Therapeutic Dilemmas – Working
 with Weight Loss in Therapy

by Hilary Tupling

It is my purpose in this paper to outline some of the myths associated with 
current paradigms of weight loss, to identify what I perceive to be
 therapeutic dilemmas in treatment, and propose an alternative paradigm 
for consideration. In my practice as a therapist I often see people who
 want to change their body shape/size without reference to their lifestyle or 
psychological circumstances, and people who want to change themselves 
without reference to their bodies. The latter tend to be labelled anorexic,
 the former overweight or obese. Unlike the person who is depressed,
 whose reward for working in therapy is to restore joy to their lives, the
 overweight or obese client looks forward, in their eyes at least, to a life of
 deprivation, or enforced exercise, or both. The underweight client 
frequently identifies getting better with an emotionally unacceptable body
size.

Ambivalence in Therapy


This perhaps goes some way towards explaining what can only be termed
 ambivalence in therapy. Those clients who present in psychotherapy, with 
or without a significant degree of over fatness, are, it may be assumed, more 
likely to have already connected their emotional distress with their eating
 habits. This awareness is not always helpful in motivating them to change
 lifestyle patterns. Historically, this ambivalence has frequently been noted
 and as frequently overlooked. The simplistic (and medical) view of obesity
 was that if you ate too much, you got fat. The simplistic solution: eat less
 and you’ll lose weight, viewed the diet as medicine. The problem was that 
the theory either didn’t work or when it did, created at times fatal
 consequences, some people couldn’t ‘eat less’ simply as a result of being 
told to do so: some people could obey the injunction, but couldn’t keep it up; and some people experienced almost a panic reaction in the face of 
trying to control their appetites. “It was our feeling that our patients
 perceived weight reduction, not as a happy end to a disabling disorder but 
rather as a threat to integrity of functioning.” Other research reported not
 only an increase in depression in overweight people undergoing diets, but 
also that the same symptoms – increased emotionality, irritability and 
anxiety – were seen in normal weight people subjected to severe food 
restriction.

Despite the research on the paucity of long term successful treatment
 outcomes, the frequently reported differences between the clinical 
experience and the research findings, the diet industry has continued to
 grow based on three significant myths:

MYTH NUMBER 1

That obesity is simple in its etiology, and also in its treatment. Amongst the
 perplexing and frustrating facts to be explained are:

1. The lack of consistency between clients – there is no one psychological 
or social profile that either accounts for overfatness nor predicts who will 
be able to master the lifestyle changes required to maintain a lower body
 fat.

2. The lack of consistency for one method of coping with the food 
environment that suits all comers – and the lack of reliability of a useful
 strategy to work in different situations for the same client.

Diet ‘industry’ programmes based around formulas, be they psychological, 
behavioural or the provision of pre-prepared meals, all presume to have the 
answer and fail to take into account the unique paradigm of the individual.

MYTH NUMBER 2

That accurate information results in behaviour change.

It is apparent that reliance on information alone is inadequate to change 
eating behaviour; even assuming availability and affordability of healthy
 food choices, emotions and the belief system of the client play a large part 
in whether accurate information is actually implemented. Clinically, it is 
rare to encounter a client who does not acknowledge that their eating 
habits, whilst not necessarily excessive, are contributing at least to the
 maintenance of their level of fatness. Most people readily identify
 frequently eaten foods (of the cake, chocolate, chips variety) which they
 consider to be inappropriate for fat loss. Although fad and old fashioned
 diet practices still abound, the overfat (or underfat) consumer is often very 
well informed about the kinds of food that make up a healthy eating
 pattern. Equally they are highly likely to be knowledgeable about the place 
of exercise in a fat loss programme.

MYTH NUMBER 3

That focusing on such information can do no harm.

In clinical practice it has become apparent that the very knowledge of food 
values, for instance about the role of fat consumption in becoming over-fat,
 may become a weapon with which the clients may both abuse and comfort 
themselves. The most obvious outcome of which may be the development
 of either disordered eating or an eating disorder.

