When Change is Hard: Interpersonal Edges in Work with Weight Loss, Maintenance & Addictive Processes

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Weight loss after weight loss surgery is often complicated by the emergence of other addictive tendencies during the process. The not atypical experience of later regaining so much weight, after it was so speedily lost, can be extremely emotionally painful. Such recidivism is reported with perplexed frustration by behaviorists (Jeffrey et al., 2000) and surgeons (Kamali, 2013). As such high recidivism rates attest, the maintenance of weight loss is elusive, typical and critical. This is not an arena psychoanalysts have taken much interest in. However, using an analytic approach, there may be much to learn about desperation, need and the nurturing aspects of structure. 

I have suggested (Tintner, 2014) that the detailed inquiry – a collaborative interpersonal process of exploration (Levenson, 1991), helps in the treatment of obesity. I will here describe how the detailed inquiry expanded awareness of actual behavior. Such awareness was absent in the doing or being of the behavior itself – be it eating, spending or smoking. I will show how a gradual, repetitive use of this inquiry was grounded in the context of the relationship between patient and analyst. In a sense then, the addictive processes themselves, as well as the underlying psychodynamic patterns, unfold along with and interwoven into the inquiry. I am also influenced by a view of an expressive use of the counter-transference, based on such work by Bollas (1983) and Maroda (2003), among others. In the following treatment, and with the powerful description of Coltart’s (1992) use of her feelings in mind, I expressed frustration at the entrenchment of the treatment process, as well at the evocative aspects of the patient’s evasive interpersonal patterns. 

The frustration I felt with the patient I will call Serena surfaced early on. Within months of starting our work, a pattern of cancellations, no-shows, and unanswered calls became apparent. When I inquired about this, Serena pinpointed a longstanding pattern of disappearing. She had been hibernating for years and had alienated close friends by disappearing on them. After a long stint of vanishing from our sessions I called and exasperatedly left a message saying I didn’t know what to do. I said I thought what was going on was important, but we had to meet to talk our way through. She came in surprised, she later told me, that I sounded so desperate. An expressive use of my feelings engaged her. We began to explore how she enacted her wish to get away from her mother, whom she termed a “succubus.” 

Serena had to stop smoking as a condition for receiving bariatric surgery (her surgeon knew about post-surgical symptom substitution). With some help from the medication Chantix, she quit smoking 6 months before her surgery. One year after surgery, both nicotine free and 100 pounds lighter, she went on a trip. Returning, she casually reported, “I just wanted a cigarette on the plane, so once I got to the airport I bought a pack.”  But, she did quit again, then smoked again. This off again, on again pattern repeated several times. Eventually her doctor said she would limit how often she prescribed Chantix. Serena then quit permanently. Even as she complained, she responded to, or needed, these limits. 

As smoking faded into the background and summer approached, Serena started shopping. When she came in for session carrying shopping bags I asked what the bags communicated that she could not say in words. Her debt had risen as we focused on her experience of eating and moving. Often, she hid her purchases for a while, then when her debt loomed, they would surface. Each time a new/old symptom surfaced I was shocked and felt a little despair over whether we could get through it. 

Serena had a long-standing pattern of “throwing” her not inconsiderable bonus at her debt. The debt then inexplicably built back up before the next bonus arrived. She took out a low interest loan. But then she had to pay it off. At one point her debt went as low as $10,000. Later she indicated that it went up to thirty, forty thousand and higher. I asked specific questions about dollar amounts (as with foods eaten). But a clear answer eluded us. Nonetheless over time, purchases became less expansive.

The primary area of collaborative exploration has been around eating. In the initial rush of post surgical weight loss Serena was surprised at how physically well she felt. She was enthused as she walked up subway stairs without soaking her clothes with profuse sweat. She also felt surprisingly refreshed after sound sleep. Only as she felt better did she realize how bad she had felt before. In particular, she was able to describe a nightly ritual of sitting on her couch eating a bag of Hershey’s Kisses – “mindless” about what she was doing. She could not and did not talk about it while it was happening. Only afterwards. She cut out the consumption of sugar during this time and linked this to the pronounced improvement in her sleep quality.  

I was curious about those “Kisses.” I asked what it was like to go to bed and she said it was hard to put herself to bed. This connected to difficulties in structure, doing homework, going to school, all daily routines her parents could not enforce. Thus, important dynamic material emerged within the therapeutic relationship during the course of the inquiry.       

