Inserting Health Behaviors Into the Scope of Psychotherapy: From Eating to Total Health

Powerful messages are attached to body size in our society. The stigmatizing of obesity is vicious. The spotlight on weight reduction partly seems to emanate from that hostility. People cycle through diets and never find comfort with their eating or their body image. Weight is not an indication for psychotherapy, but it is among the reasons people seek help. How should therapy approach this issue?

Well-intentioned efforts can have dubious outcomes. Designating obesity a disease (by AMA vote in 2013) is a boon to the weight loss industry. Dieting fuels the stigma of weight. Classifying health behaviors as lifestyle choices may be reasonable, but it minimizes social factors. Some of us have disadvantages affecting those choices. Those disadvantages impact both gaining and losing weight.

What brings the behavioral healthcare field into discussions of body size? Changing one’s body size involves behavior change. Our field owns the domain of behavior change since psychotherapy is the best vehicle we have to achieve it. Yet focusing on single issues in isolation generally fails. Health behaviors should be understood in the context of the other key dimensions of behavioral health.  

Those other key dimensions, mental health and substance use issues, are often fused with body image. One issue can reinforce the other. When weight becomes a therapy focus, it is best framed in the context of health and wellbeing goals and clarified as part of the therapeutic alliance. Agreed-upon tasks and goals are the essence of the alliance. Clients must know therapy is not a weight loss system.

Wellness programs are distinct from psychotherapy in that they are narrowly focused. The calculus behind wellness is that people must eat less and exercise more. This might be tied to metrics like calories or points. A narrow focus can become an obsession and wellness a rigidly structured life. By contrast, therapists seek to understand how health behaviors fit into the context of a person’s life.

Many people enter therapy with deep knowledge of how food and exercise can promote health. Yet many people cycle through various wellness strategies with persistent psychological distress. Therapy may be born of frustration as people become aware that no diet or wellness model will remove their distress. They begin to suspect that their goals may be the problem, not their wellness tactics.

Obesity is a well publicized epidemic. However, its solution does not start with diets. Our field should embrace a biopsychosocial approach. Work on behavior change needs grounding in a paradigm that prioritizes mental and physical wellbeing. Health At Every Size (HAES) is such a model that fits well with psychotherapy. Weight management should have basic priorities:

The HAES paradigm works to…address systemic and personal barriers to health enhancement, to offer respectful, unbiased health care, to help clients eat flexibly for well-being, rather than rigidly, according to a diet, and to promote life-enhancing, enjoyable physical activities.

These principles offer clear direction, and yet many therapists avoid this entire area of focus in their work. Some therapists specialize in health behaviors, but most have no real training or experience with these issues. It is much like the deficiency many clinicians have in the SUD domain. They think of themselves as mental health clinicians. In fact, we need them to be behavioral health clinicians.

This deficiency can be corrected. The first step is to reassure therapists they need not become dieticians or exercise physiologists to help people in therapy with these issues. People need therapy informed by all 3 pillars of behavioral health (mental health, substance use, and health behaviors), and once informed, therapy can then pursue each person’s goals for health and wellbeing.

Ensuring that our clinicians are informed about specialty issues does not mean they are specialists. Let us develop a workforce in which everyone is comfortable with the full spectrum of behavioral issues. Clinicians might then choose to add areas of sub-specialization to this basic level of competency.

This is a leadership challenge in our field as much as it is a clinical issue. We are progressively moving into the orbit of general healthcare and must position ourselves for future success. This will entail collaborating with medical providers and focusing more on total health, including physical health.

Health behaviors have not traditionally been core to our field, but beliefs are changing. Mental and physical health are transitional categories, not ends in themselves. Total health is the new objective. Why is therapy an essential health service? Because behavior change is essential to total health.

Ed Jones, PhD, is currently with ERJ Consulting, LLC and previously served as President at ValueOptions and Chief Clinical Officer at PacifiCare Behavioral Health.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.