Reading an article by Jane Brody (2017) in the New York Times, "Fat Bias Starts Early and takes a Serious Toll," prompted me to write my own version.

Some people have no compunction about  saying that they hate fat people, and it starts early on in life, making overweight children the target of bullying. These children tend to internalize the stigma, resulting in a diminished sense of self-esteem, depression, and trauma, leading them to eat more and more for the fleeting sense of comfort it provides. Yes, food is for some people what drugs and alcohol are for others, a form of self-medication.

Dr. Scott Kahan, director of the National Center for Weight And Wellness said, "Obesity has been called the last socially acceptable form of prejudice, and persons with obesity are considered acceptable targets of stigma." He said that this bias against weight occurs even in people who are otherwise fair-minded and non-judgmental.

I specialize in the treatment of patients with eating disorders and am accustomed to seeing very thin, even emaciated, and morbidly obese individuals but when a new patient came to see me, it was difficult for me not to stare. She was around 5'3'' and weighed 420-plus pounds. It took a number of weeks to stop feeling overwhelmed by the sight of her. I had never seen anyone so obese up close. I was not repelled but fascinated, just as I was when I met my first anorectic patient, a 67-year-old woman.

Shocked by her appearance, I tried not to stare at her hard bony frame, which she wore on the outside, like an insect. There was virtually no flesh, only a tight, almost transparent membrane of skin encasing her skeletal structure. She was 5' 3 1/2" and her weight had been stabilized at eighty two  pounds for three years; her lowest weight had been sixty one  pounds at the age of  thirty (Farber 2015, pp. 58-59).   

As we began working together I was able to tell my very fat patient how stunned I felt when we first met. Because I was able to struggle with and acknowledge the feelings seeing her aroused in me, it opened the door to being able to talk about this together and made our relationship closer. In our first meeting, after telling me of her history around eating and weight, she told me that when she was around three, her father left, never to return. He often failed to show up for a visit and showed little interest in her. I picked up a book and showed her the cover: Father Hunger. Immediately she began to sob and she began to tell me of how insignificant he made her feel, opening up a lifetime of pain. It was her father she hungered for, not the food that became such a poor substitute.

When acclaimed psychiatrist and psychoanalyst Irvin Yalom (1989) met a new patient who was obese, he was repelled, and wrote about it in detail in a wonderful chapter called "Fat Lady" in  his book Love's Executioner.

Every profession has within it a realm of possibility wherein the practioner may seek perfection. For the psychotherapist that realm . . .is referred to in the trade as countertransference. Where transference refers to feelings that the patient erroneously attaches ("transfers") to the therapist but that in fact originated out of earlier relationships, countertransference is the reverse--similar irrational feelings the therapist has toward the patient. Sometimes countertransference is dramatic and makes deep therapy impossible: imagine a Jew treating a Nazi or a woman who has once been sexually assaulted treating a rapist. But in milder form, countertransference insinuates itself into every course of psychotherapy.

The day Betty entered my office, the instant I saw her steering her ponderous two-hundred fifty-pound, five-foot-two-inch frame toward my trim high-tech office chair, I knew that a great deal of counter-transference was in store for me.

I have always been repelled by fat women. I find them repulsive: 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. How dare they impose that body on the rest of us?

The origins of these sorry feelings? I had never thought to inquire. So deep so they run that I never considered them prejudice. But were an explanation demanded of me, I suppose I could point to the family of fat, controlling women , including-- featuring-- my mother, who peopled my early life. Obesity, endemic in my family, was a part of what I had to leave behind when I, a driven, ambitious, first-generation American-born, decided to shake forever from my feet the dust of the Russian shtetl.

I can take other guesses. I have always admired . . . the woman's body. No, not just admired: I have elevated, idealized, ecstaticized it to a level and a goal that exceeds all reason. Di I rent the fat woman for her desecration of my desire, for bloating and profaning each lovely feature that I cherish? For stripping away my sweet illusion and revealing its base of flesh-- flesh on the rampage?

I grew up in racially segregated Washington, D.C.., the only son of the only white family in the midst of a black neighborhood. In the streets, the blacks attacked me for my whiteness, and in school, the white attacked me for my Jewishness. But there was always fatness, the fat kids, the big asses, the butts of jokes, those last chosen for athletic teams, those unable to run the circle of the athletic track. I needed someone to hate, too. Maybe this is where it began.

