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Hypnosis and Weight Reduction: Which is the Cart and Which is the Horse? Gordon Cochrane Ed.D. Published online: 21 Sep 2011.
To cite this article: Gordon Cochrane Ed.D. (1992) Hypnosis and Weight Reduction: Which is the Cart and Which is the Horse?, American Journal of Clinical Hypnosis, 35:2, 109-118, DOI: 10.1080/00029157.1992.10402993 To link to this article: http://dx.doi.org/10.1080/00029157.1992.10402993
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AMERICAN JOURNAL OF CLINICAL HYPNOSIS VOLUME
35,
NUMBER
2,
OcTOBER
1992
Hypnosis and Weight Reduction: Which is the Cart and Which is the Horse?
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Gordon Cochrane Vancouver, British Columbia
Hypnosis has often been described as a useful adjunctive treatment for excess weight. However, the literature shows that very few controlled studies have been conducted in this realm, and none have incorporated the key variables of either the hypnosis components or the weight-reduction components. In this paper I offer a brief review of the literature on hypnosis for weight reduction, present weight-reduction outcome data, outline variables common to people with chronic weight problems, and I offer suggestions for future uses of hypnosis within a comprehensive approach to weight reduction rather than as the primary treatment. Suggestions are also made concerning the multiple opportunities for future research using hypnosis in the substance-abuse field.
Hypnosis has long been considered an appropriate treatment tool for weight reduction, and some individuals have made some startling claims about its efficacy. However, when Mott and Roberts (1979) reviewed the literature on hypnosis for weight reduction they found that the research at that time did not exist to substantiate its effectiveness. They found the literature dominated by anecdotal reports, making interpretation difficult, and because essential follow-up data were not
For reprints write to Gordon J. Cochrane, Ed.D., 2095 W. 45th Ave., Vancouver, B.C., V6M 2H8, Canada. Received November 12, 1991; revised March 4, 1992; second revision July 9, 1992; accepted for publication July 13, 1992.
presented, it was impossible to assess lasting results. The hypnosis interventions employed in the literature were not described clearly, making it impossible to identify which aspects of the hypnotherapy were useful and which were not. The mosaic of variables that comprised weight problems and any common characteristics of the people with these problems (Olefsky, 1980) were ignored. In the years since the Mott and Roberts' (1979) review, there has been extensive research published on obesity, on the specifics of weight reduction, and on the characteristics of people with weight problems. However, there have been very few publications involving hypnosis for weight reduction within this time frame (Andersen, 1985; Cochrane, 1987; Cochrane & Friesen, 1986; Deyoub, 1980; Deyoub & Wilke, 1980; Wadden & Flaxman, 1981). 109
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It does appear that hypnosis has potential in the weight-loss realm (Andersen, 1985; Bolocofsky, Spinler, & Coulthard-Morris, 1985; Cochrane, 1987; Cochrane & Friesen, 1986), but much research remains to be done. Some writers (Bolocofsky, Spinler, & Coulthard-Morris, 1985; Udolf, 1987) suggest that hypnosis can be used as an adjunct to weight-loss treatment, but even they don't comment on the complexities of weight problems and the consequent multi-faceted treatment models required to address this problem (Grilo, Shiffman, & Wing, 1989; Heatherton & Baumeister, 1991; Perri, McAdoo, McAllister, Lauer, & Yancey, 1986; Williamson, Kelley, Davis, Ruggiero, & Blouin, 1985). In this paper I provide a summary of the mainstream weight-reduction literature from the last decade and then review the literature involving hypnosis in weight reduction. This dual review demonstrates the need to respect the multi-faceted complexity of weight reduction and to adapt hypnosis interventions to this complexity.
Weight Reduction: A Review The most consistent pattern arising from the weight-reduction literature is that of minimal long-term success. Wing and Jeffery (1979) compared short-term and long-term outcome data from a compilation of diet programs, exercise, behavior therapy, and medication treatments. All of the models showed promising shortterm results, but the follow-up data, much of which was gathered after a relatively short follow-up time, showed a mean weight gain for each approach with one exception: Behavioral therapy showed, across 33 studies and 981 subjects, a mean weight loss of one pound. There was no follow-up done for the exercise approach,
but regular exercise has been found (Perri et al., 1986) to be a key aspect of lasting weight reduction. Numerous studies (Baumeister& Scher, 1988; Brownwell, Marlatt, Lichenstein, & Wilson, 1986; Grilo, Shiffman, & Wing, 1989; Heatherton, Herman & Polivy, 1991; Herman, Polivy, Lank, & Heatherton, 1987; Leung, Steiger, & Puentes-Neuman, 1991; Rodin, Elias, Silberstein, & Wagner, 1988; Simmons, 1986; Wardle & Beales, 1988) indicate that the vast majority of people who take an extreme approach to weight loss regain quite rapidly as much or more weight than they lost. Grilo et al. (1989) state that 90-95% regain their lost weight regardless of the length of treatment time. A possible explanation for the generally dismal outcome data from weightreduction programs is that weight loss has traditionally been considered by many to be a homogenous issue. Treatments were designed and evaluated primarily upon initial measured weight loss with limited consideration of multiple contributing variables. Substance abuse in the form of alcoholism and drug addiction was considered much more complex than weight reduction, yet the outcome data has been consistently better with these substances than with food (Brownwell et al., 1986; Duffy & Hall, 1988; Grilo et al., 1989). This unfortunate attitude, which spawned such phrases as "just do it," "just exercise more and eat less," and "just push yourself away from the table," is being replaced with a more comprehensive perspective (Heatherton & Baumeister, 1991) that recognizes lasting weight loss as complex, difficult, and worthy of respect by practitioners and those who suffer with the problem. Diet programs have not fared well in the literature, and the more rigid the pro-
