Tears run down his cheeks as he asks me why he seems to be set on a slow suicide. Why, he asks, would he go down this self-destructive path when he has so much to live for? He’s talking about how he let himself get so obese, why he let it go so far. I hear him and see the smart and jovial man in front of me, and I’m not sure if his theory is correct. In effect, his behaviour is indeed a slow suicide, since as the years go by and the weight keeps increasing, he becomes less and less healthy, with diabetes, hypertension, sleep apnea, and joint problems, but does he really have the intention or wish to die? Is he really on a mission of self-destruction, or is there a better explanation?
This forces us to consider some deep questions, such as “is chronic overeating and the severe obesity that it produces a voluntary act, or due to an addiction completely outside the individual’s control?” I have a couple of tests for this: first, imagine you have a choice between overeating and saving the life of someone you love…which do you choose; second, less dramatically, imagine you have a choice between 10 million dollars and overeating, which do you choose? The answers are obvious, but you might still doubt that the person will stick to the commitment.
“Slow suicide” is a harsh judgment, but one I’ve heard before. A slightly less extreme version is “am I self-destructive? Why do I sabotage myself?” Psychologists have defined three types of self-destructive behaviour: 1. The person foresees and desires to harm himself, 2. The harm is foreseen but not desired, and 3. The harm is neither foreseen nor desired. Research suggests that the second type is most common, and the first type is rare except among individuals with severe emotional disorders. The common form of self-destructive behaviour among normal individuals is due to disregarding costs in favour of immediate pleasure or relief; this means to favour short-term benefits (e.g. the momentary pleasure of eating) despite long-term risks, and this is especially likely during negative mood states.
Thus, unhealthy behaviour can result from impulsive choices based on the desire for immediate gratification, or what behavioural economists call “delay discounting” (delayed outcomes are perceived as less valuable than immediate ones). Unhealthy behaviour can also be the result of routinized, automatic behaviour (“bad habits”) – see the food, want the food, eat the food… We are all creatures of habit, and it takes effort, or at least “intention plus attention” to override those habits.
A useful analogy for the dilemma one faces in trying to change an unhealthy behaviour pattern is the following: a boat is cruising along in the ocean and the crew suddenly realizes it is heading for an iceberg (for want of a more likely obstacle!). The captain orders the boat to begin turning and the necessary actions are taken to produce this effect. Slowly the boat begins to turn, first slowing its momentum in the original direction and then gradually changing course. The boat in motion can not stop on a dime and jump course; it’s a gradual process, with the time needed to make the change proportional to the momentum that must be overcome. So too, a person with a long history of bad habits will need time to reverse course. Hopefully, the corrective actions were begun in time!
My patient and I have been meeting weekly for a couple of months, and we have a good rapport. He’s talked about many things, while losing about 40 pounds so far. We still don’t have “the” answer to his question. I resist the impulse to tell him his theory of “slow suicide” is incorrect and leave the question out there. Perhaps it will help him dig deeper and motivate him to find the will to live. We have a long way to go, both in terms of his weight, and to arrive at a satisfying explanation for how he got so big and, perhaps more important, why he won’t go back.
In developing our theory, my patient and I work as collaborators with a shared mission. In this case, because he comes from the business world, we say that he is the CEO (of the weight management company) and I am the executive VP of strategy. We work together to set up goals and plans, and monitor implementation and results. We are working to create momentum in the right direction, and we seem to be moving that way. Now we must stay the course…
Stephen Stotland, Ph.D.