Therapeutic alliance is often highlighted in studies looking at treatment effectiveness, both in and beyond the realm of eating disorder therapy. Evidently, there are a number of factors that can impact how well we get along with our therapists, ranging from disagreements with the course of treatment or type of therapy to a simple, unnamable dislike for the person. But what about their appearance? What kind of impact could a therapist’s body size have on the therapy relationship?
Rance, Clarke & Moller (2014) sought out to investigate this issue, looking specifically at how clients evaluate therapists’ body size and speculate on their relationship with food, with an eye to determine what impact this might have on the therapeutic process.
I was immediately drawn to this study when I was browsing the latest literature; I wondered why this hadn’t been studied before. In some ways it seems obvious; we’re bound to compare ourselves with others, social beings that we are. So when looking at the therapeutic alliance, it would be illogical to assume that physical appearance could be left out of the picture.
The authors took a qualitative approach, conducting interviews with 11 women who considered themselves “recovered” or “on the road to recovery” and conducting thematic analysis (Braun & Clarke, 2006) on these interviews. The participants ranged in age from 18 to 50 (mean age 31.5 years) and had all received therapy from a female therapist at some point during their eating disorder (either AN or BN). There was quite a wide variation in duration of illness- between 2 and 28 years (mean 13.3 years).
The authors do not specify race/ethnicity, but all were from the UK. In their limitations section the authors suggest that future studies might examine the experiences of non-heterosexual women, so it would seem that all participants were heterosexual, as well.
SUMMARY OF MAIN RESULTS
Participants discussed their experiences of working with female therapists, but also other health professionals, including dieticians. Overall, the findings suggest that individuals with eating disorders, as expected, observe their therapists’ bodies and speculate on their relationships with food based on these observations. Assumptions made about therapists’ bodies also impacted participants’ orientation toward seeking and engaging with therapy and recovery.
Three main themes emerged during analysis:
1. “Wearing eating disorder glasses”
Participants noted feeling “primed” to notice others’ bodies, including their therapists’. The “tendency to compare” was described as both obvious and innate, and at times linked to specific areas of the body, such as the stomach. One participant noted:
If I see somebody… therapist or anything, I’ll immediately sort of scope them out
2. “You’re making all sorts of assumptions as a client”
Based on their observations, the authors noted that participants were also prone to making assumptions about their therapists on the basis on their body shape and size. Drawing on ideas about size circulating in society about bodies (e.g. seeing fatness as “loss of control” and thinness as positive), clients oriented toward therapists’ bodies based on these assumptions.
Participants also extrapolated about therapists’ relationships with food on the basis of their bodily appearance. Thoughts about therapists’ bodies informed participants’ confidence in the therapist’s ability to help. For example, “healthy-looking” therapists were seen as more able to help, as they were seen as more able to instill similar values around weight, shape, and food in clients.
Participants were aware of the assumptions they were making, saying, for example:
You’re making all sorts of assumptions as a client about what’s going on in terms of a-any-thing that’s physically obvious [about your therapist].
Neither “thin therapists” nor “fat therapists” were perceived to be as helpful as “healthy-looking” therapists; the authors suggest that participants may look down on “fat therapists” (i.e. see them as unable to relate to their struggles) or perceive “thin therapists” to not be able to understand eating disordered behaviours to be linked to anything other than the desire to be thin.
3. “Appearance matters”
This final theme highlighted how clients may resist therapy from therapists they perceived to be too fat or too thin. With respect to thin therapists, participants perceived a double standard when these therapists asked them to gain weight or eat more while the therapist was “allowed” to stay thin.
On the other hand, therapists clients saw as too fat were not seen as trustworthy, as participants worried these therapists would let them lose control. For example, one participant said they believed their therapist had “lost control so they’re not gonna tell me when it’s . . . time to stop putting on weight.”
“Healthy looking” therapists, contrarily, were taken seriously when advancing advice to “eat normally,” and their disclosures of engaging in “risky food behaviours” may have helped clients to feel better about doing the same:
Not about learning from somebody else but you want to be able to take on a bit of what they have . . . or instill a kind of sense of trust and a normal, a sense of normality about food and eating.
