A few days ago a friend reminded me of an essay written by Irving Yalom, "Fat Lady". I read it when the book, Love's Executioner back in 1989. The essay bothered me then and now it has surfaced in my consciousness again, still bothering me. A Google search tells me that this piece is used in a variety of training programs and it seems usually there is praise that Yalom admitted his bias. But I have a different thought.
The following passage opens Yalom's story, ‚"Fat Lady". In this story, Yalom, a psychiatrist, tells how he treated his obese patient, Betty, and how this process helped her lose nearly 100 pounds.
“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?
The origins of these sorry feelings? I have never thought to inquire. So deep do 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, perhaps more than many men, the woman’s body. No, not just admired: I have elevated, idealized, ecstacized it to a level and a goal that exceeds all reason. Do I resent 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 black 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 that was where I learned it.
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 those patients, attempting to understand them, and finding ways to be supportive.
But when I see a fat lady eat, I move down a couple of rungs on the ladder of human understanding. I want to tear the food away. To push her face into the ice cream. “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.”
From Ivin Yalom, Love's Executioner Basic Books, 1989 pp.94-95
There is no question that openly admitting such strong prejudice, such clear countertransference, takes some courage. But 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 folks who could be dismissed as defensive. Nevertheless, I do hand it to Yalom for saying out loud what I am quite certain that many therapists feel and never speak.
The essay goes on to talk about the process of therapy, of Betty's depression, and her weight loss, which by the time treatment ends amounts to 100 pounds. And of course the consensus is that because she lost so much weight, this therapy was spectacularly successful.
At the end of the essay, Yalom writes:
“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!”
From Love's Executioner, p. 123.
How naive for Yalom to think that Betty hadn't known all along of his distaste, for having lived in world of people who shared his feelings of disgust, she was an expert at detecting it and doing what she could to minimize herself as a target for their scorn. And in her rebuke, she points out that in fact he has changed far less than he imagines.
I wonder what Betty is like now, 20 years later. The chances are very good that she has gained back all 100 pounds and maybe added more, because that's what happens with repeated dieting as each diet leads to gaining more than was lost in a cruel slap at the efforts to tame the flesh. Or maybe she has now had bariatric surgery. Or maybe she is in that tiny minority who succeeded in maintaining that weight loss. But no one ever questioned why she would lose weight and what the effect of a therapist filled with contempt and disgust for her body would have on her feelings about herself. If even one's therapist finds one repulsive, what hope is there after all?
Honesty compels me to acknowledge that I am a fat woman. So I know what it is like to sit in Betty's place and I also know, as a therapist, what it is like to be confronted by one's shadow in the person of the patient who has come to see me.
How is a fat person, who, no matter the reasons for being fat, certainly has a whole host of emotional issues about her size and her body -- how is such a person to find the courage to talk about those feelings in the presence of someone who finds her as disgusting as she herself often does? How can she roar her anger at the prejudice she encounters? How is she to arrive at being able to care about her body and for herself lovingly rather than with contempt and hatred? And supposing she doesn't want to devote herself to losing all that weight? Supposing she wants to get off the diet merry-go-round and concentrate on being healthy and fat (and yes, that is possible)?
The operative assumption is that in a room with a normal weight therapist and a fat patient, that only the patient has a problem is, it seems to me, a very weak one. And I wonder what other unchecked assumptions that we therapists have need to be taken out into the open and wrestled with?