INTRODUCTION

Overweight and obesity are the fifth leading risk factor for death worldwide, killing at least 2.8 million adults each year. The majority of obesity cases are of multifactorial origin and include genetic, metabolic, endocrinological, and environmental factors.

We can distinguish two types of obesity:

• Endogenous obesity has internal causes and is generated, among others, by problems such as hypothyroidism, diabetes, polycystic ovary or hypogonadism. When we speak of endogenous causes, we usually refer to endocrine obesity. This type of obesity is caused by the dysfunction of an endocrine gland, such as the thyroid. It usually accounts for a minimum percentage (2-3%) of people who suffer from obesity.

• Exogenous obesity has a psychological or emotional origin. Nowadays, it is the most common form of obesity and mainly occurs due to excessive consumption of food, certain eating habits, and/or undiagnosed eating disorders such as hyperphagia or binge-eating disorder. It is also associated with affective disorders such as depression and anxiety. This type of obesity represents 90-95% of obesity cases.

One of the difficulties that many therapists encounter is organizing the treatment with these patients. First, because it was believed for a long time that it was a disease that had no place in psychology centers, which was due to the view that the origin was either genetic or organic. Second, because people who requested psychotherapy for this problem did not receive specific treatment due to a lack of knowledge on the part of the professional. Although the work with people suffering from endogenous obesity will be briefly described, this article will emphasize the approach for exogenous obesity, with a psychogenic basis.

Our goal is to help clarify the questions that arise regarding the treatment of these people and the difficulties that may ensue. We insist on the importance of learning to conceptualize the case and develop an adequate treatment plan for the person with obesity. The treatment plan includes the phase of collecting the patient's history, as well as phases in which the work focuses on softening the patient's defense system. This is a specific procedure that allows access to the processing and integration of memories of certain life experiences, which sustain the disease.

EATING DISORDERS AND OBESITY

When talking about exogenous obesity, it is necessary to refer to the eating disorders (ED) that are usually associated with people with obesity. In most cases, there are serious problems in the relationship between patient and food. Among the most common ED, we can mention the following:

• Binge Eating Disorder. Characterized by binge eating –sometimes several times a day– in which the person can ingest large quantities of food in a short period of time. The calories ingested are not compensated with any other activity. The binges are related to external triggers that activate parts in the internal world of the person, which leads them to eat to calm down and regulate themselves emotionally.

• Hyperphagia. This diagnosis refers to someone who only concentrates on eating. The desire to eat is enhanced or uncontrolled since they eat at any time and even after having eaten properly. There is an excessive intake as a reaction to stressful situations which often leads to obesity, especially in people predisposed to gaining weight.

• Nocturnal Eating Syndrome. It consists of food intake at night, which is manifested either by eating when waking from sleep in the middle of the night or by excessive consumption of food after dinner. There is awareness and memory of the intake.

THERAPEUTIC OBJECTIVES OF WORKING WITH OBESITY

Therapy for obesity focuses on those experiences of attachment or of traumatic events where the person learned to manage their discomfort through food. The goal is to understand the effect of these adverse life experiences, in order to treat a disease classified as chronic and with few possibilities for improvement.

According to the type of obesity, the objectives –which will be of main importance in the work with these patients– differ. The main objectives in working with endogenous obesity are:

• Regain motivation to foster self-care.

• Work with the defense of the "lack of disease awareness," which means that the person does not recognize that they are sick and, thus, avoid self-care.

• Improve and encourage self-concept, which can be so damaged in these people.

• Process events that may be associated with the disease.

• Work with the body and the perception of it.

In order to work with exogenous obesity, an approach that integrates issues of attachment, trauma, and dissociation is proposed. These are the pillars which support the disease when the basis is not organic. In this case, the proposed objectives include:

• Outline a treatment plan to get access to those life events that have resulted in the disease.

• Identify urge regarding food (the urge to eat).

• Identify those triggers that activate compensation for food intake.

• Identify the defenses that block access to the internal world of the person and, therefore, to the development of therapy.

• Identify the exceptions, those moments in which the person was able to regulate the food intake.

• Identify resources that help the person to stabilize.

AN OBESITY APPROACH FROM THE WORK WITH ATTACHMENT, TRAUMA, AND DISSOCIATION

The proposed approach combines working with attachment, trauma, and dissociation. These three pillars are essential to develop the therapeutic treatment for obesity. When treating attachment, trauma, and dissociation, we cover all those aspects that influence both the appearance of the disease and its development. Many of the cases of obesity find their origin in an attachment disorder since food ends up associated with adverse life experience. In other cases, food becomes the way in which the person learns to survive traumatic experiences and, in others, food is the means through which the person connects with the dissociative experience to regulate themselves or disconnect.

