July/August 2008 Issue

Weighing the Possibilities: Transferential Weight Issues in Therapy
By Karen R. Koenig, LCSW, MEd
Social Work Today
Vol. 8 No. 4 P. 20

Can an overweight therapist help a client with anorexia or can a heavy client be helped by a thin therapist? Yes, but take a look at the complex issues both parties may encounter in the process.

When treating clients with eating and weight problems, transference and countertransference may be overlooked, less acknowledged, or avoided because of the potential discomfort that may arise by addressing them. However, by recognizing and exploring reactions to weight differences existing within the clinical dyad, we can help clients’ progress by uncovering latent feelings in the present, tracing their roots to the past, and healing old wounds.

As therapists, there are many matters we can keep private about ourselves. Body size is not one of them. In this fat-phobic, thin-obsessed culture, it’s difficult not to make assumptions and judgments about body size no matter where it falls on the weight continuum. When clients meet us, transference dynamics regarding weight may automatically begin and move into play. Of course, some clients with weight problems won’t care what shape we are in as long as we can help them; others will have reactions, including transferential ones, that have nothing to do with our size.

In addition, we must deal with our feelings about clients’ size. If we have eating or weight struggles, raising transference issues which are necessary for client growth may make us feel painfully vulnerable and exposed by drawing attention to our less-than-perfect bodies. We may experience shame, anxiety, sadness, disappointment, envy, contempt, helplessness, despair, or any mix thereof. Dealing with transference and countertransference issues often entails in-depth examination of our cultural biases about weight and our personal current difficulties and troubled histories.

There are numerous transferential scenarios that may occur when treating clients with weight and eating problems.

Overweight Therapist and Client
When both therapist and client are overweight, clients may feel an instant bond, expect that the therapist instinctively understands their struggles, and assume that the therapist’s eating problems and attitudes toward his or her body are similar. If clients hate and are ashamed of being heavy, they may be relieved that they won’t be judged for their size. If they have low self-esteem and a poor body image, they may be unable to imagine that heavy individuals could feel anything but terrible about themselves.

Finding a therapist who is large may open the door to sharing self-contempt and self-disappointment in a way they could not do (or at least not early on) with slimmer clinicians. Whether the therapist actually shares body hatred is initially immaterial. Feeling mirrored by a likeness of himself or herself in a therapist perceived as competent and powerful is often all that’s needed to open the floodgates.

Alternately, overweight clients meeting with heavy therapists may experience immediate concern or even panic that they will fail to receive effective treatment. They may believe that overweight therapists have nothing to offer because they’re unable to fix their own weight problems. Clients with weight problems who are fat phobic, thin obsessed, and caught up in the diet mentality may have lethal levels of contempt for large people in general, and themselves in particular, and therapists will be no exception. Clients may feel disgusted by and contemptuous of the therapist and angry about being stuck with someone so incompetent—all this without the clinician saying a word.

If therapists are comfortable with their bodies, they may be able to use humor and skill to bond and explore issues. It’s not crucial for therapists to resolve their problems in order to help clients resolve theirs. Instead, they must recognize their issues, stay in touch with their feelings, and use them to further treatment. It’s also possible that large therapists may wish to avoid the subject of weight because they feel inadequate to provide help. If they’re ashamed of their body or hopeless about their inability to slim down, they may ignore the client’s cries for help, minimize their distress over weight, or project negative feelings onto the client. Or they may go overboard trying to fix the client because they feel so powerless to change themselves.

Ideally, overweight therapists will be emotionally healthy and comfortable enough with their body and size to reach out and give clients whatever is clinically required—acting as a role model, joining and commiserating with the client about genetic loading, or using basic clinical skills to help the client examine and resolve eating difficulties.

Underweight Therapist and Client
When both therapist and client are underweight or slim, there are also opportunities for automatic bonding or for false assumptions. There is slim and then there is malnourished; the therapist may be on the slim end of a normal weight range while the client is frighteningly below. In this case, a client with anorexia or another eating disorder may even view the therapist as weighing too much.

When both parties are slender, the undereating client may assume that the therapist hates fat and overvalues thin as the client does. Restrictive eaters may try to bond with thin clinicians by complimenting their weight, projecting their desire to hear similar flattery. If thin therapists are relatively unbiased about body weight, they can help their clients recognize that people have value derived from all aspects of personhood, not only appearance.

Just as it’s possible for an overweight therapist to focus too much on diets with an overweight client, a thin therapist and client may focus too heavily on nutrition. Watch out for these kinds of treatment traps. Sadly, slender therapists may have more credibility than their heavier counterparts and so may find it easier initially to help clients in challenging irrational thinking about food and weight. They may even generate exploration of the clients’ fat bias by asking them to imagine what discussion would be like if they were with a heavier clinician.

If overly thin therapists have unresolved eating and weight issues, they may have difficulty helping an undereating, underweight client. Regardless whether they privately overvalue thinness, therapists must help clients see that a relentless drive toward being thin is dangerous and debilitating. Therapists must know themselves inside and out, especially if they have irrational fears of becoming fat, and can use their self-understanding to aid clients in recognizing similar terrors. Thin therapists can also use their experiences eating nutritiously and living a healthy lifestyle to model how clients can keep their weight down in a reasonable way and not resort to starvation, purging, or excessive exercising.

