Journal of Religion and Health, Vol. 18, No. 2, 1979
T o w a r d an U n d e r s t a n d i n g of the O b e s e P e r s o n R O B E R T E. H O C K L E Y A B S T R A C T : Attitudes, feelings, and family backgrounds of seven very obese women were studied by m e a n s of a religious history questionnaire. Some comments are made about this research tool. Three very prominent characteristics of these women were feelings of helplessness and powerlessness, a craving for love, and strong guilt feelings. A possible psychogenic factor in morbid obesity was observed in the backgrounds of five women; pertinent information on the other two was lacking. This factor is a dual dynamic of h a r s h n e s s and indulgence. The onset of obesity seemed to occur when indulgence became the dominating influence over harshness.
Introduction A n n is 22 y e a r s old and u n m a r r i e d . She lives at h o m e w i t h h e r parents, h e r 19-year-old sister, and 12-year-old brother. A l t h o u g h v e r y i n t e r e s t e d in astrology, c o m m u n i t y service, and politics, she seldom v e n t u r e s out of the house. H e r problem is massive obesity. She has been o v e r w e i g h t from e a r l y childhood, h e r r e c e n t w e i g h t being 118 kg. (260 lbs.). M u c h of h e r t i m e h a s been spent ruminating about marriage. IfI had a man that could love me, things would be a lot b e t t e r . . , the kind of man I want couldn't want me--he wouldn't climb professionally if he had a heavy woman . . . . I know I can't have him until I lose w e i g h t . . , if I had someone who would give me security, love and companionship.., you know it is hard to stick at home and diet, and think about these things all the time . . . . I eat and it takes my mind off these things . . . . I am just longing to have a satisfactory relationship, but I am afraid I'll be rejected.., he wouldn't be the kind of man that would appeal to me if he loved a fat w o m a n . . , believe me, I think of this all the time. 23 A n n h a s a t t e m p t e d to deal w i t h h e r obesity and its r e l a t e d problems in s e v e r a l ways. She has t r i e d in v a i n to diet. She says, "My favorite hobby is to e a t . . , w h e n I was on a diet, I was m i s e r a b l e . . , sure I love to eat, m y m o t h e r was a good cook." A f t e r c o n s u l t i n g m a n y p h y s i c i a n s and psychiatrists, she sought f u r t h e r help from a p h y s i c i a n who practiced h y p n o t h e r a p y . She accepted his i n t e r p r e t a t i o n of w h y she ate, t h o u g h w i t h some difficulty: "It upsets m e to t h i n k about it . . . . I stopped the sessions to t h i n k . . . . I a m afraid of m e n - - t h i s is t h e simple r e a s o n for m y s i z e . . , subconsciously I ate to get fat so Robert E. Hockley, B.E., B.D., Th.Schol., Th.M., is the Anglican Chaplain and Clinical Supervisor of Clergy Training, Kenmore Hospital, New South Wales, Australia. 0022-4197/79/0400-0120500.95
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no man would want me for sex or marriage." The early onset of her obesity makes this interpretation highly suspect. Nevertheless, in the course of the hypnotherapy, she recalled, ~I was told to look in a mirror and imagine myself as I wanted to be--small and beautiful." Although this image did not seem to help her in any tangible way at the time, she has now found another way of achieving this objective. Ann is one of seven female patients whom I interviewed in depth, using a religious history questionnaire, at the Medical College of Virginia. All of these women had suffered from what is variously described as massive, or morbid, or super-obesity. They had also qualified for the intestinal (ileojejunal) bypass surgery at MCV. They were required: 1) to be under 50 years of age; 2) to have tried every major dietary program, including the rice diet at Duke University; 3) to have no other health problems; 4) to be at least 45 kg. overweight; and 5) to have exogenous obesity. Three (Betty, Donna, Gail) were recovering from surgery and anticipating discharge. The other four patients had returned for a liver biopsy six or twelve months subsequent to their surgery and had lost a considerable amount of weight. Other studies have focused on the psychological effects of the surgery itself 1 and of the concommitant weight loss. 2 I have not attempted to distinguish between those who have lost weight and those who have not. I would contend that the findings of this research are not contingent upon this distinction. Since all these patients have had considerably magnified symptoms, viz., their large weights, there is the possibility that both the causal factors and the resultant effects of their obesity will also be magnified and hence more easily detected and observed.
Me~od
As a method of studying the bypass patients, I chose a religious history questionnaire. 3 1 sat down at the bedside of each patient, asked the questions, and wrote down their answers as they talked, occasionally seeking clarification or further development of an idea. The open-ended nature of many of the questions required the patients to answer out of their own frame of reference and experience. A great value of this approach was that it allowed each patient to express the feelings and concerns that seemed most important to her. Because questions were framed in terms of religious belief, the threat of self-exposure was lessened. The price of this strength was the large volume of collected material. It was my hope, in choosing this research tool, that it might bring to light issues of crucial concern to the obese person and characteristic religious beliefs or psychodynamics. I would define a person's religion as his or her attempt to make sense out of life, to find ultimate meaning. The approach to obesity from the religious perspective has the potential for supplementing conventional medical and psychological diagnostic tools.
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Results T h e a n s w e r s to q u e s t i o n s t h a t a r e a m e n a b l e to s i m p l e c o m p a r i s o n a r e s e t o u t in T a b l e 1. T h e r e a s o n s g i v e n for w a n t i n g b y p a s s s u r g e r y w e r e :
Ann: I wanted to be small and beautiful . . . . I don't want to be rejected by m e n . . , once I lose m y weight, everything will fall into place, all my hang-ups will be gone.
Betty: D e s p e r a t i o n , . . did not want to live anymore . . . . I just k n o w there's another person inside you and you can't get it out yourself.
Carol: I was here for a hernia, and one of the doctors asked m e if I liked having this w e i g h t . . , asked if I d i e t e d . . , suggested the b y p a s s . . , m y weight made me shortwinded, slowed me down . . . . I wanted to look better and feel bettor.
Donna: You've seen my m o t h e r - - s m a l l and trim. She drilled into m e in my teenage years that appearance is very important .. I have a wonderful h u s b a n d . . , he will accept m e the way I am I can't. TABLE 1 ANN
BETTY
CAROL
DONNA
FAY
GAIL
22
34
49
31
41
31
25
RACE
Caucasian
Caucasian
Negro
Caucasian
Caucasian
Negro
Negro
POSITION IN FAMILY
Eldest of 3
Second of 6
Only child
Eldest of 3
Same sex twin with ~wo older
Second of 5
Eldest of 3
MARITAL STATUS
Single
Married
Sep.after 9 yrs.
Married 13 yrs.
Married 15 yrs.
M.12yrs. Div.,re-M 1 yr.
Single
WEIGHT AT SURGERY
260 lbs.
243 lbs.
330 lbs.
246 lbs,
285 lbs.
280 lbs.
248 lbs,
OVERWEIGHT SIBLINGS
Yes
Yes
Yes
No
No
Yes
ONSET OF OBESITY
Very early
1S years
25 years
18 years
14 or 15 years
26 years
V.eariy
OVERWEIGHT PARENTS
None
None
One
One
None
None
None
CHURCH NOW
No
No-too
No
Yes
Yes
No-not
No-what's
well enough
the use?
AGE
--
EDITH
heavy
RELIGION
Cath.
Bapt.
Bapt.
Meth.
Bapt.
Bapt.
Bapt.
BACKGROUND
City
Rural
City
Rural
Rural
City
City
PARENTS AT CHURCH
Yes
Yes
Yes
No
No
No
Yes
All were regular in church attendance until their mid-teens, except Carol who attended only as a child.
