As Jacob Kornbeck explained in thefirst article of this series last month,obesity is a chronic disease caused by

an imbalance between diet and exercise thataffects the health, well-being and self-esteemof an increasing range of people, including adisproportionate number of users of socialwork services. Obesity is linked with povertyand deprivation, and increased incidences ofheart disease, diabetes, and stroke. Theoccurrence of obesity is higher in peoplewho live in disadvantaged socio-economicareas. For these reasons, obesity is an issuefor social workers because the people withwhom they engage are statistically morelikely to experience the problem.

In partnership with health and education,social workers can make a significantcontribution towards countering eatingpatterns that lead to obesity. The NationalHealth Service has identified obesity as apublic health priority (DH 2005). Statistics

from the NHS Information Centre (2008)showed that in 2006, 24% of adults aged 16or over in England were classified as obese,up on the 15% recorded in 1993. The sameNHS data suggested that 16% of childrenaged two to five were obese in 2006,compared with 11% in 1995.

Informal Local strategies for tackling obesity havetended to consist of informal educationalprocesses that provide information about thehealth risks of obesity to the public as awhole, and to individuals at risk, includingdiet sheets, encouragement of healthy eating,medication, weight loss groups, and exercise.But how do social workers fit into theseefforts and how can they make acontribution to tackling obesity?

In my view there are three principles towhat social work can offer. A beginningprinciple is to draw on the social work value

of respect for persons and express empathyfor obese individuals, rather than blame ordisapproval. A second principle is to identifyjointly, in partnership with the individual,the circumstances of their obesity, takinginto account cultural, social and historicalinfluences on body size and shape, familyinfluences and beliefs, ethnic values, andsocial environments in relation to eating andfood; as well as psychological triggers forovereating. By jointly exploring issues, ashared understanding of the individual’sexperience of eating and relationship withfood can be identified as part of anempowering process. This assessment can beused to motivate individuals towards change.

Accordingly, a third principle is torecognise that to change people’s orientationtowards food, individuals must feelmotivated to examine and challenge long-standing beliefs and habits. Motivationalinterviewing, a directive client-centred

PROFESSIONALSOCIAL WORK26

Feature

www.basw.co.uk

In the second and final part of PSW’s focus on social work’s role in supporting people with obesity in makingchanges to their lifestyle in the interests of their health and their families health. Patricia Higham focuses on theforms of intervention, motivational and therapeutic, that can help to make a difference

Options against obesity

P026-027_PSW_Mar09.qxd 24/2/09 11:44 Page 10

counselling method set out in the 2002book, Motivational Interviewing: PreparingPeople for Change (Miller, W.R. and Rollnick,S.), and first developed for working withalcoholics, could be adapted for work withobese people, an approach advocated in a2005 article, titled Motivational Interviewing,in the Annual Review of Clinical Psychology(Hettema, J., Steele, J. and Miller, W. R.)

Motivational interviewing seeks toestablish a constructive relationship betweenservice user and worker, to evaluate problembehaviours and resistance to change in thelight of personal values and goals. Forresteret al’s 2008 study of the technique in relationto social work with parental alcohol abusesuggests that whilst it may be a usefulmethod for social workers, more work isneeded to develop its use in specific settings.

Once an obese person is motivatedtowards change, a social worker can choosebetween, or combine elements of, two broadintervention models: an informaleducational process similar to that used bythe NHS – which is akin to the socialpedagogue model of social work advocatedby Kornbeck and Lumsden in the 2008publication Post-Qualifying Social WorkPractice (Higham, P.) – or a therapeuticapproach based on transactional analysisthat explores psychological issues.

Educational ‘Social pedagogues’ promote individual well-being through informal educationalstrategies that enable people to manage theirlives. It can be argued that the NHSinformation-giving and awareness-raisingapproach for tackling obesity is illustrative ofa social pedagogue method. Within theUnited Kingdom, social pedagogy isperceived as a European model of socialwork that is practiced within, but notlimited to, Germany, Denmark, and theNetherlands. However, its techniques can bepractised by UK social workers whereappropriate, and it can be argued that it is anappropriate method for working withobesity, with social workers deployinginformation giving and informal educationaltechniques within supportive relationships.

In contrast, an innovative therapeuticapproach is to adapt Transactional Analysis,a personality theory that Eric Berne (GamesPeople Play – The Basic Handbook ofTransactional Analysis, 1964) adapted frompsychoanalytic theory, for tackling issues ofobesity. The Transactional Analysis approachseeks to understand how individualscommunicate through their use of habitualpatterns of relationships and behaviours,based on three ego states of the child, theparent, and the adult. Transactional Analysis

assumes that people are, in essence, ‘OK’; itclaims to provide an easily understoodmethod of diagnosing psychological issuesand bringing about change.

Kathy Leach, a psychotherapist, haswritten a practical guide, The OverweightPatient: A Psychological Approach toUnderstanding and Working with Obesity,(2006), based on Transactional Analysis forpractitioners who work with people insituations where obesity is an acknowledgedissue. Leach’s aim is to help obese individualsdevelop adult-to-adult communications as astrategy for dealing with their weightproblems. Her Transactional Analysis-basedapproach suggests different ways of thinkingabout and practising with obese individuals,with the goal of enabling the individual tomake a positive guilt-free choice to tackletheir obesity. A positive choice, Leach argues,will be made by the here-and-now rationaladult self (‘adult ego state’), rather than bythe negative, internalised ‘parent ego state’, orby the fearful inner ‘child ego state’.Although Leach pays some attention toexercise, medication, diet sheets, and weightreduction groups, she claims that unlessindividuals succeed in avoidingpsychological dependence (as the ‘child’) onthe weight loss group leader – perceived as aparent figure – they may regain weight oncethey leave and experience the loss of thatdependence. Leach argues that obeseindividuals use psychological game-playingas a source of ‘strokes’ (units of recognition)and a defence against open communication.

Leach goes on to assert that practitionerswho are not Transactional Analysistherapists, or who are not psychologicallytrained, can still make effective use of theconcepts. The usefulness of this therapeuticapproach depends on whether the socialworker can accept Leach’s hypothesis – thatobesity can be caused and maintained by

psychological causes. Although theTransactional Analysis approach takesorganic causes of obesity into account, itdoes not develop alternative explanations ofthe rising incidence of overweight people:the decline in heavy physical activity inpeople’s occupations, an increasing use ofautomobiles, less physical exercise, and foodsuppliers promoting fatty, calorific foodladen with sugar and carbohydrates.

Psychological factors are not the onlyissues that determine whether or not anindividual is obese. An inexperiencedpractitioner who adopts a therapeuticapproach without considering differentcauses of obesity and different ways ofhelping individuals to tackle the issue runsthe risk of causing harm rather than beinghelpful. Put simply, obesity is a relevant issuefor social work practice and a social worker’sability to consider environmental andcontextual issues is an appropriate skill forworking with obesity.

In turn, an empowering approach thatengages the social worker in partnershipwith the individual should lead to anappropriate choice of intervention.

www.basw.co.uk PROFESSIONALSOCIAL WORK 27

March 2009 Feature

Patricia Higham is an independent consultant. She isVisiting Professor of Social Work at the University ofNorthampton, a Non-Executive Director of a NHS PrimaryCare Trust, and Emeritus Professor of Social Work andSocial Care at Nottingham Trent University. She is also an

External Assessor for theNorthern Ireland PostQualifying Education andTraining Partnership,and the PostqualifyingConsortium Wales. Hermost recent book isPost Qualifying SocialWork Practice (Sage,2008).

P026-027_PSW_Mar09.qxd 24/2/09 11:44 Page 11