Treatment Beliefs and Preferences for Psychological Therapies for Weight Management Robyn Moffitt,1 Ashleigh Haynes,2 and Philip Mohr2 1 2

Australian Catholic University The University of Adelaide

Objective:

Treatment beliefs and preferences for psychological therapies were investigated in 80 overweight individuals trying to manage their weight. Method: Participants read 4 therapy descriptions: cognitive behavioral therapy (CBT), behavior therapy (BT), cognitive therapy (CT), and acceptance and commitment therapy (ACT). They ranked the treatments in order of preference, explained the reason for their preferred choice, and reported their beliefs about each approach. Results: Individual CBT (43.42%) and BT (31.58%), delivered face-to-face or technologically, were the most preferred treatment options, while ACT (17.12%) and CT (7.89%) were the least preferred. The main reasons cited among those who chose CBT and BT were perceived comprehensiveness and the practical nature of the approach, respectively. Treatment beliefs were strongly predicted by psychological need satisfaction as well as perceived ease and effort. Conclusions: Further research should ascertain the stability of treatment beliefs and the efficacy of modifying the treatment context to meet individual C 2015 Wiley Periodicals, Inc. J. Clin. Psychol. 71:584–596, 2015. needs. 

Keywords: treatment preferences; psychological therapy; weight management; obesity

Weight management is a challenging undertaking undermined by a complex interplay of impeding biological and lifestyle factors and is characterised by premature abandonment, small effects, and poor maintenance (Brownell, 2010). Although there is evidence for the effectiveness of theory-linked behavior change techniques for weight management, and in particular those incorporating operant and behavior change techniques, very little research has compared the long-term efficacy of different psychological treatments (Dombrowksi et al., 2012; Munsch, Meyer, & Biedert, 2012). Consequentially, the limited long-term success of even the most evidence-based psychological treatments for weight management has led some to conclude that overweight and obesity may be “resistant to psychological methods of treatment” (Cooper et al., 2010, p. 706). Accompanying the modest success of psychological treatments for weight management has been a strong and steady increase in demand for a treatment solution among health clinicians (Stroebe, van Koningsbruggen, Papies, & Aarts, 2013). The evidence used to evaluate the merit of psychological treatments has expanded from that provided through randomized controlled trials (RCTs) to include a broader consideration of research evidence in combination with clinical expertise and individual differences in treatment preferences (American Psychological Association, 2006). Accordingly, to extend understanding of the most efficacious psychological treatments for weight management, and to guide intervention development, clinical decision making, and future research effort, the current study investigated treatment beliefs and preferences for psychological therapies in an overweight sample seeking to more effectively manage their weight. A consideration of treatment preferences, through matching people with their preferred treatment, has resulted in decreased attrition from therapy (Corrigan & Salzer, 2003), stronger therapeutic alliance (Iacoviello et al., 2007), and improved outcomes (Swift & Callahan, 2009), all of which can be broadly attributed to increased motivation. Self-determination theory (SDT),

Please address correspondence to: Robyn Moffitt, Griffith University, School of Applied Psychology, 176 Messines Ridge Road, Mt Gravatt, Queensland, Australia, 4122. E-mail: [email protected] JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 71(6), 584–596 (2015) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).