Overweight Therapist and Underweight Client
Being a heavy therapist treating an underweight client can be difficult for both parties. Slim clinicians may feel relatively fine about their body based on cultural standards and feel little awkwardness when talking openly about weight. However, heavy therapists may feel ashamed and want to avoid calling attention to their size. Of course, some large therapists are comfortable in their bodies and exude such competence and self-confidence that clients generally respond positively to them. These clinicians don’t take clients’ fat-hating comments personally and are clear about who has the problem.

If the therapist is neither so skilled nor comfortable, a jumble of emotions may fill the therapeutic hour. Sensing the clinician’s frustration with or shame about weight, thin clients may feel uneasy discussing their difficulty with gaining weight for fear of hurting or embarrassing the therapist. Even clients wishing to gain 10 pounds may feel anxious talking about eating more with a therapist whom the client assumes is trying to eat less.

Therapists who have struggled unsuccessfully to achieve and maintain a healthy weight may believe clients are petty and superficial to become nearly hysterical over putting on a pound or two. Therapists who have never been thin and accept themselves as they are may feel disdain toward this country’s obsession with slenderness and fail to understand how clients would want to throw all their energy into becoming a superficial cultural ideal. Therapists at any weight who fail to understand an obsession with thinness may have difficulty empathizing with clients who have an otherwise happy and successful life but are terrified of stepping on the scale and could talk about eating and weight for hours on end.

As previously mentioned, thin clients eating restrictively may not believe a heavy therapist can help them and so may avoid bringing up eating issues or touch on them only briefly to see if the clinician picks up on them. If the therapist lets him or her pass (even for a solid clinical reason), the client may think the therapist is sidestepping the problems. Equally possible, heavy therapists may truly believe they have no good counsel to offer underweight clients. In this instance, both parties may be walking on eggshells and important issues never get raised, much less resolved.

Underweight Therapist and Overweight Client
When slim or underweight therapists see overweight clients, the latter may not believe they will be understood. Overweight clients accustomed to being shamed for their size may have trouble bringing up food-related issues. If underweight therapists avoid bringing up the subject because they feel self-conscious about their weight and concerned about shaming the client, the client may interpret this as disinterest or lack of concern.          

Thin therapists may not understand what it feels like to be overweight or obese and be reluctant to make faulty assumptions. Or they may have a prejudice against fat, lack understanding of how the clients could “let themselves go,” or feel sorry for clients and become helpless to treat them. Therapists may have the urge to fix clients rather than guide them toward finding their own ways of resolving food issues. Slim therapists who have never tried to shed pounds or who have had an easy time of it may be frustrated with heavy clients, especially when they talk about wanting to lose weight in the same breath that they confess to overeating “all the wrong things.”

Often, the more helpless clinicians feel, the more they may push a diet program or insist that the client exercise.

Therapist Has an Eating Problem But Not a Weight Problem and Client Has Either or Both
Therapists who have a hidden eating problem function similarly to those who have substance abuse issues, living with a mix of shame and denial. Clinicians who are chronic, rigidly restrictive dieters may not see themselves as having eating issues because thinness and ongoing deprivation are socially sanctioned. Similarly, heavy therapists who regularly overeat or binge may not believe they have food or weight problems because those behaviors are so universal.
 
If average weight therapists are in denial about having an eating problem, they may not validate that a client has one because that would mean facing their own issues. Instead, they may steer discussion away from what makes them uncomfortable or fail to recognize that clients have a bona fide eating disorder—that they are undernourished, not merely fashionably slim, or that they are severely obese, not just pleasantly plump.

No Magic Answer
There is no magical, one-size-fits-all solution to dealing with transference dynamics around eating and weight problems. There may be times we can benefit from consultation or ongoing supervision to handle strong transference reactions from clients and equally powerful countertransference feelings of our own. We may even need to return to therapy to resolve our food and body issues. To be effective in treating clients with food and body issues, the therapist should do the following:

• Err on the side of caution and move slowly when delving into these problems.

• Make no assumptions about feelings or eating as they relate to appearance or weight.

• Never come across as judgmental.

• Express curiosity if questions about eating and weight are deflected or ignored.

• Avoid trying to “fix” clients’ eating or weight problems and, instead, explore clients’ (and therapists’) feelings of frustration, uncertainty, helplessness, and hopelessness.

• Model healthy self-awareness and self-acceptance at any weight without ignoring or minimizing the difficulties of overcoming problems related to eating and weight.
If we can use these approaches most of the time, we have a good shot at helping clients resolve their eating and weight issues. This doesn’t mean there won’t be moments when we are highly uncomfortable or cause clients enormous discomfort. It’s our job to cause pain in the short run in order to alleviate it in the long run. The more we consider issues of eating and weight and how they may play out transferentially in the therapeutic relationship, the better we will be at addressing them with confidence and competence. 

— Karen R. Koenig, LCSW, MEd, is a cognitive-behavioral therapist and educator in Sarasota, FL. She has more than 25 years of experience treating compulsive/emotional and restrictive eaters and is the author of several books including The Rules of “Normal” Eating — A Commonsense Approach for Dieters, Overeaters, Undereaters, and Everyone In Between!