We now present a case example to demonstrate the principles of the treatment. We briefly summarize the content of each session and highlight the shift from one ETI to the next. The case presentation is based on an actual course of treatment conducted by one of the authors (M.B.M.) and supervised by another (A.D.). Identifiable patient characteristics are modified to protect confidentiality. “Tom” was a 15-year-old Caucasian boy diagnosed with bipolar I disorder receiving psychiatric care at a specialty clinic for youth with mood disorders. He was referred by his psychiatrist, who had recently prescribed a second-generation antipsychotic for the management of Tom's BP. At baseline, Tom was 5′7" tall and weighed 153 pounds, with a BMI of 24.0 (83rd percentile, high end of healthy weight).
Session 1 (week 1; in-person)
Start ETI 1: Tom attended the first session with his father. The clinician began by engaging them in a discussion about Tom's weight. Tom and his father were well versed in the factors that contribute to weight; although weight had never been a problem for Tom, others in the family had struggled with weight. Next, the clinician discussed the relationship between weight gain, BP, and Tom's medication. Tom noted that symptoms of his current depressive episode (i.e., anhedonia and fatigue) led him to be less active. Tom's father expressed concern about Tom's recent inactivity and its implications for his health and self-esteem. The clinician then provided individualized feedback about Tom's current BMI—on the upper end of the normal range.
Start ETI 2: The clinician then reviewed Tom's ratings of his Big 5 behaviors. He reported fast food <1 time/week, media time <2 hours/day, and majority of meals eaten together in the home. Tom's ratings indicated little to no physical activity, and an average of four sweet beverages/day. Because he had become depressed he reported drinking more soda to get energized from its caffeine, especially during the schooldays. Tom then described a typical week related to his Big 5 behaviors. The clinician discussed the recommended doses of the Big 5 and concluded by asking Tom to keep a daily log of his Big 5 behaviors and their association with his energy level (global daily rating of 1–10) for the next 2 weeks.
Session 2 (week 3; phone)
ETI 2 continued: The phone session occurred 2 weeks after the initial visit. Tom noted that his energy level remained low as his depression persisted. He recognized that the more he lay around, the less energy he had to do things. Additionally, although his energy and motivation increased in the short term after drinking a soda, he then “crashed” and felt even more tired. The clinician reinforced Tom's efforts and offered hope.
Session 3 (week 4; in-person)
The clinician weighed Tom prior to the session; Tom was 5′7′′ tall and weighed 150 pounds, with a BMI of 23.5 (81st percentile, high end of healthy weight, 3 pound weight loss).
Start ETI 3: The clinician reviewed the content of Session 2 with Tom individually. Tom then ranked the relative importance and confidence of each of the Big 5 behaviors (); physical activity was most important to him (5) followed by sweet beverages (4). His confidence ratings reflected most confidence in being able to change sweet beverages (5) followed by physical activity (4). These ratings, taken with prior session content, led the clinician to propose a focus on increasing physical activity and decreasing intake of sweet beverages; Tom agreed.
Next, the clinician invited Tom to consider the pros and cons of making changes in these areas. Tom identified many pros of change, including having more energy and feeling better; he was particularly motivated to play sports with his younger brother—something he had ceased doing recently. Cons included the possibility of failure. They then considered potential components of a change plan. Tom felt he could eliminate soda altogether and drink water instead. With respect to his physical activity, he proposed to shoot baskets after school and take walks with his dad.
Start ETI 4: They collaboratively developed the following change plan: Reduce sweet beverage intake to one cup/day and increase physical activity to 30 minutes/day by walking with his father and playing basketball. Tom invited his father into the session and presented the change plan; Tom's father agreed to support him in his plan.
Session 4 (week 6; phone)
Start ETI 5: Session 4 started with review of Tom's progress toward implementing his change plan. He was successful in implementing the sweet beverage change plan. He described feeling more sluggish the first 2 days he implemented the plan (he attributed this to the decreased caffeine intake). Tom stated he was mostly unable to execute his physical activity change plan (walking with his dad) because of inclement weather. They explored other ways Tom could increase his activity level by identifying alternative options (e.g., push-ups, sit-ups, stationary bicycle). Tom reported his continued depressive symptoms (i.e., insomnia and hopelessness) were also negatively impacting his motivation to implement the physical activity change plan. Together, they brainstormed solutions to improve Tom's motivation. Tom agreed to write down the change plans after the telephone call, review them with his father, and post them on the refrigerator.
Session 5 (week 11; in-person)
The clinician weighed Tom prior to the session; Tom was 5′7′′ tall and weighed 148 pounds, with a BMI of 23.0 (78th percentile, healthy weight, total 5 pound weight loss).
ETI 5 continued: With Tom and his father, the clinician reviewed experience implementing the change plan. Tom continued with the sweet beverage change plan. In addition, he walked for 30 minutes four times/week over the past 2 weeks and started playing basketball with his younger brother after school. Tom described feeling more energetic and less depressed.
The clinician and family reviewed a chart of Tom's change in BMI during the intervention (). Tom was encouraged to see the graph and expressed interest in continuing to chart his BMI trajectory at home to maintain gains. They then revisited the Big 5 behaviors and Tom's associated goals and change plan. Tom's ratings of importance of sustained change in these areas and confidence in his ability to maintain the positive changes he had made remained high (importance 9 and confidence 8 of 10). He identified improvements in mood and sleep associated with increased physical activity; his father agreed, noting less irritability since Tom had been more active. The clinician concluded by providing reinforcement for Tom's hard work and encouragement for continued success.
Tom's body mass index (BMI) trajectory over treatment.