Abstract
This is a single-case study of an obese African American female Veteran who has posttraumatic stress disorder (PTSD) and depression. Her presenting psychological symptoms included clinically significant night terrors, insomnia, low self-worth, low motivation, and social isolation. Poor dietary and physical activity responses to her psychological symptoms contributed to her weight gain, as well as interfered with weight-loss efforts. A telephone-based cognitive behavioral treatment integrating mental and behavioral health principles was provided. Over the course of eight sessions, the Veteran learned psychological symptom and behavioral monitoring, thought stopping, cognitive restructuring, deep breathing, calming thoughts, social support, sleep hygiene, and problem-solving skills. Client-centered PTSD and weight-management treatment goals were integrated into each session. The client evidenced weight loss, improved dietary and physical activity habits, and experienced a reduction in PTSD and depression symptoms. This case study demonstrates that an integrated cognitive behavioral treatment approach can be beneficial for decreasing PTSD and depression barriers to weight loss.
1 Theoretical and Research Basis for Treatment
Obesity is a growing health concern associated with increased risk of chronic disease, disability, and mortality (Malnick & Knobler, 2006). Obesity is a significant concern among Veterans, 78% of whom are overweight or obese (Allicock et al., 2013). Co-occurring depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms among obese Veterans are associated with higher body mass index (BMI), increased physical health problems, greater barriers to weight loss, and less weight loss than among Veterans without mental health symptoms (Chwastiak, Rosenheck, & Kazis, 2011; David, Woodward, Esquenazi, & Mellman, 2004; Dobie et al., 2004; Klingman et al., 2016; Littman, Boyko, McDonell, & Fihn, 2012). Coexistent PTSD and obesity is particularly problematic given that Veterans with PTSD are at greater risk of obesity and have more difficulties losing weight than Veterans with depression and/or anxiety (Maguen, Ren, Bosch, Marmar, & Seal, 2010).
The Veterans Health Administration (VHA) developed the MOVE!® program to address the current obesity epidemic among Veterans. MOVE!® is an evidence-based, multidisciplinary, comprehensive approach to weight management (Kinsinger et al., 2009) consisting of individual, group, or telephone-based sessions focusing on developing and tracking healthy eating and physical activity habits. Veterans who attend at least two treatment sessions can lose at least 5% of their body weight (Kahwati et al., 2011). MOVE!® addresses problematic health behaviors leading to obesity but does not address mental health–related barriers to weight loss. MOVE!® participants with PTSD note a desire for additional support and treatment to improve weight-loss success (Allicock et al., 2013). This suggests a need to provide supplemental mental health treatment to MOVE!® to decrease psychological barriers to weight loss.
We designed and implemented an adjunctive cognitive behavioral intervention, Healthy Emotions and Leaner Participants (HELP), for Veterans with anxiety and/or depression symptoms participating in MOVE!®. Cognitive behavioral therapy (CBT) is a collaborative, structured, time-limited therapy, which teaches clients to adapt negative thinking about themselves and the world and to modify their behaviors in order to manage distressing mental health symptoms. CBT has been identified as an empirically supported treatment for anxiety disorders (including PTSD) and depression for some time (Chambless et al., 1998) and is endorsed by the American Psychological Association as having strong empirical support for the treatment of these disorders (APA Presidential Task Force on Evidence-Based Practice, 2006). HELP is a tailored telephone-based treatment integrating mental and behavioral health treatment strategies to manage anxiety and depression symptom barriers to healthy eating and physical activity. Veterans completed PTSD, anxiety, and depression assessments to measure symptom severity. Veterans with more problematic anxiety and/or PTSD were given the HELP anxiety treatment book, and those with more problematic depression were given the HELP depression treatment manual. Some of the Veterans who were assessed for this treatment protocol demonstrated symptoms of both PTSD and depression. In these cases, treatment (i.e., either the anxiety/PTSD treatment manual or the depression treatment manual) was selected based on the highest baseline symptom score on the screening assessments.
The VHA has identified CBT as an evidence-based treatment for PTSD, anxiety, depression, and obesity (Karlin et al., 2010). There is also support for its success in treating Veterans with multiple of these disorders concurrently (Beason-Smith, Hiatt, Grubbs, & Teng, 2012; Chaison, Dunn, & Teng, 2010). Given the high prevalence of obesity in Veterans with PTSD symptoms, poor weight-management outcomes among Veterans with symptoms of PTSD in MOVE!®, and desire to integrate PTSD symptom management into MOVE!®, we decided to evaluate the effectiveness of HELP among Veterans with PTSD. In addition, the case study literature supports the usefulness of integrating treatment for PTSD and maladaptive eating habits, which are not uncommonly comorbid with one another (Mott, Menefee, & Leopoulos, 2012). The goal of this article is to discuss the role of this adjunctive treatment to MOVE!® in one obese Veteran with PTSD symptom barriers to successful weight management.