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gram the more negative the results (Grilo et al., 1989; Heatherton et al., 1991; Rodin et al., 1988; Wardle & Beales, 1988). The perfectionism and compulsiveness that plague so many dieters combined with body-image problems and a desire for immediate results generally leads to failure, disappointment, damaged self-esteem, and depression (Herman et al., 1987; Lorr & Wunderlich, 1988; Wardle & Beales, 1988). The same success-failure pattern also generally applies to exercise (Yates, 1991, p. 4), in that the more extreme the approach the greater the probability that it will be abandoned. Many overweight people struggle with accompanying problems that either directly or indirectly complicate their weightreduction efforts. Family of origin and social problems including rejection, alcoholism, low self-worth, and emotional and physical abuse appear to make any attempt to isolate weight reduction from accompanying life issues quite futile (Bronwell et al., 1986; Cochrane, 1987; Heatherton & Baumeister, 1991; Herman et al., 1987; Humphrey, 1986; Mellin, 1987; Pike & Rodin, 1991; Stammer, 1988). Grilo and Pogue-Geile (1991) suggest that genetics playa very important role in obesity, making the issue even more tenacious. Characteristics of Those Who Struggle Many overweight people, possibly as a consequence of their experiences with weight-related prejudice, ostracism, rejection, and humiliation as overweight children and adults (Beach, Freeman, & Koopman, 1991; Cochrane, 1987; Mizes, 1988; Pike & Rodin, 1991), exhibit patterns of rebelliousness, anger, hypersensitivity, and difficulty with authority figures (Kolotkin, Revis, Kirkley, & Janik, 1987; Scott & Baroffio, 1986). Consequently, a
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directive treatment model is often met with overt rebelliousness or covert rebelliousness expressed through quiet noncompliance. It is interesting to note that people with a chronic weight problem have, coexisting with this tendency to rebel when told what to do, a diminished sense of self-esteem, self-confidence, and personal power, which leads them to look outside of self for solutions to their weight problems (Clark, Abrams, Niaura, Eaton, & Rossi, 1991; Grace, Jacobson, & Eulager, 1985; Grilo et al., 1989; Kolotkin et al., 1987; Lorr & Wunderlich, 1988; McGree, Herman, Freedman, & Pliner, 1991; Mizes, 1988; Scott & Baroffio, 1986; Williamson et al., 1985). For some individuals this reduced sense of personal esteem, power, and optimism is primarily a consequence of many unsuccessful efforts to sustain weight reduction. For others the damage to self occurred in the family of origin, in adolescence, or in more recent interpersonal settings, and weight gain was reactiveratherthan causal (Leung et al., 1991), but once a weight problem develops it also contributes to the diminished sense of self. Overeating can be viewed from the diathesis/stress model of coping. Under stress some people tum to alcohol, drugs, work, sex, spending, food, or any activity or combination of activities that sedates, distracts one's attention, or gives a temporary sense ofcontrol (Baumeister & Scher, 1988; Beckwith, 1986; Duffy & Hall, 1988; Heatherton & Baumeister, 1991; Herman et al., 1987; Scott & Baroffio, 1986; Stammer, 1988). Unlike most substances and behaviors in this model, food is necessary for life and cannot be avoided, and therefore an overweight person can be compared to an alcoholic attempting to become a controlled drinker. Common across the diathesis/stress model are denial, avoid-
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ance of feelings and cognitive awareness, distortion of information, cognitive narrowing, and poor problem-solving skills (Baumeister & Scher, 1988; Beckwith, 1986; Brownwell et al., 1986; Grilo et al., 1989; Heatherton & Baumeister, 1991; Jacob, Krahn, & Leonard, 1991), which make weight reduction extremely difficult. Women tend to be more preoccupied with weight reduction than are men (Cantrell & Ellis, 1991; McAvoy & Fried, 1991; Penner, Thompson, & Coovert, 1991; Pike & Rodin, 1991), but both sexes struggle with perfectionism and the low self-esteem from which perfectionism arises (Cantrell & Ellis, 1991; Marcus, Wing, & Hopkins, 1988; Mizes, 1988). When a person is reasonably content with herself/himself, perfectionism is usually not an issue. However, our culture places relentless pressure on women to conform to a physical, behavioral, and attitudinal model that contributes to body-image distortions. Women perceive their body as larger and heavier than it actually is (Butters & Cash, 1987; Penner, Thompson, & Coovert, 1991; Scott & Baroffio, 1986; Simmons, 1986) and consequently feel inadequate, which leads to excessive dieting, exercise, and binge eating for many. This perceived failure to adhere to a societal ideal can contribute to social anxieties, inhibitions, and sexual problems among overweight women (Grace et al., 1985; Simmons, 1986; Stammer, 1988). For some, the nonacceptance ofone's body can generalize to a broader sense of "I am fat, therefore I am worthless" (Butters & Cash, 1987). The traditional female role has also encouraged women to be care-givers, consistently placing the needs of others before their own and thereby abandoning their
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weight-loss efforts when called upon to serve others. It also encourages women to value beauty because this model suggests that successful men want attractive partners, and successful men in tum offer security. Within this cultural milieu women have learned to ascribe their successes to luck, to others, or to outside sources (Beach et al., 1991; Butters & Cash, 1987). These many variables can create a powerful dilemma for overweight women when they attempt to lose weight. Some become angry and rebel against the social pressure to be slim, but most simultaneously sustain a desire to be slim and consequently experience an internal struggle (Baumeister & Scher, 1988; Cochrane, 1987; Scott & Baroffio, 1986) sometimes known as the "must-but-cannot dilemma." Others experience this dilemma as a fear of success (Baumeister & Scher, 1988), and some fear the social/sexual consequences of such success (Brownwell et al., 1986; Cochrane, 1987). Any situation that is experienced as negative and chronic can become depressing, and depression is a characteristic common to many people with a weight problem (Grilo et al., 1989; Kolotkin et al., 1987; Leung et al., 1991; Marcus et al., 1988; Mizes, 1988; Schlesier-Carter, Hamilton, O'Neil, Lydiard, & Malcolm, 1989). In some cases depression seems to be a causal component of the person's weight problem, and for others it seems to be a consequence of the chronic weight problem (Heatherton & Baumeister, 1991; Leung et al., 1991). The combination of hopelessness and helplessness that are the pillars of situational depression and an external locus of control (Clark et al., 1991) make a significant contribution to the dismal outcomes in long-term weight reduction.
