Therapy While Fat

One of the major issues I look at in The Fat Lady Sings is the issue of anti-fat bias in the psychotherapy consulting room. I write:

In a room with a slender therapist and a fat patient, it is the patient who has a weight problem. That therapist, bene tting from thin privilege may well assume that the way she eats, what she eats and how she exercises are what make her different from her patient, what make her thin and her patient fat. She may believe that because she carefully monitors what she eats and faith- fully exercises, that she has control over her body, control that the fat woman could have if only she tried harder and did as she does. There is nothing in the media or even the professional literature to contradict her assumptions.

 There is actually very little in the way of guidelines for therapists in how to work with fat patients or even how to make their offices welcoming. I have been able to locate three sets of guidelines for therapists when dealing with patients with size issues — one published in the American Psychological Association’s Monitor, one by NAAFA, and the last by Marion Woodman. So let’s look at the first two.

Guidelines for Psychologists

First, from the APA Monitor, a brief set of guidelines for therapists interested in being “size friendly” — it’s a short piece and seems to have been little noticed, though it was published in January 2004.

 Here are the guidelines:

* Don’t make assumptions about overweight clients, such as about whether they have an eating disorder or are working toward acceptance of their weight.

* Display size-friendly artwork or magazines in your office or lounge.

* Have seating in your office that can accommodate larger people. An example is armless chairs.

* Raise your colleagues’ and students’ awareness by addressing these issues in formal and informal ways, such as during clinical supervision or in workshops. 

 * Ask larger clients about eating behaviors in the same way you would ask a thin or average-sized person. 

* Through self-questioning and introspection, become aware of your own level of prejudice toward overweight people.

* Educate yourself on issues that affect overweight people, such as the genetic influences of size and the effects of dieting on physical and mental health.

* Understand that an overweight person’s problems are not always a result of their weight and that therapy does not bring thinness. Be aware that resolving life issues also does not necessarily result in weight loss.

I am willing to bet that very very few therapists are even aware that these guidelines exist, much less follow them. They are for the most part good guidelines, though whether questions about eating behavior are easily contaminated by bias. The therapist should ask herself, “Am I assuming this person eats differently from the way I do?” In my practice I do not habitually ask these questions unless they arise from my patient’s material.

NAAFA Guidelines

Next, NAAFA Guidelines  Here is their list of common assumptions for you to consider:

GUIDELINES FOR THERAPISTS WHO TREAT FAT CLIENTS

There are several assumptions, based on myth and prejudice rather than fact, which many members of our culture–including psychotherapists–believe to be true about fat people. These assumptions affect how therapists view and work with fat people in their practices. It is imperative that therapists recognize and clear out misinformation and bias in order to be most supportive and effective with their clients. We recommend that psychotherapists practice weight neutrality – i.e., make no assumptions based on a person’s weight, and not tie goals of treatment to weight outcomes.

ASSUMPTION #1: You can determine what people are doing about eating and exercise, just by looking at them. 

People naturally come in all sizes and shapes. Many fat people eat no more than thin people. some fat people are extremely active; some thin people are extremely inactive. Therapists must get to know each individual and his or her unique life.

ASSUMPTION #2: emotional issues cause “excess weight,” and once the issues are resolved, the person will lose weight. 

Humans come in a range of weights, just as they come in a range of heights. There is no evidence that emotional problems are more often the cause of higher weight. The idea that one has to explain why someone is at a higher weight is as nonsensical as trying to explain why someone is tall. There are fat people with emotional problems just as there are thin people with emotional problems, and the problems do not necessarily have anything to do with weight.

ASSUMPTION #2A: Large body size indicates sexual abuse, or a defense against sexuality. 

Some people who have been sexually abused may be fat; however, we cannot draw any conclusions about a person’s psyche based on body size. Many fat people are comfortable with their sexuality and are sexually active.

(I am not certain where the notion came from but around 15-20 years ago, the same folks who were promoting MPD were also promoting the idea that some 90% of fat women had been sexually abused. I never saw any research to support this figure but it was widely held for some time — C.F.)

ASSUMPTION #2b: fat people must be binge eaters. 

