A Cognitive Therapy Approach to Weight Loss and Maintenance: An Expert Interview With Judith S. Beck, PhD Judith S. Beck, PhD, Medscape Psychiatry & Mental Health. Posted 04/23/2007
Do Cognitive Therapy Concepts For Losing Weight Apply To Improving Compliance?
I’m convinced this Medscape interview with Judy Beck on a cognitive therapy approach to weight loss has straightforward implications for optimizing patient compliance. Rather than argue the case, however, I encourage you to check it out for yourselves. To facilitate this process, I’ve excerpted some of the portions of the interview that are pertinent to treatment adherence. I suggest reading through the selections once for a sense of Dr. Beck’s notions regarding cognitive therapy and weight reduction and then re-reading the same material, mentally transforming the goal from weight loss to patient compliance. I think you’ll find the exercise simple and enlightening.
Medscape: Do people become demoralized when they find out that dieting isn’t as easy as they had thought?
Dr. Beck: Yes. That’s why it’s important to lay the groundwork with dieters first. In fact, I suggest that people spend a couple weeks learning certain skills before they even start. One skill is to compose and read every day a list of every advantage they can think of for losing weight. They’ll need to read this list for a very long time, so when they face temptation, these advantages will be firmly in mind. And they need to prepare in advance what to say to themselves when dieting gets harder, when they feel discouraged, when the scale hasn’t gone down, when they stray from their diet, and when they start to feel the injustice of food restriction.
Medscape: What role does distorted thinking play in unsuccessful efforts to lose weight?
Dr. Beck: Dieters who fail to lose weight or fail to maintain their weight loss think differently from those who are able to lose weight and keep it off long term. They have a lot of all-or-nothing thinking:
* Being full (often overly full) is good; hunger is bad;
* They’re good if they follow their diets, but bad if they make 1 mistake;
* Their eating week was either good (relatively easy) or bad (even if they only struggled for several minutes on several days);
* Food is either good or bad even though we recommend that dieters plan in advance to modify their diets so they can eat small portions of whatever food they want as often as once a day; and
* Dieters who fail to lose weight also view themselves as either in control (100% perfect) or out of control. They often think that 1 mistake should give them license to eat whatever they want for the rest of the day and delay starting fresh until the next day. They also believe that people of ‘normal’ weight rarely restrict their eating and rarely get hungry. They think that once they lose weight, they should be able to return to their old way of eating.
Medscape: How do you get people to recognize these kinds of ideas and what do you suggest they do about them?
Dr. Beck: We use standard cognitive therapy techniques, teaching them to ask themselves what’s going through their minds when they feel hunger and craving, when they are disgruntled about not eating, when they are tempted to eat something they haven’t planned. Then they read ‘response cards’; index cards that contain compelling answers to their thoughts. They read these cards at least once a day, usually in the morning; then pull them out again on an as-needed basis, sometimes several times a day toward the beginning of their diet.
Medscape: Can you give an example of a response card?
Dr. Beck: We make them up idiosyncratically with dieters. Some common ideas are: Even though I really want to eat now, I haven’t planned to. If I eat, I’ll strengthen my ‘giving-in’ habit, which means in the future I’m more likely to give in. If I don’t eat, I’ll strengthen my ‘resistance’ habit, which makes it more likely that in the future I’ll be able to resist. I can tolerate not eating now. I’ll be very glad in a few minutes when the desire goes away. I shouldn’t give myself a choice about this. After all, I’d rather be thinner. I can’t eat whatever I want AND also be thinner. I have to make a choice. Every time matters.
Medscape: What about emotional eating?
Dr. Beck: Dieters give themselves permission to stray from their diet for any number of reasons. They’re upset, happy, tired, stressed, celebrating, traveling, busy, at a party…the list is endless. They think, ‘It’s okay to eat because…. everyone else is; it’s only a small piece; no one is watching; the food is free; I rarely get a chance to eat this kind of food.’ They need to learn the same skills to avoid straying from their plan, no matter what the reason. They have to grasp the fact that they can either eat what they want, when they want, for whatever reason they want (including being upset) — or they can be thinner. But it’s impossible to have it both ways.
Medscape: What do you suggest people do when they’re tempted by food that they’re not supposed to eat?
Dr. Beck: As I keep saying, they have to prepare in advance for these times. They need to continually remind themselves (often by reading response cards) of the reasons to lose weight, that they can tolerate the discomfort of not eating (after all, they’ve tolerated much worse discomfort in their lives), that they’ll be happy in a few minutes when the desire to eat passes that they didn’t eat and they’ll be very unhappy in a few minutes if they give in to temptation. They also need a list of things they can do when they feel tempted — such as reading a diet book, surfing the Web for diet-related sites, taking a walk, calling a friend, brushing their teeth, writing emails, and so forth. We help dieters create a list of about 20 activities or so and urge them to try 5 of them each time they’re tempted.
Medscape: You mentioned that dieters need someone to be accountable to.
Dr. Beck: Yes, we encourage everyone to find a ‘diet coach’: a friend, family member, coworker, neighbor, or maybe someone else who is trying to lose weight. Diet coaches don’t necessarily need to know much about dieting. But they do need to be highly supportive and encouraging. They also need to be willing to hunt down the dieter who has failed to keep his or her regularly scheduled weekly appointment (by telephone or email, or in person), reporting on how his/her weight has changed that week. Dieters don’t need to reveal their weight; only their change in weight. In addition, diet coaches need to be good problem solvers.
Medscape: What kinds of problems arise that dieters need help with?
Dr. Beck: Common problems include practical ones, such as not enough time to schedule in dieting and exercise activities, and psychological ones, such as demoralization and discouragement. Some dieters need encouragement (and sometimes a little assertiveness coaching) to state their needs to family and coworkers. It’s surprising how many dieters are reluctant to turn down food that others offer or to ask that others bring only a single serving of overly tempting foods into the home, at least at the beginning. Ultimately, we want to build up dieters’ control so that they can keep any kind of food in the house and eat only small, planned-in-advance amounts.