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Edith: I got so I couldn't lose w e i g h t . . , real bad nerve problem---early menopause, at 33 years o l d . . , other problems--a tumor on appendix and gallstones gave me a lot of trouble but no one took me seriously because I was so overweight. Fay: I tried diet pills, doctors, but nothing worked.., my blood pressure stayed up, 200 over 110, this was the main reason for the operation. Gail: My weight gets in the way of my relationships with men. A sense of powerlessness or helplessness was p r e s e n t in t h e responses of six patients:
Betty: Every person you see lots of love in them, it's God . . . . I think the devil is getting in this world a lot. Carol: You can do things with the help of the Lord that you can't do without h i m . . , young people won't do anything for you--three young people helped us move all our furniture from Baltimore--so God must have done it--He touched them. Donna: You can ask God for anything but I always say, ~Thy will be done"--it is anyway. I can ask but it doesn't mean it is to be. Edith: I could not do without Him [God]... [prayer] has gotten me through all of this, my marriage, my pregnancy, a lot of decisions. Fay: The devil is at work building up hopes in people who promise but don't keep it . . . . I couldn't have decided to have this operation without His [God's] help. Gail: I guess it's the devil in us--we say we are going to do one thing and turn around and do something else . . . . [God is al powerful man who does things in His own way and in His own time. These s t a t e m e n t s c o n v e y a sense of powerlessness a n d a self-image reminiscent of a helpless p a w n in a cosmic s t r u g g l e b e t w e e n God and the devil. W i t h the exception of B e t t y a n d D o n n a , a s t r o n g note of d e p e n d e n c y w a s also evident. A n n stood out from all the o t h e r s w i t h h e r c a p a c i t y for self-assertiveness: ~I can be v e r y aggressive, I a m v e r y c o m m u n i t y minded, I love politics." F r o m four of the p a t i e n t s c a m e a n expression of a l l - e m b r a c i n g love:
Betty: If I loved everybody, no matter what they do to you, that's the whole thing that the Bible says . . . . I fantasy everyone grabbing everyone else's hand and sharing, supporting each other and considering other children your children. Carol: I'm not mean . . . . I don't do anything harmful because I love everyone . . . . I pray for everyone... [I wish for] love by people. Donna: [Prayer is] something I really believe in--the blending of minds and thought-harmony, joining of minds in communication with God--God, me and other people as w e l l . . . [the most religious act is] to love not just one but all human beings.., if everyone loved everyone, what else could you ask?
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Edith: I love people and I just cannot understand why people don't like each other . . . . I wish I had more time and money--there's so many lovely people in the world. T w o of t h e o t h e r s e x p r e s s e d a s i m i l a r d e s i r e - - t h e r e m o v a l of divisions a n d conflicts: Fay: [I wish I could] bring people together like they were meant to be and the line between t h e m taken away--racism--God did not intend it to be like that. Gail: [I wish] we will all be closer together--brother and sister--and not have all this trouble ... inner peace: B y t h e i r responses, C a r o l a n d E d i t h i n d i c a t e t h a t t h e y h a v e t o t a l l y r e p r e s s e d t h e i r o w n hostile feelings in a w a y t h a t is r e m i n i s c e n t of t h e w o m a n w i t h a m o r b i d d e p e n d e n c y d e s c r i b e d by H o m e y , w h o s e " r e p r e s s e d a g g r e s s i v e a n d v i n d i c t i v e t r e n d s ''4 w e r e a m a j o r s t r a n d of h e r d e p e n d e n c y . All six r e s p o n s e s reflect a n e e d to a v o i d conflict, a n d h e n c e t h e c o n s i d e r a b l e difficulty t h e s e w o m e n h a v e in a s s e r t i n g t h e m s e l v e s . A l t h o u g h A n n is a n e x c e p t i o n in t e r m s of self-assertion, she does s h a r e w i t h t h e o t h e r s t h e c r a v i n g to be loved: " I f I h a d a m a n t h a t could love m e . . . if I h a d s o m e o n e w h o could give m e s e c u r i t y . . . . I a m j u s t l o n g i n g to h a v e a s a t i s f a c t o r y r e l a t i o n s h i p . . , f e e l i n g of i n c o m pleteness.., emptiness." I n e v e r y p a t i e n t g u i l t w a s c l e a r l y evident. H i g h ideals a n d h i g h s t a n d a r d s w e r e coupled w i t h m u c h self-criticism for f a i l i n g to r e a c h t h e s e heights: Ann: My ideals are so high . . . . I am my own worst critic. Betty: [My mother] gave all us children guilt. She made us know that He [God] saw everything we d i d . . , even now--she called from California and told me to imagine her face as I was going into the operation--I tried--all I could see was her finger saying, "behave"--I could not see her face. Carol: At school I played a lot of hooky and didn't learn what I should ..... I never liked school--it was not my parents' fault, it was mine ... my mother took me to the police station--she said "I'm not going to put up with you; anything they do to you is all right with m e " . . . . I had a good mother and grandmother--they wanted me to do what was right. Donna: The main purpose of my life is to become perfect . . . . I wasn't the greatest church worker in the world--I'd be afraid to do something w r o n g . . . "Karmic" debts-we all have these--like in a previous life, I may not have been good to my husband--I've got to deal with that in this life . . . . I always felt you had to justify being forgiven--earn it. Edith: My prayers have been answered wonderfully--I must be living right for o n c e . . . seems to me like it [evil] is getting worse all the time, but maybe we are the cause of it, because we don't reach out to people . . . . I want to be a better person because I've got m a n y faults.
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Fay: The Prodigal Son reminds me of me in a way. I've strayed away from church--
reminds me of my family too. Makes me feel funny when I read i t . . . [God has] a pretty understanding heart to take all this stuff that's being dished out and still forgive, just the things I've done. Gail: [In prayer I] beg forgiveness for not understanding, nor appreciating.., right now
I am scared to death I might not make it to heaven because of all the sins I have committed. H a r s h self-criticism is the d o m i n a n t t h e m e in these responses. E a c h one condemns h e r s e l f for failing to be, or to do, w h a t she feels she should. The sense of guilt in most of these p a t i e n t s is profound. T h e i n c a p a c i t a t i n g effects of guilt can be seen in t h e i r v a i n a t t e m p t s to control t h e i r eating. Most of t h e m expressed disgust at the size of t h e i r bodies and w e r e d e s p e r a t e to r e g a i n control of t h e i r weight. Obese persons t e n d to e a t as an a t t e m p t to feel better, w h a t e v e r the r e a s o n for t h e i r feeling discontent. Because t h e y often feel discontent, t h e y eat a lot. K n o w i n g w h a t t h e i r excessive e a t i n g does to t h e i r bodies, t h e y feel guilty. This in t u r n a c c e n t u a t e s t h e i r feeling of d i s c o n t e n t and leads to more eating, and so on. F u r t h e r clarification of this cycle and its root causes is supplied by B r u c h : Statements such as that people overeat because they feel frustrated, or substitute food for love and security really explain nothing. These and other pronouncements about the symbolic meaning of food, or of the large body size, have become very popular. The trouble is not that these statements are entirely in e r r o r . . , but they do not go far enough. They fail to explain what is wrong with these patients, what has happened in the course of their development so that they perceive, or misperceive, their bodily sensations so that the nutritional function can be misused in the service of complex emotional and interpersonal problems. [italics in original] 5 One f u r t h e r p a t t e r n h a s e m e r g e d in t h e responses, w h i c h m a y prove to be the most significant. It is a dual d y n a m i c in the i n t e r p e r s o n a l t r a n s a c t i o n s w i t h i n the family. I first noticed this in the p a r e n t s of Ann, who h a s b e e n o v e r w e i g h t from e a r l y childhood, Ann: I have always been afraid of my f a t h e r . . , he is very strict, domineering,
harsh . . . . I often think that if my father were to die, I would not really miss him . . . . I have never had the love of a father. Mother wanted for us what she did not have for herself.., she is very loving--the opposite to h i m . . , she is very sentimental and compassionate. One p a r e n t was strict a n d h a r s h , the o t h e r l e n i e n t and indulgent. It seems t h a t t h e y were polarized at e x t r e m e s , The only o t h e r p a t i e n t who h a s been o v e r w e i g h t from e a r l y childhood is Gail. She n e v e r k n e w h e r father. She h a d a s t e p f a t h e r from the age of nine.