A small minority of fat people meet the criteria for Binge eating Disorder (BeD), as do a minority of thin people. There are also fat people who are malnourished, restricting, purging, and below their “healthy” weight. People with eating disorders deserve effective treatment and are often able to recover; however, their weight may or may not change in that process. An arbitrarily chosen weight should not be a goal of treatment, since weight is not under direct control. The focus should be on a sustainable, high quality of life, and on helping the person to accept the resulting body size.

ASSUMPTION #3: If a person is distressed and fat, weight loss is the solution. 

Being the target of weight prejudice can be cause for profound distress; however, the solution to prejudice is to address the prejudice, not the stigmatized characteristic. What would we do for a thin person in similar distress? The quality of support the person is able to give herself, and the quality of support available to her in the world, are key areas of focus. We do not have interventions that lead to lasting weight change, but we do have interventions that free people to be kinder to themselves and mobilize their energy to make their lives better.

ASSUMPTION #4: fat children must have been abused or neglected. 

Their problems can be fixed by restrictive dieting and rigorous exercise. fat children and their parents have been increasingly ostracized in a culture that equates a thin body size with personal value and appropriate parenting. children often gain extra weight before a growth spurt. enforcing weight- loss dieting and competitive exercise can lead to rebellion against both, as well as disordered eating. children need to be supported in using hunger and satiety cues to make decisions about eating, and in valuing their bodies and the variety of bodies in the world. 

ASSUMPTION #5: I am not biased against fat people. 

Research consistently shows that most people, including most healthcare professionals and even those who work closely with fat people, hold negative beliefs about fat people. Please investigate your own associations with weight and bodies of different sizes, including your own body, as essential preparation for working with fat people. (2) Therapists should be able to let go of any agenda to eliminate fatness, and see the beauty in fat bodies and the strengths of fat people living under oppression.

What is your experience?

If you are in therapy or have been in therapy, how does/did your therapist stack up against these guidelines? Are there others you think should be included?

Note about the image above: This is a sculpture given to me by a friend when I was writing my book. I do not know who the artist is.

Do I look okay?

These days all of my work is online, both via telephone and video. Whether with Zoom or Skype of FaceTime, not only do I see the person I am working with but also myself. It was disconcerting for me at first to see my own image while listening or talking with another. I realized that ordinary concern about looking okay is heightened this way.

 This heightened awareness of appearance called to mind John Berger’s book, Ways of Seeing, where he writes:  

“A woman must continually watch herself.  She is almost continually accompanied by her own image of herself.  Whilst she is walking across a room or whilst she is weeping at the death of her father, she can scarcely avoid envisaging herself walking or weeping. From earliest childhood she has been taught and persuaded to survey herself continually. And so she comes to consider the surveyor and the surveyed within her as the two constituent yet always distinct elements of her identity as a woman. She has to survey everything she is and everything she does because how she appears to men, is of crucial importance for what is normally thought of as the success of her life. Her own sense of being in herself is supplanted by a sense of being appreciated as herself by another….  

One might simplify this by saying: men act and women appear. Men look at women. Women watch themselves being looked at. This determines not only most relations between men and women but also the relation of women to themselves. The surveyor of woman in herself is male: the surveyed female. Thus she turns herself into an object — and most particularly an object of vision: a sight.”

I have realized that I rarely leave the house without asking my husband “Do I look all right?” though he never asks that question about himself. And when I do, I am still scrutinizing myself, still assuming I have to meet some external standard in order to be okay. Now I see it in myself every time I see that small image of my face on the screen.

How about you?

Good News!

Photo of Paul

Back in 2008 when Jung at Heart was still pretty new, HBO began running a series about a psychotherapist and his patients. The show was called In Treatment. I loved it from the start and I set upon myself the task of blogging every episode, no small feat given that in the first season, there was a new episode every weeknight. I thought then and still believe that it is the best dramatic representation of therapy done to date. If you want to read what I wrote, just click on the In Treatment link at the top of the page — season by season, al the posts are there.

Friday I ran across this announcement — Big news! HBO plans to reboot the series. You can bet I will be watching and writing about each episode. In the meantime if you have questions or comments about the series or what I wrote about it, please post in the comments here.

Fat Arms

A couple of years ago my book was reviewed in the journal Fat Studies. It is an interesting experience to read how someone else interprets what I wrote, and by extension, my life. The review is positive and I am grateful for it. But there was something at the very end that gave me pause.

