Tag Archives: body image

Pushing back against fatphobia

By Bethany Bray November 30, 2022

“I feel fat today.”

This is a phrase that Justine Trumbetas, a licensed professional counselor (LPC) in Pennsylvania, says she often hears from clients who live in bodies of all kinds of shapes and sizes. And this seemingly simple statement contains a lot for counselors to unpack with clients.

More often than not, this thought stems from weight stigma or bias that the client has internalized from external sources. This can include anything from an offhand comment a friend makes about needing to work out to “earn” her slice of birthday cake to a medical doctor who advises weight loss for a presenting concern that is unrelated to the patient’s body size.

Trumbetas, who specializes in helping female clients with anxiety and body image-related issues, says that when clients use language such as “I feel fat” or “I feel gross,” she uses it as an opening to help them begin to recognize their emotions and negative thought patterns as well as how these thoughts affect their value and self-worth. The first step is to replace the word “fat” with a more factual, accurate word, she notes.

“I tell them that fat is not an emotion, so we can’t feel it. And we work to replace that, find the word they need … and tap in to what they’re feeling, [such as] defeated, let down, sad. And then we dig into why they feel that way,” says Trumbetas, an American Counseling Association member who has a counseling practice providing online sessions to clients in Pennsylvania and Florida. “There’s much more than feeling fat. There is a lot more underneath it. Are they comparing themselves to other people [or reacting to] something that they saw or heard from others? Typically, when we dig in, I find that their worth is tied to their body and how others view it.”

Pervasive weight stigma

Thin bodies have been idealized and prioritized in U.S. culture and society for centuries. This shows up in everything from themes in advertisements and television to the overuse — and misuse — of the body mass index (BMI) as a benchmark for health by medical professionals and others.

Weight stigma carries the message that “there’s something wrong with your body simply because of the size of it,” says Jennifer DiGennaro, an LPC with a private practice in Grand Rapids, Michigan. And it’s traumatic for an individual to be bombarded by a lifetime of messaging that implies that their worth is tied to their body size or ability to lose weight, she adds.

“We live in an eating disorder culture and a body-shaming culture,” says DiGennaro, who specializes in helping clients heal from trauma, body shame and eating disorders. “We carry this myth that everyone can control their weight,” she continues, but “there are many, many, many reasons that someone is living in a larger body, and it may have nothing to do with what they eat or how much they’re moving.”

When talking with clients and colleagues, DiGennaro finds that using different words to name this phenomenon can help others understand the stigmas surrounding weight, depending on the context and their familiarity with the issue. Weight stigma can also be described as fatphobia, fatmisia, sizeism, weight bias, weight-based discrimination, fatism or size bigotry. No matter what it’s called, fatphobia is “thinking you know things about a person simply by the size of their body, and we don’t,” DiGennaro says. “And arguing on that point is reinforcing weight stigma.”

When unpacking and dismantling weight stigma, it’s important — both for counselors and clients — to consider the full context of the messaging they receive about weight loss, nutrition, body size and related issues, says Kaitlyn Forristal, an ACA member and licensed professional clinical counselor who studied fatphobia’s influence on diagnosis decisions made by counseling graduate students in her 2018 doctoral dissertation. This includes the fact that many companies stand to benefit from keeping this stigma alive and prevalent, she adds, noting that the weight loss industry in the United States was worth $72 billion in 2018.

Trumbetas says that nearly all her clients use language in sessions that indicates they have been negatively affected by weight stigma. This ranges from describing feelings of worthlessness to noting that they had a “bad” weekend because they indulged and ate a slice of pizza, she says.

Her clients have often internalized microaggressions and messaging they’ve received from a number of sources, but she finds that the most influential are social media, their family of origin and the medical profession. Many clients talk about being raised in an atmosphere where the adults were always on a diet roller coaster, Trumbetas says, so it was common for them to make comments such as “You shouldn’t be eating that.”

She has also worked with clients who have stopped going to medical appointments because they don’t want to be judged and have assumptions made about them based on their weight. Because weight bias is deeply embedded in the medical profession, some doctors’ initial and go-to recommendation for larger-sized patients is to lose weight without finding out the context surrounding what’s bothering them, she explains.

Reconnecting to self

The counselors interviewed for this article agree that clients who have been negatively affected by weight stigma often need a combination of counseling work that focuses on quelling negative thought patterns, tolerating discomfort and reconnecting to a body that external forces have caused them to disconnect with and hate.

An important first step is educating clients on what weight stigma is and how prevalent it is in our society as well as offering the message that “your worth, your identity and your value is not in your appearance,” says Stephanie Dutson, an LPC who specializes in helping adult clients with trauma, anxiety and body image-related issues.

Dutson says she often emphasizes to clients that a body is for living in, not for looking at.

She finds that weight stigma often causes clients to feel guilt or shame about what they are or are not doing to maintain their appearance. And that guilt or shame “affects a person’s health so much more than an extra 20 pounds does,” says Dutson, who lives in Birmingham, Alabama, and has a counseling practice providing online sessions to clients located in Utah, Wisconsin and Alabama. “The research shows time and time again that social life, stress management and moving your body in a joyful way — not weight or size — are what promote health. Diet culture really squashed that intuition for most people, and [unlearning weight stigma] comes back to trusting themselves and finding connection to intuitive knowing.”

Many of Dutson’s clients have strong feelings of shame or disgust associated with their bodies, especially with parts that are often sexualized or idealized in popular culture and media (such as the abdomen, chest and arms), she notes. Dutson focuses on helping clients who feel this way regain comfort and feelings of safety with their body, including “tuning in” to parts of their body that they’ve “tuned out” or disconnected with because of weight stigma, she says.

For example, she may ask a client to gently touch or look at parts of their body that they have tuned out (e.g., a soft belly post-pregnancy) in a mirror at home. Then Dutson processes the experience and emotions the client felt at their next session. She also encourages them to spend more time doing this exercise as they become increasingly comfortable with their body. The aim, Dutson says, is to help clients gradually reconnect to their body.

Many clients have such negative feelings associated with their body that they aren’t able to look at their entire body in the mirror at first. She encourages them to start small with a handheld mirror to view one part of their body, such as an arm or leg, and eventually add additional areas.

“I tell clients to expect some feelings of discomfort, but to try and find an area of the body or [amount of] time that is moderately uncomfortable while still tolerable so they don’t become flooded or overwhelmed,” she explains.

A powerful aspect of these exercises, Dutson notes, is helping clients recognize and begin to fully feel emotions — including discomfort — in their body. “I don’t know a client with body image issues that is entirely comfortable with their emotions because emotions are so often experienced within the body,” she adds.

Trumbetas also finds mirror work helpful, and often suggests that clients focus on learning to thank their bodies for its strength. She prompts clients to think of things that their body has done for them, such as allowing them to smell their favorite scent or heal from sickness or surgery.

This is quite a perspective flip for individuals who have harbored animosity toward their body for a long time, she notes.

