Patricia K. Dennis Dissertation

INSTITUTE FOR CLINICAL SOCIAL WORK

FAT IN THE COUNTERTRANSFERENCE: CLINICAL SOCIAL WORKERS’ REACTIONS TO FAT PATIENTS

A DISSERTATION SUBMITTED TO THE FACULTY OF THE INSTITUTE FOR CLINICAL SOCIAL WORK IN PARTIAL FULFILLMENT FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

BY PATRICIA KYLE DENNIS

CHICAGO, ILLINOIS DECEMBER, 2004

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UMI Number: 3182567

Copyright 2005 by Dennis, Patricia Kyle

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ABSTRACT

This research is an exploration of the nature of clinical social workers’ countertransference to fat patients. Nine subjects, experienced clinicians working from a psychodynamic viewpoint, were chosen to participate in a set of two interviews each. The Free Association Narrative Interview method, a new narrative approach developed in Great Britain, was used to elicit stories about subjects’ work with fat patients, providing a context for the feelings and attitudes that make up countertransference in the broad sense.

The researcher analyzed the data by constructing psychosocial propositions about implicit and explicit countertransference experienced by each of the subjects concerning their fat patients. “Pen Portraits” and “Structured Summaries” were compiled for each individual, and employed to answer the following questions: What does the word fat mean to therapists who are clinical social workers? What are therapists’ reactions to patients whom they perceive as fat? How do these reactions manifest in their work with fat patients?

Results include a number of stories, richly descriptive of countertransference with fat patients, varying greatly in content by each individual subject; yet, some trends could be identified. Subjects reacted to fat patients in ways similar to those of the general population, with feelings and attitudes that were more negative than positive. A biopsychosocial perspective and a psychodynamic viewpoint may be especially useful in understanding fat patients’ experiences, and in assessing and treating their mental health needs. Subjects seemed to lack knowledge of the interdisciplinary literature on fat. Fat ii

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bias may have influenced their countertransference reactions; however, this appeared to be counteracted by empathic skills as well as the benefits of long-term therapy relationships. Active interventions were frequently employed, suggesting the influence of existential anxiety and cultural counterresistance. A great number of meanings of the word fat were reported.

These results can be used by clinical social workers to assess their needs for education, supervision, and psychotherapy in order to monitor, manage, and use their countertransference to fat patients in a productive manner. The research method is particularly useful in clinical social work research, as its interviewing and analysis techniques are similar to those used by many psychotherapists.

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ACKNOWLEDGMENTS This dissertation marks the end of a very long, rewarding journey. I did not begin my doctoral work until after I had raised my children—both a privilege and an experience for which I am extremely grateful. I feel lucky to have had the time, the good health, and the energy to pursue a doctorate and achieve my goal of being the best-educated therapist I can be. I knew when I started leading therapy groups for patients who have eating disorders that I could not rely on a two-year graduate degree to teach me all I needed to learn about treating mental illness. What I did not realize is how the acquisition of a doctoral education would be a group effort. I want to express my gratitude to people who made this achievement possible.

One group to which I owe an inestimable debt of gratitude is my dissertation committee, composed of the women I most admire at the Institute. I consider myself lucky that very early on, a faculty member told me I should move heaven and earth to get Miriam Reitz, Ph.D., to be my chair. Was she ever right. Miriam and I are a perfect match in terms of working style. We both approach a writing project in a systematic way, paying attention to detail, and carefully reviewing work as we go along. Although this appears to be a very hands-on approach, Miriam was actually very hands-off. She and I would meet, make plans, and then she would completely drop back, allowing me to work on my own and freeing me to be creative in my work. I could rely on Miriam to be there when I needed her, and to sit quietly, but observantly on the sidelines when I wanted to plow ahead by myself—just like a good mother. When I had a difficult question to ask, iv

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Miriam brought her knowledge and experience to bear, and helped me come up with an answer. Best of all, Miriam has instilled in me a love for research, which I never dreamed would occur.

Constance Goldberg, M.S., was another committee member whom I want to thank for being the birth mother of my dissertation. I remember her sitting with me in her office, hour after hour, helping me wrestle with the daunting question of a research topic.

Connie’s patience, inspiration, and encouragement helped me through a process that not only culminated in the selection of a research topic, but one that I felt was exciting and relevant to my career. I am especially appreciative of two of Connie’s strengths. She has an extensive and sophisticated knowledge of the theory on countertransference. Her comments about this phenomenon have been enlightening and challenging. She has helped me to clarify aspects of theory that are intricate and confusing. I have never met anyone who is so gifted in helping with writing style and grammar. Connie has helped me over the past nine years in many ways, as a professor, a practicum consultant, a research consultant, a mentor, and a friend.

The hardest part of writing acknowledgments is to choose the order. It does not feel right to put Barbara Berger, Ph.D., third. Barbara served on my dissertation committee, and has been of great help to me in several other capacities. I met her in the classroom in one of my favorite experiences at ICSW, and it was her first time teaching that course. I knew that I wanted to learn more from Barbara, which I did during four years in her capacity as a practicum consultant. I reserved my most difficult clinical questions for consultation with Barbara. Somehow, she made consultation fun, even though we were talking about extremely complex theory. She gave me a great deal of v

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support as I was designing my research and had the amazing grace to approve of my deleting Lacanian theory from the plan. I am most grateful to Barbara for giving me help and encouragement during times that personal life events interrupted my doctoral studies.

She knew how to change hats from authority to friend, never in a way that made me uncomfortable about the boundaries of our relationship.

My two readers have also played very important roles in my doctoral studies.

Hylene Dublin, M.S.W., CGP, shepherded my therapy groups during several years of psychological development and growth that would not have been possible without her wise guidance. Our shared interest in the American Group Psychotherapy Association has allowed me to learn from Hylene at her conference workshops and continue our friendship. I am very grateful for that circumstance. I first met Phillis Sheppard, Ph.D., when she was teaching a class. With her inspiration, I wrote a paper on symptom management that has been very useful in this doctoral research. Subsequently, Phillis taught a class on diversity that was so interesting and stimulating that the best part of the class was finding out how much I did not know that is relevant to the experience of the underclass of fat people. Phillis is a terrific teacher and I hope to be like her some day.

A group that was indispensable to this project was the clinical social workers who responded to my solicitation—over thirty people. I wish I could have included you all and I very much appreciate your expression of interest. The ten people that I did interview all served as role models to me for psychotherapists who love their work and have gone to great lengths to develop the necessary personal characteristics and skills.

My experience being with you was energizing, stimulating, and fun. Each of you gave me so much more than I ever could have wished for in terms of your willingness to tell me vi

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about your feelings and attitudes. I sincerely hope that I have done justice to your reports and points of view in this writing.

Finally, with deep gratitude and respect, I thank my group of patients, who have taught me most of what I know about doing psychotherapy. You are extraordinarily important to me. I dedicate this dissertation to you, in hopes that it will enhance your lives in some way, as you have enhanced mine.

PKD

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TABLE OF CONTENTS

Page ABSTRACT

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ACKNOWLEDGMENTS

IV

Chapter

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I. INTRODUCTION. Statement of the Problem to be Studied General Statement of Purpose Specific Objectives to be Achieved Significance for Clinical Social Work Theoretical and Conceptual Framework Statement of Assumptions Questions to be Explored II. LITERATURE REVIEW

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Overview o f the Literature on Countertransference Overview o f the Literature on Obesity and Fat Countertransference to Fat Patients III. METHOD

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Introduction Scope of Study Operational Definitions of Major Concepts Type o f Study and Design Setting Population and Sampling Sources and Nature o f Data Data Collection Methods and Instruments Data Analysis Statement on Protecting the Rights of Human Subjects Limitations of the Research Plan Methodological Implications vm

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TABLE OF CONTENTS— Continued

Page IV. RESULTS

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Patient Descriptions The Meaning of Fat Countertransference to Fat Patients Manifestations of Countertransference Overview of the Results V. DISCUSSION

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Discussion of the Results Theoretical Implications Application to Clinical Social Work Future Directions for Research Appendixes A. SOLICITATION LETTER

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B. PARTICIPANT CONFIRMATION LETTER

241

C. INFORMED CONSENT FORM

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REFERENCES

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IX

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CHAPTER I

INTRODUCTION

Fat has become a bad word in America. It might appear to be merely a neutral designation of size—fat as opposed to thin, for example. However, negative judgments and emotions often follow this word. In the media, in conversations among women, at the doctor’s office, in the workout room, many words can be heard in relation to fat: huge, obese, unhealthy, dangerous, disgusting, flabby, undesirable, unattractive, lazy, unmotivated, ugly, and more. Say fat to many American women and their reactions may indicate feelings of fear, self-loathing, anxiety, dread, and shame. Crandall and Schiffhauer (1998) describe beliefs and values that have contributed to widespread “anti­ fat prejudice” in this country.

Given that a majority of American adults are overweight1 (National Center for Health Statistics [U.S.], 2002b), and that overweight people may suffer from low self­ esteem, depression, and anxiety (Wadden, Womble, Stunkard, & Anderson, 2002), it is likely that a substantial proportion of the psychotherapy population is overweight. These patients could worry about their therapists’ attitudes and emotional reactions to their size and shape, wondering if their feelings about weight will be discounted or judged. It has

1 Words such as fat, overweight, and obese, represent the cited author’s usage o f the term. I will use fat as a word that may mean many things to many people and is not necessarily quantifiable.

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been demonstrated that therapists may react to a patient’s weight with negative judgments and biased treatment planning (Davis-Coelho, Waltz, & Davis-Coelho, 2000). In addition, the patient could react to the therapist’s weight and feelings about it. There appears to be no study of psychotherapists’ size, attitudes, or feelings about their own weight, but it is likely that there is some correlation with the general population.

Statement of the Problem to be Studied In a culture where most adults are overweight and attitudes toward fat people are mostly negative, the likelihood that therapists will bring negative attitudes, judgments, and feelings about fat into the therapy setting seems high. Psychotherapists who are influenced by psychoanalytic thinking are especially aware of the impact of countertransference upon treatment. Negative countertransference toward fat patients could have adverse affects upon the therapy and devastating consequences for the patient.

Therapists need to be sensitive to and understand the nature of their countertransference to fat patients in order to avoid these negative consequences. They need to become aware of positive transference as well in order to act as empathic listeners to fat people. At this time, there is only one research study that includes limited information about the countertransference o f psychiatrists, as a small subset of physicians, to fat patients (Brotman, Stem, & Herzog, 1984). Clinical social workers have not been studied. This research will begin by exploring the nature of clinical social workers’ countertransference to fat patients.

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General Statement of Purpose A qualitative study such as this one usually has more than one purpose. The explicit purpose is to contribute to knowledge. However, usually the author also hopes that this new knowledge will be used in some way. Due to the subjective nature of qualitative research, these hopes shape the study and influence its outcome. Therefore, it is important to be equally explicit about the purpose of the study in terms of its use.

Through this research, I hope to shed some light on the nature of countertransference to fat patients. Therapists may experience both positive and negative countertransference, both of which are likely to have an effect on their work. It is hoped that therapists will use the information from this study to better understand these reactions and how they can be used therapeutically. A greater awareness of countertransference may also help therapists anticipate and handle their negative reactions in order to avoid harming their fat patients.

Understanding therapists’ countertransference to fat people might be useful in terms of understanding the phenomenon of fat prejudice. It has already been demonstrated that therapists tend to share the same prejudices toward fat people as the rest of the population (Agell & Rothblum, 1991). Interviews with therapists who are highly attuned to their countertransference and motivated to eliminate the negative impact of these reactions could contribute to a much deeper understanding of fat prejudice than we already have.

One possible use o f this study is to set the stage for more exhaustive research about therapists’ countertransference to fat patients. Once countertransference is

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identified and understood, a question that follows is “How does this affect the therapist’s work?” One would then want to know how therapists can use countertransference productively and how to prevent countertransference from harming the patient. Many other important questions could be studied using this exploratory study as a jumping-off point. Some of these will be raised in the discussion section of this dissertation.

This study employs a narrative research method developed by -Hollway and Jefferson (2000) for the purpose of research with “defended subjects” when discussing topics that are likely to carry some emotional vulnerability. This method has not yet been used for the study o f countertransference. It is hoped that this application will contribute to refining the approach so that it may be used more effectively for research in many areas where the subjects feel too vulnerable to reveal or even be consciously aware of their feelings about the topic.

Specific Objectives to be Achieved Since this is the first study of its kind, it is exploratory, in order to get a general sense for the phenomenon and set the stage for future research. The limited scope of an exploratory study shapes the following objectives: 1.

The primary objective is to provide a general, preliminary and tentative

description of the phenomenon of countertransference to fat patients. This will be accomplished by interviewing a subset of psychotherapists, clinical social workers.

2.

Through a narrative analysis of the data, I will then identify some

commonalities among the experiences of those interviewed. It is expected that therapists

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will experience reactions to fat patients similar to those of the general population.

However, it will be particularly important to discover how the role of psychotherapist may influence these reactions. For example, psychotherapists are trained to help people improve their self-esteem. Therapists may experience shame and role conflict if they react with negative feelings toward their fat patients, knowing that their patients’ self­ esteem would be diminished if they knew of these reactions.

3.

An exploration of the nature of countertransference to fat patients will be

more useful if it goes beyond description to the suggestion of some preliminary explanations for what is observed. In this study, classical psychoanalytic theory, in particular, that o f Anna Freud and Melanie Klein, will be used to deepen understanding of what is reported by the therapists who are interviewed.

4.

As the author hopes to inspire future research, an important objective would

be to suggest areas of further study. Analysis of the therapists’ narratives might raise more questions than it answers. This is not a problem with the research, but an important objective of an exploratory study. Further research might be based on the diversity of responses with the purpose of identifying trends and contributing factors. An example would be evidence o f gender differences. These might be identified in this study, but it would require more research in order to clarify the impact of gender upon countertransference with fat patients.

5.

Taking into account the above stated purposes for the usefulness of this

research, a final objective would be to conduct the research and communicate its results in an effective manner so that others might be able to make use of the results for practice

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or to conduct future research. Aurora Levins Morales (1998, p. 37) suggests that oppressed groups are unlikely to hear the results of research through traditional academic channels and that a “delivery system” must be devised so as to ensure that these people receive direct benefit. She proposes the use of creative, alternative methods of communication for this purpose. Therapists and fat people who might never read a dissertation could benefit from disseminating the results through articles, classes, speeches, and interviews.

Significance for Clinical Social Work Catherine Kohler Reissman, a clinical social worker, wrote a classic text on narrative analysis (1993), the fundamental method to be employed in this study. In further writing (1994), Reissman described the status of qualitative research in the field of social work. In the past, quantitative research was emphasized, probably to lend legitimacy to a field that did not have a reputation for objective, empirical evidence of its efficacy (p. x). She described a recent openness to qualitative research in social work journals (p. xi) and discussed a “sympathetic connection” between social work data and qualitative data (p. ix). She published several studies in this same edited volume that demonstrated the usefulness of qualitative studies for social work research. This study is expected to contribute to social work research by again demonstrating a sympathetic connection between the process of doing psychotherapy and the process of interviewing people about a sensitive topic.

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Social work evolved from a concern for the oppressed. Oppression of fat people is well documented (Bessenoff & Sherman, 2000; Crandall & Schiffhauer, 1998; Lewis, Cash, Jacobi, & Bubb-Lewis, 1997). If clinical social workers want to contribute to eliminating fat oppression, it is important for them to examine their own fat prejudice and their tendencies to consciously or unconsciously perpetuate this oppression in their work.

Countertransference can be explored and used therapeutically. Deutch (1926) was the first writer to suggest that countertransference identification could be used to empathize with one’s patient. The present study’s focus could be used to help a clinical social worker develop greater empathy for fat patients.

Finally, this research can contribute to the practice of clinical social work by providing a greater understanding of the experience of fatness by patient and therapist in the clinical setting. Understanding the word fat, its meaning, and its associated feelings can lead to more effective clinical social work with fat people.

Theoretical and Conceptual Framework Proponents of the classical psychoanalytic theories agree on the existence of three psychological phenomena: (a) the “transference,” (b) the “unconscious,” and (c) “defense mechanisms.” These concepts serve as a fundamental underpinning to psychoanalytic thinking and distinguish this body of thought from other psychological theories. Because these concepts are central to the research question and to the method used in this study, I will use classical psychoanalysis as a theoretical framework both for the understanding of basic human responses as well as for the therapeutic relationship, with a particular

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emphasis on the contributions of Anna Freud and Melanie Klein in understanding defense mechanisms.

“Transference” has been described by Fenichel (1945) in an often-used definition: In the transference the patient misunderstands the present in terms of the past; and then instead of remembering the past, he strives, without recognizing the nature of his action, to relive the past and to live it more satisfactorily than he did in his childhood. He “transfers” the past attitude to the present, (p. 29) In turn, “countertransference” is the therapist’s tendency to do the same (S. Freud, 1953/1910). The definition of countertransference has undergone much transformation (Epstein & Feiner, 1979). It has been acknowledged as a phenomenon by other psychologies; however, the key aspects of its often unconscious and defensive nature are unique to psychoanalysis. The phenomenon of countertransference (as broadly defined) is part of the subject o f this research.

The “unconscious” is a term used to represent a part of the mind according to the topographic theory that was proposed by Freud (195 3/1915b). In another usage that is central to this study’s topic and method, “unconscious” describes thoughts and feelings that cannot be called up into conscious awareness.

An unconscious process that is of particular interest to this study is at work in the use of “ego defense mechanisms.” Several of these were proposed and expanded upon by Anna Freud in her classic, The Ego and the Mechanisms of Defence (1937). Signal anxiety leads a person to employ various unconscious methods of fending off the anxiety that arises from three sources: (a) the overwhelming urges of the id, (b) authentic dangers in one’s environment, and (c) the discomfort of superego injunctions. Ego defense mechanisms are distortions of reality and serve as evidence of a person’s feared

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impulses. They include repression, dissociation, denial, regression, rationalization, projection, displacement, reaction formation, identification, sublimation, fantasy, compensation, undoing, and intellectualization. These methods are only effective insofar as they remain unconscious.

Melanie Klein (1957) further elaborated upon the use of a defense mechanism, “projection,” to split off those parts of oneself that are feared and attribute them to someone else. According to Klein, the child is bom with aggressive impulses that threaten destruction from within. In order to control these impulses, the child projects them into the loved object, and then identifies with this “bad object” in what is called the “paranoid position.” Using primitive defenses such as projection, introjection, projective identification, splitting, idealization, omnipotence, and denial, the child defends against anxiety associated with his or her own aggressiveness and tendencies toward envy. As the child develops a sense o f agency and responsibility, he or she realizes that she is capable of hurting the loved object, and moves to the “depressive position,” experiencing “depressive anxiety” in response to fear of losing the object. The defense of mania is employed to deny danger to the good object and allow for the omnipotent belief that the child can magically restore the injured parental object. A failure of the manic defense leads the child to employ obsessive defense mechanisms in a repeated effort to allay disintegration anxiety.

In the therapeutic setting, both therapist and patient are likely to employ defense mechanisms as they attempt to fend off the anxiety that arises from their transference

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reactions to each other. It is important to understand this process in order to fully comprehend countertransference and its manifestations.

Defensive processes are of particular relevance to this research because it is based on interviews of people who may be anxious about the research question and therefore emotionally defended. Their conscious responses to interview questions may disguise split off, unconscious information, which, if known, would be of great use to answering the research question. The method (Hollway & Jefferson, 2000) I am using is based on this theoretical understanding, using classical psychoanalytic interpretive methods to speculate on unconscious content and infer meaning in data analysis. The authors of this method integrate postmodern sociological theory with psychoanalytic theory: We intend to argue for the need to posit research subjects whose inner worlds cannot be understood without knowledge of their experiences in the world, and whose experiences o f the world cannot be understood without knowledge of the way in which their inner worlds allow them to experience the outer world (p. 4) The concept of an anxious, defended subject is simultaneously psychic and social.

It is psychic because it is a product of a unique biography of anxiety-provoking life-events and the manner in which they have been unconsciously defended against. It is social in three ways: first, because such defensive activities affect and are affected by discourses (systems of meaning which are a product of the social world); secondly, because the unconscious defences that we describe are inter subjective processes (that is, they affect and are affected by others); and, thirdly, because of the real events in the external, social world which are discursively and defensively appropriated, (p. 24) It is this theory of the “psychosocial subject� that informs the method of this research.

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Statement of Assumptions Theoretical and research literature along with personal and clinical experience has led me to a number o f assumptions that will have influence on the interview process and the analysis of the data. These assumptions are: 1. Subjects will freely tell their stories and be motivated to do so.

2. The subject and the interviewer will be influenced by conscious and unconscious thoughts and motives.

3. The Free Association Narrative Interview Method will lead to the acquisition of rich, dense data and a deep understanding of the material presented.

4. Subjects may be at risk for experiencing uncomfortable or painful feelings related to their work and personal experience (see Informed Consent Form, Appendix C).

5. Fat is a word that a person will attach to many possible meanings, perceptions, and feelings. These will vary by individual.

6. Fat has come to have a particular meaning in American society as indicative of a person’s immoral lack of self-control and diminished worth.

7. Fat people as a group in American society experience prejudice and oppression.

8. Clinical social workers have an interest in assisting the suffering and oppressed.

9. Countertransference may be experienced as positive or negative reactions to the patient.

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10. Countertransference may be a source of understanding the patient’s emotional experience.

11. A therapist’s countertransference to the patient may be influenced by the therapist’s attitudes, conflicting feelings, and past emotional experiences. These must be monitored as a source of misunderstanding or psychological enactment.

12. Understanding one’s countertransference toward fat patients is necessary for doing sensitive and effective psychotherapy with them.

Questions to be Explored “What is the nature of clinical social workers’ countertransference to fat patients?” This is the main research question to be explored in this study. Other questions need to be answered in order to address this question.

First, the word fat may mean different things to different people. Clinical social workers may share some meanings of this word by virtue of the value system upon which social work is based, including a mission to assist oppressed groups. This study will attempt to clarify the meaning of fat to clinical social workers by exploring the question, “What does the word fat mean to therapists who are clinical social workers?”

Second, it will be necessary to identify and describe the phenomenon of countertransference among clinical social workers. “What are therapists’ reactions to patients whom they perceive as fat?”

Third, countertransference is a phenomenon that takes place as the result of interactions between therapist and patient. It is an intrapsychic phenomenon that has an

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impact on the psychotherapy process. Another way of exploring the therapist’s countertransference is to observe its expression in the therapeutic interaction. Therefore, I will also explore the question, “How do these reactions manifest in their work with fat patients?”

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CHAPTER II

REVIEW OF THE LITERATURE

In reading the literature about eating disorders and body image, I am struck by how infrequently female therapists (who are almost the exclusive and certainly are the most prevalent treaters of this population) acknowledge that their clients’ suffering is much like their own. Clinical literature rarely mentions that these therapists often dread gaining weight, are vigilant about their own diet and exercise regimes, and suffer from feeling dissatisfied, if not disgusted, with their own bodies. (Rabinor, 1995, p. 90) Judith Rabinor suggests that something is missing from the literature—the therapists’ own body image disturbance. It is not surprising that healers might not like to think of themselves as in need of the very healing they dispense. Her provocative statement begs to be explored. It would seem that therapists cannot effectively treat fat patients without a clear and honest knowledge of their feelings about fat in relation to their own bodies. Is it true that therapists often have these concerns? If there is a lack of discussion in the literature about therapists’ body image, is it due to avoidance on the part of the researchers or the therapists they have studied? If so, is this avoidance due to shame?

Here we see an example of the difficulty in researching a sensitive topic such as feelings about fat. Much might be avoided and thus hidden. In this chapter, I will explore what has already been written about countertransference to fat patients and point out what is missing in the literature.

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Before I discuss the literature that is directly relevant to my research question, I will create a context for understanding the phenomenon of countertransference to fat patients by providing an overview of the literature on obesity and fat, as well as the literature on countertransference. I will describe the major theories and trends along with related research results.

Hilde Bruch (1973a), in her pioneering work on obesity, emphasized its complexity, in that the experience of being fat varies from individual to individual. This complexity is demonstrated in the literature on fat and obesity, as it crosses many disciplines. Authors may discuss this topic from one or several perspectives: philosophy, semiotics, sociology, psychology, psychoanalysis, medicine, science, feminism, and history.

Countertransference is the brainchild of Freud (1910, p. 144), and is primarily addressed in the psychoanalytic literature. This discipline will be the basis of my overview of the literature on countertransference.

When it comes to the literature on therapists’ countertransference to fat patients, I plan to present a comprehensive review of research and theoretical publications. Related studies of attitudes and beliefs will be reviewed for their relevance to this subject, including writing about mental health professionals, other health professionals, and about the subject of bias and fat prejudice among health professionals. Writing on two other related subjects will also serve to guide this research: (a) countertransference to patients who have eating disorders and (b) the role in the psychotherapeutic process of the therapist’s feelings about her body.

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Overview of the Literature on Countertransference We must never let our poor neurotics drive us crazy. I believe an article on “counter-transference” is sorely needed; of course we could not publish it, we should have to circulate copies among ourselves. (Letter from Freud to Jung in McGuire, 1974, p. 476) Even with Freud’s admonition that countertransference was a formidable influence that must be further studied, not much was written about it for many years.

Some believe Freud was afraid that open discussion of this phenomenon could jeopardize the acceptance o f the newly emerging science of psychoanalysis (Cooper-White, 2002; Gabbard, 1999). An explanation for what is seen as resistance on the part of analysts was offered by Heinrich Racker (1968). He said, “The lack of scientific investigation of countertransference must be due to rejection by analysts of their own countertransference— a rejection that represents unresolved struggles with their own primitive anxiety and guilt” (p. 130). There has been a marked increase in publications about countertransference in recent years (Epstein & Feiner, 1979, p. 12). It may be that Paula Heimann’s (1950) suggestion that countertransference could be useful in the therapeutic process freed clinicians to explore and write about their experiences. Gabbard (1999) noted a correlation between more open discussion of countertransference and a shift in the view of countertransference as a two-person phenomenon. This shift may have served to remove some of the shame that could be associated with acknowledging the presence of feelings towards one’s patient.

Most would agree that countertransference is a reaction to the patient that resides in the therapist, but beyond that, there is little consensus. In the literature on countertransference, one finds varied and sometimes conflicting definitions. Thinking on

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countertransference has evolved from a narrow view (S. Freud, 1953/1910) of the phenomenon as a problem with the therapist’s unconscious feelings that must be overcome, to a broader view first introduced by Paula Heiman (1950) who suggested that countertransference is wider in scope and is useful in the therapeutic process.

Contemporary authors still disagree about the scope and origin of the phenomenon and whether it is useful or detrimental in the therapeutic process (Holmqvist & Armelius, 1994). In this brief overview of the literature on countertransference, I will trace the evolution of the concept in terms of its definition, scope, origin, and utility for clinical work. This will be followed by a review of a nascent body of research that attempts to identify and explore this phenomenon in the clinical setting.

Theoretical Literature on Countertransference Freud set the tone for the study of countertransference in 1910 when he wrote these words that have now become famous: “We have become aware of the ‘countertransference,’ which arises in him [the physician] as a result of the patient’s influence on his unconscious feelings” (p. 144). Here he provided us with a name for the concept and a reference to the locus of the phenomenon in the therapist. It is triggered by the patient’s influence. He went on to suggest its effects by saying, “we are almost inclined to insist that he shall recognize this counter-transference in himself and overcome it” (p. 145). He was particularly concerned with the erotic pull of the patient on the analyst’s feelings, especially after his experience in a complex, conflicted triangle between himself, his protege Carl Jung, and his student, Sabina Spielrein. Spielrein was being analyzed by

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Jung who had become involved in a sexual liaison with his patient. This experience appeared to influence his writing on countertransference in the only other paper he wrote on this subject (S. Freud, 1953/1915a). He admonished the analyst not to sacrifice the opportunity to help his patient in order to indulge in the “wonderful experience” of acting on the love he may feel toward her.

Little more was written on countertransference until mid-century, when several authors again took up the subject. Their contributions serve as a turning point in the understanding of the phenomenon, setting a new direction for an expanded view that became widely adopted, and remains so to this day (Epstein & Feiner, 1979; Gabbard, 1999).

Paula Heimann (1950), a Kleinian, wrote a paper that presented several new ideas. In her writing on the evolution of countertransference as a concept, Cooper-White, (2002) said she believed that Heimann’s revolutionary ideas were easily adopted because she avoided using jargon and illustrated her ideas with clinical experience. Heimann departed from the “narrow” or “classical” view of countertransference by presenting what is now called the “broad” or “totalistic” view. Rather than limit the scope of the concept to unconscious feelings of pathological origin, she included the entirety of the therapist’s emotional response to the patient. She also departed from the idea that countertransference must be suppressed. On the contrary, “the analyst’s emotional response to his patient within the analytic situation represents one of the most important tools for his work. The analyst’s countertransference is an instrument of research into the patient’s unconscious” (Heimann, 1950, p. 81). Explaining further, she said that the

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analyst must use “evenly hovering attention” to attend to his own feelings. The need for this is based on the “assumption that the analyst’s unconscious understands that of his patient. This rapport on the deep level comes to the surface in the form of feelings that the analyst notices in response to his patient, in his ‘counter-transference.’ This is the most dynamic way in which his patient’s voice reaches him” (p. 82).

Although she introduced the idea that countertransference can be useful, she also warned against communicating it to the patient. Freud felt that the feelings should be suppressed; Heimann saw them as useful, but only for the purpose of insight. She cautioned against expressing countertransference feelings in order to prevent harmful re­ enactments within the therapeutic relationship and exploitation of the patient by the analyst for his own needs.

Around the same time, D. W. Winnicott (1947) wrote a provocative paper entitled “Hate in the Countertransference.” He proposed to classify countertransference as three separate types, the first being the classical pathological view of abnormality that calls for further analysis. The second type was characterized as “identifications and tendencies belonging to an analyst’s personal experiences and personal development which provide the positive setting for his analytic work and make his work different in quality from that of any other analyst” (p. 195). Third, Winnicott introduced the idea of “objective” countertransference, meaning, “the analyst’s love and hate in reaction to the actual personality and behavior of the patient based on objective observation” (p. 195).

Winnicott insisted that he held a classical view of countertransference as pathological. He emphasized the need to work through intense countertransference

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feelings in order to have a productive relationship with the patient. Nevertheless, he felt strongly that countertransference had therapeutic value. He believed there was a place for communicating negative feelings as a form of feedback that contributes to the maturation of the patient. Occasionally, the patient breaks through the barriers between himself and the analyst in a way that forces the analyst to react in a “real” way. This could assist the patient in crossing the “transitional space” between fantasy and reality (Winnicott, 1969).

“If the patient seeks objective or justified hate he must be able to reach it else he cannot feel he can reach objective love” (Winnicott, 1947, p. 199). In addition to its usefulness in communicating information to the patient, Winnicott believed that it serves as a source of information about the patient and the therapeutic process.

Margaret Little (1951) wrote about borderline and psychotic patients in her most influential paper on countertransference. She believed that countertransference has a central position in the therapeutic process as a way of gaining access to understanding the patient’s primitive inner world. The patient perceives the real, unconscious feeling reactions of the analyst in addition to holding fantasies about him. She recommended that the analyst freely express his emotional reactions to the patient so that the patient might experience a genuine relationship with another human being. This way the patient can experience both tolerance and limitation of his discharge of affect.

Heinrich Racker (1957; 1968), also a Kleinian, wrote on the nature, meaning, and use of countertransference theory and provided a detailed, in-depth system of classification. He rejected the notion of countertransference as an aberration indicating pathology and suggested that all analysts experience “countertransference neurosis” as a

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normal reaction to the patient. Racker characterized one type of countertransference as “direct,” i.e., related to the patient; another he called “indirect,” related to others outside the therapy room such as family members or the person who referred the patient. When the therapist feels an empathic attunement with the patient, Racker called this a “concordant identification.” However, when the therapist’s feelings are a product of projective identification, his emotional reactions represent aspects of the patient’s self that are felt to be negative or toxic. The patient splits these off and then projects them onto the therapist, ridding himself of the associated pain by attributing the attributes to the therapist. The therapist’s introjection of these feelings is called “complementary identification.” The therapist may react negatively toward the patient if this process is not clearly understood.

Again departing from the classical view o f countertransference, Racker (1957; 1968) believed that countertransference is an important source of information about the patient that can be used as a therapeutic tool for understanding the patient’s object relations. However, rather than make direct statements about his reactions as Little (1951) recommended, Racker preferred to use countertransference as a guide to interpretation.

He believed that the “Talionic principle” (“an eye for an eye; a tooth for a tooth”) is universal and plays a part in all therapeutic relationships. The therapist must contain any impulses to act on these wishes. The therapist must also be alert to a tendency to avoid becoming aware of aspects of the therapist/patient relationship that are uncomfortable, a phenomenon he labeled “counterresistance.”

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Annie Reich (1951; 1960; 1966) is seen as the spokesperson for the classical view o f countertransference, publishing simultaneously with the aforementioned authors.

Epstein (1979, p. 9) described her reaction as “a strong polemic” against their position. In her 1960 paper, she emphasized that countertransference represents “the effects of the analyst’s own unconscious needs and conflicts on his understanding or technique,” excluding other kinds of responses to the patient (Reich, 1960, p. 389). She argued against using the tool of expression of countertransference feelings: “Such an approach disregards Freud’s most important formulation concerning the therapeutic aim of analysis: ‘Where id was, there shall ego be.’ Therefore, no lasting effect can be expected from these methods” (Reich, 1960, p. 394). In this paper, she also disagreed with Racker about the notion of lex talionis. seeing this idea as “a narrowing down of the beautiful variety of psychic functioning” (Reich, 1960, p. 393). According to Cooper-White (2002), “Reich made an important contribution that is worth consideration even today: that there needs to be a balance between attention to the inner and outer life of the patient, both past and present, between primitive instinctual material and higher-level ego relatedness, and between intuitive and rational processes in the therapist” (p. 64).

Considering the fact that strong feelings about the nature and utility of countertransference have contributed to a history of polarization among writers, it seems important to note that there has been a trend toward agreement. In 1979, Epstein noted that most therapists had not adopted the idea of communicating countertransference reactions. Gabbard (1999) identified consensus that the therapist can derive information about the patient from his or her countertransference. He discussed the tendency toward

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accepting the idea that both patient and therapist (according to personality type) contribute to countertransference. Cooper-White (2002) pointed out the recent contributions of the relational school of psychoanalysis, noting in particular the idea that patient and therapist participate in a non-verbal “enactment” of feelings associated with the therapeutic process. She believed that this is important information for further exploration of the nature of countertransference: “When regarded in this light, virtually every action may have meaning, and often some of the most powerful work of the therapy may be carried out at the non-verbal level” (p. 83).

Empirical Literature on Countertransference All of the literature on countertransference reviewed so far is speculation based on theory and the writers’ clinical observations. Although clinical observation is a key component of research, none of these authors set out to study the phenomenon in a systematic way. Apparently, this is often the case and is a matter for concern, as researchers and clinicians are often at odds, although it would seem that they have need of each other’s knowledge (Talley, Strupp, & Butler, 1994). Cooper-White (2002) attributed the lack of empirical research on countertransference to the difficulty in studying something that is unconscious and therefore must be explained by its effects. In recent years, a small number of researchers have set out to describe and analyze the phenomenon of countertransference.

Recently, Hayes, et al. (1998) provided a review of the research literature on countertransference as a prelude to a qualitative study. According to these authors, the

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bulk of the research to date is “analogue research” that takes place in a laboratory. The researcher tests the hypothesis in a simulated therapy encounter. The authors characterized these studies as “a disparate set of studies examining largely unrelated hypotheses” (p. 469) although they contribute to the technique of measuring countertransference.

Cooper-White (2002), in her comprehensive review of the literature on countertransference, identified several trends in what she also described as a “disparate” group of empirical studies (p. 206). Early studies focused on anxiety and detrimental countertransference. Researchers differentiated between feelings and behaviors, with an emphasis on identifying countertransference in order to manage inappropriate behavior.

Later, other factors besides anxiety were identified such as empathy, conceptualizing skills, self-insight, and self-integration. Correlation between the therapist’s experience level and positive or negative countertransference has been significant in some studies, but not others. The research is consistent in its finding that the therapist’s personality creates bias and affects judgment and outcomes in therapy. There is some controversy about the effects of patient diagnosis on countertransference. The concern that therapists respond according to patients’ fears has been demonstrated and deemed harmful.

Therapists’ personalities, likes, and dislikes influence their perceptions of patients. The effect of therapists’ personal boundaries has been studied, showing a positive influence on awareness and negative influence on behavior of the therapist. Analysts appear to agree on the utility of countertransference, showing differences in the “classicist” and “totalist” views. Qualitative studies identify a number of manifestations of

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countertransference, including affective, cognitive, bodily, and imaginative. Therapists obtain insight through identification. There are various hypotheses about gender differences among therapists with results that have yet to be replicated.

Probably the most prolific researcher in this area, who seems to get little attention in the American literature, is a Swede named Rolf Holmqvist. Since 1994, Holmqvist and his colleagues have published nine quantitative studies on countertransference (Holmqvist, 1998, 2000a, 2000b, 2001; Holmqvist & Armelius, 1994, 1996a, 1996b, 2000; Holmqvist & Gustafsson, 2002). Holmqvist believed that the empirical study of countertransference would need to begin by identifying adequate instruments for measurement. He began with an attempt to assess the reliability of a checklist that measures the arousal o f emotions among treatment staff in a psychodynamic treatment setting (Holmqvist & Armelius, 1994). The checklist proved to be reliable and to $

adequately describe variance in the feelings described by the treatment professionals.

Since that time, Holmqvist and his colleagues have looked at a number of aspects of countertransference. Using the aforementioned feeling checklist, sources of countertransference were identified (Holmqvist & Armelius, 1996b), including habitual, reciprocal, and unique reactions, all of which make a significant contribution to the therapist’s feelings. Subsequently, the patient’s impact on countertransference was explored (Holmqvist, 1998; Holmqvist & Armelius, 1996a) demonstrating that a commonly held belief that the patient’s diagnosis determines the therapist’s reactions is not the case. Instead, the main influence appears to be the individual style of the patient.

However, a later study (Holmqvist, 2000b) contradicted this result. Subsequently,

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Holmqvist (2001) demonstrated that it is the therapist’s “personal feeling style” that determines countertransference rather than any contribution by the patient. Recently, Holmqvist (2000a) has looked into the influence of countertransference on treatment outcome, finding that certain patterns of negative and positive feelings on the part of the psychiatric staff have an effect on positive outcome, depending on the whether the patient has a diagnosis of psychotic or borderline personality organization. Returning to the subset of reactions previously identified as “habitual” (Holmqvist & Armelius, 1996b), it was found that staff members who felt helpful toward patients tended to have a more positive image of mother; whereas those who felt more rejecting held negative parental images. Often in the theoretical literature, it is speculated that countertransference is a reflection of patients’ internalized relationship patterns. This was confirmed by the authors (Holmqvist & Gustafsson, 2002) who noticed some variation that merits further study.

Hayes, et al. (1998) pointed out that hypotheses in quantitative research lack grounding in field data that could come from qualitative studies. Their study is the first major naturalistic study attempting to provide a foundation for a theory of countertransference that is clinically and empirically based, while characterized by being deeply informed by field data. They define countertransference narrowly, as “irrational reactions emanating from unresolved issues within the therapist” (p. 468). This study explored the origins, triggers, manifestations, and effects of countertransference. They found that many stimuli triggered countertransference reactions, such as the therapist’s perceptions and assessments of the patient, what the patient said, and changes in

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procedures. Cultural and family issues, needs, and values as well as areas related to conducting the therapy led to manifestations of countertransference that the authors described as either drawing the therapist closer or pushing the therapist away from the patient. An effect of countertransference was to lead to reflection that informed decisions about the therapeutic process.