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Gail: No relationship as far as he is concerned . . . . I didn't like him and he knew it . . . . I felt like he should be making a bigger contribution.., being the eldest child, I had to give my money to help in the h o u s e . . , a m a n only interested in h i m s e l f . . , she [mother] was trying to impress h i m . . , she didn't think she was neglecting us, but she did treat him better.
My mother was not a person t . ask a lot but I knew when I came in I had to sweep the floor and wash the dishes. I was the only one old enough to work at the time. My brother and s i s t e r . . . I guess that's another thing I resent--he's irresponsible, he could do more. I guess I was hoping when I left home that he would take care of things since he was [then] the e l d e s t . . , my sister is 18 and dates--when I was 18 my mother didn't let me date. F o r t h e first n i n e y e a r s , Gail h a d only one p a r e n t h e r m o t h e r . I t is clear in h e r r e s p o n s e s t h a t she is v e r y a m b i v a l e n t t o w a r d h e r m o t h e r . W h e n I a s k e d h e r if she w a s e a s y or t o u g h , she said, " s o r t of mid-line." She is h u r t a n d v e r y r e s e n t f u l a t t h e d i s c r i m i n a t i o n she feels w a s s h o w n a g a i n s t h e r as t h e eldest child. H e r r e s p o n s e s i n d i c a t e she feels t h a t she w a s t r e a t e d h a r s h l y a n d t h a t her brother and sister were treated indulgently. F o r Edith, t h e o n s e t of obesity c a m e at t h e age of 14 or 15. She felt rejected by h e r p e e r s a n d did n o t d a t e d u r i n g h e r t e e n a g e y e a r s . H e r p a r e n t s w e r e 45 a n d 38 w h e n she w a s born. T h e y e v i d e n t l y f o u n d c h i l d - r e a r i n g a b u r d e n . Edith: They used to say, ~No child is worth his raising" ... my daddy was an independent c u s s . . , worked from morning till night . . . . I always hated it because he was not converted.., he was s t i n g y . . , had more friends than anyone on e a r t h . . , had a terrible temper.
My mother was always so busy, never had time for anything but work .. to this day my mother has never told me she loves me. A l t h o u g h h e r f a t h e r w a s v e r y f r i e n d l y to people outside t h e f a m i l y , she felt he w a s '~stingy." She feels t h a t she w a s t r e a t e d h a r s h l y b y b o t h h e r p a r e n t s . B u t t h i s w a s n o t t h e case for h e r t w i n sister, a s she describes it. Edith: My twin sister was more healthy--every childhood disease I had, she did not, though we were in the same [double] bed . . . . I don't know why, but she resented m e . . . She was always little Miss Queen Bee--thought she was the cutest little thing . . . . I went to business college, she stayed home and my parents loved it . . . . I always wanted her to have everything--I don't know why because she always treated me so bad.
H e r t w i n sister a p p e a r e d to be favored, t r e a t e d l e n i e n t l y in c o m p a r i s o n w i t h her. E v e n E d i t h herself, t h o u g h she felt v e r y r e s e n t f u l t o w a r d h e r sister, in fact acted i n d u l g e n t l y t o w a r d her. I n h e r e a r l y t e e n s she exploded in size. T h i s w a s a critical s t a g e in h e r r e l a t i o n s h i p w i t h h e r t w i n sister, w h e n i d e n t i t y f o r m a t i o n b e c a m e t h e i r d e v e l o p m e n t a l t a s k . As she s t r u g g l e d to find h e r o w n identity, with the compounding problem of having a twin sister, the harsh/
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indulgent dynamic came to bear as she made decisions about how she felt toward others and toward herself. She chose to be indulgent toward h e r twin sister, for instance sewing for her t h r o u g h school and paying for h e r wedding. But this self-denial was accompanied by self-indulgence over food intake. Donna became a compulsive e a t e r at the age of 18 immediately after she was married. One pole of h e r ambivalent feelings toward h e r m o t h e r was h e r resentment. Donna: She is a hard person to really please--she is just too particular about many
things . . . . I know when I buy something for mother, it won't fit, it won't be the right size.., everything has to be done to perfection.., every time we get her something it has to be exchanged five or six times.., if she wants to do something really nice for us, she fixes a nice m eal . . , she would be very hurt if we didn't eat it, but she doesn't want us to get f a t . . , she keeps fixing food--bread, pastries, starchy foods. H e r f ath er has been obese for 26 y e a r s - - s i n c e Donna was five. Both h e r brot her and sister need to watch t he i r weights very carefully. H e r m o t h e r is small and trim. Donna: My father and I are very very close.., one thing we share is that we eat
together.., my father and I are very compatible--when he walks into a room, I know that he is there. The harsh/indulgent dynamic is present to a degree within h e r parents. H e r mo th er is h a r s h in t h a t she is implacable. Donna feels very close to h e r father, which suggests t h a t he is lenient with her, though not necessarily indulgent. Donna: I have a wonderful husband. He will accept me the way I am--I can't.
The m o m e n t she moved out of her home e n v i r o n m e n t to live with her husband, whom she finds easy to please~ she lost control of h e r weight. Although h e r fath er was also easy to please, the harshness of h e r implacable m o t h e r was the dominant factor in the home. Donna needed to stay slim to please h e r mother. Indeed, she won two be a ut y contests before she married. Once she moved away from the immediate influence of h e r mother, the restraints upon h e r eating, which she had not internalized, were removed. Betty also experienced excessive weight gains from the age of 18. She was mar r ied at 16 but lived with h e r hus ba nd at home until moving away with hi m to California two years later. Betty: Mother knew that whatever we were to be, she made us . . . . We have no hate for
our parents---we knew we deserved it---she always told us why we were being disciplined.., she held two jobs, was gone all the time . . . . I've seen her come home and sit up half the night with our homework.., never a lot of time for cuddling and all t h a t . . , my sisters and I ran the family. The wrath of God is all I can think of with my fat her. . , oh boy! he used to beat us--made us choose our own switches.., studied for the ministry.., became an alco-
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holic.., got so strict, real mean, made us wash his feet at 2 a.m., beat us, but never remembered doing any of these t h i n g s . . , we knew it was a disease but it did not make us feel any better. T h e picture p r e s e n t e d h e r e of Betty's childhood is a u n i f o r m l y h a r s h one, and at some points horrifying. W h e n she and h e r h u s b a n d left t h e home, she m o v e d a w a y from the influence of h e r p a r e n t s and into r e l a t i o n s h i p w i t h two significant p e r s o n s - - h e r h u s b a n d and a n older w o m a n w h o m she m e t soon after m o v i n g to California.
Betty: My husband is a wonderful m a n . . , we are very very close.., there is nothing he would not do for me ... he says it [my excessive weight] does not matter to him but I don't believe him. I guess she was a mother substitute.., she cooked Italian style food.., she knew no strangers.., she accepted me like one of her own f a m i l y . . , she furnished an apartment for m e . . . she's special.., she's dead, but she isn't r e a l l y . . . I believe she's standing right h e r e . . . I can see her right now as my heart wants to see her. In this new setting B e t t y e x p e r i e n c e d the opposite to w h a t she was accustomed. H e r h u s b a n d is c e r t a i n l y l e n i e n t in his expectations. T h e ~mother s u b s t i t u t e " was i n d u l g e n t w i t h her. It seems t h a t w h e n she e x p e r i e n c e d leniency and indulgence a f t e r h a v i n g only h a r s h e x p e c t a t i o n s placed u p o n her, she b e c a m e i n d u l g e n t t o w a r d herself. F a y ' s w e i g h t p r o b l e m b e g a n at t h e age of 26. She associates it w i t h the t y i n g of h e r t u b e s at t h a t time. T h e r e were, however, o t h e r factors present.
