When a body meets a body: fat enters the consulting room

Over the course of my lifetime I have seen five therapists for more than a session or two. Each time, without fail, I have encountered what I call the thin gaze and with it the assumption that I should want to lose weight. The thin gaze, arising from thin privilege, is the objectifying gaze cast upon the fat person by someone who is not fat. One therapist, a man who himself was fat, assumed that I should want to lose weight because otherwise how could I ever feel desirable? Each time, with all of them, I was angry, though that anger remained unexpressed. Inside, under the anger, I felt shame and pain. Why was what concerned me of so little interest or value? Why was anything I was concerned about automatically filtered through the therapist's notions about my weight, even when weight was not the object of my concern, at least not then? How was it that when they saw me, they saw my weight more than they saw me, a woman with her own concerns and issues?

After my second child was born, I was quite depressed. I had spent three and a half months on bed rest during the pregnancy. Both my life and my child's were at risk. When he was born, I terminated my fertility because to risk another pregnancy was to seriously jeopardize my life. And within a month of his birth, I learned of my husband's infidelity during my pregnancy. All during the time I was confined to bed rest, I told myself I could fall apart after he was born. But instead of falling apart I felt crushed by depression, able to do little else than care for my baby and his three-year-old sister. So I decided to see a therapist, a woman who had five children and was said to be particularly sensitive to issues of mothering and marriage. I took my baby with me when I saw her. I told her all about what had happened. I felt I was dying inside. I needed to be heard and cared for, helped to find my way back to myself and to being alive. I was dying inside and what did she want to focus on? My weight. Again and again, I told her weight was not on my agenda, that I needed to sort out my life on a far more basic level. But she persisted. Frustrated that she simply wouldn't/couldn't hear me, I terminated with her. She sent me off with a dire statement that if I didn't deal with my weight now, I would regret it. Despite the fact that I was clearly depressed, hanging on by my fingernails, all she saw was that I was fat and she believed that I had to "deal with" my weight, meaning I should lose weight, in order to heal. Indeed for her, that I was not interested in focusing on my weight meant I was in denial and that I would suffer the consequences. Did she ever even hear me, I wonder, when I struggled to talk about my sadness about no longer being able to have children, about not feeling as alive to my new baby as I wanted to be, about my slowly failing marriage or did she only see my fat body?

When I turned forty, I had two children and an unhappy marriage. Intrigued with Jungian psychology, I had been reading everything I could find and attended workshops and seminars presented by Jungians of one kind and another. I began to think about maybe becoming a Jungian analyst, which meant finding an analyst and entering a Jungian analysis. Around that time a woman analyst, fresh from Zurich, moved to Maine and I began to see her. I needed to accumulate hours in analysis in order to apply for training, yes, but more than that I was forty and I knew I needed to deal with what I wanted in my life, things that had eluded me up to then. She was the kind of woman, slender and well dressed, who made me feel clumsy and ungainly. Even the chairs in her consulting room seemed meant for someone small and dainty. To top it all off, she looked very much like my mother. When we started, maybe even in the first session, I said something to her to the effect that the issue of my weight was non-negotiable. In my thirties I had worked too long and hard making an uneasy peace with my body, by stopping dieting and hating myself for being fat, to be willing to step into the madness of dieting again. In spite of that declaration or maybe because of it, early on she told me a dream she had when she was in analysis. At the time her own analyst was fat and she believed she had the dream for her. In her dream, Jung told her "every extra ounce costs a pound of consciousness." Her analyst had been grateful to her for telling her the dream, she said. I was not grateful. Not at all. I was furious that despite what I had stated as my concerns, she ignored me. I did not directly voice my anger to her, though I did write to her about it. I wrote to her about it because I had not yet found my voice to express my anger and my truth. I wanted her to hear me, see me as I was, and allow me to open up to her, and to myself, about my experience in my body, in my life. I needed to speak and be heard, all of me, without the blame I felt so often that all I had to do to be "normal" was to eat less and move more. I wanted her to see more than my weight. But that was not to be.

As is common among Jungians, she saw a fairy tale as a means to approach again the subject of weight. She wanted me to work with her using an English fairy tale, "The Laidly Worm of Spindleston Heugh" (The Laidly Worm of Spindleston Heugh, n.d.), a tale she connected to hunger and the mother complex. I read it. But the armor of anger I had already put on against her kept me from engaging the story with her. I did not trust her enough to make myself vulnerable to the degree necessary to explore with her the issues of my body, hunger, my mother, and my weight. Undaunted she asked if I would consider losing at least a few pounds. Had she heard nothing of what I had told her? Could she not see or accept that I was not willing to deal with this issue with her? I was furious. How many pounds would be enough? Ten? Twenty? Fifty? What would be enough? What made it acceptable for her to impose that desire on me? Why should I step again into that madness just to satisfy her? She had no answer. We never spoke about it again in the three years I worked with her. And I am sorry to say I never dealt directly with how I felt about her and about that whole episode.

