Participant Experiences of Cognitive Remediation Therapy for Obesity (CRT-O): A Qualitative Thematic Analysis

Highlights

What are the main findings?

• Cognitive remediation therapy (CRT) has recently been employed in various clinical contexts to target maladaptive cognitive patterns, including those contributing to eating disorders in anorexia nervosa and binge eating disorder.
• There is early evidence that CRT can enhance cognitive flexibility, support behavioural changes, and improve self-regulation.

What is the implication of the main finding?

• This study offers an in-depth qualitative perspective on the experiences of individuals with excess body weight undergoing a Cognitive Remediation Therapy (CRT) intervention.
• Our findings reveal significant emotional and cognitive shifts during and after the intervention, along with participants’ perceived benefits, challenges, long-term expectations, and concerns.
• The implication of these findings is that while CRT shows promise, its effectiveness is deeply intertwined with participants’ subjective experiences and the need for sustained support.
• The insights gained highlight the importance of integrating CRT strategies into daily life to address long-term expectations and concerns, ultimately emphasizing the necessity for ongoing, personalised support to maximize the benefits and ensure the longevity of the intervention’s impact on individuals living with excess body weight.

Abstract

Objective: The present study is a qualitative analysis of participant experiences and perspectives from people who received cognitive remediation therapy for adult obesity (CRT-O). Method: Post-intervention data were generated from an open-ended question requesting the participants to write, in the form of a letter to their therapist, about their experiences and reflections upon taking part in cognitive remediation therapy for adult obesity. Participants’ letters were thematically analyzed. Results: Four themes and nested subthemes emerged from participant responses, including (1) motivation and initial response to CRT-O for the adult obesity study eligibility process with the nested subthemes of initial apprehension pre-intervention and awareness and acknowledgement of one’s problematic eating behaviors; (2) perceived benefits from cognitive remediation therapy for adult obesity with the nested subthemes of the strategies and techniques that were found beneficial and the role of the cognitive remediation therapy for adult obesity therapists in facilitating positive change; (3) perceived outcomes post-intervention with the nested subthemes of changed relationship with food, self-acceptance and gaining control to effect positive lifestyle change; and (4) expectations and beliefs about the longer-term impact of cognitive remediation therapy for adult obesity with the nested subthemes of using the cognitive remediation therapy for adult obesity strategies as a lifestyle routine, apprehension about not having follow-up therapist support, and concern about potential relapse. Conclusion: Our analysis found helpful insights into the consumer perception of this novel intervention and highlighted the clinical utility of implementing cognitive remediation therapy in those living with a higher body weight.

1. Introduction

Worldwide, overweight and obesity (BMI ≥ 25 kg/m²) are conditions on the rise, with a concerning forecast that over 4 billion people may be affected by 2035, compared with over 2.6 billion in 2020; obesity is predicted to independently impact nearly 2 billion adults, children, and adolescents within the same timeframe [1]. Excess body weight is a key risk factor for developing serious medical comorbidities and reduced life expectancy. Overweight and obesity have been shown to have dose-specific associations with cardiovascular diseases, stroke, metabolic disorders, and certain types of cancers [2]. Furthermore, they are additional risk factors for developing biomechanical conditions such as sleep apnea, respiratory problems, gall bladder disease, osteoarthritis, and musculoskeletal, skin, and reproductive disorders [3,4]. With regard to mental health, in individuals who seek treatment for weight loss, studies have shown a higher rate of psychopathology including depression, body image issues, eating disorders, and reduced health-related quality of life [5,6]. Consequently, the socioeconomic burden of obesity is reflected through serious costs to healthcare systems, disease-adjusted life years (DALYs), loss of productivity, and impaired health-related quality of life [7,8,9].

