A Fat Positive Framework for Beginning Body Image Work with Plus Size Clients

Two-thirds of the United States population of women are considered plus size, but weight stigma in healthcare spaces is as pervasive as ever and has long lasting mental health implications for plus size clients (Flint et al., 2025, Christel & Dunn, 2016).  With anti-fat bias on the rise, plus size clients who are seeking therapeutic services to work on body image issues are at risk of receiving inadequate care from clinicians who may hold their own biases or feel ill-equipped to empathetically hold space for plus size clients with body image concerns (Wang et al., 2025).  As plus size clients often enter counseling, at least in part, for addressing body image issues, a framework for ethically and empathetically beginning this work feels vital.  Not all plus size clients are interested in weight-loss or even experience negative body image issues.  However, most if not all, have likely experienced microaggressions or prejudice due to weight stigma and systemic fatphobia.  Learning to approach each client’s body image needs with accurate empathy is essential to developing a strong therapeutic alliance. Using a fat positive framework with all clients, and more crucially with plus size clients, ensures an appropriate level of humility and respect that is often lacking in healthcare spaces (Philip et al., 2025).  The framework proposed in this article is based on modern Health at Every Size (HAES) research regarding anti-fat bias and body image, my work as a Licensed Professional Counselor who works specifically with queer, BIPOC, plus size clients experiencing body image issues, and my own lived experience as a fat-identified, queer, plus size woman of color (Suarez et al., 2024). I created this framework after receiving a highly positive response from participants of my course on fat positive approaches to counseling who said they agreed with the concepts of fat positivity, but did not know it could be applied clinically. Wanting this concept to be as easily applicable as possible, I designed the FRIENDS framework to be utilized as a supplement to the clinician’s existing theoretical approach(es) and coping strategies. The FRIEND framework, introduced in detail below, aims to provide a structure for competently and empathetically beginning body image work and is specifically designed for clinicians who support plus size clients in improving their body image.

FRIEND

Explore the first time they felt shame in their body.

In the context of this framework, I utilize the following definition of shame, “the intensely painful feeling or experience of believing that we are flawed and therefore unworthy of love and belonging” (Brown 2012). Clients who are plus size will typically be able to identify this moment easily as it is often a core memory for them.  It may be conceptualized, by the client, as the beginning of their issues with their body and often takes place in early childhood.

Help the client vividly recreate this moment by:

• identifying who was present,
• naming what was said,
• describing the environment they were in during the moment,
• defining what was happening somatically for them during the moment,
• exploring what were they thinking,
• and recounting any other relevant details that can help them process this pivotal moment wholly.
•  Can they remember additional context like what was happening the moment before the first moment of shame took place and what happened for them in the moments immediately after?   

This first part of the proposed framework may take at least one if not a few sessions. As it can reduce the impact of particularly traumatizing memories, Eye Movement Desensitization and Reprocessing (EMDR) would be an ideal companion processing method for this memory if the client finds the moment particularly distressing to recall.

FRIEND

Reflect on every core memory related to body shame from that moment to now. Pay particular attention to intersectionality of being plus-size in combination with additional marginalized identities.

The second part of the framework builds on the first by asking the client to walk through the most salient memories from the first moment of body shame to present day. This may mean exploring a handful of memories in session, or it may mean journaling or otherwise expressing memories outside of session and bringing their discoveries back to process.  It is important to convey that these memories must have impacted how client related to their body in a new and negative way.  For example, I was often told that “outfits should always be flattering” in order to make you appear as small as possible.  This opinion became a core belief of mine for many years and shaped how I dressed and showed up in public spaces until I learned that I am allowed to wear whatever makes me feel personally great. These moments are important and powerful to name for the client as it allows them to name and externalize the harm they were caused and how it negatively impacted their body image and self-concept.

Additionally, it is particularly important to hold intentional space for the client to identify how the intersectionality of each of their marginalized identities (i.e. race, cultural background, socioeconomic status, gender, sex assigned at birth, sexual and/or relational orientation, ability status, etc.) impacted these moments and to allow the client to reflect on this as well. This work can be painful as it asks the client to identify moments of complex trauma and label them as such—possibly for the first time.  It may be slow work because identifying one memory may unintentionally unearth multiple additional memories.  Meeting the client where they are in their unique journey is important for allowing them to internalized their significance. Having a plan to “cope ahead” by engaging in grounding nervous system regulation strategies can help clients feel safe and restored after engaging with this framework in session.

FRIEND

Identify internalized negative body image messages received and who/what/ where they came from.

Unfortunately, most of the internalized negative messages clients receive begin in childhood and come from trusted family members. Naming this can identify complex trauma patterns that you as the clinician and the client may have been unaware of because this type of repeated and constant messaging is so normalized by society today. It is important to remind yourself and the client that receiving negative messaging consistently and constantly about one’s body from loved ones, teachers, doctors, friends, strangers, social media, television, movies, and anywhere else where body shaming is normalized, is not normal, is in fact deeply harmful, and not their fault. Navigating the complexities of internalized negative body image messages can take time. It is vital to meet the client where they are emotionally and cognitively in order for this work to have the most impact for the client. It may be necessary to go slow or to pause using the framework to address other issues that arise. Identifying these negative messages may also unearth other internalized negative messaging, so creating space for processing the client’s unique intersectionality is crucial.

