THERAPEUTIC TREATMENTS OF ADULT OBESITY
Copyright © Ros Welch 2013. All rights reservered
In this article I explore obesity in adulthood, focusing on the onset as an indicator of the type of treatment congruous to the client. In addressing the onset I explore the psychological need for weight gain and the defensive intent. I present my overview and client assessment, my views on childhood and adult onset and appropriate therapeutic treatments prior to my conclusion.
Obesity indicates an impairment of cognitive controls, of using food to control emotion, restraint in diet can stimulate overeating encourage binging and low mood.
“Similarly, if a person believes their obesity is caused by their metabolism or genetics, they are unlikely to change their diet”(Ogden 2010 p196).
An obese client has determined a defense strategy, a way of coping that may have served a purpose, albeit unconsciously, their size being the outward expression of their emotional pain.
The first stage of any therapeutic process has to include an assessment session in which the therapist gains a holistic view of the client’s issues. When weight is a presenting issue the therapist, whilst obtaining an overview should not be shy of questioning pertinent to the weight issue.
Ascertaining whether this is a long term or short-term issue is of major relevance and a line of enquiry into any medical reasons for weight gain may indicate a G.P. referral.
Ask about the onset, about dieting history, body size within the family/social group/culture, about how they eat; what do they eat, where do they eat, is it secret? Is it to satisfy hunger or a feeling of emptiness? What do they eat that they feel that they shouldn’t? How do they feel afterwards and why?
“ If the client has tried lots of diet clubs and slimming aids to put weight back on each time, its clear that there are psychological problems behind the struggle”(Leach 2006 p51).
The therapist is trying to discover the reason for their client’s size, it will have a purpose, a need for food to cope with emotional emptiness or a need for size as defensive armour. Obese clients often confuse emotional and somatic sensation, have difficulty identifying anguish and pain. Being extremely defensive their body language may tell a different story.
It should be made clear to the client that as a therapist you can supply information on nutrition, you can discuss achievable goals, but are not a slimming clinic, you cannot stop them eating, that is their responsibility. What you can do is uncover the reason for emotional eating, address self-esteem issues, explore their interpersonal interactions, examine childhood trauma, attachment style and raise self-awareness, what you will not do is weigh them or put them on a diet. Once commitment, terms and boundaries are agreed and contracted therapeutic work can commence.
The client’s history taken in assessment may indicate whether the obesity had its onset in childhood or adulthood but a detailed timeline may reveal far more and can be illuminating in exploring the family dynamic.
“Overeating, or even anticipating overeating, can actually help us to cut off from some of our emotions, and may even give us a sense of pleasure that we may not be experiencing elsewhere in our lives”(Goss 2011 p63).
If the onset of obesity was in childhood, they may now be morbidly obese having had history of weight loss and gain. There may be genetic link particularly via their mothers line, they may have a leptin deficiency and be unable to recognise satiety until they feel overfull. Being ‘the obese person’ may be linked to their childhood identity, the ‘fat one’ at school, the overweight armour can be used to isolate the child, to keep others at arms length, they may play the joker, anything to disguise their emotions and feelings of shame. Their size becomes necessary for protection, it’s a survival issue. The child may have suffered loss, of a parent, sibling or grandparent, unable to console a parent feels rejected; they don’t matter, not good enough, not loveable. They may feel it’s their fault, that they are bad or evil.
Weight gain in adulthood is likely to be reactive, a bereavement, divorce, children leaving home, an affair, there will be a reason for this self-abuse, this needful self-soothing, this temporary lack of self-esteem. Whilst it can be exacerbated by a genetic disposition, the aim of weight gain is invisibility, denial of self, denial of individuality, denial of sexuality, it may be a reaction to rape or to the guilt of having had an affair, the armour of weight can be punishment for their sexual being.
The gain of weight may be to fit in, to join a community, an expression of a role or of maturity, an unspoken joining requirement of being asexual. Size may back up a role of being the funny one (hiding their emotions), the compassionate one (frightened of their bitchy thoughts), the one that doesn’t want to attract boyfriends (for fear of rejection), there will be a message behind the size, a non-verbal story to be told. Whichever the cause the size has a purpose and reduction in size will have societal repercussions.
The therapist needs to find the child within the adult, the core belief that justifies their shame, the childhood version of reality that formed the basis of their script, they are ‘not all right’. They may believe as they are not loveable that they may as well make sure they are physically unattractive, to make sure they are not included rather than face possible rejection.
Cognitive Analytic Therapy (CAT), is integrative in its exploration of childhood and the unconscious together with the raising of cognitions or self-awareness, the client may well not recognise how to accept comfort from others having kept others at arms length, may not recognise their eating triggers and motivations and be in need of balanced alternatives. A therapist working with an integrative approach using person centred skills of empathy and UPR, facilitates a movement from external to internal locus of evaluation, and using the principles of TA can enable our client to recognise the child within and listen to its voice.
The therapist should address the issues that caused onset communicating within the clients adult state, a CBT approach with a person-centred framework utilising Motivational Interviewing and NLP techniques can help the client visualise a future with and without change.
The client may have a leptin deficiency but will almost definitely have difficulty differentiating between emotional and somatic pain. A DTR should be used to examine triggers to link emotions with thoughts and behaviours, core beliefs should uncovered by Socratic questioning using patterns of behaviour from the DTR. The client needs to re-learn trust of themselves and of the comfort available from others, to re-learn autonomy develop self-awareness and self-esteem. Therapy combined with a dietary changes and exercise regime has potential for success.
Obesity is the expression of anger turned inward, the body becoming the repository of their trauma, their self-loathing justified by their size. The client may come to therapy without their size being the presenting issue, an ambivalent attachment to their mother or prime care-giver, a loss or divorce.
“Obese patients are telling their story in their body presentation”(Leach 2006 p234).
Obesity is self-harming, the health risks are known, a therapist must employ holistic and intuitive skills, addressing relationship, stress, anxiety, loss and self-defeating behaviour issues. They must discover the purpose of the size, the necessity to employ this defense mechanism, the effect of their environment and any enablement.
“Saboteur or supporter – Other people and our environment can affect our weight loss. Weight can be a very sensitive issue-if you lose weight it can make others feel uncomfortable and they can act in a way that is unhelpful to you either consciously or unconsciously”(NHS Oxfordshire).
The therapists role must be wholly non-judgemental, should teach the client that they can learn from setbacks, encourage them to accept responsibility altering their environment or enablers to endorse their own position.
The therapist should be mindful of ethics, to recommend small changes not unachievable goals, to explain that the responsibility for change is with the client and where the limits of the therapist lie. Therapist must always have the clients interest at heart, manage their expectations, use transparency, be real and honest.
Goss Ken – The Compassionate Mind Approach to Beating Overeating – 2011 – Robinson
Leach Kathy – The Overweight Patient – 2006 – JKP
NHS Oxfordshire – ‘Owls’ leaflet – 2012
Ogden Jane – The Psychology of Eating – 2010 – Wiley-Blackwell