josie geller, ph.d., r.psych. eating disorders program st. paul’s hospital enhancing readiness and...

Josie Geller, Ph.D., R.Psych.Eating Disorders Program

St. Paul’s Hospital

Enhancing Readiness and Motivation for change in the Eating Disorders

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

• 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 promotes High Investment in drinking the

Ensure

Care Provider

Sarah

Agenda: Get Sarah to

drink Ensure

What High investment looks like…

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

ContemplationThinking about change

ActionWorking on

change

Psych. Assessment; Geller et al., 2001; EDJTP; Geller et al., 2004

• Readiness scores predict:– ENROLLMENT in intensive treatment– DROPOUT– BEHAVIOUR CHANGE post treatment– RELAPSE 6 months following treatment

completion

RMI scores and outcome

Psych. Assessment; Geller et al., 2001; Psych Ass, Geller et al, 2010; EDJTP; Geller et al., 2004

Findings replicated in adolescents

Assess Symptoms

Symptom-based model

Agenda: Reduce

symptoms

Provide intensive treatment to individuals

with more severesymptoms

Symptom-based model

Treatment completers

OUTCOMESSymptom-based model

Treatment refusal

Dropout **

Treatment completers

Relapse **

OUTCOMESSymptom-based model

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

Dropout and Relapse

Assess Readiness

Readiness-based model

Agenda: Provide treatment

matched to readiness

Patients seen at intake

75% 17% 8%

Treatment refusalDropout

Good outcome Treatment completers

Relapse

(Geller, Cockell & Drab, 2001)(Geller, Drab-Hudson, Whisenhunt & Srikameswaran, 2004)

AssessReadiness

Readiness-based model

AssessReadiness

Readiness-based model

Menu of treatment

options tailored to readiness

Clinician Stance

Clinician Styles:

“Take charge”

“Encouraging”

“By the book”

“Nurturing”

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

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.

Example:

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.

_______________________________low high

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

EDJTP; Brown & Geller, 2006, Prof Psych Research and Practice; Geller et al., 2003, EDRS; Zelichowska et al., 2011

What gets in the way of using a collaborative stance?

_______________________________low high

What actually occurs

Prof Psych Research and Practice; Geller et al., 2003, EDJTP; Brown & Geller, 2006

Stance

• patients• clinicians• family• friends

Preference of

There is a universal discrepancy between what we believe is helpful and what we do

• 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

SUMMARY OF RESEARCH

Practical Pointers

• 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

Motivational Approaches

MISSION STATEMENT

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

• Stance and tone are critical

Motivational Approaches

• Stance and tone are critical• A clear plan regarding what is

helpful

Motivational Approaches

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 patientsFocus: Support for change -- Behavioural contingencies and non-negotiables -- Skill building -- Validating difficulty of change -- Relapse prevention

• 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 Approaches

• Be Curious– Best way to avoid making assumptions– Useful technique in showing empathy and

to increase understanding of client’s experience

– Game show:

MOTIVATIONAL INTERVIEWING

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)

• 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

PRACTICAL POINTERS

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 Ingredients1. Joining and setting the frame2. Clinical feedback 3. Function of the illness/Barriers to

recovery4. Higher values5. 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

• 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

1. Joining and setting the frame

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

• 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

2. Clinical Feedback

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

• 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)

3. Function of the illness

• Practice “draining”– An aspect of the ED (e.g., how does restricting or

bingeing help?)– Something else of relevance to the patient

Exercise

• 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)

3. Function of the illness

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

• 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

4. Higher Values

• 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

5. Exploring Recovery

Non-Negotiables

Care Provider Sarah

Sarah’s Choices: ( or Discharge)

Agenda: Help Sarah make the best decision for her, given her (NN) options

What LOW investment looks like…

Care Provider

Sarah

Agenda: Get Sarah to

drink Ensure

What High investment looks like…

NO ADVANCE WARNING!

ARBITRARY

INCONSISTENT

PERSONAL RESPONSIBILITYMINIMIZED

Non-Negotiable Difficulties

Non-Negotiable Philosophy

1. Surprises are minimized2. 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!