OVERWEIGHT/OBESITY

CLIENT PRESENTATION

High Body Mass Index (1)¹
1. The client reports an excess body weight relative to height that is attributed to an abnormally high proportion of body fat.
2. The client reports a Body Mass Index of 30 or more.
3. As treatment has progressed, the client has decreased his/her Body Mass Index to under 30.
Binge Eating (2)
1. The client described a recurrent pattern of binge eating during times of stress or emotional upset.
2. The client reported experiencing recent episodes of binge eating.
3. The client has not experienced any recent episodes of binge eating.
4. The client has terminated his/her pattern of binge eating.
Eating to Manage Troubling Emotions (3)
1. The client described a pattern of eating in order to manage his/her troubling emotions.
2. The client reported that his/her perception is that he/she feels “comfort” from eating when upset.
3. As the client has gained insight into the cyclical pattern of eating to manage troubling emotions, he/she has come to manage emotions in a healthier manner.
Rapid Eating (4)
1. The client reports a history of eating much more rapidly than normal.
2. The client is uncertain why he/she eats in a more rapid manner than would be expected.
3. As treatment has progressed, the client's food intake is at a more measured pace.
Uncomfortably Full (5)
1. The client reports that he/she eats until feeling uncomfortably full.
2. The client has been able to identify cues toward his/her level of comfortable fullness.
3. The client no longer experiences a sense of being uncomfortably full, but is continuing to eat more moderately.
Overeating When Not Physically Hungry (6)
1. The client reports eating large amounts of food when he/she does not actually feel physically hungry.
2. The client identifies his/her use of food when not hungry as a compensatory behavior.
3. The client has learned to eat when hunger cues are identified.
4. The client no longer eats large amounts of food when not feeling physically hungry.
Eating Alone Due to Embarrassment (7)
1. The client reports that he/she often eats alone because of feeling embarrassed about how much he/she is eating.
2. The client feels that he/she has alienated others from eating with him/her.
3. The client has become more at ease with the social aspects of eating.
4. As treatment has progressed, the client reports a more moderate food intake and feeling more at ease with the social aspect of eating with others.
Low Self-Concept Due to Overeating (8)
1. The client reports that he/she feels disgusted, depressed, or guilty after eating too much.
2. The client has explored his/her emotional reaction to overeating.
3. The client reports that as he/she has decreased his/her pattern of overeating, his/her emotional well-being has improved.

INTERVENTIONS IMPLEMENTED

Establish Trust-Based Relationship (1)²
1. Initial trust level was established with the client through use of unconditional positive regard.
2. Warm acceptance and active listening techniques were utilized to establish the basis for a nurturing relationship.
3. The client has formed a trust-based relationship and has begun to express his/her thoughts and feelings regarding his/her adoption; positive feedback was provided.
4. Despite the use of active listening, warm acceptance, and unconditional positive regard, the client remains resistant to trust and does not share his/her thoughts and feelings.
Gather Problem History (2)
1. Today's therapy session explored the factors contributing to the client's obesity.
2. The personal and family eating patterns, thoughts, attitudes, and beliefs about food and emotional status were assessed.
3. A complete history of the client's eating behavior was taken in today's therapy session.
4. Today's therapy session focused on the targets for treatment.
Assess for Psychopathology (3)
1. The child was assessed for psychopathology that may be contributing to overeating, including depression, anxiety, or other psychological conditions.
2. The parents were assessed for psychopathology that may be contributing to overeating, including depression, anxiety, or other psychological conditions.
3. Appropriate treatment was coordinated for the psychopathology uncovered within the family.
Refer/Conduct Substance Abuse Evaluation (4)
1. The client was referred for a substance abuse evaluation to assess the extent of his/her drug/alcohol usage and to determine the need for treatment.
2. The findings from the substance abuse evaluation revealed the presence of a substance abuse problem and the need for treatment.
3. The findings from the substance abuse evaluation revealed the presence of a substance abuse problem that appears to be contributing to the client's behavior control problems.
4. The evaluation findings did not reveal the presence of a substance abuse problem or the need for treatment in this area.
Provide Psychological Testing (5)
1. The client was referred for psychological testing to assist in forming the overall assessment, including confirming or ruling out psychopathology.
2. A psychological evaluation was conducted in order to assist in providing a clearer picture of the client's overall level of pathology.