 C 2015 Wiley Periodicals, Inc. DOI: 10.1002/jclp.22157

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a macrotheory of human emotion with demonstrable evidence for health-related problems, describes autonomous motivation as a potential explanatory mechanism (Deci & Ryan, 2008). Autonomous motivation, whereby people self-select, self-endorse, and internalize a chosen behavioral direction, has proven a reliable predictor of enhanced therapy outcome (Deci & Ryan, 2008; Zuroff et al., 2007). In contrast to controlled motivation where actions are contingent on perceived pressure or coercion and external contingencies, autonomously motivated action has been associated with greater psychological health and maintained change toward healthy behaviors. This association is strong across a variety of health-related behavioral indicators including adherence to treatment protocols, attendance at therapy sessions, improved self-management, and long-term maintenance of treatment gains (Deci & Ryan, 2008; Ryan & Deci, 2000). According to SDT, strong autonomous motivation can be nurtured through therapy that satisfies three innate psychological needs: competence, autonomy, and relatedness (Dwyer, Hornsey, Smith, Oei, & Dingle, 2011; Ryan & Deci, 2000). Specifically, a therapy setting that provides opportunities for mastery or success, self-direction, and social connection should facilitate the development of a strong autonomous orientation and result in enhanced commitment and long-term outcome (Deci & Ryan, 2008; Johnston & Finney, 2010; Ryan & Deci, 2000). In the existing literature, preferences for and attitudes toward psychological therapies have been explored among people seeking treatment for posttraumatic stress disorder [PTSD] (Becker, Darius, & Schaumberg, 2007; Feeny, Zoellner, Mavissakalian, & Roy-Byrne, 2009; Tarrier, Liversidge, & Gregg, 2006; Zoellner, Feeny, & Bittinger, 2009; Zoellner, Feeny, Cochran, & Pruitt, 2003) and depression (Kwan, Dimidjian, & Rizvi, 2010; Lin et al., 2005; van Schaik et al., 2004; Zuroff et al., 2007). However, this research has not investigated the predictive value of anticipated psychological need satisfaction or its association with these preferences. Furthermore, very little research has investigated treatment beliefs and preferences for psychological therapies specifically for weight management. Burke, Steenkiste, Music, and Styn (2008) explored past experiences with weight control treatments in a sample of people on a waiting list for a weight loss study. Although already registered for the weight loss study, participants identified “do-it-yourself” (30.6%) as the most popular approach; the second most preferred approach was involvement in a formal research study (22.4%). Among those who preferred a self-driven approach, the primary motivation was for personal control, and among those expressing a strong interest in a research study, the central reason provided was perceived support. Consistent with SDT, the former arguably reflects a desire for autonomy, and the latter for relatedness, in a preferred treatment approach. Burke et al. (2008) provide only indirect support for the hypothesis that psychological need satisfaction is important when selecting a weight management treatment. In addition, the findings did not provide insight into preferences for, or beliefs about, different psychological treatment options. Brody, Masheb, and Grilo (2005) compared preferences for cognitive behavioral therapy (CBT) or behavioral weight loss therapy (BWLT) in a sample of obese patients with binge eating disorder (BED). Two thirds of participants (63%) indicated a preference for CBT. However, the study confounded type of therapy with intended treatment outcome in the study descriptions: The CBT description detailed techniques to “eliminate binge eating” and the BWLT emphasized strategies to “lose weight” (Brody et al., 2005, p. 353). This is particularly problematic given that participants were diagnosed with BED and recruited from an eating disorders clinic, thus making them more likely to seek a treatment for binge eating specifically. Furthermore, BWLT involved recommendations for calorie control and physical activity, rather than teaching specific behavioral techniques to supplement these lifestyle changes. The obese BED sample used in the study also limits the generalizability of the findings more broadly. The current study investigated, in a sample of overweight people with a weight management goal, whether demographic and weight-related variables, perceived psychological need satisfaction, and pragmatic considerations were associated with beliefs about and preferences for four psychological therapies with the strongest empirical evidence for weight management: behavior therapy (BT), CBT, cognitive therapy (CT), and acceptance and commitment therapy (ACT; Ruiz, 2010; Shaw, O’Rourke, Del Mar, & Kenardy, 2005). Current research suggests that BT has the most extensive evidence base and is widely considered the treatment of choice for weight management (Munsch et al., 2012; Shaw et al., 2005). BT

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utilizes the principles of operant learning, behavioral contingencies, and positive and negative reinforcement to elicit dietary and physical activity behavioral change. Together, BT and CBT are the two most commonly evaluated and efficacious psychological therapies for weight management (Lo Presti et al., 2010). CBT not only incorporates traditional behavioral techniques but also focuses on identifying cognitive and emotional mechanisms that maintain undesired behavioral patterns. There is strong evidence in support of CBT for weight management, and recent research found comparable long-term effectiveness between BT and CBT (Cooper et al., 2010). CT has demonstrated efficacy for the treatment of disordered eating behaviors through targeting the role of maladaptive, dysfunctional, and distorted cognitions about food and one’s body weight in weight gain (Cooper & Fairburn, 2001; Munsch et al., 2012). However, although the evidence base is small, BT and CBT approaches to weight management have consistently outperformed pure CT (Shaw et al., 2005). ACT, a “third wave” psychological therapy targeting maladaptive avoidance of discomfort, has recently generated increased research attention in the weight management context (Ruiz, 2010, p. 126). Preliminary evidence supports the use of ACT for weight loss. However, the efficacy of ACT relative to other psychological interventions with a more extensive empirical base for weight management has not yet been established. Another potential focus of treatment preference concerns delivery modality. Renjilian et al. (2001) found that matching participants to their delivery modality preference (group versus individual) did not lead to greater weight loss after participation in a 6-month cognitive behavioral weight management program. Instead, participants randomly assigned to group-based treatment lost significantly more weight at posttreatment than participants who received individual treatment, independently of pretreatment delivery modality preference. However, all participants in the Renjilian et al. (2001) study received the same psychological intervention and the efficacy of matching participants to delivery modality preference, rather than psychological treatment type, was explored. This did not allow an investigation into the potential interaction between treatment and delivery modality preferences. Furthermore, participants reported greater satisfaction with individual therapy at posttreatment, and the difference in weight loss across the two delivery modalities was not deemed clinically significant. This finding has been supported in a recent systematic review investigating intervention components associated with weight losses in dietary and physical activity interventions, which revealed inconsistent findings regarding the association between intervention delivery modality and effectiveness (Greaves et al., 2011). It has been suggested that individual, group, and mixed-mode delivery can all be efficacious in the weight management context, and it has been demonstrated that electronic delivery modalities (i.e., Internet and e-mail) can be efficacious for weight management (Tate, Wing, & Winett, 2001). The current literature emphasizes a need for continuous care that is effective, affordable, and has broad impact at the community level (Latner, Ciao, Wendicke, Murakami, & Durso, 2013). Therefore, to investigate whether treatment preferences interact with delivery modality, the likely uptake of each therapy across three modalities (individual, group, or technological) was explored (Becker et al., 2007; Zoellner et al., 2003; Zoellner et al., 2009). Consistent with preferences research investigating psychological treatments in nonweight domains, participants also ranked the treatments from most to least preferred, and perceptions of scientific credibility and personal reactions to the rationale of each therapy were measured (Zoellner et al., 2009).