LIMITATIONS
As noted above, the sample was quite varied, particularly in age and duration of illness. In a small qualitative study like this, it would likely be easier to draw conclusions about themes in a more homogenous group. At the same time, the conclusions are not generalizable to men, non-heterosexual, and more racially/ethnically/culturally diverse individuals, as the authors acknowledge.
Another interesting point (noted by the authors) is that some of the participants had not actually worked with therapists who would “objectively” be called “fat” (though who decides such things, I’m not quite sure). So, some were projecting how they might feel in this situation; this is a relatively large limitation, so I’m glad the authors acknowledge it, as it certainly influences what conclusions we can draw from the results. It could be that participants assumed that they would feel negatively toward therapists with larger bodies.
IMPLICATIONS
As the authors indicate, these results hold implications for clinical practice. They argue that therapists might reflect on the impact of their bodies on therapeutic alliance. However, I am not sure how much clinicians can really do with this knowledge.
Of course it is a good thing to be aware of one’s presence and the two-way influence in therapy. Therapists influence patients and patients influence therapists, and there are all sorts of dynamics, explicit and implicit, that can impact these relationships. However, at the end of the day, there is little that a therapist can do to:
a) Stop patients from making assumptions about therapists’ food behaviours and ability to treat based on their body size and/or
b) Change their body size to better meet patients needs
This second point is especially important; the thing that I most hope no one takes from this article is that therapists should in any way work to alter their bodies to change the therapeutic relationships. Obviously, diverse bodies are healthy, regardless of which bodies patients perceive to be healthy and thus most able to help them.
This is going to sound trite but therapists are people too, and regardless of what external readings of their bodies exist, we really can’t know what their relationships with food are just by looking at them. Which is not at all what I think the authors were implying, but an important point for this post, to make my own perspective clear.
References
Rance, N.M., Clarke, V., & Moller, N.P. (2014). “If I See Somebody … I’ll Immediately Scope Them Out”: Anorexia Nervosa Clients’ Perceptions of Their Therapists’ Body. Eating Disorders, 22 (2), 111-20 PMID: 24555509
this is super important and kinda shitty! this was a major issue with all of my therapists and many times we (patients) spent time talking to each other about our therapists weight/size and feeling uncomfortable with their advice because of it.
not much to do about it but was an added stress.
Absolutely both important and unfortunate- I’m happy that this study exists and would like to see more work in this vein, because I think this is such a reality and needs to be acknowledged. Of course, as you say, there doesn’t seem to be much to be done about it. I’m wondering, though, whether ultimately work with therapists of various sizes might help to counter some of the established and internalized ideas of what types of bodies are “healthy”? Maybe not right away in treatment but later on? An ill-formed idea at this point but it got me thinking about whether this information could help to go against the grain a little bit in terms of associations between body size and health.
i just discovered this blog today – absolutely loving it. It’s nice to see the science side of EDs in addition to recovery blogs of anecdotal nature.
In any event, I have my therapist who I would consider healthy size, and a nutritionist who is quite thin. My primary doctor is even smaller – she is built very tiny! However all three, regardless of their shape, give me the same advice so perhaps having a treatment team of varying sizes does make a difference when it comes to body judgement. I will say that I tend to second guess my nutritionist more based on her size, for example, when she tells me I don’t eat enough and claims she eats more than I used to or still do, I have a hard time believing it. This is somewhat troubling to me even more so because I was diagnosed with EDNOS and never “looked like” I had an eating disorder, so I know appearance does not tell the whole story.
Again, thanks for this important blog and dissecting the “hard stuff”!
I have found myself doing this with nearly all female members of my various treatment teams over the years. The nurses, therapists, dietitians and doctors I had the most positive therapeutic relationships with tended to be the ones I perceived to be ‘normal’ and healthy. This wasn’t the only reason I found them helpful as their were definitely some healthy sized with as normal eating habits as I could infer that I certainly didn’t find supportive but it played a part in how much I trusted advice even though I knew better than to think size should be important! I had problems with one dietitian who I just couldn’t bring myself to believe as she was very overweight herself.
I now choose to have male therapists so this doesn’t seem to be a problem and I have always managed better with male psychiatrists as well.
