HAES Series: Going deep with Deb Burgard

Deb Burgard, PhD, FAED* is a psychologist and activist from the San Francisco Bay Area specializing in concerns about body image, eating, weight stigma, and relationships. She is also one of the founders of the Health at Every Size(r) model, the original BodyPositive.com website, and the Show Me the Data listserv, building communities where people can find each other and the resources to resist weight stigma, especially in medical and psychological treatment.  Her activism includes working with healthcare providers to integrate an understanding of the social determinants of health and creating interventions that address structural oppression and support stigma resistance.  She can be found at conferences sparking impromptu dance parties in the pool.
Fellow, Academy for Eating Disorders
Poodle Science video                 https://www.youtube.com/watch?v=H89QQfXtc-k
Review of HAES lit paper:          https://www.hindawi.com/journals/jobe/2014/983495/
Transcript below many thanks to Marie

Hello everybody, welcome to this weeks podcast. This week, I’m speaking to a lady called Deb Burgard. Now Deb was one of the founders of the Health At Every Size Movement. She has been involved in Health At Every Size, well just about everything in Health At Every Size for a very long time. So she is this wealth of information on it. I’m excited to talk to her, I love the conversation I had with her I’ve certainly already decided that she is coming on this podcast again so if you have any questions for her after this conversation, then shoot me an email. She’s not just full of information and common sense, she’s a really fun person actually. Thoroughly enjoyed talking to her, so I’m just going to get out of the way and get on with this conversation. Here’s Deb:

Deb: So I’m Deb Burgard, I’m a psychologist and I’m one of the founders of what has become known as the Health At Every Size model. I’m also a fat activist and my speciality in psychology is treatment of eating disorders. So I work with people across the weight spectrum with every kind of eating disorder behavioural manifestations. I’ve had my foot both in all of these worlds for decades.

T: What led you to get into the Health At Every Size stuff?

D: Well I was coming out of college in the late 70s, I had been very involved in second wave feminism with all of it’s great things and limitations. (laughs) I came out to the west coast from the east coast of the US to do my graduate school in psychology training and I really just wanted to create a space, my first real creation I guess was my dance classes for, what we were then calling larger women. That was 1983 and I did a dance class that was really advertised explicitly for women over 200lbs and it was explicitly not a weight loss space. It was a space to come and party and enjoy your body and be among other people who were also trying to do that. I did that for most of the 80s and I wrote a book with Pat Lyons called Great Shape that we published in 1988 which was really radical at the time which is still radical which is so depressing. (laughs)

T: So what was radical about Great Shape?

D: Well in Great Shape, we talked about, basically I had already been working with Intuitive Eating and I wrote a chapter which was really about Intuitive Movement, like here’s how you might get in touch with what it is that’s really appealing to you about moving your body and here are some ideas and here is a process to go through to think about that and here is how to think about it for the rest of your life.

So it was really to look towards the persons own body wisdom to guide them, that was radical. It was also saying that fat people have no moral obligation to exercise. This was not a book that was kind of like, you should get in shape and you will be a good fatty if you do that you know? We were really trying to say, no no you don’t have to do this at all but you have a right to do it and you have a right to access spaces where your body is comfortable doing it, where the equipment fits you. This is what’s not terribly ubiquitous now and we really need to change that. The whole attitude of it is still radical. Saying you don’t have to change your body, your right to be in the world and your right to choose this, or not choose it, your right to prioritize it or not prioritize it is fine, whatever you want to do.

Also that your guidance can come from inside your own body, basically this whole idea that you need experts to tell you (laughs) what to do with all this stuff. I enjoyed that about your approach and your work too. That you really speak so clearly about recovery being something that is so personal and so creative. It’s a creative act and you call upon your own wisdom here to kind of find those steps. I think that’s so important and so lacking in a lot of the approaches to any of these issues.

T: Which is sad because it’s common sense really if your body is saying for example, asking you to eat then that’s probably what you should do. If your body’s asking you to rest, that’s probably what you should do and if your body is saying I don’t like this particular form of exercise, if your body is saying it doesn’t matter what your doctor, who’s not in your body thinks. You would think wouldn’t you that it’s common sense.

