Focusing on Long-Term Weight Loss: The Art of the Possible

Judith Beck_Deborah Beck Busis_2014-2015.jpgDeborah Beck Busis, LCSW

Diet Program Coordinator

Beck Institute for Cognitive Behavior Therapy

A recent article in the American Journal of Public Health (Fildes et al., 2015) reiterates the disheartening statistics on weight loss. This study and many others have shown that most obese people who lose weight gain it back.  In our experience, a major reason for this outcome is that dieters make changes that they are unable to sustain. For example, they reduce their calories too much, eliminate favorite foods, decline social events that include food, or set exercise goals that are too strenuous or time-consuming. When they inevitably return to previous eating, social, and exercise habits, they regain weight, feel helpless, become hopeless and stop their weight loss efforts altogether.


To reverse this trend, we ensure that every change we suggest is reasonable and maintainable. This means that dieters usually do not lose weight as quickly as they have in the past or lose as much weight as they would like. But they are much more likely to keep off the weight (plus about five pounds or so) that they do lose. Our philosophy is that successful weight loss entails figuring out the art of the possible.


One of our dieters, for example, had a very busy schedule and disliked cooking. Through a variety of standard cognitive therapy techniques, we helped her prioritize exercise and healthy eating and then did problem solving. She committed to exercise 30 minutes three to four times a week, which meant reducing (but not eliminating) the time she spent watching television and reading for pleasure. She also chose not to cook dinner at home, so we created a list of healthy take out and frozen options and planned when she could make the time to pick up her food.  Could we have persuaded her to commit to several hours of shopping and cooking every Sunday to prepare healthy meals for the week? Probably. But as she disliked cooking, it seemed likely that at some point she would stop prioritizing and scheduling cooking and be left unprepared with no healthy food for the week.


Another dieter really loved pizza but believed, like many people, that he had to stop eating it altogether to lose weight.  Dieters frequently try to eliminate certain foods or entire food groups, but they almost always revert at some point to eating their favorite foods again (which is fine, as long as it is in moderation). Once they begin eating the “forbidden” food again, though, they overdo it, because they haven’t learned to plan when and how much they’re going to eat nor how to stick to this plan. They interpret their abstinence violation as a sign that they are off track and then have difficulty regaining control over their eating overall.


We taught this dieter a combination of cognitive and behavioral skills so he could stay in control around pizza. First we made a plan. He would go to a pizza shop several times and order two large slices to take out. We identified likely thoughts that would interfere with this plan and created strong responses that he read before he went. He practiced this plan several times, bringing the pizza home so he wouldn’t have immediate access to more. Once he gained confidence in his ability to eat a reasonable amount of pizza in a controlled environment, he practiced eating pizza in more difficult circumstances–when he went out to dinner and to a party. Each time we predicted the thoughts he might have that could lead him off track and developed coping cards for him to read. He was able to gain the skills and confidence to control himself around pizza, which significantly increased the probability of his keeping weight off long-term.


It just doesn’t work for most dieters long term to make changes they can sustain only in the short term. We believe that reversing the dismal statistics on weight loss starts first with a focus on the art of the possible and is predicated on two words: reasonable and maintainable.


Effectiveness of cognitive-behavioral group therapy for patients with hypochondriasis (health anxiety)

New Study (1)Abstract

Cognitive behavioral therapy (CBT) has been shown to be highly effective in the treatment of health anxiety. However, little is known about the effectiveness of group CBT in the treatment of health anxiety. The current study is the largest study that has investigated the effectiveness of combined individual and group CBT for patients with the diagnosis of hypochondriasis (N=80). Therapy outcomes were evaluated by several questionnaires. Patients showed a large improvement on these primary outcome measures both post-treatment (Cohen’s d=0.82-1.08) and at a 12-month follow-up (Cohen’s d=1.09-1.41). Measures of general psychopathology and somatic symptoms showed significant improvements, with small to medium effect sizes. Patients with more elevated hypochondriacal characteristics at therapy intake showed a larger therapy improvement, accounting for 7-8% of the variance in therapy outcome. CBT group therapy has therefore been shown to be an appropriate and cost-effective treatment for health anxiety.

Weck F., Gropalis M., Hiller W. & Bleichhardt G. (2015) Effectiveness of cognitive-behavioral group therapy for patients with hypochondriasis (health anxiety). Journal of Anxiety Disorder, 30 (1). doi: 10.1016/j.janxdis.2014.12.012. Epub 2015 Jan 3.

