Potential clients may be reluctant to enter treatment for a variety of reasons. As a clinician, it’s helpful to understand the function behind their thoughts and the emotion they feel as a result.
“Every minute in a session is precious, and we want to maximize the time we have to help clients learn to deal with the issues that are most important to them.”
Dr. Judith Beck
By Deborah Beck Busis, LCSW
Director, Beck Diet Programs
A recent article published in the New York Times, “After ‘The Biggest Loser,’ Their Bodies Fought to Regain Weight,” details how most of the contestants on the television show, “The Biggest Loser,” regained much, if not all of the weight they had lost while on the show. The article also describes how the contestants’ metabolisms slowed down as they lost weight and did not return to their original level once they regained their weight. The level of the hormone leptin, which influences hunger, also did not return to the original level, and in fact, reached only about half of what it had been before they started to diet.
The article certainly is discouraging. It also emphasized that the dieters, who lost weight through extreme calorie restriction and high levels of exercise, had to eat substantially fewer calories (up to 500 calories less) than other people who hadn’t dieted, to maintain their weight loss. We don’t believe the situation is hopeless, however. There is a significant amount of research that shows that while there is a change in metabolism as people lose weight, the amount varies. These studies generally show that the metabolic penalty is between 20-200 calories and that this penalty decreases modestly in the year following weight loss. On the other hand, a meta-analysis that was published in 2012 found no change in the metabolic rates of dieters.
In our program, most people have been able to lose weight and keep it off—when they’re willing to have periodic booster sessions to keep their cognitive and behavioral skills sharp. There are several key components of our weight loss program that are drastically different from what the contestants on the “The Biggest Loser” do. First and foremost, our clients do not lose as much weight and they do not lose it quickly; usually, the rate is half a pound to two pounds per week.
Along with slower weight loss, our clients also follow diet and exercise plans that fit in with their lives. In terms of exercise, none of our clients devote the nine hours per week that the “Biggest Loser” participants were advised to do once they returned home. Although the article didn’t describe the specific diets participants followed while they were being filmed, it is likely that the diets were quite restrictive, both in terms of number of calories and the types of permitted foods. This, too, is quite contrary to our program. From the start, we work with our clients to incorporate all their favorite foods into their diets in reasonable ways. We work hard to ensure that our clients only make changes in their eating that they can sustain in the long term.
When helping our clients make changes in eating and exercise, the two words that we constantly use are reasonable and maintainable. We have found that when dieters lose weight eating or exercising in a way they can’t maintain, they invariably gain the weight back when they revert to old behaviors. Most of our clients don’t lose as much as they’d like because to do so would require unmaintainable eating and/or exercise plans. But they do get to a place where they feel strong and in control of their eating; their health is better; they have gained most of the advantages of being at a lower weight; they experience far fewer cravings; and they feel confident that they can keep doing what they’re doing. They not only know what to do but also can competently solve problems and address dysfunctional thoughts and beliefs that interfere with maintaining the needed changes in behavior.
As far as we can tell, “The Biggest Loser” is the antithesis of our program. Although we haven’t had our clients track their metabolisms before and after weight loss, we assume that taking a much more measured approach is part of what enables our clients to lose weight and keep it off. While doing it this way is less compelling in the moment, because the pounds fail to drop off at lightning speed, it seems to pay off in the long term, as dieters lose weight by putting behaviors into place, supported by changes in cognition, that they can ultimately maintain.
Are you a professional who works with dieters?
In many cases, it’s difficult for clients to know whether they’re making progress because therapists do not necessarily state the goals and desired outcomes of therapy sessions. Clients may need to rely on their own global impressions. When clients are treated by cognitive behavior therapy (CBT) clinicians, though, they know how well therapy is working, because CBT therapists monitor progress each week by:
- evaluating clients’ symptoms
- measuring the occurrence of specific target behaviors
- assessing progress toward specific goals
In fact, research shows that when both therapists and clients receive feedback on progress, clients tend to have better outcomes (Lambert, et al., 2002).
For example, CBT clinicians ask clients to fill out symptom checklists before each session, such as those for depression and anxiety. If applicable, clients may track and report the occurrence of panic attacks, angry outbursts, or incidents of self-harm behavior. They may also track the frequency and amount of alcohol, drugs, nicotine, or food they ingested in the previous week—or the number of minutes they engaged in compulsive rituals. The type of monitoring and assessment varies from client to client, based on the goals they’ve decided they want to work toward. CBT therapists discuss these assessments with clients. When clients do not make expected progress, they conceptualize the difficulty and modify treatment accordingly.
How long can it take before clients’ symptoms decrease? Sometimes clients notice improvements almost immediately, especially when they have three kinds of experiences:
- They realize that the treatment plan their therapist describes makes sense to them. They understand how it is that they’ll overcome their difficulties. And they have confidence that their particular therapist will be competent and helpful.
- They change their unhelpful thinking in session and feel better.
- They enact an “action plan,” at home and notice an improvement in their mood. The action plan, collaboratively designed with their therapist, usually includes (1) reading “therapy notes” of the most important things they learned in session and (2) engaging in specific activities that are linked to the accomplishment of their goals. For example, a depressed client might make plans with friends; an anxious client might expose himself to a feared situation to find out to what degree a negative outcome occurs.
These three kinds of experience increase hope and clients are able not only to arrest their downward negative spiral but also to reverse direction. They then find themselves on an upward positive spiral.
So how can clients tell if therapy is working? They can ask themselves:
- How is my mood throughout the week (not just at the end of sessions)? Is it at least gradually improving (albeit with ups and downs)?
- Are my specific symptoms or problematic behaviors improving?
- Am I solving problems and working toward my goals?
If the answers are yes, then therapy is working.
Lambert, M., Whipple, J., Vermeersch, D., Smart, D., Hawkins, E., Nielsen, S., & Goates, M. (n.d.). Enhancing psychotherapy outcomes via providing feedback on client progress: A replication. Clinical Psychology & Psychotherapy Clin. Psychol. Psychother., 91-103.
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