Numbers of individuals identified as overweight and obese are escalating at a concerning rates and these circumstances are associated with various psychological and physiological health complications. Obesity is operationally defined as having a body mass index (BMI) of >30.0 kg/height in m2 (Bean, Stewart & Olbrisch. 2008). It is accompanied by increased risk of discrimination in health care, interpersonal relationships, employment, education and media representation. The cause of obesity can range from poor diet, sedentary lifestyles, accessibility of highly processed foods, or underlying personal issues that are responded to by an increase of food consumption.
A variety of treatments have been developed to treat obesity and began as psychoanalytical in nature which focused on of resolution of oral fixations, developmental disorders and personality aberrations. (Levy, 2007) Modern programs focus on behavioural, cognitive and lifestyle modifications which can be delivered in a range of settings designed to increase patient participation and program adherence through primary care, clinical research and dietic practices. (Fabricatore, 2007) Programs support modest weight loss with improvements in health conditions such as hypertension, sleep apnea and psychosocial outcomes such as mood improvement and body image. Some of these programs include behaviour therapy and cognitive behaviour therapy.
Behaviour therapy (BT) originated in functional analyses of behaviour which focuses on identifying the antecedent and consequences involved in problematic eating and exercising behaviours. The purpose of behaviour therapy is not to treat psychiatric disorder but alter eating and exercise practices for the better. The intervention teaches specific individualized skills for change without seeking insight for the origins of the problem. The intervention involves identifying and extinguishing the inappropriate psychological or environmental triggers and cues via classical conditioning principles. The use of reinforcement and consequences during behaviour therapy applies the principle of operant conditioning which results in lifestyle changes and weight loss in the short term. Collin and Bentz (2009) caution though there is no strong evidence of its long term effectiveness.
Long term programs can last for 24 weeks (Cooper, 2010) and are aimed at restricting energy intake by focusing on changing eating and physical activity through self-monitoring, goal setting, stimulus control, contingency management, behavioural substitution, and skills for increasing social support. Though BT doesn’t concentrate on cognitive processes influencing the control of weight as it primary aim, elements do address dichotomous thinking and implications of poor weight control mind sets. Cognitive change is promoted by analyzing the effects and implications of changed behaviour on new habits and weight loss.
To increase likelihood of success and support a sense of accomplishment, participants are explicitly taught self-monitoring, goal setting and behavioural reinforcement. Self-monitoring records information in context of hunger rating, emotions, activities and food intake. Other patterns examined include environmental settings, times and social correlates. Identification of eating specifics increases targeted behavioural change as part of antecedent awareness ( Wing).
Goal setting assists in responding to patterns and modifiable environmental stimuli that contributes to inappropriate behaviours in obesity. Goals are specific, small and begin as an approximation of desired behaviour. This assists with attainments, problem solving and engagement. Targeted appropriate behaviours are then reinforced through tangible rewards, verbal reinforcements and developing contingency contradicting procedures as per the principles of operant conditions (Fabricatore, 2007) Supports can incude structured meal plans, increased environmental cues such shoes by the door.
Cognitive Behaviour Therapy (CBT) varies from BT due to its core beliefs. It assumes cognition influences behaviour, cognitions can be altered and that change can influence behavioural change. CBT targets modifications of both behaviour and thoughts considered to maintain weight gain and obesity. Similar to BT, it focuses on making changes in mealtime eating behaviours ( slowing the process of ingestion, separating eating from other activities) rearranging eating cues ( eating at home in particular spots, reducing food cues as much as possible), self-monitoring behaviours and reprogramming behaviours incompatible with eating.
Processes of cognitive conceptualization that maintain the problem behaviours through thoughts and thinking patterns are understood to be central to the problem(…….).Cognitive restructuring is when negative thought can be obstacles to desired behaviour changes. Pateints are taught to monitor the thoughts that interfere with their ability to meet behavioural goals, identify distortions in those thought, and replace the dysfunctional thought with rational ones. By focusing on altering the cognitive and behavioural mechanism that maintain the problem behaviour through explicit understanding and creating alternate behaviours that honour the function, techniques are introduced to effect behavioural and cognitive change.
CBT results are more consistent in creating a weight loss change than other therapies as it seeks to make enduring changes in patterns of behaviour supporting weight control, through eating and physical activities especially when weight loss has been achieved (Bennett, 1988). The specific behavioural procedures supported by cognitive restructuring assist as self-restraining self-instruction interrupts the behavioural and negative thought pattern. Relying on untrained restraint has no influence on dieters during maintainence periods. The most important factor in determining post-treatment weight loss was length of time in program, use of a qualified therapist, involvement of dieters family, following a rigourous diet and practicing physical activity through a wider supportive social circle.