Like most fat people, I have had a long line of people in my life all too eager to police my body by shaming, cajoling or trying to make me cede control of my eating to someone or something, anything but my own desires. When she told me her dream, she said to me, as Jung said in the dream, that every extra ounce of weight cost me a pound of consciousness. Whether she intended it or not, for me she was saying that in and of itself, my body was pathological and by extension, because she was slender, she was superior to me. I felt anything of my own experience and feelings about my life, my body, my desires was less important to her than were I to take on the effort to lose weight as a demonstration of something – co-operation perhaps or desire to heal. Her countertransference, fully in synch with the cultural complex, met my internalized loathing of my body and fat, also lodged in that complex, and served to push me away from her. My negative mother complex was activated with a vengeance. I was again that little girl who defied her mother. I believed I could not risk opening up what it is like to be fat, to fully experience the thin gaze, to feel the judgment and disgust that is part of the everyday life of fat people. And I hadn't the courage to confront her. She seemed unable to fully appreciate and relate to what Susan Gutwill understands: "fatness is also seen as reason to blame the fat person who ate his or her way into 'freakishness'" (Gutwill, 1994b, p. 154). Gutwill continues, writing of a patient of hers:

She [her patient] needed to hear her experience of herself articulated. She needed to hear the actual word: "freak." she needed for her therapist to validate that, in her fat body, Rebecca was truly and objectively the target of people's worst fears, projections and hatred. Rebecca needed the reality testing that such mirroring of her own buried knowledge articulated. Once articulated, she could see her experience and begin to grieve for it and also begin to trust other parts of her inner knowledge, including how lovely, loving, and competent she was. As with any survivor of trauma, Rebecca needs to own the truth of her past order to move on from it. (Gutwill, 1994b, p. 159)

I needed support and understanding to be able to look at my own freakishness, a state I already and always felt, so that like Gutwill's patient, I could digest the truth of my own body and life. But she could not do that. Thus one of the most important issues in my life never was addressed with her because she could not put herself in my shoes and listen to my experience. She was not a bad analyst. My need brought her up against her limitations and made us a bad fit with each other.

I have been thinking and writing about the essay, "Fat Lady" in Irvin Yalom's book, Love's Executioner, which I read soon after it was published in 1989, for years. I began working with a male analyst not long after reading Yalom's book. I was greatly troubled by that essay. It made me angry and at the same time fearful that my analyst saw me the way Yalom saw Betty. I was horrified by what he wrote:

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 trial of countertransference was in store for me.

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? (Yalom, 1989, pp. 94–95)

In those days I worried that my analyst was feeling the same disgust Yalom felt as he sat across from me. I felt self-conscious before entering the room where we met. I remember photocopying the essay and giving it to him to read. I wanted him to find Yalom's attitude awful. I wanted him to understand that I feared he felt like that toward me and to reassure me but when I tried to articulate that desire, the words would not come. Because I was in the grip of the thin gaze, what he felt hardly mattered because I had interiorized it to the point that I was my own overseer, just as Foucault said of the prisoner in the panopticon.

Yalom has been much praised for openly admitting such strong prejudice, such clear negative countertransference. And indeed it takes some courage to openly admit such feelings. But in most of what I have read about that essay, no one questions that his revulsion in fact dominates the entire therapy. Nor are questions raised that he could think and feel this: "How dare they impose that body on the rest of us?" as if any of his patients owe it to him to be pleasing to his eye. Then again, it is acceptable to hate fat and to think ill of fat people so there was little chance of serious criticism except from the fat acceptance community whose opinions could be dismissed as defensive. Nevertheless, he does deserve credit for daring to say what no doubt many therapists think. And what I feared my own analyst felt.

In the course of the treatment described in Yalom's essay, Betty loses 100 pounds. Of course, because weight is seen as the cause of her depression, because she loses so much weight, the therapy is deemed spectacularly successful. Another story is revealed in the end of the essay when Yalom says:

"It's the same with me, Betty. I'll miss our meetings. But I'm changed as a result of knowing you ."

She had been crying, her eyes downcast, but at my words she stopped sobbing and looked toward me, expectantly.

"And, even though we won't meet again, I'll still retain that change."

"What change?"

"Well, as I mentioned to you, I hadn't had much professional experience with the problem of obesity." I noted Betty's eyes drop with disappointment and silently berated myself for being so impersonal.

"Well, what I mean is that I hadn't worked before with heavy patients, and I've gotten a new appreciation for the problems of… "I could see from her expression that she was sinking even deeper into disappointment. "What I mean is that my attitude about obesity has changed a lot. When we started I personally didn't feel 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!" (Yalom, 1989, p. 123)

Yalom was naïve to think that his distaste for Betty's body had not been evident to her. She lived in a world that reviled her body and likely she, like me, expected to encounter judgment. A more interesting question is why, given that she knew all along of his distaste, did she continue to work with him? The answer? She herself carries and directs those same feelings of disgust at herself.