Fay: As long as I can remember I have never heard my parents argue or split u p . . . my father never gets mad with anyone period.., he is liked by everyone .... my father is something like a father and a mother to m e . . . he did not want me to start a fight nor run from o n e . . , he would tell me that kindness would kill the other p e r s o n . . , mother said fists would do it quicker.., she was hot-tempered and would argue with other mothers--father would object to t h a t . . , he said '~turn the other cheek," she said, ~'don't, you'll get h u r t " . . , my children say my mother is cranky and e v i l . . , she said ~the boys are mine, you belong to your father." A degree of p o l a r i z a t i o n o f h a r s h n e s s and leniency can be seen in Fay's relationship to h e r m o t h e r , in c o n t r a s t w i t h t h a t to h e r father. She m a r r i e d an alcoholic, w i t h w h o m she did m u c h a r g u i n g and fighting. All h e r children h a v e ~'nerve problems." Soon a f t e r t h a t m a r r i a g e failed, she lived w i t h a m a n for about a year. It was d u r i n g this period t h a t b o t h h e r p a r e n t s rejected h e r and she b e g a n to g a i n w e i g h t rapidly.
Fay: My parents stopped speaking to me, mother more than father, but he said as soon as I can clean my house out, I would be his little girl again--that hurt me more than mother's greater rejection. F r o m F a y ' s responses it is not clear w h a t k i n d of r e l a t i o n s h i p she h a d w i t h this m a n she lived with. At the t i m e I i n t e r v i e w e d her, I did not realize how
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important the nature of this relationship might be. It is possible t h a t he expected very little from her. If it could be inferred t h a t she experienced him as compliant and indulgent in contrast to the felt harshness of her parents' rejection, then the onset of Fay's weight problems could be related to her emotional movement away from harsh rejecting parents and into an indulgent de facto relationship. Carol has been ~chunky" all her life. At the age of 15 she weighed 66 kg. (145 lbs.). At 18 she began drinking, and by 20 she was drinking heavily. Then she stopped suddenly and completely at the age of 25 when she realized, "I wasn't doing my grandmother any good." When she stopped drinking, she started eating. She was married soon after she stopped drinking and began to put on weight faster. Her father died when she was young, and she was reared by her grandmother, with a little help from her mother. Carol: My grandmother sent me to school--I played hooky a lot.., she was wonderful to
everybody--no matter who came to the door there was room for t h e m . . , she taught us that God is good even though we don't have what other people have.., she would beat all of us when no one would confess... I would say ~beat me first," because she was not too angry then--others were hiding, praying to the Lord, and she would be angrier. My mother was different from my grandmother--she would do for people but mostly would live for herself.., when I was sent to my mother for playing hooky, she said she would get me locked u p . . . you love your mother, but you don't know your mother sometimes.., you talk and I say one thing and she thinks another and we can't get close. The harshness of the expectations made of Carol is seen in the neglect by her mother, the inadequacy of her grandmother to meet her affectional needs, and the discipline administered to control her. As she moved into adulthood, her reaction was to drink heavily. Precisely why she stopped drinking and began eating is not clear to me. But it is clear t h a t weight control became a major problem as soon as she was married. Carol: We separated eight or nine years later . . . . I've always wanted to do what I
want--so maybe it was my f a u l t . . , he bosses--I don't like t h a t . . , he gets jealous of my mother and the things I do for her. Carol and her husband appear to have separated mainly because she resented the limits he was trying to place upon her. It can therefore be inferred t h a t early in their marriage he was more lenient in his expectations of her. In summary, the set of relationships within the immediate families of most of these obese patients revealed a common dual characteristic. Two opposite ways of relating were present. One was strict and harsh, the other lenient and indulgent. The patient was caught between these two polarities in a variety of ways. For Ann, the harsh polarity was represented by her father, the indulgent by her mother. For Gail, her mother represented the h a r s h polarity, while her mother's t r e a t m e n t of her siblings and her stepfather represented the indulgent polarity. Edith's parents were harsh toward her but indulgent toward her
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twin sister. Donna experienced her mother as harsh, her husband as indulgent. Betty felt her parents were harsh, her husband was lenient, and "mother substitute" indulgent. In the cases of Fay and Carol the evidence is not conclusive, though if further evidence were available, it may prove to be so. Fay felt her mother was harsh and her father lenient. If she found her lover indulgent, she would fit the pattern here emerging. Carol felt harshness from her grandmother and mother. If she experienced her husband as indulgent, as is implied, she too would fit the pattern. More can be said about this pattern. The experience of harshness always preceded or accompanied the experience of being indulged. It appears that the onset of obesity occurred when the patient was able to identify with the attitude that the significant indulgent person had toward her. When, by circumstances or by her own choice, indulgence, rather than harshness, became the dominant influence in her life, and there were negligible moderating influences, it seemed that she became indulgent toward herself and thus became obese. So this harshness/indulgence dynamic has contributed to a defective identity formation. These findings correspond with Bruch's conclusions: I have come to recognize as crucial issues in many patients with serious eating disorders, namely the basic delusion of not having an identity of their own, of not even owning their body and its sensations, with the specific inability of recognizing hunger as a sign of nutritional need. [italics in original] 6 Bruch sees these two traits as being of fundamental significance for the development of severe eating disturbances. The second has been outside the scope of this study, but my findings do support and elaborate upon the first trait, the defective identities of seven obese patients. To my knowledge, this harshness/ indulgence dynamic has not previously been observed as a pattern.
Conclusion
The use of a religious history questionnaire has revealed three prominent characteristics in this sample of obese patients: a feeling of helplessness and powerlessness, a craving for love, and strong guilt feelings. A possible psychogenic factor in morbid obesity was observed in five of the seven patients. Pertinent information on the other two patients was lacking. This factor is a dual dynamic of harshness and indulgence. Its presence in the backgrounds of the five patients was striking. The onset of obesity seemed to occur when indulgence became the dominating influence over harshness. The validity of this theory needs testing on a much wider sample of patients. Should it prove to have general validity for morbidly obese persons, it would modify one of the generally accepted categories of the psychopathology of obesity. Glucksman accepts Bruch's definition of developmental obesity as:
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This type of obesity plays a c e n t r a l role in the i n d i v i d u a l ' s growth and development. - T h e s e - p a t i e n t s become obese in ~chikihood, are preoccupied w i t h size and weight, and are u n a b l e to tolerate e i t h e r f r u s t r a t i o n or a d e l a y in gratification. 7
Five of the patients in my study are excluded from the category of developmental obesity by this definition. Yet they do not fit the categories of "absence of psychopathology" or "thin-fat people." It could be argued that theirs is "reactive obesity," the only remaining category, which would mean their obesity has followed an emotional trauma. However, the ascendancy of indulgence in identity formation is primarily a developmental process, not a reaction to a specific trauma. Hence, the definition of developmental obesity would need to be broadened in scope if the harshness/indulgence dynamic is a common factor in obesity.
References 1. Castelnuovo-Tedesco, P., and Schiebel, D., "Studies in Super Obesity: II. Psychiatric Appraisal of Jejuno-ileal Bypass Surgery," Am. J. Psychiatry, 1976, 133, 26-31. 2: Mills, M. J., and Stunkard, A. J., "Behavioral Changes Following Surgery for Obesity," loc. cit., 1976, 133, 527-531. 3. This religious history questionnaire was developed in 1969 for an unpublished research project on "Religious Ideation in Psychiatric Patients," by Daniel A. McKeever, under the supervision of C. Roy Woodruff, at Bryce Hospital, Alabama. 4. Homey, K., Self-Analysis. London, Kegan Paul, Trench, Truber and Co., 1942, p. 246. 5. Bruch, H., Eating Disorders---Obesity, Anorexia Nervosa and the Person Within. New York, Basic Books, 1973, p. 50. 6. Ibid. 7. Glucksman, M. L., "Psychiatric Observations on Obesity." In Advances in Psychosomatic Medicine, vol. 7, Hunger and Satiety in Health and Disease. Basel, 1972, pp. 199, 200.
