Clients often present to psychotherapy asking for help with weight loss. In the U.S., weight loss goals are normative in women and very common in men: 57% of women and 40% of men report trying to lose weight within the past year (Yaemsiri, Slining, & Agarwall, 2010). Psychologists and allied clinicians have rarely considered the ethical issues involved in treating clients for weight loss (although see Hawks & Gast, 2000, for an exception). The American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (2010) states that psychologists are committed to “the use of [psychological] knowledge to improve the condition of individuals, organizations and society.” The Code delineates ethical principles and enforceable standards that guide psychologists’ professional practice. In this article, I will discuss those principles and standards that may be implicated in the decision to help a psychotherapy client lose weight. I will also discuss alternatives to standard behavioral weight loss approaches that may raise fewer ethical concerns, particularly an alternative treatment paradigm, Health At Every Size® (HAES), that can be integrated with psychotherapy to promote mental and physical health for weight-concerned clients without promoting weight loss.
Ethical Principle A: Beneficence and Nonmaleficence
The Code (American Psychological Association, 2010) states that “psychologists strive to benefit those with whom they work and take care to do no harm.” Harm avoidance is also an enforceable ethical standard: 3.04, Avoiding Harm states that, “psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable.” Is psychotherapy for weight loss harmful? Nonsurgical weight loss interventions have poor efficacy. Some reviews suggest that the average patient who participates in a weight loss randomized controlled trial can expect long-term weight gain (Ayyad & Andersen, 2000; Mann, et al., 2007). If behavioral weight loss causes weight gain, recommending it appears to be a relatively clear-cut case of causing potential client harm.
Other reviews conclude that a 3-6% long-term weight loss is possible for participants who continue indefinitely with all aspects of treatment (Franz et al., 2007). However, it is unclear whether such a modest weight loss accrues substantial health benefits. What is known is that this is far less than treatment-seeking clients expect or desire. Clients expect to lose about 30% of their initial body weight (Foster et al., 1997; Masheb & Grilo, 2002), not 3-6 percent. Weight losses clients say would be “disappointing” following treatment are far in excess of typical outcomes, and in fact researchers have noted that a patient-rated “disappointing” weight loss represents a successful outcome of bariatric surgery, the most invasive and potent weight loss intervention available (Kaly et al., 2008). Thus, clients may experience even a “successful” weight loss intervention as a failure. Dieting failures, whether objective or perceived, increase clients’ risk of depression (Markowitz, Friedman & Arent, 2008), negative affect, and eating pathology (Stice, 2002). Weight cycling (i.e., losing and then regaining weight following dieting), which might be expected following “disappointing” or unsuccessful weight loss, predicts worsened cardiometabolic health (Montani, Schultz, & Dulloo, 2015). The risk of harm to clients from engaging in weight loss strategies in psychotherapy is thus considerable, even if clients’ outcomes are optimal.
Ethical Principle C: Integrity
According to the Code (APA, 2010), “psychologists seek to promote accuracy, honesty and truthfulness in the science, teaching and practice of psychology,” a principle that psychologists manifest when they engage in the informed consent process with clients. The Code is vague on whether informed consent must include information about the evidence base supporting established treatments, or their risks and benefits, but researchers have suggested that therapists should convey to clients information material to their decision to engage (Beahrs & Gutheil, 2001). For clients seeking help with weight loss, assessing and correcting treatment expectations includes providing information about the risks of weight gain and weight-cycling as a result of treatment, the modest likely benefits of successful treatment, and the requirement that clients continue with all aspects of the treatment permanently.
Ethical Principle D: Justice
Principle D states that “Psychologists … take precautions to ensure that their potential biases … do not lead to or condone unjust practices.” The Code does not refer to weight discrimination in its principles or standards. However, the risk that therapist’s weight prejudices will unjustly impact their services is substantial. Yalom (1968) provides a stark example of the way his own misogyny and hatred of fatness impacted his psychotherapy process with a fat female client: “The day Betty entered my office, the instant I saw her steering her ponderous two-hundred-fifty-pound, five-foot-two-inch frame toward my trim, high-tech office chair, I knew that a great trial of countertransference was in store for me. I have always been repelled by fat women. I find them disgusting.”
