Counselling for Obesity

Person-Centred Dialogues

Richard Bryant-Jefferies

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315345796
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

In The United Kingdom over 30, 000 deaths a year are caused by obesity. Counsellors, trainees and other healthcare and social care professionals need to understand and experience the diverse and challenging aspects of this rapidly developing issue. By including fictitious supervision as well as counselling sessions, Counselling for Obesity further aids professional development and gives a unique, person-centred insight into a client's potential needs.

PART 1

Steve confronts being overweight

Steve nodded, ‘I suppose my size has been a major factor in shaping me, the person, me, Steve, you know?’ He went quiet, the words ‘fat bastard’ came to mind, he’d been called that a few times. On a good day, he laughed, brushed it off, he could even make a joke of it himself, though if he was really honest with himself he would have to admit that at some level it hurt. On a bad day? Two reactions. Want to get away, hideaway, though that happened less rarely. More often on a bad day he’d want to punch the lights out of whoever had said it.

CHAPTER 1

Counselling session 1: forming a therapeutic relationship

Steve sat and looked at the posters on the walls in the waiting room. The chairs were small and it made him quite conscious of his size. Anywhere that he went he overflowed the seat and could sense the irritation of others. His attitude had always been ‘fuck them’, but behind that there was a discomfort that he rarely let anyone else see.

He had been large for as long as he could remember and it felt as though it had been OK and acceptable until recently, until all the fuss about obesity and people who were larger were suddenly a cause of excess costs to the health service. His GP had been mentioning his weight for years, but he had chosen to ignore it. Sometimes it might make him think, cause him to hesitate when he was contemplating what to eat, but generally he brushed it aside. His attitude was very much that of it being no one else’s business what he ate.

Now, however, his blood pressure was definitely up and the doctor was expressing serious concerns. He had also had experiences of breathlessness which had left him feeling quite dizzy and disorientated on occasions. He was being monitored closely and the choice was very much a case of lose weight or we will have to put you on medication. He didn’t like tablets. He liked to feel he was in control. But he knew that the tablets probably wouldn’t help the breathlessness anyway, and that was what had concerned him most. It was something tangible, it had stopped him and made him think – 35 years old and breathless. He couldn’t carry on like that, and yet he didn’t like feeling picked on because of his size. He reacted against that.

As he sat waiting for his appointment with the counsellor, his eyes focused on a poster – highlighting the damage to health caused by obesity. Didn’t see those on the walls a few years back. But the way it was written, it seemed so critical, blaming people for putting on weight. OK, so he had decided to build himself up, but he had always had a healthy appetite – that was what his mum had always said – and, well, he just spent a lot of time eating. He liked eating.

It can get forgotten that for many people who have a weight problem, eating is something that they enjoy. Generally people don’t like to give up or cut back on what brings them pleasure. People make choices because it gives them a benefit. We make choices and develop behaviours to satisfy needs. Eating is, for many people, a way of satisfying a range of needs: to offset boredom, to make themselves feel big, for the sensation of feeling full, to make themselves feel they are less attractive, and there are many more. And what you eat, or where you eat, can be an indicator of affluence and signify a form of status, or to be seen to be in touch with the latest fashion, to be where your friends are.

John was sitting in the counselling room. He had been a counsellor for a number of years, and had recently become interested in working with people who had weight problems. He now worked two sessions a week at the local hospital. It was a new area that was under development and he was excited by it, although he was aware that many of the issues underlying a person’s eating pattern and weight gain were those that he encountered generally as a counsellor: sexual abuse and bullying being two areas that arose frequently, together with symptoms of depression.

He noted the time and went out to look for his new client – Steve. He was always mindful of his approach. The difficulty was that in general he would know who his client was before they knew him – their size would make them stand out. Yet he also wanted to normalise things, and if there were a number of people in the waiting area, he would call out his client’s name without fixing his eyes specifically on the person who it seemed highly likely was going to be his client. It wasn’t that it was a right or wrong way to approach it, just the way that he had developed.

He went into the waiting room, and called out his client’s name. Steve had looked up when John had entered. He heard his name mentioned and met his eyes. ‘That’s me.’

‘Hi, would you like to come through?’He was always careful not to announce himself as ‘the counsellor’; the client might have met someone that they knew, but didn’t want them to know why they were attending.

Steve followed John along the corridor to the counselling room. The first thing he noticed were that the chairs were large and accommodating. ‘Where

shall I sit?’

This attention to detail communicates something to clients. Of course, how the client will receive it will be up to them, but for the person-centred counsellor what is important is that such details are an expression of their wish to communicate respect and warm acceptance to their clients as persons with their particular set of needs.

‘Whichever. Up to you.’

Steve sat in the chair opposite to where he was standing as he had come through the door.

‘So, you’ve been referred to me by your doctor. I need to say something before we start about confidentiality, although I know we sent you a leaflet describing what this means, as well as what counselling offers.’

‘Sure.’

John informed Steve as to the nature of confidentiality and its limits, and checked that Steve felt informed about what he was being offered. Steve said that he was.

Explaining the scope of confidentiality and providing information so that the client can give informed consent to receive counselling is important. It can feel rather administrative in that it is an outside agenda being imposed on the client, however, where a client is referred for something, rather than it being their own informed choice, they do need to know what they are being offered, and for what purpose.

