Therapists and Fat

 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.”  

Misfit Produce, Lady Ragnell, Mr. Rogers and Me, Pt. 2

Better late than never — a look at the story of Sir Gawain and Lady Ragnell and what it has to do with us today.

Our story is from medieval England. It is often titled ‘Sir Gawain and The Lady Ragnell. Lady Ragnell also known as the loathsome Lady Ragnell, bargained with King Arthur. A spell had been placed over him. Unless he could correctly answer the riddle “What do women desire above all else?”, he would die. She agreed to tell him the answer to the riddle. In exchange, she desired to be married to the King’s nephew, Sir Gawain. He was known as the most handsome, skilled and compassionate knight at the Round Table, whereas Lady Ragnell was a very ugly hag. Sir Gawain willingly chose to marry the Hag Ragnell, so that his King’s life would be spared. He did not know that a spell cast over Ragnell, had turned her into a loathsome Hag for half of each day, but left her as a lovely princess for the other half. 

On their first night, after brief hesitation, Gawain decides to treat his new bride as he would if she were desirable, and go to bed with her as a dutiful husband is expected to do. However, when he looks up, he is astonished to see not an ugly hag, but the most beautiful woman he has ever seen standing before him. Ragnell explains she had been under a spell to look like a hag until a good knight married her; now her looks will be restored, but only half the day. She gives him a choice-would he rather have her beautiful at night, when they are together, or during the day, when they are with others? 

He wisely gave her the right to choose, having learned that above all else, women desire the right to have sovereignty over their choices.  In giving the Hag Ragnell the right to decide when she would be beautiful, the spell was lifted, and she was beautiful all day long.

It is in fairytales that when a spell is broken, the entrapped woman becomes a beauty. Most of us have heard those stories for decades. We may think we don’t accept them as literal because we cannot see how they are present in our modern lives. The entire diet and weight loss industry and cosmetic surgery depend on our belief that we will be better loved, have more opportunity, live happily ever after if/when we lose weight, make our breasts larger or smaller, reshape our nose. Even among many therapists the assumption is that the best outcome is for s fat patient to lose weight — more about this on another day. 

We recoil from the language but fatness is also seen as reason to blame the fat person who ate his or her way into ‘freakishness’. Even using the word ‘fat” makes people uncomfortable, thus betraying the assumption that fat is bad. But many, perhaps most fat women and girls feel themselves cursed, bewitched like Lady Ragnell and condemned to life as a hag unless or until a modern day Gawain comes along and is willing to be with, to love her as she is. Because giving Ragnell the authority to choose for herself what she preferred was in fact being willing to be with her as she was. 

How many of us have head of husbands complaining that his wife “had let herself go”, meaning she had gained weight and gotten older, and implying that he wanted her less? Or know women who are constantly trying to lose that 10 or 25 or more pounds that stands between them and beauty?

In my own life, in my first marriage from the time we got married until the time of the divorce, he kept telling me he would really love me when I weighed 120 pounds. It went on for 24 years. I was angry that he kept telling me throughout the marriage that he would really love me when I weighed 120 pounds. And he was angry that I never attained that goal.  In the end the spell was broken, but I did not transform into a slender woman. I divorce him and a few years later met and married my own Gawain, a man who was and is willing to love me as I am.

Polly Young Eisendrath’s book, Women and Desire: Beyond Wanting to be Wanted . Wanting to be wanted, fearful of not finding the partner who will want us, believing ourselves that fat is unloveable, is the curse many woman live under. Therapy and doing the work of coming to value ourselves and the right to be loved for who we are is the way out.

Misfit Produce, Lady Ragnell, Mr. Rogers and Me, Part 1

Today I am beginning a several post series looking at bodies, especially fat bodies, and psychotherapy.

You might very well ask what this image — used by the company, Misfit Market which describes itself “Misfits Market delivers ugly, but otherwise perfectly edible fruits and vegetables”. I have frequently seen this image online for several months now. It struck me that even fruits and vegetables are expected to conform to some standard of beauty in order to be acceptable, even though appearance has little or nothing to do with their actual nutritional value. And that sounds so very familiar.

Take a look at this from John Berger’s book, Ways of Seeing:

“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.”

When we women don’t rise to the standard of beauty expected of us, we become as misfit people, not marketable nor desirable. And we must survey ourselves constantly to assure ourselves that we acceptable. And when we don’t measure up, when we fall outside that conventional range of attractiveness, then like the misfit produce, in a way we become freaks.