Dietary therapies, the most common weight loss approach, typically advocate for calorie restriction. Successful longer-term outcomes, however, have been a challenge as they are contingent on lasting diet adherence [10]. Bariatric surgery has been shown to be efficacious for weight loss, maintenance, and associated comorbidities when compared with non-surgical interventions [11]. Recent studies, however, have shown that there is a propensity to develop post-operative eating disorders and/or disordered eating behaviors given the sudden and striking modifications in eating patterns that occur post bariatric surgery [12,13]. Medications such as Orlistat, Phentermine, Liraglutide, and Semaglutide are the current drugs of choice in the pharmacological treatment of obesity. This mode of treatment, however, is recommended only after dietary, exercise, and behavioural approaches have commenced and been evaluated. Anti-obesity medications are also expensive and considered a management approach rather than a cure; they may also have adverse side-effects and contraindications [14].

Psychological interventions for obesity have increasingly used a multi-component approach to address lifestyle behaviors that include motivational techniques, behavioral modification such as self-monitoring, goal setting and problem-solving, cognitive reframing techniques, and a personal values-based approach, drawing from the Acceptance and Commitment Therapy framework [15]. Longer-term outcome studies have, however, shown that the prevention of weight regain still remains a challenge, with weight regain eventuating when professional contact ends [16,17]. It is vital to develop novel interventions for obesity-related lifestyle behaviours to ensure that interventions not only aid clinically significant weight loss but also assist in the prevention of weight regain in order to have a favorable impact on morbidity and mortality [16].

Recent findings in cognitive psychology have highlighted the role of executive function in obesity-related eating behaviors, including the consumption of fruits and vegetables [18,19]. Researchers have suggested that executive functions are considered a transdiagnostic process in obesity-related eating disorders to explain self-regulatory deficits in excessive food intake [20,21].

In support of the above findings, cognitive remediation therapy (CRT) has been deemed a promising and emerging intervention for obesity-related eating behaviours [22]. The use of CRT as an intervention for obesity is novel. Empirical findings in this mode of treatment are in their infancy.

A recent intervention study on cognitive remediation for obesity-related eating behaviors (CRT-O) found that cognitive flexibility and binge eating behaviors in participants improved by the 3-month post intervention follow-up [22]. In this study, participants in the experimental group were provided with eight sessions of CRT for obesity (CRT-O), and their results were compared with the non-treatment control group [23]. Further, the experimental group demonstrated clinically significant weight loss that was maintained at the 3-month follow-up. However, findings have been inconsistent in regard to weight loss [21].

Having insight into consumer experiences is important for understanding people’s perspectives of this novel therapy and how it may be further improved and developed. In this study, participants were asked to write letters to their therapist detailing their experiences with CRT-O at the conclusion of the therapy program. The aim of the current study is to explore these letters to provide a deeper understanding of their experience of the intervention and its acceptability.

2. Method

The current study is a qualitative analysis, based on the responses of participants, collected from individuals that completed a randomized controlled intervention trial on CRT-O for obesity [22]. A total of 80 participants were recruited from Sydney, Australia via advertisement to the community. Participants were included if they were between 18 and 55 years old and able to provide informed consent. Selected participants had a BMI ≥ 30 kg/m², a current weight less than 180 kg, and had completed 10 years of education in English. Those with a history of psychosis, head injury, neurological disorders, diagnosis of attention deficit hyperactivity disorder, epilepsy, developmental or intellectual disability; those using regular sedatives/stimulant medications; and those who had substance use issues were excluded from the study, as were those who were not able to complete the testing.

The individual face-to-face intervention consisted of an eight-session manualized CRT-O program that involved twice-weekly sessions provided over 4 weeks. The intervention involved activities that trained the participants in “attention to detail,” “problem solving, planning and organizational skills,” “set shifting,” “creative thinking,” “reflection and consolidation” and performing behavioral homework [23]. These aspects were achieved using in-session activities such as estimation and Stroop tasks and strategies to improve cognitive flexibility [24].

