Our culture has so accustomed us to using substances—particularly food—to change states that we hardly notice it. American businesses run on coffee. To calm down, people turn to “comfort food”: foods with high sugar, high fructose syrup, or simply “high-carb” content, or beverages containing alcohol. Our stress level or our exhaustion dictates our snacks. People also develop conditioned responses to cues in the environment; for example, going out to a movie isn’t complete without popcorn and soda. Because a positive, if temporary, feeling follows eating carbohydrates, especially simple carbohydrates, an “addictive response” sets in motion a cycle of desire for carbohydrates, ingestion, temporary satisfaction, and then more craving that can lead to a person losing control over what is consumed. The seeking circuit is highly activated in addictive responses and can lead to a progression from “liking” a food to “wanting” it to “needing” it.
This chapter focuses on weight issues as a result of food addiction. Here we explore the neurochemistry of food, the role of sugar and other simple-carbohydrate craving in obesity; the role of habit, sleep deprivation, genetics, and taste habituation; therapeutic assumptions in addressing weight issues; client assessment for weight management cases; and BCT interventions for weight loss, including case examples.
Overview of the Problem
A serious problem for many, obesity in the United States has become steadily worse. The National Center for Chronic Disease Prevention and Health Promotion (2010) reports that more than 1/3 of all adults in the United States are obese. Health-care costs attributable to obesity are in excess of $68 million annually. The physical problems that may result include hypertension, type 2 diabetes, coronary–vascular diseases, fatigue, respiratory problems, gall bladder disease, certain types of cancer, sleep apnea, arthritis, depression, anxiety, decreased social interaction, decreased sexual activity, and low self-esteem.
Many variables play a role in weight gain: genetic predisposition, biochemical factors leading to brain dysregulation, the context and social system by which the individual is influenced, the “internal weight manager,” susceptibility to external food cues when in a state of anxiety, and learned trance phenomena. These factors work together in an interactive system wherein eating is adjusted in the interests of biological regulation and adaptation to the environment. Some of the factors contributing to obesity can also lead to feelings of helplessness and lack of self-control, which in turn may perpetuate a cycle of dieting and gaining weight. Most dieters have a history of having tried numerous food programs, losing weight, then regaining the lost weight and more. As one of our clients said, “Everyone who has a weight problem is looking for the one program that will finally be the cure-all.”
Although this chapter focuses on weight issues as a result of food addiction, the principles discussed here are applicable to many types of addictive behavior. All addictions have several components in common: They attempt to ameliorate emotional or physical distress, generally depression, fear/anxiety, or fatigue. Over time, a loss of control with respect to the substance or behavior occurs. In analyzing drug addiction, Koob (2008) emphasized a two-tier problem consisting of an impulse-control disorder that leads to a compulsive disorder. The impulse-control disorder is triggered by a certain tension or level of arousal that precedes the addictive action; the compulsive disorder is stimulated by stressors or anxiety that the compulsive behavior temporarily relieves. In addiction, behavior progresses from impulsivity to compulsivity in a three-stage cycle: binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation (Koob, 2008, p. 3). Allostasis, which is the process of creating a state of stability by means of change, becomes the driver from substance use to dependence and changes the reward and stress system neurocircuits by flooding the brain with dopamine (National Institute on Drug Abuse, 2008).
The Neurochemistry of Food
Everything a person thinks or experiences—from exercise to visiting some new place—creates new neural connections. Research suggests that there are neural correlates with addictions and, specifically, with eating problems; based on that finding, we need to address the brain in treatment (Grunwald, Schrock, & Kuschinsky, 1991). In studying how the brain prunes or removes certain links (Strauch, 2004), neuroscientists have found that when particular brain circuits are exercised less frequently, the strength of their connection diminishes. Change can occur if certain habits are interrupted and the focus is moved from “my problem” to a viable solution. By shifting the brain–mind state and shifting focus when an urge to eat inappropriately is experienced, over time there is a decrease in the brain activity associated with the problem (Ratey, 2002).
The ventromedial hypothalamus is believed to maintain a satiety center. Stimulation of this area suppresses eating, whereas dysfunction in this part of the hypothalamus may lead to obesity. The lateral hypothalamus also may be responsible for “encouraging” eating behavior. Another part of the brain involved in eating disorders is the cingulate gyrus, located longitudinally through the middle part of the frontal lobes. It allows people to shift attention and change thoughts and behaviors. When an individual is caught in loops of thought or compulsive behaviors, this part of the brain has become overactive. The underlying mechanisms for these regulatory processes involve neurotransmitters and their pathways.
Overeating results in chronic inflammation and can turn on certain immune cells that attack invaders even if they are not present. Researchers discovered that if a certain pathway in the hypothalamus is stimulated, a mouse will consume more food than it needs, and cellular destruction may occur. A few months of overeating can lead to appetite dysregulation and spiraling weight gain (Zhang et al., 2008). Symptoms of Alzheimer’s disease can appear with obesity and result in neurodegeneration (Moroz, Tong, Longato, Xu, & de la Monte, 2008).
Food choices can drive many internal states and either advance brain aging or retard it by growing new cells and balancing neural chemistry. Neuroscientist James Joseph (2008) conducted a study on the effect of fruits and vegetables on the brain. With aging, the body’s ability to deal with free radicals in the system is gradually reduced. Joseph found that eating a pint of fresh strawberries or a spinach salad every day reduces brain aging. Antioxidants in the diet can forestall oxidative stress, which contributes to neurodegeneration. In fact, “every fruit, vegetable, grain, or source of protein or fat is a precursor to one of the brain chemicals” (Braverman, 2009, p. xv). Four of those key chemicals, or neurotransmitters, are dopamine, acetylcholine, gamma-aminobutyric acid (GABA), and serotonin.
