Dr. Karin Schwartz received her Doctorate of Psychology degree from the California School of Professional Psychology, at the Alliant International University in San Francisco, California. For the past 14 years, Dr. Schwartz has focused her clinical work primarily on the assessment and treatment of substance abuse and other addictions, eating disorders, bariatric/weight loss surgery evaluations and treatment, various anxiety disorders (OCD, Social Anxiety and Panic Disorders),and relationship struggles. Dr. Schwartz highlights the psychological issues that are intertwined with obesity and how they need to be managed during the weight loss process. For many of her patients food is a coping mechanism. “They celebrate with food. They mourn with food. They grieve with food. It becomes a friend to them. It becomes a companion.” She also warns that with the significant weight loss comes the possibility of transference addiction so when food is no longer an option, people turn to sex or drinking or shopping and other addictions to deal with those feelings.
I'm Dr. Karin Schwartz, and I'm a licensed clinical psychologist. I went to school at USC for my B.A. and then did my master's and doctorate at a school called Alliant International University, and I've done quite a few internships and fellowships at Berkeley Mental Health and trained physicians at Harbor UCLA. I currently have a private practice at Cedars-Sinai.
Obesity is a huge, huge problem today, 1 in 3 adults and 1 in 6 children and adolescents qualify as being obese today in the United States so it's a big problem medically, psychologically, economically. It’s a huge problem that affects pretty much every area of our society.
Is obesity a disease? That's a very interesting and controversial question. I believe that it is a disease similar to depression, anxiety, OCD. Typically people that are obese or morbidly obese struggle with diabetes, hypertension; they could be at higher risk for stroke; and similarly the way that certain medications can help situations like depression, they can also help issues related to obesity, so that in and of itself I guess would qualify it as a disease of sorts.
Patients are usually in a very vulnerable and I want to say almost desperate place when they seek me out. They've usually done multiple diets, whether that be the Jenny Craig’s, Weight Watchers, and so forth. They've tried a lot of medications to help, as well, and they've gotten to a place where they really feel like they either have to deal with the underlying issues psychologically or they might be mandated because of wanting to go into bariatric surgery. So they come to me also for the psychological evaluation of the surgery.
I start usually by trying to figure out what their relationship with food is. For a lot of people it's really been a lifelong struggle. They see as their best friend, their number one life partner, it's really their way to cope with their feelings. And I try to kind of look at it as when you're a baby and you cry, what does the mother give you? She gives you her breast or a bottle in order to soothe you, so for many people they never really learn how to use anything but food to cope with their feelings.
Not everybody that's overweight is addicted to food, but a large majority is. They're also needing more to get the same effect, which is also similar to drug addiction, so people that are addicted to certain combinations of sugars and fat need more to get the same effect in their brain. There's been a lot of studies done on serotonin and dopamine, and certain combinations of chocolates, fats, sugars, have the same effect as cocaine and marijuana do on the brain and that's why people to use more and more to get the same calming effect, at least temporarily. Some people tend to graze throughout the day so there's that need for fullness. Other people are more compulsive binge eaters where they'll eat in a short discrete period of time sort of numbing themselves, not really noticing how much they're eating, and there's almost an anesthetic like effect that happens. But if you're using food in the way a typical addict uses drugs or alcohol, it's a problem.
They celebrate with food. They mourn with food. They grieve with food. It comes a friend to them. It becomes a companion. It becomes something they go to cope. And in my practice, especially after bariatric surgery, what happens is there's a lot of transfer of addiction that happens, so when food is no longer an option, people turn to sex or drinking or shopping and other addictions, if you will, to deal with those feelings. I like to use the analogy of a kleptomaniac, if you will; you can put the handcuffs on a person but they're still going to want to steal and so something like gastric bypass, as amazingly helpful of a tool as it can be, it doesn't really deal a lot of times with the underlying psychological issues.
People that struggle with their weight or have that unhealthy relationship with food often have a very low self-esteem or self-concept and the idea of food not judging you, not talking back to you, accepting you unconditionally and again being accessible 24/7, so people will tend to go to what they know and what's familiar and what's available. It's just like giving a rat cocaine and they'll press the lever again and again and again, and we see that with people that are addicted to food. And so when people are dealing with anxiety and depression and low self-esteem, they will want to do whatever they can to get that instant gratification and there's a lot of impulse-control issues that come with that, as well. Food is a lot more socially acceptable and available than cocaine or methamphetamines or whatever other vices are there.
People that are overweight also wear it. There's not really a way to hide it like you would another addiction and so there's almost like the cry for help for somebody who's behaviorally eating in a dysfunctional way if you see them at a table.
