1. Enhancing Readiness and Motivation for change in the Eating Disorders
Josie Geller, Ph.D., R.Psych.
Eating Disorders Program
St. Paul’s Hospital

2. OUTLINE Engagement Motivational Approaches
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

3. You, me and a can of ensure

4. Sarah... 22-year old with severe BN Voluntary inpatient admission
Goal of admission:
Normalize eating
Interrupt binge/purge cycle

5. Sarah’s options Eat the meal as provided Replace for the meal with
supplement (Ensure)
Be discharged

6. 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

7. Agenda: Get Sarah to drink Ensure
What High investment looks like…
Care Provider
Agenda: Get Sarah to drink Ensure
Sarah

8. 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

9. Research on Stance

10. 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

11. Findings replicated in adolescents
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

12. Agenda: Reduce symptoms
Symptom-based model
Agenda: Reduce symptoms
Assess Symptoms

13. treatment to individuals
Symptom-based model
Provide intensive
treatment to individuals
with more severe
symptoms

14. Symptom-based model
OUTCOMES
Treatment completers

15. OUTCOMES Symptom-based model Treatment completers Treatment refusal
Dropout **
Relapse **

16. Dropout and Relapse DROP OUT RELAPSE
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

17. Assess Readiness Readiness-based model
Agenda: Provide treatment matched to readiness
Assess Readiness

18. Patients seen at intake
75%
17% 8%

19. Good outcome Treatment completers Treatment refusal Dropout Relapse
(Geller, Cockell & Drab, 2001)
(Geller, Drab-Hudson, Whisenhunt & Srikameswaran, 2004)

20. Readiness-based model
Assess
Readiness

21. Readiness-based model
Menu of
treatment
options
tailored to
readiness
Assess
Readiness

22. Clinician Stance Clinician Styles: “Nurturing” “Encouraging”
“Take charge”
“By the book”

23. Clinician / Family / Friend Stance
Directive vs. Collaborative:
Prof Psych Research and Practice; Geller et al., 2003, EDJTP; Brown & Geller, 2006

24. Think of a problem in your own life…

25. 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

26. 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.

27. _______________________________
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.

28. _______________________________
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.

29. 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

30. These findings were replicated with:
...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

31. These findings were replicated with:
...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

32. Stance _______________________________
There is a universal discrepancy between what we believe is helpful and what we do
_______________________________
low high
What actually occurs
Preference of
patients
clinicians
family
friends
Prof Psych Research and Practice; Geller et al., 2003, EDJTP; Brown & Geller, 2006

33. 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

34. Practical Pointers

35. 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

36. MISSION STATEMENT
To develop and foster a trusting, supportive relationship that promotes client self-awareness, self-acceptance, and responsibility for change

37. Motivational Approaches
Stance and tone are critical

38. Motivational Approaches
Stance and tone are critical
A clear plan regarding what is helpful

39. High Risk Patient Focus: Safety and planting seeds for the future
-- Medical stabilization
-- Alliance building
-- Distress reduction

40. 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

41. Contemplation and Action patients
Focus: Support for change
-- Behavioural contingencies and non-negotiables
-- Skill building
-- Validating difficulty of change
-- Relapse prevention

42. 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

43. Motivational Approaches
Communicate beliefs and values that foster acceptance and destigmatize 43

44. Motivational Approaches
Communicate beliefs and values that foster acceptance and destigmatize
the eating problem exists for a reason
change is difficult
change takes time 44

45. Motivational Approaches
Assume Nothing
Game Show:
SPOT THE ASSUMPTION!

46. 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!

47. 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) 47

48. 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 48

49. PRACTICAL POINTERS
Don’t try to make it all better

50. PRACTICAL POINTERS Don’t try to make it all better
Acknowledge that there may be no ‘nice’ ways out of this for the patient

51. 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

52. Menu of Options! Preparatory Treatments Non-negotiables
You, me and a can of Ensure

53. 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

54. 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.

55. Treatment Ingredients
Joining and setting the frame
Clinical feedback
Function of the illness/Barriers to recovery
Higher values
Exploring recovery

56. 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

57. 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

58. 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?

59. 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

60. 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

61. 2. Clinical Feedback DOMAINS Psychiatric symptoms
Eating disorder symptoms
Self-concept
Readiness and Motivation
Quality of life
Biological/physical

62. 2. Clinical Feedback GROUP No individualized clinical feedback
Clients estimate and discuss their stage of change

63. 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

64. 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)

65. Exercise Practice “draining”
An aspect of the ED (e.g., how does restricting or bingeing help?)
Something else of relevance to the patient

66. 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)

67. 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

68. 4. Higher Values DEATHBED QUESTION ENVISIONING
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

69. 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

70. 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

71. 5. Exploring Recovery DECISIONAL BALANCE
Identify and discuss Pros and Cons of change

72. 5. Exploring Recovery GROUP More focus on termination
Mental gifts: Feedback to each group member on qualities others appreciated

73. Non-Negotiables

74. Sarah’s Choices: ( or Discharge) Sarah Care Provider
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

75. Agenda: Get Sarah to drink Ensure
What High investment looks like…
Care Provider
Agenda: Get Sarah to drink Ensure
Sarah

76. INCONSISTENT Non-Negotiable Difficulties NO ADVANCE WARNING! ARBITRARY
PERSONAL RESPONSIBILITY MINIMIZED
INCONSISTENT

77. 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

78. You, me and a can of ensure

79. 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!

80. Takk!