There was once a time when the solution to excess weight was singular and simple: just go on a diet, we were told. Take in fewer calories and watch the pounds slip away. This recourse developed from the long-held view that overeating is a moral issue—consume in moderation, exert some self-control, and all will be well.
As science began to understand and explain that being overweight was far more of a physical problem than a moral failure, we learned that, along with ingesting fewer calories, we needed to expend more energy to burn them off. Before long, however, another factor emerged in the equation. We discovered that it mattered not only how much we ate, but what and when—small, frequent meals accelerated calorie burn-off, carbohydrates and proteins each affected appetite differently, and metabolism was more complex than anyone could have imagined.
Further studies went on to conclude that all appetites are not created equal and that hormones, heredity, and biochemistry play a far greater role in eating and weight regulation than we previously thought. We learned that specific foods alter our biochemistry and moods and that genetics may largely predetermine weight and body structure. We found out that appetite hormones and neurotransmitters were a major determinant of whether we could easily control our appetite and lose weight (not to mention regulate emotions!), and that medication and surgery could be utilized to reach our weight and eating goals.
No matter how complicated the issue of eating and weight became, however, our solution remained more or less the same—eat less and exercise more. It is easy to see how this cookie-cutter model stuck with us. Let’s face it, it is difficult for anyone not trained as a neurobiologist to understand the complexities, subtleties, and far-reaching implications of weight management. Moreover, because the subject has become so complex, it is easier to think in terms of moderation and self-discipline, which are simple and familiar concepts that have been reinforced for centuries, than to bone up on the latest weight-loss study results.
At the same time that science was redoubling its efforts to discover the causes and treatments for obesity, serious problems began to crop up at the other end of the eating spectrum, namely, an increase in cases of anorexia and bulimia nervosa. For decades these conditions were viewed as rare and somewhat exotic. Now it is hard to remember a time when they were not in our clinical lexicon. Although health practitioners (and society) learned quickly to recognize the gravity of anorexia and bulimia, it took time to develop theories about causes and efficacious treatments. Initially, the roots of these disorders were thought to be solely psychological and intrapsychic. In time, psychology began to view them as being caused, or at least exacerbated, by family dynamics, traumatic events, and societal pressures to be thin. Now we have discovered that, like overeating, anorexia and bulimia are strongly influenced by biological factors. Anorexia is not merely rebellion against parents in the service of separation and individuation; bulimia is not a symbolic rejection of the internalized bad mother.
So, where does all this rapidly changing information leave the average, conscientious therapist who tries to keep up with the latest developments in many fields—depression, anxiety, attention deficit/hyperactivity disorder (ADHD), trauma, addictions, child development, and personality disorders, among others? How can she best serve clients who have eating and weight problems without receiving extra training in the field of eating disorders or returning to school to earn a PhD in neuroscience? How can she make accurate assessments to pick up and focus on the minor as well as major eating and weight concerns of the men and women she serves? The answers lay ahead in the pages of this book.
In spite of the fact that being overweight has a strong physiological component, talk therapy is extremely successful in helping clients resolve eating and weight issues. Treatment can be integrated into any specialty—couples or family, brief treatment or psychoanalysis, solution-focused or eye movement desensitization reprocessing (EMDR)—and may be addressed in a variety of therapeutic models—cognitive-behavioral, relational, dialectical behavioral, Gestalt, and sensorimotor, to name a few.
It makes sense that medically trained clinicians such as psychiatric nurses might want to use their science training to help clients understand the biology of eating and weight management, while strict behaviorists might lean more toward helping clients set up a successful system of rewards and incentives to reach their goals. Whatever our discipline or expertise, we can use talk therapy to help clients move toward identifying, understanding, and resolving their eating issues.
Another aspect of how we view and interpret eating and weight issues is dependent on our own or our intimates’ struggles with them. If we have had—or continue to have—problems, will it make us more or less empathic with a client who eats or weighs too much or too little? How may the success or failure of our attempts to resolve our own food problems affect our willingness and ability to talk about a client’s relationship with food and her body, and the way that weight impacts health, self-esteem, and relationships?
It is time that we start to view food and weight problems not as separate from the rest of our clients’ issues, but as integrated into them. Although not every client has eating concerns that are central to therapy, many have an unhealthy relationship with food and their body, which impacts and impinges on nearly every aspect of life. Just as no competent therapist believes that sexual abuse, marital difficulties, or addictions are self-contained, no therapist should treat eating and weight issues per se as irrelevant or inconsequential to a client’s overall mental (and physical) health.