If a client makes a comment such as “I hate my thighs,” Trumbetas says she would prompt the client to spend time looking in the mirror and thanking those thighs for getting them where they want to go and being able to do things like climb stairs or walk their dog.

“Being kind to yourself in this way can be a foreign concept,” she acknowledges. “I tell my clients consistently that to get comfortable, you have to become uncomfortable.”

As clients practice looking at their body in the mirror, she suggests they take an empowering stance she calls the “Wonder Woman pose.” To do so, the client meets their own gaze while standing with their hands on their hips, holding their head high, chest out and shoulders down. Trumbetas will model the pose for clients during sessions and encourages clients to try it with her. Standing in this way can decrease anxiety and boost confidence, she says.

Trumbetas says she receives a lot of positive feedback from clients about the Wonder Woman pose, and many report that it’s helpful to do whenever they’re feeling anxious or need to feel better about themselves and reconnect to their own power.

Identifying triggers

Reconnecting to oneself in counseling allows clients not only to better understand their own emotions but also to pinpoint how it feels when they are affected by negative messaging about body size and appearance, notes Dutson, an ACA member.

“Understanding the core emotion of what a trigger brings up for you gives you a better road map of how to deal with that emotion,” she explains. “Most of the emotions that come up around body image are disgust, shame, anxiety or guilt. And when clients have that [emotional] self-awareness, they can ask, ‘What is the core emotion that I’m feeling?”

She then guides them to find ways to care for themselves when shame and other painful feelings arise, such as focusing on empathy and self-compassion.

For example, a client may be visiting an aunt who makes a comment that the client has gained weight since she last saw her or talks incessantly about her own weight loss behaviors or successes. Dutson will process this interaction with the client and prompt them to identify the emotions they felt and how they would like to handle a similar situation in the future.

She finds it helpful to prompt clients to track the moments that produce a visceral or intense emotional reaction regarding body size. Depending on the client’s situation and preference, she has them recount triggering situations to her verbally or write down details in a notebook or journal. She then guides clients to think about who was there, what was said, what emotions rose to the surface, what they were doing and feeling leading up to the interaction, and other aspects surrounding this triggering experience. Clients who reflect in this way eventually notice common threads of people or topics that activate them, she notes.

It can also be helpful, Dutson says, to suggest that clients write out a script or statements they’d like to use the next time they are in a triggering situation. Depending on where they are in their healing, this can include asking the other person not to talk about weight or body size in that way.

Trumbetas also helps clients identify and manage triggers, and one of the first things she does with clients who have been affected by weight stigma is to suggest they do an “audit” of their social media accounts to unfollow people and pages that spread body-negative messaging.

DiGennaro adds that helping clients talk about messaging related to weight stigma also requires counselor practitioners to suppress the urge to reassure or comfort clients who make statements such as “I feel like people are judging me.” A counselor’s role, DiGennaro emphasizes, is to be honest because people may very well be judging the client. Instead of offering reassurance, counselors can help the client unpack how they feel about such thoughts, recognize their origins and become intentional about the relationship they have with these thoughts and the way they affect their mental health, she says. Then they can help clients find and set boundaries to keep from internalizing harmful messaging going forward.

DiGennaro often helps clients plan for social interactions or family gatherings by guiding them to explore their values and identify what they are and are not willing to disclose or talk about.

“It’s a huge piece of healing work to first know what you need and want, then be able to put it into words and ultimately decide to share it with the appropriate people,” she says.

DiGennaro sometimes invites clients to constructively use the anger they may feel about issues related to body weight and size. “There is a lot to be angry about with the way our bodies and feelings about food have been manipulated by diet culture,” she says. “One pattern I often see is when a client takes the unconscious anger evoked by weight stigma and turns it against themselves with punishing or chaotic food behaviors. So once the anger becomes conscious [through counseling,] I tell clients to channel that appropriately outward. Feeling and acknowledging rightful anger allows for the setting of essential boundaries to protect from further harm from weight stigma.”

Rethinking restriction

Helping clients identify and work toward goals is often an important part of counseling. But what if a client is focused on a goal to diet or lose weight?

The first thing to remember is that it is outside of a professional counselor’s scope of practice to advise clients on nutrition, exercise, weight loss or other topics related to physical health. (For more, see Section C of the 2014 ACA Code of Ethics at counseling.org/ethics.)

Weight loss is not a behavioral or mental health issue, DiGennaro stresses. Whenever a client mentions a goal of weight loss in a counseling session, she uses that opportunity to dig into why they want to set that goal — and what outside influences might have contributed. She uses motivational interviewing and asks questions such as “What would it mean to you if you lose weight?” to explore the client’s underlying reasons.

Knowing the reasons behind their weight loss goal will also help counselors determine the best approach for the client. Maybe the client says they want to lose weight because of negative comments they’ve heard from family members. “If you dig into it, they might be actually fine with their body, but they’re sick of hearing comments at family gatherings,” DiGennaro says. “In that case, we need to work on boundaries.”

Another client, however, may realize that their core reason for wanting a smaller body size is a desire to feel more confident. In that case, DiGennaro says she would focus on counseling techniques that boost the client’s self-confidence without attaching it to their weight or body image.

“Food and body issues are often the tip of the iceberg,” DiGennaro says. “I have never worked with a person who discovers their heart’s desire is to be thin. It’s always more along the lines of finding peace, receiving love and finding meaning in life.”

Similarly, Trumbetas says that when a client mentions in session that they’ve lost a certain number of pounds, she avoids praising or encouraging them, which would reinforce weight stigma. Instead, she responds with a question such as “How does that make you feel?” to explore the context of the client’s statement.

Trumbetas uses these conversations to emphasize that weight and health do not mean the same thing, and that “fixating on one aspect of health leads to unhealthy thinking,” she says.

Clients sometimes tell her, “If I can only lose this amount of weight, I’ll be happier.” But she reminds clients that being thin will not magically make them into someone they will love. Instead, she focuses on helping them learn to avoid comparing themselves to others and strengthen their self-love (both love of their body and their whole self).

DiGennaro is a certified intuitive eating counselor, so she also offers clients who talk about dieting psychoeducation on intuitive eating and explains that research indicates that most people who diet eventually gain the weight back, plus extra.

“Trying to control your body [via dieting] often comes from a place of punishment and restriction. I see it as ultimately a disconnection from self,” she says. “Instead, I help clients get curious about what it might be like to reconnect to themselves from a place of nourishment, self-care and truly listening to their body. And this is complex work because often … there were protective reasons they had to disconnect from their bodies and reconnection must be done in a trauma-informed way.”

DiGennaro acknowledges that this perspective shift does not come easily for clients, and it often takes many sessions before they begin to replace the unhealthy thought and behavior patterns they’ve adopted to cope with a lifetime of weight stigma.

Dutson also focuses on helping clients shift their perspective away from a restrictive view of taking things away (including food) to one that allows them to consider adding supportive elements to their life. To do this, she often prompts clients who are healing from the effects of weight stigma to identify and add things to their life that bring them joy, nourishment and comfort. This can be anything from dancing to their favorite song to connecting with a supportive friend.

