Every so often we profile a member of the Critical Physiotherapy Network to find out a bit more about them and their work. In this ‘interview’ we asked Jenny Setchell, PhD candidate, Pilates instructor, yoga teacher and circus trainer/performer about the inspiration behind her research. Jenny works at Performance Rehab in Brisbane, Australia and has been a member of the CPN since its inception. You can find Jenny’s CPN member profile here
What made you look at physiotherapy and weight stigma in the first place?
I have always been interested in stigma and oppression and as a physiotherapist never felt like there was a place for me to discuss this in my profession beyond one-on-one conversations. Researching in this area was the perfect opportunity to begin this dialogue in a way that might have a greater impact in physiotherapy.
I was interested in weight stigma specifically as it was something I had noticed seemed to be becoming more frequent in healthcare and amongst colleagues. But also something that really people hadn’t thought about very much, or considered as stigma or prejudice. Weight stigma is particularly salient in physiotherapy because the site of our work is the body and thus weight frequently becomes involved in interactions in some way or another. There is a growing body of academic and popular discourses showing the harms of weight stigma, and that size discrimination is a case of blaming the individual rather than looking at societal or institutional issues. This has been described as a result of a neoliberal agenda, which promotes the self-regulating individual.
You say in your paper ‘Despite the size and impact of the physiotherapy profession, there has been little investigation of physiotherapists’ attitudes towards weight.’ Why do you think this is?
Generally there’s little self-reflection within physiotherapy. Firstly, on a profession wide level, there is little research or other focus on reflexivity in physiotherapy. Further, on an individual level there is minimal process in place for clinical reflection. This can be seen in that physiotherapy lacks for example, the professional supervision that some other similar health professions have throughout the career, beyond just student supervision. This lack of reflexivity means we have little ability to assess how and where we are going as a profession and as individual physiotherapists. This is concerning because as a profession that is growing in size and power globally, we will have a greater impact on people and it is important that we can assure that this impact is positive.
Whose work has influenced your understanding of weight stigma today…whose work would you recommend to others interested in reading more about this area?
I’ve had a lot of influences when investigating weight stigma and have read very widely across a number of disciplines including sociology, critical psychology, critical weight studies and beyond. Rebecca Puhl at Yale has done a huge amount of empirical research on weight stigma. She, with Chelsea Heuer, produced a paper in 2009 ‘The stigma of obesity: A review and update’ which gives a decent background to, and overview of, weight stigma in healthcare. Michael Gard, one of my PhD supervisors, has also been one of my main influences. I would recommend his book ‘The Obesity Epidemic’ (2005) to anyone wanting a thorough and detailed understanding of the science refuting that weight is simply due to an energy imbalance (diet and exercise). Michael’s book also has an in depth analysis of the social construction of the so called ‘obesity epidemic’. Deborah Lupton’s short book (2012), which is simply entitled ‘Fat’ discusses weight from a Foucauldian perspective and is also a very interesting read.
In the study you state that ‘…the most common responses [from physiotherapists in your study] were simplistic, implicitly negative and prescriptive advice.’ Can you provide more details on what concerns you have about this?
To break this down a little more, the physiotherapists in the study demonstrated simplistic understandings of the causes of weight by, almost without exception, reducing the multifactorial determinants of weight to causes attributable to individual responsibility (diet and exercise). Attributing weight to diet and exercise is thought to be due to weight stigma. Physiotherapists also spoke about weight in an implicitly negative way. This included using terms such as ‘weight issue’, ‘weight problem’ etc. It has been shown by Puhl et. al. (2012) when health professionals use more negative language to discuss weight that patients had lower motivation levels and were more likely to change health care providers. Prescriptive advice (‘educative’ communication) was the most common mode of delivering information about weight and signs of collaborative communication about weight were rare. An educative style of communication devalues the perspective and knowledge of the patient and thus is often unhelpful in the clinical interactions.
These ways of approaching weight make it likely that clients will perceive that they have been valued negatively, patronised or blamed (ie stigmatised), which results in poorer health outcomes. Other studies have shown that clients who perceive weight stigma trust their health professionals less, exercise less, have more disordered eating, and are more likely to avoid healthcare appointments.
What advice would you give to physiotherapists interested in researching this field?
Read broadly across a number of disciplines and be very critical of assumed truths, which are very common and pervasive in this field. The assumed truths (dominant discourses) about fatness, in both popular media and biomedicine, are that fatness is always unhealthy and that it is almost always the fault of the individual. The pathologisation of fatness (e.g., obesity being classified as a disease in the US in June 2013) suits a healthist and biomedical agenda that gives more power to medicine (see ‘Fat’ for more on this). Further, blaming the individual, as I mentioned earlier, suits the current neoliberal agenda focusing on individual rather than at a state or institutional responsibility. As challenging these assumed truths usurps the dominant paradigm, researchers in the field of weight stigma need to be prepared to encounter mainstream resistance.
And what support do you think we need to offer clinicians to tackle the problem of stigmatising practices?
We need to offer clinicians an understanding of stigmas generally, how they operate, how we can challenge them, the effects that they can have. Stigmas are also individual, so it’s important to understand that different stigmas will have different characteristics. Weight stigma, as a relatively new stigma, is not yet widely understood, so it would be helpful to offer education on this topic both within existing physiotherapy courses and as professional development. Education would focus on finding ways to communicate with patients without size discrimination. I am currently developing some teaching resources so feel free contact me if you would like access to these when they are developed.
In the mean time if you would like some resources Yale has brought out a simple video on weight stigma in health, which you can see here:
You could also have a look at some of the presentations I have done on weight stigma which are available on my ResearchGate profile here.