When it comes to the different genders, there are significant differences. There's a lot more social stigma for women when they struggle with their weight. When you open up a magazine, you'll see what is considered socially acceptable physical body for a woman versus for a man. Men also have a much harder time coming for help and dealing with the underlying issues. When I hear a man tell me I feel very sad, I know he's gotten to a place that it's a very vulnerable place for him.
Part of what I use in therapy in order to try to erase that social stigma is really looking at everybody on an individual basis and really getting them to also look at their life on an individual basis. It's not easy when people have been raised to believe that their sense of identity and sense of worth is based on a weight or a number on a scale. And the more weight somebody has to lose the more set their belief system is. Sort of analogous to if you're climbing this mountain and you say I'm never ever going to get to the top, why even take two or three steps to get there? It's very hard for people to conceptualize goals on a short-term basis when they have a significant amount of weight to lose. So what I find people will do is they will sabotage themselves. People obviously want to lose the weight, but it's almost like, what am I going to do when this is no longer an issue for me? What will be the focus then? What's to blame then when I don't have a relationship or when I don't get the job that I want? I can't blame it on being overweight anymore.
You ask yourself why is it that one child will struggle with food but another one won't? I believe that comes to inherent coping skills, inherent temperament, and personality. Two children of the same parents will have the same genetic loading, let's say, 50 percent propensity of the obesity gene, but one might be able to be able to use social support, their friends, their teachers, their bosses and so forth, where another one might be more of a social isolator, might have lower self-esteem, might have had a trauma history. Let's say, they remember using food or having a brownie right after they were sexually assaulted, that connection right then and there will set a lifelong pattern of using food to cope.
Oftentimes I find people that were overweight as children will continually see themselves as overweight and so there's that distorted body image, with childhood or adolescent obesity, there's a lot of stink mouth; there could be bullying; and so the child sort of gets this self-concept of I'm different, I'm damaged, I'm the fat kid. I've seen many people where they'll lose a hundred, a hundred and fifty pounds, and no matter what their identity is wrapped around being the overweight teased child. Earlier in the 60's, 70's, even early 80's, they were given speed, whether it's Dexedrine or Phentermine and Phen Phen which also gave the child the idea that something is wrong with you, here's a medication, we have to fix you, you're sick. And also many, many people that I see will tell me how everybody got sort of the regular meals in school and they would be given the carrot sticks and the cottage cheese so they learned early on to sneak. They get to this belief system, this irrational belief, that they're not loved because they're damaged in some way and they're different than their siblings and their peers.
I think the most damaging things, what I've also heard from hundreds of people, is when you take this child and you force them to eat differently than the other children, or you force them to go to a diet program, or a fat camp, that in and of itself will create a big problem in the child's self-concept. If I'm seeing somebody who's 50 years old it very much still feels like that 13-year-old. They're in a bigger, taller body and they're more mature but a lot of those thoughts and feelings, as in all addictions, are still very much stuck at that age, at 13.
I try to get people to set very short-term measurable discrete goals; things that they can achieve in a short amount of time and feel really good about. If you say to somebody, okay, your goal is to lose a hundred pounds, well, that's going to be scary and unachievable for most people. I try not to have the measurement be a number on a scale, but rather a behavior, so that can be decrease the binges from five days a week to two days a week. Or eliminate white carbohydrates three days a week. Then people have a higher sense of self-efficacy and feel good about it and continue to do that kind of behavior.
So my role in the psychological evaluation pre-bariatric surgery is really to see if the person would be an appropriate candidate. Oftentimes when people want to have the surgery, they will say and do anything possible just to get me or anybody else to approve them, but since it is permanent, you've got to really make sure the person is a good candidate.
And together oftentimes we'll make that decision, whether they really are a good candidate. I've had people come to me, wanting to lose 30 or 40 pounds; wanting me to approve them for the surgery; and in that case I don't think they're a good candidate for something like gastric bypass. Just 30 or 40 pounds and it's people that are wanting a quick fix and not recognizing really what it takes. Like with the lap band you can't eat or drink at the same time. You have to give up carbonated drinks, caffeine, other things, and these are big lifelong changes that people really have to adhere to or you could have a lot of significant side effects and damages.
A good candidate is somebody that's done all the research; knows what it takes; knows that they need 60 to 90 grams of protein a day for the rest of their life; knows that they'll need to get blood tests on a regular basis; knows that they will to take vitamins every day for the rest of their life; doesn't typically use drugs or alcohol or shopping or sex or other things to cope with feelings; has a good social support; people that are aware of what their limitations are; that won't be using triggering foods in situations that might be tempting for somebody; and somebody that's willing and able to look at the underlying issues before, during and after. Because there is a lot of changes that happen after they lose a significant amount of weight. I've see a lot of divorces happen; a lot of separations happen; a lot of issues with people coming to terms with their new bodies because they've carried around the weight and the identity and the stigma that comes with that for so many years, that if you lose a hundred or two hundred pounds, there is a big adjustment that comes with that.