Dopamine
Dopamine is both a neurotransmitter and a neurohormone released by the hypothalamus. Tyrosine, an amino acid found in proteins such as meat, nuts, eggs, dairy products, and beans, is a precursor to dopamine, and dopamine is a precursor of both epinephrine (also known as adrenaline) and another closely related molecule, norepinephrine (or noradrenaline). Epinephrine is implicated in levels of arousal and mental alertness; norepinephrine is released by the sympathetic nervous system to transmit the fight–flight–freeze response. Excessive norepinephrine production contributes to aggressive behavior. Low levels of dopamine lead to an inability to feel satisfied either physically or emotionally and can cause weight gain as an individual tries to consume something that will “fill the gap.” Subnormal levels of dopamine also impair the abilities to focus and concentrate. Extremely low levels of dopamine result in lack of energy, sleepiness, depression, and even suicidal thoughts (Robertson, 1996). Moderately elevated levels of dopamine tend to result in sleep disturbances, anxiety, and fear; extremely high levels of dopamine can induce withdrawal, paranoia, or psychosis. Colantuoni et al. (2002) discovered that dopamine is released in the brain not only when we eat but also when we perceive food cues. Sugar tends to deplete dopamine, causing a person to feel fatigued and to search for stimulants.
Acetylcholine
Acetylcholine is an excitatory neurotransmitter in both the central and peripheral nervous systems and is the only neurotransmitter used in the motor division of the somatic nervous system. By influencing the processing of bioelectrical impulses, acetylcholine determines the speed of brain function and is critical for both the storage and recall of memory. A precursor to acetylcholine is choline, a fat-like substance necessary to metabolize fats. It is found in egg yolks, red meat, wheat germ, avocados, and some types of fish and nuts. Memory problems, suspicious thinking, sexual dysfunction, and dry skin and mouth may be manifestations of low levels of acetylcholine. A craving for fatty foods may also be a sign of low acetylcholine.
Gamma-Aminobutyric Acid
GABA is the primary inhibitory neurotransmitter acting to calm and stabilize the brain. GABA is a non-essential amino acid formed from glutamic acid with the help of vitamin B6. Because it cannot penetrate the blood–brain barrier, it must be synthesized in vivo. The GABA precursors are found in complex carbohydrates such as whole grains, tree nuts, lentils, and citrus fruits, as well as fish, meats, and poultry. When GABA levels are deficient, an individual can experience headaches, dizzy spells, short-term memory loss, and anxiety. Low GABA levels can stimulate binge-eating.
Serotonin
The neurotransmitter serotonin is involved in the regulation of such bodily processes as sleep, libido, and body temperature. When serotonin levels are stable, appetite is regulated. Low serotonin levels have been implicated in numerous psychiatric disorders, including depression, OCD, anorexia, bulimia, anxiety, and phobias. Frequently, comorbidities such as depression or OCD accompany eating disorders. (Eating at night can reflect a serotonin deficiency.) Both of these comorbidities involve dysfunction in serotonin levels.
Slightly low serotonin can cause difficulty with concentration and attention; examples are misplacing a purse or wallet, putting strange things in the refrigerator, or going after something in another room only to forget what you needed when you get there. A moderately low serotonin level causes depression and may initiate changes in the bodily functions regulated by serotonin, resulting in sleep disturbance, either significant weight gain or loss, sudden unprovoked tears, and hot flashes. Very low levels of serotonin typically cause the brain to “race” and may be accompanied by OCD, outbursts of rage, “memory torture” (becoming preoccupied with terrible experiences that happened years earlier), and suicidal ideation. When serotonin levels are high, people feel relaxed and reasonably at ease with their lives.
Carbohydrates stimulate the production of serotonin via insulin and the plasma tryptophan ratio, resulting in good feelings. Simple carbohydrates that break down quickly, such as foods made with sugar or white flour, tend to cause a serotonin spike. Complex carbohyrates, such as oatmeal, are digested more slowly and lead to more stable levels of serotonin. Clients with food issues tend to choose simple carbohydrates because of the quicker effect; however, they also find that eating simple carbohydrates increases their cravings and may lead to a self-reinforcing cycle that perpetuates overeating. Consuming foods high in sugar or other simple carbohydrates also causes blood sugar levels to rise and fall dramatically, which can lead not only to carbohydrate craving but, on a longer-term basis, to diabetes.
An increase in the ratio of the amino acid tryptophan to the amino acids phenylalanine and leucine will also increase serotonin levels. Tryptophan is present to different degrees in all protein, but particularly in turkey. Fruits with a good ratio include dates, sour cherries, papaya, and banana. Other foods that increase serotonin levels are asparagus, avocado, pecans, pineapple, eggplant, spinach, walnuts, and oats. Foods with a lower ratio, including whole wheat and rye bread, inhibit the production of serotonin.
Cocoa has also been found to increase serotonin levels in the brain, but since most chocolate is high in sugar, it causes blood sugar levels to spike. When the blood sugar level drops, the serotonin level also plummets. For this reason, chocolate with a cocoa content of 70% or higher is recommended for clients who find themselves compelled to reach for candy bars to “lift their spirits.”
Although it appears counterintuitive, research also suggests that eating a diet rich in whole-grain carbohydrates and relatively lower in protein will increase serotonin by causing the secretion of insulin, which helps in amino acid competition. This is because insulin lowers the blood levels of most amino acids, with the exception of tryptophan. Consequently, once insulin has cleared the competing amino acids from the blood, tryptophan is free to enter the brain. A diet with a 40:30:30 ratio of daily calories obtained from carbohydrates, proteins, and fats, respectively (popularized as the “Zone” diet by nutritional biochemist Barry Sears), balances two main metabolic hormones: insulin, a precursor of serotonin that promotes the storing of excess calories as fat; and glucagon, a hormone secreted by the pancreas that raises blood glucose levels and promotes the burning of fat.
