Why Don’t Patients Listen to Me about Eating Better?
(Why Don’t I Listen to Myself?)
■How doctors who have eating and weight concerns feel about treating patients with similar issues
■How explicit versus implicit provider attitudes about high-weight patients differ
■Research on weight prejudice and fat stigma in the medical professions
■The impact of health professionals’ weight on their treatment of higher-weight patients
■Reactions of providers toward higher-weight patients
■How patients view providers of high weight
■Eight simple strategies to help patients with eating and weight concerns
If, as a provider, you and food aren’t on the best of terms, you may be wondering how you can possibly approach or treat your patients’ eating problems effectively. You may concur with the saying “Physician, heal thyself” and believe that unless you can manage your relationship with food, you have no right telling others how to do so. Sadly, you may even think that unless you’re the poster doc for fit and trim, you have no business advising your patients about eating or exercise.
The good news is that if you believe the above to be true, you’d be wrong! Think about psychotherapists with emotional scars who may not have completely healed from their own traumas, yet do wondrous healing with their patients who are trauma victims and survivors. Or family therapists who may have had or still have terrible relationships with their dysfunctional families who are, nevertheless, considered tops in their field. Not for nothing are those in the psychological professions called wounded healers. They know that many patients don’t expect them to be models of perfection in every aspect of life. In fact, sometimes patients are relieved that clinicians can relate to their problems and, therefore, are not looking down on and sitting in judgment of them. When this happens, patients take providers off their pedestals and place them where they belong—sitting squarely in the chair across from them.
The even better news is that, not only can you help patients resolve their eating and weight concerns without having fixed your own (by supporting patients in becoming more nonjudgmental, self-compassionate, and empowered on their journey to “normal” and nutritious eating), but these success-promoting habits will likely rub off on you. The key is not to widen the divide between you and your patients, or to pretend it doesn’t exist, but for you to join with them in spirit on their quest to attain and maintain a sane and healthy relationship with food and their bodies.
WHAT DO DOCTORS AND HEALTH CARE PROVIDERS FEEL WHEN THEY HAVE A POOR RELATIONSHIP WITH FOOD, LIVE WITH HIGH WEIGHTS, AND ARE NOT FIT AS A FIDDLE?
They feel pretty much the same as everyone else does—but more so. Some of you may be unhappy and frustrated that you do too much emotional, stress, and mindless eating, fail to exercise enough, and have trouble keeping away from high-calorie and high-fat foods. You may harbor deep shame about this failure along with self-contempt that, despite all your achievements, your eating goals continue to elude you. You may think about food and worry about your high weight more than you’d like to admit, keep promising loved ones you’ll take better care of yourself, or try to put these concerns out of your mind and pretend you’re perfectly healthy. Everyone or no one may know how badly you feel about your relationship with food and the scale.
If you’re like most people who struggle with eating dysregulation or a higher-than-comfortable weight, you’ve probably dieted as much as your patients have and gone through spurts of weight loss followed by gradual weight gain. With all you know about the human body, you’re still probably convinced that you failed at dieting, rather than that diets have failed you. You, too, have probably been brainwashed by our diet-obsessed culture and have not known what to do to resolve your own eating problems.
But, unlike most people of high weight, you’re paid to spend (at least a portion of) your days telling people how to eat healthfully, exercise more, manage stress, and get fit. You may even wonder how all this treatment focus on food and exercise came about. One day you entered medical or nursing school to heal the sick and save lives, and the next, it seems, you’re trying to persuade your patients to count carbs and climb stairs. We suspect that this isn’t what you signed up for.
Looking around, you may see only those in your profession who seem to stay magically trim, or who find the time to run 10K races or hike and bike every weekend. They seem to be paragons of self-control and you look at yourself and simply don’t know how they do it. The fact is that most medical professionals don’t do very well with keeping their bodies fit, according to statistics.
