This week there was a thread on Twitter about Irvin Yalom and how kind he is. I have read many of his books and have no doubt that in general he is indeed a kind person. 

I have been thinking and writing about the essay, “Fat Lady” in Irvin Yalom’s book, Love’s Executioner, which I read soon after it was published in 1989, for years. I was horrified by what he wrote:

The day Betty entered my office, the instant I saw her steering her ponderous two-hundred-fifty-pound, five-foot-two-inch frame toward my trim, high-tech office chair, I knew that a great trial of countertransference was in store for me.  

I have always been repelled by fat women. I find them disgusting: their absurd sidewise waddle, their absence of body contour‚ breasts, laps, buttocks, shoulders, jawlines, cheekbones, everything, everything I like to see in a woman, obscured in an avalanche of flesh. And I hate their clothes‚ the shapeless, baggy dresses or, worse, the stiff elephantine blue jeans with the barrel thighs. How dare they impose that body on the rest of us? (Yalom, 1989, pp. 94-95)

Yalom has been much praised for openly admitting such strong prejudice, such clear negative countertransference. And indeed it takes some courage to openly admit such feelings.  But in most of what I have read about that essay, no one questions that his revulsion in fact dominates the entire therapy. Nor are questions raised that he could think and feel this: “How dare they impose that body on the rest of us?” as if any of his patients owe it to him to be pleasing to his eye. Then again, it is acceptable to hate fat and to think ill of fat people so there was little chance of serious criticism except from the fat acceptance community whose opinions could be dismissed as defensive. Nevertheless, he does deserve credit for daring to say what no doubt many therapists think. But it is not enough to do that nor to feel bad about having done so. To fully understand how bad this kind of countertransference is, change “fat” to “Black” or “African American” — there would be a huge outcry over expression of such prejudice, even when admitted. But Betty was fat so many people felt and feel the way Yalom did.

In the course of the treatment described in Yalom’s essay, Betty loses 100 pounds. Of course, because weight is seen as the cause of her depression, because she loses so much weight, the therapy is deemed spectacularly successful.  Another story is revealed in the end of the essay when Yalom says:

“It’s the same with me, Betty. I’ll miss our meetings. But I’m changed as a result of knowing you .”  

She had been crying, her eyes downcast, but at my words she stopped sobbing and looked toward me, expectantly.  

“And, even though we won’t meet again, I’ll still retain that change.”  

“What change?”  

“Well, as I mentioned to you, I hadn’t had much professional experience with the problem of obesity.” I noted Betty’s eyes drop with disappointment and silently berated myself for being so impersonal.  

“Well, what I mean is that I hadn’t worked before with heavy patients, and I’ve gotten a new appreciation for the problems of… “ I could see from her expression that she was sinking even deeper into disappointment. “What I mean is that my attitude about obesity has changed a lot. When we started I personally didn’t feel comfortable with obese people.” 

In unusually feisty terms, Betty interrupted me. “Ho! ho! ho! Didn’t feel comfortable. That’s putting it mildly. Do you know that for the first six months you hardly ever looked at me? And in a whole year and a half you’ve never, not once, touched me? Not even for a handshake!”  

My heart sank. My God, she’s right! I have never touched her. I simply hadn’t realized it. And I guess I didn’t look at her very often either. I hadn’t expected her to notice!” (Yalom, 1989, p. 123)

Yalom was naïve to think that his distaste for Betty’s body had not been evident to her. She lived in a world that reviled her body and likely she, like many fat people, expected to encounter judgement. A more interesting question is why, given that she knew all along of his distaste, did she continue to work with him? The answer? She herself carries and directs those same feelings of disgust at herself.

We don’t know how Betty is now, more than thirty years later. Statistically she most likely has regained all of the weight lost and probably gained more. That is what happens when we try to tame the body through dieting. She may have had bariatric surgery and be among the minority who have not experienced complications from the surgery. Or perhaps she is in that tiny minority who succeeded in maintaining that weight loss. But in the years since the essay was published, no one questioned what losing weight was about for her and how working with a therapist filled with contempt and disgust for her body effected her feelings about herself. About what happens in a patient if even the therapist finds one’s body repulsive, even if the repulsion is not expressed.

It is all but impossible for a fat person, no matter the reasons for being fat, not to have a host of emotional issues about her size and her body. Every day the culture is telling her that she is too big, too much, not acceptable. Finding the courage to talk about those feelings in the presence of someone who finds her as disgusting as she herself often does is quite a feat. How does she find her voice about her anger at what she encounters? How is she to lovingly care about her body and for herself  if her therapist sees her body with the contempt and hatred she so often feels? And what if she is tired of having to devote herself to losing all that weight? The operative assumption is that in a room with a normal weight therapist and a fat patient, it is the patient who has a weight problem. What is it at work that makes it so difficult for the fat patient to be perceived as a whole person who might not share much less welcome the therapist’s agenda about her weight? 

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