Using mobile technology to deliver a cognitive behaviour therapy-informed intervention in early psychosis (Actissist): Study protocol for a randomised controlled trial

New Study (1)Abstract

Background: Cognitive behaviour therapy (CBT) is recommended for the treatment of psychosis; however, only a small proportion of service users have access to this intervention. Smartphone technology using software applications (apps) could increase access to psychological approaches for psychosis. This paper reports the protocol development for a clinical trial of smartphone-based CBT.
Methods/Design: We present a study protocol that describes a single-blind randomised controlled trial comparing a cognitive behaviour therapy-informed software application (Actissist) plus Treatment As Usual (TAU) with a symptom monitoring software application (ClinTouch) plus TAU in early psychosis. The study consists of a 12-week intervention period. We aim to recruit and randomly assign 36 participants registered with early intervention services (EIS) across the North West of England, UK in a 2:1 ratio to each arm of the trial. Our primary objective is to determine whether in people with early psychosis the Actissist app is feasible to deliver and acceptable to use. Secondary aims are to determine whether Actissist impacts on predictors of first episode psychosis (FEP) relapse and enhances user empowerment, functioning and quality of life. Assessments will take place at baseline, 12 weeks (post-treatment) and 22-weeks (10 weeks post-treatment) by assessors blind to treatment condition. The trial will report on the feasibility and acceptability of Actissist and compare outcomes between the randomised arms. The study also incorporates semi-structured interviews about the experience of participating in the Actissist trial that will be qualitatively analysed to inform future developments of the Actissist protocol and app.
Discussion:To our knowledge, this is the first controlled trial to test the feasibility, acceptability, uptake, attrition and potential efficacy of a CBT-informed smartphone app for early psychosis. Mobile applications designed to deliver a psychologically-informed intervention offer new possibilities to extend the reach of traditional mental health service delivery across a range of serious mental health problems and provide choice about available care.

Bucci, S., Barrowclough, c.,  Ainsworth, J., Morris, R., Berry, K.,  Machin, M., Emsley, R., Lewis, S., Edge, D., Buchan, L., & Haddock, G. (2015) Using mobile technology to deliver a cognitive behaviour therapy-informed intervention in early psychosis (Actissist): Study protocol for a randomised controlled trial. Trials Journal, 16  doi:10.1186/s13063-015-0943-3

Weighing patients within cognitive-behavioral therapy for eating disorders: How, when and why

New Study (1)Abstract
While weight, beliefs about weight and weight changes are key issues in the pathology and treatment of eating disorders, there is substantial variation in whether and how psychological therapists weigh their patients. This review considers the reasons for that variability, highlighting the differences that exist in clinical protocols between therapies, as well as levels of reluctance on the part of some therapists and patients. It is noted that there have been substantial changes over time in the recommendations made within therapies, including cognitive-behavioral therapy (CBT). The review then makes the case for all CBT therapists needing to weigh their patients in session and for the patient to be aware of their weight, in order to give the best chance of cognitive, emotional and behavioral progress. Specific guidance is given as to how to weigh, stressing the importance of preparation of the patient and presentation, timing and execution of the task. Consideration is given to reasons that clinicians commonly report for not weighing patients routinely, and counter-arguments and solutions are presented. Finally, there is consideration of procedures to follow with some special groups of patients.


Weighing patients within cognitive-behavioural therapy for eating disorders: How, when and why:Behaviour Research and Therapy, Volume 70, Issue null, Pages 1-10 Glenn Waller, Victoria A. Mountford


Workshop Participant Spotlight – Amanda May, LLMSW

Amanda, a recent graduate of University of Michigan (but a Spartans fan!) attended the Beck Institute CBT for a PTSD workshop, taught by Dr. Aaron Brinen. She traveled from Michigan with 8 other trainees from Henry Ford Health System. At HFHS, Amanda is a clinical therapist for adults and teenagers; she also runs a substance abuse group. DSC_0328

The group from HFHS had the opportunity to travel to Philadelphia and attend training at Beck Institute, because their organization recently learned that they will be providing services to first responders in the Detroit area. The CBT for PTSD workshop was the perfect fit.

When she learned she would have the opportunity to attend a workshop at Beck Institute, Amanda was thrilled because she learned and loved CBT in graduate school. “And let’s be honest, the Beck Institute is prestigious.” Other than meeting Dr. Aaron Beck, and learning more about prolonged exposure therapy, Amanda most appreciated that “Dr. Brinen is amazing with talking about difficult topics and keeping us engaged.”

Experiencing CBT from the Inside Out: Is Self-Practice Important for CBT Therapists?

