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Follow-up strategies in the behavioral treatment of overweight
Behav. Res. & Therap\.
1975, Vol
13. pp 167-172. Per$amon Press Pmted
I” Great Bntam
FOLLOW-UP STRATEGIES IN THE BEHAVIORAL TREATMENT OF OVERWEIGHT SHARON M. HALL '*,ROBERT and RICHARD ‘Wood
Veterans
G.
HANSON’
‘University of Wisconsin-Milwaukee. Administration Center and Medical (Rrceicrd
BETTYL. BORDEN’
HALL?,
W.
Milwaukee. U.S.A., and College of Wisconsin. Milwaukee.
2 1 October
USA
1974)
Summary-Overweight adult subjects were given a 12-week course in self-management training. and then divided into three I?-week follow-up conditions: booster (continued contact plus monitoring). monitoring-only. and no-contact. The dependent variable was the Weight Reduction Ratio. At the end of the first l&week period. treated subjects lost more weight than a no-treatment group of similar subjects. At the end of the second II-week period. monitoring-only subjects continued to lose weight, and differed significantly from no-contact subjects. Booster subjects did not differ significantly from either of the other two groups; however, when only those booster subjects who continued with the same therapist were considered, differences between no-contact and booster reached significance. Results are discussed in terms of the contributions of therapist contact and self-monitoring to produce the continued weight losses observed in this study.
Treatment of obesity via self-management training has produced encouraging results when short-term weight losses are considered (Harris. 1969; Wollersheim, 1970; Hagen, 1970). However, long-term follow-up results generally indicate weight g&s following treatment termination (Hall et al., 1974; Hall and Hall, 1974). Long-term effects are, of course, of primary interest in any therapeutic endeavor. To date. little effort has been devoted to the study of procedures that might enhance long-term efficacy. Special concern for the obese in this matter stems from the potentially harmful physical effects of rapid, repeated gains and losses (U.S. Public Health Service, undated). Thus the development of methods to enhance long-term weight loss would seem especially important in the treatment of obesity. One method of maintaining therapeutic change is the ‘booster session’ where the client meets with the therapist relatively infrequently to receive all or part of the treatment (Stuart, 1967; Vogler et al., 1970; Vogler, Lunde and Martin, 1971). Although frequently mentioned in the literature, few data are available as to the effectiveness of these sessions. Stuart’s (1967) case study series of 10 obese women provided follow-up sessions for approximately 11 months. Moderate. but continuing losses for these Ss were found. suggesting the sessions may have been of value. However. lack of any controls prevented any conclusions about the role of these sessions. Vogler er al. (1970. 1971) examined the efficacy of electrical aversion conditioning of alcoholics for total abstinence. In a controlled study comparing a variety of response-contingent and non-contingent presentations of shock, it was found that Ss receiving booster sessions did not relapse as quickly as other groups and were more likely to stay sober. However. unequivocal interpretation of these results is not possible because some of the Ss selected for booster sessions did not attend, and those attending may have differed in some crucial manner from subjects in other conditions. Vogler rt al. noted the self-selection process and urged caution in interpreting the findings. The purpose of the present study was to determine experimentally the effectiveness of brief booster sessions following termination of formal treatment. The study had 2 phases: A 3-month active treatment phase where Ss were provided with training in self-management skills and a 3-month follow-up phase where brief booster sessions followed termination of formal treatment for some Ss. The booster treatments were compared to no-contact * NOW at Langley Porter Neuropsychiatric Institute, University Requests for reprints should be sent to this address. t Now at Palo Alto Veterans Administration Hospital. 167
of California,
San Francisco,
California,
94143.
168
S. M. HALL. R. G. HALL. B. L. BORDEK and R. W. HASKIS
controls and a monitoring-only condition designed to control for the food monitoring alone without continued therapist contact. The received exactly the same instructions as did the booster group but the therapists except to mail their food and weight monitor sheets to
effects of weight and monitor-only group had no contact with them.