We don't know how Betty is now, more than nearly thirty years later. Statistically she most likely has regained all of the weight lost and probably gained more. That is what happens when we try to tame the body through dieting. She may have had bariatric surgery and be among the minority who have not experienced complications from the surgery. Or perhaps she is in that tiny minority who succeeded in maintaining that weight loss. But in the years since the essay was published, no one questioned what losing weight was about for her and how working with a therapist filled with contempt and disgust for her body affected her feelings about herself. If even the therapist finds one's body repulsive, given that the repulsion is not expressed,

It is all but impossible for a fat person, no matter the reasons for being fat, not to have a host of emotional issues about her size and her body. Every day the culture is telling her that she is too big, too much, not acceptable. Finding the courage to talk about those feelings in the presence of someone who finds her as disgusting as she herself often does is quite a feat. How does she find her voice about her anger at what she encounters? How is she to lovingly care about her body and for herself if her therapist sees her body with the contempt and hatred she herself so often feels? And what if she is tired of having to devote herself to losing all that weight? The operative assumption is that in a room with a normal weight therapist and a fat patient, it is the patient who has a weight problem. What is it at work that makes it so difficult for the fat patient to be perceived as a whole person who might not share much less welcome the therapist's agenda about her weight? As Susan Gutwill puts it: "The burden of an unrelenting hatred of one's body is an experience that must be acknowledged and brought into the therapy room on its own terms" (Gutwill, 1994b, p. 160).

The consulting room does not offer protection from cultural complexes much as we might wish it did. Both patient and therapist come together shaped and influenced by them. Kimbles points out:

…it should be obvious that the unconscious idioms, identifications, affect structures that contribute to a sense of being a person within a particular reference group will also become active contributors to transference and countertransference and at times make the interpretation of these dynamics difficult. Cultural differences may complicate the treatment process by generating guilt, aggression, and denial about the role of differences, and the conflict of complexes that results can generate excessive ambivalence, curiosity, doubt, defensiveness, and confusion. (Kimbles, 2004, p. 202)

One consequence of the dominance of the fat cultural complex is that it affects how fat people are treated even in settings where care and concern should be expectable. However, study after study has shown that members of the healing professions are also in the grip of this complex and attribute the responsibility for fat to the fat person. The Rudd Center located at the University of Connecticut has done extensive work exploring weight stigma and bias among healthcare professionals. Their report documents findings of a number of large surveys. Saguy summarizes this data:

A survey of 89 general practitioners (GPs) with medical practices throughout the United Kingdom showed that, on average, GPs considered their patients' tendency to eat too much, to eat the wrong foods, or not to get enough exercise as greater contributors to their obesity than genetics, glandular/ hormonal factors, or metabolism. Another study…arrived at a similar conclusion, finding that providers believed that physical inactivity, overeating, food addiction, and personality characteristics were the most important causes of overweight. A study of 600 general practitioners in France found that 30 percent considered overweight and obese patients to be lazier and more self-indulgent than normal-weight people, and 60 percent considered lack of motivation to be the most common problem in treating overweight and obesity. In another study of 620 primary care physicians in the United States, more than 50 percent reported viewing obese patients as awkward, unattractive, ugly, or noncompliant. One-third of the sample further characterized these patients as weak-willed, sloppy, and lazy. (Saguy, 2012, p. 74)

In June of 2014, at the annual meeting of the American Association of Nurse Practitioners a study of bias among nurse practitioners against obese patients reported:

… more than 50% of the clinicians surveyed agreed with statements that:

Overweight people are not as good as others.

Overweight people are not as successful as others.

Overweight people are tidy.

Overweight people are not as healthy as others.

Most people do not wish to marry an overweight person.

Overweight people have family issues.

Overweight is the result of overeating.

Overweight people are addicted to food. (Susman, 2014)

Psychotherapists of all persuasions, though they couch their bias in different terms, also lay the responsibility for fat at the feet of the fat patient, generally seeing it a consequence of overeating and/or compulsive eating in service of one or another underlying emotional issue. The Rudd Center reports: "Psychologists ascribe more pathology, more negative and severe symptoms, and worse prognosis to obese patients compared to thinner patients presenting identical psychological profiles" (Rudd Brief, 2009).

Even when well intended, this tendency to ascribe pathology to fat people seeps in. Kathy Leach, a practitioner of Transactional Analysis (TA) in the UK, looks at treating fat people in her book, The Overweight Patient: A Psychological Approach to Understanding and Working with Obesity. She opens with acknowledging that if losing weight were easy, fat people would do so. But she then moves into her theory that people who are fat become so as a way of armoring themselves, of protecting themselves and concludes that their weight is a survival decision. From her promising opening, she goes into the usual assumption that fat people are responsible for being fat and that therapy can, through the process of discovering the reasons, lead them to becoming normal. Leach effectively says if only the fat person would straighten out her thinking, life would change and she would no longer be fat:

I am working to find out why the patient needs to maintain a large size or to eat excessively…My goal is for the patient to have a choice about her weight loss and that genuine psychological and social choice comes from knowing why she has needed to overeat or be big in the world in order to cope. (Leach, 2009, p. 14) [Emphasis added]

Once again we see the cultural complex at play.

