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.