Middle Phase Altering Cognitions

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A whole series of cognitions may contribute to the maintenance of obesity, such as the attitude toward eating, poor self-esteem and the way they perceive and experience their bodies. The Spiegel & Spiegel technique (1978) described earlier, where suggestions are given that 'overeating is harmful and poisons the body', may help the patient to change their attitude toward overeating. Meanwhile, patients can once again become conscious of feelings of hunger and satiation, which can be suggested systematically during the trance (Kroger, 1970).

Obese patients very often have strong feelings of inferiority, they feel weak and powerless against their problem. They may perceive and experience their body as a great threat and even have feelings of disgust toward their body. During hypnosis, ego-strengthening suggestions can be made in order to favorably influence the sense of self-esteem (Brown & Fromm, 1987).

Patients can be given the suggestion to look at their body in a mirror and to evaluate it more positively. Patients with chronic obese problems can be invited during a guided imagery exercise to imagine themselves in a world where being overweight is highly valued.

Example

Karen, a 42-year-old unmarried secretary, entered therapy for a dramatic weight problem. Karen started therapy at 300 pounds and lost only 20 pounds after a year and a half of intensive psychotherapy. Her weight problem had originated in early childhood and in the past she had tried all kinds of diet. Each time when starting eating normally again, she put on weight immediately ... Because of her severe weight problem, she locked herself up in her apartment and only left her flat to go to work. She had extreme feelings of inferiority. Firstly, self-hypnosis was taught by means of an audiotape. We discovered that Karen had moderate to good hypnotic capacities. Since we had learnt from her weight history that losing weight would be very difficult, we decided to introduce hypnosis to alter her negative feelings and feelings of inferiority about herself. We invited Karen to imagine herself, during hypnosis, in a world where being overweight was highly valued:

And now that you are feeling more and more relaxed and comfortable, I would like to invite you to make a trip to a country where most women are overweight and where being overweight is highly valued ... In this society all women have to be obese ... To be attractive, you have to be obese. It may be a funny or confusing experience right now, since everything is so different here ... But listen to all the positive comments people are making about you ... Being plump can become a completely new experience. You may start to look at your body in a different way ... More positively

Strengthening Motivation

Obese patients are easily discouraged and often think of giving up the treatment. A minimal weight increase is often perceived as a true catastrophe. Direct suggestions can be given to strengthen motivation.

Example

And now that you have learned to respect your body by balanced eating and physical exercise, you will become even more and more aware, day after day, how important regular eating and physical exercise will remain for you for the rest of your life ... How practicing self-hypnosis daily, will help you to stabilize your weight and help you to feel relaxed, comfortable and pleased with yourself. By now, you may have noticed how all these new behaviors and efforts, have become a kind of habit and are happening automatically, and hence don't demand much effort anymore ...

The strategy of positive and negative consequences (Wright & Wright, 1987) as well as future-oriented fantasy exercises can be employed equally to strengthen motivation and to prepare the patient for a possible relapse.

Example

Joanna, a 37-year-old woman, entered the treatment program at 220 pounds and weighed 185 pounds at a 6-months follow-up and 160 pounds at a 2-year follow-up. Her weight problem started after marriage. She had tried several times to lose weight, but always gave up after some weeks. She grew up in a healthy family and seemed to be happy with her husband. Hence we decided to focus on her weight problem and to teach Joanna not to give up. To strengthen her motivation for the treatment, Joanna was invited to write down all the positive consequences of losing weight. Next these positive consequences were suggested during a hypnosis exercise, together with ego-strengthening suggestions.

And now that you imagine yourself beginning to lose weight, you may become more and more aware of all the positive consequences for you of losing weight. Now that you have started to respect your body and protect it through balanced eating, you may begin to feel healthier in your body, you can buy new clothes that fit well and make you feel more attractive. Maybe you notice how cycling has become easier and easier, just as if your cycling has become automatic. You may start to gain more self-confidence, since people give you more and more positive comments ... And this exercise may help you to become even more and more aware of all the positive future consequences of continued balanced eating and physical exercise ... Your willpower to reach your goal can become even stronger.

Exploring Ambivalence Toward Change

The combination of behavioral and hypnotherapeutic techniques may lead to merely a temporarily favorable result in some patients, and to none at all in others. An important number of patients will become anxious and/or depressed when they start to lose weight. The therapist may notice that the patient does not continue to carry out the agreements, and may give the impression of unconsciously undermining any progress. In that situation, different kinds of hypno-analytic techniques can be employed (see Edelstein, 1982), in order to explore possible unconscious obstacles and resistances to further weight loss, such as ideomotor questioning with the seven questions of Le Cron (Cheek & Le Cron, 1968). In women with a strong resistance toward change—usually those who are chronically or massively obese—we often discover that the patient's obesity conceals traumatic events and/or unsolved conflicts of a highly emotional nature. These traumatic events might be incest, rape, physical abuse, extreme emotional neglect and lack of affection, or involvement in chronic marital discord (Vander-linden, 1993). Besides the technique of ideomotor questioning, we often use egostate therapy (Watkins & Watkins, 1982) to communicate with that part of the patient that is afraid to lose weight, that induces the overeating, or that is sabotaging the treatment.

Example

Laura, a 38-year-old married woman with a severe obesity problem (250 pounds), responds enthusiastically to the suggested self-control procedures and she practices her self-hypnosis several times a day. As soon as she starts to lose weight, as she regains more control over her eating pattern, Laura becomes more and more depressed and no longer follows the agreements that had been made. She says that 'one part inside doesn't want to cooperate anymore'. We then propose to her to explore the ambivalent attitude by means of ideomotor questioning (with finger signaling and ego-state therapy).

Therapist: While you are enjoying your trance state, you can become more in touch with that 'part' in you that makes you feel depressed and forces you to overeat, when you are alone.

Further exploration during hypnosis revealed that one part called 'sadness, helplesness and anger' came in Laura's life (at the age of 4) when she felt emotionally rejected by her parents and when she saw her father beating her mother. During hypnosis she discovers how eating helped her to freeze all these negative feelings and to distance herself from the escalating fights between her parents. She further discovers how overeating became her way of dealing with feelings of loneliness and being rejected, that she experiences every evening when she comes home after work. Thereafter, the working through of these traumatic memories and feelings became an essential part in Laura's treatment. In the following sessions, Laura was exposed under hypnosis to her traumatic memories and feelings, until extinction of the intensity of the emotions was reached (see Vanderlinden & Vandereycken, 1997). Meanwhile, she was invited to comfort herself as a child and to provide support whenever she felt lonely and rejected. The therapy lasted for about 2 years. At a 1-year follow-up, her weight was decreased by 60 pounds (now 190 pounds), but problems had developed in her marriage.

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