This e-mail was a response to previous research findings and sparked the idea of writing a narrative case study with a life course perspective. Thea was in her early sixties. Forty-five years after weight loss surgery (WLS) she shared her life story revolving around body weight. Her story is analysed in light of phenomenological and narrative theory, and cultural narratives surrounding current WLS stories. Starting from narrative phenomenology, we seek to understand how experience of the world, oneself and others are told, formed, and influenced by the body. In the medical narrative genre of WLS kilos and Body Mass Index, are core concepts. Life is lived, however, and is told from the first-person perspective, and always situated within a cultural context of time and place, and narratives shaped by the medical culture tend to weave into the individual person’s particular narrative.
With Thea’s narrative we aim to investigate the complexity of dealing with being overweight over time. To understand core meanings of selfhood, body and change, we explore her rich narrative account of struggling with her body weight, feelings and eating for a lifetime. We investigate interconnections between a life story, body and self through the lens of weight loss and weight loss maintenance following surgery. Our inquiry departed from the following questions: What is it like to keep fighting for a healthy weight throughout life? In which ways do fighting weight weave into self-understanding and relationships? How does Thea’s life story and weight story interweave and make meaning?
First, we lay out the theoretical lens of this analysis combining a phenomenological and narrative perspective on embodied life. We then present the methodological underpinning before sketching out the method of producing this narrative material. Thea’s narrative is structured into two distinct genres: a brief medical narrative and a life story. Finally, in the discussion we aim to deepen the understanding of her struggles with food, body and emotions throughout life and in the wake of surgically induced weight loss.
Embodied narrative phenomenology: a theoretical lens
In phenomenology, the
first-person perspective is decisive
, meaning that any understanding of experience begins from the subjective dimension. Merleau-Ponty described the body as foundational for human existence, a premise for having experiences, thoughts and emotions, a past, a present and an anticipated future (Merleau-Ponty
1945/2012; Landes
2017). We experience ourselves related to others and through others, in action and interaction (Merleau-Ponty
1945/2012). In other words, subjects depend on and inhabit an
intersubjective world from the very start. Human existence is always already embodied and situated in both nature and culture
. The notion of the
lived body points to the subjective (thoughts and emotions) and physical dimensions of our being as inseparable, and at the same time our reaching toward and inhabiting of the sociocultural world. The body is both me and mine, I am it and I have it, I can see from it, I am visible as it. I cannot get rid of it and it will outlive me in the sense that as matter it lasts longer than I. As such, understanding the body as lived, recognizes a certain ambiguity (Merleau-Ponty
1945/2012).
Emphasizing subjectivity and the lived body does not mean that individuality takes precedence over the world of physical things and others, or that a specific truth resides deep inside each person (Merleau-Ponty
1945/2012). Rather than being encapsulated within itself, the individual exists primarily through preconscious, pre-reflective dealing with the physical and sociocultural world (Slatman
2014). The phenomenological foregrounding of the lived body and the inseparability between person and world makes it possible to bypass traditional distinctions between body and soul, nature and culture, flesh, thought and emotions, person and world. We have our bodies, are our bodies, and we are more.
Slatman (
2014) pointed out that our
own (lived) body always carry
strange elements. She explored bodily identity phenomenologically and in the context of medical interventions, and analysed bodily adjustments, bodily technology, plastic surgery and so forth. On this basis, Slatman proposed that we can adjust to dramatic bodily changes and tolerate strangeness (the bodily aspects that we cannot directly experience or fully know) precisely because of this incorporated strangeness. This results in “a paradoxical idea of identity: that which makes me `I´ is something that is simultaneously own and strange to my `me-ness´ (p. 20). The strangeness relates to the substance-dimensions of the body, to which we have a certain distance. After all, changes and processes in cells are not directly available or recognizable in our experience.
The body that we have is the body that we are, and in the moment something new occurs, like a painful injury, our relationship to own body alters. This means that the dynamics between habitual and spontaneous aspects of the lived body are central to bodily identity and are foregrounded when living through bodily changes. As we coexist and interact with others in a shared world, other people’s gaze and possible judgements or rejections raise our awareness of how the body visible to others, is the body that we have. Hence,
body image affects how we experience ourselves. Bodies vary and change, and human beings grow and alter as life unfolds. Although the body changes both invisibly and visibly in illness, through medical interventions and aging, we continue to experience ourselves as the same person. We do not become someone else (Slatman
2014). New experiences, perceptions, practices and emotions keep coming and replacing those that we once had, yet some of our experiential domain holds on to a certain continuity.