METHOD
Subjects
Percentage over ideal weight was computed from the Metropolitan Height and Weight Tables (U.S. Public Health Service, undated) for individuals with medium bone structure. Only those potential Ss who were 10 per cent or more above mean weight for their height were considered. Potential Ss with diagnosed metabolic disorders were excluded. Sixtytwo Ss (5 males, 57 females) were randomly selected from the approximately 300 suitable individuals who had answered advertisements in the newspaper and who had returned a short questionnaire. Mean age of the sample was 40 yr. mean weight in lb was 192.42. mean number of lb overweight 59.58 and mean percentage overweight was 47.34. The Ss were assigned randomly to either active treatment or a no-treatment control. For the follow-up phase, Ss were stratified on the basis of actual lb lost during treatment and randomly assigned to groups on the basis of these rankings. Apparatus and procedure
The Ss were weighed at pretreatment, posttreatment, follow-up and at weekly group meetings on a balance beam scale. All Ss initially attended one of two preliminary meetings conducted identically where the experimental nature of the study was explained. and written committment to complete the study was obtained. Subjects were given permission forms to be signed by their physician, completed data sheets and release forms. The importance of completing treatment and attendance at meetings was emphasized. Subjects were then weighed. and given the time and place of their first group meeting. Subjects in the no-treatment control group were asked to refrain from engaging in any supervised weight loss program. However, they were told to continue individual efforts to lose weight. They were promised treatment following the end of the active treatment period. Active treatmertt. Fifty-one Ss were included in the treatment group; 14 were assigned to a no-treatment control. The latter group was included to ensure that the active treatment had produced effects similar to those found in previous studies. One male and one female Ph.D. Clinical Psychologist served as therapists. Both had previous experience in conducting weight loss programs. Each therapist met with 3 treatment groups of 69 Ss each. Treatment group Ss received booklets containing caloric and nutritional information at the first meeting and discussed the need to limit caloric intake. Subjects were encouraged to think of themselves as permanently changing their eating habits, rather than as being on a temporary ‘diet’. The need to continue practicing techniques which proved effective was emphasised. Subjects met for 1 hr 11 times in the 12-week active treatment phase. Subjects were taught a self-management program similar to that of Stuart (1967) and Wollersheim (1970) described elsewhere (Hall et al., 1974) in more detail. To provide information upon which to base application of techniques and to allow therapists to check food intake. Ss were instructed to monitor weight and food intake daily. At each meeting Ss were weighed and reported weight changes to the group. Losses were met with approval from the therapist: failure with encouragement to do better. New material was presented verbally by the therapist and Ss were provided with written material reiterating the information given verbally by the therapist. With the presentation of each new technique the therapist attempted to evoke from each S a specific instance of planned application of the technique. The following week each S was asked how they had applied the technique and its outcome. Meetings 6, 9, 10 and I I were review meetings. Group participation and interaction was encouraged throughout. Missed meetings were handled by scheduling individual make-up sessions with the therapist.
Behavioral
treatment
of overweight
169
Follow-up treatment. At the end of the active treatment period, 43 treated Ss remained. Following the final meeting of the active treatment period, Ss were told of their inclusion in 1 of the follow-up groups and were given the appropriate instructions. An attempt was made to induce the same expectations of success in all subjects. regardless of condition. Subjects were told that the subsequent 3 months would be the true test of the usefulness of the treatment. All Ss were told that, to the investigator’s knowledge they had been given the best treatment for obesity available and that they could continue to lose weight during the succeeding 3 months. Thirteen Ss were assigned to the booster (therapist contact) condition. These Ss met every 2 weeks for 20-30 min in 2 groups of 6 and 7 subjects respectively for 3 months. Each therapist was assigned 1 ‘booster’ group. Because therapist effects were not observed during treatment, and such effects had not been found in the behavioral treatment of obesity (Wollersheim, 1970; Hagen, 1970; Hall et al., 1974) Ss were randomly assigned to 1 of the 2 groups within the booster condition. Thus, 6 Ss continued with the same therapist while 7 saw a new therapist. Subjects in this condition were instructed to continue to use whatever techniques had been useful to them during the active treatment period. The Ss were also instructed to continue monitoring food and weight daily and to bring these data to the group meetings. Group meetings were devoted to discussion of successes and failure of individual members, suggestions for new ways to use the techniques and to provide encouragement and support, both from the group members and the therapist. An additional 14 Ss were assigned to a monitoring-only control. Instructions to Ss in this condition were identical to those in the booster condition with one exception: Ss were told to return monitoring data via the mail at 2-week intervals. At the posttreatment meeting, these Ss were provided with data sheets and stamped. self-addressed envelopes. Data for the final 2 weeks were brought to the follow-up assessment meeting. Sixteen Ss were assigned to the no-contact control. These Ss were instructed to continue using whatever techniques had proved useful to them. They were not specifically instructed to use monitoring or any other technique. These Ss were not seen again until the final assessment at the end of the follow-up period. RESULTS
Dependent
variables
Weight change was calculated using a modification* of the Weight Reduction Index proposed by Feinstein (1959). This index takes into account both initial relative obesity and pretreatment absolute weight as indicated in the formula: Weight Reduction Index =
lb lost Initial wt x 100 Ideal wt ’ lb above ideal weight
Pounds over ideal weight, percent over ideal weight and body weight in lb were used in analyses of pretreatment data. Active treatment
In all analyses from the active treatment period, data from Ss receiving treatment were classified according to that condition which the S was assigned to during the follow-up phase of the study. Thus, all comparisons of data obtained during the active treatment period were based upon 4 cells: booster, monitoring-only, no-contact, and no-treatment. These analyses allowed checks for equivalency of conditions and treatment-no-treatment comparisons simultaneously. Prior to the active treatment period. Ss later assigned to the booster, monitoring, no-contact, and the no-treatment control did not differ with respect to lb over ideal weight, percent over ideal weight (F < 1. df= 3/50, both comparisons) or absolute body weight (F = 1.22, df = 3/50, p > 0.20). Analyses with premature terminators deleted produced similar F ratios (F < 1, all comparisons). * Feinstein’s formula does not allow for the possibility of weight gain. In order to include those few subjects who did gain weight, lb lost was expressed as a negative number, lb gained as a positive number.