Factors That Contribute to Weight Issues
Weight gain is a complex phenomenon with many contributing factors, ranging from deep biological processes to habit patterns and taste thresholds. Here we consider five categories of factors that impact the consumption and metabolism of food: genetics, sugar and other simple-carbohydrate cravings, habit, sleep deprivation, and taste habituation.
Genetics
A new area in the study of genetic signaling, known as epigenetics, examines changes in gene activity that do not involve an alteration of the genetic code, per se, but that are nonetheless passed down to at least one successive generation. These patterns of gene expression are governed by the cellular material—the epigenome—that sits on top of the genome, just outside it (the prefix epi- means “above”). Epigenetic “marks” tell genes to switch on or off, to speak loudly or whisper. It is through epigenetic marks that environmental factors such as diet, stress, and prenatal nutrition can make an imprint on genes that are passed from one generation to the next. Studies in epigenetics have shown that lifestyle may alter gene expression over generations (Pembrey et al., 2006). An ancestor’s habits of overeating, heavy drinking, and minimal exercising can contribute to the expression of “fat” genes.
Research has not yet fully demonstrated the ability to manipulate a broad spectrum of epigenetic factors, but there are at least two studies suggesting that possibility. It takes only the addition of a methyl group (one carbon atom attached to three hydrogen atoms) to change an epigenome. When a methyl group attaches to a specific spot on a gene—a process called DNA methylation—it can change the gene’s expression, turning it off or on, dampening it or making it “louder.” At Duke University, Robert Waterland and Randy Jirtle devised an experiment using mice with an “agouti” gene (i.e., a type of gene that affects coloration) that gives them yellow coats and a propensity for obesity and diabetes when the gene is expressed continuously. One group of pregnant agouti mice was fed a diet rich in B vitamins. Another group of genetically identical mice did not receive the B vitamin supplement. The B vitamins caused methyl groups to attach more frequently to the agouti gene in utero, thereby altering its expression. Simply by providing increased B vitamins—without altering the genomic structure of mouse DNA—Waterland and Jirtle induced agouti mothers to produce healthy brown pups that were of normal weight and not prone to diabetes. The control group of mice produced regular agouti offspring (Waterland & Jirtle, 2003).
A second study concerning gene expression was conducted by Dean Ornish. In a pilot study of 30 men with prostate cancer, Ornish found that changes in their diets for 3 months (mostly fruits, vegetables, and whole grains) led to 453 genes being turned off. The PSA level (prostate-specific antigen, a blood marker for prostate growth) of the men in the study dropped by an average of 4%, whereas it increased by an average of 6% in the control group. Ornish, Weiner and Fair (2005) suggested that the implications of this study go far beyond the ability of the body to heal itself under favorable conditions. Also implied may be an ability to change gene expression, such that heredity may not be a given (Hitt, 2003).
Jeffrey Friedman discovered a gene that activates the hormone leptin. Normally, leptin acts on receptors in the hypothalamus where it inhibits appetite; people who completely lack leptin eat copious amounts and are morbidly obese. For these individuals, treatment with synthetic leptin leads to dramatic weight loss. Leptin is manufactured primarily in adipose (fat) tissue, and the level of leptin is proportional to a person’s total body fat. For this reason, when most people diet, their leptin levels decrease—which is one reason that keeping the weight off is difficult (Friedman, 2001). However, as Friedman (2001) pointed out, we are the guardians of our genes, not victims of them. Jirtle, Waterland, and Ornish would agree with him.
Sugar and Other Simple-Carbohydrate Cravings
Lenoir (2007) at the University of Bordeaux in France did a study in which she found that rats that had been given cocaine preferred sugar water to cocaine. Excessive sugar in the diet can overstimulate the sweet receptors in the brain and lead to addiction and loss of control. Another researcher experimented with two groups of mice to determine the differences in response to walking over a hot plate with and without ingesting sugar. The group that ate a sugar solution prior to the experiment took twice as long to lift their feet from the hot surface (Cleary, 1996). In a third experiment, researchers measured isolation distress in baby mice. The researchers noted that when the baby mice were taken away from the mother, they cried over 300 times in a 6-minute period. However, eight baby mice given sugar water cried only 75 times in the same period. When the second group was given the drug naloxone before the sugar water, the chemical blocked the effect of the sugar. Then the second group of baby mice cried as frequently as the first group (Blass, 1986; Blass & Watt, 1999).
Sugar not only slowed the response time to a painful stimulus of the hot plate, it also seemed to depress a painful reaction to being isolated from the mother. From these studies, the researchers concluded that sugar blocked emotional as well as physical pain. Other researchers suggest that human beings may have a similar response to sugar, as the lead element in the sugar–insulin–tryptophan–serotonin cycle. To increase serotonin levels and change states, cravings for carbohydrates, alcohol, or sweets may arise. When an individual gives into the craving over multiple times, an addictive cycle may be set up (Colantuoni, 1992). Once the problem cycle is in place, any environmental stressor that is “medicated” with food becomes self-reinforcing, slows metabolism, and places the brain in a state of dysregulation. Over time, the addictive cycle is difficult to break (Yudkin, Kang, & Bruckdorfer, 1980; Fields, 1983; Ceriello, 2000). In addition, sugar consumption can increase the slower brain frequencies, which can slow thinking processes and learning (Molteni, 2002; Christensen, 1991).
The sugar–insulin–tryptophan–serotonin cycle provides a clear rationale for the fact that taste is affected by serotonin levels: The lower the serotonin level, the more sugar is required for a person to detect its taste—inducing a person to consume more sugar under low serotonin conditions. As mood stabilizes, the desire for sugar decreases (Heath, Melichar, Nutt, & Donaldson, 2006).
