Stupid. Ugly. Sloppy. Lazy. Undisciplined. Fat.

Exploring women’s experiences with weight stigma and sizeism in psychotherapy.

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Stupid. Ugly. Sloppy. Lazy. Undisciplined. Fat. These are all words frequently used to describe people who are overweight or obese in Western cultures. A new special issue of Women & Therapy (2019) titled, Make Space for Every Body: Ending Sizeism in Psychotherapy and Training, tackles the important topic of weight stigma and its existence in psychotherapeutic practice.

Weight Stigma 

Commonplace in the United States, weight stigma refers to negative beliefs associated with being obese or overweight that emerge in a culture that is sizeist (McHugh & Chrisler, 2019; Kinavey & Cool, 2019). For example, overweight and obese individuals are frequently described using a slew of negative attributes (from smelly and unstylish to lacking in moral integrity) (Puhl & Heuer, 2010). Such negative beliefs about overweight individuals often results in weight-based discrimination (Puhl & Heuer, 2010), or the maltreatment or disenfranchisement of individuals due to their weight.

Weight Stigma in Mental Health Professionals

Given that weight-based teasing and discrimination are associated with poor psychological health outcomes in people of all ages, including depression, poor self-esteem, and eating pathology (Friedman et al., 2005), one might assume that mental health professionals would not hold anti-fat attitudes. Psychologists are, in fact, ethically responsible for the health of our patients and for creating a non-judgmental therapy environment that is free from societally-based bias (Kinavey & Cool, 2019). Yet, emerging data suggests that is not the case.

Many articles in the special issue of Women & Therapy (2019) demonstrate that anti-fat attitudes and behaviors reflective of weight-bias are evident among professional mental health practitioners, even in those with an expertise in treating eating pathology (see Akoury, Shaffer, & Warren, 2019; Brochu, 2019; Harrop, 2019; Kinavey & Cool, 2019; Meulman, 2019; Scott, 2019).  For example, in a case study examining interactions between a patient with an atypical presentation of anorexia nervosa and her primary therapist in an inpatient setting, Harrop (2019) described how weight-bias in the therapist contributed to the patient’s denial of her illness and severe ruptures in the therapeutic alliance.

Similarly, my colleagues and I qualitatively explored 15 obese women’s experiences with weight-based microaggressions in psychotherapy (mean BMI = 41.52) (Akoury, et al., 2019).  Although few mental health providers openly endorse holding anti-fat attitudes and discriminatory weight-based behavior, they can communicate negative weight-based messages to patients indirectly through microaggressions, which are subtle, often unintentional expressions of negativity toward individuals due to their membership in a marginalized group (Sue et al., 2007). Our data indicated that the most common microaggressions identified by study participants included therapists who focused too much on the client’s weight; therapists who appeared to be less interested in clients because of their weight; and, dissatisfaction with waiting room seating options. Participants also indicated that their weight affects therapy sessions such that they are less forthcoming or more evasive in therapy.

In addition, weight stigma research consistently finds that healthcare professionals in other related fields (e.g., physicians, nurses, dietitians) hold biased attitudes and beliefs about obese patients (Budd et al., 2011; Mold & Forbes, 2013; Puhl & Heuer, 2010). Healthcare providers often characterize obese individuals as unmotivated and non-compliant (Brown, Stride, Psarou, Brewins, & Thompson, 2007); blame them for their weight (Foster et al., 2003); and, demonstrate implicit anti-fat attitudes (Vroman & Cote, 2010).

Recommendations for Therapists and Clients

The truth is that we live in a culture where sizeism and weight-based discrimination is highly prevalent and relatively socially acceptable (Calogero, Tylka, Mesninger, Meadows, & Danielsdottir, 2019). As such, mental health professionals were likely conditioned to believe that obese individuals are personally responsible for their weight problems because of laziness and overeating (Puhl & Heuer, 2010). Consequently, it is important for mental health professionals to educate themselves about sizeism and actively work to avoid enacting it in the therapy office, as they are likely to perpetuate weight stigma unknowingly.

Various articles in this issue of Women & Therapy (2019) offer recommendations about how to tackle weight stigma in the therapy office (see Calogero et al., 2019; Kinavey & Cool, 2019; Pause, 2019; Scott, 2019). In addition to the general rule of monitoring your own bias and not intentionally shaming a client for their body size, two general suggestions for mental health and medical professionals are: 1) to make the office a safe, accepting, non-judgmental space for clients of any body size or shape; and, 2) to not assume that “weight” is an issue for clients that they want to work on in a therapeutic context (whether they are overweight or underweight) (McHugh & Chrisler, 2019).

Naked Truth is This: 

Mental health professionals are not immune from intentionally or unintentionally communicating such anti-fat attitudes to their clients. Given that weight bias and discrimination are commonplace in mainstream Western culture (and may even be internalized by overweight and obese clients), it is critical for mental health practitioners to tackle weight stigma personally and professionally. The American Psychological Association’s practice guidelines for treatment of obesity and overweight children and adolescents (2018) should be integrated into any practice that involves obese youth.

Copyright Cortney S. Warren, Ph.D., ABPP