Ricoeur (
1994) elaborates on identity in the tension between innovation and sedimentation. He proposes that a person’s identity emerges in the identity of this person’s story. Identity can only develop through communication. It is in the construction of a story about life experiences that identity comes into being when the acting person transfers events into plots. Thus, identity is structured in the structure of the narrative. This means synthesizing a complexity of events and actions, and configuring these in relation to what passed and endure. Narrative identity thus generates from the interpretation of action in time and is shaped in the dynamic between two overlapping poles of the self. The storytelling pole expresses selfhood as consistency (
ipse).
1 Over time this consistency becomes sedimented as characteristic traits of a person’s self like habits, roles etc., which can be recognized as the same over time (
idem).
2 Thus,
what we are (idem/sameness) and
who we are (ipse/selfhood) overlaps. Selfhood depends on the support of sameness, without this support identity may be impaired by lack of stability. On the other hand, if sameness overshadows selfhood, a rigid personality may portray dominating character traits without the capacity to adjust to the varying challenges during life. Identity is not static. Driven by the tension between life as lived and life as told vast variations are possible in the configuring process (Ricoeur
1994).
Creating a coherent life story involves one’s ability to link diverging events and actions and to seek a sense of coherence in phenomena like memories, goals, habits and values, reinterpretation, and creative imagination. The spiral force creating identity depends on our imaginative capacity while moving from life to story and from story to life. When telling someone about an experience, understanding of meaning arises from how the storyteller structures the story and forms themself through narration. Stories may give coherence to the drama and the messiness of life in temporal order with beginnings, middles and ends, yet there are times when “the past bleeds into the present” and tends to interrupt order and plot (Riessman
2015). Narrative approaches hold potential to account for unexpected, unintended and complex turns in life stories, and also to indicate what is not straightforwardly narrated. They do not rely entirely on the storytellers’ capacity, they also depend on what narratives can be told in a specific context (Tengelyi
2018). Narratives told about the self may not be as orderly as they are often taken to be, and the self in action and experience may not be as messy (Mattingly
1998).
Narrative theory acknowledges that there is a tension between life as lived and life as told (Kristensson
1994), but there is a criticism that a narrative approach to selfhood tends to reduce bodily being to narration and language, and aim for too massive and ordered a representation of life stories (Tengelyi
2018). However, bodily being not only arises from the lived body, it also holds what we might become and our narration of it. According to Ricoeur, human life is deeply connected to the lifeworld. One’s own body is the mediating structure of being in the world, and the earth is the “mythical name of our corporeal anchoring in the world” (Ricoeur
1994, p 150). Here, identity is about body, experiences and world united. The body is a dimension of oneself, and the imaginative variations around the body are variations on the self.
This existential underpinning of bodily being in the world appears to follow the same line of thought as Merleau-Ponty who connected sedimentation to embodied experience, and its potential power to effect, restrict or release our bodily becoming (1945/2012). Merleau-Ponty pointed to repeated practices, attitudes, norms and beliefs that can acquire preference and become habituated and incorporated, and which are not easy to change (Zeiler
2013). We are and become ourselves in tensions between what stays the same and what changes, between being ourselves and becoming ourselves in encounters with others. According to Ricoeur, acquired identification incorporates
the other into the composition of identity in the pole of sameness. We recognize ourselves in other people and cultural heroes, and as we develop loyalty and fidelity to them their norms and values become internalized in our character traits (selfhood).
Essential to narratives is that one thing happens in consequence of another. This is commonly referred to as narrative causality. Storied description is a human way to find coherence and meaning. To what extent narrative expresses the shape versus its meaning is debated. The core question is what is primary, experience or narratives? A humanistic, person-centred approach emphasizes lived experience primary to narratives. Narratives express action and experiences in individual meaning making. Agency and identity evolve through structured stories representing the individual (Squire et al.
2013). Structuralist and poststructuralist critiques are that cultural narratives exist before action. Cultural script guides human conduct and meaning making and events imitate stories already woven into the sociocultural world. Culturally shaped narratives act as prototypes or templates and serve as scripts shaping action and meaning making. Experience is thus an enactment of pre-given stories. This means that stories act to make life social, but people may always choose the stories they grow up on (Frank
2010, p. 24).
Mattingly attempts (2010) to bridge the structural- and the experiential by integrating narrative and phenomenology. She develops narrative phenomenology as a theoretical lens to open an existential window for particular people to reveal something about the struggles of the many (Mattingly
2010, p. 8). By this we understand that a specific narrative unfolding in a given context with unique individuals may express something universal which is relevant and recognizable to other people. The narrative is then expressed and reshaped by the person’s unique point of departure and specific context. Both Frank (1995, 2012) and Mattingly (
2010) emphasize the role of narrative resources and the culturally shaped core narratives. Such narrative types are trajectories for people to tell their own unique stories. Within the dramas of health care, illness and healing canonized medical genres like in detective, battle and repair stories can be identified (Mattingly
2010). Illness narratives of the suffering may be narratives of restitution or chaos (Frank 1995). Healing as a transformative journey proposed by Mattingly and quest narratives as proposed by Frank are narrative genres displaying how people change and deal with suffering and challenges over time.