Irvin Yalom is much loved by many therapists. Yet in his book, Love’s Executioner, he too reveals an all too common view of fat women as akin to misfit produce.

“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?”

To his credit, Yalom acknowledges that this is an instance of countertransference, and that is good. But in the many comments that refer to this essay, I have not seen anyone be critical of the attitude he expresses nor what effect it had on his patient. Because though he did not voice his feelings, they were there in the room and no doubt she felt them, especially as they aligned with what she and any of us who do not fall within the range deemed attractive experience every day.

What is this issue with the body about? Let’s look at the body as shadow.

Jung, in Collected Works,Vol. 18: The Symbolic Life wrote:

We do not like to look at the shadow-side of ourselves; therefore there are many people in civilized society who have lost their shadow altogether, have lost the third dimension, and with it they have usually lost the body. The body is a most doubtful friend because it produces things we do not like: there are too many things about the personification of this shadow of the ego. Sometimes it forms the skeleton in the cupboard, and everybody naturally wants to get rid of such a thing.”

Jung sees body as shadow, avoided because it inevitably brings into the room those aspects of life we most wish to avoid — death, aging, desire, greed, excess. Certainly the female body, and especially the fat female body carries this shadow and inevitably activates in both patient and therapist all of the anxieties attendant upon these shut off aspects of life.

One more look at this trap of attractiveness from a Jungian analyst, Polly Young-Eisendrath:

From the Pandora story we can see that identifying with this “power”[of beauty] is a double bind – you’re damned if you do and damned if you don’t. If you identify with the image of female beauty, you put yourself into the Pandora box: beautiful but empty. Increasingly as a woman ages, she finds that identification with a beautiful appearance is a losing game. She will lose the game through aging when she no longer looks like Pandora, a “maiden” – youthful, slender, lovely. To identify with a beautiful appearance and to pursue that power leads to depreciation of her other strengths and ultimately to depression about falling short of standards. To disidentify with the power of appearance (and “let herself go”) usually leads to feeling like an outsider, feelings of low self-confidence, and fears of failing to find a heterosexual partner or to be the object of a certain kind of male regard.”

Damned if we do and damned if we don’t, where do we go from here? That’s for the next in this series, where we will look at the story of Sir Gawain and Lady Ragnell. Look for it on Wednesday.

Sleeping Beauty’s Mother

I am reposting this piece today because I have seen here and there renewed efforts to focus on children’s weight and controlling it. I think often  about Sleeping Beauty’s mother. Most of us are like Sleeping Beauty’s mother, eager to do whatever we can to spare our children difficulties.

 

You see that beautiful little girl in that photo? She was 5 years old there. I was delighted beyond measure when she was born. I always wanted a daughter, in part I’m sure to redeem my experience with my mother. To me she was and is the most wonderful daughter ever — smart, funny, and beautiful — everything I could hope for. 

But like Sleeping Beauty’s mother, we always fail in one way or another. Remember how it happened that the curse came to be in that fairy tale family? When the long desired child, a daughter, was born to the king and queen, they planned a great celebration. According to which version you read, they invited 7 or 12 fairies to the great feast. And whichever version, that is where the problem begins because one fairy is left out and she appears just as each fairy offers her gift to the child. She is angry at being neglected and acts out her anger by giving a curse, namely that on her 16th birthday, the girl would prick her finger on a spindle and die. The last fairy cannot undo the curse but she can mitigate it so that instead of dying, she and all the kingdom would fall into deep sleep for 100 years until a prince would come and kiss her awake. 

All The Spindles

Remember all the efforts Sleeping Beauty’s parents made to keep her from the curse placed on her at birth, that she would prick her finger on a spindle?They searched high and low determined to find and eliminate all the spindles and thus stave off the curse.

Well, knowing my body and how like the Fuller women I am, I was afraid that my daughter faced the curse of having to battle her weight all of her life. And I was determined to do anything and everything I could to protect her from it.  

Our concern here is not with interpreting the fairy tale; that has been done by many. Our concern is with the mother and all the efforts she made to keep her daughter from ever encountering a spindle and thus staving off the curse.  Such a frantic wish to protect her child.