170
S. M. HALL. R. G. HALL. B. L. J~ORDENand R. W. HASSOY
Of the 51 Ss given treatment, 8 including all males but 1, terminated prematurely. Such premature termination was noted when a S missed 2 consecutive meetings (and corresponding make-up meetings) and/or informed the therapist that he or she no longer wished to continue. Also. of the 14 subjects assigned to the no-treatment control. 3 refused to participate in the follow-up assessment. Analysis of variance in posttreatment Weight Reduction Index scores resulted in a statistically significant F-ratio (F = 6.45. LIJ‘= 3/51. p < 0.001). Further analysis indicated that the booster. monitoring. and no-contact Ss did not differ from one another: all 3 groups did differ from the no-treatment controls (Newman Keuls test, p < 0.01). Mean Weight Reduction index scores at posttreatment were -36.55, -33.66, -23.88 and + 3.58 for booster. monitoring-only. no-contact and notreatment conditions. rchpectively. Follow-up treatment
Of the 43 Ss who entered into the follow-up treatment. 3 Ss in each booster and monitoring-only groups terminated prematurely or failed to report for the final assessment. After the groups were assessed at follow-up and those who terminated during the followup treatment deleted, the groups remained equivalent on lb lost during treatment (F < 1), and lb over ideal weight at posttreatment (F = 1.22, &‘= 2131. p > 0.25), and percent overweight at posttreatment (F = 2.43, @= 2/3. 0.10 < p < 0.20). but differed significantly on actual body weight at posttreatment (F = 3.73. df’= 2131, p < 0.05). Newman Keuls tests indicated that significance was due solely to the significantly lower weight of monitoring only Ss (means were 192.5. 158.7 and 180.1 for booster. monitoring-only, and no-contact Ss). The Weight Reduction Index was used to control for bias resulting from this inequality. An analysis of weight changes during follow-up indicated the Weight Reduction Index for the booster, monitoring-only and no-contact groups differed significantly (F = 3.92, df= 2/33, p < 0.05). A Newman Keuls Test revealed that the monitoring only group differed significantly from the no-contact control. but the booster group did not differ significantly from either. Mean Weight Reduction index scores were - 11.OO,- 23.87 and + 7.41 for booster. monitoring-only and no-contact groups. respectively. A possible source of this unexpected finding was elucidated when an analysis of variance was computed on the Weight Reduction Index of only those Ss in the booster group that continued with their same therapist. A Fischer’s Exact Probability Test indicated a significant difference which favored Ss in the booster group that remained with their original therapist as opposed to those who did not (p = 0.024). Analysis of variance including in the booster group only those Ss who remained with the same therapist resulted in a significant F-ratio (F = 3.46. Ir/‘= 2,/27, p < 0.05). A further comparison via a Newman Keuls indicated both the booster and monitoring only groups were significantly different from the no-contact control group and the former 2 groups did not differ significantly from one another (Mean wt reduction score, same therapist Ss only = - 19.61). Means and standard deviations for Weight Reduction Index scores for all treatments at pre-. post- and follow-up assessment are shown in Table I. Because it might be argued that differences in monitoring among groups somehow confounded the results reported above, booster and monitoring groups were compared on monitoring performance. Therefore. the number of days of reported weight monitoring, completed food monitoring (all foods listed and calories entered and totaled each day) and partial food monitoring (all or some food data. but total calories not computed) were compared for Ss in the two conditions. The groups did not differ with regard to any of the three variables (no t-value exceeded 0.01 for the 3 comparisons). Booster same therapist Ss completed more food monitoring sheets than different therapist Ss. but not significantly more (Fischer’s Exact Probability Test, p = 0.24). Total weight losses
Of those 27 Ss who were given the opportunity for 6 months of treatment (booster and monitoring-only Ss) 6 terminated prematurely. Of the remaining 21, 28.5 per cent (n = 6) lost 20-39.9 per cent of their initial overweight (lb lost/lb over ideal wt) x 100) 9.52% (n =
Behavioral Table
I. Weight
treatment
Reduction Index scores for active and follow-up (same therapist only). monitoring-only, no-contact,
Loss from pretreatment
Booster
Booster
171
of overweight treatment for booster (all subjects), and no-treatment subjects.* Monitoronly
Nocontact
to posttreatment (Weeks I-12)
X SD. N
- 36.55 33.66 IO
- 28.48 21.00 6
- 33.66 25.74 II
-23.38 24.17 I6
Loss from posttreatment to follow-up assessment. (Weeks 13-24)
X SD. N
-11.00 23.9 1 10
- 19.67 21.48 6
- 73.87 34.00 II
+7.41 18.00 16
vvho complete
treatment
* Only those subjects
booster
Notreatment + 3.58 37.06 II
are included.