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Characteristics of Those Who Succeed Whereas no individual demonstrates all ofthe described problematic characteristics common to people with weight problems, and whereas each individual has a unique understanding of her/his problem (Cochrane, 1991; Mahoney & Lyddon, 1988), there are some general characteristics common to those who do succeed. Most successful weight losers have a sound knowledge of diet and nutrition, including simple principles such as the extremely effective manner in which the human body converts animal fats such as dairy products into stored body fat. Most recognize that extreme dieting and/or exercising ultimately fails (Heatherton et aI., 1991; Herman et al., 1987; Rodin, Elias, Silberstein, & Wagner, 1988; Wardle & Beales, 1988), though they do accept the need for regular exercise and attention to diet (Cochrane, 1987; Perri et al., 1986). Possibly the most important feature of those who succeed at lasting weight reduction is their sense of personal empowerment, self-worth, and self-esteem (Bandura, 1989; Clark et al., 1991; Cochrane, 1987; Grace et al., 1985; Grilo et al., 1989; Lorr & Wunderlich, 1988; Mizes, 1988; Perri et al., 1986; Rodin et al., 1988; Schwartz & Inbar-Saban, 1988; Scott & Baroffio, 1986). Self-worth is the sense of personal worthiness that is exclusive of accomplishments; self-esteem is the feeling that arises from acknowledging and owning one's achievements. Personal empowerment is the faith one has in her/his abilities and strengths to succeed at life's tasks. Those who achieve lasting success are ready and willing to work at building these attributes in spite of the anxieties involved (Butler & Strupp, 1986;Cochrane, 1987; Herman et al., 1987; Lorr & Wunderlich, 1988; McGree et al., 1991).
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These individuals overcome their patterns of avoidance, denial, information-distortion, and cognitive narrowing that allows them to use therapeutic tools to identify the unique factors of their weight problem. Worth, esteem, personal empowerment, and skills gained in the therapy process enhance their capacity to deal directly with their circumstances instead of indirectly through food and/or other substances (Baumeister & Scher, 1988; Browmwell et aI., 1986; Cochrane, 1987; Heatherton & Baumeister, 1991). Most of those who accomplish longterm weight loss harness their rebelliousness. They recognize the energy used in rebelling, and they overcome the selfdefeating tendencies involved (Baumeister & Scher, 1988; Cochrane, 1987). Harnessing one's energy then, including that formerly devoted to rebellion and resistance, is done through a commitment to self as an individual worthy of the efforts required to succeed (Bernier & Avard 1986; Clark et al., 1991). This committed stance enables each individual to explore and re-prioritize her/his values (Schwartz & Inbar-Saban, 1988). Part of this values clarification is an expanded perception of weight reduction as part of their quality of life (Cochrane, 1987; Cochrane, in press). These changes are not brought about quickly nor without difficulty. Most successful individuals accept that personal change is an activity rather than a naturaily occurring process and that during the change activity, life situations will arise that will cause lapses (Brownwell et al., 1986; Cochrane, 1987; Grilo et al., 1989; Perri et al., 1988). Successful weight losers have developed, by the time lapses occur, sufficient clarity of purpose and commitment to their well-being that they attend directly to ongoing disruptive situations before a relapse occurs.
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As part of their commitment to self, successful weight losers come to see regular exercise as an expression of their worth rather than as a painful task. Because they have become more comfortable with valuing self, they are much less likely to abandon their exercise schedule to meet time demands of other people and situations (Cochrane, 1987; Cochrane, in press). They tend to have high expectations for their physical fitness but avoid the extremist and polarized thinking that so often accompanies exercise and dieting (Yates, 1991, p. 136). These individuals deal with their relationship issues as directly and effectively as possible. Most personal relationships, because of the emotions involved, can disrupt an individual's sense of well-being, and therefore, those who achieve lasting success develop more effective communication and problem-solving skills (Brownwell et al., 1986; Cochrane, 1987; Grilo et aI., 1989; Kolotkin et al., 1987), thereby reducing the need to use food as an avoidance tool (Heatherton & Baumiester, 1991). Most successful weight losers reframe their relationship with food and with formerly problematic food-social situations. Like alcoholics or addicts of other substances, they come to see certain foods, such as those high in animal fat and/or sugar, as dangerous to their well-being, and they see the long-term consequences, not just the potential for seductive immediate gratification (Baumeister & Scher, 1988; Grilo et al., 1989). Most of those who achieve their goals accept that there is no completion date. They become increasingly focused upon their growing healthy sense of self, while continuing to work on the contributing issues (Bandura, 1989; Cochrane, 1987; Cochrane, in press; Heilburn & Worobow,
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1991). Increasingly, they convert what was initially a general sense of well-being to an operational sense of well-being, incorporating concrete achievable steps in the realms of behavior, cognition, emotion, and the spiritual. They understand that whereas general goals are necessary (Bandura, 1989), these general goals must be broken down into manageable units or the global task will become too anxiety arousing (Bandura, 1989; Baumeister & Scher, 1988; Butler & Strupp, 1986) and lead to relapse (Brownwell et al., 1986; Grilo et aI., 1989). In general, any comprehensive approach to lasting weight reduction needs to address the problems and characteristics common to those with a weight problem, to encourage the common aspects of success, and to recognize, within a respectful client-therapist relationship, the unique needs and realities of each individual (Butler & Strupp, 1986; Cochrane, 1987; Cochrane, 1991; Mahoney & Lyddon, 1988; Tobin, Johnson, Dennis, Steinberg, & Staats, 1991. Hypnosis in Weight Reduction There is preliminary evidence that hypnosis can playa role in the battle against excess weight (Andersen, 1985; Bolocofsky, Spinler, & Coulthard-Morris, 1985; Cochrane & Friesen, 1986; Deyoub, 1980; Deyoub & Wilke, 1980; Mott & Roberts, 1979; Wadden & Flaxman, 1981). However, the explosion of weight-reduction literature in the last few years (Heatherton & Baumeister, 1991) clearly demonstrates that obesity and lasting weight reduction are multifaceted and cannot be resolved with any singular approach. Heatherton and Baumeister (1991) discuss the variety of theoretical perspectives currently prevalent in the literature and point out that each