Most clients with eating and/or weight problems arrive at my office after decades of struggling with food and the scale. Chronic overeaters or undereaters or, more often, yo-yoers between the two, they are at the end of their rope and run the gamut between expecting miracles and fearing that they are beyond help. Aware of my experience in the eating disorder field, many expect that I will recognize what is wrong with them immediately and know exactly how to fix them. I often do have an inkling about the causes of their food dilemmas and tentative assumptions about how to get their eating back on track, but I certainly do not have all the answers.
According to MEDA, considering that at any given time in this country 45% of women and 25% of men are on a diet, two things are clear (“General Eating Disorder Fact Sheet,” MEDA Web site). The first is that a significant portion of our population is concerned about losing weight, and the second is that they consider dieting the way to do it. Not surprising! There are some 17,000 diet methods and plans available, and the diet industry spends between $40 billion and $50 billion annually to promote them (“General Eating Disorder Fact Sheet,” MEDA Web site). Dieting is so acceptable that people who want to shed pounds do not think twice about giving the South Beach or Atkins diet a whirl and cannot imagine any other way to take it all off. From magazines to medicine, we are led to believe that diets work.
But do they? One statistic that has remained steady throughout the 3 decades I have worked in this field strongly challenges conventional wisdom about dieting: 95% of people who diet and lose weight regain it, and 90% regain more than they originally lost. Meta studies of diets across the board keep coming up with this same conclusion: only 5% of dieters keep the weight off for more than 5 years (“General Eating Disorder Fact Sheet,” MEDA Web site). When we think of it that way, how many of us would throw everything we have into an investment that, at the outset, offers such a paltry chance for success? Moreover, a survey of more than 30 studies on dieting and weight loss found that “the benefits of dieting are simply too small and the potential harms of dieting are too large for it to be recommended as a safe and effective treatment for obesity” (Guthman, 2008, p. 46).
Additionally, in my experience, people in that paltry 5% of successful dieters are often what I call “white knucklers,” whose chief goal in life is to stay thin. They live in perpetual struggle with sugar and fat and most white foods and focus most of their energy on counting calories and rigid portion control. Moreover, when a segment of this group falls off the wagon, they often fall far. From never eating forbidden foods, they go to overconsuming them and, hence, put on all the weight they lost—35, 60, or even 100-plus pounds. So, while it is true that for some people diets do work, these superachievers pay a heavy price through deprivation and living in constant fear of food and fat.
Diets do not work for permanent weight loss, but that does not mean that people who are heavy need to be resigned to their weight. Many folks find healthy ways to keep weight off and have a positive, enjoyable relationship with food. With patience, practice, and perseverance, they learn, to a greater or lesser extent, the skills that “normal” or intuitive eaters (I use the terms interchangeably) employ instinctively and automatically to feel comfortable around food and maintain a healthy weight for life. “Normal” eating is called intuitive because it means making food choices based on body sensations, not external influences. “Normal” is in quotes because it does not describe one type of eater. It does, however, entail following a set of four rules: eating when hungry, making satisfying food choices, eating with awareness and enjoyment, and stopping when full or satisfied.
“Normal” eating was first advocated in the 1970s as the anti- or nondiet approach to weight loss. Unfortunately, in spite of consistent research proving that diets tend to make people fatter by decreasing metabolism and causing deprivation and rebound eating, intuitive eating has never won over large audiences. The process of change through intuitive eating is too difficult, too slow, and too demanding. And diets? They are simplistic, give us right-and-wrong instructions for success, and, unlike intuitive eating, do not require that we trust the bodies that got us into trouble in the first place. Diets are symptomatic of the superficiality of our culture and the appeal of magical thinking, our desire to cut corners, and our primitive wish to get something for nothing.
However, diets can be dangerous. Besides promoting undereating and causing rebound feeding, eating disorder experts consider them the gateway to serious problems with food. Thirty-five percent of dieters move on to yo-yo dieting and one-quarter of those who diet develop clinical eating disorders (Guthman, 2008). Naturally, not everyone who diets ends up engaged in pathological dieting, that is, restricting food in such a way that the practice becomes an obsession and causes health problems. However, a preoccupation with thinness may set the stage for a lifetime of food restriction and deprivation that permanently alters metabolism and is as destructive to a person’s emotional health as any addiction.