It appears that the obstacles to studying countertransference have been overcome and that there is a healthy interest in understanding the phenomenon in depth in order to use these insights to inform the therapeutic endeavor. Theories on countertransference are well developed; research to test these theories is well under way. There is precedent for investigation of countertransference to a particular subset of patients with a discreet diagnosis (Holmqvist, 1998, 2000b; Little, 1951; Heinrich Racker, 1968). An exploration o f countertransference to fat patients should take into account the findings of Hayes et al (1998), who demonstrate the need to understand the impact of the patient’s environment on countertransference, including cultural and family factors as well as the patient’s values. The following overview of the literature on obesity and fat is designed to fulfill this need.

Overview o f the Literature on Obesity and Fat It seems to me necessary to point out that a mechanical approach to overweight carries grave mental health hazards. The road of propagating scientific standards o f nutrition is littered with landmarks of overly zealous errors and failures. It is my impression that the over-eager propaganda about reducing diets, even though obesity is an abnormal state of nutrition, overlooks a basic human problem, the need for satisfaction of vital needs. (Bruch, 1973a, p. 208)

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The proportion of “overweight” and “obese” (for definitions, see below) adults in the United States has increased in recent years to approximately 64% of U.S. adults (National Center for Health Statistics [U.S.], 2002a). Chances are good that clinical social workers will work with many people who are considered overweight or obese. Clinicians need to be well informed about the characteristics, needs, and experiences of this population. The following section is meant to provide an overview of several disciplines that have contributed to understanding the experience of fat people. Using an inter­ disciplinary approach is consistent with the social work tradition of valuing the interaction of biological, psychological, and social factors that influence the well being of the patient.

I have divided the literature on obesity and fat into three main areas: (a) science and medicine; (b) the cultural context, including contributions from history, sociology, philosophy, semiotics, feminism, and gender studies; and (c) psychology and psychoanalysis, including literature on body image. There is a great deal of literature related to obesity in each o f these areas. This review is not intended to be comprehensive, but will serve to provide a context for exploring countertransference to fat patients. In the interest o f providing a digestible overview, I will focus on the major theories, research results, trends, and controversies.

Science and Medicine A study of obesity must begin with a definition, which, for the purposes of this section, will originate in the scientific and medical literature. This will be followed by a

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description of prevalence and trends. Finally, I will discuss treatment for obesity in view of the controversy over the association of obesity with pathology.

Since the 1960’s, the U. S. government has kept statistics on weight that are relied upon in scientific and medical research (National Center for Health Statistics [U.S.], 2002a; Wadden & Stunkard, 2002). People are classified as “healthy weight,” “overweight,” or “obese” using a widely accepted measure approved by the World Health Organization called the Body Mass Index (BMI). These terms are not merely neutral measures of size, but carry an implication that weight and fat are disease factors. Body mass takes a person’s height and weight into account. The formula is calculated by dividing weight in kilograms by the square of height measured in meters, or kg/m2. The range of BMI considered “healthy” is 18.5-24.9. “Overweight” is 25-29.9 and “obese” is greater than or equal to 30. The Body Mass Index does not describe the amount of excess body fat (again, an implication of pathology) that a person carries; it only describes a person’s size. As visceral obesity has been associated with disease (Bjomtorp, 2002), it has been recommended that circumference measurements be taken into account.

There was little variation in weights during the first two decades of measurement of BMI (National Center for Health Statistics [U.S.], 2002b). Since 1980, obesity has increased from 13% to 28% of men and 17% to 34% of women. There is little variation among racial groups for men; however, among women, the prevalence among blacks is 61% higher than among whites. This variance has yet to be explained (Hill & Melanson, 1999).

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Seeking an explanation for this sudden increase in body weight leads us to the controversy which is currently raging over the causes of weight gain and the implications for health (Bray & DeLany, 1995; Hill & Melanson, 1999; Kirschenbaum & Fitzgibbon, 1995; Neumark-Sztainer, 1999). Before looking into this debate, a glance at history provides us with a relevant and intriguing piece of information to those of us who are young enough never to have heard our doctors tell us that fat is healthy. Peter Steams (1997), in his history on fat, described a radical turnabout in the attitudes of the American public at the beginning o f the 20th century. While consumptive diseases were claiming many lives, doctors used to advise their patients to avoid losing weight and to keep a “healthy” amount of fat on their bodies as a kind of insurance policy. Only when these diseases were conquered could doctors consider the idea of supporting weight loss efforts. However, this was not the major stimulus to the change of the attitude of the medical establishment toward fat; in fact, according to Steams, this change was consumer driven. Valuing thinness was a fashion trend, and it was the patients’ demands upon doctors to prescribe diets that led the medical profession to get on the weight-loss bandwagon, very reluctantly, and not until the 1940’s. As we explore the attitudes and practices of the scientific community related to obesity, it seems important to keep in mind the many possible influences on motivation when it comes to assessment and treatment.

What is the current opinion of the scientific community about the cause and treatment of obesity? Bray and DeLany (1995) surveyed physicians and scientists who conduct research on this topic and found that there was agreement that metabolic

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contributing factors were primary, only slightly ahead of physical inactivity. Although most thought that low-fat diets would be the best treatment, there was some awareness of the problems associated with weight cycling. North Americans tended to emphasize exercise over dieting, feeling that drug treatment was also less effective, but that there might be hope for that method in the future. Other studies (Blumberg & Mellis, 1985; Hill & Melanson, 1999; Price, Desmond, Krol, Snyder, & O'Connell, 1987; Robinson, Bacon, & Oreilly, 1993; U.S. Department of Health and Human Services, 2001) showed that this is the generally accepted opinion of the scientific community. However, a controversy has emerged due to the appearance of eating disorders as well as the widespread experience o f great difficulty with losing and maintaining weight. In an article that describes this controversy, Neumark-Sztainer (1999), from the School of Public Health at the University of Minnesota, pointed out a polarization between professionals who work with obesity and those who work with eating disorders. Groups of lay persons such as those who represent the fat acceptance movement and teenagers who want to lose weight quickly are often at odds with health care professionals. She stated that although scientific research associates fat with increased health risks, there are other reasons to promote size acceptance, such as the difficulty of losing weight and maintaining weight loss, the stigma associated with being fat, and the prevalence of unhealthy attempts at weight control among young people who have gained weight. The cause of obesity is also up for debate: “viewpoints among professionals tend to differ with regard to the main contributing factors, and range from those in which the major focus is on genetic factors to those which focus more on individual choices regarding

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behavioural implementation” (p. S32). Others see the family and society as determining the conditions that have a major impact on one’s eating patterns and weight gain. These different views of etiology have an impact on treatment decisions. “The dilemma which then arises, is how to encourage people to take responsibility for their eating and exercise behaviours, without blaming them for being overweight” (p. S33). Neumark-Sztainer described the controversial views on obesity in terms of two extremes: those who believe that obesity has negative consequences for the individual and society, and those who believe that the treatment is difficult, ineffective, and not worth undertaking.

The Surgeon General of the U.S. Department of Health and Human Services, took a firm position in the first camp. In the Foreword to his recent “Call to Action” (U.S. Department of Health and Human Services, 2001), he used the words epidemic and tragic (p. XIII) to characterize the increase in the prevalence of overweight and obesity. He predicted that obesity would cause as much disease as smoking and stated that obesity is a risk factor for heart disease, diabetes, and cancer, among other health problems. Citing both personal and community responsibility, he called on government agencies to create a public health initiative that will reduce the prevalence of overweight and obesity. He based his call for research on an assumption that obesity is preventable and treatable.

However, he acknowledged a need to counteract the stigma associated with being fat and an overemphasis on appearance.

There are several recent articles that describe the epidemiological research that would lead one to conclude that the Surgeon General’s concern is justified (Allison, Fontaine, Manson, Stevens, & Vanltallie, 1999; Brownell, 2002; Hill & Melanson, 1999;

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Komer & Aronne, 2003; Manson, Skerrett, & Willett, 2002; Mokdad et ah, 1999; Must et al., 1999). Field, Bamoya, and Colditz were three Harvard professors who surveyed the research that supports this view (2002). They agreed that obesity is a public health concern of great import, citing higher weights as risk factors for mortality and a number o f diseases such as cardiovascular disease (CVD), cancer, diabetes, and mortality. They pointed out a clear causal relationship between excessive weight and death; in particular, death from CVD. Obesity worsens many diseases including hypertension, osteoarthritis, gallstones, dyslipidemia, and musculoskeletal ailments. They delineated consequences of being overweight that affect mental health, including societal rejection and mistreatment, diminished well-being and quality of life, and limits on physical functioning and vitality.

In economic terms, they described the “disease burden” of obesity to be 7% of spending on health care, with indirect costs at $48 billion for the year 1995. They emphasized the need for prevention and concluded “doctors should counsel their patients on the importance of maintaining a healthy weight and help their overweight patients lose weight and maintain the loss” (p. 13).

Health professionals who challenge the epidemiological data on obesity (Gaesser, 2003; Robison, 2003b; Szwarc, 2003) presented an alternative view o f causes of the increase in obesity and the implications for action. Robison (2003b) agreed with the national consensus that weight is on the increase, but raised three areas of controversy: “(1) whether this increased weight is necessarily a bad thing, (2) whether there is really anything we should or indeed can ‘do about it,’ and (3) whether current approaches are helping or making things worse” (p. 1).

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Scientific evidence that provides an answer to these questions is easily misinterpreted and manipulated. Szwarc (2003) pointed out four common problems with interpretation of data: (a) the tendency to equate causation and association (e.g. obesity causes health problems); (b) focus on only one factor—fat, and failure to investigate alternative explanations (e.g. inactivity, quality of diet, SES, race, age, and gender); (c) conclusions that do not match the data (such as ignoring the fact that only extremely obese patients experience higher rates of cancer and claiming that obesity causes cancer); and (d) generalization (claiming that all Americans must worry about obesity although most of the health problems associated with obesity affect only 4.7% of the population, those at a BMI o f 40 or more).

Much has been written in disagreement with the prevailing views of the medical community when it comes to losing weight (Robison, 2003b). A well-known representative of the alternative view is Glenn Gaesser (2002; 2003), who has taken the approach of examining the integrity and conclusions of existing research on obesity.

According to Gaesser, beliefs that obesity is unhealthy and that losing weight improves both health and longevity cannot be supported by research. “These beliefs are so deeply ingrained in our fat-phobic culture that they are seldom questioned� (Gaesser, 2003, p. 8) For example, the commonly cited statistic that obesity kills 300,000 people every year is based on two sources, one that does not address the relationship between obesity and mortality and another that fails to control for other possible factors leading to death.

Gaesser (2003) debunked several myths. First is the idea that thin people are healthier than fat people are. In fact, the government study that is the basis for the widely

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used statistics on obesity (National Center for Health Statistics [U.S.], 2002a) shows a Ushaped relationship between BMI and mortality, demonstrating that among some groups, those labeled “overweight” are the healthiest. Data from this study contradict their own recommendations for a healthy weight range, which is found to be more risky than being overweight. His second target was the tendency to exaggerate the health risks of obesity.

For example, he referred to the possibility that weight cycling and other unidentified factors might explain high blood pressure rather than the presence of body fat and pointed to the evidence for this. Third, no study backs up the idea that one will live longer if one loses weight. Finally, although people are advised to lose weight and keep it off, this does not seem to work. He showed that dieting is associated with weight gain and suggests that it may be contributing to what is called an epidemic of obesity. He named several limitations of the research that claims that permanent weight loss is achievable.

The implications of these findings are addressed by a movement of health care professionals and scientists called Health at Every Size. As a spokesperson for this group, Robison (2003b) has ironically joined the Surgeon General’s call for action with a set of priorities of his own:

•

•

•

Priority #1. Undo the damage that has already been done by educating the public about weight prejudice and the obsession with thinness—where it comes from, who is behind it, and what kind of damage it is doing, particularly to women and children.

Priority #2. Cease from using or endorsing traditional weight loss approaches (i.e., calorie restriction, exercise prescription, behavior modification, medication, etc.) until such time as they are shown to be effective and safe.

Priority #3. Redirect the focus for people of all sizes toward promoting selfacceptance, positive self-image, internally directed eating, and pleasurable physical activity in the context o f a “holistic” health approach that includes

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the social, emotional, and spiritual as well as physical aspects of the human experience, (p. 16) Here we see the impossibility of separating biological and social science when seeking to understand the experience of fat patients. Let us turn to an overview of the cultural context of the phenomenon.

The Cultural Context April Fallon (1990), in her discussion of the socio-cultural determinants of body image, differentiated between two views. There are those who believe that the ideal body has evolved as a reflection of the survival needs of humanity—what is attractive is whatever body shape is useful for keeping the species alive. She pointed out exceptions to this rule and argued that the key determinants are cultural, reflecting the values of a particular group and the meaning that a group assigns to bodily traits. The resulting preferences vary widely among cultures, usually shaped by genetic and biological factors, but not limited to them.

It may be that there are biological implications to fatness that would shape our feelings about and attitudes toward fat people. Yet, “body ideals vary among cultures as well as within cultures across groups and tim e.. . . In the United States, African American, Hispanic, and Native American women, despite having higher average body weights, are more satisfied with their bodies than are Caucasian women� (Jackson, 2002, p. 18). Variance within a culture lends support to the viewpoint that culture is a strong determinant of attitudes toward weight.

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A look at the history of the study of body image (Pruzinsky & Cash, 2002a), provides us with a broader view. These authors believed that an understanding of attitudes towards fat must be constructed by integrating theory and empirical studies from many different viewpoints: sociocultural, developmental, psychodynamic, cognitivebehavioral, information processing, feminist, and medical, among others. This is a reminder that a cultural perspective such as Steam’s, although instructive, might be limiting. Cash and Pruzinsky (2002a) have written an extensive chapter with many recommendations for future research in this area, implying that there is much that is yet to be understood.

As part of this broader view that informs this study, I will turn to the examination of sociocultural literature on fat, beginning with a look at history. Next will be an overview of ideas of writers from the disciplines of sociology, feminism, gender studies, and interdisciplinary studies. Finally, I will provide a philosophical perspective, including contributions from the field of semiotics, which will be useful in understanding the subsequent discussion of psychological aspects of fatness.

A few writers have provided comprehensive histories of fatness in the United States (Beller, 1977; Schwartz, 1986; Steams, 1997). In his recent review of the literature on this subject, Steams (1997) stated that he believes previous authors have missed the meaning of a key turning point in history, between 1890 and 1910. Before this time, body styles changed frequently, but the turn of the century marked a shift toward a systematic pursuit of thinness that has lasted and intensified. This shift was marked by changes in men and women’s fashions, the appearance of reducing devices, and the emergence of

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public discourse on fat. Steam’s explanation for these signs of change is rooted in the moral values of the culture. “Controlling appetite has been a significant component of appropriate moral and religious behavior at many points in human history and in diverse cultures” (p. 64). At the end of the 1900’s, two trends had moral implications that were expressed through devaluation of fat and consequently fat people. One was the rise of consumerism; the other was the changing sexual ethics correlating with the decline of the valuation of motherhood.

As religious discipline declined for many middle-class Americans, even devoted churchgoers, restraint in eating and its inescapable manifestation o f slenderness took on independent moral functions, denoting good character to those who might through diet salve their consciences, made somewhat uneasy by growing consumerist and sexual pleasure. Fat became a secular sin and an obvious one at that. (p. 64) Steams maintained that weight concern was a “clear cultural construct” (p. 65), with an intensity not to be matched in any other culture. Dieting took on religious qualities as a symbol of moral discipline and a manifestation of good character.

One century later, the obsession with fatness continues. Cavallaro (1997) showed how the development of eating disorders plays out what Steams described: “The anorexic body mirrors a work ethic of extreme self-discipline. The obese body symbolizes total self-indulgence. The bulimic body combines unrestrained consumption with drastic ‘cleaning-up’ practices” (p. 24).

It appears that the movement toward controlling fat was partly a reaction against consumerism. Ironically, the mechanism by which people reacted, weight loss dieting, has been incorporated into the consumer culture (Schroeder, 1992; Schwartz, 1986). S. Bryn Austin (1999), wrote about “the commodification o f health” from a social

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constructionist perspective (see Preface, Sobal & Maurer, 1999) by examining the market dynamics related to low-fat, a weight reduction trend beginning most recently in 1989.

She described how promoters of public health interact in partnership with the food industry, encouraging consumers to buy commodities that will solve health problems.

These problems may be real or merely anticipated. “The stalking of dietary fat in public health promotion has been pursued with a zeal well beyond that justified by the field’s own scientific research” (p. 175). Austin warned us to beware of the effects of consumerism that can cause us to accept standards that are not borne out by research and that can be harmful. Later, I will examine writing from the field of psychology on the potential harm that dieting can create.

An opposing view was put forth by Alan Wood (2002) who believed that the current focus on the food industry as a culprit to be attacked in a “war on fat” is misguided. He characterized this as an ideological attack by those who would seek to limit the market economy and its corresponding individual freedoms. For the Surgeon General to promote a campaign of public education might be reasonable, but government intervention through regulation is an assault on personal freedom and an affront to individuals in its assumption that they cannot manage their personal lives.

Here we see fatness as a focus of politics and power. Braziel and LeBesco (2001) noted that obesity literature is slanted toward a view of disease and disorder. They sought to deconstruct current discourses of consumerism, medicine, and psychology in order to “suggest new ways o f recognizing the power and politics of corpulence” (p. 8). A number o f new ideas and approaches emerge from this collection of writings including the

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exploration of modem views of fat as beautiful; fat-phobia in existence before 1900; present day ideological contradictions in the standards of beauty; ambivalence about sexuality and corpulence; and fatness “not as a fixed cultural construction but rather as a mobile category, capable of being revalued” (p. 11). The writers in this volume challenged scholarly assumptions about fatness and its sociocultural context and issued a call for further study of the social constmction o f fatness in the overlapping areas of race, class, gender, and sexuality.

What we currently know about these areas has been reviewed in an article by Bowen, Tomoyasu, and Cauce (1999). Although these authors viewed gender, poverty, and race as “risk factors,” assuming that obesity is pathological, they are sensitive to the fact that these variables are usually ignored in the obesity research. They noted the fact that prevalence of obesity is not evenly distributed by race, social class, or gender (National Center for Health Statistics [U.S.], 2002a). Women tend to be overweight more than men are, Black women in particular. A striking difference exists among Latinos of both sexes, whose incidence of obesity is 4-6 times higher than that of other Americans.

Societal pressures to be thin are stronger for women than for men, and correspondingly, body dissatisfaction is higher among women. Class interacts with gender, leading to a higher prevalence of overweight among lower socioeconomic (SES) groups of women, along with a greater degree o f stigmatization. There is no definitive explanation for class difference, but speculation is around budgetary constraints, marketing of fast food to the poor, the lack of restrained eating behaviors, lack of education about nutrition, and a lack of control over one’s environment. Least studied are racial factors. Citing a lack of

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empirical research, the authors venture explanations for the higher levels of obesity among “non-White” and non-affluent women: (a) exclusion from the dominant culture; (b) economic and environmental constraints; and (c) a stereotype connecting minority women with being well-nurtured and overweight. “Given the judgments of mainstream ideology that regards obesity as an example of personal lack of willpower, strength, or value, it is no wonder that the higher prevalence of obesity in minority and poor women reinforces existing race and class oppression” (p. 300). The authors concluded that empowering women to take control of their lives and health is a more helpful approach than weight reduction or nutrition education programs.

The correlation of obesity with oppressed groups in society suggests that the association is not coincidental, but reflects a bias against fat people as a group. Fat bias, phobia, prejudice, and discrimination have been the focus of attention by researchers from several disciplines (Puhl & Brownell, 2001). A number of measures such as the Antifat Attitudes Test and the Fat Phobia Scale have been developed and reviewed (Bacon, Scheltema, & Robinson, 2001; Lewis et al., 1997; Yuker, 1995). No instruments have gained wide acceptance and only recently have reliable measures been developed (Yuker, 1995). Nevertheless, Puhl and Brownell (2001), in their recent review o f the literature on bias, discrimination, and obesity, cited “clear and consistent scientific literature showing pervasive bias against overweight people [and] sufficient evidence of discrimination to suggest it may be powerful and occurs across important areas of living” (p. 800). Three factors characterize bias: (a) an assumption that overweight people have many flaws; (b) a belief that overweight people are imperfect and responsible for their

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size; and (c) based on this responsibility, they deserve the discrimination that comes their way. Discrimination takes place in many settings such as the workplace, where fat people are seen as less qualified and are therefore less likely to be hired, paid less, and passed up for promotions. In educational settings, children are the target of teasing and exclusion from educational opportunities, even to the extent that parents discriminate against their own overweight children in providing college support. In the health care field, “very negative” attitudes prevail and can keep fat patients from seeking care. O f particular relevance to the current study, Touster (2000) demonstrated how psychology texts continue to present outmoded information about obesity and perpetuate myths that are harmful to students and patients.

Two recent studies (Crandall et al., 2001; Crandall & Martinez, 1996) used a cross-cultural approach to better understand the origins of bias against fat. It seems clear that cultures where the prevailing ideology is one that holds individuals responsible for well-being are those where negative attitudes toward fat develop into prejudice and discrimination.

Very recently, a study (Teachman, Gapinski, Brownell, Rawlins, & Jeyaram, 2003) was undertaken to explore the possibility that bias toward fat people could be altered. “Implicit” anti-fat bias, which a person demonstrates without self-knowledge, was strong and not easily influenced. Despite these discouraging results, discourses outside the scholarly literature indicate that there is much activity directed towards fighting fat prejudice. Informal and formal communications on the Internet have this explicit purpose. One example is “showmethedata,” a listserv that exists for the

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discussion of research that reviews and debunks the mainstream publications on obesity.

Websites that encourage a “Health at Every Size” approach abound, a particularly good example being “Body Positive” (www.bodypositive.com) and “Fat! So?” (www.fatso.com). A myriad of organizations in support of fat acceptance and activism exists and has a web presence, two major groups being the National Association to Advance Fat Acceptance (NAAFA) and the Council on Weight and Size Discrimination.

A search of the Web leads to many discourses representing fiction, art, music, and poetry that celebrate bodies of all sizes and promote self-acceptance. Narratives of the experience of being fat provide a valuable source of qualitative data such as a qualitative dissertation by Dolomare (1999) and a collection of self-reports called Fat Like Us (Anspaugh, 2001). One o f the most compelling arguments with the potential to counteract fat bias is found in the literature on eating disorders such as anorexia and bulimia, showing how attitudes toward fat create a context for the adoption of extreme, destructive behaviors in order to avoid gaining weight (Gordon, 2000; Herzog, Deter, & Vandereycken, 1992; Winston, 2000).

The evidence that women are much more sensitive to weight gain and more of a target o f size discrimination than men has been the subject of much writing by feminist authors (Bordo, 1993; C. Brown & Jasper, 1993b; Burgard & Lyons, 1994; Chemin, 1985; Goodman, 1995; Maclnnis, 1993; Orbach, 1978; Wolf, 1991). Susie Orbachis often seen as the mother of the feminist writers on eating and weight. In a famous book (1978), she said: Fat is a social disease, and fat is a feminist issue. Fat is not about lack of selfcontrol or lack of willpower. Fat is about protection, sex, nurturance, strength,

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boundaries, mothering, substance, assertion and rage. It is a response to the inequality of the sexes. Fat expresses experiences of women today in ways that are seldom examined and even more seldom treated. While becoming fat does not alter the roots o f sexual oppression, an examination of the underlying causes or unconscious motivation that lead women to compulsive eating suggests new treatment possibilities, (p. 19) During the early 90s, several major works were published on women, weight, and eating (Bordo, 1993; C. Brown & Jasper, 1993a; P. Fallon, Katzman, & Wooley, 1994; Goodman, 1995; Wolf, 1991). These authors wrote about the connections between eating disorders, fat prejudice, and the oppression of women. They suggested new ways for the modem woman to think about her body and her eating, emphasizing healthy eating and self-development rather than pathology.

Feminists view female preoccupation with weight as a “cultural disorder,” not a medical one, an outgrowth of the cultural construction of femininity based on a sexual division o f labor between more “female” domestic concerns and the more autonomous, public “male” arena (Bordo, 1993). “By exerting control over their bodies, women hope to gain self-esteem and an increased sense of power and control over their lives.

Powerlessness and dissatisfaction can be replaced by the self-satisfaction, social approval, and sense of accomplishment won through weight and shape control” (C. Brown & Jasper, 1993b, p. 17). This view, in its confrontation of the existing social order, has led to the development of a stereotype of “the ugly feminist” (Wolf, 1991) and a backlash in the form of “images of female beauty as a political weapon against women’s advancement: the beauty myth” (p. 10). Wolf described the beauty myth as a currency system, determined by politics and ideology, with the goal of keeping male dominance intact. The myth uses images of beauty to prescribe behavior.

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Women who become fat experience a double bind: In escaping from the oppressive dictates of the pursuit of thinness, they become social outcasts. Feminist authors have focused on the particular plight of fat women in America (Burgard & Lyons, 1994; Goodman, 1995; Maclnnis, 1993). In a chapter on fat oppression, Beth Maclnnis (1993) emphasized a need to dispel myths associated with women and fatness, including generalizations that fat people overeat and are unhealthy. Maclnnis criticized Orbach (1978) for her suggestion that giving up dieting and accepting one’s body would lead to weight loss. “Underlying such an analysis are the assumptions that fat is abnormal, that women choose their body sizes, and that the choice to be fat represents some unresolved psychological conflict” (p. 76). The bias that underlies societal views about fat people was the subject of a book by Charisse Goodman (1995). In her description o f the fat woman as “anti-status symbol,” i.e., “failed sex object,” she pointed out the objectification of woman as commodity. Her chilling comparison of fat prejudice to anti-Semitism pointed out the origins of Nazism in the eugenics movement, an ideology that ascribes human worth to the achievement of body perfection and a narrow definition of acceptability. Feminists Debora Burgard and Pat Lyons (1993) have proposed a comprehensive strategy to combat fat oppression. “The two of us— a psychologist specializing in eating and dieting disorders, and a nurse/health education consultant specializing in health care access and delivery, respectively—work to help women be as healthy as they can, whatever their size. We focus on health and self­ acceptance, not weight loss” (p. 212). This approach has become widespread and is now popularly called the “Health at Every Size” approach.

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The last discipline to be consulted in this overview of the cultural context is philosophy, and in particular, the areas of linguistics and semiotics. Cavallaro (1997), in a book about the body from a philosophical perspective wrote: Many contemporary philosophers argue that there are no substances or ideas outside language. Substances and ideas are not realities which language reflects but rather cultural categories which language constructs. The body is no exception. It, too, is primarily a product of language, a representation^ It is only through language that the body gains meaning.. .Often the “ideal” is only ideal for certain people, it only fuels limited interests, (pp. 6-7) Representation and meaning making are concerns of a discipline called “semiotics,” the study o f signs such as words, images, and sounds to be found in various media (Chandler, 2002). (More on the contributions of semiotics to the understanding of the experiences of fat patients will be included in the discussion of psychology, below.)

Originating in the study of structural linguistics, modem semiotics has evolved to include the use of signs in social interaction, with a particular emphasis on the ways that signs serve ideological purposes. A semiotic understanding of the word fat would describe its meaning in association with people, with social interaction, and with ideologies that might make use o f these associations for the promotion o f particular ideals. For example, feminist authors (Goodman, 1995; Wolf, 1991) above have suggested that fat is associated with “female” and is used by the dominant group in society to discriminate against and control an underclass. Cavallaro (1997) pointed out that the female body is denigrated as part of a general trend that abuses all forms of “otherness.”

Kathy Davis (1997), a critic of the notion of deconstructing the body as a symbol said, “Bodies are not simply abstractions, however, but are embedded in the immediacies of everyday, lived experience. Embodied theory.. .needs to explicitly tackle the

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relationship between the symbolic and the material, between representations of the body and embodiment as experience or social practice in concrete social, cultural and historical contexts” (p. 15). This recommendation is the basis of a recent book (Coupland & Gwyn, 2002) that explored the body as an interactional resource, as a vehicle for ideological representation, and as an aspect of pathology in constructions of selfhood. Authors drew upon the experiences of individuals, as in the story of “M”: The “need” to lose weight on the part of M, who is otherwise expressly satisfied with his body image . . . may be an unreasonable proposition.. . . But this may also be an expression of a widespread fear of humans to lose (or never be able to attain) a perfect body they crave, or to ward off the inevitable: deterioration of one’s body, death and decay, for as long as possible. (Jaworski, 2002, p. 164) In the mainstream social discourse, there is a denial of subjectivity when it comes to the fat body (Kent, 2001). People from the fat liberation movement have provided representations in several media, attempting to counteract this problem by “rewriting the fat body to challenge both abject images of the fat body and the horror of the body itself’ (p. 132). Examples given are images of fat nude women with essays and poetry about them and other “fat-positive” publications outside of the mainstream.

Contributions from the socio-cultural literature to the understanding of the meaning of fat and the experience of fat people have greatly increased in recent years. A trend toward an inter-disciplinary approach has provided a rich synthesis. It no longer seems possible to make clear distinctions among “bio-,” “psycho-,” and “social-” factors in any discussion of human experience. As we will see below, much of what we have understood from studying medicine and culture will inform the literature from the fields of psychology and psychoanalysis, described in the following overview.

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Psychology and Psychoanalysis The biopsychosocial perspective that is important to clinical social workers is particularly useful in assessing needs of fat clients. Using this perspective, Melcher and Bostwick (1998) wrote an article that was intended to oppose societal myths about fatness and educate social workers about the nuances of assessment. They suggested some diagnostic categories that present a strong contrast to the widespread assumption that fat is pathological: (a) “normal and knows it,” (b) “normal but doesn’t know it,” (c) “well-adjusted overeater,” (d) “emotionally troubled normal eater,” (e) “emotionally troubled overeater.”

Although references have been made to obesity in the psychology literature for a long time, the first major article to be written on the psychological aspects of obesity was

by Hilde Bruch (1947). Bruch’s ideas were from the psychoanalytic viewpoint, the dominant school of psychology of her time. Since then, psychologists seem to have forgotten her contribution and only recently have begun to return to her line of thinking: “If we speak of psychological aspects of obesity it is well to remember that the remarks apply only within the cultural and social setting in which observations have been made, and only to that fraction of the large number of fat people who come for treatment” (p.

374).

Recently, the trend toward cognitive-behavioral theory and treatment approaches has had a strong influence on the psychological literature (Cooper & Fairbum, 2002; Wadden & Foster, 2000; Wilson & Brownell, 2002). The primary goal of this approach is to help fat people lose weight through cognitive-behavioral treatment in order to improve

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health. Based on the current trend toward viewing obesity as an outcome of poor eating habits and diminished physical activity, the goal of this treatment is to modify those habits. The cognitive-behavioral approach described by Cooper and Fairbum (2002) distinguishes itself from purely behavioral approaches in that the focus is on cognitive rather than behavioral treatment, through a combination of cognitive and behavioral procedures. Again, the primary goal is weight loss and maintenance. Patients are helped to identify and moderate unrealistic weight loss goals; to address body image concerns; and to acquire the skills and cognitive responses needed in order to lose and control their weight. Cognitive-behavioral methods have not been evaluated. Research on behavioral methods shows a consistent weight loss of 7-10% of body weight and improvement in psychological well-being and health, but results are not maintained (Wilson & Brownell, 2002).

Scientific research does not support the stereotype that fat people suffer from mental illnesses that lead to weight gain; nor does it support the idea that fat people have a distinct personality style (reviewed by Wadden et al., 2002). Psychological heterogeneity among fat people is the norm, as it is among thinner people. Fat patients in clinical settings report some depression (10-20%), negative body image, or impaired quality of life. These authors conclude, Practitioners . . . must balance the need for attentiveness with the equally important need not to stereotype their obese patients—not to attribute psychopathology or other shortcomings to them.. . . More often than not, we are impressed not by patients’ emotional problems but by their resilient spirit and tenacious efforts to control their weight, (p. 163)

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Nevertheless, there is a strong trend toward associating fatness with the presence o f an eating disorder, probably because of a confluence of two events. First is the inclusion o f a proposed new diagnosis in the DSM-IV (American Psychiatric Association, 1994) called “Binge Eating Disorder” (BED). Second is the upsurge of interest in controlling fatness after the Surgeon General’s (2001) “call to action.” These developments have paved the way for research into the problem of overeating, which is commonly assumed a primary cause of fatness. Binge Eating Disorder includes episodes of binge eating without subsequent compensatory behaviors. An illustration of the way that causality can be constructed through psychological mechanisms is the following sentence that appeared in a review of the BED literature (Dingemans, Bruna, & van Furth, 2002): “Although the diagnosis BED was created with the obese in mind, obesity is not a criterion” (p. 299). The discussion section begins with this assumption: “Binge eating disorder and obesity are obviously associated with each other” (p. 305). In the same section, the authors then say, “the majority of the subjects with BED identified in community samples are not obese.” Another recent review of the literature on BED (Williamson & Martin, 1999) states that obesity and BED are highly associated. Turning to a review of the literature (Kaplan, 1999) on the relationship between eating disorders and obesity, the reader is reminded that “obesity alone is neither a psychiatric nor an eating disorder; it is not implicitly associated with a disturbance in psychological functioning or in eating behavior” (p. 197). Clinically significant binge eating among obese people is at a prevalence of 5% to 8%.

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An area that is often assigned to the discipline of psychology is the study of body image. The current trend is toward theoretical and empirical integration of a number of previous areas of focus, such as developmental, cultural, dysfunction and disorder, medical, psychosocial, and measurement (Pruzinsky & Cash, 2002b). Much of what we know about body image is included in the literature in other sections of this review; however, there are several authors that have made important contributions to this topic as a distinct field (Aron & Anderson, 1998; Bermudez, Marcel, & Eilan, 1995; Cash & Pruzinsky, 1990, 2002b; Gilbert & Miles, 2002; Kilbome, 2002; Krueger, 1989, 2002a). I will focus on psychodynamics of body image, consistent with the theoretical viewpoint of this study. The major contributor to this knowledge, David W. Krueger (2002b) discussed body image from a developmental perspective: The body and its evolving mental representation form the foundation o f a sense of self. While Freud recognized the ego as, first and foremost, a body ego, the more inclusive term “body self’ refers to a combination of the psychic experience of body sensation, body functioning, and body image. Thus body image is the dynamically and developmentally evolving mental representation of the body self, (p. 30) Krueger conceptualized the development of body self in three stages. During Stage 1, infants distinguish themselves from their environment through sensations in the body. An empathic caretaker, through attunement to the infant’s experience, contributes to healthy development of this boundary. After a few months of life, the infant moves into Stage 2 when boundaries pertaining to both the body self and the psychological self become more clear and unified. Beginning at about 15-18 months, the infant begins to distinguish between his or her own body and that of others. Two key tasks are (a) to consolidate a stable and cohesive mental representation of the body, and (b) to acquire a

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sense of distinctness and effectiveness. Successful development is important to the development of the psychological self and an overall sense of unity and continuity. Along the way, others’ reactions to one’s appearance are incorporated.

Developmental disruptions can be precipitated by over intrusiveness, over stimulation, empathic unavailability, non-responsiveness, and inconsistency or selectivity of response. The effect of disruption is manifested in the individual’s difficulty with representation of the body and ability to articulate affect. They look to others as a mirror for a sense of body self. Lacking a coherent sense of psychological self, they turn to felt experiences of their body as a substitute.

Krueger’s thinking on the developmental aspects of body image provides a context for exploration of other contributions from psychoanalysis to our understanding of the experience of fat patients. Hilde Bruch was a pioneer in this area as part of her writing on eating disorders. In 1947, she wrote an article, “The Psychological Aspects of Obesity,” that conceptualized obesity in the clinical population as “the somatic expression of a mal-development in personality maturation” (p. 381). She named overeating and lack of physical activity as the main contributors to obesity, noting defensive functions of these symptoms: (a) a way of coping with anxiety, and (b) a substitute for more constructive ways of achieving a sense of satisfaction. Bruch assigned symbolic meanings to the resulting large size of a person: (a) a sense of strength and security that are lacking in one’s relationships, and (b) thwarted development of personality. A contemporary, Alfred Schick (1947), viewed obesity as a psychosomatic

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symptom of conflicts related to instinctual fantasies; yet he acknowledged the possibility that it might also be genetically determined or a the result of metabolic inefficiency.

A quarter of a century later, Bruch (1973b) continued to emphasize her impression that the majority of fat people have no psychological diagnoses. Her focus was on those who sought help for weight loss after several failed attempts. She distinguished between those who had a great deal of difficulty tolerating dieting, and those who did not. She pointed out that a hostile culture and the tensions of dieting are contributing factors to weight gain. However, negative self-concept develops because of psychological vulnerabilities that make the person more vulnerable to the insults they receive from others. In one group, obesity and psychological problems are closely related; in another, they are not; in a third group obesity is the result of trauma. Some people experience “developmental obesity� in tandem with severe personality disturbance, due to a family’s failure to recognize a child as an individual and promote self-expression. As a result, the child lacks awareness of body sensations such as hunger and has a fragile sense of personal effectiveness in relationships. Weight loss does not solve the underlying psychological difficulties and may increase them.

Since Bruch explicated the psychoanalytic view of psychological factors associated with obesity, subsequent writers have not departed from this explication, but have attempted to demonstrate empirical validity of the view and enlarge upon theory (Battegay, 1991; Glennon, 2001; Glucksman, 1989; Rand & Stunkard, 1983; Slochower, 1987; Stunkard, 1980). There appears to be consensus that hyperphagia (larger than normal appetite with increased consumption of food) plays a part in obesity and that there

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is an emotional basis for this symptom, along with the possibility of metabolic or genetic factors.

Stunkard has extensive experience researching the psychodynamics of obesity. He recently (1996) emphasized the disease aspect of obesity and its “multifactorial” nature, implying that emotional factors may not be as significant in its development as once believed. When investigating emotional aspects of obesity, it is important to understand that appetite is a psychological mechanism that is associated with the pleasure of anticipation and is not necessarily related to hunger. Hyperphagia originates in the oral phase of development. It has an unconscious connection to emotions and wishes such as self-indulgence, providing a reward, identification with an obese father or mother, self­ sedation, avoiding competition, and counteracting boredom, among several other possibilities in addition to the originally posited function of anxiety management.

Glennon (2001) added the use of fat as a symbolic boundary in an effort to protect oneself from external impingement. It might also represent an unconscious desire to solidity a fragile sense of self, and other meanings idiosyncratic to the individual patient’s experiences, such as an attempt to protect a marriage from outside attempts at seduction.

Slowchower (1987) elaborated on developmental issues related to the problem of overeating. She noted that mothers who have difficulty turning responsibility and control over to their children set the stage for an enactment of separation issues through abnormal eating behaviors. A prolonged conflict between mother and child over food leads to a disconnection between the decision to eat and the sensation of hunger.

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Body image disturbance is thought to occur frequently among obese patients.

Glucksman (1989) identified of two types: (a) a distortion in self-representation, occurring, for example, as part of a defensive need to be big and powerful, and (b) a consequence of societal stigma due to a high value place on thinness.

Rand and Stunkard (1983) conducted an empirical study of the efficacy of psychoanalytic treatment of obesity. After four years, 93% of obese patients lost more than 20 pounds, a result that is much higher than for other kinds of treatment. Deprivation and gratification were issues that were often a concern. The development of a tolerance of painful emotions, especially those related to abandonment or separation, was an outcome of treatment. Patients also showed improved body image and self-esteem.

Psychoanalysis as treatment for weight related concerns appears to have value, but needs to be studied further, especially in light of what is now known about the near inevitability of regaining lost weight (Gaesser, 2003). Other indications of success besides weight loss might be evaluated.

Having set the stage for an understanding of the literature on countertransference to fat patients, I turn now to that literature.