■In the United States, “roughly 6 in 10 doctors and nurses today are overweight or obese, a level approaching that in the general population.”1
■Simon Stevens, National Health Services England chief executive, has gone so far as to admonish doctors and nurses in England to slim down, citing “700,000 NHS staff classed as overweight or obese,” and saying, “It is hard to talk about how important this [issue] is if we don’t get our act together.”2
■A University of Maryland School of Nursing study found that “55% of the 2,103 female nurses they surveyed were obese, citing job stress and the effect on sleep of long, irregular hours as the cause.”3
■In a Harvard Nurses Health Study, “70% of the respondents were either overweight or obese—with 40% falling into the latter category.”4
■Keith-Thomas Ayoob, associate professor at Albert Einstein College of Medicine, speaks wisely on the subject: “Nurses are just as susceptible to health problems as the rest of society. Before we were health professionals, we were real people. Just because we became health professionals doesn’t mean we stopped being members of regular society with all the problems that go along with it. It illustrates that knowledge alone isn’t always enough to produce behavioral changes.”5
This last statement is a very telling one that is worth repeating: “Knowledge alone isn’t always enough to produce behavioral changes.” In addition to knowledge, doctors and health care providers could use more self-understanding and self-compassion—and it wouldn’t hurt to learn more about how psychology can help resolve eating problems.
Brain food for providers: How do you feel about your weight? If you have a higher weight, what’s your assessment of how diets have helped or hurt you in the long term? How do you feel speaking with patients about eating, weight, and fitness issues if you do not perceive yourself to be a role model for them? Do your food struggles make you feel more or less sympathetic to patients of high weights?
WHY WOULD I HAVE ANY FEELINGS ABOUT MY PATIENTS, NO MATTER WHAT THEIR WEIGHT, OTHER THAN WANTING TO HEAL THEM?
Why? Because you’re human. We have all sorts of beliefs and feelings about people, some of which are explicit and some of which are implicit. “Explicit attitudes and stereotyping operate in a conscious mode and are exemplified by traditional, self-report measure of these constructs. Implicit attitudes and stereotypes, in contrast, are evaluations and beliefs that are automatically activated by the mere presence (actual or symbolic) of the attitude object. They commonly function in an unconscious fashion.”6 Explicit beliefs are those we know we have, while implicit ones are the ones we don’t know we have.
This lack of awareness is why we may say (and truly believe) that we feel one way, yet have our behavior betray us. For example, you might insist that you are comfortable with your body but still choose not to look in a full length mirror after a shower if you can help it. Or you might think you believe that women can be as good in math and science as men are but be disappointed that your son chose a female adviser while writing his Ph.D. dissertation in astrophysics.
Living in our fat-phobic, thin-obsessed culture that has been sending us the same message for decades—fat is bad, fat is unhealthy, fat is ugly, fat is dangerous, and fat is fatal—how could anyone possibly think we would escape being brainwashed? We may sound as if we’re overstating our case here, but we as health care providers have been programmed as deeply as the general public into believing that fat is one of the worst things you can be on the planet.
If you’re totally honest with yourself, how do you feel about people of size—a.k.a. fat people? What crosses your mind when you watch them walk down the street or take a seat on a bus? What thought pops into your head unbidden when you see them food shopping, eating in a restaurant, or sitting at your own dining room table? (Or, heaven forbid, eating ice cream or cake?) What emotions flash through your mind when they walk into your office?
It has been said that fat is the last bastion of permissible stereotyping and discrimination in our culture. It is no longer politically correct to make gay, lesbian, black, Jewish, Mexican, or transgender jokes, but we can still make fat jokes. Moreover, not a day goes by without reading or hearing about how bad being overweight or obese is, how it’s going to kill us if we don’t “win the war” against it. Do we as health care professionals really want to participate in demonizing fat and shaming people of higher weights—or do we want to help them care for their health?
According to recent research, “Bias and stigma are well-established barriers to improving public and personal health. Bias against people with obesity has been reported to have worsened as the prevalence of obesity has increased. These data suggest that the public increasingly understands that obesity is more than a simple problem of personal responsibility. But that understanding is not translating into improved social acceptance for people with higher weights. Social acceptance of people with obesity in education, employment, and family relations may be declining. That possibility is especially troubling in light of health effects associated with social isolation. Continued monitoring of public attitudes is essential to determine how these trends will evolve. Weight bias remains a significant source of harm to people living with obesity and a significant impediment to progress in reducing obesity’s adverse effects.”7
Could we all agree, then, that there is substantial fat prejudice in this country and that, if you grew up here or have spent a great deal of time living here, you probably have some bias against people of high weight, whether you are slim, normal weight, or are large-sized yourself? This is not a condemnation of your value system or integrity and does not make you a moral failure. It makes you someone who is, more or less, just like everyone else, in that we cannot help but absorb the covert and overt messages from the society we live in. The best we can do is to not turn away from recognizing and acknowledging our prejudices and biases, but to discover what they are and compassionately try to reverse them.