Method Participants The sample comprised 80 overweight (body mass index [BMI] > 25.00) community members on a voluntary institutional participant database, with an average age of 37.55 (standard deviation [SD] = 16.50) and average BMI of 33.70 (SD = 6.44), who responded to a study advertisement sent via e-mail. Only females (n = 61) and males (n = 19) who were currently trying to lose weight or more effectively manage their weight, were not currently receiving psychological therapy, and did not have a diagnosed eating disorder were invited to participate. Although not currently

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receiving therapy, some participants reported previous experience with one of the four therapy options: CBT (n = 13), BT (n = 13), CT (n = 14), and ACT (n = 19). Among these participants, average satisfaction levels, as assessed on a 7-point satisfaction scale, were low (CBT: mean [M] = 3.60, SD = .55; BT: M = 4.00, SD = 1.87; CT: M = 3.80, SD = 1.30; ACT: M = 3.40, SD = 1.34). However, there was no significant difference in satisfaction level across therapy type, F < 1.

Materials Treatment descriptions. Treatment descriptions for the four therapies (CBT, BT, CT, and ACT) were constructed to reflect information that might be presented to an individual seeking a psychological weight management treatment. Three independent, registered psychologists with expertise in psychological therapy analysed the descriptions for accuracy and relevance to a weight management context and to ensure equivalence in clarity, engagement, structure, content, and tone. The final descriptions were piloted on four independent lay volunteers for feedback on readability and comprehension of concepts. The descriptions followed a consistent structure, commencing with the aim and operating mechanisms of the therapy and concluding with specific examples of strategies and techniques taught to achieve these aims. All treatments were framed as viable options and emphasized strategies to improve eating behavior. Specific caloric or physical activity advice was not included in the descriptions to ensure treatment beliefs and preferences related only to the psychological therapies. The descriptions also did not differ in relation to word count, reading ease, or grade level based on indices from Microsoft Word (Microsoft Inc., 2007). The detailed treatment descriptions are provided in the Appendix. Measures Weight-related measures. Participants were asked to report their ideal weight (in kilograms), from which their weight loss goal was calculated and expressed as a percentage of their current weight. Participants were also asked to report the age at which they first became overweight. Treatment preferences. Participants ranked the therapies in order of preference, from most to least preferred, and were asked to disclose the primary reason for their most preferred treatment choice in an open-ended response format. Treatment beliefs. For assessment of perceptions of treatment effectiveness and personal attitudes toward each therapy, participants completed the Credibility Scale (CS; Addis & Carpenter, 1999) and the Personal Reactions to the Rationales Scale (PRR; Addis & Carpenter, 1999). Credibility beliefs were measured using the seven-item CS, which assessed the extent to which each therapy was perceived to be logical, scientifically based, and effective for weight management (e.g., “How logical does this therapy seem to you?”) using a 7-point response scale ranging from 1 (not at all) to 7 (extremely). Higher scores indicate higher perceived credibility (range 7–49). In the current sample, internal consistency for the CS was high (CBT, α = .94; BT, α = .96; CT, α = .94; ACT, α = .92). Expectation beliefs were assessed using the five-item PRR, which measured perceptions of the personal suitability of each therapy (e.g., “How helpful do you think this therapy would be for you?”) on a scale from 1 (not at all) to 7 (extremely). Higher scores indicate more positive personal reactions and expectations (range 5–35). In the current sample, internal consistency for the PRR was high (CBT, α = .97; BT, α = .97; CT, α = .97; ACT, α = .96). Similar to Zoellner et al. (2009), a composite variable (treatment beliefs), encompassing both credibility and expectation beliefs, was calculated by summing the CS and PRR total scores for each therapy. Internal consistency for the composite scores was also high (CBT, α = .97; BT, α = .98; CT, α = .97; ACT, α = .96). Psychological need satisfaction. The few existing scales measuring general or domain specific (e.g., work and relationships) psychological need satisfaction were deemed inappropriate