Habit
Shifts in energy levels during the day are associated with the biological rhythms of state change, and people may be especially prone to overeat during these periods of biorhythm shift. Ultradian cycles are expressed in patterns, and we see them in what are called endogenous biological rhythms (Thayer, 2001). Driven by these biologically-based rhythms, individuals tend to develop habit patterns; the coffee break and the cocktail hour are culturally institutionalized examples of this biological propensity.
Habit is one of the most commonly overlooked factors in obesity. As we mention to our clients, “No one becomes significantly overweight in a day. The pointer on the bathroom scale creeps up over time as the effects of eating habits accrue.” Entrenched eating habits may become practically unconscious. Particularly under stress, people often activate automatic and trance-like eating behavior. Frequently, clients report no memory of feeling hungry or the subsequent act of eating. Trance phenomena such as amnesia (loss of ability to recall) and analgesia (loss of ability to register physical sensation) keep anxiety low and awareness of overeating from the conscious mind. We commonly find that a client’s patterns of feeling, thinking, and behaving, once set in motion, continue almost unconsciously.
Professor Ben Fletcher of the University of Hertfordshire in the United Kingdom has demonstrated that if a person can break the habit that made him or her overweight in the first place, he or she can lose weight without focusing on it. Fletcher (2007) conducted a psychological experiment in which people had to select and follow a behavior pattern that was different from their usual habit/style, chosen from a pair of contrasting behaviors each day. Samples of paired behaviors were lively/quiet, reactive/proactive, introvert/extrovert, passive/assertive, generous/stingy, shy/flirty, etc. For example, introverts would act in a specifically extroverted manner. Twice weekly, they would have to try something outside their comfort zone, such as eating something they had never tried before, turning off their cell phone for a day, or going dancing. The participants were not on a diet; they were simply taking part in a psychological study. Losing weight turned out to be a byproduct of the experiment. The striking result was that after 4 four months the subjects had lost an average of 11 pounds simply by selecting activities that did not conform to their previous habit patterns. Six months later, almost all had kept the weight off, and some continued to lose more.
Sleep Deprivation
Many Americans have a stoic idea about how much sleep a person should need. Often we hear people boasting that they can get along on 4 or 5 hours per night, with the implication that sleeping is largely a waste of time. However, enough sleep is crucial for psychological and physiological health. Dr. Emmanuel Mignot researching sleep disorders, noted: “In Western societies, where chronic sleep restriction is common and food is widely available, changes in appetite regulatory hormones with sleep curtailment may contribute to obesity” (Mignot, 2004, Conclusion section., para. 1).
Research has found that sleep loss impacts several hormones related to appetite and food intake. Two hormones, in particular—ghrelin and leptin—are thought to play a role in the interaction between short sleep duration and high body mass index (BMI). Ghrelin, primarily produced by the stomach, triggers appetite: The higher the ghrelin level, the higher a desire to eat. Leptin (derived from the Greek word leptos, meaning “thin”) is a hormone produced by fat cells. Leptin controls eating and expenditure of energy and actually can rewire the brain to facilitate the process of slimming. Low leptin levels promote appetite and are a signal of metabolic starvation. The study data showed a 14.9% increase in ghrelin and a 15.5% decrease in leptin in people who consistently slept for 5 hours compared with those who slept for 8. For people who slept less than 8 hours per night (74.4% of the sample), their increased BMI was proportional to decreased sleep. Increasing sleep duration therefore may prove to be an important way to treat inappropriate weight gain (Taheri, Lin, Austin, Young & Mignot, 2004).
A shortage of sleep reduces the capacity of the body to perform basic metabolic functions such as processing and storing carbohydrates. The changes induced by sleep deprivation in one study included profound alterations in glucose metabolism, in some situations resembling patients with Type 2 diabetes. “We found that the metabolic and endocrine changes resulting from a significant sleep debt mimic many of the hallmarks of aging,” said Eve Van Cauter, director of a study examining sleep deprivation in healthy young adults. “We suspect that chronic sleep loss may not only hasten the onset but could also increase the severity of age-related ailments such as diabetes, hypertension, obesity and memory loss” (Spiegel, Leproult & Van Cauter, 1999, p. 1437). People deprived of sleep for 4 nights exhibited signs of pre-diabetes and, because of a drop in leptin, showed a tendency to a high carbohydrate load (Peykar, 2008).
Even while sleeping, the brain can sense the smallest amount of light, and this can contribute to poor quality sleep. The hormone melatonin is secreted by the pineal gland; its level rises with dusk and subsides with sunrise, thereby regulating periods of sleep and wakefulness. Without a sufficient period of darkness, melatonin production may be impaired. In a French study, researchers demonstrated that melatonin prevented the development of obesity in animals fed a typical Western high-fat diet (Prunet-Marcassas, et al., 2003).
A lack of sleep may contribute to weight problems even in very young children. A study done by Harvard Medical School showed that 14% of preschool children ages 1–3 years old who slept less than 11 hours were overweight, compared to children who received at least 13 hours per night (Taveras, 2008).
Taste Habituation
The brain is wired to seek novelty in the case of taste, as in other experiences. For each different type of taste, the tongue has a detection threshold (or recognition threshold), meaning the point at which a person can first detect a particular taste. For example, sweetness is detectable at roughly 1 part in 200 of sucrose in solution. Bitterness (often indicative that a certain plant is toxic to eat) has a much lower detection threshold, at about 1 part in 2 million for quinine in solution. Taste sensors reach their maximum intensity after approximately 1 minute of stimulation; at that point habituation occurs and the perception is that the tastes “fades.” If a person takes a bite of one food followed by a bite of a second food, there is more novelty and the tastes of both seem more intense. When the same food is presented to taste buds repetitively, adaptation will result in the discernment of fewer individual flavors and a decreased overall flavor intensity. After the third or fourth spoonful of ice cream, the rest of the carton—if consumed in one sitting—does not taste as interesting. Because of this fading effect, an unconscious drive to regain a previously experienced intensity of taste may be a contributing factor in some overeating.