2) lost 4C~59.9 per cent of their initial overweight. 14.28 per cent (II = 3) lost 60-79 per cent of their initial overweight, and 9.52 per cent (II = 3) lost 80-100 per cent of their initial overweight. DISCUSSION
The effectiveness of monitoring as a maintainence device in this study contrasts with the unfavorable reports of its effectiveness as a treatment strategy (Hall. 1972; Mahoney, Moura and Wade, 1973; Mahoney, 1974). This discrepancy may be resolved if the data are considered in terms of Kanfer’s conceptualization of self-regulation (Kanfer. 1970; Kanfer and Karoly, 1973). Kanfer suggests a 3-phase self-control sequence: Self-monitoring, self-evaluation, and self-reinforcement. Given the instructions to monitor behavior increase the probability of self-monitoring, if the resulting self-evaluation indicates that performance is below standard, self-punishment of current behavior and emergence of new attempts at self-regulation should arise. After learning behavioral techniques. the client has a moderate repertory of effective behaviors to turn to if self-evaluation indicates his performance falls short of standard. However. if he has not learned these techniques, then increasing the probability of self-monitoring will not produce more effective self-control because the individual lacks effective controlling behaviors to call into play when his performance is below standard. For booster Ss, transfer to a new therapist was clearly deleterious. Of the 7 individuals who were transferred, 3 terminated prematurely. and 2 gained weight during the follow-up condition. All Ss who continued with the same therapist lost weight or showed no change. The simplest explanation would be that these Ss lost an important source of reinforcement for weight loss when they lost their therapist. However, this loss also occurred for the monitoring-only Ss and did not result in weight gain. There was some indication from booster Ss transferred that they felt the transfer was due to what they perceived as unsatisfactory performance during the active treatment period. Hence, they viewed the transfer as punishment for their efforts and responded with decreased performance. The data obtained from the study do imply. however. that post-treatment weight gains noted in previous studies (and replicated in our no-contact control) can be allayed. and continuing losses can be produced in behavioral treatment of obesity by measures which enhance the probability of continued self-monitoring on the part of the subject. REFERENCES FEINSTEI~’A. R. (1959) The measurement of success in weight reduction: An analysis of methods and a new index. J. Chrori. Dis. IO, 439-456. HAGEN R. L. (1970) Group therapy versus bibliothcrapy in weight reduction. Unpublished Doctoral Dissertation, University of Illinois. HALL S. M. Self-control and therapist control in the behavioral treatment of obesity. Behar. Res. & Thrrapy 10, 59-67. HALL S. M. and HALL R. G. (1974) Methodological and outcome considerations in the behavioral treatment of obesity. Brha~. Thrrapj~ 5, 352-364. HALL S. M.. HALL R. G.. HANKIN R. W. and BOKIXN B. L. (I 974) Permanence of two self-managed treatments of overweight in university and community populations. J. co/rstr/r. cfin. Pstchol. (in press). HANSON R. W. (1974) Effects of programmed learning and therapist-group contact in treating obesity. Paper read at the Western Psychological Association Meetings. San Francisco. HARRIS M. B. (1969) Self-directed program for weight control: A pilot study. J. ahnorrrr. Ps~d~o/. 74, 263-270.
172
S. M. HALL. R. G. HALL. B. L. BORDEN and R. W. HANSO%
KATXFERF. H. (1970) Self-regulation. Research, issues. speculation. In: Behauor Modificarlorl in Clitlical Psychologx. (Eds. C. NEURINGER and J. L. MICHAELS) Appleton-Century-Crofts, New York. KANFER F. H. and KAROLY P. (1972) Self-control: A behavioristic excursion into the Lion’s Den. Brhac. Therapy 3, 398-4 16. STLART R. B. (1967) Behavioral control of overeating. Behac. Rcs. & Thrrap!, 5, 357-365. U.S. Public Health Service. Division of Chronic Diseases (undated) Obesity arid Health: A source hook qfcurrmf infornuzrioQor prqfessiorml healrh persorvwl. U.S. Government Printing Office. Washington. D.C. VOGLER R. E.. LUNDE S. E.. JOHNSON G. R. and MARTIN P. L. (1970) Electrical aversion conditioning with chronic alcoholics. J. Consult. clirt. Psychol. 34, 302-307. VCICLERR. E.. LUNDE S. E. and MARTIN P. L. (1971) Electrical aversion conditioning with chronic alcoholics: Follow-up and suggestions for research. J. cordt. cliu. Psycho/. 36. 450. WOLLERSHEIMJ. P. (1970) Effectiveness of group therapy based upon learning principles in the treatment of overweight women. J. ahnorm. Psychol. 76, 462-474.