T o w a r d an U n d e r s t a n d i n g of the O b e s e P e r s o n R O B E R T E. H O C K L E Y A B S T R A C T : Attitudes, feelings, and family backgrounds of seven very obese women were studied by m e a n s of a religious history questionnaire. Some comments are made about this research tool. Three very prominent characteristics of these women were feelings of helplessness and powerlessness, a craving for love, and strong guilt feelings. A possible psychogenic factor in morbid obesity was observed in the backgrounds of five women; pertinent information on the other two was lacking. This factor is a dual dynamic of h a r s h n e s s and indulgence. The onset of obesity seemed to occur when indulgence became the dominating influence over harshness.
Introduction A n n is 22 y e a r s old and u n m a r r i e d . She lives at h o m e w i t h h e r parents, h e r 19-year-old sister, and 12-year-old brother. A l t h o u g h v e r y i n t e r e s t e d in astrology, c o m m u n i t y service, and politics, she seldom v e n t u r e s out of the house. H e r problem is massive obesity. She has been o v e r w e i g h t from e a r l y childhood, h e r r e c e n t w e i g h t being 118 kg. (260 lbs.). M u c h of h e r t i m e h a s been spent ruminating about marriage. IfI had a man that could love me, things would be a lot b e t t e r . . , the kind of man I want couldn't want me--he wouldn't climb professionally if he had a heavy woman . . . . I know I can't have him until I lose w e i g h t . . , if I had someone who would give me security, love and companionship.., you know it is hard to stick at home and diet, and think about these things all the time . . . . I eat and it takes my mind off these things . . . . I am just longing to have a satisfactory relationship, but I am afraid I'll be rejected.., he wouldn't be the kind of man that would appeal to me if he loved a fat w o m a n . . , believe me, I think of this all the time. 23 A n n h a s a t t e m p t e d to deal w i t h h e r obesity and its r e l a t e d problems in s e v e r a l ways. She has t r i e d in v a i n to diet. She says, "My favorite hobby is to e a t . . , w h e n I was on a diet, I was m i s e r a b l e . . , sure I love to eat, m y m o t h e r was a good cook." A f t e r c o n s u l t i n g m a n y p h y s i c i a n s and psychiatrists, she sought f u r t h e r help from a p h y s i c i a n who practiced h y p n o t h e r a p y . She accepted his i n t e r p r e t a t i o n of w h y she ate, t h o u g h w i t h some difficulty: "It upsets m e to t h i n k about it . . . . I stopped the sessions to t h i n k . . . . I a m afraid of m e n - - t h i s is t h e simple r e a s o n for m y s i z e . . , subconsciously I ate to get fat so Robert E. Hockley, B.E., B.D., Th.Schol., Th.M., is the Anglican Chaplain and Clinical Supervisor of Clergy Training, Kenmore Hospital, New South Wales, Australia. 0022-4197/79/0400-0120500.95
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no man would want me for sex or marriage." The early onset of her obesity makes this interpretation highly suspect. Nevertheless, in the course of the hypnotherapy, she recalled, ~I was told to look in a mirror and imagine myself as I wanted to be--small and beautiful." Although this image did not seem to help her in any tangible way at the time, she has now found another way of achieving this objective. Ann is one of seven female patients whom I interviewed in depth, using a religious history questionnaire, at the Medical College of Virginia. All of these women had suffered from what is variously described as massive, or morbid, or super-obesity. They had also qualified for the intestinal (ileojejunal) bypass surgery at MCV. They were required: 1) to be under 50 years of age; 2) to have tried every major dietary program, including the rice diet at Duke University; 3) to have no other health problems; 4) to be at least 45 kg. overweight; and 5) to have exogenous obesity. Three (Betty, Donna, Gail) were recovering from surgery and anticipating discharge. The other four patients had returned for a liver biopsy six or twelve months subsequent to their surgery and had lost a considerable amount of weight. Other studies have focused on the psychological effects of the surgery itself 1 and of the concommitant weight loss. 2 I have not attempted to distinguish between those who have lost weight and those who have not. I would contend that the findings of this research are not contingent upon this distinction. Since all these patients have had considerably magnified symptoms, viz., their large weights, there is the possibility that both the causal factors and the resultant effects of their obesity will also be magnified and hence more easily detected and observed.
Me~od
As a method of studying the bypass patients, I chose a religious history questionnaire. 3 1 sat down at the bedside of each patient, asked the questions, and wrote down their answers as they talked, occasionally seeking clarification or further development of an idea. The open-ended nature of many of the questions required the patients to answer out of their own frame of reference and experience. A great value of this approach was that it allowed each patient to express the feelings and concerns that seemed most important to her. Because questions were framed in terms of religious belief, the threat of self-exposure was lessened. The price of this strength was the large volume of collected material. It was my hope, in choosing this research tool, that it might bring to light issues of crucial concern to the obese person and characteristic religious beliefs or psychodynamics. I would define a person's religion as his or her attempt to make sense out of life, to find ultimate meaning. The approach to obesity from the religious perspective has the potential for supplementing conventional medical and psychological diagnostic tools.
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Results T h e a n s w e r s to q u e s t i o n s t h a t a r e a m e n a b l e to s i m p l e c o m p a r i s o n a r e s e t o u t in T a b l e 1. T h e r e a s o n s g i v e n for w a n t i n g b y p a s s s u r g e r y w e r e :
Ann: I wanted to be small and beautiful . . . . I don't want to be rejected by m e n . . , once I lose m y weight, everything will fall into place, all my hang-ups will be gone.
Betty: D e s p e r a t i o n , . . did not want to live anymore . . . . I just k n o w there's another person inside you and you can't get it out yourself.
Carol: I was here for a hernia, and one of the doctors asked m e if I liked having this w e i g h t . . , asked if I d i e t e d . . , suggested the b y p a s s . . , m y weight made me shortwinded, slowed me down . . . . I wanted to look better and feel bettor.
Donna: You've seen my m o t h e r - - s m a l l and trim. She drilled into m e in my teenage years that appearance is very important .. I have a wonderful h u s b a n d . . , he will accept m e the way I am I can't. TABLE 1 ANN
BETTY
CAROL
DONNA
FAY
GAIL
22
34
49
31
41
31
25
RACE
Caucasian
Caucasian
Negro
Caucasian
Caucasian
Negro
Negro
POSITION IN FAMILY
Eldest of 3
Second of 6
Only child
Eldest of 3
Same sex twin with ~wo older
Second of 5
Eldest of 3
MARITAL STATUS
Single
Married
Sep.after 9 yrs.
Married 13 yrs.
Married 15 yrs.
M.12yrs. Div.,re-M 1 yr.
Single
WEIGHT AT SURGERY
260 lbs.
243 lbs.
330 lbs.
246 lbs,
285 lbs.
280 lbs.
248 lbs,
OVERWEIGHT SIBLINGS
Yes
Yes
Yes
No
No
Yes
ONSET OF OBESITY
Very early
1S years
25 years
18 years
14 or 15 years
26 years
V.eariy
OVERWEIGHT PARENTS
None
None
One
One
None
None
None
CHURCH NOW
No
No-too
No
Yes
Yes
No-not
No-what's
well enough
the use?
AGE
--
EDITH
heavy
RELIGION
Cath.
Bapt.
Bapt.
Meth.
Bapt.
Bapt.
Bapt.
BACKGROUND
City
Rural
City
Rural
Rural
City
City
PARENTS AT CHURCH
Yes
Yes
Yes
No
No
No
Yes
All were regular in church attendance until their mid-teens, except Carol who attended only as a child.