Failure to maintain weight loss or engagement with therapy has been found in unhelpful thought patterns such as making excuses for lapses, dichotomous thinking of either success or failure as it doesn’t allow to see increase of improvement in behaviours. Thoughts and expectations can influence appetite control and control of eating. Recognising errors in thinking and reliance of emotional cues in eating is an effective CBT strategy to limit dysfunctional eating. Self-instructional training supports the dieter to identify circumstances when they find it hard to control their eating. They can develop a script of self-commands or “ answers” when managing dysfunctional thoughts . Participants are required to rehearse responses to the point of overlearning and then practiced in reality. This assists in addressing unrealistic expectations and a lack of motivation which can influence a post treatment relapse (Walsh, 2009).
An essential aspect of responding to obesity through psychological intervention is to acknowledge that obesity has many different origins. Binge Eating Disorder (BED) or recurrent episodes of uncontrolled eating that is chronic can respond to CBT. Cooper (2010) acknowledges it can support a substantial decrease in the frequency of binge eating and related behaviours. Though CBT targets overeating and low level of activity, it demonstrates an ability to focus on the cognitive element that hinders weight management. Binge eating require treatment for their eating pathology and not just body weight. Episodic eating, loss of control that accompanied it, subsequent expression of remorse are required to diagnose BED. Greater psychological distress, commonality among women rather than men, and a higher prevalence of pyschicatric illness, BED requires specialized intervention. Due to the dissociative nature of BED, participants have a higher rate of mood disorders, substance abuse issues and adissatisfied preoccupation of food and weight gain. This can be responsive to CBT treatment but BED participants terminate treatment earlier than non binge eaters compounding shame and embarrassment which fuels the BED and obesity.
Relapse and weight gain during CBT is due to a failure of participant beliefs that they can control their weight whilst in progressive in-weight decrease. There is invariable decline in the rate of weight loss experience and a realization that they may not obtain desired benefits of a markedly improved appearance leading the participant back into inappropriate behaviours.
To improve outcomes obese participants need to focus on weight management and acceptance of realistic body shape and implementation of weight maintenance behaviour. Ideally sessions are individualized, one to one, 50 min in duration over 44 weeks periods beginning at weekly sessions and then moving to fortnightly sessions. Individualised and sustained treatment with one provider has a beneficial effect on patients psychiatric symptoms and quality of life (Cooper,2010)
Concerns with BT and CBT when treating obesity are that participants lose and regain weight, only a low proportion are able to maintain a 10 or 5% weight loss over time. Though CBT assists in acceptance of body shape, it doesn’t improve long term results in weight maintenance.
Implications of treatment for psychologist include participants, especially women are vulnerable to symptoms of depression, including suicidal ideation and low self-esteem. Obese treatment seekers demonstrate high rates of psychopathology, including mood disorders and anxiety and eating disorders such as binge eating disorder, night eating syndrome and body image dissatisfaction as well as impaired health-related quality of life.
Best result are achieved through a holistic approach with a well trained specialist therapist, a treatment devised by a team that has experience developing psychological interventions for eating disorders. Long term or even indefinite treatment is required to create new change but patient attendance declines as treatment is extended in length.(Cooper 2001)
Weight loss can include decreased anxiety and depression, enhanced self-esteem, reduced body dissatisfaction and improved interpersonal functioning but extended treatment requires intensive social support and measures to promote exercise and training to prevent relapse. Progress and management of a stable weight can be due to inconsistency in goals such as management of weight lost. Fluctuations of day to day weight, underestimating significance of weight lost and increase of positive changes such as increased fitness need to be reinforced by the therapist.
A commitment to treatment is also required by the therapist as high frequency sessions when beginning can be a good predictor of long term weight loss. Other aspects of the therapist-client relationship which can contribute to attrition include discontinuation due to logistics, poor interaction and a sense of abandonment due to changes in therapist. Due to the stigmatization of obesity, language can impact the participant and imply moral judgements or assigning character flaws. Clinical language such as excess weight ot obesity as opposed to fat and morbidly obese should be used.
It is essential to establish a therapeutic momentum with long term plans where obesity is treated as a chronic disease. Mental health screening tools can assist in identifying underlying mental health issues but as yet there is no infallible screening tool. To best assist the participant in addressing their obesity and psychological and physiological health implication a multidisciplinary approach that considers social, environmental and biological factors is critical.
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