2 Case Introduction
Ms. Lola was a 32-year-old African American single mother who served as a hospital corpsman in the U.S. Navy. 1 She denied a history of mental health concerns prior to her enlistment. In the Navy, she was sexually assaulted by a group of men while returning to her domicile after a 12-hr shift. Immediately following the attack, she developed symptoms of severe PTSD and depression and was hospitalized for 3 weeks. Upon discharge, she received individual counseling. She reported that this counseling consisted of six to eight face-to-face sessions with a therapist. She remarked that she was uncomfortable discussing her trauma with this provider and, as a result, did not benefit from this treatment. She was discharged early due to an inability to perform job functions after the sexual assault and was declared 80% disabled for PTSD (Veterans Affair [VA] Service Connected).
3 Presenting Complaints
Ms. Lola presented with clinically significant symptoms of PTSD. While in HELP, she reported chronic hypervigilance and re-experiencing of the sexual assault, insomnia, a feeling of being “on edge and nervous,” fatigue, and avoidance. She frequently experienced symptoms of terror and panic when leaving her home. In addition, she reported mild symptoms of depression, including decreased motivation, sadness, anhedonia, and guilt. Ms. Lola frequently (i.e., three times per week) consumed high-calorie and high-fat foods to comfort herself, particularly when unable to sleep after a night terror.
4 History
Ms. Lola was born and raised on the west coast of the United States as the youngest of three children. She entered the Navy immediately after graduating from high school. Upon discharge, she returned to living on the west coast. She moved to a large metropolitan area in the southern United States after the death of a close family relative. While there, she married and had a child. The marriage was strained and punctuated by frequent separations. She and her husband ultimately divorced, and Ms. Lola and her child moved in with Ms. Lola’s mother. This relationship, too, was strained, and Ms. Lola was told to leave after a disagreement. Consequently, she and her child lived in a shelter for a short time.
At the time of her participation in HELP, Ms. Lola was living in an apartment with her child. She had recently attained a bachelor’s degree but had difficulty securing employment due to her poorly controlled symptoms of PTSD and depression. She reported difficulty being with friends and family, avoiding events outside her home (e.g., church gatherings, social events), and spending most of her time at home with her child. She had a history of outpatient mental health treatment at two VHA medical facilities and was prescribed fluoxetine, nefazodone, trazadone, paroxetine, diazepam, and risperidone at various times. She reported that she did not benefit from the individual or group counseling she received as part of her treatment. She stated that traveling to the VHA facility was anxiety producing for her, as was being in a room with other people, especially men. She also denied benefit from the various psychotropic medications she had utilized in the past. She had last received individual counseling 1 year prior to her participation in HELP. She denied use of psychotropic medications or psychological services while participating in HELP, despite the impact her mental health symptoms had on her health outcomes.
Ms. Lola was morbidly obese, presenting to MOVE!® with a weight of 236 pounds and a BMI of 43. She reported a desire to lose 59 pounds (25% of her current weight). She noted difficulty in losing weight, despite attempts to diet and exercise. Her weight-related problems began after her sexual assault; she was of normal weight and BMI prior to entering the Navy. She continuously gained weight after being discharged from the Navy. Associated health conditions included fatigue, insomnia, and early signs of metabolic syndrome, including hypertension, diabetes, and high cholesterol. She attended regular doctor’s visits for her physical health conditions but had difficulty managing her hypertension and diabetes.
5 Assessment
Ms. Lola was administered the Generalized Anxiety Disorder 7-Item Scale (GAD-7; Spitzer, Kroenke, Williams, & Lowe, 2006), Patient Health Questionnaire (PHQ-8; Kroenke et al., 2009), PTSD Checklist–Civilian Version (PCL-C; Weathers, Litz, Huska, & Keane, 1994), Eating Self-Efficacy Scale (ESES; Glynn & Ruderman, 1986), Exercise Confidence Survey (ECS; Sallis, Pinski, Grossman, Patterson, & Nader, 1988), 12-Item Short-Form Health Survey (SF-12; Ware, Kosinski, & Keller, 1996), and HELP Self-Efficacy Assessment (HSEA).
GAD-7
The GAD-7 is a seven-item Likert-type scale assessing how often respondents have been bothered by symptoms of anxiety (e.g., “Feeling nervous, anxious or on edge,” “Not being able to stop or control worrying”). Responses range from 0 = not at all sure to 3 = nearly every day. An eighth question queries how difficult the symptoms have made it for respondents to do their work, take care of things at home, or get along with other people. Four response options range from not difficult at all to extremely difficult. A score of 10 or higher is suggestive of clinically significant GAD. The scale was validated in U.S. adult primary care patients and demonstrated good reliability in this sample (Spitzer et al., 2006).
