Dear therapist community during fat liberation month, 

As a psychologist, I spend a lot of time talking to other therapists and belong to quite a few therapist facebook groups. In a typical week in these groups, I see questions about how to support fat clients in losing weight, the use of stigmatizing language to describe higher weight people, healthist discussions about body size in which the claim is either it’s ok to be fat as long as healthy or it’s ok to promote weight loss when it’s for “health reasons,” and conversations about therapists pursuing weight loss and how they should respond to clients when they notice their weight loss. These posts usually lead to many responses that are aligned with anti-fat bias and telling anyone who comments in support of fat liberation that they are being “extreme,” “too hostile,” or unwilling to support their clients goals as if encouraging weight loss isn’t harmful if it’s what a client is wanting. 

Us therapists have a love of dialectics. We spend a lot of time holding the both/and for clients, sitting in the gray and pointing out “all or nothing” thinking. This may be helpful when exploring relationships, feelings, and decisions with clients, but it is harmful when it comes to oppression. The desire amongst therapists to see “both sides” when discussing oppression reveals that many therapists think that fat liberation and the oppression of fat people are two equally valid perspectives. The reality is that there is no room for debate when it comes to liberation. In conversations about fat liberation there are some absolute truths:

  • If you aren’t actively working on the liberation of fat people you are participating in our oppression 
  • If you promote weight loss you are promoting eating disorders
  • There is no way to support and encourage weight loss that isn’t oppressive and harmful
  • There is no such thing as a “healthy” way to pursue weight loss 
  • If, as a therapist, you are pursuing intentional weight loss- you are harming your clients- especially your fat clients
  • It is impossible to live in this culture and not have weight stigma and anti-fat bias. If you aren’t actively working to dismantle it you are perpetuating it

This list could go on and on. I know that many people reading this are already dismissing what I’m saying and leaning further into their convictions that the culture we have been indoctrinated into that tells us fatness is to be avoided at all costs, and fat people should all be pursuing thinness is correct and what we should all be aligned with. I know many people are thinking “but what about health,” or thinking some version of how they “feel better” when they’ve been in a smaller body so that must mean that weight loss is a good thing. It’s understandable if that’s the reaction you’re having. The intentional weight loss industry is a multi billion dollar a year industry that needs you to buy into it in order to keep making money. It is fascinating to me, though, that a field that has become more and more focused on “evidence based treatment” and “treatment goals,” loses all interest in the evidence when it comes to fatness. Therapists who have been trained to reduce harm are willing to cause harm in the name of thinness. 

I know that in the era of treatment goals that can be “measured and behaviorally described” there isn’t an easier one to complete your treatment plan with than weight loss. It’s the type of treatment goal that behavioral therapists love and insurance plans swoon over. So easily defined and measured. And so incredibly harmful and messed up. It will not be the rare client who, when going over treatment goals, names one that has something to do with weight loss. It is not an exaggeration to say that almost every person has wanted to lose weight at some point in their life and many are coming into therapy with this goal in mind. Our responsibility here is to be honest with our clients about what we can help with (healing their relationship with food and body, body liberation, etc.) and what we can’t (weight loss) and even with that open and honest conversation, clients are still going to talk about wanting to lose weight. And of course they do- our culture is steeped in anti-fat bias. It is absolutely possible (necessary) to support clients' body autonomy, hold space for their process, offer empathy, let them know you will be there for them and want to understand their lived experiences while also remaining clear and firm on your commitment to fat liberation. It’s not only possible; you have an obligation to do so. 

I know that there are therapists reading this who are thinking about their own desires to lose weight, some of whom are in fat bodies, and some of whom are not in fat bodies but would still like to lose weight. I support body autonomy as one of my core values, and I have a ton of empathy towards other fat therapists who are seeking weight loss. I understand how hard it is to exist in a fat body in this culture and how the pull towards weight loss can feel like such a relief and a way to distance ourselves from stigma and oppression. Sometimes we are being told we have to lose weight to access life saving surgeries. I know how complicated it is to be a fat therapist. For those therapists in smaller bodies who think they need to lose weight, or are attempting to maintain a body size that requires restriction or restraint in eating, I see you too and respect your body autonomy. 

And, what I want to name for all of us, is that while we get to have body autonomy we also need to recognize that what we are doing with our bodies and food when it comes to pursuing weight loss impacts our clients. If you are someone who is thinking ‘well I would never talk about my weight loss attempts with clients,’ consider other ways you are communicating your feelings about your own body and perspective on fatness. Are you someone who has food available in your office and refers to it as “healthy snacks?” Do you reference your clothes being tight or your body changing during covid in a negative way? When a client mentions their dislike of their own body in passing, do you join in as if body hatred is a shared experience to connect around? Overtly talking about your weight loss attempts and dislike of your own body is absolutely damaging to fat people, but so is communicating in a more covert way. Most higher weight people have spent years learning to pick up on even the most subtle evidence of weight stigma. This hypervigilance has been necessary for survival, and will also mean that fat clients pick up on your own dieting and body hatred even when you aren’t overtly naming it.  When we diet or restrict we are harming our fat clients. There isn’t a way around that. 

