A potential client tells you that she weighs 16 stone and would like you to help her to lose 6 stone.
The structure of this essay will be based on a fictitious case history, to explore a treatment plan for a client needing to lose something in the order of 37% their total body weight. This essay is written as if presenting the case history of a past client. The treatment plan discourse will outline some of the physical and psycho-therapeutic interventions, before reviewing the three questions that are postulated within the title of the essay. What factors may have contributed to her weight gain? What would you do to help her meet her goals? Would you help her to meet her goals? Finishing with a summary and conclusion and referencing.
The obesity study The Human and Financial Burden cites that approximately 2% of the UK population are morbidly obese with 25% classified as obese. The study also takes into account the associated increases in illnesses linked to obesity such as type II diabetes, cancer, depression, arthritis and sleep apnoea (Cook, 2013). The results of this study emphasis’s the need for all therapists to have a comprehensive understanding of all the issues surrounding size and weight therapy.
Basic assumed client details and history. Jane aged 28 is married with two children age 18 months and 4 years. Jane’s current weight is 16 stone and she would like to lose 6 stone. Jane had lost weight in the past but reported that she has always regained more weight than she has lost. Jane feels the stress of coping with her family and has suffered from re-occurring depression. Jane has also recently been diagnosed with borderline Type II Diabetes. Jane’s G.P. has ruled out any medical reason for her obesity.
Jane feels that she needs to get a handle on life because her weight and general feelings are affecting Jane’s abilities to cope with the children and her relationship with her husband. Part of Jane’s initial first week’s home exercise was to complete a diary of her daily meals, how it was prepared, snacks to include times of day also how she felt before and after eating. Additionally we looked at her lifestyle with a view to introducing some daily exercise, which was also included in her daily notes.
Generally, all my clients will have some sort of homework encouraging a program of self-analysis, as highlighted by Prof Michael Yapko in his book Breaking the Pattern of Depression, using the approach of assignments, (Yapko, 1997) The Handbook Of Individual (Behavioral Therapy chapter) states the importance of behavioral analysis as a first step to formulating therapeutic strategies (O, Sullivan, 1996, p.293).
When analysing her diary, Jane was able to reflect on the quantity and quality of her food intake. I suggested she may wish to consult a dietician, as beyond making obvious dietary recommendations, I was not qualified in this area (It’s really important to clarify to the client where your expertise lies, misleading information can be very detrimental and clients have a tendency to think you know everything). As a starting point we agreed that Jane would reduce her fat and oil intake by grilling foods, then looking at the possibility of snacking on fruit and vegetables like carrots and celery, as a healthier alternative to sweet or savory snacks. We also deliberated her high bread and starch intakes together with the amount of fat consumed as spreads. Discussing snacking whilst preparing the family meals, I suggested having some crudites on hand as a coping strategy.
Asking Jane what her husband’s thoughts were regarding her seeking help, Jane said that her husband was fully supportive. I also offered that if she felt it would be helpful, Jane could bring her husband along for a couple’s counseling session so that he could feel part of the process that she was going through, and she could have an appreciation of his continued support. Eriksson was a great believer in treating clients in a holistic manner having regard for their environment and advocating the inclusion of the family within therapy when appropriate (Battino, and South, 1999, p.426).
I advised Jane to introduce changes step-by-step, that if at any time she felt she was deprived, to have a little of whatever it was that she desired, but to thoroughly enjoy the experience without feel guilty. The article on Food Addiction and Obesity published in the Journal of Psychoactive Drugs, underscored the very addictive nature of eating disorders and its effects on the levels of dopamine, emphasizing the necessity of the client not to feel deprived in any way, but rather to bring about a satisfaction of their needs within better boundaries (Yijun, Von Deneen, Kobeissy and Gold, 2010). Whilst dopamine is the addictive hormonal driver, the hormone ghrelin can be responsible for reduction and increase in hunger. The over or under activity for the production of ghrelin is often associated with stress and lack of sleep. In the study Ghrelin Increase Hunger and Food Intake In Patients with Restricting-Type Anorexia Nervosa: A Pilot Study. (Akamizu, T. Hotta,M. Ohwada, R. Kangawa, K. Shibasaki, T. Takano, K., 2009) a re-balancing of ghrelin was achieved by injecting hormones to bring up the level for those in a deprived state, Equally from my observations of my clients dealing with weight issues over the last 20 years, addressing stress, will in many cases, allow the ghrelin balance in the body to come back to a homeostasis (this is a hypothesis as the levels of ghrelin in my clients have not been clinically evaluated).
