Really? Whatever Comes To Mind?

I have posted before about secrets in therapy and every time I have, questions arise. Often people conflate privacy with secrets. So today let’s revisit this somewhat difficult issue.

Privacy vs Secrecy

Privacy is the state of being unobserved; changing clothes for example — that which I keep private, I am merely withholding from public view. Private matters are those traits, truths, beliefs, and ideas about ourselves that we keep to ourselves. They might include our fantasies and daydreams, feelings about the way the world works, and spiritual beliefs. Private matters, when revealed either accidentally or purposefully, give another person some insight into the revealer.

Secrecy is the act of keeping things hidden — that which is secret goes beyond merely private into hidden. While secrecy spills  into privacy, not all privacy is secrecy. Secrecy stems from deliberately keeping something from others out of a fear. Secrets consist of information that has potentially negative impact on someone else-emotionally, physically, or financially. The keeper of secrets believes that if they are revealed either accidentally or purposefully,  the revelation may cause  harm to the secret-keeper and those around him or her.

So that which is secret often contains an element of shame that private does not. We may keep something private for all kinds of reasons, but most of the time, we keep something secret out of fear and shame of what others would think if they knew. We keep something secret because we believe the cost of telling is so high that it’s virtually not a choice at all. Privacy is voluntary; secrecy is not.

Private: I got terrible grades in high school.

Secret: I forged my degree.

Keeping something private is an act of choosing boundaries and staying comfortably within them.

Keeping something secret is an act of hiding from the pain of disclosing something shameful.

This difference centering around the feelings about the information which is withheld is the principle factor in the difference between what is held private and that which is secret. It is this element of shame or fear attached to the secret that makes it different from something private.

Secrets, like an affair or a gambling problem or some misdeed or money problems — the kind of thing we lie awake and worry about, worry about others discovering — are often a big part of what brings people into therapy and what patients find most difficult to talk about. Shame and fear of judgment fill the room. The carefully cultivated image of respectability or responsibility or moral superiority will surely shatter into a thousand pieces the moment anyone, even the trusted therapist, finds out what is concealed beneath the facade. Each patient with such a secret imagines herself to be alone in the world, unlike and apart from all the rest of humanity, unable to imagine that the therapist has heard similar tales many times before. 

When we carry secrets like this, they become barriers between us and everyone in our lives, cutting us off from real intimacy. Anything which threatens to reveal what we seek so to hide becomes a source of anxiety and must be avoided. Maintaining the facade, the persona which covers the shame of the secret becomes paramount. In Japan I am told there is a saying that first the man takes a drink, then the drink takes a drink then the drink takes the man. The same is true of secrets as the secret comes to own the life of the person carrying it.

Secrets in therapy

Psychotherapy, like the confessional, offers a unique opportunity to break the secret and its hold on the life of the carrier. First comes the mustering of courage to say it, to tell the therapist what has been held in shame, to brave the condemnation and the rejection, the fear of which maintains the grip of the secret. And once spoken, then the work of discerning the meaning of the secret and opening to the shadow. 

I hear from people about things they are afraid to discuss with their therapists, secrets they carry and feel shame about. I know how hard it is to open up the dark corners of our lives and let another see in. It feels like a huge risk. But what is the point of being in therapy if, at some point, the secret is not told? If it remains untold and unexplored, the therapy in a very real sense is a lie because it never gets to the truth of the patients life and feelings. So we say to patients that they should say whatever comes to mind and mean to include the secrets as well.

Here are some of Jung’s thoughts, all taken from Vol. 16, pp.55-60:

Anything concealed is a secret. The possession of secrets acts like a psychic poison that alienates their possessor from the community.

All personal secrets … have the effect of sin or guilt, whether or not they are, from the standpoint of popular morality, wrongful secrets.

…if this rediscovery of my wholeness remains private, it will only restore the earlier conditions from which the neurosis, i.e. the split off complex,  sprang.

All of us are somehow divided by our secrets but instead of  seeking to cross the gulf on the firm bridge of confession, we choose the treacherous makeshift of opinion and illusion.

Jung here underlines the corrosive effect secrets have because there is no way, so long as the secret is held, for its bearer to know that she is not worse than everyone else, that the secret does not make him unlovable. The revelation of the secret within the container of a secure psychotherapy relationship begins the  cleansing effect of exposing it.

Those things which a person decides to hold private, even in therapy, may in fact be secrets rather than merely private matters. Because if there is no shame attached, then why the need for keeping such a thing outside of the secure container of therapy? 

It is by no means easy to let go of our secrets, whether we feel,  that do so would be rude or because we fear being judged or rejected or abandoned. It is hard work and takes time. But it is important to keep at it.

Saying whatever comes to mind is a goal and one it takes work to reach. An important part of that work is exploring the difficulty we have in getting there.

Let’s Talk about Dreams

This painting by Edward Robert Hughes makes me think of the oddness of dream images. And so today I want to start to talk about dreams.