There is so much more to wellness than body size, and the importance of social support is often one of the biggest contributing factors that clients overlook, especially those who have negative feelings about their bodies, Dutson adds.

“Asking ‘how can we add meaning, nourishment and joy to the body?’ is a more realistic and hopeful approach [to wellness] than restriction and taking things away,” she says.

Unlearning bias as a practitioner

Hilary Kinavey and Carmen Cool, co-authors of the 2019 Women & Therapy journal article “The broken lens: How anti-fat bias in psychotherapy is harming our clients and what to do about it,” note that researchers and mental health clinicians alike have reported on the “prevalence and negative implications of weight stigma in psychotherapy” since the 1980s.

“It is our lens, our gaze and the assumptions behind it that are the problem,” wrote Kinavey and Cool, who are both LPCs. “Diagnosis by sight is inaccurate and essentially biased. We simply cannot know who engages in overeating and who engages in restrictive eating based on the size and shape of the body in front of us. As professionals, it is our ethical duty to unpack and address this prejudice and to shift our focus and commitment to the human being who inhabits the body.”

The counselors interviewed for this article also recommend that counselors consider their own internalized weight bias to ensure they don’t inadvertently reinforce those biases in their interactions with clients.

“No one deserves to be treated badly because of their body shape, size or ability,” Trumbetas says. “If a counselor has their own negative views, they need to look inward and work on themselves — with another therapist if needed.”

Weight bias creeps into counseling, Dutson says, when a practitioner makes assumptions about a client based on their body size, such as how active clients are, how they feel about their body or what they might need to address in therapy. In turn, this can influence the questions clinicians ask (or don’t ask) and the issues they cover with the client.

staras/Shutterstock.com

“We have to recognize as counselors that we live in a society that values certain bodies over others, which can be ableist and elitist,” Dutson says. “We need to understand how marginalizing it can be to leave those beliefs unchecked. It’s not a stretch to say that our culture believes that certain genes, illnesses and conditions [that affect body size] are somehow inferior.”

Forristal, an assistant professor of clinical mental health counseling at New England College in Henniker, New Hampshire, agrees counselors need to do their own work to recognize and unlearn harmful beliefs about weight and body size. “Unless we intentionally and actively unlearn fatphobia the way we do with unlearning racism and other stereotypes, we are at risk for perpetuating this harm to our clients and communities,” she stresses.

A good first step counselors can take to combat this, Dutson says, is to decouple morality from food and body issues — both in the language counselors use in session with clients and in the way they think about things personally. This includes the questions a practitioner asks during the intake process with new clients, she adds.

Food is not good or bad, and it can be a comfort without inducing guilt. Counselors should refrain from talking about their own body or weight loss in sessions or asking leading questions of a client that reinforce weight stigma, Dutson says.

Instead, she advises counselors to borrow from mindfulness techniques and approach food and body issues from a nonjudgmental, observational lens. “We’d all benefit more from that,” Dutson acknowledges, “and modeling that for your clients is very powerful.”

Forristal says that refraining from making assumptions — either positive or negative — about a client based on their body size or shape is a good start toward ridding professional counseling of weight bias. Weight stigma is a barrier to care and help seeking, so counselors who want to combat this should mention on their website and other promotional materials that eradicating fatphobia is a goal of their clinical practice, she adds.

In their article, Kinavey and Cool suggested that counselors ensure that their office space is accessible and welcoming to larger clients, which includes having chairs that accommodate a larger person comfortably and a waiting room that does not include decor or reading materials that reinforce fatphobia, such as fashion magazines.

Forristal also encourages practitioners to address any power imbalance that can affect the therapeutic relationship such as the counselor having a larger body than the client or vice versa. A client with a thin body, for example, may not feel comfortable reporting the extent of their issues with a counselor who is larger out of fear of offending them.

Counselors should not hesitate to check in with clients and ask how they feel about discussing body image issues with a practitioner who is a different size from them to ensure that they are comfortable, Forristal adds.

“We can never address these issues if we’re too uncomfortable or unwilling to broach them in the room with clients,” she says. “If a fat client expresses body image concerns to a thin counselor, the counselor can name that they hold privilege as a thin person and check in with the client about their reactions around that. Much like it doesn’t help to take a ‘colorblind’ approach when working with BIPOC [Black, Indigenous and people of color] clients, it isn’t helpful to ignore the differences in body size and power in the room.”

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Resources for counselors who want to learn more:

The National Eating Disorders Association’s page on weight stigma: nationaleatingdisorders.org/weight-stigma
The Association for Size Diversity and Health: asdah.org
The National Association to Advance Fat Acceptance: naafa.org (Visit the “learn” menu to download a brochure with suggestions and guidelines specifically for therapists.)
Hillary Kinavey and Carmen Cool’s 2019 Women & Therapy journal article, “The Broken Lens: How Anti-Fat Bias in Psychotherapy is Harming Our Clients and What To Do About It”: org/10.1080/02703149.2018.1524070

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Fatphobia: How can counselors do better?

Compiled by Bethany Bray November 23, 2022

Stop and think for a moment: Have you ever seen a plus-size Barbie doll or rooted for a romantic hero who wasn’t thin?

Kaitlyn Forristal, a licensed professional clinical counselor, poses this question to illustrate the way fatphobia and weight stigma saturate our culture and society.

“We are programmed from a very young age to associate fatness with bad things … [and] counselors are not immune from socialized viewpoints and messages,” says Forristal, an assistant professor of clinical mental health counseling at New England College in Henniker, New Hampshire.

It’s up to counselors, therefore, to examine their own feelings and assumptions about weight and body size to keep from passing them on to clients in therapy, she stresses.

Forristal studied fatphobia’s influence on diagnosis decisions made by counseling graduate students in her 2018 doctoral dissertation; fatmisia is an area of research and specialty for her. Counseling Today sent her some questions via email to learn more about how weight stigma can show up in the therapy room and what counselors can do to dismantle it — both in themselves and in their clients.

How might fatphobia and weight stigma show up in counseling? Misdiagnosis is one area, but what else?

Yes, misdiagnosis is a concern due to a societal belief that “obesity” is a medical disease. Aside from diagnosis and treatment, counselors are also at risk for projecting their own (potentially negative) beliefs about their bodies and health status onto their fat clients. Despite what a clinician may assume, many fat clients are comfortable in their bodies and have no intention of changing them.

It could also be dangerous for counselors to assume that a fat person’s presenting issues, such as body image struggles, anxiety, depression or other mental health concerns, will be alleviated if the client loses weight. It is likely that fat people have internalized fatphobia — a set of negative beliefs about themselves because they are fat — and believe that losing weight will help them to solve their problems. While this may be true to some extent, losing weight cannot repair relational issues or make up for [brain] chemical imbalances.

If a person is struggling with the stigmas associated with being fat, or expresses hatred of themselves for being fat, attempting to change their body is not the solution. We eradicate prejudice by addressing the socialization of fatphobia and working to make our society safer and more inclusive for everyone.

