Effective Weight Loss: An Acceptance-Based Behavioral Approach, Clinician Guide (Treatments That Work) [1 ed.] 9780190232009, 0190232005

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Effective Weight Loss

T R E AT M E N T S T H A T W O R K

Editor-​In-​Chief David H. Barlow, PhD

Scientific Advisory Board Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

T R E AT M E N T S T H AT W O R K

Effective Weight Loss An Acceptance-​Based Behavioral Approach

CLINICIAN GUIDE

E VA N M .   F O R M A N MEGHAN L . BUTRYN

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1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2016 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Names: Forman, Evan M., author. | Butryn, Meghan L., author. Title: Effective weight loss : an acceptance-based behavioral approach, clinician guide / Evan M. Forman, Meghan L. Butryn. Description: Oxford ; New York : Oxford University Press, [2016] | Series: Treatments that work | Includes bibliographical references. Identifiers: LCCN 2016019075 (print) | LCCN 2016021370 (ebook) | ISBN 9780190232009 (paperback) | ISBN 9780190232016 (ebook) Subjects: LCSH: Weight loss—Psychological aspects. | Acceptance and commitment therapy. | BISAC: PSYCHOLOGY / Clinical Psychology. Classification: LCC RM222.2 .F6754 2016 (print) | LCC RM222.2 (ebook) | DDC 613.2/5—dc23 LC record available at https://lccn.loc.gov/2016019075 9 8 7 6 5 4 3 2 1 Printed by WebCom, Inc., Canada

About

T R E AT M E N T S T H AT W O R K

Stunning developments in health care have taken place over the past several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit but perhaps inducing harm (Barlow, 2010). Other strategies have been proven effective using the best current standards of evidence, resulting in broad-​based recommendations to make these practices more available to the public (McHugh & Barlow, 2010). Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world as well as health-​care systems and policymakers have decided that the quality of care should improve, that it should be evidence based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001; McHugh & Barlow, 2010). Of course the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-​based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral health-​care practices and their applicability to individual patients. This series, Treatments ThatWork, is

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devoted to communicating these exciting new interventions to clinicians on the frontlines of practice. The manuals and workbooks in this series contain step-​by-​step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing ancillary materials that approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice. In our emerging health-​care system, the growing consensus is that evidence-​based practice offers the most responsible course of action for the mental health professional. All behavioral health-​care clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. This Clinician Guide outlines an evidence-​based program for weight loss called acceptance-​based behavioral treatment. This program is based on the idea that, for many people, the core dietary and physical activity strategies of standard cognitive-​ behavioral treatments for weight loss are not sufficient, and that’s why so many people who lose weight gain it back. Making and maintaining behavioral change is very challenging and requires specialized self-​control skills in order to successfully negotiate our powerful innate desires to consume delicious foods and conserve energy. These self-​control skills revolve around a willingness to choose behaviors that may be perceived as uncomfortable, for the sake of a more valuable objective. The Effective Weight Loss program combines the nutritional, physical activity, and behavioral components of the most successful behavioral weight loss programs with strategies for acceptance, willingness, behavioral commitment, motivation, and relapse prevention, drawn from a range of therapies. This Clinician Guide presents 25 detailed sessions for administering the program and can be used by psychologists, primary care physicians, nutritionists, dietitians, and other clinicians who vi

counsel overweight clients. Clients should follow treatment in the accompanying workbook, which provides session summaries, exercises, worksheets, handouts, and assignments to complete at home. David H. Barlow, Editor-​in-​Chief Treatments ThatWork Boston, MA

References Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869–​878. Barlow, D. H. (2010). Negative effects from psychological treatments: A perspective. American Psychologist, 65(2), 13–​20. Institute of Medicine. (2001). Crossing the quality chasm:  A  new health system for the 21st century. Washington, DC: National Academy Press. McHugh, R. K., & Barlow, D. H. (2010). Dissemination and implementation of evidence-​based psychological interventions: A review of current efforts. American Psychologist, 65(2), 73–​84.

Accessing Treatments ThatWork Forms and Worksheets Online All forms and worksheets from books in the TTW series are made available digitally shortly following print publication. You may download, print, save, and digitally complete them as PDFs. To access the forms and worksheets, please visit http://​w ww.oup.com/​us/​ttw.

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Contents

Acknowledgments   xi Introduction and Principles of Treatment   xiii Chapter 1

Session 1: Welcome   1

Chapter 2

Session 2: Calorie-​Cutting Keys   15

Chapter 3

Session 3: Goal Setting; Weighing and Measuring   27

Chapter 4

Session 4: Labels, Planning, and Calorie Accounting   35

Chapter 5

Session 5: Control What You Can, Accept What You Can’t; The Home Food Environment   43

Chapter 6

Session 6: Physical Activity and Willingness (Part 1)   53

Chapter 7

Session 7: Willingness (Part 2) and Values   61

Chapter 8

Session 8: Forming Good Habits and Flexibility   67

Chapter 9

Session 9: Restaurant Eating; Handling Weekends and Special Occasions   75

Chapter 10

Session 10: Barriers to Living a Valued Life   81

Chapter 11

Session 11: Friends and Family   87

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Chapter 12

Session 12: Introduction to Defusion and Urge Surfing   93

Chapter 13

Session 13: Strategies to Help Defuse and Increase Willingness   105

Chapter 14

Session 14: Review of Dietary Principles, Mindless Eating (Part 1), and Portion Sizes   115

Chapter 15

Session 15: Mindless Eating (Part 2) and Mindful Decision-​Making   123

Chapter 16

Session 16: Transitioning to Biweekly Meetings   133

Chapter 17

Session 17: Maintaining Losses Over the Long Term   143

Chapter 18

Session 18: Willingness and Reducing Barriers to Physical Activity   153

Chapter 19

Session 19: Committed Action   163

Chapter 20

Session 20: Overeating and Emotional Eating   173

Chapter 21

Session 21: Lapse Versus Relapse and Reversing Small Weight Gains   183

Chapter 22

Session 22: Revisiting Commitment and Transition to Monthly/​Bimonthly Meetings   191

Chapter 23

Session 23: Maintaining Motivation   199

Chapter 24

Session 24: Looking Ahead   205

Chapter 25

Session 25: Celebrating Accomplishments   217

Appendix A: Weight and Lifestyle Inventory   221 Appendix B: Certificate of Completion   251 References   253 x

Acknowledgments

Behavioral weight loss treatment provides the foundation for the acceptance-​based behavioral approach described in this book. Thus we are strongly indebted to the pioneering work of Drs. Thomas Wadden and Rena Wing (among others) who have been leaders in the field in developing, refining, and providing training in the behavioral weight loss principles that are embodied in this book. Additionally, the lifestyle modification materials used in the Diabetes Prevention Program and Look AHEAD clinical trials served as a starting point for developing the acceptance-​based behavioral approach to weight loss. Those two landmark clinical trials were funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Material was also incorporated from the Healthy Habits treatment manual written by Dr. Hollie Raynor (which was created with support from NIDDK grant R01 DK074721). This approach also is deeply rooted in the acceptance and commitment therapy literature. Drs. Steven Hayes, Kirk Strosahl, and Kelly Wilson have been pioneers in developing the theory and concepts that are apparent throughout this manual. Many exercises and metaphors have been adapted from the seminal book Acceptance and Commitment Therapy by Steven C. Hayes, Kirk D. Strosahl, and Kelly G. Wilson (New York: Guildford Press, 2011). Drs. G. Alan Marlatt, Marsha Linehan, and Debra Safer have developed innovative versions of behavioral therapy that also inspired much of the treatment material. Drs. James Herbert and Michael Lowe both made important contributions to the development of this treatment approach. Several clinicians who were early providers of this treatment

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provided critical ideas for improvement, including Brooke Bailer, Vicki Clark, Kimberly Hoffman, Adrienne Juarascio, Danielle Kerns Clauss, and Alison Infield. Many other trainees were instrumental in providing feedback throughout the treatment development process and adapting the treatment manuals into book format, including Hallie Espel, Stephanie Goldstein, Stephanie Kerrigan, Lindsay Martin, Stephanie Manasse, Diane Rosenbaum, Katherine Schaumberg, and Leah Schumacher. Lauren Bradley deserves special thanks for the many important contributions she made to the original treatment manuals as well as her intelligent and careful proofreading. Words cannot adequately express our gratitude to Britt Evans for coordinating this considerable undertaking. These books in large part owe their existence to her thoughtfulness, diligence, and grace. Special thanks go to Sarah Harrington and Kate Scheinman for serving as editor and development editor, respectively. We are indebted to the NIDDK for funding three studies that supported the work of developing the original treatment manuals: Mind Your Health (R21 DK080430), ENACT (R01 DK092374) and Mind Your Health II (R01 DK095069). Finally, we thank the participants in those studies, from whom we learned so much about the challenges of weight control.

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Introduction and Principles of Treatment

The Challenge of Weight Control

Two-​thirds of adults in the United States are overweight (i.e., have a body mass index [BMI] > 25.0 kg/​m2) or obese (BMI > 30.0 kg/​m2). Obesity is associated with numerous health and psychological consequences, including increased risk for heart disease, cancer, diabetes, and other health problems, in addition to higher rates of depression, psychiatric comorbidities, and decreased quality of life. For many individuals, as little as a 5% reduction in body weight can incur significant benefits to health, both physical and psychological. Weight losses can lead directly to improvements in blood pressure, glycemic control, cholesterol levels, metabolic rates, and even life expectancy (Goldstein, 1992). The improvements yielded in these factors are even greater for those who lose 10–15% of their body weight (Wing et al., 2011). Unfortunately, losing weight is extremely challenging for most people, especially in the long term. Those attempting to lose weight in commercial and named diet programs (e.g., Weight Watchers, Atkins) experience an average weight loss of approximately 5–8% at 6 months, but only 3–6% at 12 months (Tsai & Wadden, 2005). Gold-​ standard, cognitive-​ behavioral treatments produce more weight loss in the short term. According to systematic reviews, weight loss at 12 months averages 7–10% and is accompanied by decreases in risk factors for heart disease and diabetes (Butryn, Webb, & Wadden, 2011). Once the program ends, however, most people begin to regain lost weight. In fact, fewer than 20% of overweight

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adults in the general population retain a weight loss of 10% or greater by one-​year posttreatment.

Cognitive-​Behavioral Approaches to Weight Control

Standard cognitive-​behavioral weight loss treatments incorporate a package of strategies, including nutritional-​and physical activity–​related education, specific dietary and physical activity prescriptions, cognitive strategies, and behavioral skills.

Education

Weight loss–​related education provided by standard cognitive-​ behavioral approaches centers around the concept of energy balance; that is, weight loss occurs when calories expended (from bodily processes and from physical activity) exceed caloric intake (i.e., from eating and drinking). These treatments provide information on estimating and tracking calorie intake, choosing foods that are more filling, making recipe substitutions that will lower caloric intake, eating out healthfully, and establishing a safe and maintainable program of regular exercise.

Dietary and Physical Activity Prescriptions

All participants are told to choose an initial daily calorie goal based on their weight (e.g., 1,200–​1,500 per day for those under 250 lbs.). In addition, participants are assigned a physical activity goal that gradually increases from a very small amount to an ultimate goal chosen to maintain weight loss (e.g., 250 minutes of moderate to vigorous physical activity per week).

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Cognitive Strategies

One key cognitive strategy taught in traditional cognitive-​ behavior approaches is cognitive disputation. This strategy teaches participants to recognize and correct distorted and maladaptive thinking (e.g., “I can’t believe I  ate that,” “I’ll never succeed in this program”). Some programs also teach distraction techniques for use when hunger and food cravings are problematic.

Behavioral Strategies

Core behavioral strategies for facilitating weight loss include self-​monitoring of food intake, self-​monitoring of weight, portion control, weighing and measuring foods, meal planning, and behavioral chaining. Other key strategies are modifying one’s personal environment to reduce food temptations and increase physical activity cues. Self-​monitoring, shown by research to be one of the most powerful drivers of weight loss, includes writing down all foods eaten including portion sizes, times of day, and calories consumed.

Acceptance-​Based Behavior Treatment for Weight Control

When individuals adhere to behavioral recommendations and/​ or are in highly controlled environments (such as in a weight loss “camp”), they are successful with weight loss. However, outside of controlled environments, most people are not able to stay adherent to recommendations for the long term. One of the reasons people have such trouble making and sustaining these changes is that humans have a biological disposition toward consuming high-​calorie, tasty foods and, to some degree, for staying at rest. Moreover, these dispositions are powerful and

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operate partially outside of our conscious awareness. Thus they often dictate eating and activity decisions, despite our best intentions. This treatment is based on the assumption that, for many people, the core dietary and physical activity prescriptions and behavioral strategies present in these standard cognitive-​behavioral treatments for weight loss are necessary but not sufficient. We would argue that making and maintaining behavioral changes is tremendously challenging and requires specialized psychological skills in order to successfully negotiate the powerful inborn responses to internal (e.g., cognitive, emotional) and external (e.g., environmental) cues. As mentioned, while many people are strongly motivated to lose weight, these motivations are overwhelmed by a biological predisposition to consume food, especially tasty, calorie-​rich foods. Of particular concern is that these types of foods are universally available in the modern Western environment (e.g., fast-​food restaurants, food trucks, corner stores). Moreover, our environment is now filled with labor-​saving devices that appear to exploit a predisposition to conserve energy (Church et al., 2011; Diliberti, Bordi, Conklin, Roe, & Rolls, 2004; French, Story, & Jeffery, 2001; Hill & Peters, 1998; Hill, Wyatt, Reed, & Peters, 2003; Raynor & Epstein, 2001; Wansink, 2004). Thus burning enough calories requires, for many individuals, purposeful and consistent choices to turn down available food and to engage in optional physical activity (Catenacci et al., 2011; Jeffery, Wing, Sherwood, & Tate, 2003; Weinsier et al., 2002). These deliberate choices are likely at odds with our intrinsic preferences to consume pleasurable foods and to conserve energy and can be easily overridden by internal or external cues prompting less healthy behavior. Acceptance-​ based behavioral treatments (ABTs) are meant to facilitate behavioral enactment of, and long-​term adherence to, behavioral weight control strategies in the face of opposing drives. The acceptance-​ based strategies included in our treatment are derived from “third-​ wave” cognitive xvi

behavioral therapies such as Acceptance and Commitment Therapy (ACT), Marlatt’s Relapse Prevention, and Dialectical Behavior Therapy. These treatments, particularly ACT, differ from conventional cognitive-​behavioral therapies in that their goal is not to reduce the frequency of aversive or unpleasant experiences; rather, the aim is to foster willingness to experience potentially aversive internal experiences while simultaneously promoting behavior that is consistent with desired goals and values (Forman & Herbert, 2009; Hayes, Strosahl, & Wilson, 1999).

Psychological Flexibility

Like ACT, ABT aims to build the core skill of “psychological flexibility,” which is the ability to freely choose one’s behaviors based on long-​term values rather than short-​term impulses, thoughts, or feelings. People who are struggling with weight control often display low levels of psychological flexibility. For instance, despite best intentions, someone may only be able to refrain from a delicious treat if a good-​tasting substitute is available to reduce urges. Someone else may overeat every time she feels anxious. Or someone may only be able to engage in a planned exercise bout if feeling full of energy and refreshed. When these individuals gain psychological flexibility, they are able to freely select any of the available eating and activity options, regardless of thoughts, feelings, or physical sensations. These choices will be made on the basis of a full consideration of the consequences of that choice and how those consequences bear on personal values or ultimate goals. Thus, the first person will be able to choose to refrain from the delicious treat even if the powerful urge remains. The second person will be able to refrain from eating even when experiencing strong anxiety. And the third person can decide to begin and persist in physical activity even if he is having the feeling that he is too tired. xvii

ABT components integrated within in this treatment program fall into three main categories: Values-​driven action, which makes it more likely that health behavior decisions are tied to important life values (rather than fleeting internal experiences), thus facilitating long-​ term adherence. ■ Mindful decision-​making, which allows individuals to be aware of and override automatic decision-​making that is strongly biased to intrinsic preferences to consume highly palatable food and stay sedentary. ■ Acceptance, which helps individuals tolerate reduction in pleasure associated with making healthy eating and physical activity choices, as well as uncomfortable cravings, physiological sensations, and emotions that are at odds with health goals and values. ■

Values-​Driven Action

This program emphasizes that clients choose goals that emanate from freely chosen, personal life values (e.g., living a long and healthy life; being a present, loving, active grandmother). A structured process for the identification of such life values is followed, and the connections between these values and eating and physical behaviors are emphasized. Participants are taught that commitment to difficult behavioral goals, especially those that involve sustained exposure to unpleasant experiential states, is only likely to be maintained when one connects psychologically with life values important enough and meaningful enough to make such effort and sacrifice worthwhile. Participants also learn skills for being aware of their moment-​by-​moment behavior choices and increasing the likelihood these choices reflect one’s ultimate goals (or values) rather than a more immediate wish to decrease an aversive state. Commitment is explicitly

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presented as a critical component of maintaining changes to the personal food and physical activity environment.

Mindful Decision-​Making

Our program incorporates training designed to help individuals increase awareness of the perceptual, cognitive, and affective experiences that guide eating and physical activity decision-​making. The program is meant to train clients to become more present-​centered and aware, thereby reducing the likelihood that they will engage in “mindless” eating and activity behaviors. Clients are asked to monitor their bodily reactions and feelings before, during, and after eating and exercise to focus on exploring their cognitive and affective responses. Unlike conventional mindful eating interventions, this training has a major focus on helping clients more consistently make “mindful,” deliberate behavioral choices, including what foods to buy and eat, when to eat, when to stop eating, when to start and stop physical activity, and even decisions relevant to one’s personal food or physical activity environment. These skills are designed to interrupt automatic, nonconscious influences on eating behavior that can lead to overeating and/​or sedentary behavior.

Acceptance

The intervention aims to help participants recognize that (a) eating-​related distress (urges to eat, hunger, cravings, feelings of deprivation) is bound to occur with high intensity and frequency in today’s obesogenic environment, and (b) attempts to avoid or suppress these internal experiences are ineffectual or even counterproductive. Willingness (simultaneously engaging in a valued action while accepting the discomfort it generates)

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is framed as more adaptive than distress intolerance (i.e., eating foods or ceasing/​avoiding activity in order to avoid being uncomfortable). Urge surfing (to “ride” on top of waves of discomfort) and defusion (the ability to distance oneself from unpleasant thoughts and feelings that could lead to overeating or sedentary behavior if they are acted upon) are examples of willingness skills.

Control What You Can, Accept What You Can’t

To facilitate integration of ABT and standard behavioral components, you will present strategies in this program to clients under the framework of Control what you can, accept what you can’t. This framework, which can also serve as a useful mantra, divides life into that over which we have direct control (essentially behaviors we can choose to perform, including those that would modify our immediate surroundings) and that which we do not (the internal workings of our bodies including our internal experiences, and the wider environment). Examples of Control what you can are the way we walk to work, what we put into a shopping cart, leaving our house keys in a gym locker on the way to work, putting extra portions in a freezer before sitting down for a meal, taking another step on a walk, and making a lunch to bring to work. Examples of Accept what you can’t include tiredness, anxiety, low motivation, hunger, cravings, urges to eat a particular food or type of food (like a sweet after dinner), imagining how good a food will taste, thoughts about giving up and being a failure, and thoughts that rationalize breaking one’s diet or physical activity plan. This mantra is a useful shorthand in several ways. Most centrally, it channels clients’ self-​regulation attempts into those aspects of life that are, in fact, changeable. Modifying one’s personal food-​and activity-​related environments is entirely doable and is a powerful way to improve the success of weight

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control efforts. It pays off to focus on what decisions we make about how we use our “hands and feet” (among the most controllable parts of our bodies). On the flip side, the mantra discourages attempts to change that what we do not have control over. Attempting to control the uncontrollable has numerous negative consequences, including frustration and demoralization, “using up” self-​control resources that could be better spent elsewhere, and focusing attention away from the controllable aspects of one’s existence. Moreover, there is a large body of scientific evidence pointing to the fact that attempting to suppress or avoid problematic internal experiences like cravings and anxiety paradoxically makes these experiences grow in intensity and influence. Control what you can, accept what you can’t also ties in nicely with the psychological strategies described earlier. For example, acceptance strategies are used with aversive or uncomfortable experiences (e.g., urges to snack after dinner) in combination with values-​driven action (not having snack foods in the house in order to set a good health example for children and grandchildren). The mantra also provides a framework for distinguishing between behavioral and psychological strategies, which can be confusing. For example, strategies to facilitate meeting calorie goals, self-​monitoring, and weekly weighing can be conceptualized as Control what you can (i.e., behavioral) strategies, while willingness and defusion skills for working with thoughts and feelings that come with such behaviors can be conceptualized as Accept what you can’t (i.e., psychological) strategies. In essence, while delineating the two types of strategies provided in the program, the phrase also is a shorthand for establishing that the two types of strategies work together and that one in absence of the other would be insufficient for weight control. Control what you can, accept what you can’t also instills a sense of hope and self-​efficacy to participants in the face of the

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challenging task of long-​term weight control. Most individuals entering our programs have experienced many unsuccessful attempts at weight loss, and the notion that biology and our environment put us a great disadvantage with achieving weight control can be disheartening. Control what you can, accept what you can’t can serve as a reminder that while one can make individual behavioral choices, it is normative that one will have undesirable thoughts, feelings, and sensations.

ABT is Not. . .

We have noticed that many people—​ perhaps even most people—​start off with a partially incorrect version of ABT. Many of these notions come from knowledge of other popular approaches that share vocabulary and ideas with ABT, such as Zen Buddhist–​inspired mindfulness practices, mindfulness-​ based stress reduction, mindful eating, “Weight Acceptance,” and “Health at Any Size.” As a way of helping readers fully understand our approach, we briefly point out some ideas that are not representative of ABT. ABT is not an alternative to behavioral treatment. As mentioned previously, ABT is not intended to be an alternative to standard behavioral treatments for weight loss; rather, the treatment is itself behavioral at its core. As such, ABT very much incorporates the fundamental behavioral strategies such as self-​monitoring, stimulus control, and dietary and physical activity goal-​setting. The acceptance-​based psychological strategies are designed to facilitate and maintain behavioral strategies and, ultimately, behavioral adherence to the dietary and physical activity prescriptions. For example, like most behavioral treatments, our program strongly recommends that clients weigh themselves daily during the later, weight maintenance phase. However, the program also recognizes that a number of psychological challenges arise

■

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in complying with this recommendation. Someone who experiences anxiety about having gained weight along with the thought “I know I gained weight, and I just can’t face it” is at risk for not stepping on the scale in the morning as per the recommendation. ABT teaches skills for recognizing these emotional and cognitive processes, accepting them as they are (i.e., not needing them to go away), and then mindfully deciding to step on the scale anyway because doing so serves an all-​important personal value of health. ■ ABT is not Buddhism, mindfulness meditation, or mindful/​intuitive eating. Buddhist practices emphasize the practice of mindfulness and mindfulness meditation (increasing awareness of moment-​to-​moment thoughts, feelings, and sensations) for the purpose of gaining insight into the nature of reality. While ABT emphasizes increasing awareness of internal and external cues for eating behavior, explicit mindfulness practice itself is not included. Although associated with many health benefits, mindfulness practice in and of itself does not appear to be beneficial for weight control (Godsey, 2013; O’Reilly, Cook, Spruijt‐Metz, & Black, 2014). Mindful and intuitive eating programs emphasize tuning into and trusting one’s “inner wisdom” to regulate food intake. In many ways, these mindful eating and intuitive eating programs actually run counter to the approach of our program. For example, we argue that our biology and inherent evolutionary preferences bias us toward choosing overconsumption of high-​calorie foods and staying sedentary. Thus, in our program we emphasize recognition and acceptance that these inherent preferences may have been useful to us early in our evolutionary development, but are no longer relevant in our modern food environment and society. ■ ABT is not Weight Acceptance or Health at Any Size. Both Weight Acceptance and Health at Every Size emphasize the adoption of health habits in the service of well-​being rather than weight control. While ABT is not at odds with goals related to respecting individuals of all sizes and pursuing health behaviors to improve well-​being, our program is xxiii

based around goals to lose weight and maintain lost weight. We do so given that research has repeatedly demonstrated both health and psychological benefits to weight loss.

Efficacy of This Treatment Program

A strong body of evidence, including several meta-​analyses, supports the effectiveness of ACT and other ABTs for treating a wide range of problems, including depression and anxiety (Forman, Hebert, Moitra, Yeomans, & Geller, 2007), smoking cessation (Gifford et  al., 2004), chronic pain (Veehof, Oskam, Schreurs, & Bohlmeijer, 2011), and diabetes management behaviors (i.e., diet, physical activity, glucose monitoring; Gregg, Callaghan, Hayes, & Glenn-​Lawson, 2007; Hayes, Luoma, Bond, Masuda, & Lillis, 2006). ABT has also proven successful in the weight control domain, with several open trials and randomized controlled trials providing empirical support. In a preliminary test of effectiveness and feasibility, our group conducted an open trial of a 12-​week group-​based ABT for weight control (Forman, Butryn, Hoffman, & Herbert, 2009). Participants, on average, lost 8.1% of their initial body weight during the 12-​week intervention (i.e., 7.9  kg) and maintained weight losses (additional 1.7 kg or 2.2% loss) by 6-​month follow-​up. In a separate pilot, we showed that cardiac patients who received ABT demonstrated clinically significant decreases in weight, calorie intake, saturated fat and sodium intake, and increases in physical activity, as well as in theorized mediators (awareness and acceptance). In another trial, Niemeier, Leahey, Palm Reed, Brown, and Wing (2012) administered a 24-​session ABT program to overweight individuals with disinhibited eating. Posttreatment weight losses (12.0 kg) were considerably higher than expected, as was 3-​ month posttreatment weight loss maintenance (12.1 kg). In a full-​scale randomized controlled trial (Forman et  al., 2013), our team randomized 128 overweight participants xxiv

to a year-​long, 40-​session group-​based standard behavioral treatment (SBT) or ABT. Weight loss at 18 months (i.e., 6-​ month follow-​up) was somewhat larger for those receiving ABT. Participants whom we had classified as highly vulnerable to the effect of eating cues lost considerably more weight if they had been assigned to ABT than to SBT. For example, those who engaged in higher levels of emotional eating lost nearly twice as much weight in ABT as in SBT. Those who reported higher levels of responsivity to food cues and higher levels of depression also lost approximately twice as much weight in ABT compared to SBT. We are currently conducting even larger studies to better understand who benefits the most from different approaches, including standard cognitive-​behavioral treatment, acceptance-​based approaches, treatments that focus on modifying one’s personal environment, and meal replacement approaches. We are also tracking people for longer periods of time to understand how these approaches compare in the years after the intervention ends. For example, in one ongoing study, 190 participants were randomized to 25 session of either ABT or SBT. At the one-​year assessment point, ABT participants had lost significantly more weight (13.3%) than had SBT participants (9.8%). The advantage of ABT was mediated through ABT-​linked processes, that is, changes in psychological acceptance and intrinsic motivation (Forman et al., 2016).

Who Will Benefit From ABT for Weight Control?

Behavioral treatment for weight control, the most well-​tested and effective intervention for nonsurgical weight loss, is fully integrated within this program. Thus all overweight adults who have the desire to lose weight can be expected to benefit from this treatment program. Moreover, as discussed earlier, those with increased susceptibility to food cues, increased emotional eating,

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and/​or increased disinhibition appear to especially benefit from ABT’s focus on acceptance-​based techniques and strategies.

What Populations Should Be Treated With Caution?

This treatment includes a progressive increase in the amount of physical activity prescribed. The progression is designed to be safe and achievable for those who, at baseline, are minimally able to walk at least two city blocks without stopping. However, the program’s physical activity prescriptions may not be safe for those with serious cardiovascular or other physical or medical conditions that preclude engaging in high levels of physical activity. A physician’s recommendation should be obtained in these cases. For example, a physician may recommend scaling back the physical activity goals and lowering calorie intake to compensate. This specific treatment has not been tested for those with a BMI above 50.0 kg/​m2 . Generally speaking, behavioral treatments result in similar percentages of weight loss for individuals in higher weight categories (Unick et al., 2011). However, these individuals are more likely to experience physical problems that limit mobility and medical complications that may make weight loss via behavioral methods difficult. Similarly, we have not evaluated the effectiveness of our treatment among individuals with Type I (insulin-​dependent) diabetes. Behavioral treatments have demonstrated effectiveness for those with Type I diabetes. However, insulin dependence and risks of hyper-​and hypogylcemia pose additional challenges for dietary prescriptions and regulation. The involvement of a physician is strongly recommended. Psychiatric comorbidities, such as depression and anxiety, are common in those who are overweight or obese. The presence of such problems, however, does not preclude treatment with this

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program unless the severity is so great as to prevent adoption of behavioral recommendations. In such cases, treating the psychiatric condition first may be indicated. Many overweight and obese individuals endorse disordered eating pathology, such as binge eating disorder (BED) and night eating syndrome (NES). Research suggests that weight loss programs are less effective for reducing binge eating than cognitive-​ behavioral treatment for BED, but that behavioral weight loss interventions are not necessarily contraindicated. Of note, individuals with BED tend to lose less weight in weight loss program than peers and tend to experience higher rates of weight regain. Similarly, specific behavioral treatments exist for NES, but weight loss programs, although less effective in reducing night eating, are not necessarily contraindicated for individuals with NES. This program is not designed for pregnant or nursing women, who require individualized care from their doctor regarding weight gain (or loss), diet, and exercise during pregnancy. (For example, the recommended weight gain for pregnant women varies depending on prepregnancy BMI.) Pregnant and nursing women should work with their doctor to determine appropriate weight gain or loss goals that will result in optimal health outcomes for both the woman and her infant. However, virtually all weight control strategies and skills described in this program can be adapted for use during pregnancy and nursing. The behavioral and psychological strategies contained in this program can be used to help pregnant and nursing women meet their modified dietary and weight goals when combined with individualized care from a health-​care provider.

Who Should Administer the Program?

Our research suggests that ABT is most successful when clinicians have experience delivering behavioral interventions for

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weight control. While this Clinician’s Guide presents nutritional and behavioral components of the treatment in some detail, we recommend that, prior to implementing the treatment, clinicians receive formal training in the nutritional and behavioral fundamentals of weight control.

Alternatives to ABT

Several alternatives to ABT for weight loss are available; a subset of such alternatives are: SBT. SBT is the most widely tested in-​person, nonsurgical or nonpsychopharmacological intervention for weight control. As described earlier, the behavioral strategies of SBT are identical to those included in ABT. Our research suggests that SBT is as effective, if not more effective, for individuals who have low levels of responsiveness to palatable foods, tend not to engage in emotional eating, and are low in disinhibition. ■ Medication. Common Food and Drug Administration–​ approved prescription medications for weight loss include Orlistat, Sibutrumine (Meridia), and phentermine. Such medications typically result in 3–6% weight loss at 12 months and similar outcomes to behavioral weight loss treatments in the long term (Franz et al., 2007). Several studies have also suggested that, for some, medication may be a helpful adjunct to behavioral weight loss treatments (Hutton & Fergusson, 2004). However, weight loss medications often are accompanied by serious side effects such as gastrointestinal dysfunction, heart problems, and liver disease. As such, medication is generally regarded as a second-​line treatment, after behavioral treatment fails, and only for the very obese. ■

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Bariatric surgery. Surgical options for weight loss are typically reserved for those who have a BMI of > 40.0 kg/​m2 or 35.0 kg/​m2 with medical comorbidities (e.g., Type II diabetes). Roux-​en-​Y gastric bypass and sleeve gastrectomy are the two safest and most effective procedures and typically result in 30–35% losses of body weight. Surgery poses risks of complications from nutritional deficiencies, undergoing anesthesia, wound infections, and developing blood clots.

■

Principles of Treatment Considerations of Delivering Group-​Based Treatment

As with any group-​based treatment, you will want to be attentive to individual differences in group participation. If some clients are naturally more talkative and others much less so, intervene to correct the imbalance. If a client is dominating the group, use your role as the group leader to prevent this behavior. You may need to speak to the client out of the session to explain the importance of hearing everyone’s point of view and to help the client see how his or her behavior is impacting others’ willingness to share. Some clients are tangential or overly long-​winded, thus jeopardizing the ability to sufficiently cover all the scheduled group material. In these cases, use interruption and explanation to get back on track. The treatment program we describe can be delivered with one or two clinicians. As with any form of group treatment, there are benefits to having two clinicians (co-​leaders). For example, having two clinicians allows for faster weigh-​ins, the option of dividing up responsibilities (such as delivering specific content and providing feedback on food records), the ability to attend to more group members’ nonverbal reactions, and the playing of somewhat different roles (e.g., more empathic versus more

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demanding). Having co-​leaders may be especially desirable when groups are relatively large (i.e., 10 or more members).

Adapting This Guide for Use with Individual Clients

We developed our treatment in a group format for several reasons: Group-​based behavioral weight loss treatment has been shown to be more effective than individual treatment, probably because of the additional accountability and support available, versus individual treatment. ■ Group-​ based treatment is more efficient and less costly and therefore more widely disseminable. ■

Given our experience developing a group-​based treatment and the research we have conducted evaluating its effectiveness, in this guide we describe ABT in group format. However, we realize that many clinicians would prefer to deliver a weight loss intervention in an individual format and in fact implementing in a group format may be difficult, if not impossible, for numerous logistical reasons. As such, we offer a number of specific suggestions in boxes throughout for adapting the described group treatment for individual treatment.

Assessment and Monitoring

Prior to starting treatment with a client, as a clinician you should measure the client’s weight and height and then calculate BMI lbs * 703   kg  m 2 or in 2  . Normally only overweight (i.e., BMI of 25 to

29.9) or obese (BMI of 30 or greater) individuals should enter the program.

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Clinician’s Note We strongly recommend that clients receive a medical evaluation to rule out medical conditions or medications that could be contributing to weight gain and to rule out any medical contraindications to weight loss or increasing physical activity. You may wish to administer the Weight, Activity, and Lifestyle Inventory (WALI) prior to starting treatment. (The inventory is included as Appendix A in this Clinician’s Guide.) This inventory Assesses for familial history of overweight/​obesity. ■ Asks clients to provide information about previous weight loss attempts (including commercial programs and medications) and any associated weight losses. ■ Asks about current level and type of physical activity. ■ Includes screenings for BED and NES. ■ Assesses for motivation and timing for engaging in a weight loss program. ■

The WALI allows you to put the patient’s current weight loss goals (as most overweight/​obese individuals will have tried to lose weight numerous times) in context of the patient’s weight, family, eating, and psychological history. Once treatment has commenced, measure and graph each client’s weight at every session to track progress. In addition, clients should be instructed to record each day’s food and beverage consumption, along with caloric intake. Total number of minutes of moderate to vigorous physical activity (i.e., exercise bouts of greater than 10 minutes) should also be recorded. As described in the next chapter, the client can use printed materials or electronic resources (e.g., a smartphone app) to complete these daily records.

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Role of the Clinician

In order to deliver this treatment, you must take on multiple roles, including educator, empathic listener, cheerleader, problem-​solver, and taskmaster who holds the client accountable. As a group leader or individual clinician for this program, it is necessary to empathize with the client’s difficulties in enacting and/​or maintaining changes for weight control and to point out that these challenges are normative and to be expected. However, there is also a need to balance empathy with a push for change; this dialectic is key to the client’s success. Clinicians must hold the clients accountable by asking them to give specific reports every week on the key behaviors for weight control. You are encouraged to explain this role to your clients at the onset of treatment so that it is understood that you will empathetically push the client to make changes crucial for success.

Experiential Exercises and Metaphors

We find that simply explaining information, concepts, and skills to clients is not enough to produce change. Clients need to try out skills for themselves and gain practice in them (see next section). In addition, clients need to acquire knowledge and competence through experiential exercises. As such, we include a number of these exercises throughout the guide, many adapted from ACT exercises. In addition, we have adopted ACT’s viewpoint that certain ideas cannot be fully appreciated simply by explanation. Instead, one or more metaphors give clients an alternative way to contemplate and absorb important concepts.

Between-​Session Assignments

A common finding in treatment research is that when treatment includes between-​session assignments (i.e., “homework”), xxxii

clients receive considerable additional benefit. Our weight loss approach requires clients to complete assignments after every session. These assignments allow clients to practice and implement new strategies in the “real world.” In addition to the traditional behavioral weekly assignments that are continued throughout the program (e.g., self-​monitoring food intake, physical activity goals), homework specifically related to ABT material is assigned. For example, clients may be asked to practice willingness skills three times throughout the week or note instances in which they practiced making every eating decision an “up” or “down” vote on a value. Given that many ABT strategies run counter to typical or intuitive strategies for dealing with thoughts and feelings, we believe deliberate practice via homework assignments between sessions is necessary to acquire these psychological skills. You should discuss worksheets that were assigned at the subsequent Skill Review during the check-​in portion of each session. At the end of each session, collect worksheets so that you can provide feedback to clients and return worksheets at the following session. Discussing, collecting, and providing feedback reinforce the importance of worksheets, help you get a sense of what materials clients are and are not understanding, and help clients more fully master the concepts and strategies that are being taught. In addition, every week clients will complete and turn in their food records for the week. (A blank Keeping Track Form can be found in Appendix A of the Client Workbook.) We recommend that you collect these food records and read/​provide feedback on the form, which is returned to the client the following week. When the program is delivered in group format, food record comments provide important individualized feedback on eating behavior. This process also provides context for the clients’ success or struggles with weight loss. Instructions for commenting on food records are provided in Chapter 1. xxxiii

Session Structure and Timing

Sessions are typically structured in the following manner: Weigh-​in. ■ Check-​in. ■ Skill Review. ■ Behavioral and psychological strategies. ■ Skill Builder assignments (to build skills). ■

Sessions (not including weigh-​in) are assumed to be 75 minutes long. Each section heading of the sessions in this book has suggestions for length in parentheses. We provide these as a way to keep to time and as a guide to prioritizing content. In our experience, not following timing guidelines results in spending too much time on less important content. You should come to sessions prepared with the materials needed for that day that are listed at the start of each chapter. You should also be equipped with a copy of the Client Workbook so that you are able to reference relevant content as needed.

Weigh-​In

Weigh-​in occurs before the start of the session. Each client should be weighed privately and told how much his or her weight has changed since last session, as well as total change since the program began. The weigh-​in is an opportunity to provide reinforcement for clients who are meeting weight loss or weight loss maintenance goals. If a client is disappointed with his or her progress, offer support and indicate that the session will in some way offer help to the participant, whether that be during check-​in or in the session content offered. It is best to keep the weigh-​in interaction brief, while keeping in mind that it is the only opportunity to talk about specific changes in

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weight, as amount of weight change is only addressed in private, not with the group as a whole.

Check-​In

During check-​in, clients report on their weight control behaviors for the week. Clients should complete the ABCDE Check-​ In form (located at the end of every Client Workbook chapter) prior to the session. Furthermore, to maximize efficiency, clients should use the form as a script and read directly from it. The form is organized according to an ABCDE format, which stands for: Activity (minutes and days of exercise completed) ■ Behavior (progress in meeting a particular behavioral goal) ■ Calories (calorie goal and average calories consumed per day for the week) ■ Days recorded (number of days that food intake was monitored) ■ Experiential exercise (an exercise or worksheet designed to build acceptance-​based skills) ■

Clients will be asked to complete assignments or meet specific goals related to these five areas each week. Some sessions do not identify a specific behavioral goal for clients to complete between sessions; in these instances, clients should be instructed to set a personalized behavioral goal, which they can record in the space provided in the Skill Builder section of their workbooks. Personalized behavioral goal setting can take place during check-​in, Skill Builder, or sometimes in the middle of the session, depending on content and flow of the session. It is especially important for you to help clients to set personalized behavioral goals in sessions without a pre-​determined behavioral goal, but personalized goals can be added to those already assigned in other sessions when clinically indicated. If

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a personalized goal is set, make sure to check in about progress on this goal during the next session’s ABCDE Check-​In, in addition to any other behavioral goals assigned for that session. Checking in about goals (whether personalized or standard) dramatically increases the clients’ perception of the importance of these goals and their accountability to you, and thus the likelihood that clients will complete them and make progress. Each week you will ask a few clients to elaborate on their responses during check-​in. As there is not time for everyone to share this amount of information, be sure to choose different clients for a more detailed check-​in each week. Balance giving attention to some participants who were not successful in meeting their goals with those who were successful. Participants who are struggling will benefit from extra attention and support. However, it is equally important for you to give attention to participants who are successful, providing time for them to reflect on what strategies facilitated their success and allowing them to model positive behaviors for the group. Particularly in the first several sessions of the program, it is important to address nonadherence with self-​monitoring. Some attention should be given during check-​in to clients who report not keeping a daily food record, as this is a cornerstone of behavior change. You can also address poor adherence to calorie or exercise goals. The client and the other members of the group can engage in problem-​solving. The client can be prompted to identity factors that made it difficult to meet a particular goal and identify what needs to happen differently in the future. Clients can also consider whether they could have done anything differently in retrospect. Note that you can and should integrate skills that will be covered throughout the program into check-​in. Moreover, you can include material that has not yet been introduced as a way of helping clients when they are most in need and also as a way of priming clients to be more receptive to these skills later. Repeatedly

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draw group members into the discussion, even if the check-​in focuses on one person at a time. Also, be sure to socialize the group to interact with each other by inviting group members to actively participate in problem-​solving and group discussions.

Skill Review, ABT Material, and Skill Builder

The Skill Review, ABT material, and Skill Builder sections are covered in detail for each session in this guide. During the Skill Review section of the session, you and your clients will discuss the homework assigned over the past week (specifically, homework pertaining to psychological strategies) and any misunderstandings of the strategies as well as any failures or successes with implementing the strategies. You will then present new material (psychological and behavioral), with discussion and input from clients. At the end of the session, you will assign the homework for the week (Skill Builders).

Make-​Up Sessions

You should help clients to understand the critical importance of attending every scheduled session. Point out that attendance at sessions is one of the best predictors of long-​term weight loss success. No matter how emphatic you are about not missing sessions, some clients will miss treatment sessions. When they do, be sure to ask clients to explain the reason for missing and, if indicated, engage in a problem-​solving discussion about how to prevent a reoccurrence. When the program is delivered in group format, clients should complete make-​up sessions for any sessions missed. Make-​up sessions are short (approximately 15 to 20 minutes) meetings that help the client become familiar with material that was missed.

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Didactic Versus Discussion Format

We purposefully designed our treatment sessions to be structured and to have a large amount of content delivered in the form of information, skills, and strategies. The science strongly suggests that open-​ended, client-​led discussions do not produce the best results. However, the intent is not that the sessions become monologues. When clinicians talk for long periods, clients tune out and become disengaged. Thus, we encourage you to implement the sessions in a way that mixes short didactic delivery, experiential exercises, anecdotes, back-​and-​forth discussion, and client-​to-​client interaction. In this way, the groups (or individual sessions) will be interesting, lively, and memorable, while resulting in appreciable and concrete skill and knowledge building.

Outline of Treatment Modules

Following this introduction are 25 chapters, each of which presents material for a single session. For the first four sessions, the emphasis is placed solely on psychoeducation and behavioral strategies for weight loss (e.g., self-​monitoring, weekly weighing). We believe this information is necessary as a foundation and helps clients start to make lifestyle modifications and lose weight. The framework for the ABT psychological strategies are first presented in Session 5. Throughout the rest of the program, behavioral and psychological strategies are integrated and presented together. The 25 sessions are designed to be spread out over the course of a year, following a weekly schedule for 16 weeks, biweekly for six sessions, and monthly or bimonthly for the remainder of sessions. This structure may be adapted (e.g., earlier transition to biweekly or further continuation of weekly sessions). Most clients will be actively in a weight loss phase for the majority of the

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program. However, a subset of clients will hit their weight loss goal, plateau in their weight loss, or want to practice weight loss maintenance at different points of the program. Navigating the issue of varying weight loss and maintenance goals is a complex topic and is discussed at varying points throughout this guide.