Will these prejudices and biases disappear completely? Who’s to say? Probably not. But, because what we think consciously and, more to the point, unconsciously programs our feelings and behavior, it’s far better to be aware of our biases so that we can modify them rather than walk around with blinders on. The alternative to self-knowledge is to roll merrily along, ignorant of what we think and unaware of why we’re doing what we’re doing. And in the case of medical professionals, it also means being part of the problem of treating patients of high weights rather than being part of the solution.
ARE YOU SAYING THAT PEOPLE IN THE HEALTH PROFESSIONS HAVE BIASES AGAINST THE PATIENTS OF SIZE THAT THEY’RE TREATING?
This is what the research tells us. Although many doctors, nurses, and medical practitioners may not be strongly biased, many are. The attitudes run along a continuum as they do with nonmedical practitioners. You may be surprised about the results of research regarding health professionals and fat prejudice and stigmatization. “Even health care specialists have strong negative associations toward obese persons, indicating the pervasiveness of the stigma toward obesity. Notwithstanding, there appears to be a buffering factor, perhaps related to their experience in caring for obese patients, which reduces the bias.”8
Doctors, in fact, may be nicer to “thin” patients than to “fat” patients. “A provocative new study suggests that they are—that thin patients are treated with more warmth and empathy than those who are overweight or obese. Doctors seemed just a bit nicer to their normal-weight patients, showing more empathy and warmth in their conversations. Although the study was relatively small, the findings are statistically significant. It’s not like the physicians were being overtly negative or harsh,” said the lead author, Dr. Kimberly A. Gudzune, an assistant professor of general internal medicine at the Johns Hopkins School of Medicine. “They were just not engaging patients in that rapport-building or making that emotional connection with the patient.”9 Yikes!
“For MDs who were underweight, normal weight and overweight we found strong explicit anti-fat bias.”10 Moreover, “doctors’ and nurses’ own weights may predict how helpful they are to patients with eating and weight concerns. Syntheses of the findings from the selected studies suggest that: normal-weight doctors and nurses were more likely than those who were overweight to use strategies to prevent obesity in patients, and also provide overweight or obese patients with general advice to achieve weight loss.”11In fact, weight bias and stigma have compounded the problems of people whose weight falls outside of “normal” parameters. “Stigma and discrimination toward obese persons are pervasive and pose numerous consequences for their psychological and physical health. Despite decades of science documenting weight stigma, its public health implications are widely ignored. Instead, obese persons are blamed for their weight, with common perceptions that weight stigmatization is justifiable and may motivate individuals to adopt healthier behaviors. . . . On the basis of current findings, we propose that weight stigma is not a beneficial public health tool for reducing obesity. Rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts.”12
Moreover, people are not only blamed for their size or BMI or being out of shape but also held responsible for staying that way, as if they were given the choice to be slender but made a conscious decision to stay just as they are. Studies tell us that large people are rated “high on personal responsibility” for their weight and, consequently, were “disliked, evoked little pity and high anger, and received low ratings of helping tendencies.”13 Ouch!
Brain food for providers: Take a minute to examine your feelings about your patients of size. What are your honest reactions to treating them? Can you readily acknowledge any bias you have against them without judging yourself harshly? Do you feel angry at them or at yourself?
Unfortunately, “an accumulation of research has found that health care settings are a significant source of weight stigma, which undermines obese patients’ opportunity to receive effective medical care. Both self-report and experimental research demonstrate negative stereotypes and attitudes toward obese patients by a range of health care providers and fitness professionals, including views that obese patients are lazy, lacking in self-discipline, dishonest, unintelligent, annoying, and noncompliant with treatment. There is also research indicating that providers spend less time in appointments and provide less health education with obese patients compared with thinner patients. In response, obese individuals frequently report experiences of weight bias in health care. Obese patients also indicate that they feel disrespected by providers, perceive that they will not be taken seriously because of their weight, report that their weight is blamed for all of their medical problems, and are reluctant to address their weight concerns with providers.”14
We understand that it is not your intent to treat higher-weight patients any differently than you do your thinner or normal-size patients. We get that, we really do. In fact, you may be the rare exception who attends to all your patients with equal kindness and compassion. But, even if this is the case, you probably have heard other doctors or health care professionals grousing about their “overweight” patients refusing to take responsibility for themselves, not caring about their health, or declining treatments like medication and surgeries that are designed to help them.