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perspective has something to offer, but no single theory to date incorporates all of the features necessary for a lasting solution to weight problems. Hypnosis then, in research, theory, and practice, must be adapted to the problem and perceived not as a treatment but as a potentially valuable aspect of effective treatment. In addition to the multiple variables involved in obesity, consideration also must be given to the unique perceptions of reality experienced by each individual (Cochrane, 1991; Mahoney & Lyddon, 1988). These individuals voluntarily respond to hypnosis suggestions, or they may choose not to (Lynn, Rhue, & Weekes, 1990). Consequently, there is a need for effective uncovering tools to help overweight individuals more fully identify the unique variables that constitute his/her weight problem and concurrently help the therapist offer appropriately focused suggestions. Hypnotic uncovering tools have been employed (Cochrane, 1987; Cochrane & Friesen, 1986), but specific descriptions of the interventions and how to use them effectively await future publications. Problem identification sets the stage for problem resolution where hypnosis also may have a role, through future-focused imagery and in the development of a comprehensive plan of action. The development and implementation of an action plan for any individual will require a simultaneous plan for the enhancement of self-worth (Clark, Abrams, Niaura, Eaton, & Rossi, 1991; Grace, Jacobson, & Eulager, 1985; Grilio et aI., 1989; Kolotkin et aI., 1987; Lorr & Wunderlich, 1988; McGree, Herman, Freedman, & Pliner, 1991; Mizes, 1988; Scott & Baroffio, 1986; Williamson et aI., 1985). Because people solve problems rather than get rid of them, selfworth, self-esteem, and self-confidence
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are necessary to bridge the gap between plans and action. There is potential for hypnosis to play a useful role in these realms (Cochrane, 1987; Udolf, 1987) though the specifics must await a future publication. Self-worth, self-esteem, and self-confidence are learned (Mahoney, 1988), and therefore hypnosis may have a central role to play in helping overweight people strengthen their beliefs in their ability to control events (Bandura, 1989; Cochrane, 1987; Schwartz & Inbar-Saban, 1988). Imagined success precedes the actions to realize success (Bandura, 1989; Cochrane, in press), and hypnosis could help overweight people visualize and conceptualize the specifics of their success. There is also potential for hypnosis as a vehicle for stress reduction and for positive affirmations (Bolocofsky, SpinIer, & Coulthard-Morris, 1985; Cochrane, 1987; Cochrane, in press) that are important aspects of successful weight reduction (Brownwell et aI., 1986; Heatherton & Baumeister, 1991). Much remains to be done to develop more effective interventions for lasting weight reduction, but a critical first step is to recognize weight reduction as the complex and tenacious problem that it is. Hypnotic interventions, adapted to the multiple variables of the problem as experienced by each individual, may offer some hope. Future Research Research in the field of hypnosis for weight reduction is generally wide open, because the situation reported by Mott and Roberts (1979) has changed very little. There is an obvious need to develop and refine hypnosis interventions for the growing list of characteristics and behavior
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patterns prevalent in those with a chronic weight problem. The rebelliousness issue needs further clarification, as does the role of indirect suggestion for this characteristic. The relationships among childhood trauma, dissociation, overeating, and hypnosis need further exploration, as hypnosis seems an ideal intervention tool in these realms. Longitudinal studies that incorporate the influences oflife stages on problem development and problem resolution are needed. There is a need to include a developmental psychology perspective in research on hypnotic uncovering activities and regression. Those beliefs and attitudes about body image, self-worth, personal power, and others that were learned during the concrete thinking stage of development may not be easily altered with suggestions anchored in the abstract thought of an adult. Because culturally learned gender roles play such an important role in weight reduction, research leading to the development of more helpful hypnotic interventions to overcome guilt, perceived inadequacy, and other gender-related problems is needed. There is such a dearth of research in the hypnosis weight-reduction field that the opportunities are extensive and should be encouraged through publicity and ASCH scholarships. References Andersen, M. S.( 1985). Hypnotizability as a factor in the hypnotic treatment of obesity. International Journal of Clinical and Experimental Hypnosis, 33, 150-159. Bandura, A. (1989). Human agency in social cognition theory. American Psychologist, 44,9,1175-1184. Baumeister, R. F. & Scher, S. J. (1988). Selfdefeating behaviors patterns among normal individuals: Review and analysis of common self-destructive tendencies. Psy-
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sented at the North American Association for the study of Obesity at Harvard, September. Mizes, S. J. (1988). Personality characteristics of bulimic and non-eating disordered controls: A cognitive behavioral perspective. International Journal of Eating Disorders, 7, 541-550. Mott, T. & Roberts, J. (1979). Obesity and hypnosis: A review of the literature. American Journal of Clinical Hypnosis, 22,3-7. Olefsky, J. M. (1980). Obesity. In K. Isselbacher (Ed.),Harrison' s principles of internal medicine, pp. 411-416. New York: McGraw-Hill. Penner, L. A., Thompson, J.K., & Coovert, D.L. (1991). Size overestimation among anorexics: Much ado about very little? Journal ofAbnormal Psychology, 100,9093. Perri, M. G., McAdoo, W. G., McAllister, D. A., Lauer, J. B., & Yancey, D. Z. (1986). Enhancing the efficacy of behavior therapy for obesity: Effects of aerobic exercise and a multi component maintenance program. Journal of Consulting and Clinical Psychology,54, 670-675. Pike, K. & M. Rodin, J. (1991). Mothers, daughters and disordered eating. Journal of Abnormal Psychology, 100, 198-204. Rodin, J., Elias, M., Silberstein, L. R., & Wagner, A. (1988). Combined behavioral and pharmacological treatment for obesity: Predictors of successful maintenance. Journal of Consulting and Clinical Psychology, 56, 399-404. Schlesier-Carter, B., Hamilton, S. A., O'Neil, P. M., Lydiard, R. B., & Malcolm, R. (1989). Depression and bulimia: The link between depression and bulimic cognition. Journal of Abnormal Psychology, 98, 3, 322-325. Schwartz, S. H. & Inbar-Saban, N. (1988). Value self-confrontation as a method to aid
COCHRANE in weight loss. Journal ofPersonality and Social Psychology, 54, 396-404. Scott, R. L. & Baroffio, J. R. (1986). An MMPI analysis of similarities and differences in three classifications of eating disorders: Anorexia, bulimia and morbid obesity. Journal of Clinical Psychology, 42,708-713. Simmons, D. D. (1986). Self-reports of eating behaviors, goals, imagery and health status: Principle components and sex differences. The Journal ofPsychology, 12,5760. Stammer, M. E. (1988). Understanding alcoholism and drug dependency in nurses. Quarterly Review Bulletin, March, 75-80. Tobin, D. L., Johnson, C., Dennis, A. B., Steinberg, S., & Staats, M. (1991). Multifactorial assessment of bulimia nervosa. JournalofAbnormalPsychology, 100,1421. Udolf,J. D. (1987). Handbookofhypnosisfor professionals. (2nd. ed.), pp. 248-255. New York: Van Nostrand Reinhold Company. Wadden,T. A. & Flaxman, J. (1981). Hypnosis and weight loss: A preliminary study. The International Journal ofClinical and Experimental Hypnosis, 29, 162-173. Wardle, J. & Beales, S. (1988). Control and loss of control over eating: An experimental investigation. Journal of Abnormal Psychology, 97, 35-40. Williamson, D. A., Kelley, M. C., Davis, C. J., Ruggiero, L., & Blouin, D. C. (1985). Psychopathology of eating disorders: A controlled comparison of bulimic, obese and normal subjects. Journal of Consulting and Clinical Psychology, 53, 161-166. Wing, R. & Jeffery, R. W. (1979). Outpatient treatments of obesity: A comparison of methodology and clinical results. International Journal of Obesity, 3, 261-279. Yates, A. (1991). Compulsive exercise and the eating disorders. New York: Brunner/ Mazel, Inc.