Setting Reasonable Weight Loss Goals

Clients vary in terms of their weight goals, but most hope to lose 15–​30% of their body weight, or even more. Keep in mind that motivation, genetics (set-​point), weight suppression (the extent to which current weight is below the highest-​ever weight), and other factors will impact the amount of weight that clients will lose and keep off. As we cover later, we recommend that all clients set an initial weight loss goal of 10%. You will need to explain the rationale behind this goal, that is, that this is an achievable amount that has been shown to produce highly significant health benefits. Also, stress the option to set a new goal once a 10% weight loss is attained. In addition, it is important to stay in close communication with clients about their weight loss goal and how they view that goal in light of their recent weight trajectory. At some point in the program, we recommend that clients stop trying to lose weight and set a goal of weight loss maintenance. Of course achieving a healthy weight and/​or meeting one’s ultimate weight loss goal is a time to switch to a maintenance goal. However, other reasons to make the switch include plateaus in weight loss, frustration with the pace of weight loss, and nearing the end of the program (as it is important to practice and master weight maintenance). Note that maintenance need not be a permanent goal; clients can switch back and forth between maintenance and loss goals.

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Different Types of Weight Loss Diets

An enormous amount of scientific study has investigated whether different types of diets (e.g., low carbohydrate, low fat, Mediterranean, low calorie density) produce different amounts of weight loss. Nearly all studies (and reviews of multiple studies) find that these diets produce equivalent weight losses. What does matter is the number of calories taken in and the extent to which the person is able to adhere to the diet (in combination with the amount of calories burned through physical activity). Given the evidence, our program does not emphasize one diet instead of another. Instead, we set calorie goals, and we recommend that you work with clients to find the diet that works best for them—​in other words, the diet that they will follow most faithfully and that will result in their meeting their calorie goals. You will likely need to thoroughly explain the rationale behind this thinking to clients, given the obsession with specific diets in the popular media.

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Effective Weight Loss

CHAPTER 1

Session 1: Welcome

TOPICS Welcome (5 Min.)

■

Introduction of Clients (15 Min.)

■

Treatment Overview (14 Min.)

■

Group Norms, Policies, and Procedures (15 Min.)

■

Weight, Calorie, and Activity Goals (10 Min.)

■

Cutting Back on High-​Calorie Foods (5 Min.)

■

Skill Builder (5 Min.)

■

Wrap-​Up (1 Min.)

■

MATERIALS NEEDED A private room with a scale for client weigh-​in, name plates, and food records, that is, Keeping Track Forms. (Refer to Appendix A at the end of the Client Workbook, where we present a sample food record. We recommend that you bring enough copies of the food record for every participant to complete one record between now and the next time you are scheduled to meet.) ■ Group meeting schedule. ■ Measuring cups and digital food scales for use at home, provided by clients. ■

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Calorie estimation tools that include calorie information for common foods are available in book form (e.g., The CalorieKing Calorie, Fat & Carbohydrate Counter; Calorie Counter and Diet Tracker), websites (e.g., MyFitnessPal.com), and smartphone apps (e.g., MyFitnessPal, MyNetDiary, SparkPeople). We recommend bringing a few calorie-​counting books to group for the purposes of demonstration. ■ Client Workbook 1 ■

Table 1-2: Physical Activity Goals by Program Week ■ Worksheet 1-​1: Cutting Back on High-​Calorie Foods Form ■

Clinician’s Note We recommend setting up name plates (8.5 × 11 sheets of card stock folded in half) in the middle of the table with each client’s first name so that group members and leaders can more easily get to know one another’s names. ■ Clients should be weighed in and the weight recorded (see the introductory chapter for instructions) prior to the start of group. ■ At the end of the next session, and at each session thereafter, collect any worksheets and completed food records and distribute new ones. ■

Welcome (5 Min.) Welcome the clients and let them know how excited you are about working together. Introduce yourself, including your professional credentials and your experience relevant to weight control. Follow this personal introduction with a brief overview of what you will be covering in Session 1.

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The assumption behind this treatment is that you and all clients will have copies of the Client Workbook. In addition, please note that in the Materials Needed section of the Clinician’s Guide, we list the worksheets found in the Appendix, as well as non-workbook materials needed to run the session (e.g., white board, food). We do not list material contained in the body of the Client Workbook chapters that may be referenced during sessions (e.g., Skill Builder, ABCDE Check-In, figures, tables).

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Introduction of Clients (15 Min.) Begin by asking each client to introduce him-​or herself, using the following outline [write on whiteboard (or other means of writing)] 1. Name the client would like to be called in the group 2. A one-​sentence summary of the client’s work or family information 3. A one-​sentence summary of why the client decided to join the program at this time Limit each client to 1 minute and ask him or her to follow the three-​ sentence guideline. Indicate that this is good practice for being concise in sharing information with the group. Offer an example to the group. ADAPTING FOR INDIVIDUAL FORMAT As a substitute for group introductions, you can ask your client to tell you about his or her living situation, a short summary of attempts to lose weight in the past, and why he or she has decided to seek professional weight loss treatment. You can also inform the client about commonalities between his or her responses (e.g., previous attempts and reasons for attending treatment) and those of other clients you and/​or others have treated. Example  1:  “My name is Joe. I  live in South Philadelphia with my wife and teenage daughter, and I’m working part-​time as a landscaper. I decided to join the program because I just got diagnosed with high blood pressure and I want to improve my health.” Example 2: “My name is Patricia. I am an eighth-​grade English teacher. I decided to join this program because I have a two-​year-​old son and I  noticed that it is hard for me to keep up with him. I  think losing weight will help me have more energy.” After the introductions, respond to clients’ reasons for being here (commonalities with other group members, how the program can help, unrealistic expectations, and so on).

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Treatment Overview (14 Min.) Novelty of This Treatment Behavior modification, which forms the foundation of this treatment, is considered the gold standard of treatment. In conjunction with gold-​ standard lifestyle modification, the program will also teach clients specialized psychological strategies that will enable them to choose what and how they eat and when and how much they are physically active. For example, you will train the clients to recognize what they care about most deeply and intensely and use this to motivate them. You will also teach the clients psychological skills that will enable them to choose their behaviors based on what they truly want for themselves.

Philosophy Provide clients with some background information about the treatment. First, explain to them that this treatment approach is based on several assumptions regarding weight, health, and weight loss: 1. Weight loss improves health and well-​being. Weight loss is associated with improvements in blood pressure, cholesterol, sleep apnea, arthritis, blood sugar, mood, and body image. These improvements can be achieved with modest weight losses (10%) and do not require reduction to ideal weight. 2. Long-​term change in behaviors is necessary. This program is different from many others because it is specially designed to help clients maintain weight loss in the long term. The program will provide extensive instruction in the long-​term modification of eating and exercise habits. Many clients have likely had the experience of losing weight and later regaining it; we hope that the skills they learn in this program will allow them to keep off the weight they lose, even after the group ends. 3. Overwhelming scientific evidence shows that reduced calorie intake is the most important determinant of weight loss. So this approach is focused on setting and keeping to a calorie goal. It allows for eating a wide variety of foods and portion control of high-​calorie foods (i.e., not limiting intake to a particular type of food or completely 4

cutting out a type of food, such as carbohydrates). Increased energy expenditure is the second most important determinant, so we also focus on setting and keeping exercise goals. 4. Specific psychological skills and abilities will help with weight control. After discussing these assumptions about weight loss, provide clients with information about how this program will likely be different from programs or methods that they may have tried in the past to lose weight. First, mention that long-​term weight loss is difficult, in part because all humans are biologically engineered to eat delicious food, and in the modern world, great-​tasting food is always available. This availability generates a nearly constant desire to eat, and sometimes cravings to eat particular high-​calorie foods. Similarly, the modern world encourages us to be sedentary rather than active. Many of the clients have probably tried to address these challenges by doing things like trying to convince themselves to eat a certain way or to exercise, exerting more willpower, or pushing away their hunger/​ cravings. Often these approaches do not work well, especially in the long term. This program is unique in that it will give clients some new tools for responding to challenges of long-​term behavior change. You will be teaching clients skills that have been found to enable them to choose what to eat and how active to be, even despite these challenging conditions. You will start introducing these skills in Session 5. Additionally, explain that as the goal of this program is long-​term weight loss maintenance, many of the skills clients will learn are intended to help them maintain their behavior long after they complete the program. Holding oneself accountable outside of the program and learning to monitor behavior from week to week are skills that are built over time. To gradually build self-​reliance, the program is designed so that sessions become less frequent over the course of the program. Explain to clients that a reduction in session frequency will help them develop the skills to independently confront the challenges they will face in their long-​term weight control journeys after their completion of the program. More detail is provided regarding the reduction in session frequency in Session 16. 5

Choose a schedule that works best for your group or individual client. The following suggested schedule has proven to work well: Sessions 1–​15: Weekly meetings ■ Sessions 16–​22: Biweekly meetings (every other week, starting with Session 16, for a duration of 10 weeks total) ■ Sessions 23–​24: Monthly meetings (i.e., approximately four weeks between Sessions 22, 23, and 24, respectively) ■ Session 25: Bimonthly meeting (occurring eight weeks after Session 24) ■

Goals The program is goal-​oriented and involves setting goals for calorie intake, amount of activity, weight loss, and so on.

Group Norms, Policies, and Procedures (15 Min.) Group Dates and Times Ask the clients to mark their calendars now with all of the upcoming sessions and to make meetings a priority. Indicate that sessions will begin and end promptly. ADAPTING FOR INDIVIDUAL FORMAT Individual clients benefit from a discussion—​ right upfront—​ of structure, format, and expectations. Let your clients know: The importance of attending every session The structured format of sessions and the advantages of structure. (Studies show that higher levels of structure lead to more behavior change) ■ The focus on skill development ■ The general structure of sessions (weigh-​ in, check-​in, review of previous content, new content, Skill Builders) ■ ■

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Attendance at group sessions is one of the strongest predictors of success. Clients should strive to keep the commitment they are making to themselves and their fellow group members to attend every session. Stress the importance of arriving on time! From experience we (the authors of this guide) know that clients skip group when they aren’t doing well (behaviorally or weight-​wise). However, coming to group at those times is more important than ever! Although clients may feel embarrassed or discouraged, the group will help by boosting morale, offering support, and generating ideas. If an absence is unavoidable, let your clients know that they are expected to contact a group leader. If a client does not do so, the group leader will be concerned and will contact the missing client after group. Make-​up sessions are mandatory.

Session Structure In addition to providing early expectations on attendance, setting expectations for group participation is also important. In group, refer to the section “Group Participation” on p. 3 of the Client Workbook as you introduce the importance of and rules for participation. Communicate that group is not psychotherapy. If outside therapy is indicated, you should suggest it. The focus of this program is skill development, support, education, and problem-​solving as it pertains to health and weight control. Emotional factors may serve as triggers to unhealthy behaviors, but the focus of this program is on healthy alternatives rather than resolving emotional difficulties. Explain that while the groups are highly structured and skill-​focused, they are designed to be interactive and to promote discussion. We do want everyone to participate, including asking and answering questions, providing support and suggestions to others, and discussing the best ways to implement the strategies that are taught. Give fair warning that you need to present a lot of information in the first few sessions, and so you will be doing more talking at the beginning than later on.

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Discuss with clients that confidentiality must be maintained. Clients may not discuss personal details of other group members outside of the group.

Skill Builders Each week clients will have Skill Builder assignments, which are detailed in the Client Workbook and are to be completed before the next session. All clients should complete the assignments and be prepared to discuss them in the following meetings. Completing these assignments is absolutely critical. Skill Builders often contain a worksheet component, and you should collect the completed worksheets each week, comment on them, and return them to clients the following week. Clients are not required to discuss personal matters (concerning family or friends), but will be expected to discuss weight-​control behaviors. Ask your clients to turn to p. 8 in their workbooks to see the Session 1 Skill Builder and to turn to p. 167 to see Worksheet 1-​1, so they can see what you are referring to here. (You will explain the content later.)

Weigh-​Ins Communicate to clients that they will be weighed-​in weekly, in private. Starting with Session 2, you will tell each client how much his or her weight has changed since starting the program and since the previous session. Explain to clients that it is good to get into the habit of weighing themselves at home as well, and recommend they weigh themselves at home one to two times a week. Inform the group that specific information about weight or weight changes may not be shared by group leaders or clients during group each week. Encourage clients to focus on weight-​control behaviors instead of weight during group discussion. It is fine for a client to occasionally share general weight-​related comments (e.g., “I’m frustrated because I gained weight this week, but I thought I met my calorie goal,” or “I’m happy with my weight change this week because I worked especially hard on my dinner choices”).

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During the weight loss phase, advise clients to use the weekly weigh-​ in at group as their primary form of weight monitoring (and limit the frequency of at-​home weighing to no more than twice a week). ■ During weight loss maintenance, more frequent weighing becomes advised (daily weighing is recommended, but no more than this). ■ Let clients know that you will be providing more information about the best method of weighing themselves using their home scales. ■ Let clients know that home scales will not line up perfectly with your scale, and that this is not a problem. ■

Emphasize to clients the importance of recording their weight each time they weigh themselves and that, by keeping a record over time, they will be able to notice trends in their progress and make necessary adjustments. The Home Weight Change Record (Appendix C in the Client Workbook) is a tool clients can use to visually track their weight. Point out that the Home Weight Change record includes both a graph and table format. Clients can use whichever format they prefer, or they may choose to use another format, such as a website or smartphone app. Explain that as their home scale may differ from your scale, there is also an In-​Session Weight Change Record (Appendix B in the Client Workbook) to track their weight measured at each session. At times, clients’ desire to complete food records, follow their calorie and activity goals, and even attend group might fall. Indicate to the group that group leaders and other group members will push group members, challenge them, and not accept excuses.

Weight, Calorie, and Activity Goals (10 Min.) Communicate to clients that they will set weekly and monthly weight loss goals. The program is designed to achieve a 1–2 p ​ ound weight loss per week. By five months, most clients will achieve a 10% weight loss or more. At around this point, the focus for most people shifts to maintaining lost weight. Part of the first few weeks of treatment will involve finding calorie goals for each group member that result in healthy weight loss. To start off, clients will choose their own calorie goal within a window. Group

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members who are currently less than 250 pounds will set a goal of daily intake between 1,200 and 1,500 calories. Group members who currently weigh more than 250 pounds will choose a calorie goal between 1,500 and 1,800 calories. Encourage clients to try and stay within the calorie range for their current weight in the coming week. Direct clients to p. 4 in their workbooks, which contains initial calorie goals. Emphasize to clients that we have not yet discussed in group all of the skills that they will need to accurately estimate calories, but to take a first try at weighing and measuring foods using a tool like the Calorie King book to look up calories, and staying within a calorie range. Provide clients with the following key points about how to get started with tracking their intake, referring to pp. 5–6 in the Client Workbook, under the heading “Getting Started: Self-​Monitoring” and Figure 1-​1, Example of a Completed Keeping Track Form in the Client Workbook: 1. Achieving a calorie goal requires careful tracking of what the client eats and drinks and those items’ calorie content. This program spends a great deal of time in the first few sessions teaching clients the best way to record food/​drink, serving size, and calories. 2. The first assignment is to have clients record everything they consume on the Keeping Track Form and to try to look up its calorie content in the Calorie King book or other source. This may be easier or more difficult than clients imagine; you will discuss how it went next week. 3. Instruct clients how to complete records. Clients should keep track of the time that they eat, the amount of food (portion size), a detailed description of the food, and any information about how the food was prepared. 4. Keeping Track alternatives:  If clients would like to record eating using a tool other than a Keeping Track Form (e.g., an iPhone app), they are able to do so but they must turn in a record (e.g., a printout or PDF) to the group leader every week that includes all of the information that would be provided on a Keeping Track Form (including time of eating). Each week, collect all Keeping Track Forms and provide written feedback by the next session. Point out that apps/​websites that adjust calorie goals based on physical activity are misleading, in part because our goals are already assuming

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physical activity. There are settings on most of these programs that allow clients to record physical activity without the app subtracting expended calories from calories consumed. Instruct clients that this week they should try to stay within the calorie range specified by their weight. In the coming weeks, you will identify a very specific calorie target (e.g., 1,350) for each client based on intake and weight pattern. (Emphasize that you will spend the next several weeks focusing on skills to successfully meet calorie goals.) Indicate to clients that the group will also set exercise goals. For the coming week, clients should set a goal of 15 minutes of brisk walking (or other aerobic activity), three days per week, for a minimum of 45 minutes per week. The physical activity goal will gradually increase, up to 250 minutes per week. (Direct clients to Table  1-​2, Physical Activity Goals by Program Week, in their workbooks.) Remind clients that achieving their goals will require careful tracking of calories and weight over time.

Cutting Back on High-​Calorie Foods (5 Min.) Over the course of the program, the group will discuss strategies to reduce calories. Introduce the first strategy now: cutting back on high-​ calorie foods. Direct group members to their Client Workbook. Discuss with clients that certain foods contribute a large proportion of our total calories. A good place to start in reducing total calorie intake is cutting back on these foods. 1. Fat/​oils have the most calories per gram. Thus, we want clients to cut down on the amount of high-​fat foods they eat. 2. High-​sugar foods tend to be high in calories without being very filling, so we tend to eat more to feel satisfied. As a first step in reducing total energy intake, group members will have the goal of avoiding (or at least cutting back on) the foods and drinks that are especially high in calories. “Cutting back” means reducing intake by at least one-​third. Instruct clients to go through the list and identify which foods/​drinks they would like to cut back on this week.

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After identifying these foods/​drinks, instruct clients to mark in their Keeping Track Form the following items during the upcoming week: 1. Meals/​snacks where they were able to successfully cut back on these foods (with a checkmark or “yes”). 2. Meals/​snacks where they did not successfully meet their goal of cutting back on these foods (with an X or “no”). 3. Meals/​snacks where they weren’t sure whether or not they were successful in meeting this goal (with a question mark). Refer clients to Figure  1-​1 in their workbooks for an example of a completed Keeping Track Form and Figure  1-​2, Tracking Progress with Cutting Back, for an example of how to start cutting down on high-​calorie foods. Note that examples of successes may be not having a food/​drink at a meal or snack (or between meals/​snacks) that they normally would, as well as consuming at least one-​third less than they normally would. Examples of unsuccessful attempts to meet this goal would be having a usual amount (or more than normal) of a high-​calorie food when they had planned to have one-​third less of that food/​drink this week. This will help clients to become more aware of changes they may want to make to their diet, in addition to beginning to build the skill of identifying when they are having trouble meeting their goals.

Skill Builder (5 Min.) Introduce the first Skill Builder for the coming week. Skill Builders are homework for group members to complete in between sessions. This first Skill Builder includes four components. A fifth component, an experiential exercise, will be included in future sessions. Direct clients to the Skill Builder for Session 1, on p. 8 of their workbooks, which outlines the Skill Builder for this week. The instructions below are for clients. □ Activity: Exercise (e.g., brisk walking) for 15 minutes × 3 days. □ Behavior:  Record all foods and drinks using the Keeping Track Form in Appendix A (time, amount, type, and description of food) consumed except water. (Make sure to have made multiple copies of

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the Keeping Track Form so that you can start a new one each day.) Use a calorie-​tracking book or website, measuring cups, food scale, and nutrition labels to determine caloric intake (to the best of your ability). □ Calories: Based on the Cutting Back on High Calorie Foods Form (Worksheet 1-​1), reduce intake of high-​calorie foods by one-​third. In your Keeping Track Form, mark times when you were successful (checkmark or “yes”), were unsuccessful (X or “no”), or weren’t sure whether or not you were successful (“?”) in cutting back on the high-​calorie foods and drinks you were attempting to cut back on. See Figure 1-​1 in the Client Workbook for an example of a completed form, and Figure 1-​2 for an example of how to begin reducing intake of high-​calorie foods. Try to stay within your target calorie range (1,200–​ 1,500 for 250 lbs.). □ Days Recorded: Record every day. □ Experiential Exercise: N/​A □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

Wrap-​Up (1 Min.) Express your enthusiasm for working with clients over the course of the next year as they make many important, exciting changes to their lifestyles.

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CHAPTER 2

Session 2: Calorie-​Cutting Keys

TOPICS Welcome (5 Min.)

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Abbreviated Check-​In (20 Min.)

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Self-​Monitoring (15 Min.)

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Reducing Calories (20 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbooks

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Worksheet 2-​1: Calorie Tracking Example ■ Worksheet 2-​2: Remember Your Purpose ■

Enough copies of the Keeping Track Form (Appendix A  in the Client Workbook) so every participant receives a form to record between sessions

■

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Clinician’s Note As described in the introduction, from this session on, weigh clients in a private setting as they arrive to group. You should let clients know how much weight they lost in the previous week. Have a brief (1-​to 2-​minute) discussion with each client about his or her weight trajectory. For clients who maintained or gained weight in the previous week, encourage them to brainstorm reasons this may have happened. If participants report meeting their calorie goals while maintaining or gaining weight, probe for times when they may have had lapses in self-​monitoring. Remember to collect clients’ Keeping Track Forms during weigh-​in, as well as any worksheets clients completed as homework from the last session. These materials should be collected at the end of each session. Beginning with Session 3, you should return worksheets and Keeping Track Forms, along with feedback you have provided. For guidance on how to provide feedback, see the Providing Feedback on Keeping Track Forms box in this chapter. Refer also to the introduction and Chapter 1 for more details about Keeping Track Forms.

Welcome (5 Min.) Welcome the clients and have the group members reintroduce themselves to one another by stating their names. If new members are present, include their reasons for weight loss as in Session 1, but keep this section abbreviated. Address any questions left from last session and briefly review today’s agenda.

Abbreviated Check-​In (20 Min.)

ADAPTING FOR INDIVIDUAL FORMAT While the group format necessitates that each client’s check-​in lasts only one or two minutes, individual sessions offer the luxury of stretching the check-​in to 5 or 10 minutes.

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Explain to the group that the amount of time available for check-​in and problem-​solving varies by session and often will have to proceed very efficiently. To help structure the check-​in, ask clients to follow the ABCDE script (see the following paragraph). Use the check-​in script and ask clients to turn to the Session 2 ABCDE Check-​In on p. 10 of the Client Workbook. Model how an ABCDE Check-In should go. Go quickly around the room, and tell clients to skip E for today. Problem-​solve, as time allows, with clients who are not recording every day. Set a clear expectation for 100% recording. Note that a few clients each week will be asked to provide more information about what helped them be successful or, when they struggled, what challenges they faced and how they can be addressed in the future. There is not enough time for everyone to share this information. Be sure to choose different clients for a more detailed check-​in each week. Activity: 15 minutes × 3 days Behavior: Record all food and drinks consumed except water; use Calorie King book or other source, measuring cups, labels, and food scale to try to calculate calories Calories: Cut down on high-calorie foods by one-third. If clients report challenges determining whether or not they cut back by one-third, tell them that you will talk about this challenge later in today’s session; try to stay within the target calorie range (1,200–​1,500 for < 250 lbs.; 1,500–​1,800 for > 250lbs.) Days recorded Experiential exercise for practicing new skill: None this week

Self-​Monitoring (15 Min.) Last week, clients recorded everything consumed. Ask them about this experience, including whether they found it helpful and if they recognized any patterns in their eating habits. Also ask clients if they found

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any barriers to recording their intake. Finally, ask clients how they felt when recording any episodes of overeating. Express to your clients that self-​monitoring is a critical part of this program and that there are many benefits to self-​monitoring, including: Minimizing underestimation of intake ■ Minimizing overestimation of overeating episodes ■ Enabling clients to search for patterns in their eating habits (e.g., time, place, activity) ■

Clients will be completing food records for the remainder of the program, so it is important take some time to go through the recording process in detail. First, briefly review information that clients should record (i.e., time, amount, type and description of food, method of preparation). Emphasize the importance of food weighing and measuring. Indicate that this is important so that what clients record in their Keeping Track Forms is accurate. Stress the importance of recording immediately after eating, as the longer clients wait to record, the less accurate their recall. Recommend that clients subtotal their calories throughout the day so that they have a constant understanding of how many calories they have eaten and how that compares with their calorie goal for the day. Review options for finding the calorie content of foods. Daily self-​ monitoring of calorie intake and physical activity can be facilitated by websites and smartphones apps, and many patients prefer these options over traditional, paper-​based recording. Having an app available on a smartphone promotes more accurate recording (e.g., as soon as possible after eating, with specific amounts, and with automatic totaling of calories consumed for the day). We recommend using low-​ cost apps that allow for simultaneous tracking of physical activity and calorie intake, such as MyFitnessPal, MyNetDiary, or SparkPeople. These apps also allow users to calculate calories per serving in homemade recipes and to save commonly eaten meals or food items, making it easier and faster to record these items in the future. Unfortunately, very few, if any, apps allow recording time. However, several (e.g., MyFitnessPal) do allow notes to be added; instruct clients to add time in a notes section.

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For clients who prefer to look up calories online but still record their intake on paper, several websites provide easy-​to-​access and accurate calorie counts. Recommended popular sites include CalorieKing, CalorieCount, and NutritionData, among several others. In addition, simply searching (e.g., using Google) “calories in [food item of interest]” will yield accurate and detailed nutrition information for a wide range of common food items. Given the wide range of apps and websites available today, it is important to note that some of these resources provide user-​entered nutrition information (with varying degrees of accuracy). User-​entered information is part of what makes these sites such abundant sources of calorie information. However, a search for a single food item may yield a wide range of calorie estimates, differing by up to 300 calories in the most extreme cases. It is important to warn patients to use the “common-​sense test” when relying on apps and online databases for calorie counts. If the calorie count seems too good to be true on an app or website, it probably is, and they’re better off going with a higher estimate. One additional caution to pass on to clients concerns adjusted calorie counts. Some apps and websites adjust calorie counts based on physical activity and possibly other factors. However, this program is designed around actual calorie intake amounts. Thus, clients should be sure to use a site or app that allows them to see actual calorie intake and not adjusted caloric intake. Use a meal from a client’s food record and provide an example of how to calculate calories for this meal. If possible, sketch the meal elements and their calories in a location where all members can see [e.g., whiteboard (or other means of writing), projector]. Have clients assist in looking up calorie content for different elements of the meal using their preferred method. Once you have completed this activity together, direct clients to Worksheet 2-​1 in their workbook, where they will find the Calorie Tracking Example. Ask clients to take a few minutes to complete this worksheet, and then review the answers with clients. Stress how many more calories are consumed by eating out, even for just one meal, versus preparing food at home.

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Reducing Calories (20 Min.) Remind clients of their calorie goal, which was introduced last week:  1,200 to 1,500 calories/​ day for those who weigh under 250 pounds and 1,500 to 1,800 calories/​day for those who weigh over 250 pounds. Discuss that—​through experimentation over the next few weeks—​you will help clients establish an ideal calorie goal, which will lead to weight loss of 1 to 2 pounds per week, and that, ultimately, each client will have an individualized and specific calorie goal. After clients have an understanding of calorie goals, introduce the concept of energy balance. Review the basic principles of energy balance with your group. That is, when the energy taken in exceeds energy expended, this results in weight gain. When energy taken in is equal to energy expended, this results in weight maintenance. When energy expended exceeds energy taken in, the result is weight loss. On average, a person needs to eat 3,500 calories per week less than he or she burns in order to lose 1 pound. Emphasize that the combination of energy burned by basic body processes plus energy burned by physical activity is not nearly enough by itself to lose weight. In order to lose weight, clients must dramatically reduce energy taken in by eating. Discuss with clients that most individuals underestimate their calorie intake and overestimate how many calories they burn through exercise. In the beginning of this program, the focus is more on decreasing intake as opposed to increasing output, because exercise alone is not the best method for weight loss. Let clients know that regular physical activity will become very important as the program goes on, and it is the best predictor of maintaining weight loss.

Beginning to Reduce Caloric Intake Direct clients to the corresponding section in their workbooks under the heading “TOP: Three Key Tips for Starting Out” (see pp. 13–14). Introduce the three tips that can be useful for starting to reduce calories: 1. The first suggestion is to time your eating. Encourage clients to eat on a regular schedule and to avoid going more than four to six hours

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without eating. Eating every four to six hours should help to prevent intense hunger and consequent overeating. 2. The second suggestion is to optimize the environment for success. Discuss with clients that cues in the home and in other settings, such as the workplace or car, have a strong influence on eating behavior. In fact, the increased availability of palatable foods in the environment is the driving force behind the increase in obesity in the United States. Clients will need to counteract this larger environmental change by doing what they can to reduce access to unhealthy choices and make healthy choices the default. This includes stocking up on low-​calorie snacks and eliminating high-​fat and high-​calorie temptations from the environment. 3. The third suggestion is to plan ahead. This includes examining a schedule and priming the environment with healthy choices. Ask clients to discuss the benefits of planning ahead. Direct clients to the sample meal plans on pp. 18–20 in their workbooks for examples of how to plan ahead.

Striving for a Healthy Diet Provide clients with the information that this program focuses on setting and keeping to a calorie goal, rather than completely cutting out a type of food. This flexibility will help clients be successful with weight-​ control efforts in the long term. Because there is flexibility, clients can decide what to “spend” their calories on. Even so, in order to be successful, almost all clients will find that they will need to avoid certain foods or at least eat them rarely. Tell clients to be on the lookout for such foods (refer back to the Cutting Back on High-​Calorie Foods Worksheet from Chapter 1, for examples). Introduce strategies that can be helpful in striving for a healthy diet. Clients can follow along in their workbooks under the headings “Ways to Reduce Calorie Intake and Increase Healthy Eating” (p. 14) and “Strive for a Better Diet” (pp. 14–17). First, encourage clients to increase intake of fruits and vegetables. Discuss that fruits and vegetables are generally more filling than other foods, providing more volume for less calories. Discuss ways to increase

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fruit and vegetable consumption. For instance, clients can add fruits and vegetables to dishes (e.g., reduce pasta intake to 1 cup but maintain a large portion by adding 1 cup of vegetables to it; reduce cereal intake to 1 cup but maintain a large portion by adding 1 cup fruit to it). Clients can also use fruits and vegetables for snacks, and fruits can be used to satisfy a sweet craving. Encourage clients to make these foods readily available by placing them on the counter, in the car, in their desk drawer, or in a glass bowl at the front of the refrigerator. Second, discuss increasing the consumption of lean sources of protein. For examples, clients can avoid meats, fish, and poultry cooked with butter or oil and instead bake, broil, or grill these foods, as well as remove skin and visible fat from meat. Also encourage clients to stock up on lean protein while grocery shopping. Third, discuss eating whole grains when consuming carbohydrates. Note that whole grains are not necessarily lower in calories than refined versions, although they are more filling and should allow clients to stay satisfied for longer after eating. Remind clients that packages can be misleading when it comes to whole grains. Also discuss reducing or eliminating unnecessary hidden calories that clients do not need or particularly enjoy. This may be accomplished by eliminating or reducing sugar in sodas and coffee, reducing the use of cream and butter, and instead choosing lower calorie alternatives with a similar taste. Finally, discuss limiting calories from beverages. First, these calories are not as filling as solid food. For example, 50 calories from orange slices is more filling than 100 calories from a glass of orange juice. Alcohol intake also should be limited because these are empty calories that also can trigger additional eating (and less physical activity). In order to limit calories from beverages, encourage clients to reduce the presence of caloric beverages in the home and to make water (tap, bottled, seltzer, sparkling) and other zero calorie beverages the easiest to obtain (e.g., keeping tea bags at work, bottled water in the car). Encourage clients to be conscious of the caloric cost of food choices and to ask themselves, “Are these calories worth it?” Also remind clients to avoid total deprivation and instead make changes that they can live

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with. Pleasurable foods can be a part of diet in moderate frequency and in small portions. Remind clients that they may know/​discover a particular food or two for which portion control is too difficult and elimination of that particular food is most sensible. Skill Builder (5 Min.) Direct clients to p. 21 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity: Exercise (e.g., brisk walking) for 15 minutes × 3 days. □ Behavior:  Complete the Remember Your Purpose Worksheet (Worksheet 2-​2). □ Calories:  Follow a diet that is consistent with your calorie goal (1,200–​1,500 for 250 lbs.). Total the calories for each day (and for the week), calculate a seven-​day average, and compare results to your target range. Reduce by one-​third or continue to lower your intake of high-​ calorie foods. See the Cutting Back on High Calorie Foods Form (Worksheet 1-​1) for examples of high-​calorie foods. □ Days Recorded: Using a copy of the Keeping Track Form, record all the foods and drinks (except for water) that you consume (including the time, amount, type (type of preparation), and description of food). Record every day. □ Experiential Exercise: N/​A □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories). PROVIDING FEEDBACK ON FOOD RECORDS At each session, clients should give you their recent food records (Keeping Track Forms) for review. Self-​monitoring is one of the most powerful elements of behavioral treatment. Client completion of food records is critical for success. Adherence is facilitated when you review the food record each week, because this provides an important sense of accountability. It also allows you to provide

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reinforcement for self-​ monitoring behavior. Finally, food record feedback provides an opportunity to offer support and deliver supplemental education about nutrition. Food record feedback often consists of (a) summary comments and (b) notes about specific aspects of food intake. Feedback should provide positive reinforcement (e.g., praise for keeping a complete food record or making a desirable change in eating behavior). Typically, provide one suggestion for changing eating behavior or improving self-​monitoring in each record. However, there are instances in which providing only positive feedback may be appropriate. It is also important to provide feedback about the quality of the food record. This is especially true in the first several sessions and anytime thereafter when lapses in self-​monitoring seem to occur. If a participant does not turn in a food record at all, this lapse should immediately be addressed in session. You should convey serious concern about this lack of adherence and collaboratively develop a specific plan for immediately resuming self-​monitoring. Feedback should attend to how complete the food record is, including days, meals, snacks, and beverages recorded, as well as notation of time and calculation of portion size and calories. Even with the best of intentions, food intake underreporting will usually occur. Clients may underestimate portion size, which is why regularly weighing and measuring food is important. They also may leave out “hidden calories” (e.g., from added sugar or fat) or forget to include condiments, side dishes, or beverages. When an overeating episode occurs, underreporting may be especially likely. It is important to convey a nonjudgmental stance about overeating to clients and motivate them to report all intake, even if they feel ashamed, embarrassed, or disappointed. Comparing a client’s average calorie intake for the week with that week’s weight change can provide information about how much underreporting may be occurring. Clients should be encouraged more generally to examine relationships between their eating behavior, calorie intake, and weight change. Once an appropriate calorie goal has been selected, you can provide feedback in the food record about the client’s success in meeting the calorie goal. You may also comment on patterns of

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eating behavior that may be problematic, such as going long periods of time without eating. Feedback should be provided on the composition of the diet, providing praise for desirable food choices and prompting the client to make additions, substitutions, or eliminations where appropriate. A series of examples of a Keeping Track Form with clinician comments is provided in Figure 2-1 in this guide.

Figure 2-1 Example Food Record with Clinician Feedback 25

Figure 2-1 Continued

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CHAPTER 3

Session 3: Goal Setting; Weighing and Measuring

TOPICS ABCDE Check-​In (25 Min.)

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Skill Review (5 Min.)

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Setting and Evaluating Weight Loss Goals (20 Min.)

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Weighing and Measuring (10 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 2-​2: Remember Your Purpose ■ Worksheet 3-​1: What Meals and Snacks Work for Me? ■

Enough copies of the Keeping Track Form (Appendix A) so every participant receives a form to record between sessions

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Clinician’s Note As a reminder, weigh clients prior to the start of the group. During weigh-​in, collect new Keeping Track Forms and return the Keeping Track Forms from the previous week along with your feedback. (A guide for providing feedback is provided at the end of Chapter 2.)

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Note that you can also choose to collect and/​or return Keeping Track Forms at the end of the session if that is more efficient or if clients are distracted by returned forms during group. Reminders are not repeated in subsequent chapters, but it is important to continue collecting and then returning Keeping Track Forms and worksheets. Doing so provides accountability and reinforcement, as well as the ability to understand and improve client’s current comprehension of program concepts and skills.

ABCDE Check-​In (25 Min.) Briefly remind clients of the ABCDE Check-In procedure. Instruct clients to read from their Session 3 ABCDE Check-​In sheets at the end of Session 2 in their workbooks. Remind them that: ■ ■ ■ ■ ■

A stands for activity (number of days and average minutes per day) B for behavioral goals C for calories consumed D for days recorded E for experiential exercise (tell clients to skip E for today, as there were no exercises assigned in the previous week)

Clinician’s Note There is not a “W” for weight because most clients don’t want to share their weight in a group setting. Ask clients not to share weight during check-​in but rather focus on behaviors (e.g., “I’m frustrated because I thought I hit my calorie goal but my weight went up”). Conduct the ABCDE Check-In. As referenced in the introduction, you should work to integrate ABT skills (even material not yet covered) into check-​in and actively socialize the group to interact with one another. Repeatedly draw group members into the discussion even if check-​in focuses on one person at a time. Problem-​solve, as time allows, with clients whose weekly calorie average does not match their target and those who were unsuccessful in recording seven out of seven days. Ask clients who did not meet their goals

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to identify challenging situations they faced and consider whether they could have done anything differently in retrospect. When appropriate, invite group members to offer suggestions if the featured participant wants assistance in resolving an issue.

Skill Review (5 Min.) Review the strategies for reducing calorie intake and calorie accounting discussed last week. Ask clients to share any additional strategies that were helpful. Review the concept of energy balance and the principles of engineering the environment for success, scheduled eating, and planning ahead. Also review what constitutes a healthy diet (e.g., increase fruits/​ vegetables, lean sources of protein, whole grains; eliminate unnecessary hidden calories; limit calories from beverages; and avoid deprivation).

Setting and Evaluating Weight Loss Goals (20 Min.) Refer to the Remember Your Purpose Worksheet (Worksheet 2-​2) that clients completed for homework. Highlight that clients joined the program for many great reasons and that goal setting is an important part of lifestyle change.

Weight Loss Goals Clients begin this program with varying weight loss goals. This program’s goal is 1–2 pounds per week. We (the authors of this guide) recommend an initial goal of a 10% reduction because that is associated with improvements in medical conditions, and most persons can achieve a 10% reduction with modest changes in eating and exercise. When 10% is reached, another goal can be set based on the costs and benefits, and losing more than 10% will be the best choice for most clients. Have clients discuss their reactions (e.g., disappointment, excitement), along with any assumptions about benefits (e.g., “Losing 40 pounds will make me feel/​look twice as good as losing 20 pounds”) or costs 29

(e.g., “Losing the second 20 pounds will be similar to losing the first 20 pounds”) of losing more weight. Have clients discuss the accuracy of these assumptions. Review how to complete the weight graph on the Home Weight Change Record (Appendix C of the Client Workbook). As stated in Chapter 1, clients can use the graph to visually track trends. A table version is also provided for clients who are less visual and may prefer a numeric representation of their weight change rather than a graphical one. This graph or table should be completed each week. Acknowledge that, week to week, weight is variable, so it is important to look at the overall trend displayed by the weight graph.

Effective Goal Setting Convey to clients that effective goal setting is key for many aspects of behavioral change. Review elements of effective goal setting. First, goals should be specific; that is, they should define precisely what is to be accomplished. Specific goals such as “walk two times this week after work on Tuesday and Thursday in the park” are more likely to be accomplished than general ones such as “walk more this week.” Similarly, “eat 1,200 to 1,400 calories per day” is more likely to be accomplished than “eat less this week.” Second, goals should be reasonable. This includes making small changes. If clients are not walking at all, for instance, they should not try to walk every day. If they are eating cookies for dessert every night, they should not attempt to immediately eat none. If there is a small difference between clients’ current behavior and the goal behavior, there is greater likelihood of accomplishing this goal. Third, goals should be active. This includes defining goals in terms of what to do rather than what not to do. For example, “eat every four hours” is better than “stop going all day without eating” and “walk after dinner” is better than “stop lying on the couch after dinner.” Fourth, goals should be short term. Encourage clients to assess their goals over short intervals (no more than a week). Sometimes, even shorter intervals are helpful (day by day). Looking at progress after short

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periods will enable review of accomplishments and troubleshooting of any difficulties. Goals should also be limited. Instruct clients to select no more than two goals per week. Selecting more will decrease focus and make adherence more difficult. Once goals have been accomplished and maintained, clients can select new goals. Encourage clients to record their goals and attainment of goals, as it is helpful to keep a written record of goals and progress each week. Keeping a written record will increase awareness of the goal and provide an accurate record of progress. The simplest and easiest records work best. Instruct clients to select one behavioral goal for the next week (using information in the Client Workbook under the heading “Setting Behavioral Goals” as a guide). Go around the room and have each person share his or her goal. As needed, help clients to make their goals more specific, reasonable, active, short term, and limited. Also have them record their goal on their Keeping Track Form. (They will discuss this goal during the ABCDE Check-In next week).

Weighing and Measuring (10 Min.) Discuss the importance of weighing and measuring foods. Refer to the section on weighing and measuring foods on pp. 26–27 of the Client Workbook. Provide your clients with the following example: You use olive oil as a dressing for your salad. You guess it’s about one-​ half a tablespoon (60 cal.). When you actually measure it, you realize you’ve been using 2 tablespoons (240 cal.). If you have three salads a week, that’s an extra 540 cal that is unaccounted for. Emphasize how small measuring differences can add up to big differences in terms of calories, and emphasize the resulting importance of continuing to measure foods. Discuss the importance of leveling (e.g., using a knife to push flour that is above the top of a cup measure) and what the effects are of not leveling. Discuss the importance of detecting small differences in weight when using a food scale and what that means for calories and fat intake. Remind clients to weigh meats after cooking (meats lose about a quarter of their weight during cooking).

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When measuring utensils are not available, instruct clients to estimate portion size using the “Portion Size Tricks” section on p. 27 of their workbook. Eventually clients will be able to perform occasional checks and weigh only novel foods. Introduce the use of prepackaged meals such as Slim Fast and Lean Cuisine as a strategy for making self-​monitoring easy. Review the additional benefits provided by prepackaged foods and meal replacements: there is no food prep, they reduce food shopping time, they are easy to carry and store, they can cost less than the meal they replace, and there is less exposure to tempting foods. As clients start to try new meal options that are consistent with their calorie goals, it can be helpful to record those options that are most convenient, especially satisfying, good tasting, or inexpensive. Clients should record ideas on the What Meals and Snacks Work For Me Worksheet (Worksheet 3-​1), which will be copied and shared with all group members at the next session. Over the next few weeks, psychological strategies will be introduced to help clients maintain key weight control behaviors, such as weighing and measuring. It is common for clients to find these behaviors difficult to enact—​both when trying them out for the first time and while trying to maintain them in the long term. Some clients may find weighing and measuring to be time-​consuming, tiresome, or inconvenient. As psychological strategies are introduced, it can be helpful to encourage clients to use strategies like willingness (see Chapter  6) to engage in weighing and measuring, even when it becomes difficult.

Skill Builder (5 Min.) Direct clients to pp. 27–28 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 15 minutes × 3  days. Record type and minutes on your Keeping Track Form. □ Behavior: Weigh and measure all food and drinks except water. On your Keeping Track Forms, mark with an asterisk (*) any times you

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were surprised by the number of calories in a food or drink you measured or weighed.

Work on the behavioral goal that you identified during today’s session. Reminder: In this session and in several future sessions, clients will have opportunities to identify personalized behavioral goals. In these instances, instruct clients to write down a personal behavioral goal in the space provided in their workbook and follow it, in addition to any other Skill Builder assignments for that week.



Complete the What Meals and Snacks Work for Me Worksheet (Worksheet 3-​1).

□ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. Reduce (by one-​ third) or continue to lower your intake of high-​calorie foods. □ Days Recorded: Record every day. □ Experiential Exercise: N/​A □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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Session 4: Labels, Planning, and Calorie Accounting

CHAPTER 4

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (5 Min.)

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Reading Nutrition Labels (5 Min.)

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The Importance of Meal Planning (22 Min.)

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Calorie Accounting (8 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 4-​1: Daily Meal Planner

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Access to photocopy machine to provide copies of completed What Meals and Snacks Work for Me Worksheets to group members ■ Sample food labels (optional) ■ Enough copies of the Keeping Track Form (Appendix A) so every client receives a form to record between sessions ■

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ABCDE Check-​In (30 Min.) Collect all completed What Meals and Snacks Work for Me Worksheets and make copies for all group members. This should be done during check-​in to allow the worksheets to be passed out during the group activity. Conduct the ABCDE Check-In. Specifically, check in regarding clients’ experiences with continuing to reduce (or maintain lower) intake of high-​fat and high-​sugar foods, and problem-​solve as necessary with clients who are struggling to reduce intake of these food types. Continue to socialize clients to interactive problem-​solving by (when appropriate) inviting group members to offer suggestions if the featured client wants assistance in resolving an issue. As time allows, ask some clients to share what dietary changes have been most helpful for decreasing caloric intake.