Therapeutic Assumptions in Addressing Weight Issues
A weight problem may be symptomatic of many different issues. Often, there are issues of early abuse, and weight keeps a person from being sexual. Until the abuse is resolved, successful weight loss will be impossible. Another issue is that in a family where all the members are overweight, family loyalty may be defined by weight. One client who came from a family in which the women were quite overweight found that they all chastised her for wanting to lose weight. For others, the issue may have to do with the stability of the marital relationship. We have had clients who were concerned that if they lost weight, they might want to leave their equally overweight spouse. In that situation, to engage support for the new pattern, we normally suggest that the partner also come for joint sessions. However, in all cases, certain therapeutic assumptions form the foundation of our work with overweight clients. These are outlined below:
• People have the ability to manage their weight (or other addictive behavior). In most cases, the person was not always overweight. We suggest that the client has the capacity to change states and deal with cravings and anxiety-driven eating. Cravings are emotionally driven and/or physiologically driven obsessive thoughts or sensations that a person does not know how to manage.
• Addictive behavior functions to mask or medicate unresolved issues. When a person is unsuccessful with many weight loss attempts, there are frequently deep emotional conflicts that must be addressed therapeutically. Once the veil of illusion regarding an addiction is lifted, the feelings that were hidden from awareness by overeating can be revealed, and the quest for self-understanding and mastery becomes possible.
• The motivational circuit of determination must be activated. Determination may be located in non-food-related arenas (Panksepp, 1998). People already know how to motivate themselves toward goal attainment. Those resources can be redirected for food management. Although weight loss based on either incentive or threat is usually short-lived, it may be enough to bridge a person into the target state. However, an individual must develop other motivation in order to stay there. Ultimately a person must learn to change the neurological patterns driving brain–mind states and the behavior that led to being overweight in order to maintain of lower weight.
Milton Erickson was a master in utilizing the problem and eliciting resourceful states from people. In treating an obese young woman, Erickson utilized her intense pain about her weight by asking her to stand in front of a full-length mirror and really notice how much she disliked all the fat. He continued: “If you think hard enough and look through that layer of blubber that you’ve got wrapped around you, you will see a very pretty feminine figure, but it is buried rather deeply. And what do you think you ought to do to get that figure excavated?” Erickson reported that she “excavated” 5 pounds a week (Erickson, Rossi, Ryan, & Sharp, 1983, pp. 267–268). With his intervention, Erickson elicited positive motivating anxiety by using the client’s own pain and redirecting it toward action. He helped this woman find the real body she had long been unable to see.
• A client’s weight issues are frequently embedded in a relationship and must be addressed within that context. The system in which an individual operates may serve to keep a problem active. Usually clients with weight issues are aware of many conflicts surrounding food and have good insights, but they may be less aware of the ways in which the present system is reinforcing negative behaviors and attitudes. In one case, the client’s wife unintentionally played a role in the reinforcement of symptom behavior. She was so worried about him dying from his overweight condition that she would watch him at night. When he would sneak into the pantry and begin eating, she would jump out and tell him, “I caught you.” He would then become angry and have more urge to binge. To interrupt the marital dynamics around this issue, we asked the wife to purchase a Sherlock Holmes hat and wear it at night. Her husband was to purposefully sneak into the pantry. She was to then jump out with a flare and announce, “I caught you.” After doing this twice, they were both able to laugh about this “game” and then stop it.
• Most clients with weight issues visualize themselves gaining back any lost weight. Often they use the negative practice of envisioning the worst possible future, although this visual practice is usually outside awareness until the therapist begins to ask about the idea of future success in keeping the weight off. Since we generally tend to achieve the goals we visualize, it is important to be certain that the client’s future is seen as a thinner one. In fact, we suggest that clients imagine themselves thinner up to the end of life.
• Clients may be using trance phenomena in a negative manner to shield themselves from awareness of their own behavior. Many clients with weight problems are skilled in using dissociation from body sensations such that they cannot distinguish anxiety from hunger or recognize feeling full. Often they employ amnesia for bingeing episodes and only later, if prodded, may recall a recent specific event. In trance, the client can be directed to attend to his or her bodily sensations and become more conscious of bingeing behavior and exactly what was eater during the bingeing. By learning to listen to the body, the client can become aware of its ability to provide immediate, meaningful feedback, bring him- or herself out of a dissociated state, and access more conscious choices in terms of food selection.
• Client education may be necessary. As needed, client education may include techniques of state change, basics of nutrition, how to recognize hunger and distinguish it from other sensations, and how to recognize the feeling of being full. In some cases, we may even teach simple facts about neurochemistry (e.g., the carbohydrate–insulin–tryptophan–serotonin cycle) so that the client has an understanding of the neurological basis for certain cravings.
• Teach clients about kaizen. The Japanese have a word for continuous improvement through small changes; the word has spread from the business community into common usage: kaizen (Imai, 1986). We suggest that even one small change can be the tipping point for greater change. Success does not have to be an “all or nothing, right now or never” affair. It can be achieved through kaizen—a succession of countless small changes in habit and behavior patterns. These can shift a person’s diet from one high in simple carbohydrates or in fats to one that is primarily fruits, vegetables, and lean protein with lots of variety for novel eating. After a period of time, the desire for sugar, starches and fat fades. However, if food management begins to wane, adaptation to previously well- known lethargy, sensations of bloating, inflammation, etc., will recur and weight will begin to climb (O’Mahoney, 2007).
Client Assessment for Weight Management Cases
When applying BCT to clients who come with weight as the presenting issue, the first step, as with all clients, is taking a detailed history while establishing rapport. In this case, the clinician will want to focus specifically on the client’s “food history,” which should include answers to the following questions:
1. Ask for a history of the weight problem, including the age of the client when it began.
2. Ask the client to describe any particular cravings or tendencies toward binges and the circumstances under which these occur.