Of course, I am not alone in my bias. Cultural reinforcement is everywhere. Who ever has a kind word for the fat lady? But my contempt surpasses all cultural norms. Early in my career, I worked in a maximum security prison where the least heinous offense committed by any of my patients was a simple, single murder. Yet I had little difficulty accepting these patients, attempting to understand them, and finding ways to be supportive.

But when I see a fat lady, I move down a couple of rungs on the ladder of human understanding. I want to tear the food away. "Stop stuffing yourself! Haven't you had enough, for Chrissakes?" I'd like to wire her jaws shut.

Poor Betty-- thank God, thank God-- knew none of this as she innocently continued her course toward my chair, slowly lowered her body, arranged her folds and, with her feet not quite reaching the floor, looked up at me expectantly (pp. 107-109).

She was 27, single and worked for a New York-based retail chain which had transferred her to California for 18 months to assist in opening a new franchise. Her New York therapist had referred her to Dr. Yalom. She'd always been overweight but became obese in adolescence. Aside for a few yo-yo weight losses followed by weight gains, her weight hovered between 200 and 250 since she was 21. Yalom asked what it that brought her there. "Everything," she said. She had no life, no friends, no social life, nothing to do in California. Her life consisted in working and eating and counting the days until she could return to New York. She was depressed and the anti-depressant prescribed for her did not help. She cried every evening wished she were dead. On her day off she spent the day eating in front of the television.

"My eating is out of control," Betty said, chuckling, and added, "You could say my eating is always out-of-control, but now it is really out of control. I've gained 20 pounds in the past three months, and I can't get into most of my clothes" (p. 110). She said her blood pressure was very high, talking

as though she and I were college sophomores swapping stories . . . She tried to poke me into joining the fun. She told jokes. . . . She must have laughed twenty times during the session, her high spirits apparently in no way dampened by my stern refusal to be coerced into laughing with her.

I always take very seriously the business of entering into a treatment contract with a patient. Once I accept someone for treatment, I commit myself to stand by that person: to spend all the time and all the energy that proves necessary for the patient's improvement, and most of all, to relate to the patient in an intimate, authentic manner.

But could I relate to Betty? It  was an effort for me to locate her face, so layered and swathed in flesh as it was. Her silly commentary was equally offputting. By the end of our first hour, I felt irritated and bored. Could I be intimate with her? I could scarcely think of a single person with whom I less wished to be intimate. But this was my problem, not Betty's. It was time, after twenty-five years of practice, for me to change. Betty represented the ultimate countertransference challenge-- and for that very reason, I offered then and there to be her therapist. . . .

It's the relationship that heals, the relationship that heals, the relationship that heals -- my professional rosary. How was I going to be able to be able to heal Betty through our relationship? How authentic, empathic, or accepting could I be? How honest? How would I respond when She asked about my feelings toward her? It was my hope that I would change as I Betty and I progressed in her (our) therapy. . .

I had secretly hoped that her appearance would be offset in some way by her interpersonal characteristics-- that is, by the sheer vivacity or mental agility I have found in a few fat women-- but that, alas, was not to be. The better I knew her, the less interesting she seemed. . .

She resisted every attempt on my part to dip beneath the surface. . .

 Every one of my notes of these early sessions contains phrases such as "Another boring session", "Looked at the clock about every three minutes today". . .almost fell asleep today."(pp. 111-113).

Betty had revealed that her New York therapist often fell asleep during her sessions. Yalom knew he had to confront her with the fact that she was boring, but how?

I dared not utter the word boring--far too vague and hurtful. I asked myself what, exactly, was boring about Betty, and identified two obvious characteristics. First of all, she never revealed anything intimate about herself. Second, there was her damned giggling, her forced gaiety, her reluctance to be appropriately serious.

. . . . I decided to start with her lack of self-revelation and, toward the end of a particularly soporific session, took the plunge.

"Betty, I'll explain later why I'm asking you this, but I'd like you to try something new today. Would you give yourself a score from one to ten on how much revealing about yourself you've done during our hour together today? Consider ten to be the most significant revealing you can imagine and one to be the type of revealing you might do, let's say, with strangers on a line at the movies."

A mistake. Betty spent several minutes explaining why she wouldn't go to the movies alone. She imagined people pitied her for having no friends. She sensed their dread that she might crowd them by sitting next to them. She saw the curiosity . . . as they watched  to see whether she could squeeze into a single narrow movie seat.  When she began to digress further-- extending the discussion to airline seats and how seated passengers' faces grew white with fear when she started down the aisle searching for her seat-- I interrupted her, repeated my request, and define "one" as casual conversation at work.