D: Well after all of this soaking in a culture that tells you that the reason that you are unhappy and that your life isn’t the way that it ought to be is something to do with your body and how you are or are not perfecting it or making it into an acceptable body. Of course people are doubtful about their own power to call upon that relationship with their body and not blaming their body for that bullshit that’s just everywhere.

T: So, seemed radical then and sadly does seem radical now.

D: Yes (laughs)

T: So what happened after you wrote that book?

D: Well in the next few years, the next 5 years after that were really fruitful. A lot of people who had been individually realising that the way that they were trained to do their profession around these issues was really really problematic and most of these people are RD’s. They had been trained to do weight loss interventions because this is really important for current RD’s to know that their profession, even though it identifies so much with weight normative training and that’s incredibly problematic. It is also that profession that was totally represented at the table when we were looking at what to do differently because those clinicians had looked at what happened with their clients.

They looked at clients who had tried to lose weight and regained it, clients who tried to lose weight and developed eating disorders, there were very few people who were following the path that their training had laid out for them. For them to notice that and have the courage to say this isn’t what we want to be doing and what else can we be doing? I just find that astonishing and wonderful and I just want to shout out to those people. They came from all kinds of professions but I think for RD’s especially, when you have been trained that this is what you’re supposed to do, it’s a pretty big ask to figure out what else makes sense.

So we were really pretty much finding each other, this was pre internet. About 1994, so we were meeting in the Bay areas, people had found me because of my dance classes. They had found me because there was already a really great network of fat activists, there was fat activism here. So the people who were coming together were, some of them were professionals, some of them were health professionals and clinicians, fitness people. Some of them were artists, some of them were activists so the conversations were having.

Pat Lyons my co-author of Great Shape really started these meetings. The meetings were explicitly for us to feel less isolated in our realisation of all of this stuff and to come together. She would have us go around a table and say what are you doing and what are you feeling, what are you running into and people would just tell their stories of what they were experiencing and by the time you got all the way around the table you were kind of like oh my god! This is so amazing, there are so many people doing this work even though we were 15 people. (laughs) We were feeling like OK we are not all by our selves, there is an illusion that we are all by our selves but it’s because we are all sitting in these different locations and having trouble being aware that there are a whole bunch of people coming to this same conclusion at the same time and trying to be something different.

So we were trying to talk about all of that, we were also trying to find each other nationwide and internationally even. People were beginning to have calls on the phone together where we were beginning to start to ask maybe we need a name to this approach. People had been calling it all sorts of things like, No Diet and Anti Diet, there was a whole big discussion, I had been using the language of Health At Any Size for some of my stuff online and then they said no we want to do Health At Every Size, I actually wasn’t so thrilled about either of them. I still am not.

T: Interject but why? Why not? I hadn’t really thought about it.

D: Well Health At Every Size has legitimately been criticised I think because there are some interpretations of it that sort of imply that, there are some ways that people interpret it as Healthist. Which is sort of because it starts with the word Health. That if you’re a good fatty your healthy and if your not healthy your bad. If you’re not doing, if your numbers aren’t right or if your not doing intuitive eating perfectly that you must not be practising this resistance. So that’s annoying to me and also because it just as has this very individualised focus on practises. That’s where it started which wasn’t really my, I didn’t love that. I felt like my focus was always in the broader picture.

I think when I look back at my work, it’s so much more focused on trying to change these structural sources of weight stigma in medical practice and psychology, coaching and fitness. It’s kind of like saying to these structures, we’ve got to change the structure. It’s not just about your attitude to the person you are working with and if you’re nice to them or not. Because a lot of people would say, we need to have a different conversation and then they we would say, we need a nicer way to say that their body is wrong, you know? (laughs) Which is bullshit. So I was really, I would have loved a bit different moniker for all of this stuff as we’ve gone along and had more iterations of this, I like this description of the traditional model as a weight normative model. I think that that’s a pretty accurate way to describe it and what’s wrong with it, but we’ve kind of come with parallels a lot of activists movements where you start of from the point of view of the dominant group that’s thinking about all this stuff and that’s fat white women who were straight with cisgender saying we should get our healthcare! We’re not getting our privileges here!!