Skill Review (5 Min.) Review strategies for effective goal setting, including the importance of setting specific, reasonable, active, short-​term, limited goals that one can measure through self-​monitoring records. This can be done by asking clients to recall what strategies for goal setting they remember from the previous week and filling in the gaps as necessary. Clients can also be referred back to the “Effective Goal Setting” section from Session 3 (see Chapter 3 in workbook). Ask one or two clients to share feedback about how goal setting went for them since implementing the strategies listed here. Review strategies for weighing and measuring using the same approach described earlier. Elicit discussion of clients’ experiences with weighing and measuring all food (e.g., through questions such as “What were some of the surprises or challenges you encountered with weighing and measuring?”).

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Reading Nutrition Labels (5 Min.) Clients should be instructed to read nutrition labels whenever the option to do so is available. Clients should focus on the top of the label (i.e., serving size, calories, and fat). Point out the location on the label that shows the serving size and the total number of servings per package and ensure clients understand that some packages will have multiple servings per package. When recording calories, it is essential that clients take into account the serving size. For example, if two servings of chips are consumed in one sitting, the client should double the number of calories shown on the label. Also, be sure that clients understand how many of the total calories are from fat. This can be computed by looking at how many grams of fat are contained per serving and multiplying this number by 9 (since there are always 9 calories in each gram of fat). Clients can find this on the last line of any nutrition label. In the example provided in the Client Workbook (p. 32), the product contains 10 grams of fat, which is multiplied by 9 calories per gram, for a total of 90 calories from fat. Most nutrition labels will also include calories from fat at the top of the label, on the same line as the total calories, on the right side. This number can be used to indicate that a certain food is high in fat and therefore should likely be reduced in the diet. Recommend that clients look for foods that show lower values in fat, cholesterol, and sodium on the labels, as these are likely to be healthier choices. Highlight the percent daily value (%DV) column as a way of interpreting the raw macronutrient information in the context of a 2,000 calorie diet (but note that because clients are eating less than 2,000 calories per day, the specific values should not be utilized). Optional: Demonstrate the differences in serving size and nutritional information across different types of food using additional food nutrition labels that you bring to session. The number of labels reviewed may vary depending on time constraints. Clients should be instructed to look at the ingredient list whenever possible to determine the health value of prepackaged food. The order in which ingredients are listed is based on the proportion of food that comes from each ingredient. This is especially helpful in reviewing how

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to determine if something is whole grain. If “whole” is the first word listed in the ingredients (e.g., “whole wheat,” “whole oat”), then the product is whole grain. Usually if a package says “Made with whole grain,” then it is not 100% whole grain (otherwise it would say “100% whole grain”). Although whole-​grain foods are not necessarily lower in calories, they can be more filling since whole grains take longer to break down, which will help clients feel full for a longer period of time.

The Importance of Meal Planning (22 Min.)

ADAPTING FOR INDIVIDUAL FORMAT In individual sessions, you and your client may work together to plan out one or two days of meals, with the other five or six days being completed outside of session by the client as homework. Ask clients to consider why it might be easier to adhere to their calorie target when planning meals and snacks, rather than being spontaneous about eating choices. Clients can be instructed to write down the benefits of planning in their workbooks on p. 32. Have clients discuss the extent to which they are already planning ahead and what barriers commonly arise (e.g., time, having healthy options available, having to rely on family members to cook meals and not knowing what is being prepared ahead of time). Help clients problem-​solve around barriers and encourage an interactive discussion about how other clients have successfully navigated these challenges. Discuss resources for meal and snack ideas: magazines and cookbooks from the library, websites, and so on. (Refer to Online and Written Resources for Healthy Eating [Tables 4-​1 and 4-​2, respectively] in the Client Workbook.) Emphasize the importance of following a regular schedule of eating. Eating regularly throughout the day (e.g., at least three meals and one or two snacks or eating every four to six hours) will help clients avoid intense hunger, which encourages overeating later and makes it difficult to adhere to their calorie goals. Review the What Meals and Snacks Work for Me Worksheet (Worksheet 3-​1), which clients were assigned last session. Ask clients to

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look at the Daily Meal Planner (Worksheet 4-​1). Have clients identify a calorie target for each meal or snack (e.g., 300 calories for breakfast, 400 for lunch, 500 for dinner, and 100 calories for a snack) that totals to their daily calorie goal. Then clients should identify several meal options that fit within the calorie parameters for each meal or snack and that they reasonably see themselves preparing and eating. Having several options for each meal time during a typical week lends itself to flexibility with food choices, but also facilitates consistency with calorie intake from meal to meal and day to day. This exercise also helps clients plan their grocery shopping for the week. Have clients reference Figures 2-​2 to 2-​4 in Session 2 (Meal Plan for Breakfast, Lunch, and Dinner) and problem-​solve challenges as they arise. Due to session length, clients are unlikely to finish their meal plans (Worksheet 4-​1) in session. Instead, ask clients to finish the meal plan on their own and attempt to follow it over the next week. Ask clients to shop for food based on their meal planner.

Calorie Accounting (8 Min.) You can use the analogy of a personal financial budget to describe one method clients can use to budget their calories. Financial budgeting is a skill that clients may already have, which may help to increase their understanding of the concept of balance. You might describe this concept as follows: A calorie account is like a household budget or bank account. Let’s discuss some of the basic principles of using a calorie account. You can spend according to your personal preferences. Consider how much you enjoy a particular food versus what it costs calorically. Consider which foods are most satisfying in terms of hunger. The calorie balance allows for flexibility. You can save calories for special occasions, just as you save money. For example, for a special occasion on a Saturday, you could save 100 calories per day, Monday through Friday, to have 500 extra calories for Saturday. However, try to avoid having wide variability in your daily goal to make sure that your goal for any single day is not too low.

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You also can spend less afterward to adjust for an unusually high calorie meal or day. Many clients find it helpful to tally caloric intake as they go through the day. No single overeating episode is paramount since you can balance your calorie account with adjustments. Your calorie ledger must balance at the end of the week (i.e., average to your daily calorie goal). You should calculate your weekly calorie average from all seven days. Be sure that clients understand the ways in which they can achieve flexibility using calorie accounting and problem-​solve any issues that arise. As discussed previously in the context of weighing and measuring, clients may find calorie accounting and meal planning challenging, tiresome, or inconvenient. Help clients to anticipate the thoughts (e.g., “this is not worth it”) and feelings (e.g., boredom, annoyance) they will encounter as they contemplate and/​or begin to engage in these practices. Encourage clients to use willingness in these instances to count calories and plan meals, even while simultaneously experiencing those thoughts and feelings. Willingness will be discussed in greater detail in Session 6. Instruct clients to “bank” a maximum of 200 calories per day to avoid having some days that are very low in calories. Also instruct them to avoid going under 1,000 calories per day. Emphasize the utility and importance of tallying calories throughout the day so that clients can get immediate feedback about situations in which they may need to make adjustments to stay within their goals. For example, if clients know how many calories they have already used for the day before preparing dinner, they will be able to make an informed decision about what and how much to have for dinner to stay in their calorie target. As a way of paying special attention to calorie accounting, note that clients will be asked to mark occasions where calories were “banked” on their Keeping Track Forms as part of their Skill Builder for Session 5. This exercise is delayed until the next session so that clients can give their full attention to the Daily Meal Planner this week.

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Skill Builder (5 Min.) Direct clients to p. 35 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 15 minutes × 3  days. Record type and minutes on your Keeping Track Form. □ Behavior: Complete the Daily Meal Planner Worksheet (Worksheet 4-​1) and attempt to follow it for the whole week. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: N/​A □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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Session 5: Control What You Can, Accept What You Can’t; The Home Food Environment

CHAPTER 5

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Control What You Can, Accept What You Can’t (20 Min.)

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Optimizing the Home Food Environment (10 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 5-​1: Control What You Can, Accept What You Can’t

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Enough copies of the Keeping Track Form (Appendix A) so every participant receives a form to record between sessions

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. As a reminder, detailed instructions on how to complete the check-​in are described in the introduction. Starting today, you will begin to use acceptance-​based strategies in

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group sessions. Remember that you can and should integrate skills that will be covered throughout the program into check-​in. You can include material that has not yet been introduced as a way to help clients when they are most in need, and as a way of priming clients to be more receptive to these skills in later sessions. Specifically check-​in regarding clients’ experiences with completing the seven-​day meal plan (Daily Meal Planner, Worksheet 4-​1) and following it for the past week. Ask clients what strategies worked well to help them stay on track. Review clients’ experience with marking occasions in which they “banked” calories on their Keeping Track Forms.

Skill Review (10 Min.) Review content from the previous session, including:  nutrition label reading skills (including how to use serving sizes to calculate calories); calories/​calories from fat; limiting fat, cholesterol, and sodium; and % Daily Value. Also review that the session covered how to interpret ingredient lists, including how to tell if a product is whole grain. Ask clients to independently recall information from the prior session and how they utilized this information during the week to improve calorie tracking. Fill in the gaps as needed. Ask clients what benefits they noticed from meal planning over the past week. Some examples may include feeling more empowered about food choices and spending less money on impulse food purchases (e.g., vending machines). If the group does not generate examples of benefits, you may provide examples of benefits that others have noticed in the past, and ask your clients if any of these benefits resonate with them. Discuss barriers to planning and how these can be addressed. Some common challenges that have come up in our groups have included: difficulty adhering to the meal plan when others are dining out ■ implementing plans on less structured days (e.g., weekends, holidays) ■ navigating challenging environmental factors (e.g., meetings that include food, office breakrooms with snacks, birthday parties) ■

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Problem-​solve barriers as needed, drawing out strategies that have been helpful for other group members who faced related challenges. If a topic related to a challenge that is brought up will be covered in a future session, you can forecast this for the group. Emphasize the importance of eating on a regular schedule (i.e., at least three meals and one or two snacks per day or eating every four to six hours) to help clients avoid intense hunger. Review the strategy of calorie accounting to keep track of intake—​like a household budget. Remind clients that they will need to weigh their enjoyment of a food versus its “costs.” The strategy of calorie accounting allows for flexibility and helps clients save calories for special occasions when they may want to indulge. Note that calorie banking was not assigned in the Skill Builder for Session 4; however, it will be included in this session’s Skill Builder to solidify clients’ use of calorie accounting principles.

Control What You Can, Accept What You Can’t (20 Min.) In this section, introduce the basics of the acceptance-​based approach to weight loss and how this differs from other weight loss approaches that clients may have tried in the past. The bulk of content delivered in this session will come verbally from you, and there are fewer client workbook materials; it may be helpful to monitor your pace of the content delivery so that clients will be able to follow along with fewer visual aids. The content delivered in this session is more abstract and conceptual than the material delivered in earlier sessions. It is important that clients understand the rationale for an acceptance-​based approach and apply it to their own experiences, as this will be the foundation upon which additional skills are built. Clients may vary in their thinking styles, which may impact the depth and pace of their engagement with the material. It has been our experience that most clients are able to grasp the material when sufficient time has been provided for elaboration, examples, and clarification as needed. Additionally, it can be helpful to remind clients that you will provide a great deal more information about the acceptance-​based approach in the upcoming sessions, and a complete understanding of how and when to use these skills will come over time. 45

Begin this section by discussing the biological and environmental aspects that complicate weight management. Highlight the obesogenic environment (i.e., our day-​to-​day surroundings provide easy access to an abundance of tasty, high-​calorie foods) and the body’s propensity toward weight gain as challenges that exist outside of one’s control and therefore require a different type of response than challenges that are within one’s control (e.g., behaviors such as logging calories). The following text provides some example language for how this may be delivered effectively to the group: In this program, we will address challenges of weight loss/​maintenance that many other programs neglect. Most of you have reported that in the past you have been able to change your eating and/​or physical activity behaviors in the short term, but it became hard to maintain those changes and you eventually fell back to your old habits. What was specifically hard about maintaining those changes over the long-​term? Keep this discussion brief and pull out examples that fit with an ABT treatment model, (i.e., how internal experiences such as thoughts, feelings, cravings, or physical sensations like hunger interfered). Common internal experiences reported here might include getting bored with eating the same lower calorie options over time, feeling too tired to exercise, having a lot of activities that compete for time in one’s schedule, or experiencing food cravings. Science has been showing that weight loss and especially weight maintenance is made very difficult by our biology and the environment. There is no magic bullet any weight loss program can offer you that will make long-​term weight loss effortless. Human bodies are biologically hard-​wired to desire high-​calorie foods. We are surrounded by high-​calorie foods that are very easily available. Define the obesogenic food environment and provide examples: supermarket displays, restaurant dishes at the next table, the box of donuts in a conference room, or a tray of ziti at a neighbor’s party. We also do not burn enough calories in our day-​to-​day life, so it takes a concerted effort (i.e., “exercise”) to compensate for our sedentary lifestyles. Most weight loss programs don’t address the biology and environmental problem. This program does. Specifically, it acknowledges 46

that we all exist in an environment that is constantly triggering our desire to get pleasure from food and from rest. We are going to focus on new ways to respond to those challenges and problems—​ways that are different from how you may have responded in the past. This program will teach: 1. How to establish good habits so that you don’t have to make difficult decisions as often. That is, how you can help healthy behavior to happen automatically and become habitual. 2. How to train your mind to be successful at long-​term lifestyle change by: (a) Becoming more accepting of the less comfortable, rather than the most comfortable, psychological state (e.g., choosing to go to the gym rather than staying on the couch and watching TV, choosing the less pleasurable food that’s in your desired calorie range rather than choosing the more tempting food option). (b) Becoming more willing to choose behaviors that are consistent with your most important life values, even if doing so produces a less comfortable/​less pleasurable psychological state. Examples include prioritizing time to exercise, even when you’re tired, because you value being an active person and a good role model for your kids; eating fruit for a snack rather than chips because you value your health and know the high levels of sodium in chips are against your doctor’s recommendations. (c)  Clarifying the values by which you would like to, and will come to, live your life. (d) Learning to keep these values front and center and not slip into mindless behavior that you will likely end up regretting. (e) Becoming able to sustain long-term commitment to behavior change. In this program, the term “mindless” refers to a state in which one is acting without paying sufficient attention to the activity, the reason for the behavior, or its consequences. Some clients may understand this as behaviors that occur as a “force of habit” or when one is on “auto-​pilot.” Mindless behaviors usually occur in the presence of a distraction. One example of a mindless behavior is when one sits down to have a snack in front of the television and is surprised to learn that by the time the half-​hour program has ended he or she has eaten more than intended (e.g., the whole bag of chips). 47

All of these strategies make up an overarching philosophy of this program: Control what you can, accept what you can’t. You can engage clients by asking if they are familiar with the Serenity Prayer (i.e., “Grant me the serenity to accept the things that I cannot change, to change the things that I can, and the wisdom to know the difference”). Ask clients how this applies to weight control. Clients should understand that there are many things that we cannot change about weight control (e.g., obesogenic environment, tendency toward weight gain) and about how our minds and bodies work (e.g., we will never be able to completely eliminate cravings to eat palatable foods or urges to be sedentary). But, we do have control over some aspects of our weight control, and we should use that control. Ask clients to identify behaviors that are within their control and can increase the likelihood that they will eat healthfully. Some examples include selecting the kinds of foods available in their homes, planning meals, and so on. (Some examples are also provided in the Client Workbook in Table 5-​1. These may be helpful to have on hand as samples if clients struggle to develop their own examples.) Let clients know you will discuss ways to optimize the home environment in just a few minutes. Next, point out that there are many challenges to weight loss that are not addressed by the behaviors that were just identified. You may state this position as follows: However, there is a “gap” that exists. Even after enacting many weight control behaviors, challenges remain. That is, stimulus control (i.e., limiting exposure to scenarios in which we may be more likely to make less healthy choices), self-​monitoring, planning ahead, establishing good habits, and so on is crucial, but weight loss/​maintenance continues to be difficult. A willingness to accept these difficulties is necessary for long-​term success. For example, this kind of willingness may include exercising when tired, putting up with a craving without acting on it, or giving up some pleasure from unhealthy food. You may help clarify the use of the term “willingness” by distinguishing being “willing” to choose a behavior as different from “wanting” a specific thing. For instance, a client may be willing to skip dessert, even

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though she wants to have dessert. More on willingness follows later in this session and the next session, so it may helpful to postpone an in-​ depth discussion on willingness until later content is covered. You can engage clients by asking “What do we need to accept about the environment that we live in that makes weight control challenging?” (See the following list for examples of environmental factors we must accept; these may be used as examples after clients provide some of their own.) Next, bring up internal factors by asking “What do we need to accept about how the mind and body work?” (Examples of internal factors outside of one’s control are listed here and in Table 5-​1 of the Client Workbook. Examples of environmental factors outside of our control: 1. The obesogenic food environment 2. Labor-​saving devices and options for sedentary activity are everywhere (washing machine, car, escalator, laptop, etc.) Examples of internal factors outside of one’s control: 1. The strong desire we may feel to eat palatable foods: this is a biological drive, and many scientists believe that sugar, fats, and other delicious tastes are as addictive as drugs 2. The strong desire we may have to avoid exercise and keep our bodies at rest 3. Our minds engaging in reason-​giving (similar to rationalizing), trying to tell us it is okay to eat unhealthy food or avoid exercise—​because some part of our mind focuses on what feels most comfortable in the short term. Thus, one may need to be accepting of reduction of pleasure in order to achieve weight control You can describe and elaborate on the difficulties of long-​term weight control and how this program differs in its approach in this regard. The following is an example of how this material might be delivered to clients: Our bodies do not make it easy to lose weight and keep it off. You might have tried different things in the past to deal with these challenges, such as pushing hunger/​cravings away, exerting “willpower,” etc. However, these techniques tend to not be successful in the long term.

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You may draw clients into the discussion by asking if this resonates with their experience, but try to avoid a prolonged discussion of previous unsuccessful attempts. Traditional weight loss programs have failed to address these challenges adequately; this program will also focus on giving you tools to allow you to choose healthy behaviors that are in line with your goals and values despite these challenges. The first step to this is willingness. Willingness is the ability to choose your behaviors based on what you care about and not on the basis of what you experience internally. We’ ll talk more about willingness next time. In the next stage of this session, introduce clients to acceptance-​ based principles of weight control. Often the word “acceptance” can be mistaken as meaning a sense of complacency toward challenges. It is important to help clients distinguish between acceptance of potentially uncomfortable experiences (which is how we use the term in this program) in the interest of weight control (e.g., accept that one may frequently have cravings for sweets) versus endorsement of the status quo (e.g., “accept” that one will always eat dessert after dinner). This can be a confusing point for some clients to grasp. The following text provides an example of clarification on this point for clients: Acceptance of internal experiences and our obesogenic environment does not mean an acceptance of behavior that runs counter to weight control; rather, acceptance is the first step toward being willing to experience these uncomfortable thoughts, feelings, etc. (e.g., a desire for immediate pleasure) and still choose a healthy behavior (e.g., not having dessert even when you want it, or exercising even when feeling tired). 1. This might mean acceptance of the absence of pleasure in the short term, in the service of a greater goal or value. 2. If we give up the struggle to control our internal experiences, we are more likely to have the physical and mental ability to successfully control our behaviors.

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We find it is helpful to provide a summary to review the theoretical rationale that was provided to clients, as this repetition may help take-​ away messages stand out more. Here is an example of how this might be phrased: We should control the things we can and accept the things we can’t. There is a difference between behavioral control and experiential control. If we give up the control of our internal experiences, we are more likely to have the physical and mental ability to successfully control our behaviors.

Optimizing the Home Food Environment (10 Min.) Many aspects of the food environment are outside of our control. However, it is critical that we control those aspects of our food environment that are within our control. As we’ve mentioned before, one of the reasons why it is so hard to lose weight and maintain these losses is because we live in an environment where there is an abundance of high-​calorie, delicious foods that are very easy to obtain. This is what we refer to as an “obesogenic” environment. Although we can’t change this obesogenic environment, we do have control over our personal food environments (e.g., home, car, workplace). One way to help stay within your calorie goal is to make it harder to obtain high-​calorie foods, particularly those that are difficult for you to eat in moderation. (Refer to the “Changing Your Home Environment” section of the Client Workbook, on p. 40). Some ways to do this include 1. Remove these foods from your home (e.g., throw them out, donate them, give food to others). 2. Do not continue to purchase these foods. 3. Stock your home with low-​calorie options. 4. Put higher calorie foods in the back of the fridge/​cabinets, and put lower calorie items toward the front.

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Ask clients to discuss what changes they might make at home this week and the types of challenges they anticipate (e.g., not having complete control over the food that comes into the house, not having the support of family members). Instruct your clients to make at least one change in their home or work environments that will make it easier to meet their calorie goals. Tell them that they will be discussing the changes they are making during check-​in next week.

Skill Builder (5 Min.) Direct clients to pp. 40–41 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 15 minutes × 3  days. Record type and minutes on your Keeping Track Form. □ Behavior:  (1)  Practice using the Calorie Accounting principles to keep track of calories each day. Mark on your Keeping Track Form instances in which you “banked” calories. (2)  Make at least one change in your home or work environment. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: Complete the Control What You Can, Accept What You Can’t Worksheet (Worksheet 5-​1).

Note: Let clients know that as we’re entering this new phase of introducing psychological strategies, you will be collecting written assignments and providing feedback, similar to their Keeping Track Forms.

□ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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CHAPTER 6

Session 6: Physical Activity and Willingness (Part 1)

TOPICS ABCDE Check-In (30 Min.)

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Skill Review (10 Min.)

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Benefits of Physical Activity (3 Min.)

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Planning Physical Activity (7 Min.)

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Introduction to Willingness (20 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 6-​1: Activity Goals ■ Worksheet 6-​2: Activity Planner ■ Worksheet 6-​3: Types of Exercise ■ Worksheet 6-​4: Transforming “Only If” to “Even If” Responses ■ Worksheet 6-​5: Transforming “Only If” to “Even If” Responses at Home ■ Enough copies of the Keeping Track Form (Appendix A) so every client receives a form to record between sessions ■

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ABCDE Check-​In (30 Min.) Check in regarding clients’ experiences with practicing using the calorie accounting principles to keep track of calories each day. Review clients’ experience with marking occasions in which they “banked” calories on their Keeping Track Forms.

Skill Review (10 Min.) Ask clients to review the principle of “Control What You Can, Accept What You Can’t” and fill in gaps in knowledge as needed. Remind clients of the rationale that even after enacting many weight control behaviors, challenges remain. A  willingness to accept these difficulties (e.g., exercising when tired, putting up with a craving, giving up pleasure) is necessary for long-​term success. Remind clients that the environment and our biology makes weight loss very difficult, and we all need to accept factors such as the obesogenic food environment and the strong desires that we may feel to eat palatable foods and keep our bodies at rest. Review that there is a reduction of pleasure associated with weight control, as our minds will constantly give us reasons why it is okay to eat unhealthy foods. The first step is acceptance of what clients cannot control. Remind clients that acceptance of internal experiences and the obesogenic environment does not mean an acceptance of behavior that runs counter to weight control. Review clients’ experiences with completing the Control What You Can, Accept What You Can’t Worksheet (Worksheet 5-​1). Collect Worksheet 5-​1 to provide feedback to clients. As time allows, briefly review the home environment strategies discussed during the previous session. Modifying the home environment is an important skill, because although we can’t change the obesogenic environment, we do have control over our personal food environments (e.g., home, car, workplace). Clients were asked to make at least one change to their home or work environments during the previous week. Allow clients to discuss the changes they made this past week, problem-​ solve around barriers, and set goals for additional changes they can make to their personal food environments this coming week.

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Benefits of Physical Activity (3 Min.) Ask clients to describe the numerous benefits of physical activity. Add in items from the following list that are not mentioned by clients. A. Medical 1.  Decreased death risk 2.  Reduced risk of coronary artery disease 3.  Decreased blood pressure 4.  Increased good cholesterol 5.  Increased heart strength 6.  Decreased risk of osteoporosis 7.  Improves diabetes (insulin sensitivity) 8.  Associated with long-​term weight control 9. Increased energy 10.  Need less sleep B. Psychological 1.  Reduced stress, depression 2.  Improved self-​esteem and body image 3.  Part of a healthy lifestyle and being good to oneself C. Weight 1. Not strongly associated with short-​term weight loss; it does burn calories but not enough to produce large weight losses in the short term 2.  Exercise, however, is the best predictor of maintenance of weight loss 3. Use examples of what is required to burn 3,500 kcal/​week to lose 1 pound (e.g., jog 6 miles per day, six days of the week). There is a long-​term cumulative effect of exercise. It is believed to be the most important factor for long-​term weight loss maintenance

Planning Physical Activity (7 Min.) Remind clients that the eventual goal for the program is to reach the equivalent of 250 minutes of aerobic activity per week. This week’s goal

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is to reach a total of 60 minutes of activity (e.g., at least three days for 20 minutes). Remind clients that activity should be in bouts of at least 10 minutes to count toward their activity goals. Refer clients to the Activity Goals Worksheet (Worksheet 6-​1) to see the activity progression for the next six months of this program. Reinforce the importance of keeping a daily log of activity using the exercise log, which is part of the Keeping Track Form. Clients can use the Activity Planner Worksheet (Worksheet 6-​2) to practice planning out their activity for the upcoming week. Have clients begin this activity during group and complete the remainder of the plan at home. Remind clients that brisk walking will be the best form of activity for most of them because that is a relatively easy form of exercise with many advantages. If clients prefer other forms of physical activity, refer them to the Types of Exercise Worksheet (Worksheet 6-​3) for ideas of other activities that are similar to brisk walking. Engage clients in a brief discussion of how willingness can help them achieve physical activity goals as they continue to increase.

Introduction to Willingness (20 Min.) Introduce to your clients the concept of willingness as a psychological standpoint that allows one to engage in a behavior in order to achieve something one cares about even when doing so brings a less pleasurable experience. Some example language for explaining willingness and its applicability to weight control is as follows: Although it is necessary for weight control to make changes, such as modifying our home and work environments, there will continue to be many times where it will be difficult to engage in weight control behavior due to the environment (e.g., holidays, parties, weekends), as well as other reasons we have discussed (biological drive toward highly palatable foods, etc.). We have talked about acceptance of what we cannot control (e.g., environments outside of our home, desire to have unhealthy foods, desire to stay sedentary) as a first step to engaging in weight control behaviors. Engaging in weight control behaviors even if it causes less pleasure or even discomfort is called willingness. We must first accept discomfort and loss of pleasure in order to be willing to engage in healthy behaviors. Thus, willingness is going for your morning walk 56

even though you feel tired and your mind is telling you that it will be cold and wet and that you don’t have time. And willingness is choosing an orange as a snack instead of chips even though you feel a strong craving for the chips and are imagining how good they would taste. Willingness is a psychological standpoint that allows us to engage in a behavior in order to achieve something we care about even when doing so brings a less pleasurable experience. At this stage, it is often helpful to provide clients with examples of willingness. Here we provide a general example of willingness in action, followed by two physical activity examples and an eating example: 1. Simple example:  You take off your coat and feel cold in order to wrap it around your baby who is shivering. 2. Physical activity e­xample  1:  You start your 30-​minute walk, but after 5 minutes you feel tired and out of breath; you get the thought that you should go back home, that it is okay if you stop now, and you start imagining how nice it would be to lie down on the couch and watch TV. You continue walking for another 25 minutes even while these thoughts and feelings continue. 3. Physical activity ­example  2:  You alarm goes off for your daily walk, and you feel very sleepy. You look outside and it looks like it is drizzling, and you have the thought that you want to just hit snooze, go back to sleep, and walk some other time. While having these thoughts and while feeling very sleepy, you get up, put on your walking clothes, and head out the door for your walk. 4. Eating example: You turn down the donut holes you are offered and eat the apple slices you brought with you, even while you still want the donut. It is important for clients to decide what they are willing to experience in order to meet their weight control goals. Begin by considering this in the domain of physical activity. Ask clients: What are you willing to experience (internally) in order to meet your physical activity goal each week? Some examples may include the following: Less pleasure ■ A pull to be doing an activity other than exercise ■

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Muscle tiredness ■ Fatigue ■ Shortness of breath ■ Feeling hot; sweating ■ The sense that you don’t have the time to be exercising ■ Boredom ■

When discussing internal experiences of discomfort during physical activity, it may be helpful to provide a distinction between normative discomfort associated with physical activity (e.g., fatigue, sweating, increased heart rate) and discomfort that may be a symptom of injury or overexertion (e.g., dizziness, lightheadedness, nausea). Please consult our recommendations in the introduction (see the “What Populations Should Be Treated With Caution?” section on pp. xxvi–xxvii) for further guidance on treating individuals with cardiovascular and other physical health concerns.

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After discussing the experiences that clients are willing to accept in the service of their goal of being physically fit, you can transition to a discussion of the ways in which we demonstrate willingness in our responding to these internal experiences about exercise or eating. Present the difference in the “only if” versus “even if” styles of responding. “Only if” statements imply that there are specific conditions that will impact our commitment to carrying through with our weight loss behavior plan. ■ “Even if” statements indicate a willingness to commit to our healthy plan, despite challenges that may arise. ■

An example of a way to present these concepts to your clients is as follows: All of us sometimes have “only if ” styles of responding, and these can set us up for weight control failure, because this can be the equivalent of saying “I’ ll lose weight only if I am given a magic bullet that makes it easy.” To illustrate the point further and engage clients, ask for examples from the group, and provide other examples as needed. The Transforming “Only If …” to “Even If …” Responses Worksheet (Worksheet 6-​4)

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can be used to guide the discussion with examples. Additionally, examples are provided here: I’ll be able to go for my walk only if I start to feel more energetic. ■ I will exercise after work today only if I feel like I have enough time. ■ I’d be able to meet my calorie goal only if my family would stop bringing tempting food into the house. ■ I would be able to eat a healthy dinner only if I didn’t have to go to work events at night. ■ I’d be able to meet my calorie goal only if I didn’t crave chips while I watch TV. ■

Ask clients to write down one or two “only if” thoughts that they may have in the space provided in Worksheet 6-​4 in their workbooks during group. If clients decide that they are willing to set a different agenda for weight loss, you can help them learn new skills, using an “even if” style of responding. For example, clients might become willing to respond as follows (provide these as needed, asking for additional examples from group): I’ll be able to go for my walk even if I don’t feel energetic. I will exercise after work today even if I feel like I don’t have enough time. ■ I will meet my calorie goal, even if my family brings tempting food into the house. ■ I  will eat a healthy dinner, even if I  have to go to work events at night. ■ I will meet my calorie goal, even if I crave chips while I watch TV. ■

Have clients change the “only if” statements they wrote down to “even if” statements. Ask for examples. The exercise on Worksheet 6-​4 is similar to the experiential exercise they will complete later at home, but not identical. This worksheet will help prepare clients for effective practice with this skill over the next week. Inform clients that this new style of responding is “willingness.” Provide additional explanation, as shown in the following example: Willingness is the extent to which you are willing to engage in desired behaviors even if those behaviors come with thoughts and feelings that you’ d rather not have/​that are not your first choice. It is the

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alternative to saying, “I’m only going to engage in these behaviors when it’s comfortable or easy.” Willingness is a way of being that requires deliberate effort, skill, and practice. Clients will learn specific skills that enable willingness. They will need to practice these skills and use them deliberately. We expect that these skills will allow clients to make this weight loss attempt different from previous attempts (i.e., much more successful in the long term). Remind clients that the skill they will practice for this week is noticing instances of “only if” responding and changing that to “even if” responding using Worksheet 6-​5. Clients will record instances over the next week in which they tried this skill when they noticed they were having “only if” responses on Worksheet 6-​5.

Skill Builder (5 Min.) Direct clients to pp. 45–46 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity: Exercise (e.g., brisk walking) for 20 minutes × 3 days (which is an increase from last session). Record type and minutes on your Keeping Track Form. □ Behavior: Finish the Activity Planner Worksheet (Worksheet 6-​2) that you began during group and follow your Activity Planner for the upcoming week. Read the Types of Exercise Worksheet (Worksheet 6-​3). □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record all foods and beverages consumed (including the time of eating, the amount and type of food, and the calorie content of all items). □ Experiential Exercise: Complete the Transforming “Only If . . .” Responses to “Even If . . .” Responses at Home Worksheet (Worksheet 6-​5). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten and calories). 60

CHAPTER 7

Session 7: Willingness (Part 2) and Values

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Willingness, Part 2 (15 Min.)

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Introduction to Values (15 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 7-​1: Practicing Willingness ■ Worksheet 7-​2: 10 Valued Domains ■

Enough chocolates and baby carrots for each group member to have several of each food item ■ Enough copies of the Keeping Track Form (Appendix A) so every client receives a form to record between sessions ■

ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In.

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Skill Review (10 Min.) Review the homework assignment, the Transforming “Only If . . .” to “Even If . . .” Responses at Home Worksheet (Worksheet 6-​5). Using your clients’ own examples from their homework assignment, review the Part 1 willingness material that was introduced in the last session. Willingness is a psychological standpoint that allows one to engage in a behavior in order to achieve something one cares about even when doing so brings about discomfort or a loss of pleasure. Changing “only if ” to an “even if ” style of responding is one way to encourage willingness, because willingness is the extent to which one is willing to engage in desired behaviors even if those behaviors come with thoughts and feelings that one would rather not have or are not one’s first choice. Willingness is the alternative to saying, “I’m only going to engage in these behaviors when it’s comfortable or easy.” As time allows, briefly review the benefits of physical activity and the planning exercise that was conducted in the previous session. Ask clients to reflect on how they might continue scheduling exercise throughout the program, and problem-​solve with any clients who experienced difficulty either creating an activity plan or sticking to their activity plan. When possible, note that a willingness to experience uncomfortable thoughts and feelings will help clients stick to their activity goals.

Willingness, Part 2 (15 Min.) Ask for a volunteer from the group to complete the “Pick Up the Pen” exercise. The goal of this exercise is to demonstrate that just because a client has a thought or feeling, this doesn’t mean it’s true or that he or she has to behave in accordance with it. One way to demonstrate this idea is to ask the client to imagine that he felt so tired that he couldn’t pick up the pen. As the client imagines this, have him pick up the pen and say out loud over and over, “I am too tired to pick up this pen, I can’t pick up the pen.” Afterward, discuss what this exercise demonstrates: clients can have the thought “I can’t pick up the pen” and still physically pick up the pen. Having the

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thought does not impact the ability to engage in a specific behavior. Ask clients for some examples of weight control behaviors that they think they cannot do. Are these things they truly cannot do or just things they think they cannot do (e.g., having the thought “I think I can’t work out another minute” but staying on the elliptical for two or three more minutes)? Pass out notecards to clients and ask them to write down three thoughts, feelings, or urges that their minds give them that trigger them to choose the less healthy option when faced with food choices. Indicate that these lists will be shared with a partner during the next group activity. You should first demonstrate the activity described here with you as Partner B. If you have a group coleader, that person can be Partner A. Following the exercise, ask clients to break into pairs to complete the activity:

The Chocolate and Carrot Exercise Give each client a chocolate kiss (or other unhealthy snack of choice) and a few baby carrots. Partner A should give Partner B the list he or she just created of thoughts, feelings, or urges. Explain that Partner B is acting out the part of Partner A’s mind that pushes him or her to make the unhealthy choice. For the first minute, Partner B tries to get Partner A to eat the chocolate by using the materials from the list and saying things like, “Carrots don’t taste good; this work stress is out of control, you need a break; everyone else is having dessert; don’t worry about calories.” Explain that while Partner B does so, Partner A should be eating the carrots, not the chocolate. After one or two minutes, switch roles. As the exercise concludes, Partner A should deliberately pass the chocolate to the front of the room. Relate the “Pick Up the Pen” exercise to this exercise; namely, that clients can have the experience of not wanting to eat the carrot and wanting to eat the chocolate (or whatever other food tempts them) but at the same time choose to eat the metaphorical carrot. Ask clients to predict situations in which they may be tempted to engage in a behavior not in line with their weight loss goals (e.g., eating chocolate) and record these examples on the Practicing Willingness Worksheet (Worksheet 7-1).

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Introduction to Values (15 Min.) Willingness is important because it helps us to engage in behavior that is in line with our values. Values are the ideas, principles, and domains of our lives that are most important to us. Values can serve as the guideposts for behavior and represent what we care most about in life. Moreover, values are freely chosen; each person may have different values that guide her or his behavior. Examples of values are being a devoted parent, being a committed partner in a team at work, being a loyal friend, and having a loving marriage. It often takes careful reflection to obtain clarity about one’s values. For example, if clients consider the question “Why do you go to work?” the initial answer may be “To make money.” However, asking follow-​up questions about why that is important can reveal an underlying value (e.g., “It is important to make money so that I can provide for my children,” and “It is important to provide for my children because I value being a good parent”). A value is different from a goal in that a value can never be reached or finished. Goals can be formed to be consistent with values, but values are things that cannot be attained. For example, many people want to lose weight because they value health; while weight loss (a goal) indicates that one is moving in the direction of health (a value), one can never reach the endpoint of “health” and be “finished” with that value. Because of that, values are something that clients can always work toward. We sometimes think of values like a compass; they represent the direction in which we are moving, but not a destination. Values are also different from feelings. Values are, by definition, freely chosen. Feelings, on the other hand, cannot be chosen. For example, “happiness” is not a value; it is a feeling. Living a life that is consistent with one’s values may create positive feelings, but the feeling itself is different from the value. Values are the reasons that engaging in uncomfortable behaviors is worthwhile. Weight control can be uncomfortable at times (either because clients have to give up something pleasurable, like eating a certain food each day, or because there is discomfort from things like

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cravings or physical activity). However, that discomfort is worth enduring when, ultimately, it allows us to live a life that is consistent with our values. Everyone has aspects of life that they value and that they hope will guide the way that they live. However, explain that most people have rarely taken the time to identify their more cherished values. As such, most people do not have “values clarity,” that is, a clear sense of exactly what their most cherished values are. Explain that clients will have to do mental work in order to become clearer about their values. Clients will begin the process of values clarification by completing the 10 Valued Domains Worksheet (Worksheet 7-​2) as part of the Skill Builder this week. Encourage clients to actively engage in the discussion of values. As needed, clarify what are and are not values to ensure that clients understand the concept of values and how they differ from goals and feelings. Also, explain that you will continue to work on clarifying values in the next session. Direct clients to Chapter 7 (pp. 50–51) in the Client Workbook for a summary of the material you just discussed.

Skill Builder (5 Min.) Direct clients to p. 51 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 20 minutes × 3  days. Record type and minutes on your Keeping Track Form. □ Behavior: Work on the behavioral goal that you identified during today’s session. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: Using the Practicing Willingness Worksheet (Worksheet 7-​1), record any relevant thoughts/​feelings/​urges that come up this week, rate your willingness on a scale, and write

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down the final behavior that resulted. Also complete the 10 Valued Domains Worksheet (Worksheet 7-​2). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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CHAPTER 8

Session 8: Forming Good Habits and Flexibility

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Values Clarity (10 Min.)

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Forming Good Habits/​Breaking Out of Bad Ones (20 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 8-​1: Practicing Flexibility ■ Worksheet 8-​2: Pattern Smashing Activity ■

Enough copies of the Keeping Track Form (Appendix A) so every client receives a form to record between sessions

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In.

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Skill Review (10 Min.) Review the homework assignment the Practicing Willingness Worksheet (Worksheet 7-​1). Clients were asked to record thoughts/​ feelings/​urges associated with situations related to weight control during the previous session, rate their willingness to experience these uncomfortable thoughts/​feelings/​urges on a scale 1 to 10, and record the final behavior that resulted. Ask clients how their attempts at willingness relate to the introduction to willingness skills discussed in the last session (e.g., the Pick Up the Pen exercise and the Chocolate and Carrots exercise). Problem-​solve with any clients who experienced difficulty with the homework assignment. Remind clients that willingness is a skill that takes practice to develop and that the best way to strengthen this skill is to continue practicing it whenever opportunities arise. Review the homework assignment the 10 Valued Domains Worksheet (Worksheet 7-​2). Remind clients that values are the ideas, principles, and domains of our lives that are most important to us and can serve as guideposts for our behavior. Values differ from goals in that goals can be achieved or surpassed, while values are a direction in which we move, but can never be reached, much like a compass can guide us in a certain direction, but does not represent a destination. As time allows, discuss clients’ experiences completing the worksheet and what they identified as their most valued domains.

Values Clarity (10 Min.) During the last session, clients should have completed the 10 Valued Domains Worksheet (Worksheet 7-​2), considering what their own personal values in those areas are. Discuss the identified values with clients in greater depth to help clients gain clarity about what their values are and why they are so important. ■

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Help clients understand that values are the deepest, most essential reasons to be alive, the guides to living. One way to help is to ask clients to imagine their life coming to a close. Ask them to imagine themselves as a much older person who is coming to the end of

his/​her life. Once they have put themselves in this mindset, pose questions such as, “How will you have wanted to have lived your life? What ways of living your life will be most important to you as you reflect over your satisfaction—​a nd dissatisfaction—​with how you have lived your life?” Steer clients toward answers that reflect genuine, big-​picture life values and identify ways that these values connect to eating, physical activity, or health (if they do). For example: Being a devoted, nurturing parent to my children (model healthy behavior; be in good health and alive for their adult lives) ■ Traveling to see and learn about other places and people (be in good health and physically fit) ■ Presenting myself well and looking my very best (be in good health, physically fit, and at a healthy weight) ■ Being a committed and hard worker at my job ■ Being a loyal friend ■ Building a vibrant, loving marriage ■

Help clients to “dig deeper” into their selected values as necessary by asking why listed values are important to them. For example, if someone lists money as a value, ask why money is important to them. One possible answer is “to provide for my family.” Going one step further, that may be important because the client values “being a good parent.” This last statement is the value that underlies why working, making money, and providing for a family are important. When there are no answers to the “why” question (other than “because I value it”), you have probably arrived at the core value. ■ Help clients connect healthy eating and physical activity to their values. How will values help them to reach the values they have in the domain of family? Work? ■ Discuss the compass metaphor with one or two of the client’s chosen values. For example, if someone values being a good parent, discuss how that serves as north on his or her compass. Possible mile-​markers that can indicate the client is moving “north” (toward being a good parent) include setting a good example for health, having the energy to actively play with one’s children, and keeping oneself healthy for as much of the child’s life as possible. ■

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Forming Good Habits/​Breaking Out of Bad Ones (20 Min.) A key principle of weight control is knowing how to make habits work for you and not against you. It is important to know how to form good habits and also how to break out of bad habits. Forming Good Habits Explain that behavior change is very difficult and that one of the reasons it is so difficult is that it requires making difficult choices over and over and over again. Our brains are not good at this. However, if we establish a habit (like vacuuming the carpets every Saturday morning, or washing dishes right after dinner), we no longer have to think about and make decisions. We just “do” the behavior automatically. Once we have established a good habit, we are much more likely to engage in a healthy behavior and to stick with that behavior. Ask clients: What are some physical activity-​related good habits that you have or that would be a good idea to establish? Examples: Walk when you wake up; walk to work very day; stop at the Y and swim on your way home from work every day; walk on a treadmill during your lunch hour. Ask clients: What are some eating-​related good habits that you have or that would be a good idea to establish? Examples: Eat oatmeal with raspberries every morning for breakfast; eat a salad with grilled chicken every day at lunch; record everything you ate every day after dinner; look up the menu and make a healthy ordering decision as you get ready to leave home for a meal at a restaurant; brush your teeth as soon as you finish eating dinner.

Strategies for forming a habit: 1. Perform the behavior after a “cue” like a time (right after waking up) or event (after dinner). 2. Start with a behavior that is extremely likely. (When you wake up put on your walking clothes, go outside, and enjoy the fresh air for

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five minutes. Don’t actually take a walk.) Then gradually shift the behavior so that it increasingly resembles the behavior goal. 3. Repeat the behavior after the cue for 30 days in a row.

