Unpacking Yalom’s “Fat Lady”: Anti-Fat Bias in Counselling Practice

Let’s talk about Irvin Yalom’s “Fat Lady” chapter from Love’s Executioner. I was given this chapter to read as “homework” during my first year of counselling training. Well… I wasn’t expecting it to pack such a punch.

The way Yalom talked about his client, Betty, was shocking; “I have always been repelled by fat women. I find them disgusting.”

His evocative words to describe her seemed purposely cruel, clearly chosen to make the reader uncomfortable. As a writer, I partly admired being able to evoke such strong reactions, and I’ll admit I read the whole thing captivated but astounded. I went back to my course the following week itching to talk about it, but there wasn’t space or time for discussion. So I bought it up in “open group” (like PD group) and shared my concerns about reading the “Fat Lady” chapter without any time for critical reflection. Most people said they were just blown away by Yalom’s honesty, and that was it.
​
Back then I didn’t have the knowledge, language or confidence to challenge this further, but I certainly do now! For context, I work in private practice, predominantly with people with disordered eating and body image problems, and I work with many clients who have experienced weight stigma and anti-fat biases. I train counsellors on these topics and have read and written about this extensively. It’s safe to say this blog has been a long time in the making and I hope it’s a helpful deep dive.

Irvin Yalom. Image: Wikimedia Commons

​When discussing the “Fat Lady” chapter, I feel it’s important to think about how Yalom is viewed in the counselling world. My experience of how people talk about him is one of being guru-like, put on a huge pedestal and often praised for his raw honesty. In some of his other books, I’ve appreciated this too, though I’m always acutely aware of the privilege and entitlement of his perspective and how he writes. He holds a position of real power, not only in his counselling practice but in the whole therapy world. But the allure of his honesty, and trust in his words, means we may miss important opportunities for critique and reflection. The Fat Lady chapter is still great reading for counsellors and trainees, but only with follow-up discussions with a focus on anti-fat bias.

In the Fat Lady chapter, Yalom describes feeling bored and irritated by Betty, by her trying to “entertain” him and avoiding what he considers real depth. In my view, the therapy here seems all on his terms; she is stressed at work and that’s what she needs to talk about at that time. I would anticipate that she is keeping herself safe, talking about topics she feels more comfortable with until she feels she can trust him. Betty likely felt the power imbalance and was trying to impress and entertain him. As larger people we are often socialised to please others - to be the jolly, funny, fat friend - to “make up for” the way we look and to be accepted. Fat people (and I use the word “fat” as a reclamation and as a neutral descriptor like tall/short) face weight stigma and anti-fat bias sometimes on a daily basis, so trying to be “nice” is a common learnt behaviour to keep safe and to attempt to be liked/fit in.

I often work with clients who say they feel more comfortable with a fat counsellor as I “get it”. It means they don’t have to try and explain the daily difficulties of living as a fat person – the anxiety of seeing a medical professional, having everything blamed on your weight, literally not fitting in spaces (planes, booths, chairs with arms) – or being able to fit but in discomfort – as well as the assumptions, judgements, unsolicited advice and more from people. Everybody thinks they’re entitled to have opinions about fat bodies. Assumptions are made looking at larger bodies – “if they just did this/didn’t eat that” etc. Fat people are blamed for “letting themselves go”, and working-class fat people especially get the brunt of the “lazy” fat person stereotype, and are blamed for the problems in the NHS (in the UK). It’s all exhausting for fat people.

​People in smaller bodies can be impacted terribly by body shaming and weight stigma too of course, but the barriers and biases fat people deal with are systemic, meaning moving through the world is just harder as it’s not built for us. And no, we can’t just “eat less and move more” to fix that (another harmful assumption); weight is way more complex than that. Weight-related experiences in life, especially in childhood, are traumatic. So much of my work in my counselling practice is around helping people heal from weight stigma, anti-fat biases, bullying, trauma and abuse.

In the Fat Lady chapter, I’m surprised Betty doesn’t leave therapy to begin with. What reason does she have to trust this man? I would think this may be her need to please, but also this was just her norm – surrounded by anti-fat bias. She likely hadn’t experienced any safe places with people who didn’t judge her for her size. In my practice, I’ve sometimes been the only person in my clients’ lives that don't expect them to lose weight. Often clients have well-meaning family and friends who feel they’re “helping” by encouraging them to lose weight, but all this does is exacerbate disordered eating and worsen their mental health. 

Yalom mentions the therapeutic process and transference yet doesn’t seem to explore this further. It would have been interesting to hear more about his supervision during this time, and for him to explore his feelings about “controlling fat women” and his relationship with his mother (which he only mentions briefly near the start). Although Yalom recognises this as counter-transference, he doesn’t explore or challenge this. His naming and honesty are seemingly enough. What if this were about racism and he voiced racist thoughts, with no further action to work on white privilege or anti-racism? Yalom starts the story with anti-fat views and this does not change throughout the story, in fact his views are validated as Betty starts to lose weight.