3. Inquire about family-of-origin messages regarding food. Examples are: Food equals love; food equals “good times”; “You should eat because children in name-of-remote-place are starving.” For the now-aging Baby Boomer generation, there may have been a carryover from Depression-era circumstances, during which their parents were taught to clean their plates at every meal. Frequently, clients report anxiety around mealtimes when growing up.
4. If the client is married, ask about the “contract” made regarding food and how slim each partner would remain over the years. Sometimes weight gain becomes an arena for power struggles.
5. Listen for the “food language” that a client may use unconsciously. For example, “I could really taste that success”; “That idea is something you can really get your teeth into”; “This is food for thought.” This language can then be used by the therapist in conversational hypnosis to focus attention on the impending change to a slimmer individual.
6. Discover the client’s “motivating anxiety” and consider how it might be engaged. A person needs to feel determination and positive anticipation in order to move toward goal attainment. If the client’s affect is flat, it is useful to mildly activate the anxiety circuit by helping the client identify some truly motivating positive reason to lose weight. The weight loss client usually enters therapy because he or she “failed” at dieting on his or her own, so there is already an intrinsic motivation. However, “I can’t do it alone”—which brought the person into therapy—is not enough motivation to succeed. Together, the client and the therapist must discover some compelling, emotionally based reason to lose weight from the perspective of the client (not from the doctor’s perspective or the spouse’s perspective or even the client’s own intellectually based perspective).
7. Most people have an “internal weight manager” that tells them how much weight gain is too much. This may be found by asking how the client maintains the present weight. Frequently, people use a scale or notice how their clothes fit as their internal weight manager.
8. Ascertain whether or not the client knows when he or she feels full.
9. Find out how the client related to food when he or she weighed less. For example, the therapist might ask, “How did you maintain your weight then? Were you more interested in other things? How did you comfort yourself then?”
10. Identify the trance phenomena the client may be using to keep the problem going. Inquiries might include: “Do you remember when you overeat (amnesia)?”; “Do you pay attention to feeling full? (dissociation)”; “Do you notice your hand floating to your face when you eat?” (Hand levitation is an unconscious movement of the hand, and most anxiety eating includes this behavior.)
11. Ask about expectations regarding treatment.
BCT Interventions Applied to Weight Loss Clients
Many of the BCT tools stimulate a renewed ability for self-regulation, particularly for the self-regulation of weight, so that an individual has more control, peace of mind, and self-discipline for personal success. We use the following protocol as our guide in working with patients whose focus is weight loss.
1. Assist the client in becoming consciously aware of and, specifically, able to articulate to him- or herself what emotions or feelings he or she is experiencing in stressful situations. Help the client develop descriptive labels of his or her feelings using the client’s own words. For example:
For easy reference, these can then be shortened to “caged,” “the elevator feeling,” “can’t run fast enough.” Instruct the client to watch for the feeling and make a mental note of the circumstance in which it arises. Encourage the client to become honestly curious (turns on the seeking circuit) about whether he or she is hungry or is, in fact, anxious. If the answer is “anxious,” suggest that the client deepen his or her breathing for 2 minutes as a refocus of attention. This focused breathing can even be formalized by watching the minute hand on a watch.
2. Utilize and reframe the problem to expand the number of solutions and turn on the seeking circuit. Resistance to losing weight can be framed as the person choosing to be fully in control of his or her behavior and deciding when and how he or she will lose weight. This is particularly appropriate for clients who feel “helpless,” a “victim of their circumstances,” or “out of control” when in fact none of those is the case. The pivot point is when the client can see that he or she is already making controlled choices. The seeking circuit is activated any time the client self-inquires, “What is really going on here?”
3. Retrieve resources to assist in a resolution of the problem. Clients with weight issues need to experience a sense of renewed determination to succeed. By remembering several incidents where a person strongly experienced determination, he or she can transfer the strong affect associated with the original success to resolve the weight problem. For one client, the deep determination to stay involved in the lives of his adult children and wanting their approval was associated with demonstrating success in the area of food management.
4. Help the client learn to differentiate states and manage state change. More often than not, the physical sensations of hunger and anxiety are poorly differentiated by clients with weight issues. Because the act of eating and the digestion of food may change a stressful state to a relaxed one, food becomes associated with relaxation. When a person can learn to turn on the relaxation response and practice it, there is much less urge to use food to alleviate anxiety. We have found that clients who use regular relaxation techniques or devices such as the DAVID PAL can interrupt their desire to overeat. Clients also need to learn how to turn on the circuit for nurture, care, and comfort without using food—for example, by curling up with the family cat.
5. Use deep state training to bring down the set point of arousal. The set point of arousal is the point at which stressors begin to set off a stress response. Frequently, individuals do not have a body sensation or memory of what it feels like to be completely relaxed without a substance or food. Deep state training reteaches an individual how to reconnect to a state of total relaxation.
6. Use deep state training to dislodge negative and limiting core beliefs, so that an individual can believe the process of losing weight can be successful. We note that in the deepest state of profound calmness and openness, the client may be in the most receptive state of mind. A desire to be in control dominates the thinking of many clients with weight issues. While a person may experience him- or herself as out of control, we frequently find that the individual is demonstrating a remarkable ability to eat in a way that closely maintains the weight over a number of years.
7. Use deep states to make direct suggestions about control of self, management of food, and feeling full on less food. If the clinician is using hypnosis to achieve deep states, it may be useful to conduct the hypnosis while the client is connected to a biofeedback system to access more precise information about the person’s brainwave states.