So, let’s assume that many medical professionals have a bias against higher-weight patients. Of course, you might be thinking that there is one subgroup of medical providers who actually might be less judgmental and prejudiced against patients of size: practitioners themselves who have struggled or are struggling with eating and weight. Sadly, this is not generally the case, as they too have internalized the blame and shame of compulsive, emotional or mindless eating or simply have higher-than-average poundage due to genetics or other factors that put them on the heavier end of the weight spectrum.
HOW EXACTLY DOES A HEALTH PROFESSIONALS’ WEIGHT IMPACT TREATMENT OF HIGHER-WEIGHT OR EATING DYSREGULATED PATIENTS?
On top of your feelings about your own eating and size, your profession, unlike many others, can’t help but shine a spotlight on the subject. There are a number of ways you may feel about your relationship with food and the scale and, whatever your mindset is, unless you are very conscientious and careful, it will affect how you feel about and treat your patients.
Later in this chapter, we’ll be talking about options for handling your emotions, reactions, and resultant provider-patient dynamics. For now, as you go through the possibilities below, simply notice how you feel reading them, especially any discomfort which arises. If that happens, just note it and stay with it until you feel compassion for yourself rather than judgment. You are human and allowed to have the same foibles and emotions as the rest of us. If you are going to try to treat your patients with compassion rather than judgment, this is a good time to start understanding your feelings about your own eating struggles.
Here are eight possibilities and how they may cause you to react to patients with eating concerns or high weights:
1.Situation: You may be vigilant about eating healthfully, exercising, and keeping a watchful eye on the scale, believing that if you can do this, your patients can too.
Reaction: bafflement, disgust, contempt, or frustration
2.Situation: You may struggle against mindless eating, skipping out on the gym, or going for a run, and feel an unwelcome, uneasy kinship with your patients who share your battle fatigue.
Reaction: guilt, shame, vulnerability, or hopelessness
3.Situation: You may, as a naturally thin person blessed with a fast metabolism, expect others to eat what they want as you do without packing on pounds.
Reaction: bafflement, disbelief, contempt, or pity
4.Situation: You may, as a former person with eating difficulties who has been able to shed pounds and keep them off, be unable to fathom why other people can’t stop eating when they’re full or pass up sweets and treats as you have learned to do.
Reaction: bafflement, contempt, disgust, or frustration
5.Situation: You long ago may have given up on trying to eradicate mindless eating, leaving you unable to imagine ever again being motivated to try to improve your eating habits.
Reaction: guilt, shame, vulnerability, or hopelessness
6.Situation: You may refuse to acknowledge that your eating habits are poor and that you’re not the fit triathlon competitor you were in college, yet find yourself ducking doctors’ visits and lab work alike, except in the most dire medical circumstances.
Reaction: discomfort, shame, evasiveness, or guilt
7.Situation: You may feel caught in the spotlight as a role model regarding weight and fitness and see no reason that your size should complicate or compromise treating patients—whatever their size.
Reaction: annoyance, uneasiness, or rebelliousness
8.Situation: You may be so uncomfortable with your own size or state of physical fitness that you wouldn’t dream of bringing up the subject of a patient’s eating or BMI, lest the conversation reflect badly on you as a health care role model.
Reaction: anxiety, vulnerability
Brain food for providers: Do you have compassion for yourself if you have eating or weight struggles? What would make you afraid to feel self-compassion? What emotions have you felt toward your high-weight patients, how did they get expressed, and how did patients react? What can you do to manage your own self-talk and reactions better in the future?
Let’s consider how the above situations and reactions might play out in your office while treating patients. The most likely interpersonal dynamics that could occur in this situation between you and your patients include denial, personalizing, overidentification, intellectualization, projection, and displacement.
Denial
You may be so uncomfortable about your own size that it affects whether and how you discuss patients’ eating problems or discomfort with their weight. You may be in such denial about your own eating problems that you ignore the needs of your patients, leading you to do a less than effective job in helping them with similar issues. They may ask, “Hey, doc, can you help me with my overeating?” (actually, they’ll probably ask you to help them with their weight, since many patients will not acknowledge that, often, weight problems may actually be eating problems), and you may say, “Watch your portions,” and simply move on to another subject.
Personalizing
Especially if your patients come in complaining about the same health problems visit after visit, you may take it as a personal affront that they’re not listening to you and, therefore, react with anger. You might think, “They’re just wasting my time.” Because they’re failing to reach their goals or, worse, not even attempting to do so, you may believe that they’re blaming you, as if to say, “Doc, what’s wrong with you that you can’t help me?”