Breaking Bad Habits

Narrowness Versus Flexibility The primary goal of this section is to introduce clients to the skill of flexibility. In every situation, there are thousands of different possibilities for how clients can behave. However, there are often many fewer possibilities for how clients are willing to behave. Flexibility can be introduced using a rain metaphor. Instruct your clients to imagine that they are sitting outside and some rain begins to fall. If this were to happen, how many different behaviors could they engage in? Some examples might include go inside, open an umbrella, look up and let the rain fall on your face, open your mouth to “drink” the rain, and just sit. As clients describe the various behaviors they could engage in, write these on a whiteboard (or other means of writing). Next, ask clients, “What are you most likely to do? Why?” Most clients will report that they would be most likely to choose behaviors that allow them to avoid getting wet, perhaps out of habit, a desire for comfort, or an unwillingness to have the sensation of wet skin. As clients describe what they would be most likely to do, circle the behavioral choices on the whiteboard (or other means of writing) that one who is not willing to experience any discomfort from the rain might chose. Next, ask clients, “What would it take for you to be willing to engage in one of these other options?” Probe for situations where someone might choose to experience the discomfort of getting wet because it is consistent with something they care about (e.g., watching a relative perform an outdoor concert or watching their child’s soccer game because that is consistent with an important value). The rain metaphor can be used to show that it is easy to choose behaviors out of habit or a desire to avoid distress and that this isn’t always a problematic choice. However, when it is inconsistent with one’s long-​term goals or values, it can be very limiting. Clients engage in narrowness when they are always responding in the same way to the same thoughts, feelings, and 71

situations. Flexibility, on the other hand, allows them to engage in a variety of behaviors and to break some of these problematic habits. To help identify what narrowness and flexibility might look like in the context of weight control behaviors, provide clients with the following example. Ask them to imagine that it is a Friday evening and they have been going out to eat with family or friends every Friday for the past five years. Ask your clients to name all of the possible behaviors one could engage in this Friday and list these behaviors on the whiteboard (or other means of writing). For example, they could eat out as usual, suggest a family/​friend cooking event, or offer to cook. Ask clients “What are you most likely to do? Why?” Pull for answers that support the notion that the most likely choice is the more comfortable and pleasurable option. Ask them “What would it take for you to be able to choose the more difficult or less comfortable choice?” Pull for examples of how focusing on a client’s values (e.g., wanting to be a good role model for one’s kids, wanting to prioritize one’s health) might help him or her be more willing to tolerate discomfort and choose a different behavior. You can go through the exercise again with a different example to ensure clients understand the benefits of flexibility. This time, ask clients to think about the time between dinner and when they go to sleep. Clients can imagine they are someone who often snacks during this time and that they are constantly thinking about eating and desiring certain foods they tend to snack on. Go through the same questions as in the previous exercise to highlight the narrow and flexible ways of responding to this dilemma. The goal of these examples is to help clients understand that every choice they make leads to thoughts, feelings, and sensations, and some choices may mean a momentary loss of pleasure compared to another choice. If clients are not willing to have these experiences, they lose the ability to make a specific choice. The best way to expand choices and have more flexibility in behaviors is to be willing. When someone is willing to have an experience, even if it is uncomfortable or causes a loss of pleasure, it gives that person more choices for how to behave. Letting behavior be guided by values and long-​term goals, rather than by immediate comfort/​discomfit or pleasure/​ loss of pleasure, allows for greater flexibility. In future sessions, you will provide clients with specific strategies to increase behavioral flexibility. As part of the Skill Builder this week, clients will work on increasing flexibility using the Practicing Flexibility Worksheet (Worksheet 8-​1).

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Building Flexibility: Pattern Smashing Clients should be reminded that narrowness can limit their choices and make weight control difficult. Alternatively, being flexible increases the number of possibilities they have for action. Most clients have developed narrow ways of responding to specific thoughts, feelings, and situations. For example, a client may have developed the habit of not recording his food intake over the weekend in response to the thought, “I deserve a break.” Or perhaps a client has a habit of ordering take-​out every Saturday night in response to a strong urge to eat, which consistently puts her over her daily calorie goal. Point out that (similar to the previous examples) it is often an unwillingness to experience difficult thoughts, emotions, and physical sensations that can lead a client to be less flexible. Also note that clients’ narrow (habitual) ways of responding will often be inconsistent with their chosen goals/​values. Introduce pattern smashing as a way to respond to these problematic habits and to build flexibility. Pattern smashing is deliberately engaging in a behavior that runs counter to one’s old pattern of behavior. Point out that pattern smashing is critical for weight control because old patterns of behavior were not working (i.e., taking a person farther from his or her values). Each client needs to generate more options for him-​ or herself when faced with decisions about how to eat and how active to be. When internal experiences lead to choosing behaviors that hinder a client’s weight control goals, clients should practice pattern smashing. Review examples of ways to practice pattern smashing, and ask group members to generate their own ideas of how they could try pattern smashing in the upcoming week: If a client always has a dessert after dinner, she should skip dessert one night. ■ If a client always has pizza on Friday nights, he should have something different that will help him stay under his calorie goal. ■ If a client always skips exercise when it is raining outside, she should exercise indoors instead. ■

As part of the Skill Builder this week, clients will use the Pattern Smashing Activity (Worksheet 8-​2) to brainstorm habits that make

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weight control difficult and come up with ideas of how to practice pattern smashing.

Skill Builder (5 Min.) Direct clients to pp. 55–56 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity: Exercise (e.g., brisk walking) for 20 minutes × 4 days (which is an increase from last session). Record type and minutes on your Keeping Track Form. □ Behavior: Complete the Practicing Flexibility Worksheet (Worksheet 8-​1) and practice different ways of behaving in response to the same situation. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise:  Complete the Pattern Smashing Activity (Worksheet 8-​2). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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Session 9: Restaurant Eating; Handling Weekends and Special Occasions

CHAPTER 9

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Restaurant Eating (15 Min.)

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Handling Weekends and Special Occasions (15 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 9-​1: Restaurant Eating Tips

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Enough copies of the Keeping Track Form (Appendix A) so every participant receives a form to record between sessions

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In.

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Skill Review (10 Min.) Review the strategies provided for forming good habits and for breaking bad ones. Some strategies for forming good habits are: Perform the behavior after a consistent “cue” (e.g., after dinner each day). ■ Start with a behavior that is extremely likely and then work toward the desired behavior by gradually doing more of the desired behavior each day. ■ Repeat the same behavior after the cue for 30 days in a row. ■

Also review how pattern smashing can help clients become more flexible and thus more able to break out of bad habits. Make sure they remember the distinction between narrowness (always responding in the same way to the same thoughts, feelings, situations) and flexibility (ability to break out of bad habits). Refer clients to the Practicing Flexibility Worksheet (Worksheet 8-​1) from Session 8, probing for flexible behaviors that clients demonstrated over the last week. Using the rain metaphor from the previous session, remind clients of the two psychological strategies that can expand one’s choices and facilitate flexibility: engaging in willingness to experience the less pleasurable option and making decisions based on one’s personally held values. Problem-​solve with clients who had difficulty with the homework assignment. In addition, review the rationale for pattern smashing. Emphasize that most people have developed habitual ways of responding to specific thoughts, feelings, and situations. These habits often are not consciously chosen and are not consistent with our goals/​values. However, they can be difficult to change. Additionally, some habits are not consistent with our goals/​values. Finding new ways of responding is critical for weight control, because old patterns of responding were not working (they were causing weight gain!). Pattern smashing consists of deliberately engaging in a behavior that counters a habitual way of responding. Review clients’ experiences with the pattern smashing exercise completed during the past week.

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Restaurant Eating (15 Min.) Restaurant eating is a particularly challenging type of eating situation for weight control behaviors. The first and best strategy is to eat out as little as possible. Restaurants are full of tempting choices; most people cannot resist these temptations and end up breaking their calorie goals. Briefly ask clients to describe some of the difficulties they have encountered controlling calories while eating out. Discuss reasons it is challenging to avoid eating out/​buying take-​out and possible solutions. These might include: Finding cooking difficult/​boring/​time-​consuming (Possible solutions: willingness to take the slower/​more difficult path for the sake of health; cooking practice/​lessons) ■ Eating out is an important way to be social; it is awkward to turn down invitations (Possible solutions: flexibility in coming up with alternative ways to socialize; practicing ways to explain a reluctance to socialize around food and/​or to provide alternative suggests) ■ Other reasons, as identified by group members ■

Using the Restaurant Eating Tips Worksheet (Worksheet 9-​1), review strategies for healthy eating while dining out. Ask clients to discuss ways they already use these strategies. Clients may add additional tips that they find helpful. Strategies to review include: Plan ahead. For example, look at the menu online and commit to a plan at home before cues in the restaurant become tempting. Plan how many calories you want to spend on a meal. ■ Choose restaurants wisely. Avoid going to restaurants that have high-​calorie choices that will be especially tempting. ■ Ask for what you want. Be assertive and feel comfortable asking for information and modifications to menu items. ■ Let staff know what you do not want, such as a bread basket, while you wait. ■ Choose foods carefully. Think about what parts of a meal are most worth your calories. ■ Limit alcohol intake. Having alcohol before or during a meal may lead to less control over eating. It also reduces the number of calories that can be spent on food. ■

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Limit portions of high-​calorie foods. Savor smaller servings of these, and fill up on foods that are lower in calories.

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A final note regarding habits and restaurant eating: Help clients understand that activities, such as going out to dinner at a restaurant, can be powerful triggers to eat certain foods out of habit. Ask clients to describe how they can use flexibility/​pattern smashing skills when eating out.

Handling Weekends and Special Occasions (15 Min.) Ask clients to discuss how weekends and special occasions can be challenging or helpful for weight control. Describe how eating and physical activity behavior is different (for better or worse) on weekends, vacations, and holidays. Provide examples of three common challenges that clients often face on weekends, vacations, and holidays, such as the following: 1. It is easy to feel as though one “deserves a break” from exercise, counting calories, or self-​monitoring on the weekends, especially if one has worked hard all week. 2. It is very common for clients to feel as though vacations or holidays are their “break” from their new healthy lifestyle, and that because they are on vacation or celebrating a holiday, it is excusable to abandon all of their new eating and exercise habits. 3. Clients often express difficulties around big holiday meals, including the presence of tempting foods, cooking, and expectations from others. Spend time discussing the common challenges of weekends, vacations, and holidays and problem-​solve the barriers that clients report. For example, discuss pleasures other than food that clients might engage in on the weekends and special occasions, especially if they feel that they “deserve” a reward. Ask clients to provide examples of pleasurable, nonfood-​related activities (e.g., having a spa treatment, reading a book, sitting in a garden) that they could try when faced with weekend, vacation, or holiday challenges. Remind clients that substituting new nonfood-​related activities might seem less pleasurable (especially at first) and that these instances are a good occasion to practice willingness to

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engage in these activities anyway, even when it feels difficult or undesirable to do so. Point out that lack of structure on weekends can be challenging. Ask clients how they can overcome this lack of structure. Refer clients to the “Lifestyle Balance on Weekends and Special Occasions” section of the Client Workbook (pp. 60–62), and reinforce the idea that planning ahead, even on weekends and holidays, will be necessary to stick to their new healthy lifestyle. Take a few minutes to review specific tips for staying on track while on vacation or celebrating a holiday (see workbook for elaboration on these tips).

Vacations Plan vacation/​holiday pleasures and events that are not food-​related. Bring your family/​friends who will be with you on board with your goals. ■ Set expectations you can meet for your vacation. ■ Make time for yourself while on vacation. ■ Plan ahead regarding alcohol. ■ Relax, but be active. ■ Prepare for comments regarding your weight from family/​f riends. ■ ■

Holidays Plan ahead of time what you will eat at a holiday meal. Have preemptive conversations with family members and friends asking for the support that you need. ■ Plan ahead of time what you will say to others who remark on your eating. ■ Bank calories. ■ ■

Finally, facilitate a discussion with clients regarding which unhealthy habits they engage in on weekends and special occasions and how they plan to pattern smash these habits.

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Skill Builder (5 Min.) Direct clients to p. 62 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 20 minutes × 4  days. Record type and minutes on your Keeping Track Form. □ Behavior: (1) Read the Restaurant Eating Tips Worksheet (Worksheet 9-​1). When eating out this week, identify and practice key strategies from the worksheet to help you stay in your calorie goal. (2) Identify and implement a specific behavioral strategy for handling weekends. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: N/​A □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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CHAPTER 10

Session 10: Barriers to Living a Valued Life

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Barriers to Living a Valued Life (30 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 10-​1:  In Order to Behave Consistently With My Values, I Was Willing to . . .

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Enough copies of the Keeping Track Form (Appendix A) so every client receives a form to record between sessions

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. Specifically, check in regarding clients’ experiences implementing a behavioral strategy for handling weekends and/​or restaurant eating. As time allows, ask some clients to share what strategy they tried and how successful it was.

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Skill Review (10 Min.) Review handling weekends and vacations. Emphasize that while it is common to feel like one deserves a “break” on weekends and vacations, finding other ways to reward oneself is critical for weight control. Additionally, planning ahead is key. Planning allows one to anticipate how to respond to challenges and also addresses the lack of structure that weekends and vacations may present. Also review strategies for restaurant eating. This can be done by asking clients to describe strategies they attempted over the previous week and filling in the remaining skills that were reviewed in the previous session as necessary. Restaurant eating strategies include planning ahead, choosing restaurants wisely, being assertive (i.e., asking for what one does or does not want), choosing foods carefully, limiting alcohol intake, and using portion control. Also review the ways that willingness/​flexibility will help clients break problematic habits related to restaurant eating. Remind clients that the best strategy for handling restaurant eating is to eat out as little as possible. Barriers to Living a Valued Life (30 Min.) Briefly review the importance of values (i.e., the ideas, principles, and domains of our lives that are most important to us). Values help guide our behavior to be in line with what we care about most; however, living a life that is consistent with our values can be difficult. Refer to p. 65 in the Client Workbook for information on barriers to living a valued life. Ask clients to describe why they experience difficulty choosing behaviors that are consistent with one or more of their values. Organize the discussion into three general areas: not having values in mind, short-​versus long-​term mind, and conflicting values. For each barrier, make sure that clients generate examples. Refer to p. 66 in the workbook as you discuss strategies to overcome each of these barriers. Barrier 1: Not Having Values in Mind Daily life can become busy, and it is easy for people to forget about the values they care about most. For example, if someone goes to a 82

restaurant and begins to mindlessly eat the bread that is sitting on the table, that person can quickly consume hundreds of calories before the meal even starts. That person probably was not thinking about his or her value of health or how eating those extra calories will impact his or her weight and, in turn, negatively impact health. To combat this challenge, clients should also be encouraged to make every decision a deliberate up or down vote on a value. The client who faces the temptation of the bread basket at the restaurant may explicitly ask him-​or herself, “Do I want to vote for my value of health and refuse the bread, or against my value of health and eat the bread?” Remind clients that they don’t always need to vote for their values with these decisions, but they should practice making the explicit decision, and, in the end, they should have more votes for their values than against in order to live consistently with those values. As another example, if a client feels tempted to skip the exercise he or she planned to do for the day, suggest thinking about the decision in terms of his or her values, such that “skipping exercise” equals a vote against one of his or her reasons for valuing healthy exercise habits, and “exercising even though he or she does not want to” equals a vote for this value. Another tool that can be used is a written or visual reminder of what one values. Examples of reminders a client might use include a post-​it note in the car that says, “My value: Be fit enough to live life fully,” a picture of oneself playing with one’s grandchildren, or a laminated copy of results from a doctor’s visit (such as cholesterol levels) that is placed on the refrigerator.

Barrier 2: Short-​Versus Long-​Term Mind Our brains are designed to value short-​term reward (like tasting a delicious food) over long-​term reward (like losing weight). This preference helped our ancestors to survive when food was scarce and the short term was more important. However, this neurological evolution makes it more difficult for us, in our food-​rich environments, to make decisions that are beneficial in the long term (such as those that are consistent with our values) but not the short term.

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The key strategy for addressing this barrier is to practice making decisions with a long-​term mind. Have clients remind themselves that the short term is very short (often only seconds). Use an example of a piece of chocolate or other food that clients like. Have them imagine eating that one piece or bite. Ask them how long the pleasure from eating that food will last. Emphasize that often it disappears as soon as the food is eaten. The calories and impact on the client’s weight and health, however, last much longer. Clients can consider this process before eating any tempting food. Have them explicitly consider how long the pleasure from eating any food lasts, compared to the long-​term impact of eating or not eating the food.

Barrier 3: Conflicting Values Clients likely have many values that are important to them. Ask clients to discuss instances in which one of their values has seemed to conflict with another value. For example, a client may value both “being a committed leader at work” and “being an active part of my family.” If that client has to stay late at work in order to be a committed leader, being an active part of the family may be neglected. Several strategies can be used to address this barrier. First, minimize black-​and-​white thinking. For example, if a client values both staying healthy by being active and being a good employee at work, he or she might run into a situation in which a choice between staying late at work to finish a project or going to the gym to do planned activity must be made. Someone thinking in black-​and-​white terms might think, “I can never exercise because of my work schedule. I should just give up!” However, when values truly conflict, clients may need to prioritize one over the other (like staying late at work and missing the planned exercise). However, they can make the choice to prioritize whatever had been placed on the backburner the next day. This way, they acknowledge that both values are important, and they ensure that even if one value has to temporarily be a lower priority, it does not need to be dismissed entirely. Second, clients should flexibly look for ways to move in the direction of values. There are many ways to live according to each value. One example

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is valuing being a social person. Perhaps in the past this meant going out for dinner and drinks with friends several nights per week. But there are many ways to live out the value of being a social person. A client could start a walking group or host social events that focus on an activity, such as a game night, instead of being centered on eating. With either of these options, being a social person and living a healthy life do not have to conflict. It may require a lot of effort and flexibility to make changes in domains such as one’s work or social life. Clients should develop realistic expectations that long-​term weight loss is likely not possible without meaningful change in many aspects of their behavior. Finally, clients should mindfully remind themselves of the cost of not living out a value. Values are the most important, deeply held beliefs about how we want to live our lives. When we don’t live according to our values, we are sacrificing something. Clients should actively consider what is being neglected when they choose to not live according to a value. For example, if a client chooses consistently to not engage in physical activity, what will happen in the long term? He or she may be less healthy, less active with children or grandchildren, or less of a role model for good health for his or her family. Actively considering what they are sacrificing when they don’t live according to their values should help clients choose behavior that is consistent with their values. Remind clients that living according to their values will take deliberate practice. They may need to practice willingness in order to experience the discomfort that can come with making some of the decisions to engage in healthy behavior. Clients will practice this with the In Order to Behave Consistently With My Values, I Was Willing to . . . Worksheet (Worksheet 10-​1) this week. Skill Builder (5 Min.) Direct clients to pp. 66–67 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity: Exercise (e.g., brisk walking) for 25 minutes × 4 days (which is an increase from last session). Record type and minutes on your Keeping Track Form.

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□ Behavior: Work on the behavioral goal that you identified during today’s session. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: Complete the In Order to Behave Consistently With My Values, I Was Willing to . . . Worksheet (Worksheet 10-​1). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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CHAPTER 11

Session 11: Friends and Family

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Social Support (30 Min.)

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Skill Builder (5 Min.)

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MATERIALS Client Workbook

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Session 11 Skill Builder, Session 12 ABCDE Check-​In

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Enough copies of the Keeping Track Form (Appendix A) so every participant receives a form to record between sessions

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In.

Skill Review (10 Min.) Review common barriers to living according to one’s values. Review strategies to address the barriers of not having values in mind,

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listening to one’s short-​term versus long-​term mind, and conflicting values. Discuss examples from Worksheet 10-​1 of what clients were willing to experience in order to live according to their chosen values.

Social Support (30 Min.) Social forces work both with and against weight control goals. Explain to clients that in order to achieve their weight loss goals, it is important to seek out sources of positive social support for motivation and encouragement. At the same time, they must prepare themselves for situations in which they are faced with problematic social cues that work against their weight control efforts.

Leveraging Positive Social Support Refer to the “Social Support” section on pp. 69–71 of the Client Workbook. Elicit examples of challenging social influences from clients, prompting them with the following examples as necessary: Challenge: Spouse buying cookies and placing them on the counter Challenge: Coworker bringing donuts into a work meeting and putting them in the center of the conference room table Support: Friend agreeing when you suggest going for a long walk together instead of a dinner at a restaurant Support: Cousin sending you coupons that you can use as part of your effort to keep healthy foods stocked in your kitchen Discuss with clients how to ask for support from others. Refer to the “Social Support” material in the Client Workbook (pp. 69–71). Review principles of asking for support. Principle 1:  Emphasizing health can help. Disclosing weight loss efforts is not always necessary; in some cases, clients can ask for support for “healthy eating,” “being more active,” or “having a healthier lifestyle.”

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Principle 2:  Avoid assumptions. Clients should remember that family members, friends, and coworkers may not know what to do or not to do in order to support weight control efforts. Principle 3: Be specific. When asking for support, clients should be concrete in their requests. Asking a family member to “not bring junk food into the house” will likely be less successful than asking a family member to help create a grocery list of healthy foods you can agree to shop for instead. Principle 4: Show appreciation. Just as it is important to ask for support, it is important to show and tell others that you appreciate the support that they give. Reinforcing others for the support they give you will also encourage them to continue providing you with positive support in the future. Principle 5: Practice being assertive about needs. Changing behavior will take time and effort. Clients should practice gently but firmly declining unhealthy food that is offered. It will take practice before turning down food becomes a new, more comfortable habit. Principle 6: Use willingness skills. Asking for support can be uncomfortable and anxiety-​provoking. Willingness can allow clients to have those important conversations despite this discomfort. For instance, a client might be encouraged to commit to behavior change in the following way: “I will speak to my family member about bringing cookies home from work, even if I am anxious about the response I might get.” ADAPTING FOR INDIVIDUAL FORMAT In individual sessions, you and your client can role-​play these conversations together. You can adapt role-​plays to situations that are especially relevant to the client. Clients should break into pairs to role-​play asking for support using these principles. Ask clients to practice willingness skills during these role-​plays. For example, a client might know that she would feel anxious and embarrassed asking her brother if they can change their Sunday brunch to a walk in a nearby park. Her role play would be designed to try to get her to feel anxious and embarrassed and to allow her to

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practice making the request even while having these emotions. After clients have each had the opportunity to practice asking for support, reconvene as a group to process this experience. Discuss with clients how this type of communication is different from other ways they communicate with people in their lives. Discuss with clients the thoughts and emotions that they will encounter when asking for social support. Ask how they can employ willingness to request social support even when doing so will be uncomfortable.

Adaptive Responses to Problematic Social Cues A social cue is a verbal or nonverbal signal that is associated with unhealthy behavior. Examples range from explicit requests (“Have some cake”) to subtle signs (a raised eyebrow about a food choice). Explain that the process of changing a problem social cue is similar to the process of changing a problem food or inactivity cue. There is one additional step: to be sure the cue is correctly interpreted. Social cues can be “assumed” because a person misinterprets the other person’s actions or statements. Review the following steps with clients, and incorporate discussion of how these steps can be used to address some of the problems participants provided as examples: 1. Stay away from the cue. This is not always possible, of course. But, when possible, it is a very effective way to deal with a problem cue of any kind. 2. Change the cue. This involves communication. A person should not assume that a family member or friend knows what to do/​not do or what to say/​not say in order to help. It is important to inform family and friends that a key to success is praising efforts and being kind about slips. 3. Practice responding in a healthier way. It takes time to get in the habit of saying “no” after many years of saying “yes” to food offers. It is important to say “no” in a gentle, but firm manner. At times it will be impossible to stay away from or change problematic social cues. Remind clients that, in these instances, it can be helpful to keep the “control what you can, accept what you can’t” philosophy in 90

mind and to use willingness to continue to engage in healthy behaviors, even when the surrounding social cues are outside of their control and make weight control behaviors difficult.

Skill Builder (5 Min.) Direct clients to p. 72 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 25 minutes × 4  days. Record type and minutes on your Keeping Track Form. □ Behavior: Practice asking for support for weight control efforts from a family member, friend, or coworker. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: N/​A □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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CHAPTER 12

Session 12: Introduction to Defusion and Urge Surfing

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Introduction to Defusion (15 Min.)

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Urge Surfing (15 Min.)

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Skill Builder (5 Min.)

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MATERIALS Client Workbook

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Worksheet 12-​1: Fusion Versus Defusion ■ Worksheet 12-​2: Urge Surfing ■ Session 12 Skill Builder, Session 13 ABCDE Check-​In ■

Enough copies of the Keeping Track Form (Appendix A) so every client receives a form to record between sessions

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In.

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Skill Review (10 Min.) Review principles of social support. Remind clients that social forces can work both for and against their weight loss goals. Seeking out positive support and having strategies for managing problematic social cues are both key to weight control efforts. Review the six principles of asking for support: 1. Emphasizing health can help. 2. Avoid assumptions. 3. Be specific. 4. Show appreciation. 5. Practice being assertive about needs. 6. Use willingness skills. Remind clients that when they are unable to gain social support or are faced with problematic social cues, the following steps can help them handle the situation in a positive manner: 1. Stay away from the cue when possible. 2. Change the cue. 3. Practice responding in a healthier way. Discuss with clients what social support they were able to ask for in the past week and/​or times they addressed problematic social cues and what steps or principles they used. Ask clients to describe the outcome of their conversations asking for support or their approach to dealing with problematic social situations, and problem-​solve any difficulties they encountered.

Introduction to Defusion (15 Min.) Defusion is a state of distance from internal experiences like thoughts, feelings, and sensations. Often, people experience these internal events as truths, rather than seeing them for what they are (which is simply momentary activity in the brain). Defusion is a very important skill for willingness because it facilitates choosing a behavior that connects to a goal or value even when doing so could be uncomfortable. Refer clients to pp. 75–76 in the Client Workbook for more information on defusion.

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Present clients with the following metaphors to help illustrate the concept of defusion. Ensure that all clients are actively participating in the discussion to facilitate understanding. Hands over face metaphor. Have each client place a hand over his or her face. Ask them to describe what they see. Emphasize as needed that, although clients may be aware that it is a hand on their face, what they actually see is likely the color of their skin, perhaps a line or two (from the outline of a finger), and some light. Have clients slowly move their hands away from their faces. Ask them to again describe what they see. Ask them to focus on the details, like the lines on their hands or the outline of their fingers. Prompt clients to recognize that it was only as they gain distance from their hand that they can see that they were looking at a hand. Draw the comparison to thoughts, feelings, and sensations: as they gain distance from these experiences, they will be able to see them for what they are (e.g., just thoughts). For example, when clients are fused to the thought, “I’ll never succeed at losing weight,” they likely experience it as a fact; when clients defuse from that thought, they can see it as a just a thought traveling through their mind. Giving themselves distance from their internal experiences will help clients to more freely choose their behaviors. ■ Yellow sunglasses metaphor. Ask clients to imagine they are wearing yellow-​tinted sunglasses all day. Just like with any glasses, they would eventually forget that they are wearing them. They would see the world tinted yellow and would start to experience that as their reality. Then have clients imagine moving the sunglasses several inches away from their faces. Ask them to imagine how this would make their view different. Clients would see the sunglass frames and the rims, as well as the normally colored world around the area where the world appears yellow. This metaphor can illustrate that when clients are fused to a thought, it is like seeing the world through tinted glasses. When clients are defused from a thought, it is like seeing the thought through tinted glasses held several inches away from their faces. They can still see how that thought may color the world, but they can also see that the thought is simply one lens through which the world can be viewed. ■ Leaves on a stream metaphor. Ask clients to imagine they are very small insects sitting on a leaf that is floating down a stream. Ask ■

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them to describe what they would see and feel (e.g., a green blur, blue sky overhead, feeling like they are moving somewhere); these perceptions comprise the whole of reality to that insect at that moment. That leaf represents one thought a client may be having. If the insect then flies up to a tree overhead, it can see that there are many leaves floating down a stream that could each represent a thought or feeling a client is having at any given time. When fused with a thought, clients may see this thought as the only thought they could be having; that one internal experience becomes their reality, just like the one leaf was for the insect. When defused from a thought, clients will be able to see that they often have many thoughts, feelings, and sensations; no single internal experience needs to consume all of their attention or become their whole reality. (Just like the insect who was able to see many leaves floating down the stream once it gained a distance from all of them.) Ensure that clients adequately understand the concept of defusion. Emphasize that defusion is the process of seeing oneself having an experience. For example, when one is defused from a craving, one does not just experience the craving, but rather sees that one is having a craving. Defusion allows people to see thoughts, feelings, and sensations as simply processes taking place in the brain. It can be helpful to remember that everyone’s brain is programmed to respond in specific ways to certain cues. One common cue is passing by a candy bowl at an office. Often, this will elicit some kind of wanting, or a craving, for that particular food. If someone is fused with that craving, they might feel as though they have no choice but to take a piece of candy and eat it. Or when walking through the living room intending to go outside for a walk, seeing the TV on in front of the couch may elicit the thought, “I want to sit down and watch that show instead of going outside.” If someone is fused with that TV-​watching thought, going out for a walk is no longer an option, because that thought is the “truth” of how he or she needs to respond behaviorally. In both of these cases, though, a person could defuse from that internal experience and appreciate that it is simply a process taking place within her brain, and she can choose any behavior she wishes.

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Thus, defusion is a core willingness skill; it allows people to choose behaviors independently of thoughts, feelings, and sensations. Defusing, for example, from the thought that one craves a piece of candy or wants to watch a show on TV instead of exercising allows one to make a decision to engage in a behavior that is consistent with one’s values. Ask clients to give an example of a thought, feeling, or sensation that led to an automatic action in the past. Examples include having the thought, “I’ll never be able to walk for 20 minutes,” which led to the person not going for a walk that day, or “I had a hard day so I  deserve some birthday cake,” which led to the person having a piece of a coworkers’ birthday cake. For each example of fused action, ask clients to consider what their chosen action could be next time. For these examples that may be going for a walk anyway and having a planned snack instead. Ask clients to remember the Pick Up the Pen exercise. That is an example of defusion in action. Clients had the thought, “I can’t pick up the pen,” but were able to see that it was just a thought and their behavior could be chosen without listening to that thought. Tell clients that next week they will learn strategies to help them defuse from internal experiences. This week, clients will keep track of examples of fusion and defusion on the Fusion Versus Defusion Worksheet (Worksheet 12-​1).

Urge Surfing (15 Min.) Review of Acceptance Remind participants of the “control what you can, accept what you can’t” philosophy for long-​term weight control (see Session 5 for a review). As discussed in previous sessions, there are many aspects of weight control that clients do have control over. For example, clients have control over the types of foods that are available in their homes, planning meals, and self-​monitoring. Clients should use these strategies to facilitate healthy weight control behaviors as much as possible. Use examples to discuss with clients how they have successfully used “control what you can” strategies to reduce urges to eat particularly

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tempting foods. For example, one client may find that not buying ice cream when grocery shopping (i.e., using stimulus control) helps reduce the frequency of urges to eat ice cream. Another client may find that making a food substitution helps (e.g., eating a sweet piece of fruit instead of sweet candy decreases the urge to eat candy). Clients can also provide examples of how they have successfully used “control what you can” strategies to engage in physical activity. Strategies might include goal setting, planning, or pairing activity with another pleasurable behavior (e.g., listening to a podcast while taking a brisk walk). However, there are limits to what clients can control about their weight loss experience. Some aspects of the obesogenic environment cannot be changed. Some ways in which the human mind and body work also are outside of our control. For example, clients cannot control the number of fast-​food restaurants or sidewalks that are in a neighborhood or the hard-​wired desire to eat palatable foods or stay resting on the couch. Together, biology and the environment can interact to make aspects of weight control challenging. Some urges to eat palatable, high-​calorie foods are inevitable. There is no magic pill that can make those go away. Acceptance of some of these challenging internal experiences is a key ingredient for willingness. Acceptance does not mean “grinning and bearing it.” Rather, acceptance is embracing one’s internal experiences—​even those that may make it more challenging to engage in healthy behaviors—​as part of being alive. It is not judging these internal experiences as good or bad, but instead being open to them. Most important, acceptance of internal experiences does not mean acceptance of behaviors that run counter to weight control. Instead, acceptance is the first step toward being willing to experience uncomfortable thoughts, feelings, urges, and other internal experiences and still choose to engage in a healthy behavior.

Urge Surfing Using “control what you can” strategies often means that uncomfortable experiences happen less frequently (i.e., those strategies make it

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easier to choose healthy foods and engage in physical activity). Some uncomfortable experiences are inevitable, however. When they occur, clients can practice becoming more willing to accept uncomfortable internal experiences by “urge surfing.” Urge surfing, a term coined by psychologist Alan Marlatt, is the process by which a person “rides the wave” of the thoughts, feelings (including loss of pleasure), urges, hunger, fatigue, cravings, or other internal experiences that are pushing him or her to engage in an unhealthy behavior. Illustrate the concept of urge surfing to clients by likening surfing an urge to surfing waves in the ocean. This metaphor lends itself well to the concept of urge surfing given that, as with waves in the ocean, some urges cannot be successfully controlled. In those instances, clients can take an accepting stance toward the urge and “surf” it as they would surf a wave in the ocean. You may describe the metaphor of urge surfing as follows, eliciting responses from the group where indicated: Imagine that you are standing in the ocean with the water at about waist level. As you stand there, you see waves coming toward you. If you think to yourself, “These waves are bad” or “These waves are unacceptable,” you are likely going to want to try to prevent the waves from hitting you or stop them in some way. Perhaps you raise your arm and put your hand out in an effort to command the waves to stop coming toward you. Perhaps you try to push the waves down into the ocean as they hit you in an effort to suppress them and prevent them from splashing against you. Or perhaps you try to “stand your ground” against the waves and stop them from moving you, almost as though you are trying to overpower the waves. How well do you think these efforts will work?” Allow clients to respond, making sure they understand that humans don’t have the ability to control the waves in the ocean, so efforts to stop them, suppress them, or fight against them will not work. If clients do not mention it, point out that not only will these efforts be unsuccessful, but the more a person fights against the wave, the more the wave will overpower him or her. If clients try to fight against the wave, they are going to get knocked over. Continue the metaphor as follows: It seems like we can agree that efforts to control the waves will not be successful, and the more you try to fight against the wave, the more

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the wave will overpower you. Now imagine taking an alternative stance toward the waves. Imagine that, as you stand there in the ocean with the waves coming toward you, you decide to welcome the different ways that the waves could hit you and to not worry about their shape or how much time is between each one. Instead of trying to fight the wave that is coming toward you or control it in some way, you allow yourself to be picked up by the wave and “surf ” it, so to speak. How might this work better?” Allow clients to explain how surfing the wave will work better than trying to fight the wave. As needed, point out that surfing the wave allows clients to work with the wave (which is going to come anyway), rather than fighting fruitlessly against it and being overpowered by the wave. Explain that by being aware of and mindful of their urges, clients can surf them like they would surf a wave in the ocean instead of sinking into their urges and acting on them. When clients surf an urge, the urge is still there, but they can experience it in a different way. Explain that rather than seeing the urge as “bad” and trying to get rid of or control the urge, clients can accept the urge as the experience that they are having at that particular moment in time and allow themselves to experience the urge as it rises, crests, and falls. Emphasize that surfing the urge does not mean acting on it! Instead, surfing the urge involves “riding the urge out” until it eventually subsides. Clinician’s Note If clients share other strategies for dealing with waves in the ocean, you can try to link these examples to the underlying goal of urge surfing (i.e., acceptance) as appropriate. For example, if clients say that they would dive into the wave to avoid having it crash on them, you can highlight that diving into the wave is very consistent with the idea of accepting it. Rather than trying to control or avoid the wave, the client is approaching the wave and fully experiencing it. Thus, this is another example of how taking an accepting approach toward the wave allows the client to experience the wave in a new way rather than fighting against it. If clients provide examples that are not easily connected to the concept of acceptance, or if the conversation begins to stray off-​track, simply bring the conversation back to the surfing metaphor. This can be done by making a comment such as, “That’s a very 100

creative approach to handling waves in the ocean! When responding to urges rather than real waves in the ocean, we find that ‘surfing’ the urge is the strategy that works best.”

Guidelines for Urge Surfing Direct clients to pp. 78–79 in their workbooks, which outlines guidelines for urge surfing. Review these guidelines with clients, as outlined here. The first step for urge surfing is for clients to acknowledge that they are having an urge. Once they become aware that they are having an urge, they should label it. This can be done using the language, “I’m having the urge to . . .” (or “I’m having the thought/​feeling that . . .”). ■ The second step for urge surfing is to observe the urge. This involves noticing where in their bodies clients experience urges, as well as what the urges feel like. For example, some clients may experience urges as a tightening in the chest, while other clients may experience urges as a churning in their stomachs. Clients should practice noticing where in their bodies they experience urges and what urges feel like physically. ■ The third step for urge surfing is to be open to the urge, or to accept it. Rather than trying to suppress or get rid of the urge, clients should practice accepting the urge. Remind clients that the urges should not be judged as good or bad. Instead, clients should practice simply accepting the urge as the experience that they are having at that particular moment in time as a living human being. ■ The last guideline for urge surfing is to watch the urge as it rises, crests, and then falls. It can be helpful for clients to score the intensity of the urge on a scale of 1 to 10 as they observe it (with 1 indicating a very weak intensity and 10 indicating a very strong intensity). For example, clients can say to themselves, “I’m having the urge to order a pizza right now, and the urge is at a 7,” or “I’m having the urge to drive straight home instead of going to the gym to exercise as planned, and the urge is now a 9.” As clients surf their urges, they can check back in with their urges and note whether the intensity has changed. Instruct clients to keep checking on the urge, noticing whether it is ■

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rising, peaking, or falling. Tracking the intensity of an urge in this way can help clients to recognize that, although their urges may become very intense and quite uncomfortable at times, all urges will eventually drop in intensity. Note that some clients may also be surprised by how quickly their urges subside when they allow themselves to surf the urge for a period of time rather than immediately acting on it. Reiterate to clients that even the most intense urge will not last forever. As with the largest waves in the ocean, even the most intense urge will eventually fall. As clients practice urge surfing, they may notice that one urge subsides only to be followed by another urge a short time later. Part of being open to and accepting of urges involves knowing that they may come back and continuing to take an accepting stance toward urges when they do return. Encourage clients to practice surfing these returning urges using the same guidelines outlined previously. ADAPTING FOR INDIVIDUAL FORMAT In individual sessions, you and your client may work together to identify examples of past situations in which the client surfed an urge, as well as specific future situations in which the client could use this skill. You may wish to tailor the examples of urges provided to particular challenges or urges that the client has mentioned in the past. Ask clients for any examples of times in the past week when they “surfed an urge,” perhaps even without knowing it. Clinician’s Note If clients provide examples that suggest they were trying to get rid of, suppress, or otherwise control the urge (versus being open to experiencing the urge and surfing it), gently encourage them to reflect on whether they were, in fact, accepting of the urge or whether they were trying to control it. This can be done by asking a question such as, “In that situation, it sounds like you may have actually been trying to distract yourself from the urge in an effort to make it go away, rather than being open to experiencing the urge without judging it as good or bad. What are your thoughts on that?” As needed, re-​explain to clients that the goal of urge

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surfing is not to make a “bad” urge go away (as such an approach labels this natural experience as “bad” and is focused on trying to control the urge, which is unlikely to be successful). Rather, the goal of urge surfing is to accept the urge and “ride it out” without acting on it. Prompt several group members to identify specific situations that they might encounter in the upcoming week in which they could practice urge surfing. Possible examples include having the urge to stop at a fast-​ food restaurant for dinner instead of going home and eating a healthy meal that is prepared at home as planned, having the urge to eat donuts that are in the break room at work upon seeing them, or having the urge to keep relaxing on the couch instead of getting up to go for a walk as planned. Clients will practice urge surfing on their own this week using the Urge Surfing Worksheet (Worksheet 12-​2). It is very important to note that urge surfing should not be the first line of defense for preventing unhealthy eating or other behaviors that run counter to clients’ weight control efforts. Instead, clients should utilize behavioral strategies that are within their control (such as keeping tempting foods out of the home, using portion control, and planning ahead) to reduce the likelihood of engaging in unhealthy behaviors when facing strong urges and cravings. However, urge surfing can be particularly helpful if it is not possible to use these control-​based strategies, or if clients continue to experience strong urges or cravings despite implementing these other strategies.

Skill Builder (5 Min.) Direct clients to p. 79 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 30 minutes × 4  days (which is an increase from last session). Record type and minutes on your Keeping Track Form. □ Behavior: Work on the behavioral goal that you identified during today’s session.

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□ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: (1) Complete the Fusion Versus Defusion Worksheet (Worksheet 12-​1), and (2) Complete the Urge Surfing Worksheet (Worksheet 12-​2). □ Reminder: Complete your Check-​In sheet before the next session, Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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CHAPTER 13

Session 13: Strategies to Help Defuse and Increase Willingness

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Strategies to Help Defuse and Increase Willingness (30 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 13-​1: Practicing Defusion

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Enough copies of the Keeping Track Form (Appendix A) so every client receives a form to record between sessions

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. Instruct clients to report on whether they completed the Fusion Versus Defusion and Urge Surfing worksheets from Session 12 but to wait to discuss their responses to the worksheets until the Skill Review.

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Skill Review (10 Min.) Review of Urge Surfing Review with clients the concept of and rationale for using urge surfing. Remind clients that urge surfing refers to the process by which clients “ride the wave” of their thoughts, feelings, or urges, similar to how one would “ride” or “surf” a wave in the ocean. Remind clients that although there are many aspects of weight control that they do have control over, there are also limits to what can be controlled. Urge surfing is one strategy that can be used to facilitate acceptance of some of these challenging internal experiences that cannot be controlled. Reiterate that acceptance of these internal experiences does not mean acceptance of behaviors that run counter to weight control. Rather, acceptance is the first step toward being willing to experience uncomfortable thoughts, feelings, urges, or other internal experiences and still choose to engage in a healthy behavior. Briefly remind clients of the guidelines for urge surfing. These involve acknowledging the urge, observing it, being open to it, and then watching it as it rises, crests, and falls. Ask one or two clients to report on their experiences using urge surfing during the previous week using the Urge Surfing Worksheet (Worksheet 12-​2) as a guide. Problem-​solve as needed if clients report difficulties with using this strategy. Remind clients that although urge surfing can be a very helpful tool for responding to urges, they should also use “control what you can” strategies to reduce the frequency with which they experience urges, as well as the likelihood of engaging in unhealthy behaviors when experiencing strong urges or cravings. These “control what you can” strategies include keeping tempting foods out of the home, using portion control, and planning ahead.

Review of Defusion Briefly review the major concepts related to defusion discussed in Session 12, including what defusion is; the difference between fusion 106

and defusion; how defusion relates to willingness, values, and goals; and the metaphors used to illustrate defusion (e.g., hands over face, yellow sunglasses). This can be done by asking clients what they remember from the previous session about these points and filling in information as necessary. Alternatively, the key points from the previous session can be reviewed didactically. Review clients’ responses on the Fusion Versus Defusion Worksheet (Worksheet 12-​1). Ask one or two clients to share an example of a time when they felt fused with their internal experiences and what the behavioral outcome was (i.e., what they did in response to those experiences). Also ask one or two clients to share an example of a time when they felt defused from their internal experiences and the behavioral outcome. Clarify as needed if clients express confusion about the difference between fusion and defusion, or if clients provide examples that do not accurately capture these concepts. Inform clients that specific strategies for defusing will be discussed in greater detail in this session.

Strategies to Help Defuse and Increase Willingness (30 Min.) Obtaining Distance from Internal Experiences Introduce the idea that certain strategies have been developed that can help clients to defuse from their internal experiences. These strategies can help clients to step back from their internal experiences (e.g., thoughts, feelings, urges, physical sensations) so that they can see them happening and see these internal experiences for what they are:  processes taking place in the brain or body.

“I’m Having The Thought That . . .” One strategy that clients can use to defuse involves stating the thought or feeling to themselves. This can be done using stems such as, “I’m having the thought that . . .,” or “I’m having the feeling that . . .”. Labeling thoughts as thoughts, feelings as feelings, cravings as cravings, and so on facilitates defusion because it forces our minds to step back. 107

ADAPTING FOR INDIVIDUAL FORMAT In individual sessions, you and the client can work together to identify thoughts and feelings that the client experiences and practice applying defusion strategies to these thoughts and feelings to see them for what they are. Elicit examples from one or two clients of thoughts they had in the previous week that made it difficult for them to eat healthily, be physically active, or engage in other important weight control behaviors (e.g., self-​ monitoring). Examples of the types of thoughts that should be elicited are, “That cake looks so good!” “I’m too tired to exercise,” and “I have to have this pizza!” As needed, supplement the examples that clients provide with these examples. Ask one or two clients to insert the phrase, “I’m having the thought/​ feeling that . . .” before the thought or feeling that they identify. Ask clients to describe what the experience of stating their thought/​feeling to themselves is like. Ask clients if using this strategy enables them to gain a little space from their thought/​feeling so that they are looking at it and not from it. Reiterate how helpful it can be to insert the phrase “I’m having the thought/​feeling that . . .” at the beginning of a thought/​feeling when facilitating defusion from internal experiences. Instruct clients to practice using this defusion strategy in the coming week. (Refer to the “Strategies to Help Defuse and Increase Willingness” section on pp. 81–83 in the Client Workbook.)

