Weight Loss, Obesity and the Talking Therapies
This article aims to explain why current approaches to weight loss and obesity rarely lead to successful long lasting results, often trapping the client in endless and sometimes lifelong patterns of yo-yo dieting.
I will try and illustrate the deficits of our current popular approaches to weight loss, such as dieting and show that these models are doomed to failure as is any other model that advocates direct weight reduction methods whilst neglecting the underlying causes of obesity.
The medical profession, as represented by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM IV) basically recognises only two eating disorders – Anorexia and Bulimia Nervosa. Simple obesity does not appear in the DSM IV because it has not been established as consistently occurring with any psychological or behavioural syndrome.
However the DSM-IV does describe something called binge eating disorder (BED), which in essence matches the criteria for bulimia nervosa but without any of the compensatory behaviours such as vomitting, laxative abuse and fasting. The behaviours of BED would reflect with reasonable accuracy the behaviours of many people with obesity.
Under ‘Associated Features and Disorders’ the DSM IV states that some individuals report that binge eating is triggered by dysphoric moods such as depression and anxiety. It goes on the say that ‘Others may not be able to identify specific precipitants but may report a non-specific underlying tension that is relieved by eating’.
Psychotherapy & Hypnotherapy for Weight Loss
It is important for us as psychotherapists/hypnotherapists, to expand on this and recognise and explore the clients subjective experience of this tension and the significance of this tension, which is not explored in the DSM/medical model.
Individuals with BED usually have a long history of weight loss attempts and many would have given up due to repeated failures on various weight loss programs. These programs are all generally centred on dieting and exercise – external interventions targeted at the clients physiology and aimed at removing the excess weight from their bodies in a mechanical fashion.
Based on my clinical work and the work of others in this field, I will try and demonstrate that obesity- particularly persistent and lifelong obesity can often be associated with distinct psychological and emotional patterns. This is important because it tells us that the treatment for obesity should not focus on dietary interventions, exercise regimes or behaviour modification but should rather focus on the psychological causes of obesity. In fact this would explain the poor results seen from the interventions listed above after long term follow up.
Obesity & Eating disorders
It must be stressed very early on that there is no umbrella psychological theory explaining obesity or eating disorders. Clients with these issues may have some things in common but in reality there are multiple factors that lead to obesity. It has for example been suggested that overeating is linked with controlling/inadequate parental environments during childhood and that overeating behaviours can be used as a response to excessive parental control, and as a source of comfort.
In some cases being overweight is used as a protection against the fear of annihilation and engulfment perhaps stemming from a traumatic childhood event. What is important is to listen to the client and treat everyone as unique, resisting the tendency to fit a client into a theoretical model.
The ‘food as a substitute theory’ has been around from as early as 1956, with authors such as Grinsberg emphasising the role of negation in obesity. Simply stated the obese person experiences a profound emotional loss and compensates for this by maintaining in its place a continuous relation with the substitute food.
Hilde Bruch, psychiatrist and psychoanalyst, was a pioneer in the field of the psychological treatment of eating disorders. She described obesity as a symptom and not a disease and stated that it should not be removed until the underlying disturbances are corrected (Bruch, 1957). In practical terms this means resisting the temptation to treat obesity directly with methods such as dieting until the cause of obesity itself has been addressed.
In fact, it is often the case that once the cause has been addressed there is usually little need to proceed with any dietary interventions. The exploring of underlying factors causing obesity is key here, rather than going straight in with weight loss interventions such as diets, exercise regimes and CBT which has become the treatment of choice (Kaplan, 2002), and have shown overall poor results (Wadden et al, 1988 and Orbach, 2009).
From certain psychological perspectives, the psychological and the physical are inseparable therefore focusing on physical methods and theories of obesity are bound to fail. Moving into more traditional psychoanalytic theory, Thorner describes very early events and their far reaching influence in later life. He says;
‘An insecure anxious baby who cannot understand where the breast has gone cannot feel gratitude for the breast and might feel persecuted. What is taken in then becomes a damaging/damaged object. The obese person feels full of bad hateful things and projects this hate into her body. The oral zone remains extremely important in the obese persons psychosexual development and takes precedence of the genital zone for satisfaction, as evidenced by fear of intimacy and weak libido’.
Barriers & relationships with food
It is not uncommon for overweight clients to use the excess fat as a barrier against sex and intimacy. Also it may be of value to look at infantile feeding experiences and view them as a potential template for the subsequent relationship with food. During breastfeeding mother and baby are highly sensitive to each other, each picking up on the others moods and feelings.
A mother who is not feeling able to cope, supported or bonded to her child will inevitably transmit this to her baby in their interactions – feeding is perhaps one of the most important mother-child interactions. This suggests our relationship with food starts very early on and is far more complex than we may have imagined.
Bruch, (1957), stated that the mothers of some people who become obese may have offered them food instead of some other response when they have expressed a need. Some clients relate to this saying that the only thing that was completely unrestricted in their childhood was free access to almost unlimited amounts of food, in the place of emotional contact with caregivers. Could this be the beginning of comfort eating behaviour that so many clients describe – using food as a source of comfort, medicating oneself with food (Glucksman, 1989).
Paradoxically many obese clients presenting for weight reduction, do not have a fear of being obese but rather a fear of being thin (Tedesco and Reisner, 1988). This is commonly seen in clinical practise although not immediately and often to the surprise of the clients themselves. All this is echoed by Bruch (1973) who found that obese children might need to exaggerate their size in response to feelings of emptiness or vulnerability.
Current popular interventions in the treatment of obesity and issues around weight seem unequipped in dealing with the complexity of obesity and eating. Similarly an overly directive/authoritarian psychoanalytic/psychological approach is generally considered to be unhelpful in the treating of eating disorders, (Bruch, 1973).
The danger is that obese clients will use any suggestions/interpretations in therapy as they use food, take it on as a heavy burden making them feel dull and heavy and despondent. Any authoritative psychoanalytic approaches may also echo with the strict and controlling parental backgrounds that many such clients come from.
What appears to work better is a non authoritative and non directional approach that focusses on the clients subjective and personal experience of life, dealing with the day to day concerns and giving enough space to allow material to originate from the client without excessive summarising sessions at the end and avoiding as much as possible the employment of a psychoeducational approach.
The use of dream analysis can also be useful as the material all originates from the client. In my view it is only with this sort of approach that a long lasting and sustainable weight loss can be achieved, freeing the client from endless rounds of yo-yo dieting.