Betty responded by giving herself a "ten." I was astonished (I had expected a "two" or "three) and told her so. She defended her rating on the basis  that she had told me things she had never shared before. . .

We repeated that same scenario several times. Betty insisted she was taking huge risks, yet, as I said to her, "Betty, you rate yourself "ten", yet it didn't feel that way to me. . . .

"I have never told anybody these things. . . .

"How do you feel about telling me these things?'

"I feel fine doing it."

"Can you use other words than fine? It must be scary or liberating to say these things for the first time!"

"I feel O.K. doing it. . . .  It's O.K. I feel O.K. I don't know what you want."

. . .  What did I want from her? From her standpoint she was revealing much. What was there about her revealing that left me unmoved? It struck me that she was incapable, or unwilling, to reveal herself in the immediate present that we two were sharing. Hence, her evasive response of "O.K." or "Fine" whenever I asked about her here-and-now feelings.

. . . . I'm really interested in what you said about being, or rather pretending to be jolly. I think you are determine . . . to be jolly with me."

"Hmmm, interesting theory, Dr. Watson."

"you've done this since our first meeting. You tell me about a life that is full of despair, but you do it in a bouncy 'aren't we-having-a-good-time?' way."

"That's the way I am."

"When you stay jolly like that, I lose sight of how much pain you're having."

"That's better than wallowing in it."

"But you come here for help. Why is it so necessary for you to entertain me?"

Betty flushed. She seemed staggered by my confrontation and retreated by sinking into her body. Wiping her brow. . ., she stalled for time.

"Zee suspect takes zee fifth."

"Betty, I'm going to be persistent today. What would happen if you stopped trying to entertain me?"

"I don't see anything wrong with having some fun.  . . . You're always so serious.. . . " ( pp. 116-119).

Yalom told her she knows exactly what he meant, that this is the most important material they've gotten to so far. He said he wanted, in future sessions, to interrupt her and point out when she's entertaining him. Reluctantly, she agreed and within three or four sessions, the entertaining stopped as she began to speak about her life seriously, reflecting that she had to be entertaining to keep others interested in her. She had become the stereotype of the jolly fat woman because she did not know how else to be Without it, she would feel empty She used the word empty more and more, the way many people who eat compulsively do, so that they can feel full. But her emptiness was emotional, not physical.

Now I pointed out to Betty, she was taking risks, Now she was up to eight or nine on the revealing scale. Could she feel the difference? She got the point quickly. She said she felt frightened . . .

I was less bored now. I looked at the clock less frequently and once in a while checked the time . . to see whether sufficient time remained to open up a new issue.

Nor was it necessary to sweep from my mind derogatory thoughts about her appearance. I no longer noticed her body and instead, looked into her eyes. In fact, I noted with surprise the first stirrings of empathy within me. When Betty told me about going to a western bar where two rednecks sidled up behind her and mocked her by mooing like a cow, I felt outraged for her and told her so.

My new feelings for Betty caused me to recall, and to be ashamed of, my initial response to her. I cringed when I reflected on all the other obese women whom I had related to in an intolerant fashion.

These changes all signified that we were making progress: we were successfully addressing Betty's isolation and her hunger for closeness (pp. 119-120).

As Betty became more and more engaged in this process of change, she became anxious that she would become too dependent on her therapist. Her sessions had become the most important thing in her life. She enrolled in an eating disorder clinic, lost and kept off a great deal of weight. At Yalom's suggestion, she joined a therapy group and was astonished to hear a man there say he's always been fond of fat women. Betty found she was getting positive attention from men, which made her anxious because, despite having an active fantasy life,  she had never had any physical contact with a man.

When her assignment in California was ending, her last three sessions dealt with her distress about their impending separation. What she had initially feared happened; She let herself feel deeply about Yalom. He told her that he too will miss their meetings, that he was changed as a result of knowing her. Upon hearing this, she looked up expectantly. She asked him how he changed. He blundered around, finally saying that his attitude about obesity changed a lot, that he hadn't felt comfortable with obese people.

In unusually feisty terms, Betty interrupted me. "Ho! ho! ho! Didn't feel comfortable--that's putting it mildly. Do you know that for the first six months you hardly ever looked at me? And in a whole year and a half you've never--not once--touched me? Not even for a handshake!"

My heart sank My God, she's right! I have never touched her. I simply hadn't realized it. And I guess I didn't look at her very often, either. I hadn't expected her to notice!