Countertransference to Fat Patients In response to the question, “Why is there so much prejudice against fat people?�

Theodore Isaac Rubin, M.D., author of The Thin Book by a Formerly Fat Psychiatrist. replied: Gluttony and its concomitant sins have a long-standing place in human history, including early biblical origins. I think, however, that most people are

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contemptuous of fatties because obesity indicates a lack of self-control plus a narcissistic preoccupation with self-stuffing. If an overwhelming prejudice exists it is almost always concerned with oneself and often with one’s self-image which turns out to be that of a fat man. In short, this prejudice is a self-hate projected to the individual who most reminds the hater of his own feared and loathsome self.

(Rubin & Babbie, 1993, p. 117) One might wonder about this therapist’s need to use the term “fatties,” about his view of gluttony as a sin, and whether his advice might represent an unconscious explanation for his own countertransference. Feminist therapist Laura Brown (1989) suggested to her therapist readers, “A first step towards an anti-fat-oppressive stance is the acknowledgement of one’s own fat-oppressive attitudes. There need be no shame in this.” As we shall see in this review of the literature on countertransference to fat patients, negative attitudes on the part of health care professionals are not unusual. It seems that there is only one reference (Drell, 1988) to “positive countertransference” in the literature, which is associated not with fatness, but with the good feelings that the therapist gets from helping a patient to lose weight. The possibility that therapists could have positive feelings about fatness seems to be missing from the research and may be another reflection of bias.

There appears to be only one research study (Brotman et al., 1984) of therapists’ countertransference to fat patients, and only three directly relevant theoretical contributions (Davidson, 1980; Drell, 1988; Ingram, 1978) to the understanding of the phenomenon. Douglas Ingram (1978), in an article about “counterresistance” in the treatment of an obese woman, referred to the lack of research on psychoanalysts’ attitudes about obesity. Warning of the dangers of lack of self-examination, he said, “It may be supposed that we, too, have matured in a climate in which unchallenged

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assumptions concerning obesity prevail; neither in the medical community, nor among fat people has there been a successfully proclaimed prerogative that allows one to be fat without censure” (pp. 155-156). In what seems to be the only theoretical article that is entirely devoted to the discussion of countertransference and the obese patient, Drell (1988) guessed that many therapists feel helpless and ineffective, saying that no research has been conducted on the subject. (Drell must have overlooked the 1984 study by Brotman, possibly because the title does not mention the fact that psychiatrists were among the subjects studied and the main focus was on anorexia nervosa.) Citing the pervasiveness of negative attitudes in American society and the role that obesity plays in the obese patient’s psychological functioning, he urged therapists to explore and manage their countertransference to these patients. Both of these authors wrote during a period of nearly unmitigated prejudice and misinformation about fat people. Contemporary therapists might be more likely to have been influenced by the fat acceptance movement and exposed to research that challenges the notion of obesity as pathology. Nevertheless, this is a recent development. Robison (2003a), an expert in the evaluation of obesity research, stated, “Health professionals will have to be retrained to shift the focus of their work from weight loss to helping people to be healthier at their present weight. This training must incorporate deep introspection regarding personal prejudices and struggles surrounding weight and eating” (p. 6).

It may or may not be that therapists usually experience negative countertransference to fat patients, yet that possibility certainly lends urgency to the call for research. Before exploring the actual nature of therapists’ reactions to fat patients, it

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will be useful to study relevant literature. The following is intended to be a comprehensive review of research and theoretical publications on this topic.

Writing by major authors on two related subjects will also serve to guide the present study: (a) countertransference to patients who have eating disorders and (b) the therapist’s own body in the psychotherapeutic process.

According to the totalistic conception of countertransference (Epstein & Feiner, 1979), attitudes and beliefs might shape one’s emotional responses and vice versa.

Therefore, I will review studies of therapists’ attitudes toward fat patients and beliefs about them and use them to inform the current study. Again, these are very few in number. Some related studies of attitudes and beliefs will be reviewed for what they have to offer toward the understanding of this subject: (a) other health professionals and (b) bias and fat prejudice among health and mental professionals.

Theory and Research on Therapists’ Countertransference to Fat Patients The first of the three theoretical articles that discuss therapists’ countertransference to fat patients was written by Douglas H. Ingram (1978) of the American Institute o f Psychoanalysis. Ingram coined the term “cultural counterresistance” to refer to “cultural bias that interferes with the analyst’s perceptions and effective use o f his inner responses to the patient” (p. 159). Essentially an article on the nuances o f the definition of countertransference, the particular circumstances surrounding the treatment of obese women were used to demonstrate his point.

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Mentioning the research on fat bias among physicians, Ingram suggested that psychoanalysts might also discover that their bias stimulates them to promote weight loss, an intervention that runs contrary to the psychoanalytic viewpoint on neutrality. The analyst might consider obesity to be a sign o f distress without considering research that points to constitutional and genetic factors. “A dismissive attitude about the physiology of obesity may result not only from the analyst’s participation in the culture’s derogation of obesity, but also from glorification of psychoanalysis with consequent devaluation of nonpsychoanalytic perspectives” (p. 157).

Another possible reaction on the part of the analyst could be sympathy for the patient who might be socially disabled by her condition. Expressing that feeling might prevent the patient from discovering an unconscious need for her fat and how her obesity and overeating might serve as a neurotic solution (to what problems, he did not mention).

It could also interfere with the appreciation of patient transference.

Considering the importance of thinness as a current fashion trend, Ingram’s concluding words seem particularly useful for therapy with fat patients.

Counterresistance proceeding from powerful cultural pressure may blur the analyst’s awareness of how much his own reparative urges are reactive to the patient’s unconscious prompting, on the one hand, or, on the other, of how much they are reactive to the analyst’s continued acculturation. Recognition of this form of counterresistance is enhanced by, and contributes to, the analyst’s inquisitiveness, skepticism, and wonder. These, in turn, increase the effectiveness of psychoanalysis by reducing arbitrary compliance with current fashion, (p. 160) The second o f three theoretical articles that mention countertransference to fat patients is one by Leah Davidson (1980) of the William Alanson White Institute. Writing about patients that therapists find hard to treat, she made brief mention of a crisis

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intervention case with parents whose son she perceived was “rather obese.” Davidson was able to recognize her prejudice toward fat people as she observed the boy’s weight and sulky demeanor and listened to the parents describe their differences over how to feed their son. She pointed out the importance of not becoming distracted by her countertransference so that she could focus on the real issue—the parents’ difficulty with parenting.

The boy could have had other traits besides fatness that might seem problematic to the therapist. Nevertheless, this first mention in the literature of countertransference to a fat patient made three important contributions, (a) It served as a starting point for further discussion, (b) The writer showed the ability to recognize fat prejudice that is absent from previous writing on therapy with obese patients, (c) She showed how to recognize and manage negative countertransference in order to stay on the therapeutic task and avoid harming the fat patient.

The third and most relevant article, “Countertransference and the Obese Patient” was written by William K. Drell, Baylor College of Medicine, in 1988. Drell’s focus was on improving therapeutic outcome for obese patients through careful management of countertransference, which is made up of feelings that are multiply determined. One must become aware of one’s feeling reactions and then use them as sources of information that inform therapeutic interventions. Drell’s definition o f countertransference was broad in that it included therapists’ thoughts as well as feelings, conscious and unconscious.

Drell first described therapists’ attitudes toward obesity, stating categorically “psychotherapy in general with obese patients is difficult” (p. 77). He revealed a

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pessimistic outlook about obese patients’ ability to make use of therapy. Agreeing with Ingram (1978) that sociocultural attitudes might influence the therapeutic relationship, he reviewed several scholarly articles about the negative reactions of the public toward fat people. These reactions are compounded by the belief that fat people are responsible for their disability, a belief that he shared. He agreed with Hilde Bruch (1957) that most suffer from the “unglamourous garden variety of obesity” (p. 78).

Drell described another source of countertransference deriving from the health risks that he believed were an unmistakable outcome of obesity. Not only do obese people suffer from health problems, but they also suffer from the negative judgments of physicians. He speculated that physicians cope with their feelings of helplessness and ineffectiveness by blaming the patients. Citing the lack of research on therapists’ countertransference to obese patients, his guess was that they share attitudes and behaviors matching those of physicians.

Therapists must be alert to the possibility “that the obese patient’s appearance may actually be repulsive, distorting the human physique to grotesque proportions” (p.

79). Therapists should explore and manage their feelings, and discuss patients’ feelings about their size and its relationship to other conflicts. He cautioned against either too little or too much of a focus on weight.

Turning to the uses o f countertransference, Drell discussed obesity as a neurotic solution (also referred to by Ingram, 1978, without further elaboration). First, he suggested that some obese patients use their fat as a defense against becoming aware of

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conflicted feelings. If, for example, the fat serves as a buffer in relationships, the therapist may experience an emotional reaction to the patient’s use of this defense.

Second, he cited research that tells of a group of obese patients whose body image is so disturbed that they become preoccupied with weight to the exclusion of other personality traits. Therapists may become impatient or angry with patients who continually disparage their own bodies and complain of insults by others. When the therapist feels the patient is unattractive, there may be a temptation to agree with the patient’s negative self-evaluation, colluding in the fantasy that weight loss will solve their problems.

Third, therapists may experience depressive anxiety when patients who have displaced self-hatred and distrust of others onto their fatness succeed in losing weight, yet do not feel better. This phenomenon of “dieting depression” happens when the weight that previously served as a mechanism for extemalization, is no longer available.

Fourth, therapists may feel afraid, inadequate, aroused, and other feelings when a self-effacing patient loses weight in order to seduce the therapist or make the therapist jealous of their romantic relationships.

Fifth, therapists may hope that weight loss will improve the well-being of those with schizoid or paranoid personality traits; yet, the loss of fatness as a defense against psychosis may contraindicate insight-oriented therapy for this group. Drell went on to say that many other obese patients are unable to make use of therapy, which can lead to feelings o f frustration on the therapist’s part.

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Finally, feelings of anger and ineffectiveness can arise when a patient comes for help with weight loss and then frustrates the therapist with bingeing or weight gain. Drell called this an example of complementary countertransference that could be used to identify similar feelings in the patient.

One possibility for positive countertransference occurs when the patient loses weight successfully. Drell cautioned against becoming seduced into expressing satisfaction and becoming “an overindulgent, gratifying mother-substitute” (p. 82).

In conclusion, the author pointed out that countertransference responses can be used to understand (often requiring the assistance of supervision) what the patient is feeling, particularly feelings that are split off and projected into the therapist. He listed several issues that call for further research.

It appears that no empirical research devoted wholly to the study of therapists’ countertransference to fat patients has been conducted to date. In 1984, Brotman, Stem, and Herzog of the Harvard Medical School published what may be the only relevant research, a preliminary study that was designed to stimulate further research. The subjects of the study were house officers, including psychiatrists along with other physician specialties. Data was isolated specific to each professional specialty and to each diagnosis. The main concern of the researchers was anorexia, with obesity and diabetes as comparison groups.

The authors used case examples to illustrate physicians’ negative emotional reactions with the potential o f reducing quality of care to the point of subverting therapy.

They followed this with a report of a survey done of house officers to assess the presence

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o f dysphoric affect toward their patients with anorexia, comparing them to obese and diabetic patients. The reason for choosing obese patients as a comparison group was that “their body habitus can be even more easily identified than that o f the anorectic, and both groups are in danger o f developing more serious medical complications on the basis of their eating behavior� (p. 73).

In this analogue study, 29 first-year residents responded to a questionnaire about hypothetical patients with a range of diagnoses and personality traits. They were asked to report on the presence and degree of particular emotional reactions. They were also asked to rate the degree to which quality of care was influenced by their feelings.

I will report on aspects of the study that are relevant to the present study of therapists and fat patients. The psychiatrists who responded (N=9) were divided almost evenly by gender, with an average age of 29.7 years. It was found that 44% of this group reported dysphoric (a measure combining results of several affect scales) affect toward obese patients, significantly less than they felt toward those with diabetes or anorexia. Of the five affects studied, all reported a lower degree of affect toward obese patients than toward the other two groups, except with regard to anger, which was felt equally toward obese and anorexic patients and much less so toward diabetic patients. Anger was reported by 77% of psychiatrists, stress by 44%, helplessness by 44%, sadness by 67%, and anxiety by 33%. A reported 67% of psychiatrists believed that their reactions had an influence on the quality o f their care.

In the discussion o f the results, the authors noted that limitations of the study included the small number of respondents and methodological problems with the

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dysphoria scale. Nevertheless, they felt the findings to be important because of the potential effects on patient care, noting that most of the respondents were aware of their reactions and recognized their influence on clinical care. They did not comment on the statistics related to obesity. Clearly, much negative affect toward obese patients is reported, an outcome that Drell (1988) had observed clinically and suspected was often the case.

Literature on Countertransference to Patients with Eating Disorders Therapists must be careful to keep in mind that there are many possible explanations for why a person might gain weight and to avoid an assumption that fat patients have eating disorders (Melcher & Bostwick, 1998). However, there may be some value in consulting literature on countertransference and eating disorders, which, by definition, involve an intense preoccupation with fat. Another reason for considering this literature is the strong association between binge eating disorder and obesity (Williamson & Martin, 1999). Binge eating disorder is a new diagnosis and to date, it has been missing from this literature in favor of anorexia and bulimia; however, bingeing as a feature of bulimia makes the literature relevant. The major authors will be included in this overview.

Therapists who work with fat patients may believe that they overeat and that this behavior can have adverse health effects. A concern of therapists who work with anorexia and bulimia is the self-destructiveness of these patients and its threat to patient health.

These fears cause many therapists to avoid taking patients with eating disorders into their

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practices, knowing that 5-8% of these patients are likely to die (K. J. Zerbe, 1998). Fear and anxiety may lead a therapist to focus entirely on the symptom as the problem.

“Weight in itself, however, is not necessarily a problem, although current collective attitudes would lead one to believe that success or failure in life and love depends on whether one is fat or thin” (Woodman, 1984, p. 54). When the therapist is able to hold the tension that the behaviors create, the therapist is emotionally available to “hold the mirror up to her illusions and her lies. Together we can call a spade a spade. Fat is fat, greed is greed, lust is lust, power is power, love is love. I think of myself as a tuning fork which must ring true if it is to resonate with her reality” (p. 58).

Cohler (1977) very much agreed: “the capacity of the therapist to bear these feelings o f anger, hopelessness, manipulation, and powerlessness is of the greatest importance for the treatment process. It is precisely when the patient can attribute the feelings to a therapist, who can accept and endure these feelings himself, that the patient is first able to achieve personality change and to experience a greater sense of intrapsychic integration” (p. 354). He described a patient, Rose, who feels that her mother controls every aspect of her life and who maintains a sense of separateness and autonomy through dieting. (As dieting is frequently used by fat people for many reasons, this is a story that may be instructive.) In the course of treatment, the therapist experienced intense merger anxiety as Rose accused her of being fat and of trying to make her fat. The perceived merger was threatening to Rose, whose symptoms worsened. Yet, the therapist’s ability to use her countertransference in an empathic manner and tolerate her patient’s projections allowed the patient to feel safe enough to explore her feelings.

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Gutwill (1994) wrote specifically about countertransference and the “diet mentality,” showing how the patient might demand that the therapist provide her with an eating plan.

The therapist was aware of how colluding with this wish would be a destructive re­ enactment of previous situations when the patient was not allowed to feed herself. Again, through containing her anxiety and refraining from giving advice about eating, the therapist was available for discussing the patient’s conflicted feelings about feeding herself in a healthy way.

Susan Wooley (1991) described patients with bulimia who disavow their needs in an attempt to care for and please others. Their bingeing represents an attempt to meet their own needs by proxy. Wooley examined gender aspects of countertransference to these patients. She believed that male therapists have more problems in the countertransference than do female therapists, becoming unnerved and disgusted by the patient’s lack of control and feeling puzzled by the patient’s tendency to put others’ needs first. These feelings are often the very ones that the patient seeks to project, feelings that females often project onto males. Skillful handling of the projections can help the patient modify her view of and relationships with men. Female therapists may be more likely to identify with women who have bulimia and therefore need to be careful to demonstrate integrity in relationships by allowing for expression of anger and other feelings that society deems unacceptable for girls and women to have or communicate.

Kathryn Zerbe, a prolific writer on eating disorders with a special interest in countertransference (1986; 1991; 1998) made recommendations that may be of use to therapists who see fat patients who have binge eating disorder. Drell’s (1988) concern

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that obese patients are refractory to treatment was addressed by Zerbe, who believed that with time, patience, and reflective listening, improvement is possible. “Remember that the eating disorder has served the purpose of maintaining, however destructive, a sense of identity and meaning. It will not be relinquished easily” (1998, p. 50). An intriguing recommendation is related to the therapist’s “psychophysiological reactions—including preoccupations with one’s own body image, and a host of physical aches and pains” (p.50). The patient’s difficulty with putting feelings into words (and resulting tendency to use food to meet emotional needs) combines with the therapist’s wish to connect with the patient who is living in a “preverbal world.” Helping the patient to put feelings into words leads to a lessening of the therapist’s symptoms as the need for preverbal expression abates.

In contrast to the dearth of research on countertransference and fat patients, there are some empirical studies o f countertransference and eating disorders, of which two are particularly relevant to this study (Burket & Schramm, 1995; Shisslak, Gray, & Crago, 1989). Health care professionals who work with eating disorders reported being greatly affected by their work—becoming more aware of their feelings about their bodies, developing a more positive body image over time, and moving toward healthier eating habits (Shisslak et al., 1989). Some of these professionals had a history of eating problems, but this did not seem to have a significant effect on the outcome. The positive tone of this report contrasts with research by Burket and Schramm (1995) who studied therapists in an academic setting. The authors acknowledged sample bias yet pointed out that responses did not vary with age and speculated that attitudes are formed early in

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one’s career. Among other variables, they studied countertransference, noting that subjects seemed to be aware of the phenomenon and its influence on their work. Almost one third of the participants said that they did not want to work with patients with eating disorders. The other group tended to report more feelings of empathy than the first group, but both groups reported the same emotional reactions to their patients that have been found in other studies. These feelings included frustration, anger, helplessness, and anxiety along with positive countertransference, satisfaction, and empathy.

Attitudes and Beliefs A totalistic view of countertransference takes into account the therapist’s attitudes toward the patient (Epstein & Feiner, 1979). I will turn to the literature on health professionals’ attitudes and beliefs about fat patients for information that might inform this study. A limitation of this research is that attitudes and beliefs are often formed outside of the therapy room, not in an interactive context that is fundamental to the definition of countertransference. Another limitation is methodological in that many of these are analogue studies and therefore cannot necessarily be generalized to actual psychotherapy relationships. A third limitation comes from the fact that the scope is often limited to effects of attitudes and beliefs upon clinical judgment. “Judgment” usually refers to making treatment decisions, an activity that is only a small aspect of the therapeutic process. However, it is based upon attitudes and beliefs, and could be viewed as a representation of the therapist’s response to the patient. This limitation applies to the

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only three studies of mental health professionals that appear to have been conducted (Agell & Rothblum, 1991; E. L. Harvey & Hill, 2001; Young & Powell, 1985).

Because of the pervasiveness of fat prejudice in society, many studies start with the assumption that health professionals are likely to be biased and attempt to determine whether this is actually the case. I will begin by reviewing studies that make no such assumptions; rather, they seek to determine the nature of health professionals’ attitudes and beliefs with no presuppositions. Afterward, I will focus on studies of bias and fat prejudice.

Young and Powell (1985), studied a sample of 120 mental health professionals in the private and public sector in Washington, D.C. Using an analogue approach, subjects evaluated a case history with photographs of middle-aged, middle class, white female clients that were altered to represent different degrees of obesity. They used a questionnaire that measured the clinician’s willingness to work with the patients, and their belief in the usefulness of therapeutic intervention and in a favorable prognosis.

There was no significant variation related to treatment decisions, but quite a bit of variation when it came to assigning negative symptoms to the obese clients in comparison to overweight or “best weight” clients.

Significant differences between the obese client and the overweight client are observed for the following eight symptoms: agitation, emotional behavior, impaired judgment, inadequate hygiene, inappropriate behavior, obsessivecompulsive behavior, self-injurious behavior, and stereotyped behavior. The obese client received higher scores than the best-weight client on the aforementioned eight symptoms and on four additional ones: egocentrism, hypochondriasis, intolerance for change, and suspiciousness. The largest group of differences occurred in the judgments of emotional behavior and self-injurious behavior, (p. 238)

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Gender, weight, and age of the professionals had some impact on responses.

Females viewed the obese client significantly more harshly than males. Older professionals were more judgmental than younger ones. Professionals who were overweight had somewhat less of a tendency to judge clients by weight.

An interesting finding was that only the obese, not the overweight, were judged significantly more harshly. The authors suggest that those who were labeled “overweight” might be seen as average, as this weight is becoming typical of the population. They found no clear explanation for the tendency to judge obese clients more negatively, but the authors guessed that professionals assumed these patients had eating disorders (an assumption not backed up by research). This research was limited in its restrictions by client race, SES, and age, as well as geographical location of the professionals, which might affect the generalizability of the findings. It appears that the most important aspect of this study for the purposes of the present research is the indication that “different standards of mental health are applied to the obese and nonobese” (p. 243).

It seems odd that six years later, the next authors to study this topic do not mention the one previously conducted by Young and Powell (1985). Agell and Rothblum (1991) claim that their study is the only one in existence of psychologists’ attitudes toward obesity. That is technically correct in that the other study was of mental health professionals; yet, psychologists are a subset of that group.

The aim of this study was to determine whether negative stereotypes of obese clients exist among clinical psychologists, and whether these have an effect on their

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judgments about treatment. The sample of 282 clinical psychologists was drawn from APA Division 29 members from New England states. The subjects had extensive experience, were 90% White, 66% male, and 34% female. This was also an analogue study, using case history models (no photographs) of clients whose problems were “troublesome” although not “debilitating.” Client gender was equally represented; clients varied by weight, and were labeled “obese” or “non-obese.” Using questionnaires and an inventory, subjects answered questions about perceptions, diagnosis, and prognosis.

Results indicated that psychologists were somewhat influenced negatively by client weight, viewing obese clients as more embarrassed and less attractive than nonobese clients. Positive (yet stereotypical) judgments included views of obese patients as “softer” or “kinder” than nonobese patients. A result that differs greatly from that of Young and Powell (1985) was that these judgments did not significantly affect diagnoses or treatment recommendations. Having only one other study for comparison makes it difficult to assess reasons for this difference that may or may not be related to the differences in sample characteristics. This study is limited by sample size, geographical area, race, and SES, and is skewed toward representation of males.

The previous two studies are cited by British researchers, E. L. Harvey and A. J. Hill (2001), at the University o f York, in a recent study of physicians’ and psychologists’ views of overweight people and smokers. The objective of the study was to identify and compare health professionals’ views of overweight people and smokers, with an eye to severity levels. Using a two by two, independent factorial design, the authors mailed questionnaires that solicited information on beliefs about the causes of overweight,

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attitudes toward the overweight person, and perceptions of responsibility o f the overweight person. The subjects were mostly White, middle-aged, and experienced, with an equal gender representation. Differences between psychologists (20% of the sample) and physicians (80% o f the sample) were not evaluated.

A number of findings are relevant to this study. Perceived causes of being overweight included physical inactivity (most important), addiction, depression, and mood change as well as genetic, personality, and interpersonal factors. Overweight people were perceived to have diminished self-esteem, sexual attractiveness, and health.

The higher the weight, the more negative were the professionals’ attitudes, ranging from moderately favorable to quite unfavorable. “Respondents believed overweight people should try to understand what causes them to be overweight, motivate themselves to lose weight, recognize that there is a problem, and recognize that there is a risk to their health� (p. 1258). The authors commented that they expected attitudes toward overweight people to be worse than was actually the case, and that extremely overweight people were rated positively on some items. They suspected that bias might lead the professionals to report better practices than are the actual case, understating their prejudices. They pointed out that their measurement techniques have not been validated, and that their response rate was not high.

Other groups o f health professionals, including physicians, nurses, and dieticians, have been the focus o f research on attitudes and beliefs about fat people. I will report on the major findings o f this literature that are relevant to this study.

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Three studies (Blumberg & Mellis, 1985; Hebl & Xu, 2001; Price et al., 1987) examined physician attitudes toward obese patients. These studies did indeed indicate the presence of a great deal o f bias toward obese patients. In 1985, Blumberg and Mellis found that physicians reacted in a neutral or negative way toward moderately obese patients, but strong negative feelings toward “morbidly obese” patients extended to characteristics other than weight, such as “unpleasant,” “worthless,” “bad,” “difficult to manage,” and “lack of self control.” Direct contact with morbidly obese patients did not alter these feelings. Price, et al. (1987) confirmed this outcome, adding “lazy” and “sad” to the list of judgments about obese patients. It was reported that 47% of physicians felt that counseling patients on weight loss was not professionally gratifying. The most recent study by M. R. Hebl and J. Xu (2001) reported a belief that obese people are unhappy and unstable and should be referred for counseling. Respondents referred to impressions that obese patients are depressed, drug-addicted, and in need of psychotropic medication.

Physicians spent less time with heavier patients. They perceived heavier patients in stereotypical fashion. Heavier patients were considered less healthy, less self-disciplined, and less adept at self-care.

Physicians reported that seeing patients was a greater waste of their time the heavier that they were, that physicians would like their jobs less as their patients increased in size, that heavier patients were viewed to be more annoying, and that physicians felt less patience the heavier the patient w as.. .Perhaps the most disturbing pattern shown in Table 2 is that physicians indicated having significantly less personal desire to help patients the heavier they were. (p. 1250) A study (Anderson et al., 2001) of gender differences indicated that physicians tended to encourage women with a BMI of 25 or more to lose weight and seek additional treatment more than men of the same weight; however, the reverse was true at a BMI of

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32. Physician gender differences were not found to be significant. The authors found it difficult to explain these results and recommended further study. Fat patients perceive physicians’ attitudes quite differently from researchers’ observations of these attitudes (Krainin, 2002; Wadden et al., 2000). Few patients report negative interactions with their physicians related to weight. Often physicians do not recommend losing weight. When weight is a part of the interaction, it is often mediated by gender.

A study of nurses’ attitudes toward obese patients reported more negative attitudes toward obese than non-obese patients (Gamer & Nicol, 1998), although bias does not appear to be gender-related. When nurses are dissatisfied with their own bodies, they tend to have more negative attitudes toward their obese adult patients (Bagley, Conklin, Isherwood, & Pechiulis, 1989). Nurses who harbor ethnic prejudice are more likely to be prejudiced toward the obese (Maroney, 1992). Surprisingly, this study found that the most likely target was Caucasians. The authors wondered if a societal injunction against prejudicial attitudes means that it is only acceptable to express negativity toward a majority group.

The earliest study (Maiman, Wang, Becker, Finlay, & Simonson, 1979) of dietitians’ attitudes toward obese patients concluded that there is substantial variation.

Recent studies (Harvey, Summerbell, Kirk, & Hill, 2002; McArthur & Ross, 1997) confirmed this conclusion. Harvey et al. (2002) described dietitians’ attitudes as mixed, but mostly neutral to positive. McArthur and Ross (1997) described attitudes as “ambivalent.” Noting the great difference between this descriptor and results of studies on nurses and physicians showing very negative attitudes, they guessed that dietitians

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have a more charitable attitude due to their training in counseling techniques and causes o f obesity. They also have less physical contact with obese patients. These authors also looked into dietitians’ self-perception related to weight and body image, finding attitudes and perceptions in line with the general population: negative attitudes about personal overweight, a tendency toward harsh judgments and self-blame, and an inability to correctly perceive their own weight.

Fat Bias and Prejudice Among Health Professionals Due to its problematic nature, fat bias among health professionals has been the focus of particular attention. In this section, I will review theoretical and empirical literature pertaining to mental health professionals and fat bias, supplemented by an overview of the literature pertaining to medical professionals.

Three studies (Agell & Rothblum, 1991; E. L. Harvey & Hill, 2001; Young & Powell, 1985) previously reviewed provide much evidence for the existence of fat bias arid prejudice among mental health professionals. Doctoral students (K. L. Davis, 1998; Loewy, 1995) were the first to conduct research with a specific focus on fat bias. These appear to be the first empirical studies to use the word fat instead of obese, often qualifying the word fat with the word appearing. It may be that the authors’ sensitivity to fat bias led them to understand that bias depends on peoples’ perceptions which may or may riot correlate to measurements of size. They also may have recognized the bias inherent in words such as overweight and even obese or another commonly used term, best weight.

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Loewy (1995) investigated the possibility that the perceptions of mental health professionals are affected by stereotypes. This did not appear to be true, although therapists did appear to make more mistakes in processing information about people who were fat, and fat men in particular. Those who specialized in eating disorders made fewer errors.

Kristen Davis-Coelho (K. L. Davis, 1998; Davis-Coelho et al., 2000), University of Montana, published a dissertation and later an article reporting research upon which the dissertation was based. She studied the impact of fat bias on clinical judgments and treatment planning. The population studied was clinical and counseling psychologists, 39% female, 6% “non-White,� and ranging in age from 28 to 81 years. Participants were asked to review photographs and self-reports from hypothetical clients (an analogue study).

She concluded that client weight has a significant negative effect on clinical judgments of fat patients as well as treatment planning. Specific findings are of value to the present study. Female psychologists predict a worse prognosis for fat clients. Whether this is an example of bias, or whether it indicates more sensitivity to suffering that is culturally imposed on fat women in particular, is not addressed by the author. The following results might be subjected to the same evaluation. Younger psychologists assign poorer prognosis to fat clients. There is a general tendency to predict the need for longer treatment. Bias is also evident in the activity of diagnosing fat patients. Although obesity is not part of the diagnostic criteria for eating disorders (American Psychiatric Association, 1994), respondents are likely to give that provisional diagnosis. The

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diagnosis of adjustment disorder is less likely to be assigned. Treatment goals that may or may not be relevant to the individual patient’s needs are recommended for fat patients, including improving of body image and increasing sexual satisfaction.

Around the same time as this study, a similar study (Hassel, Amici, Thurston, & Gorsuch, 2001) was conducted by a number of researchers from the Graduate School of Psychology at the Fuller Theological Seminary. The purpose was also to examine biased clinical judgments as evidenced in diagnosis, assessment of functioning, attitudes, and attributions. The population studied was composed of mental health professionals from a wide variety of professions, classified as either Christian or non-Christian. An interesting descriptive statistic, relevant to the following section on the therapist’s own body, is that fact that only 16.6% of participants expressed satisfaction with their body weight and over 79% hoped to lose weight.

This analogue study used drawings, clinical vignettes, and attitude scales to test several hypotheses. It was found that mental health professionals do judge obese clients more harshly than non-obese clients. They tend to assign a higher level of pathology to obese clients, including judgments about diagnosis, levels of functioning, and negative attributes. Females tend to rate obese patients as functioning more poorly and having negative attributes such as tense, sad, depressed, hard, and cruel. There appear to be no interactions between the variables of client gender and weight. Negative attributes were assigned by both Christians and non-Christians equally, of concern to the authors who cited Christian beliefs that one should not judge others. The amount of weight that a

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participant wants to lose does not seem to affect their judgments of clients, and personal attitudes in general do not seem to have an effect.

Hassel et al. (2001) presented ideas on ways to counteract fat bias, as did Laura S. Brown (1989) in an article about fat-oppressive attitudes of feminist therapists. Although this was not a research study, Brown did report on her professional experiences with fat bias among her colleagues, ten years before the onset of interest in empirical research.

Brown battled oppression of fat people during the 1980s. Because (she believed) she had lost a significant amount of weight so that people did not worry about expressing overt bias, she received many comments by colleagues about her outspoken views. She noted several themes. One was what she described as a “true believer” type of response, citing clinical experience with patients who had “successfully” lost weight, which had “truly” benefited their health and psychological well-being. Second, Brown felt accused of collusion with her fat patients in unconscious denial related to their weight. She believed that this response to her stance was based on (a) colleagues’ beliefs that they had the facts about weight being the cause of health problems and (b) the difficulty of coming to terms with their own struggles with weight. She noticed their defensiveness about the subject and speculated about their internalized fat oppression. Finally, she would often get a guilty response, based on a wish to rid oneself of oppression while feeling a need to align oneself with the cultural ideals, to have this source of approval as well as avoid being target o f criticism.

An example of fat prejudice is found in a book by a well-known psychotherapist, Irvin Yalom (1989) who described his attitudes toward fat women:

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I find them disgusting: their absurd sidewise waddle, their absence of body contour—breasts, laps, buttocks, shoulders, jaw lines, cheek-bones, everything. everything I like to see in a woman, obscured by 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? (pp. 87-88) Before fat bias per se was studied among medical professionals, O’Neil and Rogers (1998) reviewed the attitude literature for findings on fat prejudice, generalizing that “many members of the health care profession are not accepting of their overweight patients” (p. 765). Lynn McAfee (1997), Director of the Council on Size and Weight Discrimination, collected anecdotes from patients who felt they had been targets of fat prejudice on their visits to medical professionals. Several patients were told that their weight was a reason for not becoming pregnant or getting surgery. They were the target of fat jokes, put-downs, and insults. Patients would put off surgery for fear of being treated badly or shamed due to weight. They reported delaying checkups due to fear of “the weight lecture.” When she expressed discomfort while being examined, one woman’s gynecologist responded, “Well if you weren’t so damn fat this wouldn’t hurt.

This is your problem, not mine!” (p. 97). This kind of response might be explained by what Gallagher (1999) described as a defensive use of “otherness” by health care professionals.

When clinicians designate the quality of otherness to a patient or a patient group, healthcare clinicians may justify inadequate care by blaming the patient for the numerous management difficulties the patient may present. This reaction suggests that as a culture we need to be aware of the moral dimensions of otherness and recognize how this influences care. (p. 18) It appears that only empirical study (Teachman & Brownell, 2001) of fat bias among health professionals is a recent, rigorous study of medical professionals in

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comparison to the general population. The researchers were interested in the presence of “implicit” (unconscious) fat bias. Participants completed attitude and belief measures and reported explicit beliefs. Although lower than in the general population, significant implicit bias against fat was found, with only minimal evidence for explicit bias.

Important to the present study was the result that bias was not limited to obesity as an attribute, but was targeted at “obese persons.” Another important result that has impact on the choice of method for the present study was the great difference between what bias people report (explicit) and the actual presence of bias that is unconscious (implicit). This suggests use of a research method that can detect unconscious feelings (see Methods section below). “Relying on explicit measures alone is inadequate because individuals may not be aware of their own bias, and for people who wish to appear equitable, social desirability may influence reporting” (p. 1529).

It seems clear that fat bias is quite likely to be encountered among health and mental health professionals and that these professionals may not be consciously aware of bias or its effect on the quality of care.

The Therapist’s Own Body In the Psychotherapeutic Process Implicit fat bias has an unconscious basis and seems likely to have at its roots some denial of one’s own body hatred with a consequent need to project this feeling onto others. Brown (1989) speculated that this was an important factor in her colleagues’ negative reactions to her fat activist stance. Almost 80% of mental health professionals in one study felt they needed to lose weight (Hassel et al., 2001). There appear to be no

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research studies on therapists’ body image, but two studies reviewed above suggest that body disparagement exists among other health professions and has an impact on treatment. McArthur and Ross (1997) reported that dietitians have negative attitudes about personal overweight, a tendency toward harsh judgments and self-blame, and an inability to correctly perceive their own weight. When nurses are dissatisfied with their own bodies, they tend to have more negative attitudes toward their obese adult patients (Bagley et al., 1989).

There are three self-reports of therapists’ feelings and attitudes toward their own bodies (Burka, 1996; Lieberman, 2000; Rabinor, 1993). A theoretical context for this subject is provided by Janice S. Liebermann (2000) in her writing about looking and being looked at in psychotherapy. She discussed the importance of the role of vision in identity development and the formation of self-esteem.

The therapist’s body can be a mirror, reflecting back to the patient who the patient is, by being different from or similar to the patient, different from or similar to the societal ideal. The therapist’s physical imperfections can serve as a relief from the demands of harsh ego-ideals and/or from characterological competitiveness, (p.

207) Her own body image was shaped during a time when curves were considered desirable; yet, she was influenced by the increased emphasis on appearance and dieting, having attempted to lose weight at times, but not thinking of herself as fat. She expressed an aversion to talking about weight and appearance with her women friends rather than focusing on other aspects of self-development. Liebermann was concerned about the increasing preoccupation with weight, part of what she called “yet another war against women, one that women themselves permit, participate in, and often embrace. Women

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have been freed from their kitchens only to be chained to their treadmills” (p. 213).

Although she felt strongly that narcissistic concerns should not be an important focus of her life, she found herself affected by societal values. Referring to work with her patients, “There are times when I have to sort out on a daily basis where my issues end and theirs begin” (p. 211). She believed that it is important to depart from a position of neutrality in order to help her patients question values that she believes to be unhealthy and destructive.

After describing life experiences that shaped her body image, Judith Rabinor (1993) talked about her struggle with wishes to alter and “fix” her body. She felt that she had an understanding o f the roots of this struggle: Standing on the brink of achieving recognition and power, I had become scared, and from that scared place, the voice of my unconscious emerged, warning me of the danger o f female power. Being powerful in this new way was too frightening to acknowledge, and so I resorted to what I had learned from my mother and grandmother: to do what was safe, acceptable, and traditional—focus on my body. (p. 188) Having uncovered this information about herself, she realized that she had been hiding her discomfort from her patients and her colleagues. She began to believe that self-disclosure about body shame that has become “normative” in our society is an important therapeutic tool. This led her to conduct workshops for therapists to help them explore how they were affected by their clients’ body image and how they managed shameful feelings about their own bodies. She found a pervasive difficulty with body image among participants. She felt that adding self-disclosure and open discussion of body image to her technique has been a relief to her clients and has helped them feel validated and not alone. Research on the “effect of counselor obesity on client

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perceptions and expectations” (Vrochopoulos, 1999) showed that clients do not seem to perceive or treat counselors differently based on body size. This result, along with Rabinor’s experience, might suggest that therapists do not need to be concerned about their own perceived shortcomings when it comes to appearance and that patients benefit from sharing body image concerns.

Jane B. Burka (1996) wrote about her experience as an “overweight therapist.” It took her many years to feel comfortable with discussion of her body size in the session.

She placed her personal experiences in the context of theory about countertransference, believing that they reflected both her own unresolved issues as well as relational and cultural aspects o f the therapeutic encounter.

Burka believed that her body shape and size set a context for a maternal transference, because all children experience their mothers as “large.” Her patients tended not to bring up her size, something that Burka would watch for and interpret at the appropriate time. Sometimes her size would be a focus of competitive feelings on the part of the patient. Patients experiences fantasies of being held and wishes to be reborn through the therapeutic process.

Burka also noticed many differences in patients’ observations and changes in her body image during the course of her work. Thinking in terms of the body as “analytic object,” she talked about ways that patients would ascribe meaning to her body. She noticed the impact of the state of the relationship on her feelings about her body. For example in her work with a man who was “sizing her up,” she recognized collusion between the two of them to “create a dowdy therapist for him. I think that together we

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unconsciously retreated from the hostile sexualization he usually used to gain control in all his relations with women” (p. 265). She used her countertransference feelings to detect this dynamic. As the therapy progressed and the patient worked through many feelings about the relationship, Burka found her body image changing drastically in response to him. She pointed out the therapists’ feeling as being “co-created” in this way.

Acknowledging the importance of the body to human experience and in the therapy experience as well, Burka explored a seeming taboo related to bringing discussion of her body into the therapy. She suspected a mutual agreement to protect the therapist from vulnerable feelings and anxiety, noting, “these collusions deaden the therapy and prevent an important object, the therapist’s body, from becoming a verbalized issue that can be elaborated and understood” (p. 274).