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Edith: I got so I couldn't lose w e i g h t . . , real bad nerve problem---early menopause, at 33 years o l d . . , other problems--a tumor on appendix and gallstones gave me a lot of trouble but no one took me seriously because I was so overweight. Fay: I tried diet pills, doctors, but nothing worked.., my blood pressure stayed up, 200 over 110, this was the main reason for the operation. Gail: My weight gets in the way of my relationships with men. A sense of powerlessness or helplessness was p r e s e n t in t h e responses of six patients:
Betty: Every person you see lots of love in them, it's God . . . . I think the devil is getting in this world a lot. Carol: You can do things with the help of the Lord that you can't do without h i m . . , young people won't do anything for you--three young people helped us move all our furniture from Baltimore--so God must have done it--He touched them. Donna: You can ask God for anything but I always say, ~Thy will be done"--it is anyway. I can ask but it doesn't mean it is to be. Edith: I could not do without Him [God]... [prayer] has gotten me through all of this, my marriage, my pregnancy, a lot of decisions. Fay: The devil is at work building up hopes in people who promise but don't keep it . . . . I couldn't have decided to have this operation without His [God's] help. Gail: I guess it's the devil in us--we say we are going to do one thing and turn around and do something else . . . . [God is al powerful man who does things in His own way and in His own time. These s t a t e m e n t s c o n v e y a sense of powerlessness a n d a self-image reminiscent of a helpless p a w n in a cosmic s t r u g g l e b e t w e e n God and the devil. W i t h the exception of B e t t y a n d D o n n a , a s t r o n g note of d e p e n d e n c y w a s also evident. A n n stood out from all the o t h e r s w i t h h e r c a p a c i t y for self-assertiveness: ~I can be v e r y aggressive, I a m v e r y c o m m u n i t y minded, I love politics." F r o m four of the p a t i e n t s c a m e a n expression of a l l - e m b r a c i n g love:
Betty: If I loved everybody, no matter what they do to you, that's the whole thing that the Bible says . . . . I fantasy everyone grabbing everyone else's hand and sharing, supporting each other and considering other children your children. Carol: I'm not mean . . . . I don't do anything harmful because I love everyone . . . . I pray for everyone... [I wish for] love by people. Donna: [Prayer is] something I really believe in--the blending of minds and thought-harmony, joining of minds in communication with God--God, me and other people as w e l l . . . [the most religious act is] to love not just one but all human beings.., if everyone loved everyone, what else could you ask?
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Edith: I love people and I just cannot understand why people don't like each other . . . . I wish I had more time and money--there's so many lovely people in the world. T w o of t h e o t h e r s e x p r e s s e d a s i m i l a r d e s i r e - - t h e r e m o v a l of divisions a n d conflicts: Fay: [I wish I could] bring people together like they were meant to be and the line between t h e m taken away--racism--God did not intend it to be like that. Gail: [I wish] we will all be closer together--brother and sister--and not have all this trouble ... inner peace: B y t h e i r responses, C a r o l a n d E d i t h i n d i c a t e t h a t t h e y h a v e t o t a l l y r e p r e s s e d t h e i r o w n hostile feelings in a w a y t h a t is r e m i n i s c e n t of t h e w o m a n w i t h a m o r b i d d e p e n d e n c y d e s c r i b e d by H o m e y , w h o s e " r e p r e s s e d a g g r e s s i v e a n d v i n d i c t i v e t r e n d s ''4 w e r e a m a j o r s t r a n d of h e r d e p e n d e n c y . All six r e s p o n s e s reflect a n e e d to a v o i d conflict, a n d h e n c e t h e c o n s i d e r a b l e difficulty t h e s e w o m e n h a v e in a s s e r t i n g t h e m s e l v e s . A l t h o u g h A n n is a n e x c e p t i o n in t e r m s of self-assertion, she does s h a r e w i t h t h e o t h e r s t h e c r a v i n g to be loved: " I f I h a d a m a n t h a t could love m e . . . if I h a d s o m e o n e w h o could give m e s e c u r i t y . . . . I a m j u s t l o n g i n g to h a v e a s a t i s f a c t o r y r e l a t i o n s h i p . . , f e e l i n g of i n c o m pleteness.., emptiness." I n e v e r y p a t i e n t g u i l t w a s c l e a r l y evident. H i g h ideals a n d h i g h s t a n d a r d s w e r e coupled w i t h m u c h self-criticism for f a i l i n g to r e a c h t h e s e heights: Ann: My ideals are so high . . . . I am my own worst critic. Betty: [My mother] gave all us children guilt. She made us know that He [God] saw everything we d i d . . , even now--she called from California and told me to imagine her face as I was going into the operation--I tried--all I could see was her finger saying, "behave"--I could not see her face. Carol: At school I played a lot of hooky and didn't learn what I should ..... I never liked school--it was not my parents' fault, it was mine ... my mother took me to the police station--she said "I'm not going to put up with you; anything they do to you is all right with m e " . . . . I had a good mother and grandmother--they wanted me to do what was right. Donna: The main purpose of my life is to become perfect . . . . I wasn't the greatest church worker in the world--I'd be afraid to do something w r o n g . . . "Karmic" debts-we all have these--like in a previous life, I may not have been good to my husband--I've got to deal with that in this life . . . . I always felt you had to justify being forgiven--earn it. Edith: My prayers have been answered wonderfully--I must be living right for o n c e . . . seems to me like it [evil] is getting worse all the time, but maybe we are the cause of it, because we don't reach out to people . . . . I want to be a better person because I've got m a n y faults.
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Fay: The Prodigal Son reminds me of me in a way. I've strayed away from church--
reminds me of my family too. Makes me feel funny when I read i t . . . [God has] a pretty understanding heart to take all this stuff that's being dished out and still forgive, just the things I've done. Gail: [In prayer I] beg forgiveness for not understanding, nor appreciating.., right now
I am scared to death I might not make it to heaven because of all the sins I have committed. H a r s h self-criticism is the d o m i n a n t t h e m e in these responses. E a c h one condemns h e r s e l f for failing to be, or to do, w h a t she feels she should. The sense of guilt in most of these p a t i e n t s is profound. T h e i n c a p a c i t a t i n g effects of guilt can be seen in t h e i r v a i n a t t e m p t s to control t h e i r eating. Most of t h e m expressed disgust at the size of t h e i r bodies and w e r e d e s p e r a t e to r e g a i n control of t h e i r weight. Obese persons t e n d to e a t as an a t t e m p t to feel better, w h a t e v e r the r e a s o n for t h e i r feeling discontent. Because t h e y often feel discontent, t h e y eat a lot. K n o w i n g w h a t t h e i r excessive e a t i n g does to t h e i r bodies, t h e y feel guilty. This in t u r n a c c e n t u a t e s t h e i r feeling of d i s c o n t e n t and leads to more eating, and so on. F u r t h e r clarification of this cycle and its root causes is supplied by B r u c h : Statements such as that people overeat because they feel frustrated, or substitute food for love and security really explain nothing. These and other pronouncements about the symbolic meaning of food, or of the large body size, have become very popular. The trouble is not that these statements are entirely in e r r o r . . , but they do not go far enough. They fail to explain what is wrong with these patients, what has happened in the course of their development so that they perceive, or misperceive, their bodily sensations so that the nutritional function can be misused in the service of complex emotional and interpersonal problems. [italics in original] 5 One f u r t h e r p a t t e r n h a s e m e r g e d in t h e responses, w h i c h m a y prove to be the most significant. It is a dual d y n a m i c in the i n t e r p e r s o n a l t r a n s a c t i o n s w i t h i n the family. I first noticed this in the p a r e n t s of Ann, who h a s b e e n o v e r w e i g h t from e a r l y childhood, Ann: I have always been afraid of my f a t h e r . . , he is very strict, domineering,
harsh . . . . I often think that if my father were to die, I would not really miss him . . . . I have never had the love of a father. Mother wanted for us what she did not have for herself.., she is very loving--the opposite to h i m . . , she is very sentimental and compassionate. One p a r e n t was strict a n d h a r s h , the o t h e r l e n i e n t and indulgent. It seems t h a t t h e y were polarized at e x t r e m e s , The only o t h e r p a t i e n t who h a s been o v e r w e i g h t from e a r l y childhood is Gail. She n e v e r k n e w h e r father. She h a d a s t e p f a t h e r from the age of nine.