What would you want counselors to know about approaching the assessment and intake process in a nonstigmatizing way? How can counselors ask about weight or weight loss, eating habits, etc., without a client feeling they are being shamed or judged?

Using the same intake measures and assessments with both fat and thin clients is the best way to approach this; don’t assume that a fat person overeats or that a thin person exercises regularly.

Consider why you may want to ask about weight loss or eating habits: Is it to confirm your suspicion that a fat client doesn’t get enough cardio or because you [assume] that their weight loss/gain is a symptom of depression?

If a fat client reports on an intake form or during an interview that they struggle with self-esteem due to their body size, want to lose weight or have poor body image, counselors should address that the same way they would with a thin client. If a new client doesn’t mention struggling with these things but happens to be fat, they are probably there for other reasons and you don’t need to ask about weight loss or eating habits.

Counselors don’t need to be afraid to discuss body size, fatphobia and marginalization with fat clients, but they also don’t need to broach this with a client just because they think someone may have an issue solely because of their body size.

How might counselors be making assumptions that someone who doesn’t fit society’s norms for shape and size is unhealthy and/or somehow to be blamed for their challenges? How might this bias creep in without counselors realizing?

It is an unfortunate societal belief that we can tell someone’s health status by looking at them. We see this all the time with news coverage of the “obesity epidemic” (spoiler alert: fat people have always existed!) and dehumanizing b-roll [news footage] of [faceless] fat people walking around and living their lives.

Something that is really strange about society if you think about it is the notion that others’ bodies are for us to comment on or have an opinion about. How often do you see someone who has changed size (lost or gained weight) and made an assumption about them, whether they have “let themselves go” or are now healthier due to a smaller body? When you run into someone you haven’t seen in a while and they are smaller, do you automatically congratulate them or tell them how great they look? Each time you do this, you are making an assumption that they lost weight intentionally and that it is worth celebrating that there is now less of them.

There are many medical conditions that are often attributed to fat people (diabetes, heart disease, sleep apnea) that medical research doesn’t support. The average size person in the United States is “overweight,” so it is likely that many findings that fatness is a cause of these medical conditions are misinterpreted when fatness is correlated to these conditions. It is important to be good consumers of research and pay attention to who is putting out studies that demonize fatness (I’m looking at you, Weight Watchers!) and who the intended audience is.

Researching the history of the body mass index (BMI) can help as well. Considering that the BMI is still used in western medicine for pathology and treatment of patients is baffling and is not rooted in accuracy or health outcomes. The BMI is unnecessarily vague (e.g., “overweight” — over what weight?) and doesn’t account for muscle mass or many other confounding factors. Some of the most elite athletes in the world are “morbidly obese” according to the BMI.

It was never created to be used the way that it is now, and aside from the harmful labels it puts onto people’s bodies, it creates real issues for mental health care treatment. For example, due to the BMI categories, many fat people have difficulty receiving treatment for eating disorders, which is detrimental to client and community health and to the profession of counseling.

What do counselors need to do to check themselves and unlearn old patterns and assumptions about weight and body size? How can counselors do better?

Unlearning negative beliefs about fat people is a similar process to unlearning socialized beliefs about other marginalized identities (LGBTQIQA+ community, BIPOC [Black, Indigenous and people of color], disabled people). There is nuance to this in the United States as we are an individualistic society who believe that for the most part, people get what they deserve or work for.

Therefore, fatphobia falls into a category with other social issues like poverty where we feel more comfortable attributing blame to individuals that we believe can change their status if they only tried and worked hard enough for it. Poor people can just work harder or get better jobs to “pull themselves up from their bootstraps,” or fat people could lose weight if they only had more self-control. Obviously, neither of these things are true for the vast majority of people facing this discrimination, but the societal belief that we can change our circumstances continues to harm those in our communities.

Counselors can do better by speaking out about these things and advocating for the rights and dignity of fat people. It should come as no surprise that bias against fat people is rooted in racism and xenophobia.

Fatmisia is also rooted in capitalism; the weight loss industry was worth $72 billion in 2018. Selling weight loss programs, weight loss surgeries and weight loss-focused fitness programs is a business that is only viable because people buy into the notion that fatness should be avoided at all costs (literally).

Having this information is helpful for counselors to (a) reconceptualize the way they feel about their own bodies, (b) provide validation and psychoeducation for clients struggling with body image or other weight-related issues and (c) advocate for changes in the way that others in society view and relate to fat people.

How can counselors support a client who names weight loss as a goal in counseling? What should a counselor’s role be in this situation?

A counselor’s role is always to support their client in treatment, and there are many valid reasons for clients to want to lose weight: to be safer in society by living in a smaller body, because a family member has expressed concern for their weight, a medical provider suggests it for overall health, or as a requirement for a certain procedure, etc. However, counselors are not medical providers, physical therapists, dietitians, etc., and should refrain from providing any medical advice as this is outside of our scope of practice and unethical.

It can be easy to automatically support a client who wants to lose weight because we believe that a fat body is always an unhealthy one, but this is not the case and could cause harm. Most research on dieting shows that intentional weight loss does not work and that only 5% of dieters maintain their weight loss for an extended period of time; most dieters gain back the weight they lost and more due to the metabolic disruption of putting one’s body into starvation mode.

Counselors can, of course, ask about the reasons the client is bringing this up in session: Are they having body image concerns, experiencing disordered eating or relational problems? These are issues that counselors are trained and qualified to help with. Exploring these issues may reveal the deeper issue that a client has an eating disorder or is being verbally/emotionally abused by a partner. A counselor’s role in either of these cases would be to explore options for the client and set goals in treatment. If a counselor has training/knowledge in this area, this is a good opportunity to self-disclose their own body image concerns and ask the client if they would like [the counselor] to share with them some information about weight loss, the diet industrial complex, etc., that may help them reframe these issues.

What should counselors avoid doing or saying in sessions with clients to keep from harming them with weight stigma?

The easiest way counselors can know how to speak about clients’ bodies is by asking them! Some people prefer to describe themselves as fat because it is merely a descriptive word like tall, dark-skinned, etc. For others, there is such a negative connotation with the word fat (and a lot of harm associated with it) that they prefer other ways to describe themselves.

Counselors should avoid making assumptions about fat clients that they wouldn’t make about their thin clients, such as [whether] they overeat or binge eat, do not exercise enough, hate their body, etc. Practicing weight neutrality, or making no assumptions (good or bad) about a client’s weight or body size, is a great start.

It is also imperative that counselors resist the notion that fat people can or should lose weight to avoid stigma and marginalization due to their body size. We would not expect a little person to just grow taller to access the world with more ease, and we should not project this onto fat people either. Humans have always come in all shapes and sizes and being fat is just one way of having a body — it is that simple.

Michael Poley/canweallgo.com

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See more on this topic in a feature article, “Pushing back against fatphobia” in Counseling Today’s upcoming December magazine.

