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Introduction
Obesity is a highly visible and stigmatized disorder and there is copious evidence documenting the ways in which obese individuals experience malign treatment and prejudice in society. Wott and Carels (2010) identify different levels at which weight stigma is manifested; societal, interpersonal and internalized. Societal and interpersonal levels are conceptualized as external forms of weight stigma which play an influential role in the maintenance of internalized weight stigma. Internalized weight stigma describes the degree to which an obese person endorses weight-based negative stereotypes and attributes these to themselves (Durso et al., 2012). Internalized weight stigma mirrors negative societal attitudes, beliefs and self-criticism expressed about obese individuals, but is self-directed. Whilst there has been much written about the presence and manifestations of weight stigma, there has been little attention paid to formulation and therapeutic interventions with individuals who experience, and internalize, weight stigma. This is a specific and distinct psychological difficulty that could be neglected or overlooked because of the focus on psychological approaches to weight reduction in obesity. The aim of this paper is to propose a formulation model which outlines the processes involved in the maintenance of internalized weight-related stigma. This is relevant to practitioners working in generic psychological services as well as specific weight management/eating disorder services because as obesity rates increase, we are likely to see more people being referred for psychological difficulties associated with weight stigma.
The interplay between external and internal weight stigma
Weight stigma has been described as "negative weight-related attitudes and beliefs that are manifested by stereotypes, rejection and prejudice towards individuals because they are overweight or obese" (Puhl, Moss-Racusin, Schwartz and Brownell, 2008). Obese individuals report frequent experiences of weight stigma. Friedman, Ashmore and Applegate (2008) found that 100% of their sample of obese individuals experienced weight stigma in the past month. These included physical barriers, nasty comments and being stared at. Indeed, experiencing weight stigma is negatively associated with self-esteem (Jackson, Grilo and Masheb, 2000; Friedman et al., 2008), which indicates that external devaluation impacts on internal self-evaluation. The individual's self-concept may mirror the way in which they are (or perceive themselves) to be viewed by others. The formulation model, which is based on a hexaflex diagram, is presented...