Mary Session notes

Categories: Case Notes

Mary is a client of mine with an eating disorder. She weighs in excess of 400 lbs and feels helpless to change this. Attempts to lose weight over the years have failed, and in desperation she has signed up for Bariatric surgery. This is why she is seeing me – the surgical team picked up on the fact that she was stressed out at home and insisted that she get some counseling before they would consider her for treatment. Today she came in after a recent meeting with the Bariatric team dietician. The dietician had learned that Mary ate one meal each day, which is not unusual for many people struggling with obesity. She was going to have to get used to eating a lot more frequently after her surgery, since her stomach would be too small to hold more than a few ounces of food each sitting. The dietician’s suggestion was to try eating much more frequently – five times to be exact. Mary did not have to tell me how this story ended. Experience has taught me that when we try to change our behavior we need to pace things, and start small. How small is small? Well, ideally 5 or 10% change is the limit for really entrenched behaviors, or for increasing activity if we are really out of shape. Going from one to five meals per day is a 500% change. I knew that Mary really didn’t have a snowballs chance in hell of success.

She admitted that it had been a failure. She has lasted about a week, which is pretty impressive for such a big change in a daily habit like eating. I went over what happened, how Mary approached the problem and what went wrong. She admitted that she more or less just drifted back to her usual eating patterns. At this point I usually grab the opportunity and do some education. First, I put Mary’s failure in perspective – it was to be expected, and most people would have done the same thing. This is the truth of the matter. Had I been in her position I would have had the same results. But knowing what I have learned, there is a different approach. If we start with a realistic goal, and a clear plan, we have a much better chance of succeeding at just about anything. Also, if we understand why a plan is so important, it can help. In Mary’s example, we need to recognize that the brain has had a lot of time to settle into a habitual pattern of behavior. Her body has likely adjusted all kinds of its physiologic processes to the single meal model. She likely goes into “starvation mode” for most of the day, which has implications for her blood sugars, appetite, and energy levels. Furthermore, the brain networks that include her self control have likely reset to give her more time in “default thinking”, and less in the kind of thinking that fosters planning and initiating change. This is not something you turn around just by recognizing that there is a problem.

I suggest that starting with a goal of two meals each day is already twice her usual meal times. This is plenty ambitious as a goal, and given that Mary understood now how important it was to respect the power of her habits and take things gradually, it was pretty straightforward to set some new, more realistic goals. Plus this time she could use her android phone to set some reminders, since her memory is not exactly sharp in her present condition. I also showed her how to put a note in her calendar to record her success from day to day. Finally, we discussed how she could fit in a minute each day to review whether he had completed her goals or not. If not, what was the barrier and how would she handle it the next day?

I knew at the end of our session that Mary was going to be okay with this. As we booked her next session, she looked at me and said “you know, I hadn’t thought of it before, but it was when I left my previous job that I gained 200 lbs. In my new job I’m always on the run and its just a lot easier to eat one big meal. I’ve never connected that with my weight gain before..” It’s true. Just as a change for the better can be very small yet significant, a change for the worse can seem trivial. But all too often it is the small stuff that matters.