10 Ways Therapists Should Be Body Image Informed

Body image may seem like a niche area of work – your clients may not tend to present with related issues so it might not seem like a vital area of training, or maybe you feel like you understand enough as it is. 

The problem with this stance is that even if clients aren’t presenting with these issues, if you ask the right questions it can bring up a wealth of emotional feelings and experience around what it’s like to live in their body, in this culture.

We know from the Mental Health Foundation’s Body Image Report that: 

  • One in five adults (20%) felt shame, just over one third (34%) felt down or low, and 19% felt disgusted because of their body image in the last year. 
  • Among teenagers, 37% felt upset, and 31% felt ashamed in relation to their body image. 
  • Just over one third of adults said they had ever felt anxious (34%) or depressed (35%) because of their body image. 
  • One in eight (13%) adults experienced suicidal thoughts or feelings because of concerns about their body image. 

Their summary states: 

Higher body dissatisfaction is associated with a poorer quality of life, psychological distress and the risk of unhealthy eating behaviours and eating disorders.

>> To develop your skills in working with body image challenges, sign up to our upcoming conference *Shame and The Body* with Dr Nicole Schnackenberg on Friday 22nd March 2024 via Zoom (with catch up available if you can’t make it on the day). 

Beyond the statistics, here are 10 reasons why we need to be body image informed

So it seems that body image is something that teenagers and adults really do struggle with, even if it’s not one of the main issues they would report with in therapy. We need to then be educated on body image issues, to ensure we are working not just effectively but also safely with these clients. 

1. Avoiding harm 

A challenge we may face is that we’re living in the same culture as our clients and may well have absorbed the same messages around what makes a healthy, beautiful, or even acceptable body, and the actions we’re expected to take in response. So, without meaning to cause harm a therapist may suggest to a client talking about diet and weight loss that they go to Weight Watchers – reinforcing the idea that they should lose weight and how. Or perhaps there could be a verbal collusion in guilt and body shame, with disclosures around diets in the new year, as if this way of living is something we all have to accept. 

As well as explicit verbal remarks that may demean or collude, there’s also implicit reactions. We can all say we’re non-judgemental but do our faces and bodies tell a different story when we meet someone who looks different to how we’re expecting? Clients will pick up on these counter-transferential tells and may feel shame in your sense of surprise, or whatever else is being given away. 

2. Examine biases and broaden your world-view

To avoid harm we need to examine our own biases, which we all inevitably hold. The mainstream media remains predominantly white, slim and abled – this will influence what we expect and feel comfortable with. However, we can broaden this world view by populating our social media feeds with a diverse range of bodies – normalising this for ourselves but also enjoying the beauty in diversity itself. This can be a helpful thing for clients to do too, to feel less alone but also less pressure for their body to stay a certain way. 

There are Instagrammers of all different sizes, ethnicities, gender identities and expressions, those with skin conditions, disabilities, or chronic illnesses, the list goes on and on. We can share lists such as this one with clients, or signpost to specific accounts we think they may find helpful to follow.  

Our work with these clients may be reparative and healing, with self-esteem improving just through our therapeutic relationship, but them being able to see these kinds of images on a daily basis can also have a huge impact. 

We need to broaden our world view, and also be aware of how different intersecting identities may impact on feelings around body image.

3. Ensuring access 

Being body image informed also means being aware of what it is to live in a fat body, and how accommodating the world is – or in the most part, isn’t. Hopefully therapists keep disability access in mind, but it’s also important to consider the therapy chairs that you’re using – with an appropriate size, and potentially without arms, to accommodate larger bodies. 

>> Read our book list of The Best Books on Body Image to learn more

If a client experiences body image issues or dysmorphia, another practical thing we can do (especially in the times we’re currently living through) is explain to clients that if you’re working on Zoom, they have the option to turn off self-view. For any client seeing themselves while engaging with therapy can be challenging, but especially for those who struggle with body image. Over time it could become a way of working with these issues, but establishing safety is the most important thing. 

4. Challenging misconceptions 

As well as aesthetic ideas around what makes a beautiful body, we also absorb messages around what is healthy or not. However, a commonly talked about measure of health – BMI – is actually one of the most inaccurate indicators of health. From this numeric measure, and then from how we view bodies, we can assume smaller is healthier and bigger is unhealthier – but that’s not necessarily the case. Health At Every Size is a good book on this subject and broader assumptions around negative health impacts. Dr Joshua Wolrich is also a great person to follow on Instagram for how he clarifies misconceptions and challenges weight stigma.

This Instagram post by Alex Light illustrates this well too (click the post to read her caption on BMI):


View this post on Instagram


A post shared by Alex Light🕊 (@alexlight_ldn)

We also need to be aware that physical health isn’t always a priority to clients, and that’s not for us to judge. They are coming to us for mental health support. Even if we feel we are offering that, holding incorrect assumptions in mind can impact the therapeutic relationship. 

Would you like to learn more about working with body image in therapy? Watch our online CPD: Body Image Conference – Skin, Identity and the Gaze in Psychotherapy. See the trailer below. 

5. Knowing the shame of speaking about body image 

It can be really hard for clients to raise the topic of body image, and knowing this means we can take the initiative to sensitively ask general questions around body image in assessment or when it feels right later in therapy, while also acknowledging that this can be difficult to talk about.