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because of questionable psychometric properties (Johnston & Finney, 2010), and because they assess actual rather than projected satisfaction. Therefore, three questions were designed to measure the extent to which each treatment was expected to satisfy individual needs for competence (“I feel that I would be competent and able to engage in the behaviors and actions that this therapy might involve”), autonomy (“This therapy would encourage me to take responsibility, make choices, and drive change for myself, rather than relying on someone or something else to change my behavior”), and relatedness (“This therapy would make me feel cared for, connected, and supported”). Participants indicated the extent to which they agreed with each statement on a 7-point scale from 1 (completely disagree) to 7 (completely agree). A composite variable (need satisfaction) was calculated by summing the scores for the three items for each therapy. Internal consistency for the need satisfaction variable was high (CBT, α = .88; BT, α = .91; CT, α = .91; ACT, α = .86).

Pragmatic considerations. In an adaptation of the items used by Moffitt, Brinkworth, Noakes, and Mohr (2012), participants were asked to indicate, on 7-point scales ranging from 1 (completely disagree) to 7 (completely agree), the extent to which they agreed with three statements assessing the novelty (“This therapy uses an approach to weight management that is different to things I have already tried”), ease of engagement (“Engaging in this therapy would be easy for me”), and perceived effort required (“This therapy would require a lot of input and effort from me”) for each of the four therapies. They also indicated their likelihood of participating in each therapy in three delivery modes (group, individual, and technological) on 7-point scales ranging from 1 (highly unlikely) to 7 (highly likely). Procedure Institutional ethics approval and informed consent were obtained prior to online data collection. Participants completed demographic and weight-related measures, after which the therapy descriptions were presented in counterbalanced order. Following each therapy description, participants reported their perceptions of credibility (CS), expectations regarding personal suitability (PRR), and psychological need satisfaction. They also rated the novelty, ease, and effort required for each therapy and likelihood of uptake across the three delivery modalities. After reading and rating each therapy description, participants ranked the therapies in order of preference, from most to least preferred.

Results Descriptive Statistics According to BMI calculations, all participants met the guidelines for an overweight classification, and 71.1% for classification as obese (n = 57). In relation to BMI classifications at the population level for adults, 28.8% were preobese (n = 23; BMI 25.00–29.99), 38.8% were obese class 1 (n = 31; BMI 30.00–34.99), 20% met the criteria for obese class 2 (n = 16; BMI 35.00–39.99), and 12.5% for obese class 3 (n = 10; BMI > 40). Participants had been overweight for an average of 15.41 years (SD = 11.37) and, on average, aimed to lose a substantial 22.03% of their body weight (SD = 10.87).

Treatment Preference As revealed in Table 1, a chi-square goodness-of-fit test of frequencies of first-preference rankings revealed significant differences in preferences for the four treatments, with CBT the most preferred and CT the least preferred. To explore the reasons underlying these preferences, thematic analysis was conducted on the open-ended responses, and two independent raters assigned responses to these categories (Joffe & Yardley, 2004). Inter-rater reliability was high (r = .83, p < .001) and a consensus was reached for all discrepancies. Five primary reasons were identified (see Table 1), with clear differences apparent across treatment type. Comprehensiveness was most

.04 .14 .10 .02 -

M (SD)

hp 2

F

.94 1.25 .90 .63 -

8 (24.2) 15 (45.5) 2 (6.1) 6 (18.2) 2 (6.1) 0 (0.0)

-

-

56.68 (16.49) 32.94 (9.32) 23.74 (7.53) 14.63 (4.23) 4.86 (1.53) 5.23 (1.42) 4.54 (1.65) 4.91 (1.83) 4.28 (1.57) 5.00 (1.51) 3.61 (1.93) 5.20 (1.93) 4.10 (2.07)