A problem with nearly all of what has been written about psychotherapeutic approaches to dealing with fat is the underlying basic assumption that fat is an indicator of pathology and that psychotherapeutically treating whatever the underlying emotional/psychological issues will result in weight loss and achievement of a normal weight. There seems to be no awareness of the complexity of obesity or of the dismal success rate in achieving and maintaining long-term weight loss, regardless of the method employed. The therapeutic imagination for the most part seems to be unable to conceptualize fat as anything other than pathological. In an article looking at sexual satisfaction of obese women, the author does an excellent review of the psychotherapeutic literature on obesity and notes an important study in which Stunkard (1996) concludes:

When psychopathology is observed in obese individuals, it is now seen as a consequence rather than a cause--a consequence of the prejudice and discrimination to which the overweight are subjected. (Stunkard, 1996, p. 163)

I consider myself a Jungian. Though I wish it were otherwise, I have seen no evidence that Jungians are free of the cultural fat complex. Nonetheless I am puzzled by the silence in the Jungian literature about obesity, an issue that preoccupies so much of the culture. In fact in my research, to my surprise I discovered little in that literature about body at all and most especially about the female body. In the analytic encounter, body meets body, yet rarely is body spoken of.

Anorexia warrants books and articles, but on obesity, nothing. We find mention often of the need to connect with the body, of the body as a storehouse of memory. Quadrant, a major Jungian journal, on their website describes itself as a journal of "essays grounded in personal and professional experience, which focus on issues of matter and body, psyche and spirit." But in the archives of Quadrant I find nothing about fat, save for one article in 2009, "The epidemic of obesity in contemporary american culture: A jungian reflection" (Darlington, 2009) which focuses on compulsive eating. As is so often the case and consistent with the dominant narrative of the cultural complex, fat is equated with gluttony. Marion Woodman's book, The Owl Was A Baker's Daughter is the only book in all of the Jungian literature to deal with obesity. In the Journal of Analytical Psychology, with archives spanning over sixty years, there are but eight articles that even contain the word obesity and none that considers obesity as itself and what it means. In what was the San Francisco Library Journal now Jung Journal: Culture & Psyche, there are two interviews with Marion Woodman, in which some of her thoughts about fat are offered within reviews of her two books which dealt with fat and anorexia. And that is it, all that I have been able to find on the subject in the Jungian literature. The culture at large is preoccupied with obesity and the war it has declared on obesity, but the Jungian world, judging by its literature, is blind to it. As Jung wrote:

We do not like to look at the shadow-side of ourselves; therefore there are many people in civilized society who have lost there 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, 1976b, p. 23)

Is the assumption that fat is a symptom of underlying conflict and complexes so deep, so axiomatic that it warrants no challenge? Is it that fat disgusts us, as we saw in Yalom with his patient Betty? Barry Miller's thoughts are about homosexuality but can well be applied to fat and obesity as well:

It is useful to reflect upon how disgust is dealt with in an analytic situation... Does the analyst relate to disgust as something to be overcome or something to penetrate more deeply? Can the analyst tolerate disgust about a racial type, a form of sexual expression, unwanted desires, or even certain ideas? Is the analytic work inclined toward the dissolution of this disgust or the pursuit of its use in the life of an individual? ... The possibility here is that a contemporary psychotherapist might react to the disgust...by seeing it as something to be overcome rather than finding its relevance or purpose to his life. It is at these intersections that the analyst is challenged to separate his or her own values and goals from the process of the other individual, the analysand, who has another agenda for these feelings and attitudes. (B. Miller, 2010, p. 116)

"Can the analyst tolerate disgust about a racial type, a form of sexual expression, unwanted desires, or even certain ideas?" Miller asks. Yalom's disgust and its role in his work with Betty are apparent from his statements about how he saw her when she came to him. I do not believe it is a stretch to assume that disgust about fat and believing fat bodies are repulsive underlies much of various psychotherapeutic approaches to fat patients. Because of this, when dealing with fat patients, it seems more than usually important for the therapist to be aware of her own biases, attitudes, and complexes around weight and appearance. In an article about countertransference with an obese patient, Drell noted:

In examining one's countertransference responses to obese patients in psychotherapy, it is important to note that the obese patient's appearance may actually be repulsive, distorting the human physique to grotesque proportions...Therapists should intermittently ask themselves how they feel about their patients' obesity and how they have minimized or exaggerated the meaning of the patients' excess weight. If in the course of therapy, the patients' obesity is to discussed or if it is discussed to the exclusion of other issues, therapists should examine their countertransference responses as well as the patients' resistances. (Drell, 1988, p. 79)

Note the language he uses, words like "repulsive" and "grotesque", with which he betrays his feeling that of course such bodies arouse disgust. Even in recognizing countertransference, Drell's own feelings about fat bodies appear to be leaking out.