Both bulimia and anorexia have proved conditions which are complex in
 their etiology and resistant to treatment. It is generally regarded as
 significant that both conditions are primarily female disorders, linked to the
 social, psychological and cultural emphasis given to how a woman looks,
 as opposed to how she feels. Female (role) models continue to present
 young women with body sizes and shapes which are unachievable by the
 majority. The media, families, peers and friends continue to comment on
 deviations from these physiques as if by will-power alone, a person could
 sculpt their body to suit the fashion, or conversely, as if becoming fat was 
some kind of deliberate vandalism of the body.

Dieting


Clients may report that their disorder commenced after a significant person
 (family member, boy friend, teacher, or a co-student) remarked on the size 
of their bottom or thighs (breasts, legs…). Young women, today, identify
 strongly with their own mothers’ preoccupation with their bodies, and
 mothers themselves may project their body image concerns onto their
 daughters. By the age of 18, it has been estimated that 80% of females have
 started dieting. Many of these women have discovered bulimia for 
themselves, even if they have not been introduced to the practice by a peer 
or the media. Few have any idea of the potential consequences of their 
attempts to fix their weights at sub-optimal levels.

Dieting, for these women, takes the place of dealing with more serious
 issues such as their self esteem and body image disturbance, the transition
 to adulthood and sexuality, the development of an autonomous self and the 
initiation of intimate relationships, dysfunctional family sequelae, mood 
disturbances and on-going stress management. More recently, in addition, it 
has been suggested that a high proportion of women with eating disorders 
have a background of sexual and/or physical abuse.

A further model for eating disorders has been proposed with reference to 
obesity and non-purging bulimia, which suggests that repeated cycles of
 dieting and regaining weight lead to ‘food dependence’. Dependence is
 defined as ‘the failure to stop using a substance that is deleterious to health 
and where use results in short-term mood alteration’. In this model, food 
(specifically those foods which are reserved for bingeing episodes)
 becomes a psychoactive substance. Obese and bulimic clients frequently 
report bingeing in response to stress, frustration, rejection and other
 negative emotional states, and it seems likely that both uncontrolled eating 
and the kinds of food used (high carbohydrate/fat) act synergistically to 
lower the internal arousal state. Few of these clients are able to activate
 behavioural self-management techniques at these times.

Internal Struggle


Internal Exploration of the process whereby a person comes to over-ride 
their intention to moderate their eating habits frequently reveals an internal 
psychological struggle in which an implacable force, from which the adult 
self is dissociated, often wins over the voice of ‘reason’. At these times it 
would seem that in some way functional autonomy is protected by ‘eating
 the wrong thing’ at the expense of the (adult’s) long term health goal.

This basic contradiction is just one of many therapeutic dilemmas which 
face both client and therapist. In essence, the more successful the client is
 changing their food habits in the short term, the more likely it is that they 
will encounter the emotional distress, which may then be dealt with by
 eating.

These therapeutic dilemmas confront the therapist:

1. When is the presenting problem one of Cinderella’s slipper? Therapists 
need to consider to what extent is this client trying to fit themselves into an unrealistically small body size or shape – either in their imagined and 
idealised body image – or in their construction of a rigid dietary regimen. In 
either case, it would seem that the body will fight back.

2. What is an ecological approach to therapy with overfat clients who make
 fat loss one of their primary goals? Knowing the potential for harm
 associated with dieting per se, and the difficulty there is in maintaining a
 leaner body, the therapist has to confront the dilemma that to maintain
 good rapport and client autonomy may be to collude in an unachievable 
outcome.

3. Who describes the ideal figure/size/shape or diet, or what is or is not 
appropriate eating behaviour?

Recently a client, with a history of anorexia in her teens asked me to 
adjudicate in a dispute between her and her partner – her phobia about 
getting on the scales was surely, he argued, an indication that she was still
 worried about her weight? In this weight-obsessed society, he felt it was 
normal to weigh oneself. For her, now a yoga teacher of normal size, NOT 
to weigh herself had been one of her self-liberating solutions.