American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Hypnosis and Weight Reduction: Which is the Cart and Which is the Horse? Gordon Cochrane Ed.D. Published online: 21 Sep 2011.
To cite this article: Gordon Cochrane Ed.D. (1992) Hypnosis and Weight Reduction: Which is the Cart and Which is the Horse?, American Journal of Clinical Hypnosis, 35:2, 109-118, DOI: 10.1080/00029157.1992.10402993 To link to this article: http://dx.doi.org/10.1080/00029157.1992.10402993
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AMERICAN JOURNAL OF CLINICAL HYPNOSIS VOLUME
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Hypnosis and Weight Reduction: Which is the Cart and Which is the Horse?
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Gordon Cochrane Vancouver, British Columbia
Hypnosis has often been described as a useful adjunctive treatment for excess weight. However, the literature shows that very few controlled studies have been conducted in this realm, and none have incorporated the key variables of either the hypnosis components or the weight-reduction components. In this paper I offer a brief review of the literature on hypnosis for weight reduction, present weight-reduction outcome data, outline variables common to people with chronic weight problems, and I offer suggestions for future uses of hypnosis within a comprehensive approach to weight reduction rather than as the primary treatment. Suggestions are also made concerning the multiple opportunities for future research using hypnosis in the substance-abuse field.
Hypnosis has long been considered an appropriate treatment tool for weight reduction, and some individuals have made some startling claims about its efficacy. However, when Mott and Roberts (1979) reviewed the literature on hypnosis for weight reduction they found that the research at that time did not exist to substantiate its effectiveness. They found the literature dominated by anecdotal reports, making interpretation difficult, and because essential follow-up data were not
For reprints write to Gordon J. Cochrane, Ed.D., 2095 W. 45th Ave., Vancouver, B.C., V6M 2H8, Canada. Received November 12, 1991; revised March 4, 1992; second revision July 9, 1992; accepted for publication July 13, 1992.
presented, it was impossible to assess lasting results. The hypnosis interventions employed in the literature were not described clearly, making it impossible to identify which aspects of the hypnotherapy were useful and which were not. The mosaic of variables that comprised weight problems and any common characteristics of the people with these problems (Olefsky, 1980) were ignored. In the years since the Mott and Roberts' (1979) review, there has been extensive research published on obesity, on the specifics of weight reduction, and on the characteristics of people with weight problems. However, there have been very few publications involving hypnosis for weight reduction within this time frame (Andersen, 1985; Cochrane, 1987; Cochrane & Friesen, 1986; Deyoub, 1980; Deyoub & Wilke, 1980; Wadden & Flaxman, 1981). 109
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It does appear that hypnosis has potential in the weight-loss realm (Andersen, 1985; Bolocofsky, Spinler, & Coulthard-Morris, 1985; Cochrane, 1987; Cochrane & Friesen, 1986), but much research remains to be done. Some writers (Bolocofsky, Spinler, & Coulthard-Morris, 1985; Udolf, 1987) suggest that hypnosis can be used as an adjunct to weight-loss treatment, but even they don't comment on the complexities of weight problems and the consequent multi-faceted treatment models required to address this problem (Grilo, Shiffman, & Wing, 1989; Heatherton & Baumeister, 1991; Perri, McAdoo, McAllister, Lauer, & Yancey, 1986; Williamson, Kelley, Davis, Ruggiero, & Blouin, 1985). In this paper I provide a summary of the mainstream weight-reduction literature from the last decade and then review the literature involving hypnosis in weight reduction. This dual review demonstrates the need to respect the multi-faceted complexity of weight reduction and to adapt hypnosis interventions to this complexity.
Weight Reduction: A Review The most consistent pattern arising from the weight-reduction literature is that of minimal long-term success. Wing and Jeffery (1979) compared short-term and long-term outcome data from a compilation of diet programs, exercise, behavior therapy, and medication treatments. All of the models showed promising shortterm results, but the follow-up data, much of which was gathered after a relatively short follow-up time, showed a mean weight gain for each approach with one exception: Behavioral therapy showed, across 33 studies and 981 subjects, a mean weight loss of one pound. There was no follow-up done for the exercise approach,
but regular exercise has been found (Perri et al., 1986) to be a key aspect of lasting weight reduction. Numerous studies (Baumeister& Scher, 1988; Brownwell, Marlatt, Lichenstein, & Wilson, 1986; Grilo, Shiffman, & Wing, 1989; Heatherton, Herman & Polivy, 1991; Herman, Polivy, Lank, & Heatherton, 1987; Leung, Steiger, & Puentes-Neuman, 1991; Rodin, Elias, Silberstein, & Wagner, 1988; Simmons, 1986; Wardle & Beales, 1988) indicate that the vast majority of people who take an extreme approach to weight loss regain quite rapidly as much or more weight than they lost. Grilo et al. (1989) state that 90-95% regain their lost weight regardless of the length of treatment time. A possible explanation for the generally dismal outcome data from weightreduction programs is that weight loss has traditionally been considered by many to be a homogenous issue. Treatments were designed and evaluated primarily upon initial measured weight loss with limited consideration of multiple contributing variables. Substance abuse in the form of alcoholism and drug addiction was considered much more complex than weight reduction, yet the outcome data has been consistently better with these substances than with food (Brownwell et al., 1986; Duffy & Hall, 1988; Grilo et al., 1989). This unfortunate attitude, which spawned such phrases as "just do it," "just exercise more and eat less," and "just push yourself away from the table," is being replaced with a more comprehensive perspective (Heatherton & Baumeister, 1991) that recognizes lasting weight loss as complex, difficult, and worthy of respect by practitioners and those who suffer with the problem. Diet programs have not fared well in the literature, and the more rigid the pro-