Betty’s mood improves and she starts doing more exercise but she also goes on an extreme diet, which Yalom is delighted about and praises her each week. It is highly unethical and harmful to collude with a client in this way, especially one that has an eating disorder (binge eating disorder would not have been a formal diagnosis back then but it says later in the story she was admitted to eating disorder treatment so that was recognised in some way). Yalom’s praise – from the perspective of a man in a position of power – reinforces the idea that Betty needs to be thinner to be lovable. Eating disorders are never helped by dieting and further restriction, this will only create more disordered eating and compound the idea that fat is bad. Binge eating is often connected to restrictive eating, creating a binge cycle – I’ve written about this in detail here.

The chapter then punctuates the success points of Betty’s therapy through a countdown of her weight. Helping clients lose weight is not our domain as counsellors, and colluding with weight loss ideals only serves to undermine the work, keeping the focus on surface-level appearance ideals for self-worth rather than the deeper acceptance that is required. Yalom praises Betty and warms to her, and she likely starts to finally feel accepted, but this is conditional on weight loss. For Betty, she likely faced this conditional love and these interjected values her whole life. What she needed from a therapist is true unconditional positive regard and acceptance, and for this the therapist needs to have worked on their own perspectives and biases around body size and fatness. Most people who lose weight will gain it back – what happens to Betty then? For many people, this is how weight cycling starts, yo-yo dieting and weight going up and down. The emotions that come with this are shame and failure, over and over again. Yalom reinforces that Betty is only lovable when her body is getting smaller. She laps up this praise from him, likely also due to the transference in which he resembles her father.

In the end, Yalom says he has learnt a lot from seeing Betty, though this seems only demonstrated by him being willing to touch her. Betty knew he was repulsed by her – she sadly is used to people treating her this way – and to have Yalom hug her at the end likely felt positive for both. However, his arms reaching around her resembles her finally fitting in the space – fitting his space and his needs. She has finally pleased her father/him, the male gaze, and a society that told her she was repulsive. Any acceptance, healing and self-worth based on this is only temporary and superficial – based on her having doubled down on her disordered eating and found a way to get thin. This is again all on his terms; she had to change herself to fit a powerful man’s standard. Diet culture mirrors this on a wider scale, a powerful force demanding we reach beauty standards to be respected, valued and loved.

“When we embraced, I was surprised to find that I could get my arms all the way around her.”

This is the final line of the chapter. I wonder what Yalom’s intention was for the reader to take away from this? There certainly isn’t any obvious learning about how to deal with anti-fat bias, being as he doesn’t deal with his (though this in itself can be used as a springboard for this kind of discussion). My perspective is one of being a fat person and somebody who has learnt a lot about weight stigma and eating disorders, so that’s my personal lens. I was concerned that for some people, there might be an idea that when fat people have therapy the “successful” outcome is weight loss. This also links to other ideas popularised by Susie Orbach’s book “Fat is a Feminist Issue” – that fat women are traumatised and that therapy will help heal the trauma so the fat (supposedly there for protection) can then melt away. This is absolutely not the case – as fatness has a strong genetic component, many people are just fat. Some people just can’t be thin, and trying to be thin will only cause a lot of distress in their lives. If somebody struggling with binge eating resolves some underlying issues, their relationship with food may improve, but this doesn’t necessarily result in weight loss. If there is weight loss, that’s a side effect. Weight loss does not mean an improvement in physical or mental health.

Yalom purposely chose to tell this story in this way, for other therapists to read. He could have explored his feelings and anti-fat biases, his internal processes and relation on his relationship with these so-called “fat controlling women in his life” – but he didn’t. He could have written about this story without it being about weight, instead just focussing on Betty’s relationship with her father and their relationship, the therapeutic process and transference. But he didn’t. He chose to centre himself and his views (biases), and presented a weight loss success story, with him being the hero who saves the Fat Lady from her fatness.

Fat people don’t need fixing or saving. It’s not our jobs as counsellors to help people lose weight, and we need to be careful not to collude or cause further harm to those with body image or eating-related issues. Eating disorders can often go unnoticed, particularly for those in larger bodies, so having an understanding of weight biases, body image and disordered eating is crucial for counsellors. We have all grown up in a world of diet culture and the idealisation of thinness so we ALL have anti-fat biases. That’s not our fault but we do have a responsibility and an opportunity to reflect and challenge our biases on this in the same way that we would other forms of “diversity”, such as race and sexuality.

Further reading and recommendations:

• Therapy Today article - "Counsellors aren't Immune to Fatphobia" (accessible here)
• Workshops on disordered eating, body image and weight stigma
• Aubrey Gordon – books, podcast “Maintenance Phase” and documentary on BBC iPlayer called Your Fat Friend.
• I also have a resources page with further recommendations here.

 
I am a counsellor in private practice and offer online sessions, find out more here.