In summary, countertransference to fat patients has only begun to be addressed in the literature. Writers on theory provide many useful insights based on what seems to be extensive clinical experience with fat patients and sophisticated knowledge of conflicts and defenses related to the experience of being fat. It appears that these authors are only partially aware of research about the medical aspects of weight and the effects of cultural pressures and bias. Concern that the therapist’s countertransference might lead to pressure on the patient to lose weight is criticized not for the bias inherent in this attitude, but for the way that it could interfere with neutrality and the effectiveness of the therapy.

Although there may be value in not colluding with or taking too much at face value the patient’s feelings of inferiority and shame due to weight, it seems that the very real suffering that fat people experience is discounted. The one empirical study suggests that

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psychiatrists do experience dysphoria with regard to obese patients, with anger being particularly strong. A majority of respondents believed that their countertransference has an impact on the quality of care.

The existing literature is sparse, but it appears to be consistent with findings related to eating disorders and to research on attitudes and beliefs among health and mental health professionals about fat people. Studies on bias and fat prejudice show that it is widespread among professionals as it is in society. Researchers express much concern about the negative effects of bias on clinical care. Therapist self reports indicate that therapists struggle with their own body image, that this struggle impacts their work with patients, and that they may make use of these feelings and insights in the psychotherapy process.

Clearly, further research is needed as it has barely begun. Although it seems likely that therapists experience a multitude of feelings and attitudes toward fat patients (many of them negative), that they struggle with their own body image, and that their countertransference affects their work with patients, the actuality of these hypotheses has yet to be explored. Further research could contribute to understanding the needs of fat patients in psychotherapy as well as serve to enlighten therapists about fat bias and help them to keep it from causing harm to their patients.

A necessary first step is to determine the nature of countertransference to fat patients, which is the purpose of this exploratory study. The literature reviewed above hints at the sensitivity of the topic, a tendency for therapists to avoid it, and the existence of unconscious feelings toward fat people that can be difficult to identify. Therefore, an

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exploratory study will need to be conducted in a way that will consider both explicit and implicit data. I have identified a method that has been developed to accomplish that task, informed by psychoanalytic thinking and technique. The Free Association Narrative Interview method (Hollway & Jefferson, 2000), to be described in the following section on method, is designed to elicit and analyze data on sensitive topics, and will be used in this research.

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CHAPTER III

METHOD

Introduction In practicing psychotherapy, clinical social workers are likely to work with patients who might be described as “fat.” A review of the literature on the reactions of health professionals to fat patients showed that a wide variety of reactions exists. There has been some speculation about the nature of countertransference to fat patients in a psychotherapy relationship, with one empirical study of psychiatrists. That leaves a question about the nature of clinical social workers’ countertransference to fat patients.

This research explores that question.

The question presents a particular challenge with regard to the sensitive nature of countertransference—the fact that it involves emotional reactions that may range from uncomfortable to so threatening as to be placed out of one’s conscious awareness.

Raymond M. Lee (1993), in writing about this challenge, warned against handling it through avoidance. “The threats which research poses to research participants, to the researcher and to others need to be minimized, managed or mitigated, but without compromising the research itself or limiting the overall scope of research to address important features of contemporary society” (p. 16). Teachman and Brownell (2001) noted a great difference between what anti-fat bias health professionals report and the

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actual presence of bias that is unconscious. “Relying on explicit measures alone is inadequate because individuals may not be aware of their own bias, and for people who wish to appear equitable, social desirability may influence reporting” (p. 1529).

Wendy Hollway and Tony Jefferson (2000) recently developed a research strategy that addresses this challenge. Part of the difficulty in researching sensitive topics is that people who are interviewed will protect themselves from anxiety about the topic in a way that interferes with obtaining a comprehensive and accurate response. A research strategy must include ways to interview and interpret the material to “see through” to relevant information that may not be obvious on the surface. Rather than seeking coherence in a narrative, the researcher encourages free association and uses a method of interpretation that will lead to further insights about the material. The authors have developed a method called the “Free Association Narrative Interview” (FANI) method that was used in this study (p. 4).

Scone of Study This is a study of reports by clinical social workers on their experiences with fat patients, aimed at eliciting information about the nature of their countertransference. It is not intended to be comprehensive, but to set the stage for further research through an indepth exploration of the actual experiences of a small number of clinical social workers.

Therefore, I focused on obtaining a rich description of thoughts, feelings, and experiences from each participant rather than including a large number of subjects at the expense of

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depth. I interviewed nine subjects, a number consistent with other studies of this scope (e.g. Dolamore, 1999).

I did not attempt to interview clinical social workers that work from models other than psychodynamic, as I expected these clinicians to lack information and selfknowledge about countertransference or have a bias against this concept. I also did not interview social workers that had been trained outside of master’s level social work programs, those that had little experience, or practiced outside of the United States.

It was expected that seasoned clinical social workers would be skilled at reporting experience in an articulate, descriptive way, with the ability to express feeling and add analysis. This turned out to be the case, leading the data to be dense.

Operational Definitions of Major Concepts Clinical Social Worker For convenience, the term clinical social worker will be interchangeable with the term “therapist” in instances where it is not necessary to emphasize profession. The clinical social workers that were interviewed in this study had a master’s degree in social work plus at least five years of practice experience in a clinical setting. This was to ensure that those interviewed had experience doing psychotherapy with fat people, which subjects were asked to confirm. Only therapists who practiced in the continental United States were included, in order to understand the experience and meaning of fat in one particular culture.

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It was not judged to be necessary that the subjects be aware of their countertransference to their fat patients. Through the method of interviewing and analyzing data that was used, both conscious and unconscious countertransference could be identified. Nevertheless, I believed that the interviews would be richer if the therapist understood the role of countertransference in the therapeutic process and tried to be aware of his or her countertransference to the patient. Therefore, clinical social workers that were interviewed in this study described themselves as practicing according to a psychodynamic viewpoint.

Countertransference The literature on countertransference includes many definitions of countertransference. The “narrow” or “classical” view of countertransference (S. Freud, 1953/1910; Heimann, 1950) refers to unconscious feelings that a therapist has toward the psychotherapy patient. These feelings originate in the therapist’s own experiences. Their painful and conflicted nature leads them to be suppressed. Countertransference is viewed as something to be eliminated or at least “managed.” Over the years, authors (Epstein & Feiner, 1979; H. Racker, 1957) have expanded upon this definition in what has been called a “broad” or “totalistic” view. There are different definitions of the scope of this view. It can include both conscious and unconscious feelings. Sometimes thoughts and attitudes are included in addition to feelings. The reactions of the therapist derive from many aspects of the therapist’s current and previous experience, not just those that are negative, painful, or conflicted. Countertransference is something that can be useful to

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psychotherapy in that it provides information about the patient; it is not necessarily disruptive or harmful to the therapeutic process.

In an exploratory study, it is consistent with the goal of getting a complete picture of the situation to use a broad definition of countertransference. The literature on health and mental health professionals’ reactions to fat patients shows a variety of feelings and attitudes. Although feelings are different from attitudes, they influence each other. For example, the feeling of disgust toward a fat patient may be shaped by the attitude that fat patients are responsible for their appearance. Considering the pervasiveness and intensity of negative attitudes toward fat people, it is important to include attitudes in the definition of countertransference that is used in this study (as demonstrated by Hayes, 1998).

The broad definition of countertransference that is used in this study is “the therapist’s reactions to the patient, including feelings and attitudes.”

Fat Patients Countertransference exists in a setting where two people interact. It is one person’s response to another person. Although it might seem possible that a therapist could react to a patient’s attribute (such as fat), the reaction will include the totality of the response to the patient as well. For this reason, I have not separated the word fat from the word patient.

However, as fat patients are the focus of this study, it is necessary to define the word fat. This is a word commonly used to describe a person’s size. It can refer to body fat, but it may just mean that the person is large. Recently, the increased societal

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emphasis on the desirability of thinness means that actual measurement has become more difficult to define. One can be “too fat” regardless of body size. Fat can be an epithet. It can imply excess.

The common term used in the medical and psychology literature is “obese.” In this study, I use the word obese only when I am referring to others’ use of the term.

Obesity is only one aspect of fatness, and one that is difficult to define. Current usage is associated with the Body Mass Index, a commonly accepted definition in the scientific literature. The popular use of the term refers to someone who is very fat, more than just “overweight.” Both obese and overweight contain a judgment that fat is a problem.

Because this study is exploratory, I am using the more inclusive word fat in order to allow for a wide variety of perceptions— distorted, realistic, unhealthy, normal, judgmental, and complimentary—and many other possible characterizations that are associated with the word by individuals, groups, and sometimes society as a whole. Fat is defined as a word whose meaning is idiosyncratic to the person who utters it. This word is a focus of this study.

Type of Study and Design This is a qualitative study of countertransference to fat patients. There is a tradition o f qualitative research that informs the practice of clinical social work (Riessman, 1994). “There is a sympathetic connection between certain kinds of social work and qualitative kinds of data—talk, therapeutic conversation, agency records, narratives about experiences with organizations and macro systems” (p. ix). Maxwell

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(1996) believes that qualitative studies are particularly useful for understanding meaning, context, unanticipated phenomena and influences, process, and causal explanations. Each of these elements is an aspect of countertransference, a complex phenomenon. They also apply to the understanding of the word fat.

This study is exploratory in nature. After reviewing the literature on countertransference to fat patients, I found that there are no studies of this phenomenon among clinical social workers. An exploratory study is useful in obtaining a preliminary impression of the phenomenon. Data from an exploratory study can be used as a starting point for further research questions and theory building.

I chose a narrative approach to this research as that which most lends itself to the study of countertransference. Clandidin and Connelly (2000) describe a long evolution of their own thinking on how to approach social science research. According to these authors, Narrative inquiry is a way of understanding experience. It is a collaboration between researcher and participants, over time, in a place or series of places, and in social interaction with milieus. An inquirer enters this matrix in the midst and progresses in this same spirit, concluding the inquiry still in the midst of living and telling, reliving and retelling, the stories of the experiences that make up people’s lives, both individual and social, (p. 20) In a chapter entitled “Why Narrative?” they answer by saying, “Experience happens narratively. Narrative inquiry is a form of narrative experience. Therefore, [social science] should be studied narratively” (p. 19). This argument is particularly relevant for the study o f countertransference that occurs in the context of stories being told by a patient to a therapist. In turn, therapists, as subjects of this study, told their stories about countertransference. The authors (Hollway & Jefferson, 2000) of the method that is used

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in this study chose a narrative method because they believed that stories reflect actual life events better than methods that attempt to bring forth explanations (p. 32). For these reasons, I used a narrative approach.

The design employed in this study is based upon the Free Association Narrative Interview method developed by Hollway and Jefferson (2000). Although the name implies that it is an interviewing technique, it is actually a form of narrative inquiry with a particular emphasis on the value of data that can be obtained when the interviewer allows free association, rather than structuring the interview. The authors point out a problem with assumptions in qualitative methods that the person to be interviewed will provide a “faithful reflection of ‘reality’”—that the research subject: • • • • •

shares meanings with the researcher; is knowledgeable about him or herself (his or her actions, feelings and relations); can access the relevant knowledge accurately and comprehensively (that is, has accurate memory); can convey that knowledge to a stranger listener; is motivated to tell the truth (p. 11)

Imagine asking a therapist, “What are your reactions to fat patients?” It seems likely that the sensitive and often unconscious nature of these reactions would interfere with the five tasks quoted above. One might argue that therapists are particularly interested in the truth and in accurate portrayals; however, their good faith might belie a difficulty in reporting material that could be anxiety-laden and sometimes out of conscious awareness. Hollway and Jefferson introduced the idea of the “defended subject,” which “shows how subjects invest in discourses when these offer positions which provide protections against anxiety and therefore supports to identity” (p. 23). In

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other words, when anxiety arises, the subject will tell his or her story in a way that disguises a threatening meaning.

The defended subject is described as both psychic and social: It is psychic because it is a product o f a unique biography of anxiety-provoking life-events and the manner in which they have been unconsciously defended against. It is social in three ways: first, because such defensive activities affect and are affected by discourses (systems of meaning which are a product of the social world); secondly, because the unconscious defences that we describe are inter subjective processes (that is, they affect and are affected by others); and, thirdly, because of the real events in the external, social world which are discursively and defensively appropriated, (p. 24) This psychosocial concept is viewed by the authors as especially suitable in research of sensitive topics such as sexuality or fear of crime, and I would add countertransference to fat patients.

The theoretical underpinning of this approach is psychoanalysis and its view of the unconscious. The authors describe “unconscious intersubjective dynamics in the interview relationship, which we explain and illustrate using concepts such as countertransference, recognition and containment” (p. 4). There is precedent to applying a psychoanalytic viewpoint to narrative inquiry, adding intrapsychic to cultural dimensions and taking account of unconscious as well as conscious meanings that influence both researcher and subject (Hunt, 1989; Sass & Woolfolk, 1988; Soldz, 1996).

The FANI method includes four principles of data collection that lead to producing “meaning-frames” or gestalts. The interview should (a) “use open questions,” (b) “elicit stories,” (c) “avoid ‘why’ questions,” and (d) “follow respondents’ ordering and phrasing” (p. 53). The interviewer asks the respondent, considered a “defended

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subject,” to use free association, i.e., say whatever comes to mind. Free association is a narrative that is structured according to unconscious logic; that is, the associations follow pathways defined by emotional motivations, rather than rational intentions. According to psychoanalysis, unconscious dynamics are a product of attempts to avoid or master anxiety. This suggests that anxieties and attempts to defend against them, including the identity investments these give rise to, provide the key to a person’s Gestalt. By eliciting a narrative structured according to the principles of free association, therefore, we secure access to a person’s concerns, which would probably not be visible using a more traditional method, (p. 37) The data is “co-produced” by the interviewer and interviewee, both influenced by unconscious, intersubjective dynamics. I describe this method’s techniques for data collection in the section below, “Data Collection Methods and Instruments.”

Data analysis using this method is done in the theoretical context of holistic interpretation. Unlike the “common-sense approach” which takes a story at face value, attention is paid to curious details, especially inconsistencies, contradictions, changes of tone, and interruptions. Parts of the data are analyzed in terms of the whole; for example, a judgment that the subject makes about his or her experience is evaluated in terms of the whole story and whether this judgment is supported or contradicted.

The authors distinguish between the research setting and the clinical setting in the use of interpretation. There are two major differences. First, “clinicians interpret into the encounter, whereas researchers will save their interpretations for outside it” (p. 77).

“Research interpretation” is part of data analysis and is meant for the reader rather than the person being interviewed. Second, clinical interpretation focuses on the inner world o f the patient, whereas research interpretation adds the subject’s external, social context

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to the focus (p. 78). Their use of the word “interpretation” refers to speculation about the unconscious aspects of the subject’s psychosocial experience for the use of data analysis.

Two tools are used to get a picture of the whole: (a) “Structured Summaries” of biographical data and notes on themes and ideas, and (b) “Pen Portraits” or descriptions of the subjects that make them “come alive” for the reader and serve as a base forjudging interpretations of the data. Data analysis uses theory, e.g., the principle of the defended subject, in order to make sense of the data. For example, the concepts of projection and splitting are invoked in order to explain why a subject might claim that he or she is a “fatfriendly therapist” while describing a patient using a derogatory term such as “lazy.”

Finally, this method uses reflexivity (use of one’s own subjectivity) in data analysis to distinguish between “bad” and “good” interpretations, as objectivity is an elusive goal in both psychoanalysis and qualitative research. The researcher’s own projections or faulty memories can be tested against the text. I will elaborate on the specifics of data analysis in the section below entitled “Data Analysis.”

Hollway and Jefferson devoted a great deal of effort to evaluating their method in terms of generally recognized categories: objectivity, reliability, generalizability, and ethics. The authors are aware that bringing unconscious intersubjectivity into research principles will challenge traditional notions of objectivity. Citing Miller and Crabtree (1994), they set the standard for evidence by requiring that researchers’ stories be “methodologically, rhetorically and clinically convincing” (p. 348). The authors believe reliability to be an invalid criterion for qualitative research because of the nature of meanings, which can be unique to a person, unique to a relationship, and unique to a

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particular encounter. They prefer the term “robust” as a description of interpretations that are based on scientific theory, that can be tested by applying them to other data or by other researchers, and that can be recognized by others subjectively or refuted using alternate explanations. Generalizability is challenged as a criterion in terms of the authors’ view of the psychosocial subject. “One person’s unique defensive structures cannot be simply read off from their social, demographic characteristics” (p. 127). For this reason, they advocate taking biographical as well as demographic factors into account in any attempt to generate useful generalizations.

In carrying out research according to this method, the authors discovered some difficulties with traditional ethical guidelines related to informed consent, confidentiality, deception, and avoidance of harm, (a) With regard to informed consent, it is impossible to inform someone in advance of unconscious material that may emerge during an interview. The authors believe that they have a responsibility in their research to uncover the hidden and the secret. It is not considered unethical for a biographer or journalist to publish such material; yet, social scientists are held to this standard. The principle of consent can conflict with other ethical principles. Third parties such as relatives, friends, and others who appear in the story might want to refuse consent to publish even when the subject has given permission, (b) Confidentiality is fundamental to research as well as psychotherapy. However, details that appear in narratives can be pieced together so that a person could be recognized. Some would say that interpretation of unconscious motivation is a confidential matter; however, this conflicts with the educational standard of informing the public, (c) The ethical injunction to avoid deception is difficult to apply

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and assess in a method that explores both the researcher and subject’s tendencies toward self-deception. “We all deceive ourselves over some things since to do otherwise is often too painful; hence the need for our defences.. .a ‘truthful’ analysis may not be able to avoid distress to the participant, but it does not automatically follow that distress is harmful” (p. 97). 4) According to the psychoanalytic model, research that leads to discomfort and distress by encouraging people to remember or relive painful experiences is not necessarily harmful, but can lead to truth and thus greater well-being. It can be difficult to assess the impact upon subjects of a method that may lead to distressing feelings.

Hollway and Jefferson suggest ethical principles as a way to deal with these difficulties. They emphasize a need for the researcher to demonstrate independence to the subject, “to reflect back a reality which is not compromised by dependence or avoidance.

To strive after this as the basis for an ethical relationship in research is to pursue the values of honesty, sympathy and respect” (p. 99). By honesty, they mean, approaching the data openly and evenhandedly, in a spirit of enquiry not advocacy, deploying a theoretical framework which was laid out and justified, making only such judgements as could be supported by the evidence, and not ignoring evidence when it suited us. It also involved interrogating our responses to the data. (p. 100) By sympathy, they mean “the fact or capacity of entering into or sharing the feelings of another or others; fellow-feeling” (p. 100). Researchers must avoid labeling subjects as evil, worthy o f blame, alien, or having disreputable motives. By respect, the authors mean paying careful attention and treating a person with deference and honor. They emphasize the need to recognize self-serving defenses in a spirit of respect for the discomfort that

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this activity can generate. Their view is that these principles are not only ways to cope with the difficulties of research, but that they are in some ways more “adequate� than the traditional principles that are often unrealistic.

I am convinced o f the value of the FANI method to this study. It has particular relevance to the research of sensitive topics such as countertransference and fat. The concept of the defended subject applied to clinical social workers that I interviewed. The concept of the psychosocial subject was particularly relevant to the exploration of a twoperson phenomenon. Using theoretically informed interpretation (based on psychoanalytic ideas and techniques) in analyzing data that is not manifest was particularly useful in exploring the unconscious aspects of countertransference to fat patients. Viewing the data as a whole and paying attention to contradictions as well as links provided a more complete understanding of the data. Finally, I admire the integrity o f the approach in reviewing the difficulties in meeting traditional ethical guidelines, in challenging the validity of those guidelines, and in devising alternatives that may be even better than what is currently recommended.

Setting The size and weight of human beings are a current focus of great concern in the United States (U.S. Department of Health and Human Services, 2001). It is likely that clinical social workers will encounter fat patients in their practices and react to them with a number of possible feelings and attitudes. This research took place in the Greater Chicago area. I avoided interviewing subjects who lived in my home city of St. Louis so

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that the data would be as free as possible from influence by factors outside of the interview setting. This was intended to help clinical social workers who were my peers feel more comfortable with self-disclosure.

I met with clinical social workers in their offices for the initial interview, checking to see if they felt that their confidentiality could be protected in this setting.

This offered several advantages. Privacy was available, as provision for this is an aspect of clinical social work. Interviewing in the therapist’s office allowed me to examine the physical surroundings of the workplace as a context for his or her stories. The setting was associated with the experiences that I wanted the subject to report, so that it had the potential of evoking memories and associations that contributed to the richness of the data.

If the office o f the clinical social worker had not been available or private, I planned to meet in a setting that he or she chose. The setting would have needed to be private and free from intrusions or noises that might be distracting or could interfere with my recording equipment. This could have been the subject’s home or an office with these characteristics. One respondent chose to meet in her home for the second interview.

Another chose to meet by phone when he was unable to attend his second interview.

Population and Sampling This is a study of clinical social workers. For convenience, the term “therapist” is used interchangeably. Participants were required to have a master’s degree in social work in order to ensure that they would be well educated about social work values and

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techniques as well as clearly identified with the profession (as opposed to licensed clinical social workers who may come from a number of educational backgrounds).

Subjects practiced in the United States, a modernized, western culture that is in some ways quite heterogeneous in terms of gender, ethnicity, race, culture, SES, and other social variables that may influence attitudes towards fat people.

Due to its often unconscious or uncomfortable nature, countertransference may be difficult for therapists to recognize. I believed it was important to the goals of this study to interview people who had a conceptual awareness of countertransference as well as experience identifying and evaluating their own countertransference in their clinical experience. Therefore, I interviewed clinical social workers who were self-described as practicing according to a psychodynamic viewpoint, under the assumption that this would lead to more self-awareness of countertransference. They were required to have at least five years of practice experience in a clinical setting. It was expected that experienced clinical social workers would be skilled at telling their stories in an articulate, descriptive way, with the ability to express feeling and add analysis, leading the data to be dense.

I planned to interview 8-10 subjects recruited from the Chicago area. My sampling method was “purposive� (Rubin & Babbie, 1993). I selected subjects that I felt had the qualities that would lead to the acquisition of dense data, such as (a) articulate, (b) comfort and facility with self-disclosure, (c) willingness to discuss sensitive topics that may lead to discomfort or disagreeable information about oneself, and (d) availability for more than one interview. Therapists who had experience working with fat patients were preferred and all of the subjects met this criterion. I assessed these

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attributes in a preliminary telephone conversation with the subject about the nature of the research and aspects of participation.

Recruitment of subjects was done by mail. I solicited members of the National Association of Social Workers, the Clinical Social Work Federation (including the National Membership Committee on Psychoanalysis), the Institute for Clinical Social Work Alumni Association, the American Group Psychotherapy Association, and the Academy for Eating Disorders.

Ten subjects were selected for interviewing. After the first set of interviews, it became clear that identity of one of the respondents could not be easily disguised because of many identifying characteristics in the data associated with this person’ race, and the fact that the sample was homogeneous by race except for this one subject. For this reason, this subject’s interview material was withdrawn from the study.

The nine remaining subjects completed both interviews. They were all White.

There were three males and six females. Four subjects were in suburban private practice; four were in urban private practice; and one was in an urban agency. One was in their 40’s; six were in their 50’s; and two were in their 60’s.

Sources and Nature of Data Voice Recorded Interviews The primary source of data for this study was word-for-word narratives recorded on a digital voice recorder, allowing for 1-3 interviews per subject in order to ensure density o f data. Interviewing gives us access to aspects of people’s experiences that could

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not otherwise become known to us (Weiss, 1994). The interview is particularly suited to an exploration o f countertransference, a phenomenon that is at once both intrapsychic and interpersonal. There are several advantages to qualitative interviewing described by Weiss (1994). It allows the development of detailed descriptions. Interviewing several subjects provides multiple perspectives that contribute to a better picture of the whole.

Qualitative interviewing allows for a description of process, from antecedents to outcomes. In addition to a description of an experience, we can learn about the subject’s interpretation of the event. It allows for “bridging intersubjectivities” or providing information from the interview to the reader that can contribute to an empathic understanding.

A depth interview about a sensitive topic can be challenging in that it can raise anxiety, create stress, and contain information that makes the respondent easily identifiable (Lee, 1993). These challenges call for attention to four areas, (a) The topic must be approached in a way that does not alarm or inhibit the respondent yet allows for informed consent, (b) The complex nature of the interview, involving emotions, contradictions, and resulting stress for both respondent and researcher must be managed.

The catharsis that accompanies telling one’s story can help with this stress; other kinds of support may need to be mobilized, (c) There is a power imbalance that must be recognized. Respondents do not have much control over the use and interpretation of the data. Power can sometimes be shared in that respondents have ways of controlling the interview process, (d) Interview conditions, such as interviews that involve people who are in a relationship so that others are impacted, must be taken into account. Attention

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should be paid to the general preference of respondents to only have one interview and to the termination process. As countertransference is a sensitive topic and it involves third parties (patients), I considered these items as described below under “Data Collection Methods and Instruments.” The FANI method includes principles for managing these challenges.

I interviewed subjects according to the FANI principles that promote the use of open-ended questions in eliciting stories (see below). Respondents were encouraged to free associate while in the role of interviewer, I avoided the use of “why” questions and instead followed up with questions based on the respondents’ own words, order, and phrasing.

The population sample, clinical social workers who were experienced with free association, was comfortable with this process and able to speak in an articulate manner with much detail. Since most psychodynamically-oriented therapists are trained to seek their own therapy, I expected and found that the respondents were able to tolerate emotion and stress that arose from the interview process. Those who had not had therapy were expected to have learned to tolerate stress through experience with their patients, which can also be an emotional, stressful experience. As this situation is not unusual, therapists are encouraged to build a strong support system. I expected and found that a discussion of countertransference, while having potential to lead to strong emotions that could be stressful, was generally well tolerated.

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Field Notes Another source of data was the field notes that I kept before and during the interview process. The method I used takes into account the intersubjectivity of the interview process and the subjectivity of the researcher in analyzing the data. For this reason, I kept field notes on my personal thoughts, feelings, reactions, and experiences in relation to the interview process. I expected that, due to the sensitive nature of the topic, I could experience strong emotions and resulting stress. Just as catharsis could be helpful to the respondents, I believed these field notes could help me with the emotional challenges of the experience and found this to be so. My subjective experience with the research process had an influence on the research (see Discussion chapter).

A second form o f field notes was a recording of my observations about the interview process. I made notes of my observations of the physical setting and of the subject’s body language, and of thoughts, questions, and themes that emerge from the data during the interview. Immediately after the interview, I recorded impressions of the interview and the subject, using some free association as well as a conscious effort to record items that I felt would be of use to the research questions.

Memos Memos are reflections on the data. They are useful in organizing and interpreting the data through preliminary analysis. This method used two types of memos: (a) “structured summaries” of biographical data and notes on themes and ideas, and (b) “pen portraits” or descriptions of the subjects that make them “come alive” for the reader an

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serve as a base forjudging interpretations of the data. For details on the application of these tools to my research, see “Data Analysis” below.

Data Collection Methods and Instruments The method used for data collection was the Free Association Narrative Interview method. I believed that this was the qualitative method most suited to this research for several reasons described previously. I used this method for data production and analysis, as I believed it was adequate for meeting the goals of this study. Another reason for staying within the structure of the method as devised by the authors was that this is a relatively new method that can be refined through trials such as this one.

Clinical social workers who responded to the recruitment letter (see Appendix A) were contacted by telephone. In this call, I identified myself as a doctoral candidate at the Institute for Clinical Social Work. I determined whether the caller met the criteria for subjects as described above under “Population and Sampling.” I set up an interview time and location that was convenient for the respondent and met the requirements outlined under “Setting.” Before the meeting time, I mailed the subject a participant confirmation letter describing the study (see Appendix B) along with a copy of the form that was used for consent to be interviewed (see Appendix C), so that the participant had the chance to review this information prior to attending the interview.

At the time o f the interview, I introduced myself, providing brief information about my work as a therapist, my interest in the subject of the study, and some brief information about the study. I introduced the study as “an exploration of nature of clinical

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social workers’ countertransference to fat patients.” I used the word fat in order to make it clear that the word was part of the study and that it had no definition outside of the one that the respondent had in mind. The phrase “fat patients” was also used so that the respondent would associate to thoughts and images of a person, not just an attribute.

After this introduction, I explained the form that solicited consent for the interview in detail and answered questions.

Data collection was in the form of an interview based on open-ended questions with follow-up questions that were based on the interview material: a “focused interview” approach. These questions were intended to solicit stories. The questions were based upon the frame o f my research questions: 1. Would you tell me about what some of your fat patients have been like?

2. Would you tell me about your work with fat patients?

3. Would you tell me about your reactions to your fat patients?

4. Would you tell me about your own experience with fat?

5. Would you tell me about your experiences with fat people?

I supported the un-interrupted process of free association as much as is possible, encouraging respondents to continue with whatever came to mind, and avoided steering them in any one direction. I refrained from interpreting or judging the responses. During the interview, I took notes, using the respondents’ words and phrases and retaining the order that the respondent used in the narration.

I influenced the data collection in many ways that are characteristic of intersubjective dynamics, conscious and unconscious. This is a natural part of any

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interview and does not have to be interference. I sought to enhance data collection through the process of recognition and containment that is an important part of the process, keeping the ethical principles of honesty, sympathy and respect in mind at all times during the process.

The second interview was based on a set of follow-up questions derived from the first interview. It was designed to elicit more information about significant themes and to test emerging hypotheses about the meaning of the data to the respondent. These were based on my preliminary analysis that sought “contradictions, inconsistencies, avoidances and changes of emotional tone” (Hollway & Jefferson, 2000, p. 43).

Immediately following the interviews, I completed field notes on observations I had made before and during the interview, of the interview process, impressions of the respondent, the physical surroundings, and my thoughts and feelings about the respondent and the interview. These field notes were considered part of the data.

Hollway and Jefferson do not include the technique of “member-checking” in their data collection process. However, they admit to a tendency to react to what is being said with statements that are analytical in nature. They believe that this is a natural part of conversation. It can lead to discussion with the subject that may be useful in data analysis (p. 78), which happened frequently in the interview process.

Data Analysis The psychoanalytic viewpoint is the theoretical framework for this study of countertransference, a concept that originated in this school of thought and is based upon

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phenomena that have been well-developed and are central to psychoanalytic thinking: transference and the unconscious mind. Psychoanalysis has also provided us with a conceptualization and understanding of psychological defenses that operate to protect a person from being overwhelmed by affect, especially anxiety related to neglect, trauma and internal conflicts. The FANI method uses these concepts in data analysis. The assumption is that respondents provide narratives that are full of clues to the existence of thoughts and feelings not in one’s conscious awareness, due to the operation of one’s psychic defenses that keep them at bay. This method relies on the kind of speculation that a psychoanalyst uses in making clinical interpretations. The authors recommend the application of psychoanalytic theory (they chose Kleinian theory for their example) to the statements being made in order to guess at the missing pieces of the story and provide a coherent whole.

In the process of data analysis, I kept in mind Hollway and Jefferson’s (2000) core questions for analyzing qualitative data: • • • •

what do we notice? why do we notice what we notice? how can we interpret what we notice? how can we know that our interpretation is the “right” one? (p. 55)

Data analysis is aimed at getting a picture of the “whole” rather than fragmenting the data. Hollway and Jefferson (pp. 68-72) are attracted to the Gestalt principle of the whole as greater than the sum of its parts. Breaking down and coding data takes away from recognizing the whole of a person’s experience. They describe the prerequisite for constructing a picture o f the whole as “the internal capacity for holding those data

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together in the mind,” relating this to the practice of psychoanalysis (p. 69). Two structured tools for data analysis are used to construct a picture of the whole: the “Structured Summary” and the “Pen Portrait.”

The Structured Summary is a form (called “pro forma” by the authors) that was completed for each interviewee. It included some standard categories as well as themes derived from the interview material: 1. Identification Number 2. Age 3. Gender 4. Race 5. Employment Setting 6. Length o f clinical practice history 7. Theoretical orientations used 8. The meaning o f fat to the therapist 9. Countertransference to fat patients (themes) 10. Manifestations of countertransference in the therapy (themes) 11. Other comments/themes/summary The Structured Summary was used to begin to construct a picture of the “whole” of the subject’s experience. It was also used to suggest commonalities and differences among the subjects who were interviewed, providing a structure for reporting results.

The Pen Portrait is a written description of the subject, a summary that was constructed from field notes and interview transcripts. In the process of constructing a

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picture of the whole, the data was examined for inconsistencies, contradictions, changes of tone, word repetitions, and interruptions. I also looked for “links” (Hollway & Jefferson, 2000, p. 72-77) within the text that helped to counteract the defensiveness of the subject, who might not have wanted to make these links in a conscious way. These served as clues to the possibility that feelings and meanings existed that were not in the respondent’s conscious awareness.

Using this evidence, I made speculations in the form of “psychosocial propositions” that linked emotions to triggers and provide explanations. These propositions were based on a number of sources, including (a) information drawn from the text, (b) free association, (c) cultural assumptions of the subject and the interviewer (p. 74), and d) sociological and psychoanalytic knowledge. “Psychoanalytic knowledge,” for the purposes o f this study, includes theory on defense mechanisms as developed originally by Anna Freud (1937) and expanded upon by Melanie Klein (1975; 1977).

(See Theoretical Framework and Literature Review sections for elaboration on these theories.)

The FANI method uses the principle of reflexivity in checking psychological propositions against the data for consistency and validation (p. 65). Hollway and Jefferson note that psychoanalysts have long been aware of the difficulty of applying principles o f scientific objectivity to their analysis. They suggest using one’s own subjectivity to assist in analysis, checking statements made by the subject against one’s own perspectives and experience. Not to be used as a substitute for the use of theory, reflexivity can help to make the researcher aware of inconsistencies and

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misunderstandings or it can lend strength to a theoretical hypothesis. Subjective impressions must also be checked in a reflexive manner.

Statement on Protecting the Rights of Human Subjects Each subject that was interviewed was first asked to sign the interview consent form (see Appendix C). This consent was voluntarily given and was a prerequisite for conducting the interview. The form included the following information for assisting the subject in making a decision: 1. The purpose of this study is to explore the reactions of clinical social workers to fat patients. Research results will be published as a dissertation for the Institute for Clinical Social Work and may be used for other publications.

2. The interviewer’s name, student status, and credentials will be given.

3. The participant will be interviewed two to three times, with the use of voice recordings that will be transcribed.

4. Participation is voluntary and it will end after the final interview. Participants may withdraw at any time with no penalty or loss of benefits.

5. There are benefits to participation and to humanity related to telling one’s story and to furthering the understanding of the needs of psychotherapy patients.

6. The participant may experience some disagreeable emotions and stress due to the nature of the interview, which are expected to be manageable. If, under unforeseen circumstances, difficulties arise, the researcher will make referrals for appropriate

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assistance. The researcher will provide a contact person in the event of a research related injury.

7. In discussing experience with psychotherapy patients, the participant is requested to disguise the identity of these patients. The researcher will also take pains to do so in the published report.

8. The participant’s questions will be answered at any time during the procedures.

9. The researcher will promise to disguise identifying information in order to prevent anyone but the researcher from recognizing the participant’s identity.

Limitations of the Research Plan This research study is of a qualitative nature with limitations that are inherent to qualitative research. From the viewpoint of positivism, qualitative research lacks the kind o f concrete data that can be measured and compared based on known and accepted standards. Since qualitative research does not come from the positivist tradition, it is judged by other standards such as depth of the data and the overall contribution of the research to understanding of individual experience and meaning.

The different forms of qualitative research have inherent benefits and limitations.

This research used a narrative approach that required much painstaking work on the data from each subject; therefore, the number of subjects is small. This led to a lack of representation of various populations. It is difficult to compare and generalize across interviews because of the small number (Riessman, 1993). The small number (nine) of subjects in this study meant that these limitations did apply.

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Countertransference is a “sensitive topic” (Lee, 1993). Interviews on sensitive topics are conducted with “defended subjects” which leads to a particular set of limitations described in detail by Hollway and Jefferson (2000) and summarized above under “Type of Study and Design”. With respect to the current study, there were the following limitations. The discussion of countertransference may have led to stress from uncomfortable emotions that were expressed in the interview. I dealt with this limitation with a plan to offer referrals to outside assistance which turned out not to be needed. I purposely interviewed therapists who had experience with countertransference and with assembling their own coping mechanisms. A second limitation of this research was the problem inherent in discussing material that the respondents have an ethical obligation to keep confidential and where there is some disagreement about whether patient information is to be used for research purposes. This problem is often handled by using careful disguise o f patient material so that patients cannot be identified. I was aware that disguising material could have compromised the validity of the data; therefore, I used the principles of honesty, sympathy, and respect recommended by Hollway and Jefferson in deciding how patient material would be presented in the published research. I left it out of the report when it did not seem necessary to understanding the data, or seemed risky in some way. I reported the data in a way that would disguise identities (see Methodological Implications at the end of this chapter).

Other limitations of the research were my own biases, defenses, and transferences to the subjects. These are inherent in qualitative research. They are taken into account in the method that I used so that their harmful effects were minimized. I used the same

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techniques for examining my subjective contribution to the data and the analysis as I did for the subjects of the study.

I expected that my personal experience with fat and fat patients would strongly affect the research process. (Further details of this experience are to be found in the Discussion chapter.) I was alert to my own political agenda and its positive and negative influences on the respondents and on my interpretation of the data. Although I could not control my unconscious communication about my thoughts and feelings about the research, I considered the effects of my bias, and tried to minimize them when they seemed to interfere with the density of the data. My value of “size acceptance� is evident in the discussion. It is based on what I believe to be a rational conclusion from examining weight loss research, as well as my understanding of the dynamics of size discrimination.

It is no longer thought that research can be done from a neutral stance; some would say that politics is an inevitable factor and even desirable (Denzin, 1997). I also believe that my experience facilitated the research process because of my skills at listening empathically and my knowledge of the experiences of many fat patients. I watched for the possibility that I could make assumptions based on my experience that were not true for the people that I was interviewing.

It is important to consider the possibility that there were hidden agendas to this research. Other than fulfilling the requirements for completing a dissertation, I found that this research was personally challenging and enjoyable. I learned a great deal that I can use in my work with fat patients. I also benefited from discussion of countertransference with clinical social workers in that I had had similar experiences and enjoyed associating

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with like-minded therapists. I attempted to identify my hidden agendas using field notes and memos.

Overall, I handled limitations in the method by conducting multiple interviews; by using reflexivity and searching for links in the data; by using the principles of honesty, sympathy, and respect; by providing a clear statement of procedures; by consistent selfexamination; and by seeking consultation with the dissertation committee.

Methodological Implications As the method employed in this research is new, an opportunity presents itself for evaluating its utility. Both the method and the design of the study had strengths and limitations. Those will be described in this section, along with their methodological implications.

In this study, the design element with the greatest impact on the course of the research and the use of the FANI method was the subject population. Three characteristics o f this population were influential: (a) their psychological strengths, (b) their professional need for anonymity, and (c) their patients’ need for privacy.

Concerns about the sensitive nature of countertransference, which, by definition, includes feelings that are not conscious to the therapist, are what led to the choice of the FANI method. However, the subjects proved to be much less psychologically defended than populations for whom the method was invented, such as victims of crime who were interviewed in the authors’ prototype. This was partly anticipated, and led to an incorporation of design parameters that would increase the possibility that subjects could

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handle the sensitive aspects of the topic. It was expected that clinical social workers who were experienced and trained to work with countertransference might be less likely to defend against painful or threatening feelings that could arise during a discussion of this phenomenon.

This turned out to be the case. All nine subjects were quite forthcoming with information, thoughts, and feelings about fat, fat people, fat patients, and their own experience with fat. During the interviews, some subjects talked about feeling some discomfort, but none appeared unable to tolerate that feeling. Some seemed more willing to talk about feelings than others did; yet, those subjects also provided a great deal of rich material in answer to the interview questions.

