Psychotherapy and Weight Change

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Psychotherapy has regularly been used in conjunction with exercise and dieting to help with weight loss. Certain forms of psychotherapy, such as behavioral therapy have been more recently employed in order to facilitate weight loss. Indeed "body image treatment" through "cognitive behavioral therapy" has become commonplace in the self-treatment of both over- and underweight individuals since the development of Jonathan Butters and Thomas Cash's approach in the mid-1980s (Butters and Cash 1987). Cash's audiotape program Body-Image Therapy: A Program for Self-Directed Change, while aimed at mental-health practitioners, set the stage for self-treatment for women who desired to change their own negative body image. Other nonclinical settings like weight-loss support groups also use a psychotherapeutic model to enable the loss of weight (Jeffery et al. 1998). Experts suggest that behavioral therapy is a good non-surgical alternative when it comes to weight loss; the results, however, are not always long-lived. While there is an average weight loss of 7-10 percent of initial body weight during the first twenty-four weeks of treatment, further treatment seems to offer no more weight loss. Indeed, there seems to be a pattern of relapse attributed by behavioral therapists to their patient's inability to sustain the practices they learn in therapy. Given that such strategies are designed to change behavioral patterns, long-term efficacy is disproved (Wilson and Brownell 2002).

Behavioral techniques rest on the claim that obese people gain weight either as a response to conditioned learning or environmental stimuli or as a coping mechanism in response to stress and arousal. Thus, therapy can include stimulus control (controlling the presence of certain "trigger" foods in the home and increasing the presence of exercise cues), problem-solving strategies, social assertion (figuring out ways to assert one's dietary philosophy in an uncongenial environment), setting short-term goals to enhance positive thinking, cognitive reconditioning to help alter negative thought patterns, relapse prevention (learning to gauge which situations are detrimental to weight loss commitments), and building a support network.

Therapy for eating disorders has now reached into the online world of the Internet. There is the claim that internet-driven intervention combined with individual therapy is more effective than therapy alone. Such online activities tend, it is claimed, to reduce clients' anxiety about how they appear and being judged when they are unseen by the therapist. The use of online behavioral therapy together with online virtual reality has been claimed to modify the body awareness and thus impact on problematic social and eating behaviors (Derrig-Palumbo and Zeine 2005: 117-18).

A comparative study that assigned some participants to Weight Watchers and others to a self-help group for weight loss found that clients who attended Weight Watchers had a greater tendency to lose weight (Lowe et al. 1999: 51-9). The researchers concluded that this was due to the behavioral component of the program, which was actively reinforced through group meetings and weekly weigh-ins. Dieting, they found, could only have long-term results if it was part of a larger lifestyle philosophy instead of a compartmentalized activity one undertook merely to lose weight. Another study conducted by scientists at Baylor analyzed the difference between two types of treatment for women engaged in binge-eating: One involved dieting and behavioral therapy, while the other consisted only of behavioral therapy measures (Goodrick et al. 1998: 363-8). What the research team found six months after the treatment program was that the women who dieted and had therapy had lost about 1.32 pounds, while those who only had therapy had gained about 1.86 pounds. What these women had experienced was a marked reduction in their binge-eating patterns. An eighteen-month follow-up examination revealed that both groups had once again gained weight, but that there had been an overall reduction in binge-eating. The researchers once again concluded the ineffectuality of dieting as a weight-loss measure but saw that other behavioral patterns, such as binge-eating had undergone a significant change.

When weight gain or loss is considered to be a psychological illness rather than a behavioral aberration, very different approaches are used. Certainly, the use of "talk-therapy," whether in the form of classic psychoanalysis or short-term psychotherapy, has a long history. Indeed, family therapy remains a mainstay for the treatment of eating disorders such as bulimia and anorexia nervosa, but it is used relatively rarely as a treatment for obesity. Alternative psychoanalytic explanations, such as libido theory, have been offered to explain the presence of obesity (Friedman 1972: 364-83). The effectiveness of interpersonal psychotherapy has been claimed by Christopher Fairburn as an answer to the lack of long-term effectiveness of behavioral therapy (Fairburn 1997). One large-scale study in i977 tracked the treatment of eighty-four obese patients (paired with sixty-three normal-weight patients) treated with a wide range of psychoanalytic approaches. The resultant (short-term) weight loss was seen to be approximately the same as those patients treated specifically for weight loss (Rand and Stunkard 1977: 459-97).