1975, Vol
13. pp 167-172. Per$amon Press Pmted
I” Great Bntam
FOLLOW-UP STRATEGIES IN THE BEHAVIORAL TREATMENT OF OVERWEIGHT SHARON M. HALL '*,ROBERT and RICHARD ‘Wood
Veterans
G.
HANSON’
‘University of Wisconsin-Milwaukee. Administration Center and Medical (Rrceicrd
BETTYL. BORDEN’
HALL?,
W.
Milwaukee. U.S.A., and College of Wisconsin. Milwaukee.
2 1 October
USA
1974)
Summary-Overweight adult subjects were given a 12-week course in self-management training. and then divided into three I?-week follow-up conditions: booster (continued contact plus monitoring). monitoring-only. and no-contact. The dependent variable was the Weight Reduction Ratio. At the end of the first l&week period. treated subjects lost more weight than a no-treatment group of similar subjects. At the end of the second II-week period. monitoring-only subjects continued to lose weight, and differed significantly from no-contact subjects. Booster subjects did not differ significantly from either of the other two groups; however, when only those booster subjects who continued with the same therapist were considered, differences between no-contact and booster reached significance. Results are discussed in terms of the contributions of therapist contact and self-monitoring to produce the continued weight losses observed in this study.
Treatment of obesity via self-management training has produced encouraging results when short-term weight losses are considered (Harris. 1969; Wollersheim, 1970; Hagen, 1970). However, long-term follow-up results generally indicate weight g&s following treatment termination (Hall et al., 1974; Hall and Hall, 1974). Long-term effects are, of course, of primary interest in any therapeutic endeavor. To date. little effort has been devoted to the study of procedures that might enhance long-term efficacy. Special concern for the obese in this matter stems from the potentially harmful physical effects of rapid, repeated gains and losses (U.S. Public Health Service, undated). Thus the development of methods to enhance long-term weight loss would seem especially important in the treatment of obesity. One method of maintaining therapeutic change is the ‘booster session’ where the client meets with the therapist relatively infrequently to receive all or part of the treatment (Stuart, 1967; Vogler et al., 1970; Vogler, Lunde and Martin, 1971). Although frequently mentioned in the literature, few data are available as to the effectiveness of these sessions. Stuart’s (1967) case study series of 10 obese women provided follow-up sessions for approximately 11 months. Moderate. but continuing losses for these Ss were found. suggesting the sessions may have been of value. However. lack of any controls prevented any conclusions about the role of these sessions. Vogler er al. (1970. 1971) examined the efficacy of electrical aversion conditioning of alcoholics for total abstinence. In a controlled study comparing a variety of response-contingent and non-contingent presentations of shock, it was found that Ss receiving booster sessions did not relapse as quickly as other groups and were more likely to stay sober. However. unequivocal interpretation of these results is not possible because some of the Ss selected for booster sessions did not attend, and those attending may have differed in some crucial manner from subjects in other conditions. Vogler rt al. noted the self-selection process and urged caution in interpreting the findings. The purpose of the present study was to determine experimentally the effectiveness of brief booster sessions following termination of formal treatment. The study had 2 phases: A 3-month active treatment phase where Ss were provided with training in self-management skills and a 3-month follow-up phase where brief booster sessions followed termination of formal treatment for some Ss. The booster treatments were compared to no-contact * NOW at Langley Porter Neuropsychiatric Institute, University Requests for reprints should be sent to this address. t Now at Palo Alto Veterans Administration Hospital. 167
of California,
San Francisco,
California,
94143.
168
S. M. HALL. R. G. HALL. B. L. BORDEK and R. W. HASKIS
controls and a monitoring-only condition designed to control for the food monitoring alone without continued therapist contact. The received exactly the same instructions as did the booster group but the therapists except to mail their food and weight monitor sheets to
effects of weight and monitor-only group had no contact with them.
