the HAES® files: The Pursuit of Coherence

by Health At Every Size® Blog

by Fall Ferguson, JD, MA

My previous blog post (“The Pursuit of Happiness”) explored dimensions of the “thin equals happiness” meme. At the end, I asserted that the meme actually works as a nocebo for anyone who identifies as “not-thin.” This week, I want to expand on that concept a little, and to suggest coherence as a means for addressing the effects for this destructive meme.

The Nocebo Effect

Most people are familiar with the placebo effect (from the Latin for “I shall please”), which in biomedicine refers to when a treatment, substance, or procedure believed to have no therapeutic value is administered and winds up “working.” The placebo effect is well known in medical research, where sometimes as much as 20-30% of a control group will see the intended effect. In the field of mind-body medicine, however, the placebo effect is seen as confirmation of a strong connection between our thoughts and beliefs on the one hand, and our health and well-being on the other.

A bottle of “Nocebo” (gag gift available on Etsy.com)

The thing is, just as our thoughts and beliefs can positively affect our health, they can negatively affect our health too. From the Latin nocere meaning “to do harm,” the phrase nocebo effect is used to denote the opposite of a placebo effect, when something done by a health professional has a negative effect due to the thoughts or beliefs of the patient or client. I can’t help but speculate as to how vast the nocebo effect is. Consider every instance when a “white coat” (health authority figure) describes an individual’s health limitations as if they are “fact,” and how often those supposed limitations emerge as “the truth.” In other words, the predictions may become self-fulfilling prophecies.

I ascribe no particular malice to the health professionals who dispense nocebos as a result of their training and education. Though well intentioned, our health professionals tend to deal in fear and fatalism. It’s important to recognize the power that they yield, often with no awareness of the potential harm they can cause. The lack of ill motive does not mitigate the deleterious effect.

Memes As Nocebos

When doctors, nurses, dieticians, epidemiologists, or the media inform people that they cannot be healthy unless they are thin, that is a nocebo in my book. How many statistics about the correlation between “obesity” and chronic diseases are related to this phenomenon? It would be difficult to know, as there are of course other explanations for the known correlations between “obesity” and various health conditions. For example, weight cycling and weight stigma, both widely experienced by fat people, are deleterious to health. Moreover, some conditions (e.g., insulin resistance) are believed to cause both weight gain and higher incidence of disease. However, none of this means that nocebo isn’t also a contributor to the known correlation between obesity and ill health.

Just as “thin equals healthy” and “fat equals unhealthy” function as nocebos, so do “thin equals happy” and “fat equals unhappy.” Regardless of actual body size, those of us who self-identify as fat or even as not-thin receive the constant message that we are not happy, that we can’t be happy, and that we don’t deserve to be happy. It’s important to acknowledge that these memes also imply that thin people are not entitled to experience health issues or be unhappy.

In addition to combating these memes by educating about body diversity and realities of the weight-based health paradigm, we need to strengthen the ability of individuals to resist the dangerous nocebo effects of these memes in the meantime. In my opinion, the most effective way to do that is to work on our sense of coherence.

A Sense of Coherence

A profound and important predictor of health that often goes overlooked is a sense of coherence (SOC). (I have written a little bit about this before, here and here.) The more I think and read about coherence, the more I come to understand that it not only underlies health but happiness as well. This may reflect my expansive and overlapping definitions in which both health and happiness consist, at their core, of the capacity for living well or well-being. The bottom line for me is that both concepts rely upon an individual’s SOC.

According to Aaron Antonovsky, one’s SOC consists of three chief components:

  • comprehensibility,
  • manageability, and
  • meaningfulness.

Antonovsky developed a scale that measures these three variables; the SOC scale has been validated by a number of studies (see, e.g., this review) as a predictor of health outcomes independent of culture and socioeconomic status. In short: the stronger the SOC, the better one’s health.

