How weight stigma shows up in therapy and what to do about it

We live in a society where body size is not a neutral feature, but one imbued with assumptions and meanings. Thinness is seen as a symbol of virtue, restraint, and health, whereas fatness is believed to represent gluttony, laziness, and illness.

These pervasive societal assumptions lay the groundwork for weight stigma, which is defined as the social exclusion or devaluation of individuals whose bodies do not fit into ascribed norms of body weight or shape (Tomiyama et al., 2018). Higher-weight people face stigma and discrimination across settings (e.g., employment, education, healthcare) and within social, familial, and romantic relationships (Puhl et al., 2008). This bias can be blatant, such as verbal insults, teasing, or dirty looks, or covert, such as being praised for exercising or expressing concern for health (Cossrow et al., 2001; Lindloff et al., 2024). Exposure to weight-based discrimination is harmful to mental and physical health (Wu & Berry, 2018). 

When a higher-weight client enters therapy, it is highly likely that they have encountered weight stigma (Lee et al., 2021). This weight stigma may have exacerbated or even caused the mental health challenges that they present with (Meyer & Frost, 2013). A safe, judgment-free zone and strong therapeutic relationship are essential conditions for positive outcomes (Wampold, 2015), yet the therapeutic relationship can be yet another site of weight-based discrimination, with stigmatizing practices often used reflexively by even the most well-intentioned therapists (Puhl & Brownell, 2006). It is our moral and ethical obligation as therapists to examine our biases and prevent harm to our larger-bodied clients, and not treat higher weight as a flaw or target of therapy.

In this article, we identify common ways that weight stigma manifests within the therapeutic context, debunk prevalent societal notions about weight and health, and provide strategies for supporting higher-weight clients. 

Weight Stigma in Therapy

Previous literature demonstrates that weight stigma can manifest in various ways within the therapeutic context, including:

1. Assumptions: Therapists may make assumptions about clients based on their body size/shape, such as that all higher-weight clients overeat, lack willpower, want to lose weight, or are in poor health (Abel, 2020; Aza, 2009; Puhl et al., 2014). These scientifically unfounded assumptions (discussed below) perpetuate harmful stereotypes.
2. Overfocus on weight: Therapists may be too focused on clients’ weight and believe that high weight must cause poor mental or physical health (Abel, 2020; Akoury et al., 2019; Schafer, 2014). Overemphasizing the client’s weight can have the effect of reducing the client to their weight while overlooking other important aspects of the client’s overall experience and challenges. This behavior may leave the client feeling stereotyped, stigmatized, or otherwise unseen.
3. Treatment recommendations: Relatedly, therapists may provide unsolicited weight loss advice to clients, suggest weight loss as a treatment focus, or commend clients’ weight loss goals (Abel, 2020). These instances communicate the therapist’s preference for thinness, belief that their body or life would be better after shrinking, and the false notion that weight is largely within one’s person control. These implicit messages reinforce pervasive and harmful beliefs around body size and inadvertently stigmatizing the client and/or perpetuating the cycle of shame by suggesting the client is “at fault” for their body size.
4. Nonverbal communication: Therapists may make less eye contact with higher-weight clients or appear less interested in them; these nonverbal behaviors may be particularly apparent in group treatment settings (Akoury et al., 2019; Schafer, 2014). These nonverbal communications are often an unconscious manifestation of weight bias.
5. Physical environment: Chairs in waiting rooms and therapy offices may not accommodate individuals in larger bodies, which can cause distress, discomfort, and make clients feel unwelcomed (Akoury et al., 2019; Schafer, 2014). Materials (e.g., brochures, magazines) in the waiting room may signal a preference for thinness or equate weight loss with health, thereby marginalizing clients in larger bodies.

What about the client’s health? Debunking common weight stigma related beliefs  

Based on widespread beliefs that high weight is hazardous to health, therapists may worry that not focusing on weight or recommending weight loss could be harmful to the client. Below, we review scientific evidence that challenges these common notions.