Then of course you get a lot more educated when people of colour try to tell you what’s wrong with that, or people who are trans try to tell you what’s wrong with that, you know? People try to really understand more from the social justice perspective. So we’ve kind of gone from the language of weight neutrality to the language of inclusitvity to the language of weight justice and you can kind of see how we are trying with each iteration to sort of even the critique and really understand the deeper roots of what’s really the problem here.

So it’s not so much about you know, you need to do these practises, which was a much early stance on it. Really practises only account for I don’t know 15% of the outcomes of health. The rest of is the social determinants of health and genetics and other things that are very very power that we are only going to be able to address if we stop focusing on this liberal, individual intervention. So yes we all make a living in doing this with individuals so I think that’s why we get a lot of focus on this but we can never forget that peoples exposure to oppression and discrimination for all sorts of reasons, is something that absolutely floods the causal picture here.

Yes we need to try to make these practises that really add to peoples well-being, we need make it accessible and we need to make environments that allow people to keep them accessible for sure. But we really need to get that this whole exercise of ranking bodies in terms of their worthiness, which creates all the motivation for people do these really disastrous things to their bodies, that is the issue here. And that has been going on for a million years in all sorts of ways. When you look at the history of this country, the US and the European domination in general, so this is all kind of, it’s not a separate thing from white supremacy, it’s not a separate thing from colonialism. It’s another version of it, the white people, the white women, myself included are sort of like, hey, we were noticing that this was happening to us because we were separated from our white privilege around these issues. You know? We had the privilege, we were used to having the privilege of healthcare and when somebody says, no you don’t get to have your procedure because your BMI is too high. We don’t get insurance because your BMI is too high, that is sometimes one of the first times that somebody like me was going to have experienced what other people were having all along.

T: Right, so that’s where the justice part really starts to come into it. It sounds like this has evolved more than things have changed in the bigger picture, it’s saying that maybe attitudes haven’t changed radically in the however many years but the understanding of what Health At Every Size and what all these issues are has evolved quite a lot of within people who have practised Health At Every Size.

D: Yes and I would say things have gotten both better and worse. Things have not stayed the same in the broader culture at all. It’s very dynamic, the amount of structural discrimination is much worse I would say, in the US the only bright spot that is so tenuous is the ACA where people can get insurance who have bigger bodies, who would not have been able to get insurance before.

But even when you get that insurance, now you have got all these barriers to get the actual care once you are in the system. But that’s a good thing, I don’t want to ignore but the fact that there is so much codified weight stigma and bias and there is so much, basically I call it the weight cycling industry (laughs), that’s really what it is and that’s what it depends on, it has actually been successful  through the ACA Workplace Wellness Programs. But a lot of other, with the co-opting the American Medical Association as well. They’ve basically got this, they don’t have to find dieters one by one any more, they have got HR departments and physicians doing the marketing for them.

At this point if I was a physician and I had gone into 8 years post grad training and I was realising that basically what I’m supposed to be doing now is being a marketer for the weight cycling industry, I would be a furious as some of my doctor friends actually are. (laughs)

T: I’m actually glad to hear that they are. But maybe it’s just because they are your friends and they are the type of people you would be friends with. (Debs laughs) I think plenty of doctors aren’t furious and they should be.

D: Yes I agree, I think that there should a wellspring of resistance to all of this but I feel like doctors are in the headlights too. There is so much structural change that is going on with them, in the industrialisation of their profession. Where you’ve really gone from, here’s a person who is thought of as an autonomous decider of what should happen here because they are professional and they’ve got all this training and now we are going to default down to a bunch of algorithms that are sort of decided by corporate interests and this is what you’re going to have to enact when you have a patient in front of you whether you like it or not. That’s wow..

T: It’s kind of rude actually.

D: Horrifying, you know? So that’s got a lot worse. And also this idea that, basically a lot of the markets were drying up for the weight cycling industry in the late 90s and there was a lot of, even the National Institute of Health in 1992 or 1993, I can’t remember, put out this radical statement that basically meant for consumers that even if you are looking at something that’s a quote unquote weight loss intervention, even supervised medically, if you can’t get for them 5 years of follow up data of everybody who has been a part of that program and what’s happened in terms of safety and statements of weight loss, you shouldn’t try it. That was amazing and people were really beginning to wise up to all these shenanigans.