On the other-side of the energy equation, Jane felt continually tired and exhausted spending a considerable amount of her time at home, (an indicator of depression), with occasional outings to various playgroups and the supermarket always driving and taking very little exercise. When considering the possibility of taking on more exercise, Jane was adamant that she didn’t have time to go to the gym, but did enjoy walking and gardening before she had the children. These activities had since been neglected. Jane agreed she needed to change her lifestyle and to bring more enjoyment into her life, instead of feeling life was just a series of chores. Jane decided to make a first step towards exercising more, leaving the car at home and walking to the children’s playgroup. She would build up to include outings to the local park at weekends as fun family activity. Jane also resolved to make a start on her long neglected garden. Remembering how much she used to enjoy gardening and recognised this would be a great activity to do with the children, as gardening was one of the few activities she had enjoyed with her mother. These steps were encouraged and taken over a number of sessions; reinforcing the idea of lifestyle changes within Jane’s environment. Jane was able to identify that her weight issues were connected to how she felt about herself and how she was using food to suppress her feelings. Recognising emotional hunger was a great step forward.
We spent some time bringing Jane to a better understanding of where she was in the therapeutic process. I explained emotional eating was quite a normal pattern of behavior when considering her history, and that she should really congratulate herself for seeking help. This sort of normalising statement helps establish congruence, unconditional positive regard, feelings of acceptance and empathetic understanding. In short all the core conditions for a therapeutic relationship within the personal centred counselling model were provided (Mearns, and Thorne, 1999, p.16)). Explaining the various stages of change I pointed out to Jane that by committing to our sessions she had already taken a big step in the process of change.
I recounted to her that the circle of change model outlines six distinct stages, pre-contemplation, thinking about doing something, contemplation which is deciding and planning. This was the point where Jane was at this moment, and we were now moving on to the action part of the program, making small incremental steps in process to a healthier lifestyle. This would lead on to maintenance, sustaining a better lifestyle, recognising that life does happens that at times we relapse and this is also a stage that we plan for, getting back on track.
This is an established program first developed for smoking addiction and later for weight control by two psychologists Prochaska and Diclemnta (Bryant-Jefferies, 2005, pp.5-6). One of the first pieces of work was to teach Jane self-hypnosis. This basic skill acts as a scaffold for ego strengthening and relaxation between sessions. Later in the therapeutic process, we used self- hypnosis to incorporate visualisation techniques such as seeing a reflection of herself at her perfect weight in a visualisation journey. An example of this visualisation journey script is William, C, Wester script Historic Landmark for Treating Obesity. This particular script uses an historic landmark as a backdrop for an hypnotic journey, the script includes visualisation with future pacing to how Jane would like to see herself, metaphors for work, growth, nurturing and ego strengthening (Hammond, 1990, pp.391-392). Alternating these suggestions in this type of journey script with suggestions to fully appreciate her food and eating slowly, this become part of the foundations of Jane’s on-going treatment plan, serving to increasing Jane’s feelings of self-worth and control over her life, the importance of which is emphasized by Kroger in his book Clinical and Experimental Hypnosis (Kroger, 1977, pp.202-206).
We then progressed to doing some part disassociation work investigating the feelings and emotions arising immediately before eating inappropriately. Jane was able to immerse herself into her emotions, enabling her to investigate the associated memories that arose. Over a number of different sessions Jane regressed to various memories of instances throughout her childhood and early adolescence. The regression and part dissociation exercises gave Jane a greater degree of understanding, affording her the opportunity to work through a number of outstanding issues giving Jane insight as to why she had used food to mask her emotional pain. This led to further work, Such as Two Chair Therapy, working on forgiveness and when forgiveness was not possible, coming to a better understanding of the other parties point of reference to gain objectivity and a better prospective. David Elman highlights the need of using various techniques to pinpoint what he calls the neurosis of the problem, (Elman, 1977, pp.169-170). At the same time Jane was becoming more proficient using her self-hypnosis for confidence building, reinforcing a more positive view of herself.