In the book I wrote:

“For all the work I have done to come to terms with and embrace my body, for all that I have embraced fat acceptance and eschewed dieting and body loathing, there remains a pocket of shame about my body that gets reawakened every summer – I have very fat upper arms and though there is no sleeve that would hide that fact or make my arms look slender, the thought of baring them in a sleeveless dress fills me with anxiety and shame. It is as if every bit of shame and anxiety about revealing my body becomes located in my arms and only if I keep them covered, can I dare go out into the world. I seize upon this wonderful quote: “when it comes to dressing myself, i live by a very simple principle. i am fat, therefore, i look fat in everything; consequently, i can wear anything.” (Selling). I chuckle and I get it but still, sleeveless? How could I move about in the world knowing there is no way for my invisibility cloak to hide my arms? All this work and the thought of showing my arms undoes me. The work goes on. I support the right to bare arms. Maybe next summer my arms can go bare.” p. 134

My point in writing about the fact that I still shy away from going sleeveless in the summer was to show that coming to body acceptance is a process, a journey rather than an event. We all have good days and bad days. Days when we feel on top of the world and invincible. And days when we can’t stand ourselves. That is how it goes. In an interview in Huffington Post, Leslie Kinzel who has been writing and talking about fat acceptance and body acceptance for years now says:

I am in a place where I love my body! I got there mostly because I worked really hard at it. It’s possible in spurts, but we also have to acknowledge that there are also going to be days that you hate the way you look. For me, it’s [loving your body is] a code for acknowledging that I’m going to have good days and I’m going to have bad days, but I’m not going to beat myself up about either. I’m just going to accept that these feelings about my body are going to change from day to day, as well as 10-20 years from now. This is a process. It’s not a destination.

That is how it is with me and my upper arms. And as I have talked with other women over the couple of years, lo and behold, I discover I am most definitely not alone in my feelings about my arms. 

So when I read at the end of the review: “While I wish for Fuller to sing and dance with her bare arms waving in pride and joy of the beautiful bounty of her body, this book remains provocative and honest in its articulation.” — the second to last sentence of the review, I feel a bit of protest. I am in my 70s now. Age leaves its mark on my body. My hair is white and not as thick as it once was. I am less mobile than I once was. But this wonderful body has brought me to this age, has borne my children, been a source of great joy and sorrow, of delight and pain. I fully embrace and accept my body. As I was starting to write this yesterday, I happened upon this and found the perfect expression of what this is about for me — what has beauty got to do with it?

“Rather than fighting for every woman’s right to feel beautiful, I would like to see the return of a kind of feminism that tells women and girls everywhere that maybe it’s all right not to be pretty and perfectly well behaved. That maybe women who are plain, or large, or old, or differently abled, or who simply don’t give a damn what they look like because they’re too busy saving the world or rearranging their sock drawer, have as much right to take up space as anyone else.

I think if we want to take care of the next generation of girls we should reassure them that power, strength and character are more important than beauty and always will be, and that even if they aren’t thin and pretty, they are still worthy of respect. That feeling is the birthright of men everywhere. It’s about time we claimed it for ourselves.” -Laurie Penny

I support the right to bare arms, and the right to cover them.

On Not Being Able To Paint

That’s my art desk. It is suitably smeared with paint and certainly looks like I spend a lot of time there. But…

My brother is a painter. He paints trompe l’oile – which means fool the eye. Here is one of his paintings. 

 

Painting by Ken Fuller

Not my style but he is good at it. Somehow that he is an artist and was also my mother’s favorite led me to avoid art, focusing instead on intellectual pursuits. Still something in me kept wanting to paint and draw. My brother once said that anyone could draw, which was not encouraging to me at all. I took the art classes in school that were required but once finished with them I turned away from painting or any kind of art for many years. I think the last thing I made was a paper mache dog that I meant to be a dachshund but looked sort of like a weird brown worm with legs and ears.

Maybe a class would help

I lived in Portland, Maine for a long time. Portland is the home to a well regarded degree- granting art college. In the early 90’s I decided to take a drawing course through their continuing studies program. I hoped to find a class for people who did not think of themselves as artists, a class that would support and encourage people like me who wanted to draw but were intimidated by the doing of it. I did not find that — the people in the course saw themselves as artists and then there was the critique of every assignment. I dropped out.