Overidentification
When you overidentify with patients who are struggling with similar eating or weight issues, you may lose perspective, feel as helpless as they do, and forget that your job is to help them get beyond their sense of powerlessness. When you overidentify, you lose your power to heal your patients.
Intellectualization
You are intellectualizing, moving from heart to head mode, when you tell patients, “Just eat smaller portions” or “Don’t go out to eat so much.” When this happens, you miss the chance to connect with how patients are feeling about their eating problems, which is often more important to them than your advice. Instead, hone your skill in empathy reflection, a remarkably effective tool for establishing trust and rapport, and for letting your patient know that he or she has been heard. We’ll discuss this helpful relational tool further in Chapter 8.
Projection
In its simplest terms for our purpose here, projection occurs when something about us makes us so uncomfortable that we can’t see it in ourselves but readily see it in others. A tightwad may never fail to point out other cheapskates, an irate person may insist she’s not angry and, instead, blame others for having a bad temper, and a person who feels frightened or helpless may berate someone else for not having gumption or being proactive.
You may become frustrated with patients who have the same difficulties as you have: Why can’t you/they ever say no to sweets, exercise regularly, and think about the health consequences of your/their food choices. Rather than acknowledging having shame about these behaviors and offering them compassion, you might scold your patient for having them by admonishing, “You’re never going to get your cholesterol under control if you don’t stop eating the way you do.” How much easier to focus on the problem in your patient than in yourself.
Displacement
When we displace feelings, we project them in a safe direction away from ourselves in order to release the tension that’s been building up in us because of them. If you are frustrated with patients who you believe aren’t taking care of themselves and are careful not to show your frustration, you might instead get annoyed at your generally conscientious nurse when he forgets to give you the chart for your next patient. And he may wonder whatever has gotten into you.
Brain food for providers: Which of the above types of interactions do you recognize having had with patients? Are any of them frequent or common? What can you do to make sure these interactions don’t happen?
DO MY PATIENTS ACTUALLY VIEW ME AS MORE OR LESS EFFECTIVE DEPENDING ON MY WEIGHT?
We’d like to say it isn’t so, but, the answer is yes. “Researchers identify that the widely identified weight bias or stigma extends into the exam room. Patients of an overweight or obese physician were less trusting of their doctors, less likely to take the physicians’ lifestyle advice, and more likely to switch to a different doctor. Key factors suggested as contributors to a physician being overweight or obese included a lack of work-life balance and poor sleep habits.”15 With half of doctors and well over half of nurses being overweight or obese, this is just one more barrier (albeit one that being aware of bias and overcoming it can change) to patients of size receiving effective care and treatment for their eating and weight concerns.16
We now see that bias can come from both directions and that neither professional nor patient can easily avoid it. The subject is complex. Higher weight may be seen as a character flaw in doctors, which sometimes makes patients uneasy, especially if they are also heavy. Patients may believe that if a doctor cannot help herself, she won’t be able to help them—which is not necessarily the case. Moreover, while some “patients are more apt to trust overweight doctors when it comes to diet advice, they’re also more likely to feel that the overweight doctor is judging them about their weight.”17This is likely a case of projection, as described earlier. To complicate matters, one study found that “overweight doctors are actually less likely to address a patient’s weight issues, and feel less confident in counseling about diet and exercise.”18Because patients are judging doctors and doctors are judging patients, everybody loses out.
What does that mean for medical practice and, specifically, for practitioners? That health care providers who struggle with overeating or weight concerns should give up and find another way to make a living? Of course not. It means that they, too, need to abandon dieting, stop focusing exclusively on weight, and learn how the psychology of eating can help them reach their eating and health goals. As Margaret McCartney, a general practitioner from Glasgow, Scotland, says, “We should not assume that fat doctors are bad doctors or are ‘not thinking about it.’ Those of us who have gained, lost, gained, lost, and gained weight again are only too aware of our failings. The medical profession should be tolerant of these—the same problems that our other patients face.”19 Amen.
I WANT TO TREAT MY HIGHER-WEIGHT PATIENTS BETTER THAN I HAVE BEEN DOING, SO WHERE DO I BEGIN?
You begin with yourself. By putting your work and your role in it into perspective. As American author and historian Edward Everett Hale said, “I am only one, but I am one. I cannot do everything, but I can do something. And because I cannot do everything, I will not refuse to do the something that I can do.”20 It’s true, you don’t have the time or knowledge to do a full court press to change your patients’ eating or exercise or body-shaming habits. We appreciate that your window of opportunity for this subject in a typical 15-minute office visit is likely to be one or two minutes at most.
