A Doctor's Discovery

Shadrach Smith, MD

Gwen was living the American dream, except for a common corresponding American nightmare. She taught second grade, was happily married to a bank vice president and was mother of three healthy children. She devoted her busy busy life to her socially active husband, some church activities and three children with their hamster-like school activities. Husband, church and children were flourishing-to her delight. That's the dream part.

Gwen was also 40 pounds overweight and gaining. She was tired and a bit depressed. That's the nightmare part-- the reason she showed up at the office wanting me to fix the one flaw in her life. She was sure it was her thyroid, because Oprah had described her symptoms exactly. She just knew her problem was her metabolism.

I'm Dr. Shadrach Smith. I'm director of Truman Medical Center here in Kansas City. I specialize in weight management. Let me tell you that this is an old story and a true story. Here's what I did for her, why it didn't work, and why the Enneagram changed the story.

Apparent Self-Interest

I ran the proper tests. Her metabolism was fine. No thyroid imbalance. Her weight was causing some blood pressure problems and she was pre-diabetic. So I told her what to do. I told her what any good doctor would tell her - "Eat less, eat better and exercise. Get some more rest, too. Your fatigue and high blood pressure probably stem from stress."

I gave her some medication for blood pressure and elevated glucose. She came back later and the medications had worked: blood pressure and glucose were fine. I asked her to return in three months for a follow up.

She didn't return in three months. But nine months later, she came back with a sinus infection and her glucose levels and blood pressure were worse. She had also gained another 10 pounds. When my nurse called the pharmacy to renew the medications, it turns out she had discontinued them.

Well, I had told her what to do and she didn't do it. My advice was mainline medical practice and if she had followed my professional instructions, she would have been fine. But she ignored my expensive professional advice completely!

Gwen was intelligent, emotionally healthy, motivated --and non-compliant. Why? Why would she come for help, receive it and then ignore it? Why would she act against her apparent self-interest?

When something doesn't make sense on one level, it does on another. Shortly after Gwen's (and my?) failure, I learned the Enneagram. I had learned it in church and studied further with Clarence. The Enneagram taught me about a level of motivation that could explain why people act against their self-interest. Here's how an Enneagram-level intervention changed everything, including Gwen's weight.

Enter The Enneagram and Motivation

Gwen is an Enneagram style Two. Style Twos have some of these characteristics: they can be compulsive givers. They tend to focus on meeting the needs of others but have difficulty acknowledging their own needs. Their lives frequently revolve around taking care of everyone they can. They can often feel selfish, even immoral, if they attend to their own needs. Style Twos are intensely interpersonal. Their lives revolve around people to a degree not matched by other styles

When I learned that Gwen was a Style Two, I changed my approach considerably, and Gwen lost her weight. It is a truism among therapists and coaches that people come for help to make their current habits work better. They want to keep doing what they are doing but get better results. Gwen was no exception.

Gwen did not come to lose weight. Not really. She came to be happier (less depressed) and have more energy (less fatigue) in order to do more of what she was already doing too much: meeting the needs of her family and community. She wanted to do what Twos do best: serve the needs of others and make everyone happy. Although it would have been difficult for her to articulate exactly what she wanted, her real desire was to have more energy so she could work even harder serving others.

Fortified with my Enneagram insights, I called Gwen to come in for a new health plan. This time we addressed her real problems (her presenting complaints were only symptoms). She was working so hard she was stressed and did not have time or energy to prepare healthy meals. That was part of the physical problem. Some of her fatigue was predictable: long hours of hard work for others with little time for herself. This is not a medical problem, it is a life-style problem. The depression related to the lack of appreciation she received from her tireless service as well as the fatigue. Food, especially comfort food, was a time-tested and convenient way to reward herself each evening for all the service she had rendered that day.

We worked out a plan for some self-nurturing. She was to share her situation with the family and ask for their support. This is hard for a Two but she was helped to understand that if she stayed overweight, tired and depressed, she could not serve them. That double bind (if she kept on serving, she couldn't serve) helped her ask for their cooperation. She eased back on some of her service and attended to her own previously unacknowledged needs and desires.

New Results

Her next visit, a month later, was richly rewarding for both of us. Gwen improved her blood pressure and glucose levels; she had lost six pounds and her energy levels had risen. In another six months she lost 20 more pounds and was ecstatic. "Doc, you saved my life! I've been dieting for 25 years and this is the first plan I can continue for a lifetime because I am not doing this by myself." I felt professionally elated: I had helped cure depression, blood pressure, glucose levels and obesity. Not bad for a few hours work! I even felt sort of "two-ish" myself, being so helpful.

My elation was tempered by my understanding that while my medical training prepared me to diagnose diabetes and hypertension, it did not really equip me to diagnose and treat someone feeling overwhelmed and unloved, which was the real problem.

One battle does not win a war and one success in an epidemic isn't enough. I was looking for an answer to a chronic problem: why do intelligent, even motivated, people fail to what is necessary to control their weight?

I questioned myself deeply. My experience helping Gwen forced me to question my technical approach to healthcare. My academic education taught me to prescribe treatment based on objective-measurable and reproducible-findings. I was to base treatment on validated double-blind, placebo controlled studies that statistics supported. The personal differences in doctor and patient were deliberately effectively screened out. But Gwen's medical problems: depression, elevated glucose levels and obesity could not be treated unless Gwen's central motivation-service to others-could be harnessed. And that could not be harnessed without bringing in the personal and subjective factors. My most prestigious traditional medical treatment procedures needed one more element.

Traditional approach to illness:

Traditional medical care focuses on acute problems, not chronic disease. For example, if a patient comes with a fever and is found to have bacterial pneumonia, several days of antibodies will "cure" him, without any lifestyle modification. "Just take your meds."

However, the leading health problems of America: heart disease, obesity, hypertension and diabetes are not really curable. Not in 10 days, sometimes not at all and never by just taking some meds. The usual medical goal is to prevent complications and disease progression.

Gwen is a poster child for someone with a chronic life-style disease. We don't have chemicals she could take to "fix" her in 10 days.

But when I took another approach and understood her real motivation I could address her lifestyle problems. Preaching about non-compliance wouldn't have helped. We needed to work together so she got what she really wanted instead of just pruning one symptom off her lifestyle syndrome. She didn't need chemical adjustment; she needed to change her lifestyle. But what is important to realize is that her lifestyle had an unconscious central motive, an energy that could be harnessed. That's why the Enneagram information was central.

What my medical education assumed, and so does not address, is motivation. Despite mountains of literature, health care providers assume people act in their own best interests. The crippling corollary of this assumption is that people will follow medical instructions without any support, reward or follow-through on the part of the professional. Gwen didn't. People don't stick to diets and don't take their meds. Further, they continue to eat food you and they know are bad for them. Let's see why.