Twenty years ago I had several clients who came to me because they were overweight. They were all exhausted and discouraged by their history of dieting and of weight lost, then regained. By then I had developed a competence in working with people with eating disorders and they hoped I could help.
At that time (and for a long time afterwards) the very idea that overweight could have a psychological meaning was generally derided; there was no psychological response available. These were the first clients of this kind who had found their way to me; their plea was identical – help me lose weight. To my shame, none lost a pound.
At that time, in the early 1990s, I had already been working with people with eating disorders for 10 years. They were mostly performing arts students because I had been for part of that time the student counsellor at London Contemporary Dance School. I had evolved a way of thinking about anorexia and bulimia. My presumption, based on my psychodynamic training, was that behaviour had meaning. The simple question ‘And when did this begin?’ was often enough to elicit a story of trauma. It seemed quite clear that the eating behaviour was a response, a coping mechanism, a strategy for emotional regulation. Once the upset had been identified, it could be addressed, and the disordered eating usually remitted.1
However, there was a group for whom this magic formula did not work. These were youngsters who seemed to have more fundamental problems. I remember one in particular, a talented young woman from a privileged background, who had been completely overwhelmed by the demands of the dance school and who was steadily losing weight. This girl could not tell me what had happened to her, although I caught glimpses of a harsh mother and an ineffective father. She seemed emotionally far younger than her age; she had no words for her experience. Unfortunately my training, in the early 80s, had not prepared me for this. I hoped and waited, but the long silences were excruciating for us both and I did not know how to help. She eventually left the school. Another young woman who was bulimic had grown up in care and was maltreated there on top of maltreatment by her family. Her distress was again without words. Again I was little use to her.
I am not sure that counselling theory had really developed far enough for anyone to be able to assist clients like these at that time. Certainly my supervision and my reading were not much help. It was not until several years later that I started to see that my overeating clients had much in common with the clients that had puzzled me previously. There did not seem to be a single event; it was more an environment that had triggered their overeating. They had all been fat children; it seemed as if their behaviour was built into the foundations of their personality. At the very least their overeating was their life-management tool. They were incapable of doing without it. It seemed that something was missing in their development.
Attachment theory
Just at that time there began to appear in the literature research by other clinicians and researchers trying to address the same problem. Gradually I began to formulate an understanding of what might be going on for these clients. Others had been as puzzled as I. As early as 1991 Garner and Wooley were reporting ‘overwhelming evidence that [behavioural and dietary treatments of obesity] are ineffective in producing lasting weight loss’ (p729),2 and that ‘short-term results are frankly misleading indicators of long-term outcome’ (p737).2 But the first researcher I found who was trying to account for this behaviour was Felitti.3-5 He found in the histories of obese people stories of what he named ‘Adverse Childhood Experiences’ (ACE) – neglect, abuse, trauma. These people had a hugely increased risk of illness, addiction and, among other things, obesity. Soon there were others: Grilo, Masheb and colleagues, for instance, found correlations between childhood maltreatment and binge eating and obesity.6,7
At the same time I started to develop my knowledge of attachment theory. As a trainee I had read Bowlby and been through the ritual torture of seeing the Robertsons’ films of children separated from their parents, but I had never really understood the pervasive effect on childhood development. Through Stern8 I began to understand how crucial early relationships were to the child’s development. Then I found Allan Schore9-12 and his inspired interpreter Sue Gerhardt.13 These authors used neuroscience to explore exactly what happens to the brain of the child whose early experiences are not good.
My particular interest was in their account of how a child who is not soothed, who is maybe frightened, neglected and abused, does not ‘learn’ how to produce oxytocin or how to self-soothe and at the same time learns to mistrust others. These children had not had enough experience of being soothed and talked down from distress and upset to be able to do it for themselves and not enough experience of reliable, trusted attachment figures to believe that others would help. What Schore and Gerhardt seemed to be saying was that self-soothing and the use of others for soothing are our major strategies for managing our emotional lives (or for emotional regulation, as Schore names it). If we cannot use those strategies we will find others, such as drugs, alcohol and food, to deal with the everyday endless ups and downs in our feelings and experiences. The manipulation of food by the clients who puzzled me so much was their life management tool, because they had no other.
A further interesting set of research papers made this mechanism clearer. Colantuoni and colleagues,14 Yanovski15 and Dallman16 demonstrated that eating large quantities of fat and sugar, such as might be consumed in a binge, have a powerful effect on brain chemistry, producing cannabinoids and opioids and raising dopamine levels so that the effects of chronic stress are reduced. Bingeing clients had learned how to self-medicate to manage stress.
