As the dynamics of Obesity versus Anorexia and Bulimia are so different there is a strong feeling amongst most professionals that sufferers from these disorders cannot be treated together. Many professionals believe that because Obesity is so closely related to Addiction, the 12 step Minnesota Model is the most effective treatment approach. Although Montrose Manor does incorporate the 12 step approach in our programme, it is integrated with a more eclectic and psychodynamic approach. We have nevertheless started getting an increase in the number of over eaters interested in joining the Montrose Manor Program.
Initially we started with only one and were a little apprehensive as we were not sure if they would relate to our anorexic and bulimic clients and it may be worth sharing our experience of integrating these clients into our programme.
Typical challenges we have had to address have been:
- Judgements, comparing, envy and resentments that would be evoked by the different clients. How would an obese client feel sitting in a body image group and listening to an extremely thin client talk about “how fat and revolting” she/he is feeling?
- Managing health problems: eg: heart and breathing difficulties, often with sleep apnea, where an oxygen mask is required at night.
- Meal Plan: At meal times, overweight clients might have to eat fewer calories than the underweight clients. Some of the clients have had gastric bands or gastric bypasses or diabetes, which affect devising a meal plan in a way that is different to the under-eaters/restrictors.
- Joint pains and arthritis which affect mobility. Climbing stairs is often an issue and influences the amount and type of exercise that they are able to do.
- Whereas the anorexics and bulimics may over-exercise, the obese over-eaters may be reluctant to exercise
- Breaking furniture. Chairs and beds needed to be reinforced.
In spite of the above problems, the few clients we did admit fitted into the community easily and did very well in spite of minimum adjustments. In fact there are no groups in which we have had to separate them.
The number of obese clients who are seeking help has increased significantly and at times half our community is made up of people suffering from obesity problems. The possible benefits of combining the clients into one program seems to work and may be due to some of the following issues:
Whether the client is overweight or underweight, most of them wake up in the morning wanting to restrict and feeling guilty every time they eat. Many overweight clients believe they do not eat much and have small appetites. Our clients eat 3 meals a day and 3 snacks, but do not know how many calories are on their plate. The only difference is that the overweight clients are encouraged to select a fruit or yogurt as a snack, rather than a baked snack. They all learn that they do not have to control this process. It is helpful to have both over-eaters and under-eaters eating the same meals and realizing that the body will adjust on its own to a correct meal plan. Over the 3 months, clients with low BMI put on 3 to 5kgs and overweight clients tend to lose 10 to 12kgs.
Bulimic clients often eat more than obese clients during a binge, but do not put on as much weight because they purge. This helps the obese clients feel less shame and they can relate to the binge eaters more (In fact they are sometimes proud that they do not humiliate themselves with purging.)
Many obese clients have experienced anorexia or bulimia in the past. Fears such as an anorexic saying “If I give up my ED, will I look like you?” can be addressed directly. Other relevant issues like being judged as lazy, stupid, disgusting, can be addressed.
They all have a “wounded child” that has been neglected or badly treated. Although this originates from real or perceived childhood experiences, they have internalized the critical or nurturing parent, which leads to faulty beliefs and repeated patterns of behaviour.
They all have low self-esteem and feelings of shame and many have had co-dependent relationships, in which they have allowed themselves to be disrespected.
In all clients, there are significant control issues (either too much control or a loss of control). There is often denial and an ambivalence to “give up their ED” due to their faulty belief systems and ED rules, which they are unable to challenge. Many obese clients tell us that they “accept their bodies as they are and feel we should do the same.” They consider others to judge them unfairly “My appearance is not important, it’s what’s inside that counts!” It takes time for them to realize that they have been abusing their bodies (just like the anorexic and bulimic) and it is not OK to be so unhealthy.
A significant difference is in the amount of exercise the obese clients want to do compared to the restrictors. Where we have to put firm limits on the restrictors to decrease exercise, we often have to be firm about the obese clients doing exercise. This does need to be supervised, especially in the beginning when resistance is high. The complaints of physical conditions and painful joints also need to be addressed. Water aerobics and spinning have been successful. (We have noticed that they often say they cannot manage the morning walk, but then choose to spend the entire weekend walking in the shopping mall!)
These last 2 years that we have been admitting over-eaters has been a learning opportunity, but one that has been very rewarding. Saying goodbye to an overweight client at the end of his or her treatment and seeing the appreciation and renewed hope in their eyes has been worth all the efforts that we have made to include over-eaters on our program.
Below is a testimonial written by one of our Obese clients after her discharge:
Leaving Montrose Manor after nearly 3 months gives me a great feeling of gratitude and happiness. I would never have gotten a fulfilling and happy life back if I did not end up here. I always thought that my strange eating-habits and using cannabis were a lack of will power. Now (at the age of 53) I finally realise that it is a disease and that I cannot fight this disease on my own! With the guidance of my Higher Power, all the dialectic tools I learned, the meal plan, the gym, anger-management and giving attention to my inner child and all the other things I learned and became aware of, I am ready to go home and face the real world again I will come home as a different, better person. I feel eager to live life again at its fullest! I will continue with getting up early, doing my serenity prayer and meditation and paying attention and care to my body. I will stick to the meal plan and walk a lot with my dog and enjoy nature. I am very happy that I lost 9 kg in the 3 months of my stay but way more important is the fact that I am feeling so much better about myself. I learned to identify what made me binge and do drugs. I know now that I suppressed a lot of my emotions as anger, hurt, loneliness, sadness with food and drugs.
I know now that this only made me feel more depressed, tired and miserable. I will go to meetings and find myself a sponsor and I am going to stay focused on my recovery.
Life will still come with ups and downs but now I have the tools and my wise mind and Higher Power to deal with them! I am very grateful that I had the opportunity and finance to come here!