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gram the more negative the results (Grilo et al., 1989; Heatherton et al., 1991; Rodin et al., 1988; Wardle & Beales, 1988). The perfectionism and compulsiveness that plague so many dieters combined with body-image problems and a desire for immediate results generally leads to failure, disappointment, damaged self-esteem, and depression (Herman et al., 1987; Lorr & Wunderlich, 1988; Wardle & Beales, 1988). The same success-failure pattern also generally applies to exercise (Yates, 1991, p. 4), in that the more extreme the approach the greater the probability that it will be abandoned. Many overweight people struggle with accompanying problems that either directly or indirectly complicate their weightreduction efforts. Family of origin and social problems including rejection, alcoholism, low self-worth, and emotional and physical abuse appear to make any attempt to isolate weight reduction from accompanying life issues quite futile (Bronwell et al., 1986; Cochrane, 1987; Heatherton & Baumeister, 1991; Herman et al., 1987; Humphrey, 1986; Mellin, 1987; Pike & Rodin, 1991; Stammer, 1988). Grilo and Pogue-Geile (1991) suggest that genetics playa very important role in obesity, making the issue even more tenacious. Characteristics of Those Who Struggle Many overweight people, possibly as a consequence of their experiences with weight-related prejudice, ostracism, rejection, and humiliation as overweight children and adults (Beach, Freeman, & Koopman, 1991; Cochrane, 1987; Mizes, 1988; Pike & Rodin, 1991), exhibit patterns of rebelliousness, anger, hypersensitivity, and difficulty with authority figures (Kolotkin, Revis, Kirkley, & Janik, 1987; Scott & Baroffio, 1986). Consequently, a
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directive treatment model is often met with overt rebelliousness or covert rebelliousness expressed through quiet noncompliance. It is interesting to note that people with a chronic weight problem have, coexisting with this tendency to rebel when told what to do, a diminished sense of self-esteem, self-confidence, and personal power, which leads them to look outside of self for solutions to their weight problems (Clark, Abrams, Niaura, Eaton, & Rossi, 1991; Grace, Jacobson, & Eulager, 1985; Grilo et al., 1989; Kolotkin et al., 1987; Lorr & Wunderlich, 1988; McGree, Herman, Freedman, & Pliner, 1991; Mizes, 1988; Scott & Baroffio, 1986; Williamson et al., 1985). For some individuals this reduced sense of personal esteem, power, and optimism is primarily a consequence of many unsuccessful efforts to sustain weight reduction. For others the damage to self occurred in the family of origin, in adolescence, or in more recent interpersonal settings, and weight gain was reactiveratherthan causal (Leung et al., 1991), but once a weight problem develops it also contributes to the diminished sense of self. Overeating can be viewed from the diathesis/stress model of coping. Under stress some people tum to alcohol, drugs, work, sex, spending, food, or any activity or combination of activities that sedates, distracts one's attention, or gives a temporary sense ofcontrol (Baumeister & Scher, 1988; Beckwith, 1986; Duffy & Hall, 1988; Heatherton & Baumeister, 1991; Herman et al., 1987; Scott & Baroffio, 1986; Stammer, 1988). Unlike most substances and behaviors in this model, food is necessary for life and cannot be avoided, and therefore an overweight person can be compared to an alcoholic attempting to become a controlled drinker. Common across the diathesis/stress model are denial, avoid-
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ance of feelings and cognitive awareness, distortion of information, cognitive narrowing, and poor problem-solving skills (Baumeister & Scher, 1988; Beckwith, 1986; Brownwell et al., 1986; Grilo et al., 1989; Heatherton & Baumeister, 1991; Jacob, Krahn, & Leonard, 1991), which make weight reduction extremely difficult. Women tend to be more preoccupied with weight reduction than are men (Cantrell & Ellis, 1991; McAvoy & Fried, 1991; Penner, Thompson, & Coovert, 1991; Pike & Rodin, 1991), but both sexes struggle with perfectionism and the low self-esteem from which perfectionism arises (Cantrell & Ellis, 1991; Marcus, Wing, & Hopkins, 1988; Mizes, 1988). When a person is reasonably content with herself/himself, perfectionism is usually not an issue. However, our culture places relentless pressure on women to conform to a physical, behavioral, and attitudinal model that contributes to body-image distortions. Women perceive their body as larger and heavier than it actually is (Butters & Cash, 1987; Penner, Thompson, & Coovert, 1991; Scott & Baroffio, 1986; Simmons, 1986) and consequently feel inadequate, which leads to excessive dieting, exercise, and binge eating for many. This perceived failure to adhere to a societal ideal can contribute to social anxieties, inhibitions, and sexual problems among overweight women (Grace et al., 1985; Simmons, 1986; Stammer, 1988). For some, the nonacceptance ofone's body can generalize to a broader sense of "I am fat, therefore I am worthless" (Butters & Cash, 1987). The traditional female role has also encouraged women to be care-givers, consistently placing the needs of others before their own and thereby abandoning their
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weight-loss efforts when called upon to serve others. It also encourages women to value beauty because this model suggests that successful men want attractive partners, and successful men in tum offer security. Within this cultural milieu women have learned to ascribe their successes to luck, to others, or to outside sources (Beach et al., 1991; Butters & Cash, 1987). These many variables can create a powerful dilemma for overweight women when they attempt to lose weight. Some become angry and rebel against the social pressure to be slim, but most simultaneously sustain a desire to be slim and consequently experience an internal struggle (Baumeister & Scher, 1988; Cochrane, 1987; Scott & Baroffio, 1986) sometimes known as the "must-but-cannot dilemma." Others experience this dilemma as a fear of success (Baumeister & Scher, 1988), and some fear the social/sexual consequences of such success (Brownwell et al., 1986; Cochrane, 1987). Any situation that is experienced as negative and chronic can become depressing, and depression is a characteristic common to many people with a weight problem (Grilo et al., 1989; Kolotkin et al., 1987; Leung et al., 1991; Marcus et al., 1988; Mizes, 1988; Schlesier-Carter, Hamilton, O'Neil, Lydiard, & Malcolm, 1989). In some cases depression seems to be a causal component of the person's weight problem, and for others it seems to be a consequence of the chronic weight problem (Heatherton & Baumeister, 1991; Leung et al., 1991). The combination of hopelessness and helplessness that are the pillars of situational depression and an external locus of control (Clark et al., 1991) make a significant contribution to the dismal outcomes in long-term weight reduction.