Fate 

But the Moirae* could not be escaped no matter how vigilant she was or how hard she tried. When she was 16, the princess happened upon a woman who was spinning and asked what she was doing. She asked for the spindle and as soon as she took it into her hand, she pricked her finger — and well, you know the rest.

The mother failed in her effort. And even more, the curse happened at least in part because of the lack of a place setting for the dinner or enough goody bags, depending on the version. A careless error of omission that opened the way for this curse to come to pass.

 

I have been thinking about this a lot lately. How often we fail to be able to protect our children from whatever curse it is we fear. No matter how hard we try, there will always be one spindle. And perhaps the seeds of the whole problem lie in our frantic desire to keep our children from pain such that in the process, we fail to teach them things they really need to know. I was as much enthrall to the desirability of slenderness as anyone and so in a way my efforts led to exactly what I least desired.

I read and I talked with everyone I could think of who might be able to help me. I breastfed her for all of her first year, because it seemed breastfed babies were less likely to become fat. I held off introducing solids until she was almost 7 months old, because it was thought that early introduction of cereal predisposed to obesity. I made all of her baby food so that I knew there was no hidden sugar or modified starch. I was vigilant about what I and my husband ate, so that we were modeling healthy eating. I struggled to overcome my shame about my body so that I wouldn’t communicate that to her — I worked my ass off to get comfortable talking about my body, answering questions about it, getting comfortable in my skin.  

And it seemed to work. Until she was around 11 she was slender and I thought maybe we had escaped the curse. No matter how vigilant I was or how hard I tried, I hadn’t reckoned with genetics and puberty. She began to gain weight. She started menstruating when she was not quite 12 and it seems that it signaled the pricking of her finger on that spindle I had tried so desperately to get rid of. She became plump, with the same rounded body I have. Initially I was in despair because I had done absolutely everything right, everything that was supposed to stave off the curse. We didn’t overeat, eat junk food or any of the other “bad” things. We walked and did things together. She walked to school every day and played field hockey. None of it kept her slender.  

My heart broke for her as she struggled with it all. We talked about bodies, about doing everything possible to be healthy, that people come in all sizes. Her doctor and I determined that it was important for her to focus on being active and healthy, not dieting because she was at risk of developing an eating disorder, like several other girls in her class had.  

It was like walking through a field of land mines every day. I wanted someone, anyone to wave a wand and let her have the body she wanted. I felt guilty, that somehow I was responsible for her weight, for having passed along this terribly difficult problem to her. I worked  with renewed vigor on my own body issues. But none of it could change things. And I had to forgive her for not having escaped and myself for not having been able to save her.  

She is 43 now. She is not thin, but she has settled into an adult weight less than mine. She is active and healthy. She has been able to keep her weight fairly stable by concentrating on being healthy. She is largely free of the self-loathing I was still struggling with when I was her age. 

I read here and there and everywhere that if we get children to eat healthily, avoid junk food, and exercise, we can prevent obesity, and I think of my beautiful daughter. If they only knew how hard it is to eliminate all the spindles in the kingdom. 

* In Greek mythology, the Moirai are the Fates

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?

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.

The Fruitless Quest

But who, if it comes to that, has fully realized that history is not contained in thick books but lives in our very blood? So long as a woman lives the life of the past she can never come into conflict with history. But no sooner does she begin to deviate, however slightly, from a cultural trend that has dominated the past than she encounters the full weight of historical inertia, and this unexpected shock may injure her, perhaps fatally. C.G. Jung1

There is a lot that Jung wrote about women that we might disagree with —I know I do. But I think he hits something important here. Think about what has happened to women who deviated from the course of things and choose to run for President. All have encountered exactly what Jung says above: But no sooner does she begin to deviate, however slightly, from a cultural trend that has dominated the past than she encounters the full weight of historical inertia.

Deviating from the cultural norm gets one tagged as pathological. In the West it is no longer the case that a woman is expected to eschew ambition and stay at home raising children and caring for the home. Though a considerable portion of people in the US still subscribe to the notion that a woman’s place is in the house, but not the House, it cannot be denied that our horizons are wider than they once were, wider even than when I was a young woman. But it is still expected that a woman conform to the image of ideal femininity, that is be slender and visually appealing, mostly to men.

If Thine Eye Offend Thee

Few of us realize that we do not see unmodified images of people, especially of women, in magazines, film, or television.  The images of those we see as ideals, as possessing the looks we should aspire to are not real. We do not see those woman as we would see them were we to encounter them in the supermarket or on the street. 