So, what can you do, especially on the psychological front? For starters, you can recognize that, as with every other condition you’ve ever encountered or treated, sometimes you will succeed in a cure and sometimes you won’t. You can remind yourself that you may do your utmost and still not produce the outcome you (or your patient) desire. You can be aware that you have your limits and that patients have theirs. There, doesn’t that feel better already?
However, here are eight simple, direct actions you can take that will strongly (and perhaps surprisingly) influence your patients’ ability to make progressive changes in the eating and health arenas.
It will help enormously if you opt out of being a part of patients’ rescue fantasies, the ones in which you do all the heavy lifting and they do little or none of it. It’s crucial to understand that they may feverishly project this desire to be rescued (a.k.a. save me from myself) onto you, but that you must resist because it’s a set-up for you and them to fail. Here’s why: If you succeed in rescuing them and they eat better and become more fit because you’ve stayed on them like a Marine drill sergeant and they’ve changed only to please you, they’ve learned nothing about themselves and will almost certainly regress to old, unhealthy behaviors without your ongoing reinforcement. Remember, they can’t carry you around in their pocket like a phone app.
Alternately, if they don’t succeed when you’ve bent over backward to help them, who do you think they’re going to blame? You, very possibly. So nix the rescue fantasy. For sure, collaborate and cooperate to get the job done, possibly by suggesting small steps and strategies to generate consistency in wellness-promoting behaviors. Then remember that you are doing your best and your patients are doing theirs. It may be difficult to give up the rescue fantasy (psychotherapists battle against it regularly), but give it up you must if you want your patients to succeed.
Treat patients with respect
Respect does not mean always agreeing with patients, but it does involve taking their perspectives (ridiculous or unhealthy as they sound and may indeed be) seriously. If they say that they’re too busy to get to a gym, don’t tell them that’s not so because you’re the busiest guy in your practice and still manage to get up at 4:30 every morning to work out. Respect means acknowledging that they believe they have good reasons for doing what they’re doing, or not doing what you wish (or even) they wish they were doing. Having respect comes from the place in you that says you haven’t lived their lives, but if you had, you might be acting the same way they are.
Being respectful includes never shaming, ridiculing, or stigmatizing patients for their lack of progress with food or fitness. Never, not once, no matter how frustrated and helpless you feel. You may not be pleased that they are unhealthy or you may worry that they’re at risk for serious and fatal diseases. You may not care for their cavalier, blasé, or defensive attitudes about their bodies or their health. But, to be effective, you will need to put aside your feelings and take a more strategic approach. The truth is that you don’t need to approve of how your patients take care of themselves in order to help them make progress. What is essential is for you to start from a place of respect and empathy, no matter how exasperated you feel. Over time respect builds trust and makes patients more likely to speak up when they are finally ready to consider or attempt change.
Exude empathy
Failing to express empathy will likely derail a constructive relationship with patients of higher weights. “While BMI was not associated with perception of physician empathy, higher frequency of weight stigmatizing situations was negatively associated with perception of physician empathy. Reducing weight stigma in primary care could improve doctor-patient relationships and quality of care in patients with obesity.”21
The way you treat patients respectfully is by empathizing with them. This means trying to understand and validate their experience and take a walk in their shoes by listening closely to their explanations (or excuses) and by using empathy reflections which is a way of responding to patients in such a way that they have no doubt that you “get” what they’re thinking, saying, or feeling. This basic, learnable skill will improve your relationship with your patients exponentially. Just as a patient will not hear anything you say about the lump on her knee until you tell her that it is not cancer, a patient struggling with challenging eating is unlikely to trust you with the real truth until it is evident that you are coming from a place of caring and understanding. You’ll learn more about empathic reflection in Chapter 8.
Lead with compassion
Compassion does not mean agreeing with what patients say or do, seeing things the same way, approving of their actions, or even liking them very much. Compassion is a cousin to empathy and involves being kind to others who are hurting or suffering, understanding that they’re human and have frailties and limits, and connecting to them by knowing that they’re striving to improve in spite of their flaws. Said simply, it’s one part forgiveness of their imperfections and one part wanting to relieve their suffering. Really, is that so hard?
Compassion is the opposite of being hard on someone or yourself. Here are some examples. Rather than be angry at a colleague who misdiagnosed a patient and left you stuck cleaning up his mess, you feel compassion that your colleague did the best she could under egregious circumstances. Or instead of feeling contemptuous of a patient who can’t avoid fast food for more than a week, recognizing that he is doing the best he can right now and that coming down hard on him isn’t going to make getting healthier any easier. Remember, too, that by making improvements in lifestyle choices, our best can always get better.
