery, K. L., Kim, J. S., & Franklin, C. (2011). Acceptance
and commitment therapy for psychological and physiological
illnesses: A systematic review for social workers. Health and
Social Work, 36(3), 169–181.
My Body Gallery. (2015). My body gallery. Retrieved from http://
www.mybodygallery.com/
Neumark-Sztainer, D., Wall, M., Guo, J., Story, M., Haines, J., &
Eisenberg, M. (2006). Obesity, disordered eating, and eating
disorders in a longitudinal study of adolescents: How do dieters
fare 5 years later? Journal of the American Dietetic Association,
106(4), 559–568.
Ogden, C. L., Carroll, M. D., Kit, B. K., Flegal, K. M. (2012).
Prevalence of obesity in the United States, 2009–2010. NCHS
data brief, no. 82. Hyattsville, MD: National Center for Health
Statistics.
Pagoto, S., Bodenlos, J. S., Kantor, L., Gitkind, M., Curtin, C., & Ma,
Y. (2007). Association of major depression and binge eating
disorder with weight loss in a clinical setting. Obesity, 15(11),
2557–2559.
Pagoto, S., Schneider, K. L., Whited, M. C., Oleski, J. L., Merriam,
P., Appelhans, B., et al. (2013). Randomized controlled trial of
behavioral treatment for comorbid obesity and depression in
women: The Be Active Trial. International Journal of Obesity,
37(11), 1427–1434.
Pausch, R. (2008). The last lecture. New York: Hyperion.
Pearl, R. L., White, M. A., & Grilo, C. M. (2014). Weight bias
internalization, depression, and self-reported health among over-
weight binge eating disorder patients. Obesity, 22(5), E142–E148.
Pugh, S. (Producer). (2011). Grateful spirit yoga: Expanding into
fullness (DVD). United States: Producer.
Puhl, R. M., & Heuer, C. A. (2010). Obesity stigma: Important
considerations for public health. American Journal of Public
Health, 100(6), 1019–1028.
Richardson, L. P., Davis, R., Poulton, R., McCauley, E., Moffitt, T.
E., Caspi, A., & Connell, F. (2003). A longitudinal evaluation of
adolescent depression and adult obesity. Archives of Pediatrics
and Adolescent Medicine, 157(8), 739–745.
Roberts, R. E., Deleger, S., Strawbridge, W. J., & Kaplan, G. A.
(2003). Prospective association between obesity and depression:
Evidence from the Alameda County Study. International Jour-
nal of Obesity, 27(4), 514–521.
Ross, C. E. (1994). Overweight and depression. Journal of Health and
Social Behavior, 35, 63–79.
Rucker, D., Padwal, R., Li, S. K., Curioni, C., & Lau, D. C. (2007).
Long term pharmacotherapy for obesity and overweight: updated
meta-analysis. BMJ, 335, 1194–1199.
Sattyr, E. (2015). What is normal eating? Retrieved from http://
ellynsatterinstitute.org/hte/whatisnormaleating.php
Schwartz, M. B., & Brownell, K. D. (2004). Obesity and body image.
Body Image, 1(1), 43–56.
Simon, G. E., Ludman, E. J., Linde, J. A., Operskalski, B. H.,
Ichikawa, L., et al. (2008). Association between obesity and
depression in middle-aged women. General Hospital Psychiatry,
30(1), 32–39.
Stice, E., Cameron, R. P., Killen, J. D., Hayward, C., & Taylor, C. B.
(1999). Naturalistic weight-reduction efforts prospectively pre-
dict growth in relative weight and onset of obesity among female
adolescents. Journal of Consulting and Clinical Psychology,
67(6), 967.
Zettle, R. D. (2011). The evolution of a contextual approach to
therapy: From comprehensive distancing to ACT. International
Journal of Behavioral Consultation and Therapy, 7(1), 76.
Margit I. Berman, Ph.D., is assistant professor of psychiatry at the
Geisel School of Medicine at Dartmouth.
Stephanie N. Morton, M.S., is a medical student at the Geisel School
of Medicine at Dartmouth.
Mark T. Hegel, Ph.D., is professor of psychiatry at the Geisel School
of Medicine at Dartmouth.
278 Clin Soc Work J (2016) 44:265–278
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