2.1. Participants

Some 41 of the total 80 participants completed the intervention and were asked to write a letter to the therapist about their experiences in the intervention. The script read as follows: “Please reflect on your experience in taking part in this trial and write a letter to your therapist about your reflections. Feel free to write any reflections that come to your mind.” The participants were given a week’s notice to write their reflections and were thanked for their feedback. A total of 27 participants—6 males and 21 females—wrote to the therapist about their experiences of CRT-O. The age range for participants varied from 21 to 51 years. Participant letters were de-identified for the purposes of data analysis. Ethics approval for this project was granted through Western Sydney University (H9783, 2012)

2.2. Analysis

The qualitative method employed was thematic analysis and according to the five phases in the Framework method [24,25,26] comprised the following stages. This putatively allowed for the complexities of individuals’ experiences to be captured [27].

Codes were generated inductively to produce succinct labels for information relevant to the research aim. This was completed by three individuals independently and compared to refine the coding and ensure inter-rater reliability. After the codes were identified and refined, they were applied to all transcripts to form themes [28,29]. These themes were then reviewed to ensure they were supported by the data, and extracts were drawn [28,29].

(1) Familiarization. We reviewed a subsample of the raw data in detail. The letters were read twice by author PT to familiarise oneself with the data [28,29].

(2) Identifying a Thematic Framework. This involved ascertaining all key issues and themes in the letters by drawing both from the research aims and from the data itself.

(3) Indexing. This phase was undertaken by PT and involved systematically applying the agreed-upon thematic framework to the data by coding sections of text. Authors PT and JR undertook this independently and compared to refine the coding and ensure inter-rater reliability.

(4) Charting. This involved rearrangement of distilled summaries of the data according to the thematic framework. A thematic tree was formed to highlight the main themes that were identified by the PT.

(5) Mapping and Interpretation. This involved finding associations between themes and mapping the range and nature of phenomena to find explanations for the findings. This was carried out by PT and JR with regular reviews by PH.

3. Results

Four themes and nested subthemes (see Figure 1 below) emerged from participant responses including (1) motivation and initial response to the CRT-O study eligibility process with the nested subthemes of initial apprehension pre-intervention and awareness and acknowledgement of one’s problematic eating behaviors; (2) perceived benefits from CRT-O with the nested subthemes of the strategies and techniques that were found beneficial and the role of the CRT-O therapist in facilitating positive change; (3) perceived outcomes post-intervention with the nested subthemes of changed relationship with food, self-acceptance, and gaining control to effect positive lifestyle change; and (4) expectations and beliefs about the longer-term impact of CRT-O with the nested subthemes of using CRT-O strategies as a lifestyle routine, apprehension about not having follow-up therapist support, and concern about potential relapse.

3.1. Theme 1: Motivation and Initial Response to CRT-O

Several participants provided their reasons for being involved in the CRT-O study. These included curiosity about a novel treatment, therapy being offered free of cost, and their desire to lose weight.

3.1.1. Subtheme 1: “Let Me Check It Out”—Apprehension

“I would fail and despair…. then of course I would comfort my despair by eating. It felt like an unbreakable lifelong cycle since my teens… that’s why this study matters. I’m thinking differently, in fact, just thinking about food this way is a new habit……this is a much-needed area for change and I have every confidence that many lives will be transformed through this treatment. In time, doing the brain exercises reinforced for me that my brain can learn and change. I learnt my brain can learn to break bad eating habits and develop positive new thoughts about food and exercise—“After the first CRT session the set shifting exercise really showed me that there are options in nearly every decision we make, and I found useful options starting to appear specifically for weight management.” “Previously, I struggled to motivate myself to exercise and eat healthy but being positive and taking what I learnt from CRT, I have chosen to look at everything as an opportunity and with every week that has gone by, the muscle in my brain has gotten stronger and it urges me onwards”.”

There were diverse thoughts about taking part in a novel intervention study. The majority of participants, however, reported being unfamiliar with the concept of the CRT-O model and its tools and techniques. One of the participants stated,

“I was skeptical at first at how these little fun “mind games” would have any effect on changing my weight.”

Some participants reported apprehension as to the intervention content. One participant quoted,

“I felt some trepidation, as I really had no idea what your study really entailed, but I figured I had nothing to lose (except hopefully, some weight).”