3. The client was provided with feedback regarding the results of the assessment.
4. The psychological assessment instruments were readministered as needed to assess treatment outcome.
Assess Level of Insight (6)
1. The client's level of insight toward the presenting problems was assessed.
2. The client was assessed in regard to the syntonic versus dystonic nature of his/her insight about the presenting problems.
3. The client was noted to demonstrate good insight into the problematic nature of the behavior and symptoms.
4. The client was noted to be in agreement with others' concerns and is motivated to work on change.
5. The client was noted to be ambivalent regarding the problems described and is reluctant to address the issues as a concern.
6. The client was noted to be resistant regarding acknowledgment of the problem areas, is not concerned about them, and has no motivation to make changes.
Assess for Correlated Disorders (7)
1. The client was assessed for evidence of research-based correlated disorders.
2. The client was assessed in regard to his/her level of vulnerability to suicide.
3. The client was identified as having a comorbid disorder, and treatment was adjusted to account for these concerns.
4. The client has been assessed for any correlated disorders, but none were found.
Assess for Culturally Based Confounding Issues (8)
1. The client was assessed for age-related issues that could help to better understand his/her clinical presentation.
2. The client was assessed for gender-related issues that could help to better understand his/her clinical presentation.
3. The client was assessed for cultural syndromes, cultural idioms of distress, or culturally based perceived causes that could help to better understand his/her clinical presentation.
4. Alternative factors have been identified as contributing to the client's currently defined “problem behavior,” and these were taken into account in regard to his/her treatment.
5. Culturally based factors that could help to account for the client's currently defined “problem behavior” were investigated, but no significant factors were identified.
Assess Severity of Impairment (9)
1. The severity of the client's impairment was assessed to determine the appropriate level of care.
2. The client was assessed in regard to his/her impairment in social, relational, vocational, and occupational endeavors.
3. It was reflected to the client that his/her impairment appears to create mild to moderate effects on the client's functioning.
4. It was reflected to the client that his/her impairment appears to create severe to very severe effects on the client's functioning.
5. The client was continuously assessed for the severity of impairment, as well as the efficacy and appropriateness of treatment.
Assess for Pathogenic Care (10)
1. The home, school, and community of the client were assessed for pathogenic care and concerns.
2. The client's various environments were assessed for the persistent disregard of the child's needs, repeated changes in caregivers, limited opportunities for stable attachment, harsh discipline, or other grossly inept care.
3. Pathogenic care was identified and the treatment plan included strategies for managing or correcting these concerns and protecting the child.
4. No pathogenic care was identified and this was reflected to the client and caregivers.
Refer for Physical Examination (11)
1. The client was referred for a thorough physical examination to assess the effects that the obesity has had on his/her health.
2. The client followed through by receiving a thorough physical examination.
3. The client is opposed to receiving a thorough physical examination to assess the effects of his/her obesity.
4. The findings from the physical examination revealed that the client's obesity has had a detrimental effect on his/her health.
5. The findings from the physical examination do not reveal any serious health problems.
6. The client has not followed through on a physical examination and was redirected to do so.
Assess/Refer for Psychotropic Medication (12)
1. The client's need for psychotropic medication was assessed.
2. It was determined that the client would benefit from psychotropic medication, and a referral was made.
3. A need for psychotropic medication was not found, and thus no referral was made.
4. The client cooperated with the physician referral, and psychotropic medication has been prescribed.
5. The client has failed to follow through on the physician referral and was encouraged to do so.
Monitor Medication (13)
1. The effectiveness of psychotropic medication and its side effects were monitored.
2. The client reported that the medication has been effective in stabilizing his/her mood; the information is being relayed to the prescribing clinician.
3. The client reported that the psychotropic medication has not been effective or helpful; this information is being relayed to the prescribing clinician.
4. The client has not taken the medication on a consistent basis and was encouraged to do so.
Discuss Risks (14)
1. A discussion was held with the client and parents about how the seeming short-term rewards of overeating increase the risk for more serious medical consequences.
2. Medical consequences such as hypertension and heart disease were discussed with the client and parents.
3. The positive health benefits of good weight management practices were reviewed.
Assess Motivation (15)
1. The client and parents' motivation and readiness for change were assessed.
2. The client appears to be unmotivated for treatment at this time, so motivational interventions were utilized to help clarify and uncover the clients hidden level of motivation.