A few years ago I found  Yorem Kaufman’s The Way of the Image. It is a lovely little book of essays about dreams, images and therapy. The first 2 essays, “The Way of the Image Part 1” and part 2 are about his way of looking at dreams and about how he works with dreams in therapy, an actual technique essay, something a bit uncommon in Jungian writing.Then in the 3rd essay he writes about the analyst as he or she appears in dreams. These three essays are rich and deeply rewarding for anyone seriously interested in dreams and working with them. 

A few juicy bits from Kaufman:

“Everything that has ever been created was preceded by an image— streets, a blender, theory of relativity. Thus, we have the power of images for immense good or horrible destruction. All the history of mankind is, in essence, the unfolding of a series of images.”*

“…every individual has within themselves a unique set of images peculiarly their own. They speak ultimately to them. Although such images may be shared with others, and those others may be affected, they will not be affected equally, and they will not share in the transformative energy to the same degree. It is both the science and art of analysis to find this unique imaginal language for every analysand.”*

“I am saying that the images that an analysand brings to the analysis, in whatever form, be it dreams, his behavior, body language, etc., contain, in addition to whatever psychic messages that they bring, also a set of instructions to the analyst as to what is the best, and sometimes the only, way to conduct the analysis. Contrary to what may have emerged at the dawn of the psychoanalytic movement, there is no single technique that would be suitable for every analysand. It has been a source of continuous astonishment and awe for me that in more than 30 years of practice, I have found that I work with every analysand in different ways.”*

Over the next little while I’ll write the essays and add my thoughts. If you have a Kindle Unlimited account, this lovely book is available free. I hope some of you will read along with me and that we can talk about the book together. 

If you don’t record your dreams, consider starting. Keep paper and a pencil or pen by your bedside and as soon as you awaken, write whatever dream or bits of dream you can capture. 

 

*Kaufmann, Yoram  (2009-07-16). The Way of the Image  Zahav Books Inc.. Kindle Edition.

Mistakes

“People do not grow in sterile containers with perfect analysts; they grow in messy human relationships with analysts who try their best to do right by their patients  but whose best must frequently consist of reparative efforts vis-á-vis the difficulties they have created.”

Therapists make mistakes. I make mistakes. How do we recover from the mistakes that we make? We recover by recognizing that of course we make mistakes because we are human and it is how we learn. I have been in this work for more than 40  years and I still make mistakes — different ones, but mistakes nonetheless. 

We must start with accepting the patient’s feelings of hurt or anger or other feelings affected by our error. Which means at least initially not trying to get the patient to understand or accept an explanation of our good intentions— we have to avoid yielding to the very human effort to defend and explain. When we do that — try to explain — it is  really for the therapist, an attempt to soothe ourselves and to see ourself again in a positive light. 

 Initially I need to be able to simply accept that I made a mistake, be willing to own that mistake. Optimally the relationship is solid enough that my mistake does not end it and we have the opportunity to work through it, to look at what happened and why and how it came to be experienced painfully. 

Sometimes the therapist’s mistake breaks the relationship. What do we do then? Well, we have to sit with it, reflect on what happened to see what we can learn from it. Maybe got some supervision to see if looking at the situation with another pair of eyes illuminates it for us. We learn what we can from it and let the patient go. Pursuing trying to get her to hear the explanation starts to be its own problem.  

A wise supervisor once told me that we fail our patients in exactly the way they need to be failed and the trick is to be able to work through that. And he was right. Years ago I had a new patient come to me after having fired two previous therapists — one who fell asleep in a session with him and another he found unsympathetic. So I knew I started on thin ice, that he was looking for me to fail him also. One day he called and left me a message that he had to reschedule. I called back and left a message saying only my name and a time he could reach me. He got furious and said I had violated confidentiality by leaving the message so his roommate could hear. Now I knew I had left no indicator of who I was or why I was calling, but it didn’t matter because *for him* I failed. No amount of reasoning mattered. So we failed to work it through. I did learn to check with new patients about whether or not it was all right to leave a message if I had to get in touch by phone. And these days with the ubiquity of mobile phones, the chances that a message I might leave will be heard by someone other than the intended recipient is pretty small.

Sometimes with the best intentions, like Humpty Dumpty, all the king’s horses and all the king’s men cannot put the therapy back again.

It is hard to let go but what I want for a patient may not be what is best for her in her eyes — and those are the eyes that count. If she came back, I would be able to feel good, vindicated in some way — and sometimes patients do come back– but at the time, I have to live with the blow to my pride and my sense of my professional self. It is in these humbling experiences where we learn most. 

What would I do?

Like many of you the tensions surrounding the election and the renewed intensity of the pandemic sapped my creative energies for a while. So for the past couple of weeks I have been reading, knitting and watching Netflix to take care of myself. I hope that you have also been tending to your needs.

Today I woke up and I feel ready to write again. So here goes as I consider what to do when a patient presents a really thorny issue that might reach into  the territory of a moral dilemma.

A while back, someone asked me how a psychotherapist deals with the situation in which something the patient has come to understand she would really like to do to improve or change her life is likely to cause suffering to someone in that patient’s life? Situations like this are not uncommon, as for example someone wants to divorce her husband, an action which will doubtless cause upheaval and pain for all involved.  