PHQ-8
The PHQ-8 is an eight-item Likert-type scale assessing how often respondents have been bothered by symptoms of depression (e.g., “Little interest or pleasure in doing things,” “Feeling down, depressed, or hopeless”). Responses range from 0 = not at all to 3 = nearly every day. A score of 10 or higher is suggestive of clinically significant depression. The scale was validated in a U.S. population-based survey (Kroenke et al., 2009).
PCL-C
The PCL-C is 17-item Likert-type scale assessing how much respondents have been bothered by symptoms of PTSD in the last month (e.g., “Repeated, disturbing memories, thoughts, or images of a stressful experience from the past,” “Repeated, disturbing dreams of a stressful experience from the past”). Responses range from 1 = not at all to 5 = extremely. The PCL-C is used to determine whether a respondent meets Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for PTSD. As such, a score greater than 35 suggests clinically significant symptoms. The checklist is well validated and has demonstrated good reliability across 14 diverse samples (Wilkins, Lang, & Norman, 2011).
ESES
The ESES is a 25-item scale that assesses the factors that contribute to overeating in the respondent (Glynn & Ruderman, 1986). The scale has two factors: eating as a function of negative effects (NA) and eating as a function of socially acceptable circumstances (SA). To score, item scores for subscales (NA = 15 items and SA = 10 items) are added. Scores range from 25 to 185. The means for college students were males = 74.24 and females = 88.43. The ESES has excellent internal consistency reliability and good predictive and construct validity (Glynn & Ruderman, 1986).
ECS
The ECS is a 12-item Likert-type scale assessing how confident respondents are that they could really motivate themselves to do exercise behaviors consistently, for at least 6 months (Sallis et al., 1988). Sample items ask how confident the participant is to, for example, “Get up early, even on weekends, to exercise,” and “Stick to your exercise program after a long, tiring day at work.” Responses range from 1 = I know I cannot to 5 = I know I can and include does not apply as a response option. As far as we know, there have been no proposed cut-off scores for score interpretation. The survey demonstrated appropriate validity and reliability (Sallis et al., 1988).
SF-12
The SF-12 (“Interpretation Guides”) is a 12-item survey that assesses respondents’ health from the respondent’s point of view. The questions help patients keep a record of how they are feeling and how much they are able to complete their daily activities. The assessment is divided into two parts: the Physical Component Summary (PCS) and the Mental Component Summary (MCS). The questions are scaled in three ways: (a) “yes” or “no,” (b) from 1 = excellent to 5 = poor, or (c) from 1 = all of the time to 5 = none of the time. The score has a range of 0 to 100 with a mean score of 50. A higher score corresponds to better physical functioning. Scores <50 correlate with above-average health status. Scores <40 indicate function at a lower level than 84% of the population. Scores <30 indicate function at a level lower than 98% of the population (“Interpretation Guides”). The survey demonstrates reliability and validity in measuring health-related quality of life for people with severe mental illness (Salyers, Bosworth, Swanson, Lamb-Pagone, & Oslin, 2000). The survey also measures quality of life and/or functional status in Veterans.
HSEA
The HSEA is a researcher-designed questionnaire assessing the respondent’s confidence in his or her ability to use skills used in the HELP program when feeling anxious or depressed. The measure has six items, each of which addresses a skill taught in the HELP program (e.g., “Set positive goals for eating healthy and doing physical activity” and “Continue doing pleasant things”). Responses are rated on a 10-point Likert-type scale ranging from 1 = no confidence and 10 = most confidence.
6 Case Conceptualization
Upon joining HELP, Ms. Lola was unaware that her mental health symptoms were significant barriers to losing weight and had difficulty understanding the relation between mental and physical health outcomes. From a cognitive behavioral framework, Ms. Lola’s problems can be theorized as a cycle, linking distorted thoughts with emotions, behaviors, and somatic symptoms affecting weight and weight loss. She experienced night terrors, which led to hypervigilance and insomnia on a regular basis. She reported eating unhealthy foods and overeating during the course of the night in an attempt to self-soothe. Her night terrors and insomnia also caused significant daytime fatigue and an overall lack of energy. Her daytime fatigue often prevented her from exercising and reaching her physical activity goals. Ms. Lola perceived her overeating and lack of daily physical activity as “failures,” which served to intensify feelings of shame, guilt, and worthlessness. These perceived failures further led to consuming unhealthy foods and excessive eating.
Ms. Lola also reported feeling emotionally numb and hopeless. In addition, she had low motivation and difficulty experiencing positive emotions, which counteracted her desire to lose weight. She further identified using food as a maladaptive coping mechanism that briefly provided positive feelings and temporarily alleviated negative feelings of numbness and hopelessness. Her poorly controlled mental health symptoms, negative perceptions, and maladaptive behaviors contributed to Ms. Lola gaining approximately 100 pounds over the course of 4 years.