There was a book called Dieters Dilemma by Bennett and Gurin that was a huge best seller and so people were really becoming aware of this. There was a bunch of bankruptcies and there were a number of people in the industry that came together to form The Obesity Society which is even in existence now and is even now trying to sort of position themselves as a spokespiece for the patient quote unquote patient community. And are using the language from the disability community, saying persons with disability or actually persons with obesity and they don’t really represent those people. They represent the surgeons and corporations and the pharmaceutical industry and a bunch of lobbyists. They act like they are creating all this science like it’s neutral. Which its not at all.

They started pumping out all of this PR over the next 10-20 years which was raising alarms about people weights going up and what about this, what about this and they would release data every few months in trickles like here is this states version of this and here is the next state version of this and here is this country’s version of this and they just hammered public with all of this stuff. So they couldn’t keep going back to the well of people who basically been on to them and you can sort of see this over the last few years so they started going to other communities. They started going to the black community, they started marketing towards men and of course the pressure on men in terms of perfecting their body’s and having to do this project has only gotten worse.

So it’s gotten really bad in a lot of ways. But at the same time that all of this is happening, all the work that we were doing all these years with the activism to create what we were talking about, some way to resist all of this. That has also grown right? So you’ve got both of these trends at the same time. I started my body positive website in the mid 90s and it’s still there, it still looks as creaky, probably about the year 2000 version (laughs) trying to figure out how to archive it at this point but, it’s been sitting there and people use it like crazy.

They use it and also there is this wonderful organisation here in the Bay area, the organisation of that and I figured out that we were both using that language back in the day and we sort of have done, doing our work so all these people who have been thinking about how to do this resistance work, whether they were Health At Every Size or body positive or non diet or whatever they were from whichever direction they were coming to this, they’d been at work this whole time. When the era of the bloggers came a long that was huge as well. Then social media kind of built on that so then you’ve got communities and the fatisphere and communities online where people were doing the exact same thing that we were doing back in the late 80s and early 90s when we started meeting together.

Now we can find each other. When there’s a problem in the, when the issue is really in the culture at large, one of the solutions is really to have subculture and the subculture that is trying to heal whatever that is right? I just don’t think you can do this one by one, I think that most people are going to feel, like when they come to me we are working individually, they will say to me this is all so much of a relief to me, this works fine when I’m in your office but when I go outside I don’t know what I do any more because I’m back in the middle of my family that thinks this other way or I’m back in my doctors office and he or she thinks this way or I don’t know what do in my work place or whatever. So it really takes off when people start to find each other outside of our individual therapy and I’ve done groups for that reason because I think when people find each other and can be supportive to each other it really helps with resisting the harm from a lot of this stuff.

T: Yes

D: So all of that.

T: And so this is what’s happen and how this community has progressed and changed, where is it going to go next? What do you see happening in the future?

D: Well, I think we have been so lucky to benefit from the labour of a lot of these activists from marginalised communities who have basically said look, you can’t just look at this from the point of view of fat white women, we have to look at all of these intersections and all of these ways that people are harmed by these ideas and we have to find our solutions by working together from the ground up with the anti oppression work of dismantling this stuff and coming up with something else.

So for me, it has been a kind of my kind of struggle in the last few years, is trying to figure out, OK I need to do this anti racism work with my white peers who may or may not have had exposure to this and we are just going to keep pumping out the stuff we have been trained to do if we don’t learn how to do it differently on the one hand. But on the other hand also, being able to contribute support, labour, money, resources, whatever we can in working with people to create these new structures that are going to actually meet peoples needs in a more broad based way.

So that the most marginalised people are taken care of and not left out of the whole planning process from the beginning. I think that’s how I imagine things going forward, that there’s got to be this is work to do and going to these directions and this is what I’ve seen in the evolution of the organisation, the Association for Size Acceptance and Diversity for example where you have this mostly white organisation that’s waking up to the ways that we are actually part of the problem here, we’re not really a comfortable place for people of colour to be there because there’s clueless things happening among the white people and once people of colour are beginning to educate us about this, we are trying to have conversations about it, there is all this white fragility reaction.