5.04 (1.91) 4.18 (1.64) 5.08 (1.61) 3.63 (1.92) 5.29 (1.64) 4.24 (1.97)

M (SD)

4 (16.7) 0 (0.0) 9 (37.5) 5 (20.8) 5 (20.8) 1 (4.2)

24 (31.58)

56.05 (17.14) 32.79 (9.25) 23.26 (8.23) 14.61 (4.10) 4.98 (1.52) 5.11 (1.48) 4.53 (1.58)

33 (43.42)

.31

22.42***

BT n (%)

3.79 (2.00) 5.19 (1.85) 4.34 (2.06)

4.83 (2.04) 4.40 (1.66) 5.21 (1.39)

57.36 (16.22) 33.23 (8.81) 24.13 (7.79) 15.14 (4.31) 5.18 (1.44) 5.31 (1.51) 4.65 (1.73)

M (SD)

2 (33.3) 0 (0.0) 0 (0.0) 2 (33.3) 1 (16.7) 1 (16.7)

6 (7.89)

CT n (%)

3.46 (2.01) 5.15 (1.78) 4.31 (2.07)

4.94 (1.93) 4.25 (1.47) 5.08 (1.61)

55.14 (15.96) 32.23 (8.50) 22.91 (7.93) 14.38 (3.99) 4.98 (1.52) 4.98 (1.48) 4.43 (1.52)

M (SD)

7 (53.8) 0 (0.0) 1 (7.7) 2 (15.4) 2 (15.4) 1 (7.7)

13 (17.12)

ACT n (%)

Note. CBT = cognitive behavioral therapy; BT = behavior therapy; CT = cognitive therapy; ACT = acceptance and commitment therapy; CS = Credibility Scale; PRR = Personal Reactions to the Rationales Scale; M = mean; SD = standard deviation. *p < .05. **p < .01. ***p < .001.

Treatment beliefs CS PRR Need satisfaction Competence Autonomy Relatedness Pragmatic considerations Novelty Ease Effort Delivery modality Group Individual Technological

Treatment preference Reason for treatment preference Personal relevance Comprehensiveness Practicality Effectiveness Self-insight Unsure

CBT n (%)

Cramer’s V

χ2

Treatment Beliefs and Preferences Across Treatment Type

Table 1

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commonly mentioned as the primary reason for preferring CBT, practicality for BT, personal relevance for ACT, and personal relevance and perceived effectiveness for CT. Although differences in first-preference rankings emerged, a one-way repeated-measures analysis of variance (ANOVA), using the composite treatment beliefs variable as the dependent variable, revealed no significant difference in treatment beliefs across therapy. Two one-way repeated-measures multivariate analyses of variance also revealed no significant differences across therapy in relation to perceived psychological need satisfaction (competence, autonomy, and relatedness) or pragmatic considerations (novelty, ease, and effort). The results of these analyses, along with the means and standard deviations, are provided in Table 1.

Predictors of Treatment Beliefs Four hierarchical regression analyses were conducted, one for each treatment, to explore the extent to which psychological need satisfaction and pragmatic considerations predicted treatment beliefs after controlling for weight-related variables. At step 1, the weight-related control variables BMI, number of years overweight, and weight loss goal (reflected as a percentage of current weight) were entered. The high intercorrelations among the competence, autonomy, and relatedness items indicated the presence of multicollinearity. Therefore, the composite variable calculated by summing scores for these three items was entered at step 2 as the measure of psychological need satisfaction. Ratings of novelty, ease, and effort were included at step 3 to investigate whether pragmatic considerations were able to predict treatment beliefs over and above the SDT psychological need satisfaction construct. Preliminary assumption testing was conducted to ensure no violations of normality, linearity, multicollinearity, homoscedasticity, and independent errors. Cases exceeding the Mahalanobis distance critical value were excluded separately for each analysis (Tabachnick & Fidell, 1996). The resulting variations in sample size are reported in Table 2, together with the results of the analyses. At step 1, the weight-related variables did not significantly contribute to the prediction of treatment beliefs for CBT, BT, or ACT. The inclusion of psychological need satisfaction at step 2 increased the total variance explained to 72.6% for CBT, 76.2% for BT, and 70.9% for ACT. Ease emerged as a significant predictor at step 3 of the model for CBT and BT, explaining an additional 7.8% (CBT) and 7.6% (BT) of the variance in treatment beliefs over and above that explained by need satisfaction. For ACT, effort explained an additional 6.0% of the variance in treatment beliefs at step 3. Need satisfaction remained the strongest significant predictor of treatment beliefs in the full model for CBT, BT, and ACT. For CT, a higher BMI and a lower weight loss goal explained a significant 17.0% of the variance in treatment beliefs at step 1 of the model. At step 2, the inclusion of psychological need satisfaction increased the total variance explained to 77.5%. In the final model, effort explained an additional 2.7% of the variance in treatment beliefs, and of the four significant predictors, psychological need satisfaction again remained the strongest.