It is important for treatment teams to be aware of this but obviously they shouldn’t be embarking on weight management for their job (unless indeed they do have an eating disorder themselves in which case it is important they seek treatment)
I think the trust thing is an important element here. Particularly when being asked to do something so counter-cultural (i.e. gaining weight and eating more in a society so focused on the opposite) its so important to trust health care practitioners, but hard to do. So it’s easier to believe and trust in those who seem to actually be practicing what they preach, so to speak. I think that the whole premise behind the study speaks to some of the inferences we make about what people do and don’t do, health wise (including eating and exercise practices) based on their body size. I think the implications extend beyond the clinical encounter. That said, I’d love to see a larger and perhaps comparative study of this nature.
Very interesting that you’ve since chosen male therapists to avoid the issue!
Interesting to read, since this true according to my daughter’s treatment. While in the hospital, she never complained about the dietitian, nurses or therapists. However, now as an outpatient at a different hospital, she has a very “petite” therapist and a dietitian who many would describe as overweight. Numerous times she has mentioned how she “doesn’t trust” the dietitian due to her size and always questions whether or not the therapist has, or had, an ED.
I’m sorry to hear that evaluations of clinicians’ bodies has made things harder for your daughter. I wish that there were some practical advice I could give based on the article’s conclusions; at this point, however, there doesn’t seem to be much to be done about it. Still, I think it is encouraging that this kind of research is being done, as it will hopefully help to increase general awareness about the various factors that can come into play in building therapeutic alliance, including (but not limited to) healthcare providers’ bodies.
I think there IS something that therapists can do about this. They can be willing to talk about their own bodies and food practices in the therapeutic relationship. Given how much a client’s body and food practices are at the center of the work being done, having a therapist that’s willing to appropriately talk about those topics herself can help make the relationship feel more collaborative and equal. I previously had an e.d. therapist who was quite big, and it made me extremely uncomfortable at first. But as i learned more about her behaviors and learned that they were healthy – and learned that she knew what it was like to struggle with body image – I was more able to open up to her. However, I think I would have more of a problem with that if I saw a dietitian who was seriously overweight. I also think it would be hard for me to deal with seeing either a therapist or a dietitian who was veryy thin.
Very good point, thanks for this. I also totally agree about the need to attend to the potential issues of working with either “fat” OR “thin” therapists- either can be “read” as problematic, by patients. So certainly, it would be important for the therapist to be willing to go there with patients and talk about their embodied self.
I had one therapist for a short time that seeing her bothered me…She was so thin. She looked like she could be a patient there at the ED inpatient center….and I know it wasn’t just me, my Grandma saw her and said she thought the same thing! That’s another thing that bothers me is therapists who have “Recovered” or “used to” have an ED. I always have to side eye them (especially that therapist) in wondering if they were “really” recovered. I think at a many of these places though and non-evidence based treatments that focus on body image or just gaining to a certain weight then maintaining, has this weird…Delusion of being recovered…Not sure how to explain it…It makes me hold my breath then I think about this “recovered” state of being. So, I don’t think a “fat” therapist would actually bother me as much as a thin one- or a thin supposedly recovered one. All along the board though if they say something stupid or “triggering” regarding nutrition though, that bothers me a lot. People have biases and what they think about said subjects though, so it seems a bit tricky to find the “right” person.
I could definitely see how having a therapist that one perceives to be too thin could also be problematic. I think no matter which “direction” the appearance goes (i.e. “too fat” or “too thin”) there can be problematic comparisons or speculation. However, I think what this draws to our attention is the idea that we really can’t know what someone eats or doesn’t eat just based on their body size. I could see, too, how having a recovered therapist could cause problems in some cases- anecdotally, though, I’ve heard people either be very into or very opposed to the idea of working with a recovered therapist. I think it’s likely a personal opinion thing. Everyone seems to define recovery differently and to have different opinions about working in the field with lived experience. Personally, I think that therapists who have recovered might have insight that those who have not experienced eating disorders do not have. I’m probably biased, though, because I research eating disorders having recovered myself and I find this to be helpful, generally, in building understanding of eating disorders and driving the passion behind my research. That said, however, I think there is a time and place for disclosure, and I think that therapists should ultimately have the client’s best interests at heart and be conscious of the fact that though they may have lived experience, that does not necessarily mean they 100% understand what a client is going through. I certainly agree that it is difficult to find the “right” person; this seems to be an ongoing negotiation that client and therapist both need to actively work on.