…it is the photographic image— both the moving image on TV and film and the still photograph— that has created the new visual grammar. Its effects should not be underestimated. They are changing the way we relate to our bodies. John Berger’s prescient statement that (bourgeois) women watch themselves being looked at has been transmuted into women assuming the gaze of the observer, looking at themselves from the outside and finding that they continually fail to meet the expectations our pervasive and persuasive visual culture demands.2

We are bombarded with altered images, thousands per week — images that convey an idea of a body which does not exist in the real world.  Cosmetic surgery as a means to attain this non-existent ideal has flourished in this environment. Cosmetic surgery as a consumer option is becoming normalized. In some communities women casually discuss, even compete over the procedures they will have. To not get one’s eyelids “done” or have Botox injections to smooth wrinkles, to not alter themselves is taken as a sign of self-neglect.

The surgeon, both authoritative and solicitous, becomes the arbiter on female beauty. As he acknowledges the pain his patients feel, he demonstrates how he can change different aspects of their body for them, enabling them to reach the beauty standard he has himself set. In his engagement with them, he gives them the body they could never imagine they would have. He is confident and persuasive. He responds to their wish with gravity but also as though they were choosing their dream holiday.2

The beauty industry and the diet industry reap profits in the billions of dollars each year as women pursue the hopeless quest of achieving the perfection of the images placed in front of us thousands of time each week, of sleek flawless bodies which seem never to age. It is also worth noting that 90% of cosmetic surgeons, the “arbiter[s] on female beauty”, are male and 90% of patients seeking such surgery are female.

The Wrong Body 

What does it mean when a person says she is in the wrong body?  We hear this most in an indirect way when any of the legions of women unhappy with their weight go on diet after diet in a largely fruitless quest to release the thin woman they believe lives inside them, a thin woman trapped in the wrong body. What does that mean? The effort to find “the right body” leads to all manner of surgical solutions, ranging from the cosmetic procedures to removal of most of the stomach in order to lose weight. In other words, the quest for the right body easily leads to mutilation of the existing body. Though little noted, bariatric surgery has an unexpected consequence of significantly elevated risk of suicide post-operatively. Among patients who have undergone bariatric surgery, the suicide rate is 6-7 times higher for people who have had the surgery than those who did not.3 Suicide risk in this group, people desperate to obtain and inhabit “the right body”, suggests that in at least a significant percentage of them, the body itself is not the problem. But in a society that finds efforts to pursue perfection through surgery acceptable if not admirable, there is little critical examination of what taking that pursuit to such dramatic lengths means nor of the inherent danger of the entire notion of the perfect body.

…the very problems the style industries diagnose are the same ones the beauty industry purports to fix. They are handmaidens in the process of deconstructing and reconstructing our bodies. And the purported fixes are offered as solutions which we can’t help but wish to take advantage of. The solutions entice us. We do not see ourselves as victims of an industry bent on exploiting us. In fact we are excited to engage with and reframe the problem: there is something wrong with me that with effort exercise, cash and vigilance— I can repair. I can make my offending body part( s) right.1

1.Jung, C.G., (1964). ‘Woman in Europe’. CW10, p. 130

2. Orbach, Susie. Bodies (BIG IDEAS//small books)

3. Castaneda, D., Popov, V.B., Wander, P. et al. Risk of Suicide and Self-harm Is Increased After Bariatric Surgery—a Systematic Review and Meta-analysis. OBES SURG 29, 322–333 (2019).

 The image above is a reproduction of a sculpture found in an alcove in an underground temple on the Island of Malta, dating back approximately 6,000 years ago.

Fat: Guidelines for Therapists

A note on nomenclature: I deliberately use the term “fat” not “obese”. In groups of people who have been marginalised on the basis of race or sexual orientation, an important part of claiming agency is declaring the right to choose what members call themselves. Similarly it is the practice in the fat community to reclaim the term “fat” from the pool of epithets directed against us, as segments of the gay community have reclaimed “queer”. Therefore in what follows, I use “fat” rather than “obese” except when quoting or referring to research reports.

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. 

From the APA Monitor:

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–such as BBW Magazine–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.

From NAAFA:

Next, NAAFA(National Association to Advance Fat Acceptance ) has updated its guidelines for therapists. 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. The following stereotypes are common perceptions that should be challenged.

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.

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?