Lent. Why do we need to give up chocolate?

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A debate; Why do we  give up pleasurable experiences for 40 days?

I noticed something that made me curious today, the day before Shrove Tuesday (Pancake Day).

A debate, on social media, about what to give up for Lent. It struck me as interesting the need to give up something. Lent, traditionally is a period of penance. Penance, making an atonement for a sin, or for having done something regretful.

Cutting a delicious iced chocolate cake

Is the motivation behind giving up something for 40 days actually primarily about seeking penance for a misdeed?

The debate I hear is not ‘What is it I am sorry to have done so I can reflect on and learn from it’ but ‘Which will I be most successful in giving up; wine, cigarettes, chocolate, cakes or biscuits?’

The difference may seem trivial. I wonder if the difference is actually quite crucial.

  1. Giving up something we enjoy. Why would we do that? Is it because there is some belief that self-denial is good? What does stopping doing something you enjoy mean to you? Why do you want to stop doing pleasant things? Have you ever given yourself space to reflect on why giving up something is an important act? Perhaps you are asking yourself what is my guiltiest pleasure. What do I feel bad about enjoying (a paradox in itself)? There are some things we feel guilty about doing. We give up things we enjoy because enjoying them makes us feel guilt. It is interesting that we do not address the guilt. Guilt can be two sided, guilt because we have let ourselves down, the values by which we would like to live by, our authenticity, or guilt because of falling short of perceived expectations of society. Does stopping having pleasure remove the guilt?

Or

  1. Giving up something we enjoy. Why do we do that? An obvious answer, looking at the things most commonly given up, is that it will do us some good. Help us to lose some weight, give our liver a break, a bit of ‘detox’. We give up things that we believe are causing us harm, but there is also a sense we chose things that we will manage to give up for 40 days, avoiding a risk of failure. This is hardly penance! Find me someone who gives up walking to work? There is someone who is challenging themselves, isn’t that more like a penance? Typical Lenten acts do not appear to reflect on a misdemeanor far from it, we find ourselves becoming virtuous, and self-congratulating. Interesting, is this the intention of Lent?

It appears Lent is a period to treat some aspects of the ‘human condition’ the relief of guilt, or possibly an opportunity, which we do not usually indulge in, to pay attention to our health .

Why do we need to do this?

Would it be more helpful to be penitent?

So many questions, and I am not attempting to answer any. Guilt is a universal, existential emotion that pervades our society and has a very significant impact on mental health. It is as if we have responsibility for the cause and suffering of others. We have responsibility for our own actions, and our own self-care; for being authentic to our own standards for living. Creating cycles of enjoyment and self-deprecation, and abstinence is not helpful. We find ourselves not enjoying that which is there for our enjoyment, and preoccupied with worry. Worrying about whether we have the ‘will power’ to abstain from those things we like, but feel guilty for indulging, and to what end?  Does this diminish others’ suffering? No. It creates anxiety for ourselves.

As a psychotherapist with a passion for the attunement of mind and body, may I encourage you, this Lent, that rather than give up something, you give yourself permission to enjoy the things you love. But significantly and, whilst being kind to yourself, you notice when the enjoyment isn’t complete and then stop, and wonder why. Pay attention to your body, your emotions, and feelings. Are you properly understanding what they tell you? Are you being authentic?

It is then that seeds might be sown to facilitate giving up habits that are truly not even enjoyable, but have become a false relief for an emotional dissatisfaction. It is useful to notice what emotions you have, acknowledge their pain or joy, not deny them or impulsively satisfy them inappropriately.

Lent clearly serves a purpose in our secular world. Maybe a little reflection on the purpose of our sacrifices will help us grow to be more authentic; true to ourself.

Obesity; A Man-made Mess

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Health Care Professionals must exhibit true empathy with their ‘over weight’ clients. Judgement and stigmatisation is not helpful.

This blog is a personal reflection of the knowledge I hold regarding obesity and its treatment. Information I have gained as a dietitian and latterly a counsellor. Counsellors generally try to follow three core behaviours; empathy, unconditional positive regard and congruence. It is these that have stimulated my re-evaluation of my beliefs about obesity and created a need for me to hold several positions of understanding all of which contain truths.

It is normal for our understanding of what is true and what is not true to be about facts, and interpretation of data. I see truth as this and more. There is truth in human experience for example. A client sat opposite me, suffering with self-loathing who says;

                                   ‘I just start to eat and just cannot stop’

The client is telling me the truth. That is what they experience. Another parallel truth is that the body responds physiologically to satiety and so individuals know when they are full. Both are true simultaneously.