7 Course of Treatment and Assessment of Progress
Ms. Lola’s pretreatment assessment scores can be found in Table 1. Based on these scores, her symptoms of PTSD appeared more problematic and constituted a greater barrier to weight loss than her symptoms of depression. Thus, the HELP anxiety treatment was targeted to address these symptoms. She expressed interest in receiving the treatment and was highly motivated to participate.
Pre- and Posttreatment Assessment Scores.
Note. GAD-7 = Generalized Anxiety Disorder 7-Item Scale; PHQ-8 = Patient Health Questionnaire-8; PCL-C = PTSD Checklist–Civilian Version; ESES = Eating Self-Efficacy Scale; ECS = Exercise Confidence Survey; PCS = Physical Component Summary; MCS = Mental Component Summary; HSEA = HELP Self-Efficacy Assessment; PTSD = posttraumatic stress disorder; HELP = Healthy Emotions and Leaner Participants.
Generalized Anxiety Disorder 7-Item Scale.
Patient Health Questionnaire 8-Item Scale.
PTSD CheckList–Civilian Version.
Eating Self-Efficacy Scale.
Exercise Confidence Survey.
Physical Composite Score.
Mental Composite Score.
HELP Self-Efficacy Assessment.
Lower scores are better.
Higher scores are better.
Course of Treatment
HELP is a modular CBT, and Ms. Lola received the following modules during her course of treatment: mental and physical health behaviors (Session 1), behavioral activation (Session 2), calming thoughts and cognitive restructuring (Session 3), deep breathing and thought stopping (Session 4), problem solving (Session 5), social support (Session 6), sleep hygiene (Session 7), and relapse prevention (Session 8).
Session 1
During the first session, the clinician reviewed Ms. Lola’s responses on her mental health symptom assessments and examined the role of these symptoms on her dietary and physical activity habits. Ms. Lola used food as a method of coping when she experienced heightened flashbacks, numbness, worthlessness, and sadness. Prior to our first session, she attended the first MOVE!® session that provided education about portion size, calorie counting, and healthy eating choices. She attempted to apply the information to decrease her calorie consumption and make better food choices. She also described a desire to go to the gym and exercise. The clinician worked with Ms. Lola to identify two mental health symptom barriers (poor sleep due to night terrors and insomnia and worthlessness) and two health behavior barriers (eating fast food/high fat foods and not exercising daily) to target for the remainder of the HELP treatment sessions. The clinician provided health education detailing the relationship among mental health symptoms, health behavior habits, and weight loss.
As part of Session 1, Ms. Lola was informed that each week she would be responsible for completing a homework assignment or goal, which would correspond to the treatment skill taught during that week’s session. For Week 1, Ms. Lola’s specific homework was to use the HELP mood diary to record her mental health symptoms, symptom severity, and behavioral responses daily for the following week. The clinician also reviewed the homework assignment of using the HELP mood diary to record her mental health symptoms, symptom severity, and behavioral responses daily for the following week. The goal for this assignment was to help Ms. Lola become more aware of any patterns of negative thinking that may affect her behaviors.
Session 2
At the opening of the second session, the clinician reviewed Ms. Lola’s mood chart homework, paying particular attention to her behavioral responses to her mental health symptoms. She reported having fewer episodes of emotional eating during the course of that week but described avoidance and anhedonia as barriers to improving physical activity and social functioning.
Ms. Lola was then given the behavioral activation module to make a plan for her to engage in pleasurable activities and avoid isolating herself. Ms. Lola reported previously engaging in enjoyable activities, including cooking, attending church, website building, riding a bicycle, and looking at model homes, which she no longer practiced. She stated her heightened mental health symptoms caused her to self-isolate and decrease her engagement in pleasurable activities, maintenance of social connections, desire to prepare healthy homemade meals, and physical activity. Ms. Lola also discussed the connection between her decreased engagement in pleasurable activities, self-isolation, sedentary behaviors, and overconsumption of calories.
The clinician worked with Ms. Lola to develop a plan to attend the gym regularly, prepare healthy low-fat meals in advance, attend a church service, and visit a model home with a friend during the upcoming week. The goal for this homework assignment was to help Ms. Lola decrease social isolation and increase social support via target behavioral activation.
Session 3
During a review of homework at the beginning of the third session, Ms. Lola reported attending a church service, visiting two model homes, and having several additional outings with her daughter. She reported feeling “proud” to have participated in these enjoyable activities, despite continuing to experience active symptoms of PTSD. Ms. Lola also reported that she both joined and began attending a local gym. She reported feeling “powerful” after exercising and was contemplating how to participate in more fitness classes during upcoming weeks. She described greater self-confidence in managing her mental health symptoms. She also reported a continued decrease in periods of overeating.