At the same time as difficulties with spending became apparent, the typical struggle with maintenance of the dramatic 100 pounds weight loss continued. Surgery had reduced the size of Serena’s stomach so that made it difficult for her to overeat.  However, if she “grazed” (ate small amounts all day) or pushed herself to eat even when it hurt, the stomach stretched. A year after surgery her stomach was not as small. She had to struggle to build a framework for eating, which she resisted fiercely. Throughout, building on her understanding of her “mindless” eating, we had repeatedly addressed her gradual weight gain by collaborative inquiry of the experience of eating as well as the emotions precipitating it. Serena’s awareness of what she did not want to know about, as well what and how she ate, was growing.  Recently, she reported that for months she had a large container of individually wrapped sugar free mints on her desk at work. They were sugar free, right? So she ate them – all day long. But, one day when she took her garbage out of her office, she was surprised at how large the pile of wrappers was. It took seeing this large pile to realize how many sweets she had consumed.  But she would not have noticed it a year, maybe even 6 months earlier. She was “mindless” while actually eating. She needed the conspicuous wrappers to make her consumption conscious.    

Serena had not put on much weight in the last year. However, she had gained a total of 45 pounds since her surgery 5 years ago. Serena was worried about the weight gain. She was upset she didn’t feel as physically flexible. She was upset at losing the feeling of greater ease in her body. She was upset some newly purchased clothes no longer fit, some of them still unworn. Yet often the upset was fleeting and often she reverted to the familiar pull of detachment. She also started cancelling for not so credible reasons. 

Alongside her detachment, she did not want a plan to help her. She did not want a nutritionist or a plan of some limitation (like low-carbohydrate). She wanted the option of 2 or 3 desserts a week, but did not want a plan like Weight Watchers that would allow her to have them. Or, if she did come up with a plan, like ordering meals in bulk online or limiting desserts (both of which helped her) she could not keep going. She acknowledged she felt better with guidelines in place, but even when she chose them, she had to go against them. Then she would disappear so as not to talk about it.

Her emotional detachment was only pierced when I expressed feelings (mostly exasperation) about her being stuck. I have worked with people who had regained all of their surgically lost weight. It is excruciatingly painful. I would like to try to protect people from that. When Serena was so evasive and blasé I was therefore exasperated. So, finally, with a semi conscious mix of frustration and pain, I said I knew she didn’t want to regain all the weight. Thankfully, I noted, that it was only 45 pounds, yet Serena seemed to be out of touch with the self-destructiveness of what she was doing and the need for structure to protect her. She put her head in her hands and cried – wept actually, and said she felt very afraid of regaining the weight. She felt alone, overwhelmed and desperate about building a future for herself. I suggested that her parents either did not understand, or could not help her with, structuring herself. I wondered if she was still expressing the need for that kind of parental attention/nurturance. She ardently resisted limitation (like no cigarettes, or no sugar) while the debt/weight gain indicated a need for someone to struggle through it with her, or set a limit, which – unlike the doctor who prescribed her Chantix, I could not do. 

Reviewing the flow of addictive symptoms, there was a cycle of moving forwards then retreating to another symptom. At each go around she approached a precipice (debt, weight gain, desperation) and only regrouped or reacted in the face of that crisis. This was a replay of a life long pattern of going to the precipice, while I was unable to protect her. Maybe she will need to go further toward the edge. Maybe I have to find a way to notice the crisis (i.e. not ignore it like her parents) but also stop wanting to protect her. It has to come from her. I have to find a way to keep my balance on the tightrope I find myself on.

With each cycle, there was a little evolution of awareness of the actual behavior. It became clear that the processes of need for nurturance and mindlessness were the same for each behavior. Each time we addressed the behaviors and the patterns between us. This could involve a (too?) vehement expression of feeling on my part. Each time around it felt a little clearer. Overall part of what is perpetuated is a constant sense of chaos. This has somewhat diminished, but the multiplicity of symptoms serves to defend against change and what is threatening to her about it. 
 
References
Bollas, C. (1983), Expressive uses of the countertransference. Contemporary Psychoanalysis. 19 (1) 1-34. 
Coltart, N. (1992), Slouching towards Bethlehem. In The British School of Psychoanalysis, Ed. G. Kohon, Routledge,1986, pp.183-199.
Jeffrey, R.W. et al (2000), Long term maintenance of weight loss. Health Psychology, 19.                                                                              
Kamali, S. et al (2013), Weight recidivism post bariatric surgery. A systematic review. In Obesity Surgery 23(11), pp.1922-1933.
Levenson, E.A. (1991), The purloined self. In Interpersonal Perspectives. New York: William Alanson White Institute.           
Maroda, K. (2013), The Power of Countertransference:  Innovations in Analytic Technique. Routledge. 
Tintner, J. (2014), The use of the detailed inquiry in the treatment of obesity.  In Body States. Interpersonal and Relational Perspectives on the Treatment of Eating Disorders.  Ed. J. Petrucelli. Routledge, 2015, pp 207-219.