I began to carry out some research to see if a therapeutic approach might work for these clients.17,18 I started to see that there were clear, central issues that needed to be addressed. Among the population of overweight people was a sub-group, perhaps getting on for half, who were emotional eaters, bingeing in response to difficult feelings, with a history of poor attachment and often of abuse and neglect. This group had little awareness of feelings and inadequate emotional language. They had little capacity for self-soothing and often disastrously poor self-esteem and body image. They were frequently isolated and rarely had any emotionally intimate relationships.
I started to develop an intervention that would directly address these issues.19 The format was a year-long therapeutic intervention for groups of up to 12 women who had been referred by their doctors because of their obesity. The results were mixed but there was a core that responded well and found it revelatory and freeing. This taught me that there were several things I had not understood well enough: not all obese people were willing to think about their eating behaviour in psychological terms; not all corresponded to the profile described in the literature; a year’s intervention was far too long for those with little idea or experience of any kind of psychological understanding, and the manualised group intervention that we had developed would not work with individuals who had deep-seated emotional problems – they needed additional one-to-one therapy.
So, on the basis of about 10 years work and thinking, I developed what has become the Understanding your Eating programme (UyE).
The interventions
UyE is a manualised psycho-educational intervention, with an accompanying workbook, for use with groups of up to ten and with individuals. The introduction consists of five sessions, usually delivered weekly, that address the core issues for clients who binge or over-eat (who may not be overweight) or for clients whose eating behaviour is seriously distorted (for example, those living on sweets and biscuits). The five sessions focus on: emotional eating and words for feelings; attachment and self-soothing; selfesteem; body-esteem, and relationships. The sessions take the format of group exercises and discussion on topics relevant to the theme. For example the second session, on attachment, asks clients to think about their experience in their family of origin when something went wrong (eg the child forgot something, lost something, was late, hurt herself) and to use that information to think about their attachment pattern as a child.
About 20–30 per cent of those who attend the introduction have gone on to participate in the further modules. These are nine four-session interventions, focused on themes arising from the introduction: emotional eating; feelings and thoughts; motivation and empowerment; food monitoring; activity; self nurture; relationships; self esteem, and body esteem.
Some research has been carried out. An early piece of market research interviewed 13 people who had attended the introduction. Their comments described it variously as: supportive, packed, enlightening, helpful, a lot of information, made you think, an outlet, interesting, thought-provoking, a corner stone, painful, gave me new ideas, me time, revolutionary, focus was not on food, and packed. A study was also carried out of the first 90 attendees, from whom 71 evaluations were collected (81 per cent). The results indicated that 96 per cent would recommend it to a friend or family member; 100 per cent thought that the course content was useful or very useful; 99 per cent enjoyed the course; 85 per cent said they were likely or very likely to enrol on modules; 69 per cent said that the course had changed their eating behaviour, and a further 25 per cent said that it had not yet, but they thought it would.
Two small studies of introduction groups have been carried out. Alison Tulloh20 analysed interviews of participants in two different introduction groups using thematic analysis. She identified four domains:
- evaluative – a new start, positive experience, illuminating and wanting more
- change – awareness and insight, relationship with self, relationship with food, relationship with others and emotional freedom
- helpful – relational activity, group space and explanation
- unhelpful – threat to self or group and when it didn’t resonate.
Lynsey McMillan21 used quantitative and qualitative measures to study the outcomes for a group that had attended the introduction. Findings showed a number of key changes, including, for the majority of participants, a reduction in emotional overeating and an increase in control over food intake and improvements in internal dialogues. She suggested that a psycho-educational approach to emotional eating that focuses on cultivating a nurturing internal dialogue, improving self-esteem and encouraging the development of alternative coping strategies, particularly the seeking of social support, is a realistic aim for a shorter-term treatment for overcoming emotional eating problems.
A somewhat larger study of 30 participants in the introduction, which includes a one-year follow-up and tracks weight reduction as well as psychological wellbeing, is currently being analysed.
None of these studies have produced what would be termed ‘hard evidence’ – all are uncontrolled. However they do suggest that further research is merited. A practitioner research network is being established that will, in due course, create a database large enough for the findings to have statistical significance. A randomised controlled study would, of course, be very helpful in understanding just how useful UyE might be.
James’s story
To conclude let me share with you the experience of a recent client who has completed the introduction and has gone on to work through the modules. His identity has been disguised, but his story is told with his consent.
