“I feel fat today.”

This is a phrase that Justine Trumbetas, a licensed professional counselor (LPC) in Pennsylvania, says she often hears from clients who live in bodies of all kinds of shapes and sizes. And this seemingly simple statement contains a lot for counselors to unpack with clients. 

More often than not, this thought stems from weight stigma or bias that the client has internalized from external sources. This can include anything from an offhand comment a friend makes about needing to work out to “earn” her slice of birthday cake to a medical doctor who advises weight loss for a presenting concern that is unrelated to the patient’s body size.

Trumbetas, who specializes in helping female clients with anxiety and body image-related issues, says that when clients use language such as “I feel fat” or “I feel gross,” she uses it as an opening to help them begin to recognize their emotions and negative thought patterns as well as how these thoughts affect their value and self-worth. The first step is to replace the word “fat” with a more factual, accurate word, she notes.

“I tell them that fat is not an emotion, so we can’t feel it. And we work to replace that, find the word they need … and tap in to what they’re feeling, [such as] defeated, let down, sad. And then we dig into why they feel that way,” says Trumbetas, an American Counseling Association member who has a counseling practice providing online sessions to clients in Pennsylvania and Florida. “There’s much more than feeling fat. There is a lot more underneath it. Are they comparing themselves to other people [or reacting to] something that they saw or heard from others? Typically, when we dig in, I find that their worth is tied to their body and how others view it.”

Pervasive weight stigma 

Thin bodies have been idealized and prioritized in U.S. culture and society for centuries. This shows up in everything from themes in advertisements and television to the overuse — and misuse — of the body mass index (BMI) as a benchmark for health by medical professionals and others.

Weight stigma carries the message that “there’s something wrong with your body simply because of the size of it,” says Jennifer DiGennaro, an LPC with a private practice in Grand Rapids, Michigan. And it’s traumatic for an individual to be bombarded by a lifetime of messaging that implies that their worth is tied to their body size or ability to lose weight, she adds.

“We live in an eating disorder culture and a body-shaming culture,” says DiGennaro, who specializes in helping clients heal from trauma, body shame and eating disorders. “We carry this myth that everyone can control their weight,” she continues, but “there are many, many, many reasons that someone is living in a larger body, and it may have nothing to do with what they eat or how much they’re moving.”

When talking with clients and colleagues, DiGennaro finds that using different words to name this phenomenon can help others understand the stigmas surrounding weight, depending on the context and their familiarity with the issue. Weight stigma can also be described as fatphobia, fatmisia, sizeism, weight bias, weight-based discrimination, fatism or size bigotry. No matter what it’s called, fatphobia is “thinking you know things about a person simply by the size of their body, and we don’t,” DiGennaro says. “And arguing on that point is reinforcing weight stigma.”

When unpacking and dismantling weight stigma, it’s important — both for counselors and clients — to consider the full context of the messaging they receive about weight loss, nutrition, body size and related issues, says Kaitlyn Forristal, an ACA member and licensed professional clinical counselor who studied fatphobia’s influence on diagnosis decisions made by counseling graduate students in her 2018 doctoral dissertation. This includes the fact that many companies stand to benefit from keeping this stigma alive and prevalent, she adds, noting that the weight loss industry in the United States was worth $72 billion in 2018.

Trumbetas says that nearly all her clients use language in sessions that indicates they have been negatively affected by weight stigma. This ranges from describing feelings of worthlessness to noting that they had a “bad” weekend because they indulged and ate a slice of pizza, she says.

Her clients have often internalized microaggressions and messaging they’ve received from a number of sources, but she finds that the most influential are social media, their family of origin and the medical profession. Many clients talk about being raised in an atmosphere where the adults were always on a diet roller coaster, Trumbetas says, so it was common for them to make comments such as “You shouldn’t be eating that.”

She has also worked with clients who have stopped going to medical appointments because they don’t want to be judged and have assumptions made about them based on their weight. Because weight bias is deeply embedded in the medical profession, some doctors’ initial and go-to recommendation for larger-sized patients is to lose weight without finding out the context surrounding what’s bothering them, she explains. 

Reconnecting to self

The counselors interviewed for this article agree that clients who have been negatively affected by weight stigma often need a combination of counseling work that focuses on quelling negative thought patterns, tolerating discomfort and reconnecting to a body that external forces have caused them to disconnect with and hate.

An important first step is educating clients on what weight stigma is and how prevalent it is in our society as well as offering the message that “your worth, your identity and your value is not in your appearance,” says Stephanie Dutson, an LPC who specializes in helping adult clients with trauma, anxiety and body image-related issues.

Dutson says she often emphasizes to clients that a body is for living in, not for looking at.