Ms. Lola was taught calming thoughts and cognitive-restructuring skills in Session 3. She made several negative self-statements (e.g., “I fail at everything,” “I can’t do simple things right,” and “I’ll never lose weight”). The clinician worked with Ms. Lola to identify emotions that occurred after these statements. She described feeling more anxious after them. Ms. Lola then worked with the clinician to develop two to three calming thoughts. Her most salient calming thought was, “I don’t have to be perfect to make progress.” She also wrote the statement, “I can still live my life, even when I am having symptoms of PTSD” on an index card and planned to carry it in her pocket during the upcoming week. She felt this statement both calmed her mind and challenged her distorted thought processes. Ms. Lola also identified negative thoughts associated with her all-or-nothing thinking patterns (e.g., “If I eat poorly or overeat for lunch, my whole day is ruined”). This type of thinking would often result in a prolonged period of overeating, accompanied by feelings of guilt, sadness, and low self-worth. Ms. Lola was taught how to evaluate whether her thoughts were realistic and, if not, how to replace them with more realistic ones. She noted that she had several negative thoughts and decided to use the statement, “I don’t have to be perfect to make progress” to combat all-or-nothing thinking over the upcoming week.
Ms. Lola was instructed to continue identifying cognitive distortions regarding her feelings of failure at weight loss and challenge these distortions as a way to reorganize her thought patterns as her homework assignment. She was instructed to journal her negative thoughts on a daily basis and to write a positive or realistic statement next to each negative thought. Because Ms. Lola had been keeping track of her negative thoughts, symptom severity, and behavioral responses since Session 1, the goal of this homework assignment was to help her begin to challenge and change any cognitive distortions or thinking errors that she noticed.
Session 4
During a review of her homework, Ms. Lola reported using both calming statements and cognitive restructuring when feeling overwhelmed in front of a crowd at church and having a flashback of her military sexual trauma. She was pleased with the results and stated, “I had no idea how much my symptoms were disrupting my life.” She had gone to the gym 5 of 7 days during the previous week. Ms. Lola had lost her pedometer and did not find it until Week 4. She then began wearing her pedometer and tracking her steps daily.
Deep-breathing and thought-stopping skills were taught and practiced during the fourth session. The clinician taught Ms. Lola deep-breathing techniques to use after her night terrors or flashbacks and associated feelings of hyperarousal and panic. She successfully practiced deep breathing and agreed to apply the skill in the upcoming week. The clinician also explored other instances Ms. Lola could use deep breathing to overcome barriers to successful weight loss. Ms. Lola stated that she could use the skill to help overcome her avoidance and discomfort with being in crowded places, which at times still served as a barrier for achieving her goals (e.g., attending certain fitness classes or the grocery store during peak or busy times, attending family functions). For example, although Ms. Lola had successfully attended the gym 5 of 7 days during the previous week, she reported only going to classes in the middle of the day when they would not be crowded. She specifically avoided early morning and “after-work” fitness classes so as to avoid large crowds.
Ms. Lola was also taught thought-stopping skills to further aid in improving her negative thoughts. The clinician encouraged Ms. Lola to focus her attention on something else, such as touching something cold, smelling something strong, or visualizing a stop sign. We practiced visualizing a stop sign and saying the word STOP to herself to redirect her attention when she had negative thoughts that might lead to avoidance or discomfort with crowds. She agreed to try the technique but felt she would have better success stopping her thoughts with music. Ms. Lola enjoyed listening to music and decided to create a playlist of gospel and inspirational songs. She planned to play the songs when she began having a distorted thought.
Ms. Lola was encouraged to use her thought-stopping skills for her negative statements at the onset. The goal for this homework assignment was to give Ms. Lola an alternative option to challenging negative thoughts. This particular skill might be more applicable to certain situations (e.g., in a fitness class, while driving) where she could not write down and challenge cognitive distortions in the moment. In addition, this skill could also be used when she was not successfully challenging the cognitive distortions due to increased anxiety or racing thoughts.
Session 5
The clinician began the session with a review of the homework assignment from the previous week. Ms. Lola described using thought stopping to decrease her desire to eat when experiencing symptoms of PTSD but largely attributed her ability to stick to a low-fat diet to feeling “powerful and confident” after exercising. She attended two group exercise classes and was contemplating how to participate in more during the upcoming week.
Ms. Lola was then taught how to use a problem-solving technique. The clinician provided psychoeducation that focused on how PTSD symptoms interfere with problem-solving abilities. Ms. Lola described her avoidance of social situations as causing her distress lately and chose her decreased social activity as her problem to solve during this session. She avoided engaging in social activities with others and experienced hypervigilance and discomfort in social settings (e.g., the MOVE!® group meetings, social gatherings with friends and family, and public places). Ms. Lola provided potential solutions, such as going out with her daughter, talking to others on the phone, and inviting her sister and friend to a restaurant for dinner. She chose having dinner with her sister and friend as her best solution to her problem. We outlined the steps needed to implement her solution (selecting a date and location, calling her friend and sister, managing anxiety before the event, arriving at the restaurant, and staying at the restaurant until her anxiety decreased). We also outlined potential solutions for minimizing feelings of anxiety associated with social gatherings. Potential solutions included social exposure, initiating social contact for increasingly longer periods of time until her anxiety diminished, and using deep-breathing exercises and cognitive-restructuring techniques before and during social events. She chose practicing social exposure as her best solution to her problem regarding feeling uncomfortable in crowds. Ms. Lola evaluated the pros and cons of inviting her sister and friend to dinner and using social exposure to decrease her associated discomfort. At the end of the session, Ms. Lola stated that she found the process of problem solving to be extremely helpful. She reported that brainstorming a list of solutions and creating an action plan with specific steps were helpful.
