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.”  

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.