Many doctors and health care professionals are tough on themselves and show little, if any, self-compassion. They fear not riding themselves hard, letting themselves off the hook, and forgiving themselves for being human. If you are this kind of provider, you might find it difficult to not come down hard on patients and to show them compassion. That’s because you don’t have much for yourself. In that case, this is a necessary skill for you to learn to apply both to yourself and to your patients. As you learn to be more compassionate toward higher-weight patients, you’ll find, surprisingly, that this attitude may carry over into how you treat yourself. And as you become kinder to yourself, compassion will become more the norm in how you respond to your patients.
A reminder that being compassionate does not mean giving people a free pass all the time. Nor does it mean that you don’t expect patients to make efforts on their behalf and be accountable for their own wellness. It means being kind when they fail and letting them know that you still care about and value them. When you lead with compassion, you’re putting your best therapeutic foot forward and making clients feel less badly about themselves. When we’re critical, we make people feel badly about themselves which kills motivation. Alternately, when we’re compassionate, they feel better about themselves which helps motivate them to do better.
One of the biggest obstacles to progress that psychotherapists treating clients with eating and weight concerns come across is clients’ pronounced lack of compassion for themselves. Briefly, here are five myths about self-compassion. It (1) is a form of self-pity; (2) means weakness; (3) will make people complacent; (4) is narcissistic; and (5) is selfish.22 Actually, self-compassion means nothing more or less than feeling badly about someone’s suffering and in this case, that someone is you. Empirical evidence suggests that self-compassion can actually help reduce shame, improve body image and eating behavior.23 A free clinical intervention, with positive side effects!
Another skill that psychotherapists employ which is a bonus in every professional and personal situation is active listening, which involves setting aside everything you want to say and putting 100 percent of your attention on what another person is saying. This means listening to words as well as attending to tone and body language, while simultaneously keeping an internal focus on seeking understanding of what is being said. The aim is to tune into and comprehend what the other person means—that is, their intent—not merely to understand the words they’re saying.
You want to be constantly translating words, tone, affect, and body language into meaning and continuously thinking, “What is she really saying? What am I supposed to be understanding from what is being said? What is she trying to tell me?” If a patient maintains eye contact with you, slightly increases inflection, smiles, and sits up straighter when she says she can’t wait to join the gym, that’s one message. If a patient makes the same statement and simultaneously breaks eye contact and crosses her arms in front of her, there’s quite another story being told.
Collaborate on setting realistic goals
No matter what kind of practitioners we are, sometimes we just get caught up in the joy of seeing patients succeed. We’re happy for them that they’re training for a marathon or have begun working with a registered dietician or a diabetes educator. We definitely want to encourage them and let them know we’re in their corner. However, sometimes—and this is yet another lesson that psychotherapists learn early on—we end up working harder than our patients, and that’s because we have gone overboard in setting unrealistic goals for them.
Yes, there are many patients who train for and run a marathon who continue to run regularly long after the event is over. However, there are probably as many, if not more, who train their hearts out and exhaust their bodies, finish the marathon, and never lace up their running shoes again. Often, patients who are unhappy with their weight overreach and think they can do more than is realistically possible, setting themselves up for injury and long-term failure. They may resent when you try to scale down their goals and talk to them about baby steps, but that is what you must do if you want them to continue to make progress. Too many patients have underlying all-or-nothing thinking, which turns on for something, then later turns off. So be careful with your own enthusiasm and make sure that patients’ eating and exercise goals seem both achievable and sustainable for them.
Think like a shrink
Think like a shrink, which means using as much as you know about psychology—particularly the psychology of eating—to help heal your patients. If they seem depressed, feel free to ask if something is going on in their lives that might be stressing or distressing them. You may find out that the woman who keeps complaining that she can’t stop night eating just lost her husband and is turning to food for comfort. Or you may discover that a gay or lesbian late adolescent is being bullied at college and drives through the fast-food window every night before returning to his or her dorm room. When there’s a change in behavior from healthy to unhealthy, you will always want to ask yourself, “Why now?” This is what psychotherapists are taught to do and it is an invaluable question to ask whenever there are shifts in behavior in a negative direction.