METHOD
Subjects
Percentage over ideal weight was computed from the Metropolitan Height and Weight Tables (U.S. Public Health Service, undated) for individuals with medium bone structure. Only those potential Ss who were 10 per cent or more above mean weight for their height were considered. Potential Ss with diagnosed metabolic disorders were excluded. Sixtytwo Ss (5 males, 57 females) were randomly selected from the approximately 300 suitable individuals who had answered advertisements in the newspaper and who had returned a short questionnaire. Mean age of the sample was 40 yr. mean weight in lb was 192.42. mean number of lb overweight 59.58 and mean percentage overweight was 47.34. The Ss were assigned randomly to either active treatment or a no-treatment control. For the follow-up phase, Ss were stratified on the basis of actual lb lost during treatment and randomly assigned to groups on the basis of these rankings. Apparatus and procedure
The Ss were weighed at pretreatment, posttreatment, follow-up and at weekly group meetings on a balance beam scale. All Ss initially attended one of two preliminary meetings conducted identically where the experimental nature of the study was explained. and written committment to complete the study was obtained. Subjects were given permission forms to be signed by their physician, completed data sheets and release forms. The importance of completing treatment and attendance at meetings was emphasized. Subjects were then weighed. and given the time and place of their first group meeting. Subjects in the no-treatment control group were asked to refrain from engaging in any supervised weight loss program. However, they were told to continue individual efforts to lose weight. They were promised treatment following the end of the active treatment period. Active treatmertt. Fifty-one Ss were included in the treatment group; 14 were assigned to a no-treatment control. The latter group was included to ensure that the active treatment had produced effects similar to those found in previous studies. One male and one female Ph.D. Clinical Psychologist served as therapists. Both had previous experience in conducting weight loss programs. Each therapist met with 3 treatment groups of 69 Ss each. Treatment group Ss received booklets containing caloric and nutritional information at the first meeting and discussed the need to limit caloric intake. Subjects were encouraged to think of themselves as permanently changing their eating habits, rather than as being on a temporary ‘diet’. The need to continue practicing techniques which proved effective was emphasised. Subjects met for 1 hr 11 times in the 12-week active treatment phase. Subjects were taught a self-management program similar to that of Stuart (1967) and Wollersheim (1970) described elsewhere (Hall et al., 1974) in more detail. To provide information upon which to base application of techniques and to allow therapists to check food intake. Ss were instructed to monitor weight and food intake daily. At each meeting Ss were weighed and reported weight changes to the group. Losses were met with approval from the therapist: failure with encouragement to do better. New material was presented verbally by the therapist and Ss were provided with written material reiterating the information given verbally by the therapist. With the presentation of each new technique the therapist attempted to evoke from each S a specific instance of planned application of the technique. The following week each S was asked how they had applied the technique and its outcome. Meetings 6, 9, 10 and I I were review meetings. Group participation and interaction was encouraged throughout. Missed meetings were handled by scheduling individual make-up sessions with the therapist.
Behavioral
treatment
of overweight
169
Follow-up treatment. At the end of the active treatment period, 43 treated Ss remained. Following the final meeting of the active treatment period, Ss were told of their inclusion in 1 of the follow-up groups and were given the appropriate instructions. An attempt was made to induce the same expectations of success in all subjects. regardless of condition. Subjects were told that the subsequent 3 months would be the true test of the usefulness of the treatment. All Ss were told that, to the investigator’s knowledge they had been given the best treatment for obesity available and that they could continue to lose weight during the succeeding 3 months. Thirteen Ss were assigned to the booster (therapist contact) condition. These Ss met every 2 weeks for 20-30 min in 2 groups of 6 and 7 subjects respectively for 3 months. Each therapist was assigned 1 ‘booster’ group. Because therapist effects were not observed during treatment, and such effects had not been found in the behavioral treatment of obesity (Wollersheim, 1970; Hagen, 1970; Hall et al., 1974) Ss were randomly assigned to 1 of the 2 groups within the booster condition. Thus, 6 Ss continued with the same therapist while 7 saw a new therapist. Subjects in this condition were instructed to continue to use whatever techniques had been useful to them during the active treatment period. The Ss were also instructed to continue monitoring food and weight daily and to bring these data to the group meetings. Group meetings were devoted to discussion of successes and failure of individual members, suggestions for new ways to use the techniques and to provide encouragement and support, both from the group members and the therapist. An additional 14 Ss were assigned to a monitoring-only control. Instructions to Ss in this condition were identical to those in the booster condition with one exception: Ss were told to return monitoring data via the mail at 2-week intervals. At the posttreatment meeting, these Ss were provided with data sheets and stamped. self-addressed envelopes. Data for the final 2 weeks were brought to the follow-up assessment meeting. Sixteen Ss were assigned to the no-contact control. These Ss were instructed to continue using whatever techniques had proved useful to them. They were not specifically instructed to use monitoring or any other technique. These Ss were not seen again until the final assessment at the end of the follow-up period. RESULTS
Dependent
variables
Weight change was calculated using a modification* of the Weight Reduction Index proposed by Feinstein (1959). This index takes into account both initial relative obesity and pretreatment absolute weight as indicated in the formula: Weight Reduction Index =
lb lost Initial wt x 100 Ideal wt ’ lb above ideal weight
Pounds over ideal weight, percent over ideal weight and body weight in lb were used in analyses of pretreatment data. Active treatment
In all analyses from the active treatment period, data from Ss receiving treatment were classified according to that condition which the S was assigned to during the follow-up phase of the study. Thus, all comparisons of data obtained during the active treatment period were based upon 4 cells: booster, monitoring-only, no-contact, and no-treatment. These analyses allowed checks for equivalency of conditions and treatment-no-treatment comparisons simultaneously. Prior to the active treatment period. Ss later assigned to the booster, monitoring, no-contact, and the no-treatment control did not differ with respect to lb over ideal weight, percent over ideal weight (F < 1. df= 3/50, both comparisons) or absolute body weight (F = 1.22, df = 3/50, p > 0.20). Analyses with premature terminators deleted produced similar F ratios (F < 1, all comparisons). * Feinstein’s formula does not allow for the possibility of weight gain. In order to include those few subjects who did gain weight, lb lost was expressed as a negative number, lb gained as a positive number.