A few years ago a woman in analytic training in Zurich contacted me. She was doing her thesis on knitting and had heard that I am both a knitter and a Jungian and hoped I might be able to point her to some sources she had overlooked. After she completed her training, she again contacted me about the possibility of our meeting. She sent her thesis to me by way of thanks for some suggestions I had made and from it, I learned of her own history with eating disorders. We met for coffee one summer Sunday. The meeting went fairly well in spite of the occasional difference of opinion. Then she asked me about my current interests. I started talking about my writing and thinking about fat and the Jungian world. As I talked about the data on the overall failure of diets, things took a turn. She asserted that if only I would do what she had done by joining Food Addicts Anonymous and following their program, I would lose weight, keep it off and be healthy. As I often do in situations where I am angry and don't feel free to express my anger, I responded intellectually, citing research which supported my position. When I asked if she believed that she should urge weight loss for any fat patient who came to see her, she said yes because she would want them to be "healthy". At that point I tried to politely back us out of the whole topic. Time to part and we said our polite farewells.

I responded to her assertion intellectually. I wished later I had let her know at the time about my emotional response. Unsolicited advice is seldom welcomed by anyone. It is a sad fact that people feel free to offer advice to fat people because the belief is widespread that we are responsible for our weight and somehow it is a matter of ignorance that we have failed to take our ample selves in hand and discipline mind and body so as to become "normal" weight. But more than that, she betrayed a deeply held conviction that her agenda about weight is the correct agenda when it comes to dealing with a fat patient, that her belief that the only way for such a patient to be healthy is to lose weight, and that losing weight is a worthy and important goal in therapy no matter what the patient wants or believes. And that it is acceptable, even desirable to tell fat people what they should do to lose weight under the cover of concern for their health.

For that analyst, as for Yalom, and most therapists, it is a given that my fat is something that must be gotten rid of. As anthropologist Gayle Rubin has noted of homosexuality, "The search for a cause is a search for something that could change so that these 'problematic' [phenomena] would simply not occur." In other words, discussions about what causes homosexuality or obesity are driven by the assumption that it would be better if these phenomena did not exist at all (Saguy, 2012, p. 70).

From there it is not a big leap to the assumption that it would be better were there no fat people at all, if we did not exist. Alarmist? Yes, but not as great a leap as it might seem. All of the cultural notions about fat — the disgust, the belief that it represents unbridled appetite and all of the other common cultural beliefs – are part of the background of belief, unexamined and unconscious for most therapists and others in helping professions, gripped as they and most of our culture are by the fat complex. Stripped to basics, the belief is that the world would be a better place without fat, and hence fat people, therefore fat and fat people must be battled as an enemy. There is hope, as Kimbles suggests:

With an openness to the likely presence of cultural complexes, whether in competition or collusion, however, the opportunities for both patient and analyst to see what the unconscious has been doing with the fact of differences and to observe how this gets represented and narrated in the unfolding analysis, is rich indeed. (Kimbles, 2004, p. 202)

Philosopher A.O. Lovejoy described the human propensity that leads to the kind of climate in which we now live:

It is the beliefs which are so much a matter of course that they are rather tacitly presupposed than formally expressed and argued for, the ways of thinking which seem so natural and inevitable that they are not scrutinized with the eye of logical self-consciousness, that often are the most decisive of the character of a philosopher's doctrine, and still oftener of the dominant intellectual tendencies of an age. (Lovejoy, 1976, p. 7)

McLuhan more succinctly says, "I don't know who discovered water, but I know it wasn't the fish" (Quote investigator, n.d.). We all swim in a toxic mix of fear, disgust, judgment, and hatred of fat, leading us to see fat by itself as evil in the world, of something to be eradicated like a dreaded disease. The fat person becomes responsible for this cursed state. The complex, as we have seen earlier, is so pervasive and powerful that it seems natural and normal, unquestionable.

Thanks to the powers of the media and the power of the cultural complex, it is fair to say that most therapists, along with the people we encounter everywhere every day, assume that fat people are gluttons who eat huge portions of "unhealthy" foods like piles of doughnuts, mammoth plates of pasta, a whole pizza, junk foods of all kinds. Google "fat people eating" and the popular images show this. After all, how else could they have become fat, if not from gorging themselves on junk foods of all kinds? It is almost impossible for most people to imagine a fat person eating a salad or other foods considered "healthy". And almost as difficult to imagine a slender person devouring excessive amounts of junk foods. If we stop to think about it, we realize that of course, fat people eat salads and slender people gorge themselves sometimes. It is simply not possible to determine how or what a person eats by looking at her. Thin privilege leads people to assume that the way they eat is what allows them to be thin and that if fat people ate that same way, they too would be thin. As Gutwill notes

Therapists are easily or subtly prey to the cultural mandates for the female body...This mandate is...fat phobic, obsessed with bodily control, in revolt against aging and its concomitant bodily changes, outraged at and contemptuous of the imperfect out-of-control body and repulsed by immodest female appetites and hunger. (Gutwill, 1994, p. 154)

The assumption that it is compulsive eating which lies at the heart of obesity is one of those beliefs that Lovejoy described as so much a part of common "knowledge" that it goes unquestioned. This assumption is a significant part of Marion Woodman's theory about obesity, which I will discuss later. The only other Jungian I can find who has written about it, Beth Darlington, entirely conflates fat and gluttony and compulsive eating (Darlington, 2009). Yet all of her sources for her information about obesity come from articles in the press, with no reference to even mainstream research which counters the dominant narrative about fat. The journal Quadrant gives the following as keywords for her article: obesity, gorging, overeating, gluttony, hunger.