She finds that weight stigma often causes clients to feel guilt or shame about what they are or are not doing to maintain their appearance. And that guilt or shame “affects a person’s health so much more than an extra 20 pounds does,” says Dutson, who lives in Birmingham, Alabama, and has a counseling practice providing online sessions to clients located in Utah, Wisconsin and Alabama. “The research shows time and time again that social life, stress management and moving your body in a joyful way — not weight or size — are what promote health. Diet culture really squashed that intuition for most people, and [unlearning weight stigma] comes back to trusting themselves and finding connection to intuitive knowing.”

Many of Dutson’s clients have strong feelings of shame or disgust associated with their bodies, especially with parts that are often sexualized or idealized in popular culture and media (such as the abdomen, chest and arms), she notes. Dutson focuses on helping clients who feel this way regain comfort and feelings of safety with their body, including “tuning in” to parts of their body that they’ve “tuned out” or disconnected with because of weight stigma, she says. 

For example, she may ask a client to gently touch or look at parts of their body that they have tuned out (e.g., a soft belly post-pregnancy) in a mirror at home. Then Dutson processes the experience and emotions the client felt at their next session. She also encourages them to spend more time doing this exercise as they become increasingly comfortable with their body. The aim, Dutson says, is to help clients gradually reconnect to their body.

Many clients have such negative feelings associated with their body that they aren’t able to look at their entire body in the mirror at first. She encourages them to start small with a handheld mirror to view one part of their body, such as an arm or leg, and eventually add additional areas.

“I tell clients to expect some feelings of discomfort, but to try and find an area of the body or [amount of] time that is moderately uncomfortable while still tolerable so they don’t become flooded or overwhelmed,” she explains.

A powerful aspect of these exercises, Dutson notes, is helping clients recognize and begin to fully feel emotions — including discomfort — in their body. “I don’t know a client with body image issues that is entirely comfortable with their emotions because emotions are so often experienced within the body,” she adds.

Trumbetas also finds mirror work helpful, and often suggests that clients focus on learning to thank their bodies for its strength. She prompts clients to think of things that their body has done for them, such as allowing them to smell their favorite scent or heal from sickness or surgery.

This is quite a perspective flip for individuals who have harbored animosity toward their body for a long time, she notes.

If a client makes a comment such as “I hate my thighs,” Trumbetas says she would prompt the client to spend time looking in the mirror and thanking those thighs for getting them where they want to go and being able to do things like climb stairs or walk their dog.

“Being kind to yourself in this way can be a foreign concept,” she acknowledges. “I tell my clients consistently that to get comfortable, you have to become uncomfortable.”

As clients practice looking at their body in the mirror, she suggests they take an empowering stance she calls the “Wonder Woman pose.” To do so, the client meets their own gaze while standing with their hands on their hips, holding their head high, chest out and shoulders down. Trumbetas will model the pose for clients during sessions and encourages clients to try it with her. Standing in this way can decrease anxiety and boost confidence, she says.

Trumbetas says she receives a lot of positive feedback from clients about the Wonder Woman pose, and many report that it’s helpful to do whenever they’re feeling anxious or need to feel better about themselves and reconnect to their own power.

Identifying triggers

Reconnecting to oneself in counseling allows clients not only to better understand their own emotions but also to pinpoint how it feels when they are affected by negative messaging about body size and appearance, notes Dutson, an ACA member.

“Understanding the core emotion of what a trigger brings up for you gives you a better road map of how to deal with that emotion,” she explains. “Most of the emotions that come up around body image are disgust, shame, anxiety or guilt. And when clients have that [emotional] self-awareness, they can ask, ‘What is the core emotion that I’m feeling?” 

She then guides them to find ways to care for themselves when shame and other painful feelings arise, such as focusing on empathy and self-compassion.

For example, a client may be visiting an aunt who makes a comment that the client has gained weight since she last saw her or talks incessantly about her own weight loss behaviors or successes. Dutson will process this interaction with the client and prompt them to identify the emotions they felt and how they would like to handle a similar situation in the future.

She finds it helpful to prompt clients to track the moments that produce a visceral or intense emotional reaction regarding body size. Depending on the client’s situation and preference, she has them recount triggering situations to her verbally or write down details in a notebook or journal. She then guides clients to think about who was there, what was said, what emotions rose to the surface, what they were doing and feeling leading up to the interaction, and other aspects surrounding this triggering experience. Clients who reflect in this way eventually notice common threads of people or topics that activate them, she notes.

It can also be helpful, Dutson says, to suggest that clients write out a script or statements they’d like to use the next time they are in a triggering situation. Depending on where they are in their healing, this can include asking the other person not to talk about weight or body size in that way.

Trumbetas also helps clients identify and manage triggers, and one of the first things she does with clients who have been affected by weight stigma is to suggest they do an “audit” of their social media accounts to unfollow people and pages that spread body-negative messaging.

