When two roles clash

I was working at SHINE Health Academy, a community-based organisation that delivers a weight management programme for children and young people living with overweight and obesity. I took an additional role with a Community Eating Disorder Service (CEDs) in Child and Adolescent Mental Health Services (CAMHS). Suddenly, everything I had been teaching young people at SHINE was considered a big 'no'.

I had expected the roles may be different, but that there would also be overlap: after all, both groups had an unhealthy relationship with food. I wasn't prepared for these feelings of discomfort. I became unsure of myself and my practice. I had two opposing thoughts: 'these children need help to lose weight' and 'these children need to gain weight'. I worried that the extreme low weight children could go on to become overweight, and that the overweight children could develop an eating disorder, if my actions between groups were inconsistent. It was like the two thoughts could not exist in parallel. It was a struggle, and I began to reflect. The two distinct thoughts were based on my experiences with the extremes of either group. I was experiencing a type of cognitive dissonance.

Cognitive dissonance

Dissonance, put simply, refers to inconsistency. When this inconsistency related to thoughts, beliefs, and actions it can lead to an internal mental conflict. Cognitive dissonance (Festinger, 1957) has a real impact on people: it causes conflict in the mind, manifesting in physiological changes in the brain (Harmon-Jones & Harmon-Jones, 2007).

This can affect anyone: there can often be times when we need to behave in ways we do not agree with. Take the army, for example: there is a chain of command, and you must respect that. If your commanding officer tells you to do something, you do it, even at the expense of your own beliefs. Or consider the classic example of smoking (e.g. McMaster & Lee, 1991). A person who smokes may have a thought of 'I smoke', but they may also have a thought of 'smoking is unhealthy'. Recognising that inconsistency causes discomfort, often leading them to attempt to quit (Zhang & Duaso, 2021). But that's just one way to resolve the cognitive dissonance, through changing an action associated with the thought. There are another three options: change one of the thoughts (e.g. to 'smoking is not that bad for you), add a new thought to rationalise the inconsistency (e.g. 'I'm healthy most of the time, smoking isn't that bad then'), or play down the cognitive dissonance (e.g. 'I do not care about the health risks of smoking').

Back to my roles. Eating calorie dense foods and high amounts of carbohydrates is a norm at CEDs – encouraging that is important with patients who are physically risky. But at SHINE, we are encouraging young people to eat the appropriate portions of carbohydrates, leading to healthier eating patterns. We do work to the premise that 'no food is a bad food', but emphasise this is in moderation. Moderation appears to go out the window at CEDs in the context of anorexia. If there is a young person with anorexia nervosa, you want them to weight restore. This means gradually building them up to eating more than they would typically to maintain their weight: a good way to achieve this is through increased calorie dense foods.

Going from working with seriously underweight young people, needing a hospital admission, to work with severely overweight young people, can be a jarring difference. For young people to be referred to SHINE, they need to be above the 99.6th BMI centile or be two standard deviations above the normal range of weight and present with a comorbidity or risk of one. This means we see the extremes of higher weight young people, yet it is not as much of a shock to the system as when I see severely underweight adolescents at CEDs. This is because in society we see obesity more frequently: it is more common in the UK for people to be overweight (36.2%) and the statistics of obesity are at a record high of 28% (Baker, 2022). In comparison, the lifetime prevalence of anorexia nervosa is between 2-4% (NICE, 2019), so when we see young people with low weight and physical health risks it is more alarming. The decline in physical health can be more rapid as well (e.g. Sidiropoulos, 2007), meaning action needs to be taken at a greater speed.

Exploring similarities and differences

In hindsight, the dissonance between my two roles should have been readily apparent to me. I think I was being led by my interest in health and fitness. I had two options: leave one role, or to rationalise the discrepancy. I enjoyed working at both places: they both added to my professional and personal development, and they both gave me a sense of purpose and achievement. So I began to explore the similarities and differences between my practice. There was more in common than I had anticipated.

Both roles shared a focus on controlling weight through promoting a healthy approach to food, and not letting food control the young person. I went on to discover that both groups had health risks: one appeared more imminent (CEDs) and the other more gradual (SHINE), but either way there was a necessity for change to prevent deterioration of their physical health. I was able to reframe my thoughts to appreciate both roles were trying to achieve the same thing – a healthy young person. They both sought to provide psychoeducation around food, to normalise correct portion sizes and nutrition, whilst addressing the emotional context. They both used psychological measures to look at temporal difference, explored body image, mental health, and what a person should typically eat, to normalise correct portion sizes and nutrition. What initially appeared to be stark differences, in particular to people who have not worked in both services, held common underlying themes.

Upon further reflection, I eventually realised that the differences between the roles I had begun to surface were ways of achieving the same thing – to make a difference in a young person's life. That was why I continued both roles. Whilst I held that worry around influencing either group of young people from one extreme to the other, I had in fact taken more time to choose my words and actions. I used supervision and reflection to hold myself accountable. I finally understood that I had not been letting this cognitive dissonance impact my interaction with the young people of either group – I had been able to keep it in check.

I strongly believe that this experience of cognitive dissonance has strengthened my abilities and myself as a person. It has cemented my belief in reflective practice. I had not taken the time to sit down and really think through my cognitive dissonance. Some deep introspection around it had allowed me to overcome it. That discomfort had turned to new learning and unconditional acceptance.

Chloe Morris

Assistant Psychologist

Rotherham Doncaster and South Humber NHS Foundation Trust

CAMHS Community Eating Disorder Service

References

Baker, C. (2022, March 16). Obesity Statistics. House of Commons Library. 

Festinger, L. (1957). A Theory of cognitive dissonance. Stanford University Press.

Harmon-Jones, E., & Harmon-Jones, C. (2007). Cognitive dissonance theory after 50 years of development. Zeitschrift für Sozialpsychologie, 38(1), 7–16. 

National Institute for Health and Care Excellence. (2019). Eating disorders: How common is it?

Sidiropoulos M. (2007). Anorexia nervosa: The physiological consequences of starvation and the need for primary prevention efforts. McGill journal of medicine : MJM : an international forum for the advancement of medical sciences by students, 10(1), 20–25.

Zhang, S., & Jose Duaso, M. (2021). The delivery of smoking cessation interventions by nurses who smoke: A meta‐ethnographic synthesis. Journal of Advanced Nursing, 77(7), 2957-2970.