I am going to identify some of the truths that I believe about obesity. This is a blog. These are my educated beliefs.

Personally held truths

EMOTIONAL TRUTHS

When self-acceptance is dominated by the need to conform to external messages we become less attuned, less able, emotionally and physiologically to be who we are.

There is no such thing as a bad food, a diet that is balanced and varied can include a variety of foods. By this I do not mean a daily diet but a diet taken over weeks.

Labelling foods as ‘good’, ‘bad’, ‘naughty’, ‘rewards’, ‘treats’, ‘healthy’, unhealthy’, ‘forbidden’, ‘wicked’ is unhelpful, and potentially damaging.

We are a complicated animal, our physiological development runs parallel to our emotional one. Issues of self-esteem, self-worth, identity, recognition are all developing as we grow. In families it is common to create an emotional meaning to food, either knowingly or not and this becomes imbedded in our emotional responses as adults.

A simplified example might be the use of sweets as a reward. Because sweets (chocolate, biscuits, cake etc) may not be freely available to a child and are associated with being good a child will become less able to control their consumption using physiological markers and more likely to be influenced by emotional markers. The absence of sweets therefore being associated with negative emotion and their presence a reward. So as an adult in low mood, it is logical to make oneself feel better by giving oneself a reward, (of sweets) just as their parents would, irrespective of hunger.

‘Finish you meal’ A young child (age 1-3 ) eating to appetite-(i.e. using physiological cues) may leave food on his plate. A parent, for one of many reasons does not want this. The child who is also learning about the affect his responses have on receiving attention from his care-giver, is encouraged to finish his plate. Instead of affirmation that he knows when his body is satiated (i.e. allowed to leave food) he is encouraged to over-ride this by finishing his meal in order to get affirmation from another. He is being taught how food can manipulate others, and/or that finishing food beyond satiety pleases those he cares about. These messages become embedded and may not even be part of our conscious decision making by the time we come to adulthood.

These are two simplified examples of what might go on in childhood that has a profound affect of appetite control in adulthood. Instead of labelling them as greed and lack of self –control, perhaps HCPs think of these as examples of self-soothing, or self-affirming behaviours.

Knowledge of food and good nutrition is empowering

  • Mothers-It is our mothers, or primary care providers, who significantly influence our food choices throughout life. A mother with an adequate knowledge of nutrition and meal planning will provide experiences and habits that are reinforced throughout childhood
  • School- The curriculum can teach children about health, and this can be reinforced by the provision of appropriate food in the school environment.
  • Families-Awareness of cross-generation food preferences provides opportunity to create and sustain a varied diet, incorporating a variety of foods and cooking methods.
  • Ill health- Often this provides a motivator to be curious about optimising health, empowering individuals to take control of health, exercise and diet
  • Work place-Reinforcement of positive food choices
  • Public Health messages-By which I mean consistent, easily accessible information- for those who want to learn, feel able to change, are literate and motivated. Is an useful way to advice on evidence based dietary guidelines.

The regular supply of a varied diet throughout the life cycle without recourse to bribery or reward, would greatly enhance the normalising of food.

Lack of knowledge does not directly cause obesity

It would be paradoxical to believe the body is able to control energy intake and also believe individuals are not able to control their intake through lack of knowledge of nutrition.

Energy balance

Individuals gain weight if they consume more energy than their body requires over a long period of time

                    Energy intake =Energy output=Weight maintenance

Physiologically control

There are ways in which the body has evolved to control energy intake. These include muscle receptors along the gastrointestinal tract, secretion of regulatory hormones, nerve stimulation and brain involvement and several endocrine functions.

Breast feeding- There is a link between breast fed infants and decreased incidence of obesity. I believe the cause is multi-factorial, some factors being:

  • Demand feeding-The infant demonstrates an ability to react to hunger and satiety
  • The infants success at being fed to appetite is positively reinforced-the infant ‘learns’ to trust his body.
  • The mother responds at a physiological level to provide the necessary nutrients
  • The mother responds at an emotional level to positively reinforce that she is able to respond to the infants needs timely and appropriately. The supply of food is met without creating emotional stress or anxiety from either infant or mother.
  • The composition of breast milk is appropriate for the growing infant.

