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Assessing
Readiness and Motivation for Change:
Challenges and Practical Advice
Reprinted
from Eating Disorders Review
November/December 2000 Volume 11, Number 6
©2000 Gürze Books
Unlike
many psychiatric conditions where symptoms are experienced
as clearly distressing and disruptive, eating disorders are unusual in that the associated thoughts and behaviors
often perform a valued function in clients' lives.(1,
2)
While
individuals with other psychiatric conditions are
often eager to be rid of intrusive and unwanted aspects
of their disorders, many individuals with eating disorders typically express, either directly or indirectly,
intense ambivalence about change. Failing
to fully recognize and articulate this ambivalence
can lead to a number of treatment problems. For instance,
it is common for therapists to initiate "action-oriented"
interventions (such as increasing dietary intake)
with individuals who are not yet ready to change.
Such client-treatment mismatches typically result
in clients failing to fully engage in therapy, or
to drop out, and/or to relapse, all of which can result
in frustration for the client and therapist. When
a therapist fails to recognize a client's ambivalence
about recovery, the client may also be left wondering
whether the therapist fully understands her. This
can further interfere in the development and maintenance
of a good therapeutic alliance. Therefore, accurately
evaluating ambivalence about recovery in individuals
with eating disorders is of critical importance.
Challenges
to Assessing Client Ambivalence
Preliminary work has shown that determining a client's
readiness for change may not be a straightforward
task. For example, in one study, clinicians were asked
to rate their clients' readiness for change after
a 90-minute clinical assessment interview. In contrast
to client ratings of readiness, which predicted a
number of client change activities, clinicians' ratings
were unrelated to nearly all of the client activities
assessed (e.g., self-reevaluation, reinforcement management,
and anticipated difficulty of recovery activities).
(3)
A number of specific challenges to the eating disorders may be responsible for this lack of accuracy. First,
clients may be unaware of the extent to which they
are ambivalent and consequently may be unable to clearly
articulate their readiness for change. Alternatively,
clients who strongly desire support may feel pressured
to express greater readiness for change than they
actually feel in order to gain approval and/or access
to treatment. Finally, a complication unique to the
eating disorders is that clients' feelings of readiness
to change may differ by symptom. For example, clients
may be quite interested in reducing some symptoms
(e.g., binge eating), while not at all interested
in changing others (e.g., restrictive eating).
Strategies
for Assessing Readiness and Motivation for Change
Given these challenges, what strategies are helpful
in assessing client readiness? Although the application
of readiness and motivation for change models for
the eating disorders is in its infancy, there is a
lengthy history of work on ambivalence about change
in substance abuse populations.(4) Motivational Interviewing,
a central part of this work, offers a number of guiding
principles for working with individuals who have mixed
or negative feelings about change. Many of these are
incorporated into the Readiness and Motivation Interview
(RMI), 5 a semi-structured interview designed to assess
readiness and motivation for change in the eating
disorders. Regardless
of whether or not a formal RMI is being conducted,
a critical aspect to assessing readiness for change
is interviewer stance. For instance, in the RMI, prior
to beginning the interview, the assessor explains
that the main point of the interview is to achieve
a better understanding of the client's current experiences
with eating. The assessor expresses curiosity and
interest about the client's thoughts and feelings
about recovery, particularly the parts the client
does not want to change. Given
the challenges to assessing readiness, this stance
is critical because it communicates awareness, acceptance,
and understanding of ambivalence, and gives the client
permission, perhaps for the first time, to explore
and perhaps come to a better understanding of herself
and her feelings about change. Of note, in the RMI,
the assessor also assures the client that there will
be no negative consequences to openly sharing and
exploring these experiences. (It is therefore the
assessor's responsibility to ensure that this is indeed
the case; i.e., treatment is not contingent upon the
client's responses, and/or treatment options are available
for individuals at all stages of readiness.) The
format of the RMI involves reviewing each symptom
of an eating disorder, as defined by the diagnostic
questions of the Eating Disorder Examination (Cooper
& Fairburn, 1987). Clients are asked to talk about
the extent to which they experience each relevant
area (i.e., binge eating) as a problem. The therapist
then uses follow-up questions to explore why or why
not each symptom is (or is not) a problem. For example,
for the fear of weight gain question, the therapist
begins by asking whether in the past four weeks the
client has experienced a fear of gaining weight. If
the answer is yes, the therapist establishes how many
days this fear occurred, and then explores whether
the client views her fear of weight gain as a problem.
The therapist then prompts the client to determine
how much of her is actively working to reduce the
symptom, how much of her doesn't want to change the
symptom at all, and how much of her wants to change
the symptom, but isn't actually doing anything to
change at this time. Clients who are actively working
on change are also prompted to identify how much of
the work they are doing is for themselves versus for
someone or something else. The
RMI stance and form of questioning therefore produce
a comprehensive picture of readiness and motivation
for change across different areas of the eating disorder.