3. As the client remains unmotivated, his/her treatment for these concerns was deferred for the time being.
4. As the client appears motivated for entering treatment at this time, consent was obtained for continuing with treatment.
Assign Self-Monitoring of Eating and Exercise (16)
1. The client was assigned to self-monitor and record food intake and exercise.
2. The client was assigned the exercise “My Eating and Exercise Journal” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
3. The client's journal was processed with a focus on challenging maladaptive patterns.
4. The client was assisted in replacing maladaptive patterns with adaptive alternatives.
5. The client has not kept a journal record of food intake and exercise and he/she was redirected to do so.
Conduct Behavioral Weight Management (17)
1. Treatment was conducted via the Behavioral Weight Management approach.
2. A discussion was held about obesity, factors influencing it, including lifestyle, exercise, attitudes, cognitions/beliefs, relationships and nutrition.
3. The client was reinforced for his/her regular engagement in the discussion about factors influencing obesity.
4. The client seemed to struggle to engage in a discussion about the factors relating to obesity and was provided with remedial feedback and support.
Assign Reading of Material about Obesity (18)
1. The client and parents were assigned to read psychoeducational information about obesity, factors influencing it, the rationale for treatment, and the emphasis for treatment.
2. The client and parents were assigned to read portions of The LEARN Program for Weight Management (Brownell).
3. The client and parents have read the assigned material and key concepts were processed.
4. The client and parents have not read the assigned material and were redirected to do so.
Review Emphasis of Program (19)
1. The primary emphases of the treatment program was reviewed.
2. The attention was given to whether the client understands and agrees with the rationale and approach for treatment.
Discuss Challenges and Benefits of Treatment (20)
1. A discussion was held with the client and parents regarding realistic expectations for what therapy will entail, including the challenges and benefits.
2. An emphasis on adherence to the treatment program was maintained.
3. The discussion focused on the positive hope for success, as well as realistic expectations about the challenges.
Set Goals (21)
1. The client was assisted in establishing short-term goals, to be accomplished on a weekly basis.
2. The client was assisted in developing medium-term (monthly) goals.
3. The client was assisted in establishing long-term goals, to be accomplished in 6 months to a year.
4. The client was assisted in evaluating and updating his/her goals for treatment.
Discuss Flexible Goal-Setting (22)
1. Recognition that lapses may occur in behavioral change was given, and the need for flexible goals was emphasized.
2. An emphasis was made on the problem-solving approach that should be taken should a lapse occur.
3. Strategies for lapse situations, such as forgiving one's self, identifying triggers, generating and evaluating options for addressing risks, and getting back on track was emphasized.
Monitor Weight (23)
1. The client was assisted in routinely measuring his/her weight.
2. The client's weight was recorded on a chart/graph, in order to represent his/her changes during treatment.
Teach Healthy Nutritional Practices (24)
1. The client was taught healthy nutritional practices involving the concepts of balance and variety.
2. The client was recommended to read portions of Good Enough to Eat: A Kid's Guide to Food and Nutrition (Rockwell).
3. The client was assisted in outlining a healthy food diet consistent with good nutritional practices and aimed at attaining the client's weight goals.
4. The client was assigned the exercise “Developing and Implementing a Healthier Diet” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
Refer to Nutritionist (25)
1. The client was referred to a nutritionist experienced in eating disorders for an assessment of nutritional rehabilitation.
2. Recommendations were made by the nutritionist and these were coordinated into the care plan.
3. The client has not followed through with the referral to a nutritionist and was reminded to do so.
Develop Individualized Diet (26)
1. The client and parents were assisted in developing an individualized diet that includes the child's preferred food choices, while encouraging variety and allowing choice.
2. The client and parents were taught the principle of portion control for managing total caloric intake.
3. An emphasis was placed on the family approach to healthy eating.
4. An emphasis was placed on not prohibiting certain foods, but that moderation of intake is the key to maintaining a healthy weight.
5. The client was assigned the exercise “Developing and Implementing a Healthier Diet” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
Use Stimulus Control Techniques (27)
1. Stimulus control techniques were used to reduce exposure to triggers of spontaneous food buying, selecting, or eating.