I stammered, "You know, psychiatrists don't ordinarily touch their - - -"

"Let me interrupt you before you tell any more fibs and your nose gets longer and longer like Pinocchio," Betty seemed amused by my squirming. . . .

"Well, you're pointing out one of my blind spots! It's true-- or rather, was true-- that, when we first began to meet, I was put off by your body."

"I know. It wasn't too subtle."

"Tell me, Betty, knowing this . . ., why did you stay? Why didn't you stop seeing me and find someone else? Plenty of other shrinks around."  . . .

"Well. I can think of two reasons. First, remember that I'm used to it. It's not like I expect anything more. Everyone treats me that way. People hate my looks. No one ever touches me.  . . . And even though you wouldn't look at me, you at least seemed interested in what I had to say-- no, no, that's not right--you were interested in what I could or might say if I stopped being so jolly. Actually, that was helpful. Also, you didn't fall asleep. . . .

"You said there were two reasons,"

"The second reason is that I could understand how you felt. You and I are very much alike--in one way, at least. Remember when you were pushing me to go to Overeaters Anonymous? To meet other obese people--make some friends, get some dates?"

 "Yeah, I remember. You said you hated groups."

"Well, that's true. I do hate groups. But it wasn't the whole truth. The real reason is that I can't stand fat people. They turn my stomach. I don't want to be seen with them. So how can I get down on you for feeling the same way?"

We were both on the edge of our chairs when the clock said we had to finish. Our exchange had taken my breath away, and I hated to end. I didn't want to stop seeing Betty. I wanted to keep on talking to her, to keep on knowing her.

We got up to leave, and I offered her my hand, both hands.

"Oh no! Oh no, I want a hug! That's the only way you can redeem yourself."

When we embraced, I was surprised to find that I could get my arms all the way around her (pp. 138-139).

In his afterward to the book, written in 2012 at age eighty, twenty-five years later, Yalom wrote

           "Though I feel proud of this book, I have regrets about one story--"Fat Lady". Several obese women have emailed me that my words seriously offended them., and today I would probably not be so insensitive. Nonetheless, though I have put myself on trial several times and found myself guilty, let me take advantage of this opportunity to state my defense. I am the main character  in the story, not the patient.It is a story about countertransference-- that is, irrational, often shemeful feelings a therapist experiences toward a patient that constitute a formidable obstacle in therapy. My negative feelings about obese people prevented me from achieving the deep engagement that I believe is necessary for effective therapy. WHile I struggled internally with these felings, i had not expected my patient to perceive them. She had, nonetheless, accurately sensed my feelings, as she recounts at the end of the story. The story depicts my struggle to work throughthese unruly feelings in order to relate to the patient at a human level. However I may deplore these feelings, I can take pride in the denouement xpressed in the story's final words: "I could get my arms all the way around her" (p.284).

Then five years later, in Becoming Myself: A Psychiatrists Memoir , he wrote that although there was a flood of negative responses from women,

            it also resulted in an even greater outpouring of positive letters from young therapists who felt relieved as they tried to work through their own negative feelings toward some of their patients. My honesty, they said, made it easier to live with themselves when they harbored negative feelings and enabled them to speak  openly of such feelings to a supervisor or colleague (Yalom 2017, pp. 232-233).

If you hate fat people or if you are a fat person, you ought to read Roxane Gay's (2017) new book, Hunger: A Memoir of (My) Body. In it, she revealed the terrible trauma that led her to eat so much that she ended up weighing 577 pounds. Roxane {Gay, 2017 2832 /id}, a professional writer, described the experience of writing this book to be the most difficult and challenging writing experiences of her life.

References

Brody, J. (2017, August 21). Fat Bias Starts Early and Takes a Serious Toll. The New York Times.https://www.nytimes.com/2017/08/21/well/live/fat-bias-starts-early-and-takes-a-serious-toll.html?mcubz=3

Farber, S. (2015). "Tell Them It is Not Too Late for Someone Like Me" :A "Failure-to-Thrive Child" Grows Old and Begins an Attachment Based Psychotherapy at Sixty-seven. Attachment: New Directions in PSychotherappy and Relational Psychoanalysis, 9: 57-81.

Gay, R. (2017). Hunger: A Memoir of (My) Body. New York: Harper.

Yalom, I. (1989). Love's Executioner: & Other Tales of Psychotherapy. New York: Basic Books.

Yalom, I. (2017). Becoming Myself: A Psychiatrist's Memoir. New York: Basic Books.

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