8. Use future orientation in time to help the client to envision a time at which the problem has been resolved. Ask the client to bring in a photograph of him- or herself at the target weight and to remember how he or she felt when at that weight. This image can be used in a trance induction involving future orientation in time. In hypnosis, various scenarios of being thinner and enjoying looking as he or she did in the photograph can be employed. Self-regulation can also be encouraged by having the client visualize his or her ideal future body on a regular basis—for example, as he or she exercises.
Case Example: Imagining a Life of Her Own
Nearly in tears of frustration, Kimberly told Carol, “I just have no control over my eating when I am upset, lonely, or bored.” This belief controlled her behavior and had been strongly reinforced by attending a self-help group that underscored the belief that she was uncontrollably addicted to food. In the process of gathering a history of Kim’s overeating, Carol learned that her mother had tried to control her by being intrusive about what and when she could eat. Kim recounted that the refrigerator had been “practically a lockbox.” About her mother, Kim said, “It was like she always had a mental inventory of the fridge and could tell by looking if anything had been moved—or removed” [history of eating disorder]. Introducing the family to someone new, her parents would refer to her with embarrassment as “our little chub” [food message]. Early on, Kimberly said, she had became enraged by her mother’s attitude toward her and decided that she would be in charge. In later years, any attempt on her part to limit her food intake was met forcefully by her own resistance and resentment, just as it had been elicited originally in the context of the family dynamics.
Listening to her, Carol pointed out that she truly was in charge of whether she gained or lost weight—just as she had been as a child [therapeutic assumption that people have the ability to manage their weight]. It was totally her decision, and Carol would support her ability to decide. This therapeutic position took Kim out of the victim role, placed her in charge of herself, and eliminated the basis for blaming anyone else for her decision. Perhaps for the first time, Kim consciously grasped the reality of her own empowerment.
Carol suggested that if she decided to lose weight, it would not be a matter of willpower, of constantly trying to “just say no” to food, as Kim put it, but one of focusing her mind on the goal and allowing any other thoughts or feelings to just come and go, like shooting stars. This verbalization gave her a positive focus rather than a negative one. Carol also used alpha–theta biofeedback in conjunction with guided visualization to reinforce the fact that it was entirely Kim’s decision to choose “bad” foods or not. The visualization continued to place her in charge and, ultimately, she chose to skip the high-fat, high-calorie foods most of the time while keeping the option to have them on occasion.
Determination or persistence is a resource that all people have in different contexts. During one session, Kim mentioned that when she was 9 and her two older brothers were both riding their bicycles “hands free,” she became absolutely determined to be able to do it too. Practicing in secret, it took her a couple months and quite a few falls, but she managed it. Having located the previously developed resource of strong persistence as an internal state [motivational circuit], Carol used conversational hypnosis to help Kim review the feeling and overlay it onto the goal of managing her weight.
Kim also became fascinated [internal circuit of curiosity] with how slimmer people keep their weight under control. In the process of studying other people’s behaviors and strategies for mood regulation, she also learned a little about the neurochemistry of nutrition and became more educated in managing her own mind states [client education, in this case self-directed].
After 4 months of therapy, Kimberly had lost 23 pounds; she had also become aware of the ways in which she had structured much of her life as an unconscious means of “just saying no” to her mother. And for the first time, she was ready to actively address the question, “Who would I be—and what would my life look like—if I started to ‘just say yes’ to me?”
Additional Specific Interventions
In addition to the general guidelines provided in the protocol described above, we recommend the following specific interventions for consideration when working with clients who have weight issues:
• Help the client develop a self-hypnotic feeling of fullness by remembering a time when he or she was really full and then attempting to feel the sensation again in the stomach. If the client reports difficulty identifying this sensation, we normally suggest drinking a glass of water in the session. After the memory is stimulated (or the sensation created during the session by drinking a glass of water), the client can memorize the feeling and recall the sensation.
• Advise the client to return to a food plan and an exercise routine with which the client has had success (at least, temporarily) in the past. If the client does not have either of those, assist the client in creating them. For example, the client may need encouragement to engage a personal trainer at a gym for a period of time in order to fashion an appropriate exercise regimen. Particularly for clients with diabetes, high blood pressure, or other medical complications, make certain that they are also coordinating with their internist or cardiologist.
• Teach the client to interrupt the agitation of wanting something not on the food plan with an internal sound or song. This could be the word click, the song line “I want to be in that number … ” (from “When the Saints Come Marching In”), or a sound like “yeeeeeeeeee”. Almost anything, however brief, can be enough to shift a person’s attention. The intent is to replace the object of desire by interrupting the focus of concentration long enough for a different thought to enter.
• Help the client identify ways to reward progress with something other than food.
• Encourage the client to develop the habit of consistently practicing the relaxation response by focusing attention on the breath and allowing any thought or sensation to pass by without judgment.
Case Example: Weighting for the Light
Aaron, a physician whose specialty was oncology, knew the dangers of obesity with clinical exactitude. Nonetheless, he was 100 pounds overweight and had struggled with eating problems all his life. Coming from a family in which anxiety was calmed by food, both his parents and brother were obese. His father had died from a heart attack, and his brother had been hospitalized recently with heart trouble. Aaron reported that his overweight mother used to act like the “food police” and tell him what he should and should not eat. Not surprisingly, he responded with rebellion, anger, and resentment.
Aaron had already worked with a number of therapists, consulted nutritionists, and tried many weight loss programs. He had spent years in analysis and had substantial insight into the issues underlying his weight, but he still could not stop bingeing. His excess pounds were a constant source of frustration, grief, embarrassment, and self-loathing. He said he was waiting for “the light to come on”—for the one insight that would be illuminating enough to propel him to success.
He had binged for years by stopping at four or five restaurants on his way home from his office at the end of the day. Whenever he was surprised by having to be on call with little notice, a resurgence of the old anger and resentment toward authority triggered further bingeing episodes. He felt victimized when his answering service called him after-hours for an emergency, even though being on call was an unavoidable part of his medical practice.