Leaves On a Stream Instruct clients to recall the metaphor from Session 12 of thoughts and feelings as leaves on a stream. A second defusion strategy involves visualizing oneself looking down at a stream from the riverbank and imagining that each thought, feeling, urge, and so on that the client is experiencing is a leaf on that stream. As time allows, ask one or two clients how visualizing internal experiences as leaves on a stream could help them to step back from their

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thoughts and feelings. Encourage clients to try this visualization strategy to help defuse from thoughts, feelings, and other internal experiences.

Uncoupling Internal Experiences From Behaviors Explain to clients that defusing from internal experiences facilitates the uncoupling of thoughts, feelings, and other internal experiences from behavior. In this way, defusion is a valuable tool for facilitating willingness (see Sessions 6 and 7 on pp. 53–66 for a review of willingness). Explain to clients that their behavior does not have to follow their momentary thoughts and feelings—​they can have a certain thought, feeling, or other internal experience and choose not to behave in accordance with that thought or feeling. This can be done without first having to make the thought or feeling go away. Remind clients of what should be guiding their behaviors: their long-​term goals and values. Choosing behaviors based on one’s values and goals, rather than on one’s momentary internal experiences, is essential for long-​term weight control. Ask clients to recall the “Pick Up the Pen” exercise from Session 7. Explain that defusion is picking up the pen even when your mind is telling you not to. Ask a client to explain how the “Pick Up the Pen” exercise illustrates defusion. As necessary, explain that this exercise illustrates defusion by demonstrating that an individual can have the thought “I can’t pick up the pen” and feel too tired to pick up the pen—​ and still pick up the pen while having those thoughts and feelings. This exercise thus illustrates how clients can uncouple their thoughts and feelings from their behaviors to facilitate willingness to engage in weight control behaviors. As needed, provide the following examples to clients to further illustrate what defusion looks like in action. Example 1: A person thinks, “That brownie looks amazing. I have to have it!” Rather than eating the brownie because of this thought, the person uncouples this thought from her behavior and decides not to eat the brownie despite having the thought “I have to have it.”

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Example 2: A person thinks, “I don’t want to know how many calories this food has.” Again, rather than behaving in accordance with this thought, the person uncouples the thought from his behavior and looks up the calorie information for the food before deciding whether to eat it. As time allows, elicit one or two additional examples of behaviors that illustrate defusion from clients. Clinician’s Note If a client provides an example that does not accurately illustrate defusion, gently correct the client’s understanding of this concept. This can be done by praising the client for trying to apply this somewhat difficult concept to his or her own life, telling the client that the example provided does not quite illustrate defusion and explaining why, and amending the example provided to accurately illustrate defusion. Alternatively, if other group members appear to be understanding this concept, a gentle correction can be made by asking a question such as, “What does the group think—​does the example [client’s name] provided illustrate defusion?” You can then supplement group members’ responses using the approach outlined above as necessary. Tell clients that there are several additional strategies that can be used to uncouple one’s thoughts/​feelings from one’s behaviors, as described in the following.

Replacing “But” With “And” One strategy involves replacing the word “but” with the word “and” in certain thoughts that clients may have. Explain to clients that it is common for people to have thoughts in which they tell themselves why they cannot engage in a valued behavior given the thoughts, feelings, or other internal experiences that they are currently experiencing. For example, a client may have a thought such as, “I planned to have an apple for my afternoon snack, but those chips look really good!” In this thought, eating an apple for a snack would be consistent with the client’s values, but the thought about the chips looking good appears to 110

be preventing the client from engaging in this values-​consistent behavior (as indicated by the use of “but”). Briefly ask clients for additional examples of thoughts like this that they have experienced. Explain to clients that one way to uncouple their thoughts/​feelings from their behavior in situations like these is to replace the word “but” with the word “and.” Using the previous example, the thought “I planned to have an apple for my afternoon snack, but those chips look really good!” thus becomes, “I planned to have an apple for my afternoon snack, and those chips look really good!” Making this simple word substitution can remind clients that their behaviors need not be dictated by their momentary thoughts/​feelings. In this way, replacing “but” with “and” can facilitate defusion. As needed, further illustrate the use of this defusion strategy by providing the following examples: Example 1: A person has the thought, “I am scheduled to walk after dinner, but I  feel tired.” This person can replace the “but” in this thought with “and” in order to uncouple her feeling of tiredness from skipping the planned walk. Thus, the thought now becomes, “I am scheduled to walk after dinner, and I feel tired.” Example 2: A person has the thought, “I want to meet my calorie goal today, but those cookies look good.” This person can defuse from this thought by replacing the “but” with an “and” to produce the following sentence:  “I want to meet my calorie goal today, and those cookies look good.” As time allows, elicit one or two additional examples from clients of thoughts for which they could convert “but” to “and” in order to uncouple their thoughts from their behaviors.

“Thank You, Mind” Tell clients that another defusion strategy involves “thanking your mind (or body)” for the thought, feeling, or urge that is currently being experienced. Explain to clients that our minds are hard-​wired to desire tasty foods, to want to avoid being physically active, and to create reasons why it is okay to eat these foods or not engage in activity. These tendencies helped our ancestors to survive in times of food shortage.

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Although our food environment has changed and we no longer need to eat food whenever it is available or to conserve energy to facilitate survival, our minds and bodies are hard-​wired to produce these thoughts. Thus, unsurprisingly, clients can expect to have thoughts, feelings, and urges that may be in opposition to their weight control goals and values (e.g., “I want that cookie!” or “I’m too tired to go for my walk”) at times. Explain to clients that they do not need to be angry at their minds for producing these thoughts, feelings, and other internal experiences, nor do they need to be surprised or disturbed when they have these internal experiences. Their minds are simply doing their jobs! Emphasize to clients that, at the same time, just because they have these thoughts or feelings does not mean that they have to act in concert with them. The “thank you, mind” defusion strategy involves thanking one’s mind for doing its job of producing thoughts, feelings, and behaviors, while at the same time recognizing that just because one’s mind produced a thought or a feeling, one does not need to act on it. Clients can say, “thank you, mind” or “thank you, body” when experiencing a distressing thought, feeling, or urge to themselves in their minds, or they can actually say these words aloud to defuse from their thoughts/​feelings and uncouple them from their behavior. Provide one or both of the following examples of how to use the “thank you, mind” strategy to defuse for clients: Example 1: A person has the thought, “I need to have that pasta. It looks so delicious!” Upon having this thought, this person says to herself, “Thank you for that thought, mind” and chooses to have the salad she packed for lunch instead of the pasta. Example  2: A person has the thought, “I’m tired of counting calories. I’m just going to skip it for today.” In order to help uncouple this thought from his behavior, this person says, “Thank you, mind” to himself and decides to continue tracking his calories while at the same time continuing to feel bored with calorie counting. As time allows, ask one or two clients to share examples of scenarios in which they could see themselves using the “thank you, mind” or “thank you, body” strategy to defuse from internal experiences.

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“Just Do It” Tell clients that a final strategy that can be used to facilitate the uncoupling of thoughts and feelings from actions is the “just do it” method. Explain to clients that this strategy involves having a thought, having a feeling, or having an urge and choosing to engage in a behavior that runs counter to these thoughts, feelings, or urges anyway. Explain to clients that this is not “grinning and bearing it.” Rather, the “just do it” method involves accepting and even welcoming whatever internal experiences they are having (again, their minds are just doing their jobs!), while at the same being willing to engage in values-​ consistent behavior even if it runs counter to the thought or feeling that they are experiencing. Tell clients that individuals often find it helpful to simply call to mind the “just do it” slogan when experiencing uncomfortable thoughts, feelings, or urges in order to remind themselves that they can behave in a way that runs counter to their thoughts or feelings without first having to make those thoughts or feelings go away. Review for clients the following example of a scenario in which the “just do it” strategy can be used to defuse: Example 1: A person suspects that she has gained weight and thinks, “I’ll just skip my weekly weigh-​in. I don’t want to see how much damage I’ve done.” She reminds herself that she can “just do it” and steps on the scale while at the same time still thinking to herself that she would rather not know her weight. As time allows, ask one or two clients for examples of scenarios in which they could see themselves using the “just do it” strategy. Clinician’s Note If clients express concern that simply defusing from a thought or feeling will not necessarily make them behave differently, validate this point. Even after clients have defused from thoughts, feelings, or urges, they still have to decide how to behave. Remind clients that defusion is an extremely helpful tool for increasing willingness to choose behaviors that are consistent with their values and long-​term goals but are also difficult

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to enact. Encourage clients to use defusion strategies in conjunction with the other acceptance-​based skills that they are learning to build new patterns of behavior that are guided by what they truly care about rather than by momentary thoughts, feelings, or urges. Direct clients to the Practicing Defusion Worksheet (Worksheet 13-​1). Instruct clients to use this worksheet to practice using defusion strategies in the coming week. Remind clients that, as with any new skill, they will need to practice using these strategies in order to become good at using them. Although it may feel difficult to use these strategies at first, defusing from uncomfortable thoughts, feelings, and other internal experiences will become easier with practice.

Skill Builder (5 Min.) Direct clients to p. 83 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 30 minutes × 4  days. Record type and minutes on your Keeping Track Form. □ Behavior: Work on the behavioral goal that you identified during today’s session. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: Complete the Practicing Defusion Worksheet (Worksheet 13-​1). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten and calories).

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CHAPTER 14

Session 14: Review of Dietary Principles, Mindless Eating (Part 1), and Portion Sizes

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Review of Dietary Principles (10 Min.)

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Mindless Eating, Part 1 (10 Min.)

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Portion Sizes (10 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Enough copies of the Keeping Track Form (Appendix A) so every client receives a form to record between sessions

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. Specifically check in regarding clients’ experiences meeting their individualized behavioral goals that were set in the previous session. Instruct clients to report on whether they

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completed the Practicing Defusion Worksheet from Session 13 but to wait to discuss their responses until the Skill Review.

Skill Review (10 Min.) Ask several clients to share an example from the Practicing Defusion Worksheet of a situation in which they used one of the defusion strategies discussed in Session 13. These strategies include naming the thought or feeling, visualizing one’s internal experiences as leaves on a stream, replacing “but” with “and,” thanking one’s mind for the thought, and thinking “just do it.” As clients share their responses, prompt them to discuss what was helpful about using the defusion strategies. Also prompt them to discuss any challenges they encountered when trying to utilize the strategies. Problem-​solve these challenges with clients, clarifying how to implement the defusion strategies. Reiterate that defusion facilitates the uncoupling of thoughts and feelings from behavior and is thus a key willingness skill. Clinician’s Note If a client shares an example of a situation in which he or she attempted to use a defusion strategy to engage in a healthy behavior, but the behavioral outcome was engagement in an unhealthy behavior, praise the client for trying to implement a new skill and problem-​solve with the client around what he or she could do differently next time. Remind clients that, as with any new skill, they will need to actively practice using defusion strategies to become proficient with them. Encourage clients to continue to intentionally practice using these strategies in their daily lives. It may also be helpful to remind clients that although defusion is a key willingness skill, clients should continue to use other behavioral and psychological strategies as well in order to facilitate engagement in healthy behaviors.

Review of Dietary Principles (10 Min.) Review the key components of a healthy and low-​calorie diet, including having a high intake of fruits and vegetables, consuming lean sources

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of protein, and choosing whole-​grain options when consuming carbohydrates. Remind clients that these types of foods facilitate weight control because they are filling without being energy-​dense. Thus, clients can eat a relatively large volume of these foods and feel satiated while consuming relatively few calories. Eating a diet that consists largely of these low energy-​dense, nutritious foods (rather than more highly caloric foods) is key to long-​term weight control. Prompt clients to discuss improvements to their diets that they have established and maintained since the start of the program. Praise clients for making and maintaining these positive changes to their diets. Instruct clients to continue to use the “control what you can, accept what you can’t” philosophy as a framework for healthy eating. Clients should continue to control what they can by stocking their homes with healthy, nutritious foods; eliminating tempting, high-​ calorie foods from their homes; using portion control strategies to actively manage portion sizes; and choosing behaviors that are consistent with their values and long-​term goals. Encourage clients to also continue the practice of accepting what they cannot change by using willingness to choose the healthier option, even when it is not necessarily the most comfortable or pleasurable option. Clients can control their behavior (e.g., their food and activity choices) but not their internal experiences (e.g., hunger and cravings in response to foods that are not a part of a healthy diet). Clients should practice accepting their internal experiences while at the same time choosing to engage in healthy behaviors. Remind clients that urge surfing can help them refrain from indulging cravings to eat energy-​dense foods (such as desserts or fried foods). Clients can use urge surfing to refrain from buying foods for which they find portion control especially difficult, therefore preventing these foods from even entering the home. Instruct clients to identify and implement one change they will make toward eating a healthier diet this week as part of their Skill Builder. Remind clients to follow the principles for effective goal setting when identifying their goal, including making their goal specific, measurable, realistic, and active. Direct clients to record the change they will

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make on their weekly Keeping Track Form. If time allows, have clients share their goal with the group.

Mindless Eating, Part 1 (10 Min.) What Is Mindless Eating? Introduce the topic of mindless eating by asking clients to describe what they think of when they hear the term “mindless eating.” Also prompt clients to provide examples of situations in which they feel they eat mindlessly. Write clients’ responses on a whiteboard (or other means of writing). ADAPTING FOR INDIVIDUAL FORMAT In individual sessions, you and your client can work together to define and provide examples of mindless eating. As needed, supplement the definitions provided by clients to define mindless eating as “eating without deliberate intent or even awareness.” Also supplement the examples provided by clients by describing the following types of mindless eating scenarios: Scenario 1: Eating while engaging in another behavior, such as cooking, watching television, or driving and paying little or no attention to what one is eating or how much is being consumed. Scenario 2: Eating in response to a negative thought, feeling, or bodily sensation (e.g., stress, boredom) without carefully considering other options for responding to the internal experience or thinking about how effective eating is as a strategy for responding to this thought, feeling, or sensation. Scenario 3: Making a decision about eating (e.g., whether or not to eat, what to eat, how much to eat) on “autopilot” without paying deliberate attention to the eating decision, the different eating behavior options in the situation, or the likely consequences of each option. 118

Clinician Note If clients provide examples of eating episodes that sound more like binge-​ eating (i.e., eating episodes during which clients feel driven or compelled to continue eating and feel unable to stop eating despite wanting to stop), you can gently contrast these instances of eating with mindless eating. During binge-​eating episodes, most clients are likely very aware of their eating, but feel unable to stop. In contrast, during mindless eating episodes, clients are unaware of or are not paying close attention to their eating decisions, but presumably could stop eating if they became more aware and decided to stop. You can encourage any clients who report possible binge-​eating to think about examples of times when they have experienced eating that is better characterized as mindless eating and redirect the conversation back to this topic. As appropriate, you may wish to follow up with any clients who report eating episodes that may be characterized by “ loss of control” eating privately after the group session to determine the frequency, nature, and extent of any binge-​eating that these individuals are experiencing. As you see fit, you may wish to provide these clients with outside referrals for additional help for managing their binge eating, or continue to work with these individuals to monitor and address their binge eating.

Portion Sizes (10 Min.) One reason that making deliberate decisions and defusing from internal experiences is so important is that our food environment makes it hard for us to automatically regulate how much we eat. One scenario in which we may have difficulty regulating how much food we consume is when we eat mindlessly. Large portion sizes in restaurants are another reason that weight control can be difficult. Decades ago, fast-​food chains started competing for consumer dollars by offering larger portions. This spread to all types of restaurants, convenience stores, food outlets, and grocery stores. Ask clients to identify examples of foods that are served in especially large portions. Refer to clients to Figure 14-​1 (p. 87) in Client Workbook for additional illustrations. This effect has even spread to the home. Because so much of the food we consume has increased in portion size, it can be hard to determine what a reasonable

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portion size really is. In the United States, adults consume an average of 150 calories more each day than they did 20 years ago, which can cause several pounds of weight gain per year. Increases in portion sizes are problematic because research has consistently shown that the amount of food presented serves as a very powerful cue for how much food will be consumed; the bigger the portion size, the more people will tend to eat. Discuss with clients how to actively manage the portion sizes of foods in their homes. Refer clients to Table 14-​1 (p. 88) in the workbook for strategies. Purchasing single-​serving versions of food. Single-​serving containers can help limit calorie intake. For example, if a client likes ice cream for a once-​per-​week dessert, or chips for a once-​per-​week snack, it may be helpful to buy a single-​serving container of the food to keep in the house for the week, rather than the larger pint of ice cream or bag of chips. That way, they can still have the food they enjoy without being tempted to consume more than intended. ■ Pre-​portioning foods as soon as they are brought home. Eating from a large container, like a bag of pretzels, makes it difficult to limit calories. Instead, clients should pre-​portion foods as soon as they are brought into the home using plastic baggies or containers. This way, clients can grab a pre-​portioned snack or meal and know exactly how many calories they are consuming. ■ Using smaller dishware. Dishware is often designed to hold much more than the portion sizes clients should be consuming. Using smaller dishware, including plates, bowls, utensils, and serving spoons, will help clients to limit intake. Using bigger dishware only tempts clients to take larger portions, often without awareness. ■ Portioning food when it is served. Clients should practice putting on their plates only what they intend to eat. Rather than taking a large helping and planning to only eat part of it, clients should take exactly what they intend to eat and then put the rest away. Sitting around a dinner table with more food on the counter or table will make it tempting to take an extra helping or serve oneself more than one portion. Instead, clients should measure out the amount ■

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they plan to eat and then remove temptation by immediately putting leftovers in the freezer or refrigerator. Ask clients to give examples of portion control strategies they have used in the past. Emphasize that clients should identify which foods provide the highest risk for exceeding calorie goals at a particular meal or snack. Those foods are especially good candidates for portion control strategies. Removing those foods from the environment entirely also should be considered. Remind clients to be on the lookout for ways that portion sizes, dishware, and other cues could be subtly influencing their eating decisions. Encourage them to make eating decisions mindfully to prevent these cues from having a problematic, unconscious influence. Note that you’ll be addressing mindful eating strategies in the next session.

Skill Builder (5 Min.) Direct clients to p. 88 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 30 minutes × 4  days. Record type and minutes on your Keeping Track Form. □ Behavior:  Choose and implement at least one portion control strategy. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: N/​A □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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CHAPTER 15

Session 15: Mindless Eating (Part 2) and Mindful Decision-​Making

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Mindless Eating, Part 2 (5 Min.)

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Maximizing Mindful Decision-​Making (25 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 15-​1: Mindful Decision-​Making

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Enough copies of the Keeping Track Form (Appendix A) so every client receives a form to record between sessions ■ Whiteboard (or other means of writing) ■

ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. Specifically check in regarding clients’ experiences during the past week using portion control strategies at home or in other environments in which they regularly eat.

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Problem-​solve as necessary with clients who struggled to implement portion control.

Skill Review (10 Min.) Review of a Healthy Diet Briefly review with clients the key components of a healthy and low-​ calorie diet, including eating a diet high in fruits and vegetables, lean protein, and whole grains. Remind clients that the reason eating these types of foods facilitates weight control is because, in addition to being nutritious, these foods are filling without being extremely energy-​ dense. Thus, clients can eat a relatively large volume of these foods and feel satiated, while also eating a diet that is consistent with their calorie goals. Reiterate the importance of always tracking calories and being mindful of portion sizes, because eating too much of any type of food can lead clients to exceed their calorie goals.

Review of Mindless Eating, Part 1 Remind clients that mindless eating is defined as eating without deliberate intent or awareness. Mindless eating may occur when one is engaged in another behavior or when one eats automatically in response to a certain thought, feeling, or situation, without giving much thought to the decision to eat or the food being consumed. Tell clients you will be talking more about the dangers of mindless eating and strategies to avoid these dangers later in the session.

Review of Portion Control Briefly review the rationale for using portion control strategies in the home. Ask clients to recall the rationale for implementing portion control in the home discussed in Session 14 through questions such as “What do you find helpful about using portion control strategies at home?” and fill in the gaps as necessary. Key aspects of the rationale for

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potion control to review include the dramatic increase in portion sizes over the past several decades, the spread of larger portions from restaurants to the home, and the problematic nature of larger portion sizes given the power of portion size as a cue for how much to eat. Review specific strategies that clients can use to control their portion sizes, including buying single-​serving versions of items, transferring foods that are un-​portioned into individual serving sizes, using smaller dishware, and serving themselves only as much as they intend to eat. Discuss which specific changes clients have already made, and which specific changes clients are planning to make. As needed, refer clients back to the information on Portion Control Strategies from Session 14 (Table 14-​1 on p. 88). Instruct clients to continue using portion control strategies to actively manage the portion sizes of foods in their homes.

Mindless Eating, Part 2 (5 Min.) The Dangers of Mindless Eating Briefly review the concept of mindless eating with the group. Prompt clients to consider how mindless eating is problematic for long-​term weight control. Ask one or two clients to share their thoughts on how mindless eating could make long-​term weight control more difficult. As needed, supplement clients’ responses by identifying the following two primary dangers of mindless eating: The lack of monitoring. Because clients are not paying conscious attention to their eating behavior when engaging in mindless eating, they are not monitoring the amount of food they are eating. This lack of monitoring can lead clients to consume more calories than intended. It can also make it difficult to accurately record how many calories were consumed during an eating episode. Remind clients of the portion control strategies discussed last week and how these strategies can help prevent overeating due to a lack of monitoring. ■ The lack of conscious decision-​making awareness that is present during mindless eating. This lack of awareness or attention when making ■

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decisions about eating can lead clients to make eating choices that they soon regret. For example, if a client sees a plate of cookies on a table at a party and immediately eats one even though he is not hungry and without first thinking carefully about this decision, he may soon regret eating the 300-​calorie cookie when he was not even hungry and it did not fit into his meal plan for the day. Tell clients that, oftentimes, a lack of decision-​making awareness when making eating choices leads to the prioritization of short-​term rewards over long-​term rewards. Clients often regret this prioritization of short-​term rewards after the fact, once they have thought more fully about the different eating options available in the situation and the consequences of each decision. As time allows, prompt clients to provide examples of times when they have felt regretful or experienced other negative weight control consequences as a result of mindless eating.

Maximizing Mindful Decision-​Making (25 Min.) Tell clients that although mindless eating and mindless decision-​ making about eating choices are problematic for long-​term weight control, mindful decision-​making is a skill that can be learned. Mindful decision-​making involves increasing one’s awareness, attention, and intention when making decisions about what and how much to eat. Tell clients that mindful decision-​making about eating choices requires practice and intention and can be very helpful for preventing mindless eating. Inform clients that there are several strategies that can be used to maximize mindful decision-​making. Review these strategies with clients as outlined in the following section.

“Stop, Think” The first step to breaking the automaticity of eating behavior is to simply stop and take a moment to think about the decision one is making. Oftentimes when we engage in mindless eating, decisions

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about eating can happen so quickly or occur so automatically that it can feel as though there was no decision point at all. Tell clients that the goal of the “stop, think” strategy is to stop and think about the decisions they are making, rather than having these decisions happen to them. Ask clients if they have heard the adage, “Think before you speak.” Inform clients that a similar idea can be applied to eating decisions. Just as clients can practice thinking before they speak, clients can practice thinking before they eat. Reiterate that this habit of deliberately stopping and taking a moment to think about what to eat and how much to eat before eating takes practice, but it can be an extremely helpful strategy for preventing mindless eating. Inform clients that simply calling to mind the phrase “Stop, think” when they are in a situation where there is food can go a long way in preventing mindless eating. Prompt clients to discuss situations where mindless eating is likely to occur and in which “Stop, think” may be a useful strategy. Situations in which this strategy are particularly helpful include those where eating currently feels automatic or clients often eat out of habit (e.g., always buying popcorn when going to the movies or snacking while watching television in the evenings). “Stop, think” may also be particularly helpful in situations where clients are not paying close attention to their eating decisions (e.g., when socializing at a party where there is food or walking past a candy dish at work). As needed, supplement clients’ responses with these examples.

Slow Down and Pay Deliberate Attention Another strategy that can be used to reduce mindless eating and maximize mindful decision-​making involves slowing down and paying deliberate attention to the decision-​making process. Explain to clients that, normally, our minds work at a very rapid pace, and we are unaware of the factors that are driving us to behave in certain ways. By slowing down this process, we can become more aware of the factors that are driving our behavior and make more deliberate decisions.

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Explain that slowing down the decision-​making process can be accomplished through deliberately noticing the cues that are prompting clients to want to eat. These cues can be both external and internal. Explain that external cues include anything that is external to (outside of) clients, such as things they see, hear, or smell. Ask clients for examples of external cues that may trigger eating. As needed, supplement clients’ responses with some of the following examples of external cues that may prompt a desire to eat: seeing a particular restaurant or food store, seeing a certain type of food, seeing other people eat, seeing a commercial or other food advertisement (e.g., a billboard), hearing other people talk about eating, hearing the sound of a package of food being opened (e.g., a bag of chips), and smelling food. Explain that internal cues, such as thoughts, urges, and feelings, can also trigger a desire to eat. Ask clients for examples of internal cues that may trigger eating. As needed, supplement their responses with some of the following examples:  thinking about how good the food will taste, thinking that they deserve the food, feeling bored, feeling stressed, feeling tired, having an urge for a particular food, noticing their mouths watering, and picturing themselves eating the food. Explain that when using the “slow down and pay deliberate attention” strategy, clients should practice noticing both the external and internal cues that are pushing them to eat. Inform clients that extra attention to these cues is necessary when they are in situations where eating has become a habit. Elicit one or two examples from clients of situations in which eating has become habitual and they may therefore have to pay extra attention to the cues that are driving them to want to eat. Such situations may include eating while watching television, eating while cooking, or eating while working on the computer. Tell clients that one strategy they can use to practice the skill of slowing down and paying deliberate attention to the decision-​making process involves imagining themselves as a sports commentator. You can illustrate use of the sports commentator strategy using the following script: Imagine that there is a commentator reporting on every aspect of your decision-​making process around eating and that the speed of his voice has been placed on slow motion. For instance, imagine that you are

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sitting on the couch in your living room and you suddenly smell popcorn. Imagine the commentator reporting on the instant the smell hits your nose or you see the food. If you think about it, you can almost hear the commentator now. (Note:  Speak slowly as you read the following text, as if your speech is in slow motion. You may also wish to exaggerate your voice, as if emulating a sports commentator.) And here comes the smell of popcorn; it’s about to hit her nose—​there it is: she smells it! Her eyes quickly glance around to determine where the smell is coming from. She walks into the kitchen and sees her husband putting a handful of popcorn into his mouth. She begins to salivate. (Note: As you read the next part, enact the gesture as you speak.) She slowly reaches out to put her hand in the bowl, without calculating whether or not she has calories left for an evening snack and without assessing whether or not she is truly hungry. Then, she pauses and steps back from the bowl for a moment to consider … Explain to clients that using the sports commentator technique can be a fun and effective way to notice the cues that are triggering a desire to eat and slow down the decision-​making process around eating. Ask one or two clients for examples of situations in which they could see themselves using the “slow down and pay deliberate attention” strategy.

Up or Down Vote on a Value A third strategy that can be used to maximize mindful decision-​making is to make every decision a deliberate “up” or “down” vote on a value or something that one cares about. Briefly remind clients that values are the ideas, principles, and domains in our lives that are most precious to us. Values can serve as guiding principles for our behavior and represent what we want our lives to be about (see Session 7 on pp. 61–66 for a review of values).

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As mentioned briefly in Session 10, behaviors can be conceptualized as “votes” for or against a value. One way to combat the tendency to make mindless decisions that are based on short-​term (and short-​lived) reward and to increase mindful decision-​making is to think of each decision as a vote up or a vote down on a value. Imagining that each eating decision is an up or down vote on a value can help clients to consider the long-​term consequences of their decisions in the moments they are making them and thus facilitate decision-​making that is more consistent with what clients care most about. Explain to clients that this strategy can be especially helpful in situations where they are tempted to make an eating decision that is rewarding in the short term but is inconsistent with their long-​term weight control goals. Provide the following example to illustrate what using the “up or down vote on a value” strategy to maximize mindful decision-​making would look like in real life. Example: A person walks into a convenience store to buy an afternoon snack. Without really thinking about it, she walks over to the snack aisle and picks up a bag of her favorite potato chips. As she does so, she remembers the “up or down vote on a value” strategy and calls to mind her value of being an active, healthy mother. She asks herself whether buying the potato chips for her snack is a vote up or down on this value. She decides that buying the chips would be a down vote on this value. She therefore puts the bag of chips back on the shelf and decides to buy a healthier alternative (a yogurt) for her snack instead. Ask several clients to share examples of situations where they could see themselves using the “up or down vote on a value” strategy to facilitate mindful decision-​making. Inform clients that they can use this strategy in conjunction with either “stop, think” or “slow down and pay deliberate attention.” Specifically, after clients have paused for a moment to think about their eating decisions (“stop, think”) or become more aware of the factors that are triggering their desire to eat (“slow down and pay deliberate attention”), they can use the “up or down vote on a value” strategy to choose a behavior that is most aligned with their values and long-​term goals.

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Mindful Decision-​Making and Other Behaviors Explain to clients that while discussion of these strategies has focused on eating decisions given the particular dangers associated with mindless eating, clients can use these strategies to maximize mindful decision-​making related to other behaviors, such as physical activity and self-​monitoring. For example, a client might often make a “mindless” decision to sit at his desk during lunch, rather than go for a short walk to help meet an activity goal. Clients can use the “up or down vote on a value” strategy when deciding whether to go for a walk as planned. As time allows, prompt clients to identify other scenarios related to physical activity or other weight control behaviors in which they could use mindful decision-​making strategies to facilitate healthy behaviors. Clients will use the Mindful Decision-​Making Worksheet (Worksheet 15-​1) at home this week to identify additional situations in which they could engage in mindful decision-​making and record the outcome of this behavior.

Skill Builder (5 Min.) Direct clients to p. 93 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 30 minutes × 4  days. Record type and minutes on your Keeping Track Form. □ Behavior: Choose a specific strategy to improve the accuracy of your Keeping Track Form (e.g., always record right after eating, keep your form in a visible location, weigh/​measure all foods, record planned food in advance). □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: Use the Mindful Decision-​Making Worksheet (Worksheet 15-​1) to practice mindful decision-​making with regard to food or physical activity. Each day for the next seven days, choose

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an eating/​activity decision point and use the strategies discussed in the session. For each day, record (1) the situation, (2) the strategy utilized, and (3) the outcome. □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories).

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CHAPTER 16

Session 16: Transitioning to Biweekly Meetings

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Transitioning to Biweekly Meetings (10 Min.)

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Overall Skill Review (10 Min.)

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Weekly Review (10 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 16-​1: Skill Review

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Schedule of remaining biweekly and monthly group meetings Enough copies of the Keeping Track Form (Appendix A) so every client can record each week until the next session ■ Enough copies of the Weekly Review Form (Appendix D) so every client can complete one form each week until the next session ■ ■

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Clinician’s Note Because this program focuses on long-​term weight loss maintenance, many of the skills taught are designed to help clients maintain their behavior long after they complete the full course of treatment. For many clients, the added accountability of weekly group sessions and checking in with a clinician on a regular basis is a crucial element to weight loss success. However, it is important for clients to gradually learn to build this accountability for themselves, in a way that is sustainable in the long term. Holding oneself accountable outside of the program and learning to monitor behavior from week to week are skills that are built over time. This program is designed to help clients build self-​reliance gradually, through a progressive reduction in session frequency. As sessions become less frequent, ask clients to practice monitoring their weight and behavior during the “off” weeks. Future sessions will focus on helping clients to trouble-​shoot the inevitable challenges they will encounter in their long-​term weight control journeys. For many clients, a decrease in session frequency can be anxiety-​ provoking, because they believe that the support of weekly sessions, rather than their own commitment to their health, explains their success thus far. For others, reducing session frequency can lead to beliefs that the program is “winding down,” and their between-​session behavior is less important. Taking time during the session to discuss the specific reasons for the transition and the importance of staying engaged with the treatment process helps place clients in the optimal mindset for the remainder of the program. Throughout this session, it is important to be alert to any beliefs, such as those listed here, that may lead clients to become disengaged with the program at this time. Clinicians are encouraged to choose a schedule that works best for the group or individual client, but the following suggested schedule has proven to work well:  Sessions 16–​22: Biweekly (meeting every other week, starting with Session 16, for a duration of 10 weeks total) ■  Sessions 23–​24: Monthly (i.e., with approximately four weeks between Sessions 22, 23, and 24, respectively) ■  Session 25: Bimonthly (i.e., with approximately eight sessions occurring between Sessions 23, 24, and 25) ■

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. Specifically check in regarding clients’ experiences with choosing a specific strategy to improve their accuracy when completing their Keeping Track Forms, and problem-​solve as necessary with clients who are struggling to record accurately on a consistent basis. As time allows, ask some clients to share strategies that are most helpful for keeping accurate eating and exercise records. If clients identify any psychological or emotional barriers to recording (boredom, low motivation), this is a good opportunity to discuss how psychological strategies may be used to overcome these barriers. For example, if a client has the thought that “Recording is too tedious for me to do every day,” you might encourage the client to connect daily self-​monitoring to a personal value (e.g., health).

Skill Review (10 Min.) Review the pitfalls of mindless eating, which include failure to account for calories consumed (forgetting to record), unintended consumption of excess calories (even if recorded), and a tendency to prioritize short-​ term rewards (i.e., pleasurable taste of a palatable food) over long-​term rewards of sustained weight loss and improved health. Review strategies to maximize mindful eating, including the “stop, think” approach, slowing down and paying deliberate attention to the internal and external cues influencing decisions in the present moment, and making every decision an up or down vote for or against a personal value. Discuss the specific strategies that clients can use to slow down and make mindful decisions about their food intake. Techniques may include noticing external cues that promote eating; noticing thoughts, feelings, and urges related to food; and paying particular attention to behaviors or situations that have become habitual (e.g., always eating in front of the television). Clients can practice these skills by becoming a “sports commentator” of their internal experiences. Ask one or two clients to share feedback about how they were able to incorporate mindful eating into their behavior during the past week and how this may have helped improve their eating habits. Elicit discussion of clients’ experiences through open-​ended questions (e.g., “What about mindful 135

eating did you find to be the most challenging?” “How did you overcome these challenges?”)

Transitioning to Biweekly Meetings (10 Min.)

ADAPTING FOR INDIVIDUAL FORMAT You may decide to utilize an alternate schedule with an individual client. However, we still recommend that you follow a principle of gradual fading; that is, sessions become less and less frequent before coming to an end. Take time to congratulate clients on successfully completing the first phase of the program. This is a good opportunity to acknowledge and reinforce clients’ commitment to themselves and their health through continued session attendance and willingness to persist in their weight loss efforts during the past several weeks, even when challenges arose. Prompt clients to discuss their feelings about completing the first phase. How has their work over the past few months compared to their previous weight loss efforts? Clients may be tempted to attribute their success thus far to the program itself rather than to their individual efforts. Redirect any of these comments to center clients’ attention on what they have done differently to sustain their commitment to themselves and their health. Review the schedule of meetings for the remainder of the program. Remind clients that the group will continue to meet every other week for the next three months (roughly) and then monthly and bimonthly for the next five months. Provide an extra copy of the schedule of remaining sessions, and encourage clients to add these dates into their calendars if they have not already done so. Stress the importance of attending sessions as they become less frequent and the need to schedule around them. (For example, if a client misses a meeting, he or she will be missing group for an entire month or more!) These meetings are critical because they teach skills for long-​ term weight control. If a client begins struggling with weight loss, it can be tempting to miss a meeting, because he or she may want to

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avoid the scale or check-​in or may feel as if the group meeting will not be helpful. These are the times when it is most important to attend, and, when practicing willingness, experiencing the discomfort associated with discussing one’s challenges is crucial. Clinicians and fellow group members are critical sources of support and can provide a sense of accountability that is helpful. Elicit a discussion about any concerns or questions clients may have about reducing the frequency of group sessions. For example, clients are often concerned about having less accountability from clinicians and needing to rely more on themselves to stay on track between sessions. Clinician’s Note Clients will have varying goals for weight loss and maintenance over the next few months. Some will want to lose more, and some will start focusing on keeping off the weight they have lost. Often, clients find that after they have lost 10% of their weight, continued weight loss becomes difficult, and focusing for a period of time on weight loss maintenance can make sense. Re-​emphasize that this period of the program is critical, because it facilitates a gradual shift toward self-​reliance to maintain the psychological and behavioral changes clients have already made (and will continue to improve upon). Many clients have experienced prior short-​term success at weight loss, but they have struggled to maintain their behavior change long term. Skills that are taught during the remainder of the program will be helpful to everyone, regardless of specific weight loss or maintenance goals. During this phase, clients will learn to deal with long-​term issues (e.g., lapses or small weight gains) and develop ways to monitor their weight and behavior when they no longer attend program sessions. Many clients will express ambivalence about the reduced level of accountability and support that accompanies less frequent sessions. Validation of these concerns is important—​weight control is a challenging process, and we would be surprised if clients succeeded at maintaining their weight losses without experiencing “hiccups” along the way. However, the gradual reduction in meeting frequency is designed to give clients extended practice at implementing the skills they have

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learned during the first phase of this program, while still providing an opportunity for them to return to group and receive support for any challenges they face.

Overall Skill Review (10 Min.) Ask clients to consider how the psychological strategies they have learned thus far have helped them to maintain their behaviors in the long term. Experience tells us that continuing to engage in the behaviors required for sustained weight control becomes difficult over time. Clients may begin to experience reductions in motivation, self-​ monitoring may begin to feel monotonous, or life stressors may make maintaining one’s weight control routine more challenging. Ask them which of the strategies they imagine will be most important as they start working toward addressing the long-​term challenges associated with weight loss maintenance. Ask clients to look at the Skill Review Worksheet (Worksheet 16-​1). Briefly review each of the skills listed, referring back to the experiential exercises practiced in previous sessions. Ask clients to identify particular situations in which they have found each of the skills to be helpful. In addition, clients should begin to consider how they plan to use these strategies to maintain their lifestyle changes in the long term. Table 16-1 serves as a guide for reviewing the definitions, experiential exercises practiced during group, and potential future applications of the psychological skills. Each client may find some of the strategies particularly helpful and others less so. The key is for them to identify what works for them, and when, so they are better prepared (psychologically and behaviorally) when they encounter similar challenges in the future.

Weekly Review (10 Min.) One skill that will become crucial for clients to build on in the coming weeks is developing a system for regularly “checking in” with themselves about the key behaviors related to weight control. Remind clients that, in group sessions, this weekly review has been accomplished

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Table 16-1  Skill Review of Psychological Strategies for Weight Control Skill

Willingness: engaging in a valued behavior, regardless of uncomfortable internal experiences Mindful Decision-​ Making: slowing down the decision-​making process so as not to engage in mindless eating or exercise behavior

Defusion: a state of distance from internal experiences; fosters willingness

Values: guiding ideas, principles we constantly aspire to in life; serve as a compass or guide for our behavior

Experiential Exercises

Example Situations in Which the Skill Might Be Helpful

 Chocolate and carrot exercise ■ Changing “even if” to “only if” ■ Urge surfing

Exercising outdoors, even if the weather is unpleasant; stepping on the scale, even if you’re worried you will be disappointed with the number

 “Stop, think;” notice internal and external cues leading to the desire to eat or stay sedentary ■ “Sports Commentator” notion of slowing down the action ■ Make every decision an “up” or “down” vote on a value

Making deliberate decisions about food in the presence of external cues for eating (e.g., candy dish at work, bread dish at a restaurant, TV commercials)

 Hand over face metaphor; yellow sunglasses ■ Labeling thoughts/​feelings (e.g., “I’m having the thought that . . .”) ■ Changing “but” to “and”

Dealing with urges and cravings; decoupling thoughts (e.g., “I’m not the kind of person who exercises in the rain”) from actions (exercise anyway)

 Clarifying healthy eating and activity-​related values ■ Connecting to values in the moment (e.g., visual reminders) ■ Putting long-​term mind in charge

Engaging in committed action over the long term; remembering why you are continuing to monitor weight, activity level, and food intake, even when it becomes monotonous or tiresome

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through the ABCDE Check-In. Now, clients will be asked to complete this check-​in on their own, through the Weekly Review (Appendix D). Ask clients to discuss the potential benefits of doing a weekly check-​ in at home. Weekly check-​ins provide an opportunity to assess their progress in a realistic manner, avoiding extremes of denial (“Gaining a few pounds is no big deal; I’ve lost 20”) or catastrophizing (“I’ve gained

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2 pounds; I’ll never be able to keep this weight off!”). Most important, weight control depends on clients being highly aware of changes in behavior and patterns of weight change, so they can act quickly to prevent significant weight regains. Review the process of completing the Weekly Review with clients. Remind them that they should also be keeping track of changes in their weight at home, and review the process of monitoring one’s weight progress. If they have not already been doing so, clients should be weighing themselves at least once each week; we recommend daily weighing. Each client should have access to a digital scale that provides accurate and reliable weight measurements. Ideally, weighing should take place in the morning, before eating or drinking, but after going to the bathroom. Clients can graph their weights, or track them in a table, using Appendix C: Home Weight Change Record. Self-​weighing more than once daily is not recommended, since marked water fluctuations can occur throughout the day. As needed, problem-​solve with clients to select the optimal weighing frequency and scheduled time for the Weekly Review on an individual basis. Allow time for discussion of clients’ concerns about transitioning to biweekly and monthly meetings. Encourage clients to help one another plan to deal with these challenges in the future. For example, now that clients are not coming in to be weighed weekly, they may feel they have “longer” to lose the weight (i.e., two weeks instead of one) and be tempted to be more lenient with themselves during the first week. Emphasize that making mindful decisions and choosing to act in line with one’s long-​term mind (rather than one’s short-​term mind) are important to continue making progress between sessions. Clients should select a regular “appointment time” for their weekly check-​in, on a day that they can commit to completing it on a consistent basis. Many clients find it easiest to schedule the weekly review on the same day of the week as their group meeting day, since it is already a day associated with weight control.

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Skill Builder (5 Min.) Direct clients to p. 98 in their workbooks, which outlines the following Skill Builder for the coming weeks: □ Activity:  Exercise (e.g., brisk walking) for 30 minutes × 5  days (which is an increase from last session). Record type and minutes on your Keeping Track Form. □ Behavior: Purchase a digital scale to weigh yourself regularly, if one is not readily available. Complete your Weekly Review sheet (Appendix D) in the off-​week(s) between now and the next session. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise:  Complete the Skill Review Worksheet (Worksheet 16-​1). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories) and Home Weight Change Record.

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CHAPTER 17

Session 17: Maintaining Losses Over the Long Term

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Maintaining Weight Losses Over the Long Term (30 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 17-​ 1:  How Do You Compare to the NWCR Members? ■ Worksheet 17-​2: Your Weight Maintenance Plan for Success ■ Worksheet 17-​ 3:  Using Psychological Strategies to Maintain Weight Control Behaviors ■

Enough copies of the Keeping Track Form (Appendix A) so every client can record each week until the next session ■ Enough copies of the Weekly Review Form (Appendix D) so every client can complete one form each week until the next session ■

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. Specifically check in regarding clients’ experiences with completing the Weekly Review at home during the past week, and problem-​solve as necessary with clients who struggled to complete the review. As time allows, ask some clients to share strategies that worked best to ensure they completed all steps of the review (e.g., adding a reminder to their weekly calendar; setting aside a specific amount of time to complete the task; practicing willingness to step on the scale, even when uncertain about whether they would be satisfied with the number).