170
S. M. HALL. R. G. HALL. B. L. J~ORDENand R. W. HASSOY
Of the 51 Ss given treatment, 8 including all males but 1, terminated prematurely. Such premature termination was noted when a S missed 2 consecutive meetings (and corresponding make-up meetings) and/or informed the therapist that he or she no longer wished to continue. Also. of the 14 subjects assigned to the no-treatment control. 3 refused to participate in the follow-up assessment. Analysis of variance in posttreatment Weight Reduction Index scores resulted in a statistically significant F-ratio (F = 6.45. LIJ‘= 3/51. p < 0.001). Further analysis indicated that the booster. monitoring. and no-contact Ss did not differ from one another: all 3 groups did differ from the no-treatment controls (Newman Keuls test, p < 0.01). Mean Weight Reduction index scores at posttreatment were -36.55, -33.66, -23.88 and + 3.58 for booster. monitoring-only. no-contact and notreatment conditions. rchpectively. Follow-up treatment
Of the 43 Ss who entered into the follow-up treatment. 3 Ss in each booster and monitoring-only groups terminated prematurely or failed to report for the final assessment. After the groups were assessed at follow-up and those who terminated during the followup treatment deleted, the groups remained equivalent on lb lost during treatment (F < 1), and lb over ideal weight at posttreatment (F = 1.22, &‘= 2131. p > 0.25), and percent overweight at posttreatment (F = 2.43, @= 2/3. 0.10 < p < 0.20). but differed significantly on actual body weight at posttreatment (F = 3.73. df’= 2131, p < 0.05). Newman Keuls tests indicated that significance was due solely to the significantly lower weight of monitoring only Ss (means were 192.5. 158.7 and 180.1 for booster. monitoring-only, and no-contact Ss). The Weight Reduction Index was used to control for bias resulting from this inequality. An analysis of weight changes during follow-up indicated the Weight Reduction Index for the booster, monitoring-only and no-contact groups differed significantly (F = 3.92, df= 2/33, p < 0.05). A Newman Keuls Test revealed that the monitoring only group differed significantly from the no-contact control. but the booster group did not differ significantly from either. Mean Weight Reduction index scores were - 11.OO,- 23.87 and + 7.41 for booster. monitoring-only and no-contact groups. respectively. A possible source of this unexpected finding was elucidated when an analysis of variance was computed on the Weight Reduction Index of only those Ss in the booster group that continued with their same therapist. A Fischer’s Exact Probability Test indicated a significant difference which favored Ss in the booster group that remained with their original therapist as opposed to those who did not (p = 0.024). Analysis of variance including in the booster group only those Ss who remained with the same therapist resulted in a significant F-ratio (F = 3.46. Ir/‘= 2,/27, p < 0.05). A further comparison via a Newman Keuls indicated both the booster and monitoring only groups were significantly different from the no-contact control group and the former 2 groups did not differ significantly from one another (Mean wt reduction score, same therapist Ss only = - 19.61). Means and standard deviations for Weight Reduction Index scores for all treatments at pre-. post- and follow-up assessment are shown in Table I. Because it might be argued that differences in monitoring among groups somehow confounded the results reported above, booster and monitoring groups were compared on monitoring performance. Therefore. the number of days of reported weight monitoring, completed food monitoring (all foods listed and calories entered and totaled each day) and partial food monitoring (all or some food data. but total calories not computed) were compared for Ss in the two conditions. The groups did not differ with regard to any of the three variables (no t-value exceeded 0.01 for the 3 comparisons). Booster same therapist Ss completed more food monitoring sheets than different therapist Ss. but not significantly more (Fischer’s Exact Probability Test, p = 0.24). Total weight losses
Of those 27 Ss who were given the opportunity for 6 months of treatment (booster and monitoring-only Ss) 6 terminated prematurely. Of the remaining 21, 28.5 per cent (n = 6) lost 20-39.9 per cent of their initial overweight (lb lost/lb over ideal wt) x 100) 9.52% (n =
Behavioral Table
I. Weight
treatment
Reduction Index scores for active and follow-up (same therapist only). monitoring-only, no-contact,
Loss from pretreatment
Booster
Booster
171
of overweight treatment for booster (all subjects), and no-treatment subjects.* Monitoronly
Nocontact
to posttreatment (Weeks I-12)
X SD. N
- 36.55 33.66 IO
- 28.48 21.00 6
- 33.66 25.74 II
-23.38 24.17 I6
Loss from posttreatment to follow-up assessment. (Weeks 13-24)
X SD. N
-11.00 23.9 1 10
- 19.67 21.48 6
- 73.87 34.00 II
+7.41 18.00 16
vvho complete
treatment
* Only those subjects
booster
Notreatment + 3.58 37.06 II
are included.