A couple of years later my good friend and I found two wild wonderful women artists who were offering classes for people just like us. And it was just what I needed. Supportive, encouraging, full of laughter — a place where my very timid artist self could creep out and start to experiment, to express myself in paint.

Along the way I discovered that I love art supplies. I loved accumulating tubes of watercolors and oil paints. Lots of them. Brushes. Paper. Canvases. I was a very well supplied pretty unproductive artist. After a while the class died out. I painted a little more. I used them in my analysis. But away from the class, just on my own I struggled to paint anything. And then I stopped. And then I gave away all my supplies.

Fast forward to the last few years when I discovered the wonderful world of online art courses. I began again to accumulate art supplies. My lust for paints and brushes and the like was reawakened. I even did a few of the projects. But I still felt inhibited. And besides I was finishing my book. I watched every video. I liked the idea of mixed media. Images of potential projects would come to me but they never came to life on paper, mostly because I hated that I couldn’t bring into being what my mind’s eye saw.

Painting and Analysis Intersect

In addition to being a therapist, I was also in Jungian analysis for a long time — we ended just over 3 months ago. It was where I could struggle with my demons and learn more about myself. You might think that therapists make good therapy patients but really, not so much.

One of the features of Jungian analysis is opening to express feelings, experiences creatively — in art or poetry or writing or dance — a transformative process. As I said above, drawing and painting I kind of consigned to my brother. He was good at; I believed I was not. But writing — now that is a different story, I write easily and without fear, unlike what happens when I attempt to express myself in pigments on paper. Whatever I painted, I then looked at with a critical eye, a judging eye rather than seeing it for what it was, an effort to express something.

My analyst kept urging me to paint. And I would — for a while and then I would stop again. It was an ongoing struggle for me. I understood that the very fact that writing came so easily to me made painting important for my growth, not as an artist but of my self.

Recently I remembered a book I read at least 30 years ago — and truth be told, did not really understand when I read it. It is a bit of a classic published in 1950, written by Marion Milner, herself an analyst. I dug out the book, On Not Being Able to Paint. And began to read it. There in the foreword was this:

It is fascinating for the reader to follow the author’s attempts to rid herself of the obstacles which prevent her painting, and to compare this fight for freedom of artistic expression with the battle for free association and the uncovering of the unconscious mind which make up the core of an analyst’s therapeutic work. The amateur painter, who first puts pencil or brush to paper, seems to be in much the same mood as the patient during his initial period on the analytic couch. Both ventures, the analytic as well as the creative one, seem to demand similar external and internal conditions. There is the same need for ‘circumstances in which it is safe to be absent-minded’ (i.e. for conscious logic and reason to be absent from one’s mind). There is the same unwillingness to transgress beyond the reassuring limits of the secondary process and ‘to accept chaos as a temporary stage’. There is the same fear of the ‘plunge into no-differentiation’ and the disbelief in the ‘spontaneous ordering forces’ which emerge, once the plunge is taken. There is, above all, the same terror of the unknown. Evidently, it demands as much courage from the beginning painter to look at objects in the external world and see them without clear and compact outlines, as it demands courage from the beginning analysand to look at his own inner world and suspend secondary elaboration. There are even the same faults committed. The painter interferes with the process of creation when, in the author’s words, he cannot bear the ‘uncertainty about what is emerging long enough, as if one had to turn the scribble into some recognisable whole when, in fact, the thought or mood seeking expression had not yet reached that stage’. Nothing can resemble more closely than this the attitude of haste and anxiety on the analyst’s or patient’s part which leads to premature interpretation, closes the road to the unconscious and puts a temporary stop to the spontaneous upsurge of the id-material. On the other hand, when anxieties and the resistances resulting from them are overcome, and the ‘surrender of the planning conscious intention has been achieved’, both – painter and analysand – are rewarded by ‘a surprise, both in form and content’.

I sat down this morning and looked at a blank piece of watercolor paper. Nothing came for what felt like a long time. And then I began to make marks on the paper. No image in mind of what I wanted it to be. I just let the brush make marks until  I felt done.

As my analyst did, I often suggest to my patients that they paint or make collages or write or dance or work with clay. Most often they, like I, balk, resist, say they don’t know how or what they create isn’t any good. For some of us the road to being able to express ourselves is long and often hard, but it is worth the journey.

Maybe you can paint something today? Or write something? Or go inside a dream and explore it? Try it.