Fat Patient, Thin Therapist

It is usually assumed that in a room with a slender therapist and a fat patient, it is the patient who has a weight problem. That therapist, benefitting 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 faithfully 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 are powerful transference/countertransference forces operating in therapy when fat enters the picture. As a fat patient I came to work with slender analysts with a full set of baggage and expectations based solely on my fears and projections about how my fat body would be experienced and regarded. Nothing in my experience with others contradicted these fears. And more often than not, my fears were borne out as valid. The language used to describe obesity – words like “grotesque”, “gargantuan”, “repulsive” – betray much about feelings toward fat people. It is important for the slender therapist to look within about her own attitudes and responses to fat.

A fat patient who wants to talk about weight exclusively, as if it were all that matters in life, is as much avoidant as is the fat patient who ignores weight entirely. And in either case, the therapist needs to be aware of how her own biases and/or discomfort play a role in this. There are very fine lines here. Weight and appearance and being outside the established norms are touchy things. It is difficult to become accepting of one’s own deviant(in the sense of differing from whatever is considered ‘normal’) body, to be at home with being different. The ambivalence is massive. The longing to fit in is right there next to defiance and anger about not being accepted. The therapist needs to walk that line without falling to either side, either by urging and cajoling weight loss or by denying the difficulties of being different from the expected norm. These are tricky waters for a therapist with thin privilege to try to navigate.

Just as we now know white analysts need to learn about African American culture, our fictional slender analyst needs to learn about the life her fat patient leads, about fat experience, about the experience of being reviled, judged, shunned, pathologized on a daily basis. And consider what her own unresolved body issues might be, because as Barbara Miller writes:

the experience of the analyst may…have to do with his or her own neurotic blind spots. And the analyst needs to consider such a possibility. Concerning neurosis Jung writes, ‘Behind a neurosis there is often concealed all the natural and necessary suffering the patient has been unwilling to bear’… And we can say that the analyst’s own not suffered pain can all too easily be disowned and then ‘found’ as the pain of the analysand: the neurotic countertransference. 

A female therapist, regardless of her weight, has had to deal with the expectations that women should be slender and attractive. Most likely she has dieted or thought about  dieting, fretted about any fluctuation in her weight, and experienced some anxiety about whether or not she is pretty enough, slender enough to attract a partner. In this sense she and her fat patient have shared experience, but her patient’s anxiety and fretting have not resulted in the slender body that the therapist has. And this can well become a source for a blind spot in the therapist – if she has been able through diet and exercise to be thin, then why wouldn’t that also be the answer for her fat patient?

That slender therapist needs to consider where her ideas about fat and fat people come from, what supports those ideas. The one article in Quadrant, a Jungian journal, in which obesity is even addressed carries bias right in the keywords given for the article: obesity, gorging, overeating, gluttony, hunger. 

Outside of the realm of fat studies, the Health At Every Size movement, and fat acceptance circles, the fat person is not seen as trustworthy or reliable about her own lived experience because it is assumed she is always defensive and denying the reality of her condition. If she says she eats moderately, often it will be asserted that she is in denial about how much she actually eats or some comment will be made about the unreliability of self-report. The fat woman is simply not trustworthy. 

Wilfred Bion’s dictum is to approach each session without memory or desire. If the therapist has in mind that her fat patient needs to lose weight in order to heal, whatever that means, then she is in fact imposing her agenda without determining if that is what the patient wants or needs. When the therapist holds this desire for her patient to change in particular ways, when she asserts her own agenda for the patient, Barbara Stevens Sullivan suggests that desire “reflects a yearning to be helped. “If I can put all the woundedness I sense in the room into the patient, and if I can fix it in him, I will be fixed, too”

The assumption, for both therapist and patient, most often is that if the patient loses weight and becomes slender, she will become more the person she is meant to be, that she will be healthier and happier. For any fat woman, her fat identity will remain no matter her weight — her memories of being fat, of her longings and pain alongside secret delight in her big body — are part of the fabric of her being and need to be heard, witnessed, and accepted. For the thin therapist this may mean receiving anger toward her as a representative of thin privilege, as one of the oppressors her fat patient has lived with. I think of my own rage when my first analyst blithely suggested I could lose a few pounds no matter my goals. A paradox for the therapist of a fat patient is that as Sullivan says,  “the analyst must let go of desire, even the desire to help, at the same time as she remains involved and concerned, desiring the best for her patient” and, I would add, accept that the best for her patient may not be what she herself would want or choose.