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Introduction
Obesity is defined by the World Health Organization (WHO) as “a condition of abnormal or excessive fat accumulation in adipose tissue, to the extent that health may be impaired” (WHO, 2000, p. 6). Body mass index is the usual recommended measure for weight categorization; however, in children and adolescents, sex and age are also taken into account for nutritional classification, in view of the variation observed when their actual height is compared with what is expected for their age. Thus, the American sex-specific BMI curves are endorsed (Ministério da Saúde, 2021).
The WHO (2018) shows that obesity has nearly tripled since 1975, accounting currently for more deaths than weight deficit or malnutrition; in 2016, 13% of adults (above 18 years) were obese all over the world. In children and adolescents (between 5 and 19 years), 18% were overweight or obese. This data asserts the need to view obesity as a major public health issue, both in developed countries and in those under development, such as Brazil.
According to the evaluation of nutritional conditions of the Brazilian population carried out by the Pesquisa de Orçamentos Familiares (Consumer Expenditure Survey) 2008-2009 (IBGE, 2010), around one fifth of persons aged 10 to 19 years were diagnosed as overweight. This is most prevalent in South and Southwest regions, with a higher incidence in urban areas. It was estimated that about 5% of this population fit a diagnosis of obesity, which was most common in males. WHO (2017) data show that in Brazil, 9% of the population in the same age bracket presented obesity in 2016, also recording a higher frequency in males (10.1%).
The etiology of obesity is a complex and controversial matter, but there is a consensus in the literature that this condition arises out of an interaction of various factors. It is thus considered multicausal, a result of combining genetic, psychological and social characteristics that affect its inception and development. Constitutional (hereditary), socio-cultural, familial and emotional factors should, then, be taken into account, which may act independently or mutually interact (Azevedo & Spadotto, 2004).
Regarding psychological factors associated with obesity, there are both descriptions of psychic aspects arising from this condition, and factors that play a major role in gaining and keeping weight (Campos, 2005). Azevedo and Spadotto (2004) detail that excess weight may be considered as expressing an underlying emotional imbalance, characterizing hyperphagia as an attempt to deal with emotional suffering. However, hitherto there is no consensus on the direction of the association of emotional suffering and obesity, that is, which one promotes the other. Regardless of the direction, which precludes thinking of a cause-and-effect relation, the fact is that obesity and emotional difficulties are often linked, and thus both must be subjects for psychology, as well as other sciences such as medicine, nutrition and sociology. In sum, this demands a multidisciplinary approach.
Campos (2011) states that caution is required when approaching obesity as a psychosomatic issue, which suggests taking a biological phenomenon as a “psychic symptom”. Therefore, one must not envision it as a psychological disorder or a psychopathology, but rather as an expression of diverse forms of subjectivation and possible suffering. In this way, though Campos (2011) does not conceive of obesity as a “symptom”, she nevertheless keeps in mind the psychic aspect it presents.
Still according to Campos (2011), the feeling of being excluded from society for failing to conform to a standard built by the media and by medical and psychological sciences is what leads obese individuals to “malaise”. They are often discriminated against in educational, professional and social contexts, which leads to anxiety, anger, and doubts about their own abilities (Azevedo & Spadotto, 2004). Having a deprecatory self-image is commonplace among the obese, which may impact negatively in social relations. In this view, it is the stigma attached to obesity that furthers psychic pain.
On the other hand, the psychological literature also points out there are difficulties in symbolization in obese individuals, and asserts their drives find impediments to flow and be processed by words or fantasies (Almeida-Prado & Féres-Carneiro, 2010; Mishima & Barbieri, 2009). According to that perspective, Almeida-Prado and Féres-Carneiro (2010) remark that obese individuals’ difficulty with symbolization evokes significant drawbacks in the elaboration of living experiences, their frustrations and conflicts, due to a lack of psychic continence and internal resources.
The fading of social bonds and deficiencies in symbolic ability hinder proper defensive efforts and the elaboration ability of individuals faced with anguish that overloads and swamps them (Barbosa et al., 2012). Thus, social structures determine the possibilities for symbolization of desire, and indirectly affect the build-up of subjectivity (Campos, 2011).
In the case of adolescents, these emotional and social factors blend with biological and physical ones inherent to that stage of development. In adolescence, caloric needs go up because of pubertal growth spurt, and so do appetite and weight gains. This is then a risky phase, when media urgings and peer pressure to consume highly caloric and processed foods may lead youngsters to adopt unhealthy habits (Pereira, 2006).