But this questions contains, I believe, a misperception about what therapy is about and what the role of the therapist is.  

A new patient comes to me. I gather a bit of basic data and then ask her to tell me why she is here, to tell the story in whatever way makes sense for her. I listen. Very rarely is what I hear framed as a moral dilemma. I ask and ask many times during the time we work together “What is the life you want?”, because this is a pivotal issue. And as she frame possible actions, I ask if that action will take her closer to the life she wants. And we do that process again and again. I don’t tell anyone what to do. I am not really a problem solver.  

I deal with what is the life the person wants, what keeps them from having that life, and how/if it can be achieved and what the cost of achieving it might be. In my years of practice, to the best of my knowledge, I have never seen a pedophile or rapist or person who engages in behavior that I think is beyond the pale — those people don’t come in for therapy, at least not to me. Once I saw a person who might have been a murderer. I checked with colleagues and the appropriate state agency to see what my responsibility was to him and to the community. I saw him 3 times and discharged him to a more appropriate facility. That was a professional decision not a moral one.  

So how do psychotherapists navigate these waters?  

I don’t give answers when asked what people should do. I can help them look at why they want to do it and what the consequences are and whether it will get them what they want. But I do not make the decision.  

In two sets of conditions, I am bound to act on what I hear. If I am told by someone that they abuse someone or are abused, in most states, I am mandated to report the abuse. If someone threatens the life of another, case law says I must inform the authorities, but statute does not — so I consult and then report or not. Otherwise, my task is to listen.  

I am not Dr. Phil. I am not a priest. It is VERY hard sometimes not to try to tell people what to do. Because the work I do is not short term and because I usually work with people over the course of months, and  years, we have time to sort through issues, to examine them from as many sides as possible. And ultimately what they do is up to them. 

“The principle aim of psychotherapy is not to transport one to an impossible state of happiness, but to help (the client) acquire steadfastness and patience in the face of suffering. “
-C.G. Jung

Be Still My Heart

What was rumored a few weeks ago is becoming a reality — In Treatment Season 4! Uzo Aduba (Emmy® winner for “Mrs. America” and “Orange is the New Black”) will play the lead role of the therapist at the center of the season, Dr. Brooke Lawrence.

Back in 2008 when the series first ran and this site was new, I became a big fan and wrote about each episode as it ran. You can find these posts still by selecting In Treatment above and choosing the season you wish to read about. If you haven’t seen this series, I urge you to do so — it is available on DVD and if you subscribe to HBO Max, is available there. And of course, do read my posts and ask questions and comment — more discussion is welcome.

In my mind, this is the best dramatic presentation of therapy I have seen. Of course the therapy is compacted and made more dramatic for purposes of the drama. But still, it is faithful to the basics.

In sadder news, Daniel Menaker, who wrote my favorite novel about psychoanalysis (this is a genre, you ask??), died this week. His book,The Treatment, which was also made into a movie, is based on his own analysis. The book is funny and moving and well worth the read.

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.

A bit more on therapy

“Exchanging words is the essence of psychotherapy.” Nor Hall

I met with someone new the other day. When I meet with a new patient, I always have a slight anxiety before starting with this new person — anxiety and also anticipation Will we “click”? What new doors will open through this person and our work — because this process changes both of us, though not to the same degree. So there is that tingle of the new and unknown as I answer the door or the Zoom window as we do today. And then, once in my office, whether in person or on the screen via Zoom, Skype or FaceTime, we sit down and I ask, as I always do, “What brings you here today?” and we begin.

It is a curious process, therapy is. I have no visible tools. No questionnaires. No workbooks. No pills or potions. I do have a magic wand, though it is only for effect and rarely brought out. I bring with me 40+ years of sitting and listening in the same way plus my own life experience and analysis and a lot of reading. The journey is never the same with any two people. Which is why I never get tired of it, never weary of starting again with “What brings you here today”.

When psychotherapy works, it is not magic. For me, the experience of seeing therapy work though is like a miracle. I go about my business, and I know how to attend to my work. I observe. I listen. I take in. I accept the person as he or she chooses to present in my office, with as little or as much as they disclose. I attempt to the best of my ability to bracket my own issues and unfinished business, my own insecurities, trusting myself to the moment and the occasion of our meeting.

Then, I describe what I am observing and experiencing in the presence of this unique person who has come for help. It is to me a signal of transcendence that that simple process can change things.

Freud wrote,

“Nothing takes place between them except that they talk to each other. The analyst makes use of no instruments— not even for examining the patient—nor does he prescribe any medicines. If it is at all possible, he even leaves the patient in his environment and in his usual mode of life during the treatment…The analyst agrees upon a fixed regular hour with the patient, gets him to talk, listens to him, talks to him in his turn and gets him to listen… It is as though he were thinking: ‘Nothing more than that?… ‘So it is a kind of magic,’ he comments: ‘you talk,and blow away his ailments.’ Quite true. It would be magic if it worked rather quicker. An essential attribute of a magician is speed—one might say suddenness—of success. But analytic treatments take months and even years: magic that is so slow loses its miraculous character.”

~~~~~~~~~~~~

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.