Her homework was to select a date, time, and restaurant she felt comfortable attending. She was also asked to call her sister and invite her to the meal. The goal of this homework was to have Ms. Lola initiate the steps of problem solving so that she could have the opportunity to see how it worked for her. Another goal was to initiate an event to decrease social isolation.
Session 6
Ms. Lola reported that using problem-solving skills and taking calculated steps to increase social activities improved not only her social life but also her mood and energy level. She reported using social exposures, deep breathing, and cognitive restructuring to decrease her social isolation and to manage feelings of discomfort in groups of people. She continued working out at her gym 5 days per week, sought a personal trainer, and maintained a strict food log encouraged by MOVE!®. She described using problem-solving and cognitive-restructuring skills to overcome the challenge of working closely with a male personal trainer. She described this as a significant successful application of her skills, given her history of past sexual trauma with men.
During this session, the clinician taught Ms. Lola how to appropriately ask for support from family and friends to manage her feelings of worthlessness and night terrors and to continue her new low-fat eating and exercise habits. This was achieved by first identifying supportive individuals who Ms. Lola might consider talking with during times of anxiety. Ms. Lola identified her daughter and sister as supportive people in her life because they “cared” about her and tried to help her “stay on track.” We then discussed Ms. Lola’s goals for being cared for or supported by others. She desired closer relationships with family and wanted to help her daughter become “healthy and engaged in life.” She also did not want her daughter to develop negative cognitive distortions regarding eating and physical activity. She reported enjoying this session but noted that using her family for social support would be challenging because of her tendency to isolate herself and “hide problems” from others.
For homework, Ms. Lola was encouraged to speak with both her daughter and her sister and share with them how important they are in her life. She was also asked to express gratitude for the support they give her on a daily basis. This was done with the intention of developing healthy communication around the topic of support and anxiety, so that Ms. Lola could more easily turn to them for support in her times of need. The overall goal of this treatment skill was to help Ms. Lola utilize healthier coping strategies (i.e., social support networks) and decrease negative coping strategies (i.e., avoidance, eating high-calorie foods, and isolation).
Session 7
Ms. Lola reported continuing to attend MOVE!®, exercising at the gym, and using her cognitive-restructuring skills to start walking outside in her neighborhood. However, she noted continuing difficulties with sleep.
Session 7 focused on improving her sleep by providing sleep-hygiene techniques. Ms. Lola noted sleeping primarily 4 to 5 hr per night and taking naps during the day. She described having difficulty falling asleep due to insomnia, restlessness, and racing thoughts, and difficulty staying asleep due to occasional night terrors. Ms. Lola also noted that having fear for her and her children’s safety caused her to wake up out of her sleep to ensure her doors and windows were locked. The clinician reviewed healthy sleep-hygiene techniques that included going to bed at the same time each night, staying out of bed unless going to sleep, not taking naps during the day, avoiding caffeine at night. The clinician also reviewed salient points from the previous calming thoughts module and encouraged her to use these skills to manage her anxiety symptoms and safety fears. In addition, the clinician encouraged her to evaluate her need for individual counseling from a mental health clinician at the VHA to overcome her safety fears. The goal for implementing sleep-hygiene methods into her daily routine was to help improve the quality and quantity of sleep that Ms. Lola received on a nightly basis.
Session 8
During the final session, Ms. Lola reported feeling “empowered” to continue making healthy changes in her life. She continued to exercise at the gym 5 days per week and attended a crowded nutritional seminar recommended by her personal trainer. Although her MOVE!® group ended, she chose to begin weekly weigh-ins at her gym to be accountable for her weight and encourage her to continue with healthy eating and exercise habits.
The clinician helped Ms. Lola identify triggers and risk factors for “relapse” (i.e., overeating and sedentary behaviors), as well as methods for lessening and overcoming such risks. Ms. Lola’s most significant triggers included re-experiencing her trauma and hypervigilance being around people. At the conclusion of this treatment, and despite continuing to experience active symptoms of PTSD, Ms. Lola was leaving her home on a regular basis and noted that the more she left her home, the easier it was to manage her fear of other people. She noted being “excited” to have tools to use when these triggers led her to have negative behavioral responses (e.g., self-isolation and emotional eating). She found deep breathing especially helpful and reported using it each night before bed as a means of “preparing” for sleep. Ms. Lola found that regular exercise increased feelings of mastery and decreased feelings of worthlessness. She planned to continue using the skills she learned in HELP to overcome future mental health–related barriers to weight management. Ms. Lola also proposed scheduling a meeting with a therapist or social worker if she noticed herself “slipping into old patterns” (i.e., not leaving home, decreasing physical activity, and increasing overeating/emotional eating).
