June was an 18-year-old biracial female who lived with her parents. She was a senior in high school with sporadic attendance. June was referred for psychotherapy and multicomponent behavioral weight treatment, with specific concerns focused on her difficulty making healthy eating choices and her low motivation to engage in physical activity. Her body mass index (BMI) was 33. June did not plan her meals, had difficulty modulating her portions, and snacked often. She typically ate in front of the television. She did not enjoy physical activity, and attributed this to difficulty finding the motivation to exercise.
June’s difficulties with general weight management were complicated by her symptoms of depression and anxiety, including low mood, frequent worries, decreased energy, anhedonia, sleep disturbance, social withdrawal, avoidance, and difficulty concentrating. While she did not currently experience suicidal ideation, she did endorse a history of hopelessness and suicidal thoughts. Her symptoms began in middle school, following significant weight-based bullying from peers. June’s mood symptoms affected her ability to adhere to her health goals and regularly attend school. June was offered an anti-depressant by her gynecologist but was concerned about the potential impact on her weight. The physician helped her understand the risks of obesity and untreated depression before referring her to the combined psychotherapy and weight management services.
Three treatment goals were identified. The first was to improve June’s eating behaviors by generating healthy food options. The second was to improve physical activity by using self-monitoring and increasing enjoyable physical activities. And the third was to address her low mood and anxiety by increasing adaptive coping skills and using behavioral activation techniques. June met with both a dietician and an exercise specialist and each gathered more detailed information about June’s current food consumption and activities. This information was used by the psychologist to develop treatment options and the psychologist referred June later in treatment to these specialists for more detailed guidance.
At the outset of treatment, the psychologist used motivational interviewing to empathize with and empower June to take steps toward change. The psychologist affirmed her strengths and acknowledged some of her uncertainty about change and addressing barriers to change. Despite her difficulty with motivation and low energy, June was cooperative and displayed a consistent commitment to treatment.
Next, the psychologist used cognitive behavioral and mindfulness-based strategies to address June’s low mood and to increase her emotional awareness. The psychologist started by providing psychoeducation regarding the effect of mood on motivation. June and the psychologist also spent considerable time in the early weeks of treatment tracking June’s emotional experiences, including antecedents and consequences of her negative emotions, and how these experiences affected her eating and exercise behaviors. She benefited from the completion of non-judgmental emotional awareness/present-focused mindfulness exercises in session. June displayed insight when she made the connection between a negative comment regarding her weight and her mood, sleep, appetite, motivation, and cognitions in the days following. June engaged in weekly behavioral activation activities outside of session to slowly increase her engagement with peers. Additionally, the psychologist gave June sleep hygiene recommendations to help her adopt a consistent sleep schedule, eliminate naps, and reduce electronics used before bedtime, as well as during meals. Over time, June reported positive changes in her mood, relationships with her family and peers, as well as increased participation at school.
June’s psychologist observed a clinically significant shift in June’s mood symptoms and an increase in June’s motivation toward her lifestyle goals. At that point, the psychologist employed solution-focused and behavioral modification strategies to target June’s poor eating habits and increase her physical activity. This stage of treatment utilized self-monitoring tools in order to obtain baseline information, as well as to determine entry points for behavioral change. June tracked her food choices and physical activities using smart devices and free apps. To meet physical activity goals, several sessions focused on identifying activities for June that were both enjoyable and not time consuming. June was less overwhelmed by introducing small workouts rather than lengthy exercise routines. She successfully increased her daily steps by marching in place during television commercial breaks, taking the stairs in her apartment building, and completing brief high-intensity workouts on a daily basis.
Regarding her healthy food goals, June took successful approximations toward healthier choices, such as gradually switching from sugary soda to a low-sugar beverage and then to water, and by replacing calorie-high and nutrition-low snacks with high protein alternatives in the afternoons. Moreover, she identified several obstacles to making healthy food choices, including the fact that she did not purchase her own food and often ate fast food with family members as a means of social connection. In response, several sessions were focused on increasing communication with her parents and other family members regarding her treatment goals, brainstorming alternative ways to socially connect with her family, and finally, taking active steps to be included in all food planning responsibilities. June enjoyed meeting with the dietician and gaining knowledge about the nutritional needs of 18-year-old females. This knowledge helped her contribute actively to discussions about meals so that near the end of treatment, June was working with her parents to food shop and plan meals together. She ate most of her meals within the home, and she found a communal joy in preparing and sharing meals with her family.
Over the treatment course, June was able to achieve success in making her lifestyle behavioral changes by first addressing her motivation, low mood, and anxiety. This underscores the value of targeting psychological difficulties in order to achieve health goals. Finally, the use of self-monitoring tools and motivational interviewing techniques not only allowed, but empowered, June to set obtainable treatment goals as well as to identify and overcome barriers to progress. By the end of brief treatment with the psychologist, her BMI had declined to 30.