4. When identity is threatened by changes in the lifestyle, whose side is the
 therapist on?

When being fat is central to a client’s sense of self, is the fundamental
 connection with family of origin, is the consequence of the lifestyle
 dictated by the demands of the executive job, is the precarious means by
 which the problems in the marriage relationship are solved – losing weight 
becomes a threat to the future, not the apparently attractive and idealised 
event. A number of my clients, currently are facing the uncomfortable 
reality that they either continue to be fat and prestigious, or they literally ‘
downsize’ themselves – out of a job.

5. Under what conditions would this person be easily close to their healthy
 weight? – Are those conditions achievable in the present or near future? (9) A 
former client sent me a Christmas card last year in which she wanted me to
 know that she felt much better about herself, but had not lost any weight.
 Classifiable as in the obese weight range, this highly intelligent, creative
 woman had spent only one period of her adult life in the normal weight 
range – when she had been on an overseas posting for a voluntary teaching
 agency, somewhere on the Thai-Cambodian border. There she ate as did
 the people she was teaching: principally rice, vegetables and fish. Once a
 week the American ice cream truck visited. In these conditions, for two
 years, she had no problems maintaining her weight in the Healthy Weight
 Range. She taught English, wrote, swam for exercise, meditated daily and 
felt largely free from social, family and sexual pressures. Once she returned
 to Australia, her weight again started to climb, consequent to her use of 
food to cope with pressure. She dated her first return to binge eating as a
 consequence of having to deal with a sexual advance she felt neither 
comfortable accepting or rejecting.

New Paradigm

A new paradigm for therapists working with fat loss must account for both the psychological significance of food in the person s life as well as the 
functional significance of being fat. Essentially this means we start by 
accepting that we know nothing about how this client’s unique paradigm
 works, nor what he or she particularly needs to change to maintain long
 term health.

The Client’s Story

Each person has their own unique story about how they come to be 
overfat; this comprises beliefs, tastes and habits, family of origin messages,
 a description of their body and its internal representation (body image), the 
emotions and thoughts which influence their eating behaviour and activity
 pattern. It may include aspects which are unconscious to the person (
”don’t know why” processes), and secondary gains from both their eating
 behaviours and their size. In short, the individual him or herself is acting
 according to the paradigm he or she has formed. Within this paradigm the
 habitual behaviour makes sense, even if it is disliked and fought against,
 since the eating pattern itself is locked in by other elements of network 
which may or may not be open to permanent change. The following may
be important in identifying how embedded is the current paradigm:

* The duration of overfatness, the perceived cause or start of the problem.
* Genetic and metabolic disadvantage – how these are viewed.
* The duration of the individual’s pre-occupation with dieting or body
 image 
(not necessarily the same as the duration of overfatness)
* The degree of attachment to present eating and activity patterns
 (lifestyle).
* The presence or absence of secondary gain from eating behaviour or
 fatness.
* Male/female differences, sexuality and history
* Knowledge of food, food/taste preferences.
* Expectations of the change process, degree of difficulty, how long etc.

Internal Consistency of the Pattern


How does the client manage their health when all is going well, and what
 happens when faced with stress, conflict or opposition?
 Clinically it is common to hear reports of times when the individual is able
 to make positive food or behavioural choices, and other times when these 
choices seem blocked by stronger forces, sometimes external to the 
person, such as social occasions, time constraints and the influence of
 other people, and sometimes internal, such as the internal dialogue or 
negative thoughts and feelings.

A possible framework for exploring the dynamic of this internal
 consistency is that of  ‘The Rescue Triangle (also known as Karpman’s
 Triangle)’ – in which the internal experience of powerlessness (Victim) -
 deriving either from external circumstances, or from habitual patterns of 
self denigration (Persecution) – are dealt with by the offering of foods
 associated with pleasure or calming (Rescue). The cycle, even if triggered from the outside, becomes self-maintaining as the positive response to 
eating is followed by self Persecution (guilt, blame) and the internal state 
swings from Good Victim (“Just make me feel better”) to Bad Victim (“Well,
 I’m going to eat it anyway”).

Fat loss counsellors and therapists may inadvertently get caught up in this
 triangle, as Rescuer, setting up a system that perpetuates the pattern, by 
offering copious advice, problem-solving for the client, and becoming
 powerless (Victims) or angry (Persecutors) themselves in the course of 
time.