With the reappearance of "Body Dysmorphic Disorder" as a major diagnosis for certain forms of mental illness in the standard American handbook of mental illnesses (DSM-IVR) and the championing of this by American psychiatry, the relationship between eating disorders (also a psychiatric category) and body dysmorphic disorder has been raised. "Dysmorphophobia" is a diagnostic category coined by the Italian psychiatrist Enrico Morselli (1852-1929) in 1891. Given that the treatment of choice of the latter is the prescription of serotonin reuptake inhibitors, a class of psychotropic drugs, one can imagine the use of such interventions in the treatment of eating disorders (Phillips 2002: 113-17). Thus, weight loss (and gain) comes to be understood as a somatic rather than a psychological disorder.

Even in the application of alternative approaches to weight loss, such as mental imagery, there is a neurological claim for efficacy. Imaging is " 'seeing' in the absence of actual visual sensory imputs" and is claimed to activate the dopamine reward pathway and thus enhance weight loss (Heinkel et al. 2003: 226). The creation of "aversive imagery," such as "disgusting images" of "rat droppings in chocolate chip cookies," seems to be effective in weight reduction (Johnson and Karkut 1996: 664). Such approaches have a wide range of therapeutic modalities. As early as 1843, hypnotism was used to "control a female patient's appetite for certain foods which exacerbated dyspepsia in her" (Gravitz 1988: 68-9). By the 1960s, hypnotism (now restored to clinical acceptability) reappeared for the treatment of overweight.

SLG/Shruthi Vissa

See also Anorexia; Binge-eating; Bruch; Internet; Nidetch; Self-help

References and Further Reading Butters, J.W. and Cash, T.F. (1987) "Cognitive-Behavioral Treatment of Women's Body Image Dissatisfaction," Journal of Consulting and Clinical Psychology 55 (2): 889-97. Derrig-Palumbo, Kathleene and Zeine, Foojan (2005)

Online Therapy, New York: Norton. Fairburn, C.G. (1997) "Interpersonal Psychotherapy for Bulimia Nervosa," in D.M. Garner and P.E. Garfinkel (eds), Handbook of Treatment for Eating Disorders, New York: Guilford Press, pp. 278-94. Friedman, Stanley (1972) "On the Presence of a Variant Form of Instinctual Regression: Oral Drive," Psychoanalytic Quarterly 41 (3): 364-83. Goodrick, G. Ken, Kimball, Kay T., Reeves, Rebecca S., and Foreyt, John P. (1998) "Non-Dieting Versus Dieting Treatment for Overweight Binge-Eating Women," Journal of Consulting and Clinical Psychology 66 (2): 363-8.

Gravitz, M.A. (1988) "Early Uses of Hypnosis in Smoking Cessation and Dietary Management: A Historical Note," American Journal of Clinical Hypnosis 31 (1): 68-9.

Heinkel, Colleen, Rosenfeld, Michelle and Sheikh, Anees A. (2003) "Imagery in Smoking Cessation and Weight Management," in Anees A. Sheikh (ed.) Healing Images: The Role of Imagination in Health, Amityville, NY: Baywood Publishing, pp. 223-54.

Jeffery, R.W., Wing, Rena R., Thorson, Carolyn, and Burton, Lisa R. (1998) "Use of Personal Trainers and Financial Incentives to Increase Exercise in a Behavioral Weight-Loss Program," Journal of Consulting and Clinical Psychology 66 (5): 777-83.

Johnson, D.L. and Karkut, R.T. (1996) "Participation in Multicomponent Hypnosis Treatment Programs for Women's Weight Loss with and Without Overt Aversion," Psychological Reports 79 (2): 659-68.

Lowe, Michael R., Miller-Kovach, Karen, Frye, Nema, and Phelan, Susan (1999) "An Initial Evaluation of a Commercial Weight Loss Program: Short-Term Effects on Weight, Eating Behavior and Moods," Obesity Research 7 (1): 51-9.

Phillips, Katharine A. (2002) "Body Image and Body Dysmorphic Disorder," in Christopher G. Fairburn and Kelly D. Brownell (eds), Eating Disorders and Obesity: A Comprehensive Handbook, 2nd edn, New York: Guilford Press, pp. 113-17.

Rand, Collen S. and Stunkard, Albert J. (1977) "Psychoanalysis and Obesity," Journal of the American Academy of Psychoanalysis 5 (4): 459-97.

Wilson, G. Terence and Brownell, Kelly D. (2002) "Behavioral Treatment for Obesity," in Christopher G. Fairburn and Kelly D. Brownell (eds), Eating Disorders and Obesity: A Comprehensive Handbook, 2nd edn, New York: Guilford Press, pp. 524-8.

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