‘Great, I have to mention all this, and I have to be sure that you are giving consent to treatment.’ John had the momentary thought to himself of the fact that he didn’t think of counselling as a treatment, but that within the health service that was the language that was used. As a person-centred counsellor he saw himself offering contact and relationship which he believed encouraged clients to become more accurately and authentically self-aware. For him, working with people on eating issues so often related back to experiences in their lives. People developed particular eating patterns for reasons, they had their own specific meaning that they attached to it, and to themselves as a person who had extra weight. If people could resolve the psychological factors he believed very strongly that the eating pattern could then change, and most importantly, change in a sustainable way.

‘Sure, that’s fine.’ Steve made himself comfortable, although he was aware of feeling a bit anxious and uncertain, not being sure quite what would happen next.

‘So, where would you like to begin? What’s going on for you?’

Steve took a deep breath. ‘Well, I don’t know how much of a problem I’ve got, but the doctor thinks that I have.’ Steve didn’t want to openly admit to the problem, or that his eating was causing a problem, he didn’t want someone judging him as having made himself ‘unwell’, which was how he felt lots of people viewed people with obesity issues.

‘Mhmm, the doctor thinks you have a problem, but you’re not so sure.’

‘I mean, I’ve always been big, long as I can remember and, well, I don’t like anyone telling me there’s something wrong with me – makes me feel like, I don’t know, I’m suddenly a problem.’

‘So you don’t like anyone telling you something’s wrong, you don’t like being made to feel that you’re suddenly a problem, yes?’

Steve nodded. ‘That’s right. I don’t like it and I won’t put up with it.’

‘People telling you that you’re a problem, well, you’re not going to stand for it.’

‘No, no I’m not.’ Although Steve felt quite tense as he spoke and had strong feelings about this; he was also relaxing a little into the session and into a dialogue with John. ‘I mean, OK, so, yeah, so I’m big, but I’ve always been big, so what? So I have some health issues. OK. But I don’t want people to start blaming me.’

This series of empathic responses has meant that the client has moved more fully into his feelings and that they are becoming more present in his physical state and through his tone of words. Empathic understanding is not conveyed by the person-centred therapist to achieve this, they offer empathic responses in order to convey their understanding of what the client is telling them. The effect will be as it is. Often, however, it will enable clients to engage more fully with their feelings or thoughts because they have felt heard and respected, and either feel they can disclose more, or simply connect with feelings that demand to be expressed.

‘Yes, I think I understand, it’s more the sense of people blaming you, and I suppose – and this is a word that is present for me – a sense of people “judging you”.’ John used the word ‘judging’ not because it was a common feeling among clients in these kinds of situations, but because it arose within him strongly in response to what Steve was saying, and the way he was saying it.

‘I don’t like being judged. I’m not fat, I’m large.’

‘And large is what you have been for as long as you can remember. You don’t feel fat and you don’t want to be judged. That all sounds pretty clear to me.’

Steve nodded, thinking to himself that at least he’d made that clear. He wanted to get things straight. Make sure this guy John knew who he was talking to and what he was saying.

It is worth considering whether the tone and content of what the client is saying is in some way linked to the fact that his counsellor is male. Might he talk differently if the counsellor was a woman? Would this have been more, or less, therapeutically valuable? All we can say is that it would have been different and, from a person-centred perspective, what is important is that a therapeutic relationship is established. Nevertheless, certain gender mixes will have particular meanings for clients.

Another issue is the size and shape of the counsellor. Would it help if they, too, were large? Or does it make little difference? Does a difference in size encourage or discourage a client to express him or herself in different ways? It will vary from person to person. It may prove helpful for the counsellor to acknowledge any awareness that they have of difference, but only if it emerges in the context of what the client is experiencing and describing, otherwise it would simply direct the client towards the counsellor’s awareness.

Steve lapsed into silence and John stayed with it, respecting it. His sense was that perhaps Steve had said what he needed to for the moment and that he had felt heard, and therefore now knew he didn’t need to say it again, but maybe wasn’t sure what to say next. This was, in fact, quite true. Steve did feel heard, and it was actually a rather new experience to him, at least, it was from someone who wasn’t large like he was. Some of his friends were large and they understood what he felt, and they generally felt the same, but anyone who wasn’t his size, he’d usually sense that they weren’t really listening or understanding. Over the years he’d become quite sensitive to peoples’ reactions, you could see it in their eyes. And they had ‘judgement’ written all over them. Pissed him off.

Steve’s thoughts were back with his doctor, who he also felt was quite judgemental. Seemed to be telling him what to do, how to live his life. Well, he’d done what he’d said, he’d come to see this counsellor, and now he was wondering what next. He’d told him how he felt and, yeah, he felt the guy had understood. Well, that was something. Now what?

John felt that he would acknowledge the silence and give Steve an opportunity to say what was happening for him. He was always reluctant to break in on a silence, and yet he also knew that in silences early on in a counselling relationship, and in this context where it seemed that a client had said their piece and then ground to a halt, he felt it was helpful to acknowledge what was happening. ‘I hope that I’ve heard what you had to say just then, Steve, and maybe you’re wondering what next?’

‘I guess it happens a lot?’ Steve thought that John was making some standard response.

‘It can do. It can take a ...