Enhancing Readiness and Motivation for change in the Eating Disorders Josie Geller, Ph.D., R.Psych. Eating Disorders Program St. Paul’s Hospital OUTLINE • Engagement – Investment and readiness for change – Research on stance • Motivational Approaches – Practical pointers – Menu of options! • • • • Preparatory Treatments Treatment non-negotiables Role play Working with chronic EDs You, me and a can of ensure Sarah... • 22-year old with severe BN • Voluntary inpatient admission • Goal of admission: – Normalize eating – Interrupt binge/purge cycle Sarah’s options Eat the meal as provided Replace for the meal with supplement (Ensure) Be discharged What promotes High Investment in drinking the Ensure • Investment HIGH – Sarah’s short and long term outcome will be better if she has the Ensure – If she refuses I will have to spend energy trying to convince her – If she refuses, this says something about me as a care provider What High investment looks like… Care Provider Agenda: Get Sarah to drink Ensure Sarah Moral of the story: • I may not always know what is in my clients’ best interests with regard to long term symptom change • Letting go of my investment in (rapid) recovery may promote a better outcome Research on Stance The Readiness and Motivation Interview • Provides stage of change and Internality scores for: • • • • Dietary restriction Binge eating Compensation Cognitive/affective Precontemplation Not wanting change Contemplation Thinking about change Action Working on change Psych. Assessment; Geller et al., 2001; EDJTP; Geller et al., 2004 RMI scores and outcome • Readiness scores predict: – ENROLLMENT in intensive treatment – DROPOUT – BEHAVIOUR CHANGE post treatment – RELAPSE 6 months following treatment completion Findings replicated in adolescents Psych. Assessment; Geller et al., 2001; Psych Ass, Geller et al, 2010; EDJTP; Geller et al., 2004 Symptom-based model Agenda: Reduce symptoms Assess Symptoms Symptom-based model Provide intensive treatment to individuals with more severe symptoms Symptom-based model OUTCOMES Treatment completers Symptom-based model OUTCOMES Treatment completers Treatment refusal Dropout ** Relapse ** Dropout and Relapse DROP OUT – 49% (clinical trial of CBT for AN) Halmi et al., 2005 – 27% to 55% (treatment of BN) Fairburn et al., 2009; Agras et al., 2000, RELAPSE – 30 to 50% (weight-restored individuals with AN) Olmstead et al., 2005 – 30 to 63% (recovered individuals with BN) Pike et al., 2000 Readiness-based model Agenda: Provide treatment matched to readiness Assess Readiness Patients seen at intake 75% 17% 8% Good outcome Treatment completers Treatment refusal Dropout Relapse (Geller, Cockell & Drab, 2001) (Geller, Drab-Hudson, Whisenhunt & Srikameswaran, 2004) Readiness-based model Assess Readiness Readiness-based model Assess Readiness Menu of treatment options tailored to readiness Clinician Stance Clinician Styles: “Take charge” “Nurturing” “Encouraging” “By the book” Clinician / Family / Friend Stance Directive vs. Collaborative: Prof Psych Research and Practice; Geller et al., 2003, EDJTP; Brown & Geller, 2006 Think of a problem in your own life… Directive and Collaborative Approaches Key points DIRECTIVE COLLABORATIVE Who determines how problem is addressed? Someone other than you You are an active participant What strategies are used to help you? Behavioral contracting Development of shared goals in consideration of barriers What is your role? Accept and comply Work on shared goals in the context of safety “non-negotiables” Response to lack of change? Repetition or reinforcement of directives / withdrawal Curiosity. No assumptions or judgment / revisiting goals and barriers Example: Alison is a long distance runner and has been extremely underweight for a number of years. She went to her family doctor for treatment of her third stress fracture in 6 months. _______________________________ low high Low collaboration (directive): The doctor said that he warned Alison that this would happen if she kept ignoring his medical recommendations. He told Alison that he could only repeat the advice he gave her before: stop running and gain weight. _______________________________ low high High collaboration (motivational): The doctor asked Alison how these stress fractures were affecting her. He asked whether Alison had thought any more about their last conversation about lifestyle changes to prevent future stress fractures. RESULTS: Clinicians and clients consistently prefer collaborative