It turns out that a strong SOC is also highly predictive of a high quality of life (QoL):

Results supporting [SOC] as a factor promoting QoL were reported in patients with schizophrenia, patients with coronary heart disease, Japanese civil servants, patients with ischaemia, elderly patients with hip fracture and among middle-aged subjects at high risk of psychiatric disturbances. The findings are consistent, the stronger the SOC, the better the QoL.

Combating the Memes with Coherence

Body size does not determine happiness.

When the overwhelming cultural messaging informs fat people that they lack control, that they are not managing their lives well, that they lack self-efficacy and follow-through, that they are lazy, and that they are out of sync with what is normal or acceptable, what might be the resulting effect on their SOC? Might it not lead to a learned lack of coherence, something akin to the idea of learned helplessness?

The weight cycling process, too, seems to promote a learned lack of coherence. Doctors, authors, and employees of the weight cycling industry repeatedly give dieters the message that any so-called failures (e.g., plateauing, regaining, etc.) are the individual’s fault. Individuals may know they are being “good” (e.g., deprivation of food, overexercising), but are told they are “bad.” That kind of cognitive dissonance teaches us that our lives are incomprehensible, unmanageable, and meaningless, surely.

All of this suggests to me that fat people have the deck stacked against them when it comes to maintaining a strong SOC. (Note: one can speculate about an intersectionality effect for members of many different stigmatized minorities.)

Promoting a strong sense of coherence should be considered a priority when providing health care and health promotion services to anyone with a history of weight cycling or anyone who identifies as fat and therefore may have experienced this learned lack of coherence. Of course, we need to alter the predominant memes that suggest that thin equals healthy and happy … but in the meantime, the victims of this meme can be supported by strengthening their sense that the experiences in their lives are comprehensible, manageable, and meaningful.

Just as the rights to “life, liberty, and the pursuit of happiness” are first principles of our social covenant embodied in the Declaration of Independence, I submit that the pursuit of coherence should be a first principle of health promotion.

6 Responses to “the HAES® files: The Pursuit of Coherence”

  1. Sense of coherence comes from knowing who you are, your identity….and knowing why you are here, your purpose. All people strive to know these two basic and underlying facts. When you know who you really are…who you were created to be….there is not a person that can take that away from you or tarnish it with words or actions because you are set, unmovable. Likewise if you don’t know…like myself for most of my adult life…you are blown by wind and tossed by the waves of the storms of life. I submit that the pursuit of identity should be the first principle of health promotion.

    • Excellent points, jodi. I definitely was careful to state that I felt building coherence was A first principle, not THE first principle, of health promotion. You make a good case that identity and purpose should be first principles also. Note: I don’t want to lose sight that equity and access are important first principles too. I would never agree that we should shift the focus entirely onto the individual.

  2. Nocevo is a real good concept to health providers who manage wiht overwheight people because of, a vast majority of those people don´t have real coherence and probably everything that we said them sound as a refletion on their skills, way of live, etc,
    When i was reading the post i renembered a talk with a young girl who asked for her pain knee and “someone” answered back that she must to lose weight….
    She felt it a real nocevo and make her ashamed

  3. I really enjoyed reading this article… I can really relate to having a learned lack of coherence. It’s very hard to overcome.
    I had a couple family members who would always tell me how I was going to become fat and I had already learned that being fat would equal being lazy etc. Not a good thing to tell a kid. Now I just have to try to reverse this brainwashing, easier said than done.

    • Yes, queeofzenk,you’re right, it’s much easier said than done. I am sorry that this was done to you by the very people whom you loved and trusted.. It’s very complicated to heal from deep wounding such as you describe. And, I do think healing is possible. I would never say that “coherence” is the whole story, but part of the process involves cultivating the skills and mindset that create comprehensibility, manageability, and meaningfulness. Indeed, simply recognizing and naming the wounds and “brainwashing” for what they are is already a massive step toward coherence.

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