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Gail: No relationship as far as he is concerned . . . . I didn't like him and he knew it . . . . I felt like he should be making a bigger contribution.., being the eldest child, I had to give my money to help in the h o u s e . . , a m a n only interested in h i m s e l f . . , she [mother] was trying to impress h i m . . , she didn't think she was neglecting us, but she did treat him better.
My mother was not a person t . ask a lot but I knew when I came in I had to sweep the floor and wash the dishes. I was the only one old enough to work at the time. My brother and s i s t e r . . . I guess that's another thing I resent--he's irresponsible, he could do more. I guess I was hoping when I left home that he would take care of things since he was [then] the e l d e s t . . , my sister is 18 and dates--when I was 18 my mother didn't let me date. F o r t h e first n i n e y e a r s , Gail h a d only one p a r e n t h e r m o t h e r . I t is clear in h e r r e s p o n s e s t h a t she is v e r y a m b i v a l e n t t o w a r d h e r m o t h e r . W h e n I a s k e d h e r if she w a s e a s y or t o u g h , she said, " s o r t of mid-line." She is h u r t a n d v e r y r e s e n t f u l a t t h e d i s c r i m i n a t i o n she feels w a s s h o w n a g a i n s t h e r as t h e eldest child. H e r r e s p o n s e s i n d i c a t e she feels t h a t she w a s t r e a t e d h a r s h l y a n d t h a t her brother and sister were treated indulgently. F o r Edith, t h e o n s e t of obesity c a m e at t h e age of 14 or 15. She felt rejected by h e r p e e r s a n d did n o t d a t e d u r i n g h e r t e e n a g e y e a r s . H e r p a r e n t s w e r e 45 a n d 38 w h e n she w a s born. T h e y e v i d e n t l y f o u n d c h i l d - r e a r i n g a b u r d e n . Edith: They used to say, ~No child is worth his raising" ... my daddy was an independent c u s s . . , worked from morning till night . . . . I always hated it because he was not converted.., he was s t i n g y . . , had more friends than anyone on e a r t h . . , had a terrible temper.
My mother was always so busy, never had time for anything but work .. to this day my mother has never told me she loves me. A l t h o u g h h e r f a t h e r w a s v e r y f r i e n d l y to people outside t h e f a m i l y , she felt he w a s '~stingy." She feels t h a t she w a s t r e a t e d h a r s h l y b y b o t h h e r p a r e n t s . B u t t h i s w a s n o t t h e case for h e r t w i n sister, a s she describes it. Edith: My twin sister was more healthy--every childhood disease I had, she did not, though we were in the same [double] bed . . . . I don't know why, but she resented m e . . . She was always little Miss Queen Bee--thought she was the cutest little thing . . . . I went to business college, she stayed home and my parents loved it . . . . I always wanted her to have everything--I don't know why because she always treated me so bad.
H e r t w i n sister a p p e a r e d to be favored, t r e a t e d l e n i e n t l y in c o m p a r i s o n w i t h her. E v e n E d i t h herself, t h o u g h she felt v e r y r e s e n t f u l t o w a r d h e r sister, in fact acted i n d u l g e n t l y t o w a r d her. I n h e r e a r l y t e e n s she exploded in size. T h i s w a s a critical s t a g e in h e r r e l a t i o n s h i p w i t h h e r t w i n sister, w h e n i d e n t i t y f o r m a t i o n b e c a m e t h e i r d e v e l o p m e n t a l t a s k . As she s t r u g g l e d to find h e r o w n identity, with the compounding problem of having a twin sister, the harsh/
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indulgent dynamic came to bear as she made decisions about how she felt toward others and toward herself. She chose to be indulgent toward h e r twin sister, for instance sewing for her t h r o u g h school and paying for h e r wedding. But this self-denial was accompanied by self-indulgence over food intake. Donna became a compulsive e a t e r at the age of 18 immediately after she was married. One pole of h e r ambivalent feelings toward h e r m o t h e r was h e r resentment. Donna: She is a hard person to really please--she is just too particular about many
things . . . . I know when I buy something for mother, it won't fit, it won't be the right size.., everything has to be done to perfection.., every time we get her something it has to be exchanged five or six times.., if she wants to do something really nice for us, she fixes a nice m eal . . , she would be very hurt if we didn't eat it, but she doesn't want us to get f a t . . , she keeps fixing food--bread, pastries, starchy foods. H e r f ath er has been obese for 26 y e a r s - - s i n c e Donna was five. Both h e r brot her and sister need to watch t he i r weights very carefully. H e r m o t h e r is small and trim. Donna: My father and I are very very close.., one thing we share is that we eat
together.., my father and I are very compatible--when he walks into a room, I know that he is there. The harsh/indulgent dynamic is present to a degree within h e r parents. H e r mo th er is h a r s h in t h a t she is implacable. Donna feels very close to h e r father, which suggests t h a t he is lenient with her, though not necessarily indulgent. Donna: I have a wonderful husband. He will accept me the way I am--I can't.
The m o m e n t she moved out of her home e n v i r o n m e n t to live with her husband, whom she finds easy to please~ she lost control of h e r weight. Although h e r fath er was also easy to please, the harshness of h e r implacable m o t h e r was the dominant factor in the home. Donna needed to stay slim to please h e r mother. Indeed, she won two be a ut y contests before she married. Once she moved away from the immediate influence of h e r mother, the restraints upon h e r eating, which she had not internalized, were removed. Betty also experienced excessive weight gains from the age of 18. She was mar r ied at 16 but lived with h e r hus ba nd at home until moving away with hi m to California two years later. Betty: Mother knew that whatever we were to be, she made us . . . . We have no hate for
our parents---we knew we deserved it---she always told us why we were being disciplined.., she held two jobs, was gone all the time . . . . I've seen her come home and sit up half the night with our homework.., never a lot of time for cuddling and all t h a t . . , my sisters and I ran the family. The wrath of God is all I can think of with my fat her. . , oh boy! he used to beat us--made us choose our own switches.., studied for the ministry.., became an alco-
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holic.., got so strict, real mean, made us wash his feet at 2 a.m., beat us, but never remembered doing any of these t h i n g s . . , we knew it was a disease but it did not make us feel any better. T h e picture p r e s e n t e d h e r e of Betty's childhood is a u n i f o r m l y h a r s h one, and at some points horrifying. W h e n she and h e r h u s b a n d left t h e home, she m o v e d a w a y from the influence of h e r p a r e n t s and into r e l a t i o n s h i p w i t h two significant p e r s o n s - - h e r h u s b a n d and a n older w o m a n w h o m she m e t soon after m o v i n g to California.
Betty: My husband is a wonderful m a n . . , we are very very close.., there is nothing he would not do for me ... he says it [my excessive weight] does not matter to him but I don't believe him. I guess she was a mother substitute.., she cooked Italian style food.., she knew no strangers.., she accepted me like one of her own f a m i l y . . , she furnished an apartment for m e . . . she's special.., she's dead, but she isn't r e a l l y . . . I believe she's standing right h e r e . . . I can see her right now as my heart wants to see her. In this new setting B e t t y e x p e r i e n c e d the opposite to w h a t she was accustomed. H e r h u s b a n d is c e r t a i n l y l e n i e n t in his expectations. T h e ~mother s u b s t i t u t e " was i n d u l g e n t w i t h her. It seems t h a t w h e n she e x p e r i e n c e d leniency and indulgence a f t e r h a v i n g only h a r s h e x p e c t a t i o n s placed u p o n her, she b e c a m e i n d u l g e n t t o w a r d herself. F a y ' s w e i g h t p r o b l e m b e g a n at t h e age of 26. She associates it w i t h the t y i n g of h e r t u b e s at t h a t time. T h e r e were, however, o t h e r factors present.