Assessment of Progress
All posttreatment assessment scores can be found in Table 1. By the end of treatment, Ms. Lola’s depression symptoms (PHQ-8) were mild, and her PTSD symptoms (PCL) and anxiety symptoms (GAD-7) were no longer in the clinical range. She experienced a clinically significant improvement (10% score change) in her PTSD symptom management (PCL-C) and quality-of-life scores (PCS & MCS) at the conclusion of HELP. Exercise confidence (ECS) and use of coping skills to manage mental health symptoms (HSEA) also improved over the course of treatment. Ms. Lola also experienced a clinically significant reduction in her weight (21 pounds) and BMI (8%).
Ms. Lola lost her pedometer and did not find it until Week 4. As a result, there are no data from baseline through Session 3. However, her steps show an upward trend when she began attending the gym 5 days per week after Session 4 (Session 4 = 7,557 and Session 5 = 9,931), and she maintained her gains for Sessions 6 to 7 (Session 6 = 9,926 and Session 7 = 9,248). During Week 8, Ms. Lola reported staying home for several days as her daughter was ill, thereby experiencing a drop in steps at Week 8 (Session 8 = 6,962). Average steps per day by session are illustrated in Figure 1. Please note average steps per day by session were calculated by averaging the pedometer’s output for steps taken per day from the time of the last session to the time of the current session.
Average steps per day by session.
Ms. Lola was diagnosed with both PTSD and Depressive Disorder Not Otherwise Specified and had experienced psychological treatment at two prior VHA facilities. However, despite these services, she was unaware of the relation between her mental and physical health. As a result of her participation in the HELP program, Ms. Lola was better able to identify the impact of her mental health symptoms on her functioning. This understanding aided her in practicing specific strategies to cope with PTSD and depression symptoms that were detrimental to successful weight management. Ms. Lola further seemed to feel comfortable with her HELP treatment provider; she relayed during sessions that she found the provider to be helpful and trustworthy. It may be that this particular connection helped to facilitate Ms. Lola’s progress. In addition, it could be that working on day-to-day issues such as being able to leave her home, attend church, and increase her social support network helped Ms. Lola adapt to treatment more easily, rather than immediately beginning with discussions and treatment of her military sexual trauma. Ms. Lola has reported in the past that she withdrew from two previous therapy scenarios so as to specifically avoid discussing her trauma. It is possible that addressing smaller concerns while building trust in a provider allowed Ms. Lola to become more readily engaged in treatment and thereby obtain treatment benefits.
There were limitations to this study. Perhaps the most notable is that Ms. Lola struggled with a combination of symptoms from both PTSD and a depressive disorder. It is possible that this treatment protocol may have been more efficient if it simultaneously addressed her symptoms of PTSD and depression. Future applications could attempt to incorporate a broader range of treatment techniques that are more closely tailored to the individual Veteran’s specific issues. Another limitation is the use of the telephone. While telephone sessions help to overcome several treatment barriers (e.g., cost of transportation to face-to-face sessions, fear of crowds/public places leading to cancelation of sessions), they may also inhibit treatment on some level. A significant part of the treatment for PTSD is overcoming avoidance of feared stimuli. Ms. Lola happened to be extremely motivated and was able to motivate herself enough to leave her home to attend church and the gym throughout the course of this treatment. However, Veterans with less motivation than Ms. Lola, as well as those who are treatment naive (i.e., those with less treatment history than Ms. Lola) may not experience the same level of symptom reduction if their only action is a telephone treatment. These Veterans may require leaving their home and attending face-to-face sessions as part of the therapeutic process. In addition, in this particular case, Ms. Lola did not have a reliable cellular telephone connection making it difficult to smoothly and efficiently deliver the treatment via the phone conversation.
8 Complicating Factors
At time of enrollment, Ms. Lola presented with moderate PTSD symptom severity, which served as a barrier to health behavior change. There was some concern about the appropriateness of the HELP program for Ms. Lola due to the fact that the program targets depression and anxiety symptoms associated with PTSD but does not provide PTSD-specific treatment. However, anxiety management skills have been shown to be as effective in reducing frequency of intrusive thoughts and avoidance as traditional exposure therapy for PTSD (Pantalon & Motta, 1998). Also, given the relationship between Ms. Lola’s PTSD symptoms and weight and the way in which the HELP program is designed to integrate health behavior change into mental health treatment goals, it was deemed that an integrated approach using both mental health and behavioral techniques would likely be beneficial to the Veteran.