One of the major problems with referring clients to diet plans and programs is that they are based on the faulty assumption that anyone who tries can succeed at losing weight and that failure to do so is due to lack of motivation and willpower. In short, diet failures blame the victim, which, as therapists, we work hard to avoid doing (think incest and physical abuse). Moreover, because they are simplistic, diets fly in the face of what every clinician knows and tries to teach clients—that there are complex roots to most of our issues, that change takes substantial time and effort, that creating a life that is joyful and meaningful is not a linear process, that resolving our difficulties generally involves making changes in many, if not all, aspects of our lives, and that long-lasting transformation requires that we pay attention to who we are and want to be pretty much around the clock.
This book will help the reader gain confidence and competence in assessing and treating weight and eating issues through:
• understanding their multifaceted causes, providing a solid foundation for assessment approaches and treatment options, and giving a deeper appreciation of how strongly these issues may affect and permeate clients’ lives;
• sorting out the non-life-threatening problems clients have with eating and weight from serious issues that undermine their physical and mental health and endanger their lives;
• identifying when food and body struggles may be symptomatic of more serious issues of mood problems, cognitive distortions, and impulse control disorders;
• recognizing and dealing with transference and countertransference issues that arise in therapy around size and weight issues between clinician and client.
Chapter One, “A Comprehensive Approach to Treating Eating, Weight, and Body Image Issues,” lays out both the obvious and subtle ways that food disturbances intrude into a client’s life and how to begin thinking like an eating disorders therapist. This chapter provides a context for making connections about assessing and addressing eating and weight issues with a wide range of clients. Chapter Two, “How Clients Express Themselves Through Food,” looks at historical and cultural stereotypes of being fat, being thin, and overeating, offering an overview of how clients with eating and weight problems may perceive themselves and how others may see them. It describes the ways that disordered eating—along the continuum from minor to major dysfunction—may be a symbol of unspoken or unmet needs and how they get acted out with food and weight.
Chapter 3, “The Biology of Eating and Weight,” is an explanation of the complexity of this subject matter due to variances in individual biochemistry, and how biochemical imbalances that lead to eating and weight problems also correlate to mood and impulse disorders. This chapter, more than any other, illustrates why diets fail to work for most people. Chapter 4, “Health and Medical Problems,” provides a comprehensive description of what can happen when the body receives too little nourishment, and describes the physical consequences of being over- or underweight. Written in lay terms, it details how eating too many of the wrong foods and not enough of the right ones may lead to life-threatening health issues.
Chapter 5, “Personality Traits and Family Dynamics,” offers an overview of the impact that personality has on eating problems and vice versa. It presents a context for understanding how characterological and family influences contribute to struggles with food and weight. Chapter 6, “Assessment,” sets out the practitioner mind-set that is necessary for ongoing evaluation of subclinical food and body issues and provides tools for determining the nature and extent of motivation, dysfunction, and skills for recovery. The focus is on how clients might present with eating problems in therapy and how to relate them to other issues in their lives.
Chapter 7, “Clinical Disorders,” explains how depressive, anxiety, and dissociative disorders relate to food and weight problems, as well as how trauma and sexual abuse can impact body image and the regulation of appetite. This chapter details how eating may be a way of coping with psychological problems as well as an activity that exacerbates them. Chapter 8, “Life-Cycle Issues,” shows how eating and weight problems surface in various phases of life. It covers age-related stages as well as conditions such as pregnancy, menopause, and illness.
Chapter 9, “Nutrition and Fitness,” explores what clinicians need to know to help clients eat healthily and become fit. It outlines the information that clients must have to nourish themselves adequately and achieve all-around fitness goals. In Chapter 10, “Transference and Countertransference,” discussion turns to how unconscious biases of both clinician and client impact treatment of eating and weight issues. This chapter explores ways to anticipate how these processes may arise in treatment and how to deal with them if they do. Chapter 11, “Treatment Options,” covers the numerous ways that therapists might address food and body struggles through material that clients bring up. This chapter also covers treatment traps that can bog down the therapy and prevent clients from finding solutions to eating and weight problems.
Each chapter contains two types of questions: those that encourage the therapist to reflect on therapeutic issues arising from the material being presented, and those that should be directed at the client to gain and clarify information, assess its relevance to treatment, and collaborate in moving forward. Questions for clients may be used as is or as a basis for exploring their responses.
This book is not meant to provide all the answers to treating people with eating and weight issues. Even experts in the field do not have them and need to rely on updated information about appetite and weight regulation, new scientific data about treatment options, experience and intuition, and consultation and supervision for difficult cases. If this book succeeds in increasing your clinical comfort and skill at assessing and treating weight and eating issues, it will have done its job.