The understanding of the psychodynamics likely to lead adolescents to obesity or to come up as effects of such situation is particularly important because, at this evolutive stage, there is a “revival” of the whole previous emotional development, this being the last phase when change in the nature of the personality structure taking shape is possible (Bergeret, 1991). This circumstance, combined with the particularly sensitive quality of this stage regarding body changes and the need for approval and belonging to a group, are likely to make clinical interventions more fruitful, by acting directly at the roots of difficulties lived and re-lived by the patient, and finding more flexible grounds for therapeutic work to blossom.
Towards that, Pereira (2006) described the association between struggles in socialization and excess weight in adolescence. He noted that obesity promoted social isolation, hindering the feeling of belonging to social groups; it thus affected negatively the forging of an individual’s identity. However, Pereira also reported, as did Novaes (2009), that obesity at this stage may be linked to a regressive desire to remain in infancy, which may act as protection in the development of sexuality.
Andrade et al. (2014), as they studied 491 obese children and adolescents under psychological evaluation, found emotional endangerment in most of them (85.7%), rooted in family psychodynamics. Besides a high prevalence of obesity in the family, they described overprotective parents and maternal rejection as the most frequent problems. Most children and adolescents showed low self-esteem, social isolation, shyness, complaints of social discrimination and a lot of anxiety. In contrast, Coury (2016) evaluated 60 children, 30 obese and 30 eutrophic. The comparison of emotional and cognitive indices in the Human Figure Drawing (DFH) test between the two groups did not show statistically significant differences, also not found in the personality variables assessed by Rorschach’s method.
Azevedo (2003) obtained results different from Coury’s (2016), in a study that also evaluated 60 children, 30 obese and 30 eutrophic, by means of the DFH: obese children presented a higher occurrence of emotional indices, showing signs of more insecurity, withdrawal, dependence, immaturity and repressed aggression. Likewise, Mishima and Barbieri (2009) described these same characteristics in obese children they evaluated with the Children’s Apperception Test with Animal Figures (CAT-A): they also showed passivity, low self-esteem, shyness, insecurity, shame, belief they were different from others, feelings of incapacity, and lack of motivation. Mishima and Barbieri reported there existed in these children difficulty in the contact with others, affective disengagement, impairment in creative process with attachment to external reality, and inability to play spontaneously.
In relation to adult obese individuals, Santos et al. (2002) reported attachment to earlier stages of emotional development, tending towards immaturity, dependence and passivity. They evaluated ten adults of both genders with morbid obesity by means of the DFH. Besides these characteristics, they found reluctance in accepting their own bodies, sexual conflicts, and impulse control impairment. Body image was imbued with feelings of inadequacy, inferiority, dissatisfaction, low self-esteem and inhibition. Nevertheless, most of them displayed good adaptive resources.
From these observations in the psychological literature on obesity, this study sought to find out the psychodynamics of obese adolescents through the Thematic Apperception Test (TAT), to deepen the knowledge about this subject. It may thus help to lay the foundation to develop intervention strategies more attuned to the needs of individuals afflicted by this condition who endure emotional suffering as a result.
Method
A clinical-qualitative psychoanalytical investigation was carried out, using a projective procedure to access conscious and unconscious experiences of adolescents that fit the diagnostic criteria for obesity.
Participants
The sample comprised seven adolescents from two medical clinics of a public health service in a medium-sized city in the state of São Paulo. Participants met the following inclusion criteria: to be between 12 and 18 years old, to have a diagnosis of obesity, to come from a family of medium or low socio-economic level, and to be in a school grade compatible with their age. As exclusion criteria, youths could not take part in the study who were suspected of psychiatric pathologies such as psychosis, addiction, bulimia, or cognitive deficit, as well as visual, verbal or neurologic impairments that would hinder the application of the evaluation technique, or an apparent physical condition that would interfere directly in their body image. These aspects were checked both during the volunteers’ first contact and along the evaluation and in the data analysis. One case was excluded for possible intellectual deficit.
Of the seven adolescents that made up the final sample, five were male and two female; their ages were between 12 and 14 years old. Only two of them were not under medical monitoring for obesity at the time of the evaluation. For ethical reasons, they will be referred to in this study by fictitious names (Pedro, Ângelo, Diego, Camila, Mateus, Caio and Luísa).