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counseling Connoisseur: Reconnection — Healing the embodied self

By Cheryl Fisher January 6, 2022

“Everything we know, everything we do, and everything we are is mediated by the body.”

– Joan C. Chrisler and Ingrid Johnston-Robledo, Woman’s Embodied Self: Feminist Perspectives on Identity and Image

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Embodiment is a concept originating with the French philosopher Maurice Merleau-Ponty, who noted that we experience our humanity through and with our bodies. This is not an isolated experience but one that is impacted by interactions with others. The embodied self is a psychospiritual concept that hosts existential questions of “Who am I? What am I? Where does my value lay?”

In addition, we experience our bodies in a cultural context. Body parts and experiences may be objectified (e.g., breasts, buttocks) or medicalized (e.g., pregnancy). Furthermore, there appears to be social sanction around when a body or body part is acceptable and when it is not, and the resolve is a lifelong relationship of self-projects and self-loathing. For example, Marilyn Yalom, a feminist author and cultural historian, described the psychosocial and political history of the breast in her book A History of the Breast. As stated in the book’s blurb:

Through the centuries, the breast has been laden with hugely powerful and contradictory meanings. There is the “good breast” of reverence and life, the breast that nourishes infants and entire communities, as depicted in ancient idols, fifteenth-century Italian Madonnas, and representations of equality in the French Revolution. Then there is the “bad breast” of Ezekiel’s wanton harlots, Shakespeare’s Lady Macbeth, and the torpedo-breasted dominatrix, symbolizing enticement and aggression.

Therefore, there are sociocultural prescriptions to the body, including that of gender. In their 1987 article “Doing Gender,” Candace West and Don Zimmerman argue that gender is a performance that people “do” that is based on social norms. A person may choose to perform gender in a normative way (cisgender), with their preferred gender that may differ from the one assigned at birth (transgender) or in a way that feels more genuine.

Our relationship with our bodies is complex. It is informed by society’s view of our bodies. The size, shape, skin color and hair texture inform our experiences, along with the gender we perform. Additionally, illness and injury to the body affects our image of self in the context of society’s understanding of ableness. An attempt to “fit in” to normative standards may result in efforts to alter our physical appearance or disregard and disconnect from our embodied self.

Disconnection

Our relationship with our bodies can be fraught with neglect and dissociation as we learn to ignore the many messages it sends to us. We ignore the hunger and push through lunch. We hold our bladder until we are dizzy with urge. We shiver or sweat, ignoring the clear signals. We pull all-nighters when our body is begging for rest. We discount and dismiss the value of our physicality and dissociate from our embodied self.

The embodied self can be experienced in a positive or negative manner, and it is strongly related to self-esteem, self-image, and one’s satisfaction with personal and sexual intimacy. A positive sense of an embodied self is associated with autonomy, functionality, joy and fulfillment. However, chronic illness, disability and accidents, and negative social sanctions can result in a sense of disembodiment. For example, a former track athlete loses his legs during combat, the neurological impact of a stroke leaves a brilliant novelist unable to write a sentence, or a 17-year-old African American girl asks her parents for plastic surgery to “make her nose more normal” (i.e., conform to an unrealistic, Western beauty standard).

In my own research, I encountered a 35-year-old woman who had been diagnosed with metastatic breast cancer, and she described her body after a complete double mastectomy and oophorectomy in the following way:

I felt like a freak. I had lost my hair from the chemotherapy. What was left from my 34C cups were scars and lopsided breasts with tattooed nipples. I didn’t recognize the body in the mirror.

After someone experiences a sense of disembodiment, the sociocultural context of healthism (e.g., I have cancer.), medicalism (e.g., my body is subject to scans and treatments making it a medical object), sexism (e.g., I am a female but now I do not have breasts and reproductive organs), ageism (e.g., I am only 35 but my treatments caused me to have early menopause) and ableism (e.g., I cannot do the things other 35-year-old women can do) further challenges their ability to reconnect with their body.

Reconnection to self

Researchers Niva Piran and Tanya Teall describe positive embodiment in their article “The developmental theory of embodiment” as one with “agency, self-care, and joyfulness.” Therefore, healthy connection, reconnection and adaptation to the body requires the experience of physical and mental liberation and social empowerment. This has implications when working with marginalized populations. For example, the 17-year-old African American girl who wanted to change her appearance due to negative social constructs must cultivate an appreciation and a liberation of her embodied self.

Learning to adapt to the alterations of the body is greatly impacted by the previous connection to body. If a person’s self-worth was associated to the objectification of body as beautiful, then a disfigurement may attack one’s self-worth — “I am not ‘pretty’ therefore I am no longer valuable.” However, befriending the body in a way that affords compassion can be empowering. For example, the metastatic breast cancer survivor previously mentioned said during counseling,

I don’t want lopsided breasts and tattooed nipples. I am a seventh-degree black belt in karate. I want to remove these false pretenses and replace them with a tattoo of a warrior’s breast plate. This is how I see my body now. This is empowering!

Counselors can encourage clients to engage in physical approaches such as yoga, breathwork, martial arts or free-form dancing (e.g., Nia — a holistic fitness practice that combines dance, martial arts and mindfulness) to help them reconnect to their physicality. And because being in nature is a multisensory approach to engaging the body, counselors can recommend clients to spend time in the natural world either in green spaces (e.g., forests, parks) or blue spaces (e.g., oceans, lakes, rivers).

Reconnection to others

A chronic diagnosis or injury can alter not only one’s physicality but also their social connections. The new diagnosis and treatment often test previous social supports and challenge friendships. For example, the combat vet who returned with a double amputation of his legs noticed his priorities were different from his civilian friends. “I was struggling to learn how to walk,” he recalled, “and they [his friends] were complaining about gas prices. We just didn’t have anything in common any longer.”

Clients can reconnect with their embodied self by finding others who share similar experiences and bodily appearances. I connected the combat vet with other soldiers with amputations who also identified as athletes and trained regularly. The physical connection to his body in an empowering way was part of his healing.

In addition to social supports, it is important to become reacquainted to intimate partners. This can be a difficult task because few clinicians or providers invite discussion around sexual and personal intimacy in the recovery process. However, it is important to begin this exploration to discover new and creative ways to experience the new body in a sensual and sexually satisfying way. Counselors can begin the dialogue by normalizing and validating that when we are disconnected from our bodies we are often disconnected from others and this lack of intimacy crosses into our personal and sexual intimacy behavior. Counselors can also provide insight into this connection and refer to sex therapists and sexologists when needed.

Reconnection to sacredness

Counselors can help clients learn to experience their bodies in the present moment by bringing their attention to their physicality in the here and now. When we fully embrace and experience this physicality of our bodies, we allow for opportunities of awe and wonder. The first snowflake melting on our tongue. The smell of homemade gingerbread. Crossing the finish line of that first 5K race. Reaching the highest peak of a hike and overlooking the terrain below. Pausing a moment after a strong paddle to the middle of a lake. The pain and pleasure of birth and then skin-to-skin contact that warms this precious body.