Delivery Modality As shown in Table 1, a repeated-measures factorial ANOVA comparing likelihood of uptake across delivery modality and treatment type revealed no main effect for treatment type. There was no interaction, F(6, 74) = 1.24, p = .30. However, there was a significant main effect for delivery modality, F(2, 78) = 30.33, p < .001, partial η2 = .44. Repeated contrasts revealed that technological (M = 4.25, standard error [SE] = .20) was preferred over group delivery (M = 3.62, SE = .20, p = .012), and individual face-to-face delivery (M = 5.21, SE = .17) was preferred over technological delivery (p < .001), independent of treatment type.

Discussion The present study investigated treatment beliefs and preferences for psychological weight loss therapies in an overweight sample. The most preferred treatment options were CBT and BT. Fewer participants preferred ACT, and CT was the least preferred treatment option. There was

.63 .22 .33 .018

.34 .12 .18 .28 .726*** .708***

.30 .10 .16 .35 .78 .78 .81 .804*** .078***

−.38 .08 .25 3.63

−.36 .00 .22 2.39 .83 3.46 .95

SE B

.47 −.05 −.03

B

−.11 .00 .13 .56*** .09 .33*** .09

−.12 .05 .15 .86***

.15 −.03 −.02

β

−.17 −.07 .20 2.28 .84 3.55 .70

.13 −.04 .05 3.38

1.22 −.14 −.55

B

.25 .11 .13 .29 .60 .76 .69 .837*** .076***

.28 .11 .15 .24 .762*** .689***

.53 .21 .27 .072

SE B

BT n = 76

−.06 −.01 .13 .59*** .09 .34*** .07

.05 −.02 .03 .87***

.43 −.08 −.36

β

.68 −.10 −.37 2.51 .37 1.07 2.14

.77 −.01 −.39 3.15

1.55 .12 −.85

B

.27 .11 .14 .32 .52 .66 .89 .802* .027*

.26 .10 .14 .23 .775*** .605***

.49 .19 .26 .170**

SE B

CT n = 74

.25* −.06 −.26* .65*** .05 .11 .18*

.29** −.01 −.27** .81***

.58** .07 −.58**

β

.42 −.01 −.25 2.72 .94 1.56 1.81

.39 .09 −.23 3.26

1.20 −.12 −.71

B

.29 .12 .15 .28 .58 .79 .70 .770** .060**

.31 .12 .16 .27 .709*** .619***

.53 .21 .27 .090

SE B

ACT n = 77

.14 −.01 −.16 .68*** .11 .14 .18*

.14 .06 −.15 .82***

.41 −.07 −.47

β

Note. CBT = cognitive behavioral therapy; BT = behavior therapy; CT = cognitive therapy; ACT = acceptance and commitment therapy; BMI = body mass index; SE = standard error. *p < .05. **p < .01. ***p < .001.

Model 1 BMI Years overweight Weight loss goal R2 Model 2 BMI Years overweight Weight loss goal Need satisfaction R2 R2 Change Model 3 BMI Years overweight Weight loss goal Need satisfaction Novelty Ease Effort R2 R2 Change

Predictor

CBT n = 73

Summary of Hierarchical Regression Analyses for Variables Predicting Treatment Beliefs Across Treatment Type

Table 2

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Journal of Clinical Psychology, June 2015

