Learning Objectives

The reader will be able to:

• Explain the psychological meanings of food, appetite, and weight, and the underlying motivations that apply to eating disorders.
  
• Explain the issue of relapses in weight loss from the perspective of psychoanalytic theory.
  
• Identify the aims and methods of various psychodynamic treatments in weight management and their commonalities.
  
• Describe how gender differences affect weight and self-esteem.

Introduction

The obese are at a great disadvantage in our society. They are stigmatized in the workplace, in social situations, and even within their own families. They are more readily subject to denigration than most other groups. In a society whose puritanical roots lead us to believe that anything is achievable if one makes the effort, obesity is perceived as a moral failure. Even more importantly, obese people often see themselves as failures and feel out of control of their own lives. They suffer ostracism starting in early childhood and are subtly alienated from society. However, statistics show that the ability to lose weight and maintain that loss are dismally low.

Although psychological factors do not play a role in the rise in obesity levels in the last 20 years, they are an important consideration in our understanding of its impact on the individual and in our approaches to treatment.

This chapter will focus on the psychological meanings of food, appetite, and weight, and the underlying motivations that apply to eating disorders. We will address the issue of relapses in weight loss from the perspective of psychoanalytic theory. Since the problems of disordered eating occur predominantly among women, sex differences will also be explored. The aims and methods of various psychodynamic treatment approaches will be discussed. Clearly, genetic, physiological, nutritional, and social considerations are essential to understanding obesity, but for this chapter we will isolate the psychological issues.

Sex Differences and Obesity

History of Sex Differences

At least since the story of Adam and Eve, women have been seen as subordinate to men and as morally inferior. Due to childbearing and child rearing, a woman’s body is seen as her defining characteristic. The mind/body dualism, which is the cornerstone of much of Western philosophy, attributes mind to the male persona and body to the female. As Spelman (1) points out, the attitude toward “body” has deep implications for the attitude toward women. It is the elevation to mind or soul that raises us to heavenly heights and the base body that keeps us tied to lowly pursuits. It is the burden of this historical reality that sets the stage for women to scorn their own bodies and creates fertile ground for the fetish of dieting and the struggle to control the body.

Social Pressure and Sex Differences—stereotyping of Obesity

Americans are besieged by advertisements in the media encouraging them to buy products to enhance their appearances, whether it is the latest weight-loss scheme, creams to delay the signs of aging, or devices that protect against cellulite. Virtually all of these ads are directed at women, the major purchasers of such products, who are not very subtly pressured to improve their supposed imperfections. The sheer numbers of these messages, which assail us on a daily basis, create an overwhelming pressure to conform, if not to body type, then at least to purchasing the products that are marketed to encourage bodily-focused insecurity. The individual defines herself by reflected visual appraisals from the society at large. Women are vulnerable to the obvious stigmatization of obesity and organize their self-concepts around the actual or potential contempt and scorn that they perceive or expect. Whether it is the bustle or the burka, women’s bodies are to be subdued and their lines redrawn.

Feminist Orientation

Feminism is clearly not a theory of mind, but it is an important organizing principle for understanding eating disorders and their proliferation among women in our culture. In psychoanalytic theories of the mind, the psychic life of the individual is extracted from the social milieu for heuristic purposes. In reality, our minds cannot exist outside of the social matrix. When we work analytically, the feminist perspective informs our understanding of the part that social norms play in women’s dilemma about their bodies. It is not just defining woman so exclusively in terms of her body, or constantly exercising the pressure for a certain type of body, but that defining her with such absolute demand also skews her self-perception and the focus of her motivations. In this lopsided emphasis on women’s bodies, there is often a corresponding de-emphasis on the development of other capacities.

From the feminist point of view, society is pervaded by male bias. Personal qualities of autonomy, strength, and self-assertion are highly valued and considered superior and in the realm of the “masculine.” Those of dependency and relationship are devalued and considered “feminine”. “The idealization of the masculine is evidenced in the devaluation of women’s capacity to form relationships, to empathize, and to cooperate with others” (2). These capacities are the very definition of femininity.