DiGennaro adds that helping clients talk about messaging related to weight stigma also requires counselor practitioners to suppress the urge to reassure or comfort clients who make statements such as “I feel like people are judging me.” A counselor’s role, DiGennaro emphasizes, is to be honest because people may very well be judging the client. Instead of offering reassurance, counselors can help the client unpack how they feel about such thoughts, recognize their origins and become intentional about the relationship they have with these thoughts and the way they affect their mental health, she says. Then they can help clients find and set boundaries to keep from internalizing harmful messaging going forward.

DiGennaro often helps clients plan for social interactions or family gatherings by guiding them to explore their values and identify what they are and are not willing to disclose or talk about.

“It’s a huge piece of healing work to first know what you need and want, then be able to put it into words and ultimately decide to share it with the appropriate people,” she says. 

DiGennaro sometimes invites clients to constructively use the anger they may feel about issues related to body weight and size. “There is a lot to be angry about with the way our bodies and feelings about food have been manipulated by diet culture,” she says. “One pattern I often see is when a client takes the unconscious anger evoked by weight stigma and turns it against themselves with punishing or chaotic food behaviors. So once the anger becomes conscious [through counseling,] I tell clients to channel that appropriately outward. Feeling and acknowledging rightful anger allows for the setting of essential boundaries to protect from further harm from weight stigma.”

Rethinking restriction

Helping clients identify and work toward goals is often an important part of counseling. But what if a client is focused on a goal to diet or lose weight?

The first thing to remember is that it is outside of a professional counselor’s scope of practice to advise clients on nutrition, exercise, weight loss or other topics related to physical health. (For more, see Section C of the 2014 ACA Code of Ethics at counseling.org/ethics.)

Weight loss is not a behavioral or mental health issue, DiGennaro stresses. Whenever a client mentions a goal of weight loss in a counseling session, she uses that opportunity to dig into why they want to set that goal — and what outside influences might have contributed. She uses motivational interviewing and asks questions such as “What would it mean to you if you lose weight?” to explore the client’s underlying reasons.

Knowing the reasons behind their weight loss goal will also help counselors determine the best approach for the client. Maybe the client says they want to lose weight because of negative comments they’ve heard from family members. “If you dig into it, they might be actually fine with their body, but they’re sick of hearing comments at family gatherings,” DiGennaro says. “In that case, we need to work on boundaries.”

Another client, however, may realize that their core reason for wanting a smaller body size is a desire to feel more confident. In that case, DiGennaro says she would focus on counseling techniques that boost the client’s self-confidence without attaching it to their weight or body image.

“Food and body issues are often the tip of the iceberg,” DiGennaro says. “I have never worked with a person who discovers their heart’s desire is to be thin. It’s always more along the lines of finding peace, receiving love and finding meaning in life.”

Similarly, Trumbetas says that when a client mentions in session that they’ve lost a certain number of pounds, she avoids praising or encouraging them, which would reinforce weight stigma. Instead, she responds with a question such as “How does that make you feel?” to explore the context of the client’s statement.

Trumbetas uses these conversations to emphasize that weight and health do not mean the same thing, and that “fixating on one aspect of health leads to unhealthy thinking,” she says.

Clients sometimes tell her, “If I can only lose this amount of weight, I’ll be happier.” But she reminds clients that being thin will not magically make them into someone they will love. Instead, she focuses on helping them learn to avoid comparing themselves to others and strengthen their self-love (both love of their body and their whole self).

DiGennaro is a certified intuitive eating counselor, so she also offers clients who talk about dieting psychoeducation on intuitive eating and explains that research indicates that most people who diet eventually gain the weight back, plus extra.

“Trying to control your body [via dieting] often comes from a place of punishment and restriction. I see it as ultimately a disconnection from self,” she says. “Instead, I help clients get curious about what it might be like to reconnect to themselves from a place of nourishment, self-care and truly listening to their body. And this is complex work because often … there were protective reasons they had to disconnect from their bodies and reconnection must be done in a trauma-informed way.”

DiGennaro acknowledges that this perspective shift does not come easily for clients, and it often takes many sessions before they begin to replace the unhealthy thought and behavior patterns they’ve adopted to cope with a lifetime of weight stigma.

Dutson also focuses on helping clients shift their perspective away from a restrictive view of taking things away (including food) to one that allows them to consider adding supportive elements to their life. To do this, she often prompts clients who are healing from the effects of weight stigma to identify and add things to their life that bring them joy, nourishment and comfort. This can be anything from dancing to their favorite song to connecting with a supportive friend.

There is so much more to wellness than body size, and the importance of social support is often one of the biggest contributing factors that clients overlook, especially those who have negative feelings about their bodies, Dutson adds.