During the process o f data analysis, it was decided not to include inferences of unconscious content, for two reasons. First, it appeared unnecessary to go to that length in order to answer the research questions, as the subjects did not appear to be highly defended. Second, in order to present and justify speculations about unconscious content, a description o f the subject would have to be so comprehensive as to lead to the possibility that this person could be identified. Some readers of this research may be clinical social workers in the Chicago area who might easily recognize their colleagues.

There was also the possibility that patients who read the results might recognize their therapists. They could be exposed to information about the therapist’s history and intrapsychic functioning that would compromise their needs for therapist anonymity.

It was also decided not to report a holistic description of each subject, for protection o f the privacy needs of his or her patients. Reporting subject descriptions and

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narratives using the pen portrait could increase the chances that the patients who were discussed could be identified, a risk that was ethically unacceptable. Instead, pen portraits and structured summaries were used as resources for the final report of the results. In this report, subject narratives were divided up and interspersed among other subject responses, organized according to themes under the headings of research questions. This adaptation obscured identities by making it difficult to piece together details about any one subject.

To protect both subject (therapist) and patient anonymity, many identifying details were not reported and were removed from quotations.

In summary, the following adaptations were made to the method, (a) Speculations about unconscious content were not reported in the results, (b) A holistic “pen portrait� of each subject was constructed for data analysis, but excluded from reporting, (c) Many identifying details were excluded from the report. Although the report of the results would be enhanced with pen portraits and the inclusion of unconscious material, there is still a great deal of new information from this exploratory study that both adds to knowledge and is of clinical import—the main goals of this research.

Overall, the design contributed to the goals of the research and data collection and analysis went smoothly. As mentioned above, the parameters of subject selection led to the inclusion of nine subjects who were comfortable and sophisticated in their discussion of countertransference. They responded with energy and enthusiasm for the project, possibly because of their awareness that the researcher shared their theoretical viewpoint and level of clinical experience. It appeared that they were very interested in contributing

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to further knowledge of countertransference to fat patients. The narrow subject selection parameters provided the above benefits; however, future studies might be expanded to obtain responses from therapists of other disciplines, theoretical viewpoints, and experience levels.

One element in subject selection was lacking, which proved to be a problem.

When it was discovered during the first set of interviews that subjects and their patients could be easily identified, more attention was paid to identifying details. One of the ten original subjects was of a different race than all the rest and could have been easily identified due to this unique characteristic. This subject’s data was excluded from the study. This could have been prevented through the addition of racial diversity or homogeneity to the subject selection parameters. A limitation of this design was that the subjects were of all one race. Incorporating diversity into the design of future studies would lead to a greater understanding of the impact of race on the research question.

A design element that worked well was interviewing subjects in their offices.

Observing the therapist in the clinical setting proved to be enriching to my experience and understanding of the subject and the interview material. It appeared that the subjects felt comfortable in familiar surroundings. Free association was facilitated by returning to the settings where the reported experiences had taken place.

Interviewing nine subjects more than once was intended to ensure variety and depth in the data collected for this exploratory study. This design element produced the intended effect. In the future, this could be altered, with other good effects. A single case study with multiple interviews might allow for much more detail about the experience of

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both the subject and each patient who was discussed. On the other hand, inclusion of a greater number of subjects might provide a greater variety of responses.

The Free Association Narrative Interview method proved to be of immense value for obtaining and analyzing the data in this study. What makes this method different from other narrative approaches is its use of ideas from psychoanalytic theory for researching sensitive topics. The theoretical “language� of the method matched that of the researcher and the subjects, all of whom practice psychotherapy from that viewpoint. This made it easy for the me to understand and apply the research techniques. The subjects were already familiar with the techniques, so they needed no explanation. Since countertransference is a psychoanalytic concept, the techniques were particularly suited to exploring the phenomenon.

Data acquisition was through interviews, using open-ended questions with a minimum amount o f interference in the subject’s associations to the question. This technique is one that both the subjects and I knew well, through training and experience. I did not find it necessary to coach subjects or steer them toward certain topics. Most of the research questions were answered in the first interview. Second interviews were used in part for acquiring demographic information. As the method recommended, second interview questions were derived from a preliminary analysis of the first interview in order to fill in missing pieces or achieve more depth. Although these questions were more constrained, I attempted to present them in an open-ended manner, continuing to encourage the free association process. As psychodynamic psychotherapists know well, free association did not lead to useless wandering away from the topic; on the contrary, it

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led to stories and feelings that were of great relevance. It also led to much material that would suggest unconscious feelings and thoughts. Free association worked well for this subject population. With other populations who are not familiar with free association, or who feel threatened by its lack of structure, the technique might have some drawbacks.

Data analysis was a process of noting themes and inconsistencies in the narratives. Using the recommended technique of linking these items, “psychosocial propositions” were constructed about the nature of each subject’s countertransference to their fat patients. Although inferences about unconscious material were not reported, they were useful in the data analysis process. They allowed for construction of pen portraits that were greatly enhanced by the inclusion of all of my impressions about the subject’s experience, thoughts, attitudes and feelings, whether conscious or not. Constructing the recommended “picture of the whole” led me to identify important themes and results as well as identify meaning in these results. I found the data analysis techniques to be straightforward and familiar, again because of their similarity to the task of the psychodynamic psychotherapist. Researchers who do not have this background might find it very difficult to acquire enough knowledge about psychoanalytic theory and technique to conduct a thorough and sophisticated analysis in the prescribed way.

Reporting of the results was not clearly addressed by the method. Even though the value of holistic data analysis was achieved, this report is limited by its fragmentation of the data, something that the authors discouraged. The compromise that was made in order to solve problems with privacy and anonymity is an example of a value that the authors strongly encouraged in their discussion of ethics; that is, maintaining an attitude of

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respect and sensitivity when it comes to the needs of subjects. This attitude was recommended as a guideline for resolving difficulties with the method. Although fragmented, the report still offers a great deal of new and useful information.

Overall, the FANI method lends itself well to the studies of topics related to psychotherapy by clinical social workers, especially those who are psychoanalytically informed. In this study, the strengths of the method combined with the strengths of the subjects led to fruitful data production. It appears that this method could be quite effective for researching sensitive topics in the general population, if the researcher is skillful and well prepared.

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CHAPTER IV

RESULTS

Nine clinical social workers completed two interviews each during the early months of 2004. All of the research subjects were cooperative and seemed highly motivated to help in understanding the nature of countertransference to fat patients. They were articulate and talkative in the interview process. It did not take long for them to get an understanding of the nature of the research and begin giving detailed, descriptive answers to my questions.

The interview content varied considerably with each individual. Although a strong effort was made to gather information on all of the interview questions, free association was encouraged and produced varying results. Some subjects disclosed much personal information about themselves, their experiences with fat patients, and their feelings. Others tended toward more of an intellectual focus on theory, knowledge, and technique. Most described their work with several patients; one chose to focus on only one. Some talked mostly about themselves; others talked mostly about their patients. No matter how they answered the interview questions, all 18 of the interviews are rich in terms of material that shed light on the questions that this research was designed to answer.

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In this chapter, the results of these interviews are reported, beginning with descriptive information about patients who were discussed by their therapists. This will be followed by a description of the nature of the clinical social workers’ countertransference to their fat patients under headings that reflect the three research questions of this study: (a) The Meaning of F at (b) Countertransference to Fat Patients, and (c) Manifestations of Countertransference. Each therapist’s real name has been replaced with a pseudonym.

Patient Descriptions In sum, 28 patients were discussed by the nine clinical social workers that were interviewed.

Length o f Therapy Long-term therapy is frequently encouraged and practiced by psychodynamic psychotherapists. Length of therapy was not an interview question but was discussed directly by some therapists and deduced from stories of events in therapy. Most of the patients described had been in therapy with the subjects for a number of years. My impression is that length of therapy generally ranges from 2 to 10 years. The highest number mentioned is 22. Several patients had seen their therapists over a long period, taking short or long breaks. There was no mention of short-term therapy.

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Presenting Problems and Diagnoses Although weight was often discussed in therapy, with the exception of one, these patients originally came to therapy for other concerns that are typical of the general clinical population. Therapists were not directly queried about presenting problems or patient diagnoses, but many volunteered this information. Some of the older patients experienced depression, loneliness, and difficulties with activities of daily living. Several of the patients reported problems that their therapists describe as personality disorders, mostly borderline and some narcissistic, ranging from low to high functioning. A number of patients suffered from stress, depression and/or anxiety and used food, tobacco, pornography, and/or alcohol for relief. Difficulties in relationships were common, including conflict, sexual dysfunction, and breakups. Several patients had difficulties with anger, passive behavior, and hostility. Also mentioned are grieving, Post Traumatic Stress Disorder related to a history of sexual abuse, conflict in the workplace, and ambivalence about career advancement.

A history of body image disturbance and eating disorders, as well as current disordered eating were reported by the therapists relative to most of their patients.

However, not all of the patients were concerned about or wished to discuss their eating and weight. Often the discussion of these concerns was initiated by the therapist.

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Age of Patients Therapists reported their patients’ ages at the beginning of therapy, estimating age according to decade, e.g., “in her 30s.” Age groupings ranged from 20s to 70s, following a rough bell curve. Three patients began therapy in their 20s, eight in their 30s, six in their 40s, seven in their 50s, two in their 60s, and two in their 70s.

Gender o f Patients Ten male and 18 female patients were discussed. Approximately one third of the group was male and two thirds female.

Race of Patients A majority of patients discussed was White. A substantial minority, approximately one fifth, was comprised of people of color including African American, Asian, and White/Hispanic.

Weight of Patients Most of these patients were described by their therapists as “fat.” A few patients described themselves that way, but their therapists were not always in agreement. In order to get a sense for patient size, I asked each therapist to estimate a number that represented the patient’s weight. I did not ask for Body Mass Index estimates. Although BMI is a popular descriptor for size that considers height, the calculation is so complex

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that most people would find it difficult to make an intuitive guess. Most therapists cited a number. Some gave a range (e.g. “in the 200s”).

Reported weights ranged from 100s to 400s. About one fifth of the total number of patients discussed was estimated to weigh less than 200 pounds. Nearly half was estimated to weigh 200-300 pounds. Over one fifth of the patients were estimated to weigh over 300 pounds. Therapists said they could not estimate the weight of three patients. A few of the thinner patients were not described as “fat” by their therapists, but were reported to have significant concerns about fat and/or a history of weight gain.

Socioeconomic Status of Patients Therapists were asked to describe the socioeconomic status of each patient they discussed. The results are characterized by a bell curve, skewed slightly to the left.

“Poor” was the word used to describe almost 18% of patients. Over 21% were lower middle class; over 28% were middle class; and over 28% were upper middle class.

“Upper class” represented over 3% of patients.

The Meaning of Fat The meaning of the word fat to the clinical social workers who were interviewed was derived from two types of statements about themselves, their patients, and other fat people who came to mind. First, some subjects made direct statements about the meaning of fat. Second, the interviews contained words and statements that appeared to have

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meaning to the subjects relative to fat, although subjects did not directly attribute meaning. Inferences based on the second type of statement are identified as such.

In the report that follows, the results are grouped into six categories of meaning that are evident in the data. These include fat as (a) a word, (b) a substance, (c) an attribute, (d) an indicator, (e) a function, and (f) a problem.

Fat as a Word Some therapists demonstrated a reluctance to use the word fat. Meredith expressed a concern about participating in research that would use this word in its title, wanting my assurance that I would be sensitive to the potential of the word to be used in hurtful ways.

“You teach your kids not to say that, if someone says, ‘Oh, that person’s fat.’ It’s not a kind thing to say,” Alice said. “I associate it with kids sorting out who’s different, who’s fat, who’s not. I think of someone fat, like there’s a negative connotation with it.

There’s some judgment or something in there.. . . I’m just thinking of that expression ‘until the fat lady sings.’”

Hannah agreed that the word has a negative connotation that can be used to hurt people. “It’s a word I never use myself,” she said. “You think about kids on the school yard and right after ‘You’re a sissy’ is ‘You’re fat.’”

Other therapists did not say anything about the word fat and used it freely throughout the interviews.

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Fat as a Substance Two therapists talked about fat as a substance. Fat tissue is what came to mind when I asked Alice about her experience with fat. With some hilarity, she remembered attending a Weight Watchers meeting, where a pound of fat tissue was demonstrated to the participants as a motivational technique. She noted that it was bigger in volume than a pound of butter, which was how she had previously thought of fat.

David defined a distinction between a fat person who is “overweight” and one who “is just a guy with a big gut.” It appears that he did not view this kind of body fat as a problem.

Fat as an Attribute Often the word fat was used as a description of size. Subjects found it difficult to quantify the word. According to Christina, “Fat is such a relative term.. . . You can have someone who is five feet four inches, who weighs 110 and looks in the mirror and feels fat and someone like myself who is definitely very—I’m quite overweight and I don’t feel that way, I don’t feel fat.” When asked about her fat patients, Hannah reacted by differentiating fat from other categories of size. “I am asked to make the distinction as to who is a little chubby, who’s overweight, who’s normal but is not going to make it on the cover of People Magazine, and who would I consider fat.”

Words related to size were used in association to the word fat and fat patients, often with confusion or hesitation. “When I think of the word, it comes up as a sort of ‘roundness,’” Meredith said. Alice called her fat patient “heavy—whatever you want to

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say . . . like a double person.” In reference to another patient, she said, “I wouldn’t describe her as super (pause) . . . She’s not really heavy at all, particularly. She looks like somebody who had kids, which is true. You know.” The words big, heavy, large, and big­ boned were used by some therapists as a substitute for the word fat, as in the following statement by Brad: “Well, she was big. She was heavy. She would be considered ‘fat.’”

Some believed that the meaning of fat as an attribute is idiosyncratic. Hannah responded, “It’s impossible for me to generalize what my fat clients have been like because they’ve been so different.” Christina noted, “The word fat is what it means to an individual. For all the people who, to our eyes aren’t fat, and they feel f a t . .. ” She referred to a collective standard of fatness among therapists—“to our eyes aren’t fat” that was nevertheless labeled as a perception. She also brought up the idea that people can “feel fat” regardless of any objective measurement of size. Others mentioned patients who would continue to feel fat after they had lost weight and had become what their therapists described as “thin.”

In addition to these direct comments about fat, attributes were described in association to fatness or fat patients that appear to shed light on the meaning of fat to the therapist. Fatness was associated with the words elephant and blimp. Sin was the word that a therapist used to describe a person’s weight gain. “To watch a person, because really from the age o f 50 on, it’s like this is a sin,” David said. “’You are a [health professional]. You know about this. You’re killing yourself and you are being blithe about it, you know.’” Christina associated losing weight to “cleaning up” her body. In describing a fat patient who said he loved food, Tom said, “I think that’s one of the

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problems in working with . . . overweight, or fat, people is, most of them probably do like food.” Without directly linking these terms to fatness, Sarah frequently described her fat patients as “limited” and having the attributes described in the following example: “I have another one who I would say is passive aggressive, passive hostile, hostile compliant. [Quoting patient] ‘I can’t possibly do this.’ And she keeps gaining, looks so unhappy, miserable.” A link between fatness and aging was made by Hannah, who has become more aware of her weight and others’ as she has grown older. Abusive was a word that David used to describe his patient’s fat, referring afterwards to his ill health.

Comments by Brad about the experience of a fat patient in the context of oppression due to her race suggested a link with oppression due to her size. Meredith overtly mentioned a patient’s experience of size discrimination in the workplace. These links suggest an association of fat with class or group of people who are oppressed. Alice said that fat people were not a class per se, only in that they might describe themselves that way.

Fat as an Indicator The therapists who were interviewed often described ways that they and others perceived fatness as an indicator of an attribute, a condition, or a situation related to the fat person. The indicator took the form of a sign or a symbol. At times, the indicator was a symptom of mental illness or psychological deficit.

A variety of meanings was ascribed to fat as a sign or symbol. It appeared that Hannah saw her patient’s fatness as a sign that there was a “relentless hunger inside of

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her.” Brad gave an account of someone who allowed her fat to be visible in public. He talked about this behavior as “out of control,” saying that this person’s fatness indicated that she had been out of control for many years.

Fat as a signal that something is going wrong with a patient was reported by one therapist. Rachel said that she learned this from her father, who believed that fatness indicates that a person is not eating right or getting enough exercise. To him, fatness meant that a person was “unaccomplished in some way” and was “an indication of not working hard enough or at pleasing.”

Christina said that she had always felt that a person’s fat indicated that he or she was unhappy.

Although part of me knew something a little different than that. I remember meeting . . . a woman that was thin and beautiful and she was the most depressed, unhappy person in the world and it all of a sudden hit me you know. I am wrong to think that everyone walking who’s thin is happy (laughing). Finally it started to compute that’s not really true you know.

Disability and death appear to be symbolized by a person’s fatness in Hannah’s description of a patient and her father. The patient did not want to identify her father as fat, probably, the therapist speculated, because she associated her father’s fatness with his disability and a fear that it was killing him. This therapist believed that her patient eventually died of obesity.

Fat as a symptom of psychiatric disorder, developmental delay, or psychological deficit was frequently mentioned. However, there was much discussion of fat patients’ emotional difficulties with no reference to their size. Christina distinguished between patients who experienced painful feelings about their fat and others for whom fatness was

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not an issue. She believed that negative feelings about fat often indicated low self-esteem, which was not actually caused by the person’s fatness.

In describing her own experience with fat, Hannah talked of it as a sign of immaturity.

All of the sudden it seemed like, “You know what, grow up.” Everybody has to be responsible for their health and well being and the idea that I could eat anything I want and there would be no repercussions either nutrition-wise or weight-wise.. . . There is something about being grown up where you . . . brush your teeth and floss. You have to do things that maybe aren’t fun.

Many therapists saw fat as a symptom of self-destructive tendencies. Christina explained this as: . . . the difference between being overweight to a point where it’s self-destructive to you. Like, if you’re so overweight that you’re going to die sooner. To me, that’s the same as if you drink and get in a car and drive. It’s a suicidal kind of— or a slow dying, you know—a dangerous kind of thing.

Rachel expressed a belief that fat was a sign of avoidance or denial. She spoke of her own fat and that of her patients as a symptom of a tendency to avoid feelings.

Noting that all of her fat patients used alcohol and grew up with alcoholic parents, Alice wondered if fat might be a symptom of alcoholism or difficulties related to growing up in an alcoholic family.

Loss of fat could be a symptom of depression, two therapists said. Hannah reported having had this experience, herself. Christina expressed a concern that her fat patients who were losing large amounts of weight after weight loss surgery were vulnerable to depression, due to the loss of food as a coping mechanism.

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Three therapists talked of fat as a symptom of an eating disorder. Fat, to David, was an “outcome” o f eating disordered behavior. In particular, he described this behavior as an attempt to “self-medicate” in order to “make feelings go away.” Christina described patients whose fat was a focus of the obsessive thinking that is a feature of eating disorder diagnoses. She noted that not all fat patients have eating disorders. The idea that fat is a symptom o f an eating disorder was explored by Hannah: Do we have a conception of fat that is not inherently eating disordered, or do we say if someone is fat then they are by definition eating disordered? And if we don’t accept that, if we say that there is such a thing as your normal everyday person with their normal everyday whatever and they are fat but we wouldn’t call them eating disordered, how does it change the whole question of fat if the three clients I presented to you I considered eating disordered?

Fat as a Function The meaning o f fat was occasionally connected by therapists to functions as tools and assets in interpersonal relationships.

Brad described a fat patient as “such an imposing, steely-faced, ‘stay-away-ffomme’ kind of person.. . . She just put her ‘suit of armor’ on and went in and did what needed to be done and that was that.” He believed that fat “is normally a matter of taking in more than you need and putting on weight to protect yourself in some way—to cover some fragile, vulnerable, frightened, maybe even terrified part of someone.”

David stated that fat was used by a male patient to “distance himself from people.” He noted that women also use fat to protect themselves in interpersonal relationships, but more specifically to stay isolated in order to keep men away.

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Two male patients used their “size” to influence people’s reactions to them, according to a Sarah: He likes to be threatening, though. With both of these men, it’s important to have size. They talk about size as a way of um, how people react to them.. . . I think how I react to them is n o t . . . as I know them, but I understand kind of my initial reactions may be kind of physical responses . . . to their physical appearance . . . as what they say they want.. . . I’m not saying that it works for them, but that’s how they experience what they do.

Referring partly to what she believes is a need to be fat, Christina discussed the impact of this need on her own attempts to lose weight: My conscious being wants this . . . wants to be . . . at a normal weight, a healthy weight. My unconscious wants to overindulge, eat a lot for whatever reasons.

There’s a conflict between them. And so many times I would . . . keep struggling and struggling . . . and trying to do the will power and feeling . . . horrible if I gave it up and all that.

Fat as a Problem Whereas in the previous section, the meaning of fat was positive in terms of serving a purpose, next I will report on negative meanings associated with fat as a problem. “When I see fat,” said David, “from my point of view it’s the enemy. I try to understand it but I also try to be at times somewhat direct about the fact that this isn’t a good thing to be wearing.” Rather than using the word fat, therapists frequently elected to use words that imply a problem with the person’s larger size, words such as overweight, obese, and weight problem. With great concern, Rachel spoke of a patient’s weight gain: “She had gained about. . . oh my goodness . . . I don’t even know . . . maybe 50, 7 5 . . . .

She was obese!” Alice made a distinction between people who have a “weight problem” and those who do not, but believe that they do. Several therapists reported their own and

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their patients’ fear of gaining weight and becoming fat, as in the following statement made by Hannah: “Oh my gosh, am I going to gain twenty pounds?” Five types of problems were associated with fat, which was described as (a) a flaw, (b) an interpersonal problem, (c) an emotional liability, (d) a physical liability, and (e) a health problem.

Fat as a Flaw Two therapists referred to the idea that fat might be normal as opposed to a flaw.

Alice referred to fat that is the outcome of pregnancy. Christina suggested it might be the result of genetic endowment.

Tom spoke of his patient’s weight in contrast to his intelligence: “[He] is very bright, but is hugely overweight.” As previously cited, Alice thought that the word fat is commonly used as a way to emphasize a person’s “difference,” especially in the “negative” sense of the word. Other comments about fat as a flaw related to appearance, and reflected the opinions of the therapists who made them. Two therapists commented on fat thighs as if they were flawed. Rachel contrasted her own to the slimness of a relative. David associated to his mother’s thighs when asked about his experience with fat people. In reference to a patient, he said, “She was, you know, rolls of fat, and her thighs were pretty good size. It was one of those things where you think, looking at her, like, ‘God! You really put on weight!”’

Adjectives used by other therapists to describe patients’ fat included awful, gross. and unattractive. I asked Brad, who described a fat person (not his patient) this way, to tell me more.

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Subject: I mean it got to the point so you didn’t want to be around her. She was uncomfortable to look at. She was, it was just gross.

Interviewer: Could you say a bit more about her being uncomfortable to look at and ‘gross.’ What is gross about her? What is uncomfortable?

S: What I do with this is I begin to think about what it would be like for me to carry that kind of weight around.

I: Okay.

S: And I have done such things as walk up stairs carrying ten pound weights, so it is like I am 20 pounds heavier—what that just feels like on my body.

I: Overall.

S: Yeah and its awful. At 20 pounds it is like, “My god!” You know, your knees, your joints, your heart, it is just ridiculous. This woman is about my size or a little shorter.

I: Okay.

S: A hundred pounds on me! Give me a break! Clothing, body hygiene, going to the toilet, getting into a public stall.

I: You are talking about imagining yourself dealing with all that.

S: Right.

Fat as an Interpersonal Problem Fat was described as presenting a problem in interpersonal relationships. Alice commented that fat “interferes in [fat people’s] social relationships because other people react to them because of their weight.” Often, the problem is in handling the criticism of others, particularly family members. Rachel described a feeling that she could not please her father due his view o f her fat as “unappealing,” “unaccomplished,” and an indication of not working hard enough. Alice reported her experience of being criticized about her weight and eating by both parents: And then it didn’t come off that easily. I got involved with Weight Watchers. I can remember my mom saying to me, so this is my next association around the word fat, ‘Well, I guess we’ll just have to get used to having a fat daughter.’ I was really m a d . . . . I was like, “What is wrong with you?” I was just mad at her.. . .

From that comes my next association, which is my stepfather. Here I’ve lost weight and my stepfather is riding me about what I’m eating, you know he always

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rode us. He rode my mom, rode me, if we were in the kitchen and having one of those “moments.”

An interpersonal problem that was mentioned by a few therapists was fat as a barrier between people. Commenting on the word fat, Meredith said, “I am a visual person and when I think of the word, it comes up as sort of ‘roundness’ in which you can’t reach the person—that arms don’t extend long enough, metaphorically, to reach the person.”

Brad talked about his perception that families can experience “embarrassment” and “mortification” when appearing in public with a relative who is “quite overweight.”

Fat as an Emotional Liability To Meredith, gaining weight made her feel that her “life as a woman” was “over.” Others talked o f their own feelings and their patients’ feelings that fat is an emotional burden. While describing a struggle to come to terms with her own fatness, Christina contradicted herself more than once, as in this example: I’m no longer self-conscious about it. I mean, I wear long things, because I know that it’s not attractive. So, I’m covering up that much, but it doesn’t get in my way. I don’t think about being a heavy person. I have made the decision that it’s unattractive to see the shape of overweight people. I’m not making a judgment for anyone else but for me it’s unattractive for a very overweight person to wear tight clothes. And I think they look better when they’re wearing looser clothing. I don’t even know if I should say that about that. I just know for myself, I do not like looking in the mirror wearing something tight-fitting. So, is it hiding or is it just covering up the flaws the way if you have dark bags under your eyes you put erase on. I look at it more in that way—not hiding but trying to enhance your looks. So, I cover up. A lot of times when I say to people, ‘Oh my god you know I could lose fifty pounds,’ they don’t even get it or see it a lot of times. I say, ‘Believe me if you saw me undressed you’d see it.’ I’m not going to flaunt something unattractive. I’m not sure I’d call it hiding—I would just call it ‘cover flaws and enhance the better things.’

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Fat as a Physical Liability “When I see someone who can’t-fit-in-a-chair kind of fat, I just feel so bad for them,” said Christina, speaking of the physical challenges that fat patients may experience.

David described a similar reaction and association to the word fat: I have reactions to her. I feel badly for h e r.. . . She’s probably 5’6” and I wouldn’t be surprised if she weighed around 300 pounds or more. And she has trouble walking. And on some level, that’s what I think of as “fat.”

Part o f what makes a person “fat” is whether their weight creates a “safety risk,” Alice believed.

While discussing the meaning of fat, Brad spoke of his own “weight gain,” which he believed was a result of decreasing the amount of exercise he was used to getting.

Gaining weight made him feel “nutsy.” I asked him to elaborate.

There comes a point (laughing) where you gotta realize that you are as old as you are and some of these things may be a little foolish to keep doing unless you are working out regularly.. . . So the “nutsiness” may be about the competitiveness as opposed to the weight.

He agreed that for him, fat meant “losing his competitive edge,” which he associated with the loss of physical abilities due to aging.

Fat as a Health Problem Christina believed that fat is not necessarily unhealthy. “Someone who’s thin but gets no exercise is going to die sooner than someone who’s overweight and exercises.”

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The other eight therapists associated fat with health problems. Whether a person is “fat” depends partly on whether their fat is a health risk, according to Christina. David stated more strongly that people are not fat unless their fat is creating a health risk: When I see really, really fat people I have trouble with i t . . . . It’s nothing to do with appearance. It’s about health.. . . You’ve got about 10 or 15 pounds on you extra and this is not good for you. Whether you were smoking or doing that, it’s all the same to m e .. . . It’s really what we are told, and what’s drummed into us, and what we hear about. . . . You know, women get breast cancer and men get heart attacks.

Countertransference to Fat Patients The second question this research attempts to answer is, “What are therapists’ reactions to patients whom they perceive as fat?” Two kinds of reactions are included in the definition of countertransference for purposes of this research and are reported in this section. The first kind consists of attitudes that therapists demonstrated or verbalized as they described their experiences with fat patients. These attitudes fall into four main subject areas: (a) the fat patient’s experience, (b) characterizations of fat patients, (c) health risks, and (d) treatment needs. The second kind of reaction consists of feelings that therapists expressed in reaction to their fat patients. These are divided into three types of positive feelings and nine types of negative feelings.

Attitudes The Fat Patient’s Experience Attitudes about the fat patient’s experience were often evident in expressions of empathy. For example, some therapists gave opinions that fat people are vulnerable to

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oppression due to their size. As this attitude was shown with expressions of feeling, it will be described more fully in the section below entitled “Feelings.”

One therapist, Tom, spoke about the effects of socioeconomic status on his patients’ eating and weight. His conclusion, with some reservation, was that the availability of money led them to eat more and gain weight. In this example, he talked of a man and a woman whose low incomes had recently increased: I think there’s been kind of unspoken sense in our culture that up until recently maybe when there has been much more health consciousness.. .if you can afford to eat a lot of food .... it’s good to do so. And, I think in both cases their ability to purchase food contributed to their consumption of a lot of it. So, I think having more money and able to eat more food. However, the other two gentlemen had very little money but they still managed to spend a lot of it on food and unhealthy food and gain w eight.. . . I think that my hunch is that having more money contributed to more fat.

Attitudes about fat patients’ experience of overeating were evident throughout the data. The view that overeating can be a symptom of emotional distress was expressed by all, as in this example contributed by Christina. Her patient had gained a “huge amount” of weight due to what she believed was a grief reaction. When he stopped smoking, he gained more weight. “The eating is another symptom . . . he’s using food, you know, now, instead of alcohol or pills, or something.” Tom believed that patients can be overweight because of their lack of exercise and difficulty with portion control, and that they can approach weight control with lack of knowledge that renders the effort ineffective. An example of this is in the following description o f an older female patient: She doesn’t buy terrible foods. It’s not like she’s just sitting around just eating cookies. She buys sugar-free ice cream and candies, but buys a lot of produce and meats and actually does some cooking for herself. I think her main problem is that she doesn’t get enough exercise and I don’t really see her eat, but she has been— and continues to be— overweight, definitely quite a bit overweight.. . . She talks

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about needing to lose weight, and buying diet soda and these fat-free or sugar-free candies, but feel that she doesn’t really get that it’s more about portion control than about buying sugar-free products and then eating who knows how much pasta at a sitting, or whatever, or ham, or smoked salmon, or bagels and cream cheese. And it seems to me that she buys an enormous amount o f food for one person.. .who also gets home delivered meals. She has a lot of food crammed into a small refrigerator and now, she’s also—with her increased income— she’s able to order out occasionally on Chinese food, or ribs or whatever and does do that from time to time.

When asked why he thought his fat patients did not get more exercise, Tom answered that there were a number of factors that made it difficult for them to do so, including physical disabilities, fear of leaving the house or going out alone, too much weight, and “a lot of excuses.” His opinion was that they felt more comfortable about getting exercise in a group setting, which was an aspect of his agency’s program.

Patient Characterizations The therapists were asked to talk about patients whom they would consider “fat.”

They were not given a definition of this word. Although several therapists were reluctant to use the word and struggled with its definition, they all went on to choose one or more patients that they believed could be described this way. They reported a variety of other characteristics while speaking of their patients. These other characteristics were not necessarily linked to the patient’s fatness. Links that were made are reported below.

All therapists described their patients in terms of pathology. These included posttraumatic stress disorder (particularly related to sexual abuse), personality disorders (borderline and narcissistic), anti-social behaviors, Oedipal conflict, addictions,

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“neediness,” and depression. The following statement by Hannah is typical of the wide range o f levels of functioning that therapists noted: I would say in terms o f pathology, they represent a very severely disturbed woman where her disturbance interfered with every single level of her functioning, to a very highly functioning woman, where her issues can all be maintained in terms o f conflict or her own angst, disappointment or depression or anxiety, and they don’t really interfere with her external success.

Alice made a link between her patients’ overeating, weight loss attempts, and other addictions. She noted that her fat patients often grew up in alcoholic families and substituted food for alcohol in their own attempts to self-soothe. When these patients attempt to lose weight, “you’re just going to get a conversion to something else,” she said, referring to smoking or drinking. “Equally difficult. . . you stop drinking, you start eating, but maybe that’s not a bad thing. In some ways it’s healthier.” A corollary of this belief was her guess that depression could be linked with her fat patient’s attempt to lose weight with surgical methods.

You get a shift, you can’t eat, and you’re going to get some emotional reaction to that. Now, maybe there’s also chemicals, soliloquy to the surgery, but it’s really very interesting.. . . It seems to be that depression could be a starvation reaction.

Fatness is a frequent outcome of a history of sexual abuse, Hannah believed. She noted the current trend toward associating thinness with sexual attraction and gave an example o f fat as a source of protection: I think her story is in many ways, very stereotypical of a lot of fat women. She had some unsettling sexual experiences as a child.. . . It’s been very clear in her struggle around eating and body image that the weight protects her from feeling that she will be too sexually attractive and that she will draw attention that will make her uncomfortable, which she doesn’t want.

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When asked specifically about characteristics particular to her fat patients, Alice wondered about a link to borderline personality disorder, although she said that this did not apply to all her fat patients.

I was thinking o f the volatility, the erraticism in life, either in the room or elsewhere. Difficulty in relationships, job issues, and probably financial issues, probably never get it together—like debt and problems with debt. So, that probably fits right in—having trouble controlling.

Concern with appearance is a higher level of body image development, Hannah believed. She described a fat patient whose “relationship to her body was very much like an infant’s .. .does it give you pleasure? Does it hurt?” She believed this patient had not reached a level of concern about what she should look like and her attractiveness to men.

Several patients were described as having problems that were related to Oedipal conflict. Christina talked of weight and appearance of daughters in contrast to their mothers: But the one that comes to mind . . . was a person in the day treatment program that could hardly fit through the door. She was also diagnosed chronically mentally ill—couldn’t function in many other ways. She hardly could move and her mother was this glamorous, beautiful, thin woman, which I’ve seen that a few times. Her whole life wasn’t working and it wasn’t just her weight.

Therapists attributed other characteristics to their fat patients besides pathology.

The worth of his fat patient was the subject of this comment by Brad: “This heavy set, overweight, I mean, obese guy comes in, but I saw in him something of value.” Other comments on patients’ weight included characterizations as “unattractive” and references to being too big. Therapists frequently used the term overweight to describe their fat patients. Tom said his patient shopped at “oversized” clothing stores.

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Tom elaborated on his belief that weight gain is an outcome of “unethical” behavior.

It’s bad for the person who’s doing it and it’s bad for society because the person ends up getting sick and having a lot of medical costs which may end up being paid for by tax dollars and so it’s . . . I can see “sinful” makes it sound like a religious thing. I didn’t really mean it to have that connotation. I guess I just meant “unethical.” . . . That’s probably a controversial point of view to take. I don’t want to be biased against overweight or fat people. Some overweight people are very good-natured and that’s kind of a stereotype but I think there’s something to it. People enjoy things that they are doing, enjoy food, enjoy eating, and it just kind of happens.

Another therapist, Sarah, characterized her patient’s resistance to weight loss surgery in the following way: She’s passively hostile, she’s passively compliant, hostilely compliant is actually what you might want to say about her. Much less now, but can’t let you get too close. Raise the surgery, but then because insurance won’t cover it, doesn’t want to do it, but won’t talk to me about it. So talks about it, gets excited about it, then when she finds out it won’t be covered, won’t even talk about the process. Very difficult.

Two therapists described behaviors and attributes related to fat and eating that they thought were funny. Tom said that one of his patients had been losing weight.

“She’s funny, I mean she sort of makes a show o f trying to eat better—like she will buy sugar free ice cream, but then she may eat a lot of it.” Sarah laughingly described a patient as “so big” that he “topped out the scale” and another patient’s effort to take off her coat and sit down: “Can I imitate her? She’ll come in and she’ll sit down and take off her coat. Ugh! (tongue sticking out and much laughter; then imitating her sitting down) Whuh!”

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Health Risks Tom talked about the death of a fat patient and what he believed were the causes: He essentially ate himself to death, is the way the pastor who worked with him described it. I think that’s accurate. He just had a heart attack and died. He was coming back from a doctor’s appointment, getting out of a car and it was just too much exertion. He was someone who arguably could have started to walk a little bit and made some improvement, but I think the depression, coupled with health issues, was just too much for him.

Other attitudes about fat patients’ health are discussed below in the section of this chapter entitled “Feelings.”

Treatment Needs Attitudes about treatment needs of their patients with respect to their weight varied widely. For example, Alice tended to downplay the contribution of sociocultural factors in her evaluation of the struggle with weight that her African American patient experienced. She felt that her marital problems were the cause of her distress and that this overshadowed any cultural factors. She did not consider the idea that cultural factors might be a stressor in the marriage. Hannah believed that weight is not a significant factor in psychotherapy. “Weight is only secondary as it is filtered through the level of their structuralization and the cohesiveness of the self.”

Other than Alice, who expressed concern about weight loss attempts leading to depression and symptom conversion, there was consensus among the other eight therapists that their fat patients would benefit from weight loss. Three therapists stated a belief that weight loss can be influenced by psychotherapy. Rachel said about one patient who had used food for self-soothing, “I really wouldn’t be surprised if she is already

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getting healthier now that she is back [in therapy] so it may at some point filter down to her losing weight, too.” Christina mentioned a patient’s decision to lose weight as a standard for improvement in mental functioning: “She didn’t feel like the ugly duckling any more. Now, who knows whether she has given up the weight or not; but nevertheless, she started feeling good about herself.” A patient’s weight gain as an indication that the therapist has failed was discussed by Sarah: I think about her regaining the weight and get a sense of my failure, but I think because she is so limited, although she’s doing so well (I know it’s a lot of projective identification), she really can’t tolerate my feeling that good or that much pride in my work with her in the same way as I can in my work with other people.

Feelings Feelings that therapists reported in reaction to their fat patients were both positive and negative.

Positive Feelings Three therapists spoke of their fat patients in ways that demonstrated caring, compassion, affection, and love. Brad made a strong effort to “deflect” what he described as “the depressive, negative, angry edge” that he perceived in his fat African American patient. He would think of her as the character, Bloody Mary, from the film “South Pacific.” When asked what his associations were to this character, he thought of “a heavyset, happy Polynesian or black woman who is singing all the time.” This helped him “keep a sense of humor, a sense of positiveness, a sense that there was something of

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value underneath that exterior that she was presenting to m e .. . . It was this song, ‘Bloody Mary is the blah, blah, blah . . . ’” The words that he had forgotten are “girl I love.”

While describing the body shape of one of his patients, Tom said, “He’s not very big up here, but he’s got a quite huge midsection, this big, bloated stomach, but he is so unselfconscious about it—it’s one of the beautiful things I like about working with him.”

He experienced another patient as a “really kind, nice person” who was appreciative of the help he received and seemed to enjoy himself on agency “outings.” He felt sorry for him and when this man died, Tom felt sad. “Not that I could have saved him, but we were trying to get him into a more controlled environme n t.. . . I think it was a thing where we just didn’t get it done soon enough.” Rachel reported similar feelings of responsibility that she noted were characteristic of her work with her fat patients. About one of her fat patients, Sarah said, “He’s terminating, which is breaking my heart.”

Empathy and a sense of identification were expressed by several therapists toward their fat patients. Continuing to talk about his feelings toward his patient who died, Tom said,

I’ll be honest and say there was a little part of me that identified with him and what it would be like to just sit in bed and watch movies on video and cable TV and eat. There’s probably a part of me that would like to do that.

Meredith related a story about a patient who lost weight at the same time as she did, and who had a similar history of weight gain, loss and regain. She called this phenomenon “an echo.” “I thought that when she lost weight, she felt empowered through love, or through the fantasy of love and that she said she did not need to e a t.. . . I

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see all these connections too..

because of her own, similar experience. A parapraxis

occurred when she referred to “the time that I had been in treatment with her,” suggesting a strong identification with this patient.