The field of therapy itself is perceived as having become more feminized and maternalized as women have become the majority of practitioners and central to revisionist theories stressing early deprivations, traumas, and relational patterns. Thus, a therapeutic focus and understanding of “women’s issues,” including body image and weight, have an increasingly influential place in psychotherapy.

Psychological Development and Gender Differences

From a psychodynamic perspective, child rearing by mothers has many consequences for their offspring. As Chodorow (3) has pointed out, boys and girls have to separate from their mothers in order to gain independence and autonomy as they grow. For the boy child, the father, with whom he becomes identified, supports this differentiation from the mother. The girl’s thrust to independence may be more problematic. Separation from the mother is complicated by the ultimate identification with her and with maternal and feminine goals. As mother is the prime caregiver and nurturer, these functions become embedded in the female child’s identity. Thus, her connection to food and feeding remains a mainstay of her self-perceptions and may imbue food and eating with symbolic meanings that have to do with her very identity as a woman. It is a compelling notion that these differences in developmental struggles lead to the uneven distribution of eating disorders in women. In this society, men are judged by what they can do, women by what they look like. Body image distortion and dysmorphia, concomitants of obesity, are prevalent among women. It is normative in our society for women to have negative perceptions and affects about their bodies. Thus, even those women who meet the criteria for “normal” body weight still are extremely critical of their bodies.

Psychological Understanding of Obesity

Whereas physiology emphasizes the biological workings of the body and the harmful effects of obesity on one’s health, the psychological approach focuses on the role the mind plays in obesity as a symptom of underlying psychic needs or conflicts. Moreover, the therapist understands the patient’s weight problem as having been developed as an attempted solution to a problem that may not be conscious. Thus, what is maladaptive in terms of health might be adaptive in terms of psychological functioning. There are many psychodynamic formulations that address the use of food as an adaptive response to immediate feeling states; lack of attunement in early caregiving, particularly around feeding (4); use of food as a transitional object (a self-soothing object that is imbued with the child’s belief that she has total control over her environment), or competitive strivings with the mother (5). The psychologist’s role is to help the patient understand that this condition, despite all the sanctions against obesity, may be helpful in the maintenance of psychic equilibrium. From this dynamic standpoint although losing weight is still the goal of treatment, its mechanism is achieved through the understanding of the symptoms and their eventual reconsideration. The misuse of food, the act of overeating, and the obesity itself are seen as symbolic of underlying conflicts or deficits. Bringing these conflicts into awareness and creating an understanding of automatic responses to stressful situations is the core of psychodynamic work. From the vantage point of intrapsychic value, the resistance to change is not about set point but about giving up a tried and true adaptation or defense to an emotionally charged early developmental situation.

Theoretical and Treatment Approaches

Treatment of this problem is based on several theoretical conceptualizations. Although there are frequent overlaps in the following formulations, each has a particular focus on etiology and treatment. Whether it is an internal conflict based on sexual and aggressive drives, a problem in relationships, or compensation for a deficit, food, eating, and weight may become symbols of underlying problems. Theories to be considered in this chapter are the contemporary Freudian model, the relational/interpersonal approach, and the self-psychological orientation.

Contemporary Freudian (Intrapsychic) Model

Freud’s theories have been called a biology of the mind, as he viewed mental life and its development as intrapsychic (arising from internal constitutional factors). Thus, mental life is seen as autonomous, resistant to outside influences, self-sustaining, housing one’s unconscious fantasies. Societal demands require that we repress unacceptable expression of sexual and aggressive impulses that have their origins in our early life, while allowing for their discharge via indirect or symbolic means. In later years, these compromised adaptations may be expressed as sublimations that are socially acceptable or in an array of neurotic symptoms, for example, eating to avoid unpleasant affects.