“Asking ‘how can we add meaning, nourishment and joy to the body?’ is a more realistic and hopeful approach [to wellness] than restriction and taking things away,” she says.

Unlearning bias as a practitioner

Hilary Kinavey and Carmen Cool, co-authors of the 2019 Women & Therapy journal article “The broken lens: How anti-fat bias in psychotherapy is harming our clients and what to do about it,” note that researchers and mental health clinicians alike have reported on the “prevalence and negative implications of weight stigma in psychotherapy” since the 1980s.

“It is our lens, our gaze and the assumptions behind it that are the problem,” wrote Kinavey and Cool, who are both LPCs. “Diagnosis by sight is inaccurate and essentially biased. We simply cannot know who engages in overeating and who engages in restrictive eating based on the size and shape of the body in front of us. As professionals, it is our ethical duty to unpack and address this prejudice and to shift our focus and commitment to the human being who inhabits the body.”

The counselors interviewed for this article also recommend that counselors consider their own internalized weight bias to ensure they don’t inadvertently reinforce those biases in their interactions with clients.

“No one deserves to be treated badly because of their body shape, size or ability,” Trumbetas says. “If a counselor has their own negative views, they need to look inward and work on themselves — with another therapist if needed.”

Weight bias creeps into counseling, Dutson says, when a practitioner makes assumptions about a client based on their body size, such as how active clients are, how they feel about their body or what they might need to address in therapy. In turn, this can influence the questions clinicians ask (or don’t ask) and the issues they cover with the client.

“We have to recognize as counselors that we live in a society that values certain bodies over others, which can be ableist and elitist,” Dutson says. “We need to understand how marginalizing it can be to leave those beliefs unchecked. It’s not a stretch to say that our culture believes that certain genes, illnesses and conditions [that affect body size] are somehow inferior.”

Forristal, an assistant professor of clinical mental health counseling at New England College in Henniker, New Hampshire, agrees counselors need to do their own work to recognize and unlearn harmful beliefs about weight and body size. “Unless we intentionally and actively unlearn fatphobia the way we do with unlearning racism and other stereotypes, we are at risk for perpetuating this harm to our clients and communities,” she stresses.

A good first step counselors can take to combat this, Dutson says, is to decouple morality from food and body issues — both in the language counselors use in session with clients and in the way they think about things personally. This includes the questions a practitioner asks during the intake process with new clients, she adds.

Food is not good or bad, and it can be a comfort without inducing guilt. Counselors should refrain from talking about their own body or weight loss in sessions or asking leading questions of a client that reinforce weight stigma, Dutson says.

Instead, she advises counselors to borrow from mindfulness techniques and approach food and body issues from a nonjudgmental, observational lens. “We’d all benefit more from that,” Dutson acknowledges, “and modeling that for your clients is very powerful.” 

Forristal says that refraining from making assumptions — either positive or negative — about a client based on their body size or shape is a good start toward ridding professional counseling of weight bias. Weight stigma is a barrier to care and help seeking, so counselors who want to combat this should mention on their website and other promotional materials that eradicating fatphobia is a goal of their clinical practice, she adds.

In their article, Kinavey and Cool suggested that counselors ensure that their office space is accessible and welcoming to larger clients, which includes having chairs that accommodate a larger person comfortably and a waiting room that does not include decor or reading materials that reinforce fatphobia, such as fashion magazines.

Forristal also encourages practitioners to address any power imbalance that can affect the therapeutic relationship such as the counselor having a larger body than the client or vice versa. A client with a thin body, for example, may not feel comfortable reporting the extent of their issues with a counselor who is larger out of fear of offending them.

Counselors should not hesitate to check in with clients and ask how they feel about discussing body image issues with a practitioner who is a different size from them to ensure that they are comfortable, Forristal adds.

“We can never address these issues if we’re too uncomfortable or unwilling to broach them in the room with clients,” she says. “If a fat client expresses body image concerns to a thin counselor, the counselor can name that they hold privilege as a thin person and check in with the client about their reactions around that. Much like it doesn’t help to take a ‘colorblind’ approach when working with BIPOC [Black, Indigenous and people of color] clients, it isn’t helpful to ignore the differences in body size and power in the room.”

 

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Resources for counselors who want to learn more:

• The National Eating Disorders Association’s page on weight stigma: nationaleatingdisorders.org/weight-stigma
• The Association for Size Diversity and Health: asdah.org
• The National Association to Advance Fat Acceptance: naafa.org (Visit the “learn” menu to download a brochure with suggestions and guidelines specifically for therapists.)
• Hillary Kinavey and Carmen Cool’s 2019 Women & Therapy journal article, “The Broken Lens: How Anti-Fat Bias in Psychotherapy is Harming Our Clients and What To Do About It”: org/10.1080/02703149.2018.1524070

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.