Jane completed numerous CBT (Cognitive Behavioral Therapy) homework assignments between sessions. This facilitated Jane to review her thought patterns modifying many dysfunctional beliefs. This work is in line with the ideas of Aaron T Beck’s imperial testing of beliefs to weed out irrational and dysfunctional thought systems (Weishaar, 1993, pp.34-35).
Now let us review the core skills that that Jane came with. These core skills are the foundations to build further skills and solutions within the therapeutic programme. Jane’s presenting herself as a client is a big step. Acknowledgement of the problem and desire to do something, recognising that weight control is not just about dieting. Jane had lost weight in the past, demonstrating emotional strength and an ability to follow through.
Jane’s GP has ruled out any medical reason for her weight gain. The act of consulting her GP, is further confirmation of actively looking for a solution. Jane had lost weight in the past, always putting on more than she has lost, this negative statement can also be used in a very positive way to reinforce the idea that weight loss is only one important step in a healthy living program. Jane said that her husband was fully supportive. The value of having active family support has been shown to be pivotal in many cases, to a successful outcome. Jane used to enjoy gardening with her mother, this particular gem of Jane enjoying gardening with her mother opens the door to a number of benefits; (1) a good nurturing emotional experience from her past, (2) being in nature, growing and nurturing things are wonderful metaphors for future work, (3) the calming effect of being in nature with gardening providing a focus in a very grounding way, (4) including her family in the activity creates a more cohesive nurturing family unit, (5) the benefit of relearning to enjoy a physical activity.
The dysfunctional statements arising in the case history give us the unique pointers for further investigation, “feeling life was just a series of chores,” this statement serves as an indicator of Jane’s condition, the stress of coping coupled with re-occurring depressions. Jane has always regained more weight than she has lost, has a salutary lifestyle, suffers from a loss of libido, causing further distress in her relationship and reinforcing her depression. Whilst on the surface the statement “feeling life is just a series of chores” may seem entirely negative, however as with most negative statements once the core issues had been dealt with they can be transformed in some why as a learning from the past, to serve as further motivation for her goals, in Jane’s journey to a happier healthier lifestyle.
The three questions.What factors may have contributed to her weight gain? What would you do to help her meet her goal? If indeed you would? (Taking this to mean would I help her)
What factors may have contributed to her weight gain? The factors that may have contributed to Jane’s weight loss are depression, stress and anxiety. Jane stated “feeling life was just a series of chores,” revealing her general feelings about herself which included low self-confidence and low self-esteem also relating to body image. The nutritional quality and quantity of food being consumed, combined with the strong addictive nature of sugars and fats, coupled with the lack of physical exercise and the stress and anxiety created around her family circumstance has resulted in a toxic downward spiral culminating in her depression and weight gain.
What would you do to help her meet her goal? To help Jane meet her goal I would start by taking a case history. There is only one expert on the client and that’s the client. I need to hear her story to understand the client and equally for the client to feel listened to and understood. Then to introduce a normalising statement to establish congruence, unconditional positive regard, feelings of acceptance and empathy. Having established a congruent relationship, I would then bring awareness to the client that change is a step-by-step process, inoculating against unrealistic expectations together with concepts that she may at times temporarily relapse into old habits. I would introduce homework into the therapeutic process. Homework emphasises that therapy is not restricted to just consultation sessions but an on-going process.
One of the first’s tasks would be a food and emotion diary for the client and therapist to reflect on and gain more insight, an example of these insights might be portion control, accompanied by suggestions to use a side plate instead of a dinner plate to make small quantities seem larger. In addition, advice will be given that food should be visually pleasing to satisfy eye hunger. I would educate Jane that the food should have different textures, and that it takes 20 minutes for the stomach to register with the brain that it is full. Discussing various types of hunger would help Jane identify when she had a true physical need to eat. A hunger scale would be introduced furthering her awareness and encouraging a process of self-monitoring her own habits. Part of the therapy would discourage Jane feeling deprived or guilty, encouraging her to be kind to her-self and enjoy whatever she felt was a transgression within better boundaries. Eliciting family support to help through the process of change is also integral to my treatment to avoid external sabotage and create a more nurturing environment.