JBL photo 2014James Bennett-Levy, Ph.D., University of Sydney, Australia

Guest Author

“Your growth as a cognitive therapist will be enhanced if you start applying the tools described in this book to yourself.”  J. Beck (1995)

 So wrote Judith Beck in the 1995 edition of Cognitive Therapy: Basics and Beyond. Seven years earlier, I had done a 6-month training in CBT at the Institute of Psychiatry, London. Soon after commencing, I was struck by the potential relevance of CBT not only to patients but to my own life. So I said to a fellow trainee: “Why don’t we try CBT out on ourselves?” The experience was eye-opening and turned out to be the genesis of the self-experiential training strategy known as self-practice/self-reflection (SP/SR). I piloted SP/SR as a training strategy for the first time in 1998, fortified by Judith Beck’s and Christine Padesky’s assertions of the importance of practicing CBT techniques on oneself. Now, after 17 years of SP/SR research, we have published the first SP/SR manual, Experiencing CBT from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists (Bennett-Levy, Thwaites, Haarhoff & Perry, 2015).

We have learned many things along the way. Researchers in England, Australia, New Zealand, Ireland, Austria and Germany have demonstrated that SP/SR makes a unique contribution to therapist skill development, whether therapists are novices or experienced. A constant refrain from SP/SR participants is that using SP/SR to stand in the patient’s shoes has increased their empathy and understanding and led to a more nuanced approach to therapy. For instance, one experienced therapist reflected: “I feel I have taken away so many important things, but having experienced therapy has deepened my understanding of the importance of a good therapeutic alliance, collaboration, interest, trust, acceptance, compassion…

Another key finding has been that therapists report that their reflective capacity is enhanced by SP/SR. The 1980s work of Donald Schon (The Reflective Practitioner, 1983) and David Kolb (Experiential Learning, 1984) highlighted the key role that reflection plays in adult learning.  SP/SR therapists report becoming more reflective through the process. Consequently, their CBT understanding and skills improve, and they are better able to integrate conceptual, technical and interpersonal aspects of the therapy. More recently, we are also starting to see reports that SP/SR may also increase therapist resilience and decrease propensity for burnout. For a comprehensive SP/SR bibliography, click here).

So what is SP/SR?

Typically, SP/SR comes in a manualized form, with 6-12 modules. Participants work through the modules week-by-week. Each module may take about 2 hours. Participants select a particular problem they wish to work on during an SP/SR program. For novice therapists, we recommend that the problem is a ‘therapist problem’ – typically, this might be ‘to stop criticizing myself and undermining my confidence as a CBT therapist’. For more experienced therapists, we suggest they take either a therapist problem (e.g. ‘my difficulty working with assertive patients’) or a personal problem (e.g. ‘my social anxiety when it comes to public speaking’).

Underpinning the self-practice (SP) element of Experiencing CBT from the Inside Out is a strengths-based, behavioral/experiential approach, designed to reflect contemporary understandings of change processes in CBT. In the first part of the workbook, participants formulate and deepen their understanding of their Old (Unhelpful) Ways of Being. In the second half of the workbook, they create and strengthen their New Ways of Being drawing on experiential strategies such behavioural experiments, imagery and body-oriented interventions and narrative strategies. To amplify the old/new contrast, we have introduced a modified method of formulation, the Old Ways of Being/New Ways of Being Disk model, a transdiagnostic schema-based method of contrasting ‘how I am now’ with ‘how I’d like to be’ for anyone, regardless of their problem.

However, the self-practice (SP) aspect of the SP/SR experience is only half the story. The other equally potent half is the self-reflection (SR). SP/SR modules finish with a series of self-reflective questions, typically something like: What was your experience of using imagery to construct New Ways of Being? How do you understand this experience? What are the implications of your experience for your work with patients? How does your experience affect your understanding of cognitive theory? These reflective questions move the SP/SR participant from personal experience to professional implications. SP/SR is therefore designed as a targeted, focused training strategy, which – in contrast to personal therapy which usually just focuses on the personal – makes an explicit link between the personal and the professional.

We have offered SP/SR to groups of participants ranging from interns and assistant psychologists through to experienced supervisors. Invariably, the experience of those who engage with the program is one of astonishment – new insights, a different experience “from the inside out.” SP/SR works best in groups where participants share their reflections in group forums such as internet message boards. At the start of the program, the group decides how this is done, how frequently, etc. We have learnt that facilitating an SP/SR program requires a different skillset to ‘usual training skills’. So in our new book, we have devoted specific chapters to providing guidelines for both SP/SR facilitators and participants. A key element in fostering engagement with the SP/SR process is ensuring that SP/SR participants feel safe with the process that involves sharing self-reflections. While SP/SR can be done individually or in groups, our recommendation, if you can, is to get together a small group of colleagues – or students in a university program. Then take 2 weeks for each module, sharing the written reflections.

So is experiencing CBT from the inside out important for contemporary CBT therapists? Absolutely! The benefit of SP/SR is that it cuts both ways: it’s a stimulating, challenging way to help our patients by developing our CBT skills – and to make changes for ourselves.