People who are freaking out, why is this politics? We don’t need politics we are doing this other thing and then oh actually the sort of integration of the knowledge of this thing that we tried to do from the very beginning, it was a form of resistance to oppression. And it was based in fat activism and the fat activism was done in the 70s and even them there was a critique from the fat people and the fat underground of the medical vector of oppression of fat people and how wrong all of this policing was based on information that was already there in medical research, it was already there. We already knew about set point theory, we knew about it since the 50s. We already knew that this stuff didn’t work. We knew about it from 1960. We knew people who were experts saying this stuff doesn’t work. They were already saying here’s a whole bunch of stuff that we’ve unearthed from the medical libraries look at this and so understanding that this is where this comes from. Yes a lot of us have one foot in fat activism and one foot in eating disorder recovery and research and treatment. And that’s the point, that they are related.

T: Yes!

D: This is not something that is two different sides. This is of course something that with my work  was just impossible to me to not make all these connections. That is one of the reasons why it’s so completely bewildering to me how there are so many professionals in the eating disorder community who don’t seem to get this you know? Who really don’t seem to get this at all. For me there was like no way that I was going to take, if I’m working with someone who’s come into my office and basically everybody agrees that their pursue of more weight suppression is a problem. And the reason that we can all really see that is because they are so thin and that’s why it’s not ambiguous to anybody.

This is all something we can agree on, the truth is what is really problematic about that is the way that their lives are being stolen from them and that whatever is making this happen is the problem. It’s not what they way and so here I have another person who comes into my office who’s doing the very same things and they are at a higher weight and people all around them are slapping them on the back. Even their doctors. To me, it’s very clear this person’s got anorexia. They’ve got anorexia even though they started at a higher weight. There’s an arbitrary truth to this. They’ve started at a higher weight and I am not going to collude with this persons behaviours and thoughts and beliefs and how they need to suppress their weight when I don’t for a thin person, that makes no sense at all.

People with higher weight anorexia are barred from treatment essential they don’t get diagnosed, they cant stay in treatment and they don’t get into treatment. I just got back a couple of months ago from an international conference on eating disorders and yet again every time I went up to the mic trying to talk about this and the researchers who are defining anorexia as a BMI less than 18.5 and I’m like you’re not even going to be able to solve this research question, how do you answer the question if you don’t have all the people who have this disease?

T: Absolutely you’re not collecting data from the people with larger bodies who have anorexia. Absolutely.

D: And so then the defensive response from the researchers are we need data not opinions and I’m like right? (laughs)

T: It’s just so tricky because of the damn DSM. I did a video on You can have anorexia at any size on YouTube a week or so ago, there is a lot of people who are there and understand but there are also people who say, you don’t know the definition of anorexia, you should check out DSM V.

D: The DSM V, there has been controversy about this from the beginning. I’ve been talking to Tim Walsh from the very beginning about all this stuff and saying, you should just call this disorder of the pursuit of weight loss. Maybe we need something for Pica but disorders for the pursuit of weight loss is pretty much going to cover a lot of it, it’s not totally going to cover it because there’s going to be people who’s experience of restriction is from food insecurity, I don’t want to eliminate them out of being able to get treatment and so forth because that’s wrong. Even if physiologically what we are talking about is that restriction is at the heart of all these problems.

T: Yes

D: The reasons that people are barred from access to food vary and that a real, that it is something that has to be taken into account of course and all these prevention of treatment issues. All of these are important however I think the notion that we could sort of do away with the small, medium and large categorising we have been doing and we’ve been doing all these years, it’s like what is that? It’s so bizarre that that’s even a part of our, I can’t think of anything in medicine that is designed like that, that you’re disease changes based on your body size is. What is that?

I was just doing about clinicians who give feedback around these mental health diagnoses and I’m trying to write about this because even the things they sent me was so absurd. Here is the definition of Bulimia, here is the definition of BED and they are trying to carve out something about, you don’t really have an eating disorder if it’s a culturally sanctioned activity, that you’re doing. And I’m thinking to myself, this is some new fuckery here. This is sort of like, OK so if everyone wants you to diet and you are restricting and you really have anorexia but we’re not going to call it that, we are going to call it dieting because your weight isn’t low enough for us to call it anorexia. We’re not going to have to treat you.