2. The client was taught to avoid buying and eating high caloric snacks after school.
3. The client was taught to eat prior to shopping for food, or going to a place where unhealthy food is not readily available.
4. The client was taught to shop for food from a list.
5. The family was asked to make a commitment to have nonnutritional snack foods openly available in the home.
6. The family was encouraged to prepare foods from a preplanned menu.
Use Mealtime Stimulus Control Techniques (28)
1. The client was taught about meal time stimulus control techniques.
2. The client was encouraged to serve food on a smaller plate, and to eat slowly.
3. The family was encouraged to create a pleasant meal time ambiance to create an eating routine conducive to pleasurable, moderated eating.
Make Small Exercise Goals (29)
1. The parents and client were encouraged to identify small, doable changes in activities consistent with therapeutic exercise goals.
2. Lifestyle wellness techniques such as parking further away to promote walking, taking the stairs, walking to school, and other activities was encouraged.
3. The client was assigned “Increasing My Physical Activity” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
4. The client was reinforced for his/her increased activity.
Encourage Physical Activity Games (30)
1. The parents and child were encouraged to play games that require physical movement.
2. The parents and child were encouraged that any computer games should be interactive, physically involved games.
3. The child was reinforced for his/her regular use of physical movement games.
Encourage Organized Physical Activities (31)
1. The client was encouraged to participate in organized physical activities such as physical education, swimming, and youth club sports.
2. The client was reinforced for his/her regular participation in organized physical activities.
Explore Self-Talk (32)
1. The client's self-talk and beliefs that mediate his/her nontherapeutic eating habits were reviewed.
2. The client was taught to challenge his/her biases that promote nontherapeutic eating habits.
3. The client was assisted in replacing biased messages with reality-based positive alternatives.
4. The client has moved from overeating, eating to manage emotions, and poor self-concept to eating for health and using character/values to define self.
Assign Self-Talk Homework (33)
1. The client was assigned homework exercises in which he/she identifies self-talk and creates reality-based alternatives.
2. The client was assigned the exercise “Bad Thoughts Lead to Depressed Feelings” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
3. The client was assisted in reviewing his/her self-talk replacement exercises, with corrective feedback for failure and reinforcement for success.
Reinforce Positive Self-Talk (34)
1. Behavioral techniques such as modeling, corrective feedback, imagine rehearsal, and social reinforcement were used to teach the client positive self-talk.
2. The client was taught to reward himself/herself in order to facilitate new behavior change efforts.
3. The client was assigned the exercise “Positive Self-Talk” from the Adult Psychotherapy Homework Planner (Jongsma).
Teach Calming Skills for High-Risk Situations (35)
1. The client was taught tailored calming skills to manage high-risk situations.
2. The client was taught both cognitive and somatic calming skills.
3. Modeling, role-playing and behavior rehearsal were used to work through how to use calming skills in several current situations.
4. The client was assigned the exercise “Progressive Muscle Relaxation” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
5. The client was assigned portions of The Relaxation and Stress Reduction Workbook (Davis, Robbins-Eshelman, and McKay).
6. The client displayed clear understanding of the calming skills for managing problematic situations and was positively reinforced for this.
7. The client struggled to understand how to use calming skills to manage high-risk situations and was provided with remedial feedback in this area.
Teach Problem-Solving Skills for High-Risk Situations (36)
1. The client was taught tailored problem-solving skills to manage high-risk situations.
2. The client was taught about pinpointing the situation, generating options, listing pros and cons of each option, selecting an option, implementing an option, and refining.
3. Modeling, role-playing, and behavior rehearsal were used to work through how to use problem-solving skills in several current situations.
4. The client was assigned the “Problem-Solving Exercise” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
5. The client displayed clear understanding of the problem-solving skills for managing problematic situations and was positively reinforced for this.
6. The client struggled to understand how to use problem-solving skills to manage high-risk situations and was provided with remedial feedback in this area.
Teach Conflict Resolution Skills for High-Risk Situations (37)
1. The client was taught tailored conflict resolution skills to manage high-risk situations.
2. The client was taught about empathy, active listening, and “I messages.”
3. Modeling, role-playing, and behavior rehearsal were used to work through how to use conflict resolution skills in several current situations.
4. The client was assigned the exercise “Negotiating a Peace Treaty” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
5. The client displayed clear understanding of the conflict resolution skills for managing problematic situations and was positively reinforced for this.