Our bodies are beautifully made, and our embodied experiences can be transcendent. Rediscovering the body in this way is not only empowering but also sacred.

Role of mental health providers

As mental health providers, we have the privilege of entering this vulnerable world of recovery and rediscovery. We can validate and normalize the incredible losses (both visible and invisible). We can create a space for the tasks of grief.

In addition to addressing the grief and loss, we can cultivate a bottom-up approach to recovery. Rather than emphasize the cognitive reprisal of the experience and the resulting new body, we can create a multisensory therapeutic space that emphasizes the physical self, the embodied self.

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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online master’s in clinical counseling. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer, nature-informed therapy and geek therapy. Contact her at cyfisherphd@gmail.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

‘But my clients don’t get eating disorders’

By Laura H. Choate January 11, 2021

Almost all counselors encounter clients who engage in behaviors such as extreme dieting, excessive exercising, fasting, emotional overeating and binge eating. These symptoms can be initially mild and overlooked or even viewed as normative in our thinness-and-appearance-obsessed culture. Sometimes it is hard to tell the difference between a client who is experimenting with the latest fad diet and a client who is quickly spiraling downward on the path toward a destructive eating disorder. There are two reasons this can happen.

One reason is a lack of counselor awareness. Few counselors receive much training in the area of eating disorders treatment, so they might not be aware of the need for further assessment when a client has initial problems related to eating, weight and body image. The problem is that without effective assessment and treatment, these types of symptoms have the potential to escalate into full-syndrome eating disorders such as anorexia nervosa, bulimia nervosa and binge eating disorder.

Once eating disorders have developed, they frequently become serious, complex, chronic disorders with significant biopsychosocial consequences, including potentially lethal medical complications, poor treatment outcomes, high rates of remission and high mortality rates. Anorexia nervosa in particular is associated with the highest mortality rate of all psychiatric disorders, and both anorexia nervosa and bulimia nervosa are associated with suicide attempt rates that are considerably higher than those for the general population. Suffice it to say, even the most highly trained, seasoned counselor is not equipped to work with this population alone; all clinical guidelines call for a team approach to the treatment of eating disorders. Therefore, regardless of whether we are specialists, we need to establish relationships with other providers in our communities and know when to make referrals for specialized services.

The second reason that initial symptoms might be overlooked or dismissed is that we are not just counselors, we are also individuals who live in a society in which we are all bombarded daily with messages about weight and appearance. We are all exposed to cultural ideals that equate thinness with beauty, happiness and success and that dictate strict standards regarding an ideal body shape. We all have to manage these pressures for ourselves, and few of us are exempt from developing biases and blind spots around these issues. Because of countertransference reactions in this emotionally charged area, we might unintentionally misjudge a client’s pain due to our own struggles and experiences. Therefore, when working with clients who present with issues such as body image, chronic dieting and pressures to be thin, it is extremely difficult to separate our own personal values from what is best for our clients.

So, even though you might never intend to work as an eating disorders specialist, all counselors need adequate preparation to recognize disordered eating symptoms in their clients, to know when and how to provide appropriate referrals, to understand the importance of a multidisciplinary approach to treatment, and to effectively manage personal values. To illustrate, I include three scenarios that highlight some of the complex concerns that can arise for counselors when working with clients who have problems related to eating, weight and body image.

Scenario 1: April’s intermittent fasting goals

April attends an initial session with Karyn, a licensed professional counselor with three years of experience. April reports that she has been on an extreme intermittent fasting diet for the past six months, allowing herself to eat only during a two-hour window per day. She adheres to a vegan diet because she believes it is the healthiest option for keeping a low weight. She also engages in binge/purge episodes three or four times per month (during which she does not adhere to a vegan diet but eats anything she wants). Her body mass index (BMI) is in the low to normal range.

Although April is reporting occasional dizziness, she does not want to give up her diet because she still has not reached her weight loss goal. Instead, she wants to get rid of her binge/purge behaviors, improve her body image and improve her self-esteem. She wants to work exclusively with Karyn even though Karyn does not have a specialized background in treating issues related to weight or binge eating.

Karyn believes April’s goals seem reasonable for individual treatment because she does not appear to be underweight. In addition, because April’s symptoms do not meet criteria for a diagnosis of anorexia nervosa or bulimia nervosa, Karyn does not consider April’s problems to be severe. In fact, Karyn knows a bit about intermittent fasting and its current popularity, so she believes that she can help April evaluate her diet plan.

Implications for counseling practice:

The ACA Code of Ethics states that counselors must know their scope of competence and practice within their areas of training and experience. Karyn is taking a risk in her agreement to treat April because without additional medical assessment, she has no way of knowing the extent of April’s disordered eating behaviors or how her symptoms are affecting her physiologically. It is likely that April is experiencing medical complications even though she does not appear to be underweight.

American Psychiatric Association practice guidelines state that in treating eating disorders, we should always work as part of a treatment team that includes at minimum a therapist, a dietitian and a medical professional. By agreeing to work in isolation and ignoring the need for collaboration, Karyn would not be able to adequately address the medical components of April’s weight loss — and without a medical referral, she would be working outside of her scope of competence, which could cause potential harm to April. In addition, she seems to ignore the fact that April’s behaviors could possibly be progressing to a severe eating disorder.

One way to address these potential problems is for Karyn to inform April that in order to begin treatment, she will need to agree to see a medical professional for evaluation. Based on these results, Karyn might also need to work with a nutritionist, in addition to possibly making a referral to a mental health professional who has more expertise in treating emerging
eating disorders.

Scenario 2: Nila’s secret and Asha’s dilemma

Nila is a 15-year-old who is in counseling at her mother’s insistence. Nila tells her counselor, Asha (a child and adolescent counselor in a general private practice), that her mother is too intrusive in her life, is always telling her that she should lose weight, and tries to control all of Nila’s food intake.

A few weeks into therapy, Asha notices that Nila has swelling in her neck area and has a large scrape on the fingers of one hand. When asked about this, Nila reveals that she has been trying to diet according to her mother’s demands but “just can’t stick to it.” Subsequently, she has engaged in binge eating by sneaking food from the pantry and eating it quickly so her mother will not know. She hides the wrappers in her book bag and throws them away later. Nila then uses self-induced vomiting, a technique she learned from watching YouTube videos, to try to “get rid of the calories.” She begs Asha not to tell her mother because she does not want her mother to become even more controlling of her food intake.

Asha isn’t sure of the next best step to take because Nila is in a normal weight range and seems to be healthy overall. Asha decides not to inform Nila’s parents and keeps working with Nila individually because she wants to respect Nila’s privacy.

Implications for counseling practice:

In resolving the issue of whether Nila’s parents need to know about her binge/purge behaviors, Asha has to balance the parents’ legal right to know what is disclosed in sessions, Nila’s ethical right to privacy and autonomy, and the counselor’s duty to provide effective treatment and protect Nila from future harm. In making this decision, Asha recognizes that Nila does have an ethical right to privacy and could possibly be harmed if her mother becomes even more controlling over her food intake.