interventions and consider them to be: - more acceptable - more likely to engage and produce favorable outcomes ...than directive interventions... Prof Psych Research and Practice; Geller et al., 2003 ...they also believed that the two types of interventions (collaborative and directive) are equally likely to occur in practice These findings were replicated with: Friends, Partners, Parents, and Siblings EDJTP; Brown & Geller, 2006, Prof Psych Research and Practice; Geller et al., 2003, EDRS; Zelichowska et al., 2011 ...they also believed that the two types of interventions (collaborative and directive) are equally likely to occur in practice These findings were replicated with: Friends, Partners, Parents, and Siblings What gets in the way of using a collaborative stance? EDJTP; Brown & Geller, 2006, Prof Psych Research and Practice; Geller et al., 2003, EDRS; Zelichowska et al., 2011 Stance There is a universal discrepancy between what we believe is helpful and what we do What actually occurs _______________________________ low high Preference of • • • • patients clinicians family friends Prof Psych Research and Practice; Geller et al., 2003, EDJTP; Brown & Geller, 2006 SUMMARY OF RESEARCH • Ambivalence about change is common • Client ambivalence can bring up intense feelings in clinicians – It is common for us to say things that are not helpful to the client • There is a discrepancy between what we believe is most helpful and what we actually do Practical Pointers Motivational Approaches • Stance is open, curious and free of assumptions – Emphasis on ambivalence – Importance of fostering a collaborative relationship and honest discussion about readiness for change • Treatment is tailored to client readiness – Client is responsible for change Motivational Interviewing; Miller & Rollnick, 2002 MISSION STATEMENT To develop and foster a trusting, supportive relationship that promotes client self-awareness, self-acceptance, and responsibility for change Motivational Approaches • Stance and tone are critical Motivational Approaches • Stance and tone are critical • A clear plan regarding what is helpful High Risk Patient • Focus: Safety and planting seeds for the future -- Medical stabilization -- Alliance building -- Distress reduction Stable precontemplators and contemplators • Focus: Exploring barriers to recovery – Understanding ED maintaining factors – Exploring client values and priorities – Experimenting with small changes IJED, Geller et al., 2011 Contemplation and Action patients Focus: Support for change -- Behavioural contingencies and non-negotiables -- Skill building -- Validating difficulty of change -- Relapse prevention Motivational Approaches • Stance and tone are critical • A clear plan regarding what is helpful • Care provider knowledge about their own values and beliefs about change Motivational Approaches • Communicate beliefs and values that foster acceptance and destigmatize Motivational Approaches • Communicate beliefs and values that foster acceptance and destigmatize – the eating problem exists for a reason – change is difficult – change takes time Motivational Approaches • Assume Nothing – Game Show: SPOT THE ASSUMPTION! MOTIVATIONAL INTERVIEWING • Be Curious – Best way to avoid making assumptions – Useful technique in showing empathy and to increase understanding of client’s experience – Game show: BE CURIOUS! PRACTICAL POINTERS • Help her work out how the eating disorder has been helpful – find out what parts of her eating disorder self she values and why? (DRAINING TECHNIQUE) PRACTICAL POINTERS • Set goals that are meaningful for her and that are realistic – a modest goal that she genuinely cares about is more useful that an ambitious goal that is not hers PRACTICAL POINTERS • Don’t try to make it all better PRACTICAL POINTERS • Don’t try to make it all better – Acknowledge that there may be no ‘nice’ ways out of this for the patient SUMMARY • Engagement Ingredients: – Attention to investment and stance – Fostering a trusting, empowering relationship – No assumptions, curiosity – Tailoring what we do to readiness – Having a clear plan regarding non-negotiables Menu of Options! Preparatory Treatments Non-negotiables You, me and a can of Ensure Individual and Group Treatments that Enhance Motivation for Change • Single session MET (Dunn, Neighbors & Larimer, 2010) • 5-session individual therapy (Geller, Srikameswaran & Brown, 2011) • 12-session group therapy Treatment for Purpose: To help the individual develop a better understanding of her eating disorder and to decide what, if anything, she wants to do about it. Treatment Ingredients 1. 