Don't make assumptions about overweight clients, such as about whether they have an eating disorder or are working toward acceptance of their weight.
These are certainly two of the most important points from the guidelines against size bias that I cited last week. And, I think probably the most difficult for many therapists to follow. Change comes slowly but in my professional lifetime, we have moved from seeing therapy as a corrective to homosexuality* so that in a recent article in the Journal of Analytical Psychology**, we find the following:
Analytical psychology pursues the purpose or goal of the psyche and its products. Consequently what is reflected upon are the variety of phenomena the psyche produces that may or may not form into a defined category of homosexuality or other non-normative sexualities. The analytic challenge may then be to view these erotic products of the psyche as meaningful in the context of an individual life, with implications that only become significant through that individual’s proclivities. p.115
Clearly the individuation promoted in analysis is not to change the homosexual to a heterosexual, and not to make the promiscuous man monogamous. If change is not the goal, then what might be expected? For the man ... being in relationship to the phallus and its symbolic power would demand a development in his relationship to himself. p.121
And if we change the focus of this piece from homosexuality to fat, then consider ho the same material might be read:
Analytical psychology pursues the purpose or goal of the psyche and its products. Consequently what is reflected upon are the variety of phenomena the psyche produces that may or may not form into a defined category of weight or other non-normative bodies. The analytic challenge may then be to view these products of the psyche as meaningful in the context of an individual life, with implications that only become significant through that individual’s proclivities.
Clearly the individuation promoted in analysis is not to change the fat person to a thin person. If change is not the goal, then what might be expected? For the person ... being in relationship to the body and its symbolic power would demand a development in her relationship to herself.
I come back again and again to Bion and his dictum that we approach sessions without memory or desire. I have to remember when I work with someone that it is not my life we are considering, nor are my choices or the choices I think I would make necessarily the best ones for the patient. This is a tough position to hold, to be as neutral about what the patient chooses as humanly possible in order that the choice be his or hers.
It is a challenge, particularly for so-called normal sized therapists to look at a fat patient and not see something that should be changed, that can be changed if only...
In Yalom's essay, "Fat Lady", he talks 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, he 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!” ***
Many times a patient will say to me, "I know you think I should do X", because that is what they want for me to think and want. And often they are initially unhappy when I remind them that what they decide will not change my life, but it may change theirs so it is what they want, what they choose that matters.
When I enter a session with a patient I endeavor to do so without memory or desire -- which is to say that any day as I meet with my patient, I put away thoughts about this blog, about my husband's latest project, about other patients, and about our last session with each other and I prepare to meet her in the moment and without an agenda. I wait for her to begin and allow her to set the agenda for our time together. I follow the thread of her concerns and as I do so, bits and pieces of the other times we have met come to mind. I hear more of her themes and as we go along I am relating them to themes I have heard from others and what I know about such themes. I am aware of issues in her life that have led to her personality being structured as it is -- this is a clinical piece where I touch into my database of experience with people who have similar histories and who have had the constellation of issues in their lives that she has has and what I know from more theoretical material as well. I challenge a bit here, ask a question there, offer a suggestion, share a personal experience. I watch as we do our dance of of speaking and listening and I see when an interpretive arrow hits the mark and when it misses.
Bion wrote:
Desires for results, 'cure' or even understanding must not be allowed to proliferate.****
How difficult this is in an age of treatment plans and goals, of war on obesity, to say nothing of our own biases, blind spots, unconscious desires, and personal experiences! And yet, it is imperative if we are to honor the patient's goals, and the purpose of her psyche.
There are gray areas, there is no doubt about that. Times when the patient's life is at stake, as we saw last season of In Treatment seem to demand that we take action and assert our own goals. Even in that instance, it is not clear that Paul had to act as he did, that there was no other way to get April the medical treatment she did need. And his action did ultimately destroy the therapy.
But the gray areas are uncommon. Far more common are instances such as confronted Yalom when he worked with Betty. When his very negative attitudes toward her weight and her body met and colluded with hers own internalized loathing of it leaving no room for understanding of the meaning of her weight and her feelings about it to develop. Because that meaning was subsumed by her, and it seems by Yalom as well, to the goal of changing her, of making her more normal.
Being without desire to change our patients, to make them more "normal" is not easy.
“We cannot change anything until we accept it. Condemnation does not liberate, it oppresses.” C.G. Jung
* I do not regard efforts to change sexual orientation as valid psychotherapeutic enterprise.
**"Expressions of Homosexuality and the perspective of analytical psychology", JAP, 2010, 55, 112-124
*** Yalom: Love's Executioner & Other Tales Of Psychotherapy. New York Basic Books, 1989. p. 123
**** Bion: "Notes on Memory and Desire"