The Development of Self-Soothing and Self-Esteeming


In order to maintain a changed lifestyle, the individual must be able to 
manage both internal and external stressors by means which do not
 threaten the integrity of that change. Particularly important are the other
 (non food) strategies the individual uses to self-soothe and maintain self esteem. Of relevance to this is the extent to which food was used as a
 means of soothing during childhood either provided by, or in spite of the 
parent, the degree of autonomy the child had to choose the amount and
 kind of food he/she ate, and the implied message(s) regarding the reliability
 of hunger-appetite-satiety signals. Stress management techniques such as
 effective time management, assertiveness, and cognitive reframing can all 
assist the individual to cope more effectively with demands, but require an 
essential valuing of ‘self’ as worth protecting in this way. A variable which 
may be important to explore is the dimension of distortions in parental 
bonding, particularly those of over-protection accompanied by high or low 
care (“affectionless control”). At either extreme over-protection may be 
seen as an interference with normal self-limiting eating mechanisms, either
 overfeeding or intrusive restriction, and a potential disruption to the
 development of autonomy, together with a predisposition to depression in 
adult life.

Healthy Change


For an ecologically healthy change to take place, the internal paradigm 
(‘who am I, really?’) must change. The pattern of self must be re-formed
 with respect and integrity. The therapist’s role in fat loss counselling is to 
be a catalyst for the client’s own paradigm shift. What follows are possible 
steps in the process:

Forms a partnership – No Rescuing

1. The therapeutic encounter is presented as an unique partnership
 relationship, in unknown territory. The therapist role is to offer support 
and encouragement for the client’s journey, to provide realistic information
 about strategy; and is non-judgmental. The client owns the problem, and is
 responsible for finding solutions.

2. Facilitates exploration of present paradigm – how does it work? The 
client’s story, how it currently makes sense, how overfatness and eating 
habits interact and maintain themselves, history of fat loss, other important 
people, conscious and unconscious self talk family history. Functions of fat and eating habits in maintaining personal integrity. Feedback loops.

3, Flags identification of constraints

– Knowledge?         – Environment?        – All-or-none thinking
– Habits?                 – Self-limiting beliefs?   – Secondary gains?
– Support or lack of it?

4. Provides information only when necessary

Myth-busting, new information, fat-and-fibre counting, exercise/movement 
planning. Preferably in a non-didactic form.

5. Encourages development of a new paradigm.
 The client’s task is to re arrange the pieces of the pattern in a new way so 
as to make health maintenance a way of life. Therapist’s role during this
 process is to provide encouragement, challenge inconsistencies, be alert
 for pieces of the old pattern that creep in, help deal with sabotage from 
other members of the dynamic during the experimental phase. The new 
paradigm may set up stress and panic reactions (e.g. having to be assertive 
in new situations, face up to family issues, deal with history of sexual 
abuse, explore current sexuality and relationship crises). It is important for 
the therapist to stay apart from the new paradigm – i.e. avoid setting up 
dependency – and metaphorically act as a catalyst rather than an active 
ingredient.

6. Assists in the development of ‘life’ experiments, in which how to be
 different may be safely learnt.

-Small chunks                         – Achievable goals                         – Reframe failure

Could be challenging self-talk, be behavioural rehearsal, thought-stopping, 
distraction and relaxation techniques, self-nourishing activities, stalking 
habits, time management strategies. Relapses are common, and need to be
 reframed, prepared for and accepted as indicators of new learning (i.e. the
 discovery of what you don’t know).

7. Provides long term support.

The re-forming of eating/exercise habits constitutes a lifelong process. This 
may be at odds with the old paradigm of ‘six months on a diet’. Each
 change may reveal new stresses, or confrontation with self and body image.
 Those who seek help, as opposed to those who do not. may by self-
selection be revealing a vulnerability to this process. Long term support, in
 the form of regular counselling, peer support or access to these is probably
 necessary for some people.

Hilary Tupling is a therapist working in Sydney, Australia, who
 specialises in Eating Disorders.