It’s a startling fact: Two out of every three adults in the United States are overweight or obese.

That statistic, among others, is revealed in “F as in Fat: How Obesity Policies Are Failing in America 2009,” a report released in July by the Trust for America’s Health and the Robert Wood Johnson Foundation. The report shows children aren’t faring much better, with the percentage of obese and overweight children ages 10 to 17 at or above 30 percent in 30 states.

While the cost of obesity weighs heavily on health care, the toll it’s taking on mental health cannot be ignored either. As the epidemic reaches sobering new heights (and weights), counselors believe their role is more important than ever. Weight issues often stem from issues more complicated than one too many Big Macs, experts say, and it’s the work to be done beneath the surface where counseling can help most.

In light of new statistics concerning the ever-expanding obesity epidemic, Counseling Today spoke with three counselors who specialize in body image and asked for their insights on how therapy can help.

Pennsylvania: 26.7 percent adult obesity

“We have become a nation of convenience, and certainly, packaged food products, fast food restaurants and portion sizes all play a role,” says Judith Warchal, a psychologist at the Reading Hospital and Medical Center in Reading, Pa. “But it’s not just about the food that we eat. It’s a far more complex issue. If it was just ‘Stop eating,’ it would be a far easier problem to solve. Alcoholics can stop drinking (and still survive), but we can’t stop eating. So it becomes a more complex issue in trying to manage the food that we eat.”

People who are overweight or obese often experience bias and discrimination, says Warchal, an American Counseling Association member and coordinator of the master’s program in community counseling at Alvernia University in Reading. “With children, we tend to say it’s the parents’ fault, but with adults, there’s a lot of bias that they’re lazy, that they have no willpower, that they can’t perform.” According to Warchal, research has shown that overweight and obese people face discrimination at work, and doctors spend less face-to-face time with obese patients.

“Managing portion sizes is a huge issue,” Warchal says, noting that portion sizes, as well as plate sizes, have grown dramatically over the years. “We fill up our plate without thinking that maybe 10 or 20 years ago, the plate would have been a little bit smaller.”

And while our intake of food is greater, we’re exercising less as a society. Warchal notes that when a person is overweight or obese – and possibly dealing with health complications – the likelihood of exercising decreases. “If you’re tired and fatigued and you have sore joints, it’s difficult to exercise,” she says. “Physically, it becomes a vicious cycle.”

The complexity of the issue shouldn’t steer counselors away, Warchal says, because their help is needed more than ever. “I think that (a person’s weight) becomes a hidden issue,” she says. “Oftentimes in the counseling office, clients will talk about depression, social isolation and feeling alienated, but they might not address directly that their weight could be contributing to those issues.”

One solution, Warchal says, is intake screening. Just as counselors screen for things such as child abuse and suicidality, adding a question along the lines of “Has your weight ever been an area of concern for you?” could offer significant insight into the client. “There is a great opportunity for counselors to begin to assess the impact of weight and eating behaviors on their clients’ overall physical and emotional health,” Warchal says.

Many of Warchal’s clients deal with social isolation. “People who are overweight tend to avoid situations where their weight will become an issue for them,” she says. “What they report to me are feelings of embarrassment and fear.” Among the stories clients have shared: panic at the prospect of getting on an airplane because of a fear they won’t fit in their seats; a dislike of grocery shopping because they think others stare at the food in their carts; avoidance of family picnics because they worry there won’t be a chair big enough for them.

“One of the first things counselors can do is assess their own feelings about treating someone who is overweight or obese,” Warchal says. “Eliminate the self-bias – that is really important.” Overweight or obese individuals are often more attuned to other people’s reactions, she says, so creating a safe environment where clients feel unconditionally accepted is important.

Before launching into talk about weight control, Warchal cautions counselors to focus on the issue that’s most important to the client. If the client doesn’t perceive his or her weight to be an issue, the counselor should back off. “Assess readiness for change, because if the person isn’t ready, we’re not going to get anywhere,” Warchal says.