Instrument
The Thematic Apperception Test (TAT) was used. This is an instrument made of cards with images of somewhat ambiguous scenes, and the evaluee is asked to tell stories based on each. The stories elicited are regarded as induced unconscious fantasies. The application of this instrument and the interpretation of the output was performed based on the Parisian School framework, as proposed by Shentoub (1990), described and updated by Brelet-Foulard and Chabert (2008), which focus mostly on the nature of the respondent’s discourse vis-à-vis the latent contents of each image. In this framework, 14 of the 31 cards in the full test are applied, depending on the respondent’s gender (cards 1, 2, 3RH, 4, 5, 6RH, 7RH, 8RH, 10, 11, 12RM, 13R, 19 and 16 for male participants; cards 1, 2, 3RH, 4, 5, 6MF, 7MF, 9MF, 10, 11, 12RM, 13R, 19 and 16 for female participants). According to the Parisian School, these cards would be the most pertinent and meaningful considering the clinical material induced.
Procedure
Data collection started after the project was approved by the Research Ethics Committee of the authors’ home institution. To recruit participants, contact was made with a public health service clinic dedicated to treating obesity and an otorhinolaryngology clinic in the same institution which had many obese patients, because of comorbidity with the pathologies dealt with there, such as breathing afflictions and sleep apnea.
In this process, a preliminary analysis of patients’ records was carried out by the psychologist conducting the study and the doctors managing the clinics, to identify cases that fit the inclusion and exclusion criteria. The initial contact with a youngster and their family was made during scheduled appointments, by doctors or by the researcher herself, while patient and parents waited for their consultations. With patients who showed an interest in taking part in the study, a telephone contact was arranged, then a meeting outside the institution was set up. The meetings took place either in a psychology school-clinic, or in the participant’s own home, according to their convenience. Requirements were always verified regarding privacy, furnishings, lighting, among others necessary in psychological assessment procedures.
Data analysis
The analysis of the TAT was performed beginning with the systematization of topics mentioned by the participants and the procedures they employed to address them in each story produced. The topics were defined based on the main anguish or source of concern conveyed in each story, which were later classified into six categories: loss of object, fear of drive experiences, fear of helplessness, resurgence of the Oedipus conflict, mourning for childhood identity, and desire for autonomy. Those that came up in one or two stories by the participant were deemed low frequency; the ones present in three or four stories were said to be of intermediate frequency; and those that occurred in five or more stories were high-frequency topics.
Regarding the procedures to address the topic, they consist of defense mechanisms employed by the ego, expressed in the elaboration of the evaluee’s discourse. According to the Parisian School framework, proposed by Shentoub (1990) and updated by Brelet-Foulard and Chabert (2008), they are arranged in four series (A, B, C and E), each of which contains subdivisions gathering mechanisms upheld by the same psychic conducts. There may be more than one procedure in each story, which is usually the case.
All the procedures detected in each participant’s stories were identified and their percentages stipulated in the individual protocols, based on the total of procedures the participant employed. The same was done regarding the series the procedures belonged to (A, B, C, E). In this process, because no normative data about the expected frequency for each series in a typical protocol were available for the Brazilian population, it was assumed that, if there was an equal distribution, each series would have a 25% chance of coming up in a story. So, the occurrence of procedures from a series 25% of the time in a protocol could be considered average. Hence, a 10-point band above and below that value (i.e., 15% to 35%) was established as moderate frequency; series below 15% of presence were said to be of low frequency; and those above 35% of incidence in the protocols were defined as high frequency. Despite the arbitrary character of this classification, for lack of better guidelines, these parameters were adopted in this study to enable a discussion about the themes and procedures used by the adolescents.
Ethical concerns
The research project for this study was approved by the Research Ethics Committee of the authors’ home institution. All of the participants’ rights were complied with, such as privacy, the volunteer character of participation, and the freedom to withdraw from or drop out of the study at any time. These aspects were spelled out at the time the Term of Consent was signed by a participant’s parents, and the Term of Free and Informed Assent by the participant, who were handed copies of both documents.
Results
In this section, the main concerns revealed in the narratives elicited by the cards will be presented, followed by the defensive procedures used to deal with them. Examples will be reproduced to make these concerns and procedures clear.
Concerns
Table 1 shows the categories that arrange the concerns observed in each participant’s narratives, and how often they came up.
