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.
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.
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.
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