Culturally shaped narratives of medicine and health care influence expectations and experiences of illness and health. Moreover, expectations of positive health outcomes and socially rewarding changes following WLS tend to take precedence over stories on fluctuating weight, problematic eating and illness: “Weight regain stories are easily silenced, buried beneath social, cultural, and institutional/ medical narratives of successful weight loss and transformation” (Groven and Glenn
2016).
Weight loss for health and wellbeing: cultural narratives at play
In western societies, there is a constant push towards lean, active and productive bodies, supported by health authorities, popular culture and governments (Lupton
2012a,
2012b).
Healthism indicates a particular way to situate health problems and their solutions at the individual level, shaping popular beliefs on illness and health (Crawford
1980). On this notion, health is a subjective matter, the premise for our well-being, and a goal we can reach primarily through modification of lifestyles, either self-directed or with the help of health practitioners or therapists. Being larger bodied does not align with cultural norms and how people should present and live, and is a vulnerable situation saturated with moral meanings.
Weight issues are primarily faced as self-inflicted, a sign of personal failure, potentially shameful, triggering blame or pity (Puhl and Heuer
2009; Puhl et al.
2013). Living as large and being an active participant in society is hard, as
weight stigma, discrimination and feelings of body shame and guilt are prevalent and alienating (Ramos Salas et al.
2019). Weight stigma is at play in social interaction, for example, when someone assume that they know something about another individual and her life because of her bodily appearance, and therefore has less interest in getting to know her, hesitates to accept her, discriminates or harasses her. In contrast, practices of self-improvement and disciplining the body attract positive recognition. Engaging with diets, exercise and other weight loss practices signals personal strength, mastery, productivity and independence (Bordo
2003).
The
obesity epidemic or
pandemic are popular concepts to illustrate the rising prevalence of overweightness and obesity in several countries as an alarming and deeply concerning trend (Ng et al.
2014). Hence, monitoring populations’ weight and developing strategies for obesity prevention and treatment have become important health priorities.
3 From a
medical perspective, high level of body fat equals health risk and indicates increased sickness and costs. This means that living as large attracts both medical and political attention, as health resources are scarce and costs related to obesity are significant (Tremmel et al.
2017). Consequently, the prevailing narrative is that of excess weight as dangerous, unwanted and unsustainable.
Severe obesity involves a health risk and potentially suffering and social burdens.
4 Therefore, health authorities emphasize obesity prevention and offer help for severe obesity, in some countries even financed by the state. Medical interventions for severe obesity are typically lifestyle programs, medicine (pharmacotherapy) or surgery. Surgery is popular worldwide because of its effectiveness compared with lifestyle approaches and medical treatment, resulting in larger and more sustainable weight losses and health benefits (Adams et al.
2007; Karlsson et al.
2007; Arterburn et al.
2015; Schauer et al.
2017). However, the treatment is invasive and patients risk unintended consequences, as the long-term effects are not clear (Colquitt et al.
2014; Puzziferri et al.
2014; Courcoulas et al.
2014).
Weight regain is a common phenomenon after weight loss, including after WLS (Velapati et al.
2018; Santos et al.
2017). Most nonsurgical weight loss attempts fail within the first year and regain is prevalent (Wing and Phelan
2005; Dombrowski et al.
2014; Thomas et al.
2014). Patients with weight regain after WLS have reported higher rates of problematic eating/eating psychopathology afterwards (Mauro et al.
2019). Despite the risk of weight regain or side effects following surgery, for people of size, surgical treatment remains an opportunity to change their bodies and lives via weight loss, offering more optimistic future prospects on health and longevity. In this, WLS facilitates a
transformation narrative (Bocchieri et al.
2002). However, ambivalence, risks and uncertainties about the future leave this narrative open ended.
Furthermore, medical and experiential narratives seem partly incongruent, favouring normalization of bodies and lives over uncertainties, failure and vulnerability. Severe obesity is thus situated in a tension between canonized medical narratives where surgery appears to have much to offer, and other cultural narratives of living large as de-valued and shameful, partly related to the medical narrative. Stuck in between are the personal narratives of hope, joy, disappointment, and the fear of failing to transform. In the becoming of, being and combating a large body, this tension seems like a kernel as a driving force throughout a lifespan in persons’ lived experiences after WLS.