Reprinted from "Eating Disorders" issue of Visions Journal, 2002, No. 16, pp. 29-30
Individuals with eating disorders are ambivalent about change, and lack of motivation has been associated with high levels of treatment refusal, dropout, and relapse. Recent research has turned to address readiness and motivation in this group. This research has shown that readiness scores are associated with important clinical outcomes, including the decision to enroll in intensive treatment, behavioural change, and dropout.2 Despite the clinical importance of readiness and motivation, eating disorder clinicians have been shown to be poor at estimating this client characteristic.1 The discrepancy between client and care provider understanding of readiness may explain the clinical difficulties encountered in treating this group. Motivational Interviewing (MI) has been shown to be an effective approach for populations described as ‘treatment resistant’6 and has recently been applied to eating disorders. This article reviews the motivational interviewing stance, and addresses how it can be used in assessing and treating individuals with eating disorders.
Communicate Beliefs and Values that Foster Client Self-Acceptance
Many individuals with eating disorders come to treatment feeling shame about having a problem and blaming themselves for their eating difficulties. Given that higher levels of distress are associated with lower levels of readiness for change,2 care providers can help clients prepare for change by letting them know that eating disorders typically develop for a reason, that recovery is difficult, and that change takes time.
It is easy to make assumptions about the client’s experience, and consequently, for clients to feel misunderstood. Care providers may make assumptions about the client’s readiness and motivation for change that are either inaccurate or an oversimplification of the client’s experience. For instance, it is possible to assume that the client is distressed by her poor health when she is primarily concerned about her lack of control over her eating.
The best way to avoid making assumptions is to be curious. The therapeutic alliance can be greatly enhanced by care providers using open-ended questions to show interest in the client’s experience of the problem, how the problem has been helpful, and how she has coped with pressures to change. Care provider curiosity also helps the client develop a better understanding of herself and her eating disorder.
Throughout treatment, motivational work involves actively pursuing a greater understanding of barriers to recovery, and using this information to assist the client in making the best decisions for her care. MI is based upon the premise that failing to address such barriers is likely to lead to treatment failure.
Be on the Same Side
Discrepancies between client wishes and the treatment plan can easily lead to conflicts. When such conflicts arise, it is critical for care providers to take time to understand the client’s perspective, and to express a genuine desire to help. This can set the stage for a more productive discussion aimed at assisting the client in determining the best solution for her, given her available options.
The Client is Responsible for Change
When clients express ambivalence about making changes or engaging in treatment, it is common for care providers to feel responsible for initiating this change. Unfortunately, overly directive approaches have been shown to be detrimental to the therapeutic alliance, and to decrease the likelihood that the client will follow through on treatment recommendations.4 In motivational approaches, responsibility for change is the client’s.
Use the Transtheoretical Model of Change (TMC)7
In eating disorders, the Readiness and Motivation Interview (RMI) 2,3 has been used to assess readiness and motivation across eating disorder symptom types. In the RMI, individuals estimate the extent to which they are in precontemplation, contemplation, and action/maintenance for each symptom domain. Precontemplation refers to not wanting to change, contemplation is seriously thinking about change, and action/maintenance is actively working to change or to maintain changes previously made. Internality is the extent to which individuals are making changes for themselves versus for others. Given the research that shows that the degree of readiness for change predicts treatment refusal, symptom change, dropout, and relapse,2,8 it is useful to include questions about readiness in assessment protocols.
Ask about all Aspects of the Eating Disorder
Overall, research has shown that individuals with eating disorders are most interested in making changes to binge symptoms, and least interested in making changes to restriction over eating and to the use of compensatory strategies.2 In order for clinicians to fully capture an individual’s readiness for change, all aspects of the eating disorder need to be addressed.
Assure the Client that There are No Negative Consequences to Being Honest
In order to understand the client’s genuine feelings about change, care providers need to express interest and curiosity about any ambivalence the client may be feeling. The client is more likely to be honest if she is assured that her truthful responses will not be judged, and will not hinder her access to treatment.
Explore What is Helpful About the Eating Disorder
It is helpful for care providers to assist clients in exploring reasons that the eating disorder exists. Determining the role that it plays in her life will help the client feel more accepting of herself, and reduce feelings of shame and guilt.
Validate Client Reasons for Not Wanting to Change
In addition to assisting the client develop an understanding of the functions of her eating disorder, it is useful to acknowledge that it makes sense for her to be experiencing ambivalence about making changes. Simply communicating acceptance that the eating disorder may be the client’s best method of coping will assist in validating her experience.
Make Treatment Responsive to Client Wishes
The motivational approach involves assisting the client in articulating what she wants to get out of treatment, and ensuring that her agenda is addressed. Care providers can use information about the client’s readiness status in assisting her to determine which treatment alternatives are best suited for her.
Determine Treatment Non-Negotiables and Communicate These Clearly to the Client
Individuals with eating disorders can be at risk for a variety of severe medical and psychiatric complications. As a result, for both therapeutic and ethical reasons, it is sometimes necessary to implement treatment non-negotiables. Non-negotiables have been described as acceptable to clients when a reasonable rationale was provided prior to their implementation, surprises were eliminated, and client choices were maximized.5
Maximize Client Autonomy at All Stages of Treatment
It is common for clinicians to feel that it is their job to ‘fix’ the problem, and to apply pressure to eating disorder clients to change their behaviours. Unfortunately, this subtle (or not so subtle) influence can be detrimental, as clients may react to what they perceive as a threat to their sense of control. Such client reactions can interfere with both client and care provider ability to understand the client’s experience and to determine what is in her best interest. The motivational stance involves informing the client that unless her health is at serious risk, she is in charge of all treatment decisions.
About the authorJosie works with the Eating Disorders Program out of St. Paul’s Hospital. Krista and Suja are with the Department of Psychiatry, University of British Columbia.
Geller, J. (2002). Estimating readiness for change in anorexia nervosa: Comparing clients, clinicians, and research assessors. International Journal of Eating Disorders, 31, 251-260.
Geller, J., Cockell, C., & Drab, D.L. (2001). Assessing readiness for change in the eating disorders: The psychometric properties of the Readiness and Motivation Interview. Psychological Assessment, 13(2), 189-198.
Geller, J. & Drab, D.L. (1999). The Readiness and Motivation Interview: A symptom-specific measure of readiness for change in the eating disorders. European Eating Disorders Review, 7, 259-278.
Geller, J., Hastings, F., Goodrich, S., Zaitsoff, S.L., & Srikameswaran, S. (2001, November). Client and care provider responses to motivational and nonmotivational therapeutic encounters: A treatment acceptability study. Paper presented at the meeting of the Eating Disorders Research Society, Albuquerque, New Mexico.
Geller, J., Williams, K., & Srikameswaran, S. (2001). Clinician stance in the treatment of chronic eating disorders. European Eating Disorders Review, 9, 1-9.
Miller, W., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York: Guilford Press.
Prochaska, J.O., & DiClemente, C.C. (1984). The transtheoretical approach: Crossing traditional boundaries of change. Homewood, IL: Dorsey Press.
Whisenhunt, B., Geller, J. (2002, April). Internal motivation for recovery in the eating disorders predicts long term outcome. Short paper presentation at Psychiatry Research Day, Vancouver, 2002.