When a patient presents for psychological treatment she might see her obesity as the shameful and painful indication of her failure as a woman. She has incorporated as her own the social bias against obesity. Her goal is to find a way to lose weight. She is frustrated and angry at her inability to diet effectively though she wants nothing more than to be “thin.” She repeats the same behaviors of losing and gaining. Sometimes she is aware of anxiety and discomfort when she has lost some weight.

The psychologist sees her eating as a symptom of a conflict that she may not be fully aware of. The problem is not in the dieting but in the mind of the patient. The therapist is an interested historian, a detective if you will, piecing together the narrative of the patient’s life and trying to locate the source of the conflict. In this approach, the mechanism of the work is the transference (a phenomenon in therapy where the patient projects experiences of early, important relationships onto the therapist). The therapeutic encounter is a safe environment for the displacement of these feelings and associations onto the therapist, who helps the patient to analyze and interpret their meanings. Neutrality (an analytic stance wherein the therapist imputes no approval or disapproval of the thoughts, feelings or actions of the patient and takes no side in their conflicts) is an important tool for the therapist. It fosters an environment where the patient feels it is safe to experience her forbidden wishes. According to this theory, the patient defends against the uncovering of unacceptable wishes that are the source of the conflict and symptoms begin to become understood through resistance (the unconscious sabotaging of both memory and insight). The symptom is a compromise between these unacceptable wishes (as in the rivalrous oedipal fantasies of a child) and the demands of reality (the sublimated form of competition in socially acceptable striving for success).

In the Freudian approach, it is the interpretation that is considered curative. It encourages the recall of memories that bring unconscious wishes and fears into consciousness and thus frees the patient to re-examine from the point of view of an adult rather than a child what appear to be her maladaptive behaviors. For example, a patient who saw herself as her father’s favorite becomes aware that she was undermining her own efforts to lose weight for the childhood fear of losing her mother’s love.

Examples of the Freudian Approach

Neutrality As a Therapeutic Stance

Glucksman describes a case of a patient who has been in treatment for 14 years. She gains and loses weight during the treatment but at the time of the writing of this article, she weighs about the same as she did when she began. The therapist remains neutral about weight gain and loss throughout the treatment. The patient becomes angry with the therapist for not supporting her weight loss and for not assisting her in her efforts, but because his goal is for her to accept herself at any weight, he abstains from involving himself in her weight loss projects. He sees that she has split herself into the unacceptable, unlovable, and hateful “fat self” and the desirable fantasized “thin self” that she wishes to become. This thin self will afford her the realization of her forbidden sexual fantasies. However, whenever she approaches her “ideal weight,” anxiety and fear overtake her attempts to remain “in control” of her eating. A reduction of self-loathing, a pragmatic view of her body image, and an integration of her self-perception, are ultimately more important than praise for that elusive body type.

Increased Weight As a Symptom of Unconscious Conflict (Emily)

Emily came to treatment for depression. She was angry and withholding, yet extremely timid in social situations. She was filled with self-loathing but scarcely articulated this to herself. Although she was quite overweight, she never considered that her eating and weight were connected to her internal conflicts and struggles. Throughout the treatment she complained bitterly about her situation and her helplessness to do anything about it. She was angry with the therapist because she didn’t help her to lose weight. Yet she was a successful banker and extremely competent at her work. She was a mass of contradictions, able to manage million dollar accounts but unable to navigate simple social situations. Rather than confront anyone, she played a zero-sum game, withholding from significant others so that she was spared the humiliation of longing for things that she could not get.

