What is CBT? Cognitive Behavioural Interventions in Weight Management. Aims for today

Transcription

1 Cognitive Behavioural Interventions in Weight Management Dr Ross Shearer Clinical Psychologist GCWMS Aims for today 1. What is Cognitive Behavioural Therapy? 2. Why CBT in weight management? 3. Specific CBT strategies for Preparation; Action; Maintenance; Relapse 4. Conclusions GCWMS- Training 2 What is CBT? A psychological approach that emphasises the role of thoughts in how we feel and what we do Supports people to change Collaborative effort Has a framework to follow, is educational, and sets goals Evidence base across range of emotional & behavioural problems GCWMS- Training 3 1

2 Behavioural Model Problem behaviours are the result of past and present learning processes Alter environmental cues: Classical conditioning (Pavlov) Alter reinforcers (positive/negative): Operant conditioning (Thorndike) GCWMS- Training 4 Behavioural CBT Model Social learning: observation of others behaviour & selfefficacy (Bandura) GCWMS- Training 5 Cognitive Model Beck 1970 s/80 s Early experiences can influence our thinking Negative Automatic Thoughts Assumptions Core Beliefs GCWMS- Training 6 2

3 Cognitive Behavioural Model THOUGHTS I m going to fail again Stop attending groups; stop trying BEHAVIOURS FEELINGS Sad Low Hopeless GCWMS- Training 7 Why CBT in weight management? SIGN Guidelines (2010) Individual or group based psychological interventions should be included in weight management programmes. CBT techniques specifically mentioned NICE (2006) Interventions should be multi-component and include behaviour change European Obesity Management Task Force (2004) Multiple treatment approaches should be used. CBT approaches mentioned specifically. CBT approaches can and should be delivered by other professionals, with training SEHD : Review of Bariatric Surgical Services in Scotland (2004) Psychological assessment & support required through patient s journey BPS Report (2011) Obesity in the UK- BT and CBT interventions need to be tailored to the complexity of the client GCWMS- Training 8 CBT in GCWMS 1:1 DEG Psychology talks Weight loss groups GCWMS- Training 9 3

4 Aim of CBT in WM groups Combine with dietary therapy to achieve a negative energy balance for weight loss; Alter eating habits to reduce calorie consumed Use up more energy (activity) Support people to develop self-help skills to help them control their weight GCWMS- Training 10 Components of CBT Approaches for Obesity Self Monitoring Cognitive Restructuring Problem Solving Contingency Management / RP & Maintenance Social Support Stress Management Stimulus Control GCWMS- Training 11 Wadden and Foster. Med Clin North Am 2000:84:441. Strategies to Prepare for Change What do I need to change? GCWMS- Training 12 4

5 Self Monitoring Time 8 am Food 2 slices wholemeal bread, margarine, Orange juice Tea Banana Hunger Situation Before work, in front of TV Break at work Calories Portions 2 starch 1 fat 1 fruit 1 fruit Mood Feelings Feel pleased, positive start to the day Normally crisps, trying to swap for healthy snack, pleased I managed the craving GCWMS- Training 13 Self-Monitoring Consistency and Weight Loss Weight change (lb) at 18 wk of behavior therapy P = 0.01 for weight change among quartiles Self-Monitoring Index Quartiles GCWMS- Training 14 Baker and Kirschenbaum. Behav Ther 1993;24:377. Specific Change Strategies for Later Stages How will I change? GCWMS- Training 15 5

6 GCWMS- Training 16 Useful CBT Strategies for Preparation and Action Goal Setting Developing a Change Plan for each goal To initiate the plan and take control; Stimulus Control - Changing Environmental Triggers - Controlling Internal Triggers GCWMS- Training 17 SMART Exercise Goals Specific Measurable Achievable Relevant Time-specific GCWMS- Training 18 6

7 My CHANGE PLAN My goal for the fortnight: The main reason I want to make these changes are: The most important reasons I want to make these changes are: The ways I will reward myself are: Some things that could make my plan difficult: Things I can do to help me cope with difficult situations: GCWMS- Training 19 Stimulus Control Unplanned eating is triggered by either INTERNAL or EXTERNAL events Internal - emotions such as boredom, anger, sadness, tiredness or feelings of hunger/thirst GCWMS- Training 20 GCWMS- Training 21 7