In many families there tends to be what is called an identified patient which is the person or the child that is the problematic person, if you will, in the family that that keeps the balance going because if Johnny is the one with the problem, we can all focus on Johnny. When Johnny loses a significant amount of weight, there is no longer the problem. There's a destruction or anarchy that sort of happens. And I see this almost daily in my practice. And so there will be sort of other family members that will start to create issues or sabotage the person that's losing weight and obviously a lot of resentment that comes with that, both from the person losing from the weight and from the family member. Because when things are a certain way, when Johnny is the one that's always trying to lose weight, that's what they do, and all of a sudden there's a huge shift that happens in the family. It's really interesting.
Sometimes it can be a letdown, too. It can be, well, I thought life was going to be perfect and was going to be great when I'm 150 pounds because all of a sudden it isn't because in many ways you are the same person you were before, with the same struggles, with the same personality, with the same temperament.
Once they get through the honeymoon phase of the weight loss, whether that be a year into it, a year-and-a-half into it, there can be a depression that sets in and then it sorts of brings on this issue of, well, now what, now that I've lost this weight and I've met my goal weight, what am I going to focus on now to make me happy. The issue being that if we look for something external to make us feel good about ourselves it usually doesn't work. And part of that is setting goals for ourselves, whether that be weight goals or otherwise, and reaching that and having an increase in self-efficacy and feeling good about who we are as people.
One of the things I think that's really important for caregivers to look at is not trying to control the situation or the behavior. Part of the big, big issue with people struggling to lose weight is control. And people get to place of being overweight by feeling that food is the only thing in their environment that they can control, ultimately what goes in and out of their body. And so caregivers, oftentimes with good intentions, will say, you know, honey, did you eat enough vegetables today or did you have your protein intake, and even though it is very important and you want to make sure the person is doing the right thing or following what they should, taking more of a backseat approach and letting the person sort of dictate their needs and let you know what they need from you, and so I think really be more of a support system and asking the person what they need. Another issue is also to not focus on the number. I think it's a big one because the person is typically so concerned with the fear of gaining weight, if anybody else asks them what they've eaten or how much weight they've lost, that can be a big trigger for people who have lost a significant amount of weight. Talk to the person, see what they need, see what they're wanting. There's a huge fear for people that have lost a significant amount of weight is weight re-gain, so that’s something to be aware of.
In the long term does losing weight make people happy? That's a loaded question. It makes people feel good that they've reached their goal if that's been their life-long goal but it does not deal with the underlying issues that caused them to gain weight in the first place. So it makes you more socially acceptable. It makes you feel that you fit in a room better. It makes you feel like people approach you differently, but I wouldn't say that it ultimately is the happy pill.
The issue of obesity is harder to treat than a substance abuse issue like alcoholism or food addiction. I find that food addiction is actually harder, and the reason being if somebody is a drug addict or an alcoholic you can abstain by no longer getting in contact with your dealer; no longer associating with your using friends; avoiding all bars or certain triggering parties. As a food addict, you can't really avoid food. You need food to live and so it's really changing for most people a life-long relationship, sort of the idea of living to eat versus eating to live. And so how do you change your relationship with something you have to deal with 3 to 5, 6 times a day? You can't stop eating. You have to still eat. And so it's much harder, much, much harder.
So one-on-one therapy is oftentimes helpful for people that have never really addressed their relationship with food. They might have a lot of shame, a lot of stigma, a lot of guilt about it, and so on a one-on-one basis it allows us to go deeper. It allows people to open up in a safer, more discreet environment. And group therapy is also really, really helpful for people, not just from an economical basis because typically it's less expensive, but you also get a camaraderie among people in the same situation so you get to see that you're not alone. Many, many people that struggle with all sorts of addiction feel that their situation is unique and they're alone and nobody can understand them. When you're in a group, you realize that many people are in the same situation, with the same thoughts and the same feelings and it makes you feel really good to have that support, to be able to get that empathy or tips from other people. There are free groups like OA Overeaters Anonymous which can be really helpful, as well. Some people have an issue, given that it's 12-step based, and they'll ask you to abstain from a specific food that's a triggering food. So some people have an issue with that. Some people find it really helpful.
I've seen many, many, many people overcome this obstacle in their life and change their relationship with food and more importantly with themselves. And it's not just about following a specific diet. It's getting to the root of the issue, understanding what it is you use food for or to hold on to this identity of being overweight, and it can be a huge significant change for you and your loved ones and for our health, both psychological and medical, and I've seen it many, many times, and with the right frame of mind and hard work, it's doable.