a consistent preference for more personalized individual face-to-face or technological delivery over group delivery, independent of treatment type. These findings extend the existing preferences literature through providing evidence for the appeal of CBT and BT in overweight people seeking a psychological weight management treatment (Brody et al., 2005). Although group therapy has been found to be more effective than individual therapy for weight loss (Renjilian et al., 2001), these findings also support current trends for increased flexibility, tailoring and personalization, and cost-effective technological (i.e., online or electronic) delivery of psychological interventions (Tate & Zabinski, 2004). Among participants who preferred CBT, the primary reason provided was perceived comprehensiveness, whereas for those who selected BT, the primary reason identified was practicality. The reasons underlying treatment preferences primarily reflected a desire for an all-inclusive treatment approach that taught practical behavioral strategies over a treatment approach targeting internal processes. Treatment beliefs, projected psychological need satisfaction, and pragmatic considerations did not differ with treatment type. The perceived substantial equivalence across treatments in relation to credibility and relevance for weight management is congruent with the theoretical soundness and recorded empirical success of the four therapies, relative to opportunity (Brownell, 2010; Shaw et al., 2005). Because all treatment descriptions were framed as viable options, the inclusion of an assessment of preference strength might have enabled further differentiation among equally theoretically sound and credible treatment alternatives (Swift, Callahan, & Vollmer, 2011). Nevertheless, treatment preferences, and specific reasons underlying these preferences, still emerged. These preferences were diverse, which further highlights the potential importance of considering individual differences in treatment preferences and using these preferences to tailor treatment programs and maximize motivation, uptake and outcome (Corrigan & Salzer, 2003; Iacoviello et al., 2007; Swift & Callahan, 2009). In the prediction of treatment beliefs, BMI, the length of time participants had been overweight, and the size of the weight loss goal did not emerge as significant predictors for CBT, BT, or ACT. However, a higher BMI and smaller weight loss goal significantly predicted more positive treatment beliefs for CT. These discrepant findings are reminiscent of previous preferences research where demographic and weight-related variables have emerged as significant predictors of treatment beliefs in some samples and not others (Zoellner et al., 2009). Notwithstanding these inconsistencies, perceived psychological need satisfaction emerged as the strongest predictor of treatment beliefs across all four therapies after controlling for the weight-related variables. Congruent with SDT, treatments that were expected to provide greater opportunity for competence, autonomy, and relatedness were more positively evaluated (Deci & Ryan, 2008; Ryan & Deci, 2000; Zuroff et al., 2007). These relationships were substantial given the number of variables that may contribute to the formation of these beliefs (Swift & Callahan, 2009); perceived need satisfaction consistently explained at least 70% of the variability in attitudes towards treatments. Perceived ease of engagement emerged as a significant unique predictor for CBT and BT. For the least preferred treatments, ACT and CT, effort emerged as a significant predictor of more favourable treatment beliefs. Importantly, the CBT and BT treatment descriptions were overtly focused on behavior, whereas the ACT and CT descriptions more strongly emphasized cognitions. The positive association between rated effort and treatment beliefs for ACT and CT may reflect an acknowledgement of the challenge of managing cognitive factors contributing to the difficulties of weight management. These findings have important implications for the psychological treatment of overweight and obesity. At the individual level, matching people with their preferred treatment has been associated with increased motivation, more rapid improvement, decreased attrition, and improved outcomes across a variety of domains (Corrigan & Salzer, 2003; Iacoviello et al., 2007; Swift & Callahan, 2009). This approach has ecological validity and is more consistent with the real-world autonomously driven decision-making processes that people use to select a treatment option (Corrigan & Salzer, 2003). At the group level, overweight and obesity is a substantial public health concern for which group-delivered psychological treatments in community settings have shown some long-term promise (Latner et al, 2013). The treatment preferences reported here may assist health clinicians and researchers make informed decisions regarding the most appropriate