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Characteristics of Those Who Succeed Whereas no individual demonstrates all ofthe described problematic characteristics common to people with weight problems, and whereas each individual has a unique understanding of her/his problem (Cochrane, 1991; Mahoney & Lyddon, 1988), there are some general characteristics common to those who do succeed. Most successful weight losers have a sound knowledge of diet and nutrition, including simple principles such as the extremely effective manner in which the human body converts animal fats such as dairy products into stored body fat. Most recognize that extreme dieting and/or exercising ultimately fails (Heatherton et aI., 1991; Herman et al., 1987; Rodin, Elias, Silberstein, & Wagner, 1988; Wardle & Beales, 1988), though they do accept the need for regular exercise and attention to diet (Cochrane, 1987; Perri et al., 1986). Possibly the most important feature of those who succeed at lasting weight reduction is their sense of personal empowerment, self-worth, and self-esteem (Bandura, 1989; Clark et al., 1991; Cochrane, 1987; Grace et al., 1985; Grilo et al., 1989; Lorr & Wunderlich, 1988; Mizes, 1988; Perri et al., 1986; Rodin et al., 1988; Schwartz & Inbar-Saban, 1988; Scott & Baroffio, 1986). Self-worth is the sense of personal worthiness that is exclusive of accomplishments; self-esteem is the feeling that arises from acknowledging and owning one's achievements. Personal empowerment is the faith one has in her/his abilities and strengths to succeed at life's tasks. Those who achieve lasting success are ready and willing to work at building these attributes in spite of the anxieties involved (Butler & Strupp, 1986;Cochrane, 1987; Herman et al., 1987; Lorr & Wunderlich, 1988; McGree et al., 1991).
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These individuals overcome their patterns of avoidance, denial, information-distortion, and cognitive narrowing that allows them to use therapeutic tools to identify the unique factors of their weight problem. Worth, esteem, personal empowerment, and skills gained in the therapy process enhance their capacity to deal directly with their circumstances instead of indirectly through food and/or other substances (Baumeister & Scher, 1988; Browmwell et aI., 1986; Cochrane, 1987; Heatherton & Baumeister, 1991). Most of those who accomplish longterm weight loss harness their rebelliousness. They recognize the energy used in rebelling, and they overcome the selfdefeating tendencies involved (Baumeister & Scher, 1988; Cochrane, 1987). Harnessing one's energy then, including that formerly devoted to rebellion and resistance, is done through a commitment to self as an individual worthy of the efforts required to succeed (Bernier & Avard 1986; Clark et al., 1991). This committed stance enables each individual to explore and re-prioritize her/his values (Schwartz & Inbar-Saban, 1988). Part of this values clarification is an expanded perception of weight reduction as part of their quality of life (Cochrane, 1987; Cochrane, in press). These changes are not brought about quickly nor without difficulty. Most successful individuals accept that personal change is an activity rather than a naturaily occurring process and that during the change activity, life situations will arise that will cause lapses (Brownwell et al., 1986; Cochrane, 1987; Grilo et al., 1989; Perri et al., 1988). Successful weight losers have developed, by the time lapses occur, sufficient clarity of purpose and commitment to their well-being that they attend directly to ongoing disruptive situations before a relapse occurs.
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As part of their commitment to self, successful weight losers come to see regular exercise as an expression of their worth rather than as a painful task. Because they have become more comfortable with valuing self, they are much less likely to abandon their exercise schedule to meet time demands of other people and situations (Cochrane, 1987; Cochrane, in press). They tend to have high expectations for their physical fitness but avoid the extremist and polarized thinking that so often accompanies exercise and dieting (Yates, 1991, p. 136). These individuals deal with their relationship issues as directly and effectively as possible. Most personal relationships, because of the emotions involved, can disrupt an individual's sense of well-being, and therefore, those who achieve lasting success develop more effective communication and problem-solving skills (Brownwell et al., 1986; Cochrane, 1987; Grilo et aI., 1989; Kolotkin et al., 1987), thereby reducing the need to use food as an avoidance tool (Heatherton & Baumiester, 1991). Most successful weight losers reframe their relationship with food and with formerly problematic food-social situations. Like alcoholics or addicts of other substances, they come to see certain foods, such as those high in animal fat and/or sugar, as dangerous to their well-being, and they see the long-term consequences, not just the potential for seductive immediate gratification (Baumeister & Scher, 1988; Grilo et al., 1989). Most of those who achieve their goals accept that there is no completion date. They become increasingly focused upon their growing healthy sense of self, while continuing to work on the contributing issues (Bandura, 1989; Cochrane, 1987; Cochrane, in press; Heilburn & Worobow,
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1991). Increasingly, they convert what was initially a general sense of well-being to an operational sense of well-being, incorporating concrete achievable steps in the realms of behavior, cognition, emotion, and the spiritual. They understand that whereas general goals are necessary (Bandura, 1989), these general goals must be broken down into manageable units or the global task will become too anxiety arousing (Bandura, 1989; Baumeister & Scher, 1988; Butler & Strupp, 1986) and lead to relapse (Brownwell et al., 1986; Grilo et aI., 1989). In general, any comprehensive approach to lasting weight reduction needs to address the problems and characteristics common to those with a weight problem, to encourage the common aspects of success, and to recognize, within a respectful client-therapist relationship, the unique needs and realities of each individual (Butler & Strupp, 1986; Cochrane, 1987; Cochrane, 1991; Mahoney & Lyddon, 1988; Tobin, Johnson, Dennis, Steinberg, & Staats, 1991. Hypnosis in Weight Reduction There is preliminary evidence that hypnosis can playa role in the battle against excess weight (Andersen, 1985; Bolocofsky, Spinler, & Coulthard-Morris, 1985; Cochrane & Friesen, 1986; Deyoub, 1980; Deyoub & Wilke, 1980; Mott & Roberts, 1979; Wadden & Flaxman, 1981). However, the explosion of weight-reduction literature in the last few years (Heatherton & Baumeister, 1991) clearly demonstrates that obesity and lasting weight reduction are multifaceted and cannot be resolved with any singular approach. Heatherton and Baumeister (1991) discuss the variety of theoretical perspectives currently prevalent in the literature and point out that each