Harm is one of those words that can be kind of ambiguous and I want to be clear that what we are talking about here is not ‘just’ microaggressions, but actually putting our fat clients lives at risk. It is becoming more common to hear stories of medical providers who diagnose clients as fat instead of diagnosing their strep throat or ear infections; who miss a cancer diagnosis because they were so focused on weight loss; and who refuse life saving surgeries because they deem a client too fat for surgery all while suggesting clients have bariatric surgery. These are horrific situations and, while the details may be different, we are also putting fat clients' lives at risk in therapy. As someone who works with a lot of higher weight clients, I hear the stories of the therapist that encouraged weight loss and the client spiraled into a life-threatening eating disorder; of the therapist that encouraged a fat client to have bariatric surgery that resulted in life-threatening complications; of the therapist who talked so much about their own body hatred that their fat client felt hopeless about their own body and contemplated suicide. These experiences aren’t rare. If you aren’t hearing about them from your clients it’s because your office isn’t a safe place for them to talk about it. 

As a fat therapist myself, the violence I hear towards fat people in therapist communities is staggering. It’s as if so many therapists forget- or don’t care- that there are fat therapists reading and listening to what they are saying. I get harmed and sad anytime I encounter weight stigma amongst therapists, and I have the knowledge and skill to seek out care that is fat affirming and validating of my lived experience. I am terrified when I about all of the people in higher weight bodies who are seeking therapy and are met with such violence and erasure. I know for sure that therapists who are talking about fatness with such disgust and dismissiveness in therapist groups are also communicating that to their clients. Sadly, this kind of attitude doesn’t exist only in therapists outside of the eating disorder field. The fat hatred and promotion of weight loss exists within the eating disorder field as well. 

If you are a therapist working with clients, you are a therapist working with fat clients. You are a therapist working with clients with eating disorders. You are a therapist working with clients who have a dieting history, a desire for weight loss, a complicated relationship with food and their body. You are a therapist who occupies their own body in the room, has their own complicated relationship with food and your body and possibly your own history of dieting or an eating disorder. You are a therapist with power in the room and a therapist who has the capacity to enact harm and violence on your fat clients or to support their healing. 

The world is full of weight stigma and I am holding therapists to a higher standard. If you have not done your own work on your relationship with your body, have not explicitly embraced fat liberation, are not firmly rooted in an anti-diet framework, are not willing to stop dieting or suppressing your weight, are not educated on the intersection of anti-Blackness and anti-fatness, are not naming clearly that you do not encourage or support weight loss, are not working on unpacking your internalized weight stigma, are not speaking up and pushing back when you see weight stigma occur amongst therapists, and are not deeply aware of the ways that anti-fat bias puts fat peoples lives at risk, know that fat clients are not safe in your care and refer them elsewhere. 

As therapists we have a lot of work to do around many different issues. Most of us have experienced graduate school that tried to train the humanity out of us. We have been indoctrinated into oppressive systems and were never exposed to the liberatory frameworks we should have learned in grad school. Many therapists are now openly committed to social justice but fail to include fatness. If you aren’t including fatness in your social justice work it’s not intersectional and it’s not liberatory. During this fat liberation month, I hope that the therapist community will take a long look at themselves and identify the ways that the profession continues to cause harm both in the therapy room and in the field as a whole. 

As recently as 2018 the American Psychological Association released a stigmatizing and oppressive document steeped in anti-fat bias on how to “treat” higher weight people. Ask new therapists how many of them were subjected to Yalom’s “Fat Lady” with no critical analysis or naming of the violence the same way much older therapists were. Take a few minutes to read through some of the more popular books on CBT, ACT, and DBT and notice how frequently weight loss is used as an example of a treatment goal, food is talked about in reference to addiction or a “maladaptive coping strategy,” and how often more psychodynamic or psychoanalytically trained therapists talk about fatness as an attempt to be less sexually desirable in response to trauma that will change once the trauma is treated. We have a ton of work to do. 

In the various therapist spaces conversations about ethics are commonplace. Typically these conversations require a ton of nuance and discernment. Not once in a therapist group (unless it’s explicitly fat positive therapists) have I seen anyone mention how unethical it is to treat clients from a framework that supports weight loss. Not once I have seen anyone name how unethical it is to stigmatize and further oppress fat clients. The absolute truth here is that you are either working to be safe for fat people; or you are dangerous for us. You are either supporting our liberation or you are putting our lives at stake. 

Rachel Millner (she/her), PsyD, CEDS, CBTP
Healing Relationship with Food and Body
[email protected]   |    215-932-9885
Designed by Andrew Collings