Substance -Related Disorders Additional Readings: Read Sims’s pgs 49-50; 105; 136; 374-376.
2. Read Fernandez’s A big Fat Slob and To be a Man pgs, 160-162.
http://ncadi.samhsa.gov/Links to an external site. http://www.well.com/user/woa/Links to an external site. http://www.addictionrecov.org/index2.htmLinks to an external site.
Class Participation
A Big Fat Slob
Issues with weight and eating have become a significant problem in the US and many other industrialized nations. A combination of easy accessibility of high caloric food and limited physical activity in the context of a high stress society has produced this so called “epidemic” of overweight individuals. I have found in years as practicing clinician that many overweight and obese individuals end up with secondary depression, sleep difficulties and a host of other health-related ailments.
I once treated such a patient. She was a very pleasant, young-looking African-American woman in her thirties. She had been referred to me by her Psychiatrist to help her with therapy for her depression. In the course of our sessions, she once told me: “I can’t feel good about myself; I am just this big, fat slob”. I looked at her and said “I’m not sure I understand what you mean”. She looked puzzled (I always wonder if patients when they hear my accent may think I actually do not understand them!). She said “Just look at me, I am hopeless”. I asked her, “Tell me how many pounds overweight you think you are? She proceeded to tell me she was so many pounds over her “idea” body weight, etc.
I told her, “OK, do you see differences between saying for instance you are 50 pounds overweight and saying you are a big fat slob”? Once again, she seemed puzzled and wondering where I was going with this, and said she thought there was a difference, but could not say for sure what it was. This was my opportunity to explain to her in a respectful but jovial manner that when we talk about “the fifty pounds” we can actually do something about it; we could get in a diet to lose weight, we could start running Marathons, or we could suck it out, liposuction it, etc., however, what can we do about a big fat slob? This simple perspective was helpful to her, at least as far as not continuing to blame herself for her “fatness and laziness” and actually helped her start a plan to lose weight, which as far as I remember, was moderately successful. She had other related medical conditions, which required medical supervision and by the time we were terminating our sessions, she had made a decision to do bariatric surgery.
Her depression, on the other hand, began to lift and she became much more hopeful and active in her life, and this was primarily the result of a change in her relationship to herself and her body-image.
In many cases of eating-related disorders, there is a compulsive, almost addictive quality about it, not very dissimilar to the addictions that occur with substances or gambling. A person may actually use food both as an escape as well as a relief from tension and anxiety.
There is a temporary reprieve from the anxiety of the moment, which is then followed by intense self-recriminations for their inability to control themselves or look “too fat”. Unlike more “traditional addictions”, food is something we can’t just stop using or avoid, so in a sense, the patient has to totally work-out a new relationship to food, eating, and body image.
Most of these cases however, are not easy ones since the self-image driven by the patient’s own attributions of her worth (based on her weight) is at times, unshakable, and it is constantly being reinforced by the failure to lose weight. Their “self-world” which Heidegger termed the Eigen-welt begins to color the patients experience. This has been my experience working with traditional eating disorder patients such as those diagnosed anorexics or bulimics who typically have confronted this dilemma.
The Therapist needs to be compassionate and aware that to lose weight, the patient has to make significant and life altering changes which feel daunting at times. With this in mind, it is important to understand that an existential exploration of the patient’s feelings, thoughts and life-orientation is primordial. Finally, the undeclared ( or unconscious) motivations to maintain the weight should not be ruled out or ignored.
The patient may have a hidden reason to be fat; from generating self/other pity to have a ready excuse to avoid hard choices, to fear of being attractive. Whoever has done long-term therapy with these patients know that those issues are sometimes present in the patient and unless they are addressed, even when the patient may lose weight, the problem is never resolved.
Finally, another important factor in these cases is the common finding that the person’s will is dominated by a substance and/or behavior and that he or she either avoids acknowledging this dependence ( the common denial effect) or if admitted, a projection of the problem in sources beyond their control: genes, childhood, society, stress, and many others. Like with almost every other human problem, the place to start begins with our acceptance of our problem and our responsibility towards changing it in our lives.