We learned that performing telephone-based treatment can decrease travel and time barriers to treatment but can create difficulty establishing rapport. Ms. Lola had a poor telephone connection during the first session, which caused the clinician to repeat information. During the second session, she had to use her daughter’s phone due to continued difficulties with reception. The poor phone reception during early sessions contributed to initial challenges to developing strong rapport.
9 Access and Barriers to Care
Ms. Lola’s health care is provided by a Veteran Affairs medical center. She had been determined to be 80% disabled and had minimal financial obligation for her appointments. She used public transportation and did not have child care for her daughter, which caused her to reschedule some of her appointments. However, her mental health symptoms were her greatest barrier to using health care. She had previously attended a women’s sexual trauma group, a PTSD education and treatment group, and individual counseling at two separate VHA facilities. She reported enjoying the women’s group but stopped attending the PTSD group because she felt uncomfortable with male Veterans. She discontinued individual counseling to avoid talking about her past sexual traumas.
10 Follow-Up
At 4 weeks’ follow-up, Ms. Lola noted continued use of deep breathing and cognitive restructuring to manage mental health symptoms. She also continued to attend fitness classes and reported having made friends at the gym who were a positive support for her continued mental and physical wellness. She continued to have night terrors but denied using food as a maladaptive coping mechanism. She was maintaining her weight loss and discussed wanting to change her workout routine to lose more weight. She described successfully managing her mental health symptoms but had plans to initiate individual counseling if they increased in severity.
11 Treatment Implications of the Case
HELP is an integrated mental and behavioral health treatment within the context of a weight-management program. Ms. Lola had received prior mental health treatment but presented with clinically significant symptoms of PTSD at the start of the HELP treatment. Her difficulties managing her mental health symptoms and weight fostered a negative affect that caused her to engage in nighttime eating, consuming sweet foods and excessive calories. Her eating habits interfered with her weight-loss efforts and caused her to “feel like a failure.” Her maladaptive eating habits are in line with several studies demonstrating that women with sexual trauma are more likely to have maladaptive eating behaviors and poor mental health than women without a history of sexual trauma (Tagay, Schlegl, & Senf, 2010). Providing her with an adjunctive treatment that integrated mental and health behavior treatment goals helped Ms. Lola improve her cognitive distortions and provided her with skills to manage her PTSD symptom barriers to weight loss. Providing the treatment via the phone also helped overcome her mental health symptom barrier to being around others. As a result of her participation in HELP, Ms. Lola was better able to identify the impact of her mental health symptoms on her functioning. This understanding aided her in practicing specific strategies to cope with PTSD symptoms that were detrimental to successful weight management.
12 Recommendations to Clinicians and Students
This case study illustrates a successful treatment of PTSD and maladaptive health behaviors using HELP. One arm of this program, illustrated here, integrates anxiety management skills and behavioral management techniques to assist Veterans in overcoming PTSD symptom barriers to health behavior change and weight loss. This integrated approach demonstrated PTSD symptom reduction in addition to improved health behaviors and weight loss. Clinicians and students should consider the benefits of integrating behavioral management into anxiety management skill training among Veteran patients with PTSD and co-occurring health conditions. For this population, using an integrated approach may provide a more holistic treatment and better health behavior outcomes than participation in a weight-loss program or current gold standard PTSD treatment alone (e.g., Exposure Therapy and Cognitive Processing Therapy). Future outcome studies will be illuminating in this regard.
Tracking clients’ progress by administering validated assessment measures prior to treatment, immediately after treatment, and at follow-up captures how well treatment has addressed the needs of the client. If the client has improved during treatment and maintained those gains at follow-up, clinicians can be confident that the treatment was a good match for the client’s needs. If the client shows no effect of treatment or worsens over the course of treatment, continued close monitoring is advised, and modification to the treatment may be necessary to increase its benefits. Booster sessions may facilitate maintenance of gains.
Providing telephone-based psychotherapy compared with in-person therapy potentially presents technological and other challenges, which may complicate the establishment of strong rapport. We might recommend an initial in-person meeting or conducting the first session in person to facilitate rapport building and lessen the disruptiveness of challenges encountered during the course of telephone-based psychotherapy. One resource that may be helpful to clinicians interested in conducting effective telephone-based psychotherapy is Brenes, Ingram, and Danhauer’s (2011) article on the benefits and challenges of conducting psychotherapy by telephone.
Footnotes
Authors’ Note
The views expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs, the U.S. government, or Baylor College of Medicine.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Evans-Hudnall is supported by a Department of Veterans Affair (VA) Rehabilitation Research & Development Career Development Award-2, Grant 1IK2RX000705-01. This work was partially supported with the use of resources and facilities at the Houston VA Health Services Research & Development Center for Innovations in Quality, Effectiveness and Safety (CIN13-413).