Brief Motivational Intervention for People with Eating Disorders

Can education and counseling
increase readiness for change?

Patients with eating disorders are often ambivalent about recovery, and readiness for change is not always present. In fact, refusing treatment, dropping out of therapy, and relapse are all too common among patients with eating disorders.

Josie Geller, PhD, and colleagues in Vancouver and Honolulu tested a brief motivational program to see if education and counseling could increase readiness for change. The program, termed Readiness and Motivation Therapy (RMT) is a five-session individual preparatory intervention (Int J Eat Disord 2011; 44:49).

Motivational Interviewing was originally developed for use in patients with alcohol and substance abuse and is designed to increase clients’ willingness to engage in future treatment, which may be extensive. The approach has been adapted for many other populations, including individuals with obsessive-compulsive disorder, suicidality, and for pathological gamblers.

The Readiness and Motivation Interview is a semi-structured interview that assesses an individual’s degree of pre-contemplation (not wanting to change), contemplation (thinking about change), or action/maintenance (actively working to reduce or maintain change to eating disorders behaviors).

Subjects in the study were recruited from a tertiary care Canadian eating disorder treatment program when they were first referred to the treatment center. After the initial assessment, 181 individuals who met the study criteria were randomly assigned to a treatment group (5 sessions of RMT; n=57) or to a wait-listed control group (n=56).If at any time a patient became psychiatrically or medically unstable, she (or he) was withdrawn from the study.

RMT Therapy

Participants first completed the Readiness and Motivation Interview and measures of eating disorder symptoms, self-esteem and psychiatric symptoms at intake. RMT treatment involved study therapists who were clinical psychologists, counseling psychologists, and nurse clinicians. These therapists were trained by two of the authors of the study, and read the study manual and listenedto tapes of pilot sessions. The therapists were then supervised while conducting five sessions of RMT with pilot participants. The sessions were then tape-recorded and reviewed to make certain that the therapists were adhering to the study protocol.

Patients in the treatment group were provided with five 1-hour sessions given once a week. The first session was designed to increase the participants’ understanding of the eating disorder and to help them decide what, if anything, they wished to change. In the second session, participants were provided with detailed feedback from their research assessment about their eating disorder and psychiatric symptoms, quality of life, biological complications, self-esteem, and readiness for change. The third session focused on increasing the patient’s awareness and understanding of the purposes that the eating disorder served in their lives. Personal strengths were highlighted in this session. At the fourth session, participants were invited to identify their personal values and encouraged to explore what, if any, changes would be needed for them to live according to these values. At the fifth and final session, participants were encouraged to reflect on their experience of the previous sessions. Possible next steps, which might or might not include further treatment, were discussed.

During the 5-month study, the authors also tracked patients’ treatment decisions. The authors found that 63% of patients received some form of individual therapy. In addition, 54% of patients saw a psychiatrist, 84% saw their family doctor, 66% visited a dietician, 84% saw a physician who specialized in treating eating disorders, 20% attended community support groups, 21% attended family therapy, and 56% took part in psychoeducational groups.

Some unexpected results

At baseline, there were no demographic variables between the two groups. The groups also did not vary in baseline readiness for change, eating disorder and psychiatric symptoms, or self-esteem. Over time, there was a significant reduction in patients’ contemplation of restricting eating and an increase in restriction over time in both the RMT and control groups. Both groups had been studied with the Eating Disorder Inventory, and there was a significant reduction in EDI composite scores (sum of drive for thinness, bulimia, and body dissatisfaction in both groups.

Improvements in readiness for change as well as in depression, drive for thinness and bulimic symptoms occurred at 6-week and 3-month follow-up in both groups, with no group differences.

The authors had not anticipated that the control group would improve. Was it the clinical setting, where most participants received some form of treatment during the study period? Or could exposure to other health care professionals have led to improvement in readiness to change? Despite the limitations of the study, the authors noted at both time points that persons who participated in RMT were significantly less likely to be highly ambivalent about treatment than those in the control condition, which suggested that RMT was especially useful in this group.

Dr. Geller and colleagues concluded that RMT may be beneficial to highly reluctant, clinically challenging patients’, and may help them make better use of future, action-oriented, treatment.