Table 1 — Concerns expressed in the TAT narratives of each participant
| Participant | Major concerns | ||||||
|---|---|---|---|---|---|---|---|
|
| |||||||
| Loss of object | Fear of drive experiences | Fear of helplessness | Resurgence of the Oedipus conflict | Mourning for childhood identity | Desire for autonomy | No concern expressed | |
| Pedro | 2 | 6 | 0 | 0 | 0 | 0 | 6 |
| Ângelo | 1 | 5 | 0 | 2 | 2 | 4 | 0 |
| Diego | 2 | 1 | 1 | 1 | 0 | 0 | 9 |
| Camila | 1 | 1 | 3 | 5 | 2 | 2 | 0 |
| Mateus | 0 | 3 | 2 | 4 | 2 | 2 | 1 |
| Caio | 1 | 2 | 4 | 1 | 0 | 0 | 6 |
| Luísa | 2 | 3 | 2 | 3 | 2 | 2 | 0 |
| Total | 9 | 21 | 12 | 16 | 8 | 10 | 22 |
Table 1 shows that in 22.5% of narratives no concerns were expressed; the participant did not go beyond a plain description of the card, without projecting any internal aspects. In these cases, no movements or interactions among the characters was mentioned, nor any conflict or concern acknowledged; the participant remained at the surface of the story. This kind of approach to the card exposes a disturbance endured in the face of its latent contents, refusing or avoiding the concern, which blocks the expression of the conflict. This classification of unexpressed concerns was the most prevalent, arising in 22 stories, and can be exemplified by Diego’s discourse in card 11:
Hmm? I can’t even see what’s in this image. I can’t understand what’s here. I see a bridge, a pile of rocks and… I don’t know if this is a dragon… looks like a dragon, only the shape of the head not so much. There is a wall. This here I don’t know what it is, I don’t know if it’s an animal, I don’t know if it’s people, don’t know… There’s nothing else to say here… (What is happening…?) [shakes his head in denial].
Regarding the concerns actually expressed, the most common was the fear of drive experiences, present in 21.4% of stories. All participants mentioned this fear, in varying degrees. Aggressive drives were often projected onto the physical realm and emerged in the stories as able to wreak irreparable destruction and calamities, which made them frightful. Ângelo’s story for card 19 demonstrates this fear:
[…] One day the whole family together too, but they lived on a beach house. Then everybody was together, celebrating, it was a party. Then they all went up the hill to see the fireworks, ’cause it was the end of the year. The whole family, everyone. Then a strong wind started, real strong, they were quite scared, then the waves started to rise, then suddenly they saw back there a wave, a tsunami coming, and they were frightened, there was no way to go down, no way to get away, all was stopped on the hill, just waiting for the tsunami. Then it toppled the house, the backyard, the front porch, it razed the house and everything, the friends, the friends’ houses around, everything, and the last thing they saw of the house was the tsunami engulfing the houses.
This way, the fear of being invaded and controlled by the drives (or become their victim if they are projected onto the environment) seems to strongly affect the experiences and fantasies of these adolescents, often triggering a drive inhibition, as will be detailed below, in the analysis of defensive procedures.
The resurgence of the Oedipus conflict was also quite frequent in the adolescents’ stories (16.3%), absent only in Pedro’s output (see further details below). The ability to elaborate the Oedipus conflict varied among the participants, some of whom resorted to more regressive strategies, as shown by Camila in her story for card 9MF:
The girl’s mother saw the girl running away and went after her to beat her, but the girl escapes and her mother cannot find her. The girl was hanging clothes to dry. Ten years later, the mother is still looking for her. But she can’t find her. After a long time, more than ten years, the daughter comes with a kid, three kids to her mother’s home, but unfortunately the mother has passed away. She takes all that her mother left as inheritance and stays in the house. Her father and her brother are still alive.
In this story, Camila deals with the matter of rivalry with her mother, and in the end the daughter prevails over that character and takes her place. In this case, the conflict seems to be lived quite directly, with little symbolization.
Though one of the participants, Pedro, did not create Oedipus-themed stories, this does not mean he wasn’t in a process of re-experiencing this conflict (which came up as background for some of his stories). The analysis of his case showed, rather, a deliberate effort on his part to avoid that theme. This seems to be one of the reasons why he found it hard to access the conflicts, having produced a number of stories with no concern expressed.