If a client lives with acne, and feels shame over this – it may be something they wouldn’t want to bring to someone else’s attention, including their therapist. Yet their days may be hugely impacted by the low mood and decreased confidence related to their skin. It may become harder still to talk about their skin, and associated feelings, if their therapist has perfect skin and is conventionally attractive – regardless of gender, but also if their therapist is of the gender they are attracted to. This is where staying aware of our differences and privileges can be helpful. 

> Linda Cundy will be exploring the subject of skin and how it affects relationships at our Body Image Conference. 

Speaking about body image issues can feel vulnerable and exposing, and may be avoided. Being aware of, and acknowledging this, can help clients feel more at ease.

6. Shame as the cause of body image issues 

Conversely, rather than just being an effect of body image issues – shame can also be the cause of them. Experiences such as abuse can lead to shame which is then projected onto the body, with all of the physical self being seen and experienced as unacceptable. For this reason we need to be trauma informed and ready to work with this, or ready to refer on when appropriate.  

>> Nicole Schnackenberg will be talking about this in her talk at our Body Image Conference 

The lesson here is that body image issues are not simply aesthetic – they’re not skin deep, but instead can be fuelled by our life experiences and beliefs. A client with already low self-esteem and a core belief of being “not good enough” may struggle more with becoming visibly disabled and different to others, for example.

7. Self care over endless striving for change 

By educating ourselves on body image issues, we will also learn about the dieting industry – and how diets are so often designed to fail once they finish. Clients can be in endless stressful cycles trying to find a diet that works, and this stress can take its toll in itself. Education can help us inform and signpost clients to useful resources around this, but we can also explore what this lifestyle means for their mental health. 

With this, we may hear how else clients treat their bodies – grabbing at rolls of fat and speaking with cruelty to themselves. We can help clients consider instead how they may learn to treat their body with kindness, not grabbing but instead stroking their skin and speaking with words of compassion. Self-Compassion in general can be really worth exploring and Kristin Neff’s book Self-Compassion is a great place to start. 

Sofie Hagen (comedian and author of Happy Fat) shared a self-care tip with this photo: “If you find it hard to love your stomach, make it more obvious just how utterly cute and loveable it is.”

8. Body Image and intersectional diverse identities 

Body image issues are not just internal – they’re relational and systemic too. How we feel about our body is going to be affected by the culture we live in: insecurity and shame may arise from the differences felt while living in a certain community, linked to identity (or several intersecting identities). Experiences of racism, sexism, ableism, transphobia, or other forms of prejudice and discrimination that may be experienced on a daily basis, alongside harmful or absent representation in the media, can all contribute to body image issues.

If you’re the only black woman when picking up your kids from school it’s likely you will experience racial microaggressions, as well as more explicit racism. When hearing such a client talk about their bodily insecurities in therapy, such as shame around hair type, we need to hold this in mind and bring it into the room. 

The media has a big role to play too. When the overwhelming majority of disabled characters are objects of horror, despair, pity or inspiration – that’s going to be impact on both your own self-esteem, and how others treat you. Too often these disabled characters are also played by abled actors. Writer and activist Jen Campbell made a brilliant point in one of her videos on how the anthem from the film “The Greatest Showman”, This is Me, sounds like a powerful declaration of pride in relation to difference. When you learn that all the actors are abled and lacking these bodily differences themselves, it instead feels like another sad indicator that, actually, difference is still not being embraced. 

Each diverse client group may have a different relationship with body image, and this may change over time through ageing and life experiences. There will be specific issues that men and women generally face, as well as the pressures on trans men and women to “pass” and meet the ideal beauty standards of their gender (and the risks to them if they don’t). Those who are non-binary are often perceived differently to how they feel and desires for non-conventional medical interventions are often misunderstood by others, including therapists.

>> Jeff Lane will be exploring men and body image, and how both men and women are portrayed in the media, at our Body Image conference

Those of varying sexualities will also face certain issues, and understanding the different aesthetic “types” that are talked about within LGBTQ+ communities – such as bears and twinks for gay men, can give insight into what body image issues may be present. 

Some differences may also be held with pride by the client, who may associate their features with a sense of belonging to their family and cultural community. It’s not about making assumptions that a client’s appearance will make them feel a certain way, instead remaining curious and asking questions – while holding the knowledge of issues that may present. 

9. Anticipating common issues

Working with body image issues also means navigating the client’s relationships with others. If family members are often making derogatory, shaming comments, asking intrusive questions around weight or discussing diets and weight loss, this can be incredibly hard to manage.

Knowing that this issue can come up, especially around the holidays, means we can help clients in setting boundaries and perhaps even rehearse responses that feel manageable for them to shut the conversation down.

10. Body image and eating disorders 

Eating disorders are often not about aesthetic appearances, and body image issues do not always lead to disordered eating. However – there can be crossover and we need to be aware of this. Through assessment (when beginning therapy but also over time) we can gleam whether the client is in a place where we can work with their issues, or if we need to refer onto another therapist or specialist team. 

Body Image CPD

Would you like to learn more about working with body image in therapy? Watch our online CPD: Body Image Conference – Skin, Identity and the Gaze in Psychotherapy. See the trailer below. 

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