Emily was the third of five children, raised in a very organized and well-run home. It was this quality of her mother’s, taking care of the business of homemaking without attending to the emotional lives of her children, that left Emily feeling empty and alone. She recalls sneaking into the pantry to eat crackers and gulping them down as if in a trance. Her mother never seemed to notice the missing food. Because of her father’s work demands, the family moved frequently, compromising the possibility of forming close friendships. It was interesting that in this milieu the sisters did not rely on one another. Emily experienced herself as an only child. She never counted on her siblings for comfort and understanding. She was a model child who fitted into her organized household perfectly, never defiant, always compliant. Underneath this were raging feelings. Food became for her a symbolic expression of that rage turned inward. It is interesting to note that the foods that most gratified her were “crunchy things I can really sink my teeth into.” On another, more conscious level, food was the soother of sorrow, the possibility of a friend, and the psychic equivalent of a maternal touch.

As treatment progressed, Emily began to explore her “good girl” stance in the family and how this represented an avoidance of aggressive and competitive expressions of her personality. This served to ward off the dangerous possibility of alienating her mother, whose tolerance for disruption within her well- run home was minimal. She developed an understanding of how it saved her from her anxiety about being abandoned and she began to assert herself in many situations that formerly would have driven her to withdraw. Her empathy for herself as a frightened and bewildered child grew and she became more accepting of her body. She joined a gym and started seeing a nutritionist. By the termination of treatment, she had sustained a weight loss of 23 kg for three years. This was not the aim of the work but a consequence of it. Her self-acceptance and appreciation for her “adaptive” responses to a difficult upbringing freed her to make this change. More importantly, this patient was able to make new and meaningful life decisions and to respect her own strivings and needs.

The Relational/Interpersonal Model

The relational model sees the self as striving for relationship throughout the life cycle. This approach focuses on the patient as inherently object-seeking and on her interpersonal world as lived through the analytic encounter. Interpersonal relations, and the corresponding internal world that is largely their product, are shaped from the beginning of life through our caregivers. The degree to which these significant others deprive, constrict, or intrude upon our needs, and our constitutional tolerance for these failures, may not result in developmental arrest as proposed in the deficit model (described below) of Winnicott and Kohut, but will set in motion interactional patterns that will become a template for further developments. These early attachment patterns are maintained for security and they inform more current interpersonal experiences; in this way old configurations are anticipated and fulfilled (6). Althea Horner (7) states: “Eating disorders are disorders of human relationships that have been displaced to the arena of food, appetite and hunger.”

In this approach, it is not the interpretation that cures but the enacted or lived-out therapeutic relationship. An essential part of this process is an enactment (a situation in the therapeutic encounter where the therapist becomes a participant in the patient’s transference without the therapist being aware of it at the time). Through the analysis of these enactments, the patient and therapist become aware of the maladaptive patterns that are expressed through the patient’s symptoms. The therapist uses his or her countertransference (the therapist’s reactions to the patient that are evoked in the therapeutic encounter) as a key complement to inform the work. Whereas the Freudian model requires neutrality from the therapist so that the patient is free to imagine without interference, the relational model allows for judicious self-disclosure that arises as a consequence of the therapist’s countertransference enactments.

Examples of the Relational Approach

Engaging Negative Transference in the Therapeutic Interaction (Samantha)

Samantha, an articulate, attractive, successful photographer, came to treatment because she felt she was sabotaging her efforts to lose weight and find a meaningful relationship. Aged 32, she was considerably overweight and had tried a variety of diets that had been successful, but she could not sustain these weight losses. Frustrated, she had given up dieting for several years and now wanted to see if she could understand what was causing her setbacks. She was psychologically sophisticated and had been in therapy before. It was difficult for her to return to treatment because she would then feel compelled to view her prior efforts as a failure. She was a very aggressive woman and felt she had attained stature in her field by being tough and fearless. She believed that other women who suffer from obesity have low self-esteem but that she, as an aggressive businesswoman, was superior. This sense of superiority, however, was quite fragile because it was based on a defense against feelings of being unlovable.