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perspective has something to offer, but no single theory to date incorporates all of the features necessary for a lasting solution to weight problems. Hypnosis then, in research, theory, and practice, must be adapted to the problem and perceived not as a treatment but as a potentially valuable aspect of effective treatment. In addition to the multiple variables involved in obesity, consideration also must be given to the unique perceptions of reality experienced by each individual (Cochrane, 1991; Mahoney & Lyddon, 1988). These individuals voluntarily respond to hypnosis suggestions, or they may choose not to (Lynn, Rhue, & Weekes, 1990). Consequently, there is a need for effective uncovering tools to help overweight individuals more fully identify the unique variables that constitute his/her weight problem and concurrently help the therapist offer appropriately focused suggestions. Hypnotic uncovering tools have been employed (Cochrane, 1987; Cochrane & Friesen, 1986), but specific descriptions of the interventions and how to use them effectively await future publications. Problem identification sets the stage for problem resolution where hypnosis also may have a role, through future-focused imagery and in the development of a comprehensive plan of action. The development and implementation of an action plan for any individual will require a simultaneous plan for the enhancement of self-worth (Clark, Abrams, Niaura, Eaton, & Rossi, 1991; Grace, Jacobson, & Eulager, 1985; Grilio et aI., 1989; Kolotkin et aI., 1987; Lorr & Wunderlich, 1988; McGree, Herman, Freedman, & Pliner, 1991; Mizes, 1988; Scott & Baroffio, 1986; Williamson et aI., 1985). Because people solve problems rather than get rid of them, selfworth, self-esteem, and self-confidence
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are necessary to bridge the gap between plans and action. There is potential for hypnosis to play a useful role in these realms (Cochrane, 1987; Udolf, 1987) though the specifics must await a future publication. Self-worth, self-esteem, and self-confidence are learned (Mahoney, 1988), and therefore hypnosis may have a central role to play in helping overweight people strengthen their beliefs in their ability to control events (Bandura, 1989; Cochrane, 1987; Schwartz & Inbar-Saban, 1988). Imagined success precedes the actions to realize success (Bandura, 1989; Cochrane, in press), and hypnosis could help overweight people visualize and conceptualize the specifics of their success. There is also potential for hypnosis as a vehicle for stress reduction and for positive affirmations (Bolocofsky, SpinIer, & Coulthard-Morris, 1985; Cochrane, 1987; Cochrane, in press) that are important aspects of successful weight reduction (Brownwell et aI., 1986; Heatherton & Baumeister, 1991). Much remains to be done to develop more effective interventions for lasting weight reduction, but a critical first step is to recognize weight reduction as the complex and tenacious problem that it is. Hypnotic interventions, adapted to the multiple variables of the problem as experienced by each individual, may offer some hope. Future Research Research in the field of hypnosis for weight reduction is generally wide open, because the situation reported by Mott and Roberts (1979) has changed very little. There is an obvious need to develop and refine hypnosis interventions for the growing list of characteristics and behavior
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patterns prevalent in those with a chronic weight problem. The rebelliousness issue needs further clarification, as does the role of indirect suggestion for this characteristic. The relationships among childhood trauma, dissociation, overeating, and hypnosis need further exploration, as hypnosis seems an ideal intervention tool in these realms. Longitudinal studies that incorporate the influences oflife stages on problem development and problem resolution are needed. There is a need to include a developmental psychology perspective in research on hypnotic uncovering activities and regression. Those beliefs and attitudes about body image, self-worth, personal power, and others that were learned during the concrete thinking stage of development may not be easily altered with suggestions anchored in the abstract thought of an adult. Because culturally learned gender roles play such an important role in weight reduction, research leading to the development of more helpful hypnotic interventions to overcome guilt, perceived inadequacy, and other gender-related problems is needed. There is such a dearth of research in the hypnosis weight-reduction field that the opportunities are extensive and should be encouraged through publicity and ASCH scholarships. References Andersen, M. S.( 1985). Hypnotizability as a factor in the hypnotic treatment of obesity. International Journal of Clinical and Experimental Hypnosis, 33, 150-159. Bandura, A. (1989). Human agency in social cognition theory. American Psychologist, 44,9,1175-1184. Baumeister, R. F. & Scher, S. J. (1988). Selfdefeating behaviors patterns among normal individuals: Review and analysis of common self-destructive tendencies. Psy-
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chological Bulletin, 104, 1,3-22. Beach, B., Freeman, R., & Koopman, R. (1991). Multi-dimensional self-esteem: The role of self-rated importance. Canadian Psychologist, 32 :29, 348. Beckwith, J. B. (1986). Eating, drinking and smoking and their relationship in adult women. Psychological Reports, 59,10751089. Bernier, M. & Avard, J. (1986). Self-efficacy, outcome and attrition in a weight-reduction program. Cognitive Therapy and Research, 10,319-338. Bolocofsky, D. N., Spinier, D., & CoulthardMorris, L. (1985). Effectiveness of hypnosis as an adjunct to behavior weight management. Journal ofClinical Psychology, 41,35-41. Brownwell, K. D., Marlatt, G. A., Lichenstein, E.,& Wilson,G.T.(1986). Understanding and preventing relapse. American Psychologist, 4 I, 7, 765-782. Butler, S. F. & Strupp, H. H. (1986). Specific and nonspecific factors in psychotherapy: A problematic paradigm for psychotherapy research. Psychotherapy, 23, 1,30-40. Butters, J. W. & Cash, T. F. (1987). Cognitive behavioral treatment of women's bodyimage dissatisfaction. Journal ofConsultingandClinical Psychology, 55, 889-897. Cantrell, P. J. & Ellis, J. B. (1991). Gender role and risk patterns for eating disorders in men and women. Journal of Clinical Psychology, 47,53-57. Clark, M. M., Abrams, D. B., Niaura, R. S., Eaton, C. A., & Rossi, J. S. (1991). Selfefficacy in weight management. Journal of Consulting and Clinical Psychology, 59,739-744. Cochrane, G. J. (1987). Hypnotherapy in weight-loss treatment: Case illustration. American Journal of Clinical Hypnosis, 30, 1,20-27. Cochrane, G. J. (1991). Client-therapist collaboration in the preparation of hypnosis interventions: Case illustrations. American Journal ofClinical Hypnosis, 33, 254262. Cochrane, G. J. (in press). Inside out: How to
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