Christina considered herself fat and had sought psychotherapy for help with weight loss. In her childhood, gaining weight was a symptom of distress that was not adequately addressed by her parents, she felt. Her parents had their own “issues around weight” that she thought might have interfered with their handling her weight gain in a productive way. Over time, she had experienced fluctuations in weight, at times feeling that she was overweight, and at other times losing weight and maintaining the loss for a while. These experiences have contributed to strong feelings of identification and empathy for her fat patients, she believed. When a patient was referred to her for help with weight loss, she felt “horrified” that the referring therapist believed this patient was too fat to attract a man. “It was the most degrading, insulting thing to do to a young, pretty girl whose confidence wasn’t that great anyway.” “I feel so compassionate towards her. I feel so bad for her,” she said of another fat patient. “I think I identify with every one of my patients that eats.. . . My overuse of food clearly gives me enough experience to empathize with that.”

When asked how her fat patient felt about going to a gym to get exercise, Sarah responded in a detailed manner, showing that she understood what it was like to be in this person’s shoes, even though Sarah says she has always been thin: We talked about the idea of having to change into work out clothes in front of people and to expose yourself in that way when you are feeling badly about yourself. I think it was real threatening for her and it was a relief that there are women with different kinds of body issues. The thing about gyms, they say, “Go

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work out in a gym.” People look great in a gym and if you’re fat, you can’t go to a gym because you feel horrible there.

Having been thin her whole life, Hannah had recently gained weight. Never having worried about weight in the past, she said that she realized “I would like to be eight, ten pounds thinner. I would be more comfortable, that would feel better to me.” These feelings were similar to what she understood her fat patients were feeling about their weight.

Negative Feelings A wide range of negative feelings toward their fat patients was reported by all of the therapists interviewed. These feelings were linked often, but not always, with their patients’ fatness. Feelings included variations of discomfort, detachment, anxiety, anger, disgust, powerlessness, and guilt.

Tom said that it felt “hard to sit with” a patient who talks and talks and talks about her discomfort and I listen and maybe occasionally make a suggestion.. . . She does what she’s going to do, so she doesn’t let doctors tell her and she doesn’t let me tell her . . . not that I tell people what to do, but she doesn’t really listen very w ell.. . . It’s a challenge to stay with her because she talks very quickly and her thoughts don’t seem to develop.. . . There’s not usually any emotion connected to anything she’s saying which is, I think, why it’s hard to listen to her.

David also expressed feelings of discomfort, saying he felt “concerned” and “bothered” at the sight of “really, really fat” patients because of what he felt was a threat to their health.

I have an ongoing fantasy when I see people like that. I’ve got this imaginary place, it’s up in Canada, it’s in the middle of nowhere, I control the amount of food they eat, and they are going to be chopping wood and doing stuff and you’re

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getting 1,500 calories a day. If you want to eat more, there’s pine nuts, acorns. And I mean so clearly I’ve got a thing about it because I say to myself, “What’s up with you?” It bothers me. It’s like, “Lose that weight!” I know that some people have the metabolism of a sleeping deep sea turtle— a calorie a year if they run 500 miles a day and their ability to lose weight is zero.

Some therapists reported a lack of feelings or thoughts about their patients’ weight. Hannah said that she did not usually notice a patient’s weight and that generally it was not the focus of therapy. David, who earlier talked of his discomfort around very fat patients, said, Certainly, the weight thing doesn’t have much of an impact on me. I have to think about the people I’ve seen. I have to think about the fact that they are overweight. . . . I’ve never disliked a patient because of their weight.

Anxiety, expressed as “concern,” “alarm,” and “fear,” was reported by four therapists. Meredith said that she feared for her patient who was gaining weight because she worried that she would be “subject to disregard” that she likened to a gang rape.

Sarah and Brad worried that their patients would break their furniture. “I was terrified that he would break the table and be humiliated.. .horrified.. .What if one of my suitemates saw him,” said Sarah, who then acknowledged that her suitemates probably would not be as angry as she feared. When asked what came to mind about one patient’s size, Brad said, “big, black, scary, and imposing.”

Rachel spoke of a feeling of alarm when her patients gained weight: She had gained about, oh my goodness, I don’t even know, maybe 50, 75, she was obese! She came into treatment originally, left-as a kind of petite, young woman, and then came back years later having gained all this weight. While I can explain and understand some things that happened, the weight gain was just so alarming to me, just alarming!

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Anger was expressed either directly or indirectly during the interview by most of the therapists. Often the feelings were about a fat patient’s eating behaviors and weight loss attitudes, but other behaviors and attitudes were the focus as well. Feelings ranged from mild to intense.

Brad talked about one patient who owed him a great deal of money and never paid this bill. He said that he felt angry with the patient and angry with himself as well.

The feelings are, “How the hell did you let that happen? I mean after all these years and all this experience, you still get stuck!” And I answered, “Because the son-of-a-bitch had me thinking that we were doing something good, that this had some meaning for him, and I was ignoring that he was dissing me big time.”

Alice commented on her feelings toward a patient who did not want to discuss his lack of career advancement: That was very upsetting to m e . . . . I wanted to respect [his evasion] but I often felt like, “What am I doing? You know, here you come all the time, you’re on time, this has importance to you, but what am I doing?”

Similar feelings were reported by Sarah in response to patients who behaved in what she called a “passive-hostile” manner: You feel like you can’t help them. You feel boxed out. I feel like I . . . haven’t helped her very much. But that is what she would like me to feel because she’s scared, she’s afraid o f her dependence on me. So, what it’s like for me is it’s extremely frustrating and you know, it’s like it’s true—you can’t feed her right.

Brad was asked what it had been like for him to watch a patient lose weight and then regain it.

Frustrating. Angering....She knows what she needs to do. She knows diets backwards and forwards. She has been through the eating disorders clinic....She has been in groups. She knows all the tricks of the trade and she can’t do it. It doesn’t turn into action. There are times when my own feelings get frustrated to the point of, “You have to be actively trying to sabotage this thing.” (small chuckle) “You say you watch what you eat.” But I saw her once . . . having lunch,

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and she had fish and chips, deep-fried fish and chips, battered, and all this stuff, which I had actually had always wanted to have and finally bought one day and they were awful. I mean they were so god dam greasy.. . . I was so disappointed because they weren’t like the way they would be in a nice restaurant.. . .

Somehow or another they can do it so they come out with absolutely no grease on them at all. You know the batter is real light and fluffy and of course, you know you are paying three times as much for them.

So there was this sense that she sort of fools herself. She can one minute eat her veggies and so on, and the next minute it’s as if she is another person who will eat the fish and chips. She splits it you know. One hand does not know what the other hand is doing.

I think a lot of that is better. It is not as bad as it used to be. The thing I don’t know, she talks about her metabolism being all screwed up, and I don’t understand all that. I don’t know. I am led to believe that that is what happens when people do this yo-yo dieting stuff but they really foul up the mechanism and then it’s a crap shoot because things don’t work your way. You eat the things that [are on the] diet and your body doesn’t know what to do with them. It doesn’t respond like it used to when you were younger. I guess that’s what it is, which makes that internal experience then for the person even more frustrating.

When asked about his feelings toward a fat patient that he said did not lose weight, David stated: It irks me. It bothers me. I don’t like to see her doing that to herself. I know she doesn’t like to be that heavy because she has told me she doesn’t. I know it’s a battle for her to not eat.

Two therapists expressed feelings of disgust or revulsion in their experience with fat patients. Meredith accepted a gift of food from one patient. “I have to admit, I didn’t eat it,” she said, and went on to explain: She has a way o f describing herself in such graphic, negative detail as to make you not want to get anywhere near he r.. . . She will come in and talk in great detail about bowel movements. It’s almost like she makes herself so unappealing.

About an older, male patient, Tom said, On one or two occasions, I was probably repulsed by him. He would tend to get something caked up in the comer of his mouth, some sort of white substance. He had stains on his shirt and he didn’t smell good, always. Anyway, he really didn’t take very good care of himself.

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Feeling of powerlessness, including “helpless,” “hopeless,” and “overwhelmed,” were reported by four therapists. As reported above, Sarah felt helpless in the face of “passive-hostile” behaviors by some of her fat patients. Two therapists talked of feeling overwhelmed by their patients. Commenting on her reaction to one patient who she believed weighed about 380 pounds, Sarah said: You are a little overwhelmed by him when you see him, his size, one is. There’s a lot of him! This is real countertransference in some ways. There are times when I, I mean this is just my experience of him, when I’m not sure how tall he is, because, and this is his experience of himself as well, but I’m not sure how tall he is, I mean I just can’t see the end, you know sometimes. You can’t tell how old he is. He said that people think he’s ten years younger because they think he’s so big.

Hannah also reported feeling overwhelmed by a fat patient whom she treated at the beginning of her career.

This woman overwhelmed me. I was so unprepared to deal with that level of, you know, in terms of her own [psychological] structure. I was just too brand new. As I became more and more overwhelmed and lost in my work, she loomed larger and larger and larger in my vision of her.

After describing his sense of helplessness and sadness when one of his fat patients died of heart disease, Tom talked of feeling hopeless about this patient’s situation and that of others in the agency’s older patient population:

I think a lot of the people we work with, if they don’t get worse, it’s a success.

We’re not always working with people who are going to adjust to what we call a wholly engaged life. So, we try to give people some sense of hope. But sometimes it can be, you can look at someone and say they’re in a hopeless situation, like the guy who died. There was some hope and we were working toward building something better for him, helping him do that, but it wasn’t soon enough.

Guilt was a feeling that Meredith discussed in terms of weight and its connection to dynamics in the therapeutic relationship:

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She had this fantasy about my being her mother and how loving I was going to be, and how gratifying. She really entered treatment not wanting treatment, but wanting a concrete replacement. When we began to talk about that, when that fantasy got disrupted, she then began to gain weight. Then o f course, I wasn’t the “loved object” anymore. The more weight she began to gain, the more I became, I think, guilty about having not been able to, you know, of course I couldn’t live up to those fantasies, and it wouldn’t have been fair to do that. But nevertheless, I think I felt guilty about it and began to be concerned that she was actually going to do herself in due to this disillusionment as a way of defending against really feeling it, grieving it, working it through. She would do it sporadically, but you know, she fed herself more than anything.

Manifestations of Countertransference Finally, this research explored ways in which therapists’ reactions to their fat patients manifested in their work. A few therapists talked about the results of therapy.

Most of the focus was on therapeutic techniques for working with fat-related “symptoms,” e.g., overeating and weight gain. Several therapists reported uncertainty about whether and how overeating and weight gain should be addressed, describing conflicting ideas, and feelings ranging from confusion to guilt.

These characteristics are used as subject headings to report manifestations of countertransference in their work with fat patients as described by the therapists who were interviewed. The first section includes the following therapeutic techniques: (a) identifying underlying issues, (b) interpretation, (c) containment, (d) confrontation, (e) self-disclosure, (f) behavioral prescriptions, (g) advice-giving, (h) providing information, and (i) referral to other professionals and programs. Conflict over addressing symptoms is the topic of the next section. The last section describes reactions related to therapeutic

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outcome, including (a) negative reactions to the therapist by the patient, (b) failed treatments and impasses, and (c) good outcomes.

Therapeutic Technique Identifying Underlying Issues As reported above, Hannah believed that weight is not a significant factor in treatment. This was borne out in her discussion o f her work, which was directed toward the psychological structure of the patient. She believed that her reaction to one fat patient’s appearance and size symbolized a feeling of being overwhelmed by other factors related to the treatment frame in one of her first jobs as a school social worker: It didn’t have the ordinary structure and boundaries of let’s say a mental health center. I didn’t have the kind of supervision and support that you might have. It’s not that kind of contract. I was so over my head in both knowing how to work with her. She had been through every kind of mental health agency that existed in the city without much success.. . . I knew enough when I was so young professionally . . . to understand that the unorthodox nature of our relationship both helped her and allowed her to make a connection with me and trust me because I didn’t follow all of those rules and keep all of those boundaries.. . . I had to meet her on her terms. And so in some ways I both knew that that worked and I knew that put me totally over my head and in uncharted territory and I lacked safety nets so that I was so vulnerable to my own professionally imagery.

Christina believed that resolution of psychological difficulties related to overeating and weight gain requires long-term work on underlying issues, particularly the necessity to analyze and work through a repetition compulsion.

I always feel that even if something’s not resolved yet, it still can be, and the only thing that I ever worry about is—with any of my patients—that they don’t have the patience to wait it out. I think they do pick up my hopefulness and optimism.

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Interpretation David, who strongly believed that fat is unhealthy, also looked for underlying causes of overeating and weight gain. He gave examples of the use of interpretation in helping his patients explore and manage feelings. Using a transference interpretation, he encouraged one fat patient to link his reaction to the therapist’s thin, athletic, “perfect” body to similar feelings toward a significant person in his history. Another fat patient’s inactivity was interpreted as identification with the mother and disidentification with the father. He talked with this man about “getting up off the couch and leaving his depressed mother behind.” Colorful language was a technique he described in helping patients to see the meaning o f their overeating and compensatory behaviors: “Are you medicating yourself? Whether you are puking or drinking or exercising until your brains are coming out of your ears?” That is sort of the language I’ve always used. People have always liked that. They have always found it useful and eventually adopt it and make use of it so that when they are doing it, they say it: “When I am medicating myself, what are my feelings?” You have got to give them something clinical, not judgmental.

Containment Some therapists demonstrated the technique of “containing” one’s reactions to patient material, i.e., noting the reaction without expressing it, sometimes analyzing it in an attempt to reduce any potentially irrational or harmful aspects.

A recurrent feeling of alarm is described above in relation to Rachel’s experience with her fat patients. She has made a conscious effort to reduce the intensity of that reaction by tying it to her family history.

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In my family, no, not just growing up, to this day, the family describes people and relates to people and keeps track of people in all our distance and our reconnections and absences . . . where everybody is described initially on whether they’ve gained or lost weight. So, it’s a very big factor. I think if anything, I would defend against that normally. I would try to avoid that with people when I describe them or am conscious of it. But I mean seeing her, it was hard to not be kind of like my family, like, “Oh my god.” I was thinking, “I can hold the line here and I am not going to overreact with a client,” but it just felt really bad.

Efforts at containment were described by Brad. He felt it was important to “remain upbeat” with a fat patient who “had very little in her life that was something to look forward to.” He had difficulty with her angry demeanor, so he invoked the positive image o f Bloody Mary from the film “South Pacific” as an aid in containing his reaction to her when she was feeling bad. “It helped me sit with her for periods of time when she wouldn’t say anything and I didn’t know what to say.” He sometimes struggled with containing frustration with another fat patient who was overeating and making what he felt were unwise food choices.

I think the reason that it worked was that I wasn’t intrusive. There were times when I would try and tell her to exercise or a little bit of my frustration would in the process come up and she would let me know, “Don’t go there.” (chuckles)

Confrontation Four therapists reported using confrontation of what they viewed as passive or self-destructive behaviors related to overeating and gaining weight. Tom expressed concern when he believed that a patient was not getting enough exercise. Meredith confronted a patient about her weight.

I brought it up because I began to get concerned about her health. She developed high blood pressure. She developed diabetes. I was envisioning that here is this

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woman that is alone in the world, who’s going to end up dead from a heart attack in her bed.

At this point, the therapist speculated that she had done so partly in reaction to feelings of helplessness that she had experienced in the face of terminal illness in her own family.

“It’s like, ‘Do something while you can, woman!’ (laughs) ‘Before it’s too late!” ’ Christina also confronted her fat patient about health risks: I talk also about the health aspect of making sure . . . that all these years of smoking and now the overweight is not going to do him i n . . . . I want to let him know, which he does, that the eating is another symptom, that he’s using food instead of alcohol or pills, or something. That it is real, it’s something that he should be aware of. And the only other thing that I have wanted to focus on, is his health, to make sure that, just like the smoking was very destructive to his health, that this overeating is not going to cause him to have a heart attack.. . . I’m just focusing on the health aspect, more than the looks.

David elaborated on the technique of confronting patients about what he believes are the health risks of their weight and eating, while attempting to contain his feelings about their behavior.

I got pretty hot under the collar about [it] but.. .1 wouldn’t tell them how much heat it might generate in m e . . . . Sometimes if I just think they are really doing something deadly, I might get pretty firm. I’m fairly confrontational but I do it much more with sarcasm, hopefully therapeutic sarcasm. I mean I give people a lot a grief about shit but I try to do it in a way that I’m not just punching them in the nose to where . . . it’s hard to argue with what I am saying, other than like it or not. It’s not just jamming them, because it’s easier to defend against that, so I try to come in sideways on them.

Self-disclosure Alice said she had been influenced by psychoanalytic authors such as Karen Maroda, who encourage self-disclosure under certain circumstances. She used this technique in working with what she judged to be body image distortions.

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I was thinking of people who define themselves with a weight problem, “those fat people,” and some of those people I don’t think have any weight problem .. . .

Sometimes I might say, “From my point of view, I don’t see it, but I can understand that you feel that way or that it’s important to you.” That’s a more recent development that I might say that.

David also reported using self-disclosure when his fat patients feared that he would not be able to empathize with their experience of being fat. It appears that he shared their concern and hoped that his disclosure would encourage further discussion of the problem.

People have talked about when their weight comes up, having me as their therapist. “I imagine you’re perfect, you never have to think about this stuff, and you never have to diet, and you exercise.” I have my [sports] magazines out in the waiting room.. . . I always bring it up. I say, "Look, I know I’m thin. So, we are talking about something I never had to think about. In fact, I had the opposite problem when I was growing up because I was thin and I always wanted to get bigger.”

Behavioral Prescriptions Two therapists spoke of using behavioral prescriptions when they believed that patients needed to lose weight. David explained, “Since I went through my Chemical dependency training program, the psychodynamic approach has always been part of it, but I’ve always actually been behavioral with people. I always thought there was efficacy in that.”

Brad tried behavioral prescriptions with one fat patient for a long time before he felt that they had good effect.

She was still very overweight, but she is one of these people who was anti­ exercise. She just hated to sweat. She didn’t like it. She didn’t like how it felt. For years, I would quietly try to suggest walking or this or that, and one day, she walked by an office advertising Pilates, and she said, “I want to do this.” So, she

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has been doing Pilates twice per week for a year now .. . . She is certainly tightening her body up and improving her sense of self esteem and self-image in some way.

Tom believed that it was important for his fat patients to be active, not necessarily having weight loss as a goal. O f one housebound patient, he said: I worked hard with him, did a lot of that sort of case management stuff a little bit more, and I think that was good for him. He’s someone for whom, by getting him to go downstairs and get in the car and go somewhere, had benefits because he was being active. Forgot about the destination or anything like that. Just getting him to do anything was a good thing for him.

Advice-giving Based on a belief that fat patients were not eating in a healthy way, Tom gave them advice about what to eat. One of his responsibilities was to take them shopping for food. He felt this was an important opportunity to encourage healthier food choices, and it was part of his work that he enjoyed.

I will kind of point people toward fresh food rather than canned or frozen food if it’s affordable or I will often, if I notice something is on sale, I’ll call their attention to it. I may try to encourage a client to get a leaner cut of meat than a fattier one and so in little, small ways, I will help them make better decisions . . .

When Alice felt that her patients needed to lose weight, she reported that she might suggest ways that they might go about doing so. Her ambivalence about using this technique is discussed below in the section on controversy over addressing symptoms.

Providing Information Feelings of responsibility led Meredith to give one patient an article with information about diabetes.

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My sense was that she didn’t understand the significance of her weight on her diabetes, she understood that maybe the weight might have prompted her development of Type II diabetes or may have had some relationship, but she was having a hard time controlling her diabetes currently. So, it is not uncommon for us to talk about her testing her blood. And her being shocked that it is as high as it is in the morning, being confused about why this is happening because when she was immediately diagnosed, she had a kind of honeymoon period in which she did lose weight and her blood levels were good.. . . [She] presents herself to me as someone who needs a mother to take care of her.. . . The fact that she started to gain weight as a result of being disillusioned [with me], I think I may feel all the more sense of responsibility.. .especially when it is almost like she is trying to elicit my concern because she reports her blood levels are out of whack and she goes to what I think is sort of a schlocky doctor, who doesn’t put her on any medication.

Feelings of pain led another therapist, Sarah, to give her fat patient a newspaper article, something she said she never does normally. This patient was considering weight loss surgery, after which the patient would not be able to eat more than small amounts of food at any one time. This article was a description of weight loss surgery and its effects.

Sarah’s reactions to the article were: “Oh my god, why would anybody do this? Its like, I could never do this.” “Anybody who would put themselves through this surgery, have I really realized how miserable she is?” Sarah described this patient’s love of food and fine restaurants and said,

When we were talking about the surgery, it’s so painful, she told me she was ready to give it u p . . . . I don’t think she w as .. . . She brought me the material from the doctor that she was going to go with.. . . Have you ever read that material? (gasps).. . . I gave her [the] article.

The conflict that both therapists felt about providing information is described below in the section on controversy over addressing symptoms.

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Referral to Other Professionals and Programs A number of therapists mentioned that they have referred their fat patients to other professionals and programs. Referrals were made for a variety of reasons and possibly in response to feelings that were reported before mentioning the referral.

When describing his feelings when a patient did not lose weight, David talked about referring patients to behavioral programs.

I want to punch his lights out because I know it’s dangerous.. . . It makes me furious when people put themselves at risk like that when they don’t have to. My way out of it is.. .1 can help him deal with his feelings.. . . Habits like that can be broken if the underlying cause is disrupted. Meaning your feelings aren’t so overwhelming and you can deal with them and in a much more direct way. Then it’s whole lot easier to let go, whether it’s drinking Coke, or drinking beer.. . . If he was an alcoholic, I’ve recommended twelve step programs quite frequently. . . . I’ve recommended Overeaters Anonymous to somebody.. . . I don’t think they’re magical but I think they can have value for some people. Try it and find out that it has no value, but you’ve got nothing to lose except shame, which we can talk about in terms of getting there.

Rachel often referred patients who had a drinking problem to Alcoholics Anonymous. She described some frustration with a patient’s weight gain after he achieved sobriety, saying that she felt there were some drawbacks to AA. What people draw from the program often is this idea that you shouldn’t be angry. . . . You should pray if you have uncomfortable feelings. While all of those things might actually help in early sobriety to some extent, it becomes a way not to address the issues.

Sarah said that one o f her fat patients very much wanted to lose weight and not regain it. The patient had considered going to Curves, a nationally franchised gym for women, but hesitated to go.

I know that I was really wanting to get her to do this but there was a crisis in her life.. . . She had already found an excuse or five million. I would have kept it as an option, but she is very rejecting of i t . . . . I do feel sad at her limitations. What

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she liked about Curves and what she and I joked about is, no showers, you run in, you run out, you don’t have to change, you know, just 30 minutes, really fast.. . .

But whenever she allows herself to have something good, she always has to destroy it or make it bad. In the meantime, there has to be something wrong also.

And I think it’s related to loss, fear of loss, and I think there’s an issue for her that if she is too successful, we might not be able to have our relationship.

Saying that she was a “big Weight Watchers fan,” Alice commented, “It’s healthy, reasonable, so that’s what I’m likely to suggest to people. It has some support.

Sometimes I’ll mention OA [Overeaters Anonymous], especially if people have done anything like A1 Anon or ACOA [Adult Children of Alcoholics], that they might like OA.” When asked if she thought that came from a reaction she was having, she said she believed it came from her own personal experience of losing weight. “It certainly is out of hoping that the person could have what they w ant.. ..You want to have hope and you want to hold out hope.. ..I think I get swept into hope.”

Two therapists related stories of referring fat patients to doctors. Both worried about their patients “doing themselves in” by gaining too much weight and compromising their health. Christina believed that overeating was a symptom; nevertheless, it was important to see a doctor to check for heart problems. Meredith described an experience with a patient who reported chest pain, palpitations, and exhaustion. She urged her to go to a doctor, but the patient resisted, saying that doctors were prescribing weight loss medications that were hurting people. Eventually, at her therapist’s urging, she saw a doctor who diagnosed her with diabetes.

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Conflict over Addressing Symptoms All therapists interviewed believed that overeating and fat could be symptoms of physical or mental illness. Their training from a psychodynamic viewpoint emphasized listening, interpretation, neutrality, and containment as opposed to more active, behavioral techniques that directly address the patient’s symptoms. Nevertheless, many behavioral interventions are described above. Eight of the nine therapists expressed ambivalence, confusion, and sometimes guilt or shame about addressing symptoms directly. The other therapist, Brad, said that he refrained from doing so. This section reports the feelings of conflict that the eight therapists experienced after acting on feelings o f concern and responsibility for getting patients to address their symptoms more directly.

Hannah, as stated previously, strongly believed that weight was not a significant factor in treatment. Yet, she said of her experience with one patient, “I always felt like I was a failure that she had gained weight.”

While discussing her patient’s weight gain, Rachel said, “It’s just awful because honestly, it almost seems I’m not focusing on his weight.. ..He is concerned about it and we have explored different possibilities of how to deal with it, but that isn’t really the focus of the work.”

After feeling “outraged” by what she read about weight loss surgery, Sarah took a stand against it with one of her fat patients. “I felt so ambivalent. . . because I had taken this stand against it and I don’t know whether I should have.” She tried to counteract

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what she felt were possible negative effects of giving her opinion by encouraging her patient to continue to discuss this option.

Christina described a conflict she felt after expressing her belief that underlying issues should be the focus of psychotherapy.

So, that’s the number one thing that it’s not the symptom. Let’s look at what’s underneath. And then, on the other hand, I do feel that if they’re unhappy with their symptom, that while they’re working on it—and this comes from my personal experience, of course—that to just say, “Well, just work on the underlying cause,” and not talk about the symptom, isn’t fair, because if they’re miserable and uncomfortable, to wait ten years until it clears up, or doesn’t clear up, isn’t fair. “So, of course, I’ll talk about that with you, too. I’ll support you in finding a diet, or doing this or that, what you can do, so that we’re trying all angles at the same time.”

In the examples o f treatment techniques above, David stated a belief that behavioral interventions were important, especially when patients were putting their health at risk, about which he had strong feelings. He used a confrontational approach to point out that fat patients were using food to self-medicate. This appears to be in contrast to the caveat about symptom management that he expressed at the end of this statement: You try to think about what it is that’s getting her there, what purpose it’s serving, you try to help her understand that, and knowing that if you want a mother who shrieks at you about your weight, there is an endless supply on the planet and that’s not why you are coming to see m e . . . . I never need to take peoples’ symptoms away from them. And I wouldn’t see somebody who I did because I know that would be deadly.

Meredith talked about her experience of giving one fat patient a medical article, including feelings that led to the action and resulted from it.

The profound loss o f mothering reverberates so deeply with this woman, that I think that I get hooked into a kind of projective identification business with her sometimes. But it is mostly that I pick up the powerfulness of the need, and I think I slip into trying to fill that need in some way, but being so conflicted about it, that it comes out backwards.

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Referring to this awareness, she commented, “But it doesn’t stop me from getting sucked (laugh) into this horribly concrete, oh god, you know, embarrassing things.. . . It is not without a ton of shame;. . . not self-aware enough to not do (laugh) those things.”

In his agency setting, Tom had responsibility for directly influencing patients’ food choices and exercise habits. After one of his fat patients died of a heart attack, he thought a great deal about the pros and cons of active intervention.

I wondered, after he died, whether I should have been a little bit pushier with getting him to think about how he is endangering himself by eating so much.... whether I should have been more direct with him and could’ve said, “I’m not a doctor, but you’re probably in danger o f having a major heart attack and dying, unless you do something about your condition, and start to exercise a little bit and eat a little less.”

When asked to elaborate on his hesitation about doing so, he commented: Because I’m not a doctor and I really can’t say, I can’t predict the future, I don’t know with any certainty what’s going to happen to anybody. I guess I wanted to sort o f accept him as he was and take a gentler approach. I guess I just didn’t want him to feel criticized or put down.. . . Working with overweight or fat people is, most of them probably do like food, and so to deny people the pleasure, especially [when] people may not have a lot of other sources of pleasure in their life, seems kind of harsh. I think I felt that a little bit with him.

Alice talked about “slipping into” advice giving and felt that she had to resolve whatever was leading to that tendency.

Sometimes I get caught, like I still think I want to do something, probably around my sitting with my feelings about the upset the person’s having....My hesitation is, when is advice useful and when is it just feeding into the person’s frustration?

When might it work and be helpful? Am I sending some message in some way, about the person? I don’t know. Like would it be, “Oh well, yeah, you’re not accepted for who you are” by saying, “Well, you know, why don’t you try this or that or whatever?” I hadn’t thought about that—just going along with, “You’re right that people react to you because of your weight and if your weight were different, probably people would react differently to you.” So like, agreeing with them. There is part of me that [thinks] that is a reality in our culture and so it is

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something to reconcile. So then, is that helpful to that person, or should I be trying to help them accept themselves? Or, should I say, “Well, yeah, that’s the reality,” you know?

Outcome Therapists reported reactions to various treatment outcomes, including (a) negative reactions to the therapist by the patient, (b) failed treatments and impasses, and (c) good outcomes.

Meredith was described in the previous section as feeling responsible and concerned about a fat patient who was developing health problems. She began encouraging her to think about the implications of her weight. The patient became angry in response. Meredith struggled with a mixture of frustration, empathy, and shame in reaction.

If I said something directly to her, or recommended something to her, which is not typical of our relationship, she would announce to me, “Don’t you know that I can’t take that in, and you know I just have to resist it.” So, that would come up around the issue of the weight.. . . She refused to talk to me about it. She said, “I am not you,” and she got into this (sigh) I don’t know how you would describe it. . . . I think she felt like Cinderella— I got all the good stuff because I was thin and blond and she got all the shit. At times she would want to identify and feel like we were similar and at other times it felt like it robbed her of her own identity.

While telling about his frustration and confusion about how to help one of his fat patients make healthier food choices, Tom related the negative reaction of the patient to efforts to influence him. “He says he’ll never change, and no one ever should try to make him try to change that about himself, that he’ll never change the way he eats.”

Sarah was asked what it was like for her when her patient resisted doing what it would take to lose weight.

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There’s something dishonest in the treatment—it’s on her end—because she wants to not be so heavy but she doesn’t want to or she isn’t able to talk about not being heavy. So, I’m in this terrible bind of how do I talk to her about her experience of being heavy when she can’t talk to me about her experience of being heavy. I really feel like I have to be quite artful because she gets hostile.. . .

I think I feel frustrated. I really hate when she zings me things. She splits. She also starts every session with “I had a good week.” You know it’s really, I worked with her for a long time, again, frustration. But also, it’s sort of like, “Get real.” I mean I think she is a lot happier than she used to be.

As previously mentioned, Hannah felt that she had failed with a patient who gained weight during therapy. Two other therapists talked about treatment impasses that were confusing to them. Alice noted that more than one fat patient seemed to leave therapy without letting her know the reasons.

With one person, I don’t think they ever really told me what they were really feeling in relationship to me. Like was I helping, was I not helping? Never really knew the truth in there, if that makes sense. When they left treatment, just like left unexplainably and didn’t accept callbacks or letters, or didn’t want to give me a statement of what happened. And someone I’d seen for a long time, so that was very frustrating.. ..You think everything’s fine, but it’s not.. . . And so, that part is like (gasp). I’ve gotten a little better about. . . listening to the material and thinking, “OK this has to do with me” and trying to work on [analyzing the transference], so I feel better about that treatment.

Rachel described a treatment impasse that occurred after her patient had achieved sobriety and in the process, gained so much weight that she became alarmed.

The guy is sort o f bugging me right now. I’m not sure; I mean I will get on it.

There is something going on that I have not, it just hasn’t hit. I just know it. I know it’s not like he’s using, I don’t really think he is.

Although other therapists talked about their work with fat patients in terms of its benefits, only Rachel mentioned feeling good about her work with a patient relative to changes in her eating and weight. .

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Well it was sort of like she handled it, I mean she started taking care of herself, basically. She became committed to doing what she needed to do for her own well-being. She experienced the results of that instead of focusing on dieting. It just made things become more consistent. She stopped that yo-yo of weight gain, and loss, and diets, and that sort of thing.. . . It was like for a good I would say year, year and a half where she was at the weight, where I’m sure was a comfortable weight for her. And she was not focused on it. Not just because she didn’t talk about it in the session, but you know kind of like I would have known by her references. So, it sounded like if anything, it took up less of her time and attention. But she was also doing other things. Her relationships were much improved, so she was getting a lot more from her other aspects of her life. So, I think that probably had something to do with it, too.

Overview of the Results A huge amount of information and useful results can be gleaned from the data.

This overview summarizes results that I believe to have especially important implications for knowledge and theory as well as applications to clinical social work with fat patients.

1. Fat had a great variety of meanings to these individuals, mostly negative.

2. The subjects reported a wide range of attitudes and feelings toward fat patients, similar to those found in the general population.

3. These clinical social workers differed from the general population in their increased ability to understand (a) the fat patient’s experience; (b) the potential psychological functions of overeating and fat; and (c) the potential of overeating and fat to be symptoms of psychological disorder or deficit.

4. The subjects expressed a belief that fat is a problem for their fat patients and the people who care for them. They did not speak of fat as good or neutral. Fat was invariably associated with health problems and was often believed to be a cause. Weight

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loss was seen as desirable, but there was some awareness of risk associated with weight loss attempts.

5. The subjects reported a belief that weight gain is the result of overeating due to emotional distress. A few showed awareness that genetic, social, and physiological factors may contribute to fatness, but they did not consider these to be of much importance.

6. Subjects who had a history of weight fluctuations showed a deeper understanding of their patients’ experience with fatness, and greater empathy for the difficulties of attempting to change their eating and weight.

7. Although the subjects’ patient population sought their help for a number of psychological problems, descriptions of pathology were often consistent with negative characterizations of fat people in the greater society and may represent bias.

8. Subjects reported positive feelings toward their fat patients, showing empathy, caring, dedication, and concern for their well-being. Often reported were feelings of concern about and responsibility for their fat patients’ weight.

9. Subjects demonstrated a wide range of negative feelings toward their fat patients, more negative than positive. Included were variations of discomfort, detachment, anxiety, disgust, anger, powerlessness, and guilt. Often the focus of these feelings was what the subjects perceived as self-destructive behaviors leading to weight gain.

10. In contrast to the traditional psychodynamic stance of listening and interpretation, active and behavioral interventions were used frequently.

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11. Most subjects reported and demonstrated confusion and ambivalence about the use of active interventions and the notion of symptom management.

12. Subjects consistently focused on the needs of the person-as-a-whole. Weight and overeating were viewed as aspects of the patient's complex, subjective experience.

13. Self-awareness of countertransference and its origins ranged from somewhat to very aware.

14. Trends related to age, gender, race, and socioeconomic status were not apparent.

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CHAPTER V

DISCUSSION

Variety and contrast characterize the results of this exploratory research on the nature of clinical social workers’ countertransference to fat patients. The results are highly subjective and individual. They cannot be separated from the context of the mind and experience o f each therapist who was interviewed. I added my subjectivity to the data, through interview questions and reactions to subject responses. My subjectivity affected data analysis and reporting. Although generalizations cannot be made from this qualitative data, descriptions, impressions, events, trends, contrasts, and aberrations are useful for comparing and adding to existing knowledge while providing directions for future research. They have implications for theory and clinical applications. Included in this chapter is a discussion of the results, their importance, and their implications.

Discussion of the Results What makes the results important is how they add to existing knowledge. By virtue of the fact that this is the first exploration of clinical social workers’ countertransference to fat patients, all of the data gathered is new knowledge. How the results compare to what we know is discussed in this section, in the contexts of (a) the overall results, (b) the theoretical literature, and (c) the research literature.

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When using a qualitative approach, the researcher’s subjectivity has a strong influence on data acquisition, analysis, and discussion. The choice of the preceding 15 results and the following discussion are highly influenced by the attitudes, feelings, and experiences of the researcher. To provide the reader with a sense for the lens through which this study is filtered, a first-person introduction of the researcher is in order.

My interest in this study comes from many years of working with fat patients who have sought my help as a specialist in the treatment of eating disorders. I began my career with a burst of optimism in the early 1980s, after ending a long-term personal struggle with overeating and body image. This was during the era of the “anti-diet” movement, when feminists were encouraging women to reconsider the importance of being thin, to legalize all foods, and to stop dieting. My relationship to food and my body changed so drastically that I wanted to share my new knowledge with other people. As a master’s degree student in social work school, I developed a short-term therapy group for women who were overeating and gaining weight, which I have continued to offer to this day. I decided to specialize in the treatment o f all the eating disorders, with a focus on the problems of overeating and gaining weight. This particular focus was not associated with a discreet diagnosis. Only recently, with the strong surge of interest in fat as a health problem, has a disorder that begins to address the difficulties of this population been added to the appendix of the DSM-IV (Binge Eating Disorder).

Over the years, I have learned a great deal about the needs and experiences of fat patients. Most important was the fact that my personal experience of recovery could not be generalized to everyone I treated. Many patients were not overeating, but were fat.

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Many fat patients were not dissatisfied with their bodies, but were overeating. Some patients were not overeating, but had such a difficult time with the prejudice that they encountered every day, that it affected their mood and self-esteem. The idea that “diets don’t work” and should be avoided was frequently challenged by many of my fat patients who wanted to experiment with losing weight, whether or not it was realistic, healthy, or politically correct. My current stance is to provide an empathic space for my patients to get help with understanding and overcoming the physical, emotional, and social problems that may come with being fat. If emotional overeating is a part of the problem, I help patients remove the obstacles to healthy eating by providing psychodynamic psychotherapy. To counteract patients’ lack of knowledge about weight loss, I provide education about the problems of dieting and the benefits of attuned eating.

I have found it difficult to walk the fine line between the neutrality required of a scientific researcher and the outrage that is naturally felt by a therapist who witnesses the effects of misunderstanding, scapegoating, derision, and bad advice, every day in my practice. After hearing countless stories of harassment and rejection, I have a strong interest in contributing to the demise of fat prejudice. My optimism has been tempered by the continuing increase in the incidence and severity of eating disorders as well as the current hysteria over fat that seems to have overtaken our culture, no longer a female concern, but now including men and most recently, children. While attempting to sort out fact from myth in the scientific debate over the health risks of fat, I have learned how much misinformation influences people’s choices, adds to the suffering of fat people, and exacerbates disordered eating, which has become pervasive in our culture. I find it ever

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more important to channel my feelings into political activism, while working diligently to stay informed of scientific knowledge and debate. I still look forward to a day when skeletal thinness is not longer socially desirable and fat ceases to carry a stigma.

I would hope that my strong feelings of advocacy for fat patients would not interfere with my ability to obtain and report interview material with integrity, nor deter me from analyzing results in a balanced way. On the other hand, poststructuralists such as Norman K. Denzin, (1997, pp. 9-10) would argue with the idea of producing a “valid and authoritative text.” He takes a “politically informed, antifoundational” stance, based on . . . a commitment to post-Marxism and feminism with hope but no guarantees. . . . A good text exposes how race, class, and gender [and size, according to the researcher] work their ways into the concrete lives of interacting individuals [and should be judged by] the degree to which a given research project empowers and emancipates a research community.

The following is a discussion of each result listed under the overview at the end of the previous chapter.

1. Fat had a great variety of meanings to these individuals, mostly negative.

In view of the fact that fat is a descriptor related to size, such as thin, short, or tall. it is worth considering why so much negativity was associated with the word by those who were interviewed. Three therapists objected to the use of the word fat, feeling uncomfortable with its stigma. The other therapists seemed willing to use the word, but often avoided it by using socially accepted substitutes such as heavy. During the time that the study was conducted, I often received negative feedback about the inclusion of the word fat in the title. Clinical social workers in particular seem especially sensitive to the

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word, possibly because of the sensitivity of the profession to the social problems of prejudice and oppression. However neutral the word fat may seem, it has taken on a negative connotation in association with the nuances of meaning assigned to the word.

The results of this study include a number of associations to the word that contribute to an overall negative connotation.

