As a therapist I am very interested in how therapists respond to fat patients and how fatness is viewed psychotherapeutically. I have had some interesting experiences myself with therapists who made assumptions about me and the issues I wanted to work on based on my size rather than what I said. It is  interesting to me that the literature is relatively silent on this subject. I have searched long and hard to find pieces written by therapists about their reactions to fat patients and written by fat therapists about patients’ reactions to them — the picking are pretty slim.

One of the books I stumbled upon is Eating Problems: A Feminist Psychoanalytic Treatment Model. I am impressed that the articles in this book do not take what I would consider a fat negative posture at all, but offer the author’s thoughts and experiences with patients — anorexic, bulimic, fat and everything in between — in light of feminist theory and with a deep understanding of cultural forces we must all contend with. The net result is an approach that offered me some fresh insights into my own history and some very useful material I can use with my patients.

Here is a statement that it seems to me describes what underlies so much of the negative feelings every fat woman and many who only fear being fat that I know has struggled with at least some of her life:

“A fat body is cruelly stigmatizing in this culture. It is treated, seen, and felt as an object of disgust and fear. Many disabilities are so treated and seen; but fatness is also seen as reason to blame the fat person who ate her way into “freakishness”.  ” p. 154

I found myself nodding in agreement frequently as I read this book, underlining many paragraphs and sitting and reflecting on the ideas therein. If you are a therapist, I recommend this one. And consider this:

The therapist can feel concern about weight, but to be invested in weight loss as a goal is to be aligned with the cultural and internal saboteur.” P. 70

 When therapy works, when patient and therapist are able to influence each other, both do change. In the case of dealing with fat, usually it would be that the fat patient becomes free enough of the cultural fat complex, a fish able to see the water, and who then can dare to confront her therapist’s attitudes and beliefs. She can begin to tell her story in her own voice. Jane Burka asks:

If my body is present and significant for me and for my patients, but remains outside the discourse of the therapy, what kind of taboo have my patients and I created? 

A great deal of change is needed for it to become the norm rather than the exception for a fat therapy patient to be perceived as a person who should be asked what she wants to work on, for her not to be subject to the suggestion that she could/should lose at least a little weight, for it to enter the mind of the therapist that this patient may not see her weight per se as the problem in her life, even though she experiences the negative effects of stigma and bias. Or that it may be that she needs most to deal with the pain, the trauma of having a stigmatized body. In a little book published in the late 80s, Fat Oppression and Psychotherapy, Laura Brown puts her finger on a problem: “…while it was acceptable for clients to be fat women, therapists as so-called models of good functioning, we’re required to stay thin.”  

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