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Contemporary cultural attitudes may be observed as providing a strict definition of the limits of body fatness for young women. Because the analyst is likely to share these cultural attitudes to a greater or lesser extent, his treatment of the young woman who presents with the chief complaint of overweight offers a clinical instance from which we may learn how culture may affect the perspectives and attitudes that the analyst brings to his work.
Reviewing the literature about cultural influences on the analytic relationship and treatment, Speigel stresses that difficulties arise mainly when patient and therapist are from different ethnic groups.1 He regards psychoanalysis as an essentially middle-class treatment modality because of implicit values prized by psychoanalysts—values such as personal autonomy and responsibility for future commitments. This view holds that psychoanalysis, its theory and practice, is a manifestation of broad historical currents, cultural flux, and social class: it demands of the psychoanalyst qualities of skepticism and wonder that extend to the analyst's and the culture's most cherished values. Skepticism and wonder function in the psychoanalyst to encourage humility in the face of immense arbitrariness. They function, more specifically, by opposing ready compliance with cultural norms.
But suppose skepticism and wonder are stifled by a culture in which there is an insufficient divergence of values, and, in consequence, a tyranny of fashion prevails. Behavior and wishes that run contrary to the norm will then seem wrong, sick, criminal, or unaesthetic.2
Among physicians, derogatory characterizations of obesity and a disinclination to treat obesity were reported by Maddox et al.3 and Maddox and Leiderman4 despite the belief among the doctors studied that obesity contributes to physical illness in middle and later life. Similarly, Stunkard and McLaren-Hume note that physicians generally regard the failure of their patients to reduce weight as