Indeed, women seeking behavioral weight loss report that medical providers see and treat them as second class citizens (Thompson & Thomas, 2000). Medical and allied provider weight stigma is pervasive and leads to negative health outcomes via biased provider decision-making, stigmatizing provider behavior, poorer therapeutic alliance, client avoidance of care, client non-compliance, and direct effects on client stress, stigma, and health (Phelan et al., 2015). Women generally report that they were placed on their first diets by family or health care providers, generally in adolescence, and most report that they did not want to be on a diet and describe their diets in overwhelmingly negative terms (Ikeda et al., 2004). Justice requires that psychologists and therapists assess and ameliorate the effects of their own implicit and explicit anti-fat biases, that they avoid encouraging clients toward weight loss, and that they be alert to the possibility that clients are being coerced into losing weight.
How Can We Help Clients with Weight Management Ethically?
The risks of offering clients psychotherapy to support weight loss are substantial, and raise serious ethical concerns related to justice, beneficence and non-maleficence, and integrity. Are there circumstances where the benefits to clients may outweigh the risks? Weight loss treatment outcomes are highly heterogeneous, with standard deviations in weight loss as large or larger than means (MacLean et al., 2014). How can therapists determine if a client seeking weight loss help might benefit more than the typical client? Therapists considering offering weight loss should undertake a detailed assessment of each individual client’s weight loss history, since clients with early dieting experiences and multiple dieting failures may be at the highest risk of harm (Ikeda et al., 2004). However, if clients are coming to treatment for their first attempt at weight loss, therapists must beware of the possibility that they have been coerced into treatment. Therapists should never encourage weight loss to clients of any size who have not requested it.
However, even if a client has no history of unsuccessful weight loss and requests help freely and independently, attaining a realistic view of likely outcomes may attenuate enthusiasm for the effort. Few clients may be eager to undertake a permanent and pervasive lifestyle change to attain a modest, visually undetectable weight loss with potentially negligible health benefits. And yet that is the best that therapists or clients can realistically expect.
An alternative is to assist clients in enhancing their mental and physical well-being regardless of weight or weight change using the HAES paradigm. HAES can be readily integrated with psychotherapy to produce integrated wellness programs that offer mental and physical health benefits. My team and I, for example, have integrated HAES with Acceptance and Commitment Therapy to create a treatment called Accept Yourself! for obese women with depression (Berman, Hegel, & Morton, 2016a, 2016b). HAES has also been integrated with Motivational Interviewing (Glovsky, 2013), and has demonstrated efficacy across several studies as a stand-alone wellness program (Bacon & Aphramor, 2011). The HAES paradigm works to encourage weight inclusivity and the inherent diversity of body shapes and sizes, to address systemic and personal barriers to health enhancement, to offer respectful, unbiased health care, to help clients eat flexibly for well-being, rather than rigidly, according to a diet, and to promote life-enhancing, enjoyable physical activities (Association for Size Diversity and Health, 2017). HAES principles, when internalized by therapists and integrated in psychotherapy practice and patient advocacy, allow us to circumvent the ethical concerns involved with behavioral weight management while promoting optimal client health and well-being.
Psychotherapy for weight loss is of limited efficacy, and raises ethical concerns for psychologists. Principles of beneficence, non-maleficence, integrity, justice, as well as associated enforceable ethical standards for psychologists, may all be threatened by psychotherapy for weight loss. Situations of exceptionally high ethical risk are highlighted. The HAES paradigm is offered as an alternative approach for weight-concerned clients that addresses these ethical concerns while promoting optimal client physical and mental health.