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?