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