Finding a reason

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Publication Date: 
Thu, 2011-03-31

Exploring  motivational  interviewing as a technique for treating eating disorders

By Stephanie Cassin

Despite the proliferation of research on the treatment of eating disorders and the increased availability of empirically supported treatments in the community (e.g., cognitive behavioural therapy), eating disorders continue to have a reputation as being difficult to treat.  With these advances in mind,  you might be left wondering, “Why do some women develop chronic eating disorders that don’t seem to respond to treatment?” or “Why do some women relapse following apparently successful treatment?”  One potential explanation is that, for a variety of legitimate reasons, not all women who seek treatment for an eating disorder actually feel ready to change.  Motivational interviewing is a brief intervention that was developed with this issue in mind. 

As health care professionals, we often assume that individuals seek treatment because they are: 1) concerned about their physical or mental health, and 2) ready to make a change of some sort that might lead to alleviation of physical or emotional pain.  For example, we might assume that a woman who presents for treatment of anxiety or depression is distressed by her symptoms and is interested in learning some coping skills or taking some medication to improve her anxiety or mood.  With any luck, our assumptions turn out to be correct, treatment proceeds, symptoms are alleviated, and quality of life improves.  With even more luck, these improvements persist over time. 

The treatment of eating disorders can pose some special challenges, in part because the assumptions that we typically hold often turn out to be problematic. 

Assumption #1:

Women present for eating disorder treatment because they are concerned about their physical or mental health.
This assumption can be problematic because some women with eating disorders feel that their disordered eating behaviours are consistent with their values and self-image.  For example, a woman with anorexia nervosa might deliberately restrict her caloric intake and exercise excessively in order to achieve a low body weight, similar to the models promoted in the mainstream media.  To her, an ultra thin physique might be a sign of willpower rather than a sign of a psychological disorder.  The diagnostic criteria for the disorder specifies that individuals with anorexia “refuse” to maintain a minimally normal body weight and “deny” the seriousness of their low body weight.  Some women present for eating disorder treatment, not because they are concerned with their physical and mental health, but rather because their significant others, family, and friends are worried and/or frustrated and insist that they seek treatment.
 
Assumption #2:

Women who present for eating disorder treatment are ready to start making changes. 
This assumption can be problematic because even women who are concerned about their eating disorder and feel that it is important for them to change, might not feel that they are ready to make changes immediately.  Eating disorder symptoms (e.g., binge eating or excessive exercise) often serve important functions—emotion regulation, distraction, stress relief, and reward—and a woman might not feel ready to change her eating or exercise behaviours until other coping skills are in place to fulfill these important functions.  On a related note, she might lack confidence in her ability to initiate and sustain behavioural changes, particularly if she has had difficulty maintaining changes in the past.

Anyone who has had the experience of working with women with eating disorders, or with any disorder that might serve an important and valuable function, for that matter, will tell you that attempts to prescribe change for individuals who are ambivalent about change are typically met with resistance.  So, how can we put our assumptions aside and work effectively with ambivalence rather than fighting against it?

Motivational interviewing is a technique that was developed in the field of addictions, and it has since been adapted for the treatment of eating disorders due to the similarity in some symptoms and ambivalence about change.  Motivational interviewing is essentially a collaborative conversation about change that avoids argumentation, and rolls with resistance and ambivalence.  It seeks to elicit and explore an individual’s own arguments for change in order to strengthen personal motivation for, and commitment to, change.  Arguments for change are much more powerful when vocalized by the client herself, rather than by health care professionals, family members, or friends.   

Some conversation points for those doing a motivational interview:

Rather than beginning with the assumption that your client is ready to change, begin with the assumption that the behaviour likely serves a valuable function in her life.  It is helpful to begin the conversation with a non-judgemental discussion about the “good things” about the behaviour in order to understand the potential functions (e.g., self-soothing, reward, time out for self).  Next, you can transition into a discussion about the “not so good things” about the behaviour (e.g., impact on physical health, emotional health, social relationships, academic or occupational functioning, and finances).  This open discussion about the “good things” and “not so good things” about the behaviour can then set the stage for a conversation about the advantages and disadvantages of continuing the behaviour exactly as it is versus attempting to change the behaviour.
Intrinsic motivation for change can also be enhanced by asking questions that develop a discrepancy between your client’s current behaviour and her values and ultimate goals.  This can be facilitated by asking your client to describe her ideal life, and then following up this discussion by asking how she envisions her current eating disorder behaviours fitting in with her ideal life.  For example, her ideal life might consist of getting married and having children, but the eating disorder behaviours have been a source of conflict in many of her relationships and her low body weight has caused her menstrual cycle to stop.

The previous discussion points are aimed at increasing the importance of change from your client’s perspective.  However, readiness for change stems from both the perceived importance of change and the confidence that your client has about successfully making the change.  Given that many women with eating disorders have had many unsuccessful change attempts, it is critical to enhance her self-efficacy for change.  This can be accomplished by having a discussion about behaviours that she has successfully changed in the past (e.g., quitting smoking, cutting down on drinking) and the coping skills she used in order to make these changes.  On a related note, if she is able to resist the urge to engage in eating disordered behaviours from time to time (e.g., she does not have eating binges every day), it can be helpful to inquire about what she does differently on those days.  Before concluding this discussion, ask her to rate how confident she is that she can change a specific behaviour (e.g., reduce binge eating, increase caloric intake) on a scale from 1 to 10.  If her response is 5, for example, a question such as, “What makes it a 5 rather than a 3 or 4?” can prompt her to vocalize the reasoning behind her confidence.  A question such as, “What would it take to bump it up a notch to a 6 or a 7?” can lead to a discussion about what would help her to prepare for making a change.

Eating disorders are complex and no single factor explains why some women develop chronic eating disorders that don’t seem to respond to treatment and why some women relapse following apparently successful treatment.  One potential factor is that “action-oriented” treatments that focus on making changes are not necessarily effective or appropriate for individuals who are not yet considering change.  Motivational interviewing is an effective strategy that helps to resolve ambivalence and prepare women for action-oriented treatments such as cognitive behavioural therapy. 

Stephanie E. Cassin, Ph.D., C.Psych. Psychologist, Bariatric Surgery Program, Toronto Western Hospital

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