Additional homework for Jane would be self-hypnosis to reinforce the work carried out in therapy sessions. The therapeutic work would consist of suggestions and metaphors relating to, ego strengthening, encouraging self-acceptance both in the present as well as future pacing. These suggestions would be conducted both in and out of the hypnotic states. More in depth work would be centered around part disassociation work to investigate feelings and emotions arising and their associated memories. This would be completed either through reviewing and understanding, were appropriate inner child work giving new meanings or outcomes. Two Chair Therapy often allows the client to assert their opinions helping them to resolve issues and frequently brings about an acceptance, if not forgiveness. Cognitive and behavioral assignments which may be written or situational would be introduced into an established homework pattern. Within the context of this particular case history, I would emphasis a review of things that she might enjoy doing as a written assignment list, to start the process of bringing a sense of more satisfaction into her life.
Experience within my own practice has shown in that in the early stages of therapy until the client has been uplifted by some minor successes, clients find it difficult to be motivated to do much homework. Therefore it is generally best to start with something that would take only a few minutes daily. The benefits of combining CBT and hypnosis is borne out by the following study. The study Hypnosis As An Adjunct To CBT: Treating Self-Defeating Eaters, proposes that cognitive behavioral techniques have the best empirical record and that, it may be useful to use hypnosis as an adjunct to the treatment programme (Gow,K. Huchinson-Philips, S., 2005).
If indeed you would? (Taking this to mean would I help her) In the study (Cooper, Z. Doll H A, And Hawker, D A. 2010, pp. 706-713). Looking at the long term benefits of Cognitive Behavioral Treatment for obesity incorporating a randomised controlled trial with a three-year follow-up. The study’s conclusions were that the long-term benefits were very modest. This emphasizes the need to transform the ethos of weight loss to lifestyle. That we are faced with a challenging therapeutic problem with considerable physical consequences doesn’t mean we can just simply turn our backs on our clients. As therapists we need to challenge ourselves to research and develop the best possible therapeutic models to help our clients.Bearing this in mind, yes I would help Jane
Summary and Conclusions Summary The title of this essay presents a potential client that is morbidly obese. The opening statement highlights the breadth and depth of the problem, that such a large proportion of our society are dealing with a condition for which the majority of solutions on offer do not lead to long-term sustained benefit. Creating a fictitious case history to match the parameters of the essay, allows a sequentially review of a treatment plan, dealing with a client in an integrated manner. Identifying past conditioning and faulty beliefs are the foundational building blocks of the majority of therapeutic interventions. The client’s past experiences and beliefs become the determining direction forming the basis within which change occurs to a healthier lifestyle relevant to her experiences and environment.
It’s important to look at the client holistic way, from a psycho analytical point of view, but also there physiological state as well. Just changing a person’s posture can create less stress, affects the balance of the various chemicals that underline and create the emotions that we experience. It’s well documented that exercise has a profound psychological effect on a person. The utilisation of a diary as a tool brings into conscious awareness what’s happening as an automatic reaction, helping clients to change their mind set with understanding. Making the client aware that weight loss is a goal leading to weight maintenance within a healthier life style is fundamental to any weight loss program as is understanding that therapeutic intervention is a process with distinct stages. In this instance I utilised the model, The Circle of Change.
Conclusion: would I help Jane to meet her goal? Yes I would help Jane, with a therapeutic mixture as I have outlined here, solely designed around Jane’s individual needs. The most important skill as a therapist is empathy. I’ve quoted Carl Rogers but in reality I could have just as easily quoted Freud or Milton Erickson. In fact it’s pretty much universally accepted that even if the therapists gets a lot of things wrong, empathy is the most overriding therapeutic skill, together with unconditional regard for your client. The normalising statement helps the client feel that they have been listened to and understood in a non-judgemental way, creating that magic between client and therapist we call empathy.
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