A key to making change is being able to access internal resources for problem resolution and solution maintenance. In the first hypnosis session, we suggested, “You can go back in time and discover two or three experiences when you were completely determined to succeed.” Immediately, he described his “full” focus in medical school [food language] and ability to complete the work. Another resourceful memory was the unwavering determination to spend time with his children after his divorce, even though his ex-wife attempted to keep the children from him. We suggested: “You can fully remember these feelings—first one event and then the other. Really savor the flavor of your determination [food language] to succeed. Then, remember what you looked like, how your body felt, and how people responded to you when you were 100 pounds lighter.” These resourceful memories “jumpstarted” the loss of weight. [Access internal resources for motivation.]
Aaron returned to a food program with which he had previously had some success, but the bingeing continued. After each frustrating day, he would stop at three or four restaurants and feel a growing level of shame as he progressed from one to the next. Curiously, his report of these events lacked much emotion. When we asked him where the missing feelings were, he became aware that there was little positive motivating anxiety driving him to resolve the problem. But the pattern clearly had to be interrupted for him to succeed.
We realized that Aaron needed to find a way to manage his attitude regarding his work and a way to change his brain state in order to interrupt the bingeing episodes. He reported that he always felt exhausted before he binged.
He agreed to use the DAVID PAL device, which shifts the brain into a state of relaxation and calms the whole body (Seiver, 2003), before leaving work each evening. By this means, he achieved a more positive state of mind, managed to let go of the day’s tension, and rediscovered the ability to drive straight home. He was successful until he had a particularly upsetting and stressful workday, at which time he binged again. Obviously, more drastic measures were needed. [Facilitate state change.]
At the next session, we asked him what he would be able to do if he had the motivation to take charge and manage his weight differently. He replied that he could easily lose 1 pound a week without any struggle or feeling of deprivation and could keep himself from bingeing.
We then asked Aaron to name the person or persons whom he most hated. After much thought, he said that it had to be the American Nazi Party. We asked him to take out his checkbook, write a check for $1,000 to the American Nazi Party, and to leave it in the office. He was told that if he could not maintain his commitment to lose a pound a week and cease bingeing, the check would be mailed. Cautionary Note: An intervention of this sort should not be used with any client who has a previous history of abuse or trauma. Such a client might well feel that he was being asked to “collude in his own emotional blackmail,” or it might feel “punishing” and the effect could be highly counterproductive. [Access hidden determination.]
He suddenly imagined being placed on the group’s mailing list and receiving their literature for the rest of his life. What would his letter carrier think? Would word of this reach his rabbi? Of course he could blame it on his therapist, but would anyone really believe him? What would his Jewish neighbors think, to say nothing of his friends and family? All of the color drained from his face, but he wrote out the check. “Aaron, you’ve been waiting for the light to come on,” we said. “Perhaps you could imagine the swastika rotating and a beam of light coming from its center each time you see an unhealthy food or a fast-food restaurant. Can you see the light?” [Increase motivating anxiety.]
Because we did not know the address of the American Nazi Party, we asked Aaron to look it up on the Internet. He had the address at the next session and confided that he had searched the Internet late at night so that no one in the family would know. Positive motivating anxiety was now activated, and he lost 3 pounds the first week. For the first time since he had started bingeing, he was successful in controlling his state and behavior.
Thus, for a short time Aaron’s motivation was his fear of an external threat—that we would mail the check. In essence, as therapists we were temporarily carrying his motivation for him. However, as soon as Aaron could demonstrate a measure of success—most importantly, to himself—we needed to reinvest him with an internally driven sense of motivation. We asked him to bring in a picture of himself at a time when he was at his target weight. The photograph that he showed us was of a lean and tanned younger man, confidently smiling at the helm of catamaran. That photograph became an icon of the man he wanted to reclaim and connected him to the motivation that eventually took him to his target weight.
Aaron began eating five times per day, including a protein and a complex carbohydrate each time he ate. We encouraged him to eat fibrous vegetables with protein in the evening and avoid white carbohydrates after 5:00 P.M. Exercising with light weights three times a week and at least 20–30 minutes of aerobics were suggested. Whenever Aaron had lost weight previously, he realized, he had visualized himself as heavy again. This time, we instructed him to practice two visualizations while he exercised each time. One was to visualize himself as thin and enjoying others admiring his physique. The other was to develop an image of himself as healthy and old.
We included alpha–theta training to teach Aaron methods of self-soothing. We also used deep hypnosis to allow Aaron to practice various scenarios in which he could make healthy food choices. Suggestions for the proper balance of protein, complex carbohydrates, and vegetables were paired with feelings of comfort, delight, fullness, and enjoyment of a lighter sensation (Blum & Tractenberg, 1990). Over time, he responded by feeling less stress daily, being in a more positive mood, and continuing to losing weight.
By the time Aaron terminated therapy, he had lost 100 pounds. With his consent, we kept the $1,000 check in our office fireproof file cabinet so he could remember that this assistance would always be in our office. At follow-up 8 years later, he reported that he had not binged again.
This chapter discussed the neurochemistry of food, including simple carbohydrate craving and the four key neurotransmitters, dopamine, acetylcholine, gamma-aminobutyric acid (GABA), and serotonin. It explored the roles of genetics, sleep deprivation, habit and taste habituation in weight issues; therapeutic assumptions in working with clients having weight issues; client assessment for weight management cases; and BCT interventions weight loss.
In the next chapter we describe the use of three combined treatment modalities—hypnosis and meditation used to harness the power of the unconscious mind, alpha–theta training to augment the healing ability of the CNS, and group relational support—in treating life-threatening or chronic illnesses. Working with a small group of participants to explore all three possibilities, we developed applicable mind-training techniques, qualitative themes, a collaborative process for the creation of individual healing journeys, and group metaphors for healing.