Unlearning Fatphobia in Mental Health Care: Tips and Reflective Questions for Becoming a More Fat-Affirming Therapist
By: Rachel Brazie, LCSW
One of the most important professional growth practices a therapist can commit themselves to is unlearning. Unlearning, or the process of unraveling and divesting from harmful narratives and paradigms that we have been taught both consciously and unconsciously, is a critical part of liberation work. We must unlearn the harmful beliefs that bind us, and our clients, in order to imagine and build new ways of moving through the world.
Today, we’re going to explore how to unlearn fatphobia. In her podcast, “Rebel Eaters Club,” author and activist Virgie Tovar defines fatphobia as “a form of bigotry and a form of discrimination that says that people of higher weight are inferior physically, intellectually, morally and health-wise.” Fatphobia is deeply intertwined with many structures of oppression (white supremacy, misogyny, classism, ableism, etc.) and disproportionately impacts folks at the intersections of these systems.
As with any unlearning, it can often be daunting to figure out where to start in unpacking and changing both explicit and implicit biases. As a fat therapist, I’ve compiled some guidance and reflective questions, which I invite you to explore as a starting off point:
Use the word Fat.
Language matters. As therapists, our words are both incantations and billboards, alternately cultivating spaces of safety or reinforcing harmful status quo. The words we use to talk about bodies are political. As such, it is important to use the identity-based language that communities choose for themselves. Fat liberation activists use the word fat to refer to people in larger bodies. It is not derogatory, it is simply descriptive. By using the language chosen by fat liberation activists, we also affirm the socio-political nature of fatness as a part of one’s identity: for fat folks, the size of our bodies impacts the ways that we move through the world. Acknowledging this, and the social and financial implications that accompany it, is a critical part of understanding a fat client’s experience. By using direct language, we invite discussions of identity into the therapy room, making space for all sorts of nuanced processing that’s foreclosed upon when we only talk about body size in medical terms, rather than socio-cultural.
Choosing affirming language also means intentionally stepping away from harmful terms. In this case, fat liberation invites us to discard terms like obese and overweight. These medicalized terms originated in 19th-century statistical sciences and continue to be used to pathologize and cause harm to fat folks. For more information, see this piece published by the NIH on the unethical use of the Body Mass Index (BMI) as a metric of health.
If using the word fat in this way feels uncomfortable or foreign for you, I invite you to lean into that discomfort. Take some time and space to get curious with yourself: Why does the word fat make me uncomfortable? What meanings have I been taught to associate with the word fat? Who taught me those associations? What am I afraid to lose if I let go of those meanings?
Avoid interpreting behaviors and symptoms through a lens of fatphobia, especially when assessing and treating eating disorders
When assessing mental health symptoms in fat clients, research shows that many providers rely on assumptions and preconceived notions about the client based on their fatness (Puhl et al., 2014). While this bias can cause harm across diagnoses and symptom profiles, it is most acutely felt in assessment and treatment of disordered eating. If a client is fat, it is often assumed that they are eating too much and need to lose weight. Changes in diet and exercise in the service of intentional weight loss may even be discussed in therapy as a way to help a client feel more comfortable in their body or improve depressive symptoms. In this way, many fat clients are prescribed the restrictive and disordered eating practices that, when reported by thin folks, often cause concern and meet diagnostic criteria for an eating disorder. If this behavior approaches unsafe territory, a fat client is less likely to have their concerns around restricting taken seriously. In contrast, they may be lauded for the behavior if it results in weight loss, categorizing it as “self-discipline” and “self-control”, rather than deprivation grounded in harmful beliefs about how a body should look.
Anorexia Nervosa has the highest mortality rate of any mental health disorder, making it critical that all clients experiencing associated symptoms be able to access affirming and effective treatment. Yet research shows that clients’ body size significantly impacts the way providers interact with clients and subsequently affects treatment outcomes (Puhl et al., 2014). Puhl, Latner, King, and Luedicke conducted a study in 2014 exploring the prevalence of weight bias in professionals treating eating disorders (EDs) and found that the majority (56%) of the 329 ED professionals polled reported that they had observed other professionals in the field making negative comments about fat patients. The study also found that professionals with a strong weight bias were more likely to express negative attitudes and frustration about fat clients, perceive poor treatment outcomes for these clients, and attribute higher weight to behavioral causes.
It can be intimidating to examine the ways in which our own implicit biases may have caused others harm, and it is a critical part of growing as therapists. Consider taking some time to reflect on these questions: What messaging have I been given by my culture about fat people’s character traits? What assumptions do I make about fat clients? How do I respond if a fat client tells me they’re dieting, aka restricting calories?
Consider your space; accessibility and representation matter
The physical space we present clients with communicates non-verbal cues about our beliefs, values, and safety, long before we speak our first well-intentioned therapist words. Therefore, it’s important to consider what messages your practice spaces (both physical and virtual communicate to fat clients.
Assess your space(s) and consider the following questions: What are my chairs like? Could a fat client sit comfortably in both the waiting room and therapy room? What magazines are in my waiting room? What bodies are represented in my social media or on the resources I share with clients? Do they show pictures of fat people experiencing joy? Do they show fat bodies as “before” pictures in the proverbial “before and after” weight loss cover stories? What messages do these pictures and articles send to my clients about what beliefs I hold about their bodies?
Once you take stock of your status quo, make adjustments. Invest in resources that help your space feel not only accessible, but affirming, to fat clients.
Feel free to check out resources like Can We All Go’s library of free fat stock photos for creating affirming digital content or consider the questions in this article when assessing seating for your space.
Continue to educate yourself
I’m so glad you’ve spent time reading this post today. I hope it has offered you an opportunity for introspection and new perspectives to mull over with friends and colleagues. But mostly, I hope you know this is just the beginning of unlearning fatphobia. I hope that you will read more things written by fat folks. I hope you will learn more about the intersection of fatphobia and other structures of oppression. I hope you will follow fat creators on social media and start to fill your feed with fat joy. I hope you will consider investing your time and money in trainings led by fat therapists, activists, and thinkers that offer fat liberation and body-neutrality informed frameworks for client care. I hope this is just your beginning.
To get you started, here are some resources I recommend to friends, colleagues, and clients starting to undo their (implicit or explicit) alliance to fatphobia and increase their solidarity with fat liberation:
Books:
“The Body is Not an Apology” by Sonya Renee Taylor
“Landwhale” by Jes Baker
“Fearing the Black Body: Racial Origins of Fatphobia” by Sabrina Springs
Podcasts and Videos:
“Trust Your Body” episode of Dear Sugars podcast
“Body Trust is a Birthright” Ted Talk by Dana Sturtevant and Hilary Kinavey
Social Media Accounts:
What are some of your favorite resources? Feel free to email them to me at rbrazie@andstillwerise.us so that we can share in a future post and continue to learn, and unlearn, together.
About:
Rachel Brazie (She/They) is a Licensed Certified Clinical Social Worker (LCSW) working as a Psychotherapist at And Still We Rise. Learn more about Rachel here.