When the word was used as an attribute, subjects showed much difficulty with quantifying fat. One therapist believed that fat could only be defined by the individual.

Others referred to body image disturbance, as if there is “true” fat vs. “imagined” fat, or “denied” fat vs. “admitted” fat. When asked to estimate the weight in pounds of each fat patient they discussed, there was much reluctance, hesitation, and confusion. It may be that the moral aspect of fatness as a representation of over consumption (Steams, 1997) explains the difficulty that the subjects had in speaking of fat and fat people. If fat indicates “sin,” as David said, and needs to be “cleaned up,” according to Christina, it might be difficult to think or speak of fat with dispassion or objectivity.

To this is added the recent upsurge in societal anxiety (Neumark-Sztainer, 1999) about what is viewed to be an epidemic of obesity that is leading to serious health consequences. Only Christina believed that fat is not necessarily a cause of health problems, correctly guessing that lack of exercise is of greater concern (Gaesser, 2003).

Yet, she and another therapist stated that health risk is an important aspect of the definition of fat. All nine of the subjects associated fat with health problems to some extent. Considering the controversy over the connection between weight and health, it seems unfortunate that the meaning of the word fat has taken on such a strong association

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with illness. It appeared to me that this meaning has been used by the subjects to make assumptions about the health needs of their fat patients that can at best, be distracting from the work of psychotherapy and at worst, add to the fat patient’s problems.

Other attributes besides sinful and unhealthy were associated with fat by the subjects: elephant, blimp, limited, passive, aggressive, hostile, unhappy, miserable, aging. and abusive. Clearly, these associations could indicate prejudice, and may do so, in part or in whole. To call someone a blimp hardly seems complimentary. However, it is important to keep in mind that these words were used to describe individuals, not fat people as a group; moreover, the context of these descriptions was psychotherapy for emotional and personality problems. Further comments about negative attributes and pathology are to be found below in Section 7.

Some therapists saw fat as a flaw. Included in the definition of flaw are synonyms such as defect and fault. These words go beyond mere disability with their implications of lower worth and character. Two therapists saw fat as possibly normal, but others used expressions such as bright, but hugely overweight, awful, gross, and ridiculous. Fat thighs symbolized this flaw to some. These associations did not appear to differ according to the gender of the fat person. The literature explains this view of fat as a flaw. Steams (1997) would see it as an example of the modem view of fat as a character flaw, representing failure to curtail one’s appetite. Feminist authors (Goodman, 1995; Wolf, 1991) believe that the flaw that fat symbolizes is actually the flaw of being or appearing “female,” i.e., defective. Cavallaro (1997) sees the flaw as a sign of “otherness,” deserving o f abuse. Similar to this idea is the Kleinian notion of projection

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in that fat represents feared and hated aspects of one’s personality. In the paranoid position, those attributes are projected onto another person. Escaping the guilt of the depressive position can result in turning away from the loved object and attempting to derive self esteem from the environment. One example of this development is an obsessive pursuit o f thinness, in which context fat is a flaw.

It is not surprising that fat is viewed as a problem by the nine subjects interviewed, considering the meanings examined so far—a health problem, a physical liability, and a flaw. Other problems mentioned all seem to stem from these. Fat patients and therapists experienced criticism and rejection by significant others who felt embarrassed or frustrated about the fat person’s weight. Fat was reported as an emotional liability that was associated with frustration, self-hatred, shame, and discouragement.

When considering the meaning of fat as an emotional liability, a distinction must be made that has important clinical implications to be discussed below. How much of the emotional difficulty that fat people experience is due to “actual” problems with fat and how much is due to being a target of prejudice? Determining the actuality of problems with fat is very difficult. Whether fat is a problem is partly a subjective judgment, and partly a controversial scientific question. In this research, what appears quite frequently is the association of fat with health problems due to self-destructive behaviors. Certainly, this would elicit many negative feelings in those who care about the fat person’s well being. However, even if self-destructiveness is a problem for some fat people, it could still serve as a convenient rationale for making them a target for prejudice (McEneaney, 2004). Many feminists and fat activists believe that in the absence of fat prejudice, fat

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people could be quite happy. One therapist, Christina, considered this idea as a possibility. A few fat patients did not appear to be concerned about their weight, according to their therapists’ reports.

In the data, fat was often seen as an indicator of its many reported meanings.

Probably due to the nature of their work, the subjects demonstrated a particular interest in fat as indicator of emotional distress or disorder. In their reports, fat indicated that a person might be out of control, unaccomplished, self-destructive, depressed, eating disordered, or low on self-esteem. A question of societal and clinical value is, how much of its meaning as an indicator is based on myth or bias? Again, it is important to invoke a principle from scientific research that says that association does not imply causality. Fat may be associated with eating disorders, for example, but this does not lead to the conclusion that all fat people have eating disorders; Kaplan’s (1999) review of the literature shows a prevalence of only 5-8%. Further research might be conducted to determine how often therapists use fat as an indicator, how much of this usage is based on myth or prejudice, and how careful they are not to make assumptions.

The subjects assigned meaning to fat as a function, specifically as a tool or asset in interpersonal relationships. There was much speculation about fat as an aspect of psychological defense mechanisms. Psychodynamic psychotherapists such as those who participated in this study are quite familiar with and alert to defense mechanisms, since they were originally conceptualized by psychoanalytic thinkers (A. Freud, 1937; Klein, 1957). Bruch (1947), Schick (1947), and Glennon (2001) wrote about their clinical experience and conclusions that fat may serve a defensive purpose.

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Subjects gave three examples of fat playing a role in defense mechanisms that are of particular interest: (a) using fat as a way of distancing oneself, (b) using fat to fend off unwanted sexual interest, and (c) using fat to appear threatening. The Kleinian view of the first, using fat as a way to distance, is that this is a schizoid mechanism resulting in schizoid withdrawal as part of the paranoid position. The purpose of this withdrawal is to protect the fragile ego from one’s own aggressive tendencies. Withdrawal also protects the object from the projected aggressive impulses of the patient. Fat has a function in this dynamic by providing the patient with a rationale for withdrawing due to fear of rejection. The second example is the use of fat to fend off unwanted sexual interest. This might be due to what Anna Freud calls anxiety based on a real danger such as the experience of sexual abuse, or it could be a projection of a sexual interest that is forbidden by the superego. Third, using fat to appear threatening could again be based on the real danger of appearing weak, or it could be a manifestation o f persecutory anxiety characteristic of the paranoid position—an identification with the projected aggressiveness in the bad object.

There is a danger of assuming that a person actively gains weight for psychological purposes, when there are many other possible explanations for a person’s fat, especially genetic, hormonal, and metabolic (Neumark-Sztainer, 1999). None of the subjects appeared to make assumptions about their patients’ use of fat as a defense. This may be due to their training, which encourages validation of any hypotheses about the patient’s psychological functioning through the patient’s responses to interpretation.

Subjects did report patient experiences to back up their beliefs.

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When fat serves a purpose, it could be seen as having a positive meaning, but that may be diminished by the fact that a psychological defense mechanism is usually a replacement for more effective methods of functioning. All the other meanings assigned to fat above have a negative quality. This result may be interpreted in several ways. First, it might be accepted for what it is, the subjective experience of those who reported it.

Second, it might be seen as a reflection of the societal trend to view fat as bad. Third, it might be consistent with the fact that the focus of the subjects’ work is their patients’ presentation of problems, so they are more likely to talk about fat as a problem than in any other way.

More than once, subjects associated fat with oppression. Their awareness and empathy, in contrast to the aforementioned negative associations, may be an example of what Winnicott (1947) meant when he suggested that therapists have the capacity to hate their patients, even with the best of intentions. “Hate in the Countertransference” is the title of his well known essay. Of particular relevance to this study is this quote: “If the analyst is going to have crude feelings imputed to him he is best forewarned and so forearmed, for he must tolerate being placed in that position. Above all he must not deny hate that really exists in himself.”

2. The subjects reported a wide range of attitudes and feelings toward fat patients, similar to those found in the general population.

A microcosm of this result is the story of Tom. Tom expressed much affection, admiration, and empathy for his fat patients. At the same time, he expressed revulsion

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about their weight and their odors. He was frustrated with their food choices. He went so far as to call their behavior a “sin.” This mixture of love and hate appears throughout the interviews. Feelings range from mild to strong. The attitudes that are reflected in the data are often based on strong opinions. Just as often, it appears that the subjects are confused about how to think in relation to their fat patients’ experiences. The perception of fat as a problem shapes attitudes and gives them a negative quality. Overall, what we find in the literature about societal feelings and attitudes toward fat people is reflected in the data.

As clinical social workers are trained to be sensitive to oppression, it might be expected that the subjects o f this research would report attitudes and feelings toward fat patients that would be quite different from those of the general population. In some ways, this was evident and will be discussed in the next section. More often than not, therapists held widely accepted views and responded with typical feelings. There is a question about why this occurred. One possibility is that none of the therapists appeared to have more knowledge about the literature on fat and the fat patient’s experience than non­ therapists. (For further discussion, see #5 below.) Second, feelings and attitudes are shaped from birth by personal experiences and societal influences. This long-term development of responses to fat people might have a more powerful effect on countertransference than any kind of education.

While talking about their fat patients, therapists reported many personal experiences with fat, with fat relatives, and other fat people in their lives. I acquired the impression during data analysis that current attitudes and feelings usually had antecedents in the subject’s personal history. Often it appeared that the therapists had transferred

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these attitudes and feelings onto their fat patients. These impressions are important areas for future research.

The subjects’ similarity to the general population in their feelings and attitudes toward fat patients mirrors the existing literature. The variety in this study also appears in the one study that contains data on countertransference to fat patients (Brotman et al., 1984). Studies on bias and fat prejudice consistently show that it is as widespread among professionals as it is in society, and the results of this study appear to be no exception.

3. These clinical social workers differed from the general population in their increased ability to understand (a) the fat patient’s experience; fbt the potential psychological functions of overeating and fat; and tel the potential of overeating and fat to be symptoms of psychological disorder or deficit.

Many narratives in the preceding chapter show examples of these three abilities.

The fact that the subjects are particularly adept in these areas is probably attributable to their training. Psychodynamic psychotherapists are keenly interested in the patient’s subjective experience as a source of understanding their psychological difficulties. They use techniques such as free association and providing an atmosphere of safety and trust, which are conducive to eliciting feelings and stories that will lead to a deep and comprehensive understanding of the patient’s experience. In spite of evidence of lack of understanding, most of the subjects made a strong effort to empathize with their patients’ experience of fatness. Sarah, who had always been thin, nevertheless showed the ability to put herself in her patient’s shoes when she said, “People look great in a gym and if

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you’re fat, you can’t go to a gym because you feel horrible there.” Tom, who was quite condemning of his patient’s tendency to overeat, admitted that he identified with him in his wish to just watch TV and eat.

As previously discussed, many of the subjects in this study associated fat with psychological defense mechanisms. There is discussion of fat as a defense mechanism in the theoretical literature written by psychodynamic psychotherapists. This outlook sets these subjects apart from the general population, as well as most other health professionals that have been studied. Again, the subjects’ tendency to think this way is probably mostly influenced by their training.

Many of the subjects believed that fat held potential as a symptom of psychological deficit or disorder. This will be discussed more fully under Section Five below. This is a belief that is often held in the general population, sometimes with such conviction that it represents bias. These subjects appeared to have a much deeper understanding o f the nature and functioning of fat as a symptom than the layperson. Most of the time, the therapists did not make assumptions that a patient’s fat implied mental illness, with one exception: it appeared that almost all of the therapists believed that their patients’ fat was the result of overeating triggered by emotions. It may be that this belief was based on a preconceived notion. Another possibility was that their patients reported overeating that was linked to emotional distress, and the therapists assumed a causal link to fat. As not all fat people overeat (Gaesser, 2003), fat is not necessarily a symptom of overeating or emotional distress.

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This result has important clinical implications (see section below), and deserves further exploration. Future studies could survey a larger population with varied theoretical viewpoints.

4. The subjects expressed a belief that fat is a problem for their fat patients and the people who care for them. They did not speak of fat as good or neutral. Fat was invariably associated with health problems and was often believed to be a cause. Weight loss was seen as desirable, but there was some awareness of risk associated with weight loss attempts.

These are results reflecting attitudes about the fat patient’s weight. Again, these results mirror societal attitudes. In particular, they are consistent with the prevailing views of the medical profession, views that are highly controversial (Neumark-Sztainer, 1999).

Many o f the meanings that subjects attributed to the word fat fall into the category of problems: physical, emotional, and interpersonal. When Brad tried to imagine being 20 pounds heavier, his thoughts were, “My god! You know, your knees, your joints, your heart, it is just ridiculous!” His thought associated with gaining 100 pounds was, “Give me a break!” Only Christina believed that fat was not necessarily unhealthy, saying “Someone who’s thin but gets no exercise is going to die sooner than someone who’s overweight and exercises.” Eight therapists agreed that losing weight is a desirable goal.

The exception was Alice, who worried that dieting could lead to depression and symptom conversion.

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One explanation for these results might be located in the stories that the therapists told. Much of what is reported here about the meaning of fat was derived from complaints they heard their fat patients make. For example, Meredith described a patient’s experiences with fatness. Not only was she struggling with a wish to lose weight and with repeated weight loss failures, but she also felt she was at risk of being fired from her job due to her size. Meredith did not assume that the patient’s weight was the cause of all her problems, but she seemed to agree with her patient that fat was a problem. Many other similar stories were reported by other subjects who shared the belief that fat could not be blamed for all the patient’s problems but that that the patient would probably be better off thin. Hannah was the only therapist to describe a fat patient who did not appear to be dissatisfied with her weight, and who seemed to believe that her fat was an asset to her sexuality.

Subjects also described personal experiences with fat relatives and friends, and their own struggles with weight. These experiences are also likely to have had an influence on their attitudes about weight. This is expanded upon in Section 10 below.

There is no question that fat people are vulnerable to a host of problems.

However, the subjects seemed to lack knowledge of the interdisciplinary literature that sheds light on the complex nature of problems that fat people often face. The subjects rarely questioned the idea that fat causes problems. Most did not seem to be familiar with the controversy about losing weight as a solution to these problems.

Missing from the data was material that would indicate awareness, interest, and knowledge related to many areas of critical importance to working with fat people. Some

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subjects gave passing mention to some of the following areas, but only Christina showed a strong interest in and knowledge of this material. There was little mention of the societal contributors to fat as a problem, in particular the existence of widespread bias. As bias is a problem that has been shown to exist among health professionals and to create problems for their patients (Agell & Rothblum, 1991; E. L. Harvey & Hill, 2001; Hassel et al., 2001; Young & Powell, 1985), the literature on this area is directly relevant to the work that the subjects were doing, but they did not appear to be aware of this literature.

My impression is that none of the subjects believed that they were biased toward fat people and therefore felt they did not need to pay attention to this area. The subjects also seemed to have little knowledge of the controversy about weight as a cause of health problems. The desirability of attempting to lose weight seemed to be taken for granted.

Robison (2003a), an expert in the evaluation of obesity research, has warned against the wholesale adoption of mainstream beliefs about the necessity and feasibility of weight loss. “Health professionals will have to be retrained to shift the focus of their work from weight loss to helping people to be healthier at their present weight. This training must incorporate deep introspection regarding personal prejudices and struggles surrounding weight and eating� (p. 6). Deep introspection was evident throughout the interviews, but this strength did not seem to be as significant as personal experience with being fat when it came to understanding their fat patient’s experiences. Another area that was not often mentioned was body image disturbance. References to body image were limited to distortions in the direction of feeling fatter than was actually the case. There was no mention of fat as attractive, desirable, or loveable. No one seemed to consider the idea

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that their fat patients experienced body image disturbance in the form of hatred of their fat and that self-acceptance might be a good outcome of psychotherapy.

Considering the important clinical implications of this lack of knowledge (to be discussed below), it would be important to understand why it is the case. Only recently has mainstream scientific research and opinion about the “problem� of fat been expanded to question the assumptions upon which it is built. If these assumptions are fueled by society’s need to set apart fat people as an underclass, it is unlikely that there will be much motivation to challenge them. Besides, the complexities of weight gain and loss are very difficult to understand. Much remains unknown. Challenges to the existing research are only beginning to be published and disseminated. It is no wonder that these therapists, like most people, often assume that fat is purely problematic. A second explanation might be fat bias, which could prevent therapists from believing that they need to look deeper at the issue of fat and its relation to problems. A third explanation for the lack of this material in the data could be that psychodynamic psychotherapists tend to focus on the underlying problems of their patients and considered fatness to be a symptom or an outcome, but not an essential area of focus. Therefore, their education tends to be directed towards understanding the mental illnesses that their fat patients present, rather than understanding fatness per se.

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5. The subjects reported a belief that weight gain is the result of overeating due to emotional distress. A few showed awareness that genetic, social, and physiological factors may contribute to fatness, but they did not consider these to be of much importance.

Psychodynamic psychotherapists tend to believe, like Alice, that drinking, smoking, overeating, and similar behaviors serve the purpose of soothing emotional pain.

Subjects gave many examples of overeating as part of their fat patients’ experience. It appeared that most believed that this behavior explained their patients’ weight gain.

David talked at length about his methods of helping fat patients understand the reasons for and effects of their overeating, making direct links with their weight. Hannah and Christina spoke o f weight gain as a sign that therapy had not gone far enough to enable the fat person to change his or her eating behaviors.

The psychodynamic approach is very useful in understanding and treating patients who are overeating as a way to self-soothe. The focus on self-soothing in psychotherapy is of particular importance in the practice of Self Psychology which has had a strong influence in the Chicago area and possibly inspires these therapists to see overeating in that light. It is my experience that overeating among the clinical population is often linked to emotional distress and leads to weight gain. However, it is easy to make the common sense leap that overeating makes people fat, without considering other important factors. Because o f their interest in providing people with the ability to self-soothe without external mechanisms, it may be that these therapists were less aware of, or interested in other factors that contribute to fatness.

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This study’s review of the literature shows that scientists and social scientists believe that other important factors contribute to weight gain. There is controversy about the relative significance o f these factors, but their presence shows that assumptions cannot be made that a fat person is overeating. Biological factors include the influence of a person’s genetic predisposition to a certain body shape and size. A widely accepted theory is that a person’s metabolism adjusts according to weight to defend the person against starvation. Once a person’s metabolic rate slows in order to slow a weight loss, calories are not burned up so quickly so that weight can easily be regained. Bray and Delaney (1995) found that this factor is believed to be primary among physicians and scientists, who cite lack of exercise as the second most important contributor to weight gain. Recently, there has been a great deal of attention paid to the influence of hormones on weight. Specialists in eating disorders are especially aware of the problem of weight cycling, when a period of food deprivation creates an overvaluation of food resulting in a reactive phase o f over consumption. What begins with an effort to lose weight leads to a rebound in weight and ends with a net gain.

Without making a concerted effort to understand the etiology of weight gain, these therapists might be less familiar with the above factors, as they are neither generally understood nor popularly accepted (with the exception of lack of exercise). However, most of the therapists interviewed had experience working with eating disorders. It would seem that they would be aware that their patients’ fat could be an outcome of years of dieting. The focus of the psychodynamic approach on underlying issues may make it less likely for therapists who practice from this viewpoint to consider symptoms as part of the

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cause. This includes the idea that symptoms can be self-perpetuating, e.g., the purge leads to the binge. The integration of a focus on symptoms with a traditional focus on underlying pathology in the treatment of eating disorders has been suggested by Goodsitt (1997) writing from a Self Psychological viewpoint.

Many factors contributing to overeating and weight gain come from knowledge that is outside of the professional scope of clinical social work. A “team approach” of professionals from several disciplines is often used to insure that treatment is based on interdisciplinary knowledge.

6. Subjects who had a history of weight fluctuations showed a deeper understanding of their patients’ experience with fatness, and greater empathy for the difficulties of attempting to change their eating and weight.

Four of the nine subjects talked about their painful childhood experiences associated with being fat. Alice said that her experience led her to try to understand the emotional issues that are connected with overeating. For Tom, the effect of being “pudgy” as a child was that he felt he had to be extra careful about his eating and exercise. He was aware of “idealizing thinness,” but felt he needed to be careful not to repeat the fat prejudice that he was exposed to in his family. He had successfully lost weight by cutting back on certain foods, but feared that he could regain it. He said that the effect of his own experience on his understanding of his patients was mixed. He was concerned that they might never feel good physically, but believed that for some fat people, other aspects o f their lives were more important than their fat. Rachel felt she was

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at risk of eating too much and eating when she was not hungry. She felt “vulnerable to something with [her] coffee, specifically powered sugar doughnuts,” and worried that she had to use self-discipline when it came to eating. She also felt that her eating was a reflection of her mood. Christina described a long battle with her weight and a great deal of effort spent trying to understand her overeating and figure out what could be done about her size. The effect of her experience on her work with fat patients was evident in the story she told of a woman who was referred to her because of her weight. Christina was horrified about the referral, because the referring therapist had told the patient that her weight was preventing her from attracting someone for a relationship. She felt that this was lacking in sensitivity to the real needs of the patient.

These subjects appeared to have a deep understanding of their fat patients’ experience with fatness that was informed by their ability to identify with them. At the same time, their experiences might have made them more likely to assume that fat was a problem for their patients, when, as Tom said, some fat people do not seem to experience it that way.

The other five therapists had a history of being thin. The therapists who did not have a history of being fat appeared to have a harder time empathizing with the struggle of their fat patients. The five subjects who had never dieted in the past seemed to believe that fat was optional and that with enough willpower, it could be lost. However, those who had felt they were too thin as children told stories of being a “skinny Minnie,” feeling lacking in masculinity, being teased for being thin, and of struggling to gain weight. Both men and women reported much pain associated with the experience of

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being “too thin.” They showed a strong identification with their fat patients’ feelings of unacceptability due to their weight. All of these therapists had experienced a recent weight gain. They reported difficulty adjusting to this change and confusion about how and whether to address it. They were beginning to question some of their old attitudes toward fat and weight loss. Wrestling with this new development may have contributed to their interest in this study.

It would seem that the experience of being “too thin” and of struggling with weight gain for the first time would have led these five therapists to develop greater empathy for their fat patients. Their insistence that willpower would solve the problem might originate in their own transferences based on experiences with parents who insisted that this was true. It also could represent a disavowal of their feelings of lack of control over their bodies, projected onto their patients.

The possibility that the therapist’s personal history of being fat leads to greater empathy for fat patients, merits further study to determine whether this is actually the case, how frequently it occurs, and what might be done to help therapists who have not had the experience of being fat to develop greater empathy.

7. Although the subjects’ patient population sought their help for a number of psychological problems, descriptions of pathology were often consistent with negative characterizations of fat people in the greater society and may represent bias.

It might be taken at face value that the great number of presenting problems and diagnoses listed in the previous chapter represent nothing more than patient self-report.

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However, in modem society, fat is commonly associated with physical and psychological defects and difficulties. Often these associations are the foundation of bias. They can be used to justify bias. As attitudes of mental health professionals have been shown to reflect the prejudice that is found in the greater society (Agell & Rothblum, 1991; Hassel et al., 2001; Young & Powell, 1985), it seems possible that some of the attitudes of the nine therapists interviewed for this study contain bias. When evaluating the data for evidence of bias, it is important to keep in mind the fact that the subjects’ task is to diagnose the source o f emotional stress that brings people to therapy. The fact that a therapist calls a fat patient “borderline” does not necessarily demonstrate bias.

Some o f the ways that the subjects described pathology in their individual patients were: “self destructive,” “resistant,” “passive,” “hostile,” “in denial,” “addicted to food,” “relationship averse,” and “lacking in social skills.” When looking at these characteristics as a group, they resemble a negative stereotype of a fat person. Although these characteristics were not grouped by the therapists or applied to fat patients as a group, it may be instmctive to discuss each individual characteristic in terms of its potential for bias. Overeating and weight gain, behaviors that might be seen as “self-destructive,” could also be efforts at self-preservation in the face of contempt shown by others who cannot tolerate fat and who wish to control the fat person. Along the same lines, a fat patient’s “resistance” to a suggestion to go hungry in order to lose weight that is likely to be regained, may be a logical reaction to a therapist who does not understand the implications o f this suggestion. There is evidence that this suggestion creates more problems than it solves, so it cannot be assumed that the fat patient is “in denial” when he

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or she refuses to consider it. A fat patient may indeed be “passive” or “hostile,” but how much of this behavior is intrinsic to psychological makeup and how much is an outcome o f being a target of discrimination and derision? As previously discussed, a fat patient may indeed struggle with an “addiction” to food; but often assumptions are made about overeating as the cause of weight gain without consideration of the many other possible factors. A fat patient who is “relationship averse” or “lacking in social skills” might have these problems at any weight; but the question remains, what caused these problems? Is the patient withdrawing from people after a history of being rejected and verbally abused because o f his or her fat?

Whether or not the subjects showed bias in their reporting of problems and diagnoses is difficult to determine. My impression is that therapists reported presenting problems as articulated by their patients and that diagnoses were based on the therapists’ judgments after a long history of working with each patient. Nevertheless, the question remains to be explored. Further research might focus on investigating therapists’ attitudes, patients’ histories, and links between the two.

8. Subjects reported positive feelings toward their fat patients, showing empathy, caring, dedication, and concern for their well-being. Often reported were feelings of concern about and responsibility for their fat patients’ weight.

Brad worked hard to maintain positive feelings toward a fat patient whose pain and anger bothered him. He used a mental exercise that helped him associate to loving feelings. Tom felt sadness when one of his fat patients died of a heart attack. Sarah also

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reported a strong grief reaction to losing a fat patient. Both Tom and Rachel noted feelings o f responsibility that were characteristic of their work with fat patients. Several therapists showed empathy and some appeared to identify with their fat patients’ struggles.

It may be that a patient’s fat would not hinder any good therapist from developing a strong connection with the patient and experiencing positive feelings toward that person. Considering the many reports of negative feelings toward their fat patients, it is important to explore the sources of their positive feelings, which are essential to carrying out effective work. It may be that these therapists also had to overcome bias in order to feel positive toward their fat patients.

Some aspects of the therapeutic relationships that were described seem relevant and important. All o f the relationships were long term. This allowed each therapist time to get to know the patient’s strengths as well as weakness. It also gave the therapeutic relationship time to mature and deepen, which set the stage for the development of positive countertransference. A theme throughout the reports of positive feelings for their fat patients was the therapists’ feelings of identification with their patients. In particular, they seemed to relate to their patients’ suffering. When the suffering was linked to fat, those therapists who had similar experiences in their history seemed to identify more strongly than did the therapists who had always been thin. The nine subjects showed the ability to see beyond their patients’ fat and relate to them as people (see #14 below).

The therapists who were interviewed demonstrated a strong dedication to helping their fat patients, even if they were not always sure how to do that. A theme throughout

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the interviews was feelings of responsibility for the welfare of their fat patients, in particular for their health. These feelings were so strong in some of the therapists that they departed from their usual stance of neutrality in order to give patients advice, encouragement, and sometimes strong confrontation in an effort to get patients to do what they felt would improve their health. At times, it appeared that the feeling of responsibility was more negative than positive, becoming a burden to the therapist and a source of unwanted pressure to the patient. However, it also appeared that these feelings were rooted in a deep sense of caring.

It may be fruitful to consider the possibility that unconscious negative feelings are behind these positive expressions and that they constitute a reaction formation. The superego injunction not to hate one’s patient could lead therapists who have felt anger and hostility toward their fat patients to fend off anxiety about breaking this injunction by adopting a caring, responsible stance. The Kleinian view of this circumstance is that it is evidence of the depressive position, a defense against the fear of hurting the object through one’s aggressiveness. These therapists’ departure from their usual neutrality into acts of reparation might be seen as a manic defense based in a fantasy of restoring the injured parental object (transferred onto the patient).

Further study will be important in understanding the development o f positive countertransference toward fat patients and ways that it might be promoted.

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9. Subjects demonstrated a wide range of negative feelings toward their fat patients, more negative than positive. Included were variations of discomfort, detachment, anxiety, disgust, anger, nowerlessness. and guilt. Often the focus of these feelings was what the subjects perceived as self-destructive behaviors leading to weight gain.

When all the nuances of the above feelings are included, the list is quite long.

Feelings range from mild to intense. For example, angry feelings included irritation, frustration, anger, and rage. Although the subjects told many stories with no particular feelings attached, when they did report feelings, they tended to be more negative than positive. As fat people are often the target of negative reactions, it is important to consider explanations for this trend.

Negative countertransference is natural and predictable in the therapeutic setting, and as Winnicott (1947) said, can be acknowledged and used constructively by the therapist. It is likely that this idea was part of the subjects’ training, so that they were comfortable with identifying and disclosing their negative feelings about their patients to the interviewer. Doing psychotherapy is a difficult and challenging task. Most therapists have little opportunity to talk about their work. It may be that these therapists welcomed the chance to “vent” to an interviewer that they knew would understand and accept negative countertransference.

Whether the proportion of negative feelings reported in relation to their fat patients represents bias might be evaluated by considering the kinds of countertransference they represent. Using examples of reactions to patients’ perceived self-destructive behaviors might help to shed light on the reason that these were in

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preponderance. A case in point is Brad, who reported anger in reaction to a patient’s fat.

One possibility is that this represents complementary countertransference, which is an identification with the anger of those people who are in close relationship to the patient. It is quite likely that this could be the case, in an atmosphere of widespread concern about “the obesity epidemic.” For the same reason, the patient might have been feeling angry at herself about her weight gain. Brad could have identified with (or introjected) the patient’s feeling, an example of concordant countertransference. In these situations where Brad’s feelings are a strong reflection of the feelings of others, it is difficult to know where the feelings originate. Therapist bias may or may not have contributed to his identifications.

Another possibility is that this anger represents objective countertransference, meaning a feeling that is a natural, appropriate reaction to the “real” danger represented by the patient’s fat. Whether fat is dangerous is a subject of great controversy, which makes it difficult to determine whether Brad’s perception is realistic or biased.

The therapist’s feeling of anger about a patient’s fat might also be a defensive displacement. Several subjects reported anger toward their own fat relatives whose illnesses were perceived to have been caused by their weight. It is possible that this anger could be transferred onto a fat patient. A form of displacement is projection. All of the subjects reported experiences of gaining weight at some time. Their anger with their fat patients might be a projection of anger with themselves for gaining weight. Fat bias could contribute to the intensity of these reactions and make fat patients more vulnerable as targets for displacement. Burgard (2004) commented on this dynamic:

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I think it really creates a panic in people to not have fat folks as a target for binding up their existential anxiety. If you can't get control of your life by losing weight, then . . . ? If you can't ward of death by dieting, th e n . . . ? If you can't reduce terrorism to a minor concern compared to obesity, then...? If someone you loved died and you give up the idea it could have been prevented by a diet, then . . . ?

It is notable that the focus of many negative countertransference reactions reported was on self-destructive behavior that therapists believed led to weight gain and consequent health problems. What appeared to be most disturbing about this was the aspect of self-destruction. What was it about this perception that created such intense reactions? In talking about their own experiences with fat, many therapists reported illness and deaths in their family that they believed were weight-related. Because of their strong connections to these people, the idea that they brought this suffering on themselves and their families unnecessarily was associated with great frustration. This reaction is reminiscent o f feelings toward family members with advanced alcoholism, before the advent of the disease model of alcoholism treatment. Previously, the alcoholic was blamed for his or her lack of self-control, much as the fat person is blamed today. The disease model of alcoholism treatment led to a better understanding of the lack of control that is experienced by those who are alcohol-dependent. Although food dependency is not something that a person can give up in the same way as one can abstain from drinking alcoholic beverages, there seems to be even less acceptance for the idea that overeating (or fat) may not be a matter of choice.

Disgust was sometimes expressed about the fat patient’s self-destructiveness. This disgust appeared to be an expression of rage about the person’s behavior in that it created abandonment (through illness and death) and sometimes a sick person that required

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caretaking. Expression of disgust might have been an attempt to shame the person into taking better care of him or herself. In addition, this feeling could be a projection of disgust with oneself for not having control over the patient’s illness. In the Kleinian view, this is would represent the magical, omnipotent fantasy of repairing hurt to the patient caused by the therapist, a manic defense. In this situation, the therapist has transferred his parental object onto the patient. Another reason for this disgust and rage could originate in the therapist’s history of not having control over his or her parent’s illness and over the parent’s consequent neglect of the therapist as a child.

For a therapist who has been engaged to help a patient heal, observing the patient’s continued self-destructive behavior while in treatment can be difficult indeed.

The behavior may be experienced as resistant, non-compliant, and a failure. The therapist might feel rejected, helpless, and ineffective. For some, this might be a challenge; for others with more of a tendency toward grandiosity, it might be experienced as a narcissistic injury. Kleinians would see this as a failure of the therapist’s employment of a manic defense in the depressive position.

So far, this discussion has drawn on the therapists’ concerns about fat and health.

However, negative feelings were also expressed about many other aspects of the subjects’ experiences with their patients. Alice, for example, felt very upset by a patient who did not want to discuss his lack of career advancement. Sarah reported feeling helpless and “boxed out” by patients who asked for help and then rejected it in what she called a “passive-hostile” manner. Certainly, it is possible that these negative reactions have nothing to do with fat. At the same time, their similarity to stereotypes about fat people

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such as “lazy,” “hostile,” and “resistant,” suggests the possibility that these feelings have something to do with the fact that the patients who were being discussed were fat.

Although I sensed that fat prejudice sometimes played a part in the negative reactions that were reported, no conclusions about the presence of fat bias can be drawn.

The controversy over the link between weight and health makes it difficult to determine whether opinions on this issue represent bias or fact. However, there are many other aspects of bias, such as moral judgments of fat people, which are more clear-cut. The negative feelings reported may or may not have had a relationship to the person’s size.

Certainly many o f the experiences that the therapists reported could have happened whether the patient was fat or thin. However, the number of negative feelings reported and the content of some of the statements suggests that bias may be present. Further study is needed.

Finally, with respect to the negative countertransference that was reported by the subjects, an important question is whether they were able to contain these feelings in a manner that was conducive to effective work with their patients. This will be addressed in the discussion of the next three results that are related to the third research sub question: manifestations of countertransference in the therapists’ work with their fat patients.

10. In contrast to the traditional psvchodvnamic stance of listening and interpretation, active and behavioral interventions were used frequently.

All of the therapists interviewed stated that psychodynamic theory and technique were central to their treatment approach. This was evident in every interview. The results

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contain examples of traditional psychodynamic techniques, including listening, identifying underlying issues, interpretation, and containment o f countertransference reactions. The other techniques reported in the results were more active, ranging from controversial to proscribed, according to the psychodynamic viewpoint. Subjects also used self-disclosure, behavioral prescriptions, advice-giving, providing information, and referrals to other professionals and programs.

This contrast between what can be described as psychodynamic vs. behavioral technique, is a striking result, considering the apparent devotion of these therapists to psychoanalytic theory and the long, satisfactory experience with this viewpoint that all appeared to have. Why did these nine therapists look outside their training and experience for interventions with fat patients? Does this phenomenon originate in countertransference reactions?

The tendency toward active intervention appeared to reflect a defensive acting out of countertransference reactions that were difficult to contain. This may have happened when therapists were feeling flooded by anxiety, pain, and anger. These reactions were mostly to the patients’ self-destructive behaviors (discussed above), which represented their being “out of control,” i.e., lacking self-control as well as being out of the therapist’s control. Instructing a fat patient to take better care of himself or herself was a way to relieve the therapist’s anxiety by pushing the patient to change. The overwhelming countertransference reactions were based on conscious beliefs that the patient was in danger. It is possible that the patient was truly in danger. Another possibility is that the danger represents the therapist’s fantasized fear of having hurt the

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patient accompanied by a need to make reparations (a Kleinian view of the manic defense associated with the depressive position).

However, many stories of therapists’ fat friends and family members suggested that their anxiety about their fat patients’ health had antecedents in their personal history.

Particularly when one’s caretakers are out of control, a child will feel helpless and flooded by anxiety. Several therapists reported such experiences. Their tendency to use behavioral interventions due to feelings of anxiety might have had transference origins. A common reaction to this situation is for the child to develop a grandiose feeling of responsibility for the parent, with a sense of urgency fueled by the child’s dependency on the impaired parent. The enactments that seem to be a result of this kind of countertransference might be seen as a reaction formation—feelings of hopefulness and empowerment transformed defensively in the face of despair. Certainly, the healing responsibility that is part of the role of therapist sets the stage for a reenactment o f an earlier struggle to shore up the ailing parent.

In my clinical experience, most fat patients are aware that lack of exercise is problematic. Yet, some o f the therapists felt the need to urge their fat patients to get exercise, as if they did not already know this was important. For example, Brad said, “I would quietly try to suggest walking...” and Tom reported “case management stuff’ consisting of getting his fat patient to go downstairs and become more active. This action of informing the fat patient of a need to exercise seems infantilizing. As this is very far away from what the patient actually needs (empathic understanding for the difficulties of getting exercise), it suggests that these normally empathic therapists are acting in

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response to a previous experience with someone that they perceived to be childlike and helpless. Again, what suggests itself is the parent/child role reversal that happens when a parent is impaired. The therapist might be treating the patient as if she were the helpless child that the therapist once felt herself to be. The therapist might be telling the patient what to do, replicating her own experience with the parent who seemed not to know how to take care of himself or herself, or the child.

Active and behavioral interventions, which might also be seen as enactments, are bound to have a profound impact on the transference. The fat patient may experience the injunction to lose weight and increase exercise as infantilizing. He or she may already be struggling with this injunction, internalized in the superego, and conflicting with the despair of many failed attempts. Consciously, the fat patient may hear confrontations or recommendations as caring; unconsciously as hostile. He or she may feel that the therapist lacks understanding of defensive needs for fat or overeating, or for the extreme difficulty, maybe impossibility, of losing weight. Melanie Klein’s approach would be strictly limited to interpretation of the defensive purposes that fat or overeating represent.

The focus would be on the patient’s anxieties about aggressive wishes. Confronting the defensive use of fat or overeating would, in her view, be missing the point.

Maybe the negative reactions to the therapists, failed treatments, and impasses that were reported at the end of the last chapter were partly a result of inappropriate interventions that helped the therapists with their difficult countertransference reactions rather than addressing the needs of the patients. Meredith, who was very aware of the drawbacks of her more active interventions, said,

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If I said something directly to her, or recommended something to her, which is not typical of our relationship, she would announce to me, “Don’t you know that I can’t take that in, and you know I just have to resist it.” So, that would come up around the issue of the w eight.. . . She refused to talk to me about it. She said, “I am not y o u . . . ” Sarah felt that her patient was being dishonest by not talking about her experience of being fat. She did not seem to be aware that her well-meaning encouragement to take better care of herself might have been experienced by her patient as an empathic break.

11. Most subjects reported and demonstrated confusion and ambivalence about the use of active interventions and the notion of symptom management.

The two therapists who had a strong background in alcoholism treatment, Rachel and David, felt an obligation to focus on fat patients’ weight and overeating; yet, both therapists also made statements showing a belief that symptoms should not be addressed directly. Although Tom spoke out strongly for the idea of encouraging his patients to adopt healthier eating and exercise behaviors, he questioned his stance by imagining how his patients must feel, and that they might have other priorities. Christina, Sarah, Meredith, and Alice seemed to feel strongly that active intervention around symptoms was a mistake. They expressed guilt and shame about “slipping into” behaviors such as advice giving. Christina expressed a reservation about the traditional psychodynamic stance: “ .. .to just say, ‘Well, just work on the underlying cause,’ and not talk about the symptom, isn’t fair, because if they’re miserable and uncomfortable, to wait ten years until it clears up, or doesn’t clear up, isn’t fair.” Hannah made the strongest statements against the idea of managing symptoms, yet blamed herself for a patient’s weight gain.