If the client is ready, Warchal says, self-monitoring activities such as keeping a food journal, exercise journal or journal of thoughts and behaviors can be useful. Clients can then write about and later talk in session about things such as their eating triggers, their feelings at a family gathering or their experience with exercise. “The perception about what others are thinking keeps a lot of people who are overweight and obese from going into a gym,” Warchal says. Beyond helping each client with his or her individual issues, Warchal challenges counselors to help change perceptions related to those who are overweight and obese. “Try to change the perception in general – our own perceptions, the client’s perceptions and the perceptions of other people in the client’s life’s – to a focus on health and not appearance.”

Illinois: 25.9 percent adult obesity

Let your client take the lead. That’s one of the most important lessons Dana Steiner ever learned.

Steiner remembers the 40-something married woman who came to her private practice in Gurnee, Ill. The client was morbidly obese, and although Steiner called her weight the “pink elephant” in the room, weight wasn’t what the woman wanted to address. Instead, she wanted to talk about her children, her husband and her career. So Steiner, an ACA member, followed her lead. Not until they’d gone through five months of weekly sessions did Steiner begin learning more about the woman’s past and present as they related to her weight.

After building trust with Steiner, the client shared that she had been raped as a teenager. In addition, her family held rigid ideas of sexuality being taboo, and she then married a man with very similar beliefs. The upshot, Steiner says, was that the client wanted to work on her image, lose weight and develop a healthier lifestyle, but her husband was opposed to those goals. He was worried that if she lost weight, her self-esteem would increase and she would assume greater power in the relationship.

Although the client stopped coming to counseling before the situation was resolved and Steiner doesn’t know how everything ultimately worked out, she keeps that lesson fresh in her mind when seeing clients. “I really learned to take my client’s pace, because if I had jumped the gun, she would have been out of there earlier,” Steiner says. “When you think it’s obvious what the client wants to talk about, don’t be so sure.”

Working with clients who struggle with their weight is familiar territory for Steiner, who estimates at least half of her clients are overweight or obese. She observes that our culture inundates people with confusing messages. “You see one ad for diet foods, one ad for McDonald’s and one ad with skinny models,” Steiner says. “Not only does it promote confusion, it promotes the sense of ‘I’m not good enough.’” And when people have a sense of self-loathing or low self-esteem, she says, it’s easy to turn to emotional eating to find some comfort. “You set up a vicious cycle,” she says.

Steiner also says our daily lives are more sedentary than they once were. Children sit in front of video games, and many adults now spend a large portion of their work life sitting in front of a computer. The trouble, Steiner says, is that we haven’t changed our eating accordingly. “We still think with the farmer mentality of three squares a day, but we don’t need that,” she says. “If you’re having three large meals a day, that’s probably way more calories than the average sedentary person needs.”

In Steiner’s experience, clients tend to minimize issues with weight not only because they feel shame in talking about them but because they believe if they only had more willpower or chose the right foods, the problem would be fixed. “It’s easy to take the client’s view that it’s not a big deal, but in fact, it is,” she says. It’s important for counselors to find out what kind of relationship the client has with his or her body, Steiner says, because people often use weight and eating as ways of distancing themselves from their physical self.

Steiner has seen clients mask issues related to self-worth, relationships and sexuality, among other things, with weight. “(The question is) what is the weight and eating doing for them, because it’s got to be doing something for them. Otherwise, they wouldn’t be doing it,” she says. Steiner first recommends that counselors aim to find out what purpose the eating serves for the client – is it to combat high stress, is the person uncomfortable with his or her sexuality, is the person eating out of boredom, is it a form of self-mutilation because the person is self-loathing? Then the counselor’s role is to help the client find an alternative solution, she says.

Many times, Steiner says, people who are overweight put their lives on hold, telling themselves they will wait to date or buy new clothes until they lose weight. What clients put on hold can be very revealing to counselors. “Maybe whatever they say they want to do, they have fears about, and the weight is the protective mechanism,” says Steiner, who often asks clients to do whatever they’ve been waiting to do – right now.

While working through the issues that may be behind their weight struggles, Steiner encourages clients not to weigh themselves. Instead of focusing on a number on the scale, she urges them to find activities and relationships that provide them with the sense of a “full” life.