In her most recent book, The Mystery of Analytical Work, Barbara Stevens Sullivan brings together Jung and Bion. In my own practice I have tried for many years to hew to Bion's dictum to approach each patient, each hour without memory, desire or understanding. Sullivan does a lovely job of explicating what this means in practice. Of the three, I find eschewing desire to be especially important. This means setting aside any agenda for the patient, any wish that I have about the patient. To quote her:

A desire to help the patient is similar: is the patient inducing in me a subjective sense of helplessness or weakness? Is he bringing up a savior complex or sadistically rubbing my nose in the "helplessness" I feel when faced with his "extraordinary" pain? In wanting to help, am I unconsciously striving to exclude some level of suffering that is trying to enter the room? The desire to help the patient will mean something slightly different every time it comes up, even with the same patient, let alone with different people. But whatever its precipitant, the desire blinds the analyst to the ways the patient needs to be seen and accepted in his wounded condition, as is, before he can begin to let it go. This desire to help is a particularly seductive one. Our patients want us to help them and most therapists entered the field out of a conscious wish to help people. But it is important to let go of the wish because, as far as we can tell, it is usually not helpful to try to help. Trying to understand the patient as he is generally loosens his character structure and begins or reinforces a growth process inside him that leads to positive ("helpful") developments in his inner world. (Stevens Sullivan, 2009, p. 217)

Darlington and Woodman, my first analyst, and my coffee companion of that summer Sunday all fall prey to the same bias against fat that we see in other health professionals and like most therapists, are unable to set aside their own agenda about weight and the judgments about weight from the culture and simply listen to the patient and her experience. As Sullivan said, "the desire [to help] blinds the analyst to the ways the patient needs to be seen and accepted in his wounded condition, as is, before he can begin to let it go" and sometimes even in letting it go, the resulting change is not what the therapist might wish, that is, that the patient lose weight.

Reparative therapy or, as it is also known, conversion therapy, is psychotherapeutic treatment aiming to convert homosexual and transgender people into heterosexuals, the assumption being that heterosexuality is what is normal and healthy. It capitalizes on those members of the LGBT community who are conflicted and/or self-loathing about their sexual orientation and identity and promises to make them happy and normal provided that they renounce homosexuality. In essence, as in the obesity narrative, the sufferer is blamed for his or her suffering. The failure rate of these therapies is nearly 100 percent over time.

As the fog of a cultural complex about homosexuality has slowly been clearing, we have seen within recent decades the removal of sexual orientation from the Diagnostic and Statistical Manual as a psychiatric disorder and the rise of condemnation of these conversion therapies as unethical with increasing pressure to make them illegal as well. This represents a major change from seeing homosexuality as pathological and something to be "cured".

How different is reparative therapy really from the multitude of failed therapeutic approaches to treating obesity? The underlying assumptions are the same — both homosexuals and fat people are seen as responsible for their own suffering, as pathological, disgusting, and a departure from what nature (or God) intends. Both assume an absence of self-discipline, inability to curb appetite, and lack of moral strength. Both treatments have a near total failure rate. And in neither approach is serious attention given to the misery that can come from being a member of a marginalized and judged community. The essential message in both is "Repent your evil ways and you will be saved from your life of sin and misery."

The dominant paradigm in psychotherapy research favors cognitive behavioral approaches because of the belief that it is more scientifically based and standardized and therefore is more amenable to short-term outcome studies. Therefore there is little to no funding for any other approaches. It should come as no surprise then that when a psychological component is included in obesity treatment, it is invariably behavioral. Weight Watchers has included these principles since the early 90s drawing on research by psychologist Kelly Brownell.

In 2012:

the U.S. Preventive Services Task Force urged doctors to identify patients with a body mass index (BMI) of 30 or more and either provide counseling themselves or refer the patient to a program designed to promote weight loss and improve health prospects...These programs would set weight-loss goals, improve knowledge about nutrition, teach patients how to track their eating and set limits, identify barriers to change (such as a scarcity of healthful food choices near home) and strategise on ways to maintain lifestyle changes. (Healy, 2012)

Anticipating that psychologists could play a large role in the mandate for treatment and treatment guidelines under the Affordable Care Act, the American Psychological Association convened a panel to develop guidelines to address the problem of obesity:

… for much of the population, obesity is associated with disease and mortality. It can be effectively treated through behavior change, which falls within the domain of psychologists. As collaborations between psychologists and other healthcare professionals increase, psychologists are expected to be called upon more frequently to address obesity and other physical conditions. (APA to establish treatment guideline panels, 2012)