8 Stimulus Control External situations we are in such as shopping, at home alone, seeing adverts etc. GCWMS- Training 22 GCWMS- Training 23 Stimulus Control Coping with INTERNAL/ EXTERNAL Triggers Make changes Internal & External environment to reduce exposure to triggers. Start with: 1. Self-monitor using a diary to identify the context of eating i.e. setting, situation, thoughts, feelings 2. Use this information for Functional Analysis to increase self-awareness of problems e.g. behaviour chains GCWMS- Training 24 8

9 Breaking the Habit Chain Overeating in the evening. Late getting up for work. Miss breakfast to compensate for overeating. Get home and go into the kitchen. Light lunch to compensate for overeating. Feel very hungry and can t be bothered cooking. Call takeaway and eat crisps while you wait. Overeating in the evening. GCWMS- Training 25 Stimulus Control Making changes to EXTERNAL Triggers Designed to limit exposure to problem situations and foods. Advice is given on; - Storing food - Preparing food - Consuming food Rewarding positive eating behaviours Learned Self-control GCWMS- Training 26 GCWMS- Training 27 9

10 Stimulus Control Coping with INTERNAL Triggers Cravings and Urges Psychological desire to eat rather than physical hunger. Need to learn to distinguish the two. Let them pass: Distraction techniques - Activity based - Cognitive based GCWMS- Training 28 Physical Hunger VS Cravings In our stomach Eat anything Gnawing Shaky/Light headed Is it time to eat? Gets worse In our head Specific foods Agitated Trigger? Have you eaten? Go away GCWMS- Training 29 Cognitive Restructuring Challenging Negative thinking Clients with weight problems often express a number of negative thoughts about their weight, their difficulties controlling it and chances of achieving change. Negative thoughts have certain characteristics; - Automatic - Distorted - Unhelpful - Plausible - Involuntary GCWMS- Training 30 10

11 Are our thoughts always true? How would you think about the following situation? You come along to your first group meeting. You sit down and say hello to the person sitting next to you. They look at you and don t say hello back. GCWMS- Training 31 Thoughts, Feelings, and Behaviour You might think that this person is very rude because they ignored you. You might think they ignored you because they don t like you. You might think they are very shy. **Not all of these thoughts are TRUE. The way you think about this situation will affect the way you feel and behave.** GCWMS- Training 32 Cognitive Restructuring- Thinking Errors Modifying negative thinking & unhelpful beliefs All or nothing Mind reading Fortune-telling Catastrophising Emotional reasoning GCWMS- Training 33 11

12 Emily I have always been unhappy with my weight and appearance. My dad used to call me chubby and I was larger than the other girls at school. Looking back at pictures of myself I don t think I was that big. I used to tell myself I was really fat and ugly. I especially hated my thighs, hips, and bottom. I would stare at them for hours at a time, pinching, folding, and pulling the fat and skin backwards. I am now a lot bigger and I hate my body more than ever! I m disgusting! My thighs are so fat and wobbly. The cellulite on my body is criminal! I deserve to be in jail because I am so fat and unattractive. My body image has gotten so bad that I rarely go out. When I do go out, I often think people are staring at me and making comments about my weight. I spend hours deciding on what to wear and sometimes get so frustrated that I decide to stay at home and eat instead. GCWMS- Training 34 Challenge Unhelpful Thoughts The first step is to identify unhelpful thoughts and write them down. The second step is to challenge those thoughts: What would you say to a friend? What is the evidence that the thought is true/ false? Over time we should be able to retrain our thoughts and become more realistic in our thinking. GCWMS- Training 35 What then?..useful CBT Methods for Maintenance and Relapse Relapse Prevention - Managing lapses and relapses Weight Maintenance Skills - Clients need to be taught how to stop weight cycling problems GCWMS- Training 36 12

