It’s not uncommon to put on a few pounds while recovering from an injury or health issue. Psychologist Amy Walters, PhD, sees this quite often in her practice helping people carry out recommendations from their physicians designed to improve patients’ health.

“People are usually referred to me by physicians and dieticians because they are struggling with improving their health and making behavior and lifestyle changes,” says Walters. “Weight is one of the most common health factors I address with patients. Sometimes, it’s accompanied by multiple health issues. So, it’s not surprising to hear people say they’re having a hard time adhering to treatment.”

So, how exactly does a psychologist like Walters help people with weight loss and overcoming barriers to living a healthy life? APA asked Walters to walk us through a typical treatment situation.

Real life scenario: Psychologists helping with behavior change

An adult male in his 50s with Type 2 diabetes has major surgery to an injured shoulder. Exercise is limited during his recovery period. He gains weight and is told by his physician to lose weight. The man tries multiple diets on his own but is not successful. Since Walters is on staff at a diabetes center, this patient is referred to her by the staff dietician to help with changing behaviors.

So what happened during the initial visit?
Walters: When this patient first came to me, we talked about his goals, and obtained a full history including health, weight loss efforts, mental health, education, current life situation, social supports, stress levels and coping skills. I looked for emotional and behavioral concerns while discussing his history and basic beliefs about food. In this case, I learned he had a number of ingrained habits and attitudes about food and eating that did not support his health goals. For example, he believed that he had to clean his plate; have desert after each meal; and could eat whatever he wanted after exercising. He had a habit of stopping by the local bakery after leaving the gym. He also kept eating at meals even when he was no longer hungry and often used food to cope with feelings of boredom. These are common patterns I see among many patients. Unfortunately these behaviors and beliefs often sabotage weight loss efforts. We also talked about his challenges to making healthy choices and identified triggers that prompted him to make unhealthy selections. In addition, I completed a screening for anxiety and depression, both common in people with chronic illnesses (like diabetes) and can sometimes contribute to weight issues.
What was accomplished in the first visit?

Walters: By the end of the first visit, I had a comprehensive picture of this person. I highlighted what he was doing well and should continue. And then, we discussed his needs and difficulties. In this case, he had a number of beliefs and habits that were interfering with his weight loss goals. He agreed he would like to work with me, so we set up regular weekly appointments and started mapping out a treatment plan for him.

What was involved in the treatment plan?

Walters: Treatment plans are different for everyone. Treatment often involves teaching self-monitoring behaviors, challenging and changing old beliefs, building new coping skills and changing the home and work environment to support their health goals. Ultimately, I am helping people address obstacles and develop new behavior skills and ways of thinking. I assess and analyze current behaviors and identify positive ways to change unhealthy habits.  

In the case of this male patient, we first identified what he wanted to accomplish and which issue was most important to focus on. We concentrated on one health behavior at a time. For example, evenings were a challenge for him when it came to good eating habits. I asked him to keep a log of food he ate in the evenings and make notes about his environment, how he was feeling at the time and what he was thinking. These factors provided important information on what was driving his eating behaviors and helped us figure out a way to address them.

Tell us more about how you handled this patient’s diabetes.

Walters: Diabetes is a self-managed disease, so self-regulating and being consistent with daily lifestyle behaviors is important. A diabetes regimen includes testing of blood sugar throughout the day, getting regular exercise, monitoring food intake, and for some, taking medications. Being consistent is critical. I’ve seen cases in which people with diabetes had anxiety about testing their blood sugar or taking their insulin, so they avoided these activities. So, as part of my work with these patients, we address their avoidance issue.

Another important aspect of managing diabetes is following a meal plan. Many patients know they need to make changes, but aren’t sure where to start or how to do it. I help patients figure out how to begin the change process and carry out their desired changes on a daily basis. Diabetes is a demanding disease. It requires patients to adhere to a complex medical regimen in order to achieve good outcomes. This can become tiresome and many patients experience burnout. In many cases, physicians refer their patients to me for help in boosting their motivation.

So, what happened with this patient?

Walters: After several sessions he began making some significant changes. He started challenging his old beliefs about food and practicing new ones that supported his health goals. He changed his daily routine to support healthy behaviors and make the healthy choice the easy choice. He stopped visiting the bakery after workouts and instead put that money in a jar to save for a new MP3 player he could use while exercising. Finally, he found alternative ways to deal with his feelings of boredom. As a result of these changes, he began to lose weight and his blood sugar levels improved.  He and his physician were both very happy with his progress.   

How long does treatment typically last?

Walters: Everyone is different. I always determine where people are emotionally and physically, and start there. Treatment tends to consist of six to 10 visits either once a week or every other week. Then we move to monthly follow up visits or as needed. People with extreme anxiety and depression (or other mental health needs) may require longer and or more frequent treatment.

My ultimate goal is to help people develop skills so they can lead healthy lives.

Amy Walters, PhD, is Director of Behavioral Health Services at St. Luke’s Humphrey Diabetes Center, Boise, Idaho. She is a member of the APA and contributes to APA’s "Your Mind Your Body" blog.

Changing your eating behaviors

Typical things Walters asks of patients to help change their eating behaviors.

  • Self-monitor behaviors
    Research is clear that people who write down what they eat in a daily log are more successful at losing weight. In addition, I ask patients to record information about their thoughts, feelings and the environment to help understand their eating behaviors and identify areas for intervention.

  • Understanding and changing food associations
    Behaviors are habitual and learned. Sometimes people may associate certain emotions, experiences or daily activities with particular behaviors. For example, if you typically eat while watching TV your brain is making an association between food and TV. You could be sitting in front of the TV and not feel hungry. But, in your mind TV and eating are paired together, so you feel the urge to eat in this instance, although eating has nothing to do with being hungry. So we focus on breaking the association of eating with watching TV.

  • Track emotions
    It’s important to figure out what is going on emotionally while snacking, overeating or choosing unhealthy foods. Is it boredom? I tell patients to determine if they are really hungry or responding to another emotion like boredom. Second, I ask them to think of what to do instead of eating to find another way to meet that need. If they are bored we identify ways to feel stimulated or interested that doesn’t involve food like reading a book or taking a walk. Another example is dealing with negative emotions. When feeling down or stressed, people often turn to food to feel better. For example, someone has a rough day and wants to eat a pint of ice cream at night. Unfortunately, this behavior sabotages their health goals. So part of tracking emotions involves being mindful of feelings and finding healthy ways to cope with them.

  • Change environment
    One of my female patients had a weakness for Oreo cookies and had actually won a supply of them. She had a hard time getting away from those cookies because they were so easily accessible. So, we made a decision to keep the cookies out of her kitchen pantry and instead, store them in a bin in her garage. By making this small change, the cookies were out of sight and not easily accessible. And, she was now less inclined to snack on them.

  • Behavior modification
    Psychological science tells us it is important to reinforce behaviors we are trying to increase. Too often, patients have negative feelings about changing their health behaviors and see the process as punitive. We work together to find ways to reward the changes they are making in their eating behaviors. For example, when a patient is trying to reduce her sweets intake, I may have her put the money she would usually spend on cookies or candy in a jar. This money then becomes hers to spend on something else she would enjoy for example clothes, music or a massage. It serves as a reward for making healthy eating choices and reinforces her positive behaviors.