Samantha believed that the very elements of her personality that led to her success had diminished her femininity and her attractiveness to men. She believed that she had to sacrifice any efforts to focus on “making myself more beautiful” in her pursuit of entrepreneurial success. She was caught in a dilemma between the roles of “passive” femininity and “active” masculinity. Consonant with the superior, competitive side of her self-image, she condescended to her female therapist. She often criticized the therapist in a number of subtle ways (e.g., is the therapist aware that paint is chipping from the walls, the office is too cold, therapist has a run in her stockings?), so as to minimize the status of the therapist and the therapy. In reaction, the therapist became vaguely aware of some discomfort. This scenario repeated itself frequently in the treatment sessions. Samantha then came to a session upset, afraid that she had alienated the therapist. How else could she understand that her previous session had ended 10 minutes earlier than it was supposed to? The therapist then saw that her vague discomfort was related to her patient’s devaluation of her and this enactment brought about a realization that an old and maladaptive relational pattern had been repeated in the treatment: Samantha’s largely unconscious belief that in order to succeed, she must defeat her competitors by belittling and devaluing them. Her momentary victory was over those deemed unimportant and unlovable, feelings about herself she hoped she now projected out. But in the enactment, there was no victory; a significant other reacted by rejecting her. Interpretation of this interaction eventually led to an understanding of the role that overeating played for Samantha: in the same way that she filled herself up in the therapy by being “bigger” than the therapist and inflating her self-esteem, filling herself with food made her feel “bigger and stronger” than others. In this symbolic way, losing pounds would mean “carrying less weight” and “becoming a lightweight.” Seeing the therapist as valuable meant a diminution of her own substance. Samantha’s need to binge as a reflexive, unthinking response to stressful situations began to decrease as she became more aware of the metaphoric meaning of this behavior. It was now less needed because it was understood to be less useful to her.

The Self-Psychological/Deficit Model

The self-psychological perspective formulated originally by Heinz Kohut (8) emphasized developmental deficits and their repair through a treatment method very much in contrast to that of either Freudian conflict or relational theory. Because this theory is based on certain critical needs (especially related to empathy and mirroring) not having been adequately met in early development, Kohut believed that the developing self of the individual, her sense of meaning, creativity and hopefulness, has been damaged. Therapy is therefore a program of regrowth based on empathy and attunement much like a “holding environment” (in which, unlike the relational model, the therapist puts aside countertransference as a tool so as to provide an unvarying supportive posture for the patient). Challenging observations or interpretations by the therapist are held in abeyance and are replaced, in a manner reminiscent of the Rogerian or humanistic psychology model, with the attentive, uncritical support of the patient’s expressions.

Hilde Bruch, who was not a self-psychologist, may have lent support to this view when she theorized: “Paucity or absence of continuing responses to child-initiated clues appeared to be related to the patients’ deficits in self-concept and in hunger awareness.” The task of the therapist, then, is “not to give insight about the symbolic significance of symptoms and behavior” but to aid the patient in the stalled formation of self through the “constructive use of ignorance (a fact finding approach implying that the therapist does not know and can find out only with the patient’s active participation in the inquiry).” In this stance, the therapist is not the interpreter but the listener/reflector and the patient is encouraged to develop a sense of self and overcome the feelings of emptiness or falseness that are prevalent as the presenting problem in these cases.

Kohut’s self-psychology is especially noted for its treatment method. Instead of understanding the child’s fantasies about himself and others as an unrealistic stage to be overcome, Kohut saw this era as one of expansiveness and personal creativity—a healthy exuberance that we lose as we grow older. The problem was how to preserve this robust self-regard (9) into healthy adulthood rather than having it derailed into a form of shame in which the patient must compensate through self-inflation and grandiosity. In order to permit the growth of this interrupted self to start again, the therapist’s task is to create an ideally receptive and approving environment. While in Freudian technique the patient’s transference wishes (such as fantasies in which she should be treated in some especially accommodating fashion) are to be analyzed rather than gratified, in Kohut’s model these are not seen as neurotic infantile wishes but as purely legitimate frustrated needs. Therefore, the therapist’s stance is one of steady empathy, mirroring all of the patient’s desires and fears, not analyzing them but attentively responding to them with an even posture of legitimacy. The patient in this therapy starts out feeling that she is in control and that at least in the world she is creating here, others will dance to her tune. What was thwarted or crushed before will now be recognized and appreciated. This maternal-like atmosphere is designed for minimal frustration and is considered to be conducive to the rebirth of the patient’s stunted development. Unlike a relational/interpersonal or Freudian therapy, where interaction takes place between two adults, the self-psychologist is a neutral outsider, an expert observer and facilitator applying a technique that will transmute the internal world of the patient.