Ways to make your practice more inclusive for all bodies

Investigate your own weight bias

• Consider:
  • What assumptions are you making about people’s character, intelligence, or health based on their body size?
  • What automatic emotional reactions do you have towards higher-weight clients? How might this affect your treatment?

Normalize and explore origins of clients desires for weight loss

• Normalize the client’s desire for thinness within our societal context.
• Express your acceptance for the client at any size and shape. Share your firm belief people of all shapes and sizes are unequivocally worthy and deserving to be treated with dignity and respect.
• Help the client become curious about where they learned about the superiority/inferiority of different bodies and how those messages and/or experiences of weight stigma have impacted them.

Unpack client’s expectations of weight loss to formulate treatment goals

• Clients who wish to lose weight should be informed of the limitations of behavioral weight loss; there are no known long-term solutions for weight loss.
• Identifying what the client believed weight loss would give to them (e.g., how they imagined it would benefit them) may uncover treatment goals for the client that can be pursued directly (e.g., improved self-esteem).  

Ask about the client’s health behaviors rather than assuming them

• Investigate whether health concerns are legitimate or rooted in internalized weight stigma.
  • Clients may believe that they are “unhealthy” simply because they’re in a larger body and have internalized pervasive messages about higher weight, without any medical indicators.  

Encourage weight-neutral, value-driven health behavior engagement

• Help client connect with value-driven reasons for health improvement (e.g., “I want to be able to play with my children”) outside of weight loss, which is not a value.
• Investigate what previously obstructed engagement in these activities, with a particular attention to unwanted thoughts and emotions but including external constraints (e.g., finances, time).
• Use client’s case conceptualization and overall treatment goals to guide determination of activities that would be joyful, nourishing, and feasible for the client. 

Adopt a non-judgmental attitude and language 

• Assume a non-judgmental attitude when discussing client’s health behaviors, including language choices around food/body and avoiding terms that connote a value of moral judgment around food choices (e.g., “bad vs. good,” “junk food”).
• Place priority on helping clients eat enough food to nourish their bodies. Refer to anti-diet or health at every size dieticians or physical trainers when necessary.

Concluding Thoughts

Everyone deserves high-quality therapeutic care. Therapists’ biases and beliefs about weight can interfere with treatment and ultimately harm the therapeutic relationship and the client. The creation of a safe and accepting space for higher-weight clients will require a conscious effort to unlearn pervasive societal beliefs and to understand the client as a complete person.

Interested in learning more? Additional Health at Every Size and weight-inclusive therapy resources are linked or listed below:

Scholarly Articles:

Kinavey, H., & Cool, C. (2019). The broken lens: How anti-fat bias in psychotherapy is harming our clients and what to do about it. Women & Therapy, 42(1-2), 116-130.

McHugh, M. C., & Kasardo, A. E. (2012). Anti-fat prejudice: The role of psychology in explication, education and eradication. Sex Roles, 66, 617-627.

Tylka, T. L., Annunziato, R. A., Burgard, D., Daníelsdóttir, S., Shuman, E., Davis, C., & Calogero, R. M. (2014). The weight‐inclusive versus weight‐normative approach to health: evaluating the evidence for prioritizing well‐being over weight loss. Journal of Obesity, 2014(1), 983495.

Online Resources:

The Ethics of Helping Clients with Weight Loss in Psychotherapy
Health at Every Size: A Concept to Reduce Weight-Centric Thinking and to Promote Body Positivity
Should Your Therapist Help You Lose Weight?

Websites:

Association for Size Diversity and Health (ASDAH)

Books:

• Health At Every Size: The Surprising Truth about Your Weight” Lindo Bacon (2008)
• “Anti-Diet: Reclaim Your Time, Money, Well-Being and Happiness Through Intuitive Eating” Christy Harrison (2019)
•  “Shrill: Notes From a Loud Woman” Lindy West (2019)
• “Things No One Will Tell Fat Girls: A Handbook for Unapologetic Living” Jes Baker (2015)
• “FAT!SO?” Marilyn Wann (1998)

Podcasts:

• Food Psych with Christy Harrison
• Maintenance Phase with Aubrey Gordan and Michael Hobbes
• IWeigh with Jameela Jamil