Six Steps for Addressing Anti-Fat Bias in Therapy

Fatphobia and anti-fat bias can undermine the therapeutic relationship and reduce the safety and effectiveness of therapy.

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Mental health counselors are uniquely situated to combat the negative mental health impacts of anti-fat bias in their clients, but first, they must address their own internalized fatphobia.

Stella B. Kerl-McClain, Cort M. Dorn-Medeiros, and Kelsey McMurray of Lewis and Clark College offer six steps for counselors and counselors-in-training (CITs) to address fatphobia in the clinical setting better.

“Anti-fat oppression has an acute impact on mental health and overall well-being. Such effects can include but are not limited to increased depression and anxiety, disordered eating behaviors, internalized stigma, and subsequent body shame, and increased mental and physical stress from diet and weight cycling,” the authors write.
“Professional counselors and CITs are particularly well-positioned as agents of change within mental health, medical, and family systems to advocate for and with their fat and larger-bodied clients. Unfortunately, counselors and CITs are not immune to the incessant social and cultural messaging regarding fat stigma and anti-fat bias. However, through education, self-compassion, reflection, and challenge to internalized anti-fat messaging, counselors can begin the process of unpacking their own anti-fat bias to provide better care for all clients.”

In their newly published article, “Addressing Anti-Fat Bias: A Crash Course for Counselors and Counselors-in-Training,” the authors begin their argument by outlining the history and foundation of fatphobia and fat stigma both in the United States and abroad, taking special note to not medicalize fatness by refraining from using words like “obese,” “obesity,” and “overweight.”

In the 1950s, the World Health Organization began emphasizing holistic bodily health, free of disease and infirmity but also complete with physical, mental, and social well-being. However, according to the authors, this emphasis on health was weaponized against fat people.

“Health can also serve as a code word for a positive range of qualities that any given society wishes to see in its citizens.”

In the 1980s came the “obesity epidemic.” With this “epidemic,” fatness became integrated into medical narratives of deviance and disease, hinging on moral outrage and panic—not dissimilar to the medicalization of mental illness. Due to the medicalization of fatness and fat stigma, thinness is desired in citizens globally, both aesthetically and medically.

The authors note that fat stigma is the “social discrediting of people perceived as fat within a culture that attaches negative social meanings to fatness.” In other words, fat people are considered lazy, unintelligent, and personally responsible for their size despite a breadth of evidence that links fatness to systems of oppression like racism, classism, and homophobia. Fat stigma fuels anti-fat bias, the negative evaluation of a person based on their perceived amount of body fat, and fatphobia.

Because anti-fat bias and fatphobia stem from medicine, medical outcomes are typically worse for fat people than their thin counterparts—not because they are less healthy but because fat stigma directly impacts the healthcare process. Fat people typically postpone care due to assumed or previously experienced size discrimination and humiliation. In particular, the authors note that:

“Fat women, in particular, may experience ongoing medical mistreatment and negligence due to their body size.” 

With the medicalization of fatness also came the fat acceptance movement in the 60s and 70s. The National Association to Advance Fat Acceptance, The Body Positive, and the Association for Size Diversity and Health have developed models and approaches for clinicians and practitioners to better address their learned prejudice against fat people and unpack their anti-fat bias.

The authors highlight the HAES approach, which includes a curriculum focusing on body acceptance, intuitive eating, and active embodiment.

However, the lived experiences of fat stigmatization, anti-fat bias, and fat shaming are still daunting and damaging to one’s joy, mental health, and well-being. And, when fat people seek counseling and therapy, they may unknowingly enter into a therapeutic relationship with someone who is fatphobic—this is dangerous for many reasons, but perhaps the most insidious is that fat people are inadvertently assigned more severe and significant pathology than thin people.

Thus, counselors must educate themselves on how to support their fat clients and actively fight against anti-fat bias in the clinical setting. The authors offer six specific recommendations.

  1. Educate yourself: “Do your own work to educate yourself about anti-fat bias, fatphobia, sizeism, and the intersections of racism, classism, and sexism.”
  2. Practice self-compassion: “It is normal to feel conflicted about your own body. Hold a compassionate space for your process in challenging your own biases and assumptions around body size.”
  3. Reflect and debrief: “Take inventory of your biases about fat, weight, and body size.” There are even formal assessments and measurements to take that explore anti-fat bias that can be used both personally and with clients.
  4. Challenge your assumptions: “…refrain from the speculation that fat clients are either working on losing weight, want to lose weight, or are sedentary and do not engage in exercise or intentional movement.”
  5. Broach and be an advocate: “Professional counselors and CITs should advocate with and for clients within mental health, medical, and family systems regarding weight, body size, and fatness.”
  6. Keep learning: “Seek out additional training.” 

Epistemic injustice is rife within all healthcare, not just mental healthcare. Fat people are especially vulnerable due to the many intersections of fatness with systems of oppression and anti-Black racism. Not only are fat people especially vulnerable to epistemic injustice but also to the development of eating disorders—which are also frequently mismanagedmisunderstood, and mistreated in mainstream mental healthcare. Fat people deserve better; this is how we can begin doing the bare minimum.