2. 3. 4. 5. Joining and setting the frame Clinical feedback Function of the illness/Barriers to recovery Higher values Exploring recovery 1. Joining and setting the frame • Purpose: to describe the therapy and establish a working alliance • Frame: to help the client understand her eating disorder better and decide what, if anything, she wants to do about it 1. Joining and setting the frame • PREAMBLE: Describe purpose, stance, and investment • COMPONENTS: – Review of previous treatment • review client’s understanding of what worked/didn’t work • drain client on what was helpful and why • drain client on what wasn’t helpful and why 1. Joining and setting the frame – “What, if anything, is the problem from your perspective?” • Is there anything that you would like to change? • Is there anything that you would like not to change? 1. Joining and setting the frame • GROUP – Set the frame for group • Confidentiality • What is okay to talk about • Hopes and fears about being in the group – Pairs introduction exercise: • What a care provider said or did that was least helpful 2. Clinical Feedback • Purpose: to provide the client with information on how things are going based on test materials completed prior to treatment • Delivery: – therapist is not invested in convincing client to change – little elaboration of results 2. Clinical Feedback • DOMAINS – Psychiatric symptoms – Eating disorder symptoms – Self-concept – Readiness and Motivation – Quality of life – Biological/physical 2. Clinical Feedback • GROUP – No individualized clinical feedback – Clients estimate and discuss their stage of change 3. Function of the illness • Purpose: – Reduce client’s distress – Increase client’s understanding of the function of the eating disorder – Support client’s strengths and resources 3. Function of the illness • Therapist stance – There is good reason for the existence of the ED • ED may have been the best solution at the time it developed • Change is difficult and takes time – Focus on reinforcing strengths • Questions: – How does _______ (restricting/bingeing/purging) help? (drain) Exercise • Practice “draining” – An aspect of the ED (e.g., how does restricting or bingeing help?) – Something else of relevance to the patient 3. Function of the illness • GROUP – Group provides a unique opportunity to examine the association between eating disorder symptoms and relationships – Group members write an advertisement for an eating disorder (complete with voiceover warnings) 4. Higher Values • Purpose: – To help the client explore and articulate her personal value system – To examine whether the ED is allowing her to live according to her higher values 4. Higher Values • DEATHBED QUESTION – If you were on your deathbed thinking about your life, what experiences do you think would stick out as most meaningful to you? • ENVISIONING – Imagine life 5/10 years from now 4. Higher Values • GROUP – Group members write two letters to a friend 5 years from now • Not recovered from eating disorder • Recovered from eating disorder 5. Exploring Recovery • Purpose: to consolidate thoughts and feelings that arose as a result of this work and to articulate where to go next – Treatment is conceptualized as a work in progress – Reinforce work accomplished and acknowledge client’s courage – Talk about small steps 5. Exploring Recovery • DECISIONAL BALANCE – Identify and discuss Pros and Cons of change 5. Exploring Recovery • GROUP – More focus on termination – Mental gifts: Feedback to each group member on qualities others appreciated Non-Negotiables What LOW investment looks like… Sarah’s Choices: ( or Discharge) Agenda: Help Sarah make the best decision for her, given her (NN) options Care Provider Sarah What High investment looks like… Care Provider Agenda: Get Sarah to drink Ensure Sarah Non-Negotiable Difficulties NO ADVANCE WARNING! ARBITRARY PERSONAL RESPONSIBILITY MINIMIZED INC NSISTENT O Non-Negotiable Philosophy 1. Surprises are minimized 2. There is a really good reason for the non-negotiable - the rationale is clearly explained 3. Non-negotiables are implemented consistently 4. Client autonomy is maximized You, me and a can of ensure SUMMARY • Critical to delivery of motivational approaches is: – A clear plan regarding what is helpful – Attention to investment and stance – Clearly articulated treatment non-negotiables – Practice! Takk!