The fear of helplessness was the third most frequent concern in the adolescents’ narratives, and the dominant one in twelve stories. This referred, directly or indirectly, to the need for the other to perform some activities, or to the impossibility to carry them out alone, as exemplified in Caio’s story for card 1:
I see a disoriented brat, with nothing to do, sitting, uh… looking at the violin. And I think he can’t play it, he doesn’t know how to handle a violin… I don’t know, he is sad, depressed… Alone. Left to himself. Deserted.
In this story, Caio alludes to a feeling of disorientation in the face of helplessness, with no one’s help to count on. There seems to be a fear of not having what is required to be able to complete tasks independently, and a distrust of his own autonomy (even if that entails taking the initiative to seek the help of others when needed).
In opposition to that fear, the theme of desire and the search for autonomy also had its place in the adolescents’ narratives. However, it was not so frequent among the participants; only Ângelo expressed it in four of his stories, as in the one for card 2:
It’s… a family of peasants, a father who worked in the fields, he did… he had a farm and the mother wanted the daughter to help her with the household chores. Like doing… washing dishes and such, house cleaning, but the girl wanted to study. And the mother didn’t want her to study, wanted her help at home, but the little girl wanted to study. So, though the mother didn’t want her to, she studied by herself, covertly, and after some time she managed to graduate and she made her proud… she showed her mother that studying was very good for her, it wasn’t bad as she used to say. She pulled her family out of poverty, improved the farm, the house, got some profit, and the studies were very good.
In this story, the character tries to achieve autonomy by distinguishing herself from her family. However, this quest often comes together with feelings of guilt, followed by the need to make amends to the parents: there seemed to have been a fear that, by achieving autonomy, this would imply fully detaching from them.
The concern of loss of object was there in almost all participants. Despite being unanimous, it seldom appeared in the stories; it can be illustrated in Luísa’s narrative for card 5:
That’s an elderly woman arriving home. She lives alone, she has no one left. As far as she knew, there was nobody from her daughter with her anymore. She lives alone in the house… but she is very happy… But on this day she was looking for something very dear, a photo, the only photo she has to remind herself of her daughter, who died at 25 in a car accident. But she couldn’t find the photo anywhere. She was worried. She was sad on that day because the photo was nowhere to be found. And then her life plunged into this sadness, because she had no memories left of her daughter. That’s all.
The main theme of that story is the loss of object, with the fear that it won’t survive in the psychic reality. This anguish, though less frequent in the output, seemed to dwell in the imaginary of most adolescents (only Mateus did not display it), and was often associated with the fear of helplessness. Nevertheless, these two categories are distinct, because the latter is more linked to the difficulty to hold oneself as an autonomous being, while the loss of object is related to its absence or the privation of its love.
Regarding the mourning for childhood identity, Table 1 records its presence in four of the adolescents, but in few, only eight, of their stories. In this context, it bears considering that most participants were at the beginning of adolescence, 12 or 13 years old (only Mateus was 14); so, they had only recently entered this evolutive stage. Therefore, the losses of childhood seemed not to hold much sense for them yet.
Two of Mateus’ stories are emblematic of this process of mourning and nostalgia, identified both by their contents and by the sequence they came in, as responses to cards 12RM and 13R:
This here is a place where lots of people have died. But now it is deserted, dirty and neglected. This. (card 12RM)
I think this is the little boy in a very old house. Even though it’s old, he’s thankful… for he has a house. That’s it. (card 13R)
In the first narrative, Mateus alludes to a place once full of life that was left behind, abandoned. However, in the story he told next, he presents the possibility of being thankful for what he once had, that is, there is a mourning for losses and, simultaneously, the feeling of having had something good, that remained in the past but can be internalized.
In sum, the theme of mourning for the loss of childhood was the least frequent concern among the participants. It requires a degree of contact with the losses of childhood, but is distinct from the concern of loss of object, because it is a part of the process of entering adolescence. Though most of the adolescents demonstrated some level of contact with it, three of them did not seem to be living this experience. They seemed somewhat distant from a definite entrance into the new evolutive stage, still very deferential to the environment and to authority figures, which suggests a strong attachment to the identity of children.
Discursive procedures
Table 2 shows how often each procedure series (A, B, C and E) was employed by the participants and their respective percentages. It reveals that the mechanisms most used by the adolescents belonged to C series (conflict avoidance) and to A series (rigidity), followed by B series (lability), whereas those in E series (emergence of primary processes) were barely used.