In the process, barriers to change are often also
identified. Interestingly, in addition to providing
clinicians with important information, some clients
have told us that the opportunity to clearly articulate
what they experience as a problem they wish to change,
and also what they may not want to change, was also
a useful, perhaps therapeutic, process for them.
What
Have We Learned Thus Far?
Interestingly, RMI scores reveal different patterns
of readiness for different symptom types. For instance,
among a sample of 98 individuals with mixed eating
disorder diagnoses, individuals were most likely to
be actively working on changing binge symptoms and
least interested in changing purging and dietary restriction.(7) Unlike clinicians' ratings of client readiness, which
were unrelated to client recovery behavior, RMI assessors'
global ratings of readiness were shown to predict
a number of clinically meaningful outcomes.(3) For
example, RMI assessors' ratings of the extent to which
clients wanted treatment for their eating disorder
were related to questionnaire reports of change activities,
and actual completion of assigned recovery activities.
This form of questioning may therefore be a useful
addition to standard intake assessments. Ongoing work
has also shown that RMI readiness ratings (e.g., pre-contemplation
scores) predicted treatment engagement and treatment
dropout. Collecting accurate readiness information
may therefore be helpful in clinical decision-making.(6)
Medical
Risk
One of the most difficult situations clinicians
face is managing clients who are critically ill and
in need of urgent medical attention. Although the
acuity of such clients' conditions may necessitate
immediate intervention, the approach used to evaluate
readiness and motivation for individuals in this group
is no different from that used with individuals who
have less severe illness. That is, showing curiosity
and interest regarding clients' concerns and wishes
while clearly communicating the available non-negotiable
options can de-escalate what can otherwise become
a stressful confrontation. Critical to such conversations
is empathy for the client (given that none of the
options are typically desirable to her), and a frank
and open communication style.
Other
Useful Tools
Aside from the RMI, a number of other tools have been
developed to help clinicians better understand clients'
experiences with and feelings about change. For instance,
clients can be prompted to write letters to their
eating disorder as a friend or foe.(1) This process
may identify key themes for the individual, as well
as critical barriers to recovery. Another
useful clinical tool is to assist clients in identifying
the pros and cons of their eating disorder. The therapist
can assist the client to generate reasons for and
against change. This exercise may enhance the therapist's
and client's understanding and awareness of the positive
and negative functions of the eating disorder. The
relative weight of pros and cons of an eating disorder can also be assessed in the form of a decisional balance
questionnaire.(8) Other questionnaires that measure
the stages and processes of change in the eating disorders
have been adapted from the substance abuse literature.(9)
General
Recommendations
Assessing readiness for change in the eating disorders
is greatly facilitated by a curious, open, nonjudgmental
stance, in which the assessor makes it clear that
there will be no cost to the client for exploring
and talking about his or her ambivalence toward change.
Ideally, this discussion would address all aspects
of the individual's eating disorder, given that readiness
and motivation for change differ across eating disorder
symptoms. Tools that identify clients' barriers to
change may also contribute to the development of a
better understanding of clients' experience of, and
concerns about letting go of their eating disorder. In order to facilitate discussions about readiness
for change with clients, treatment options that address
the needs of clients who are ambivalent about change
must be available. The development and validation
of such treatments is a critical area for future work.
References
1. Serpell L, Treasure J, Teasdale J, et al. Anorexia
nervosa: Friend or foe? Int J Eat Disord 1999;
25:177.
2. Vitousek KB, Watson S, Wilson, GT. Enhancing motivation
for change in treatment-resistant eating disorders.
Clin Psychol Rev 1998:18:391.
3. Geller J, Cockell SJ, Zaitsoff S, et al. Predicting
Behaviour Change in Anorexia Nervosa: A Comparison
of Readiness Assessment Strategies. Paper presented
at the meeting of the Eating Disorders Research Society,
San Diego, 1999.
4. Miller WR, Rollnick S. Motivational interviewing:
Preparing people for change. New York: Guilford Press,
1999.
5. Geller J, Drab D. The Readiness and Motivation
Interview: A symptom-specific measure of readiness
for change in the eating disorders. European Eat
Disord Rev 1999:7, 259-278.
6. Geller J, Zaitsoff SL, Cockell SJ. Clinical Decision-Making:
Contribution of Readiness and Motivation Information.
Paper presented at the meeting of the Eating Disorders
Research Society, Bavaria, Germany, 2000.
7. Geller J, Cockell SJ, Drab D. Predicting recovery
behaviour in anorexia nervosa: The readiness and motivation
interview. Paper presented at the meeting of the Association
for the Advancement of Behaviour Therapy, Toronto,
1999.
8. Cockell, SJ. A decisional balance measure of readiness
for change in anorexia nervosa. Unpublished dissertation,
University of British Columbia, Vancouver, B.C., 2000.
9. Blake W, Turnbull S, Treasure J. Stages and processes
of change in eating disorders: Implications for therapy.
Clin Psychol & Psychother 1997; 4(3), 186.
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