The above quote signifies the uncertainty around the novelty of a new intervention and apprehension around its suitability for managing weight management issues. There was, however, an optimistic and open mindset that the intervention may at its worst not cause any harm and at its best assist in weight loss.

3.1.2. Subtheme 2: “I Need to Face It”—Awareness and Acknowledgement of Problematic Eating

“awakening”,

The initial step of CRT-O was to fill out the pre-intervention survey questionnaires to assess the eating patterns and weight management issues of participants. The participants reported that this process was confronting, and it was hard to consciously accept that they had problematic eating behaviours that contributed to their excessive weight. For example, one participant mentioned,

“When I first did the initial surveys, I was in shock at the extent of my problem, especially the questionnaire that showed my addiction to food. I had been over 80 kgs for a couple of years and was almost accepting that as my fate.”

In the above quote, the participant refers to “accepting” being overweight as their “fate”, which reflects passive acceptance potentially arising from perceived helplessness to change their present situation. On a similar note, one of the participants used the word “denial” as a way to avoid or ignore the issue of obesity and portrayed it as something which does not exist when she is not looking in the mirror. In her words,

“I guess when I look in the mirror, I see something I do not want to see—fat. Lots of it. But, when I am not in front of a mirror, I still feel like I did when I was thin. Is that called denial? I think so.”

3.2. Theme 2: Perceived Benefits from CRT-O

The participants reported that there were CRT-O exercises that they found beneficial during the program.

3.2.1. Subtheme 1: New Strategies and Techniques

The set shifting technique, random generation exercises, estimation, attention to detail, and memory exercises that were part of the CRT-O program were found to be helpful to the participants. As one of the participants stated,

“After the first CRT session, the set shifting exercise really showed me that there are OPTIONS in nearly every decision we make, and I found useful options starting to appear specifically for weight management.”

Participants stated that the exercises made them more aware and focused while grocery shopping, such as reading the labels and ingredient lists. One of the participants quoted,

“The exercises we did were lot of fun and helped me understand how I was thinking and my deficiencies, but also the ability to re-train my brain.”

3.2.2. Subtheme 2: The Role of Therapist

All the participants unanimously agreed and acknowledged that the skills and expertise of the therapist in providing the CRT sessions made a significant difference. They described the non-judgmental behaviour of the therapist as an important positive experience whilst receiving the therapy. As one of the participants stated,

“You have an amazing approach in leading me to an outcome in a very quiet, unassuming, positive, empowering way so that I have a clear head to tackle challenges without judgement or rules.”

The CRT-O therapist was also found to have a significant role in defining the treatment outcome. Trust in the treatment aligned with the perceived expertise of the health professional, as exemplified in the following quote by a participant: “I found you to be very encouraging and insightful person and someone who has a clear passion for your subject of study and vocation.”

3.3. Theme 3: CRT Outcomes

The effectiveness of therapy sessions was the primary concern for all participants when discussing their experiences, and the CRT approach was perceived as helpful. This might be attributed to the fact that talking about obesity issues openly in group with other members with similar issues provided a sense of normalization and empathy.

3.3.1. Subtheme 1: Changed Relationship with Food

“I am pleased to say the program has succeeded—I have much healthier relationship with food! I no longer feel guilt ridden when eating (well, not as much), and I am enjoying food a lot more.”

“Most importantly, this process has taken my focus off food (not having realized what a focus it was previously) and out to far more enriching and progressive ideas that bring far more joy.”

3.3.2. Subtheme 2: “I Am What I Am”—Self-Acceptance

“I have come to appreciate that this is who I am—a person who loves good food, eats too much of it and is starting to love exercise. Now I just need to translate that into weight loss!”

One of the participants stated

“I have been irritable with myself for slipping up but try to keep reminding myself that I am at least doing better than I have and that is something.”