Table 2 — Series of procedures in TAT narratives of each participant
| Participant | Series of procedures | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||
| A: Rigidity | B: Lability | C: Conflict avoidance | E: Emergence of primary processes | Total | ||||||
|
| ||||||||||
| freq. | % | freq. | % | freq. | % | freq. | % | freq. | % | |
| Pedro | 21 | 26% | 18 | 21% | 33 | 39% | 12 | 14% | 84 | 100% |
| Ângelo | 31 | 26% | 47 | 39% | 27 | 23% | 14 | 12% | 119 | 100% |
| Diego | 32 | 42% | 3 | 4% | 35 | 46% | 6 | 8% | 76 | 100% |
| Camila | 28 | 24% | 42 | 38% | 20 | 18% | 22 | 20% | 112 | 100% |
| Mateus | 18 | 33% | 16 | 29% | 17 | 31% | 4 | 7% | 55 | 100% |
| Caio | 23 | 27% | 11 | 13% | 43 | 49% | 10 | 11% | 87 | 100% |
| Luísa | 15 | 21% | 26 | 37% | 23 | 32% | 7 | 10% | 71 | 100% |
| Total | 168 | 28% | 163 | 27% | 198 | 33% | 75 | 12% | 604 | 100% |
Regarding series C, three adolescents (Pedro, Diego and Caio) used it often (39%, 46% and 49%, respectively); the others, moderately. These mechanisms made plain an individual’s struggle to reach intra-psychic conflicts, and could be detected by long latency times, silences in mid-narrative, tending to or actually refusing a card, trivialization or failing to assert conflicts, and character anonymity, as displayed in Diego’s story for card 10:
(TL: 2’42” and TT: 4’17”) It’s… […] [2’42”] It’s a man and a woman, that’s all I can see, I don’t understand anything else that’s going on in this image. (No? Can’t you say what they’re doing?) Ha-hamm. (Want to try to invent, or go to the next?) I want to go to the next.
A strong tendency to refuse is noticeable in this card. Latency time is high, there’s the anonymity of the characters, who show no connection: Diego doesn’t go beyond trying to describe what he sees, sticking to the perception.
The heavy use of C series procedures uncovers the adolescents’ difficulty to get in touch with conflicts, prompting blocking and avoidance mechanisms to keep some balance, which was more evident in Diego and Caio. One must emphasize the higher frequency of inhibition, which suggests a lessened ego functionality.
Regarding A series, it collects the procedures related to defense mechanisms rooted on rigidity. Most participants used resources from this series moderately (between 21% and 42%; 28% of total); only Diego used them more often in his stories (42%). The most employed mechanisms from this series were of the obsessive kind, codified when the speech includes verbal precautions, hesitation between interpretations, reiteration of ideas, and minimal expression of affection, as illustrated in Diego’s story for card 3RH:
Well… Humm… This here may be a cemetery, the corner of a room, or a sofa. I think it’s a woman. If it’s a cemetery, that’s probably because the husband or the son died. If it’s a sofa, a corner of a room, probably she was assaulted or got some news. This is what I see. (Uhm! That’s all?) [shakes his head affirmatively]
As the sample shows, Diego started with a verbal precaution “here may be”, with an attempt at spatial precision (cemetery or corner of a room). He again uses a verbal precaution (“I think”), hesitating between interpretations. There was also a minimal expression of affection.
In this way, by employing procedures of the obsessive kind, the participants try not to be directly implicated by interpreting (using verbal precautions), cancel the conflicts the card evokes, revert drives to their opposites (reactive formation), deny the connections, as well as toning down the affective burdens elicited. This was quite common among the adolescents, which underscores the weight of this defense. The recurrent application of these mechanisms happened at the expense of those related to investments in internal reality, making intra-psychic conflicts seldom expressed.
Series B, the third in the preference of participants, deals with the use of lability procedures. Application of these defenses varied considerably among the adolescents, as is shown in Table 2 (between 4% and 39%). Among the procedures in this series, those of investment in the relation were the most employed, with Diego alone using them sparingly. They are identified when the narrative stresses relationships, characters absent in the card are included, or expressions of affection are introduced. Mateus’ narrative for card 6BM is an instance:
The father of this… this young man died. His mother is sad and he is sad. But in the end everything will be alright, he will take care of his mother. That.
There is in this narrative the introduction of a character who is not in the image, the “father”, an outlined relation between mother and son, and the expression of the affection “sadness”. The employment of such procedures signals an engagement in the relationships. Thus, B series procedures generally imply a preserved relational investment by the participants. In Diego’s output, these procedures showed up much less, which evidences a depletion of object relationships.