In understanding the therapeutic action of self-psychology, it is important to understand that it is a theory of developmental arrest. Self-psychology has raised the self to the status of a psychic structure fully equivalent, for example, to the tripartite structures in Freudian theory. Faulty, non-responsive parenting is thought to bring development of the self to a halt so that one finds, in certain kinds of pathology, an adult functioning with only the self of a child. The treatment model of self-psychology can be thought of as analogous to a kind of re-parenting in which, through mirroring and meeting the narcissistic needs of the patient, the therapist is a better parent in the here-and-now than the patient’s actual parent was in the past. This therapeutic behavior, defined by self-psychologists as empathic attunement, is thought to jump-start development of the self, so that maturation can proceed and the self can “catch up” to where it is supposed to be (10). Recently, there has been renewed interest in trauma as a cause of eating disorders. Trauma is seen as another explanation for deficits. The theory is that the therapist and patient can uncover historical events that have been lost through dissociation (an alternate state of consciousness which one can be fleetingly aware of, but without concomitant affects). These events were emotionally traumatic in nature and could not be registered directly when they were experienced. Thus they result in symptoms that seek to allay or deflect overwhelming feelings. Often one can see the use of food and alcohol as numbing agents in these cases. As it appears that the patient cannot tolerate interpretations, the self-psychological approach may be thought to be the preferred way to begin the treatment.

Case Examples of the Self-Psychological Approach

Restoring the Patient’s Sense of Self (Claire)

Claire came to treatment for depression. At 33 she was a dynamic, high-energy woman who underneath her bravado experienced herself as empty and hurt. She was obsessed with her weight and her eating: it was an issue that permeated her sense of self. This obsession appeared to be symbolic of her hunger for attachments she could experience as dependable. She used the therapy to talk about what she ate, why she had lost control of what she ate, and why she binged. She could not see what the therapist perceived: that she was beautiful, well-proportioned, and full of sparkle.

Claire was artistically talented as a performance artist, painter, musician, and playwright. Her mother was a professor; her father was as businessman. These two successful parents saw Claire’s talents as a badge of honor, another marker of their success. Her mother delighted in Claire’s artistic talent and this had led her into a career as a performance artist. This desire to be delightful to others became an essential part of Claire’s personality. Her identity developed on the basis of what her parents approved of. Aspects of her developing autonomy were subtly neglected; for example, her intelligence and evolving sexual identity were not acknowledged. Thus she treated herself as her parents had treated her, always seeking the limelight and seeing the world in terms of how it would satisfy her needs. Claire became an example of a personality overly reliant on reflected appraisals. In exchange for her reduced autonomy she became her parents’ “golden child.” In this favored status, she developed feelings of entitlement, but also a need to be extroverted. Clearly, these adaptations were her way of maintaining psychic balance because if she were to step out of the limelight, she would not feel loved.

In therapy, she blamed the therapist when things went wrong and never seemed interested in the therapist as a person. The therapist was there to serve her. Food was there to fulfill her sense of self by metaphoric approval. The therapist saw her as a narcissistically injured woman fighting the awareness that her parents saw her as an achievement rather than as a person. It was through empathic mirroring and attunement that she began to see herself as a more fully realized person. The affirming responses of the therapist gave Claire the opportunity to see herself in new and independent ways. Unconditional acceptance of all aspects of her inner states helped Claire to realize a self that felt more authentically her own. She lost a small amount of weight but was able to give up her obsession with eating and become more engaged in her relationships and her art.