Linda Bacon writes:

The [Affordable Care] Act enforces the recent recommendation from the U.S. Preventive Services Task Force stating that all doctors should warn "obese" patients that their weight puts them at high risk for disease, but that weight loss and lifestyle changes can help – and then direct them to intensive weight-loss counseling. Currently, few insurance companies pay for such programs. Under "Obamacare," however, insurers will be required to cover most medically advised weight-loss expenses and employers will almost surely intensify their anti-obesity campaigns. Weight Watchers' stock has already surged in anticipation of the bounty to come. (Bacon, 2012)

But notice that no consideration is given to consulting or including fat people. Again we see thin privilege at work, in the way that notes:

I have benefited from thin privilege… in that people tend to attribute positive traits to me and other thin people solely because of our body weight. Because of my relative thinness, I am often unfairly considered a more objective, and thus more credible, commentator on debates over fatness than if I were fat…In this sense, thinness in our culture is what sociologists call an "unmarked category." (Saguy, 2012, p. 25)

Evidence does not exist that obesity can be effectively treated over the long term through behavioral change. No so-called treatment for obesity has at more than five to ten percent success rate long term. Most types of cancer have better prognoses. And how is it ethical to promote a treatment that fails almost every time within five years, thereby increasing the suffering and shame that brings most fat people to seek change in the first place? The APA panel issued a briefing sheet in 2014 "to help psychologists solve the obesity epidemic in the U.S.…offering direction on how to prevent obesity and treat the one-third of Americans with the disease" (American Psychological Association, 2014). Again there is no input from fat people nor were any fat people included on the panel that issued the briefing sheet. Nor are there any approaches suggested for dealing with fat stigma. There is no recognition of the absence of any evidence for any weight loss method with more than a very slight long-term success rate. What the APA proposes as the ways psychologists can help is:

-   Psychologists play an integral role in the treatment of obesity by providing effective interventions that include self-monitoring of eating habits and physical activity, stress management, stimulus control, contingency management, cognitive restructuring, and social support.

-   Psychologists can also assist primary care physicians in tracking patient behaviors related to diet, physical activity, and weight; providing more consistent guidance for patients; improving time efficiency during visits; and promoting integrated care. Fewer than half of primary care physicians reported providing specific guidance on diet, physical activity, or weight control, and fewer than 22% reported routinely and systematically monitoring patients' behaviors or other measures of progress related to diet, physical activity, or weight.      

-   Weight-loss surgery is an additional option for weight reduction in a limited number of patients meeting criteria for clinically severe obesity (i.e., body mass index >40 or >35 kg/m2with comorbid conditions).

-   Psychological evaluations to determine emotional stability/readiness for surgery are not only critical for patient safety and success but are also now required by insurance companies.

-   Psychoeducational groups and support groups, as well as individual counseling, have been used as effective supplemental treatment approaches for weight-loss surgery.

-   Many studies have supported the effectiveness of behavioral therapy, cognitive-behavioral therapy, mindfulness, and motivational interviewing interventions for weight loss in obese patients.

-   Psychologists have the knowledge and training to assist with the prevention of weight problems, adherence to weight-loss programs, and maintenance of healthy weight and lifestyle, which are greatly needed to address the current obesity epidemic. The American Psychological Association is currently developing clinical practice guidelines for the treatment of obesity based on systematic reviews of the scientific literature. (Briefing series on the role of psychology in health care: Adult obesity, 2014) [Emphasis added]

Notice the concluding statement. If this were true, then that review would include the extensive literature on stigma, anti-fat bias, and the fallacy of there being anything like a simple behavioral solution to something as complex in origin as obesity. In fact more evidence of the harm arising from anti-fat bias appeared very recently. In their study, Sutin and colleagues conclude:

The association between mortality and weight discrimination was generally stronger than that between mortality and other attributions for discrimination. In addition to its association with poor health outcomes, weight discrimination may shorten life expectancy. (Sutin, Stephan, & Terracciano, 2015, p. 1803)

I am not holding my breath. As one of the respected critics of psychiatric over-reach, the psychiatrist who writes the blog 1BoringOldMan says:

Therapeutic Zeal. It's the danger behind the Hippocratic Oath's injunction to "Do No Harm." These radical treatments were introduced for the devastating, often fatal illnesses only seen behind the walls of Asylums and State Hospitals. But with some successes, they were increasingly applied in patients with less debilitating illness or diagnoses. That's what Therapeutic Zeal means, becoming too invested in treating and overlooking the dangers. (1 Boring Old Man, 2013)

These interventions are proposed in the guise of helping fat people to become "normal", acceptable, slender. And they carry at least the hint of coercion with penalties such as increased premiums for health insurance if the fat person does not comply.