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psychological approach for more widespread community intervention, perhaps incorporating individualized online or technological delivery. Importantly, the current study findings do not speak directly to the efficacy of matching people to treatment preferences for treatment outcome and weight loss success; this is a research question that warrants further investigation. Furthermore, although this study has provided novel insight into the psychological treatment preferences for weight management in a sample of overweight people, it remains unclear the extent to which the treatment beliefs observed were preexisting, were influenced by the treatment descriptions provided, and are modifiable (Zoellner et al., 2009). It is also not clear to what extent treatment expectations of people who lack a background in psychological theory will be influenced by stereotypical or na¨ıve perceptions of the valid targets and principles of a behavior change intervention. Thus, for example, the notion of acceptance that underlies a relatively novel treatment like ACT may, to a layperson, seem counterintuitive and primarily palliative in intent. Such a possibility suggests a constraint on the desirability of matching treatments to preexisting beliefs. Future research is important to investigate the elasticity of treatment beliefs (Kwan et al., 2010). To ensure objective comparison, the treatment descriptions were based on theoretical understanding of the various treatment options in a weight management context (Cooper et al., 2010). However, it is acknowledged that, in both research and practice, psychological weight management interventions do not always subscribe to a single theoretical or therapeutic orientation. The current study also included four psychological therapies known to be associated with weight management efficacy to the exclusion of other potentially viable treatment alternatives (e.g., dialectical behavior therapy or interpersonal therapy), which have an evidence base specifically for the treatment of obese people with BED (Lo Presti, Lai, Hildebrandt, & Loeb, 2010). In addition, insight can be provided only into preferences for psychological treatments for weight management, without a consideration of alternative pharmaceutical or surgical options (Brownell, 2010). The importance of heightened ease for the most preferred treatment options in the current study may indicate that these alternative treatment approaches might be preferred over psychological therapies in the weight management context, despite their expense, potential side effects, and limitations in addressing internal processes and underlying psychological cause (Brownell, 2010). This possibility warrants further investigation, as does the possible influence of individual differences in participant conceptualisation of the concepts of ease and effort in a weight management context. Given the observed importance of projected psychological need satisfaction in predicting treatment beliefs, future intervention research should also measure actual satisfaction of these needs during and after psychological weight management treatment within each of the therapeutic contexts investigated in the current study (Dwyer et al., 2011). The treatment preferences identified in the current study, although heterogeneous, are congruent with existing research evidence and provide further evidence for the appropriateness of CBT and BT in the context of psychological weight management treatment (Shaw et al., 2005). Our exploration of the reasons underlying these treatment preferences has illuminated autonomy support (namely, psychological need satisfaction), personalized treatment delivery, and pragmatic considerations including efficiency, effort, and ease as important predictors of more positive treatment beliefs. Future research is important to explore treatment beliefs across the broad spectrum of evidence-based psychological, pharmaceutical, and surgical treatment options, as well as further exploring the relationship between treatment preference matching and weight loss outcome. These insights will enable more holistic evaluation of consumer attitudes towards psychological therapies and the utility of individual preferences for the complex and multifaceted management of overweight and obesity.

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Appendix Cognitive Behavioural Therapy (CBT) This therapy aims to help you achieve your weight management goals by teaching you strategies to change both your unhelpful thoughts and behaviours related to eating and by helping you feel more positive so that you are more likely to engage in healthy eating behaviours. Through engaging in this therapy, you will learn how to:

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Identify, actively challenge and replace or get rid of any unhelpful thoughts or biased thinking patterns you have relating to food, eating, and your weight (e.g., “I’m a failure, there’s no hope for me to lose weight” or “I have no will power”) Practice and try out new ways of behaving in difficult eating related situations (e.g., by setting yourself food challenges and practicing different coping strategies in these situations)

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Use relaxation, breathing techniques and positive coping statements to distract yourself from unhelpful thoughts that lead you to make poor eating choices

Behaviour Therapy (BT) This therapy aims to help you achieve your weight management goals by teaching you to identify, and more effectively manage, the triggers that might lead you to make poor eating choices so that you are more likely to engage in healthy eating behaviours. Through engaging in this therapy, you will learn how to:

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Keep a daily diary of your food intake, weight and eating related thoughts and behaviours to pinpoint the situations that can trigger you to make poor eating choices (e.g., boredom, sadness, stress) and the positive outcomes that can follow (e.g., distraction or relief from these feelings) Develop strategies to replace or get rid of these triggers (e.g., modifying your immediate environment by removing unhealthy foods from the home) Create specific, measurable, and sensible goals relating to your eating and food intake and plan an incentive-based program where you are rewarded for reaching your goals

Cognitive Therapy (CT) This therapy aims to help you achieve your weight management goals by teaching you strategies to change the way you think about food, eating, and yourself and by helping you feel more positive so that you are more likely to engage in healthy eating behaviours. Through engaging in this therapy, you will learn how to:

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Recognize any unhelpful or biased thinking you may be engaging in (e.g., “black and white thinking” where small deviations from a diet are interpreted as evidence of complete failure) and identify how this may contribute to poor eating choices Dispute and challenge your unhelpful thinking through seeking evidence, questioning the logic of your conclusions and considering the usefulness of some of your thoughts (e.g., “does it really help when I call myself fat or lazy?”) Generate new more helpful and realistic thoughts that you truly believe in, and that encourage you to make better eating choices

Acceptance and Commitment Therapy (ACT) This therapy aims to help you achieve your weight management goals by teaching you to accept and more effectively handle your internal experiences related to eating so that you feel more committed and motivated to engage in healthy eating behaviours. Through engaging in this therapy, you will learn how to:

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Manage internal experiences like unhelpful thoughts, cravings for foods, and negative feelings (e.g., guilt, sadness) by openly accepting them rather than trying to push them away Live in the present moment, engaging fully in what you are doing without worrying about poor eating choices from the past or what might happen in the future Connect with, and clarify, your values (e.g., what sort of person you want to be, what is most important and meaningful to you, what you want to stand for in life) and use this direction to set goals that motivate you into committed action no matter how many setbacks you encounter