 Other factors that inhibit or prevent or disguise our ability to control physiologically our energy balance.

External factors

  • The food industry-Expansive food choice, manufacturing methods, marketing, additives-colour, flavour, and preservatives all these and more serve to stimulate desire for foods outwith physiological need.
  • The glamour industry-How an idealised body shape, both for men and women detracts from the beautiful array of healthy shapes and sizes that men and women naturally have, these become unacceptable especially to those with low self-esteem and self-worth. We only need to look at other cultures and through history to appreciate how our interpretation of a ‘beautiful’ shape and sized body is a societal concept not a health one.
  • The health industry- Obesity has become a disease measured by a scale created for insurance purposes. It has made the assumption that there is a direct correlation with weight and health for all resulting in the belief all people with a BMI (for example) of 27 are equally as ‘unhealthy’. This belief is rarely challenged.

So what?

There will be individuals, physically fit and healthy with a BMI of 27, a proportion will have low self-esteem, a poor sense of self-worth, and generally not feel good about their size- (after all society teaches them it is ‘bad’). Assuming they can actually control their weight perfectly adequately using physiological markers, there self-worth is undermined by external factors and they begin dieting. They are told they are unhealthy! Foods that were once enjoyed and managed become ‘naughty, bad, denied’ and then craved. Their weight yoyos. Ironically it is this yo-yoing in weight that is more harmful than obesity per se. So the diet industry and our obsession with the perfect form and an inappropriate non-reflective use of BMI as a measure of health have made low self esteem into an obesity problem.

Just this month (Jan 2015) research from Cambridge has provided evidence that inactivity is more significant than obesity in increasing mortality rates. http://www.cam.ac.uk/research/news/lack-of-exercise-responsible-for-twice-as-many-deaths-as-obesity

As a counsellor and dietitian my approach to clients who want to change their eating habits, is to first help them love and honour themselves. In time, with support and empathic challenging their emotional hunger will not need to be satisfied by diet, and their self-esteem not affected by inappropriate stereotypes.

The weight loss industry should perhaps begin to feel some responsibility for its perpetuation of the false idea that obesity is self-inflicted, and begin to offer empathy and positive regard for those it serves.

I endorse regular activity and a varied balanced diet as a means to good health.

The Johari Window and Improving our Understanding of our Patients

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Joseph Luft and Harrington Ingham in 1955 created this ‘Window’ concept to understand how individuals work  within teams and to improve productivity, communication and collaborative working. It is frequently used within counselling to explore self awareness.

It is a metaphor for displaying ourselves, drawing on ideas of visibility and transparency as well as curtaining off areas to keep them protected from on lookers who may mean harm.

I wonder if this tool can also be used to understand the complexity of the patient presenting to their doctor or Health Care Professional (HCP)?

The Open Quadrant

The transparent two way picture.

This is what the patient is willing and able to show to their doctor. But what is it that the doctor believes they are being shown? And what are they willing to see? The picture is quite a simple discrete one, I believe that too often the view for the doctor and HCP is the illness and  treatment for which their patient has been diagnosed. This is not necessarily so for the patient, their presenting picture; what they make visible, may be quite different, not even on the radar of the doctor or HCP. For example they may be showing as an anxious parent unsure of their ability to provide for their children, a highly paid business man who is in denial  ‘not very ill at all’. So  despite this quadrant being ‘open’, and that our patient willing to disclose some of them self, is the same picture being seen by the doctor? Is the doctor, only looking to see a patient with an illness, not a person?

The Blind Quadrant

This area is designed to represent what the other person can see but the patient themselves cannot see. I have  interpreted this slightly differently to emphasise the knowledge the HCP or doctor has about the patient because of their illness.

This area is saturated by the doctor’s knowledge about the patient’s diagnosis, prognosis, and expected complications. So they see, or focus on their own intelligence and ‘dump’ it on the patient. Whether they are able to tune into other aspects of the patient ( not their illness) such as their bravado, courage, or fear,  would provide potential for an improved empathic relationship. Do the blind and open quadrants merge, the patient becoming the illness, detached from the person?

Perhaps the doctor too is being blind?

The Secret Quadrant

This is describing the things the patient is keeping well guarded and hidden from the HCP or doctor who will be completely unaware of them.

An acknowledgement by HCP’s that they in fact are not being presented with the whole of their patient and the patient is concealing aspects of themselves may be useful. It may be relevant to reflect: what is my patient hiding from me?Is this related to their illness?  The situation, environment? Am I being presented with the whole person? How can I facilitate openness? What impact will this have on concordance? Self management?