It’s like a fetishisation of the kinds of features that I think when people first hear about the features of anorexia they get stuck, on these, the morbid fascination, how thin people bodies can get around this, how people can starve themselves or they get kind of stuck on these things as if they are the point. It’s the viewpoint of the observer that has nothing to do with the lived experience of this disease. That is leading to all of this distortion and again this is why I am so grateful to you for what you’re doing because I think it’s going to be the voices of the people with the lived in experience when you think about what’s going to happen in the future, all of these categories have to be reimagined from point of view from the people who are actually the experts on what this is. And the people who are experts are the the people who have the lived in experience of what this is.

T: It’s so frustrating actually, even when I was sick it would be frustrating to be told by somebody who I knew had no lived in experience of what I was experiencing, them telling me in their opinion what I was experiencing. It is very frustrating especially and more so for adults who do question more then we do when we are children about what somebody is telling you about yourself.

D: Yep in psychology there is something called a fundamental attribution bias and it is the phenomenon where if you have a bunch of observers who are watching somebody do something and you say to the observers why do you think the person did this? They will almost always locate the explanation in some personality trait of that person. But if you ask the person who actually do the acting, why did you do this? They will almost always talk about something in the environment that they are responding too.

So this fundamental attribution bias creates all this trouble when it comes too these disease definitions right? Because it’s like a bunch a anthropologists who are standing around watching the behaviour of the natives right? (laughs) It’s absolutely racist and imperialist and colonialists and awful and it’s just not even questioned when it comes to medicine.

T: Yes and I think that a really incredible point. And I know that many people listening will really thank you for saying that.

D: Well I have to thank the people who’ve done the emotional labour of trying to make this more apparent to me and you know it’s just really humbling for me after all these years, I can look back on things and just think cringe worthy moment when I wrote this you know?

T: I’m sure yes.

D: And I sit there and I think actually I’m kind of glad that that’s true because if I had not learned I would still be saying this stuff. I wouldn’t be cringing because I wouldn’t know I just have to really just be so grateful for the sense that I have of this work placing in a river of humanity. (laughs) So each person who offered that, sort of standing on the shoulders of the people who came before and I just feel like that’s just absolutely critical to keep acknowledging this has been my, I am wherever I am in the middle or towards the end I don’t know, in the stretch of time that I’m available on this planet to do this work but I just feel so connected to the work of all these other people who have been addressing this in some form for 100s or even 1000s of years.

T: If people want to find out more about you where can they do that?

D: That’s a good question! (laughs) I have these ancient things up on the web, pretty much if you just google me I’m pretty sure people can find me and there’s a lot of different representations online of the work that I do. There’s the BodyPositive.com website has my phone number at the bottom of every page so even though it’s really creaky and old I don’t think that’s going to change any time soon.

Hopefully I will get the bandwidth to really kind of revamp this stuff so it’s a lot more accessible online, I’m trying to figure out how to, my favourite thing to do is to really work with people around this transition to help support those moments where people are kind of going, I don’t want to keep doing this but what else do I want to do? People who are in the field or people who are making this transition or people even in the public who are saying I don’t want to do this to my body any more, whatever that is and so I do a lot of work with people one to one or groups or in workshops or in conferences or things like that. My work is kind of all around it’s also very likely I’ll always be involved ASDA and ASDA has a conference this August in Portland which I think it’s going to be pretty interesting so that’s another organisation that you can usually track me down. (laughs)

T: Well that’s another person that I could have spoken to for hours. I hope you know about Health At Every Size now and please don’t be intimidated I know it seems like there is a lot in there, I know it seems like it’s quite political really isn’t it? I strongly recommend if you are sitting there thinking gosh, I don’t really know what I’d say about Health At Every Size now without putting my foot in my mouth, go and join a group on social media and watch and read and listen for a while. You’ll absorb so much, there is so much great information out there. Wonderful people like Deb who are very clear and have been in it for years and have seen all of the changes and all of those things are reflected that they write and the things that they put down into these groups. So Facebook groups,Health At Every Size and you will find some. Thank you for listening, until next time cheers and cheerio.

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