Attachment

Attachment in exogenous obesity is key, since it is one of the three pillars by which the disease is supported and which determines its origin.

Bowlby (1969) proposed that attachment is a specific aspect of the relationship between the child and the attachment figure (usually the mother). This relationship is asymmetric: the mother provides care and the child depends on her. Attachment is the product of the activity of numerous behavioral systems, composed of behaviors such as crying, smiling, following, etc. The common goal of these behaviors is to achieve the proximity, safety, and protection of the attachment figure, which are the three characteristics and functions that define attachment.

• Searching for proximity is defined as any behavior of the child aimed at seeking and maintaining closeness with the figure of attachment.

• Safety refers to the child's ability to use the figure of attachment as a source of comfort in situations in which it is required.

• Protection refers to the child's ability to use the figure of attachment as a source of safety (a secure base) (Bowlby, 1969; Hazan & Shaver, 1994).

According to Bowlby (1969), the repetition of these behaviors reveals the predominant attachment pattern the child has with the mother, which can be different with other people, such as the father or grandparents. The type of attachment can be constant over time and can influence the way people relate to others throughout their life. It is known that when a person has a secure attachment pattern in childhood, their social interactions are adequate and their levels of stress and anxiety low. In contrast, when they have an insecure attachment pattern, they tend to have problems relating to others, and high levels of stress and anxiety.

Attachment styles are also present in adulthood. Insecure (anxious and avoidant) attachment styles in adults have been related to family adversity, psychological development, and self-regulation of the child's behavior (Fröhlich, Pott, Albayrak, Hebebrand, & Pauli-Pott, 2011). Since the mother is usually the primary caregiver, it becomes relevant to address the relationship between the child's attachment pattern and the maternal one. Parents, especially the mother, create the environment in which the child grows up. This influences the child’s eating patterns (Phrase, Skouteris, McCabe, Ricciardelli, Milgrom, & Baur, 2011; May, Alen, Kateryna, & Ming Chin, 2012; Ihmels et al., 2009).

Of particular relevance to this article is the fact that the parents' insecure attachment styles have been linked to obesity in their children (Anderson, Gooze, Lemeshow, & Whitaker, 2012; Pott, Albayrak, Hebebrand & Pauli-Pott, 2009; Trombini et al., 2003).

In people who suffer from obesity, there is a direct causal relationship between childhood experiences and their regulation strategies through food. In clinical field work –and associated with the regulation factor in the relationship with the main attachment figure– it is frequently observed that food is an activating element of the secure base. There are several characteristics of attachment in obesity, which are described below:

• When the attachment figure is overfeeding the child (Seijo, 2015) and feeds to regulate themselves and the child.

• The relationship between food and attachment experiences.

• When food covers unmeet attachment needs.

• When the mother has a problem with food and her body and projects it on her child.

Dissociation

Dissociation may be present at different levels in people who are obese. It is essential to know how to identify and diagnose it in order to carry out a proper case conceptualization and a treatment plan. To understand the patient's inner world –where the different aspects, states or parts of the personality will be shown–, the therapist can do a simple exercise that consists of drawing a circle on a blank sheet of paper and asking the patient to draw the different parts or aspects that represent her. There are also other techniques through which the internal world can be represented, and all of them are valid, as long as they allow us to talk about those internal parts, since through them we can enter into the person’s inner world.

The parts or aspects of the personality that we usually find in the inner world of these patients and to which we must pay special attention are:

• The Fat Self (Seijo, 2013). It is the part that is related to the rejection of the body and is the most resistant to change during treatment. The therapist has to understand the meaning of this part in order to see how the whole dissociative structure that influences the disease has been generated.

• The child who could not grow up (Seijo, 2012). This is the part that did not have an adequate maturative development and shows behaviors that do not fit with the biological age of the person. It is an aspect of the personality that leads the person to defend themselves by being complacent and that, instead of expressing what they feel, they eat.

• The Hidden Self. It is the part that protects the internal system by hiding. It tends not to expose itself, not to show itself, because in the past it could have been threatening or dangerous to do so. Staying in the shadows is the safest thing to do. It is closely associated with the body, and it is the part of the person that somaticizes what cannot be expressed in any other way. We can understand this part with examples of some patient comments. “I think my fatness has helped me to hide inside myself. It's like I put on layers and layers of fat to protect myself. So, no man can be attracted to me and do to me what he did to me that left me so damaged,” said one patient when she became aware of her father's childhood sexual abuse during a session. Another version of the hidden self is evident in another patient's comments: “My needs were never met, and I always had the belief that there was no place for me in the world. By being obese, I would be seen, even if it was at my own expense.”

In this type of patient with obesity, we usually find the following types of dissociation:

• Somatic Dissociation. The body itself is felt as alien, as something external, even sometimes felt as “the enemy.” Examples of this type of disassociation could be expressed as: “This (pointing to the body) is what does not let me live” or “this body is what I got, and I live trapped in it.”

