Q: I’m comfortable working with clients on all types of issues, but I notice that I feel a sense of disapproval toward clients I consider fat. How can I change my attitude?
A:When I started specializing in eating and weight issues, I made many of the negative assumptions that are common in our culture about people who are considered fat. I assumed that they were overweight simply because they were overeating, and that if they only normalized their relationship with food, they’d lose weight and be healthy and happy. Despite my best efforts to accept them for who they were, some part of me still made judgments about their body size.
Over the past couple of decades, I’ve spent a lot of time examining my own attitudes about body size, weight, and health. I’ve delved into research that shows overwhelmingly that diets and weight-management programs produce only short-term weight loss. To date, not a single program has data to show long-term success, considered to be two to five years. Although you may know someone who has sustained a substantial weight loss, the chances for that outcome are about 5 in 100.
In shifting how you think about—and ultimately help—your clients, it’s useful to consider the idea that weight is a characteristic, not a behavior. It’s not simply a matter of calories in and calories out, and our weight-regulation system is largely outside of conscious control. All sorts of variables influence weight, including genetics, frequency of yo-yo dieting, medications, and the environment. By focusing on sustainable behaviors, such as exercise, eating a wide variety of food, getting a good night’s sleep, and practicing mindfulness or meditation, your clients are in the strongest position to reach their goals for health and well-being, regardless of whether they lose weight in the process. Likewise, for higher-weight clients who struggle with binge or emotional overeating, resolving these issues can, but won’t necessarily, result in some weight loss as a side effect. This paradigm, known as the Health at Every Size (HAES) approach, is gaining greater recognition as an evidence-based framework that supports the well-being of people of all shapes and sizes.
I’ve come to believe that the way we as therapists feel about our clients’ body size is not only a clinical concern, but a social justice issue. It’s not easy to challenge internal attitudes that are reinforced every day in the general culture, but if you’re willing to go against the cultural current, here are some things you can do to help you assess—and transform—your internalized views about weight and dieting.
Practice empathy. To begin with, it’s important to pay special attention to the struggles of your higher-weight clients as they share their stories about how they’ve viewed their bodies and how others have responded to them. Nina, for example, is one of my larger-sized clients who tries to take care of herself by swimming at her local YMCA a couple of times a week. She loves the way she feels after exercise, but she explained to me that she frequently overhears negative comments from other women about her size when she’s in the locker room. On days when she feels stronger, she ignores the comments and gets herself into the pool, but on days when she feels the shame that’s been with her since childhood, she can barely get through the experience.
As you listen to your clients’ experiences of how they’ve tried to deal with their weight and the stigma they suffer, you may notice your view changing from disapproval to compassion. Or you may find yourself thinking, If she just lost weight, she wouldn’t have to experience these judgments. But you should consider how that attitude blames the victim, which does little to help the client and perpetuates a culture of prejudice.
Examine internalized stigmas. Weightism, also known as weight stigma, refers to judging another person based on his or her shape or size. As with other forms of discrimination, weightism fuels behaviors such as bullying and hate speech, and it can limit an affected person’s access to education, employment, and healthcare. There’s also an abundance of evidence that the chronic stress that comes from being part of a stigmatized group can increase rates of long-term health problems.
When I conduct workshops on weight stigma for therapists, I ask participants to call out their
associations to the words thin and fat. Typically, they associate thin with the words successful, happy, confident, sexy, and healthy; and they associate fat with the words unhealthy, lazy, out of control, miserable, and stupid. You can take a test online that measures implicit attitudes toward weight by going to Harvard’s Project Implicit at implicit.harvard.edu/implicit.
These associations are so common that many therapists don’t realize that they’re attaching them to their higher-weight clients. Also, it’s important to keep in mind that an oppressed group often internalizes negative associations. Your client may believe that because of her size, she’s unlovable or worthless, and your own feelings toward her size have the power to reinforce her beliefs or help her move from shame toward a place of acceptance, self-compassion, and self-care. The Association for Size Diversity and Health, a professional organization composed of members committed to the HAES principles, can offer you helpful information to support your clients.
Expose and challenge yourself. As with other groups that reclaim a term that’s been used against them, there’s been a movement to take back the word fat as merely a description of size, rather than a derogatory word. When my clients want to learn more about the size-acceptance movement, I suggest they read the blog “Dances with Fat” by Ragen Chastain, a large woman who’s an award-winning ballroom dancer. She writes, “My greatest accomplishment has been learning to love myself and my body, and to be truly happy living completely outside the cultural beauty norm. As a plus-sized professional athlete, I practice Health at Every Size and as a human being I’m an unwavering advocate for Size Acceptance—the civil rights truth that every body deserves respect and that the rights to life, liberty, and the pursuit of happiness are inalienable, not contingent on size, health, or dis/ability.” Her blog entries are one of many resources that give insight into the experiences of a fat person at psychological, social, cultural, and political levels.
There are also educational resources that dispel myths about people at higher weights. The National Association to Advance Fat Acceptance, for instance, is a civil-rights organization dedicated to ending size discrimination and building a society where people of every size are treated with dignity and equality in all aspects of life. Their Guidelines for Therapists Who Treat Fat Patients examine common assumptions made by mental health professionals and offer stereotype-management skills.
Seek affirmations. Confirmation bias is the tendency to pay attention to information that confirms our beliefs and ignore information that doesn’t, especially when it comes to emotionally charged or deeply entrenched issues. The fear of fat runs so deep in our culture that it may be hard to consider letting go of these beliefs. At a personal level, I encourage you to become aware of the lens you use to evaluate people based on size, and then to challenge your ingrained stereotypes. Think about higher-weight people you know—friends, family members, colleagues—who affirm that fat people can be smart, healthy, in good relationships, and attractive. The converse is to think of thinner people you know who have health issues, struggle in relationships, and don’t look particularly attractive. The point, of course, isn’t to start judging these friends and colleagues, but to unhook your assumptions about people based on their weight.
Practice self-compassion. If you want to shift your attitudes toward higher-weight clients, it may take time to make these changes at a deep level in your psyche. At the same time, as members of a profession we have an obligation to move forward.
One participant approached me the day after a workshop and said how upset she was to recognize that she’s been assuming these automatic negative attitudes based on stereotypes. My response to her was that it’s wonderful that she’s now aware of these attitudes so that she can challenge and reevaluate her beliefs.
In my own journey, I’ve spent countless hours listening to the challenges and victories of people of higher weights. Witnessing the transformation that occurs when people learn to let go of the shame and treat themselves with acceptance has transformed me.
Moving beyond cultural stereotypes and fully embracing one’s humanity is difficult, but it can be done, as one of my former clients recently expressed at a conference.
“At 37, the worldview that I accepted told me that I wasn’t really worthy of much with a larger body,” she said, “even though I was a strong and courageous mother, loved by a wonderful and caring husband, and extremely successful as an elementary schoolteacher and teachers’ mentor. In my inner world, the only way to be worthwhile was to be thin. Twenty years later, I’ve become me. The judgments are gone; the self-esteem issues are gone; righteousness when I stayed on a diet is gone. I don’t physically look like I thought I would, or even how I may eventually look someday—who knows?—but I’m happy, peaceful, and extremely thankful.”
Judith Matz, LCSW, is the coauthor of Beyond a Shadow of a Diet: The Comprehensive Guide to Treating Binge Eating Disorder, Compulsive Eating and Emotional Overeating (April 2014) and The Diet Survivor’s Handbook: 60 Lessons in Eating, Acceptance and Self-Care. She’s the director of the Chicago Center for Overcoming Overeating, Inc. and has a private practice in Skokie, Illinois.