The last series, E (emergence of primary processes), was the least employed, with most participants seldom using these procedures. When used, the massive projection mechanism was the most frequent. It was chiefly Camila who repeatedly used this device, which is identified in the narrative by calling forth themes of persecution, bad objects, or crude expressions related to sexual or aggressive themes, as depicted in her narrative for card 5:
A woman invaded another woman’s home, her neighbor, to spy, and found her husband with the neighbor, having coffee. She saw them together and didn’t like it, made to strike the woman. (It ended like that?) No… She breaks up with the man, finds that… she got pregnant by him. (She who?) The man’s real wife. And she’s pregnant by him, the neighbor also had a baby with him. Both are pregnant at the same time. The babies will be born and go up for adoption. Done.
In this narrative, there is the theme of persecution (“spy”), as a bare expression of aggressivity. Along the story, two other E series procedures come up: the mixed-up identities when the pronoun “she” is used, making it unclear who Camila is talking about, as well as a temporal incoherence, in that the woman who had a baby is pregnant again. In this case, there is an intrusion by phantoms, indicating moments of confusion.
In short, the participants displayed defenses meant mainly to avoid contact with conflicts, using mostly inhibition, that is, blocking access to intra-psychic matters. In this context, the overinvestment in external reality takes precedence over contact with the internal reality. Rigidity, also frequent in the adolescents’ protocols, especially obsessive procedures, substantiates this observation, sustaining inhibitory procedures and affective control. The reference to external reality supports this dynamic of not getting emotionally implicated in the situations. However, there was also a good investment in relationship matters, with Diego alone presenting some difficulty about that. Thus, affective rigidity and inhibition are balanced by this possibility of access to affections and object investment, imparting more flexibility to the adolescents.
Though the most used procedures belong to series C, which denotes operating closer to borderline states, the frequency of use of mechanisms from series A and B lends to the group a trait more compatible with a dynamics of neurotic nature. This hypothesis is validated by the limited use of procedures from the emergence of primary processes (series E), which refutes a dominant psychotic functioning, but suggests the possibility of an enhanced permeability among psychic instances.
Ultimately, the analysis of the stories produced in the TAT by the adolescents unveiled an effort not to express problems (which happened in four participants), and when they were expressed, the predominance of the kind related to the fear of exposing drives. These anguishes and efforts lead to, and were also a result of, the employment of defensive procedures of inhibition and of an obsessive kind. Therefore, the adolescents, when confronted with latent contents elicited by the cards, showed a tendency to blocking and inhibition, resulting in a struggle to express their internal world, with which they seem to have little contact.
Discussion
The analysis of the matters expressed and procedures employed to manage them, as evidenced in the TAT, has shown that the adolescents proved to be more compliant to exterior reality, still dependent on authority figures. Though these results may support observations by Pereira (2006) and Novaes (2009) about obesity masking a youngster’s wish to remain in infancy, shielded from the development of sexuality, one must bear in mind that, in this study, participants were newcomers to this evolutive stage, whose psychodynamics (mourning, conflicts and anguishes) seemed to have just begun to emerge. As such, they told few stories about mourning the loss of childhood identity, some not coming up with any narrative on that subject, as well as having made scant reference to sexual drives.
However, the adolescents evidenced a somewhat diminished ability to symbolize, which seemed to jeopardize their capacity to elaborate anguish. Thus, they showed in their stories significant difficulties in contacting and expressing intra-psychic conflicts, and so, a lesser freedom of self-expression. This observation agrees with conclusions by Almeida-Prado and Féres-Carneiro (2010) and by Mishima and Barbieri (2009), who pointed out the absence of psychic continence in obese individuals, which entails impairment in the elaboration of life situations, frustrations and conflicts. Still, Barbosa et al. (2012) stated that the difficulties of symbolization and elaboration of anguish would be general attributes of individuals in contemporary western society, rather than specific of obese persons.
In fact, compromises to symbolization are found in psychological suffering of various sorts, such as addictions, pathologies of the act, eating disorders, and psychosomatic illnesses. Obesity might, then, be added to these other problems, with no pretension of deeming symbolization flaws as its pathognomonic trait. Therefore, the results of this study lead to a conclusion akin to Campos’ (2011), that, though there are psychodynamic factors that foster excess weight, it is impossible to establish a single profile or mental structure for obese individuals (Campos, 2005).