Skill Review (10 Min.) First, review the rationale behind the Weekly Reviews, which are completed during any weeks on which sessions do not occur. A weekly self-​ check-​in provides a structured opportunity for clients to assess their progress in a realistic manner. Evaluating objective information about progress can help clients avoid the extremes of catastrophizing or denial about getting off track with eating or physical activity. Second, it increases awareness of changes in exercise, self-​monitoring, and weight. This allows clients to act quickly and prevent significant weight regain or relapse. Also review the key behaviors involved in the Weekly Review, including (a)  weekly weighing on a reliable scale, (b)  graphing or charting weekly weight progress, and (c) completing all components of the Weekly Review Form (calorie average, behavioral goals, and physical activity minutes). Problem-​solve with any clients who had difficulty completing all components of the Weekly Review, drawing in psychological strategies as indicated (e.g., willingness to devote time to the Weekly Review, connecting to one’s values and long-​term mind if their short-​term mind says, “It’s not a big deal if I miss one week—​I’m too busy anyway”). Next, review the psychological strategies that were covered in the overall Skill Review in the previous session, including willingness, defusion, mindful decision-​making, and values. Have clients define each of the strategies, and lead a discussion about how these strategies facilitate engaging in weight control behavior. Ask clients to provide examples of 144

past situations in which each of the strategies have been helpful, and ask them to consider any future challenges for which they anticipate these skills will be particularly useful.

Maintaining Weight Losses Over the Long Term (30 Min.) Begin this section with a discussion of clients’ previous attempts at weight loss. Almost without exception, clients who seek treatment for weight loss will have made attempts in the past. Many have successfully lost substantial amounts of weight over relatively brief periods of time, but gained the weight back gradually. In almost all cases, this happens because they stopped following a healthy lifestyle plan and went back to their prior eating habits. Reassure clients that they are not alone in this experience. The majority of clients who lose weight regain approximately one-​third of that weight in the year after weight loss treatment ends. This information is not intended to discourage clients, but instead to emphasize that the challenges of maintaining weight control behavior in the long term are universal. Emphasize, however, that there is good news: there are many individuals who have lost weight and kept it off over a sustained period of time, and clients can learn from their successes to plan their own long-​term weight loss maintenance. This session will provide an opportunity for clients to develop an identity as a successful weight loser/​maintainer and to plan specific strategies for the long term.

Learning From Others Who Succeed: The National Weight Control Registry Introduce the National Weight Control Registry (NWCR) as a very special type of club. Like any club, there are certain requirements for joining—​members must have lost 30 pounds or more. ADAPTING FOR INDIVIDUAL FORMAT If a computer is available, you may spend 5 to 10 minutes with your client exploring the NWCR website at www.nwcr.ws. Clients may find it inspiring or motivating to review personal stories of NWCR

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members, or they may want to review the process for registration that they will eventually be able to complete themselves. On average, these individuals have actually lost about 70 pounds and kept it off for almost six years. During this session, clients will have the opportunity to review how their weight maintenance behaviors “measure up” to those of NWCR members. These individuals can tell us a lot about what works for long-​term weight control. Review the key characteristics listed in Box 17-​1, underscoring the similarities between NWCR members and your client (e.g., having struggled with weight since childhood, having a triggering event that prompted them to lose weight). Emphasize that many NWCR members had lost the weight before, only to regain it again. (This experience may resonate with many of your clients.) Registry members identify two key differences between their past weight loss attempts and their last attempt that resulted in long-​term success. First, members report that, this time, they were more committed to behavior change and weight loss. They made weight maintenance a top priority and stayed focused on their ultimate goal of weight control. Second, members say that they dieted more strictly and used more physical activity than they did in previous attempts. Over 90% of registry members say they used both diet and exercise to lose weight and maintain it.

Box 17-1 Becoming a Weight Maintenance Pro: A Snapshot of the NWCR Who are the NWCR Members?

Over 4,000 members ■ Mostly women ■ On average, members are in their mid- ​40s, but the registry also has members of all ages ■ Long-​time struggles with weight: many report being overweight as a child and having one or two parents who were overweight ■ Many report a triggering event that motivated their weight loss (e.g., developing diabetes, relative having a heart attack) ■

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Key Behaviors for Weight Loss Maintenance Success Extensive research has been conducted to determine what “common threads” may emerge from NWCR members’ diverse experiences. Several of these have been identified, which are listed here. Lead clients through a review of the key behaviors that NWCR members enact to lose weight and keep it off. 1. Successful weight losers report eating a low-​calorie, low-​fat diet. On average, these members report eating about 1,400 calories per day (or 1,800 calories with error of estimation). They also report that 24–27% of their calories are from fat. This is far below the average American, whose diet consists of closer to 36% of calories from fat. 2. Very few eat a low-​ c arbohydrate diet (like Atkins). Rather, these individuals report eating a high-​carbohydrate, low-​fat diet, with lots of variety in the fruits, vegetables, and low-​fat bread products. 3. Most NWCR members (78%) report eating breakfast every day. Only 4% report that they never eat breakfast. The breakfast typically includes cereal, fruit, and milk; NWCR members who report eating breakfast have an overall daily caloric intake that is no higher than people who skip breakfast. 4. NWCR members report five eating episodes per day (breakfast, lunch, dinner, and two snacks). They report eating out about three times per week but go to fast-​food restaurants less than once per week. 5. Physical activity is a major factor in their weight loss maintenance success. Registry members engage in about an hour a day of physical activity. Walking is the most frequently cited physical activity, but aerobic dance, cycling, and strength training are also reported frequently. The amount of physical activity that is reported by NWCR members far exceeds the Surgeon General’s recommendation of 30 minutes of activity on most days of the week. 6. Registry members weigh themselves regularly. Almost half of the members weigh themselves every day, and three-​quarters weigh themselves at least once a week. 7. Registry members were asked whether they watched their diet and physical activity as closely on weekends as they do during the week

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(or as closely on vacations/​holidays as they do during the rest of the year). About half report that they are equally careful at both times, and the other half say they are more careful on weekdays or normal/​routine days (i.e., days that were not holidays, birthdays, or vacation days). Researchers followed these two groups for over a year to see which group did better. Results indicated that those individuals who were equally careful on both weekdays and weekends (and on holidays and routine days) were less likely to regain weight over the year of follow-​up. Why might this be true? Perhaps members who give themselves “breaks” from diet and exercise on weekends also start giving themselves “breaks” at other times and thus end up eating more and exercising less over time. You will be providing clients with extensive information about a variety of key weight control strategies during this session. To help them consolidate and integrate this information into their own weight control plans, it is helpful to summarize the key themes for them. Some of the most important behaviors to highlight include: Regular weighing of body weight (at least weekly, but up to every day) ■ Keeping to fixed calorie goals ■ Eating a low-​fat, high-​fiber diet ■ Eating scheduled meals throughout the day ■ Incorporating a large amount of physical activity into daily schedules ■

Is there anything about NWCR members’ habits that surprises clients? What key behaviors do NWCR members engage in that clients are not yet doing or could be doing better? At the conclusion of the discussion, give clients a few minutes to fill out the How Do You Compare with NWCR Members? Worksheet (Worksheet 17-​1) and then discuss their answers. Clients can use Worksheet 17-​1 to help them build their long-​term weight maintenance plan; also refer them to the Your Weight Maintenance Plan for Success Worksheet (Worksheet 17-​2). Provide time for clients to begin developing their plan. Ask a few clients to share an example of a behavior they are already enacting consistently and one that they will add to their plan to increase long-​term success.

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Clinician’s Note Some clients may feel overwhelmed by the long list of weight control strategies provided during this session. They may find it unrealistic to expect that they can maintain every one of the behaviors listed in the long term. It is important to emphasize to clients that while there are certainly common themes among NWCR members’ behaviors, there is no “one plan fits all” approach to weight control. Clients will be most successful if they find an action plan that works best for them. Remind them that they are their own “experts” when it comes to knowing which strategies are the most useful day-​to-​day.

Using Psychological Strategies to Support Weight Loss Maintenance Long-​term weight loss maintenance requires consistent use of behavioral strategies, such as those used by NWCR members. Emphasize that psychological strategies will help clients maintain these behaviors, even when they become difficult or tedious. Using the Using Psychological Strategies to Maintain Weight Control Behaviors Worksheet (Worksheet 17-​3), have clients select three specific behaviors that they will add to their routines to help them achieve weight loss for life. These should be realistic, specific, and attainable goals. Briefly discuss answers, and ask clients to identify specific psychological strategies that will facilitate attainment of these goals. Finish the session by asking for clients’ reactions to this information. Are they encouraged to hear how well these NWCR members have done and that it is possible to keep weight off for life, even though that’s not the experience for the majority of people who set out to lose weight? Or do they feel differently? We know that many of the behaviors necessary for weight control are difficult to maintain over the long term. This program is designed to address many of the key challenges that people face during the process. Ask clients:  What psychological strategies do you foresee as being helpful for maintaining these weight control behaviors over the long term? For example, self-​monitoring over the long term requires willingness and keeping values in the forefront

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of one’s mind. Ask clients to spend additional time considering which psychological strategies they will use to help them continue to engage in each of their chosen weight control behaviors, even when they hit a bump in the road on their weight control journey, or their motivation fluctuates. Clinician’s Note It is important to be attentive to any clients’ tendencies to be dismissive of the NWCR as an unrealistic goal that they are incapable of achieving. Sustaining behaviors in the long term can be challenging, and it requires that clients accept a potential reduction in pleasure, particularly in the face of highly palatable foods. For clients who are resistant to the idea of maintaining these behaviors in the long term (e.g., viewing vacations as a time to be more vigilant moving forward, rather than as a time to “take a break” from weight control behavior), it might be helpful to refer back to their values. For example, you might respond: “It’s certainly true that committing to these behaviors in the long term means being willing to have your life look different than it did before you joined the program. But there is a reason you joined this program in the first place. What was that reason? And what are you willing to experience in order to live your life in line with this value?” End the discussion on a positive note—​clients are well on their way to becoming eligible for the NWCR through the changes they have made thus far. Instill confidence in each client that becoming an NWCR member is something that each of them can strive for and aspire to in the coming year. Indeed, many clients who have completed this program are already enrolled as NWCR members today.

Skill Builder (5 Min.) Direct clients to p. 105 in their workbooks, which outlines the following Skill Builder for the coming weeks: □ Activity:  Exercise (e.g., brisk walking) for 30 minutes × 5  days. Record type and minutes on your Keeping Track Form.

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□ Behavior:  Follow the goals identified on the Your Weight Maintenance Plan for Success Worksheet (Worksheet 17-​2). Complete your Weekly Review sheet (Appendix D) in the off-​week(s) between now and the next session. □ Calories: Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: Complete the Using Psychological Strategies to Maintain Weight Control Behaviors Worksheet (Worksheet 17-​3). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories) and Home Weight Change Record.

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CHAPTER 18

Session 18: Willingness and Reducing Barriers to Physical Activity

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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A Review of Willingness: Passengers on the Bus (20 Min.)

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Barriers to Being Active (10 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 18-​1: Overcoming Barriers to Physical Activity

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Enough copies of the Keeping Track Form (Appendix A) so every client can record each week until the next session ■ Enough copies of the Weekly Review Form (Appendix D) so every client can complete one form each week until the next session ■

ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In and problem-​solve, as time allows, with clients who had difficulty recording their intake for the full two

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weeks or who encountered difficulty maintaining other weight control behaviors during the longer time interval between sessions. As with the previous session, check in regarding clients’ experiences with completing the Weekly Review (Appendix D) at home during the past week, and problem-​solve as necessary with clients who struggled to complete the review.

Skill Review (10 Min.) Review the importance of maintaining key weight loss behaviors over the long term. Many people experience weight gain after a large weight loss, and it is likely that many clients have also had this experience. Weight regain usually occurs because individuals stop following a healthy lifestyle plan and go back to their prior eating habits (i.e., “go off” their short-​term diets). Stress that this program emphasizes life-​ long maintenance of key weight control behavior changes, which is crucial to long-​term success. Review the key characteristics of the National Weight Control Registry (NWCR), which is a rich source of information about how the most successful weight losers and maintainers have achieved their goals. Members of the NWCR must have lost 30 pounds or more and kept it off for at least a year. On average, these individuals have actually lost about 70 pounds and kept it off for almost six years. Ask clients to review the most important behavioral strategies employed by NWCR members, which include the following: Careful self-​monitoring of weight (including weekly or even daily weighing) ■ Sticking to a fixed calorie goal (around 1,400 calories per day, but varies by individual) by carefully tracking dietary intake ■ Eating a low-​fat diet ■ Eating scheduled meals throughout the day ■ Incorporating large amounts of physical activity on a daily basis ■

Maintaining these behaviors over a lifetime can be difficult and requires a high level of commitment to one’s health values and willingness to experience a reduction in pleasure associated with controlling weight.

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Review how each of the psychological strategies discussed in the previous session can help clients to maintain these behaviors in the future. As time allows, ask a few clients to identify (a) a key behavior employed by NWCR members that they would like to add or improve in their own weight control regimen and (b) how one of the psychological strategies taught in this program can help clients maintain that behavior, even when it becomes challenging to do so.

A Review of Willingness: Passengers on the Bus (20 Min.) During this session, you will (a) review the concept of willingness with clients and (b) illustrate the idea that maintaining high levels of willingness, no matter what is going on in one’s internal or external environment, is key to staying on track with weight control on the “highway of life.” Ask clients to describe what willingness means to them and how they enact it in their own lives. As a refresher, remind them that willingness is the skill of engaging in valued behavior, no matter what impact it has on one’s thoughts and feelings. By accepting a reduction in comfort (e.g., reduced sedentary time) or a temporary increase in discomfort (e.g., getting tired or sweaty while exercising), we become flexible enough to choose behavior that is consistent with our most important values (such as health). Initiate a brief discussion among group members exploring how willingness applies to physical activity decisions. In addition, help them connect with why they are willing to experience discomfort associated with physical activity (i.e., what are the values they are working toward?). As clients provide examples of willingness, encourage them to consider what more they are willing to accept in order to move toward their values. Can they accept more: Emotions (anxiety about how they appear while exercising, boredom)? ■ Thoughts (about having too much else to do, not being the “type of person” who exercises)? ■ Physical sensations (tiredness, soreness, sweating)? ■

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and can they accept less: Fun and enjoyment (associated with other activities they might prefer over exercise)? ■ Comfort (from sedentariness)? ■

for the sake of what matters most to them in life?

Passengers on the Bus Metaphor The remainder of the session is devoted to leading clients through an experiential exercise called Passengers on the Bus to help illustrate and reinforce the concept of willingness. For this exercise, clients will be asked to imagine themselves as drivers of a bus. They are driving this bus on the highway leading them in the direction of their values. “Passengers” aboard the bus represent uncomfortable internal experiences (thoughts, emotions, physical sensations) that will inevitably arise as clients drive their buses forward toward their values. As with all experiential exercises described in this program, it is crucial that you be engaged and enthusiastic while conducting the experiential exercise. This exercise provides clients with a metaphor that can be applied to uncomfortable internal experiences (which helps them to defuse from thoughts and emotions), which ultimately facilitates increased willingness and sustained behavior change. An example introduction to this exercise might sound something like this: ADAPTING FOR INDIVIDUAL FORMAT The Passengers on the Bus experiential exercise can be completed on an individual basis as well. Have the client act as several different “passengers,” giving many different reasons not to exercise while you are acting as the driver. I would like to take you through a demonstration to help you fully “get” the idea of willingness. Let’s pretend that I am one of you [a client in the program] and I am driving a bus down the highway of life, toward an important life value. Let’s pretend that each of

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you represents different thoughts or feelings that tend to push you toward not engaging in physical activity. Taking turns, for a couple of minutes, I would like everyone to shout out at me (the driver) different thoughts or feelings that I might have that would stop me from exercise. Ask clients to imagine that they are either getting up in the morning or are on their way home from work. They have the intention of exercising and then decide not to do it. Ask for examples of thoughts their minds might tell them—​thoughts that have led them to remain sedentary in the past. What might they be thinking or feeling that could discourage them from exercising? Some example responses include “I’m tired,” “It’s cold and dark outside,” “I don’t feel like exercising,” “The couch would be so much more comfortable,” or “I need my sleep—​I can exercise later.” As clients call out different thoughts, turn around and engage with them (e.g., talk back to them, tell them to be quiet, argue with them, tell them to stop being so loud). As clients continue to repeat their statements, let go of the steering wheel and place your hands over your ears, telling the “passengers” you can’t hear them anymore. Eventually, stand up (getting out of your driver’s seat) and turn around to engage fully with your “passengers.” (At this point, you have stopped your bus and have stopped moving in your valued direction completely.) After about one to two minutes of this exercise, ask clients to discuss their reactions and interpretations of this activity. The following questions may be particularly helpful to spur the discussion: Was the driver able to accept all the thoughts coming from his or her mind?

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Answer: No, because the driver got out of his or her seat, argued with the thoughts, and got side-​tracked by them.

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Was the driver willing to keep driving in his or her chosen, valued direction, despite the thoughts that were coming from the back of the bus (i.e., despite what the driver’s mind was telling him or her)?

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Answer: No. Reiterate to clients, I actually lost control of where I was going a few times, took my hands off of the steering wheel, and eventually stopped driving completely!

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Did the “passengers” disappear or quiet down when the driver tried to shut them out, ignore them, or argue with them?

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Answer: No. In fact, sometimes they even became louder when the driver tried to suppress them or change them.

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Repeat the exercise, but this time indicate that you are going to continue to drive and stay in the driver’s seat, no matter what happens in the back of the bus. After one or two minutes, process the exercise again. What was different this time, particularly with regard to the driver’s willingness to experience uncomfortable internal experiences? Clients can often become confused about the difference between accepting thoughts and feelings and attempting to change or suppress these experiences. Reiterate that you were not ignoring the voices or trying the change them in any way, even though it may have looked like that. To address this, a statement like this can be helpful: I definitely heard your voices, and sometimes it was uncomfortable and discouraging. In fact, you really annoyed me, and it was unpleasant. I  couldn’t pretend that you guys weren’t there, even if I wanted to and tried very hard. Ask clients what it would mean in their own lives to be driving a bus with their own passengers on board. Explicitly relate driving the bus with physical activity, and ask clients to imagine how this metaphor might play out if each of them were in the driver’s seat. As time allows, elicit examples from clients of what their “passengers” might say to them and what behaviors they would need to enact to practice willingness, even if those passengers never quieted down. For example, you might say something like this to clients: You are driving down the highway of healthy eating and an active life, and on the bus are these passengers (urges for pleasure, wanting more, desire to stay at rest). We are suggesting that—​if you are willing—​you can let them be, accept them, and continue to drive

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toward an active life. We do not know of a magic bullet that can get rid of these passengers. If you wait to start your journey until your bus is cleared out of these passengers, you will never even begin. What would it be like to refocus attention and energy on your goal rather than engaging and struggling with the distressing thoughts/​ feelings? Keeping values in mind and using them to make decisions (i.e., every decision as an “up” or “ down” vote) will foster willingness and will lead to healthier eating and physical activity choices. If you can move forward with these types of thoughts/​feelings present, then you have the choice whether to eat/​what to eat/​when to eat/​to exercise. Thoughts and feelings, no matter how distressing, cannot make you do anything!

Barriers to Being Active (10 Min.) The discussion of valued action can serve as a good transition to a discussion of why clients are committing to maintaining high levels of physical activity each week. Ask clients to identify their valued reasons for engaging in physical activity. Clients will likely review the mood-​ boosting and cardiovascular benefits of exercise. In addition, remind clients that the weight control benefit of physical activity is most pronounced during weight loss maintenance. Individuals who engage in a very high level of physical activity after six months of active weight loss (i.e., where clients are right now in the program) are the most likely to avoid regaining the weight that they will have lost by that point. High levels of physical activity can be difficult for clients to maintain in the long term for a variety of reasons. These can include environmental/​logistical factors (weather, the gym being closed during certain hours), as well as internal factors (thoughts, feelings, bodily sensations). Encourage clients to take a “control what you can, accept what you can’t” approach to these different barriers. For external and environmental factors, clients are encouraged to exert as much control as possible and to practice flexibility. If their most preferred mode of physical activity is unavailable to them (e.g., the gym is closed on a night they had to work late), they can opt for another strategy and still fit in the 159

Table 18-1  Psychological Strategies to Overcome Barriers to Physical Activity Common Perceived Barrier

Suggested Response to Clients

Behavioral or Acceptance-​Based Strategy

Feeling self-​ conscious about weight and being seen by others while exercising

Once clients start exercising, the anxiety about being seen by others will decrease. Most other exercisers are focusing on their own activity, not judging others.

Defusion: “I’m having the thought/​feeling that other people are looking at me or judging me.”

Feeling physically uncomfortable during exercise (e.g., short of breath, sore, sweating)

Brisk walking is an ideal way to increase fitness and, for many clients, experience less physical discomfort. The gradual increase in exercise prescribed in this program also is designed to minimize physical discomfort.

Willingness: “I am going to keep walking even if my legs feel tired or I’m out of breath.”

Not being in the mood or having the energy to exercise

Ask clients to discuss what happens to their mood and energy level when they exercise. Most will say it usually improves or that their anticipation of what physical activity will be like is much worse than it actually turns out to be.

Acceptance: “My mood may or may not improve, but I can’t control that. I’m willing to accept either emotion.”

Weather (raining, too hot, too cold, etc.)

Ask clients how they have dealt with inclement weather previously, including walking in a mall.

Willingness: Change “but” to “and” by saying, “I am leaving for my walk now, and I’m going to get wet.”

Time: not enough time to fit in a full 30-​ to 45-​minute workout

Every bit of activity helps. Clients should grab 10 minutes of exercise whenever they can.

Be flexible with values: balancing multiple values (work, family, health, etc.) requires compromise. Consider spending quality time with family members by going for a walk together.

Values: Make every decision an “up” or “down” vote on a value.

exercise (e.g., complete an exercise video at home that day). Focus this discussion on the psychological barriers to being physically active (or clients’ “Passengers on the Bus”). Invite clients to discuss barriers to being physically active that they already are facing or that they anticipate facing as activity goals continue 160

to increase and as they attempt to sustain that level of activity during long-​term weight maintenance. What has gotten in the way of physical activity in the past? Problem-​solve with behavioral and acceptance-​ based strategies where appropriate. Table 18-1: Psychological Strategies to Overcome Barriers to Physical Activity provides an overview of common barriers and potential strategies. For all barriers, attending to the short-​term costs of physical activity, rather than to the long-​term benefits, can lead to reduced physical activity and increases in values-​ inconsistent behaviors (staying in bed, watching TV, etc.). It is crucial that clients override their natural inclination to remain sedentary and engage their long-​term mind in the decision-​making process. For homework, clients should continue considering their personal barriers to being physically active and complete the Overcoming Barriers to Physical Activity Worksheet (Worksheet 18-​1). Clinician’s Note Some clients may also report disliking exercise because sweating can wreak havoc on their hairstyles. Adopting brisk walking as the primary form of activity is a good solution to this, because it can minimize the amount of sweating that occurs. It also may help to wear a bandana made of a wicking fabric around the neck (i.e., a cool cloth).

Skill Builder (5 Min.) Direct clients to p. 109 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity: Exercise (e.g., brisk walking) for 40 minutes × 5  days (which is an increase from last session). Record type and minutes on your Keeping Track Form. □ Behavior: Complete your Weekly Review sheet (Appendix D) in the off-​week between now and the next session. Work on the behavioral goal that you identified during today’s session. □ Calories: Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. 161

□ Days Recorded: Record every day. □ Experiential Exercise: Complete the Overcoming Barriers to Physical Activity Worksheet (Worksheet 18-​1). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories) and Home Weight Change Record.

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CHAPTER 19

Session 19: Committed Action

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Introduction to Committed Action (10 Min.)

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Strategies for Committed Action (10 Min.)

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Stand and Commit (10 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 19-​1: Committed Action

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Enough copies of the Keeping Track Form (Appendix A) so every client can record each week until the next session ■ Enough copies of the Weekly Review form (Appendix D) so every client can complete one form each week until the next session ■

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. Specifically check in regarding clients’ experiences with utilizing both psychological and behavioral strategies to meet program goals. As time allows, ask some clients to share what strategies have been the most helpful for meeting program goals. Clinician’s Note Optional: If time allows, check in with clients who set personal behavioral goals during the previous session’s ABCDE Check-In to follow-​up on their progress.

Skill Review (10 Min.) Review the concept of willingness—​the skill of engaging in valued behavior no matter what the effect on one’s thoughts and feelings. This can be done by asking clients to recall the definition of willingness as they remember it from the previous week and filling in the gaps as necessary. Recall the Passengers on the Bus metaphor by asking one or two clients to (a) describe the metaphor and (b) clarify how the metaphor illustrates willingness and applies to physical activity. Clients can also be referred back to the material from Session 18 in the Client Workbook. Review barriers to physical activity. Elicit discussion of clients’ experiences with identifying barriers and using behavioral and/​or psychological strategies to overcome those barriers by prompting them to share responses on Worksheet 18-​1:  Overcoming Barriers to Physical Activity. Be sure to highlight the myriad of different physical activity barriers (e.g., feeling self-​c onscious, feeling physically uncomfortable during exercise, not being in the mood or not having the energy to exercise, weather, time, hair care), how both behavioral and willingness skills can help to overcome these barriers, and the importance of engaging in the long-​term mind rather than the short-​term mind. At the end of the Skill Review, collect Worksheet 18-​1.

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Introduction to Committed Action (10 Min.) Preface this section by validating that clients have worked very hard thus far in the program to establish healthy patterns of eating and exercise behavior. However, as many clients have discovered from past attempts to lose weight, maintaining healthy lifestyle changes will take just as much effort. Emphasize that many of the remaining sessions of the program will focus on skills for maintaining the important diet and physical activity changes that clients have made. Clients should be aware of the realities of long-​term weight control. Although we are providing them with all of the skills necessary to succeed, there are still challenges to maintaining new behaviors. Begin a discussion by asking clients to identify why maintaining a healthy lifestyle will be challenging. Be sure to emphasize two key challenges through their responses. First, motivation often declines over time. It is often the case that maintaining weight loss will feel less “rewarding” than actively losing weight. When the number on the scale plateaus, clients may find that they feel the daily hassles of adhering to diet and physical activity recommendations are no longer worth it. During this time, it is easy to lose sight of values (e.g., longevity, health, acting as a role model) that can make these behaviors more rewarding. ■ Second, there are many factors that influence eating and exercise behaviors (e.g., support from others, stress, optimism, mood, cravings). These factors are not always within the clients’ control and are likely to ebb and flow over time. It is important to acknowledge that clients cannot count on these factors always being at the “ideal” level for them to easily meet their goals. If applicable to the discussion, refer back to Session 5, in which clients learned that eating/​exercise change would never happen if they waited for the perfect conditions. ■

Introduce the notion of committed action, which is the act of maintaining behavior, regardless of how easy or hard it is. Ask clients to share personal examples of how they are already engaging in committed action. As clients share examples, reinforce that they are engaging in behaviors that they have identified as important for weight control, despite

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any challenges that arise. If necessary, you can supplement with other examples such as: You walk every morning before work. Now that the weather has changed, it feels harder to go. To engage in committed action means that you go for your morning walk regardless of the weather changing. You’ve been eating fruit –​and only fruit–​for your afternoon snack at work every day. Today is, once again, a coworker’s birthday. Your coworkers, who used to be supportive of you skipping cake, say “Come on, you’ve passed up on the cake so many times, you’ve lost so much weight, having cake today won’t kill you.” Committed action means still choosing not to eat any birthday cake today. You’ve been cooking yourself a healthy breakfast every morning, Today, you just feel like you do not have the energy, and you are craving Dunkin’ Donuts instead. Committed action means eating your usual healthy breakfast despite these cravings. Another way to think about committed action is to compare clients to hikers on a path. For hikers, it is very important to stay on course even when it may be difficult to see the big picture. Similarly, it is important for clients to maintain diet and exercise changes even when it feels difficult to see their progress. You may describe this metaphor as follows: On the path up the weight loss mountain, you might be convinced that you are never going to get to the top. Hiking up a mountain can involve hard work that does not always seem to be paying off, and there will be times when trees or foggy weather block your view of where you are going. However, a person across the valley with binoculars can see that you are going in precisely the right direction. Committed action is staying the course even when you cannot easily see the progress that you are making. Clients should be training themselves to recognize that success is defined by the behavior of putting one foot in front of the other and propelling oneself forward. In other words, success should not simply be defined by a number on the scale or a daily calorie goal. Rather, clients should start to view the ability to persist in the face of inevitable challenges (e.g., motivation decreasing, being exposed to additional food temptations while on a trip) and uncertainties (e.g., unsure how to measure progress) that come with long-​term weight control. To return to the metaphor of the

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hikers, success is not defined by arrival at the top of the mountain. As clients have identified earlier in the program (Session 7), the value of achieving a healthy lifestyle has no “end point” or “arrival.” To continue to illustrate the importance of committed action with clients, you can use another metaphor that is related to the hikers on a path. You may describe this metaphor as follows: Imagine you are a hiker, and you walking on a path that is covered with large rocks. If you stop each time you encounter the rocks, then you will not make progress down the path. If you look for a different path around the rocks, then your progress forward may be slowed significantly. Committed action means that you walk or climb over the rocks and continue on the path no matter how difficult it may become. Tie the metaphors together by summarizing and discussing the commonalities. In both instances, hikers are facing uncertainties and challenges on their paths up the mountain. However, if they waited for these uncertainties and challenges to clear, then they would not make any progress. Clients should understand that, just like the hikers, they will face challenges and uncertainties related to weight control. However, success (through committed action) is measured by propelling forward regardless of imperfect conditions. Clinician’s Note Optional: Combine both metaphors by incorporating the “rocky path” into the first metaphor. The rocky path can be referred to as another barrier (in addition to fog and trees) that may deter the hiker from staying the course.

Strategies for Committed Action (10 Min.) Ask clients to consider what strategies they have used thus far in the program to ensure that they are engaging in committed action. Refer clients to Table 19-​1 (p. 113) in their workbook to review helpful methods of maintaining committed action. One strategy for committed action is to remind ourselves to take responsibility for our actions. It is important that

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clients understand that they are “response-​able.” This means that they are able to respond to situations in which it may be difficult to maintain healthy lifestyle changes. Clients should understand that the concept of being “response-​able” means that they have the freedom of choice and power to choose how to respond and how to behave. If helpful, remind clients that they have already learned this skill, and refer back to Session 12 in which they learned to uncouple their behaviors from thoughts/​feelings. This concept should not be interpreted as playing the blame game, but rather that clients are empowering themselves by freely choosing to maintain the changes that they have made throughout the program even when conditions are not always ideal. Additionally, clients should be instructed to use language (with both themselves and others) that is consistent with the message of “response-​ability.” Inserting the phrase, “I am the person who . . .” is one example of using language to remind clients that they are the ones with the power to make their own choices. Provide clients with some examples, such as, “I am the person who decided to lose weight. I am the person who stuck with my calorie goal for the past 11 days. I am the person who has been keeping track of my calorie intake since I started this program.” Another strategy for engaging in committed action is to write goals down and place them in visible places. Clients will find that they have different preferred techniques for this strategy. For instance, some may record goals on notecards, while others may choose to write on their Keeping Track Forms. Allow clients to be creative with this strategy. Other examples include saving a goal as their computer background or screensaver, using the background on their mobile phone, using a picture that is somewhere visible (e.g., nightstand, refrigerator, dressing mirror), writing on their bathroom mirror, keeping a note in their cars, or keeping a measuring spoon in their purses. Instruct clients to periodically switch the location, wording, color, content, and so on of the goal so that the reminder stays prominent and visible (e.g., they do not automatically overlook it). Ask a few clients to share what they might write and where they might place it. A similar strategy for committed action is to share short-​term goals and long-​term values with others who will hold the client accountable. At this stage, many clients will have expressed concerns regarding the shift in accountability to themselves (rather than the program or clinicians).

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By sharing goals with others, clients will find that they can create a more sustainable source of accountability. Furthermore, committing to others will provide clients with another source of motivation when it becomes more difficult to see progress. Ask clients what they might share and with whom.

Stand and Commit (10 Min.)

ADAPTING FOR INDIVIDUAL FORMAT In individual sessions, you and your client may work together to plan out how the client can make a public commitment to someone that he or she trusts. The plan to publically commit, as well as the commitment itself, should be very specific and detailed. For example, “Tomorrow, when I pick my sister up from work, I will share with her my commitment to go for a 30-​minute walk each day at lunch.” One way that clients can stay committed to the behaviors that they care about is to announce them out loud to the group. After all, the group has become a significant source of support and accountability over the past months. Ask each client to prepare to make a commitment to a specific weight control behavior and share it with the group. Provide specific guidelines for choosing a behavior. First, tell them to think of a behavior that is key to weight control success and that also requires mindfulness and commitment. Clients should be specific about the commitment (e.g., what, when, how many times, where). They should choose a commitment that is not easy, but that they are also fairly confident they can honor. Provide clients with a few examples, such as: I will complete my Keeping Track Form every day until the program is over. I commit to keeping fruit in the house and unhealthy snacks out of it. I commit to waking up at 6:30 am and taking a 45-​minute walk every day. I commit to weighing myself every week even when I do not want to see the number on the scale.

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Answer any remaining questions about the exercise, and instruct clients to write down their commitment in the Client Workbook on pp. 113– 114. Ask clients, one by one, to stand and make their commitments to the group. Inform clients that, as a part of the exercise, you will also be recording each of their commitments and checking in with them in a couple of sessions. Remind them that several strategies for keeping these commitments were just reviewed, and they should attempt to employ these strategies over the next couple weeks. Let clients know they should complete the Committed Action Worksheet (Worksheet 19-​1) as part of their Skill Builder to list their commitments for the next few weeks, as well as potential challenges they anticipate and strategies that can help them stay committed. Let clients know that when you check in about whether they were able to stay committed you will also inquire about their use of strategies for committed action. Clinician’s Note If necessary, gently probe each client who is not following the guidelines for choosing a commitment. For instance, if a client is not specific enough, ask him or her questions such as, “When will you do this?” or “Where will you do this?” Alternatively, if a client chooses a behavior that seems too difficult to honor, ask questions such as, “Does this seem feasible to you?” or “How different is this from what you have been doing?” Record and save all commitments for use during Session 22, when commitments should be publically displayed on poster board with the clients’ names and corresponding commitment in text large enough to see from a distance.

Skill Builder (5 Min.) Direct clients to p. 114 in their workbooks, which outlines the following Skill Builder for the coming weeks: □ Activity:  Exercise (e.g., brisk walking) for 40 minutes × 5  days. Record type and minutes on your Keeping Track Form.

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□ Behavior: Carry out the behavior you committed to during “Stand and Commit” (which you recorded earlier). Complete your Weekly Review sheet (Appendix D) in the off-​week(s) between now and the next session. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: Complete the Committed Action Worksheet (Worksheet 19-​1). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories) and Home Weight Change Record.

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CHAPTER 20

Session 20: Overeating and Emotional Eating

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Preventing Overeating Episodes (10 Min.)

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Emotional Eating (20 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 20-​1: Identifying Triggers of Overeating ■ Worksheet 20-​2: Rate Your Emotional Eating ■ Worksheet 20-​3: Healthy Behaviors I Will Choose in Response to Difficult Emotions ■ Worksheet 20-​4: Putting It Into Action ■

Enough copies of the Keeping Track Form (Appendix A) so every client can record each week until the next session ■ Enough copies of the Weekly Review Form (Appendix D) so every client can complete one form each week until the next session ■

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. Briefly check in regarding clients’ experiences with utilizing both psychological and behavioral strategies to continue the behavior that they committed to during the “stand and commit” exercise during the previous session. As time allows, ask some clients to share what strategies have been the most helpful for facilitating engagement in committed action. Remind clients that you will formally check in with everyone about their “Stand and Commit” behavior again in a couple of weeks. Clinician’s Note Optional: If time allows, check in with clients who set personal behavioral goals during the previous session’s ABCDE Check-In to follow-​up on progress.

Skill Review (10 Min.) Review the concept of committed action—​that is, the act of maintaining a valued behavior, regardless of how easy or hard it is. Ask clients to recall the definition of committed action as they remember it from the previous week, and fill in the gaps as necessary. Recall the hikers on a path/​Rocky Path metaphors by asking one or two clients to (a) describe the metaphors and (b) clarify how the metaphors illustrate committed action and apply to weight control (both eating and physical activity behaviors). Clients should be reminded that success, within the program model, may seem different from how they have defined it in prior weight loss attempts. That is, success is not defined by arrival at the “top of the mountain.” A healthy lifestyle has no “end point” or “arrival.” Rather, success can be measured by continuing to move forward, regardless of the inevitable challenges and uncertainties that come with long-​term weight control. Review the strategies for committed action. Elicit discussion of clients’ experiences with choosing a behavior to which to commit. Discuss

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psychological strategies for committed action by prompting clients to share responses on the Committed Action Worksheet (Worksheet 19-​ 1). Be sure to highlight the different strategies for committed action covered in the previous session. Recall such strategies as: Becoming “response-​able” ■ Using language that reminds us of response-​ability (e.g., “I am the person who . . .”) ■ Creating visual reminders of goals/​commitments ■ Sharing goals with others ■ Publically making commitments ■

At the end of the Skill Review, collect the Committed Action Worksheets.

Preventing Overeating Episodes (10 Min.) Begin this section by orienting clients to the definition of overeating episodes. For the purposes of this program, overeating episodes are characterized by eating more in one siting than one intends to. Ask clients why preventing overeating episodes may be critical for long-​term weight control. Clients should come to the conclusion that successive overeating episodes will ultimately jeopardize their calorie balance, which could lead to weight gains. Ask clients to indicate what strategies they have found helpful for preventing overeating episodes. Supplement responses with the strategies listed on Table 20-​1 (see p. 118 in the Client Workbook). Emphasize that these strategies are behavioral or “control what you can” methods of preventing overeating. First, clients should engineer their environments. This means controlling the availability of food in places where they commonly spend time (e.g., home, work, car) by continually removing high-​calorie or tempting items from these locations. Emphasize that this may be a continuous process because (given our obesogenic environment) high-​calorie foods often creep back into our environments over time.

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If needed, refer to C ­ hapter 5 to review the concept of the obesogenic environment and strategies to control the home environment. ■ Second, clients should use portion control. Portion control strategies include avoiding eating directly from a large container or family-​ style, pre-​portioning foods immediately after purchase, and placing leftovers in the refrigerator before eating a meal. Portion control lessens mindless eating and will help clients make more mindful decisions about whether to consume more food. ■ Third, clients should follow a regular eating schedule to avoid intense hunger that will undermine conscious control over eating behavior. ■ Last, clients should attempt to identify their personal triggers of overeating to understand more about what factors puts them at risk and then target those risk factors. Clinician’s Note Optional: If time allows, ask clients to share personal examples of how they will (or already do) use any of the previously discussed strategies to prevent overeating. Direct clients to the Identifying Triggers of Overeating Worksheet (Worksheet 20-​1). Clients will be completing this worksheet for their homework. Note that the worksheet will ask about specific situations, times, events, and emotions that typically trigger overeating. Emphasize that this worksheet will assist clients in “taking inventory” of their specific triggers. Once clients complete the worksheet, they will have a greater knowledge about where and how they can intervene to prevent overeating. For example, if a client notices that he typically overeats in the evening while watching TV, then he might choose to do something else with his time in the evening or portion control the food that he consumes while watching TV. Emphasize that the triggers for overeating, as well as the preferred strategy to target such triggers, are individual and will look different for each client. Answer any questions regarding this worksheet before moving to the next session.

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Clinician’s Note Optional: If time allows, begin a preliminary discussion of client reactions to the questions listed on the worksheet.

Emotional Eating (20 Min.) Ask clients if they have ever had the experience of eating in response to an emotion (e.g., sadness, happiness, anger, boredom). When we use eating as a way to cope with emotions, we call this emotional eating. Explain that many people find that eating distracts from and/​or reduces the intensity of uncomfortable emotions. The brain processes the reduction of discomfort as a reward (much like a drug). Therefore, when a person feels emotional discomfort, the brain seeks out the behavior that has previously “resolved” this issue (i.e., eating). Once this process plays out a few times, eating becomes a learned response to emotion; in other words, eating in response to emotions becomes a habit. Thus, clients who endorse emotional eating will be able to recognize a pattern in which they experience a strong (seemingly unconscious) desire to eat whenever they experience emotional discomfort. Direct clients to Figure 20-​1 in their workbooks (p. 119) for an illustration of the reinforcement cycle of emotional eating. Clinician’s Note Often clients will endorse eating in response to boredom. While boredom is not universally perceived as distressing, it is uncomfortable enough that people use eating as a solution or to fill a void out of habit. An additional subset of clients may endorse eating in response to happiness, which does not quite fit into the model of using eating as a method to cope with “ distressing” feelings. Acknowledge that though this may feel different, it is still eating habitually in response to a feeling (maybe even to prolong that happiness). If clients do raise either of these issues, quickly clarify and move through the rest of the session material for the sake of time.

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Ask clients to consider how effective emotional eating is as a way of coping with sadness, anger, stress, boredom, happiness, or other types of emotions by taking a moment to answer the prompts in the “Emotional Eating” section in the Client Workbook (pp. 118–123). As a group, ask clients to share their experiences. Prompt them to consider if eating provides them with “relief” from emotions, and, if so, how long the relief lasts. Ask clients to reflect on the effect that emotional eating has on how they feel about themselves and their weight control. During this discussion clients should conclude that the relief experienced by eating is usually short-​lived (sometimes only lasting for mere seconds). However, there are long-​term costs to emotional eating. Often clients will report that these types of eating episodes make them feel guilty, shameful, frustrated, or hopeless about the process of weight control. Furthermore, emotional eating may jeopardize their abilities to meet calorie goals, which can lead to weight gain. Clients should also conclude that eating in response to emotions usually does not resolve the issue and can sometimes compound the problem. For example, a client is upset because he just had an argument with a friend and subsequently decides to eat a bag of potato chips to feel better. In this example, not only will this client have gone over his calorie goal for the day and feel angry/​upset at himself, but the underlying problem (the fight with the friend) is still not resolved. Validate that this can be a frustrating experience for clients who have reinforced this habit for a long time, especially because they are clearly able to identify the drawbacks of emotional eating (yet engage in it anyway). If emotional eating is a habit, however, then that means it can be broken (much like many of the other unhealthy eating and physical activity habits that clients have already tackled). You should emphasize the good news that clients already have the skills to break bad habits, and these can be applied to emotional eating as well. Direct clients to Table 20-​2 on p. 121 in the Client Workbook. Generally, clients should be able to follow the steps outlined in this table to practice breaking the habit of emotional eating and replacing it with new ways of responding to emotions. The first step is to practice awareness and nonjudgmental acceptance. Clients can begin this process by naming and describing the emotion(s) that they are experiencing. Instruct clients to use the Rate Your

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Emotional Eating Worksheet (Worksheet 20-​2) to enhance their awareness of emotions that will lead to urges to eat. Next, they should notice what triggered (or came just before) the emotion and the function that the emotion serves. Clarify that emotions are adaptive and serve an important purpose (e.g., they often “tell” us something about ourselves or the world). For example, when people experience a loss, they might feel sad. Alternatively, if someone were to anticipate something negative happening in the near future, she might feel anxious. Identifying the function of an emotion can be helpful for embracing an accepting stance toward emotions. Clients should practice adopting a welcoming stance toward emotions of every kind. Rather than judging emotions as good or bad, they should just notice them for what they are (e.g., serving a function) and as a part of that moment’s existence. Emphasize that this will likely be a very different attitude toward emotions than many clients have previously held. Because this is a new concept, clients may have to be continuously aware of their judgments regarding their emotional experiences. They may have to repeatedly remind themselves to treat their emotions as simply existing and be open to accepting them without judgment. Note that when we refer to an “acceptance” we are not referring to an acceptance of the situation (e.g., just accept what is happening to you because you are helpless). Rather, we are referring to the acceptance of the human experience, of which emotions are an important part. Along this vein, it can be helpful for clients to remind themselves that there is nothing truly dangerous or threatening about emotions and that they are a normal part of being human and of being fully alive. The next step is to practice uncoupling emotion and action. As discussed, once an emotion is followed by eating a few times, a particular emotion will automatically trigger an impulse to eat. However, that does not mean that clients need to follow through with the impulse to eat. Recall (from Session 13) that the human mind is constantly offering up observations, urges, thoughts, and feelings. Thus, impulses to eat in response to emotions are simply the mind doing its job. This does not mean that clients’ actions need to follow suit. It is possible for clients to feel a difficult emotion and to still adhere to a healthy diet.