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All of the eight therapists who expressed confusion and ambivalence about symptom management appeared to have a clear awareness of its drawbacks, and saw it as an issue of treatment philosophy. It seemed that only Meredith was aware that it might be a countertransference issue. The shame she felt about active intervention was related to what she believed to be a lack of self-awareness that could prevent her from a concrete enactment. Her narratives contained many comments that indicated that she had put much thought into her countertransference reactions and how they had influenced her work with fat patients. In particular, she was aware of the process of projective identification and how it would lead her to take action, replicating her experience of caring for the impaired mother.

A question that deserves further study is, why might well-trained psychodynamic psychotherapists have such a difficult time refraining from active intervention with fat patients? It seems likely that most therapists are influenced by the strong pressure coming from the health care establishment to deal with the “obesity epidemic.� In addition, they are probably influenced by the current extreme social pressures for thinness. Myths based on the idea of fat as a sign of moral failure might lead therapists to see weight gain as a choice that merits confrontation. If the therapist is framing fat as an outcome of denial, he or she might feel obligated to take some kind of action.

All of these factors might have an influence; yet, the narratives suggest something more primal, less conscious. Observing a patient whose nutritional needs are not being properly met might tap into a therapist’s anxiety related to the very earliest dependency on the mother for life-giving nourishment. According to Klein (1952), interactions

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between the mother and child set the course of the child’s development and in particular, the child’s ability to manage anxiety. Seeing and working with a fat patient, hearing about the patient’s struggle with eating and with managing feelings, could evoke countertransference reactions that are related to the therapist’s own experience with nurturing. Taking direct action to help the patient manage symptoms and associated anxieties might be a defensive move on the therapist’s part. Seen as an aspect of the paranoid position, the patient’s struggle could be reminiscent of the therapist’s own struggle. Taking action rather than making interpretations might be evidence of a failure of the therapist’s defensive efforts to contain aggressive impulses, resulting in an aggressive demand on the patient to change his or her behaviors. Seen as an aspect of the depressive position, taking action as an effort to repair hurts might be based in the therapist’s transference to the patient, as well as in an identification with the patient’s projection of guilt.

If the need to intervene actively with fat patients is unconscious, as it appears to be with all but one therapist, then it would make sense that an injunction against symptom management would lead to confusion and ambivalence.

12. Subjects consistently focused on the needs of the nerson-as-a-whole. Weight and overeating were viewed as aspects of the patient's complex, subjective experience.

Much of what has been discussed so far was drawn from the data because of its relevance to patients’ experiences of being fat. Especially after hearing of the subjects’ tendency to focus on the patients’ weight through active interventions, the reader might

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incorrectly conclude that treatment was centered on fat-related concerns. This was clearly not the case, as a full reading of the interview transcripts would demonstrate. In fact, the therapists all worked in a way that was consistent with their stated psychodynamic approach, which was to get to know each individual patient, his or her developmental history, current situation, and psychological strengths and deficits; and then to assess treatment needs. Hannah wanted to be sure that although she was participating in research about fat patients, there would be no mistake about her view of the place of a single attribute (weight) in treatment: And my work with them is much more characterized by the level of pathology and intactness and the developmental issues. I think I tend to see people in terms of development. I worked in a child development center for a number of years.

And the weight is only secondary as it is filtered through the level of their structuralization and the cohesiveness of the self. So, it’s like the weight is in all three treatments, but it’s not a significant factor.

This result is important when it comes to evaluating the effects of bias on treatment. As many fat patients have experienced the limitations of being defined by their weight in a fat-phobic culture, it is important that their therapists do not repeat this form of oppression in the treatment setting. Although the results of this study show that these subjects had attitudes and feelings towards fat patients that were similar to those of the general population, and that these countertransference reactions were evident in their work, overall they appeared to be quite successful in refraining from defining patients by their fatness. This ability may have come from their training in a psychodynamic approach combined with the biopsychosocial orientation of clinical social work.

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13. Self-awareness o f countertransference and its origins ranged from somewhat to very aware.

As it is important for therapists to identify, understand, and work effectively with their countertransference reactions to patients, this result deserves further study. It appeared that some of the therapists, particularly Meredith and Christina, showed a strong awareness of and interest in the influence of their own feelings on their work with fat patients. Although most spoke freely of their own weight histories and experiences with fat people who were significant figures in their lives, only Rachel, Alice, Christina, and Meredith made direct links between their own history and their countertransference reactions. Others seemed to focus more on treatment technique, expressing feelings and attitudes in that context. Especially in the process of discussing concerns about their fat patients’ health, many feelings emerged. Often, statements were made that appeared to reveal bias, sometimes hostility. Only Tom mentioned a concern about bias; others seemed unaware that some of their attitudes and feelings might reflect bias. As previously speculated, some o f the treatment impasses that were reported might have been the result of countertransference reactions that were not adequately contained or appropriately used to inform treatment.

As for whether the subjects took measures to identify, understand, and contain countertransference reactions, this was discussed directly by only Brad and Rachel (see section on “Containment� in previous chapter). However, other therapists spoke of their countertransference and their own histories in ways that demonstrated a great deal of introspection, with references their own therapy.

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A difficult aspect o f working with countertransference is that when it is unconscious, the therapist remains unaware that it needs to be addressed. For this reason, supervision and the therapist’s own psychotherapy are essential elements of psychodynamic technique. Part of the motivation for participating in this study may have been a wish to explore their own countertransference reactions to fat patients. Nobody mentioned their supervision experiences during the interviews (which does not necessarily mean that supervision was not being obtained). Considering the result that the subjects’ attitudes and feelings toward fat patients seemed to mirror those of society, it would seem to be important that therapists pay special attention to the need to identify unconscious countertransference reactions that, if not contained, could cause harm.

Further research might explore the supervision practices and needs of therapists who work with fat patients.

14. Trends related to age, gender, race, and socioeconomic status were not apparent.

This exploratory study included a subject population of nine who discussed a patient population of 28. The subjects were homogeneous by age, race, and socioeconomic status, and heterogeneous by gender. The patient population was heterogeneous by all variables— age, gender, race, and socioeconomic status.

These are small numbers, and because this is the first study of its kind, there is no basis for comparison. Therefore, it is difficult to identify trends related to the above variables. The heterogeneity to be found among the patient population as well as by therapist gender would suggest that the data could be evaluated for trends related to

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demographic variables in a future study. I was alert to these differences and did not note anything of a conclusive nature. However, a few impressions might be useful in constructing future research questions.

The subjects told stories of a number of patients of various races. As all of the subjects were white, I expected to find references to these patients that were race-related.

This was strikingly absent, and led me to guess that the long-term relationships that were characteristic of the narratives allowed the therapists to relate more to their patients as people, rather than in terms of their attributes. Similar to my impression that the attribute of fat was not significant in the overall work with their patients (as discussed above), race also did not seem to play a major part. In terms of treating the whole person, this might be a desirable state; in terms of addressing the special needs of people who experience difficulties related to racism, this might represent oversight on the part of the therapists.

Regarding the other variables, all of the subjects seemed to be quite aware of the impact of age, gender, and SES on their patients’ development and functioning.

Male subjects appeared to be more aware of feelings of repulsion and anger toward fat patients. Female patients seemed more in touch with feelings of anxiety about their patients. Another impression was that the male subjects differed from the female subjects along the same line that I have noted in my clinical practice. The male therapists seemed to be more concerned about the health implications of fat. The female therapists seemed to be more concerned with body image. If these impressions about subject gender differences are accurate, they might suggest that gender socialization has an impact on

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countertransference and should be taken into account when exploring and making use of one’s countertransference reactions.

Theoretical Implications The existing literature (reviewed in a previous chapter) contains theory and research hypotheses about the nature of therapists’ countertransference to fat patients. In this section, the results will be discussed in light of this literature. In addition, comments will be made on the implications of this research for theoretical conflicts related to countertransference. Finally, suggestions will be made about new contributions to theory based on this research.

Three theoretical articles discussed therapists’ countertransference to fat patients.

Ingram (1978) proposed the idea that bias might lead psychoanalysts to abandon their neutral stance in order to promote weight loss. One of the major results of this research confirms this idea in that some subjects used active and behavioral techniques aimed at this goal, as well as the goals of curbing unhealthy eating behaviors and increasing exercise. Ingram also suggested that the analyst was liable to emphasize the contribution of emotional factors to obesity, ignoring other possibilities such as genetic factors. As he predicted, the subjects in this study did not seem to be aware of the literature that attempts to explain why people become fat. Statements contained in the narratives centered on self-destructive tendencies, denial, deficits related to self-soothing, and other emotional contributors. He guessed that therapists might express sympathy for their fat patients’ disabilities, preventing patients from discovering unconscious needs for fat and

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overeating. Although several of the subjects expressed this feeling in the interviews, it was not clear whether they expressed it to their patients. Subjects did seem to be aware of the possibility that Ingram suggested, that patients might have an unconscious need for their fat and overeating. Alice, for example, worried that weight loss might lead to depression. Ingram warned that “counterresistance,” originating in cultural pressures for thinness, could decrease the effectiveness of the therapy. He recommended that the therapist be on the alert for this possibility. It did appear that subjects in this study were not conscious of their counterresistance, and therefore were not actively on the lookout for its effects.

The second of three theoretical articles was written by Leah Davidson (1980). Her focus was on managing countertransference. She noted that her own fat bias was distracting her from the therapeutic task, by leading to a focus on her patient’s fat rather than on the difficulties he was experiencing with his parents. As was noted in the present study’s result on the subjects’ self-awareness of countertransference, some of the subjects made strong efforts to manage their countertransference reactions toward their fat patients, but others were less aware of their reactions and did not report these kinds of efforts.

Drell (1988) wrote the article that is most directly relevant to this study, “Countertransference and the Obese Patient.” Like Davidson, he emphasized careful management of countertransference reactions. He believed that cultural attitudes could influence the therapeutic relationship, something that was demonstrated in the stories told by the subjects of this research. The current cultural emphasis on taking responsibility for

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one’s weight as well as the prevailing view that fat is a problem were attitudes that were frequently reported in the interviews and appeared to inform many interventions that encouraged weight loss and exercise. His speculation that therapists would cope with their feelings of helplessness and ineffectiveness by blaming the patients appeared to be true in some cases; however, several subjects blamed themselves. Some of the subjects in this study felt repulsed by their fat patients’ bodies and smells. This was anticipated by Drell, who recommended careful exploration and management of this reaction. It is interesting that Drell believed that it is therapeutically advisable to discuss patients’ feelings about their size and its relationship to other conflicts. This is in line with the tendencies of the subjects in this study to focus on the patients’ weight; however, the focus was more on health implications than on the patients’ feelings about weight. Drell suggested six uses of countertransference reactions toward fat patients. All six contained predictions of how the therapists might feel that were reported in this study. Most o f the reactions that he named were reported by the subjects, such as impatience, anger, anxiety, fear, feelings of inadequacy, frustration, and satisfaction with weight loss. However, none of the subjects talked about using these feelings for understanding and interpreting the fat patient’s needs and experience.

Brotman, Stem, and Herzog (1984) conducted the only empirical research that is directly relevant to this study. They found that a small number of psychiatrists experienced five dysphoric affects in response to obese patients, including anger, stress, helplessness, sadness, and anxiety. These reactions were also reported by the subjects in the present study. What appears to be different is that most o f the respondents in

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Brotman’s study recognized the influence of their reactions on patient care, whereas most of the subjects in the present study did not appear to be aware of this influence.

Most of what appears in the literature reported so far has been replicated in the present study. The degree of negativity in the feelings reported by the subjects has been previously noted. They appear to be acutely aware of their reactions. However, awareness of counterresistance and efforts to manage countertransference feelings were only reported briefly by two o f the nine subjects. This seems curious, as all of the therapists who were interviewed were quite interested in the countertransference phenomenon and well read about its characteristics and clinical implications. This might be explained by the limited scope of this study, its research questions, and its interview questions, which were directed toward identifying the nature of countertransference. This study did not go so far as to enquire about the subjects’ uses or management of countertransference; nevertheless, it is odd that so few subjects mentioned this. Further study is needed to address this question.

Literature on countertransference to patients with eating disorders was also consulted for this study, as people with binge eating disorder often gain weight (Williamson & Martin, 1999). This literature is much better developed than the literature on countertransference and fat. The authors that were reviewed for this study have much to say that is relevant to the results that are reported here. An empirical study of countertransference and eating disorders by Burkett and Schramm (1995) reported countertransference reactions that were similar to those reported in the current research: frustration, anger, helplessness and anxiety, along with positive countertransference,

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satisfaction, and empathy. Zerbe (1998) noted the anxiety about eating disorders that many therapists seem to have, and suggested that these feelings may lead to a focus on the symptom as the problem. This may be an explanation for the tendency of the subjects in this study to override their theoretical convictions and focus on weight as a symptom, as anxiety about patients’ health was consistently reported. Woodman (1984) reminded the reader that weight is not necessarily a problem, and urged therapists to hold their anxiety so that the patient could proceed with his or her own exploration of weight and eating concerns. Cohler (1977) wrote extensively about this process in his work with a patient who had these concerns. Gutwill (1994) provided useful suggestions for avoiding the advice giving that was prevalent in the narratives of the current study, noting that containment of this urge allows the patient’s conflicted feelings to emerge and be discussed.

Gender aspects o f countertransference to patients with bulimia were discussed by Wooley (1991). In this study, the finding that male therapists seemed to feel more anger and repulsion toward fat patients appeared to be similar to that of Wooley, who attributed this to the tendency o f female patients to project feelings related to lack of control onto males. She noted a tendency of female therapists to identify with women who have bulimia. This appears similar to my impression that the female subjects tended to feel anxious about their patients’ weight. She offered techniques for handling these countertransference reactions that might be useful for work with fat patients.

Turning to the literature on attitudes and beliefs, Young and Powell (1985) studied mental health professionals’ assessments of the severity of symptoms. Obese

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clients were judged to have significantly higher rates of the following symptoms than nonobese clients: agitation, emotional behavior, impaired judgment, inadequate hygiene, inappropriate behavior, obsessive-compulsive behavior, self-injurious behavior, stereotyped behavior, egocentrism, hypochondriasis, intolerance for change, and suspiciousness. Several of these symptoms were described by subjects in the current study, most notably self-injurious behavior, which was also one of the largest differences reported by subjects in the Young and Powell study.

An aspect of research design that was not available in the current study was the ability to compare judgments of obese and nonobese clients. The researchers used the same case study, altering photographs of the client to represent different degrees of obesity. The results suggested that bias did indeed play a part. This may shed some light on the question raised earlier in this chapter about the stereotypical characteristic of the list of fat patients’ reported symptoms and whether this reflected bias. Agell and Rothblum (1991), who also found negative attitudes associated with client weights, reported that these did not significantly affect diagnosis or treatment recommendations.

This matches my impression, as mentioned previously.

Harvey and Hill (2001) conducted a study of physicians’ and psychologists’ views o f overweight people. Their findings are similar to reports in the present study.

Their subjects believed that being overweight was caused by physical inactivity, addiction, depression, and mood change, along with genetic, personality, and interpersonal factors. Being overweight was associated with diminished self-esteem, sexual attractiveness, and health. A quote from their report aptly characterizes an attitude

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that was expressed frequently by subjects in the current study: “Respondents believed overweight people should try to understand what causes them to be overweight, motivate themselves to lose weight, recognize that there is a problem, and recognize that there is a risk to their health” (p. 1258). These findings do not necessarily reflect bias, but there is much controversy about the cause of weight gain and the advisability of losing weight.

Fat bias and prejudice among health professionals is another topic of literature reviewed in this study. Davis (1998) concluded that weight has a significant negative effect on clinical judgment and treatment planning with regard to fat patients. As stated earlier, this negative effect was not apparent in the narratives of the present study. Hassel et al. (2001) found significant bias toward obese clients in mental health professionals’ attitudes. Again, these studies allowed for comparisons based on weight that were not made in the current study. The possibility that fat bias might have played a part in the attitudes of the subjects in the current study suggests that an analysis of therapist bias by Laura Brown (1989) might be useful in understanding this phenomenon. She reported that therapists often believed that weight was the cause of health problems and that they had difficulty coming to terms with their own struggles with weight, also evident in the current study. She thought that therapist defensiveness and guilt reflected a conflict between the wish to rid oneself of oppression and the need to align oneself with cultural ideals. Self-reports o f therapists’ feelings and attitudes toward their own bodies (Burka, 1996; Lieberman, 2000; Rabinor, 1993) provide much information to support these ideas, and are useful in understanding and managing negative countertransference.

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Two controversies in the theoretical literature on the concept of countertransference are relevant to the current study and deserve comment. First is the evolution of the scope of countertransference from a narrow to a broad definition.

According to the broad conception of countertransference (Epstein & Feiner, 1979), attitudes and beliefs might shape one’s emotional responses. The broad definition was chosen for this exploration of the nature of countertransference to fat patients because it was anticipated that attitudes would have a strong influence on clinical social workers’ reactions to fat patients. One way to think about this choice is to ask what the study would have been like if attitudes were excluded. For example, how is the prevalence of frustration and anxiety in response to patients’ fat to be fully understood without considering the attitude that fat causes illness? Another attitude that seemed to have an influence on several subjects was the belief that fat is the outcome of overeating.

Although this may be true in some cases, there is much evidence for the influence of other factors. Nevertheless, the subjects in this study often reacted to patients’ fat and made decisions about treatment techniques based on this belief. Indeed, it appears that attitudes and feelings cannot be separated with regard to countertransference.

The second controversy is over the question of focusing on a particular diagnosis when it comes to countertransference. Some would say that countertransference is so complex that one cannot specify a particular attribute and arrive at any generalizations.

According to this viewpoint, a therapist’s reactions to a fat patient are stimulated by so many diverse factors that the attribute of fat cannot be separated and analyzed. Holmqvist (2000a), provided evidence for the correlation of diagnoses with countertransference

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reactions, after conducting previous studies that showed no effect. The results of this research suggest that countertransference reactions to fat patients who were diagnosed with eating disorders had many similarities among subjects. For example, there was no exception to the incidence of concern about health that was expressed. Another very common reaction was to perceived self-destructiveness related to overeating, including feelings of frustration, alarm, and responsibility. Theoretical literature about countertransference to fat patients includes distinct countertransference reactions related to the diagnosis of obesity that were replicated in this study.

What this study adds to existing theory is new knowledge about clinical social workers’ countertransference to fat patients, the first exploration of its kind. As it is a qualitative study, no generalizations can be made; rather, specific useful information, researcher’s impressions, and trends derived from the data make up the contributions of this study. Theory might be built upon these contributions, especially after further research is conducted. In summary, this research suggests the following tentative additions to theory: 1. Clinical social workers may react to fat patients in ways similar to the general population and to other mental health professionals, including both negative and positive feelings, more negative than positive.

2. Clinical social workers who work from a biopsychosocial perspective and a psychodynamic viewpoint may offer an exceptional ability to understand (a) the fat patients’ experience, (b) the potential psychological functions of overeating and fat; and (c) the potential of overeating and fat to be symptoms of psychological disorder or

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deficit. Their training may also help them to consider the needs of each patient as a human being rather than as someone who is defined by their fat.

3. Clinical social workers may need to acquire knowledge of the interdisciplinary literature on fat in order to better understand and manage countertransference reactions to fat patients.

4. A personal history of weight fluctuations may give the therapist greater empathy for the experience of fat patients in modem society.

5. Fat bias may influence the countertransference reactions of clinical social workers.

6. Active interventions that are contraindicated in psychoanalytic thinking may be indicative of counterresistance and may deny a fat patient’s need for the therapist to contain his or her reactions and remain neutral.

7. The word fat has a great number of meanings that fall under six categories: (a) a word, (b) a substance, (c) an attribute, (d) an indicator, (e) a function, and (f) a problem.

Application to Clinical Social Work Although this is an exploratory study of a small number of subjects, the results have relevance to the practice of clinical social work. The previous discussion of each result includes details of several possible clinical applications. A summary of those suggestions and some additional ideas are included in this section. Although this research focuses on work with fat patients, patients of all sizes may have concerns about fat for which these applications may be useful.

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1. Clinical social workers can be alert to the meanings of fat, to themselves, to their patients, and to society. This understanding will be useful in working with fa) patients’ concerns about fat, and fb) countertransference to fat patients.

Several subjects experienced discomfort and had difficulty using the word fat.

This showed sensitivity to the stigma of the word in the general culture. Many fat activists have recommended that this word be freely used in an effort to restore its former neutral designation of size. Therapists can pay special attention to the meaning of the word to each individual patient, and consider the impact of their use of this word when speaking with patients of all sizes.

Fat is sometimes seen as a flaw or a moral failing. The therapist can be alert to this meaning in the countertransference and explore the origins of this judgment.

Therapists need to keep in mind that this attitude can lead to harmful comments or interventions. At the same time, it might be a basis for understanding the patient’s similar attitude, or that of people who are important to the patient. It must be kept in mind that the patient’s subjective experience of fat may be that it is a flaw. Whether or not the therapist believes this to be so, the patient’s experience is based on events that constitute the patient’s subjective reality. The therapist can think carefully about the implications of discounting or dismissing this attitude.

When fat is seen as an indicator of problems or a symptom of mental illness, the therapist might be mindful of the following alternatives. First, the therapist can evaluate the contribution of fat prejudice to this view of the problem. How much of the problem is

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the patient’s actual experience? Is the definition of the problem based on bias? Is the problem created by bias? Second, the principle that association does not imply causality should be kept in mind when considering the possibility that a patient’s fat is creating a problem. Third, the therapist can be careful not to assume that fat is a problem for the patient. When it is, the therapist can be careful not to assume that he or she understands the patient’s experience of the problem. This understanding should be based on the individual patient’s narratives.

2. Clinical social workers may be especially helpful to fat patients in understanding their experience, attending to psychological symptoms and functions related to fat, and addressing emotional overeating, when present.

Again, it is important to be alert to the possibilities that fat patients may experience certain psychological difficulties without making assumptions.

The psychodynamic viewpoint offers much in the way of theory and technique for working with the mental health needs of fat patients who experience overeating or fat as a problem. The idea that fat may be consciously felt to be a problem but can also serve an unconscious defensive purpose is of particular value. Therapists might validate the patient’s description of distress related to being fat, while helping the patient explore evidence that being fat is not necessarily bad and may be useful in some ways. Helping the patient see the contribution of societal prejudice to his or her suffering can provide relief from self blame. Remaining neutral about the validity of the patient’s wishes to lose

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weight while helping the patient to explore the realities of this option is a difficult, but important task.

One of the results of this study was that subjects often showed empathy, caring, dedication and concern for their fat patients’ well being. This behavior reflects clinical social work values that are especially important in working with a patient population that often experiences misunderstanding, derision, and neglect.

3. Clinical social workers need to educate themselves in the interdisciplinary literature on fatness, fat prejudice, and therapy needs of fat patients.

The subjects of this research reported attitudes and feelings toward fat patients that are similar to those o f the general population, many of which suggested bias or lack of information. It seemed that these attitudes were shaped by personal experiences as well as assumptions that have widespread exposure in the media. Two attitudes are of particular concern.

First is the association of fat with health problems and the assumption that fat is a cause. The literature contains many challenges to these ideas. Because fat patients and their needs may be misunderstood, therapists can become educated about the controversies and alert to the effects of misinformation on fat patients’ suffering and coping strategies.

Second, weight loss as a solution to problems associated with fat lends itself to the fantasy of finding a magical answer to these problems. Many fat patients not only place a great deal of faith in weight loss, but feel pressure to pursue this goal. Since the

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Surgeon General declared that there is an epidemic of obesity, health professionals have placed increased emphasis on the need to lose weight. There is much evidence to support the idea that this is neither realistic nor effective in alleviating weight-related suffering.

At the same time, fat patients may have reasons for losing weight that are a matter of personal preference, physical comfort, and subjective evaluation of need. Therapists need to avoid judging fat patients’ wishes to lose weight as inappropriate or unhealthy. Again, it is the therapist’s role to assist the patient in his or her evaluation of options rather than to give advice. If the therapist believes that education is an important component of therapy, it will be useful to ascertain whether the patient is aware of lesser-known facts about weight loss.

4. Clinical social workers who have not experienced fluctuations in weight may need to take steps to increase empathy for fat patients, and to review their attitudes and feelings about weight loss.

Subjects who related personally to their fat patients’ stories appeared to have more empathy for the fat patient’s experience and a more sophisticated understanding of the problems with dieting. Therapists who have never found it difficult to stay thin may need to be alert to an assumption that others can do so with ease, or with the mere application of will. They can become familiar with the literature that outlines myths about weight loss and provides first person narratives of the experience of being fat. They can seek supervision and therapy to explore countertransference reactions that might be

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influenced by displacement, projection, or experiences with other fat people who have been important to them.

Clinical social workers that do have experience with weight fluctuations should not assume that this makes them experts on the experiences and needs of their fat patients. The complex psychological makeup and experience of each individual patient is what matters most. The therapist’s experience of being fat can assist with empathy, but does not guarantee a familiarity with the facts about weight loss or the needs of fat patients.

5. Clinical social workers need to be introspective about their own fat prejudice and take measures to eliminate it.

As fat people are vulnerable to oppression, it is particularly important for clinical social workers to be alert to the aspects of their countertransference that are based on ignorance, misunderstandings, or failures to identify with their patients. The degree of negativity found in subject reports of attitudes and feelings toward fat patients, along with the similarity of some o f the descriptions of pathology to stereotypes, suggest that bias may be present. Consistent with the social work value of fighting oppression, the mere hint of bias needs to be taken seriously. Therapists can approach this task by becoming familiar with the literature on fat bias. They can examine their own beliefs for similarity to bias and then examine the basis of their beliefs. Several examples of ways in which certain attributes may be evaluated for fat bias were described in a previous section, for

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instance, refraining pathological “resistance” as the fat patient’s healthy attempt to counteract an unrealistic suggestion for losing weight.

6. When working with fat patients, clinical social workers need to identify and manage countertransference feelings that are related to weight and eating.

As one of the results of this research showed that the subjects varied in their awareness of countertransference, this need seems particularly important. Because of its often-unconscious nature and the barrier that fat prejudice may create, a special, ongoing effort may be needed and supervision may be necessary. Ingram (1978) recommended that cultural counterresistance also be explored. As it appears to affect some of the responses o f the subjects in this research, clinical social workers need to pay attention to the impact of cultural beliefs upon their ability to work therapeutically with fat patients.

Negative countertransference needs to be monitored for its potential to interfere with the healing process. As Davidson (1980) warned, countertransference reactions to fat patients may distract the therapist from a clear therapeutic focus. Burgard (2004) provided an analysis of the defensive nature of negative countertransference toward fat patients in light of defensive displacement of existential anxiety. Negative countertransference might reflect other types of projection or transference reactions that are not relevant to the patient’s experience.

On the other hand, countertransference can also be used to understand fat patients’ feelings and experiences, as well as those of people who are important to them.

In earlier discussion of the negative feelings reported toward fat patients, an example of

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the analysis a feeling was provided. Its role in complementary, concordant, and objective countertransference was explored. Drell’s (1988) suggestions for using countertransference reactions in work with obese patients (see literature review) should be consulted, while keeping in mind that they contain some controversial ideas about weight loss.

7. There may be a place for active interventions in therapy with fat patients, such as when providing information that is relevant to their mental health but which may not be readily available.

Many people are not aware of the research that shows the futility and possible harmful effects of weight loss attempts, most recently the trend toward surgical methods.

Often fat people feel tremendous pressure to lose weight in order to improve health, a goal that is not adequately supported by research. Clinical social workers must consider the costs of remaining neutral when observing that the patient lacks information.

On the other hand, when clinical social workers use active interventions, they should examine the possibility that they are acting out of anxiety or frustration rather than staying in the role o f helping the patient explore feelings and options.

Countertransference behind this kind of intervention is likely to be based upon unconscious feelings that require exploration in psychotherapy and supervision.

In light of Drell’s (1988) recommendation that the therapist should avoid either over or underemphasizing weight, a discussion of feelings about weight might be a good middle ground between symptom management and ignoring the symptom. Two caveats

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are in order: (a) Fat is not necessarily a symptom, (b) Discussing weight may not be on the patient’s agenda. Consistent with the social work value of respecting the patient’s autonomy and view of his or her needs, the therapist can evaluate the necessity for a confrontation that may not be welcome or needed, and that may exacerbate existing difficulties associated with overeating and fat.

8. Clinical social work skills and training are particularly useful to the clinical ponulation of fat patients.

This population has a need to be understood as individuals, as whole human beings, and as people who may have complex, often misunderstood problems related to being fat, including the impact of fat prejudice.

This research suggests that long-term treatment enhances the therapist’s ability to develop a deeper understanding of the individual patient and his or her needs. This sets the stage for positive countertransference and may help to counteract the effects of bias and negative countertransference.

Feelings of caring and responsibility are part of the repertoire of clinical social workers. These were evident in the narratives and appeared to be crucial to establishing an effective working relationship with their fat patients. Sometimes therapists acted on these feelings in ways that may have deprived their patients of the chance to work through their difficulties independently. With this in mind, therapists can evaluate how they act on these feelings in treatment.

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Subjects consistently focused on the needs of their fat patients in terms of the person-as-a-whole. They were able to view weight and overeating as aspects of the fat patient’s complex, subjective experience. This important achievement should be noted by clinical social workers who work with fat patients. It appears that the subjects were able to metabolize fat bias in order to work effectively. Their psychodynamic and biopsychosocial perspectives as well as their own therapy and supervision appeared to contribute to this ability.

9. The Free Association Narrative Interview method is especially useful for the conduct of clinical social work research.

First, it is designed to enable the researcher to counteract subject defensiveness when it comes to sensitive topics. Most of the focus of clinical social work is on sensitive material, which means that a method such as this one is indispensable. Second, the use of knowledge related to psychological defenses in data analysis provides clinicians with a familiar tool for research and increases the chances that analysis will be sophisticated and productive. Third, its emphasis on the person-as-a-whole is consistent with social work values and practice. Finally, its strong focus on ethical considerations meets the needs of clinical social work research, which requires attention to a rigorous set of ethics with respect to patient needs.

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Future Directions for Research

In the foregoing discussion of the results, many suggestions were made with respect to future studies that might dispute, confirm, or expand upon these results. This section summarizes these suggestions as well as ideas for method and design alterations.

Recommendations are grouped according to three categories: method, design, and research questions.

Method 1. In order to enable holistic reporting of the results, secure the permission of all parties, including therapists and their patients. Allow for member checking and consider the possibility of including patients in this process.

2. Expand the report of results to include implicit countertransference, i.e., speculation about countertransference that is based on unconscious feelings and thoughts (an aspect of the FANI method).

Design 1. Examine the data collected for this study for trends related to demographic variables other than race (as the subjects were all White).

2. Vary subject selection parameters such as theoretical viewpoint, experience level, profession, race, age, socioeconomic status, and gender.

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3. Conduct a single case study in order to provide more detail about the experiences of the therapist and each patient who is discussed.

4. Repeat this study with a greater number of subjects.

Research Questions 1. How do clinical social w^k-drs’ attitudes and feelings vary from those of the general population?

2. Do clinical social workers lack knowledge of the interdisciplinary literature on fat? If so, why is this the case? How can acquisition of this knowledge be promoted?

3. Are clinical social workers aware of the impact of age, gender, and SES on their fat patients’ development and functioning? How can this awareness be increased?

4. How often do clinical social workers use fat as an indicator of health and mental health problems?

5. How do clinical social workers examine a fat patient’s history to determine whether fat is a problem to the patient?

6. Does bias influence the countertransference reactions of clinical social workers? Does it lead to counterresistance? Is assessment and diagnosis of fat patients by clinical social workers influenced by bias?

7. How careful are clinical social workers to refrain from making assumptions about fat patients? Do they take steps to identify and counteract bias in their attitudes and interventions?

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8. To what degree are clinical social workers aware of their countertransference feelings toward fat patients? How do they address implicit countertransference?

9. How do clinical social workers manage negative countertransference in order to prevent harm to the fat patient? What is their assessment of the origin of their reactions?

Do they seek psychotherapy and supervision in order to increase awareness of and manage negative countertransference reactions?

10. How do clinical social workers use their countertransference reactions to shed light on the fat patient’s experience or that of his or her significant others?

11. How often do clinical social workers use active interventions related to eating and weight with fat patients? What is the appeal of these interventions? How often are they indicative of counterresistance?

12. How do clinical social workers develop positive countertransference to fat patients and how can this be promoted?

13. Do clinical social workers possess a greater capacity for empathy for fat patients than the general population or other mental health professionals? How can training promote empathy?

14. Does a personal history of weight fluctuations enhance the clinical social worker’s capacity for empathy for the fat patient? Does it contribute to countertransference based on projection rather than the patient’s experience?

15. What might be done to help clinical social workers that have not had personal experience being fat to develop greater empathy for the fat patient?

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These research questions might also include therapists other than clinical social workers. In any case, the heretofore under-researched topic of countertransference to fat patients deserves a great deal of additional study, as the quality of the therapeutic relationship is o f primary influence on the outcome of psychotherapy, and the needs of fat people have a history of being neglected by society.

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APPENDIX A RECRUITMENT LETTER

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[date, name, address] Dear I am writing to you as a fellow member of [organization] to request your assistance in research that I am conducting as a doctoral candidate at the Institute for Clinical Social Work in Chicago.

The purpose o f this research is to explore the nature of clinical social workers’ reactions to fat patients. Government statistics report that 64% of American adults are “overweight.” We are likely to see many patients in our psychotherapy practices whom we might describe as “fat” or who describe themselves that way. A clear awareness of our attitudes and feelings toward these patients would help us understand how they affect our work.

I am hoping that you would have an interest in contributing to this knowledge by participating in two to three interviews to be used in a qualitative study. As opposed to traditional statistical research, qualitative research uses interviews and stories as sources of data. The idea is to get a whole picture of a situation rather than attempting to measure particular aspects. The method is particularly useful in studying human relations that cannot be quantified. There is a rich tradition of qualitative research in clinical social work, possibly because stories are very much a part of our work.

Although licensing laws allow for research based on patient information, they also call for protection o f patient privacy and confidentiality. My research method addresses these needs.

If you are a clinical social worker who practices psychotherapy according to a psychodynamic viewpoint and has had at least 5 years of full-time clinical experience, including work with fat patients, please consider contacting me at the address below to discuss participation. I look forward to the interview experience as something that will be mutually beneficial as well as a contribution to knowledge.

Best wishes, Patricia Kyle Dermis, M.S.W. Doctoral Candidate Institute for Clinical Social Work Chicago, Illinois

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APPENDIX B PARTICIPANT CONFIRMATION LETTER

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[date, name, address] Dear Thank you for responding to my request for participants in a doctoral research study on clinical social workers’ reactions to fat patients. This letter is to confirm our appointment for a first interview at [hour] on [day, date]. The location will be [place]. I anticipate that the interview will last from one to two hours.

No preparation is necessary; however, I am enclosing a sample consent form in case you would like to review it before we meet. At that time, we will review it again and there will be time allowed for you to ask questions before you decide whether to participate.

Your interest and willingness to participate is very much appreciated. Please feel free to ask questions or discuss rescheduling or canceling our meeting by contacting me at the addresses or phone number below.

Best wishes,

Patricia Kyle Dennis, M.S.W.

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APPENDIX C INFORMED CONSENT FORM

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INSTITUTE FOR CLINICAL SOCIAL WORK Individual Consent for Participation in Research I , _______________________________ , agree to be interviewed for the research entitled Print name “Fat in the Countertransference: Clinical Social Workers’ Reactions to Fat Patients.”

This work will be carried out by Patricia Kyle Dennis, M.S.W., under the supervision of Miriam Reitz, Ph.D. This work is conducted under the auspices of the Institute for Clinical Social Work (ICSW), 180 N. Michigan Avenue, Suite 1605, Chicago, Illinois, 60601, telephone (312) 726-8480.

Purpose: The purpose of this study is to conduct research that will explore the nature of reactions of clinical social workers to fat patients. Clinical social workers are likely to work with a number of patients whom they might describe as “fat.” This study will investigate the meaning of the word fat to the clinical social worker, the clinical social worker’s reactions to these, patients, and how these reactions are manifested in their work.

Procedures Used in the Study and the Duration: The researcher will interview clinical social workers, asking questions about their experiences, thoughts, and feelings related to their work with fat patients. Two to three interviews will take place at times convenient to both the researcher and the participant, in a location that provides privacy and is agreeable to both. The interview will last as long as the participant is interested in answering questions, up to two hours. Participation will end at the close of the final interview. The interview data and researcher observations will be analyzed by the researcher to construct a description of the participant’s response that includes both interview answers and the researcher’s inferences about thoughts, feelings, and meanings related to fat patients that may not be apparent to the participant.

Benefits: It is expected that this research will benefit society by providing knowledge that will help clinical social workers practice more effectively with fat patients, a large group in American society. There may be benefits that can be experienced by being interviewed, such as having the opportunity to talk with and be heard by an experienced colleague about aspects of one’s work. The interview might provide a chance to express frustration, anxiety or other negative feelings as well as positive feelings of such as satisfaction or enjoyment. The participant’s contribution of information that can be beneficial to a patient population could lead to a sense of satisfaction.

Costs: There will be no monetary costs associated with participating in this study.

Possible Risks or Side Effects: Talking about experiences with patients may bring up uncomfortable thoughts, feelings, or memories related to work with these patients or one’s own personal experience. Clinical social workers are trained to work with challenging situations where negative thoughts and emotions can arise, so it is expected

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that participants will not experience more than a small amount of anxiety or discomfort due to participation in this study, and that the participant will be able to manage these feelings. The interview process itself may aid in managing any discomfort that is experienced. If the participant reports difficulty in managing reactions to the interview process or other aspects of participation in this study, he or she will be offered up to three (3) debriefing sessions with the researcher under the supervision of the Dissertation Committee Chair, Miriam Reitz, Ph.D. Privacy/Confidentiality: Interview audiotape recordings and researcher’s notes on observations and information gathered will be kept by the researcher in locked storage and destroyed 5 years after completion of the research. Names and other information that could lead to identification of participants will be separated or removed from all research data and reporting. This identifying information will be known only by the researcher.

The participant should refrain from revealing patient identities or other identifying information. The researcher will take extra precautions to ensure that information that could lead to identification of psychotherapy patients is removed from audiotapes or notes and is not discussed or published.

Participant’s Rights: By signing this consent form the participant agrees to take part in this study. The participant does not give up any rights or release this institution from responsibility for carelessness. The participant may cancel this consent and refuse to continue in this study at any time without penalty or loss of benefits. The participant’s relationship with the staff of the ICSW will not be affected in any way, now or in the future, if the participant refuses to take part or begins the study and then withdraws.

Questions about the research method may be directed to Patricia Kyle Dennis, M.S.W. Researcher, or Miriam Reitz, Ph.D., Dissertation Committee Chair. Questions about rights as a research subject may be directed to Daniel Rosenfeld, M.A., Chair of the ICSW Institutional Review Board. These persons may be reached at ICSW, 180 N. Michigan Avenue, Suite 1605, Chicago, Illinois, 60601, telephone (314) 726-8480. ? H A V e ' r E A D T fflS C O N SE N T FO R M A N d ' i ' a GREE TO TA K E PA R t ' iN THIS ST U D Y A S IT IS E X P L A IN E D IN THIS C O N SE N T FORM .

Participant’s Signature________________________________ Date___________________ I CERTIFY T H A T I H A V E E X P L A IN E D TH E R ESEA R C H T O ____________________________ A N D BE L IEV E THIS P E R SO N U N D E R S T A N D S A N D H A S A G R E E D TO PARTICIPA TE FR EELY . I A G R E E TO A N SW E R A N Y A D D IT IO N A L Q U ESTIO N S A B O U T PA R TIC IPA TIO N IN TH E R E SEA R C H W H E N TH EY A R ISE D U R IN G TH E R E SE A R C H A N D AFTERW ARD.

Researcher’s Signature_________________________________Date________________

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