The absence in this study of a control group made of eutrophic adolescents devoid of emotional suffering prevents a debate and a contrast with Barbosa’s (Barbosa et al., 2012) assertions. However, if disruptions of symbolization could encompass everyone in contemporary society, as claimed by that author, their harmful effects on mental health would be universal, which would entail a widespread degradation of the population’s emotional well-being, a most questionable stance.
Though the literature suggests there are, among obese individuals, obstacles to socialization and complaints of discrimination, with social isolation and reticence (Pereira, 2006; Andrade et al., 2014), that was not apparent in this study. Social sphere did not seem impaired among the participants, even though they displayed some dependence on their families and reticence during contact, as betrayed by their inhibitions in coming up with stories in the TAT and their infrequent mentions of the topic of seeking autonomy. These traits, which sustain reports of dependence, immaturity, insecurity and stifled belligerence some studies detail (Santos et al., 2002; Andrade et al., 2014; Azevedo, 2003; Mishima & Barbieri, 2009), though they occur in the adolescents in this study, did not seem to impact on their contact with peers and other people outside their families. Thus, none of them regarded obesity as having any adverse repercussion in these domains.
However, a greater difficulty by the participants to reach conflicts and express them was found, which led to a lower possibility of elaborating them effectively, mainly due to the massive use of drive repression. Though these characteristics may correspond to what Campos (2011) pointed out as factors likely to lead to emotional issues, the adolescents evaluated in this study cannot be represented as having any unsettling trace of open psychopathology, neither among those under treatment for obesity or among those who fit the criteria for that diagnosis, but had not undergone a specific intervention for it. Only Diego featured a few signs of more acute suffering, which cannot, though, be conclusively identified as emotional disturbance.
In sum, the results of this study have been found to agree with those in the scientific literature that reported difficulties in symbolization and creative expression among obese individuals. The inhibition and submission to external reality were patent in the participants’ output, denoting a lesser capacity for psychic continence. They avoided access to internal conflicts, which made it harder to elaborate and express drive experiences. In this sense, drives, especially aggressive ones, were suppressed, which contributed to their propensity to remain in infancy, undifferentiated from their parents, eternizing their dependence from them. However, these traits, as well as the superficiality of relationships ascertained in the evaluations, did not seem to impact negatively in the adolescents’ social bonds, nor did they reach levels that would warrant a psychopathology diagnosis.
Final considerations
The results of this study allowed the identification of some obstacles, raised by the obese adolescents studied, to the contact with their own creativity and its expression, and thus for symbolization, handling affections and elaboration of conflicts. According to Novaes’ (2009) observations, the participants found it hard to discard the child identity, with scant signs of seeking autonomy. However, the participants being at the beginning of adolescence demands caution with this kind of interpretation, considering that conflicts related to dependence, to autonomy, and to the loss of childhood bisexuality may not have reached their peak.
In spite of the difficulties mentioned, the participants did not show manifest emotional suffering arising from their condition of excess weight, either in the individual or in the social spheres. However, they showed common traits that, though they are not specific or pathognomonic of obesity, are likely to contribute to emotional difficulties at times of higher affective mobilization. This possibility is mainly due to deficiency in the abilities of symbolization and psychic elaboration. In this context, it is important to take into account the family help to assist the youngster in developing and strengthening these capacities. The family group, inasmuch as it provides limits to contain the adolescent’s anxiety (Winnicott, 2000), offers an external support that, by introjection, helps to build up the capacity for psychic continence; from there, ways for the elaboration of conflicts and anguish are opened and the symbolization ability can flourish.
In view of that, interventions about obesity must heed the adolescent’s psychodynamic operation, as the results of this study have shown, to gain depth when the family group may also be known for its abilities to absorb the adolescent’s anxiety and help them develop these important emotional achievements he seems to fail at. This joint undertaking with the adolescent’s family will constitute an extension of this study.
Nevertheless, the individual output of the adolescents who took part in this study in the Thematic Apperception Test already provide relevant evidence regarding the psychological approach to these cases, to be detailed in psychotherapeutic care, when that becomes necessary. The results suggest that interventions to stimulate the free expression of these individuals, whether in conversation groups or through creative and artistic activities, might be beneficial, emotionally speaking, together with medical and nutritional care for this situation. These might be ways to help them express their own creativity, and hence develop their symbolization capacity.
