Transcript treatment non

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!