Psychotherapists know that behavioral motivation is rarely unilateral. There’s almost always an upside and a downside. So when they’re presented with the upside from patients who say, for example, “I haven’t watched TV and eaten a pint of ice cream in one sitting all week,” psychotherapists automatically wonder if there’s a downside and might ask, “Is that easy or difficult for you? Is there any self-talk going on in your mind that might sabotage this healthy new behavior?” Equally, when they’re presented with a downside such as, “I can’t stop watching TV without eating a pint of ice cream every night,” psychotherapists assume there might be a brighter side to the story and ask, “Is there anything that would help you stop this behavior? What does the voice in you that wants to take care of yourself say about eating ice cream watching TV every night?”
Asking these types of questions to root out internal conflict is an important psychological tool that gets patients thinking and can help them begin to anticipate obstacles and formulate a plan to regulate behavior. Even if you cannot solve their problems for them, you always can get the ball rolling by asking great questions that make them curious to explore their own beliefs and emotions. It is in that internal investigation, rather than in your well-intentioned admonitions to improve their behaviors, that crucial answers will be found. Health and wellness coaches are taught that behavioral change is more likely to last when a person is able to find his or her own solutions that motivate from within.
One more thing that psychotherapists know and recognize in the patient-provider relationship is that transference and countertransference will occur.24 Without getting too clinical, think of transference as patients viewing and reacting to providers as if they were major, significant people in their past or present—for example, if you come off as authoritarian and they had a my-way-or-the-highway kind of mother, they may either rebel against you or go all passive and yes you to death. Or, if you tend to be a “just the facts kind of clinician,” and they have a similar kind of unemotional, detached father or husband, your lack of warm and fuzzy may trigger resentment and anger.
To complicate matters, not only do patients have transference toward us, we may have what’s called countertransference toward them—a whiny patient may unconsciously remind you of your constant complainer of a father or spouse, a patient whom you believe to be depressed may laugh off your suggestion that he is and trigger feelings about your depressed sister who would never admit the depths of her despair and eventually committed suicide. Being mindful of this consideration will help us maintain professional equanimity and empathy with all of our patients.
Brain food for providers: What strategies will be most helpful for improving your relationship with higher-weight patients? Which strategies will come most easily for you? Which ones will be harder to adopt? What benefit would you and your patients derive from learning to practice these strategies until they are more natural to you?
We want to repeat that we’re not expecting you to morph into psychotherapists. You have your very essential niche and they have theirs. But, just as medicine has changed psychotherapy for the better—making it more evidence based and using medical technology to understand the brain and emotions, for example—the psychology of eating has much to teach doctors and health care professionals to improve their care of themselves and their patients.
Providers, try . . .
1.Telling yourself that despite whatever eating and weight concerns you may have, you can still help your patients.
2.Talking with colleagues about how to manage fat bias and weight prejudice in the office.
3.Examining and changing the beliefs you have that generate fat bias and weight prejudice.
4.Allowing yourself to feel frustrated with your own and your patients’ struggles with food and the scale.
5.Striving to understand the dynamics at play with you and your higher-weight patients, including projection, denial, intellectualizing, personalizing, displacement, and overidentification.
6.Leading with compassion and empathy when treating patients with eating and weight concerns, understanding that even though you may not do it perfectly, these tools promote patient progress and success in improving lifestyle behaviors.
7.If you are interested, reading books on the basic elements of psychotherapy such as Sheldon Roth, M.D.’s Psychotherapy: The Art of Wooing Nature and Leston Havens, M.D.’s A Safe Place: A Glimpse Into the Private World and Complex Relationship of Patient and Therapist.
8.Learning more about the psychology of eating and about how to resolve your own eating problems, if they exist. (See our resource list at the end of this book.)
9.Gently making compassionate but corrective comments when others express size or weight stigmatizing remarks and establishing a zero tolerance policy for that kind of talk in the office.
Patients, try . . .
1.Gently educating health professionals about how to best approach your eating or weight concerns.
2.Speaking up assertively and appropriately if you feel judged or stigmatized about your weight or size.
3.Not putting on a happy face about it when you feel shamed or invalidated by your health care provider.
4.Not dieting and instead looking to becoming a “normal,” nutritious eater by finding an eating disorders therapist or appropriately trained eating coach to help you.
5.Making sure your doctor takes a weight, dieting, and an eating history for you, noting how often you’ve lost weight and regained it.
6.Letting providers know what they do or say that works for you and what doesn’t.
7.Not judging your providers by their size, but giving them the benefit of the doubt that they can be of help to you, until proven otherwise.