3.3.3. Subtheme 3: “Taking Charge”—Doing Things

Female participant: “I find I can change my habits rather than just having a hope or a wish or desire to do so I am action on what we are talking about which is through your homework, because I “have’ to do it.”

Another participant stated, “I would describe this as an awareness of my potential to change. My attitude towards life in general has changed from “it is too hard” to “get over it and do it.””

3.4. Theme 4: Concluding Thoughts

3.4.1. Subtheme 1: CRT as Lifestyle Intervention

All the participants reported improved eating and lifestyle behaviours, improvements in quality of life, and cognitive flexibility after CRT intervention. There were several self-reports on how CRT-O created awareness of style of thinking rather than focusing on the content of thinking.

Becoming part of CRT provided a new perspective to the participants in dealing with challenges and day-to-day tasks. As one of the participants quoted,

“Previously, I struggled to motivate myself to exercise and eat healthy but being positive and taking what I learnt from CRT, I have chosen to look at everything as an opportunity.”

CRT equipped the participants with essential tools and methods of staying positive and working on strengthening the brain muscles. Even though the therapy was part of a work in progress, it paves the way for a better future and better health outcomes.

Similarly, for one of the participants, CRT interventions affected his life as a whole, including perspectives on food too. He stated,

“I feel a sense of hopefulness and a glimpse of a new life and a new way of thinking and doing I am hopeful that I can use CRT techniques to influence the way I see, eat and enjoy food changed perspectives for life and about food.”

3.4.2. Subtheme 2: Challenges—Continuity of Care

After the set number of CRT sessions had been completed, most participants felt the need for regular follow-up or continuity of care to stay on track. For example, one of the participants said,

“It is hard doing it consistently by yourself you lose yourself motivation unless there is someone like you supporting one on one.”

In a much similar fashion, another participant said,

“I think I need little voice prompts all around the house to be conscious of what I should be doing ALL THE TIME.”

Even though the participants reported a number of benefits of having CRT, there were a few concerns that they reported. One of the participants stated,

“I still have concerns about my emotional aspect of it. There are lots of aspects that still plague me and on days when I feel emotionally heavy. I do just want to eat all the wrong and yummy things. This area still needs work.”

As the therapy sessions ran only for eight sessions, some participants felt the need for an extended period of care to deal with their eating behaviours.

4. Discussion

Qualitative data in the form of letters to the therapist—written by participants about their experiences with CRT-O—were analyzed. Insights into participant experiences and perspectives are elucidated in this section. Four major themes surfaced, each nested with subthemes that offered important insights into how CRT-O impacted participants’ lives, their relationship with food, and their outlook on long-term health management.

Participants’ initial response to CRT-O showed that they entered the program with a mixture of curiosity, apprehension, and a strong desire to find a sustainable solution to their weight management challenges. The initial theme of motivation highlighted the skepticism many participants felt towards this novel therapeutic approach, particularly given their familiarity with more traditional weight loss methods. Despite this initial hesitation, participants expressed the desire to attempt a novel intervention, this potentially demonstrating the importance they have placed on weight management. This initial phase in therapy is pivotal, as it lays the foundations for participants to engage with therapy and be open to the changes it might bring [30].

The second theme highlighted aspects of the CRT-O intervention that were perceived as significant by the participants. Participant responses showed that they received significant benefits from the CRT-O intervention, particularly in terms of pragmatic strategies that they could apply to their daily lives. The cognitive flexibility and problem-solving activities were particularly well received. Participants stated that these techniques helped them become more mindful of their eating habits and decision-making processes. Other important findings from participant feedback indicated a growing awareness that there are several ways to view their recovery process (“options”). This awareness is deemed critical, as the metacognitive training in CRT focuses on creating insight into the possibility of new ways of thinking. Participant feedback indicated that this awareness was made possible through this intervention.

