Successful Psychotherapy Comes Down to Finding the Motivation for Change By Tom Medlar, LMHC on 6/13/23 - 2:38 AM

Peter: Comfort in Food and Resistance to Change

“I have an Italian last name and I always wanted a good Italian first name like Pasquale or Aureliano, but what I got was just Peter.”

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

Peter was a single man in his early 50’s when he came to the nursing facility. Until then, he had lived his whole life with his mother, and he was anguished over being apart from her. “I don’t even feel like I’m a separate person from her,” Peter said during a psychotherapy session.

Peter recalled being diagnosed in late childhood with a Rett Syndrome variant, apparently related to a speech disturbance. He had experienced early learning difficulties, yet he had developed language skills and general motor skills. He showed mild autistic features and lifelong obesity. He never fit in with his siblings or peers, didn’t play sport games, and found socializing desirable yet dreadful due to anxiety and uncertainty. His mother and brother did not have detailed recall of his childhood medical information, and his mother simply said, “He was always different, never like other people.”

After his weight reached 625 pounds, Peter refused to be weighed anymore at the nursing facility. He would sometimes request double portions of meals, ordered in fast-food meals, and often requested snacks. Peter would mimic the lectures he had so often been given by family and healthcare providers about the risks of obesity and the potential benefits of weight loss. He understood the risks inherent in his lifestyle of lying in bed, eating, and watching TV.

In psychotherapy, Peter wanted to express his outrage over his mother’s refusal to allow him to return home, yet he was willing to consider her stated viewpoint: she was aging, and his daily care needs exceeded her ability to manage them. He defended his unwillingness to consider any dieting or change of his daily routines yet was willing to review in psychotherapy the information and concerns others had communicated to him about eating and health risks. Peter was also unwilling to give up the style of eating that he felt was a lifeline. He was not motivated to change. Yet he liked psychotherapy because, “You listen to me, and you don’t look down on me, and see some good in me, and nobody else does that.”

Peter had not worn clothes for years. In bed he was covered by a sheet, and when he got out of bed, he would be clad in a checkerboard of hospital gowns draped and tied around his body. The facility purchased a custom-made wheelchair that was four feet wide. It would not fit through any doors, so it stayed against the wall outside his room. Peter would use a walker to come to the door, then edge sideways out the door, and settle into the wheelchair. Stretched out behind the chair, I would push him to a niche at the end of a hall where we could sit for sessions.

Emotional tensions in the case came from nurses and aides who felt uncomfortable with his ways of eating. Many team meetings and individual consultations were needed to clarify and resolve differences in viewpoint and approach. Individual staff persons might try to intervene by refusing his requests for foods, and by hectoring him — ‘you’re killing yourself; you know.’ Peter was cognitively capable of making informed choices about his daily behaviors and his healthcare. Nurses fretted that, ‘I might lose my license if he dies, and I didn’t do something to stop him.’

We had many conversations about the rights of a (mentally intact) person to make choices, even if we disagreed with those choices, and even if we noticed health risks attached to those choices. We spoke of how a staff person might smoke, eat fast foods regularly, text while driving, or do any number of other potentially risky behaviors, and how others do not try to take away your rights to make such choices (unless you live in California, that is).

Peter experienced developmental complications due to a type of genetic disorder — one often linked with obesity. He had a deeply conflicted relationship with his mother, and he had experienced a lack of peer relationships and appropriate socializing opportunities in his life. He exhibited social anxiety and avoidance, and profound feelings of shame and self-loathing. He felt unwilling and unable to endure prolonged discomfort and deprivation to pursue goals that he felt were not his own. But he relished therapy conversations in which he could discuss — without feeling shamed — all the above topics and many others, including his extensive knowledge of TV shows and movies over the prior few decades. He remained obese.

Mykela: Discomfort and the Motivation to Change

Mykela was also in her early 50’s. She had lived for the past few years with her father in his house. She rarely left the house due to feelings of anxiety and depression, and embarrassment over her body weight. She came to the nursing facility after an illness that required hospital care. Mykela weighed 450 pounds, and she felt strongly motivated to lose weight. She immediately wanted Bariatric surgery to assist her weight loss, yet the doctor wanted her to lose significant weight before he would agree to the procedure, due to possible risks and complications. The doctor still wanted her to lose more weight, yet he did eventually agree to surgery after she’d lost 50 pounds which took her about a year to achieve.

Mykela spoke in psychotherapy of her history of depression and its roots in childhood experiences. She verbalized the distress she felt in public when others might mock, deride, or insult her. She wept as we discussed whether she would (dare to) join a group outing from the nursing facility to an apple orchard to pick apples, but she returned more confident because she had endured unpleasant looks and comments without collapsing emotionally.

After her Bariatric surgery, she did adhere to a rigorous diet plan, and she steadily lost more weight. Mykela lost so much weight that large folds of skin would swing and clap against her body as she walked with her walker. She had further surgery to remove skin folds — and rather than feeling ashamed, she wanted to show off her surgical scars and her now slimmer body — as signs of her fortitude and motivation. Mykela returned home, walking without support. She cared for her aging father and drove her car. She became a spokeswoman at the Bariatric clinic to encourage and support others interested in making positive life changes.


In nursing facilities, I work with clients who, like Peter and Mykela, have quite complex problems, and who exhibit varied degrees of motivation, or even capacity to effectively make the kinds of changes others might recommend. Peter had felt rejected and despised for most of his life. He did not want for himself what others had strongly advised for decades. He felt relieved, though, to find a therapeutic relationship in which he could feel safe, and he was then willing to look at the viewpoints of others without defensiveness. But he was unwilling or unable to make comprehensive and sustained changes to his lifelong patterns of behavior. Mykela, in contrast, felt an inherent motivation to change, yet she needed the support of psychotherapy to help her connect with her strengths and to foster the fortitude and resilience needed to effectively achieve her goals. Unlike body weight, success is not always easily measured.   

File under: The Art of Psychotherapy, A Day in the Life of a Therapist