Fay: As long as I can remember I have never heard my parents argue or split u p . . . my father never gets mad with anyone period.., he is liked by everyone .... my father is something like a father and a mother to m e . . . he did not want me to start a fight nor run from o n e . . , he would tell me that kindness would kill the other p e r s o n . . , mother said fists would do it quicker.., she was hot-tempered and would argue with other mothers--father would object to t h a t . . , he said '~turn the other cheek," she said, ~'don't, you'll get h u r t " . . , my children say my mother is cranky and e v i l . . , she said ~the boys are mine, you belong to your father." A degree of p o l a r i z a t i o n o f h a r s h n e s s and leniency can be seen in Fay's relationship to h e r m o t h e r , in c o n t r a s t w i t h t h a t to h e r father. She m a r r i e d an alcoholic, w i t h w h o m she did m u c h a r g u i n g and fighting. All h e r children h a v e ~'nerve problems." Soon a f t e r t h a t m a r r i a g e failed, she lived w i t h a m a n for about a year. It was d u r i n g this period t h a t b o t h h e r p a r e n t s rejected h e r and she b e g a n to g a i n w e i g h t rapidly.
Fay: My parents stopped speaking to me, mother more than father, but he said as soon as I can clean my house out, I would be his little girl again--that hurt me more than mother's greater rejection. F r o m F a y ' s responses it is not clear w h a t k i n d of r e l a t i o n s h i p she h a d w i t h this m a n she lived with. At the t i m e I i n t e r v i e w e d her, I did not realize how
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important the nature of this relationship might be. It is possible t h a t he expected very little from her. If it could be inferred t h a t she experienced him as compliant and indulgent in contrast to the felt harshness of her parents' rejection, then the onset of Fay's weight problems could be related to her emotional movement away from harsh rejecting parents and into an indulgent de facto relationship. Carol has been ~chunky" all her life. At the age of 15 she weighed 66 kg. (145 lbs.). At 18 she began drinking, and by 20 she was drinking heavily. Then she stopped suddenly and completely at the age of 25 when she realized, "I wasn't doing my grandmother any good." When she stopped drinking, she started eating. She was married soon after she stopped drinking and began to put on weight faster. Her father died when she was young, and she was reared by her grandmother, with a little help from her mother. Carol: My grandmother sent me to school--I played hooky a lot.., she was wonderful to
everybody--no matter who came to the door there was room for t h e m . . , she taught us that God is good even though we don't have what other people have.., she would beat all of us when no one would confess... I would say ~beat me first," because she was not too angry then--others were hiding, praying to the Lord, and she would be angrier. My mother was different from my grandmother--she would do for people but mostly would live for herself.., when I was sent to my mother for playing hooky, she said she would get me locked u p . . . you love your mother, but you don't know your mother sometimes.., you talk and I say one thing and she thinks another and we can't get close. The harshness of the expectations made of Carol is seen in the neglect by her mother, the inadequacy of her grandmother to meet her affectional needs, and the discipline administered to control her. As she moved into adulthood, her reaction was to drink heavily. Precisely why she stopped drinking and began eating is not clear to me. But it is clear t h a t weight control became a major problem as soon as she was married. Carol: We separated eight or nine years later . . . . I've always wanted to do what I
want--so maybe it was my f a u l t . . , he bosses--I don't like t h a t . . , he gets jealous of my mother and the things I do for her. Carol and her husband appear to have separated mainly because she resented the limits he was trying to place upon her. It can therefore be inferred t h a t early in their marriage he was more lenient in his expectations of her. In summary, the set of relationships within the immediate families of most of these obese patients revealed a common dual characteristic. Two opposite ways of relating were present. One was strict and harsh, the other lenient and indulgent. The patient was caught between these two polarities in a variety of ways. For Ann, the harsh polarity was represented by her father, the indulgent by her mother. For Gail, her mother represented the h a r s h polarity, while her mother's t r e a t m e n t of her siblings and her stepfather represented the indulgent polarity. Edith's parents were harsh toward her but indulgent toward her
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twin sister. Donna experienced her mother as harsh, her husband as indulgent. Betty felt her parents were harsh, her husband was lenient, and "mother substitute" indulgent. In the cases of Fay and Carol the evidence is not conclusive, though if further evidence were available, it may prove to be so. Fay felt her mother was harsh and her father lenient. If she found her lover indulgent, she would fit the pattern here emerging. Carol felt harshness from her grandmother and mother. If she experienced her husband as indulgent, as is implied, she too would fit the pattern. More can be said about this pattern. The experience of harshness always preceded or accompanied the experience of being indulged. It appears that the onset of obesity occurred when the patient was able to identify with the attitude that the significant indulgent person had toward her. When, by circumstances or by her own choice, indulgence, rather than harshness, became the dominant influence in her life, and there were negligible moderating influences, it seemed that she became indulgent toward herself and thus became obese. So this harshness/indulgence dynamic has contributed to a defective identity formation. These findings correspond with Bruch's conclusions: I have come to recognize as crucial issues in many patients with serious eating disorders, namely the basic delusion of not having an identity of their own, of not even owning their body and its sensations, with the specific inability of recognizing hunger as a sign of nutritional need. [italics in original] 6 Bruch sees these two traits as being of fundamental significance for the development of severe eating disturbances. The second has been outside the scope of this study, but my findings do support and elaborate upon the first trait, the defective identities of seven obese patients. To my knowledge, this harshness/ indulgence dynamic has not previously been observed as a pattern.
Conclusion
The use of a religious history questionnaire has revealed three prominent characteristics in this sample of obese patients: a feeling of helplessness and powerlessness, a craving for love, and strong guilt feelings. A possible psychogenic factor in morbid obesity was observed in five of the seven patients. Pertinent information on the other two patients was lacking. This factor is a dual dynamic of harshness and indulgence. Its presence in the backgrounds of the five patients was striking. The onset of obesity seemed to occur when indulgence became the dominating influence over harshness. The validity of this theory needs testing on a much wider sample of patients. Should it prove to have general validity for morbidly obese persons, it would modify one of the generally accepted categories of the psychopathology of obesity. Glucksman accepts Bruch's definition of developmental obesity as:
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This type of obesity plays a c e n t r a l role in the i n d i v i d u a l ' s growth and development. - T h e s e - p a t i e n t s become obese in ~chikihood, are preoccupied w i t h size and weight, and are u n a b l e to tolerate e i t h e r f r u s t r a t i o n or a d e l a y in gratification. 7
Five of the patients in my study are excluded from the category of developmental obesity by this definition. Yet they do not fit the categories of "absence of psychopathology" or "thin-fat people." It could be argued that theirs is "reactive obesity," the only remaining category, which would mean their obesity has followed an emotional trauma. However, the ascendancy of indulgence in identity formation is primarily a developmental process, not a reaction to a specific trauma. Hence, the definition of developmental obesity would need to be broadened in scope if the harshness/indulgence dynamic is a common factor in obesity.
References 1. Castelnuovo-Tedesco, P., and Schiebel, D., "Studies in Super Obesity: II. Psychiatric Appraisal of Jejuno-ileal Bypass Surgery," Am. J. Psychiatry, 1976, 133, 26-31. 2: Mills, M. J., and Stunkard, A. J., "Behavioral Changes Following Surgery for Obesity," loc. cit., 1976, 133, 527-531. 3. This religious history questionnaire was developed in 1969 for an unpublished research project on "Religious Ideation in Psychiatric Patients," by Daniel A. McKeever, under the supervision of C. Roy Woodruff, at Bryce Hospital, Alabama. 4. Homey, K., Self-Analysis. London, Kegan Paul, Trench, Truber and Co., 1942, p. 246. 5. Bruch, H., Eating Disorders---Obesity, Anorexia Nervosa and the Person Within. New York, Basic Books, 1973, p. 50. 6. Ibid. 7. Glucksman, M. L., "Psychiatric Observations on Obesity." In Advances in Psychosomatic Medicine, vol. 7, Hunger and Satiety in Health and Disease. Basel, 1972, pp. 199, 200.