FRIEND

Externalize and explore the impact fatphobia and diet culture have had on the client’s life from the first moment of shame until now.

This part of the framework requires the clinician to have a foundational understanding of systemic fatphobia, diet culture, and its impact on plus size people. While still somewhat rare, there are resources to help clinicians understand the massive and systemic impact of fatphobia and diet culture on clients. These resources will be listed at the end of this article.

Once the clinician has sufficiently addressed their own weight bias and has acquired a baseline level of knowledge about systemic fatphobia and diet culture harm, then they can begin to help the client explore the impact these systems have had on the client (Philip et al., 2025; Robinson et al., 2025). Fatphobic rhetoric is embedded into every facet of our culture and is internalized as early as childhood for many. It cannot be stated enough how essential the “unlearning” of fatphobic societal norms is for competently and compassionately working with plus size clients. This externalization part of the framework is important for expanding the client’s worldview and providing vital psychoeducation about the racist and patriarchal origins of the anti-fat “beauty standards” that are pervasive today (Strings, 2019). 

Externalizing the impact of the client’s experience with dieting and diet culture can help them understand that their body is not an inherent problem to be fixed (Bacon, 2014). Helping the client understand that the problem lies within capitalistic diet industries profiting from the public’s sustained and severe insecurity in their body image can alleviate clients’ misplaced body shame. Pyschoeducation about the deeply racist origins of modern “beauty standards”, can also help externalize shame and guilt clients may feel for not meeting these fabricated standards that are unachievable for the majority of the world. (Strings, 2019)

This step in the framework may include the client naming the times they have experienced weight/size-based discrimination in the workplace, healthcare settings, or in their personal lives.  It may also include the client naming and processing any diets or diet industry products they have tried and how it impacted their relationship with their body.

FRIEND

Name current feelings and thoughts about your present body image and how past messages and experiences inform those current feelings.

This part of the FRIEND framework aims to encourage the client to gently and honestly acknowledge and take ownership of the current state of their body image.  It allows them to acknowledge how they came to be, where they are currently in their body image journey, and what external sources led them there. 

Gentle reflection on what this feels like and how their current body image impacts their activities of daily life is an important component of the framework. Naming the past messages and experiences that inform their current body image may feel redundant here, but it is essential to continue to reflect that the client’s negative body image is not inherent—it was projected onto them by external sources and is not their fault. A major theme that will likely arise from this stage is a need to release shame about their body. This is long-term work and may take many multiple sessions to achieve progress. It is important to acknowledge that navigating body image issues is also a lifelong journey which makes setting accurate expectations for coping even more imperative.

FRIEND

Client Decides to change the way they relate to their body with a renewed empathetic lens and define how they would like to think and feel about their body.

This stage in the FRIEND framework is where the client can begin to conceptualize how they would like to relate to their body in a more positive way—and on their own terms. It empowers them to take ownership of their own thoughts and feelings about body image and decide how they would like to perceive themselves and their body. 

The client may be able to easily and eagerly define what they want for their new body image, or they may struggle to even identify what is possible for an improved body image. The “magic question” technique can help the client begin to define this for themselves. In this context, the “magic question” could be stated as follows, “If you waved a magic wand and woke up in the body you have now with the exact relationship you have always wanted to have with your body, what would it look like?”. If they need more help, the below examples may be a comforting starting point for them:

• Body Neutrality
  You don’t have to love your body—you just don’t have to hate it. Your body is allowed to simply exist without constant judgment.

• Body Acceptance
  Acknowledging your body as it is right now, even if you have mixed feelings about it.

• Body Respect
  Treating your body with care and dignity—feeding it, resting it, moving it—regardless of how you feel about it.

• Body Positivity
  Actively challenging harmful beauty standards and affirming that all bodies are worthy, visible, and valuable.

• Body Love
  Feeling appreciation, gratitude, or affection toward your body—not because it’s perfect, but because it’s yours.

Considerations and Conclusion

Reminding the client that body image will ebb and flow day to day (which is normal and okay), is important to ensure the client understands that the goal is not to have an unrealistically positive relationship with their body. The overall goal is to reduce the level of distress and harm caused by their negative body image.

Using the FRIEND framework as a supplemental support system to the clinician’s existing theoretical approach(es) will benefit plus size clients seeking support with their body image. It provides a framework for clinicians to reference when questioning how to competently support plus size clients on their body image journey and will also help build rapport and enhance the therapeutic alliance between client and counselor. 

Additional resources are listed below.

Podcast:

Maintenance Phase by Aubrey Gordon

Books:

Fearing the Black Body: The Racial Origins of Fatphobia by Sabrina Strings

What We Don’t Talk About When We Talk About Fat by Aubrey Gordon

Reclaiming Body Trust: Break Free from a Culture of Body Perfection, Disordered Eating, and Other Traumas by Hilary Kinavey MS, LPC, and Dana Sturtevant MS, RD

Health at Every Size by Lindo Bacon, PhD

National Board for Certified Counselors (NBCC) Approved Continuing Education Course:

Becoming a Fat Positive Counselor: An Unlearning and Relearning Guide for Competently Working with Clients of Size By Sofia Siraj-Wu MS, LPC https://ondemand.modernpath.net/p/becoming-a-fat-positive-counselor-an-un-learning-and-re-learning-guide-for-competently-working-with-clients-of-size