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Last, clients should choose a new behavior that they can purposefully engage in, in response to emotions. This new behavior should be more adaptive and should not conflict with client-​held values (e.g., health, longevity). Depending on the situation, the new behavior that clients choose can take several forms. First, clients should consider whether the emotion is letting them know about a problem that is solvable. If clients can link their emotions directly to a problem that is within their control, then they should take steps to actively make the situation better. However, not all emotions occur in response to solvable problems. Clients will likely find themselves in situations where there is not an immediate solution, and it may be more appropriate to choose an alternative behavior that they consider an adaptive, healthy response. Refer clients to Table 20-​3 on p. 122 of the workbook for a list of both activating and soothing activities that may be considered as alternatives to eating in response to emotions. Instruct clients to use Table 20-​3 to complete the Healthy Behaviors I Will Choose in Response to Difficult Emotions Worksheet (Worksheet 20-​3). Completing this worksheet will allow clients to identify, in advance, what deliberate actions they will take when experiencing difficult emotions. Clients should understand that eating in response to emotions feels good because it is a practiced behavior. For any deliberate action that they choose, they will need to repeatedly practice engaging in that new behavior in response to emotions. These deliberate actions are not designed to change emotions (remember, we cannot control internal experiences). Instead they are designed to replace an old habit (e.g., eating) with behavior that is better aligned with values. Changing habits in this manner is consistent with the program philosophy of “control what you can” (e.g., choose a deliberate action instead of eating) and “accept what you can’t” (e.g., understand that you cannot control emotions regardless of what action you choose). In this respect, clients should not expect to modify an internal experience. Recall that emotions fall into the category of experiences that individuals cannot change and therefore call for “acceptance.” Thus, for the most part, clients should adopt an accepting stance of whatever they experience, be it no change at all, a little change, or a big change in emotions. Instruct clients to use this as an opportunity to practice flexibility by choosing the deliberate action no matter how much they would like to 180

engage in a habitual response (eating). Prompt clients to also practice willingness by accepting whatever emotions they are experiencing in that moment and not wishing that they felt differently than they do. The best guideline to follow in these instances is to choose activities that are adaptive and/​or healthy (not activities that one hopes will alter one’s internal experiences). Alternative activities should (a) have value to the client, (b)  help them to accomplish something, or (c)  be fun. Instruct clients to use the Putting It Into Action Worksheet (Worksheet 20-​4) to record instances throughout the next two weeks in which they were aware of an emotion and responded in either an adaptive (through deliberate action) or nonadaptive (through eating) way. You can summarize with the following: Using the steps that we covered today in session, the man in our example could develop new responses to his feelings that do not jeopardize his weight loss goals. He would develop emotional acceptance skills by naming the emotion of sadness and recognizing that the idea of potentially losing a friend is making him feel sad. He might notice that he has the urge to push away, or get rid, of his sadness, because it is a “bad” emotion. Instead, he would practice adopting a welcoming stance toward his sadness, and remind himself that there is nothing dangerous about being sad and that it actually makes him human. As he notices his sadness and urges to eat in response to feeling sad, he would uncouple his emotions and actions through statements such as, “I can feel sad and still adhere to my eating plan for the day.” Last, he would choose a new behavior. He might choose to apologize or resolve the issue with his friend (if it is easily solvable), or he might choose to go for a walk, listen to music, or do some chores around the house (instead of eat). Over time, he will learn more adaptive responses to his emotions that are also consistent with his values.

Skill Builder (5 Min.) Direct clients to p. 123 in their workbooks, which outlines the following Skill Builder for the coming weeks: □ Activity: Exercise (e.g., brisk walking) for 45 minutes × 5 days (which is an increase from last session). Record type and minutes on your Keeping Track Form. 181

□ Behavior: Complete the Identifying Triggers of Overeating Worksheet (Worksheet 20-​1) and the Rate Your Emotional Eating Worksheet (Worksheet 20-​2). Complete your Weekly Review sheet (Appendix D) in the off-​week(s) between now and the next session. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise:  Complete the Healthy Behaviors I  Will Choose in Response to Difficult Emotions Worksheet (Worksheet 20-​3) and the Putting It Into Action Worksheet (Worksheet 20-​4). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories) and Home Weight Change Record.

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CHAPTER 21

Session 21: Lapse Versus Relapse and Reversing Small Weight Gains

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Lapse Versus Relapse (15 Min.)

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Preventing and Reversing Small Weight Gains (15 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 21-​1: High-​R isk Situations ■ Worksheet 21-​ 2:  My Behavioral Action Plan for High-​R isk Situations ■ Worksheet 21-​ 3: My Psychological Action Plan for High-​R isk Situations ■ Worksheet 21-​4: My Plan for Reversing a Small Weight Gain ■ Session 21 Skill Builder, Session 22 ABCDE Check-​In ■

Enough copies of the Keeping Track Form (Appendix A) so every client can record each week until the next session

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Enough copies of the Weekly Review Form (Appendix D) so every client can complete one form each week until the next session ■ Enough copies of the Home Weight Change Record (Appendix C) so every client has one to practice creating his or her “Red Zone” graph or table (whichever is preferred) ■

ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. Specifically check in regarding clients’ experiences with utilizing both psychological and behavioral strategies to meet program goals. As time allows, ask some clients to share what strategies have been the most helpful for preventing overeating or emotional eating episodes. Remind clients that next week you will be checking in regarding their “stand and commit” behavioral goals. Clinician’s Note If time allows, check in with clients who set personal behavioral goals during the previous session’s ABCDE Check-In to follow-​up on progress.

Skill Review (10 Min.) Review the concept of preventing overeating episodes. For instance, you can ask clients to reflect on why it is important to prevent such episodes. Clients should conclude that overeating episodes can put one at risk for going over calorie goals and therefore cause weight gain. Ask clients to share which strategies they used to prevent overeating episodes, and fill in the gaps as necessary. Be sure to remind clients that strategies such as engineering one’s environment, implementing portion control, following a regular schedule of eating, and identifying triggers can be particularly helpful for preventing overeating.

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Review emotional eating. Remind clients that emotional eating can become a habit, as it is a learned response to emotion. That is, the brain recognizes eating to be rewarding and is therefore more likely to keep seeking food in response to emotions. Ask clients to reflect on both the short-​term and long-​term effects of emotional eating (e.g., How long does the relief last? What effect does it have on weight control?). Clients should be developing new ways of responding to emotions. Recall the steps outlined in Session 20: ■ ■ ■ ■ ■ ■

Practicing awareness and nonjudgmental acceptance Naming the emotion Noticing what triggered the emotion Adopting a welcoming and nonjudgmental stance toward emotions Uncoupling emotion and action Choosing a new behavior

Ask clients to share with the group their own experiences with developing new responses to emotions. Problem-​solve any issues that may arise. At the end of the Skill Review, collect the Healthy Behaviors I  Will Choose in Response to Difficult Emotions Worksheet (Worksheet 20-​ 3) and the Putting It Into Action Worksheet (Worksheet 20- ​4).

Lapse Versus Relapse (15 Min.) Prompt clients to discuss (a) any previous successes that they may have had with short-​term weight loss and (b)  any fears they might have about regain of their current weight losses. You should validate client concerns while also reassuring clients that the program is specifically designed to teach them skills to prevent weight regain in the long term. In other words, clients will learn skills to prevent lapses from turning into relapses. A lapse is a single event that is relatively easy to change or reverse, while a relapse is a bigger sequence of events (or string of lapses) that requires more effort to reverse. Sometimes it can be helpful to provide a non-​weight-​related example, such as cigarette smoking. In this case, a lapse would mean smoking one cigarette and then getting back on track. A relapse, on the other hand, might involve smoking an additional cigarette each day until one is back to smoking one pack

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per day. Weight loss is a difficult and extended process, and because of this we expect everyone to experience lapses at some point. Lapses are a part of the process and do not necessarily indicate failure but merely a deviation from one’s plan for the day. However, the ultimate goal clients will set for themselves is to not allow a lapse to become a relapse. This can be done by (a) identifying the lapse, (b) determining the cause of the lapse, and (c) learning from the lapse. Review these steps in more detail. Clients should use two methods of identifying lapses. The first is developing a heightened awareness of behavioral signs. For example, clients should notice when they stopped engaging in a known weight control behavior (e.g., walking, self-​monitoring, menu planning, food logging, weighing, or low-​c alorie eating). These episodes are considered lapses because they are unplanned deviations from the program and will likely contribute to weight gain in the future. When determining if a specific behavior is a lapse, a good rule of thumb is to ask oneself, “If I kept doing this each day for a month, would I gain weight?” The second technique for identifying a lapse is noticing a small weight gain (which will be discussed later in session). When attempting to determine a cause of a lapse, there are several factors to consider. Ask clients to consider what types of causes might lead (or have already led) to lapses for them personally. Supplement the discussion with information regarding the proximal, distal, and psychological causes of lapses. Refer clients to Table 21-​1: Factors Affecting Lapses in their workbooks: A proximal cause can be defined as an event that immediately precedes the lapse. Examples of proximal causes are reduced Keeping Track Form logging, reduced menu planning, reduced physical activity, lowered motivation, change in mood, or skipping program sessions. ■ A distal cause can be defined as triggers that are not directly related to weight control, but make weight control efforts easier or more difficult. Examples of distal causes are stressful life circumstances, conflict in relationships, loss or setback, weather, or a holiday weekend. ■

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If clients did not discuss the possible psychological causes of lapses, ask them to consider what psychological factors could contribute to lapsing. Several causes should be highlighted: One psychological cause for lapses could be making mindless eating and activity choices. Clients should be careful to always be mindful of their actions and to make every decision deliberately. When indicated, make the decision an “up” or “down” vote on their values. ■ Lowered commitment and motivation can also lead to lapses. Lowered commitment can be a result of not keeping one’s values in mind or having a lack of values clarity altogether. ■ Lapses can result from a difficulty in accepting and defusing from various distressing internal experiences related to weight control. For example, at times clients may have difficulty with experiencing a loss of pleasure, food cravings, strong emotions (e.g., sadness, boredom), or thoughts (e.g., “one cookie won’t hurt me”). ■

These situations will likely lead to lapses if clients allow their internal experiences, not their healthy values, to guide their decisions to eat. Once the cause(s) of the lapse have been determined, clients should use that information to identify high-​risk situations for the future. It is possible for high-​risk situations to be either positive or negative experiences, depending on the individual. Some examples could be social situations (e.g., parties, social conflict), breaks in routine (e.g., vacation, busy time at work), emotions (e.g., celebrating, feeling overwhelmed), physical states (e.g., fatigue), or temptations (e.g., someone gives you a box of chocolates). Ask clients to consider what high-​risk situations may be particularly relevant for them using the High-​R isk Situation Worksheet (Worksheet 21-​1). Once risks have been identified, it is important to develop a plan for use in such situations. Part of successful weight management is having a plan to prevent high-​risk situations from becoming lapses. For their Skill Builder, clients will create both behavioral (e.g., control what you can strategies) and psychological (e.g., accept what you can’t strategies) actions for high-​risk situations using Worksheets 21-​2 and 21-​3. The plans should involve taking action to change the situation, clients’ approach to their thoughts, and/​ or clients’ behaviors. These actions should also be specific and detailed so that clients are likely to follow them when in the middle of a high-​ risk situation. 187

Preventing and Reversing Small Weight Gains (15 Min.) As stated earlier in session, one method of detecting a lapse is recognizing a small weight gain. Preventing and reversing these small weight gains is a principal skill of long-​term weight control. As with overeating episodes, the weight gain itself is not the most important factor—​it is what clients do about it that will determine long-​term success or not. Given that small weight gains result from lapses, clients should expect weight gains as a normal part of weight control and be prepared for them. Because weight gain can be upsetting, it is useful to have a structured plan (developed ahead of time) to follow to help one get back on track. The most critical component of this plan is self-​monitoring of weight. Clients should weigh themselves at least weekly and record their weights (either via graph or table; refer to Appendix C in the Client Workbook). Daily weighing is likely helpful, but more than once daily is discouraged. Recording the weight is essential so that clients can accurately compare their current weight to their previous weight. Otherwise, there could be a tendency to “round down” or guesstimate the comparison, which will likely lead to a failure to detect weight gain until it becomes much larger. Weight gain is of special concern when it reflects a trajectory of increasing weight over time. A  trajectory is used because with only a single instance of weight gain it can be difficult to know how much of the weight change can be explained by changes in behavior and how much can be due to other factors, such as fluid retention. A weight gain of 3 to 5 pounds should be taken seriously before it becomes larger. The weight that is 3 to 5 pounds above clients’ current weights is considered the “Red Zone” weight. Instruct clients to take a moment to write down their current weight and calculate their Red Zone weights. Refer clients to Figure 21-​1 in their workbooks for an example of marking the Red Zone weight. Ask each client to plot his or her current weight on the blank graph provided on Appendix C.  Note that the Red Zone weight will move as clients lose weight. Refer to Figure 21-​2 in the workbook for a depiction of how the Red Zone should move when a client loses more weight. The Red Zone does not move when a client gains weight. If one’s weight

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gain is large enough (e.g., 3 to 5 lbs.) to reach the Red Zone, a plan for reversing small weight gains should be executed. In addition to self-​monitoring of weight, clients’ plans for reversing small weight gains should include some additional strategies that they know to be helpful for weight control. First, plans should incorporate self-​monitoring of intake and physical activity. Typically when individuals are experiencing a small weight gain, self-​monitoring of these behaviors has decreased to some degree. Self-​monitoring of intake and activity is important for providing awareness and information about relevant behaviors. Second, plans should include implementation of key behavioral strategies. Direct clients to Figure 21-​2 in the workbook for behavioral strategies that can be the most helpful for responding to small weight gains. Instruct clients to check off behavioral strategies that they will include in their plans for reversing small weight gains. During times when weight control is not going particularly well, clients should be aware of thoughts and feelings that could lead them to avoid weighing themselves (and therefore miss the chance to reverse a small weight gain). Prompt clients to consider thoughts that they may have (or may have already had) that would make it difficult to step on the scale (e.g., “It’s better not to know my weight”). Ask clients to consider how those thoughts might make them feel (e.g., anxious, guilty). Similar to many other distressing thoughts and feelings that clients have dealt with thus far in the program, clients should decouple from these experiences using defusion strategies (e.g., “I am having the thought that . . .”; changing “but” to “and”). If time allows, ask a few clients to share how they might use defusion strategies to respond to the interfering thoughts described earlier. Furthermore, clients should practice willingness by stepping on the scale (a valued behavior that will move them in the direction of what they ultimately desire) even when they do not want to. If time allows, ask a few clients to share why they might be willing to self-​weigh despite difficult thoughts/​feelings. Refer clients to Table 21-​3 in their workbooks for a review of psychological strategies. For the Skill Builder this week, clients will each make her or his own plan for reversing small weight gains. Refer clients to the My Plan for Reversing a Small Weight Gain Worksheet (Worksheet 21-​4). Instruct clients to include two or three behavioral and psychological strategies

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from Tables  21-​2 and 21-​3 in their plans for reversing small weight gains. Clients’ plans should be specific and sufficiently intensive to reverse small weight gains if and when they occur. For example, a specific and sufficient goal would be to “eliminate restaurant eating entirely for two weeks” rather than “reduce eating out.” Prompt clients to discuss how they might use the psychological strategies in order to achieve their behavioral goals. Returning to the restaurant example, a helpful psychological strategy may involve using willingness to tolerate choosing the less pleasurable option. Emphasize the importance of this exercise even if one is not currently experiencing a small weight gain. In fact, these plans tend to work the best when formulated ahead of time, when an individual is not already in distress because of weight gain.

Skill Builder (5 Min.) Direct clients to pp. 132–133 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 50 minutes × 5  days (which is an increase from last session). Record type and minutes on your Keeping Track Form. □ Behavior: Complete the My Behavioral Action Plan for High-​R isk Situations Worksheet (Worksheet 21-​2) and the My Psychological Action Plan for High-​R isk Situations Worksheet (Worksheet 21-​3). Complete your Weekly Review sheet (Appendix D) in the off-​week(s) between now and the next session. □ Calories: Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: Complete the My Plan for Reversing a Small Weight Gain Worksheet (Worksheet 21-​4). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories) and Home Weight Change Record.

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CHAPTER 22

Session 22: Revisiting Commitment and Transition to Monthly/​ Bimonthly Meetings

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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Revisiting Commitments (15 Min.)

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Transitioning to Monthly/​Bimonthly Meetings (15 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 22-​1: Recommitment!

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Board of Personal Commitments (from “Stand and Commit” exercise) ■ Enough copies of the Keeping Track Form (Appendix A) so every client can record each week until the next session ■ Enough copies of the Weekly Review Form (Appendix D) so every client can complete one form each week until the next session ■ Ensure clients have Appendix C: Home Weight Change Record (or their chosen weight-​tracking method) ■

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In. As part of the check-​in, clients were instructed to state whether or not they completed their behavioral and psychological action plan for dealing with high-​risk lapse situations and their plan for reversing small weight gains. As time allows, encourage clients to share different behavioral and/​or psychological strategies that they came up with for dealing with high-​risk lapse situations and for reversing small weight gains.

Skill Review (10 Min.) Review the difference between a lapse and a relapse: a lapse is a single event that is relatively easy to change or reverse, while a relapse is a sequence of events (or string of lapses) that are more difficult to reverse and indicate a return to old, problematic weight control behaviors. Clients were taught to identify signs that they have lapsed, including situations in which they hit their Red Zone weight or when they have stopped engaging in a known weight control behavior (e.g., walking, self-​monitoring, menu planning, food logging, weighing, low-​calorie eating). The causes of lapses (proximal, distal, psychological) were discussed, and clients were taught to identify individual high-​risk situations for lapses (social, emotional, breaks in routine). Refer the group to their behavioral and/​ or psychological action plans for dealing with high-​risk situations and ask for volunteers to share different aspects of their plans. Review strategies for preventing and reversing small weight gains. Remind clients that it is useful to have a structured plan ahead of time and that self-​ monitoring of intake and activity is critical to this plan. Also remind clients that psychological strategies may be necessary to engage in the behavioral strategies described in their plans (e.g., willingness to step on the scale while embracing uncomfortable thoughts/​feelings about weight gain).

Revisiting Commitments (15 Min.) Congratulate clients on their strong levels of commitment to maintaining their weight losses and preventing and reversing small weight gains. 192

Note that commitment is a skill that can be learned and strengthened like any other and that today’s session will focus on learning a new style of commitment to weight control behaviors. Remind the group that it is inevitable that we occasionally break commitments (i.e., have lapses). In the past, many clients likely found that after experiencing a lapse, their tendency was to give up their commitments because of how terrible the lapse made the client feel. In this program, clients will be establishing a new habit of recommitment in the face of lapses: Make Commitment → Lapse → Feel frustrated/​hopeless/​angry and thinking about giving up → Recommit anyway! Facilitate a discussion in which clients discuss strategies and approaches that they can use to recommit when they find themselves in the Red Zone. Point out that psychological/​acceptance-​based skills are likely to be necessary to successfully recommit after a series of lapses (e.g., be mindful of values, purposefully move in direction of values even when it is uncomfortable or challenging, purposefully practice willingness to engage in weight control behaviors even when another behavior would be more enjoyable). Clinician’s Note Post the group’s commitments from the “Stand and Commit” exercise (introduced in Session 19). Clients began practicing commitment skills a few months ago with a personal commitment they shared with the group. Ask clients to turn to the “Personal Commitment Report” section in their Client Workbooks (p. 135) and complete the items (“One key to keeping this commitment has been …” or “One change I am going to make as part of recommitting is …”) and prepare to share responses with the group. Discuss responses. Provide encouragement to continue practicing the skill of commitment, gently reminding clients that keeping their values at the forefront of their minds is likely to be helpful for keeping commitments (as well as recommitting after lapses). As part of their Skill Builder,

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clients will use the Recommitment! Worksheet (Worksheet 22-​1) to record situations in which following their commitments proved challenging and strategies they used to recommit. ADAPTING FOR INDIVIDUAL FORMAT The “Stand and Commit” review above should be slightly modified for individual format. For example, start by discussing the client’s experience carrying out the public commitment plan she made in Session 19. If the plan was not carried out, discover why and form a new plan making use of psychological strategies that will ensure success. Also discuss how the client can continue to make and benefit from public commitments.

Transitioning to Monthly/​Bimonthly Meetings (15 Min.)

ADAPTING FOR INDIVIDUAL FORMAT As an alternative to setting a schedule for the remaining sessions, you may take time to schedule the next several sessions with the client based on his or her individual scheduling needs. Take time to congratulate clients on successfully completing six months of the program. Acknowledge and reinforce clients’ commitment to themselves and their health through continued group attendance and willingness to persist in their weight loss efforts despite challenges that have arisen in the past several weeks. Remind clients that groups will begin meeting monthly and then bimonthly, rather than every two weeks, for the next six months. Prompt clients to discuss their feelings about completing six months and transitioning to monthly meetings. How has their work over the past few months compared to their previous weight loss efforts? Clients may be tempted to attribute their success thus far to the program itself, rather than to their individual efforts. Redirect any of these comments to center clients’ attention on what they have done differently to sustain their commitment to themselves and their health.

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Stress the importance of attending these monthly and bimonthly meetings and the need to schedule around them. (If a client misses a meeting, he or she will be missing group for two months or more!) These meetings are critical because they teach skills for long-​term weight control. If a client begins regaining weight, it can be tempting to miss a meeting because of a desire to avoid the scale or check-​in or because he or she feels the group meeting will not be helpful. These are the times when it is most important to attend and when practicing willingness to experience the discomfort associated with discussing one’s challenges is crucial. Clinicians and fellow group members are critical sources of support and can provide a sense of accountability that is helpful. Elicit a discussion of any concerns or questions clients may have about reducing the frequency of group sessions. For example, clients are often concerned about having less accountability from clinicians and needing to rely more on themselves to stay on track between sessions. Clinician’s Note Clients will have varying goals for weight loss and maintenance over the next few months. Some will want to lose more, and some will start focusing on keeping off the weight they have lost. Often clients find that after they have lost 10% of their weight, continued weight loss becomes difficult, and focusing for a period of time on weight loss maintenance can make sense. Reemphasize that this period of the program is valuable because it facilitates another shift in which clients learn to gradually depend on themselves to maintain the changes they have been making (and will continue to improve upon). Many group members have experienced prior short-​term success at weight loss, but have struggled to maintain their behavior change long term. Skills that are taught during the remainder of the program will be helpful to clients regardless of specific weight loss or maintenance goals. Clients will continue to learn to deal with long-​term issues (e.g., lapses or small weight gains) and develop new ways to monitor their weight and behavior when they no longer attend group sessions.

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Clinician’s Note Many clients will express ambivalence about the new reduced level of accountability and support that accompanies less frequent sessions (monthly and bimonthly). Validation of these concerns is important—​ weight control is a challenging process, and it would be surprising if clients succeeded at maintaining their weight losses without experiencing “ hiccups” along the way. However, this next gradual reduction in meeting frequency is designed to give clients extended practice at implementing the skills they have learned during the first two phases of this program, while still providing opportunities for them to return to group and receive support for any challenges that come up. Remind clients that completing the Weekly Review (Appendix D) of weight and goals at home is even more important during the next six months. Ask clients to share what aspects of the Weekly Review have been most helpful and what strategies they use for remembering to complete it. Reiterate the critical importance of weighing oneself at home weekly (or more frequently, if desired). Clients have learned two important groups of skills in the past six months that have prepared them for this transition. In the final phase of the program, we will build on and integrate all of these: 1. Clients have established the foundation of behavior change by self-​ monitoring eating behavior, setting goals for calorie intake and physical activity, changing the home environment, and problem-​ solving when challenges arise. 2. Clients have also learned specialized psychological strategies that enable them to make mindful decisions, recognize what they care about most deeply and intensely, and use this information to commit to long-​term change.

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Skill Builder (5 Min.) Direct clients to p. 136 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 50 minutes × 5  days. Record type and minutes on your Keeping Track Form. □ Behavior: Work on the behavioral goal that you identified during today’s session. Complete your Weekly Review sheet (Appendix D) in the off-​week(s) between now and the next session. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: Complete the Recommitment! Worksheet (Worksheet 22-​1). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories) and Home Weight Change Record.

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CHAPTER 23

Session 23: Maintaining Motivation

TOPICS ABCDE Check-​In (30 Min.)

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Skill Review (10 Min.)

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 Maintaining Motivation:  Importance of Values Awareness (30 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 23-​1: Visual Reminders to Stay Motivated ■ Worksheet 23-​2: Are You Voting for What You Value? ■

Enough copies of the Keeping Track Form (Appendix A) so every client can record each week until the next session ■ Enough copies of the Weekly Review Form (Appendix D) so every client can complete one form each week until the next session ■ Ensure clients have Appendix C: Home Weight Change Record (or their chosen weight-​tracking method) ■

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ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In.

Skill Review (10 Min.) Review the concept of recommitment. Remind clients that eating and physical activity lapses are inevitable and that in order to best meet weight control goals, clients should adopt a new habit of recommitment in the face of lapses: Make Commitment → Lapse → Feel frustrated/​hopeless/​angry and thinking about giving up → Recommit anyway! Review psychological strategies and approaches that clients can use to recommit when they find themselves in the Red Zone: Holding values at the forefront of one’s mind ■ Purposefully make mindful decisions that move one in the direction of values, even when it is uncomfortable or challenging ■ Purposefully practicing being willing to accept difficult internal experiences (thoughts, feelings, physical sensations) and engage in weight control behaviors even when another behavior would be more enjoyable ■

Briefly review important points covered regarding the transition to monthly and bimonthly meetings. Emphasize the importance of these meetings, pointing out that the last phase of the program is especially valuable because it facilitates participants learning to gradually depend on themselves to maintain the changes that they have been making. Finally, remind clients that the last phase of the program will continue to build on and integrate the two groups of skills that they have been learning: behavioral and psychological.

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Maintaining Motivation: Importance of Values Awareness (30 Min.) As the program enters its final months, clients likely recognize that they have acquired a lot of knowledge about diet and exercise. Emphasize that this knowledge is necessary for successful weight control; however, all of this knowledge is not sufficient. Motivation to maintain these lifestyle changes is key to sustaining weight loss. Point out that maintaining motivation can be challenging because sustaining a weight loss can feel less reinforcing than the process of initially losing weight. Ask clients to consider reasons for diminished motivation. As needed, highlight the following reasons: A powerful reinforcer/​motivator (i.e., accumulating weight loss) has slowed for many participants (e.g., no longer feeling the sense of reward of dropping one pant size per month, no longer feeling the sense of accomplishment that resulted from getting attention from others for weight loss). ■ Weight regain occurs slowly, and negative consequences of that weight gain are less salient or less noticeable (e.g., eating out more frequently on the weekends with the rationale that “one more meal out won’t hurt,” when in fact those extra calories are subtly contributing to weight gain). ■

The Passengers on the Bus metaphor, (previously discussed in Chapter 18), can provide suggestions for how to manage this challenge of decreased motivation. Remind clients that they are driving down the road to weight loss/​maintenance and a healthy lifestyle and being asked to carry with them a number of bothersome passengers. These passengers are the internal experiences that make long-​term weight control difficult. For example, a client might struggle to give up the pleasure of another behavior that would be more rewarding in the short term, such as watching TV rather than going out to walk or choosing a lower calorie food even when feeling tempted by a high-​calorie food. Remind clients that, unfortunately, we know of no magic bullet for getting passengers off the bus.

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Point out that clients have a choice to either continue down this road, accepting that passengers are along for the ride, or pull over and stop making progress toward weight loss maintenance. We think participants have learned all of the skills necessary for continuing to drive toward a healthy lifestyle. One of the best strategies to keep moving forward is to “keep your eyes on the compass.” A compass can tell you if you are moving in the direction of what you value. Participants are most likely to make progress if they keep their values at the forefront of their minds and stay mindful of why they want to keep driving down this road: Values make the hard work of willingness worth it. Ask participants to imagine driving for hours and hours on the weight loss maintenance/​healthy lifestyle highway with unruly and bothersome passengers on the bus. Ask clients to describe who the passengers are and what they are doing. What is tempting them to pull over and turn off the engine? ■ When frustrations and temptations arise, what values have the ability to keep clients on the road? Have clients come up with and share one or two values (e.g., being active with one’s children, getting off one’s blood pressure medications) that motivate the hard work of living healthfully. ■ Ask clients what strategies they can use to stay aware of and connected to their values. What will help them to keep their eyes on the compass? ■

Point out that visual reminders can be helpful (e.g., post-​it notes, letters/​e-​mails to self, meaningful fridge magnets, photo frames with a value represented inside, symbolic jewelry that a client buys for this very purpose). Instruct clients to complete the Visual Reminders to Stay Motivated Worksheet (Worksheet 23-​1) at home. Also remind clients that every behavior is a vote for or against health/​ one’s values (mindful decision-​making). Instruct clients to complete the Are You Voting for What You Value? Worksheet (Worksheet 23-​2) on a weekly basis.

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Reintroduce the Rocky Path/​Mountain Metaphor Without goals and values, there is no need for willingness. (You could engage in any desirable behavior without worrying about consequences.) However, clients are here because they have expressed goals and values related to weight control and living a healthy lifestyle. Reintroduce the following metaphor: Imagine that you are hiking through an area with beautiful forests, lakes, and mountains. You start out walking and very soon come to a rocky path. If you didn’t care about seeing the forests, lakes, or mountains, what would you do? (Turn around.) ■ But what if you want to walk through the forests to see the wildlife and trees, swim in the lakes, and climb the mountains to see the view from the top? What if there are many places where you must walk on a rocky path? Are you willing to experience the difficulty of walking through the rocks? What makes you willing? ■

Ask participants to relate this metaphor to weight control. If necessary, explain that the journey to a healthy lifestyle is often difficult, but going through the difficulties is in the service of one’s goals and values related to maintaining a healthy weight and lifestyle. (Clients must be willing to experience a loss of pleasure, cravings, urges, and other internal experiences.) Use the previous mountain metaphor to solidify for clients what behavioral commitment will look like: Ask clients to describe what the big rocks they will have to climb might be (i.e., situations that will threaten weight control, such as loss of pleasure in future situations). ■ What strategies can be used to remind clients of the beautiful mountain that they are hiking toward? ■

Take-​Home Message Engaging in weight maintenance behaviors over the long term is difficult, and people often lose motivation. It is important to stay aware of why it is worth it to continue practicing weight control behaviors.

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If clients recognize how certain behaviors can move them in the direction of the life they want to be living, they will be more likely to stay on track and continue moving in that direction.

Skill Builder (5 Min.) Direct clients to p. 142 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 50 minutes × 5  days. Record type and minutes on your Keeping Track Form. □ Behavior: Work on the behavioral goal that you identified during today’s session. Complete your Weekly Review sheet (Appendix D) in the off-​week(s) between now and the next session. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise:  Complete the Visual Reminders to Stay Motivated Worksheet (Worksheet 23-​1) and the Are You Voting for What You Value? Worksheet (Worksheet 23-​2). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories) and Home Weight Change Record.

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CHAPTER 24

Session 24: Looking Ahead

TOPICS ABCDE Check-​In (20 Min.)

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Skill Review (10 Min.)

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Looking Ahead: Behavioral and Psychological Strategies for Success (40 Min.)

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Skill Builder (5 Min.)

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MATERIALS NEEDED Client Workbook

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Worksheet 24-​1: Keys to My Long-​Term Success

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Enough copies of the Keeping Track Form (Appendix A) so every client can record each week until the next session ■ Enough copies of the Weekly Review Form (Appendix D) so every client can complete one form each week until the next session ■ Ensure clients have Appendix C: Home Weight Change Record (or their chosen weight-​tracking method) ■

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ABCDE Check-​In (20 Min.) Conduct a shortened ABCDE Check-In to allow enough time for the review of strategies covered in the program.

Skill Review (10 Min.) Review the importance of values awareness in maintaining motivation for long-​term weight maintenance. Ask clients to provide reasons why motivation to maintain weight control behaviors diminishes in the long term. One major reason is the slowing (or stopping) of weight loss, and thus there is lessened reward from stepping on the scale. Additionally, weight regain occurs slowly; thus the negative consequences of engaging in behaviors counter to weight control (e.g., eating out more frequently) seem less detrimental than when weight loss was occurring quickly. The Passengers on the Bus metaphor can provide suggestions for how to manage the challenge of degrading motivation in the long term. You may wish to ask a client to remind the group of the Passengers on the Bus metaphor and, as necessary, fill in the gaps to communicate the main point of the metaphor. Clients are driving down the road to weight loss maintenance and a healthy lifestyle, carrying a load of “passengers” (internal experiences such as giving up pleasure or feeling cold or tired when exercising). Clients have a choice to continue down the road (accepting that the passengers will be there) or to fight with the passengers (thus needing to pull over the bus). One of the best strategies for clients to continue making progress is to keep their values at the forefront of their minds. Remind clients that values make the hard work of willingness worth it. There are several creative methods that clients can use to keep their values in mind. Ask clients to share examples of what they have already used as reminders of their values. One example is visual reminders (e.g., post-​it notes, pictures, symbolic jewelry, letters to oneself). Changing the meaning of an item (e.g., walking shoes to symbolize health) or creating a tangible item (e.g., a laminated copy of recent doctor’s labs) can also be a useful way to keep values in mind. Last, weekly reviews can be a way to “check-​in” on values-​ consistent behavior. 206

Ask a client to explain the Rocky Path metaphor to the group. This metaphor illustrates that without goals/​values, there is no need for willingness (clients could engage in any desired behavior without worrying about the consequences). Expand on the client’s explanation as necessary. A challenging uphill hike with rocks may not be worth it without the promise of something valuable at the end, such as a beautiful mountain, lakes, or forests. The take-​home message is that long-​term weight maintenance is difficult, and thus staying aware of one’s values (and how engaging in weight control behaviors is consistent with these values) is key to staying on track even when weight control behaviors are no longer as immediately rewarding.

Looking Ahead: Behavioral and Psychological Strategies for Success (40 Min.) Begin this session by asking clients how they feel about treatment ending after next session. Clients may feel disappointed or anxious about losing the support of the treatment and group members. Others may report feeling ready to move on and to pursue weight loss maintenance independently. Emphasize that any of these feelings, or a combination of them, are natural at this stage of treatment. Even if clients are feeling anxious or disappointed about the end of treatment, remind them of the significant progress they have made over the past 10  months. Independently pursuing long-​term weight control is the next step in the process. In this session, you will help clients plan for their weight control future. There are several key behaviors that will maximize clients’ future weight control success. The Keys to My Long-​Term Success Worksheet (Worksheet 24-​1) contains tables posing questions for each key behavior including: 1. How important will each behavior be as part of the long-​term weight control plan? 2. What challenges may arise in implementing each behavior? 3. What personal goal will clients have for this behavior in the next six months? 4. What strategies will they use to meet each goal?

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Clients should make notes on Worksheet 24-​1 during the discussion and complete it for homework. The questions posted in Worksheet 24-​1 can be raised throughout the discussion as time allows. For the review of key behaviors and behavioral and psychological strategies for maintaining these behaviors, conduct a discussion in which clients offer their go-​to strategies for implementing key behaviors. You may wish to frame the review of behavioral and psychological strategies for each behavior as “control what you can” and “accept what you can’t” strategies. As much as possible, the session should be discussion-​based rather than didactic, but you should supplement the discussion with additional behavioral and psychological strategies for long-​term implementation of key behaviors. This overall review of strategies works best when clients are generating most of the discussion and providing their personal core strategies for weight control. Thus, you may wish to order the discussion of the review material based on answers provided by participants. For example, you could start the review with a question such as, “What is one of the key behaviors for maintaining weight loss in the long-​ term?” and conducting the discussion based on client responses. It is not important that behavioral and psychological strategies be reviewed separately from each other. In fact, it may be helpful to emphasize that implementing the psychological strategies enhances the ability to engage in the behavioral strategies. Additionally, although a review of specific psychological strategies is listed under specific key behaviors, most psychological strategies can be applied to numerous behaviors. Thus, it is also not important that specific psychological strategies be discussed for specific key behaviors, as long as the major psychological strategies are reviewed in the context of the entire review.

Key Behavior 1: Self-​Monitoring Weight Reemphasize the importance of continuing to weigh oneself by asking clients why it is important to weigh oneself regularly whether in the weight loss or weight maintenance phase. Frequent weighing facilitates increased awareness of eating behaviors and allows clients to catch any small weight gains before they become difficult to reverse.

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Behavioral Strategies for Self-​Monitoring Weight Ask a few clients how often they are currently weighing themselves at home and how they have chosen the frequency of their weighing. In the maintenance phase, many clients find it useful to weigh themselves more than once per week. In fact, many successful clients weigh themselves daily once they are in the weight loss maintenance phase. However, you may wish to emphasize that there is no “correct” frequency of weighing, as long as it is at least once weekly and not more than once per day. Clients should physically record or graph their weight at least weekly in order to track weight trends over time. Ask clients to define the Red Zone of weight regain (i.e., 3 to 5 lbs. above maintenance weight) and briefly discuss their plan if the Red Zone is reached. If the Red Zone is reached, clients can implement the plan they created in Session 21. One important strategy to facilitate frequent weighing is to keep the scale and weight chart in a prominent place at home (rather than tucked away in a cabinet or drawer).

Psychological Strategies for Self-​Monitoring Weight Although most clients realize that regular monitoring of weight and food intake is a critical strategy for long-​term weight control, certain thoughts and feelings may lead to avoidance of weighing themselves. Ask clients to provide examples of such thoughts/​feelings (e.g., “It’s better not to know,” “I will lose my motivation if I’ve gained weight,” “I’m sure I’m doing fine,” anxiety, dread, guilt). Although more comfortable in the short term, avoidance of the scale may actually intensify unpleasant thoughts and feelings in the long term rather than alleviate them. Avoidance also keeps clients from engaging in behaviors that are critical to their values (e.g., health). Invite clients to discuss what the alternatives are to responding to negative thoughts and feelings with avoidance. Expand upon and clarify psychological strategies discussed by clients. If clients provide behavioral strategies when prompted for psychological strategies, acknowledge the helpfulness of the strategy and briefly reiterate the difference between “control what you can” and “accept what

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you can’t” strategies. Although any psychological strategies provided and utilized by clients may be useful for facilitating self-​monitoring of weight, probe clients especially for the following strategies (either when discussing self-​monitoring of weight or other key weight control behaviors, depending on clients’ responses) and review in more detail as necessary. To prevent the discussion from becoming overly didactic, you may wish to ask clients to define these strategies and provide an example in which they have tried the strategy (whether successful or not). 1. Acceptance is the mental state of embracing thoughts and feelings related to behavior (such as self-​monitoring weight) without trying to avoid, minimize, or change those thoughts or feelings. Being accepting of distressing thoughts and feelings does not mean clients have to enjoy them or want to have them—​just that they are willing to experience them in the service of a greater value. 2. Willingness is the behavioral act of doing. For example, willingness could mean actually weighing oneself or looking up calorie information despite uncomfortable internal experiences. Ask clients for examples of thoughts or feelings that could lead to avoidance of the scale (e.g., “I’d rather not know how holiday eating impacted my weight”). Willingness means making choices because clients want the long-​term outcome of these choices (i.e., because it moves clients toward what they value) even if those choices mean experiencing unpleasant thoughts/​feelings in the moment. 3. Defusion strategies can help put willingness into action. For example, clients can choose to step on the scale at the exact same moment that they feel fearful/​hopeless or have the thought, “It’s better not to know.” Ask a client to review the Pick Up the Pen metaphor and how it may apply to self-​monitoring of weight.

Key Behavior 2: Limiting Calorie Intake To maintain a weight that is lower than one’s pre-​treatment weight, calorie intake must stay lower than it was pre-​treatment. Clients should be made aware that returning to old patterns of eating will cause weight gain.

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Behavioral Strategies for Limiting Calorie Intake Ask clients to generate and discuss the core behavioral strategies for limiting calorie intake. These strategies should be very familiar to clients at this stage of treatment, thus, in the interest of time, you may wish to move quickly through the review of behavioral strategies to leave enough time to discuss psychological strategies. 1. Self-​monitoring of calorie intake. Self-​monitoring of calories is the cornerstone of behavioral weight control. Although clients may vary in the extent to which they continue to self-​monitor in the future, most who are successful with weight loss maintenance in the long term engage in at least some form of self-​monitoring, even if minimal. Even if clients decide not to formally self-​monitor using monitoring forms or a smartphone app, it should be the first behavior they engage in when small weight gains or lapses occur. 2. Limit portion sizes. Potion sizes have grown dramatically in recent years, and food is sold in large quantities, which can facilitate overeating. Clients should implement strategies such as avoiding buying in bulk, using small plates, and putting leftovers away before sitting down to eat a meal. Clients may wish to purchase food in individual servings or to pre-​portion food into baggies or containers right after purchase. 3. Limit temptations in the home environment. Humans are hard-​wired to want to eat good-​tasting, high-​calorie food when it is present. Clients should make access to such foods as difficult as possible by not keeping them in the home or by putting such foods in places (e.g., back of the top cabinet) that are not immediately visible. 4. Grocery shop according to a meal plan. Clients should stock up on the healthy foods they plan to eat frequently. They should plan out meal and snack options for the week and shop according to this plan. Healthy foods should be easily accessible and visible (e.g., a fruit bowl on the kitchen table). 5. Limit restaurant/​fast-​food eating. Restaurants serve large portions of high-​calorie food, and thus excessive restaurant eating should be avoided. If clients do decide to eat out, they should try to look up the menu online, choose establishments that publish calorie information, and/​or have a portion of their meal boxed up as soon as it is brought to the table to limit unintended overeating. Also, alcohol 211

intake should be limited in order to prevent intake of excess calories from the alcohol and also via disinhibited eating. 6. Plan ahead. In our toxic food environment, a person must constantly exercise self-​control to make healthy eating choices. Constant exertion of self-​control can become exhausting and may leave too much room for error. Clients should not count on being able to make healthy decisions in the heat of the moment (e.g., when wait staff circulate with trays of hors d’oeuvres at a party or when they smell donuts on their way to work) and instead should arm themselves with a plan ahead of time (e.g., eating before going to the party; taking a walking route that does not pass by the donut shop). 7. Ask for support from others, especially people who have influence over what food is available at home, work, and other settings. Having positive social support related to eating and physical activity (e.g., being willing to keep tempting foods out of the house, suggesting a long walk instead of watching TV) can make it easier for clients to make healthy lifestyle decisions.

Psychological Strategies for Limiting Calorie Intake Ask clients which psychological, or “accept what you can’t,” strategies have been helpful for limiting calorie intake, especially in challenging situations such as social or work events. Mindful decision-​making may be useful for many clients when faced with a tempting food or situation. The mind often makes decisions without awareness (especially when distracted, emotional, or in the presence of food cues). Mindless food decisions are often those that lead to eating large portions of high-​ calorie foods. Again, remind clients that controlling the food environment and planning ahead will help prevent mindless eating, but the following strategies can be used when controlling the food environment is not possible: 1. “Stop, think.” Clients can slow down and pay deliberate attention to both internal (e.g., cognitive, emotional) and external (e.g., smells, sights of foods) cues driving the desire to eat. Ask participants to discuss why slowing down the decision-​making process is helpful for preventing mindless eating. Heightened awareness allows for conscious decision-​making to occur. 212

2. One way for clients to slow down the decision-​making process is to practice being a sports commentator for the process of eating. Ask a client to remind the group of the Sports Commentator metaphor. Acting as a sports commentator brings to awareness every small step that leads to the decision of eating. 3. Make every decision a vote for or against life values; ask a client to volunteer why making every decision an “up” or “down” vote on a value could be helpful for long-​term weight control. For example, does eating a cookie at the party take the client closer to or farther from their ultimate value of being a healthy grandparent? Carefully considering each eating decision in the context of long-​term values will facilitate decreasing mindless eating that often does not consider long-​term consequences of overeating.

Key Behavior 3: Engaging in High Levels of Physical Activity Clients should be aiming to complete 250 minutes of moderate to vigorous physical activity per week in the long term to prevent weight regain. Clients may choose to divide the 250 minutes across the week as they please, but activity should take place in at least 10-​minute bouts in order to derive the cardiovascular health benefits of physical activity. Ask clients what types of physical activities they have been doing to meet the 250 minutes per week goal. Brisk walking is an ideal way to complete activity because there are fewer barriers (e.g., driving to the gym, lack of equipment). However, clients may wish to have several different options for physical activity to prevent boredom.