Mirroring As a Conduit to Self-Awareness (Marie)

At the age of 32, Marie came to therapy in a state of upheaval. She had been deeply disappointed for not having gotten a promotion at work that she fully expected would be hers. An only child, she lived with her parents and her grandmother. Her mother saw Marie as an extension of herself and needed her daughter to minister to her own infantile needs. She never acknowledged Marie’s internal life and required her daughter to help maintain her own psychic equilibrium. Thus when Marie came to therapy it was with only a rudimentary sense of self. She lived in a negative dependence with her mother, unable to experience a self-directed identity or new interpersonal relationships. An early goal in this treatment was to help her gain the ability to be an independent person, have her own living arrangement and explore deeper relationships outside the home. The deeper goal was to help her identify her separate self. Much of therapy revolved around defining, validating, and building a self that was positively valued. Traditional interpretations, such as ones exploring competitive feelings toward her mother, would be extremely wounding to her. Anything other than mirroring was seen as criticism. In this context, the therapist began the work of helping her listen to herself.

What role does a person’s body play in the construction of a self? In Marie’s case, she began treatment with apparently no sense of body. The awareness and acceptance of her body in any form would be an important element in her growth. In fact, as the therapy progressed, she came to view her body as a positive aspect of her self. Although she actually gained weight during the treatment, it did not make her feel deficient. More importantly, it was her body and she would take good care of it. She had lived outside the social expectation of thinness for women and this had helped immunize her from these pressures. However, given her history in the long and arduous building of a self, her apparent ignorance about social expectations in relation to her body was a benefit. This was one more hurdle she would not have to overcome because in learning to accept herself, she learned to embrace her body as well. In this case, grappling with obesity became learning to accept it.

Conclusion

Eating, weight, and body perception have become central to a wide variety of psychological complaints and conditions. Frequently, these are a means of deflecting psychological conflicts to the body. The problem seems apparent and what needs to be addressed seems therefore obvious. Is this manifest symptom going to be the primary focus of our attention? Rarely in psychotherapy does any presenting problem emerge as the exclusive direction of the work.

Obesity is particularly resistant to any form of intervention. Where, then, does the therapist, whatever her approach, find access to a psychological process so as to reach unconscious conflict, old relational patterns, developmental deficits, or dissociated trauma? As our clinical examples demonstrate, engagement of patients’ unconscious process (i.e., underlying conflicts) is facilitated through the appropriate use of interpretations, the therapeutic relationship, empathic technique, and other means. Use of these various approaches is based on the developmental needs of the patient. These considerations will shape the form of the therapy.

In whatever method described above, commonalities appear in the psychological approach to the patient presenting with obesity. The primary tool is the patient’s relived experience in the transference. How this experience is interpreted or worked with in the treatment may vary, but its transformative power is the bedrock of all forms of psychotherapy. How the patient relates to the evolving significance of the other, represented by the therapist, is the beginning of—and will increasingly become—the psychological traction between the two. This will be the playing field (Freud called it the “playground”) in which change will become possible. Only under the worst of circumstances will the therapist, for example, become the agent of a society that disapproves of the patient’s appearance and her lack of willpower. In the best of circumstances the therapist becomes the agent of self-acceptance by the patient. The patient may believe she came into treatment to solve her obesity or her body image and this may remain the objective that is the central issue in the therapy, or the patient’s objectives may broaden as she gains insight into the underlying nature of the problem, and this may legitimately vary on a case-by-case basis.

Clearly, solutions to the problem of obesity and weight loss have proven to be elusive. From a psychodynamic standpoint, it is only a symptom, the starting point if you will, of a psychological inquiry. The goal of sustained weight loss from this perspective is at best tenuous and secondary to the goal of self-understanding and acceptance. We do believe, however, that the achievement of self-acceptance has many benefits: a greater sense of agency and a decrease in social anxiety and in the pressure to conform.