• Somatoform Dissociation. This type of dissociation differs from somatic dissociation in that there is no distorted perception of the body. The person projects her discomfort on a physical level.

• Depersonalization. Persistent or recurrent experiences of detachment, as if one were an external observer of one's own mental and physical process, as if the person were dreaming. There is a sense of unreality of oneself or one's body. Suzette Boon (2017) classifies as mild or more common symptoms feeling strange, unreal or disconnected from oneself; feeling or behaving like “on autopilot” or like a robot, and feeling disconnected from emotions or dull. Severe symptoms of depersonalization include somatoform depersonalization (sensation of disconnection from the body, to the point of not being able to feel the body or parts of it) and psychoform depersonalization (experience of being outside the body).

• Dissociative Fantasy (Seijo, 2012). It usually goes unnoticed unless the clinician can identify it. It has a protective function and emerges at very early ages as a refuge or safe place to avoid suffering. It is the favorite refuge of the hidden self, who learned to protect herself by hiding.

ANOTHER KEY POINT IN WORKING WITH OBESITY: THE BODY

The body is associated with negative life experiences, and that is where the disease is somaticized. This can be seen very clearly in the beliefs mentioned above of the “maybe-I-fatten-up-to-hide” style. The work with the body, the rejection and shame towards it, becomes indispensable. In people who are obese, the body expresses life experiences through weight. For these people, the body is the enemy, as it is the cause of social mockery and humiliation. Being obese generates enormous social pressure, as well as a series of important handicaps such as clothes or seats in public places, such as airplanes. It may also just be that the first insult that an obese person receives in any conflictive situation is, unfortunately, related to the body.

With obesity, the body is one of the most damaged parts. Physically, the weight changes caused by the extreme diets they underwent throughout their lives cause scars that are sometimes rather intense and difficult to disguise, such as stretch marks or tissue sagging. All this is damaging to a person's self-esteem and social life. They need help to repair them by working with compassion, acceptance, and coping skills. The objective is always to promote self-care, helping the person to stop associating with food what it is not naturally associated with, such as the compensation of the emotional states as described earlier. In this way, a healthy integration of food can be achieved.

SUMMARY

This article describes the key points that must be taken into account in the treatment of obesity in order to obtain good therapeutic results. Unfortunately, psychotherapeutic treatments with obesity lack these fundamental principles that meet the needs of patients. Meeting these needs becomes the foundation for good work and a successful treatment plan. Without it, many patients, with their sense of learned helplessness, begin unsuccessful diets and treatments that lead to drop-outs, time and time again.

BIBLIOGRAPHIC REFERENCES

Seijo, N. (2015). Treating Obesity with EMDR Therapy. Workshop presented at the EMDR National Conference in Madrid, Spain.
Seijo, N. (2015). Eating Disorders and Dissociation. ESTD Newsletter. Vol. 4, number 1.
Seijo, N. (2016). The Rejected Self: Working with Body Image Distortion in Eating Disorders. ESTD Newsletter. Vol. 5, number 4.
Seijo, N. (2015). Las Defensas Somáticas en EMDR. Máster de EMDR. Universidad Nacional de Educación a Distancia (UNED).
Seijo, N. (2016). EMDR Protocol for Eating Disorders. In M. Luber (Ed.) Eye Movement Desensitization and Reprocessing EMDR Therapy: Scripted Protocols and Summary Sheets. New York: Springer Publishing Company. (in press).
Seijo, N. (2016). EMDR Protocol for Body Image Distortion: The Rejected Self. In M. Luber (Ed.) Eye Movement Desensitization and Reprocessing EMDR Therapy: Scripted Protocols and Summary Sheets. New York: Springer Publishing Company. (in press).
Seijo, N. (2009). EMDR in Complex Trauma and Dissociative Disorders. Annual EMDRIA Conference. Atlanta.
Seijo, N. (2015). Treating Eating Disorders with EMDR therapy. EMDR International Association Conference. Philadelphia.
https://es.scribd.com/doc/49998539/Obesidad-exogena-y-endogena
(Saakvitne, K. 2000) Childhood Mental Health Consultation.
https://www.ecmhc.org/tutorials/trauma/mod1_1.html Centre for Early
Renn, P. (2006). Aggression and Destructiveness: Psychoanalytic Perspectives. New York: Routledge. In: C. Harding (Ed.)
Bromberg, P. (2001). Treating Patients with Symptoms and Symptoms with Patience: Reflections on Shame, Dissociation, and Eating Disorders. ISSN: 1048-1885 (Print) 1940-9222 (Online) Journal homepage: http://www.tandfonline.com/loi/hpsd20