However, Asha should also be very concerned about Nila’s emerging diet/binge/purge cycle because this is a potentially high-risk behavior. While the binge/purge behaviors are not currently life-threatening, Asha needs to consider the serious and potentially lethal nature of eating disorders, the chronic and compulsive nature of the diet/binge/purge cycle, and the medical and psychological consequences of any emerging eating disorder. Because Nila is an adolescent, her health could deteriorate quickly due to weight loss and purging behaviors.

American Academy of Child and Adolescent Psychiatry practice guidelines call for a comprehensive medical examination, working with a treatment team, and family involvement in the treatment of eating disorders. For any of these treatment aspects to occur, the parents would need to be informed of Nila’s disordered eating behaviors; Nila can’t arrange for them herself. In this case, therefore, Nila’s parents would need to be informed, even if this goes against Nila’s wishes.

In order to respect Nila’s right to privacy and minimal disclosure, however, Nila should be involved as much as possible when her parents are informed. If feasible, the information should be shared in a family session. If Nila can be in the session when information is disclosed, she is less likely to feel betrayed by Asha. If Asha can establish an alliance with the parents while also maintaining trust with Nila, Asha can start to work with the family system to create better communication. The parents need assistance in allowing for increased, developmentally appropriate autonomy and privacy for Nila. At the same time, Nila will have to accept her parents’ assistance in helping her manage her disordered eating symptoms.

The entire family would benefit from education about the harms of dieting, particularly for children and adolescents, and how food restriction is directly linked to binge eating and
is often the trigger for binge/purge cycles. With Asha’s help, the family can start to focus more on overall health and communication and far less on control over Nila’s eating, weight and body shape.

Scenario 3: Jamie’s diet advice

Jamie is a female counselor who works for a community counseling agency. Jamie’s client Dan reports frequent binge eating that causes him a great deal of distress, guilt and shame. Dan is a 45-year-old man who is in a higher-weight body. Jamie assumes that Dan needs to eat less and lose weight to feel better about himself because of his larger body size. She does not assess for an eating disorder but rather persuades him to pursue weight loss as his treatment goal.

In contrast with what she deems as Dan’s “weaknesses,” Jamie is highly invested in maintaining her own weight, daily exercise routine and “clean eating.” She feels a certain pride in her own self-discipline and thinks that Dan’s problems result from a lack of willpower and effort on his part. She is quite uncomfortable with Dan’s body size and tells him he would be better off in his career and relationships if he were to lose weight.

Dan reluctantly agrees to restrict his calories and to exercise more, even though he has tried “hundreds of diets” over the years. As time progresses, he feels discouraged and even worse than he did prior to treatment with Jamie because he can neither adhere to the weight loss plan nor stop his binge eating. He drops out of treatment, believing he is a failure.

Implications for counseling practice:

Even though binge eating disorder is by far the most common eating disorder (occurring in 3.5% of women and 2% of men), it was overlooked by Jamie in this example because her client is male and has a larger body size. In addition to neglecting assessment for binge eating disorder, Jamie seems to lack awareness of effective treatment for binge eating.

American Psychiatric Association practice guidelines for the treatment of binge eating disorder state that dietary restriction is actually contraindicated; in fact, dieting is known to trigger and sustain binge eating. There are biological and psychological reasons for this relationship. When Dan (or anyone on a diet) restricts food, he begins to deprive himself of the energy needed to maintain his current weight. As a result, the brain sends out warning signals telling his body to slow down because it thinks it is entering a time of famine. It also tells Dan to take in more fuel to prevent what it perceives as starvation. In an effort to preserve energy and fight against weight loss, his body’s metabolism will decrease, he will have more thoughts about food, and he will become increasingly hungry.

Second, the more Dan imposes restriction and deprivation on his life, the more he will experience psychological reactance — an internal battle that ensues anytime we perceive that our personal freedoms are being restricted. He will start to think about, crave and, eventually, overeat the very foods that he has ruled “off-limits.” He will likely eat more, not less, because of dietary rules. And for Dan, who has a long history of binge eating, his hunger, deprivation and dietary rules will most likely serve as triggers for continued binge eating. This will lead to a cycle of guilt/shame, dieting, broken rules, binges and more guilt/shame.

In addition to pushing a potentially harmful treatment plan, Jamie seems to be having difficulty managing her countertransference reactions. Like so many people in today’s culture (including many mental health and medical professionals), Jamie appears to have a bias against people in larger bodies. Because she believes that losing weight is the “answer” to Dan’s problems, she imposes this value on him even though he is seeking treatment not for weight loss but for reducing his symptoms of binge eating. Jamie’s discomfort with her client’s body is a form of weight-based discrimination that can cause Dan to feel judged and further marginalized.

Research indicates that weight stigma actually demotivates, rather than encourages, health behavior change. In response to weight stigma, people tend to eat an increased amount of food and are less likely to adhere to a diet plan. To avoid further stigmatization, they tend to avoid exercise, fearing additional judgment from others. They also tend to delay medical care to avoid stigmatization from medical professionals who may further criticize, blame or shame them for their weight. Jamie’s personal values in this case are causing her to display a lack of respect for Dan’s dignity and welfare. In sum, her biases and lack of knowledge of effective treatment for binge eating disorder are actually causing her client harm.

Key takeaways

The following list is a summary of considerations for counselors when they encounter clients who experience problems with eating, weight and body image:

Remember that anyone can develop an eating disorder. Do not assume that only underweight white women have eating disorders. For example, binge eating disorder is the most common eating disorder, and it occurs in people of all sizes and cuts across both gender and race/ethnicity.
During the intake process, ask questions about the client’s attitudes and behaviors toward eating, weight and body image. Remain aware that initial symptoms can potentially progress to full-syndrome, complex eating disorders.
Regardless of your treatment setting, be aware of resources, and be prepared to make proper referrals so that clients can receive specialized care when needed.
Effective eating disorders treatment involves a multidisciplinary approach.
Counselors, like all people, can have strong biases in the areas of eating, weight, body image and the importance of appearance. We have to be careful about imposing these values on our clients.
Weight stigma is a form of discrimination that serves to marginalize and shame people. It is not a value supported by the counseling profession.

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Recommended resources:

“Ethical Issues in the Treatment of Eating Disorders” by Laura H. Choate (in The Cambridge Handbook of Applied Psychological Ethics, edited by Mark M. Leach and Elizabeth Reynolds Welfel, Cambridge University Press, 2018)
“Assessment and diagnosis of eating disorders” by Kelly C. Berg and Carol B. Peterson (in Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment, edited by Laura H. Choate, American Counseling Association, 2013)
American Psychiatric Association practice guideline for the treatment of patients with eating disorders (2010): tinyurl.com/APAEatingDisorders
“Practice parameter for the assessment and treatment of children and adolescents with eating disorders” by James Lock, Maria C. La Via and the American Academy of Child and Adolescent Psychiatry Committee on Quality Issues, Journal of the American Academy of Child and Adolescent Psychiatry, 2015
National Eating Disorders Association: nationaleatingdisorders.org
Academy of Eating Disorders: aedweb.org/home

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Laura H. Choate is the Jo Ellen Levy Yates endowed professor of counselor education at Louisiana State University in Baton Rouge. She is the author of five books, the most recent of which is Depression in Girls and Women Across the Lifespan: Treatment Essentials for Mental Health (2020). She has 40 publications in journals and books, most of which have been related to girls’ and women’s mental health. She is a member of the ACA Ethics Committee. Contact her at lchoate@lsu.edu.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

I don’t care what my body looks like on the beach, bro!