The Hidden Quadrant

Neither the HCP nor the patient knows what is hidden. But by providing space to explore the potential for understanding how the patient’s illness is impacting on relationships, behaviours and emotions will only serve to increase the potential for our patient to modify their behaviour  to help them reach the potential they hope for themselves. So facilitating the exploration of anxiety, poor sleep patterns, bad dreams and other negative characteristics may prove beneficial for physical health and the relationship between patient and HCP/ doctor,  and patient and their illness.

Johari-Window-Medical-Model

I would just like to conclude that there are missed opportunities within the NHS care settings that deny the patient the opportunity to be truly known by health care professionals such as doctors, who claim to wish to do patients no harm and yet understand very little about the patient they wish to avoid harming.

Is the medical model the right way to support people with long term medical conditions?

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I am writing this as a concerned health professional with experience of the NHS for over two decades and also as a psychotherapist, with an appreciation of why individuals may behave contrary, to what might be thought of, as against their best interest. My thoughts are my own. I have used the term ‘patient’ reluctantly; this term, inherent in the medical model is probably the most familiar to my readers.

BLOG003cThe first paradox I encounter is that the medical model extrapolates clinical evidence obtained from Randomized Controlled Trials (RCT) to individuals. Is it appropriate to apply objective data (data aiming to be objective) directly to an individual subject?

Secondly the general assumption of the medical model is that the ‘patient’ wants his illness to progress slowly to maximise life expectancy, and consequently there is an implicit power differential that the health professional has the knowledge to help the patient achieve this outcome.

Thirdly this implicit power differential can be disempowering for the ‘patient’, this can have a variety of consequences:-

  1. He rebels against the health professional and so behaves contrary to advised,BLOG003
  2. He submits to the Health Professional; complies but is not doing so for themselves and so may become angry, frustrated, depressed or rebellious
  3. He becomes dependent on the Health Professional and loses self autonomy
  4. He avoids the situation; begins to fail to attend and aims to manage their illness on their own,
  5. It can prevent a significant number of ‘patients’ from asking personal or challenging questions, resulting in dissatisfaction.
  6. It creates additional barriers to forming healthy, useful relationships, ‘patients’ being labelled as ‘poor attendees’ ‘non-compliant’, ‘troublesome’, ‘time consuming’ and sometimes relatives also being labelled similarly.

Finally (in this blog at least) the NHS does not appear; yet, to add equal weighting to  Patient Reported Outcome Measures (PROMs) compared to mortality rates or length of hospital stay, as a measure of its success.

BLOG003bThe outcome of the medical model, to varying degrees is that individuals with long term conditions have an increased incidence of mental illness, unemployment, and reliance on others for financial support, the latter most likely due to lack of independence but, ironically, on the positive, possibly live longer than had they not had health care input.

Health professionals declare that they should knowingly do no harm. Currently interpreted as insuring the ‘patient’ has been provided with everything they need to know (within their capacity) regarding how to manage their illness appropriately, and which medication to take. Is failure to provide this unasked for information being negligent? I have indicated doing so may in fact cause more harm than not.

What is the alternative?

It is difficult to change a culture. As I see it there are two factors that need addressing. The first is the power and authority that is given to knowledge by health professionals. Knowledge is only valuable to those that seek it. An individual will value knowledge about his illness when he has sought it and that is likely to be when he will find it applicable and appropriate for his own personal needs. As health professionals we need a new set of skills. We need to know how to use our ‘expensive’ time to listen to the person sat facing us, and hear them as a fellow human being who has to deal with what might colloquially be called ‘crap’ and then give them the information they ask for and is relevant for them. This month NICE has introduced a new guidance, on Behaviour Change, which may help http://guidance.nice.org.uk/PHG/55

Secondly, there are many theories regarding the roles we create for ourselves, our need to fit into social norms-conforming; they can be below the surface or in the sub conscious. One of these is the relationship between patient and doctor/ health professional. I described this relationship as one about power earlier. I do wonder whether we used different labels, ‘patients’ became people and doctors or health care providers were ‘advisers’, as any other advisor, available when needed. Not thrust upon us like a PPI sales man.

I am aware, people do not know what they do not know, and this can be where my ideology fails. May I just pose that we, Health Professionals- need to shift our priorities from informing to listening?