2) lost 4C~59.9 per cent of their initial overweight. 14.28 per cent (II = 3) lost 60-79 per cent of their initial overweight, and 9.52 per cent (II = 3) lost 80-100 per cent of their initial overweight. DISCUSSION
The effectiveness of monitoring as a maintainence device in this study contrasts with the unfavorable reports of its effectiveness as a treatment strategy (Hall. 1972; Mahoney, Moura and Wade, 1973; Mahoney, 1974). This discrepancy may be resolved if the data are considered in terms of Kanfer’s conceptualization of self-regulation (Kanfer. 1970; Kanfer and Karoly, 1973). Kanfer suggests a 3-phase self-control sequence: Self-monitoring, self-evaluation, and self-reinforcement. Given the instructions to monitor behavior increase the probability of self-monitoring, if the resulting self-evaluation indicates that performance is below standard, self-punishment of current behavior and emergence of new attempts at self-regulation should arise. After learning behavioral techniques. the client has a moderate repertory of effective behaviors to turn to if self-evaluation indicates his performance falls short of standard. However. if he has not learned these techniques, then increasing the probability of self-monitoring will not produce more effective self-control because the individual lacks effective controlling behaviors to call into play when his performance is below standard. For booster Ss, transfer to a new therapist was clearly deleterious. Of the 7 individuals who were transferred, 3 terminated prematurely. and 2 gained weight during the follow-up condition. All Ss who continued with the same therapist lost weight or showed no change. The simplest explanation would be that these Ss lost an important source of reinforcement for weight loss when they lost their therapist. However, this loss also occurred for the monitoring-only Ss and did not result in weight gain. There was some indication from booster Ss transferred that they felt the transfer was due to what they perceived as unsatisfactory performance during the active treatment period. Hence, they viewed the transfer as punishment for their efforts and responded with decreased performance. The data obtained from the study do imply. however. that post-treatment weight gains noted in previous studies (and replicated in our no-contact control) can be allayed. and continuing losses can be produced in behavioral treatment of obesity by measures which enhance the probability of continued self-monitoring on the part of the subject. REFERENCES FEINSTEI~’A. R. (1959) The measurement of success in weight reduction: An analysis of methods and a new index. J. Chrori. Dis. IO, 439-456. HAGEN R. L. (1970) Group therapy versus bibliothcrapy in weight reduction. Unpublished Doctoral Dissertation, University of Illinois. HALL S. M. Self-control and therapist control in the behavioral treatment of obesity. Behar. Res. & Thrrapy 10, 59-67. HALL S. M. and HALL R. G. (1974) Methodological and outcome considerations in the behavioral treatment of obesity. Brha~. Thrrapj~ 5, 352-364. HALL S. M.. HALL R. G.. HANKIN R. W. and BOKIXN B. L. (I 974) Permanence of two self-managed treatments of overweight in university and community populations. J. co/rstr/r. cfin. Pstchol. (in press). HANSON R. W. (1974) Effects of programmed learning and therapist-group contact in treating obesity. Paper read at the Western Psychological Association Meetings. San Francisco. HARRIS M. B. (1969) Self-directed program for weight control: A pilot study. J. ahnorrrr. Ps~d~o/. 74, 263-270.
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S. M. HALL. R. G. HALL. B. L. BORDEN and R. W. HANSO%
KATXFERF. H. (1970) Self-regulation. Research, issues. speculation. In: Behauor Modificarlorl in Clitlical Psychologx. (Eds. C. NEURINGER and J. L. MICHAELS) Appleton-Century-Crofts, New York. KANFER F. H. and KAROLY P. (1972) Self-control: A behavioristic excursion into the Lion’s Den. Brhac. Therapy 3, 398-4 16. STLART R. B. (1967) Behavioral control of overeating. Behac. Rcs. & Thrrap!, 5, 357-365. U.S. Public Health Service. Division of Chronic Diseases (undated) Obesity arid Health: A source hook qfcurrmf infornuzrioQor prqfessiorml healrh persorvwl. U.S. Government Printing Office. Washington. D.C. VOGLER R. E.. LUNDE S. E.. JOHNSON G. R. and MARTIN P. L. (1970) Electrical aversion conditioning with chronic alcoholics. J. Consult. clirt. Psychol. 34, 302-307. VCICLERR. E.. LUNDE S. E. and MARTIN P. L. (1971) Electrical aversion conditioning with chronic alcoholics: Follow-up and suggestions for research. J. cordt. cliu. Psycho/. 36. 450. WOLLERSHEIMJ. P. (1970) Effectiveness of group therapy based upon learning principles in the treatment of overweight women. J. ahnorm. Psychol. 76, 462-474.