Assessing Readiness & Motivation for Change: Challenges & Practical Advice

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.