6. The client struggled to understand how to use conflict resolution skills to manage high-risk situations and was provided with remedial feedback in this area.
Teach Assertiveness Skills for High-Risk Situations (38)
1. The client was taught tailored assertiveness skills to manage high-risk situations.
2. The client was taught about respectful communication, assertiveness without aggression, and compromise.
3. Modeling, role-playing, and behavior rehearsal were used to work through how to use assertiveness skills in several current situations.
4. The client was assigned the exercise “Becoming Assertive” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
5. The client displayed clear understanding of the assertiveness skills for managing problematic situations and was positively reinforced for this.
6. The client struggled to understand how to use assertiveness skills to manage high-risk situations and was provided with remedial feedback in this area.
Teach Family Stress Management Skills (39)
1. All family members were taught stress management skills.
2. Family members were taught calming, problem-solving, communication, and conflict resolution skills.
3. The family members were encouraged to use stress management skills in order to manage stress and facilitate the client's progress in treatment.
Teach Parents about Prompting and Rewarding (40)
1. The parents were taught about how to prompt and reward treatment-consistent behavior.
2. The parents were taught about empathetically ignoring excessive complaining and modeling the behavior that is being prescribed for the client.
3. The parents were reinforced for their success in prompting and rewarding treatment-consistent behavior.
4. The parents were assisted in redirecting themselves about situations in which they have failed to reward treatment-consistent behavior.
Reduce Enabling (41)
1. The family was assisted in identifying and overcoming the tendency to reinforce the client's poor eating habits and misplaced motivations.
2. The family members were taught constructive ways to reward the client's progress.
Encourage Ongoing Support (42)
1. The parents were encouraged to develop and coordinate ongoing support for the client in weight management efforts.
2. The parents were encouraged to utilize email messages, phone calls, texting, and postal mail notes to support the client in his/her changes.
3. The parents were encouraged to engage others in providing support to the client.
Differentiate between Lapse and Relapse (43)
1. A discussion was held with the client regarding the distinction between a lapse and a relapse.
2. A lapse was associated with an initial and reversible return of poor eating habits.
3. A relapse was associated with the decision to return to the old patterns that contributed to and maintained obesity.
4. The client was provided with support and encouragement as he/she displayed an understanding of the difference between a lapse and a relapse.
5. The client struggled to understand the difference between a lapse and a relapse, and he/she was provided with remedial feedback in this area.
Discuss Management of Lapse Risk Situations (44)
1. The client was assisted in identifying future situations or circumstances in which lapses could occur.
2. The session focused on rehearsing the management of future situations or circumstances in which lapses could occur.
3. The client was reinforced for his/her appropriate use of lapse management skills.
4. The client was redirected in regard to his/her poor use of lapse management skills.
Encourage Routine Use of Strategies (45)
1. The client was instructed to routinely use the strategies that he/she has learned in therapy (e.g., cognitive restructuring, assertiveness).
2. The client was urged to find ways to build his/her new strategies into his/her life as much as possible.
3. The client was reinforced as he/she reported ways in which he/she has incorporated coping strategies into his/her life and routine.
4. The client was redirected about ways to incorporate his/her new strategies into his/her routine and life.
Develop a Coping Card (46)
1. The client was provided with a coping card on which specific coping strategies were listed.
2. The client was assisted in developing his/her coping card in order to list his/her helpful coping strategies.
3. The client was encouraged to use his/her coping card when struggling with high-risk situations.
Refer to Group Weight Loss Program (47)
1. The client and parents were referred to a group behavioral weight loss program.
2. The use of a weight loss program was emphasized, with an emphasis on changes in lifestyle, exercise, attitudes, relationships, and nutrition.
3. The client has been regularly engaged in a group behavioral weight loss program and his/her experience and results were reviewed.
4. The client has not been involved in a group behavioral weight loss program and was redirected to do so.
Investigate Emotional Needs (48)
1. Sensitive questioning, active listening, and unconditional regard were used to probe, discuss, and interpret positive emotional needs being met through eating.
2. The client was probed for possible emotional neglect or abuse.
Reinforce Insight (49)
1. The client was reinforced for his/her insight into past emotional pain and its connection to present overeating.
2. The client was assisted in developing greater insight into how his/her past emotional pain has been connected to present overeating.