James (a pseudonym), a post-graduate performing arts student, was referred to me because he had been told that he would not be given parts at his then weight of 22 stone. He had repeatedly lost substantial amounts of weight, only to regain it all, and more. Using the introduction, we established that he was without doubt an emotional eater (and drinker) and that feelings in his family of origin were communicated via anger, quarrels or withdrawing. His schooldays had been miserable because of bullying; his parents were unwilling to do anything to protect him and largely ignored his feelings or emotional welfare. They were bound up in a destructive dance with each other that excluded concern for James. He had responded by developing a desperate clinging to his mother in an attempt to win her approval, but each success that he reported was met by her envious and destructive comments, such as: ‘You’re getting very arrogant since you’ve been studying there.’ These insights were both painful and freeing for James. We went on to discuss self-esteem and body image and to recognise how hard he had struggled to maintain a façade of the jolly, expansive, party person.
We began to see how many of his ‘friends’ had colluded in his excesses and how little they had been concerned for him. As we did this work, James became increasingly aware of his use of food for emotional regulation and began to learn a range of alternative strategies, including cognitive methods, for self-soothing. He found a girlfriend with whom he could become emotionally as well as physically intimate. Within four months of beginning the work he lost nearly four stones in weight – none of it by dieting, but only by recognising his emotional eating and finding alternatives.
Julia Buckroyd is Emeritus Professor of Counselling at the University of Hertfordshire and a BACP Honorary Fellow.
References
1 Buckroyd J. Eating your heart out: the emotional meaning of eating disorders. London: MacDonald Optima; 1989.
2 Garner DM, Wooley SC. Confronting the failure of behavioural and dietary treatments for obesity. Clinical Psychology Review 1991; 11: 729–780.
3 Felitti VJ. Long-term medical consequences of incest, rape and molestation. Southern Medical Journal 1991; 84(3): 328–331.
4 Felitti VJ. Childhood sexual abuse, depression and family dysfunction in adult obese patients: a case control study. Southern Medical Journal 1993; 86(7): 732–736.
5 Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine 1998; 14: 245–258.
6 Grilo CM, Masheb RM. Childhood psychological, physical and sexual maltreatment in outpatients with binge eating disorder: frequency and associations with gender, obesity and eating-related psychopathology. Obesity Research 2001; 9: 320–325.
7 Grilo CM, Masheb RM, Brody M, Toth C, Burke-Martindale C, Rothschild B. Childhood maltreatment in extremely obese male and female bariatric surgery candidates. Obesity Research. 2005; 13(1): 123–130.
8 Stern DN. The interpersonal world of the infant. New York: Basic Books; 1985.
9 Schore AN. Early organization of the nonlinear right brain and development of a predisposition to psychiatric disorders. Developmental Psychopathology 1997; 9(4): 595–631.
10 Schore AN. Effects of a secure attachment relationship on right brain development, affect regulation and infant mental health. Infant Mental Health Journal 2001; 22(1–2): 7–66.
11 Schore AN. Affect regulation and the repair of the self. New York: WW Norton; 2003.
12 Schore AN. Affect dysregulation and disorders of the self. New York: WW Norton; 2003.
13 Gerhardt S. Why love matters: how affection shapes a baby’s brain. Hove: Brunner Routledge; 2004.
14 Colantuoni C, Rada P, McCarthy J, Patten C, Avena NM, Chadeayne A, Hoebel BG. Evidence that intermittent, excessive sugar intake causes endogenous opioid dependency. Behaviour Modification 2002; 27: 478–488.
15 Yanovski S. Sugar and fat: cravings and aversions. Journal of Nutrition 2003, 133: 835s–837s.
16 Dallman MF, Pecoraro NC, la Fleur SE. Chronic stress and comfort foods: self-medication and abdominal obesity. Brain, Behavior and Immunity 2005; 19: 275–280.
17 Buckroyd J, Rother S, Stott D. Weight loss as a primary objective of therapeutic groups for obese women: two preliminary studies. British Journal of Guidance and Counselling 2006; 34(2): 244–265.
18 Seamoore D, Buckroyd J, Stott D. Changes in eating behaviour following group therapy for women who binge eat: a pilot study. Journal of Psychiatric and Mental Health Nursing 2006; 13: 337–346.
19 Buckroyd J, Rother S. Therapeutic groups for obese women: a group leader’s handbook. Chichester: John Wiley & Sons Ltd; 2007.
20 Tulloh A. Clients’ experience of change following participation in the ‘Understanding your Eating’ introductory course: a self-referred psycho-educational group intervention for emotional eaters. Unpublished dissertation. Glasgow: University of Strathclyde; 2011.
21 McMillan L. The effectiveness of a psycho-educational intervention for emotional eating problems. Unpublished MSc dissertation. Copies can be obtained from Lynsey McMillan at 0605875@live.abertay.ac.uk.