“What are the activities that make you want to get out of bed in the morning?” Steiner asks. “It shouldn’t be your breakfast, unless maybe you’re a chef.” Removing the emotions from eating is important, she says, because quitting cold turkey isn’t an option. “They can’t stop eating. It has to be about food as a source of energy and providing nurture to your body.”

As a word of caution, Steiner reminds her fellow counselors that their best service to clients who are overweight or obese likely doesn’t involve providing nutritional education. “Don’t whip out your food pyramid,” she says. “We’re not talking about lack of education here. They’ve been there, they’ve read the books, they’ve tried everything. If all you present is education, then you’re missing the boat.”

Counseling this population can be challenging, Steiner concedes, because many times, weight loss happens slowly, if at all. Counselors should reframe their definition of success, she adds, because it’s not solely about getting the client down to a healthy weight. “Success is getting the client to do some cognitive restructuring about their weight and food.” Be aware of and celebrate any change, no matter how small, she says.

When working with this population, it’s also helpful for counselors to have some working knowledge of the biochemistry behind weight, Steiner says. She went back to her local community college and took a few introductory courses, including biology, anatomy and chemistry. While counselors shouldn’t be dispensing medical advice, Steiner says, being knowledgeable about the workings of the body can help them gain a better understanding of what’s going on with certain clients.

Above all else, Steiner says, “Don’t make assumptions about (clients’) readiness to address their weight or what their weight means.” She points out that a person who is 10 pounds overweight might be much more concerned with his weight than another client who is morbidly obese. Which goes back to Steiner’s original lesson – always let the client take the lead.

North Carolina: 28.3 percent adult obesity

Greensboro, N.C., counselor and dietician Julie Duffy Dillon estimates that about 50 percent of the clients she sees struggle with being overweight and are dissatisfied with their size. The reasons for the obesity epidemic are wide-ranging, but to Dillon, an ACA member, three factors stand out.

“It seems like more families are having to do things during dinnertime,” she says. When parents work late or spend much of the evening shuttling kids between sports and other activities, family mealtimes are often pushed aside, making parents more likely to forgo opportunities to set an example for their children, Dillon explains. In addition, on-the-go foods might be less healthy and lack variety. “I think it makes the kids really picky and not curious about new foods,” Dillon says. “They’re not seeing how adults eat.”

Exercise is another factor. “People are just not naturally moving as much,” says Dillon, who adds that years ago, people walked more, danced for fun and were more likely to engage in outdoor activities. What Dillon hears from her clients today is that they go to the gym, work out on a stationary machine and don’t derive much enjoyment from it. “Why would you keep doing it then?” she asks.

Weight issues also stem from a lack of self-care, Dillon says, explaining that people don’t generally take the time to listen to their bodies or refuel them properly. Many of Dillon’s clients tell her they try to work through their hunger pangs or don’t feel hungry until the end of the day. She compares that to holding your breath for a long period of time – when you finally breathe again, you gasp in a lot of air. It’s the same with food, Dillon says. When people ignore their hunger and wait to eat, they need more to feel full, portion sizes increase and they might gravitate toward instant-energy foods such as candy or cereal.

Individuals who are already overweight are just as susceptible to falling into this cycle, Dillon says, because when they feel hunger signals, they know they have overeaten in the past and don’t believe they should actually be hungry again. “People end up not trusting themselves,” she says. That mind-set often leads people who are overweight to delay eating, only to then overeat again later.

Adding to that lack of self-trust are all the stereotypes applied to larger people, from laziness to lack of intelligence to weak willpower. “Many clients start to internalize those stereotypes,” Dillon says. “If they’re not going to believe they can do it or if the message they’re getting is that it’s their fault, then they’re not going to have much motivation to change.”

Dillon uses a non-diet approach called intuitive eating with her clients. The underlying idea is to give clients unconditional permission to eat what their bodies need, she says. The approach considers clients to be their own experts, encourages them to trust their hunger and fullness signals and accepts them exactly as they are. “It allows the person to feel more accepted, more OK with themselves, more OK with their body,” Dillon says. “When a person feels that, there’s less enjoyment or craving to eat outside of hunger cues.”