There is very little written about body meeting body in psychotherapy of any kind. When patient and therapist sit down together, they are meeting body-to-body as well as mind-to-mind. And each brings with her all of her assumptions, feelings, and projections about bodies, both her own and that of the other. Jane Burka, in an unusual example of a fat therapist writing about her experience, writes:

… heavy people represent a threat because they embody a pervasive fear that underlies our culture: the loss of self-control. Heavy women are considered lazy and self-indulgent, lacking self-regulation. They have given into their impulses instead of restricting them. They have not harnessed themselves to moderation. We live in an era in which greed is supposed to be expressed through ambition, not indulgence; in which we are led toward excessive consumption of products and services, not food. The standards for what is or is not attractive become equated with what is good or bad, right or wrong, and so matters of appearance become confused with issues of morality. (Burka, 2001, p. 258)

This is as true for the fat therapist as for the slender one.

In the years that we have worked together, my analyst and I have both learned about the toxic waters of the cultural fat complex. Many years ago he asked my permission to use a dream of mine in a paper he was writing. I agreed. He gave me the finished paper to read and asked how I felt about it. In reading it, I discovered a phrase he used in his description of me, a phrase that infuriated me, "her weight belies her intelligence." I wanted him to remove it but it had gone to press already. I was angry and afraid that what I had feared was true, that he in fact believed that my weight and my intelligence were mutually exclusive somehow.

We talked and argued about that phrase many times over the years, each time broadening our understanding of what it meant, both to me and to him. I became better able to say what was false about it, about the bias inherent in it. I became clearer about what it was that upset me and how to express that and how it fit into my history of living in a non-conforming body. And he came to see it was in fact a ridiculous thing to say and tell that he would not use it were he writing now.

When he wrote it, in the grip of the cultural fat complex with its attendant thin privilege, what he said seemed reasonable. Of course one would not expect fat is a marker for lack of intelligence, because after all if a person is intelligent, she would control her weight. And of course because I had internalized all of the negative messages of the complex, instead of expressing my anger, I felt shame and disappointment. Thin privilege creates blindness to the lived experience of the fat person.

Use of the couch in Jungian analysis is less common than in traditional psychoanalysis. But I wanted to try it so for some months I lay on the couch during sessions. The couch was old, and creaked, and groaned when I lay down on it. The couch itself seemed to be rebuking me for being too much, seemed to be threatening to break under my weight. I abandoned the couch for many months. When I wanted to return to it, he told me that I couldn't, that it would not hold me. It didn't register with me that he was saying the couch was broken. I heard what he said as meaning I, only I, could not lie on it because I was too heavy. That it had simply broken down did not occur to me. I was humiliated, ashamed, and furious because I thought I was being told that I was too much for it. I felt that he was rejecting me as I am by having a couch that couldn't hold me. I felt as if the space that could hold all of me had shrunk. Yet as we wound our way through the field of land mines surrounding this issue of fat and my body, he was open to hearing my experience, which is a major determinative factor in creating a positive therapeutic environment. In a second analysis with him years later when I was ready to deal with my body, I asked him to read Judith Moore's book, Fat Girl, which is a brutally frank memoir of her life as a fat child and woman. He read it. That mattered.

The Jungian approach to therapy employs the belief that both patient and therapist change in the course of the therapy. The patient on an unconscious level functions as therapist to the unconscious patient in the therapist. Jung describes it:

In any effective psychological treatment the doctor is bound to influence the patient; but this influence can only take place if the patient has a reciprocal influence on the doctor. You can exert no influence if you are not susceptible to influence. (Jung, 1966b, p. 71)

In the prevailing mode of therapy used today, cognitive behavioral therapy, the Jungian view most definitely does not apply. But in a model where both patient and therapist are in the soup together, both do change. In the case of dealing with fat, it is the fat patient who confronts the cultural fat complex and in that process dares 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? What deadness is insured and what vitality is precluded? Will the therapy have to take a skewed direction in order to protect my anxieties as the therapist, just as the infant learns to develop a pathological way to cope with a mother's anxieties? (Burka, 2001, p. 274)

A great deal of change is needed for it to become the usual for a fat therapy patient to encounter a therapist free of an agenda about her patient's weight. She should be able to expect to be asked what she wants to work on, what her own goals in therapy are and not to be subject to an agenda that she could/should lose at least a little or a lot of weight. The therapist needs to be willing to hear and accept that her fat patient may not see her weight per se as the problem in her life, even as she experiences the negative effects of stigma and bias, that it may be that the pain of living in a stigmatized body is what she most needs and wants help with. Most importantly that it not be the therapist's agenda that sets the course of the therapy. In a book published in the late 80s, Fat Oppression and Psychotherapy, Laura Brown identifies 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" (Brown, 1989, p. 26).

The end to the domination of the cultural fat complex in the field of psychotherapy is nowhere in sight because the field is as much in the grip of that complex as the culture at large is. It falls to fat patients, and fat therapists, find our voices to protest and begin to force that change. That would bring a Stonewall moment perhaps. Or so I hope.

- Cheryl Fuller, PhD is a Jungian Psychotherapist living on the coast of Maine. 'The Fat Lady Sings: A Psychological Exploration of the Cultural Fat Complex and Its Effects' will be published in March by Karnac.