13 What is Relapse Prevention? Psycho-educational approach to habit change Is more relapse management rather that prevention as it is concerned with the PROCESS of change rather than absolute success Teaches principles of self-management or selfcontrol A method of learning from mistakes as well as successes GCWMS- Training 37 What is Relapse? Most common outcome of interventions to change behaviour. Slips occur in High Risk Situations Lapses and Relapses are not the same thing Lapse = a one-off slip Relapse = sequence of lapses Collapse = complete return to old eating patterns *it is the largely psychological factors (thinking processes and mood) following a lapse that decide whether relapsing is more likely Thinking Traps = Apparently Irrelevant Decisions & Rule Violation Effect GCWMS- Training 38 High Risk Situations A HRS is any situation or condition that poses a threat to the clients sense of control (self-efficacy). Broad general categories associated with high rates of relapse: Internal causes -negative emotional states -positive emotional states Social Causes - interpersonal conflict - Social pressure GCWMS- Training 39 13

14 John Every time I visit my mother she always buys in loads of cakes and biscuits for me coming. I keep telling her that I m trying to lose weight and that I don t want those foods anymore. She always says that I m fine the way I am and don t need to lose weight. Most of the time I end up eating the cakes and biscuits because she always seems really offended and put out when I say no, but the other day I got really mad and shouted at her. She got very upset and started to cry. It doesn t matter what I do, I cant get the message across that I don t want to eat like that anymore. GCWMS- Training 40 Relapse Prevention Strategies Increasing self-awareness i.e. self-monitoring (identify habit pattern, possible triggers, high risks, consequences etc.) Skills training and behavioural procedures (anxiety management / assertiveness training) Cognitive strategies (cognitive restructuring) Lifestyle interventions (lifestyle balance, substitute indulgences, stimulus control) GCWMS- Training 41 Weight Maintenance Plan Reasons for not wanting to regain weight: The good habits I will continue: Danger areas and risky situations: Things I can do to help in risky situations: Who will support me: What I will do if my weight increases by 5Ibs: GCWMS- Training 42 14

15 Conclusions Useful to teach clients HOW to make the changes required to their diet not just tell them WHAT they should do Client readiness to change behaviour is crucial Increasing clients awareness of the external and internal cues for problem-eating & teaching skills to manage these situations is helpful There should be an emphasis on weight maintenance GCWMS- Training 43 References Baker and Kirschenbaum. Behav Ther 1993;24:377. Adapted from Wadden and Foster. Med Clin North Am 2000;84:441. Björvell and Rössner. Int J Obes Relat Metab Disord 1992;16:623 British Psychological Society (2011) Obesity in the UK: A Psychological Perspective. BPS: Leicester Cooper, Z., Fairburn, C.G & Hawker, D. (2003) Cognitive-Behavioural Treatment of Obesity. The Guilford Press Effective Health Care; The prevention and treatment of obesity (1997), NHS Centre for Reviews and Dissemination, University of York European Obesity Management Task Force, (2004) Management of Obesity in Adults: Project for European Primary Care, International Journal of Obesity, 28, S Health Development Agency (2003) The management of obesity and overweight: an analysis of reviews of diet, physical activity and behavioural approaches. Website: Hunt, P. & Hillsdon, M. (1996) Changing Eating & Exercise Behaviour. Blackwell Science.. GCWMS- Training 44 Klem et al. Am J Clin Nutr 1997;66:239 Miller, W.R & Rollnick, S. (2002) Motivational Interviewing: preparing people for change. (2nd edition). The Guilford Press. Miller, W.R. (1999) Enhancing motivation for change in substance abuse treatment. (Treatment Improvement Protocol [TIP] series no. 35). Rockville, MD: Center for Substance Abuse Treatment McGuire et al.int J Obes Relat Metab Disorder 1998;22:572. National Institute for Health and Clinical Excellence (NICE). (2006). Obesity: the prevention, identification, assessment, and management of overweight and obesity in adults and children. London: NICE. Resnicow, K. & Blackburn, D. (2005). Motivational Interviewing in Medical Settings. Obesity Management, 1 (4), Scottish Intercollegiate Guidelines Network (SIGN). (2010). Management of Obesity- a national clinical guideline. SIGN: UK Wadden and Foster. Med Clin North Am 2000:84:441. Wanigaratne, S et al (1995) Relapse Prevention for Addictive Behaviours. Blackwell Science. * GCWMS- Training 45 15