Intuitive eating helps a person eat for fuel, not emotional reasons, which is an ability we’re born with, Dillon says. She gives the example of toddlers who eat until they’re full and then go off to play. “That’s before we mess around with it and tell them to clean their plate,” she says. “(The intuitive eating approach) helps a person come back to that.”

The common phrase “war on obesity” communicates a sense of urgency to people, Dillon says. While some urgency is necessary – given that poor health is never good – it can also have a downside. “What it makes people end up thinking is that they need a quick fix,” Dillon says. But all too often, quick fixes don’t stick. “Learning to trust in the body again takes time. This is more of a solution for the long term.”

One of Dillon’s clients was a woman in her 20s whose weight had reached 400 pounds. Because she was suffering medical problems due to her obesity, the woman’s doctor had referred her to Dillon. Dillon learned that the woman’s parents had put her on various diets at a very young age. She started sneaking and hoarding food, and when her parents found out, they made her feel ashamed.

Initially, rather than talking about the woman’s weight, Dillon worked to help the client accept herself just as she was. As they continued through therapy, Dillon introduced the woman to intuitive eating so she could relearn her hunger and fullness signals. The weight came off slowly at first, but after two years, the woman had lost 200 pounds. “She needed to be heard and she needed to heal her relationship with food,” Dillon says. “Giving her unconditional permission to eat is something that healed her.”

If a counselor is seeing a client who struggles with depression, it’s OK to ask how that individual feels about his or her body, Dillon says. If eating or weight has become problematic for the client, Dillon suggests that counselors team up for treatment with a doctor or a dietician because of their in-depth knowledge of physiology.

Counseling can be especially useful in helping clients explore their history with food and how they were raised, Dillon says. Being taught to clean their plate as children, being brought up in a home where money was tight or having parents who put them on a diet can all figure into people’s relationships with food later on. Dillon recommends that counselors help clients determine the factors that push them to eat beyond their hunger cues. Many times, eating is an emotional reaction – eating out of boredom, loneliness or frustration, she says. And although emotional eating can be a normal reaction according to Dillon, when it gets out of control, counselors can help clients find an alternative way of dealing with those emotions.

Dillon also cautions counselors to be aware of their own body image and food issues. For instance, a counselor might think that sugar is bad and that eating less of it is a surefire way to lose weight, but that’s not always true, Dillon says. “I wish counselors wouldn’t pass on their own food beliefs,” she says. “That’s something that really affects clients because they trust their counselor and they’re going to honor their request.”

Dillon hears from many of her clients how hard it is to bring up weight issues in counseling because of the shame they feel. It’s incredibly important for counselors to make it OK for clients to talk about weight, she says, and for that reason, Dillon believes acceptance is key above all else. “Tell clients either in actions or words that I accept you as you are,” she says. “That acceptance is what I see most clients needing, and that’s what ends up helping them lose weight in the end.”

SIDEBAR

Keeping tabs on the kids

Peter Warchal, who has been a high school counselor for 34 years in Reading, Pa., says that to attack obesity effectively at the adolescent level, schools need to implement a systemwide approach. At Warchal’s school, multiple parties are invested in trying to stem obesity among students.

1. Teachers: Tasked with imbedding good health practices and educating students about the effects of obesity through the health and physical education curriculum.
2. School nurse: Monitors student weights and communicates with the parents.
3. Administration: Warchal’s school district has taken a larger role in deciding what foods and drinks are available to students in vending machines.
4. School counselors: Warchal says he, like other school counselors, can tackle weight and obesity issues on an individual basis.

“The obesity issue needs to be done with a systemwide perspective. If you have that going for you, you have a shot at making an impact in a youngster’s life,” says Warchal, husband of fellow ACA member Judith Warchal, who also counsels overweight and obese clients in her work at the Reading Hospital and Medical Center.

– Lynne Shallcross

Lynne Shallcross is a staff writer for Counseling Today. Contact her at lshallcross@counseling.org.
Letters to the editor: ct@counseling.org.