 

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Kerl-McClain, S. B., Dorn-Medeiros, C. M., & McMurray, K. (2022). Addressing Anti-Fat Bias: A Crash Course for Counselors and Counselors-in-Training. Journal of Counselor Preparation and Supervision, 15(4), 3. (Link)

7 COMMENTS

  1. This is a helpful article, but I don’t know many therapists who can even begin to implement these steps. Some prerequisites for therapists who just fat-shame their clients as a power play, because of their ‘therapeutic process’. Written in step-form, as follows:

    1) Know that antipsychotics do cause weight gain. Refrain from saying the favorite line “do you want to be FAT OR CRAZY?”

    2) Do not directly mock your fat/ large body clients. Do not say this: “BUT YOU ARE OVERWEIGHT. I see your fat all over your body. I know that I am more thin than you. You need to lose weight because anyone who bullies you about your weight is correct.” (almost a direct quote from my former practitioner of the mental arts)

    3) Do not give diet advice to your clients, do not give diet advice after your clients specifically asks you to stop: “I am just trying to share things that make ME feel healthy.” The egregiously bad bad diet tips they would give me in sessions were always by a *therapist* who had zero training in nutrition

    4) Do not have your clients diagnosed with “binge eating disorder” simply because they gained weight on antipsychotics. Don’t send them for “med checks” for the sole purpose of bringing in a nurse practitioner to ambush them about their weight.

    5) This is for everyone- understand that this field is incredibly abusive and many therapists behave so horribly that they don’t even meet the bad standards we debate here.

    • Wow, even I am shocked and disgusted that “mental health” personnel would ever talk in such a fashion to clients! That is absolutely disgusting! Though I definitely have gotten the “let’s put you on a diet after making you fat with antipsychotics” energy a lot. Seriously, are these folks incapable of basic cause-and-effect reasoning?

      • Thanks Steve,

        For people with SMI diagnosis, the body-shaming is blatant and intended to be cruel.

        Personally, I sometimes feel shocked by the mildness of the professional’s viewpoints. These articles seem to be too gracious. The MH system bullies their clients, especially if their client is “disabled” or considered “seriously mentally ill”. This protocol is as regular as not informing patients about side effects…

      • “Seriously, are these folks incapable of basic cause-and-effect reasoning?”

        You would think that they would teach them the process of denial and error at Universities wouldn’t you? I mean it’s not exactly rocket appliances. (Thanks Ricky of Trailer Park Boys)

  2. I think this phenomena of focusing others’ body parts is the culprit.

    The fat phenomena is becoming more apparent because of the internet and the social media where “influencers” are all types and shapes and people realize everybody has something to say. Where before the internet, the gates for certain people were shut hard!

    BUT.

    I think the issue is much deeper and has much bigger consequences for at least 50% of the population.

    What am I getting at is all these ideas of noticing, commenting, leering, judging, touching (without consent – it happens a lot more to black and pregnant people), talking, and considering about a woman’s body is so primitive and frankly stupid! in our societies all over the world!

    I will even go one step deeper and say – saying women are sexy, beautiful, fashionable, blonde, blue eyes, brown hair, brown eyes, tall, short, long hair…..why are we still talking about people’s bodies as if they are cattle? Does anyone enjoy for being told you are beautiful anymore? I would love to ask why?

    It may sound a bit radical but why is this normal? Who said this is normal to focus on women’s body. We know the history of America and how they treated the slaves by objectifying their bodies for profit and then it switched to women afterwards…my thinking. I do not know much about the genesis of this fat medicalization but I bet it has something to do with profit…I can smell it.

    I am on the fence now. I do not comment on anyone’s body shape or body related at work. If I notice a person’s body, I know my feelings about that and they are not something that I need to share with the person because frankly, my feelings show me how narrow I think.

    How empty my mind is looking for something out there to latch on. So with my own stupidity on focusing others’ body parts, I realized the deep programming and started to challenge my own free flowing attention looking for something else. I no longer consider a compliment to validate a person’s body part! Sure compliments may feel good but also they feel cringe! I wanted to add a caveat that we can play with words and bodies but this requires understanding, relationship, and consent to comment on each others bodies…what I am focusing on my comment is the insidious and taken for granted of commenting on women’s body in everyday situations.

    Idk where I am going with this but I think we need to really focus on what the person is saying, writing, thinking, and sharing than what a human may look like! We all determine we sort of all look alike…no one has their eyes on their toes!

    Beauty is art not a person minding their own business.

    PS. I know a body can be treated as an art but I am not talking about that. I am talking about this normalization of body comparing and mindless body focus as yours against mine mentality.

  3. One of the newer songs on the radio that makes me smile … once I understood it … is the Victoria’s secret song.

    “God I wish somebody would have told me
    “When I was younger that all bodies aren’t the same
    “Photoshop itty-bitty models on magazine covers
    “Told me I was overweight”

    “If I could go back and tell myself
    “When I was younger, I’d say, psst”

    “I know Victoria’s secret
    “And girl you wouldn’t believe
    “She’s an old man who lives in Ohio
    “Making money off of girls like me
    “Cashing in on body issues
    “Selling skin and bones with big boobs
    “I know Victoria’s secret
    “She was made up by a dude (dude)”

    The irony of it all is that, as a kid, I used to babysit in the summers for four little boys, whose mom was related to the very same Limited owners, who own Victoria’s Secret.

    But the bottom line is the song is right, we live in a way too paternalistic society. And psychiatry and psychology are a huge part of the problem, within our way too paternalistic – to the point of being downright misogynistic – society.