Thoughts like these are completely natural for dieters, but they aren't helpful. To deal with them, dieters need to learn how to anticipate them and prepare themselves in advance, while continuing to remind themselves why it's worth the effort to limit their eating. So a major component of a successful CBT dieting strategy is helping clients learn to practice responses to the thoughts that undermine motivation, increase disappointment, and exacerbate a sense of deprivation—all of which reinforce old, maladaptive eating patterns.
Perhaps the most basic tool that helps clients learn the cognitive skills they need to adhere to their diets is the use of index cards on which they write messages they'll need to read when they're tempted to overeat. They develop the practice of reading "response cards" containing these helpful messages every morning and at least one more time, at their most vulnerable part of the day. Here are a few examples of response-card messages:
- I can eat whatever I want, whenever I want, or I can be thinner. I can't have it both ways.
- Hunger and craving always pass. I can make them go away faster by focusing my attention on something else.
- My body doesn't know it's a holiday. It'll process food in exactly the same way as on other days.
Reading these cards daily, even when motivation is high, allows dieters to immerse themselves in crucially important ideas that prepare them for the inevitable difficult times, especially the thoughts that lead to negative, motivation-sapping emotions: This is just too hard leads to discouragement. It's not fair leads to anger and a sense of deprivation. I really want to eat this right now leads to disappointment. Dieters can't prevent these sabotaging thoughts from entering their minds, but if they've been practicing helpful responses, they'll be able to deal with them and modify their habitual eating behavior.
Research is increasingly demonstrating that lasting behavioral change—not only in eating, but also in the areas of substance use, overspending, procrastination, gambling, aggressive behavior, or self-harm—requires changes in dysfunctional thought patterns. To challenge old, entrenched patterns, people need to know what to tell themselves when they're feeling stressed, tired, unmotivated, discouraged, disappointed, or deprived; when they want to overindulge because of cravings or emotional distress; when they want to celebrate, keep a good mood going, or eat like everyone else.
Despite the fact that the dieting industry has largely failed to recognize the importance of changing thought patterns when attempting to change behavior, a growing body of recent research bears out the importance of having a dual emphasis on behavior and cognition. For example, in a study reported in 2005, psychiatrists Lisbeth Stahre and Tore Hallstrom found that participants in the CBT modality of their randomized controlled trial lost, on average, 17 pounds. Even more impressively, they continued to lose, on average, another 5 pounds during the 18-month follow-up period, while patients on the waiting list gained weight. Likewise, another randomized controlled trial of dieters who received CBT, conducted by psychologist Marieke Werrij of Maastricht University and colleagues, reported in 2009, found that they not only lost weight, but also were more successful in keeping it off than those in a program without CBT. The results of these studies and others like them contrast starkly with a metanalysis performed by weight-loss expert Michael Dansinger and reported in 2007. He found that dietary counseling focusing on nutritional and behavioral advice produces little weight loss—and dieters almost always gain weight back.