The role of the therapist was also highlighted as a critical factor in the success of the intervention. Participants noted that the therapist’s non-judgmental, supportive approach was a key element that facilitated positive change. This finding is in line with previous research that has shown that therapeutic alliance plays a vital role in the efficacy of intervention delivery. This finding also highlights the importance of training and skill-building in CRT therapists. The similarity between the two parallel yet distinct therapeutic models of cognitive behavioural therapy (CBT) and CRT should be noted in that both CBT and CRT address thought content and thought processes. While CBT addresses what we think (i.e., the thought content), CRT aims to address how we think (the thinking style). There is thus a risk of therapist drift across the two modalities that needs to be addressed in CRT training and supervision.

The third theme highlighted the trial participants’ perceived outcomes post intervention. The CRT-O program appears to have had a significant impact on participants’ relationships with food. Many participants described a shift in their perspective from viewing food as a source of guilt and shame to seeing it as something to be enjoyed in moderation. This change in mindset was associated with an increased sense of control over eating behaviours and lifestyle choices. Moreover, participants expressed a newfound sense of self-acceptance, recognizing that their journey with weight management is ongoing but that they now have the tools to make positive changes. This shift from self-criticism to self-compassion is a noteworthy outcome. Self-criticism has been shown to be associated with the development and escalation of maladaptive beliefs and aberrant eating behaviours. Further, improved self-compassion has been increasingly shown to be an effective goal in the therapy of people with eating disorders [31].

The fourth and the final theme, that of expectations and beliefs about the longer-term impact of CRT-O, consolidated the findings from the other three themes and brought together the main objectives of the intervention. While the immediate benefits of CRT-O were articulated with ease, participants also expressed concerns about maintaining these gains in the absence of ongoing therapist support. Most participants stated that CRT-O had a significant impact on them, and they intended to follow what they learned. There were, however, some participants who stated that they required more sessions to become better at applying it and that having an extended support program might be helpful should relapses occur. This theme highlights the importance of follow-up care and the need for relapse prevention strategies that participants can use post CRT-O completion. The notion of CRT-O as a lifestyle intervention rather than a short-term fix was a recurring theme, with participants recognizing that the tools they acquired could be integrated into their daily lives. However, their apprehension about potential relapse highlights the need for future interventions to include longer-term support mechanisms, potentially through extended therapist contact or peer support networks. Regular reinforcement and support post program might aid in the maintenance of lifestyle changes achieved during the CRT-O intervention.

The findings of this study help to provide more insight into and understanding of the participant experience of the intervention and its acceptability. The novel brain training strategies taught in CRT-O appeared to resonate with participants, providing them with practical tools to manage their eating behaviours and improve their self-compassion. The role of the therapist also appears to be important, suggesting that training for CRT-O practitioners should emphasize the importance of building a strong therapeutic alliance and specialized CRT skills. The participants’ concerns about sustaining progress are of particular relevance. Future CRT-O programs could benefit from incorporating follow-up sessions or digital tools to help participants maintain their cognitive and behavioural gains over time.

Limitations and Future Directions

While this study provides valuable insights, it is important to acknowledge its limitations. The sample size was relatively small, which may limit the generalizability of the findings. Secondly, the voluntary nature of the letter submissions introduced the potential for selection bias, as individuals more inclined to share positive experiences may have been overrepresented. Further, social desirability bias could have influenced the content of these submissions. Additionally, the relatively short duration of the intervention, comprising only eight sessions, and the absence of structured follow-up protocols necessitate cautious interpretation of long-term effects. Future research should prioritize the implementation of follow-up assessments, in particular maintenance of intervention effects, emergence of new issues, and long-term health indicators to ascertain the sustainability of observed outcomes. Future research should also aim to include larger, more diverse samples and explore the long-term effects of CRT-O as a stand-alone or adjunct therapy [32] on weight management and cognitive flexibility.

In conclusion, this study, through its qualitative analysis, offers rich insights into the nuances of the participant journey through the intervention, and we obtained key factors influencing their perceptions. This deeper understanding of their lived experiences and views on acceptability provides valuable context for future implementation and refinement of the intervention. This study further highlights the potential of CRT-O as an innovative approach to weight management in obesity, offering participants new ways of thinking about food and themselves.