Behavioral Strategies for Engaging in Physical Activity Invite clients to provide and discuss their go-​to behavioral strategies for consistently engaging in high levels of physical activity. You may wish to supplement the discussion by reminding clients of the following strategies: 1. Clients should reduce television watching, as the television serves as a cue to stay sedentary. However, clients may choose to exercise

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while watching TV (e.g., at the gym or on a treadmill in their living room). 2. Clients should try to surround themselves with others who are active, so they can serve as cues to exercise, and have activity partners to keep them accountable. 3. Clients may wish to put workout items or reminders in a visible place (e.g., schedule workouts on a daily calendar, put notes in the car, put gym clothes in a visible location). Clients should treat plans to exercise like an appointment for work or with a friend that they would not normally cancel or reschedule. 4. Clients may wish to change their daily routine so it includes more movement (e.g., park farther away from the office, get off the bus a stop early, walk on the treadmill or outside when having a conversation with a friend, or change a weekly work meeting to a walking meeting).

Psychological Strategies for Engaging in Physical Activity Ask clients to discuss which psychological strategies have been most useful in facilitating their engagement in physical activity, especially when conditions are not ideal (e.g., fatigue, bad weather, lack of time). Although any psychological strategies can facilitate physical activity, willingness and defusion can serve as particularly helpful strategies for engaging in high levels of physical activity in the long term. When motivation drops, clients can get distance from internal experiences that drive them not to exercise and engage in the behavior anyway. Clients should step back from these thoughts and feelings and see themselves as separate from them. Supplement the discussion with strategies for increasing willingness, including: 1. Practice labeling thoughts as thoughts. For example, instead of saying “I do not want to get out of bed and exercise,” clients can say, “I am having the thought that I do not want to get out of bed and exercise.” Ask clients to describe the difference between two such statements. Labeling thoughts as thoughts allows clients the flexibility to choose a behavior that is distinct from their thoughts. 2. Clients can acknowledge their minds for doing its job with “thank you mind.” For example, clients can thank their mind for doing its job 214

when it tells them to “Leave your workout clothes at home when you go on vacation—​you deserve a break.” Acknowledging the mind’s innate desire to keep clients at rest can allow for the freedom to choose to be active despite the mind’s hard-​wired desires. 3. Separate the thought from behavior by substituting “and” for “but.” For example, instead of saying “I should go to the gym right now, but I  am so tired,” clients can say “I should go to the gym right now, and I am so tired.” Ask clients to describe how the substitution changes the implication of the thought. This subtle change in language separates the behavior of going to the gym from the internal experience of feeling tired; feeling tired does not necessitate not going to the gym. Instead, the client has the option to exercise even if feeling tired. 4. Clients can practice the “Just Do It Method.” Clients can feel the feeling (e.g., dread of exercise and tiredness) and have the thought of not wanting to exercise and do it anyway. Clients can first practice these strategies with the smallest of behaviors (e.g., tying sneakers and taking a step) and then use them with bigger behaviors (e.g., going for a walk even when it is raining).

Key Behavior 4: Staying Mindful of Values to Remain Motivated Ask clients to reflect on how they have stayed motivated or increased motivation for weight control in the past. You may wish to ask what, if anything, is different about their motivation in their weight control efforts in this program versus past efforts and what they may do differently in the future to keep up their motivation, especially for weight loss maintenance. Motivation can decrease because keeping off weight feels less rewarding than losing weight (e.g., positive comments from peers are heard less frequently). Controlling the food environment should make it easier for clients to engage in healthy eating even when motivation wanes. However, in challenging moments, motivation will remain key for clients to adhere to healthy behaviors. Clients can prepare for these challenges by reflecting often on their values. For example, what do clients want their lives to be about? What do clients want to be able to do in the years to come? Clients may wish to 215

use reminders (e.g., post-​its, mottos) to keep values at the forefront of their minds. Conclude the session by reviewing with clients that they should expect to continue to work on weight control behaviors in the same way that they keep up maintenance on the car or at home. For example, clients cannot expect to do spring cleaning of the house and expect it to stay clean without daily straightening, weekly mopping, and so on.

Skill Builder (5 Min.) Direct clients to pp. 151–152 in their workbooks, which outlines the following Skill Builder for the coming week: □ Activity:  Exercise (e.g., brisk walking) for 50 minutes × 5  days. Record type and minutes on your Keeping Track Form. □ Behavior: Work on the behavioral goal that you identified during today’s session. Complete your Weekly Review sheet (Appendix D) in the off-​week(s) between now and the next session. □ Calories:  Follow a diet that is consistent with your calorie goal. Total the calories for each day (and for the week), calculate a seven-​ day average, and compare results to your calorie target. □ Days Recorded: Record every day. □ Experiential Exercise: Complete the Keys to My Long-​Term Success Worksheet (Worksheet 24-​1). □ Reminder: Complete your Check-​In sheet before the next session. Also, don’t forget to bring your Keeping Track Forms (or printout that includes foods, time eaten, and calories) and Home Weight Change Record.

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CHAPTER 25

Session 25: Celebrating Accomplishments

TOPICS ABCDE Check-​In (30 Min.)

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Concluding Group Meetings and Review (15 Min.)

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Recognizing Accomplishments (20 Min.)

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MATERIALS NEEDED Client Workbook

■

Worksheet 25-​1: Celebrating Accomplishments ■ Certificates (Sample certificate provided in Appendix B) ■

ABCDE Check-​In (30 Min.) Conduct the ABCDE Check-In.

Concluding Group Meetings and Review (15 Min.) Congratulate clients on all of the hard work that they have put into the program. Emphasize the important changes that they have made in eating and physical activity. Acknowledge fears associated with ending

217

group meetings, while reassuring clients that they have all of the tools necessary to be successful. Remind clients that making lifestyle changes is an ongoing process that has no beginning or end. Long-​term weight management will require them to continually implement the skills and strategies that worked best for them during this program. Emphasize that weight loss maintenance is hard work, but it is possible. Briefly remind clients of the six keys to success that will maximize weight control success in the future. 1. Self-​monitoring weight. 2. Limiting calorie intake. 3. Engaging in high levels of physical activity. 4. Checking in on your progress regularly. 5. Engineering your environment to make healthy choices easier. 6. Staying mindful of values to remain motivated. Stress that clients should use psychological strategies learned in this program (e.g., stay mindful of values, be mindful when making decisions, practice willingness) to achieve key behaviors. Remind clients to optimize environments to make healthy eating and activity as easy and automatic as possible. ADAPTING FOR INDIVIDUAL FORMAT In individual sessions, you and your client can work collaboratively to identify the weight control strategies that were most successful for the client. You can then work with the client to develop a concrete action plan for continuing to use those strategies over the long term. We recommend taking special care to develop a plan that you and the client believe will truly enable long-​term utilization of the strategies, as their use tends to fade over time. For example, you could discuss ways the client can remind him or herself to review the list of strategies on a regular basis. You may also want to recognize the accomplishments of your client by creating a formal certificate of accomplishment as described in the main section of the chapter.

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Lead a discussion regarding what specific psychological and behavioral skills each client has found to be the most helpful for weight control during the program. Elicit suggestions for how they can continue to incorporate these strategies permanently, without the accountability of group meetings.

Recognizing Accomplishments (20 Min.) Encourage clients to reflect on the accomplishments they have made during the program by completing the Celebrating Accomplishments Worksheet (Worksheet 25-​1). Have each client share a brief summary of what he or she is most proud of accomplishing or learning during this program. Clinician’s Note This session is an important chance to recognize the progress that the group has made. As each client finishes sharing his or her summary, have that client walk to the front of the room to be handed a certificate of accomplishment (a sample certificate is provided at the end of this Clinician’s Guide), and offer a handshake to each client. You may wish to offer additional praise for each client when the certificate is handed out, and you should be sure to do so equitably.

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Appendix A Weight and Lifestyle Inventory

Source: Wadden, T. A & Foster, G. D. (2006). The Weight and Lifestyle Inventory (WALI). Obesity, 14(Suppl 2):99S–118S. The WALI is copyrighted by Thomas A. Wadden, Ph.D., and Gary D. Foster, Ph.D. © 2006. Reprinted here with permission of the authors. Electronic or other reproduction or dissemination of this instrument is expressly prohibited without written consent from the authors.

The WALI is designed to obtain information about your weight and dieting histories, your eating and exercise habits, and your relationships with family and friends. Please complete the questionnaire carefully and make your best guess when unsure of the answer. Feel free to use the margins and bottom of pages when you need more space for your answers. You will have an opportunity to review your answers with a member of our professional staff. Please allow 60–​90 minutes to complete this questionnaire. Your answers will help us better identify problem areas and plan your treatment accordingly. Please be assured that the information you provide will be kept confidential and will only be available to the treatment staff. Thank you for taking the time to complete this questionnaire.

SECTION A: IDENTIFYING INFORMATION

Name ​ ______ _​_​_​_​_​_​_​ lbs.

Date of Birth

Age

Weight

_​_​_​_​_​_ ​f t. _​​_​_​_​_​_​_​_​ inches​ Height

​

Address

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_​_​_​_​_​_​_​_​_​_​_​_​_​_____ Phone: Day

_​__​_​_​_​_​_​______​_​_​_​_​_​_​_​ Evening

_​_​_​_​_​_​_​_​_​_​____​_​_​______​_​ Social Security #

_​_​_​_​_​_​_​_​_​_​_​_​_​_​​_​_​/​_​_​_​_​_​_​_​ yrs. Occupation/​# of yrs. at job

_​_​_​_​_​_​___​_​_​_​_​_​_​_​_​_​_​_​_​ Today’s Date

Highest year of school completed: (Circle one.) 1 2 3 4 5 6 7 8 9 10 11 12 High School

13 14 15 16 College

Masters

Doctorate

Ethnicity (Circle all that apply.):  American  Indian  Asian  African  American Hispanic White Other:  ​ How did you hear about our program? (Check all that apply.) _​_​_​_​_​_​ Newspaper _​_​_​_​_​_​ Physician

_​_​_​_​_​_​ Other Professional

_​_​_​_​_​_​ Friend

_​_​_​_​_​_​ Other (Please Specify) _________________

_​_​_​_​_​_​ Employer

_​_​_​_​_​_​ Website

SECTION B: WEIGHT HISTORY 1.  At what age were you first overweight by 10 lbs. or more? _​_​_​_​_​_​_​yrs. old How do you remember that you were overweight at this time? (e.g., pictures, clothing size, others telling you) 

​

2. What has been your highest weight after age 21?

​ lbs.

​ yrs. old

3. What has been your lowest weight (not due to illness) after age 21, which you have maintained for at least 1 year? lbs. yrs. old, maintained for ​ yrs. Was this weight reached after a weight loss effort? (Circle one.) Yes No 4. Circle the number of the statement that best describes you. “During the past 6 months my weight has …” 1. decreased more than 10 lbs. or more 4. increased by 5 to 19 lbs. 2. decreased by 5 to 10 lbs. 3. been relatively stable

5. increased by more than 10 lbs. or more

5. What was your weight: 6 months ago? _​_​_​_​_​ lbs. 1 year ago? _​_​_​_​_​ lbs. 2 years ago? _​_​_​_​_​ lbs. 222

6. For each time period shown below, please list your maximum weight. If you cannot remember what your maximum weight was, make your best guess and mark “G” (for guess) next to your answer. In addition, please note any events related to your gaining weight during this period. For ages 16 and beyond, please identify the figure, from those shown below, the most resembles your figure at that time. Record the number of the figure. AGE

MAXIMUM WEIGHT

FIGURE #

EVENTS RELATED TO WEIGHT GAIN

a.   5–​10

​ ​ ​

b.  11–​15

​ ​ ​

c.  16–​20

​ ​ ​

d. 21–25

​ ​ ​

e.  26–​30

​ ​ ​

f.  31–​35

​ ​ ​

g.  36–​40

​ ​ ​

h.  41–​50

​ ​ ​

i.  51–​60

​ ​ ​

j.  60–​70

​ ​ ​

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

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SECTION C: FAMILY WEIGHT HISTORY 1.  Please indicate the average height and weight of your biological mother and father during their middle-​age years. Also, please select from the figures on the previous page the one that is most similar to your parents’ body shapes. If you do not know your biological parents’ height and weight, please mark NA (not applicable) in the spaces.    Parent

Height (ft.+in.)

Weight (lbs.)

Current Age or year of death

Figure # (from previous page)

a. Mother

​ ​ ​ ​

b. Father

​ ​ ​ ​

2.  Please indicate the height and weight of the following members of your immediate family. Indicate any half-​brothers or half-​sisters. Family Member

Height (ft.+in.)

Weight (lbs.)

Current Age or year of death

Figure # (from previous page)

a. Spouse/ Significant Other

​ ​ ​ ​

b.  Oldest brother

​ ​ ​ ​

c.  2nd oldest brother

​ ​ ​ ​

d.  3rd oldest brother

​ ​ ​ ​

e.  Oldest sister

​ ​ ​ ​

f.  2nd oldest sister

​ ​ ​ ​

g.  3rd oldest sister

​ ​ ​ ​

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SECTION D: WEIGHT, PREGNANCY, AND MENSTRUAL CYCLE (For Women Only) 1.  Have you borne children? (Circle one.)  Yes  No If yes, a.  What was your weight at the start of your pregnancy? What was your weight at delivery? lbs. What was your lowest weight after delivery? lbs.

lbs.

b.  What was your weight at the start of your second pregnancy? What was your weight at delivery? lbs. What was your lowest weight after delivery? lbs.

lbs.

c.  What was your weight at the start of your third pregnancy? What was your weight at delivery? lbs. What was your lowest weight after delivery? lbs.

lbs.

d.  What was your weight at the start of your fourth pregnancy? What was your weight at delivery? lbs. What was your lowest weight after delivery? lbs.

lbs.

Please turn to the last page if you need more space. 2.  Do you experience a regular menstrual cycle? (Circle one.)  Yes  No If yes, a.  Describe your eating around the time of your menstruation. (Circle one.) Eat Much Less  Eat less  No Change  Eat More  Eat Much More b. Do you crave particular foods around the time of your menstruation? (Circle one.) Yes No c.  If yes, which foods do you crave?

​

​

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SECTION E: WEIGHT LOSS HISTORY

1. Please record your major weight loss efforts, (i.e., diet, exercise, moderation, etc.) which resulted in a weight loss of 10 pounds or more. Take time to think over your previous efforts, starting with the first one, whether in childhood or adulthood. You may have difficulty remembering this information at first, but most people can if they take their time. Start with your first weight loss effort and proceed in order until you reach your most recent one. Age at time of effort

Weight at start # lbs. lost of effort

Method used to lose weight

a.

​ ​ ​ ​

b.

​ ​ ​ ​

c.

​ ​ ​ ​

d.

​ ​ ​ ​

e.

​ ​ ​ ​

f.

​ ​ ​ ​

g.

​ ​ ​ ​

h.

​ ​ ​ ​

i.

​ ​ ​ ​

j.

​ ​ ​ ​

Please turn to the last page if you need additional space. 2. Please pick a number from 1 to 10 to indicate below how accurate you think you were in remembering and recording your weight loss history. Pick any number from 1 to 10: 1 = not at all accurate and 10 = completely accurate.

Your number is:

3. In the past year, how many times have you started a weight loss program on your own that lasted for more than 3 days? ​

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4. In the past year, how many times have you started a weight loss program that lasted for 3 days or less?  ​ 5. Have you ever experienced any significant physical or emotional symptoms while attempting to lose weight or after losing weight? (Circle one.)  Yes  No If yes, please describe your symptoms, how long they lasted and the type of professional help sought, if any. Problem

Year

Duration (wks.)

Type of Professional Help

​ ​ ​ ​

​ ​ ​ ​

​ ​ ​ ​

SECTION F: WEIGHT LOSS GOALS 1. How much weight would you like to lose at this time? 2. This would bring you down to a body weight of 3. When did you last weigh this amount?

​

4. How long was this weight maintained?

 months

​ lbs.

​ lbs.

5. Was it achieved after a weight loss effort? (Circle one.)  Yes  No 6. If you are successful in our program, in changing your eating and exercise habits, how much weight do you realistically expect to lose after: a.  6 months _______ lbs.

b.  12 months ______ lbs.

SECTION G: TOBACCO AND ALCOHOL USE 1. Do you currently smoke cigarettes? (Circle one.)  Yes  No If yes, a. How many do you smoke a day? ​ b. How many years have you smoked?

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2. Have you ever smoked cigarettes and stopped? (Circle one.)  Yes  No If yes, a. When did you stop smoking? ​ b. How many cigarettes did you smoke? ​/​day c. Did you experience any weight gain after stopping smoking? (Circle one.)  Yes  No If yes, how many pounds? ​ 3. During the past year: a. How many glasses of wine did you typically drink a week?

​

b. How many bottles of beer did you typically drink a week?

​

c. How many mixed drinks or liqueurs did you typically have a week?

​

4. Have you ever had a problem with alcohol consumption or the use of other drugs? (Circle one.) Yes No a. If yes, please describe the problem and any help you received for it.

​

​

​

SECTION H: EATING HABITS

1. Please indicate the degree to which you believe each of the following behaviors causes you to gain weight. In answering these questions, please use the 5-​point scale below. Pick the one number that best describes how much the behavior contributes to your increased weight: 1. does not contribute at all

4. contributes a large amount

2. contributes a small amount

5. contributes the greatest amount

3. contributes a moderate amount

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_​_​_​_​_​ a. Eating with family/​friends

_​_​_​_​_​ m. Eating while cooking/​ preparing food

_​_​_​_​_​ b. Eating when socializing/​celebrating

_​_​_​_​_​ n. Eating when stressed

_​_​_​_​_​ c. Eating at business functions

_​_​_​_​_​ o. Eating when depressed/​upset

_​_​_​_​_​ d. Eating when happy _​_​_​_​_​ e. Eating in response to sight or smell of food _​_​_​_​_​ f. Eating because of the good taste of foods

_​_​_​_​_​ p. Eating when angry _​_​_​_​_​ q. Eating when anxious _​_​_​_​_​ r. Eating when alone

_​_​_​_​_​ g. Eating because I can’t stop once I’ve begun _​_​_​_​_​ h. Overeating at dinner

_​_​_​_​_​ s. Eating when bored _​_​_​_​_​ t. Eating when tired _​_​_​_​_​ u. Overeating at lunch

_​_​_​_​_​ i. Eating too much food _​_​_​_​_​ j. Continuing to eat because I don’t feel full after a meal _​_​_​_​_​ k. Eating because I crave certain foods

_​_​_​_​_​ v. Overeating at breakfast _​_​_​_​_​ w. Snacking after dinner _​_​_​_​_​ x. Snacking between meals

_​_​_​_​_​ l. Eating because I feel physically hungry Please indicate any other factors that contribute a moderate amount or more to your weight gain.    2. How many days a week do you eat the following meals? Write the number of days in the space and the usual time of each meal. a. Breakfast

days a week Time: 

​ Morning Snack ______ days a week Time: 

​

b. Lunch



days a week Time: 

​ Afternoon Snack ______ days a week Time: 

​

c. Dinner



days a week Time: 

​ Evening Snack ______days a week Time: 

​

3. Who prepares meals at your home? 

229

4. Who does the food shopping?  5. Please list your five favorite foods:   6. Do you have any food allergies? (Circle one.)  Yes  No If yes, please specify the food and the allergic reactions. 7. Please specify the amount (in cups, 8 oz.) of the following fluids you typically consume a day. _​_​_​_​_​ skim milk _​_​_​_​_ low fat milk _​_​_​_​_ whole milk _​_​_​_​_ seltzer water _​_​_​_​_​ fruit juice _​_​_​_​_ diet soda _​_​_​_​_​ water

_​_​_​_​_ tea

_​_​_​_​_​ regular soda _​_​_​_​_ wine

_​_​_​_​_ coffee

_​_​_​_​_ beer

_​_​_​_​_ hard liquor _​_​_​_​_ other

8. During a typical week, how many meals do you eat at a fast-​food restaurant (including drive-​thru and convenience stores)? Breakfast

_​_​_​_​_​  meals a week

Lunch

_​_​_​_​_​  meals a week

Dinner

_​_​_​_​_​  meals a week

9. During a typical week, how many meals do you eat a traditional restaurant, coffee shop, cafeteria, or similar establishment? Breakfast

_​_​_​_​_  meals a week

Lunch

_​_​_​_​_​  meals a week

Dinner

_​_​_​_​_​  meals a week

10.  How many times a week do you typically eat out with others (including family)? 

230

SECTION I: FOOD INTAKE RECALL Please indicate the foods you consume on a typical weekday.

Meal

Time

Location

Food and Beverages Consumed

Amount

Breakfast Morning Snack Lunch Afternoon Snack Dinner Evening Snack Please indicate the foods you consume on a typical weekend day.

Meal

Time

Location

Food and Beverages Consumed

Amount

Breakfast Morning Snack Lunch Afternoon Snack Dinner Evening Snack

231

SECTION J: EATING PATTERNS I The Questionnaire on Eating and Weight Patterns–​Revised is reprinted here from Yanovski, S.Z. (1993). Obesity Research, 1, 306–​324. 1. During the past 6 months, did you often eat an unusually large amount of food within a two-​ hour period (an amount that most people would agree is unusually large)? (Circle one.) Yes No 2. During the times when you ate an unusually large amount of food, did you often feel you could not stop eating or control what or how much you were eating? (Circle one.) Yes No IF NO, SKIP TO QUESTION 11 in this section. Do not complete questions 3-​10. 3. During the past 6 months, how often, on average, did you have times when you ate unusually large amounts of food and felt that your eating was out of control? (There may have been some weeks when it was not present-​just average those in.) (Circle one.) a. Less than one day a week

d. Four or five days a week

b. One day a week

e. Nearly every day

c. Two or three days a week 4. Did you usually have any of the following experiences during these occasions? Complete all items. a. Eating much more rapidly than usual? (Circle one.)

Yes

No

b.  Eating until you felt uncomfortably full? (Circle one.)

Yes

No

c. Eating large amounts of food when you didn’t feel physically hungry? (Circle one.)

Yes

No

d. Eating alone because you were embarrassed by how much you were eating? (Circle one.)

Yes

No

e. Feeling disgusted with yourself, depressed or feeling very guilty after overeating? (Circle one.)

Yes

No

f. Eating large amounts of food throughout the day with no planned mealtimes? (Circle one.)

Yes

No

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5. Think about a typical time when you ate this way (that is, large amounts of food and feelings that your eating was out of control) What time of day did the episode start? (Circle one.) a. Morning (8 AM to 12 Noon) b. Early afternoon (12 Noon to 4 PM) c. Late afternoon (4 PM to 7 PM) d. Evening (7 PM to 10 PM) e. Night (After 10 PM) 6. Approximately how long did this episode of eating last, from the time you started to eat until when you stopped and did not eat again for at least two hours? ____________ hours ____________ minutes 7. As best as you can remember, please list everything you might have eaten or drunk during that episode. If you ate for more than two hours, describe the food eaten and liquids drunk that you ate the most. Be specific-​include amounts and brand names (when possible). Estimate as best as you can. For example:  7 ounces Ruffles potato chips; 1 cup Breyer’s chocolate ice cream with 2 teaspoons of hot fudge; two 8-​ounce glasses of Coca-​Cola; and 1½ ham and cheese sandwiches with mustard. FOOD

AMOUNT

BRAND (if possible)

​ ​ ​

​ ​ ​

​ ​ ​

​ ​ ​

​ ​ ​

​ ​ ​

​ ​ ​

233

8. At the time this episode started, how long had it been since you had previously finished eating a meal or snack? hours minutes 9. In general, during the past 6 months, how upset were you by overeating episodes in which you ate unusually large amounts of food? (Circle one.) a. Not at all

d. Greatly

b. Slightly

e. Extremely

c. Moderately 10. In general, during the past 6 months, how upset were you by feeling that you could not stop eating or could not control what or how you were eating? (Circle one.) a. Not at all

d. Greatly

b. Slightly

e. Extremely

c. Moderately 11. In general, during the past 6 months, how important has your weight or shape been in how you feel about or evaluate yourself as a person-​compared to other aspects of your life (i.e. how you do at work, as a parent, or how you get along with other people)? Weight and shape … a. were not very important b. played a part in how I felt about myself c. were among the main things that affected how I felt about myself d. were the most important things that affected how I felt about myself 12.  During the past 3 months, did you ever make yourself vomit in order to avoid gaining weight after binge eating? (Circle one.)  Yes  No If Yes: How often, on average, was that? (Circle one.) a. Less than once a week b. Once a week c. Two or three times a week

234

d. Four or five times a week e. More than five times a week 13.  During the past 3 months, did you ever take more than twice the recommended dose of laxatives in order to avoid gaining weight after binge eating? (Circle one.)  Yes  No If Yes: How often, on average, was that? (Circle one.) a. Less than once a week b. Once a week c. Two or three times a week d. Four or five times a week e. More than five times a week 14.  During the past 3 months, did you ever take more than twice the recommended dose of diuretics (water pills) in order to avoid gaining weight after binge eating? (Circle one.)  Yes  No If Yes: How often, on average, was that? a. Less than once a week b. Once a week c. Two or three times a week d. Four or five times a week e. More than five times a week 15.  During the past 3 months, did you ever fast (not eat anything at all for at least 24 hours) in order to avoid gaining weight after binge eating? (Circle one.)  Yes  No If Yes: How often, on average, was that? a. Less than once a week b. Once a week c. Two or three times a week d. Four or five times a week e. More than five times a week

235

16.  During the past 3 months, did you ever exercise for more than one hour specifically in order to avoid gaining weight after eating? (Circle one.)  Yes  No If Yes: How often, on average, was that? a. Less than once a week b. Once a week c. Two or three times a week d. Four or five times a week e. More than five times a week 17.  During the past 3 months, did you ever take more than twice the recommended dosage of a diet pill in order to avoid gaining weight after binge eating? (Circle one.)  Yes  No If Yes: How often, on average, was that? a. Less than once a week b. Once a week c. Two or three times a week d. Four or five times a week e. More than five times a week

SECTION K: EATING PATTERNS II Directions: Please circle ONE answer for each question. 1. How hungry are you usually in the morning? 0

1

2

3

4

Not at all

A little

Somewhat

Moderately

Very

2. When do you usually eat for the first time?

236

0

1

2

3

4

Before 9 AM

9:01 to 12 PM

12:01 to 3 PM

3:01 to 6 PM

6:01 or later

3. Do you have cravings or urges to eat snacks after supper, but before bedtime? 0

1

2

3

4

Not at all

A little

Somewhat

Very much so

Extremely so

4. How much control do you have over your eating between supper and bedtime? 0

1

2

3

4

Not at all

A little

Some

Very much

Complete

5. How much of your daily food intake do you consume after suppertime? 0

1

2

3

4

0%

1–​25%

26–​50%

51–​75%

76–​100%

(none)

(up to a quarter)

(about half)

(more than half)

(almost all)

6. Are you currently feeling blue or down in the dumps? 0

1

2

3

4

Not at all

A little

Somewhat

Very much so

Extremely

7. When are you feeling blue, is your mood lower in the: 0

1

2

3

4

Early Morning Late Morning Afternoon Early Evening Late Evening/​Nighttime 8. How often do you have trouble getting to sleep? 0

1

2

3

4

Never

Sometimes

About half the time

Usually

Always

9. Other than only to use the bathroom, how often do you get up at least once in the middle of the night? 0

1

2

3

4

Never

Less than once a week

About once a week

More than once a week

Every night

**************** IF 0 ON #9, PLEASE STOP HERE **************** 237

10.  Do you have cravings or urges to eat snacks when you wake up at night? 0

1

2

3

4

Not at all

A little

Somewhat

Very much so

Extremely so

11.  Do you need to eat in order to get back to sleep when you awake at night? 0

1

2

3

4

Not at all

A little

Somewhat

Very much so

Extremely so

12.  When you get up in the middle of the night, how often do you snack? 0

1

2

3

4

Never

Sometimes

About half the time

Usually

Always

**************** IF O ON #12, PLEASE SKIP TO #15 **************** 13.  When you snack in the middle of the night, how aware are you of your eating? 0

1

2

3

4

Not at all

A little

Somewhat

Very much so

Completely

14.  How much control do you have over your eating while you are up at night? 0

1

2

3

4

None at all

A little

Some

Very much

Complete

15.  How long have your difficulties with night eating been going on? months

​ years

The Night Eating Questionnaire is reprinted here from: Allison, K. C., Stunkard, A. J., & Thier, S. L. (2004). Overcoming night eating syndrome: A step-​by-​step guide to breaking the cycle. Oakland, CA: New Harbinger.

238

SECTION L: PHYSICAL ACTIVITY 1. To what extent do you enjoy physical activity? (Check one.) not at all

slightly



moderately



greatly

2. Do you have any physical problems that limit your physical activity? (Circle one.) Yes No If yes, please describe.  ​ ​ 3. Please check the types of physical activity that you enjoy. Check only those that you have participated in during the last year. _​_​_​ a. walking outside

_​_​_​ e. biking outside

_​_​_​ b. walking (indoors, including treadmill) _​_​_​ f. biking (stationary) _​_​_​ c. jogging _​_​_​ g. aerobic class _​_​_​ d. running

_​_​_​ h. tennis/​racket _​_​_​ k. golf sports _​_​_​ l.  dancing _​_​_​ i. swimming _​_​_​ m. strength _​_​_​ j. basketball training

_​_​_​​ n. other, Please describe ​ 4. For your most preferred activity, how many times have you participated in this activity in the past 6 months? _​_​_​_​_​ times 5. How many hours of TV do you watch on an average weekday? _​_​_​_​_​ hours 6. How many hours of TV do you watch on an average weekend day? _​_​_​_​_​ hours 7. Approximately how many city blocks or the equivalent do you regularly walk each day? _​_​_​_​_​ blocks (12 blocks = 1 mile) 8. How many flights of stairs do you climb up each day? _​_​_​_​_​flights a day (1 flight = 10 steps)

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9. Please describe your daily lifestyle activity (i.e., how active you are) by picking any number from 1 to 10 in which 1 = very sedentary and 10 = very active. Your number is: _​_​_​_​_​

SECTION M: FAMILY AND LIVING ARRANGEMENTS

1. I am currently: (Check one.)

2. Currently, I am: (Check all that apply.)

_​_​_​_​_​ Single

_​_​_​_​_​ living alone

_​_​_​_​_​ Married

_​_​_​_​_​ living with a spouse/​partner

_​_​_​_​_​ Divorced

_​_​_​_​_​ living with a significant other

_​_​_​_​_​ Separated

_​_​_​_​_​ living with children

_​_​_​_​_​ Widowed

_​_​_​_​_​ living with parents/​step-​parents _​_​_​_​_​ living with other relatives _​_​_​_​_​ living with roommates

3. Please indicate the total number of persons living in your home. _​_​_​_​_​ 4. If you are currently involved in an intimate relationship (significant other), please answer these questions. What is this person’s attitude towards your efforts to lose weight? (Circle one) a. strongly supports my efforts b. supports my efforts c. neutral d. opposes my efforts e. strongly opposes my efforts f. Please describe briefly what this person does either to help or hinder your efforts to lose weight.  ​ 

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5. How satisfied are you with your overall relationship with this person? (Circle one.) a. very satisfied b. satisfied c. neutral d. dissatisfied e. very dissatisfied 6. Will other people support your efforts to lose weight? (Circle one.)  Yes  No If yes, how many people will? _​_​_​_​_​Who are these people? 

​

 a. How many of these people are actively helpful to you?

​ ​

7. How many people do you talk with about your weight and when you are upset about it? ​ a. How many of these people are helpful to you? _​_​_​_​___​ 8. Will other people oppose or undermine your efforts to lose weight? (Circle one.)  Yes  No If yes, how many will? _​_​_​_​_​ a. Who are these people? 

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​

SECTION N: SELF-​PERCEPTIONS 1. How satisfied are you with your current weight? (Check one.) _​_​_​_​_​ very satisfied _​_​_​_​_​ moderately satisfied _​_​_​_​_​ slightly satisfied _​_​_​_​_​ neutral _​_​_​_​_​ slightly dissatisfied

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_​_​_​_​_​ moderately dissatisfied _​_​_​_​_​ very dissatisfied 2. How satisfied are you with your current shape? (Check one.) _​_​_​_​_​ very satisfied _​_​_​_​_​ moderately satisfied _​_​_​_​_​ slightly satisfied _​_​_​_​_​ neutral _​_​_​_​_​ slightly dissatisfied _​_​_​_​_​ moderately dissatisfied _​_​_​_​_​ very dissatisfied 3. How satisfied are you with your current overall appearance? _​_​_​_​_​ very satisfied _​_​_​_​_​ moderately satisfied _​_​_​_​_​ slightly satisfied _​_​_​_​_​ neutral _​_​_​_​_​ slightly dissatisfied _​_​_​_​_​ moderately dissatisfied _​_​_​_​_​ very dissatisfied 4. Pick the one sentence that best describes your overall feelings about yourself. “In general, I am …” (Check one.) _​_​_​_​_​ very happy with who I am _​_​_​_​_​ happy with who I am _​_​_​_​_​ok with who I am but have some mixed feelings _​_​_​_​_​ unhappy with who I am _​_​_​_​_​ very unhappy with who I am 242

5. “As compared with most people, I think I have …” (Check one.) _​_​_​_​_​ very good self-​esteem _​_​_​_​_​ good self-​esteem _​_​_​_​_​ average self-​esteem _​_​_​_​_​ poor self-​esteem _​_​_​_​_​ very poor self-​esteem 6. Pick the one sentence that best describes your feelings about the way you looked the last time you lost a lot of weight. “I was …” (Check one.) _​_​_​_​_​very happy with the way I looked _​_​_​_​_​ happy with the way I looked _​_​_​_​_​ok with the way I looked, but with some mixed feelings _​_​_​_​_​ unhappy with the way I looked _​_​_​_​_​very unhappy with the way I looked 7. How much weight did you lose? _​_​_​_​_​lbs. At what weight did you start to diet during this time? _​_​_​_​_​ lbs.

SECTION O: PSYCHOLOGICAL FACTORS 1. Have you ever had any problems anytime with depression, anxiety, or other emotions that disrupted your normal functioning? (Circle one.)  Yes  No 2. Have you ever sought professional help for emotional problems? If yes, specify below. Problem

Year

Duration (wks.)

Type of Professional Help

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​ 





​ 

​ 



​

​

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3. During the past month, have you felt depressed, sad, or blue much of the time? (Circle one.)

Yes

No

4. During the past month, have you often felt hopeless about the future? (Circle one.)

Yes

No

5. During the past month, have you had little interest or pleasure in doing things? (Circle one.)

Yes

No

6. Have you ever been subjected to physical abuse? (Circle one.)

Yes

No

7. Have you ever been subjected to sexual abuse? (Circle one.)

Yes

No

8. Are any of your immediate family members alcoholic? (Circle one.)

Yes

No

SECTION P: TIMING 1. Please indicate if you are currently experience any greater than usual stress in your life related to the following events. Complete each item by circling the appropriate answer. a. Work: (Circle one.)

Yes

No

b. Health: (Circle one.)

Yes

No

c. Relationship with spouse/​significant other: (Circle one.)

Yes

No

d. Activities related to your children: (Circle one.)

Yes

No

e. Activities related to your parents: (Circle one.)

Yes

No

f. Legal/​financial trouble: (Circle one.)

Yes

No

g. School: (Circle one.)

Yes

No

h. Moving : (Circle one.)

Yes

No

i. Other: 

​

Please explain in a sentence any items to which you responded yes: 

​

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2. Are you planning any major life changes (i.e., new job, moving, relationship, etc.) during the next 6 months? (Circle one.)  Yes  No

If yes, please briefly describe below: ​ 

​



​

3. How stressful has your life been during the past 6 months? (Circle one.) 1.  much less stressful than usual 2.  less stressful than usual 3.  average level of stress 4.  more stressful than usual 5.  much more stressful than usual 4. How stressful do you think that your life will be in the next 6 months, excluding your efforts to lose weight. Pick a number from above.  ​ 5. How motivated are you to lose weight at this time? Pick a number between 1 and 10, in which 1 = not motivated and 10 = greatest motivation you have ever had. Your number is:  ​

6. Why do you want to lose weight right now, as compared to 1  year ago? What has prompted you to lose weight now? ​ 

​



7. What is the single most important thing that you hope to achieve as a result of losing weight? ​ 

​



​

8. People who want to achieve long-​term weight control need to spend at least 30 minutes a day, for a minimum of 6 months trying to change their eating, exercise, and thinking habits.

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Please check the number below that best describes you: 

1. I definitely will not be able to devote 30 minutes daily to weight control.



2. I’m not sure if I can find 30 minutes daily for weight control.



3. I can definitely find 30 minutes daily for weight control.



4. I can devote more than 30 minutes daily to weight control.

9. Rate how confident you are that you will be able to significantly change your eating and exercise habits. Pick a number from 1 to 10 in which 1  =  not all confident and 10 = extremely confident. Your number is: 

SECTION Q: MEDICAL HISTORY 1.  Please indicate if you have had any of the medical conditions listed below:

YES Heart Disease Angina (chest pains) Palpitations, heart beats fast or hard Stroke, mild stroke (cerebrovascular accident) Rheumatic fever Heart murmur Pacemaker Breathing problems (asthma, lung disease) High blood pressure Anemia Back problems

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NO

Joint or bone problems Hiatal hernia Arthritis Gout (elevated uric acid) Gallbladder disease Thyroid problems Kidney disease Ulcers Bowel disease Liver disease Diabetes (type I or II) Sleep Apnea Bodily pain Other (specify) 2. List all medications you currently take (including vitamins and supplements). Please indicate the dosage and frequency (number of times a day) of each medication. Medication

Dosage

Frequency

Reason for taking



​ 

​ 

​ ​



​ 

​ 

​ ​



​ 

​ 

​ ​



​ 

​ 

​ ​



​ 

​ 

​ ​



​ 

​ 

​ ​

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​ 

​ 

​ ​



​ 

​ 

​ ​

Please indicate your primary care physician’s name, telephone number, and address here. Name:   Tel: 

​

Address: 

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​

ADDITIONAL INFORMATION (Please use this space to provide any additional information that you think is important to understanding you or your weight problem, as well as the goals you seek.)               

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249

                       

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Appendix B

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References

Butryn, M. L., Webb, V., & Wadden, T. A. (2011). Behavioral treatment of obesity. The Psychiatric Clinics of North America, 34(4), 841. Catenacci, V. A., Grunwald, G. K., Ingebrigtsen, J. P., Jakicic, J. M., McDermott, M. D., Phelan, S., . . . Wyatt, H. R. (2011). Physical activity patterns using accelerometry in the National Weight Control Registry. Obesity, 19(6), 1163–​70. Church, T. S., Thomas, D. M., Tudor-​Locke, C., Katzmarzyk, P. T., Earnest, C. P., Rodarte, R. Q., . . . Bouchard, C. (2011). Trends over 5 decades in U.S. occupation-​related physical activity and their associations with obesity. PLoS ONE, 6(5), e19657. Diliberti, N., Bordi, P. L., Conklin, M. T., Roe, L. S., & Rolls, B. J. (2004). Increased portion size leads to increased energy intake in a restaurant meal. Obesity Research, 12(3), 562–​568. Forman, E. M., Butryn, M. L., Hoffman, K. L., & Herbert, J. D. (2009). An open trial of an acceptance-​based behavioral treatment for weight loss. Cognitive and Behavioral Practice, 16, 223–​235. Forman, E. M., Butryn, M. L., Juarascio, A. S., Bradley, L. E., Lowe, M. R., Herbert, J. D., & Shaw, J. A. (2013). The Mind your Health project: A randomized controlled trial of an innovative behavioral treatment for obesity. Obesity 21(6), , 1119–​1126. Forman, E. M., Butryn, M. L., Manasse, S. M., Wyckoff, E. P., & Goldstein, S. P (2016, April). Acceptance-​based behavioral weight loss treatment outperforms standard BT:  Outcomes from the Mind Your Health study. Paper to be presented at the 37th Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine, Washington, D.C. Forman, E. M., & Herbert, J. D. (2009). New directions in cognitive behavior therapy:  Acceptance-​based therapies. In W. O’Donohue & J. E. Fisher (Eds.), General principles and empirically supported techniques of cognitive behavior therapy (pp. 77–​101). Hoboken, NJ: Wiley. Forman, E. M., Hebert, J. D, Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behavior Modification, 31(6), 772–​799.

253

Franz, M. J, VanWormer, J. J., Crain, A. L., Boucher, J. L., Histon, T., Caplan, W., . . . Pronk, N. P. (2007). Weight-​loss outcomes: A systematic review and meta-​analysis of weight-​loss clinical trials with a minimum 1-​year follow-​up. Journal of the American Dietetic Association, 107(10), 1755–​1767. French, S. A., Story, M., & Jeffery, R. W. (2001). Environmental influences on eating and physical activity. Annual Review of Public Health, 22, 309–​335. Gifford, E. V., Kohlenberg, B. S., Hayes, S. C., Antonuccio, D. O., Piasecki, M. M., Rasmussen-​Hall, M. L., & Palm, K. M. (2004). Acceptance-​based treatment for smoking cessation. Behavior Therapy, 35(4), 689–​705. Godsey, J. (2013). The role of mindfulness based interventions in the treatment of obesity and eating disorders:  An integrative review. Complementary Therapies in Medicine, 21(4), 430– ​439. Goldstein, D. J. (1992). Beneficial health effects of modest weight loss. International Journal of Obesity and Related Metabolic Disorders, 16(6), 397–​415. Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-​Lawson, J. L. (2007). Improving diabetes self-​ management through acceptance, mindfulness, and values:  A  randomized controlled trial. Journal of Consulting and Clinical Psychology, 75(2), 336–​343. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–​25. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy:  An experiential approach to behavior change. New York, NY: Guilford Press. Hill, J. O., & Peters, J. C. (1998). Environmental contributions to the obesity epidemic. Science, 280(5368), 1371–​1374. Hill, J. O., Wyatt, H. R., Reed, G. W., & Peters, J. C. (2003). Obesity and the environment: Where do we go from here? Science, 299(5608), 853–​855. Hutton, B., & Fergusson, D. (2004). Changes in body weight and serum lipid profile in obese patients treated with orlistat in addition to a hypocaloric diet: A systematic review of randomized clinical trials. The American Journal of Clinical Nutrition, 80(6), 1461–​1468. Jeffery, R. W., Wing, R. R., Sherwood, N. E., & Tate, D. F. (2003). Physical activity and weight loss: Does prescribing higher physical activity goals improve outcome? The American Journal of Clinical Nutrition, 78(4), 684– ​689.

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Niemeier, H. M., Leahey, T., Palm Reed, K., Brown, R. A., & Wing, R. R. (2012). An acceptance-​based behavioral intervention for weight loss: A pilot study. Behavior Therapy, 43(2), 427–​435. O’Reilly, G. A., Cook, L., Spruijt‐Metz, D., & Black, D. S. (2014). Mindfulness‐based interventions for obesity‐related eating behaviours: A literature review. Obesity Reviews, 15(6), 453–​461. Raynor, H. A., & Epstein, L. H. (2001). Dietary variety, energy regulation, and obesity. Psychological Bulletin, 127(3), 325–​341. Tsai, A. G., & Wadden, T. A. (2005). Systematic review: An evaluation of major commercial weight loss programs in the United States. Annals of Internal Medicine, 142(1), 56–​66. Unick, J. L., Beavers, D., Jakicic, J. M., Kitabchi, A. E., Knowler, W. C., Wadden, T. A., & Wing, R. R. (2011). Effectiveness of lifestyle interventions for individuals with severe obesity and Type 2 diabetes:  Results from the Look AHEAD trial. Diabetes Care, 34(10), 2152–​2157. Veehof, M. M., Oskam, M. J., Schreurs, K. M., & Bohlmeijer, E. T. (2011). Acceptance-​based interventions for the treatment of chronic pain: A systematic review and meta-​analysis. Pain, 152(3), 533–​542. Wansink, B. (2004). Environmental factors that increase the food intake and consumption volume of unknowing consumers. Annual Review of Nutrition, 24, 455–​479. Weinsier, R. L., Hunter, G. R., Desmond, R. A., Byrne, N. M., Zuckerman, P. A., & Darnell, B. E. (2002). Free-​living activity energy expenditure in women successful and unsuccessful at maintaining a normal body weight. The American Journal of Clinical Nutrition, 75(3), 499–​504. Wing, R. R., Lang, W., Wadden, T. A., Safford, M., Knowler, W. C., Bertoni, A. G., . . . Wagenknecht, L. (2011). Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with Type 2 diabetes. Diabetes Care, 34(7), 1481–​1486.

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