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Beyond Lip Service: Confronting Our Prejudices Against Higher-Weight Clients

By Judith Matz

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

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.

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1 Comment

  • Comment Link Sunday, 23 March 2014 08:27 posted by Lizbeth Binks

    For those still unacquainted with HAES and other important developments in our understanding of weight-related issues, this is a gentle and thoughtful introduction. Ms. Matz highlights excellent resources that every therapist - even or perhaps ESPECIALLY those who don't treat weight and eating issues - should be familiar with. People who are fat are members of a subculture with many shared (and often traumatic) experiences, and understanding that experience is requisite to multicultural competency.