By Andrew M. Watley July 25, 2019

Many guys and girls alike trained hard during the frigid winter months under a common belief: Summer bodies are made in the winter. Traditionally, getting “beach body ready” was associated with women. But that idea is so 20th century. Now, through the influence of social media and many other factors, guys are just as likely as women to stress about their appearance during these warm summer months.

Let’s take Instagram, for example. I don’t know about everybody else, but my page is filled with diet tips, workout routines, and guys who have the body type that I desire. The posts from these extremely “ripped” gentlemen are a double-edged sword.

One side is inspirational. These people put in a lot of time, dedication and patience to mold their bodies, like art, into the creation they see fit when they look in the mirror. Guys like me who strive to be in better shape look up to these men, hoping that the same level of fitness is obtainable for us.

The other side of the sword can bring about despair because of society’s decision that these model bodies — a body type that is not like mine — is what is considered favorable. Take a walk in history through People magazine’s “Sexiest Man Alive” covers. Most, if not all, of the men who have won these “competitions” have had favorable bodies. What an honor it must be to be considered the sexiest man to walk the Earth at a given time.

The idea that men don’t worry about their bodies is simply not true. Like the male peacock, we like to “strut our stuff” to gain the attention of those we might find attractive or for the man we see staring back at us in the mirror. He seems to be the hardest critic to impress.

Of course, negative consequences can be associated with the sometimes obsessive desire to be “Instagram worthy.” The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) specifies muscle dysmorphic disorder (MDD) as a subdisorder of body dysmorphic disorder (BDD). Muscle dysmorphia is defined as a preoccupation with the idea that one’s body build is too small or not muscular enough.

MDD occurs almost exclusively in men. This diagnosis can lead individuals down a path of obsessive behavior such as extreme exercise programs and long hours of weightlifting to gain muscle mass. These men may work out to the point of injury and often ignore said injury to continue their muscle growth. These individuals typically engage in unhealthy diet habits such as mass consumption of protein-rich foods to increase weight. In extreme cases, men may resort to the use of steroids or other addictive performance-enhancing drugs.

I conducted a doctoral research project in 2017 that studied men who considered themselves members of the fitness culture. The study conducted interviews of seven men and observed their gym habits. I paid close attention to how these habits and thoughts about their routines and physiques affected their mental health. According to these men, a muscular or fit physique brings not only desired attention but also validation of a man’s masculinity.

Society has equated a muscular or physically fit man with being more masculine than those men who are smaller in stature and weight. Obtaining this physique has become a social norm for the masculine guy. Maintaining a muscular physique is yet another gender norm that men are expected to adhere to in North American culture.

One gender norm that is changing is the notion that men do not talk about their feelings. It is not as far-fetched today to have men lying on the counseling couch as it was previously. It is possible that some of the men who end up in your office may experience symptoms related to a negative body image.

Unfortunately, counselors do not have a magic wand to use to “bibbidi-bobbidi-boo” our clients into the most muscular men at the ball. Nor do we have a single can of spinach that we can give our clients to instantly make them ripped like Popeye. But what we do have is research stating that when treating clients with dysmorphic disorders, cognitive behavioral techniques work best.

One of the first steps in cognitive behavior therapy is gaining an understanding of the problem. BDD/MDD may be the result of an underlying issue or concern. As with most eating disorders, muscle dysmorphia is likely caused by biological, psychological and social factors.

For some, it could be a traumatic event that was caused by unhealthy choices. One of the gentlemen I interviewed during my doctoral research recalled a moment when he had to run after a bus and, because he was overweight at the time, he couldn’t catch up to it in time. He equated his health and the laughter of the bystanders with his image. This moment pushed him into a lifestyle that would eventually lead to body dysmorphic disorder.

Another interviewee who identified as a member of the LGBTQ+ community discussed his desire to be viewed as attractive. He explained that some members of the community could be superficial, and in order to fit in with certain crowds, he needed to look a certain way. These represent just brief examples of how discovering the root of a client’s BDD or MDD may open the door to a helpful discussion about the person’s obsession with obtaining the “perfect” body.

As counselors, we need to help these clients first identify their automatic thoughts. As a theories class refresher, an automatic thought is one that is triggered by a particular stimulus that leads to an emotional response. Individuals maintain certain beliefs about themselves, others and the world. It is safe to assume that our male clients with BDD/MDD have similar negative views of themselves as it pertains to what is beautiful and accepted and what is not. These automatic thoughts can lead to cognitive distortions or faulty ways of thinking. As long as a client’s negative view of himself does not match his positive automatic thoughts about the world, he will feel as if he can’t comfortably be happy with himself as he currently is.

As trained professional counselors, we are no strangers to working with clients with anxiety. Anxiety is a big part of dysmorphia. Clients may experience anxiety when thinking about how others may perceive them. That faulty perception can then be reflected on themselves.

Helping clients to overcome anxiety is key. Anxiety is a fear of the “what ifs” in our lives, and 99% of the time, these events never take place. A person who struggles with BDD/MDD may be preoccupied with the thoughts of “What if I gain/lose weight?” “What if I don’t look like him/her?” Or, more common these days, “What if I don’t get enough likes?”

By helping clients confront the negative thoughts that plague their minds, we can potentially eliminate the harmful and, most times, irrational thoughts that haunt them.

Perhaps the most beneficial thing we can do as counselors is help our clients learn the importance of both acceptance and change. The DSM says that most men who struggle with MDD usually appear to be in pretty good shape already. Although it may be challenging, we must try to help these clients see their muscles as “half full” rather than “half empty.” Introducing them to the habit of positive self-talk may help them remember that it is OK to have a cheat meal or to miss a day at the gym.

If our clients are unhappy with the way they look, it can be beneficial to help them find healthy ways to change. Pointing them in the direction of a nutritionist or a personal trainer may be a healthy alternative for those who take extreme measures to alter their bodies.

Be proud to strut whatever you have at the beach this season, fellas. Remember that maintaining a muscular body takes time, effort and patience. If you aren’t where you want to be this year, set the goal to be there by next beach season. Be proud of the way that you look, and be sure to wear your shades and sunblock so that the rays of the haters can’t touch you.

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Andrew M. Watley is a licensed professional counselor and an adjunct professor in New Orleans. His practice specializes in children, adolescents, men’s issues, and struggles that may arise for members of the LGBTQ+ community. Learn more about him and his practice at drandrewwatley.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.