Some patients are deeply attached to their fat and cannot bear the thought of losing it. If they are intelligent, popular and successful in spite of their handicap, this is a source of pride. Some fat girls look upon their condition as a safeguard against erotic involvements, of which they are afraid. They work out a pattern of life in which their obesity plays a determining role and then become reluctant to upset this pattern and face a new kind of life which will be entirely different after their figure has become normal and often very attractive. They fear that people will like them – or be jealous – on account of their figure rather than be attracted by their intelligence or character only. Some have a feeling that reducing means giving up an almost cherished and intimate part of themselves. In many of these cases psychotherapy can be helpful, as it enables these patients to see the whole situation in the full light of consciousness. An affectionate attachment to abnormal fat is usually seen in patients who became obese in childhood, but this is not necessarily so.
In all other cases the best psychotherapy can do in the usual treatment of obesity is to render the burden of hunger and never-ending dietary restrictions slightly more tolerable. Patients who
have successfully established an erotic transfer to their psychiatrist are often better able to bear their suffering as a secret labor of love.
There are thus a large number of ways in which obesity can be initiated, though the disorder itself is always due to the same mechanism, an inadequacy of the diencephalic fat-center and the laying down of abnormally fixed fat deposits in abnormal places. This means that once obesity has become established, it can no more be cured by eliminating those factors which brought it on than a fire can be extinguished by removing the cause of the conflagration. Thus a discussion of the various ways in which obesity can become established is useful from a preventative point of view, but it has no bearing on the treatment of the established condition. The elimination of factors which are clearly hastening the course of the disorder may slow down its progress or even halt it, but they can never correct it.